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Sizemore J, Furlong-Dillard J, Wilkens S, Kozik D, Deshpande S, Trivedi J, Alsoufi B. Outcomes of heart transplantation in children with previously palliated hypoplastic left heart syndrome. Eur J Cardiothorac Surg 2024; 66:ezae255. [PMID: 38913846 DOI: 10.1093/ejcts/ezae255] [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: 10/30/2023] [Revised: 04/26/2024] [Accepted: 06/21/2024] [Indexed: 06/26/2024] Open
Abstract
OBJECTIVES Paediatric heart transplantation in children who fail multistage palliation for hypoplastic left heart syndrome is associated with challenges related to immune, clinical or anatomic risk factors. We review current outcomes and risk factors for survival following heart transplantation in this challenging patient population. METHODS The United Network for Organ Sharing transplantation database was merged with Paediatric Health Information System database to identify children who received heart transplantation following prior palliation for hypoplastic left heart syndrome. Multivariable Cox analysis of outcomes and factors affecting survival was performed. RESULTS Our cohort included 849 children between 2009 and 2021. The median age was 1044 days (interquartile range 108-3535), and the median weight was 13 kg (interquartile range 7-26). Overall survival at 10 years following heart transplantation was 71%, with most of the death being perioperative. On multivariable analysis, risk factors for survival included Black race (hazard ratio = 1.630, P = 0.0253), blood type other than B (hazard ratio = 2.564, P = 0.0052) and male donor gender (hazard ratio = 1.367, P = 0.0483). Recipient age, the use of ventricular assist device or extracorporeal membrane oxygenation were not significantly associated with survival. Twenty-four patients underwent retransplantation, and 10-year freedom from retransplantation was 98%. Rejection before hospital discharge and within 1 year from transplantation was 20% and 24%, respectively, with infants having lower rejection rates. CONCLUSIONS Compared with existing literature, the number of children with prior hypoplastic left heart syndrome palliation who receive heart transplantation has increased in the current era. Survival following transplantation in this patient population is acceptable. Most of the death is perioperative. Efforts to properly support these patients before transplantation might decrease early mortality and improve overall survival.
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Affiliation(s)
- Johnna Sizemore
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Jamie Furlong-Dillard
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Sarah Wilkens
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Deborah Kozik
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Shriprasad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
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Hansen K, Jenkins E, Zhu A, Collins S, Williams K, Garcia A, Weng Y, Kaufman B, Sacks LD, Cohen H, Shin AY, Patel MD. A parental communication assessment initiative in the paediatric cardiovascular ICU. Cardiol Young 2024:1-9. [PMID: 38682563 DOI: 10.1017/s104795112402506x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
OBJECTIVE Challenges to communication between families and care providers of paediatric patients in intensive care units (ICU) include variability of communication preferences, mismatched goals of care, and difficulties carrying forward family preferences from provider to provider. Our objectives were to develop and test an assessment tool that queries parents of children requiring cardiac intensive care about their communication preferences and to determine if this tool facilitates patient-centred care and improves families' ICU experience. DESIGN In this quality improvement initiative, a novel tool was developed, the Parental Communication Assessment (PCA), which asked parents with children hospitalised in the cardiac ICU about their communication preferences. Participants were prospectively randomised to the intervention group, which received the PCA, or to standard care. All participants completed a follow-up survey evaluating satisfaction with communication. MAIN RESULTS One hundred thirteen participants enrolled and 56 were randomised to the intervention group. Participants who received the PCA preferred detail-oriented communication over big picture. Most parents understood the daily discussions on rounds (64%) and felt comfortable expressing concerns (68%). Eighty-six percent reported the PCA was worthwhile. Parents were generally satisfied with communication. However, an important proportion felt unprepared for difficult decisions or setbacks, inadequately included or supported in decision-making, and that they lacked control over their child's care. There were no significant differences between the intervention and control groups in their communication satisfaction results. CONCLUSIONS Parents with children hospitalised in the paediatric ICU demonstrated diverse communication preferences. Most participants felt overall satisfied with communication, but individualising communication with patients' families according to their preferences may improve their experience.
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Affiliation(s)
- Katherine Hansen
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Erin Jenkins
- Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Aihua Zhu
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Shawna Collins
- Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Kimberly Williams
- Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Ariadna Garcia
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Beth Kaufman
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Loren D Sacks
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Harvey Cohen
- Palliative Care Program, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew Y Shin
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Meghna D Patel
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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Ronai C, Garcia Godoy L, Madriago E. Homogenous access to fetal cardiac care in a heterogeneous state. Cardiol Young 2024; 34:500-504. [PMID: 37485827 DOI: 10.1017/s1047951123002536] [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: 07/25/2023]
Abstract
BACKGROUND Timely prenatal diagnosis of CHD allows families to participate in complex decisions and plan for the care of their child. This study sought to investigate whether timing of initial fetal echocardiogram and the characteristics of fetal counselling were impacted by parental socio-economic factors. METHODS Retrospective chart review of fetal cardiac patients from 1 January, 2017 to 31 December, 2018. We reviewed gestational age at first fetal echo, maternal age and ethnicity, zip code, rurality index, and hospital distance. Counselling was evaluated based on documentation regarding use of interpreter, time billed for counselling, and treatment option chosen. RESULTS Total of 139 maternal-fetal dyads were included, and 29 dyads had single-ventricle heart disease. There was no difference in income, hospital distance or rurality index, and first fetal echo timing. There was no significant difference between maternal ethnicity and maternal age, gestational age at initial visit, or follow-up. Patients in rural areas had increased counselling time (p < .05). There was no difference between socio-economic factors and ultimate parental choices (termination, palliative delivery, or cardiac interventions). CONCLUSION Oregon comprises a heterogeneous population from a large geographical catchment. While prenatal counselling and family decision-making are multifaceted, we demonstrated that dyads were referred from across the state and received care in a uniformly timely manner, and once at our centre received consistent counselling despite differences in parental socio-economic factors.
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Affiliation(s)
- Christina Ronai
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, OR, USA
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Laura Garcia Godoy
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, OR, USA
| | - Erin Madriago
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, OR, USA
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4
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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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Warren PW, Beck AF, Zang H, Anderson J, Statile C. Inequitable access: factors associated with incomplete referrals to paediatric cardiology. Cardiol Young 2024; 34:428-435. [PMID: 35848164 DOI: 10.1017/s1047951122002037] [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: 01/31/2023]
Abstract
OBJECTIVE To assess the variables associated with incomplete and unscheduled cardiology clinic visits among referred children with a focus on equity gaps. STUDY DESIGN We conducted a retrospective chart review for patients less than 18 years of age who were referred to cardiology clinics at a single quaternary referral centre from 2017 to 2019. We collected patient demographic data including race, an index of neighbourhood socio-economic deprivation linked to a patient's geocoded address, referral information, and cardiology clinic information. The primary outcome was an incomplete clinic visit. The secondary outcome was an unscheduled appointment. Independent associations were identified using multivariable logistic regression. RESULTS There were 10,610 new referrals; 6954 (66%) completed new cardiology clinic visits. Black race (OR 1.41; 95% CI 1.22-1.63), public insurance (OR 1.29; 95% CI 1.14-1.46), and a higher deprivation index (OR 1.32; 95% CI 1.08-1.61) were associated with higher odds of incomplete visit compared to the respective reference groups of White race, private insurance, and a lower deprivation index. The findings for unscheduled visit were similar. A shorter time elapsed from the initial referral to when the appointment was made was associated with lower odds of incomplete visit (OR 0.62; 95% CI 0.52-0.74). CONCLUSION Race, insurance type, neighbourhood deprivation, and time from referral date to appointment made were each associated with incomplete referrals to paediatric cardiology. Interventions directed to understand such associations and respond accordingly could help to equitably improve referral completion.
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Affiliation(s)
- Paul W Warren
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229, USA
| | - Andrew F Beck
- General and Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Huaiyu Zang
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Jeffrey Anderson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Christopher Statile
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
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Markovitz B, Kingsley J. Ethnic and Racial Disparities in Pediatric Cardiac ECMO Utilization: Do They Exist, Does It Matter? JACC. ADVANCES 2023; 2:100630. [PMID: 38938706 PMCID: PMC11198181 DOI: 10.1016/j.jacadv.2023.100630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Barry Markovitz
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital-Los Angeles, Los Angeles, California, USA
| | - Jenny Kingsley
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital-Los Angeles, Los Angeles, California, USA
- CHLA Center for Bioethics, Children’s Hospital-Los Angeles, Los Angeles, California, USA
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Duong SQ, Elfituri MO, Zaniletti I, Ressler RW, Noelke C, Gelb BD, Pass RH, Horowitz CR, Seiden HS, Anderson BR. Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease. J Am Coll Cardiol 2023; 82:801-813. [PMID: 37612012 DOI: 10.1016/j.jacc.2023.05.069] [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: 02/22/2023] [Revised: 05/22/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Racial and ethnic disparities in outcomes for children with congenital heart disease (CHD) coexist with disparities in educational, environmental, and economic opportunity. OBJECTIVES We sought to determine the associations between childhood opportunity, race/ethnicity, and pediatric CHD surgery outcomes. METHODS Pediatric Health Information System encounters aged <18 years from 2016 to 2022 with International Classification of Diseases-10th edition codes for CHD and cardiac surgery were linked to ZIP code-level Childhood Opportunity Index (COI), a score of neighborhood educational, environmental, and socioeconomic conditions. The associations of race/ethnicity and COI with in-hospital surgical death were modeled with generalized estimating equations and formal mediation analysis. Neonatal survival after discharge was modeled by Cox proportional hazards. RESULTS Of 54,666 encounters at 47 centers, non-Hispanic Black (Black) (OR: 1.20; P = 0.01), Asian (OR: 1.75; P < 0.001), and Other (OR: 1.50; P < 0.001) groups had increased adjusted mortality vs non-Hispanic Whites. The lowest COI quintile had increased in-hospital mortality in unadjusted and partially adjusted models (OR: 1.29; P = 0.004), but not fully adjusted models (OR: 1.14; P = 0.13). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (P = 0.64) and 16.8% (P = 0.029), depending on model specification. In neonatal multivariable survival analysis (n = 13,987; median follow-up: 0.70 years), the lowest COI quintile had poorer survival (HR: 1.21; P = 0.04). CONCLUSIONS Children in the lowest COI quintile are at risk for poor outcomes after CHD surgery. Disproportionally increased mortality in Black, Asian, and Other populations may be partially mediated by COI. Targeted investment in low COI neighborhoods may improve outcomes after hospital discharge. Identification of unmeasured factors to explain persistent risk attributed to race/ethnicity is an important area of future exploration.
