Eliminating Race-Based Medicine

Implementing Clinical Practice Guidelines: Considerations for Epileptologists

Over 5000 epilepsy-related articles are indexed annually, posing a challenge for clinicians to stay updated on all relevant research. Clinical Practice Guidelines (CPGs) are vital tools for translating evidence into practice and promoting equitable, high-quality care while addressing practice variations. This review examines CPG applicability for epileptologists, emphasizing the nuances between primary and specialty care, addressing disparities, and comparing guideline usage in the United States and internationally. CPGs are utilized differently across specialties. General practitioners often manage initial epilepsy cases guided by first-seizure and new-onset epilepsy guidelines. Specialists, dealing with complex cases like treatment-resistant epilepsy, face challenges as guidelines may lag behind emerging therapies. Yet, evidence shows specialists heavily rely on CPGs to ensure optimal care. The use of race in medical algorithms highlights disparities, with examples like race-based adjustments in glomerular filtration rate calculations raising equity concerns. While frameworks exist to reduce biases, ongoing monitoring and inclusive approaches are critical. Globally, CPG implementation varies. The UK's centralized system integrates cost-effectiveness analyses, while the United States adopts a decentralized approach prioritizing clinical efficacy. Emerging technologies, such as electronic medical records and clinical decision support systems, improve CPG adoption and patient outcomes. Success stories like the "Get with the Guidelines" stroke program illustrate the potential of structured CPG frameworks. However, challenges persist, such as inconsistencies in epilepsy guidelines for acute seizure management. Ultimately, bridging the gap between evidence and practice requires rigorous, inclusive guideline development, effective communication, and proactive implementation strategies tailored to diverse healthcare systems.

Implicit bias assessment by career stage in medical education training: a narrative review

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person based on individual characteristics. Early evaluation of implicit bias in medical training can prevent long-term adverse health outcomes related to racial bias. However, to our knowledge, no present studies examine the sequential assessment of implicit bias through the different stages of medical training. The objective of this narrative review is to examine the breadth of existing publications that assess implicit bias at the current levels of medical training, pre-medical, graduate, and postgraduate. Protocol for this study was drafted using the Scale for the Assessment of Narrative Reviews (SANRA). Keyword literature search on peer-reviewed databases Google Scholar, PubMed, Ebsco, ScienceDirect, and MedEd Portal from January 1, 2017, to March 1, 2022, was used to identify applicable research articles. The online database search identified 1,512 articles. Full screening resulted in 75 papers meeting the inclusion criteria. Over 50% of extracted papers (74%) were published between 2019 and 2021 and investigated implicit bias at the post-graduate level (43%), followed by the graduate level (34%), and pre-medical level (9.4%). Fourteen percent were classified as mixed. Studies at the medical and medical graduate level identified an implicit preference towards white, male, non-LGBTQIA+, thin, patients. Study findings highlight notable gaps within the sequential assessment of implicit bias, specifically at the pre-medical training level. Longitudinal epidemiological research is needed to examine the long-term effect of implicit biases on existing healthcare disparities.

Moving Towards an Equitable Future: Rethinking the use of Race in Pediatric Densitometry

Current guidelines from the International Society for Clinical Densitometry (ISCD) recommend considering race, sex, and age in calculating pediatric bone density z-scores by Dual-Energy X-ray Absorptiometry (DXA). However, as patient populations become increasingly diverse, the application of these guidelines presents significant challenges, potentially leading to racial bias and systemic inequities in care. In response to growing calls for a reevaluation of race's role in clinical decision-making, we aimed to assess the readiness of front-line providers of DXA services to address these challenges. We conducted a professional, anonymized clinical practice survey targeting DXA technologists from various centers as part of a workshop for Reevaluation of the Role of Race, Ethnicity, and Ancestry in Clinical Decision-Making at the 2024 Annual Meeting of the Pediatric Academic Society. The survey focused on their experiences with the recording and use of race demographics. Our findings revealed inconsistencies in race data collection practices, varying levels of perceived patient comfort, and concerns about the potential perpetuation of racial bias. These results highlight the need for standardized guidelines to facilitate the sensitive and unbiased collection of race-related data during DXA exams, ultimately promoting equitable care for all patients.

Total Serum IgE in a Cohort of Children With Food Allergy

BACKGROUND

Total serum IgE (TsIgE) has not been examined in children with food allergy.

OBJECTIVE

To evaluate associations of TsIgE with patient, household, environmental, and community-level characteristics among children with food allergy.

METHOD

We used linear mixed-effects models of data from 398 Black and/or African American (B/AA) and White and/or European American (W/EA) children with allergist-diagnosed food allergy from the multicenter, observational cohort FORWARD (Food Allergy Outcomes Related to White and African American Racial Differences); TsIgE (kU/L) was the primary outcome measure.

RESULTS

In univariable analyses of data from all study sites, children's TsIgE was positively associated with older age (P < .001); B/AA race (P < .001); male sex (P = .014); lower household income (P = .005); lower caregiver education (P = .005); higher Area Deprivation Index (P < .001); presence of allergic rhinitis (P < .001), asthma (P < .001), and eczema (P = .024); and a higher number of food allergies (P < .001), but not with tobacco smoke exposure. With covariable adjustment in multivariable analysis, total serum IgE was higher in older versus younger children (P < .001), male versus female children, B/AA versus W/EA children (P < .001), and in children with allergic rhinitis (P = .010), asthma (P < .001), eczema (P = .007), or a higher number of food allergies (P < .001), but not with tobacco smoke exposure or Area Deprivation Index.

CONCLUSIONS

In children with food allergy, age, sex, race, atopic diagnosis, allergic rhinitis, asthma, and eczema are associated with TsIgE. These findings are important when TsIgE values are used in diagnosis and therapies.

Complying with Joint Commission Health Equity Requirements: Medical-Legal Partnership Data and Health-Related Social Needs

BACKGROUND

Medical-legal partnerships (MLPs) are a hospital-based resource for patients and families to address health-related legal needs, which often align closely with health-related social needs (HRSNs). For instance, patients and their families with housing insecurity or education, immigration, family law, or other legal needs, or who are having trouble accessing government benefits programs are referred by their health care provider to the MLP. Next, an intake process determines eligibility for MLP services that will result in connecting the patients and their families with resources or legal assistance to address the HRSNs. The Joint Commission's health equity requirements were established as a quality and safety imperative and focus on obtaining patient-specific data for HRSNs in the populations a hospital serves to address the root causes of disparities in patients' health outcomes. The authors examined data for pediatric patients referred to the hospital's MLP as an example of using legal referral data to obtain HRSNs data to comply with these requirements.

METHODS

The researchers collected and analyzed data on sociodemographic factors, clinical characteristics, and reason for referral of pediatric patients to a hospital-based MLP. Data were collected from January 1, 2019, to December 31, 2021, spanning the duration of the COVID-19 pandemic. The legal matters from January 1, 2019, to March 9, 2020, were classified as pre-COVID-19 pandemic legal matters, and the legal matters from March 10, 2020, to December 31, 2021, were classified as having occurred during the COVID-19 pandemic. These two time periods were analyzed to account for any pandemic-related effects.

