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
One possibility is that caregivers and/or patients with more social disadvantage markers are more influenced by context when assessing physical functioning. This could lead to an underestimation of functioning when asked to recall baseline physical functioning at the time of acute illness and overestimation of functioning after recovery from an illness. This possibility is consistent with a form of response bias, extreme response tendencies, in which lower socioeconomic subgroups tend to choose the more extreme response options of a scale.28 In the absence of longitudinal assessments of HRQoL across the care continuum over time, disentangling whether these differences are due to response bias or representative of true changes in physical functioning remains challenging.
Given that disparities in physical functioning at baseline were consistent with prior evidence, another possibility is that hospitalization provided an opportunity to address gaps in access and quality that may have existed for patients with social disadvantage in the community setting. The 24/7 nature of hospital care, usually from a multidisciplinary team of providers, lends itself to opportunities to receive intensive education related to the current illness or to address other health concerns that parents or providers identify during a hospital stay. For example, consistent and repetitive asthma education may be more beneficial to patients and families with more social disadvantage markers. The fact that the association between social disadvantage markers and change in physical functioning scores were greater for patients with asthma supports this reasoning. Hospital care may also provide an opportunity to address other unmet medical needs or psychosocial needs by providing efficient access to subspecialists, social workers, or interpreters. Further research is needed to elucidate whether families received additional services in the hospital setting that were not available to them prior to hospitalization, such as consistent interpreter use, social work engagement, and subspecialty/community referrals. Further studies should also determine whether the provision of equitable medical and social support services is associated with improvements in HRQoL disparities. Additionally, studies should examine whether physical functioning improvements following hospitalization return to baseline levels after a longer period of time and, if so, how we might sustain these reductions in HRQoL disparities. Such studies may identify tangible targets and interventions to reduce disparities in HRQoL for these children.
This study highlights the importance of assessing for difficulty/delays accessing care in addition to social disadvantage markers, as this was also a significant predictor of lower child physical functioning. Differences in PedsQL scores between those who reported any versus no difficulty/delays accessing care were more pronounced at baseline compared with follow-up. A possible reason for these findings is that receiving hospital care may have addressed some access to care issues that were present in the outpatient setting, which resulted in improved perceptions of physical functioning. For example, hospital care may mitigate access to care barriers such as limited after-hours clinic appointments, language barriers, and lack of insurance, thus providing some patients with an alternative pathway to address their health concerns. Alternatively, hospital staff may assist families in scheduling follow-up appointments with the patient’s primary medical home after discharge, which potentially reduced some access to care barriers. The question is whether these disparities will widen once again after a longer follow-up period if families continue facing barriers to accessing needed care in the outpatient setting.
