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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024:S1053-2498(24)01679-6. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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Kim HA, Yu AG, Kim NP, Iqbal MS, Butts R. Lower opportunity ZIP code is associated with worse outcomes after listing in pediatric heart transplantation. J Heart Lung Transplant 2024; 43:1298-1307. [PMID: 38704128 DOI: 10.1016/j.healun.2024.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/14/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND The Child Opportunity Index (COI) comprehensively measures children's social determinants of health. We describe association between COI and outcomes after listing for heart transplantation. METHODS We conducted a retrospective review of the United Network for Organ Sharing (UNOS) database for U.S. children listed for heart transplant between 2012 and 2020. ZIP codes were utilized to assign COI. Primary outcome was survival from time of listing. Secondary outcomes included waitlist survival, 1-year post-transplant survival, and conditional 1-year post-transplant survival. Cox regression was performed adjusting for payor, age, race, diagnosis, and support at listing for all outcomes except waitlist survival, for which Fine-Gray competing risk analysis was performed. RESULTS Of 5,723 children listed, 109 were excluded due to missing ZIP codes. Race/ethnicity and payor were associated with COI (p < 0.001). Patients living in very low COI ZIP codes compared to all others had increased mortality from time of listing (HR 1.16, CI 1.03-1.32, p = 0.02) with 1-, 5-, and 9-year survival of 79.3% vs 82.2%, 66.5% vs 73.0%, and 53.6% vs 64.7% respectively, were more likely to be removed from the waitlist due to death or being too sick (subdistribution HR 1.26, 95% CI 1.10-1.42), and had increased mortality conditional on one-year post-transplant survival (HR 1.38, 1.09-1.74, p = 0.008) with 1-, 3-, and 5- year survival of 94.7% vs 97.3%, 87.0% vs 93.1%, and 78.6% vs 86.9%. CONCLUSIONS Children living in lower opportunity ZIP codes had poorer survival from time of listing, poorer waitlist survival, and poorer conditional one-year post-transplant survival.
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Affiliation(s)
- Heidi A Kim
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Andrew G Yu
- Division of Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Nicole P Kim
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, Texas
| | - Mehreen S Iqbal
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Ryan Butts
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas.
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Chowdhury D, Elliott PA, Asaki SY, Amdani S, Nguyen Q, Ronai C, Tierney S, Levy VY, Puri K, Altman CA, Johnson JN, Glickstein JS. Addressing Disparities in Pediatric Congenital Heart Disease: A Call for Equitable Health Care. J Am Heart Assoc 2024; 13:e032415. [PMID: 38934870 PMCID: PMC11255720 DOI: 10.1161/jaha.123.032415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
While significant progress has been made in reducing disparities within the US health care system, notable gaps remain. This article explores existing disparities within pediatric congenital heart disease care. Congenital heart disease, the most common birth defect and a leading cause of infant death, has garnered substantial attention, revealing certain disparities within the US health care system. Factors such as race, ethnicity, insurance coverage, socioeconomic status, and geographic location are all commonalities that significantly affect health disparities in pediatric congenital heart disease. This comprehensive review sheds light on disparities from diverse perspectives in pediatric care, demonstrates the inequities and inequalities leading to these disparities, presents effective solutions, and issues a call to action for providers, institutions, and the health care system. Recognizing and addressing these disparities is imperative for ensuring equitable care and enhancing the long-term well-being of children affected by congenital heart disease. Implementing robust, evidence-based frameworks that promote responsible and safe interventions is fundamental to enduring change.
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Affiliation(s)
- Devyani Chowdhury
- Cardiology Care for ChildrenLancasterPAUSA
- Nemours Cardiac CenterWilmingtonDEUSA
| | | | - S. Yukiko Asaki
- Department of Pediatric CardiologyUniversity of Utah, and Primary Children’s HospitalSalt LakeUTUSA
| | - Shahnawaz Amdani
- Division of Cardiology & Cardiovascular Medicine, Children’s Institute Department of HeartVascular & ThoracicClevelandOHUSA
| | - Quang‐Tuyen Nguyen
- Division of General Pediatrics, Department of PediatricsPrimary Children’s Hospital, University of UtahSalt Lake CityUTUSA
| | - Christina Ronai
- Department of Pediatrics, Division of Pediatric CardiologyOregon Health and Sciences UniversityPortlandORUSA
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Seda Tierney
- Department of Pediatrics, Division of Cardiology, Lucile Packard Children’s HospitalStanford University Medical CenterPalo AltoCAUSA
| | - Victor Y. Levy
- Division of Pediatric Cardiology and NeonatologyLogan Health Children’s HospitalKalispellMTUSA
| | - Kriti Puri
- Section of Pediatric Cardiology, Department of PediatricsBaylor College of MedicineHoustonTXUSA
| | | | - Jonathan N. Johnson
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric CardiologyMayo ClinicRochesterMNUSA
| | - Julie S. Glickstein
- Division of Cardiology, Department of PediatricsColumbia University Irving Medical CenterNew YorkNYUSA
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Amdani S, Dewey EN, Schold JD. Public Reporting of Heart Transplant Center Performance: Promoting Clarity or Causing Confusion? JACC. HEART FAILURE 2024; 12:1274-1283. [PMID: 38613559 DOI: 10.1016/j.jchf.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/07/2023] [Accepted: 01/22/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Transplant center report cards are publicly available and used by regulators, insurance payers, and importantly patients and families. OBJECTIVES In this study, the authors sought to evaluate the variability in reported public performance ratings of pediatric and adult heart transplant centers. METHODS Program-specific reports from the Scientific Registry of Transplant Recipients from 2017-2021 were used to evaluate stability, volatility, and reliability of 3 publicly reported ratings: waitlist survival (WS), getting to a faster transplant (FT), and post-transplantation graft failure (GF). RESULTS There were 112 adult and 55 pediatric centers. Over the study period, nearly all centers (98%) had at least 1 change in rating in at least 1 of the tiers. The average time to the first rating change of any magnitude was 12-18 months for all tiers and centers. For adult centers, the most volatile rating was WS (SD: 0.77), followed by GF (SD: 0.76) and then FT (SD: 0.57). For pediatric centers, the most volatile rating was WS (SD: 0.79), followed by both GF (SD: 0.66) and FT (SD: 0.68), which were equally volatile. All tiers except adult FT had an estimated Fleiss's kappa <0.20, indicating poor agreement/consistency across the study period. In addition, the intraclass correlation coefficient for all tiers was <0.50, indicating poor reliability. CONCLUSIONS The current 5-tier reporting of transplant center performance is highly volatile and has poor reliability and consistency. Given the unintended and significant negative consequences these reports can have, critical revision of these ratings is warranted.
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Affiliation(s)
- Shahnawaz Amdani
- Children's Institute Department of Heart, Vascular and Thoracic, Division of Cardiology and Cardiovascular Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA.
| | - Elizabeth N Dewey
- Center for Populations Health Research, Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Butto A, Wright LK, Dyal J, Mao CY, Garcia R, Mahle WT. Impact of ventricular assist device use on pediatric heart transplant waitlist mortality: Analysis of the scientific registry of transplant recipients database. Pediatr Transplant 2024; 28:e14787. [PMID: 38766980 DOI: 10.1111/petr.14787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/25/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Children awaiting heart transplant (Tx) have a high risk of death due to donor organ scarcity. Historically, ventricular assist devices (VADs) reduced waitlist mortality, prompting increased VAD use. We sought to determine whether the VAD survival benefit persists in the current era. METHODS Using the Scientific Registry of Transplant Recipients, we identified patients listed for Tx between 3/22/2016 and 9/1/2020. We compared characteristics of VAD and non-VAD groups at Tx listing. Cox proportional hazards models were used to identify risk factors for 1-year waitlist mortality. RESULTS Among 5054 patients, 764 (15%) had a VAD at Tx listing. The VAD group was older with more mechanical ventilation and renal impairment. Unadjusted waitlist mortality was similar between groups; the curves crossed ~90 days after listing (p = .55). In multivariable analysis, infant age (HR 2.77, 95%CI 2.13-3.60), Black race (HR 1.57, 95%CI 1.31-1.88), congenital heart disease (HR 1.23, 95%CI 1.04-1.46), renal impairment (HR 2.67, 95%CI 2.19-3.26), inotropes (HR 1.28, 95%CI 1.09-1.52), and mechanical ventilation (HR 2.23, 95%CI 1.84-2.70) were associated with 1-year waitlist mortality. VADs were not associated with mortality in the first 90 waitlist days but were protective for those waiting ≥90 days (HR 0.43, 95%CI 0.26-0.71). CONCLUSIONS In the current era, VADs reduce waitlist mortality, but only for those waitlisted ≥90 days. The differential effect by race, size, and VAD type is less clear. These findings suggest that Tx listing without VAD may be reasonable if a short waitlist time is anticipated, but VADs may benefit those expected to wait >90 days.
