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Kancherla V, Ma C, Purkey NJ, Hintz SR, Lee HC, Grant G, Carmichael SL. Factors Associated with Transfer Distance from Birth Hospital to Repair Hospital for First Surgical Repair among Infants with Myelomeningocele in California. Am J Perinatol 2024; 41:e1091-e1098. [PMID: 36646096 DOI: 10.1055/s-0042-1760431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The objective of our study was to examine factors associated with distance to care for first surgical repair among infants with myelomeningocele in California. STUDY DESIGN A total of 677 eligible cases with complete geocoded data were identified for birth years 2006 to 2012 using data from the California Perinatal Quality Care Collaborative linked to hospital and vital records. The median distance from home to birth hospital among eligible infants was 9 miles, and from birth hospital to repair hospital was 15 miles. We limited our analysis to infants who lived close to the birth hospital, creating two study groups to examine transfer distance patterns: "lived close and had a short transfer" (i.e., lived <9 miles from birth hospital and traveled <15 miles from birth hospital to repair hospital; n = 92), and "lived close and had a long transfer" (i.e., lived <9 miles from birth hospital and traveled ≥15 miles from birth hospital to repair hospital; n = 96). Log-binomial regression was used to estimate crude and adjusted risk ratios (aRRs and 95% confidence intervals (CIs). Selected maternal, infant, and birth hospital characteristics were compared between the two groups. RESULTS We found that low birth weight (aRR = 1.44; 95% CI = 1.04, 1.99) and preterm birth (aRR = 1.41; 95% CI = 1.01, 1.97) were positively associated, whereas initiating prenatal care early in the first trimester was inversely associated (aRR = 0.64; 95% CI = 0.46, 0.89) with transferring a longer distance (≥15 miles) from birth hospital to repair hospital. No significant associations were noted by maternal race-ethnicity, socioeconomic indicators, or the level of hospital care at the birth hospital. CONCLUSION Our study identified selected infant factors associated with the distance to access surgical care for infants with myelomeningocele who had to transfer from birth hospital to repair hospital. Distance-based barriers to care should be identified and optimized when planning deliveries of at-risk infants in other populations. KEY POINTS · Low birth weight predicted long hospital transfer distance.. · Preterm birth was associated with transfer distance.. · Prenatal care was associated with transfer distance..
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Affiliation(s)
- Vijaya Kancherla
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Chen Ma
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Neha J Purkey
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Henry C Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Gerald Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University, Stanford, California
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Andrist E, Clarke RG, Phelps KB, Dews AL, Rodenbough A, Rose JA, Zurca AD, Lawal N, Maratta C, Slain KN. Understanding Disparities in the Pediatric ICU: A Scoping Review. Pediatrics 2024; 153:e2023063415. [PMID: 38639640 DOI: 10.1542/peds.2023-063415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized. METHODS Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables. RESULTS The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature. CONCLUSIONS Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.
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Affiliation(s)
- Erica Andrist
- Division of Pediatric Critical Care Medicine
- Departments of Pediatrics
| | - Rachel G Clarke
- Division of Pediatric Critical Care Medicine, Upstate University Hospital, Syracuse, New York
- Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York
| | - Kayla B Phelps
- Division of Pediatric Critical Care Medicine, Louisiana State University Health Sciences Center, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Alyssa L Dews
- Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
- Susan B. Meister Child Health and Adolescent Research Center, University of Michigan, Ann Arbor, Michigan
| | - Anna Rodenbough
- Division of Pediatric Critical Care Medicine, Children's Hospital of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jerri A Rose
- Pediatric Emergency Medicine
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adrian D Zurca
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nurah Lawal
- Stepping Stones Pediatric Palliative Care Program, C.S. Mott Children's Hospital, Ann Arbor, Michigan
- Departments of Pediatrics
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine N Slain
- Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Vervoort D, Jin H, Edwin F, Kumar RK, Malik M, Tapaua N, Verstappen A, Hasan BS. Global Access to Comprehensive Care for Paediatric and Congenital Heart Disease. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:453-463. [PMID: 38205434 PMCID: PMC10777200 DOI: 10.1016/j.cjcpc.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/05/2023] [Indexed: 01/12/2024]
Abstract
Paediatric and congenital heart disease (PCHD) is common but remains forgotten on the global health agenda. Congenital heart disease is the most frequent major congenital anomaly, affecting approximately 1 in every 100 live births. In high-income countries, most children now live into adulthood, whereas in low- and middle-income countries, over 90% of patients do not get the care they need. Rheumatic heart disease is the most common acquired cardiovascular disease in children and adolescents. While almost completely eradicated in high-income countries, over 30-40 million people live with rheumatic heart disease in low- and middle-income countries. Challenges exist in the care for PCHD and, increasingly, adult congenital heart disease (ACHD) worldwide. In this review, we summarize the current status of PCHD and ACHD care through the health systems lens of workforce, infrastructure, financing, service delivery, information management and technology, and governance. We further highlight gaps in knowledge and opportunities moving forward to improve access to care for all those living with PCHD or ACHD worldwide.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Hyerang Jin
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frank Edwin
- School of Medicine, University of Health and Allied Sciences, Ho, Ghana
- National Cardiothoracic Center, Accra, Ghana
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Mahim Malik
- Department of Cardiac Surgery, Rawalpindi Institute of Cardiology, Rawalpindi, Punjab, Pakistan
| | - Noah Tapaua
- Department of Surgery, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Amy Verstappen
- Global Alliance for Rheumatic and Congenital Hearts, Philadelphia, Pennsylvania, USA
| | - Babar S. Hasan
- Division of Cardiothoracic Sciences, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
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Brunetti MA, Griffis HM, O'Byrne ML, Glatz AC, Huang J, Schumacher KR, Bailly DK, Domnina Y, Lasa JJ, Moga MA, Zaccagni H, Simsic JM, Gaynor JW. Racial and Ethnic Variation in ECMO Utilization and Outcomes in Pediatric Cardiac ICU Patients. JACC. ADVANCES 2023; 2:100634. [PMID: 38938717 PMCID: PMC11198441 DOI: 10.1016/j.jacadv.2023.100634] [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: 01/31/2023] [Revised: 06/15/2023] [Accepted: 07/26/2023] [Indexed: 06/29/2024]
Abstract
Background Previous studies have reported racial disparities in extracorporeal membrane oxygenation (ECMO) utilization in pediatric cardiac patients. Objectives The objective of this study was to determine if there was racial/ethnic variation in ECMO utilization and, if so, whether mortality was mediated by differences in ECMO utilization. Methods This is a multicenter, retrospective cohort study of the Pediatric Cardiac Critical Care Consortium clinical registry. Analyses were stratified by hospitalization type (medical vs surgical). Logistic regression models were adjusted for confounders and evaluated the association between race/ethnicity with ECMO utilization and mortality. Secondary analyses explored interactions between race/ethnicity, insurance, and socioeconomic status with ECMO utilization and mortality. Results A total of 50,552 hospitalizations from 34 hospitals were studied. Across all hospitalizations, 2.9% (N = 1,467) included ECMO. In medical and surgical hospitalizations, Black race and Hispanic ethnicity were associated with severity of illness proxies. In medical hospitalizations, race/ethnicity was not associated with the odds of ECMO utilization. Hospitalizations of other race had higher odds of mortality (adjusted odds ratio [aOR]: 1.61; 95% CI: 1.22-2.12; P = 0.001). For surgical hospitalizations, Black (aOR: 1.24; 95% CI: 1.02-1.50; P = 0.03) and other race (aOR: 1.50; 95% CI: 1.17-1.93; P = 0.001) were associated with higher odds of ECMO utilization. Hospitalizations of Hispanic patients had higher odds of mortality (aOR: 1.31; 95% CI: 1.03-1.68; P = 0.03). No significant interactions were demonstrated between race/ethnicity and socioeconomic status indicators with ECMO utilization or mortality. Conclusions Black and other races were associated with increased ECMO utilization during surgical hospitalizations. There were racial/ethnic disparities in outcomes not explained by differences in ECMO utilization. Efforts to mitigate these important disparities should include other aspects of care.
