Research Priorities in Pediatric Asthma Morbidity: Addressing the Impacts of Systemic Racism on Children with Asthma in the United States. An Official American Thoracic Society Workshop Report.

Background: In the United States, Black and Latino children with asthma are more likely than White children with asthma to require emergency department visits or hospitalizations because of an asthma exacerbation. Although many cite patient-level socioeconomic status and access to health care as primary drivers of disparities, there is an emerging focus on a major root cause of disparities-systemic racism. Current conceptual models of asthma disparities depict the historical and current effects of systemic racism as the foundation for unequal exposures to social determinants of health, environmental exposures, epigenetic factors, and differential healthcare access and quality. These ultimately lead to biologic changes over the life course resulting in asthma morbidity and mortality. Methods: At the 2022 American Thoracic Society International Conference, a diverse panel of experts was assembled to identify gaps and opportunities to address systemic racism in childhood asthma research. Panelists found that to examine and address the impacts of systemic racism on children with asthma, researchers and medical systems that support biomedical research will need to 1) address the current gaps in our understanding of how to conceptualize and characterize the impacts of systemic racism on child health, 2) design research studies that leverage diverse disciplines and engage the communities affected by systemic racism in identifying and designing studies to evaluate interventions that address the racialized system that contributes to disparities in asthma health outcomes, and 3) address funding mechanisms and institutional research practices that will be needed to promote antiracism practices in research and its dissemination. Results: A thorough literature review and expert opinion discussion demonstrated that there are few studies in childhood asthma that identify systemic racism as a root cause of many of the disparities seen in children with asthma. Community engagement and participation in research studies is essential to design interventions to address the racialized system in which patients and families live. Dissemination and implementation studies with an equity lens will provide the multilevel evaluations required to understand the impacts of interventions to address systemic racism and the downstream impacts. To address the impacts of systemic racism and childhood asthma, there needs to be increased training for research teams, funding for studies addressing research that evaluates the impacts of racism, funding for diverse and multidisciplinary research teams including community members, and institutional and financial support of advocating for policy changes based on study findings. Conclusions: Innovative study design, new tools to identify the impacts of systemic racism, community engagement, and improved infrastructure and funding are all needed to support research that will address impacts of systemic racism on childhood asthma outcomes.

Caregiver Adverse Childhood Experiences and Pediatric Infection-Related Outcomes.

BACKGROUND: Higher caregiver adverse childhood experiences (ACEs) have been associated with multiple adverse pediatric outcomes. However, no studies have examined links between caregiver ACEs and infectious outcomes like antibiotic prescriptions or infection-related clinical encounters. METHODS: We conducted a retrospective cohort study including patients from two pediatric primary care sites, serving predominantly non-Hispanic Black, publicly-insured populations. Our outcomes were antibiotic prescriptions and infection-related ambulatory clinical encounters for children 0-3 years old. We captured these outcomes and additional covariates (demographics, health-related social risk screen results, and socioeconomic deprivation index scores linked to geocoded street addresses), from the electronic health record. High (≥4) or low (≤3) caregiver ACEs, and individual ACE question answers, were our exposures. Multivariable logistic regression was used to determine associations with any antibiotic use. Cox proportional hazards regression was used to assess time to first antibiotic exposure and first infection-related visit. RESULTS: A total of 1,465 children 0-3 years were included (50.0% female, 75.0% Black, 2.6% Hispanic). High caregiver ACEs were not associated with pediatric antibiotic exposure. The presence of caregiver-witnessed parental abuse was associated with higher likelihood of any antibiotic exposure (odds ratio [OR 1.90]; 95% confidence interval [CI] 1.2, 3.2) and time to first antibiotic exposure (hazard ratio [HR] 1.77; 95%CI 1.23, 2.56). Sexual abuse of the caregiver was associated with time to first infection-related clinical visit (HR 1.27; 95%CI 1.05, 1.53). CONCLUSIONS: Certain caregiver ACEs were associated with pediatric antibiotic use and infection-related visits. Future studies need to evaluate underlying mechanisms and test effective clinical responses.

A retrospective observational study - exploring food pantry referral as a clinical proxy for residents' ability to address unmet health-related social needs.

