Purpose Individuals who self-report as Black or African American are historically underrepresented in genome-wide studies of disease risk, a disparity particularly evident in pediatric disease research. To address this gap, Cincinnati Children’s Hospital Medical Center (CCHMC) established a biorepository and developed a comprehensive DNA sequencing resource including 15,684 individuals who self-identified as African American or Black and received care at CCHMC. Methods Participants were enrolled through the CCHMC Discover Together Biobank and sequenced. Admixture analyses confirmed the genetic ancestry of the cohort, which was then linked to electronic medical records. Results Genome-wide genotypes from common variants accompanied by medical record-sourced data are available through the Genomic Information Commons. This data set performs well in genetic studies. Specifically, we replicated known associations in sickle-cell disorder (HBB, HGNC:4827, P = 4.05 × 10-148), anxiety (PLAAT3, HGNC:17825, P = 6.93 × 10-9), and asthma (PCDH15, HGNC:14674, P = 5.6 × 10-10), while also identifying novel loci associated with anxiety, asthma, and asthma severity. Conclusion We present the acquisition and quality of genetic and disease-associated data and present an analytical framework for using this resource. In partnership with a community advisory council, we have codeveloped a valuable framework for data use and future research.

BACKGROUND:Multicenter collaborative studies examining disparities in in-hospital outcomes are lacking in pediatric cardiology. We hypothesized that Black and Hispanic patients in pediatric acute care cardiology units (ACCUs) have increased length of stay (LOS) and complications compared with their counterparts. METHODS:Utilizing the Pediatric Acute Care Cardiology Collaborative registry, we examined ACCU hospitalizations from January 2, 2019, to July 30, 2021. Hospitalizations were categorized by race and ethnicity and subcategorized by region. Differences in LOS and mean total number of complications were assessed using Wilcoxon rank sum and Kruskal-Wallis testing. Generalized linear models were constructed to evaluate differences between regions, race, and ethnicity. Multiple testing correction was performed which established a significance threshold of .001. RESULTS:Analysis included 29 079 hospitalizations from 28 centers. Patients identifying as non-Hispanic (NH) Black (median, 5.0 [IQR, 3.0-13.0]) and NH other (6.0 [3.0-15.0]) had longer LOS than NH white patients (5.0 [IQR, 2.0-11.0]; P < .0001). Hispanic patients had a shorter LOS than NH patients (median, 5.0 [IQR, 2.0-11.0] vs 6.0 [3.0-14.0]; P < .0001). The number of complications was significantly higher for patients who identify as NH Black or NH other compared with NH white patients. The gaps between LOS and complications persisted in US regions with some areas demonstrating greater difference: LOS difference for NH Black patients was more pronounced in the West than in the Northeast (median, 5.5 [IQR, 3.0-15.0] vs 5.0 [2.0-12.0]). For Hispanic patients in the South, LOS and complications were lower compared with those in the West and the Northeast. CONCLUSION:Significant racial and ethnic disparities exist in hospital LOS and complications in pediatric cardiology, with some regions of the United States demonstrating greater disparity than others.

Providing autonomy to resident physicians is critical to their professional development. However, opportunities to foster entrustment, and thereby resident-led medical decision making, are often limited in pediatric training. We sought to examine attending physicians' and residents' perceptions of resident autonomy on inpatient pediatric wards with regard to specific medical decisions and patient-care tasks. We conducted a cross-sectional study of pediatric residents and attendings at five academic medical centers in the United States (US): Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Nationwide Children's Hospital, Columbus, OH; Children's Hospital of Philadelphia, Philadelphia, PA; Johns Hopkins Children's Center, Baltimore, MD; and Children's Wisconsin, Milwaukee, WI. Respondents completed an eight-item survey that rated the percentage of time residents were given autonomy for specific medical decisions. We performed descriptive statistical analysis to compare responses between the groups. Overall, we identified general concordance between attending and resident ratings of autonomy. There were statistically significant differences between resident and attending responses pertaining to antimicrobial choice and addressing patient/family concerns.

