PEACH Projects

Project Lead: Toby Lewis

Question: Are there differences in the recommended prescription treatment of inhaled corticosteroid (ICS) based anti-inflammatory relievers (AIR) for asthma based on patient sociodemographic factors, health factors, or provider type?

Project Lead: Dalia Ishaq and Marisa Louie

Question: Do patients presenting to the ED with musculoskeletal pain/injury experience differences in (1) nurse-initiated patient care orders (NIPCO) activation, (2) time to pain assessment, (3) time to radiograph orders, and (4) time pain medication orders associated with their demographic characteristics including LEP?

Project Lead: Patrice Hicks

Question: Among pedatric patients who screen positive for visual impariment, are there differences by demographics in who recieves a referral to Ophthalmology and of those referred to Michigan Medicine Ophthalmology, complete an appointment/

Project Lead: Jessica Gratz, Aparna Joshi, and Anastasia Hryhorczuk

Question: Is imaging (ultrasound, CT scan, MRI) used differentially in patients with abdominal pain based on BMI? 

Project Lead: Morgan Bolen

Question: Is there variation in wait times for child therapy iniation by patient demographics? 

Project Lead: Karen Wilson

Question(s): Do caregivers of pediatric patients (one and under) in cardiology receive the same rooming in requirements across racial and socioeconomic backgrounds? 

Project Lead: Jeremy Adler and Keyonna Williams

Question(s): For patients with IBD, does the time from first gastroenterology appointments to evaluation (endoscopy) and imaging (MRI) procedures vary by race, ethnicity, socioeconomic status and gender?

Project Lead: Keyonna Williams

Question(s): Are there differences in referral to Child Protective Services for specific injuries by race, ethnicity, income gradient and gender?

Project Lead: Susan Woolford

Question(s): Are weight loss medications prescribed differentially for those 13-21 years old by race, ethnicity, socioeconomic status, and gender? Is there a clinic or location effect? Is there an insurance effect?

Project Leads: Kennedy Miller and Karin Muraszko

Question(s): Follow-up care for very low birthweight infants with Grade III/IV intraventricular hemorrhage who receive an intraventricular shunt (IVS) is essential to ensure proper functioning of the shunt and to prevent an adverse neurological condition known as hydrocephalus. Are there differences among groups of infants (race, gender, SES, language) with IVS regarding routine follow up after shunt placement? Are there differences among groups of infants (race, gender, SES, language) with IVS regarding imaging after shunt placement? Which children are referred to social work prior to discharge from shunt placement?

Project Leads: Uswa Iqbal, Aparna Joshi, Anastasia Hryhoczuk

Question(s): Among outpatient patients who receive same-day accommodations for ultrasounds (that do not require this accommodation due to clinical indication), do they differ by race, ethnicity, and income?

Project Leads: Gary Freed

Question(s): Does use of annual depression and anxiety screenings (via PHQ-9, EPDS, GAD-7) and subsequent management in Michigan Medicine primary care clinics vary for patients by race, ethnicity, socioeconomic status, primary language spoken, gender, and weight status? 

Project Leads: Zubin Modi

Question(s): Are there inequities in referrals to Nephrology for pediatric patients at MM with evidence of PCKD?

Project Leads: Joi Sessum and Phoebe Jordan

Question(s): Across Michigan Medicine primary care clinics, do referral rates to Integrated Behavioral Health vary by patient sociodemographic characteristics? 

Project Leads: Erin Boulger

Question(s): Does parent/caregiver portal access vary by race of child? 

Project Leads: Dario Alvarez and Erin Carlton

Question(s): Does activation of the Rapid Response Team (RTT) vary by preferred language, SES (median income, ADI, and type of insurance), race, ethnicity, gender, and BMI? Amongst those with an RTT activated, is there a differentiation of timing of when the RRT is called for children admitted for a specific diagnosis (i.e., bronchiolitis)? Amongst those with an RRT called, does intubation within six hours of RRT vary by social factors? Amongst those with an RRT called, does use of vasoactive medications within six hours of RRT vary by social factors?

