Health Disparities in Pediatric Surgery

Health Disparities in Pediatric Surgery Ala Stanford, MD, FACS, FAAP Cooper Children s Regional Hospital Cooper Medical School of Rowan University The American Academy of Pediatrics 2015 National Conference & Exhibition October 24, 2015 1

Health Disparities in Pediatric Surgery I have nothing to disclose. 2

Pediatric Surgery Health Disparities Facts and definitions Review Pediatric Surgery health disparities literature over the past 5 years Acute surgery and Chronic conditions Disparity, outcome and solutions Real time efforts to reduce health disparities 3

Introduction: Health Disparities Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. Populations can be defined by factors such as race or ethnicity, gender, education or income, disability, geographic location (e.g., rural or urban), or sexual orientation. Health disparities are inequitable and are directly related to the historical and current unequal distribution of social, political, economic, and environmental resources. CDC, 2015 4

Introduction: Health Disparities Preventable differences socially disadvantaged race or ethnicity, gender, education or income, disability geographic location, sexual orientation directly related to the historical and current unequal distribution of social, political, economic, and environmental resources CDC, 2015 5

Acute surgical conditions ACUTE INJURY ISSUE DISPARITY INSTITUTTION YEAR FACIAL LACERATION MANAGEMENT INSURANCE TYPE BROWN AND HARVARD 7/2015 ABDOMINAL PAIN OUTCOMES RACE AND SOCIOECONOMIC STATUS STANFORD 8/2015 MALROTATION AND MIDGUT VOLVULUS MORTALITY RACE AND SOCIOECONOMIC STATUS CHILDREN S HOSPITAL OF PHIL AND ABINGTON MEMORIAL HOSPITAL 10/2013 PERFORATED APPENDICITIS HOSPITAL TYPE AND ACCESS CARE QUALITY MATTEL CHILDREN S HOSPITAL 2012 6

Acute surgical conditions ACUTE INJURY ISSUE DISPARITY INSTITUTTION YEAR FACIAL LACERATION MANAGEMENT INSURANCE TYPE BROWN AND HARVARD 7/2015 ABDOMINAL PAIN OUTCOMES RACE AND SOCIOECONOMIC STATUS STANFORD 8/2015 MALROTATION AND MIDGUT VOLVULUS MORTALITY RACE AND SOCIOECONOMIC STATUS CHILDREN S HOSPITAL OF PHIL AND ABINGTON MEMORIAL HOSPITAL 10/2013 PERFORATED APPENDICITIS HOSPITAL TYPE AND ACCESS CARE QUALITY MATTEL CHILDREN S HOSPITAL 2012 7

PLOS ONE DOI:10.1371/journal.pone.0132758 August 12, 2015 8

The abdominal pain measured was secondary to non-perforated and perforated appendicitis. Separated from UTI, dehydration, diarrhea, GERD Used PHIS 43 children s hospitals CHCA, 2004-2011 Chi-square, multivariate logistic regression 9

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Results Minority and low income patients have less surgery, increased perforated appendicitis and longer hospital stays; and had lower rates of imaging including CT scans. The combined impact of race and low socioeconomic status is greater than either variable separately. High income black patients have less hospitalization and worse outcomes than low income whites. 12

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Purpose To characterize disparities in surgical outcomes of malrotation/midgut volvulus across major children s hospitals To determine if disparities were explained by the hospital s experience serving African American or Hispanic families 14

Methods Study population < 5 y.o 1 st admission with diagnosis of malrotation and/or midgut volvulus Underwent surgical procedure for malrotation and/or midgut volvulus January 2000 March 2011 Pediatric Health Information System (PHIS) data source Analysis Logistic regression model, bivariate analysis and hospital included as a fixed effect Adjusted for patient and hospital-level variables 15

Methods Outcomes Bowel resection +/- ostomy Mortality during 1 st admission Hospital-level factors n=4,219 Size (<200, 200-250, 251-300, >300 beds) Region (Midwest, Northeast, South, West) Hospital Hispanic composition (quartiles) 16

Methods: Cohort Developed (PHIS Jan 1, 2000 March 31, 2011) n = 83,756 Dx of malrotation and midgut volvulus on 1 st hospitalization, < 5 yo Excluded: CDH, Abd wall defects biliary atresia, RACHS >1 n=1,404 Unknown or other race/ethnicity/insurance n=1,764 8,407 8,380 6,976 5,983 4,219 Cohort (malrotation, midgut volvulus or Ladd's) Incorrect MRN n=27 Did not receive surgery on first admission n=993

Bowel Resection/Ostomy Non-Hispanic *27.7 (25.6-29.7) Hispanic 34.2 (31.2-37.2) *p<0.01 Predicted probability (upper and lower confidence intervals) 18

Mortality during 1 st admission Non-Hispanic 2.6 (2.1-3.1) Hispanic 4.1 (2.3-5.9) Probability (upper and lower confidence intervals) 19

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Hospital Hispanic Composition Quartile Composition (%) 1 0-5.9 2 6-15.9 3 16 39.9 4 40-64.6 21

Ostomy and Bowel Resection Rates at Predominately Hispanic or Non-Hispanic Hospitals 22

Variables contributing to HD Proximity to Surgeon Delayed presentation Misdiagnosed Parents Healthcare providers Institution Post-operative care, follow-up short long-term Rehabilitation 23

