BACKGROUND

Despite unparalleled advances in perioperative medicine, surgical outcomes remain poor for racial minority patients relative to their white counterparts. Little is known about the excess costs to the health care system related to these disparities.

METHODS

We performed a retrospective analysis of data from the Nationwide Inpatient Sample between 2001 and 2018. We included children younger than 18 years admitted with appendicitis who underwent an appendectomy during their hospital stay. We examined the inflation-adjusted hospital costs attributable to the racial disparities in surgical complications and perforation status, focusing on differences between non-Hispanic white patients and non-Hispanic Black patients.

RESULTS

We included 100 639 children who underwent appendectomy, of whom 89.9% were non-Hispanic white and 10.1% were non-Hispanic Black. Irrespective of perforation status at presentation, surgical complications were consistently higher for Black compared with white children, with no evidence of narrowing of the racial disparity gap over time. Black children consistently incurred higher hospital costs (median difference: $629 [95% confidence interval: $500–$758; P < .01). The total inflation-adjusted hospital costs for Black children were $518 658 984, and $59 372 044 (11.41%) represented the excess because of the racial disparities in perforation rates.

CONCLUSIONS

Although all patients had a progressive decline in post appendectomy complications, Black children consistently had higher rates of complications and perforation, imposing a significant economic burden. We provide an empirical economic argument for sustained efforts to reduce racial disparities in pediatric surgical outcomes, notwithstanding that eliminating these disparities is simply the right thing to do.

What’s Known on This Subject:

Nearly every metric indicates that minority pediatric patients have poor surgical outcomes compared with their white counterparts. However, little is known about the excess costs to the health care system related to these disparities.

What This Study Adds:

In an era of renewed attention to systematic inequalities in the United States, we outlined a two-decade trend of racial disparities in appendectomy outcomes and its attendant economic impact on our health care system.

Despite unparalleled advances in perioperative medicine over the last 20 years, surgical outcomes remain poor for racial minority pediatric patients compared with that of their white counterparts. Indeed, staggering inequalities exist for Black children, compared with white children, in the risk of surgical morbidity and mortality across several pediatric surgical procedures, including abdominal surgery,15  cardiac surgery,69  hematopoietic stem cell transplant,10,11  urologic surgery,1214  neurosurgery,15  pediatric oncology,16  trauma,17  and appendectomy care.1,18  These disparities persist even in apparently healthy children who are expected to develop few complications.19 

Concordant with the disparity in surgical outcomes for Black children is the exponential increase in surgical cost, driven partly by advances in surgical techniques but principally by complications.2023  However, little is known about the excess costs to the health care system related to disparities based on race. Further research or new policies to reduce the disparity gap would likely require a sustained commitment to achieving the desired outcome. Therefore, exploring the costs to the health care system attributable to the racial disparities in surgical outcomes is critically important. Such data should address skeptical counter argument to acting on even the most morally imperative issue, sometimes questioning, “how are we going to pay for it?”

Quantifying the excess costs to the health care system associated with disparities for Black children in surgical outcomes requires selecting a surgical practice that is common, is random in occurrence, and has variability in measured outcomes by race. Pediatric appendectomy fulfills these criteria for several reasons. Between 60 000 to 80 000 appendectomies are performed in the United States annually, making it one of the most common general surgery procedures.2427  Furthermore, Black children undergoing appendectomy have a higher risk of surgical complications, readmissions, and longer hospital stay than their white peers do.28  Because inequities in pediatric surgical outcomes are well documented29  yet their economic ramifications unknown, our overarching goal was to quantify the economic dimensions of disparity in appendectomy outcomes over an 18-year period.

This study builds on our previous work demonstrating disparities between Black and white children undergoing surgery, including the use of do-not-resuscitate orders,30  pain management,31  and risk of death.19,32  To identify interventions to address disparities between Black and white children, we decided a priori to focus specifically on the trends in pediatric appendectomy outcomes and the related health care system costs attributable to disparities in postappendectomy complications among Black and white children.

We performed a retrospective analysis of data from Nationwide Inpatient Sample (NIS) data spanning 18 years, between 2001 and 2018.33  In brief, the NIS is a large, nationally representative hospital inpatient stay database maintained by the Healthcare Cost and Utilization Project (HCUP) and sponsored by the Agency for Healthcare Research and Quality. The NIS collects all-payer data on 7 to 8 million hospital stays annually across participating states, including an array of individual-level sociodemographic characteristics, payer information, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and International Classification of Diseases, 10th Revision, Clinical Modification, (ICD-10-CM), diagnostic and procedural codes. In 2012, the NIS was drawn from a frame of 44 states, representing >95% of the US population.34  In 2018, the NIS comprises data from 47 states plus Washington, DC, covering 97% of the US population. The NIS is a publicly available deidentified data set and does not constitute human subject research.

We studied children younger than 18 years who were admitted with appendicitis and underwent an appendectomy. We used the primary diagnostic codes 540.0, 540.1, 540.9, 541, or 542 (ICD-9), and K35.80, K35.89, K36, K37, K35.2, or K35.3 (ICD-10), to identify children with a final primary diagnosis of appendicitis.35,36  We identified children who underwent appendectomy during the same admission by using the procedure codes 47.01, 47.09, 54.11, 54.21 (ICD-9-CM) and 0DTJ0ZZ and 0DTJ4ZZ (ICD-10).

