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Sooy-Mossey M, Matsuura M, Ezekian JE, Williams JL, Lee GS, Wood K, Dizon S, Kaplan SJ, Li JS, Parente V. The Association of Race and Ethnicity with Mortality in Pediatric Patients with Congenital Heart Disease: a Systematic Review. J Racial Ethn Health Disparities 2024; 11:2182-2196. [PMID: 37436684 DOI: 10.1007/s40615-023-01687-2] [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: 01/16/2023] [Revised: 06/09/2023] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
CONTEXT Congenital heart disease (CHD) is a common condition with high morbidity and mortality and is subject to racial and ethnic health disparities. OBJECTIVE To conduct a systematic review of the literature to identify differences in mortality in pediatric patients with CHD based on race and ethnicity. DATA SOURCES Legacy PubMed (MEDLINE), Embase (Elsevier), and Scopus (Elsevier) STUDY SELECTION: English language articles conducted in the USA focused on mortality based on race and ethnicity in pediatric patients with CHD. DATA EXTRACTION Two independent reviewers assessed studies for inclusion and performed data extraction and quality assessment. Data extraction included mortality based on patient race and ethnicity. RESULTS There were 5094 articles identified. After de-duplication, 2971 were screened for title and abstract content, and 45 were selected for full-text assessment. Thirty studies were included for data extraction. An additional 8 articles were identified on reference review and included in data extraction for a total of 38 included studies. Eighteen of 26 studies showed increased risk of mortality in non-Hispanic Black patients. Results were heterogenous in Hispanic patients with eleven studies of 24 showing an increased risk of mortality. Results for other races demonstrated mixed outcomes. LIMITATIONS Study cohorts and definitions of race and ethnicity were heterogenous, and there was some overlap in national datasets used. CONCLUSION Overall, racial and ethnic disparities existed in the mortality of pediatric patients with CHD across a variety of mortality types, CHD lesions, and pediatric age ranges. Children of races and ethnicities other than non-Hispanic White generally had increased risk of mortality, with non-Hispanic Black children most consistently having the highest risk of mortality. Further investigation is needed into the underlying mechanisms of these disparities so interventions to reduce inequities in CHD outcomes can be implemented.
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Affiliation(s)
- Meredith Sooy-Mossey
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA.
| | - Mirai Matsuura
- Deparment of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Jordan E Ezekian
- Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jason L Williams
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA
| | - Grace S Lee
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kathleen Wood
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA
| | - Samantha Dizon
- Division of Cardiology, Columbia University Department of Medicine, New York, NY, USA
| | - Samantha J Kaplan
- Medical Center Library and Archives, Duke University, Durham, NC, USA
| | - Jennifer S Li
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA
| | - Victoria Parente
- Pediatric Hospital Medicine, Duke University School of Medicine, Durham, NC, USA
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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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Saha P, Tjoeng YL, Algaze C, Kameny R, Pinto N, Chan T. Racial and Ethnic Disparities in Cardiac Reintervention After Pediatric Cardiac Surgical Procedures. Ann Thorac Surg 2024; 117:1195-1202. [PMID: 37923240 DOI: 10.1016/j.athoracsur.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/17/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Children undergoing cardiac surgical procedures may require postoperative surgical or catheter-based reintervention before discharge. We examined racial/ethnic variations in reintervention and associated in-hospital death. METHODS Children undergoing cardiac surgical procedures from 2004 to 2015 were identified in the Pediatric Health Information Systems (PHIS) database. Regression analysis measured associations between race/ethnicity, in-hospital death, and postoperative cardiac surgical or catheter-based reintervention (surgical/catheter reintervention). RESULTS Of 124,263 patients, 8265 (6.7%) had a surgical/catheter reintervention. Black patients had fewer reinterventions (5.9% vs 6.7%) and higher in-hospital mortality (3.9% vs 2.7%, P < .01) than White patients. After adjusting for sociodemographic and illness severity indicators, Black patients remained less likely to receive surgical/catheter reintervention (adjusted hazard ratio [aHR], 0.89; 95% CI, 0.82-0.98) despite having similar risk of death after reintervention (adjusted odds ratio, 1.17; 95% CI, 0.98-1.41) compared with White patients. The risk of death without surgical/catheter reintervention was also higher for Black (aHR, 1.26; 95% CI, 1.08-1.47) and other race/ethnicity (aHR, 1.33; 95% CI, 1.13-1.57) patients than for White patients. Similar trends were demonstrated when mechanical circulatory support and cardiac transplantation were included as reinterventions. CONCLUSIONS Patients of Black and other race/ethnicity undergoing pediatric cardiac surgical procedures are more likely to die without postoperative cardiac reintervention than White patients. Black patients are also less likely to receive reintervention despite no significant difference in mortality with reintervention. Further studies should evaluate etiologies and methods of addressing these disparities.
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Affiliation(s)
- Priyanka Saha
- The Heart Center, Seattle Children's Hospital, University of Washington, Seattle, Washington; Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.
| | - Yuen Lie Tjoeng
- The Heart Center, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Claudia Algaze
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Rebecca Kameny
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Nelangi Pinto
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Titus Chan
- The Heart Center, Seattle Children's Hospital, University of Washington, Seattle, Washington
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Andrist E, Clarke RG, Phelps KB, Dews AL, Rodenbough A, Rose JA, Zurca AD, Lawal N, Maratta C, Slain KN. Understanding Disparities in the Pediatric ICU: A Scoping Review. Pediatrics 2024; 153:e2023063415. [PMID: 38639640 DOI: 10.1542/peds.2023-063415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized. METHODS Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables. RESULTS The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature. CONCLUSIONS Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.
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Affiliation(s)
- Erica Andrist
- Division of Pediatric Critical Care Medicine
- Departments of Pediatrics
| | - Rachel G Clarke
- Division of Pediatric Critical Care Medicine, Upstate University Hospital, Syracuse, New York
- Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York
| | - Kayla B Phelps
- Division of Pediatric Critical Care Medicine, Louisiana State University Health Sciences Center, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Alyssa L Dews
- Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
- Susan B. Meister Child Health and Adolescent Research Center, University of Michigan, Ann Arbor, Michigan
| | - Anna Rodenbough
- Division of Pediatric Critical Care Medicine, Children's Hospital of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jerri A Rose
- Pediatric Emergency Medicine
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adrian D Zurca
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nurah Lawal
- Stepping Stones Pediatric Palliative Care Program, C.S. Mott Children's Hospital, Ann Arbor, Michigan
- Departments of Pediatrics
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine N Slain
- Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Tjoeng YL, Werho DK, Algaze C, Nawathe P, Benjamin S, Schumacher KR, Chan T. Development of an Equity, Diversity, and Inclusion Committee for a collaborative quality improvement network: Pediatric Cardiac Critical Care Consortium (PC 4) Equity, Diversity and Inclusion (EDI) Committee: white paper 2023. Cardiol Young 2024; 34:563-569. [PMID: 37577942 DOI: 10.1017/s1047951123002950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Racial and ethnic disparities are well described in paediatric cardiac critical care outcomes. However, understanding the mechanisms behind these outcomes and implementing interventions to reduce and eliminate disparities remain a gap in the field of paediatric cardiac critical care. The Pediatric Cardiac Critical Care Consortium (PC4) established the Equity, Diversity, and Inclusion (EDI) Committee in 2020 to promote an equity lens to its aim of improving paediatric cardiac critical care quality and outcomes across North America. The PC4 EDI Committee is working to increase research, quality improvement, and programming efforts to work towards health equity. It also aims to promote health equity considerations in PC4 research. In addition to a focus on patient outcomes and research, the committee aims to increase the inclusion of Black, Indigenous, and People of Color (BIPOC) members in the PC4 collaborative. The following manuscript outlines the development, structure, and aims of the PC4 EDI Committee and describes an analysis of social determinants of health in published PC4 research.
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Affiliation(s)
- Yuen Lie Tjoeng
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - David K Werho
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | - Claudia Algaze
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Pooja Nawathe
- Division of Pediatric Critical Care, Guerin Children's, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Solange Benjamin
- Division of Pediatric Cardiology, Levine Children's Hospital, Charlotte, NC, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C. S. Mott Children's Hospital, University of Michigan. Ann Arbor, MI, USA
| | - Titus Chan
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
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Warren J, Gibbs A, Mpody C, Nafiu OO, Tobias JD, Willer BL. Failure to rescue following postoperative pneumonia in pediatrics: Is there a racial disparity? Paediatr Anaesth 2024; 34:220-224. [PMID: 38055569 DOI: 10.1111/pan.14815] [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: 08/08/2023] [Revised: 11/15/2023] [Accepted: 11/19/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Racial disparities in measures of health and healthcare processes are well described. Limited work exists on disparities in failure to rescue - hospital mortality following a major adverse event. Postoperative pneumonia is a serious, potentially preventable adverse event that often leads to death, i.e., failure to rescue. This study examined the association of racial grouping with failure to rescue following postoperative pneumonia. METHODS We utilized the National Surgical Quality Improvement Program-Pediatrics Participant Use Data File to assemble a cohort of children <18 years who underwent inpatient surgery from 2012 to 2022. We included Black and White patients who developed pneumonia following an index surgery. The primary outcome was failure to rescue, defined as mortality following postoperative pneumonia. We used logistic regression models to estimate the odds ratio and 95% confidence intervals of failure to rescue, comparing Black and White children. RESULTS The study cohort included 3139 children <18 years who developed pneumonia following inpatient surgery. Of those, 2333 (74.3%) were White and 806 (25.7%) were Black. Failure to rescue occurred in 117 of the children (3.7%); 82 were White (3.5%) and 35 were Black (4.3%). After adjusting for gender, age, American Society of Anesthesiologists Physical Status classification, emergent/urgent vs. elective case status, year of operation, and pre-existing comorbidities, the odds of failure to rescue for Black children with postoperative pneumonia did not differ from White children (adjusted-Odds Ratio: 1.00; 95% Confidence Interval 0.62-1.61; p-value = .992). CONCLUSION We found no significant difference in the odds of failure to rescue following postoperative pneumonia between Black or White children. To improve postoperative care for all children and to narrow the racial gap in postoperative mortality, future studies should continue to investigate the association of race with failure to rescue following other postoperative complications.
