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Ivey LC, Rodriguez FH, Shi H, Chong C, Chen J, Raskind‐Hood CL, Downing KF, Farr SL, Book WM. Positive Predictive Value of International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification, Codes for Identification of Congenital Heart Defects. J Am Heart Assoc 2023; 12:e030821. [PMID: 37548168 PMCID: PMC10492959 DOI: 10.1161/jaha.123.030821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/28/2023] [Indexed: 08/08/2023]
Abstract
Background Administrative data permit analysis of large cohorts but rely on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes that may not reflect true congenital heart defects (CHDs). Methods and Results CHDs in 1497 cases with at least 1 encounter between January 1, 2010 and December 31, 2019 in 2 health care systems, identified by at least 1 of 87 ICD-9-CM/ICD-10-CM CHD codes were validated through medical record review for the presence of CHD and CHD native anatomy. Interobserver and intraobserver reliability averaged >95%. Positive predictive value (PPV) of ICD-9-CM/ICD-10-CM codes for CHD was 68.1% (1020/1497) overall, 94.6% (123/130) for cases identified in both health care systems, 95.8% (249/260) for severe codes, 52.6% (370/703) for shunt codes, 75.9% (243/320) for valve codes, 73.5% (119/162) for shunt and valve codes, and 75.0% (39/52) for "other CHD" (7 ICD-9-CM/ICD-10-CM codes). PPV for cases with >1 unique CHD code was 85.4% (503/589) versus 56.3% (498/884) for 1 CHD code. Of cases with secundum atrial septal defect ICD-9-CM/ICD-10-CM codes 745.5/Q21.1 in isolation, PPV was 30.9% (123/398). Patent foramen ovale was present in 66.2% (316/477) of false positives. True positives had younger mean age at first encounter with a CHD code than false positives (22.4 versus 26.3 years; P=0.0017). Conclusions CHD ICD-9-CM/ICD-10-CM codes have modest PPV and may not represent true CHD cases. PPV was improved by selecting certain features, but most true cases did not have these characteristics. The development of algorithms to improve accuracy may improve accuracy of electronic health records for CHD surveillance.
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Affiliation(s)
- Lindsey C. Ivey
- Division of CardiologyEmory University School of MedicineDivision of CardiologyAtlantaGAUSA
| | - Fred H. Rodriguez
- Division of CardiologyEmory University School of MedicineDivision of CardiologyAtlantaGAUSA
- Children’s Healthcare of Atlanta CardiologyAtlantaGAUSA
| | - Haoming Shi
- Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGAUSA
| | - Cohen Chong
- Emory University Rollins School of Public HealthAtlantaGAUSA
- Now with Philadelphia College of Osteopathic MedicinePhiladelphiaPAUSA
| | | | | | - Karrie F. Downing
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGAUSA
| | - Sherry L. Farr
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGAUSA
| | - Wendy M. Book
- Division of CardiologyEmory University School of MedicineDivision of CardiologyAtlantaGAUSA
- Emory University Rollins School of Public HealthAtlantaGAUSA
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Delany DR, Chowdhury SM, Corrigan C, Buckley JR. Preoperative in-hospital mortality in neonates with critical CHD. Cardiol Young 2022; 32:1794-1800. [PMID: 34961569 PMCID: PMC9462391 DOI: 10.1017/s1047951121004996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Data regarding preoperative mortality in neonates with critical CHD are sparse and would aid patient care and family counselling. The objective of this study was to utilise a multicentre administrative dataset to report the rate of and identify risk factors for preoperative in-hospital mortality in neonates with critical CHD across US centres. STUDY DESIGN The Pediatric Health Information System database was utilised to search for newborns ≤30 days old, born 1 January 2009 to 30 June 2018, with an ICD-9/10 code for d-transposition of the great arteries, truncus arteriosus, interrupted aortic arch, or hypoplastic left heart syndrome. Preoperative in-hospital mortality was defined as patients who died prior to discharge without an ICD code for cardiac surgery or interventional catheterisation. RESULTS Overall preoperative mortality rate was at least 5.4% (690/12,739) and varied across diagnoses (d-TGA 2.9%, TA 8.3%, IAA 5.5%, and HLHS 7.3%) and centres (0-20.5%). In multivariable analysis, risk factors associated with preoperative mortality included preterm delivery (<37 weeks) (OR 2.3, 95% CI: 1.8-2.9; p < 0.01), low birth weight (<2.5 kg) (OR 3.8, 95% CI: 3.0-4.7; p < 0.01), and genetic abnormality (OR 1.6, 95% CI: 1.2-2.2; p < 0.01). Centre average surgical volume was not a significant risk factor. CONCLUSION Approximately 1 in 20 neonates with critical CHD suffered preoperative in-hospital mortality, and rates varied across diagnoses and centres. Better understanding of the factors that drive the variation (e.g. patient factors, preoperative care models, surgical timing) could help identify patient care improvement opportunities and inform conversations with families.
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Affiliation(s)
- Dennis R Delany
- Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | | | - Corinne Corrigan
- Quality Management, Medical University of South Carolina, Charleston, SC, USA
| | - Jason R Buckley
- Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
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Sarkar S, Sen R. Insights into Cardiovascular Defects and Cardiac Epigenome in the Context of COVID-19. EPIGENOMES 2022; 6:epigenomes6020013. [PMID: 35645252 PMCID: PMC9150012 DOI: 10.3390/epigenomes6020013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/30/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023] Open
Abstract
Although few in number, studies on epigenome of the heart of COVID-19 patients show that epigenetic signatures such as DNA methylation are significantly altered, leading to changes in expression of several genes. It contributes to pathogenic cardiac phenotypes of COVID-19, e.g., low heart rate, myocardial edema, and myofibrillar disarray. DNA methylation studies reveal changes which likely contribute to cardiac disease through unknown mechanisms. The incidence of severe COVID-19 disease, including hospitalization, requiring respiratory support, morbidity, and mortality, is disproportionately higher in individuals with co-morbidities. This poses unprecedented strains on the global healthcare system. While their underlying conditions make patients more susceptible to severe COVID-19 disease, strained healthcare systems, lack of adequate support, or sedentary lifestyles from ongoing lockdowns have proved detrimental to their underlying health conditions, thus pushing them to severe risk of congenital heart disease (CHD) itself. Prophylactic vaccines against COVID-19 have ushered new hope for CHD. A common connection between COVID-19 and CHD is SARS-CoV-2’s host receptor ACE2, because ACE2 regulates and protects organs, including the heart, in various ways. ACE2 is a common therapeutic target against cardiovascular disease and COVID-19 which damages organs. Hence, this review explores the above regarding CHDs, cardiovascular damage, and cardiac epigenetics, in COVID-19 patients.
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Affiliation(s)
- Shreya Sarkar
- New Brunswick Heart Centre, Saint John Regional Hospital, Saint John, NB E2L 4L2, Canada;
| | - Rwik Sen
- Active Motif, Inc., 1914 Palomar Oaks Way, Suite 150, Carlsbad, CA 92008, USA
- Correspondence:
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Karamlou T, Javorski MJ, Weiss A, Pasquali SK, Welke KF. Utility of administrative and clinical data for cardiac surgery research: A case-based approach to guide choice. J Thorac Cardiovasc Surg 2021; 162:1157-1165. [DOI: 10.1016/j.jtcvs.2020.09.135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/24/2022]
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Nomenclature for Pediatric and Congenital Cardiac Care: Unification of Clinical and Administrative Nomenclature - The 2021 International Paediatric and Congenital Cardiac Code (IPCCC) and the Eleventh Revision of the International Classification of Diseases (ICD-11). Cardiol Young 2021; 31:1057-1188. [PMID: 34323211 DOI: 10.1017/s104795112100281x] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Substantial progress has been made in the standardization of nomenclature for paediatric and congenital cardiac care. In 1936, Maude Abbott published her Atlas of Congenital Cardiac Disease, which was the first formal attempt to classify congenital heart disease. The International Paediatric and Congenital Cardiac Code (IPCCC) is now utilized worldwide and has most recently become the paediatric and congenital cardiac component of the Eleventh Revision of the International Classification of Diseases (ICD-11). The most recent publication of the IPCCC was in 2017. This manuscript provides an updated 2021 version of the IPCCC.The International Society for Nomenclature of Paediatric and Congenital Heart Disease (ISNPCHD), in collaboration with the World Health Organization (WHO), developed the paediatric and congenital cardiac nomenclature that is now within the eleventh version of the International Classification of Diseases (ICD-11). This unification of IPCCC and ICD-11 is the IPCCC ICD-11 Nomenclature and is the first time that the clinical nomenclature for paediatric and congenital cardiac care and the administrative nomenclature for paediatric and congenital cardiac care are harmonized. The resultant congenital cardiac component of ICD-11 was increased from 29 congenital cardiac codes in ICD-9 and 73 congenital cardiac codes in ICD-10 to 318 codes submitted by ISNPCHD through 2018 for incorporation into ICD-11. After these 318 terms were incorporated into ICD-11 in 2018, the WHO ICD-11 team added an additional 49 terms, some of which are acceptable legacy terms from ICD-10, while others provide greater granularity than the ISNPCHD thought was originally acceptable. Thus, the total number of paediatric and congenital cardiac terms in ICD-11 is 367. In this manuscript, we describe and review the terminology, hierarchy, and definitions of the IPCCC ICD-11 Nomenclature. This article, therefore, presents a global system of nomenclature for paediatric and congenital cardiac care that unifies clinical and administrative nomenclature.The members of ISNPCHD realize that the nomenclature published in this manuscript will continue to evolve. The version of the IPCCC that was published in 2017 has evolved and changed, and it is now replaced by this 2021 version. In the future, ISNPCHD will again publish updated versions of IPCCC, as IPCCC continues to evolve.
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Chami J, Nicholson C, Strange G, Cordina R, Celermajer DS. National and regional registries for congenital heart diseases: Strengths, weaknesses and opportunities. Int J Cardiol 2021; 338:89-94. [PMID: 33965467 DOI: 10.1016/j.ijcard.2021.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aim to establish a new and informative bi-national Registry for Congenital Heart Disease (CHD) patients in Australia and New Zealand, to document the burden of disease and clinical outcomes for patients with CHDs across the lifespan. When planning for the implementation of this Registry, we sought to evaluate the strengths and weaknesses of existing national and large regional CHD databases. METHODS We characterised 15 large multi-institutional databases of pediatric and/or adult patients with CHD, documenting the richness of their datasets, the ease of linkage to other databases, the coverage of the target cohort and the strategies utilised for quality control. RESULTS The best databases contained demographic, clinical, physical, laboratory and patient-reported data, and were linked at least to the national/regional death registry. They also employed automatic data verification and regular manual audits. Coverage ranged from around 25% of all eligible CHD cases for larger databases to near 100% for some smaller registries of patients with specific CHD lesions, such as the Australia and New Zealand Fontan Registry. CONCLUSIONS Existing national and regional CHD databases have strengths and weaknesses; few combine complete coverage with high quality and regularly audited data, across the broad range of CHDs.
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Affiliation(s)
- Jason Chami
- Sydney Medical School, University of Sydney, Camperdown, NSW 2006, Australia
| | - Calum Nicholson
- Heart Research Institute, 7 Eliza St, Newtown, NSW 2042, Australia
| | - Geoff Strange
- School of Medicine, University of Notre Dame Australia, 21 Henry St, Freemantle, WA 6160, Australia
| | - Rachael Cordina
- Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - David S Celermajer
- Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia.
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Han B, Tang Y, Qu X, Deng C, Wang X, Li J. Comparison of the 1-year survival rate in infants with congenital heart disease diagnosed by prenatal and postnatal ultrasound: A retrospective study. Medicine (Baltimore) 2021; 100:e23325. [PMID: 33530157 PMCID: PMC7850709 DOI: 10.1097/md.0000000000023325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/21/2020] [Indexed: 01/05/2023] Open
Abstract
The impact of prenatal diagnosis on the survival outcome of infants with congenital heart disease (CHD) is still unclear. This study aimed to compare the 1-year survival rate between the prenatally and postnatally diagnosed infants with CHDs.A single-center population-based retrospective cohort study was performed on data from all infants diagnosed with CHD born between January 1998 and December 2017. Among infants with isolated CHDs, the 1-year Kaplan-Meier survival probabilities for prenatal and postnatal diagnosis were estimated. Cox proportional hazard ratios were adjusted for critical CHD (CCHD) status and gestational age.A total of 424 (40 prenatally and 384 postnatally) diagnosed infants with CHDs were analyzed. Compared with non-CCHDs, infants with CCHDs were more likely to be prenatally diagnosed (55.0% vs 18.0%; P < .001). Among the 312 infants with isolated CHDs, the 1-year survival rate for the prenatally diagnosed was significantly lower than postnatally diagnosed (77.1% vs 96.1%; P < .001). For isolated CCHDs, the 1-year survival rate for the prenatally diagnosed was significantly lower than postnatally diagnosed (73.4% vs 90.0%; P < .001). The 1-year survival rate was increased with the increase of age at diagnosis. Among infants with isolated CHDs and CCHDs, the adjusted hazard ratios for 1-year mortality rates for the prenatally versus postnatally diagnosed were 2.554 (95% confidence interval [CI], 1.790, 3.654; P < .001) and 2.538 (95% CI: 1.796, 3.699; P < .001), respectively.Prenatal diagnosis is associated with lower 1-year survival rate for infants with isolated CCHDs. This could probably due to variation in the disease severity among the CCHD subtypes.
