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Williamson CG, Park MG, Mooney B, Mantha A, Verma A, Benharash P. Insurance-Based Disparities in Congenital Cardiac Operations in the Era of the Affordable Care Act. Pediatr Cardiol 2023; 44:826-835. [PMID: 36906870 PMCID: PMC10063518 DOI: 10.1007/s00246-023-03136-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/25/2023] [Indexed: 03/13/2023]
Abstract
A body of literature has previously highlighted the impact of health insurance on observed disparities in congenital cardiac operations. With aims of improving access to healthcare for all patients, the Affordable Care Act (ACA) expanded Medicaid coverage to nearly all eligible children in 2010. Therefore, the present population-based study aimed to examine the association of Medicaid coverage with clinical and financial outcomes in the era the ACA. Records for pediatric patients (≤ 18 years) who underwent congenital cardiac operations were abstracted from the 2010-2018 Nationwide Readmissions Database. Operations were stratified using the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Category. Multivariable regression models were developed to evaluate the association of insurance status on index mortality, 30-day readmissions, care fragmentation, and cumulative costs. Of an estimated 132,745 hospitalizations for congenital cardiac surgery from 2010 to 2018, 74,925 (56.4%) were insured by Medicaid. The proportion of Medicaid patients increased from 57.6 to 60.8% during the study period. On adjusted analysis, patients with Medicaid insurance were at an increased odds of mortality (1.35, 95%CI: 1.13-1.60) and 30-day unplanned readmission (1.12, 95%CI: 1.01-1.25), experienced longer lengths of stay (+ 6.5 days, 95%CI 3.7-9.3), and exhibited higher cumulative hospitalization costs (+ $21,600, 95%CI: $11,500-31,700). The total hospitalization cost-burden for patients with Medicaid and private insurance were $12.6 billion and $8.06 billion, respectively. Medicaid patients exhibited increased mortality, readmissions, care fragmentation, and costs compared to those with private insurance. Our results of outcome variation by insurance status indicate the necessity of policy changes to attempt to approach equality in surgical out comes for this high-risk cohort. Baseline characteristics, trends, and outcomes by insurance status over the ACA rollout period 2010-2018.
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Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA
| | - Mina G Park
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA
| | - Bailey Mooney
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA
| | - Aditya Mantha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA.,Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 64-249 CHS, Los Angeles, CA, 90095, USA.
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Lopez KN, Baker-Smith C, Flores G, Gurvitz M, Karamlou T, Nunez Gallegos F, Pasquali S, Patel A, Peterson JK, Salemi JL, Yancy C, Peyvandi S. Addressing Social Determinants of Health and Mitigating Health Disparities Across the Lifespan in Congenital Heart Disease: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2022; 11:e025358. [PMID: 35389228 PMCID: PMC9238447 DOI: 10.1161/jaha.122.025358] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the overall improvement in life expectancy of patients living with congenital heart disease (congenital HD), disparities in morbidity and mortality remain throughout the lifespan. Longstanding systemic inequities, disparities in the social determinants of health, and the inability to obtain quality lifelong care contribute to poorer outcomes. To work toward health equity in populations with congenital HD, we must recognize the existence and strategize the elimination of inequities in overall congenital HD morbidity and mortality, disparate health care access, and overall quality of health services in the context of varying social determinants of health, systemic inequities, and structural racism. This requires critically examining multilevel contributions that continue to facilitate health inequities in the natural history and consequences of congenital HD. In this scientific statement, we focus on population, systemic, institutional, and individual‐level contributions to health inequities from prenatal to adult congenital HD care. We review opportunities and strategies for improvement in lifelong congenital HD care based on current public health and scientific evidence, surgical data, experiences from other patient populations, and recognition of implicit bias and microaggressions. Furthermore, we review directions and goals for both quantitative and qualitative research approaches to understanding and mitigating health inequities in congenital HD care. Finally, we assess ways to improve the diversity of the congenital HD workforce as well as ethical guidance on addressing social determinants of health in the context of clinical care and research.
