# Socioeconomic Status, Rurality, and Pediatric Critical Care Admission

## TL;DR

Children in rural and deprived areas have higher rates of critical care admission, suggesting systemic factors in larger centers may help reduce these disparities.

## Contribution

This study identifies how rurality and socioeconomic disadvantage uniquely interact to affect pediatric critical care admission rates in a universal health system.

## Key findings

- Rural and small population centers show higher critical care admission rates linked to socioeconomic disadvantage.
- Medium and large population centers do not show increased admission rates with higher deprivation.
- The highest admission rates are in rural areas with the most socioeconomic deprivation.

## Abstract

This cohort study examines the association between area-level deprivation, rurality, and the incidence of critical care admission among children in British Columbia, Canada, between 2014 and 2023.

In an area with a universal health system, does rurality modify the association of neighborhood socioeconomic disadvantage with rate of pediatric critical care admission?

In this cohort study of 13 990 pediatric critical care admissions, rates of critical care admission were higher in areas of greater socioeconomic disadvantage in rural and small areas but not in medium or large population centers.

These findings suggest that protective systemic and structural factors in medium and large population centers may mitigate neighborhood socioeconomic disadvantages.

Neighborhood-level socioeconomic deprivation has been associated with higher incidence and severity of pediatric critical illness; however, structural factors underlying observed differences have received limited attention.

To describe the association between area-level deprivation, rurality, and incidence of critical care admission among children.

This retrospective cohort study used linked data of individuals aged 0 to 17 years who were admitted to intensive care units in British Columbia (BC), Canada, between 2014 and 2023. Data were analyzed from June to November 2025.

Age, sex, rurality, and neighborhood situational vulnerability (a measure of socioeconomic disadvantage).

The primary outcome was the incidence rate of critical care admission. Poisson regression models were used to estimate incidence rate ratios (IRRs) between exposure groups. The possible interaction between situational vulnerability quintile and population center type was examined.

A total of 10 048 children were admitted 13 990 times to intensive care units (incidence rate of 154 per 100 000 person years). Most admissions were for male children (7641 [54.6%]) and children younger than 5 years (7528 [53.8%]). The IRR for rural or small population centers compared with medium or large was 1.35 (95% CI, 1.28-1.41). Similarly, the IRR for the most vs least deprived quintile was 1.31 (95% CI, 1.23-1.39); however, in medium or large population centers, there was no association between situational vulnerability quintile and critical care admission (eg, quintile 5 vs 1: IRR 1.04; 95% CI, 0.97-1.12). Those in rural or small areas of the most deprived quintile had the highest overall rate (IRR, 2.02; 95% CI, 1.87-2.19 vs highest quintile in large or medium population centers).

In this retrospective cohort study there was higher burden of critical care admission for children living in rural areas and small population centers, and areas with higher situational vulnerability. The association between situational vulnerability and critical care incidence was unique to rural or small regions. Targeted strategies are needed to address contributing factors and ensure timely access to pediatric acute care in underserved areas.