Racial/Ethnic Variation in Emergency Department Care for Children With Asthma.

OBJECTIVE: To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients. METHODS: This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED. RESULTS: The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01). CONCLUSIONS: In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.

Leaving the emergency department without complete care: disparities in American Indian children.

BACKGROUND: Children who leave the emergency department (ED) without complete evaluation or care (LWCET) have poorer outcomes in general. Previous studies have found that American Indian (AI) children have higher rates of LWCET than other racial or ethnic groups. Therefore, this study aims to examine LWCET in AI children by exploring differences by ED location and utilization patterns. METHODS: This is a retrospective cohort study of five EDs in the upper Midwest between June 2011 and May 2012. We included all visits by children aged 0-17 who identified as African American (AA), AI or White. Logistic regression was used to determine differences in LWCET by race and ED location controlling for other possible confounding factors including sex, age, insurance type, triage level, distance from ED, timing of visit, and ED activity level. RESULTS: LWCET occurred in 1.73% of 68,461 visits made by 47,228 children. The multivariate model revealed that AIs were more likely to LWCET compared to White children (Odds Ratio (OR) = 1.62, 95% Confidence Interval (CI) = 1.30-2.03). There was no significant difference in LWCET between AA and White children. Other factors significantly associated with LWCET included triage level, distance from the ED, timing of visit, and ED activity level. CONCLUSION: Our results show that AI children have higher rates of LWCET compared to White children; this association is different from other racial minority groups. There are likely complex factors affecting LWCET in AI children throughout the upper Midwest, which necessitates further exploration.

Emergency Department Utilization by Native American Children.

OBJECTIVES: The aims of this study were to determine differences in emergency department (ED) use by Native American (NA) children in rural and urban settings and identify factors associated with frequent ED visits. METHODS: This cross-sectional, cohort study examined visits to 6 EDs: 2 rural, 2 midsize urban, and 2 large urban EDs from June 2011 to May 2012. Univariate and multiple regression analyses were conducted. Frequent ED visitors had more than 4 visits in the study period. RESULTS: We studied 8294 NA visits (5275 patients) and 44,503 white visits (33,945 patients). Rural EDs had a higher proportion of NA patients, those below 200% of the income poverty level, and those who traveled more than 10 miles from their residence to attend the ED (all P < 0.05) compared with midsize and urban EDs. Native American patients had a high proportion of mental health diagnoses compared with whites (4.9% vs 1.9%, P < 0.001). Frequent ED visitors had greater odds of NA race, age younger than 1 year, public insurance, female sex, residence within less than 5 miles from the ED, and chronic disease. CONCLUSIONS: Native American children seem to have greater challenges compared with whites obtaining care in rural areas. Native American children were more likely to be frequent ED visitors, despite having to travel farther from their residence to the ED. Native American children visiting rural and midsize urban EDs had a much higher prevalence of mental health problems than whites. Additional efforts to provide both medical and mental health services to rural NA are urgently needed.

Community Perspectives on Emergency Department Use and Care for American Indian Children.

Emergency department (ED) utilization by American Indian (AI) children is among the highest in the nation. Numerous health disparities have been well documented in AI children, but limited information is available on parental experiences of care for AI children in the ED. Our objective was to understand parental attitudes towards ED care for AI children. Focus groups were held with AI parents/caregivers at five sites in the Upper Midwest. Traditional content analysis was used to identify themes. A total of 70 parents participated in ten focus groups. Three main themes were identified: healthcare environment, access to care, and interaction with providers. Healthcare environment issues included availability of specialists, wait times, and child-friendly areas. Transportation and financial considerations were major topics in access to care. Issues in interaction with providers included discrimination, stereotyping, and trust. This is one of the first studies to assess parent perspectives on ED use for AI children. Obtaining parental perspectives on ED experiences is critical to improve patient care and provide important information for ED providers.

Predicting Frequent Emergency Department Use by Pediatric Medicaid Patients.

The objective of this study was to determine the patient characteristics and health care utilization patterns that predict frequent emergency department (ED) use (≥4 visits per year) over time to assist health care organizations in targeting patients for care management. This was a retrospective, population-based study of 13,265 Medicaid children aged 0-20 years who were attributed to a single pediatric accountable care organization for at least 2 consecutive years between June 2012 and May 2015. Year-to-year persistence as a frequent ED user was 36.3% (95% confidence interval [CI]: 33.4 to 38.4), which does not support the notion that once a frequent user, always a frequent user. Hence, interventions to reduce frequent ED use may appear to be effective when ED use would have regressed toward the mean without any intervention. At an individual patient level, predictability of frequent ED use was 0.437 (95% CI: 0.358 to 0.485) across frequent ED users of all ages compared with 0.723 (95% CI: 0.435 to 0.824) for those aged <1 year. Accordingly, this latter group may be a better target for interventions than frequent ED users generally.

