ASA Monitor September 2021, Vol. 85, 19.
Your colleague tells you anecdotally that African American patients seem to be at higher risk of adverse events perioperatively compared to their white peers. According to a recent study of pediatric surgical patients, which of the following BEST describes the risks for apparently healthy African American children compared with white children undergoing inpatient surgery?
- □ (A) Similar overall risk for postoperative complications
- □ (B) An 80% relative increased risk of serious adverse events
- □ (C) Three times the risk of death within 30 days
The current literature provides evidence of ethnic and racial disparities in health care, with poorer outcomes in African American versus white populations. A commonly held tenet is that African American patients have increased preoperative comorbidities compared to their white peers that would explain the poorer outcomes, as healthy patients are generally expected to have a low risk of complications after surgical procedures. The authors of a recent study aimed to determine the association between race and postoperative mortality and morbidity rates in apparently healthy pediatric patients undergoing surgery. The primary outcome was the 30-day in-hospital postoperative mortality rate. Secondary outcomes were postoperative rates of complications and serious adverse events. Serious adverse events were defined to include sepsis, cardiac arrest, readmission, and reoperation.
A retrospective review of the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database from 2012 through 2017 identified 276,917 children, of whom 172,549 met the study criteria. NSQIP-P is a program that collects de-identified data on risk-adjusted surgical outcomes from pediatric cases across 186 medical centers in the United States. The data are from admission to 30 days after surgery. The children included in this review were aged 17 years and younger with an ASA physical status of I or II who had undergone inpatient operations. Univariable and risk-adjusted logistic regression were used to estimate the odds ratios of postoperative outcomes, comparing African American and white children. African American children made up 11.4% of the sample, while white children made up 70.1%. Overall, 80.8% were older than 12 months, 15.8% were between one and 12 months, and 3.4% were younger than one month. Males constituted 54.2% of the sample. Current Procedural Terminology risk tertiles were comparable in white and African American children, as were the distribution of baseline comorbidities, age, and sex. An ASA physical status of II was assigned in 73.5% of African American children versus 68.2% of white children.
The results showed the following:
- The overall 30-day mortality rate was 0.02% (0.07% for African American children vs. 0.02% for white children). African American children had more than a three-fold increased risk of death within 30 days (odds ratio, 3.43; 95% CI, 1.73-6.79).
- The overall rate of composite postoperative complications was 13.9% (16.87% for African American children vs. 13.80% for white children). African American children had 18% relative higher odds of postoperative complications (odds ratio, 1.18; 95% CI, 1.13-1.23).
- The overall rate of serious adverse events was 5.7% (6.17% for African American children vs. 5.71% for white children). African American children had 7% relative higher odds of serious adverse events (odds ratio, 1.07; 95% CI, 1.01-1.14).
Similar relative results remained after adjusting for covariates such as sex, age, work relative value unit, procedure year, urgency status, and surgery duration.
These study results suggest that African American children are more likely to experience worse postoperative outcomes, even when the preoperative burden of disease is evaluated as minimal. These results are disconcerting and imply that patient comorbidities alone do not contribute to the poorer outcomes in African American children. It has been speculated that possible contributors include biological factors (e.g., phenotypical disease presentation), systemic factors (e.g., provider bias, physician-patient communication, resource allocation), and social factors (e.g., socioeconomic status, limited access to specialty medical care).
Limitations of the study include possible misclassification errors in ASA physical status and a lack of detail regarding the hospital site of surgical care. It is known that high-quality care is not equally accessible to all racial groups, and this enables the continuation of racial disparities in health outcomes. The authors caution that although no causality is implied in this study, race may be a risk factor to consider when optimizing perioperative care.
In summary, African American children had three-fold higher odds of postoperative mortality and an increased rate of complications compared to white children, even in apparently healthy patients (ASA physical status I and II). The results suggest that preoperative comorbidities alone do not explain the disparity in postoperative outcomes between African American children and their white peers.
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