Disparities and implicit bias in the management of low-risk febrile infants: a mixed methods study protocol

Abstract

IntroductionThe management of low-risk febrile infants presents a model population for exploring how implicit racial bias promotes inequitable emergency care for children who belong to racial, ethnic and language minority groups. Although widely used clinical standards guide the clinical care of febrile infants, there remains substantial variability in management strategies. Deviations from recommended care may be informed by the physician’s assessment of the family’s values, risk tolerance and access to supportive resources. However, in the fast-paced emergency setting, such assessments may be influenced by implicit racial bias. Despite significant research to inform the clinical care of febrile infants, there is a dearth of knowledge regarding health disparities and clinical guideline implementation. The proposed mixed methods approach will (1) quantify the extent of disparities by race, ethnicity and language proficiency and (2) explore the role of implicit bias in physician–patient communication when caring for this population.Methods and analysisWith 42 participating sites from the Pediatric Emergency Medicine Collaborative Research Committee, we will conduct a multicenter, cross-sectional study of low-risk febrile infants treated in the emergency department (ED) and apply multivariable logistic regression to assess the association between (1) race and ethnicity and (2) limited English proficiency with the primary outcome, discharge to home without lumbar puncture or antibiotics. We will concurrently perform an interpretive study using purposive sampling to conduct individual semistructured interviews with (1) minority parents of febrile infants and (2) paediatric ED physicians. We will triangulate or compare perspectives to better elucidate disparities and bias in communication and medical decision-making.Ethics and disseminationThis study has been approved by the University of Florida Institutional Review Board. All participating sites in the multicenter analysis will obtain local institutional review board approval. The results of this study will be presented at academic conferences and in peer-reviewed publications.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants

“…The data collection tool was developed and revised with input from experienced febrile infant and health disparities investigators and based on pilot testing at 3 participating institutions. When abstracting clinician-documented data, we used a hierarchical approach, using data from the most senior clinician possible . The trained investigators abstracted data on included infants through manual electronic health record review into a central REDCap database hosted at the University of Florida …”

Approach to the Febrile Infant (<3 Months)

“…In 2022, Gutman et al 17 published an article describing a planned study on disparities and implicit bias in the management of low-risk febrile infants despite widely used clinical standards that guide care; however, no results or conclusions are presented. The introduction states that “health inequities based on patient race, ethnicity, and language are widespread in pediatric emergency medicine.” 17 Because the guidelines and current practice frequently recommend shared decision-making, this study may shed light on implicit bias that occurs with physicians communicating with patients/parents of a different language or culture, and whether that impacts their clinical decision-making.…”

“…This article also agrees with and emphasizes the 2-level ANC criteria (2 different values with and without procalcitonin). 16 In 2022, Gutman et al 17 published an article describing a planned study on disparities and implicit bias in the management of low-risk febrile infants despite widely used clinical standards that guide care; however, no results or conclusions are presented. The introduction states that "health inequities based on patient race, ethnicity, and language are widespread in pediatric emergency medicine."…”

“…The introduction states that "health inequities based on patient race, ethnicity, and language are widespread in pediatric emergency medicine." 17 Because the guidelines and current practice frequently recommend shared decision-making, this study may shed light on implicit bias that occurs with physicians communicating with patients/parents of a different language or culture, and whether that impacts their clinical decision-making.…”

Language Barriers in Care for Low-Risk Febrile Neonates

“…While there has been extensive investigation of clinical determinants to identify neonates at low risk for invasive bacterial infection (IBI), there has been little investigation into the impact of sociodemographic characteristics on management of this population. The study by Gutman et al in JAMA Pediatrics examines the impact of race, ethnicity, and language for care on interventions performed for well-appearing febrile infants at low risk for IBI by clinical criteria in pediatric emergency departments (EDs). Among 4042 well-appearing, clinically low-risk febrile infants, 969 (24%) had at least 1 unnecessary intervention, such as lumbar puncture, antibiotic administration, and/or hospitalization.…”