Impact of Socioeconomic Status, Race and Ethnicity, and Geography on Prenatal Detection of Hypoplastic Left Heart Syndrome and Transposition of the Great Arteries

Abstract

Background: Prenatal detection (PND) has benefits for infants with hypoplastic left heart syndrome (HLHS) and transposition of the great arteries (TGA), but associations between sociodemographic and geographic factors with PND have not been sufficiently explored. This study evaluated whether socioeconomic quartile (SEQ), public insurance, race and ethnicity, rural residence, and distance of residence (distance and driving time from a cardiac surgical center) are associated with the PND or timing of PND, with a secondary aim to analyze differences between the United States and Canada. Methods: In this retrospective cohort study, fetuses and infants <2 months of age with HLHS or TGA admitted between 2012 and 2016 to participating Fetal Heart Society Research Collaborative institutions in the United States and Canada were included. SEQ, rural residence, and distance of residence were derived using maternal census tract from the maternal address at first visit. Subjects were assigned a SEQ z score using the neighborhood summary score or Canadian Chan index and separated into quartiles. Insurance type and self-reported race and ethnicity were obtained from medical charts. We evaluated associations among SEQ, insurance type, race and ethnicity, rural residence, and distance of residence with PND of HLHS and TGA (aggregate and individually) using bivariate analysis with adjusted associations for confounding variables and cluster analysis for centers. Results: Data on 1862 subjects (HLHS: n=1171, 92% PND; TGA: n=691, 58% PND) were submitted by 21 centers (19 in the United States). In the United States, lower SEQ was associated with lower PND in HLHS and TGA, with the strongest association in the lower SEQ of pregnancies with fetal TGA (quartile 1, 0.78 [95% CI, 0.64–0.85], quartile 2, 0.77 [95% CI, 0.64–0.93], quartile 3, 0.83 [95% CI, 0.69–1.00], quartile 4, reference). Hispanic ethnicity (relative risk, 0.85 [95% CI, 0.72–0.99]) and rural residence (relative risk, 0.78 [95% CI, 0.64–0.95]) were also associated with lower PND in TGA. Lower SEQ was associated with later PND overall; in the United States, rural residence and public insurance were also associated with later PND. Conclusions: We demonstrate that lower SEQ, Hispanic ethnicity, and rural residence are associated with decreased PND for TGA, with lower SEQ also being associated with decreased PND for HLHS. Future work to increase PND should be considered in these specific populations.

Perioperative Course and Socioeconomic Status Predict Long-Term Neurodevelopment Better Than Perioperative Conventional Neuroimaging in Children with Congenital Heart Disease

“…In CHD, lower SES is associated with multiple medical disadvantages during fetal and perioperative care. These include lower fetal detection rates 65 resulting in higher neonatal mortality, 66 longer time until surgery, 67,68 fewer interventions with extracorporeal membrane oxygenation, 69 fewer catheterizations 68 , and poorer adherence to cardiological and neurodevelopmental follow-up appointments. [70][71][72][73] Further, SES emerges repeatedly as an important factor in short-and long-term cognitive development in CHD patients 21,22,68,[74][75][76] and its impact on the cognitive outcome increases with advancing age.…”

Addressing Social Determinants of Health and Mitigating Health Disparities Across the Lifespan in Congenital Heart Disease: A Scientific Statement From the American Heart Association

“… 15 Studies have shown that families with a lower socioeconomic status (SES) are associated with lower rates of prenatal detection of congenital HD, which results in gaps in appropriate referrals (ie, access to care). 16 , 17 …”

Distance from home to birth hospital, transfer, and mortality in neonates with hypoplastic left heart syndrome in California

“…Infants born into >75th percentile for census tract poverty level were more likely to live close to the birth hospital and be transferred. Prior studies, including a recently published review using a national Medicaid dataset, have linked poverty with a lower likelihood of prenatal diagnosis (Campbell et al, 2021; Hill, Block, Tanem, & Frommelt, 2015; Krishnan et al, 2021). Our study further supports these findings.…”

“…In our study, it is unknown if the link between poverty and transfer after delivery is related to a failure of prenatal diagnosis, challenges in planning for birth hospitalization or relocation, or if there are other patient‐related barriers preventing relocation of mothers in this situation. A recent multicenter analysis from the Fetal Heart Society Research Collaborative, including 1,171 patients with HLHS from 2012 to 2016, found prenatal diagnosis of the defect to be less likely among mothers experiencing poverty, Hispanic mothers, and mothers living in rural locations (Krishnan et al, 2021). Future research should attempt to confirm if prenatal relocation is also less likely in poorer populations, and if this difference is attributable to physician error, systemic bias related to socioeconomic status, insurance status, or patient choice due to other stressors such as the need for childcare for other children, unstable housing, or job insecurity.…”