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Chronic Disease ELECTIVE SURGERY FOR CHRONIC CONDITIONS ISSUE DISPARITY INSTITUTTION YEAR CONGENITAL HEART SURGERY RACIAL AND ETHNIC FACTORS MORBIDITY EMORY 2011 CONGENITAL HEART SURGERY RACE AND INSURANCE MORTALITY UNIVERSITY OF UTAH 2/2012 SOLID NON-CNS TUMORS RACE AND ETHNICITY OUTCOMES MD ANDERSON 2015 PALATE REPAIR RACE AND INSURANCE DELAY BOSTON CHILDREN S AND MA EYE AND EAR 25

Chronic Disease ELECTIVE SURGERY FOR CHRONIC CONDITIONS ISSUE DISPARITY INSTITUTTION YEAR CARDIAC SURGERY FINANCIAL AND INCOME ACCESS AND INEQUALITY ANN AND ROBERT LURIE CHILDREN S HOSPITAL OF CHICAGO 9/2015 NON-SYNDROMIC CRANIOSYNOSTOSIS INSURANCE AND RACE DELAY IN SURGERY UNIVERSITY OF UTAH 2/2012 RENAL ALLOGRAFT SURVIVAL RACE AND ETHNIC DISPARITIES LONG TERM GRAFT SUCCESS EMORY, COLUMBIA AND CHOP 26

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Results: CHS Length of stay was longest for Blacks and Hispanics Increased risk of in hospital mortality Thought that the mortality was due to genetic causes, however mortality for black and white patients were equal in some states suggesting access Hospital type and underperforming hospitals? even after adjusting for insurance type and hospital type deaths remained highest in Black children 30

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MD Anderson Non-CNS solid tumors 1995-2009 n=4,600 Disease stage and overall survival (OS) Driving distance to COG center Texas Cancer Registry part of CDC and NPCR 32

MD Anderson: Results >Male, <10 years Black and Hispanic children had a more advanced stage at diagnosis. Low socioeconomic status was not significant in stage at diagnosis nor OS Driving distance also not significant Black children that were not from a low socioeconomic background also presented later and had poorer OS 33

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Parent and Guardian 25% Education Access 25% Geography Provider 25% Bias Patient Comorbid 25% Conditions 35

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Cooper Rowan Clinic Camden is our classroom. Camden is our home. 39

www.ittakesphilly.org 41

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Conclusion Health disparities are persistent, pervasive and prevalent in the United States Eradication of health disparities IS NOT insurmountable. The solution(s) require a multi-tiered approach. Know the community that you serve so you may best serve them. 46

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21.Boston, MA (pp 609,690) 22.Milwaukee, WI (pop 602,057) 23.El Paso, TX (pop 587,400) 24.Washington, DC, (pop 582,049) 25.Nashville-Davidson,TN (pop 579.748) 26.Seattle, WA (pop 575,719) 27.Denver, CO (pop 561,323) 28.Las Vegas, NV (pop 544,806) 29.Portland, OR (pop 534,093) 30.Oklahoma City, 1.New OK York, (pop 532,006) NY (pop 8,213,839) 31.Tucson, AZ (pop 2.Los 528,483) Angeles, CA (pop 3,794,640 32.Albuquerque, 3.Chicago, NM (pop 496,801) IL (pop 2,824,584) 33.Atlanta, GA (pop 4.Houston, 483,108) TX (pop 2,076,189) 34.Long Beach, 5.Philadelphia, CA (pop 467,851) PA (pop 1,517,628) 35.Kansas City, 6.Phoenix, MO (pop 463,985) AZ (pop 1,476,331) 36.Fresno, CA (pop 7.San 456,574) Diego, CA (pop 1,284,347) 37.New Orleans, 8.San LA (pop Antonio, 455,188) TX (pop 1,258,733) 38.Cleveland, OH 9.Dallas, (pop 449,188) TX (pop 1,246,185) 39.Sacramento, CA (pop 448,842) 10.Detroit, MI (pop 921,147) 40.Mesa, AZ (pop 448,520) 11.San Jose, CA (pop 908,870) 12.Indianapolis, IN (pop 789,250) 13.Jacksonville, FL (pop 786,938) 14.San Francisco, CA (pop 777,660) 15.Columbus, OH (pop 738,782) 16.Austin, TX (pop 708,293) 17.Memphis, TN (pop 680,515) 18.Baltimore, MD (pop 640,064) 19.Charlotte, NC (pop 634,059) 20.Fort Worth, TX (pop 622,311) 21.Boston, MA (pp 609,690) 22.Milwaukee, WI (pop 602,057) 23.El Paso, TX (pop 587,400) 24.Washington, DC, (pop 582,049) 25.Nashville-Davidson,TN (pop 579.748) 26.Seattle, WA (pop 575,719) 27.Denver, CO (pop 561,323) 28.Las Vegas, NV (pop 544,806) 29.Portland, OR (pop 534,093) 30.Oklahoma City, OK (pop 532,006) 31.Tucson, AZ (pop 528,483) 32.Albuquerque, NM (pop 496,801) 33.Atlanta, GA (pop 483,108) 34.Long Beach, CA (pop 467,851) 35.Kansas City, MO (pop 463,985) 36.Fresno, CA (pop 456,574) 37.New Orleans, LA (pop 455,188) 38.Cleveland, OH (pop 449,188) 39.Sacramento, CA (pop 448,842) 40.Mesa, AZ (pop 448,520) 49