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

Study objective: With increasing improvement in perioperative care, post-surgical complication and mortality rates have continued to decline in the United States. Nonetheless, not all racial groups have benefitted equally from this transformative improvement in postoperative outcomes. We tested the hypothesis that among a cohort of "sick" (ASA physical status 4 or 5) Black and White children, there would be no systematic difference in the incidence of postoperative morbidity and mortality.

Design: Retrospective cohort study.

Setting: Institutions participating in the National Surgical Quality Improvement Program-Pediatric (2012-2019).

Patients: Black and White children who underwent inpatient operations and were assigned ASA physical status 4 or 5.

Measurements: risk adjusted odds ratios for 30-day postoperative mortality and complications using multivariable logistic regression models, controlling for various baseline covariates.

Main results: There were 16,097 children included in the analytic cohort (77.0% White and 23.0% Black). After adjusting for baseline covariates, Black children were estimated to be 20% more likely than their White counterparts to die within 30 days after surgery (9.3% vs. 7.2%, adjusted-OR: 1.20, 95% CI: 1.05-1.38, P = 0.007). Black children were also more likely to develop pulmonary complications compared to their White peers (52.1% vs. 44.6%, adjusted-OR: 1.13, 95%CI: 1.04, 1.23, P = 0.005). Being Black also conferred an estimated 28% relative greater odds of developing cardiovascular complications (4.6% vs. 3.3%, 95%CI: 1.06, 1.54, P = 0.010). Finally, being Black conferred an estimated 33% relative greater odds of requiring an extended LOS compared to Whites (50.7% vs. 38.7%, adjusted-OR: 1.33, 95% CI: 1.22-1.46, P < 0.001).

Conclusion: In this cohort of children with high ASA physical status, Black children compared to their White peers experienced significantly higher rates of 30-day postoperative morbidity and mortality. These findings suggest that racial differences in postoperative outcomes among the sickest pediatric surgical patients may not be entirely explained by preoperative health status.