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Knowles RL, Ridout D, Crowe S, Bull C, Wray J, Tregay J, Franklin RCG, Barron DJ, Parslow RC, Brown K. Ethnic-specific mortality of infants undergoing congenital heart surgery in England and Wales. Arch Dis Child 2019; 104:844-850. [PMID: 30824491 DOI: 10.1136/archdischild-2018-315505] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 12/31/2018] [Accepted: 01/25/2019] [Indexed: 11/04/2022]
Abstract
PURPOSE To investigate ethnic differences in mortality for infants with congenital heart defects (CHDs) undergoing cardiac surgery or interventional catheterisation. DESIGN Observational study of survival to age 1 year using linked records from routine national paediatric cardiac surgery and intensive care audits. Mortality risk was investigated using multivariable Poisson models with multiple imputation. Predictors included sex, ethnicity, preterm birth, deprivation, comorbidities, prenatal diagnosis, age and weight at surgery, preprocedure deterioration and cardiac diagnosis. SETTING All paediatric cardiac surgery centres in England and Wales. PATIENTS 5350 infants with CHDs born from 2006 to 2009. MAIN OUTCOME MEASURE Survival at age 1 year. RESULTS Mortality was 83.9 (95% CI 76.3 to 92.1) per 1000 infants, with variation by ethnic group. Compared with those of white ethnicity, infants in British Asian (Indian, Pakistani and Bangladeshi) and 'all other' (Chinese, mixed and other) categories experienced significantly higher mortality by age 1 year (relative risk [RR] 1.52[95% CI 1.19 to 1.95]; 1.62[95% CI 1.20 to 2.20], respectively), specifically during index hospital admission (RR 1.55 [95% CI 1.07 to 2.26]; 1.64 [95% CI 1.05 to 2.57], respectively). Further predictors of mortality included non-cardiac comorbidities, prenatal diagnosis, older age at surgery, preprocedure deterioration and cardiac diagnosis. British Asian infants had higher mortality risk during elective hospital readmission (RR 1.86 [95% CI 1.02 to 3.39]). CONCLUSIONS Infants of British Asian and 'all other' non-white ethnicity experienced higher postoperative mortality risk, which was only partly explained by socioeconomic deprivation and access to care. Further investigation of case-mix and timing of risk may provide important insights into potential mechanisms underlying ethnic disparities.
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Affiliation(s)
- Rachel L Knowles
- Life Course Epidemiology & Biostatistics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Deborah Ridout
- Population Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Catherine Bull
- Department of Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jenifer Tregay
- Department of Clinical Psychology, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Rodney C G Franklin
- Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
| | - David J Barron
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Roger C Parslow
- Paediatric Epidemiology Group, University of Leeds, Leeds, UK
| | - Katherine Brown
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Best KE, Vieira R, Glinianaia SV, Rankin J. Socio-economic inequalities in mortality in children with congenital heart disease: A systematic review and meta-analysis. Paediatr Perinat Epidemiol 2019; 33:291-309. [PMID: 31347722 DOI: 10.1111/ppe.12564] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/02/2019] [Accepted: 05/27/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND The impact of socio-economic status (SES) on congenital heart disease (CHD)-related mortality in children is not well established. OBJECTIVES We aimed to systematically review and appraise the existing evidence on the association between SES (including poverty, parental education, health insurance, and income) and mortality among children with CHD. DATA SOURCES Seven electronic databases (Medline, Embase, Scopus, PsycINFO, CINAHL, ProQuest Natural, and Biological Science Collections), reference lists, citations, and key journals were searched. STUDY SELECTION AND DATA EXTRACTION We included articles reporting original research on the association between SES and mortality in children with CHD if they were full papers published in the English language and regardless of (a) timing of mortality; (b) individual or area-based measures of SES; (c) CHD subtype; (d) age at ascertainment; (e) study period examined. Screening for eligibility, data extraction, and quality appraisal were performed in duplicate. SYNTHESIS Meta-analyses were performed to estimate pooled ORs for in-hospital mortality according to health insurance status. RESULTS Of 1388 identified articles, 28 met the inclusion criteria. Increased area-based poverty was associated with increased odds/risk of postoperative (n = 1), neonatal (n = 1), post-discharge (n = 1), infant (n = 1), and long-term mortality (n = 2). Higher parental education was associated with decreased odds/risk of neonatal (n = 1) and infant mortality (n = 5), but not with long-term mortality (n = 1). A meta-analysis of four US articles showed increased unadjusted odds of in-hospital mortality in those with government/public versus private health insurance (OR 1.40, 95% CI 1.24, 1.56). The association between area-based income and CHD-related mortality was conflicting, with three of eight articles reporting significant associations. CONCLUSION This systematic review provides evidence that children of lower SES are at increased risk of CHD-related mortality. As these children are over-represented in the CHD population, interventions targeting socio-economic inequalities could have a large impact on improving CHD survival.
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Affiliation(s)
- Kate E Best
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Rute Vieira
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK.,The Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK
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Kucik JE, Nembhard WN, Donohue P, Devine O, Wang Y, Minkovitz CS, Burke T. Community socioeconomic disadvantage and the survival of infants with congenital heart defects. Am J Public Health 2014; 104:e150-7. [PMID: 25211743 DOI: 10.2105/ajph.2014.302099] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the association between survival of infants with severe congenital heart defects (CHDs) and community-level indicators of socioeconomic status. METHODS We identified infants born to residents of Arizona, New Jersey, New York, and Texas between 1999 and 2007 with selected CHDs from 4 population-based, statewide birth defect surveillance programs. We linked data to the 2000 US Census to obtain 11 census tract-level socioeconomic indicators. We estimated survival probabilities and hazard ratios adjusted for individual characteristics. RESULTS We observed differences in infant survival for 8 community socioeconomic indicators (P < .05). The greatest mortality risk was associated with residing in communities in the most disadvantaged deciles for poverty (adjusted hazard ratio [AHR] = 1.49; 95% confidence interval [CI] = 1.11, 1.99), education (AHR = 1.51; 95% CI = 1.16, 1.96), and operator or laborer occupations (AHR = 1.54; 95% CI = 1.16, 1.96). Survival decreased with increasing numbers of indicators that were in the most disadvantaged decile. Community-level mortality risk persisted when we adjusted for individual-level characteristics. CONCLUSIONS The increased mortality risk among infants with CHDs living in socioeconomically deprived communities might indicate barriers to quality and timely care at which public health interventions might be targeted.
