Racism and pediatric health outcomes

Multi-institutional exploration of pediatric residents' perspectives on anti-racism curricula: a qualitative study

BACKGROUND

Anti-racism curricula are increasingly being recognized as an integral component of medical education. To our knowledge, there has not yet been a publication exploring resident perspectives from multiple institutions and explicitly representing both underrepresented in medicine (UIM) and non-UIM perspectives.

OBJECTIVE

To explore and compare UIM and non-UIM pediatric residents' perspectives on the content and qualities of meaningful anti-racism curricula.

METHODS

We performed an IRB-approved multi-institutional, qualitative study that incorporated Sotto-Santiago et al's conceptual framework for anti-racism education. Between February and May 2021, we conducted focus groups of UIM and non-UIM pediatric residents at three large residency programs in the United States. We developed focus group guides using literature review, expert consensus, feedback from study team racial equity experts, and piloting. Focus groups were conducted virtually, audio-recorded, and transcribed verbatim. We employed thematic analysis to code transcripts, create categories, and develop themes until we reached thematic sufficiency. We completed member checking to ensure trustworthiness of themes.

RESULTS

Forty residents participated (19 UIM and 21 non-UIM) in a total of six focus groups. We identified 7 themes, summarized as: 1) racism in medicine is pervasive, therefore (2) anti-racism education is critical to the development of competent physicians, and 3) education should extend to all healthcare providers. 4) Residents desired education focused on action-oriented strategies to advance anti-racism, 5) taught by those with both learned and lived experiences with racism, 6) in a psychologically safe space for UIM residents, and 7) with adequate time and financial resources for successful implementation and engagement.

CONCLUSION

Our multi-institutional study affirms the need for pediatric resident anti-racism education, promotes co-creation as a method to affect culture change, and provides practical strategies for curricular design and implementation.

Racial/Ethnic and Linguistic Disparities in Self-reported Health-Related Quality of Life Among Children Undergoing Elective Surgery

OBJECTIVE

This study examines disparities in self-reported HRQoL among English-speaking non-Latinx White, English-speaking Latinx, and Spanish-speaking Latinx children ages 4-12 years undergoing surgery.

DESIGN

A total of 357 children completed the Child Health Rating Inventories, an animated, computer-administered method, to measure overall, physical, and mental health, as well as pre-operative anxiety. A multivariate general linear model was used to analyze the main effects of race/ethnicity and language on self-reported HRQoL.

RESULTS

Results demonstrated differences in child self-reported overall [F(2,311) = 3.11, p = 0.05)] and mental health F(2,311) = 3.56, p = 0.03)], and preoperative anxiety F(2,311) = 5.70, p = 0.004)] by race/ethnicity and language. Post hoc comparisons using the Bonferroni test indicated that English-speaking Latinx children reported significantly poorer overall (p = 0.04) and mental health (p = 0.04) compared to English-speaking non-Latinx children. English-speaking and Spanish-speaking Latinx children reported significantly higher preoperative anxiety (p = 0.004 and p = 0.02, respectively) compared to English-speaking non-Latinx White children.

CONCLUSION

Latinx children from English-speaking households as young as 4 years old reported their overall and mental health to be poorer compared to Non-Latinx White children from English-speaking households. Latinx children, regardless of spoken language, reported higher preoperative anxiety compared to non-Latinx White children. These findings highlight the need to consider early childhood experiences in understanding health disparities. Factors such as family dynamics, acculturative stress, and access to healthcare resources could potentially account for disparities in young children's health experiences.

Historical redlining and survival among children, adolescents, and young adults with cancer diagnosed between 2000-2019 in Seattle and Tacoma, Washington

BACKGROUND

Historical redlining has been associated with inferior survival in adult-onset cancers. However, its relationship with pediatric, adolescent, and young-adult-onset cancer outcomes is unknown.

