Are There Racial Disparities in Family-Reported Experiences of Care in Inpatient Pediatrics?

Association between nurse-child communication and family caregivers' global ratings to hospital: a retrospective study

PURPOSE

Effective nurse-child communication is a fundamental aspect of delivering pediatric nursing care. Family caregivers' global ratings to hospital are considered a proxy-reported measure for assessing a child's inpatient stay experience. We investigate the associations between nurse-child communication and family caregivers' global ratings to hospital.

DESIGN AND METHODS

A retrospective analysis of a national child patient experience survey data was conducted. Patient experience with nurse-child communication and the family caregivers' global ratings of hospital were measured using the Child Hospital Consumer Assessment of Healthcare Providers and Systems. Hierarchical linear models were constructed to examine the association between nurse-child communication measures and family caregivers' global ratings to hospital.

RESULTS

Data from 1010 patients at six National Regional Centers for Pediatric in China were collected. The overall rating of hospitals and the willingness to recommend the hospital showed increasing trends as the nurse-child communication score increased. How often nurses encourage children to ask questions was significantly associated with family caregivers' overall ratings of hospital and the family caregivers' willingness to recommend the hospital.

CONCLUSIONS

Effective communication by nurses with the child is associated with significantly higher global ratings to the hospital by family caregivers during inpatient care. Encouraging children to ask questions is a promising contributor to caregivers' global ratings to hospital.

PRACTICE IMPLICATIONS

Pediatric nurses should emphasis encouraging children to ask questions for effective communication in nursing practice. Future research is also needed to develop more targeted strategies to assist pediatric nurse to communicate with child better.

"Racism Happens Every Day, All the Time": Black Families' Outpatient Experiences of Racism Across a Large Pediatric System

OBJECTIVE

To qualitatively understand and characterize the experience of racism in outpatient pediatric healthcare settings from the perspectives of Black families.

METHODS

We conducted focus groups with parents or guardians of Black children, recruited from academic primary care offices at a single pediatric institution. Focus groups were facilitated virtually by Black team members using an open-ended, semi-structured focus group guide. We analyzed focus group transcripts using iterative, thematic, inductive open coding performed independently by trained coders, with final codes reached by group consensus.

RESULTS

We conducted 6 focus groups of 3 to 5 participants each and 1 individual interview, with 24 total parents. We identified the following themes: 1) "I just felt like we was a number": Black families perceived experiences that felt impersonal and lacked empathy; 2) "Why is the doctor treating me like I don't matter?": Black families perceived experiences with poor care and worse treatment; 3) Black families experience racism across socioecological levels when interacting with pediatric health systems; 4) Positive perceived experiences can guide improvement; and 5) Improvement will require antiracist efforts across the levels of racism.

CONCLUSIONS

In this qualitative study, we found that Black families have had many poor pediatric experiences, perceive racism as affecting child health broadly across socioecological levels, and recommend a multidimensional antiracist approach to improvement. Our findings underscore the importance of elevating Black family voices in developing policies that prioritize antiracism and work to eliminate the harmful impacts of racism on child health.

Understanding Disparities in the Pediatric ICU: A Scoping Review

BACKGROUND AND OBJECTIVES

Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized.

METHODS

Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables.

RESULTS

The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature.

CONCLUSIONS

Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.

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

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

Understanding Racial, Ethnic, and Socioeconomic Differences in the Ambulatory Care Experience

BACKGROUND AND OBJECTIVE

Racial and ethnic and socioeconomic differences in patient experience are prevalent and can negatively impact health outcomes. Our objective was to examine differences in family experience of care in the pediatric ambulatory setting.

METHODS

We conducted interviews with parents of patients from different demographic groups who had received care at 1 of 3 clinics at a quaternary children's hospital. Multidisciplinary team conducted inductive and deductive thematic analysis of transcribed interviews. Sentiments and recurring themes were compared within and between racial and ethnic groups, insurance status, and language.

RESULTS

Eighty parents were interviewed. Three primary themes were identified: (1) mitigation of system issues: parents' mixed experiences with staff or clinicians mitigating system issues impacted their overall perceptions of care; (2) pivotal role of personal interactions: clinicians' interactions positively influenced family-clinician relationships and offset negative experiences; (3) effective explanations: clinicians' clear and thorough explanations were crucial in enhancing parent confidence in care. As an overarching theme, discrimination and disrespect by staff undermined trust in care, affecting all aspects of experience. With the exception of explanations, a higher proportion of publicly-insured parents reported negative experiences across all themes compared to those with private insurance. Asian parents with public insurance had the highest proportion of interviews that were mainly negative in sentiment.

