O2040: The Role of Child Opportunity, Race and Ethnicity, and Language Barriers in Outcomes in Congenital Cardiac Surgery

Background: Racial and ethnic disparities and language barriers coexist with disparities in a child’s educational, environmental, and economic opportunity as measured by the child opportunity index (COI), a US census-track-based, nationally normed composite metric that provides a more holistic representation of social determinants of health (SDOH). We attempted to evaluate the association between COI, racial and ethnic disparities, and language barriers in congenital heart surgical outcomes at a single institution.

Project Description: Utilizing the Society of Thoracic Surgeons database, we conducted a single center, retrospective cohort study of patients who underwent congenital cardiac surgery from 2010 to 2023 at an institution. Patients were classified by nationally normed quintiles (from "very low" to "very high") of neighborhood level COI scores; patients with missing neighborhood identifiers were excluded. Patients with “high” and “very high” COI categories were combined to allow for meaningful analysis. Outcomes included mortality at hospital discharge, hospital length-of-stay (LOS), and major complications. Crude associations were evaluated across COI quintiles using Kruskal-Wallis and Chi-square or Fisher’s exact tests where appropriate. Generalized linear mixed models with random patient intercepts were fitted to evaluate adjusted associations between COI and outcomes.

Discussion: The cohort included 1568 patients. Most of the cohort self-identified as non-Hispanic white (51.21%) and had public insurance (64.09%). Among the entire cohort, 57.40% had very low/low COI and 22.58% had moderate COI. In unadjusted analyses, race/ethnicity, primary language, and insurance payer were associated with COI (p <.0001). In multivariable analysis, COI was not associated with outcomes. In comparison to non-Hispanic White patients, non-Hispanic Black patients had increased odds of mortality at discharge (OR:2.19 [95% CI :1.07-5.30]) and increased mean length of stay (Coefficient: 0.25 [95% CI: 0.090-0.042). In comparison to patients with English speaking caregivers, patients of non-English speaking caregivers had increased length of stay (Coefficient: 0.30 [95%CI:0.098-0.51).

Conclusion: Over a 13-year period, COI category was not associated with mortality at hospital discharge, major complications, or LOS. Patients identifying as non-Hispanic Black race had an increased risk of mortality at hospital discharge and increased length of stay relative to the non-Hispanic White race. Patients with caregivers who self-identified as speakers of a non-English primary language had an increased length of stay. Increased mortality in the non-Hispanic Black population as well as increased length of stay in non-English speaking families speaks to how these factors are more central towards poor outcomes. While proposed interventions are often focused on social determinants of health, our data suggests that a systematic approach to mitigating the negative effects of unconscious bias may be vital to eliminating disparities. Further studies evaluating the interventions to ameliorate the impact of social determinants of health and race in surgical outcomes of congenital cardiac surgery are needed.