Socioeconomic Mediators of Racial and Ethnic Disparities in Congenital Heart Disease Outcomes: A Population‐Based Study in California

Abstract

Background Racial/ethnic and socioeconomic disparities exist in outcomes for children with congenital heart disease. We sought to determine the influence of race/ethnicity and mediating socioeconomic factors on 1‐year outcomes for live‐born infants with hypoplastic left heart syndrome and dextro‐Transposition of the great arteries. Methods and Results The authors performed a population‐based cohort study using the California Office of Statewide Health Planning and Development database. Live‐born infants without chromosomal anomalies were included. The outcome was a composite measure of mortality or unexpected hospital readmissions within the first year of life defined as >3 (hypoplastic left heart syndrome) or >1 readmissions (dextro‐Transposition of the great arteries). Hispanic ethnicity was compared with non‐Hispanic white ethnicity. Mediation analyses determined the percent contribution to outcome for each mediator on the pathway between race/ethnicity and outcome. A total of 1796 patients comprised the cohort (n=964 [hypoplastic left heart syndrome], n=832 [dextro‐Transposition of the great arteries]) and 1315 were included in the analysis (n=477 non‐Hispanic white, n=838 Hispanic). Hispanic ethnicity was associated with a poor outcome (crude odds ratio, 1.72; 95% confidence interval [CI], 1.37–2.17). Higher maternal education (crude odds ratio 0.5; 95% CI , 0.38–0.65) and private insurance (crude odds ratio, 0.65; 95% CI , 0.45–0.71) were protective. In the mediation analysis, maternal education and insurance status explained 33.2% (95% CI , 7–66.4) and 27.6% (95% CI , 6.5–63.1) of the relationship between race/ethnicity and poor outcome, while infant characteristics played a minimal role. Conclusions Socioeconomic factors explain a significant portion of the association between Hispanic ethnicity and poor outcome in neonates with critical congenital heart disease. These findings identify vulnerable populations that would benefit from resources to lessen health disparities.

Secular trends in pregnancy rates, delivery outcomes, and related health care utilization among women with congenital heart disease

“…Indeed, in the United States, uninsured infants had a higher risk of mortality than those with private insurance . Moreover, state‐insured children had an increased risk of mortality and morbidity in their first year of life . Therefore, universal insurance in Quebec may have led to better access to care and early childhood interventions, thereby improving adult CHD outcomes and resulting pregnancy rates.…”

“…37 Moreover, state-insured children had an increased risk of mortality and morbidity in their first year of life. 37,38 Therefore, universal insurance in Quebec may have led to better access to care and early childhood interventions, thereby improving adult CHD outcomes and resulting pregnancy rates. Finally, since indications for cesarean sections and hospitalizations were not reported, firm conclusions on the cause of increased use of operative delivery and hospitalizations could not be drawn.…”

Re-conceptualizing Associations between Race and Morbidities of Extreme Prematurity

“…Instead of concluding that genetic differences may drive these disparities, authors performed a mediation analysis to determine the contribution of Hispanic ethnicity to outcomes, and found that maternal education and insurance status explained a significant portion of the association of ethnicity and health outcomes. 21 Using the example of BPD, the reason for preterm birth (more than simply chorioamnionitis or preterm labor) may indeed differ by racial group and lead to differential risk of BPD. For example, the hormonal and immunologic milieu may differ among preterm infants born to women with preeclampsia compared with women with abruption or rupture of membranes.…”

Reduced brain mammillary body volumes and memory deficits in adolescents who have undergone the Fontan procedure

“…Our findings identified lower SES in the SVHD group compared to controls, with 50% of the SVHD sample of Hispanic ethnicity. Disparities have been identified in population-based studies in children with critical CHD in which SES explains a significant portion of the association between Hispanic ethnicity and worse health outcomes (35). However, controlling for SES in our analysis, there were still significant differences in mammillary body volumes and functional outcomes in the SVHD group compared to controls, and SES did not contribute to those variables.…”