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Affiliation(s)
- Son Q Duong
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Mahmud O Elfituri
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai- H+H Elmhurst, New York, New York, USA
| | | | - Robert W Ressler
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Clemens Noelke
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Bruce D Gelb
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert H Pass
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carol R Horowitz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Howard S Seiden
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brett R Anderson
- Department of Pediatrics, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
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Downing KF, Nembhard WN, Rose CE, Andrews JG, Goudie A, Klewer SE, Oster ME, Farr SL. Survival From Birth Until Young Adulthood Among Individuals With Congenital Heart Defects: CH STRONG. Circulation 2023; 148:575-588. [PMID: 37401461 PMCID: PMC10544792 DOI: 10.1161/circulationaha.123.064400] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/12/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Limited population-based information is available on long-term survival of US individuals with congenital heart defects (CHDs). Therefore, we assessed patterns in survival from birth until young adulthood (ie, 35 years of age) and associated factors among a population-based sample of US individuals with CHDs. METHODS Individuals born between 1980 and 1997 with CHDs identified in 3 US birth defect surveillance systems were linked to death records through 2015 to identify those deceased and the year of their death. Kaplan-Meier survival curves, adjusted risk ratios (aRRs) for infant mortality (ie, death during the first year of life), and Cox proportional hazard ratios for survival after the first year of life (aHRs) were used to estimate the probability of survival and associated factors. Standardized mortality ratios compared infant mortality, >1-year mortality, >10-year mortality, and >20-year mortality among individuals with CHDs with general population estimates. RESULTS Among 11 695 individuals with CHDs, the probability of survival to 35 years of age was 81.4% overall, 86.5% among those without co-occurring noncardiac anomalies, and 92.8% among those who survived the first year of life. Characteristics associated with both infant mortality and reduced survival after the first year of life, respectively, included severe CHDs (aRR=4.08; aHR=3.18), genetic syndromes (aRR=1.83; aHR=3.06) or other noncardiac anomalies (aRR=1.54; aHR=2.53), low birth weight (aRR=1.70; aHR=1.29), and Hispanic (aRR=1.27; aHR=1.42) or non-Hispanic Black (aRR=1.43; aHR=1.80) maternal race and ethnicity. Individuals with CHDs had higher infant mortality (standardized mortality ratio=10.17), >1-year mortality (standardized mortality ratio=3.29), and >10-year and >20-year mortality (both standardized mortality ratios ≈1.5) than the general population; however, after excluding those with noncardiac anomalies, >1-year mortality for those with nonsevere CHDs and >10-year and >20-year mortality for those with any CHD were similar to the general population. CONCLUSIONS Eight in 10 individuals with CHDs born between1980 and 1997 survived to 35 years of age, with disparities by CHD severity, noncardiac anomalies, birth weight, and maternal race and ethnicity. Among individuals without noncardiac anomalies, those with nonsevere CHDs experienced similar mortality between 1 and 35 years of age as in the general population, and those with any CHD experienced similar mortality between 10 and 35 years of age as in the general population.
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Affiliation(s)
- Karrie F Downing
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA (K.F.D., C.E.R., M.E.O., S.L.F.)
| | - Wendy N Nembhard
- Department of Epidemiology, Fay W. Boozman College of Public Health and the Arkansas Center for Birth Defects Research and Prevention, University of Arkansas for Medical Sciences, Little Rock (W.N.N.)
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA (K.F.D., C.E.R., M.E.O., S.L.F.)
| | - Jennifer G Andrews
- Department of Pediatrics, University of Arizona, Tucson (J.G.A., S.E.K.)
| | - Anthony Goudie
- Department of Pediatrics, Center for Applied Research and Evaluation, College of Medicine, Little Rock, AR (A.G.)
| | - Scott E Klewer
- Department of Pediatrics, University of Arizona, Tucson (J.G.A., S.E.K.)
| | - Matthew E Oster
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA (K.F.D., C.E.R., M.E.O., S.L.F.)
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA (M.E.O.)
| | - Sherry L Farr
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA (K.F.D., C.E.R., M.E.O., S.L.F.)
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Soszyn N, Cloete E, Sadler L, de Laat MWM, Crengle S, Bloomfield F, Finucane K, Gentles TL. Factors influencing the choice-of-care pathway and survival in the fetus with hypoplastic left heart syndrome in New Zealand: a population-based cohort study. BMJ Open 2023; 13:e069848. [PMID: 37055204 PMCID: PMC10106067 DOI: 10.1136/bmjopen-2022-069848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVES To better understand the relative influence of fetal and maternal factors in determining the choice-of-care pathway (CCP) and outcome in the fetus with hypoplastic left heart syndrome (HLHS). DESIGN A retrospective, population-based study of fetuses with HLHS from a national dataset with near-complete case ascertainment from 20 weeks' gestation. Fetal cardiac and non-cardiac factors were recorded from the patient record and maternal factors from the national maternity dataset. The primary endpoint was a prenatal decision for active treatment after birth (intention-to-treat). Factors associated with a delayed diagnosis (≥24 weeks' gestation) were also reviewed. Secondary endpoints included proceeding to surgical treatment, and 30-day postoperative mortality in liveborns with an intention-to-treat. SETTING New Zealand population-wide. PARTICIPANTS Fetuses with a prenatal diagnosis of HLHS between 2006 and 2015. RESULTS Of 105 fetuses, the CCP was intention-to-treat in 43 (41%), and pregnancy termination or comfort care in 62 (59%). Factors associated with intention-to-treat by multivariable analysis included a delay in diagnosis (OR: 7.8, 95% CI: 3.0 to 20.6, p<0.001) and domicile in the maternal fetal medicine (MFM) region with the most widely dispersed population (OR: 5.3, 95% CI: 1.4 to 20.3, p=0.02). Delay in diagnosis was associated with Māori maternal ethnicity compared with European (OR: 12.9, 95% CI: 3.1 to 54, p<0.001) and greater distance from the MFM centre (OR: 3.1, 95% CI: 1.2 to 8.2, p=0.02). In those with a prenatal intention-to-treat, a decision not to proceed to surgery was associated with maternal ethnicity other than European (p=0.005) and the presence of major non-cardiac anomalies (p=0.01). Thirty-day postoperative mortality occurred in 5/32 (16%) and was more frequent when there were major non-cardiac anomalies (p=0.02). CONCLUSIONS Factors associated with the prenatal CCP relate to healthcare access. Anatomic characteristics impact treatment decisions after birth and early postoperative mortality. The association of ethnicity with delayed prenatal diagnosis and postnatal decision-making suggests systemic inequity and requires further investigation.
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Affiliation(s)
- Natalie Soszyn
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Elza Cloete
- The University of Auckland Liggins Institute, Auckland, New Zealand
- Neonatal Unit, Christchurch Women's Hospital, Te Whatu Ora - Health New Zealand, Waitaha Canterbury, Christchurch, New Zealand
| | - Lynn Sadler
- Women's Health, Auckland City Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
- The University of Auckland Department of Obstetrics and Gynaecology, Auckland, New Zealand
| | - Monique W M de Laat
- Women's Health, Auckland City Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Sue Crengle
- Otago Medical School Department of Preventive and Social Medicine, Dunedin, New Zealand
| | - Frank Bloomfield
- The University of Auckland Liggins Institute, Auckland, New Zealand
| | - Kirsten Finucane
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Thomas L Gentles
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
- Faculty of Medical and Health Sciences, The University of Auckland Department of Paediatrics Child and Youth Health, Auckland, New Zealand
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10
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Al-Dewik N, Samara M, Younes S, Al-Jurf R, Nasrallah G, Al-Obaidly S, Salama H, Olukade T, Hammuda S, Marlow N, Ismail M, Abu Nada T, Qoronfleh MW, Thomas B, Abdoh G, Abdulrouf PV, Farrell T, Al Qubaisi M, Al Rifai H. Prevalence, predictors, and outcomes of major congenital anomalies: A population-based register study. Sci Rep 2023; 13:2198. [PMID: 36750603 PMCID: PMC9905082 DOI: 10.1038/s41598-023-27935-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/10/2023] [Indexed: 02/09/2023] Open
Abstract
Congenital anomalies (CAs) are a leading cause of morbidity and mortality in early life. We aimed to assess the incidence, risk factors, and outcomes of major CAs in the State of Qatar. A population-based retrospective data analysis of registry data retrieved from the Perinatal Neonatal Outcomes Research Study in the Arabian Gulf (PEARL-Peristat Study) between April 2017 and March 2018. The sample included 25,204 newborn records, which were audited between April 2017 and March 2018, of which 25,073 live births were identified and included in the study. Maternal risk factors and neonatal outcomes were assessed for association with specific CAs, including chromosomal/genetic, central nervous system (CNS), cardiovascular system (CVS), facial, renal, multiple congenital anomalies (MCAs) using univariate and multivariate analyses. The incidence of any CA among live births was 1.3% (n = 332). The most common CAs were CVS (n = 117; 35%), MCAs (n = 69, 21%), chromosomal/genetic (51; 15%), renal (n = 39; 12%), CNS (n = 20; 6%), facial (14, 4%), and other (GIT, Resp, Urogenital, Skeletal) (n = 22, 7%) anomalies. Multivariable regression analysis showed that multiple pregnancies, parity ≥ 1, maternal BMI, and demographic factors (mother's age and ethnicity, and infant's gender) were associated with various specific CAs. In-hospital mortality rate due to CAs was estimated to be 15.4%. CAs were significantly associated with high rates of caesarean deliveries (aOR 1.51; 95% CI 1.04-2.19), Apgar < 7 at 1 min (aOR 5.44; 95% CI 3.10-9.55), Apgar < 7 at 5 min (aOR 17.26; 95% CI 6.31-47.18), in-hospital mortality (aOR 76.16; 37.96-152.8), admission to neonatal intensive care unit (NICU) or perinatal death of neonate in labor room (LR)/operation theatre (OT) (aOR 34.03; 95% CI 20.51-56.46), prematurity (aOR 4.17; 95% CI 2.75-6.32), and low birth weight (aOR 5.88; 95% CI 3.92-8.82) before and after adjustment for the significant risk factors. This is the first study to assess the incidence, maternal risk factors, and neonatal outcomes associated with CAs in the state of Qatar. Therefore, a specialized congenital anomaly data registry is needed to identify risk factors and outcomes. In addition, counselling of mothers and their families may help to identify specific needs for pregnant women and their babies.
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Affiliation(s)
- Nader Al-Dewik
- Department of Research, Women's Wellness and Research Center, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar. .,Translational Research Institute (TRI), Hamad Medical Corporation (HMC), Doha, Qatar. .,Genomics and Precision Medicine (GPM), College of Health and Life Science (CHLS), Hamad Bin Khalifa University (HBKU), 34110, Doha, Qatar. .,Faculty of Health and Social Care Sciences, Kingston University, St. George's University of London, London, UK. .,Department of Pediatrics and Neonatology, Neonatal Intensive Care Unit, Newborn Screening Unit, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar.
