Call to Action: Examining Health Disparities at the Institutional Level
“Yeah, but do you really think we treat kids differently because of their race?”
It was a common question interviewers would ask me as I navigated subspecialty fellowship interviews across the country just a few years ago. Despite the Healthy People 2000 goal of reducing health disparities among Americans, we have made woefully little progress in achieving this goal 20 years later. If anything, the mountain of evidence that health disparities exist at all levels of care only continues to grow. In the pediatric heart disease population, recent studies have shown that black patients have higher odds of mortality after experiencing a complication, higher odds of mortality after congenital heart surgery, and higher odds of transplant waitlist mortality compared with their white counterparts. So yes, I do think we can say with certainty that kids have different outcomes based on their race or ethnicity. The real question is why, and what are we going to do about it?
Determining a way forward to achieve health equity is not an area that has been adequately explored in pediatric cardiology. A number of studies use large databases, which are not specifically designed to evaluate health disparities. Type of insurance is often riddled with missing data fields. Race and ethnicity data are not required fields in some databases. Primary language, zip code, or parental education are not consistently collected by ICU databases, even though many institutions collect this information. The absence of information does not allow for full examination of interaction terms, confounding variables, or more sophisticated analyses of racial disparities to enable the development of targeted interventions. Furthermore, there is a paucity of prospective data looking at interventions to reduce disparities in general, let alone in the pediatric cardiac intensive care population.
Yet, despite the limitations of research thus far, the evidence in the field is consistent, significant, and compelling. In response to the Cardiac Networks United Health Equity Webinar in August 2020, the Pediatric Cardiac Critical Care Consortium (PC4) has taken the necessary and initial step to include a race/ethnicity filter to allow for comparison of outcomes across race/ethnicity and centers. Still, we have a long way to go in understanding how to complete database information to assess for health disparities in a meaningful way. These research limitations suggest that a closer look at the institutional level may yield more nuanced and timely information that will allow for targeted interventions.
I challenge our community in a “Call to Action” to join me in undertaking the uncomfortable task of looking inward at ourselves and each of our own institution’s outcomes and practices. Multi-institutional studies make it clear that racial disparities exist, while we continue to deny their very existence at our own hospitals. This topic can no longer be filed under an “everybody else” problem. Systemic racism seeps deep into the policies and procedures of every institution and can have a devastating impact on our patients and BIPOC colleagues. We have a social, moral, and professional obligation to look at data at an institutional level to uncover disparities in morbidity and mortality across race and ethnicity, to hold one another accountable in creating inclusive working environments, and to invest in interventions that will eliminate racial disparities. It is far past time for a reckoning with our own complicity.
Yuen Lie Tjoeng, MD MS
Assistant Professor of Pediatrics
Cardiac Intensive Care Unit & Single Ventricle Program
Seattle Children’s Hospital