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Martin SR, Kain ZN. The intersection of pediatric anesthesiology and social determinants of health. Curr Opin Anaesthesiol 2024; 37:271-276. [PMID: 38441068 PMCID: PMC11042989 DOI: 10.1097/aco.0000000000001367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
PURPOSE OF REVIEW There is increasing evidence of racial and ethnic disparities in pediatric perioperative care, which indicates a need to identify factors driving disparities. Social determinants of health (SDOH) play a fundamental role in pediatric health and are recognized as key underlying mechanisms of healthcare inequities. This article summarizes recent research exploring the influence of SDOH on pediatric perioperative outcomes. RECENT FINDINGS Despite the scarcity of research exploring SDOH and pediatric perioperative outcomes, recent work demonstrates an association between SDOH and multiple outcomes across the perioperative care continuum. Measures of social disadvantage were associated with preoperative symptom severity, longer hospital stays, and higher rates of postoperative complications and mortality. In some studies, these adverse effects of social disadvantage persisted even when controlling for medical comorbidities and clinical severity. SUMMARY The existing literature offers compelling evidence of the impact of SDOH on perioperative outcomes in children and reveals a critical area in pediatric anesthesia that necessitates further exploration and action. To improve outcomes and address care inequities, future efforts should prioritize the integration of SDOH assessment into pediatric perioperative research and practice.
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Affiliation(s)
- Sarah R. Martin
- Department of Anesthesiology and Perioperative Care, University of California Irvine School of Medicine, Irvine CA
- Center on Stress & Health, University of California Irvine, Irvine, CA
- Emergency Medicine, Children’s Hospital of Orange County, Orange, CA
| | - Zeev N. Kain
- Department of Anesthesiology and Perioperative Care, University of California Irvine School of Medicine, Irvine CA
- Center on Stress & Health, University of California Irvine, Irvine, CA
- Yale University Child Study Center, New Haven, Connecticut
- Children’s Hospital of Orange County, Orange, CA
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Banks KC, Wei J, Morales LM, Islas ZA, Alcasid NJ, Susai CJ, Sun A, Burapachaisri K, Patel AR, Ashiku SK, Velotta JB. Differences in outcomes by race/ethnicity after thoracic surgery in a large integrated health system. Surg Open Sci 2024; 19:118-124. [PMID: 38655068 PMCID: PMC11035076 DOI: 10.1016/j.sopen.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
Background Disparities exist throughout surgery. We aimed to assess for racial/ethnic disparities among outcomes in a large thoracic surgery patient population. Methods We reviewed all thoracic surgery patients treated at our integrated health system from January 1, 2016-December 31, 2020. Post-operative outcomes including length of stay (LOS), 30-day return to the emergency department (30d-ED), 30-day readmission, 30- and 90-day outpatient appointments, and 30- and 90-day mortality were compared by race/ethnicity. Bivariate analyses and multivariable logistic regression were performed. Our multivariable models adjusted for age, sex, body mass index, Charlson Comorbidity Index, surgery type, neighborhood deprivation index, insurance, and home region. Results Of 2730 included patients, 59.4 % were non-Hispanic White, 15.0 % were Asian, 11.9 % were Hispanic, 9.6 % were Black, and 4.1 % were Other. Median (Q1-Q3) LOS (in hours) was shortest among non-Hispanic White (37.3 (29.2-76.1)) and Other (36.5 (29.3-75.4)) patients followed by Hispanic (46.8 (29.9-78.1)) patients with Asian (51.3 (30.7-81.9)) and Black (53.7 (30.6-101.6)) patients experiencing the longest LOS (p < 0.01). 30d-ED rates were highest among Hispanic patients (21.3 %), followed by Black (19.2 %), non-Hispanic White (18.1 %), Asian (13.4 %), and Other (8.0 %) patients (p < 0.01). On multivariable analysis, Hispanic ethnicity (Odds Ratio (OR) 1.43 (95 % CI 1.03-1.97)) and Medicaid insurance (OR 2.37 (95 % CI 1.48-3.81)) were associated with higher 30d-ED rates. No racial/ethnic disparities were found among other outcomes. Conclusions Despite parity across multiple surgical outcomes, disparities remain related to patient encounters within our system. Health systems must track such disparities in addition to standard clinical outcomes. Key message While our large integrated health system has been able to demonstrate parity across many major surgical outcomes among our thoracic surgery patients, race/ethnicity disparities persist including in the number of post-operative return trips to the emergency department. Tracking outcome disparities to a granular level such as return visits to the emergency department and number of follow up appointments is critical as health systems strive to achieve equitable care.
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Affiliation(s)
- Kian C. Banks
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Julia Wei
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Leyda Marrero Morales
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Zeuz A. Islas
- Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Nathan J. Alcasid
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Cynthia J. Susai
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Angela Sun
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Katemanee Burapachaisri
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Ashish R. Patel
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Simon K. Ashiku
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Jeffrey B. Velotta
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA 91101, USA
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Margol ML, Dantes G, Dutreuil VL, Jahan A, Santore MT, Linden AF. The Association of Social Determinants of Health With Short Term Pediatric Gastrostomy Tube Outcomes. J Surg Res 2024; 296:352-359. [PMID: 38306941 DOI: 10.1016/j.jss.2023.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Social determinants of health (SDH) have been found to be important contributors to postoperative outcomes, especially those related to procedures that require significant postoperative resources. The association between short-term gastrostomy tube (GT) outcomes and SDH in the pediatric population is unknown. METHODS A retrospective review was performed of all patients less than 18 y old who received a GT between January 2018 and December 2020 at a single institution. Data including demographics, area deprivation index (ADI), and perioperative information were collected. Patient characteristics were compared in those that did and did not have an unexpected emergency department (ED) visit within 6 wk of discharge from GT placement. Statistical analysis was performed using Wilcoxon sum-rank, Chi-squared test, and Fisher's exact test where applicable, and univariable and multivariable logistic regression. RESULTS Of the 541 children who underwent GT placement, 112 (20.7%) returned to the ED within 6 wk postdischarge. In univariable analysis, Black children had 1.64 the odds of an unexpected ED visit compared to White children (95% confidence interval [CI] 1.04-2.60, P = 0.03). When controlling for ethnicity, primary language, insurance, ADI and comorbidities, Black children had 1.80 the odds of an unexpected ED visit compared to White children (95% CI 1.10-2.97, P = 0.02). Final model fit which added a race by ADI interaction term revealed Black children had 2.52 the odds of an unexpected ED visit compared to White children in the low (1-6) ADI group (95% CI 1.41-4.60, P = 0.002). Within advantaged neighborhoods (ADI 1-6), the probability of unplanned ED visits for White children was 17.3% (95%CI 8.9% - 31.1%), which was significantly lower than that for Black children (34.6%, 95% CI 18.8% - 54.7%; P value = 0.006). CONCLUSIONS Race and neighborhood disadvantage can be associated with unexpected ED visits within 6 wk of discharge from GT placement in the pediatric population. For procedures that require significant postdischarge resources it is important to study the effect of SDH on return to the healthcare system as they can be an important driver of disparities in outcomes.