CONCLUSIONS

Our findings offer nuanced insights into differences in the experience of ambulatory care. Insurance status emerged as an important marker of differential perceptions of care. Our study points to areas for improvement and highlights family-clinician interactions as vital to overall positive experience.

Improving Patient Experience Scores Using Simultaneous Interpretation on Family-Centered Rounds

OBJECTIVES

Patients speaking a primary language other than English face barriers to equitable care, particularly patient-provider communications. There is no gold standard for providing inpatient medical interpretation on family-centered rounds (FCR). We aimed to implement simultaneous, in-person interpretation of FCR for Spanish-speaking families and hypothesized improved satisfaction in care.

METHODS

In-person, Spanish Equipment-Assisted Simultaneous Medical Interpretation (EASMI) was implemented in March 2018 on FCR. Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) experience scores on communication domains were analyzed for Spanish and English-speaking families pre- (n = 118) and postimplementation (n = 552). Postimplementation, we conducted medical team surveys (n = 104) and semistructured interviews with Spanish-speaking families (n = 25) to determine satisfaction with interpretation modalities (phone, video, and EASMI).

RESULTS

Spanish-speaking families exhibited statistically significant improvements in Child HCAHPS top box scores compared to English-speaking families in multiple communication and informed care-related domains. For example, "How often did your child's doctors explain things to you in a way that was easy to understand?" top box scores improved from 58% to 95% for Spanish-speaking families, compared to 85% to 83% for English speakers, with the differential effect of the intervention showing statistical significance (P = .001). Medical team surveys demonstrated high satisfaction with EASMI. Qualitative themes from interviews and open-ended survey responses emphasized multiple care benefits with EASMI, including a perceived reduction of communication errors and increased family participation.

CONCLUSIONS

EASMI was associated with significant improvements in Child HCAHPS scores in communication domains and increased medical team and family members' satisfaction with interpretation. EASMI presents a novel method for equitable FCR for Spanish-speaking families.

Racial and ethnic disparities in communication study enrollment for young people with cancer: A descriptive analysis of the literature

OBJECTIVE

We aimed to evaluate the racial and ethnic diversity of study participants in recent pediatric cancer communication literature.

METHODS

We systematically searched for communication studies in pediatric oncology published between January 2018 and September 2020, limiting analysis to US studies. We considered race and ethnicity as separate categories in our analysis. Two authors screened studies and abstracted characteristics of race and ethnicity reporting and enrollment.

RESULTS

Of 98 articles included in this analysis, many studies failed to report participants' race (21/98) and ethnicity (40/98). Most studies ascertained race and ethnicity by self-report (51/98); 25 studies did not describe how they ascertained race and ethnicity. White participants were overrepresented in studies relative to the US population (median 80% in studies vs 72% in 2020 US census). Racial and ethnic minorities were underrepresented (Black: 7% vs 14%; Asian: 4% vs 7%; Pacific Islander: 0% vs 0.5%; Native American: 0.5% vs 3%; Hispanic 8% vs 19%).

CONCLUSION

Communication literature in pediatric oncology underrepresents all racial and ethnic minority populations and is inconsistent in the reporting of race and ethnicity.

PRACTICE IMPLICATIONS

Future work should follow best practices to ensure this literature adequately represents the experiences of all families in pediatric oncology.

Drivers of paediatric inpatient experience: retrospective analysis of casemix factors for the Alberta Paediatric Inpatient Experience Survey in Alberta, Canada

OBJECTIVE

In Alberta, the Alberta Paediatric Inpatient Experience Survey (APIES) is used as a proxy-reported measure of paediatric experience. To our knowledge, the influence of casemix factors on patient experience as measured by paediatric patient experience surveys have not been reported within Canadian paediatric samples. In this paper, we sought to determine the patient and respondent factors associated with paediatric inpatient experiences in Alberta, Canada.

DESIGN

Retrospective analysis of patient experience survey data.

SETTING

Inpatiet acute care hospitals in Alberta, Canada.

