BOB Ped Surg 2023 - Shelby Sferra, AAP - Presentation

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 days 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.