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
The results of the effect modification analysis demonstrated that the association between social disadvantage and change in PedsQL scores from baseline to follow-up was not significantly different based on a child’s ability to access care. In our stratified analysis, difficulty/delays accessing care added to baseline disparities at each social disadvantage level but did not alter how perceptions of physical functioning change over time. Therefore, physical functioning improvements may rely more heavily on the type of care received within the hospital setting as opposed to accessing care in the first place. However, future studies should examine whether access to high-quality care instead of simply measuring difficulty/delays in accessing care would lead to different results. Access to a comprehensive medical home may be a better measure to assess for effect modification because it measures features beyond access to care, such as continuity, comprehensiveness, communication, and coordination of outpatient care.29-31
If additional studies find evidence that the nature of hospital care, an intensive 24/7 care setting, differentially benefits patients with higher social disadvantage markers (particularly those with =/> 3 markers and chronic illness), this would support the need for systematic screening for social disadvantages or difficulty/delays accessing care in the inpatient setting. Systematic screening could help ensure all patients who may benefit from additional services, such as intensive, culturally tailored education or connections to food, housing, or financial services, will in fact receive them, which may lead to sustained reductions in health disparities.20 Further research into pairing validated screening tools with proven interventions is needed.32
This study has additional limitations aside from those noted above. First, we did not reassess perceived or actual access to care after hospitalization, which may have allowed for analyses to examine access to care as a mediator between social disadvantage and lower child physical functioning. Second, this study included only English- and Spanish-speaking patients and families. Patients with less commonly spoken languages may experience more difficulty accessing or navigating the health system, which may further impact access to care and HRQoL. Third, we had a considerable amount of missing social disadvantage marker data (mainly income); however, our sensitivity analyses did not result in significantly different or clinically meaningful differences in our findings. Insurance status is more feasible to obtain from administrative data and could serve as a proxy for income or as an additional social disadvantage marker in future studies. Finally, we could calculate illness severity only for patients with asthma based on the available data; therefore, we could not adequately control for illness severity across all conditions.CONCLUSIONS
Social disadvantage was associated with lower child physical functioning before hospitalization, but differences were not apparent after hospitalization for children with acute respiratory illness. Caregiver-perceived difficulty/delays accessing care was found to be an additional predictor of lower physical functioning at baseline but did not significantly alter the association between social disadvantage and improvement in physical functioning over time. Further studies are needed to understand how hospital care may differentially impact child physical functioning for patients with higher social disadvantage makers in order to sustain improvements in HRQoL disparities.