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Affiliation(s)
- Matthew L Margol
- Emory University School of Medicine, Atlanta, Georgia; Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Valerie L Dutreuil
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Afrin Jahan
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Allison F Linden
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Langham MR. Commentary on "Social Determinants of Health: What Every Pediatric Surgeon Should Know". J Pediatr Surg 2024:S0022-3468(24)00154-4. [PMID: 38565476 DOI: 10.1016/j.jpedsurg.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Max R Langham
- University of Tennessee Health Science Center, Memphis, TN, USA.
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5
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Grabski DF, Vavolizza RD, Baumgarten HD, Fleming MA, Moneme C, McGahren ED, Swanson JR, Kabagambe SK, Gander JW. Post-operative Opioid Reduction Protocol Reduces Racial Disparity in Clinical Outcomes in Children. J Pediatr Surg 2024; 59:53-60. [PMID: 37858396 DOI: 10.1016/j.jpedsurg.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/21/2023]
Abstract
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.
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Affiliation(s)
- David F Grabski
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, VA, USA
| | - Rick D Vavolizza
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, VA, USA
| | - Heron D Baumgarten
- University of Louisville School of Medicine, Division of Pediatric Surgery, Louisville, KY, USA
| | - Mark A Fleming
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, VA, USA
| | - Chioma Moneme
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, VA, USA
| | - Eugene D McGahren
- University of Virginia School of Medicine, Department of Surgery, Division of Pediatric Surgery, Charlottesville, VA, USA
| | - Jonathan R Swanson
- University of Virginia School of Medicine, Department of Pediatrics, Charlottesville, VA, USA
| | - Sandra K Kabagambe
- University of Virginia School of Medicine, Department of Surgery, Division of Pediatric Surgery, Charlottesville, VA, USA
| | - Jeffrey W Gander
- University of Virginia School of Medicine, Department of Surgery, Division of Pediatric Surgery, Charlottesville, VA, USA.
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Willer BL, Mpody C, Nafiu O, Tobias JD. Racial Disparities in Pediatric Mortality Following Transfusion Within 72 Hours of Operation. J Pediatr Surg 2023; 58:2429-2434. [PMID: 37652843 DOI: 10.1016/j.jpedsurg.2023.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 07/24/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Postoperative bleeding and transfusion are correlated with mortality risk. Furthermore, postoperative bleeding may often initiate the cascade of complications that leads to death. Given that minority children have increased risk of surgical complications, this study aimed to investigate the association of race with pediatric surgical mortality following postoperative transfusion. METHODS We used the NSQIP-P PUF to assemble a retrospective cohort of children <18 who underwent inpatient surgery during 2012-2021. We included White, Black, Hispanic, and 'Other' children who received a transfusion within 72 h of surgery. The primary outcome was defined as all-cause mortality within 30 days following the primary surgical procedure. Using logistic regression models, we estimated the risk-adjusted odds ratio (aOR) and 95% confidence intervals (CI) of mortality, comparing each racial/ethnic cohort to White children. RESULTS A total of 466,230 children <18 years of age underwent inpatient surgical procedures from 2012 to 2021. Of these, 46,200 required transfusion and were included in our analysis. The majority of patients were non-Hispanic White (64.6%, n = 29,850), while 18.9% (n = 8752) were non-Hispanic Black, 11.7% (n = 5387) were Hispanic, and 4.8% (n = 2211) were 'Other' race. The overall rate of mortality following transfusion was 2.5%. White children had the lowest incidence of mortality (2.0%), compared to children of 'Other' race (2.5%), Hispanic children (3.1%), and Black children (3.6%). After adjusting for sex, age, comorbidities, case status, preoperative transfusion within 48 h, and year of operation, we found that Black children experienced 1.24 times the odds of mortality following a postoperative transfusion compared to a White child (aOR: 1.24; 95%CI, 1.03-1.51; P = 0.025). Hispanic children were also significantly more likely to die following a postoperative transfusion than White children (aOR: 1.19; 95%CI, 1.02-1.39; P = 0.027). CONCLUSION We found that minority children who required a postoperative transfusion had a higher odds of death than White children. Future studies should explore adverse events following postoperative transfusion and the differences in their management by race that may contribute to the higher mortality rate for minority children. LEVEL OF EVIDENCE Level II. CLINICAL TRIAL NUMBER AND REGISTRY Not applicable.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Cary MP, Zink A, Wei S, Olson A, Yan M, Senior R, Bessias S, Gadhoumi K, Jean-Pierre G, Wang D, Ledbetter LS, Economou-Zavlanos NJ, Obermeyer Z, Pencina MJ. Mitigating Racial And Ethnic Bias And Advancing Health Equity In Clinical Algorithms: A Scoping Review. Health Aff (Millwood) 2023; 42:1359-1368. [PMID: 37782868 PMCID: PMC10668606 DOI: 10.1377/hlthaff.2023.00553] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
In August 2022 the Department of Health and Human Services (HHS) issued a notice of proposed rulemaking prohibiting covered entities, which include health care providers and health plans, from discriminating against individuals when using clinical algorithms in decision making. However, HHS did not provide specific guidelines on how covered entities should prevent discrimination. We conducted a scoping review of literature published during the period 2011-22 to identify health care applications, frameworks, reviews and perspectives, and assessment tools that identify and mitigate bias in clinical algorithms, with a specific focus on racial and ethnic bias. Our scoping review encompassed 109 articles comprising 45 empirical health care applications that included tools tested in health care settings, 16 frameworks, and 48 reviews and perspectives. We identified a wide range of technical, operational, and systemwide bias mitigation strategies for clinical algorithms, but there was no consensus in the literature on a single best practice that covered entities could employ to meet the HHS requirements. Future research should identify optimal bias mitigation methods for various scenarios, depending on factors such as patient population, clinical setting, algorithm design, and types of bias to be addressed.
