Understanding and Addressing Racial and Ethnic Inequities in Pediatric Length of Stay Free

Prolonged pediatric hospitalizations can lead to financial and capacity strain for health systems and generate psychosocial and economic stress for children and their caregivers. Hospital length of stay (LOS) is therefore often measured as an indicator of health care quality, reflecting differences in both access to high-quality preventive care before admission and quality and efficiency of care delivered in the inpatient setting. Several recent studies have found that Black and Hispanic/Latine children, as well as children from other minoritized groups, have a longer average LOS when admitted for common pediatric conditions like appendicitis and severe sepsis.^1,2  These studies provide critical quantitative evidence of inequities within our health system and underscore the need for interventions that address key drivers of these disparities and promote more equitable health care delivery.

In this issue of Hospital Pediatrics, Harrington et al³  add to this existing literature by describing differences in LOS across racial and ethnic groups for 10 of the most common pediatric inpatient diagnoses. Using data from the 2016 and 2019 Kids’ Inpatient Database, they find evidence of significantly longer inpatient LOS for Black, Hispanic/Latine, or Asian American/Pacific Islander or Native American children, as compared with non-Hispanic white children, across 8 of these 10 diagnoses. Furthermore, they note that many of these disparities persisted from 2016 to 2019. This work offers an important contribution to the literature by corroborating previous evidence of increased LOS for minoritized children with appendicitis and sepsis, documenting additional disparities in LOS for conditions like diabetes and urinary tract infection, and demonstrating that many of these disparities persisted over time.

Their findings should be interpreted in the context of some key limitations. First, statistically significant differences and clinically meaningful disparities are distinct concepts.⁴  A statistically significant difference in LOS may not be clinically meaningful or impactful to families, particularly if it is a difference of a few hours rather than a few days. Similarly, the absence of a statistically significant difference may only indicate a lack of statistical power and should not be used to conclude that no clinical disparity in care exists. Second, focusing on LOS alone may limit the authors’ ability to detect important disparities in other health outcomes. For example, the authors report no differences in asthma LOS across racial or ethnic groups in 2019 and optimistically ascribe this to more equitable asthma care delivery, but other studies have documented persistent racial and ethnic inequities in pediatric asthma incidence, morbidity, and mortality during the same time period.^5,6  Lastly, as the authors acknowledge, their use of a combined category of “Asian American or Pacific Islander, Native American, and other race” may obscure differences in LOS within or across these heterogeneous groups, and future studies should use disaggregated data to more clearly characterize inequities.

Despite these limitations, Harrington et al’s work provides valuable evidence of the presence and persistence of racial and ethnic differences in pediatric LOS between 2016 and 2019. This descriptive work is critically important but also insufficient, and achieving equitable child health outcomes will require a shift from describing the problem of racial and ethnic differences in LOS to developing, implementing, and evaluating evidence-based solutions.⁷  As they conceptualize and develop these solutions, pediatric providers and health systems should consider the mechanisms underlying differences in LOS, including the potential role of structural, institutional, interpersonal, and intrapersonal or internalized racism and oppression.⁸ 

Structural factors that contribute to disparities in LOS include population-level social determinants of health, which may lead to more severe illness at the time of presentation and consequently longer LOS required for stabilization and recovery. For example, children from minoritized racial and ethnic groups may be disproportionately exposed to harsh environmental conditions that worsen chronic disease control for conditions like asthma and diabetes. Their families may face economic and geographic barriers to accessing high-quality preventive care and necessary medications because of structural racism and resulting economic disinvestment in their communities.⁹  Harrington et al partially account for differences in severity of illness by adjusting for hospitalization resource intensity score for kids.¹⁰  Future quantitative studies could examine severity of illness as a mediator of differences in LOS, rather than a covariate, to assess how reducing inequities in illness severity on presentation might impact LOS. In addition, interventions like medical–financial partnerships and home and neighborhood-level environmental remediation may help address structural racism as a driver of differences in LOS.¹¹ 