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Affiliation(s)
- Arene Butto
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Lydia K Wright
- Pediatric Cardiology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jameson Dyal
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Chad Y Mao
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Richard Garcia
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - William T Mahle
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Amdani S, Marino BS, Boyle G, Cassedy A, Lorts A, Morales D, Joong A, Burstein D, Bansal N, Sutcliffe DL. Impact of center volume on outcomes after ventricular assist device implantation in pediatric patients: An analysis of the STS-Pedimacs database. J Heart Lung Transplant 2024; 43:787-796. [PMID: 38199514 DOI: 10.1016/j.healun.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 12/01/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND To date, no pediatric studies have highlighted the impact of center's ventricular assist device (VAD) volumes on post implant outcomes. METHODS Children (age <19) enrolled in Pedimacs undergoing initial left ventricular assist device implantation from 2012 to 2020 were included. Center volume was analyzed as a continuous and categorical variable. For categorical analysis, center volumes were divided as: low volume (1-15 implants), medium volume (15-30 implants), and high volume (>30 implants) during our study period. Patient characteristics and outcomes were compared by center's VAD volumes. RESULTS Of 44 centers, 16 (36.4%) were low, 11 (25%) were medium, and 17 (38.6%) were high-volume centers. Children at high-volume centers were least likely intubated, sedated, or paralyzed, and most likely ambulating preimplant (p < 0.05 for all). Center's VAD volumes were not a significant risk factor for mortality post implant when treated as a continuous or a categorical variable (p > 0.05). Compared to low volume, children at high-volume centers had fewer early neurological events. Compared to medium volume, those at high-volume centers had fewer late bleeding events (p < 0.05 for all). There were no significant differences in survival after an adverse event by hospital volumes (p > 0.05). CONCLUSIONS Although hospital volume does not affect post-VAD implant mortality, pediatric centers with higher VAD volumes have fewer patients intubated, sedated, paralyzed pre implant, and have lower adverse events. Failure to rescue was not significantly different between low, medium, and high-volume VAD centers.
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Affiliation(s)
- Shahnawaz Amdani
- Division of Pediatric Cardiology, Department of Heart, Vascular & Thoracic, Children's Institute, Cleveland Clinic Children's, Cleveland, Ohio.
| | - Bradley S Marino
- Division of Pediatric Cardiology, Department of Heart, Vascular & Thoracic, Children's Institute, Cleveland Clinic Children's, Cleveland, Ohio
| | - Gerard Boyle
- Division of Pediatric Cardiology, Department of Heart, Vascular & Thoracic, Children's Institute, Cleveland Clinic Children's, Cleveland, Ohio
| | - Amy Cassedy
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Angela Lorts
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - David Morales
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Anna Joong
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Danielle Burstein
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai School of Medicine, New York, New York
| | - David L Sutcliffe
- Division of Pediatric Cardiology, Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri
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7
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Greenberg JW, Kulshrestha K, Guzman-Gomez A, Fields K, Lehenbauer DG, Winlaw DS, Perry T, Villa C, Lorts A, Zafar F, Morales DLS. Modifiable risk factor reduction for pediatric ventricular assist devices and the influence of persistent modifiable risk factors at transplant. J Thorac Cardiovasc Surg 2024; 167:1556-1563.e2. [PMID: 37414356 PMCID: PMC10766860 DOI: 10.1016/j.jtcvs.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/25/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVES Ventricular assist devices (VADs) are associated with a mortality benefit in children. Database-driven analyses have associated VADs with reduction of modifiable risk factors (MRFs), but validation with institutional data is required. The authors studied MRF reduction on VAD and the influence of persistent MRFs on survival after heart transplant. METHODS All patients at the authors' institution requiring a VAD at transplant (2011-2022) were retrospectively identified. MRFs included renal dysfunction (estimated glomerular filtration rate <60 mL/min/1.73 m2), hepatic dysfunction (total bilirubin ≥1.2 mg/dL), total parenteral nutrition dependence, sedatives, paralytics, inotropes, and mechanical ventilation. RESULTS Thirty-nine patients were identified. At time of VAD implantation, 18 patients had ≥3 MRFs, 21 had 1 to 2 MRFs, and 0 had 0 MRFs. At time of transplant, 6 patients had ≥3 MRFs, 17 had 1 to 2 MRFs, and 16 had 0 MRFs. Hospital mortality occurred in 50% (3 out of 6) patients with ≥3 MRFs at transplant vs 0% of patients with 1 to 2 and 0 MRFs (P = .01 for ≥3 vs 1-2 and 0 MRFs). MRFs independently associated with hospital mortality included paralytics (1.76 [range, 1.32-2.30]), ventilator (1.59 [range, 1.28-1.97]), total parenteral nutrition dependence (1.49 [range, 1.07-2.07]), and renal dysfunction (1.31 [range, 1.02-1.67]). Two late mortalities occurred (3.6 and 5.7 y), both in patients with 1 to 2 MRFs at transplant. Overall posttransplant survival was significantly worse for ≥3 versus 0 MRFs (P = .006) but comparable between other cohorts (P > .1). CONCLUSIONS VADs are associated with MRF reduction in children, yet those with persistent MRFs at transplant experience a high burden of mortality. Transplanting VAD patients with ≥3 MRFs may not be prudent. Time should be given on VAD support to achieve aggressive pre-transplant optimization of MRFs.
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Affiliation(s)
- Jason W Greenberg
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Kevin Kulshrestha
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amalia Guzman-Gomez
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katrina Fields
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David G Lehenbauer
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S Winlaw
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tanya Perry
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Chet Villa
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela Lorts
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Farhan Zafar
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Wright LK, Gajarski RJ, Hayes E, Parekh H, Yester JW, Nandi D. DQB1 antigen matching improves rejection-free survival in pediatric heart transplant recipients. J Heart Lung Transplant 2024; 43:816-825. [PMID: 38232791 DOI: 10.1016/j.healun.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Presence of donor-specific antibodies (DSAs), particularly to class II antigens, remains a major challenge in pediatric heart transplantation. Donor-recipient human leukocyte antigen (HLA) matching is a potential strategy to mitigate poor outcomes associated with DSAs. We evaluated the hypothesis that antigen mismatching at the DQB1 locus is associated with worse rejection-free survival. METHODS Data were collected from Scientific Registry of Transplant Recipients for all pediatric heart transplant recipients 2010-2021. Only transplants with complete HLA typing at the DQB1 locus for recipient and donor were included. Primary outcome was rejection-free graft survival through 5 years. RESULTS Of 5,115 children, 4,135 had complete DQB1 typing and were included. Of those, 503 (12%) had 0 DQB1 donor-recipient mismatches, 2,203 (53%) had 1, and 1,429 (35%) had 2. Rejection-free survival through 5 years trended higher for children with 0 DQB1 mismatches (68%), compared to those with 1 (62%) or 2 (63%) mismatches (pairwise p = 0.08 for both). In multivariable analysis, 0 DQB1 mismatches remained significantly associated with improved rejection-free graft survival compared to 2 mismatches, while 1 DQB1 mismatch was not. Subgroup analysis showed the strongest effect in non-Hispanic Black children and those undergoing retransplant. CONCLUSIONS Matching at the DQB1 locus is associated with improved rejection-free survival after pediatric heart transplant, particularly in Black children, and those undergoing retransplant. Assessing high-resolution donor typing at the time of allocation may further corroborate and refine this association. DQB1 matching may improve long-term outcomes in children stabilized either with optimal pharmacotherapy or supported with durable devices able to await ideal donors.
