Disparities in utilization of outpatient surgical care among children

Assessing the Impact of Neighborhood and Built Environment on Pediatric Perioperative Care: A Systematic Review of the Literature

CONTEXT

Neighborhood and built environment encompass one key area of the Social Determinants of Health (SDOH) and is frequently assessed using area-level indices.

OBJECTIVE

We sought to systematically review the pediatric surgery literature for use of commonly applied area-level indices and to compare their utility for prediction of outcomes.

DATA SOURCES

A literature search was conducted using PubMed, Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print, PsycInfo, and an artificial intelligence search tool (1/2013-2/2023).

STUDY SELECTION

Inclusion required pediatric surgical patients in the US, surgical intervention performed, and use of an area-level metric.

DATA EXTRACTION

Extraction domains included study, patient, and procedure characteristics.

RESULTS

Area Deprivation Index is the most consistent and commonly accepted index. It is also the most granular, as it uses Census Block Groups. Child Opportunity Index is less granular (Census Tract), but incorporates pediatric-specific predictors of risk. Results with Social Vulnerability Index, Neighborhood Deprivation Index, and Neighborhood Socioeconomic Status were less consistent.

LIMITATIONS

All studies were retrospective and quality varied from good to fair.

CONCLUSIONS

While each index has strengths and limitations, standardization on ideal metric(s) for the pediatric surgical population will help build the inferential power needed to move from understanding the role of SDOH to building meaningful interventions towards equity in care.

TYPE OF STUDY

Systematic Review.

LEVEL OF EVIDENCE

Level III.

Health Literacy and Health-care Resource Utilization Following Gastrostomy Tube Placement in Pediatric Patients

INTRODUCTION

Parental health literacy and neighborhood socioeconomic disadvantage are associated with adverse health outcomes and increased health-care resource utilization in children. We sought to evaluate the association between community-level health literacy and neighborhood socioeconomic disadvantage and their relationships with outcomes of pediatric patients undergoing gastrostomy tube (GT) placement.

METHODS

Pediatric patients who underwent GT placement from 2000 to 2019 were identified using the IBM MarketScan Research database. Claims data were merged with the health literacy index (HLI) and area deprivation index (ADI), measures of community-level health literacy and neighborhood socioeconomic disadvantage, respectively. We used multivariate logistic regression to estimate factors associated with postoperative 30- and 90-day ED visits (EVs) and 30-day readmissions.

RESULTS

A total of 4374 pediatric patients underwent GT placement. In this cohort, 6.1% and 11.4% had 30-day and 90-day EV; and 30-day readmissions in 19.75%. HLI was lower in those with 30-(244.6 ± 6.1 versus 245.4 ± 6.1; P = 0.0482) and 90-(244.5 ± 5.8 versus 245.5 ± 6.1; P = 0.001) day EV, and 30-day readmission (244.5 ± 5.56 versus 245.4 ± 6.1; P = 0.001) related to GT. ADI was lower in those with 90-day EV (55.1 ± 13.1 versus 55.9 ± 14.6; P = 0.0244). HLI was associated with decreased odds of 30- (adjusted odds ratio: 0.968; 95% confidence interval: 0.941-0.997) and 90-day (adjusted odds ratio: 0.975; 95% confidence interval: 0.954-0.998) EV following GT placement. ADI was also significantly associated with 30 and 90-day EV following GT placement.

CONCLUSIONS

In pediatric patients undergoing GT placement, higher ecologically-measured health literacy and neighborhood socioeconomic disadvantage are associated with decreased health-care resource utilization, as evidenced by decreased ED visits. Future studies should focus on the role of individual parental health literacy in outcomes of pediatric surgical patients.

Impact of consensus guideline publication on the timing of elective pediatric umbilical hernia repair

BACKGROUND

The American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear.

METHODS

This retrospective study used data from children's hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects.

RESULTS

16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05-1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01-1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74-0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24-0.84).

CONCLUSION

Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.

Location of Treatment Among Infants Requiring Complex Surgical Care

INTRODUCTION

Rural children have worse health outcomes compared to urban children. One mechanism for this finding may be decreased access to specialized care at children's hospitals. The objective of this study was to evaluate the hospital types where complex surgical care in infants is performed nationally.

