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Fischer K, Ugalde IT. Pediatric Emergency Medicine Joins Choosing Wisely, But Is It Enough? Ann Emerg Med 2024; 84:176-178. [PMID: 38597848 DOI: 10.1016/j.annemergmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/01/2024] [Accepted: 03/07/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Kayleigh Fischer
- Department of Emergency Medicine, McGovern Medical School, UTHealth, Houston, TX
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School, UTHealth, Houston, TX.
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2
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Mulakaluri A, Julian KR, Fernandez A, Kamal RN, Shapiro LM. Are Clinical Practice Guidelines Representative of Patients With Distal Radius Fractures? A Review of Patient Demographics and Patient-Reported Outcome Measures Used to Inform Guidelines. J Hand Surg Am 2024; 49:649-655. [PMID: 38739072 DOI: 10.1016/j.jhsa.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 03/03/2024] [Accepted: 03/20/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE Clinical practice guidelines (CPGs) are recommendations developed for broad application to optimize high-quality care and decision-making. The composition of patients and outcome measures used in studies informing CPGs; however, has not been rigorously evaluated. With growing evidence that outcomes in musculoskeletal surgery vary by sociocultural factors, we aimed to: (1) review the linguistic, racial, and ethnic representation of the patients in the studies informing CPGs for distal radius fractures and (2) assess their use of linguistically and culturally adapted patient-reported outcome measures (PROMs). METHODS The American Academy of Orthopaedic Surgeons website was used to identify relevant studies. Key variables were extracted, including inclusion and exclusion criteria, language of study, patient language and proficiency, patient race and ethnicity, and use of translated or culturally adapted PROMs. If provided, the clinical trial registration page for the study was evaluated. Descriptive statistics were used to describe the frequency of each variable. RESULTS Fifty-four published texts were evaluated. Participant language was reported in four (7%) of the published texts and six (11%) when including the clinical trial registration information. Of the published texts, one (2%) reported ethnic group/race data and 40 (74%) used PROMs. Of those using PROMs, eight (20%) of 40 reported the use of translated PROMs, and three (8%) of 40 reported the use of culturally adapted PROMs. CONCLUSIONS There is a lack of reporting of linguistic, racial, and ethnic data and inconsistent use of PROMs, particularly those that are translated and culturally adapted, in studies included in the American Academy of Orthopaedic Surgeons CPG for distal radius fractures. As sociocultural characteristics and PROMs are associated with outcomes, ensuring they are broadly represented in studies, may improve equity and shared decision-making. CLINICAL RELEVANCE Greater inclusion and reporting of demographic data and PROMs are required in musculoskeletal studies to ensure broad applicability and advance health equity.
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Affiliation(s)
- Ashley Mulakaluri
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Kaitlyn R Julian
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Alicia Fernandez
- Department of Medicine, University of California, San Francisco, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California, San Francisco, CA.
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3
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Martin AA, Jacobs JW, Armijo PR, Allan JM, Booth GS, Spector ND, Overholser B, Silver JK. Analysis of Pediatric Clinical Practice Guideline Authors by Gender, Race, and Ethnicity. J Womens Health (Larchmt) 2024. [PMID: 38842430 DOI: 10.1089/jwh.2023.1132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Background and Objectives: Clinical practice guidelines (CPGs) have significantly influenced medical practice worldwide. Nevertheless, the authorship of CPGs produced by several medical societies has not been representative of the field and population they address, as women and individuals from racial and ethnic minority groups have been underrepresented as authors. We hypothesized that women and individuals from minoritized racial and ethnic groups would also be underrepresented as authors of CPGs produced by the American Academy of Pediatrics (AAP). Methods: In this cross-sectional study, the gender, race, and ethnic composition of authors and subcommittee participants of AAP-produced CPGs published from January 2010 through May 2023 were analyzed and compared to the 2010 and 2021 U.S. population and 2010 and 2022 U.S. medical school pediatric faculty. Results: Women (39.7%, 127/320 of all positions, and 42.5%, 85/200 of named author positions) and women physicians (35.2%, 101/287 of all positions, and 36.4%, 64/176 of named author positions) were significantly underrepresented-while men and men physicians were significantly overrepresented-from their respective composition in the U.S. Census and pediatric faculty. Women and women physicians from all racial and ethnic groups and men and men physicians from minority racial and ethnic groups were significantly underrepresented-from their respective composition in the U.S. Census and pediatric faculty. No Black man was identified as an author. Conclusions: Medical societies that produce CPGs should be cognizant of these inequities and ensure appropriate authorship diversity.
