Association of Racial Disparities With In-Hospital Outcomes in Severe Bronchopulmonary Dysplasia

Medical and social factors associated with prolonged length of stay for chronically ventilated children

OBJECTIVES

This study seeks to determine the overall and post-intensive care unit (ICU) length of stay (LOS) for children with tracheostomies and chronic mechanical ventilation. We hypothesized that medical and social factors would be associated with prolonged LOS.

STUDY DESIGN

This single-center retrospective review included children who were discharged after initiation of chronic ventilation via tracheostomy over an 8-year period (2015-2022). Patients were divided into two groups for analysis, those who had been previously home before admission (HBA) and those who had not (Not HBA). Medical and social determinants of health (SDOH) data were obtained from the electronic medical record for univariate and multivariable analyses.

RESULTS

A total of 161 patients were included. HBA subjects (n = 52) were expectedly older at the time of tracheostomy. Not HBA subjects (n = 109) were more likely to be born prematurely and have sequelae of premature birth. Overall and post-ICU LOS increased for both groups during the study period. In the HBA subgroup, congenital heart disease and younger age were associated with longer overall LOS with these factors and the absence of gastric fundoplication being associated with longer post-ICU LOS. For Not HBA patients, younger age, pulmonary hypertension, seizures, and several SDOH were associated with longer overall LOS, whereas only SDOH were associated with a longer post-ICU LOS.

CONCLUSIONS

Overall and post-ICU LOS for all children hospitalized for tracheostomy and chronic mechanical ventilation are increasing. Prolonged LOS is significantly associated with several medical factors and SDOH.

Need for Gastrostomy Tube in Periviable Infants

OBJECTIVE

 We sought to identify clinical and demographic factors associated with gastrostomy tube (g-tube) placement in periviable infants.

STUDY DESIGN

 We conducted a single-center retrospective cohort study of live-born infants between 22 and 25 weeks' gestation. Infants not actively resuscitated and those with congenital anomalies were excluded from analysis.

RESULTS

 Of the 243 infants included, 158 survived until discharge. Of those that survived to discharge, 35 required g-tube prior to discharge. Maternal race/ethnicity (p = 0.006), intraventricular hemorrhage (p = 0.013), periventricular leukomalacia (p = 0.003), bronchopulmonary dysplasia (BPD; p ≤ 0.001), and singleton gestation (p = 0.009) were associated with need for gastrostomy. In a multivariable logistic regression, maternal Black race (Odds Ratio [OR] = 2.88; 95% confidence interval [CI]: 1.11-7.47; p = 0.029), singleton gestation (OR = 3.99; 95% CI: 1.28-12.4; p = 0.017) and BPD (zero g-tube placement in the no BPD arm; p ≤ 0.001) were associated with need for g-tube.

CONCLUSION

 A high percentage of periviable infants surviving until discharge require g-tube at our institution. In this single-center retrospective study, we noted that maternal Black race, singleton gestation, and BPD were associated with increased risk for g-tube placement in infants born between 22 and 25 weeks' gestation. The finding of increased risk with maternal Black race is consistent with previous reports of racial/ethnic disparities in preterm morbidities. Additional studies examining factors associated with successful achievement of oral feedings in preterm infants are necessary and will inform future efforts to advance equity in newborn health.

KEY POINTS

· BPD, singleton birth, and Black race are associated with need for g-tube in periviable infants.. · Severe intraventricular hemorrhage is associated with increased mortality or g-tube placement in periviable infants.. · Further investigation into the relationship between maternal race and g-tube placement is warranted..

Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is a chronic lung disease, associated with premature birth, that arises during the infantile period. It is an evolving disease process with an unchanged incidence due to advancements in neonatal care which allow for the survival of premature infants of lower gestational ages and birth weights. Currently, there are few effective interventions to prevent BPD. However, careful attention to BPD phenotypes and comprehensive care provided by an interdisciplinary team have improved care. Interventions early in the disease course hold promise for improving long-term survival and outcomes in adulthood for this high-risk population.