Objective To understand the feelings of pediatrics residents early in the COVID-19 pandemic and to offer insights still relevant today. Methods We performed a thematic analysis exploring resident feelings early in the pandemic using free-text responses on a national survey distributed between May and June 2020. We analyzed responses from the following multi-part free text question embedded in the larger survey, “Which of the following feelings have you experienced in your role as a pediatric resident during the COVID-19 pandemic” with response prompts including relief, guilt, pride, sadness, worry, fear, and other. Results While many feelings that respondents shared were common to society at large, some were specific to their intersecting roles as healthcare workers, pediatricians, and trainees. Some issues uncovered have continued relevance today including varied interactions with program and institutional leadership, training away from established support networks and during an important life stage, and societal concerns. Conclusions This study uncovered vulnerabilities inherent to being a trainee such as limited control over one’s own schedule or institutional policies and training away from established supports. Their feelings shine light on the moral distress experienced in residency and the role program and institutional leadership can play in the experiences of residents.

BACKGROUND:Anti-racism curricula are increasingly being recognized as an integral component of medical education. To our knowledge, there has not yet been a publication exploring resident perspectives from multiple institutions and explicitly representing both underrepresented in medicine (UIM) and non-UIM perspectives. OBJECTIVE:To explore and compare UIM and non-UIM pediatric residents' perspectives on the content and qualities of meaningful anti-racism curricula. METHODS:We performed an IRB-approved multi-institutional, qualitative study that incorporated Sotto-Santiago et al's conceptual framework for anti-racism education. Between February and May 2021, we conducted focus groups of UIM and non-UIM pediatric residents at three large residency programs in the United States. We developed focus group guides using literature review, expert consensus, feedback from study team racial equity experts, and piloting. Focus groups were conducted virtually, audio-recorded, and transcribed verbatim. We employed thematic analysis to code transcripts, create categories, and develop themes until we reached thematic sufficiency. We completed member checking to ensure trustworthiness of themes. RESULTS:Forty residents participated (19 UIM and 21 non-UIM) in a total of six focus groups. We identified 7 themes, summarized as: 1) racism in medicine is pervasive, therefore (2) anti-racism education is critical to the development of competent physicians, and 3) education should extend to all healthcare providers. 4) Residents desired education focused on action-oriented strategies to advance anti-racism, 5) taught by those with both learned and lived experiences with racism, 6) in a psychologically safe space for UIM residents, and 7) with adequate time and financial resources for successful implementation and engagement. CONCLUSION:Our multi-institutional study affirms the need for pediatric resident anti-racism education, promotes co-creation as a method to affect culture change, and provides practical strategies for curricular design and implementation.

OBJECTIVES Families identifying as members of marginalized racial groups may be less likely to attend family-centered rounds (FCR) and receive associated benefits. At our institution, caregivers of Black patients admitted to Hospital Medicine (HM) were less likely to be physically present on FCR than their white counterparts (72.2% vs 81.8%). We sought to increase the percentage of caregivers present, physically or by telephone, on HM FCR for Black patients from 72.2% to 83% in 5 months. METHODS We conducted a quality improvement initiative at a large, urban, freestanding children’s hospital. Our primary measure was physical or telephone presence of a caregiver during FCR, disaggregated by caregiver-reported patient race. We formulated key drivers, including early identification of Black patients at higher risk of poor communication. We conducted plan-do-study-act cycles. We tracked the percentage of caregivers of Black and white patients present on FCR using annotated 2-line run charts and statistical process control charts. RESULTS Over 15 months of interventions, the percentage of caregivers present on FCR increased to 81.7% in caregivers of Black patients and 85.2% in caregivers of white patients. This improvement was not initially sustained. Therefore, we returned to active interventions to achieve reimprovement. We detected special cause variation after implementing 2 interventions: (1) discussing caregiver preferences regarding their presence during FCR on admission and (2) calling all caregivers who were not physically present during rounds. CONCLUSION/DISCUSSION We successfully improved the presence of caregivers on FCR while also decreasing the racial gap in caregiver presence.

OBJECTIVE:To determine the association of patient race, patient-provider racial congruence, patient ethnicity, and family primary language with patient family experience (PFE) survey responses. METHODS:Cross-sectional review of PFE survey responses from all ambulatory medical encounters at a large, urban children's hospital system June 1, 2020-May 31, 2022. Exposures were patient race, patient-provider racial congruence, patient ethnicity, and family primary language. We adjusted analyses for neighborhood-level socioeconomic deprivation, patient sex and age, encounter specialty, and location of care. Outcomes were PFE survey scores for five questions focused on overall experience, respect, and safety; categorized using industry standard metric of presence of a "top-box" score, defined as a nine or 10 for questions on an 11-point scale or as four on a four-point scale. RESULTS:We included 89,175 surveys (15.6% response rate). The odds of having optimal, "top-box" responses for several assessed questions were lower for patients identified as Asian (eg, adjusted odds ratio [OR] 0.46; 95% confidence interval [CI] 0.40, 0.52) or Black (eg, OR 0.65; CI 0.60, 0.70) compared to White, and for Hispanic (eg, OR 0.84; CI 0.72, 0.97) compared to non-Hispanic. Similarly, the odds of having "top-box" scores were lower for Spanish-primary-language (eg, OR 0.38; CI 0.30, 0.48) compared to English-primary-language patients. Patient-provider racial congruence had higher odds of "top-box" responses for two of five assessed questions (eg, OR 1.18; CI 1.04, 1.35). CONCLUSIONS:We found previously unreported inequities in ambulatory pediatric PFE outcomes, with worse experiences reported by Asian, Black, Hispanic, and Spanish-language patients.