Project Leads: Susan Woolford

Question(s): re weight loss medications prescribed differentially for those 12 - <21 years old by race, ethnicity, socioeconomic status, language preference, and gender?

Project Leads: Esther Yoon

Question(s): Are there inequities by sociodemographic factors for pediatric patients attending well-child visits for whom lead screening and anemia tests were ordered?

Project Leads: Catherine Cheng and Allison Cator

Question(s): Do patient characteristics (e.g., race, SES, and language preference) influence likelihood of referral to CPS (i.e., a 3200 report) for accidental ingestion (controlling for severity and ingestion type)?

Project Lead: Monica Rosen

Question(s): Does disability status, race, and ethnicity impact likelihood of whether female patients seen in Michigan Medicine primary care clinics receive any vaccination for human papillomavirus (HPV)?

Project Lead: Jamie MacLaren

Question(s): Are there inequities by race, ethnicity, and language in CLABSI prevention practices?

Project Lead: Carolina Typaldos 

Question(s): C-section rates for first-time, low-risk mothers are below the expected rate for White mothers, while above the expected rate for Black mothers and this gap seems to be widening. What is the reason for this gap? 

Project Lead: Anisha Coughlin

Question(s): Sepsis, a life-threatening condition, can result in significant morbidity and mortality. Prompt recognition and management of sepsis is critical to mitigating these outcomes. Dr. Coughlin is assessing any potential inequity in the sepsis detection and management measures at C.S. Mott Children's Hospital.

Project Lead: Gary Freed 

Question(s): Does vision screening of 4- and 5-year-old pediatric patients at well child primary care visits vary by race, ethnicity, gender, and socioeconomic status? Does vision screening vary by primary care clinic and/or the specialty providing primary care?  

This study investigates potential inequities in pediatric vision screenings for young children within the Michigan Medicine healthcare system. While early detection is vital for preventing permanent vision loss, the data reveals that White and Non-Hispanic children receive screenings at significantly higher rates than their Black and Hispanic peers. 

Interestingly, these inequities are largely linked to the specific medical specialty or clinic location providing the care, rather than a family's financial status. General Pediatrics clinics demonstrated much higher screening consistency compared to Family Medicine or Med-Peds departments. 

Because the clinics serving the highest number of minority patients had the lowest testing rates, the researchers advocate for standardized screening protocols across all locations. This effort aims to align every clinic with national health recommendations to ensure equitable developmental outcomes for all children.

Project Lead: Monica Rosen

Several national organizations, including the United States Preventative Task Force (USPSTF), the American Academy of Pediatrics (AAP), and the Centers for Disease Control (CDC), have released guidelines recommending screening for STIs in sexually active females under the age of 25 years. Yet, research suggests there is insufficient sexual health screening provided at routine care visits. Moreover, there is reason to believe that some adolescents may be particularly likely to experience a paucity of sexual health screening: adolescents with disabilities. Despite the reality that individuals with physical and intellectual disabilities are at increased risk of sexual abuse and research on adults with disabilities indicates they experience higher prevalence of sexually transmitted infections, providers may exhibit implicit biases around the sexual health needs of adolescents with disabilities and/or be more likely to defer to guardians to understand their sexual health needs. Additionally, race, ethnicity, and language preference have been shown to be associated with differences in gynecologic care. Dr. Monica Rosen questioned: Does disability status, race, and ethnicity impact likelihood of whether female patients 16-<21 seen for well child visits are screened for sexually transmitted infections (STIs)?

Over a roughly 3-year time period (July 1, 2021 to Sept. 13, 2024), 19,161 well visits[i] with female adolescents (16 - <21) were identified. Providers ordered STI screening in 3,559 (18.6%) of these encounters. Disability was associated with lower odds of STI screening, unadjusted and adjusting for race, ethnicity, language preference, and age. Analyses examining different categories of disability – physical, sensory, developmental/behavioral, psychological, and intellectual – showed that physical, developmental/behavioral, and intellectual disability were associated with lower odds of STI screening, unadjusted and adjusting for race, ethnicity, language preference, and age. Psychological diagnoses were associated with greater odds of disability screening, and sensory disabilities showed a trend of greater odds of screening with marginal statistical significance (which did not meet our a priori criteria of p<0.05).

