Racial and Ethnic Disparity Hampers Kids' Sepsis Survival

Black children have not benefited as much from recent declines in sepsis mortality as other groups, a national database showed.

From 2009 to 2018, admission rates for sepsis rose from 42.5 to 49.4 cases per 1,000 hospitalizations, while mortality rates dropped from 7.9% to 5.0% (both P<0.001 for trend), reported Peyman Benharash, MD, of the University of California Los Angeles, and colleagues, writing in a research letter in JAMA Pediatrics.

However, adjusted multivariable regression analysis showed that Black sepsis patients had 12% higher risk of mortality than white patients (adjusted OR 1.12, 95% CI 1.04-1.20; P=0.003). No significant difference was observed between white and Hispanic or Asian children.

One key factor appeared to be prevalence of complex chronic conditions, which were more common for Black and Hispanic children compared with white sepsis patients and were linked to mortality risk. For example, cardiac disease prevalence per 1,000 sepsis hospitalizations were 15.3 and 15.4 versus 14.3, for the three groups respectively, which held a relative 89% elevated risk of mortality (all comparisons P<0.001).

At the same time, Benharash's group didn't discount the potential impact of biases and structural racism.

"Implicit racial biases alter patient-clinician decision-making and may be exacerbated in the emergent context of sepsis," the researchers noted. "Further investigation is needed to elucidate underlying structural factors embedded in the health care system."

They cited a 2019 single-institution study in Pediatrics that showed white children were 2.4 times more likely to have a second electronic alert and 40% more likely to have the sepsis pathway activated than were Black children overall. They were also 3.4-fold more likely to be treated for sepsis when diagnosis was left to clinical judgment alone without assistance from an electronic alert system.

Severe sepsis is a leading cause of death in kids around the world, Benharash's group noted. Following the start of the Surviving Sepsis Campaign in 2001, sepsis-related deaths among children in the U.S. have substantially declined. However, racial and ethnic disparities still exist despite such efforts. A prior study found Black children were at 19% higher risk of sepsis-related death than were white children.

For this cross-sectional study, Benharash and colleagues retrospectively examined National Inpatient Sample data on 476,017 pediatric patients who were hospitalized for sepsis from 2009 to 2018. Cases were identified by either ICD-9 or ICD-10 diagnostic codes. Mortality rates were stratified by race and ethnicity, then adjusted for demographics, complex chronic conditions, income, transfer status, year of admission, and hospital location, among other factors.

The mean patient age was 6 years, and 54% of sepsis patients were boys. Most were white (47.3%), followed by Hispanic (22.5%), and Black (19.5%) patients.

Throughout the decade, risk-adjusted mortality rates continued to show significant disparity between Black and white pediatric patients, while mortality rates remained comparable among Asian, Hispanic, and white patients.

As to the overall downward trend in sepsis mortality, the researchers wrote: "More timely recognition of sepsis through initiatives, such as Surviving Sepsis Campaign and Pediatric Early Warning Scores, may have been a factor."

A higher risk of mortality was associated with complex chronic conditions of neuromuscular disease (adjusted OR 2.26, 95% CI 2.10-2.43) and cardiac disorders (adjusted OR 1.89, 95% CI 1.77-2.02).

The authors acknowledged several limitations, including the use of administrative data. Although this study used the largest all-payer data source to augment generalization, cultural differences were not accounted for in the end-of-life preferences of patients.

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