Who faces poor urologic surgery outcomes?

July 14, 2016

A new report reveals that black children, and children undergoing more invasive bladder and urinary diversions, undergo more complications after surgery than their peers.

Black children and those undergoing bladder or urinary diversions suffer the most pediatric urologic surgery complications, according to a new study published in Pediatrics. The researchers sought to understand in what circumstances and in what populations most urologic complications occur in an effort to advance quality improvement.

Quality improvement is an ongoing effort across healthcare, especially since the passage of the Affordable Care Act and the connection of reimbursements to quality care. Clinicians have been tasked with finding ways to reduce complications, but also to identify risk factors that can lead to adverse events. Race has been identified in a number of studies as a factor in a variety of medical conditions, and is an important risk factor in surgical readmission rates, complications, and morbidity.

In this study, data collected through the National Surgical Quality Improvement Program–Pediatrics (NSQIP-P) on nearly 115,000 national pediatric urology cases from more than 50 hospitals between 2012 and 2013 was analyzed to review 30-day postoperative complications. The analysis considered preoperative, intraoperative, and postoperative factors, as well as mortality and morbidity outcomes in both inpatient and outpatient cases. Included in the consideration of complications were surgical site infection (SSI), pneumonia, reintubation, renal insufficiency, urinary tract infection, venous thrombotic events, neurologic problems, graft failure, cardiac arrest, transfusion, sepsis, central line-associated bloodstream infection (CLABSI), unplanned readmission, and unplanned reoperation.

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Patients were split into groups of non-Hispanic whites, non-Hispanic blacks, and “other” races, which included Hispanics, Asians, American Indians, and more. The analysis revealed that the overall complication rate of pediatric urologic surgeries was 5.9%. Bladder and urinary diversion accounted for the highest rates of 30-day complication, at 23% and 22%, respectively. Researchers also found that non-Hispanic black children and those undergoing renal and ureteral procedures had higher odds of having complications.

Non-Hispanic black children had a 34% greater chance of experiencing 30-day complications than non-Hispanic white children. Non-Hispanic black children also had a 53% higher chance of experiencing a hospital-acquired infection (HAI) in the postoperative period compared with non-Hispanic white children. Bladder and urinary diversions also were associated with higher HAI rates compared with testicular procedures.

“The public health implications of possible racial disparities in pediatric urologic complications certainly warrant additional exploration,” the researchers note. “One possible explanation is that black children may be more likely to receive care at hospitals with fewer resources, which may drive the association between race and outcomes.”

NEXT: What have past studies found?

 

In this study, researchers were unable to find out more about the hospitals where the complications occurred because the NSQIP-P has restrictions on the release of information by hospital or region.

Immune responses also may play a role in the disparity, according to the study, evidenced by previous research detailing different innate cytokine responses in children of European versus African descent.

“Clinically, black compared with white race has been significantly associated with infectious complications. Among hospitalized adult patients, blacks were found to have 34% higher odds of developing HAI, including CLABSI, urinary tract infection (UTI), and pneumonia, compared with whites,” said the report. “Similarly, among adults who underwent elective vascular surgical procedures, blacks were found to have 77% higher odds of subsequent pneumonia, UTI, SSI, or sepsis compared with white patients.”

In addition to risk factors identified by race and procedure, the research team found that younger age and more comorbidities also were associated with increased surgical complications.

Lead researcher David I Chu, MD, from the Children's Hospital of Philadelphia in Pennsylvania, says more research is needed to apply the results of the study to clinical practice. “Health disparities have become increasingly present, even among children, and even among the surgical subspecialties, and the next critical step is in developing effective interventions to reduce or eliminate them,” he says.

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Previous research echoes Chu’s findings in older populations, including a 2005 report in the Annals of Surgery revealing a 65% higher chance of surgical complications in black patients. In that study, the higher incidence of complications was partially explained by differences among black patients in length of hospital stay and the type of hospital where the surgery was performed. Also, blacks were found to reside in areas with lower median incomes and more often relied on self-pay or government programs for their healthcare, leading researchers to hypothesize that hospital factors were a large contributor to the difference in complication rates.

Another report, published in Health Services Research, also points to differences in the rate of surgical complications by socioeconomic and payer status. The report found that patients without private health insurance were 30% to 50% more likely to experience postoperative complications, and patients from low-income communities were 12% more likely to experience complications. “Race does not appear to be an important determinant of in-hospital postsurgical complications, but insurance and community characteristics have an effect,” those authors note.

Chu says although there is research to support racial differences in morbidity and mortality for whatever reason, it is clear that it will take a joint effort from many stakeholders to identify a solution.

“We do not know exactly why our findings of racial disparity exist in pediatric urology, but we believe that type of hospital (public vs private vs safety-net, primary patient population, etc.) may play an important role,” Chu says. “The potential causes of disparities in healthcare in general are multifactorial and very complex, ranging from hospital-level factors like quality of care, to provider-level factors like implicit bias, to patient-level factors like self-care. The bottom line is that interventions to reduce these disparities clearly require a joint effort from hospital, community, and policy leaders.”