Association of pediatric mortality with the Child Opportunity Index among children presenting to the emergency department

  • Megan M. Attridge
    Correspondence: Megan Attridge, MD MS, Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Box 62, Chicago, IL 60611, Phone: (312) 227-0648, Fax: (312) 227-9475
    Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
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  • Julia A. Heneghan
    Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital; University of Minnesota, Minneapolis, Minnesota, United States of America
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  • Manzilat Akande
    Section of Pediatric Critical Care, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, United States of America
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  • Sriram Ramgopal
    Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
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Published:January 19, 2023DOI:



      Child health and development is influenced by neighborhood context. The Child Opportunity Index (COI) is a multidimensional measure of neighborhood conditions. We sought to evaluate the association of COI with mortality among children presenting to the emergency department (ED).


      We performed a multicenter cross-sectional study of pediatric (<18 years) ED encounters from a statewide dataset from 2016-2020. We constructed a multivariable logistic regression model to evaluate the association between COI and in-hospital mortality after adjusting for sociodemographic characteristics and medical complexity.


      Among 4,653,070 included encounters, in-hospital mortality occurred in 1,855 (0.04%). There was a higher proportion of encounters with mortality in the lower COI categories relative to the higher COI categories (0.053%, 0.038%, 0.031%, 0.034%, 0.034% ranging from Very Low to Very High, respectively). In adjusted models, child residence in Low (adjusted odds ratio 1.26, 95% CI 1.04-1.53) and Very Low (adjusted odds ratio 1.58, 95% CI 1.31-1.90) COI neighborhoods was associated with mortality relative to residence in Very High COI neighborhoods. This association was noted across all domains of COI (education, health and environment, and social and economic), using an expanded definition of mortality, using nationally normed COI, and excluding patients with complex chronic conditions. Other factors associated with increased odds of mortality included age, medical complexity, payor status, age, and race/ethnicity.


      Understanding the association of neighborhood context on child mortality can inform public health interventions to improve child mortality rates and reduce disparities.



      COI (Child Opportunity Index), ED (emergency department), ZIP (Zone Improvement Plan), CCC (complex chronic conditions), OR (odds ratio), aOR (adjusted odds ratio), NH (Non-Hispanic), Ref (reference category), CI (confidence interval)
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