Impact of patient race/ethnicity on emergency department management of pediatric gastroenteritis in the setting of a clinical pathway
Impact of patient race/ethnicity on emergency department management of pediatric gastroenteritis in the setting of a clinical pathway
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DOI：
10.1111/acem.14255
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发表时间：
2021-04-13
影响因子：
4.4
通讯作者：
Johnson, Tiffani J.
中科院分区：
文献类型：
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作者：
Congdon, Morgan;Schnell, Stephanie A.;Johnson, Tiffani J.
背景急性胃肠炎(AGE)是急诊中常见的儿科疾病，每年就诊170万人次。我们对标准化护理模式设置中的种族/民族护理差异知之甚少。方法我们使用2011年至2018年期间6个月至18岁儿童的质量改善数据，向通过临床路径治疗的大型城市儿科急诊室(ED)年龄/脱水进行治疗。种族/民族被评估为单一变量(非西班牙裔[NH]-白人、NH-黑人、西班牙裔和NH-其他)，与恩丹西酮和静脉输液(IVF)给药、ED住院时间(LOS)、住院和ED复诊有关。结果30849例因年龄/脱水而就诊的ED患者中，NH-白人18.0%，NH-Black 57.2%，西班牙裔12.5%，NH-其他12.3%。控制年龄、性别、分诊敏感度、支付方式和语言的多变量混合效应广义线性回归显示，与NH-White患者相比，NH-其他患者更有可能接受昂丹西酮治疗(调整后的优势比[95%CI]=1.30[1.17至1.43])。NH黑人、西班牙裔和NH-其他患者接受试管受精的可能性显著降低(0.59[0.53至0.65]；0.74[0.64至0.84]；0.74[0.65至0.85])或住院(0.54[0.45至0.64]；0.62[0.49至0.78]；0.76[0.61至0.94])。NH-Black和西班牙裔患者的LOS较短(NH-White为245分钟，NH-Black为176例，西班牙裔199例，NH-Other为203例)，无显著差异。结论尽管存在指导治疗的临床路径，NH-Black、西班牙裔和NH-其他年龄/脱水到ED的儿童接受试管受精或住院的可能性较小，与NH-White患者相比，LOS较短。在患者复诊方面没有差异，这表明即使在临床指南到位的情况下，NH-White患者也可以随意过度治疗。需要进一步的研究来了解护理差异的驱动因素，以制定促进儿科急救护理公平的干预措施。
Background Acute gastroenteritis (AGE) is a common pediatric diagnosis in emergency medicine, accounting for 1.7 million visits annually. Little is known about racial/ethnic differences in care in the setting of standardized care models.Methods We used quality improvement data for children 6 months to 18 years presenting to a large, urban pediatric emergency department (ED) treated via a clinical pathway for AGE/dehydration between 2011 and 2018. Race/ethnicity was evaluated as a single variable (non-Hispanic [NH]-White, NH-Black, Hispanic, and NH-other) related to ondansetron and intravenous fluid (IVF) administration, ED length of stay (LOS), hospital admission, and ED revisits using multivariable regression.Results Of 30,849 ED visits for AGE/dehydration, 18.0% were NH-White, 57.2% NH-Black, 12.5% Hispanic, and 12.3% NH-other. Multivariable mixed-effects generalized linear regression controlling for age, sex, triage acuity, payer, and language revealed that, compared to NH-White patients, NH-other patients were more likely to receive ondansetron (adjusted odds ratio [95% CI] = 1.30 [1.17 to 1.43]). NH-Black, Hispanic, and NH-other patients were significantly less likely to receive IVF (0.59 [0.53 to 0.65]; 0.74 [0.64 to 0.84]; 0.74 [0.65 to 0.85]) or be admitted to the hospital (0.54 [0.45 to 0.64]; 0.62 [0.49 to 0.78]; 0.76 [0.61 to 0.94]), respectively. NH-Black and Hispanic patients had shorter LOS (median = 245 minutes for NH-White, 176 NH-Black, 199 Hispanic, and 203 NH-other patients) without significant differences in ED revisits.Conclusions Despite the presence of a clinical pathway to guide care, NH-Black, Hispanic, and NH-other children presenting to the ED with AGE/dehydration were less likely to receive IVF or hospital admission and had shorter LOS compared to NH-White counterparts. There was no difference in patient revisits, which suggests discretionary overtreatment of NH-White patients, even with clinical guidelines in place. Further research is needed to understand the drivers of differences in care to develop interventions promoting equity in pediatric emergency care.