Child Opportunity Index 2.0 and acute care utilization among children with medical complexity

Abstract

Background: Disproportionately high acute care utilization among children with medical complexity (CMC) is influenced by patient-level social complexity.

Objective: The objective of this study was to determine associations between ZIP code-level opportunity and acute care utilization among CMC.

Design, setting, and participants: This cross-sectional, multicenter study used the Pediatric Health Information Systems database, identifying encounters between 2016-2019. CMC aged 28 days to <16 years with an initial emergency department (ED) encounter or inpatient/observation admission in 2016 were included in primary analyses.

Main outcome and measures: We assessed associations between the nationally-normed, multi-dimensional, ZIP code-level Child Opportunity Index 2.0 (COI) (high COI = greater opportunity), and total utilization days (hospital bed-days + ED discharge encounters). Analyses were conducted using negative binomial generalized estimating equations, adjusting for age and distance from hospital and clustered by hospital. Secondary outcomes included intensive care unit (ICU) days and cost of care.

Results: A total of 23,197 CMC were included in primary analyses. In unadjusted analyses, utilization days decreased in a stepwise fashion from 47.1 (95% confidence interval: 45.5, 48.7) days in the lowest COI quintile to 38.6 (36.9, 40.4) days in the highest quintile (p < .001). The same trend was present across all outcome measures, though was not significant for ICU days. In adjusted analyses, patients from the lowest COI quintile utilized care at 1.22-times the rate of those from the highest COI quintile (1.17, 1.27).

Conclusions: CMC from low opportunity ZIP codes utilize more acute care. They may benefit from hospital and community-based interventions aimed at equitably improving child health outcomes.

Figure 1.. Adjusted Utilization Days by COI Quintile among Children with 3+ Complex Chronic Conditions

Calculations pursued using negative binomial generalized estimating equations adjusted for child age and distance to hospital, clustered by hospital. Utilization Days= Hospital Bed Days + ED Discharges.

Figure 2.. Care Utilization Rate Ratio among Children with 3+ Complex Chronic Conditions, Very Low COI v. Very High COI

Calculations adjusted for child age and distance to hospital, clustered by hospital. Utilization Days= Hospital Bed Days + ED Discharges

Figure 3.. Utilization Days and Cost Rate Ratio, Very Low COI v. Very High COI in Full and Restricted Cohorts of Children with 3+ Complex Chronic Conditions (CCCs)

Calculations adjusted for child age and distance to hospital, clustered by hospital. Distance-Restricted Cohort= Living within the 75%ile of distance from the hospital Annual Utilization Cohort = ED discharge or inpatient/observation encounter in every year of the study, 2016–2019