Acknowledging Social Determinants of Health - APSA Practice Gaps 2019

A seven-week-old boy with pyloric stenosis had three emergency room visits over three weeks before diagnosis, requiring three days of rehydration for severe hyperchloremic metabolic alkalosis before pyloromyotomy could be performed.

The St. Peter's study presented an algorithm for fluid resuscitation in pyloric stenosis based on chloride cutoffs: chloride <88 requires three boluses before rechecking, <96 requires two boluses, and 96-100 requires one bolus.

Public insurance (Medicaid) was the correct answer for the factor most associated with delayed presentation in the case vignette, chosen by 23% of survey respondents.

Multiple studies show that African-American or black and Hispanic patients have poorer outcomes for disease severity when compared to Caucasians in the United States.

Patients with public insurance, limited insurance, or no insurance have poorer outcomes, decreased access to care, and decreased ability to get appropriate care.

Studies of appendicitis, traumatic injuries, and other pediatric surgical diseases show a strong and pervasive link between black or Hispanic race and outcomes, as well as poverty.

Public insurance is a marker for degree of poverty.

In a study of pyloric stenosis, patients with Medicaid had chloride levels 8 to 10 points lower than those with commercial insurance.

In the same pyloric stenosis study, commercial insurance patients had seen a pediatrician three times more often in the preceding weeks than Medicaid patients.

Despite years of publishing studies on disparities in appendicitis and other conditions, no changes have been made that show a measurable difference in outcomes.

Addressing social determinants of health is firmly within the lane of pediatric surgeons and needs to be done.

Pediatric surgeons need to universally recognize and agree that social determinants of health matter as a first step.

The American Academy of Pediatrics has advocacy outreach programs at regional, district, state, and federal levels that pediatric surgeons can link into.

Concrete improvements will require allocation of resources such as hiring more social workers, discharge planning staff, and funding schools of public health for surveys and targeted improvements.

African-American or black premature babies do poorly compared to gestational age counterparts, making black race a risk factor even before birth.

Disparities in neonatal outcomes start with prenatal care, affecting undereducated mothers in poverty who cannot seek adequate prenatal care.

A study in the Kaiser system, where everybody has insurance, showed elimination of disparities in perforated appendicitis rates across education, income level, and race.

Community health workers in Sub-Saharan Africa and other global settings achieve significantly higher medication adherence rates than in resource-rich settings by going door-to-door to help families.

Community health workers could be used in disenfranchised communities in the US to help get people into the healthcare system more timely with recognition at a community level.