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Risk factors for unanticipated hospitalizations in children and youth with spina bifida at an urban children’s hospital: a cross-sectional study

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Risk factors for unanticipated hospitalizations in children and youth with spina bifida at an urban children’s hospital: a cross-sectional study

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RISK FACTORS FOR UNANTICIPATED HOSPITALIZATIONS IN CHILDREN AND
YOUTH WITH SPINA BIFIDA AT AN URBAN CHILDREN’S HOSPITAL: A CROSS-
SECTIONAL STUDY

by
Kathryn Ann Smith

A Thesis Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
CLINICAL, BIOMEDICAL AND TRANSLATIONAL INVESTIGATIONS

August 2021

Copyright 2021 Kathryn Ann Smith
ii
Acknowledgements
The author wishes to acknowledge the following individuals for their assistance with this
research:
Sharon Hudson, PhD
Jason Chwa
Rhonda Cellura, BSN
Alex Van Speybroeck, MD, MPH
Cecily Betz, RN, PhD

iii
TABLE OF CONTENTS

Acknowledgments………………………………………………………………………ii

List of Tables……………………………………………………………………………iv

List of Figures…………………………………………………………………………...v

Abstract………………………………………………………………………………… vi

Introduction……………………………………………………………………………. 1

Methods………………………………………………………………………………... 2

Results…………………………………………………………………………………. 4

Discussion……………………………………………………………………………... 5

Conclusion……………………………………………………………………………...10

References……………………………………………………………………………...19

iv
List of Tables

Table 1 Demographics ………………………………………………………………………….13

Table 2 Diagnosis Categories …………………………………………………………………..14

Table 3 Diagnostic Categories for Hospitalization and Lesion Level Percentages …………….16

Table 4 Hospitalization and Sociodemographic and Clinical Factors across Diagnoses ………17

Table 5 Bivariate Associations with Ambulation Status ……………………………………….18

v
List of Figures

Figure 1 Patient Inclusion Criteria Flow Chart …………………………………………………12

vi
Abstract

Background and Objectives
Spina bifida (SB) is a condition resulting from the improper closure of the neural tube
and vertebral column during fetal development. While patients’ life expectancy and quality of
life have improved dramatically due to medical advances such as cerebral spinal fluid (CSF)
diversion and clean intermittent catheterization, children continue to experience health-related
issues that often require hospitalizations. This cross-sectional study investigates the association
between sociodemographic and clinical characteristics and unanticipated hospitalizations (UH)
among children with myelomeningocele type SB.
Methods
A convenience sample of eligible children and youth ages 1 month to 21 years of age was
identified through automatic flagging in the electronic medical record af ter being seen in the
emergency department (ED) of a large urban children’s hospital (Children’s Hospital Los
Angeles-CHLA) between May 2017 and July 2019. Chart review and abstraction were carried
out for those admitted to the hospital.
Sociodemographic variables included sex, age, type of insurance and ethnicity (Hispanic,
Non-Hispanic). Clinical variables included level of lesion, ambulation status, presence of a shunt
and diagnostic categories. Univariate, bivariate and multivariate analyses were conducted to
identify factors associated with unanticipated hospitalizations.
Results
In this study of 108 unanticipated hospitalizations, univariable results showed that factors
associated with increased unanticipated hospitalization included being male, between the ages of
vii
5 and 18 years, low lumbar level lesions, non-ambulatory, with public insurance, Hispanic and
with a history of shunt placement. Most hospitalizations (73%) were for neurologic or urologic
conditions. Factors independently associated with increased unanticipated hospitalization were
race for urologic conditions, ambulatory ability for metabolic conditions and age for
gastroenterology conditions.
Conclusion
Patients with myelomeningocele type SB are more likely to be hospitalized if they are
male, school age (5-18 years of age), have a low lumbar level lesion and are not ambulatory.
Our sample population was more likely to have public insurance, identify as Hispanic and have a
shunt, characteristics of our clinic population. Common reasons for hospitalizations in this
sample included shunt malfunction, urinary tract infection and fever, consistent with other
studies.