METHODS

This study identified incident cancer among individuals <40 years of age living in Seattle and Tacoma between 2000-2019 via the population-based Cancer Surveillance System. The authors determined case redlining status using Home Owners' Loans Corporation data overlaid with 2000 and 2010 census tracts. Kaplan-Meier methods and multivariable Cox proportional hazards models were used to determine 5- and 10-year overall survival and hazard ratio (HR) of death according to redlined status. Cox models adjusted for patient and tumor characteristics and area-level poverty; interaction between redlining and area-level poverty was also assessed.

RESULTS

Among 4355 cases (median age at diagnosis 32 years), overall survival at 5 years was lower (85.1%; 95% confidence interval [CI], 83.5%-86.5%) among individuals residing in redlined neighborhoods compared with those in unexposed neighborhoods (90.3%; 95% CI, 89.0%-91.5%). Survival differences persisted at 10 years. The unadjusted hazard of death for redlined exposed individuals with cancer was higher than redlined unexposed (hazard ratio [HR], 1.62; 95% CI, 1.39-1.89). In the fully adjusted model, mortality remained higher for redlined cases (HR, 1.32; 95% CI, 1.12-1.56). There did not appear to be effect modification from area-level poverty in the relationship between redlining and death (p = .49).

CONCLUSIONS

Among young individuals with cancer, residence at diagnosis in previously redlined neighborhoods was associated with lower survival compared with those residing in nonredlined neighborhoods, supporting the hypothesis that structural racism exerts persistent effects on contemporary health outcomes.

"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.

A systematic review of racial health disparities among children and youth with physical disabilities

PURPOSE

Children and youth who belong to a racially minoritized group commonly experience multiple and complex forms of discrimination and health disparities. The purpose of this review was to explore racial disparities in health care and health outcomes among children and youth with physical disabilities.

METHODS

Six international databases (Ovid Medline, Healthstar, Embase, PsycINFO, Scopus, and Web of Science) were searched and screened for inclusion. A narrative synthesis was used to identify the common trends.

RESULTS

Thirty-seven articles met the inclusion criteria, which involved 218 555 children and youth with various types of physical disabilities spanning over 29 years. We noted the following trends: (1) racial disparities in accessing or receiving care; (2) racial disparities in health outcomes and mortality rates; and (3) factors affecting racial disparities. Most studies reported at least one finding indicating that racially minoritized youth had differential access to care and/or disparities in health outcomes compared to white youth.

CONCLUSIONS

Our findings highlight the concerning racial disparities among children and youth with physical disabilities within health care. There is an urgent need for advocacy and interventions at multiple levels to address the perpetual racism and racial disparities that racially minoritized youth with physical disabilities experience.Implications for rehabilitationThere is an urgent need for health care leaders and health care providers to address the systemic health inequalities in rehabilitation for racially minoritized children and youth with physical disabilities.Health care leaders and clinicians should recognize the racial disparities that racially minoritized youth with physical disabilities encounter in accessing or receiving care in addition to health outcomes.Health care leaders and decision-makers should advocate for policy change to optimize equitable and inclusive health care to enhance the well-being of racially minoritized children with disabilities.Health care providers should engage in training to understand how to recognize and address how intersectional forms of a child's identity such as disability, race, and socio-economic status can influence health care experiences and health outcomes.

Asthma Knowledge, Self-Efficacy, and Self-Management Among Rural Adolescents with Poorly Controlled Asthma

Rural adolescents with asthma are a disparate group. Self-management is essential to asthma control. We describe asthma knowledge, self-efficacy, and self-management behaviors among 198 rural adolescents with poorly controlled asthma, exploring demographic differences; we also test the application of Social Cognitive Theory to asthma self-management examining if self-efficacy mediates associations between knowledge and self-management. Asthma knowledge and self-management were relatively poor in our sample, particularly among male and White adolescents; greater knowledge was significantly associated with better symptom prevention and management. Self-efficacy partially mediated the association between knowledge and symptom prevention, but not acute symptom management, suggesting that knowledge may not improve symptom prevention behaviors without confidence to implement such behaviors and that factors beyond knowledge and self-efficacy likely play a role in asthma self-management in this population. Addressing asthma knowledge and self-efficacy could improve self-management and, ultimately, enhance asthma control among rural adolescents with poorly controlled asthma.

