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Comparative Study
. 2024 Dec 2;7(12):e2449672.
doi: 10.1001/jamanetworkopen.2024.49672.

Comparative Analysis of Indices for Social Determinants of Health in Pediatric Surgical Populations

Caroline Q Stephens  1 , Ava Yap  1 , Lan Vu  1 , Jacqueline M Saito  2 , Dwight Barry  3 , Amy M Shui  1 , Hannah Cockrell  3 , Sarah Cairo  1 , Derek Wakeman  4 , Loren Berman  5 , Sarah Greenberg  3 , Allison F Linden  6 , Jonathan Kohler  7 , KuoJen Tsao  8 , Nicole A Wilson  4
Affiliations
Comparative Study

Comparative Analysis of Indices for Social Determinants of Health in Pediatric Surgical Populations

Caroline Q Stephens et al. JAMA Netw Open. .

Abstract

Importance: Conclusions vary substantially among studies examining associations between area-based social determinants of health (SDOH) and pediatric health disparities based on the selected patient population and SDOH index. Most national studies use zip codes, which encompass a wide distribution of communities, limiting the generalizability of findings.

Objectives: To characterize the distributions of composite SDOH indices for pediatric surgical patients within a national sample of academic children's hospitals and to assess SDOH index precision in classifying patients at similar levels of disadvantage.

Design, setting, and participants: This multicenter retrospective cohort study included patients younger than 18 years who underwent surgery from January 1, 2016, to December 31, 2021, at 8 American College of Surgeons National Surgical Quality Improvement Program Pediatric children's hospitals. Data were analyzed November 15, 2023, to September 25, 2024.

Exposures: Exposures included the Social Vulnerability Index (SVI), Area Deprivation Index (ADI), and Child Opportunity Index (COI), which are composite scores of SDOH factors within a geographic area. A standardized, high-fidelity process was developed to link individual patients to SDOH indices at the US census tract and census block group level.

Main outcomes and measures: The primary outcome was composite SDOH index distribution, which was assessed using interrater reliability scores. Substantial agreement was defined as a Cohen κ statistic higher than 0.60.

Results: Of 55 865 included patients, 54.6% were male; 34.8% were infants and toddlers (0-3 years of age), 39.0% were school age (4-12 years), and 26.2% were adolescents (13-17 years). A total of 3468 patients (6.2%) could not be matched to either an SVI, ADI, or COI. Patients with missing geocodes were more likely to be Hispanic (20.1% vs 17.1%; P < .001) and have Medicaid insurance (48.1% vs 44.6%; P < .001) compared with patients with addresses that could be geocoded. With all institutions grouped, SDOH indices showed only minor variations. However, within each institution and among institutions, indices varied considerably, especially the ADI. Indices had low-to-fair interrater reliability within institutions (κ range, 0.15-0.33), indicating that each index classified individual patients differently according to disadvantage.

Conclusions and relevance: In this multicenter retrospective cohort study of 55 865 pediatric surgical patients, 3 different composite measures of SDOH classified disadvantage for individual patients differently. The SDOH index components should be understood and carefully considered prior to inclusion of a composite measure in the analysis of children's surgical outcomes.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Wakeman reported receiving personal fees from Gibson, McAskill & Crosby, LLP for legal consulting outside the submitted work. Dr Wilson reported receiving grants from the National Institutes of Health National Institute of Allergy and Infectious Diseases and the National Institute of Diabetes and Digestive and Kidney Diseases outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Components of Area-Based Indices for Social Determinants of Health
Each index—the Area Deprivation Index (ADI), Social Vulnerability Index (SVI), and Child Opportunity Index (COI)—uses a variable number of components in its calculation. These components can be divided into categories (shown with dotted connecting lines): education, income & socioeconomic status, race and ethnicity as a single variable, built environment, employment, and housing characteristics. Solid lines connect each index to its constituent components. The weight of the solid line indicates how many indices share that constituent component (eg, high school diploma is shared by all 3 indices). Definitions and sources of each component are given in eAppendix 2 in Supplement 1. AP indicates advanced placement; ECE, early childhood education; and FPL, federal poverty level.
Figure 2.
Figure 2.. Distribution of Missingness for Social Determinants of Health Indices
ADI indicates Area Deprivation Index; COI, Child Opportunity Index; and SVI, Social Vulnerability Index.
Figure 3.
Figure 3.. Distribution of Indices for Social Determinants of Health Among 8 Children’s Hospitals
For each index, patients were allocated to deciles, and the subsequent distributions were plotted. To align index directionality, the Child Opportunity Index (COI) was reversed (101 − COI). ADI indicates Area Deprivation Index; and SVI, Social Vulnerability Index.
See this image and copyright information in PMC

References

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