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Haac BE, O'Hara NN, Haut ER, Manson TT, Slobogean GP, O'Toole RV, Stein DM. Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns. OTA Int 2024; 7:e331. [PMID: 38623266 PMCID: PMC11013691 DOI: 10.1097/oi9.0000000000000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 01/17/2024] [Accepted: 02/01/2024] [Indexed: 04/17/2024]
Abstract
Objectives To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial. Design Prospective randomized trial. Setting Level I trauma center. Patients Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis. Intervention VTE imaging studies recorded within 90 days post injury. Main Outcome Measurements Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study. Results Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26-5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05-1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00-1.30). Conclusions VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance. Level of Evidence Level I, Therapeutic.
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Affiliation(s)
- Bryce E. Haac
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Nathan N. O'Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Elliott R. Haut
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Robert V. O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Deborah M. Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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Lee SYJ, Alzeen M, Ahmed A. Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing. J Am Med Inform Assoc 2024; 31:958-967. [PMID: 38349846 PMCID: PMC10990499 DOI: 10.1093/jamia/ocae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/16/2024] [Accepted: 01/19/2024] [Indexed: 02/15/2024] Open
Abstract
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.
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Affiliation(s)
- Seung-Yup Joshua Lee
- Department of Health Services Administration, School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Mohammed Alzeen
- Department of Health Services Administration, School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Abdulaziz Ahmed
- Department of Health Services Administration, School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL 35233, United States
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Momplaisir F, Rogo T, Alexander Parrish R, Delair S, Rigaud M, Caine V, Absalon J, Word B, Hewlett D. Ending Race-Conscious College Admissions and Its Potential Impact on the Infectious Disease Workforce. Open Forum Infect Dis 2024; 11:ofae083. [PMID: 38444821 PMCID: PMC10913839 DOI: 10.1093/ofid/ofae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/12/2024] [Indexed: 03/07/2024] Open
Abstract
On 29 June 2023, the Supreme Court of the United States ruled that race-conscious consideration for college admission is unconstitutional. We discuss the consequences of this ruling on the delivery of equitable care and health system readiness to combat current and emerging pandemics. We propose strategies to mitigate the negative impact of this ruling on diversifying the infectious disease (ID) workforce.
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Affiliation(s)
- Florence Momplaisir
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- The Penn Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tanya Rogo
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ronika Alexander Parrish
- Vaccines & Antivirals Medical and Scientific Affairs, Pfizer Biopharmaceuticals Group, New York, New York, USA
| | - Shirley Delair
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mona Rigaud
- Department of Pediatrics at NYU Grossman School of Medicine, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA
| | - Virginia Caine
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Judith Absalon
- Infectious Diseases & Virology, Development Clinical Sciences, GlaxoSmithKline Pharmaceutical, New York, New York, USA
| | - Bonnie Word
- Houston Travel Medicine Clinic, Houston, Texas, USA
| | - Dial Hewlett
- Tuberculosis Services, Westchester Department of Health, Chair IDSA Committee on Diversity Access & Equity, White Plains, New York, USA
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4
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Grabski DF, Vavolizza RD, Baumgarten HD, Fleming MA, Moneme C, McGahren ED, Swanson JR, Kabagambe SK, Gander JW. Post-operative Opioid Reduction Protocol Reduces Racial Disparity in Clinical Outcomes in Children. J Pediatr Surg 2024; 59:53-60. [PMID: 37858396 DOI: 10.1016/j.jpedsurg.2023.09.030] [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: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Racial disparities in health outcomes continue to exist for children requiring surgery. Previous investigations suggest that clinical protocols may reduce racial disparities. A post-operative opioid reduction protocol was implemented in children undergoing abdominal surgery who were less than 1 years old at a tertiary level hospital. The purpose of this investigation was to determine if the clinical protocol was associated with a reduction in racial disparity in post-operative opioid prescribing patterns and associated clinical outcomes. METHODS A post-operative opioid reduction protocol based on standing intravenous acetaminophen, educational sessions with nursing staff, and standardized post-operative sign-out between the surgical and NICU teams was implemented in children under 1 year old in 2016. A time series and before and after analysis was conducted using a historical pre-intervention cohort (Jan 2011-Dec 2015) and prospectively collected post-intervention cohort (Jan 2016-Jan 2021). Primary outcomes included post-operative opioid use and post-operative pain scores stratified by race. Secondary outcomes included associated clinical outcomes also stratified by race. RESULTS A total of 249 children were included in the investigation, 117 in the pre-intervention group and 132 in the post intervention group. The majority of patients in both cohorts were either White or Black. The two cohorts were equally matched in terms of pre-operative clinical variables. In the pre-intervention cohort, the median post-operative morphine equivalents in White children was 2.1 mg/kg (IQR 0.2, 11.1) while in Black children it was 13.1 mg/kg (IQR 2.4, 65.3), p-value = 0.0352. In the post-intervention cohort, the median value for White children and Black children was statistically identical (0.05 mg/kg (IQR 0, 0.5) and 0.0 mg/kg (IQR 0, 0.3), respectively, p-value = 0.237). This pattern was also demonstrated in clinical variables including length of stay, intubation length and total parenteral nutrition use. In the pre-intervention cohort, the total length of stay for white children was 16 days while for black children it was 45 days (p = 0.007). In the postintervention cohort the length of stay for both White and Black children were identical at 8 days (p = 0.748). CONCLUSION The use of a clinical opioid reduction protocol implemented at a tertiary medical center was associated with a reduction in racial disparity in opioid prescribing habits in children. Prior to the protocol, there was a racial disparity in clinical variables associated with prolonged opioid use including length of stay, TPN use, and intubation length. The clinical protocol reduced variability in opioid prescribing patterns in all racial groups which was associated with a reduction in variability in associated clinical variables. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- David F Grabski
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, VA, USA
| | - Rick D Vavolizza
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, VA, USA
| | - Heron D Baumgarten
- University of Louisville School of Medicine, Division of Pediatric Surgery, Louisville, KY, USA
| | - Mark A Fleming
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, VA, USA
| | - Chioma Moneme
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, VA, USA
| | - Eugene D McGahren
- University of Virginia School of Medicine, Department of Surgery, Division of Pediatric Surgery, Charlottesville, VA, USA
| | - Jonathan R Swanson
- University of Virginia School of Medicine, Department of Pediatrics, Charlottesville, VA, USA
| | - Sandra K Kabagambe
- University of Virginia School of Medicine, Department of Surgery, Division of Pediatric Surgery, Charlottesville, VA, USA
| | - Jeffrey W Gander
- University of Virginia School of Medicine, Department of Surgery, Division of Pediatric Surgery, Charlottesville, VA, USA.
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Polich M, Mannino-Avila E, Edmunds M, Rungvivatjarus J, Patel A, Stucky-Fisher E, Rhee KE. Disparities in Management of Acute Gastroenteritis in Hospitalized Children. Hosp Pediatr 2023; 13:1106-1114. [PMID: 38013511 DOI: 10.1542/hpeds.2023-007283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Acute gastroenteritis (AGE) is a common health care problem accounting for up to 200 000 pediatric hospitalizations annually. Previous studies show disparities in the management of children from different ethnic backgrounds presenting to the emergency department with AGE. Our aim was to evaluate whether differences in medical management also exist between Hispanic and non-Hispanic children hospitalized with AGE. METHODS We performed a single-center retrospective study of children aged 2 months to 12 years admitted to the pediatric hospital medicine service from January 2016 to December 2020 with a diagnosis of (1) acute gastroenteritis or (2) dehydration with feeding intolerance, vomiting, and/or diarrhea. Differences in clinical pathway use, diagnostic studies performed, and medical interventions ordered were compared between Hispanic and non-Hispanic patients. RESULTS Of 512 admissions, 54.9% were male, 51.6% were Hispanic, and 59.2% were on Medicaid. There was no difference between Hispanic and non-Hispanic patients in reported nausea or vomiting at admission, pathway use, or laboratory testing including stool studies. However, after adjusting for covariates, Hispanic patients had more ultrasound scans performed (odds ratio 1.65, 95% confidence interval 1.04-2.64) and fewer orders for antiemetics (odds ratio 0.53, 95% CI 0.29-0.95) than non-Hispanic patients. CONCLUSIONS Although there were no differences in many aspects of AGE management between Hispanic and non-Hispanic patients, there was still variability in ultrasound scans performed and antiemetics ordered, despite similarities in reported abdominal pain, nausea, and vomiting. Prospective and/or qualitative studies may be needed to clarify underlying reasons for these differences.
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Affiliation(s)
- Michelle Polich
- Rady Children's Hospital, San Diego, California, and University of California San Diego, San Diego, California
| | - Elizabeth Mannino-Avila
- Rady Children's Hospital, San Diego, California, and University of California San Diego, San Diego, California
| | - Michelle Edmunds
- Rady Children's Hospital, San Diego, California, and University of California San Diego, San Diego, California
| | - Jane Rungvivatjarus
- Rady Children's Hospital, San Diego, California, and University of California San Diego, San Diego, California
| | - Aarti Patel
- Rady Children's Hospital, San Diego, California, and University of California San Diego, San Diego, California
| | - Erin Stucky-Fisher
- Rady Children's Hospital, San Diego, California, and University of California San Diego, San Diego, California
| | - Kyung E Rhee
- Rady Children's Hospital, San Diego, California, and University of California San Diego, San Diego, California
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Gil LA, Asti L, Beyene TJ, Cooper JN, Minneci PC, Besner GE. Inequities in the Diagnosis of Pediatric Appendicitis in Tertiary Children's Hospitals and the Consequences of Delayed Diagnosis. J Surg Res 2023; 292:158-166. [PMID: 37619501 DOI: 10.1016/j.jss.2023.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/11/2023] [Accepted: 07/12/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Missed diagnosis (MD) of acute appendicitis is associated with increased risk of appendiceal perforation. This study aimed to investigate whether racial/ethnic disparities exist in the diagnosis of pediatric appendicitis by comparing rates of MD versus single-encounter diagnosis (SED) between racial/ethnic groups. METHODS Patients 0-18 y-old admitted for acute appendicitis from February 2017 to December 2021 were identified in the Pediatric Health Information System (PHIS). International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes for Emergency Department visits within 7 d prior to diagnosis were evaluated to determine whether the encounter represented MD. Generalized mixed models were used to assess the association between MD and patient characteristics. A similar model assessed independent predictors of perforation. RESULTS 51,164 patients admitted for acute appendicitis were included; 50,239 (98.2%) had SED and 925 (1.8%) had MD. Compared to non-Hispanic White patients, patients of non-Hispanic Black (odds ratio 2.5, 95% confidence interval 2.0-3.1), Hispanic (2.1, 1.8-2.5), and other race/ethnicity (1.6, 1.2-2.1) had higher odds of MD. There was a significant interaction between race/ethnicity and imaging (P < 0.0001). Among patients with imaging, race/ethnicity was not significantly associated with MD. Among patients without imaging, there was an increase in strength of association between race/ethnicity and MD (non-Hispanic Black 3.6, 2.7-4.9; Hispanic 3.3, 2.6-4.1; other 2.0, 1.4-2.8). MD was associated with increased risk of perforation (2.5, 2.2-2.8). CONCLUSIONS Minority children were more likely to have MD. Future efforts should aim to mitigate the risk of MD, including implementation of algorithms to standardize the workup of abdominal pain to reduce potential consequences of implicit bias.
