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Implementation of an Enhanced Recovery Protocol Attenuates Disparities in Pediatric Surgical Care
Johanna M Borst1, Alexandra Highet2, Ashley C Dodd1
1Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
Objective:
To assess whether implementation of an enhanced recovery protocol (ERP) reduces racial and ethnic disparities in pediatric surgical care.
Background:
ERPs have narrowed disparities in adult surgical care, but their impact in pediatric surgery is unknown.
Methods:
We performed a secondary analysis of the ENhanced Recovery in CHildren Undergoing Surgery (ENRICH-US) trial, a stepped-wedge, cluster-randomized trial across 18 pediatric surgery sites. Sites were guided through baseline, implementation, and sustainability phases. Applied implementation strategies facilitated uptake of 17 ERP elements for 597 surgical episodes in patients, ages 10-18, undergoing gastrointestinal surgery. Multilevel mixed-effects models assessed adjusted, phase-specific changes in ERP element delivery by race/ethnicity. Domain- and element-level differences were explored.
Results:
ERP delivery increased from 11.4 elements at baseline to 13.3 during implementation to 14.0 during the sustainability phase (P<0.001). Among race/ethnicity categories, significant disparities were identified only between Hispanic/Latino and non-Hispanic White patients. Hispanic/Latino patients received fewer elements than non-Hispanic White patients across all phases; however, disparities narrowed from 1.1 at baseline (Hispanic/Latino: 10.4 vs. non-Hispanic White: 11.6; P=0.003) to 0.5 elements during the sustainability phase (Hispanic/Latino: 13.5 vs. non-Hispanic White: 14.0; P=0.24). Baseline disparities were concentrated in the preoperative domain, where Hispanic/Latino patients received 0.6 fewer elements than non-Hispanic White patients (P<0.001). This domain also demonstrated the greatest improvement, with the absolute difference narrowing to 0.1 elements by the sustainability phase (83% reduction).
Conclusions:
Applied implementation of a pediatric ERP was associated with increased delivery of evidence-based care for all patients and substantial attenuation of baseline disparities for Hispanic/Latino children.
