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Second-Trimester Ultrasound Receipt Mediates the Relationship Between Public Insurance and Prenatal Diagnosis of a
Joyce L Woo1,2, Rupali Gandhi3,4, Christina Laternser1
1Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Insights
Insurance status affects prenatal diagnosis of congenital heart defects (CHD). Lower rates of second-trimester ultrasounds in publicly insured individuals explain a significant portion of these disparities.
Area of Science:
- Medical Research
- Public Health
- Cardiology
Background:
- Insurance status is linked to disparities in prenatal diagnosis of congenital heart defects (CHD).
- Understanding the mechanisms driving these disparities is crucial for equitable healthcare.
- Prenatal diagnosis of CHD impacts management and outcomes.
Purpose of the Study:
- To investigate the role of second-trimester ultrasound in insurance-related disparities in prenatal CHD diagnosis.
- To quantify the mediation effect of ultrasound receipt on the relationship between insurance status and diagnosis.
Main Methods:
- Retrospective analysis of electronic health records for infants undergoing CHD surgery (2019-2020).
- Examined insurance status as exposure, prenatal diagnosis as outcome, and second-trimester ultrasound as mediator.
- Utilized mediation analysis with multivariable fixed-effects regression.
Main Results:
- Public insurance was associated with a lower probability of prenatal diagnosis.
- Public insurance was linked to reduced second-trimester ultrasound receipt.
- Second-trimester ultrasound receipt mediated 39% of the association between public insurance and prenatal diagnosis.
Conclusions:
- Lower frequency of second-trimester ultrasounds among publicly insured individuals contributes significantly to disparities in prenatal CHD diagnosis.
- Addressing ultrasound access may help reduce insurance-related inequities in CHD diagnosis.
- Ensuring equitable access to prenatal screening is vital for congenital heart defect care.
Objective:
To delineate the mechanism behind insurance-related disparities in the prenatal diagnosis of a congenital heart defect (CHD).
Methods:
This was a retrospective analysis of electronic health records of pregnant individuals whose infants received CHD surgery between 2019 and 2020 in the third-largest United States metropolitan area. The outcome was whether a prenatal diagnosis was received. The exposure was the pregnant individual's insurance status. The mediator was second-trimester ultrasound receipt. Control variables included sociodemographic and clinical characteristics of the pregnant individual and infant. The relationships between exposure, mediator, and outcome were quantified using mediation analysis with multivariable fixed-effects regression.
Results:
In total, 496 pregnant individuals met inclusion criteria; 215 (43.3%) were publicly insured and 305 (61.5%) had prenatal diagnosis. In bivariate regressions, public insurance was associated with a 12.6% lower probability (CI 3%-21%) of prenatal diagnosis. In multivariable models, public insurance was associated with 13.2% lower probability (CI 2%-25%) of second-trimester ultrasound receipt but was no longer associated with prenatal diagnosis after adjusting for second-trimester ultrasound receipt, suggesting a possible mediation effect. Mediation analysis confirmed that second-trimester ultrasound receipt mediated 39% of the relationship between public insurance and prenatal diagnosis.
Conclusion:
An appreciable portion of insurance-related differences in prenatal CHD diagnosis is due to the lower frequency of second-trimester ultrasound receipt among those with public insurance.
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