Inpatient Food Insecurity and Hospital Length of Stay in Pediatric Patients With Asthma

Asthma ranks third in pediatric hospital admissions, costing $452.2 million annually in the United States.1 Household food insecurity (HFI) is associated with higher rates of asthma in children.2–4 However, the potential impact of HFI and inpatient food insecurity (IFI), food insecurity experienced by caregivers during a child’s hospitalization, on hospital outcomes have not been explored among pediatric patients with asthma. We theorize that patients with asthma and IFI represent a distinct population from those with HFI (Figure 1). In this study we assess whether IFI and/or HFI are associated with increased length of stay (LOS), and we hypothesize that HFI and IFI are both associated with increased LOS in pediatric patients with asthma.Data were retrospectively captured at 1 children’s hospital within an academic medical center in North Carolina between May 2022 and December 2023. IFI was measured using a 3-item screening tool adapted from modified HFI surveys to assess the IFI of caregivers during a hospitalization.5 HFI was measured via the 2-item Hunger Vital Sign. Nursing staff screened caregivers at least once during the hospitalization and documented results in the electronic health record (EHR). Eligible participants with asthma were identified by International Classification of Diseases, Tenth Revision codes starting with J45 from the visit diagnoses, problem list, and medical history. IFI and HFI status and participant characteristics were compared using chi-square or t tests. To improve normalization, we Winsorized at the 95th percentile (11 days) and log-transformed the LOS variable. We used linear regression to assess the association of IFI and HFI with LOS in patients with asthma, adjusting for child age, sex, race, ethnicity, language, and insurance type. Secondary analyses examined the association of LOS with (1) IFI in patients without HFI, (2) HFI in patients without IFI, and (3) a model including both HFI and IFI; all models were adjusted for same covariates as primary analyses. After analyses using log-transformed data, estimates for the beta coefficient and 95% CIs were exponentiated. Analyses were performed using Stata SE (version 14.2; College Station, TX). This study was approved by the Wake Forest University School of Medicine Institutional Review Board.Of 21 071 hospital encounters, 3236 had a diagnosis of asthma; 1459 of these encounters included screening for IFI, 1001 for HFI, 547 for both IFI and HFI, and 1323 had no documented screening (Tables 1 and 2). Characteristics of screened and unscreened participants are found in Supplemental Table 1. IFI was more common among children with Medicaid insurance (Table 1). Of participants screened for both, of those with IFI, 40% screened negative for HFI. The median (IQR) LOS was 2 (1-3) days. Participants with IFI had a statistically significant 1.39 days longer LOS and participants with HFI had 1.42 days longer LOS compared with those without IFI and HFI, respectively (Table 3). In secondary analyses, LOS was not significantly associated with (1) IFI among participants without HFI, (2) HFI among participants without IFI, or (3) IFI or HFI when both were included in a single model (Supplemental Table 2).IFI and HFI were both associated with a longer LOS in hospitalized children with asthma. Despite some overlap, IFI and HFI screening captured distinct populations, as 40% of children with IFI screened negative for HFI, highlighting a population of families with food support at home but who may struggle to afford food during a child’s hospitalization. No association of IFI or HFI with LOS in secondary analyses is likely attributed to the small sample size of participants screened for both IFI and HFI.Our finding of increased LOS is consistent with another study showing the association of longer LOS with IFI/HFI.5 Although etiologies remain unknown, we hypothesize that increased LOS is secondary to increased asthma disease severity, requiring prolonged hospital interventions. Previous work demonstrated decreased asthma-related emergency department visits among those receiving governmental food benefits among pediatric patients with asthma, suggesting improved asthma control.6 Future studies should explore if pediatric patients admitted for asthma with HFI or IFI require increased interventions compared with those without HFI or IFI.Study limitations include data from a single institution, lack of universal IFI and HFI screening, inclusion of all children with asthma as a diagnosis in the EHR, and the occurrence of the study during the COVID-19 pandemic when HFI rates were lower.