Racial and ethnic disparities in pediatric emergency department patients with missed opportunities for diagnostic excellence
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Keren Eyal
,
Jan Leonard
Abstract
Objectives
To compare proportions of pediatric emergency department (PED) patients with missed opportunities for diagnostic excellence (MODEs) by patient race and ethnicity, defined as either White non-Hispanic/Latino (WNH), or non-WNH. In addition, to assess the thoroughness of the PED patient evaluation by patient race and ethnicity.
Methods
Electronic trigger (E-trigger) followed by manual screening identified children with unplanned admission within 10 days of an index PED or pediatric urgent care (PUC) encounter from January 2018 through July 2022. Cases with disparate diagnoses at index encounter and hospital discharge were reviewed using the Revised Safer Dx tool to determine the presence of a MODE. Patient race and ethnicity were abstracted from the electronic record. The primary outcome was proportion of MODEs by race and ethnicity, analyzed using univariate comparisons; the secondary outcome was the completeness of the diagnostic evaluation. Independent predictors of MODEs were identified following multivariable logistic regression analysis.
Results
A total of 816 patients were screened in for Revised Safer Dx review, and a total of 183 potential MODEs were identified. Non-WNH populations did not differ significantly by proportion of potential MODEs when compared to WNH patients. WNH patients received a higher median number of diagnostic tests (p=0.02), more diagnostic workup (p=0.03), and more frequently had the eventual correct diagnosis initially considered (p=0.02) than non-WNH patients. Race and ethnicity did not significantly affect the odds of a MODE.
Conclusions
While race and ethnicity did not predict higher odds of a MODE, non-WNH PED/PUC populations received disparate levels of diagnostic consideration.
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Research ethics: The local Institutional Review Board deemed the study exempt from review.
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Informed consent: Not applicable.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Use of Large Language Models, AI and Machine Learning Tools: None declared.
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Conflict of interest: The authors state no conflict of interest.
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Research funding: None declared.
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Data availability: Not applicable.
References
1. Plint, AC, Newton, AS, Stang, A, Cantor, Z, Hayawi, L, Barrowman, N, et al.. How safe are paediatric emergency departments? A national prospective cohort study. BMJ Qual Saf 2022;31:806–17. https://doi.org/10.1136/bmjqs-2021-014608.Search in Google Scholar PubMed PubMed Central
2. Meyer, AND, Singh, H. The path to diagnostic excellence includes feedback to calibrate how clinicians think. JAMA 2019;321:737–8. https://doi.org/10.1001/jama.2019.0113.Search in Google Scholar PubMed
3. McDonald, KM. Achieving equity in diagnostic excellence. JAMA 2022;327:1955–6. https://doi.org/10.1001/jama.2022.7252.Search in Google Scholar PubMed
4. Ingram, ME, Calabro, K, Polites, S, McCracken, C, Aspelund, G, Rich, BS, et al.. Systematic review of disparities in care and outcomes in pediatric appendectomy. J Surg Res 2020;249:42–9. https://doi.org/10.1016/j.jss.2019.12.018.Search in Google Scholar PubMed
5. Bhatia, S. Disparities in cancer outcomes: lessons learned from children with cancer. Pediatr Blood Cancer 2011;56:994–1002. https://doi.org/10.1002/pbc.23078.Search in Google Scholar PubMed PubMed Central
6. Lam, D, Leonard, J, Wiersma, A, Grubenhoff, JA. Use of e-triggers to identify diagnostic errors in the paediatric ED. BMJ Qual Saf 2022;31:735–43. https://doi.org/10.1136/bmjqs-2021-013683.Search in Google Scholar PubMed
7. Ramgopal, S, Varma, S, Victor, TW, McCarthy, DM, Rising, KL. Pediatric return visits in the emergency department: the time to return curve. Pediatr Emerg Care 2022;38:1454–61. https://doi.org/10.1097/pec.0000000000002790.Search in Google Scholar
8. Pham, JC, Kirsch, TD, Hill, PM, DeRuggerio, K, Hoffmann, B. Seventy-two-hour returns may not be a good indicator of safety in the emergency department: a national study. Acad Emerg Med 2011;18:390–7. https://doi.org/10.1111/j.1553-2712.2011.01042.x.Search in Google Scholar PubMed
9. Aaronson, E, Borczuk, P, Benzer, T, Mort, E, Temin, E. 72h returns: a trigger tool for diagnostic error. Am J Emerg Med 2018;36:359–61. https://doi.org/10.1016/j.ajem.2017.08.019.Search in Google Scholar PubMed
10. Weinstock, MB, Jolliff, H. High-risk medicolegal conditions in pediatric emergency medicine. Emerg Med Clin N Am 2021;39:479–91. https://doi.org/10.1016/j.emc.2021.04.001.Search in Google Scholar PubMed
11. Glerum, KM, Selbst, SM, Parikh, PD, Zonfrillo, MR. Pediatric malpractice claims in the emergency department and urgent care settings from 2001 to 2015. Pediatr Emerg Care 2021;37:376–9. https://doi.org/10.1097/pec.0000000000001602.Search in Google Scholar PubMed
