The authors of a recent study found African American children who are otherwise apparently healthy are 3.43 times more likely to die within 30 days after surgery when compared with white patients.1

In a retrospective study, investigators analyzed the National Surgical Quality Improvement Program Pediatric database, identifying children who underwent inpatient operations from 2012 through 2017. They included children who were assigned an American Society of Anesthesiologists (ASA) physical status classification of 1 or 2.

An ASA classification of 1 means the patient does not have any disease. A classification of 2 means the patient has mild, systemic disease that does not interfere with activities of daily living, says Olubukola O. Nafiu, MD, FRCA, MS, vice chair for academic affairs in the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, OH. Of 172,549 apparently healthy children, the 30-day mortality rate was 0.02%, postoperative complications were 13.9%, and serious adverse events were 5.7%. There were significant differences between African American children’s outcomes and those of white children. Among African American children, researchers observed a 18% relative greater odds of developing postoperative complications and a 7% relative greater odds of developing serious adverse events.

“The two key areas of questions we set up in the database provided one answer we were expecting and one answer we didn’t expect,” Nafiu says. “We expected complications and mortality rates would be low in this relatively healthy group of children, and the overall mortality was low.”

But what investigators did not expect was that African American children, who represented about 12% of the study sample, would be much more likely to die within 30 days of surgery.

“We did not expect that magnitude of difference in outcomes,” Nafiu shares. “These were relatively healthy children, and we thought we wouldn’t find any difference by race, if the argument was that health drove postoperative mortality.”

Even after controlling for as many variables as possible, including surgical severity, investigators still observed a more than three times difference in death after surgery.

But there were limitations. For instance, the data do not indicate where surgery took place. “It’s possible that just a few hospitals are contributing to the majority of the numbers, but [the name and location] of hospitals is not included in the database,” Nafiu explains.

“We cannot say that mortality rates are coming from this hospital and are drivers of complications. That’s important because previous investigators have shown that hospital volume and quality affect patient outcomes, and African American patients tend to receive care from low-quality-type hospitals.”

Nafiu and colleagues also could not access information about patients’ socioeconomic status. They did not know ZIP codes or other information that might help them assess patients’ access to care and timeliness of care, which are important predictors of surgical outcome.

“There can be two patients present with the same lump in a leg or belly. On one hand, it might take one patient a week or two to see a primary care provider and get to a surgeon. On the other hand, it might take months to get to a doctor and surgeon,” Nafiu explains. “All of those things can affect outcomes, and we don’t have access to those data.”

Other factors that affect surgical outcomes include a surgeon’s volume of patients and how comfortable the surgeon is in caring for children of any particular group. Also, some surgeons have more experience and skill in recognizing complications and dealing with them.

“I would argue that data like these have shown that it’s important to consider a patient’s race when it comes time to care for them,” Nafiu says. “When you are risk-stratifying patients before any procedure, keep in mind that patients of a specific ethnicity have a higher risk of complications and mortality.”

The goal is to be alert to this as a factor so that it might help surgeons improve patient care and raise awareness about possible complications. “We need to continue to search for answers and find underlying causes for these disparities in outcomes,” Nafiu adds.


  1. Nafiu OO, Mpody C, Kim SS, et al. Race, postoperative complications, and death in apparently healthy children. Pediatrics 2020;146:e20194113.