Race, Ethnicity, Insurance Payer, and Pediatric Cardiac Arrest Survival

Lower survival rates among Black adults relative to White adults after in-hospital cardiac arrest are well-described, but these findings have not been consistently replicated in pediatric studies.

To use a large, national, population-based inpatient database to evaluate the associations between in-hospital mortality in children receiving cardiopulmonary resuscitation (CPR) and patient race or ethnicity, patient insurance status, and the treating hospital's proportion of Black and publicly insured patients.

This retrospective population-based cohort study used the Healthcare Cost and Utilization Project Kids' Inpatient Database (1997-2019 triennial versions). Participants included pediatric inpatients (aged <18 years) who received in-hospital CPR. Initial data analysis occurred January 20 to July 31, 2023. Revision analyses were completed December 1, 2024, to March 3, 2025.

The exposures for the primary analyses were race or ethnicity and insurance payer. The secondary analyses exposures were the proportion of the treating hospital's admissions (not limited to those receiving CPR) of Black patients and of publicly insured patients.

The primary outcome for all analyses was in-hospital mortality.

The final cohort included 27 332 children (6366 neonates aged 5-28 days [23.3%], 9665 infants aged 29 days to <1 year [35.4%], 4867 aged 1 year to <8 years [17.8%], and 6434 aged ≥8 years [23.5%]; 15 356 male [56.2%]; 6081 (22.2%) Black; 5123 (18.7%) Hispanic; 13 062 (47.8%) White; and 3066 (11.2%) other race or ethnicity) who received in-hospital CPR at sites with 3899 unique hospital identification numbers. Relative to White children, higher odds of in-hospital mortality were observed for Black (adjusted odds ratio [AOR], 1.20; 95% CI, 1.08-1.34; P < .001) and Hispanic (AOR, 1.16; 95% CI, 1.04-1.30; P = .006) children and those of other race or ethnicity (AOR, 1.37; 95% CI 1.20-1.58; P < .001). Public insurance was not associated with in-hospital mortality compared with private insurance (AOR, 1.00; 95% CI, 0.91-1.11; P = .93). On multivariable analysis of the 2003-2019 datasets, children receiving CPR at hospitals with the highest proportion of Black patients (>30.1%) had higher odds of in-hospital mortality than children receiving CPR at hospitals with the lowest proportion of Black patients (AOR, 1.50; 95% CI, 1.17-1.92; P = .001).

In this retrospective cohort study of pediatric in-hospital cardiac arrest in a large, national, administrative dataset, children of racial and ethnic minority groups receiving CPR had higher odds of in-hospital mortality. In addition, the odds of in-hospital mortality among children receiving CPR were higher at hospitals with the highest proportion of Black patients.