Social Disadvantage, Access to Care, and Disparities in Physical Functioning Among Children Hospitalized with Respiratory Illness
BACKGROUND AND OBJECTIVES: Understanding disparities in child health-related quality of life (HRQoL) may reveal opportunities for targeted improvement. This study examined associations between social disadvantage, access to care, and child physical functioning before and after hospitalization for acute respiratory illness.
METHODS: From July 1, 2014, to June 30, 2016, children ages 8-16 years and/or caregivers of children 2 weeks to 16 years admitted to five tertiary care children’s hospitals for three common respiratory illnesses completed a survey on admission and within 2 to 8 weeks after discharge. Survey items assessed social disadvantage (minority race/ethnicity, limited English proficiency, low education, and low income), difficulty/delays accessing care, and baseline and follow-up HRQoL physical functioning using the Pediatric Quality of Life Inventory (PedsQL, range 0-100). We examined associations between these three variables at baseline and follow-up using multivariable, mixed-effects linear regression models with multiple imputation sensitivity analyses for missing data.
RESULTS: A total of 1,325 patients and/or their caregivers completed both PedsQL assessments. Adjusted mean baseline PedsQL scores were significantly lower for patients with social disadvantage markers, compared with those of patients with none (78.7 for >3 markers versus 85.5 for no markers, difference −6.1 points (95% CI: −8.7, −3.5). The number of social disadvantage markers was not associated with mean follow-up PedsQL scores. Difficulty/delays accessing care were associated with lower PedsQL scores at both time points, but it was not a significant effect modifier between social disadvantage and PedsQL scores.
CONCLUSIONS: Having social disadvantage markers or difficulty/delays accessing care was associated with lower baseline physical functioning; however, differences were reduced after hospital discharge.
© 2020 Society of Hospital Medicine
Examining disparities in health-related quality of life (HRQoL) outcomes in children provides a unique patient-centered perspective on pediatric health services equity.1,2 Prior studies have demonstrated the relationship between minority race, low socioeconomic status, and lower maternal education with poorer HRQoL outcomes in children.3-6 Some studies have also shown a dose-response relationship between social disadvantage markers and poorer child health status.7,8 Furthermore, the associations between social disadvantage and poor access to care,9-11 and between poor access to care and lower HRQoL, are also well established.12-14
Examining HRQoL before and after hospitalization can further our understanding of how disparities in HRQoL may change once children engage with the medical system for an acute illness.15 Children requiring hospitalization constitute a useful population for examination of this question as they represent a group of children with variable social disadvantage markers and access to outpatient care.16 Although interventions to address social determinants of health for patients with social disadvantages have been associated with within-group improvements in HRQoL, none have assessed changes in disparities as an outcome.17 Furthermore, many of these studies were conducted in the outpatient setting,18,19 whereas hospitalization provides an additional point of care to address the social determinants of health for vulnerable families.20 Even for short hospitalizations, the 24/7 nature of hospital care provides the opportunity for frequent interactions with clinicians, nurses, and support staff to clarify illness-related questions, discuss other health concerns and unmet needs, and connect with social services or community resources. These opportunities may be particularly important for families with a higher number of social disadvantage markers and even more beneficial to those with difficulty accessing needed care from their primary medical home.
In this study, we focused on children with common respiratory illnesses (asthma, bronchiolitis, and pneumonia), which constitute the majority of childhood hospitalizations.21 Additionally, we only focused on the child’s physical functioning component of HRQoL because this component is most likely to improve after hospitalization for children with an acute respiratory illness.22 A prior study examining HRQoL before and after hospitalization demonstrated that most children return to and/or surpass their baseline physical functioning by 1 month after hospital discharge.23
Our primary objective was to examine associations between several markers of social disadvantage, access to care, and child physical functioning before and after hospitalization for acute respiratory illness. Second, we aimed to understand if access to care (defined as perceived difficulty/delays getting care) acts as an independent predictor of improvement in physical functioning from baseline to follow-up and/or if it modifies the relationship between social disadvantage and improvement in physical functioning (Appendix Figure).
