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
METHODS
Study Design and Population
This study was nested within a multicenter, prospective cohort study of children who were hospitalized for asthma, bronchiolitis, or pneumonia between July 2014 and June 2016 at one of five children’s hospitals in the Pediatric Research in Inpatient Settings Network.24
We approached families for study participation within 72 hours of admission to the hospital using a standard protocol. Patients and their caregivers were eligible to participate in the study if the patient was 2 weeks to 16 years old and if the primary caregiver’s preferred language for medical communication was either English or Spanish. Patients with chronic medical conditions (except asthma), with moderate to severe developmental delay, with a history of prematurity <32 weeks, or who received care in the intensive care unit were excluded. Patients could only participate in the study once.
The study team set out to enroll an even number of patients across all three conditions. If a patient’s discharge diagnosis differed from their admission diagnosis (eg, from bronchiolitis to pneumonia), discharge diagnosis was used for condition group assignment. If the discharge diagnosis was not one of these three respiratory conditions, we excluded the patient from further analysis.
Data Collection
We collected data using two surveys. The first survey was administered within 72 hours of admission. This survey asked questions related to (1) caregiver-reported markers of social disadvantage, (2) caregiver perceptions of access to care, and (3) caregiver- and patient-reported assessments of physical functioning. The second survey was administered within 2 to 8 weeks after the patient’s discharge and included a second assessment of physical functioning.
Social Disadvantage
Patients were considered to have a marker of social disadvantage if their caregiver reported (1) being of non-White race and/or Hispanic ethnicity, (2) primarily speaking a language other than English at home and not speaking English very well (ie, limited English proficiency), (3) attaining at most a high school or equivalent degree, or (4) having a =/<$30,000 annual household income.
Access to Care
We used the following survey item from the 2009-2010 National Survey of Children with Special Health Care Needs25 to measure caregiver perceptions of access to care: “In the last six months, did you have any difficulties or delays getting care for your child because there were waiting lists, backlogs, or other problems getting an appointment?” We narrowed the original assessment time frame from 12 months to 6 months to provide a more proximal assessment of access in relation to the hospitalization.
Child Physical Functioning
We assessed child physical functioning using the physical functioning domain of the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and PedsQL Infant Scales, which have been validated for use in the inpatient setting.22 Caregivers completed one of these scales based on their child’s age. Assenting patients 8 to 16 years old completed the self-report PedsQL 4.0 Generic Core Scales instrument. When completing the first PedsQL survey, caregivers and patients reflected on the previous month before their child (or they) became ill to obtain a baseline physical functioning assessment.23 When completing the second PedsQL survey, caregivers and patients reflected on the past 7 days to obtain a follow-up assessment.
