Poverty, the Elephant in the Room

Abstract

As is often referenced, the Institute of Medicine defines quality of care in 6 domains: safety, effectiveness, patient centeredness, timeliness, efficiency, and equity.1 And although we have seen tremendous focus on the first 5 domains in pediatric health care, equity (provision of care that does not vary in quality because of characteristics such as sex, race, ethnicity, or socioeconomic status) is a dimension that we need to continue to address. Efforts to improve population health and promote equity have led to efforts to define and address social determinants of health (SDOH): the conditions in which people are born, grow, live, work, and age.2 SDOH encompass aspects of well-being, like food security and adequate housing, that are linked to health outcomes.3,4 Poverty is a key factor that limits access to food and housing, and poverty is the “elephant in the room” when navigating patient and family factors that affect chronic disease management.5 In this month’s Hospital Pediatrics, Foster et al6 evaluated the association between SDOH and emergency department (ED) encounters or hospital admission among children with chronic disease. They demonstrated that participants who reported unaddressed housing and food insecurity at the time of enrollment in a case management program had increased ED use, and those who reported addressed food insecurity (referring to families who had received food-related resources and assistance before enrollment in this case management program) had decreased ED use. Neither food nor housing insecurity, addressed or unaddressed at the time of program enrollment, was associated with hospitalization rates.6 The impact of these SDOH on ED encounter versus hospitalization rates may reflect the impact that SDOH have on caregiver-driven versus provider-driven use. Foster et al6 highlight an important consideration: do SDOH impact use differences in health care access (seeking care in …