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Affiliation(s)
- Lydia K Wright
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio.
| | - Robert J Gajarski
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Emily Hayes
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Hemant Parekh
- Clinical Histocompatibility Laboratory, The Ohio State University, Columbus, Ohio
| | - Jessie W Yester
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Deipanjan Nandi
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio
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9
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Shen J, Clinton AJ, Penka J, Gregory ME, Sova L, Pfeil S, Patterson J, Maa T. Smartphone-Based Virtual and Augmented Reality Implicit Association Training (VARIAT) for Reducing Implicit Biases Toward Patients Among Health Care Providers: App Development and Pilot Testing. JMIR Serious Games 2024; 12:e51310. [PMID: 38488662 PMCID: PMC11004623 DOI: 10.2196/51310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/24/2023] [Accepted: 12/12/2023] [Indexed: 04/12/2024] Open
Abstract
Background Implicit bias is as prevalent among health care professionals as among the wider population and is significantly associated with lower health care quality. Objective The study goal was to develop and evaluate the preliminary efficacy of an innovative mobile app, VARIAT (Virtual and Augmented Reality Implicit Association Training), to reduce implicit biases among Medicaid providers. Methods An interdisciplinary team developed 2 interactive case-based training modules for Medicaid providers focused on implicit bias related to race and socioeconomic status (SES) and sexual orientation and gender identity (SOGI), respectively. The simulations combine experiential learning, facilitated debriefing, and game-based educational strategies. Medicaid providers (n=18) participated in this pilot study. Outcomes were measured on 3 domains: training reactions, affective knowledge, and skill-based knowledge related to implicit biases in race/SES or SOGI. Results Participants reported high relevance of training to their job for both the race/SES module (mean score 4.75, SD 0.45) and SOGI module (mean score 4.67, SD 0.50). Significant improvement in skill-based knowledge for minimizing health disparities for lesbian, gay, bisexual, transgender, and queer patients was found after training (Cohen d=0.72; 95% CI -1.38 to -0.04). Conclusions This study developed an innovative smartphone-based implicit bias training program for Medicaid providers and conducted a pilot evaluation on the user experience and preliminary efficacy. Preliminary evidence showed positive satisfaction and preliminary efficacy of the intervention.
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Affiliation(s)
- Jiabin Shen
- Department of Psychology, University of Massachusetts Lowell, Lowell, MA, United States
| | - Alex J Clinton
- Department of Psychology, University of Massachusetts Lowell, Lowell, MA, United States
| | | | - Megan E Gregory
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Lindsey Sova
- Center for Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, Ohio State University, Columbus, OH, United States
| | - Sheryl Pfeil
- College of Medicine, Ohio State University, Columbus, OH, United States
| | - Jeremy Patterson
- Advanced Computing Center for Arts and Design, Ohio State University, Columbus, OH, United States
| | - Tensing Maa
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, OH, United States
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10
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Amdani S, Deshpande SR, Liu W, Urschel S. Impact of the Pediatric ABO Policy Change on Listings, Transplants, and Outcomes for Children Younger Than 2 Years Listed for Heart Transplantation in the United States. J Card Fail 2024; 30:476-485. [PMID: 37328049 DOI: 10.1016/j.cardfail.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND We assessed the impact of the liberalized ABO pediatric policy change on candidate characteristics and outcomes for children undergoing heart transplant (HT). METHODS AND RESULTS Children <2 years undergoing HT with ABO strategy reported at listing and HT from December 2011 to November 2020 to the Scientific Registry of Transplant Recipients database were included. Characteristics at listing, HT, and outcomes during the waitlist and post-transplant were compared before the policy change (December 16, 2011 to July 6, 2016), and after the policy change (July 7, 2016 to November 30, 2020). The percentage of ABO-incompatible (ABOi) listings did not increase immediately after the policy change (P = .93); however, ABOi transplants increased by 18% (P < .0001). At listing, both before and after the policy change, ABOi candidates had higher urgency status, renal dysfunction, lower albumin, and required more cardiac support (intravenous inotropes, mechanical ventilation) than those listed ABO compatible (ABOc). On multivariable analysis, there were no differences in waitlist mortality between children listed as ABOi and ABOc before the policy change (adjusted hazard ratio [aHR] 0.80, 95% confidence interval [CI] 0.61-1.05, P = .10) or after the policy change (aHR 1.2, 95% CI 0.85-1.6, P = .33). Post-transplant graft survival was worse for ABOi transplanted children before the policy change (aHR 1.8, 95% CI 1.1-2.8, P = .014), but not significantly different after the policy change (aHR 0.94, 95% CI 0.61-1.4, P = .76). After the policy change, ABOi listed children had significantly shorter waitlist times (P < .05). CONCLUSIONS The recent pediatric ABO policy change has significantly increased the percentage of ABOi transplantations and decreased waitlist times for children listed ABOi. This change in policy has resulted in broader applicability and actual performance of ABOi transplantation with equal access to ABOi or ABOc organs, and thus eliminated the potential disadvantage of only secondary allocation to ABOi recipients.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
| | - Shriprasad R Deshpande
- Department of Cardiology, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Wei Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Simon Urschel
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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11
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Bogle C. Unlocking the key: Delving into implicit bias in pediatric heart transplantation. Pediatr Transplant 2024; 28:e14733. [PMID: 38436213 DOI: 10.1111/petr.14733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Carmel Bogle
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
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12
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Amdani S, Gossett JG, Chepp V, Urschel S, Asante-Korang A, Dalton JE. Review on clinician bias and its impact on racial and socioeconomic disparities in pediatric heart transplantation. Pediatr Transplant 2024; 28:e14704. [PMID: 38419391 DOI: 10.1111/petr.14704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/18/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024]
Abstract
This expert review seeks to highlight implicit bias in health care, transplant medicine, and pediatric heart transplantation to focus attention on the role these biases may play in the racial/ethnic and socioeconomic disparities noted in pediatric heart transplantation. This review breaks down the transplant decision making process to highlight points at which implicit bias may affect outcomes and discuss how the science of human decision making may help understand these complex processes.
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Affiliation(s)
- Shahnawaz Amdani
- Children's Institute Department of Heart, Vascular & Thoracic, Division of Cardiology & Cardiovascular Medicine, Cleveland, Ohio, USA
| | - Jeffrey G Gossett
- Northwell, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Valerie Chepp
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Simon Urschel
- Division of Pediatric Cardiology at the University of Alberta, Edmonton, Alberta, Canada
| | - Alfred Asante-Korang
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Jarrod E Dalton
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
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13
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Robinson J, Sahai S, Pennacchio C, Sharew B, Chen L, Karamlou T. Effects of Sociodemographic Factors on Access to and Outcomes in Congenital Heart Disease in the United States. J Cardiovasc Dev Dis 2024; 11:67. [PMID: 38392282 PMCID: PMC10889660 DOI: 10.3390/jcdd11020067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024] Open
Abstract
Congenital heart defects (CHDs) are complex conditions affecting the heart and/or great vessels that are present at birth. These defects occur in approximately 9 in every 1000 live births. From diagnosis to intervention, care has dramatically improved over the last several decades. Patients with CHDs are now living well into adulthood. However, there are factors that have been associated with poor outcomes across the lifespan of these patients. These factors include sociodemographic and socioeconomic positions. This commentary examined the disparities and solutions within the evolution of CHD care in the United States.
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Affiliation(s)
- Justin Robinson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Siddhartha Sahai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Caroline Pennacchio
- Case Western Reserve University School of Medicine, Cleveland, OH 44195, USA
| | - Betemariam Sharew
- Cleveland Clinic Learner College of Medicine, Cleveland, OH 44195, USA
| | - Lin Chen
- Case Western Reserve University School of Medicine, Cleveland, OH 44195, USA
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Division of Pediatric Cardiac Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue, Desk M41, Cleveland, OH 44195, USA
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14
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Amdani S, Aljohani OA, Kirklin JK, Cantor R, Koehl D, Schumacher K, Nandi D, Khoury M, Dreyer W, Rose-Felker K, Nasman C, Kemna MS. Assessing Donor-Recipient Size Mismatch in Pediatric Heart Transplantation: Lessons Learned From Over 7,500 Transplants. JACC. HEART FAILURE 2024; 12:380-391. [PMID: 37676215 DOI: 10.1016/j.jchf.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/20/2023] [Accepted: 07/10/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND To date, no studies have identified an optimal metric to match donor-recipient (D-R) pairs in pediatric heart transplantation (HT). OBJECTIVES This study sought to identify size mismatch metrics that predicted graft survival post-HT. METHODS D-R pairs undergoing HT in Pediatric Heart Transplant Society database from 1993 to 2021 were included. Effects of size mismatch by height, weight, body mass index, body surface area, predicted heart mass, and total cardiac volume (TCV) on 1- and 5-year graft survival and morbidity outcomes (rejection and cardiac allograft vasculopathy) were evaluated. Cox models with stepwise selection identified size metrics that independently predicted graft survival. RESULTS Of 7,715 D-R pairs, 36.0% were well matched (D-R ratio: -20% to +20%) by weight, 39.0% by predicted heart mass, 50.0% by body surface area, 57.0% by body mass index, 71.0% by height, and 93.0% by TCV. Of all size metrics, only D-R mismatch by height and TCV predicted graft survival at 1 and 5 years. Effects of D-R size mismatch on graft survival were nonlinear. At both 1 and 5 years post-HT, D-R undersizing and oversizing by height led to increased graft loss, with graft loss observed more frequently with undersizing. Moderately undersized donors by height (D-R ratio: <-30%) frequently experienced rejection post-HT (P < 0.001). Assessing D-R size matching by TCV, minimal donor undersizing was protective, while oversizing up to 25% was not associated with increased graft loss. CONCLUSIONS In pediatric HT, D-R appear most optimally matched using TCV. Only D-R size mismatch by TCV and height independently predicts graft survival. Standardizing size matching across centers may reduce donor discard.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA.
