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.