Our primary outcome was the hospital costs attributable to the racial disparities in surgical complications and perforation rates. Costs and charges have different definitions, with charges referring to the amount billed to patients or payers for a service provided. Specific to the NIS data set, hospital charges refer to the amount, excluding professional and noncovered fees, billed for the entire hospital stay. Hospital costs represent the total amount spent by hospitals to deliver care, including wages, supplies, and utilities. We obtained hospital costs by using hospital-specific cost-to-charge ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services.37  We also inflated the costs to 2018 US dollars using the Consumer Price Index for the gross domestic products.38 

Our primary exposure was the racial disparities in surgical complications and perforation rates defined as the difference in the risk-adjusted rates across racial groups, controlling for sex, age, median income for zip code, location and teaching status of the hospital, insurance status, laparoscopy status, and number of comorbidities. We defined race according to the HCUP data element that follows a categorization based on the 1977 Office of Management and Budget directive (separate groups for Hispanic and 5 non-Hispanic racial groups: white, Black, Asian and Pacific Islander, American Indian or Alaska Native, and other) and included subjects that were either non-Hispanic white or non-Hispanic Black.20  We used ICD-9-CM and ICD-10-CM, diagnosis codes to identify surgical complications, as defined by the Pediatric Health Information System and used in previous studies.3941  The complete list of ICD codes flagged as surgical complications can be found through the children's hospital association Web site.42  In Supplemental Table 3, we include the ICD codes of findings that were flagged as surgical complications in our study population.

We accounted for survey design complexity by incorporating sampling weights according to HCUP recommendations, thereby producing population estimates of proportions and regression coefficients. We estimated the costs attributable to the racial disparities in perforation rates by multiplying the difference in risk-adjusted rates of perforation between Black and white children with the number of perforations in Black and white children and the excess hospitalization costs because of perforation.43  We obtained the risk-adjusted difference in perforation rates between Black and white children using Poisson regression, adjusting for sex, age, median income for zip code, location and teaching status of the hospital, insurance status, laparoscopy status, and number of comorbidities. We obtained the excess hospitalization costs because of perforation using quantile regression, estimating the median difference in costs comparing hospitalization with and without perforation. With this approach, the estimated costs attributable to the racial disparities would reflect the avoidable hospital costs, assuming perforation rates were similar between Black and white children, while adjusting for individual and hospital-level covariates.

We used quantile regression analysis, accounting for intrahospital clustering of costs, with a two-way interaction term between race and discharge year to examine trends in hospital costs and evaluate whether the costs in Black and white children were converging or diverging across years. We chose the quantile regression models because of their appropriateness for skewed health care costs data and asymptotic validity under heteroskedasticity and model misspecification.44  We also examined the trends in surgical complications using Poisson regression models, with an interaction term for race and discharge year.45  To produce stable estimates from the trend analyses, we pooled data into nine 2-year cycles: 2001–2002, 2003–2004, 2005–2006, 2007–2008, 2009–2010, 2011–2012, 2013–2014, 2015–2016, and 2017–2018. We performed all analyses using Stata version 15 (Stata Corp, College Station, TX) and considered a P value <.05 to be statistically significant.

We included 100 639 children who underwent appendectomy between 2001 and 2018, corresponding to a weighted study population of 483 813 children. The study subjects were 89.9% (95% confidence interval [CI]: 89.3% to 90.5%) non-Hispanic white children and 10.1% (95% CI: 9.5% to 10.7%) non-Hispanic Black children. There were no differences between Black and white children regarding sex and age at the time of surgery. Overall, Black children were more likely to be living in the South (51.5% vs 35.8%), belong to families with a lower median income for zip code (<$39 000 per year: 41.9% vs 17.6%), be cared for in urban teaching hospitals (67.5% vs 48.7%), and be enrolled in Medicaid (53.5% vs 24.2%) (Table 1). Black and white children were comparable with regards to the use of laparoscopic surgery and timing of surgery within 48 hours of admission.

TABLE 1

Characteristics of Children <18 Years of Age Who Underwent an Inpatient Appendectomy (2001–2018)