Emergency Department Utilization for Mental Health in American Indian Children.

OBJECTIVES: To examine emergency department (ED) visits for mental health concerns by American Indian children in a multicenter cohort. To analyze demographic and clinical factors, the types of mental health concerns, and repeat mental health visits. STUDY DESIGN: Cross-sectional study of children 5-18 years old who visited 1 of 6 EDs in the Upper Midwest from June 2011 to May 2012 and self-identified as white or American Indian. Mental health visits were identified by primary diagnosis and reasons for visit and were categorized into diagnostic groups. We explored racial differences in ED visits for mental health, diagnostic groups, and repeat mental health visits. Analysis involved χ(2) tests, Cochran-Mantel-Haenszel tests, and regression models including age, triage, timing, and insurance, and their interactions with race. RESULTS: We identified 26 004 visits of which 1545 (5.4%) were for a mental health concern. The proportion of visits for mental health differed by race and age. American Indian children had lower odds of a mental health visit for 5-10 year olds (OR, 0.40; 95% CI, 0.26-0.60), but higher odds for 11-17 year olds (OR, 1.62; 95% CI, 1.34-1.95). In the older age group, American Indian children were seen primarily for depression and trauma- and stressor-related disorders, whereas white children were seen primarily for depression and disruptive, impulse control, and conduct disorders. Repeat visits were not different by race. CONCLUSIONS: Differences were noted in mental health visits between American Indian and white children and were influenced by age. These findings warrant further investigation into care-seeking patterns and treatment for mental health in American Indian children.

The Role of Bias by Emergency Department Providers in Care for American Indian Children.

BACKGROUND: American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. OBJECTIVE: Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. RESEARCH DESIGN: We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. RESULTS: A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. CONCLUSIONS: The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.

Racial Differences in Pediatric Emergency Department Triage Scores.

BACKGROUND: Racial disparities are frequently reported in emergency department (ED) care. OBJECTIVES: To examine racial differences in triage scores of pediatric ED patients. We hypothesized that racial differences existed but could be explained after adjusting for sociodemographic and clinical factors. METHODS: We examined all visits to two urban, pediatric EDs between August 2009 and March 2010. Demographic and clinical data were electronically extracted from the medical record. We used logistic regression to analyze racial differences in triage scores, controlling for possible covariates. RESULTS: There were 54,505 ED visits during the study period, with 7216 (13.2%) resulting in hospital admission. White patients accounted for 36.4% of visits, African Americans 28.5%, Hispanics 18.0%, Asians 4.1%, and American Indians 1.8%. After adjusting for potential confounders, African American (adjusted odds ratio [aOR] 1.89, 95% confidence interval [CI] 1.69-2.12), Hispanic (aOR 1.77, 95% CI 1.55-2.02), and American Indian (aOR 2.57, 95% CI 1.80-3.66) patients received lower-acuity triage scores than Whites. In three out of four subgroup analyses based on presenting complaints (breathing difficulty, abdominal pain, fever), African Americans and Hispanics had higher odds of receiving low-acuity triage scores. No racial differences were detected for patients with presenting complaints of laceration/head injury/arm injury. However, among patients admitted to the hospital, African Americans (aOR 1.47, 95% CI 1.13-1.90) and Hispanics (aOR 1.71, CI 1.22-2.39) received lower-acuity triage scores than Whites. CONCLUSION: After adjusting for available sociodemographic and clinical covariates, African American, Hispanic, and American Indian patients received lower-acuity triage scores than Whites.

Effect of Attribution Length on the Use and Cost of Health Care for a Pediatric Medicaid Accountable Care Organization.