Methodologic considerations in estimating racial disparity of mortality among very preterm infants

This review explores methodological considerations in estimating racial disparities in mortality among very preterm infants (VPIs). Significant methodological variations are evident across studies, potentially affecting the estimated mortality rates of VPIs across racial groups and influencing the perceived direction and magnitude of racial disparities. Key methodological approaches include the birth-based approach versus the fetuses-at-risk approach, with each offering distinct insights depending on the specific research questions posed. Cohort selection and the decision for crude versus adjusted comparison are also critical elements that shape the outcomes and interpretations of these studies. This review underscores the importance of careful methodological planning and highlights that no single approach is definitively superior; rather, each has its strengths and limitations depending on the research objectives. The findings suggest that adjusting the methodological approach to align with specific research questions and contexts is essential for accurately assessing and addressing racial disparities in neonatal mortality. IMPACT: Elucidates the impact of methodological choices on perceived racial disparities in neonatal mortality. Offers a comprehensive comparison of birth-based vs. fetuses-at-risk approaches in the context of racial disparity research. Provides guidance on the cohort selection and adjustment criteria critical for interpreting studies on racial disparities in very preterm infant mortality.

Follow the citations: Tracing pathways of "race as biology" assumptions in medical algorithms in eGFR and spirometry

Despite overwhelming evidence to the contrary, the concept of 'race' as a biological unit continues to persist in various scientific disciplines, notably in the field of medicine. This paper explores the persistence of 'race as biology' in medical research via examining select citational practices that have perpetuated this problematic concept. Citations serve as a cornerstone in scientific literature, signifying reliability and expert affirmation. By analyzing citation threads and historical patterns, we aim to shed light on the creation and perpetuation of false scientific truths and their impact on medical research, training, and practice. We focus on two prominent examples, eGFR and Spirometry, and trace key articles' citational histories, highlighting the flawed evidence in support of racial corrections in medical assessments. The eGFR equation incorporates 'race' as a factor based on the erroneous belief that Black individuals have higher muscle mass than white individuals. Our analysis reveals that key cited sources for this belief lack robust and well-developed datasets. Similarly, Spirometry measurements incorporate racial correction factors, relying on questionable evidence dating back to the Civil War era. Citations serve as a cornerstone in scientific literature, signifying reliability and expert affirmation. They play a crucial role in shaping theoretical positions and validating data and assumed knowledge. Evaluating citation threads and key articles consistently referenced over time can reveal how falsehoods and erroneous assertions are constructed and maintained in scientific fields. This study underscores the need for critical examination of citational practices in medical research and urges a shift toward a more cautious approach when citing sources that support 'race as biology.' The paper calls for a reevaluation of pedagogical approaches and assigned readings in medical education to prioritize an anti-racist perspective in future research endeavors.

Respiratory culture growth and 3-years lung health outcomes in children with bronchopulmonary dysplasia and tracheostomies

BACKGROUND

While bacteria identification on respiratory cultures is associated with poor short-term outcomes in children with bronchopulmonary dysplasia (BPD) and tracheostomies, the influence on longer-term respiratory support needs remains unknown.

OBJECTIVE

To determine if respiratory culture growth of pathogenic organisms is associated with ongoing need for respiratory support, decannulation, and death at 3 years posttracheostomy placement in children with BPD and tracheostomies.

METHODS

This single center, retrospective cohort study included infants and children with BPD and tracheostomies placed 2010-2018 and ≥1 respiratory culture obtained in 36 months posttracheostomy. Primary predictor was any pathogen identified on respiratory culture. Additional predictors were any Pseudomonas aeruginosa and chronic P. aeruginosa identification. Outcomes included continued use of respiratory support (e.g., oxygen, positive pressure), decannulation, and death at 3 years posttracheostomy. We used Poisson regression models to examine the relationship between respiratory organisms and outcomes, controlling for patient-level covariates and within-patient clustering.