RESULTS

A total of 628 patients (median age 9.0 years; male 48.2%) were referred for 611 legal matters (referrals including more than 1 patient from a single household were counted once). Patients were more likely to be Hispanic/Latino, Black/African American, English-speaking, and publicly insured. Many had at least one complex chronic condition (44.4%). More than half of referrals were for housing insecurity (52.1%). This was consistent in the pre-COVID-19 pandemic period and during the COVID-19 period (52.0% vs. 52.2%, p = 0.95).

CONCLUSION

Most MLP referrals were for housing insecurity in children from medically underserved or marginalized populations. Aligning The Joint Commission's health equity requirements with legal referral data is a generalizable approach to improve the collection of HRSNs data for addressing disparities in health outcomes in the populations the hospital serves.

Construction and performance of a clinical prediction rule for ureteral stone without the use of race or ethnicity: A new STONE score

Objectives

The original STONE score was designed to predict the presence of uncomplicated renal colic and the corresponding absence of alternate serious etiologies. It was retrospectively derived and prospectively validated and resulted in five variables: Sex (male gender), Timing (acute onset of pain), "Origin" (non-Black race), Nausea/vomiting (present), and Erythrocytes (microscopic hematuria). With recent increased awareness of the potential adverse impacts of including race (a socially constructed identity) in clinical prediction rules, we sought to determine if a revised STONE score without race could be constructed with similar diagnostic accuracy.

Methods

We used data from the original STONE score that utilized retrospective data on patients with confirmed kidney stone by computed tomography (CT) to derive a clinical prediction rule as well as prospective data to validate the score. These data were used to construct a revised STONE score after removing race as a variable. We performed univariate and multivariable logistic regression and compared the old and new STONE scores (including multivariable, integral, and three-level risk) using the area under the receiver operating characteristic curve (AUC) and misclassification rates.

Results

After the elimination of race, multivariable logistic regression revealed that gross hematuria was the next strongest feasible variable for the prediction of ureteral stone. This was incorporated into a revised STONE score by substituting "obvious hematuria" for "origin" (formerly race). The revised STONE score had similar predictive accuracy to the original STONE score: AUC 0.85 versus 0.86 (95% confidence interval [CI]: 0.82-0.87 and 0.79-0.93); misclassification rates were also unchanged, 0.23 versus 0.23 (95% CI: 0.20-0.25 and 0.20-0.25).

Conclusions

We modified the STONE score to remove race and include "obvious hematuria" without losing clinical accuracy. Considering the potential adverse effects of propagating racial bias in clinical algorithms, we recommend using the revised STONE score. Future research could investigate the potential contributions of social drivers of health (SDOH) to the diagnosis of kidney stone.

Characteristics Associated With Positive Social Determinants of Health Screening in Patients Admitted to Pediatric Hospital Medicine

BACKGROUND AND OBJECTIVE

There is limited research on screening for social determinants of health (SDOH) in hospitalized pediatric patients. In this article, we describe patient characteristics related to SDOH screening in the hospital setting and examine relationships with acute care metrics.

METHODS

This is a retrospective cohort study. From July 2020 to October 2021, a 14-question SDOH screener was administered to families of patients admitted or transferred to the hospital medicine service. Information was collected regarding screen results, demographics, patient comorbidities, patient complexity, and acute care metrics. Unadjusted and multivariable analyses were performed using generalized estimation equation logistic regression models.

RESULTS

Families in 2454 (65%) patient encounters completed SDOH screening, with ≥1 need identified in 662 (27%) encounters. Families with significant odds for positive screening results in a multivariable analysis included primary language other than English (odds ratio [OR] 4.269, confidence interval [CI] 1.731-10.533) or Spanish (OR 1.419, CI 1.050-1.918), families identifying as "Black" (OR 1.675, CI 1.237-2.266) or Hispanic (OR 1.347, CI 1.057-1.717) or having a child on the complex care registry (OR 1.466, CI 1.120-1.918). A positive screening result was not associated with increased length of stay, readmission, or 2-year emergency department or acute care utilization.

CONCLUSIONS

In hospitalized pediatric patients, populations at the greatest odds for positive needs include families with primary languages other than English or Spanish, those that identified as certain races or ethnicities, or those having a child on the complex care registry. A positive SDOH screening result in this study was not associated with an increase in length of stay, readmission, or acute care utilization.

Guidance for unbiased predictive information for healthcare decision-making and equity (GUIDE): considerations when race may be a prognostic factor

Clinical prediction models (CPMs) are tools that compute the risk of an outcome given a set of patient characteristics and are routinely used to inform patients, guide treatment decision-making, and resource allocation. Although much hope has been placed on CPMs to mitigate human biases, CPMs may potentially contribute to racial disparities in decision-making and resource allocation. While some policymakers, professional organizations, and scholars have called for eliminating race as a variable from CPMs, others raise concerns that excluding race may exacerbate healthcare disparities and this controversy remains unresolved. The Guidance for Unbiased predictive Information for healthcare Decision-making and Equity (GUIDE) provides expert guidelines for model developers and health system administrators on the transparent use of race in CPMs and mitigation of algorithmic bias across contexts developed through a 5-round, modified Delphi process from a diverse 14-person technical expert panel (TEP). Deliberations affirmed that race is a social construct and that the goals of prediction are distinct from those of causal inference, and emphasized: the importance of decisional context (e.g., shared decision-making versus healthcare rationing); the conflicting nature of different anti-discrimination principles (e.g., anticlassification versus antisubordination principles); and the importance of identifying and balancing trade-offs in achieving equity-related goals with race-aware versus race-unaware CPMs for conditions where racial identity is prognostically informative. The GUIDE, comprising 31 key items in the development and use of CPMs in healthcare, outlines foundational principles, distinguishes between bias and fairness, and offers guidance for examining subgroup invalidity and using race as a variable in CPMs. This GUIDE presents a living document that supports appraisal and reporting of bias in CPMs to support best practice in CPM development and use.

Prenatal Substance Exposure and Infant Discharge Placement: Results From the ACT NOW Study

It is critical that researchers gather evidence of factors that identify infants at risk of out-of-home placement based on types of substance exposures and demographic characteristics. This study applied a validated medical record data extraction tool on data derived from a multi-site (N = 30) pediatric clinical trials network (ISPCTN) study of Neonatal Opioid Withdrawal (ACT NOW study). Participants included 1808 birthing parent-infant dyads with documented NOWS scoring or prenatal opioid exposure. Non-Hispanic White pregnant persons comprised the largest proportion of the sample (69.8%), followed by Non-Hispanic Black (11.6%), Non-Hispanic Multiracial and Other race (8.5%), and Hispanic (6.2%). Most notably, infant prenatal substance exposure across alcohol, cocaine, meth/amphetamine, and opioids, had the lowest possibility of discharging to parent(s). Additionally, latent class analysis identified distinct classes of substance use during pregnancy that were associated with different probabilities of discharging to parent(s). Specifically, less than half of infants (47%-49%) in the Poly-use and Meth/amphetamine classes were discharged to their parent(s). Severity of infant withdrawal symptoms influenced placement decisions within the Poly-use and Prescription Opioid classes. Findings can inform standard practices for increasing support for pregnant persons and substance-exposed infants including identification, subsequent referrals, communication with Child Protective Services, and plans of safe care.