CharacteristicsOverall, Weighed Prevalence, % (95% CI)Non-Hispanic White, Weighed Prevalence, % (95% CI)Non-Hispanic Black, Weighed Prevalence, % (95% CI)
Study population 100 89.9 (89.3 to 90.5) 10.1 (9.5 to 10.7) 
Male sex 60.5 (60.2 to 60.9) 60.2 (59.9 to 60.6) 63.3 (62.3 to 64.3) 
Age, y    
 ≥13 45.7 (44.9 to 46.5) 45.5 (44.6 to 46.4) 47.5 (46.2 to 48.8) 
 6–12 48.2 (47.4 to 48.9) 48.4 (47.7 to 49.2) 45.9 (44.6 to 47.1) 
 ≤5 6.1 (5.9 to 6.4) 6.1 (5.8 to 6.4) 6.6 (6.1 to 7.2) 
Median income for zip code, $    
 >63 000 32.0 (30.1 to 33.9) 33.8 (31.9 to 35.8) 15.3 (13.7 to 17.1) 
 39 000–63 000 48.0 (46.6 to 49.4) 48.6 (47.1 to 50.1) 42.8 (41.0 to 44.6) 
 <39 000 20.0 (19.0 to 21.2) 17.6 (16.5 to 18.7) 41.9 (39.6 to 44.3) 
Insurance status    
 Commercial 65.4 (64.3 to 66.4) 68.5 (67.4 to 69.5) 38.1 (36.5 to 39.8) 
 Medicaid 27.1 (26.2 to 28.1) 24.2 (23.3 to 25.1) 53.5 (51.9 to 55.0) 
 Other 3.5 (3.3 to 3.8) 3.5 (3.3 to 3.8) 3.6 (3.1 to 4.1) 
 None 3.9 (3.7 to 4.2) 3.8 (3.6 to 4.1) 4.8 (4.2 to 5.6) 
Census region    
 Midwest 24.6 (22.3 to 27.1) 24.6 (22.2 to 27.2) 24.8 (21.9 to 28.0) 
 Northeast 19.3 (17.7 to 21.0) 19.8 (18.2 to 21.5) 15.2 (13.0 to 17.8) 
 South 37.4 (34.7 to 40.1) 35.8 (33.1 to 38.5) 51.5 (47.8 to 55.3) 
 West 18.7 (16.9 to 20.6) 19.8 (18.0 to 21.9) 8.4 (7.2 to 9.7) 
Perforated appendicitis 31.4 (30.7 to 32.0) 30.8 (30.1 to 31.4) 36.9 (35.7 to 38.0) 
Laparoscopy 63.7 (62.2 to 65.2) 63.9 (62.3 to 65.4) 62.3 (60.0 to 64.6) 
Surgery within 48 h 98.4 (98.3 to 98.5) 98.6 (98.5 to 98.6) 97.0 (96.5 to 97.4) 
Location and teaching status    
 Rural 14.5 (13.5 to 15.6) 15.4 (14.3 to 16.5) 7.3 (6.2 to 8.6) 
 Urban and nonteaching 34.8 (32.5 to 37.2) 35.9 (33.5 to 38.4) 25.2 (22.7 to 27.9) 
 Urban and teaching 50.6 (48.0 to 53.2) 48.7 (46.0 to 51.4) 67.5 (64.4 to 70.3) 
Year    
 2001–2002 11.3 (10.2 to 12.5) 11.4 (10.3 to 12.6) 10.6 (9.2 to 12.3) 
 2003–2004 11.8 (10.7 to 13.0) 11.7 (10.7 to 12.9) 12.5 (10.5 to 14.8) 
 2005–2006 12.6 (11.3 to 14.1) 12.8 (11.5 to 14.3) 10.9 (9.3 to 12.8) 
 2007–2008 12.9 (11.8 to 14.1) 12.9 (11.8 to 14.1) 12.7 (11.0 to 14.5) 
 2009–2010 14.1 (12.5 to 15.9) 14.3 (12.7 to 16.0) 13.0 (10.9 to 15.4) 
 2011–2012 12.1 (11.1 to 13.2) 12.1 (11.1 to 13.3) 12.0 (10.4 to 13.7) 
 2013–2014 10.0 (9.2 to 10.8) 9.8 (9.0 to 10.7) 11.3 (10.0 to 12.7) 
 2015–2016 8.4 (7.7 to 9.1) 8.2 (7.5 to 8.9) 9.9 (8.8 to 11.2) 
 2017–2018 6.7 (6.2 to 7.4) 6.7 (6.1 to 7.3) 7.1 (6.2 to 8.1) 
CharacteristicsOverall, Weighed Prevalence, % (95% CI)Non-Hispanic White, Weighed Prevalence, % (95% CI)Non-Hispanic Black, Weighed Prevalence, % (95% CI)
Study population 100 89.9 (89.3 to 90.5) 10.1 (9.5 to 10.7) 
Male sex 60.5 (60.2 to 60.9) 60.2 (59.9 to 60.6) 63.3 (62.3 to 64.3) 
Age, y    
 ≥13 45.7 (44.9 to 46.5) 45.5 (44.6 to 46.4) 47.5 (46.2 to 48.8) 
 6–12 48.2 (47.4 to 48.9) 48.4 (47.7 to 49.2) 45.9 (44.6 to 47.1) 
 ≤5 6.1 (5.9 to 6.4) 6.1 (5.8 to 6.4) 6.6 (6.1 to 7.2) 
Median income for zip code, $    
 >63 000 32.0 (30.1 to 33.9) 33.8 (31.9 to 35.8) 15.3 (13.7 to 17.1) 
 39 000–63 000 48.0 (46.6 to 49.4) 48.6 (47.1 to 50.1) 42.8 (41.0 to 44.6) 
 <39 000 20.0 (19.0 to 21.2) 17.6 (16.5 to 18.7) 41.9 (39.6 to 44.3) 
Insurance status    
 Commercial 65.4 (64.3 to 66.4) 68.5 (67.4 to 69.5) 38.1 (36.5 to 39.8) 
 Medicaid 27.1 (26.2 to 28.1) 24.2 (23.3 to 25.1) 53.5 (51.9 to 55.0) 
 Other 3.5 (3.3 to 3.8) 3.5 (3.3 to 3.8) 3.6 (3.1 to 4.1) 
 None 3.9 (3.7 to 4.2) 3.8 (3.6 to 4.1) 4.8 (4.2 to 5.6) 
Census region    
 Midwest 24.6 (22.3 to 27.1) 24.6 (22.2 to 27.2) 24.8 (21.9 to 28.0) 
 Northeast 19.3 (17.7 to 21.0) 19.8 (18.2 to 21.5) 15.2 (13.0 to 17.8) 
 South 37.4 (34.7 to 40.1) 35.8 (33.1 to 38.5) 51.5 (47.8 to 55.3) 
 West 18.7 (16.9 to 20.6) 19.8 (18.0 to 21.9) 8.4 (7.2 to 9.7) 
Perforated appendicitis 31.4 (30.7 to 32.0) 30.8 (30.1 to 31.4) 36.9 (35.7 to 38.0) 
Laparoscopy 63.7 (62.2 to 65.2) 63.9 (62.3 to 65.4) 62.3 (60.0 to 64.6) 
Surgery within 48 h 98.4 (98.3 to 98.5) 98.6 (98.5 to 98.6) 97.0 (96.5 to 97.4) 
Location and teaching status    
 Rural 14.5 (13.5 to 15.6) 15.4 (14.3 to 16.5) 7.3 (6.2 to 8.6) 
 Urban and nonteaching 34.8 (32.5 to 37.2) 35.9 (33.5 to 38.4) 25.2 (22.7 to 27.9) 
 Urban and teaching 50.6 (48.0 to 53.2) 48.7 (46.0 to 51.4) 67.5 (64.4 to 70.3) 
Year    
 2001–2002 11.3 (10.2 to 12.5) 11.4 (10.3 to 12.6) 10.6 (9.2 to 12.3) 
 2003–2004 11.8 (10.7 to 13.0) 11.7 (10.7 to 12.9) 12.5 (10.5 to 14.8) 
 2005–2006 12.6 (11.3 to 14.1) 12.8 (11.5 to 14.3) 10.9 (9.3 to 12.8) 
 2007–2008 12.9 (11.8 to 14.1) 12.9 (11.8 to 14.1) 12.7 (11.0 to 14.5) 
 2009–2010 14.1 (12.5 to 15.9) 14.3 (12.7 to 16.0) 13.0 (10.9 to 15.4) 
 2011–2012 12.1 (11.1 to 13.2) 12.1 (11.1 to 13.3) 12.0 (10.4 to 13.7) 
 2013–2014 10.0 (9.2 to 10.8) 9.8 (9.0 to 10.7) 11.3 (10.0 to 12.7) 
 2015–2016 8.4 (7.7 to 9.1) 8.2 (7.5 to 8.9) 9.9 (8.8 to 11.2) 
 2017–2018 6.7 (6.2 to 7.4) 6.7 (6.1 to 7.3) 7.1 (6.2 to 8.1) 