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Affiliation(s)
- Michael P Cary
- Michael P. Cary Jr. , Duke University, Durham, North Carolina
| | - Anna Zink
- Anna Zink, University of Chicago, Chicago, Illinois
| | - Sijia Wei
- Sijia Wei, Northwestern University, Chicago, Illinois
| | | | | | | | | | | | | | | | | | | | - Ziad Obermeyer
- Ziad Obermeyer, University of California Berkeley, Berkeley, California
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Rice-Townsend SE, Nicassio L, Glazer D, Avansino J, Durham MM, Frischer J, Calkins C, Rentea RM, Ralls M, Fuller M, Wood RJ, Rollins M, Lee J, Lewis KE, Reeder RW, Smith CA. Fecal continence outcomes and potential disparities for patients with anorectal malformations treated at referral institutions for pediatric colorectal surgery. Pediatr Surg Int 2023; 39:157. [PMID: 36952009 DOI: 10.1007/s00383-023-05447-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE Fecal incontinence is a problem for many patients born with an anorectal malformation (ARM) that can impact quality of life. It is unknown if racial, ethnic, and socioeconomic disparities relate to fecal continence in these children. We sought to examine outcomes and potential disparities in care. METHODS We performed a multicenter retrospective study of children > 3y with ARM evaluated at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The primary outcome was fecal continence. We evaluated for associations between fecal continence and race, sex, age, and insurance status. RESULTS 509 patients with ARM from 11 institutions were included. Overall, 24% reported complete fecal continence, and fecal continence was associated with older age (p < .001). For school-aged children, 27% reported complete continence, while 53% reported none. On univariate analysis, patients with combined private and public insurance showed lower rates of continence when compared to those with private insurance (23 vs. 12%; p = 0.02). Age was associated with continence on univariate and multivariable analyses. CONCLUSION Rates of complete fecal continence in this population are low. Differences based on payor status may exist. There were no observed disparities related to sex and race. Further investigation is warranted to improve care for this patient population. LEVEL OF EVIDENCE III. TYPE OF STUDY Multi-institutional retrospective comparative study.
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Affiliation(s)
- Samuel E Rice-Townsend
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA.
| | - Lauren Nicassio
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Deb Glazer
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Jeffrey Avansino
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Megan M Durham
- Children's Healthcare of Atlanta, Emory University Pediatric Institute, Atlanta, GA, USA
| | | | - Casey Calkins
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | | | | - Justin Lee
- Phoenix Children's Hospital, Phoenix, AZ, USA
| | | | | | - Caitlin A Smith
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
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Cockrell H, Barry D, Dick A, Greenberg S. Socioeconomic disadvantage and pediatric surgical outcomes. Am J Surg 2023; 225:891-896. [PMID: 36754749 DOI: 10.1016/j.amjsurg.2023.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/13/2023] [Accepted: 02/02/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The impact of socioeconomic status on surgical outcomes has not been well-studied in children. Area Deprivation Index (ADI) is a validated measure of neighborhood-level socioeconomic disadvantage. METHODS A retrospective analysis of surgical patients ages 0-21 years was performed at a quaternary pediatric hospital from 1/1/2016-12/31/2020. Logistic regression was used to assess the relationship between ADI, 30-day postoperative mortality and serious adverse events (SAE). RESULTS Among 56,655 patients, the incidence of 30-day mortality and SAE were 0.3% and 8.9%. On univariable regression, patients from higher state ADI neighborhoods had increased odds of 30-day postoperative mortality and SAE. After controlling for covariates, patients from a neighborhood with state ADI ranks of 9 and 10 had 24% (95% CI: 1.06-1.45) and 27% (95% CI: 1.08-1.49) increased odds of experiencing SAE. DISCUSSION Pediatric surgical patients from disadvantaged neighborhoods may experience worse postoperative outcomes irrespective of patient demographics and preoperative health status.
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Affiliation(s)
- Hannah Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Dwight Barry
- Department of Clinical Analytics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Andre Dick
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA; Division of Transplant Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Sarah Greenberg
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA
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10
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Yap A, Laverde R, Thompson A, Ozgediz D, Ehie O, Mpody C, Vu L. Social vulnerability index (SVI) and poor postoperative outcomes in children undergoing surgery in California. Am J Surg 2023; 225:122-128. [PMID: 36184328 DOI: 10.1016/j.amjsurg.2022.09.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/27/2022] [Accepted: 09/18/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Area-based social determinants of health (SDoH) associated with disparities in children's surgical outcomes are not well understood, though some may be risk factors modifiable by public health interventions. METHODS This retrospective cohort study investigated the effect of high social vulnerability index (SVI), defined as ≥90th percentile, on postoperative outcomes in children classified as ASA 1-2 who underwent surgery at a large institution participating in the National Surgical Quality Improvement Program (2015-2021). Primary outcome was serious postoperative complications, defined as postoperative death, unplanned re-operation, or readmission at 30 days after surgery. RESULTS Among 3278 pediatric surgical procedures, 12.1% had SVI in the ≥90th percentile. Controlling for age, sex, racialization, insurance status, and language preference, serious postoperative complications were associated with high overall SVI (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.02-2.44) and high socioeconomic vulnerability (SVI theme 1, OR 1.75, 95% CI 1.03-2.98). CONCLUSION Neighborhood-level socioeconomic vulnerability is associated with worse surgical outcomes in apparently healthy children, which could serve as a target for community-based intervention.
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Affiliation(s)
- Ava Yap
- University of California San Francisco, Department of Surgery, USA.
| | - Ruth Laverde
- University of California San Francisco, School of Medicine, USA
| | - Avery Thompson
- University of California San Francisco, School of Medicine, USA
| | - Doruk Ozgediz
- University of California San Francisco, Department of Surgery, USA
| | | | - Christian Mpody
- Nationwide Children's Hospital, Department of Anesthesiology and Pain Medicine, USA
| | - Lan Vu
- University of California San Francisco, Department of Surgery, USA
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Sanford EL, Nair R, Alder A, Sessler DI, Flores G, Szmuk P. Racial/ethnic differences in receipt of surgery among children in the United States. J Pediatr Surg 2022; 57:852-859. [PMID: 35568523 DOI: 10.1016/j.jpedsurg.2022.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/07/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND It is unknown whether racial/ethnic disparities exist in surgical utilization for children. The aim, therefore, was to evaluate the odds of surgery among children in the US by race/ethnicity to test the hypothesis that minority children have less surgery. METHODS Cross-sectional data were analyzed on children 0-18 years old from the 1999 to 2018 National Health Interview Survey, a large, nationally representative survey. The primary outcome was odds of surgery in the prior 12 months for non Latino African-American, Asian, and Latino children, compared with non Latino White children, after adjustment for relevant covariates. The National Surgical Quality Improvement Program Pediatric Dataset was used to analyze the odds of emergent/urgent surgery by race/ethnicity. RESULTS Data for 219,098 children were analyzed, of whom 10,644 (4.9%) received surgery. After adjustment for relevant covariates, African-American (AOR, 0.54; 95% CI, 0.50-0.59), Asian (AOR, 0.39; 95% CI, 0.33-0.46), and Latino (AOR, 0.62; 95% CI, 0.57-0.67) children had lower odds of surgery than White children. Latino children were more likely to require emergent or urgent surgery (AOR, 1.71; 95% CI, 1.68-1.74). CONCLUSIONS Latino, African-American, and Asian children have significantly lower adjusted odds of having surgery than White children in America, and Latino children were more likely to have emergent or urgent surgery. These racial/ethnic differences in surgery may reflect disparities in healthcare access which should be addressed through further research, ongoing monitoring, targeted interventions, and quality-improvement efforts. LEVEL OF EVIDENCE II. TYPE OF STUDY Prognosis study.