RESULTS

Among 170 children, 59.4% had a pathogen identified, 28.8% ever had P. aeruginosa, and 3.5% had chronic P. aeruginosa. At 3 years, 33.1% of alive children required ongoing respiratory support and 24.8% achieved decannulation; 18.9% were deceased. In adjusted analysis, any pathogen and P. aeruginosa were not associated with ongoing respiratory support or mortality. However, P. aeruginosa was associated with decreased decannulation probability (adjusted risk ratio 0.48, 95% CI 0.23-0.98). Chronic P. aeruginosa was associated with lower survival probability.

CONCLUSION

Our findings suggest that respiratory pathogens including P. aeruginosa may not promote long-term respiratory dysfunction, but identification of P. aeruginosa may delay decannulation.

The association of maternal country/region of origin and nativity with infant mortality rate among Hispanic preterm infants

OBJECTIVES

Among US-born preterm infants of Hispanic mothers, we analyzed the unadjusted and adjusted infant mortality rate (IMR) by country/region of origin and maternal nativity status.

STUDY DESIGN

Using linked national US birth and death certificate data (2005-2014), we examined preterm infants of Hispanic mothers by subgroup and nativity. Clinical and sociodemographic covariates were included and the main outcome was death in the first year of life.

RESULTS

In our cohort of 891,216 preterm Hispanic infants, we demonstrated different rates of infant mortality by country and region of origin, but no difference between infants of Hispanic mothers who were US vs. foreign-born.

CONCLUSION

These findings highlight the need to disaggregate the heterogenous Hispanic birthing population into regional and national origin groups to better understand unique factors associated with adverse perinatal outcomes in order to develop more targeted interventions for these subgroups.

To Trach or Not To Trach: Long-term Tracheostomy Outcomes in Infants with BPD

See Bonus NeoBriefs videos and downloadable teaching slides Infants born preterm who are diagnosed with bronchopulmonary dysplasia (BPD) demonstrate a wide spectrum of illness severity. For infants with the most severe forms of BPD, safe discharge from the hospital may only be possible by providing long-term ventilation via a surgically placed tracheostomy. Though tracheostomy placement in infants with BPD is infrequent, recent reports suggest that rates of tracheostomy placement are increasing in this population. Even though there are known respiratory and neurodevelopmental risks associated with tracheostomy placement, no evidence-based criteria or consensus clinical practice guidelines exist to inform tracheostomy placement in this growing and vulnerable population. An incomplete knowledge of long-term post-tracheostomy outcomes in infants with BPD may unduly bias medical decision-making and family counseling regarding tracheostomy placement. This review aims to summarize our current knowledge of the epidemiology and long-term outcomes of tracheostomy placement in infants with BPD to provide a family-centered framework for tracheostomy counseling.

Tracheostomy in Severe Bronchopulmonary Dysplasia-How to Decide in the Absence of Evidence

Infants with the most severe forms of bronchopulmonary dysplasia (BPD) may require long-term invasive positive pressure ventilation for survival, therefore necessitating tracheostomy. Although life-saving, tracheostomy has also been associated with high mortality, postoperative complications, high readmission rates, neurodevelopmental impairment, and significant caregiver burden, making it a highly complex and challenging decision. However, for some infants tracheostomy may be necessary for survival and the only way to facilitate a timely and safe transition home. The specific indications for tracheostomy and the timing of the procedure in infants with severe BPD are currently unknown. Hence, centers and clinicians display broad variations in practice with regard to tracheostomy, which presents barriers to designing evidence-generating studies and establishing a consensus approach. As the incidence of severe BPD continues to rise, the question remains, how do we decide on tracheostomy to provide optimal outcomes for these patients?

