Racial Inequities in Pediatric Emergency Care

In JAMA Network Open, Marin et al¹ used 4 years of data from the Pediatric Health Information System to assess the association between pediatric emergency department visits and use of diagnostic imaging studies stratified by race/ethnicity. The analyses included more than 13 million visits among 6 million patients younger than 18 years who presented for emergency care at 44 children’s hospitals across the US between 2016 and 2019. This large population was racially/ethnically diverse; 25.5% were non-Hispanic Black individuals, 28.4% were Hispanic individuals, 34.4% were non-Hispanic White individuals, and 11.7% of individuals were classified as other race/ethnicity. The authors reported that, after adjusting for relevant covariates, non-Hispanic Black and Hispanic patients had lower odds of undergoing radiography, ultrasonography, computed tomography, or magnetic resonance imaging compared with non-Hispanic White patients (adjusted odds ratio for any imaging: non-Hispanic Black individuals, 0.82 [95% CI, 0.82-0.83]; Hispanic individuals, 0.87 [95% CI, 0.87-0.87]). Disparities in the use of imaging were more pronounced when limiting analyses to patients discharged home (adjusted odds ratio: non-Hispanic Black vs White individuals, 0.79 [95% CI, 0.79-0.80]; Hispanic vs non-Hispanic White individuals, 0.84 [95% CI, 0.84-0.85]).

The findings presented by Marin et al¹ are important, yet they should not come as a surprise as they are consistent with decades of previous research documenting inequalities in health care delivery based on race/ethnicity.^2,3 Hospitals across the US do not provide equal care to patients who present for an emergent evaluation; children of color, similar to their parents and grandparents, receive care that is different from what is provided to their non-Hispanic White peers. Differences in health care delivery by race/ethnicity, as described by Marin et al,¹ must be examined in the context of inequities within the social framework of a community.³ The driving force behind disparities in health care delivery is multifactorial. Marin et al¹ identified several plausible factors associated with variation in diagnostic imaging, including parenteral preferences, provider bias, structural factors, language barriers, and perceived risk tolerance.¹ However, as described by Hardeman et al⁴ in 2016, to substantially address disparities, we need to “center at the margins”; future research must focus on the experiences and barriers faced by marginalized individuals.

The existing literature has presented ample evidence that disparities exist regarding care for Black, Hispanic, and Native American patients. Physicians, researchers, and health care leaders must partner with the communities they serve to develop and implement interventions to address these substantial inequities in care. Unfortunately, there have been few evidence-based interventions specifically evaluated in this context.⁵ However, I will highlight 3 approaches that begin to address the root causes for inequities in care and structural racism. Foremost among these is a need for medical professionals to recognize that we all carry biases. Implicit bias refers to beliefs or attitudes that are subconscious but impact how we deliver care.⁵ Several studies have shown that implicit bias and antiracism training can help clinicians develop empathy and understand patients and families of different cultures.^5,6 Second, health systems must address the structural racism that exists within hospitals or health systems and impacts the communities they serve.⁴ One example of a successful health system intervention comes from Kaiser Permanente, where clinicians and leaders have partnered with community-based organizations to deliver community-centered care. Kaiser has demonstrated improvement in several markers of health among Black and Hispanic members and has credited partnerships that provide nonclinical support, such as job-placement services, as key to their success.⁷ Third, as described in the 2019 American Academy of Pediatrics Policy Statement on the Impact of Racism and Children and Adolescent Health,² health care systems should prioritize employing a workforce that is diverse and reflects the populations served. Partnering with medical and nursing schools with a diverse student population as well as recruiting a diverse medical leadership team may help improve the climate and culture of an organization.

As the US grapples with a pandemic that has disproportionately affected Black, Hispanic, and Native American communities and highlighted persistent health disparities, there is an urgent need to promote equity in health care delivery. In a 1966 speech, the late Dr Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”⁸ We need to hear and believe these words and then work in partnership with the communities we serve to address structural racism in health care.

Published: January 29, 2021. doi:10.1001/jamanetworkopen.2020.34019

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kharbanda AB. JAMA Network Open.

Corresponding Author: Anupam B. Kharbanda, MD, MSc, Department of Pediatric Emergency Medicine, Children’s Minnesota, 2545 Chicago Ave S, Minneapolis, MN 55404 (Anupam.Kharbanda@childrensmn.org).

Conflict of Interest Disclosures: None reported.