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Affiliation(s)
- Ethan L Sanford
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA; Department of Pediatric Critical Care, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, Texas, USA; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Rasmi Nair
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam Alder
- Department of Pediatric Surgery, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Glenn Flores
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA; Holtz Children's Hospital, Jackson Health System, Miami, FL, USA
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA; Outcomes Research Consortium, Cleveland, OH, USA
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12
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Tan H, Mendoza BA, Fortier MA, Kain Z. Perioperative pain disparity in children: A call for action. Paediatr Anaesth 2022; 32:1365-1367. [PMID: 36114806 DOI: 10.1111/pan.14557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022]
Abstract
Racial and ethnic disparities in both healthcare management and delivery have been extensively documented in medical literature. For example, patients from non-White minority backgrounds in the United States have been found to experience worse clinical outcomes after surgery, to receive fewer surgical procedures, and to experience worse perioperative pain management compared with patients from non-minority backgrounds. A recent NIH-ACS Symposium on Surgical Disparities Research has identified an urgent need for research aimed at addressing and understanding these disparities. The present review summarizes existing literature describing perioperative pain disparities in children in the United States, as well as highlights the paucity of research in this domain. Specifically, there is a need for randomized control trials and health services research studying pediatric perioperative pain disparities. A multidisciplinary systems-based approach would help translate findings from scientific research to clinical practice and is a crucial step to ensuring all children of diverse backgrounds receive optimal perioperative care.
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Affiliation(s)
- Heidi Tan
- School of Medicine, University of California, Irvine, California, USA
| | - Beverly A Mendoza
- Center on Stress & Health, University of California, Irvine, California, USA.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California, USA.,Children's Hospital of Orange County, Orange, California, USA
| | - Michelle A Fortier
- Center on Stress & Health, University of California, Irvine, California, USA.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California, USA.,Children's Hospital of Orange County, Orange, California, USA.,Sue & Bill Gross School of Nursing, University of California, Irvine, California, USA.,Department of Psychological Science, University of California, Irvine, California, USA
| | - Zeev Kain
- Center on Stress & Health, University of California, Irvine, California, USA.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California, USA.,Children's Hospital of Orange County, Orange, California, USA.,Yale University School of Medicine, New Haven, Connecticut, USA
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13
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Muacevic A, Adler JR, Shah A, Falgons C, Quan T, Malyavko A, Tabaie S. Association of Race With Post-operative Complications After Spinal Fusion in Children With Cerebral Palsy. Cureus 2022; 14:e32920. [PMID: 36578858 PMCID: PMC9790147 DOI: 10.7759/cureus.32920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2022] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Neuromuscular scoliosis in children with cerebral palsy (CP) can lead to debilitating difficulties with pain, ambulation, sitting, and respiratory or cardiac compromise. Spinal fusion can halt deformity progression, though the decision to undergo surgery involves an individualized risk-benefit assessment. The purpose of this study was to evaluate whether race is a risk factor for patients with CP to experience post-operative complications after spinal fusion. METHODS This is a retrospective cohort analysis of a national database. Analyses methods include univariate analyses, multivariate regression models, and other ad-hoc tests. RESULTS There were 3,081 pediatric patients with CP who underwent spinal fusion. Black patients had an increased risk of experiencing any post-operative complication compared to Caucasians (OR 1.322, 95% CI 1.099-1.590). Both Caucasian(p=0.005) and Black (p<0.001) races were risk factors for experiencing medical complications; Black patients had an increased risk compared to Caucasians (OR 1.373, 95% CI 1.130-1.667). Other races had a greater length of ICU stay than Caucasians (median {Mdn}=3.00 days vs Mdn=2.00, p=0.029), and longer total hospital stays than Caucasian and Black patients (Mdn=9.00 days vs Mdn=6.00 days vs Mdn=6.00 days, p<0.001). CONCLUSION Race is an independent risk factor for pediatric patients with CP to experience medical complications following spinal fusion surgery, with Black patients having an increased risk compared to Caucasians. Further, other races were found to have significantly longer ICU and total hospital length of stay. This study is the first to present race as a risk factor for children with CP to experience increased post-operative complications following spinal fusion and will be valuable in understanding their individualized peri-operative courses and risks.
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14
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Perioperative mortality in pediatric patients: a systematic review of risk assessment tools for use in the preoperative setting. Anesthesiology 2022; 137:555-567. [PMID: 36069894 DOI: 10.1097/aln.0000000000004369] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are multiple preoperative risk scores for pediatric mortality. The aim of this study was to systematically describe and compare the existing studies of patient-specific multispecialty risk prediction scores for perioperative mortality in pediatric populations, with the goal of guiding clinicians on which may be most appropriate for use in the preoperative setting. METHODS We conducted a systematic literature review of published journal articles that presented the development, extension/updating, and/or validation of a risk score which predicted all-cause mortality (up to 30 days postoperatively) in pediatric patients undergoing a procedure in which anesthesia was used. Scores needed to be applicable to surgeries in more than one non-cardiac surgical specialty and had to be able to be calculated by the anesthesiologist at the time of the pre-anesthetic assessment. Two investigators independently screened studies for inclusion and assessed study quality in the domains of clinical applicability, feasibility/ease of use in the clinical setting, and risk of bias. RESULTS A total of 1,681 titles were retrieved. Of these, 10 studies met inclusion criteria: nine reported the development and validation of scores, and one was an external validation of an existing score. Seven studies used varying years of multicenter data from the National Surgical Quality Improvement Program - Pediatric Participant Use File for development and/or validation. The unadjusted rate of mortality in the studies ranged from 0.3% to 3.6%. The preoperative predictors of mortality used in score development included patient demographics, preoperative therapies, and chronic conditions, among others. All models showed good discrimination upon validation (AUC > 0.8). Most risk scores had high or unclear risks of bias. CONCLUSION There are numerous scores available for the prediction of mortality in pediatric populations, all of which exhibited good performance. However, many have high or unclear risks of bias, and most have not undergone external validation.
