Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, MA (B.Z., M.L., L.A.S., D.W.B.).
Section of Cardiology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Denver (E.M.B.).
Circulation. 2024 Jul 16;150(3):190-202. doi: 10.1161/CIRCULATIONAHA.124.069127. Epub 2024 Jun 19.
The interstage period after discharge from stage 1 palliation carries high morbidity and mortality. The impact of social determinants of health on interstage outcomes is not well characterized. We assessed the relationship between childhood opportunity and acute interstage outcomes.
Infants discharged home after stage 1 palliation in the National Pediatric Quality Improvement Collaborative Phase II registry (2016-2022) were retrospectively reviewed. Zip code-level Childhood Opportunity Index (COI), a composite metric of 29 indicators across education, health and environment, and socioeconomic domains, was used to classify patients into 5 COI levels. Acute interstage outcomes included death or transplant listing, unplanned readmission, intensive care unit admission, unplanned catheterization, and reoperation. The association between COI level and acute interstage outcomes was assessed using logistic regression with sequential adjustment for potential confounders.
The analysis cohort included 1837 patients from 69 centers. Birth weight (<0.001) and proximity to a surgical center at birth (=0.02) increased with COI level. Stage 1 length of stay decreased (=0.001), and exclusive oral feeding rate at discharge increased (<0.001), with higher COI level. More than 98% of patients in all COI levels were enrolled in home monitoring. Death or transplant listing occurred in 101 (5%) patients with unplanned readmission in 987 (53%), intensive care unit admission in 448 (24%), catheterization in 345 (19%), and reoperation in 83 (5%). There was no difference in the incidence or time to occurrence of any acute interstage outcome among COI levels in unadjusted or adjusted analysis. There was no interaction between race and ethnicity and childhood opportunity in acute interstage outcomes.
Zip code COI level is associated with differences in preoperative risk factors and stage 1 palliation hospitalization characteristics. Acute interstage outcomes, although common across the spectrum of childhood opportunity, are not associated with COI level in an era of highly prevalent home monitoring programs. The role of home monitoring in mitigating disparities during the interstage period merits further investigation.
从第一阶段姑息治疗出院后的过渡期发病率和死亡率都很高。健康的社会决定因素对过渡期结果的影响还没有得到很好的描述。我们评估了童年机会与急性过渡期结果之间的关系。
回顾性分析了全国儿科质量改进合作组织第二阶段登记册（2016-2022 年）中第一阶段姑息治疗后出院回家的婴儿。邮政编码级别的儿童机会指数（COI）是一个由 29 个指标组成的综合指标，涵盖了教育、健康和环境以及社会经济领域，用于将患者分为 5 个 COI 水平。急性过渡期结果包括死亡或移植登记、计划外再入院、重症监护病房入院、计划外导管插入术和再次手术。使用逻辑回归评估 COI 水平与急性过渡期结果之间的关联，并依次调整潜在混杂因素。
分析队列包括来自 69 个中心的 1837 名患者。出生体重（<0.001）和出生时靠近手术中心（=0.02）随着 COI 水平的增加而增加。第一阶段住院时间缩短（<0.001），出院时经口喂养率增加（<0.001），COI 水平较高。所有 COI 水平的患者中，超过 98%接受家庭监测。101 名患者发生死亡或移植登记（5%），987 名患者发生计划外再入院（53%），448 名患者发生重症监护病房入院（24%），345 名患者发生导管插入术（19%），83 名患者发生再次手术（5%）。在未调整或调整分析中，COI 水平之间任何急性过渡期结果的发生率或发生时间均无差异。种族和民族与儿童机会之间的急性过渡期结果没有相互作用。
邮政编码 COI 水平与术前危险因素和第一阶段姑息治疗住院特征的差异有关。急性过渡期结果虽然在儿童机会的整个范围内都很常见，但在高度普及家庭监测计划的时代，与 COI 水平无关。家庭监测在缓解过渡期期间的差异的作用值得进一步研究。
