Department of Surgery, Indiana University School of Medicine, Indianapolis.
Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland.
JAMA Netw Open. 2023 Sep 5;6(9):e2332160. doi: 10.1001/jamanetworkopen.2023.32160.
Presentation to emergency departments (EDs) with high levels of pediatric readiness is associated with improved pediatric survival. However, it is unclear whether children of all races and ethnicities benefit equitably from increased levels of such readiness.
To evaluate the association of ED pediatric readiness with in-hospital mortality among children of different races and ethnicities with traumatic injuries or acute medical emergencies.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study of children requiring emergency care in 586 EDs across 11 states was conducted from January 1, 2012, through December 31, 2017. Eligible participants included children younger than 18 years who were hospitalized for an acute medical emergency or traumatic injury. Data analysis was conducted between November 2022 and April 2023.
Hospitalization for acute medical emergency or traumatic injury.
The primary outcome was in-hospital mortality. ED pediatric readiness was measured through the weighted Pediatric Readiness Score (wPRS) from the 2013 National Pediatric Readiness Project assessment and categorized by quartile. Multivariable, hierarchical, mixed-effects logistic regression was used to evaluate the association of race and ethnicity with in-hospital mortality.
The cohort included 633 536 children (median [IQR] age 4 [0-12] years]). There were 557 537 children (98 504 Black [17.7%], 167 838 Hispanic [30.1%], 311 157 White [55.8%], and 147 876 children of other races or ethnicities [26.5%]) who were hospitalized for acute medical emergencies, of whom 5158 (0.9%) died; 75 999 children (12 727 Black [16.7%], 21 604 Hispanic [28.4%], 44 203 White [58.2%]; and 21 609 of other races and ethnicities [27.7%]) were hospitalized for traumatic injuries, of whom 1339 (1.8%) died. Adjusted mortality of Black children with acute medical emergencies was significantly greater than that of Hispanic children, White children, and of children of other races and ethnicities (odds ratio [OR], 1.69; 95% CI, 1.59-1.79) across all quartile levels of ED pediatric readiness; but there were no racial or ethnic disparities in mortality when comparing Black children with traumatic injuries with Hispanic children, White children, and children of other races and ethnicities with traumatic injuries (OR 1.01; 95% CI, 0.89-1.15). When compared with hospitals in the lowest quartile of ED pediatric readiness, children who were treated at hospitals in the highest quartile had significantly lower mortality in both the acute medical emergency cohort (OR 0.24; 95% CI, 0.16-0.36) and traumatic injury cohort (OR, 0.39; 95% CI, 0.25-0.61). The greatest survival advantage associated with high pediatric readiness was experienced for Black children in the acute medical emergency cohort.
In this study, racial and ethnic disparities in mortality existed among children treated for acute medical emergencies but not traumatic injuries. Increased ED pediatric readiness was associated with reduced disparities; it was estimated that increasing the ED pediatric readiness levels of hospitals in the 3 lowest quartiles would result in an estimated 3-fold reduction in disparity for pediatric mortality. However, increased pediatric readiness did not eliminate disparities, indicating that organizations and initiatives dedicated to increasing ED pediatric readiness should consider formal integration of health equity into efforts to improve pediatric emergency care.
重要性：在儿科准备水平较高的急诊科就诊与儿科生存率的提高有关。然而，尚不清楚所有种族和族裔的儿童是否都能平等地从这种准备水平的提高中受益。
目的：评估急诊科儿科准备水平与创伤或急性医疗紧急情况下不同种族和族裔儿童院内死亡率之间的关联。
设计、地点和参与者：这项在 11 个州的 586 个急诊科进行的儿童急诊护理队列研究于 2012 年 1 月 1 日至 2017 年 12 月 31 日进行。符合条件的参与者包括因急性医疗紧急情况或创伤而住院的 18 岁以下儿童。数据分析于 2022 年 11 月至 2023 年 4 月进行。
暴露因素：因急性医疗紧急情况或创伤而住院。
主要结果和措施：主要结局是院内死亡率。通过 2013 年国家儿科准备项目评估的加权儿科准备评分（wPRS）衡量急诊科儿科准备水平，并按四分位数进行分类。采用多变量、分层、混合效应逻辑回归评估种族和族裔与院内死亡率的关系。
结果：队列包括 633536 名儿童（中位数[IQR]年龄为 4[0-12]岁]）。有 557537 名儿童（98504 名黑人[17.7%]、167838 名西班牙裔[30.1%]、311157 名白人[55.8%]和 147876 名其他种族或族裔[26.5%]）因急性医疗紧急情况住院，其中 5158 人（0.9%）死亡；75999 名儿童（12727 名黑人[16.7%]、21604 名西班牙裔[28.4%]、44203 名白人[58.2%]和 21609 名其他种族和族裔[27.7%]）因创伤住院，其中 1339 人（1.8%）死亡。患有急性医疗紧急情况的黑人儿童的调整死亡率明显高于西班牙裔、白人儿童和其他种族和族裔的儿童（比值比[OR]，1.69；95%CI，1.59-1.79），跨越所有四分位的急诊科儿科准备水平；但在比较患有创伤的黑人儿童与患有创伤的西班牙裔、白人和其他种族和族裔的儿童时，死亡率没有种族或族裔差异（OR，1.01；95%CI，0.89-1.15）。与急诊科儿科准备水平最低的四分位数的医院相比，在最高四分位数的医院接受治疗的儿童在急性医疗紧急情况队列（OR，0.24；95%CI，0.16-0.36）和创伤损伤队列（OR，0.39；95%CI，0.25-0.61）中的死亡率显著降低。与高儿科准备水平相关的最大生存优势是急性医疗紧急情况下的黑人儿童。
结论和相关性：在这项研究中，在治疗急性医疗紧急情况的儿童中存在与死亡率相关的种族和族裔差异，但在治疗创伤的儿童中则没有。增加急诊科儿科准备水平与减少差异有关；据估计，将 3 个最低四分位数的医院急诊科儿科准备水平提高将导致儿科死亡率的差异减少约 3 倍。然而，增加儿科准备水平并没有消除差异，这表明致力于提高急诊科儿科准备水平的组织和倡议应考虑将健康公平正式纳入改善儿科急诊护理的努力中。