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Affiliation(s)
- Jalen Warren
- Ohio University Heritage College of Osteopathic Medicine, Dublin Campus and Ohio University, Athens, Ohio, USA
| | - Anna Gibbs
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
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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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Abreu AA, Meier J, Alterio RE, Farah E, Bhat A, Wang SC, Porembka MR, Mansour JC, Yopp AC, Zeh HJ, Polanco PM. Association of race, demographic and socioeconomic factors with failure to rescue after hepato-pancreato-biliary surgery in the United States. HPB (Oxford) 2024; 26:212-223. [PMID: 37863740 DOI: 10.1016/j.hpb.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/12/2023] [Accepted: 10/01/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND We aimed to describe the association of patient-related factors such as race, socioeconomic status, and insurance on failure to rescue (FTR) after hepato-pancreato-biliary (HPB) surgeries. METHODS Using the National Inpatient Sample, we analyzed 98,788 elective HPB surgeries between 2004 and 2017. Major and minor complications were identified using ICD9/10 codes. We evaluated mortality rates and FTR (inpatient mortality after major complications). We used multivariate logistic regression analysis to assess racial, socioeconomic, and demographic factors on FTR, adjusting for covariates. RESULTS Overall, 43 % of patients (n = 42,256) had pancreatic operations, 36% (n = 35,526) had liver surgery, and 21% (n = 21,006) had biliary interventions. The overall major complication rate was 21% (n = 20,640), of which 8% (n = 1655) suffered FTR. Factors independently associated with increased risk for FTR were male sex, older age, higher Charlson Comorbidity Index, Hispanic ethnicity, Asian or other race, lower income quartile, Medicare insurance, and southern region hospitals. CONCLUSIONS Medicare insurance, male gender, Hispanic ethnicity, and lower income quartile were associated with increased risk for FTR. Efforts should be made to improve the identification and subsequent treatment of complications for those at high risk of FTR.
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Affiliation(s)
- Andres A Abreu
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jennie Meier
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rodrigo E Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emile Farah
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Archana Bhat
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sam C Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Abrahim O, Premkumar A, Kubi B, Wolfe SB, Paneitz DC, Singh R, Thomas J, Michel E, Osho AA. Does Failure to Rescue Drive Race/Ethnicity-based Disparities in Survival After Heart Transplantation? Ann Surg 2024; 279:361-365. [PMID: 37144385 DOI: 10.1097/sla.0000000000005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
OBJECTIVE The objective was to assess whether race/ethnicity is an independent predictor of failure to rescue (FTR) after orthotopic heart transplantation (OHT). SUMMARY BACKGROUND DATA Outcomes following OHT vary by patient level factors; for example, non-White patients have worse outcomes than White patients after OHT. Failure to rescue is an important factor associated with cardiac surgery outcomes, but its relationship to demographic factors is unknown. METHODS Using the United Network for Organ Sharing database, we included all adult patients who underwent primary isolated OHT between 1/1/2006 snd 6/30/2021. FTR was defined as the inability to prevent mortality after at least one of the UNOS-designated postoperative complications. Donor, recipient, and transplant characteristics, including complications and FTR, were compared across race/ethnicity. Logistic regression models were created to identify factors associated with complications and FTR. Kaplan Meier and adjusted Cox proportional hazards models evaluated the association between race/ethnicity and posttransplant survival. RESULTS There were 33,244 adult, isolated heart transplant recipients included: the distribution of race/ethnicity was 66% (n=21,937) White, 21.2% (7,062) Black, 8.3% (2,768) Hispanic, and 3.3% (1,096) Asian. The frequency of complications and FTR differed significantly by race/ethnicity. After adjustment, Hispanic recipients were more likely to experience FTR than White recipients (OR 1.327, 95% CI[1.075-1.639], P =0.02). Black recipients had lower 5-year survival compared with other races/ethnicities (HR 1.276, 95% CI[1.207-1.348], P <0.0001). CONCLUSIONS In the US, Black recipients have an increased risk of mortality after OHT compared with White recipients, without associated differences in FTR. In contrast, Hispanic recipients have an increased likelihood of FTR, but no significant mortality difference compared with White recipients. These findings highlight the need for tailored approaches to addressing race/ethnicity-based health inequities in the practice of heart transplantation.
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Affiliation(s)
- Orit Abrahim
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
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Hentati F, Kim J, Hoying D, D'Anza B, Rodriguez K. Race and Area of Deprivation Index Predict Outcomes of Endoscopic Sinus Surgery for Chronic Sinusitis. Am J Rhinol Allergy 2024; 38:6-13. [PMID: 37796754 DOI: 10.1177/19458924231204129] [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] [Indexed: 10/07/2023]
Abstract
OBJECTIVE The purpose of this study is to characterize the presentation, outcomes, and barriers to care for White and non-White patients undergoing endoscopic sinus surgery (ESS). BACKGROUND ESS is often successful in providing long-term relief for patients suffering from chronic rhinosinusitis (CRS). Literature that uses robust measures of socioeconomic status (SES) and barriers to care to assess ESS outcomes is limited. METHODS A retrospective matched cohort study of patients who underwent ESS for CRS between 1/1/2015 and 6/1/2021 at a single tertiary care academic center was conducted. White and non-White patients were matched 1-to-1 by sex and age (± 5 years). SES was evaluated using the area of deprivation index (ADI). RESULTS Of the 298 patients included in the study, 149 are White and 149 are non-White, 111 (37.2%) have CRS with nasal polyposis (CRSwNP), 141 (47.3%) had allergic rhinitis, 90 (30.2%) had asthma and 22 (7.4%) required revision ESS. Non-White patients were 3.62 times more likely to present with CRSwNP (95% confidence interval [CI] 2.2-5.96) and had 2.87 times increased odds for requiring revision ESS than age and sex-matched White patients (95% CI 1.090-7.545). The median ADI for non-White (6.00) patients was higher than for White patients (3.00) (P < .001) and 21.5% more non-White patients presented with Medicaid (P < .001). CONCLUSION Non-White patients undergoing ESS for CRS are more likely to present from areas with fewer resources and be underinsured. Using robust measures of SES, such as ADI, may allow for care to be tailored to patients with barriers to care.
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Affiliation(s)
- Firas Hentati
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jaehee Kim
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - David Hoying
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Brian D'Anza
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kenneth Rodriguez
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Alabbadi S, Rowe G, Gill G, Chikwe J, Egorova N. Racial Disparities in Failure to Rescue after Pediatric Heart Surgeries in the US. J Pediatr 2024; 264:113734. [PMID: 37739060 DOI: 10.1016/j.jpeds.2023.113734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVE To identify the trend in failure to rescue (FTR) and risk factors contributing to racial disparities in FTR after pediatric heart surgery using contemporary nationwide data. STUDY DESIGN We identified 85 267 congenital heart surgeries in patients <18 years of age from 2009 to 2019 using the Kid's Inpatient Database. The primary outcome was FTR. A mixed-effect logistic regression model with hospital random intercept was used to identify independent predictors of FTR. RESULTS Among 36 753 surgeries with postoperative complications, the FTR was 7.3%. The FTR decreased from 7.4% in 2009 to 6.3% in 2019 (P = .02). FTR was higher among Black than White children for all years. The FTR was higher among girls (7.2%) vs boys (6.6%), children aged <1 (9.6%) vs 12-17 years (2.4%), and those of Black (8.5%) vs White race (5.9%) (all P < .05). Black race was associated with a higher FTR odds (OR, 1.40; 95% CI, 1.20-1.65) after adjusting for demographics, medical complexity, nonelective admission, and hospital surgical volume. Higher hospital volume was associated with a lower odds of FTR for all racial groups, but fewer Black (19.7%) vs White (31%) children underwent surgery at high surgical volume hospitals (P < .001). If Black children were operated on in the same hospitals as White children, the racial differences in FTR would decrease by 47.3%. CONCLUSIONS Racial disparities exist in FTR after pediatric heart surgery in the US. The racial differences in the location of care may account for almost half the disparities in FTR.
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Affiliation(s)
- Sundos Alabbadi
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Georgina Rowe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - George Gill
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
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12
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Smith MB, Dervan LA, Watson RS, Ohman RT, Albert JEM, Rhee EJ, Vavilala MS, Rivara FP, Killien EY. Family Presence at the PICU Bedside: A Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:1053-1062. [PMID: 38055001 DOI: 10.1097/pcc.0000000000003334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
OBJECTIVES To determine factors associated with bedside family presence in the PICU and to understand how individual factors interact as barriers to family presence. DESIGN Mixed methods study. SETTING Tertiary children's hospital PICU. SUBJECTS Five hundred twenty-three children of less than 18 years enrolled in the Seattle Children's Hospital Outcomes Assessment Program from 2011 to 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Quantitative: Family was documented every 2 hours. Exposures included patient and illness characteristics and family demographic and socioeconomic characteristics. We used multivariable logistic regression to identify factors associated with presence of less than 80% and stratified results by self-reported race. Longer PICU length of stay (LOS), public insurance, and complex chronic conditions (C-CD) were associated with family presence of less than 80%. Self-reported race modified these associations; no factors were associated with lower bedside presence for White families, in contrast with multiple associations for non-White families including public insurance, C-CD, and longer LOS. Qualitative: Thematic analysis of social work notes for the 48 patients with family presence of less than 80% matched on age, LOS, and diagnosis to 48 patients with greater than or equal to 95% family presence. Three themes emerged: the primary caregiver's prior experiences with the hospital, relationships outside of the hospital, and additional stressors during the hospitalization affected bedside presence. CONCLUSIONS We identified sociodemographic and illness factors associated with family bedside presence in the PICU. Self-reported race modified these associations, representing racism within healthcare. Family presence at the bedside may help identify families facing greater disparities in healthcare access.
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Affiliation(s)
- Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA
| | - Robert T Ohman
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
| | - J Elaine-Marie Albert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Eileen J Rhee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Department of Anesthesiology, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Frederick P Rivara
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
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13
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Tjoeng YL, Olsen J, Friedland-Little JM, Chan T. Association Between Race/Ethnicity and Severity of Illness in Pediatric Cardiomyopathy and Myocarditis. Pediatr Cardiol 2023; 44:1788-1799. [PMID: 37329452 DOI: 10.1007/s00246-023-03203-z] [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: 03/04/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Previous reports demonstrate racial/ethnic differences in survival for children hospitalized with cardiomyopathy and myocarditis. The impact of illness severity, a potential mechanism for disparities, has not been explored. METHODS Using the Virtual Pediatric Systems (VPS, LLC), we identified patients ≤ 18 years old admitted to the intensive care unit (ICU) for cardiomyopathy/myocarditis. Multivariate regression models were used to evaluate the association between race/ethnicity and Pediatric Risk of Mortality (PRISM 3). Multivariate logistic and competing risk regression was used to examine the relationship between race/ethnicity and mortality, CPR, and ECMO. RESULTS Black patients had higher PRISM 3 scores on first admission (𝛽 = 2.02, 95% CI: 0.15, 3.90). There was no difference in survival across race/ethnicity over multiple hospitalizations. Black patients were less likely to receive a heart transplant (SHR = 0.65, 95% CI: 0.45-0.92). Black and unreported race/ethnicity had higher odds of CPR on first admission (OR = 1.64, 95% CI: 1.01-2.45; OR = 2.12, 95% CI: 1.11-4.08, respectively). CONCLUSION Black patients have higher severity of illness on first admission to the ICU, which may reflect differences in access to care. Black patients are less likely to receive a heart transplant. Additionally, Black patients and those with unreported race/ethnicity had higher odds of CPR, which was not mediated by severity of illness, suggesting variations in care may persist after admission.