IMPORTANCE: Little is known about the effect of pediatric accountable care organizations (ACOs) on the use and costs of health care resources, especially in a Medicaid population. OBJECTIVE: To assess the association between the length of consistent primary care (length of attribution) as part of an ACO and the use and cost of health care resources in a pediatric Medicaid population. DESIGN, SETTING, AND PARTICIPANTS: A retrospective study of Medicaid claims data for 28,794 unique pediatric patients covering 346,277 patient-attributed months within a single children's hospital. Data were collected for patients attributed from September 1, 2013, to May 31, 2015. The effect of the length of attribution within a single hospital system's ACO on the use and costs of health care resources were estimated using zero-inflated Poisson distribution regression models adjusted for patient characteristics, including chronic conditions and a measure of predicted patient use of resources. EXPOSURES: Receiving a plurality of primary care at an ACO clinic during the preceding 12 months (attribution to the ACO). MAIN OUTCOMES AND MEASURES: The primary outcome measure was the length of attribution at an ACO clinic compared with subsequent inpatient hospitalization and subsequent use and cost of outpatient and ancillary health care resources. RESULTS: Among the 28,794 pediatric patients receiving treatment covering 346,277 patient-attributed months during the study period, continuous attribution to the ACO for more than 2 years was associated with a decrease (95% CI) of 40.6% (19.4%-61.8%) in inpatient days but an increase (95% CI) of 23.3% (2.04%-26.3%) in office visits, 5.8% (1.4%-10.2%) in emergency department visits, and 15.3% (12.5%-18.0%) in the use of pharmaceuticals. These changes in the use of health care resources combined resulted in a cost reduction of 15.7% (95% CI, 6.6%-24.8%). At the population level, the impact of consistent primary care was muted by the many patients in the ACO having shorter durations of participation. CONCLUSIONS AND RELEVANCE: These findings suggest significant and durable reductions of inpatient use and cost of health care resources associated with longer attribution to the ACO, with attribution as a proxy for exposure to the ACO's consistent primary care. Consistent primary care among the pediatric Medicaid population is challenging, but these findings suggest substantial benefits if consistency can be improved.

Pediatric Inpatient Readmissions in an Accountable Care Organization.

OBJECTIVE: To assess the association between the length of consistent primary care as part of an accountable care organization (attribution length) and population-level and same-hospital readmissions. Readmission studies are generally focused on same-hospital readmissions rather than readmissions to any hospital (population-level readmissions). STUDY DESIGN: A retrospective study of Medicaid claims data for 28,794 unique pediatric patients attributed to a single children's hospital between September 2013 and May 2015. Study used logistic regression to estimate the impact of attribution length on readmissions and a zero-inflated Poisson model to assess the impact of attribution length on readmission cost and readmission days. RESULTS: The study showed attribution length was associated with a significant reduction in the population-level 30-day readmission rate from 8.9%-6.2% (P = .010) primarily by reducing readmissions that occurred at hospitals other than the discharging hospital. There was no significant reduction in the same-hospital readmission rate. Readmissions to a different hospital occurred in 37% of readmissions. Although not significant at the P = .05 level, attribution length was associated with a 44% reduction (P = .100) in 30-day readmission costs or a 5.0% reduction in the cost of an inpatient episode of care and a 53% reduction (P = .019) in readmission days. CONCLUSIONS: Consistent primary care (attribution length) may be able to reduce 30-day, pediatric Medicaid patients' readmissions at the population level. The decrease occurred primarily in readmissions to hospitals other than the discharging hospital. There was no decrease in the rate of same-hospital readmissions.

Lead Testing in a Pediatric Population: Underscreening and Problematic Repeated Tests.

CONTEXT: Underscreening and problematic repeat lead testing in children. OBJECTIVE: Identify proportion of underscreening for elevated blood-lead levels in children. For children who receive a lead test, measure the level of problematic repeat lead tests, defined as those with a high probability of not meeting recommended guidelines for lead testing in children measured using a combination of patients' age, test type and sequencing, days between tests, and encounter diagnosis coding. DESIGN: A population-based retrospective cross-sectional design. SETTING: All health care services organizations in the state of Minnesota that delivered health services to the defined study population. PARTICIPANTS: The study population was a Medicaid cohort of 12 436 children aged 0 to 18 years observed over a 1-year period. MAIN OUTCOME MEASURES: Proportion of eligible children not receiving at least 1 lead test; proportion of problematic repeat lead tests. RESULTS: Thirty-five percent of children who should have received at least 1 lead test (n = 1714) during the study period did not. A total of 1856 children had at least 1 lead test and 190 had 2 or more. Fifty percent (50%) of the repeat tests were identified as problematic, representing 5.1% of the lead tests performed. Repeat tests performed in different health systems than the systems where the initial tests were performed had 5.3 times greater odds (adjusted odds ratio: 5.3 [95% confidence interval, 2.8-9.9]) of being problematic. CONCLUSIONS: The current approach to delivering mandatory lead testing across the state Medicaid population does not ensure that children are appropriately tested and has potential inefficiencies in that testing when it does take place. Use of multiple health care systems is associated with increased potential inefficiencies. Future Medicaid accountable care agreements between the state Medicaid program and participating health systems should emphasize clear population accountability for test screenings to improve patients' safety. A central queryable health resource or health information exchange may enable this.

