The Child Opportunity Index 2.0 and Hospitalizations for Ambulatory Care Sensitive Conditions


BACKGROUND AND OBJECTIVES Hospitalizations for ambulatory care delicate situations (ACSCs) are considered avoidable with high-quality outpatient care. Morbidity associated to ACSCs has been related to socioeconomic contextual components, which don’t essentially seize the complicated pathways by which a baby’s atmosphere impacts well being outcomes. Our main goal was to check the affiliation between a multidimensional measure of neighborhood-level baby alternative and pediatric hospitalization charges for ACSCs throughout 2 metropolitan areas.

METHODS This was a retrospective population-based evaluation of ACSC hospitalizations inside the Kansas Metropolis and Cincinnati metropolitan areas from 2013 to 2018. Census tracts have been included if situated in a county the place Kids’s Mercy Kansas Metropolis or Cincinnati Kids’s Hospital Medical Middle had >80% market share of hospitalizations for youngsters <18 years. Our predictor was baby alternative as outlined by a composite index, the Baby Alternative Index 2.0. Our final result was hospitalization charges for Eight ACSCs.

RESULTS We included 604 943 kids inside 628 census tracts. There have been 26 977 complete ACSC hospitalizations (46 hospitalizations per 1000 kids; 95% confidence interval [CI]: 45.4–46.5). The hospitalization fee for all ACSCs revealed a stepwise discount from 79.9 per 1000 kids (95% CI: 78.1–81.7) in very low alternative tracts to 31.2 per 1000 kids (95% CI: 30.5–32.0) in very excessive alternative tracts (P < .001). This development was noticed throughout cities and diagnoses.

CONCLUSIONS Hyperlinks between ACSC hospitalizations and baby alternative lengthen throughout metropolitan areas. Focusing on interventions to lower-opportunity neighborhoods and enacting insurance policies that equitably bolster alternative might enhance baby well being outcomes, scale back inequities, and reduce well being care prices.

  • Abbreviations:
    ambulatory care delicate situation
    Cincinnati Kids’s Hospital Medical Middle
    confidence interval
    Kids’s Mercy Kansas Metropolis
    Baby Alternative Index
  • What’s Identified on This Topic:

    Hospitalizations for ambulatory care delicate situations (ACSCs) are considered avoidable with high-quality outpatient care. Morbidity associated to ACSCs has been related to socioeconomic contextual components, together with these captured within the Baby Alternative Index.

    What This Research Provides:

    Decrease measured neighborhood alternative was considerably related to greater charges of pediatric hospitalizations for ACSCs. This affiliation could also be generalizable throughout metropolitan areas. Focusing on interventions to lower-opportunity neighborhoods might enhance baby well being outcomes and reduce burdens on well being care techniques.

    Acute care use for ambulatory care delicate situations (ACSCs) is commonly used as a measure of outpatient well being care entry and high quality. A hospitalization occasion for an ACSC may characterize a missed alternative for prevention and a destructive expertise for a kid and his or her household. Such an occasion may additionally point out that high-quality outpatient care is both missing or inaccessible. But these doubtlessly preventable hospitalizations stay frequent. In pediatrics alone, they have been accountable for $Four billion in hospital expenses in 2006,1 which doesn’t embody the financial ramifications that hospitalization occasions can have for households and their communities, reminiscent of missed college or missed work.2,3

    Earlier work has revealed robust relationships between low socioeconomic standing or greater ranges of earnings inequality and elevated hospitalization charges for ACSCs at each household and group ranges.48 Though neighborhood poverty is predictive of doubtless preventable hospitalizations and different poor well being outcomes in kids,7,9,10 unidimensional measures, reminiscent of median family earnings or poverty fee, don’t totally seize the complicated and interrelated social determinants of well being driving this affiliation. Neighborhood context is multidimensional, influencing entry to care and well being outcomes by a number of distinct pathways. For instance, earlier analysis has linked pediatric bronchial asthma outcomes to totally different options of kids’s neighborhood environments, together with air air pollution, high quality of housing, entry to transportation, proximity to main care suppliers, and group financial assets.11 Every of those options relate to separate causal pathways that affect components reminiscent of danger of publicity to dangerous toxins (eg, mildew, air air pollution) and entry to protecting assets (eg, wealth, transportation, well being care). Specializing in a single pathway might underestimate the function neighborhoods play in shaping kids’s well being outcomes.