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Affiliation(s)
- Amarilis A Martin
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
- Stony Brook Children's Hospital, Stony Brook, New York, USA
| | | | | | - Jessica M Allan
- Palo Alto Medical Foundation, Palo Alto, California, USA
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Garrett S Booth
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy D Spector
- Executive Leadership in Academic Medicine®, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Barbara Overholser
- Executive Leadership in Academic Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Julie K Silver
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
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4
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Nama N, Panda P, Montez K, Nafiu OO, First LR, Kemper AR. Trends in the Use and Discussion of Race in Pediatrics Articles Over 75 Years. Pediatrics 2024; 153:e2023064819. [PMID: 38591136 DOI: 10.1542/peds.2023-064819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Race-based medicine, which falsely assumes that race is biological, is common in the published medical literature. We analyzed trends in the use of race in Pediatrics articles over a 75-year period. METHODS We analyzed a random sample of 50 original research articles published each decade in Pediatrics from 1948 to 2022. RESULTS Of 375 articles, 39% (n = 147) included race. Among articles, 85% (n = 116) used race only to describe study subjects, 7% (n = 9) described race as a social construct, and 11% (n = 15) described race as a biological construct. Only 7% (n = 10) of studies provided a reason for including race. Statements reflective of racial bias or discrimination were identified in 22% (n = 30) of the articles that mentioned race. Although statements concerning for explicit racial bias were uncommon, with none identified in the most recent decade, statements suggestive of implicit racial bias still occurred (22%, 5 of 23). Race was presented as a dichotomy, such as "white/nonwhite," in 9% of studies (n = 12). Regarding currently nonrecommended terminology, the term "minorities" was used in 13% of studies (n = 18); 25% of studies used the term "others" (n = 34), and among these, 91% (n = 31 of 34) did not provide any definition, an occurrence that increased over time at a rate of 0.9%/year. CONCLUSIONS Although there has been improvement over the past 75 years in the reporting of race in published studies in Pediatrics, significant opportunities for further improvement remain.
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Affiliation(s)
- Nassr Nama
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Preeti Panda
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kimberly Montez
- Department of Pediatrics and Social Sciences & Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Olubukola O Nafiu
- Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Lewis R First
- Department of Pediatrics, Robert Larner College of Medicine, University of Vermont and University of Vermont Children's Hospital, Burlington, Vermont
| | - Alex R Kemper
- Division of Primary Care Pediatrics, Departments of Pediatrics
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5
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Belay B, Kraus EM, Porter R, Pierce SL, Kompaniyets L, Lundeen EA, Imperatore G, Blanck HM, Goodman AB. Examination of Prediabetes and Diabetes Testing Among US Pediatric Patients With Overweight or Obesity Using an Electronic Health Record. Child Obes 2024; 20:96-106. [PMID: 36930745 PMCID: PMC10505239 DOI: 10.1089/chi.2022.0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
Background: Youth with excess weight are at risk of developing type 2 diabetes (T2DM). Guidelines recommend screening for prediabetes and/or T2DM after 10 years of age or after puberty in youth with excess weight who have ≥1 risk factor(s) for T2DM. Electronic health records (EHRs) offer an opportunity to study the use of tests to detect diabetes in youth. Methods: We examined the frequency of (1) diabetes testing and (2) elevated test results among youth aged 10-19 years with at least one BMI measurement in an EHR from 2019 to 2021. We examined the presence of hemoglobin A1C (A1C), fasting plasma glucose (FPG), or oral glucose tolerance test (2-hour plasma glucose [2-hrPG]) results and, among those tested, the frequency of elevated values (A1C ≥6.5%, FPG ≥126 mg/dL, or 2-hrPG ≥200 mg/dL). Patients with pre-existing diabetes (n = 6793) were excluded. Results: Among 1,024,743 patients, 17% had overweight, 21% had obesity, including 8% with severe obesity. Among patients with excess weight, 10% had ≥1 glucose test result. Among those tested, elevated values were more common in patients with severe obesity (27%) and obesity (22%) than in those with healthy weight (8%), and among Black youth (30%) than White youth (13%). Among patients with excess weight, >80% of elevated values fell in the prediabetes range. Conclusions: In youth with excess weight, the use of laboratory tests for prediabetes and T2DM was infrequent. Among youth with test results, elevated FPG, 2hrPG, or A1C levels were most common in those with severe obesity and Black youth.
