The Hidden Effect of Socioeconomics on Pediatric Health Care Utilization

Chalanda Jones, MD

Charles A. Pohl, MD––Series Editor

Chronic conditions and lower socioeconomic status have been associated with longer hospital stays, higher costs of care, and a higher risk of hospital readmission in adults. Does the same hold true for the pediatric population? And if it does, what contributes to that higher financial inpatient burden? Fieldston and colleagues addressed these questions in their analysis of the inpatient costs for children hospitalized with common conditions in relation to the children’s estimated median annual household income.1

Using the Pediatric Health Information System (PHIS), a database that accounts for 20% of all U.S. pediatric hospitalizations, this multicenter, retrospective, national cohort study reviewed patient demographics, zip codes, and hospital charges for services from 32 children’s hospitals during the 2 calendar years of 2010 and 2011. The analysis focused on 2 chronic diseases (asthma and diabetes mellitus) and 3 acute infectious diseases (bronchiolitis and respiratory syncytial virus pneumonia; pneumonia from other causes; and kidney and urinary tract infections).

In total, patients who resided in zip codes with the lowest annual household incomes had $8.4 million more in hospital costs and $13.6 million more in patient costs than patients in zip codes with higher household incomes. The cost differences in both of these categories were smallest for pneumonia and largest for diabetes. Length of hospital stay was the biggest factor accounting for the differences in costs. Kidney and urinary tract infections showed the least variation in cost for all 5 disease categories.

Among the study’s several limitations is that the sample population was derived from patients of freestanding children’s hospitals, most of which are located in urban settings. Therefore, it might be difficult to generalize results owing to selection bias, especially with length of stays and readmissions to a particular hospital. The authors also were unable to account for socioeconomic status differences in referral patterns or for family preferences for a particular hospital; moreover, because no individual income demographics are included in the PHIS database, the authors were able to only approximate family income levels based on zip code.

Despite the analysis’s noted limitations, it serves as an interesting study in hospitalization utilization as it relates to common pediatric health conditions and socioeconomic status. It challenges one to think about the role of inpatient and outpatient medical access in disease management. Intuitively, one would think that a higher cost of inpatient hospitalization—whether a result of severity of disease, length of stay, or recurrent admissions—suggests poor disease management. Focusing on trends in patients’ adherence to therapy, response to therapy, and hospitalizations for these 5 common conditions may provide a window for better overall health management.

The results of this study also raise the interesting question of hospital reimbursement, which focuses on severity of disease but does not factor in the socioeconomic risk factors of a hospital’s patient population, which may contribute to longer lengths of stay.

Dr Jones is a pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Charles A. Pohl, MD––Series Editor: Dr Pohl is professor of pediatrics and senior associate dean of student affairs and career counseling at Jefferson College in Philadelphia, Pennsylvania.


1. Fieldston ES, Zaniletti I, Hall M, et al. Community household income and resource utilization for common inpatient pediatric conditions. Pediatrics. 2013;132(6):e1592-e1601.