Screening for Social Determinants of Health in the Pediatric Intensive Care Unit

INTRODUCTION

In the United States (US), more than 100,000 deaths annually are linked with adverse social determinants of health (SDoH), many of which are preventable with access to supportive resources.¹ SDoH are the economic, political, and environmental systems that affect a person’s capacity to live a healthy life.² Key SDoH include socioeconomic status, education, neighborhood and physical environment, employment, social support networks, and access to health care. Differences in individual, family, and neighborhood SDoH are primary drivers of health disparities among US children and are exacerbated by inequitable distribution of societal resources, and discriminatory and exclusionary public policies.^3–5 Racial and ethnic minority groups have been especially affected by these inequities. Black children have higher death rates than White children across all age groups; in fact, all minority US children, including Black, Latino, Asian, Pacific Islander, American Indian, have worse health indices compared with their White peers.^5–7 With racial and ethnic diversity among US children growing, identifying, understanding, and eliminating differential health outcomes becomes increasingly important.⁸

In the next 10 years, an estimated 1 million US children will require critical care services.⁹ Given the emerging evidence that SDoH negatively affect children across the continuum of critical illness, placing them at risk for higher illness severity, higher hospital utilization, and challenges in posthospital recovery, it is imperative that we understand and address the equity gaps in pediatric critical care and outcomes.¹⁰ To meet the standards of health care quality set forth by the National Academies of Medicine and adopted by the Agency for Healthcare Quality, the pediatric critical care community must ensure that care we deliver is equitable.¹¹ In this article, we provide a rationale for universal SDoH screening and resource provision in the pediatric intensive care unit (PICU) as a key first step to the implementation of a clinical and research agenda to understand and mitigate health disparities affecting critically ill children. Our objectives therefore are 2-fold: (1) summarize SDoH impact on pediatric critical illness and outcomes to provide justification for routine screening and resource provision and (2) highlight important practical aspects of social screening that should be considered before implementation in the PICU setting.

IMPACT OF SOCIAL DETERMINANTS OF HEALTH ON PEDIATRIC CRITICAL ILLNESS

SDoH affect people throughout the life course through varied, complex, and interrelated mechanisms, and their influence on health make routine screening in both the outpatient and inpatient settings imperative. Multicenter PICU database studies show that Hispanic, Black, publicly insured, and low-income children have higher illness severity, rates of PICU admission, in-hospital mortality, readmission rates, and poorer functional outcomes than children who are White, commercially insured, or come from higher-income families.^10,12–17 Routine screening and associated data collection can contribute to our mechanistic understanding of how SDoH influence pediatric critical illness. SDoH are categorized by the Centers for Disease Control and Prevention into 5 domains: economic stability, community and built environment, education access and quality, health care access and quality, and social and community context (Fig. 1).¹⁸ Below is a brief summary of what is currently known about the relationship between these SDoH domains and pediatric critical illness and injury.

Fig. 1.

Impact of universal social screening on risk and outcomes of critical illness in children. (SDOH Domains adapted from Artiga S and Hinton E. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Kaiser Family Foundation via https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/. Accessed November 2015; with permission.)

Health Care Access and Quality

This domain includes factors that influence a person’s access to health care, an individual’s health literacy, and existence of differential health-care quality based on social factors, including race or ethnicity. The evidence for inequality in the American healthcare system is overwhelming and sobering. Among high-income countries, the US ranks among the lowest in objective measures of health-care access.¹⁹ Low health literacy, defined as difficulties in understanding and navigating the health-care system, may affect half of all US adults.²⁰ The National Academies of Medicine landmark publication Unequal Treatment describes pervasive differences in health-care quality between White and minority race populations.²¹ Socioeconomic and racial differences in rates of health insurance and access to preventive care, subspecialty care (including critical care), and pharmacy resources may place children, especially those with chronic health-care needs, at higher risk for critical illness and associated high hospital utilization.^22–25 Disturbingly, race-based differences in in-hospital and surgical-related mortality exist.^26–28 Single-center PICU studies suggest that publicly insured families and families of minority race or ethnicity experience differential care compared with White and privately insured families. This includes more instances of failed communication, higher rate of conflicts with the health care team, and higher rates of discrimination.^29–32