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Affiliation(s)
- Brook Belay
- Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Emily M. Kraus
- Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Public Health Informatics Institute, Atlanta, GA, USA
| | - Renee Porter
- Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, GA, USA
- McKing Consulting Corporation, Atlanta, GA, USA
| | - Samantha Lange Pierce
- Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lyudmyla Kompaniyets
- Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elizabeth A. Lundeen
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Giuseppina Imperatore
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Heidi M. Blanck
- Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alyson B. Goodman
- Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, GA, USA
- United States Public Health Service, Atlanta, GA, USA
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Shapiro LM, Katz P, Stern BZ, Kamal RN. Equitable Integration of Patient-Reported Outcomes Into Clinical Practice-Opportunities, Challenges, and a Roadmap for Implementation. J Am Acad Orthop Surg 2024; 32:187-195. [PMID: 38194644 DOI: 10.5435/jaaos-d-23-00798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/08/2023] [Indexed: 01/11/2024] Open
Abstract
Patient-reported outcome measures (PROMs) provide a standardized assessment from the patient about their own health status. Although originally developed as research tools, PROMs can be used in clinical care to complement objective functional measures (eg, range of motion) and are increasingly integrated to guide treatment decisions and predict outcomes. In some situations, when PROMs are used during clinical care they can improve patient mortality, outcomes, engagement, well-being, and patient-physician communication. Guidance on how PROMs should be communicated with patients continued to be developed. However, PROM use may have unintended consequences, such as when used implemented without accounting for confounding factors (eg, psychological and social health) or in perpetuating healthcare disparities when used imprecisely (eg, lack of linguistic or cultural validation). In this review, we describe the current state of PROM use in orthopaedic surgery, highlight opportunities and challenges of PROM use in clinical care, and provide a roadmap to support orthopaedic surgery practices in incorporating PROMs into routine care to equitably improve patient health.
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Affiliation(s)
- Lauren M Shapiro
- From the Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA (Shapiro), the Department of Medicine, University of California-San Francisco, San Francisco CA (Katz), the Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine, New York, NY (Stern), the VOICES Health Policy Research Center, and Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Kamal)
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7
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Gutman CK, Aronson PL, Singh NV, Pickett ML, Bouvay K, Green RS, Roach B, Kotler H, Chow JL, Hartford EA, Hincapie M, St. Pierre-Hetz R, Kelly J, Sartori L, Hoffmann JA, Corboy JB, Bergmann KR, Akinsola B, Ford V, Tedford NJ, Tran TT, Gifford S, Thompson AD, Krack A, Piroutek MJ, Lucrezia S, Chung S, Chowdhury N, Jackson K, Cheng T, Pulcini CD, Kannikeswaran N, Truschel LL, Lin K, Chu J, Molyneaux ND, Duong M, Dingeldein L, Rose JA, Theiler C, Bhalodkar S, Powers E, Waseem M, Lababidi A, Yan X, Lou XY, Fernandez R, Lion KC. Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants. JAMA Pediatr 2024; 178:55-64. [PMID: 37955907 PMCID: PMC10644247 DOI: 10.1001/jamapediatrics.2023.4890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/02/2023] [Indexed: 11/14/2023]
Abstract
Importance Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.
