Complications after pediatric emergency appendectomy in the UK
Myron Yaster MD, Olubukola Nafiu, MD, FRCA, MS and Francis Veyckemans MD
Depressingly, racial and ethnic disparities in health and health care outcomes are persistent features of all racialized societies. Since the cataclysmic upheaval in the Summer of 2020 in the United States and across the globe ignited by the murder of George Floyd and the profound disparities in the incidence of and deaths from the COVID pandemic, there has been renewed interest in many Western societies in taking a closer look at racial and ethnic health disparities. Hitherto, most of the work on health disparities have been from the United States. In today’s PAAD from the United Kingdom, Sogbodjor et al.1 examined the incidence of postoperative complications in children who underwent appendectomy. The underlying premise of the study was that, because of the National Health Service (NHS) assures healthcare to all UK citizens there will be no racial disparity in postoperative complications. Sadly, as you will see, this assumption was incorrect. Myron Yaster MD
Original article
Sogbodjor LA, Razavi C, Williams K, Selman A, Pereira SMP, Davenport M; CASAP investigators; Moonesinghe SR. Risk factors for complications after emergency surgery for paediatric appendicitis: a national prospective observational cohort study. Anaesthesia. 2024 May;79(5):524-534. doi: 10.1111/anae.16184. Epub 2024 Feb 22. PMID: 38387160.
Appendectomy is one of the most common surgical procedures performed in children. And yet, “despite this high prevalence, significant variation has been reported in both the care delivered and outcomes seen in children,”1 “Demographic factors such as age, ethnicity and socio-economic status have been associated with worse outcomes in children with acute appendicitis in the USA.2,3 It is not known whether the same is true in the UK, where healthcare is available to all at the point of need, and independent of one’s circumstance.”1
“This multicenter prospective observational cohort study, which included children aged 1–16 y who underwent surgery for suspected appendicitis, was conducted between November 2019 and January 2022. The primary outcome was 30-day postoperative morbidity. Data collected included: patient characteristics; comorbidities; and physiological status. Multivariable regression analysis was used to identify independent risk factors for poor outcomes. Data from 2799 children recruited from 80 hospitals were analysed, of which 185 (7%) developed postoperative complications. Children from black and other ́ minority ethnic groups were at significantly higher risk of poor outcomes: OR (95%CI) 4.13 (1.87–9.08), p<0.001 and 2.08 (1.12–3.87), p=0.021, respectively. This finding was independent of socio-economic status and type of appendicitis found on histology.
Other risk factors for complications and are not at all surprising included: Long term health conditions (ASA physical status ≥3) (OR (95%CI) 4.05 (1.70–9.67), p=0.002); preoperative signs of inflammation (raised C-reactive protein (OR 95%CI 1.01 (1.00–1.01), p<0.001); pyrexia (OR (95%CI) 1.77(1.20–2.63), p=0.004); and peri-operative oxygen supplementation (OR (95%CI) 4.20 (1.44–12.24), p=0.009).
Despite the many limitations of the study (small sample size in the racial minority, group, lumping of patients into unconventional racial and ethnic groups, numerous confounding variables and use of an outcome classification scheme developed for adults – the Clavien-Dindo Classification system of surgical complications), the authors are to be commended for taking on the question of health disparity in a nation with a state-sponsored healthcare program. (Indeed, Myron wonders if any of you have ever heard of this classification system?)
The findings of the study were surprising to Myron but not to Bukky and Francis: Specifically, there were higher rates of post-appendectomy complications among Black children compared to their White peers. Because medicine is a microcosm of a larger society, and the UK is a racialized society, health outcomes for minority populations are unfortunately worse than for the majority White population. That is the essence of health disparity which refers to the societal factors that influence the health status of certain populations regardless of their utilization of health services; (2) compounded by the lack of availability and accessibility of health services for “disadvantaged populations,” and by the treatment these populations receive even after they enter the health care system; and (3) they are unjust, unfair, and, most importantly, avoidable.
We encourage future investigators from the UK interested in exploring health disparity questions to be mindful of the many limitations of the report by Sogbodjor et al to avoid generating more questions than answers. Nonetheless, we commend the efforts of this group to shine a much-needed light about pediatric perioperative health disparity in the UK. The fundamental take-away from this report is that health outcomes in so called high income countries are mediated by complex, highly varied systemic factors of which access to health care is a tiny fraction. We must consider upstream factors which are in large part outside the control of health institutions. Put another way, to tackle health disparities, look beyond the shiny walls of health institutions. Fix societal inequities and the other inequities will be ameliorated.
It would be most interesting to explore whether the same results are observed in other European countries with different health systems. I (FV) was surprised to uncover that, in some countries (e.g., in France), patient’s ethnicity cannot be considered for research by Law or is simply not registered in their files. This is probably meant to avoid any racial discrimination but should be changed, if only to help improving quality of care.
What do you think? Did these results surprise or simply depress you? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Sogbodjor LA, Razavi C, Williams K, et al. Risk factors for complications after emergency surgery for paediatric appendicitis: a national prospective observational cohort study. Anaesthesia 2024;79(5):524-534. (In eng). DOI: 10.1111/anae.16184.
2. Zwintscher NP, Steele SR, Martin MJ, Newton CR. The effect of race on outcomes for appendicitis in children: a nationwide analysis. American journal of surgery 2014;207(5):748-53; discussion 753. (In eng). DOI: 10.1016/j.amjsurg.2013.12.020.
3. Mpody C, Willer B, Owusu-Bediako E, Kemper AR, Tobias JD, Nafiu OO. Economic Trends of Racial Disparities in Pediatric Postappendectomy Complications. Pediatrics 2021;148(4) (In eng). DOI: 10.1542/peds.2021-051328.