| | - Muthanna Samara
- Department of Psychology, Kingston University London, Kingston upon Thames, UK
| | - Salma Younes
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, Doha, Qatar
| | - Rana Al-Jurf
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, Doha, Qatar
| | - Gheyath Nasrallah
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, Doha, Qatar
| | - Sawsan Al-Obaidly
- Obstetrics and Gynecology Department, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Husam Salama
- Department of Pediatrics and Neonatology, Neonatal Intensive Care Unit, Newborn Screening Unit, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Tawa Olukade
- Department of Pediatrics and Neonatology, Neonatal Intensive Care Unit, Newborn Screening Unit, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Sara Hammuda
- Department of Psychology, Kingston University London, Kingston upon Thames, UK
| | - Neil Marlow
- Institute for Women's Health, UCL, London, UK
| | - Mohamed Ismail
- Translational Research Institute (TRI), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Taghreed Abu Nada
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, Doha, Qatar
| | - M Walid Qoronfleh
- Q3CG Research Institute, Research & Policy Division, 7227 Rachel Drive, Ypsilanti, MI, 48917, USA
| | - Binny Thomas
- Department of Pharmacy, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Ghassan Abdoh
- Department of Pediatrics and Neonatology, Neonatal Intensive Care Unit, Newborn Screening Unit, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Palli Valapila Abdulrouf
- Department of Pharmacy, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Thomas Farrell
- Obstetrics and Gynecology Department, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Mai Al Qubaisi
- Department of Pediatrics and Neonatology, Neonatal Intensive Care Unit, Newborn Screening Unit, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Hilal Al Rifai
- Department of Pediatrics and Neonatology, Neonatal Intensive Care Unit, Newborn Screening Unit, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
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11
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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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12
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Vergales J, Figueroa M, Frommelt M, Putschoegl A, Singh Y, Murray P, Wood G, Allen K, Villafane J. Transitioning Neonates With CHD to Outpatient Care: A State-of-the-Art Review. Pediatrics 2022; 150:189880. [PMID: 36317969 DOI: 10.1542/peds.2022-056415m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jeffrey Vergales
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Mayte Figueroa
- Divisions of Pediatric Cardiology and Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Michele Frommelt
- Children's Wisconsin, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adam Putschoegl
- Division of Pediatric Cardiology, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Yogen Singh
- Division of Pediatric Cardiology and Neonatology, Cambridge University Hospitals, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Peter Murray
- Division of Neonatology, University of Virginia, Charlottesville, Virginia
| | - Garrison Wood
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Kiona Allen
- Division of Pediatric Cardiology and Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Juan Villafane
- Cincinnati Children's Hospital, Division of Pediatric Cardiology, University of Cincinnati, Cincinnati, Ohio
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13
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Serfas J, Spates T, D’Ottavio A, Spears T, Ciociola E, Chiswell K, Davidson-Ray L, Ryan G, Forestieri N, Krasuski RA, Kemper AR, Hoffman TM, Walsh MJ, Sang CJ, Welke KF, Li JS. Disparities in Loss to Follow-Up Among Adults With Congenital Heart Disease in North Carolina. World J Pediatr Congenit Heart Surg 2022; 13:707-715. [DOI: 10.1177/21501351221111998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The AHA/ACC Adult Congenital Heart Disease guidelines recommend that most adults with congenital heart disease (CHD) follow-up with CHD cardiologists every 1 to 2 years because longer gaps in care are associated with adverse outcomes. This study aimed to determine the proportion of patients in North Carolina who did not have recommended follow-up and to explore predictors of loss to follow-up. Methods Patients ages ≥18 years with a healthcare encounter from 2008 to 2013 in a statewide North Carolina database with an ICD-9 code for CHD were assessed. The proportion with cardiology follow-up within 24 months following index encounter was assessed with Kaplan-Meier estimates. Cox regression was utilized to identify demographic factors associated with differences in follow-up. Results 2822 patients were identified. Median age was 35 years; 55% were female. 70% were white, 22% black, and 3% Hispanic; 36% had severe CHD. The proportion with 2-year cardiology follow-up was 61%. Those with severe CHD were more likely to have timely follow-up than those with less severe CHD (72% vs 55%, P < .01). Black patients had a lower likelihood of follow-up than white patients (56% vs 64%, P = .01). Multivariable Cox regression identified younger age, non-severe CHD, and non-white race as risk factors for a lower likelihood of follow-up by 2 years. Conclusion 39% of adults with CHD in North Carolina are not meeting AHA/ACC recommendations for follow-up. Younger and minority patients and those with non-severe CHD were particularly vulnerable to inadequate follow-up; targeted efforts to retain these patients in care may be helpful.
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Affiliation(s)
- J.D. Serfas
- Duke University Medical Center, Durham, NC, USA
| | - Toi Spates
- Duke University Medical Center, Durham, NC, USA
| | | | - Tracy Spears
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Grace Ryan
- Duke Clinical Research Institute, Durham, NC, USA
| | - Nina Forestieri
- State Center for Health Statistics, North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | | | | | | | | | | | - Karl F. Welke
- Levine Children’s Hospital/Atrium Health, Charlotte, NC, USA
| | - Jennifer S. Li
- Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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14
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Bauser-Heaton H, Aggarwal V, Graziano JN, Ligon RA, Keeshan B, Stapleton G, Sutton NJ, Fleming G, El-Said H, Kim D, Ing FF. Health Care Disparities in Congenital Cardiology: Considerations Through the Lens of an Interventional Cardiologist. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100388. [PMID: 39131467 PMCID: PMC11308374 DOI: 10.1016/j.jscai.2022.100388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/29/2022] [Accepted: 05/23/2022] [Indexed: 08/13/2024]
Abstract
When resources in a society are dispersed unevenly, generally through allocation standards, distinct patterns emerge along lines of socially defined categories of people. Power, religion, kinship, prestige, race, ethnicity, gender, age, sexual orientation, and class all play a role in determining who has access to social goods in society. In most cases, social inequality refers to a lack of equality of outcome, but it can also refer to a lack of equality of access to opportunity. Unfortunately, health care is not immune to these social disparities and/or inequalities. These health care disparities in interventional cardiology were recently brought to the forefront by the Society for Cardiovascular Angiography and Interventions (SCAI) as a major focus of 2020-2021. In a recent publication, unique factors leading to disparities were reported to exist among the subsections of interventional cardiology. The congenital heart disease council of SCAI created a task force to further investigate the unique challenges and disparities impacting the practice of congenital heart disease and pediatric cardiology.
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Affiliation(s)
- Holly Bauser-Heaton
- Division of Cardiology, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Varun Aggarwal
- Division of Pediatric Cardiology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | | | - R. Allen Ligon
- Division of Cardiology, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Britton Keeshan
- Division of Cardiology, Department of Pediatrics, Yale New Haven Children’s Hospital, New Haven, Connecticut
| | - Gary Stapleton
- Department of Cardiology, Texas Children’s Hospital, Houston, Texas
| | - Nicole J. Sutton
- Division of Pediatric Cardiology, The Children’s Hospital at Montefiore, Bronx, New York
| | - Gregory Fleming
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Howaida El-Said
- Division of Pediatric Cardiology, Rady Children’s Hospital, University of California, San Diego, California
| | - Dennis Kim
- Division of Cardiology, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Frank F. Ing
- Division of Pediatric Cardiology, Children’s Hospital, University of California Davis, Sacramento, California
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15
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Forero-Manzano MJ, Triana-Palencia E, Figueroa-Rueda JA, Flórez-Rodríguez CX, Castro-Monsalve JM, Quintero-Lesmes DC, Gamboa-Delgado EM. Association of social determinants with the severity of congenital heart disease. Pediatr Res 2022; 93:1391-1398. [PMID: 35986145 DOI: 10.1038/s41390-022-02205-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/03/2022] [Accepted: 06/22/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Congenital heart diseases are the most prevalent congenital malformations and cause greater morbi-mortality in newborns and infants. The aim of this study was to analyze the social determinants in families with children with the severity of congenital heart disease. METHODS Analytical cross-sectional study in 140 families of children with congenital heart disease to whom a structured survey was applied addressing topics related to family structure, health, economic conditions, exposure factors, and other social conditions relevant to the study, during 1 year. RESULTS In all, 53.7% of the studied population belonged to low socioeconomic levels. No association was found between the severity of the heart disease and the presence of pathological antecedents in the parents. The families resided in urban areas. Also, 28.3% of the mothers had four or fewer prenatal controls during pregnancy. Only 22% of heart diseases were diagnosed during pregnancy. It was found that exposure to cigarette and wood smoke during pregnancy, in addition to low socioeconomic status, was associated with greater severity of heart disease (RACHS-1 and STS-Score), when evaluated by pathophysiological groups (cyanotic/non-cyanotic/single ventricle). CONCLUSIONS Exposure to cigarette smoke, wood smoke during pregnancy, and low socioeconomic status turned out to be social determinants associated with the severity of heart disease analyzed by pathophysiological groups. IMPACT The social component has not been well characterized as a cause of congenital heart disease, especially in countries like ours, where the existence of gaps and social inequities have a high impact. The findings of this study could have an impact on public health to the extent that policies are implemented to reduce exposure to cigarettes, especially during pregnancy. Knowledge of these changes and their measurement in this type of pathology could open the door to the creation of policies aimed at their prevention, focusing on the local risk factors found, which can impact the disease.
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Affiliation(s)
- Mario J Forero-Manzano
- Neumología Pediátrica, Hospital Internacional de Colombia HIC - Instituto Cardiovascular, Fundación Cardiovascular de Colombia, Piedecuesta, Santander, Colombia.,Servicio de Cardiocirugía Pediátrica, Hospital Internacional de Colombia HIC - Instituto Cardiovascular, Fundación Cardiovascular de Colombia, Piedecuesta, Santander, Colombia.,Fundación Universitaria FCV, Floridablanca, Santander, Colombia
| | - Eddy Triana-Palencia
- Servicio de Cardiocirugía Pediátrica, Hospital Internacional de Colombia HIC - Instituto Cardiovascular, Fundación Cardiovascular de Colombia, Piedecuesta, Santander, Colombia
| | - Jenny A Figueroa-Rueda
- Servicio de Cardiocirugía Pediátrica, Hospital Internacional de Colombia HIC - Instituto Cardiovascular, Fundación Cardiovascular de Colombia, Piedecuesta, Santander, Colombia
| | - Claudia X Flórez-Rodríguez
- Neumología Pediátrica, Hospital Internacional de Colombia HIC - Instituto Cardiovascular, Fundación Cardiovascular de Colombia, Piedecuesta, Santander, Colombia.,Servicio de Cardiocirugía Pediátrica, Hospital Internacional de Colombia HIC - Instituto Cardiovascular, Fundación Cardiovascular de Colombia, Piedecuesta, Santander, Colombia.,Fundación Universitaria FCV, Floridablanca, Santander, Colombia
| | - Javier M Castro-Monsalve
- Neumología Pediátrica, Hospital Internacional de Colombia HIC - Instituto Cardiovascular, Fundación Cardiovascular de Colombia, Piedecuesta, Santander, Colombia.,Servicio de Cardiocirugía Pediátrica, Hospital Internacional de Colombia HIC - Instituto Cardiovascular, Fundación Cardiovascular de Colombia, Piedecuesta, Santander, Colombia
| | - Doris C Quintero-Lesmes
- Centro de Investigaciones, Fundación Cardiovascular de Colombia FCV, Floridablanca, Santander, Colombia.
| | - Edna M Gamboa-Delgado
- Escuela de Nutrición y Dietética, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
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16
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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: 4] [Impact Index Per Article: 2.0] [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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17
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Purkey NJ, Ma C, Lee HC, Hintz SR, Shaw GM, McElhinney DB, Carmichael SL. Distance from home to birth hospital, transfer, and mortality in neonates with hypoplastic left heart syndrome in California. Birth Defects Res 2022; 114:662-673. [PMID: 35488460 DOI: 10.1002/bdr2.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Prior studies report a lower risk of mortality among neonates with hypoplastic left heart syndrome (HLHS) who are born at a cardiac surgical center, but many neonates with HLHS are born elsewhere and transferred for repair. We investigated the associations between the distance from maternal home to birth hospital, the need for transfer after birth, sociodemographic factors, and mortality in infants with HLHS in California from 2006 to 2011. METHODS We used linked data from two statewide databases to identify neonates for this study. Three groups were included in the analysis: "lived close/not transferred," "lived close/transferred," and "lived far/not transferred." We defined "lived close" versus "lived far" as 11 miles, the median distance from maternal residence to birth hospital. Log-binomial regression models were used to identify the association between sociodemographic variables, distance to birth hospital and transfer. Cox proportional hazards models were used to identify the association between mortality and distance to birth hospital and transfer. Models were adjusted for sociodemographic variables. RESULTS Infants in the lived close/not transferred and the lived close/transferred groups (vs. the lived far/not transferred group) were more likely to live in census tracts above the 75th percentile for poverty with relative risks 1.94 (95% confidence interval [CI] 1.41-2.68) and 1.21 (95% CI 1.05-1.40), respectively. Neonatal mortality was higher among the lived close/not transferred group compared with the lived far/not transferred group (hazard ratio 1.77, 95% CI 1.17-2.67). CONCLUSIONS Infants born to mothers experiencing poverty were more likely to be born close to home. Infants with HLHS who were born close to home and not transferred to a cardiac center had a higher risk of neonatal mortality than infants who were delivered far from home and not transferred. Future studies should identify the barriers to delivery at a cardiac center for mothers experiencing poverty.