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Affiliation(s)
- Colleen K. Gutman
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
- Department of Pediatrics, University of Florida College of Medicine, Gainesville
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nidhi V. Singh
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Kamali Bouvay
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rebecca S. Green
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School and Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Britta Roach
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Hannah Kotler
- Division of Emergency Medicine, The George Washington University School of Medicine and Health Sciences and Children’s National Health System, Washington, DC
| | - Jessica L. Chow
- Division of Emergency Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Emergency Medicine, University of California, Los Angeles
| | - Emily A. Hartford
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle
| | - Mark Hincapie
- Department of Pediatrics, University of Pittsburgh Medical Center and Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Pediatric Emergency Medicine, Nicklaus Children’s Hospital, Miami, Florida
| | - Ryan St. Pierre-Hetz
- Department of Pediatrics, University of Pittsburgh Medical Center and Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jessica Kelly
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura Sartori
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer A. Hoffmann
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jacqueline B. Corboy
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis, Minnesota
| | - Bolanle Akinsola
- Department of Pediatrics and Emergency Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Vanessa Ford
- Department of Pediatrics and Emergency Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie J. Tedford
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City
| | - Theresa T. Tran
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City
| | - Sasha Gifford
- Ronald O. Perelman Department of Emergency Medicine/New York University Langone Health, New York, New York
- Department of Emergency Medicine, Weill Cornell Medical College, New York, New York
| | - Amy D. Thompson
- Department of Pediatrics, Nemours Children’s Hospital of Delaware, Wilmington
| | - Andrew Krack
- Department of Pediatrics, School of Medicine, Section of Emergency Medicine, University of Colorado and Children’s Hospital Colorado, Aurora
| | - Mary Jane Piroutek
- Department of Emergency Medicine, University of California Irvine and Children’s Hospital of Orange County, Orange
| | - Samantha Lucrezia
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - SunHee Chung
- Department of Emergency Medicine, Oregon Health and Science University, Portland
- Department of Pediatrics, Oregon Health and Science University, Portland
| | - Nabila Chowdhury
- Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Kathleen Jackson
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston
| | - Tabitha Cheng
- Department of Emergency Medicine, Harbor University of California Los Angeles Medical Center and the David Geffen School of Medicine at the University of California, Los Angeles
| | - Christian D. Pulcini
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington
- Department of Emergency Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Nirupama Kannikeswaran
- Department of Pediatrics, Central Michigan University College of Medicine and Children’s Hospital of Michigan, Detroit
| | - Larissa L. Truschel
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Karen Lin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jamie Chu
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, Texas
- Texas Children’s Pediatrics, Houston
| | - Neh D. Molyneaux
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Myto Duong
- Division of Pediatric Emergency Medicine, Southern Illinois University, Carbondale
| | - Leslie Dingeldein
- Rainbow Babies and Children’s Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jerri A. Rose
- Rainbow Babies and Children’s Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Carly Theiler
- Department of Emergency Medicine, University of Iowa, Iowa City
| | - Sonali Bhalodkar
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Emily Powers
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Muhammad Waseem
- Department of Pediatrics, Lincoln Medical Center, Bronx, New York
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Ahmed Lababidi
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
- Department of Pediatrics, University of Florida College of Medicine, Gainesville
| | - Xinyu Yan
- Department of Biostatistics, University of Florida College of Medicine and College of Public Health and Health Professions, Gainesville
| | - Xiang-Yang Lou
- Department of Biostatistics, University of Florida College of Medicine and College of Public Health and Health Professions, Gainesville
| | - Rosemarie Fernandez
- Department of Emergency Medicine and the Center for Experiential Learning and Simulation, University of Florida College of Medicine, Gainesville
| | - K. Casey Lion
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
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8
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Rosen RH, Epee-Bounya A, Curran D, Chung S, Hoffmann R, Lee LK, Marcus C, Mateo CM, Miller JE, Nereim C, Silberholz E, Shah SN, Theodoris CV, Wardell H, Winn AS, Toomey S, Finkelstein JA, Ward VL, Starmer A. Race, Ethnicity, and Ancestry in Clinical Pathways: A Framework for Evaluation. Pediatrics 2023; 152:e2022060730. [PMID: 37974460 DOI: 10.1542/peds.2022-060730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 11/19/2023] Open
Abstract
Clinical algorithms, or "pathways," promote the delivery of medical care that is consistent and equitable. Race, ethnicity, and/or ancestry terms are sometimes included in these types of guidelines, but it is unclear if this is appropriate for clinical decision-making. At our institution, we developed and applied a structured framework to determine whether race, ethnicity, or ancestry terms identified in our clinical pathways library should be retained, modified, or removed. First, we reviewed all text and associated reference documents for 132 institutionally-developed clinical pathways and identified 8 pathways that included race, ethnicity, or ancestry terms. Five pathways had clear evidence or a change in institutional policy that supported removal of the term. Multispecialty teams conducted additional in-depth evaluation of the 3 remaining pathways (Acute Viral Illness, Hyperbilirubinemia, and Weight Management) by applying the framework. In total, based on these reviews, race, ethnicity, or ancestry terms were removed (n = 6) or modified (n = 2) in all 8 pathways. Application of the framework established several recommended practices, including: (1) define race, ethnicity, and ancestry rigorously; (2) assess the most likely mechanisms underlying epidemiologic associations; (3) consider whether inclusion of the term is likely to mitigate or exacerbate existing inequities; and (4) exercise caution when applying population-level data to individual patient encounters. This process and framework may be useful to other institutional programs and national organizations in evaluating the inclusion of race, ethnicity, and ancestry in clinical guidelines.
