The Relationship Between Social Determinants of Health and PICU Delirium

Introduction: Delirium is a syndrome of acute brain dysfunction prevalent in pediatric intensive care unit (PICU) patients. It is associated with poor PICU outcomes, including mortality, but its relationship with social determinants of health (SDOH) has not been explored. This study aims to assess the relationship between SDOH (including race, ethnicity, insurance status, childhood opportunity index (COI)) and the development of PICU delirium.


Methods: Retrospective analysis of a prospective observational study conducted at an urban academic tertiary care PICU. All patients admitted to the PICU September 2014 to August 2015 were screened for delirium twice daily throughout the PICU stay. Race and ethnicity (self-reported) and insurance status were extracted from the medical record. COI (a nationally-normed measure incorporating 29 social, environmental, educational and health resources impacting children) was determined by subject address and corresponding census tract.


Results: Of 1,547 PICU admissions, there were 1269 unique patients. Race and ethnicity data were recorded for 951 children (23.7% missing). Delirium rates differed by race and ethnicity, highest in Asian/Pacific Islander, Black non-Hispanic, and Hispanic (22%, 19%, and 17%) vs. White non-Hispanic (14%) children (p < 0.001). Subjects with public insurance had a higher rate of delirium (19%) compared to those with private (12%, p=0.001). 1246 children had an address that corresponded to one of five COI quintile groups (1=very low, 2=low, 3=moderate, 4=high and 5=very high). Incidence of delirium was higher among subjects from lower opportunity neighborhoods (COI groups (1-3)) as compared to higher (4-5) (18% vs. 12%, p=0.003). Lower COI was associated with increased delirium risk after adjusting for other predictors of delirium (aOR 1.486; CI = 1.01-2.21; p=0.047). Data-driven variable selection procedures (stepwise selection and LASSO) retain COI as a meaningful predictor.


Conclusions: Social determinants of health including race and ethnicity, insurance type, and COI are associated with delirium risk in univariate analyses. Lower COI was independently associated with a 49% increase in odds of developing PICU delirium as compared to high COI. Future study should focus on the mechanisms underlying these relationships.