Kids from low-income areas fare worse after heart surgery, finds study

Life of kids hinges on the income of neighborhoods.

Heart in baby's crib. (child care concept)
Heart in baby's crib. (child care concept) Image: Getty images

A national study upon more than 86,000 kids with congenital heart disease have investigated that children from low-income neighborhoods had a higher mortality rate and higher hospital costs after heart surgery compared with those from higher-income neighborhoods.

The enormity of the neighborhood impact, which persisted even after accounting for race, type of insurance, and hospital, was analogous for children of all disease severities.

The study conducted by using data from the Pediatric Health Information System (the largest U.S. database of pediatric discharges) to assess post-surgical mortality, length of stay, and standardized hospital costs in 86,104 children with congenital heart defects at 46 U.S. pediatric hospitals between 2005 and 2015.

The results were assorted with U.S. Census Bureau data on median household income by zip code, where they discovered that, overall, 2.9 percent of the children who had heart surgery succumb. Children from the lowest-income neighborhoods, which included more families with public insurance, had an 18 percent rise in peril of death compared with children from the highest-income neighborhoods, after adjusting for differences in race, insurance, and disease severity.

Length of hospital stay and costs were both 7 percent higher for children from the lowest-income neighborhoods compared to children from the highest-income neighborhoods.

The findings were published online today in Pediatrics.

Brett Anderson, the study’s lead investigator said, “These results were surprising.”

“The fact that disparities exist in health care is nothing new. But the fact that we see such a big effect in this population is shocking.”

“We think of this group of children as being particularly well-integrated into the health care system, regardless of their background. Most children with congenital heart disease are diagnosed prenatally or as newborns, and the children in this study—mostly infants—all had access to highly specialized cardiac care teams at major tertiary children’s hospitals. While we expected to see some differences, we assumed the effect would be minor compared to what is seen in general pediatric populations. In fact, the effect was essentially identical to that observed in general pediatric patients.”

The researchers investigated outcomes in 857,833 children who were hospitalized for other conditions between 2013 and 2015. About half of this group had a chronic condition. Similarly, children from the lowest-income neighborhoods had a 22 percent greater chance of dying in the hospital compared with kids from higher-income neighborhoods. Length of stay and in-hospital costs were about 3 percent higher for children from the lowest-income neighborhoods.

Anderson stated, “When neighborhood disparities have been described in other studies, they have been largely attributed to differences among hospitals or in environmentally mediated differences in behavioral health.”

“In our study, even when the hospital effect was taken into account, neighborhood remained an important predictor of outcomes.”

The study discovered a higher incidence of severe heart disease in children from low-income neighborhoods, but the neighborhood effect remained after controlling for disease severity.

She added, “Certain environmental factors—such as maternal stress, nutrition, or health expectations—might have contributed to the differences in outcomes that we saw in children from the low-income neighborhood.”

“But until we conduct detailed qualitative studies, we can’t be sure why these disparities persist. Ideally, such studies would examine the role of both families and providers—such as how long it takes before a family makes or obtains an appointment with a subspecialists and whether providers knowingly or unknowingly make different care choices based on a family’s income level or the socioeconomic of the neighborhood from which the child comes.”

The other authors are Evan S. Fieldston (University of Pennsylvania, Philadelphia, PA), Jane W. Newburger (Harvard Medical School, Cambridge, MA), Emile A. Bacha (Columbia), and Sherry A. Glied (New York University, New York, NY).