INTERVENTION AND MAIN OUTCOME MEASURES

Retrospective analyses were conducted using APIES surveys linked with eligible inpatient records (n=6262). Descriptive statistics were reported. χ² tests were performed to assess distribution of casemix between general and paediatric hospitals. Logistic regression was performed with overall hospital experience as the dependent variable with casemix and hospital variables as independent variables.

RESULTS

Casemix characteristics were unevenly distributed between general and paediatric hospitals. Compared with reference categories, older respondents, healthier patients and treatment at paediatric facilities had increased odds of providing most-positive ratings. Increased respondent education was associated with decreased odds of providing most-positive ratings. Likelihood-ratio tests showed that most casemix variables improved model fit, except for respondent relationship to the patient.

CONCLUSIONS

To improve reports of paediatric inpatient experience, administrators and providers require reliable and comparable measurement. Both the Child Hospital Consumer Assessment of Healthcare Providers and Systems and other measures of patient and family experience need to consider patient and respondent characteristics when interpreting results. Considered with other research from patient experience in Alberta, we discuss future directions and quality improvement implications.

Parent Protector: Perceptions of NICU-to-Home Transition Readiness for NICU Parents of Black Preterm Infant

Black infants have twice the incidence of infant mortality (IM), death before the first birthday, and preterm birth in comparison to other US racial/ethnic groups; these factors make Black infants a high-risk group. The literature on the factors impacting caregivers and home environments for these infants is sparse. The purpose of this descriptive qualitative study was to explore perceived parental readiness to care for their Black preterm infants at home after discharge from a neonatal intensive care unit (NICU). Ten NICU parents of Black preterm infants completed a structured interview and self-report questionnaires before hospital discharge; data were analyzed using descriptive and semantic content methods. Coded parent responses were categorized as Parent Protector of Infants' Health (n = 94, 29.2%); Hindrances to Parental Readiness for Transition to Home (n = 97, 30.1%), and Parent as Partner in NICU to Home Transition (n = 131, 40.6%). All parents rated themselves "confident" (n = 6) or "very confident" (n = 4) in their ability to care for their infant after NICU discharge. Partnership with the healthcare team was described as involving health information resources, effective communication, and, most importantly, support for the parental role as infant protector for transition to home for their high-risk infant after NICU discharge.

Malnutrition Increases Hospital Length of Stay and Mortality among Adult Inpatients with COVID-19

Background: Malnutrition has been linked to adverse health economic outcomes. There is a paucity of data on malnutrition in patients admitted with COVID-19. Methods: This is a retrospective cohort study consisting of 4311 COVID-19 adult (18 years and older) inpatients at 5 Johns Hopkins-affiliated hospitals between 1 March and 3 December 2020. Malnourishment was identified using the malnutrition universal screening tool (MUST), then confirmed by registered dietitians. Statistics were conducted with SAS v9.4 (Cary, NC, USA) software to examine the effect of malnutrition on mortality and hospital length of stay among COVID-19 inpatient encounters, while accounting for possible covariates in regression analysis predicting mortality or the log-transformed length of stay. Results: COVID-19 patients who were older, male, or had lower BMIs had a higher likelihood of mortality. Patients with malnutrition were 76% more likely to have mortality (p < 0.001) and to have a 105% longer hospital length of stay (p < 0.001). Overall, 12.9% (555/4311) of adult COVID-19 patients were diagnosed with malnutrition and were associated with an 87.9% increase in hospital length of stay (p < 0.001). Conclusions: In a cohort of COVID-19 adult inpatients, malnutrition was associated with a higher likelihood of mortality and increased hospital length of stay.

Antiracism, Black Lives Matter, and Critical Race Theory: The ABCs of Promoting Racial Equity in Pediatric Practice

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.].

Association of Social Determinants of Health With Rapid Response Events: A Retrospective Cohort Trial in a Large Pediatric Academic Hospital System

BACKGROUND

Social determinants of health (SDH) are known to impact hospital and intensive care unit (ICU) outcomes. Little is known about the association between SDH and pediatric rapid response (RR) events and understanding this impact will help guide future interventions aimed to eliminate health disparities in the inpatient setting.

OBJECTIVES

The primary objective of this study is to describe the association between SDH and RR utilization (number of RR events, time to RR event, shift of event and caller). The secondary objective is to determine if SDH can predict hospital length of stay (LOS), ICU transfer, critical deterioration (CD), and mortality.

