Jonathan R. Kaltman|Kristin M. Burns|Gail D. Pearson|David C. Goff|F.J. Evans
Disparities in Congenital Heart Disease Mortality Based on Proximity to a Specialized Pediatric Cardiac Center
National Heart Lung and Blood Institute|National Institutes of Health|National Heart Lung and Blood Institute|National Institutes of Health|National Heart Lung and Blood Institute|National Institutes of Health|National Heart Lung and Blood Institute|National Institutes of Health|National Heart Lung and Blood Institute|National Institutes of Health
homecirculationvol 141 12disparities congenital heart disease mortality based proximity specialized pediatric cardiac center free accessletterpdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessletterpdfepubdisparities congenital heart disease mortality based proximity specialized pediatric cardiac center jonathan r kaltman md kristin burns md gail pearson md scd david c goff md phd frank evans phd jonathan r kaltmanjonathan r kaltman jonathan kaltman md division cardiovascular sciences national institutes health national heart lung blood institute 6701 rockledge drive 8104 bethesda md 20817 email email address email protected division cardiovascular sciences national heart lung blood institute national institutes health bethesda md kristin burnskristin burns division cardiovascular sciences national heart lung blood institute national institutes health bethesda md gail pearsongail pearson division cardiovascular sciences national heart lung blood institute national institutes health bethesda md david c goffdavid c goff division cardiovascular sciences national heart lung blood institute national institutes health bethesda md frank evansfrank evans division cardiovascular sciences national heart lung blood institute national institutes health bethesda md originally published10 feb 2020httpsdoiorg101161circulationaha119043392circulation 202014110341036other versions articleyou viewing recent version article previous versions february 10 2020 ahead print racial socioeconomic disparities exist congenital heart diseaserelated infant mortality chdim blacks infants mothers medicaid insurance greater poverty experience worse outcomes12 united states expertise resources manage complex patients congenital heart disease chd concentrated typically specialized pediatric cardiac centers pccs located metropolitan areas hypothesize source disparity proximity familys residence specialized pccwe tested hypothesis using crosssectional populationbased sample linked birthinfant death data files national center health statistics centers disease control prevention3 containing live births 2011 2015 deaths infants 365 days age born us residents given year included outcome death attributable chd underlying cause death certificate based international statistical classification diseases related health problems tenth revision codes q200 q289 main exposure proximity 1 50 top pccs pcct50 per us news world report 20174 threshold 50 chosen us news world report ranks 50 centers exposure variable defined dichotomously based whether maternal residence metropolitan area least one pcct50 chdim per 1000 live births determined infants whose mothers lived proximal pcct50 versus chdim also determined infants whose mothers lived metropolitan area pcc among pcct50 unadjusted chdim 95 cis calculated proximity stratum sex maternal raceethnicity birth weight gestational age maternal education insurance payment method delivery unadjusted associations evaluated using 2 test poisson regression provided estimated rate ratios comparing chdim infants whose mothers lived proximal pcct50 versus adjusted sex gestational age maternal raceethnicity maternal education insurance birth weight collinear gestational age excluded final model sensitivity analysis poisson regression repeated infants died critical chd5 cchd noncchd human subjects research thus institutional review board approval obtainedfrom 2011 2015 unadjusted chdim rate 0331000 live births 6532 chdrelated deaths19 849 688 live births chdim rates varied covariate strata tabletable maternal infant characteristics among cases infant mortality attributable congenital heart disease proximity top 50 pediatric cardiac centercharacteristictotalmaternal residence proximal top 50 pediatric cardiac centermaternal residence proximal top 50 pediatric cardiac centerstrata specific adjusted rate ratio proximal vs proximal 95 cino deathsno live birthsrate 95 cino deathsno live birthsrate 95 cino deathsno live birthsrate 95 cioverall653219 849 688033 03203426019 253 660028 027029391810 551 525037 036038128 121135sex female29309 691 402030 02903111734 519 373026 02402717505 150 510034 032036127 117138 male360210 158 286035 03403714284 734 287030 02903221685 401 015040 038042128 119138maternal raceethnicity white nonhispanic309910 522 111029 0280319294 091 872023 02102421686 426 136034 032035134 123146 black nonhispanic11622 853 790041 0380435991 589 130038 0350415631 262 807045 041048116 102132 hispanic15784 548 867035 0330367412 418 646031 0280338282 093 830040 037042123 110138 other6701 724 313039 0360423171 020 482031 028035352701 834050 045056139 117165birth weight g 1499931285 740326 305347389134 989288 260318539150 402358 329390121 105140 1500249916491 313 960125 120132657613 430107 099116991698 274142 133151129 115144 2500394818 245 539022 02102215548 503 178018 01701923859 700 527025 024026129 121139gestational age wk 3724082 269 721106 1021109821 042 394094 08810014221 223 916116 110122121 111132 37410517 561 040023 02302416138 203 314020 01902124849 316 777027 026028132 123141maternal education 12th grade less degree12572 892 744043 0410464871 290 403038 0340417701 595 943048 045052127 112143 high school graduate ged completed16664 507 775037 0350396131 896 997032 03003510492 604 275040 038043127 114141 college associate degree17265 251 777033 0310346412 199 542029 02703110813 043 746036 033038128 116142 bachelors degree8433 420 990025 0230264071 836 372022 0200244351 571 064028 025030129 112149 advanced degree masters doctorate professional3581 941 010018 0170201961 181 203017 014019161754 207021 018025132 106163insurance medicaid30727 831 852039 03804111863 450 049034 03203618854 380 114043 041045126 116137 private23138 573 543027 0260289954 333 944023 02202413174 236 