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Affiliation(s)
- Yuen Lie Tjoeng
- Seattle Children's Hospital, Division of Pediatric Critical Care, University of Washington, 4800 Sand Point Way NE M/S RC2.820, Seattle, WA, 98105, USA.
| | - Jillian Olsen
- Boston Children's Hospital, Division of Critical Care Medicine, Harvard Medical School, Boston, Massachusetts), USA
| | - Joshua M Friedland-Little
- Seattle Children's Hospital, Division of Pediatric Cardiology, University of Washington, Seattle, Washington), USA
| | - Titus Chan
- Seattle Children's Hospital, Division of Pediatric Critical Care, University of Washington, 4800 Sand Point Way NE M/S RC2.820, Seattle, WA, 98105, USA
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14
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Willer BL, Mpody C, Nafiu O, Tobias JD. Racial Disparities in Pediatric Mortality Following Transfusion Within 72 Hours of Operation. J Pediatr Surg 2023; 58:2429-2434. [PMID: 37652843 DOI: 10.1016/j.jpedsurg.2023.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 07/24/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Postoperative bleeding and transfusion are correlated with mortality risk. Furthermore, postoperative bleeding may often initiate the cascade of complications that leads to death. Given that minority children have increased risk of surgical complications, this study aimed to investigate the association of race with pediatric surgical mortality following postoperative transfusion. METHODS We used the NSQIP-P PUF to assemble a retrospective cohort of children <18 who underwent inpatient surgery during 2012-2021. We included White, Black, Hispanic, and 'Other' children who received a transfusion within 72 h of surgery. The primary outcome was defined as all-cause mortality within 30 days following the primary surgical procedure. Using logistic regression models, we estimated the risk-adjusted odds ratio (aOR) and 95% confidence intervals (CI) of mortality, comparing each racial/ethnic cohort to White children. RESULTS A total of 466,230 children <18 years of age underwent inpatient surgical procedures from 2012 to 2021. Of these, 46,200 required transfusion and were included in our analysis. The majority of patients were non-Hispanic White (64.6%, n = 29,850), while 18.9% (n = 8752) were non-Hispanic Black, 11.7% (n = 5387) were Hispanic, and 4.8% (n = 2211) were 'Other' race. The overall rate of mortality following transfusion was 2.5%. White children had the lowest incidence of mortality (2.0%), compared to children of 'Other' race (2.5%), Hispanic children (3.1%), and Black children (3.6%). After adjusting for sex, age, comorbidities, case status, preoperative transfusion within 48 h, and year of operation, we found that Black children experienced 1.24 times the odds of mortality following a postoperative transfusion compared to a White child (aOR: 1.24; 95%CI, 1.03-1.51; P = 0.025). Hispanic children were also significantly more likely to die following a postoperative transfusion than White children (aOR: 1.19; 95%CI, 1.02-1.39; P = 0.027). CONCLUSION We found that minority children who required a postoperative transfusion had a higher odds of death than White children. Future studies should explore adverse events following postoperative transfusion and the differences in their management by race that may contribute to the higher mortality rate for minority children. LEVEL OF EVIDENCE Level II. CLINICAL TRIAL NUMBER AND REGISTRY Not applicable.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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15
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Ross FJ, Latham G, Tjoeng L, Everhart K, Jimenez N. Racial and Ethnic Disparities in U.S Children Undergoing Surgery for Congenital Heart Disease: A Narrative Literature Review. Semin Cardiothorac Vasc Anesth 2023; 27:224-234. [PMID: 36514942 DOI: 10.1177/10892532221145229] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Congenital Heart Disease (CHD) is a significant source of pediatric morbidity and mortality. As in other fields of medicine, studies have demonstrated racial and ethnic disparities in congenital heart disease outcomes. The cause of these outcome disparities is multifactorial, involving biological, behavioral, environmental, sociocultural, and systemic medical factors. Potential contributors include differences in preoperative illness severity secondary to coexisting medical conditions, differences in the rate of prenatal and early postnatal detection of CHD, and delayed access to care, as well as discrepancies in socioeconomic and insurance status, and systemic disparities in hospital care. Understanding the factors that contribute to these disparities is an essential step towards developing strategies to address them. As stewards of the perioperative surgical home, anesthesiologists have an important role in developing institutional policies that mitigate racial disparities. Here, we provide a thorough narrative review of recent research concerning perioperative factors contributing to surgical outcomes disparities for children of all ages with CHD, examine potentially modifiable contributing factors, discuss avenues for future research, and suggest strategies to address disparities both locally and nationally.
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Affiliation(s)
- Faith J Ross
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Gregory Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Lie Tjoeng
- Department of Critical Care Medicine/Department of Cardiology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Kelly Everhart
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
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16
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El-Amin A, Koehlmoos T, Yue D, Chen J, Benharash P, Franzini L. Does universal insurance influence disparities in high-quality hospital use for inpatient pediatric congenital heart defect care within the first year of diagnosis? BMC Health Serv Res 2023; 23:702. [PMID: 37381049 DOI: 10.1186/s12913-023-09668-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Healthcare disparities are an issue in the management of Congenital Heart Defects (CHD) in children. Although universal insurance may mitigate racial or socioeconomic status (SES) disparities in CHD care, prior studies have not examined these effects in the use of High-Quality Hospitals (HQH) for inpatient pediatric CHD care in the Military Healthcare System (MHS). To assess for racial and SES disparities in inpatient pediatric CHD care that may persist despite universal insurance coverage, we performed a cross-sectional study of the HQH use for children treated for CHD in the TRICARE system, a universal healthcare system for the U.S. Department of Defense. In the present work we evaluated for the presence of disparities, like those seen in the civilian U.S. healthcare system, among military ranks (SES surrogate) and races and ethnicities in HQH use for pediatric inpatient admissions for CHD care within a universal healthcare system (MHS). METHODS We conducted a cross-sectional study using claims data from the U.S. MHS Data Repository from 2016 to 2020. We identified 11,748 beneficiaries aged 0 to 17 years who had an inpatient admission for CHD care from 2016 to 2020. The outcome variable was a dichotomous indicator for HQH utilization. In the sample, 42 hospitals were designated as HQH. Of the population, 82.9% did not use an HQH at any point for CHD care and 17.1% used an HQH at some point for CHD care. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of SES status. Patient demographic information at the time of index admission post initial CHD diagnosis (age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, and provider region) and clinical information (complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity) were used as covariates in multivariable logistic regression analysis. RESULTS After controlling for demographic and clinical factors including age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, provider region, complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity, we did not find disparities in HQH use for inpatient pediatric CHD care based upon military rank. After controlling for demographic and clinical factors, lower SES (Other rank) was less likely to use an HQH for inpatient pediatric CHD care; OR of 0.47 (95% CI of 0.31 to 0.73). CONCLUSIONS We found that for inpatient pediatric CHD care in the universally insured TRICARE system, historically reported racial disparities in care were mitigated, suggesting that this population benefitted from expanded access to care. Despite universal coverage, SES disparities persisted in the civilian care setting, suggesting that universal insurance alone cannot sufficiently address differences in SES disparities in CHD care. Future studies are needed to address the pervasiveness of SES disparities and potential interventions to mitigate these disparities such as a more comprehensive patient travel program.
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Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD, US.
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US.
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD, US
| | - Dahai Yue
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
| | - Jie Chen
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, US
- Department of Surgery, University of California, Los Angeles, CA, US
| | - Luisa Franzini
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
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17
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Sooy-Mossey M, Neufeld T, Hughes TL, Weiland MD, Spears TG, Idriss SF, Campbell MJ. Health Disparities in the Treatment of Supraventricular Tachycardia in Pediatric Patients. Pediatr Cardiol 2022; 43:1857-1863. [PMID: 35536424 PMCID: PMC10116600 DOI: 10.1007/s00246-022-02924-x] [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: 02/13/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
Supraventricular tachycardia (SVT) is a common pediatric arrhythmia. The objective of this investigation was to investigate the existence and degree of the health disparities in the treatment of pediatric patients with supraventricular tachycardia based on sociodemographic factors. This was retrospective cohort study at a large academic medical center including children ages 5-18 years old diagnosed with SVT. Patients with congenital heart disease and myocarditis were excluded. Initial treatment and ultimate treatment with either medical management or ablation were determined. The odds of having an ablation procedure were determined based on patient age, sex, race, ethnicity, and insurance status. There was a larger portion of non-White patients (p = 0.033) within the cohort that did not receive an ablation during the study period. Patients that were younger, female, American Indian/Alaskan Native, unknown race, and had missing insurance information were less likely to receive ablation therapy during the study period. In this single center, regional evaluation, we demonstrated that disparities in the treatment of pediatric SVT are present based on multiple patient sociodemographic factors. This study adds evidence to the presence of inequities in health care delivery across pediatric populations.
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Affiliation(s)
- Meredith Sooy-Mossey
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA.
| | - Thomas Neufeld
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Taylor L Hughes
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - M David Weiland
- Division of Pediatric Cardiology, Department of Pediatrics, University of Mississippi, Jackson, MS, USA
| | | | - Salim F Idriss
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA
| | - Michael J Campbell
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA
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18
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Racial/Ethnic Disparities in the Management of Pediatric Acute Pancreatitis Across Children's Hospitals. J Pediatr Gastroenterol Nutr 2022; 75:650-655. [PMID: 36305883 DOI: 10.1097/mpg.0000000000003597] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Racial or ethnic disparities in health care delivery and resource utilization have been reported in a variety of pediatric diseases. In acute pancreatitis (AP), there is an association between Black race and increased inpatient mortality. Data on the association of race and ethnicity and resource use for managing pediatric AP are lacking. The aim of this study is to investigate this potential association in pediatric AP. METHODS Retrospective study of children 0-18 years diagnosed with AP in the Pediatric Health Information System (PHIS) database from 2012 to 2018. Descriptive statistics were used to summarize cohort characteristics. Race/ethnicity classifications included non-Hispanic Black (NHB), non-Hispanic White (NHW, used as reference), Hispanic, and "Other." Associations between patient characteristics and race/ethnicity were determined using χ2 tests. Generalized linear mixed regression model was used to determine the association of race/ethnicity with odds of resource utilization, costs, and length of hospital stay after adjusting for covariates with a random intercept for site. RESULTS Five thousand nine hundred sixty-three patients from 50 hospitals were included. Adjusted analysis showed that NHB children hospitalized with AP were at lower odds of receiving opioids in the first 24 hours [adjusted odds ratio (aOR) = 0.82, 95% confidence interval (CI) = 0.70-0.98] and receiving intravenous fluids during the hospitalization (aOR = 0.64, 95% CI = 0.43-0.96) when compared with NHW children. Additionally, NHB and Hispanic children had a prolonged adjusted mean length of hospital stay and higher hospital costs when compared with NHW children. Although there was no significant association between race/ethnicity and diagnosis of pancreatic necrosis or sepsis, Hispanic and "Other" children were at higher odds of receiving antibiotics during hospitalization for AP (aOR = 1.33, 95% CI = 1.13-1.57 and aOR = 1.37, 95% CI = 1.09-1.73, respectively) than NHW children. CONCLUSIONS Disparities exist in utilization of health care interventions for pediatric AP patients by race/ethnicity. Future studies should investigate why these disparities exist and if these disparities affect outcomes.
