Reply to Wang et al.To the Editor,We sincerely appreciate the thoughtful response from Wang et al.1, regarding our recent study2. We are grateful for the effort the authors put into expressing potential limitations of our work, as such comments enrich the dialogue in the emerging intersection of pediatric healthcare and health geography. In this interdisciplinary field, constructive discourse is essential to refining methodologies and fostering collaborations that drive innovative solutions. We welcome the opportunity to address their concerns and engage further in this important conversation.Firstly, we acknowledge that a more diverse study sample would have been beneficial. The overall patient population in our health system are diverse across race, ethnicity, language, illness, environmental exposures, and geography. However, the nature of this single center study, as Wang et al. correctly point out, is that our patient study population are less diverse, particularly, in overall geographic composite index measures such as the Social Vulnerability Index (SVI) and Child Opportunity Index (COI). Notably, our study sample represents a group with particularly high scores on SVI and lower scores on COI. That said, a multicenter study involving patients from other health systems would indeed help us further understand the association between SVI or COI and the risk for pediatric intensive care unit (PICU) admission for status asthmaticus. Scaling out to a multicenter study using patient addresses and spatially granular data can be challenging due to the need to protect patient privacy3. Establishing the partnerships, information sharing infrastructure, and processes necessary to conduct a more comprehensive multicenter study is an ongoing area of focus for our team. We are committed to advancing this critical work.Secondly, we acknowledge that a large percentage of patients at the time of our study have reported race and ethnicity values of “other” or “unknown.” Unfortunately, this can be common across health systems with diverse patient populations. Despite the Meaningful Use mandate by the Centers for Medicare and Medicaid Services requiring the collection of race and ethnicity values in electronic health records (EHR), many health systems lack comprehensive race and ethnicity data for their patient populations4. While sub-optimal, there are multiple reasons for responses of “other” and “unknown.” For one, EHRs were traditionally designed with limited race and ethnicity options for patients to choose from, leading to an oversimplification of race and ethnicity categories. Limited options and discrete choices may not always reflect the identity of patients4. Not to mention, directly asking patients how they identify is difficult because the conversation can be uncomfortable for all those involved4. Also, the value of race and ethnicity data for research may not always be fully understood by healthcare professionals and patients leading to subpar data collection4. Still, it is worth noting that since our study was completed, our health system has conducted a large systemic effort to improve the collection of race and ethnicity data. For instance, patients are given more options to self-identify their race and ethnicity with better processes in place during clinic appointments to facilitate data collection. Efforts to minimize missing race and ethnicity data for health disparities research and other health system applications continues to be an important work for all healthcare systems.Thirdly, we concur that other factors, including the residential environment, air pollution, and indoor allergens are important considerations in pediatric healthcare and respiratory diseases. The exposome encompasses a wide array of factors that are associated with asthma5. As we work toward improving our understanding of addressing pediatric health, future work will integrate the physical, social, and environment as key drivers of health. A more holistic approach to understanding this extended environment as it relates to patient health can unlock a better understanding of health and open opportunities to create meaningful and effective interventions. Linking individual environmental factor data remains a key focus for this team.We are thankful for the insightful comments provided by Wang et al. Response to research work provides us all with the opportunity to engage in thoughtful discourse amongst our colleagues to drive research and healthcare forward. Our study of PICU admissions for status asthmaticus is ongoing and a part of a growing work in progress. We share the same ideals Wang et al. express, but more importantly, we share the same desire to advance the health of children everywhere through research.Alicia Adiwidjaja, BS1,2Justin Jones, MD1Patrick Ross, MD1,3Matthew Keefer, MD1,3Margaret J Klein, MS1Jonathan M. Tan, MD MPH MBI1,2,31Children’s Hospital Los Angeles, Los Angeles, California, USA2University of Southern California Spatial Sciences Institute, Los Angeles, California, USA3University of Southern California Keck School of Medicine, Los Angeles, California, USAConflicts of InterestJonathan Tan receives research grant funding from the Anesthesia Patient Safety Foundation, Foundation for Anesthesia Education and Research, and the Southern California Environmental Health Sciences Center. Jonathan Tan is a consultant for GE HealthCare, Edwards Lifesciences, and Medtronic. Jonathan Tan is on the Board of Directors for the Society for Pediatric Anesthesia.ReferencesWang C, Tian H, Shang J. Comment on Justin Jones et al.Pediatric Allergy and Immunology. 2024.Jones J, Klein MJ, Adiwidjaja A, Ross P, Keefer M, Tan JM. The association between composite measures of social vulnerability and PICU admission for status asthmaticus. Pediatric Allergy and Immunology. 2024;35(11). doi:https://doi.org/10.1111/pai.14278. PMID: 39526837. U.S. Department of Health and Human Services. Summary of the HIPAA Privacy Rule. 2003.Diallo MS, Tan JM, Heitmiller ES, Vetter TR. Achieving Greater Health Equity: An Opportunity for Anesthesiology. Anesth Analg. 2022 Jun 1;134(6):1175-1184. doi: 10.1213/ANE.0000000000005937. Epub 2022 Feb 2. PMID: 35110516.Guillien, A., Cadiou, S., Slama, R., & Siroux, V. (2021). The Exposome Approach to Decipher the Role of Multiple Environmental and Lifestyle Determinants in Asthma. International Journal of Environmental Research and Public Health, 18(3), 1138. https://doi.org/10.3390/ijerph18031138