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Affiliation(s)
- Bing Han
- Department of Ultrasound, Qilu Hospital of Shandong University, Jinan
- Department of Ultrasound, Shandong Weihai Municipal Hospital
| | - Yi Tang
- Department of Ultrasound, The Affiliated Weihai Second Municipal Hospital of Qingdao University, Weihai, Shandong, China
| | - Xueling Qu
- Department of Ultrasound, Shandong Weihai Municipal Hospital
| | - Chuanjun Deng
- Department of Ultrasound, Shandong Weihai Municipal Hospital
| | - Xing Wang
- Department of Ultrasound, Shandong Weihai Municipal Hospital
| | - Jie Li
- Department of Ultrasound, Qilu Hospital of Shandong University, Jinan
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Nasr VG, Staffa SJ, Faraoni D, DiNardo JA. Trends in mortality rate in patients with congenital heart disease undergoing noncardiac surgical procedures at children's hospitals. Sci Rep 2021; 11:1543. [PMID: 33452368 PMCID: PMC7810725 DOI: 10.1038/s41598-021-81161-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/01/2021] [Indexed: 11/09/2022] Open
Abstract
Advances made in pediatric cardiology, cardiac surgery and critical care have significantly improved the survival rate of patients with congenital heart disease (CHD) leading to an increase in children with CHD presenting for noncardiac surgical procedures. This study aims (1) to describe the trend and perioperative mortality rates in patients with CHD undergoing noncardiac surgical procedures at children's hospitals over the past 5 years and (2) to describe the patient characteristics and the most common type of surgical procedures. The Pediatric Health Information System (PHIS) is an administrative database that contains inpatient, observation, and outpatient surgical data from 52 freestanding children's hospitals. Thirty-nine of the 52 hospitals submitted data on all types of patient encounters for the duration of the study from 2015 to 2019. The total numbers of non-cardiac surgical encounters among patients with history of a CHD diagnosis significantly increased each year from 38,272 in 2015 to 45,993 in 2019 (P < 0.001). Despite the increase in case numbers, there has been a significant decline in mortality rates to the most recent incidence of 1.06% in 2019. Careful patient selection and medical optimization of patients aligned with specific expertise at dedicated children's hospitals may lead to improvement in mortality rate. Future studies comparing the outcomes of patients with cardiac disease based on hospital type and volume as well as type of providers may help determine the future of care including potential need for regionalization of noncardiac care for this vulnerable patient population.
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Affiliation(s)
- Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
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Zimmerman MS, Smith AGC, Sable CA, Echko MM, Wilner LB, Olsen HE, Atalay HT, Awasthi A, Bhutta ZA, Boucher JL, Castro F, Cortesi PA, Dubey M, Fischer F, Hamidi S, Hay SI, Hoang CL, Hugo-Hamman C, Jenkins KJ, Kar A, Khalil IA, Kumar RK, Kwan GF, Mengistu DT, Mokdad AH, Naghavi M, Negesa L, Negoi I, Negoi RI, Nguyen CT, Nguyen HLT, Nguyen LH, Nguyen SH, Nguyen TH, Nixon MR, Noubiap JJ, Patel S, Peprah EK, Reiner RC, Roth GA, Temsah MH, Tovani-Palone MR, Towbin JA, Tran BX, Tran TT, Truong NT, Vos T, Vosoughi K, Weintraub RG, Weldegwergs KG, Zaidi Z, Zheleva B, Zuhlke L, Murray CJL, Martin GR, Kassebaum NJ. Global, regional, and national burden of congenital heart disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. THE LANCET. CHILD & ADOLESCENT HEALTH 2020; 4:185-200. [PMID: 31978374 PMCID: PMC7645774 DOI: 10.1016/s2352-4642(19)30402-x] [Citation(s) in RCA: 302] [Impact Index Per Article: 75.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Previous congenital heart disease estimates came from few data sources, were geographically narrow, and did not evaluate congenital heart disease throughout the life course. Completed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017, this study aimed to provide comprehensive estimates of congenital heart disease mortality, prevalence, and disability by age for 195 countries and territories from 1990 to 2017. METHODS Mortality estimates were generated for aggregate congenital heart disease and non-fatal estimates for five subcategories (single ventricle and single ventricle pathway congenital heart anomalies; severe congenital heart anomalies excluding single ventricle heart defects; critical malformations of great vessels, congenital valvular heart disease, and patent ductus arteriosus; ventricular septal defect and atrial septal defect; and other congenital heart anomalies), for 1990 through to 2017. All available global data were systematically analysed to generate congenital heart disease mortality estimates (using Cause of Death Ensemble modelling) and prevalence estimates (DisMod-MR 2·1). Systematic literature reviews of all types of congenital anomalies to capture information on prevalence, associated mortality, and long-term health outcomes on congenital heart disease informed subsequent disability estimates. FINDINGS Congenital heart disease caused 261 247 deaths (95% uncertainty interval 216 567-308 159) globally in 2017, a 34·5% decline from 1990, with 180 624 deaths (146 825-214 178) being among infants (aged <1 years). Congenital heart disease mortality rates declined with increasing Socio-demographic Index (SDI); most deaths occurred in countries in the low and low-middle SDI quintiles. The prevalence rates of congenital heart disease at birth changed little temporally or by SDI, resulting in 11 998 283 (10 958 658-13 123 888) people living with congenital heart disease globally, an 18·7% increase from 1990 to 2017, and causing a total of 589 479 (287 200-973 359) years lived with disability. INTERPRETATION Congenital heart disease is a large, rapidly emerging global problem in child health. Without the ability to substantially alter the prevalence of congenital heart disease, interventions and resources must be used to improve survival and quality of life. Our findings highlight the large global inequities in congenital heart disease and can serve as a starting point for policy changes to improve screening, treatment, and data collection. FUNDING Bill & Melinda Gates Foundation.
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10
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Tsaur S, Gleason L, Kim Y. Quality Indicator Completion Rates for Adults with Tetralogy of Fallot. Pediatr Cardiol 2018; 39:1700-1706. [PMID: 30121865 DOI: 10.1007/s00246-018-1954-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Abstract
Quality indicators for adult congenital heart disease (ACHD) were recently published due to a lack of consensus regarding delivery of care to adults with congenital heart disease (CHD). The objective of this study was to examine adherence to quality indicators for the care of patients with tetralogy of Fallot. Adults with tetralogy of Fallot seen in outpatient cardiology clinics at a tertiary care facility between July 2014 and June 2015 were included, and electronic medical records for each visit were reviewed. Completion rates for eight proposed quality indicator metrics were recorded and results for ACHD and non-ACHD cardiologists were compared. A total of 96 eligible patients completed 179 cardiology visits (134 ACHD and 45 non-ACHD). The quality indicator completion rates were over 80% for 7 of the 8 indicators. Metric 5 (cardiac magnetic resonance imaging every five years) had the lowest completion rate at 38.7%. Compared to non-ACHD cardiologists, ACHD cardiologists had higher completion rates for QRS assessment (88.1% vs. 75.6%, p = 0.04), echocardiogram by CHD expert (97.8% vs. 80.0%, p < 0.001), and infective endocarditis counseling (95.9% vs. 77.4%, p = 0.001). In this single center study, there was a wide range of quality indicator completion rates for tetralogy of Fallot. Routine cardiac MRI by an expert in CHD was identified as an area for improvement. There were significant differences in quality indicator completion between ACHD and non-ACHD cardiologists.
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Affiliation(s)
- Stephen Tsaur
- Philadelphia Adult Congenital Heart Center, Philadelphia, PA, USA. .,The Children's Hospital of Philadelphia and Penn Medicine, Philadelphia, PA, USA.
| | - Lacey Gleason
- Philadelphia Adult Congenital Heart Center, Philadelphia, PA, USA.,The Children's Hospital of Philadelphia and Penn Medicine, Philadelphia, PA, USA
| | - Yuli Kim
- Philadelphia Adult Congenital Heart Center, Philadelphia, PA, USA.,The Children's Hospital of Philadelphia and Penn Medicine, Philadelphia, PA, USA
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11
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Hill KD, Mann SD, Carboni MP, Doyle TP, Idriss SF, Janssen DF, Nicholson GT, Sathanandam S, Fleming GA. Variability in radiation dose and image quality: A comparison across fluoroscopy-system vendors, generations of equipment and institutions. Catheter Cardiovasc Interv 2018; 92:E471-E477. [PMID: 30208245 DOI: 10.1002/ccd.27793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 06/21/2018] [Accepted: 06/24/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate differences in radiation dose and image quality across institutions, fluoroscope vendors and generations of fluoroscopes for pediatric cardiac catheterization. BACKGROUND Increased recognition of the potentially harmful effects of ionizing radiation has spurred technological advances in fluoroscopes, as well as increased focus on optimizing fluoroscope performance. There is currently little understanding of variability in the dose-image quality relationship across institutions, fluoroscope vendor and/or generation of equipment. METHODS We evaluated latest generation fluoroscopes from Phillips, Siemens, GE, and Toshiba, and an older generation Phillips fluoroscope (release date 2003) at three different institutions. Radiation dose was measured using an anthropomorphic dose-assessment phantom with effective dose in mSv estimated from Monte Carlo simulations. Image quality phantom images were scored on a 12-point scale by three blinded reviewers. RESULTS Fluoroscope effective doses ranged from 0.04 to 0.14 mSv/1,000 pulses for fluoroscopy with associated composite image quality scores ranging from 8.0 ± 0.6 to 10.4 ± 1.3. For cineangiography, effective doses ranged from 0.17 to 0.57 mSv/1,000 frames with image quality scores ranging from 10.1 ± 0.3 to 11.1 ± 0.3. There was modest correlation between effective dose and image quality (r = 0.67, P = 0.006). The older generation fluoroscope delivered consistently higher doses than the newer generation systems (2.3- to 3.5-fold higher for fluoroscopy; 1.1- to 3.4-fold higher for cineangiography) without appreciable differences in image quality. CONCLUSION Technological advances have markedly improved fluoroscope performance. Comparing latest generation systems across vendors and institutions, we found variability in the dose-IQ relationship and speculate that this reflects both equipment and institutional optimization practices.
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Affiliation(s)
- Kevin D Hill
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Steve D Mann
- Clinical Imaging Physics Group, Duke University Medical Center, Durham, North Carolina
| | - Michael P Carboni
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Thomas P Doyle
- Division of Pediatric Cardiology, Department of Pediatrics at the Ann and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Salim F Idriss
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Dana F Janssen
- Division of Pediatric Cardiology, Department of Pediatrics at the Ann and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - George T Nicholson
- Division of Pediatric Cardiology, Department of Pediatrics at the Ann and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Shyam Sathanandam
- Division of Pediatric Cardiology, Department of Pediatrics, Le Bonheur Children's Hospital, Memphis
| | - Greg A Fleming
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
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12
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Glidewell J, Book W, Raskind-Hood C, Hogue C, Dunn JE, Gurvitz M, Ozonoff A, McGarry C, Van Zutphen A, Lui G, Downing K, Riehle-Colarusso T. Population-based surveillance of congenital heart defects among adolescents and adults: surveillance methodology. Birth Defects Res 2018; 110:1395-1403. [PMID: 30394691 DOI: 10.1002/bdr2.1400] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/14/2018] [Accepted: 08/27/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Improved treatment of congenital heart defects (CHDs) has increased survival of persons with CHDs; however, no U.S. population-based systems exist to assess prevalence, healthcare utilization, or longer-term outcomes among adolescents and adults with CHDs. METHODS Novel approaches identified individuals aged 11-64 years who received healthcare with ICD-9-CM codes for CHDs at three sites: Emory University in Atlanta, Georgia (EU), Massachusetts Department of Public Health (MA), New York State Department of Health (NY) between January 1, 2008 (2009 for MA) and December 31, 2010. Case-finding sources included outpatient clinics; Medicaid and other claims data; and hospital inpatient, outpatient, and emergency visit data. Supplemental information came from state vital records (EU, MA), and birth defects registries (EU, NY). Demographics and diagnostic and procedural codes were linked, de-duplicated, and shared in a de-identified dataset. Cases were categorized into one of five mutually exclusive CHD severity groups; non-cardiac comorbidity codes were grouped into broad categories. RESULTS 73,112 individuals with CHD codes in healthcare encounters were identified. Primary data source type varied: clinics (EU, NY for adolescents), claims (MA), hospital (NY for adults). There was a high rate of missing data for some variables and data varied in format and quality. Some diagnostic codes had poor specificity for CHD ascertainment. CONCLUSIONS To our knowledge, this is the first population-based, multi-site CHD surveillance among adolescents and adults in the U.S. Identification of people living with CHDs through healthcare encounters using multiple data sources was feasible, though data quality varied and linkage/de-duplication was labor-intensive.