Do Pediatric Patients Who Receive Care Across Multiple Health Systems Have Higher Levels of Repeat Testing?

Repetition by clinicians of the same tests for a given patient is common. However, not all repeat tests are necessary for optimal care and can result in unnecessary hardship. Limited evidence suggests that an electronic health record may reduce redundant laboratory testing and imaging by making previous results accessible to physicians. The purpose of this study is to establish a baseline by characterizing repeat testing in a pediatric population and to identify significant risk factors associated with repeated tests, including the impact of using multiple health systems. A population-based retrospective cross-sectional design was used to examine initial and repeat test instances, defined as a second test following an initial test of the same type for the same patient. The study population consisted of 8760 children with 1-25 test claims over a 1-year period. The study setting included all health care service organizations in Minnesota that generated these claims. In all, 17.2% of tests met the definition of repeat test instances, with several risk factors associated with per patient repeat test levels. The incidence of repeat test instances per patient was significantly higher when patients received care from more than 1 health system (adjusted incidence rate ratio 1.4; 95% confidence interval: 1.3-1.5). Repeat test levels are significant in pediatric populations and potentially actionable. Interoperable health information technology may reduce the incidence of repeat test instances in pediatric populations by making prior test results readily accessible. (Population Health Management 2016;19:102-108).

The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety Events.

BACKGROUND: Adverse events, diverse and often costly, commonly occur in pediatric intensive care units (PICUs). Serious safety events (SSEs) are captured through well-developed systems, typically by voluntary reporting. Less serious safety events (LSSEs), including close calls, however, occur at a higher frequency than those that result in immediate harm or death but are underestimated by standard reporting systems. LSSEs can reveal system defects and precede serious events resulting in patient or provider harm. METHODS: A unique active surveillance program was created at Children's Hospitals and Clinics of Minnesota to quantify and categorize, and, ultimately reduce, LSSEs, in PICUs. Premedical college graduates without formal health care training daily canvassed the PICUs and facilitated reporting of LSSEs at the point of care. Events were recorded on a Web application and stored in a relational database management system. Events were enumerated and categorized according to distinctive characteristics (Theme Index) and real or potential harm (Harm Index). RESULTS: Some 1,980 PICU patients, representing 10,766 PICU patient-days in a 15-month period (June 1, 2013- August 31, 2014) experienced 2,465 LSSEs-5.4 LSSEs/ day or 0.23 LSSEs/patient-day. Such events resulted in a patient intervention 38% of the time. Some 158 quality/safety improvement projects were initiated during the observation period, 74 of which have been completed. Quality/safety information was broadcasted to providers, local leadership, and hospital management. CONCLUSIONS: LSSEs occur frequently in our PICUs. Non-health care providers can cost-effectively facilitate reporting by actively canvassing PICU providers on a daily basis and can contribute to quality/safety improvement projects and local safety culture. Reported events can serve as a focus for quality/safety improvement projects. A Web application and mobile tablet interfaces are efficient tools to record events.

Reductions in invasive device use and care costs after institution of a daily safety checklist in a pediatric critical care unit.

BACKGROUND: In the critical care unit, complexity of care can contribute to both medical errors and increased costs, particularly when clinicians are forced to rely on memory. Checklists can be used to improve safety and reduce cost. A number of omission-related adverse events in 2010 prompted the development of a checklist to reduce the possibility of similar future events. METHODS: The PICU Safety Checklist was implemented in the pediatric ICU (PICU) at Children's Hospitals and Clinics of Minnesota. During a 21-month period, the checklist was used to prompt the care team to address quality and safety items during rounds. The initial checklist was paper, with two subsequent versions being incorporated into the electronic medical record (EMR). RESULTS: The daily safety checklist was successfully implemented in the PICU. Work-flow improvements based on regular multidisciplinary feedback led to more consistent use of the checklist. Improvements on all quality and safety metrics were identified, including invasive device use, medication costs, antibiotic and laboratory test use, and compliance with standards of care. Staff satisfaction rates were > 80% for safety, communication, and collaboration. CONCLUSION: By using a daily safety checklist in the pediatric critical care unit, we improved quality and safety, as well as the collaborative culture among all clinicians. Incorporating the checklist into the EMR improved compliance and accountability, ensuring its application to all patients. Clinicians now often individually address many checklist items outside the formal rounding process, indicating that the checklist content has become part of their usual practice. A successful implementation showing tangible clinical improvements can lead to interest and adoption in other clinical areas within the institution.

