The Child Opportunity Index: Another Dimension of Addressing Perioperative Disparities in Anesthesiology

“As an ever-evolving medical discipline, addressing disparities in healthcare delivery should be an important priority in anesthesiology.”Image: J. P. Rathmell.On a busy day in the operating rooms of a pediatric hospital, a surgical cancellation or patient no-show can seem like an inconsequential occurrence. However, surgical cancellations might have negative repercussions for all involved parties. For a child, a delay in surgical care could lead to poorer outcomes. Parents and guardians who have taken time off from work to bring their child in for a procedure may have lost a day of income.1 An unplanned gap in operating room time can be costly for the healthcare system, and case cancellations have been associated with longer wait times, higher complication rates, and increased costs of care.2 Thus, we should endeavor to identify any addressable contributing factors and address them, particularly if we can identify the highest risk populations. Disparities in perioperative medicine have previously focused primarily on race and ethnicity.3,4 However, other key factors have been demonstrated to affect the health of individuals and populations. Social determinants of health are the conditions in the environment of individuals that affect aspects of health. These factors may include where people live, learn, work, and play. Housing conditions, environmental exposures, access to transportation, and economic instability are some of the key elements of social determinants of health. As anesthesiologists, we may interact with patients daily who have their health negatively affected because of social determinants of health risk factors.5 In this issue of Anesthesiology, Willer et al.6 conducted a retrospective cohort study of children scheduled for ambulatory surgery at a tertiary pediatric hospital between 2017 and 2022. They aimed to determine the association of day-of-surgery cancellation with neighborhood opportunity (as measured by the Child Opportunity Index 2.0) and evaluate the interaction of neighborhood opportunity with race and ethnicity on the risk of day-of-surgery cancellation.6 Willer et al.6 used the patient’s primary address to geographically link the patient to their respective Child Opportunity Index 2.0 value.7 They observed a strong relationship between pediatric day-of-surgery cancellation and neighborhood opportunity and reported evidence of an interaction of Child Opportunity Index with race and ethnicity. The authors concluded that Black children at every level of opportunity had the highest risk of cancellation, suggesting that there are additional factors that render them more vulnerable to neighborhood disadvantage.6 The study by Willer et al.6 is a fine example of the power of using data to answer clinically and socially relevant questions in anesthesiology and perioperative medicine. Although Child Opportunity Index 2.0 as a geographically based social determinant of health measure has been applied extensively in public health and pediatrics for many years, this article is unique in bringing Child Opportunity Index 2.0 to perioperative medicine.8 Studying disparities using geographically based indices for social determinants of health has many advantages, including the opportunity to identify more vulnerable populations that need targeted assistance and to enable a more comprehensive assessment of resources and challenges that exist in the environment that affect childhood opportunity.9 Furthermore, geographically based indices can enable an additional level of comparison of populations across different health systems. However, adopting geographically based measures and applying them to individual perioperative patients requires further work to be conducted in collaboration with spatial scientists, geographers, and public health scientists to ensure that the use of geographically based measures of health is statistically valid and scientifically sound and discussed in the proper context. Some critical areas of using geographically based measures for individual patient analysis include ensuring that every patient’s privacy is protected, demonstrating that Health Insurance Portability and Accountability Act (HIPAA)–compliant methods were used in the geocoding process, and ensuring that maps adhere to well-established scientific standards in cartography. Furthermore, the relationship between geographic indices and the individual patient must be examined carefully over both space and time. Two well-studied statistical concerns in the geographic sciences include considerations of how space and time data are aggregated. Known as the “Modifiable Areal Unit Problem” and the “Modifiable Temporal Unit Problem,” these issues highlight how the analysis and subsequent results can be problematic if a suboptimal scale of geography (census tract vs. ZIP code) is selected to conduct the analysis. Similarly, the statistical implications of time segmentation and aggregation can also significantly affect the analysis. Willer et al.6 performed their analysis using the preferrable the geographic granularity (census tract), yet they included the use of Child Opportunity Index 2.0 data from 2015 for analysis in a data set with patients from 2017 to 2022. Many of these areas of concern are inevitable and may be limited by the available data, methods employed, and technology used. Future researchers should address these same limitations while advancing the study of disparities in anesthesiology and perioperative medicine by harnessing the power of multidisciplinary methods and teams. As an ever-evolving medical discipline, addressing disparities in healthcare delivery should be an important priority in anesthesiology.10 Clinicians may read the findings reported by Willer et al.,6 agree with the results, and nod familiarly to their own practice experience. Some readers may further state that disparities in race, ethnicity, and socioeconomic status, including in perioperative medicine, have already been documented in the literature for years—if not decades. For both types of readers, Willer et al.6 provide additional insight toward understanding health disparities in perioperative medicine. The next crucial step is the development of interventions and perioperative policies that address these disparities. Through effective, equitable, and efficient local, regional, and national policy interventions, healthcare professionals and health systems can ensure that every child, regardless of race, ethnicity, socioeconomic status, or where they are living, can receive the care they deserve. Willer et al.6 should be commended for advancing the study of health disparities in perioperative medicine through the study of race, ethnicity, and childhood opportunity. Each study of disparities in health and healthcare delivery enables a better understanding of the areas where our care can improve individually and systematically. This study and others like it serve as an important starting point for developing evidence-based interventions and scientifically demonstrating reductions in health disparities.11 Research Support Support was provided solely from institutional and/or departmental sources. Competing Interests Dr. Tan receives research grant funding from the Anesthesia Patient Safety Foundation (Rochester, Minnesota), the Foundation for Anesthesia Education and Research (Schaumburg, Illinois), and the Southern California Environmental Health Sciences Center (Los Angeles, California). Dr. Tan is a consultant for Edwards Lifesciences (Irvine, California) and GE HealthCare (Chicago, Illinois). Dr. Simpao is an associate editor for Anesthesiology and Pediatric Anesthesia. Dr. Garcia-Marcinkiewicz receives research grant funding from the Anesthesia Patient Safety Foundation and is an editor for Pediatric Anesthesia.