We retained children admitted for appendicitis and underwent appendectomy during the hospital stay between 2001 and 2018 and were entered in the NIS database.

Figure 1 summarizes the risk-adjusted rates of overall surgical complications. Overall, the rates decreased for both Black and white children over time, but the rates were always higher for Black children. Although the rates of surgical complications were decreasing for both Black and white patients, we found no statistically significant evidence of narrowing of the racial difference in surgical complications over time (adjusted relative risk [RR]: 1.00; 95% CI: 0.97 to 1.03; P = .96). The largest difference in surgical complication rates was observed in 2001–2002, when Black children, compared with their white peers, were estimated to be 63% more likely to develop surgical complications (adjusted RR: 1.63; 95% CI: 1.34 to 1.99; P < .01).

FIGURE 1

Race-specific trends in surgical complications in children who were admitted for appendicitis and underwent appendectomy, controlling for sex, age, median income for zip code, location and teaching status of hospital, insurance status, perforated appendicitis status, laparoscopy status, and number of comorbidities (NIS 2001–2018). Each additional cycle was associated with a relative decrease in the risk of surgical complications in both white (adjusted RR: 0.91; 95% CI: 0.88 to 0.94; P < .01) and Black children (adjusted RR: 0.91; 95% CI: 0.89 to 0.92; P < .01). There was no evidence of narrowing of the disparity gap over time because the 2-way interaction term between cycle and race was not statistically significant at the alpha level of 0.05 (adjusted RR: 1.00; 95% CI: 0.97 to 1.03; P = .96).

FIGURE 1

Race-specific trends in surgical complications in children who were admitted for appendicitis and underwent appendectomy, controlling for sex, age, median income for zip code, location and teaching status of hospital, insurance status, perforated appendicitis status, laparoscopy status, and number of comorbidities (NIS 2001–2018). Each additional cycle was associated with a relative decrease in the risk of surgical complications in both white (adjusted RR: 0.91; 95% CI: 0.88 to 0.94; P < .01) and Black children (adjusted RR: 0.91; 95% CI: 0.89 to 0.92; P < .01). There was no evidence of narrowing of the disparity gap over time because the 2-way interaction term between cycle and race was not statistically significant at the alpha level of 0.05 (adjusted RR: 1.00; 95% CI: 0.97 to 1.03; P = .96).

Close modal

Next, we examined surgical complications by perforated appendicitis status. Expectedly, surgical complication rates were higher for children with a perforated appendicitis (Fig 2). Similar to the pattern for the overall complication rates, the rates of surgical complications decreased for Black and white children over the study period. However, irrespective of perforation status at presentation, surgical complications were consistently higher for Black children versus their white peers throughout the study period (Fig 2).

FIGURE 2

Race-specific trends in surgical complications in children who were admitted for (A) perforated and (B) nonperforated and appendicitis and underwent appendectomy, controlling for sex, age, median income for zip code, census region, location and teaching status of hospital, insurance status, perforated appendicitis status, laparoscopy status, and number of comorbidities (NIS 2001–2018).

FIGURE 2

Race-specific trends in surgical complications in children who were admitted for (A) perforated and (B) nonperforated and appendicitis and underwent appendectomy, controlling for sex, age, median income for zip code, census region, location and teaching status of hospital, insurance status, perforated appendicitis status, laparoscopy status, and number of comorbidities (NIS 2001–2018).

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The median hospital costs for appendectomy have risen steadily and were consistently higher in Black children than in their white peers throughout the study period (adjusted median difference: $629 (95% CI: $500 to $758; P < .01) (Fig 3). The median annual changes in hospital costs were $401 (95% CI: $370 to $432; P < .01) in white children and $383 (95% CI: $332–$435; P < .01) in Black children (Fig 3). However, we found no evidence of narrowing of the racial gap in hospital costs throughout the study period: $−17 (95% CI: $−60 to $26; P = .28) (Fig 3).