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Affiliation(s)
- Marissa A. Brunetti
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather M. Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael L. O'Byrne
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C. Glatz
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jing Huang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kurt R. Schumacher
- Department of Pediatrics, University of Michigan Medical School and C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - David K. Bailly
- Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Yuliya Domnina
- Division of Cardiac Critical Care Medicine, George Washington University School of Medicine and Children’s National Hospital, Washington, DC, USA
| | - Javier J. Lasa
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Alice Moga
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Hayden Zaccagni
- Section of Cardiac Critical Care Medicine, Department of Pediatrics, Children’s of Alabama and University of Alabama Medicine, Birmingham, Alabama, USA
| | - Janet M. Simsic
- The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - J. William Gaynor
- Department of Surgery, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Ross FJ, Latham G, Tjoeng L, Everhart K, Jimenez N. Racial and Ethnic Disparities in U.S Children Undergoing Surgery for Congenital Heart Disease: A Narrative Literature Review. Semin Cardiothorac Vasc Anesth 2023; 27:224-234. [PMID: 36514942 DOI: 10.1177/10892532221145229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Congenital Heart Disease (CHD) is a significant source of pediatric morbidity and mortality. As in other fields of medicine, studies have demonstrated racial and ethnic disparities in congenital heart disease outcomes. The cause of these outcome disparities is multifactorial, involving biological, behavioral, environmental, sociocultural, and systemic medical factors. Potential contributors include differences in preoperative illness severity secondary to coexisting medical conditions, differences in the rate of prenatal and early postnatal detection of CHD, and delayed access to care, as well as discrepancies in socioeconomic and insurance status, and systemic disparities in hospital care. Understanding the factors that contribute to these disparities is an essential step towards developing strategies to address them. As stewards of the perioperative surgical home, anesthesiologists have an important role in developing institutional policies that mitigate racial disparities. Here, we provide a thorough narrative review of recent research concerning perioperative factors contributing to surgical outcomes disparities for children of all ages with CHD, examine potentially modifiable contributing factors, discuss avenues for future research, and suggest strategies to address disparities both locally and nationally.
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Affiliation(s)
- Faith J Ross
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Gregory Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Lie Tjoeng
- Department of Critical Care Medicine/Department of Cardiology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Kelly Everhart
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
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Millen SM, Olsen CH, Flanagan RP, Scott JS, Dobson CP. The effect of geographic origin and destination on congenital heart disease outcomes: a retrospective cohort study. BMC Cardiovasc Disord 2023; 23:99. [PMID: 36814200 PMCID: PMC9945673 DOI: 10.1186/s12872-023-03037-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 01/02/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Congenital heart disease (CHD) is a common and significant birth defect, frequently requiring surgical intervention. For beneficiaries of the Department of Defense, a new diagnosis of CHD may occur while living at rural duty stations. Choice of tertiary care center becomes a function of geography, referring provider recommendations, and patient preference. METHODS Using billing data from the Military Health System over a 5-year period, outcomes for beneficiaries age < 10 years undergoing CHD surgery were compared by patient origin (rural versus urban residence) and the distance to treatment (patient's home and the treating tertiary care center). These beneficiaries include children of active duty, activated reserves, and federally activated National Guard service members. Analysis of the outcomes were adjusted for procedure complexity risk. Treatment centers were further stratified by annual case volume and whether they publicly reported results in the society of thoracic surgery (STS) outcomes database. RESULTS While increasing distance was associated with the cost of admission, there was no associated risk of inpatient mortality, one year mortality, or increased length of stay. Likewise, rural origination was not significantly associated with target outcomes. Patients traveled farther for STS-reporting centers (STS-pr), particularly high-volume centers. Such high-volume centers (> 50 high complexity cases annually) demonstrated decreased one year mortality, but increased cost and length of stay. CONCLUSIONS Together, these findings contribute to the national conversation of rural community medicine versus regionalized subspecialty care; separation of patients between rural areas and more urban locations for initial CHD surgical care does not increase their mortality risk. In fact, traveling to high volume centers may have an associated mortality benefit.
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Affiliation(s)
- Spencer M Millen
- Walter Reed National Military Medical Center, Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Cara H Olsen
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - John S Scott
- Veterans' Health Administration, Washington, DC, USA
| | - Craig P Dobson
- Walter Reed National Military Medical Center, Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Van Swol J, Wolf BJ, Toumey J, Pecha P, Patel KG. Follow-Up Care Barriers for Patients with Orofacial Clefts. Cleft Palate Craniofac J 2022; 59:1213-1221. [PMID: 34678105 PMCID: PMC10731588 DOI: 10.1177/10556656211042162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate whether a patient with a cleft's age, associated syndrome, cleft phenotype or travel distance affects their follow-up rate. DESIGN This study is a retrospective review of patients with CL/P treated by a craniofacial clinic. SETTING The setting was a craniofacial clinic at a tertiary care university hospital. PATIENTS, PARTICIPANTS Candidates were patients seen by the craniofacial clinic between January 2007 and December 2019. An initial pool of 589 patients was then reduced to 440 due to exclusion criteria. INTERVENTIONS None. MAIN OUTCOME MEASURE(S) The outcome measure was actual patient attendance to the craniofacial team compared to the team goal expectation of annual return visits. RESULTS The mean age of participants at the end of the study was 9.0 ± 5.4 years with a mean follow-up period (total possible follow-up period length based on patient age at presentation and study window) of 5.5 ± 3.6 years. There was no association between cleft phenotype, type of syndrome, or distance to the clinic with attendance. Children with syndromes had an 11% decrease in the odds of attending follow-up visits with each 1-year increase in age compared to a 4% decrease in children without syndromes. CONCLUSIONS The only significant factors determining patient attendance were the presence of a syndrome and increasing age.
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Affiliation(s)
- Joshua Van Swol
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Bethany J. Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Julia Toumey
- Craniofacial Anomalies and Cleft Palate Team, Medical University of South Carolina, Charleston, SC, USA
| | - Phayvanh Pecha
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Krishna G. Patel
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Kaur A, Hornberger LK, Fruitman D, Ngwezi D, Eckersley LG. Impact of rural residence and low socioeconomic status on rate and timing of prenatal detection of major congenital heart disease in a jurisdiction of universal health coverage. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:359-366. [PMID: 35839119 DOI: 10.1002/uog.26030] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Socioeconomic status (SES) and distance of residence from tertiary care may impact fetal detection of congenital heart disease (CHD), partly through reduced access to and quality of obstetric ultrasound screening. It is unknown whether SES and remoteness of residence (RoR) affect prenatal detection of CHD in jurisdictions with universal health coverage. We examined the impact of SES and RoR on the rate and timing of prenatal diagnosis of major CHD within the province of Alberta in Canada. METHODS In this retrospective study, we identified all fetuses and infants diagnosed with major CHD in Alberta, from 2008 to 2018, that underwent cardiac surgical intervention within the first year after birth, died preoperatively, were stillborn or underwent termination. Using maternal residence postal code and geocoding, Chan SES index quintile, geographic distance from a tertiary-care fetal cardiology center and the Canadian Index of Remoteness (IoR) were calculated. Outcome measures included rates of prenatal diagnosis and diagnosis after 22 weeks' gestation. Risk ratios (RR) were calculated using log-binomial regression and stratified by rural (≥ 100 km from tertiary care) or metropolitan (< 100 km from tertiary care) residence, adjusting for year of birth and the obstetric ultrasound screening view in which CHD would most likely be detected (four-chamber view; outflow-tract view; three-vessel or three-vessels-and-trachea or non-standard view; septal view). RESULTS Of 1405 fetuses/infants with major CHD, prenatal diagnosis occurred in 814 (57.9%). Residence ≥ 100 km from tertiary care (adjusted RR, 1.19; 95% CI, 1.05-1.34) and higher IoR (adjusted RR, 1.9; 95% CI, 1.1-3.3) were associated with missed prenatal diagnosis of major CHD. Similarly, residence ≥ 100 km from tertiary care (adjusted RR, 1.41; 95% CI, 1.22-1.62) and higher IoR (adjusted RR, 3.6; 95% CI, 2.2-8.2) were associated with prenatal diagnosis after 22 weeks. Although adjusted and unadjusted analyses showed no association between Chan SES index quintile and prenatal-diagnosis rate overall nor for residence in rural areas, in metropolitan regions, lower SES quintiles were associated with missed prenatal diagnosis (quintile 1: RR, 1.24; 95% CI, 1.02-1.50) and higher risk of diagnosis after 22 weeks' gestation (quintile 1: RR, 1.46; 95% CI, 1.10-1.93; quintile 2: RR, 1.66; 95% CI, 1.24-2.23). CONCLUSIONS Despite universal healthcare, rural residence in Alberta is associated with lower rate of prenatal diagnosis of major CHD and higher risk of late prenatal diagnosis (≥ 22 weeks). Within metropolitan regions, lower SES impacts negatively prenatal-diagnosis rate and timing. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Kaur
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - L K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - D Fruitman
- Division of Cardiology, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada
| | - D Ngwezi
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - L G Eckersley
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
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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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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: 15] [Impact Index Per Article: 7.5] [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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Sabatino ME, Dennis RJ, Sandoval-Trujillo P, Valencia S, Moreno-Medina K, Londoño D, Garcia-Torres AE, Tulloch D, Herrera-Almario GE, Peck GL, Sandoval N. Access to paediatric cardiac surgery in Colombia: a population-based study. Eur J Cardiothorac Surg 2021; 61:320-327. [PMID: 34591973 DOI: 10.1093/ejcts/ezab404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/28/2021] [Accepted: 08/12/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Globally congenital heart disease mortality is declining, yet the proportion of infant deaths attributable to heart disease rises in Colombia and other middle-sociodemographic countries. We aimed to assess the accessibility of paediatric cardiac surgery (PCS) to children <18 years of age in 2016 in the South American country of Colombia. METHODS In Bogotá, Colombia, a multi-national team used cross-sectional and retrospective cohort study designs to adapt and evaluate 4 health system indicators at the national level: first, the population with timely geographic access to an institution providing PCS; second, the number of paediatric cardiac surgeons; third, this specialized procedure volume and its national distribution; and fourth, the 30-day perioperative mortality rate after PCS in Colombia. RESULTS Geospatial mapping approximates 64% (n = 9 894 356) of the under-18 Colombian population lives within 2-h drivetime of an institution providing PCS. Twenty-eight cardiovascular surgeons report performing PCS, 82% (n = 23) with formal training. In 2016, 1281 PCS procedures were registered, 90% of whom were performed in 6 of the country's 32 departments. National non-risk-adjusted all-cause 30-day perioperative mortality rate after PCS was 2.73% (n = 35). CONCLUSIONS Colombia's paediatric population had variable access to cardiac surgery in 2016, largely dependent upon geography. While the country may have the capacity to provide timely, high-quality care to those who need it, our study enables future comparative analyses to measure the impact of health system interventions facilitating healthcare equity for the underserved populations across Colombia and the Latin American region.