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Affiliation(s)
- Jill Glidewell
- Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia
| | | | | | | | - Julie E Dunn
- Massachusetts Department of Public Health, Boston, Massachusetts
| | | | - Al Ozonoff
- Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Alissa Van Zutphen
- New York State Department of Health, Albany, New York.,University at Albany School of Public Health, Rensselaer, New York
| | - George Lui
- Stanford University School of Medicine, Stanford, California
| | - Karrie Downing
- Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Tiffany Riehle-Colarusso
- Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia
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13
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Steurer MA, Baer RJ, Burke E, Peyvandi S, Oltman S, Chambers CD, Norton ME, Rand L, Rajagopal S, Ryckman KK, Feuer SK, Liang L, Paynter RA, McCarthy M, Moon‐Grady AJ, Keller RL, Jelliffe‐Pawlowski LL. Effect of Fetal Growth on 1-Year Mortality in Neonates With Critical Congenital Heart Disease. J Am Heart Assoc 2018; 7:e009693. [PMID: 30371167 PMCID: PMC6201429 DOI: 10.1161/jaha.118.009693] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 06/29/2018] [Indexed: 12/21/2022]
Abstract
Background Infants with critical congenital heart disease ( CCHD ) are more likely to be small for gestational age (GA). It is unclear how this affects mortality. The authors investigated the effect of birth weight Z score on 1-year mortality separately in preterm (GA <37 weeks), early-term (GA 37-38 weeks), and full-term (GA 39-42 weeks) infants with CCHD . Methods and Results Live-born infants with CCHD and GA 22 to 42 weeks born in California 2007-2012 were included in the analysis. The primary predictor was Z score for birth weight and the primary outcome was 1-year mortality. Multivariable logistic regression was used. Results are presented as adjusted odds ratios and 95% confidence intervals ( CIs ). The authors identified 6903 infants with CCHD . For preterm and full-term infants, only a Z score for birth weight <-2 was associated with increased mortality compared with the reference group ( Z score 0-0.5, adjusted odds ratio, 2.15 [95% CI , 1.1-4.21] and adjusted odds ratio, 3.93 [95% CI , 2.32-6.68], respectively). In contrast, in early-term infants, the adjusted odds ratios for Z scores <-2, -2 to -1, and -1 to -0.5 were 3.42 (95% CI , 1.93-6.04), 1.78 (95% CI , 1.12-2.83), and 2.03 (95% CI , 1.27-3.23), respectively, versus the reference group. Conclusions GA seems to modify the effect of birth weight Z score on mortality in infants with CCHD . In preterm and full-term infants, only the most severe small-for-GA infants ( Z score <-2) were at increased risk for mortality, while, in early-term infants, the risk extended to mild to moderate small-for-GA infants ( Z score <-0.5). This information helps to identify high-risk infants and is useful for surgical planning.
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Affiliation(s)
- Martina A. Steurer
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
- California Preterm Birth InitiativeUniversity of California San FranciscoSan FranciscoCA
| | - Rebecca J. Baer
- California Preterm Birth InitiativeUniversity of California San FranciscoSan FranciscoCA
- Department of PediatricsUniversity of California San DiegoLa JollaCA
| | - Edmund Burke
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
| | - Shabnam Peyvandi
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
| | - Scott Oltman
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
- California Preterm Birth InitiativeUniversity of California San FranciscoSan FranciscoCA
| | | | - Mary E. Norton
- Department of Obstetrics, Gynecology, and Reproductive SciencesUniversity of California San FranciscoSan FranciscoCA
| | - Larry Rand
- Department of Obstetrics, Gynecology, and Reproductive SciencesUniversity of California San FranciscoSan FranciscoCA
| | - Satish Rajagopal
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
| | - Kelli K. Ryckman
- Department of EpidemiologyCollege of Public HealthUniversity of IowaIowa CityIA
| | - Sky K. Feuer
- California Preterm Birth InitiativeUniversity of California San FranciscoSan FranciscoCA
| | - Liang Liang
- Department of GeneticsStanford UniversityStanfordCA
| | - Randi A. Paynter
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
- California Preterm Birth InitiativeUniversity of California San FranciscoSan FranciscoCA
| | - Molly McCarthy
- California Preterm Birth InitiativeUniversity of California San FranciscoSan FranciscoCA
| | - Anita J. Moon‐Grady
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
| | - Roberta L. Keller
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
| | - Laura L. Jelliffe‐Pawlowski
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
- California Preterm Birth InitiativeUniversity of California San FranciscoSan FranciscoCA
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14
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Rodriguez FH, Ephrem G, Gerardin JF, Raskind-Hood C, Hogue C, Book W. The 745.5 issue in code-based, adult congenital heart disease population studies: Relevance to current and future ICD-9-CM and ICD-10-CM studies. CONGENIT HEART DIS 2017; 13:59-64. [PMID: 29266726 DOI: 10.1111/chd.12563] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 11/18/2017] [Accepted: 11/20/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Although the ICD-9-CM code 745.5 is widely used to indicate the presence of a secundum atrial septal defect (ASD), it is also used for patent foramen ovale (PFO) which is a normal variant and for "rule-out" congenital heart disease (CHD). The ICD-10-CM code Q21.1 perpetuates this issue. The objective of this study was to assess whether code 745.5 in isolation or in combination with unspecified CHD codes 746.9 or 746.89 miscodes for CHD, and if true CHD positives decrease with age. DESIGN Echocardiograms of patients with an ICD-9-CM code of 745.5 in isolation or in combination with unspecified CHD codes 746.9 or 746.89 were reviewed to validate the true incidence of an ASD. This observational, cross-sectional record review included patients between 11 and 64 years of age. RESULTS Medical charts and echocardiograms of 190 patients (47.9% males) were reviewed. The number of falsely coded patients with 745.5 (no ASD) was high (76.3%). Forty-five (23.7%) patients had a true ASD. Among the 145 patients without an ASD, 100 (52.6%) were classified as having a PFO, 37 (19.5%) had a normal non-CHD echocardiogram, and 8 (4.2%) had some other CHD anomaly. The likelihood that 745.5 coded for a true ASD was higher in children aged 11-20 (64.3%) than adults aged 21-64 years (20.6%). CONCLUSIONS This validation study demonstrates that 745.5 performed poorly across all ages. As 745.5 is widely used in population-level investigations and ICD-10-CM perpetuates the problem, future analyses utilizing CHD codes should consider separate analysis of those identified only through code 745.5.
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Affiliation(s)
- Fred H Rodriguez
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Georges Ephrem
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer F Gerardin
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cheryl Raskind-Hood
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Carol Hogue
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Wendy Book
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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15
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Nomenclature for congenital and paediatric cardiac disease: the International Paediatric and Congenital Cardiac Code (IPCCC) and the Eleventh Iteration of the International Classification of Diseases (ICD-11). Cardiol Young 2017; 27:1872-1938. [PMID: 29286277 DOI: 10.1017/s1047951117002244] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
An internationally approved and globally used classification scheme for the diagnosis of CHD has long been sought. The International Paediatric and Congenital Cardiac Code (IPCCC), which was produced and has been maintained by the International Society for Nomenclature of Paediatric and Congenital Heart Disease (the International Nomenclature Society), is used widely, but has spawned many "short list" versions that differ in content depending on the user. Thus, efforts to have a uniform identification of patients with CHD using a single up-to-date and coordinated nomenclature system continue to be thwarted, even if a common nomenclature has been used as a basis for composing various "short lists". In an attempt to solve this problem, the International Nomenclature Society has linked its efforts with those of the World Health Organization to obtain a globally accepted nomenclature tree for CHD within the 11th iteration of the International Classification of Diseases (ICD-11). The International Nomenclature Society has submitted a hierarchical nomenclature tree for CHD to the World Health Organization that is expected to serve increasingly as the "short list" for all communities interested in coding for congenital cardiology. This article reviews the history of the International Classification of Diseases and of the IPCCC, and outlines the process used in developing the ICD-11 congenital cardiac disease diagnostic list and the definitions for each term on the list. An overview of the content of the congenital heart anomaly section of the Foundation Component of ICD-11, published herein in its entirety, is also included. Future plans for the International Nomenclature Society include linking again with the World Health Organization to tackle procedural nomenclature as it relates to cardiac malformations. By doing so, the Society will continue its role in standardising nomenclature for CHD across the globe, thereby promoting research and better outcomes for fetuses, children, and adults with congenital heart anomalies.
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16
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Jantzen DW, He X, Jacobs JP, Jacobs ML, Gaies MG, Hall M, Mayer JE, Shah SS, Hirsch-Romano J, Gaynor JW, Peterson ED, Pasquali SK. The Impact of Differential Case Ascertainment in Clinical Registry Versus Administrative Data on Assessment of Resource Utilization in Pediatric Heart Surgery. World J Pediatr Congenit Heart Surg 2017; 5:398-405. [PMID: 24958042 DOI: 10.1177/2150135114534274] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/07/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Resource utilization in congenital heart surgery is typically assessed using administrative data sets. Recent analyses have called into question the accuracy of coding of cases in administrative data; however, it is unclear whether miscoding impacts assessment of associated resource use. METHODS We merged data coded within both an administrative data set and clinical registry on children undergoing heart surgery (2004-2010) at 33 hospitals. The impact of differences in coding of operations between data sets on reporting of postoperative length of stay (PLOS) and total hospital costs associated with these operations was assessed. RESULTS For each of the eight operations of varying complexity evaluated (total n = 57,797), there were differences in coding between data sets, which translated into differences in the reporting of associated resource utilization for the cases coded in either data set. There were statistically significant differences in PLOS and cost for seven of the eight operations, although most PLOS differences were relatively small with the exception of the Norwood operation and truncus repair (differences of two days, P < .001). For cost, there was a >5% difference for three of the eight operations and >10% difference for truncus repair (US$10,570; P < .01). Grouping of operations into categories of similar risk appeared to mitigate many of these differences. CONCLUSION Differences in coding of cases in administrative versus clinical registry data can translate into differences in assessment of associated PLOS and cost for certain operations. This may be minimized through evaluating larger groups of operations when using administrative data or using clinical registry data to accurately identify operations of interest.
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Affiliation(s)
- David W Jantzen
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Xia He
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jeffrey P Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G Gaies
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Matt Hall
- Children's Hospital Association, Overland Park, KS, USA
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jennifer Hirsch-Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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17
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Steurer MA, Baer RJ, Keller RL, Oltman S, Chambers CD, Norton ME, Peyvandi S, Rand L, Rajagopal S, Ryckman KK, Moon-Grady AJ, Jelliffe-Pawlowski LL. Gestational Age and Outcomes in Critical Congenital Heart Disease. Pediatrics 2017; 140:peds.2017-0999. [PMID: 28885171 DOI: 10.1542/peds.2017-0999] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is unknown how gestational age (GA) impacts neonatal morbidities in infants with critical congenital heart disease (CCHD). We aim to quantify GA-specific mortality and neonatal morbidity in infants with CCHD. METHODS Cohort study using a database linking birth certificate, infant hospital discharge, readmission, and death records, including infants 22 to 42 weeks' GA without chromosomal anomalies (2005-2012, 2 988 925 live births). The International Classification of Diseases, Ninth Revision diagnostic and procedure codes were used to define CCHD and neonatal morbidities (intraventricular hemorrhage, retinopathy, periventricular leukomalacia, chronic lung disease, necrotizing enterocolitis). Adjusted absolute risk differences (ARDs) with 95% confidence intervals (CIs) were calculated. RESULTS We identified 6903 out of 2 968 566 (0.23%) infants with CCHD. The incidence of CCHD was highest at 29 to 31 weeks' GA (0.9%) and lowest at 39 to 42 weeks (0.2%). Combined neonatal morbidity or mortality in infants with and without CCHD was 82.8% and 57.9% at <29 weeks and declined to 10.9% and 0.1% at 39 to 42 weeks' GA. In infants with CCHD, being born at 34 to 36 weeks was associated with a higher risk of death or morbidity than being born at 37 to 38 weeks (adjusted ARD 9.1%, 95% CI 5.5% to 12.7%), and being born at 37 to 38 weeks was associated with a higher risk of death or morbidity than 39 to 42 weeks (adjusted ARD 3.2%, 95% CI 1.6% to 4.9%). CONCLUSIONS Infants born with CCHD are at high risk of neonatal morbidity. Morbidity remains increased across all GA groups in comparison with infants born at 39 to 42 weeks. This substantial risk of neonatal morbidity is important to consider when caring for this patient population.