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Affiliation(s)
- James E Kucik
- James E. Kucik and Owen Devine are with the Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA. Wendy N. Nembhard is with the Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa. Pamela Donohue is with the Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD. Ying Wang is with the Bureau of Environmental and Occupational Epidemiology, Center for Environmental Health, New York State Department of Health, Albany, NY. Cynthia S. Minkovitz is with the Department of Population, Family and Reproductive Health, and Thomas Burke is with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Kucik JE, Cassell CH, Alverson CJ, Donohue P, Tanner JP, Minkovitz CS, Correia J, Burke T, Kirby RS. Role of health insurance on the survival of infants with congenital heart defects. Am J Public Health 2014; 104:e62-70. [PMID: 25033158 DOI: 10.2105/ajph.2014.301969] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the association between health insurance and survival of infants with congenital heart defects (CHDs), and whether medical insurance type contributed to racial/ethnic disparities in survival. METHODS We conducted a population-based, retrospective study on a cohort of Florida resident infants born with CHDs between 1998 and 2007. We estimated neonatal, post-neonatal, and infant survival probabilities and adjusted hazard ratios (AHRs) for individual characteristics. RESULTS Uninsured infants with critical CHDs had 3 times the mortality risk (AHR = 3.0; 95% confidence interval = 1.3, 6.9) than that in privately insured infants. Publicly insured infants had a 30% reduced mortality risk than that of privately insured infants during the neonatal period, but had a 30% increased risk in the post-neonatal period. Adjusting for insurance type reduced the Black-White disparity in mortality risk by 50%. CONCLUSIONS Racial/ethnic disparities in survival were attenuated significantly, but not eliminated, by adjusting for payer status.
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Affiliation(s)
- James E Kucik
- James E. Kucik, Cynthia H. Cassell and Clinton J. Alverson are with the Division of Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta. Pamela Donohue is with the Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD. Jean Paul Tanner and Russell S. Kirby are with the Birth Defects Surveillance Program, Department of Community and Family Health, College of Public Health, University of South Florida, Tampa. Cynthia S. Minkovitz is with the Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore. Jane Correia is with the Florida Birth Defects Registry, Bureau of Epidemiology, Division of Disease Control and Health Protection, Florida Department of Health, Tallahassee. Thomas Burke is with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
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Fixler DE, Xu P, Nembhard WN, Ethen MK, Canfield MA. Age at referral and mortality from critical congenital heart disease. Pediatrics 2014; 134:e98-105. [PMID: 24982105 DOI: 10.1542/peds.2013-2895] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Newborn pulse oximetry screening is recommended to promote early referral of neonates with critical congenital heart disease (CCHD) and reduce mortality; however, the impact of late referral on mortality is not well defined. The purpose of this population-based study was to describe the association between timing of referral to a cardiac center and mortality in 2360 liveborn neonates with CCHD. METHODS Neonates with CCHD born before pulse oximetry screening (1996-2007) were selected from the Texas Birth Defects Registry and linked to state birth and death records. Age at referral was ascertained from date of first cardiac procedure at a cardiac center. Logistic and Cox proportional hazards regression models were used to estimate factors associated with late referral and mortality; the Kaplan-Meier method was used to estimate 3-month survival. RESULTS Median age at referral was 1 day (25th-75th percentile: 0-6 days). Overall, 27.5% (649 of 2360) were referred after age 4 days and 7.5% (178 of 2360) had no record of referral. Neonatal mortality was 18.1% (277 of 1533) for those referred at 0 to 4 days of age, 9.0% (34 of 379) for those referred at 5 to 27 days of age, and 38.8% (69 of 178) for those with no referral. No improvement in age at referral was found across the 2 eras within 1996-2007. CONCLUSIONS A significant proportion of neonates with CCHD experienced late or no referral to cardiac specialty centers, accounting for a significant number of the deaths. Future population-based studies are needed to determine the benefit of pulse oximetry screening on mortality and morbidity.