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Affiliation(s)
- Marlena E Sabatino
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Rodolfo J Dennis
- Department of Research, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | | | - Sergio Valencia
- Department of Surgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Karen Moreno-Medina
- Department of Research, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Darío Londoño
- Department of Surgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Alberto E Garcia-Torres
- Department of Paediatric Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - David Tulloch
- Department of Landscape Architecture, Rutgers School of Environmental & Biological Sciences, New Brunswick, NJ, USA
| | - Gabriel E Herrera-Almario
- Department of Surgery, Universidad de los Andes School of Medicine, Bogotá, Colombia.,Department of Surgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Gregory L Peck
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Néstor Sandoval
- Department of Landscape Architecture, Rutgers School of Environmental & Biological Sciences, New Brunswick, NJ, USA
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12
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Social determinants of health and outcomes for children and adults with congenital heart disease: a systematic review. Pediatr Res 2021; 89:275-294. [PMID: 33069160 DOI: 10.1038/s41390-020-01196-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Social determinants of health (SDH) can substantially impact health outcomes. A systematic review, however, has never been conducted on associations of SDH with congenital heart disease (CHD) outcomes. The aim, therefore, was to conduct such a systematic review. METHODS Seven databases were searched through May 2020 to identify articles on SDH associations with CHD. SDH examined included poverty, uninsurance, housing instability, parental educational attainment, immigration status, food insecurity, and transportation barriers. Studies were independently selected and coded by two researchers based on the PICO statement. RESULTS The search generated 3992 citations; 88 were included in the final database. SDH were significantly associated with a lower likelihood of fetal CHD diagnosis, higher CHD incidence and prevalence, increased infant mortality, adverse post-surgical outcomes (including hospital readmission and death), decreased healthcare access (including missed appointments, no shows, and loss to follow-up), impaired neurodevelopmental outcomes (including IQ and school performance) and quality of life, and adverse outcomes for adults with CHD (including endocarditis, hospitalization, and death). CONCLUSIONS SDH are associated with a wide range of adverse outcomes for fetuses, children, and adults with CHD. SDH screening and referral to appropriate services has the potential to improve outcomes for CHD patients across the lifespan. IMPACT Social determinants of health (SDH) are associated with a wide range of adverse outcomes for fetuses, children, and adults with congenital heart disease (CHD). This is the first systematic review (to our knowledge) on associations of SDH with congenital heart disease CHD outcomes. SDH screening and referral to appropriate services has the potential to improve outcomes for CHD patients across the lifespan.
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13
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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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14
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Gaskin K, Kennedy F. Care of infants, children and adults with congenital heart disease. Nurs Stand 2020; 34:37-42. [PMID: 31468777 DOI: 10.7748/ns.2019.e11405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2019] [Indexed: 12/13/2022]
Abstract
Congenital heart disease refers to an anatomical or physiological defect of the heart that is present at birth. Over the past three decades there have been significant advances in surgical, medical and nursing care for infants and children requiring cardiac surgery for congenital heart disease. This has meant that the number of adults with moderate and complex congenital heart disease now exceeds the number of children with the disease. This article details the background and diagnosis of congenital heart disease. It considers the implications for infants and children with congenital heart disease, as well as their parents, such as screening methods, risk factors, parental stress and psychosocial needs. This article also discusses the care of adults with congenital heart disease, including specialist monitoring and patient education.
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Affiliation(s)
- Kerry Gaskin
- Three Counties School of Nursing and Midwifery, University of Worcester, Worcester, England, and chairperson of the Congenital Cardiac Nurses Association
| | - Fiona Kennedy
- Barts Health NHS Trust, London, England, and member of the British Adult Congenital Cardiac Nurses Association
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15
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Abstract
Aortic dilatation is common in patients with congenital heart disease and is seen in patients with bicuspid aortic valve and those with conotruncal congenital heart defects. It is important to identify patients with bicuspid aortic valve at high risk for aortic dissection. High-risk patients include those with the aortic root phenotype and those with syndromic or familial aortopathies including Marfan syndrome, Loeys-Dietz syndrome, and Turner syndrome. Aortic dilatation is common in patients with conotruncal congenital heart defects and rarely results in aortic dissection.
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16
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Woo JL, Anderson BR, Gruenstein D, Conti R, Chua KP. Minimum Travel Distance Among Publicly Insured Infants with Severe Congenital Heart Disease: Potential Impact of In-state Restrictions. Pediatr Cardiol 2019; 40:1599-1608. [PMID: 31463514 PMCID: PMC6851488 DOI: 10.1007/s00246-019-02193-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/23/2019] [Indexed: 11/30/2022]
Abstract
Travel distance to surgical centers may be increased when coverage restrictions prevent children with congenital heart disease (CHD) from receiving care at out-of-state congenital heart surgery centers. We estimated the minimum travel distance to congenital heart surgery centers among publicly insured infants with time-sensitive CHD surgical needs, under two different scenarios: if they were and were not restricted to in-state centers. Using 2012 Medicaid Analytic eXtract data from 40 states, we identified 4598 infants with CHD that require surgery in the first year of life. We calculated the minimum travel distance between patients' homes and the nearest cardiac surgery center, assuming patients were and were not restricted to in-state centers. We used linear regression to identify demographic predictors of distance under both scenarios. When patients were not restricted to in-state centers, mean minimum travel distance was 43.7 miles, compared to 54.1 miles when they were restricted. For 5.9% of patients, the difference in travel distance under the two scenarios exceeded 50 miles. In six states, the difference in mean minimum travel distance exceeded 20 miles. Under both scenarios, distance was positively predicted by rural status, residence in middle-income zip codes, and white/non-Hispanic or American Indian/Alaskan Native race/ethnicity. For some publicly insured infants with severe CHD, facilitating the receipt of out-of-state care could mitigate access barriers. Existing efforts to regionalize care at fewer centers should be designed to avoid exacerbating access barriers among publicly insured CHD patients.