12. Lowe, JT, Leonard, J, Dominguez, F, Widmer, K, Deakyne Davies, SJ, Wiersma, AJ, et al.. Preferred language and diagnostic errors in the pediatric emergency department. Diagnosis (Berl) 2023;11:49–53. https://doi.org/10.1515/dx-2023-0079.Search in Google Scholar PubMed
13. Al-Mutairi, A, Meyer, AND, Thomas, EJ, Etchegaray, JM, Roy, KM, Davalos, MC, et al.. Accuracy of the Safer Dx instrument to identify diagnostic errors in primary care. J Gen Intern Med 2016;31:602–8. https://doi.org/10.1007/s11606-016-3601-x.Search in Google Scholar PubMed PubMed Central
14. Payne, NR, Puumala, SE. Racial disparities in ordering laboratory and radiology tests for pediatric patients in the emergency department. Pediatr Emerg Care 2013;29:598–606. https://doi.org/10.1097/pec.0b013e31828e6489.Search in Google Scholar
15. Goyal, MK, Chamberlain, JM, Webb, M, Grundmeier, RW, Johnson, TJ, Lorch, SA, et al.. Racial and ethnic disparities in the delayed diagnosis of appendicitis among children. Acad Emerg Med 2021;28:949–56. https://doi.org/10.1111/acem.14142.Search in Google Scholar PubMed
16. Polhemus, S, Pickett, ML, Liu, XJ, Fraser, R, Ferguson, CC, Drendel, AL. Racial disparities in the emergency department evaluation of adolescent girls. Pediatr Emerg Care 2022;38:307–11. https://doi.org/10.1097/pec.0000000000002675.Search in Google Scholar
17. Muskens, JLJM, Kool, RB, van Dulmen, SA, Westert, GP. Overuse of diagnostic testing in healthcare: a systematic review. BMJ Qual Saf 2022;31:54–63. https://doi.org/10.1136/bmjqs-2020-012576.Search in Google Scholar PubMed PubMed Central
18. Fleary, SA, Ettienne, R. Social disparities in health literacy in the United States. Health Lit Res Pract 2019;8:47–52. https://doi.org/10.3928/24748307-20190131-01.Search in Google Scholar PubMed PubMed Central
19. Cifra, CL, Custer, JW, Smith, CM, Smith, KA, Bagdure, DN, Bloxham, J, et al.. Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Crit Care Med 2023;51:1492–501. https://doi.org/10.1097/ccm.0000000000005942.Search in Google Scholar
20. Sacco, AY, Self, QR, Worswick, EL, Couperus, CJ, Kolli, SS, Munoz, SA, et al.. Patients’ perspectives of diagnostic error: a qualitative study - PubMed. J Patient Saf 2021;17:1749–64.10.1097/PTS.0000000000000642Search in Google Scholar PubMed
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Articles in the same Issue
- Frontmatter
- Reviews
- Accuracy of pulse wave velocity for screening coronary artery disease: a systematic review and meta-analysis
- Prenatal screening for genetic disorders: updated guidelines, proposed counseling, a holistic approach for primary health care providers in developing countries
- A scoping review of fever of unknown origin with normal serum C-reactive protein
- Mini Review
- Overview of dengue diagnostic limitations and potential strategies for improvement
- Opinion Papers
- Demystifying cognitive bias in the diagnostic process for frontline clinicians and educators; new words for old ideas
- Physicians’ prism: illuminating history with structured expertise
- Original Articles
- Implementation of a curriculum on communicating diagnostic uncertainty for clerkship-level medical students: a pseudorandomized and controlled study
- A synthesized differential diagnosis is associated with fewer diagnostic errors compared to an inventorial list
- Equity-Driven Diagnostic Excellence framework: An upstream approach to minimize risk of diagnostic inequity
- Two decades of autopsy-detected diagnostic errors in Japan
- Does management reasoning display context specificity? An exploration of sleep loss and other distracting situational (contextual) factors in clinical reasoning
- Cognitive biases in osteopathic diagnosis: a mixed study among French osteopaths
- Racial and ethnic disparities in pediatric emergency department patients with missed opportunities for diagnostic excellence
- Diagnostic accuracy of non-mydriatic fundus photography as a triage and telemedicine tool for patients with vision loss
- “Innumerable” lesion burden on brain MRI ‒ a diagnostic approach
- Factors associated with positive findings of deep infection on computed tomography among patients with extremity cellulitis
- Exploring emergency department providers’ uncertainty in neurological clinical reasoning
- Analytical performance and user-friendliness of four point-of-care measuring systems for monitoring prothrombin time international normalized ratio in the hands of the intended users
- Fetal hematological phenotypes of various hemoglobinopathies and demonstration of embryonic hemoglobins on capillary electrophoresis: a large cohort data from prenatal screening program
- Development and assessment of autoverification system for routine coagulation assays in inpatient and outpatient settings of tertiary care hospital: algorithm performance and impact on laboratory efficiency
- Validation of new, circulating biomarkers for gliomas
- Short Communications
- Using language to evaluate curricular impact: a novel approach in assessing clinical reasoning curricula
- Comparative evaluation of routine coagulation testing on Stago sthemO 301 and Werfen ACL TOP 750
- Letters to the Editor
- Reversible systemic vasoconstriction syndrome: a new diagnostic family of generalized vasospasm in multiple organs
- The value of designating symptoms as “vague” in diagnosis
- Immunoglobulin E in an inverted skin-prick test for rapid detection of cutaneous antigens