Economic Stability

Economic stability has a profound influence on health due to its direct relationship with basic human needs. This domain includes poverty, employment, food security, and housing stability. Income inequality is closely linked to health inequality, and the US has one of the highest child poverty rates among all developed nations.³³ Observational studies suggest low-income children are at higher risk for adverse outcomes related to critical illness including in-hospital mortality, longer hospital lengths of stay, and more frequent hospital readmissions.^12,34 All poverty-related SDoH can be considered adverse childhood exposures, which predisposes a child to toxic stress. The eco-bio-developmental model of childhood health posits that repeated exposures to toxic stress can alter immune/inflammatory responses, providing a potential mechanistic explanation for the unfavorable hospital outcomes frequently observed in low-income children.³⁵ Household poverty is also associated with substandard living conditions and lower use of preventative care, which may predispose children to higher risk of critical disease and higher severity of illness on presentation.^12,14 Low-income families are also overburdened by out-of-pocket expenses related to their child’s hospitalization and required follow-up care.³⁶ In addition, children and their families may also experience financial effects after critical illness, including inability of caregivers to return to work, which could hinder recovery and potentiate post-PICU morbidity.³⁷

Community and Built Environment

There is increasing evidence that where one lives affects health status, quality of life, and even life expectancy.³⁸ In addition to child-level and family-level SDoH, the neighborhood context also contributes to disparities in a child’s risk of illness, hospital course, and recovery. Availability of public transportation, pharmacies and doctors, employment and educational opportunities, healthy foods, green space, and exposure to violence, crime, and pollutants are neighborhood factors potentially placing children at risk for higher severity of illness and need for intensive care services.^39,40 Disadvantaged neighborhoods may lack resources needed to make the physical and built environment conducive for optimal health. This situation leaves families underequipped to support children recovering from critical illness or children with chronic health issues, thus increasing their risk for acute exacerbations and acute care use. Furthermore, neighborhood measures of relative socioeconomic disadvantage have been linked to worse PICU outcomes, such as longer length of stay, increased need for mechanical ventilation, and increased mortality.^12,34,41 Higher PICU admission rates and severity of illness scores have been observed in neighborhoods with higher rates of persons living in poverty.¹⁴ Children residing in lower socioeconomic areas seem to be at higher risk of critical illness and traumatic injury, and Black children residing in these areas have lower rates of bystander out-of-hospital resuscitation for cardiac arrests, compared with children living in more socioeconomically advantaged areas.^10,42 Neighborhoods with high rates of PICU readmissions for asthma have high social vulnerability, and higher exposure to environmental toxins such as industrial pollutants, airborne microparticles, and higher ozone concentrations.⁴³ Understanding the resources and limitations of the child’s neighborhood may inform discharge planning to reduce the risk of adverse outcomes and readmission following an episode of critical illness.

Education Access and Quality

This domain includes access to early childhood education, overall educational attainment, and literacy.¹⁸ There is strong evidence linking education and health; increasing educational attainment is associated with healthier behaviors, longer life expectancy, and overall well-being throughout the life course.^44,45 In resource-limited countries, higher maternal education is linked to lower child mortality but the association between parental education and risk of severe illness and death, outside the neonatal period, among US children is not well described.^46–48 Additionally, a severe illness or injury during childhood may have a profound influence on cognitive outcomes and school performance, and this relationship may be exacerbated by SDoH.⁴⁹ As educational attainment is linked to long-term health outcomes, income stability, and wealth generation, preventing and responding to disparities in educational outcomes is crucially important for child survivors of critical illness.⁵⁰

Social and Community Context

Studies routinely demonstrate a protective effect of social support, social cohesion, and community engagement on overall health and well-being.^51,52 Accordingly, increasing community and social support is a major objective of the Healthy People 2030 initiative.⁵³ There are limited studies on the relationship between community and social context and the risk and outcomes of critical illness in children, in part due to challenges in operationalizing the definition of “social outcome.”⁵⁴