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Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Tariku J Beyene
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Gail E Besner
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.
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7
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Toce MS, Dorney K, D'Ambrosi G, Monuteaux MC, Paydar-Darian N, Raghavan VR, Bourgeois FT, Hudgins J. Resource utilization among children presenting with cannabis poisonings in the emergency department. Am J Emerg Med 2023; 73:171-175. [PMID: 37696075 DOI: 10.1016/j.ajem.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Exploratory pediatric cannabis poisonings are increasing. The aim of this study is to provide a national assessment of the frequency and trends of diagnostic testing and procedures in the evaluation of pediatric exploratory cannabis poisonings. METHODS This is a retrospective cross-sectional study of the Pediatric Health Information Systems database involving all cases of cannabis poisoning for children age 0-10 years between 1/2016 and 12/2021. Cannabis poisoning trends were assessed using a negative binomial regression model. A new variable named "ancillary testing" was created to isolate testing that would not confirm the diagnosis of cannabis poisoning or be used to exclude co-ingestion of acetaminophen or aspirin. Ancillary testing was assessed with regression analyses, with ancillary testing as the outcomes and year as the predictor, to assess trends over time. RESULTS A total of 2001 cannabis exposures among 1999 children were included. Cannabis exposures per 100,000 ED visits increased 68.7% (95% CI, 50.3, 89.3) annually. There was a median of 4 (IQR 2.0, 6.0) diagnostic tests performed per encounter. 64.5% of encounters received blood tests, 28.8% received a CT scan, and 2.4% received a lumbar puncture. Compared to White individuals, Black individuals were more likely to receive ancillary testing (OR 1.52 [95% CI, 1.23, 1.89]). Compared to those 2-6 years, those <2 years were more likely to receive ancillary testing (OR 1.55 [95% CI, 1.19, 2.02). We found no significant annual change in the odds of receiving ancillary testing (OR 1.04 [95% CI, 0.97, 1.12]). CONCLUSIONS We found no change in the proportion of encounters associated with ancillary testing, despite increases in exploratory cannabis poisonings over the study period. Given the increasing rate of pediatric cannabis poisonings, emergency providers should consider this diagnosis early in the evaluation of a pediatric patient with acute change in mental status. While earlier use of urine drug screening may reduce ancillary testing and invasive procedures, even a positive urine drug screen does not rule out alternative pathologies and should not replace a thoughtful evaluation.
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Affiliation(s)
- Michael S Toce
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America.
| | - Kate Dorney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Niloufar Paydar-Darian
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Vidya R Raghavan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America; Computational Health Informatics Program (CHIP), Boston Children's Hospital, Boston, MA, United States of America
| | - Joel Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
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Rogo T, Holland S. Impact of health disparity on pediatric infections. Curr Opin Infect Dis 2023; 36:394-398. [PMID: 37466089 DOI: 10.1097/qco.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
PURPOSE OF REVIEW The COVID-19 pandemic highlighted the health disparities among minoritized children due to structural racism and socioeconomic inequalities. This review discusses how health disparities affect pediatric infections and how they can be addressed. RECENT FINDINGS In addition to disparities in healthcare access due to poverty, geography, and English-language proficiency, implicit and explicit bias affects the healthcare quality and subsequent outcomes in children and adolescents with infections. Disparities in clinical trial enrollment affect the generalizability of research findings. Physicians who understand their patients' languages and the contexts of culture and socioeconomic conditions are better equipped to address the needs of specific populations and the health disparities among them. SUMMARY Addressing disparities in pediatric infections requires prioritization of efforts to increase physician workforce diversity in Pediatric Infectious Diseases, as well as education in bias reduction and culturally sensitive clinical practice, in addition to socioeconomic interventions that improve healthcare access, delivery, and outcomes.
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Affiliation(s)
- Tanya Rogo
- Division of Pediatric Infectious Diseases, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Young AL, Monuteaux MC, Cooney TM, Michelson KA. Predictors of Delayed Diagnosis of Pediatric CNS Tumors in the Emergency Department. Pediatr Emerg Care 2023; 39:617-622. [PMID: 37079623 PMCID: PMC10527910 DOI: 10.1097/pec.0000000000002943] [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] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Central nervous system (CNS) tumor diagnoses are frequently delayed in children, which may lead to adverse outcomes and undue burdens on families. Examination of factors associated with delayed emergency department (ED) diagnosis could identify approaches to reduce delays. STUDY DESIGN We performed a case-control study using data from 2014 to 2017 for 6 states. We included children aged 6 months to 17 years with a first diagnosis of CNS tumor in the ED. Cases had a delayed diagnosis, defined as 1 or more ED visits in the 140 days preceding tumor diagnosis (the mean prediagnostic symptomatic interval for pediatric CNS tumors in the United States). Controls had no such preceding visit. RESULTS We included 2828 children (2139 controls, 76%; 689 cases, 24%). Among cases, 68% had 1 preceding ED visit, 21% had 2, and 11% had 3 or more. Significant predictors of delayed diagnosis included presence of a complex chronic condition (adjusted odds ratio [aOR], 9.73; 95% confidence interval [CI], 6.67-14.20), rural hospital location (aOR, 6.37; 95% CI, 1.80-22.54), nonteaching hospital status (aOR, 3.05, compared with teaching hospitals; 95% CI, 1.94-4.80), age younger than 5 years (aOR, 1.57; 95% CI, 1.16-2.12), public insurance (aOR, 1.49, compared with private; 95% CI, 1.16-1.92), and Black race (aOR, 1.42, compared with White; 95% CI, 1.01-1.98). CONCLUSIONS Delayed ED diagnosis of pediatric CNS tumors is common and frequently requires multiple ED encounters. Prevention of delays should focus on careful evaluation of young or chronically ill children, mitigating disparities for Black and publicly insured children, and improving pediatric readiness in rural and nonteaching EDs.
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Affiliation(s)
- Ann L Young
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Tabitha M Cooney
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Hospital, Boston, MA
| | - Kenneth A Michelson
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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10
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Jefferson AA, Brown CC, Eyimina A, Goudie A, Rezaeiahari M, Perry TT, Tilford JM. Asthma Quality Measurement and Adverse Outcomes in Medicaid-Enrolled Children. Pediatrics 2023:e2022059812. [PMID: 37497577 PMCID: PMC10389769 DOI: 10.1542/peds.2022-059812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 07/28/2023] Open
Abstract
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.
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Affiliation(s)
- Akilah A Jefferson
- Department of Pediatrics, Allergy & Immunology Division
- Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Clare C Brown
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Arina Eyimina
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Anthony Goudie
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Mandana Rezaeiahari
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Tamara T Perry
- Department of Pediatrics, Allergy & Immunology Division
- Arkansas Children's Research Institute, Little Rock, Arkansas
| | - J Mick Tilford
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
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11
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Taft M, Garrison J, Fabio A, Shah N, Forster CS. Equity in Receipt of a Lumbar Puncture for Febrile Infants at an Academic Center. Hosp Pediatr 2023; 13:216-222. [PMID: 36785977 DOI: 10.1542/hpeds.2022-006799] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND The evaluation of febrile infants ≤60 days of age is often guided by established protocols. However, structural racism and physicians' implicit bias may affect how such clinical guidelines are applied. OBJECTIVE To determine the association between self-identified race, insurance type, ZIP code-based median household income (MHI) and receiving a guideline-concordant lumbar puncture (GCLP) in febrile infants. METHODS This was a 3-year retrospective cross-sectional study of all febrile infants ≤60 days old presenting to a children's hospital from 2015 to 2017. GCLP was defined as obtaining or appropriately not obtaining a lumbar puncture as defined by the hospital's clinical practice guideline, which recommended performing a lumbar puncture for all febrile infants ≤60 days of age unless an infant was >28 days of age and had respiratory syncytial virus-positive bronchiolitis. Univariate analyses were used to identify variables associated with receiving a GCLP. Variables with a P < .1 were included in a multivariate logistic regression with race, MHI, and insurance type. RESULTS We included 965 infants. Age (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97) and temperature on arrival (adjusted odds ratio, 1.36; 95% confidence interval, 1.04-1.78) were significantly associated with receipt of a GCLP. Self-identified race, insurance type, and MHI were not associated with receiving a GCLP. CONCLUSION Receipt of a GCLP was not associated with race, MHI, or insurance type. As recent national guidelines change to increase shared decision-making, physician awareness and ongoing assessment of the role of factors such as race and socioeconomic status in the clinical evaluation and outcomes of febrile infants will be critical.
