Original Article|Articles in Press

Neighborhood Poverty and Distance to Pediatric Hospital Care

  • Lauren Brown
    Correspondence to: Lauren Brown, MD, MPH, Brigham and Women's Hospital, L1 Anesthesia Department, 75 Francis St, MA 02115; Phone: 617-355-7327, Fax: 617-730-0453
    Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston, MA

    Harvard Medical School, Boston, MA

    Mass General Brigham, Brigham and Women's Hospital, Department of Anesthesiology
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  • Urbano L. França
    Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston, MA

    Harvard Medical School, Boston, MA
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  • Michael L. McManus
    Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston, MA

    Harvard Medical School, Boston, MA
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Published:February 05, 2023DOI:



      To describe the relationship between neighborhood poverty and geographic access to pediatric inpatient care.


      This is a retrospective, cross-sectional study using 2017-2018 hospital and demographic data, as well as geographic data from the 2010 census. Acute care hospitals in seventeen states were included, comprising approximately one third of the national population. The main outcome was distance to capable pediatric hospital care by neighborhood Area Deprivation Index, both overall and by urbanicity.


      Median distance to pediatric hospital care increased linearly with poverty across Area Deprivation Index national deciles (Pearson coefficient of 0.986; p<0.001). The most advantaged neighborhoods were a median of 2.5 miles from the nearest pediatric capable hospital (IQR 1.2-5.6) while those in the most disadvantaged were a median of 13.8 miles away (IQR 3.3-35.9; p<0.001). The nearest hospital admitted children in 51.17% (7,927) of advantaged neighborhoods (lowest national ADI quintile) and only 26.02% (3,729) of disadvantaged neighborhoods (highest national ADI quintile). The association between poverty and median distance to care was observed in rural, suburban, and urban CBGs (p<0.001 for all trends). In suburban neighborhoods, children from the most disadvantaged neighborhoods were three times as likely as children from the most advantaged neighborhoods to live more than twenty miles from pediatric inpatient care (27.85%, 456,533 of children from bottom quintile neighborhoods vs. 9.24%, 259,787 of children from top quintile neighborhoods, p<0.001).


      Distances to capable pediatric hospital care are greater from poor than affluent neighborhoods. This carries potential implications for disparities in pediatric health outcomes.



      ADI (Area Deprivation Index), CBG (Census Block Group), HCI (Hospital Capability Index), pHCI (Pediatric Hospital Capability Index)
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        • Council on Community Pediatrics
        Poverty and Child Health in the United States.
        Pediatrics. 2016; 137e20160339
      1. Parker K, Horowitz JM, Brown A, Fry R, Igielnik DCAR. Demographic and Economic Trends in Urban, Suburban and Rural Communities. Pew Research Center; 2005.

        • França UL
        • McManus ML.
        Availability of Definitive Hospital Care for Children.
        Jama Pediatr. 2017; 171 (e171096-e171096)
        • França UL
        • McManus ML.
        Trends in Regionalization of Hospital Care for Common Pediatric Conditions.
        Pediatrics. 2017; 141e20171940
        • Ray K
        • Olson L
        • Edgerton E
        • et al.
        Access to High Pediatric-Readiness Emergency Care in the United States.
        J Pediatr. 2018; 194 (2250232.e1)
        • Chien AT
        • Pandey A
        • Lu S
        • et al.
        Pediatric Hospital Services Within a One-Hour Drive: A National Study.
        Pediatrics. 2020; 146e20201724
        • Cushing AM
        • Bucholz E
        • Michelson KA.
        Trends in Regionalization of Emergency Care for Common Pediatric Conditions.
        Pediatrics. 2019; 145e20192989
        • França UL
        • McManus ML.
        Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis.
        Jama Netw Open. 2018; 1e183249
        • França UL
        • McManus ML.
        Assessment of Acute Hospital Use and Transfers for Management of Pediatric Seizures.
        Jama Netw Open. 2020; 3e203148
        • McManus ML
        • França UL.
        Availability of Inpatient Pediatric Surgery in the United States.
        Anesthesiology. 2021; 134: 852-861
        • Brown LE
        • França UL
        • McManus ML.
        Opportunities for Restructuring Hospital Transfer Networks for Pediatric Asthma.
        Academic Pediatrics (Online First). 2021;
        • Vandenbroucke JP
        • von Elm E
        • Altman DG
        • et al.
        Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and Elaboration.
        PLoS Med. 2016; (Published online)
        • Databases HCUP
        Healthcare Cost and Utilization Project (HCUP).
        Agency for Healthcare Research and Quality, Rockville, MD2009
      2. Massachusetts Acute Hospital Inpatient Discharge, Emergency Department, and Outpatient Observation Case Mix Databases, Massachusetts Center for Health Information and Analysis, Boston MA.