Managing neonatal hyperbilirubinemia: An updated guideline

ABSTRACT

More than 80% of newborn infants experience jaundice as a result of elevated bilirubin during the first few weeks after birth. In most cases, hyperbilirubinemia is physiologic, but persistent and extreme elevations can lead to serious long-term complications, such as kernicterus. To avoid these complications and help clinicians in the successful assessment, evaluation, and treatment of hyperbilirubinemia, the American Academy of Pediatrics updated its clinical practice guideline for neonatal hyperbilirubinemia. This article reviews the guideline and highlights significant updates, such as an elevation in the threshold for phototherapy and exchange transfusion, inclusion of gestational age, and removal of racially based norms.

Community and Patient Features and Health Care Point of Entry for Pediatric Concussion

Importance

Many recent advances in pediatric concussion care are implemented by specialists; however, children with concussion receive care across varied locations. Thus, it is critical to identify which children have access to the most up-to-date treatment strategies.

Objective

To evaluate differences in the sociodemographic and community characteristics of pediatric patients who sought care for concussion across various points of entry into a regional health care network.

Design, Setting, and Participants

This cross-sectional study included children seen for concussions across a regional US health care network from January 1, 2017, to August 4, 2023. Pediatric patients aged 0 to 18 years who received an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification code for concussion were included. The study took place at emergency department (ED) and outpatient (primary care [PC] and specialty care [SC]) settings.

Exposures

Age at visit, biological sex, parent-identified race and ethnicity, payer type, median income and percentage of adults with a bachelor's degree for home zip code, and overall and subdomain Child Opportunity Index (COI) score based on patient address.

Main Outcomes and Measures

The association of exposures with point of entry of ED, PC, and SC were examined in both bivariate analysis and a multinomial logistic regression.

Results

Overall, 15 631 patients were included in the study (median [IQR] age, 13 [11-15] years; 7879 [50.4%] male; 1055 [6.7%] Hispanic, 2865 [18.3%] non-Hispanic Black, and 9887 [63.7%] non-Hispanic White individuals). Race and ethnicity were significantly different across settings (1485 patients [50.0%] seen in the ED were non-Hispanic Black vs 1012 [12.0%] in PC and 368 [8.7%] in SC; P < .001) as was insurance status (1562 patients [52.6%] seen in the ED possessed public insurance vs 1624 [19.3%] in PC and 683 [16.1%] in SC; P < .001). Overall and individual COI subdomain scores were also significantly different between settings (overall COI median [IQR]: ED, 30 [9-71]; PC, 87 [68-95]; SC, 87 [69-95]; P < .001). Race, insurance status, and overall COI had the strongest associations with point of entry in the multivariable model (eg, non-Hispanic Black patients seen in the ED compared with non-Hispanic White patients: odds ratio, 2.03; 95% CI, 1.69-2.45).

Conclusions and Relevance

In this cross-sectional study, children with concussion seen in the ED setting were more likely to be non-Hispanic Black, have public insurance, and have a lower Child Opportunity Index compared with children cared for in the PC or SC setting. This highlights the importance of providing education and training for ED clinicians as well as establishing up-to-date community-level resources to optimize care delivery for pediatric patients with concussion at high risk of care inequities.

Understanding Health Equity in Patient-Reported Outcomes

Patient-reported outcomes (PROs) are measures of patients' health that are conveyed directly by individual patients. These measures serve as instruments to evaluate the impact of interventions on any aspect of patients' health, from specific symptoms to broader quality of life indicators. However, their effectiveness relies on capturing relevant factors accurately. Whereas they are commonly used in clinical trials, PROs extend their influence across health care settings, informing clinicians, health care payers, regulators, and administrators to guide quality improvement and reimbursement decisions. Neglecting health equity considerations in PRO development and implementation widens health disparities, leading to biased interpretations, medical mismanagement, and poor health outcomes among marginalized groups. To foster equitable health care, efforts must focus on considering the values of underrepresented populations in PRO design, addressing barriers to completion, enhancing representation in research, providing cultural competency training for clinicians, and allocating research funding to support health equity research. By addressing these issues, advances can be made toward fostering inclusive, equitable health care for all individuals.

Obesity is associated with hyperandrogenemia in a nationally-representative sample of U.S. girls aged 6-18 years

CONTEXT

Studies have associated obesity with peri-pubertal hyperandrogenemia. However, these studies were performed in academic centers and could have been influenced by selection bias.

OBJECTIVE

To investigate if free testosterone levels are elevated in peri-pubertal girls with obesity.

DESIGN/SETTING

We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 2013-2016 databases.

PARTICIPANTS

1,299 girls aged 6-18 years residing in U.S.

MAIN OUTCOME MEASURES

Mean free testosterone concentration (calculated from total testosterone and sex hormone-binding globulin).

RESULTS

Among girls aged 6-9 years, mean (95% CI) free testosterone was 0.33 pg/ml (0.28-0.38) in healthy weight girls vs. 0.86 pg/ml (0.67-1.05) in girls with obesity. Among girls aged 10-14 years, free testosterone was 2.29 pg/ml (2.05-2.53) in healthy weight girls vs. 4.10 pg/ml (3.60-4.60) in girls with obesity. Among girls aged 15-18 years, free testosterone was 3.33 pg/ml (2.96-3.70) in healthy weight girls and 5.64 pg/ml (4.93-6.36) in girls with obesity. Girls with obesity in all age groups had higher free testosterone levels compared to healthy weight girls. In each age group, the 95% CIs for free testosterone did not overlap between healthy weight vs. obesity subgroups. A multiple regression model accounted for 42% of the variance in free testosterone (R2=0.42), and both weight and age categories were independent predictors of free testosterone (p<0.0001 for each).

CONCLUSION

In a nationally-representative sample of U.S. girls, obesity is associated with elevated free testosterone, suggesting an important relationship between obesity and peri-pubertal hyperandrogenemia.

Local Public Health Strategies for Addressing Social Determinants of Health-Analysis of Recent Community Health Improvement Plans

CONTEXT

The Public Health 3.0 (PH3.0) framework encourages local health departments (LHDs) to address the social determinants of health (SDOHs) that impact health equity.

OBJECTIVE

This study sought to understand how often LHDs are working to address SDOH, which SDOHs are most often being addressed, as well as the mix of strategies that have been proposed to address this work.

DESIGN

We reviewed recent Community Health Improvement Plans (CHIPs) to analyze the current involvement of LHDs in addressing SDOH.

SETTING

CHIPs published from 2020.

PARTICIPANTS

Accredited LHDs from across the United States (n = 80).

MAIN OUTCOME MEASURES

We developed a qualitative guidebook to characterize CHIP strategies based on the SDOH domain they addressed and the strategic mechanism they proposed.