Race also impacted likelihood of STI screening. Encounters in which the patient was categorized as “Other” race had lower odds of STI screening when compared to encounters with White patients. There were no differences on the rate of screening by ethnicity. Additionally, there was a significant interaction between race and disability: patients identified as Other race with a disability had a higher rate of STI screening than those of Other race without a disability, whereas among White and Black patients, those with a disability had a lower rate of screening compared to those without a disability.

This study confirms the primary hypothesis: patients with disabilities, particularly physical, developmental/behavioral, and intellectual, are less likely to be screened for STIs. Analysis of race and ethnicity indicates that race impacts screening rates, specifically when comparing patients designated as “Other” race with White patients, as well as when investigating interactions between disability and race. As a result, it is now moving into the quality improvement phase.

Project Leads: Children's Emergency Services: Prashant Mahajan, Luke Rasmussen, and Breeanna Lorenzen; Psychiatric Emergency Services: Prashant Mahajan, Victor Hong, Luke Rasmussen

Question(s): Does use of restraints vary for pediatric patients by race, socioeconomic status, weight status, primary language spoken, and gender in Children's Emergency Services and Psychiatric Emergency Services, and Adult Emergency Services?

Project Leads: Keyonna Williams and Peter Ehrlich

Question(s): Are there differences in care provided to pediatric trauma patients relative to English proficiency, SES, and other social factors?

Project Lead: Rachael Pace

Question(s): For very low birthweight patients in the first 14 days of life spent in the Neonatal Intensive Care Unit (NICU), is the duration of Kangaroo Care the same across patients of different racial and socioeconomic backgrounds?

Kangaroo care (a method of holding a baby to a caretaker's chest for skin-to-skin contact) is vital to ensuring optimal immediate and long-term cognitive, social, and behavioral outcomes for children born preterm or with low birth weight. 

This research study investigates whether Kangaroo Care is distributed fairly among diverse racial groups within the Neonatal Intensive Care Unit. By reviewing medical records from a two-year period, researchers assessed the frequency and duration of this vital therapy for vulnerable infants during their first weeks of life. 

The findings reveal a significant inequity in the administration of this care, showing that White infants received more treatment than those from minority backgrounds. 

To address these inequities, the study suggests implementing standardized documentation and identifying the specific resources needed to support all families. Ultimately, the project highlights the role of nursing staff and parental expectations in ensuring that these life-saving bonding practices are accessible to every patient.

Project Leads: Maleea Roy and Meredith Irvine

Question(s): Are legacy interventions delivered equitably among hospitalized children?

Legacy Interventions are offered at the hospital to provide support to families of patients who pass away. They involve keepsakes in memoriam of the deceased, including molds and prints of hands and feet, locks of hair, heartbeat recordings, and pendants. Maleea Roy, a music therapist for Child & Family Life, questioned: Are Legacy Interventions provided universally to all bereaving families of pediatric patients?

Examining records of pediatric decedents from Jan. 1, 2022 to April 30, 2023, the primary predictor of whether a Legacy Intervention was offered was location: whether the pediatric patient died in C.S. Mott Hospital, where Legacy Interventions were offered. However, analyses revealed that a different process was in place to offer Legacy Interventions in the case of stillbirths in Von Voightlander Women's Hospital, and not all stillbirths resulted in the offering of a Legacy Intervention during the study period. Child & Family Life has since added staffing, and PEACH is now working with the project leads to monitor whether Legacy Intervention are offered in all stillbirths.

Project Lead: Jennifer Erb-Downward  

Question(s): For pediatric patients who report a concern with food, utilities, or housing insecurity and a desire to be connected to resources to their primary care providers via the Partners in Care Questionnaire (PICQ), do they receive appropriate referrals to social work?