1
Introduction
Spina bifida (SB) is a condition resulting from the improper closure of the neural tube
and vertebral column during fetal development. The prevalence of spina bifida in the US is 3.7
per 10,000 live births, or approximately 1,500 cases annually (1). Individuals with spina bifida
experience morbidities associated with the condition including bowel and bladder incontinence,
hydrocephalus, impaired sensation below the level of the lesion and paraplegia that limits
ambulation (2). The degree of disability is associated with the level (location) and severity of the
neural tube defect (3). While individuals’ life expectancy and quality of life have improved due
to medical advances such as cerebral spinal fluid (CSF) diversion to prevent hydrocephalus and
regimens to protect renal function, children and youth with spina bifida continue to experience
health-related complications that often require hospitalizations (3, 4, 5).
Children with spina bifida experience hospitalizations at a greater rate than their typically
developing peers as well as those with other chronic conditions, including muscular dystrophy
and Fragile X syndrome (6, 7, 8, 9). In a study of 30-day readmission rates among youth and
young adults 15 to 30 years of age with complex chronic diseases, readmissions occurred at a
higher rate for those with spina bifida compared to those with inflammatory bowel disease, a rate
similar to those with cystic fibrosis and type one diabetes and less than those with sickle cell
anemia (10). Despite this, there is limited information as to factors that are associated with
unanticipated hospitalizations in children and youth with spina bifida (11, 12, 13, 14). Ample
evidence demonstrates higher costs of care associated with spina bifida throughout childhood,
with special emphasis on the costs of newborn care (12, 13, 15, 16, 17, 18, 19). There is,
however, a limited body of information about emergency department use and subsequent
2
hospitalization for these children, and studies report that shunt malfunction and urinary
complaints are among the most frequent causes identified (11, 14, 20).
This study investigated the association between sociodemographic and clinical variables,
including sex, age, spinal cord lesion level, ambulation status, insurance, ethnicity and shunt
status and unanticipated hospitalizations (UH) among children with myelomeningocele type
spina bifida. We hypothesized that among children and youth from 1 month to age 21 years with
myelomeningocele type spina bifida, younger age, those with higher-level lesions, with shunts
and non-ambulatory status are associated with increased UH. This study aimed to contribute to
understanding the primary sociodemographic and clinical factors associated with UH in children
and youth with myelomeningocele type SB.
Methods
A convenience sample of eligible children and youth was identified through automatic
flagging in the electronic medical record after patients with SB were seen in the emergency
department (ED) of a large urban children’s hospital (CHLA) in the western United States.
Reports of children and youth seen in the ED and admitted to the hospital were sent daily to one
of the co-investigators for consideration for the study. Inclusion criteria were as follows: 1)
diagnosis of myelomeningocele type SB, 2) children and youth age 1 month to 21 years of age,
and 3) an unanticipated hospitalization between May 2017 and July 2019. Exclusion criteria
included: 1) patients with other types of SB (e.g., caudal regression syndrome, sacral agenesis
and meningocele), 2) or those who had a scheduled admission to the hospital. Review of the
electronic medical record was completed first to determine eligibility for the study and then to
obtain relevant data for those eligible for participation. The following data were obtained for
each admission: sex, age, level of lesion, ambulation status, insurance, ethnicity, presence of a
3
shunt and admitting diagnosis. Underlying chronic conditions associated with the SB (for
instance, neurogenic bladder or central sleep apnea) were not included, only the acute reasons
leading to the hospitalization, since this was the focus of the study.
Sociodemographic variables were modeled as follows: sex (male, female), age (1-12
months, 13- 35 months, 36- 60 months, 5 to 12 years, 13 to 18 years and 19 to 21 years; age
began at one month to exclude the initial post birth surgical hospitalization), type of insurance
(public insurance such as Medicaid, State Title V Program for Children with Special Needs,
Medicare and any commercial insurance including employer sponsored, purchased, or any
combination) and ethnicity (Hispanic, Non-Hispanic). Clinical variables included SB severity
defined by level of lesion (thoracic, high lumbar, mid lumbar, low lumbar and sacral),
hydrocephalus with shunt (yes/no) and mobility (non-ambulatory, household ambulator or
community ambulator). Diagnoses were categorized by organ system.