    Research of neighborhood results on kids’s well being can profit from conceptualizing neighborhood as a multidimensional context. That is very true for analyses of ACSC hospitalizations, that are unlikely to be defined by a single causal pathway. Earlier work has revealed the utility of composite indices in analyses of spatial inequalities in inhabitants well being.1216 Composite indices could also be extra sturdy to measurement issues that have an effect on unidimensional measures, might have higher predictive validity than their elements, and will higher seize racial and ethnic inequities in entry to neighborhood alternative.13,1618 They facilitate the measurement of associations between a number of interrelated neighborhood traits and outcomes, in addition to simplify comparisons throughout research and over time.1922

    Earlier work inside single metropolitan areas has linked the Baby Alternative Index (COI) 1.0, a multidimensional measure of neighborhood context, to elevated use of pressing care facilities and emergency departments for ACSCs in addition to greater hospitalization charges for bronchial asthma.2325 Conversely, residing in a higher-opportunity neighborhood might supply a protecting benefit for youngsters in households of low socioeconomic standing.26 Though the COI 1.Zero couldn’t be used to match cities, an up to date COI 2.Zero is comparable throughout all neighborhoods in the US.17,23,27 We leveraged this functionality to construct on earlier work and supply higher proof for a constant and generalizable affiliation between a multidimensional measure of neighborhood-level social context and well being. Our main goal was to check the affiliation between baby alternative, as outlined by an general COI 2.Zero rating, and pediatric hospitalization charges for ACSCs throughout 2 metropolitan areas. Our secondary goal was to check this identical affiliation through the use of knowledge from the COI 2.Zero training, well being and atmosphere, and social and financial domains.


    Research Design, Contributors, and Setting

    On this retrospective cross-sectional evaluation, we examined hospitalizations for ACSCs amongst kids <18 years of age inside the main service areas of Cincinnati Kids’s Hospital Medical Middle (CCHMC) and Kids’s Mercy Kansas Metropolis (CMKC) occurring from January 1, 2013, to December 31, 2018. Each CCHMC and CMKC are quaternary care, freestanding kids’s hospitals that dominate their native market share. That stated, to make sure accuracy of pediatric hospitalization charges and approximate population-level samples, we solely included hospitalization occasions originating from census tracts inside counties the place CCHMC or CMKC had >80% market share for pediatric hospitalizations (Hamilton County for CCHMC and Cass, Clay, Jackson, Johnson, and Platte Counties for CMKC). Hospitalizations have been included if the affected person had a sound dwelling handle that allowed for geocoding to a census tract the place COI 2.Zero measures might be assigned.


    The affected person’s dwelling handle hooked up to the hospitalization occasion allowed for geocoding of data to the census tract geography. This enabled linkage to COI 2.Zero knowledge in addition to further key census-available measures, together with baby inhabitants and demographics of kids inside the recognized census tract.28 Census tracts are small, comparatively everlasting statistical subdivisions of a county, every averaging ∼4000 residents.29 They have an inclination to align carefully with native conceptions of neighborhoods or suburbs; that is significantly true in each Better Cincinnati and Better Kansas Metropolis.

    COI 2.0

    Our main unbiased variable was baby alternative, as outlined by the 2015 general and domain-specific COI 2.Zero baby alternative ranges, for every included census tract within the Cincinnati and Kansas Metropolis metropolitan areas.17 The COI 2.Zero consists of 29 indicators spanning Three domains (training, well being and atmosphere, and social and financial). Contextual variables inside the COI embody entry to high-quality early childhood training and colleges, inexperienced house, wholesome meals, toxin-free environments, and socioeconomic assets (reminiscent of employment alternatives). To mix indicators right into a composite index, COI builders first standardized them utilizing the z rating transformation after which took a weighted common throughout indicator z scores inside every area to acquire common area z scores. The indicator-specific weights replicate how strongly every indicator predicts kids’s long-term well being and financial outcomes. The COI builders then mixed common area z scores and mixed them into an general rating utilizing an identical weighting method. They outlined baby alternative ranges by rating all neighborhoods in the US alongside their general and domain-specific common z scores and dividing them into 5 ordered teams, every containing 20% of the US baby inhabitants. These teams have been labeled very low, low, average, excessive, and really excessive alternative.