BACKGROUND: Assessment of residents' ability to address unmet health-related social needs to promote social accountability remains subjective and difficult. Existing approaches rely on self-assessment surveys of residents' knowledge, skills, and attitudes following social determinants of health training, with few studies explicitly measuring clinical practice. We aimed to characterize social accountability using resident referrals to a food pantry embedded in a pediatric primary care center as an objective measure of resident ability to address unmet health-related social needs in clinical practice. METHODS: This retrospective observational study occurred from 1 January 2019, to 30 June 2020, at an urban, pediatric primary care center with an embedded food pantry. All pediatric residents received social accountability education during a 2-week Advocacy rotation intern year. During clinic visits, pediatric residents were expected to act on results of a standardized social screen that included two food insecurity questions. Food pantry referral was the primary outcome. Food pantry referral data were extracted from food pantry logs. RESULTS: During the 18-month study period, the pediatric primary care center food pantry was accessed at 1,031 visits. Of the 860 physician-based visits that resulted in pantry referral, 63% (n = 545) were initiated by residents. Eighty-six percent of residents (134/156) made ≥ 1 referral. Across all years, residents placed a mean of 3 (range 1-16) food pantry referrals. CONCLUSIONS: During our study, most residents placed at least one pantry referral in response to identifying food insecurity either via the screen or during conversation with the family. Referral to a primary care embedded food pantry, one way to address acute food insecurity may serve as a measurable proxy to assess residents' ability to address unmet health-related social needs and promote social accountability in healthcare delivery.

The Test and Protect Program: A Data-Driven, Community-Engaged Approach to COVID-19 Testing Site Localization.

As the COVID-19 pandemic progressed, reliable, accessible, and equitable community-based testing strategies were sought that did not flood already overburdened hospitals and emergency departments. In Hamilton County, Ohio, home to ~800 000 people across urban, suburban, and rural areas, we sought to develop and optimize an accessible, equitable county-wide COVID-19 testing program. Using Coronavirus Aid, Relief, and Economic Security Act funding, multidisciplinary, multiorganization partners created the test and protect program to deliver safe, reliable testing in neighborhoods and organizations needing it most. Our approach involved: (1) use of geospatial analytics to identify testing locations positioned to optimize access; (2) community engagement to ensure sites were in trusted places; and (3) tracking of data over time to facilitate ongoing improvement. Between August 2020 and December 2021, more than 65 000 tests were completed for nearly 46 000 individuals at community-based testing sites. These methods could have application beyond COVID-19 and our region.

Potential Bias in Social Work Consultations in the Pediatric Inpatient Setting.

BACKGROUND AND OBJECTIVES: Failure to thrive, brief resolved unexplained event, accidental ingestion, and drowning admissions commonly involve social work (SW) consultation. Care team biases likely influence SW consultation decisions. We examined whether SW consultations varied by patient race for these diagnoses. METHODS: We conducted a retrospective cohort study of children <6 years of age admitted for failure to thrive, brief resolved unexplained event, accidental ingestion, and drowning between July 1, 2012 and June 30, 2020 at a single, academic, standalone children's hospital in an urban environment. The outcome was SW consultation; the predictor was patient race. We used multivariable logistic regression, adjusting for ethnicity, language, insurance, and diagnosis. We completed a supplemental chart review of a random sample of 10% of patients with SW consultation to determine the reasons that consultations were placed. RESULTS: We included 1199 unique patients; 64% identified as white, and 22% identified as Black. Black patients had 1.61 times higher adjusted odds of SW consultation compared with white patients (95% confidence interval 1.14-2.29). Publicly insured, compared with privately insured, patients had 6.10 times higher adjusted odds of SW consultation (95% confidence interval 4.28-8.80). Upon supplemental chart review, Black patients had SW consultations that focused more often on abuse, neglect, and safety; this was also found for publicly insured patients. There was parity in consultation for resource needs across groups. CONCLUSIONS: Black children were more likely than white children to receive SW consultation during hospitalization, as were publicly insured children compared with their privately insured peers; in supplemental review, this was not due to differences in consultations for resource needs. The standardization of SW consultation may promote equitable care.

Hospital Diversity, Equity, and Inclusion Efforts: Perspectives of Patient and Family Advisors.

