Racial disparities in postoperative morbidity and mortality among high-risk pediatric surgical patients

Postoperative complications in the pediatric population. Malnutrition or phase angle? Which one do we use?

Background and Aims

Malnutrition increases post-operative risks like infections and prolonged stays. Pediatric assessment challenges require using anthropometric measurements and phase angle, which reflects body cell mass and health outcomes. Phase angle varies by maturation stages, making it crucial for pre-surgical evaluations alongside BMI. This study aimed to determine the relationship between nutritional status, phase angle, and postoperative complications in pediatric patients who underwent surgery.

Methods

Prospective study with patients aged 3-17 undergoing major non-ambulatory surgery. Anthropometric measurements (weight, height, BMI Z-scores) hand grip strength, dietary intake and body composition via bioimpedance to assess phase angle were recorded. Postoperative complications were monitored, including surgical site infections, morbidity (pneumonia, inotropic support, infections, thromboembolism), and mortality. Surgical risks and pre- and postoperative conditions were documented.

Results

After the application of the selection criteria, a total of 391 patients who underwent surgery were included; 60% (n = 235) were within the range of the preschool and school-age groups. During the follow-up period, 51 (13%) patients developed at least one postoperative complication, with surgical site infections being the most common. Moreover, as phase angle decreased, the length of stay (LOS) increased in all the participants. Among children aged ≤12 years old, malnutrition was a risk factor for complications [OR 3.86 (1.61-9.27 95%CI)], whereas among adolescents, phase angle served as a protective factor [OR 0.63 (0.42-0.94 95%CI)].

Conclusion

Significant associations were observed between nutritional status, by BMI z-score, and post-surgical complications in younger patients. Additionally, in adolescents, the phase angle emerged as a protective factor against these complications.

Disparities in Healthcare Utilization: An Analysis of Disease Specific and Patient Level Factors in a Congenital Diaphragmatic Hernia Clinic

OBJECTIVES

Our study examines if the disease severity profile of our Congenital Diaphragmatic Hernia (CDH) patient cohort adherent to long-term follow-up differs from patients lost to follow-up after discharge and examines factors associated with health care utilization.

METHODS

Retrospective review identified CDH survivors born 2005-2019 with index repair at our institution. Primary outcome was long-term follow-up status: "active" or "inactive" according to clinic guidelines. Markers of CDH disease severity including CDH defect classification, oxygen use, tube feeds at discharge, and sociodemographic factors were examined as exposures.

RESULTS

Of the 222 included patients, median age [IQR] was 10.2 years [6.7-14.3], 61% male, and 57 (26%) were insured by Medicaid. Sixty-three percent (139/222) of patients were adherent to follow-up. Seventy-six percent of patients discharged on tube feeds had active follow-up compared to 55% of patients who were not, with similar findings for oxygen at discharge (76% vs. 55%). Kaplan-Meier analysis showed patients with smaller defect size had earlier attrition compared to patients with larger defect size. Other race (Hispanic, Asian, Middle Eastern) patients had 2.87 higher odds of attrition compared to white patients (95% CI 1.18-7.0). Medicaid patients had 2.64 higher odds of attrition compared to private insurance (95% CI 1.23-5.66).

CONCLUSION

Loss to follow-up was associated with race and insurance type. Disease severity was similar between the active and inactive clinic cohorts. Long-term CDH clinic publications should examine attrition to ensure reported outcomes reflect the discharged population. This study identified important factors to inform targeted interventions for follow-up adherence.

LEVEL OF EVIDENCE

Level III.

Racial Bias in Pediatric Pain Perception

Racial disparities in pediatric pain care are prevalent across a variety of health care settings, and likely contribute to broader disparities in health, morbidity, and mortality. The present research expands on prior work demonstrating potential perceptual contributions to pain care disparities in adults and tests whether racial bias in pain perception extends to child targets. We examined the perception and hypothetical treatment of pain in Black and White boys (experiment 1), Black and White boys and girls (experiment 2), Black and White boys and adult men (experiment 3), and Black, White, Asian, and Latinx boys (experiment 4). Across this work, pain was less readily perceived on Black (vs White) boys' faces-though this bias was not observed within girls. Moreover, this perceptual bias was comparable in magnitude to the same bias measured with adult targets and consistently predicted bias in hypothetical treatment. Notably, bias was not limited to Black targets-pain on Hispanic/Latinx boys' faces was also relatively underperceived. Taken together, these results offer strong evidence for racial bias in pediatric pain perception. PERSPECTIVE: This article demonstrates perceptual contributions to racial bias in pediatric pain recognition. Participants consistently saw pain less readily on Black boys' faces, compared with White boys, and this perceptual bias consistently predicted race-based gaps in treatment. This work reveals a novel factor that may support pediatric pain care disparities.