METHODS

A retrospective cohort study was conducted. We reviewed all RR events from 2016 to 2019 at a large, academic, pediatric hospital system including a level 1 trauma center and two satellite community campuses. All hospitalized patients up to age 25 who had a RR event during their index hospitalization were included. Exposure variables included age, gender, race/ethnicity, language, income, insurance status, chronic disease status, and repeat RR event. The primary outcome variables were hospital LOS, ICU transfer, CD, and mortality. The odds of mortality, CD events and ICU transfer were assessed using unadjusted and multivariable logistic regression. Associations with hospital LOS were assessed with unadjusted and multivariable quantile regression.

RESULTS

Four thousand five hundred and sixty-eight RR events occurred from 3,690 unique admissions and 3301 unique patients, and the cohort was reduced to the index admission. The cohort was largely representative of the population served by the hospital system and varied according to race and ethnicity. There was no variation by race/ethnicity in the number of RR events or the shift in which RR events occurred. Attending physicians initiated RR calls more for event for non-Hispanic patients of mixed or other race (31.6% of events), and fellows and residents were more likely to be the callers for Hispanic patients (29.7% of events, p = 0.002). Families who are non-English speaking are also less likely to activate the RR system (12% of total RR events, p = 0.048). LOS was longest for patients speaking languages other than Spanish or English and CD was more common in patients with government insurance. In adjusted logistic regression, Hispanic patients had 2.5 times the odds of mortality (95% CI: 1.43-4.53, p = 0.002) compared with non-Hispanic white patients.

CONCLUSION

Disparities exist in access to and within the inpatient management of pediatric patients. Our results suggest that interventions to address disparities should focus on Hispanic patients and non-English speaking patients to improve inpatient health equity. More research is needed to understand and address the mortality outcomes in Hispanic children compared to other groups.

Use of Patient-Reported Experience Measures in Pediatric Care: A Systematic Review

Introduction: Patient-reported Experience Measures (PREMs) are validated questionnaires, that gather patients' and families' views of their experience receiving care and are commonly used to measure the quality of care, with the goal to make care more patient and family-centered. PREMs are increasingly being adopted in pediatric population, however knowledge gaps exist around understanding the use of PREMs in pediatrics. Objective: To identify and synthesize evidence on the use of PREMs in pediatric healthcare settings and their characteristics. Evidence Review: Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines governed the conduct and reporting of this review. An exhaustive search strategy was applied to MEDLINE, EMBASE, PsycINFO, Cochrane Library, and CINAHL databases to identify relevant peer-reviewed articles from high-income countries. Additionally, gray literature was searched to capture real-world implementation of PREMs. All the articles were screened independently by two reviewers in two steps. Data was extracted independently, synthesized, and tabulated. Findings from gray literature was synthesized and reported separately. Risk of bias for the studies identified through scientific databases was assessed independently by two reviewers using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: The initial search identified 15,457 articles. After removing duplicates, the title and abstracts of 11,543 articles were screened. Seven hundred ten articles were eligible for full-text review. Finally, 83 articles met the criteria and were included in the analyses. Of the 83 includes studies conducted in 14 countries, 48 were conducted in USA, 25 in European countries and 10 in other countries. These 83 studies reported on the use of 39 different PREMs in pediatric healthcare settings. The gray literature retrieved 10 additional PREMs. The number of items in these PREMs ranged from 7 to 89. Twenty-three PREMs were designed to be completed by proxy, 10 by either pediatric patients or family caregivers, and 6 by pediatric patients themselves. Conclusion and Relevance: This comprehensive review is the first to systematically search evidence around the use of PREMs in pediatrics. The findings of this review can guide health administrators and researchers to use appropriate PREMs to implement patient and family-centered care in pediatrics.

Selected predictors of parental satisfaction with child nursing care in paediatric wards in Poland-Cross-sectional study

BACKGROUND

Assessment of parental satisfaction with child nursing is the key issue in evaluation of the care quality, enabling the adjustment of the services provided to the needs and expectations of recipients, and thus ensuring safety and achieving better long-term health effects.

AIM

Assessment of parental satisfaction with child nursing in paediatric wards including its determinants.