Background: In Michigan, one in eight children face hunger. One in ten children experience homelessness during grades k-12, with higher rates among Black and Hispanic children. Food and housing insecurity can dramatically impact children’s health and wellbeing. In recognition of the importance of such factors, Michigan Medicine screens patients to assess for unmet needs through the PICQ (initiated in primary care in 2018), including food and housing insecurity. On the PICQ, patients are asked if they would like assistance with any unmet needs reported. Michigan Medicine developed a process in 2020 through the Care Management Department to monitor PICQ requests for assistance and respond to them, so the onus was not on providers to ensure appropriate referrals were made to social work. Within this department, a Complex Care Management Team receives all requests for assistance and sends a referral internally within 2-3 days. (Patients that report they do not want assistance or leave the question on assistance blank do not receive a referral.) This project ultimately investigated whether that process occurred uniformly.  

Results: From August 1, 2021-June 24, 2024, 4,842 PICQs with a patient reporting a housing, utilities, and/or food insecurity concern were recorded in the SDOH Data Mart. These surveys were either completed in clinic or on the patient portal. A subset of patients reported on the survey that they did not want assistance (n=3052) or left the question blank (i.e., item non-response) (n=478). Of 1312 requests for assistance, 778 (59.3%) were documented as receiving referrals to social work. Per the Care Management Department, a new role was hired in February 2023 to further coordinate responses to the PICQ: SDOH coordinator. After this change, 1,740 PICQs were identified with a housing, utilities, and/or food insecurity concern. Among these PICQs, 626 patients requested assistance, but 149 had no documented referral to social work. These 149 encounters were chart reviewed. Chart review showed that the Complex Care Management Team, including their SDOH coordinator, responded to 146 of the patients as documented in the patient portal either before or after their office visit. Two records had no clear follow-up action documented, and one record included a note that the request for assistance was made in error. 

Conclusion: This study indicates that Michigan Medicine (through the Complex Care Team) has been successful in ensuring pediatric patients who report a need for assistance receive a response in the form of a referral to social work or information about available community resources in the patient portal. 

Project Leads: Katherine Salada and Jodi Ehrmann

Question(s): Do children admitted to the general pediatric hospitalist service for growth faltering (previously known as "failure to thrive") vary by race/ethnicity, socioeconomic status, and primary language spoken in terms of: the threshold for admission, length of stay, social consultations received (e.g., social work and Children's Protective Services), and the threshold for discharge?

Project Lead: Anne Baetzel 

Question(s): Are there racial and socioeconomic differences among infants undergoing delayed circumcision (4-35 months) in terms of whether they receive awake spinal anesthesia or general anesthesia? 

Project Leads: Kimberly Slonaker, Anna McEvoy and Allison Cator

Question(s): Are there inequities in drug testing practices in Emergency Services for pediatric patients?

Project Leads: Katie O'Brien and Monica Rosen

Endometriosis is a chronic condition marked by chronic pelvic pain (CPP), dysmenorrhea, and subfertility that often presents in adolescence. Research in the adult population has demonstrated that non-White race is associated with greater delay in surgical diagnosis of endometriosis. Drs. Katie O'Brien and Monica Rosen examined whether there is inequity among adolescents in receipt of a diagnostic laparoscopy for dysmenorrhea based on race, ethnicity, socioeconomic status, and language preference.

Of the 4,480 patients meeting inclusion criteria, 4,426 were expectantly managed, 47 underwent scheduled diagnostic laparoscopy, and 7 underwent emergent laparoscopy. Only 3.5% (n=2) of Black patients received any laparoscopy, both for emergent care. Black patients were significantly less likely to receive any laparoscopy or non-emergent surgery than White patients. Patients of Asian descent were less likely to undergo any laparoscopy than White patients. Hispanic patients were less likely to undergo scheduled laparoscopy than non-Hispanic patients. Older patients were more likely to have laparoscopy. There was no significant difference in rate of laparoscopy according to Area Deprivation Index.

