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.

Development of a Multidisciplinary Medical Home Program for NICU Graduates.

OBJECTIVE: Typical primary care practices are often not equipped to meet the medical, developmental or social needs of infants discharged from a neonatal intensive care unit (NICU). These needs are exacerbated for infants and caregivers residing in poverty. This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population. METHODS: This is a descriptive analysis of a cohort of patients in the Next Steps Program (NSP), a multidisciplinary primary care medical home. Key program elements include: continuity of care from the NICU to primary care, routine developmental surveillance, care coordination, and proactive screening to address medical and social needs. RESULTS: The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down. DISCUSSION: Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.

Intergenerational Associations of Parent Adverse Childhood Experiences and Child Health Outcomes.

BACKGROUND: Adverse childhood experiences (ACEs) robustly predict future morbidity and mortality. Researchers are just beginning to investigate intergenerational effects. We hypothesize there are intergenerational associations between parent ACE exposure and worse child health, health behaviors, and health care access and use. METHODS: We linked data from 2 population-based cross-sectional telephone surveys in Philadelphia, Pennsylvania, that were used to ask parents about their past exposure to ACEs and their child's health, respectively. Participants were 350 parent-child dyads. Logistic regression models adjusted for parent and child characteristics. Parent ACE score was used to summarize indicators of parents' childhood adversity. Child health outcomes were poor overall health status, asthma diagnosis, obesity, low fruit and vegetable consumption, any soda consumption, inadequate physical activity, excessive television watching, no health insurance, no usual source of health care, and no dental examination in past 12 months. RESULTS: Of adult participants, 80% were female participants and 45% were non-Latino African American. Eighty-five percent of parents had experienced ≥1 ACE and 18% had experienced ≥6 ACEs. In adjusted models, each additional parent ACE was associated with higher odds of poor child overall health status (odds ratio [OR] = 1.19; 95% confidence interval [CI]: 1.07-1.32), asthma (OR = 1.17; 95% CI: 1.05-1.30), and excessive television watching (OR = 1.16; 95% CI: 1.05-1.28). CONCLUSIONS: The full scope of the health effects of ACEs may not be limited to the exposed individual, highlighting the need for a 2-generation approach to addressing the social determinants of child health.

A New EHR Training Curriculum and Assessment for Pediatric Residents.

Background Conventional classroom Electronic Health Record (EHR) training is often insufficient for new EHR users. Studies suggest that enhanced training with a hands-on approach and closely supported clinical use is beneficial. Objectives Our goals were to develop an enhanced EHR learning curriculum for Post Graduate Year 1 (PGY1) residents and measure changes in EHR skill proficiency, efficiency, and self-efficacy. Methods A novel three-phase, multimodal enhanced EHR curriculum was designed for a cohort of PGY1 residents. After basic training, residents began phase 1 of enhanced training, including demonstrations, live practice, and order set review. Phase 2 involved skills-oriented assignments, role playing, and medication entry. Phase 3 included shadowing, scribing histories, and supervised order entry. Residents' EHR skills and attitudes were measured and compared before and after the enhanced curriculum via proficiency test and a survey of efficiency and self-efficacy. Results Nineteen of 26 PGY1 residents participated in the study (73%). There was significant improvement in mean proficiency scores and two of the five individual proficiency scores. There were significant improvements in most efficiency survey responses from pre- to postintervention. For the self-efficacy presurvey, many PGY1s reported to be "very" or "somewhat confident" performing each of the five tasks, and perceptions did not improve or worsened on most postsurvey responses. The greatest resource was the time required to design and deliver the enhanced training. Conclusion An enhanced training curriculum along with a proficiency assessment was developed and described here. An enhanced training curriculum significantly improved PGY1 EHR efficiency and some measures of proficiency but not self-efficacy. This intervention may support improved EHR-related clinic workflows, which ultimately could enable residents and preceptors to prioritize patient care and time for clinical education.

Hot topics, urgent priorities, and ensuring success for racial/ethnic minority young investigators in academic pediatrics.