| | - Othman A Aljohani
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, San Francisco, California, USA
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kurt Schumacher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Deipanjan Nandi
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michael Khoury
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - William Dreyer
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kirsten Rose-Felker
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Colleen Nasman
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
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15
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McCulloch MA, Alonzi LP, White SC, Haregu F, Porter MD. Pediatric donor heart acceptance practices in the United States: What is really being considered? Pediatr Transplant 2024; 28:e14649. [PMID: 38013204 PMCID: PMC10872937 DOI: 10.1111/petr.14649] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Recent studies demonstrate high offer decline and organ non-utilization rates are associated with increased pediatric heart transplant waitlist mortality. We sought to determine which donor, candidate, and offer specific variables most importantly influenced these decisions using only data available at the time of each offer. METHODS Retrospective review of pediatric (<18 years) heart donor offers made to pediatric candidates in the United States between 2010 and 2020. In addition to standard donor, candidate, and offer data available in UNOS, we extracted objective and qualitative valvar and myocardial function data from all available donor echocardiogram reports. RESULTS During the study period, 5625 pediatric donor hearts produced 30 156 offers to 4905 unique candidates, of which 88.7% of all offers were declined and 39.2% of organs were not utilized by pediatric waitlisted candidates. Of the 60.8% utilized hearts, 89.7% had a 'cumulatively' normal echocardiogram at the time of offer acceptance; 62.9% of hearts not utilized for a pediatric candidate also had a cumulatively normal final echocardiogram. Random forest and logistic regression modeling demonstrated good predictive performance (AUROC ≥0.83) of likelihood to accept when utilizing donor, candidate, and offer specific variables. SHAP variable importance scores demonstrated number of prior offer declines and candidate institution's prior year acceptance rates as the two most important variables influencing offer decisions. CONCLUSIONS Behavioral economics appear to play a significant role in pediatric heart transplant candidate institutions' acceptance practices, even when considering the arguably healthier pediatric donor population. Removal of prior institution's decisions from DonorNet may help increase donor utilization.
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Affiliation(s)
- M A McCulloch
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - L P Alonzi
- School of Data Science, University of Virginia, Charlottesville, Virginia, USA
| | - S C White
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - F Haregu
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - M D Porter
- School of Data Science, University of Virginia, Charlottesville, Virginia, USA
- Department of Systems and Information Engineering, University of Virginia, Charlottesville, Virginia, USA
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16
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Amdani S, Auerbach SR, Bansal N, Chen S, Conway J, Silva JPDA, Deshpande SR, Hoover J, Lin KY, Miyamoto SD, Puri K, Price J, Spinner J, White R, Rossano JW, Bearl DW, Cousino MK, Catlin P, Hidalgo NC, Godown J, Kantor P, Masarone D, Peng DM, Rea KE, Schumacher K, Shaddy R, Shea E, Tapia HV, Valikodath N, Zafar F, Hsu D. Research Gaps in Pediatric Heart Failure: Defining the Gaps and Then Closing Them Over the Next Decade. J Card Fail 2024; 30:64-77. [PMID: 38065308 DOI: 10.1016/j.cardfail.2023.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 01/13/2024]
Abstract
Given the numerous opportunities and the wide knowledge gaps in pediatric heart failure, an international group of pediatric heart failure experts with diverse backgrounds were invited and tasked with identifying research gaps in each pediatric heart failure domain that scientists and funding agencies need to focus on over the next decade.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio.
| | - Scott R Auerbach
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, Icahn School of Medicine, New York, New York
| | - Sharon Chen
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Conway
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Julie Pires DA Silva
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Jessica Hoover
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Kimberly Y Lin
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shelley D Miyamoto
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kriti Puri
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Jack Price
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Joseph Spinner
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Rachel White
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph W Rossano
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David W Bearl
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Melissa K Cousino
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Perry Catlin
- Department of Psychology, Marquette University, Milwaukee, Wisconsin
| | - Nicolas Corral Hidalgo
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Justin Godown
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Paul Kantor
- Children's Hospital Los Angeles and the Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - David M Peng
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kelly E Rea
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kurt Schumacher
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Robert Shaddy
- Children's Hospital Los Angeles and the Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Erin Shea
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - Henry Valora Tapia
- Division of Pediatric Cardiology, University of Utah. Salt Lake City, Utah
| | - Nishma Valikodath
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Daphne Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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17
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Amdani S, Lopez R, Schold JD, Tang WHW. 30- and 60-Day Readmission Rates for Children With Heart Failure in the United States. JACC. HEART FAILURE 2024; 12:83-96. [PMID: 37943220 DOI: 10.1016/j.jchf.2023.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/07/2023] [Accepted: 08/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Studies on readmission for pediatric heart failure (HF) patients is sparse. OBJECTIVES This study evaluated 30- and 60-day readmission rates in pediatric HF patients from 2010 to 2019. METHODS The authors used data from the Nationwide Readmission Database to evaluate trends in 30- and 60-day hospital readmissions among pediatric patients with HF and compare them with adults with HF. Readmissions were also stratified by sex, diagnosis, neighborhood income, and hospital volume. RESULTS There were 84,731 hospital admissions for HF. Compared with children without HF, those with HF were older, had Medicare/Medicaid insurance, and resided in micropolitan areas and low-income neighborhoods. The 30- (19.5% vs 3.1%) and 60-day (27.5% vs 4.3%) all-cause readmission rates were higher for children with HF compared with those without HF. Compared with children without HF, lengths of stay, deaths, and costs related to their readmission were higher for children readmitted with HF (P < 0.05 for all). There was no significant decline in pediatric HF-related 30- or 60- day readmissions during the study period overall, or for those with congenital heart disease (P > 0.05), unlike adult HF readmissions (P < 0.01). Infants were at highest risk, and readmission rates for teenagers are rising. CONCLUSIONS The 30- and 60-day readmission rates for pediatric patients with HF in the current era is high (∼20% and 30%, respectively). Unlike adult HF, pediatric HF readmission rates have not declined. Pediatric HF patients readmitted to the hospital have higher death rates and greater resource utilization than patients without HF. National measures to decrease readmissions for pediatric patients with HF is warranted.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA.
| | - Rocio Lopez
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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18
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Brugha R, Wu D, Spencer H, Marson L. Disparities in lung transplantation in children. Pediatr Pulmonol 2023. [PMID: 38131456 DOI: 10.1002/ppul.26813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
Lung transplantation is a recognized therapy for end-stage respiratory failure in children and young people. It is only available in selected countries and is limited by access to suitable organs. Data on disparities in access and outcomes for children undergoing lung transplantation are limited. It is clear from data from studies in adults, and from studies in other solid organ transplants in children, that systemic inequities exist in this field. While data relating specifically to pediatric lung transplantation are relatively sparse, professionals should be aware of the risk that healthcare systems may result in disparities in access and outcomes following lung transplantation in children.
