Inequitable Treatment Persists Across Pediatric Specialties, Review Shows

Children in racial and ethnic minority groups received poorer healthcare services compared with white kids, a review of quantitative studies showed.

Inequitable treatment persisted across pediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care, reported Nia Heard-Garris, MD, of Northwestern University’s Feinberg School of Medicine in Chicago, and colleagues.

“Our review of recent literature reveals an urgent need to develop and implement effective interventions, including coordinated healthcare and cross-sectoral strategies that fundamentally redesign systems and policies to promote equitable and excellent health for all children,” they wrote in the first paper of a two-part series focused on racism and child health in the U.S., published in The Lancet Child & Adolescent Health.

Looking at the literature on neonatology, one study of infants with very low birthweight showed that, relative to white infants, Black and Native American infants were less likely to receive any human milk at hospital discharge. Additionally, a study of nearly 440,000 low-risk newborns from 40 hospitals in New York City found that unexpected complications were more likely among Hispanic and Black infants relative to white infants. Another study of more than 19,000 preterm infants from 12 clinical sites showed that sepsis was higher among Black and Hispanic neonates relative to white neonates.

In primary care, a study focused on provider recommendation of human papillomavirus (HPV) vaccination within a longitudinal cohort found that Black parents had significantly lower odds of receiving a recommendation for their child than parents of white children.

The emergency department was the clinical area with the most studies showing pediatric disparities, Heard-Garris and colleagues noted. Recent studies showed disparities in wait times, assignment of triage acuity, and evaluation for suspected child abuse. They also pointed to disparities in the provision of opioid analgesics for children presenting with any painful condition, as well as those with an objective diagnosis like long bone fractures, appendicitis, and migraines.

As for mental healthcare, a study of Medicaid data from four states found that the reduction in antidepressant prescribing following an FDA box warning about increased suicide ideation was slower among providers treating large numbers of minoritized children. In addition, a study of more than 800 patients at five hospitals found that Black children with suicidality were less likely to have documentation of caregiver counseling on lethal means restriction before discharge relative to their white counterparts.

Potential causes for disparities across pediatric specialties ranged from implicit biases and stereotyping underlying providers’ clinical decisions, to differences in the site of care, such as the size and racial composition of a practice. Studies reviewed by the research team also examined provider characteristics like responsiveness to concerns, provision of patient-centered care, specialty training, and years of experience.

To address disparities across pediatric specialties, Heard-Garris and colleagues suggested conducting qualitative, quantitative, and mixed-methods studies to “better understand and effectively intervene on the drivers of provider decision making that perpetuate inequitable treatment,” and using such research to better understand parents’ and children’s experiences of racism in healthcare.

Additional recommendations included the adoption of equity metrics as part of quality improvement portfolios and incorporating recurrent audits with feedback to providers, as well as ending racial segregation of pediatric care and boosting diversity of the medical workforce.

Other Contributors to Child Health Equity

A companion paper also published in The Lancet Child & Adolescent Health focused on policies related to housing, employment, health insurance, immigration, and the criminal legal system, which also have the potential to affect child health equity.

Policies within these sectors “can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritized children,” noted Monique Jindal, MD, MPH, of the University of Illinois School of Medicine in Chicago, and colleagues.

Recommendations within these sectors posed by Jindal and team included establishing community investment initiatives like financial incentives for organizations with healthy food projects and resources for improving green spaces, as well as providing mortgage or rental assistance, and increasing the stock of affordable housing through measures like tax credits to owners of rental properties.

They also suggested creating federal minimum benefits for safety-net programs and expanding paid family and sick leave, as well as providing universal health insurance coverage for children and individuals who are pregnant or postpartum, and increasing Medicaid and Children’s Health Insurance Program provider reimbursement to Medicare levels.

Additional recommendations included expanding eligibility for federal-funded and state-funded health insurance and safety-net benefits like food assistance to include all immigrant children and adolescents up to 21 years of age and pregnant people through 12 months’ postpartum.

They further proposed reforming parental incarceration policies to increase parent-child contact and connectedness, and ensuring re-entry support at release for parents and young people, such as continuity of Medicaid coverage and access to vocational and educational support.

The review of quantitative studies by Heard-Garris and colleagues included those published from January 2017 through July 2022. The studies were adjusted for or stratified by insurance status to account for group difference in access. The research team excluded studies in which differences in access were likely driven by patient preferences or appropriateness of intervention.

“Overall, the research designs were strong: half of the studies included control variables for socioeconomic position beyond insurance status, a large majority included control variables for clinical characteristics (e.g., comorbidities or condition severity), and many studies used data collected from multiple sites, thus increasing generalizability,” the authors wrote.

At the same time, they noted that experiences of Asian American and Native American children, and those classified as multiethnic or multiracial, were “less represented within the existing literature relative to other groups of children.”

Furthermore, though their review was limited to quantitative studies, “qualitative research can be superior for understanding patient perceptions and experiences of care,” they wrote.

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