BOB in Ped Surg 2023 - AAP Winner - Shelby Sferra, MD

All right, we're moving on to the next side. What do we got here? AAP. This is you, Alan. Yeah, my turn. Um, we have so much, so much great work from all over the world. It's amazing. Um, and we have more, 3 more societies to go. So next is AAP, the American Association of Pediatrics, and representing them, we have 3 presentations. The first is from Doctor Andrew Fleming, a surgery resident from Saint Jude Children's Hospital, and his presentation is entitled Aggressive Pursuit of No Evidence of Disease Status and Hepatoblastoma Improved Survival. This is a retrospective single institution study from 2005 to 2021, and their aim was to investigate the utility of pursuing no evidence of disease status for patients with hepatoblastoma. Our second presentation from AAP, we have Doctor Maria Tegos, also a surgery resident, and she's from the University of Nebraska, but with a prior research fellow with Washington University in St. Louis and Saint Louis Children's Hospital, and her presentation is entitled Disruption of Enterohepatic Circulation Ameliorates Small Bowel resection Associated with hepatic injury. This is a lab experiment done in mice, and their aim was to determine the mechanism for TPN independent small bowel resection associated hepatic injury. And finally, our third presentation from from AAP is Doctor Shelby Spera, a research fellow at Johns Hopkins, and this presentation was racial and ethnic disparities and outcomes among newborns with congenital diaphragmatic hernia, results from a National Children's Hospital Database. This was a retrospective cohort study from the PIS database between 2015 and 2020. And their aim is to assess CDH survival based on race, ethnicity, and, and to assess institutional level factors to affect that, that might affect outcomes in minority patients. Awesome. So 3 great presentations from AEP. I'm gonna start the poll. And uh we'll see a message from our sponsors as, as you vote. All right, Ellen, I don't know if you can see the poll results, but I can. Yeah, what do you guys think? The last one, racial ethnic disparities in CDS. Yeah, perfect. Let's see it. 42.9%. Uh, so there we go, yeah. Good morning and thank you for the opportunity to present our work. I have no disclosures. Health disparities driven by race and ethnicity are pervasive in healthcare and are known to impact all aspects of pediatric care. In congenital diaphragmatic hernia, or CDH specifically, these disparities affect care from prenatal diagnosis and surveillance through postnatal management. Existing studies on disparities in CDH show that black race is an independent risk factor for mortality and is further compounded by low socioeconomic status. However, the data are limited, and there remain many unanswered questions. The purpose of our study was to assess survival in different racial and ethnic patient populations and to assess institutional level factors that could improve outcomes for minority patients. We performed a retrospective cohort study using the FIS database from 2015 to 2020. We queried the database for patients admitted on day of life zero with an ICD diagnosis code for CDH and an ICD procedure code for repair. Racial and ethnic groups with very low numbers were omitted from the analysis. Our final cohort included 1,625 patients with a racial and ethnic composition as shown here. There are two definitions that are important to this study. The first is hospital volume, which we defined as less than 10 cases per year as low volume and 10 or more cases representing high volume. The second is institutional level racial and ethnic diversity, which we defined as the percentage of black and or Hispanic CDH patients treated at each institution. This was stratified into pre-specified levels ranging from less than 20% to greater than 40%. For all of our comparisons, white patients served as the reference group. The primary outcomes were in hospital and 60 day survival, and the secondary outcomes were length of stay, discharge to home, and tracheostomy use. Household incomes of black and Hispanic patients were significantly lower than that for white patients. White and Asian patients had primarily commercial insurance, whereas black and Hispanic patients had largely Medicaid payer status. When assessing markers of disease severity, black patients were born at significantly lower gestational ages and were more likely to be born preterm. They had lower birth weights and lower Apgar scores. Black patients were cannulated to extra corporeal life support more often than white patients. They were also mechanically ventilated for longer and required pulmonary anti-hypertensives for longer as well. These differences were not seen in Hispanic and Asian patients when compared to white patients. Morbidity and mortality were also increased in black patients. Black patients were admitted for significantly longer, discharged home less often, and were more likely