Racial, ethnic disparities emerge in adherence to guidelines for infant fever
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Key takeaways:
- White infants were more likely to have inflammatory markers obtained.
- A lower proportion of Hispanic/Latino infants had documented follow-up recommendations when discharged from the ED.
Black and Hispanic/Latino infants who were brought to hospitals with a fever were less likely to have documented shared decision-making regarding lumbar puncture and ED discharge, a study found.
This disparity emerged after the AAP published guidance for managing fever in infants aged 8 to 60 days in 2021. The guidelines aimed to reduce unnecessary lumbar punctures, antibiotics and hospitalizations and promote shared decision-making with infants’ caregivers.
“Typically, research and quality improvement efforts are boxed into three categories in regard to their impact on equity: 1) no change, 2) widening disparities, 3) improving disparities,” Corrie McDaniel, DO, associate professor of pediatrics at the University of Washington School of Medicine, told Healio. “What we discovered in this work, though, is potentially the risk for a fourth category — creating disparities that were not there at baseline.”
McDaniel and colleagues recruited 103 hospitals to document their implementation of the new AAP guidelines from November 2021 to October 2022. Four Canadian hospitals were excluded due to their lack of race and ethnicity data.
The cross-sectional study published in Pediatrics included 16,961 infants who presented with a fever at participating hospitals.
The primary measures were appropriate use of lumbar puncture, ED disposition, antibiotic prescription and length of inpatient stay. Secondary measures included appropriate prescription of oral antibiotics for infants with positive urinalysis and documentation of shared decision-making with caregivers about lumbar puncture and ED discharge.
Before the guidelines were implemented, McDaniel noted that no patients had shared decision-making documented.
The largest proportion of infants in the study were white (42%), followed by Hispanic or Latino (26%), Black (10%) and other races or ethnicities (14%). Nine percent of infants had unknown race or ethnicity.
A greater proportion of white infants had inflammatory markers obtained (2%; 95% CI, 0.7-3.3) than the rest of the cohort, and a lower proportion of Hispanic/Latino infants had inflammatory markers obtained (–2.3%; 95% CI, –4 to –0.6).
The researchers did not find a difference in adherence to primary measures based on race or ethnicity.
Compared with the rest of the cohort, white infants were more likely to have documentation of ED follow-up recommendations (2.5%; 95% CI, 0.3-4.8), whereas a smaller proportion of Hispanic/Latino infants had documented follow-up advice (–3.6%; 95% CI, –6.4 to –0.8),
Hispanic/Latino infants were also less likely to have documented shared decision-making about lumbar puncture (–6.9%; 95% CI, –13.8 to –0.03), as were Black infants (–12.5%; 95% CI, –23.1 to –1.9).
“Recommendations by governing bodies need to consider equity when compiling evidence,” McDaniel said. “Shared decision-making is a fantastic example of this. It is an excellent ideal, yet the practical implementation is highly subjective. This makes it prone to bias.
“When making recommendations that are high risk for bias in implementation, even when strongly evidence based, it is important to acknowledge the risk of bias and provide additional resources.”
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