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Affiliation(s)
- Joyce L Woo
- Division of Pediatric Cardiology, Columbia University Medical Center, 3959 Broadway, CHN-253, New York, NY, 10032, USA.
| | - Brett R Anderson
- Division of Pediatric Cardiology, Columbia University Medical Center, 3959 Broadway, CHN-253, New York, NY, 10032, USA
| | - Daniel Gruenstein
- Department of Pediatrics, Section of Cardiology, University of Chicago Medical Center, 5839 S. Maryland Ave, MC 4051, Chicago, IL, 60637, USA
| | - Rena Conti
- Institute of Health System Innovation and Policy Markets, Public Policy, and Law, Boston University, 595 Commonwealth Ave, Boston, MA, 02215, USA
| | - Kao-Ping Chua
- Department of Pediatrics, University of Michigan Medical Center, 300 North Ingalls, SPC 5456, Room 6E18, Ann Arbor, MI, 48109, USA
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17
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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: 97] [Impact Index Per Article: 19.4] [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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Salciccioli KB, Oluyomi A, Lupo PJ, Ermis PR, Lopez KN. A model for geographic and sociodemographic access to care disparities for adults with congenital heart disease. CONGENIT HEART DIS 2019; 14:752-759. [PMID: 31361081 DOI: 10.1111/chd.12819] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/16/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Follow-up at a regional adult congenital heart disease (ACHD) center is recommended for all ACHD patients at least once per the 2018 ACC/AHA guidelines. Other specialties have demonstrated poorer follow-up and outcomes correlating with increased distance from health care providers, but driving time to regional ACHD centers has not been examined in the US population. OBJECTIVE To identify and characterize potential disparities in access to ACHD care in the US based on drive time to ACHD centers and compounding sociodemographic factors. METHODS Mid- to high-volume ACHD centers with ≥500 outpatient ACHD visits and ≥20 ACHD surgeries annually were included based on self-reported, public data. Geographic Information System mapping was used to delineate drive times to ACHD centers. Sociodemographic data from the 2012-2016 American Community Survey (US Census) and the Environmental Systems Research Institute were analyzed based on drive time to nearest ACHD center. Previously established CHD prevalence estimates were used to estimate the similarly located US ACHD population. RESULTS Nearly half of the continental US population (45.1%) lives >1 hour drive to an ACHD center. Overall, 39.7% live 1-4 hours away, 3.4% live 4-6 hours away, and 2.0% live >6 hours away. Hispanics were disproportionately likely to live a >6 hour drive to a center (p < .001). Compared to people with <1 hour drive, those living >6 hours away have higher proportions of uninsured adults (29% vs. 18%; p < .001), households below the federal poverty level (19% vs. 13%; p < .001), and adults with less than college education (18% vs. 12%; p < .001). CONCLUSIONS We estimate that ~45% of the continental US population lives >1 hour to an ACHD center, with 5.4% living >4 hours away. Compounding barriers exist for Hispanic, uninsured, lower socioeconomic status, and less-educated patients. These results may help drive future policy changes to improve access to ACHD care.
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Affiliation(s)
- Katherine B Salciccioli
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Abiodun Oluyomi
- Environmental Health Service, Section of General Internal Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Philip J Lupo
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Peter R Ermis
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Keila N Lopez
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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19
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Kogon BE, Oster ME, Wallace A, Chiswell K, Hill KD, Cox ML, Jacobs JP, Pasquali S, Karamlou T, Jacobs ML. Readmission After Pediatric Cardiothoracic Surgery: An Analysis of The Society of Thoracic Surgeons Database. Ann Thorac Surg 2019; 107:1816-1823. [DOI: 10.1016/j.athoracsur.2019.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/31/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
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20
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Lytzen R, Vejlstrup N, Bjerre J, Petersen OB, Leenskjold S, Dodd JK, Jørgensen FS, Søndergaard L. Mortality and morbidity of major congenital heart disease related to general prenatal screening for malformations. Int J Cardiol 2019; 290:93-99. [PMID: 31130278 DOI: 10.1016/j.ijcard.2019.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/03/2019] [Accepted: 05/05/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Major congenital heart diseases (CHD) often demand intervention in the neonatal period. Prenatal diagnosis may improve mortality by eliminating the diagnostic delay; however, there is controversy concerning its true effect. We aimed to evaluate the effect of general prenatal screening on prognosis by comparing a period without general prenatal screening to a period with general prenatal screening. METHODS We conducted a nationwide retrospective study including live born children and terminated fetuses diagnosed with major CHD. Prenatal screening was recommended only in high risk pregnancies between 1996 and 2004, whereas general prenatal screening was recommended between 2005 and 2013. We assessed the influence of general prenatal screening on all-cause mortality, cardiac death, preoperative and postoperative 30-day mortality and complication rate. RESULTS 1-year mortality decreased over both periods, but the decrease was greater in the screening period (Odds ratio 0.92 (CI 0.83-1.00), p = 0.047). Prenatal detection of major CHD was associated with cardiac death in the period without general screening (Hazard Ratio 2.40 (CI 1.72-3.33), p < 0.001), whereas there was no significant association once general screening was implemented. Similarly, the association between prenatal diagnosis and pre- and postoperative mortality found in the period without general screening was insignificant after the implementation of general screening. CONCLUSION Mortality in major CHD decreased throughout the study, especially in the period with general prenatal screening. However, comparing a prenatally diagnosed group with a postnatally diagnosed group is vulnerable to selection bias and proper interpretation is difficult.
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Affiliation(s)
- Rebekka Lytzen
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Alle 7, 2100 Copenhagen O, Denmark.
| | - Niels Vejlstrup
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Alle 7, 2100 Copenhagen O, Denmark.
| | - Jesper Bjerre
- Department of Paediatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Olav Bjørn Petersen
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Stine Leenskjold
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade 15, 9000 Aalborg, Denmark.
| | - James Keith Dodd
- Department of Paediatrics, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark.
| | - Finn Stener Jørgensen
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark.
| | - Lars Søndergaard
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Alle 7, 2100 Copenhagen O, Denmark.
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21
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Birth Location of Infants with Critical Congenital Heart Disease in California. Pediatr Cardiol 2019; 40:310-318. [PMID: 30415381 DOI: 10.1007/s00246-018-2019-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
Abstract
The American Academy of Pediatrics classifies neonatal intensive care units (NICUs) from level I to IV based on the acuity of care each unit can provide. Birth in a higher level center is associated with lower morbidity and mortality in high-risk populations. Congenital heart disease accounts for 25-50% of infant mortality related to birth defects in the U.S., but recent data are lacking on where infants with critical congenital heart disease (CCHD) are born. We used a linked dataset from the Office of Statewide Health Planning and Development to access ICD-9 diagnosis codes for all infants born in California from 2008 to 2012. We compared infants with CCHD to the general population, identified where infants with CCHD were born based on NICU level of care, and predicted level IV birth among infants with CCHD using logistic regression techniques. From 2008 to 2012, 6325 infants with CCHD were born in California, with 23.7% of infants with CCHD born at a level IV NICU compared to 8.4% of the general population. Level IV birth for infants with CCHD was associated with lower gestational age, higher maternal age and education, the presence of other congenital anomalies, and the diagnosis of a single ventricle lesion. More infants with CCHD are born in a level IV NICU compared to the general population. Future studies are needed to determine if birth in a lower level of care center impacts outcomes for infants with CCHD.