    Our main final result was the pediatric hospitalization fee on the census tract degree for ACSCs, each general and for particular diagnoses. The Company of Healthcare Analysis and High quality and former pediatric well being providers analysis outline ACSCs as situations which will keep away from hospitalization with well timed and efficient outpatient administration.5,30 Utilizing earlier work as a information,8,31,32 we recognized pediatric ACSCs mostly leading to hospitalization utilizing codes for particular All Affected person Refined Analysis Associated Teams. These included bronchial asthma, bronchiolitis, bacterial pneumonia, cellulitis, gastroenteritis and dehydration, diabetes mellitus with issues, epilepsy, and urinary tract an infection. Hospitalizations labeled as inpatient and commentary have been each included. We additional characterised included hospitalizations utilizing scientific and useful resource use knowledge from the Pediatric Well being Info System knowledge set, a deidentified administrative and billing database organized and distributed by the Kids’s Hospital Affiliation (Lenexa, KS).33


    We collected population-level demographic traits of included census tracts, together with age, intercourse, race (white, Black or African American, or different), and ethnicity (Hispanic or non-Hispanic).16 We collected these identical demographic traits on the affected person degree for hospitalization occasions, in addition to sort of insurance coverage (public, personal, or different). Scientific traits included the size of keep (in days), want for intensive care providers, and comorbid well being situations. Comorbidities have been stratified into Three classes: no persistent illness, presence of a noncomplex persistent illness, and presence of a posh persistent illness. To outline every class, we used the Company for Healthcare Analysis and High quality’s Power Situation Indicator to categorize Worldwide Classification of Illnesses, Ninth Revision, Scientific Modification and Worldwide Classification of Illnesses, 10th Revision, Scientific Modification hospital diagnoses as persistent or not persistent.34 Second, we filtered the checklist of persistent situations into complicated persistent situations and noncomplex persistent situations by making use of the Feudtner et al35 Worldwide Classification of Illnesses, Ninth Revision and Worldwide Classification of Illnesses, 10th Revision coding scheme.

    Statistical Evaluation

    We in contrast variations in population-level demographic traits of included census tracts throughout the COI 2.Zero ranges (very low to very excessive) utilizing Kruskal-Wallis checks. We used frequencies and percentages to explain demographic and scientific traits of the hospitalized sufferers and decided statistical significance with χ2 checks. To match charges of hospitalizations for ACSCs (all trigger and by analysis) throughout the 5 COI 2.Zero ranges, we used unadjusted Poisson regression fashions. All fashions have been examined for overdispersion and used an offset equal to the log of the kid inhabitants dimension in every census tract. We calculated doubtlessly avoidable hospitalizations for ACSCs by discovering the distinction in hospitalization charges between every COI 2.Zero group (ie, very low, low, average, and excessive) and the very excessive COI 2.Zero group after which multiplying by the inhabitants of kids within the respective COI 2.Zero group.

    P values of <.05 have been thought of statistically important. All analyses have been carried out through the use of SAS software program (model 9.4; SAS Institute, Inc, Cary, NC).

    The CCHMC Institutional Evaluate Board and the Workplace of Analysis Integrity at CMKC each evaluated this examine and independently deemed it to be exempt from additional assessment.


    Research Inhabitants: Census Tracts and Populations of Kids

    We included 604 943 kids inside 628 census tracts from the Cincinnati and Kansas Metropolis metropolitan areas (Desk 1). This included 222 (35.4%) census tracts and 187 626 (31.0%) kids from Better Cincinnati and 406 (64.6%) census tracts and 417 317 (69.0%) kids from Better Kansas Metropolis. Kids residing in included census tracts have been extra generally white (74.4%) and non-Hispanic (93.6%). Total, the distribution of census tracts throughout alternative ranges adopted a U-shaped distribution, through which tracts most frequently had both a really low (21.7%) or a really excessive (30.9%) alternative degree.

    TABLE 1

    Inhabitants-Stage Demographics for Included Census Tracts

    We noticed important racial variations between kids residing in very low and really excessive alternative census tracts. The vast majority of kids in very low alternative census tracts have been Black or African American (56.1%), whereas nearly all of kids in very excessive alternative census tracts have been white (88.8%). By way of ethnicity, there was a better proportion of Hispanic kids in very low in contrast with very excessive alternative census tracts (10.5% vs 4%). The age distribution skewed barely youthful in very low alternative census tracts.

    Kids Hospitalized for an ACSC

    There have been 20 331 distinctive kids hospitalized for an ACSC in the course of the examine interval, contributing a complete of 26 977 ACSC hospitalizations (Desk 2). These kids extra generally have been <5 years of age (62.3%), have been non-Hispanic white (52%), had public insurance coverage (53.5%), and didn’t have any persistent comorbidities (56.3%). The median size of keep was 2 days (interquartile vary 1–Three days), and seven.4% required admission to an ICU. The frequencies of every ACSC diagnostic group have been as follows: bronchiolitis, 27.3%; bronchial asthma, 25.8%; seizure, 12.1%; bacterial pneumonia, 9.7%; gastroenteritis and dehydration, 8.8%; cellulitis, 7.5%; urinary tract an infection, 4.7%; and diabetes mellitus with issues, 4.3%.