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Affiliation(s)
- Rossa Brugha
- Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
- Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Diana Wu
- General Surgery, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Helen Spencer
- Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
| | - Lorna Marson
- Transplant Unit, Royal Infirmary Edinburgh, Edinburgh, UK
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19
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Heitner R, Rogers M, Chambers B, Pinotti R, Silvers A, Meier DE, Bowman B, Johnson KS. The Experience of Black Patients With Serious Illness in the United States: A Scoping Review. J Pain Symptom Manage 2023; 66:e501-e511. [PMID: 37442530 DOI: 10.1016/j.jpainsymman.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023]
Abstract
CONTEXT Black patients experience health disparities in access and quality of care. OBJECTIVE To identify and characterize the literature on the experiences of Black patients with serious illness across multiple domains - physical, spiritual, emotional, cultural, and healthcare utilization. METHODS We conducted a scoping review of US literature from the last ten years using the PRISMA-ScR framework. PubMed was used to conduct a comprehensive search, followed by recursive citation searches in Scopus. Two reviewers screened the resulting citations to determine eligibility for inclusion and extracted data, including study methods and sample populations. The included articles were categorized by topic and then further organized using the Social-Ecological Model. RESULTS From an initial review of 433 articles, a final sample of 160 were included in the scoping review. The majority of articles used quantitative research methods and were published in the last four years. Articles were categorized into 20 topics, ranging from Access to Hospice and Utilization (42 articles) to Community Outreach and Services (three articles). Three-quarters (76.3%) of the included studies provided evidence that racial disparities exist in serious illness care, while less than one-quarter examined causes of disparities. The most common Model levels were the Health Care System (102 articles) and Individual (71 articles) levels. CONCLUSION More articles focused on establishing evidence of disparities between Black and White patients than on understanding their root causes. Further investigation is warranted to understand how factors at the patient, provider, health system, and society levels interact to remediate disparities.
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Affiliation(s)
- Rachael Heitner
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Maggie Rogers
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brittany Chambers
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel Pinotti
- Gustave L. and Janet W. Levy Library (R.P.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Allison Silvers
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brynn Bowman
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics (K.S.J.), Duke University School of Medicine, Durham, NC, USA, Geriatrics Research Education and Clinical Center, Veteran Affairs Health System, Durham, North Carolina, USA
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20
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Wright LK, Culp S, Gajarski RJ, Nandi D. Racial and socioeconomic disparities in status exceptions for pediatric heart transplant candidates under the current U.S. Pediatric Heart Allocation Policy. J Heart Lung Transplant 2023; 42:1233-1241. [PMID: 37088341 DOI: 10.1016/j.healun.2023.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND The 2016 revision of the US Pediatric Heart Allocation Policy developed stringent rules for priority status creating impetus for clinicians to seek status exceptions. We hypothesized there may be differential status exceptions based on race and socioeconomic status (SES) contributing to disparities in waitlist outcomes. METHODS The Scientific Registry for Transplant Recipients was queried for children listed for heart transplant from 2012 to 2020. Waitlist status & mortality with regards to race and neighborhood SES were stratified by listing before (Era 1) or after (Era 2) the policy change. RESULTS The use of both 1A and 1B exceptions (E) increased in Era 2. In Era 1, there was no association between patient race or neighborhood SES on use of 1A(E) or 1B(E) when controlling for age and diagnosis. In Era 2, neither race nor neighborhood SES were associated with 1A(E), but both were associated with 1B(E): non-Hispanic (NH) Black children and those from low- and middle-SES neighborhoods were significantly less likely to be listed 1B(E). In Era 1, there were no significant differences in waitlist mortality based on race at any waitlist status; in Era 2, NH Black children had higher waitlist mortality when initially listed 1B or 2. CONCLUSIONS Since the 2016 policy change, racial disparities in waitlist mortality have worsened among children initially listed with lower priority status. Unequal use of 1B exceptions, which lower waitlist mortality, may explain some of these disparities. Recently implemented standardized pediatric exception guidance has the potential to improve equity.
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Affiliation(s)
- Lydia K Wright
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio.
| | - Stacey Culp
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | | | - Deipanjan Nandi
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
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21
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Greenberg JW, Bryant R, Villa C, Fields K, Fynn-Thompson F, Zafar F, Morales DLS. Racial disparity exists in the utilization and post-transplant survival benefit of ventricular assist device support in children. J Heart Lung Transplant 2023; 42:585-592. [PMID: 36710094 PMCID: PMC10121747 DOI: 10.1016/j.healun.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 12/04/2022] [Accepted: 12/18/2022] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Children of minority race and ethnicity experience inferior outcomes postheart transplantation (HTx). Studies have associated ventricular assist device (VAD) bridge-to-transplant (BTT) with similar-to-superior post-transplant-survival (PTS) compared to no mechanical circulatory support. It is unclear whether racial and ethnic discrepancies exist in VAD utilization and outcomes. METHODS The United Network for Organ Sharing (UNOS) database was used to identify 6,121 children (<18 years) listed for HTx between 2006 and 2021: black (B-22% of cohort), Hispanic (H-21%), and white (W-57%). VAD utilization, outcomes, and PTS were compared between race/ethnicity groups. Multivariable Cox proportional analyses were used to study the association of race and ethnicity on PTS with VAD BTT, using backward selection for covariates. RESULTS Black children were most ill at listing, with greater proportions of UNOS status 1A/1 (p < 0.001 vs H & W), severe functional limitation (p < 0.001 vs H & W), and greater inotrope requirements (p < 0.05 vs H). Non-white children had higher proportions of public insurance. VAD utilization at listing was: B-11%, H-8%, W-8% (p = 0.001 for B vs H & W). VAD at transplant was: B-24%, H-21%, W-19% (p = 0.001 for B vs H). At transplant, all VAD patients had comparable clinical status (functional limitation, renal/hepatic dysfunction, inotropes, mechanical ventilation; all p > 0.05 between groups). Following VAD, hospital outcomes and one-year PTS were equivalent but long-term PTS was significantly worse among non-whites-(p < 0.01 for W vs B & H). On multivariable analysis, black race independently predicted mortality (hazard ratio 1.67 [95% confidence interval 1.22-2.28]) while white race was protective (0.54 [0.40-0.74]). CONCLUSIONS Pediatric VAD use is, seemingly, equitable; the most ill patients receive the most VADs. Despite similar pretransplant and early post-transplant benefits, non-white children experience inferior overall PTS after VAD BTT.
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Affiliation(s)
- Jason W Greenberg
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Roosevelt Bryant
- Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Chet Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katrina Fields
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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22
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Restaino K, Zhang X, Faerber JA, Rossano JW, Burstein D, Wittlieb-Weber CA, Lin KY, Edelson JB, Edwards JJ, O’Connor MJ. Temporal trends in primary payers in pediatric heart transplant and association with long-term survival. Pediatr Transplant 2023; 27:e14484. [PMID: 36751006 PMCID: PMC10290494 DOI: 10.1111/petr.14484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pediatric heart transplantation (HT) is resource intensive. In adults, there has been an increase in the proportion of HTs funded by public insurance, with post-HT outcomes inferior to those funded by private sources. Trends in the funding of pediatric HT and outcomes in children have not been described. METHODS We queried the United Network for Organ Sharing (UNOS) database for children (<18 years) listed for and undergoing HT between 2004 and 2021. We identified the primary payer at listing, HT, 1 year, and 1-5 years following HT. Trends were analyzed using generalized logit models. Multivariable-extended Cox regression models were used to test the relationship between insurance type at the time of transplant and time to death or re-transplant. RESULTS There were 6382 pediatric patients who underwent transplants and had either public or private insurance at the time of transplant. The percentage of patients with public insurance at the time of HT increased over time. Public insurance at the time of HT was associated with an increased risk of death or re-transplant beyond 2 months after HT (adjusted HR at 6 months = 1.43, 95% CI: 1.13-1.81, p = .003; adjusted HR at 9 months = 1.67, 95% CI: 1.17-2.37, p = .004). CONCLUSION There has been a statistically significant trend toward increasing public insurance for children awaiting, at the time of, and after HT. Black patients and those with public insurance at HT have worse long-term outcomes. This study highlights ongoing disparities in pediatric HT and the need to focus efforts on achieving equitable outcomes.
