Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.
College of Medicine, The Ohio State University, Columbus.
JAMA Netw Open. 2022 Mar 1;5(3):e222989. doi: 10.1001/jamanetworkopen.2022.2989.
Racial disparities in postoperative outcomes have remained difficult to eliminate. It is commonly understood that socioeconomic status (SES) is an important factor associated with excess risk of postoperative morbidity and death. To date, comparable data exploring the association of family SES with pediatric postoperative mortality are unavailable, and it is unknown whether the advantage provided by higher income status is equitable across racial groups.
To assess whether increasing family SES is associated with lower pediatric postoperative mortality and, if so, whether this association is equitable among Black and White children.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from 51 freestanding pediatric tertiary care hospitals across the US that reported to the Children's Hospital Association Pediatric Health Information System. The study included 1 378 111 Black and White children younger than 18 years who underwent inpatient surgical procedures between January 1, 2004, and December 31, 2020.
The exposures of interest were race (Black and White) and parental income quartile (used as a proxy for SES and measured by median income quartile of the zip code of residence). 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 was risk-adjusted in-hospital mortality rates by race and parental income quartile controlled for baseline covariates. To evaluate whether belonging to the highest income quartile modified the association between race and postoperative mortality, multiplicative and additive interactions were examined.
Among 1 378 111 children (773 364 [56.1%] male; mean [SD] age, 7 [6] years) who received inpatient surgical procedures during the study period, 248 464 children (18.0%) were Black, and 1 129 647 children (82.0%) were White; 211 127 children (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 with 482 758 White children (43.0%). The overall mortality rate was 1.2%, and mortality rates decreased as income quartile increased (1.4% in quartile 1 [lowest income], 1.3% in quartile 2, 1.0% in quartile 3, and 0.9% in quartile 4 [highest income]; P < .001). 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). 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). Postoperative mortality rates among Black children in the highest income quartile (1.30%; 95% CI, 1.19%-1.42%) were comparable to those of White children in the lowest income quartile (1.20%; 95% CI, 1.16%-1.25%). 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.
In this cohort study, increasing SES was associated with lower pediatric postoperative mortality. However, postoperative mortality rates were significantly higher among Black children in the highest SES category compared with White children in the same category, and mortality rates among Black children in the highest SES category were comparable to those of White children in the lowest SES category. These findings suggest that increasing family SES did not provide equitable advantage to Black compared with White children, and interventions that target socioeconomic inequities alone may not fully address persistent racial disparities in pediatric postoperative mortality.
术后结局的种族差异仍然难以消除。人们普遍认为，社会经济地位（SES）是与术后发病率和死亡率过高相关的一个重要因素。迄今为止，尚无比较家庭 SES 与儿科术后死亡率关联的可用数据，也不知道高收入状况带来的优势在不同种族群体之间是否公平。
评估 SES 增加是否与儿科术后死亡率降低相关，如果相关，这种关联在黑人和白人儿童中是否公平。
设计、地点和参与者：本回顾性队列研究使用了美国 51 家独立的儿科三级保健医院的数据，这些医院向儿童保健协会儿科健康信息系统报告。研究包括 1378111 名年龄在 18 岁以下的黑人和白人儿童，他们在 2004 年 1 月 1 日至 2020 年 12 月 31 日期间接受了住院手术。
感兴趣的暴露因素是种族（黑人/白人）和父母收入四分位数（用作 SES 的代理指标，通过居住邮政编码的中位数收入四分位数来衡量）。种族由父母或监护人在入院时自行报告，或由符合每个医院政策和州立法的登记团队评估。
主要结局是通过种族和父母收入四分位数（控制基线协变量）调整后的住院死亡率。为了评估属于最高收入四分位数是否改变了种族与术后死亡率之间的关联，检验了乘法和加法交互作用。
在研究期间接受住院手术的 1378111 名儿童中（773364 名男性[56.1%]；平均[SD]年龄，7[6]岁），248464 名儿童（18.0%）为黑人，1129647 名儿童（82.0%）为白人；211127 名儿童（15.3%）为西班牙裔，825477 名儿童（59.9%）为非西班牙裔。只有 49541 名黑人儿童（20.3%）属于最高收入四分位数，而 482758 名白人儿童（43.0%）属于最高收入四分位数。总体死亡率为 1.2%，随着收入四分位数的增加，死亡率逐渐降低（四分位 1[最低收入]为 1.4%，四分位 2 为 1.3%，四分位 3 为 1.0%，四分位 4[最高收入]为 0.9%；P<0.001）。在属于前 3 个低收入四分位数的儿童中，黑人儿童术后死亡的几率比白人儿童高 33%（调整后的优势比，1.33；95%CI，1.27-1.39；P<0.001）。在属于最高收入四分位数的儿童中，这种种族差异仍持续存在（调整后的优势比，1.39；95%CI，1.25-1.54；P<0.001）。黑人儿童在最高收入四分位数（1.30%；95%CI，1.19%-1.42%）的术后死亡率与白人儿童在最低收入四分位数（1.20%；95%CI，1.16%-1.25%）的死亡率相当。在乘法尺度上（交互作用的β值为 1.04；95%CI，0.93-1.17；P=0.45）或加法尺度上（交互作用导致的相对超额风险=0.01；95%CI，-0.11 至 0.11；P>0.99），黑人和收入之间的交互作用均无统计学意义，这表明随着 SES 水平的增加，差异差距没有缩小。
在这项队列研究中，SES 增加与儿科术后死亡率降低相关。然而，在最高 SES 类别中，黑人儿童的术后死亡率明显高于同类别中的白人儿童，而在最高 SES 类别中黑人儿童的术后死亡率与最低 SES 类别中的白人儿童相当。这些发现表明，SES 增加并没有为黑人儿童提供与白人儿童相比的公平优势，而仅针对社会经济不平等的干预措施可能无法完全解决儿科术后死亡率中持续存在的种族差异。
