Name of the project
- Health Care Disparities in the Pediatric Intensive Care Unit: Acute Respiratory Failure
Project abstract/brief description
- Health care disparities have been documented between different racial and ethnic groups in the United States. While some health care disparities can be viewed historically, through the influence of the United States government, others are apparent from the growing body of medical literature documenting different outcomes between racial and ethnic groups for adults with specific medical conditions. However, there is a paucity of information regarding these disparities in children and fewer explorations in the pediatric critical care environment. It is important to explore the prevalence of these disparities and determine factors that create them, so that we may deliver equitable health care for all racial and ethnic groups in the United States.
The United States government was responsible for creating health care disparities in the past, which may be a piece of the puzzle to understanding the racial or ethnic differences in health care seen today. The African American population experienced a period of slavery in the United States from 1640 to 1863. During the period of 1863 to 1965, there was a reconstruction era that saw several constitutional amendments that outlawed slavery (13th amendment, 1865), gave citizenship to all persons born in the United States or naturalized (14th amendment, 1868), and barred states from prohibiting any male citizen from voting (15th amendment, 1870). While this period ensured certain freedoms, African Americans were still relegated to second-class citizens. They received substandard health care and education (LaVeist, 2005). This was epitomized by the Tuskegee Syphilis Study, carried out in Macon County, Alabama, from 1932 to 1972. Adequate treatment was withheld from a group of poor African American men in an attempt to learn more about syphilis. The United States Public Health Service performed this study.
A number of studies, in the adult population, have been performed in order to identify racial or ethnic disparities within different medical conditions. In a computerized survey, Schulman et al found that the race of a patient independently influenced how physicians managed chest pain (Schulman, 1999). African American patients with chest pain were less likely to be referred for cardiac catheterization than Caucasians (OR = 0.6; 95% C.I. = 0.4 – 0.9; P = 0.02) (Schulman, 1999). In a retrospective study, Bach et al showed that the five-year survival rate for African American patients with non-small-cell lung cancer was lower than Caucasians with the same diagnosis (26.4% vs. 34.1%, respectively; P < 0.001). Furthermore, the rate of surgery was significantly lower between African Americans and Caucasians (64.0% vs. 76.7%, respectively; P < 0.001) for this disease. Bach et al concluded that this lower survival rate was due to the lower surgical intervention rate (Bach, 1999). In another retrospective study, Epstein et al explored racial differences in access to renal transplantation. Among patients considered to be appropriate candidates for transplantation, African Americans were less likely than Caucasians to be referred for evaluation (90.1% vs. 98.0%; P = 0.008), to be placed on the waiting list (71.0% vs. 86.7%; P = 0.007), or to undergo transplantation (16.9% vs. 52.0%; P < 0.001) (Epstein, 2000). These are but a few examples of the racial and ethnic health care disparities documented in the adult medical literature.
In children, although the body of literature is limited, there is evidence of racial and ethnic health care disparities. In the management of appendicitis, Kokoska et al found that African Americans were less likely to undergo laparoscopic treatment (OR = 0.78; 95% C.I. = 0.74 – 0.87) and more likely to have a perforated appendix (OR = 1.39; 95% C.I. = 1.30 – 1.49) than Caucasians. Hispanics were more likely to have a perforated appendix (OR = 1.10; 95% C.I. = 1.05 – 1.16) than Caucasians as well. Subsequently, the treatment of African American and Hispanic children was associated with a longer hospital stay and higher charges (Kokoska, 2007). Furthermore, Smink et al found that African American (OR = 1.24; 95% C.I. = 1.10 – 1.39) and Hispanic (OR = 1.19; 95% C.I. = 1.10 – 1.29) children were more likely to have perforated appendicitis than Caucasian children as well (Smink, 2005). These disparities may be explained by differences in medical insurance and delayed administration care. With regard to appendicitis, both Bratton et al and Smink et al found that children with Medicaid insurance had an increased risk of complicated disease (Bratton, 2000; Smink, 2005).