FIGURE 3

Race-specific trends in median hospital costs in children who were admitted for appendicitis and underwent appendectomy, controlling for sex, age, median income for zip code, location and teaching status of hospital, insurance status, perforated appendicitis status, laparoscopy status, and number of comorbidities (NIS 2001–2018). Overall, the median hospital costs comparing Black children with white children was $629 (95% CI: $500–$758; P < .01) throughout the study period. The median annual changes in hospital costs were $401 (95% CI: $370 to $432; P < .01) in White children and $383 (95% CI: $332 to $435; P < .01) in Black children. The interaction term between cycle and race was not statistically significant (median difference: −$17; 95% CI: −$60 to $26; P = .28).

FIGURE 3

Race-specific trends in median hospital costs in children who were admitted for appendicitis and underwent appendectomy, controlling for sex, age, median income for zip code, location and teaching status of hospital, insurance status, perforated appendicitis status, laparoscopy status, and number of comorbidities (NIS 2001–2018). Overall, the median hospital costs comparing Black children with white children was $629 (95% CI: $500–$758; P < .01) throughout the study period. The median annual changes in hospital costs were $401 (95% CI: $370 to $432; P < .01) in White children and $383 (95% CI: $332 to $435; P < .01) in Black children. The interaction term between cycle and race was not statistically significant (median difference: −$17; 95% CI: −$60 to $26; P = .28).

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Table 2 displays the hospital costs attributable to the racial disparities in perforation rates. Over the 18-year study period, the total hospital costs for Black children were $518 658 984, and $59 372 044 (11.4%) represented the excess because of the racial disparities. The largest economic impact of the racial disparities occurred in 2015–2016, when $11 969 801 reflects the spending that would have been avoidable if Black and white children had comparable perforation rates.

TABLE 2

Inflation-Adjusted Hospital Costs Attributable to the Racial Disparities in Perforation Rates.

YearRates of Surgical ComplicationsMedian Excess Cost Due to Perforation, $Excess Cost Attributable to the Higher Risk of Perforation in Black Children, $Total Hospital Cost in Black Children, $Fraction of Hospital Cost in Black Children That is Excess, %
White, %Black, %
2001–2002 5.2 8.0 4393 4 130 923 46 556 610 8.9 
2003–2004 5.7 8.8 5185 4 939 751 61 781 049 8.0 
2005–2006 5.1 7.9 5191 4 842 720 57 276 967 8.5 
2007–2008 4.9 7.6 4700 4 433 107 65 855 370 6.7 
2009–2010 3.9 6.0 4324 4 729 631 61 339 210 7.7 
2011–2012 3.5 5.5 5935 7 303 323 60 942 388 12.0 
2013–2014 4.1 6.3 4853 7 591 212 62 302 973 12.2 
2015–2016 3.4 5.3 5245 11 969 801 62 471 128 19.2 
2017–2018 1.8 2.7 3825 9 431 576 40 133 289 23.5 
Total — — — 59 372 044 518 658 984 11.4 
YearRates of Surgical ComplicationsMedian Excess Cost Due to Perforation, $Excess Cost Attributable to the Higher Risk of Perforation in Black Children, $Total Hospital Cost in Black Children, $Fraction of Hospital Cost in Black Children That is Excess, %
White, %Black, %
2001–2002 5.2 8.0 4393 4 130 923 46 556 610 8.9 
2003–2004 5.7 8.8 5185 4 939 751 61 781 049 8.0 
2005–2006 5.1 7.9 5191 4 842 720 57 276 967 8.5 
2007–2008 4.9 7.6 4700 4 433 107 65 855 370 6.7 
2009–2010 3.9 6.0 4324 4 729 631 61 339 210 7.7 
2011–2012 3.5 5.5 5935 7 303 323 60 942 388 12.0 
2013–2014 4.1 6.3 4853 7 591 212 62 302 973 12.2 
2015–2016 3.4 5.3 5245 11 969 801 62 471 128 19.2 
2017–2018 1.8 2.7 3825 9 431 576 40 133 289 23.5 
Total — — — 59 372 044 518 658 984 11.4 

We inflated the costs to 2018 United States dollars using the Consumer Price Index for the gross domestic products. Adjusted for sex, age, median income for zip code, census region, location and teaching status of hospital, insurance status, perforated appendicitis status, laparoscopy status, and number of comorbidities (NIS 2001–2018).

We sought to outline a two-decade trend of disparities for Black children in appendectomy outcomes and its attendant economic impact on our health care system. Although both Black and white children had a progressive decline in appendectomy complications, there was no significant decrease in the disparity gap, leading to Black children consistently having higher rates of complications. These persisting disparities exist even with uncomplicated appendicitis. The excess risk of perforation in Black patients was associated with a significant financial burden to the health care system because of consistently higher costs incurred by Black children.

The persisting disparity gap that is occurring against the overall improvement in surgical complications implies that the progress achieved throughout almost 2 decades did not address the structural racism that may explain the excess risk of surgical complications in Black children. The surgical practice has improved over time with uptake in laparoscopic approach, and several policy changes have encouraged hospitals and providers to enact quality improvement initiatives, including value-based surgical care and Enhanced Recovery After Surgery protocols.46,47  Our findings imply that intervening is not only fair but also likely cost-effective and may procure larger benefits. In an era of renewed attention to systematic inequalities in the United States,48  our study demonstrates the economic impact on our health care system of persisting inequalities in pediatric surgical outcomes. As the most common pediatric abdominal surgical emergency in the United States,28  appendectomy offers a unique opportunity to evaluate value-based care as well as differences across groups in the incidence and economic implications of group-specific excess risk of postoperative complications.

