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Inequities in the Application of Behavioral Flags for Hospitalized Pediatric Patients
April Edwell1, Jia Xin Huang1, Tasce Bongiovanni2
1Department of Pediatrics, University of California, San Francisco.
Insights
Black and African American children are more likely to receive behavioral flags in their electronic health records (EHR). This study highlights inequities in pediatric healthcare, particularly for young Black children, suggesting bias in flag assignment.
Area of Science:
- Health Equity
- Pediatric Health
- Health Informatics
Background:
- Behavioral flags in electronic health records (EHRs) can perpetuate structural racism and discrimination.
- Understanding inequities in how behavioral risk markers are communicated is crucial for improving pediatric patient and family experiences in hospitals.
Purpose of the Study:
- To investigate whether racially and socioeconomically marginalized pediatric patients are disproportionately assigned behavioral flags in their EHRs.
- To identify specific patient demographics associated with higher rates of behavioral flag placement.
Main Methods:
- Retrospective cohort study utilizing EHR data from pediatric patients (<18 years) hospitalized between June 2012 and July 2021 at UCSF health care facilities.
- Analysis included over 55,000 pediatric encounters, examining primary outcomes of behavioral flags (e.g., witnessed substance abuse, security, CPS hold).
- Key variables analyzed included patient race, ethnicity, insurance status, and primary language.
Main Results:
- Approximately 0.4% (236 of 55,865) of pediatric encounters had behavioral flags.
- Encounters among Black or African American patients were more likely to receive a behavioral flag compared to White patients (IRR, 2.07).
- Patients with government insurance had higher flag incidence than those with private insurance (IRR, 2.60). Black or African American children under 8 years old showed a significantly higher likelihood of flag placement.
Conclusions:
- The study reveals significant inequities in the incidence of behavioral flags within EHRs for racially and socioeconomically marginalized pediatric patients.
- The heightened likelihood of flag placement among young Black or African American children suggests potential bias related to family race rather than individual patient behavior.
Importance:
Behavioral flags in the electronic health record (EHR) may introduce bias and perpetuate structural racism and discrimination. Descriptions of differences in the way that markers of behavioral risk are communicated will help clarify the inequities that pediatric patients and their families experience in the hospital.
Objective:
To assess whether racially and socioeconomically marginalized pediatric patients and families are more likely than their counterparts to be assigned a behavioral flag in their EHR.
Design, Setting, And Participants:
This retrospective cohort study used EHR data for pediatric patients (aged <18 years) hospitalized from June 2012 to July 2021 across care settings at the University of California, San Francisco health care facilities, an academic quaternary care hospital system that includes 2 pediatric inpatient facilities. The analysis was completed from December 29, 2022, to November 22, 2024.
Main Outcome And Measures:
The primary outcome of interest was any of the following behavioral flags placed in a patient's EHR: witnessed substance abuse, history of inappropriate behavior, security, violent behavior, dismissal from practice, and child protective services (CPS) hold. The primary variables were patients' race, ethnicity, insurance status, and primary language.
Results:
Of 55 865 pediatric encounters (52.2% among males; median patient age at the first encounter, 3 years [IQR, 0-12 years]), 236 (0.4%) had behavioral flags. Compared with encounters among patients who identified as White, encounters among patients who identified as Black or African American were more likely to have a behavioral flag (incidence rate ratio [IRR], 2.07; 95% CI, 1.32-3.25). Behavioral flags were also more likely among encounters of individuals with government insurance compared with those with private insurance (IRR, 2.60; 95% CI, 1.85-3.65). Black or African American patients younger than 1 year (IRR, 3.53; 95% CI, 1.80-6.91) and aged 1 to 7 years (IRR, 2.87; 95% CI, 1.34-6.15) had a higher likelihood of flag placement compared with their White counterparts.
Conclusions And Relevance:
This cohort study found significant inequities in incidence of behavioral flags in the EHR among racially and socioeconomically marginalized pediatric patients. This finding was most pronounced for Black or African American patients younger than 8 years, suggesting that this phenomenon may be a response to Black families rather than specific patient behavior.
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