In children with critical illness, there are even fewer studies appraising racial or ethnic health care disparities. Haider et al showed African American children had worse clinical and functional outcomes at discharge when compared to Caucasian children with moderate or severe traumatic brain injury (Haider, 2007). Howard et al explored racial and ethnic disparities in children with traumatic brain injury and found that minority children were more likely to be a pedestrian or cyclist struck by a vehicle and were less likely to require transfer to the emergency department and were more likely to be publicly insured (Howard, 2005). Milazzo et al found that African American children underwent bidirectional Glenn and Fontan procedures for single ventricle anatomy at a later age than Caucasian children (13.8 ± 10.8 vs. 5.6 ± 2.3 months, P = 0.01, and 106.8 ± 84.0 vs. 45.6 ± 36.0 months, P = 0.005, respectively) (Milazzo, 2002).
It is important to explore the prevalence of racial and ethnic disparities in health care and determine factors that create these discrepancies. The literature on this subject is growing, but still lacking in pediatrics, especially critical care. By exposing the difference and identifying factors that can be controlled, we may be able to intervene and create more equitable health care for all racial and ethnic groups in the United States. We must first ask the question, “Are there racial and ethnic disparities in health care in the pediatric intensive care unit?”
General Hypothesis:
For pediatric intensive care unit patients with acute respiratory failure, there will be significant differences in length of pediatric intensive care unit stay, functional outcomes, technology usage and survival between different racial/ethnic groups, when controlling for disease severity.
Specific Objectives:
· To determine the relationship between race/ethnicity and mortality, after controlling for severity of illness with standardized mortality scores such as PIM 2 and PRISM III, in children with acute respiratory failure.
· To determine the relationship between race/ethnicity and length of intensive care stay, after controlling for severity of illness with standardized mortality scores such as PIM 2 and PRISM III, in children with acute respiratory failure.
· To determine the relationship between race/ethnicity and change in functional outcome (admission vs. discharge PCPC and POPC), after controlling for severity of illness with standardized mortality scores such as PIM 2 and PRISM III, in children with acute respiratory failure.
· To determine the relationship between race/ethnicity and utilization of equipment/technologies (central venous catheter, arterial catheter, endotracheal intubation, and mechanical ventilation), after controlling for severity of illness with standardized mortality scores such as PIM 2 and PRISM III, in children with acute respiratory failure.
References:
LaVeist TA. Minority Populations and Health: An Introduction to Health Disparities in the United States. 2005, San Francisco: Jossey-Bass Press.
Schulman KA, et al. The Effect of Race and Sex on Physician’s Recommendations for Cardiac Catheterization. The New England Journal of Medicine 1999; 340: 618-626.
Bach PB, et al. Racial Differences in The Treatment of Early-Stage Lung Cancer. The New England Journal of Medicine 1999; 341: 1198-1205.
Epstein AM, et al. Racial Disparities in Access to Renal Transplantation: Clinically Appropriate or Due to Underuse or Overuse? The New England Journal of Medicine 2000; 343: 1537-1544.
Kokoska ER, et al. Racial Disparities in the Management of Pediatric Appendicitis. Journal of Surgical Research 2007; 137: 83-88.
Smink DS, et al. Effects of Race, Insurance Status, and Hospital Volume on Perforated Appendicitis in Children. Pediatrics 2005; 115: 920-925.
Bratton SL, Haberkern CM, and Waldhausen JHT. Acute Appendicitis Risks of Complications: Age and Medicaid Insurance. Pediatrics 2000; 106: 75-78.
Haider AH, et al. Black Children Experience Worse Clinical and Functional Outcomes after Traumatic Brain Injury: An Analysis of the National Pediatric Trauma Registry. Journal of Trauma 2007; 62(5); 1259-1262.
Howard I, Joseph JG, and Natale JE. Pediatric Traumatic Brain Injury: Do Racial/Ethnic Disparities Exist in Brain Injury Severity, Mortality, or Medical Disposition? Ethn Dis 2005; 15(4 Suppl 5): S5 51-61.