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15
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Brock R, Chu A, Lu S, Brindle ME, Somayaji R. Postoperative complications after gastrointestinal pediatric surgical procedures: outcomes and socio-demographic risk factors. BMC Pediatr 2022; 22:358. [PMID: 35733099 PMCID: PMC9215078 DOI: 10.1186/s12887-022-03418-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several socio-demographic characteristics are associated with complications following certain pediatric surgical procedures. In this comprehensive study, we sought to determine socio-demographic risk factors and resource utilization of children with complications after common pediatric surgical procedures. METHODS We performed a population-based cohort study utilizing the 2016 Healthcare Cost and Use Project Kids' Inpatient Database (KID) to identify and characterize pediatric patients (age 0-21 years) in the United States with common inpatient pediatric gastrointestinal surgical procedures: appendectomy, cholecystectomy, colonic resection, pyloromyotomy and small bowel resection. Multivariable logistic regression modeling was used to identify socio-demographic predictors of postoperative complications. Length of stay and hospitalization costs for patients with and without postoperative complications were compared. RESULTS A total of 66,157 pediatric surgical hospitalizations were identified. Of these patients, 2,009 had postoperative complications. Male sex, young age, African American and Native American race and treatment in a rural hospital were associated with significantly greater odds of postoperative complications. Mean length of stay was 4.58 days greater and mean total costs were $11,151 (US dollars) higher in the complication cohort compared with patients without complications. CONCLUSIONS Postoperative complications following inpatient pediatric gastrointestinal surgery were linked to elevated healthcare-related expenditure. The identified socio-demographic risk factors should be considered in the risk stratification before pediatric surgical procedures. Targeted interventions are required to reduce preventable complications and surgical disparities.
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Affiliation(s)
- Robert Brock
- Department of Pediatric and Adolescent Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Angel Chu
- Department of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shengjie Lu
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mary Elizabeth Brindle
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
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16
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Characterizing the use of botulinum toxin in patients with Hirschsprung disease treated at referral institutions for pediatric colorectal surgery. J Pediatr Surg 2022; 57:1033-1039. [PMID: 35292167 DOI: 10.1016/j.jpedsurg.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Botulinum toxin (BT) is used to treat pediatric patients with Hirschsprung disease (HD) with obstructive symptoms. We aimed to characterize use of BT in HD patients across pediatric colorectal surgery referral centers. METHODS A multicenter retrospective study of BT use in children (0-18y) with HD was performed using the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) between 2017 and 2021. Sites with <10 HD patients recorded were excluded. Patterns were evaluated using Fisher's exact, Wilcoxon rank-sum, Kruskal-Wallis, and Cochran-Armitage trend test. RESULTS 494 patients at 8 centers were included. 118 (23.9%) received at least one BT injection. Among patients who required redo pullthrough procedures, 53.1% received BT compared to 22.7% of patients who only underwent one pullthrough (p<0.001). Age at pullthrough was also significantly associated (p = 0.021). A lower proportion of Hispanic patients received BT (9.6% vs. 26.3%;p = 0.006). Percentage of HD patients receiving BT varied significantly across sites (p<0.001). CONCLUSIONS Use of BT in patients with HD varies widely with greater use in patients who underwent redo surgery and in those who underwent pullthrough at an older age. Hispanic patients received less BT. These findings highlight the need to develop consensus guidelines and for further study on timing of injections and potential disparities in care. LEVEL OF EVIDENCE III.
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17
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Dela Merced P, Vazquez Colon C, Mirzada A, Oke A, Gal Z, Cheng J, Oetgen MM, Martin B, Pestieau SR, Cronin JA. Association between implementation of a coordinated care pathway in idiopathic scoliosis patients and a reduction in perioperative outcome disparities. Paediatr Anaesth 2022; 32:556-562. [PMID: 34758176 DOI: 10.1111/pan.14330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are well-documented racial and ethnic disparities in treatment and perioperative outcomes for patients with adolescent idiopathic scoliosis. AIMS We hypothesize that the implementation of a coordinated care pathway for pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may be associated with a reduction in racial and ethnic disparities in perioperative outcomes. METHODS This is a retrospective pre- and post-test cohort study of patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution between July 1, 2013 and August 5, 2019. We implemented a coordinated care pathway in March 2015. Patient demographics included age, race, ethnicity, weight, gender, insurance status, ASA class, time between the date surgery was ordered and the date surgery occurred, degree of scoliosis, and the number of spinal levels fused. The primary outcome was length of stay. The secondary outcomes included transfusion rates, pain scores, and postoperative complications. Multivariable regression models compared outcome medians across race/ethnicity. Disparities were defined as the difference in adjusted outcomes by race/ethnicity. RESULTS Four hundred twenty-four patients underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution (116 prepathway and 308 postpathway). The median length of stay of Black patients was 1.0 day (95% CI: 0.4, 1.5; p = .006) longer than White patients prepathway. Prepathway patients who self-identified as Other had a 1.2 (95% CI: 0.5, 1.9; p = .004) higher median average pain score on postoperative day 1 compared with White patients. On postoperative day 2, patients who identified as Other had 2.0 (95% CI: 0.8, 3.2; p = .005) higher pain score compared with White patients prepathway. Postpathway, there were no significant differences in outcomes by race/ethnicity. CONCLUSIONS Our study supports the hypothesis that use of a coordinated care pathway is associated with a reduction in racial and ethnic disparities in length of stay and pain scores in pediatric patients undergoing posterior spinal fusion.
