Pediatric Postoperative Mortality Rates High in Black Patients

Brittany L. Willer, MD

A new investigation from Nationwide Children’s Hospital found that increasing socioeconomic status (SES) was associated with lower pediatric postoperative mortality. However, postoperative mortality rates were still significantly higher among Black children in the highest socioeconomic category than White children in the same category.

Mortality rates among Black children in the highest category were also comparable to those of White children in the lowest socioeconomic category, leading investigators to suggest that increasing socioeconomic status in families did not provide any equitable advantages to Black children compared to White children.

In addition to patient comorbidity burden, family SES is considered another source of racial and healthy disparity in clinical care, with a monotonic association between SES and health being observed in previous studies.

Decreasing socioeconomic status and worse surgical outcomes have also been observed.

To further explore the complex associations between race, socioeconomic status, and health, investigators led by Brittany L. Willer, MD, Nationwide Children’s Hospital in Columbus, Ohio, conducted a cohort study to determine whether SES was associated with lower pediatric postoperative mortality.

The Methods

Initially, Willer and colleagues performed a retrospective analysis of the Children’s Hospital Association Pediatric Health Information System (PHIS).

Data from the 51 pediatric tertiary care hospitals included in the PHIS included demographic information, diagnoses, procedures, billing codes for procedures, medications, and lab tests.

The team searched for data for both Black and White children younger than 18 years who underwent inpatients surgical procedures between January 1, 2004, and December 31, 2020. Patients with missing information on race and median household income of the zip code of residence were included in the study.

Investigators grouped household income into 4 quartiles, with quartile 1 (lowest income) indicating less than $33 190 per year, quartile 2 indicating $33 190 to $41 850 per year, quartile 3 indicating $41 851 to $54 728 per year, and quartile 4 (highest income) indicating more than $54 728 per year. Race was self-reported by parents or guardians at admission or assessed by the registration team consistent with each hospital’s policy and state legislation.

The primary outcome for the study was in-hospital postoperative mortality defined as death after an index surgical procedure.

The Findings

A total of 1,378,111 children who received inpatient surgical procedures were included in the study, 773,364 of whom were male. Among these participants, 248,464 were Black (18%) , 112,647 were White (82%), 211,127 (15.3%) were Hispanic, and 825, 477 (59.9%) were non-Hispanic.

Only 49,541 Black children (20.3%) belonged to the highest income quartile compared to 482,758 White children (43.0%).

As income quartile increased, investigators noted the mortality rate decreased, with the overall mortality being 1.2%. Among those belonging to the 3 lowest income quartiles, Black children had 33% higher odds of postoperative death compared with White children (adjusted odds ratio, 1.33; 95%CI, 1.27-1.39; P < .001).

The team observed that this racial disparity gap persisted among children belonging to the highest income quartile (adjusted odds ratio, 1.39; 95%CI, 1.25-1.54; P < .001), with postoperative mortality rates among Black children in the highest income quartile (1.30%; 95%CI, 1.19%-1.42%) being comparable to those of White children in the lowest income quartile (1.20%; 95%CI, 1.16%-1.25%).

Additionally, the interaction between Black race and income was not statistically significant on either the multiplicative scale (β for interaction = 1.04; 95%CI, 0.93-1.17;P = .45) or the additive scale (relative excess risk due to interaction = 0.01; 95%CI, −0.11 to 0.11; P > .99), suggesting no reduction in the disparity gap across increasing income levels.

With this data, Willer and investigators suggested that the interventions addressing socioeconomic disparities have not fully addressed the persistent racial disparities in pediatric postoperative mortality.

“A multifaceted approach that includes dismantling of socioeconomic barriers, equitable availability of comprehensive pediatric surgical care, and personalized care for children of all races is needed,” the team wrote.