It is intuitive to assume that racial variation in perforation rates is the main contributor to the differential costs of surgery for Black patients. However, even in children with nonperforated appendicitis, Black children compared with white children were more likely to develop surgical complications and incur higher hospital costs. This implies that perforated appendicitis may only partly explain the persisting racial disparities in surgical outcomes and their economic impact on our health care system. On the other hand, it is not realistic to discard the role of presurgical factors that may explain the racial differences in perforation rates. Indeed, acute appendicitis is a “delay-sensitive” condition, meaning that the natural history of the disease in the absence of treatment is predictable and involves progression to perforation, systemic infection, bleeding, and death.49,50  The disparities in appendicitis outcomes may be related to the delay in disease milestones, such as a patient complaint of abdominal pain, parental recognition of condition urgency, initial presentation for care, obtaining appropriate time-sensitive diagnostic laboratories and imaging studies, accurate diagnosis, and then ultimately surgical intervention.25,49,51,52  The need for sustained commitment to reducing the human and economic impact of the racial differences in surgical outcomes implicates everyone, upstream or downstream from surgery.

This study should be interpreted in the context of its limitations. Race can be misclassified in administrative databases. The outcome data are also subject to misclassification bias and coding errors, but this is unlikely to be differential on the basis of child race. This study is focused only on the difference in economic burden between non-Hispanic Black and non-Hispanic white children with appendicitis because of the well-recognized disparities in surgical outcomes.26,53  We also recognize that the study database does not measure pediatric hospital status, which may play a role in surgical complication rates. Furthermore, the NIS does not capture readmission and only captures complications that occur during a single stay. The burden of postsurgical complications also depends on other factors, such as hospital quality and volume, individual surgeon's experience, and other intraoperative variables not available in administrative databases. Additionally, some of the ICD code descriptions lack specificity (eg, “digestive system complications”) Finally, this study was conducted from the perspective of the health care system, so factors such as parental lost productivity, work-related losses, or illness-related school absenteeism are not included.

Compared with non-Hispanic white children, Black children have higher perforation rates of postappendectomy complications, contributing to a higher cost of surgical care for Black children. This disparity has barely changed in the last 2 decades. Although many factors determine surgical outcomes and cost, our estimates underscore the substantial economic consequences of complications-related disparities in the United States and call for targeted efforts to reduce these complications in Black children. To inspire action on even the most morally pressing issues, it is sometimes necessary to spotlight material justification as to why intervention is warranted. We identified a long-standing disparity that requires sustained commitment to reducing the excess risk of surgical complications in Black children that is not only morally but also economically the expedient thing to do.

Dr Mpody helped with the idea conception, study design, critical review of the literature, data acquisition and analyses, writing of the manuscript, and revision; Drs Willer, Owusu-Bediako, and Kemper helped with the study design and interpretation of data and critically reviewed and revised the manuscript; Dr Tobias contributed to the idea conception, oversaw the acquisition and analyses of the data as well as the review of literature, and critically reviewed and revised the manuscript; Dr Nafiu helped with the idea conception, study design, critical review of the literature, data acquisition, manuscript preparation, and revision; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