Double chart reviews and data entry were conducted by the principal investigator and a
research assistant for all participants to assure accuracy of the data. For any discrepancies
between reviewers, a third member of the research team was consulted. Approval for the study
was received from the institution’s Institutional Review Board (IRB) and waiver of consent was
approved, as this was a chart review of usual clinical care.
Power was calculated based on the sample size needed to detect a small to medium effect
size in a 2 x 3 contingency table: for an effect size of 0.3, 143 subjects are required ; for an effect
size of 0.4 only 81 subjects are required (21, 22). All variables of interest were initially analyzed
using descriptive statistics including frequencies, means, standard deviations, and medians. To
assess for differences in age, race/ethnicity and ambulatory ability by lesion level, bivariate
analyses using chi-square (or Fisher’s Exact Test for variables with sparse data) was used. This
4
same analytic strategy was also used to determine whether receiving a diagnosis in a given
diagnostic category varied significantly by lesion level. Two-sided P values < .05 were
considered statistically significant. Multivariate analyses tested a model of factors associated
with increased ambulatory status; all variables found to be significantly associated with
ambulatory status in bivariate analyses were included in a multivariable logistic regression.
Analysis was conducted using SAS for Windows, version 9.4 (SAS Institute Inc., Cary, NC).
Results
A total of 522 patient visits for children and youth with SB ages 1 month to 21 years of
age occurred in the ED from May 2017 to July 2019. Of those, 386 resulted in discharge home
and 136 resulted in hospital admission. Twenty-eight of the hospitalized patients were excluded
from this study because they did not have myelomeningocele, but rather other types of SB; 108
remained for inclusion (see Figure 1).
Hospitalized patients were primarily males (53%) between 5 and 18 years of age (56%).
The largest group (39%) had a low lumber level lesion. Fifty-nine (55%) patients were non-
ambulatory, 41 (38%) were community ambulators and 8 (7%) were household ambulators. All
patients had insurance: 90 (83%) had public insurance, 14 (13%) had both public and
commercial insurance and 3 (3%) had commercial insurance. Seventy-six (70%) patients were
Hispanic. Ninety-seven (90%) had a ventriculoperitoneal shunt in place (see Table 1). Primary
diagnoses by category for hospitalization included the following: neurologic (37%), urologic
(36%), miscellaneous (22%), gastrointestinal (19%), metabolic (11%), musculoskeletal (10%),
skin (10%), cardiovascular (9%), respiratory (7%) and psychiatric (<1%); some patients had
diagnoses in more than one category (see Table 2).
5
Lesion level and diagnostic categories for hospitalization demonstrate a statistically
significant relationship between level of lesion and skin (p = .02) and cardiovascular conditions
(p = .001) (see Table 3).
Reasons for hospitalization by socio demographic and clinical factors indicate a
statistically significant relationship between race and urologic conditions (p = .001); ambulation
status and metabolic conditions (p = .003); and age and gastrointestinal conditions (p = .02). No
other variables were significantly associated with the outcomes (see Table 4).
In bivariate analyses, ambulatory status was significantly associated with patient age (p =
0.0001), gender (p = .01), lesion level (p = < 0.0001), and having a metabolic diagnosis (p =
0.0035). The multivariate model including these variables was not statistically significant. Even
when metabolic diagnosis was removed from the model to improve power, the multivariate
model was not significant, and 95% confidence intervals were very wide (Table 5).
Discussion
This study investigated the association between sociodemographic and clinical variables,
including sex, age, spinal cord lesion level, ambulation status, insurance, ethnicity and shunt
status and unanticipated hospitalizations among children with myelomeningocele type spina
bifida. We hypothesized that among children and youth from 1 month to age 21 years of age
with myelomeningocele type spina bifida, younger age, higher-level lesions, those with shunts
and non-ambulatory status are associated with increased unanticipated hospitalizations. The
findings of this study showed that unanticipated hospitalizations were associated with
sociodemographic and clinical variables. Patients requiring hospitalization were more likely to
be male, between the ages of 5 and 18 years, with low lumbar level lesions, non-ambulatory,
6
with public insurance, Hispanic and a history of shunt placement. Most hospitalizations were
for neurologic or urologic conditions. Results from multiple regression indicate that factors
associated with unanticipated hospitalization included race for urologic conditions, ambulatory
ability for metabolic conditions and age for gastrointestinal (GI) conditions.