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Affiliation(s)
- Maia Taft
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania.,Paul C. Gaffney Division of Pediatric Hospital Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jessica Garrison
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania.,Paul C. Gaffney Division of Pediatric Hospital Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony Fabio
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Neema Shah
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Catherine S Forster
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania.,Paul C. Gaffney Division of Pediatric Hospital Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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12
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Goldberg JE, Prabhu V, Smereka PN, Hindman NM. How We Got Here: The Legacy of Anti-Black Discrimination in Radiology. Radiographics 2023; 43:e220112. [PMID: 36633971 DOI: 10.1148/rg.220112] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Current disparities in the access to diagnostic imaging for Black patients and the underrepresentation of Black physicians in radiology, relative to their representation in the general U.S. population, reflect contemporary consequences of historical anti-Black discrimination. These disparities have existed within the field of radiology and professional medical organizations since their inception. Explicit and implicit racism against Black patients and physicians was institutional policy in the early 20th century when radiology was being developed as a clinical medical field. Early radiology organizations also embraced this structural discrimination, creating strong barriers to professional Black radiologist involvement. Nevertheless, there were numerous pioneering Black radiologists who advanced scholarship, patient care, and diversity within medicine and radiology during the early 20th century. This work remains important in the present day, as race-based health care disparities persist and continue to decrease the quality of radiology-delivered patient care. There are also structural barriers within radiology affecting workforce diversity that negatively impact marginalized groups. Multiple opportunities exist today for antiracism work to improve quality of care and to apply standards of social justice and health equity to the field of radiology. An initial step is to expand education on the disparities in access to imaging and health care among Black patients. Institutional interventions include implementing community-based outreach and applying antibias methodology in artificial intelligence algorithms, while systemic interventions include identifying national race-based quality measures and ensuring imaging guidelines properly address the unique cancer risks in the Black patient population. These approaches reflect some of the strategies that may mutually serve to address health care disparities in radiology. © RSNA, 2023 See the invited commentary by Scott in this issue. Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Julia E Goldberg
- From the Department of Radiology, NYU Langone Health, 550 1st Ave, New York, NY 10016
| | - Vinay Prabhu
- From the Department of Radiology, NYU Langone Health, 550 1st Ave, New York, NY 10016
| | - Paul N Smereka
- From the Department of Radiology, NYU Langone Health, 550 1st Ave, New York, NY 10016
| | - Nicole M Hindman
- From the Department of Radiology, NYU Langone Health, 550 1st Ave, New York, NY 10016
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13
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Zamor RL, Vaughn LM, McCann E, Sanchez L, Page EM, Mahabee-Gittens EM. Perceptions and experiences of Latinx parents with language barriers in a pediatric emergency department: a qualitative study. BMC Health Serv Res 2022; 22:1463. [PMID: 36457015 PMCID: PMC9717444 DOI: 10.1186/s12913-022-08839-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 10/17/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Prior research has shown disparities exist among Latinx children who require treatment for respiratory illnesses within the pediatric emergency department (PED). Limited data exist regarding Latinx families' experiences on the care they received at PEDs within non-traditional destination areas (NDA). Their experiences can identify areas of improvement to potentially reduce healthcare disparities among pediatric patients within this population. The purpose of this qualitative study was to explore the lived experiences of Latinx families with low English proficiency in the PED with a NDA. The broader purpose was to identify areas of improvement for reducing health care disparities among Latinx families. METHODS We used qualitative methods to analyze semi-structured interviews among Latinx families who presented to the PED with their 0-2 year-old child for a respiratory illness from May 2019 through January 2020. All participants had low English proficiency and requested a Spanish interpreter during registration. All interviews were transcribed and reviewed using thematic analysis based on a phenomenology framework. RESULTS Interviews were conducted with 16 Latinx parents. Thematic analysis revealed four major themes: (1) Uncertainty - Families expressed uncertainty regarding how to care for a child with distressing symptoms, (2) Communication - Families favored in-person interpreters which enhanced communication and allowed families to feel more informed, (3) System Burden - Families reported that the unfamiliarity with the US health system and lack of resources are additional burdens, and (4) Emotional Support - The emergency department visits garnered confidence and reassurance for families. CONCLUSIONS Our study identified four major themes among Latinx families within a PED of a NDA. Potential areas of interventions should focus on supporting access to an interpreter, improving information delivery, and enhancing education on community resources for families with low English proficiency.
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Affiliation(s)
- Ronine L. Zamor
- grid.239573.90000 0000 9025 8099Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267 USA ,grid.189967.80000 0001 0941 6502Present Address: Division of Emergency Medicine, Children’s Healthcare of Atlanta, Emory University, 1547 Clifton Road, NE 2nd Floor, Atlanta, GA 30322 USA
| | - Lisa M. Vaughn
- grid.239573.90000 0000 9025 8099Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267 USA
| | - Erin McCann
- grid.239573.90000 0000 9025 8099Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - Luisanna Sanchez
- grid.239573.90000 0000 9025 8099Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - Erica M. Page
- grid.239573.90000 0000 9025 8099Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA
| | - E. Melinda Mahabee-Gittens
- grid.239573.90000 0000 9025 8099Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267 USA
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Chang G, Blackstone M, McGuire JL. Race and the emergency department management of febrile seizures. Medicine (Baltimore) 2022; 101:e31315. [PMID: 36281195 PMCID: PMC9592322 DOI: 10.1097/md.0000000000031315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Gina Chang
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- * Correspondence: Gina Chang, Division of Neurology at The Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104, USA (e-mail: )
| | - Mercedes Blackstone
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer L McGuire
- Division of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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15
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Dickerson-Young T, Uspal NG, Prince WB, Qu P, Klein EJ. Racial and Ethnic Differences in Ondansetron Use for Acute Gastroenteritis in Children. Pediatr Emerg Care 2022; 38:380-385. [PMID: 35353794 DOI: 10.1097/pec.0000000000002610] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There is limited research examining racial/ethnic disparities in antiemetic use for acute gastroenteritis (AGE). We assessed racial/ethnic differences in the care of children with AGE. METHODS The Pediatric Health Information System was used to conduct a retrospective cohort study of children 6 months to 6 years old with AGE seen in participating emergency departments from 2016 to 2018. Cases were identified using International Classification of Diseases, Tenth Revision codes. The primary outcome was administration of ondansetron, secondary outcomes were administration of intravenous (IV) fluids and hospitalization, and primary predictor was race/ethnicity. Multivariable logistic regression followed by a mixed model adjusted for sex, age, insurance, and hospital to examine the association of race/ethnicity with each outcome. RESULTS There were 78,019 encounters included; 24.8% of patients were non-Hispanic White (NHW), 29.0% non-Hispanic Black (NHB), 37.3% Hispanic, and 8.9% other non-Hispanic (NH) race/ethnicity. Compared with NHW patients, minority children were more likely to receive ondansetron (NHB: adjusted odds ratio, 1.36 [95% confidence interval, 1.2-1.55]; Hispanic: 1.26 [1.1-1.44]; other NH: 1.22 [1.07-1.4]). However, minority children were less likely to receive IV fluids (NHB: 0.38 [0.33-0.43]; Hispanic: 0.44 [0.36-0.53]; other NH: 0.51 [0.44-0.61]) or hospital admission (NHB: 0.37 [0.29-0.48]; Hispanic: 0.41 [0.33-0.5]; other NH: 0.52 [0.41-0.66]). Ondansetron use by hospital ranged from 73% to 95%. CONCLUSIONS This large database analysis of emergency departments around the nation found that NHW patients were less likely to receive ondansetron but more likely to receive IV fluids and hospital admission than minority patients. These findings are likely multifactorial and may represent bias, social determinants of health, access to care, or illness severity among other possible causes.
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Affiliation(s)
| | | | | | - Pingping Qu
- Biostatistics Epidemiology and Analytics in Research (BEAR), Seattle Children's Research Institute, Seattle, WA
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16
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Polhemus S, Pickett ML, Liu XJ, Fraser R, Ferguson CC, Drendel AL. Racial Disparities in the Emergency Department Evaluation of Adolescent Girls. Pediatr Emerg Care 2022; 38:307-311. [PMID: 35353799 DOI: 10.1097/pec.0000000000002675] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Racial disparities and differences exist in emergency care. Obtaining a sexual history is standard of care for adolescents with abdominal pain. Testing for sexually transmitted infections (STIs) and pregnancy should be based on historical findings. The objective of this study was to determine whether differential care was provided to adolescent female patients with abdominal pain based on patient race or healthcare provider characteristics by evaluating the documentation of sexual history, STI testing, and pregnancy testing. METHODS This was a retrospective chart review of female patients between the ages of 14 and 18 years with abdominal pain presenting to a pediatric emergency department. Patient and provider characteristics, sexual history documentation, STI, and pregnancy testing were abstracted. Data were analyzed using χ 2 test and logistic regression model. RESULTS Eight hundred eighty-six encounters were included in the analysis. Median patient age was 16 years (range, 14-18 years); 359 (40.5%) were non-White. Differential care was provided. Non-White patients compared with White patients were more likely to have a documented sexual history (59.9% vs 44.0%, P < 0.001), STI testing (24.8% vs 7.8%, P < 0.001), and pregnancy testing (76.6% vs 66.2%, P < 0.001). Among sexually active female patients, the racial disparity for STI testing persisted ( P = 0.010). Provider type and sex did not result in differences in sexual history documentation, STI, or pregnancy testing for non-White compared with White patients ( P > 0.05). CONCLUSIONS Differential care was provided to non-White adolescents with abdominal pain compared with White adolescents. They were more likely to have a documented sexual history, STI testing, and pregnancy testing. Healthcare provider characteristics did not impact patient care. This racial disparity resulted in better medical care for non-White adolescents, but this may be the consequence of underlying implicit bias.
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Affiliation(s)
| | - Michelle L Pickett
- From the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Xuerong Joy Liu
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Raphael Fraser
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | | | - Amy L Drendel
- From the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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17
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Van Winkle PJ, Lee SN, Chen Q, Baecker AS, Ballard DW, Vinson DR, Greenhow TL, Nguyen THP, Young BR, Alabaster AL, Huang J, Park S, Sharp AL. Clinical management and outcomes for febrile infants 29–60 days evaluated in community emergency departments. J Am Coll Emerg Physicians Open 2022; 3:e12754. [PMID: 35765310 PMCID: PMC9206108 DOI: 10.1002/emp2.12754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 11/06/2022] Open
Abstract
Objective Describe emergency department (ED) management and patient outcomes for febrile infants 29–60 days of age who received a lumbar puncture (LP), with focus on timing of antibiotics and type of physician performing LP. Methods Retrospective observational study of 35 California EDs from January 1, 2010 through December 31, 2019. Primary analysis was among patients with successful LP and primary outcome was hospital length of stay (LOS). Logistic regression analysis included variables associated with LOS of at least 2 days. Secondary outcomes were bacterial meningitis, hospital admission, length of antibiotics, and readmission. Results Among 2569 febrile infants (median age 39 days), 667 underwent successful LP and 633 received intravenous antibiotics. Most infants (n = 559, 88.3%) had their LP before intravenous antibiotic administration. Pediatricians performed 54% of LPs and emergency physicians 34%. Sixteen infants (0.6% of 2569) were diagnosed with bacterial meningitis, and none died. Five hundred and fifty‐eight (88%) infants receiving an LP were hospitalized. Among patients receiving an LP and antibiotics (n = 633), 6.5% were readmitted within 30 days. Patients receiving antibiotics before LP had a longer length of antibiotics (+ 7.9 hours, 95% confidence interval [CI] 3.8–13.4). Primary analysis found no association between timing of antibiotics and LOS (odds ratio [OR] 0.67, 95% CI 0.34–1.30), but shorter LOS when emergency physicians performed the LP (OR 0.66, 95% CI 0.45–0.97). Conclusions Febrile infants in the ED had no deaths and few cases of bacterial meningitis. In community EDs, where a pediatrician is often not available, successful LP by emergency physician was associated with reduced inpatient LOS.
