Racial Inequities in Sepsis Mortality Among Children in the United States

Association between Child Opportunity Index and paediatric sepsis recognition and treatment in a large quality improvement collaborative: a retrospective cohort study

BACKGROUND

The Child Opportunity Index (COI) is a multidimensional measure of US neighbourhood-level conditions needed for healthy development. COI is associated with healthcare delivery and outcomes. Formal quality improvement (QI) may influence the relationship between COI, quality of care and outcomes in children.

OBJECTIVE

To assess the association between COI and paediatric sepsis care delivery and outcomes and determine if baseline disparities in care change over time among hospitals in the Improving Pediatric Sepsis Outcomes (IPSO) collaborative.

METHODS

Retrospective cohort study of IPSO patients probabilistically linked to the Pediatric Health Information System database from 2017 to 2021. Primary exposure was COI. We estimated differences in the proportions of patients in each COI quintile identified via standardised sepsis recognition protocols (screening tool, huddle documentation and/or order set use) and who received a bundle of recommended care (standardised sepsis recognition, plus bolus <1 hour and antibiotic <3 hours). We further assessed the timeliness of each bundle component and mortality. We evaluated changes in standardised sepsis recognition over time using generalised linear models.

RESULTS

31 260 sepsis cases from 24 hospitals were included. Cross-sectional analysis over the entire study period found patients in the Very High COI quintile were most likely to be identified via standardised recognition protocols and receive IPSO's recommended care bundle (67.7% and 46%, respectively). Over time, standardised sepsis recognition improved for all; the greatest improvements were among inpatients in the Very Low COI quintile.

CONCLUSION

Disparities exist in paediatric sepsis care delivery by COI. Over the course of the IPSO collaborative, care improved most for children in the lowest COI quintile. QI collaboratives focused on standardisation and shared learning may reduce disparities.

Patterns of inpatient antibiotic utilization by race and ethnicity at US children's hospitals

BACKGROUND AND OBJECTIVES

Racial and ethnic variations in antibiotic utilization are well-reported in outpatient settings but little is known about inpatient settings. Our objective was to describe national inpatient antibiotic utilization among children by race and ethnicity.

METHODS

This study included hospital visit data from the Pediatric Health Information System between 01/01/2022 and 12/31/2022 for patients <20 years. Primary outcomes were the percentage of hospitalization encounters that received an antibiotic and antibiotic days of therapy (DOT) per 1000 patient days. Mixed-effect regression models were used to determine the association of race-ethnicity with outcomes, adjusting for covariates.

RESULTS

There were 846,530 hospitalizations. 45.2% of children were Non-Hispanic (NH) White, 27.1% were Hispanic, 19.2% were NH Black, 4.5% were NH Other, 3.5% were NH Asian, 0.3% were NH Native Hawaiian/Other Pacific Islander (NHPI) and 0.2% were NH American Indian. Adjusting for covariates, NH Black children had lower odds of receiving antibiotics compared to NH White children (aOR 0.96, 95%CI 0.94-0.97), while NH NHPI had higher odds of receiving antibiotics (aOR 1.16, 95%CI 1.05-1.29). Children who were Hispanic, NH Asian, NH American Indian, and children who were NH Other received antibiotic DOT compared to NH White children, while NH NHPI children received more antibiotic DOT.

CONCLUSIONS

Antibiotic utilization in children's hospitals differs by race and ethnicity. Hospitals should assess policies and practices that may contribute to disparities in treatment; antibiotic stewardship programs may play an important role in promoting inpatient pharmacoequity. Additional research is needed to examine individual diagnoses, clinical outcomes, and drivers of variation.

Race, Ethnicity, and Intensive Care Utilization for Common Pediatric Diagnoses: U.S. Pediatric Health Information System 2019 Database Study

OBJECTIVES

Racial and ethnic disparities in healthcare delivery for acutely ill children are pervasive in the United States; it is unknown whether differential critical care utilization exists.

DESIGN

Retrospective study of the Pediatric Health Information System (PHIS) database.

SETTING

Multicenter database of academic children's hospitals in the United States.

PATIENTS

Children discharged from a PHIS hospital in 2019 with one of the top ten medical conditions where PICU utilization was present in greater than or equal to 5% of hospitalizations.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Race and ethnicity categories included Asian, Black, Hispanic, White, and other. Primary outcomes of interest were differences in rate of PICU admission, and for children requiring PICU care, total hospital length of stay (LOS). One-quarter ( n = 44,200) of the 178,134 hospital discharges included a PICU admission. In adjusted models, Black children had greater adjusted odds ratio (aOR [95% CI]) of PICU admission in bronchiolitis (aOR, 1.08 [95% CI, 1.02-1.14]; p = 0.01), respiratory failure (aOR, 1.18 [95% CI, 1.10-1.28]; p < 0.001), seizure (aOR, 1.28 [95% CI, 1.08-1.51]; p = 0.004), and diabetic ketoacidosis (DKA) (aOR, 1.18 [95% CI, 1.05-1.32]; p = 0.006). Together, Hispanic, Asian, and other race children had greater aOR of PICU admission in five of the diagnostic categories, compared with White children. The geometric mean (± sd ) hospital LOS ranged from 47.7 hours (± 2.1 hr) in croup to 206.6 hours (± 2.8 hr) in sepsis. After adjusting for demographics and illness severity, children from families of color had longer LOS in respiratory failure, pneumonia, DKA, and sepsis.

CONCLUSIONS

The need for critical care to treat acute illness in children may be inequitable. Additional studies are needed to understand and eradicate differences in PICU utilization based on race and ethnicity.