BACKGROUND: The number of racial/ethnic minority children will exceed the number of white children in the USA by 2018. Although 38% of Americans are minorities, only 12% of pediatricians, 5% of medical-school faculty, and 3% of medical-school professors are minorities. Furthermore, only 5% of all R01 applications for National Institutes of Health grants are from African-American, Latino, and American Indian investigators. Prompted by the persistent lack of diversity in the pediatric and biomedical research workforces, the Academic Pediatric Association Research in Academic Pediatrics Initiative on Diversity (RAPID) was initiated in 2012. RAPID targets applicants who are members of an underrepresented minority group (URM), disabled, or from a socially, culturally, economically, or educationally disadvantaged background. The program, which consists of both a research project and career and leadership development activities, includes an annual career-development and leadership conference which is open to any resident, fellow, or junior faculty member from an URM, disabled, or disadvantaged background who is interested in a career in academic general pediatrics. METHODS: As part of the annual RAPID conference, a Hot Topic Session is held in which the young investigators spend several hours developing a list of hot topics on the most useful faculty and career-development issues. These hot topics are then posed in the form of six "burning questions" to the RAPID National Advisory Committee (comprised of accomplished, nationally recognized senior investigators who are seasoned mentors), the RAPID Director and Co-Director, and the keynote speaker. RESULTS/CONCLUSIONS: The six compelling questions posed by the 10 young investigators-along with the responses of the senior conference leadership-provide a unique resource and "survival guide" for ensuring the academic success and optimal career development of young investigators in academic pediatrics from diverse backgrounds. A rich conversation ensued on the topics addressed, consisting of negotiating for protected research time, career trajectories as academic institutions move away from an emphasis on tenure-track positions, how "non-academic" products fit into career development, racism and discrimination in academic medicine and how to address them, coping with isolation as a minority faculty member, and how best to mentor the next generation of academic physicians.

Household and community-level Adverse Childhood Experiences and adult health outcomes in a diverse urban population.

Adverse Childhood Experiences (ACEs), which include family dysfunction and community-level stressors, negatively impact the health and well being of children throughout the life course. While several studies have examined the impact of these childhood exposures amongst racially and socially diverse populations, the contribution of ACEs in the persistence of socioeconomic disparities in health is poorly understood. To determine the association between ACEs and health outcomes amongst a sample of adults living in Philadelphia and examine the moderating effect of Socioeconomic Status (SES) on this association, we conducted a cross-sectional survey of 1,784 Philadelphia adults, ages 18 and older, using random digit dialing methodology to assess Conventional ACEs (experiences related to family dysfunction), Expanded ACEs (community-level stressors), and health outcomes. Using weighted, multivariable logistic regression analyses along with SES stratified models, we examined the relationship between ACEs and health outcomes as well as the modifying effect of current SES. High Conventional ACE scores were significantly associated with health risk behaviors, physical and mental illness, while elevated Expanded ACE scores were associated only with substance abuse history and sexually transmitted infections. ACEs did have some differential impacts on health outcomes based on SES. Given the robust impact of Conventional ACEs on health, our results support prior research highlighting the primacy of family relationships on a child's life course trajectory and the importance of interventions designed to support families. Our findings related to the modifying effect of SES may provide additional insight into the complex relationship between poverty and childhood adversity.

Keeping the Heat on for Children's Health: A Successful Medical-Legal Partnership Initiative to Prevent Utility Shutoffs in Vulnerable Children.

OBJECTIVE: Energy insecurity may result in adverse consequences for children's health, particularly for children with special health needs or chronic health conditions. We aimed to determine whether a multimodal intervention addressing energy insecurity within the framework of a medical-legal partnership (MLP) resulted in an increase in the provision of certifications of medical need for utility coverage in an inner city academic primary care practice. METHODS: Working within a medical-legal partnership, we standardized criteria for providers approving medical need utility certification requests. We compared prior-year utility certification requests and approvals (pre-intervention) with the intervention year for families who reported energy insecurity on a waiting-room screening questionnaire. RESULTS: Between the first and second years of the study, certification of medical need approvals increased by 65%, preventing utility shut-offs for 396 more families with vulnerable children. CONCLUSIONS: Energy insecurity can be screened for and addressed in a busy urban practice, potentially improving the wellbeing of vulnerable children.

Adverse Childhood Experiences: Expanding the Concept of Adversity.

INTRODUCTION: Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups. METHODS: Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014. RESULTS: Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs. CONCLUSIONS: To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

New Century Scholars: A Mentorship Program to Increase Workforce Diversity in Academic Pediatrics.

This article describes a program aimed to increase workforce diversity and underrepresented minority (URM) representation in academic pediatric medicine. The New Century Scholars (NCScholars) program is a core program in the Academic Pediatric Association, the largest national organization for academic pediatric generalists. The program selects URM pediatric (or medicine-pediatrics) residents who are interested in academic careers and provides each NCScholar with a junior and senior mentor, as well as travel grants to the Pediatric Academic Societies annual meeting where activities specific to the program are held, and provides ongoing mentorship and career counseling support.The authors discuss the origination, operation, and changes to the program over the first 10 years of its existence, as well as outcome data for the participants in the program. To date, 60 of the 63 NCScholars have finished residency and/or have made postresidency plans, and 38 of these URM pediatricians (63%) have entered academic careers. The authors suggest that this type of mentorship program for URM pediatric trainees can be used as a model for other specialties and medical organizations.

Perceived racism and discrimination in children and youths: an exploratory study.