Milazzo AS, et al. Racial and Geographic Disparities in Timing of Bidirectional Glenn and Fontan Stages of Single-Ventricle Palliation. J Natl Med Assoc 2002; 94(10); 873-878.
Name of Principal Investigator
Department/division/center/school in which the project is based
- Department of Anesthesia/Critical Care Medicine at Children's Hospital Los Angeles
Primary institution in which this project is based
- Childrens Hospital Los Angeles (CHLA)
Name and email address for the Project Director / Manager, or person responsible for overseeing the day-to-day activities of this project
If we were to request additional information about this project, pelase provide the name of the person to contact and his/her email address
- Project Director / Manager listed above
Are there any Co-Investigators on this project?
Please name all Co-Investigators and their institutional affiliation
- Co-Investigator - Institutional affiliation
- Robinder Khemani, MD/Children's Hospital Los Angeles
- Co-Investigator - Institutional affiliation
- Barry Markovitz, MD/Children's Hospital Los Angeles
- Co-Investigator - Institutional affiliation
- Carolyn Wong, PhD/Children's Hospital Los Angeles
- Co-Investigator - Institutional affiliation
- Karen Waters, RN/Children's Hospital Los Angeles
- Co-Investigator - Institutional affiliation
- Michele Kipke, PhD/Children's Hospital Los Angeles
Which, if any, of the following institutions are you partnering with for this project?
- Childrens Hospital Los Angeles (CHLA)
- Other (please specify)
For each partner institution listed, please indicate the specific department / division / institute / center with which you are partnering
- Department of Research on Children Youth and Families/Children's Hospital Los Angeles
Are you collaborating with any other academic, clinical or community organizations on this project?
List any academic, clinical and / or community organizations with which you are collaborating. Please include each partner organization's location
Which institutional IRBs have reviewed and approved this project?
- Childrens Hospital Los Angeles (CHLA)
- Other (please specify)
Which of the following best characterizes the agency(ies) funding this project? (IF THIS IS A SUBCONTRACT, PLEASE IDENTIFY THE CORE FUNDING SOURCE, e.g., NIH, CDC, etc.)
What month and year does / did funding begin?
What month and year does/did funding end?
Which of the following best describes the project's thematic focus?
- Reducing healthcare disparities
In what context do your project activities (e.g. data collection) take place?
- Hospital/in-patient setting
How would you classify this project?
Please indicate which of the following best characterizes the type of research you are conducting?
Which of the following best characterizes your study design?
What type of data collection methods are used?
- Data collected from existing dataset (secondary data collection/analysis)
Which services does your program provide?
- NOT a service project - Research only
How many participants will be/were recruited to participate in your research or service program over the funding/study period?
Which of the following best describe the population this project targets?
Which of the following best describes the age groups this project targets?
- Infants/children (0-11 years)
- Adolescents (12-18 years)
Which of the following best describes the racial/ethnic characteristics of the project participants?
Please provide any additional characteristics of your project participants that are specific to the goals of the project, e.g., low-income, un-insured, incarcerated, pregnant/parenting teens, populations with disabilities, specific conditions, etc.
- Children admitted to the pediatric intensive care unit
Which of the following best describes the location(s) in which this project takes/took place?
In which LA County Service Planning Area (SPA) do/did your project activities take place?
In which locations outside LA County do your project activities take place?
Does this project have an advisory board?
How often does your advisory board meet?
Please indicate which of the following best describes the membership of this project's advisory board?
Which of the following best describe the type of guidance your advisory group provides for your project?
In what ways, if any, has your project disseminated information about your project, including findings and lessons learned?
Which dissemination activities do you/did you find to be most effective?
How useful do you think a CTSI Research/Service Clearinghouse will be to the following audiences?
How likely are you to use the CTSI web-based clearinghouse?
How would you envision using a resource like the CTSI web-based clearinghouse?
- Connect with other researchers interested in similar research topics.
What specific information would you want in the CTSI web-based clearinghouse to maximize its utlility to you, other researchers, and representatives of the community?
What would you like to see in terms of the CTSI web-based clearinghouse design and functionality that would maximize the clearinghouse's utility for you and others?