Racial and Ethnic Disparities in Sudden Unexpected Infant Death Among US Infants Born Preterm

OBJECTIVE

To investigate among US infants born at <37 weeks gestation (a) racial and ethnic disparities in sudden unexpected infant death (SUID) and (b) state variation in SUID rates and non-Hispanic Black (NHB)-non-Hispanic White (NHW) SUID disparity ratio.

METHODS

In this retrospective cohort analysis of linked birth and death certificates from 50 states from 2005 to 2014, SUID was defined by the following International Classification of Diseases, 9th or 10th edition, codes listed on death certificates: (7980, R95 or Recode 135; ASSB: E913, W75 or Recode 146; Unknown: 7999 R99 or Recode 134). Multivariable models were used to assess the independent association between maternal race and ethnicity and SUID, adjusting for several maternal and infant characteristics. The NHB-NHW SUID disparity ratios were calculated for each state.

RESULTS

Among 4 086 504 preterm infants born during the study period, 8096 infants (0.2% or 2.0 per 1000 live births) experienced SUID. State variation in SUID ranged from the lowest rate of 0.82 per 1000 live births in Vermont to the highest rate of 3.87 per 1000 live births in Mississippi. Unadjusted SUID rates across racial and ethnic groups varied from 0.69 (Asian/Pacific Islander) to 3.51 (NHB) per 1000 live births. In the adjusted analysis, compared with NHW infants, NHB and Alaska Native/American Indian preterm infants had greater odds of SUID (aOR, 1.5;[95% CI, 1.42-1.59] and aOR, 1.44 [95% CI, 1.21-1.72]) with varying magnitude of SUID rates and NHB-NHW disparities across states.

CONCLUSIONS

Significant racial and ethnic disparities in SUID among preterm infants exist with variation across US states. Additional research to identify the drivers of these disparities within and across states is needed.

Racial and Ethnic Disparities in Outcomes Among Newborns with Congenital Diaphragmatic Hernia

Importance

There is some data to suggest that racial and ethnic minority infants with congenital diaphragmatic hernia (CDH) have poorer clinical outcomes.

Objective

To determine what patient- and institutional-level factors are associated with racial and ethnic differences in CDH mortality.

Design, Setting, and Participants

Multicenter cohort study of 49 US children's hospitals using the Pediatric Health Information System database from January 1, 2015, to December 31, 2020. Participants were patients with CDH admitted on day of life 0 who underwent surgical repair. Patient race and ethnicity were guardian-reported vs hospital assigned as Black, Hispanic (White or Black), or White. Data were analyzed from August 2021 to March 2022.

Exposures

Patient race and ethnicity: (1) White vs Black and (2) White vs Hispanic; and institutional-level diversity (as defined by the percentage of Black and Hispanic patients with CDH at each hospital): (1) 30% or less, (2) 31% to 40%, and (3) more than 40%.

Main Outcomes and Measures

The primary outcomes were in-hospital and 60-day mortality. The study hypothesized that hospitals managing a more racially and ethnically diverse population of patients with CDH would be associated with lower mortality among Black and Hispanic infants.

Results

Among 1565 infants, 188 (12%), 306 (20%), and 1071 (68%) were Black, Hispanic, and White, respectively. Compared with White infants, Black infants had significantly lower gestational ages (mean [SD], White: 37.6 [2] weeks vs Black: 36.6 [3] weeks; difference, 1 week; 95% CI for difference, 0.6-1.4; P < .001), lower birthweights (White: 3.0 [1.0] kg vs Black: 2.7 [1.0] kg; difference, 0.3 kg; 95% CI for difference, 0.2-0.4; P < .001), and higher extracorporeal life support use (White: 316 patients [30%] vs Black: 69 patients [37%]; χ21 = 3.9; P = .05). Black infants had higher 60-day (White: 99 patients [9%] vs Black: 29 patients [15%]; χ21 = 6.7; P = .01) and in-hospital (White: 133 patients [12%] vs Black: 40 patients [21%]; χ21 = 10.6; P = .001) mortality . There were no mortality differences in Hispanic patients compared with White patients. On regression analyses, institutional diversity of 31% to 40% in Black patients (hazard ratio [HR], 0.17; 95% CI, 0.04-0.78; P = .02) and diversity greater than 40% in Hispanic patients (HR, 0.37; 95% CI, 0.15-0.89; P = .03) were associated with lower mortality without altering outcomes in White patients.