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Affiliation(s)
- Neha J Purkey
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Chen Ma
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Henry C Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary M Shaw
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Doff B McElhinney
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
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18
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Williamson CG, Tran Z, Rudasill S, Hadaya J, Verma A, Bridges AW, Satou G, Biniwale RM, Benharash P. Race-based disparities in access to surgical palliation for hypoplastic left heart syndrome. Surgery 2022; 172:500-505. [PMID: 35450745 DOI: 10.1016/j.surg.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/15/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial disparities in outcomes have been shown to persist in many operative specialties, including the management of congenital heart disease. Using a demographic-adjusted methodology, we examined whether patient race influenced access to high-performing centers for the operative management of hypoplastic left heart syndrome. METHODS The 2005-2017 National Inpatient Sample was queried to identify all pediatric (≤5 years) hospitalizations with an operation for hypoplastic left heart syndrome. A racial disparity index was generated for each hospital and defined as the proportion of White patients receiving operative management for hypoplastic left heart syndrome divided by the proportion of White patients admitted for respiratory failure. This methodology quantified hospital-level racial variation while adjusting for the local racial makeup of each center. RESULTS Of the 17,275 patients who met inclusion criteria, 64.1% were managed at high-volume centers. Patients at high-volume centers had a similar distribution of operative type, age, and burden of comorbidities. The mean racial disparity index steadily grew from 1.06 at the lowest volume decile of operative volume to 1.51 at the highest, indicating an increasing proportion of White patients as volume increased. Using risk-adjusted analysis, each decile increase in hospital volume was associated with a 14% relative reduction in odds of mortality and a 0.06 increase in predicted racial disparity index. Increasing volume was further associated with reduced odds of non-home discharge but did not alter resource utilization. CONCLUSION We demonstrate that high-volume centers disproportionally serve White patients and have superior clinical outcomes compared to low-volume centers. This study highlights the critical importance of equitable access to expert care for high-risk conditions such as hypoplastic left heart syndrome.
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Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sarah Rudasill
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Alexander W Bridges
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Gary Satou
- Division of Pediatric Cardiology, Mattel Children's Hospital, University of California, Los Angeles, CA
| | - Reshma M Biniwale
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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Tran R, Forman R, Mossialos E, Nasir K, Kulkarni A. Social Determinants of Disparities in Mortality Outcomes in Congenital Heart Disease: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:829902. [PMID: 35369346 PMCID: PMC8970097 DOI: 10.3389/fcvm.2022.829902] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSocial determinants of health (SDoH) affect congenital heart disease (CHD) mortality across all forms and age groups. We sought to evaluate risk of mortality from specific SDoH stratified across CHD to guide interventions to alleviate this risk.MethodsWe searched electronic databases between January 1980 and June 2019 and included studies that evaluated occurrence of CHD deaths and SDoH in English articles. Meta-analysis was performed if SDoH data were available in >3 studies. We included race/ethnicity, deprivation, insurance status, maternal age, maternal education, single/multiple pregnancy, hospital volume, and geographic location of patients as SDoH. Data were pooled using random-effects model and outcome was reported as odds ratio (OR) with 95% confidence interval (CI).ResultsOf 17,716 citations reviewed, 65 met inclusion criteria. Sixty-three were observational retrospective studies and two prospective. Of 546,981 patients, 34,080 died. Black patients with non-critical CHD in the first year of life (Odds Ratio 1.62 [95% confidence interval 1.47–1.79], I2 = 7.1%), with critical CHD as neonates (OR 1.27 [CI 1.05-1.55], I2 = 0%) and in the first year (OR 1.68, [1.45-1.95], I2 = 0.3%) had increased mortality. Deprived patients, multiple pregnancies, patients born to mothers <18 years and with education <12 years, and patients on public insurance with critical CHD have greater likelihood of death after the neonatal period.ConclusionThis systematic review and meta-analysis found that Black patients with CHD are particularly vulnerable for mortality. Numerous SDoH that affect mortality were identified for specific time points in CHD course that may guide interventions, future research and policy.Systematic Review Registration[https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019139466&ID=CRD42019139466], identifier [CRD42019139466].
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Affiliation(s)
- Richard Tran
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- *Correspondence: Richard Tran,
| | - Rebecca Forman
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Institute, Houston Methodist Hospital, Houston, TX, United States
| | - Aparna Kulkarni
- Cohen Children’s Medical Center, Donald and Barbara Zucker School of Medicine, New Hyde Park, NY, United States
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20
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Glinianaia SV, Rankin J, Pierini A, Coi A, Santoro M, Tan J, Reid A, Garne E, Loane M, Given J, Cavero-Carbonell C, de Walle HEK, Gatt M, Gissler M, Heino A, Khoshnood B, Klungsøyr K, Lelong N, Neville AJ, Thayer DS, Tucker D, Urhøj SK, Wellesley D, Zurriaga O, Morris JK. Ten-Year Survival of Children With Congenital Anomalies: A European Cohort Study. Pediatrics 2022; 149:184766. [PMID: 35146505 DOI: 10.1542/peds.2021-053793] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To investigate the survival up to age 10 for children born alive with a major congenital anomaly (CA). METHODS This population-based linked cohort study (EUROlinkCAT) linked data on live births from 2005 to 2014 from 13 European CA registries with mortality data. Pooled Kaplan-Meier survival estimates up to age 10 were calculated for these children (77 054 children with isolated structural anomalies and 4011 children with Down syndrome). RESULTS The highest mortality of children with isolated structural CAs was within infancy, with survival of 97.3% (95% confidence interval [CI]: 96.6%-98.1%) and 96.9% (95% CI: 96.0%-97.7%) at age 1 and 10, respectively. The 10-year survival exceeded 90% for the majority of specific CAs (27 of 32), with considerable variations between CAs of different severity. Survival of children with a specific isolated anomaly was higher than in all children with the same anomaly when those with associated anomalies were included. For children with Down syndrome, the 10-year survival was significantly higher for those without associated cardiac or digestive system anomalies (97.6%; 95% CI: 96.5%-98.7%) compared with children with Down syndrome associated with a cardiac anomaly (92.3%; 95% CI: 89.4%-95.3%), digestive system anomaly (92.8%; 95% CI: 87.7%-98.2%), or both (88.6%; 95% CI: 83.2%-94.3%). CONCLUSIONS Ten-year survival of children born with congenital anomalies in Western Europe from 2005 to 2014 was relatively high. Reliable information on long-term survival of children born with specific CAs is of major importance for parents of these children and for the health care professionals involved in their care.
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Affiliation(s)
- Svetlana V Glinianaia
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Judith Rankin
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anna Pierini
- Unit of Epidemiology of Rare diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alessio Coi
- Unit of Epidemiology of Rare diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Michele Santoro
- Unit of Epidemiology of Rare diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Joachim Tan
- Population Health Research Institute, St George's, University of London, London, United Kingdom
| | - Abigail Reid
- Population Health Research Institute, St George's, University of London, London, United Kingdom
| | - Ester Garne
- Pediatric Department, Hospital Lillebaelt, Kolding, Denmark
| | - Maria Loane
- Faculty of Life & Health Sciences, Ulster University, Northern Ireland, United Kingdom
| | - Joanne Given
- Faculty of Life & Health Sciences, Ulster University, Northern Ireland, United Kingdom
| | - Clara Cavero-Carbonell
- Rare Diseases Research Unit, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, Valencia, Spain
| | - Hermien E K de Walle
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Miriam Gatt
- Malta Congenital Anomalies Registry, Directorate for Health Information and Research, Tal-Pietà, Malta
| | - Mika Gissler
- Information Services Department, THL Finnish Institute for Health and Welfare. Helsinki, Finland
| | - Anna Heino
- Information Services Department, THL Finnish Institute for Health and Welfare. Helsinki, Finland
| | - Babak Khoshnood
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM-INRA, Université de Paris, Center of Research in Epidemiology and Statistics (CRESS), Paris, France
| | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
| | - Nathalie Lelong
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM-INRA, Université de Paris, Center of Research in Epidemiology and Statistics (CRESS), Paris, France
| | - Amanda J Neville
- Center for Clinical and Epidemiological Research, University of Ferrara, Ferrara, Italy
| | - Daniel S Thayer
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | | | - Stine K Urhøj
- Pediatric Department, Hospital Lillebaelt, Kolding, Denmark
| | - Diana Wellesley
- Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, United Kingdom
| | - Oscar Zurriaga
- Rare Diseases Research Unit, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, Valencia, Spain
| | - Joan K Morris
- Population Health Research Institute, St George's, University of London, London, United Kingdom
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21
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Gilboa SM, Tepper NK, Reefhuis J. Multijurisdictional Analyses of Birth Defects: Considering the Common Data Model Approach. Pediatrics 2022; 149:184765. [PMID: 35146507 PMCID: PMC9113651 DOI: 10.1542/peds.2021-055285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/24/2022] Open
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22
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Downing KF, Oster ME, Klewer SE, Rose CE, Nembhard WN, Andrews JG, Farr SL. Disability Among Young Adults With Congenital Heart Defects: Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being 2016-2019. J Am Heart Assoc 2021; 10:e022440. [PMID: 34666499 PMCID: PMC8751822 DOI: 10.1161/jaha.121.022440] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Disabilities have implications for health, well‐being, and health care, yet limited information is available on the percentage of adults with congenital heart defects (CHD) living with disabilities. We evaluated the prevalence of disability and associated characteristics among the 2016–2019 CH STRONG (Congenital Heart Survey to Recognize Outcomes, Needs, and Well‐Being) population‐based sample of 19‐ to 38‐year‐olds with CHD from 3 US locations. Methods and Results Prevalence of disability types (hearing, vision, cognition, mobility, self‐care, living independently) were compared with similarly aged adults from the general population as estimated by the American Community Survey and standardized to the CH STRONG eligible population to reduce nonresponse bias and confounding. Health‐related quality of life (HRQOL) was measured via Patient‐Reported Outcomes Measurement Information System Global Health Scale T‐scores standardized to US 18‐ to 34‐year‐olds. Separate multivariable regression models assessed associations between disability and HRQOL. Of 1478 participants, 40% reported disabilities, with cognition most prevalent (29%). Of those reporting disability, 45% ever received disability benefits and 46% were unemployed. Prevalence of disability types were 5 to 8 times higher in adults with CHD than the general population. Those with ≥1 disability had greater odds of being female, and of having non‐Hispanic Black maternal race and ethnicity, severe CHD, recent cardiac care, and noncardiac congenital anomalies. On average, adults with CHD and cognition, mobility, and self‐care disabilities had impaired mental HRQOL and those with any disability type had impaired physical HRQOL. Conclusions Two of 5 adults with CHD may have disabilities, which are associated with impaired HRQOL. These results may inform healthcare needs and services for this growing population.
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Affiliation(s)
- Karrie F Downing
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
| | - Matthew E Oster
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA.,Children's Healthcare of Atlanta and Emory University School of Medicine Atlanta GA
| | - Scott E Klewer
- Department of Pediatrics University of Arizona Tucson AZ
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
| | - Wendy N Nembhard
- Department of Epidemiology Fay W Boozman College of Public Health and the Arkansas Center for Birth Defects Research and Prevention University of Arkansas for Medical Sciences Little Rock AR
| | | | - Sherry L Farr
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
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23
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Udine ML, Evans F, Burns KM, Pearson GD, Kaltman JR. Geographical variation in infant mortality due to congenital heart disease in the USA: a population-based cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:483-490. [PMID: 34051889 DOI: 10.1016/s2352-4642(21)00105-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Little is known about geographical variation in infant mortality due to congenital heart disease (CHD) and the social determinants of health that might mediate such variation. We aimed to examine US county-level estimates of infant mortality due to CHD to understand geographical patterns and factors that might influence variation in mortality. METHODS This US population-based cohort study used linked livebirth-infant death cohort files from the US National Center for Health Statistics from Jan 1, 2006, to Dec 31, 2015. All deaths attributable to congenital heart disease in infants in a given year were included. We used hierarchical Bayesian models to estimate rates of infant mortality due to congenital heart disease for all US counties. We mapped model-based estimates to explore geographical patterns. Covariates included infant sex, gestational age, maternal race and ethnicity, percentage of the county population below the poverty level, and proximity of the county to a US News & World Report 2015 top-50 ranked paediatric cardiac centre. FINDINGS From 2006 to 2015, 40 847 089 livebirths occurred, of which there were 13 988 infant deaths attributed to congenital heart disease, with an unadjusted infant mortality rate due to CHD of 0·34 per 1000 livebirths (95% CI 0·34-0·35). Kentucky and Mississippi had the greatest proportions of counties with a predicted rate of infant mortality due to CHD above the 95th percentile. All counties in Connecticut, Massachusetts, and Rhode Island had a predicted rate below the fifth percentile. In the model, lower mortality risk correlated with closer proximity to a top-50 ranked paediatric cardiac centre (odds ratio [OR] 0·890, 95% credible interval [CrI] 0·840-0·942), whereas higher mortality risk correlated with higher levels of poverty (OR 1·181, 95% CrI 1·125-1·239). INTERPRETATION Substantial geographical variation exists in infant mortality due to CHD in the USA, highlighting the potential importance of bolstering care delivery for infants from economically deprived communities and areas remote from top-performing paediatric cardiac centres. FUNDING None.