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Affiliation(s)
| | - Rebecca J Baer
- Department of Pediatrics, University of California, San Diego, La Jolla, California; and
| | | | | | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, La Jolla, California; and
| | - Mary E Norton
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | | | - Larry Rand
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | | | - Kelli K Ryckman
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
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18
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Parikh LI, Grantz KL, Iqbal SN, Huang CC, Landy HJ, Fries MH, Reddy UM. Neonatal outcomes in fetuses with cardiac anomalies and the impact of delivery route. Am J Obstet Gynecol 2017; 217:469.e1-469.e12. [PMID: 28578168 DOI: 10.1016/j.ajog.2017.05.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/14/2017] [Accepted: 05/22/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown. OBJECTIVE We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity. STUDY DESIGN Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use. RESULTS Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85-3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77-1.27) cardiac anomalies. CONCLUSION Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.
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19
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Li M, Xue L, Zhu HY, Wang H, Xu X, Zhang PA, Wu G, Xu GY. Protein Kinase C Mediates the Corticosterone-induced Sensitization of Dorsal Root Ganglion Neurons Innervating the Rat Stomach. J Neurogastroenterol Motil 2017; 23:464-476. [PMID: 28343377 PMCID: PMC5503297 DOI: 10.5056/jnm16161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/31/2016] [Accepted: 01/15/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Gastric hypersensitivity contributes to abdominal pain in patients with functional dyspepsia. Recent studies showed that hormones induced by stress are correlated with visceral hypersensitivity. However, the precise mechanisms underlying gastric hypersensitivity remain largely unknown. The aim of the present study was designed to investigate the roles of corticosterone (CORT) on excitability of dorsal root ganglion (DRG) neurons innervating the stomach. METHODS DRG neurons innervating the stomach were labeled by DiI injection into the stomach wall. Patch clamp recordings were employed to examine neural excitability and voltage-gated sodium channel currents. Electromyograph technique was used to determine the responses of neck muscles to gastric distension. RESULTS Incubation of acutely isolated DRG neurons with CORT significantly depolarized action potential threshold and enhanced the number of action potentials induced by current stimulation of the neuron. Under voltage-clamp mode, incubation of CORT enhanced voltage-gated sodium current density of the recorded neurons. Pre-incubation of GF109203X, an inhibitor of protein kinase C, blocked the CORT-induced hyperexcitability and potentiation of sodium currents. However, pre-incubation of H-89, an inhibitor of protein kinase A, did not alter the sodium current density. More importantly, intraperitoneal injection of CORT produced gastric hypersensitivity of healthy rats, which was blocked by pre-administration of GF109203X but not H-89. CONCLUSIONS Our data strongly suggest that CORT rapidly enhanced neuronal excitability and sodium channel functions, which is most likely mediated by protein kinase C but not protein kinase A signaling pathway in DRG neurons innervating the stomach, thus underlying the gastric hypersensitivity induced by CORT injection.
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Affiliation(s)
| | | | | | | | | | | | | | - Guang-Yin Xu
- Correspondence: Guang-Yin Xu, MD, PhD, Jiangsu Key Laboratory of Translational Research and Therapy for Neuro-Psycho-Diseases, Institute of Neuroscience, Soochow University, 199 Ren-Ai Road, Suzhou 215123, China, Tel: +86-512-6588-2817, Fax: +86-512-6588-3602, E-mail:
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20
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Steurer MA, Norton ME, Baer RJ, Shaw GM, Keating S, Moon-Grady AJ, Chambers CD, Jelliffe-Pawlowski LL. The association of maternal lymphatic markers and critical congenital heart defects in the fetus-A population based case-control study. Am J Med Genet A 2017; 173:1231-1236. [PMID: 28323386 DOI: 10.1002/ajmg.a.38152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/30/2016] [Accepted: 01/02/2017] [Indexed: 11/06/2022]
Abstract
The objective ot this study was to investigate whether lymphatic markers measured in women during the second trimester are associated with critical congenital heart defects (CCHDs) in offspring. This is a retrospective cohort study of pregnant women who participated in the California Prenatal Screening Program. CCHD data in the offspring was captured by linking birth certificate data with hospital patient discharge records. Second trimester samples were assayed for vascular endothelial growth factor (VEGF), platelet derived growth factor (PDGF) AA/BB, and PDGF AB. Logistic models were used to evaluate the association between lymphatic biomarkers and CCHD. Models were adjusted for other serum biomarkers and maternal characteristics. Results are presented in odds ratios (OR) with 95% confidence intervals (CI). We identified 93 cases with CCHDs and 194 controls without CCHDs. The crude and adjusted OR for log (ln) VEGF was 1.07 (95%CI 0.94-1.22) and 1.08 (95%CI 0.94-1.24), respectively; for ln PDGF AB/BB was 0.93 (95%CI 0.6-1.35) and 0.58 (95%CI 0.32-1.05), respectively. There was a significant association between ln PDFG AA and CCHDs (crude OR 1.83 (95%CI 1.05-3.2); adjusted OR 2.41 (95%CI 1.06-5.44)). Levels of circulating PDGF AA were highest in cases with hypoplastic left heart syndrome (HLHS) (mean 8.78 +/- 1.54 pg/ml). In this study, increased mid-pregnancy maternal serum levels of PDGF AA were associated with CCHDs in offspring. The highest PDGF AA levels were found in mothers of fetuses with HLHS. These findings may be useful in screening for CCHDs and offer insight into their association with nuchal translucency.
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Affiliation(s)
- Martina A Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Rebecca J Baer
- Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Gary M Shaw
- Department of Pediatrics, Stanford University, Stanford, California
| | - Sheila Keating
- Blood Systems Research Institute, San Francisco, California
| | - Anita J Moon-Grady
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Christina D Chambers
- Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Laura L Jelliffe-Pawlowski
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
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21
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Friedman D, Fryzek J, Jiang X, Bloomfield A, Ambrose CS, Wong PC. Respiratory syncytial virus hospitalization risk in the second year of life by specific congenital heart disease diagnoses. PLoS One 2017; 12:e0172512. [PMID: 28253361 PMCID: PMC5333829 DOI: 10.1371/journal.pone.0172512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 02/05/2017] [Indexed: 11/19/2022] Open
Abstract
Children with hemodynamically significant congenital heart disease (CHD) are at elevated risk of morbidity and mortality due to respiratory syncytial virus (RSV) disease compared to their healthy peers. Previous studies have demonstrated lower RSV hospitalization risk among all children with CHD at 12-23 months of age versus 0-11 months of age. However, RSV hospitalization risk at 12-23 months of age by specific CHD diagnosis has not been characterized. Both case-control and cohort studies were conducted using data from the US National Inpatient Sample from 1997 to 2013 to characterize relative risk of RSV hospitalization among children 12-23 months of age with CHD. Related CHD diagnoses were combined for analysis. Hospitalizations for RSV and unspecified bronchiolitis were described by length of stay, mechanical ventilation use, mortality, and total charges. Over the 17-year period, 1,168,886 live birth hospitalizations with CHD were identified. Multiple specific CHD conditions had an elevated odds ratio or relative risk of RSV hospitalization. Mean total RSV hospitalization charges were significantly higher among children with CHD relative to those without CHD ($19,650 vs $7,939 in 2015 dollars) for this period. Compared to children without CHD, children with Ebstein's anomaly, transposition of the great arteries, aortic stenosis, heterotaxia, and aortic arch anomalies had 367-, 344-, 203-, 117- and 47-fold increased risk of inpatient RSV mortality, respectively. Unspecified bronchiolitis hospitalization odds and relative risk across CHD diagnoses were similar to those observed with RSV hospitalization; however, unspecified bronchiolitis hospitalizations were associated with shorter mean days of stay and less frequently associated with mechanical ventilation or mortality. Among children with more severe CHD diagnoses, RSV disease remains an important health risk through the second year of life. These data can help inform decisions regarding interventions to protect children with CHD from severe RSV disease during their second year of life.
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Affiliation(s)
- Deborah Friedman
- Department of Pediatrics, New York Medical College, Valhalla, NY, United States of America
- * E-mail: (DF); (AB)
| | - Jon Fryzek
- EpidStat Institute, Rockville, MD, United States of America
| | - Xiaohui Jiang
- EpidStat Institute, Rockville, MD, United States of America
| | - Adam Bloomfield
- AstraZeneca, Gaithersburg, MD, United States of America
- * E-mail: (DF); (AB)
| | | | - Pierre C. Wong
- Division of Cardiology, Children's Hospital, Los Angeles, CA, United States of America
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22
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Jacobs JP, Mayer JE, Mavroudis C, O’Brien SM, Austin EH, Pasquali SK, Hill KD, Overman DM, St. Louis JD, Karamlou T, Pizarro C, Hirsch-Romano JC, McDonald D, Han JM, Becker S, Tchervenkov CI, Lacour-Gayet F, Backer CL, Fraser CD, Tweddell JS, Elliott MJ, Walters H, Jonas RA, Prager RL, Shahian DM, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on Outcomes and Quality. Ann Thorac Surg 2017; 103:699-709. [DOI: 10.1016/j.athoracsur.2017.01.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/08/2017] [Accepted: 01/10/2017] [Indexed: 11/16/2022]
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Oster ME, Watkins S, Hill KD, Knight JH, Meyer RE. Academic Outcomes in Children With Congenital Heart Defects: A Population-Based Cohort Study. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003074. [PMID: 28228450 DOI: 10.1161/circoutcomes.116.003074] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 01/13/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Most studies evaluating neurocognitive outcomes in children with congenital heart defects (CHD) have focused on high-risk patients or used specialized, resource-intensive testing. To determine the association of CHD with academic outcomes and compare outcomes according to the severity of CHD, we linked state educational records with a birth defects registry and birth certificates. METHODS AND RESULTS We performed a retrospective cohort study using data from the North Carolina Birth Defects Monitoring Program, North Carolina Department of Public Instruction, and North Carolina Department of Health and Human Services vital records. We performed logistic regression, adjusting for maternal education, race/ethnicity, enrollment in public pre-Kindergarten, and gestational age, to determine the association of CHD with not meeting standards on reading and math end-of-grade examinations in third grade in 2006 to 2012. Of 5624 subjects with CHD and 10 832 with no structural birth defects, 2807 (50%) and 6355 (59%) were linked, respectively. Children with CHD had 1.24× the odds of not meeting standards in either reading or math (95% confidence interval, 1.12-1.37), with 44.6% of children with CHD not meeting standards in at least one of these areas compared with 37.5% without CHD. Although children with both critical and noncritical CHD had poorer outcomes, those with critical CHD were significantly more likely to receive exceptional services compared with the noncritical group (adjusted odds ratio, 1.46; 95% confidence interval, 1.15-1.86). CONCLUSIONS Children with all types of CHD have poorer academic outcomes compared with their peers. Evaluation for exceptional services should be considered in children with any type of CHD.
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Affiliation(s)
- Matthew E Oster
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.).
| | - Stephanie Watkins
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.)
| | - Kevin D Hill
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.)
| | - Jessica H Knight
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.)
| | - Robert E Meyer
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.)
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24
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Wright JM, Evans A, Kaufman JA, Rivera-Núñez Z, Narotsky MG. Disinfection By-Product Exposures and the Risk of Specific Cardiac Birth Defects. ENVIRONMENTAL HEALTH PERSPECTIVES 2017; 125:269-277. [PMID: 27518881 PMCID: PMC5289901 DOI: 10.1289/ehp103] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/02/2016] [Accepted: 07/14/2016] [Indexed: 05/19/2023]
Abstract
BACKGROUND Epidemiological studies suggest that women exposed to disinfection by-products (DBPs) have an increased risk of delivering babies with cardiovascular defects (CVDs). OBJECTIVE We examined nine CVDs in relation to categorical DBP exposures including bromoform, chloroform, dibromochloromethane (DBCM), bromodichloromethane (BDCM), monobromoacetic acid (MBAA), dichloroacetic acid (DCAA), trichloroacetic acid (TCAA), and summary DBP measures (HAA5, THMBr, THM4, and DBP9). METHODS We calculated adjusted odds ratios (aORs) in a case-control study of birth defects in Massachusetts with complete quarterly 1999-2004 trihalomethane (THM) and haloacetic acid (HAA) data. We randomly matched 10 controls each to 904 CVD cases based on week of conception. Weight-averaged aggregate first-trimester DBP exposures were assigned to individuals based on residence at birth. RESULTS We detected associations for tetralogy of Fallot and the upper exposure categories for TCAA, DCAA, and HAA5 (aOR range, 3.34-6.51) including positive exposure-response relationships for DCAA and HAA5. aORs consistent in magnitude were detected between atrial septal defects and bromoform (aOR = 1.56; 95% CI: 1.01, 2.43), as well as DBCM, chloroform, and THM4 (aOR range, 1.26-1.67). Ventricular septal defects (VSDs) were associated with the highest bromoform (aOR = 1.85; 95% CI: 1.20, 2.83), MBAA (aOR = 1.81; 95% CI: 0.85, 3.84), and DBCM (aOR = 1.54; 95% CI: 1.00, 2.37) exposure categories. CONCLUSIONS To our knowledge, this is the first birth defect study to develop multi-DBP adjusted regression models as well as the first CVD study to evaluate HAA exposures and the second to evaluate bromoform exposures. Our findings, therefore, inform exposure specificity for the consistent associations previously reported between THM4 and CVDs including VSDs. Citation: Wright JM, Evans A, Kaufman JA, Rivera-Núñez Z, Narotsky MG. 2017. Disinfection by-product exposures and the risk of specific cardiac birth defects. Environ Health Perspect 125:269-277; http://dx.doi.org/10.1289/EHP103.
