Disparities Associated with Sepsis Mortality in Critically Ill Children

Abstract

Disparities in health care related to socioeconomic status and race/ethnicity are well documented in adult and neonatal sepsis, but they are less characterized in the critically ill pediatric population. This study investigated whether socioeconomic status and/or race/ethnicity is associated with mortality among children treated for sepsis in the pediatric intensive care unit (PICU). A retrospective cohort study was conducted using information from 48 children's hospitals included in the Pediatric Health Information System database. We included visits by children ≤ 21 years with All Patients Refined Diagnosis-Related Groups (APR-DRG) diagnosis codes of septicemia and disseminated infections that resulted in PICU admission from 2010 to 2016. Multivariable logistic regression was used to measure the effect of race/ethnicity and socioeconomic status (insurance status and median household income for zip code) on mortality after adjustment for age, gender, illness severity, and presence of complex chronic condition. Among the 14,276 patients with sepsis, the mortality rate was 6.8%. In multivariable analysis, socioeconomic status, but not race/ethnicity, was associated with mortality. In comparison to privately insured children, nonprivately insured children had increased odds of mortality (public: adjusted odds ratio [aOR]: 1.2 [1.0, 1.5]; uninsured: aOR: 2.1 [1.2, 3.7]). Similarly, children living in zip codes with the lowest quartile of annual household income had higher odds of mortality than those in the highest quartile (aOR: 1.5 [1.0, 2.2]). These data suggest the presence of socioeconomic, but not racial/ethnic, disparities in mortality among children treated for sepsis. Further research is warranted to understand why such differences exist and how they may be addressed.

Keywords

pediatrics - intensive care - socioeconomic status - race - health disparities

Note

The study was completed while the author was affiliated with Children's National; however, the current corresponding address is Children's Hospital of Philadelphia.