Treatment Facility Case Volume and Disparities in Outcomes of Congenital Diaphragmatic Hernia Cases

INTRODUCTION

Congenital diaphragmatic hernia (CDH) is a life-threatening, prenatally diagnosed congenital anomaly. We aim to characterize care and outcomes of infants with CDH in Texas and the impact of treating facilities volume of care.

METHODS

Retrospective cohort study using a state-wide Hospital Inpatient Discharge Public Use Data File was conducted (2013-2021). Neonates and infants <1 year of age were included using CDH ICD-9/ICD-10 codes. Neonates transferred to an outside hospital were excluded to avoid double-counting. Descriptive statistics, chi-square and logistic regression analysis were performed.

RESULTS

Of 1314 CDH patient encounters identified, 728 (55%) occurred at 5 higher volume centers (HVC, >75 cases), 326 (25%) at 9 mid-volume centers (MVC, 20-75 cases) and 268 (20%) at 79 low volume centers (LVC, <20 cases). HVC had lower mortality rates (18%, MVC 22% vs LVC 27%; p = 0.011) despite treating sicker patients (extreme illness severity: HVC 71%, MVC 62% vs LVC 50%; p < 0.001) with longer length-of-stay (p < 0.001). Extracorporeal membrane oxygenation was used in 136 (10%) and provided primarily at HVC. LVC treated proportionately more non-white Hispanic patients (p < 0.001) and patients from counties along the Mexican border (p < 0.001). The predicted probability of mortality in CDH patients decreases with higher treatment facility CDH case volume, with a 0.5% decrease in the odds of mortality for every additional CDH case treated (p < 0.001).

CONCLUSIONS

Patients treated in HVC have significantly lower mortality despite increased severity. Our data suggest minority populations may be disproportionately treated at LVC associated with worse outcomes.

TYPE OF STUDY

Retrospective Prognosis Study.

LEVEL OF EVIDENCE

Level II.

Failure to rescue following postoperative pneumonia in pediatrics: Is there a racial disparity?

INTRODUCTION

Racial disparities in measures of health and healthcare processes are well described. Limited work exists on disparities in failure to rescue - hospital mortality following a major adverse event. Postoperative pneumonia is a serious, potentially preventable adverse event that often leads to death, i.e., failure to rescue. This study examined the association of racial grouping with failure to rescue following postoperative pneumonia.

METHODS

We utilized the National Surgical Quality Improvement Program-Pediatrics Participant Use Data File to assemble a cohort of children <18 years who underwent inpatient surgery from 2012 to 2022. We included Black and White patients who developed pneumonia following an index surgery. The primary outcome was failure to rescue, defined as mortality following postoperative pneumonia. We used logistic regression models to estimate the odds ratio and 95% confidence intervals of failure to rescue, comparing Black and White children.

RESULTS

The study cohort included 3139 children <18 years who developed pneumonia following inpatient surgery. Of those, 2333 (74.3%) were White and 806 (25.7%) were Black. Failure to rescue occurred in 117 of the children (3.7%); 82 were White (3.5%) and 35 were Black (4.3%). After adjusting for gender, age, American Society of Anesthesiologists Physical Status classification, emergent/urgent vs. elective case status, year of operation, and pre-existing comorbidities, the odds of failure to rescue for Black children with postoperative pneumonia did not differ from White children (adjusted-Odds Ratio: 1.00; 95% Confidence Interval 0.62-1.61; p-value = .992).

CONCLUSION

We found no significant difference in the odds of failure to rescue following postoperative pneumonia between Black or White children. To improve postoperative care for all children and to narrow the racial gap in postoperative mortality, future studies should continue to investigate the association of race with failure to rescue following other postoperative complications.

Post-operative Opioid Reduction Protocol Reduces Racial Disparity in Clinical Outcomes in Children

INTRODUCTION

Racial disparities in health outcomes continue to exist for children requiring surgery. Previous investigations suggest that clinical protocols may reduce racial disparities. A post-operative opioid reduction protocol was implemented in children undergoing abdominal surgery who were less than 1 years old at a tertiary level hospital. The purpose of this investigation was to determine if the clinical protocol was associated with a reduction in racial disparity in post-operative opioid prescribing patterns and associated clinical outcomes.

METHODS

A post-operative opioid reduction protocol based on standing intravenous acetaminophen, educational sessions with nursing staff, and standardized post-operative sign-out between the surgical and NICU teams was implemented in children under 1 year old in 2016. A time series and before and after analysis was conducted using a historical pre-intervention cohort (Jan 2011-Dec 2015) and prospectively collected post-intervention cohort (Jan 2016-Jan 2021). Primary outcomes included post-operative opioid use and post-operative pain scores stratified by race. Secondary outcomes included associated clinical outcomes also stratified by race.

