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.

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.

AI-based automation of enrollment criteria and endpoint assessment in clinical trials in liver diseases.

Clinical trials in metabolic dysfunction-associated steatohepatitis (MASH, formerly known as nonalcoholic steatohepatitis) require histologic scoring for assessment of inclusion criteria and endpoints. However, variability in interpretation has impacted clinical trial outcomes. We developed an artificial intelligence-based measurement (AIM) tool for scoring MASH histology (AIM-MASH). AIM-MASH predictions for MASH Clinical Research Network necroinflammation grades and fibrosis stages were reproducible (κ = 1) and aligned with expert pathologist consensus scores (κ = 0.62-0.74). The AIM-MASH versus consensus agreements were comparable to average pathologists for MASH Clinical Research Network scores (82% versus 81%) and fibrosis (97% versus 96%). Continuous scores produced by AIM-MASH for key histological features of MASH correlated with mean pathologist scores and noninvasive biomarkers and strongly predicted progression-free survival in patients with stage 3 (P < 0.0001) and stage 4 (P = 0.03) fibrosis. In a retrospective analysis of the ATLAS trial (NCT03449446), responders receiving study treatment showed a greater continuous change in fibrosis compared with placebo (P = 0.02). Overall, these results suggest that AIM-MASH may assist pathologists in histologic review of MASH clinical trials, reducing inter-rater variability on trial outcomes and offering a more sensitive and reproducible measure of patient responses.

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.

A Case Report of Delayed Opioid Toxidrome After Administration of Naloxone.

Introduction: Opioid use is an epidemic that plagues the United States. Patients frequently present to the emergency department (ED) after opioid toxicity, which can lead to respiratory failure, apnea, and death. Although there is an effective antidote, naloxone, the current guidelines surrounding post-naloxone administration monitoring are loosely defined. Case Report: We present a case in which an individual was administered naloxone after an intentional opioid overdose and was monitored for four hours, as is standard in our institution. He remained in the ED for additional workup following this observation period and subsequently experienced signs of severe respiratory depression, requiring bag-valve-mask ventilation, naloxone, and admission. Had he been discharged, as is typical after a four-hour observation period, the consequences could have been fatal. We present multiple theories as to why his opioid toxidrome may have presented in a delayed manner, including ingestion of fentanyl analogues and variability in metabolization of both opioids and naloxone. We also explore alternative overdose antidote products approved by the US Food and Drug Administration, which may impact post overdose care. Conclusion: This case suggests that the correct amount of time to monitor patients after naloxone administration may be longer than originally thought. Our aim in this article was to further the discussion regarding the most appropriate observation period in cases of opioid toxicity.

Evaluation of the sensitivity of a measles diagnostic real-time RT-PCR assay incorporating recently observed priming mismatch variants, 2024.

We investigated a variant of measles virus that encodes three mismatches to the reverse priming site for a widely used diagnostic real-time RT-PCR assay; reduction of sensitivity was hypothesised. We examined performance of the assay in context of the variant using in silico data, synthetic RNA templates and clinical specimens. Sensitivity was reduced observed at low copy numbers for templates encoding the variant sequence. We designed and tested an alternate priming strategy, rescuing the sensitivity of the assay.

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.

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

BACKGROUND: Although atopic diseases and associated co-morbidities 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 using hazard ratios (HR) 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, 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 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 compared to those with commercial insurance. Conversely, in EA children, those with Medicaid insurance showed a lower HR compared to 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-years follow up, mean differences in TTR were shorter in AA children compared to EA children in AD, FA, and asthma. CONCLUSION: 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.

Effectiveness of smoking cessation interventions among adults: an overview of systematic reviews.