Food insecurity and childhood outcomes: a cross-sectional analysis of 2016-2020 National Survey of Children's Health data

CONTEXT

Racial inequalities across social determinants of health (SDOHs) are often influenced by discriminatory policies that reinforce systems that further uphold these disparities. There is limited data describing the influence of food insecurity (FI) on childhood racial discrimination.

OBJECTIVES

Our objective was to determine if the likelihood of experiencing racial discrimination was exacerbated by FI.

METHODS

We conducted a cross-sectional analysis of the 2016-2020 National Survey of Children's Health (NSCH) to extract data on childhood racial discrimination and food security. We extracted sociodemographic variables to utilize as controls and constructed logistic regression models to determine associations, via odds ratios (ORs), between food security and whether the child experienced racial discrimination.

RESULTS

We found statistically significant associations between experiencing FI and childhood racial discrimination. Individuals who experienced food shortages were significantly more likely to experience racial discrimination compared to those without food limitations when controlling for race, food voucher usage, age, and % federal poverty guidelines (FPG, adjusted odds ratio [AOR]: 3.34; 95 % CI: 2.69-4.14).

CONCLUSIONS

Our study found that parents of minority children all reported high rates of racial discrimination, which was exacerbated by concurrent FI. Children of families that were the most food insecure reported the highest percentage of racial discrimination at 11.13 %, compared with children who always had enough nutritious meals to eat at 2.87 %. Acknowledging the intersection that exists between FI, race, gender, and socioeconomic status (SES), might be a way forward in addressing the adverse health effects experienced by food-insecure children and adults.

Advancing equity, diversity, inclusivity, and accessibility in primary care: The development of an integrated educational experience model

This article presents the development of the Equity, Diversity, Inclusivity, and Accessibility (EDIA) Cross-Cutting Theme Project within the Team Primary Care (TPC) initiative, aimed at addressing systemic inequities through innovative educational strategies. Grounded in the social accountability of health professions framework, this project aims to equip primary care teams with the knowledge, skills, and attitudes necessary to promote health equity. The EDIA Integrated Educational Experience (IEE) model includes a self-assessment tool, digital learning space, and national mentorship network, providing a comprehensive approach for primary care teams to promote health equity. The IEE model utilizes a layered micro, meso, and macro approach to support cultural transformation within highly complex healthcare environments. Key lessons learned involve trust- and relationship-building processes to help dismantle historical silos and encourage open dialogue. Future efforts focus on implementation, ensuring adaptability, scalability, and sustainability, positioning the model as a catalyst for equitable primary care delivery.

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.

Causal Mediation of Neighborhood-Level Pediatric Hospitalization Inequities

BACKGROUND AND OBJECTIVES

Population-wide racial inequities in child health outcomes are well documented. Less is known about causal pathways linking inequities and social, economic, and environmental exposures. Here, we sought to estimate the total inequities in population-level hospitalization rates and determine how much is mediated by place-based exposures and community characteristics.

METHODS

We employed a population-wide, neighborhood-level study that included youth <18 years hospitalized between July 1, 2016 and June 30, 2022. We defined a causal directed acyclic graph a priori to estimate the mediating pathways by which marginalized population composition causes census tract-level hospitalization rates. We used negative binomial regression models to estimate hospitalization rate inequities and how much of these inequities were mediated indirectly through place-based social, economic, and environmental exposures.

RESULTS

We analyzed 50 719 hospitalizations experienced by 28 390 patients. We calculated census tract-level hospitalization rates per 1000 children, which ranged from 10.9 to 143.0 (median 45.1; interquartile range 34.5 to 60.1) across included tracts. For every 10% increase in the marginalized population, the tract-level hospitalization rate increased by 6.2% (95% confidence interval: 4.5 to 8.0). After adjustment for tract-level community material deprivation, crime risk, English usage, housing tenure, family composition, hospital access, greenspace, traffic-related air pollution, and housing conditions, no inequity remained (0.2%, 95% confidence interval: -2.2 to 2.7). Results differed when considering subsets of asthma, type 1 diabetes, sickle cell anemia, and psychiatric disorders.

