The study by Howell et al¹ in this issue of JAMA Pediatrics is a carefully done, methodologically sound examination of the racial/ethnic disparities in the outcomes for very preterm infants in New York City. The authors partitioned the racial/ethnic differences in a combined morbidity and mortality index into those attributable to maternal and infant factors present at delivery, those attributable to which hospital cared for each infant, and other unexplained factors. Not surprisingly, infant health risks, such as gestational age at delivery, explained most of the large racial/ethnic disparities in neonatal outcomes. What is concerning about the results is that differences in where care was provided explained 40% of the black-white disparity and 30% of the Hispanic-white disparity in mortality/morbidity rates. In these New York City data there was a very large range in risk-adjusted mortality/morbidity rates across the study hospitals (9.7% to 57.7%). Looking at the results (see eFigure 1 in the article’s Supplement¹) shows there were no racial/ethnic differences in access to the best-performing hospitals (the top 2 quintiles). However, black and Hispanic patients were, on average, more likely to receive care at hospitals within the lower 3 quintiles. It was notable that almost no white patients were cared for in the lowest performing quintile of hospitals. One encouraging finding from this article is that the authors did not find any within-hospital disparities in outcomes. Previous studies looking at this topic in perinatal medicine yielded mixed results, with some studies finding no difference in hospital care between infants of different racial/ethnic status while others found significant differences in access to high-quality hospitals.^2- 5 Similar to this work, racial/ethnic disparities in access to high-quality care have been noted in the hospitalized care of adult patients⁶ and access to outpatient services.⁷ Because the data are only from New York City, we cannot assume that the disparity patterns found by Howell et al¹ apply to the rest of the country. But, if it were to apply to the rest of the country, these results would point to an alarming driver of disparities in perinatal outcomes by race/ethnicity.

Howell等人¹在本期《JAMA儿科》中的研究是对纽约市早产儿的种族/族裔差异在结局方面进行的精心研究，方法上合理的检查。作者将合并发病率和死亡率的种族/族裔差异分为可归因于分娩时母婴因素，因医院照顾每个婴儿而引起的因素以及其他无法解释的因素。毫不奇怪，婴儿健康风险，例如分娩时的胎龄，解释了新生儿结局中大部分种族/种族差异。结果令人担忧的是，提供护理的差异解释了死亡率/发病率中40％的黑人与白人之间的差异和30％的西班牙裔与白人之间的差异。在这些纽约市的数据中，各研究医院的风险调整后死亡率/发病率范围非常大（9.7％至57.7％）。查看结果（请参阅本文补编中的e图1）¹）显示，在进入表现最好的医院（前五分之二）的医院中，没有种族/种族差异。但是，平均而言，黑人和西班牙裔患者更有可能在较低的三分之二内的医院接受护理。值得注意的是，在表现最差的医院中，几乎没有白人患者得到护理。这篇文章令人鼓舞的发现是，作者没有发现医院内结局方面的差异。以前在围产期医学中针对该主题进行的研究得出的结果参差不齐，有些研究发现不同种族/民族状态的婴儿在医院护理方面没有差异，而另一些研究则发现优质医院的获得机会存在显着差异。^{2 - 5}与这项工作类似，在成年患者的住院治疗⁶和门诊服务中也注意到了在获得高质量护理方面的种族/种族差异。⁷因为数据仅来自纽约市，所以我们不能假设Howell等人¹发现的差异模式适用于美国其他地区。但是，如果将其应用到全国其他地区，这些结果将表明种族/族裔造成围产期结果差异的一个令人震惊的驱动因素。