O2147: Assessing the Impact of Neighborhood and Built Environment on Pediatric Perioperative Care: A Systematic Review of the Literature

Background: The importance of equitable surgical care and the role of social determinants of health (SDOH) has gained attention in recent years. Neighborhood and built environment encompass one key area of SDOH, according to Healthy People 2030. While several area-level indices have been developed to better understand the multidimensional social risk associated with neighborhood and built environment, there is a lack of standardization between studies. We sought to systematically review the literature for area-level deprivation indices and compare their utility for assessment of pediatric perioperative care.

Methods: An electronic search was conducted using PubMed, Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print, PsycInfo, and an artificial intelligence literature search tool (1/2013 – 2/2023). Inclusion required pediatric patients in the U.S. who had undergone a surgical procedure and the use of an area-level deprivation metric to assess perioperative care. Extraction domains included study, patient, and procedure characteristics. Study quality was assessed using the NIH Quality Assessment tool for Observational Cohort or Cross-Sectional Studies.

Results: Of 196 studies, 27 retrospective studies were included (Figure 1). Area deprivation index (ADI) was associated with increased likelihood of complicated appendicitis, increased length of stay (LOS) and hospital costs, missing pediatric surgery clinic appointments, but not postoperative complications or surgical site infections. Childhood opportunity index (COI) was associated with delays from anterior cruciate ligament (ACL) injury to surgical repair, increased LOS, hospital costs, risk of reintervention, and risk of late death following cardiac surgery. Social vulnerability index (SVI) was associated with serious postoperative complications and likelihood of readmission, but not with elective vs. emergent procedures or rates of testicular torsion or orchiectomy. Neighborhood deprivation index (NDI) was associated with transplant rejection and rate of graft loss in one study, but not with mortality or graft failure in another. For cardiac transplant, neighborhood socioeconomic status (nSES) was associated with overall 1A exception listing, long-term medical treatment of rejection, and medical non-adherence. Associations of nSES with mortality rates, hospital costs, LOS, and readmissions differed between studies. Quality assessments ranged from “Good” to “Fair” for all studies (Figure 2).

Conclusion: Understanding how SDOH impact outcomes after surgery in pediatric patients is critical. ADI is the most consistent and most commonly accepted area-level index. It is also the most granular index, as it uses Census Block Groups (600-3000 people). COI is less granular (Census Tract, 1200-8000 people), but incorporates pediatric-specific predictors of social risk. Results with SVI, NDI, and nSES were inconsistent. While each index has strengths and limitations, standardization on ideal metric(s) for the pediatric surgical population will help build the inferential power needed to move from understanding the role SDOH play in healthcare outcomes to building meaningful interventions that move the needle towards equity in pediatric surgical care.