Racism may be a factor contributing to poor health and health care disparities in minority children through multiple mechanisms, including effects on psychological and physical wellbeing. Little is known about the experiences of racism that children encounter in their lives. This study describes the occurrences of perceived racism in children, including the settings and contexts in which it occurs. A questionnaire was administered to a convenience sample of urban children (eight to 16 years of age) asking about settings and situations in which they perceived discrimination. Two hundred and seventy-seven children completed the questionnaire; 88 percent ofthe children had at least one experience with racial discrimination, and 11.6 percent had experienced racism in at least half (12) of the 23 situations addressed in the questionnaire. Settings included schools and community contexts, and both peers and adults were perceived to be perpetrators. There were few differences in perceptions of racist episodes among different ethnocultural minority groups. Racism is perceived to be a common occurrence in many minority children's lives. Studies investigating perceptions of racism and how they relate to health disparities need to be conducted.

Perceptions of Racism in Children and Youth (PRaCY): properties of a self-report instrument for research on children's health and development.

Experiences of racial discrimination have been demonstrated to be related to racial and ethnic disparities in mental and physical health and healthcare. There has been little study, however, of the relationship between racism and health in children, and few psychometrically valid and reliable instruments to measure Perceptions of Racism in Children and Youth (PRaCY) exist. This paper reports on the development and testing of such an instrument, the PRaCY. Development of the instrument began with open-ended qualitative interviews, from which a proto-questionnaire was created. The questionnaire gathered information on the prevalence, attribution, emotional responses, and coping responses to 23 situations identified by participants in the qualitative phase. The proto-questionnaire was administered to 277 children between the ages of 8 and 18 years (38% Latino/a, 31% African-American, 19% multiracial/multicultural, 7% West Indian/Caribbean, and 5% Other). Item analysis resulted in two developmentally appropriate 10-item instruments (one for ages 7-13, another for ages 14-18). Internal consistency reliability was strong (alpha = 0.78 for both versions of the instrument). Confirmatory factor analysis demonstrated good fit for both versions (younger-Comparative Fit Index (CFI): 0.967, Root Mean Square Error of Approximation (RMSEA): 0.047; older-CFI: 0.934, RMSEA: 0.056). Differential item functioning analyses demonstrated no group-specific biases in item response. PRaCY scores were appropriately associated with higher depressive symptom scores and elevated anxiety scores in the younger sample. Results indicate that the PRaCY is a valid and reliable instrument that measures perceptions of racism and discrimination in children and youth aged 8-18 from diverse racial/ethnic backgrounds.

Racism and child health: a review of the literature and future directions.

OBJECTIVE: Racism is a mechanism through which racial/ethnic disparities occur in child health. To assess the present state of research into the effects of racism on child health, a review of the literature was undertaken. METHODS: A MEDLINE review of the literature was conducted between October and November 2007. Studies reporting on empirical research relating to racism or racial discrimination as a predictor or contributor to a child health outcome were included in this review. The definition of "child health" was broad and included behavioral, mental, and physical health. RESULTS: Forty articles describing empirical research on racism and child health were found. Most studies (65%) reported on research performed on behavioral and mental health outcomes. Other areas studied included birth outcomes, cardiovascular and metabolic diseases, and satisfaction with care. Most research has been conducted on African-American samples (70%), on adolescents and on older children, and without a uniformly standardized approach to measuring racism. Furthermore, many studies used measures that were created for adult populations. CONCLUSIONS: There are a limited number of studies evaluating the relationship between racism and child health. Most studies, to date, show relationships between perceived racism and behavioral and mental health. Future studies need to include more ethnically diverse minority groups and needs to consider studying the effects of racism in younger children. Instruments need to be developed that measure perceptions of racism in children and youth that take into account the unique contexts and developmental levels of children, as well as differences in the perception of racism in different ethnocultural groups. Furthermore, studies incorporating racism as a specific psychosocial stressor that can potentially have biophysiologic sequelae need to be conducted to understand the processes and mechanisms through which racism may contribute to child health disparities.

The health of Latino children: urgent priorities, unanswered questions, and a research agenda.

Latinos recently became the largest racial/ethnic minority group of US children. The Latino Consortium of the American Academy of Pediatrics Center for Child Health Research, consisting of 13 expert panelists, identified the most important urgent priorities and unanswered questions in Latino child health. Conclusions were drawn when consensus was reached among members, with refinement through multiple iterations. A consensus statement with supporting references was drafted and revised. This article summarizes the key issues, including lack of validated research instruments, frequent unjustified exclusion from studies, and failure to analyze data by pertinent subgroups. Latino children are at high risk for behavioral and developmental disorders, and there are many unanswered questions about their mental health needs and use of services. The prevalence of dental caries is disproportionately higher for Latino children, but the reasons for this disparity are unclear. Culture and language can profoundly affect Latino children's health, but not enough cultural competency training of health care professionals and provision of linguistically appropriate care occur. Latinos are underrepresented at every level of the health care professions. Latino children are at high risk for school dropout, environmental hazards, obesity, diabetes mellitus, asthma, lack of health insurance, nonfinancial barriers to health care access, and impaired quality of care, but many key questions in these areas remain unanswered. This article suggests areas in which more research is needed and ways to improve research and care of Latino children.