Study Highlights

• The retrospective cohort for this 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, at 51 freestanding pediatric tertiary care hospitals across the US that reported to the Children's Hospital Association Pediatric Health Information System.
• Mean age was 7±6 years; 56.1% were male, 18.0% were Black, 82.0% were White; and 15.3% were Hispanic and 59.9% were non-Hispanic.
• Median income quartile of the ZIP code of residence was used as a proxy for SES.
• Only 20.3% of Black children belonged to the highest income quartile compared with 43.0% of White children.
• The primary outcome was risk-adjusted in-hospital mortality rates by race and parental income quartile controlled for baseline covariates.
• Mortality rate was 1.2% overall and decreased with increasing income quartile (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 the 3 lowest income quartiles, Black children had 33% higher odds of postoperative death than White children (aOR, 1.33; 95% CI, 1.27-1.39; P<.001).
• This racial disparity gap persisted among children in the highest income quartile (aOR, 1.39; 95% CI, 1.25-1.54; P<.001).
• Postoperative mortality rates among Black people in the highest income quartile (1.30%; 95% CI, 1.19%-1.42%) were similar to those of White people in the lowest income quartile (1.20%; 95% CI, 1.16%-1.25%).
• Among Black people, the mortality rate difference between those in the highest vs lowest SES quartiles was smaller than that of White people in the highest vs lowest quartiles.
• The interaction between Black race and income was not statistically significant on either the multiplicative scale or the additive scale, suggesting no reduction in disparity gap across increasing income levels.
• Similarly, there was no significant interaction between Black race and income among patients requiring vs not requiring intensive care unit beds.
• The investigators concluded that increasing SES was associated with lower pediatric postoperative mortality.
• However, postoperative mortality rates were significantly higher among Black vs White children in the highest SES category, and mortality rates among Black people in the highest SES category were similar to those of White people in the lowest SES category.
• Despite substantial improvements in pediatric perioperative care within the last 3 decades, disparity in surgical outcomes has persisted, with higher rates of postoperative complications and mortality among Black people than White people.
• Traditional explanations for these racial disparities include greater preoperative comorbidity burden among Black people and greater likelihood that Black people vs White people will receive treatment in low-performing hospitals and have lower SES.
• However, the study findings suggest that increasing family SES did not provide equitable advantage to Black children compared with White children and that interventions targeting socioeconomic inequities alone may not fully address persistent racial disparities in pediatric postoperative mortality.
• Measures to reduce racial disparity in pediatric postoperative mortality must look beyond social factors, such as family SES or preoperative comorbidity burden.
• Hospital-based clinical interventions addressing traditional risk factors may be associated with reductions in postoperative complications and mortality, but they are unlikely to eliminate disparities in surgical outcomes without directly addressing upstream factors associated with low SES.
• A multifaceted approach is therefore needed, including dismantling socioeconomic barriers, equitable availability of comprehensive pediatric surgical care, and personalized care for children of all races.
• Examination of hospital systems to assess variability in health care intensity and quality of outcomes is warranted, as quality of care in hospital systems may be easier to address than patient-level variables.
• Hospital systems might consider additional actions to reduce medical debt for disadvantaged patients, including those with low SES or belonging to minority groups.
• Although this study cannot link the findings to structural racism, some investigators have suggested that systemic discrimination, economic and spatial segregation and deprivation, and social factors associated with health likely explain worse health outcomes among racial minority pediatric patients.
• Study limitations include reliance on ZIP code-level median household income as a proxy for family SES, inability to evaluate inequities in health care delivery and outcomes on an institutional level, difficulty characterizing multiracial children, and inability to determine the role of additional processes of care, such as do-not-resuscitate status or variation in surgical profiles (specialty, complexity, and postoperative complications) across racial groups.