Massachusetts Pediatric Injury Equity Review (MassPIER): A Process to Address Injury Inequities

The institutional review boards at Boston Medical Center and Johns Hopkins Bloomberg School of Public Health deemed the study exempt. The project had 2 phases. Phase 1 included participation in CDR local team meetings to understand the CDR process in Massachusetts, and begin development of equity-focused process and tools. Phase 2 involved adaptation of the initial tools and process, and evaluation of the resulting equity-focused injury prevention recommendations.

In Massachusetts, local CDR teams generate recommendations for submission to the state team, where dissemination and implementation primarily occur. Between November 2021 and April 2022, we attended CDR team meetings for 3 local teams in Massachusetts. Additionally, we gathered feedback from local and state CDR team members and leadership regarding their roles in the process and the tools they used. This information supplemented our understanding of their procedures for reviewing fatalities and generating recommendations. During that time, we recorded notes on a shared drive accessible only by the research team. In addition, we considered literature describing tools used for injury and equity evaluations. The aforementioned input, observations, and literature informed our development of the MassPIER tools and process.

From May 2022 to October 2022, the MassPIER process was implemented with the 3 local CDR teams in each of their regularly scheduled meetings. The decision was made to focus on 2 injury mechanisms (drowning and traffic) given their prevalence in Massachusetts and the need to focus on fewer mechanisms to determine the MassPIER process. Local teams met quarterly and spent the first quarterly meeting reviewing drowning and the second quarterly meeting reviewing traffic injury fatalities utilizing the tools and process developed by the research team.

We collected feedback from CDR team members through individual surveys and focus groups immediately after each meeting. Surveys were sent by e-mail and completed using Research Electronic Data Capture (REDCap).⁸ The survey included 23 questions. Most were multiple-choice, Likert-scale questions, with a few open-ended questions. The survey questions were divided into 5 sections, including questions on the respondent and their role with the CDR team, feedback on the process, feedback on the data summary and injury equity matrix, feedback on the CDR team setting and case(s), and other general thoughts or feedback.

Focus group questions were open-ended and based on a questionnaire developed by the research team. Questions were asked by the facilitator (a member of the research team), with additional follow-up questions asked when necessary. Focus groups were recorded via Zoom and the transcripts downloaded.

The research team reviewed and discussed the focus group transcript and survey results after each meeting, and determined adaptations to the MassPIER process and tools to be implemented in the next local team meeting. The research team completed a Framework for Reporting Adaptations and Modifications-Enhanced adaptation tracking form to document each adaptation.⁹ Framework for Reporting Adaptations and Modifications-Enhanced is an implementation science framework designed to systematically adapt an evidence-based intervention to improve its fit or increase effectiveness.⁹ Phase 2a is summarized in Fig 1.

We evaluated recommendations generated using the MassPIER process and those generated in previous years by the same local teams to determine the number of recommendations that addressed equity before and after MassPIER. These numbers were compared using a χ² test or Fisher’s exact test, as applicable.¹⁰ To improve the accuracy of the evaluation and minimize bias, 2 members of the research team independently coded the recommendations. They discussed any discrepancies to reach an agreement.

The survey instrument, focus group guide, and a sample adaptation tracking form are available by request.

We developed 2 tools during the implementation, which we refined after each meeting on the basis of the teams' feedback and discussion within the research team. The Injury Equity Framework, a conceptual framework for understanding the complex factors which contribute to inequitable injury outcomes, was developed and published.¹¹ It integrates factors from the Haddon Matrix with the socioecological model and cliff of good health.^12,13 The Haddon Matrix helps to identify contributors to injury outcomes and opportunities to intervene and reduce associated risk. The socioecological model and cliff of good health are used to understand the complex factors which contribute to inequities in health and health care outcomes.