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Affiliation(s)
- David E Fixler
- Division of Pediatric Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas;
| | - Ping Xu
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida; and
| | - Wendy N Nembhard
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida; and
| | - Mary K Ethen
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
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Nembhard WN, Xu P, Ethen MK, Fixler DE, Salemi JL, Canfield MA. Racial/ethnic disparities in timing of death during childhood among children with congenital heart defects. ACTA ACUST UNITED AC 2013; 97:628-40. [DOI: 10.1002/bdra.23169] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 06/27/2013] [Accepted: 07/02/2013] [Indexed: 01/21/2023]
Affiliation(s)
- Wendy N. Nembhard
- Department of Epidemiology and Biostatistics, College of Public Health; University of South Florida; Tampa; Florida
| | - Ping Xu
- Department of Epidemiology and Biostatistics, College of Public Health; University of South Florida; Tampa; Florida
| | - Mary K. Ethen
- Birth Defects Epidemiology and Surveillance Branch; Texas Department of State Health Services; Austin; Texas
| | - David E. Fixler
- Division of Cardiology, Department of Pediatrics; University of Texas Southwestern Medical Center; Dallas; Texas
| | - Jason L. Salemi
- Department of Epidemiology and Biostatistics, College of Public Health; University of South Florida; Tampa; Florida
| | - Mark A. Canfield
- Birth Defects Epidemiology and Surveillance Branch; Texas Department of State Health Services; Austin; Texas
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Racial and insurance disparities in hospital mortality for children undergoing congenital heart surgery. Pediatr Cardiol 2012; 33:1026-39. [PMID: 22349675 DOI: 10.1007/s00246-012-0221-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 01/05/2012] [Indexed: 10/14/2022]
Abstract
Many studies of racial and insurance disparities after congenital heart surgery have used limited regional data over short periods. This study examines the association of race and insurance with hospital mortality using a national hospitalization database spanning almost a decade. A retrospective, repeated cross-sectional analysis was performed. All the admissions from the Kids' Inpatient Database from 1997 through 2006 that fit a Risk Adjustment for Congenital Heart Surgery-1 category were examined. Multivariate logistic regression models examining hospital mortality, nonelective admission, and referral to high-mortality hospitals were constructed. Medicaid insurance [odds ratio (OR) 1.26, 95% confidence interval (CI) 1.09-1.46] and nonwhite race (OR 1.36, 95% CI 1.19-1.54) were independent risk factors for mortality. Furthermore, Medicaid insurance (OR 1.23, 95% CI 1.15-1.31) and nonwhite race (OR 1.26, 95% CI 1.19-1.34) were associated with nonelective admission for congenital heart surgery. Finally, children with Medicaid insurance (OR 1.18, 95% CI 1.10-1.27) and black children (OR 1.30, 95% CI 1.17-1.44) had higher odds of referral to high-mortality hospitals. Over the past decade, children undergoing congenital heart surgery continued to experience admission, referral, and survival disparities based on insurance and racial status.
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Fixler DE, Nembhard WN, Xu P, Ethen MK, Canfield MA. Effect of acculturation and distance from cardiac center on congenital heart disease mortality. Pediatrics 2012; 129:1118-24. [PMID: 22566422 DOI: 10.1542/peds.2011-3114] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Despite improvements in congenital heart disease (CHD) survival over the past 4 decades, ethnic disparities persist. Several studies have shown higher postoperative CHD adjusted mortality in black and Hispanic children. Others noted that non-English-speaking language at home was associated with appointment noncompliance, which the parents attributed to misunderstanding and living too far from a health center. The purpose of this study was to determine the effect of home distance to a cardiac center, or having a Latin American-born parent, on first-year mortality in infants with severe CHD. METHODS Infants with severe CHD, having an estimated first-year mortality >25%, born 1996-2003, were identified from the Texas Birth Defects Registry and linked to state and national vital records. We examined the effects of defect type; birth weight; gestational age; extracardiac anomalies; infant gender; maternal race/ethnicity, marital status, and education; residence in a Texas county bordering Mexico; home distance to cardiac center; and parental birth country on first-year survival. RESULTS Overall first-year survival was 59.9%, and no race/ethnic differences were noted; however, survival was significantly (P < .05) lower for Hispanic infants with hypoplastic left heart syndrome. Neither home distance to a cardiac center nor parental birth country was related to first-year survival; however, survival was noted to be lower in Texas counties bordering Mexico, counties that have high rates of poverty. CONCLUSIONS Further studies are needed to determine if these disparities in survival of infants with severe CHD are attributable to delays in referral to a cardiac center.
