Program on Equity in Child Health at Mott Hospital

Project start and end dates:11/01/2020 – 12/31/2021

Background: Considerable research demonstrates differences by gender, income, race and ethnicity in the way adult patients are provided care across numerous conditions (e.g., heart attacks, treatment for pain, diagnostic testing). However, with very rare exception, similar studies have not been conducted regarding the care of children. Simply put, although we believe clinicians and children’s hospitals make the same decisions regarding the care of children and their families across gender, income, disability status, sexual orientation, race and ethnicity, we simply do not know because such research has not been conducted. Furthermore, existing work on inequities in adult care suggests the same may be true for the care of children. This Program provides the first critical steps in beginning a process to assess the perceptions of inequities at Mott Hospital. Discussions with nursing, clerical and therapy staff identified several potential areas where hypothesized inequities in the way families are provided care may exist. Three of these areas were prioritized by the leadership of Mott Hospital for initial assessment: 1) documentation of race and ethnicity in patient medical records, 2) security assistance requests, and 3) granted visitor exceptions during the COVID pandemic. If inequities are found, the Quality Improvement Department at Mott Hospital will design and implement QI programs to address them.

Objectives:
Aim 1 - Race and Ethnicity Verification: Determine the method(s) of identification and collection of racial and ethnic identity found in patient medical records and the degree of accuracy of those assessments
Aim 2 – Security Assistance Requests: Determine the SES, racial and ethnic composition of the patients of whom the families have had security called and how this compares to the overall demographic composition of patients
Aim 3 – Visitor Exceptions: Determine the actual process by which exceptions to the limitations in neonatal and pediatric intensive care units (NICU / PICU) visitor policy (in place due to COVID) were granted and the SES, racial and ethnic composition of those granted exceptions

Research Topics & Methods:
Aim 1: Determination of the method(s) of identification and collection of racial and ethnic identity found in patient medical records

Interviews are being conducted with registration and check-in clerical staff to determine the methods by which clerks determine the race/ethnicity designations for new patients, policies/practices for verification of existing race/ethnicity designations, and policies/practices if a discrepancy or error in previous race/ethnicity designations is determined.

The degree of accuracy of racial and ethnic identity found in medical records is being assessed by surveying parents of patients receiving care at both Mott inpatient and UM outpatient locations. Parents are being asked to provide the name, birth date, race, and ethnicity of their child. This information is then being compared to the child’s medical record to assess the accuracy of racial and ethnic designations. A summary report will be prepared by the project team for Mott Hospital leadership with specific recommendations for the standardization of collection methods and resolution of discrepancies.

Aim 2: Determine the SES, racial and ethnic composition of the patients of whom the families have had security called and how this compares to the overall demographic composition of patients

Records are maintained by hospital security on every request for assistance including the unit making the request, the name of the patient/family of interest and the disposition of the request. These data are being obtained and analyzed to assess the race/ethnicity of the patient (from the medical record) from each of the pediatric/neonatal ICU units, the pediatric psychiatry ward and Mott hospital overall for the calendar years 2019 and 2020. Insurance status of the patients is also being assessed with the designation of Medicaid or uninsured used as a proxy for low income. Project QI specialists will investigate any unit-specific or hospital-wide disparities in the consultation of security with staff in the respective units.

Aim 3: Determine the actual process by which exceptions to the limitations in NICU visitor policy (in place due to COVID) were granted and the SES, racial and ethnic composition of those patients granted exceptions

Semi-structured interviews with nurse leadership are being conducted to gain a comprehensive understanding of the way in which exceptions to the visitor policy were considered and the process by which subsequent determinations of those requests were made. Additionally, NICU and PICU staff (including physicians, fellows, nurse practitioners and nurses) are surveyed using written patient scenarios (varied by the race/ethnicity and income status of patients) where participants will state whether they would or would not support an exception to the visitor policy in each of these cases. Based on results from the leadership interviews and provider/staff surveys, the QI specialists on the project team will develop QI programs to address any disparities observed in the granting of visitor exceptions.

Implications: This project is the first step in the development of a larger program that will provide a core platform of conceptual, methodological, database and statistical expertise to facilitate a multi-disciplinary cadre of faculty and staff from across the University of Michigan to engage in research on child health care equity.

Funders: Children’s Foundation, Poverty Solutions

Collaborators: Mott Children’s Hospital, Michigan Medicine Canton Health Center, Michigan Medicine East Ann Arbor Health Center, Michigan Medicine Ypsilanti Health Center