523 - Association between Childhood Opportunity Index and Clinical Management of Pediatric Pneumonia

Publication Number: 523.3571

Jillian Cotter, University of Colorado & Children's Hospital Colorado, Aurora, CO, United States; Matthew Hall, Children's Hospital Association, Lenexa, KS, United States; Adam Hersh, University of Utah School of Medicine, Salt Lake City, UT, United States; Daniel Shapiro, University of California, San Francisco, School of Medicine, San Francisco, CA, United States; Susan Lipsett, Boston Children's Hospital/Harvard Medical School, Boston, MA, United States; Jeffrey Gerber, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Jonathan Cogen, Seattle Children's, Seattle, WA, United States; Thomas V.. Brogan, University of Washington School of Medicine, Seattle, WA, United States; Anne J.. Blaschke, University of Utah School of Medicine, Salt Lake City, UT, United States; Lilliam Ambroggio, Children's Hospital Colorado, Aurora, CO, United States; Mark Neuman, Boston Children's Hospital, Boston, MA, United States

Background: While disparities in antibiotic prescribing have been established in the outpatient setting, very few studies have included hospitalized children. Furthermore, few studies have evaluated disparities in the management of hospitalized children with pneumonia, one of the most common and costly diagnoses. Due to uncertainty about which patients with pneumonia need diagnostic testing and antibiotics, national practice patterns are highly variable and susceptible to unconscious bias and systemic inequities.

Objective: We evaluated the association between Childhood Opportunity Index (COI), a robust measure of disparities based on 29 different neighborhood opportunities that help children develop in a healthy manner, and antibiotic and diagnostic utilization for children hospitalized with pneumonia.

Design/Methods: This retrospective cohort study included children hospitalized with pneumonia at one of 43 hospitals in the Pediatric Health Information System (2022-2023). We evaluated the association between the lowest and highest COI quintiles (low representing low opportunity neighborhoods) and antibiotic and diagnostic utilization using generalized estimating equations adjusted for potential confounders (i.e., age, insurance, Hospitalization Resource Intensity Score for Kids, a quantitative severity of illness marker, concurrent diagnosis of bronchiolitis and asthma). Antibiotic utilization included any antibiotics, and among those who received antibiotics - broad-spectrum antibiotics, intravenous antibiotics, and macrolide antibiotics. Diagnostic utilization included blood tests, chest radiographs, and respiratory pathogen testing.

Results: Of 27,867 hospitalized children, 21% were in the very low COI quintile and 22% in the very high COI quintile. Unadjusted outcomes by COI quintile are displayed in Figure 1. Children in the very low COI quintile had greater odds of receiving any antibiotics (adjusted Odds Ratio [aOR] 1.72, 95% CI: 1.09, 2.71), broader-spectrum antibiotics (aOR 1.35; 95% CI: 1.1, 1.64), and intravenous antibiotics (aOR 1.41, 95% CI: 1.07, 1.84) compared to those in the very high COI quintile (Table 1, Figure 2). There were no differences in diagnostic utilization by COI.

Conclusion(s): Children residing in the lowest opportunity neighborhoods had greater odds of receiving antibiotics, broader-spectrum antibiotics, and intravenous antibiotics for pneumonia. Given that antibiotics are frequently overused in pneumonia and unnecessary antibiotics, particularly more intense therapy, increase potential harms, this risk may be disproportionally impacting children already with less opportunity.

Figure 1. Unadjusted (A) Antibiotic Utilization Outcomes and (B) Diagnostic Utilization Outcomes by COI Quintile for Children Hospitalized with Pneumonia


Table 1. Adjusted ORs for Antibiotic and Diagnostic Utilization Outcomes by COI Quintile
CBC, complete blood cell count; IV, intravenous
* p-values <0.05 compared with Very High COI reference group (n=6,195)
1 among children who received antibiotics for typical CAP (n=21,656 or 77% of overall cohort)

Figure 2. Forest Plot of Adjusted Antibiotic and Diagnostic Utilization Outcomes by COI Quintile for Children Hospitalized with Pneumonia


Figure 1. Unadjusted (A) Antibiotic Utilization Outcomes and (B) Diagnostic Utilization Outcomes by COI Quintile for Children Hospitalized with Pneumonia


Table 1. Adjusted ORs for Antibiotic and Diagnostic Utilization Outcomes by COI Quintile
CBC, complete blood cell count; IV, intravenous
* p-values <0.05 compared with Very High COI reference group (n=6,195)
1 among children who received antibiotics for typical CAP (n=21,656 or 77% of overall cohort)

Figure 2. Forest Plot of Adjusted Antibiotic and Diagnostic Utilization Outcomes by COI Quintile for Children Hospitalized with Pneumonia