A novel method for detecting inpatient pediatric asthma encounters using administrative data.

Multiple methods for detecting asthma encounters are used today in public surveillance, quality reporting, and clinical research. Failure to detect asthma encounters can make it difficult to measure the scope and effectiveness of hospital or community-based interventions important in comparative effectiveness research and accountable care. Given the pairing of asthma with certain respiratory conditions, the objective of this study was to develop and test an asthma detection algorithm with specificity and sensitivity using 2 criteria: (1) principal discharge diagnosis and (2) asthma diagnosis code position. A medical record review was conducted (n=191) as the gold standard for identifying asthma encounters given objective criteria. The study team observed that for certain principal respiratory diagnoses (n=110), the observed odds ratio that encounters were for asthma when asthma was coded in the second or third code position was not significantly different than when asthma was coded as the principal diagnosis, 0.36 (P=0.42) and 0.18 (P=0.14), respectively. In contrast, the observed odds ratio was significantly different when asthma was coded in the fourth or fifth positions (P<.001). This difference remained after adjusting for covariates. Including encounters with asthma in 1 of the 3 first positions increased the detection sensitivity to 0.84 [95% confidence interval (CI): 0.76-0.92] while increasing the false positive rate to 0.19 [95% CI: 0.07-0.31]. Use of the proposed algorithm significantly improved the reporting accuracy [0.83 95%CI:0.76-0.90] over use of (1) the principal diagnosis alone [0.55 95% CI:0.46-0.64] or (2) all encounters with asthma 0.66 [95% CI:0.57-0.75]. Bed days resulting from asthma encounters increased 64% over use of the principal diagnosis alone. Given these findings, an algorithm using certain respiratory principal diagnoses and asthma diagnosis code position can reliably improve asthma encounter detection for population-based health impact measurement.

Does initial length of stay impact 30-day readmission risk in pediatric asthma patients?

OBJECTIVES: Accountable care puts pressure on hospitals to manage care episodes. Initial length of stay (ILOS) and readmission risk are important elements of a care episode and measures of care quality. Understanding the association between these two measures can guide hospital efforts in managing care episodes. This study was designed to explore the association between ILOS and readmission risk in a cohort of pediatric asthma patients. MATERIALS AND METHODS: The sample cohort (n = 4965) consisted of all asthma patients discharged from Children's Hospitals and Clinics of Minnesota (CHC MN) from January 2008 through August 2012. Asthma discharges included cases with a principal diagnosis of asthma or certain respiratory cases with asthma listed as a secondary diagnosis. Multiple logistic regression was used to test associations, adjusting for covariates. RESULTS: Adjusting for covariates, we found no significant association between ILOS and readmission (OR: 1.04 [95% CI: 0.98-1.10]). Analyzing ILOS categorically by length of stay, one-day stays did not have a significantly higher readmission risk (OR:1.27 [95% CI: 0.87-1.85]) than two-day stays, which had the lowest observed readmission risk. Risk increased as ILOS exceeded two days but was not significantly different by day. We found no association when comparing the difference in actual versus expected ILOS and readmission risk (shorter than expected OR: 1.13 [95% CI: 0.74-1.71]; longer than expected OR: 0.97 [95% CI: 0.69-1.38]). CONCLUSIONS: Attempts to prolong ILOS would dramatically increase costs with little impact on readmissions. For example, increasing one-day visits to two-day visits would increase hospital patient days 38% (1870 d) in this cohort while decreasing total readmissions by 3.8% [95% CI: 3.6-4.0%]. Understanding the mechanisms that impact readmissions is essential in evaluating cost-effective approaches to improving patient outcomes and lowering the cost of care.

Racial disparities in ordering laboratory and radiology tests for pediatric patients in the emergency department.