Conclusions and Relevance

In this cohort study of 1565 who underwent surgical repair patients with CDH, Black infants had higher 60-day and in-hospital mortality after adjusting for disease severity. Hospitals treating a more racially and ethnically diverse patient population were associated with lower mortality in Black and Hispanic patients.

Sociodemographic factors associated with tracheostomy and mortality in bronchopulmonary dysplasia

OBJECTIVES

We sought to investigate how race, ethnicity, and socioeconomic status relate to tracheostomy insertion and post-tracheostomy mortality among infants with bronchopulmonary dysplasia (BPD).

METHODS

The Vizient Clinical Database/Resource Manager was queried to identify infants born ≤32 weeks with BPD admitted to US hospitals from January 2012 to December 2020. Markers of socioeconomic status were linked to patient records from the Agency for Healthcare Research and Quality's Social Determinants of Health Database. Regression models were used to assess trends in annual tracheostomy insertion rate and odds of tracheostomy insertion and post-tracheostomy mortality, adjusting for sociodemographic and clinical factors.

RESULTS

There were 40,021 ex-premature infants included in the study, 1614 (4.0%) of whom received a tracheostomy. Tracheostomy insertion increased from 2012 to 2017 (3.1%-4.1%), but decreased from 2018 to 2020 (3.3%-1.6%). Non-Hispanic Black infants demonstrated a 25% higher odds (aOR 1.25, 1.09-1.43) and Hispanic infants demonstrated a 20% lower odds (aOR 0.80, 0.65-0.96) of tracheostomy insertion compared with non-Hispanic White infants. Patients receiving public insurance had increased odds of tracheostomy insertion (aOR 1.15, 1.03-1.30), but there was no relation between other metrics of socioeconomic status and tracheostomy insertion within our cohort. In-hospital mortality among the tracheostomy-dependent was 14.1% and was not associated with sociodemographic factors.

CONCLUSIONS

Disparities in tracheostomy insertion are not accounted for by differences in socioeconomic status or the presence of additional neonatal morbidities. Post-tracheostomy mortality does not demonstrate the same relationships. Further investigation is needed to explore the source and potential mitigators of the identified disparities.

Outcomes of infants with severe bronchopulmonary dysplasia who received tracheostomy and home ventilation

OBJECTIVE

To describe the survival rate, timing of liberation from the ventilator, and factors favorable for decannulation among infants with severe bronchopulmonary dysplasia (sBPD) who received tracheostomy.

METHODS

Demographics and clinical outcomes were obtained through retrospective chart review of 98 infants with sBPD who were born between 2004 and 2017, received tracheostomy at <1 year of age, and were followed in the Infant Tracheostomy and Home Ventilator clinic up to 4 years of age.

RESULTS

The number of infants with sBPD who received tracheostomy increased significantly over the study period. The median age at tracheostomy was 4 months (IQR 3, 5) or 43 weeks corrected gestational age; the median age at NICU discharge was 7 months (IQR 6, 9). At 48 months of age, all subjects had been liberated from the ventilator, at a median age of 24 months (IQR 18, 29); 52% had been decannulated with a median age at decannulation of 32 months (IQR 26, 39). Only 1 (1%) infant died. Multivariate logistic regression showed infants who were White, liberated from the ventilator by 24 months of age and have public insurance had significantly greater odds of being decannulated by 48 months of age. Tracheobronchomalacia was associated with decreased odds of decannulation.

CONCLUSION

Infants with sBPD who received tracheostomy had an excellent survival rate. Liberation from home ventilation and decannulation are likely to occur by 4 years of age.