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Childhood Opportunity and Surgical Outcomes in Congenital Heart Disease
Quick Takes
- There is a disproportionately higher in-hospital mortality among Black, Asian, and “Other” racial/ethnic groups undergoing congenital heart disease surgery even after adjusting for traditional surgical risk factors and neighborhood opportunity levels.
- Furthermore, the lowest Childhood Opportunity Index (COI) quintile had decreased survival compared to the highest COI quintile.
- Overall, these findings suggest that racial/ethnic disparities in surgical outcome persist independently of the childhood disparities captured by the COI, but COI may mediate the association of race and mortality.
Study Questions:
What are the associations between childhood opportunity, race/ethnicity, and pediatric congenital heart disease (CHD) surgery outcomes?
Methods:
The investigators linked pediatric Health Information System encounters aged <18 years from 2016–2022 with International Classification of Diseases-10th edition codes for CHD and cardiac surgery to ZIP code-level Childhood Opportunity Index (COI), a score of neighborhood educational, environmental, and socioeconomic conditions. Effects of race/ethnicity and COI on in-hospital surgical death were modeled with generalized estimating equations and formal mediation analysis. Neonatal survival post-discharge was modeled by Cox proportional hazards.
Results:
Of 54,666 encounters at 47 centers, non-Hispanic Black (Black, odds ratio [OR], 1.20; p = 0.01), Asian (OR, 1.75; p < 0.001), and “Other” (OR, 1.50; p < 0.001) groups had increased adjusted mortality versus non-Hispanic White. The lowest COI quintile had increased in-hospital mortality in unadjusted and partially adjusted models (OR, 1.29; p = 0.004), but not fully adjusted models (OR, 1.14; p = 0.13). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (p = 0.64) and 16.8% (p = 0.029) depending on model specification. In neonatal multivariable survival analysis (n = 13,987; median follow-up 0.70 years), the lowest COI quintile had poorer survival (hazard ratio, 1.21; p = 0.04).
Conclusions:
The authors report that children in the lowest COI quintile are at risk for a poor outcome after CHD surgery.
Perspective:
This large retrospective review of pediatric congenital heart surgery outcomes reports a disproportionately higher in-hospital mortality among Black, Asian, and “Other” racial/ ethnic groups even after adjusting for traditional surgical risk factors and neighborhood opportunity levels. Furthermore, the lowest COI quintile had decreased survival compared to the highest COI quintile. Overall, these findings suggest that racial/ethnic disparities in surgical outcome persist independently of the childhood disparities captured by the COI, but COI may mediate the association of race and mortality. While neighborhood investment in educational, environmental, and socioeconomic opportunities may reduce disparities in surgical outcomes for children with CHD, additional research is needed to define underlying reasons for disparity in different racial and ethnic groups.
Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease
Keywords: African Americans, Asian Americans, Cardiac Surgical Procedures, Ethnic Groups, Heart Defects, Congenital, Hospital Mortality, Minority Health, Patient Discharge, Pediatrics, Race Factors, Risk Factors, Secondary Prevention, Socioeconomic Factors, Survival
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