We hypothesized that most hospitalizations would occur among our youngest patients,
given potential vulnerabilities related to development and age. However, this was not the case;
28% of the study population was in the 5 to 12-year age group and 28% within the 13 to 18-year
age group, thus school age children and adolescents accounted for 56% of the hospital
admissions. Related to specific conditions, we found a clinically and statistically significant
relationship (p = .02) between age and GI conditions, among those 13 months to 18 years. The
primary reasons for hospitalization were vomiting, followed by pain, constipation,
gastroenteritis, ileus and feeding issues. We recognize that vomiting may also be related to shunt
malfunction, rather than a GI etiology like infection or constipation (20). We found that the
youngest group was most likely to experience respiratory diagnoses, however it did not reach
significance. This was a small group and included those with respiratory distress and/or upper
and lower respiratory tract infections. In so far as these are more common in younger children
than older (23, 24, 25) this may be related more to the age of the subjects than comorbidities
associated with spina bifida. We identified an increase in skin conditions for the group 5-18
years of age (63%), however this did not achieve significance. This may be related to the
amount of time this group spends sitting at a desk or wheelchair in school. In addition, most will
be incontinent (26) and may experience challenges in accessing diaper changes or
catheterizations while in school or may be reluctant to interrupt their activities to attend to
7
bladder care resulting in excess moisture and skin damage. Ill-fitting braces can also contribute
to skin breakdown.
We found that the most frequent lesion level for those hospitalized was low lumbar (L4
and L5) level (39%). This is counter to our hypothesis that those with higher level lesions would
be more likely to be hospitalized. Level of lesion can be an important predictor of the impact of
spina bifida, with higher level lesions generally associated with greater morbidity affecting a
variety of bodily functions (27). Level of lesion, in large part, predicts the ability for those with
SB to ambulate (28, 29). Those with low lumbar level lesions generally have fair to good
potential for household and community ambulation (30, 31). In our sample, 55% of the patients
were not ambulatory, while 52% of our sample had either a low lumbar or sacral lesion, the
groups most likely to be able to ambulate. We therefore surmise that a number of patients with
low lumbar level lesions were no longer ambulatory and may experience risks for hospitalization
that may occur as a result of non-ambulation. Impaired ambulation can increase the potential for
various complications including skin breakdown, orthopedic conditions such as fractures and
contractures, and obesity (32, 33, 34, 35). Although we did not consider weight or BMI in our
analysis, both the literature (35, 36) and our clinic experience demonstrate that many patients
with spina bifida are overweight or obese. This might also impact their ability to ambulate, and
in turn, make them more susceptible to conditions resulting in hospitalizations. This point
requires further study; understanding a relationship between level of lesion and hospitalization
can help to identify those as highest risk.
We found a clinically meaningful and statistically significant relationship between
ambulation status and a metabolic condition (p = .003); the most common diagnosis in the
metabolic category was dehydration (83%). Because of the myriad causes of dehydration, we
8
are not able to draw any conclusions about the relationship between ambulation status and a
metabolic condition.
Virtually all our clinic patients have public insurance, most often Medicaid, in
combination with California’s (CA) State Title V Program for Children with Special Health Care
Needs- California Children’s Services (CCS), and this is reflected in our study population. Both
Medi-Cal (CA’s Medicaid program) and CCS serve primarily low-income children, thus
insurance type may serve as a proxy for socioeconomic status (SES) in our population. While
we did not attempt to understand the role of SES in our analysis, we recognize the challenges
associated with poverty, poor educational opportunities, limited access to care, housing and food
insecurity and literacy that may impact care and patient outcomes (28, 37).
Most of our study participants were Hispanic (70%), which is in line with the large
percent of patients seen in our clinic who identify as Hispanic. We found a clinically meaningful
and significant relationship (p = .0011) between Hispanic ethnicity and hospitalization for a
urologic condition. This is consistent with prior work that identifies that those who identify as
Hispanic may be less likely to have bladder and bowel continence (38). This finding validates