RESULTS

A total of 249 children were included in the investigation, 117 in the pre-intervention group and 132 in the post intervention group. The majority of patients in both cohorts were either White or Black. The two cohorts were equally matched in terms of pre-operative clinical variables. In the pre-intervention cohort, the median post-operative morphine equivalents in White children was 2.1 mg/kg (IQR 0.2, 11.1) while in Black children it was 13.1 mg/kg (IQR 2.4, 65.3), p-value = 0.0352. In the post-intervention cohort, the median value for White children and Black children was statistically identical (0.05 mg/kg (IQR 0, 0.5) and 0.0 mg/kg (IQR 0, 0.3), respectively, p-value = 0.237). This pattern was also demonstrated in clinical variables including length of stay, intubation length and total parenteral nutrition use. In the pre-intervention cohort, the total length of stay for white children was 16 days while for black children it was 45 days (p = 0.007). In the postintervention cohort the length of stay for both White and Black children were identical at 8 days (p = 0.748).

CONCLUSION

The use of a clinical opioid reduction protocol implemented at a tertiary medical center was associated with a reduction in racial disparity in opioid prescribing habits in children. Prior to the protocol, there was a racial disparity in clinical variables associated with prolonged opioid use including length of stay, TPN use, and intubation length. The clinical protocol reduced variability in opioid prescribing patterns in all racial groups which was associated with a reduction in variability in associated clinical variables.

LEVEL OF EVIDENCE

Level III.

Racial Disparities in Failure to Rescue after Pediatric Heart Surgeries in the US

OBJECTIVE

To identify the trend in failure to rescue (FTR) and risk factors contributing to racial disparities in FTR after pediatric heart surgery using contemporary nationwide data.

STUDY DESIGN

We identified 85 267 congenital heart surgeries in patients <18 years of age from 2009 to 2019 using the Kid's Inpatient Database. The primary outcome was FTR. A mixed-effect logistic regression model with hospital random intercept was used to identify independent predictors of FTR.

RESULTS

Among 36 753 surgeries with postoperative complications, the FTR was 7.3%. The FTR decreased from 7.4% in 2009 to 6.3% in 2019 (P = .02). FTR was higher among Black than White children for all years. The FTR was higher among girls (7.2%) vs boys (6.6%), children aged <1 (9.6%) vs 12-17 years (2.4%), and those of Black (8.5%) vs White race (5.9%) (all P < .05). Black race was associated with a higher FTR odds (OR, 1.40; 95% CI, 1.20-1.65) after adjusting for demographics, medical complexity, nonelective admission, and hospital surgical volume. Higher hospital volume was associated with a lower odds of FTR for all racial groups, but fewer Black (19.7%) vs White (31%) children underwent surgery at high surgical volume hospitals (P < .001). If Black children were operated on in the same hospitals as White children, the racial differences in FTR would decrease by 47.3%.

CONCLUSIONS

Racial disparities exist in FTR after pediatric heart surgery in the US. The racial differences in the location of care may account for almost half the disparities in FTR.

Racial Inequity in Pediatric Anesthesia

Purpose of Review

Minority health disparities have received renewed attention in the USA following several highly publicized racial injustices in 2020. Though the focus has been largely on adults, children are not immune to these inequities. By reviewing racial disparities in pediatric perioperative care, we aim to engage the anesthesia community in the fight against systemic racism.

Recent Findings

Minority children have higher rates of anesthetic and surgical morbidity compared to White children, including respiratory events, length of stay, hospital costs, and even death. These inequities occur across surgical specialties and environments.

Summary

Racial disparities in the perioperative health and management of children are ubiquitous. Herein, we will summarize recent pediatric health disparity literature, discuss some important contributors to persistent inequities, and propose avenues for anesthesiologists to impact the pursuit of equitable healthcare outcomes.

Racial and Ethnic Disparities in Outcomes Among Newborns with Congenital Diaphragmatic Hernia

Importance

There is some data to suggest that racial and ethnic minority infants with congenital diaphragmatic hernia (CDH) have poorer clinical outcomes.

Objective

To determine what patient- and institutional-level factors are associated with racial and ethnic differences in CDH mortality.

Design, Setting, and Participants

Multicenter cohort study of 49 US children's hospitals using the Pediatric Health Information System database from January 1, 2015, to December 31, 2020. Participants were patients with CDH admitted on day of life 0 who underwent surgical repair. Patient race and ethnicity were guardian-reported vs hospital assigned as Black, Hispanic (White or Black), or White. Data were analyzed from August 2021 to March 2022.

Exposures

Patient race and ethnicity: (1) White vs Black and (2) White vs Hispanic; and institutional-level diversity (as defined by the percentage of Black and Hispanic patients with CDH at each hospital): (1) 30% or less, (2) 31% to 40%, and (3) more than 40%.

