SCCM Resource Library-37-The Association of Socioeconomic Status and Pediatric Sepsis Outcomes

Video Transcription

Good afternoon, my name is Kayla Brownder-Phelps, and I will be presenting on the Association of Socioeconomic Status and Pediatric Sepsis Outcomes.  Funding for this project was provided by the Michigan Medicine Department of Pediatric Diversity, Equity, and Inclusion Research Training Grant.  To begin, I'd like to quickly review what we know about how socioeconomic status impacts health outcomes.  The term social determinants of health has been defined as the conditions in which people are born, grow, live, work, and age.  It's very well established in both the medical and public health literature that social determinants  of health have a far greater impact on health outcomes compared to medical interventions. Social determinants of health include both individual and community-level factors.  Individual socioeconomic status includes variables such as one's individual income and education status.  Community socioeconomic characteristics include things such as neighborhood poverty and violence levels or access to healthcare and healthful foods.  What we know about socioeconomic status and pediatric sepsis, well, let's first start with what we know about adult sepsis disparities.  The literature is robust around adult sepsis disparities and include studies showing that individuals with lower income levels have increased 30-day mortality for septic ICU  patients and another study showing earlier readmission rate among survivors. Interestingly, when we look at neighborhood poverty rates for adult patients, these patients  living in neighborhoods with higher poverty rates have an increased bloodstream infection risk, higher sepsis mortality rate, and higher readmission rate.  Additionally, studies have shown an association between poverty and other pediatric disease states, including neonatal bacterial infections, asthma, migraine, and many others.  However, to date, there has been no published data specific to poverty and pediatric sepsis outcomes.  This led me to my research question, does socioeconomic status influence a child's sepsis-related mortality and morbidity?  To help answer this question, I'm using the National Readmission Database, known as NRD, from the Healthcare Costs and Utilization Project, which is from the Agency of Healthcare  Research and Quality, which is run by the Department of Health and Human Services. I'm looking at the years 2016 and 2017.  The NRD contains discharge data from 28 geographically dispersed states, accounting for 60% of the total U.S. resident population and 58.2% of all U.S. hospitalizations.  It is designed to be able to track patient readmissions in a given calendar year. Inclusion criteria for our study is children aged 0 to 18 hospitalized with severe sepsis.  An exclusion criteria includes any neonatal sepsis or pregnancy-related sepsis. To define severe sepsis, we're utilizing the Dombrowski sepsis criteria, which uses specific  ICD-10 codes to identify severe sepsis. We're also including admissions that have a concurrent ICD-10 codes for bacteremia and organ dysfunction.  I am using Stata15 for my data analysis.  The main exposure variable for the analysis is a patient's zip code-related income quartile. This is defined as the median household income for a patient's zip code.  For reference, the NRD income quartile cutoffs for 2016 and 2017 are shown here. Again, these quartiles reflect the estimated median household income of the residents in  a patient's zip code. The main outcome variables that we are analyzing include a patient's in-hospital mortality  rate for all patients diagnosed with severe sepsis, for hospital survivors, their length of stay, and the readmission rate at both 30 and 90 days.  When we look at the results of our study, I'll first start with some general patient characteristics.  We identified 10,130 severe sepsis hospitalizations for our patient cohort, which represented about 1% of all the pediatric hospitalizations in the NRD for those years.  The overall mortality rate for severe sepsis was 8.4%, which is consistent with previously published data.  We then looked at the distribution of patients that were hospitalized with severe sepsis per income quartile, and we found that 30% of our cohort lives in the zip codes in the  lowest medium income quartile, compared to only 17% of the patients living in the highest income quartile.  Interestingly, this trend is consistent for all the pediatric hospitalizations in the NRD database.  Diving deeper into the patient characteristics, we found three statistically significant characteristics I wanted to share.  First, patients in the lowest income quartile were younger, with a median age of 11 years and an interquartile range of 4 to 16 years, compared to their peers in the highest income  quartile, with a median age of 13 years and an interquartile range of 6 to 17 years. This was significant with a p-value less than 0.001.  Second, as we expect, patients in the lowest income quartile were more likely to have Medicaid insurance compared to their peers.  This was significant with a p-value of less than 0.001 as well.  Finally, we found that patients living in zip codes in the lowest income quartile were more likely to have a complex chronic condition compared to their peers in the highest income  quartile, and this was significant at a p-value of 0.03. The other patient characteristics that we analyzed included gender, APR-DRG severity  scores, and the number of organ failures present, and these were not found to be statistically significant.  When we look at our outcome variables, we find that there's no association between the mortality rate and the patient's income quartile.  The mortality rate for those in the lowest income quartile was about 8.6%, and those in the highest was about 7.6%.  However, when we look at our severe sepsis survivors and their hospital length of stay, we do find an association that was significant.  Those in the lowest income quartile had an average length of stay of 9 days with an interquartile  range of 5 to 20, whereas those in the highest had an average length of stay of 8 days with an interquartile range of 4 to 17.  And finally, we looked at readmission rates for the entire cohort and found that 19% were readmitted within 30 days and 30% were readmitted within 90 days.  However, there was no association between the readmission rates across the income quartiles. And so, in conclusion, we find that there's no association between in-hospital mortality  and ZIP Code-related income quartiles for pediatric patients hospitalized with severe sepsis.  However, for our severe sepsis survivors, pediatric patients living in the lowest income quartile were found to have a longer length of stay compared to those in the highest income  quartile. And while there is an association with length of stay, the readmission rates were the same across income quartiles.  I would like to thank my primary mentor, Dr. Aaron Carlton, as well as my other mentors and co-authors, Dr. Ryan Barbaro, Dr. Gary Fried, and Dr. Mary Dahmer, as well as the  University of Michigan's Pediatric DEI Committee for their support. Thank you all so much for your time and let me know if you have any questions.  Thank you.

