Neighborhood Opportunity and Delays After Day-of-Surgery Cancellations: A Hidden Driver of Pediatric Surgical Inequity

BACKGROUND: Day-of-surgery cancelations (DOSCs) are common in pediatric care and disproportionately affect socially disadvantaged families. However, disparities in post-cancelation care trajectories, including timeliness of rescheduling and risk of repeat cancelation remain poorly characterized. This study evaluated the association between neighborhood opportunity (a composite measure of neighborhood-level resources that support child development, including education, health/environment, and socioeconomic conditions) and outcomes following a DOSC. METHODS: We conducted a retrospective cohort study of children (<18 years) who experienced a DOSC at a tertiary pediatric hospital between January 1, 2017, and June 30, 2024. The primary exposure was neighborhood opportunity, measured using the Child Opportunity Index (COI) 3.0 and categorized into national quintiles. The primary outcome was procedure completion status within 12 months of the original scheduled date (completed/not completed). Time-to-event methods were used to evaluate differences in the rate of procedure completion over time across COI quintiles; with non-completion censored at 12 months. The secondary outcome was additional cancelations (yes/no). Cox proportional hazards models with a time-varying effect for COI (COI × log time) estimated adjusted hazard ratios (HRs) for completion and modified Poisson regression estimated relative risks (RRs) of repeat cancelation. RESULTS: Among 7015 patients who experienced an index DOSC, the median age was 5 (IQR: 3-8) years, and 56.6% (3969/7015) were male. Completion differed across neighborhood opportunity (log-rank P = .02). In time-to-event analyses, no early differences were observed after cancelation; however, disparities emerged over time, with higher completion rates in neighborhoods with less than very high opportunity by 90 days that persisted through 180 days. Repeat cancelations occurred in 8.2% (565/6896) of patients and were more common among children from low (adjusted RR: 1.40, 95% CI, 1.03-1.92) and very low (aRR: 1.51, 95% CI, 1.10-2.07) opportunity neighborhoods. CONCLUSIONS: Neighborhood opportunity was not strongly associated with overall procedure completion within 12 months but was associated with differences in the timing of completion and patterns of repeat cancelation. Children from lower-opportunity neighborhoods were more likely to experience repeat cancelations and delayed early completion. Measuring the timing of completion may represent a novel equity metric for perioperative quality improvement. Interventions such as social risk screening and automated rescheduling may help reduce inequities in post-cancelation care pathways.