OBJECTIVE: The objective of this study was to examine the association of race and language on laboratory and radiological testing in the pediatric emergency department (ED). METHODS: This retrospective, case-cohort study examined laboratory and radiological testing among patients discharged home from 2 urban, pediatric EDs between March 2, 2009, and March 31, 2010. RESULTS: There were 75,254 visits among 49,164 unique patients, of whom 31.0% had laboratory and 30.5% had radiological testing. African American (adjusted odds ratio [aOR], 0.93; confidence interval [CI], 0.89-0.98; P = 0.004) and biracial racial categories (aOR, 0.91; CI, 0.86-0.98; P = 0.007) were associated with decreased odds of laboratory testing compared with non-Hispanic whites. Similarly, Native American (aOR, 0.82; CI, 0.73-0.94), African American (aOR0.81; CI, 0.72-0.81), biracial (aOR, 0.82; CI, 0.77-0.88), Hispanic (aOR.76; CI, 0.72-0.81), and "other" (aOR, 0.84; CI, 0.73-0.97) racial categories were each associated with lower odds of radiological testing compared with non-Hispanic whites. Subgroup analysis of visits with a final diagnosis of fever and upper respiratory tract infection, conditions for which there were few treatment protocols, confirmed the racial differences. Subgroup analysis in visits for head injury, for which there is an established evaluation protocol, did not find a lower odds of laboratory or radiological testing by race compared with non-Hispanic whites. CONCLUSIONS: Racial disparities in laboratory and radiological testing were present in pediatric ED visits. No racial differences were seen in the radiological and laboratory charges in the head injury subgroup, suggesting that evaluation algorithms can ameliorate racial disparities in pediatric ED care.

The complex association of race and leaving the pediatric emergency department without being seen by a physician.

OBJECTIVES: This study examined the influence of race and language on leaving the emergency department (ED) without complete evaluation and treatment (LWCET). METHODS: This retrospective, case-cohort study examined LWCET among patients discharged home from 2 EDs between March 2, 2009, and March 31, 2010. Race and language were obtained by family self-report. We also explored wait time to see a physician as an explanation of racial disparities. RESULTS: One thousand two hundred eighty-five (1.7%) of 76,931 ED encounters ended in LWCET. Factors increasing LWCET were high ED activity, low acuity, and medical assistance (MA) insurance. American Indian, biracial, African American, and Hispanic races were also associated with higher odds of LWCET among visits by MA insurance patients compared with those of white patients on private insurance. Restricting the analysis to visits by MA insurance patients, only American Indian race was associated with LWCET compared with white race. Visits by patients using an interpreter or speaking a language other than English at home had lower odds of ending in LWCET. Sensitivity analyses in subgroups confirmed these findings. We developed a measure of ED activity that correlated well with wait time to see a physician (correlation coefficient = 0.993; P < 0.001). Among non-LWCET visits, wait time to see a practitioner did not correlate with racial disparities in LWCET. CONCLUSIONS: Race, language, and insurance status interact to form a complex relationship with LWCET. Medical assistance insurance status appears to account for much of the excessive instances of LWCET seen in nonwhites. After restricting the analysis to MA insurance patients, only visits by American Indian patients had higher odds of LWCET compared with whites on MA insurance. Wait time to see a physician did not explain racial differences in LWCET.

Validated assessment tools for pediatric airway endoscopy simulation.

OBJECTIVE: To determine the interrater reliability and construct validity of 3 separate assessment tools for assessing trainee skills in pediatric airway endoscopy simulation. DESIGN: An Objective Structured Assessment of Technical Skills (OSATS) was developed in which examinees were asked to name and assemble the airway foreign body instruments and retrieve a foreign body from an infant airway mannequin. Each examinee's performance was assessed in a blinded fashion by 3 pediatric otolaryngology faculty at separate residency programs using 3 assessment tools: (1) objective quantifiable measures list (eg, assists needed, forceps openings, foreign body drops), (2) 15-point OSATS checklist, and (3) Global Rating Index for Technical Skills (GRITS). Setting Otolaryngology residency program. Subjects Examinees (medical students, n = 3; otolaryngology residents, n = 17; pediatric otolaryngology faculty, n = 3) and raters (n = 3). Main Outcome Measures Interrater reliability and construct validity. Results Anonymized split-screen videos simultaneously capturing each examinee's instrument handling and the endoscopic videos were created for all 23 examinees. Nineteen videos were chosen for review by 3 raters. The interrater reliability as measured by the intraclass correlation for objective quantifiable measures ranged from 0.46 to 0.98. The intraclass correlation coefficient was 0.95 for the 15-point OSATS checklist and 0.95 for the GRITS; both showed a high degree of construct validity with scores correlating with previous experience. Conclusion Assessment tools for skills assessments must have high interrater reliability and construct validity. When assessing trainee skills in pediatric airway foreign body scenarios, the 15-point OSATS checklist developed by this group or the GRITS meets these criteria.