For hospitalized patients and families who speak languages other than English (LOE), consistent interpreter-mediated communication is necessary to ensure equitable health care delivery. Despite the availability of interpreter services, variability exists in their presence for all communication touchpoints during hospitalization. To improve interpreter presence during hospitalization, our quality improvement study aimed to increase the average number of interpreted encounters per LOE patient day within 6 months. Our multidisciplinary improvement team tracked all interpreted in-person, phone, and remote audio and video encounters on a hospital medicine unit. Using the Model for Improvement, we performed Plan-Do-Study-Act cycles to test interventions, including provider education, increased language access devices on the unit, and in-room family language signs. Our outcome measure was the average number of interpreted encounters per LOE patient day measured weekly. We also tracked the proportion of in-person interpreted encounters per LOE patient day as a balancing measure to ensure improving remote interpreter availability did not discourage requesting in-person interpreters. During the 6-month intervention period, there was a total of 651 LOE patient days. The average number of interpreted encounters per LOE patient day increased from a mean of 1.8 to 3.2, and the balancing measure of average number of in-person interpreted encounters per LOE patient day remained unchanged at 0.11. We observed increased presence of interpreters per LOE patient day on a hospital medicine unit without significant changes to in-person interpreter presence. Creating standard workflows and increased availability of language access devices were key interventions.

AimDelays in care may be a driver of inequities in perforated appendicitis rates. The goal of this study was to explore potential causes of delay in care for children with perforated appendicitis.MethodsWe conducted an interview study of caregivers of children admitted with perforated appendicitis to a children's hospital between December 2022 and March 2023. Semi‐structured interviews based on an iteratively revised interview guide were conducted in‐person during the child's admission. All interviews were transcribed, coded and underwent a process of thematic analysis.ResultsWe reached thematic saturation after 12 interviews. The median age for children was 13.5 years, 50% were male, 83% of caregivers self‐identified as White, and one interview required an interpreter. Through thematic analysis, four major themes for potential causes of delay emerged. The first theme of symptom recognition includes delays related to recognising the symptoms, their severity and the need for medical evaluation. The second theme – accessing care – describes delays that occur after a decision was made to seek care until the child was evaluated. The third theme includes delays that occur in making the diagnosis after evaluation. The last theme captures potential delays in definitive treatment after a diagnosis of appendicitis is made.ConclusionWe identify four major themes from the patient and family perspective, each with multiple sub‐themes, for potential delays in definitive care for children with perforated appendicitis. Additional research is needed to further characterise these potential delays and quantify their role in contributing to inequities in perforation rates.

This Viewpoint discusses the 4P's Road Map for population health and health equity research.

BACKGROUND AND OBJECTIVES Population-wide racial inequities in child health outcomes are well documented. Less is known about causal pathways linking inequities and social, economic, and environmental exposures. Here, we sought to estimate the total inequities in population-level hospitalization rates and determine how much is mediated by place-based exposures and community characteristics. METHODS We employed a population-wide, neighborhood-level study that included youth <18 years hospitalized between July 1, 2016 and June 30, 2022. We defined a causal directed acyclic graph a priori to estimate the mediating pathways by which marginalized population composition causes census tract-level hospitalization rates. We used negative binomial regression models to estimate hospitalization rate inequities and how much of these inequities were mediated indirectly through place-based social, economic, and environmental exposures. RESULTS We analyzed 50 719 hospitalizations experienced by 28 390 patients. We calculated census tract-level hospitalization rates per 1000 children, which ranged from 10.9 to 143.0 (median 45.1; interquartile range 34.5 to 60.1) across included tracts. For every 10% increase in the marginalized population, the tract-level hospitalization rate increased by 6.2% (95% confidence interval: 4.5 to 8.0). After adjustment for tract-level community material deprivation, crime risk, English usage, housing tenure, family composition, hospital access, greenspace, traffic-related air pollution, and housing conditions, no inequity remained (0.2%, 95% confidence interval: -2.2 to 2.7). Results differed when considering subsets of asthma, type 1 diabetes, sickle cell anemia, and psychiatric disorders. CONCLUSIONS Our findings provide additional evidence supporting structural racism as a significant root cause of inequities in child health outcomes, including outcomes at the population level.

