Poor children have less easy access to pediatric critical care services, and this matters

It’s long been known poverty among children is highly associated with poorer overall health outcomes. A similar thing occurs in adults, but in children the effects are particularly striking. A recent study in Pediatric Critical Care Medicine highlights a new aspect of this issue — distance from a PICU. The authors examined the relationship between neighborhood socioeconomic status, race, and distance to PICUs throughout the United States. Using a data set with fairly precise neighborhood granularity, they explored this phenomenon nationally and within urban and rural cohorts. The data set they used is called the Area Deprivation Index, which is derived from 17 measures of education, employment, housing, and poverty. In this composite measure, the most advantaged neighborhoods return ADI’s of 1 and the most deprived neighborhoods return ADI’s of 10. The specific question they tried to answer was if children living in areas of higher ADIs were located further away from a PICU than children in more affluent areas. This is important because it’s known transport time matters in outcomes, as does the need to transfer a child from a hospital without a PICU to one with a PICU.

The results are quite interesting — and quite striking to me:

As you can see, there is a consistent linear relationship between ADI and distance to a PICU, from 15 miles in the more affluent places to 40-50 miles in poorer neighborhoods; the distance to pediatric critical care services decreases with affluence throughout the United States. Unlike adult critical care services, where a similar relationship is driven mainly by rural versus urban residential patterns, this was true in pediatrics across urban/suburban and rural regions. This phenomenon is fueled by the physical concentration of pediatric critical care services and by the growing number of suburban poor.

These observations carry implications well beyond the care of pediatric critical illness; it also impacts more ordinary pediatric care. In the United States, pediatric hospital care has become increasingly regionalized, with even very common medical conditions, such as abdominal pain and uncomplicated seizures, now being much more likely to be referred to specialized centers. I have seen this steady development over my own 40 plus years of PICU practice, and have written about it in the past here. Since a reasonable marker of these referral centers is the presence of a PICU, distance to the nearest PICU is also a measure of distance to solutions for a wide range of pediatric medical problems. Distance matters. As the authors conclude:

In summary, we have observed a strongly linear relationship between neighborhood affluence and distance to pediatric critical care services. As a result, children in the least affluent communities need to travel nearly three times as far to reach intensive care as those in the most affluent. This carries important implications for healthcare access and may contribute to income-related disparities in some pediatric health outcomes.