RESULTS

Across our entire sample, CHIPs were roughly 1.5 times more likely to address Health Care Access than Food Insecurity and Access to Healthy Food (65%), Neighborhood Infrastructure (61%), or Affordable Housing (65%), and they were 3 to 4 times more likely to address Health Care Access than Safe Housing (23%), Education Access and Quality (31%), or Economic Stability (24%). Across all major domains, a few concerned policy changes and a handful focused on improving systems or developing the built environment. Most strategies focused on service provision through events or the education of the public and professionals on health-related topics.

CONCLUSIONS

The results of this study demonstrate that not all SDOHs are addressed equally by LHDs within their CHIPs. There is significant variation in how SDOHs are addressed along at 2 dimensions: first, in the likelihood that a CHIP addresses the domain and, second, in the mechanism by which each domain is addressed. Practically, the list of strategies we documented from the 80 CHIPs included in our sample may serve as the basis for strategies that other communities may wish to consider when addressing SDOH.

Impact of Racism on the Diversification of the Pediatric Workforce

This narrative review examines the impact of racism in academic pediatrics. We begin with our challenges in diversifying the pediatric physician workforce and the downstream impact of selection and recruitment practices compounded by disparities in resident dismissal rates. We present best practices in recruitment and resources from academic societies and institutions, including examples of successful holistic review processes. We then shift our focus to the effect of racism on the clinical learning environment and the use of race in curricular materials, clinical research reports, and practice guidelines. We discuss the need to create new guidelines for the inclusion of race in teaching materials and strategies to teach residents to critically interrogate clinical practice guidelines. Ultimately, we examine how racism impacts retention for faculty. We present the demographics of underrepresented in medicine faculty, the impact of racism in the work environment on attrition and mentorship, and where national programs are working to fill the gaps.

Hyperbilirubinemia and retinopathy of prematurity: a retrospective cohort study

Retinopathy of prematurity (ROP) is a vasoproliferative retinal disease in preterm infants. Oxidative stress plays a key role in the pathogenesis of ROP. Due to its antioxidant effects, bilirubin has been proposed to be protective against ROP. This study explored the association between hyperbilirubinemia and ROP. We analyzed a 10-year cohort from a neonatal intensive care unit in Milan, Italy, including 1606 infants born under 32 weeks and/or < 1500 g. Data from 1606 infants meeting specific inclusion criteria were reviewed. Eighty infants were excluded due to lack of data, 1526 were deemed eligible for analysis, and 1269 had hyperbilirubinemia requiring phototherapy. There was a higher incidence of ROP among infants with hyperbilirubinemia (13.8%) versus those without (7.8%, p<0.01). Infants with any ROP, non-severe or severe ROP, were exposed to hyperbilirubinemia for a significantly higher number of days compared with those without ROP. Each additional day of exposure increases the risk of developing any ROP by 5%, non-severe ROP by 4%, and severe ROP by 6%. However, this correlation was not observed in infants with gestational age less than 27 weeks and/or body weight less than 1000 g.    Conclusion: Our data show that hyperbilirubinemia requiring phototherapy is associated with an increased risk of developing ROP. However, severe hyperbilirubinemia and ROP share many of their risk factors. Therefore, rather than being a risk factor itself, hyperbilirubinemia may be a surrogate for other risk factors for ROP.    Clinical Trial Registration: NCT05806684. What is Known: • The development of retinopathy of prematurity (ROP) is influenced by several critical risk factors, including low gestational age, low birth weight, supplemental oxygen use, and increased oxidative stress. • In vitro, unconjugated bilirubin is an effective scavenger of harmful oxygen species and a reducing agent, highlighting its potential protective role against oxidative stress. What is New: • Hyperbilirubinemia requiring phototherapy was associated with an increased risk of developing ROP, but this association was not observed in the most vulnerable population of extremely preterm infants. • Every additional day of phototherapy for hyperbilirubinemia increases the risk of ROP by 5% for any ROP, 4% for non-severe ROP, and 6% for severe ROP.

Equity in Pediatric Hospital-Based Safety and Quality Improvement

There are well-documented inequities in the quality of care and health outcomes of minoritized youth. Patient safety and quality improvement (QI) work with an equity focus has been identified as an important strategy to remedy these existing inequities. In this article, we will present evidence of inequities in pediatric hospital-based care, describe root causes with a focus on structural racism, highlight existing frameworks for applying equity principles to patient safety and QI, and provide best practices and recommendations on evaluating patient safety and QI data towards advancing equity in pediatric hospital-based care.

Addressing the Health Impacts of Racism on Children and Youth: Equity Until Equality

Race is a sociopolitical construct based on physical characteristics, not a biological construct. Racism is a system that ascribes value and resources based on the sociopolitical construct called "race." In the United States and other countries around the world, racism is associated with disparate health outcomes and shortened life expectancies. Health equity employs health-related systems (eg, health care providers, insurance companies, hospitals, research, pharmaceutical companies) across multiple sectors (eg, housing, education, business, government) to allocate resources and services to correct and promote political and social determinants associated with health and wellness. Applying health equity practices and policies ensures that each child, youth, and adult receives comprehensive, evidence-informed, culturally relevant, and needs-based services to achieve optimum health. This article provides an overview of the impact of racism embedded in systems and policies that challenge optimal health for children and youth and offers evidence-supported paths forward to advance health and wellness in the United States. Until each child and adolescent enjoys optimal and equal health outcomes, health equity practices and social justice are mandatory.

Disparities in Guideline Adherence for Febrile Infants in a National Quality Improvement Project

BACKGROUND

Interventions aimed to standardize care may impact racial and ethnic disparities. We evaluated the association of race and ethnicity with adherence to recommendations from the American Academy of Pediatrics' clinical practice guideline for febrile infants after a quality improvement (QI) intervention.

METHODS

We conducted a cross-sectional study of infants aged 8 to 60 days enrolled in a QI collaborative of 99 hospitals. Data were collected across 2 periods: baseline (November 2020-October 2021) and intervention (November 2021-October 2022). We assessed guideline-concordance through adherence to project measures by infant race and ethnicity using proportion differences compared with the overall proportion.

RESULTS

Our study included 16 961 infants. At baseline, there were no differences in primary measures. During the intervention period, a higher proportion of non-Hispanic white infants had appropriate inflammatory markers obtained (2% difference in proportions [95% confidence interval (CI) 0.7 to 3.3]) and documentation of follow-up from the emergency department (2.5%, 95% CI 0.3 to 4.8). A lower proportion of non-Hispanic Black infants (-12.5%, 95% CI -23.1 to -1.9) and Hispanic/Latino infants (-6.9%, 95% CI -13.8 to -0.03) had documented shared decision-making for obtaining cerebrospinal fluid. A lower proportion of Hispanic/Latino infants had appropriate inflammatory markers obtained (-2.3%, 95% CI -4.0 to -0.6) and appropriate follow-up from the emergency department (-3.6%, 95% CI -6.4 to -0.8).

CONCLUSIONS

After an intervention designed to standardize care, disparities in quality metrics emerged. Future guideline implementation should integrate best practices for equity-focused QI to ensure equitable delivery of evidence-based care.

