Zaidi Abbas H, Saleeb Susan F, Gurvitz Michelle, Bucholz Emily, Gauvreau Kimberlee, Jenkins Kathy J, de Ferranti Sarah D
Department of Cardiology Boston Children's Hospital Boston MA.
Department of Pediatrics Harvard Medical School Boston MA.
J Am Heart Assoc. 2024 Feb 20;13(4):e028883. doi: 10.1161/JAHA.122.028883. Epub 2024 Feb 14.
Gaps in care (GIC) are common for patients with congenital heart disease (CHD) and can lead to worsening clinical status, unplanned hospitalization, and mortality. Understanding of how social determinants of health (SDOH) contribute to GIC in CHD is incomplete. We hypothesize that SDOH, including Child Opportunity Index (COI), are associated with GIC in patients with significant CHD.
A total of 8554 patients followed at a regional specialty pediatric hospital with moderate to severe CHD seen in cardiology clinic between January 2013 and December 2015 were retrospectively reviewed. SDOH factors including race, ethnicity, language, and COI calculated based on home address and zip code were analyzed. GIC of >3.25 years were identified in 32% (2709) of patients. GIC were associated with ages 14 to 29 years (<0.001), Black race or Hispanic ethnicity (<0.001), living ≥150 miles from the hospital (=0.017), public health insurance (<0.001), a maternal education level of high school or less (<0.001), and a low COI (<0.001). Multivariable analysis showed that GIC were associated with age ≥14 years, Black race or Hispanic ethnicity, documenting <3 caregivers as contacts, mother's education level being high school or less, a very low/low COI, and insurance status (C statistic 0.66).
One-third of patients followed in a regional referral center with significant CHD experienced a substantial GIC (>3.25 years). Several SDOH, including a low COI, were associated with GIC. Hospitals should adopt formal GIC improvement programs focusing on SDOH to improve continuity of care and ultimately overall outcomes for patients with CHD.
先天性心脏病（CHD）患者中，医疗服务差距（GIC）很常见，可能导致临床状况恶化、计划外住院和死亡。目前对于健康的社会决定因素（SDOH）如何导致CHD患者出现GIC的理解尚不完整。我们假设，包括儿童机会指数（COI）在内的SDOH与患有严重CHD的患者的GIC相关。
回顾性分析了2013年1月至2015年12月期间在一家地区专科儿童医院心脏病诊所就诊的8554例中重度CHD患者。分析了SDOH因素，包括种族、民族、语言以及根据家庭住址和邮政编码计算的COI。32%（2709例）的患者存在超过3.25年的GIC。GIC与14至29岁（<0.001）、黑人种族或西班牙裔（<0.001）、居住在距离医院≥150英里处（=0.017）、公共医疗保险（<0.001）、母亲教育水平为高中及以下（<0.001）以及低COI（<0.001）相关。多变量分析显示，GIC与年龄≥14岁、黑人种族或西班牙裔、记录的联系人少于3名护理人员、母亲教育水平为高中及以下、极低/低COI以及保险状况相关（C统计量为0.66）。
在一家地区转诊中心接受随访的中重度CHD患者中有三分之一经历了显著的GIC（超过3.25年）。包括低COI在内的多个SDOH与GIC相关。医院应采用注重SDOH的正式GIC改善计划，以改善护理的连续性，并最终改善CHD患者的总体结局。
