Standardizing Clinical Care to Reduce Disparities

In this issue of Pediatrics, Atigapramoj et al investigated the impact of race, ethnicity, and socioeconomic status (SES) on computed tomography (CT) use for children who experienced blunt abdominal or minor head trauma.1 This study was a planned secondary analysis of a multicenter prospective validation study for the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for blunt abdominal or minor head trauma.2 Their analysis focused on the effects of standardization of clinical decision-making on known disparities in imaging practices in this patient population.3,4 Standardization of clinical decision-making has been an effective method to reduce disparities in other pediatric contexts such as in nonaccidental trauma evaluation in the emergency department5 and in postoperative opioid prescribing practices in infants undergoing abdominal surgery.6 In addition, standardizing pediatric readiness has reduced child mortality.7 Expanding clinical standardization furthers the mission to improve equitable outcomes for all children.Atigapramoj et al found no differences in the use of abdominal CT scans based on race, ethnicity, or SES. Similarly, head CT use did not vary by race, ethnicity, or SES, except that Hispanic children aged younger than 2 years were less likely to receive a head CT for head trauma compared with the primarily non-Hispanic white children in the reference group. Because this study used the same patients as the parent validation study, the authors were able to ensure that all included patients had been exposed to the PECARN clinical prediction rules, which strengthens the study findings. Another strength of their methodology is that the authors used clinician perception to define participants’ race and ethnicity in their analyses, which captures perceptions that can lead to inequitable health care delivery.8 The authors also controlled for SES in their logistic regression model to assess the independent association between clinician-perceived race and ethnicity with the likelihood of obtaining CT imaging. This is important, since race and ethnicity and social determinants of health are closely linked due to structural racism but are not interchangeable. Distinguishing between these factors is essential, as they contribute to disparities via different mechanisms, and interventions need to be tailored accordingly.8,9As the authors state, these “results suggest that the adoption of evidence-based decision support tools can help mitigate health care disparities in injured children as well as race- and ethnicity-based disparities in patients with other health conditions.”1 We agree that this study adds to the growing body of literature supporting the use of standardization to close equity gaps. It is important to note, however, that this study demonstrated that the PECARN clinical prediction tools reduced disparities when universally applied to the study population. It is not known whether these clinical prediction tools would have a similar impact when application is not guaranteed. To address this uncertainty, the next steps following development, validation, and publication of evidence-based prediction tools such as this one are dissemination and implementation. Clinical tools cannot reduce disparities unless they are being used at the bedside for every patient for whom they are applicable. PECARN has taken deliberate steps to ensure the dissemination of tools like these, and we urge other researchers and organizations to devote similar time and resources to disseminating validated clinical prediction tools.10 The field of implementation science has also enhanced the uptake of evidence-based tools,11 and both local quality-improvement (QI) projects and broader implementation efforts may ensure that tools like those described by Atigapramoj et al are available to clinicians in diverse practice settings.12–14Promoting the use of clinical decision support via QI and other implementation efforts is not guaranteed to reduce disparities, however. Without equity-focused measures, the implementation of clinical tools and guidelines has the potential to create or worsen disparities in patient outcomes. For example, after the 2017 American Academy of Pediatrics (AAP) published guidelines on pediatric blood pressure screening, a retrospective study in a large health system found that despite an 89% adherence rate, children with public insurance, children in clinics with higher Medicaid populations, and children with obesity had lower odds of having guideline-adherent blood pressure screenings.15 On a larger scale, a national QI project to implement the 2021 AAP Clinical Practice Guidelines on febrile infants noted racial disparities in guideline adherence for non-Hispanic Black and Hispanic/Latino patients and an increased rate of return emergency department visits for Hispanic/Latino patients after the guidelines were implemented.16 Equity-focused design and implementation are absolutely imperative to ensure that the implementation of standardized clinical guidelines does not worsen disparities,17,18 and we encourage organizations implementing these decision support tools to engage in ongoing audit and feedback to ensure they are being applied appropriately and equitably.Front-line clinicians also have an important role in the reduction of health disparities, through thoughtful adoption and application of evidence-based clinical tools and guidelines. Validated tools that standardize evaluation may target implicit biases, which may not be readily apparent to each of us, and avoid unnecessary practice variations. However, clinicians should remain thoughtful about the components of the tools themselves and how they apply them. For example, one of the components of the blunt abdominal trauma clinical prediction rule is the presence of a seatbelt sign. This measure may be inherently biasing, as a seatbelt sign can be harder to detect on darker skin.19 Despite this, Atigapramoj et al found no difference in abdominal CT use by race and ethnicity in this study. We encourage clinicians to be aware of the potential for missing a seatbelt sign on children with darker skin. Overall, clinicians should feel empowered to thoughtfully incorporate the use of evidence-based clinical support tools and guidelines into their practice.The PECARN blunt abdominal and minor head trauma clinical prediction tools have not only been validated2 but also have the potential to reduce health disparities in exposure to radiating imaging. These tools, when implemented and applied thoughtfully and with a focus on equity, can help to improve the health and well-being of all children.