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Affiliation(s)
- J. Michael Wright
- National Center for Environmental Assessment (NCEA), Office of Research and Development (ORD), U.S. Environmental Protection Agency (EPA), Cincinnati, Ohio, USA
- Address correspondence to J.M. Wright, U.S. EPA, National Center for Environmental Assessment, 26 W. Martin Luther King Dr. (MS-A110), Cincinnati, OH 45268 USA. Telephone: (513) 569-7922. E-mail:
| | - Amanda Evans
- School of Osteopathic Medicine, Campbell University, Lillington, North Carolina, USA
| | - John A. Kaufman
- ASPPH/EPA Environmental Health Fellowship Program, hosted by NCEA, ORD, U.S. EPA, Cincinnati, Ohio, USA
| | - Zorimar Rivera-Núñez
- Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Michael G. Narotsky
- National Health and Environmental Effects Research Laboratory, ORD, U.S. EPA, Research Triangle Park, North Carolina, USA
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25
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Riehle-Colarusso TJ, Bergersen L, Broberg CS, Cassell CH, Gray DT, Grosse SD, Jacobs JP, Jacobs ML, Kirby RS, Kochilas L, Krishnaswamy A, Marelli A, Pasquali SK, Wood T, Oster ME. Databases for Congenital Heart Defect Public Health Studies Across the Lifespan. J Am Heart Assoc 2016; 5:JAHA.116.004148. [PMID: 27912209 PMCID: PMC5210337 DOI: 10.1161/jaha.116.004148] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tiffany J Riehle-Colarusso
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lisa Bergersen
- Department of Cardiology, Harvard Medical School, Children's Hospital of Boston, MA
| | - Craig S Broberg
- Adult Congenital Heart Program, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR
| | - Cynthia H Cassell
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Darryl T Gray
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, MD
| | - Scott D Grosse
- Office of the Director, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, FL.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Marshall L Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, FL.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Russell S Kirby
- Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, FL
| | - Lazaros Kochilas
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Asha Krishnaswamy
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Arianne Marelli
- McGill Adult Unit for Congenital Heart Disease, Montreal, Québec, Canada
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Thalia Wood
- Association of Public Health Laboratories, Silver Spring, MD
| | - Matthew E Oster
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA.,Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
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26
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Ooi YK, Kelleman M, Ehrlich A, Glanville M, Porter A, Kim D, Kogon B, Oster ME. Transcatheter Versus Surgical Closure of Atrial Septal Defects in Children: A Value Comparison. JACC Cardiovasc Interv 2016; 9:79-86. [PMID: 26762915 DOI: 10.1016/j.jcin.2015.09.028] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/04/2015] [Accepted: 09/08/2015] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether a transcatheter procedure or surgical closure offers a better value proposition for atrial septal defect (ASD) closure. BACKGROUND Secundum ASDs are common congenital heart defects with both transcatheter and surgical treatment options. Although both options have been shown to have excellent results in children, the relative value of the 2 procedures is unclear. METHODS Using data from the Pediatric Hospital Information System for 2004 to 2012, we compared the value of transcatheter versus surgical ASD closure for children ages 1 to 17 years, with value being defined as outcomes relative to costs. Total charges for procedure-related encounters were converted to costs using hospital-specific cost-to-charge ratios, and all costs were adjusted for inflation to reflect 2012 dollars. RESULTS There were 4,606 transcatheter procedures and 3,159 surgeries at 35 children's hospitals. Those undergoing transcatheter closure were more likely to be older (5.6 years vs. 4.5 years, p < 0.0001). There was no mortality in either group. Children with a surgical procedure had a longer length of stay (4.0 days vs. 1.5 days, p < 0.0001), were more likely to have an infection (odds ratio: 3.73, p < 0.0001) or procedural complication (odds ratio: 6.66, p < 0.0001). Costs for transcatheter procedure encounters were lower than costs for surgical encounters (mean of $19,128 vs. $25,359, p < 0.0001). CONCLUSIONS Both transcatheter and surgical ASD closure had excellent short-term outcomes, but transcatheter procedures had lower lengths of stay, rates of infection, and complications, resulting in lower overall costs. For children who are eligible, transcatheter ASD closure provides better short-term value than surgery.
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Affiliation(s)
- Yinn Khurn Ooi
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
| | - Michael Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Alexandra Ehrlich
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michelle Glanville
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Arlene Porter
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Dennis Kim
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Brian Kogon
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew E Oster
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
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27
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Pasquali SK. Transforming Data Into Information. World J Pediatr Congenit Heart Surg 2016; 7:178-9. [PMID: 26957400 DOI: 10.1177/2150135115627652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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28
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Jacobs ML, Jacobs JP, Pasquali SK, Hill KD, Hornik C, O'Brien SM, Shahian DM, Habib RH, Edwards FH. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2016 Update on Research. Ann Thorac Surg 2016; 102:688-695. [PMID: 27492669 DOI: 10.1016/j.athoracsur.2016.07.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/06/2016] [Accepted: 07/11/2016] [Indexed: 11/29/2022]
Abstract
The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) is the largest congenital and pediatric cardiac surgical clinical data registry in the world. With more than 400,000 total operations from nearly all centers performing pediatric and congenital heart operations in North America, the STS CHSD is an unparalleled platform for clinical investigation, outcomes research, and quality improvement activities in this subspecialty. In 2015, several major original publications reported analyses of data in the CHSD pertaining to specific diagnostic and procedural groups, age-defined cohorts, or the entire population of patients in the database. Additional publications reported the most recent development, evaluation, and application of metrics for quality measurement and reporting of pediatric and congenital heart operation outcomes. This use of the STS CHSD for outcomes research and for quality measurement continues to expand as database participation and the available wealth of data in it continue to grow. This article reviews outcomes research and quality improvement articles published in 2015 based on STS CHSD data.
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Affiliation(s)
- Marshall L Jacobs
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland; Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, Florida
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kevin D Hill
- Duke University School of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Christoph Hornik
- Duke University School of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Sean M O'Brien
- Duke University School of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - David M Shahian
- Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - Fred H Edwards
- Division of Cardiothoracic Surgery, University of Florida, Jacksonville, Florida
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29
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Landis BJ, Ware SM. The Current Landscape of Genetic Testing in Cardiovascular Malformations: Opportunities and Challenges. Front Cardiovasc Med 2016; 3:22. [PMID: 27504451 PMCID: PMC4959014 DOI: 10.3389/fcvm.2016.00022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/30/2016] [Indexed: 12/21/2022] Open
Abstract
Human cardiovascular malformations (CVMs) frequently have a genetic contribution. Through the application of novel technologies, such as next-generation sequencing, DNA sequence variants associated with CVMs are being identified at a rapid pace. While clinicians are now able to offer testing with NGS gene panels or whole exome sequencing to any patient with a CVM, the interpretation of genetic variation remains problematic. Variable phenotypic expression, reduced penetrance, inconsistent phenotyping methods, and the lack of high-throughput functional testing of variants contribute to these challenges. This article elaborates critical issues that impact the decision to broadly implement clinical molecular genetic testing in CVMs. Major benefits of testing include establishing a genetic diagnosis, facilitating cost-effective screening of family members who may have subclinical disease, predicting recurrence risk in offsprings, enabling early diagnosis and anticipatory management of CV and non-CV disease phenotypes, predicting long-term outcomes, and facilitating the development of novel therapies aimed at disease improvement or prevention. Limitations include financial cost, psychosocial cost, and ambiguity of interpretation of results. Multiplex families and patients with syndromic features are two groups where disease causation could potentially be firmly established. However, these account for the minority of the overall CVM population, and there is increasing recognition that genotypes previously associated with syndromes also exist in patients who lack non-CV findings. In all circumstances, ongoing dialog between cardiologists and clinical geneticists will be needed to accurately interpret genetic testing and improve these patients’ health. This may be most effectively implemented by the creation and support of CV genetics services at centers committed to pursuing testing for patients.
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Affiliation(s)
- Benjamin J Landis
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stephanie M Ware
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
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30
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Jacobs JP, Mayer JE, Mavroudis C, O'Brien SM, Austin EH, Pasquali SK, Hill KD, He X, Overman DM, St Louis JD, Karamlou T, Pizarro C, Hirsch-Romano JC, McDonald D, Han JM, Dokholyan RS, Tchervenkov CI, Lacour-Gayet F, Backer CL, Fraser CD, Tweddell JS, Elliott MJ, Walters H, Jonas RA, Prager RL, Shahian DM, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2016 Update on Outcomes and Quality. Ann Thorac Surg 2016; 101:850-62. [PMID: 26897186 DOI: 10.1016/j.athoracsur.2016.01.057] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/09/2016] [Accepted: 01/12/2016] [Indexed: 11/19/2022]
Abstract
The Society of Thoracic Surgeons Congenital Heart Surgery Database is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and the improvement of quality in this subspecialty. This article summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency. The reported data about aggregate national outcomes are exemplified by an analysis of 10 benchmark operations performed from January 2011 to December 2014 and documenting overall discharge mortality (interquartile range among programs with more than 9 cases): off-bypass coarctation, 1.0% (0.0% to 0.9%); ventricular septal defect repair, 0.7% (0.0% to 1.1%); tetralogy of Fallot repair, 1.0% (0.0% to 1.7%); complete atrioventricular canal repair, 3.2% (0.0% to 6.5%); arterial switch operation, 2.7% (0.0% to 5.6%); arterial switch operation plus ventricular septal defect, 5.3% (0.0% to 6.7%); Glenn/hemiFontan, 2.1% (0.0% to 3.8%); Fontan operation, 1.4% (0.0% to 2.4%); truncus arteriosus repair, 9.6% (0.0 % to 11.8%); and Norwood procedure, 15.6% (10.0% to 21.4%).
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Affiliation(s)
- Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, and Orlando, Florida.
| | - John E Mayer
- Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - Constantine Mavroudis
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, and Orlando, Florida
| | | | - Erle H Austin
- Kosair Children's Hospital, University of Louisville, Louisville, Kentucky
| | - Sara K Pasquali
- C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | - Xia He
- Duke University, Durham, North Carolina
| | - David M Overman
- The Children's Heart Clinic at Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - James D St Louis
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | | | | | | | - Jane M Han
- The Society of Thoracic Surgeons, Chicago, Illinois
| | | | | | | | - Carl L Backer
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Charles D Fraser
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - James S Tweddell
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Martin J Elliott
- The Great Ormond Street Hospital, London, England, United Kingdom
| | - Hal Walters
- Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan
| | | | | | - David M Shahian
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, and Orlando, Florida
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31
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Balekian DS, Linnemann RW, Castro VM, Perlis R, Thadhani R, Camargo CA. Pre-birth cohort study of atopic dermatitis and severe bronchiolitis during infancy. Pediatr Allergy Immunol 2016; 27:413-8. [PMID: 26766307 PMCID: PMC10983116 DOI: 10.1111/pai.12532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infants hospitalized for bronchiolitis (i.e. severe bronchiolitis) are at increased risk of childhood asthma. There are many known risk factors for severe bronchiolitis, including cardiac and pulmonary diseases. Less is known about the association between atopic diseases and risk of severe bronchiolitis. We sought to further examine risk factors for severe bronchiolitis, focusing on atopic dermatitis (AD). METHODS We conducted a nested cohort study within the Massachusetts General Hospital Obstetric Maternal Study (MOMS), a prospective cohort of pregnant women enrolled during 1998-2006. Children of mothers enrolled in MOMS were included in the analysis if they received care within our health system (n = 5407). Potential risk factors for bronchiolitis and hospitalization data were extracted from the children's electronic health records; we also examined pregnancy and perinatal risk factors collected from the underlying MOMS data. RESULTS During the first year of life, 125 infants (2.3%) had severe bronchiolitis. Eighteen of these patients had AD; 11 (61%) were diagnosed with AD prior to bronchiolitis hospitalization. In unadjusted analyses, AD was associated with severe bronchiolitis (χ(2) 14.6; p < 0.001). In multivariable analyses adjusting for nine known risk factors for severe bronchiolitis, including demographics, birth season, disposition at birth, cardiac disease, maternal parity, and delivery mode, AD was associated with increased odds of severe bronchiolitis (odds ratio 2.72, 95% confidence interval 1.60-4.63). CONCLUSIONS Atopic dermatitis is significantly associated with severe bronchiolitis in infancy. The mechanism of the AD-bronchiolitis association is unclear and merits further study; this research may shed light on the pathogenesis of asthma.