SOCIAL DETERMINANTS OF HEALTH SCREENING IN THE PEDIATRIC INTENSIVE CARE UNIT

To date, there are no studies directly linking routine social risk screening to improved health outcomes in hospitalized children. In the outpatient setting, 2 randomized studies conducted in primary care clinics associated implementation of social risk screening with improved child health, operationalized as a decrease in documented medical abuse and neglect in one study, and an improvement in parent-reported child health in another study.^55,56 Despite lack of empiric evidence, routine screening is universally endorsed by professional societies and federal agencies, and the Centers for Medicare and Medicaid Services recently issued guidance to state Medicaid directors to encourage universal screening as part of an overall shift from fee-for-service reimbursement models to value-based care.⁵⁷ These organizations recognize that investment in social health has the potential to improve individual and population-level health and lead to significant cost savings to the health care sector.⁵⁸ We believe that routine, standardized screening for the SDoH is imperative for identification and mitigation of health disparities among children admitted to the PICU. We think that social screening, as part of a larger effort to achieve pediatric health equity, has the potential to improve the health of individuals and populations, and is required if we are to successfully provide just, ethical, and equitable care for critically ill children.

Screening for Social Determinants of Health May Improve the Health of Individuals

There are several potential benefits to families if routine social risk screening is implemented in an intensive care setting. First, family-centered care requires effective patient–provider communication, cultural humility and competence, acknowledgment of implicit biases, knowledge of health literacy, and an understanding of a family’s lived experiences, cultural and religious beliefs, and goals of care—all of which can be facilitated by routine screening for SDoH.^59,60 Second, understanding if families struggle with food security, housing stability, adequate health-care access, and fragile support systems can allow PICU providers to contextualize a family’s ability to navigate their child’s hospitalization.⁶¹ Third, for families with identified needs, social resources that may be available within the health-care system can be mobilized.⁶² Fourth, the PICU encounter offers an opportunity to identify social needs in children previously not screened by their primary care providers. Although most pediatricians acknowledge its importance, few screen.⁶³ Finally, screening can identify family and community factors that could help or hinder recovery after critical illness. Up to 70% of children develop a new morbidity following the PICU stay, and it is increasingly recognized that the development of postintensive care syndrome is related to both illness factors and the social milieu, including SDoH.^64,65 In-depth assessments of family social needs during the acute phase of critical illness are necessary for provision of optimal anticipatory guidance to families in preparation for recovery after critical illness.

Screening for Social Determinants of Health May Improve the Health of Populations

Section 4302 (Understanding Health Disparities: Data Collection and Analysis) of the Affordable Care Act outlines minimum data-collection standards for race, ethnicity, sex, language, and disabilities for all Department of Health and Human Services programs and surveys.⁶⁶ The Institute for Healthcare Improvement and the Agency for Healthcare Research and Quality have independently stated systematic collection of the aforementioned demographic data, as well as universal screening for SDoH, is necessary for identification, understanding, and elimination of the root causes of health disparities.^67–69 As part of local and multicenter collaborative patient safety initiatives, PICUs routinely perform quality improvement projects that rely on accurate data collection for stratification and dissemination of quality performance. Examples of improvement targets include health-care–acquired conditions, patient handoffs, antibiotic and blood culture stewardship, and pediatric severe sepsis.^70–73 To date, there are no large-scale databases with SDoH data for critically ill children, which could inform health equity projects.⁷⁴ The Virtual Pediatric Systems (VPS, LLC http://www.myvps.org/) database includes more than 1 million PICU admissions from more than 130 centers and was developed to improve PICU care delivery through quality improvement and research initiatives.⁷⁵ The Pediatric Health Information System (Children’s Hospital Association, Lenexa, KS) is an administrative database including resource utilization data from more than 45 tertiary centers associated with the Children’s Hospital Association. Both datasets were designed, in part, to drive health care improvement through benchmarking, quality improvement, and research initiatives, although arguably they currently lack the data necessary to fully identify inequitable health-care delivery.^75,76 For example, race and ethnicity was not a “mandatory” data field in VPS until 2021, and neither registry collects data on family-level social determinants.