the need to provide care consistent with cultural and linguistic considerations and written
educational and follow up materials in Spanish as well as English.
Shunt placements are near universal in the spina bifida population and 90% of our sample
had a shunt. Symptoms of shunt malfunction, including vomiting, headache and lethargy can be
present in other conditions, making it challenging to understand, from our sample, which ED
visits were related to shunt malfunction versus another condition with similar symptoms. Parents
and referring providers often err on the side of caution when possible, shunt related symptoms
occur and have a child seen in the emergency department to assure that a serious or life-
9
threatening shunt complication is not present. Thus, consistent with other studies (11, 12, 14,
19), shunt-related complaints are a frequent cause of emergency department visits.
As identified in other studies of hospitalizations for persons with spina bifida (11, 14,
19), and consistent with our study, neurologic (37%) and urologic (36%) conditions were the
most frequent reasons for the hospitalization. Given the percent of patients with spina bifida
who have shunts (2) and the frequency of neurogenic bladder with resultant morbidities (39), this
is not surprising, although it does provide information about areas for potential intervention to
reduce ED visits, especially related to complications associated with neurogenic bladder.
Prevention interventions may include greater emphasis on clean intermittent catheterization,
fluid intake and prevention of constipation.
There are several limitations of this study. First, the results may not be generalizable to
patients with spina bifida widely, as the population of SB patients in this study is cared for in a
large academic pediatric hospital and differ from those seen in other clinics around the country,
as evidenced by demographic information available through the National Spina Bifida Patient
Registry (38). Our population has a considerably higher percent of patients who are Hispanic
and have public (vs. private) insurance. Second, since this study is based on chart review it is
possible that there was inconsistent use of various diagnostic terms to describe symptoms
related to the ED visit or hospitalizations may result in missed or incomplete diagnoses for
analyses. Finally, we did not consider the extent of underlying conditions that patients may have
had; only the admitting diagnosis was considered in the analysis. This may result in factors
impacting hospital admission that we did not include.
Children and youth with SB experience frequent hospitalizations related to comorbidities
associated with their condition (11, 12, 13, 14). Hospitalizations are burdensome for patients,
10
families and society. Patients miss school and family life and can suffer traumatic effects from
the hospitalization experience (40, 41, 42). Family members miss work and school, parents are
challenged to care for their hospitalized child and those left at home and can experience
burdensome out of pocket expenses (43). High societal costs can be associated with lengthy or
preventable hospitalizations (43). Our aim was to determine whether there was a relationship
between demographic and clinical factors and diagnostic categories associated with
hospitalizations resulting from an emergency department visit. Understanding the major factors
associated with ED visits leading to hospitalization may result in opportunities to prevent these
experiences, improving health and quality of life for patients and families and reducing health
care costs.
Conclusion
Patients with myelomeningocele type SB are more likely to be hospitalized if they are
male, school age (5-18 years of age), have a low lumbar level lesion and are not ambulatory.
Our sample population was more likely to have public insurance, identify as Hispanic and have a
shunt, characteristics of our clinic population. Common reasons for hospitalizations in this
sample included shunt malfunction, urinary tract infection and fever, consistent with other
studies.
This study contributes to our understanding of children most at risk for hospitalization as
demonstrated by our findings. Particularly for those with urologic findings, this provides an
opportunity to identify and provide interventions to avoid preventable hospitalizations.
Interestingly, we had few hospitalizations for pressure sores. This is different from other studies
(13) and may be related to the fact that there is a team of wound care nurses available to our
clinic that addresses issues early and aggressively, perhaps preventing hospitalizations. Given
11
the expense and disruption of family life, school and social opportunities, prevention of
avoidable hospitalizations is especially important for this complex patient population.
Future research directions can be aimed at identifying those at highest risk for
hospitalization, and piloting and evaluating strategies to prevent or limit unanticipated hospital
stays.