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Affiliation(s)
- David E Fixler
- Division of Pediatric Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Langlois PH, Marengo LK, Canfield MA. Time trends in the prevalence of birth defects in Texas 1999-2007: Real or artifactual? ACTA ACUST UNITED AC 2011; 91:902-17. [DOI: 10.1002/bdra.22847] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 06/09/2011] [Accepted: 06/15/2011] [Indexed: 11/06/2022]
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Oster ME, Strickland MJ, Mahle WT. Racial and ethnic disparities in post-operative mortality following congenital heart surgery. J Pediatr 2011; 159:222-6. [PMID: 21414631 DOI: 10.1016/j.jpeds.2011.01.060] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 12/07/2010] [Accepted: 01/27/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study assessed racial/ethnic disparities in post-operative mortality after surgery for congenital heart disease (CHD) and explored whether disparities persist after adjusting for access to care. STUDY DESIGN We used the Pediatric Health Information System database to perform a retrospective cohort study of 44,017 patients with 49,833 CHD surgery encounters in 2004-2008 at 41 children's hospitals. We used χ(2) analysis to compare unadjusted mortality rates by race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic) and constructed Poisson regression models to determine adjusted mortality risk ratios (RRs) and 95% CIs. RESULTS In-hospital post-operative mortality rate was 3.4%; non-Hispanic whites had the lowest mortality rate (2.8%), followed by non-Hispanic blacks (3.6%) and Hispanics (3.9%) (P < .0001). After adjusting for age, sex, genetic syndrome, and surgery risk category, the RR of death was 1.32 for non-Hispanic blacks (CI, 1.14-1.52) and 1.21 for Hispanics (CI, 1.07-1.37), both compared with non-Hispanic whites. After adjusting for access to care (insurance type and hospital of surgery), these estimates did not appreciably change (non-Hispanic blacks: RR, 1.27; CI, 1.09-1.47; Hispanics: RR, 1.22; CI, 1.05-1.41). CONCLUSIONS There are notable racial/ethnic disparities in post-operative mortality after CHD surgery that do not appear to be explained by differences in access to care.
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Affiliation(s)
- Matthew E Oster
- Children's Healthcare of Atlanta, Division of Pediatric Cardiology, Emory University, Sibley Heart Center, Atlanta, GA 30322, USA.
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Nembhard WN, Salemi JL, Ethen MK, Fixler DE, Dimaggio A, Canfield MA. Racial/Ethnic disparities in risk of early childhood mortality among children with congenital heart defects. Pediatrics 2011; 127:e1128-38. [PMID: 21502234 DOI: 10.1542/peds.2010-2702] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Infants with congenital heart defects (CHDs) have increased risk of childhood morbidity and mortality. However, little is known about racial/ethnic differences in early childhood mortality. PATIENTS AND METHODS We conducted a retrospective cohort study with data from the Texas Birth Defect Registry on 19 530 singleton, live-born infants with a CHD and born January 1, 1996, to December 31, 2003, to non-Hispanic (NH) white, NH black, and Hispanic women. Texas Birth Defect Registry data were linked to Texas death records and the National Death Index to ascertain deaths between January 1, 1996, and December 31, 2005. Kaplan-Meier survival estimates were computed, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated from multivariable Cox-proportional hazard regression models to determine the effect of maternal race/ethnicity on mortality for selected CHD phenotypes. RESULTS After adjusting for covariates, compared with NH white children, NH black children had increased early childhood mortality risk for transposition of the great arteries (HR: 2.04 [95% CI: 1.40-2.97]), tetralogy of Fallot (HR: 1.85 [95% CI: 1.09-3.12]), pulmonary valve atresia without ventricular septal defect (VSD) (HR: 2.60 [95% CI: 1.32-5.12]), VSD (HR: 1.56 [95% CI: 1.19-2.03]), and atrial septal defect (HR: 1.34 [95% CI: 1.08-1.66]). Hispanic children had higher mortality risk for pulmonary valve atresia without VSD (HR: 1.76 [95% CI: 1.06-2.91]) and hypoplastic left heart syndrome (HR: 1.51 [95% CI: 1.13-2.02]). CONCLUSIONS We provide evidence that supports racial/ethnic disparities in early childhood mortality among infants with CHDs. Identifying infants with the greatest risk of early childhood mortality will facilitate development of interventions and policies to mitigate these risks.
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Affiliation(s)
- Wendy N Nembhard
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL 33612-3805, USA.
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Abstract
Objectives. To determine the difference between children with private and public insurance at the time of referral to a pediatric otolaryngologist. Study Design. Prospective study. Setting. Tertiary care hospital. Subjects and Methods. Data relating to the severity of a patient’s otitis media (number of infections, doctor visits, antibiotic courses) were collected by phone interview. All patients referred to a pediatric otolaryngologist at an urban tertiary care hospital over a 5-month period were included. Results. One hundred eighty-three children were studied: 87 consecutive patients in the private third-party insurance group (PIN) and 96 patients in the state-based Medicaid insurance group (PA). During the 6 months prior to referral, children in the PIN group had a median 4 acute otitis media infections with 5 courses of oral antibiotics and 6 primary care visits compared to 3 infections with 3 courses of antibiotics and 4 primary care visits for the PA group ( P = .0009, P ≤ .0001, P = .0003, respectively). For recurrent acute otitis media, the PA group had a significantly longer time with disease prior to referral than the PIN group ( P = .0478). Conclusion. Children in this metropolitan area referred for tympanostomy tube placement with PIN are younger, have more episodes of acute otitis media, receive more antibiotic courses, and have more primary care visits in the 6 months prior to referral than their PA counterparts. Additional research is required to determine why these differences exist, especially in light of ongoing changes to the health care system.
