160 - Outcomes and Best Practices From a Comprehensive Review of Race & Ethnicity in Clinical Pathways

Poster Number: 160
Publication Number: 160.411

Robert H. Rosen, Boston Combined Residency Program, Boston, MA, United States; Alexandra Epee-Bounya, Harvard Medical School, Boston, MA, United States; Sarita Chung, Boston Children's Hospital, Boston, MA, United States; Dorothy Curran, Boston Children's Hospital, Boston, MA, United States; Robert M. Hoffmann, Boston Children's Hospital, BOSTON, MA, United States; Lois K. Lee, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Carolyn Marcus, Boston Children's Hospital, Boston, MA, United States; Camila M. Mateo, Division of General Pediatrics, Boston Children's Hospital, Jamaica Plain, MA, United States; Jason E. Miller, Boston Children's Hospital, Somerville, MA, United States; Cameron D. Nereim, USF Health Morsani College of Medicine, Tampa, FL, United States; Snehal N. Shah, Boston Children's Hospital, Boston, MA, United States; Elizabeth Silberholz, Boston Children's Hospital, Boston, MA, United States; Christina V. Theodoris, Boston Children's Hospital, Boston, MA, United States; Sara Toomey, Boston Children's Hospital, Boston, MA, United States; Ariel Winn, Boston Children's Hospital, Weston, MA, United States; Hanna Wardell, Boston Children's Hospital, Boston, MA, United States; Jonathan Finkelstein, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States; Valerie L. Ward, Boston Children's Hospital, Boston, MA, United States; Amy J. Starmer, Boston Children's Hospital, Boston, MA, United States

Background: The inclusion of race/ethnicity in clinical algorithms has been broadly documented, with recent debates on the appropriateness of their use in clinical decision-making. The extent to which race/ethnicity appear in pediatric clinical guidelines has not been well described.

Objective: To characterize the use of race/ethnicity within a pediatric quaternary care hospital’s clinical pathways library and to develop a framework to evaluate whether identified references to race/ethnicity should be retained, modified, or removed.

Design/Methods: A review of all text and associated reference documents for 132 institutionally-developed clinical pathways identified 8 that included mention of race/ethnicity (Table 1). Three of these pathways were selected (acute viral illness, hyperbilirubinemia, and weight management) for in-depth evaluation, as race/ethnicity was a potentially determining factor in the decision-making algorithm. These pathways were evaluated by 3 separate multi-specialty teams of faculty and trainees from December 2020-April 2021 using a structured framework to review the literature and develop recommendations (Table 2). The five remaining pathways did not undergo in-depth review as there was either clear evidence or a change in institutional policy that led to their modification.

Results: The reference to race was removed (n=6) or modified (n=2) in all eight pathways. The rationale for removal varied by pathway (Tables 1 & 3). In the modified pathways of acute viral illness and weight management, the most plausible mechanisms underlying the reported epidemiological associations between race/ethnicity and health outcomes were socio-environmental. Use of the reviewer framework established several best practices, including: (1) define race, ethnicity, and ancestry rigorously; (2) assess the most likely mechanisms underlying epidemiologic associations; (3) consider whether references may mitigate or exacerbate existing disparities; and (4) exercise caution when applying population-level data to individual patient encounters.Conclusion(s): Review of the use of race/ethnicity in institutional clinical pathways using a structured framework resulted in removal or modification of references to race/ethnicity in multiple pathways. National and institutional recognition of the issue of race and ethnicity in clinical decision-making is essential to advocate for change, including provider and health system leadership education, community partnerships, review of local data to understand hospital-specific risk, and review of other clinical decision support tools.
Curriculum VitaeRosen.Robert CV_Harvard Format 1.3.22.pdf
Table 2. Structured Reviewer Framework for Assessment of References to Race/Ethnicity in Clinical Algorithms1. Selected guiding questions adapted from Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020:1-9. doi:10.1056/nejmms2004740