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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: 25] [Impact Index Per Article: 4.2] [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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Sommerhalter KM, Insaf TZ, Akkaya-Hocagil T, McGarry CE, Farr SL, Downing KF, Lui GK, Zaidi AN, Van Zutphen AR. Proximity to Pediatric Cardiac Surgical Care among Adolescents with Congenital Heart Defects in 11 New York Counties. Birth Defects Res 2018; 109:1494-1503. [PMID: 29152921 DOI: 10.1002/bdr2.1129] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/31/2017] [Accepted: 08/25/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Many individuals with congenital heart defects (CHDs) discontinue cardiac care in adolescence, putting them at risk of adverse health outcomes. Because geographic barriers may contribute to cessation of care, we sought to characterize geographic access to comprehensive cardiac care among adolescents with CHDs. METHODS Using a population-based, 11-county surveillance system of CHDs in New York, we characterized proximity to the nearest pediatric cardiac surgical care center among adolescents aged 11 to 19 years with CHDs. Residential addresses were extracted from surveillance records documenting 2008 to 2010 healthcare encounters. Addresses were geocoded using ArcGIS and the New York State Street and Address Maintenance Program, a statewide address point database. One-way drive and public transit time from residence to nearest center were calculated using R packages gmapsdistance and rgeos with the Google Maps Distance Matrix application programming interface. A marginal model was constructed to identify predictors associated with one-way travel time. RESULTS We identified 2522 adolescents with 3058 corresponding residential addresses and 12 pediatric cardiac surgical care centers. The median drive time from residence to nearest center was 18.3 min, and drive time was 30 min or less for 2475 (80.9%) addresses. Predicted drive time was longest for rural western addresses in high poverty census tracts (68.7 min). Public transit was available for most residences in urban areas but for few in rural areas. CONCLUSION We identified areas with geographic barriers to surgical care. Future research is needed to determine how these barriers influence continuity of care among adolescents with CHDs. Birth Defects Research 109:1494-1503, 2017.© 2017 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Tabassum Z Insaf
- New York State Department of Health, Albany, New York.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York
| | - Tugba Akkaya-Hocagil
- New York State Department of Health, Albany, New York.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York
| | | | - Sherry L Farr
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Karrie F Downing
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - George K Lui
- Divisions of Cardiovascular Medicine and Pediatric Cardiology, Stanford School of Medicine, Stanford, California
| | - Ali N Zaidi
- Children's Hospital at Montefiore, Bronx, New York.,Albert Einstein College of Medicine, Bronx, New York
| | - Alissa R Van Zutphen
- New York State Department of Health, Albany, New York.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York
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24
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Oliveira AC, Mattos S, Coimbra M. Development and Assessment of an E-learning Course on Pediatric Cardiology Basics. JMIR MEDICAL EDUCATION 2017; 3:e10. [PMID: 28490416 PMCID: PMC5443913 DOI: 10.2196/mededu.5434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 11/14/2016] [Accepted: 02/02/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Early detection of congenital heart disease is a worldwide problem. This is more critical in developing countries, where shortage of professional specialists and structural health care problems are a constant. E-learning has the potential to improve capacity, by overcoming distance barriers and by its ability to adapt to the reduced time of health professionals. OBJECTIVE The study aimed to develop an e-learning pediatric cardiology basics course and evaluate its pedagogical impact and user satisfaction. METHODS The sample consisted of 62 health professionals, including doctors, nurses, and medical students, from 20 hospitals linked via a telemedicine network in Northeast Brazil. The course was developed using Moodle (Modular Object Oriented Dynamic Learning Environment; Moodle Pty Ltd, Perth, Australia) and contents adapted from a book on this topic. Pedagogical impact evaluation used a pre and posttest approach. User satisfaction was evaluated using Wang's questionnaire. RESULTS Pedagogical impact results revealed differences in knowledge assessment before and after the course (Z=-4.788; P<.001). Questionnaire results indicated high satisfaction values (Mean=87%; SD=12%; minimum=67%; maximum=100%). Course adherence was high (79%); however, the withdrawal exhibited a value of 39%, with the highest rate in the early chapters. Knowledge gain revealed significant differences according to the profession (X22=8.6; P=.01) and specialty (X22=8.4; P=.04). Time dedication to the course was significantly different between specialties (X22=8.2; P=.04). CONCLUSIONS The main contributions of this study are the creation of an asynchronous e-learning course on Moodle and the evaluation of its impact, confirming that e-learning is a viable tool to improve training in neonatal congenital heart diseases.
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Affiliation(s)
- Ana Cristina Oliveira
- Faculdade de Ciências da Universidade do Porto and Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Sandra Mattos
- Círculo do Coração, Unidade de Cardiologia e Medicina Fetal, Real Hospital Português de Pernambuco, Recife, Brazil
| | - Miguel Coimbra
- Instituto de Telecomunicações, Faculty of Sciences of the University of Porto, Porto, Portugal
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25
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Nelson JS, Stebbins RC, Strassle PD, Meyer RE. Geographic distribution of live births with tetralogy of Fallot in North Carolina 2003 to 2012. ACTA ACUST UNITED AC 2016; 106:881-887. [PMID: 27891781 DOI: 10.1002/bdra.23566] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/21/2016] [Accepted: 08/24/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Geographic variation in congenital heart disease is not well-described. This study uses geographic information systems (GIS) to describe the spatial epidemiology of tetralogy of Fallot (TOF), in North Carolina (NC) and to compare travel time for cases to congenital heart centers in NC. METHODS Using the NC Birth Defects Monitoring Program database, live births with TOF born between 2003 and 2012 were identified. Birth certificates provided demographic variables. A denominator of live births/zip code was obtained from the NC live births database. ArcGIS® software was used to illustrate TOF prevalence by zip code, and SatScanTM was used to identify spatial clusters of TOF cases and to identify changes in cluster location over time. Driving time to each of five NC congenital heart centers was predicted based on road systems information. RESULTS A total of 496 infants were born with TOF between 2003 and 2012. The prevalence was 4.2/10,000 live births. A large cluster (330 zip codes, 306 cases) was identified in northeastern NC. Average driving time for each case to closest congenital heart center was: University of North Carolina 37 min, Vident Medical Center 64 min, Duke University 58 min, Carolina's Medical Center 89 min, and Wake Forest Baptist Health 57 min. Overall, average predicted driving time to the nearest congenital heart center was 61 min. CONCLUSION Approximately 50 infants/year were born with TOF in NC. One cluster was identified. Further study is necessary to explore potential explanations for the observed case cluster. As interest in regionalization of congenital heart surgery grows, GIS and spatial analysis can become increasingly useful tools for health care planning. Birth Defects Research (Part A) 106:881-887, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jennifer S Nelson
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Rebecca C Stebbins
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Paula D Strassle
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Robert E Meyer
- North Carolina State Center for Health Statistics Birth Defects Monitoring Program, Raleigh, North Carolina
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Lara DA, Ethen MK, Canfield MA, Nembhard WN, Morris SA. A population-based analysis of mortality in patients with Turner syndrome and hypoplastic left heart syndrome using the Texas Birth Defects Registry. CONGENIT HEART DIS 2016; 12:105-112. [PMID: 27685952 DOI: 10.1111/chd.12413] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 07/25/2016] [Accepted: 08/25/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Hypoplastic left heart syndrome (HLHS) is strongly associated with Turner syndrome (TS); outcome data when these conditions coexist is sparse. We aimed to investigate long-term survival and causes of death in this population. METHODS The Texas Birth Defects Registry was queried for all live born infants with HLHS during 1999-2007. We used Kaplan-Meier and Cox regression analyses to compare survival among patients with HLHS with TS (HLHS/TS+) to patients who had HLHS without genetic disorders or extracardiac birth defects (HLHS/TS-). RESULTS Of the 542 patients with HLHS, 11 had TS (2.0%), 71 had other extracardiac birth defects or genetic disorders, and 463 had neither. The median follow-up time was 4.2 y (interquartile range [IQR] 2.1-6.5). Comparing those with HLHS/TS+ to HLHS/TS-, 100% versus 35% were female (P < .001), and median birth weight was 2140 g (IQR 1809-2650) versus 3196 g (IQR 2807-3540, P < .001). Neonatal mortality was 36% in HLHS/TS+ versus 27% in HLHS/TS- (log rank = 0.431). Ten of the 11 TS+ patients died during the study period for cumulative mortality of 91% versus 50% (hazard ratio (HR) for TS+: 2.90, 95% CI 1.53-5.48). Six patients died prior to surgery, 5 underwent Stage 1 palliation (S1P), 3 died after S1P, 2 survived past S2P, and one of these died at age 19 mo. The underlying cause of death was listed as congenital heart disease on all the death certificates of HLHS/TS+ patients. In multivariable analysis controlling for low birth weight (<2500 g), TS remained associated with significantly increased cumulative mortality, although females without TS had higher mortality than males (HR for TS+ versus males: 2.42, 95% CI 1.24-4.73; HR for TS- females versus males: 1.41, 95% CI 1.08-1.83). CONCLUSION TS with HLHS is associated with significant mortality. The increased mortality in females without documented TS calls to question if TS is undetected in a portion of females with HLHS.
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Affiliation(s)
- Diego A Lara
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Mary K Ethen
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, TX, USA
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, TX, USA
| | - Wendy N Nembhard
- University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Shaine A Morris
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Crowe S, Ridout DA, Knowles R, Tregay J, Wray J, Barron DJ, Cunningham D, Parslow RC, Utley M, Franklin R, Bull C, Brown KL. Death and Emergency Readmission of Infants Discharged After Interventions for Congenital Heart Disease: A National Study of 7643 Infants to Inform Service Improvement. J Am Heart Assoc 2016; 5:JAHA.116.003369. [PMID: 27207967 PMCID: PMC4889202 DOI: 10.1161/jaha.116.003369] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [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 Improvements in hospital‐based care have reduced early mortality in congenital heart disease. Later adverse outcomes may be reducible by focusing on care at or after discharge. We aimed to identify risk factors for such events within 1 year of discharge after intervention in infancy and, separately, to identify subgroups that might benefit from different forms of intervention. Methods and Results Cardiac procedures performed in infants between 2005 and 2010 in England and Wales from the UK National Congenital Heart Disease Audit were linked to intensive care records. Among 7976 infants, 333 (4.2%) died before discharge. Of 7643 infants discharged alive, 246 (3.2%) died outside the hospital or after an unplanned readmission to intensive care (risk factors were age, weight‐for‐age, cardiac procedure, cardiac diagnosis, congenital anomaly, preprocedural clinical deterioration, prematurity, ethnicity, and duration of initial admission; c‐statistic 0.78 [0.75–0.82]). Of the 7643, 514 (6.7%) died outside the hospital or had an unplanned intensive care readmission (same risk factors but with neurodevelopmental condition and acquired cardiac diagnosis and without preprocedural deterioration; c‐statistic 0.78 [0.75–0.80]). Classification and regression tree analysis were used to identify 6 subgroups stratified by the level (3–24%) and nature of risk for death outside the hospital or unplanned intensive care readmission based on neurodevelopmental condition, cardiac diagnosis, congenital anomaly, and duration of initial admission. An additional 115 patients died after planned intensive care admission (typically following elective surgery). Conclusions Adverse outcomes in the year after discharge are of similar magnitude to in‐hospital mortality, warrant service improvements, and are not confined to diagnostic groups currently targeted with enhanced monitoring.