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Affiliation(s)
- Diana S. Balekian
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rachel W. Linnemann
- Harvard Medical School, Boston, MA, USA
- Division of Pediatric Pulmonology, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Victor M. Castro
- Research Information Systems and Computing, Partners HealthCare System, Boston, MA, USA
- Department of Neurology, Laboratory of Computer Science, Massachusetts General Hospital, Boston, MA, USA
| | - Roy Perlis
- Center for Experimental Drugs and Diagnostics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Thadhani
- Harvard Medical School, Boston, MA, USA
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Carlos A. Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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da Cruz EM, Tabbutt S, Eisenhaur MC, Jacobs JP, Graham EM, Smith LC, Simsic J, Laussen PC. Confessions of PCICU Leaders: Tales From the Past, Lessons for the Future. World J Pediatr Congenit Heart Surg 2016; 6:556-64. [PMID: 26467870 DOI: 10.1177/2150135115596440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pediatric cardiac intensive care environment is challenging and unpredictable due to the heterogeneous patient population. Leadership within this complex environment is critical for optimal outcomes. METHODS The 10th International Meeting of the Pediatric Cardiac Intensive Care Society provided a forum for leaders to share their own practice and experience that concluded with take-home messages regarding quality, safety, clinical effectiveness, stewardship, and leadership. RESULTS Presentations defined vital aspects for successful outcomes and highlighted ongoing challenges. CONCLUSIONS Accomplishing exceptional outcomes requires a blend of clinical expertise, leadership, communication skills with briefing and debriefing, meaningful use of data, and transparency among peers and toward patients and their families.
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Affiliation(s)
- Eduardo M da Cruz
- Children's Hospital Colorado Heart Institute, University of Colorado Denver, School of Medicine, Aurora, CO, USA
| | - Sarah Tabbutt
- University of California San Francisco Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA, USA
| | | | - Jeffrey P Jacobs
- Johns Hopkins All Children's Heart Institute, Johns Hopkins University, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Eric M Graham
- The Children's Heart Program of South Carolina, Medical University of South Carolina, Charleston, SC, USA
| | - Liz C Smith
- Great Ormond Street Hospital for Sick Children, London, United Kingdom
| | - Janet Simsic
- The Heart Center at Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Peter C Laussen
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Jenkins KJ, Koch Kupiec J, Owens PL, Romano PS, Geppert JJ, Gauvreau K. Development and Validation of an Agency for Healthcare Research and Quality Indicator for Mortality After Congenital Heart Surgery Harmonized With Risk Adjustment for Congenital Heart Surgery (RACHS-1) Methodology. J Am Heart Assoc 2016; 5:e003028. [PMID: 27207997 PMCID: PMC4889177 DOI: 10.1161/jaha.115.003028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/23/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The National Quality Forum previously approved a quality indicator for mortality after congenital heart surgery developed by the Agency for Healthcare Research and Quality (AHRQ). Several parameters of the validated Risk Adjustment for Congenital Heart Surgery (RACHS-1) method were included, but others differed. As part of the National Quality Forum endorsement maintenance process, developers were asked to harmonize the 2 methodologies. METHODS AND RESULTS Parameters that were identical between the 2 methods were retained. AHRQ's Healthcare Cost and Utilization Project State Inpatient Databases (SID) 2008 were used to select optimal parameters where differences existed, with a goal to maximize model performance and face validity. Inclusion criteria were not changed and included all discharges for patients <18 years with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for congenital heart surgery or nonspecific heart surgery combined with congenital heart disease diagnosis codes. The final model includes procedure risk group, age (0-28 days, 29-90 days, 91-364 days, 1-17 years), low birth weight (500-2499 g), other congenital anomalies (Clinical Classifications Software 217, except for 758.xx), multiple procedures, and transfer-in status. Among 17 945 eligible cases in the SID 2008, the c statistic for model performance was 0.82. In the SID 2013 validation data set, the c statistic was 0.82. Risk-adjusted mortality rates by center ranged from 0.9% to 4.1% (5th-95th percentile). CONCLUSIONS Congenital heart surgery programs can now obtain national benchmarking reports by applying AHRQ Quality Indicator software to hospital administrative data, based on the harmonized RACHS-1 method, with high discrimination and face validity.
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Affiliation(s)
| | | | - Pamela L Owens
- Agency for Healthcare Research and Quality, Rockville, MD
| | - Patrick S Romano
- University of California Davis School of Medicine, Sacramento, CA
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Vendetti N, Gerber JS, Sammons JS, Fisher BT, Zaoutis TE, Coffin SE. Administration of Palivizumab in the NICU. Hosp Pediatr 2016; 6:354-8. [PMID: 27164941 DOI: 10.1542/hpeds.2015-0238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The American Academy of Pediatrics recommends palivizumab prophylaxis against respiratory syncytial virus (RSV) for infants at high risk for severe disease within 72 hours of hospital discharge to prevent community-associated RSV. The American Academy of Pediatrics does not recommend palivizumab to prevent health care-associated RSV (HA-RSV). METHODS A retrospective, multicenter cohort of hospitalized infants who received nondischarge palivizumab (NDP) between January 2009 and December 2013 was established from 14 hospitals. NDP was defined as a charge for palivizumab >7 days before hospital discharge and no previous documented RSV. Infants were considered high risk for severe disease if they had chronic lung disease, chronic heart disease, or prematurity. Nondischarge palivizumab use was examined for high- and low-risk infants. HA-RSV was defined as an RSV-positive test (polymerase chain reaction, enzyme immunoassays, or culture) >3 days after admission and the frequency was measured for infants who did and did not receive NDP. RESULTS We identified 1263 patients who received at least 1 dose of NDP, most of whom were classified as high risk (80%). Among high-risk patients, the predictors of receipt of NDP included longer length of stay, institution, and no comorbid conditions. Most of the low-risk patients (88%) who received NDP had no comorbid conditions. NDP use varied widely among institutions. Overall, 25 eligible patients developed HA-RSV; 17 of whom received NDP. CONCLUSIONS Despite current recommendations, palivizumab for prevention of HA-RSV was common, even among patients at low risk of severe RSV.
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Affiliation(s)
- Neika Vendetti
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, and Merck & Co., Blue Bell, Pennsylvania
| | - Jeffrey S Gerber
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, and Department of Pediatrics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Shaklee Sammons
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, and Department of Pediatrics, and Department of Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian T Fisher
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, and Department of Pediatrics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theoklis E Zaoutis
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, and Department of Pediatrics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan E Coffin
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, and Department of Pediatrics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Department of Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
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Abstract
In the domain of paediatric and congenital cardiac care, the stakes are huge. Likewise, the care of these children assembles a group of "A+ personality" individuals from the domains of cardiac surgery, cardiology, anaesthesiology, critical care, and nursing. This results in an environment that has opportunity for both powerful collaboration and powerful conflict. Providers of healthcare should avoid conflict when it has no bearing on outcome, as it is clearly a squandering of individual and collective political capital. Outcomes after cardiac surgery are now being reported transparently and publicly. In the present era of transparency, one may wonder how to balance the following potentially competing demands: quality healthcare, transparency and accountability, and teamwork and shared decision-making. An understanding of transparency and public reporting in the domain of paediatric cardiac surgery facilitates the implementation of a strategy for teamwork and shared decision-making. In January, 2015, the Society of Thoracic Surgeons (STS) began to publicly report outcomes of paediatric and congenital cardiac surgery using the 2014 Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) Mortality Risk Model. The 2014 STS-CHSD Mortality Risk Model facilitates description of Operative Mortality adjusted for procedural and patient-level factors. The need for transparency in reporting of outcomes can create pressure on healthcare providers to implement strategies of teamwork and shared decision-making to assure outstanding results. A simple strategy of shared decision-making was described by Tom Karl and was implemented in multiple domains by Jeff Jacobs and David Cooper. In a critical-care environment, it is not unusual for healthcare providers to disagree about strategies of management of patients. When two healthcare providers disagree, each provider can classify the disagreement into three levels: • SDM Level 1 Decision: "We disagree but it really does not matter, so do whatever you desire!" • SDM Level 2 Decision: "We disagree and I believe it matters, but I am OK if you do whatever you desire!!" • SDM Level 3 Decision: "We disagree and I must insist (diplomatically and politely) that we follow the strategy that I am proposing!!!!!!" SDM Level 1 Decisions and SDM Level 2 Decisions typically do not create stress on the team, especially when there is mutual purpose and respect among the members of the team. SDM Level 3 Decisions are the real challenge. Periodically, the healthcare team is faced with such Level 3 Decisions, and teamwork and shared decision-making may be challenged. Teamwork is a learned behaviour, and mentorship is critical to achieve a properly balanced approach. If we agree to leave our egos at the door, then, in the final analysis, the team will benefit and we will set the stage for optimal patient care. In the environment of strong disagreement, true teamwork and shared decision-making are critical to preserve the unity and strength of the multi-disciplinary team and simultaneously provide excellent healthcare.
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Mburia-Mwalili A, Yang W. Interpregnancy interval and birth defects. ACTA ACUST UNITED AC 2015; 103:904-12. [PMID: 26397383 DOI: 10.1002/bdra.23420] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/20/2015] [Accepted: 07/22/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Interpregnancy interval is a risk factor for various adverse birth outcomes including birth defects. We investigated the relationship between interpregnancy interval and birth defects. METHODS We conducted a retrospective cohort study using linked data from Nevada Birth Outcomes Monitoring System and birth certificate data for 124,341 singleton live births, of which 4641 infants had 7192 birth defects, among Nevada resident women between 2006 and 2011. We used logistic regression to assess factors independently associated with birth defects. RESULTS Women who had an interpregnancy interval of 36 months or more, adjusted odds ratio (AOR) = 1.16, 95% confidence interval [CI], 1.01-1.33, were more likely to have an infant with a birth defect compared with women with an interpregnancy interval of 18 to 23 months. Other independent risk factors for birth defects included male infants, AOR = 1.34, 95% CI, 1.26-1.42; maternal age (30-34 years) and advanced maternal age (35 years and older), AOR = 1.10, 95% CI, 1.01-1.19 and AOR = 1.29, 95% CI, 1.18-1.42, respectively; being a Black woman, AOR = 1.46, 95% CI, 1.32-1.61; three and four or more previous births, AOR = 1.12, 95% CI, 1.02-1.23 and AOR = 1.24, 95% CI, 1.11-1.38, respectively; smoking, AOR = 1.23, 95% CI, 1.10-1.38; and prescription drug use, AOR = 1.14, 95% CI, 1.07-1.21. CONCLUSION A long interpregnancy interval is an independent risk factor for birth defects. It may be helpful for maternal and child health programs and health care providers to highlight the deleterious effects of a long interpregnancy interval.
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Affiliation(s)
- Adel Mburia-Mwalili
- Environmental Sciences Graduate Program, University of Nevada, Reno, Nevada.,Office of Public Health Informatics and Epidemiology, Nevada Division of Public and Behavioral Health, Carson City, Nevada
| | - Wei Yang
- Environmental Sciences Graduate Program, University of Nevada, Reno, Nevada.,School of Community Health Sciences, University of Nevada, Reno, Nevada
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Simeone RM, Oster ME, Hobbs CA, Robbins JM, Collins RT, Honein MA. Population-based study of hospital costs for hospitalizations of infants, children, and adults with a congenital heart defect, Arkansas 2006 to 2011. BIRTH DEFECTS RESEARCH. PART A, CLINICAL AND MOLECULAR TERATOLOGY 2015; 103:814-20. [PMID: 26069215 PMCID: PMC4565745 DOI: 10.1002/bdra.23379] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/05/2015] [Accepted: 03/12/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Congenital heart defects (CHDs) are common birth defects and are associated with high hospital costs. The objectives of this study were to assess hospitalization costs, across the lifespan, of patients with CHDs in Arkansas. METHODS Data from the 2006 to 2011 Healthcare Cost and Utilization Project Arkansas State Inpatient Databases were used. We included hospitalizations of patients whose admission occurred between January 1, 2006, and December 31, 2011, and included a principal or secondary CHD ICD-9-CM diagnosis code (745.0-747.49, except 747.0 and 745.5 for preterm infants). Hospitalizations were excluded if they involved out-of-state residents, normal newborn births, or if missing data included age at admission, state of residence, or hospital charges. Children were defined as those < 18 years-old at time of admission. RESULTS Between 2006 and 2011, there were 2,242,484 inpatient hospitalizations in Arkansas. There were 9071 (0.4%) hospitalizations with a CHD, including 5,158 hospitalizations of children (2.2% of hospitalizations among children) and 3,913 hospitalizations of adults (0.2% of hospitalizations of adults). Hospital costs for these CHD hospitalizations totaled $355,543,696. The average annual cost of CHD hospitalizations in Arkansas was $59,257,283 during this time period. Infants accounted for 72% of all CHD-related hospital costs; total costs of CHD hospitalizations for children were almost five times those of hospitalization costs for adults with CHD. CONCLUSION Hospitalizations with CHDs account for a disproportionate share of hospital costs in Arkansas. Hospitalizations of children with CHD accounted for a higher proportion of total hospitalizations than did hospitalizations of adults with CHD.