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Affiliation(s)
- Patrick J. Van Winkle
- Department of Pediatrics Kaiser Permanente Southern California, Anaheim Medical Center Anaheim California USA
- Department of Clinical Science Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena California USA
| | - Samantha N. Lee
- Undergraduate in Biological Sciences University of CA, Los Angeles Los Angeles California USA
| | - Qiaoling Chen
- Department of Research and Evaluation Southern California Permanente Medical Group Pasadena California USA
| | - Aileen S. Baecker
- Department of Research and Evaluation Southern California Permanente Medical Group Pasadena California USA
| | - Dustin W. Ballard
- Department of Emergency Medicine and the Division of Research The Permanente Medical Group, Kaiser Permanente Northern California Oakland California USA
| | - David R. Vinson
- Department of Emergency Medicine and the Division of Research The Permanente Medical Group, Kaiser Permanente Northern California Oakland California USA
| | - Tara L. Greenhow
- Department of Pediatric Infectious Diseases Kaiser Permanente Northern CA San Francisco California USA
| | - Tran H. P. Nguyen
- Department of Inpatient Pediatrics Kaiser Permanente Northern CA Roseville California USA
| | - Beverly R. Young
- Department of Inpatient Pediatrics Kaiser Permanente Northern CA Roseville California USA
| | - Amy L. Alabaster
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Stacy Park
- Department of Research and Evaluation Southern California Permanente Medical Group Pasadena California USA
| | - Adam L. Sharp
- Department of Clinical Science Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena California USA
- Department of Research and Evaluation Southern California Permanente Medical Group Pasadena California USA
- Department of Emergency Medicine Kaiser Permanente Southern California, Los Angeles Medical Center Los Angeles California USA
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18
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Emergency Department Evaluation of Abnormal Uterine Bleeding in US Children's Hospitals. J Pediatr Adolesc Gynecol 2022; 35:288-293. [PMID: 34999231 DOI: 10.1016/j.jpag.2021.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/15/2021] [Accepted: 12/29/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To assess initial evaluation patterns of patients presenting to the Emergency Department (ED) with abnormal uterine bleeding (AUB) including differences by race DESIGN: Retrospective multicenter cohort study from October 2015 through September 2020 SETTING: Forty-seven children's hospitals submitting data to the Pediatric Health Information System PARTICIPANTS: Female patients aged 8-21 with an ED encounter with AUB as the primary diagnosis code INTERVENTIONS AND MAIN OUTCOME MEASURES: Proportion of visits with at least 1 laboratory assessment for the evaluation of anemia, iron deficiency, and/or hemostatic disorders RESULTS: We identified 17,759 unique patients with AUB seen in the ED who met inclusion criteria. Median age was 16.3 years (IQR, 14.1-17.8 years). Most encounters (n = 11,576, 65.2%) included evaluation for anemia, but only 6.8% (n = 1,215) included assessment for iron deficiency and 26.2% (n = 4,654) for hemostatic disorders. Black patients accounted for 34.7% (n = 6,155) of AUB encounters yet constituted only 25% of all ED encounters (n = 198,192). Black patients with AUB were less likely to undergo bleeding disorder evaluation (OR = 0.76; 95% CI, 0.69-0.83) but more likely to receive evaluation for sexually transmitted infections (OR = 1.63; 95% CI, 1.48-1.80) compared with White patients, despite controlling for age and concomitant pain. CONCLUSIONS In a national cohort of adolescents presenting to the ED with AUB, evaluations for anemia and hemostatic disorders were infrequently performed, and racial differences existed regarding initial assessment. Further studies are needed to understand the factors underlying racial differences in hematologic testing and the impact of this disparity on health outcomes for females with AUB.
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Samuels-Kalow ME, De Souza HG, Neuman MI, Alpern E, Marin JR, Hoffmann J, Hall M, Aronson PL, Peltz A, Wells J, Gutman CK, Simon HK, Shanahan K, Goyal MK. Analysis of Racial and Ethnic Diversity of Population Served and Imaging Used in US Children's Hospital Emergency Departments. JAMA Netw Open 2022; 5:e2213951. [PMID: 35653156 PMCID: PMC9164005 DOI: 10.1001/jamanetworkopen.2022.13951] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/07/2022] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Elizabeth Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Jennifer R. Marin
- Department 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 Hoffmann
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alon Peltz
- Department of Population Medicine, Harvard Pilgrim Health Care, Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Jordee Wells
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Colleen K. Gutman
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | - Harold K. Simon
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
- Department of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Kristen Shanahan
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Monika K. Goyal
- Department of Pediatrics, Children’s National Hospital, George Washington University, Washington, DC
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20
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Johnson TJ. Antiracism, Black Lives Matter, and Critical Race Theory: The ABCs of Promoting Racial Equity in Pediatric Practice. Pediatr Ann 2022; 51:e95-e106. [PMID: 35293809 DOI: 10.3928/19382359-20220217-01] [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] [Indexed: 11/20/2022]
Abstract
Police shootings of unarmed Black men, women, and children at the intersection of disparities in the setting of the coronavirus disease 2019 pandemic have resulted in a long overdue national awakening regarding race and racism in society. This article defines some of the key terms, providing a foundation to help promote equity in pediatric practice. Although no single article can result in full competency regarding such complex issues, it is meant to provide a foundation for pediatricians on a journey to deepen their knowledge and understanding toward a path to action. [Pediatr Ann. 2022;51(3):e95-e106.].
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21
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Jordan J, McGinty G. Health Equity: What the Neuroradiologist Needs to Know. AJNR Am J Neuroradiol 2022; 43:341-346. [PMID: 35177548 PMCID: PMC8910825 DOI: 10.3174/ajnr.a7420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 12/04/2021] [Indexed: 11/07/2022]
Abstract
Health equity means that everyone has the opportunity to be as healthy as possible, but achieving health equity requires the removal of obstacles to health such as poverty, discrimination, unsafe environments, and lack of access to health care. The pandemic has highlighted the awareness and urgency of delivering patient-centered, high-value care. Disparities in care are antithetical to health equity and have been seen throughout medicine and radiology, including neuroradiology. Health disparities result in low value and costly care that is in conflict with evidence-based medicine, quality standards, and best practices. Although the subject of health equity is often framed as a moral or social justice issue, there are compelling economic arguments that also favor health equity. Not only can waste in health care expenditures be countered but more resources can be devoted to high-value care and other vital national economic interests, including sustainable support for our health system and health providers. There are many opportunities for neuroradiologists to engage in the advancement of health equity, while also advancing the interests of the profession and patient-centered high-value care. Although there is no universal consensus on a definition of health equity, a recent report seeking clarity on the lexicon offered the following conceptual framework: "Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care."1 This definition contrasts with that of health disparities that contribute to inequitable care as a result of demographic differences among populations such as those attributable to race, sex, access, residence, socioeconomic status, insurance status, age, religion, and disability.2,3 In effect, the greater the health disparities and negative social determinants of health, the greater the health inequities will be.
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Affiliation(s)
- J.E. Jordan
- From the Department of Radiology (J.E.J.), Providence Little Company of Mary Medical Center, Torrance, California,Department of Radiology (J.E.J.), Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, California
| | - G.B. McGinty
- Department of Radiology (G.B.M.), Weill Cornell Medicine and the New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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22
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Li J, Ramgopal S, Marin JR. Racial and ethnic differences in low-value pediatric emergency care. Acad Emerg Med 2022; 29:698-709. [PMID: 35212440 DOI: 10.1111/acem.14468] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School Boston Massachusetts USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine UPMC Children's Hospital of Pittsburgh University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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23
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Metzger P, Allum L, Sullivan E, Onchiri F, Jones M. Racial and Language Disparities in Pediatric Emergency Department Triage. Pediatr Emerg Care 2022; 38:e556-e562. [PMID: 34009885 DOI: 10.1097/pec.0000000000002439] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Peter Metzger
- From the Department of Pediatrics, University of Washington
| | | | | | | | - Maya Jones
- Division of Emergency Medicine, Department of Pediatrics, University of Washington, Seattle, WA
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24
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Andrade EG, Onufer EJ, Thornton M, Keller MS, Schuerer DJE, Punch LJ. Racial disparities in triage of adolescent patients after bullet injury. J Trauma Acute Care Surg 2022; 92:366-370. [PMID: 34538831 DOI: 10.1097/ta.0000000000003407] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While pediatric trauma centers (PTCs) and adult trauma centers (ATCs) exhibit equivalent trauma mortality, the optimal care environment for traumatically injured adolescents remains controversial. Race has been shown to effect triage within emergency departments (EDs) with people of color receiving lower acuity triage scores. We hypothesized that African-American adolescents were more likely triaged to an ATC than a PTC compared with their White peers. METHODS Institutional trauma databases from a neighboring, urban Level I PTC and ATC were queried for gunshot wounds in adolescents (15-18 years) presenting to the ED from 2015 to 2017. The PTC and ATC were compared in terms of demographics, services, and outcomes. Results were analyzed using univariate analysis and logistic regression. RESULTS Among 316 included adolescents, 184 were treated in an ATC versus 132 in a PTC. Patients at the PTC were significantly more likely to be younger (16.1 vs. 17.5 years; p < 0.001), White (16% vs. 5%; p = 0.001), and privately insured (41% vs. 30%; p = 0.002). At each age, the proportion of Whites treated at the PTC exceeded the proportion of African-Americans. At the PTC, patients were more likely to receive inpatient and outpatient social work follow-up (89% vs. 1%, p < 0.001). Adolescents treated at the PTC were less likely to receive opioids (75% vs. 56%, p = 0.001) at discharge and to return to ED within 6 months (25% vs. 11%, p = 0.005). On multivariate logistic regression, African-American adolescents were less likely to be treated at a PTC (odds ratio, 0.30; 95% confidence interval, 0.10-0.85; p = 0.02) after controlling for age and Injury Severity Score. CONCLUSION Disparities in triage of African-American and White adolescents after bullet injury lead to unequal care. African-Americans were more likely to be treated at the ATC, which was associated with increased opioid prescription, decreased social work support, and increased return to ED. LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Erin G Andrade
- From the Department of Surgery (E.G.A., E.J.O., M.T., M.S.K., D.J.E.S.), Washington University in St. Louis School of Medicine; and The T (L.J.P.), St. Louis, Missouri
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25
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DeBenedectis CM, Spalluto LB, Americo L, Bishop C, Mian A, Sarkany D, Kagetsu NJ, Slanetz PJ. Health Care Disparities in Radiology-A Review of the Current Literature. J Am Coll Radiol 2022; 19:101-111. [PMID: 35033297 DOI: 10.1016/j.jacr.2021.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Health care disparities exist in all medical specialties, including radiology. Raising awareness of established health care disparities is a critical component of radiology's efforts to mitigate disparities. Our primary objective is to perform a comprehensive review of the last 10 years of literature pertaining to disparities in radiology care. Our secondary objective is to raise awareness of disparities in radiology. METHODS We reviewed English-language medicine and health services literature from the past 10 years (2010-2020) for research that described disparities in any aspect of radiologic imaging using radiology search terms and key words for disparities in OVID. Relevant studies were identified with adherence to the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS The search yielded a total 1,890 articles. We reviewed the citations and abstracts with the initial search yielding 1,890 articles (without duplicates). Of these, 1,776 were excluded based on the criteria set forth in the methods. The remaining unique 114 articles were included for qualitative synthesis. DISCUSSION We hope this article increases awareness and inspires action to address disparities and encourages research that further investigates previously identified disparities and explores not-yet-identified disparities.