BACKGROUND AND OBJECTIVES: Patient and family advisory councils are common within children's hospitals. However, lack of diversity among patient and family advisors (PFAs) may result in exclusion of crucial perspectives and perpetuate inequities. We sought to understand PFA perspectives on how children's hospitals should approach: (1) recruitment and support of PFAs from groups at greater risk of health inequities; and (2) development of meaningful partnerships with PFAs or patient and family advisory councils on institutional diversity, equity, and inclusion (DEI) efforts. METHODS: We conducted a qualitative study of PFAs of children's hospitals from communities at greater risk for health inequities based on self-identified race, ethnicity, gender, socioeconomic status, disability, language, or other factors. Focus groups were virtual and group discussions were recorded, transcribed, and analyzed using inductive qualitative analysis. RESULTS: In total, 17 PFAs participated across 5 focus groups (4 in English, 1 in Spanish). We identified 6 themes: (1) PFA diversity is necessary to understand existing health inequities; (2) diversity needs to be considered broadly; (3) recruiting for diverse PFAs requires intentionality, visibility of PFACs within and outside of the hospital, and deliberate connections with families and communities; (4) efforts to increase PFAC diversity must be accompanied by work to develop inclusive environments; (5) diversity efforts require meaningful engagement and equity; and (6) diverse PFACs can enrich DEI efforts but require organizational commitment and follow-through. CONCLUSIONS: Insights from our qualitative study of PFAs can be used by healthcare systems to foster diversity and inclusion in PFACs and advance hospital DEI efforts.

Improving Screening for Social Determinants of Health in an Outpatient Complex Care Clinic.

BACKGROUND: Families of children with medical complexity (CMC) may face challenges related to Social Determinants of Health (SDoH). Although standardized SDoH screening has been implemented in numerous medical settings, there has been limited study of screening among CMC. Our global aim is to improve access to institutional and community resources for families of CMC with identified needs. Here, we aimed to establish SDoH screening for families in our outpatient Complex Care Center and attain a screening rate of 80%. METHODS: A multidisciplinary team in our clinic used quality improvement methods to implement and study an expanded SDoH screen, which included 3 questions specific to the needs of CMC (ie, emergency planning, social support, and medical equipment concerns). Interventions, informed and refined by 5 key drivers, were tested over a 12-month period. A statistical process control chart tracked key outcome and process measures over time. RESULTS: SDoH screening sustained a mean of 80% after implementation during the study period. Incorporating registration staff in screen distribution was our most impactful intervention. At least 1 SDoH concern was identified on 56% of screens; concerns specific to CMC and mental health were most frequently reported. A total of 309 responses to positive screens were reported in total. CONCLUSIONS: Successful implementation of an expanded, tailored SDoH screen revealed a multitude of social needs specific to families of CMC that otherwise may not have been recognized. Our team continues to develop and distribute resources to address identified needs.

Racial, Ethnic, and Language Inequities in Ambulatory Pediatrics Patient Family Experience.

OBJECTIVE: To determine the association of patient race, patient-provider racial congruence, patient ethnicity, and family primary language with patient family experience (PFE) survey responses. METHODS: Cross-sectional review of PFE survey responses from all ambulatory medical encounters at a large, urban children's hospital system June 1, 2020-May 31, 2022. Exposures were patient race, patient-provider racial congruence, patient ethnicity, and family primary language. We adjusted analyses for neighborhood-level socioeconomic deprivation, patient sex and age, encounter specialty, and location of care. Outcomes were PFE survey scores for 5 questions focused on overall experience, respect, and safety; categorized using industry standard metric of presence of a "top-box" score, defined as a 9 or 10 for questions on an 11-point scale or as 4 on a 4-point scale. RESULTS: We included 89,175 surveys (15.6% response rate). The odds of having optimal, "top-box" responses for several assessed questions were lower for patients identified as Asian (e.g., adjusted odds ratio [OR] 0.46; 95% confidence interval [CI] 0.40, 0.52) or Black (e.g., OR 0.65; CI 0.60, 0.70) compared to White, and for Hispanic (e.g., OR 0.84; CI 0.72, 0.97) compared to non-Hispanic. Similarly, the odds of having "top-box" scores were lower for Spanish-primary-language (e.g., OR 0.38; CI 0.30, 0.48) compared to English-primary-language patients. Patient-provider racial congruence had higher odds of "top-box" responses for 2 of 5 assessed questions (e.g., OR 1.18; CI 1.04, 1.35). CONCLUSIONS: We found previously unreported inequities in ambulatory pediatric PFE outcomes, with worse experiences reported by Asian, Black, Hispanic, and Spanish-language patients.

