Race, Postoperative Complications, and

Death in Apparently Healthy Children

By Nafiu et al 2020

Elliot Turkiew, PGY5

Journal Club
10/13/23
Background
• African American patients have poorer surgical outcomes
compared with their white peers
• Presumed to be due to a high preoperative comorbidity
burden among African American patients
• Racial differences in postsurgical outcomes have not been
investigated among apparently healthy children
Study Objectives
Question: Is there a difference in outcomes between apparently
healthy children (who are expected to have low risk of postsurgical
complications) between white and African American children?
Hypothesis: Being African American relative to being white does not
confer a higher risk of postoperative mortality and complications
among apparently healthy children.
Aim: Specifically assess whether poor baseline health alone explains
why African American children are more likely to die in surgical care.
Design
• Retrospective observational study
• National Surgical Quality Improvement Program-
Pediatric (NSQIP-P) database review
• Setting: Data from 186 medical centers across the US
• Enrollment: 2012-2017
• Analysis: multivariable logistic regression analysis
Study Population
• ASA 1 & 2 children, age 0-
17 y/o, who underwent
inpatient non-cardiac
surgical procedures
• n = 172,549 “healthy”
inpatient children (healthy
= ASA 1 or 2)
• African American cohort n
= 19675 (11.4%)
• White cohort n = 120991
(70.1%)
Characteristics of Apparently Healthy Children Who
Underwent Inpatient Surgery (NSQIP-P 2012-2017)
Overall (N = 140 666) White (n = 120 991) AA (n = 19 675)

No. Children (%)a No. Children (%)a No. Children (%)a

Sociodemographic characteristics

Age, mo

>24 (older children) 113 773 (80.9) 97 746 (80.8) 16 027 (81.5)

1–12 (infants) 22 140 (15.7) 19 154 (15.8) 2986 (15.2)

<1 (neonates) 4753 (3.4) 4091 (3.4) 662 (3.4)

Male sex 76 319 (54.3) 65 545 (54.2) 10 774 (54.8)

Perioperative profile

ASA class

1 43 643 (31.0) 38 420 (31.8) 5223 (26.5)

2 97 023 (69.0) 82 571 (68.2) 14 452 (73.5)

 Overall (N = 140 666) White (n = 120 991) AA (n = 19 675)

No. Children (%)a No. Children (%)a No. Children (%)a

Case urgency

Elective 85 406 (60.7) 72 980 (60.3) 12 426 (63.2)

Urgent 32 090 (22.8) 28 027 (23.2) 4063 (20.7)

Emergent 23 170 (16.5) 19 984 (16.5) 3186 (16.2)

Operating time >250 min 12 883 (9.2) 10 686 (8.8) 2197 (11.2)

Preoperative comorbidities

Cardiac risk factors 6479 (4.6) 5427 (4.5) 1052 (5.3)

Gastrointestinal disease 22 366 (15.9) 19 111 (15.8) 3255 (16.5)

Childhood malignancy 2533 (1.8) 2259 (1.9) 274 (1.4)

Sepsis 19 857 (14.1) 17 497 (14.5) 2360 (12.0)

Seizure disorder 3335 (2.4) 2747 (2.3) 588 (3.0)

Structural pulmonary abnormalities 4540 (3.2) 3818 (3.2) 722 (3.7)

Structural CNS abnormality 14 320 (10.2) 12 424 (10.3) 1896 (9.6)

Chronic lung disease 1374 (1.0) 1054 (0.9) 320 (1.6)

Methods
• Case information collected from NSQIP-P database, a multi-
institutional reporting system designed to collect risk-adjusted
surgical outcomes among children undergoing surgical
procedures at 186 medical centers in the US
• Primary outcome: overall 30 day in-hospital postop mortality
• Secondary outcome: overall 30 day postop complications &
serious adverse effects: cardiac arrest, sepsis, readmission, or
reoperation
• All outcome measures compared between AA & white children
Results
 Incidence of Postoperative Outcomes
p ≤ 0.05
Comparing African American to White Children
 Univariate & Multivariate Analyses of 30-day Mortality, Composite
30-day Complications, and SAEs, Crude & Adjusted Odds Ratios

30-d Mortality Composite 30-d Complications SAEs

No. No.
cOR (95% aOR (95% cOR (95% aOR (95% No. SAEs/n cOR (95% aOR (95%
Mortality/ Complications/
CI) CI) CI) CI) (%)a CI) CI)
n (%) a
n (%) a

23/120 991 16 698/120 991 6913/120 991

White Referent Referent Referent Referent Referent Referent
(0.02) (13.8) (5.7)

13/19 675 3.48 (1.76– 3.43 (1.73– 3320/19 675 1.27 (1.22– 1.18 (1.13– 1213/19 675 1.08 (1.02– 1.07 (1.01–
AA
(0.07) 6.87) 6.79) (16.9) 1.32) 1.23) (6.2) 1.15) 1.14)
 30-d Mortality Composite 30-d Complications SAEs