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Affiliation(s)
- Michelle L Udine
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Frank Evans
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kristin M Burns
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Gail D Pearson
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Division of Cardiology, Children's National Hospital, Washington, DC, USA.
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24
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Grines CL, Klein AJ, Bauser-Heaton H, Alkhouli M, Katukuri N, Aggarwal V, Altin SE, Batchelor WB, Blankenship JC, Fakorede F, Hawkins B, Hernandez GA, Ijioma N, Keeshan B, Li J, Ligon RA, Pineda A, Sandoval Y, Young MN. Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease. Catheter Cardiovasc Interv 2021; 98:277-294. [PMID: 33909339 DOI: 10.1002/ccd.29745] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.
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Affiliation(s)
- Cindy L Grines
- Cardiology, Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA
| | - Andrew J Klein
- Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Holly Bauser-Heaton
- Pediatric Cardiology, Sibley Heart Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Neelima Katukuri
- Cardiology, Orlando VA Medical Center, University of Central Florida, Orlando, Florida, USA
| | - Varun Aggarwal
- Pediatric Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - S Elissa Altin
- Cardiovascular Disease, Yale University, New Haven, Connecticut, USA
| | - Wayne B Batchelor
- Interventional Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
| | - James C Blankenship
- Internal Medicine, Cardiology Division, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Foluso Fakorede
- Interventional Cardiology, Cardiovascular Solutions of Central Mississippi, Cleveland, Mississippi, USA
| | - Beau Hawkins
- Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Gabriel A Hernandez
- Cardiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Britton Keeshan
- Clinical Pediatrics, Yale New Haven Children's Hospital, New Haven, Connecticut, USA
| | - Jun Li
- Cardiology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - R Allen Ligon
- Pediatric Cardiology, Joe DiMaggio Children's Hospital - Memorial Healthcare System, Hollywood, Florida, USA
| | - Andres Pineda
- Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Michael N Young
- Cardiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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25
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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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26
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Siddiqui S, Anderson BR, LaPar DJ, Kalfa D, Chai P, Bacha E, Freud L. Weight impacts 1-year congenital heart surgery outcomes independent of race/ethnicity and payer. Cardiol Young 2021; 31:279-285. [PMID: 33208210 PMCID: PMC8711065 DOI: 10.1017/s1047951120003911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Body mass index, race/ethnicity, and payer status are associated with operative mortality in congenital heart disease (CHD). Interactions between these predictors and impacts on longer term outcomes are less well understood. We studied the effect of body mass index, race/ethnicity, and payer on 1-year outcomes following elective CHD surgery and tested the degree to which race/ethnicity and payer explained the effects of body mass index. Patients aged 2-25 years who underwent elective CHD surgery at our centre from 2010 to 2017 were included. We assessed 1-year unplanned cardiac re-admissions, re-interventions, and mortality. Step-wise, multivariable logistic regression was performed.Of the 929 patients, 10.4% were underweight, 14.9% overweight, and 8.5% obese. Non-white race/ethnicity comprised 40.4% and public insurance 29.8%. Only 0.5% died prior to hospital discharge with one additional death in the first post-operative year. Amongst patients with continuous follow-up, unplanned re-admission and re-intervention rates were 14.7% and 12.3%, respectively. In multivariable analyses adjusting for surgical complexity and surgeon, obese, overweight, and underweight patients had higher odds of re-admission than normal-weight patients (OR 1.40, p = 0.026; OR 1.77, p < 0.001; OR 1.44, p = 0.008). Underweight patients had more than twice the odds of re-intervention compared with normal weight (OR 2.12, p < 0.001). These associations persisted after adjusting for race/ethnicity, payer, and surgeon.Pre-operative obese, overweight, and underweight body mass index were associated with unplanned re-admission and/or re-intervention 1-year following elective CHD surgery, even after accounting for race/ethnicity and payer status. Body mass index may be an important modifiable risk factor prior to CHD surgery.
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Affiliation(s)
- Saira Siddiqui
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Brett R Anderson
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Damien J LaPar
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - David Kalfa
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Chai
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Emile Bacha
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Lindsay Freud
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY, USA
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27
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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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28
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Purkey NJ, Ma C, Lee HC, Hintz SR, Shaw GM, McElhinney DB, Carmichael SL. Timing of Transfer and Mortality in Neonates with Hypoplastic Left Heart Syndrome in California. Pediatr Cardiol 2021; 42:906-917. [PMID: 33533967 PMCID: PMC7857096 DOI: 10.1007/s00246-021-02561-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/16/2021] [Indexed: 11/30/2022]
Abstract
Maternal race/ethnicity is associated with mortality in neonates with hypoplastic left heart syndrome (HLHS). We investigated whether maternal race/ethnicity and other sociodemographic factors affect timing of transfer after birth and whether timing of transfer impacts mortality in infants with HLHS. We linked two statewide databases, the California Perinatal Quality Care Collaborative and records from the Office of Statewide Health Planning and Development, to identify cases of HLHS born between 1/1/06 and 12/31/11. Cases were divided into three groups: birth at destination hospital, transfer on day of life 0-1 ("early transfer"), or transfer on day of life ≥ 2 ("late transfer"). We used log-binomial regression models to estimate relative risks (RR) for timing of transfer and Cox proportional hazard models to estimate hazard ratios (HR) for mortality. We excluded infants who died within 60 days of life without intervention from the main analyses of timing of transfer, since intervention may not have been planned in these infants. Of 556 cases, 107 died without intervention (19%) and another 52 (9%) died within 28 days. Of the 449 included in analyses of timing of transfer, 28% were born at the destination hospital, 49% were transferred early, and 23% were transferred late. Late transfer was more likely for infants of low birthweight (RR 1.74) and infants born to US-born Hispanic (RR 1.69) and black (RR 2.45) mothers. Low birthweight (HR 1.50), low 5-min Apgar score (HR 4.69), and the presence of other major congenital anomalies (HR 3.41), but not timing of transfer, predicted neonatal mortality. Late transfer was more likely in neonates born to US-born Hispanic and black mothers but was not associated with higher mortality.
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Affiliation(s)
- Neha J. Purkey
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| | - Chen Ma
- Division of Neonatology and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| | - Henry C. Lee
- Division of Neonatology and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| | - Susan R. Hintz
- Division of Neonatology and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| | - Gary M. Shaw
- Division of Neonatology and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| | - Doff B. McElhinney
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA ,Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, USA
| | - Suzan L. Carmichael
- Division of Neonatology and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA ,Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, USA
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Meza BC, Iacone D, Talwar D, Sankar WN, Shah AS. Socioeconomic Deprivation and Its Adverse Association with Adolescent Fracture Care Compliance. JB JS Open Access 2020; 5:e0064. [PMID: 33123665 PMCID: PMC7418910 DOI: 10.2106/jbjs.oa.19.00064] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Socioeconomic deprivation increases fracture incidence in adolescents, but
its impact on fracture care is unknown. The area deprivation index (ADI),
which incorporates 17 factors from the U.S. Census, measures socioeconomic
deprivation in neighborhoods. This investigation aimed to determine the
impact of socioeconomic deprivation and other socioeconomic factors on
fracture care compliance in adolescents. Methods: This study included patients who were 11 to 18 years of age and received
fracture care at a single urban children’s hospital system between
2015 and 2017. Demographic information (sex, race, caregiver status,
insurance type) and clinical information (mechanism of injury, type of
treatment) were obtained. The ADI, which has a mean score of 100 points and
a standard deviation of 20 points, was used to quantify socioeconomic
deprivation for each patient’s neighborhood. The outcome variables
related to compliance included the quantity of no-show visits at the
orthopaedic clinic and delays in follow-up care of >1 week. Risk
factors for suboptimal compliance were evaluated by bivariate analysis and
multivariate logistic regression. Results: The cohort included 457 adolescents; 75.9% of the patients were male, and the
median age was 16.1 years. The median ADI was 101.5 points (interquartile
range, 86.3 to 114.9 points). Bivariate analyses demonstrated that higher
ADI, black race, single-parent caregiver status, Medicaid insurance,
non-sports mechanisms of injury, and surgical management are associated with
suboptimal fracture care compliance. Adolescents from the most socially
deprived regions were significantly more likely to have delays in care
(33.8% compared with 20.1%; p = 0.037) and miss scheduled orthopaedic
visits (29.9% compared with 7.1%; p < 0.001) compared with adolescents
from the least deprived regions. ADI, Medicaid insurance, and initial
presentation to the emergency department were independent predictors of
suboptimal care compliance, when controlling for other variables. Conclusions: Socioeconomic deprivation is associated with an increased risk of suboptimal
fracture care compliance in adolescents. Clinicians can utilize caregiver
and insurance status to better understand the likelihood of fracture care
compliance. These findings highlight the importance of understanding
differences in each family’s ability to adhere to the recommended
follow-up and of implementing measures to enhance compliance.
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Affiliation(s)
- Blake C Meza
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dina Iacone
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Divya Talwar
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wudbhav N Sankar
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Apurva S Shah
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Abstract
BACKGROUND CHD is the most common birth defect type, with one-fourth of patients requiring intervention in the first year of life. Caregiver understanding of CHD may vary. Health literacy may be one factor contributing to this variability. METHODS The study occurred at a large, free-standing children's hospital. Recruitment occurred at a free-of-charge CHD camp and during outpatient cardiology follow-up visits. The study team revised the CHD Guided Questions Tool from an eighth- to a sixth-grade reading level. Caregivers of children with CHD completed the "Newest Vital Sign" health literacy screen and demographic surveys. Health literacy was categorised as "high" (Newest Vital Sign score 4-6) or "low" (score 0-3). Caregivers were randomised to read either the original or revised Guided Questions Tool and completed a validated survey measuring understandability and actionability of the Guided Questions Tool. Understandability and actionability data analysis used two-sample t-testing, and within demographic group differences in these parameters were assessed via one-way analysis of variance. RESULTS Eighty-two caregivers participated who were largely well educated with a high income. The majority (79.3%) of participants scored "high" for health literacy. No differences in understanding (p = 0.43) or actionability (p = 0.11) of the original and revised Guided Questions Tool were noted. There were no socio-economic-based differences in understandability or actionability (p > 0.05). There was a trend towards improved understanding of the revised tool (p = 0.06). CONCLUSIONS This study demonstrated that readability of the Guided Questions Tool could be improved. Future work is needed to expand the study population and further understand health literacy's impact on the CHD community.