"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 which felt impersonal and lacked empathy; 2)"Why is the doctor treating me like I don't matter?": Black families perceived experiences with poor care, 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.

Social Needs Screening Via Electronic Tablet in Pediatric Primary Care.

OBJECTIVES: (1) Assess whether health-related social needs (HRSN)/caregiver mental health concerns (CMHC) disclosure rates differ when screening questions are administered on paper versus electronic tablet. (2) Evaluate whether changes in need identification alters referral rates to social work and our medical-legal partnership (MLP). METHODS: We conducted a retrospective review of HRSN/CMHC screening in publicly insured patients 0-18 years presenting for well-child visits in three primary care practices. Our primary outcome was HRSN/CMHC disclosure rate, comparing the proportion of positive HRSN/CMHC screens during the 11 months before and after screening modality change. Generalized estimating equations and interrupted time series (ITS) were used to assess changes over time. Mediation analyses assessed the indirect effect of HRSN/CMHC disclosure during the electronic screening period on changes in referrals to social work/MLP. RESULTS: A total of 16,151 patients had paper-based HRSN/CMHC screens; 13,019 patients had electronic screens. Overall, 11% of paper-based screens identified ≥1 need, compared to 26% of electronic screens (p<0.001). All three practices saw an increase in disclosure rate after transition from paper to electronic screening (odds ratio [OR] range 1.54 to 4.24). Using ITS, two of three practices had significantly increased odds of need disclosure with electronic screens compared to paper (OR 3.0, 95% confidence interval [CI] 2.5, 3.6; and OR 1.7, 95%CI 1.2, 2.4). Increased HRSN/CMHC disclosure rates from transitioning to electronic screening mediated increased referrals to social work/MLP. CONCLUSIONS: Electronic screening was associated with an increased HRSN/CMHC disclosure rate compared to paper, which led to increased referrals to social work/MLP.

What Are Epidemiological Foundations for Integrating Legal Services Into Health Care Settings?

Medical-legal partnerships vary widely in how they are structured and use data to inform service delivery. Epidemiological data on certain chronic conditions' prevalence, the incidence of potentially preventable morbidity, and health-harming legal factors also influence approaches to care. This article draws on a pediatric example of how data-driven medical care complements data-driven legal care. This article also considers medical and public health ethical frameworks to guide protected information sharing, promote optimal service delivery, and achieve the best possible medical-legal outcomes.

Analyzing Racial Disparities in Pediatric Atopic Comorbidity Emergency Department Visitation Using Electronic Health Records.

BACKGROUND: Although atopic diseases and associated comorbidities are prevalent in children, little is known about racial differences in emergency department (ED) visitation. OBJECTIVE: We sought to examine racial differences in ED visitation among children with allergic comorbidities. METHODS: We conducted a retrospective study of patients (<21 years) who visited the ED at a large pediatric hospital for atopic dermatitis (AD), food allergy (FA), asthma, allergic rhinitis (AR), and eosinophilic esophagitis (EoE) from 2015 to 2019. We determined the probability of ED encounter-free survival time using hazard ratios (HRs) and time to recurrence (TTR) of ED encounter for patients identified as Black/African American (AA) and White/European American (EA). We assessed potentially underlying allergic, demographic, and place-based factors and potential interactions between factors. RESULTS: A total of 30,894 patients (38% AA and 62% EA) had 83,078 ED encounters (38,378 first ED encounters and 44,700 recurrent ED encounters) during the study period. Asthma and AR showed the highest rate of comorbidity in ED encounters in both AA and EA children. AA children exhibited a higher HR for encounter following index AD and asthma encounters. We found an interaction between the type of insurance and race in ED encounters for AD, FA, AR, and EoE. In AA children, those insured by Medicaid demonstrated a higher HR for any encounter than those with commercial insurance. Conversely, in EA children, those with Medicaid insurance showed a lower HR than their commercially insured peers. Regardless of race, allergic comorbidity increased the HR of ED encounter (1.12-1.62) for all allergic diseases. At 5-year follow-up, mean differences in TTR were shorter in AA children than EA children in AD, FA, and asthma. CONCLUSIONS: Identification of disease-specific racial disparities in ED visitation related to atopic diseases is a necessary first step toward the design and implementation of interventions capable of equitably reducing emergency care in atopic comorbid children.