Main Outcomes and Measures

The primary outcomes were in-hospital and 60-day mortality. The study hypothesized that hospitals managing a more racially and ethnically diverse population of patients with CDH would be associated with lower mortality among Black and Hispanic infants.

Results

Among 1565 infants, 188 (12%), 306 (20%), and 1071 (68%) were Black, Hispanic, and White, respectively. Compared with White infants, Black infants had significantly lower gestational ages (mean [SD], White: 37.6 [2] weeks vs Black: 36.6 [3] weeks; difference, 1 week; 95% CI for difference, 0.6-1.4; P < .001), lower birthweights (White: 3.0 [1.0] kg vs Black: 2.7 [1.0] kg; difference, 0.3 kg; 95% CI for difference, 0.2-0.4; P < .001), and higher extracorporeal life support use (White: 316 patients [30%] vs Black: 69 patients [37%]; χ21 = 3.9; P = .05). Black infants had higher 60-day (White: 99 patients [9%] vs Black: 29 patients [15%]; χ21 = 6.7; P = .01) and in-hospital (White: 133 patients [12%] vs Black: 40 patients [21%]; χ21 = 10.6; P = .001) mortality . There were no mortality differences in Hispanic patients compared with White patients. On regression analyses, institutional diversity of 31% to 40% in Black patients (hazard ratio [HR], 0.17; 95% CI, 0.04-0.78; P = .02) and diversity greater than 40% in Hispanic patients (HR, 0.37; 95% CI, 0.15-0.89; P = .03) were associated with lower mortality without altering outcomes in White patients.

Conclusions and Relevance

In this cohort study of 1565 who underwent surgical repair patients with CDH, Black infants had higher 60-day and in-hospital mortality after adjusting for disease severity. Hospitals treating a more racially and ethnically diverse patient population were associated with lower mortality in Black and Hispanic patients.

Orthopaedic Diagnoses in the Black Pediatric Population

The Black pediatric population is one that has been historically underserved and continues to have unmet needs. Factors including lack of diversity in orthopaedic studies and in historical standards, such as bone age, may inadvertently lead to inferior care. There are certain conditions in this population for which the practicing orthopaedic surgeon should have a higher degree of suspicion, including slipped capital femoral epiphysis, Blount disease, and postaxial polydactyly. Systemic diseases with higher rates in this population have orthopaedic manifestations, including sickle cell disease, vitamin D deficiency, and obesity. Racial discrepancies in access to prenatal care can have orthopaedic consequences for babies, especially cerebral palsy and myelodysplasia. Racial discrepancy exists in evaluation for nonaccidental trauma. Increased awareness of these issues better prepares practitioners to provide equitable care.

Geospatial analysis of patients' social determinants of health for health systems science and disparity research

Social context matters for health, healthcare processes/quality and patient outcomes. The social status and circumstances we are born into, grow up in and live under, are called social determinants of health; they drive our health, and how we access and experience care; they are the fundamental causes of disease outcomes. Such circumstances are influenced heavily by our location through neighborhood context, which relates to support networks. Geography can influence proximity to resources and is an important dimension of social determinants of health, which also encompass race/ethnicity, language, health literacy, gender identity, social capital, wealth and income. Beginning with an explanation of social determinants, we explore the use of Geospatial Analysis methods and geocoding, including the importance of collaborating with geography experts, the pitfalls of geocoding, and how geographic analysis can help us to understand patient populations within the context of Social Determinants of Health. We then explain mechanisms and methods of geospatial analysis with two examples: (1) Bayesian hierarchical regression with crossed random effects and (2) discontinuity regression i.e., change point analysis. We leveraged the local University of Utah and Yale cohorts of the Multicenter Perioperative Outcomes Group (MPOG.org ), a perioperative electronic health registry; we enriched the Utah cohort with US-census tract level social determinants of health after geocoding patient addresses and extracting social determinants of health from the National Neighborhood Database (NaNDA). We explain how to investigate the impact of US-census tract level community deprivation indices and racial/ethnic composition on (1) individual clinicians’ administration of risk-adjusted perioperative antiemetic prophylaxis, (2) patients’ decisions to defer cataract surgery at the cusp of Medicare eligibility and finally (3) methods to further characterize patient populations at risk through publicly available datasets in the context of public transit access. Our examples are not rigorous analyses, and our preliminary inferences should not be taken at face value, but rather seen as illustration of geospatial analysis processes and methods. Our worked examples show the potential utility of geospatial analysis, and in particular the power of geocoding patient addresses to extract US-census level social determinants of health from publicly available databases to enrich electronic health registries for healthcare disparity research and targeted health system level countermeasures.