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Published on: October 13, 2018
Neighborhood-Level Socioeconomic Disadvantage and Adverse Outcomes for Infants with Biliary Atresia in the United
Alexandra Highet1, Johanna M Borst2, Susan Gutierrez3
1Department of Surgery, University of California San Francisco, San Francisco, CA; Division of Pediatric Surgery, University of California San Francisco Benioff Children's Hospital, San Francisco, CA.
Insights
Infants with biliary atresia from disadvantaged neighborhoods experienced delayed surgery. However, neighborhood socioeconomic status did not impact postoperative outcomes or readmissions. Targeted interventions could improve surgical access for this population.
Area of Science:
- Pediatric Surgery
- Health Services Research
- Socioeconomic Determinants of Health
Background:
- Biliary atresia is a severe liver disease in infants requiring timely surgical intervention.
- Socioeconomic factors may influence access to care and surgical timing for pediatric conditions.
- The Child Opportunity Index (COI) quantifies neighborhood-level socioeconomic status.
Purpose of the Study:
- To investigate the association between the Child Opportunity Index (COI) and the timing of Kasai hepatoportoenterostomy (HPE) for infants with biliary atresia.
- To examine the relationship between COI and postoperative healthcare utilization, including length of stay and hospital readmissions, following HPE.
- To assess the impact of neighborhood socioeconomic status on surgical outcomes in a US pediatric population.
Main Methods:
- Retrospective cohort study of 1,182 infants with biliary atresia undergoing HPE (2014-2024) using the Pediatric Health Information System database.
- Primary exposure: Child Opportunity Index (COI) at the ZIP code level.
- Outcomes: Age at HPE, postoperative length of stay (LOS), and hospital revisits within two years. Statistical models included quantile regression, negative binomial regression, and recurrent event models, with adjustments for race, ethnicity, and insurance status.
Main Results:
- Infants in the most socioeconomically disadvantaged neighborhoods (very low COI) had a median delay of 8 days in undergoing HPE compared to those in the most advantaged neighborhoods.
- Child Opportunity Index (COI) was not significantly associated with postoperative length of stay (LOS).
- While unadjusted analysis showed a higher risk of readmission for infants in very low COI areas, this association lost statistical significance after adjusting for race, ethnicity, and insurance status.
Conclusions:
- Infants with biliary atresia residing in socioeconomically disadvantaged neighborhoods experience delays in receiving Kasai hepatoportoenterostomy (HPE).
- Neighborhood-level socioeconomic status, as measured by COI, was not found to be associated with postoperative LOS or hospital readmissions.
- Targeted interventions utilizing the COI framework are recommended to enhance timely surgical access for vulnerable pediatric populations with biliary atresia.
Objective:
To examine the associations between Child Opportunity Index (COI) and time to surgery as well as postoperative health care utilization for infants with biliary atresia (BA) undergoing Kasai hepatoportoenterostomy (HPE) in the United States.
Study Design:
We conducted a retrospective cohort study of all infants with BA who underwent HPE within the Pediatric Health Information System database between 2014 and 2024. Our primary exposure was the COI, a composite measure of socioeconomic status at the ZIP code level. Primary outcomes were age at HPE in days; post-HPE length of stay (LOS); and hospital revisits (inpatient, observation, and emergency department) within 2 years post-HPE. We modeled median age at HPE using quantile regression, postoperative LOS using negative binomial regression, and revisits using Anderson-Gill recurrent event models with robust standard errors. We compared unadjusted models, models adjusted for race and ethnicity, and models adjusted for race and ethnicity as well as insurance status.
Results:
Among 1182 infants at 48 hospitals, median COI was 43 (Q1-Q3 20, 69) and median age at HPE was 56 days (Q1-Q3 38, 70). After adjustment, infants in the 20% most disadvantaged neighborhoods (very low COI) underwent HPE 8 days later than very high COI infants (β = 8.00, 95% CI 2.00-11.00, P = .001). COI was not associated with postoperative LOS. Very low COI was associated with higher risk of all-cause readmission in the univariable model (HR 1.38, 95% CI 1.14-1.68, P = .001) but lost significance in the model adjusted for race and ethnicity as well as insurance status (HR 1.22, 0.98-1.51, P = .076).
Conclusions:
Although infants with BA from the most socioeconomically disadvantaged neighborhoods undergo HPE at later ages, neighborhood-level socioeconomic status was not associated with postoperative LOS or readmissions. Targeted interventions using the COI could improve timely access to surgical care for this vulnerable population.