An Institutional Approach to Equity and Improvement in Child Health Outcomes.

Pediatric health inequities are pervasive. Approaches by health care institutions to address inequities often, and increasingly, focus on social needs screening without linked, robust responses. Even when actions in pursuit of health equity do occur within health care institutions, efforts occur in isolation from each other, standing in the way of cross-learning and innovation. Learning network methods hold promise when institutions are confronted with complex, multidimensional challenges. Equity-oriented learning networks may therefore accelerate action to address complex factors that contribute to inequitable pediatric health outcomes, enabling rapid learning along the way. We established an institutional Health Equity Network (HEN) in pursuit of excellent and equitable health outcomes for children and adolescents in our region. The HEN supports action teams seeking to eliminate pediatric health inequities in their clinical settings. Teams deploy targeted interventions to meet patients' and families' needs, addressing both medical and social factors affecting health and wellbeing. The primary, shared HEN measure is the equity gap in hospitalization rates between Black patients and all other patients. The HEN currently has 10 action teams and promotes rapid learning and scaling of interventions via monthly "action period calls" and "solutions labs" focused on successes, challenges, and potential common solutions (eg, scaling of existing medical-legal partnership to subspecialty clinics). In this Advocacy Case Study, we detail the design, implementation, and early outcomes from the HEN, our equity-oriented learning network.

A regional learning health system of congregate care facilities for COVID-19 response.

Introduction: The COVID-19 pandemic disproportionately affected congregate care (CC) facilities due to communal living, presence of vulnerable populations, inadequate preventive resources, and limited ability to respond to the pandemic's rapidly evolving phases. Most facilities function independently and are not organized for collaborative learning and operations. Methods: We formed a learning health system of CC facilities in our 14-county metropolitan region, coordinated with public health and health care sectors, to address challenges driven by COVID-19. A CC steering committee (SC) was formed that represented diverse institutions and viewpoints, including skilled nursing facilities, transitional care facilities, residential facilities, prisons, and shelters. The SC met regularly and was guided by situational awareness and systems thinking. A regional CC COVID-19 dashboard was developed based on publicly available data and weekly data submitted by participating facilities. Those experiencing outbreaks or supply shortages were quickly identified. As the pandemic progressed, the role of the SC shifted to address new and forecasted needs. Results: Over 60 facilities participated in data sharing. The SC shared new guidelines, regulations, educational material, and best practices with the participating facilities. Information about testing sites, supplies, vaccination rollout, and facilities that had the capacity to accept COVID-19 patients was regularly disseminated. The SC was able to direct resources to those facilities experiencing outbreaks or supply shortages. Conclusions: A novel learning health system of regional CC facilities enabled preparedness, situational awareness, collaboration, and rapid dissemination of best practices across pandemic phases. Such collaborative efforts can play an important role in addressing other public and preventive health challenges.

A Road Map for Population Health and Health Equity Research.

This Viewpoint discusses the 4P's Road Map for population health and health equity research.

Characterizing Inequities in Pediatric Appendicitis Delayed Diagnosis and Perforation.

