Racial/Ethnic Variation in Emergency Department Care for Children With Asthma

Exploring the Impact of Race on Addressing Intimate Partner Violence in the Emergency Department

OBJECTIVES

Research highlights racial disparities among those experiencing intimate partner violence (IPV), yet little is known about disparities in addressing IPV in the emergency department (ED). This study was designed to examine variability in offering IPV universal education to adult caregivers across patient race within an urban pediatric ED and to explore provider attitudes regarding the role of race in this process.

METHODS

We conducted a mixed-methods study using quantitative data on rates of offering adult caregivers IPV universal education and rates of missing documentation for when IPV universal education was not offered to adult caregivers from January 2016 to December 2020. Analyses compared both rates by patient race listed in the electronic health record. We also conducted semistructured interviews with ED providers, which were qualitatively analyzed for common themes.

RESULTS

Caregivers of Black patients were both more likely to have received IPV universal education compared with caregivers of White patients (31.1% vs 27.3%, P < 0.05) and more likely to lack a documented reason for not offering than caregivers of White patients (70.4% vs 53.9%, P < 0.05). Our semistructured interviews with nurses, nurse practitioners, and physicians in the pediatric ED were able to ascertain specific racial biases that may influence these disparities.

CONCLUSIONS

Our study showed that racial disparities exist in both offering IPV universal education and documentation deferral in our pediatric ED. Combined analysis of our quantitative and qualitative data shows the importance of identifying biases that cause health disparities and increasing diversity among healthcare providers. The results of this study can be used to inform new methodologies for healthcare providers to address their personal biases and ensure that all caregivers visiting the ED are offered IPV support resources.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department

OBJECTIVE

To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity.

STUDY DESIGN

We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, using data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type.

RESULTS

In total, 94 884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI 0.66-0.75) and 26% (aOR 0.74; 95% CI 0.69-0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI 0.73-0.86) and 22% (aOR 0.78; 95% CI 0.71-0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly greater among Asian children (aOR 2.12; 95% CI 1.19-3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure.

CONCLUSIONS

Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.

Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing

OBJECTIVES

The study aims to assess racial and language disparities in pediatric emergency department (ED) triage using analytical techniques and provide insights into the extent and nature of the disparities in the ED setting.

MATERIALS AND METHODS

The study analyzed a cross-sectional dataset encompassing ED visits from January 2019 to April 2021. The study utilized analytical techniques, including K-mean clustering (KNN), multivariate adaptive regression splines (MARS), and natural language processing (NLP) embedding. NLP embedding and KNN were employed to handle the chief complaints and categorize them into clusters, while the MARS was used to identify significant interactions among the clinical features. The study also explored important variables, including age-adjusted vital signs. Multiple logistic regression models with varying specifications were developed to assess the robustness of analysis results.

RESULTS

The study consistently found that non-White children, especially African American (AA) and Hispanic, were often under-triaged, with AA children having >2 times higher odds of receiving lower acuity scores compared to White children. While the results are generally consistent, incorporating relevant variables modified the results for specific patient groups (eg, Asians).

DISCUSSION

By employing a comprehensive analysis methodology, the study checked the robustness of the analysis results on racial and language disparities in pediatric ED triage. The study also recognized the significance of analytical techniques in assessing pediatric health conditions and analyzing disparities.

CONCLUSION

The study's findings highlight the significant need for equal and fair assessment and treatment in the pediatric ED, regardless of their patients' race and language.

Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

Asthma Quality Measurement and Adverse Outcomes in Medicaid-Enrolled Children

OBJECTIVES

To determine the association between the asthma medication ratio (AMR) quality measure and adverse outcomes among Medicaid-enrolled children with asthma in Arkansas, given concerns regarding the utility of the AMR in evaluating pediatric risk of asthma-related adverse events (AAEs).

METHODS

We used the Arkansas All-Payer Claims Database to identify Medicaid-enrolled children with asthma using a nonrestrictive case definition and additionally using the standard Healthcare Effectiveness Data and Information Set (HEDIS) persistent asthma definition. We assessed the AMR using the traditional dichotomous HEDIS AMR categorization and across 4 expanded AMR categories. Regression models assessed associations between AMR and AAE including hospitalization and emergency department utilization, with models conducted overall and by race and ethnicity.