BACKGROUND: This overview of reviews aims to identify evidence on the benefits (i.e. tobacco use abstinence and reduction in smoking frequency) and harms (i.e. possible adverse events/outcomes) of smoking cessation interventions among adults aged 18 years and older. METHODS: We searched Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, the CADTH Health Technology Assessment Database and several other websites for grey literature. Searches were conducted on November 12, 2018, updated on September 24, 2020, with publication years 2008 to 2020. Two reviewers independently performed title-abstract and full-text screening considering pre-determined inclusion criteria. Data extraction and quality assessments were initially completed by two reviewers independently (i.e. 73% of included studies (n = 22)) using A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR 2), and the remainder done by one reviewer and verified by another due to resources and feasibility. The application of Grading of Recommendations Assessment, Development and Evaluation (GRADE) was performed by one independent reviewer and verified by another. RESULTS: A total of 22 Cochrane systematic reviews evaluating the impact of smoking cessation interventions on outcomes such as tobacco use abstinence, reduction in smoking frequency, quality of life and possible adverse events were included. Pharmaceutical (i.e. varenicline, cytisine, nicotine replacement therapy (NRT), bupropion) and behavioural interventions (i.e. physician advice, non-tailored print-based self-help materials, stage-based individual counselling, etc.) showed to have increased smoking cessation; whereas, data for mobile phone-based interventions including text messaging, hypnotherapy, acupuncture, continuous auricular stimulation, laser therapy, electrostimulation, acupressure, St John's wort, S-adenosyl-L-methionine (SAMe), interactive voice response systems and other combination treatments were unclear. Considering harms related to smoking cessation interventions, small/mild harms (i.e. increased palpitations, chest pain, nausea, insomnia, headache) were observed following NRT, varenicline and cytisine use. There were no data on harms related to behavioural therapies (i.e. individual or group counselling self-help materials, internet interventions), combination therapies or other therapies (i.e. laser therapy, electrostimulation, acupressure, St John's wort, SAMe). CONCLUSION: Results suggest that pharmacological and behavioural interventions may help the general smoking population quit smoking with observed small/mild harms following NRT or varenicline. Consequently, evidence regarding ideal intervention strategies and the long-term impact of these interventions for preventing smoking was unclear. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018099691.

Global Update on Measles Molecular Epidemiology.

Molecular surveillance of circulating measles variants serves as a line of evidence for the absence of endemic circulation and provides a means to track chains of transmission. Molecular surveillance for measles (genotyping) is based on the sequence of 450 nucleotides at the end of the nucleoprotein coding region (N450) of the measles genome. Genotyping was established in 1998 and, with over 50,000 sequence submissions to the Measles Nucleotide Surveillance database, has proven to be an effective resource for countries attempting to trace pathways of transmission. This review summarizes the tools used for the molecular surveillance of measles and describes the challenge posed by the decreased number of circulating measles genotypes. The Global Measles and Rubella Laboratory Network addressed this challenge through the development of new tools such as named strains and distinct sequence identifiers that analyze the diversity within the currently circulating genotypes. The advantages and limitations of these approaches are discussed, together with the need to generate additional sequence data including whole genome sequences to ensure the continued utility of strain surveillance for measles.

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.

Effectiveness of e-cigarettes as a stop smoking intervention in adults: a systematic review.

BACKGROUND: This systematic review aims to identify the benefits and harms of electronic cigarettes (e-cigarettes) as a smoking cessation aid in adults (aged ≥ 18 years) and to inform the development of the Canadian Task Force on Preventive Health Care's (CTFPHC) clinical practice guidelines on e-cigarettes. METHODS: We searched Ovid MEDLINE®, Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non-Indexed Citations, PsycINFO, Embase Classic + Embase, and the Cochrane Library on Wiley. Searches were conducted from January 2016 to July 2019 and updated on 24 September 2020 and 25 January 2024. Two reviewers independently performed title-abstract and full-text screening according to the pre-determined inclusion criteria. Data extraction, quality assessments, and the application of Grading of Recommendations Assessment, Development and Evaluation (GRADE) were performed by one independent reviewer and verified by another. RESULTS: We identified 18 studies on 17 randomized controlled trials that compared e-cigarettes with nicotine to e-cigarettes without nicotine and e-cigarettes (with or without nicotine) to other interventions (i.e., no intervention, waitlist, standard/usual care, quit advice, or behavioral support). Considering the benefits of e-cigarettes in terms of smoking abstinence and smoking frequency reduction, 14 studies showed small or moderate benefits of e-cigarettes with or without nicotine compared to other interventions; although, with low, very low or moderate evidence certainty. With a focus on e-cigarettes with nicotine specifically, 12 studies showed benefits in terms of smoking abstinence when compared with usual care or non-nicotine e-cigarettes. In terms of harms following nicotine or non-nicotine e-cigarette use, 15 studies reported mild adverse events with little to no difference between groups and low to very low evidence certainty. CONCLUSION: The evidence synthesis on the e-cigarette's effectiveness shows data surrounding benefits having low to moderate evidence certainty for some comparisons and very low certainty for others, indicating that e-cigarettes may or probably increase smoking cessation, whereas, for harms, there is low to very low evidence certainty. Since the duration for outcome measurement varied among different studies, it may not be long-term enough for Adverse Events (AEs) to emerge, and there is a need for more research to understand the long-term benefits and potential harms of e-cigarettes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018099692.

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.

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.

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.

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.