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Childhood Opportunity and Acute Interstage Outcomes: A National Pediatric Cardiology Quality Improvement
Benjamin Zielonka1, Emily M Bucholz2, Minmin Lu1
1Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, MA (B.Z., M.L., L.A.S., D.W.B.).
Insights
Childhood opportunity did not impact acute interstage outcomes after stage 1 palliation. Home monitoring programs may be mitigating disparities in this high-risk period for infants with congenital heart disease.
Area of Science:
- Pediatric Cardiology
- Health Outcomes Research
- Social Determinants of Health
Background:
- The interstage period following stage 1 palliation for congenital heart disease is associated with significant morbidity and mortality.
- The influence of social determinants of health, such as childhood opportunity, on these interstage outcomes is not well understood.
Purpose of the Study:
- To assess the relationship between childhood opportunity and acute interstage outcomes in infants undergoing stage 1 palliation.
- To investigate if the Childhood Opportunity Index (COI) is associated with adverse events during the interstage period.
Main Methods:
- Retrospective review of infants from the National Pediatric Quality Improvement Collaborative Phase II registry (2016-2022) discharged after stage 1 palliation.
- Utilized zip code-level Childhood Opportunity Index (COI) to categorize patients into 5 levels.
- Assessed acute interstage outcomes including death, transplant listing, readmission, ICU admission, catheterization, and reoperation using logistic regression.
Main Results:
- The study included 1837 patients; higher COI levels were associated with increased birth weight and proximity to surgical centers, shorter stage 1 length of stay, and higher rates of exclusive oral feeding at discharge.
- Over 98% of patients were enrolled in home monitoring across all COI levels.
- No significant differences in the incidence or timing of acute interstage outcomes were observed across different COI levels, even after adjusting for confounders.
Conclusions:
- Childhood opportunity, as measured by COI, is linked to variations in preoperative risk factors and hospitalization characteristics for stage 1 palliation.
- Despite common occurrence, acute interstage outcomes were not associated with COI levels in this cohort, likely due to widespread home monitoring.
- Further research is warranted to explore the role of home monitoring in mitigating potential disparities during the interstage period.
Background:
The interstage period after discharge from stage 1 palliation carries high morbidity and mortality. The impact of social determinants of health on interstage outcomes is not well characterized. We assessed the relationship between childhood opportunity and acute interstage outcomes.
Methods:
Infants discharged home after stage 1 palliation in the National Pediatric Quality Improvement Collaborative Phase II registry (2016-2022) were retrospectively reviewed. Zip code-level Childhood Opportunity Index (COI), a composite metric of 29 indicators across education, health and environment, and socioeconomic domains, was used to classify patients into 5 COI levels. Acute interstage outcomes included death or transplant listing, unplanned readmission, intensive care unit admission, unplanned catheterization, and reoperation. The association between COI level and acute interstage outcomes was assessed using logistic regression with sequential adjustment for potential confounders.
Results:
The analysis cohort included 1837 patients from 69 centers. Birth weight (P<0.001) and proximity to a surgical center at birth (P=0.02) increased with COI level. Stage 1 length of stay decreased (P=0.001), and exclusive oral feeding rate at discharge increased (P<0.001), with higher COI level. More than 98% of patients in all COI levels were enrolled in home monitoring. Death or transplant listing occurred in 101 (5%) patients with unplanned readmission in 987 (53%), intensive care unit admission in 448 (24%), catheterization in 345 (19%), and reoperation in 83 (5%). There was no difference in the incidence or time to occurrence of any acute interstage outcome among COI levels in unadjusted or adjusted analysis. There was no interaction between race and ethnicity and childhood opportunity in acute interstage outcomes.
Conclusions:
Zip code COI level is associated with differences in preoperative risk factors and stage 1 palliation hospitalization characteristics. Acute interstage outcomes, although common across the spectrum of childhood opportunity, are not associated with COI level in an era of highly prevalent home monitoring programs. The role of home monitoring in mitigating disparities during the interstage period merits further investigation.
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