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Affiliation(s)
- Carolynn M DeBenedectis
- Vice-Chair, Education; Director, Radiology Residency Program; Department of Radiology, President-elect, New England Roentgen Ray Society; and Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Lucy B Spalluto
- Vice-Chair, Health Equity; Director, Women in Radiology; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Ingram Cancer Center, Nashville, Tennessee; Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research; and Education and Clinical Center (GRECC), Nashville, Tennessee
| | - Lisa Americo
- Department of Radiology, Staten Island University Hospital Northwell Health, Staten Island, New York
| | - Casey Bishop
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Asim Mian
- Director, Radiology Residency Program; Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - David Sarkany
- Director, Radiology Residency Program; Department of Radiology, Staten Island University Hospital Northwell Health, Staten Island, New York
| | - Nolan J Kagetsu
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Priscilla J Slanetz
- Vice-Chair, Academic Affairs; Associate Program Director, Radiology Residency Program, Boston Medical Center; President-elect Massachusetts Radiologic Society; Secretary, Association of University Radiologists; Chair, Breast Imaging Panel 2, ACR Appropriateness Guidelines Committee; and Department of Radiology, Boston Medical Center, Boston, Massachusetts
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26
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Mateo CM, Johnston PR, Wilkinson RB, Tennermann N, Grice AW, Chuersanga G, Ward VL. Sociodemographic and Appointment Factors Affecting Missed Opportunities to Provide Neonatal Ultrasound Imaging. J Am Coll Radiol 2022; 19:112-121. [PMID: 35033298 DOI: 10.1016/j.jacr.2021.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of this study was to assess disparities in outpatient imaging missed care opportunities (IMCOs) for neonatal ultrasound by sociodemographic and appointment factors at a large urban pediatric hospital. METHODS A retrospective review was performed among patients aged 0 to 28 days receiving one or more outpatient appointments for head, hip, renal, or spine ultrasound at the main hospital or satellite sites from 2008 to 2018. An IMCO was defined as a missed ultrasound or cancellation <24 hours in advance. Population-average correlated logistic regression modeling estimated the odds of IMCOs for six sociodemographic (age, sex, race/ethnicity, language, insurance, and region of residence) and seven appointment (type of ultrasound, time, day, season, site, year, and distance to appointment) factors. The primary analysis included unknown values as a separate category, and the secondary analysis used multiple imputation to impute genuine categories from unknown variables. RESULTS The data set comprised 5,474 patients totaling 6,803 ultrasound appointments. IMCOs accounted for 4.4% of appointments. IMCOs were more likely for Black (odds ratio [OR], 3.31; P < .001) and other-race neonates (OR, 2.66; P < .001) and for patients with public insurance (OR, 1.78; P = .002). IMCOs were more likely for appointments at the main hospital compared with satellites (P < .001), during work hours (P = .021), and on weekends (P < .001). Statistical significance for primary and secondary analyses was quantitatively similar and qualitatively identical. CONCLUSIONS Marginalized racial groups and those with public insurance had a higher rate of IMCOs in neonatal ultrasound. This likely represents structural inequities faced by these communities, and more research is needed to identify interventions to address these inequities in care delivery for vulnerable neonatal populations.
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Affiliation(s)
- Camila M Mateo
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Patrick R Johnston
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Ronald B Wilkinson
- Information Services Department, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Tennermann
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, Massachusetts
| | - Amanda W Grice
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Geeranan Chuersanga
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, Massachusetts
| | - Valerie L Ward
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Boston Children's Hospital, Boston, Massachusetts; Senior Vice-President, Chief Equity and Inclusion Officer, and Director, Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, Massachusetts.
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27
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Su D, Li Q, Zhang T, Veliz P, Chen Y, He K, Mahajan P, Zhang X. Prediction of acute appendicitis among patients with undifferentiated abdominal pain at emergency department. BMC Med Res Methodol 2022; 22:18. [PMID: 35026994 PMCID: PMC8759254 DOI: 10.1186/s12874-021-01490-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/08/2021] [Indexed: 11/12/2022] Open
Abstract
Background Early screening and accurately identifying Acute Appendicitis (AA) among patients with undifferentiated symptoms associated with appendicitis during their emergency visit will improve patient safety and health care quality. The aim of the study was to compare models that predict AA among patients with undifferentiated symptoms at emergency visits using both structured data and free-text data from a national survey. Methods We performed a secondary data analysis on the 2005-2017 United States National Hospital Ambulatory Medical Care Survey (NHAMCS) data to estimate the association between emergency department (ED) patients with the diagnosis of AA, and the demographic and clinical factors present at ED visits during a patient’s ED stay. We used binary logistic regression (LR) and random forest (RF) models incorporating natural language processing (NLP) to predict AA diagnosis among patients with undifferentiated symptoms. Results Among the 40,441 ED patients with assigned International Classification of Diseases (ICD) codes of AA and appendicitis-related symptoms between 2005 and 2017, 655 adults (2.3%) and 256 children (2.2%) had AA. For the LR model identifying AA diagnosis among adult ED patients, the c-statistic was 0.72 (95% CI: 0.69–0.75) for structured variables only, 0.72 (95% CI: 0.69–0.75) for unstructured variables only, and 0.78 (95% CI: 0.76–0.80) when including both structured and unstructured variables. For the LR model identifying AA diagnosis among pediatric ED patients, the c-statistic was 0.84 (95% CI: 0.79–0.89) for including structured variables only, 0.78 (95% CI: 0.72–0.84) for unstructured variables, and 0.87 (95% CI: 0.83–0.91) when including both structured and unstructured variables. The RF method showed similar c-statistic to the corresponding LR model. Conclusions We developed predictive models that can predict the AA diagnosis for adult and pediatric ED patients, and the predictive accuracy was improved with the inclusion of NLP elements and approaches. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01490-9.
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Affiliation(s)
- Dai Su
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
| | - Qinmengge Li
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, USA.,Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Tao Zhang
- Department of Epidemiology and Biostatistics, West China School of Public Health School, Sichuan University, Chengdu, China
| | - Philip Veliz
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, USA
| | - Yingchun Chen
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Research Center for Rural Health Services, Hubei Province Key Research Institute of Humanities and Social Sciences, Wuhan, China
| | - Kevin He
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Prashant Mahajan
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, USA
| | - Xingyu Zhang
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, USA.
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28
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Nash KA, Kimia A, Fleegler EW, Guedj R. Equitable and Timely Care of Febrile Neonates: A Cross-Sectional Study. Pediatr Emerg Care 2021; 37:e1351-e1357. [PMID: 32011559 DOI: 10.1097/pec.0000000000002034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Katherine A Nash
- From the Yale National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT
| | - Amir Kimia
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School
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Dennis JA. Racial/Ethnic Disparities in Triage Scores Among Pediatric Emergency Department Fever Patients. Pediatr Emerg Care 2021; 37:e1457-e1461. [PMID: 32150002 DOI: 10.1097/pec.0000000000002072] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Jeff A Dennis
- From the Department of Public Health, Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center, Lubbock, TX
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30
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Al-Dulaimi R, Duong PA, Chan BY, Fuller MJ, Ross AB, Dunn DP. Revisiting racial disparities in ED CT utilization during the Affordable Care Act era: 2009-2018 data from the NHAMCS. Emerg Radiol 2021; 29:125-132. [PMID: 34713355 DOI: 10.1007/s10140-021-01991-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010. MATERIALS AND METHODS Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed. RESULTS Between 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups. CONCLUSION Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.
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Affiliation(s)
- Ragheed Al-Dulaimi
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Phuong-Anh Duong
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Brian Y Chan
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Matthew J Fuller
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Andrew B Ross
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Dell P Dunn
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA.
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Purtell R, Tam RP, Avondet E, Gradick K. We are part of the problem: the role of children's hospitals in addressing health inequity. Hosp Pract (1995) 2021; 49:445-455. [PMID: 35061953 DOI: 10.1080/21548331.2022.2032072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
Racism is an ongoing public health crisis that undermines health equity for all children in hospitals across our nation. The presence and impact of institutionalized racism contributes to health inequity and is under described in the medical literature. In this review, we focus on key interdependent areas to foster inclusion, diversity, and equity in Children's Hospitals, including 1) promotion of workforce diversity 2) provision of anti-racist, equitable hospital patient care, and 3) prioritization of academic scholarship focused on health equity research, quality improvement, medical education, and advocacy. We discuss the implications for clinical and academic practice.Plain Language Summary: Racism in Children's Hospitals harms children. We as health-care providers and hospital systems are part of the problem. We reviewed the literature for the best ways to foster inclusion, diversity, and equity in hospitals. Hospitals can be leaders in improving child health equity by supporting a more diverse workforce, providing anti-racist patient care, and prioritizing health equity scholarship.