The Injury Equity Matrix was developed as a companion working tool to the Injury Equity Framework and subsequently divided into the Injury Equity Matrix for Recommendation Development (Fig 2) and the Injury Equity Matrix for Refinement and Implementation (Fig 3). The Injury Equity Matrix for Recommendation Development is a fillable tool to evaluate inequities in a specific injury mechanism which includes, from left to right, a column for categories of countermeasures, specific modifiable factors within each category of countermeasure, intersectional identities (the demographic factors with which a person or group identifies),^14,15 and recommendations. The categories of countermeasures were dictated by the Haddon Matrix, and include environment, education, equipment/safety products, and treatment and recovery.¹² Each of these factors is known to impact injury outcomes. The Injury Equity Matrix for Refinement and Implementation (Fig 3) was developed to identify relevant legislation, policies, or programs and the respective accountable organization or governing body. The columns in this tool will be discussed further in the process development section below.

A 7-step process for pediatric injury equity review was developed (Table 1). Many steps mirrored the existing CDR process in Massachusetts, in which local teams perform reviews of child deaths and make recommendations to a state-level team. Additional steps were added at the local and state levels to adapt the process for an equity-focused review of injuries including structural factors.

The steps include team identification, population-level data preparation, literature review, case identification and review, data review, discussion of modifiable factors to develop recommendations, and recommendation refinement, dissemination, and implementation. For Step 1, team identification, certain team members in Massachusetts are mandated including the chief medical examiner, a pediatrician, and representatives from various law enforcement and child health agencies within state and local government. We recommend also inviting subject matter experts and/or representatives from agencies directly involved in some aspect of the injury mechanism being reviewed as helpful participants in the review meeting (eg, a representative from the Department of Transportation when reviewing traffic injury death cases, or representative from the Department of Conservation and Recreation when reviewing drowning death cases).

Steps 2 and 3, population-level data preparation and literature review, were done by the research team, and included the preparation of population-level county and state data on the injury mechanism being reviewed. These data were provided by the Massachusetts Department of Public Health. Tools used included graphs by rate of injury utilizing different demographic identities and geographic information system (GIS) mapping. GIS mapping was used to demonstrate environmental factors related to the specific injury mechanism being discussed (eg, demonstrating the location of free or reduced cost swim lessons in a county when discussing drowning). In addition, the research team conducted a literature review of factors that may contribute to injury inequities to add to the injury equity matrix (for use during the meeting to assist with the discussion).

Step 4, identification and review of cases that resulted in the death of a child, was performed by the CDR local team coordinators with input from the research team. Although the number of deaths reviewed varied in each meeting, each meeting was dedicated to a specific injury mechanism, and if >1 death was reviewed, all involved a similar injury mechanism (traffic injuries or drowning).

Step 5, data review, was done during the meeting, and involved a review of population-level data collected to share the context of injury at the local and state levels. Step 6 was a discussion of modifiable factors by the entire team during the meeting, utilizing the Injury Equity Matrix for Recommendation Development to help guide discussion around factors contributing to inequities. This discussion concluded with recommendation development by team members.

In step 7, as meetings concluded, recommendations generated were collated and refined by the research team using the Injury Equity Matrix for Recommendation Refinement and Implementation. The recommendations were evaluated for their impact on equity (utilizing an equity score), specific disparity(s) addressed, and area of impact on the basis of the injury equity matrix and socioecological model.

In the refinement process, we removed or combined the related or overlapping recommendations. We used Specific, Measurable, Achievable, Relevant, Time-Bound criteria to refine them.¹⁶ We employed a simple equity scoring system with 4 categories (likely to decrease disparities, mixed impact on disparities, likely to increase disparities, and inconclusive impact on disparities) to identify the highest-value, equity-focused recommendations.¹⁷ 

The refinement step is crucial because sometimes the recommendations are inherently beneficial, but their effectiveness in addressing injury inequities may vary depending on the implementation details and the communities they serve. For instance, offering free and affordable swim classes could reduce disparities only if they are readily accessible to populations which have been historically marginalized and underserved. Finally, to move the theoretical recommendation to the critical next stage of dissemination and implementation, we identified relevant legislation, policies, or programs, as well as the accountable or governing body to which we directed the recommendation, and shared it with the state team for review. The steps are summarized in Table 1.