MATERIAL AND METHODS

The study covered 1030 parents of children hospitalised in paediatric and surgical wards of seven hospitals of different levels of health security in Poland. The Polish adaptation of the Empathic standardised questionnaire for assessment of the level of parents' satisfaction with nursing care, developed by Latour et al. and the self-constructed summary of socio-demographic data were applied in the study.

RESULTS

More than 90% of respondents expressed high level of satisfaction with nurses' Availability, the lowest, but still high score of respondents' satisfaction was observed for Parental Participation. The highest satisfaction was observed among the parents of children at the preschool, early school and puberty stage, admitted to the hospital on the elective basis, referred for diagnostic assessment and with the length of hospital stay less than 7 and longer than 28 days. Achieving preschool age was the strongest factor which increased assessment of satisfaction in most domains.

CONCLUSIONS

There is a need for optimising nursing care especially in the area of parental participation. The nursing care' quality improvement plan in paediatric departments should focus particularly on early childhood patients and their parents who are the most critical in satisfaction' assessment.

We are part of the problem: the role of children's hospitals in addressing health inequity

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.

The role of weight bias and role-modeling in medical students' patient-centered communication with higher weight standardized patients

OBJECTIVE

Patients with obesity may experience less patient-centered care. We assessed whether medical students' implicit/explicit weight-related attitudes and perceptions of normative attitudes are associated with patient-centered care for patients with obesity.

METHODS

Third and fourth year medical students (N = 111) at one medical school completed a survey and participated in a patient care scenario with a standardized patient with obesity. Encounters were coded for patient-centered behavior. Predictors of patient-centered behaviors were assessed.

RESULTS

Student perceptions that negative attitudes about patients with obesity are normative in medical school were significantly associated with poorer patient-centered behaviors, including lower attentiveness (b=-0.19, p = 0.01), friendliness (b=-0.28, p < 0.001), responsiveness (b=-0.21, p = 0.002), respectfulness (b=-0.17, p = 0.003), interactivity (b=-0.22, p = 0.003), likelihood of being recommended by observers (b=-0.34, p < 0.001), and patient-centeredness index scores (b=-0.16, p = 0.002). Student reported faculty role-modeling of discrimination against patients with obesity predicted lower friendliness (b=-0.16, p = 0.03), recommendation likelihood (b=-0.22, p = 0.04), and patient-centeredness index score (b=-0.12, p = 0.03).

CONCLUSIONS

Negative normative attitudes and behaviors regarding obesity in the medical school environment may adversely influence the quality of patient-centered behaviors provided to patients with obesity.

PRACTICE IMPLICATIONS

Efforts to improve patient-centered communication quality among medical trainees may benefit from intervention to improve group normative attitudes about patients with obesity.

The Impact of Demographics on Child and Parent Ratings of Satisfaction with Hospital Care

Introduction

Patient satisfaction ratings differ between minority and nonminority respondents in studies of hospitalized adults, but little is known about such differences in pediatrics. Our goal was to determine if patient satisfaction ratings completed by hospitalized children and their parents at the point of discharge differed by race/ethnicity, language, child gender, and age.

Methods

We used a mixed-methods design. English and Spanish-speaking families from 5 inpatient units at 1 pediatric hospital completed ratings, face-to-face, before scheduled hospital discharge (T1), and again by telephone after discharge (T2). Participating children and their parents completed an 8-item satisfaction survey, and parents additionally completed 7 discharge readiness items.

Results

The refusal rate was 10.7%, with 600 families enrolled; non-white families represented 66% of both study refusals and completions. The proportion of racial/ethnic groups in our study exceeded those in our standard survey sample. There were no significant differences in satisfaction ratings between non-white and white families or by child gender, age, or language.

Conclusions

The lack of rating differences by demographic characteristics, the low refusal and attrition rates, and a more racially/ethnically representative sample of both child and parent perspectives indicate this approach to measuring satisfaction is acceptable and feasible to demographically diverse families.