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Affiliation(s)
- Kathryn Restaino
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Xuemei Zhang
- Data Science and Biostatistics Team, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer A. Faerber
- Data Science and Biostatistics Team, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Danielle Burstein
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Kimberly Y. Lin
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan B. Edelson
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan J. Edwards
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew J. O’Connor
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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23
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Sferra SR, Salvi PS, Penikis AB, Weller JH, Canner JK, Guo M, Engwall-Gill AJ, Rhee DS, Collaco JM, Keiser AM, Solomon DG, Kunisaki SM. Racial and Ethnic Disparities in Outcomes Among Newborns with Congenital Diaphragmatic Hernia. JAMA Netw Open 2023; 6:e2310800. [PMID: 37115544 PMCID: PMC10148194 DOI: 10.1001/jamanetworkopen.2023.10800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/02/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Shelby R. Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pooja S. Salvi
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Annalise B. Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennine H. Weller
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph K. Canner
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew Guo
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Abigail J. Engwall-Gill
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel S. Rhee
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph M. Collaco
- Division of Pediatric Pulmonology, Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Amaris M. Keiser
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Daniel G. Solomon
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Shaun M. Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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24
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Trends in Contemporary Use of Ventricular Assist Devices in Children Awaiting Heart Transplantation and Their Outcomes by Race/Ethnicity. ASAIO J 2023; 69:210-217. [PMID: 35438653 DOI: 10.1097/mat.0000000000001747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
This retrospective study included children aged ≤18 years who had durable ventricular assist devices (VADs) as a bridge to transplantation from the United Network Organ Sharing (UNOS) database between 2011 and 2020. We evaluated 90 day waitlist mortality and 1 year posttransplant mortality after VAD implantation in children stratified by race/ethnicity: Black, White, and Others. The VAD was used in a higher proportion of Black children listed for heart transplantation (HT) (26%) versus Other (25%) versus White (22%); p < 0.01. Black children had Medicaid health insurance coverage (67%) predominantly at the time of listing for HT. There was no significant overall difference in waitlist survival among the three groups supported with VAD at the time of listing (log-rank p = 0.4). On the other hand, the 90 day waitlist mortality after the VAD implantation at listing and while listed was the lowest among Black (6%) compared with White (13%) and Other (14%) ( p < 0.01). The multivariate regression analysis showed that Other race (hazard ratio [HR], 2.29; p < 0.01), Black race (HR, 2.13; p < 0.01), use of mechanical ventilation (HR, 1.72; p = 0.01), and Medicaid insurance (HR, 1.54; p = 0.04) were independently associated with increased 1 year posttransplant mortality. In conclusion, Black children had more access to durable VAD support than White children. The 90 day waitlist mortality was significantly lower in Black children compared with White and Other after VAD implantation. However, Black and Other racial/ethnic children with VAD at transplant had higher 1 year posttransplant mortality than White children. Future studies to elucidate the reasons for these disparities are needed.
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25
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Rea KE, West KB, Dorste A, Christofferson ES, Lefkowitz D, Mudd E, Schneider L, Smith C, Triplett KN, McKenna K. A systematic review of social determinants of health in pediatric organ transplant outcomes. Pediatr Transplant 2023; 27:e14418. [PMID: 36321186 DOI: 10.1111/petr.14418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods. METHODS Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases. RESULTS Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent. CONCLUSION This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Kara B West
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Dorste
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Debra Lefkowitz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Mudd
- Cleveland Clinic Children's, Center for Pediatric Behavioral Health, Wilmington, North Carolina, USA
| | - Lauren Schneider
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Courtney Smith
- Norton Children's, University of Louisville, Louisville, Kentucky, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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26
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Amdani S, Tang A, Schold JD. Children from socioeconomically disadvantaged communities present in more advanced heart failure at the time of transplant listing. J Heart Lung Transplant 2023; 42:150-155. [PMID: 36270922 DOI: 10.1016/j.healun.2022.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 01/18/2023] Open
Abstract
Transplant registries in the US do not collect information about community level risk factors. We utilized a community level socio-economic risk indicator, the distressed communities' index to understand its association with clinical presentation among children listed for heart transplant (HT). We found that currently, majority (40%) of children listed from distressed communities are Black. On multivariable analysis, compared to children from prosperous communities, those from distressed communities listed for HT were significantly more likely to be Status 1A (adjusted odds ratio [aOR] 1.39) and on a ventricular assist device (aOR 1.44). Compared to White children from prosperous communities, both Black and White children from distressed communities were more likely to be listed Status 1A (aOR 2.1 and 1.36 respectively) and have renal dysfunction (aOR 1.71 and 1.52 respectively). In conclusion, heart failure severity at listing appears more likely associated with community-level risk factors and less so with child's race/ethnicity.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Ohio.
| | - Anne Tang
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Jesse D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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27
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Lopez KN, Jordan CAL, Moreno J. Sociodemographic indices in pediatric heart failure: Maximizing data to influence future social determinants of health interventions. J Heart Lung Transplant 2023; 42:156-159. [PMID: 36428204 DOI: 10.1016/j.healun.2022.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Keila N Lopez
- Texas Children's Hospital, Section of Pediatric Cardiology, Houston, TX; Texas Children's Hosiptal/Baylor College of Medicine, Department of Pediatrics, Houston, TX.
| | | | - Jasmine Moreno
- Texas Children's Hosiptal/Baylor College of Medicine, Department of Pediatrics, Houston, TX
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28
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Amdani S, Conway J, Kleinmahon J, Auerbach S, Hsu D, Cousino MK, Kaufman B, Alejos J, Cruz JH, Lee HY, Rudraraju R, Kirklin JK, Asante-Korang A. Race and Socioeconomic Bias in Pediatric Cardiac Transplantation. JACC. HEART FAILURE 2023; 11:19-26. [PMID: 36599545 DOI: 10.1016/j.jchf.2022.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND To date, no studies evaluated implicit bias among clinicians caring for children with advanced heart failure. OBJECTIVES This study aims to evaluate implicit racial and socioeconomic bias among pediatric heart transplant clinicians. METHODS A cross-sectional survey of transplant clinicians from the Pediatric Heart Transplant Society was conducted between June and August 2021. The survey consisted of demographic questions along with explicit and validated race and socioeconomic status (SES) implicit association tests (IATs). Implicit and explicit biases among survey group members were studied and associations were tested between implicit and explicit measures. RESULTS Of 500 members, 91 (18.2%) individuals completed the race IAT and 70 (14%) completed the SES IAT. Race IAT scores indicated moderate levels of implicit bias (mean = 0.33, d = 0.76; P < 0.001; ie, preference for White individuals). SES IAT scores indicated strong implicit bias (mean = 0.52, d = 1.53; P < 0.001; ie, preference for people from upper SES). There were weak levels of explicit race and wealth bias. There was a strong level of explicit education bias (mean = 5.22, d = 1.19; P < 0.001; ie, preference for educated people). There were nonsignificant correlations between the race and the SES IAT and explicit measures (P > 0.05 for all). CONCLUSIONS As observed across other health care disciplines, among a group of pediatric heart transplant clinicians, there is an implicit preference for individuals who are White and from higher SES, and an explicit preference for educated people. Future studies should evaluate how implicit biases affect clinician behavior and assess the impact of efforts to reduce such biases.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA.
| | - Jennifer Conway
- Department of Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jake Kleinmahon
- Department of Cardiology, Ochsner Hospital for Children, New Orleans, Louisiana, USA
| | - Scott Auerbach
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Daphne Hsu
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, Bronx, New York, USA
| | - Melissa K Cousino
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Beth Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, USA
| | - Juan Alejos
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Jason Hopper Cruz
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Hannah Y Lee
- Department of Pediatrics, Program for Pediatric Cardiomyopathy, Heart Failure and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Ramaraju Rudraraju
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alfred Asante-Korang
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
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29
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Amdani S, Korang AA, Law Y, Cantor R, Koehl D, Kirklin JK, Ybarra M, Rusconi P, Azeka E, Ruiz ACP, Schowengerdt K, Bostdorff H, Joong A. Waitlist and post-transplant outcomes for children with myocarditis listed for heart transplantation over 3 decades. J Heart Lung Transplant 2023; 42:89-99. [PMID: 36038480 DOI: 10.1016/j.healun.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/09/2022] [Accepted: 07/12/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND There is limited and conflicting information on waitlist and transplant outcomes for children with myocarditis. METHODS Retrospective review included children with myocarditis and dilated cardiomyopathy (DCM) listed for HT from January 01, 1993 to December 31, 2019 in the Pediatric Heart Transplant Society database. Clinical characteristics, waitlist and post-HT outcomes (graft loss, rejection, cardiac allograft vasculopathy, infection and malignancy) for children listed from early (1993-2008) and current era (2009-2019) with myocarditis were evaluated and compared to those with DCM. RESULTS Of 9755 children listed, 322 (3.3%) had myocarditis and 3178 (32.6%) DCM. Compared to DCM, children with myocarditis in the early and the current era were significantly more likely to be listed at higher urgency; be in intensive care unit; on mechanical ventilation; extracorporeal membrane oxygenation and ventricular assist device (p < 0.05 for all). While unadjusted analysis revealed lower transplant rates and higher waitlist mortality for children with myocarditis, in multivariable analysis, myocarditis was not a risk factor for waitlist mortality. Myocarditis, however, was a significant risk factor for early phase post-HT graft loss (HR 2.46; p = 0.003). Waitlist and post-HT survival for children with myocarditis were similar for those listed and transplanted in the early era to those listed and transplanted in the current era (p > 0.05 for both). CONCLUSIONS Children with myocarditis have a higher acuity of illness at listing and at HT and have inferior post-HT survival compared to children with DCM. Outcomes for children with myocarditis have not improved over the 3 decades and efforts are needed to improve outcomes for this cohort.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Ohio.
