Socioeconomic Disadvantage Is Associated with Higher Long-Term Mortality After Cardiac Surgery

M. C. Haverty¹, R. Mehta², J. Reitz³, A. Venna⁴, A. Tongut⁵, M. Desai⁶, D. Wessel⁷, Y. d'Udekem¹, J. Klein^7
1Division of Cardiac Surgery, Children's National Hospital, Washington, D.C., USA., Washington, District of Columbia ²Division of Cardiac Surgery, Children's National Hospital, Washington, D.C., USA., Washignton, District of Columbia ³Children's National Hospital, Washington DC., Washington, District of Columbia ⁴Children's National Hospital, Washignton, District of Columbia ⁵Children’s National Hospital, Washington DC, District of Columbia ⁶Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA., Washington, District of Columbia ⁷Children's National Hospital, Washington, District of Columbia

Purpose: Socioeconomic disadvantage is linked to adverse outcomes after surgery for congenital heart disease, but its impact beyond hospital discharge is unclear.

Methods: Clinical and demographic data were collected on pediatric cardiac surgery patients over a 15-year period (2007-2022) in a single-center retrospective analysis. Patients lacking follow-up as of 8/3/2022 were submitted to the Center for Disease Control’s National Death Index service to determine mortality status. Using the Child Opportunity Index (COI), an index that uses environmental, educational, and socioeconomic criteria to group neighborhoods into quintiles, patients were assigned a socioeconomic status based on their census-tract. Patients in the two lowest COI quintiles were designated as “disadvantaged” while patients in the highest two COI quintiles were designated as “advantaged.” Multivariable mixed model analyses were conducted to understand the factors associated with overall mortality.

Results: A total of 2,546 individuals met the inclusion criteria. Disadvantaged neighborhoods comprised 48.5% (n=1235) of the total cohort, moderate neighborhoods 20.6% (n=524), and advantaged neighborhoods 30.9% (n=787). As compared to advantaged neighborhoods, patients from disadvantaged neighborhoods suffered in a great proportion both long-term mortality [n=168 (13.6%) vs 66 (8.4%), p< 0.001] and major complications [n=168 (13.6%) vs 81 (10.3%), p< 0.001]. Genetic syndromes were more prominent in patients from disadvantaged neighborhoods [n=288 (23.3%) vs n=147 (18.7%) p=0.021]. The median weight of 5.15 kg (IQR: 3.4 – 13.5) for disadvantaged patients at time of surgery was significantly lower than the median weight of 5.6 kg (IQR: 3.6 – 16.5) observed in advantaged patients (p=0.006). Patients from disadvantaged neighborhoods were found to be at greater risk of mortality after long-term follow up (OR: 1.711; CI: 1.274 – 2.322, p< 0.0001) in bivariable analysis. The positive association between neighborhood disadvantage and long-term mortality was maintained in stepwise logistic regression multivariable analysis after controlling for differences between surgeons (OR: 1.524; CI: 1.095 – 2.123, p=0.0126). Multivariable analysis further found that genetic syndromes (OR: 1.6; CI: 1.166 – 2.195, p=0.0036) and weight at surgery (OR: 0.655; CI: 0.533 – 0.806, p< 0.0001) were also associated with increased mortality.

Conclusion: Patients from disadvantaged neighborhoods are at greater risk of long-term mortality after pediatric cardiac surgery. The relationship between socioeconomic status and long-term mortality might be mediated by genetic syndromes and surgical weight, suggesting potential targets for intervention to reduce the mortality burden seen by disadvantaged neighborhoods.

Identify the source of the funding for this research project: No external funding