RESULTS

Of the 22 788 children in the analysis, 9.0% had an AAE (6.7% asthma-related emergency department visits; 3.0% asthma-related hospitalizations). We found poor correlation between AMR and AAE, with higher rates of AAE (10.5%) among children with AMR ≥0.5 compared with AMR <0.5 (8.5%; P < .001), and similar patterns stratified by racial and ethnic subgroups. Expanded AMR categorization revealed notable differences in associations between AMR and AAEs, compared with traditional dichotomous categorization, with worse performance in Black children.

CONCLUSIONS

The AMR performed poorly in identifying risk of adverse outcomes among Medicaid-enrolled children with asthma. These findings underscore concerns of the utility of the AMR in population health management and reliance on restrictive HEDIS definitions. New population health frameworks incorporating broader considerations that accurately identify at-risk children are needed to improve equity in asthma management and outcomes.

Relationship Between Physical Activity and Adult Asthma Control Using NHANES 2011-2020 Data

BACKGROUND The purpose of this study was to determine whether PA is associated with asthma control using data from the National Health and Nutrition Examination Survey (NHANES) for 2011-2020. We did not find a relationship between physical activity (PA) and asthma control. MATERIAL AND METHODS In this study, we measured asthma control by counting asthma attacks and emergency room visits for asthma in the past year. Physical activity was divided into recreational physical activity and work physical activity. A total of 3158 patients (≥20 years old) were included in the study, of which 2375 were in the asthma attack group and 2844 were in the emergency care group, with indicators of asthma control and physical activity as dichotomous variables. Multiple sets of covariates were selected, such as age, gender, and race. Multiple logistic regression analysis and subgroup analysis were used to analyze the data. RESULTS Active workload was significantly correlated with acute asthma attacks, but the relationship with emergency care was not statistically significant. We found that the relationship between physical activity and emergency care was influenced by race, education, and economic level. CONCLUSIONS The amount of work activity was correlated with acute asthma attacks, and the relationship between physical activity and emergency case was influenced by race, education, and economic level.

Undertriage for Children With Caregivers Preferring Languages Other Than English

OBJECTIVES

Undertriage, the underestimation of acuity, can result in delayed care and potential morbidity in the emergency department (ED). Although inequities in ED care based on language preference have been noted, little is known about its association with undertriage. We evaluated for differences in undertriage based on caregiver language preference.

METHODS

This was a retrospective cross-sectional study of patients aged younger than 21 years, triaged as Emergency Severity Index (ESI) level 4 or 5 (nonurgent), to the pediatric ED from January 1, 2019, through January 31, 2021. Indicators of undertriage were defined as hospital admission, significant ED resource use, or return visits with admission. We used logistic regression with generalized estimating equations to measure the association of preferred language with undertriage.

RESULTS

Of 114 266 ED visits included in the study, 22 525 (19.8%) represented patients with caregivers preferring languages other than English. These children were more likely to experience undertriage compared with those with caregivers preferring English (3.7% [English] versus 4.6% [Spanish] versus 5.9% [other languages]; Spanish versus English: odds ratio [OR], 1.3; 95% confidence interval [CI], 1.2-1.4] and other languages versus English: OR, 1.6; 95% CI, 1.2-2.2). Differences remained after adjusting for sex, insurance, mode of arrival, and clustering by triage nurse (Spanish versus English: adjusted OR, 1.3; 95% CI, 1.3-1.5) and other languages versus English: adjusted OR, 1.6; 95% CI, 1.2-2.2).

CONCLUSIONS

Children accompanied by caregivers preferring languages other than English are more likely to be undertriaged in the pediatric ED. Efforts to improve the triage process are needed to promote equitable care for this population.

Toward Improving Patient Equity in a Pediatric Emergency Department: A Framework for Implementation

Disparities in health care delivery and health outcomes for patients in the emergency department (ED) by race, ethnicity, and language for care (REaL) are common and well documented. Addressing inequities from structural racism, implicit bias, and language barriers can be challenging, and there is a lack of data on effective interventions. We describe the implementation of a multifaceted equity improvement strategy in a pediatric ED using Kotter's model for change as a framework to identify the key drivers. The main elements included a data dashboard with quality metrics stratified by patient self-reported REaL to visualize disparities, a staff workshop on implicit bias and microaggressions, and several clinical and operational tools that highlight equity. Our next steps include refining and repeating interventions and tracking important patient outcomes, including timely pain treatment, triage assessment, diagnostic evaluations, and interpreter use, with the overall goal of improving patient equity by REaL over time. This article presents a roadmap for a disparity reduction intervention, which can be part of a multifaceted approach to address health equity in EDs.

Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair

OBJECTIVES

Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores.

METHODS

We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables.

RESULTS

We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score.

CONCLUSION

The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.

Race and the emergency department management of febrile seizures

To determine if racial disparities exist in the management of febrile seizures in a large pediatric emergency department (ED), We performed a retrospective cross-sectional analysis of children 6 months to 6 years-old who presented to the ED with a febrile seizure over a 4-year period. Multivariate logistic regression models were built to examine the association between race and the primary outcome of neuroimaging, and secondary outcomes of hospital admission and abortive anticonvulsant prescription at ED discharge. There were 980 ED visits during the study period. Overall, 4.0% of children underwent neuroimaging and 11.1% were admitted. Of the 871 children discharged from the ED, 9.4% were prescribed an abortive anticonvulsant. There were no differences by race in neuroimaging or hospital admission. However, black children were less likely to be prescribed abortive anticonvulsants (adjusted odds ratio [aOR] 0.47; 95% confidence interval [CI]: 0.23-0.96) compared to non-black peers, when adjusting for demographic and clinical confounders. Stratification by insurance revealed that this disparity existed in Medicaid-insured patients (aOR 0.33, 95% CI: 0.14-0.78) but not in privately-insured patients. We found no racial disparities in neuroimaging or hospital admission among ED patients with febrile seizures. We did find racial disparities in our secondary outcome of abortive anticonvulsant prescription, driven primarily by individuals on Medicaid insurance. This pattern of findings may reflect the lack of standardized recommendations regarding anticonvulsant prescription, in contrast to the guidelines issued for other ED management decisions. Further investigation into the potential for treatment guidelines to reduce racial disparities is needed.

Analysis of Racial and Ethnic Diversity of Population Served and Imaging Used in US Children's Hospital Emergency Departments

Importance

Lower rates of diagnostic imaging have been observed among Black children compared with White children in pediatric emergency departments. Although the racial composition of the pediatric population served by each hospital differs, it is unclear whether this is associated with overall imaging rates at the hospital level, and in particular how it may be associated with the difference in imaging rates between Black and White children at a given hospital.

Objective

To examine the association between the diversity of the pediatric population seen at each pediatric ED and variation in diagnostic imaging.

Design, Setting, and Participants

Cross-sectional analysis of ED visits by patients younger than 18 years at 38 children's hospitals from January 1, 2016, through December 31, 2019, using data from the Pediatric Health Information System. Data were analyzed from April to September 2021.

Exposures

Proportion of patients from minoritized groups cared for at each hospital.

Main Outcomes and Measures

The primary outcome was receipt of an imaging test defined as radiography, ultrasonography, computed tomography, or magnetic resonance imaging; adjusted odds ratios (aORs) were calculated to measure differences in imaging by race and ethnicity by hospital, and the correlation between the proportion of patients from minoritized groups cared for at each hospital and the aOR for receipt of diagnostic imaging by race and ethnicity was examined.

Results

There were 12 310 344 ED visits (3 477 674 [28.3%] among Hispanic patients; 3 212 915 [26.1%] among non-Hispanic Black patients; 4 415 747 [35.9%] among non-Hispanic White patients; 6 487 660 [52.7%] among female patients) by 5 883 664 pediatric patients (mean [SD] age, 5.84 [5.23] years) to the 38 hospitals during the study period, of which 3 527 866 visits (28.7%) involved at least 1 diagnostic imaging test. Diagnostic imaging was performed in 1 508 382 visits (34.2%) for non-Hispanic White children, 790 961 (24.6%) for non-Hispanic Black children, and 907 222 (26.1%) for Hispanic children (P < .001). Non-Hispanic Black patients were consistently less likely to receive diagnostic imaging than non-Hispanic White patients at each hospital, and for all imaging modalities. There was a significant correlation between the proportion of patients from minoritized groups cared for at the hospital and greater imaging difference between non-Hispanic White and non-Hispanic Black patients (correlation coefficient, -0.37; 95% CI, -0.62 to -0.07; P = .02).