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Affiliation(s)
- Sundip Patel
- Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - James W. Schroeder
- Department of Pediatric Surgery, Children’s Memorial Hospital, Chicago, IL, USA
- Department of Otolaryngology–Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Nembhard WN, Salemi JL, Ethen MK, Fixler DE, Canfield MA. Mortality among infants with birth defects: Joint effects of size at birth, gestational age, and maternal race/ethnicity. ACTA ACUST UNITED AC 2010; 88:728-36. [DOI: 10.1002/bdra.20696] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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16
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Skinner AC, Mayer ML. Effects of insurance status on children's access to specialty care: a systematic review of the literature. BMC Health Serv Res 2007; 7:194. [PMID: 18045482 PMCID: PMC2222624 DOI: 10.1186/1472-6963-7-194] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Accepted: 11/28/2007] [Indexed: 11/23/2022] Open
Abstract
Background The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care. Methods We conducted a systematic review of original research published between January 1, 1992 and July 31, 2006. Searches were performed using Pubmed. Results Of 30 articles identified, the majority use number of specialty visits or referrals to measure access. Uninsured children have poorer access to specialty care than insured children. Children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children. Findings on the effects of managed care are mixed. Conclusion Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.
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Affiliation(s)
- Asheley Cockrell Skinner
- Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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17
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Kowalsky RH, Newburger JW, Rand WM, Castañeda AR. Factors determining access to surgery for children with congenital cardiac disease in Guatemala, Central America. Cardiol Young 2006; 16:385-91. [PMID: 16839431 DOI: 10.1017/s1047951106000412] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2005] [Indexed: 11/06/2022]
Abstract
BACKGROUND Surgical intervention for children with congenital cardiac disease in the developing world often occurs late. Our objective was to identify factors that placed Guatemalan children at risk for delayed care. METHODS We investigated the medical and socioeconomic background of 178 children under the age of 18 years who received their first corrective surgery for congenital cardiac disease at the Unidad de Cirugía Cardiovascular de Guatemala in 2002. A retrospective review of medical records was performed. Each case was stratified into one of three surgical classes based upon customary practice in the United States of America. The outcome we measured was age at surgery, adjusting for the surgical class. Logistic regression was performed and odds ratios calculated. RESULTS In univariate analyses, patients presented later for surgery if they were from rural areas (p equals 0.001), did not have social security membership (p equals 0.004), or paid any amount towards the cost of their surgery (p less than 0.001). Age at surgery was also positively correlated with the distance of the home of the patient from the surgical centre (p equals 0.002). For the subset of patients who applied for financial assistance, we found that children presented later for surgery if they required institutional support (p equals 0.001), or came from households of larger size (p less than 0.001). CONCLUSIONS Guatemalan children with congenital cardiac disease may be at risk for delayed surgical care if they come from rural areas, areas distant from the surgical centre, or from families without membership of social security.
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Affiliation(s)
- Rachel H Kowalsky
- Morgan Stanley Children's Hospital of New York Presbyterian, New York, NY, USA.
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18
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Benavidez OJ, Gauvreau K, Jenkins KJ. Racial and ethnic disparities in mortality following congenital heart surgery. Pediatr Cardiol 2006; 27:321-8. [PMID: 16565899 DOI: 10.1007/s00246-005-7121-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Our objective was to assess risk-adjusted racial and ethnic disparities in mortality following congenital heart surgery. We studied 8483 congenital heart surgical cases from the Kids' Inpatient Database 2000. Black sub-analysis was performed using predetermined regional categories. For our Hispanic sub-analyses, we categorized Hispanics into state groups according to a state's predominant Hispanic group: West (Mexican-American), Southeast (Cuban-American), Northeast (Puerto Rican), and Mixed/Heterogeneous. Risk adjustment was performed using the Risk Adjustment for Congenital Heart Surgery method. Multivariate analyses assessed the effect of race/ethnicity and Hispanic state group on mortality and explored the effects of gender, income, insurance type, and region. Black children had a higher risk for death than Whites odds ratio (OR), [1.65; p = 0.003]. Hispanics and the Cuban-American state group showed a trend toward a higher death risk (Hispanic: OR, 1.24; p = 0.16; Southeast Cuban-American: OR 1.55; p = 0.08). Disparities were not influenced by insurance. Among Blacks, disparities were greatest in the Northeast region (OR, 2.25; p = 0.007). After adjusting for gender, income, and region, Blacks (OR, 1.76; p = 0.002) and Hispanics (OR, 1.34; p = 0.05) had a higher death risk. Racial and ethnic disparities in risk-adjusted mortality following congenital heart disease exist for Blacks and Hispanics. These disparities are not due to insurance but are partially explained by gender and region.