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31
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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: 99] [Impact Index Per Article: 24.8] [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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Abstract
OBJECTIVE To evaluate the impact of state-mandated policies for pulse oximetry screening on healthcare utilisation, with a focus on use of echocardiograms. DATA SOURCES/STUDY SETTING Healthcare Cost and Utilisation Project, Statewide Inpatient Databases from 2008 to 2014 from six states. METHODS We defined pre- and post-mandate cohorts based on dates when pulse oximetry became mandated in each state. Linear segmented regression models for interrupted time series assessed associations between implementation of the screening and changes in rate of newborns with Critical CHD-negative echocardiogram results. We also evaluated the changes in rate of newborns who underwent echocardiogram but were not diagnosed with any health issues that could cause hypoxemia. RESULTS We identified 5967 critical CHD-negative echocardiograms (2847 and 3120 in the pre- and post-mandate periods, respectively). Our models detected a statistically significant increasing trend in rate of critical CHD-negative echocardiograms in the pre-mandate period (Incidence Rate Ratio: 1.08, p = 0.02), but did not detect any statistical differences in changes between pre- and post-mandate periods (Incidence Rate Ratio: 0.93, p = 0.14). Among non-Whites, an increasing trend of Critical CHD-negative echocardiogram during the pre-mandate period was detected (Incidence Rate Ratio 1.12, p < 0.01) and was attenuated during the post-mandate period (Incidence Rate Ratio 0.89, p = 0.02). Similar results were observed in the sensitivity analyses among both Whites and non-Whites. CONCLUSIONS Results suggest that mandatory state screening policies are associated with reductions in false-positive screening rates for hypoxemic conditions, with reductions primarily attributed to trends among non-Whites.
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33
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Naim MY, Putt M, Abend NS, Mastropietro CW, Frank DU, Chen JM, Fuller S, Gangemi JJ, Gaynor JW, Heinan K, Licht DJ, Mascio CE, Massey S, Roeser ME, Smith CJ, Kimmel SE. Development and Validation of a Seizure Prediction Model in Neonates After Cardiac Surgery. Ann Thorac Surg 2020; 111:2041-2048. [PMID: 32738224 DOI: 10.1016/j.athoracsur.2020.05.157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Electroencephalographic seizures (ESs) after neonatal cardiac surgery are often subclinical and have been associated with poor outcomes. An accurate ES prediction model could allow targeted continuous electroencephalographic monitoring (CEEG) for high-risk neonates. METHODS ES prediction models were developed and validated in a multicenter prospective cohort where all postoperative neonates who underwent cardiopulmonary bypass (CPB) also underwent CEEG. RESULTS ESs occurred in 7.4% of neonates (78 of 1053). Model predictors included gestational age, head circumference, single-ventricle defect, deep hypothermic circulatory arrest duration, cardiac arrest, nitric oxide, extracorporeal membrane oxygenation, and delayed sternal closure. The model performed well in the derivation cohort (c-statistic, 0.77; Hosmer-Lemeshow, P = .56), with a net benefit (NB) over monitoring all and none over a threshold probability of 2% in decision curve analysis (DCA). The model had good calibration in the validation cohort (Hosmer-Lemeshow, P = .60); however, discrimination was poor (c-statistic, 0.61), and in DCA there was no NB of the prediction model between the threshold probabilities of 8% and 18%. By using a cut point that emphasized negative predictive value in the derivation cohort, 32% (236 of 737) of neonates would not undergo CEEG, including 3.5% (2 of 58) of neonates with ESs (negative predictive value, 99%; sensitivity, 97%). CONCLUSIONS In this large prospective cohort, a prediction model of ESs in neonates after CPB had good performance in the derivation cohort, with an NB in DCA. However, performance in the validation cohort was weak, with poor discrimination, poor calibration, and no NB in DCA. These findings support CEEG of all neonates after CPB.
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Affiliation(s)
- Maryam Y Naim
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology, Critical Care Medicine, and Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Mary Putt
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas S Abend
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher W Mastropietro
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana
| | - Deborah U Frank
- Division of Critical Care, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Jonathan M Chen
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James J Gangemi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristin Heinan
- Division of Neurology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Daniel J Licht
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shavonne Massey
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark E Roeser
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Clyde J Smith
- Division of Critical Care, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Stephen E Kimmel
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Peyvandi S, Baer RJ, Moon-Grady AJ, Oltman SP, Chambers CD, Norton ME, Rajagopal S, Ryckman KK, Jelliffe-Pawlowski LL, Steurer MA. Socioeconomic Mediators of Racial and Ethnic Disparities in Congenital Heart Disease Outcomes: A Population-Based Study in California. J Am Heart Assoc 2019; 7:e010342. [PMID: 30371284 PMCID: PMC6474947 DOI: 10.1161/jaha.118.010342] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Racial/ethnic and socioeconomic disparities exist in outcomes for children with congenital heart disease. We sought to determine the influence of race/ethnicity and mediating socioeconomic factors on 1‐year outcomes for live‐born infants with hypoplastic left heart syndrome and dextro‐Transposition of the great arteries. Methods and Results The authors performed a population‐based cohort study using the California Office of Statewide Health Planning and Development database. Live‐born infants without chromosomal anomalies were included. The outcome was a composite measure of mortality or unexpected hospital readmissions within the first year of life defined as >3 (hypoplastic left heart syndrome) or >1 readmissions (dextro‐Transposition of the great arteries). Hispanic ethnicity was compared with non‐Hispanic white ethnicity. Mediation analyses determined the percent contribution to outcome for each mediator on the pathway between race/ethnicity and outcome. A total of 1796 patients comprised the cohort (n=964 [hypoplastic left heart syndrome], n=832 [dextro‐Transposition of the great arteries]) and 1315 were included in the analysis (n=477 non‐Hispanic white, n=838 Hispanic). Hispanic ethnicity was associated with a poor outcome (crude odds ratio, 1.72; 95% confidence interval [CI], 1.37–2.17). Higher maternal education (crude odds ratio 0.5; 95% CI, 0.38–0.65) and private insurance (crude odds ratio, 0.65; 95% CI, 0.45–0.71) were protective. In the mediation analysis, maternal education and insurance status explained 33.2% (95% CI, 7–66.4) and 27.6% (95% CI, 6.5–63.1) of the relationship between race/ethnicity and poor outcome, while infant characteristics played a minimal role. Conclusions Socioeconomic factors explain a significant portion of the association between Hispanic ethnicity and poor outcome in neonates with critical congenital heart disease. These findings identify vulnerable populations that would benefit from resources to lessen health disparities.
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Affiliation(s)
- Shabnam Peyvandi
- 1 Divisions of Cardiology and Critical Care Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Rebecca J Baer
- 2 Department of Epidemiology & Biostatistics and the California Preterm Birth Initiative University of California San Francisco Benioff Children's Hospital San Francisco CA.,4 Department of Pediatrics University of California San Diego La Jolla California
| | - Anita J Moon-Grady
- 1 Divisions of Cardiology and Critical Care Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Scott P Oltman
- 2 Department of Epidemiology & Biostatistics and the California Preterm Birth Initiative University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Christina D Chambers
- 4 Department of Pediatrics University of California San Diego La Jolla California
| | - Mary E Norton
- 3 Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Satish Rajagopal
- 1 Divisions of Cardiology and Critical Care Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Kelli K Ryckman
- 5 Department of Epidemiology College of Public Health, University of Iowa Iowa City Iowa
| | - Laura L Jelliffe-Pawlowski
- 2 Department of Epidemiology & Biostatistics and the California Preterm Birth Initiative University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Martina A Steurer
- 1 Divisions of Cardiology and Critical Care Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco CA.,2 Department of Epidemiology & Biostatistics and the California Preterm Birth Initiative University of California San Francisco Benioff Children's Hospital San Francisco CA
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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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36
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Spector LG, Menk JS, Knight JH, McCracken C, Thomas AS, Vinocur JM, Oster ME, St Louis JD, Moller JH, Kochilas L. Trends in Long-Term Mortality After Congenital Heart Surgery. J Am Coll Cardiol 2019; 71:2434-2446. [PMID: 29793633 DOI: 10.1016/j.jacc.2018.03.491] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/21/2018] [Accepted: 03/06/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Congenital heart surgery has improved the survival of patients with even the most complex defects, but the long-term survival after these procedures has not been fully described. OBJECTIVES The purpose of this study was to evaluate the long-term survival of patients (age <21 years) who were operated on for congenital heart defects (CHDs). METHODS This study used the Pediatric Cardiac Care Consortium data, a U.S.-based, multicenter registry of pediatric cardiac surgery. Survival analysis included 35,998 patients who survived their first congenital heart surgery at <21 years of age and had adequate identifiers for linkage with the National Death Index through 2014. Survival was compared to that in the general population using standardized mortality ratios (SMRs). RESULTS After a median follow-up of 18 years (645,806 person-years), 3,191 deaths occurred with an overall SMR of 8.3 (95% confidence interval [CI]: 8.0 to 8.7). The 15-year SMR decreased from 12.7 (95% CI: 11.9 to 13.6) in the early era (1982 to 1992) to 10.0 (95% CI: 9.3 to 10.8) in the late era (1998 to 2003). The SMR remained elevated even for mild forms of CHD such as patent ductus arteriosus (SMR 4.5) and atrial septal defects (SMR 4.9). The largest decreases in SMR occurred for patients with transposition of great arteries (early: 11.0 vs. late: 3.8; p < 0.05), complete atrioventricular canal (31.3 vs. 15.3; p < 0.05), and single ventricle (53.7 vs. 31.3; p < 0.05). CONCLUSIONS In this large U.S. cohort, long-term mortality after congenital heart surgery was elevated across all forms of CHD. Survival has improved over time, particularly for severe defects with significant changes in their management strategy, but still lags behind the general population.
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Affiliation(s)
- Logan G Spector
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Jeremiah S Menk
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota
| | - Jessica H Knight
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Amanda S Thomas
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jeffrey M Vinocur
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Matthew E Oster
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - James D St Louis
- Department of Pediatric Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - James H Moller
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Lazaros Kochilas
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia.
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37
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Demianczyk AC, Behere SP, Thacker D, Noeder M, Delaplane EA, Pizarro C, Sood E. Social Risk Factors Impact Hospital Readmission and Outpatient Appointment Adherence for Children with Congenital Heart Disease. J Pediatr 2019; 205:35-40.e1. [PMID: 30366772 PMCID: PMC6527093 DOI: 10.1016/j.jpeds.2018.09.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/16/2018] [Accepted: 09/12/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To examine the relations of individual and cumulative social risk factors to hospitalization outcomes and adherence to outpatient cardiology appointments within the first 2 years of life for congenital heart disease survivors. STUDY DESIGN Data were extracted for 219 patients who underwent infant cardiac surgery with cardiopulmonary bypass. Cumulative social risk was dichotomized into high social risk (≥2 risk factors; n = 103) versus low social risk (≤1 risk factor; n = 116). The risk of morbidity by procedure was assigned from 1 to 5 (Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery Morbidity Scores and Categories). Two-way ANOVAs examined the effects of social risk and morbidity risk on length of first surgical hospitalization, number of readmissions and readmission days, subsequent cardiac surgical interventions, and adherence to outpatient cardiology appointments. RESULTS An interaction between social risk and morbidity risk was identified for number of readmission days, F(4, 209) = 3.07, P = .02, η2 = .06. Pairwise comparisons demonstrated that, among those patients with the lowest risk of morbidity by procedure (morbidity scores of 1 and 2), patients at high social risk had more readmission days than patients at low social risk (morbidity score 1: 16.63 ± 34.41 days vs 3.02 ± 7.13 days; morbidity score 2: 27.68 ± 52.11 days vs 2.20 ± 4.43 days). High social risk also predicted significantly worse adherence to cardiology appointments. CONCLUSIONS Cumulative social risk impacts readmission days for patients with congenital heart disease with a low risk of morbidity by procedure. Social risk assessment can identify families who may benefit from social/behavioral interventions to optimize discharge readiness, congenital heart disease home management, and long-term outcomes.