12
Figure 1 Patient Inclusion Criteria Flow Chart

* 1 of the 28 arrived from El Salvador without medical records.

N=522 patients with spina bifida seen in
the CHLA ED from May 2017 – July
2019
N=136
N=108 for
analysis
Excluded 28* patients with
non-myelomeningocele lesion
types
Excluded 386 patients who
were discharged home from the
ED (not admitted to the
hospital)

13
Table 1 Demographics (n= 108)

Sex
Male
Female

57 (53%)
51 (47%)
Ages
1-12 months
13-36 months
37-59 months
5-12 years
13-18 years
19-21 years

17 (16%)
13 (12%)
7 (6%)
30 (28%)
30 (28%)
11 (10%)
Level of Lesion
Thoracic
High Lumbar
Mid Lumbar
Low Lumber
Sacral

19 (18%)
5 (4%)
28 (26%)
42 (39%)
14 (13%)
Ambulation Status
Non-Ambulatory
Household Ambulator
Community Ambulator

59 (55%)
8 (7%)
41 (38%)
Insurance
Any Public
Any Commercial
Both Public and Commercial
Unknown

90 (83%)
3 (3%)
14 (13%)
1 (1%)
Ethnicity
Hispanic
Non-Hispanic
Unknown

76 (70%)
27 (25%)
5 (5%)
Shunt
Yes
No

97 (90%)
11 (10%)

14
Table 2 Diagnosis Categories *

Neurologic 40 (37%) Shunt malfunction 15
Seizure 7
Altered mental status 4
Headache 14
Neck pain 1
Irritability 2
Dizziness 2
Intracranial bleed 1
Dysconjugate gaze 1
Bulging fontanelle 1
Blurry vision 1
Leg numbness 1
Urologic 39 (36%) Urinary tract infection 37
Acute renal failure 1
Chronic kidney disease 3
Acute kidney injury 1
Left flank pain 1
Nephrolithiasis 1
Uremia 1
Hydronephrosis 1
Urachal Cyst 1
Miscellaneous 24 (22%) Fever 13
Viral illness 2
Leukemia 1
Abnormal labs 1
Vaginal bleeding 1
Bleeding 1
ACTH deficiency 1
Anemia 1
Abdominal cyst 1
Sepsis 1
Abdominal abscess 1
Acute otitis media 1
Other 1
Gastrointestinal 21 (19%) Abdominal pain 3
Constipation 2
Fecal impaction 1
Ileus 2
Diarrhea 3
Gastroenteritis 2
Feeding issues 2
Nausea 1
Gastritis 1
15
Acute vomiting 13
Small bowel obstruction 1
Appendicitis 1
Metabolic 12 (11%) Dehydration 10
Hyperkalemia 2
Hyponatremia 2
Metabolic acidosis 1
Hypokalemia 1
Musculoskeletal 11 (10%) Fractures 4
Osteomyelitis 6
Foot pain 1
Back pain 2
Swelling of back 1
Skin 11 (10%) Skin breakdown 6
Cellulitis 6
Abscess 1
Cardiovascular 10 (9%) Hypertension 1
Chest pain 1
Bradycardia 3
Tachycardia 5
Palpitations 1
Respiratory 8 (7%) Upper respiratory infection
1
Lower respiratory infection
2
Pneumonia 1
Obstructive sleep apnea 1
Restrictive lung disease 0
Respiratory distress 1
Tachypnea 1
Nocturnal hypoxia 1
Hypoxia 1
Respiratory Failure 0
Psychiatric 1 (<1%) Suicidal ideation 1
* Numbers do not equal 100% as some subjects had more than one diagnosis on admission.

16
Table 3 Diagnostic Categories for Hospitalization and Lesion Level Percentages

Thoracic
(n=19)
L1
(n=5)
L2-3
(n=28)
L4-5
(n=42)
Sacral
(n=14)
Fisher
p-
value
Neurologic 31.6% 20.0% 32.1% 40.5% 50.0% 0.6996
Urologic 42.1% 0.0% 32.1% 33.3% 57.1% 0.2042
Skin 21.1% 20.0% 17.9% 2.4% 0.0% 0.0269
Respiratory 5.3% 0.0% 10.7% 9.5% 0.0% 0.8469
Gastrointestinal 15.8% 20.0% 17.9% 26.2% 7.1% 0.6293
Musculoskeletal 21.1% 0.0% 17.9% 7.1% 0.0% 0.2075
Cardiovascular 10.5% 20.0% 25.0% 0.0% 0.0% 0.0018
Psychiatric 0.0% 0.0% 3.6% 0.0% 0.0% 0.6111
Metabolic 21.1% 40.0% 3.6% 9.5% 7.1% 0.0906

17
Table 4 Hospitalization and Sociodemographic and Clinical Factors across Diagnoses

Neurologic Urologic Skin Respiratory Musculoskeletal

No
(n=68)
Yes
(n=40)
p-
value
No
(n=69)
Yes
(n=39)
p-
value
No
(n=97)
Yes
(n=11)
p-
value
No
(n=100)
Yes
(n=8)
p-
value
No
(n=96)
Yes
(n=12)
p-
value
Ambulatory ability 0.5214 0.4066 0.6092 0.2649 1.0000
Community amb. 33.8% 45.0%