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Affiliation(s)
- Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah A Ridout
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Rachel Knowles
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Jenifer Tregay
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - David Cunningham
- NICOR: National Institute for Cardiovascular Outcomes Research, UCL, London, UK
| | | | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Rodney Franklin
- Royal Brompton and Harefield Hospitals NHS Trust, London, UK
| | - Catherine Bull
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
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28
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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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Radcliff E, Delmelle E, Kirby RS, Laditka SB, Correia J, Cassell CH. Factors Associated with Travel Time and Distance to Access Hospital Care Among Infants with Spina Bifida. Matern Child Health J 2015; 20:205-217. [PMID: 26481364 DOI: 10.1007/s10995-015-1820-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Using geographic information systems (GIS), we examined travel time and distance to access hospital care for infants with spina bifida (SB). METHODS This study was a statewide, population-based analysis of Florida-born children with SB, 1998-2007, identified by the Florida Birth Defects Registry and linked to hospitalizations. We geocoded maternal residence at delivery and identified hospital locations for infants (<1 year). Using 2007 Florida Department of Transportation road data, we calculated one-way mean travel time and distance to access hospital care. We used Poisson regression to examine selected factors associated with travel time and distance [≤30 vs. >30 min/miles (reference)], including presence of hydrocephalus and SB type [isolated (no other major birth defect) versus non-isolated SB]. RESULTS For 612 infants, one-way mean (median) travel time was 45.1 (25.9) min. Infants with both non-isolated SB and hydrocephalus traveled longest to access hospitals (mean 60.8 min/48.5 miles; median 34.2 min/26.9 miles). In adjusted results, infants with non-isolated SB and whose mothers had a rural residence were less likely to travel ≤30 min to hospitals. Infants born to mothers in minority racial/ethnic groups were more likely to travel ≤30 min. CONCLUSIONS Birth defects registry data and GIS-based methods can be used to evaluate geographic accessibility to hospital care for infants with birth defects. Results can help to identify geographic barriers to accessing hospital care, such as travel time and distance, and inform opportunities to improve access to care for infants with SB or other special needs.
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Affiliation(s)
- Elizabeth Radcliff
- South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stonebridge Drive, Suite 102, Columbia, SC, 29210, USA.
| | - Eric Delmelle
- Department of Geography and Earth Sciences and Center for Applied GIScience, College of Liberal Arts and Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Russell S Kirby
- Birth Defects Surveillance Program, Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, FL, USA
| | - Sarah B Laditka
- Department of Public Health Sciences, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Jane Correia
- Florida Department of Health, Florida Birth Defects Registry, Tallahassee, FL, USA
| | - Cynthia H Cassell
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Mattos SDS, Hazin SMV, Regis CT, Soares de Araújo JS, Albuquerque FCDL, Moser LRDN, Hatem TDP, Gomes de Freitas CP, Mourato FA, Tavares TR, Gomes RGS, Severi R, Santos CR, Ferreira da Silva J, Rezende JL, Vieira PC, de Lima Filho JL. A telemedicine network for remote paediatric cardiology services in north-east Brazil. Bull World Health Organ 2015; 93:881-7. [PMID: 26668441 PMCID: PMC4669725 DOI: 10.2471/blt.14.148874] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 06/16/2015] [Accepted: 06/19/2015] [Indexed: 12/21/2022] Open
Abstract
Problem Providing health care for children with congenital heart diseases remains a major challenge in low- and middle-income countries. Approach In October 2011, the Government of Paraíba, Brazil, established a paediatric cardiology network in partnership with the nongovernmental organization Círculo do Coração. A cardiology team supervised all network activities, using the Internet to keep in contact with remote health facilities. The network developed protocols for screening heart defects. Echocardiograms were performed by physicians under direct online supervision of a cardiologist; alternatively, a video recording of the examination was subsequently reviewed by a cardiologist. Cardiovascular surgeons came to a paediatric hospital in the state capital once a week to perform heart surgeries. Local setting Until 2011, the State of Paraíba had no structured programme to care for children with heart disease. This often resulted in missed or late diagnosis, with adverse health consequences for the children. Relevant changes From 2012 to 2014, 73 751 babies were screened for heart defects and 857 abnormalities were identified. Detection of congenital heart diseases increased from 4.09 to 11.62 per 1000 live births (P < 0.001). Over 6000 consultations and echocardiograms were supervised via the Internet. Time to diagnosis, transfers and hospital stays were greatly reduced. A total of 330 operations were carried out with 6.7% (22/330) mortality. Lessons learnt Access to an echocardiography machine with remote supervision by a cardiologist improves the detection of congenital heart disease by neonatologists; virtual outpatient clinics facilitate clinical management; the use of Internet technology with simple screening techniques allows resources to be allocated more efficiently.
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Affiliation(s)
- Sandra da Silva Mattos
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | | | - Cláudio Teixeira Regis
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | | | | | | | - Thamine de Paula Hatem
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | | | - Felipe Alves Mourato
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | - Thiago Ribeiro Tavares
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | | | - Rossana Severi
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | - Cícera Rocha Santos
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | | | - Juliana Landim Rezende
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | - Paulo Coelho Vieira
- Círculo do Coração de Pernambuco, Av. Portugal, 163 Paissandu, Recife PE, CEP 52010-010, Brazil
| | - José Luiz de Lima Filho
- Laboratório de Imunopatologia Keiso Asami, Universidade Federal de Pernambuco, Recife, Brazil
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Unexpected deaths and unplanned re-admissions in infants discharged home after cardiac surgery: a systematic review of potential risk factors. Cardiol Young 2015; 25:839-52. [PMID: 25547262 DOI: 10.1017/s1047951114002492] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Babies with CHDs are a particularly vulnerable population with significant mortality in their 1st year. Although most deaths occur in the hospital within the early postoperative period, around one-fifth of postoperative deaths in the 1st year of life may occur after hospital discharge in infants who have undergone apparently successful cardiac surgery. Aim To systematically review the published literature and identify risk factors for adverse outcomes, specifically deaths and unplanned re-admissions, following hospital discharge after infant surgery for life-threatening CHDs. METHODS A systematic search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Knowledge, and PsycINFO electronic databases, supplemented by manual searching of conference abstracts. RESULTS A total of 15 studies were eligible for inclusion. Almost exclusively, studies were conducted in single US centres and focussed on children with complex single ventricle diagnoses. A wide range of risk factors were evaluated, and those more frequently identified as having a significant association with higher mortality or unplanned re-admission risk were non-Caucasian ethnicity, lower socio-economic status, co-morbid conditions, age at surgery, operative complexity and procedure type, and post-operative feeding difficulties. CONCLUSIONS Studies investigating risk factors for adverse outcomes post-discharge following diverse congenital heart operations in infants are lacking. Further research is needed to systematically identify higher risk groups, and to develop interventions targeted at supporting the most vulnerable infants within an integrated primary and secondary care pathway.
