Equity in Receipt of a Lumbar Puncture for Febrile Infants at an Academic Center

Abstract

Background The evaluation of febrile infants ≤60 days of age is often guided by established protocols. However, structural racism and physicians’ implicit bias may affect how such clinical guidelines are applied. Objective To determine the association between self-identified race, insurance type, ZIP code–based median household income (MHI) and receiving a guideline-concordant lumbar puncture (GCLP) in febrile infants. Methods This was a 3-year retrospective cross-sectional study of all febrile infants ≤60 days old presenting to a children’s hospital from 2015 to 2017. GCLP was defined as obtaining or appropriately not obtaining a lumbar puncture as defined by the hospital’s clinical practice guideline, which recommended performing a lumbar puncture for all febrile infants ≤60 days of age unless an infant was >28 days of age and had respiratory syncytial virus-positive bronchiolitis. Univariate analyses were used to identify variables associated with receiving a GCLP. Variables with a P < .1 were included in a multivariate logistic regression with race, MHI, and insurance type. Results We included 965 infants. Age (adjusted odds ratio, 0.95; 95% confidence interval, 0.94–0.97) and temperature on arrival (adjusted odds ratio, 1.36; 95% confidence interval, 1.04–1.78) were significantly associated with receipt of a GCLP. Self-identified race, insurance type, and MHI were not associated with receiving a GCLP. Conclusion Receipt of a GCLP was not associated with race, MHI, or insurance type. As recent national guidelines change to increase shared decision-making, physician awareness and ongoing assessment of the role of factors such as race and socioeconomic status in the clinical evaluation and outcomes of febrile infants will be critical.