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Disparities in Guideline Adherence for Febrile Infants in a National Quality Improvement Project
Corrie E McDaniel1, Larissa L Truschel2, Ellen Kerns3
1Division of Hospital Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington.
Insights
Quality improvement interventions to standardize care for febrile infants revealed emerging racial and ethnic disparities in adherence to clinical guidelines. These findings highlight the need for equity-focused approaches in healthcare quality initiatives.
Area of Science:
- Pediatric healthcare quality improvement
- Health equity research
- Clinical guideline implementation
Background:
- Standardizing medical care can inadvertently affect racial and ethnic disparities.
- The American Academy of Pediatrics' clinical practice guideline for febrile infants was the focus of a quality improvement (QI) intervention.
- This study evaluated if race and ethnicity influenced adherence to these guidelines post-QI intervention.
Purpose of the Study:
- To assess the association between infant race/ethnicity and adherence to pediatric febrile infant care recommendations.
- To determine if a quality improvement intervention altered guideline adherence across different racial and ethnic groups.
- To identify potential disparities in healthcare quality metrics following a standardized care initiative.
Main Methods:
- A cross-sectional study design was employed, analyzing data from 99 hospitals.
- Infants aged 8 to 60 days were included, with data collected during baseline and intervention periods (November 2020-October 2022).
- Guideline concordance was measured by adherence to project metrics, comparing proportions across racial and ethnic groups.
Main Results:
- No baseline differences in primary measures were observed across racial and ethnic groups.
- During the intervention, non-Hispanic white infants showed higher adherence for inflammatory markers and emergency department follow-up documentation.
- Non-Hispanic Black and Hispanic/Latino infants had lower adherence for shared decision-making regarding cerebrospinal fluid, and Hispanic/Latino infants also showed lower adherence for inflammatory markers and ED follow-up.
Conclusions:
- A quality improvement intervention aimed at standardizing care led to the emergence of racial and ethnic disparities in quality metrics.
- Future implementation of clinical guidelines must incorporate equity-focused quality improvement strategies.
- Ensuring equitable delivery of evidence-based care requires proactive measures to address disparities.
Background:
Interventions aimed to standardize care may impact racial and ethnic disparities. We evaluated the association of race and ethnicity with adherence to recommendations from the American Academy of Pediatrics' clinical practice guideline for febrile infants after a quality improvement (QI) intervention.
Methods:
We conducted a cross-sectional study of infants aged 8 to 60 days enrolled in a QI collaborative of 99 hospitals. Data were collected across 2 periods: baseline (November 2020-October 2021) and intervention (November 2021-October 2022). We assessed guideline-concordance through adherence to project measures by infant race and ethnicity using proportion differences compared with the overall proportion.
Results:
Our study included 16 961 infants. At baseline, there were no differences in primary measures. During the intervention period, a higher proportion of non-Hispanic white infants had appropriate inflammatory markers obtained (2% difference in proportions [95% confidence interval (CI) 0.7 to 3.3]) and documentation of follow-up from the emergency department (2.5%, 95% CI 0.3 to 4.8). A lower proportion of non-Hispanic Black infants (-12.5%, 95% CI -23.1 to -1.9) and Hispanic/Latino infants (-6.9%, 95% CI -13.8 to -0.03) had documented shared decision-making for obtaining cerebrospinal fluid. A lower proportion of Hispanic/Latino infants had appropriate inflammatory markers obtained (-2.3%, 95% CI -4.0 to -0.6) and appropriate follow-up from the emergency department (-3.6%, 95% CI -6.4 to -0.8).
Conclusions:
After an intervention designed to standardize care, disparities in quality metrics emerged. Future guideline implementation should integrate best practices for equity-focused QI to ensure equitable delivery of evidence-based care.
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