Rehospitalization Is a Major Determinant of Inpatient Care Costs in Adult Congenital Heart Disease

Health Care Usage Among Adolescents With Congenital Heart Defects at 5 Sites in the United States, 2011 to 2013

Background

We sought to characterize health care usage for adolescents with congenital heart defects (CHDs) using population‐based multisite surveillance data.

Methods and Results

Adolescents aged 11 to 18 years with ≥1 CHD‐related diagnosis code and residing in 5 US sites were identified in clinical and administrative data sources for the years 2011 to 2013. Sites linked data on all inpatient, emergency department (ED), and outpatient visits. Multivariable log‐binomial regression models including age, sex, unweighted Charlson comorbidity index, CHD severity, cardiology visits, and insurance status, were used to identify associations with inpatient, ED, and outpatient visits. Of 9626 eligible adolescents, 26.4% (n=2543) had severe CHDs and 21.4% had Charlson comorbidity index >0. At least 1 inpatient, ED, or outpatient visit was reported for 21%, 25%, and 96% of cases, respectively. Cardiology visits, cardiac imaging, cardiac procedures, and vascular procedures were reported for 38%, 73%, 10%, and 5% of cases, respectively. Inpatient, ED, and outpatient visits were consistently higher for adolescents with severe CHDs compared with nonsevere CHDs. Adolescents with severe and nonsevere CHDs had higher health care usage compared with the 2011 to 2013 general adolescent US population. Adolescents with severe CHDs versus nonsevere CHDs were twice as likely to have at least 1 inpatient visit when Charlson comorbidity index was low (Charlson comorbidity index =0). Adolescents with CHDs and public insurance, compared with private insurance, were more likely to have inpatient (adjusted prevalence ratio, 1.5 [95% CI, 1.3–1.7]) and ED (adjusted prevalence ratio, 1.6 [95% CI, 1.4–1.7]) visits.

Conclusions

High resource usage by adolescents with CHDs indicates a substantial burden of disease, especially with public insurance, severe CHDs, and more comorbidities.

Clinical Outcomes During Admissions for Heart Failure Among Adults With Congenital Heart Disease

Background

Heart failure (HF) admissions in adults with congenital heart disease (CHD) are becoming more common. We compared in‐hospital and readmission events among adults with and without CHD admitted for HF.

Methods and Results

We identified all admissions with the primary diagnosis of HF among adults in the California State Inpatient Database between January 1, 2005 and January 1, 2012. International Classification of Disease (ICD) codes identified the type of CHD lesion, comorbidities, and in‐hospital and 30‐day readmissions events. Adjusted odds ratio (AOR, 95% CI) was calculated after adjusting for admission year, age, sex, race, household income, primary payor, and Charlson comorbidity index. Of 203 759 patients admitted for HF, 539 had CHD other than atrial septal defect. Compared with patients admitted for HF without CHD, those with CHD were younger, more often male, and had fewer comorbidities as determined by Charlson comorbidity index. On multivariate analysis, CHD patients admitted for HF had higher odds of length of stay ≥7 days (AOR 2.5 [95% CI 2.0–3.1]), incident arrhythmias (AOR 2.8 [95% CI 1.7–4.5]), and in‐hospital mortality (AOR 1.9 [95% CI 1.1–3.1]). Also, CHD patients had lower odds of readmission for HF (AOR 0.6 [95% CI 0.3–0.9]), but similar odds of other 30‐day readmission events. Complex CHD patients had higher odds of length of stay ≥7 days (AOR 1.9 [95% CI 1.1–3.3]) than patients with noncomplex CHD lesions, but similar odds of all other clinical outcomes.

Conclusions

Among patients admitted with the primary diagnosis of HF in California, adults with CHD have substantially higher odds of longer length of stay, incident arrhythmias, and in‐hospital mortality compared with non‐CHD patients. These results suggest a need for HF risk stratification strategies and management protocols specific for patients with CHD.

HAND1 Loss-of-Function Mutation Causes Tetralogy of Fallot

As the most prevalent form of birth defect in humans worldwide, congenital heart disease (CHD) is responsible for substantial morbidity and is still the leading cause of birth defect-related demises. Increasing evidence demonstrates that genetic defects play an important role in the pathogenesis of CHD, and mutations in multiple genes, especially in those coding for cardiac core transcription factors, have been causally linked to various CHDs. Nevertheless, CHD is a genetically heterogeneous disease and the genetic determinants underpinning CHD in an overwhelming majority of patients remain elusive. In the current study, genomic DNA was extracted from venous blood samples of 165 unrelated patients with CHD, and the coding exons and splicing junction sites of the HAND1 gene, which encodes a basic helix-loop-helix transcription factor essential for cardiovascular development, were sequenced. As a result, a novel heterozygous mutation, p.R118C, was identified in a patient with tetralogy of Fallot (TOF). The missense mutation, which was absent in 600 referential chromosomes, altered the amino acid that was completely conserved evolutionarily. Biological assays with a dual-luciferase reporter assay system revealed that the R118C-mutant HAND1 protein had significantly reduced transcriptional activity when compared with its wild-type counterpart. Furthermore, the mutation significantly decreased the synergistic activation of a downstream target gene between HAND1 and GATA4, another cardiac core transcription factor associated with TOF. To our knowledge, this is the first report on the association of a HAND1 loss-of-function mutation with enhanced susceptibility to TOF in humans. The findings provide novel insight into the molecular etiology underlying TOF, suggesting potential implications for the improved prophylactic and therapeutic strategies for TOF.