METHODS

This study examined infants (<1 y old) in the Kids' Inpatient Database from 2009 to 2019 who underwent surgery for one of the following conditions: esophageal atresia, gastroschisis, omphalocele, Hirschsprung disease, anorectal malformation, pyloric stenosis, small bowel atresia, congenital diaphragmatic hernia, and necrotizing enterocolitis. The relationship between patient residence (rural versus urban) and location of surgical care (children's hospital versus other) was compared in relation to other covariates using multivariable logistic regression models.

RESULTS

Among 29,185 infants undergoing these operations, 16.0% lived in a rural area. Rural infants were more frequently White (64.8% versus 43.4% P < 0.001), from the lowest two income quartiles (86.5% versus 52.0%, P < 0.001), and from the South or Midwest regions (P < 0.001). Surgical care was predominantly (94.1%) provided at urban teaching hospitals but frequently not at children's hospitals, especially among rural infants. After adjusting for other covariates, rural infants were significantly less likely to undergo care at a children's hospital for both 2009 (adjusted odds ratio 0.66, P < 0.001) and 2012-2019 (adjusted odds ratio 0.78, P < 0.001).

CONCLUSIONS

A sizable portion of complex surgical care in infants is performed outside children's hospitals, especially among those from rural areas. Further work is necessary to ensure adequate access to children's hospitals for rural children.

Characterizing rural families' experiences receiving pediatric surgical care: A qualitative study

PURPOSE

Access to pediatric surgical care is influenced by multiple factors, including proximity to care and financial resources. There is limited understanding regarding the process by which rural children acquire surgical care. We qualitatively explored rural families' experiences seeking surgical care for their children at a major children's hospital.

METHODS

Parents or legal guardians ≥18 years of age with children who received general surgical care at a major children's hospital and who lived in rural areas were included. Operative logs from 2020 to 2021 and postoperative clinic visits were used to identify families. Semi-structured interviews explored rural families' experiences receiving surgical care. Interviews were inductively and deductively analyzed to create codes and identify thematic domains. Twelve interviews (with 15 individuals) were conducted before thematic saturation was reached.

FINDINGS

Children were predominantly White (92%) and lived a median of 98.3 mi (interquartile range 49.4-147.0 mi) from the hospital. Four thematic domains were identified: (1) Accessing surgical care included difficulties with referral processes and travel/lodging burdens; (2) surgical care processes involved treatment details and provider/hospital expertise; (3) resources for navigating care encompassed families' employment status, financial burden, and technology use; and (4) social support included family situations, emotions and stress, and coping with diagnoses.

CONCLUSIONS

Rural families experienced difficulties with obtaining referrals, challenges with travel and employment, and the benefits of technology use. These findings can be applied to the development of tools that can ease challenges faced by rural families whose children require surgical care.

The association between childhood opportunity index and pediatric hospitalization for firearm injury or motor vehicle crash

BACKGROUND

Community-level factors can profoundly impact children's health, including the risk of violent injury. This study's objective was to understand the relationship between the Childhood Opportunity Index and pediatric firearm injury owing to interpersonal violence compared with a motor vehicle crash.

METHODS

All pediatric patients (<18 years) who presented with an initial encounter with a firearm injury or motor vehicle crash between 2016 to 2021 were identified from 35 children's hospitals included in the Pediatric Health Information System database. The child-specific community-level vulnerability was determined by the Childhood Opportunity Index, a composite score of neighborhood opportunity level data specific to pediatric populations.

RESULTS

We identified 67,407 patients treated for injuries related to motor vehicle crashes (n = 61,527) or firearms (n = 5,880). The overall cohort had a mean age of 9.3 (standard deviation 5.4) years; 50.0% were male patients, 44.0% non-Hispanic Black, and were 60.8% publicly insured. Compared with motor vehicle crash injuries, patients with firearm-related injuries were older (12.2 vs 9.0 years), more likely to be male patients (77.7% vs 47.4%), non-Hispanic Black (63.5% vs 42.1%), and had public insurance (76.4 vs 59.3%; all P < .001). In multivariable analysis, children living in communities with lower Childhood Opportunity Index levels were more likely to present with firearm injury than those living in communities with a very high Childhood Opportunity Index. The odds increased as the Childhood Opportunity Index level decreased (odds ratio 1.33, 1.60, 1.73, 2.00 for high, moderate, low, and very low Childhood Opportunity Index, respectively; all P ≤ .001).

