There are ethnic and racial disparities in accessibility and ease of primary care visits for children recovering from cardiac surgery, a new study suggests, as researchers lay bare the significant needs and costs of long-term pediatric health care. In a cohort of Medicaid-enrolled children, Hispanic patients, when compared to their non-Hispanic (NH) White counterparts, had more emergency department visits, inpatient admissions, and subspecialist visits in years 2 to 5. However, Hispanic patients received fewer primary care visits and had a greater 5-year mortality in research published Monday online and in the April 18 issue of the Journal of the American College of Cardiology. “We reaffirmed previous observations of disparate mortality and expanded upon this, showing that NH-Black and Hispanic children were seen less often in primary care offices and more often in emergency rooms.,” the paper says. “In some models, NH-Black and Hispanic children also had more subspecialist visits and spent more days in hospital than NH-White children. … One needs to understand, e.g., whether they result from greater postoperative morbidity among NH-Black and Hispanic children— pointing to issues during or before the operative stay—or whether they reflect diverse access to postoperative providers.” Costs of cardiac surgery Further findings by the New-York based team found that on average, Medicaid-enrolled children undergoing cardiac surgery had expenditures of $139,000 per child over the first 5 postoperative years ($263,000 including initial hospitalization). This figure is in comparison with $20,000 per child for children without cardiac surgery ($23,000 including birth hospitalizations). The retrospective analysis drew on data from the Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources (CHS-COLOUR) Registry. Here, 5,241 children age <18 years who underwent initial cardiac surgery while enrolled in New York State (NYS) Medicaid for at least 1 postoperative month were included in the investigation. Also included was a comparison cohort that consisted of NYS Medicaid-enrolled children who did not undergo cardiac surgery, matched 1-to-1 from the overall Medicaid pediatric population. Led by Sarah Crook, PhD, from New York-Presbyterian/Columbia University Irving Medical Center, the team noted the number and duration of inpatient admissions, emergency department visits, and outpatient primary care and subspecialty visits. Although not a primary endpoint, mortality was also assessed. Due to imperfect reporting of race and ethnicity in both clinical and claims data, the team utilized both data sources to assign race and ethnicity. Race and ethnicity were categorized as Hispanic, NH-Asian, NH-Black, NH-White, or other. Other races included American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or any other race. Final results Results revealed that compared with NH-White, Hispanic children, on average, had 11% more inpatient admissions (95% confidence interval [CI]: 6% to 17%) in year 1; and 44% (95% CI: 18% to 76%) more in years 2-5. Hispanic children also visited the emergency department 62% more (95% CI: 41% to 86%) in year 1; and 51% (95% CI: 30% to 76%) more in years 2-5. Subspecialist visits by Hispanic children occurred more in year 1 by 11% (95% CI: 3% to 21%] more in year 1; and 20% (95% CI: 8% to 34%) during years 2-5. However, these children saw primary care doctors 23% less frequently (95% CI: 27% to 37%) during year 1; and 25% (95% CI: 18% to 32%) less during years 2-5. NH-Black children experienced similar relative patterns of health care utilization, with 54% more emergency department visits (95% CI: 34% to 78%) during year 1; and 42% (95% CI: 23% to 63%) more years 2-5. These children also had 23% fewer primary care visits (95% CI: 18% to 28%) during year 1; and 36% (95% CI: 25% to 46%) fewer visits during years 2-5 when compared to NH-White children. Overall mean Medicaid expenditures per child after cardiac surgery were $15,500 ± $62,000 per month in year 1 ($5,200 per month in year 1 after initial hospital discharge) and $1,600 ± $9,100 per month in year 5. This reflected an average of $186,000 in expenditures and 52.9 days spent visiting doctors or in hospital in year 1, and $19,200 in expenditures and 9.4 doctor/hospital days in year 5. In contrast, mean Medicaid expenditures for noncardiac surgical comparators was $700 ± $6,600 per month in the first year of matched enrollment ($500 excluding birth admissions) and $300 ±$2,200 per month in year 5. This represented an average of $8,400 in expenditures and 9.6 doctor/hospital days in year 1 and 4.8 doctor/hospital days in year 5. Lost work and school days “While these data reflect the money spent from Medicaid, it does not consider the true expenses to the family,” said an accompanying editorial, authored by Mitchell I. Cohen, MD, Jamie E. Cohen, and James St. Louis, MD. “From a health economic vantage, one must also consider the lost days of parental or maternal work from hospitalizations, emergency room visits or doctor visits. There are also the lost school days for the child and what that means for future academic achievement in the long run.” Mitchell l. Cohen and St. Louis, from Inova L.J. Murphy Children’s Hospital in Fairfax, Virginia, and Jamie E. Cohen from the Brunswick Group, in Washington, D.C., thought the study raised important questions about accessibility and ease of primary care visits for Hispanic and NH-Black children. “Would earlier and more proactive visits to a primary care physician avoid unnecessary emergency room visits and subsequent inpatient admissions?” they asked. “It is unclear from this manuscript how many inpatient admissions were short stays or discharged within 12 hours that might have been avoided by a visit to a primary care specialist.” Heart surgery outcomes The editorialists also pointed out that it was unclear whether NH-Black children and Hispanic children had greater postoperative morbidity and if this explained the increase in emergency room visits and inpatient utilization. “While the reasons are not entirely clear, numerous studies have shown worse outcomes after congenital heart surgery for lower-socioeconomic-status patients,” they said. “Strategies at both the population and institutional level should be implemented to mitigate health inequities and ensure uniform subspecialty and primary care access across all racial and societal levels.” Sources: Crook S, Dragan K, Woo JL, et al. Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid. J Am Coll Cardiol. 2023;81:1605–1617. Cohen MI, Cohen JE, St. Louis J. Health Care Expenditures in Cardiac Children: The Time to Act Is Now. J Am Coll Cardiol. 2023;81:1618–1620. Image Credit: Pebo – stock.adobe.com