236031 029033132 121145 selfpay306767 485040 036045113356 722032 026038185382 557048 042056148 116189 other235844 469028 02403290297 621030 024037144539 493027 023031091 070119ged indicates general equivalency degreemissing unknown strata included covariates missing represented 0 81 live birth records unknown represented 0 11 live birth records per covariateincludes maternal residence proximal proximal top 50 pediatric cardiac center well records proximity could determinedadjusted sex gestational age maternal raceethnicity maternal education payment method except variable defines strataall pcct50s located metropolitan areas n46 mothers residential proximity pcc could determined records 44 503 02 live births mothers living proximal pcct50 unadjusted chdim rate 0281000 live births 2601 deaths9 253 660 live births comparison chdim rate 0371000 live births 3918 deaths10 551 525 live births mothers living proximal pcct50 p00001 mothers living proximal nontop 50 pcc n26 metropolitan areas unadjusted chdim rate 0371000 live births 792 deaths2 119 821 live births 95 ci 035040 mortality rates lower maternal residence proximal pcct50 within covariate stratum except delivery covered insurance tablepoisson regression analysis demonstrated proximity pcct50 related chdim infants whose mothers live proximal pcct50 adjusted chdim rate 28 greater adjusted rate ratio 128 95 ci 121135 infants whose mothers lived proximal pcct50 table results consistent across subgroups defined covariates multivariable model 2way interaction tests p010 except insurance p004 sensitivity analysis demonstrated consistent relation proximity pcct50 chdim cchd noncchd cchd adjusted rate ratio 133 95 ci 121147 noncchd adjusted rate ratio 123 95 ci 110138chdim differs whether mother lives metropolitan area topranked pcc finding robust across infant maternal factors access utilization specialized healthcare resources likely important determinant difference findings implications discussions regionalization care bolstering care networks feed pccs might enhance monitoring highrisk infants chd limitations include counting deaths chd underlying cause rather contributing cause potential misclassification variables proximity defined dichotomous rather continuous variable potential residual confounding including lack homogeneity diagnoses proximal nonproximal areas maternal economic status health literacy maternal medical comorbidities ranking quality care based us news world report limitation rank constructed part reputation among pediatric subspecialists results add maternal proximity pcct50 known profile atrisk infants chd support efforts evaluate effect enhanced regional care coordination outcomes infants chddisclosuresthere conflicts views expressed article authors necessarily represent views national heart lung blood institute national institutes health us department health human servicesfootnotesdata sharing linked birthinfant death cohort data files obtained national center health statistics centers disease control prevention httpswwwcdcgovnchsnvsslinkedbirthhtm authors make analytic methods available researchershttpswwwahajournalsorgjournalcircjonathan kaltman md division cardiovascular sciences national institutes health national heart lung blood institute 6701 rockledge drive 8104 bethesda md 20817 email email protectednihgovreferences1 almli lm alter cc russell rb tinker sc howards pp cragan j petersen e carrino ge reefhuis j association infant mortality attributable birth defects payment source delivery united states 20112013mmwr morb mortal wkly rep 2017 668487 doi 1015585mmwrmm6603a4crossrefmedlinegoogle scholar2 peyvandi baer rj moongrady aj oltman sp chambers cd norton rajagopal ryckman kk jelliffepawlowski steurer socioeconomic mediators racial ethnic disparities congenital heart disease outcomes populationbased study californiaj heart assoc 2018 7e010342 doi 101161jaha118010342linkgoogle scholar3 xu j murphy sl kochanek kd arias e mortality united states 2015nchs data brief 2016 26718google scholar4 us news world report best childrens hospitals 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mcelhinney carmichael 2022 distance home birth hospital transfer mortality neonates hypoplastic left heart syndrome california birth defects research 101002bdr22020 lopez k bakersmith c flores g gurvitz karamlou nunez gallegos f pasquali patel peterson j salemi j yancy c peyvandi 2022 addressing social determinants health mitigating health disparities across lifespan congenital heart disease scientific statement american heart association journal american heart association 118 online publication date 19apr2022 moynihan k lelkes e kumar r decourcey 2021 good gets implications asymptotic mortality decline approaching nadir pediatric intensive care european journal pediatrics 101007s00431021042778 1812 479487 online publication date 1feb2022 madec bonnet 2021 retrospective descriptive study causes death children heart disease 2010 2020 archives cardiovascular diseases supplements 101016jacvdsp202106077 134 318320 online publication date 1sep2021 udine evans f burns k pearson g kaltman j 2021 geographical variation infant mortality due congenital heart disease usa populationbased cohort study lancet child adolescent health 101016s235246422100105x 57 483490 online publication date 1jul2021 su z xiang l liu z wu h li chen h zhang h 2021 current landscape congenital heart surgery northern china geographic populationbased analysis frontiers pediatrics 103389fped2021555141 9 purkey n c lee h hintz shaw g mcelhinney carmichael 2021 timing transfer mortality neonates hypoplastic left heart syndrome california pediatric cardiology 101007s0024602102561w 424 906917 online publication date 1apr2021 lopez k morris sexson tejtel espaillat salemi j 2020 us mortality attributable congenital heart disease across lifespan 1999 2017 exposes persistent racialethnic disparities circulation 14212 11321147 online publication date 22sep2020 march 24 2020vol 141 issue 12 advertisement article informationmetrics 2020 american heart association inchttpsdoiorg101161circulationaha119043392pmid 32078376 originally publishedfebruary 10 2020 keywordsheart defects congenitalinfant mortalityhospitals pediatricpdf download advertisement subjectsepidemiologypediatricsrisk factors