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Affiliation(s)
- Rebecca Purtell
- Assistant Professor of Pediatrics, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Reena P Tam
- Assistant Professor of Pediatrics, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Erin Avondet
- Assistant Professor of Pediatrics, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Katie Gradick
- Assistant Professor of Pediatrics, Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Hester G, Nickel AJ, Watson D, Bergmann KR. Factors Associated With Bronchiolitis Guideline Nonadherence at US Children's Hospitals. Hosp Pediatr 2021; 11:1102-1112. [PMID: 34493589 DOI: 10.1542/hpeds.2020-005785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The objective with this study was to explore factors associated with nonadherence to national bronchiolitis guidelines at 52 children's hospitals. METHODS We included patients 1 month to 2 years old with emergency department (ED) or admission encounters between January 2016 and December 2018 and bronchiolitis diagnoses in the Pediatric Health Information System database. We excluded patients with any intensive care, stay >7 days, encounters in the preceding 30 days, chronic medical conditions, croup, pneumonia, or asthma. Guideline nonadherence was defined as receiving any of 5 tests or treatments: bronchodilators, chest radiographs, systemic steroids, antibiotics, and viral testing. Nonadherence outcomes were modeled by using mixed effects logistic regression with random effects for providers and hospitals. Adjusted odds ratio (aOR) >1 indicates greater likelihood of nonadherence. RESULTS A total of 198 028 encounters were included (141 442 ED and 56 586 admission), and nonadherence was 46.1% (ED: 40.2%, admissions: 61.0%). Nonadherence increased with patient age, with both ED and hospital providers being more likely to order tests and treatments for children 12 to 24 months compared with infants 1 ot 2 months (ED: aOR, 3.39; 95% confidence interval [CI], 3.20-3.60; admissions: aOR, 2.97; CI, 2.79-3.17]). Admitted non-Hispanic Black patients were more likely than non-Hispanic white patients to receive guideline nonadherent care (aOR, 1.16; CI, 1.10-1.23), a difference driven by higher use of steroids (aOR, 1.29; CI, 1.17-1.41) and bronchodilators (aOR, 1.39; CI, 1.31-1.48). Hospital effects were prominent for viral testing in ED and admission encounters (intraclass correlation coefficient of 0.35 and 0.32, respectively). CONCLUSIONS Multiple factors are associated with national bronchiolitis guideline nonadherence.
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Affiliation(s)
| | | | | | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
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Foster AA, Porter JJ, Monuteaux MC, Hoffmann JA, Hudgins JD. Pharmacologic Restraint Use During Mental Health Visits in Pediatric Emergency Departments. J Pediatr 2021; 236:276-283.e2. [PMID: 33771581 DOI: 10.1016/j.jpeds.2021.03.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the trends and hospital variation in the use of pharmacologic restraint among pediatric mental health visits in the emergency department (ED). STUDY DESIGN We examined ED visits with a mental health diagnosis in patients aged 3-21 years at children's hospital EDs from 2009 to 2019. We calculated the frequency of pharmacologic restraint use and determined visit characteristics associated with restraint use. We calculated cumulative percent change for visits with restraints and for all mental health visits. We used logistic regression to test trends over time and evaluate hospital variation in the frequency of restraint use. RESULTS We identified 389 885 mental health ED visits (54.9% female, median age 14.3 years) and 13 643 (3.5%) visits with pharmacologic restraint use. Characteristics associated with pharmacologic restraint use were late adolescent age (18-21 years), male sex, Black race, non-Latino ethnicity, public insurance, and admission to the hospital (P < .001). During the study period, both mental health ED visits increased by 268% and mental health ED visits with pharmacologic restraint use increased by 370%. The rate of pharmacologic restraint in this patient population remained constant. Hospital use of pharmacologic restraint for mental health visits varied significantly across hospitals (1.6%-11.8%, P < .001). CONCLUSIONS Pediatric mental health ED visits with and without pharmacologic restraint are increasing over time. In addition, the overall number of pharmacologic restraint use has increased threefold. Significant hospital variation in pharmacologic restraint use signifies an opportunity for standardization of care and restraint reduction.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | | | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Joel D Hudgins
- Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Jones NK, Badolato GM, Boyle MD, Goyal MK. Racial/ethnic disparities in management of acute gastroenteritis in a pediatric emergency department. Acad Emerg Med 2021; 28:1067-1069. [PMID: 34533263 DOI: 10.1111/acem.14315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/27/2021] [Accepted: 05/30/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Nathaniel K. Jones
- Division of Pediatric Emergency Medicine Children's National Hospital Washington DC USA
| | - Gia M. Badolato
- Division of Pediatric Emergency Medicine Children's National Hospital Washington DC USA
| | - Meleah D. Boyle
- Division of Pediatric Emergency Medicine Children's National Hospital Washington DC USA
| | - Monika K. Goyal
- Division of Pediatric Emergency Medicine Children's National Hospital Washington DC USA
- George Washington University Washington DC USA
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Congdon M, Schnell SA, Londoño Gentile T, Faerber JA, Bonafide CP, Blackstone MM, Johnson TJ. Impact of patient race/ethnicity on emergency department management of pediatric gastroenteritis in the setting of a clinical pathway. Acad Emerg Med 2021; 28:1035-1042. [PMID: 33745207 DOI: 10.1111/acem.14255] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/01/2021] [Accepted: 03/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute gastroenteritis (AGE) is a common pediatric diagnosis in emergency medicine, accounting for 1.7 million visits annually. Little is known about racial/ethnic differences in care in the setting of standardized care models. METHODS We used quality improvement data for children 6 months to 18 years presenting to a large, urban pediatric emergency department (ED) treated via a clinical pathway for AGE/dehydration between 2011 and 2018. Race/ethnicity was evaluated as a single variable (non-Hispanic [NH]-White, NH-Black, Hispanic, and NH-other) related to ondansetron and intravenous fluid (IVF) administration, ED length of stay (LOS), hospital admission, and ED revisits using multivariable regression. RESULTS Of 30,849 ED visits for AGE/dehydration, 18.0% were NH-White, 57.2% NH-Black, 12.5% Hispanic, and 12.3% NH-other. Multivariable mixed-effects generalized linear regression controlling for age, sex, triage acuity, payer, and language revealed that, compared to NH-White patients, NH-other patients were more likely to receive ondansetron (adjusted odds ratio [95% CI] = 1.30 [1.17 to 1.43]). NH-Black, Hispanic, and NH-other patients were significantly less likely to receive IVF (0.59 [0.53 to 0.65]; 0.74 [0.64 to 0.84]; 0.74 [0.65 to 0.85]) or be admitted to the hospital (0.54 [0.45 to 0.64]; 0.62 [0.49 to 0.78]; 0.76 [0.61 to 0.94]), respectively. NH-Black and Hispanic patients had shorter LOS (median = 245 minutes for NH-White, 176 NH-Black, 199 Hispanic, and 203 NH-other patients) without significant differences in ED revisits. CONCLUSIONS Despite the presence of a clinical pathway to guide care, NH-Black, Hispanic, and NH-other children presenting to the ED with AGE/dehydration were less likely to receive IVF or hospital admission and had shorter LOS compared to NH-White counterparts. There was no difference in patient revisits, which suggests discretionary overtreatment of NH-White patients, even with clinical guidelines in place. Further research is needed to understand the drivers of differences in care to develop interventions promoting equity in pediatric emergency care.
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Affiliation(s)
- Morgan Congdon
- Department of General Pediatrics Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Stephanie A. Schnell
- Department of Neonatology Children’s Hospital of Los Angeles Los Angeles California USA
| | - Tatiana Londoño Gentile
- Department of General Pediatrics Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Jennifer A. Faerber
- Department of Biomedical and Health Informatics Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Christopher P. Bonafide
- Department of General Pediatrics Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Mercedes M. Blackstone
- Department of Emergency Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Tiffani J. Johnson
- Department of Emergency Medicine University of California, Davis Sacramento California USA
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Abstract
OBJECTIVES Health disparities between racial and ethnic groups have been documented in Canada, the United States, and Australia. Despite evidence that differences in emergency department (ED) care based on patient race and ethnicity exist, there are no comprehensive literature reviews in this area. The objective of this review is to provide an overview of the literature on the impact of patient ethnicity and race on the processes of ED care. METHODS A scoping review was conducted to capture the broad nature of the literature. A database search was conducted in MEDLINE/PubMed, EMBASE, CINAHL Plus, Social Sciences Citation Index, SCOPUS, and JSTOR. Five journals and reference lists of included articles were hand searched. Inclusion and exclusion criteria were defined iteratively to ensure literature captured was relevant to our research question. Data were extracted using predetermined variables, and additional extraction variables were added as familiarity with the literature developed. RESULTS Searching yielded 1,157 citations, reduced to 153 following removal of duplicates, and title and abstract screening. After full-text screening, 83 articles were included. Included articles report that, in EDs, patient race and ethnicity impact analgesia, triage scores, wait times, treatments, diagnostic procedure utilization, rates of patients leaving without being seen, and patient subjective experiences. Authors of included studies propose a variety of possible causes for these disparities. CONCLUSIONS Further research on the existence of disparities in care within EDs is warranted to explore the causes behind observed disparities for particular health conditions and population groups in specific contexts.
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Lacson R, Shi J, Kapoor N, Eappen S, Boland GW, Khorasani R. Exacerbation of Inequities in Use of Diagnostic Radiology During the Early Stages of Reopening After COVID-19. J Am Coll Radiol 2021; 18:696-703. [PMID: 33482115 PMCID: PMC7834847 DOI: 10.1016/j.jacr.2020.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Assess diagnostic radiology examination utilization and associated social determinants of health during the early stages of reopening after state-mandated shutdown of nonurgent services because of coronavirus disease 2019 (COVID-19). METHODS This institutional review board-approved, retrospective study assessed all patients with diagnostic radiology examinations performed at an academic medical center with eight affiliated outpatient facilities before (January 1, 2020, to March 8, 2020) and after (June 7, 2020, to July 15, 2020) the COVID-19 shutdown. Examinations during the shut down (March 9, 2020, to June 6, 2020) were excluded. Patient-specific factors (eg, race, ethnicity), imaging modalities, and care settings were extracted from the Research Data Warehouse. Primary outcome was the number of diagnostic radiology examinations per day compared pre- and post-COVID-19 shutdown. Univariate analysis and multivariable logistic regression determined features associated with completing an examination. RESULTS Despite resumption of nonurgent services, marked decrease in radiology examination utilization persisted in all care settings post-COVID-19 shutdown (869 examinations per day preshutdown [59,080 examinations in 68 days] versus 502 examinations per day postshutdown [19,594 examinations in 39 days]), with more significantly decreased odds ratios for having examinations in inpatient and outpatient settings versus in the emergency department. Inequities worsened, with patients from communities with high rates of poverty, unemployment, and chronic disease having significantly lower odds of undergoing radiology examinations post-COVID-19 shutdown. Patients of Asian race and Hispanic ethnicity had significantly lower odds ratios for having examinations post-COVID-19 shutdown compared with White and non-Hispanic patients, respectively. DISCUSSION The COVID-19 pandemic has exacerbated known pre-existing inequities in diagnostic radiology utilization. Resources should be allocated to address subgroups of patients who may be less likely to receive necessary diagnostic radiology examinations, potentially leading to compromised patient safety and quality of care.