CONCLUSIONS

Our findings provide additional evidence supporting structural racism as a significant root cause of inequities in child health outcomes, including outcomes at the population level.

Social Determinants of Health Screening in Type 1 Diabetes Management

Type 1 diabetes management is intricately influenced by social determinants of health. Economic status impacts access to vital resources like insulin and diabetes technology. Racism, social injustice, and implicit biases affect equitable delivery of care. Education levels affect understanding of self-care, leading to disparities in glycemic outcomes. Geographic location can limit access to health care facilities. Stressors from discrimination or financial strain can disrupt disease management. Addressing these social factors is crucial for equitable diabetes care, emphasizing the need for comprehensive strategies that go beyond medical interventions to ensure optimal health outcomes for all individuals with type 1 diabetes.

Methodologies to Advance Health Equity and Reduce Health Inequities in Nursing Research

The Centers for Disease Control and Prevention affirm that health equity is only achieved when everyone has opportunities to attain full health potential without disadvantages related to social position or socially determined circumstances. To reduce health inequities in nursing research, researchers must increase diversity in study samples and ensure that study participants are representative of all populations in the United States. Identifying effective methods for recruiting underrepresented populations must be a thoughtful and reflective component of every research methodology. To achieve health equity in research studies, nurse researchers and clinicians must carefully plan ways to recruit study participants who represent all populations.

Machine learning data sources in pediatric sleep research: assessing racial/ethnic differences in electronic health record-based clinical notes prior to model training

Introduction

Pediatric sleep problems can be detected across racial/ethnic subpopulations in primary care settings. However, the electronic health record (EHR) data documentation that describes patients' sleep problems may be inherently biased due to both historical biases and informed presence. This study assessed racial/ethnic differences in natural language processing (NLP) training data (e.g., pediatric sleep-related keywords in primary care clinical notes) prior to model training.

Methods

We used a predefined keyword features set containing 178 Peds B-SATED keywords. We then queried all the clinical notes from patients seen in pediatric primary care between the ages of 5 and 18 from January 2018 to December 2021. A least absolute shrinkage and selection operator (LASSO) regression model was used to investigate whether there were racial/ethnic differences in the documentation of Peds B-SATED keywords. Then, mixed-effects logistic regression was used to determine whether the odds of the presence of global Peds B-SATED dimensions also differed across racial/ethnic subpopulations.

Results

Using both LASSO and multilevel modeling approaches, the current study found that there were racial/ethnic differences in providers' documentation of Peds B-SATED keywords and global dimensions. In addition, the most frequently documented Peds B-SATED keyword rankings qualitatively differed across racial/ethnic subpopulations.

Conclusion

This study revealed providers' differential patterns of documenting Peds B-SATED keywords and global dimensions that may account for the under-detection of pediatric sleep problems among racial/ethnic subpopulations. In research, these findings have important implications for the equitable clinical documentation of sleep problems in pediatric primary care settings and extend prior retrospective work in pediatric sleep specialty settings.

Depressive symptoms are related to asthma control but not self-management among rural adolescents

Background

Depression, a relevant comorbidity with asthma, has been reported to be associated with asthma morbidity. Asthma self-management is essential to asthma control and may be negatively impacted by depression. We examined these associations in rural adolescents, a group with relatively high asthma morbidity and depressive symptoms, a population often ignored in asthma research.

Methods

We used baseline data from a randomized trial of an asthma intervention for adolescents in rural South Carolina (n = 197). Adolescents completed the Center for Epidemiological Studies-Depression (CES-D), three indices of asthma self-management (the Asthma Prevention Index, the Asthma Management Index and the Asthma Self-Efficacy Index), and the Asthma Control Test (ACT). Poisson and linear regression tested associations between depression, self-management, and asthma control. The models controlled for demographic variables and included school as a fixed effect.

