The pediatric hospitalist serves the unique role of caring for children during acute illnesses. However, in reality we often discover that the health of our patients has less to do with their health care and more to do with their life beyond the walls of the hospital. In 2016, the American Academy of Pediatrics (AAP) published a Pediatrics Policy Report on Poverty, which highlighted the role of poverty in impacting the health of children in the US. It found that approximately 37% of all children live in poverty for some period during their childhood. The report advocated for utilization of screening tools by pediatricians to identify and offer resources to families in need. In this month’s Hospital Pediatrics, Kopsombut et al. investigate the characteristics and acute care metrics of patients with positive social determinants of health (SDOH) screening assessments admitted to a freestanding children’s hospital (10.1542/hpeds.2023-007434).
The authors conducted a retrospective cohort study in which members of the pediatric hospital medicine care team (attendings, residents, medical students etc.) administered a 14-question SDOH screener to families of patients admitted or transferred to the hospital medicine service. Overall, 2,454 patients (65%) successfully completed screenings. Of those, 662 (27%) of the encounters identified 1 need. When evaluating what patient characteristics were associated with a positive screening, the authors found the following characteristics increased the likelihood: primary language other than English or Spanish (OR 4.3, 95% CI 1.7-10.5), primary language of Spanish (OR 1.4, 95% CI 1.1-1.9), patients identifying as Black (OR 1.7, 1.2-2.3), and families with patients in the complex care registry (OR 1.5, 95% CI 1.1-1.9). Positive screening was not associated with increased length of stay, readmission, or 2-year emergency department or acute care utilization. While these findings may offer insight into identifying at-risk populations, it is important to consider the implications of targeting screenings toward specific sociodemographic groups of people. In their commentary in this month’s Hospital Pediatrics, Masciale et al. argue that targeted screening approaches for social needs may perpetuate stereotypes and implicit biases and lead to feelings of non-belonging and alienation among those screened (10.1542/hpeds.2024-008069).
When assessing the feasibility of screening, Kopsombut et al. found that the odds of receiving a screening were not significantly different based on primary language (English compared to Spanish), insurance type, inpatient versus observation stays, or filing time. Significant odds of not being screened included primary language other than English or Spanish (OR 0.42, 95% CI 0.21-0.82), inclusion in the complex care registry (OR 0.8, 95% CI 0.65-0.98), extreme severity of illness (OR 0.64, 95% CI 0.41-0.999), and extreme risk of mortality (OR 0.28, 95% CI 0.14-0.56). These disparities highlight the real possibility that screening tools may inadvertently exclude vulnerable populations. As mentioned by Masciale et al., quality improvement efforts may sometimes have the unintended consequence of worsening disparities if there is greater uptake among populations with better outcomes at baseline.
Ultimately, this study demonstrates that pediatric hospitalists can effectively conduct large-scale social risk screenings in the inpatient setting. It also underscores the importance of implementing equitable screening practices to ensure that patients are neither unfairly targeted nor excluded based on their risk factors. As we continue to evolve in our roles as pediatric hospitalists, integrating social screenings into clinical practice will be vital for fostering a more equitable and effective healthcare system, ultimately enhancing the well-being of our patients and their families.
