Moderating Effects of Race and Preoperative Comorbidity on Surgical Mortality in Infants

Background: We sought to investigate the risk of pediatric surgical mortality associated with the combined effects of key preoperative comorbidities and race. Methods: We performed a retrospective study that included infants who underwent inpatient surgical procedures between 2012 and 2017 and were entered into the NSQIP-P registry. We assessed additive moderation by estimating the proportion of mortality risk attributable to the combined effects of race and the presence of a preoperative comorbidity (attributable proportion [AP]). Results: The study group was comprised of 58466 surgical cases, of whom 15711(26.9%) were neonates and 42755(73.1%) older infants. Among neonates, a history of prematurity carried a poorer prognosis in black babies than their white peers (OR:1.53, 95%CI:1.20,1.95). Additionally, there was evidence of additive moderation by race on the association between prematurity and postoperative mortality (AP: 23.9%; 95%CI: 3.8,43.9, P value = 0.020). In older infants, presence of preoperative sepsis carried almost two times higher risk of mortality for black patients than their white counterparts (OR:1.81; 95%CI:1.21,2.73). This explained 38.4% of mortality cases in black patients with preoperative sepsis (95%CI:14.0,62.7; P = 0.002). A history of prematurity also carried a greater risk of mortality in older infants of black race (OR:1.69; 95%CI: 1.27, 2.24), accounting for 24.2% of mortality cases (AP:24.2%; 95%CI:0.90, 47.5, P = 0.041). Conclusions: We quantified the surgical burden of mortality resulting from the differential impact of key comorbidities on black neonates and infants. Our data suggest that race-specific interventions to mitigate the incidence of the identified comorbidities could narrow the racial disparities in post surgical mortality.