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Affiliation(s)
- Robert H Rosen
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Alexandra Epee-Bounya
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dorothy Curran
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sarita Chung
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Robert Hoffmann
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Lois K Lee
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Carolyn Marcus
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Camila M Mateo
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Cameron Nereim
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Elizabeth Silberholz
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Snehal N Shah
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Christina V Theodoris
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Hanna Wardell
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Ariel S Winn
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sara Toomey
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Valerie L Ward
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Amy Starmer
- Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Baystate Children's Hospital, Springfield, Massachusetts
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9
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Batman S, Rivlin K, Robinson W, Brown O, Carter EB, Lindo E. A Rubric to Center Equity in Obstetrics and Gynecology Research. Obstet Gynecol 2023; 142:772-778. [PMID: 37678908 PMCID: PMC10510789 DOI: 10.1097/aog.0000000000005336] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/17/2023] [Accepted: 05/25/2023] [Indexed: 09/09/2023]
Abstract
The Steering Committee for the Obstetrics & Gynecology special edition titled "Racism in Reproductive Health: Lighting a Path to Health Equity" formed a working group to create an equity rubric. The goal was to provide a tool to help researchers systematically center health equity as they conceptualize, design, analyze, interpret, and evaluate research in obstetrics and gynecology. This commentary reviews the rationale, iterative process, and literature guiding the creation of the equity rubric.
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Affiliation(s)
- Samantha Batman
- University of Texas MD Anderson Cancer Center, Houston, Texas; University of Chicago Medicine, Chicago, Illinois; Duke University School of Medicine, Durham, North Carolina; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Washington University School of Medicine in St. Louis, St. Louis, Missouri; and University of Washington Medicine, Seattle, Washington
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Jenkins PC, Lin A, Ames SG, Newgard CD, Lang B, Winslow JE, Marin JR, Cook JNB, Goldhaber-Fiebert JD, Papa L, Zonfrillo MR, Hansen M, Wall SP, Malveau S, Kuppermann N. Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity. JAMA Netw Open 2023; 6:e2332160. [PMID: 37669053 PMCID: PMC10481245 DOI: 10.1001/jamanetworkopen.2023.32160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 09/06/2023] Open
Abstract
Importance Presentation to emergency departments (EDs) with high levels of pediatric readiness is associated with improved pediatric survival. However, it is unclear whether children of all races and ethnicities benefit equitably from increased levels of such readiness. Objective To evaluate the association of ED pediatric readiness with in-hospital mortality among children of different races and ethnicities with traumatic injuries or acute medical emergencies. Design, Setting, and Participants This cohort study of children requiring emergency care in 586 EDs across 11 states was conducted from January 1, 2012, through December 31, 2017. Eligible participants included children younger than 18 years who were hospitalized for an acute medical emergency or traumatic injury. Data analysis was conducted between November 2022 and April 2023. Exposure Hospitalization for acute medical emergency or traumatic injury. Main Outcomes and Measures The primary outcome was in-hospital mortality. ED pediatric readiness was measured through the weighted Pediatric Readiness Score (wPRS) from the 2013 National Pediatric Readiness Project assessment and categorized by quartile. Multivariable, hierarchical, mixed-effects logistic regression was used to evaluate the association of race and ethnicity with in-hospital mortality. Results The cohort included 633 536 children (median [IQR] age 4 [0-12] years]). There were 557 537 children (98 504 Black [17.7%], 167 838 Hispanic [30.1%], 311 157 White [55.8%], and 147 876 children of other races or ethnicities [26.5%]) who were hospitalized for acute medical emergencies, of whom 5158 (0.9%) died; 75 999 children (12 727 Black [16.7%], 21 604 Hispanic [28.4%], 44 203 White [58.2%]; and 21 609 of other races and ethnicities [27.7%]) were hospitalized for traumatic injuries, of whom 1339 (1.8%) died. Adjusted mortality of Black children with acute medical emergencies was significantly greater than that of Hispanic children, White children, and of children of other races and