Deciphering the influence of demographic factors on the treatment of pediatric patients in the emergency department

Persistent demographic disparities have been identified in the treatment of patients seeking care in the emergency department (ED). These may be driven in part by subconscious biases, which providers themselves may struggle to identify. To better understand the operation of these biases, we performed a retrospective cross-sectional analysis using electronic health records describing 339,400 visits to the ED of a single US pediatric medical center between 2019-2024. Odds ratios were calculated using propensity-score matching. Analyses were adjusted for confounding variables, including chief complaint, insurance type, socioeconomic deprivation, and patient comorbidities. We also trained a machine learning [ML] model on this dataset to identify predictors of admission. We found significant demographic disparities in admission (Non-Hispanic Black [NHB] relative to Non-Hispanic White [NHW]: OR 0.77, 95% CI 0.73-0.81; Hispanic relative to NHW: OR 0.80, 95% CI 0.76-0.83). We also identified disparities in individual decisions taken during the ED stay. For example, NHB patients were significantly less likely than NHW patients to be assigned an 'emergent' triage acuity score of (OR 0.70, 95% CI 0.67-0.72), but emergent NHB patients were also significantly less likely to be admitted than NHW patients with the same triage acuity (OR 0.86, 95% CI 0.80-0.93). Demographic disparities were particularly acute wherever patients had normal vital signs, public insurance, moderate socio-economic deprivation, or a home address distant from the hospital. An ML model assigned higher importance to triage score for NHB than NHW patients when predicting admission, reflecting these disparities in assignment. We conclude that many visit characteristics, clinical and otherwise, may influence the operation of subconscious biases and affect ML-driven decision support tools.