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Affiliation(s)
- Abigail C. Demianczyk
- Division of Behavioral Health, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Shashank P. Behere
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Deepika Thacker
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Maia Noeder
- Division of Behavioral Health, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Emily A. Delaplane
- Department of Patient and Family Services, Nemours/Alfred I. duPont Hospital for Children, Wilmington,
DE
| | - Christian Pizarro
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Erica Sood
- Division of Behavioral Health, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Pace ND, Oster ME, Forestieri NE, Enright D, Knight J, Meyer RE. Sociodemographic Factors and Survival of Infants With Congenital Heart Defects. Pediatrics 2018; 142:peds.2018-0302. [PMID: 30111552 DOI: 10.1542/peds.2018-0302] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To examine the first-year survival of infants with congenital heart defects (CHDs) and investigate the potential role of socioeconomic and demographic factors on survival. METHODS Subjects included 15 533 infants with CHDs born between 2004 and 2013 ascertained by the NC Birth Defects Monitoring Program. We classified CHDs into the following 3 groups: critical univentricular (n = 575), critical biventricular (n = 1494), and noncritical biventricular (n = 13 345). We determined vital status and age at death through linkage to state vital records and used geocoded maternal residence at birth to obtain census information for study subjects. We calculated Kaplan-Meier survival estimates by maternal and infant characteristics and derived hazard ratios from Cox proportional hazard models for selected exposures. RESULTS Among all infants with CHDs, there were 1289 deaths (8.3%) in the first year. Among infants with univentricular defects, 61.6% (95% confidence interval [CI]: 57.7%-65.7%) survived. Survival among infants with univentricular defects was considerably better for those whose fathers were ≥35 years old (71.6%; 95% CI: 63.8%-80.3%) compared with those whose fathers were younger (59.7%; 95% CI: 54.6%-65.2%). Factors associated with survival among infants with any biventricular defect included maternal education, race and/or ethnicity, marital status, and delivery at a heart center. The hazard of infant mortality was greatest among non-Hispanic African American mothers. CONCLUSIONS Survival among infants with critical univentricular CHDs was less variable across sociodemographic categories compared with survival among infants with biventricular CHDs. Sociodemographic differences in survival among infants with less severe CHDs reinforces the importance of ensuring culturally effective pediatric care for at-risk infants and their families.
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Affiliation(s)
- Nelson D Pace
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; .,Birth Defects Monitoring Branch, and
| | - Matthew E Oster
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia; and.,Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | | | - Dianne Enright
- Health and Spatial Analysis Branch, State Center for Health Statistics, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Jessica Knight
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
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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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Ruggiero KM, Hickey PA, Leger RR, Vessey JA, Hayman LL. Parental perceptions of disease-severity and health-related quality of life in school-age children with congenital heart disease. J SPEC PEDIATR NURS 2018; 23. [PMID: 29266743 DOI: 10.1111/jspn.12204] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 11/20/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Understanding parents' perceptions of their child's health status is important as parents are drivers of healthcare utilization in the pediatric setting. Understanding parent-perceived disease-severity and its effects on a child's health-related quality of life (HRQOL) in children with congenital heart disease (CHD) is necessary to evaluate outcomes of care, improve care coordination, and inform policies focused on advancing family-centered care for pediatric cardiac patients. The impact of CHDs and disease-severity on the child's HRQOL has been investigated with inconsistent results. The overall aim of this study was to examine parents' perceptions of HRQOL in their school-age child with CHD, and to compare HRQOL among patients with CHD across severity categories. DESIGN This was a descriptive correlational study design. METHODS A total of 71 parents of school-age children aged 5-12 years completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (PedsQL) (including total, physical health, and psychosocial health summary scores) and cardiac-specific HRQOL Scale (PedsQL 3.0). PedsQL scores among CHD severity categories were compared by analysis of variance. RESULTS School-age children with CHDs had an overall good HRQOL with significant differences among disease severity categories for all scores. Parents reported lower scores on their HRQOL of older children compared to younger children across severity groups (p < .01) and for those children with more severe disease (p < .01). PRACTICE IMPLICATIONS Based on the results of this study, interventions should focus on targeting psychosocial health in older children with CHD and physical health in younger children with CHD. This information is useful in providing practical recommendations in caring for children with CHDs while informing relevant policies.
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Affiliation(s)
- Kristine M Ruggiero
- Pediatric Nurse Practitioner/ Nurse Scientist, Medical Services, Boston Children's Hospital, Boston, MA, USA; Assistant professor, Department of Nursing, MGH Institute of Health Professions, Boston, MA, USA
| | - Patricia A Hickey
- Vice President; Associate Cheif Nurse, Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA
| | - Robin R Leger
- Professor, Department of Nursing, Salem State University, Salem, MA, USA
| | - Judith A Vessey
- Nurse Scientist, Medical Services, Boston Children's Hospital, Boston, MA, USA; Professor, Department of Nursing, Boston College, Boston, MA, USA
| | - Laura L Hayman
- Professor, Department of of Nursing, University of Massachusetts Boston, Boston, MA, USA
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Lopez KN, Nembhard WN, Wang Y, Liu G, Kucik JE, Copeland G, Gilboa SM, Kirby RS, Canfield M. Birth defect survival for Hispanic subgroups. Birth Defects Res 2017; 110:352-363. [PMID: 29195034 DOI: 10.1002/bdr2.1157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/15/2017] [Accepted: 10/16/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Previous studies demonstrate that infant and childhood mortality differ among children with birth defects by maternal race/ethnicity, but limited mortality information is published for Hispanic ethnic subgroups. METHODS We performed a retrospective cohort study using data for children with birth defects born to Hispanic mothers during 1999-2007 from 12 population-based state birth defects surveillance programs. Deaths were ascertained through multiple sources. Survival probabilities were estimated by the Kaplan-Meier method. Cox proportional hazards regression was used to examine the effect of clinical and demographic factors on mortality risk. RESULTS Among 28,497 Hispanic infants and children with major birth defects, 1-year survival was highest for infants born to Cuban mothers at 94.6% (95% confidence intervals [CI] 92.7-96.0) and the lowest for Mexicans at 90.2% (95% CI 89.7-90.6; p < .0001). For children aged up to 8 years, survival remained highest for Cuban Americans at 94.1% (95% CI 91.8-95.7) and lowest for Mexican Americans at 89.2% (95% CI 88.7-89.7; p = .0002). In the multivariable analysis using non-Hispanic White as the reference group, only infants and children born to Mexican mothers were noted to have a higher risk of mortality for cardiovascular defects. CONCLUSIONS This analysis provides a better understanding of survival and mortality for Hispanic infants and children with selected birth defects. The differences found in survival, particularly the highest survival rates for Cuban American children and lowest for Mexican American children with birth defects, underscores the importance of assessing Hispanic ethnic subgroups, as differences among subgroups appear to exist.
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Affiliation(s)
- Keila N Lopez
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Wendy N Nembhard
- Arkansas Reproductive Health Monitoring System, Arkansas Children's Research Institute & University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ying Wang
- Division of Data Analysis and Research, Office of Primary Care and Health System Management, New York State Department of Health, New York, New York
| | - Gang Liu
- Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, State University of New York, Albany, New York
| | - James E Kucik
- Office of the Associate Director for Policy, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Glenn Copeland
- Michigan Department of Health and Human Services, Michigan Birth Defects Registry, Lansing, Michigan
| | - Suzanne M Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Russell S Kirby
- Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, Florida
| | - Mark Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
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Best KE, Tennant PWG, Rankin J. Survival, by Birth Weight and Gestational Age, in Individuals With Congenital Heart Disease: A Population-Based Study. J Am Heart Assoc 2017; 6:JAHA.116.005213. [PMID: 28733436 PMCID: PMC5586271 DOI: 10.1161/jaha.116.005213] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Congenital heart disease (CHD) survival estimates are important to understand prognosis and evaluate health and social care needs. Few studies have reported CHD survival estimates according to maternal and fetal characteristics. This study aimed to identify predictors of CHD survival and report conditional survival estimates. METHODS AND RESULTS Cases of CHD (n=5070) born during 1985-2003 and notified to the Northern Congenital Abnormality Survey (NorCAS) were matched to national mortality information in 2008. Royston-Parmar regression was performed to identify predictors of survival. Five-year survival estimates conditional on gestational age at delivery, birth weight, and year of birth were produced for isolated CHD (ie, CHD without extracardiac anomalies). Year of birth, gestational age, birth weight, and extracardiac anomalies were independently associated with mortality (all P≤0.001). Five-year survival for children born at term (37-41 weeks) in 2003 with average birth weight (within 1 SD of the mean) was 96.3% (95% CI, 95.6-97.0). Survival was most optimistic for high-birth-weight children (>1 SD from the mean) born post-term (≥42 weeks; 97.9%; 95% CI, 96.8-99.1%) and least optimistic for very preterm (<32 weeks) low-birth-weight (<1 SD from mean) children (78.8%; 95% CI, 72.8-99.1). CONCLUSIONS Five-year CHD survival is highly influenced by gestational age and birth weight. For prenatal counseling, conditional survival estimates provide best- and worst-case scenarios, depending on final gestational age and birth weight. For postnatal diagnoses, they can provide parents with more-accurate predictions based on their baby's birth weight and gestational age.
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Affiliation(s)
- Kate E Best
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
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Jernigan EG, Strassle PD, Stebbins RC, Meyer RE, Nelson JS. Effect of Concomitant Birth Defects and Genetic Anomalies on Infant Mortality in Tetralogy of Fallot. Birth Defects Res 2017. [PMID: 28627098 DOI: 10.1002/bdr2.1057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A substantial proportion of infants born with tetralogy of Fallot (TOF) die in infancy. A better understanding of the heterogeneity associated with TOF, including extracardiac malformations and chromosomal anomalies is vital to stratifying risk and optimizing outcomes during infancy. METHODS Using the North Carolina Birth Defects Monitoring Program, infants diagnosed with TOF and born between 2003 and 2012 were included. Kaplan-Meier survival curves were used to estimate cumulative 1-year mortality, stratified by the presence of concomitant birth defects (BDs) and chromosomal anomalies. Multivariable logistic regression was used to estimate the direct effect of each concomitant BD, after adjusting for all others. RESULTS A total of 496 infants with TOF were included, and 15% (n = 76) died. The number of concomitant BD systems was significantly associated with the risk of death at 1-year, p < 0.0001. Specifically, the risk of mortality was 8% among infants with TOF with or without additional cardiac defects, 16% among infants with TOF and 1 extracardiac BD system, 19% among infants with 2 extracardiac BD systems, and 39% among infants with ≥ 3 extracardiac BD systems. After adjustment, concomitant eye and gastrointestinal defects were significantly associated increased with 1-year mortality, odds ratio 2.83 (95% confidence interval, 1.08-7.32) and odds ratio 4.43 (95% confidence interval, 1.57, 12.45), respectively. Infants with trisomy 13 or trisomy 18 were also significantly more likely to die, p < 0.0001. CONCLUSION Both concomitant BDs and genetic anomalies increase the risk of mortality among infants with TOF. Future studies are needed to identify the underlying genetic and socioeconomic risk factors for high-risk TOF infants. Birth Defects Research 109:1154-1165, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Eric G Jernigan
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Paula D Strassle
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Rebecca C Stebbins
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Robert E Meyer
- North Carolina State Center for Health Statistics Birth Defects Monitoring Program, Raleigh, North Carolina.,Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer S Nelson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Department of Cardiothoracic, Surgery Nemours Children's Hospital, Orlando, FL, USA
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Danton MHD. Larger Centers Produce Better Outcomes in Pediatric Cardiac Surgery: Regionalization is a Superior Model - The Con Prospective. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017; 19:14-24. [PMID: 27060038 DOI: 10.1053/j.pcsu.2015.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/10/2015] [Indexed: 11/11/2022]
Abstract
Regionalization, in the context of congenital heart surgery, describes a process where smaller units close and patients are redistributed to larger centers. Proponents argue this will produce superior patient outcome based primarily on a volume-outcome effect. The potential disadvantage is that, as distance to center increases, access to service is compromised. In this article the volume-outcome effect is appraised and the effect of risk-stratification and threshold volumes explored. Access to service, and how certain congenital lesions and demographics might be disadvantaged, is reviewed. Alternative models are considered including collaborative programing and a standardizing approach of agreed parameters in personnel and infrastructure. Finally the influence of newer developments and quality metrics, including outcome databases, digital technologies and team-cognitive performance, needs to be factored in as the future unfolds. Ultimately, the design of a national congenital cardiac program should aspire to deliver care that is optimal, equitable and economic for the whole population. The solution lies in the distillation of competing variables cognizant of regional demographics and geography.
