Markers of Social Disadvantage and Hospital Quality of Care for Pediatric Respiratory Illness

Background: Understanding disparities in pediatric quality of care may reveal opportunities for targeted improvement. Objective: To examine associations between social disadvantage (SD) markers and performance on the Pediatric Respiratory Illness Measurement System (PRIMES) quality indicators during hospitalization for acute respiratory illness. Methods: This study was nested within a prospective cohort study of children aged 2 weeks-16 years who received emergency department or inpatient care at 5 tertiary children’s hospitals from 7/1/14-6/30/16 for one of four respiratory illnesses: asthma, bronchiolitis, croup, or pneumonia. We collected four parent-reported SD markers (minority race/ethnicity, limited English proficiency, low education level, and low income) at the time of admission and an additional marker (public insurance) from the Pediatric Health Information System. Data for PRIMES quality of care indicators were abstracted via medical record review, and indicators were classified as underuse (appropriate care processes or interventions that should be provided) or overuse (unnecessary care processes or interventions that should not be provided). Indicators were used to generate 3 PRIMES composite scores scaled from 0-100: an overall score that included all indicators, an underuse score, and an overuse score. Higher scores indicated better adherence to the quality indicators (i.e. patient received more appropriate care or less inappropriate care). We examined associations between the number of SD markers and PRIMES scores using multivariate linear regression models. Models were adjusted for patient age, sex, medical complexity, respiratory condition, secondhand smoke exposure, and hospital site. Results: 1,806 patients met inclusion criteria, and 1274 patients (70%) had >1 SD marker. In adjusted analyses, patients with >3 SD markers had a 1.2 point (95% CI: 0.1, 2.4) higher PRIMES overall composite score and a 2.2 point (95% CI: 0.3, 4.2) higher PRIMES overuse composite score (i.e. received less inappropriate care) compared with patients who had no SD markers (Table 1). We did not detect a significant association between SD markers and PRIMES underuse composite scores or a consistent correlation between the number of SD markers and PRIMES composite score performance. In analysis stratified by respiratory condition, asthma patients with >1 SD markers had higher overall and underuse PRIMES composite scores (Table 2). Croup was excluded from stratified models due to insufficient power for analysis. Conclusions: Overall, children who had markers of SD received less inappropriate care for their respiratory illnesses. In patients with asthma, the presence of SD markers was associated with the provision of more appropriate care and higher quality of care overall. These findings suggest that children with markers of SD may receive higher quality care for inpatient respiratory conditions than their counterparts. Further research is needed to understand how parental care preferences or standardized clinical pathways might affect this association.