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Children from low-income neighborhoods had a higher mortality rate and higher hospital costs after heart surgery compared with those from higher-income neighborhoods, found a national study of more than 86,000 kids with congenital heart disease. The magnitude of the neighborhood effect, which persisted even after accounting for race, type of insurance, and hospital, was similar for children of all disease severities.

The findings were published online today in Pediatrics.

“These results were surprising,” said Brett Anderson, MD, MBA, an attending pediatric cardiologist at NewYork-Presbyterian Morgan Stanley Children’s Hospital, assistant professor of pediatrics at Columbia University Irving Medical Center, and the study’s lead investigator. “The fact that disparities exist in healthcare 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 healthcare 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.”

How the study was conducted

The researchers used data from the Pediatric Health Information System (the largest U.S. database of pediatric discharges) to evaluate 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 combined with U.S. Census Bureau data on median household income by zip code.

What the study found

Overall, 2.9 percent of the children who had heart surgery died. Children from the lowest-income neighborhoods, which included more families with public insurance, had an 18 percent increase in risk 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 researchers also looked at 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.

What caused the disparities?

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

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

“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 low-income neighborhoods,” said Dr. Anderson. “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 subspecialist, and whether providers knowlingly or unknowingly make different care choices based on a family’s income level or the socioeconomics of the neighborhood from which the child comes.”

The study is titled, “Disparities in Outcomes and Resource Utilization after Hospitalization for Cardiac Surgery by Neighborhood Income.” The other authors are Evan S. Fieldston (University of Pennsylvania, Philadelphia, PA), Jane W. Newburger (Harvard Medical School, Cambridge, MA), Emile A. Bacha (CUIMC), and Sherry A. Glied (New York University, New York, NY).

The study was supported by grants from National Institutes of Health (KL2TR001874 and K23HL133454).

The authors declare no financial or other conflicts of interest.

Columbia University Irving Medical Center

Columbia University Irving Medical Center provides international leadership in basic, preclinical, and clinical research; medical and health sciences education; and patient care. The medical center trains future leaders and includes the dedicated work of many physicians, scientists, public health professionals, dentists, and nurses at the Vagelos College of Physicians and Surgeons, the Mailman School of Public Health, the College of Dental Medicine, the School of Nursing, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. Columbia University Medical Center is home to the largest medical research enterprise in New York City and State and one of the largest faculty medical practices in the Northeast. For more information, visit cumc.columbia.edu or columbiadoctors.org.

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