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Cost and Cost-Effectiveness Assessments of Newborn Screening for Critical Congenital Heart Disease Using Pulse Oximetry: A Review. Int J Neonatal Screen 2017; 3:34. [PMID: 29376140 PMCID: PMC5784211 DOI: 10.3390/ijns3040034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Screening newborns for critical congenital heart disease (CCHD) using pulse oximetry is recommended to allow for the prompt diagnosis and prevention of life-threatening crises. The present review summarizes and critiques six previously published estimates of the costs or cost-effectiveness of CCHD screening from the United Kingdom, United States, and China. Several elements that affect CCHD screening costs were assessed in varying numbers of studies, including screening staff time, instrumentation, and consumables, as well as costs of diagnosis and treatment. A previous US study that used conservative assumptions suggested that CCHD screening is likely to be considered cost-effective from the healthcare sector perspective. Newly available estimates of avoided infant CCHD deaths in several US states that implemented mandatory CCHD screening policies during 2011-2013 suggest a substantially larger reduction in deaths than was projected in the previous US cost-effectiveness analysis. Taking into account these new estimates, we estimate that cost per life-year gained could be as low as USD 12,000. However, that estimate does not take into account future costs of health care and education for surviving children with CCHD nor the costs incurred by health departments to support and monitor CCHD screening policies and programs.
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Nembhard WN, Bourke J, Leonard H, Eckersley L, Li J, Bower C. Twenty-five-year survival for aboriginal and caucasian children with congenital heart defects in Western Australia, 1980 to 2010. ACTA ACUST UNITED AC 2016; 106:1016-1031. [DOI: 10.1002/bdra.23572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Wendy N. Nembhard
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine; University of Arkansas for Medical Sciences, Arkansas Children's Hospital Research Institute; Arkansas
- Telethon Kids Institute; University of Western Australia; Western Australia Australia
| | - Jenny Bourke
- Telethon Kids Institute; University of Western Australia; Western Australia Australia
| | - Helen Leonard
- Telethon Kids Institute; University of Western Australia; Western Australia Australia
| | - Luke Eckersley
- Children's Cardiac Centre; Princess Margaret Hospital; Western Australia Australia
| | - Jingyun Li
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine; University of Arkansas for Medical Sciences, Arkansas Children's Hospital Research Institute; Arkansas
| | - Carol Bower
- Telethon Kids Institute; University of Western Australia; Western Australia Australia
- Western Australian Register of Developmental Anomalies; King Edward Memorial Hospital; Western Australia Australia
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Best KE, Rankin J. Long-Term Survival of Individuals Born With Congenital Heart Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2016; 5:e002846. [PMID: 27312802 PMCID: PMC4937249 DOI: 10.1161/jaha.115.002846] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/19/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Estimates of long-term survival are required to adequately assess the variety of health and social services required by those with congenital heart disease (CHD) throughout their lives. METHODS AND RESULTS Medline, Embase, and Scopus were searched from inception to June 2015 using MeSH headings and keywords. Population-based studies that ascertained all persons born with CHD within a predefined area and reported survival estimates at ≥5 years were included. Unadjusted survival estimates for each CHD subtype at ages 1 year, 5 years, 10 years, and so forth were extracted. Pooled survival estimates for each age were calculated using meta-analyses. Metaregression was performed to examine the impact of study period on survival. Of 7840 identified articles, 16 met the inclusion criteria. Among those with CHD, pooled 1-year survival was 87.0% (95% CI 82.1-91.2), pooled 5-year survival was 85.4% (95% CI 79.4-90.5), and pooled 10-year survival was 81.4% (95% CI 73.8-87.9). There was significant heterogeneity of survival estimates among articles (P<0.001 for 1-, 5-, and 10-year survival). A more recent study period was significantly associated with greater survival at ages 1 year (P=0.047), 5 years (P=0.013), and 10 years (P=0.046). Survival varied by CHD subtype, with 5-year survival being greatest for those with ventricular septal defect (96.3%, 95% CI 93.7-98.2) and lowest for those with hypoplastic left heart (12.5%, 95% CI 0.0-41.4). CONCLUSIONS Among persons with CHD, the mortality rate is greatest during the first year of life; however, this systematic review and meta-analysis showed that survival decreases gradually after infancy and into adulthood.
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Affiliation(s)
- Kate E Best
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Jenkins KJ, Koch Kupiec J, Owens PL, Romano PS, Geppert JJ, Gauvreau K. Development and Validation of an Agency for Healthcare Research and Quality Indicator for Mortality After Congenital Heart Surgery Harmonized With Risk Adjustment for Congenital Heart Surgery (RACHS-1) Methodology. J Am Heart Assoc 2016; 5:e003028. [PMID: 27207997 PMCID: PMC4889177 DOI: 10.1161/jaha.115.003028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/23/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The National Quality Forum previously approved a quality indicator for mortality after congenital heart surgery developed by the Agency for Healthcare Research and Quality (AHRQ). Several parameters of the validated Risk Adjustment for Congenital Heart Surgery (RACHS-1) method were included, but others differed. As part of the National Quality Forum endorsement maintenance process, developers were asked to harmonize the 2 methodologies. METHODS AND RESULTS Parameters that were identical between the 2 methods were retained. AHRQ's Healthcare Cost and Utilization Project State Inpatient Databases (SID) 2008 were used to select optimal parameters where differences existed, with a goal to maximize model performance and face validity. Inclusion criteria were not changed and included all discharges for patients <18 years with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for congenital heart surgery or nonspecific heart surgery combined with congenital heart disease diagnosis codes. The final model includes procedure risk group, age (0-28 days, 29-90 days, 91-364 days, 1-17 years), low birth weight (500-2499 g), other congenital anomalies (Clinical Classifications Software 217, except for 758.xx), multiple procedures, and transfer-in status. Among 17 945 eligible cases in the SID 2008, the c statistic for model performance was 0.82. In the SID 2013 validation data set, the c statistic was 0.82. Risk-adjusted mortality rates by center ranged from 0.9% to 4.1% (5th-95th percentile). CONCLUSIONS Congenital heart surgery programs can now obtain national benchmarking reports by applying AHRQ Quality Indicator software to hospital administrative data, based on the harmonized RACHS-1 method, with high discrimination and face validity.
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Affiliation(s)
| | | | - Pamela L Owens
- Agency for Healthcare Research and Quality, Rockville, MD
| | - Patrick S Romano
- University of California Davis School of Medicine, Sacramento, CA
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Brown KL, Wray J, Knowles RL, Crowe S, Tregay J, Ridout D, Barron DJ, Cunningham D, Parslow R, Franklin R, Barnes N, Hull S, Bull C. Infant deaths in the UK community following successful cardiac surgery: building the evidence base for optimal surveillance, a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWhile early outcomes of paediatric cardiac surgery have improved, less attention has been given to later outcomes including post-discharge mortality and emergency readmissions.ObjectivesOur objectives were to use a mixed-methods approach to build an evidenced-based guideline for postdischarge management of infants undergoing interventions for congenital heart disease (CHD).MethodsSystematic reviews of the literature – databases used: MEDLINE (1980 to 1 February 2013), EMBASE (1980 to 1 February 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1981 to 1 February 2013), The Cochrane Library (1999 to 1 February 2013), Web of Knowledge (1980 to 1 February 2013) and PsycINFO (1980 to 1 February 2013). Analysis of audit data from the National Congenital Heart Disease Audit and Paediatric Intensive Care Audit Network databases pertaining to records of infants undergoing interventions for CHD between 1 January 2005 and 31 December 2010. Qualitative analyses of online discussion posted by 73 parents, interviews with 10 helpline staff based at user groups, interviews with 20 families whose infant either died after discharge or was readmitted urgently to intensive care, and interviews with 25 professionals from tertiary care and 13 professionals from primary and secondary care. Iterative multidisciplinary review and discussion of evidence incorporating the views of parents on suggestions for improvement.ResultsDespite a wide search strategy, the studies identified for inclusion in reviews related only to patients with complex CHD, for whom adverse outcome was linked to non-white ethnicity, lower socioeconomic status, comorbidity, age, complexity and feeding difficulties. There was evidence to suggest that home monitoring programmes (HMPs) are beneficial. Of 7976 included infants, 333 (4.2%) died postoperatively, leaving 7634 infants, of whom 246 (3.2%) experienced outcome 1 (postdischarge death) and 514 (6.7%) experienced outcome 2 (postdischarge death plus emergency intensive care readmissions). Multiple logistic regression models for risk of outcomes 1 and 2 had areas under the receiver operator curve of 0.78 [95% confidence interval (CI) 0.75 to 0.82] and 0.78 (95% CI 0.75 to 0.80), respectively. Six patient groups were identified using classification and regression tree analysis to stratify by outcome 2 (range 3–24%), which were defined in terms of neurodevelopmental conditions, high-risk cardiac diagnosis (hypoplastic left heart, single ventricle or pulmonary atresia), congenital anomalies and length of stay (LOS) > 1 month. Deficiencies and national variability were noted for predischarge training and information, the process of discharge to non-specialist services including documentation, paediatric cardiology follow-up including HMP, psychosocial support post discharge and the processes for accessing help when an infant becomes unwell.ConclusionsNational standardisation may improve discharge documents, training and guidance on ‘what is normal’ and ‘signs and symptoms to look for’, including how to respond. Infants with high-risk cardiac diagnoses, neurodevelopmental conditions or LOS > 1 month may benefit from discharge via their local hospital. HMP is suggested for infants with hypoplastic left heart, single ventricle or pulmonary atresia. Discussion of postdischarge deaths for infant CHD should occur at a network-based multidisciplinary meeting. Audit is required of outcomes for this stage of the patient journey.Future workFurther research may determine the optimal protocol for HMPs, evaluate the use of traffic light tools for monitoring infants post discharge and develop the analytical steps and processes required for audit of postdischarge metrics.Study registrationThis study is registered as PROSPERO CRD42013003483 and CRD42013003484.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The National Congenital Heart Diseases Audit (NCHDA) and Paediatric Intensive Care Audit Network (PICANet) are funded by the National Clinical Audit and Patient Outcomes Programme, administered by the Healthcare Quality Improvement Partnership (HQIP). PICAnet is also funded by Welsh Health Specialised Services Committee; NHS Lothian/National Service Division NHS Scotland, the Royal Belfast Hospital for Sick Children, National Office of Clinical Audit Ireland, and HCA International. The study was supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. Sonya Crowe was supported by the Health Foundation, an independent charity working to continuously improve the quality of health care in the UK.
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Affiliation(s)
- Katherine L Brown
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rachel L Knowles
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Jenifer Tregay
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - David J Barron
- Cardiac Surgery Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - David Cunningham
- National Institute for Cardiovascular Outcomes Research, University College London, London, UK
| | - Roger Parslow
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Rodney Franklin
- Paediatric Cardiac Unit, Royal Brompton and Harefield Hospitals NHS Trust, London, UK
| | - Nick Barnes
- Department of Paediatrics, Northampton General Hospital NHS Trust, Northampton, UK
| | - Sally Hull
- Primary Care Department, Queen Mary University of London, London, UK
| | - Catherine Bull
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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