No.
No. Mortality/n cOR (95% aOR (95% No. SAEs/n cOR (95% aOR (95%
cOR (95% CI) aOR (95% CI) Complications/n
(%)a CI) CI) (%)a CI) CI)
(%)a

Sex

12 824/79 046 4364/79 046

Female 22/79 046 (0.03) Referent Referent Referent Referent Referent Referent
(16.2) (5.5)

0.81 (0.44– 0.64 (0.34– 11 288/93 503 0.71 (0.69– 0.87 (0.85– 5597/93 503 1.09 (1.05– 1.08 (1.04–
Male 21/93 503 (0.02)
1.47) 1.17) (12.1) 0.73) 0.90) (6.0) 1.13) 1.13)

Age, mo

19 352/139 380 7730/139 380

>12 17/139 380 (0.01) Referent Referent Referent Referent Referent Referent
(13.9) (5.5)

4.21 (2.07– 4.68 (2.26– 1.07 (1.03– 1.17 (1.13– 1664/27 276 1.11 (1.05– 1.13 (1.07–
1–12 14/27 276 (0.05) 4006/27 276 (14.7)
8.54) 9.69) 1.11) 1.22) (6.1) 1.17) 1.20)

16.73 (7.99– 14.89 (6.65– 0.91 (0.84– 1.07 (0.98– 567/5893 1.81 (1.66– 1.76 (1.60–
<1 12/5893 (0.20) 754/5893 (12.8)
35.04) 33.30) 0.98) 1.16) (9.6) 1.98) 1.92)
 30-d Mortality Composite 30-d Complications SAEs

No.
No. Mortality/n cOR (95% No. SAEs/n
cOR (95% CI) aOR (95% CI) Complications/n aOR (95% CI) cOR (95% CI) aOR (95% CI)
(%)a CI) (%)a
(%) a

8068/145
RVU ≤25 30/145 945 (0.02) Referent Referent 12 686/145 945 (8.7) Referent Referent Referent Referent
945 (5.5)

8.03 (7.79– 5.22 (5.04– 1835/26 124 1.29 (1.23– 1.22 (1.15–
RVU 25–50 11/26 124 (0.04) 2.05 (1.03–4.09) 1.87 (0.87–3.99) 11 322/26 124 (43.3)
8.28) 5.40) (7.0) 1.36) 1.30)

20.35 (4.85– 5.04 (1.11– 2.91 (2.34– 2.15 (1.71– 2.35 (1.78– 1.80 (1.36–
RVU >50 2/480 (0.42) 104/480 (21.7) 58/480 (12.1)
85.40) 22.80) 3.61) 2.70) 3.09) 2.38)

18 482/104 575 5931/104

Elective 24/104 575 (0.02) Referent Referent Referent Referent Referent Referent
(17.7) 575 (5.7)

0.44 (0.42– 0.98 (0.94– 2440/40 118 1.08 (1.03– 1.18 (1.12–
Urgent 11/40 118 (0.03) 1.19 (0.59–2.44) 1.47 (0.67–3.19) 3441/40 118 (8.6)
0.45) 1.02) (6.1) 1.13) 1.24)

0.40 (0.38– 0.85 (0.80– 1590/27 856 1.01 (0.95– 1.07 (1.01–
Emergent 8/27 856 (0.03) 1.25 (0.56–2.79) 1.27 (0.54–2.98) 2189/27 856 (7.9)
0.42) 0.89) (5.7) 1.07) 1.14)

Op. time 16 706/156 706 8746/156

39/156 706 (0.02) Referent Referent Referent Referent Referent Referent
<250 min (10.7) 706 (5.6)

Op. time 7.36 (7.11– 3.39 (3.25– 1214/15 827 1.41 (1.32– 1.39 (1.29–
4/15 827 (0.03) 1.02 (0.36–2.84) 1.12 (0.36–3.48) 7402/15 827 (46.8)
≥250 min 7.63) 3.53) (7.7) 1.50) 1.49)
Discussion/Conclusions
• Results refute the initial hypothesis
• Even among apparently healthy children (ASA 1 or 2), African American children had a
higher risk of postoperative complications and mortality compared with their white peers
• This finding was in spite of having a relatively healthy cohort, suggesting that preoperative
comorbidity burden may only partly explain the racial disparity in postsurgical outcomes
in children
• Suggests that there is an association between racial category and postoperative
morbidity and mortality in apparently healthy African American children relative to
white children
Limitations/Criticisms
• NSQIP-P database discourages identification of specific hospitals in the database,
limiting site-specific differences in care as a variable
• ASA physical status as surrogate category; certain “mild systemic diseases” confer
greater risks of postoperative/postanesthetic complications (i.e., asthma,
smoking/vaping & reactive airway sequela, obesity w/ BMI 30 vs 39.9, etc.)
• Other socioeconomic determinants of health not specifically accounted for in this study
but are known putative mechanisms causing health & care disparities: poverty, lack of
access to health care, home environment/exposures, educational level, etc.
• Other ethnic groups were included but not specifically examined/compared in this
analysis, including Asian American, American Indian, Hispanic, and Native Hawaiian
children, which represent 18.5% of total NSQIP-P cases analyzed (future direction?)
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