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Being open: Good, Bad, or Ugly?
- Amitabh Shankar (30 March 2009)
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Amitabh Shankar, Specialist Registrar RCPI (Medicine of Childhood)
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amitabhshankar{at}hotmail.com Amitabh Shankar
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I read this article with great interest. It has been a long time since a PICU data from England and Wales has been published in the Archives of Diseases in Childhood. Interestingly, I noted that although the admission in 1-4 yr age group was lesser (7.54 & 7.22%) than other age groups (more than 10%) amongst male and female South Asians respectively, the 0–4 yr standardised admission (incident) rate amongst South Asian males [351 (336 to 367 95%CI)] and females [264 (250 to 278 95% CI)] is significantly more than non-South Asian males and females [252 (248 to 256 95% CI)] and [195 (192 to 199 95% CI)] respectively. This presumably reflects that less South Asian babies are born per 100,000 South Asian population in the U.K. compared to non-South Asian babies per 100,000 non-South Asians. But is that really so? Secondly, I wonder what the standardised incidence rate is for South Asian and non-South Asian infants less than 1 years of age; and moreover what proportion of this figure comprises of congenital heart defects, chromosomal abnormalities, respiratory tract infections and NAIs (suspected or proven). Since 95% CI of Odds Ratio of death in all Townsend categories lie on both sides of 1, the data does not reliably suggest that chance of a paediatric patient’s death is higher if he/she comes from a less deprived community, in contrary to author’s statement. It was also interesting to note that the risk of a paediatric patient’s death generally increases given that a surgical procedure took place; irrespective of sex, ethnic origin or Townsend category of the patient. I could not locate any data mentioning the impact of PIM index on admission on the actual standardised (proportional population adjusted) mortality rates in South Asians and non-South Asians respectively. This parameter would in my opinion open up the very debatable and controversial grey area of possibility of any treatment bias which we may have in treating non-South Asian and South Asian subsets of PICU patients (the bias originating from their ethnic origins). This paper clearly states that South Asian children are at greater risk of dying compared to their non-South Asian counterparts when admitted in PICU setting in the given geographical area studied: England and Wales. I believe such a statement would automatically raise issue of quality of medical service provided to the South Asian children when they are treated in the PICU. Putting this rather boldly, I mean: Is the PICU staff in England and Wales really intolerant to racial discrimination while treating their patients? Will this study lead to a modification in PIM scoring to a higher mortality prediction score for a South Asian child admitted in PICU in future? The Authors have probed into some reasons that could explain this phenomenon, including higher infant mortality in South Asians in general, possibility of effect of consanguineous marriages in Pakistani population leading to chromosomal disorders. They acknowledged that their study could not identify children with congenital abnormalities in their collected data. I would be more interested to know if PIM index of South Asian and non-South Asian children really reflected their actual population adjusted mortality rates. If it does, then it would reflect PICU staff’s good medical and ethical (of intolerance to racial discrimination) practice. However, if it does not, then unfortunately it might open up, I am afraid, the unwanted floodgate of debate on racial discrimination in paediatric practice until proven otherwise |
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