Publications

OBJECTIVE: There are significant racial and ethnic inequities in neonatal care and outcomes. Accurate race and ethnicity demographic information is the cornerstone of equity-focused quality improvement. The collection of accurate race and ethnicity demographic information is complex for neonates that cannot self-report and do not yet have personal identity formation. In a large, academic, level III neonatal intensive care unit (NICU), we implemented a quality improvement initiative aimed at increasing the completeness and accuracy of race and ethnicity demographic information in patient records.

METHODS: We conducted a quality improvement initiative using data from January 2021 to June 2025 among patients admitted to a large, academic, level III NICU. The primary goal was to reduce the percentage of missing or unknown racial and ethnic demographic information. Our study included a preintervention data quality assessment period followed by 3 plan-do-study-act (PDSA) cycles focused on patient registration and cross-departmental collaborations with the birth registry and the Department of Obstetrics and Gynecology.

RESULTS: During the preintervention data quality assessment, we demonstrated a steady state with 30% of patients admitted to the NICU having missing or unknown race and ethnicity demographic information. We observed 3 shifts associated with PDSA cycles. During the last PDSA cycle, the missing or unknown demographic information was 10%.

CONCLUSION: We decreased the proportion of missing or unknown demographic data in a large, academic, level III NICU through a multidisciplinary hospital-wide collaboration. This initiative serves as the first step to implement equity-focused quality improvement.

Neonatal Intensive Care Units (NICU) are often designed to primarily optimize the health of critically ill newborns. However, prolonged hospitalizations and stressors, in particular for diverse families can lead to alienation. In this Perspective, we explore how NICUs can be designed to center the diversity of families care for in the NICU including, but not limited to, racial and ethnic diversity, LGBTQ+ headed families, non-traditional families, families with disabled caregivers, families who prefer a language other than English, and those with low health literacy. Through thoughtful and inclusive designed spaces, we highlight how a NICU can become a place of healing for families and infants and foster a sense of inclusion and belonging.

IMPORTANCE: Infants born at less than 32 weeks of gestation have an increased risk for adverse developmental and functional outcomes. The Early Intervention program provides developmental support to at-risk infants and has been shown to improve outcomes, but inequities may exist along the complex cascade from referral to receiving an Individualized Family Service Plan (IFSP).

OBJECTIVES: To determine where inequities exist along the Early Intervention Care Cascade and to quantify their magnitude.

DESIGN, SETTING, AND PARTICIPANTS: This longitudinal cohort study used data from the Pregnancy to Early Life Longitudinal database, a Massachusetts population-based dataset linking live births and Early Intervention data. A total of 7169 very preterm infants (gestational age less than 32 weeks) born between January 1, 2012, through December 31, 2019, in Massachusetts were identified. These data were analyzed from January 2025 through July 2025.

EXPOSURE: Infant race and ethnicity, defined as the birthing individual's race.

MAIN OUTCOMES AND MEASURES: The primary outcomes were the steps along the Early Intervention Care Cascade, including referral to Early Intervention, evaluation, and a signed IFSP. The steps along the Early Intervention Care Cascade were modeled using sequential logistic regression models adjusted for infant and family covariables.

RESULTS: Of the 7169 infants, 567 identified as Asian/Pacific Islander, 1644 as Hispanic, 55 as Native American or Alaska Native, 1278 as non-Hispanic Black, and 3449 as Non-Hispanic White. There were 84%, 71.3%, and 64.5% who were referred, evaluated, and received an IFSP, respectively. Compared with non-Hispanic White infants, infants in racial and ethnic minority groups were less likely to be referred, evaluated, and receive an IFSP. Non-Hispanic Black infants had a numerically lower odds of referral (81.3%; adjusted odds ratio [aOR], 0.93; 95% CI, 0.77-1.44), evaluation (62.5%; aOR, 0.57; 95% CI, 0.46-0.70), and receiving an IFSP (55.0%; aOR, 0.83; 95% CI, 0.62-1.12) vs non-Hispanic White infants (84.6%, 75.4%, and 68.4%, respectively). Associations were attenuated when adjusting for infant and family social variables.