Institutional racism or oppression refers to health system-level pathways, policies, and services that systematically advantage or disadvantage patients on the basis of their race or ethnicity. For example, clinical practice guidelines or pathways that include race as a predictor of disease severity can falsely imply that there are biological differences in children’s health based on their race and result in systematic under- or overtreatment of minoritized populations. It is encouraging to see recent national shifts toward removing race from clinical algorithms, as with the pediatric guidelines for urinary tract infections, but continued culture shifts at the institution level are critical.¹²  In addition, institutional policies around accommodations for families who speak languages other than English, such as the accessibility of interpreters in the emergency department, on rounds, and at the time of discharge, may contribute to differences in LOS.¹³  Therefore, pediatric health systems seeking to address inequities in LOS should critically review their own institutional policies, with a focus on dissolving race-based algorithms while promoting equitable, culturally competent care.

Interpersonal racism in health care delivery encompasses implicit and explicit biases held by members of a child’s care team, which may influence their medical decision-making. Several studies have documented associations between clinicians’ implicit biases and inequities in their treatment recommendations, pain and symptom management, and empathy toward minoritized patients.^14,15  Collectively, these factors may lead to delays in treatment and influence when families are deemed “ready” for discharge, resulting in prolonged LOS. Longitudinal provider education focused on implicit bias, inequities in child health outcomes, and the relationship between racism and these health outcomes may help providers identify and address their own biases and promote a more uniform, equitable standard of care.

Finally, intrapersonal factors may also contribute to disparities in LOS. Internalized racism refers to subconscious acceptance of the established racial hierarchy, often instilled in caregivers of color by the aforementioned forms of racism.¹⁶  This internalization can influence their sense of self-worth, especially in unfamiliar spaces, and lead our minoritized families to feel as though they are not adequately equipped to advocate for their children. These intrapersonal feelings of stigma or self-doubt may only be compounded by the psychological stress generated by hospitalization.¹⁷  Health systems may be able to address intrapersonal racism by employing trained, culturally concordant community health workers to help families navigate their inpatient stay and by adopting a family-centered, strengths-based approach to assessing and addressing families’ social needs while their children are hospitalized.^18,19 

When designing interventions to address racial and ethnic differences in LOS, it will also be critically important to elicit families’ perspectives on these differences and their recommendations for improving care. Prolonged LOS is typically viewed as a negative outcome given its association with financial burdens for caregivers and health systems. However, it is possible that, in some cases, a longer LOS may, in fact, be more family-centered. For example, families who speak a language other than English might require more time for discharge education with an interpreter, and families with conflicting work and child care obligations might find discharge in the evening more convenient than the early morning. In addition, as a growing number of pediatric health systems implement social needs screening in the inpatient setting, some families may require a longer LOS to ensure any urgent needs are adequately addressed before discharge. How do we generate meaningful improvements in LOS in a way that is family-centered? Perhaps the way to establish health equity is not by working toward an equal LOS for all patients, but rather by ensuring the right balance of high-quality care and family-centered support to meet each family’s needs for the duration of their inpatient stay.

As Harrington et al hypothesized, disparities in LOS for most diagnoses were consistent over their 3-year study period. This finding was not particularly surprising, because we are unaware of any concerted efforts to address racial disparities from 2016 to 2019, and we know that quality improvement efforts can often maintain or even worsen disparities if they are not designed with an explicit focus on health equity.²⁰  Since 2020, many health systems have announced commitments to addressing structural racism, in response to the murder of George Floyd and the stark racial disparities laid bare by the severe acute respiratory syndrome coronavirus 2 pandemic, but it remains to be seen whether these announcements will translate into meaningful interventions that generate more equitable outcomes. Unpacking the mechanisms underlying disparities in child health outcomes and understanding their influence on families’ lives will be essential to designing and implementing effective interventions. A concerted, multitiered approach addressing structural, institutional, interpersonal, and intrapersonal racism and oppression in health care will be critical to ensuring that all children can receive the high-quality care they deserve, when and where they need it.