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Disparities and implicit bias in the management of low-risk febrile infants: a mixed methods study protocol
  1. Colleen K Gutman1,2,
  2. K Casey Lion3,4,
  3. Paul Aronson5,
  4. Carla Fisher6,7,
  5. Carma Bylund7,
  6. Antionette McFarlane1,
  7. Xiangyang Lou8,
  8. Mary D Patterson1,9,
  9. Ahmed Lababidi2,
  10. Rosemarie Fernandez1,9
  1. 1Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
  2. 2Department of Pediatrics, University of Florida, Gainesville, Florida, USA
  3. 3Department of Pediatrics, University of Washington, Seattle, Washington, USA
  4. 4Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, USA
  5. 5Departments of Emergency Medicine and Pediatrics, Yale University, New Haven, Connecticut, USA
  6. 6College of Journalism and Communications, University of Florida, Gainesville, Florida, USA
  7. 7Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
  8. 8Department of Biostatistics, University of Florida, Gainesville, Florida, USA
  9. 9Center for Experiential Learning and Simulation, University of Florida, Gainesville, Florida, USA
  1. Correspondence to Dr Colleen K Gutman; ckays21{at}


Introduction The management of low-risk febrile infants presents a model population for exploring how implicit racial bias promotes inequitable emergency care for children who belong to racial, ethnic and language minority groups. Although widely used clinical standards guide the clinical care of febrile infants, there remains substantial variability in management strategies. Deviations from recommended care may be informed by the physician’s assessment of the family’s values, risk tolerance and access to supportive resources. However, in the fast-paced emergency setting, such assessments may be influenced by implicit racial bias. Despite significant research to inform the clinical care of febrile infants, there is a dearth of knowledge regarding health disparities and clinical guideline implementation. The proposed mixed methods approach will (1) quantify the extent of disparities by race, ethnicity and language proficiency and (2) explore the role of implicit bias in physician–patient communication when caring for this population.

Methods and analysis With 42 participating sites from the Pediatric Emergency Medicine Collaborative Research Committee, we will conduct a multicenter, cross-sectional study of low-risk febrile infants treated in the emergency department (ED) and apply multivariable logistic regression to assess the association between (1) race and ethnicity and (2) limited English proficiency with the primary outcome, discharge to home without lumbar puncture or antibiotics. We will concurrently perform an interpretive study using purposive sampling to conduct individual semistructured interviews with (1) minority parents of febrile infants and (2) paediatric ED physicians. We will triangulate or compare perspectives to better elucidate disparities and bias in communication and medical decision-making.

Ethics and dissemination This study has been approved by the University of Florida Institutional Review Board. All participating sites in the multicenter analysis will obtain local institutional review board approval. The results of this study will be presented at academic conferences and in peer-reviewed publications.

  • accident & emergency medicine
  • paediatrics
  • paediatric A&E and ambulatory care

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  • Contributors CG was responsible for conceptualisation and design of the study, drafting of the initial manuscript and implemented all critical revisions of the manuscript. KCL, PA, CF, CB, MDP and RF oversaw and participated in study design. AM participated in designing the qualitative data collection and analytic plan. XL participated in designing the quantitative statistical analytic plan. AL participated in quantitative study design. All authors critically revised the manuscript for important intellectual content.

  • Funding This work was supported in part by NCATS 1KL2TR001429 (to CG) and AHRQ K08HS026006 (to PA).

  • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.