Using the Social Vulnerability Index to Examine Demographics and Disparities in Surgical Outcomes in Pediatric Trauma Patients

Background: The rates of complications following surgery in the United States are known to be higher among patients with lower socioeconomic status. Many studies highlighting inequality in surgical outcomes focus on a narrow definition of social determinants of health, often using single variables in isolation. The Social Vulnerability Index (SVI) is a composite measure formulated by the Centers for Disease Control and Prevention (CDC) that is geocoded at the census tract level yielding a percentile ranking. SVI is comprised of four categories that contribute to population-level social vulnerability. While originally developed as a tool to predict disaster preparedness, it has the potential to identify target populations at risk of postoperative surgical morbidity. We hypothesized that high SVI percentiles will be correlated with higher morbidity following surgery for pediatric trauma patients.

Methods: All highest and intermediate level pediatric trauma activations ( < 18 years old) who underwent surgery during their initial hospitalization from January 2010-December 2020 at our institution were included for analysis. Patients were geocoded to identify their census tract of residence and estimated SVI, and subsequently stratified into low SVI ( <70th percentile) and high SVI (>70th percentile) groups. Demographics, clinical information, and surgical outcomes [hospital length of stay (LOS), intensive care unit (ICU) LOS, surgical site infection (SSI), pneumonia, urinary tract infection (UTI), deep vein thrombosis (DVT), central line associated blood stream infection (CLABSI), and mortality] were obtained and compared between groups using Kruskal-Wallis and Fisher’s exact tests.

Results: A total of 355 pediatric trauma patients required surgery during their initial hospital admission and were included for analysis. Of these, 21.4% (76) had high SVI percentiles, while 78.6% (279) had low SVI percentiles. Patients with high SVI percentiles were more likely to have government insurance (73.7% vs 37.2%, p<0.001), be of minority race (49.8% vs 19.1%, p<0.001), and present with a penetrating mechanism of injury (32.9% vs. 19.7%, p=0.007) compared to those with low SVI percentiles (Table 1). When evaluating surgical morbidity, there was a higher incidence of postoperative SSI in the high SVI group compared to the low SVI group (3.9% vs. 0.4%, p=0.03). There were no significant differences in other surgical outcomes or mortality between the two groups. Full results are highlighted in Table 2.

Conclusion: Pediatric trauma patients who underwent surgery during their initial hospitalization with high SVI percentiles were more likely to have government insurance, be of minority race, present with penetrating mechanisms of injury, and develop postoperative SSIs compared to those with low SVI percentiles. SVI has the potential to examine healthcare disparities in pediatric trauma patients and identify discrete at-risk target populations for intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.