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Affiliation(s)
- O J Benavidez
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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19
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20
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Hadley J. Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income. Med Care Res Rev 2003; 60:3S-75S; discussion 76S-112S. [PMID: 12800687 DOI: 10.1177/1077558703254101] [Citation(s) in RCA: 281] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.
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Abstract
Care for children with congenital heart disease requires specialized services and various healthcare resources. The purpose of this article is to provide an updated overview of healthcare resources for infants and children with heart disease. In 2001, there were 1609 certified pediatric cardiologists in the United States. The ratio was approximately 45,000 children younger than 18 years per pediatric cardiologist. It is estimated that more than 19,000 cardiac surgeries are performed in children younger than 18 years in the United States each year. This article also reviews the effect of patient characteristics on access to healthcare and use of pediatric cardiac services, and discusses issues related to optimal use of these resources and the development of an organized approach toward service management by regionalization. The authors believe that improved access to high-quality facilities and providers coupled with thoughtful changes in the healthcare delivery system represent an excellent opportunity for optimizing outcomes for children with heart disease.
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Affiliation(s)
- Ruey-Kang R Chang
- Division of Cardiology, Department of Pediatrics, Mattel Children's Hospital at the University of California-Los Angeles, 90024, USA.
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22
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Chang RKR, Chen AY, Klitzner TS. Female sex as a risk factor for in-hospital mortality among children undergoing cardiac surgery. Circulation 2002; 106:1514-22. [PMID: 12234958 DOI: 10.1161/01.cir.0000029104.94858.6f] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to investigate whether sex disparity in cardiovascular outcomes exists in children who undergo cardiac surgery. METHODS AND RESULTS Statewide hospital discharge data from California from 1995 to 1997 were used. Children <21 years old who had a procedure code (by ICD9-CM) that indicated cardiac surgery were selected. The outcome variable was binary, in-hospital death versus alive at discharge. Twenty-three surgical procedures were selected and adjusted for risk by procedure type. We used logistic regression analysis to evaluate the effect of sex on in-hospital mortality, controlling for age, race and ethnicity, type of insurance, home income, type of admission, date and month of surgery, hospital case volume, and type of procedure. There were 6593 cases of cardiac surgery, with 345 in-hospital deaths (mortality rate 5.23%). Crude mortality rates for males (4.98%) and females (5.54%) were not significantly different. However, fewer females were neonates, and females had more low-risk procedures than males. Multivariate logistic regression showed that females had a higher odds ratio (OR) for mortality than males (OR 1.51, P<0.01). The OR for mortality was 3.86 for neonates and 2.98 for infants compared with children aged > or =1 year. Low-volume hospitals had higher mortality rates than high-volume hospitals (OR 1.67, P<0.01). The risk-adjusted length of hospital stay and charges were similar between females and males. CONCLUSIONS For children undergoing cardiac surgery, female sex was associated with 51% higher odds of death than male sex. The mechanism by which female sex acts as a risk factor requires further investigation.
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Affiliation(s)
- Ruey-Kang R Chang
- Division of Cardiology, Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, Calif 90509, USA.
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23
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Kuhlthau K, Ferris TG, Beal AC, Gortmaker SL, Perrin JM. Who cares for medicaid-enrolled children with chronic conditions? Pediatrics 2001; 108:906-12. [PMID: 11581443 DOI: 10.1542/peds.108.4.906] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To estimate generalist, pediatric subspecialist, and any subspecialist use by Medicaid-enrolled children with chronic conditions and to determine the correlates of use. METHODS We analyzed Medicaid claims data collected from 1989 to 1992 from 4 states for 57 328 children and adolescents with 11 chronic conditions. We calculated annual rates of generalist, subspecialist, and pediatric subspecialist use. We used logistic regression to determine the association of demographics, urban residence, and case-mix (Adjusted Clinical Groups) with the use of relevant pediatric and any subspecialist care. RESULTS Most children with chronic conditions had visits to generalists (range per condition: 78%-90% for children with Supplemental Security Income [SSI] and 85%-94% for children without SSI) during the year studied. Fewer children visited any relevant subspecialists (24%-59% for children with SSI and 13%-56% for children without SSI) or relevant pediatric subspecialists (10%-53% for children with SSI and 3%-37% for children without SSI). In general, children who were more likely to use pediatric subspecialists were younger, lived in urban areas, were white (only significant for non-SSI children), and had higher Adjusted Clinical Groups scores. Use of any subspecialists followed a similar pattern except that urban residence is statistically significant only for children with SSI and the youngest age group does not differ from the oldest age group for children without SSI. CONCLUSIONS Children who had chronic conditions and were enrolled in Medicaid received a majority of their care from generalist physicians. For most conditions, a majority of children did not receive any relevant subspecialty care during the year and many of these children did not receive care form providers with pediatric-specific training.