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Affiliation(s)
- Philip Dela Merced
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Caroll Vazquez Colon
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Ariana Mirzada
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Ayodele Oke
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Zsombor Gal
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Jenhao Cheng
- Division of Quality and Safety, Children's National Hospital, Washington, District of Columbia, USA
| | - Matthew M Oetgen
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Benjamin Martin
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Sophie R Pestieau
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Jessica A Cronin
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
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18
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Kain ZN, Fortier MA, Dinh PN, Spanhel K, Campos B. Cultural Adaptation in the Perioperative Space: A Case Study. Anesth Analg 2022; 134:573-577. [PMID: 35180175 DOI: 10.1213/ane.0000000000005876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Zeev N Kain
- From the Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California
- Children's Hospital of Orange County, Orange, California
- Center on Stress & Health, University of California Irvine, Irvine, California
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle A Fortier
- From the Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California
- Children's Hospital of Orange County, Orange, California
- Center on Stress & Health, University of California Irvine, Irvine, California
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California
| | - Peter N Dinh
- From the Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California
- Children's Hospital of Orange County, Orange, California
- Center on Stress & Health, University of California Irvine, Irvine, California
| | - Kerstin Spanhel
- Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany
| | - Belinda Campos
- Department of Chicano/Latino Studies, University of California Irvine, Irvine, California
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19
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Webber AM, Willer BL. Obesity, Race, and Perioperative Complications. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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The Association Between Race and Adverse Postoperative Outcomes in Children With Congenital Heart Disease Undergoing Noncardiac Surgery. Anesth Analg 2021; 134:357-368. [PMID: 33999011 DOI: 10.1213/ane.0000000000005571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The association between race and perioperative outcomes has been evaluated in adult cardiac surgical and in healthy pediatric patients but has not been evaluated in children with congenital heart disease (CHD) presenting for noncardiac procedures. This study compares the incidence of the primary outcome of 30-day mortality and adverse postoperative outcomes following noncardiac surgery between Black and White children with CHD, stratified by severity. METHODS This is a retrospective study. Comparison of outcomes between Black and White children was performed using the 2012-2018 American College of Surgeons National Surgical Quality Improvement Program Pediatric database and after stratification for severity of CHD and propensity score matching. RESULTS A total of 55,859 patients were included, and divided into 28,601 minor, 23,839 major, and 3419 severe CHD. Black and White children in each category were matched and compared. Following matching in the overall CHD cohort, there were significantly higher rates of the following adverse postoperative outcomes among Black patients as compared to White patients: 30-day mortality (1.84% vs 1.49%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05-1.48; P = .014), composite secondary outcomes (19.90% vs 17.88%; OR, 1.14; 95% CI, 1.08-1.21; P < .001), cardiac arrest (1.42% vs 0.98%; OR, 1.46; 95% CI, 1.19-1.79; P < .001), 30-day reoperation (7.59% vs 6.67%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), and reintubation (3.9% vs 2.95%; OR, 1.34; 95% CI, 1.19-1.52; P < .001). No significant statistical interaction between race and CHD severity was found. Following matching and within the minor CHD cohort, Black children had significantly higher rates of composite secondary outcome (17.44% vs 15.60%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), cardiac arrest (1.02% vs 0.53%; OR, 1.94; 95% CI, 1.37-2.76; P < .001), 30-day reoperation (7.19% vs 5.77%; OR, 1.26; 95% CI, 1.11-1.43; P < .001), and thromboembolic complications (0.49% vs 0.23%; OR, 2.17; 95% CI, 1.29-3.63; P = .003) compared to White children. In the major CHD cohort, Black children had significantly higher rates of 30-day mortality (2.75% vs 2.05%; OR, 1.35; 95% CI, 1.08-1.69; P = .008) and reintubation (4.82% vs 3.72%; OR, 1.32; 95% CI, 1.11-1.56; P = .002). There were no statistically significant differences in outcomes in the severe CHD category for 30-day mortality (3.36% vs 3.3%; OR, 1.02; 95% CI, 0.60-1.73; P = .946), composite secondary outcome (22.65% vs 21.36%; OR, 1.08; 95% CI, 0.86-1.36; P = .517) nor the components of the composite secondary outcomes. CONCLUSIONS Race is associated with postoperative mortality and complications in children with minor and major CHD undergoing noncardiac surgery. No significant association was observed between race and postoperative outcomes in patients with severe CHD. This is consistent with previous findings wherein in patients with severe CHD, residual lesion burden and functional status is the leading predictor of outcomes following noncardiac surgery. Nevertheless, there is no evidence that the relationship between race and outcomes differs across the CHD severity categories. Future studies to understand the mechanisms leading to the racial difference, including institutional, clinical, and individual factors are needed.
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21
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Mpody C, Willer BL, Minneci PC, Tobias JD, Nafiu OO. Moderating Effects of Race and Preoperative Comorbidity on Surgical Mortality in Infants. J Surg Res 2021; 264:435-443. [PMID: 33848843 DOI: 10.1016/j.jss.2021.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/01/2021] [Accepted: 02/27/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND We sought to investigate the risk of pediatric surgical mortality associated with the combined effects of key preoperative comorbidities and race. METHODS We performed a retrospective study that included infants who underwent inpatient surgical procedures between 2012 and 2017 and were entered into the NSQIP-P registry. We assessed additive moderation by estimating the proportion of mortality risk attributable to the combined effects of race and the presence of a preoperative comorbidity (attributable proportion [AP]). RESULTS The study group was comprised of 58466 surgical cases, of whom 15711(26.9%) were neonates and 42755(73.1%) older infants. Among neonates, a history of prematurity carried a poorer prognosis in black babies than their white peers (OR:1.53, 95%CI:1.20,1.95). Additionally, there was evidence of additive moderation by race on the association between prematurity and postoperative mortality (AP: 23.9%; 95%CI: 3.8,43.9, P value = 0.020). In older infants, presence of preoperative sepsis carried almost two times higher risk of mortality for black patients than their white counterparts (OR:1.81; 95%CI:1.21,2.73). This explained 38.4% of mortality cases in black patients with preoperative sepsis (95%CI:14.0,62.7; P = 0.002). A history of prematurity also carried a greater risk of mortality in older infants of black race (OR:1.69; 95%CI: 1.27, 2.24), accounting for 24.2% of mortality cases (AP:24.2%; 95%CI:0.90, 47.5, P = 0.041). CONCLUSIONS We quantified the surgical burden of mortality resulting from the differential impact of key comorbidities on black neonates and infants. Our data suggest that race-specific interventions to mitigate the incidence of the identified comorbidities could narrow the racial disparities in post surgical mortality.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Brittany L Willer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.
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22
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Morrison ZD, Reyes-Ferral C, Mansfield SA, Alemayehu H, Bowen-Jallow K, Tran S, Santos MC, Bischoff A, Perez N, Lopez ME, Langham MR, Newman EA. Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association. J Pediatr Surg 2021; 56:641-647. [PMID: 33309300 DOI: 10.1016/j.jpedsurg.2020.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/06/2020] [Accepted: 11/14/2020] [Indexed: 01/10/2023]
Affiliation(s)
| | | | | | - Hanna Alemayehu
- Children's and Women's Hospital, University of South Alabama Health System, Mobile, AL, USA
| | | | - Sifrance Tran
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | - Numa Perez
- Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Erika A Newman
- CS Mott Children's Hospital, The University of Michigan, Ann Arbor, MI, USA.