Results

Most participants (mean age = 16.3 ± 1.2 years) self-identified as female (68.5%) and Black (62.43%). The mean CES-D score was 19.7 ± 10.3, with 61.4% of participants at risk for depression. The depressive symptoms were significantly related to asthma control [β = -0.085, 95% confidence interval (CI) = -0.14 to -0.03] but not to prevention [relative risk (RR) = 1.00, 95% CI = 0.99-1.01], management (RR = 1.00, 95% CI = 0.99-1.01), or self-efficacy (β = -0.002, 95% CI = -0.01 to 0.01).

Conclusions

In this sample of rural adolescents, as depressive symptoms increased, asthma control declined. Depressive symptoms were not associated with asthma self-management, suggesting that the aspects of self-management we assessed are not an avenue by which depression impacts asthma control. Additional research is needed to further understand the relationship between depressive symptoms, asthma self-management, and control.

Research Priorities for Pediatric Emergency Care to Address Disparities by Race, Ethnicity, and Language

Importance

Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking.

Objective

To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations.

Design, Setting, and Participants

In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks.

Outcome

Consensus agenda of research priorities to identify and address health care disparities in PEC.

Results

PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation.

Conclusions and Relevance

These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.

Racial and Ethnic Disparities in Pediatric Musculoskeletal Care

PURPOSE OF REVIEW

This article provides a review of recent published research studying racial, ethnic, and socioeconomic disparities in pediatric musculoskeletal care.

RECENT FINDINGS

Disparities in pediatric musculoskeletal care are demonstrated in two general realms: access to care and health outcomes. Though initiatives have been proposed or enacted to address disparities, underrepresented minorities and patients from lower socioeconomic statuses continue to face barriers across the spectrum of orthopedic care and poorer ultimate outcomes after both non-operative and operative management. Minority pediatric patients and those from lower socioeconomic statuses experience delays across the spectrum of orthopedic care for both urgent and non-urgent conditions. They wait longer between injury date and initial orthopedic evaluation, longer to receipt of diagnostic imaging, and longer to ultimate treatment than their counterparts. When finally able to obtain musculoskeletal care and treatment, they are at higher risk of poor in-hospital outcomes and inpatient complications, worse patient reported outcomes, and suboptimal pain management. In the outpatient setting, they receive less physical therapy and follow-up clinic visits, resulting in greater stiffness and strength deficits, and are ultimately less likely to meet return to sport criteria.

Characteristics of Patients Associated With Restraint Use at a Midwest Children's Hospital

BACKGROUND AND OBJECTIVES

Restraint use is associated with negative mental health outcomes, injury risk, and known disparities in use. Improved understanding of restraint use among hospitalized children is critical given the increased frequency of hospitalized children with complex and/or acute mental health needs. Our objective is to describe the demographic and clinical features of children associated with mechanical restraint.

METHODS

In a single-center retrospective cohort study of patients hospitalized from 2017 to 2021, restraint encounters were identified from electronic health records. Odds of restraint was modeled as a function of patient demographic and clinical characteristics, as well as hospitalization characteristics using logistic regression modeling adjusted for clustering of hospitalizations within patients and for varying lengths of stay.

RESULTS

Among 29 808 children (46 302 encounters), 225 patients (275 encounters) had associated restraint use. In regression modeling, odds of restraint were higher with restraint at the preceding hospitalization (adjusted odds ratio [aOR] 8.6, 95% confidence interval [CI] 4.8-15.5), diagnosis of MH conditions such as psychotic disorders (aOR 5.4, 95% CI 2.7-10.4) and disruptive disorders (aOR 4.7, 95% CI 2.8-7.8), male sex (aOR 1.9, 95% CI 1.5-2.5), and Black race (aOR relative to White patients 1.9, 95% CI 1.4-2.6).