ethnicities (odds ratio [OR], 1.69; 95% CI, 1.59-1.79) across all quartile levels of ED pediatric readiness; but there were no racial or ethnic disparities in mortality when comparing Black children with traumatic injuries with Hispanic children, White children, and children of other races and ethnicities with traumatic injuries (OR 1.01; 95% CI, 0.89-1.15). When compared with hospitals in the lowest quartile of ED pediatric readiness, children who were treated at hospitals in the highest quartile had significantly lower mortality in both the acute medical emergency cohort (OR 0.24; 95% CI, 0.16-0.36) and traumatic injury cohort (OR, 0.39; 95% CI, 0.25-0.61). The greatest survival advantage associated with high pediatric readiness was experienced for Black children in the acute medical emergency cohort. Conclusions and Relevance In this study, racial and ethnic disparities in mortality existed among children treated for acute medical emergencies but not traumatic injuries. Increased ED pediatric readiness was associated with reduced disparities; it was estimated that increasing the ED pediatric readiness levels of hospitals in the 3 lowest quartiles would result in an estimated 3-fold reduction in disparity for pediatric mortality. However, increased pediatric readiness did not eliminate disparities, indicating that organizations and initiatives dedicated to increasing ED pediatric readiness should consider formal integration of health equity into efforts to improve pediatric emergency care.
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Affiliation(s)
- Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Amber Lin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Craig D. Newgard
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Benjamin Lang
- Department of Pediatrics, Dell Medical School, University of Texas at Austin
- Department of Surgery, Dell Medical School, University of Texas at Austin
| | - James E. Winslow
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- North Carolina Office of Emergency Medical Services, Raleigh
| | - Jennifer R. Marin
- Departments of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer N. B. Cook
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care, and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Mark R. Zonfrillo
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew Hansen
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Stephen P. Wall
- Ronald O. Perelman Department of Emergency Medicine, Department of Population Health, New York University School of Medicine, New York, New York
| | - Susan Malveau
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento
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Bensignor MO, Bramante CT, Bomberg EM, Fox CK, Hale PM, Kelly AS, Mamadi R, Prabhu N, Harder-Lauridsen NM, Gross AC. Evaluating potential predictors of weight loss response to liraglutide in adolescents with obesity: A post hoc analysis of the randomized, placebo-controlled SCALE Teens trial. Pediatr Obes 2023; 18:e13061. [PMID: 37264767 PMCID: PMC10926323 DOI: 10.1111/ijpo.13061] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND As childhood obesity prevalence increases, determining which patients respond to anti-obesity medications would strengthen personalized approaches to obesity treatment. In the SCALE Teens trial among pubertal adolescents with obesity (NCT02918279), liraglutide 3.0 mg (or maximum tolerated dose) significantly reduced body mass index (BMI) standard deviation score on average versus placebo. That said, liraglutide effects on BMI reduction varied greatly among adolescents, similar to adults. OBJECTIVES To identify post hoc characteristics predictive of achieving ≥5% and ≥10% BMI reductions at 56 weeks with liraglutide versus placebo in adolescents from the SCALE Teens trial. METHODS Logistic regression analysis was performed in 251 adolescents treated with liraglutide (n = 125) or placebo (n = 126) for 56 weeks. Baseline characteristics (selected a priori) included sex, race, ethnicity, age, Tanner (pubertal) stage, glycemic status (hyperglycemia [type 2 diabetes/prediabetes] vs. normoglycemia), obesity category (Class II/III vs. I), severity of depression symptoms (Patient Health Questionnaire-9), and weight variability (weight fluctuations over time). The effects of early responder status (≥4% BMI reduction at week 16) on week 56 response were assessed using descriptive statistics. RESULTS Baseline characteristics did not affect achievement of ≥5% and ≥10% BMI reductions at week 56 in adolescents treated with liraglutide. Further, there was no association between weight variability and BMI reduction. Early liraglutide responders appeared to have greater BMI and body weight reductions at week 56 compared with early non-responders. CONCLUSIONS This secondary analysis suggests that adolescents with obesity may experience significant BMI reductions after 56 weeks of liraglutide treatment, regardless of their sex, race, ethnicity, age, pubertal stage, glycemic status, obesity category, severity of depression symptoms, or weight variability. Early response may predict greater week 56 response.
