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Updated: Jun 27, 2025
Implantation of Total Artificial Heart in Congenital Heart Disease
Published on: July 18, 2014
Lower opportunity ZIP code is associated with worse outcomes after listing in pediatric heart transplantation
Heidi A Kim1, Andrew G Yu2, Nicole P Kim3
1Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas.
Insights
Children in low Child Opportunity Index (COI) areas face worse survival rates after heart transplant listing. This highlights the impact of social determinants on pediatric transplant outcomes.
Area of Science:
- Pediatric Cardiology
- Transplant Surgery
- Health Equity Research
Background:
- The Child Opportunity Index (COI) measures children's social determinants of health.
- Understanding COI's impact on pediatric heart transplant outcomes is crucial.
Purpose of the Study:
- To investigate the association between the Child Opportunity Index (COI) and outcomes in children listed for heart transplantation.
- To determine if lower socioeconomic opportunity impacts survival and waitlist status.
Main Methods:
- Retrospective review of the United Network for Organ Sharing (UNOS) database (2012-2020).
- Assignment of COI based on patient ZIP codes.
- Cox regression and competing risk analysis to assess survival outcomes.
Main Results:
- Children in very low COI ZIP codes experienced increased mortality risk post-listing (HR 1.16).
- Lower COI was linked to higher likelihood of waitlist removal due to death or clinical decline.
- Increased mortality was observed conditional on one-year post-transplant survival (HR 1.38).
Conclusions:
- Lower Child Opportunity Index (COI) is associated with poorer survival outcomes for children undergoing heart transplantation.
- Social determinants of health significantly influence pediatric heart transplant success.
- Addressing socioeconomic disparities may improve outcomes for pediatric transplant recipients.
Background:
The Child Opportunity Index (COI) comprehensively measures children's social determinants of health. We describe association between COI and outcomes after listing for heart transplantation.
Methods:
We conducted a retrospective review of the United Network for Organ Sharing (UNOS) database for U.S. children listed for heart transplant between 2012 and 2020. ZIP codes were utilized to assign COI. Primary outcome was survival from time of listing. Secondary outcomes included waitlist survival, 1-year post-transplant survival, and conditional 1-year post-transplant survival. Cox regression was performed adjusting for payor, age, race, diagnosis, and support at listing for all outcomes except waitlist survival, for which Fine-Gray competing risk analysis was performed.
Results:
Of 5,723 children listed, 109 were excluded due to missing ZIP codes. Race/ethnicity and payor were associated with COI (p < 0.001). Patients living in very low COI ZIP codes compared to all others had increased mortality from time of listing (HR 1.16, CI 1.03-1.32, p = 0.02) with 1-, 5-, and 9-year survival of 79.3% vs 82.2%, 66.5% vs 73.0%, and 53.6% vs 64.7% respectively, were more likely to be removed from the waitlist due to death or being too sick (subdistribution HR 1.26, 95% CI 1.10-1.42), and had increased mortality conditional on one-year post-transplant survival (HR 1.38, 1.09-1.74, p = 0.008) with 1-, 3-, and 5- year survival of 94.7% vs 97.3%, 87.0% vs 93.1%, and 78.6% vs 86.9%.
Conclusions:
Children living in lower opportunity ZIP codes had poorer survival from time of listing, poorer waitlist survival, and poorer conditional one-year post-transplant survival.
