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Association between race/ethnicity, illness severity, and mortality in children undergoing cardiac surgery
Yuen Lie Tjoeng1, Kathy Jenkins2, Jason F Deen3
1Division of Critical Care Medicine, Seattle Children's Hospital, University of Washington, Seattle, Wash; Division of Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Wash.
Insights
African-American children undergoing cardiac surgery face higher mortality, but this disparity is linked to greater illness severity, not race itself. Addressing illness severity may reduce survival differences in pediatric cardiac surgery.
Area of Science:
- Pediatric Cardiac Surgery
- Health Disparities Research
- Critical Care Medicine
Background:
- Previous studies link nonwhite race/ethnicity and insurance status to increased mortality after pediatric congenital heart surgery.
- The impact of illness severity on this association remains unclear.
- Understanding mediating factors is crucial for addressing disparities in pediatric cardiac surgery outcomes.
Purpose of the Study:
- To investigate the relationship between race/ethnicity, illness severity, and mortality in pediatric cardiac surgery.
- To determine if illness severity mediates the increased surgical mortality observed in nonwhite patients.
- To identify potential drivers of survival disparities in this population.
Main Methods:
- Retrospective cohort study of 40,545 children (<18 years) undergoing cardiac surgery from 2009-2016 using the Virtual Pediatric Systems database.
- Multivariate regression models were employed to analyze the association between race/ethnicity, illness severity, and intensive care unit mortality.
- Illness severity was assessed as a potential mediator in the relationship between race/ethnicity and mortality.
Main Results:
- African-American children presented with significantly higher illness severity scores compared to white children.
- After adjusting for covariates, African-American children had a higher odds of postoperative mortality (OR, 1.40).
- This increased mortality risk was mediated by higher illness severity, as adjustment for severity eliminated the survival disadvantage for Black patients.
Conclusions:
- Higher postoperative mortality in African-American children undergoing cardiac surgery is mediated by greater illness severity.
- Preoperative and intraoperative factors likely contribute to the observed survival disparities.
- Targeting illness severity may be a key strategy to reduce mortality differences in pediatric cardiac surgery.
Objective:
Prior studies demonstrate an association between nonwhite race/ethnicity, insurance status, and mortality after pediatric congenital heart surgery. The influence of severity of illness on that association is unknown. We examined the relationship between race/ethnicity, severity of illness, and mortality in congenital cardiac surgery, and whether severity of illness is a mechanism by which nonwhite patients experience increased surgical mortality.
Methods:
We performed a retrospective cohort study of children younger than age 18 years old undergoing cardiac surgery admitted to the intensive care unit (n = 40,545) between 2009 and 2016 from the Virtual Pediatric Systems (VPS, LLC, Los Angeles, Calif) database. Multivariate regression models were constructed to examine the role of severity of illness as a mediator between race/ethnicity and mortality in children undergoing cardiac surgery.
Results:
In multivariate models examining severity of illness scores, African-American patients had statistically significant higher severity of illness scores when compared with their white counterparts. In multivariate models of intensive care unit mortality after adjustment for covariates, African-American patients had a higher odds of postoperative mortality (odds ratio, 1.40, 95% confidence interval, 1.04-1.89) when compared with white children. This increased odds of mortality was mediated through higher severity of illness, because adjustment for severity of illness removed this survival disadvantage for black patients.
Conclusions:
Although African-American children undergoing cardiac surgery had higher postoperative mortality, this survival difference appears to be mediated via severity of illness. Preoperative and intraoperative factors may be drivers for this survival disparity.
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