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Affiliation(s)
- Megan O. Bensignor
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Carolyn T. Bramante
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Eric M. Bomberg
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Claudia K. Fox
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Paula M. Hale
- Clinical Development, Medical & Regulatory Affairs, Novo Nordisk Inc., Plainsboro, New Jersey, USA
| | - Aaron S. Kelly
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rashmi Mamadi
- Global Medical Affairs, Novo Nordisk, Bangalore, India
| | | | | | - Amy C. Gross
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Roberts JE, Williams K, Dallas J, Eckert M, Huie L, Smitherman E, Soulsby WD, Zhao Y, Son MBF. Insurance Status and Tumor Necrosis Factor Inhibitor Initiation Among Children With Juvenile Idiopathic Arthritis in the CARRA Registry. J Rheumatol 2023; 50:1047-1057. [PMID: 36521922 PMCID: PMC10303749 DOI: 10.3899/jrheum.220871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Prompt escalation to tumor necrosis factor inhibitors (TNFis) is recommended for children with juvenile idiopathic arthritis (JIA) and ongoing disease activity despite treatment with conventional disease-modifying antirheumatic drugs (cDMARDs). It is unknown whether these recommendations are equitably followed for children with different insurance types. We assessed the association of insurance coverage on the odds and timing of TNFi use. METHODS We conducted a retrospective study of children with newly diagnosed JIA in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. We compared the odds of starting a TNFi in the first year and time from cDMARD to TNFi initiation between those with public and private insurance. RESULTS We identified 1086 children with new JIA diagnoses. Publicly insured children had significantly higher active joint counts and parent/patient global assessment scores at the enrollment visit. They were also more likely to have polyarticular arthritis compared to those with private insurance. Odds of any TNFi use in the first year did not differ between publicly and privately insured children. Publicly insured children were escalated from cDMARD to TNFi more quickly than privately insured children. CONCLUSION Children who were publicly insured had more severe disease and polyarticular involvement at registry enrollment compared to those who were privately insured. Whereas overall TNFi use did not differ between children with different insurance types, publicly insured children were escalated more quickly, consistent with their increased disease severity. Further research is needed to determine why insurance coverage type is associated with disease severity, including how other socioeconomic factors affect presentation to care.
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Affiliation(s)
- Jordan E Roberts
- J.E. Roberts, MD, MPH, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, and Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, and Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Kathryn Williams
- K. Williams, MS, J. Dallas, BA, M.B.F. Son, MD, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Johnathan Dallas
- K. Williams, MS, J. Dallas, BA, M.B.F. Son, MD, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mary Eckert
- M. Eckert, BS, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Livie Huie
- L. Huie, BA, E. Smitherman, MD, MSc, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Emily Smitherman
- L. Huie, BA, E. Smitherman, MD, MSc, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - William D Soulsby
- W.D. Soulsby, MD, University of California at San Francisco, San Francisco, California
| | - Yongdong Zhao
- Y. Zhao, MD, PhD, Seattle Children's Hospital, University of Washington School of Medicine, and Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
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Lee LK, Ellison A. The Responsibility of Addressing Health Disparities in Emergency Medicine. Ann Emerg Med 2023; 81:393-395. [PMID: 36841660 DOI: 10.1016/j.annemergmed.2023.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA.
| | - Angela Ellison
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Health Equity, Children's Hospital of Philadelphia, Philadelphia, PA
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Bell S, Falusi O, Lindo E. Elimination of race-based medicine: a call to action. THE LANCET CHILD & ADOLESCENT HEALTH 2022; 6:597-598. [DOI: 10.1016/s2352-4642(22)00166-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022]
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