Geospatial Analysis of Neighborhood Level Social Determinants of Health in Children with Acute Respiratory Failure Requiring Mechanical Ventilation and their Causal Association with All-Cause Hospital Mortality Restricted; Files Only

Abstract

Poverty, racial bias, and disparities are linked to adverse health outcomes for children in the United States. The social vulnerability and child opportunity indices are composite measures of the social, economic, education, health, and environmental qualities that impact human health for every U.S. census tract. We performed a cross-sectional study of children admitted to pediatric intensive care units for acute respiratory failure requiring invasive mechanical ventilation at two urban free-standing children’s hospitals in Atlanta, Georgia. Residential addresses were geocoded and spatially joined to census tracts. Neighborhood hot spots were defined as census tracts where admissions were at the 90^th percentile or greater per 1,000 children. We compare composite measures of social vulnerability and child opportunity by neighborhood hot spot status. We used multivariate logistic regression and mediation analysis to model whether a low child opportunity index was associated with all-cause hospital mortality. Residential addresses were geocoded and spatially joined to census tracts for 3,514 children. Composite measures of social vulnerability and child opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots (n = 340, 9.7%) versus non-hot spots. Hot spots were associated with a worse overall social vulnerability index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a worse overall child opportunity index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower child opportunity were associated with longer total median duration of hospital days per 1000 children in a census tract. Children living in low opportunity neighborhoods had an age-adjusted odds of dying that was 1.29 (95% CI: 1.03, 1.60) times that of children in high opportunity neighborhoods with 26% of the effect mediated by hospital location. The detailed metrics of validated, ranked scores that identify opportunity gaps may inform interventions designed to increase opportunity and reduce mortality for critically ill children. Interventions that address neighborhood child opportunity are needed to decrease disparities in intensive care admissions for acute respiratory failure requiring mechanical ventilation.

Table of Contents

Chapter 1. Geospatial Analysis and the Social Determinants of Health in Pediatric Critical Illness 1

Introduction 1

Neighborhood, Population-Level versus Individual-Level Factors 4

Geospatial Visualization and Analysis Methods 5

The Area Deprivation Index 7

Other Indices of Neighborhood Material Deprivation 8

The Social Vulnerability Index 8

The Child Opportunity Index 2.0 (COI) 10

Implications of Using a Neighborhood Opportunity Index in Pediatric Critical Care Medicine 12

Study Motivation, Objectives, and Hypotheses 13

Chapter 2. Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated with Pediatric Intensive Care Use for Acute Respiratory Failure Requiring Mechanical Ventilation 15

Introduction 15

Methods 16

Study Setting and Design 16

Ethics Statement 16

Geocoding, Mapping, and Census Tract Data 16

Hot spot Identification 17

Outcome Measures 17

Statistical analyses 18

Results 18

Study population 18

Social Vulnerability Index is higher in children residing in neighborhood hot spots 22

Child Opportunity Index is lower in children residing in neighborhood hot spots 23

Outcomes 28

Discussion 29

Chapter 3. The Child Opportunity Index is Associated with Disparities in All-Cause Hospital Death of Mechanically Ventilated Children Across Georgia 36

Introduction 36

Methods 37

Study Design, Setting, and Participants 37

Ethics Statement 38

Geocoding, Mapping, and Census Tract Data 38

Variables 38

Statistical Methods 40

Mediation Analysis 41

Sensitivity and Subgroup Analyses 41

Results 42

Study Population 42

All-Cause Hospital Mortality by COI Exposure 45

Mediation Analysis 47

Sensitivity and Subgroup Analyses for All-cause Hospital Mortality by COI Exposure 48

Multivariable Analysis of Prolonged Hospitalization by COI Exposure 51

Discussion 51

Bibliography 58

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research
Degree	M.S.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Medicine and Surgery Geography
Keyword	mechanical ventilation acute respiratory failure social determinants of health social vulnerability index pediatric intensive care child opportunity index geocoding
Committee Chair / Thesis Advisor	Anne M. Fitzpatrick, Emory University
Committee Members	Jordan A. Kempker, Emory University Sara C. Auld, Emory University

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