Disparities in Shared Decision Making and Service Receipt Among Children With Special Health Care Needs and Developmental Delay: A National Survey Analysis

Shared decision making (SDM) is associated with increased service satisfaction among pediatric patients. Our objective was to examine the association between SDM and service use experiences across racial/ethnic child groups. This secondary data analysis used the 2009-2010 National Survey of Children with Special Health Care Needs (CSHCN) and 2011 Pathways to Diagnosis and Services Survey. We used a rank-and-replace matching approach consistent with Institute of Medicine recommendations for health disparities research. We included CSHCN aged 6 to 17 years. The exposure of interest was parents of CSHCN reporting engagement in SDM with clinicians. There were 4032 CSHCN included in analysis. CSHCNs experiencing SDM had a 16% higher probability of reporting service use compared to those not experiencing it (95% CI, 14.24-19.42). Black children experiencing SDM reported seeing all needed care providers at a lower rate than whites (79% and 87.6% respectively; 95% CI, -14.05-3.27). The benefit of SDM over not experiencing it for blacks was 12.2% less than for whites for the outcome of seeing all needed care providers. For the outcome of receiving all needed treatments and services, the SDM benefit was 9.1% lower for Hispanics compared with whites. SDM can improve service experiences but implementation flexibility may be needed.

Racial Differences in Do-Not-Resuscitate Orders among Pediatric Surgical Patients in the United States

Background: Very few studies have investigated the racial differences in do-not-resuscitate (DNR) orders in children, and these studies are limited to oncological cases. We aim to characterize the racial difference in DNR orders among U.S. pediatric surgical patients. Methods: We retrospectively evaluated the mortality of all children who underwent an inpatient surgery between 2012 and 2017 from the National Surgical Quality Improvement Program. We used log-binomial models to estimate the relative risk (RR) and 95% confidence interval (CI) of DNR use comparing white with African American (AA) children. To estimate the risk-adjusted difference in DNR orders, we controlled the analyses for age, prematurity status, emergent case status, American Society of Anesthesiologists class, year of operation, surgical specialty, and surgical complexity. Results: Between 2012 and 2017, a total of 276,917 children underwent inpatient surgery, of whom 0.8% (n = 1601) died within 30 days of operation. Of the 1601 mortality cases, we retained 1212 children who were of either AA (26.0%, n = 350) or white (63.9%, n = 862) race. Most children were neonates, had an American Society of Anesthesiologists class ≥4 (70.0%, n = 811), and developed one or more postoperative complications (68.7%, n = 833). Overall, AA children were more likely to be neonates at the time of surgery (42.0% vs. 40.3%, p < 0.001), to be premature (66.3% vs. 49.0%, p < 0.001), and develop one or more postoperative complications (73.7% vs. 66.7%, p = 0.017). White children were three times more likely to have a DNR order than their AA peers (adjusted RR: 3.01, 95% CI: 1.09-8.56, p = 0.044). Conclusion: Among pediatric surgical patients in the United States, children of white race were three times more likely to have a DNR order in place than their AA peers despite the latter being "sicker" and more likely to develop postoperative complications. The mechanisms underlying this racial difference deserve further elucidation to improve shared decision making and goal-concordant care.

Addressing implicit bias in pediatric hematology-oncology

Although awareness of implicit bias and its influence on providers and patients is increasing, the effects of implicit bias on the field of pediatric hematology-oncology are less clear. This Special Report reviews the literature on implicit bias in pediatrics and medical oncology and further provides case examples and suggestions on what can be done to address implicit bias. There is a need for further research on how implicit bias impacts the complex care of pediatric hematology-oncology patients.

Racial and Ethnic Differences in Parental Decision-Making Roles in Pediatric Oncology

Background: Prior work in adult oncology suggests minority patients are less involved in decision making than preferred. However, few studies have explored decision-making experiences of minority parents in pediatric oncology. Objective: To determine whether parental decision-making preferences and experiences vary by race/ethnicity. Design: Questionnaire-based cohort study. Setting/Subjects: Three hundred sixty five parents of children with cancer and their oncologists at two academic centers. Measurements: Parents reported on preferred and actual decision-making roles. Associations between race/ethnicity and decision-making outcomes determined by chi-squared test. Results: Most parents preferred shared decision making (235/368, 64%), whereas 23% (84/368) preferred parent-led decision making and 13% (49/368) preferred oncologist-led decision making. Parental decision-making preferences did not differ by race/ethnicity (p = 0.38, chi-squared test). However, the actual role parents played in decision making differed by parental race/ethnicity, with 25% (71/290) of white parents reporting parent-led decision making, versus 37% (9/24) of black parents, 48% (13/27) of Hispanic parents, and 56% (15/27) of Asian/other parents (p = 0.005, chi-squared test). Oncologists accurately predicted parental preferences for decision making 49% of the time (n = 165/338), but accuracy also differed by race and ethnicity. Oncologists accurately predicted parental preferences for 53% of white parents (140/266), 23% of black parents (5/22), 37% of Hispanic parents (10/27), and 43% of Asian/other race parents (10/23) (p = 0.026, chi-squared test). Conclusions: Minority parents held more active roles than white parents, and oncologists had more difficulty predicting decisional preferences for minority parents relative to white parents. These findings suggest that minority parents are at risk of inferior decision-making experiences.