CONCLUSIONS

Our results suggest racial inequities in restraint use for hospitalized children. This finding mirrors inequities in restraint use in the emergency department and adult settings. Understanding the behavioral needs of such patients may help in reducing restraint use and improving health equity.

Partnering with Families and Communities to Improve Child Health and Health Equity

Pediatricians and other pediatric health providers collaborate with families and communities, including schools, health departments, and other partners to advance pediatric health challenges and health equity. This article will discuss best practices and guiding principles to support engagement and effective partnership with families and communities. Models for engaging families and communities while promoting health equity will also be discussed. Case studies and examples will be shared, as well as how they may be applied by pediatric health providers to promote child health.

Addressing Structural Racism in Pediatric Clinical Practice

Structural racism is the inequitable allocation of various social determinants of health to different communities. Exposure to this and other discrimination levied from intersectional identities is the primary driver of disproportionately adverse health outcomes for minoritized children and their families. Pediatric clinicians must vigilantly identify and mitigate racism in health care systems and delivery, assess for any impact of patient and family exposure to racism and direct them to appropriate health resources, foster an environment of inclusion and respect, and ensure that all care is delivered through a race-conscious lens with the utmost cultural humility and shared decision-making.

Race, ethnicity, and clinical outcome following sport-related concussion: a systematic review

Introduction

This systematic review examined whether race or ethnicity are associated with clinical outcomes (e.g., time to return to school/sports, symptom duration, vestibular deficits, and neurocognitive functioning) following sport-related concussion among child, adolescent, or college-aged student athletes. Additionally, this review assessed whether the existing literature on this topic incorporated or included broader coverage of social determinants of health.

Methods

The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched.

Results

A total of 5,118 abstracts were screened and 12 studies met inclusion criteria, including 2,887 youth and young adults. Among the included articles, only 3 studies (25%) examined whether race and ethnicity were associated with outcomes following concussion as a primary objective. None of the studies assessed the association between social determinants of health and outcomes following concussion as a primary objective, although 5 studies (41.7%) addressed a social determinant of health or closely related topic as a secondary objective.

Discussion

Overall, the literature to date is extremely limited and insufficient for drawing conclusions about whether race or ethnicity are categorically associated with outcomes from sport-related concussion, or more specifically, whether there are socioeconomic, structural, or cultural differences or disparities that might be associated with clinical outcome.

Systematic review registration

identifier: PROSPERO, CRD42016041479, CRD42019128300.

Racial Inequity in Pediatric Anesthesia

Purpose of Review

Minority health disparities have received renewed attention in the USA following several highly publicized racial injustices in 2020. Though the focus has been largely on adults, children are not immune to these inequities. By reviewing racial disparities in pediatric perioperative care, we aim to engage the anesthesia community in the fight against systemic racism.

Recent Findings

Minority children have higher rates of anesthetic and surgical morbidity compared to White children, including respiratory events, length of stay, hospital costs, and even death. These inequities occur across surgical specialties and environments.

Summary

Racial disparities in the perioperative health and management of children are ubiquitous. Herein, we will summarize recent pediatric health disparity literature, discuss some important contributors to persistent inequities, and propose avenues for anesthesiologists to impact the pursuit of equitable healthcare outcomes.

Pediatric Ethics Consultation Services, Scope, and Staffing

BACKGROUND AND OBJECTIVES

National standards and guidelines call for a mechanism to address ethical concerns and conflicts in children's hospitals. The roles, responsibilities, and reach of pediatric ethics consultation services (PECS) remain unmeasured. The purpose of this study is to quantify staffing, structure, function, scope, training, and funding of PECS.

METHODS

Cross-sectional online survey was shared with an ethics informant at 181 children's hospitals in the United States from March to June 2022. Data were summarized descriptively and with semantic content analyses.