| | | | - Yuk Law
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Ryan Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marion Ybarra
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Paolo Rusconi
- Department of Pediatrics, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Estela Azeka
- Heart Institute (InCor) University of Sao Paulo Medical School, Brazil
| | | | - Kenneth Schowengerdt
- Division of Pediatric Cardiology, Cardinal Glennon Children's Hospital, St. Louis University School of Medicine, St. Louis, Missouri
| | - Hannah Bostdorff
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Ohio
| | - Anna Joong
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Bansal N, Lal AK, Koehl D, Cantor RS, Kirklin JK, Ravekes WJ, Auerbach SR, Baker-Smith CM, Cabrera AG, Amdani S, Urschel S. Impact of race and health coverage on listing and waitlist mortality in pediatric cardiac transplantation. J Heart Lung Transplant 2022; 42:754-764. [PMID: 36641295 DOI: 10.1016/j.healun.2022.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Social factors like race and insurance affect transplant outcomes. However, little is known in pediatric heart transplantation. We hypothesized that race and insurance coverage impact listing and waitlist outcomes across eras. METHODS Data from the Pediatric Heart Transplant Society multi-center registry prospectively collected between January 1, 2000-December 31, 2019 were analyzed. Patients were divided by race as Black, White and other and by insurance coverage at listing (US governmental, US private and non-US single payer systems (UK, Canada). Clinical condition at listing and waitlist outcomes were compared across races and insurance coverages. Categorical variables were compared using a chi-square test and continuous variables using the Wilcoxon rank sum test. Risk factors for waitlist mortality were examined using multiphase parametric hazard modeling. A sensitivity analysis using parametric hazard explored the interaction between race and insurance. RESULTS At listing, compared to Whites (n = 5391) and others (n = 1167), Black patients (n = 1428) were older, more likely on US governmental insurance and had cardiomyopathy as the predominant diagnosis (p < 0.0001). Black patients were more likely to be higher status at listing, in hospital, on inotropes or a ventricular assist device (p < 0.0001). Black patients had significantly shorter time on the waitlist compared to other races (p < 0.0001) but had higher waitlist mortality (p = 0.0091), driven by the earlier era (2000-2009) (p = 0.0005), most prominently within the US private insurance cohort (p = 0.015). Outcomes were not different in other insurance cohorts or in the recent era (2010-2019). CONCLUSION Black children are older and sicker at the time of listing, deteriorate more often and face a higher wait list mortality, despite a shorter waitlist period and favorable clinical factors, with improvement in the recent era associated with the recent US healthcare reforms. The social construct of race appears to disadvantage Black children by limiting referral, consideration or access to pediatric cardiac transplantation.
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Affiliation(s)
- Neha Bansal
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York.
| | - Ashwin K Lal
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, Albama
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, Albama
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, Albama; Department of Surgery, University of Alabama, Birmingham, Albama
| | | | | | | | - Antonio G Cabrera
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | | | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
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Wright LK, Gajarski RJ, Phelps C, Hoffman TM, Lytrivi ID, Magnetta DA, Shaw FR, Thompson C, Weisert M, Nandi D. Worsening racial disparity in waitlist mortality for pediatric heart transplant candidates since the 2016 Pediatric Heart Allocation Policy revision. Pediatr Transplant 2022; 27:e14412. [PMID: 36329630 DOI: 10.1111/petr.14412] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The US Pediatric Heart Allocation Policy (PHAP) was revised in March 2016, with the goal of reducing waitlist mortality. We evaluated the hypothesis that these changes, which increased status exceptions, have worsened racial disparities in waitlist outcomes. METHODS Children in the Pediatric Heart Transplant Study database listed for first heart transplant from January 2012 - June 2020 were included and stratified by listing before (Era 1) or after (Era 2) the PHAP revision. RESULTS A total of 4,089 children were listed during the study period. Compared with white children (n = 2648), non-white children (n = 1441) were more likely to have an underlying diagnosis of cardiomyopathy in both eras. Waitlist mortality was similar in white and non-white children in Era 1, but comparatively worse for non-white children in Era 2. In multivariable analysis controlling for diagnosis, age, and severity markers, non-white children had a significantly higher waitlist mortality only in Era 2 (Era 1: sHR 1.22 [95%CI 0.90 - 1.66] vs. Era 2: sHR 1.57 [95%CI 1.17 - 2.10]). CONCLUSIONS Widening racial disparities in waitlist mortality may be an unintended consequence of the 2016 PHAP revision. Additional analyses may inform the degree to which this policy vs. unrelated changes in care differentially contribute to these disparities.
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Affiliation(s)
- Lydia K Wright
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Robert J Gajarski
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christina Phelps
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Timothy M Hoffman
- University of North Carolina Children's Hospital, Chapel Hill, NC, USA
| | - Irene D Lytrivi
- Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center New York, New York, New York, USA
| | - Defne A Magnetta
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | | | - Molly Weisert
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Deipanjan Nandi
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
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Knaus ME, Onwuka AJ, Bowder A, Courtney C, Deans KJ, Downard CD, Duran YK, Fallat ME, Fraser JD, Gadepalli SK, Kabre R, Kalbfell EL, Kohler J, Lal DR, Landman MP, Lawrence AE, Leys CM, Lu P, Mak GZ, Markel TA, Merchant N, Nguyen T, Pilkington M, Port E, Rymeski B, Saito J, Sato TT, St Peter SD, Wright T, Minneci PC, Grabowski JE. Disparities in the Management of Pediatric Breast Masses. J Surg Res 2022; 279:648-656. [PMID: 35932719 DOI: 10.1016/j.jss.2022.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/18/2022] [Accepted: 06/25/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass. METHODS A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses. RESULTS A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis. CONCLUSIONS We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.
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Affiliation(s)
- Maria E Knaus
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Amanda J Onwuka
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | | | | | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | | | | | | | | | | | | | | | | | - Dave R Lal
- Children's Wisconsin, Milwaukee, Wisconsin
| | | | - Amy E Lawrence
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Patricia Lu
- St. Louis Children's Hospital, St. Louis, Missouri
| | - Grace Z Mak
- Comer Children's Hospital, Chicago, Illinois
| | | | - Naila Merchant
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tina Nguyen
- C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | | | - Elissa Port
- Lurie Children's Hospital, Chicago, Illinois
| | - Beth Rymeski
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | | | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
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Zubair MM, Chen Q, Rowe G, Gill G, Thomas J, Timbalia SA, Osho AA, Bowdish ME, Sood V, Schumacher KR, Chikwe J, Kim RW. Evolving Trends and Widening Racial Disparities in Children Listed for Heart Transplantation in the United States. Circulation 2022; 146:262-264. [PMID: 35861769 DOI: 10.1161/circulationaha.122.060223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M Mujeeb Zubair
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.)
| | - Qiudong Chen
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.)
| | - Georgina Rowe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.)
| | - George Gill
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.)
| | - Jason Thomas
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.)
| | - Shrishiv A Timbalia
- Department of Vascular Surgery, Houston Methodist Hospital, Houston, TX (S.A.T.)
| | - Asishana A Osho
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.).,Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA (A.A.O.)
| | - Michael E Bowdish
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.)
| | - Vikram Sood
- University of Michigan Congenital Heart Center, C. S. Mott Children's Hospital, Ann Arbor, MI (V.S., K.R.S.)
| | - Kurt R Schumacher
- University of Michigan Congenital Heart Center, C. S. Mott Children's Hospital, Ann Arbor, MI (V.S., K.R.S.)
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.)
| | - Richard W Kim
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.)
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Lehman LL, Mostofsky E, Salia S, Gupta S, Barrera FJ, Liou L, Mittleman MA. Racial and Ethnic Disparities in Incidence and Prognosis of Perioperative Stroke Among Pediatric Cardiac Transplant Recipients. J Am Heart Assoc 2022; 11:e025149. [PMID: 35861816 PMCID: PMC9707814 DOI: 10.1161/jaha.121.025149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
In the general population, Black children have a higher incidence of stroke and all‐cause mortality after stroke than White children. Beginning 6 months following cardiac transplantation, Black children have higher mortality than White children. However, whether there are racial and ethnic disparities in incidence and all‐cause mortality following perioperative stroke among pediatric cardiac transplant recipients is unknown.