Addressing the Impacts of Racism on American Indian and Alaska Native Child Health

The legacy of racism toward Native Americans is far-reaching. We will review the topic using the conceptual model of racism as a form of violence as it is inherent in racism, as are prejudice and power. Using the basic frameworks of racism as internalized, interpersonal, institutional, and structural, we will discuss the many types of racism affecting Native Americans today. Racism is the bedrock of generations of trauma experienced in Native communities. The generational/historical trauma of racism has led to epigenetic-level changes affecting Native American people today. We will cover the health impacts of racism and the many institutions built in racist frameworks that continue to perpetuate racism, such as family separation and child removal by child protective services, adverse policing, and disparate incarceration. These allow reflection on policies and the intentionality of racist structures. We will conclude with what can and should be done, particularly as clinicians who work within and adjacent to existing systems of oppression.

The role of competency based medical education in addressing health inequities and cultivating inclusive learning environments

Pediatric health inequities are pervasive and reflect the confluence of social and structural determinants of health including racism in all its forms. Current approaches in graduate medical education that prepare trainees to address health inequities and improve population health are inadequate. Competency based medical education (CBME) can advance equity-oriented efforts to improve patient outcomes, optimize the learning environment and encourage lifelong learning. We briefly describe the impact of racism and discrimination on the clinical learning environment. We then highlight how to apply the 5 core principles of CBME to equip learners across the continuum to address health inequities. We provide specific examples including 1) how CBME can inform teaching, assessment and professional development activities to promote equitable pediatric health outcomes via enturstable professional activities, 2) competency-focused instruction that address racism and inequities, 3) multimodal learning approaches to facilitate the acquisition of the desired competencies to address health inequities, 4) sequenced learning approaches across the continuum of practicing pediatricians, and 5) tools and resources for programmatic assessment of trainee and program performance in addressing pediatric health inequities.

Long-Acting but Reversible: Opportunities to Address Provider Bias in Contraceptive Care

Jasmine is an 18-year-old Black female bringing her infant to the pediatrician for a newborn weight check. She asks her pediatrician's opinion about hormonal contraceptive injections, sharing that they were strongly recommended after she gave birth. The recommending health care provider told her, "We don't want you to end up back here any time soon." Rosita, a 16-year-old Latina female, visits her pediatrician for a well check. She reports a history of vaginal sex with 2 male partners and agrees to have a hormonal subcutaneous implant placed to avoid pregnancy. After 4 months of bothersome spotting, Rosita returns to have the implant removed. Rosita's provider strongly counsels against removal. Jasmine and Rosita are members of populations that have been systematically marginalized throughout American history. Their stories are derived from real cases and reveal how structural racism impacts modern contraceptive care. Specifically, their cases are examples of statistical discrimination, wherein the tendency to disproportionately recommend long-acting reversible contraception to historically marginalized communities does not follow the central tenants of sexual and reproductive justice, including acknowledging historical harms in health care and honoring bodily autonomy for all people. By sharing Jasmine and Rosita's stories, we use a reproductive justice lens to (1) examine the historical roots of disproportional prescription of long-acting reversible contraception to historically marginalized individuals, (2) discuss provider bias related to sexual and reproductive health care, and (3) illustrate how trauma-informed care with a recognition of historical trauma and the use of individuation can facilitate positive and equitable health outcomes.

Concordance Between Electronic Health Record-Recorded Race and Ethnicity and Patient Report in Emergency Department Patients

OBJECTIVE

We assessed the concordance of patient-reported race and ethnicity for emergency department (ED) patients compared with what was recorded in the electronic health record.

METHODS

We conducted a single-center, prospective, observational study of 744 ED patients (English- and/or Spanish-speaking), asking them to describe their race and ethnicity. We compared the distributions of ethnicity and race between patient-reported and electronic health record data using McNemar's test. We calculated percent agreement and Cohen's kappa, with 95% confidence intervals (CI), for the concordance of patient-reported race and ethnicity with electronic health record data.

RESULTS

Of 744 ED patients, 731 participants who completed the survey reported their ethnicity, resulting in 98.2% of electronic health records obtained ethnicities matched self-reported data (kappa = 0.95; 95% CI: 0.92 to 0.98). For those who self-reported as Hispanic, only 92.3% agreement was observed between the self-reported and electronic health record values. For all patients who had race recorded, 85.4% agreement was observed (kappa = 0.75; 95% CI 0.71 to 0.79). High rates of agreement were observed for Black or African American patients (98.7%) and White patients (96.6%), with low rates for those who identified as "More than one race" (22.9%) or "Other" race (1.8%). In the subset of Hispanic patients, low rates of agreement (25.0%) were observed for race (kappa = 0.10; 95% CI 0.01 to 0.19).

CONCLUSIONS

Documentation discordance regarding race and ethnicity exists between electronic health records and self-reported data for our ED patients, particularly for ethnically Hispanic and Latino/a patients. Future efforts should focus on ensuring that demographic information in the electronic health record is accurately collected.

Collecting Sociodemographic Data in Pediatric Emergency Research: A Working Group Consensus

Understanding and addressing health care disparities relies on collecting and reporting accurate data in clinical care and research. Data regarding a child's race, ethnicity, and language; sexual orientation and gender identity; and socioeconomic and geographic characteristics are important to ensure equity in research practices and reported outcomes. Disparities are known to exist across these sociodemographic categories. More consistent, accurate data collection could improve understanding of study results and inform approaches to resolve disparities in child health. However, published guidance on standardized collection of these data in children is limited, and given the evolving nature of sociocultural identities, requires frequent updates. The Pediatric Emergency Care Applied Research Network, a multi-institutional network dedicated to pediatric emergency research, developed a Health Disparities Working Group in 2021 to support and advance equitable pediatric emergency research. The working group, which includes clinicians involved in pediatric emergency medical care and researchers with expertise in pediatric disparities and the conduct of pediatric research, prioritized creating a guide for approaches to collecting race, ethnicity, and language; sexual orientation and gender identity; and socioeconomic and geographic data during the conduct of research in pediatric emergency care settings. Our aims with this guide are to summarize existing barriers to sociodemographic data collection in pediatric emergency research, highlight approaches to support the consistent and reproducible collection of these data, and provide rationale for suggested approaches. These approaches may help investigators collect data through a process that is inclusive, consistent across studies, and better informs efforts to reduce disparities in child health.

Youth Suicide and Preceding Mental Health Diagnosis

Importance

Suicide is a leading cause of death among US youths, and mental health disorders are a known factor associated with increased suicide risk. Knowledge about potential sociodemographic differences in documented mental health diagnoses may guide prevention efforts.

Objective

To examine the association of documented mental health diagnosis with (1) sociodemographic and clinical characteristics, (2) precipitating circumstances, and (3) mechanism among youth suicide decedents.

Design, Setting, and Participants

This retrospective, cross-sectional study of youth suicide decedents aged 10 to 24 years used data from the Centers for Disease Control and Prevention National Violent Death Reporting System from 2010 to 2021. Data analysis was conducted from January to November 2023.

Exposures

Sociodemographic characteristics, clinical characteristics, precipitating circumstances, and suicide mechanism.

Main Outcomes and Measures

The primary outcome was previously documented presence of a mental health diagnosis. Associations were evaluated by multivariable logistic regression.