CONCLUSION

Children from lower-Childhood Opportunity Index communities are disproportionately impacted by firearm violence, and these findings have important implications for both clinical care and public health policy.

Disparities in high risk prenatal care adherence along racial and ethnic lines

The term "high-risk pregnancy" describes a pregnancy at increased risk for complications due to various maternal or fetal medical, surgical, and/or anatomic issues. In order to best protect the pregnant patient and the fetus, frequent prenatal visits and monitoring are often recommended. Unfortunately, some patients are unable to attend these appointments for various reasons. Moreover, it has been documented that patients from ethnically and racially diverse backgrounds are more likely to miss medical appointments than are Caucasian patients. For instance, a case-control study retrospectively identified the race/ethnicity of patients who no-showed for mammography visits in 2018. Women who no-showed were more likely to be African American than patients who kept their appointments, with an odds ratio of 2.64 (4). Several other studies from several other primary care and specialty disciplines have shown similar results. However, the current research on high-risk obstetric no-shows has focused primarily on why patients miss their appointments rather than which patients are missing appointments. This is an area of opportunity for further research. Given disparities in health outcomes among underrepresented racial/ethnic groups and the importance of prenatal care, especially in high-risk populations, targeted attempts to increase patient participation in prenatal care may improve maternal and infant morbidity/mortality in these populations.

Addressing pediatric surgical health inequities through quality improvement efforts

Concepts of healthcare quality and health equity should be inextricably linked but are often pursued separately. Quality improvement (QI) can serve as a powerful means to eliminate health inequities by adopting an equity-focused lens to diagnose and address baseline disparities among pediatric populations using targeted interventions. QI and pediatric surgery practitioners should integrate concepts of equity at every stage of formulating a QI project including conceptualization, planning, and execution. Early adaptation of an equity conscious perspective using QI methodology can prevent exacerbation of preexisting disparities while improving overall outcomes.

Defining high-quality care in pediatric surgery: Implications for performance measurement and prioritization of quality and process improvement efforts

Establishing a standardized and comprehensive framework for defining surgical quality is essential for meaningful performance measurement and process improvement efforts. The goal of this chapter is to provide a conceptual framework for defining surgical quality based on the perspectives of relevant stakeholders, and to identify infrastructure and care processes necessary for the delivery of high-quality surgical care. Central to this framework are the complementary approaches for quality assessment as outlined by the Institute of Medicine and Donabedian paradigms, and how these should be used together to develop a robust and granular taxonomy of quality constructs relevant to all surgical conditions. The utility of balancing and composite measures for quality assessment is also reviewed, as are practical considerations for identifying and prioritizing process improvement opportunities based on procedure volume and perioperative risk.

Disparities in Utilization of Same-Day Discharge Following Appendectomy in Children

INTRODUCTION

Disparities in the delivery of pediatric surgical care exist for racial and ethnic minority groups. Utilization of same-day discharge (SDD) following appendectomy for acute, uncomplicated appendicitis is increasing; however, rates among diverse populations have not been explored to evaluate equitable care delivery and healthcare utilization. Our objective was to determine whether race and ethnicity are associated with rates of SDD and postdischarge healthcare utilization. We hypothesized that racial and ethnic minority groups would have lower rates of SDD.

METHODS

This retrospective cohort study used data from the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program-Pediatric clinical registry and included children who underwent appendectomy. Patients with complicated appendicitis were excluded. Primary exposure was racial or ethnic group. The primary outcome was SDD, and secondary outcomes included postdischarge emergency department visits and hospital readmissions.

RESULTS

Of 37,579 simple appendicitis patients, SDD after appendectomy occurred in 10,012 (26.6%). On multivariable analysis, Black or African American race was associated with lower likelihood of SDD (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [95% CI]:0.79-0.92; P < 0.0001). Hispanic ethnicity was associated with higher likelihood of SDD (aOR: 1.19; 95% CI: 1.12-1.25; P < 0.0001). Likelihood of postoperative emergency department visits was higher in Black or African American patients (aOR: 1.36; 95% CI: 1.14-1.62; P < 0.001) and Hispanic patients (aOR: 1.37; 95% CI: 1.12-1.58; P < 0.0001). Hospital readmission rates were similar across groups.

