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Making PROGRESS – Pediatric Emergencies and Healthcare Disparities 

February 1, 2024

Written by Jason Lesnick

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This systematic review and meta-analysis identified multiple social determinants of health that were related to increased utilization of pediatric ED (PED) services by children from racial minority and lower socioeconomic status (SES) groups.  

Social determinants of health apply to PED visits
This systematic review and meta-analysis of 58 observational studies from 1995 to 2022 included 17,275,090 children and 103,296,839 PED visits. 84% (49) of studies were performed in the USA; 34 studies were retrospective cohort studies; 23 were cross-sectional studies, and one study was a prospective cohort study. Researchers evaluated the association between social determinants of health and ED outcomes in pediatric patients.

Social determinants of health can be defined as the conditions in which people are born, grow, work, live and age; this study used the PROGRESS-Plus framework which includes: Place of residence, Race/ethnicity/culture/language, Occupation, Gender and sex, Religion, Education, Socioeconomic Status, and Social capital and networks. Plus refers to other factors associated with social adversity such as immigration. The reference group for the study included emergency users with a position of privilege in the PROGRESS factors for comparison. 

Outcomes of interest were ED utilization (visits and revisits), frequent ED use, ED wait times, ED length of stay (LOS), leaving against medical advice (AMA), leaving without being seen (LWBS), and admission status (which was further categorized into admit from index ED visit, admit from return ED visit, and discharge from ED). If there were at least two studies similar enough, a meta-analysis was also performed; data were only sufficient to meta-analyze for association between race/ethnicity and ED utilization and LWBS. All other social determinants of health data were summarized narratively. 

PED utilization varied by race/ethnicity – children identified as African Americans/Black compared to children identified as White had increased odds of using the PED in a pooled analysis of 3 studies showing a pooled OR 3.16 (95%CI 2.46-4.08). Children identified as Latino/Hispanic compared to children identified as White had increased PED use, with 7 studies reporting adjusted ORs ranging from 1.3 (95%CI 1.1-1.5) to 4.76 (95%CI 3.43-6.61). PED visit characteristics also had multiple observed differences – there was a decreased odds of hospitalization among Black and Hispanic children compared to White children in 6/7 studies, while 4/4 studies found wait times for Hispanic and non-Hispanic Black children were 26.1-33% and 14.2-27% longer compared to White children, respectively. PED LOS for Hispanic and Black children was shorter compared to White children in 3/5 studies: 176, 199, and 245 minutes, respectively.

PED utilization was associated with low SES measures, such as public insurance (21/23 studies; 10/11 studies with adjusted analysis; aOR range 1.22 (95%CI 1.06-1.39) to 3.18 (95%CI 2.75-3.67) and low income (9/14; 3/5 studies with adjusted analyses; aOR range 1.43 (95%CI 1.29-1.59) to 2.21 (95%CI 2.06-2.37). Interestingly, children without health insurance had higher odds of leaving AMA (8.9% vs 1.0%); aOR 2.37% (95%CI 1.88-2.96).  The authors postulate some of the observed differences could be due to limited health insurance or access to health care.

How will this change my practice?
This study is fascinating and I’d highly recommend at least viewing table 3 (which spans almost 2 pages and summarizes all of the results by social determinant). This study provides me with valuable data on how health disparities affect our pediatric patients in the ED and reinforces our position as society’s safety net where we, as individuals, can attempt to make up for the system’s failings while future policies are developed to help provide much needed systemic solutions.

Editor’s note: I included this study on JF because I noticed an increasingly large number on non-English speaking parents were bringing their children for care in the PED. This study confirms my experience with data. Although this shows some potential failings of our US healthcare system, it highlights the unique importance of the care we provide in the PED for our patients in need. ~Clay Smith

Source
Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies. Ann Emerg Med. Published online December 6, 2023. doi:10.1016/j.annemergmed.2023.10.010

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