Video Summary

The study aimed to determine if socioeconomic status (SES) affects the outcomes of pediatric sepsis. Using the National Readmission Database, the researchers analyzed data from over 10,000 pediatric sepsis hospitalizations. They found that there was no association between in-hospital mortality and SES. However, children from lower income neighborhoods had a longer length of stay compared to those from higher income neighborhoods. There was no difference in readmission rates across income quartiles. These findings highlight the impact of socioeconomic factors on pediatric sepsis outcomes and the need to address health disparities in vulnerable populations.

Asset Subtitle

Pediatrics, Sepsis, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Kayla Phelps

Introduction/Hypothesis: Among adults with severe sepsis, socioeconomic status (SES) is associated with significant health disparities, including higher mortality and readmission rate. In children, the association between SES and adverse health outcomes is known for bronchiolitis, asthma, and neonatal bacterial infections. However, the association of a child's SES on sepsis outcomes is not well understood, highlighting a knowledge gap for possible clinical and population based interventions. We hypothesize that children with lower SES will have higher mortality and longer length of stay (LOS) compared to their peers with higher SES.

Methods: Using the Nationwide Readmissions Database (2016/17), pediatric severe sepsis hospitalizations were identified by ICD-10 codes for severe sepsis/septic shock or by concurrent codes for sepsis and organ failure. ZIP Code related income quartiles estimate median household income of residents in the patient's ZIP Code, ranging from the lowest income quartile (Q1) (income $1 - 43,999) to the highest income quartile (Q4) (income $74,000+). We compared the rate of in-hospital mortality and LOS between income quartiles using chi-square analysis and ANOVA, respectively. Next, we compared outcomes between the lowest and highest income quartiles using chi-square and Wilcoxon rank sum.

Results: Among 1,048,470 pediatric hospitalization, we identified 10,130 (0.96%) severe sepsis hospitalization. There was no association between the rate of severe sepsis hospitalizations and income quartile. Overall, 851 (8.4%) of severe sepsis patients died during hospitalization. There were 3,140 (30.1%) hospitalizations in Q1, 2,759 (27.2%) in Q2, 2,357 (23.3%) in Q3, and 1,736 (17.1%) in Q4. Children in Q1 were younger (median age 11 years [IQR 4-16] vs 13 years [IQR 6-17] in Q4) and more likely to have Medicaid Insurance compared to peers in Q4 (73.8% vs 35.3%) (p<0.001). There was no association between income quartile and mortality (p=0.319). Of sepsis survivors, patients in Q1 had a longer LOS compared to those in Q4 (Median 9 days [IQR 5-20] vs 8 days [IQR 4-17]; p<0.001).

Conclusions: In children with severe sepsis, there was no difference in mortality rate by income quartile. However, children living in the lowest ZIP Code related income quartile had longer LOS compared to those in the highest.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Sepsis

Knowledge Level Advanced

Membership Level Select

Tag Scoring Systems

Tag Monitoring

Year 2021

Keywords

socioeconomic status

pediatric sepsis

length of stay

income neighborhoods

health disparities

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