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.

Causal Mediation of Neighborhood-Level Pediatric Hospitalization Inequities.

BACKGROUND AND OBJECTIVES: Population-wide racial inequities in child health outcomes are well documented. Less is known about causal pathways linking inequities and social, economic, and environmental exposures. Here, we sought to estimate the total inequities in population-level hospitalization rates and determine how much is mediated by place-based exposures and community characteristics. METHODS: We employed a population-wide, neighborhood-level study that included youth <18 years hospitalized between July 1, 2016 and June 30, 2022. We defined a causal directed acyclic graph a priori to estimate the mediating pathways by which marginalized population composition causes census tract-level hospitalization rates. We used negative binomial regression models to estimate hospitalization rate inequities and how much of these inequities were mediated indirectly through place-based social, economic, and environmental exposures. RESULTS: We analyzed 50 719 hospitalizations experienced by 28 390 patients. We calculated census tract-level hospitalization rates per 1000 children, which ranged from 10.9 to 143.0 (median 45.1; interquartile range 34.5 to 60.1) across included tracts. For every 10% increase in the marginalized population, the tract-level hospitalization rate increased by 6.2% (95% confidence interval: 4.5 to 8.0). After adjustment for tract-level community material deprivation, crime risk, English usage, housing tenure, family composition, hospital access, greenspace, traffic-related air pollution, and housing conditions, no inequity remained (0.2%, 95% confidence interval: -2.2 to 2.7). Results differed when considering subsets of asthma, type 1 diabetes, sickle cell anemia, and psychiatric disorders. CONCLUSIONS: Our findings provide additional evidence supporting structural racism as a significant root cause of inequities in child health outcomes, including outcomes at the population level.

Racial Inequities in Palliative Referral for Children with High-Intensity Neurologic Impairment.

OBJECTIVE: To evaluate whether racial and socioeconomic inequities in pediatric palliative care utilization extend to children with high-intensity neurologic impairment (HI-NI), which is a chronic neurological diagnosis resulting in substantial functional morbidity and mortality. STUDY DESIGN: We conducted a retrospective study of patients with HI-NI who received primary care services at a tertiary care center from 2014 through 2019. HI-NI diagnoses that warranted a palliative care referral were identified by consensus of a multidisciplinary team. The outcome was referral to palliative care. The primary exposure was race, categorized as Black or non-Black to represent the impact of anti-Black racism. Additional exposures included ethnicity (Hispanic/non-Hispanic) and insurance status (Medicaid/non-Medicaid). Descriptive statistics, bivariate analyses, and multivariable logistic regression models were performed to assess associations between exposures and palliative care referral. RESULTS: A total of 801 patients with HI-NI were included; 7.5% received a palliative referral. There were no differences in gestational age, sex, or ethnicity between patients who received a referral and those who did not. In multivariable analysis, adjusting for ethnicity, sex, gestational age, and presence of complex chronic conditions, Black children (aOR 0.47, 95% CI 0.26, 0.84) and children with Medicaid insurance (aOR 0.40, 95% CI 0.23, 0.70) each had significantly lower odds of palliative referral compared with their non-Black and non-Medicaid-insured peers, respectively. CONCLUSIONS: We identified inequities in pediatric palliative care referral among children with HI-NI by race and insurance status. Future work is needed to develop interventions, with families, aimed at promoting more equitable, antiracist systems of palliative care.

Voter Participation is Associated with Child Health Outcomes at the Population Level.

Civic engagement, including voting, has been linked to health outcomes for adults. Here, we found that census tract-level voter participation rates are significantly associated with pediatric inpatient bed-day rates even after adjustment for socioeconomic deprivation. Such links suggest that promotion of voting participation could be warranted in healthcare settings.

Area-Level Socioeconomic Factors Are Associated With Noncompletion of Pediatric Preventive Services.

We examined 4872 infants born consecutively, 2011-2012, and seen at 3 primary care centers to determine whether area-based socioeconomic measures were associated with noncompletion of common preventive services within the first 15 months. Addresses were geocoded and linked to census tract poverty, adult educational attainment, and household vehicle ownership rates. The quartile of patients in the highest poverty (adjusted odds ratio [aOR] 1.25; 95% confidence interval [CI] 1.01-1.54) and lowest vehicle ownership tracts (aOR 1.32; 95% CI 1.07-1.63) had significantly increased odds of service noncompletion. There were significant spatial clusters of low completion in Cincinnati's urban core. These findings have implications for preventive service delivery.

Increased frequency of dietitian visits is associated with improved body mass index outcomes in obese youth participating in a comprehensive pediatric weight management program.

BACKGROUND: Comprehensive weight management (CWM) interventions are most effective for obese youth when they include multiple components, such as nutrition, physical activity, and behavioral strategies. However, effectiveness of different approaches to delivering the nutrition component is unknown. Our aim was to evaluate two dietary approaches and extent of registered dietitian (RD) involvement on outcomes of obese youth participating in a CWM program. METHODS: A retrospective review of CWM patients was conducted before and after redesign of the nutrition component. The earlier clinical model (CM1) introduced a portion-controlled diet at an RD visit after the initial medical visit, whereas the later clinical model (CM2) introduced a reduced glycemic load diet at the initial medical visit. CWM patients were included if they had at least one RD visit and an initial and 3- to 6-month medical follow-up visit during CM1 or CM2. Differences between CM1 and CM2 groups regarding changes in BMI and programmatic success (BMI change ≤0) were evaluated. RESULTS: Median BMI change during follow-up did not differ between CM1 (n=41) and CM2 (n=51) groups (p=0.41). In a multiple logistic regression model combining study groups, each additional RD visit was associated with a 28% increased odds of success (odds ratio [95% confidence interval]: 1.28 [1.00, 1.64]; p=0.05). The probability of success exceeded 78% with ≥1 RD visit/month versus 43% with minimal RD exposure. CONCLUSIONS: Increased frequency of RD visits is associated with improved BMI outcomes in obese youth participating in a CWM program regardless of dietary intervention implemented.