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Disparities in Congenital Heart Disease Mortality Based on Proximity to a Specialized Pediatric Cardiac Center

2020; Lippincott Williams & Wilkins; Volume: 141; Issue: 12 Linguagem: Inglês

10.1161/circulationaha.119.043392

1524-4539

Jonathan R. Kaltman, Kristin M. Burns, Gail D. Pearson, David C. Goff, F.J. Evans,

Ultrasound in Clinical Applications

HomeCirculationVol. 141, No. 12Disparities in Congenital Heart Disease Mortality Based on Proximity to a Specialized Pediatric Cardiac Center Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBDisparities in Congenital Heart Disease Mortality Based on Proximity to a Specialized Pediatric Cardiac Center Jonathan R. Kaltman, MD, Kristin M. Burns, MD, Gail D. Pearson, MD, ScD, David C. Goff, MD, PhD and Frank Evans, PhD Jonathan R. KaltmanJonathan R. Kaltman Jonathan Kaltman, MD, Division of Cardiovascular Sciences, National Institutes of Health, National Heart, Lung, and Blood Institute, 6701 Rockledge Drive #8104, Bethesda, MD 20817. Email E-mail Address: [email protected] Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD. , Kristin M. BurnsKristin M. Burns Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD. , Gail D. PearsonGail D. Pearson Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD. , David C. GoffDavid C. Goff Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD. and Frank EvansFrank Evans Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD. Originally published10 Feb 2020https://doi.org/10.1161/CIRCULATIONAHA.119.043392Circulation. 2020;141:1034–1036Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 10, 2020: Ahead of Print Racial and socioeconomic disparities exist in congenital heart disease–related infant mortality (CHD-IM). Blacks and infants of mothers with Medicaid insurance or greater poverty experience worse outcomes.1,2 In the United States, the expertise and resources to manage complex patients with congenital heart disease (CHD) are concentrated typically at specialized pediatric cardiac centers (PCCs) located in metropolitan areas. We hypothesize that a further source of disparity is the proximity of a family's residence to a specialized PCC.We tested this hypothesis using a cross-sectional, population-based sample of linked birth/infant death data files from the National Center for Health Statistics at the Centers for Disease Control and Prevention3 containing live births from 2011 through 2015. All deaths of infants (<365 days of age) born to US residents in a given year are included. The outcome was death attributable to CHD as the underlying cause on the death certificate, based on International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes Q20.0 through Q28.9. The main exposure was proximity to 1 of 50 top PCCs (PCC-T50) per the US News& World Report in 2017.4 The threshold of 50 was chosen because US News & World Report ranks only 50 centers. The exposure variable was defined dichotomously based on whether the maternal residence was in a metropolitan area with at least one PCC-T50. CHD-IM (per 1000 live births) was determined for infants whose mothers lived proximal to a PCC-T50 versus those who did not. CHD-IM was also determined for infants whose mothers lived in a metropolitan area with a PCC not among the PCC-T50. Unadjusted CHD-IM (95% CIs) was calculated by proximity for each stratum of sex, maternal race/ethnicity, birth weight, gestational age, maternal education, and insurance payment method for delivery. Unadjusted associations were evaluated using the χ2 test. Poisson regression provided estimated rate ratios comparing CHD-IM