Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated With Pediatric Intensive Care Use for Life-Threatening Asthma

Abstract

Background: Social determinants of health are associated with asthma prevalence and healthcare use in children with asthma, but are multifactorial and complex. Whether social determinants similarly influence exacerbation severity is not clear.

Objective: Composite measures of social determinants of health and readmission outcomes were evaluated in a large regional cohort of 1,403 school-age children admitted to a pediatric intensive care unit (PICU) for asthma.

Methods: Residential addresses were geocoded and spatially joined to census tracts. Composite measures of social vulnerability and childhood opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots, where PICU admission rates per 1,000 children are at or above the 90th percentile, versus non-hot spots.

Results: A total of 228 children resided within a neighborhood hot spot (16%). Hot spots were associated with a higher (ie, poorer) composite Social Vulnerability Index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a lower (ie, poorer) composite Childhood Opportunity Index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower childhood opportunity were associated with PICU readmission. Residing within a hot spot was further associated with a longer duration of hospital stay, individual inpatient bed days, and total census tract inpatient bed days.

Conclusions: Social determinants of health identified by geospatial analyses are associated with more severe asthma exacerbation outcomes in children. Outpatient strategies that address both biological and social determinants of health are needed to care for and prevent PICU admissions optimally in children with asthma.

Keywords: Census tract; Childhood Opportunity Index; Geocoding; Neighborhood; Pediatric intensive care unit; Social Vulnerability Index; Social determinants of health; disparities; status asthmaticus.

Figure 1.. Maps of Georgia (A) and the Atlanta-Sandy Springs-Roswell metropolitan statistical area (B) including the Overall Child Opportunity Index (COI) 2.0 Georgia-based rankings for each of the census tracts.

Admissions to a Children’s Healthcare of Atlanta pediatric intensive care unit for status asthmaticus occurring during the 2015 – 2020 study period are shown. Census tracts are percentile ranked relative to other Georgia census tracts using the COI 2.0 from 1 – 100. Yellow indicates a census tract with a low COI 2.0. Purple indicates a census tract with a high COI 2.0.

Figure 2.. Social Vulnerability Index census tract ranking for Georgia for children with and without two or more pediatric intensive care admissions for status asthmaticus.

Box and whisker plots of A) socioeconomic status, B) household composition and disability, C) minority status and language, D) housing type and transportation, E) overall composite percentile ranking. Center line is the median, outer box is the 25^th and 75^th percentile, whiskers are the 95% confidence intervals. There were n = 185 children with multiple admissions and n = 1219 children with one admission. *p < 0.05, ***p < 0.001

Figure 3.. Childhood Opportunity Index 2.0 census tract ranking for Georgia for children with and without two or more pediatric intensive care admissions for status asthmaticus.

Box and whisker plots of A) Education domain, B) Health and Environment domain, C) Social and Economic domain, D) Overall Composite Index. There were n = 185 children with multiple admissions and n = 1219 children with one admission. Center line is the median, outer box is the 25^th and 75^th percentile, whiskers are the 95% confidence intervals. ***p < 0.001, ****p < 0.0001