Exploring national trends of patient- and family-centered care among US children

We explored national trends in the receipt of high-quality patient-physician communication and patient empowerment through behavioral health counseling among children in the United States. We used data from the Medical Expenditure Panel Survey from 2010 to 2014. We employed two measures of patient- and family-centered care (PFCC): (1) a composite measure of high-quality patient-physician communication ( n = 34,629) and (2) patient empowerment through behavioral health counseling about healthy eating ( n = 36,527) and exercise ( n = 38,318). We used multivariate logistic regression models to estimate the variation of receiving PFCC by social determinants of health over time. Rates of receiving behavioral health counseling about healthy eating (53-60%) and exercise (37-42%) were lower than the rate of receiving high-quality physician-patient communication (92-93%). Parents were significantly more likely to report receiving high-quality physician-patient communication in 2014 than in 2010 (odds ratio 1.37, confidence interval 1.08-1.67); however, no association was found for empowerment through behavioral health counseling. Low income and parental educational attainment, and lack of insurance were associated with lower odds of receiving behavioral health counseling. Results showed significant variation of physician-patient communication and empowerment by social and demographic factors. The results suggest more providers need to empower parents and their children to self-care through behavioral health counseling.

Are Caregivers Who Respond to the Child HCAHPS Survey Reflective of All Hospitalized Pediatric Patients?

OBJECTIVES

The Child Hospital Consumer Assessment of Healthcare Providers and Systems (C-HCAHPS) survey was developed to measure satisfaction levels of pediatric inpatients' caregivers. Studies in adults have revealed that certain demographic groups (people of color or who are multiracial and people with public insurance) respond to surveys at decreased rates, contributing to nonresponse bias. Our primary goal was to determine if results from the C-HCAHPS survey accurately reflect the intended population or reveal evidence of nonresponse bias. Our secondary goal was to examine whether demographic or clinical factors were associated with increased satisfaction levels.

METHODS

This was a retrospective cohort study of responses (n = 421) to the C-HCAHPS survey of patients admitted to a tertiary-care pediatric hospital between March 2016 and March 2017. Respondent demographic information was compared with that of all hospital admissions over the same time frame. Satisfaction was defined as "top-box" scores for questions on overall rating and willingness to recommend the hospital.

RESULTS

Caregivers returning surveys were more likely to be white, non-Hispanic, and privately insured (P < .001). Caregivers with the shortest emergency department wait times were more likely to assign top-box scores for global rating (P = .025). We found no differences in satisfaction between race and/or ethnicity, length of stay, insurance payer, or total cost.

CONCLUSIONS

Caregivers who identified with underrepresented minority groups and those without private insurance were less likely to return surveys. Among the surveys received, short emergency department wait time and older age were the only factors measured that were associated with higher satisfaction. Efforts to increase patient satisfaction on the basis of satisfaction scores may exacerbate existing disparities in health care.

Inpatient care experiences differ by preferred language within racial/ethnic groups

Objective

To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups.

Data Source

2014‐2015 HCAHPS survey data.

Study Design

We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient‐mix adjusted overall, between‐ and within‐hospital differences in patient experience by language, using linear regression.

Data Collection Methods

Surveys from 5 480 308 patients discharged from 4517 hospitals 2014‐2015.

Principal Findings

Within each racial/ethnic group, mean reported experiences for non‐English‐preferring patients were almost always worse than their English‐preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within‐hospital differences by language were often larger than between‐hospital differences and were largest for Care Coordination. Where between‐hospital differences existed, non‐English‐preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English‐preferring counterparts.

Conclusions

Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non‐English‐preferring patients, focusing on cultural competence and language‐appropriate services.