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23
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Sivak E, Mpody C, Willer BL, Tobias J, Nafiu OO. Race and major pulmonary complications following inpatient pediatric otolaryngology surgery. Paediatr Anaesth 2021; 31:444-451. [PMID: 33502081 DOI: 10.1111/pan.14142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 01/04/2021] [Accepted: 01/13/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Compared to their white peers, black children are more likely to experience serious respiratory complications in the perioperative period. Whether a racial difference exists in the occurrence of late postoperative respiratory complications is largely unknown. Here, we evaluated a multi-institutional cohort of children who underwent various elective otolaryngology procedures to examine the racial differences in major postoperative pulmonary complications. METHODS We performed a retrospective analysis of elective inpatient otolaryngology cases from the National Surgical Quality Improvement Program (2012-2018). We used propensity score matching of black to white patients to compare the risk of postoperative pulmonary complications, defined as the occurrence of either pneumonia, unplanned reintubation, or prolonged postoperative mechanical ventilation. RESULTS The matched cohort was comprised of 4786 black and white patients (2 393 of each race). Black children were more likely to develop postoperative pulmonary complications compared to white peers (29.3% vs. 24.2%; odds ratio: 1.38; 95% confidence interval: 1.20, 1.59; P-value < .001). Furthermore, black children were almost two times more likely to require unplanned postoperative reintubation, relative to their white peers (2.6% vs. 1.3%; odds ratio: 2.07; 95% confidence interval: 1.33, 3.22; P-value < .001). Similarly, black children were estimated to have 37% relative greater odds of requiring prolonged mechanical ventilation (28.6% vs. 23.7%; 95% confidence interval: 1.19, 1.58; P-value < .001). Finally, being of black race conferred greater odds of requiring prolonged hospital length of stay, relative to being of white race (38.6% vs. 34.5%; odds ratio:1.24; 95% confidence interval: 1.09, 1.42; P-value = .004). CONCLUSION Black children undergoing elective otolaryngological surgery are more likely to develop major postoperative pulmonary complications.
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Affiliation(s)
- Erica Sivak
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Joseph Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
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Stewart JH, Butler PD, Tseng JF, Kennard AC, Mellinger JD, Buyske J. Acknowledgment, Reflection, and Action: The American Board of Surgery Leans into Antiracism. Ann Surg 2021; 273:619-622. [PMID: 33351484 DOI: 10.1097/sla.0000000000004684] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- John H Stewart
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Paris D Butler
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jennifer F Tseng
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | | | - John D Mellinger
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Jo Buyske
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- American Board of Surgery, Philadelphia, Pennsylvania
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Willer BL, Mpody C, Tobias JD, Nafiu OO. Racial Disparities in Failure to Rescue Following Unplanned Reoperation in Pediatric Surgery. Anesth Analg 2021; 132:679-685. [PMID: 33332903 DOI: 10.1213/ane.0000000000005329] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Failure to rescue (FTR) and unplanned reoperation following an index surgical procedure are key indicators of the quality of surgical care. Given that differences in unplanned reoperation and FTR rates among racial groups may contribute to persistent disparities in postsurgical outcomes, we sought to determine whether racial differences exist in the risk of FTR among children who required unplanned reoperation following inpatient surgical procedures. METHODS We used the National Surgical Quality Improvement database (2012-2017) to assemble a cohort of children (<18 years), who underwent inpatient surgery and subsequently returned to the operating room within 30 days of the index surgery. We used logistic regression models to estimate the odds ratio (OR) and 95% confidence interval (CI) of FTR, comparing African American (AA) to White children. We estimated the risk-adjusted odds ratio (aOR) for FTR by controlling the analyses for demographic characteristics, surgical profile, and preoperative comorbidities. We further evaluated the racial differences in FTR by stratifying the analyses by the timing of unplanned reoperation. RESULTS Of 276,917 children who underwent various inpatient surgical procedures, 10,425 (3.8%) required an unplanned reoperation, of whom 2016 (19.3%) were AA and 8409 (80.7%) were White. Being AA relative to being White was associated with a 2-fold increase in the odds of FTR (aOR: 2.03; 95% CI, 1.5-2.74; P < .001). Among children requiring early unplanned reoperation, AAs were 2.38 times more likely to die compared to their White peers (8.9% vs 3.4%; aOR: 2.38; 95% CI, 1.54-3.66; P < .001). In children with intermediate timing of return to the operating room, the risk of FTR was 80% greater for AA children compared to their White peers (2.2% vs 1.1%; aOR: 1.80; 95% CI, 1.07-3.02; P = .026). Typically, AA children die within 5 days (interquartile range [IQR]: 1-16) of reoperation while their White counterparts die within 9 days following reoperation (IQR: 2-26). CONCLUSIONS Among children requiring unplanned reoperation, AA patients were more likely to die than their White peers. This racial difference in FTR rate was most noticeable among children requiring early unplanned reoperation. Time to mortality following unplanned reoperation was shorter for AA than for White children. Race appears to be an important determinant of FTR following unplanned reoperation in children and it should be considered when designing interventions to optimize unplanned reoperation outcomes.
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Affiliation(s)
- Brittany L Willer
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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Nasr VG, DiNardo JA. Racial Disparities in Perioperative Outcomes in Children: Where Do We Go From Here? Anesth Analg 2021; 132:676-678. [PMID: 33591091 DOI: 10.1213/ane.0000000000005383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Viviane G Nasr
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Akbilgic O, Shin EK, Shaban-Nejad A. A Data Science Approach to Analyze the Association of Socioeconomic and Environmental Conditions With Disparities in Pediatric Surgery. Front Pediatr 2021; 9:620848. [PMID: 33777865 PMCID: PMC7994338 DOI: 10.3389/fped.2021.620848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Scientific evidence confirm that significant racial disparities exist in healthcare, including surgery outcomes. However, the causal pathway underlying disparities at preoperative physical condition of children is not well-understood. Objectives: This research aims to uncover the role of socioeconomic and environmental factors in racial disparities at the preoperative physical condition of children through multidimensional integration of several data sources at the patient and population level. Methods: After the data integration process an unsupervised k-means algorithm on neighborhood quality metrics was developed to split 29 zip-codes from Memphis, TN into good and poor-quality neighborhoods. Results: An unadjusted comparison of African Americans and white children showed that the prevalence of poor preoperative condition is significantly higher among African Americans compared to whites. No statistically significant difference in surgery outcome was present when adjusted by surgical severity and neighborhood quality. Conclusions: The socioenvironmental factors affect the preoperative clinical condition of children and their surgical outcomes.
