Effect of Institutional Guidelines on Equitable Management of Pediatric Osteomyelitis

Acute hematogenous osteomyelitis (AHO) in children requires timely diagnosis and multidisciplinary management to optimize outcomes. Clinical practice guidelines aim to standardize care and reduce variation; however, their impact on health equity is not well understood. We evaluated whether implementation of institutional AHO guidelines improved care delivery and reduced disparities in sociodemographic groups.

We conducted a retrospective cohort study of children aged 90 days to 18 years hospitalized with AHO at a tertiary care children's hospital. Patients were stratified into pre- (September 1, 2014-July 31, 2017) and post-guideline implementation (November 1, 2017-December 31, 2023) periods. Care processes included blood culture acquisition, laboratory testing, imaging use and timing, bone biopsy, administration of any antibiotics, administration of appropriate empiric antibiotics, number of inpatient Pediatric Infectious Diseases (PID) consult visits, and Pediatric Orthopedic Surgery involvement. Outcomes were compared across demographic variables including race, ethnicity, preferred language, sex, age, and Area Deprivation Index (ADI).

131 patients were included (35 pre-implementation, 96 post-implementation). Baseline characteristics were similar between groups. Following guideline implementation, rate of appropriate empiric antibiotic administration increased (79.1% vs. 37.1%, p<0.001) and median number of inpatient PID consult visits increased (3 vs. 2, p=0.039). Across the full cohort, patients from higher-deprivation neighborhoods were less likely to have blood cultures obtained (70.8% high ADI vs. 94.5% low ADI, p=0.008). Black children had fewer PID consult visits (median 1 vs. 3 in other race groups, p<0.001) as did children from high-ADI neighborhoods (median 2 vs. 3 in other ADI groups, p=0.001). These disparities persisted in the post-implementation period.

Implementation of an institutional AHO guideline increased appropriate empiric antibiotic use and PID subspecialty involvement but did not eliminate disparities in care delivery. Persistent differences by race and socioeconomic status highlight the need for equity-focused implementation strategies to ensure consistent, high-quality care for all children.