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When Zip Codes Matter: The Hidden Forces Behind Pediatric Health Outcomes

January 27, 2025

How can a family adequately manage a diagnosis of Type 1 diabetes if they live in a food desert without reliable meals? How can they control asthma if their public housing has mold? How can they stay on a vaccination schedule if they do not have transportation to pediatrician appointments? As pediatric hospitalists, we must recognize that what may present like non-compliance is the work of more complex issues called social determinants of health.

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that, ultimately, affect their health outcomes. Many hospitals attempt small-scale interventions, such as providing gas vouchers and food pantries to those with hospitalized children. Because these individual strategies cannot address the underlying social and economic factors, research is shifting to a more community-wide focus.

Leveraging a 2022 study that found that children from lower income zip codes presented more often with complicated appendicitis, our authors sought to explore the relationship between neighborhood-level SDOH and healthcare usage as a whole. Because appendicitis is the most common acute pediatric surgical condition and can be classified as simple or complicated, it serves as a valuable indicator of potentially delayed access to surgical care. In this issue of Hospital Pediatrics, Ciuchta et al. hypothesized that patients with acute uncomplicated appendicitis (AUA) from lower opportunity neighborhoods would have increased healthcare utilization (10.1542/hpeds.2024-007937).

In this multicenter retrospective cohort study, they identified patients under 19 years old who were hospitalized through an emergency department at 52 different tertiary children's hospitals with a diagnosis of AUA between January 1, 2017, and February 20, 2022. Outcomes of interest were prolonged length of stay, defined as more than 3 days, related 30-day return visits, or both. The primary variable of interest was the Childhood Opportunity Index, or COI, a validated multi-dimensional composite variable that seeks to fully capture the inequitable distribution of opportunity across neighborhoods. It is composed of 29 indicators such as access to education, health resources, and economic and social opportunities.

The results demonstrated that children from neighborhoods with very low COI were more likely to have prolonged length of stay, return visits, or both, even when adjusting for sex, age, weight, and COVID-19 pandemic timeframes. These findings highlight the profound impact that SDOH have on patient outcomes. Prolonged length of stay leaves our patients more susceptible to hospital-acquired infections, not to mention the significant cost and financial strain on the parents. The authors also appreciate that even the smallest increase in length of stay puts a considerable strain on the already limited number of hospital beds that are available, particularly during the respiratory season.

This article acknowledges that the relationship between lower COI and increased healthcare utilization is complex, and likely points to a larger, more systemic interaction. But it also offers explanations as to why this relationship may exist, understanding that it will take future research to evaluate the impact of these disparities and successful interventions. 

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