    TABLE 2

    Affected person-Stage Demographics for Included Hospitalizations (N = 26 977)

    Charges of Hospitalizations for ACSCs Throughout COI Strata

    Total, the hospitalization fee for all ACSCs was 46.Zero per 1000 kids (95% confidence interval [CI]: 45.4–46.5); 50.7 per 1000 kids (95% CI: 49.7–51.7) in Cincinnati and 42.6 per 1000 kids (95% CI: 42.0–43.2) in Kansas Metropolis. In mixture, hospitalization charges for all ACSCs revealed a stepwise discount from 79.9 per 1000 kids (95% CI: 78.1–81.7) in census tracts with very low alternative to 31.2 per 1000 kids (95% CI: 30.5–32.0) in census tracts with very excessive alternative (Desk 3). Almost similar parallel stepwise reductions in hospitalization charges for all ACSCs have been noticed when disaggregated by metropolis (Fig 1) or by COI area (Fig 2). Statistically important decreases in hospitalization charges have been noticed for all classes of ACSCs when evaluating very low with very excessive alternative census tracts (all P values < .001; Desk 3). This lower was largest for bronchial asthma, with a 5.5-fold discount in hospitalization charges from very low to very excessive alternative census tracts. Pneumonia and gastroenteritis and dehydration revealed the smallest lower, with a 1.6-fold discount.

    FIGURE 1
    FIGURE 1

    ACSC hospitalization fee by baby alternative degree in Kansas Metropolis and Cincinnati.

    FIGURE 2
    FIGURE 2

    ACSC hospitalization fee by COI area.

    TABLE 3

    ACSC Hospitalization Charges per 1000 Kids by Situation

    Burdens of Hospitalizations for ACSCs Related With the COI

    If hospitalization charges amongst census tracts from all alternative ranges have been lowered to the hospitalization fee of census tracts from the very excessive alternative degree, ∼778 (44.3%) fewer ACSC-related hospitalizations and 2416 (56%) fewer ACSC-related hospital days might have occurred in Cincinnati and Kansas Metropolis yearly.


    On this retrospective cross-sectional evaluation, we examined the affiliation between a multidimensional measure of neighborhood context, the COI 2.0, and pediatric hospitalizations for ACSCs in each Better Cincinnati and Better Kansas Metropolis. We discovered that decrease measured neighborhood alternative was considerably related to greater charges of pediatric hospitalizations for ACSCs. This affiliation was current for all Eight of the included pediatric ACSCs, with bronchial asthma having the strongest affiliation with alternative degree. When the three COI 2.Zero domains and the two included metropolitan areas have been examined individually, every development was just like the general outcomes. Our findings assist the speculation that neighborhoods with decrease alternative, as outlined by measures embedded inside the COI 2.0, are at greater danger for opposed inhabitants well being outcomes. Focusing on interventions to lower-opportunity neighborhoods and advocating for insurance policies that equitably bolster alternative might enhance baby well being outcomes, scale back health-related socioeconomic inequities, and reduce well being care prices.3639

    Our examine seems to verify earlier work utilizing the COI 1.Zero and gives additional perception into the affect that neighborhood situations have on baby well being and well being care use throughout the care continuum. We have been in a position to leverage the capabilities of the revised COI 2.Zero to look at 2 metropolitan areas concurrently. This novel method revealed that the affiliation between a complete measure of neighborhood social context and a well being final result, reminiscent of pediatric hospitalizations for ACSCs, could also be generalizable between cities. Our outcomes additionally revealed decrease alternative ranges and better ACSC hospitalization charges amongst Black or African American and Hispanic kids. This examine was not particularly designed to additional quantify beforehand described associations between structural racism, together with residential segregation, and well being inequities.40,41 That stated, our findings recommend that ramifications of such racism, as highlighted by the clear racial and ethnic disparities current throughout COI 2.Zero baby alternative ranges, continues to negatively have an effect on kids’s environment. This publicity seems to increase from their instructional, environmental, and socioeconomic alternative to their alternative to keep away from doubtlessly preventable hospitalizations.