OBJECTIVES:We sought to create a computational pipeline for attaching geomarkers, contextual or geographic measures that influence or predict health, to electronic health records at scale, including developing a tool for matching addresses to parcels to assess the impact of housing characteristics on pediatric health. MATERIALS AND METHODS:We created a geomarker pipeline to link residential addresses from hospital admissions at Cincinnati Children's Hospital Medical Center (CCHMC) between July 2016 and June 2022 to place-based data. Linkage methods included by date of admission, geocoding to census tract, street range geocoding, and probabilistic address matching. We assessed 4 methods for probabilistic address matching. RESULTS:We characterized 124 244 hospitalizations experienced by 69 842 children admitted to CCHMC. Of the 55 684 hospitalizations with residential addresses in Hamilton County, Ohio, all were matched to 7 temporal geomarkers, 97% were matched to 79 census tract-level geomarkers and 13 point-level geomarkers, and 75% were matched to 16 parcel-level geomarkers. Parcel-level geomarkers were linked using our exact address matching tool developed using the best-performing linkage method. DISCUSSION:Our multimodal geomarker pipeline provides a reproducible framework for attaching place-based data to health data while maintaining data privacy. This framework can be applied to other populations and in other regions. We also created a tool for address matching that democratizes parcel-level data to advance precision population health efforts. CONCLUSION:We created an open framework for multimodal geomarker assessment by harmonizing and linking a set of over 100 geomarkers to hospitalization data, enabling assessment of links between geomarkers and hospital admissions.

Objectives: Critical CHD is associated with morbidity and mortality, worsened by delayed diagnosis. Paediatric residents are front-line clinicians, yet identification of congenital CHD remains challenging. Current exposure to cardiology is limited in paediatric resident education. We evaluated the impact of rapid cycle deliberate practice simulation on paediatric residents' skills, knowledge, and perceived competence to recognise and manage infants with congenital CHD. Methods: We conducted a 6-month pilot study. Interns rotating in paediatric cardiology completed a case scenario assessment during weeks 1 and 4 and participated in paired simulations (traditional debrief and rapid cycle deliberate practice) in weeks 2-4. We assessed interns' skills during the simulation using a checklist of "cannot miss" tasks. In week 4, they completed a retrospective pre-post knowledge-based survey. We analysed the data using summary statistics and mixed effect linear regression. Results: A total of 26 interns participated. There was a significant increase in case scenario assessment scores between weeks 1 and 4 (4, interquartile range 3-6 versus 8, interquartile range 6-10; p-value < 0.0001). The percentage of "cannot miss" tasks on the simulation checklist increased from weeks 2 to 3 (73% versus 83%, p-value 0.0263) and from weeks 2-4 (73% versus 92%, p-value 0.0025). The retrospective pre-post survey scores also increased (1.67, interquartile range 1.33-2.17 versus 3.83, interquartile range 3.17-4; p-value < 0.0001). Conclusion: Rapid cycle deliberate practice simulations resulted in improved recognition and initiation of treatment of simulated infants with congenital CHD among paediatric interns. Future studies will include full implementation of the curriculum and knowledge retention work.

INTRODUCTION:This qualitative research study explored practices that support and advance diverse membership in Patient and Family Advisory Councils (PFACs) in children's hospitals and the involvement of PFACs in organization-level diversity, equity, and inclusion work.METHOD:This study consisted of a focused literature review and 17 key informant interviews. The study sought to identify important learnings about (1) recruiting and supporting patient and family advisors (PFAs) from historically marginalized populations and (2) ways to develop and sustain meaningful partnerships with PFAs and PFACs in diversity, equity, and inclusion work.RESULTS:The study findings highlighted a number of best practices for hospitals to adopt, including more actively reaching out to communities served, addressing barriers to participation through approaches and structures such as specialty PFACs and "tiered" options for participation by PFAs, and co-creation of inclusive environments.DISCUSSION:To move forward with this work, additional research, true commitment from health care organizations, and shared guidance and tools for the field are needed.