The child opportunity index and discharge disposition among children with new tracheostomy and long-term mechanical ventilation

RATIONALE: Although discharge to home is the goal for many children on new long-term mechanical ventilation via tracheostomy (LTMV-T), families often face barriers to access, such as home health nursing. Disparities in discharge disposition and the impact of social determinants of health (SDOHs) remain understudied. OBJECTIVE: To examine the association between neighborhood-level SDOHs and discharge disposition among children on new LMTV-T. METHODS: This retrospective cohort study included children aged 0 to 18 years newly discharged with LTMV-T between 2014 and 2023 from 47 pediatric hospitals, using the Pediatric Health Information System database. The primary outcome was discharge disposition, defined as home or skilled facility. The primary exposure was the Child Opportunity Index (COI), a composite measure of neighborhood-level SDOHs, reported in quintiles (very low to very high opportunity). The association between COI and discharge disposition was evaluated using a multivariable mixed-effects logistic regression model with a random effect for hospitals and states. A mediation analysis was conducted to assess whether COI mediated racial and ethnic disparities in discharge disposition. RESULTS: Of the 5042 eligible children, most were male (57%), covered by government insurance (61%), and non-Hispanic White (45%) and non-Hispanic Black (23%). Median length of stay was 148 days (IQR, 81-232 days), and median age at discharge was 10 months (IQR, 7-18 months). A total of 1011 (20%) children were discharged to a skilled facility, and 2554 (51%) lived in very low to low COI neighborhoods, with more than half of the non-Hispanic Black population living in very low to low COI neighborhoods. Compared to children from very high opportunity neighborhoods, children from very low COI (adjusted odds ratio [aOR] = 3.11; 95% CI, 2.30-4.21), low COI (aOR = 2.22; 95% CI, 1.63-3.02), moderate COI (aOR = 2.19; 95% CI, 1.60-2.99), and high COI (aOR = 1.65; 95% CI, 1.20-2.26) had increased odds of being discharged to skilled facility than home. Among non-Hispanic Black children, only 24% of the total effect between race/ethnicity and discharge disposition was mediated by COI. CONCLUSION: Disparities in institutionalization exist among children with LTMV-T from lower COI compared to very high COI neighborhoods. Addressing neighborhood-level conditions and implementing policies such as paid family caregiving or insurance reimbursement may reduce inequities in discharge disposition.