to require a tracheostomy at the time of discharge. Black patients had decreased in hospitals survival rates of 79% compared to 88% in white patients. Hispanic and Asian patients had comparable survival rates to white patients at 88% and 92% respectively. When assessing survival based on institutional level, racial and ethnic diversity, low diversity levels defined as diversity of less than 20%, as shown in the blue line, were associated with decreased survival in white, black, and Hispanic patients. Conversely, higher levels of diversity, between 31 and 40% as shown in the red line, were associated with improved survival for white, black, and Hispanic patients. These differences were not observed in Asian patients. Finally, we performed a Cox regression analysis to control for severity, socioeconomic status, and institutional covariants, including hospital volume. It showed that while white patients had comparable outcomes regardless of institutional diversity, institutions with greater than 30% conferred a protective effect against mortality for black patients treated there. In addition, institutions with a diversity of greater than 20% conferred a protective effect for Hispanic patients treated there. In conclusion, our data found that black patients with CDH are subject to more severe disease and experience higher morbidity and mortality. These differences are not observed in other minority populations, namely those who identify as Hispanic or Asian. We demonstrate that treating a more racially and ethnically diverse patient population improves outcomes for black as well as Hispanic CDH patients without negatively impacting white patients. These findings provide further evidence of the disparities that exist for Black and Hispanic CDH patients and confirm a need for institutional initiatives aimed at delivering more equitable care for the betterment of all of our patients. Thank you, Shelby, for that paper. Um, so, I, I have a question, a frustration question to ask you. You know, we, um, have been, thankfully over the last 5 to 10 years, there's been a, a rapidly growing awareness and institutional, I mean, curriculums on, on DEI and racial ethnic disparities among patient outcomes. Yet I still keep seeing the papers being presented. Are we not making a difference? Are we not seeing Any benefit of all of these uh initiatives to try to decrease. And if it's not working, then how do we change course, or am I reacting too soon? How do we change course so that we can start having better impacts where we stop seeing these papers being presented? Yeah, I think that that's a great point. Um, I think, unfortunately, that's a little bit farther past the scope of our work. Um, and I definitely think that more research needs to be done, um, looking at how we can make changes. Um, again, I think it's a little bit past the scope of our work, but I do think that there are a lot of studies out there that show. That having patient physician concordance um and racial and ethnic disparities definitely improves outcomes for the minority patient population and so I think that there needs to be more initiatives to bring more minority providers into the health care system and I think that that at least the data has shown has improved outcomes and improved survival in many um cases um and in CDH also so I think that's one initiative and. I think also having continued education is something that we need to do better um as providers. I think that we talk about these disparities, um, and maybe you get one course in medical school on, um, treating racial and ethnic diverse patient populations, but I think that this needs to be something that started in medical school and then continues on in medical education and residency fellowship, um, and even at the attending level as well. Um, so those are some of my ideas, but unfortunately we didn't get to tackle that, um, specifically with our research. Thank you. Anyone else have a comment or a question? I think uh part of this uh issue, Todd is a lot of these uh the the the disparities are related to socioeconomic and other issues, but I think as surgeons as caregivers, we have to be clearly aware of these disparities so we can optimize our own skills the best we can and I think that's really the, the lesson from your paper and I think it's very important. Yeah. And I, I, you know, there are, besides just education, it's incorporation into the daily work, you know, I know we now have that as part of our weekly Eminem conference. We asked if this was something that led to the outcome, uh, for, for the out. So, uh, thanks to Mira Kotagal. So, um, uh, I, I think, you know, there was questions about, uh, Uh, I guess, Shelby, if you can go into the chat and answer some of these questions about insurance and why CDH would have an increased severity, there's questions on why there would be differences, um, please go ahead and answer that. Congratulations, Great paper. Very, very important. Thank you.