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The Impact of Race on Ambulatory Urine Testing Among Febrile Children in the United States
Carina De La Cueva, BA, MSc, Natalia Leva, MD, Debbie Goldberg, MS, Hillary L. Copp, MD, MS.
University of California San Francisco, San Francisco, CA, USA.

Background: In 2021, the American Academy of Pediatrics (AAP) UTI guideline was retired due to the use of race as a predictor for UTI (lower UTI risk in non-White females and Black males). We aim to evaluate whether rates of urine testing differed among children by race. We predict that testing among Black children will be lower compared with White children.
Methods: We conducted a repeated cross-sectional analysis of children 60 days to 24 months evaluated in emergency rooms (ERs) or outpatient clinics in the United States for fever ≥38 oC without other source using the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey from 2002 to 2019. Our primary outcome was urine testing utilization (urinalysis or urine culture). We calculated the frequency of urine testing stratified by race and sex. Univariate and multivariable logistic regression analyses were performed to examine racial differences in urine testing stratified by sex. We estimated the predicted probabilities of urine testing by race stratified by sex and ​temperature (38.0-38.9oC and ≥39oC) and adjusted for ethnicity.
Results: 2065 children presented to ERs and outpatient clinics for fever without another source representing an estimated 11,213,047 visits nationally. Urine testing was performed in 26.7% (95% CI, 23.7-29.7) of children presenting with fever without another source and in 23.7% (95% CI, 18.0-29.4) of febrile Black children compared with 27.5% (95% CI, 23.6-31.4) of febrile White children. On multivariable analysis, there was a higher odds of undergoing urine testing in younger children (2-12 months: OR, 1.41; 95%CI: 1.21-1.64 vs 13-24 months), females (OR, 1.54; 95%CI, 1.33-1.79), ER patients (ER: OR, 1.50; 95%CI, 1.17-1.92 vs outpatient clinic), and those with higher temperatures (temperature ≥39oC: OR, 1.31; 95%CI, 1.12-1.53 vs temperature 38.0-38.9oC) while a lower odds of urine testing was found in Black children (OR, 0.71; 95%CI, 0.54-0.95 vs White) and Hispanic children (OR, 0.68; 95%CI, 0.49-0.95 vs Non-Hispanic). When stratified by sex and adjusted for ethnicity non-White females were less likely to undergo urine testing versus White females (25.7% [95%CI 17.3-34.1] vs 39.8% [95%CI 33.1-46.4]; adjusted OR = 1.41 [95% CI, 1.11-1.78]) and differences in urine testing probability in non-White vs White females were magnified with higher temperatures (Figure).
Conclusions: Disparities in urine testing by race were observed with Black children less likely to undergo any urine testing compared with White children. Urine testing differences between non-White and White females were further exaggerated at higher temperatures. While the AAP UTI guideline was recently retired, data presented herein demonstrate a disparate impact by race has already been made on testing for and likely treatment of UTIs. Continued efforts must be made to identify significant risk factors for UTI without the use of race as a predictor.


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