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Affiliation(s)
- Ronilda Lacson
- Director of Education, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Junzi Shi
- Harvard Medical School, Boston, Massachusetts; Chief Resident and Chief Fellow, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Neena Kapoor
- Harvard Medical School, Boston, Massachusetts; Director of Diversity, Equity, and Inclusion, Quality and Patient Safety Officer, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sunil Eappen
- Harvard Medical School, Boston, Massachusetts; Chief Medical Officer, Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Giles W Boland
- Harvard Medical School, Boston, Massachusetts; President of the Brigham and Women's Physicians Organization, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ramin Khorasani
- Harvard Medical School, Boston, Massachusetts; Vice-Chair of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.
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Javalkar K, Robson VK, Gaffney L, Bohling AM, Arya P, Servattalab S, Roberts JE, Campbell JI, Sekhavat S, Newburger JW, de Ferranti SD, Baker AL, Lee PY, Day-Lewis M, Bucholz E, Kobayashi R, Son MB, Henderson LA, Kheir JN, Friedman KG, Dionne A. Socioeconomic and Racial and/or Ethnic Disparities in Multisystem Inflammatory Syndrome. Pediatrics 2021; 147:peds.2020-039933. [PMID: 33602802 PMCID: PMC8086000 DOI: 10.1542/peds.2020-039933] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To characterize the socioeconomic and racial and/or ethnic disparities impacting the diagnosis and outcomes of multisystem inflammatory syndrome in children (MIS-C). METHODS This multicenter retrospective case-control study was conducted at 3 academic centers from January 1 to September 1, 2020. Children with MIS-C were compared with 5 control groups: children with coronavirus disease 2019, children evaluated for MIS-C who did not meet case patient criteria, children hospitalized with febrile illness, children with Kawasaki disease, and children in Massachusetts based on US census data. Neighborhood socioeconomic status (SES) and social vulnerability index (SVI) were measured via a census-based scoring system. Multivariable logistic regression was used to examine associations between SES, SVI, race and ethnicity, and MIS-C diagnosis and clinical severity as outcomes. RESULTS Among 43 patients with MIS-C, 19 (44%) were Hispanic, 11 (26%) were Black, and 12 (28%) were white; 22 (51%) were in the lowest quartile SES, and 23 (53%) were in the highest quartile SVI. SES and SVI were similar between patients with MIS-C and coronavirus disease 2019. In multivariable analysis, lowest SES quartile (odds ratio 2.2 [95% confidence interval 1.1-4.4]), highest SVI quartile (odds ratio 2.8 [95% confidence interval 1.5-5.1]), and racial and/or ethnic minority background were associated with MIS-C diagnosis. Neither SES, SVI, race, nor ethnicity were associated with disease severity. CONCLUSIONS Lower SES or higher SVI, Hispanic ethnicity, and Black race independently increased risk for MIS-C. Additional studies are required to target interventions to improve health equity for children.
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Affiliation(s)
- Karina Javalkar
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts;,Contributed equally as co-first authors
| | - Victoria K. Robson
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts;,Contributed equally as co-first authors
| | - Lukas Gaffney
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts
| | - Amy M. Bohling
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Puneeta Arya
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Division of Cardiology and
| | - Sarah Servattalab
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Massachusetts General Hospital for Children, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Jordan E. Roberts
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jeffrey I. Campbell
- Infectious Diseases and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sepehr Sekhavat
- Department of Pediatrics, Boston University, Boston, Massachusetts;,Department of Cardiology, Boston Medical Center, Boston, Massachusetts
| | - Jane W. Newburger
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sarah D. de Ferranti
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Annette L. Baker
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Pui Y. Lee
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Megan Day-Lewis
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Emily Bucholz
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Ryan Kobayashi
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mary Beth Son
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lauren A. Henderson
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - John N. Kheir
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Kevin G. Friedman
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Audrey Dionne
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; .,Cardiology, Boston Children's Hospital, Boston, Massachusetts
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Dang R, Schroeder AR, Patel AI, Parsonnet J, Wang ME. Temperature Measurement at Well-Child Visits in the United States. J Pediatr 2021; 232:237-242. [PMID: 33508277 DOI: 10.1016/j.jpeds.2021.01.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/03/2020] [Accepted: 01/20/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the frequency and predictors of temperature measurement at well-child visits in the US and report rates of interventions associated with visits at which temperature is measured and fever is detected. STUDY DESIGN In this cross-sectional study, we analyzed 22 518 sampled well-child visits from the National Ambulatory Medical Care Survey between 2003 and 2015. We estimated the frequency of temperature measurement and performed multivariable regression to identify patient, provider/clinic, and seasonal factors associated with the practice. We described rates of interventions (complete blood count, radiograph, urinalysis, antibiotic prescription, and emergency department/hospital referral) by measurement and fever (temperature ≥100.4 °F, ≥38.0 °C) status. RESULTS Temperature was measured in 48.5% (95% CI 45.6-51.4) of well-child visits. Measurement was more common during visits by nonpediatric providers (aOR 2.0, 95% CI 1.6-2.5; reference: pediatricians), in Hispanic (aOR 1.9, 95% CI 1.6-2.3) and Black (aOR 1.5, 95% CI 1.2-1.9; reference: non-Hispanic White) patients, and in patients with government (aOR 2.0, 95% CI 1.7-2.4; reference: private) insurance. Interventions were more commonly pursued when temperature was measured (aOR 1.3, 95% CI 1.1-1.6) and fever was detected (aOR 3.8, 95% CI 1.5-9.4). CONCLUSIONS Temperature was measured in nearly one-half of all well-child visits. Interventions were more common when temperature was measured and fever was detected. The value of routine temperature measurement during well-child visits warrants further evaluation.
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Affiliation(s)
- Rebecca Dang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA.
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Anisha I Patel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Julie Parsonnet
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Marie E Wang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
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Evaluation of the Etiology, Clinical Presentation, Findings and Prophylaxis of Children with Headache. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:128-133. [PMID: 33935547 PMCID: PMC8085460 DOI: 10.14744/semb.2019.36604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 04/15/2019] [Indexed: 11/20/2022]
Abstract
Objectives: A headache is prevalent in childhood and constitutes a significant part of outpatient applications. This study aimed to evaluate the results of etiology, clinical features, examination results, prophylactic treatment and follow-up in patients with a headache. Methods: Between January 2017 and December 2018, the files of the patients with the complaint of headache were reviewed retrospectively in this study. A headache was classified according to the International Headache Society (IHS) criteria. Results: In this study, 350 patients aged between 3-17 years old and the mean age of 11.2±2.7 with a headache were included; 212 (60.6%) of them was female and 138 (39.4%) of them was male. The rate of a primary headache was higher in females than in males (p=0.004). The headache causes were a migraine in 51.1%, tension-type headache in 32.3%, secondary in 13.4%, and not classified in 3.1%. The mean age of the patients with a primary headache was significantly higher than patients with a secondary headache (p<0.001). The most common trigger factor was insomnia (52.7%). Abnormal physical/neurological signs and symptoms were detected in 17 (9.49%) patients. Cranial magnetic resonance imaging (MRI) examination was performed in 121 (34.5%) patients. Abnormal findings were found in 35 (28.9%) of these. In this study, 33 patients underwent electroencephalography (EEG); none of the had an epileptiform abnormality. Flunarizine (23.2%) and cyproheptadine (7.5%) were the most administered prophylactic treatments. It was observed that all patients who had prophylaxis and who had come to control had a significant decrease in headaches. Conclusion: The cause of childhood headaches is mostly migraine and tension-type headache. As long as there is no abnormality in the history and neurological examination, neuroimaging studies are not required in the routine evaluation of patients with a headache. Prophylactic treatment increases the quality of life in selected cases.
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Balter DR, Bertram A, Stewart CM, Stewart RW. Examining black and white racial disparities in emergency department consultations by age and gender. Am J Emerg Med 2021; 45:65-70. [PMID: 33677264 DOI: 10.1016/j.ajem.2021.01.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While significant racial inequities in health outcomes exist in the United States, these inequities may also exist in healthcare processes, including the Emergency Department (ED). Additionally, gender has emerged in assessing racial healthcare disparity research. This study seeks to determine the association between race and the number and type of ED consultations given to patients presenting at a safety-net, academic hospital, which includes a level-one trauma center. METHOD Retrospective data was collected on the first 2000 patients who arrived at the ED from 1/1/2015-1/7/2015, with 532 patients being excluded. Of the eligible patients, 77% (74.6% adults and 80.7% pediatric patients) were black and 23% (25.4% adults and 19.3% pediatric patients) were white. RESULTS White and black adult patients receive similar numbers of ED consultations and remained after gender stratification. White pediatric males have a 91% higher incidence of receiving an ED consultation in comparison to their white counterparts. No difference was found between black and white adult patients when assessing the risk of receiving consultations. White adult females have a 260% higher risk of receiving both types of consultations than their black counterparts. Black and white pediatric patients had the same risk of receiving consultations, however, white pediatric males have a 194% higher risk of receiving a specialty consultation as compared to their white counterparts. DISCUSSION Future work should focus on both healthcare practice improvements, as well as explanatory and preventive research practices. Healthcare practice improvements can encompass development of appropriate racial bias trainings and institutionalization of conversations about race in medicine.
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Affiliation(s)
| | - Amanda Bertram
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Abstract
It may seem unlikely that the field of radiology perpetuates disparities in health care, as most radiologists never interact directly with patients, and racial bias is not an obvious factor when interpreting images. However, a closer look reveals that imaging plays an important role in the propagation of disparities. For example, many advanced and resource-intensive imaging modalities, such as MRI and PET/CT, are generally less available in the hospitals frequented by people of color, and when they are available, access is impeded due to longer travel and wait times. Furthermore, their images may be of lower quality, and their interpretations may be more error prone. The aggregate effect of these imaging acquisition and interpretation disparities in conjunction with social factors is insufficiently recognized as part of the wide variation in disease outcomes seen between races in America. Understanding the nature of disparities in radiology is important to effectively deploy the resources and expertise necessary to mitigate disparities through diversity and inclusion efforts, research, and advocacy. In this article, the authors discuss disparities in access to imaging, examine their causes, and propose solutions aimed at addressing these disparities.