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Cassell CH, Grosse SD, Kirby RS. Leveraging birth defects surveillance data for health services research. ACTA ACUST UNITED AC 2014; 100:815-21. [DOI: 10.1002/bdra.23330] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Cynthia H. Cassell
- National Center on Birth Defects and Developmental Disabilities; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Russell S. Kirby
- Birth Defects Surveillance Program; Department of Community and Family Health; College of Public Health, University of South Florida; Tampa Florida
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Turner J, Preston L, Booth A, O’Keeffe C, Campbell F, Jesurasa A, Cooper K, Goyder E. What evidence is there for a relationship between organisational features and patient outcomes in congenital heart disease services? A rapid review. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThe purpose of this rapid evidence synthesis is to support the current NHS England service review on organisation of services for congenital heart disease (CHD). The evidence synthesis team was asked to examine the evidence on relationships between organisational features and patient outcomes in CHD services and, specifically, any relationship between (1) volume of cases and patient outcomes and (2) proximity of colocated services and patient outcomes. A systematic review published in 2009 had confirmed the existence of this relationship, but cautioned this was not sufficient to make recommendations on the size of units needed.ObjectivesTo identify and synthesise the evidence on the relationship between organisational features and patient outcomes for adults and children with CHD.Data sourcesA systematic search of medical- and health-related databases [MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library and Web of Science] was undertaken for 2009–14 together with citation searching, reference list checking and stakeholder recommendations of evidence from 2003 to 2014.Review methodsThis was a rapid review and, therefore, the application of the inclusion and exclusion criteria to retrieved records was undertaken by one reviewer, with 10% checked by a second reviewer. Five reviewers extracted data from included studies using a bespoke data extraction form which was subsequently used for evidence synthesis. No formal quality assessment was undertaken, but the usefulness of the evidence was assessed together with limitations identified by study authors.ResultsThirty-nine papers were included in the review. No UK-based studies were identified and 36 out of 39 (92%) studies included only outcomes for paediatric patients. Thirty-two (82%) studies investigated the relationship between volume and mortality and seven (18%) investigated other service factors or outcomes. Ninety per cent were from the USA, 92% were multicentre studies and all were retrospective observational studies. Twenty-five studies (64%) included all CHD conditions and 14 (36%) included single conditions or procedures. Although the evidence does demonstrate a relationship between volume and outcome in the majority of studies, this relationship is not consistent. The relationship was stronger for single-complex conditions or procedures. A mixed picture emerged revealing a range of factors as well as volume that influence outcome, including condition severity, individual centre and surgeon effects and clinical advances over time. We found limited (seven studies) evidence about the impact of proximity and colocation of services on outcomes, and about volume on non-mortality outcomes.LimitationsThis was a rapid review that followed standard methods to ensure transparency and reproducibility. The main limitations of the included studies were the retrospective nature, reliance on routine data sets, completeness, selection bias and lack of data on key clinical and service-related processes.ConclusionsThis review identified a substantial number of studies reporting a positive relationship between volume and outcome, but the complexity of the evidence requires careful interpretation. The heterogeneity of findings from observational studies suggests that, while a relationship between volume and outcome exists, this is unlikely to be a simple, independent and directly causal relationship. The effect of volume on outcome relative to the effect of other as yet undetermined health system factors remains a complex and unresolved research question.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Janette Turner
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Louise Preston
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Colin O’Keeffe
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Amrita Jesurasa
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Kucik JE, Nembhard WN, Donohue P, Devine O, Wang Y, Minkovitz CS, Burke T. Community socioeconomic disadvantage and the survival of infants with congenital heart defects. Am J Public Health 2014; 104:e150-7. [PMID: 25211743 DOI: 10.2105/ajph.2014.302099] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the association between survival of infants with severe congenital heart defects (CHDs) and community-level indicators of socioeconomic status. METHODS We identified infants born to residents of Arizona, New Jersey, New York, and Texas between 1999 and 2007 with selected CHDs from 4 population-based, statewide birth defect surveillance programs. We linked data to the 2000 US Census to obtain 11 census tract-level socioeconomic indicators. We estimated survival probabilities and hazard ratios adjusted for individual characteristics. RESULTS We observed differences in infant survival for 8 community socioeconomic indicators (P < .05). The greatest mortality risk was associated with residing in communities in the most disadvantaged deciles for poverty (adjusted hazard ratio [AHR] = 1.49; 95% confidence interval [CI] = 1.11, 1.99), education (AHR = 1.51; 95% CI = 1.16, 1.96), and operator or laborer occupations (AHR = 1.54; 95% CI = 1.16, 1.96). Survival decreased with increasing numbers of indicators that were in the most disadvantaged decile. Community-level mortality risk persisted when we adjusted for individual-level characteristics. CONCLUSIONS The increased mortality risk among infants with CHDs living in socioeconomically deprived communities might indicate barriers to quality and timely care at which public health interventions might be targeted.
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Affiliation(s)
- James E Kucik
- James E. Kucik and Owen Devine are with the Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA. Wendy N. Nembhard is with the Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa. Pamela Donohue is with the Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD. Ying Wang is with the Bureau of Environmental and Occupational Epidemiology, Center for Environmental Health, New York State Department of Health, Albany, NY. Cynthia S. Minkovitz is with the Department of Population, Family and Reproductive Health, and Thomas Burke is with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Kucik JE, Cassell CH, Alverson CJ, Donohue P, Tanner JP, Minkovitz CS, Correia J, Burke T, Kirby RS. Role of health insurance on the survival of infants with congenital heart defects. Am J Public Health 2014; 104:e62-70. [PMID: 25033158 DOI: 10.2105/ajph.2014.301969] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the association between health insurance and survival of infants with congenital heart defects (CHDs), and whether medical insurance type contributed to racial/ethnic disparities in survival. METHODS We conducted a population-based, retrospective study on a cohort of Florida resident infants born with CHDs between 1998 and 2007. We estimated neonatal, post-neonatal, and infant survival probabilities and adjusted hazard ratios (AHRs) for individual characteristics. RESULTS Uninsured infants with critical CHDs had 3 times the mortality risk (AHR = 3.0; 95% confidence interval = 1.3, 6.9) than that in privately insured infants. Publicly insured infants had a 30% reduced mortality risk than that of privately insured infants during the neonatal period, but had a 30% increased risk in the post-neonatal period. Adjusting for insurance type reduced the Black-White disparity in mortality risk by 50%. CONCLUSIONS Racial/ethnic disparities in survival were attenuated significantly, but not eliminated, by adjusting for payer status.
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Affiliation(s)
- James E Kucik
- James E. Kucik, Cynthia H. Cassell and Clinton J. Alverson are with the Division of Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta. Pamela Donohue is with the Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD. Jean Paul Tanner and Russell S. Kirby are with the Birth Defects Surveillance Program, Department of Community and Family Health, College of Public Health, University of South Florida, Tampa. Cynthia S. Minkovitz is with the Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Jane Correia is with the Florida Birth Defects Registry, Bureau of Epidemiology, Division of Disease Control and Health Protection, Florida Department of Health, Tallahassee. Thomas Burke is with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
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Peterson C, Ailes E, Riehle-Colarusso T, Oster ME, Olney RS, Cassell CH, Fixler DE, Carmichael SL, Shaw GM, Gilboa SM. Late detection of critical congenital heart disease among US infants: estimation of the potential impact of proposed universal screening using pulse oximetry. JAMA Pediatr 2014; 168:361-70. [PMID: 24493342 PMCID: PMC4470377 DOI: 10.1001/jamapediatrics.2013.4779] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Critical congenital heart disease (CCHD) was added to the Recommended Uniform Screening Panel for Newborns in the United States in 2011. Many states have recently adopted or are considering requirements for universal CCHD screening through pulse oximetry in birth hospitals. Limited previous research is directly applicable to the question of how many US infants with CCHD might be identified through screening. OBJECTIVES To estimate the proportion of US infants with late detection of CCHD (>3 days after birth) based on existing clinical practice and to investigate factors associated with late detection. DESIGN, SETTING, AND PARTICIPANTS Descriptive and multivariable analysis. Data were obtained from a multisite population-based study of birth defects in the United States, the National Birth Defects Prevention Study (NBDPS). We included all live-born infants with estimated dates of delivery from January 1, 1998, through December 31, 2007, and nonsyndromic, clinically verified CCHD conditions potentially detectable through screening via pulse oximetry. MAIN OUTCOMES AND MEASURES The main outcome measure was the proportion of infants with late detection of CCHD through echocardiography or at autopsy under the assumption that universal screening at birth hospitals might reduce the number of such late diagnoses. Secondary outcome measures included prevalence ratios for associations between selected demographic and clinical factors and late detection of CCHD. RESULTS Of 3746 live-born infants with nonsyndromic CCHD, late detection occurred in 1106 (29.5% [95% CI, 28.1%-31.0%]), including 6 (0.2%) (0.1%-0.4%) first receiving a diagnosis at autopsy more than 3 days after birth. Late detection varied by CCHD type from 9 of 120 infants (7.5% [95% CI, 3.5%-13.8%]) with pulmonary atresia to 497 of 801 (62.0% [58.7%-65.4%]) with coarctation of the aorta. In multivariable analysis, late detection varied significantly by CCHD type and study site, and infants with extracardiac defects were significantly less likely to have late detection of CCHD (adjusted prevalence ratio, 0.58 [95% CI, 0.49-0.69]). CONCLUSIONS AND RELEVANCE We estimate that 29.5% of live-born infants with nonsyndromic CCHD in the NBDPS received a diagnosis more than 3 days after birth and therefore might have benefited from routine CCHD screening at birth hospitals. The number of infants in whom CCHD was detected through screening likely varies by several factors, including CCHD type. Additional population-based studies of screening in practice are needed.