    There was a rising motion within the discipline of pediatrics to display screen for and intervene to deal with sufferers’ social wants, reminiscent of housing, meals, and transportation. These efforts are more and more thought to be a central ingredient to advertise the well-being of kids and households.2022 Nonetheless, focusing solely on particular person wants falls in need of impacting community-level social determinants of well being, together with the neighborhoods into which kids are born and the place they develop up.42 An extended line of observational and, extra just lately, experimental research reveal that neighborhoods have sizeable long-term results on socioeconomic attainment, bodily well being, and psychological well-being.4346 Our outcomes reveal {that a} multidimensional measure of neighborhood situations just like the COI 2.Zero has vital prognostic worth that would inform patient- and community-level interventions (eg, medical-legal partnerships or dwelling evaluation and restore applications), public well being planning, and coverage.11,14,15

    One potential critique of a multidimensional measure just like the COI 2.Zero is that it doesn’t essentially level to a single issue with the best affect on well being outcomes and subsequently doesn’t recommend a single resolution. In actuality, the exterior forces affecting well being all through the life span don’t act in isolation. Though the element indicators of a composite index might be used to determine particular contextual components with higher affect, significant enhancements in neighborhood alternative and associated well being outcomes will most definitely require community-driven, multifaceted options to stimulate alternative in neighborhoods which have been uncared for by generational disinvestment in infrastructure, enterprise, training, and entry to providers. By together with neighborhood options from totally different domains, a composite index just like the COI 2.Zero gives a typical metric for cross-sector collaboration in assist of complete, community-focused interventions and system-level coverage change.36,47 The COI 2.Zero may additionally function a benchmark that might be used to watch the native affect of those investments, each towards different metropolitan areas and over time. The well being care sector can play a significant function on this work by supporting community-wide studying networks in analysis or high quality enchancment efforts, illustrating how interventions and insurance policies affecting alternative can enhance baby well being, and advocating that well being fairness be prioritized when key selections about useful resource allocation are made.

    Our examine did have limitations. First, we acknowledge that ACSCs haven’t been as constantly outlined in pediatric in contrast with grownup literature and are an imperfect measure of well being care entry on this inhabitants. Though the COI 2.Zero accounts for charges of medical health insurance protection, different dimensions of well being care accessibility and high quality went unmeasured and stay areas for future examine. Second, the COI 2.Zero is measured on the census tract degree, which doesn’t essentially align with how inhabitants of a metropolis outline their neighborhoods. To make use of the COI 2.Zero in planning or monitoring the impact of neighborhood-level interventions, it could be needed to acknowledge when these totally different geographic boundaries overlap and when they don’t. Third, though we solely included counties the place the kids’s hospital had a excessive market share for pediatric hospitalizations, it’s potential {that a} small variety of related hospitalizations may have been excluded if a baby have been admitted at one other hospital. Fourth, the two metropolitan areas included in our examine share sure geographical and demographic traits, together with an identical and important diploma of racial residential segregation, which can have contributed to the same traits we noticed in our outcomes. In different phrases, outcomes might differ in metropolitan areas with totally different demographic traits. Lastly, it’s potential that particular person affected person traits, which our population-based examine design couldn’t account for, might have contributed to hospitalization charges along with neighborhood context. The diploma to which patient- and population-level components differentially contribute to ACSCs warrants additional inquiry, reminiscent of using multilevel modeling to match the efficiency of patient- and neighborhood-level measures of alternative. Extra analysis may additionally mannequin the trajectory of ACSC hospitalizations or different well being care high quality measures over time.


    ACSC morbidity is disproportionately felt inside neighborhoods characterised by decrease instructional, environmental, and socioeconomic alternative, as measured by the COI 2.0. This relationship persists throughout metropolitan areas and for a various group of pediatric situations. Our outcomes recommend that well being care techniques and coverage makers fascinated by attaining higher, extra equitable outcomes ought to goal interventions to geographic areas with decrease alternative. The COI 2.0, a multidimensional measure of neighborhood context, seems to be one choice for benchmarking the interplay of neighborhood context and related well being outcomes, each over time and inside and between cities.


    • Tackle correspondence to Molly Ok. Krager, MD, Division of Pediatrics, Kids’s Mercy Kansas Metropolis, 2401 Gillham Rd, Kansas Metropolis, MO 64108. E-mail mkkrager{at}
    • Deidentified particular person participant knowledge is not going to be made obtainable.

    • FINANCIAL DISCLOSURE: The authors have indicated they haven’t any monetary relationships related to this text to reveal.

    • FUNDING: No exterior funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they haven’t any potential conflicts of curiosity to reveal.

    • COMPANION PAPER: A companion to this text could be discovered on-line at

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