Influence of Socioeconomic Context on the Rehospitalization Rates of Infants Born Preterm

doi:10.1016/j.jpeds.2017.08.001

The Journal of Pediatrics

Volume 190, November 2017, Pages 174-179.e1

https://doi.org/10.1016/j.jpeds.2017.08.001 Get rights and content

Objective

To investigate the impact of social inequalities on the risk of rehospitalization in the first year after discharge from the neonatal unit in a population of preterm-born children.

Study design

Preterm infants were included if they were born between 2006 and 2013 at ≤32 + 6 weeks of gestation and who received follow-up in a French regional medical network with a high level of healthcare. Socioeconomic context was estimated using a neighborhood-based socioeconomic deprivation index. Univariate and logistic regression analyses were used to identify risk factors associated with rehospitalization.

Results

For the 2325 children, the mean gestational age was 29 ± 2 weeks and the mean birth weight was 1315 ± 395 g. In the first year, 22% were rehospitalized (n = 589); respiratory diseases were the primary cause (44%). The multiple rehospitalization rate was 18%. Multivariable analysis showed that living in the most deprived neighborhoods (socioeconomic deprivation index of 5) was associated with overall rehospitalization (OR, 2.2; 95% CI, 1.5-3.6; P <.001), and multiple rehospitalizations (OR, 2.5; 95% CI, 1.2-4.9; P <.01); with socioeconomic deprivation index of 1 (least deprived) as reference. Deprivation was associated with all causes of hospitalization. Female sex (P <.001) and living in an urban area (P = .001) were protective factors.

Conclusions

Despite regional routine follow-up for all children, rehospitalization after very preterm birth was higher for children living in deprived neighborhoods. Families' social circumstances need to be considered when evaluating the health consequences of very preterm birth.

Section snippets

Methods

This cohort study analyzed prospectively acquired perinatal and infant follow-up data collected in the western part of the Provence-Alpes-Côte-d'Azur region (West-PACA) by the medical network known as the Naître et Devenir-Mediterranée Network (the NaDeM Network). The NaDeM Network is registered with the French data protection authority for clinical research (Commission Nationale de l'Informatique et des Libertés or CNIL, No. 1460797). The study was approved by the local institutional ethics

Results

During the study period, 3719 preterm infants with GA of <32 + 6 weeks were born in the West-PACA area and survived to the neonatal period; 3140 infants were eligible after exclusion of infants whose parents did not reside in the West-PACA area (n = 579). Exclusions from the study (refusal of consent, congenital anomalies, inadequate residential address, family moved out of the area, lost to follow-up, and sudden infant death syndrome) are shown in Figure 1 (available at www.jpeds.com). The

Discussion

This study showed that children who were born preterm and lived in an area of socioeconomic deprivation had a significantly higher risk of being rehospitalized within the first year of life than those who lived in less socioeconomically deprived areas. This association was also observed for all causes of rehospitalization. Although this vulnerable population of children received routine follow-up by a large medical network (NaDeM) in France, where there is extensive welfare and coverage for

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Citation Excerpt :
BPD was defined as the need for oxygen or ventilator support (including high-flow nasal cannula therapy) at 36 weeks postmenstrual age. Infants with valid family addresses, those with no severe congenital anomalies, and those who received follow-up care from a regional medical network based in the west of the Provence–Alpes–Côte d’Azur (PACA) region, the Naître et Devenir−Mediterranée (NaDeM) Network, up to 1 year after discharge from the neonatal unit were eligible for inclusion.17 Among infants who were born and living in the region, approximately 82% received care from the network for up to age 1 year during the study period.
To investigate the impact of neighborhood conditions on respiratory-related hospital admissions in the first year after discharge from the neonatal unit in a population of infants born very preterm with bronchopulmonary dysplasia (BPD).
Very preterm infants (gestational age <33 weeks) who had BPD at 36 weeks postconceptional age and who received follow-up in a French regional medical network were included. Socioeconomic context was estimated using a neighborhood-based Socioeconomic Deprivation Index. Poisson regression analysis was used to identify risk factors associated with rehospitalization.
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Disadvantaged neighborhoods adversely impact early respiratory outcomes in infants born very preterm with BPD. The social context should be considered in routine follow-up care of children born preterm. Further studies investigating the underlying mechanisms are warranted for implementing preventive strategies.
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The strengths of this work include a longitudinal study of NICU graduates using geocoding to examine the impact of neighborhood risk on ED use, analyses that adjusted for environmental, psychosocial, and medical risk factors, and findings that justify using neighborhood risk to impact policy and protocols to improve outcomes for high-risk infants. We acknowledge that living in a high-risk neighborhood in Rhode Island and Southeastern Massachusetts may differ with living in a high-risk neighborhood in other parts of the country; however, given what is measured with the index (high prevalence of sociodemographic and housing characteristics known to be associated with poor health outcomes), we would expect the overall findings to be generalizable to other areas of the country.8,14-22,27 Limitations include the characteristics of our cohort; 100% of the families received enhanced transition home services which may have led to an underestimate of neighborhood impact and ED use rates.

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: The authors declare no conflicts of interest.

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Original ArticlesInfluence of Socioeconomic Context on the Rehospitalization Rates of Infants Born Preterm

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Soc Sci Med

Soc Sci Med

First year of life medication use and hospital admission rates: premature compared with term infants

J Pediatr

Effects of gestational age at birth on health outcomes at 3 and 5 years of age: population based cohort study

BMJ

Gestational age, birth weight, and risk of respiratory hospital admission in childhood

Pediatrics

Association of gestational age at birth with reasons for subsequent hospitalisation: 18 years of follow-up in a Western Australian population study

PLoS ONE

Identification of extremely premature infants at high risk of rehospitalization

Pediatrics

Rehospitalization in the first 2 years of life in children born preterm

Acta Paediatr

Hospital admissions in the first year of life in very preterm infants

J Paediatr Child Health

Portrait of socio-economic inequality in childhood morbidity and mortality over time, Québec, 1990-2005

J Paediatr Child Health

Socio-economic inequalities in childhood mortality in low- and middle-income countries: a review of the international evidence

Br Med Bull

Time trends in socio-economic factors and risk of hospitalisation with infectious diseases in pre-school children 1985-2004: a Danish register-based study

Paediatr Perinat Epidemiol

Widening socioeconomic disparities in US childhood mortality, 1969-2000

Am J Public Health

Disadvantage

The development of a standardized neighborhood deprivation index

J Urban Health

Proximate and contextual socioeconomic determinants of mortality: multilevel approaches in a setting with universal healthcare coverage

Am J Epidemiol

Original Articles
Influence of Socioeconomic Context on the Rehospitalization Rates of Infants Born Preterm