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Affiliation(s)
- Cora Peterson
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia2currently affiliated with National Center for Injury Prevention and Con
| | - Elizabeth Ailes
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia3Epidemic Intelligence Service, Scientific Education and Professional De
| | - Tiffany Riehle-Colarusso
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew E. Oster
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia4Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University
| | - Richard S. Olney
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cynthia H. Cassell
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David E. Fixler
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas
| | - Suzan L. Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
| | - Gary M. Shaw
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
| | - Suzanne M. Gilboa
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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Dean PN, McHugh KE, Conaway MR, Hillman DG, Gutgesell HP. Effects of race, ethnicity, and gender on surgical mortality in hypoplastic left heart syndrome. Pediatr Cardiol 2013; 34:1829-36. [PMID: 23722968 PMCID: PMC4023351 DOI: 10.1007/s00246-013-0723-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
Information is limited regarding the effect of race, ethnicity, and gender on the outcomes of the three palliative procedures for hypoplastic left heart syndrome (HLHS). This study examined the effects of race, ethnicity, gender, type of admission, and surgical volume on in-hospital mortality associated with palliative procedures for HLHS between 1998 and 2007 using data from the University HealthSystem Consortium. According to the data, 1,949 patients underwent stage 1 palliation (S1P) with a mortality rate of 29 %, 1,279 patients underwent stage 2 palliations (S2P) with a mortality rate of 5.4 %, and 1,084 patients underwent stage 3 palliation (S3P) with a mortality rate of 4.1 %. The risk factors for increased mortality with S1P were black and "other" race, smaller surgical volume, and early surgical era. The only risk factors for increased mortality with S2P were black race (11 % mortality; odds ratio [OR], 3.19; 95 % confidence interval [CI] 1.69-6.02) and Hispanic ethnicity (11 % mortality; OR 3.30; 95 % CI 1.64-6.64). For S2P, no racial differences were seen in the top five surgical volume institutions, but racial differences were seen in the non-top-five surgical volume institutions. Mortality with S1P was significantly higher for patients discharged after birth (37 vs 24 %; p = 0.004), and blacks were more likely to be discharged after birth (12 vs 5 % for all other races; p < 0.001). No racial differences with S3P were observed. The risk factors for increased mortality at S1P were black and "other" race, smaller surgical volume, and early surgical era. The risk factors for increased in-hospital mortality with S2P were black race and Hispanic ethnicity.
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Affiliation(s)
- Peter N. Dean
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Avenue, Washington, DC 20010-2970, USA
| | - Kimberly E. McHugh
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Mark R. Conaway
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA, USA
| | - Diane G. Hillman
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA, USA
| | - Howard P. Gutgesell
- Division of Cardiology, Department of Pediatrics, University of Virginia Health System, Charlottesville, VA, USA
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Maternal race/ethnicity and survival experience of children with congenital heart disease. J Pediatr 2013; 163:1437-42.e1-2. [PMID: 23932315 DOI: 10.1016/j.jpeds.2013.06.084] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 06/05/2013] [Accepted: 06/28/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To investigate the existence of racial/ethnic disparity in mortality risk among children with individual congenital heart defects and identify any other risk factors. STUDY DESIGN The study cohort, comprising children born between 1983 and 2006 with a selected congenital heart defect, was matched to death records to ascertain vital status. The birth and maternal risk factors were obtained from birth certificates. RESULTS After adjusting for covariates using a multivariate regression model, the risk of mortality was significantly higher in children of non-Hispanic black mothers with transposition of the great arteries (hazard ratio (HR), 1.31; 95% CI, 1.07-1.60), tetralogy of Fallot (HR, 1.34; 95% CI, 1.06-1.69), and coarctation of the aorta (HR, 1.40; 95% CI, 1.10-1.79), compared with children of non-Hispanic white mothers. Time trends analysis examining the mortality risk by survival age and birth period found a significant decrease in 5-year mortality risk from 1983 to 2003 births, with a nearly 50% reduction for hypoplastic left heart syndrome and coarctation of the aorta across 3 maternal racial/ethnic groups examined. CONCLUSION Our findings may help identify at-risk populations and mortality risk factors and thereby contribute to improved survival and quality of life for these children across the lifespan.
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Delmelle EM, Cassell CH, Dony C, Radcliff E, Tanner JP, Siffel C, Kirby RS. Modeling travel impedance to medical care for children with birth defects using Geographic Information Systems. BIRTH DEFECTS RESEARCH. PART A, CLINICAL AND MOLECULAR TERATOLOGY 2013; 97:673-84. [PMID: 23996978 PMCID: PMC4507419 DOI: 10.1002/bdra.23168] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/27/2013] [Accepted: 07/02/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Children with birth defects may face significant geographic barriers accessing medical care and specialized services. Using a Geographic Information Systems-based approach, one-way travel time and distance to access medical care for children born with spina bifida was estimated. METHODS Using 2007 road information from the Florida Department of Transportation, we built a topological network of Florida roads. Live-born Florida infants with spina bifida during 1998 to 2007 were identified by the Florida Birth Defects Registry and linked to hospital discharge records. Maternal residence at delivery and hospitalization locations were identified during the first year of life. RESULTS Of 668 infants with spina bifida, 8.1% (n = 54) could not be linked to inpatient data, resulting in 614 infants. Of those 614 infants, 99.7% (n = 612) of the maternal residential addresses at delivery were successfully geocoded. Infants with spina bifida living in rural areas in Florida experienced travel times almost twice as high compared with those living in urban areas. When aggregated at county levels, one-way network travel times exhibited statistically significant spatial autocorrelation, indicating that families living in some clusters of counties experienced substantially greater travel times compared with families living in other areas of Florida. CONCLUSION This analysis demonstrates the usefulness of linking birth defects registry and hospital discharge data to examine geographic differences in access to medical care. Geographic Information Systems methods are important in evaluating accessibility and geographic barriers to care and could be used among children with special health care needs, including children with birth defects.
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Affiliation(s)
- Eric M. Delmelle
- Department of Geography and Earth Sciences and Center for Applied GI Science, College of Liberal Arts and Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Cynthia H. Cassell
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Coline Dony
- Department of Geography and Earth Sciences and Center for Applied GI Science, College of Liberal Arts and Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Elizabeth Radcliff
- Department of Public Health Sciences, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Jean Paul Tanner
- Birth Defects Surveillance Program, Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, Florida
| | - Csaba Siffel
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Russell S. Kirby
- Birth Defects Surveillance Program, Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, Florida
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Cassell CH, Krohmer A, Mendez DD, Lee KA, Strauss RP, Meyer RE. Factors associated with distance and time traveled to cleft and craniofacial care. ACTA ACUST UNITED AC 2013; 97:685-95. [PMID: 24039055 DOI: 10.1002/bdra.23173] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 06/28/2013] [Accepted: 07/13/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Information on travel distance and time to care for children with birth defects is lacking. We examined factors associated with travel distance and time to cleft care among children with orofacial clefts. METHODS In 2006, a mail/phone survey was administered in English and Spanish to all resident mothers of children with orofacial clefts born 2001 to 2004 and identified by the North Carolina birth defects registry. We analyzed one-way travel distance and time and the extent to which taking a child to care was a problem. We used multivariable logistic regression to examine the association between selected sociodemographic factors and travel distance (≤60 miles and >60 miles) and time (≤60 min and >60 min) to cleft care. RESULTS Of 475 eligible participants, 51.6% (n = 245) responded. Of the respondents, 97.1% (n = 238) were the child's biological mother. Approximately 83% (n = 204) of respondents were non-Hispanic White; 33.3% (n = 81) were college educated; and 50.0% (n = 115) had private health insurance. One-way mean and median travel distances were 80 and 50 miles, respectively (range, 0-1058 miles). One-way mean and median travel times were 92 and 60 min, respectively (range, 5 min to 8 hr). After adjusting for selected sociodemographics, travel distance varied significantly by maternal education, child's age, and cleft type. Travel time varied significantly by child's age. Approximately 67% (n = 162) reported taking their child to receive care was not a problem. CONCLUSION Approximately 48% of respondents traveled > 1 hr to receive cleft care. Increasing access to care may be important for improving health outcomes among this population.
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Affiliation(s)
- Cynthia H Cassell
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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Boss RD, Clarke-Pounder JP. Perinatal and neonatal palliative care: targeting the underserved. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/1743291x12y.0000000039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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