Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease

Son Q Duong; Mahmud O Elfituri; Isabella Zaniletti; Robert W Ressler; Clemens Noelke; Bruce D Gelb; Robert H Pass; Carol R Horowitz; Howard S Seiden; Brett R Anderson

doi:10.1016/j.jacc.2023.05.069

Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease

J Am Coll Cardiol. 2023 Aug 29;82(9):801-813. doi: 10.1016/j.jacc.2023.05.069.

Authors

Affiliations

¹ Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address: son.duong@mssm.edu.
² Department of Pediatrics, Icahn School of Medicine at Mount Sinai- H+H Elmhurst, New York, New York, USA.
³ Children's Hospital Association, Lenexa, Kansas, USA.
⁴ Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA.
⁵ Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁶ Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁷ Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁸ Department of Pediatrics, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.

PMID: 37612012
DOI: 10.1016/j.jacc.2023.05.069

Abstract

Background: Racial and ethnic disparities in outcomes for children with congenital heart disease (CHD) coexist with disparities in educational, environmental, and economic opportunity.

Objectives: We sought to determine the associations between childhood opportunity, race/ethnicity, and pediatric CHD surgery outcomes.

Methods: Pediatric Health Information System encounters aged <18 years from 2016 to 2022 with International Classification of Diseases-10th edition codes for CHD and cardiac surgery were linked to ZIP code-level Childhood Opportunity Index (COI), a score of neighborhood educational, environmental, and socioeconomic conditions. The associations of race/ethnicity and COI with in-hospital surgical death were modeled with generalized estimating equations and formal mediation analysis. Neonatal survival after discharge was modeled by Cox proportional hazards.

Results: Of 54,666 encounters at 47 centers, non-Hispanic Black (Black) (OR: 1.20; P = 0.01), Asian (OR: 1.75; P < 0.001), and Other (OR: 1.50; P < 0.001) groups had increased adjusted mortality vs non-Hispanic Whites. The lowest COI quintile had increased in-hospital mortality in unadjusted and partially adjusted models (OR: 1.29; P = 0.004), but not fully adjusted models (OR: 1.14; P = 0.13). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (P = 0.64) and 16.8% (P = 0.029), depending on model specification. In neonatal multivariable survival analysis (n = 13,987; median follow-up: 0.70 years), the lowest COI quintile had poorer survival (HR: 1.21; P = 0.04).

Conclusions: Children in the lowest COI quintile are at risk for poor outcomes after CHD surgery. Disproportionally increased mortality in Black, Asian, and Other populations may be partially mediated by COI. Targeted investment in low COI neighborhoods may improve outcomes after hospital discharge. Identification of unmeasured factors to explain persistent risk attributed to race/ethnicity is an important area of future exploration.

Keywords: Childhood Opportunity Index; congenital heart disease; health disparities.

Publication types

Comparative Study
Multicenter Study
Research Support, Non-U.S. Gov't

MeSH terms

Asian
Black or African American
Child
Ethnicity
Heart Defects, Congenital* / epidemiology
Heart Defects, Congenital* / ethnology
Heart Defects, Congenital* / mortality
Heart Defects, Congenital* / surgery
Hispanic or Latino
Hospital Mortality / ethnology
Humans
Infant, Newborn
Social Determinants of Health* / ethnology
Social Determinants of Health* / statistics & numerical data
Treatment Outcome
United States / epidemiology
White People