Objective: We sought to characterize the impact of a child's sociodemographic characteristics on their odds of delayed diagnosis and perforation in pediatric appendicitis. Study design: We performed a single-center, retrospective cohort study of all pediatric appendicitis admissions between 2016 and 2021. Using a multivariable model, we evaluated for associations between delayed diagnosis and perforation and a child's sociodemographic characteristics, including their age, sex, race and ethnicity, insurance status, and their home census-tract Material Community Deprivation Index value. Results: The study included 3248 patients. The median age was 12.1 years (IQR 9.5-14.9 years). Most patients were male (60.3%), identified as non-Hispanic White (78.0%), and had private insurance (55.4%). The delayed diagnosis and perforation rates were 6.4% and 25.1%, respectively. Delayed diagnosis cases had a greater perforation rate (56% compared with 21.5%, P < .001). On adjusted analysis, older age decreased the odds (OR 0.91, CI 0.87-0.94) of delayed diagnosis, whereas female sex (OR 1.50, CI 1.13-2.00) and socioeconomic disadvantage (OR 1.56 for quartile 4 vs quartile 1, CI 1.00-2.43) increased the odds. Furthermore, older age (OR 0.91, CI 0.89-0.93) decreased the odds of perforation, whereas non-Hispanic Black (OR 1.72, CI 1.3-2.29) or Hispanic (OR 1.60, CI 1.24-2.08) compared with non-Hispanic White identification and socioeconomic disadvantage (OR 1.43 Q4 vs Q1, CI 1.12-1.83) increased the odds. Conclusions: Our reported delayed diagnosis rate is greater than recent literature, highlighting the need to consider visits that occur across different health care settings. We further identify sociodemographic factors, including socioeconomic status, that impact a child's risk of delayed diagnosis and perforation.

Addressing food insecurity in the inpatient setting: Results of a postdischarge pilot study.

BACKGROUND AND OBJECTIVES: With a growing interest in screening for food insecurity (FI) during pediatric hospitalization, there is a parallel need to develop interventions. With input from caregivers experiencing FI, we sought to identify interventions to assist with short-term FI after discharge and evaluate their feasibility, acceptability, and appropriateness. METHODS: We first employed qualitative methods to identify potential interventions. Next, we conducted a pilot study of selected interventions for families experiencing FI. Seven days postdischarge, caregivers rated the intervention's feasibility, acceptability, and appropriateness. We also assessed for ongoing FI. We summarized the median and proportion of "completely agree" responses to feasibility, acceptability, and appropriateness questions, and we compared in-hospital and postdischarge FI using McNemar's test. RESULTS: In the qualitative stage, 14 caregivers prioritized three interventions: grocery store gift cards, grocery delivery/pick-up, and frozen meals. In the pilot study, 53 caregivers (25% of those screened) endorsed FI during their child's hospitalization and received one or more of the interventions. Every caregiver selected the grocery gift card option; 37 families (69.8%) also received frozen meals. Seven days after discharge, most caregivers rated the intervention as "completely" feasible (76%), acceptable (90%), and appropriate (88%). There was a significant decrease in caregivers who reported FI after discharge compared to during the hospitalization (p < .001). CONCLUSIONS: This study demonstrates the feasibility, acceptability, and appropriateness of inpatient interventions to address FI, particularly at the time of pediatric hospital discharge and transition home. Randomized trials are needed to further evaluate the efficacy of interventions employed during hospitalization.

The Impact of Structural Racism on Continuity of Care at Pediatric Academic Primary Care Clinics.

OBJECTIVE: Using a structural racism framework, we assessed racial inequities in continuity of care, using the Usual Provider Continuity Index (UPC - the proportion of visits with the provider the patient saw most frequently out of all visits), in a set of large pediatric academic clinics. METHODS: We conducted a retrospective cohort study. Patients 12-24 months seen at three pediatric academic primary care clinics for any visit during October 1-31, 2021 were included. We then reviewed continuity for these patients in the preceding 12 months. Outcomes included each patient's UPC for all visits, and a modified UPC for well child checks only (UPC Well). Covariates included race, ethnicity, insurance, clinic site, age, sex, care management, or seeing a social worker. We evaluated for differences in outcomes using bivariate analyses and multivariable regression models. RESULTS: Our cohort included 356 patients (74% Black, 5% Hispanic, 85% Medicaid, 52% female, median age 15.8 months). The median UPC was 0.33 and median UPC Well was 0.40. Black patients had significantly lower median values for UPC (0.33 Black vs 0.40 non-Black, P < .01) and UPC Well (0.33 Black vs 0.50 non-Black, P < .01). There were similar inequities in continuity rates by insurance and clinic site. In multivariable models, clinic site was the only variable significantly associated with continuity. CONCLUSIONS: Clinic sites serving higher percentages of Black patients had lower rates of continuity. The main driver of racial inequities in continuity rates was at the institutional level.

Elevating the Importance of Local Elections.

This Viewpoint discusses the reasons why local elections are important and the ways that health care professionals can get involved.