Health Care Utilization During the COVID-19 Pandemic Among Individuals Born Preterm

{"Background": "The COVID-19 pandemic caused significant shifts in pediatric health care utilization, including reductions in emergency department, subspecialty, and primary care visits alongside rapid increases in telehealth. Individuals born preterm (<37 weeks gestation) represent a distinct risk group with medical fragility, increased rates of diseases such as bronchopulmonary dysplasia (BPD), and special health care needs. A 2022 meta-analysis including only 2 studies reported that the risk of severe COVID-19 was 2 times higher in neonates born preterm than in those born at term. Despite over 10% of all US births being preterm and associated with billions in estimated costs, there was a significant lack of data on pandemic-related health care utilization among this population. The NIH-funded Environmental Influences on Child Health Outcomes (ECHO) Program provided an opportunity to investigate these patterns in a large sample of children and young adults ages 1-18 years.", "Methods": "This cohort study analyzed data from 42 ECHO cohorts comprising 1691 mother-offspring pairs (270 preterm, 1421 term) with complete data on gestational age, singleton vs multiple birth, COVID-19 outcomes, maternal age at delivery, offspring age at questionnaire administration, maternal education, maternal race and ethnicity, offspring sex, maternal history of psychiatric disorders, and offspring respiratory disease (BPD or asthma). Preterm birth was defined as <37 weeks gestation; term as \u226537 weeks. Subgroups included extremely preterm (<28 weeks), very preterm (28-31 weeks), moderate preterm (32-33 weeks), and late preterm (34-36 weeks). The primary outcome was health care utilization related to COVID-19 symptom concerns, defined as overnight hospital stay due to suspected SARS-CoV-2, in-person care at clinic/office/urgent care/ED for COVID-19 symptoms, or phone/email/online contact with a practitioner regarding COVID-19 concerns. Generalized estimating equations (GEE) with binomial distribution and logit link were used to calculate adjusted odds ratios (aOR) and 95% CIs, adjusting for month/year of questionnaire completion, offspring age, maternal age, singleton vs multiple birth, offspring sex, asthma/BPD diagnosis, maternal education, maternal psychiatric history, maternal race/ethnicity, and ECHO cohort membership. Questionnaires were completed between April 2020 and August 2021.", "Key Results": "Among 1691 participants (mean age 8.4-8.8 years), 270 were born preterm (mean GA 27.9 weeks; 58.5% extremely preterm <28 weeks) and 1421 were term-born (mean GA 39.2 weeks). Preterm-born individuals had significantly higher rates of BPD (52.8% vs 0%) and asthma (43.7% vs 16.4%). Parents of preterm-born individuals sought health care for COVID-19 concerns more frequently than term-born parents (51.1% vs 33.6%; P<.001). In-person evaluations occurred in 28.6% of preterm vs 18.8% of term (P<.001); phone/telehealth evaluations in 28.3% vs 18.8% (P<.001). No hospitalizations were reported for either group. Respiratory symptoms prompted 40.7% of evaluations in preterm vs 26.4% in term (P<.001). In multivariable analysis, preterm birth was associated with increased odds of health care utilization (aOR 1.70; 95% CI 1.21-2.38). Extremely preterm birth (<28 weeks) showed the strongest association (aOR 2.15; 95% CI 1.40-3.29), while those born at 28-36 weeks did not have significantly increased odds (aOR 1.32; 95% CI 0.85-2.05). Maternal history of psychiatric disorder was independently associated with higher utilization (aOR 1.44; 95% CI 1.17-1.78), as was offspring asthma or BPD diagnosis (aOR 1.32; 95% CI 1.00-1.74). Approximately one-quarter of both groups missed health care appointments (26.8% preterm vs 27.2% term; P=.92).", "Clinical Implications": "This is the first report of differences in COVID-19-related health care utilization between individuals born preterm and at term. The findings suggest that preterm birth history, particularly extremely preterm birth (<28 weeks), is an independent risk factor for seeking care during pandemic surges, even after adjusting for respiratory comorbidities. The absence of hospitalizations in both groups aligns with low pediatric COVID-19 hospitalization rates during the study period. The significant association with maternal psychiatric history highlights the potential role of parental mental health in driving health care utilization, which warrants further investigation given the pandemic's mental health burden. These results may help health systems identify high-risk subgroups for targeted interventions, including refined telemedicine services for individuals with special health care needs and COVID-19 educational tools addressing preterm-specific conditions. The finding that missed appointments did not differ between groups is reassuring. Limitations include potential selection bias from excluding participants with missing data, reliance on caregiver-reported questionnaires subject to recall bias, and the cohort not being representative of the general US population."}