Disparities in Guideline Adherence for Febrile Infants in a National Quality Improvement Project

Abstract

Background: Interventions aimed to standardize care may impact racial and ethnic disparities. We evaluated the association of race and ethnicity with adherence to recommendations from the American Academy of Pediatrics' clinical practice guideline for febrile infants after a quality improvement (QI) intervention.

Methods: We conducted a cross-sectional study of infants aged 8 to 60 days enrolled in a QI collaborative of 99 hospitals. Data were collected across 2 periods: baseline (November 2020-October 2021) and intervention (November 2021-October 2022). We assessed guideline-concordance through adherence to project measures by infant race and ethnicity using proportion differences compared with the overall proportion.

Results: Our study included 16 961 infants. At baseline, there were no differences in primary measures. During the intervention period, a higher proportion of non-Hispanic white infants had appropriate inflammatory markers obtained (2% difference in proportions [95% confidence interval (CI) 0.7 to 3.3]) and documentation of follow-up from the emergency department (2.5%, 95% CI 0.3 to 4.8). A lower proportion of non-Hispanic Black infants (-12.5%, 95% CI -23.1 to -1.9) and Hispanic/Latino infants (-6.9%, 95% CI -13.8 to -0.03) had documented shared decision-making for obtaining cerebrospinal fluid. A lower proportion of Hispanic/Latino infants had appropriate inflammatory markers obtained (-2.3%, 95% CI -4.0 to -0.6) and appropriate follow-up from the emergency department (-3.6%, 95% CI -6.4 to -0.8).

Conclusions: After an intervention designed to standardize care, disparities in quality metrics emerged. Future guideline implementation should integrate best practices for equity-focused QI to ensure equitable delivery of evidence-based care.

FIGURE 1

Differences in proportion for obtaining recommended inflammatory markers. Qualifying IMs included procalcitonin, c-reactive protein, or absolute neutrophil count.

FIGURE 2

Differences in proportion of adherence to primary project measures by race and ethnicity. Measure definitions: Appropriate CSF - % of infants 29 to 60 days with normal inflammatory markers (and either a negative urinalysis [UA] or a positive UA) that do not have CSF obtained. Appropriate disposition from the ED - % of infants 29 to 60 days with normal inflammatory markers and negative UA that are discharged from the ED. Appropriate receipt of antibiotics - % of infants 29 to 60 days with normal inflammatory markers and negative UA that do not receive antibiotics. Appropriate discharge from the hospital - % of infants 8 to 60 days with negative cultures that have appropriate discharge from the hospital within 36 hours from the time blood cultures were received by the laboratory. CSF, cerebrospinal fluid; ED, emergency department.

FIGURE 3

Differences in proportion of adherence to secondary project measures by race and ethnicity. Measure definitions: Appropriate follow-up - % of infants 22 to 60 days discharged from the ED that have documented education with parents about the importance of follow-up within 1 calendar day. Appropriate parent engagement – CSF - % of infants 22 to 28 days with normal inflammatory markers and negative UA that have documented physician-parent discussion about the harms/benefits of having CSF obtained. Appropriate parent engagement – discharge from the ED - % of infants 22 to 28 days with normal inflammatory markers, negative UA, and normal CSF that have documented physician-parent discussion about the harms or benefits of hospitalization vs discharge from the ED after 1 dose of parenteral antibiotic therapy. Oral antibiotic use for infants 29 to 60 days with positive UAs - % of infants 29 to 60 days with a positive UA, negative inflammatory markers, and normal CSF (if obtained) that receive oral antibiotics (with or without 1 dose of parenteral antibiotic therapy). CSF, cerebrospinal fluid; ED, emergency department.

FIGURE 4

Differences in proportion of adherence to balancing project measures by race and ethnicity. Measure definitions: appropriate evaluation – 8 to 21 days: % of infants 8 to 21 days who have a urinalysis and/or urine culture, blood culture, and CSF culture obtained, and who are hospitalized on parenteral antibiotic therapy. Appropriate evaluation – 22 to 60 days: % of infants 22 to 60 days who have a urinalysis and/or urine culture, blood culture, and inflammatory markers obtained. ED revisit: % of infants 22 to 60 days who did not have CSF obtained or did not receive antibiotic therapy who return to the emergency department within 7 days of discharge. ED readmission - % of infants 22 to 60 days who did not have CSF obtained or receive antibiotic therapy who are readmitted to the hospital within 7 days of discharge. CSF, cerebrospinal fluid; ED, emergency department.