Conclusions and Relevance

In this cross-sectional study, hospitals with a higher percentage of pediatric patients from minoritized groups had larger differences in imaging between non-Hispanic Black and non-Hispanic White patients, with non-Hispanic White patients consistently more likely to receive diagnostic imaging. These findings emphasize the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine.

Adultification of Black children negatively impacts their health: Recommendations for health care providers

Adultification is the term used to define how Black children are viewed as older than they are. Systemic racism has forced Black children into social, emotional, and physical adult roles before they are adults, contributing to adultification. Pediatric and family health care providers must be knowledgable of the harms of adultification bias and that the factor of intersectionality, for example, children who are Black and female, or Black with a disability, enhances bias. Recognition of adultification by health care providers may improve the health and wellness of Black children.

Racial and ethnic differences in low-value pediatric emergency care

BACKGROUND

Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED).

METHODS

We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital.

RESULTS

We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients.

CONCLUSIONS

NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.

Patient Race or Ethnicity and the Use of Diagnostic Imaging: A Systematic Review

OBJECTIVE

To summarize the existing literature evaluating differences in imaging use based on patient race and ethnicity.

METHODS

The authors performed a structured search of four databases for the dates January 1, 2000, to April 13, 2021, using key words and derivatives focused on imaging and patient race. Retrieved citations were reviewed by abstract and then full text to identify articles that evaluated the likelihood of imaging use by patient race or ethnicity controlling for sociodemographic factors. Data regarding publication characteristics, study population, clinical setting, and results was extracted and summarized.

RESULTS

The structured search identified 2,938 articles of which 206 met inclusion criteria. Most studies (87%, 179 of 206) were conducted in the United States, and the majority (72%, 149 of 206) found decreased or inappropriate imaging use in minority groups. Breast cancer screening was the most common clinical setting (50%, 104 of 206), followed by cancer care (10%, 21 of 206) and general imaging use (9%, 19 of 206). Government-administered surveys were the most common data source (40%, 82 of 206). Only a small minority of studies (8%, 17 of 206) evaluated strategies to mitigate the unequal use of imaging based on patient race and ethnicity.

DISCUSSION

The existing literature shows decreased or inappropriate use of diagnostic imaging for minority patients across a wide variety of clinical settings. Although the number of articles on the topic is large, the majority are clustered around specific topics, and few articles evaluate potential strategies to reduce the inequitable use of diagnostic imaging.

Racial and Language Disparities in Pediatric Emergency Department Triage

OBJECTIVE

The aim of this study was to assess the impact race and language have on emergency department (ED) triage scores while accounting for illness severity. We hypothesized that non-White and non-English-speaking patients were assigned lower-acuity triage scores compared with White and English-speaking patients, respectively.

METHODS

We used a chart review-based retrospective cohort study design, examining patients aged 0 to 17 years at our pediatric ED from July 2015 through June 2016. Illness severity was measured using a truncated Modified Pediatric Early Warning Score calculated from patient vital signs. We used univariate and multivariate multinomial logistic regression to assess the association between race and language with Emergency Severity Index scores.

RESULTS

Our final data set consisted of 10,815 visits from 8928 patients. Non-Hispanic (NH) White patients accounted for 34.6% of patients. In the adjusted analyses, non-White patients had significantly reduced odds of receiving a score of 2 (emergency) (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.33-0.49) or 3 (urgent) (OR, 0.5; 95% CI, 0.45-0.56) and significantly higher odds of receiving a score of 5 (minor) (OR, 1.34; 95% CI, 1.07-1.69) versus a score of 4 (nonurgent). We did not find a consistent disparity in Emergency Severity Index scores when comparing English- and non-English-speaking patients.

CONCLUSIONS

We confirm that non-White patients receive lower triage scores than White patients. A more robust tool is required to account for illness severity and will be critical to understanding whether the relationship we describe reflects bias within the triage system or differences in ED utilization by racial groups.

Equitable and Timely Care of Febrile Neonates: A Cross-Sectional Study

OBJECTIVES

In pediatric emergency departments (EDs), racial/ethnic minorities are less likely to receive needed and timely care; however, clinical protocols have the potential to mitigate disparities. Neonatal fever management is protocolized in many EDs, but the timeliness to antibiotic administration is likely variable. We investigated the timeliness of antibiotic administration for febrile neonates and whether timeliness was associated with patients' race/ethnicity.