     
  • CI

    confidence interval

  •  
  • HCUP

    Healthcare Cost and Utilization Project

  •  
  • ICD

    International Classification of Diseases

  •  
  • NIS

    Nationwide Inpatient Sample

  •  
  • RR

    relative risk

1
Zwintscher
NP
,
Steele
SR
,
Martin
MJ
,
Newton
CR
.
The effect of race on outcomes for appendicitis in children: a nationwide analysis
.
Am J Surg
.
2014
;
207
(
5
):
748
753
,
discussion 753
2
Song
YK
,
Nunez Lopez
O
,
Mehta
HB
, et al
.
Race and outcomes in gastroschisis repair: a nationwide analysis
.
J Pediatr Surg
.
2017
;
52
(
11
):
1755
1759
3
Lee
H
,
Lewis
J
,
Schoen
BT
,
Brand
T
,
Ricketts
RR
.
Kasai portoenterostomy: differences related to race
.
J Pediatr Surg
.
2001
;
36
(
8
):
1196
1198
4
Andrews
A
,
Franklin
L
,
Rush
N
,
Witts
R
,
Blanco
D
,
Pall
H
.
Age, sex, health insurance, and race associated with increased rate of emergent pediatric gastrointestinal procedures
.
J Pediatr Gastroenterol Nutr
.
2017
;
64
(
6
):
907
910
5
Mogul
DB
,
Luo
X
,
Chow
EK
, et al
.
Impact of race and ethnicity on outcomes for children waitlisted for pediatric liver transplantation
.
J Pediatr Gastroenterol Nutr
.
2018
;
66
(
3
):
436
441
6
Perryman
M
,
Rivers
PA
.
The effects of location and race on the performance of cardiac procedures
.
J Health Care Finance
.
2007
;
33
(
4
):
79
85
7
Lasa
JJ
,
Cohen
MS
,
Wernovsky
G
,
Pinto
NM
.
Is race associated with morbidity and mortality after hospital discharge among neonates undergoing heart surgery?
Pediatr Cardiol
.
2013
;
34
(
2
):
415
423
8
DiBardino
DJ
,
Pasquali
SK
,
Hirsch
JC
, et al
.
Effect of sex and race on outcome in patients undergoing congenital heart surgery: an analysis of the society of thoracic surgeons congenital heart surgery database
.
Ann Thorac Surg
.
2012
;
94
(
6
):
2054
2059
,
discussion 2059–2060
9
Green
DJ
,
Brooks
MM
,
Burckart
GJ
, et al
.
The influence of race and common genetic variations on outcomes after pediatric heart transplantation
.
Am J Transplant
.
2017
;
17
(
6
):
1525
1539
10
Sano
H
,
Hilinski
JA
,
Applegate
K
,
Chiang
KY
,
Haight
A
,
Qayed
M
, et al
.
African American race is a newly identified risk factor for postengraftment blood stream infections in pediatric allogeneic blood and marrow transplantation
.
Biol Blood Marrow Transplant
.
2017
;
23
(
2
):
357
360
11
Joshua
TV
,
Rizzo
JD
,
Zhang
MJ
, et al
.
Access to hematopoietic stem cell transplantation: effect of race and sex
.
Cancer
.
2010
;
116
(
14
):
3469
3476
12
Amaral
S
,
Patzer
R
.
Disparities, race/ethnicity and access to pediatric kidney transplantation
.
Curr Opin Nephrol Hypertens
.
2013
;
22
(
3
):
336
343
13
Katznelson
S
,
Gjertson
DW
,
Cecka
JM
.
The effect of race and ethnicity on kidney allograft outcome
.
Clin Transpl
.
1995
;
379
394
14
Chu
DI
,
Canning
DA
,
Tasian
GE
.
Race and 30-day morbidity in pediatric urologic surgery
.
Pediatrics
.
2016
;
138
(
1
):
e20154574
15
Greene
WB
,
Terry
RC
,
DeMasi
RA
,
Herrington
RT
.
Effect of race and gender on neurological level in myelomeningocele
.
Dev Med Child Neurol
.
1991
;
33
(
2
):
110
117
16
Williams
LA
,
Frazier
AL
,
Poynter
JN
.
Survival differences by race/ethnicity among children and adolescents diagnosed with germ cell tumors
.
Int J Cancer
.
2020
;
146
(
9
)
2433
2441
17
Hakmeh
W
,
Barker
J
,
Szpunar
SM
,
Fox
JM
,
Irvin
CB
.
Effect of race and insurance on outcome of pediatric trauma
.
Acad Emerg Med
.
2010
;
17
(
8
):
809
812
18
Scarborough
JE
,
Bennett
KM
,
Pappas
TN
.
Racial disparities in outcomes after appendectomy for acute appendicitis
.
Am J Surg
.
2012
;
204
(
1
):
11
17
19
Nafiu
OO
,
Mpody
C
,
Kim
SS
,
Uffman
JC
,
Tobias
JD
.
Race, postoperative complications, and death in apparently healthy children
.
Pediatrics
.
2020
;
146
(
2
):
e20194113
20
Barrett
ML
,
Wier
LM
,
Washington
R
.
Trends in pediatric and adult hospital stays for asthma, 2000
.
Statistical Brief
.
2010
;
169
:
2014
21
Vonlanthen
R
,
Slankamenac
K
,
Breitenstein
S
, et al
.
The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients
.
Ann Surg
.
2011
;
254
(
6
):
907
913
22
Handy
JR
,
Denniston
K
,
Grunkemeier
GL
,
Wu
YX
.
What is the inpatient cost of hospital complications or death after lobectomy or pneumonectomy?
Ann Thorac Surg
.
2011
;
91
(
1
):
234
238
23
Yu
HY
,
Hevelone
ND
,
Lipsitz
SR
,
Kowalczyk
KJ
,
Nguyen
PL
,
Hu
JC
.
Hospital volume, utilization, costs and outcomes of robot-assisted laparoscopic radical prostatectomy
.
J Urol
.
2012
;
187
(
5
):
1632
1637
24
Scott
JW
,
Olufajo
OA
,
Brat
GA
, et al
.
Use of national burden to define operative emergency general surgery
.
JAMA Surg
.
2016
;
151
(
6
):
e160480
25
Goyal
MK
,
Chamberlain
JM
,
Webb
M
, et al;
Pediatric Emergency Care Applied Research Network (PECARN)
.
Racial and ethnic disparities in the delayed diagnosis of appendicitis among children [published online ahead of print September 29, 2020]
.
Acad Emerg Med
.
doi:10.1111/acem.14142
26
Goyal
MK
,
Kuppermann
N
,
Cleary
SD
,
Teach
SJ
,
Chamberlain
JM
.
Racial disparities in pain management of children with appendicitis in emergency departments
.
JAMA Pediatr
.
2015
;
169