      3. American Hospital Association. AHA Annual Survey Database. Accessed June 1, 2021.

        • França UL
        • McManus ML.
        Transfer Frequency as a Measure of Hospital Capability and Regionalization.
        Health Serv Res. 2017; 52: 2237-2255
        • Kind AJH
        • Buckingham W.
        Making Neighborhood Disadvantage Metrics Accessible: The Neighborhood Atlas.
        New England Journal of Medicine,. 2018; 378 (Available at:) (Accessed March 5, 2021): 2456-2458
      4. Bureau USC. 2010 Census - Block Maps. Accessed March 5, 2021.

        • Boscoe FP
        • Henry KA
        • Zdeb MS.
        A Nationwide Comparison of Driving Distance Versus Straight-Line Distance to Hospitals.
        Prof Geogr. 2012; 64: 188-196
        • Jones SG
        • Ashby AJ
        • Momin SR
        • Naidoo A.
        Spatial Implications Associated with Using Euclidean Distance Measurements and Geographic Centroid Imputation in Health Care Research.
        Health Serv Res. 2010; 45: 316-327
        • Sinnott RW.
        Virtues of the Haversine.
        Sky and Telescope. 1984; 68: 159
      5. US Census Bureau. 2012—2016 ACS 5-Year Data Profile. Accessed March 5, 2021.

        • Airgood-Obrycki W
        • Rieger S
        Defining Suburbs: How Definitions Shape the Suburban Landscape.
        Joint Center for Housing Studies of Harvard University, 2019 (Accessed June 1, 2021)
        • McManus K
        • Finlay E
        • Palmer S
        • Anders JF
        • Hendry P
        • Fishe JN.
        A Statewide Analysis of EMS’ Pediatric Transport Destination Decisions.
        Prehosp Emerg Care. 2020; 24: 1-13
        • Ames S
        • Davis B
        • Marin J
        • Fink E
        • et al.
        Emergency Department Pediatric Readiness and Mortality in Critically Ill Children.
        Pediatrics. 2019; 144e20190568
        • Fung JST
        • Wong S
        • Murthy S
        • Muttalib F.
        Hospital outcomes of children admitted to intensive care in British Columbia via interfacility transfer versus direct admission from 2015 to 2017: a descriptive analysis.
        Cmaj Open. 2021; 9: E602-E606
        • Faine BA
        • Noack JM
        • Wong T
        • et al.
        Interhospital Transfer Delays Appropriate Treatment for Patients With Severe Sepsis and Septic Shock.
        Crit Care Med. 2015; 43: 2589-2596
        • Bayne AP
        • Madden-Fuentes RJ
        • Jones EA
        • et al.
        Factors Associated With Delayed Treatment of Acute Testicular Torsion—Do Demographics or Interhospital Transfer Matter?.
        J Urology. 2010; 184: 1743-1747
        • Islam DAF
        • Amed S.
        Type 1 diabetes outcomes: Does distance to clinic matter?.
        Pediatr Diabetes. 2012; 19: 1331-1336
        • Epstein D
        • Reibel M
        • Unger JB
        • et al.
        The Effect of Neighborhood and Individual Characteristics on Pediatric Critical Illness.
        J Commun Health. 2014; 39: 753-759
        • Rees CA
        • Monuteaux MC
        • Raphael JL
        • Michelson KA.
        Disparities in Pediatric Mortality by Neighborhood Income in United States Emergency Departments.
        J Pediatrics. 2020; 219 (e3): 209-215
        • Felland LE
        • Lauer JR
        • Cunningham PJ.
        Suburban poverty and the health care safety net.
        Res Brief. 2009; : 1-12
        • Cushing AM
        • Bucholz EM
        • Chien AT
        • Rauch DA
        • Michelson KA.
        Availability of Pediatric Inpatient Services in the United States.
        Pediatrics. 2021; 148e2020041723
        • VonAchen P
        • Gaur MD
        • Wickremasinghe MW
        Assessment of Underpayment for Inpatient Care at Children's Hospitals.
        JAMA Pediatr. 2020; 175: 972-974
        • França UL
        • McManus ML.
        An Approach to Consolidating Pediatric Hospital Beds During the COVID-19 Surge.
        Pediatrics. 2020; 146e20201464