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Affiliation(s)
- Regina M. Simeone
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew E. Oster
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
- Sibley Heart Center, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - James M. Robbins
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Margaret A. Honein
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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The science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care. Curr Opin Cardiol 2015; 30:100-11. [PMID: 25469591 DOI: 10.1097/hco.0000000000000133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although significant progress has been made in the care of patients with paediatric and congenital cardiac disease, optimization of outcomes remains a constant goal. This review article will discuss the latest advances in the science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care, and will also review some of the latest associated research. RECENT FINDINGS Important advances continue to be made in each of the following domains: standardized nomenclature; established uniform core dataset; evaluation of case complexity; verification of the completeness and accuracy of the data; collaboration between subspecialties; strategies for longitudinal follow-up; and incorporating quality improvement. In January 2015, the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) will begin voluntary public reporting of programmatic congenital cardiac surgical outcomes using a new risk model that includes both procedural risk (as defined by the procedure itself and STAT Categories) and a number of patient-specific characteristics including age, weight, prior cardiothoracic operation, prematurity, chromosomal abnormalities, syndromes, noncardiac congenital anatomic abnormalities and preoperative factors. Clinical databases have been linked with administrative database to answer questions neither dataset can answer independently, providing new information about long-term mortality, rates of rehospitalization, long-term morbidity, comparative effectiveness of various treatments, and the cost of healthcare. Multiple research initiatives have recently been published using STS-CHSD. SUMMARY The science of assessing the outcomes and improving the quality of congenital and paediatric cardiac care continues to evolve. Recent advances will facilitate the continued evolution of a meaningful method of multiinstitutional outcomes analysis for congenital and paediatric cardiac surgery.
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Broberg C, Sklenar J, Burchill L, Daniels C, Marelli A, Gurvitz M. Feasibility of Using Electronic Medical Record Data for Tracking Quality Indicators in Adults with Congenital Heart Disease. CONGENIT HEART DIS 2015; 10:E268-77. [PMID: 26239748 DOI: 10.1111/chd.12289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND In order to determine the feasibility of tracking quality of care in adults with congenital heart disease (ACHD), we aimed to estimate the availability of relevant data in electronic medical records (EMR) used in North American ACHD centers. METHODS Previously proposed quality indicators (QIs) were reviewed to consider what types of data would be required for each. ACHD program directors were surveyed about the nature of electronic data in existing EMRs. From the survey, the availability of data types needed for the denominator and numerator of each QI were estimated, and an overall estimate of data availability was calculated for each QI. These estimates were adjusted by the sensitivity of identifying the patients through administrative codes. Analysis was repeated for scenarios in which various data type estimates were hypothetically dropped by half to determine the overall impact of each data type. RESULTS A total of 64 ACHD program directors responded to the survey. Of 55 QIs, average estimated data availability was 67%. QIs for tetralogy of Fallot had the highest estimated data availability (mean 88%), whereas those for atrial septal defect were lowest (mean 23%), reflecting both the need for interpretation of imaging studies and the lower reliability of billing codes for identification of ACHD patients. QIs with highest estimates were based largely on administrative data, which had the biggest impact on overall estimates. QIs needing interpretation of imaging findings had the lowest estimates, as well as certain overuse measures. CONCLUSIONS For a wide range of ACHD programs, data for proposed QIs based on administrative data are most likely to be obtainable through EMR. Data related to imaging interpretation or overuse measures are least likely. Our findings can inform future efforts to establish registry efforts or data reporting tools to track these indicators.
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Affiliation(s)
- Craig Broberg
- Adult Congenital Heart Disease Program, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore, USA
| | - Jiri Sklenar
- Adult Congenital Heart Disease Program, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore, USA
| | - Luke Burchill
- Adult Congenital Heart Disease Program, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore, USA
| | - Curt Daniels
- Columbus Ohio Adult Congenital Heart Disease Program, The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.,Departments of Pediatrics and Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Arianne Marelli
- MAUDE Unit (McGill Adult Unit for Congenital Heart Disease), McGill University Health Center, Montreal, QC, Canada
| | - Michelle Gurvitz
- Boston Adult Congenital Heart Disease and Pulmonary Hypertension Program, Boston Children's Hospital, Boston, Mass, USA.,Department of Cardiology, and Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA
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Pasquali SK, Jacobs ML, O'Brien SM, He X, Gaynor JW, Gaies MG, Peterson ED, Hirsch-Romano JC, Mayer JE, Jacobs JP. Impact of Patient Characteristics on Hospital-Level Outcomes Assessment in Congenital Heart Surgery. Ann Thorac Surg 2015; 100:1071-6; discussion 1077. [PMID: 26245503 DOI: 10.1016/j.athoracsur.2015.05.101] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 05/15/2015] [Accepted: 05/18/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Accurate hospital outcome measures in congenital heart surgery are important to multiple initiatives. While methods have been developed to account for differences in procedural case-mix, characteristics patients bring into the operation that may also vary across hospitals and influence outcome have received less attention. We evaluated the impact of these characteristics in a large cohort. METHODS Patients undergoing congenital heart surgery at centers participating in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 to 2013) with adequate data quality were included. Variation across hospitals in important patient characteristics was examined, and hospital operative mortality rates were compared with and without adjustment for patient characteristics. RESULTS Overall, 86 centers (52,224 patients) were included. There was greater than twofold variation across hospitals for nearly all patient characteristics examined. For example, the proportion of a center's surgical population comprised of neonates ranged from 12.8% to 26.6% across hospitals; the proportion with a non-cardiac anomaly ranged from 0.7% to 5.0%. When hospital mortality rankings were evaluated based on "standard" (adjustment for differences in procedural case-mix alone) versus "full" models (adjustment for both differences in procedural case-mix and patient characteristics), 14.0% changed their ranking for mortality by 20 or greater positions, 34.9% of centers changed which mortality quartile they were classified in, and 14.0% changed their statistical classification (statistically higher, lower, or same-as-expected mortality). CONCLUSIONS Characteristics of patients undergoing congenital heart surgery vary across centers and impact hospital outcomes assessment. Methods to assess outcomes and relative performance should account for these characteristics.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins All Children's Heart Institute, Saint Petersburg, Tampa, and Orlando, Florida; Florida Hospital for Children, Orlando, Florida
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Xia He
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael G Gaies
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins All Children's Heart Institute, Saint Petersburg, Tampa, and Orlando, Florida; Florida Hospital for Children, Orlando, Florida
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Simeone RM, Oster ME, Hobbs CA, Robbins JM, Thomas Collins R, Honein MA. Factors associated with inpatient hospitalizations among patients aged 1 to 64 years with congenital heart defects, Arkansas 2006 to 2011. ACTA ACUST UNITED AC 2015; 103:589-96. [PMID: 26172576 DOI: 10.1002/bdra.23402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/02/2015] [Accepted: 06/05/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Individuals with congenital heart defects (CHDs) have high hospital resource use. We sought to identify factors associated with hospital costs and multiple hospitalizations among individuals with CHDs. METHODS Data from the 2006 to 2011 Healthcare Cost and Utilization Project Arkansas State Inpatient Databases were linked across encrypted patient identifiers to develop a cohort of Arkansas residents aged 1 to 64 years who were hospitalized at least once with a CHD during this time period. Infants were excluded because patient identifiers were missing for 18 to 52% each year. CHDs were identified using principal and secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses codes. All hospitalizations of individuals ever admitted with a CHD were included. Mean and median patient-level costs were estimated; the association of hospital costs and patient readmissions were examined with linear and logistic regression. RESULTS There were 1,185,868 inpatient hospitalizations of Arkansas residents aged 1 to 64 years between 2006 and 2011; these were accrued by 603,925 patients. Of those, 2542 patients (0.42%) had at least one hospitalization with a CHD diagnosis. Total costs for these 2542 patients were $126,999,837 and they accumulated 7898 hospitalizations. Factors associated with increased costs included patient age, CHD type, cardiac procedures, and comorbidities. Factors associated with hospital readmission within 1 year included age, CHD type, expected payer, and comorbidities. CONCLUSION Individuals with CHDs in Arkansas experience variation in hospital use and costs by patient characteristics. Future research should investigate factors associated with readmissions, cardiac procedures, and comorbidities, as these are strongly associated with hospital costs. Birth Defects Research (Part A) 103:589-596, 2015. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Regina M Simeone
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Matthew E Oster
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Charlotte A Hobbs
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - James M Robbins
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - R Thomas Collins
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Margaret A Honein
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Sullivan PM, Dervan LA, Reiger S, Buddhe S, Schwartz SM. Risk of congenital heart defects in the offspring of smoking mothers: a population-based study. J Pediatr 2015; 166:978-984.e2. [PMID: 25578997 DOI: 10.1016/j.jpeds.2014.11.042] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 10/14/2014] [Accepted: 11/18/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To conduct a population-based study examining the occurrence of congenital heart defects (CHDs) in relation to maternal smoking during the first trimester of pregnancy. STUDY DESIGN This retrospective case-control study used Washington State birth certificates from 1989 to 2011 and linked hospital discharge International Classification of Diseases, 9th revision, codes to identify singleton nonsyndromic CHD cases and determine maternal prenatal smoking status. We calculated ORs from multivariate logistic regression models to compare maternal first-trimester smoking status (any and daily number of cigarettes) among 14,128 cases, both overall and by phenotype, and 60,938 randomly selected controls frequency matched on birth year. RESULTS Offspring of mothers reporting cigarette use in the first trimester of pregnancy were more likely to be born with a CHD (aOR 1.16 [1.08-1.24]) independent of demographic characteristics and other prenatal risk factors for CHDs. Maternal smoking was most strongly associated with pulmonary valve anomalies (aOR 1.48 [95% CI: 1.15-1.90]), pulmonary artery anomalies (aOR 1.71 [1.40-2.09]), and isolated atrial septal defects (aOR 1.22 [1.08-1.38]). The association between maternal smoking and CHDs was stronger with increasing number of daily cigarettes and among older (35+ years) mothers compared with younger mothers. CONCLUSIONS We provide evidence that maternal smoking during pregnancy is a risk factor for select CHD phenotypes. Maternal smoking may account for 1.4% of all CHDs. New findings include a strong dose-dependence of the association and augmented risk in older mothers.
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Affiliation(s)
- Patrick M Sullivan
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, CA.
| | - Leslie A Dervan
- Division of Pediatric Critical Care, Seattle Children's Hospital, Seattle, WA
| | - Sheridan Reiger
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA
| | - Sujatha Buddhe
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA
| | - Stephen M Schwartz
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA
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Tinker SC, Gilboa S, Reefhuis J, Jenkins MM, Schaeffer M, Moore CA. Challenges in Studying Modifiable Risk Factors for Birth Defects. CURR EPIDEMIOL REP 2015; 2:23-30. [PMID: 26236577 PMCID: PMC4516719 DOI: 10.1007/s40471-014-0028-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Conducting research to identify modifiable risk factors for birth defects is difficult for a variety of reasons. While some challenges are familiar to researchers across many disciplines, the confluence of issues affecting birth defects research may not be well understood by those outside of the field. This article describes several methodological challenges to the study of birth defects and ways these challenges might be addressed: (1) ascertainment, definition and classification of birth defects; (2) exposure assessment on modifiable risk factors; (3) analytical challenges related to small numbers and multiple statistical tests; (4) the role of genetics, including the collection of specimens and analysis of genetic data; and (5) challenges in translating research and demonstrating public health impact. Understanding these issues is important for researchers planning studies, reviewers evaluating the scientific merit of results from these studies, and consumers of the research, including fellow researchers, policy makers, health care providers, and families.