(
11
):
996
1002
27
Lee
WH
,
O’Brien
S
,
Skarin
D
, et al;
PREDICT
.
Pediatric abdominal pain in children presenting to the emergency department [published online ahead of print March 12, 2019]
.
Pediatr Emerg Care
.
doi:10.1097/PEC.0000000000001789
28
Benedict
LA
,
Sujka
JA
,
Sobrino
JA
, et al
.
Mitigating disparity in children with acute appendicitis: impact of patient-driven protocols
.
J Pediatr Surg
.
2021
;
56
(
4
):
663
667
29
Heard-Garris
N
,
Onwuka
E
,
Davis
MM
.
Surgical mortality and race as a risk factor: a compass, not a destination
.
Pediatrics
.
2018
;
141
(
2
):
e20173894
30
Mpody
C
,
Humphrey
L
,
Kim
S
,
Tobias
JD
,
Nafiu
OO
.
Racial differences in do-not-resuscitate orders among pediatric surgical patients in the United States
.
J Palliat Med
.
2021
;
24
(
1
):
71
76
31
Nafiu
OO
,
Chimbira
WT
,
Stewart
M
,
Gibbons
K
,
Porter
LK
,
Reynolds
PI
.
Racial differences in the pain management of children recovering from anesthesia
.
Paediatr Anaesth
.
2017
;
27
(
7
):
760
767
32
Willer
BL
,
Mpody
C
,
Tobias
JD
,
Nafiu
OO
.
Racial disparities in failure to rescue following unplanned reoperation in pediatric surgery
.
Anesth Analg
.
2021
;
132
(
3
):
679
685
33
Agency for Healthcare Research and Quality
.
Overview of the national (nationwide) inpatient sample (NIS)
.
Available at: www.hcup-us.ahrq.gov/ nisoverview.jsp. Accessed December 15, 2020
34
Houchens
RL
,
Ross
D
,
Elixhauser
A
.
Using the HCUP National Inpatient Sample to Estimate Trends
.
Rockville, MD
:
Agency for Healthcare Research and Quality
;
2017
35
Bachur
RG
,
Levy
JA
,
Callahan
MJ
,
Rangel
SJ
,
Monuteaux
MC
.
Effect of reduction in the use of computed tomography on clinical outcomes of appendicitis
.
JAMA Pediatr
.
2015
;
169
(
8
):
755
760
36
Bachur
RG
,
Lipsett
SC
,
Monuteaux
MC
.
Outcomes of nonoperative management of uncomplicated appendicitis
.
Pediatrics
.
2017
;
140
(
1
):
e20170048
37
Agency for Healthcare Research and Quality
.
Cost-to-charge ratio for inpatient files
.
Available at: www.hcup-us.ahrq.gov/db/ccr/ip-ccr/ip-ccr.jsp. Accessed November 5, 2020
38
US Department of Commerce Bureau of Economic Analysis
.
National income and product accounts tables. Section 1, domestic product and income
.
Available at: www.bea.gov/iTable/iTable.cfm?ReqID=9&step=1#. Accessed January 12, 2021
39
Canizares
MF
,
Feldman
L
,
Miller
PE
,
Waters
PM
,
Bae
DS
.
Complications and cost of syndactyly reconstruction in the United States: analysis of the pediatric health information system
.
Hand (N Y)
.
2017
;
12
(
4
):
327
334
40
Ares
GJ
,
Helenowski
I
,
Hunter
CJ
,
Madonna
M
,
Reynolds
M
,
Lautz
T
.
Effect of preadmission bowel preparation on outcomes of elective colorectal procedures in young children
.
J Pediatr Surg
.
2018
;
53
(
4
):
704
707
41
Bennett
WE
 Jr
,
Whittam
BM
,
Szymanski
KM
,
Rink
RC
,
Cain
MP
,
Carroll
AE
.
Validated cost comparison of open vs. robotic pyeloplasty in American children’s hospitals
.
J Robot Surg
.
2017
;
11
(
2
):
201
206
43
Chumney
EC
,
Mauldin
PD
,
Simpson
KN
.
Charges for hospital admissions attributable to health disparities for African-American patients, 1998-2002
.
J Natl Med Assoc
.
2006
;
98
(
5
):
690
694
44
Stoltzfus
JC
,
Nishijima
D
,
Melnikow
J
.
Why quantile regression makes good sense for analyzing economic outcomes in medical research
.
Acad Emerg Med
.
2012
;
19
(
7
):
850
851
45
Beer
L
,
Bradley
H
,
Mattson
CL
,
Johnson
CH
,
Hoots
B
,
Shouse
RL
;
Medical Monitoring Project
.
Trends in racial and ethnic disparities in antiretroviral therapy prescription and viral suppression in the United States, 2009-2013
.
J Acquir Immune Defic Syndr
.
2016
;
73
(
4
):
446
453
46
Cheng
H
,
Clymer
JW
,
Po-Han Chen
B
, et al
.
Prolonged operative duration is associated with complications: a systematic review and meta-analysis
.
J Surg Res
.
2018
;
229
:
134
144
47
Yu
MC
,
Feng
YJ
,
Wang
W
,
Fan
W
,
Cheng
HT
,
Xu
J
.
Is laparoscopic appendectomy feasible for complicated appendicitis? A systematic review and meta-analysis
.
Int J Surg
.
2017
;
40
:
187
197
48
Williams
DR
,
Lawrence
JA
,
Davis
BA
.
Racism and health: evidence and needed research
.
Annu Rev Public Health
.
2019
;
40
:
105
125
49
Jablonski
KA
,
Guagliardo
MF
.
Pediatric appendicitis rupture rate: a national indicator of disparities in healthcare access
.
Popul Health Metr
.
2005
;
3
(
1
):
4
50
Bickell
NA
,
Siu
AL
.
Why do delays in treatment occur? Lessons learned from ruptured appendicitis
.
Health Serv Res
.
2001
;
36
(
1
,
pt 1
):
1
5
51
Guagliardo
MF
,
Teach
SJ
,
Huang
ZJ
,
Chamberlain
JM
,
Joseph
JG
.
Racial and ethnic disparities in pediatric appendicitis rupture rate
.
Acad Emerg Med
.
2003
;
10
(
11
):
1218
1227
52
Kokoska
ER
,
Bird
TM
,
Robbins
JM
,
Smith
SD
,
Corsi
JM
,
Campbell
BT
.
Racial disparities in the management of pediatric appenciditis
.
J Surg Res
.
2007
;
137
(
1
):
83
88
53
Haider
S
,
Wood
K
,
Bui
A
,
Leitman
IM
.
Racial disparities in outcomes after common abdominal surgical procedures-the impact of access to a minimally invasive approach
.
J Surg Res
.
2021
;
257
:
85
91

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data