CONCLUSION AND RELEVANCE: In this longitudinal cohort study of very preterm infants, there was notable inequity and attrition across the Early Intervention Care Cascade. Targeted structural interventions at each step can close the equity gap.

OBJECTIVE: Describe the engagement of opioid-exposed infants (OEI) with recommended developmental surveillance and supports in the first year of life.

METHODS: We conducted a single-site retrospective cohort study of OEI delivered between 2016 and 2021, linking birth hospitalization, developmental follow-up (DFU) clinic, and early intervention (EI) records. Primary outcomes were attendance at DFU clinic and evaluation by EI. We used multivariable modified Poisson regression to examine how birthing parent-, infant-, and clinic-level factors are associated with service engagement.

RESULTS: Of 256 OEI, 75% engaged in at least 1 developmental service. Referral and attendance rates at the DFU clinic were 69% and 33%, respectively. Ninety-three percent were referred to EI, 73% evaluated and 58% enrolled in services. EI evaluation was positively associated with prolonged infant hospitalization (adjusted risk ratio [aRR] 1.01; CI, 1.002-1.01) and exposure to antidepressants (aRR 1.23; CI, 1.02-1.49) and cocaine (aRR 1.28; CI, 1.09-1.50). Probability of attendance at DFU was higher for infants born to parents receiving care at an integrated perinatal substance use clinic (aRR 2.13; CI, 1.07-4.24) and exposed to antipsychotics (aRR 1.73; CI, 1.12-2.67), whereas those remaining in parental custody had lower probability of engagement (aRR 0.62; CI, 0.39-0.97).

CONCLUSION: Three-quarters of the OEI engaged in developmental surveillance services in the first year of life. Factors relating to disease severity, location of birthing parent care, birthing parent co-exposures, and parental custody were associated with engagement. Efforts to improve engagement in recommended follow-up should elicit the perspectives of caregivers to better understand the mechanisms that drive these differences.

INTRODUCTION: Effectively working with medical interpreters is a critical skill for all physicians. We partnered with interpreters, students, and faculty to co-design and co-teach an educational session to improve medical students' knowledge and confidence in working with interpreters.

METHODS: The multimodal educational intervention lasted 120 minutes and included a didactic presentation, video role-play encounters, and a panel discussion with interpreters. The intervention was evaluated with pre- and post-session surveys. McNemar's test was used to compare knowledge and confidence scores.

RESULTS: A total of 161 pre-clinical medical students participated in the session. Students identified knowledge they learned, including the role of interpreters, the importance of not relying on family members as interpreters, the use of pre-encounter huddles, and appropriate physical positioning. After the intervention, the majority of students identified best practices for working with interpreters (n = 64 (57.7%), pre-session vs. n = 45 (71.4%), post-session; p = 0.04) and reported improved confidence working with interpreters (n = 73 (65.8%), pre-session vs. n = 60 (95.2%), post-session; p < 0.001).

DISCUSSION: This innovative curriculum was unique in its interprofessional co-design and co-teaching approach and introduction of nuanced, contemporary clinical scenarios. Overall, this innovative curriculum was successful in enhancing student knowledge and confidence in working with interpreters.

Racial and ethnic health inequities are pervasive in the US healthcare system and affect individuals at all stages of life. These inequities are the result of racism and not due to biology. Racism is a multi-level system that embodies institutional, structural, interpersonal, and internalized racism. Racism in the healthcare setting creates hierarchies of power based on the social construct of race that impact opportunity, access, quality, and experiences of minoritized individuals. Most interventions to address health inequity in the healthcare setting target individual-level racism, but this has largely been ineffective in closing the equity gap. Few interventions have been developed to target structural and institutional racism. This may in part be due to a lack of healthcare-specific tools that can identify targets for intervention at the structural and institutional level. In this article, we report the development of the Healthcare Racial Justice Assessment Tool (HC-RJAT), a novel tool specifically designed to identify modifiable loci of structural and institutional racism within the healthcare setting to guide equity-focused interventions.