Results

Among 40 618 youth suicide decedents (23 602 aged 20 to 24 years [58.1%]; 32 167 male [79.2%]; 1190 American Indian or Alaska Native [2.9%]; 1680 Asian, Native Hawaiian, or Other Pacific Islander [4.2%]; 5118 Black [12.7%]; 5334 Hispanic [13.2%]; 35 034 non-Hispanic; 30 756 White [76.1%]), 16 426 (40.4%) had a documented mental health diagnosis and 19 027 (46.8%) died by firearms. The adjusted odds of having a mental health diagnosis were lower among youths who were American Indian or Alaska Native (adjusted odds ratio [aOR], 0.45; 95% CI, 0.39-0.51); Asian, Native Hawaiian, or Other Pacific Islander (aOR, 0.58; 95% CI, 0.52-0.64); and Black (aOR, 0.62; 95% CI, 0.58-0.66) compared with White youths; lower among Hispanic youths (aOR, 0.76; 95% CI, 0.72-0.82) compared with non-Hispanic youths; lower among youths aged 10 to 14 years (aOR, 0.70; 95% CI, 0.65-0.76) compared with youths aged 20 to 24 years; and higher for females (aOR, 1.64; 95% CI, 1.56-1.73) than males. A mental health diagnosis was documented for 6308 of 19 027 youths who died by firearms (33.2%); 1691 of 2743 youths who died by poisonings (61.6%); 7017 of 15 331 youths who died by hanging, strangulation, or suffocation (45.8%); and 1407 of 3181 youths who died by other mechanisms (44.2%). Compared with firearm suicides, the adjusted odds of having a documented mental health diagnosis were higher for suicides by poisoning (aOR, 1.70; 95% CI, 1.62-1.78); hanging, strangulation, and suffocation (aOR, 2.78; 95% CI, 2.55-3.03); and other mechanisms (aOR, 1.59; 95% CI, 1.47-1.72).

Conclusions and Relevance

In this cross-sectional study, 3 of 5 youth suicide decedents did not have a documented preceding mental health diagnosis; the odds of having a mental health diagnosis were lower among racially and ethnically minoritized youths than White youths and among firearm suicides compared with other mechanisms. These findings underscore the need for equitable identification of mental health needs and universal lethal means counseling as strategies to prevent youth suicide.

The Child Opportunity Index 2.0 and exacerbation-prone asthma in a cohort of urban children

RATIONALE

Social determinants of health underlie disparities in asthma. However, the effects of individual determinants likely interact, so a summary metric may better capture their impact. The Child Opportunity Index 2.0 (COI) is one such tool, yet its association with exacerbation-prone (EP) asthma is unknown.

OBJECTIVE

To investigate the association between the COI and EP asthma and clinical measures of asthma severity in children.

METHODS

We analyzed data from two prospective observational pediatric asthma cohorts (n = 193). Children were classified as EP (≥1 exacerbation in the past 12 months) or exacerbation-null (no exacerbations in the past 5 years). Spirometry, exhaled nitric oxide, IgE, and Composite Asthma Severity Index (CASI) were obtained. The association between COI and EP status was assessed with logistic regression. We fit linear and logistic regression models to test the association between COI and each clinical measure.

RESULTS

A 20-point COI decrease conferred 40% higher odds of EP asthma (OR 1.4; 95%CI 1.1-1.76). The effect was similar when adjusted for age and sex (OR 1.38, 95%CI 1.1-1.75) but was attenuated with additional adjustment for race and ethnicity (OR 1.19, 95%CI 0.92-1.54). A similar effect was seen for the Social/Economic and Education COI domains but not the Health/Environment Domain. A 20-point COI decrease was associated with an increase in CASI of 0.34. COI was not associated with other clinical measures.

CONCLUSIONS

Lower COI was associated with greater odds of EP asthma. This highlights the potential use of the COI to understand neighborhood-level risk and identify community targets to reduce asthma disparities.

Guidance on Conversations About Race and Racism in Pediatric Clinical Settings

OBJECTIVE

To develop guidance for pediatric clinicians on how to discuss race and racism in pediatric clinical settings.

METHODS

We conducted a modified Delphi study from 2021 to 2022 with a panel of pediatric clinicians, psychologists, parents, and adolescents with expertise in racism and child health through scholarship or lived experience. Panelists responded to an initial survey with open-ended questions about how to talk to youth about race and racism. We coded the responses using qualitative methods and presented them back to the panelists. In iterative surveys, panelists reached a consensus on which themes were most important for the conversation.

RESULTS

A total of 29 of 33 panelists completed the surveys and a consensus was reached about the concepts pediatric clinicians should consider before, during, and after conversations about race and racism and impediments clinicians may face while having these discussions. Panelists agreed that it was within the pediatric clinician's role to have these conversations. An overarching theme was the importance of having background knowledge about the systemic nature of racism. Panelists agreed that being active listeners, learning from patients, and addressing intersectionality were important for pediatric clinicians during conversations. Panelists also agreed that short- and long-term benefits may result from these conversations; however, harm could be done if pediatric clinicians do not have adequate training to conduct the conversations.

CONCLUSIONS

These principles can help guide conversations about race and racism in the pediatric clinical setting, equipping clinicians with tools to offer care that acknowledges and addresses the racism many of their patients face.

Reexamining the use of race in medical algorithms: the maternal health calculator debate

The concept of race is prevalent in medical, nursing, and public health literature. Clinicians often incorporate race into diagnostics, prognostic tools, and treatment guidelines. An example is the recently heavily debated use of race and ethnicity in the Vaginal Birth After Cesarean (VBAC) calculator. In this case, the critics argued that the use of race in this calculator implied that race confers immutable characteristics that affect the ability of women to give birth vaginally after a c-section. This debate is co-occurring as research continues to highlight the racial disparities in health outcomes, such as high maternal mortality among Black women compared to other racial groups in the United States. As the healthcare system contemplates the necessity of utilizing race-a social and political construct, to monitor health outcomes, it has sparked more questions about incorporating race into clinical algorithms, including pulmonary tests, kidney function tests, pharmacotherapies, and genetic testing. This paper critically examines the argument against the race-based Vaginal Birth After Cesarean (VBAC) calculator, shedding light on its implications. Moreover, it delves into the detrimental effects of normalizing race as a biological variable, which hinders progress in improving health outcomes and equity.