RESULTS

One hundred seventeen surveys were received from individual children's hospitals in 45 states and Washington DC (response rate 65%), with 104 qualifying for survey completion. Almost one-quarter of settings received 50 or more pediatric ethics consults in the past 12 months. On average, 7.4 people at each institution have responsibility for completing ethics consults. Estimated full-time equivalent salary support for ethics is on average 0.5 (range 0-3, median 0.25). One-third (33%) of facilities do not offer any salary support for ethics and three-quarters do not have an institutional budget for the ethics program. Clinical staff primarily initiate consults. End-of-life, benefits versus burdens of treatments, and staff moral distress were the most frequently consulted themes. Almost one-quarter (21%) of children's hospitals do not receive any consults from patients or families.

CONLUSIONS

The findings from this study reveal wide variation in PECS practices and raise concern about the lack of financial support provided for PECS despite substantial workloads.

Ableism, racism, and the quality of life of Black, Indigenous, people of colour with intellectual and developmental disabilities

BACKGROUND

Research indicates Black, Indigenous, people of colour (BIPOC) with intellectual and developmental disabilities face disparities in quality of life outcomes. This study's aim was to examine how ableism and racism impacted the quality of life of BIPOC with intellectual and developmental disabilities.

METHODS

Using a multilevel linear regression, we analysed secondary quality of life outcome data from Personal Outcome Measures® interviews with 1393 BIPOC with intellectual and developmental disabilities and implicit ableism and racism data from the 128 regions of the United States in which they lived (discrimination data came from 7.4 million people).

RESULTS

When BIPOC with intellectual and developmental disabilities lived in regions of the United States which were more ableist and racist, they had a lower quality of life, regardless of their demographics.

CONCLUSION

Ableism and racism are a direct threat to BIPOC with intellectual and developmental disabilities' health, wellbeing, and overall quality of life.

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

BACKGROUND

Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline.

METHODS

A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus.

RESULTS

60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations.

CONCLUSIONS

Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

Tools for Supporting the MCH Workforce in Addressing Complex Challenges: A Scoping Review of System Dynamics Modeling in Maternal and Child Health

OBJECTIVES

System Dynamics (SD) is a promising decision support modeling approach for growing shared understanding of complex maternal and child health (MCH) trends. We sought to inventory published applications of SD to MCH topics and introduce the MCH workforce to these approaches through examples to support further iteration and use.

METHODS

We conducted a systematic search (1958-2018) for applications of SD to MCH topics and characterized identified articles, following PRISMA guidelines. Pairs of experts abstracted information on SD approach and MCH relevance.

RESULTS

We identified 101 articles describing applications of SD to MCH topics.

APPROACH

27 articles present qualitative diagrams, 10 introduce concept models that begin to quantify dynamics, and 67 present more fully tested/analyzed models.

PURPOSE

The most common purposes described were to increase understanding (n = 55) and support strategic planning (n = 26). While the majority of studies (n = 53) did not involve stakeholders, 40 included what we considered to be a high level of stakeholder engagement - a strength of SD for MCH.

TOPICS

The two Healthy People 2020 topics addressed most frequently were early and middle childhood (n = 30) and access to health services (n = 26). The most commonly addressed SDG goals were "End disease epidemics" (n = 26) and "End preventable deaths" (n = 26).

CONCLUSIONS FOR PRACTICE

While several excellent examples of the application of SD in MCH were found, SD is still underutilized in MCH. Because SD is particularly well-suited to studying and addressing complex challenges with stakeholders, its expanded use by the MCH workforce could inform an understanding of contemporary MCH challenges.

Inflammatory bowel disease in underserved populations: lessons for practice

PURPOSE OF REVIEW

The incidence of inflammatory bowel disease (IBD) is increasing in minority groups across the USA. There are racial and ethnic disparities in IBD care and outcomes that are rooted in historical injustice and inequities in the social determinants of health.

RECENT FINDINGS

Current literature has identified racial, ethnic and sociodemographic disparities in therapeutics and outcomes for IBD, including disease severity, morbidity and mortality.

SUMMARY

Strategies to achieve equity in IBD include tackling structural racism as a driver of health disparities and making actionable changes against multilevel barriers to care.