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19
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Sengupta A, Gauvreau K, Bucholz EM, Newburger JW, Del Nido PJ, Nathan M. Contemporary Socioeconomic and Childhood Opportunity Disparities in Congenital Heart Surgery. Circulation 2022; 146:1284-1296. [PMID: 36164982 DOI: 10.1161/circulationaha.122.060030] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND While singular measures of socioeconomic status have been associated with outcomes after surgery for congenital heart disease, the multifaceted pathways through which a child's environment impacts similar outcomes remain incompletely characterized. We sought to evaluate the association between childhood opportunity level and adverse outcomes after congenital heart surgery. METHODS Data from patients undergoing congenital cardiac surgery from January 2011 to January 2020 at a quaternary referral center were retrospectively reviewed. Outcomes of interest included predischarge (early) mortality or transplant, postoperative hospital length-of-stay, inpatient cost of hospitalization, postdischarge (late) mortality or transplant, and late unplanned reintervention. The primary predictor was a US census tract-based, nationally-normed composite metric of contemporary child neighborhood opportunity comprising 29 indicators across 3 domains (education, health and environment, and socioeconomic), categorized as very low, low, moderate, high, and very high. Associations between childhood opportunity level and outcomes were evaluated using logistic regression (early mortality), generalized linear (length-of-stay and cost), Cox proportional hazards (late mortality), or competing risk (late reintervention) models, adjusting for baseline patient-related factors, case complexity, and residual lesion severity. RESULTS Of 6133 patients meeting entry criteria, the median age was 2.0 years (interquartile range, 3.6 months-8.3 years). There were 124 (2.0%) early deaths or transplants, the median postoperative length-of-stay was 7 days (interquartile range, 5-13 days), and the median inpatient cost was $76 000 (interquartile range, $50 000-130 000). No significant association between childhood opportunity level and early mortality or transplant was observed (P=0.21). On multivariable analysis, children with very low and low opportunity had significantly longer length-of-stay and incurred higher costs compared with those with very high opportunity (all P<0.05). Of 6009 transplant-free survivors of hospital discharge, there were 175 (2.9%) late deaths or transplants, and 1008 (16.8%) reinterventions at up to 10.5 years of follow-up. Patients with very low opportunity had a significantly greater adjusted risk of late death or transplant (hazard ratio, 1.7 [95% CI, 1.1-2.6]; P=0.030) and reintervention (subdistribution hazard ratio, 1.9 [95% CI, 1.5-2.3]; P<0.001), versus those with very high opportunity. CONCLUSIONS Childhood opportunity level is independently associated with adverse outcomes after congenital heart surgery. Children from resource-limited settings thus constitute an especially high-risk cohort that warrants closer surveillance and tailored interventions.
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Affiliation(s)
- Aditya Sengupta
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA
| | - Kimberlee Gauvreau
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Emily M Bucholz
- Cardiology (K.G., E.M.B., J.W.N.), Boston Children's Hospital, MA
| | - Jane W Newburger
- Cardiology (K.G., E.M.B., J.W.N.), Boston Children's Hospital, MA.,Departments of Pediatrics (J.W.N.), Harvard Medical School, Boston, MA
| | - Pedro J Del Nido
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Surgery (P.J.dN., M.N.), Harvard Medical School, Boston, MA
| | - Meena Nathan
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Surgery (P.J.dN., M.N.), Harvard Medical School, Boston, MA
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20
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Gallegos FN, Woo JL, Anderson BR, Lopez KN. Disparities in surgical outcomes of neonates with congenital heart disease across regions, centers, and populations. Semin Perinatol 2022; 46:151581. [PMID: 35396037 PMCID: PMC9177851 DOI: 10.1016/j.semperi.2022.151581] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To summarize existing literature on neonatal disparities in congenital heart disease surgical outcomes and identify potential policies to address these disparities. FINDING Disparities in outcomes for neonatal congenital heart surgery were largely published under four domains: race/ethnicity, insurance type, neighborhood/socioeconomic status, and cardiac center characteristics. While existing research identifies associations between these domains and mortality, more nuanced analyses are emerging to understand the mediators between these domains and other non-mortality outcomes, as well as potential interventions and policies to reduce disparities. A broader look into social determinants of health (SDOH), prenatal diagnosis, proximity of birth to a cardiac surgical center, and post-surgical outpatient and neurodevelopmental follow-up may accelerate interventions to mitigate disparities in outcomes. CONCLUSION Understanding the mechanisms of how SDOH relate to neonatal surgical outcomes is paramount, as disparities research in neonatal congenital heart surgery continues to shift from identification and description, to intervention and policy.
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Affiliation(s)
- Flora Nuñez Gallegos
- Stanford University School of Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Division of Pediatric Cardiology, Palo Alto, CA
| | - Joyce L. Woo
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital, Department of Pediatrics, Division of Pediatric Cardiology, Chicago, IL
| | - Brett R. Anderson
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Department of Pediatrics, Division of Pediatric Cardiology, New York, NY
| | - Keila N. Lopez
- Baylor College of Medicine Texas Children’s Hospital Department of Pediatrics, Division of Pediatric Cardiology, Houston TX,Corresponding Author:
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21
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Buchanan R, Roy N, Parra MF, Staffa SJ, Brown ML, Nasr VG. Race and Outcomes in Patients with Congenital Cardiac Disease in an Enhanced Recovery Program. J Cardiothorac Vasc Anesth 2022; 36:3603-3609. [PMID: 35577651 DOI: 10.1053/j.jvca.2022.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Disparities in perioperative outcomes exist. In addition to patient and socioeconomic factors, racial disparities in outcome measures may be related to issues at the provider and institutional levels. Recognizing a potential role of standardized care in mitigating provider bias, this study aims to compare the perioperative sedation and pain management and consequent outcomes in Enhanced Recovery After Surgery (ERAS) cardiac patients of different races undergoing congenital heart surgery at a single quaternary children's hospital. DESIGN A retrospective study. SETTING A single quaternary pediatric hospital. PARTICIPANTS Patients, infants to adults, undergoing elective congenital cardiac surgery and enrolled in the ERAS protocol from October 2018 to December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the patients, 872 were reviewed and 606 with race information were analyzed. There was no significant difference in intraoperative and postoperative oral morphine equivalent, perioperative sedatives, and regional blockade in Asian or African American patients when compared to White patients. Postoperative pain scores and outcomes among African American and Asian races were also not statistically different when compared to White patients. CONCLUSIONS Racial disparity in perioperative management and outcomes in patients with standardized ERAS protocols does not exist at the authors' institution. Future comparative studies of ERAS noncardiac patients may provide additional information on the role of standardization in reducing implicit bias.
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Affiliation(s)
- Rica Buchanan
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
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22
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Webber AM, Willer BL. Obesity, Race, and Perioperative Complications. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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23
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The Association Between Race and Adverse Postoperative Outcomes in Children With Congenital Heart Disease Undergoing Noncardiac Surgery. Anesth Analg 2021; 134:357-368. [PMID: 33999011 DOI: 10.1213/ane.0000000000005571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The association between race and perioperative outcomes has been evaluated in adult cardiac surgical and in healthy pediatric patients but has not been evaluated in children with congenital heart disease (CHD) presenting for noncardiac procedures. This study compares the incidence of the primary outcome of 30-day mortality and adverse postoperative outcomes following noncardiac surgery between Black and White children with CHD, stratified by severity. METHODS This is a retrospective study. Comparison of outcomes between Black and White children was performed using the 2012-2018 American College of Surgeons National Surgical Quality Improvement Program Pediatric database and after stratification for severity of CHD and propensity score matching. RESULTS A total of 55,859 patients were included, and divided into 28,601 minor, 23,839 major, and 3419 severe CHD. Black and White children in each category were matched and compared. Following matching in the overall CHD cohort, there were significantly higher rates of the following adverse postoperative outcomes among Black patients as compared to White patients: 30-day mortality (1.84% vs 1.49%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05-1.48; P = .014), composite secondary outcomes (19.90% vs 17.88%; OR, 1.14; 95% CI, 1.08-1.21; P < .001), cardiac arrest (1.42% vs 0.98%; OR, 1.46; 95% CI, 1.19-1.79; P < .001), 30-day reoperation (7.59% vs 6.67%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), and reintubation (3.9% vs 2.95%; OR, 1.34; 95% CI, 1.19-1.52; P < .001). No significant statistical interaction between race and CHD severity was found. Following matching and within the minor CHD cohort, Black children had significantly higher rates of composite secondary outcome (17.44% vs 15.60%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), cardiac arrest (1.02% vs 0.53%; OR, 1.94; 95% CI, 1.37-2.76; P < .001), 30-day reoperation (7.19% vs 5.77%; OR, 1.26; 95% CI, 1.11-1.43; P < .001), and thromboembolic complications (0.49% vs 0.23%; OR, 2.17; 95% CI, 1.29-3.63; P = .003) compared to White children. In the major CHD cohort, Black children had significantly higher rates of 30-day mortality (2.75% vs 2.05%; OR, 1.35; 95% CI, 1.08-1.69; P = .008) and reintubation (4.82% vs 3.72%; OR, 1.32; 95% CI, 1.11-1.56; P = .002). There were no statistically significant differences in outcomes in the severe CHD category for 30-day mortality (3.36% vs 3.3%; OR, 1.02; 95% CI, 0.60-1.73; P = .946), composite secondary outcome (22.65% vs 21.36%; OR, 1.08; 95% CI, 0.86-1.36; P = .517) nor the components of the composite secondary outcomes. CONCLUSIONS Race is associated with postoperative mortality and complications in children with minor and major CHD undergoing noncardiac surgery. No significant association was observed between race and postoperative outcomes in patients with severe CHD. This is consistent with previous findings wherein in patients with severe CHD, residual lesion burden and functional status is the leading predictor of outcomes following noncardiac surgery. Nevertheless, there is no evidence that the relationship between race and outcomes differs across the CHD severity categories. Future studies to understand the mechanisms leading to the racial difference, including institutional, clinical, and individual factors are needed.
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Richardson CJ, Itua P, Duong T, Lewars J, Tiesenga F. Racial and socioeconomic disparities in congenital heart surgery: A research article. J Card Surg 2021; 36:2454-2457. [PMID: 33749883 DOI: 10.1111/jocs.15511] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Though the modern era has proven to be reassuring with the advancement of perioperative care leading to improved survival, congenital heart disease (CHD) continues to underscore its significance in the lives of newborns and families worldwide. Particularly, CHD has disproportionately afflicted vulnerable minorities such as Black and Hispanic populations from the standpoint of ethnic disparities in mortality following heart surgery, increased resource utilization, and longer durations of stay. This study aims to identify and provide insight regarding the relationships between the aforementioned factors to develop targeted strategies of intervention to mitigate the outcomes for patients of these specific populations. METHODS Free, current peer-reviewed literature from databases such as the American Heart Association, The European Heart Journal, Science Direct, and PubMed regarding CHD, racial disparities, and socioeconomic variances were accessed. The study was narrowed to a patient population including only infants without chromosomal anomalies or those that passed away before hospital discharge. RESULTS Having private insurance and maternal education showed positive correlations with positive outcomes of patients post congenital heart surgery. Teaching hospitals were linked with increased mortality and complications. Male infants showed higher rates of complications. Hispanics had increased odds of complications. Black patients had increased risk for failures in being rescued. CONCLUSIONS Race plays a major role in the disparities in CHD, it is imperative to evaluate the socioeconomic contributors, surgical efforts, and provisions in place regarding minority patients. The apparency of these disparities, and willingness to invoke changes in practice has the potential for improvements in outcomes for these patients.