Unpacking the prevalence: A warning against overstating the recently narrowed gap for Black autistic youth

Recent findings from the Centers for Disease Control and Prevention's (CDC) Autism and Developmental Disabilities Monitoring (ADDM) Network's 2020 prevalence report indicate that disparities in autism diagnoses between Black and White youth have narrowed, reflecting improved screening, awareness, and access to services (Maenner et al., 2023. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C.: 2002), 72, 1-14.). Claims of reducing disparities beyond prevalence rates, however, are not fully supported, as indicated by the reality that Black youth whose screenings indicate autistic traits are still not being referred for full evaluation or early intervention services at the same rate as their White peers (Major et al., 2020. Autism, 24, 1629-1638; Smith et al., 2020. Pediatrics, 145, S35-S46.). Black 8-year-olds identified as autistic still experience disparate educational placements (Waitoller et al., 2010. The Journal of Special Education. 44, 29-49.) where services may not be autism-specific or have Individual Education Plan goals only focused on "behavior problems" (Severini et al., 2018. Journal of Autism and Developmental Disorders, 48, 3261-3272.), are served in the most restrictive environments (Skiba et al., 2006. Exceptional Children, 72, 411-424.) and lack consistent augmentative and alternative communication support (Pope et al., 2022. American Journal of Speech-Language Pathology, 31, 2159-2174.). Additionally, ADMM researchers report consistent disparities in the identification of co-occurring intellectual disability where Black autistic children have significantly more co-occurrences than White autistic children. The purpose of this commentary is to first examine the assertion that the narrowed gap indicates, "…improved…access to services among historically underserved groups," (p. 9) (Maenner et al., 2023. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C.: 2002), 72, 1-14.). We will then recommend strategies to address the ongoing disparities.

Clinicians' perspectives on race-specific guidelines for hypertensive treatment

Despite the general consensus that there is no biological basis to race, racial categorization is still used by clinicians to guide diagnosis and treatment plans for certain diseases. In medicine, race is commonly used as a rough proxy for unmeasured social, environmental, and genetic factors. The American College of Cardiology's Eighth Joint National Committee's (JNC 8) guidelines for the treatment of hypertension provide race-specific medication recommendations for Black versus non-Black patients, without strong evidence for race-specific physiological differences in drug response. Clinicians practicing family or geriatric medicine (n = 21) were shown a video of a mock hypertensive patient with genetic ancestry test results that could be viewed as discordant with their phenotype and self-identified race. After viewing the videos, we conducted in-depth interviews to examine how clinicians value and prioritize different cues about race -- namely genetic ancestry data, phenotypic appearance, and self-identified racial classifications - when making treatment decisions in the context of race-specific guidelines, particularly in situations when patients claim mixed-race or complex racial identities. Results indicate that clinicians inconsistently follow the race-specific guidelines for patients whose genetic ancestry test results do not match neatly with their self-identified race or phenotypic features. However, many clinicians also emphasized the importance of clinical experience, side effects, and other factors in their decision making. Clinicians' definitions of race, categorization of the patient's race, and prioritization of racial cues greatly varied. The existence of the race-specific guidelines clearly influences treatment decisions, even as clinicians' express uncertainty about how to incorporate consideration of a patient's genetic ancestry. In light of widespread debate about removal of race from medical diagnostics, researchers should revisit the clinical justification for maintaining these race-specific guidelines. Based on our findings and prior studies indicating a lack of convincing evidence for biological differences by race in medication response, we suggest removing race from the JNC 8 guidelines to avoid risk of perpetuating or exacerbating health disparities in hypertension.

Patient and Parent Experience with Pediatric Care Providers During the COVID-19 Pandemic: A Comparison of Press Ganey Survey Scores for Telehealth and In-Person Encounters

Background: Prior research suggests that pediatric patients and their parents/guardians are generally satisfied with care provided through telehealth. The objective of this study was to compare Press Ganey provider-oriented experience survey scores between telehealth and in-person patient encounters among a variety of pediatric clinical specialties at a large academic medical center. Methods: We analyzed Press Ganey survey data from pediatric patient encounters from UC Davis Health, collected between August 2020 and February 2022. Survey results analyzed respondents' satisfaction with care providers, including satisfaction with explanations given, discussions led, concern showed, and inclusion by providers; and the likelihood the survey respondent would recommend the provider to others. We used logistic regression models, which included case mix variables and clinical specialty to compare the odds of scoring the highest possible survey response ("top box" score). Results: Of the 6,093 survey responses that met inclusion criteria, 1,157 (19%) were associated with telehealth encounters and 4,936 (81%) were associated with in-person encounters. We found no significant difference in the odds of respondents giving a top box score to rate their satisfaction with their care provider between telehealth and in-person encounters. When respondents were asked whether they would recommend the care provider to others, the odds of giving a top box score following a telehealth encounter relative to an in-person encounter was 1.22 (95% confidence interval [0.97-1.52]; p-value = 0.09). Discussion: We found that survey respondents' experiences with their care provider are high and comparable for telehealth and in-person encounters in a pediatric population.

Urology Mythbusters: Does prevalence of vesicoureteral reflux in children vary by race?

In this edition of Mythbusters, we examine the premise that prevalence of vesicoureteral reflux (VUR) in children varies by race. Specifically, we consider whether there is evidence supporting the contention that VUR is more common in White children and less common in Black children. Statements regarding the lower prevalence of VUR in Black children are ubiquitous in both research papers and reviews. Many of the references cited in support of these statements do not actually support the existence of racial variation in VUR, due to uncontrolled single-arm study designs, highly selected samples at risk for bias, or simply not addressing VUR prevalence at all. There is a small group of studies which directly compared VUR prevalence among children undergoing cystography, and these studies have found VUR to be less common among Black children compared to White children. However, the results of such papers can only be considered in the context of a system in which systemic bias and racism may impact access and care delivery in profound ways. Given that race is a social construct that bears little relationship to shared genetic ancestry or underlying biological characteristics, these findings must be approached with extreme caution. The goals of pediatric urological care should be to confer equitable care to all young children regardless of race.

Trends in the Use and Discussion of Race in Pediatrics Articles Over 75 Years

BACKGROUND AND OBJECTIVES

Race-based medicine, which falsely assumes that race is biological, is common in the published medical literature. We analyzed trends in the use of race in Pediatrics articles over a 75-year period.

METHODS

We analyzed a random sample of 50 original research articles published each decade in Pediatrics from 1948 to 2022.

RESULTS

Of 375 articles, 39% (n = 147) included race. Among articles, 85% (n = 116) used race only to describe study subjects, 7% (n = 9) described race as a social construct, and 11% (n = 15) described race as a biological construct. Only 7% (n = 10) of studies provided a reason for including race. Statements reflective of racial bias or discrimination were identified in 22% (n = 30) of the articles that mentioned race. Although statements concerning for explicit racial bias were uncommon, with none identified in the most recent decade, statements suggestive of implicit racial bias still occurred (22%, 5 of 23). Race was presented as a dichotomy, such as "white/nonwhite," in 9% of studies (n = 12). Regarding currently nonrecommended terminology, the term "minorities" was used in 13% of studies (n = 18); 25% of studies used the term "others" (n = 34), and among these, 91% (n = 31 of 34) did not provide any definition, an occurrence that increased over time at a rate of 0.9%/year.

CONCLUSIONS

Although there has been improvement over the past 75 years in the reporting of race in published studies in Pediatrics, significant opportunities for further improvement remain.

The Impact of Health Care Algorithms on Racial and Ethnic Disparities : A Systematic Review

BACKGROUND

There is increasing concern for the potential impact of health care algorithms on racial and ethnic disparities.

PURPOSE

To examine the evidence on how health care algorithms and associated mitigation strategies affect racial and ethnic disparities.

DATA SOURCES

Several databases were searched for relevant studies published from 1 January 2011 to 30 September 2023.