Recommendations for addressing drowning and traffic injury inequities generated with the 3 teams during the 6 months of MassPIER reviews focused on a wide range of underlying factors which contribute to injury inequities. The 6 meetings (2 meetings with each team, 1 focusing on drowning injuries, the other on traffic injuries) yielded 57 recommendations. Table 2 displays the number of equity-focused recommendations by different intersectional identities.

Fifty-seven recommendations were developed during the year MassPIER was implemented compared with 60 in the 5 years before MassPIER (2016–2020). Around 28% of recommendations generated by local CDR teams through the MassPIER process addressed at least 1 of the equity criteria defined in the injury equity matrix. This suggests more than twofold improvement in the equity focus of recommendations compared with those generated by the same local teams during 21 meetings over the preceding 5 years, in which 13% addressed inequities. There is a statistically significant association between using the MassPIER process and generating equity-focused recommendations when evaluated collectively (P = .048), and specifically in recommendations that address economic inequities (P = .003).

The survey received responses from a variety of CDR team members, including CDR coordinators, team leads, and various other affiliate team members with primary roles such as physician, judge, child welfare, and public health professionals. Each team was asked to complete the survey twice, after each of the 2 meetings which were focused on the MassPIER process. Among the responses, 100% strongly agreed or agreed that it was simple to follow and adaptable to any type of injury. Additionally, 95% strongly agreed or agreed that the approach could be replicated by other teams. Furthermore, 95.5% strongly agreed or agreed that the injury equity matrix facilitated equity-focused thinking and discussion around risk factors and possible recommendations. Only 20% of participants thought that additional data were needed to complete each injury equity review. Participants had mixed opinions on including additional partners external to the usual CDR process in the injury equity review, with 43% believing that including additional partners would have improved the review.

Results reveal the successful adaptation of the CDR process to be used for an equity-focused, multifactorial review of injury inequities at the local level, with the potential for translation and implementation at the state level. Although the CDR process has continued to grow in terms of the data accessed and its expanded attention to prevention and recently equity,^5,16 there is still a gap in its focus on equity-oriented initiatives, as well as its focus on the importance of systemic and structural change. Previous studies have focused on increasing the injury prevention recommendations through CDR but have not focused on inequities in injury specifically.^18,19 Determinants of childhood injury have been discussed in the literature previously,²⁰ and the MassPIER process, as described herein, is another tool that can be used to identify these determinants and use them for implementing programs and policy to address them.

The limited accessibility of local fatality data stratified by injury mechanism, race, ethnicity, and other characteristics is a limitation. Data were often suppressed for confidentiality purposes because of low overall fatalities at the local level for certain injury mechanisms. In addition, data collection, analysis, and presentation were time-consuming processes that were performed by the research team. On the programmatic side, the 1-year time frame of the study and set CDR team meeting dates limited our ability to leverage additional partnerships and the input of relevant partners outside of the core CDR team. This may have contributed to the mixed opinions of participants on including partners, who we theorize may have increased the robustness and feasibility of recommendations developed.

In this study, we were able to develop a 7-step process to address pediatric injury inequities, built on the Massachusetts CDR process. The resulting process was effective in promoting equity-focused recommendation development and feasible and acceptable to CDR team members. Furthermore, MassPIER was determined to be adaptable to different injury mechanisms and geographic locations. Future work will focus on adapting the data collection and presentation process for increased usability by CDR team members without the support of the research team, and identifying additional partners who are well-positioned to further refine, implement, and disseminate recommendations from the MassPIER process.

We thank Jonathan Bressler, MSPH, and Dr Samatha Riley for analyzing and providing data; Dr Megan Sandel for her contribution to the study design; Drs Michelle Macy and Mark Zonfrillo for their input into the injury equity framework and matrices; Dr Mari-Lynn Drainoni for her assistance in the implementation science framework; and the Suffolk, Norfolk, and Middlesex County CDR teams, who graciously partnered with us for this work.

CDR

child death review

MassPIER

Massachusetts Pediatric Injury Equity Review