CONCLUSIONS

Rates of SDD following appendectomy vary among racial and ethnic groups. Interventions to achieve equitable healthcare delivery including SDD after appendectomy are needed.

Distribution of acute appendicitis care in children: A statewide assessment of the surgeons and facilities providing surgical care

BACKGROUND

Pediatric appendicitis is managed by general and pediatric surgeons at both children's hospitals and non-children's hospitals. A statewide assessment of surgeons and facilities providing appendicitis care was performed to identify factors associated with location of surgical care.

METHODS

Children aged <18 years undergoing appendectomy for appendicitis in Wisconsin from 2018-2020 were identified through the International Classification of Diseases, 10th revision, and Current Procedural Terminology codes using Wisconsin Hospital Association data. Patient residence and hospital locations were used to determine travel distance, rurality, and neighborhood-level socioeconomic status.

RESULTS

Among 3,604 children with appendicitis, 36.0% and 12.8% had an appendectomy at 2 major children's hospitals and 4 other children's hospitals, respectively, and 51.2% had an appendectomy at 99 non-children's hospitals. Pediatric surgeons performed 76.1% of appendectomies at children's hospitals and 2.9% at non-children's hospitals. Only 32.2% of patients received care at the hospital closest to their homes. Non-children's hospitals disproportionally cared for older, non-Hispanic White, and privately insured children, those with uncomplicated appendicitis, and those living in rural areas, in mid-socioeconomic status neighborhoods, and greater distances from children's hospitals (all P < .001). After multivariable adjustment, receipt of care at children's hospitals was associated with younger age, minority race, complicated appendicitis, shorter distance to children's hospitals, and urban residence.

CONCLUSION

Over half of surgical care for pediatric appendicitis occurred at non-children's hospitals, especially among older children and those living in rural areas far from children's hospitals. Future work is necessary to determine which children benefit most from care at children's hospitals and which can safely receive care at non-children's hospitals to avoid unnecessary time and resource utilization associated with travel to children's hospitals.

Postdischarge Racial and Ethnic Disparities in Pediatric Appendicitis: A Mediation Analysis

INTRODUCTION

Significant racial and ethnic disparities exist for children presenting with acute appendicitis; however, it is unknown if disparities persist after initial management and hospital discharge.

MATERIALS AND METHODS

We performed a retrospective cohort study of children (aged < 18 y) who underwent treatment for acute appendicitis in 47 U.S. Children's Hospitals between 2017 and 2019. Primary outcomes were 30-d emergency department (ED) visits and 30-d inpatient readmission. Hierarchical multivariable logistic regression models were developed to determine the association of race and ethnicity on the primary outcomes. Inverse odds-weighted mediation analyses were used to estimate the degree to which complicated disease, insurance status, urbanicity, and residential socioeconomic status- mediated disparate outcomes.

RESULTS

A total of 67,303 patients were included. Compared with Non-Hispanic White children, Non-Hispanic Black (NHB) (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.23-1.59) and Hispanic/Latinx (HL) children (OR 1.55, 95% CI 1.44-1.67) had higher odds of ED visits. Only NHB children had higher odds of readmission (OR 1.43, 95% CI 1.30-1.57). On a multivariable analysis, NHB (adjusted OR 1.19, 95% CI 1.04-1.36) and HL (adjusted OR 1.19, 95% CI 1.09-1.31) children had higher odds of ED visits. Insurance, disease severity, socioeconomic status, and urbanicity mediated 61.6% (95% CI 29.7-100%) and 66.3% (95% CI 46.9-89.3%) of disparities for NHB and HL children, respectively.

CONCLUSIONS

Children of racial and ethnic minorities are more likely to visit the ED after treatment for acute appendicitis, but HL patients did not have a corresponding increase in readmission. These differences were mediated mainly by insurance status and urban residence. A lack of appropriate postdischarge education and follow-up may drive disparities in healthcare utilization after pediatric appendicitis.