Collection of demographic and social determinant data should be standardized, and when possible, captured in institutional electronic health records (EHRs) and multiinstitutional research and administrative databases. This would allow PICUs to stratify outcome data, including mortality, length of stay, hospital-acquired conditions, and readmissions-a necessary first step in the effort to achieve health equity. Social screening can promote better understanding of the unique needs of the PICU patient population, and spur hospital-wide initiatives aimed to improve population health, such as financial navigation programs⁷⁷ for medical-related financial stress, hospital-based food pantries,⁶² and housing interventions⁷⁸ for food and housing insecurity. Finally, adding a social risk “score” alongside an index of mortality or illness severity score (eg, pediatric logistic organ dysfunction-2 [PELOD-2] score) could highlight those patients who may have a more difficult PICU course, or those who will be at higher risk for mortality or require intensive post-PICU follow-up to optimize chances for good health outcomes. Furthermore, there is a critical need for empirical research on SDoH screening in the PICU, and implemented interventions aimed at reducing identified inequalities or disparities. Any research program, however, must collect and report on race and ethnicity, recognizing these labels as social constructs. Data must be collected with adequate rigor to allow sufficient evaluation of race and ethnicity as contributors to the research outcomes of interest, within a racial equity framework.⁷⁹

As evidence builds for place-based disparities in risk of pediatric critical illness, collecting neighborhood-level data can facilitate identification of “hot spots” amenable to public health interventions collaboratively developed by health systems, communities, and governments.⁸⁰ The influence of neighborhood on child health is complex, with research revealing multiple, distinct, but overlapping relationships between a child’s environment and its health. For example, unfavorable asthma outcomes have independently been linked to poor housing quality, high levels of air pollution, challenges in access to preventative care and pharmacies, and lack of transportation.⁸¹ Identifying communities conferring high levels of risk with composite markers of neighborhood health, such as the publicly available Child Opportunity Index, could allow researchers to measure associations between multidimensional, interrelated neighborhood characteristics and health outcomes.⁸² The Breathe Easy at Home program in Boston and the Collaboration to Lessen Environmental Asthma Risks at Cincinnati Children’s Hospital are examples of neighborhood-based programs through which disparities in asthma outcomes were identified and mitigated through health system-community collaborations.^83,84 Furthermore, incorporating composite neighborhood risk scores into the EHR could facilitate a deeper understanding of disease risk and challenges with recovery, allowing clinicians the opportunity to tailor their anticipatory guidance and therapeutic choices for individual patients, and support the development of relationships with community partnerships to affect population health outcomes.⁸¹

Screening in an Acute Care Setting

In the last decade, the American Academy of Pediatrics (AAP) has recognized the importance of poverty and related social determinants to child health and wellbeing by releasing 4 policy statements.^85–88 Although most pediatricians think that routine screening for social needs is important, few think that implementation is feasible.⁸⁹ In outpatient clinics, time constraints, lack of staff and referral resources, workflow disruptions, and inadequate reimbursement policies contribute to overall low rates of screening.⁹⁰ Subspecialty pediatricians and hospital-based pediatricians report similar barriers to screening.^90,91 Although the AAP makes no specific recommendations surrounding SDoH screening in the acute care setting, in developing an interdisciplinary approach to mitigating social risk, the Academy emphasizes the benefits of the medical home, medical-legal partnerships, health system-community partnerships, and care coordination, all of which can—and should—be facilitated by hospital-based care teams.⁸⁵ A PICU admission offers a unique opportunity for SDoH screening; however, to our knowledge, no implementation framework or validated tool exists for SDoH screening in the PICU.⁹² High staff-to-patient ratios, parent and guardian presence, and the availability of social workers and case workers at many tertiary care PICUs make screening for SDoH and resource referral potentially feasible. When planning the implementation of SDoH screening and data collection, the following should be considered:

1. Educate providers on the impact of SDoH and the relevance of screening. All staff members involved in the direct care of PICU patients should be educated on influences SDoH have on the continuum of critical illness and the influence of screening, with the goal of improving their understanding of the structures, practices, policies and processes that contribute to health inequities, and the importance of addressing unmet social needs of patients and their families.

2. All families should undergo screening. Universal screening, as part of the intake process, will minimize a family from feeling targeted, identify needs in families who may otherwise not ask for help if not screened, allows staff members to gain expertise in screening through repetition, and provides an accurate population-based picture of the social needs of the PICU population.