for infants whose mothers lived proximal to a PCC-T50 versus those who did not, adjusted for sex, gestational age, maternal race/ethnicity, maternal education, and insurance. Birth weight was collinear with gestational age and was excluded from the final model. As a sensitivity analysis, Poisson regression was repeated for infants who died of critical CHD5 (CCHD) and of non-CCHD. This was not human subjects research, and, thus, no institutional review board approval was obtained.From 2011 through 2015, the unadjusted CHD-IM rate was 0.33/1000 live births (6532 CHD-related deaths/19 849 688 live births). CHD-IM rates varied by covariate strata (Table).Table. Maternal and Infant Characteristics Among Cases of Infant Mortality Attributable to Congenital Heart Disease, by Proximity to a Top 50 Pediatric Cardiac CenterCharacteristic*Total†Maternal Residence Proximal to Top 50 Pediatric Cardiac CenterMaternal Residence Not Proximal to Top 50 Pediatric Cardiac CenterStrata Specific Adjusted‡ Rate Ratio: Not Proximal vs Proximal (95% CI)No. of DeathsNo. of Live BirthsRate (95% CI)No. of DeathsNo. of Live BirthsRate (95% CI)No. of DeathsNo. of Live BirthsRate (95% CI)Overall653219 849 6880.33 (0.32–0.34)26019 253 6600.28 (0.27–0.29)391810 551 5250.37 (0.36–0.38)1.28 (1.21–1.35)Sex Female29309 691 4020.30 (0.29–0.31)11734 519 3730.26 (0.24–0.27)17505 150 5100.34 (0.32–0.36)1.27 (1.17–1.38) Male360210 158 2860.35 (0.34–0.37)14284 734 2870.30 (0.29–0.32)21685 401 0150.40 (0.38–0.42)1.28 (1.19–1.38)Maternal race/ethnicity White, non-Hispanic309910 522 1110.29 (0.28–0.31)9294 091 8720.23 (0.21–0.24)21686 426 1360.34 (0.32–0.35)1.34 (1.23–1.46) Black, non-Hispanic11622 853 7900.41 (0.38–0.43)5991 589 1300.38 (0.35–0.41)5631 262 8070.45 (0.41–0.48)1.16 (1.02–1.32) Hispanic15784 548 8670.35 (0.33–0.36)7412 418 6460.31 (0.28–0.33)8282 093 8300.40 (0.37–0.42)1.23 (1.10–1.38) Other6701 724 3130.39 (0.36–0.42)3171 020 4820.31 (0.28–0.35)352701 8340.50 (0.45–0.56)1.39 (1.17–1.65)Birth weight, g ≤1499931285 7403.26 (3.05–3.47)389134 9892.88 (2.60–3.18)539150 4023.58 (3.29–3.90)1.21 (1.05–1.40) 1500–249916491 313 9601.25 (1.20–1.32)657613 4301.07 (0.99–1.16)991698 2741.42 (1.33–1.51)1.29 (1.15–1.44) ≥2500394818 245 5390.22 (0.21–0.22)15548 503 1780.18 (0.17–0.19)23859 700 5270.25 (0.24–0.26)1.29 (1.21–1.39)Gestational age, wk <3724082 269 7211.06 (1.02–1.10)9821 042 3940.94 (0.88–1.00)14221 223 9161.16 (1.10–1.22)1.21 (1.11–1.32) ≥37410517 561 0400.23 (0.23–0.24)16138 203 3140.20 (0.19–0.21)24849 316 7770.27 (0.26–0.28)1.32 (1.23–1.41)Maternal education 12th grade or less with no degree12572 892 7440.43 (0.41–0.46)4871 290 4030.38 (0.34–0.41)7701 595 9430.48 (0.45–0.52)1.27 (1.12–1.43) High school graduate or GED completed16664 507 7750.37 (0.35–0.39)6131 896 9970.32 (0.30–0.35)10492 604 2750.40 (0.38–0.43)1.27 (1.14–1.41) Some college or associate degree17265 251 7770.33 (0.31–0.34)6412 199 5420.29 (0.27–0.31)10813 043 7460.36 (0.33–0.38)1.28 (1.16–1.42) Bachelor's degree8433 420 9900.25 (0.23–0.26)4071 836 3720.22 (0.20–0.24)4351 571 0640.28 (0.25–0.30)1.29 (1.12–1.49) Advanced degree (master's, doctorate, or professional)3581 941 0100.18 (0.17–0.20)1961 181 2030.17 (0.14–0.19)161754 2070.21 (0.18–0.25)1.32 (1.06–1.63)Insurance Medicaid30727 831 8520.39 (0.38–0.41)11863 450 0490.34 (0.32–0.36)18854 380 1140.43 (0.41–0.45)1.26 (1.16–1.37) Private23138 573 5430.27 (0.26–0.28)9954 333 9440.23 (0.22–0.24)13174 236 2360.31 (0.29–0.33)1.32 (1.21–1.45) Self-pay306767 4850.40 (0.36–0.45)113356 7220.32 (0.26–0.38)185382 5570.48 (0.42–0.56)1.48 (1.16–1.89) Other235844 4690.28 (0.24–0.32)90297 6210.30 (0.24–0.37)144539 4930.27 (0.23–0.31)0.91 (0.70–1.19)GED indicates general equivalency degree.