METHODS

Retrospective cross-sectional study of febrile neonates evaluated in one pediatric ED that uses an evidence-based guideline for the management of neonatal fever between March 2010 and December 2015. Primary outcome was time from ED arrival to antibiotic administration. Analysis of variance tests compared mean time with antibiotic administration across race/ethnicity. Multivariable linear regression investigated racial/ethnic differences in time to antibiotic administration after adjusting for patient demographics, timing of visit, the number of physicians involved, and ED census.

RESULTS

We evaluated 317 febrile neonates. Of the 269 patients with racial/ethnic data (84.9%), 54% were white non-Hispanic, 13% were black non-Hispanic, and 23% were Hispanic. The mean time to antibiotic administration was 204 minutes (range = 51-601 minutes). There was no significant association between patient race/ethnicity and time to first antibiotic administration. Emergency department census was significantly associated with timeliness.

CONCLUSIONS

There was a 10-hour range in the time to antibiotic administration for febrile neonates; however, variability in timeliness did not differ by race or ethnicity. This study demonstrates the need to further examine the role of protocols in mitigating disparities as well as factors that influence timeliness in antibiotic administration to febrile neonates.

Racial/Ethnic Disparities in Triage Scores Among Pediatric Emergency Department Fever Patients

OBJECTIVES

Emergency department (ED) triage scores are assigned to patients in a short period based on assessment of need for lifesaving measures, risk and pain levels, resource needs, and vital signs. Racial/ethnic disparities have been found across a number of outcomes but are not consistent across all studies. This study examines pediatric ED cases reporting fever, a commonly reported triage symptom, to explore racial/ethnic and age disparities in triage score assignment.

METHODS

This study uses the 2009-2015 National Hospital Ambulatory Medical Care Survey, an annual national sample of ED visits in the United States. Pediatric cases where fever is the sole reported reason for visit are analyzed for racial/ethnic disparities, controlling for sex, age, insurance status, body temperature, region, and hospital type.

RESULTS

Among all pediatric fever cases, temperature is the sole significant predictor of triage scores. However, non-Hispanic (NH) black pediatric patients older than 1 year have approximately 22% greater risk of being given a less urgent triage score relative to NH white patients.

CONCLUSIONS

Findings suggest racial disparities in the triage of NH black pediatric patients older than 1 year for fever. Although fever is a single and often non-life-threatening condition, especially after infancy, findings of racial disparities in triage scores suggests a need for further evaluation of the assignment of patient urgency in emergency medicine.

Racial and ethnic disparities in bronchiolitis management in freestanding children's hospitals

OBJECTIVE

Variation in bronchiolitis management by race and ethnicity within emergency departments (EDs) has been described in single-center and prospective studies, but large-scale assessments across EDs and inpatient settings are lacking. Our objective is to describe the association between race and ethnicity and bronchiolitis management across 37 U.S. freestanding children's hospitals from 2015 to 2018.

METHODS

Using the Pediatric Health Information System, we analyzed ED and inpatient visits from November 2015 to November 2018 of children with bronchiolitis 3 to 24 months old. Rates of use for specific diagnostic tests and therapeutic measures were compared across the following race/ethnicity categories: 1) non-Hispanic White (NHW), 2) non-Hispanic Black (NHB), 3) Hispanic, and 4) other. The subanalyses of ED patients only and children < 1 year old were performed. Mixed-effect logistic regression was performed to compare the adjusted odds of receiving specific test/treatment using NHW children as the reference group.

RESULTS

A total of 134,487 patients met inclusion criteria (59% male, 28% NHB, 26% Hispanic). Adjusted analysis showed that NHB children had higher odds of receiving medication associated with asthma (odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.22 to 1.32) and lower odds of receiving diagnostic tests (blood cultures, complete blood counts, viral testing, chest x-rays; OR = 0.78, 95% CI = 0.75 to 0.81) and antibiotics (OR = 0.58, 95% CI = 0.52 to 0.64) than NHW children. Hispanic children had lower odds of receiving diagnostic testing (OR = 0.94, 95% CI = 0.90 to 0.98), asthma-associated medication (OR = 0.92, 95% CI = 0.88 to 0.96), and antibiotics (OR = 0.74, 95% CI = 0.66 to 0.82) compared to NHW children.

