Racial Differences in Urine Testing of Febrile Young Children Presenting to Pediatric Hospitals

Introduction: Dating back to 2011, practice guidelines considered Black race a factor associated with lower risk of urinary tract infection (UTI). Race-based clinical decisions raise concerns about potential treatment disparities. We investigate urine testing (urinalysis and/or urine culture) among young febrile children in the emergency department (ED), revisits, and potential missed diagnoses by race/ethnicity. Methods: We performed a multicenter retrospective cohort study of children 2–24 months evaluated in 26 US EDs from 2009 to 2019 with a fever diagnosis. We evaluated longitudinal testing trends, constructed a generalized linear mixed-effects model to identify the association of race/ethnicity with testing, and characterized UTI diagnoses and ≤ 7-day revisits. Results: Of 734,730 included patients, 24.1% were Black. Variation in urine testing was observed by patient race/ethnicity (23.4% Black, 31.7% White, 33.9% Hispanic, 30.0% other race). Relative differences in testing persisted over time. Black patients had lower adjusted odds of testing (0.70, 95% confidence interval [CI] 0.69–0.71). Among patients with urine testing, 2.4% (95% CI 2.3–2.6%) of Black and 3.3% (95% CI 3.1–3.4%) of White patients were diagnosed with UTI. Among Black patients with urine testing on the index visit, 8.5% (95% CI 8.2–8.8%) had return visits compared to 7.6% (95% CI 7.5–7.8%) among those without urine testing on index visit. Among patients with urine testing on revisit, UTI diagnosis was similar by race/ethnicity. Conclusion: Black patients had lower rates of urine testing and UTI diagnoses relative to other racial/ethnic groups. This was not associated with higher rates of missed diagnoses or unscheduled return visits.