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Affiliation(s)
- Crystal J Richardson
- Department of Internal Medicine, Saint James School of Medicine, The Quarter, Anguilla
| | - Priscilla Itua
- Department of Internal Medicine, All Saints University School of Medicine, Roseau, Dominica
| | - Thuy Duong
- Department of Internal Medicine, Windsor University School of Medicine, Cayon, Saint Kitts and Nevis
| | - Jennaire Lewars
- Department of Internal Medicine, Saint James School of Medicine, Arnos Vale, Saint Vincent and the Grenadines
| | - Frederick Tiesenga
- Department of General Surgery, West Suburban Hospital Medical Center, Oak Park, Illinois, USA
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25
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Willer BL, Mpody C, Tobias JD, Nafiu OO. Racial Disparities in Failure to Rescue Following Unplanned Reoperation in Pediatric Surgery. Anesth Analg 2021; 132:679-685. [PMID: 33332903 DOI: 10.1213/ane.0000000000005329] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Failure to rescue (FTR) and unplanned reoperation following an index surgical procedure are key indicators of the quality of surgical care. Given that differences in unplanned reoperation and FTR rates among racial groups may contribute to persistent disparities in postsurgical outcomes, we sought to determine whether racial differences exist in the risk of FTR among children who required unplanned reoperation following inpatient surgical procedures. METHODS We used the National Surgical Quality Improvement database (2012-2017) to assemble a cohort of children (<18 years), who underwent inpatient surgery and subsequently returned to the operating room within 30 days of the index surgery. We used logistic regression models to estimate the odds ratio (OR) and 95% confidence interval (CI) of FTR, comparing African American (AA) to White children. We estimated the risk-adjusted odds ratio (aOR) for FTR by controlling the analyses for demographic characteristics, surgical profile, and preoperative comorbidities. We further evaluated the racial differences in FTR by stratifying the analyses by the timing of unplanned reoperation. RESULTS Of 276,917 children who underwent various inpatient surgical procedures, 10,425 (3.8%) required an unplanned reoperation, of whom 2016 (19.3%) were AA and 8409 (80.7%) were White. Being AA relative to being White was associated with a 2-fold increase in the odds of FTR (aOR: 2.03; 95% CI, 1.5-2.74; P < .001). Among children requiring early unplanned reoperation, AAs were 2.38 times more likely to die compared to their White peers (8.9% vs 3.4%; aOR: 2.38; 95% CI, 1.54-3.66; P < .001). In children with intermediate timing of return to the operating room, the risk of FTR was 80% greater for AA children compared to their White peers (2.2% vs 1.1%; aOR: 1.80; 95% CI, 1.07-3.02; P = .026). Typically, AA children die within 5 days (interquartile range [IQR]: 1-16) of reoperation while their White counterparts die within 9 days following reoperation (IQR: 2-26). CONCLUSIONS Among children requiring unplanned reoperation, AA patients were more likely to die than their White peers. This racial difference in FTR rate was most noticeable among children requiring early unplanned reoperation. Time to mortality following unplanned reoperation was shorter for AA than for White children. Race appears to be an important determinant of FTR following unplanned reoperation in children and it should be considered when designing interventions to optimize unplanned reoperation outcomes.
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Affiliation(s)
- Brittany L Willer
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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26
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Olsen J, Tjoeng YL, Friedland-Little J, Chan T. Racial Disparities in Hospital Mortality Among Pediatric Cardiomyopathy and Myocarditis Patients. Pediatr Cardiol 2021; 42:59-71. [PMID: 33025028 DOI: 10.1007/s00246-020-02454-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/07/2020] [Indexed: 11/25/2022]
Abstract
Racially disparate health outcomes exist for a multitude of populations and illnesses. It is unknown how race and ethnicity impact mortality for children with cardiomyopathy or myocarditis. This retrospective cross-sectional study employed the Kids' Inpatient Database to analyze 34,617 hospital admissions for patients ≤ 18 years old with cardiomyopathy, myocarditis, or both, without concomitant congenital heart disease. Multivariate logistic regression models investigated the impact of race/ethnicity on in-hospital mortality adjusting for age, calendar year, sex, insurance type, diagnostic category, treatment at a pediatric hospital, and non-cardiac organ dysfunction. African American race and Hispanic ethnicity were independent risk factors for mortality (African American: odds ratio (OR) 1.25, 95% confidence interval (CI) 1.01-1.53 and Hispanic: OR 1.29, 95% CI 1.03-1.60). African American race was also found to be significantly associated with the use of extracorporeal membrane oxygenation (ECMO), mortality while on ECMO, and cardiac arrest. Adjusting the regression model for ECMO and arrest attenuated the impact of African American race on mortality, suggesting that these variables may indeed play a role in explaining the impact of race on mortality for African American patients with myocardial disease. Hispanic ethnicity remained associated with higher risk of mortality despite controlling for all mechanical circulatory support and transplant (OR 1.30, 95% CI 1.04-1.63). Children of racial and ethnic minorities hospitalized with cardiomyopathy or myocarditis are more likely to die than their white counterparts, a trend that may be due at least in part to in-hospital differences in care or response to therapy.
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Affiliation(s)
- Jillian Olsen
- The Heart Center, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Yuen Lie Tjoeng
- The Heart Center, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Joshua Friedland-Little
- The Heart Center, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Titus Chan
- The Heart Center, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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Kim S, Balmert L, Raval MV, Johnson EK, Abdullah F, Chu DI. Association of number and type of serious complications with failure to rescue in children undergoing surgery: A NSQIP-Pediatric analysis. J Pediatr Surg 2020; 55:2584-2590. [PMID: 32430105 DOI: 10.1016/j.jpedsurg.2020.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/23/2020] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Failure to rescue (FTR) represents death after a serious complication. This study aims to determine the FTR rate in a pediatric surgical population, and if number (1 or 2+) and type of serious complications are associated with FTR. METHODS A secondary analysis was performed using the National Surgical Quality Improvement Program Pediatric database from 2012 to 2016. Primary and secondary exposures of interest were number (1 or 2+) and type of serious complications, respectively. Propensity score analysis adjusted for baseline covariates. Primary outcome was FTR. RESULTS Of 36,167 children with ≥1 serious complication, there were 851 deaths resulting in a FTR rate of 2.4%. Having 2+ serious complications was associated with higher adjusted odds of FTR (OR 1.77, 95% CI 1.52-2.08, p < 0.0001). Among those who had one complication, the type of serious complication was significantly associated with FTR. When type of initial serious complication was adjusted, number of serious complications continued to be strongly associated with FTR (OR 2.00, 95% CI 1.67-2.38, p < 0.0001). CONCLUSIONS FTR rate within a large, diverse, multi-specialty pediatric surgical population was 2.4%. Both number and type of postoperative complications were associated with FTR. These findings may facilitate early recognition of high-risk patients and identify quality targets for pediatric surgical centers. LEVEL OF EVIDENCE Retrospective study (secondary analysis), Level II.
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Affiliation(s)
- Soojin Kim
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada; Department of Urologic Sciences, British Columbia Children's Hospital, Vancouver, BC, Canada.
| | - Lauren Balmert
- Biostatistics Collaboration Center, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mehul V Raval
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilie K Johnson
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Fizan Abdullah
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David I Chu
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
BACKGROUND The perioperative complications rate in paediatric cardiac surgery, as well as the failure-to-rescue impact, is less known in low- and middle-income countries. AIM To evaluate perioperative complications rate, mortality related to complications, different patients' demographics, and procedural risk factors for perioperative complication and post-operative death. METHODS Risk factors for perioperative complications and operative mortality were assessed in a retrospective single-centre study which included 296 consecutive children undergoing cardiac surgery. RESULTS Overall mortality was 5.7%. Seventy-three patients (24.7%) developed 145 perioperative complications and had 17 operative mortalities (23.3%). There was a strong association between the number of perioperative complications and mortality - 8.1% among patients with only 1 perioperative complication, 35.3% - with 2 perioperative complications, and 42.1% - with 3 or more perioperative complications (p = 0.007). Risk factors of perioperative complications were younger age (odds ratio 0.76; (95% confidence interval 0.61, 0.93), previous cardiac surgery (odds ratio 3.5; confidence interval 1.33, 9.20), extracardiac structural anomalies (odds ratio 3.03; confidence interval 1.27, 7.26), concomitant diseases (odds ratio 3.23; confidence interval 1.34, 7.72), and cardiopulmonary bypass (odds ratio 6.33; confidence interval 2.45, 16.4), whereas the total number of perioperative complications per patient was the only predictor of operative death (odds ratio 1.89; confidence interval 1.06, 3.37). CONCLUSIONS In a program with limited systemic resources, failure-to-rescue is a major contributor to operative mortality in paediatric cardiac surgery. Despite the comparable crude mortality, the operative mortality among patients with perioperative complications in our series was significantly higher than in the developed world. A number of initiatives are needed in order to improve failure-to-rescue rates in low- and middle-income countries.
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29
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The global unmet need of congenital cardiac care: a quantitative analysis of the global burden of disease. Cardiol Young 2020; 30:1688-1693. [PMID: 32815495 DOI: 10.1017/s1047951120002577] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND CHDs are one of the most frequent congenital malformations, affecting one in hundred live births. In total, 70% will require treatment in the first year of life, but over 90% of cases in low- and middle-income countries receive no treatment or suboptimal treatment. As a result, CHDs are responsible for 66% of preventable deaths due to congenital malformations in low- and middle-income countries. This study examines the unmet need of congenital cardiac care around the world based on the global burden of disease. MATERIALS AND METHODS CHD morbidity and mortality data for 2006, 2011, and 2016 were collected from the Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool and analysed longitudinally to assess trends in excess morbidity and mortality. RESULTS Between 2006 and 2016, a 20.7% reduction in excess disability-adjusted life years and 20.6% reduction in excess deaths due to CHDs were observed for children under 15. In 2016, excess global morbidity and mortality due to CHDs remained high with 14,788,418.7 disability-adjusted life years and 171,761.8 paediatric deaths, respectively. In total, 90.2% of disability-adjusted life years and 91.2% of deaths were considered excess. CONCLUSION This study illustrates the unmet need of congenital cardiac care around the world. Progress has been made to reduce morbidity and mortality due to CHDs but remains high and largely treatable around the world. Limited academic attention for global paediatric cardiac care magnifies the lack of progress in this area.
