Social determinants of health and emergency and hospital use by children with chronic disease

OBJECTIVES: To evaluate the association between caregiver-reported social determinants of health (SDOH) and emergency department (ED) visits and hospitalizations by children with chronic disease. METHODS: This was a nested retrospective cohort study (December 2015 to May 2017) of children (0-18 years) receiving Supplemental Security Income and Medicaid enrolled in a case management program. Caregiver assessments were coded for 4 SDOH: food insecurity, housing insecurity, caregiver health concerns, and safety concerns. Multivariable hurdle Poisson regression was used to assess the association between SDOH with ED and hospital use for 1 year, adjusting for age, sex, and race and ethnicity. ED use was also adjusted for medical complexity. RESULTS: A total of 226 children were included. Patients were 9.1 years old (SD: 4.9), 60% male, and 30% Hispanic. At least 1 SDOH was reported by 59% of caregivers, including food insecurity (37%), housing insecurity (23%), caregiver health concerns (18%), and safety concerns (11%). Half of patients had an ED visit (55%) (mean: 1.5 per year [SD: 2.4]), and 20% were hospitalized (mean: 0.4 per year [SD: 1.1]). Previously unaddressed food insecurity was associated with increased ED use in the subsequent year (odds ratio: 3.43 [1.17-10.05]). Among those who had $1 ED visit, the annualized ED rate was higher in patients with a previously unaddressed housing insecurity (rate ratio: 1.55 [1.14-2.09]) or a safety concern (rate ratio: 2.04 [1.41-2.96]). CONCLUSIONS: Over half of caregivers of children with chronic disease enrolled in a case management program reported an SDOH insecurity or concern. Patients with previously unaddressed food insecurity had higher ED rates but not hospitalization rates.