33.3% 46.2%

39.2% 27.3%

40.0% 12.5%

38.5% 33.3%

Household amb. 8.8% 5.0%

7.3% 7.7%

7.2% 9.1%

7.0% 12.5%

7.3% 8.3%

Non-ambulatory 57.4% 50.0%

59.4% 46.2%

53.6% 63.6%

53.0% 75.0%

54.2% 58.3%

Age 0.9290 0.2479 0.0873 0.0812 0.1389
1-12 months 14.7% 17.5%

20.3% 7.7%

16.5% 9.1%

13.0% 50.0%

17.7% 0.0%

13-59 months 20.6% 15.0%

18.8% 18.0%

20.6% 0.0%

19.0% 12.5%

18.8% 16.7%

5-18 years 54.4% 57.5%

49.3% 66.7%

54.6% 63.6%

57.0% 37.5%

55.2% 58.3%

19-21 years 10.3% 10.0%

11.6% 7.7%

8.3% 27.3%

11.0% 0.0%

8.3% 25.0%

Race/ethnicity 0.4438 0.0011 0.8401 0.782 1.0000
Hispanic 73.5% 65.0%

78.3% 56.4%

69.1% 81.8%

69.0% 87.5%

69.8% 75.0%

Non-Hispanic 23.5% 27.5%

14.5% 43.6%

25.8% 18.2%

26.0% 12.5%

25.0% 25.0%

Unknown 2.9% 7.5%

7.3% 0.0%

5.2% 0.0%

5.0% 0.0%

5.2% 0.0%

Cardiologic Psychiatric Metabolic Gastro

No
(n=98)
Yes
(n=10)
p-
value
No
(n=107)
Yes
(n=1)
p-
value
No
(n=96)
Yes
(n=12)
p-
value
No
(n=87)
Yes
(n=21)
p-
value

Ambulatory ability 0.4169 1.0000 0.0035 0.2632

Community amb. 39.8% 20.0%

38.3% 0.0%

42.7% 0.0%

41.4% 23.8%

Household amb. 7.1% 10.0%

7.5% 0.0%

6.3% 16.7%

6.9% 9.5%

Non-ambulatory 53.1% 70.0%

54.2% 100.0%

51.0% 83.3%

51.7% 66.7%

Age 0.3948 0.1019 0.5359 0.0257

1-12 months 17.4% 0.0%

15.9% 0.0%

16.7% 8.3%

17.2% 9.5%

13-59 months 18.4% 20.0%

18.7% 0.0%

16.7% 33.3%

12.6% 42.9%

5-18 years 55.1% 60.0%

56.1% 0.0%

56.3% 50.0%

58.6% 42.9%

19-21 years 9.2% 20.0%

9.4% 100.0%

10.4% 8.3%

11.5% 4.8%

Race/ethnicity 0.1378 1.0000 0.8506 0.1171

17
18
Table 5 Bivariate Associations with Ambulation Status

Community
Ambulatory
Household
Ambulatory
Non-ambulatory p-value (Fisher’s
exact test)
Age <0.0001
1-12 months 0 0 17 (28.8%)
13-59 months 6 (14.6%) 1 (12.5%) 13 (22.0%)
5-18 years 34 (82.9%) 6 (75%) 20 (33.9%)
19-21 years 1 (2.4%) 1 (12.5%) 9 (15.3%)

Patient gender 0.0199
Female 24 (58.5%) 6 (75%) 21 (35.6%)
Male 17 (41.5%) 2 (25%) 38 (64.4%)

Race/ethnicity 0.1512
Hispanic 25 (61.0%) 7 (87.5%) 44 (74.6%)
Non-Hispanic 14 (34.2%) 0 13 (22.0%)
Unknown 2 (4.9%) 1 (12.5%) 2 (3.4%)

Lesion level <0.0001
High lumbar (L1) 1 (2.44%) 2 (25%) 2 (3.4%)
Low lumbar (L4-5) 21 (51.2%) 4 (50%) 17 (28.8%)
Mid-lumbar (L2-3) 7 (17.1%) 2 (25%) 19 (32.2%)
Sacral 12 (29.3%) 0 2 (3.4%)
Thoracic 0 0 19 (32.2%)

19
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Creator Smith, Kathryn Ann (author)

Core Title Risk factors for unanticipated hospitalizations in children and youth with spina bifida at an urban children’s hospital: a cross-sectional study

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Degree Conferral Date 2021-08

Publication Date 08/02/2021

Defense Date 07/29/2021

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