Association between neighborhood food environments and bariatric surgery outcomes

BACKGROUND

Individual characteristics associated with weight loss after bariatric surgery are well established, but the neighborhood characteristics that influence outcomes are unknown.

OBJECTIVES

The objective of this study was to determine if neighborhood characteristics, including social determinants and lifestyle characteristics, were associated with weight loss after bariatric surgery.

SETTING

Single university healthcare system, United States.

METHODS

In this retrospective cohort study, all patients who underwent primary bariatric surgery from 2008 to 2017 and had at least 1 year of follow-up data were included. Patient-level demographics and neighborhood-level social determinants (area deprivation index, urbanicity, and walkability) and lifestyle factors (organic food use, fresh fruit/vegetable consumption, diet to maintain weight, soda consumption, and exercise) were analyzed. Median regression with percent total body weight (%TBW) loss as the outcome was applied to examine factors associated with weight loss after surgery.

RESULTS

Of the 647 patients who met inclusion criteria, the average follow-up period was 3.1 years, and the mean %TBW loss at the follow-up was 22%. In adjusted median regression analyses, Roux-en-Y gastric bypass was associated with greater %TBW loss (11.22%, 95% confidence interval [8.96, 13.48]) compared to sleeve, while longer follow-up time (-2.42% TBW loss per year, 95% confidence interval [-4.63, -0.20]) and a preoperative diagnosis of diabetes (-1.00% TBW loss, 95% confidence interval [-1.55, -0.44]) were associated with less. None of the 8 neighborhood level characteristics was associated with weight loss.

CONCLUSIONS

Patient characteristics rather than neighborhood-level social determinants and lifestyle factors were associated with weight loss after bariatric surgery in our cohort of bariatric surgery patients. Patients from socioeconomically deprived neighborhoods can achieve excellent weight loss after bariatric surgery.

Emerging Racial Disparities in Outpatient Utilization of Total Joint Arthroplasty

BACKGROUND

Racial and ethnic disparities within the field of total joint arthroplasty (TJA) have been extensively reported. To date, however, it remains unknown how these disparities have translated to the outpatient TJA (OP-TJA) setting. The purposes of this study were to compare relative OP-TJA utilization rates between White and Black patients from 2011-2019 and assess how these differences in utilization have evolved over time.

METHODS

We conducted a retrospective review from 2011-2019 using the National Surgical Quality Improvement Program (NSQIP). Differences in the relative utilization of OP (same-day discharge) versus inpatient TJA between White and Black patients were assessed and trended over time. Multivariable logistic regressions were run to adjust for baseline patient factors and comorbidities.

RESULTS

During the study period, Black patients were significantly less likely to undergo OP-TJA when compared to White patients (P < .001 for both outpatient total knee arthroplasty and outpatient total hip arthroplasty [OP-THA]). From 2011 to 2019, an emerging disparity was found in outpatient total knee arthroplasty and OP-THA utilization between White and Black patients (eg, White versus Black OP-THA: 0.4% versus 0.6% in 2011 compared with 10.2% versus 5.9% in 2019, P_trend < .001). These results held in all adjusted analyses.

CONCLUSION

In this study we found evidence of emerging and worsening racial disparities in the relative utilization of OP-TJA procedures between White and Black patients. These results highlight the need for early intervention by orthopaedic surgeons and policy makers alike to address these emerging inequalities in access to care before they become entrenched within our systems of orthopaedic care.

Utilization and Adequacy of Telemedicine for Outpatient Pediatric Surgical Care

INTRODUCTION

Telemedicine (TM) use accelerated out of necessity during the COVID-19 pandemic, but the utility of TM within the pediatric surgery population is unclear. This study measured utilization, adequacy, and disparities in uptake of TM in pediatric surgery during the COVID-19 pandemic.

METHODS

Scheduled outpatient pediatric surgery clinic encounters at a large academic children's hospital from January 2020 through March 2021 were reviewed. Sub-group analysis examined post-operative (PO) visits after appendectomy and umbilical, epigastric, and inguinal hernia repairs.

