A new analysis finds that children from the lowest Childhood Opportunity Index (COI) neighborhoods undergoing congenital heart disease (CHD) surgery had disproportionately higher in-hospital mortality and decreased short-term survival. The results also show that this increased mortality rate was disproportionally seen in Black, Asian, and other populations, of which the COI partially explains this observation. The research team, led by Son Q. Duong, MD, MS, from the Icahn School of Medicine at Mount Sinai in New York, suggests there are additional unmeasured factors on CHD outcomes for which more research is needed to identify specific and actionable sources of racism and disparity affecting these children. “It is beyond the scope of this analysis to determine the mechanism of the observed persistent risk attributed to race/ ethnicity,” say the authors of the paper, which appears in the Aug. 29 issue of the Journal of the American College of Cardiology, “but we speculate several possibilities might include explicit or implicit provider bias, unaccounted disparities in social determinants of health, communication barriers, quality of care, delayed treatment, and lack of prenatal care/diagnosis.” Main findings of review In this retrospective review, which was also published Monday online, researchers collected information from 54,666 surgical hospitalizations at 47 centers throughout the U.S. Here, non-Hispanic Black (Black) (odds ratio [OR]: 1.20; 95% confidence interval [CI]: 1.04-1.39; P=0.01), Asian (OR: 1.75; 95% CI: 1.36-2.25; P<0.001), and other (OR: 1.50; 95% CI: 1.31-1.72; P<0.001) groups had increased adjusted mortality vs non-Hispanic whites. In unadjusted analyses, there were significant differences across race/ethnicity (P<0.001), with higher proportions of deaths in Black (3.4%), Asian (3.2%), and Other (3.8%) groups compared with the white (2.6%) and Hispanic (2.5%) groups. In unadjusted and partially adjusted models, the lowest COI quintile had increased in-hospital mortality (OR: 1.29; 95% CI: 1.08-1.54; P=0.004), but not in the fully adjusted model (OR: 1.14; 95% CI: 0.96-1.35; P=0.13). Further findings revealed that in-hospital mortality was negatively correlated with COI percentile (r= –0.37; P < 0.001), with the lowest mortality in the highest opportunity quintile (2.4%) and the highest mortality in the lowest opportunity quintile (3.3%). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (P=0.64) and 16.8% (P=0.029), depending on model specification. In neonatal multivariable survival analysis (n=13,987; median follow-up: 0.70 years), the lowest COI quintile had poorer survival (HR: 1.21; 95% CI: 1.00-1.46; P=0.04). “These findings overall suggest that racial/ethnic disparities in surgical outcome persist independent of the childhood disparities captured by the COI, but that COI may mediate the association of race and mortality,” say the paper’s authors. “In particular, the lowest COI quintile may be independently susceptible to poor outcomes after discharge from the hospital.” ‘An important first step in better understanding SDoH’ Carlos M. Mery, MD, and Andrew Well, MD, both from the Dell Children’s Medical Center and UT Health Austin in Texas, described the review as “an important first step in better understanding the effect of SDoH [social drivers of health] on outcomes after congenital heart surgery.” In their accompanying editorial comment, they went on to highlight the heterogeneity of CHD as one key challenge that could affect SDoH’s influence on patients post-surgery. “Although large administrative datasets such as Pediatric Health Information System (PHIS) allow for the assessment of large numbers of individuals across a wide geographic area, they lack the clinical granularity to truly assess the impact of SDoH between patients with similar diagnoses or operations,” they said. The commentators also pointed out that SDoH have been associated with clinical factors that potentially have an impact on outcomes in CHD, such as differential rates of prenatal diagnosis—factors that cannot be assessed in PHIS or other administrative datasets. While COI alleviates some of the complexities of neighborhood-level SDoH, the commentators point out that evaluating only indices limits the opportunity to have actionable results. “The COI is developed from 29 different factors of neighborhood SDoH,” the experts said. “Finding an association between aggregate scores and outcomes does not point to which particular SDoH should be targeted for intervention to potentially improve outcomes.” Study methodology Encounters with patients <18 years old with ≥1 International Classification of Diseases (ICD)-10 diagnostic code for CHD and ICD-10 procedure code for open heart surgery were identified from the PHIS, a database of >50 children’s hospitals in the United States. Data that were collected included age on admission (neonatal [0-29 days], age 30 days to 1 year, 1-5 years, 5-13 years, and 13-18 years) and sex. Race and ethnicity were assigned as mutually exclusive categories: Non-Hispanic white (white), non-Hispanic Black (Black), Hispanic, non-Hispanic Asian (Asian), and other (a combined category of Native Hawaiian, Pacific Islander, American Indian, Alaskan Native, other and missing). Data were linked to COI v2.0 scores from 2015 by patient 5-digit ZIP code obtained at surgical encounter admission and indexed nationally to allow for comparison across metropolitan areas. Surgical risk was categorized using the RACHS-2 model, which was compared against the Society for Thoracic Surgeons-European Association of Thoracic Surgery Congenital Heart Surgery Mortality Categories in locally held clinical registry data. The primary outcome of interest was in-hospital mortality during the surgical hospitalization, and the primary exposures of interest were patient race/ethnicity category and COI quintile. Sources: Duong SQ, Elfituri MO, Zaniletti I, et al. Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease. J Am Coll Cardiol. 2023;82:801–813. Mery CM, Well A. Congenital Heart Surgery Outcomes: Looking Beyond the Hospital Walls. J Am Coll Cardiol. 2023;82:814–816. Image Credit: trongnguyen – stock.adobe.com