Severe Sepsis Mortality Worse for Black Children in US South, West

By Anne Harding

December 31, 2020

NEW YORK (Reuters Health) - Black children with severe sepsis are more likely to die in the hospital than white children, especially when they're treated at hospitals in the southern and western U.S., according to new findings.

The findings are a "call to action" to understand and address the factors underlying these disparities, Dr. Hannah K. Mitchell of Children's Hospital of Philadelphia (CHoP), the study's lead author, told Reuters Health by phone.

"When we see disparities in adult populations which are generally very well described you think of them as being an accumulated lifetime exposure to structural racism," she added. "When you see disparities in people who are very much younger, I think that's more surprising, and that begs the question of why."

Dr. Mitchell and her colleagues also found that there were no differences in mortality based on whether a child was publicly or privately insured. "That's a really very encouraging and positive thing that we found in our results," she said.

"That means that access to Medicaid is potentially a mechanism, and an enforcement mechanism, to actually improve outcomes in children," Dr. Nadir Yehya, the senior author of the study and an attending physician in the Pediatric Sepsis Program and the Division of Critical Care Medicine at CHoP, said in a phone interview.

Drs. Mitchell and Yehya and their colleagues looked at data on more than 3.1 million discharges from 4,200 hospitals in 47 states from the 2016 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID).

Their final cohort for analysis included 9,816 children. About 55% were publicly insured, 37% had private insurance, 3% were self-pay, 0.3% were not charged, and 4.8% were "other." About 48% were white, 17% were Black, 26% were Hispanic, 4% were Asian or Pacific Islander, 1% were Native American and 5% were "Other."

Black and Hispanic children lived in areas with lower income than those where white children lived, and whites were more likely to have private insurance, the researchers report in The Lancet Child and Adolescent Health.

About 71% of white children had complex chronic conditions, versus 78% of Black children and 75% of Hispanic children.

The risk of death were higher for Black than for white children (adjusted odds ratio, 1.19; P=0.028), particularly in the South (aOR, 1.30; P=0.019) and West (aOR, 1.58; P=0.027). Mortality was similar for white and Hispanic children.

Hospital stays were longer for Hispanic (adjusted hazard ratio, 0.94; P=0.049) and Black (aHR, 0.88; P=0.0002) children for whites, and the difference was most pronounced for Black newborns (aHR, 0.53; P=0.0011).

Mortality was similar for publicly and privately insured children, but children with other insurance status were at significantly increased risk of mortality.

Children with complex conditions had more than seven-fold greater odds of mortality than those who did not have these conditions (OR, 7.21; P<0.0001). Mortality was highest for children younger than one year and decreased with age.

"America doesn't have an overarching single healthcare network obviously, we have multiple little regional areas that for a variety of reasons end up having disparities in regional care," Dr. Yehya noted. The findings don't mean that the U.S. Northeast and Midwest don't have their own issues in terms of racial and socioeconomic health disparities, he added.

It's important to remember, according to the authors, that "race" should be seen as the experience of a Black person living in the U.S. and being exposed to structural racism, rather than as an intrinsic biological factor. They also note that factors at the systemic, regional, hospital, and individual provider level are likely involved in health disparities.

The finding that children with public and private insurance had similar outcomes "is a huge plus in favor of expanding Medicaid access rather than restricting it," Dr. Yehya said.

He continued: "This problem has taken a long time to get there. It's not going to go away with AI or better use of electronic medical records. There's a larger discussion to be had about how best to tackle these disparities, and the stage we're at right now is really the infancy of identifying these disparities."

SOURCE: The Lancet Child and Adolescent Health, online December 14, 2020.