Neighborhood Socioeconomic Status and Outcomes Following the Norwood Procedure: An Analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Data Set

Abstract

Background: Children with single ventricle heart disease require frequent interventions and follow-up. Low socioeconomic status (SES) may limit access to high-quality care and place these children at risk for poor long-term outcomes.

Methods and results: Data from the SVR (Pediatric Heart Network Single Ventricle Reconstruction Trial Public Use) data set were used to examine the relationship of US neighborhood SES with 30-day and 1-year mortality or cardiac transplantation and length of stay among neonates undergoing the Norwood procedure (n=525). Crude rates of death or transplantation at 1 year after Norwood were highest for patients living in neighborhoods with low SES (lowest tertile 37.0% versus middle tertile 31.0% versus highest tertile 23.6%, P=0.024). After adjustment for patient demographics, birth characteristics, and anatomy, patients in the highest SES tertile had significantly lower risk of death or transplant than patients in the lowest SES tertile (hazard ratio 0.62, 95% confidence interval, 0.40, 0.96). When SES was examined continuously, the hazard of 1-year death or transplant decreased steadily with increasing neighborhood SES. Hazard ratios for 30-day transplant-free survival and 1-year transplant-free survival were similar in magnitude. There were no significant differences in length of stay following the Norwood procedure by SES.

Conclusions: Low neighborhood SES is associated with worse 1-year transplant-free survival after the Norwood procedure, suggesting that socioeconomic and environmental factors may be important determinants of outcome in critical congenital heart disease. Future studies should investigate aspects of SES and environment amenable to intervention.

Clinical trial registration: URL:http://www.clinicaltrials.gov> http://www.clinicaltrials.gov. Unique identifier: NCT00115934.

Keywords: single ventricle; socioeconomic position; surgery; survival.

Figure 1

Kaplan–Meier curves for (A) 30‐day mortality or cardiac transplantation, (B) 1‐year mortality or cardiac transplantation, and (C) 1‐year mortality or cardiac transplantation among 30‐day transplant‐free survivors by neighborhood socioeconomic status (SES) tertiles.

Figure 2

Association between neighborhood socioeconomic status (SES) tertile with (A) 1‐year mortality or transplantation, and (B) log‐transformed Norwood length of stay (days) sequentially adjusted for patient demographic and clinical characteristics. CI indicates confidence interval.

Figure 3

Unadjusted hazard ratios (95% confidence intervals [CI]) for (A) 30‐day mortality or cardiac transplantation among all patients, (B) 1‐year mortality or cardiac transplantation among all patients, and (C) 1‐year mortality or cardiac transplantation among 30‐day transplant‐free survivors with a flexible cubic spline fit to neighborhood socioeconomic status (SES) modeled. Hazard ratios were estimated using Cox proportional hazards models. Vertical lines correspond to cutoff values for SES tertiles.

Figure 4

Distribution of Norwood hospitalization length of stay by neighborhood socioeconomic status (SES) tertile.