Disparities in Social Work Consultations in the Pediatric Inpatient Setting

Background: Race, ethnicity, language, and socioeconomic status influence how patients are evaluated, diagnosed, and referred for interventions. Failure to thrive (FTT), brief resolved unexplained event (BRUE), accidental ingestion, and drowning are diagnoses that commonly involve inpatient social work (SW) consultation, usually out of concern for abuse/neglect or to assist with other potential social, economic, or environmental challenges. However, the decision to consult SW may be attributed to provider biases. Identifying disparities in SW consultations is a necessary step towards equitable care provision. We sought to examine the association of patient race, ethnicity, language, and insurance with SW consultations in children hospitalized with the diagnoses of FTT, BRUE, accidental ingestion, and drowning.

Methods: We conducted a retrospective cohort study at a large, quaternary children’s hospital. Children <6 years of age discharged from the hospital medicine service from July 1, 2012 to June 30, 2020 with admission diagnoses of FTT, BRUE, accidental ingestion, and drowning were included. Patients were identified via ICD-9 or 10 diagnostic codes in the electronic health record (EHR); only the first encounter was included for patients with multiple admissions. Patient age at admission, gender, race, ethnicity, language, and insurer were extracted from the EHR. SW consult orders and notes were extracted and reviewed. Bivariate analyses were pursued using Chi square or Fisher’s exact tests. Multivariable logistic regression was used with race as the primary predictor and SW consultation as the outcome.

Results: A total of 1232 unique patients were included, of which 837 were for FTT, 347 for BRUE, 26 for accidental ingestion, and 22 for drowning; 109 repeat encounters were excluded. Patient demographics are noted in Table 1. Black and White patients received SW consults in 73% and 52% of admissions for all diagnoses, respectively. Publicly-insured patients also received SW consultation more frequently than privately-insured patients. Similar relationships were present within each diagnostic category.
These relationships held in multivariable models (Table 2). Black and multiracial patients had 1.85 and 1.8 greater odds of receiving a SW consult, respectively, compared to White patients. Odds of consultation for those with public insurance was 4.87-times higher than those with private insurance. No significant differences in SW consultation were seen by ethnicity or language.

Conclusion: FTT, BRUE, accidental ingestion, and drowning are common admitting diagnoses in which care team bias, implicit or explicit, may affect management decisions. Black, multiracial, and publicly-insured patients were more likely to receive SW consults. This may be related to overassessing abuse/neglect or other potential challenges for Black, multiracial, or publicly-insured children or underassessing such issues for White or privately-insured children. Targeted efforts to better understand SW consult patterns and standardize criteria for consults are critical for promoting equitable care practices.