In its 2003 landmark document Unequal Treatment, the Institutes of Medicine reported that racial and ethnic disparities in health care delivery and quality of care exist despite controlling for socioeconomic differences for persons of color, and further concluded that discrimination at the individual and patient-provider level involving bias, stereotyping and uncertainty in clinical communication and family-centered decision making have substantial impacts on such disparities.1 Unfortunately, similar disparities and resultant variability in care delivery have also been demonstrated for preterm infants, a population that is already at high risk for vulnerability from a health standpoint. In addition, these disparities can be attributed to differential care based upon race and ethnicity, but are also further compounded by the care provided in low versus high quality neonatal intensive care unit (NICU) settings, defined by using hospital-level NICU quality measures, such as healthcare-associated bacterial or fungal infections, discharge on human breast milk, mortality during the birth hospitalization and growth velocity.2,3 Several community-level factors influence families receiving care at lower quality NICUs, including residential segregation, poverty, health care access, language barriers, and health insurance coverage. While there have been strides in recognition of racial and ethnic disparities in health care delivery, unfortunately, systemic racism within healthcare continues to serve as a primary barrier toward further progress.4,5,6 High-cost health care utilization, such as repeated emergency room visits by publicly insured patients has been well established, and further mirrors societal barriers to equitable access to care.7 Kuzniewicz et al. revealed in comparing emergency department (ED) utilization by moderate preterm, late preterm, and early term infants after discharge from NICU, there was no significant difference in emergency department utilization based upon gestational age, but there was increased ED use by Black and Hispanic infants.8

In this brief report by Karvonen et al., the authors studied whether publicly insured preterm infants have differential ED utilization based upon race and ethnicity. They defined acute care visits as ≥2 ED or other acute care visits in 1 year, and focused on publicly insured preterm infants, with gestational ages spanning 22–36 weeks gestation. Their results revealed the highest rates of acute care utilization amongst Black infants but also found that Black and Hispanic infants born <32 weeks had an increased likelihood of frequently accessing acute care visits compared to White infants. The authors concluded that further investigation into NICU discharge processes and access to primary care was important in understanding potential reasons for such discrepancies in high-cost care utilization. Additionally, while Karvonen et al. restricted the study population to publicly insured infants, in hopes of controlling for social factors, they still found that Black and Hispanic infants had increased frequency in acute care utilization, potentially linked to inadequate access to primary care or increased severity of illness. In the context of the severity of illness, the span of vulnerability for preterm (whether early vs moderate vs late) varies greatly in terms of potential disease severity, especially for infants < 32 weeks. In addition, an association between Black and Hispanic infant acute care utilization tied to young maternal age and maternal education revealed an interesting discrepancy that was not further discussed. This finding is important to recognize, as it underscores the need for supportive and educational resources for young mothers of preterm infants. Finally, concepts of structural racism, community-level poverty, and social determinants of health and their potential impacts upon race and ethnic disparities in health care delivery utilization were briefly noted.

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