Effect of Institutional Guidelines on Equitable Management of Pediatric Osteomyelitis
Timothy Schurz, Cheyney C Dobson, Gary L Freed, William E Gillespie, Niko A Kaciroti, Harlan McCaffery, Jason B Weinberg, Elizabeth C LloydAbstract
Background
Disparities in acute hematogenous osteomyelitis (AHO) management and outcomes based on race and ethnicity have been reported. Guidelines for management of pediatric AHO were implemented at our institution in 2017 with the goal of decreasing variation in care. We hypothesized that standardization of care with guideline implementation would decrease differences in AHO management related to factors such as race, ethnicity, language, sex, age, and socioeconomic status.
Methods
We performed retrospective chart review of pediatric patients (90 days to 18 years old) hospitalized at a single tertiary care center for AHO. We excluded patients with head/neck infections, decubitus ulcers, implanted surgical hardware, and recent trauma or surgery. Patients in the full cohort were stratified into pre- (9/1/2014-7/31/2017) and post- (11/1/2017-12/31/2023) implementation groups. We assessed whether key aspects of care delivery differed in the entire cohort based on patient demographics, including race, ethnicity, language, sex, age, and area deprivation index (ADI; high ADI = greater deprivation). We compared pre- and post-implementation groups to determine whether guideline implementation affected care delivery. Categorical, numerical, and count outcomes were compared using Fisher’s exact test, Kruskal-Wallis test, and simple Poisson regression, respectively.
Results
In the full cohort (n=131), blood cultures were less likely to be obtained in patients with high ADI (p=0.008), while black patients (p<0.001) and patients with high ADI (p=0.001) had fewer inpatient Pediatric Infectious Diseases (PID) encounters than other comparator groups. Compared to the pre-implementation group (n=35), patients in the post-implementation group (n=96) had more inpatient PID encounters (3.0 vs. 2.0, p=0.039) and were more likely to have MRI (88.5% vs. 77.1%, p=0.158) and antibiotics started after, rather than before, bone biopsy (97.2% vs. 81.2%, p=0.081). However, black patients had significantly fewer inpatient PID encounters than other racial groups in the post-implementation group (0.5 vs. 3.0 for white and 3.0 for other races, p<0.001). There were no other significant differences between pre- and post-implementation groups in measures of care delivery.
Conclusions
We identified important differences in care delivery for AHO related to race and socioeconomic status. Implementation of institutional guidelines for AHO management was associated with improvements in several areas of care delivery, but disparities in care persisted. These findings underscore the value of care standardization while highlighting the need for ongoing efforts to address inequities in care delivery.