Can we reduce racial and ethnic disparities in pediatric trauma care?
Imagine a 2-year-old boy presents to the ED with minor head trauma. During the examination, parents ask whether he will need a head CT.
Trauma is a major cause of morbidity and mortality in children. CT scans are often used in the ED to quickly assess for the presence and extent of internal bleeding. While CT provides fast, valuable information, it also exposes children to radiation, which increases the long‑term risk of cancer. Thus, clinicians are encouraged to use CT scans only when necessary.
To guide safer imaging practices, the Pediatric Emergency Care Applied Research Network (PECARN) developed clinical rules that identify children with blunt head trauma (BHT) or abdominal trauma (BAT) who are very low risk for clinically important injuries. For these patients, CT scans can usually be avoided without compromising care. These decision support tools have become widely used to reduce unnecessary radiation exposure.
However, research shows that CT use in pediatric trauma isn’t always equitable. Studies before the introduction of these PECARN trauma support tools revealed that Hispanic and Black children at low or intermediate risk for traumatic brain injuries (TBIs) receive CT scans less frequently than white children. Similar disparities exist in the evaluation of blunt abdominal trauma, especially for Black non‑Hispanic children.
Ensuring both appropriate CT use and equitable care is essential. Every child should receive evidence‑based, unbiased evaluation—helping improve outcomes while minimising avoidable risks.
What did they do?
This was a secondary analysis of children (<18 years) with BHT and/or BAT enrolled in a prospective observational study at 6 pediatric trauma centres.
Enrolling clinicians assessed Injury severity on each child using the PECARN prediction rules.
To assess potential disparities in care, multivariable logistic regression was used, controlling for site, age, sex, Social Deprivation Index, and injury severity as assessed by the PECARN rules.
What were the results?
17,339 patients with BHT were enrolled.
For children older than 2 years, compared with the reference group (~85% non-Hispanic White patients), there was no difference in CT use for Hispanic ethnicity, non-Hispanic Asian, or Black race.
For children aged ≤2-years-old, there was no difference in CT use for Asian or Black race. However, CT use was lower among Hispanic patients (aOR, 0.75; 95% CI, 0.59–0.96).
6,821 patients with BAT were also enrolled.
Compared with the reference group (~95% non-Hispanic white), there were no significant differences in CT use for patients who were Asian, Black, or Hispanic.
The validation of the rule demonstrated that the models performed extremely well.
What did it add?
In this secondary analysis of a large multicentre study at 6 pediatric trauma centres, the use of the PECARN blunt head and abdominal trauma prediction rules to evaluate trauma patients helped to mitigate race and ethnic disparities previously observed, except for CT use, which was lower in Hispanic children younger than 2 years in the BHT group.
What were the limitations?
The study was performed in US academic level-1 trauma centre EDs caring for diverse populations. Hence, results may not be generalizable to other ED settings or in other countries.
No surveys on physicians’ race and ethnic biases were reported in this study. Patients with missing or unknown clinician-perceived race or ethnicity were excluded from the analysis; thus, results may vary with clinician variability in documenting perceived race and ethnicity.
Socioeconomic status was estimated using patients’ zip codes, which are correlated with race and ethnicity in research studies but may not be completely precise.
Lastly, PECARN prediction rules do not include race and ethnicity, but these were included on the data collection forms. Thus, clinicians were asked to choose a race and ethnicity, which may have prompted reflection of their own potential biases. However, this was also a strength of the study, as the investigators sought to assess the impact of the evidence provided by the PECARN rules on mitigating implicit bias.
What did the authors conclude, and what does it mean for current practice?
Results of this study did not detect previously identified disparities in CT use for children with minor BHT and BAT, except for Hispanic children aged younger than 2 years with BHT, who received CT less frequently than the reference group.
Overall, this study highlights that the use of objective evidence, in the form of clinical prediction rules to guide evidence-based care, may lead to a reduction of racial and ethnic disparities in pediatric trauma care.
CASP Checklist for cohort studies
Does this address a clearly focused issue?
Yes. The authors aimed to determine whether clinician‑perceived race or ethnicity influenced CT scan use in children with minor head trauma (BHT) or blunt abdominal trauma (BAT). This is a highly relevant question given well‑documented disparities in emergency care.
Was the cohort recruited in an acceptable way?
Yes. Secondary analysis of a large, multicenter, prospective cohort, with >24,000 children eligible (17,339 head trauma; 6,821 abdominal trauma with recorded race/ethnicity). Recruitment was systematic across 6 Level‑1 pediatric trauma centres, improving generalizability.
Was the exposure accurately measured to minimise bias?
Partially. Race/ethnicity was recorded as clinician‑perceived, not self‑reported. This reflects real‑world biases—but also introduces the potential for misclassification.
The authors acknowledge this limitation.
Was the outcome accurately measured to minimise bias?
Yes. CT use was determined objectively from clinical records and not influenced by researchers. Risk severity was categorised using validated PECARN decision rules, which are the gold standard for pediatric trauma evaluation.
Have the authors identified all-important confounding factors?
Yes. They also performed sensitivity analyses replicating methods from prior studies that had shown disparities.
Was the follow-up of subjects complete and accurate?
Yes. Follow‑up included hospital admission data and a 7‑day phone follow‑up after discharge. Loss to follow‑up was minimal and unlikely to bias CT‑ordering outcomes.
Do you believe the results?
Yes. The methods were rigorous, the statistical adjustments thorough, and the multicenter design strengthens reliability.
Can the results be applied to a local population?
Partially yes. Especially, in systems using PECARN guidelines or similar clinical prediction tools. However, all study centres were pediatric trauma centres; results in community EDs may differ.
Do the results fit with other evidence available?
Yes. Notably, they contradict older evidence. Past PECARN studies before the creation of the PECARN rules found disparities in CT use among Black and Hispanic children.
This validation cohort suggests that decision support tools may reduce provider bias. Using standardised clinical algorithms may improve equity in clinical care.
