Although guidelines for prescribing insulin pumps to patients with type 1 diabetes (T1D) focus on patient assessment, sociological research shows decision-making is influenced by the organizations within which actors are embedded. However, how organizational context shapes unequal resource allocation by race and class is less well understood. To investigate this, we compare two pediatric endocrinology centers differing in racial and socio-economic equity in pump use. Using over 400 h of observations and 16 provider interviews, we find allocation is shaped by how organizations use patient cultural health capital to determine pump eligibility, frame technology use, and structure decision-making processes. Overall, findings extend health inequalities research by describing how organizations shape technology resource allocation by race and class.

INTRODUCTION: To illustrate how quality improvement can produce unexpected positive outcomes. METHODS: We compared a retrospective review of perioperative management and outcomes of baseline 122 pediatric total thyroidectomies to 121 subsequent total thyroidectomies managed by an Electronic Medical Record protocol in a large, free-standing children's healthcare system. Process measures included serum calcium measurement 6-12 hours postoperatively; parathyroid hormone measurement 6 hours postoperatively; preoperative iodine for Graves disease, and postoperative prophylactic calcium carbonate administration. In addition, we completed 4 Plan-Do-Study-Act (PDSA) cycles, focusing on implementation, refinement, usage, education, and postoperative calcitriol administration. The primary outcome included transient hypocalcemia during admission. RESULTS: All perioperative process measures improved over PDSA cycles. Measurement of postoperative serum calcium increased from 42% at baseline to 100%. Measurement of postoperative PTH increased from 11% to 97%. Preoperative iodine administration for Graves disease surgeries improved from 72% to 94%. Postoperative calcium carbonate administration increased from 36% to 100%. There was a trend toward lower rates of severe hypocalcemia during admission over the subsequent PDSA cycles starting at 11.6% and improving to 3.4%. With the regular review of outcomes, surgical volume consolidated among high-volume providers, associated with a decrease in a permanent hypoparathyroid rate of 20.5% at baseline to 10% by the end of monitoring. CONCLUSIONS: In standardizing care at 1 large pediatric institution, implementing a focused quality improvement project involving the perioperative management of transient hypocalcemia in total thyroidectomy pediatric patients resulted in additional, unanticipated improvements in patient care.