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.

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.

Effects of a Curriculum Addressing Racism on Pediatric Residents' Racial Biases and Empathy.

Background: Racism is a longstanding driver of health inequities. Although medical education is a potential solution to address racism in health care, best practices remain unknown. Objective: We sought to evaluate the impact of participation in a curriculum addressing racism on pediatric residents' racial biases and empathy. Methods: A pre-post survey study was conducted in 2 urban, university-based, midsized pediatric residency programs between July 2019 and June 2020. The curriculum sessions included Self-Reflection on Implicit Bias, Historical Trauma, and Structural Racism. All sessions were paired with empathy and perspective-taking exercises and were conducted in small groups to facilitate reflective discussion. Wilcoxon signed rank tests were used to assess changes in racial bias and empathy. Linear regression was used to assess the effect of resident characteristics on racial bias and empathy. Results: Ninety of 111 residents receiving the curriculum completed pre-surveys (81.1%), and among those, 65 completed post-surveys (72.2%). Among participants with baseline pro-White bias, there was a statistically significant shift (0.46 to 0.36, P=.02) toward no preference. Among participants with a baseline pro-Black bias, there was a statistically significant shift (-0.38 to -0.21, P=.02), toward no preference. Among participants with baseline pro-White explicit bias, there was a statistically significant shift (0.54 to 0.30, P<.001) toward no preference. Among all residents, there was a modest but statistically significant decrease in mean empathy (22.95 to 22.42, P=.03). Conclusions: Participation in a longitudinal discussion-based curriculum addressing racism modestly reduced pediatric residents' racial preferences with minimal effects on empathy scales.

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

Police shootings of unarmed Black men, women, and children at the intersection of disparities in the setting of the coronavirus disease 2019 pandemic have resulted in a long overdue national awakening regarding race and racism in society. This article defines some of the key terms, providing a foundation to help promote equity in pediatric practice. Although no single article can result in full competency regarding such complex issues, it is meant to provide a foundation for pediatricians on a journey to deepen their knowledge and understanding toward a path to action. [Pediatr Ann. 2022;51(3):e95-e106.].

Structuring Poverty: How Racism Shapes Child Poverty and Child and Adolescent Health.

Black, Native, and Latinx populations represent the racial and ethnic groups most impacted by poverty. This unequal distribution of poverty must be understood as a consequence of policy decisions-some that have sanctioned violence and others that have created norms-that continue to shape who has access to power, resources, rights, and protections. In this review, we draw on scholarship from multiple disciplines, including pediatrics, public health, environmental health, epidemiology, social and biomedical science, law, policy, and urban planning to explore the central question-What is the relationship between structural racism, poverty, and pediatric health? We discuss historic and present-day events that are critical to the understanding of poverty in the context of American racism and pediatric health. We challenge conventional paradigms that treat racialized poverty as an inherent part of American society. We put forth a conceptual framework to illustrate how white supremacy and American capitalism drive structural racism and shape the racial distribution of resources and power where children and adolescents live, learn, and play, ultimately contributing to pediatric health inequities. Finally, we offer antipoverty strategies grounded in antiracist practices that contend with the compounding, generational impact of racism and poverty on heath to improve child, adolescent, and family health.

Implicit Bias and Caring for Diverse Populations: Pediatric Trainee Attitudes and Gaps in Training.

The objective of this study was to determine the attitudes, skill level, and preferred educational interventions of pediatric residents related to implicit bias and caring for diverse patient populations. A cross-sectional survey of pediatric residents at a single, large urban residency program was utilized. Surveys were completed by 88 (55%) residents who were 69% female and 35% non-White or mixed race. Almost all residents felt that it was very or extremely important to receive training on health disparities, diverse patient populations, and implicit bias. Self-assessment of skill level revealed that residents felt confident in areas often covered by cultural competency curricula, such as interpreter use, but were less confident in other areas. The top 3 areas identified for further training included implicit bias, working with transgender and gender nonconforming patients, and weight bias. For the majority of diversity and bias-related skills, prior training was significantly correlated with higher skill level (P < .05).

Executions and Police Conflicts Involving Children, Adolescents and Young Adults.

Police violence in the United States represents a pressing public health crisis impacting youth, particularly youth of color. This article reviews the recent epidemiology of police executions and conflicts involving children, adolescents, and young adults. The roles of social determinants of health and centuries-long history of white supremacy and racism as root causes of adverse policing are emphasized. The article summarizes the evidence as to how direct and vicarious experiences of police violence impact youth academic, behavioral, and health outcomes. Recommendations are provided for pediatricians to address this public health crisis through clinical practice, education, advocacy, and research.

Racial Bias and Its Impact on Children and Adolescents.

Racial bias is pervasive throughout society and can impact children and adolescents in the health care, education, and criminal justice systems. This article provides a state-of-the-science review of implicit bias in health care. It also reviews the evidence of how bias impacts children in other aspects of society, explores bias as it relates to the broader context of structural racism in America, and summarizes the impact of bias and discrimination on youth academic, behavioral, and health outcomes. Evidence-based strategies are provided to help pediatricians identify and confront their own personal biases.

A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test.

Disparities in the care and outcomes of US racial/ethnic minorities are well documented. Research suggests that provider bias plays a role in these disparities. The implicit association test enables measurement of implicit bias via tests of automatic associations between concepts. Hundreds of studies have examined implicit bias in various settings, but relatively few have been conducted in healthcare. The aim of this systematic review is to synthesize the current knowledge on the role of implicit bias in healthcare disparities. A comprehensive literature search of several databases between May 2015 and September 2016 identified 37 qualifying studies. Of these, 31 found evidence of pro-White or light-skin/anti-Black, Hispanic, American Indian or dark-skin bias among a variety of HCPs across multiple levels of training and disciplines. Fourteen studies examined the association between implicit bias and healthcare outcomes using clinical vignettes or simulated patients. Eight found no statistically significant association between implicit bias and patient care while six studies found that higher implicit bias was associated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy. All seven studies that examined the impact of implicit provider bias on real-world patient-provider interaction found that providers with stronger implicit bias demonstrated poorer patient-provider communication. Two studies examined the effect of implicit bias on real-world clinical outcomes. One found an association and the other did not. Two studies tested interventions aimed at reducing bias, but only one found a post-intervention reduction in implicit bias. This review reveals a need for more research exploring implicit bias in real-world patient care, potential modifiers and confounders of the effect of implicit bias on care, and strategies aimed at reducing implicit bias and improving patient-provider communication. Future studies have the opportunity to build on this current body of research, and in doing so will enable us to achieve equity in healthcare and outcomes.

Comparison of Physician Implicit Racial Bias Toward Adults Versus Children.

BACKGROUND AND OBJECTIVES: The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training. METHODS: We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores. RESULTS: Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty. CONCLUSIONS: This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.

The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias.

OBJECTIVES: The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias. METHODS: This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores. RESULTS: Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21). CONCLUSIONS: While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.