Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity.
Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity.
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DOI：
10.1001/jamanetworkopen.2023.32160
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发表时间：
2023-09-05
影响因子：
13.8
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中科院分区：
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本队列研究调查了急诊科（艾德）儿科准备情况和不同种族和民族儿童死亡率的差异。提高急诊科（艾德）儿科准备程度是否与所有种族和民族儿童死亡率的公平降低相关？在这项队列研究中，633536名儿童在11个州的586个急诊室接受治疗，在所有四分位数的准备水平上，黑人儿童的死亡率高于白色儿童，这些儿童患有急性医疗紧急情况，但没有创伤性损伤。准备程度的提高与整体死亡率的下降有关，而在患有急性医疗紧急情况的黑人儿童中，死亡率下降最多。这些研究结果表明，增加艾德儿科准备可能会减少，但不能消除急性医疗紧急情况的儿童之间的差距，这表明致力于增加艾德儿科准备的组织和倡议应考虑正式整合健康公平的努力，以改善儿科急诊护理。急诊科（ED）的儿科准备程度高与提高儿科生存率相关。然而，尚不清楚所有种族和族裔的儿童是否都能平等地受益于这种准备程度的提高。评估不同种族和民族创伤性损伤或急性医疗紧急情况儿童的艾德儿科准备状态与住院死亡率之间的关系。这项对11个州586名急诊科需要紧急护理的儿童进行的队列研究于2012年1月1日至2017年12月31日进行。合格的参与者包括因急性医疗紧急情况或创伤性损伤住院的18岁以下儿童。数据分析于二零二二年十一月至二零二三年四月期间进行。因急性医疗紧急情况或创伤性损伤住院。主要结局为住院死亡率。通过2013年国家儿科准备项目评估的加权儿科准备评分（wPRS）测量艾德儿科准备情况，并按四分位数分类。采用多变量、分层、混合效应logistic回归分析评价种族和民族与住院死亡率的关系。该队列包括633536名儿童（中位[IQR]年龄4 [0-12]岁）。有557 537名儿童（98 504名黑人[17.7%]、167 838名西班牙裔[30.1%]、311 157名白色[55.8%]和147 876名其他种族或族裔儿童[26.5%]）因急性医疗紧急情况住院，其中5158名（0.9%）死亡; 75999名儿童（12727名黑人[16.7%]，21604名西班牙裔[28.4%]，44203名白色[58.2%]; 21609名其他种族和民族[27.7%]）因创伤住院，其中1339名（1.8%）死亡。黑人儿童急性医疗紧急情况的校正死亡率明显高于西班牙裔儿童、白色儿童和其他种族和民族的儿童（比值比[OR]，1.69; 95% CI，1.59-1.79）在所有四分位数水平的艾德儿科准备状态中;但是，当将患有创伤性损伤的黑人儿童与西班牙裔儿童、白色儿童其他种族和民族的儿童创伤性损伤（OR 1.01; 95% CI，0.89-1.15）。与儿科艾德准备程度最低的四分位数医院相比，在最高四分位数医院接受治疗的儿童在急性医疗紧急队列（OR 0.24; 95%CI，0.16-0.36）和创伤性损伤队列（OR，0.39; 95%CI，0.25-0.61）中的死亡率显著降低。在急性医疗急救队列中，黑人儿童经历了与儿科高度准备相关的最大生存优势。在这项研究中，因急性医疗紧急情况而不是创伤性损伤而接受治疗的儿童的死亡率存在种族和民族差异。增加艾德儿科准备与减少差异相关;据估计，在3个最低四分位数中增加医院的艾德儿科准备水平将导致儿科死亡率差异减少3倍。然而，增加儿科准备并没有消除差距，这表明致力于增加艾德儿科准备的组织和倡议应考虑将健康公平正式纳入改善儿科急诊护理的努力中。
This cohort study examines emergency department (ED) pediatric readiness and differences in mortality among children of different races and ethnicities. Is increased emergency department (ED) pediatric readiness associated with an equitable decrease in the mortality of children of all races and ethnicities? In this cohort study of 633 536 children treated in 586 EDs across 11 states, mortality of Black children was greater than that of White children at all quartile levels of readiness among those with acute medical emergencies but not traumatic injuries. Increased readiness was associated with decreased mortality overall, and it decreased most for Black children with acute medical emergencies. These findings suggest that increased ED pediatric readiness may reduce but not eliminate disparities among children with acute medical emergencies, indicating that organizations and initiatives dedicated to increasing ED pediatric readiness should consider formal integration of health equity into efforts to improve pediatric emergency care. Presentation to emergency departments (EDs) with high levels of pediatric readiness is associated with improved pediatric survival. However, it is unclear whether children of all races and ethnicities benefit equitably from increased levels of such readiness. To evaluate the association of ED pediatric readiness with in-hospital mortality among children of different races and ethnicities with traumatic injuries or acute medical emergencies. This cohort study of children requiring emergency care in 586 EDs across 11 states was conducted from January 1, 2012, through December 31, 2017. Eligible participants included children younger than 18 years who were hospitalized for an acute medical emergency or traumatic injury. Data analysis was conducted between November 2022 and April 2023. Hospitalization for acute medical emergency or traumatic injury. The primary outcome was in-hospital mortality. ED pediatric readiness was measured through the weighted Pediatric Readiness Score (wPRS) from the 2013 National Pediatric Readiness Project assessment and categorized by quartile. Multivariable, hierarchical, mixed-effects logistic regression was used to evaluate the association of race and ethnicity with in-hospital mortality. The cohort included 633 536 children (median [IQR] age 4 [0-12] years]). There were 557 537 children (98 504 Black [17.7%], 167 838 Hispanic [30.1%], 311 157 White [55.8%], and 147 876 children of other races or ethnicities [26.5%]) who were hospitalized for acute medical emergencies, of whom 5158 (0.9%) died; 75 999 children (12 727 Black [16.7%], 21 604 Hispanic [28.4%], 44 203 White [58.2%]; and 21 609 of other races and ethnicities [27.7%]) were hospitalized for traumatic injuries, of whom 1339 (1.8%) died. Adjusted mortality of Black children with acute medical emergencies was significantly greater than that of Hispanic children, White children, and of children of other races and ethnicities (odds ratio [OR], 1.69; 95% CI, 1.59-1.79) across all quartile levels of ED pediatric readiness; but there were no racial or ethnic disparities in mortality when comparing Black children with traumatic injuries with Hispanic children, White children, and children of other races and ethnicities with traumatic injuries (OR 1.01; 95% CI, 0.89-1.15). When compared with hospitals in the lowest quartile of ED pediatric readiness, children who were treated at hospitals in the highest quartile had significantly lower mortality in both the acute medical emergency cohort (OR 0.24; 95% CI, 0.16-0.36) and traumatic injury cohort (OR, 0.39; 95% CI, 0.25-0.61). The greatest survival advantage associated with high pediatric readiness was experienced for Black children in the acute medical emergency cohort. In this study, racial and ethnic disparities in mortality existed among children treated for acute medical emergencies but not traumatic injuries. Increased ED pediatric readiness was associated with reduced disparities; it was estimated that increasing the ED pediatric readiness levels of hospitals in the 3 lowest quartiles would result in an estimated 3-fold reduction in disparity for pediatric mortality. However, increased pediatric readiness did not eliminate disparities, indicating that organizations and initiatives dedicated to increasing ED pediatric readiness should consider formal integration of health equity into efforts to improve pediatric emergency care.