Currently, a standardized threshold for when a diagnostic laparoscopy is warranted does not exist. Through deliberation with project leads, it was determined that the best path forward would be to share the results among the small provider group and discuss within this group a potential threshold of failed medications before laparoscopy. If any specific quality improvement opportunities are identified by this group moving forward, PEACH will be available to offer additional support.

Project Leads: Maria Skoczylas, Amanda Costa and Lauren Oshman

Question(s): Is meconium drug testing done equitably within the Michigan Medicine health system?

This project examined newborn drug testing (meconium screens), which can help identify intrauterine substance exposure but may also lead to unintended harms, including unnecessary Child Protective Services (CPS) involvement. Prior research shows Black families are disproportionately impacted by CPS reporting, raising concerns about potential bias in clinician-directed testing decisions.

In 2022, the team identified higher rates of meconium drug testing among Black newborns compared to White newborns. To address this disparity, a multidisciplinary group implemented a guideline in February 2023 to standardize clinical indications for testing and reduce variability in ordering practices.

However, the disparity worsened after implementation (Feb 2023–Apr 2024). Testing rates increased for both groups but more sharply for Black newborns — from 5.3% to 9.1% — compared to White newborns, which rose from 3.2% to 3.8%. This increase was largely driven by marijuana-only testing, which rose from 4.5% to 7.2% in Black newborns but remained stable in White newborns (2.6% to 2.7%).

Because the intervention did not reduce inequities, the team is now pursuing system-level changes, including engagement with state officials on CPS reporting requirements and efforts to revise institutional drug testing policies.

Project Lead: Rebecca Hong 

Question(s): Is there a difference in pain management between neuromuscular and idiopathic pediatric patients? Within the neuromuscular group, is there a difference if the patient is verbal versus nonverbal?

Project Leads: Jason Weinberg, Liz Lloyd and Tim Schurz

Question(s): Did implementation of institutional guidelines for management of acute osteomyelitis improve patient outcomes and decrease variablity in treament based on race, ethnicity, primary language, SES and gender? Are there inequities currently present?

Project Lead: Elizabeth Speck and Nikhil Shah

Question(s): Are there differences in length of stay after laparoscopic appendectomy for uncomplicated appendicitis by race, ethnicity, language preference, income gradient and gender? If so, are these differences caused by the health system? Can a standardized protocol designed by the research team help increase equity in same-day discharge procedures?

Project Lead: Katie Kruse 

Question(s): Does use of restraints and seclusion vary for pediatric patients by race, socioeconomic status, weight status, primary language spoken, and gender in: 

• a 3-bed psychiatric unit for patients with neurodevelopmental disorders? 

• the pediatric psychiatric ward more generally?

Project Leads: Erin Isaacson and Monica Rosen 

This project looked at patient referrals to the Fertility Preservation Program at Michigan Medicine.

Pediatric patients undergoing gonadotoxic treatments, such as chemotherapy and radiation, can permanently damage reproductive function. As a result, various organizations have established guidelines that encourage providers to offer patients referrals to reproductive specialists to discuss options for fertility preservation before undergoing gonadotoxic treatments.

Drs. Erin Isaacson and Monica Rosen examined whether there were inequities in referral to the Fertility Preservation Program among patients who receive medication that causes ovarian toxicity.

The total cohort included 236 patients, of which 122 (51.6%) were referred for fertility preservation services. There was no significant difference in racial or ethnic backgrounds between those referred and not referred. Those referred were more likely to speak English, although only nine patients were identified as having a primary language other than English. Those referred were also significantly older, although this could be explained, in part, by the fact that Michigan Medicine does not offer the fertility preservation needed by younger children.

Given these results, project leads determined the best path forward would be to share results with their Reproductive Endocrinology & Infertility colleagues to assess whether greater education around the fertility preservation referral is needed. If any quality improvement opportunities are identified by this group, PEACH will be available to support them.

Project Lead: FW Williamson

Question: Are there inequities in the occurrence and quality of risk communication with pediatric urology patients and caregivers?