Methods and Results
Using the Scientific Registry of Transplant Recipients, we studied children who underwent their first heart transplant in the United States between January 1994 and September 2019. Using multivariable logistic regression, we assessed the association between race and ethnicity and perioperative stroke. We used multivariable piecewise Cox regression to examine the association between race and ethnicity and mortality among survivors of perioperative stroke. Among 8224 children who had a first cardiac transplant, 255 (3%) had a perioperative stroke. Black children had 32% lower odds of perioperative stroke compared with White children (adjusted odds ratio, 0.68 [95% CI, 0.46–0.996]). Following perioperative stroke, mortality rates were similar for Black and White children in the first 6 months (adjusted hazard ratio [HR], 0.99 [95% CI, 0.44–2.26]). However, Black children had a higher mortality rate than White children beyond 6 months (adjusted HR, 3.36 [95% CI, 1.22–9.22]).
Conclusions
Among pediatric cardiac transplant recipients, Black children have a lower incidence of perioperative stroke than White children. Among survivors of perioperative stroke, mortality is initially similar by race and ethnicity, but beyond 6 months, Black children have over a 3‐fold higher mortality rate than White children. Identifying and intervening on potential differences in care is essential to addressing these disparities.
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Affiliation(s)
- Laura L. Lehman
- Department of Neurology Boston Children’s Hospital Boston MA
- Harvard Medical School Boston MA
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
| | - Elizabeth Mostofsky
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
| | - Soziema Salia
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
- Department of Internal Medicine Cape Coast Teaching Hospital Cape Coast Ghana
| | - Suruchi Gupta
- Harvard Medical School Boston MA
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine Beth Israel Deaconess Medical Center Boston MA
- Harvard Vanguard Medical Associates Boston Boston MA
| | | | - Lathan Liou
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
- Merck & Co., Merck Research Laboratories Boston MA
| | - Murray A. Mittleman
- Harvard Medical School Boston MA
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
- Division of Cardiovascular Medicine, Department of Medicine Beth Israel Deaconess Medical Center Boston MA
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Abstract
Heart transplantation (HTx) has a storied past, with origins dating back to the early twentieth century and the first pediatric orthotopic heart transplant performed in 1967 on a neonate with Ebstein abnormality. Today, approximately 500 pediatric HTx are performed annually, with survival times now measured in decades rather than days or weeks. In large part, advances in immunosuppression, critical care, dedicated transplant teams and mechanical circulatory support have paved the way for improvements in waitlist mortality and post-transplant survival, with future directions including the development of intracorporeal ventricular assist devices (VADs) for small children, expanding/standardizing donor criteria, and xenotransplantation.
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Waitlist Outcomes for Children With Congenital Heart Disease: Lessons Learned From Over 5000 Heart Transplant Listings in the United States. J Card Fail 2022; 28:982-990. [PMID: 35301110 DOI: 10.1016/j.cardfail.2022.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND We evaluated the impact of pediatric heart-allocation policy changes over time and the approval of the Berlin ventricular assist device (VAD) on waitlist (WL) outcomes for children with congenital heart disease (CHD). METHODS The Scientific Registry of Transplant Recipients database was evaluated to include all children (age < 18) with CHD and cardiomyopathy (CMP) on the WL between 1999 and 2019, divided into 4 eras: Era 1 (1999-2008); Era 2 (2009-2011); Era 3 (2012-2016); and Era 4 (2016-2019). WL characteristics and survival outcomes were evaluated for patients with CHD over time and were compared to those with CMP listed currently (Era 4). RESULTS We included 5185 children with CHD on the WL during the study period; 1999 (39%) were listed in Era 1; 693 (13%) in Era 2; 1196 (23%) in Era 3; and 1297 (25%) in Era 4. Compared to the CHD WL in eras 1 and 2, those in Era 4 were less likely to be infants (48% vs 49% vs 43%), on mechanical ventilation (30% vs 26% vs 19%), on extracorporeal membrane oxygenation (15% vs 9.7% vs 6.2%), and were more likely to be on a VAD (2.4% vs 2.2% vs 6.0%) (P < .05 for all). WL survival improved in children with CHD from Era 1 to Era 4 (P < .001). However, in Era 4, children with CHD had lower WL survival than those with CMP (P < .001). CONCLUSION Children with CHD are increasingly being listed with less advanced heart failure, and they have had improved WL survival over time; however, WL outcomes remain inferior to those with CMP. Advances in pediatric medical and VAD therapy may improve future WL outcomes.
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Amdani S, Marino BS, Rossano J, Lopez R, Schold JD, Tang WHW. Burden of Pediatric Heart Failure in the United States. J Am Coll Cardiol 2022; 79:1917-1928. [PMID: 35550689 DOI: 10.1016/j.jacc.2022.03.336] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/18/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND There are currently limited accurate national estimates for pediatric heart failure (HF). OBJECTIVES This study aims to describe the current burden of primary and comorbid pediatric HF in the United States. METHODS International Classification of Diseases, Clinical Modification codes were used to identify HF cases and comorbidities from the Kids' Inpatient Database, National Inpatient Sample, National Emergency Department (ED) Sample, and National Vital Statistics System for 2012 and 2016. To describe HF events, all visits/events among pediatric and adult subjects were included in the analysis. HF events were classified into 1 of 3 groups: 1) no HF; 2) primary HF; or 3) comorbid HF. We compared patients with and without HF and calculated unique event rates with age and sex standardization. RESULTS Congenital heart disease, conduction disorders/arrhythmias, and cardiomyopathy were responsible for the majority of pediatric HF-related ED visits and hospitalizations. Compared to 2012, in 2016, there was an increase in comorbid HF ED visits (rate ratio: 1.93; P < 0.001) and primary HF hospitalizations (rate ratio: 1.14; P = 0.002). Pediatric HF burden was lower compared to adult HF; however, deaths in the ED and in-hospital were significantly more likely in children presenting with HF than adults. CONCLUSIONS The burden of pediatric HF continues to increase. Compared to adults with HF presenting to the ED and in-hospital, outcomes are inferior and per patient resource use is higher for children hospitalized with HF. National initiatives to understand risk factors for morbidity and mortality in pediatric HF and continued surveillance and mitigation of preventable risk factors may attenuate this uptrend.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA.
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Joseph Rossano
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rocio Lopez
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Bhimani SA, Hsich E, Boyle G, Liu W, Worley S, Bostdorff H, Nasman C, Saarel E, Amdani S. Sex disparities in the current era of pediatric heart transplantation in the United States. J Heart Lung Transplant 2021; 41:391-399. [PMID: 34933797 DOI: 10.1016/j.healun.2021.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND While sex-related differences in transplant outcomes have been well characterized amongst adults, there are no sex-specific pediatric heart transplant studies over the last decade and none evaluating waitlist outcomes. In a contemporary cohort of children undergoing heart transplantation in the United States, this analysis was performed to determine if there were sex disparities in waitlist and/or post-transplant outcomes. METHODS Retrospective review of Scientific Registry of Transplant Recipients database from December 16, 2011 to February 28, 2019 to compare male and female children after listing and after transplant. Demographic, clinical characteristics and outcomes were compared unadjusted and after 1:1 propensity matching for selected covariates. RESULTS Of 4089 patients, 2299 (56%) were males. At listing, males were more likely to be older, have congenital heart disease (58% vs 48%), renal dysfunction (49% vs 44%) and implantable cardioverter defibrillator (9% vs 7%). At transplant, males were more likely to have renal (42 % vs 35%) and liver dysfunction (13% vs 10%), PRA >10% (29% vs 22%) and ischemic time >3.5 hours (p < 0.05 for all). There were no significant sex differences found in unadjusted rates of transplant or mortality. After propensity matching, females had increased waitlist mortality (HR 1.3, 95%CI 1.04-1.5; p =0.019) compared to males. There were no significant differences in post-transplant morbidity or mortality (HR 1.2, 95% CI 0.93-1.5; p = 0.18) between groups. CONCLUSION In a contemporary pediatric cohort, females have inferior heart transplant waitlist survival compared to propensity-matched males despite lower acuity of illness at listing and similar rates of transplantation. There were no sex-disparities noted in post-transplant outcomes.
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Affiliation(s)
- Salima A Bhimani
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Eileen Hsich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gerard Boyle
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Wei Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Hannah Bostdorff
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Colleen Nasman
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | | | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
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