RESULTS

Of 9149 scheduled visits, 87.9% were in-person and 12.1% were TM. TM visits were scheduled for PO care (76.9%), new consultations (7.1%), and established patients (16.0%). Although TM visits were more frequently canceled or no shows (P < 0.001), most canceled TM visits were PO visits, of which 41.7% were canceled via electronic communication reporting the absence of any PO concerns. TM visits were adequate for accomplishing visit goals in 98.2%, 95.5%, and 96.2% of PO, new, and established patient visits, respectively. Patients utilizing TM visits were more frequently of white race, privately-insured, from less disadvantaged neighborhoods, and living a greater distance from clinic (P < 0.001 for all comparisons).

CONCLUSIONS

TM was adequate for the majority of visits in which it was utilized, including the basic PO visits that occurred via TM. TM was used more by patients with greater travel and less by those of minority race, with public insurance, and from more disadvantaged neighborhoods. Future work is necessary to ensure broad access to this useful tool for all children requiring surgical care.

Racial and ethnic disparities in the timing of orchiopexy for cryptorchidism

INTRODUCTION

Many children do not undergo surgery for cryptorchidism in a timely fashion, increasing risk of infertility and malignancy. Racial and ethnic disparities in surgery timing has been suggested in other specialties, but has not been well-explored in Pediatric Urology.

OBJECTIVES

Our aim was to investigate the association of race and ethnicity with age at orchiopexy.

MATERIALS AND METHODS

We performed a retrospective cohort study of individuals <18 years of age as captured in the NSQIPP PUF from 2012 to 2016. Those with cancer were excluded. The primary outcome of interest was age at time of surgery. Secondary outcome was the proportion of individuals undergoing surgery by recommended age. Generalized linear models and logistic regression models were created for the outcomes of interest.

RESULTS

The median age at orchiopexy was 17.4 months (10.7, 43.0) and overall, 51% of subjects underwent orchiopexy by 18 months of age. Non-Hispanic white individuals were most likely to have undergone orchiopexy by 18 months of age, at 56%, compared with only 44% of non-Hispanic black individuals (p < 0.001). When adjusting for co-morbidities and developmental delay, Hispanic patients underwent orchiopexy 5 months later than white patients, on average, and black patients had a delay of 7 months compared to white patients.

DISCUSSION

These data suggest that orchiopexy is happening at younger ages compared to prior large-scale studies. However, minority patients are on average older at time of orchiopexy, potentially increasing future risk of infertility or malignancy. While an estimated average delay of 5-7 months may not seem high, studies suggest there is an appreciable change in risk with a 6-month delay. Patient, provider, and system-level factors likely all contribute, and these need to be further elucidated.

CONCLUSIONS

Many racial and ethnic minorities with cryptorchidism have later orchiopexies, and are more likely to have surgery outside the recommended timeframe. Further investigation is warranted to determine the factors contributing to these disparities.

Geographic barriers to children's surgical care: A systematic review of existing evidence

BACKGROUND

Ensuring that children have access to timely and appropriate surgical care is a vital component of comprehensive pediatric care. This study systematically reviews the existing evidence related to geographic barriers in children's surgery.

METHODS

Medline and Scopus databases were searched for any English language studies that examined associations between geographic burden (rural residence or distance to care) and a quantifiable outcome within pediatric surgical subspecialties. Two independent reviewers extracted data from each study.

RESULTS

From 6331 studies screened, 22 studies met inclusion criteria. Most studies were retrospective analyses and conducted in the U.S. or Canada (14 and three studies, respectively); five were conducted outside North America. In transplant surgery (seven studies), greater distance from a transplant center was associated with higher waitlist mortality prior to kidney and liver transplantation, although graft outcomes were generally similar. In congenital cardiac surgery (five studies), greater travel was associated with higher neonatal mortality and older age at surgery but not with post-operative outcomes. In general surgery (eight studies), rural residence was associated with increased rates of perforated appendicitis, higher frequency of negative appendectomy, and increased length of stay after appendectomy. In orthopedic surgery (one study), rurality was associated with decreased post-operative satisfaction. No evidence for disparate outcomes based upon distance or rurality was identified in neurosurgery (one study).

CONCLUSIONS

Substantial evidence suggests that geographic barriers impact the receipt of surgical care among children, particularly with regard to transplantation, congenital cardiac surgery, and appendicitis.