Black children consistently have more medical complications during appendectomies than their white peers, including higher rates of “perforated” or burst appendixes. That not only leads to extended hospital stays for the children, but it’s costing the U.S. health care system millions.
Over the past two decades alone, that racial disparity has added up to an estimated $59 million in avoidable costs due to the excess rate of perforations, according to a study published Thursday in Pediatrics.
While racial disparities in surgical outcomes are longstanding, the new study is the first to put a price tag on the problem in pediatric appendectomies.
From 2001 to 2018, hospitals incurred an average cost of $629 more per patient treating Black appendectomy patients than white ones, largely due to complications from burst appendixes, the study found. Some of that might be explained by unequal access to care and other socioeconomic factors that could have worsened their conditions on arrival, but even when Black and white patients showed up in the same stage of appendicitis, Black children were more likely than white children to experience complications once hospitalized, the study says.
Complications in the operating room can mean the difference between a child being discharged the same day and a child spending days in the hospital on antibiotics. All of that makes treating a basic condition more expensive than it needs to be, said lead author Christian Mpody, a researcher in the Department of Anesthesiology and Pain Medicine at Nationwide Children’s Hospital in Columbus, Ohio.
“We are not comparing, we are not equalizing the human cost to the economic cost. We cannot compare that,” he said. “We are providing an empirical economic argument.”
Still, Mpody’s research does not account for other, harder-to-measure costs, like the reduced productivity of parents caring for their sick children, or the days children are absent from school. And the study does not calculate how costs incurred by the hospital make their way down to patients.
Even if there were no fiscal consequences, Mpody added, “eliminating disparity would always be the right thing to do.”
Mpody said he and his colleagues chose to look at appendectomies because they are common (60,000 to 80,000 per year in the U.S.) and random.
They studied a randomly selected pool of 100,639 children — 10% of them non-Hispanic Black and 90% white — from across the United States who received appendectomies between 2001 and 2018. The rate of surgical complications declined for both groups during the study period, from 8% to 2.7% for Black children and from 5.2% to 1.8% for white children. But there was no statistically significant narrowing of the racial difference over that time, the authors said.
The research was limited to these racial groups because there is “clear and consistent” evidence of disparities between them, Mpody said. Black children have a higher risk of surgical morbidity and mortality than white children in numerous surgeries, including heart surgery, neurosurgery, oncology and abdominal surgery.
If, as Mpody hypothesized, they found a racial disparity gap in outcomes and costs of appendectomies, that data could be used to make the case for wider, systemic change to address inequities. The gap was evident in the data: although complications overall became less frequent for appendectomies during the two decades, “the rates were always higher for Black children.”
“We know how to treat appendicitis, and there shouldn’t be inequities in these outcomes but there are,” said Laurie Zephyrin, vice president of health system equity at the Commonwealth Fund, a private foundation that funds independent health care research.
Studies like Mpody’s are critical in addressing unequal outcomes, said Zephyrin, who spent years leading systemic change efforts in national health systems. Once health care providers have reliable data on patient outcomes and care, they can then drill down to figure out why inequities exist, who is most affected by disparities, and start on the path toward fixing them.
“You can’t address them unless you know where they are,” she said. “So, for this study, this should inspire health care system leaders to say, ‘Hey, let me look at my pediatric quality data.’”
Health systems can save money by addressing gaps like the ones Mpody’s study highlights, then use that money to invest in promoting racial equity, Zephyrin said.
Maya Ragavan, an assistant professor of pediatrics at the University of Pittsburgh, said it was important for the new study to show how, over a period of time, the gap between Black children and white children receiving appendectomies has not budged. And it’s not limited to one system or provider.
“This paper acknowledges that documentation is not enough,” she said. “The disparity has been called out but then it’s limited to that. [Document it] and then call out that it’s due to racism, that it’s due to inequity, that it’s due to historical mistrust and trauma that marginalized communities have experienced by health care.”
Mpody said his next step is to figure out what is happening in hospitals to cause complications and unequal outcomes. That study is in the works.
STAT has received a grant from the Commonwealth Fund to report on health inequities.
Isabella is the inaugural recipient of the Sharon Begley-STAT Science Reporting Fellowship.