CONCLUSION

NHB children more often receive corticosteroid and bronchodilator therapies; NHW children more often receive antibiotics and chest radiography. Given that current guidelines generally recommend supportive care with limited diagnostic testing and medical intervention, these findings among NHB and NHW children represent differing patterns of overtreatment. The underlying causes of these patterns require further investigation.

Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status

OBJECTIVE

To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities.

METHODS

Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA.

RESULTS

We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P = .01), have longer inpatient length of stay (31 vs 29 hours, P = .01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P = .02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures.

CONCLUSION

At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.

Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019

IMPORTANCE

Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown.

OBJECTIVE

To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019.

EXPOSURES

Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses.

RESULTS

A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category.

CONCLUSIONS AND RELEVANCE

In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.

Racial and Ethnic Disparities in Pain Management of Children With Limb Fractures or Suspected Appendicitis: A Retrospective Cross-Sectional Study

Objective: To evaluate whether racial/ethnical differences in analgesia administration existed in two different cohorts of children with painful conditions: children with either limb fracture or suspected appendicitis. Methods: Retrospective cross-sectional analysis of children visiting a pediatric emergency department (Boston Children Hospital) for limb fracture or suspected appendicitis from 2011 to 2015. We computed the proportion of children that received any analgesic treatment and any opioid analgesia. We performed multivariable logistic regressions to investigate race/ethnicity differences in analgesic and opioid administration, after adjusting for pain score, demographics and visit covariates. Results: Among the 8,347 children with a limb fracture and the 4,780 with suspected appendicitis, 65.0 and 60.9% received any analgesic treatment, and 35.9 and 33.4% an opioid analgesia, respectively. Compared to White non-Hispanic Children, Black non-Hispanic children and Hispanic children were less likely to receive opioid analgesia in both the limb fracture cohort [Black: aOR = 0.61 (95% CI, 0.50-0.75); Hispanic aOR = 0.66 (95% CI, 0.55-0.80)] and in the suspected appendicitis cohort [Black: aOR = 0.75 (95% CI, 0.58-0.96); Hispanic aOR = 0.78 (95% CI, 0.63-0.96)]. In the limb fracture cohort, Black non-Hispanic children and Hispanic children were more likely to receive any analgesic treatment (non-opioid or opioid) than White non-Hispanic children [Black: aOR = 1.63 (95% CI, 1.33-2.01); Hispanic aOR = 1.43 (95% CI, 1.19-1.72)]. Conclusion: Racial and ethnic disparities exist in the pain management of two different painful conditions, which suggests true inequities in health care delivery. To provide equitable analgesic care, emergency departments should monitor variation in analgesic management and develop appropriate universal interventions.

Epidemiology of readmissions in early infancy following nonelective cesarean delivery

OBJECTIVE

Determine incidence and risk factors for readmissions in early infancy.

STUDY DESIGN

Secondary analysis of data from the Cesarean Section Optimal Antibiotic Prophylaxis trial. All unplanned revisits (unplanned clinic, ER visits, and hospital readmissions) and hospital readmissions (initial discharge to 3-month follow-up) were analyzed.

RESULTS

295 (15.9%) of 1850 infants had revisits with risk factors being ethnicity (adjusted odds ratio (aOR): 0.6 for Hispanic), maternal postpartum antibiotics (1.89), azithromycin treatment (1.22), small for gestational age (1.68), apnea (3.82), and hospital stay after birth >90th percentile (0.49). 71 (3.8%) of 1850 infants were readmitted with risk factors being antenatal steroids (aOR 2.49), elective repeat C/section (0.72), postpartum maternal antibiotics (2.22), O₂ requirement after delivery room (2.82), and suspected/proven neonatal sepsis (0.55).

CONCLUSION(S)

Multiple risk factors were identified, suggesting potential impact on the neonatal microbiome (maternal postpartum antibiotics) or issues related to access/cost of care (Hispanic ethnicity associated with fewer revisits).

Patient Race/Ethnicity and Diagnostic Imaging Utilization in the Emergency Department: A Systematic Review

PURPOSE

Diagnostic imaging often is a critical contributor to clinical decision making in the emergency department (ED). Racial and ethnic disparities are widely reported in many aspects of health care, and several recent studies have reported a link between patient race/ethnicity and receipt of imaging in the ED.