3. Employ a strength-based approach. Each family has unique strengths, and most thrive despite adversity. These strengths should be recognized and celebrated through strength-based screening, which provides families with opportunities and experiences to build their protective factors, such as parental resilience and social support.⁹³ This approach will improve participation and engagement of patients and families.⁹⁴ Providers should avoid screening approaches that may create a sense of shame, or that place blame for structural socio-economic conditions outside of families’ control.^93,94

4. Staff should be trained to screen. Families may be reticent to answer sensitive questions, and those who conduct social needs screening with families must be trained and/or have experience in the core competencies of trauma-informed and culturally effective care.⁹³

5. SDoH needs identified from screening should be paired with appropriate referrals and resources. SDoH screening followed by linkage to appropriate resources within the hospital and/or community has been associated with improved child health outcomes.⁵⁵ Hospitals have successfully partnered with community organizations to establish food pantries, offer transportation resources, and provide housing vouchers to families in need. A compendium of local and national resources, such as the United Way’s national 2–1-1⁹⁵ program, can be created and made readily available to share with families in need.

6. Build upon existing systems. To successfully implement widespread screening and intervention processes across PICUs, it will be important to leverage existing systems and ensure collaboration occur across multidisciplinary teams, both within and across institutions. Integrating SDoH screening tools into the EHR available to different care providers at transition points in a patient’s care will facilitate resource provision and rapid analysis of social risk as a factor that may directly or indirectly affect the patient’s critical care trajectory and can also prevent families from undergoing repeated screening within the same institution.⁹⁵ Consideration should be made for EHR documentation of identified social needs, using the International Classification of Diseases, 10th revision “miscellaneous Z codes” for the purposes of case management and follow-up, risk-adjustment modeling, and for inclusion in future reimbursement initiatives.^96–98

7. Develop valid and reliable screening tools. Few screening tools currently used in pediatric practice have undergone validity and reliability testing.⁹⁹ Ensuring the tools are accurate and inform care for intended patient populations should be a priority area of research in this area.

Screening for the Social Determinants of Health is Required for Just and Equitable Health Care

As a group, critical care clinicians provide ethically sound care and are well-versed in maximizing patient good (beneficence) and minimizing patient harm (nonmaleficence). Ethical health-care delivery must also incorporate principles of justice that affect individual-level and population-level care. As a core principle of biomedical ethics, achieving justice in health care requires that (1) individuals have an equal right to basic needs and liberties and (2) when resources are limited, decisions related to resource distribution ensure those individuals with the greatest need are benefited, and all individuals have equal opportunity to obtain resources.¹⁰⁰ Addressing health-related social risks through SDoH screening can ensure that basic health needs are met, whereas assessing for and responding to structural barriers or systemic inequities will promote justice.

Identification of structural barriers to health may uncover social needs that we are unable to provide immediate resources for thus creating moral dilemma for both health-care providers and patients. However, building a narrative for resources or policy changes to address these concerns is critical to ultimately reducing their impact. Collaborating with medical legal partnerships can be an effective mechanism both to address individual and systemic level social risks through advocacy-recent research suggests that this collaborative approach can lead to improved health outcomes.¹⁰¹

SUMMARY

Disparities in the risk, care, and outcomes of critical illness in children are prevalent and unacceptable. Widespread implementation of SDoH screening in our PICUs is an important first step in addressing the causes of these disparities. Beyond increasing our understanding of the mechanisms that potentiate disparities, SDoH screening will facilitate identification of vulnerable families and children likely to benefit from linkage to resources within the hospital and community. Furthermore, information gathered through screening will enable the development of effective interventions and policies aimed at ensuring distribution of resources to those with the greatest need—a core element of just and equitable health care.

KEY POINTS.

• SDoH impact children along the continuum of critical illness, making screening an important first step in improving clinical care delivery through quality improvement and research initiatives.

• A child’s admission to a PICU offers a unique opportunity for social screening. High staff to patient ratios, parent presence, and availability of social workers at tertiary centers can make screening feasible.

• Widespread implementation of SDoH screening across PICUs has the potential to increase our understanding of mechanisms that potentiate health disparities, facilitate linkage of vulnerable families to social resources, and enable development of public health interventions.

CLINICS CARE POINTS.

• Multicenter cohort studies have demonstrated the existence of disparities in illness severity, rates of PICU admission, in-hospital mortality, readmission rates, and long-term functional outcomes based on race, ethnicity, insurance status, and socioeconomic status.

• Implementation of universal SDoH screening in a PICU should include appropriate staff training, employ a strengths-based approach, and be paired with appropriate hospital-based and community-based resource referral.

• Development of a valid and reliable screening tools for use in the PICU setting should be a priority of future research.