Chang R K, Chen A Y, Klitzner T S
Division of Cardiology, Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California 90509, USA.
Pediatrics. 2000 May;105(5):1073-81. doi: 10.1542/peds.105.5.1073.
Previous studies have shown that children with congenital heart disease (CHD) who live in nonurban areas or who do not have private insurance are at risk for delayed referral to a pediatric cardiologist. However, the effect of these factors on the age at which cardiac surgery is performed has not been evaluated. This study is designed to evaluate the factors that influence the age at which definitive surgical repair is performed.
Data on hospital discharges for 1995 and 1996 in California were obtained from the Office of Statewide Health Planning and Development database. Children <18 years who underwent surgical repair for atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), or atrioventricular canal (AVC) were included in the study. Age at surgery was evaluated using type of CHD, gender, race, type of insurance, surgical centers, urban or rural home location, and distance between home and surgical center as independent variables.
In 1995-1996, 666 children underwent ASD closure (mean age: 5.1 years; median: 4.0 years), 582 VSD closure (mean age: 2.8; median: 1.1 years), 394 TOF repair (mean age: 1.7; median:.9 years), and 177 AVC repair (mean age: 1.1; median:.6 years). Comparing median and mean age at surgery, we found: AVC<TOF<VSD<ASD (< indicates younger than). A consistent trend for all 4 types of CHD was seen indicating that for median age at operation: private insurance<managed care<Medicaid. Gender or race had no effect on age at operation, although Asians tended to be older at surgery for all 4 types of CHD. There is a significant negative correlation between the case volume of surgical centers and median age at operation for ASD (r = -.37), VSD (r = -.49), TOF (r = -.63), and AVC (r = -.17). In addition, significant positive correlation was found between degree of urbanization of home locations (measured by population density) and median age at operation for ASD (r =.50), VSD (r =.77), and TOF (r =.18). No significant correlation was found between distance to surgical center and age at operation.
Many medical and nonmedical variables play important roles in determining age for definitive repair of CHD in children. Type of insurance, a recognized surrogate for access to care, may play an important role. In addition, centers with higher surgical case volume were more likely to operate at a younger age. Finally, children in urban areas tend to be older at the time of surgery for ASD, VSD, and TOF.
既往研究表明，居住在非城市地区或没有私人保险的先天性心脏病（CHD）患儿有延迟转诊至儿科心脏病专家处的风险。然而，这些因素对心脏手术年龄的影响尚未得到评估。本研究旨在评估影响进行确定性手术修复年龄的因素。
从加利福尼亚州全州卫生规划与发展办公室数据库获取1995年和1996年的医院出院数据。纳入接受房间隔缺损（ASD）、室间隔缺损（VSD）、法洛四联症（TOF）或房室通道（AVC）手术修复的18岁以下儿童。将CHD类型、性别、种族、保险类型、手术中心、家庭所在城市或农村以及家庭与手术中心之间的距离作为自变量，对手术年龄进行评估。
1995 - 1996年，666例患儿接受了ASD封堵术（平均年龄：5.1岁；中位数：4.0岁），582例接受了VSD封堵术（平均年龄：2.8岁；中位数：1.1岁），394例接受了TOF修复术（平均年龄：1.7岁；中位数：0.9岁），177例接受了AVC修复术（平均年龄：1.1岁；中位数：0.6岁）。比较手术时的中位数年龄和平均年龄，我们发现：AVC＜TOF＜VSD＜ASD（＜表示小于）。所有4种CHD类型均呈现出一致的趋势，表明手术时的中位数年龄：私人保险＜管理式医疗＜医疗补助。性别或种族对手术年龄无影响，但亚洲人在所有4种CHD类型手术时的年龄往往较大。手术中心的病例数量与ASD（r = -0.37）、VSD（r = -0.49）、TOF（r = -0.63）和AVC（r = -0.17）手术时的中位数年龄之间存在显著负相关。此外，家庭所在地的城市化程度（以人口密度衡量）与ASD（r = 0.50）、VSD（r = 0.77）和TOF（r = 0.18）手术时的中位数年龄之间存在显著正相关。未发现距离手术中心的远近与手术年龄之间存在显著相关性。
许多医学和非医学变量在确定儿童CHD确定性修复的年龄方面发挥着重要作用。保险类型作为获得医疗服务的公认替代指标，可能起着重要作用。此外，手术病例数量较多的中心更有可能在患儿年龄较小时进行手术。最后，城市地区的儿童在进行ASD、VSD和TOF手术时的年龄往往较大。