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Affiliation(s)
- K Kuhlthau
- Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston, MA 02114, USA.
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24
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Baron AM, Donnerstein RL, Kanter E, Meaney FJ, Goldberg SJ. Congenital heart disease in the Medicaid population of Southern Arizona. Am J Cardiol 2001; 88:462-5. [PMID: 11545781 DOI: 10.1016/s0002-9149(01)01706-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A M Baron
- Department of Pediatrics, Steele Memorial Children's Research Center, University of Arizona College of Medicine, Tucson, Arizona, USA
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25
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Miller MR, Forrest CB, Kan JS. Parental preferences for primary and specialty care collaboration in the management of teenagers with congenital heart disease. Pediatrics 2000; 106:264-9. [PMID: 10920149 DOI: 10.1542/peds.106.2.264] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We examined parental preferences for locus of service delivery for their teenager's congenital heart disease (CHD) and the influence of disease severity, sociodemographic factors, and insurance on these preferences. METHODS A consecutive sample of parents of teenagers followed in a pediatric cardiology clinic completed a mailed questionnaire. Disease severity was classified as low (</=1 cardiovascular procedure), moderate (>1 cardiovascular procedure), and high (cyanosis or single ventricle physiology). RESULTS Eighty-six of 148 parents responded (58%): 40, low severity; 36, moderate severity; and 10, high severity of illness. Parents preferred using primary care providers (PCPs) as a point of first contact for all 11 of 11 general health concerns and 5 of 7 potential cardiovascular-related concerns: chest pain (52%), syncope (73%), seeming seriously ill (79%), sports physical examination (79%), and endocarditis prophylactic antibiotics (94%). Increasing disease severity was significantly associated with preferring cardiologists for 6 of 7 cardiovascular-related concerns. Overall, 58% of parents viewed their care as a PCP-cardiologist comanagement model versus a cardiologist-dominated model. Lower family income (odds ratio [OR]: 1.5; confidence interval [CI]: 1.0-2.2) and severity of illness (OR: 2.1; CI: 1.0-4.4) were associated with a comanagement model of health care versus a cardiologist-dominated model. CONCLUSIONS This study suggests that the majority of parents of teenagers with CHD prefer to use their teenager's PCP for all routine health care needs and many cardiovascular health needs. Severity of illness and family income are positively associated with greater preference for cardiologist care.
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Affiliation(s)
- M R Miller
- Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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26
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Chang RK, Chen AY, Klitzner TS. Factors associated with age at operation for children with congenital heart disease. Pediatrics 2000; 105:1073-81. [PMID: 10790465 DOI: 10.1542/peds.105.5.1073] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Previous studies have shown that children with congenital heart disease (CHD) who live in nonurban areas or who do not have private insurance are at risk for delayed referral to a pediatric cardiologist. However, the effect of these factors on the age at which cardiac surgery is performed has not been evaluated. This study is designed to evaluate the factors that influence the age at which definitive surgical repair is performed. METHODS Data on hospital discharges for 1995 and 1996 in California were obtained from the Office of Statewide Health Planning and Development database. Children <18 years who underwent surgical repair for atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), or atrioventricular canal (AVC) were included in the study. Age at surgery was evaluated using type of CHD, gender, race, type of insurance, surgical centers, urban or rural home location, and distance between home and surgical center as independent variables. RESULTS In 1995-1996, 666 children underwent ASD closure (mean age: 5.1 years; median: 4.0 years), 582 VSD closure (mean age: 2.8; median: 1.1 years), 394 TOF repair (mean age: 1.7; median:.9 years), and 177 AVC repair (mean age: 1.1; median:.6 years). Comparing median and mean age at surgery, we found: AVC<TOF<VSD<ASD (< indicates younger than). A consistent trend for all 4 types of CHD was seen indicating that for median age at operation: private insurance<managed care<Medicaid. Gender or race had no effect on age at operation, although Asians tended to be older at surgery for all 4 types of CHD. There is a significant negative correlation between the case volume of surgical centers and median age at operation for ASD (r = -.37), VSD (r = -.49), TOF (r = -.63), and AVC (r = -.17). In addition, significant positive correlation was found between degree of urbanization of home locations (measured by population density) and median age at operation for ASD (r =.50), VSD (r =.77), and TOF (r =.18). No significant correlation was found between distance to surgical center and age at operation. CONCLUSIONS Many medical and nonmedical variables play important roles in determining age for definitive repair of CHD in children. Type of insurance, a recognized surrogate for access to care, may play an important role. In addition, centers with higher surgical case volume were more likely to operate at a younger age. Finally, children in urban areas tend to be older at the time of surgery for ASD, VSD, and TOF.
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Affiliation(s)
- R K Chang
- Division of Cardiology, Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California 90509, USA.
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