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Gurney JK, McLeod M, Stanley J, Campbell D, Boyle L, Dennett E, Jackson S, Koea J, Ongley D, Sarfati D. Postoperative mortality in New Zealand following general anaesthetic: demographic patterns and temporal trends. BMJ Open 2020; 10:e036451. [PMID: 32973053 PMCID: PMC7517556 DOI: 10.1136/bmjopen-2019-036451] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES In this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017. DESIGN, PARTICIPANTS AND SETTING We use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period. RESULTS AND CONCLUSION A total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3-6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Māori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties.
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Affiliation(s)
- Jason K Gurney
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Melissa McLeod
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - James Stanley
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Doug Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland DHB Anaesthesia, Auckland District Health Board, Auckland, New Zealand
| | - Luke Boyle
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | - Elizabeth Dennett
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
- Department of General Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Sarah Jackson
- Department of Anaesthesia, Capital and Coast District Health Board, Wellington, New Zealand
| | - Jonathan Koea
- Department of General Surgery, Waitemata District Health Board, Takapuna, New Zealand
| | - Dick Ongley
- Department of Anaesthesia, Canterbury District Health Board, Christchurch, New Zealand
| | - Diana Sarfati
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
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31
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Pecha PP, Hamberis A, Patel TA, Melvin CL, Ford ME, Andrews AL, White DR, Schlosser RJ. Racial Disparities in Pediatric Endoscopic Sinus Surgery. Laryngoscope 2020; 131:E1369-E1374. [PMID: 32886373 DOI: 10.1002/lary.29047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/14/2020] [Accepted: 08/04/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the impact of race and ethnicity on 30-day complications following pediatric endoscopic sinus surgery (ESS). STUDY DESIGN Cross-sectional cohort study. SUBJECTS AND METHODS Patients ≤ 18 years of age undergoing ESS from 2015 to 2017 were identified in the Pediatric National Surgical Improvement Program-Pediatric database. Patient demographics, comorbidities, surgical indication, and postoperative complications were extracted. Patient race/ethnicity included non-Hispanic black, non-Hispanic white, Hispanic, and other. Multivariable logistic regression was performed to determine if race/ethnicity was a predictor of postoperative complications after ESS. RESULTS A total of 4,337 patients were included in the study. The median age was 10.9 (interquartile range: 14.5-6.7) years. The cohort was comprised of 68.3% non-Hispanic white, 13.9% non-Hispanic black, 9.7% Hispanic, and 2.1% other. The 30-day complication rate was 3.2%, and the mortality rate was 0.3%. The rate of reoperation was 3.8%, and readmission was 4.1%. Black and Hispanic patients had higher rates of urgent operations (P = .003 and P < .001, respectively), and black patients had a higher incidence of emergent operations (P < .001) compared to their white peers. For elective ESS cases, multivariable analysis adjusting for sex, age, comorbidities, and surgical indication indicated that children of Hispanic ethnicity had increased postoperative complications (odds ratio: 1.57, 95% confidence interval: 1.04-2.37). CONCLUSION This analysis demonstrated that black and Hispanic children disproportionately undergo more urgent and emergent ESS. Hispanic ethnicity was associated with increased 30-day complications following elective pediatric ESS. Further studies are needed to elucidate potential causes of these disparities and identify areas for improvement. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E1369-E1374, 2021.
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Affiliation(s)
- Phayvanh P Pecha
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Alexandra Hamberis
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Terral A Patel
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Cathy L Melvin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Marvella E Ford
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Anne L Andrews
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - David R White
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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Lopez KN, Morris SA, Sexson Tejtel SK, Espaillat A, Salemi JL. US Mortality Attributable to Congenital Heart Disease Across the Lifespan From 1999 Through 2017 Exposes Persistent Racial/Ethnic Disparities. Circulation 2020; 142:1132-1147. [PMID: 32795094 DOI: 10.1161/circulationaha.120.046822] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Congenital heart disease (CHD) accounts for ≈40% of deaths in US children with birth defects. Previous US data from 1999 to 2006 demonstrated an overall decrease in CHD mortality. Our study aimed to assess current trends in US mortality related to CHD from infancy to adulthood over the past 19 years and determine differences by sex and race/ethnicity. METHODS We conducted an analysis of death certificates from 1999 to 2017 to calculate annual CHD mortality by age at death, race/ethnicity, and sex. Population estimates used as denominators in mortality rate calculations for infants were based on National Center for Health Statistics live birth data. Mortality rates in individuals ≥1 year of age used US Census Bureau bridged-race population estimates as denominators. We used joinpoint regression to characterize temporal trends in all-cause mortality, mortality resulting directly attributable to and related to CHD by age, race/ethnicity, and sex. RESULTS There were 47.7 million deaths with 1 in 814 deaths attributable to CHD (n=58 599). Although all-cause mortality decreased 16.4% across all ages, mortality resulting from CHD declined 39.4% overall. The mean annual decrease in CHD mortality was 2.6%, with the largest decrease for those >65 years of age. The age-adjusted mortality rate decreased from 1.37 to 0.83 per 100 000. Males had higher mortality attributable to CHD than females throughout the study, although both sexes declined at a similar rate (≈40% overall), with a 3% to 4% annual decrease between 1999 and 2009, followed by a slower annual decrease of 1.4% through 2017. Mortality resulting from CHD significantly declined among all races/ethnicities studied, although disparities in mortality persisted for non-Hispanic Blacks versus non-Hispanic Whites (mean annual decrease 2.3% versus 2.6%, respectively; age-adjusted mortality rate 1.67 to 1.05 versus 1.35 to 0.80 per 100 000, respectively). CONCLUSIONS Although overall US mortality attributable to CHD has decreased over the past 19 years, disparities in mortality persist for males in comparison with females and for non-Hispanic Blacks in comparison with non-Hispanic Whites. Determining factors that contribute to these disparities such as access to quality care, timely diagnosis, and maintenance of insurance will be important moving into the next decade.
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Affiliation(s)
- Keila N Lopez
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston (K.N.L., S.A.M., S.K.S.T.)
| | - Shaine A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston (K.N.L., S.A.M., S.K.S.T.)
| | - S Kristen Sexson Tejtel
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston (K.N.L., S.A.M., S.K.S.T.)
| | - Andre Espaillat
- Department of Pediatrics, Texas Children's Hospital, Houston (A.E.)
| | - Jason L Salemi
- College of Public Health (J.L.S.), University of South Florida, Tampa.,Department of Obstetrics and Gynecology, Morsani College of Medicine (J.L.S.), University of South Florida, Tampa
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Knowles RL, Ridout D, Crowe S, Bull C, Wray J, Tregay J, Franklin RCG, Barron DJ, Parslow RC, Brown K. Ethnic-specific mortality of infants undergoing congenital heart surgery in England and Wales. Arch Dis Child 2019; 104:844-850. [PMID: 30824491 DOI: 10.1136/archdischild-2018-315505] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 12/31/2018] [Accepted: 01/25/2019] [Indexed: 11/04/2022]
Abstract
PURPOSE To investigate ethnic differences in mortality for infants with congenital heart defects (CHDs) undergoing cardiac surgery or interventional catheterisation. DESIGN Observational study of survival to age 1 year using linked records from routine national paediatric cardiac surgery and intensive care audits. Mortality risk was investigated using multivariable Poisson models with multiple imputation. Predictors included sex, ethnicity, preterm birth, deprivation, comorbidities, prenatal diagnosis, age and weight at surgery, preprocedure deterioration and cardiac diagnosis. SETTING All paediatric cardiac surgery centres in England and Wales. PATIENTS 5350 infants with CHDs born from 2006 to 2009. MAIN OUTCOME MEASURE Survival at age 1 year. RESULTS Mortality was 83.9 (95% CI 76.3 to 92.1) per 1000 infants, with variation by ethnic group. Compared with those of white ethnicity, infants in British Asian (Indian, Pakistani and Bangladeshi) and 'all other' (Chinese, mixed and other) categories experienced significantly higher mortality by age 1 year (relative risk [RR] 1.52[95% CI 1.19 to 1.95]; 1.62[95% CI 1.20 to 2.20], respectively), specifically during index hospital admission (RR 1.55 [95% CI 1.07 to 2.26]; 1.64 [95% CI 1.05 to 2.57], respectively). Further predictors of mortality included non-cardiac comorbidities, prenatal diagnosis, older age at surgery, preprocedure deterioration and cardiac diagnosis. British Asian infants had higher mortality risk during elective hospital readmission (RR 1.86 [95% CI 1.02 to 3.39]). CONCLUSIONS Infants of British Asian and 'all other' non-white ethnicity experienced higher postoperative mortality risk, which was only partly explained by socioeconomic deprivation and access to care. Further investigation of case-mix and timing of risk may provide important insights into potential mechanisms underlying ethnic disparities.
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Affiliation(s)
- Rachel L Knowles
- Life Course Epidemiology & Biostatistics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Deborah Ridout
- Population Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Catherine Bull
- Department of Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jenifer Tregay
- Department of Clinical Psychology, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Rodney C G Franklin
- Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
| | - David J Barron
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Roger C Parslow
- Paediatric Epidemiology Group, University of Leeds, Leeds, UK
| | - Katherine Brown
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Best KE, Vieira R, Glinianaia SV, Rankin J. Socio-economic inequalities in mortality in children with congenital heart disease: A systematic review and meta-analysis. Paediatr Perinat Epidemiol 2019; 33:291-309. [PMID: 31347722 DOI: 10.1111/ppe.12564] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/02/2019] [Accepted: 05/27/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND The impact of socio-economic status (SES) on congenital heart disease (CHD)-related mortality in children is not well established. OBJECTIVES We aimed to systematically review and appraise the existing evidence on the association between SES (including poverty, parental education, health insurance, and income) and mortality among children with CHD. DATA SOURCES Seven electronic databases (Medline, Embase, Scopus, PsycINFO, CINAHL, ProQuest Natural, and Biological Science Collections), reference lists, citations, and key journals were searched. STUDY SELECTION AND DATA EXTRACTION We included articles reporting original research on the association between SES and mortality in children with CHD if they were full papers published in the English language and regardless of (a) timing of mortality; (b) individual or area-based measures of SES; (c) CHD subtype; (d) age at ascertainment; (e) study period examined. Screening for eligibility, data extraction, and quality appraisal were performed in duplicate. SYNTHESIS Meta-analyses were performed to estimate pooled ORs for in-hospital mortality according to health insurance status. RESULTS Of 1388 identified articles, 28 met the inclusion criteria. Increased area-based poverty was associated with increased odds/risk of postoperative (n = 1), neonatal (n = 1), post-discharge (n = 1), infant (n = 1), and long-term mortality (n = 2). Higher parental education was associated with decreased odds/risk of neonatal (n = 1) and infant mortality (n = 5), but not with long-term mortality (n = 1). A meta-analysis of four US articles showed increased unadjusted odds of in-hospital mortality in those with government/public versus private health insurance (OR 1.40, 95% CI 1.24, 1.56). The association between area-based income and CHD-related mortality was conflicting, with three of eight articles reporting significant associations. CONCLUSION This systematic review provides evidence that children of lower SES are at increased risk of CHD-related mortality. As these children are over-represented in the CHD population, interventions targeting socio-economic inequalities could have a large impact on improving CHD survival.
