PEACH Projects

Project Lead: FW Williamson

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

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 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 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 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: 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 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 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: Jennifer Erb-Downward  

Question(s): Do children and adolescents whose caregivers report a concern about housing or food insecurity receive appropriate referrals to services within the primary care setting?

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: 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: 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: Kimberly Slonaker, Anna McEvoy and Allison Cator

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

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 Lead: Gary Freed 

Visual impairment is the most common cause of disability in children. Early detection is critical for increasing the likelihood of successful treatment and promoting positive outcomes, including academic performance. Given its importance, the American Academy of Pediatrics (AAP) recommends screening children’s vision at pediatric primary care visits. A pediatric ophthalmologist fellow, Olivia Killeen, brought this question to PEACH, which Gary Freed led investigation of: are 4-year-old and 5-year-old pediatric patients seen for a well-child visit at Michigan Medicine primary care clinics receiving vision screening?

Analyses showed that rates of screening varied by race and ethnicity. White patients had higher rates of screening compared to both Black patients and patients classified as "Other" race (classified as such due to small sample sizes of each of the combined racial groups); Non-Hispanic patients had higher rates of screening compared to Hispanic patients. Gender and Area Deprivation Index (proxy of socioeconomic status) analyses did not demonstrate clinically meaningful differences between groups. Across the individual 18 clinics, overall screening rates varied from 27% to 95%. When controlling for clinical site, race differences were no longer significant, indicating Black children were more likely to be seen in the primary care clinics with lower rates of screening. The project also found that screening rates varied by provider specialty: lower rates of screening were seen in Family Medicine and Med Peds clinics.

In sum, this project found that vision screening rates varied by race and ethnicity, in part due to lower rates of screening in the pediatric clinic that provided care to the majority of Black children. 

To improve rates of screening among Black and Hispanic children and promote the wellbeing of all children, we are working with our health system to ensure primary care clinics provide vision screening to all children in accordance with the AAP recommendations.

Project Leads: Maleea Roy and Meredith Irvine

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 Leads: Maria Skoczylas, Amanda Costa and Lauren Oshman

This project focused on newborn drug testing (i.e., meconium drug screens). Testing newborns for intrauterine drug exposure may be useful in certain cases to diagnose potential problems that can be addressed through medical and social service follow-up. However, newborn drug testing also can have unintended negative consequences, including involving families with Child Protection Services (CPS) when not beneficial, and in some cases, detrimental. Research shows that Black families are disproportionately impacted by CPS reporting – and that even the process of investigation alone is associated with adverse outcomes. While newborn drug testing is informed by key federal and state policies and providers must report to CPS known or suspected intrauterine drug exposure, clinicians have discretion regarding who they test for substances. This creates opportunity for bias to shape how tests are ordered.

In 2022, the study team identified that rates of meconium drug screening were higher in Black patients when compared to White patients. Concerned with this disparity, the study team convened a multidisciplinary team of experts to identify key drivers and design an intervention. Lack of standardized indications (i.e., reasons for testing) was identified as a driver of the disparity. In February 2023, this team implemented a guideline to standardize indications and added them to an order set for meconium drug testing. The goal was to reduce undesirable variability in clinician decision making by having clinicians select an indication for any drug test ordered. PEACH supported the study team in investigating the following question: Did the 2023 guideline to standardize clinical indication for newborn meconium drug testing reduce racial disparities in meconium drug testing at C.S. Mott Hospital?

Results showed that the disparity increased after the intervention (February 1, 2023-April 9, 2024). Both Black and White newborns experienced an increase in rate of testing, but the increase was higher for Black newborns. The rate of testing of White newborns increased from 3.2% (140 tests ordered) to 3.8% post-guideline (169 tests ordered). For Black newborns, it increased from 5.3% (48 tests ordered) pre-guideline to 9.1% post-guideline (72 tests ordered). The increase in testing for Black newborns was largely driven by marijuana testing. Of all tests sent for marijuana use during pregnancy as the only indication for testing, rates of meconium newborn testing increased for Black newborns from 4.5% pre-guideline to 7.2% post-guideline. For White newborns, it remained stable at 2.6% pre-guideline to 2.7% post-guideline. For all other tests, rates of testing increased from 0.8% pre-guideline to 2% post-guideline for Black newborns, and 0.6% to 1.1% for White newborns.

Given that the team's quality improvement intervention did not reduce the disparity, they are now interested in advocating for system-level change. Study team members are in communication with state officials to discuss CPS requirements around drug testing. Study team members are also interested in working with Michigan Medicine on improving its drug testing policy.

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: Toby Lewis

Question(s): Do patients who do not use the patient portal receive the same recommended protocols around asthma care as patients who do use the patient portal? Do patients without portal access have fewer interactions with healthcare system and worse outcomes?

Project Lead: Melinda Rushing

Question(s): Are there any associations between pain-treatment inequities in the Mott Emergency Department and uncontrolled pain episodes during subsequent admissions?