Social Determinants of Health and End-of-Life Circumstances in a Quaternary Children's Hospital.

CONTEXT: Inequitable access to quality care based on social determinants of health (SDoH) adversely impacts outcomes. Prior studies suggest that disparities extend to end-of-life (EOL) and subspecialty pediatric palliative care (SPPC) utilization, although pediatric data remain limited.

OBJECTIVES

To examine relationships between SDoH, SPPC, and EOL circumstances among decedents in a quaternary children's hospital.

METHODS

We conducted a retrospective cohort study of all inpatient deaths at a quaternary pediatric hospital (1.1.2018-12.31.2023). Clinical data, SDoH (race/ethnicity, interpreter involvement, insurance, and Child Opportunity Index [COI3.0]), SPPC consultation, and EOL circumstances (EOL care intensity, peri‑mortem cardiopulmonary resuscitation [CPR]) were analyzed using multivariable regression with adjusted odds ratios (aOR) and 95% confidence intervals (CI) presented. COI and race/ethnicity were modeled separately given collinearity.

RESULTS

Among 679 pediatric decedents (median age 19 months [Interquartile range (IQR) 0.4-130]; 44.3% female), SPPC was involved in 334 cases (49.2%). SPPC involvement was inversely associated with age (i.e., aOR [CI] for infants vs. older children 0.39 [0.22-0.67]), general surgical diagnoses (0.49 [0.25-0.99]), international/self-pay insurance (0.18 [0.07-0.48]), and positively associated with certain subspecialties (i.e., hematology/oncology, cardiac, and chronic respiratory diagnoses aORs 9.02 [4.99-16.32], 1.65 [1.11-2.45] and 2.66 [1.67-4.24], respectively) as well as greater numbers of comorbidities. Neither COI nor race/ethnicity was associated with SPPC. For EOL circumstances, international/self-pay insurance was associated with lower EOL intensity (0.45 [0.20-1.01]), while interpreter involvement was associated with higher odds of CPR on the day of death (2.27 [1.22-4.24]), CPR as the mode of death (1.91 [0.97-3.74]), and prolonged intensive care unit stay (3.83 [1.88-7.78]). SPPC was associated with lower EOL intensity and less CPR.

CONCLUSION

Clinical factors and certain social determinants, specifically insurance type and interpreter usage, were associated with SPPC involvement and EOL outcomes.