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Affiliation(s)
- Kate E Best
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Rute Vieira
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK.,The Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK
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Failure to rescue as a center-level metric in pediatric trauma. Surgery 2019; 165:1116-1121. [PMID: 31072669 DOI: 10.1016/j.surg.2019.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/25/2019] [Accepted: 03/06/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Failure to rescue is defined as death after a complication and has been used to evaluate quality of care in adult trauma patients, but there are no published studies on failure to rescue in pediatric trauma. The aim of this study was to define the relationship among rates of mortality, complications, and failure to rescue at centers caring for pediatric (<18 years of age) trauma patients in a nationally representative database. METHODS We performed a retrospective cohort study of the 2015 and 2016 National Trauma Data Bank. We included patients <18 years of age with an Injury Severity Score of ≥9. We excluded centers with <50 pediatric patients or that reported no complications. We calculated the complication, failure to rescue, mortality, and precedence rates by center and divided centers into tertiles of mortality. We compared complication and failure-to-rescue rates between high and low tertiles of mortality using the Kruskal-Wallis test. RESULTS Of 62,190 patients from 284 centers, 2,204 patients had at least 1 complication for an overall complication rate of 4% (center level 0%-15%), and 120 patients died after a complication for an overall failure-to-rescue rate of 5% (center level 0%-67%). High-mortality centers had both higher failure-to-rescue rates (10% vs 0.6%, P < .001) and higher complication rates (5% vs 4%, P = .001) than lower-mortality hospitals. The overall precedence rate was 15% with a median rate of 0% (interquartile range 0%-25%). CONCLUSION Both complication and failure-to-rescue rates are low in the pediatric injury population, but both complication and failure-to-rescue rates are higher at higher-mortality centers. The low overall complication rates and precedence rates likely limit the utility of failure to rescue as a valid center-level metric in this population, but further investigation into individual failure-to-rescue cases may reveal important opportunities for improvement.
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Harris VC, Links AR, Kim JM, Walsh J, Tunkel DE, Boss EF. Follow-up and Time to Treatment in an Urban Cohort of Children with Sleep-Disordered Breathing. Otolaryngol Head Neck Surg 2018; 159:371-378. [PMID: 29685083 PMCID: PMC6551520 DOI: 10.1177/0194599818772035] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 03/30/2018] [Indexed: 12/22/2022]
Abstract
Objective To evaluate follow-up and timing of sleep-disordered breathing diagnosis and treatment in urban children referred from primary care. Study Design Retrospective longitudinal cohort analysis. Setting Tertiary health system. Subjects and Methods Pediatric outpatients with sleep-disordered breathing, referred from primary care for subspecialty appointment or polysomnography in 2014, followed for 2 years. Timing of polysomnography or subspecialty appointments, loss to follow-up, and sleep-disordered breathing severity were main outcomes. Chi-square and t-test identified differences in children referred for polysomnography, surgery, and loss to follow-up. Logistic regression identified predictors of loss to follow-up. Days to polysomnography or surgery were evaluated using the Kaplan-Meier estimator, with Cox regression comparing estimates by polysomnography receipt and disease severity. Results Of 216 children, 188 (87%) had public insurance. Half (109 [50%]) were lost to follow-up after primary care referral. More children were lost to follow-up when referred for polysomnography (50 [76%]) compared with subspecialty evaluation (35 [32%]; P < .001). Children referred to both polysomnography and subspecialty were more likely to be lost to follow-up (odds ratio = 2.73, 95% confidence interval = 1.29-5.78; P = .009). For children who obtained polysomnography, an asymmetric distribution of obstructive sleep apnea severity was not observed ( P = .152). Median time to polysomnography and surgery was 75 and 226 days, respectively. Obstructive sleep apnea severity did not influence time to surgery ( P = .410). Conclusion In this urban population, half of the children referred for sleep-disordered breathing evaluation are lost to follow-up from primary care. Obstructive sleep apnea severity did not predict follow-up or timeliness of treatment. These findings suggest social determinants may pose barriers to care in addition to the clinical burden of sleep-disordered breathing.
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Affiliation(s)
- Vandra C. Harris
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne R. Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Julia M. Kim
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David E. Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Abstract
Centers with higher surgical and extracorporeal membrane oxygenation (ECMO) volumes have improved survival for children undergoing pediatric cardiac surgery and ECMO, respectively. We examined the relationship between both cardiac surgical and cardiac ECMO volumes, with survival. Using data from the Pediatric Health Information System, we reviewed patients who underwent ECMO during the hospitalization for cardiac surgery or heart transplantation from January 2003 to June 2014. Among 106,967 patients in 43 centers undergoing a Risk Adjustment for Congenital Heart Surgery-1 1-6 procedure (n = 104,951) or cardiac transplantation (n = 2,016), 2.9% (n = 3,069) underwent ECMO support. Centers were categorized into volume quartiles based on annual ECMO and cardiac surgical volumes. Multivariable logistic regression models controlling for clustering by center and adjusting for factors associated with mortality were constructed. Although mortality was lower in ECMO centers that performed ≥7 ECMO runs (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.22-0.88)] and centers performing ≥158 cardiac surgical cases (OR: 0.37, 95% CI: 0.22-0.63), surgical volume was more strongly associated with ECMO mortality. Centers with higher cardiac surgical volume had fewer ECMO complications. Cardiac surgical volume, compared with ECMO volume, is more strongly associated with cardiac ECMO survival.
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Racial variations in extracorporeal membrane oxygenation use following congenital heart surgery. J Thorac Cardiovasc Surg 2018; 156:306-315. [PMID: 29681396 DOI: 10.1016/j.jtcvs.2018.02.103] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Previous studies demonstrate racial and ethnic disparities among children undergoing congenital heart surgery. Extracorporeal membrane oxygenation (ECMO) is used to support critically ill children after congenital heart surgery and improve survival. Thus, racial or ethnic variations in postoperative ECMO use following congenital heart surgery may be associated with racial/ethnic disparities in hospital survival. METHODS All children in the Pediatric Health Information Systems dataset undergoing congenital heart surgery from 2004 to 2015 were examined. Multivariable, multinomial regression models examining hospital survival without ECMO use, survival after ECMO, death after ECMO, and death without ECMO support were constructed. RESULTS Of 130,860 congenital cardiac surgery patients, 95.4% survived to hospital discharge without requiring ECMO support, whereas 1.3% survived after ECMO support, 1.3% died after ECMO support, and 1.9% died without receiving ECMO support. After adjustment for other covariates, black patients (odds ratio, 1.22; 95% confidence interval [CI], 1.05-1.42) and patients of other race (odds ratio, 1.36; 95% CI, 1.17-1.58) were at increased odds of mortality compared with white patients. In multivariable multinomial models, black patients had increased risk of death without ECMO support (relative risk, 1.31; 95% CI, 1.11-1.56). Patients of other race (relative risk, 1.37; 95% CI, 1.10-1.69) and governmental insurance (relative risk, 1.24; 95% CI, 1.12-1.37) were also at increased risk of death without ECMO. CONCLUSIONS Black children and children of other race are at increased odds of mortality after congenital heart surgery. These disparities can be traced to variations in ECMO utilization across racial/ethnic groups.
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40
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Lowry A. Perfect is the enemy of good: Use of administrative databases in characterizing rare events and outcomes. J Thorac Cardiovasc Surg 2018; 156:316-317. [PMID: 29703412 DOI: 10.1016/j.jtcvs.2018.03.068] [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: 03/14/2018] [Accepted: 03/19/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Adam Lowry
- Pediatrics, University of Central Florida College of Medicine, Orlando, Fla; Division of Cardiac Critical Care, Nemours Cardiac Center, Nemours Children's Hospital, Orlando, Fla.
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Liou DZ, Serna-Gallegos D, Mirocha J, Bairamian V, Alban RF, Soukiasian HJ. Predictors of Failure to Rescue After Esophagectomy. Ann Thorac Surg 2018; 105:871-878. [PMID: 29397102 DOI: 10.1016/j.athoracsur.2017.10.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/17/2017] [Accepted: 10/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Failure to rescue (FTR), defined as death after a major complication, is a metric increasingly being used to assess quality of care. Risk factors associated with FTR after esophagectomy have not been previously studied. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent esophagectomy with gastric conduit between 2010 and 2014. Patients with at least one major postoperative complication were grouped according to inhospital mortality (FTR group) and survival to discharge (SUR group). A stepwise logistic regression model was used to identify predictors of FTR. RESULTS A total of 1,730 patients comprised the study group, with 102 (5.9%) in the FTR group and 1,628 (94.1%) in the SUR group. The FTR patients were older (69.0 versus 64.0 years, p < 0.0001) compared with the SUR patients. There were no differences in sex, body mass index, preoperative weight loss, smoking status, operation type, or surgeon specialty between the two groups. Age greater than 75 years (adjusted odds ratio 2.68, p < 0.0001), black race (adjusted odds ratio 2.75, p = 0.001), American Society of Anesthesiologists class 4 or 5 (adjusted odds ratio 1.82, p = 0.02), and the occurrence of pneumonia, respiratory failure, acute renal failure, sepsis, or acute myocardial infarction were predictive of FTR based on multivariable logistic regression. CONCLUSIONS Nearly 6% of patients who have a major complication after esophagectomy do not survive to discharge. Age greater than 75 years, black race, American Society of Anesthesiologists class 4 or 5, and complications related to major infection or organ failure predict FTR. Further research is necessary to investigate how these factors affect survival after complications in order to improve rescue efforts.
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Affiliation(s)
- Douglas Z Liou
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Derek Serna-Gallegos
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Vahak Bairamian
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F Alban
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harmik J Soukiasian
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Heard-Garris N, Onwuka E, Davis MM. Surgical Mortality and Race as a Risk Factor: A Compass, Not a Destination. Pediatrics 2018; 141:peds.2017-3894. [PMID: 29321254 DOI: 10.1542/peds.2017-3894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Nia Heard-Garris
- Division of Academic General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois; .,Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ekene Onwuka
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Matthew M Davis
- Division of Academic General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Departments of Medical Social Sciences, Medicine, and Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Lantin-Hermoso MR, Berger S, Bhatt AB, Richerson JE, Morrow R, Freed MD, Beekman RH, Minich LL, Ackerman MJ, Jaquiss RDB, Jenkins KJ, Mahle WT, Marino BS, Vincent JA. The Care of Children With Congenital Heart Disease in Their Primary Medical Home. Pediatrics 2017; 140:peds.2017-2607. [PMID: 29084831 DOI: 10.1542/peds.2017-2607] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Congenital heart disease (CHD) is the most common birth anomaly. With advances in repair and palliation of these complex lesions, more and more patients are surviving and are discharged from the hospital to return to their families. Patients with CHD have complex health care needs that often must be provided for or coordinated for by the primary care provider (PCP) and medical home. This policy statement aims to provide the PCP with general guidelines for the care of the child with congenital heart defects and outlines anticipated problems, serving as a repository of current knowledge in a practical, readily accessible format. A timeline approach is used, emphasizing the role of the PCP and medical home in the management of patients with CHD in their various life stages.