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Affiliation(s)
- Oguz Akbilgic
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, United States
| | - Eun Kyong Shin
- Department of Sociology, Korea University, Seoul, South Korea
| | - Arash Shaban-Nejad
- Department of Pediatrics, Center for Biomedical Informatics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
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Network Analysis of Postoperative Surgical Complications in a Cohort of Children Reported to the National Surgical Quality Improvement Program: Pediatric. Ann Surg 2020; 275:1194-1199. [PMID: 33196492 DOI: 10.1097/sla.0000000000004234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To understand the temporal relationships of postoperative complications in children and determine if they are related to each other in a predictable manner. SUMMARY OF BACKGROUND DATA Children with multiple postoperative complications have increased suffering and higher risk for mortality. Rigorous analysis of the temporal relations between complications, how complications might cluster, and the implications of such clusters for children have not been published. Herein, we analyze the relationships between postoperative complications in children. METHODS Data source: Surgical operations included in the National Surgical Quality Improvement Program Pediatric Participant Use Data File from 2013 to 2017. The main outcomes measure was presence of 1 or more postoperative complications within 30 days of surgery. Operations followed by multiple complications were analyzed using network analysis to study prevalence, timing, and co-occurrences of clusters of complications. RESULTS This study cohort consisted of 432,090 operations; 388,738 (89.97%) had no postoperative complications identified, 36,105 (8.35%) operations resulted in 1 postoperative complication and 7247 (1.68%) operations resulted in 2 or more complications. Patients with multiple complications were more likely to be younger, male, African American, with a higher American Society of Anesthesiologists score, and to undergo nonelective operations (P < 0.001). More patients died with 2 complication versus 1 complication vs no complication (5.3% vs 1.5% vs 0.14%, P < 0.001). Network analysis identified 4 Louvain clusters of complications with dense intracluster relationships. CONCLUSIONS Children with multiple postoperative complications are at higher risk of death, than patients with no complication, or a single complication. Multiple complications are grouped into defined clusters and are not independent.
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Nafiu OO, Mpody C, Kim SS, Uffman JC, Tobias JD. Race, Postoperative Complications, and Death in Apparently Healthy Children. Pediatrics 2020; 146:peds.2019-4113. [PMID: 32690804 DOI: 10.1542/peds.2019-4113] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND That African American (AA) patients have poorer surgical outcomes compared with their white peers is established. The prevailing presumption is that these disparities operate within the context of a higher preoperative comorbidity burden among AA patients. Whether these racial differences in outcomes exist among apparently healthy children (traditionally expected to have low risk of postsurgical complications) has not been previously investigated. METHODS We performed a retrospective study by analyzing the National Surgical Quality Improvement Program-Pediatric database from 2012 through 2017 and identifying children who underwent inpatient operations and were assigned American Society of Anesthesiologists physical status 1 or 2. We used univariable and risk-adjusted logistic regression to estimate the odds ratios and their 95% confidence intervals (CIs) of postsurgical outcomes comparing AA to white children. RESULTS Among 172 549 apparently healthy children, the incidence of 30-day mortality, postoperative complications, and serious adverse events were 0.02%, 13.9%, and 5.7%, respectively. Compared with their white peers, AA children had 3.43 times the odds of dying within 30 days after surgery (odds ratio: 3.43; 95% CI: 1.73-6.79). Compared with being white, AA had 18% relative greater odds of developing postoperative complications (odds ratio: 1.18; 95% CI: 1.13-1.23) and 7% relative higher odds of developing serious adverse events (odds ratio: 1.07; 95% CI: 1.01-1.14). CONCLUSIONS Even among apparently healthy children, being AA is strongly associated with a higher risk of postoperative complications and mortality. Mechanisms underlying the established racial differences in postoperative outcomes may not be fully explained by the racial variation in preoperative comorbidity.
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Affiliation(s)
- Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Stephani S Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joshua C Uffman
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Mpody C, Humphrey L, Kim S, Tobias JD, Nafiu OO. Racial Differences in Do-Not-Resuscitate Orders among Pediatric Surgical Patients in the United States. J Palliat Med 2020; 24:71-76. [PMID: 32543271 DOI: 10.1089/jpm.2020.0053] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Very few studies have investigated the racial differences in do-not-resuscitate (DNR) orders in children, and these studies are limited to oncological cases. We aim to characterize the racial difference in DNR orders among U.S. pediatric surgical patients. Methods: We retrospectively evaluated the mortality of all children who underwent an inpatient surgery between 2012 and 2017 from the National Surgical Quality Improvement Program. We used log-binomial models to estimate the relative risk (RR) and 95% confidence interval (CI) of DNR use comparing white with African American (AA) children. To estimate the risk-adjusted difference in DNR orders, we controlled the analyses for age, prematurity status, emergent case status, American Society of Anesthesiologists class, year of operation, surgical specialty, and surgical complexity. Results: Between 2012 and 2017, a total of 276,917 children underwent inpatient surgery, of whom 0.8% (n = 1601) died within 30 days of operation. Of the 1601 mortality cases, we retained 1212 children who were of either AA (26.0%, n = 350) or white (63.9%, n = 862) race. Most children were neonates, had an American Society of Anesthesiologists class ≥4 (70.0%, n = 811), and developed one or more postoperative complications (68.7%, n = 833). Overall, AA children were more likely to be neonates at the time of surgery (42.0% vs. 40.3%, p < 0.001), to be premature (66.3% vs. 49.0%, p < 0.001), and develop one or more postoperative complications (73.7% vs. 66.7%, p = 0.017). White children were three times more likely to have a DNR order than their AA peers (adjusted RR: 3.01, 95% CI: 1.09-8.56, p = 0.044). Conclusion: Among pediatric surgical patients in the United States, children of white race were three times more likely to have a DNR order in place than their AA peers despite the latter being "sicker" and more likely to develop postoperative complications. The mechanisms underlying this racial difference deserve further elucidation to improve shared decision making and goal-concordant care.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lisa Humphrey
- Division of Palliative Care, Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Stephani Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
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Abstract
Text fields in electronic medical records (EMR) contain information on important factors that influence health outcomes, however, they are underutilized in clinical decision making due to their unstructured nature. We analyzed 6497 inpatient surgical cases with 719,308 free text notes from Le Bonheur Children’s Hospital EMR. We used a text mining approach on preoperative notes to obtain a text-based risk score to predict death within 30 days of surgery. In addition, we evaluated the performance of a hybrid model that included the text-based risk score along with structured data pertaining to clinical risk factors. The C-statistic of a logistic regression model with five-fold cross-validation significantly improved from 0.76 to 0.92 when text-based risk scores were included in addition to structured data. We conclude that preoperative free text notes in EMR include significant information that can predict adverse surgery outcomes.
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32
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Heard-Garris N, Onwuka E, Davis MM. Surgical Mortality and Race as a Risk Factor: A Compass, Not a Destination. Pediatrics 2018; 141:peds.2017-3894. [PMID: 29321254 DOI: 10.1542/peds.2017-3894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Nia Heard-Garris
- Division of Academic General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois; .,Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ekene Onwuka
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Matthew M Davis
- Division of Academic General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Departments of Medical Social Sciences, Medicine, and Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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