*Missing and unknown strata are not included for covariates. Missing represented from 0% to 8.1% of live birth records and unknown represented 0% to 1.1% of live birth records per covariate.†Includes maternal residence proximal to and not proximal to a top 50 pediatric cardiac center as well as records where proximity could not be determined.‡Adjusted for sex, gestational age, maternal race/ethnicity, maternal education, and payment method, except for the variable that defines the strata.All PCC-T50s were located in metropolitan areas (n=46). Mothers' residential proximity to a PCC could not be determined from the records of 44 503 (0.2%) live births. For mothers living proximal to a PCC-T50, the unadjusted CHD-IM rate was 0.28/1000 live births (2601 deaths/9 253 660 live births) in comparison with a CHD-IM rate of 0.37/1000 live births (3918 deaths/10 551 525 live births) for mothers not living proximal to a PCC-T50 (P 0.10), except for insurance (P=0.04). Sensitivity analysis demonstrated a consistent relation between proximity to a PCC-T50 and CHD-IM for both CCHD and non-CCHD (CCHD adjusted rate ratio, 1.33 [95% CI, 1.21–1.47]; non-CCHD adjusted rate ratio, 1.23 [95% CI, 1.10–1.38]).CHD-IM differs by whether a mother lives in a metropolitan area with a top-ranked PCC. This finding was robust across infant and maternal factors. Access to and utilization of specialized healthcare resources is likely an important determinant of this difference. These findings have implications for discussions about regionalization of care. Bolstering the care networks that feed into PCCs might enhance monitoring of high-risk infants with CHD. Limitations include counting deaths with CHD as the underlying cause rather than a contributing cause, potential misclassification of variables, proximity defined as a dichotomous rather than a continuous variable, and potential residual confounding, including lack of homogeneity of diagnoses in proximal and nonproximal areas, maternal economic status and health literacy, and maternal medical comorbidities. Ranking quality of care based on the US News & World Report is a limitation because the rank is constructed, in part, on reputation among pediatric subspecialists. These results add maternal proximity to a PCC-T50 to the known profile for at-risk infants with CHD and support efforts to evaluate the effect of enhanced regional care coordination on outcomes of infants with CHD.DisclosuresThere are no conflicts. The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the US Department of Health and Human Services.FootnotesData sharing: The linked birth/infant death cohort data files can be obtained from the National Center for Health Statistics at the Centers for Disease Control and Prevention (https://www.cdc.gov/nchs/nvss/linked-birth.htm). The authors will make their analytic methods available to other researchers.https://www.ahajournals.org/journal/circJonathan Kaltman, MD, Division of Cardiovascular Sciences, National Institutes of Health, National Heart, Lung, and Blood Institute, 6701 Rockledge Drive #8104, Bethesda, MD 20817. Email [email protected]nih.govReferences1. Almli LM, Alter CC, Russell RB, Tinker SC, Howards PP, Cragan J, Petersen E, Carrino GE, Reefhuis J. 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March 24, 2020Vol 141, Issue 12 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.043392PMID: 32078376 Originally publishedFebruary 10, 2020 Keywordsheart defects, congenitalinfant mortalityhospitals, pediatricPDF download Advertisement SubjectsEpidemiologyPediatricsRisk Factors