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Affiliation(s)
- M. Regina Lantin-Hermoso
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital Heart Center, Houston, Texas
| | - Stuart Berger
- Heart Center, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Ami B. Bhatt
- Adult Congenital Heart Disease Program, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Robert Morrow
- Physician Organizations and Academic Relations, Children’s Health Children’s Medical Center, Dallas, Texas
| | - Michael D. Freed
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Robert H. Beekman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan
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Song YK, Nunez Lopez O, Mehta HB, Bohanon FJ, Rojas-Khalil Y, Bowen-Jallow KA, Radhakrishnan RS. Race and outcomes in gastroschisis repair: a nationwide analysis. J Pediatr Surg 2017; 52:1755-1759. [PMID: 28365103 PMCID: PMC7772778 DOI: 10.1016/j.jpedsurg.2017.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND The incidence of gastroschisis has increased 30% between the periods 1995-2005 and 2006-2012, with the largest increase in Black neonates born to Black mothers younger than 20years old. OBJECTIVE Racial disparities in peri- and post-operative outcomes have been previously identified in several types of adult and pediatric surgical patients. Is there an association between race and clinical outcomes and healthcare resource utilization in neonates with gastroschisis? METHODS Retrospective study using national administrative data from the Kid's Inpatient Database (KID) from 2006, 2009, and 2012 for neonates (age<28days) with gastroschisis. Multivariable logistic regression was constructed to determine the association of race and socioeconomic characteristics with complications and mortality; linear regression was used for length of stay and hospital charges. RESULTS We identified 3846 neonates with gastroschisis that underwent surgical repair, including 676 patients with complex gastroschisis. When controlling for birth weight, payer status, socioeconomic status, and hospital characteristics, Black neonates had increased odds of having complex gastroschisis and associated atresias. Mortality was higher in patients with complex gastroschisis, patients from the lowest income quartiles, and patients with Medicaid as primary payer (compared to those with private insurance). Length of stay (LOS) was increased in patients with complex gastroschisis, birth weight <2500g, and Medicaid patients. Hospital charges were higher in complex gastroschisis, Black and Hispanic neonates (as compared to Whites), males, birth weight <2500g, and Medicaid patients. CONCLUSIONS There is an association between race and complex gastroschisis, associated intestinal atresias, and total charges in neonates with gastroschisis. In addition, income status is associated with mortality and hospital charges while payer status is associated with complications, mortality, LOS, and hospital charges. Public health and prenatal interventions should target at-risk populations to improve clinical outcomes. PROGNOSIS STUDY Level of Evidence: II.
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Affiliation(s)
- Ye Kyung Song
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Omar Nunez Lopez
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Hemalkumar B Mehta
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Fredrick J Bohanon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | | | - Ravi S Radhakrishnan
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Pediatrics, University of Texas Medical Branch, Galveston, TX.
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Healthcare Disparities in Outcomes of a Metropolitan Congenital Heart Surgery Center: The Effect of Clinical and Socioeconomic Factors. J Racial Ethn Health Disparities 2017; 5:410-421. [PMID: 28849382 DOI: 10.1007/s40615-017-0384-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The purpose of this study is to identify the impact of demographic, socioeconomic, and clinical factors on congenital heart surgery outcomes. STUDY DESIGN This retrospective cohort study included 234 congenital heart surgery patients from 2011 through 2015, in a racially/ethnically diverse metropolitan children's hospital. Outcomes included length of stay (LOS), age at first echocardiogram, length of mechanical ventilation, and incidence of complications. RESULTS Compared to others, black children underwent their first echocardiogram at a later age (median 23 versus 2 days, p = 0.014) and were more likely to be diagnosed with congenital heart disease in the emergency room (p = 0.026). Hispanic children were more likely to have major non-cardiac congenital anomalies (p = 0.045). Increased LOS during elective admissions was associated with higher surgical complexity (STAT category 4 and 5 Estimate 3.905 days, p = 0.001), compared to STAT category 1, and number of complications (Estimate = 2.306 days per complication, p < 0.001). Increased LOS in non-elective admissions was associated with the number of complex chronic conditions (Estimate = 15.446 days, p = 0.045) and the number of complications (Estimate = 11.591 days per complication, p < 0.001). However, in multivariate analysis, race and ethnicity was not associated with increased LOS or age at first echocardiogram. CONCLUSION In this diverse setting, race/ethnicity was not associated with increased LOS, age at first echocardiogram, length of ventilation, or complications. Surgical complexity, chronic conditions, and complications were associated with increased LOS. We discuss some interventions to reduce disparities in congenital heart surgery outcomes.
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Ridgeway JL, Wang Z, Finney Rutten LJ, van Ryn M, Griffin JM, Murad MH, Asiedu GB, Egginton JS, Beebe TJ. Conceptualising paediatric health disparities: a metanarrative systematic review and unified conceptual framework. BMJ Open 2017; 7:e015456. [PMID: 28780545 PMCID: PMC5724162 DOI: 10.1136/bmjopen-2016-015456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE There exists a paucity of work in the development and testing of theoretical models specific to childhood health disparities even though they have been linked to the prevalence of adult health disparities including high rates of chronic disease. We conducted a systematic review and thematic analysis of existing models of health disparities specific to children to inform development of a unified conceptual framework. METHODS We systematically reviewed articles reporting theoretical or explanatory models of disparities on a range of outcomes related to child health. We searched Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus (database inception to 9 July 2015). A metanarrative approach guided the analysis process. RESULTS A total of 48 studies presenting 48 models were included. This systematic review found multiple models but no consensus on one approach. However, we did discover a fair amount of overlap, such that the 48 models reviewed converged into the unified conceptual framework. The majority of models included factors in three domains: individual characteristics and behaviours (88%), healthcare providers and systems (63%), and environment/community (56%), . Only 38% of models included factors in the health and public policies domain. CONCLUSIONS A disease-agnostic unified conceptual framework may inform integration of existing knowledge of child health disparities and guide future research. This multilevel framework can focus attention among clinical, basic and social science research on the relationships between policy, social factors, health systems and the physical environment that impact children's health outcomes.
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Affiliation(s)
- Jennifer L Ridgeway
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zhen Wang
- Department of Health Sciences Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lila J Finney Rutten
- Department of Health Sciences Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle van Ryn
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Joan M Griffin
- Department of Health Sciences Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Department of Health Sciences Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gladys B Asiedu
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason S Egginton
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy J Beebe
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Raphael JL, Lion KC, Bearer CF. Policy solutions to recruiting and retaining minority children in research. Pediatr Res 2017; 82:180-182. [PMID: 28590464 DOI: 10.1038/pr.2017.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/03/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Jean L Raphael
- Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, Texas
| | - K Casey Lion
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Cynthia F Bearer
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
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Abstract
OBJECTIVES Previous studies have suggested an association between nonwhite race and poor outcomes in small subsets of cardiac surgery patients who require extracorporeal life support. This study aims to examine the association of race/ethnicity with mortality in pediatric patients who receive extracorporeal life support for cardiac support. DESIGN Retrospective analysis of registry data. SETTING Prospectively collected multi-institutional registry data. SUBJECTS Data from all North American pediatric patients in the Extracorporeal Life Support International Registry who received extracorporeal life support for cardiac support between 1998 and 2012 were analyzed. Multivariate regression models were constructed to examine the association between race/ethnicity and hospital mortality, adjusting for demographics, diagnosis, pre-extracorporeal life support care, extracorporeal life support variables, and extracorporeal life support-related complications. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 7,106 patients undergoing cardiac extracorporeal life support, the majority of patients were of white race (56.9%) with black race (16.7%), Hispanic ethnicity (15.8%), and Asian race (2.8%) comprising the other major race/ethnic groups. The mortality rate was 53.9% (n = 3,831). After adjusting for covariates, multivariate analysis identified black race (relative risk = 1.10; 95% CI, 1.04-1.16) and Hispanic ethnicity (relative risk = 1.08; 95% CI, 1.02-1.14) as independent risk factors for mortality. CONCLUSIONS Black race and Hispanic ethnicity are independently associated with mortality in children who require cardiac extracorporeal life support.
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Peterson JK, Chen Y, Nguyen DV, Setty SP. Current trends in racial, ethnic, and healthcare disparities associated with pediatric cardiac surgery outcomes. CONGENIT HEART DIS 2017; 12:520-532. [PMID: 28544396 DOI: 10.1111/chd.12475] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/10/2017] [Accepted: 04/22/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Despite overall improvements in congenital heart disease outcomes, racial and ethnic disparities have continued. The purpose of this study is to examine the effect of race and ethnicity, as well as other risk factors on congenital heart surgery length of stay and in-hospital mortality. DESIGN From the 2012 Healthcare Cost and Utilization Project Kids Inpatient Database (KID), we identified 13 130 records with Risk Adjustment in Congenital Heart Surgery complexity score-eligible procedures. Multivariate logistic and linear regression modeling with survey weights, stratification and clustering was used to examine the relationships between predictor variables and length of stay as well as in-hospital mortality. RESULTS No significant mortality differences were found among all race and ethnicity groups across each age group. Black neonates and black infants had a longer length of stay (neonatal estimate = 8.73 days, P = .0034; infant estimate 1.10 days, P = .0253), relative to whites. Government-sponsored insurance was associated with increased odds of neonatal mortality (odds ratio = 1.51, P = .0055), increased length of stay in neonates (estimate = 4.26 days, P = .0009) and infants (estimate = 1.52 days, P = .0181), relative to private insurance. Government-sponsored insurance was associated with increased number of chronic conditions, which were also associated with increased LOS (estimate 8.39 days, P < .001 in neonates; estimate 3.60 days, P < .001 in infants; estimate 1.87 days, P < .001 children). CONCLUSIONS Racial/ethnic disparities in congenital heart surgical outcomes may be changing compared with previous studies using the KID database. Increased length of stay in children with government-sponsored insurance may reflect expansion of individual states government-sponsored insurance eligibility criteria for children with complex chronic medical conditions. These findings warrant cautious optimism regarding racial and ethnic disparities in congenital heart surgery outcomes.
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Affiliation(s)
- Jennifer K Peterson
- Long Beach Memorial Hospital/Miller Children's and Women's Hospital, Long Beach, California, USA
| | - Yanjun Chen
- Biostatistics, Epidemiology, and Research Design Unit, University of California, Irvine, California, USA
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine School of Medicine, Orange, California, USA
| | - Shaun P Setty
- Long Beach Memorial Hospital/Miller Children's and Women's Hospital, Long Beach, California, USA
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Assessing Risk Factors for Hospital-Based, Acute Care Within Thirty Days of Craniosynostosis Surgery Using the Healthcare Cost and Utilization Project. J Craniofac Surg 2016; 27:1385-90. [DOI: 10.1097/scs.0000000000002827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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