Publication History

Received: 06 September 2020

Accepted: 04 November 2020

Article published online:
26 December 2020

• References

• 1 Balamuth F, Weiss SL, Neuman MI. et al. Pediatric severe sepsis in U.S. children's hospitals. Pediatr Crit Care Med 2014; 15 (09) 798-805
• 2 Czaja AS, Zimmerman JJ, Nathens AB. Readmission and late mortality after pediatric severe sepsis. Pediatrics 2009; 123 (03) 849-857
• 3 Ruth A, McCracken CE, Fortenberry JD, Hall M, Simon HK, Hebbar KB. Pediatric severe sepsis: current trends and outcomes from the Pediatric Health Information Systems database. Pediatr Crit Care Med 2014; 15 (09) 828-838
• 4 Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002
• 5 Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348 (16) 1546-1554
• 6 Barnato AE, Alexander SL, Linde-Zwirble WT, Angus DC. Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics. Am J Respir Crit Care Med 2008; 177 (03) 279-284
• 7 Mayr FB, Yende S, Linde-Zwirble WT. et al. Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis. JAMA 2010; 303 (24) 2495-2503
• 8 Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med 2002; 347 (20) 1585-1592
• 9 Baghdadi JD, Wong M, Comulada WS, Uslan DZ. Lack of insurance as a barrier to care in sepsis: a retrospective cohort study. J Crit Care 2018; 46: 134-138
• 10 Galiatsatos P, Brigham EP, Pietri J. et al. The effect of community socioeconomic status on sepsis-attributable mortality. J Crit Care 2018; 46: 129-133
• 11 Epstein D, Wong CF, Khemani RG. et al. Race/ethnicity is not associated with mortality in the PICU. Pediatrics 2011; 127 (03) e588-e597
• 12 Falcone Jr RA, Martin C, Brown RL, Garcia VF. Despite overall low pediatric head injury mortality, disparities exist between races. J Pediatr Surg 2008; 43 (10) 1858-1864
• 13 Furth SL, Garg PP, Neu AM, Hwang W, Fivush BA, Powe NR. Racial differences in access to the kidney transplant waiting list for children and adolescents with end-stage renal disease. Pediatrics 2000; 106 (04) 756-761
• 14 Omoloja A, Stolfi A, Mitsnefes M. Racial differences in pediatric renal transplantation-24-year single center experience. J Natl Med Assoc 2006; 98 (02) 154-157
• 15 Centers for Disease Control and Prevention (CDC). Racial disparities in diabetes mortality among persons aged 1-19 years--United States, 1979-2004. MMWR Morb Mortal Wkly Rep 2007; 56 (45) 1184-1187
• 16 Willi SM, Miller KM, DiMeglio LA. et al; T1D Exchange Clinic Network. Racial-ethnic disparities in management and outcomes among children with type 1 diabetes. Pediatrics 2015; 135 (03) 424-434
• 17 Forno E, Celedón JC. Health disparities in asthma. New York, NY: American Thoracic Society; 2012
• 18 Gupta RS, Carrión-Carire V, Weiss KB. The widening black/white gap in asthma hospitalizations and mortality. J Allergy Clin Immunol 2006; 117 (02) 351-358
• 19 Bohanon FJ, Nunez Lopez O, Adhikari D. et al. Race, income and insurance status affect neonatal sepsis mortality and healthcare resource utilization. Pediatr Infect Dis J 2018; 37 (07) e178-e184
• 20 Weston EJ, Pondo T, Lewis MM. et al. The burden of invasive early-onset neonatal sepsis in the United States, 2005-2008. Pediatr Infect Dis J 2011; 30 (11) 937-941
• 21 Hsu BS, Meyer BD, Lakhani SA. Financial, resource utilization and mortality impacts of teaching hospital status on pediatric patients admitted for sepsis. Pediatr Infect Dis J 2017; 36 (08) 712-719
• 22 Gluck E, Nguyen HB, Yalamanchili K. et al. Real-world use of procalcitonin and other biomarkers among sepsis hospitalizations in the United States: a retrospective, observational study. PLoS One 2018; 13 (10) e0205924
• 23 O'Connor GT, Quinton HB, Kneeland T. et al. Median household income and mortality rate in cystic fibrosis. Pediatrics 2003; 111 (4 Pt 1): e333-e339
• 24 Colvin JD, Zaniletti I, Fieldston ES. et al. Socioeconomic status and in-hospital pediatric mortality. Pediatrics 2013; 131 (01) e182-e190
• 25 Bettenhausen JL, Colvin JD, Berry JG. et al. Association of income inequality with pediatric hospitalizations for ambulatory care–sensitive conditions. JAMA Pediatr 2017; 171 (06) e170322-e170322
• 26 Cassidy LD, Lambropoulos D, Enters J, Gourlay D, Farahzad M, Lal DR. Health disparities analysis of critically ill pediatric trauma patients in Milwaukee, Wisconsin. J Am Coll Surg 2013; 217 (02) 233-239
• 27 Putnam LR, Tsao K, Nguyen HT, Kellagher CM, Lally KP, Austin MT. The impact of socioeconomic status on appendiceal perforation in pediatric appendicitis. J Pediatr 2016; 170: 156-60.e1
• 28 Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997. Pediatrics 2000; 106 (1 Pt 2): 205-209
• 29 Muldoon JH. Structure and performance of different DRG classification systems for neonatal medicine. Pediatrics 1999; 103 (01, Suppl E): 302-318
• 30 Lopez AM, Tilford JM, Anand KJ. et al. Variation in pediatric intensive care therapies and outcomes by race, gender, and insurance status. Pediatr Crit Care Med 2006; 7 (01) 2-6
• 31 Goodwin AJ, Nadig NR, McElligott JT, Simpson KN, Ford DW. Where you live matters: the impact of place of residence on severe sepsis incidence and mortality. Chest 2016; 150 (04) 829-836
• 32 Cohen S, Doyle WJ, Turner RB, Alper CM, Skoner DP. Childhood socioeconomic status and host resistance to infectious illness in adulthood. Psychosom Med 2004; 66 (04) 553-558
• 33 Zorrilla EP, Luborsky L, McKay JR. et al. The relationship of depression and stressors to immunological assays: a meta-analytic review. Brain Behav Immun 2001; 15 (03) 199-226
• 34 Dowd JB, Haan MN, Blythe L, Moore K, Aiello AE. Socioeconomic gradients in immune response to latent infection. Am J Epidemiol 2008; 167 (01) 112-120
• 35 Kumar G, Taneja A, Majumdar T, Jacobs ER, Whittle J, Nanchal R. Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators. The association of lacking insurance with outcomes of severe sepsis: retrospective analysis of an administrative database*. Crit Care Med 2014; 42 (03) 583-591
• 36 Rush B, Wiskar K, Celi LA. et al. Association of household income level and in-hospital mortality in patients with sepsis: a nationwide retrospective cohort analysis. J Intensive Care Med 2018; 33 (10) 551-556
• 37 Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health 2006; 96 (12) 2113-2121
• 38 Jha AK, Orav EJ, Epstein AM. Low-quality, high-cost hospitals, mainly in South, care for sharply higher shares of elderly black, Hispanic, and Medicaid patients. Health Aff (Millwood) 2011; 30 (10) 1904-1911
• 39 Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic status and risk for substandard medical care. JAMA 1992; 268 (17) 2383-2387
• 40 Rapoport J, Gehlbach S, Lemeshow S, Teres D. Resource utilization among intensive care patients. Managed care vs traditional insurance. Arch Intern Med 1992; 152 (11) 2207-2212
• 41 Raman J, Johnson TJ, Hayes K, Balamuth F. Racial differences in sepsis recognition in the emergency department. Pediatrics 2019; 144 (04) e20190348