METHODS

The authors conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching three databases (PubMed, Embase, and the Cochrane Library) through July 2020 using keywords related to diagnostic imaging, race/ethnicity, and the ED setting, including both adult and pediatric populations and excluding studies that did not control for the important confounders of disease severity and insurance status.

RESULTS

The search strategy identified 7,313 articles, of which 5,668 underwent title and abstract screening and 238 full-text review, leaving 42 articles meeting the inclusion criteria. Studies were predominately conducted in the United States (41), split between adult (13) and pediatric (17) populations or both (12), and spread across a variety of topics, mostly focusing on specific anatomic regions or disease processes. Most studies (30 of 42 [71.4%]) reported an association between Black, African American, Hispanic, or nonwhite race/ethnicity and decreased receipt of imaging.

CONCLUSIONS

Despite heterogeneity among studies, patient race/ethnicity is linked with receipt of diagnostic imaging in the ED. The strength and directionality of this association may differ by specific subpopulation and disease process, and more efforts to understand potential underlying factors are needed.

Change of address as a measure of housing insecurity predicting rural emergency department revisits after asthma exacerbation

OBJECTIVE

Housing insecurity is an important socioeconomic factor that may impact emergency department (ED) use for children with asthma, but housing insecurity screening has primarily relied on patient surveys or linkage to external data sources. Using patient addresses recorded in the electronic medical record (EMR), we sought to correlate recent changes in address (as a proxy for housing insecurity) with ED revisit risk.

METHODS

We retrospectively identified patients age 2-17 years seen in our rural ED for asthma exacerbation during 2016-2018. We used EMR data from the 12 months before the earliest ED visit to compare patients with and without a recent change of address (over previous 12 months) on 30- and 90-day all-cause and asthma-specific ED revisits.

RESULTS

The study included 632 children, of whom 85 (13%) had a recent address change before the index ED visit. Moving was not associated with asthma-specific 30-day or 90-day revisits. Ninety-day all-cause revisits were more common among patients who had recently moved (36% vs. 25%; p = 0.019), although this difference was not statistically significant after multivariable adjustment for Medicaid insurance coverage and number of recent health system encounters (odds ratio: 1.49; 95% confidence interval: 0.91, 2.46; p = 0.114).

CONCLUSIONS

A history of recent address change in the EMR was not independently associated with repeat ED visits for asthma exacerbation. Many children presenting to the ED did not have recent encounters with our health system where address could be ascertained. This EMR-based proxy for housing insecurity may be more applicable to patients under continuous follow-up.

Language Barriers and the Management of Bronchiolitis in a Pediatric Emergency Department

OBJECTIVE

Language barriers may influence the management of pediatric emergency department (PED) patients who may not align with evidence-based guidelines from the American Academy of Pediatrics. Our objective was to determine if a family's preferred language of Spanish versus English was associated with differences in management of bronchiolitis in the PED.

METHODS

We conducted a retrospective study of children ≤2 years old diagnosed with bronchiolitis in a PED over a 7-year period. Rates of PED testing, interventions, and disposition among children whose families' preferred language was Spanish were compared to children whose families' preferred language was English. Primary outcomes were frequencies of chest x-ray and bronchodilator orders. Secondary outcomes were diagnostic testing, medication orders, and disposition. Logistic regression was used to calculate adjusted odds ratios after controlling for age, emergency severity index, prior visit, and nesting within attending physicians.

RESULTS

A total of 13,612 encounters were included. Spanish-speaking families were more likely to have chest x-rays (35.8% vs 26.7%, P < .0001; adjusted odds ratio [aOR] 1.5; 95% confidence interval [CI] 1.2-1.9), complete blood counts (8.2% vs 4.9%, P < .005; aOR 1.7; 95% CI 1.2-2.5), and blood cultures ordered (8.1% vs 5.0%, P < .05; aOR 1.7; 95% CI 1.2-2.4). No other differences in bronchodilators, medication orders, or disposition were found between the 2 groups.

CONCLUSIONS

Among children diagnosed with bronchiolitis, Spanish-speaking families were more likely to have chest x-rays, complete blood counts, and blood cultures ordered compared to English-speaking families. Further research on how clinical practice guidelines and equity-focused guidelines can impact disparities in diagnostic testing within the PED is warranted.