Social Determinants of Health and Timing of Tracheostomy for Severe Bronchopulmonary Dysplasia

Abstract

To estimate the association of ZIP code-level social determinants of health (SDoH), specifically household income, education level, and unemployment rate, with post-menstrual age (PMA) at tracheostomy placement in patients with severe bronchopulmonary dysplasia (BPD). This was a retrospective observational study of infants born <32 weeks' gestation and discharged from a Children's Hospitals Neonatal Consortium newborn intensive care unit. Patients were diagnosed with severe BPD and received tracheostomies before discharge. Maternal ZIP code at admission was linked to that ZIP code's SDoH via the 2021 US Census Bureau 5-year data. Unadjusted and adjusted analyses were completed with separate models fit for each SDoH marker. 877 patients received tracheostomies at median (interquartile) 48 (44-53) weeks' PMA. In multivariable models, patients in the highest education groups received tracheostomies earlier (OR: 95% CI = 0.972: 0.947-0.997, p=0.031), and non-Hispanic Black patients received tracheostomies later compared with non-Hispanic White patients (OR: 1.026; 95% CI =1.005-1.048, p=0.017). For household income and unemployment, the PMA at tracheostomy did not differ by SDoH or race. For all three models, male sex, small for gestation status, and later PMA at admission were associated with later PMA at tracheostomy. For each SDoH marker, significant inter-center variation was noted as several centers had independently increased PMA at tracheostomy. Education at the ZIP code-level influenced PMA at tracheostomy after adjusting for patient and clinical factors. Adjusted for each SDoH studied, significant differences were noted among centers. Factors leading to the decision and timing of neonatal tracheostomy need further evaluation.