STUDY SELECTION

Using predefined criteria and dual review, studies were screened and selected to determine: 1) the effect of algorithms on racial and ethnic disparities in health and health care outcomes and 2) the effect of strategies or approaches to mitigate racial and ethnic bias in the development, validation, dissemination, and implementation of algorithms.

DATA EXTRACTION

Outcomes of interest (that is, access to health care, quality of care, and health outcomes) were extracted with risk-of-bias assessment using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and adapted CARE-CPM (Critical Appraisal for Racial and Ethnic Equity in Clinical Prediction Models) equity extension.

DATA SYNTHESIS

Sixty-three studies (51 modeling, 4 retrospective, 2 prospective, 5 prepost studies, and 1 randomized controlled trial) were included. Heterogenous evidence on algorithms was found to: a) reduce disparities (for example, the revised kidney allocation system), b) perpetuate or exacerbate disparities (for example, severity-of-illness scores applied to critical care resource allocation), and/or c) have no statistically significant effect on select outcomes (for example, the HEART Pathway [history, electrocardiogram, age, risk factors, and troponin]). To mitigate disparities, 7 strategies were identified: removing an input variable, replacing a variable, adding race, adding a non-race-based variable, changing the racial and ethnic composition of the population used in model development, creating separate thresholds for subpopulations, and modifying algorithmic analytic techniques.

LIMITATION

Results are mostly based on modeling studies and may be highly context-specific.

CONCLUSION

Algorithms can mitigate, perpetuate, and exacerbate racial and ethnic disparities, regardless of the explicit use of race and ethnicity, but evidence is heterogeneous. Intentionality and implementation of the algorithm can impact the effect on disparities, and there may be tradeoffs in outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Quality and Research.

A scoping review of web-based, interactive, personalized decision-making tools available to support breast cancer treatment and survivorship care

PURPOSE

We reviewed existing personalized, web-based, interactive decision-making tools available to guide breast cancer treatment and survivorship care decisions in clinical settings.

METHODS

The study was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We searched PubMed and related databases for interactive web-based decision-making tools developed to support breast cancer treatment and survivorship care from 2013 to 2023. Information on each tool's purpose, target population, data sources, individual and contextual characteristics, outcomes, validation, and usability testing were extracted. We completed a quality assessment for each tool using the International Patient Decision Aid Standard (IPDAS) instrument.

RESULTS

We found 54 tools providing personalized breast cancer outcomes (e.g., recurrence) and treatment recommendations (e.g., chemotherapy) based on individual clinical (e.g., stage), genomic (e.g., 21-gene-recurrence score), behavioral (e.g., smoking), and contextual (e.g., insurance) characteristics. Forty-five tools were validated, and nine had undergone usability testing. However, validation and usability testing included mostly White, educated, and/or insured individuals. The average quality assessment score of the tools was 16 (range: 6-46; potential maximum: 63).

CONCLUSIONS

There was wide variation in the characteristics, quality, validity, and usability of the tools. Future studies should consider diverse populations for tool development and testing.

IMPLICATIONS FOR CANCER SURVIVORS

There are tools available to support personalized breast cancer treatment and survivorship care decisions in clinical settings. It is important for both cancer survivors and physicians to carefully consider the quality, validity, and usability of these tools before using them to guide care decisions.

Physician Workforce Diversity Is Still Necessary and Achievable if It Is Intentionally Prioritized

The 2023 Supreme Court Decision from Students for Fair Admissions v. Harvard and Students for Fair Admissions v. University of North Carolina threatens the current progress in achieving diversity within undergraduate and graduate medical education. This is necessary to achieve a diverse healthcare workforce, which is a key to healing historical healthcare trauma, eliminating health disparities, and providing equitable healthcare access for all communities. Although the Supreme Court decision seems obstructionist, viable opportunities exist to enhance recruitment further and solidify diversity efforts in undergraduate and graduate medical education to achieve these goals.

Social inequalities in the risk of giving birth to a small for gestational age child in Sweden 2010-16: a cross-sectional study adopting an intersectional approach

BACKGROUND

Well-established associations exist between the risk of small for gestational age (SGA) and unidimensional sociodemographic factors. We investigated social inequalities in SGA risk and adopted an intersectional approach that simultaneously considers different social categories. By doing so, we could assess heterogeneities in SGA risk within unidimensional sociodemographic categories.

METHODS

We included all live 679 694 singleton births in Sweden between 2010 and 2016. The outcome was SGA, and the exposures were age, maternal educational level, dichotomous migration status and civil status. Thirty-six possible combinations of these factors constituted the exposure in an intersectional model. We present odds ratios (ORs) with 95% confidence intervals (95% CIs) and the area under the receiver operating characteristic curve (AUC)-a measurement of discriminatory accuracy (i.e. the ability to discriminate the babies born SGA from those who are not).

RESULTS

Women with low education and women born outside Sweden had ORs of 1.46 (95% CI 1.38-1.54) and 1.50 (95% CI 1.43-1.56) in unidimensional analyses, respectively. Among women aged under 25 with low education who were born outside Sweden and unmarried, the highest OR was 3.06 (2.59-3.63). The discriminatory accuracy was low for both the unidimensional model that included all sociodemographic factors (AUC 0. 563) and the intersectional model (AUC 0.571).

CONCLUSIONS

The intersectional approach revealed a complex sociodemographic pattern of SGA risk. Sociodemographic factors have a low accuracy in identifying SGA at the individual level, even when quantifying their multi-dimensional intersections. This cautions against interventions targeted to individuals belonging to socially defined groups to reduce social inequalities in SGA risk.

Diversity, Equity, and Inclusion, Child Health, and the Pediatric Subspecialty Workforce

Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists.

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.

External Validation of the UTICalc with and Without Race for Pediatric Urinary Tract Infection

OBJECTIVE

To validate externally the UTICalc, a popular clinical decision support tool used to determine the risk of urinary tract infections (UTIs) in febrile children, and compare its performance with and without the inclusion of race and at differing risk thresholds.

METHODS

We performed a retrospective, singlecenter case-control study of febrile children (2-24 months) in an emergency department. Cases with culture-confirmed UTI were matched 1:1 to controls. We compared the performance of the original model which included race (version 1.0) to a revised model which did not consider race (version 3.0). We evaluated model performance at risk thresholds between 2% and 5%.

RESULTS

We included 185 cases and 197 controls (median age 8.4 months; IQR, 4.4-13.0 months; 60.5% girls). When using UTICalc version 1.0, the model area under the receiver operator characteristic curve (AUROC) was 73.4% (95% CI 68.4%-78.5%), which was similar to the version 3.0 model (73.8%; 95% CI 68.7%-78.8%). When using a 2% risk threshold, the version 3.0 model demonstrated a sensitivity of 96.7% and a specificity of 25.0%, with declines in sensitivity and gains in specificity at higher risk thresholds. Version 1.0 of the UTICalc had 12 false negatives, of whom 10 were Black (83%); whereas version 3.0 had 6 false negatives, of whom 2 were Black (33%).

CONCLUSIONS

Versions of the UTICalc with and without race had similar performance to each other with a slight decline from the original derivation sample. The removal of race did not adversely affect the accuracy of the UTICalc.