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Affiliation(s)
- Stephen Waite
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
| | - Jinel Scott
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
| | - Daria Colombo
- From the Department of Radiology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 (S.W., J.M.S.); and Department of Psychiatry, Weill Cornell Medical College, New York, NY (D.C.)
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Mitchell HK, Reddy A, Montoya-Williams D, Harhay M, Fowler JC, Yehya N. Hospital outcomes for children with severe sepsis in the USA by race or ethnicity and insurance status: a population-based, retrospective cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:103-112. [PMID: 33333071 PMCID: PMC9020885 DOI: 10.1016/s2352-4642(20)30341-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/02/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Disparities in outcomes of adult sepsis are well described by insurance status and race and ethnicity. There is a paucity of data looking at disparities in sepsis outcomes in children. We aimed to determine whether hospital outcomes in childhood severe sepsis were influenced by race or ethnicity and insurance status, a proxy for socioeconomic position. METHODS This population-based, retrospective cohort study used data from the 2016 database release from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The 2016 KID included 3 117 413 discharges, accounting for 80% of national paediatric discharges from 4200 US hospitals across 47 states. Using multilevel logistic regression, clustered by hospital, we tested the association between race or ethnicity and insurance status and hospital mortality, adjusting for individual-level and hospital-level characteristics, in children with severe sepsis. The secondary outcome of length of hospital stay was examined through multilevel time to event (hospital discharge) regression, with death as a competing risk. FINDINGS 12 297 children (aged 0-21 years) with severe sepsis with or without shock were admitted to 1253 hospitals in the 2016 KID dataset. 1265 (10·3%) of 12 297 patients did not have race or ethnicity data recorded, 15 (0·1%) were missing data on insurance, and 1324 (10·8%) were transferred out of hospital, resulting in a final cohort of 9816 children. Black children had higher odds of death than did White children (adjusted odds ratio [OR] 1·19, 95 % CI 1·02-1·38; p=0·028), driven by higher Black mortality in the south (1·30, 1·04-1·62; p=0·019) and west (1·58, 1·05-2·38; p=0·027) of the USA. We found evidence of longer hospital stays for Hispanic children (adjusted hazard ratio 0·94, 95% CI 0·88-1·00; p=0·049) and Black children (0·88, 0·82-0·94; p=0·0002), particularly Black neonates (0·53, 95% CI 0·36-0·77; p=0·0011). We observed no difference in survival between publicly and privately insured children; however, other insurance status (self-pay, no charge, and other) was associated with increased mortality (adjusted OR 1·30, 95% CI 1·04-1·61; p=0·021). INTERPRETATION In this large, representative analysis of paediatric severe sepsis in the USA, we found evidence of outcome disparities by race or ethnicity and insurance status. Our findings suggest that there might be differential sepsis recognition, approaches to treatment, access to health-care services, and provider bias that contribute to poorer sepsis outcomes for racial and ethnic minority patients and those of lower socioeconomic position. Studies are warranted to investigate the mechanisms of poorer sepsis outcomes in Black and Hispanic children. FUNDING None.
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Affiliation(s)
- Hannah K Mitchell
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Anireddy Reddy
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Michael Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Jessica C Fowler
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Barnes EL, Loftus EV, Kappelman MD. Effects of Race and Ethnicity on Diagnosis and Management of Inflammatory Bowel Diseases. Gastroenterology 2021; 160:677-689. [PMID: 33098884 DOI: 10.1053/j.gastro.2020.08.064] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/07/2020] [Accepted: 08/15/2020] [Indexed: 02/07/2023]
Abstract
Although Crohn's disease (CD) and ulcerative colitis (UC) have been considered as disorders that affect individuals of European ancestry, the epidemiology of the inflammatory bowel diseases (IBDs) is changing. Coupled with the increasing incidence of IBD in previously low-incidence areas, the population demographics of IBD in the United States are also changing, with increases among non-White races and ethnicities. It is therefore important to fully understand the epidemiology and progression of IBD in different racial and ethnic groups, and the effects of race and ethnicity on access to care, use of resources, and disease-related outcomes. We review differences in IBD development and progression among patients of different races and ethnicities, discussing the effects of factors such as access to care, delays in diagnosis, and health and disease perception on disparities in IBD care and outcomes. We identify research priorities for improving health equity among minority patients with IBD.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open 2021; 4:e2033710. [PMID: 33512517 PMCID: PMC7846940 DOI: 10.1001/jamanetworkopen.2020.33710] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer R. Marin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Guedj R, Marini M, Kossowsky J, Berde CB, Kimia AA, Fleegler EW. Racial and Ethnic Disparities in Pain Management of Children With Limb Fractures or Suspected Appendicitis: A Retrospective Cross-Sectional Study. Front Pediatr 2021; 9:652854. [PMID: 34414139 PMCID: PMC8369476 DOI: 10.3389/fped.2021.652854] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 07/06/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Romain Guedj
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatric Emergency Medicine, Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne Université, Paris, France.,Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, Paris, France
| | - Maddalena Marini
- Istituto Italiano di Tecnologia, Center for Translational Neurophysiology, Ferrara, Italy
| | - Joe Kossowsky
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
| | - Charles B Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
| | - Amir A Kimia
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States
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Patient Race/Ethnicity and Diagnostic Imaging Utilization in the Emergency Department: A Systematic Review. J Am Coll Radiol 2020; 18:795-808. [PMID: 33385337 DOI: 10.1016/j.jacr.2020.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 01/27/2023]
Abstract
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.
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Running Bear U, Asdigian NL, Beals J, Manson SM, Kaufman CE. Health outcomes in a national sample of American Indian and Alaska Native adults: Differences between multiple-race and single-race subgroups. PLoS One 2020; 15:e0242934. [PMID: 33270688 PMCID: PMC7714360 DOI: 10.1371/journal.pone.0242934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/11/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To determine differences among multi-race (MR) American Indian and Alaska Natives (AIAN), single race (SR) AIANs, and SR-Whites on multiple health outcomes. We tested the following hypotheses: MR-AIANs will have worse health outcomes than SR-AIANs; SR-AIANs will have worse health outcomes than SR-Whites; MR-AIANs will have worse health outcomes than SR-Whites. METHODS Behavioral Risk Factor Surveillance System data were used to examine general health, risk behaviors, access to health care, and diagnosed chronic health conditions. Those identifying as SR-White, SR-AIAN, and MR-AIAN were included in multinomial logistic regression models. RESULTS Compared to SR-AIANs, MR-AIANs had more activity limitations, a greater likelihood of experiencing cost as a barrier to health care and were more likely to be at increased risk and diagnosed with more chronic health conditions. Both SR and MR-AIANs have worse health than SR-Whites; MR-AIANs appear to be at increased risk for poor health. CONCLUSIONS The current study examined access to health care and nine chronic health conditions, neither of which have been considered in prior work. MR AIANs are at increased risk compared to SR groups. These observations beg for further inquire into the mechanisms underlying these differences including stress related to identify, access to care, and discrimination. Findings support the continued need to address health disparities among AIANs regardless of SR or MR identification.
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Affiliation(s)
- Ursula Running Bear
- Department of Population Health, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, United States of America
| | - Nancy L. Asdigian
- Department of Community and Behavioral Health, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz, Medical Campus, Aurora, CO, United States of America
| | - Janette Beals
- Department of Community and Behavioral Health, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz, Medical Campus, Aurora, CO, United States of America
| | - Spero M. Manson
- Department of Community and Behavioral Health, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz, Medical Campus, Aurora, CO, United States of America
| | - Carol E. Kaufman
- Department of Community and Behavioral Health, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz, Medical Campus, Aurora, CO, United States of America
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Morrow A, Dongarwar D, Salihu HM. Health Disparities and Constipation Management among Pediatric Patients in the Emergency Department. J Natl Med Assoc 2020; 112:541-549. [PMID: 32624239 DOI: 10.1016/j.jnma.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/03/2020] [Accepted: 05/19/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Constipation is a common cause of abdominal pain in children. Prior studies have demonstrated that nearly half of the children with constipation receive enemas; however, studies regarding constipation management based on race and ethnicity have not been pursued. The goal of this investigation is to determine if demographic disparities namely, race and ethnicity and insurance status affect emergency department (ED) management of constipation and prescription of enema. METHODS This was a retrospective cross-sectional study utilizing ED 2005-2016 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) in children <21 years old. Groups were analyzed according to race and also by insurance status. We performed adjusted survey binomial regression to evaluate the association between patient characteristics and receipt of enema among patients with constipation. RESULTS 3,168,240 children with constipation were seen in a sampling of EDs during the study period. 12.9% (408,937) received an enema. There was no statistically significant difference for Non-Hispanic Black and Hispanic patients to receive enema (OR: 0.92, CI: [0.47-1.82] and OR: 0.81, CI: [0.34-1.91], respectively) as compared to Non-Hispanic White patients. While Medicare patients were more likely to receive an enema (OR 187.76, CI [2,35-149.65]) compared to Medicaid patients, there was no difference between Medicaid patients and private payers. DISCUSSION Racial and health disparities do not appear to impact a physician's decision on giving an enema to children with constipation presenting to the ED.
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Affiliation(s)
- Asha Morrow
- Baylor College of Medicine, Department of Pediatrics, Section of Emergency Medicine, USA
| | - Deepa Dongarwar
- Baylor College of Medicine, Center of Excellence in Health Equity, Training and Research, USA.
| | - Hamisu M Salihu
- Baylor College of Medicine, Center of Excellence in Health Equity, Training and Research, USA
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Zamor R, Byczkowski T, Zhang Y, Vaughn L, Mahabee-Gittens EM. Language Barriers and the Management of Bronchiolitis in a Pediatric Emergency Department. Acad Pediatr 2020; 20:356-363. [PMID: 31981655 PMCID: PMC7102638 DOI: 10.1016/j.acap.2020.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/14/2020] [Accepted: 01/18/2020] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Ronine Zamor
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio.
| | - Terri Byczkowski
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center (Y Zhang), Cincinnati, Ohio
| | - Lisa Vaughn
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
| | - E Melinda Mahabee-Gittens
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
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