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Affiliation(s)
- Sarah C. Tinker
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E86, Atlanta, GA 30333, Phone: 404-498-3509, Fax: 404-498-3040
| | - Suzanne Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E86, Atlanta, GA 30333, Phone: 404-498-4425, Fax: 404-498-3040
| | - Jennita Reefhuis
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E86, Atlanta, GA 30333, Phone: 404-498-3917, Fax: 404-498-3040
| | - Mary M. Jenkins
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E86, Atlanta, GA 30333, Phone: 404-498-3889, Fax: 404-498-3550
| | - Marcy Schaeffer
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E86, Atlanta, GA 30333, Phone: 404-498-0265, Fax: 404-498-3040
| | - Cynthia A. Moore
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E86, Atlanta, GA 30333, Phone: 404-498-3927, Fax: 404-498-3040
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Pasquali SK, He X, Jacobs JP, Jacobs ML, Gaies MG, Shah SS, Hall M, Gaynor JW, Peterson ED, Mayer JE, Hirsch-Romano JC. Measuring hospital performance in congenital heart surgery: administrative versus clinical registry data. Ann Thorac Surg 2015; 99:932-8. [PMID: 25624057 DOI: 10.1016/j.athoracsur.2014.10.069] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/23/2014] [Accepted: 10/31/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND In congenital heart surgery, hospital performance has historically been assessed using widely available administrative data sets. Recent studies have demonstrated inaccuracies in case ascertainment (coding and inclusion of eligible cases) in administrative versus clinical registry data; however, it is unclear whether this impacts assessment of performance on a hospital level. METHODS Merged data from The Society of Thoracic Surgeons (STS) database (clinical registry) and the Pediatric Health Information Systems (PHIS) database (administrative data set) for 46,056 children undergoing cardiac operations (2006-2010) were used to evaluate in-hospital mortality for 33 hospitals based on their administrative versus registry data. Standard methods to identify/classify cases were used: Risk Adjustment in Congenital Heart Surgery, version 1 (RACHS-1) in the administrative data and STS-European Association for Cardiothoracic Surgery (STAT) methodology in the registry. RESULTS Median hospital surgical volume based on the registry data was 269 cases per year; mortality was 2.9%. Hospital volumes and mortality rates based on the administrative data were on average 10.7% and 4.7% lower, respectively, although this varied widely across hospitals. Hospital rankings for mortality based on the administrative versus registry data differed by 5 or more rank positions for 24% of hospitals, with a change in mortality tertile classification (high, middle, or low mortality) for 18% and a change in statistical outlier classification for 12%. Higher volume/complexity hospitals were most impacted. Agency for Healthcare Quality and Research (AHRQ) methods in the administrative data yielded similar results. CONCLUSIONS Inaccuracies in case ascertainment in administrative versus clinical registry data can lead to important differences in assessment of hospital mortality rates for congenital heart surgery.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Xia He
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jeffrey P Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kansas
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
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Birth prevalence of congenital heart defects in Norway 1994-2009--a nationwide study. Am Heart J 2014; 168:956-64. [PMID: 25458661 DOI: 10.1016/j.ahj.2014.07.030] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 07/16/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND The reasons for decreasing birth prevalence of congenital heart defects (CHDs) in several European countries and Canada are not fully understood. We present CHD prevalence among live births, stillbirths, and terminated pregnancies in an entire nation over a period of 16 years. METHODS Information on all births in the Medical Birth Registry of Norway, 1994-2009, was updated with information on CHD from the hospitals' Patient Administrative Systems, the National Hospital's clinical database for children with heart disease, and the Cause of Death Registry. Individuals with heart defects were assigned specific cardiac phenotypes. RESULTS Among 954,413 births, 13,081 received a diagnosis of CHD (137.1 per 10,000 births, 133.2 per 10,000 live births). The prevalence per 10,000 births was as follows: heterotaxia, 1.6; conotruncal defects, 11.6; atrioventricular septal defects, 5.6; anomalous pulmonary venous return, 1.1; left outflow obstructions, 8.7; right outflow obstructions, 5.6; septal defects, 65.5; isolated patent ductus arteriosus, 24.6; and other specified or unspecified CHD, 12.7. Excluding preterm patent ductus arteriosus, the CHD prevalence was 123.4 per 10,000; per year, the prevalence increased with 3.5% (95% CI 2.5-4.4) in 1994-2005 and declined with 9.8% (-16.7 to -2.4) from 2005 onwards. Severe CHD prevalence was 30.7 per 10,000; per-year increase was 2.3% (1.1-3.5) in 1994-2004, and per-year decrease was 3.4% (-6.6 to -0.0) in 2004-2009. Numbers included severe CHD in stillbirths and terminated pregnancies. CONCLUSIONS The birth prevalence of CHD declined from around 2005. Specifically, the prevalence of severe CHD was reduced by 3.4% per year from 2004 through 2009.
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Sulkowski JP, Cooper JN, McConnell PI, Pasquali SK, Shah SS, Minneci PC, Deans KJ. Variability in noncardiac surgical procedures in children with congenital heart disease. J Pediatr Surg 2014; 49:1564-9. [PMID: 25475794 PMCID: PMC4259048 DOI: 10.1016/j.jpedsurg.2014.06.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 05/30/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this study was to examine the volume and variability of noncardiac surgeries performed in children with congenital heart disease (CHD) requiring cardiac surgery in the first year of life. METHODS Patients who underwent cardiac surgery by 1 year of age and had a minimum 5-year follow-up at 22 of the hospitals contributing to the Pediatric Health Information System database between 2004 and 2012 were included. Frequencies of noncardiac surgical procedures by age 5 years were determined and categorized by subspecialty. Patients were stratified according to their maximum RACHS-1 (Risk Adjustment in Congenital Heart Surgery) category. The proportions of patients across hospitals who had a noncardiac surgical procedure for each subspecialty were compared using logistic mixed effects models. RESULTS 8857 patients underwent congenital heart surgery during the first year of life, 3621 (41%) of whom had 13,894 noncardiac surgical procedures by 5 years. Over half of all procedures were in general surgery (4432; 31.9%) or otolaryngology (4002; 28.8%). There was significant variation among hospitals in the proportion of CHD patients having noncardiac surgical procedures. Compared to children in the low risk group (RACHS-1 categories 1-3), children in the high-risk group (categories 4-6) were more likely to have general, dental, orthopedic, and thoracic procedures. CONCLUSIONS Children with CHD requiring cardiac surgery frequently also undergo noncardiac surgical procedures; however, considerable variability in the frequency of these procedures exists across hospitals. This suggests a lack of uniformity in indications used for surgical intervention. Further research should aim to better standardize care for this complex patient population.
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Affiliation(s)
- Jason P. Sulkowski
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Patrick I. McConnell
- Division of Cardiothoracic Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Sara K. Pasquali
- Division of Cardiology, Department of Pediatrics, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, MI
| | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Peter C. Minneci
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Katherine J. Deans
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
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Dawson AL, Cassell CH, Oster ME, Olney RS, Tanner JP, Kirby RS, Correia J, Grosse SD. Hospitalizations and associated costs in a population-based study of children with Down syndrome born in Florida. ACTA ACUST UNITED AC 2014; 100:826-36. [PMID: 25124730 DOI: 10.1002/bdra.23295] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 07/11/2014] [Accepted: 07/22/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Our objective was to examine differences in hospital resource usage for children with Down syndrome by age and the presence of other birth defects, particularly severe and nonsevere congenital heart defects (CHDs). METHODS This was a retrospective, population-based, statewide study of children with Down syndrome born 1998 to 2007, identified by the Florida Birth Defects Registry (FBDR) and linked to hospital discharge records for 1 to 10 years after birth. To evaluate hospital resource usage, descriptive statistics on number of hospitalized days and hospital costs were calculated. Results were stratified by isolated Down syndrome (no other coded major birth defect); presence of severe and nonsevere CHDs; and presence of major FBDR-eligible birth defects without CHDs. RESULTS For 2552 children with Down syndrome, there were 6856 inpatient admissions, of which 68.9% occurred during the first year of life (infancy). Of the 2552 children, 31.7% (n = 808) had isolated Down syndrome, 24.0% (n = 612) had severe CHDs, 36.3% (n = 927) had nonsevere CHDs, and 8.0% (n = 205) had a major FBDR-eligible birth defect in the absence of CHD. Infants in all three nonisolated DS groups had significantly higher hospital costs compared with those with isolated Down syndrome. From infancy through age 4, children with severe CHDs had the highest inpatient costs compared with children in the other sub-groups. CONCLUSION Results support findings that for children with Down syndrome the presence of other anomalies influences hospital use and costs, and children with severe CHDs have greater hospital resource usage than children with other CHDs or major birth defects without CHDs.
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Affiliation(s)
- April L Dawson
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia
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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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Simeone RM, Oster ME, Cassell CH, Armour BS, Gray DT, Honein MA. Pediatric inpatient hospital resource use for congenital heart defects. ACTA ACUST UNITED AC 2014; 100:934-43. [PMID: 24975483 DOI: 10.1002/bdra.23262] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Congenital heart defects (CHDs) occur in approximately 8 per 1000 live births. Improvements in detection and treatment have increased survival. Few national estimates of the healthcare costs for infants, children and adolescents with CHDs are available. METHODS We estimated hospital costs for hospitalizations using pediatric (0-20 years) hospital discharge data from the 2009 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) for hospitalizations with CHD diagnoses. Estimates were up-weighted to be nationally representative. Mean costs were compared by demographic factors and presence of critical CHDs (CCHDs). RESULTS Up-weighting of the KID generated an estimated 4,461,615 pediatric hospitalizations nationwide, excluding normal newborn births. The 163,980 (3.7%) pediatric hospitalizations with CHDs accounted for approximately $5.6 billion in hospital costs, representing 15.1% of costs for all pediatric hospitalizations in 2009. Approximately 17% of CHD hospitalizations had a CCHD, but it varied by age: approximately 14% of hospitalizations of infants, 30% of hospitalizations of patients aged 1 to 10 years, and 25% of hospitalizations of patients aged 11 to 20 years. Mean costs of CHD hospitalizations were higher in infancy ($36,601) than at older ages and were higher for hospitalizations with a CCHD diagnosis ($52,899). Hospitalizations with CCHDs accounted for 26.7% of all costs for CHD hospitalizations, with hypoplastic left heart syndrome, coarctation of the aorta, and tetralogy of Fallot having the highest total costs. CONCLUSION Hospitalizations for children with CHDs have disproportionately high hospital costs compared with other pediatric hospitalizations, and the 17% of hospitalizations with CCHD diagnoses accounted for 27% of CHD hospital costs.
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Affiliation(s)
- Regina M Simeone
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia; Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
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Peterson C, Ailes E, Riehle-Colarusso T, Oster ME, Olney RS, Cassell CH, Fixler DE, Carmichael SL, Shaw GM, Gilboa SM. Late detection of critical congenital heart disease among US infants: estimation of the potential impact of proposed universal screening using pulse oximetry. JAMA Pediatr 2014; 168:361-70. [PMID: 24493342 PMCID: PMC4470377 DOI: 10.1001/jamapediatrics.2013.4779] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Critical congenital heart disease (CCHD) was added to the Recommended Uniform Screening Panel for Newborns in the United States in 2011. Many states have recently adopted or are considering requirements for universal CCHD screening through pulse oximetry in birth hospitals. Limited previous research is directly applicable to the question of how many US infants with CCHD might be identified through screening. OBJECTIVES To estimate the proportion of US infants with late detection of CCHD (>3 days after birth) based on existing clinical practice and to investigate factors associated with late detection. DESIGN, SETTING, AND PARTICIPANTS Descriptive and multivariable analysis. Data were obtained from a multisite population-based study of birth defects in the United States, the National Birth Defects Prevention Study (NBDPS). We included all live-born infants with estimated dates of delivery from January 1, 1998, through December 31, 2007, and nonsyndromic, clinically verified CCHD conditions potentially detectable through screening via pulse oximetry. MAIN OUTCOMES AND MEASURES The main outcome measure was the proportion of infants with late detection of CCHD through echocardiography or at autopsy under the assumption that universal screening at birth hospitals might reduce the number of such late diagnoses. Secondary outcome measures included prevalence ratios for associations between selected demographic and clinical factors and late detection of CCHD. RESULTS Of 3746 live-born infants with nonsyndromic CCHD, late detection occurred in 1106 (29.5% [95% CI, 28.1%-31.0%]), including 6 (0.2%) (0.1%-0.4%) first receiving a diagnosis at autopsy more than 3 days after birth. Late detection varied by CCHD type from 9 of 120 infants (7.5% [95% CI, 3.5%-13.8%]) with pulmonary atresia to 497 of 801 (62.0% [58.7%-65.4%]) with coarctation of the aorta. In multivariable analysis, late detection varied significantly by CCHD type and study site, and infants with extracardiac defects were significantly less likely to have late detection of CCHD (adjusted prevalence ratio, 0.58 [95% CI, 0.49-0.69]). CONCLUSIONS AND RELEVANCE We estimate that 29.5% of live-born infants with nonsyndromic CCHD in the NBDPS received a diagnosis more than 3 days after birth and therefore might have benefited from routine CCHD screening at birth hospitals. The number of infants in whom CCHD was detected through screening likely varies by several factors, including CCHD type. Additional population-based studies of screening in practice are needed.
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Affiliation(s)
- Cora Peterson
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia2currently affiliated with National Center for Injury Prevention and Con
| | - Elizabeth Ailes
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia3Epidemic Intelligence Service, Scientific Education and Professional De
| | - Tiffany Riehle-Colarusso
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew E. Oster
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia4Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University
| | - Richard S. Olney
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cynthia H. Cassell
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David E. Fixler
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas
| | - Suzan L. Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
| | - Gary M. Shaw
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
| | - Suzanne M. Gilboa
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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