Effect Of Family Socioeconomic Status On All-cause Mortality And Unplanned Readmission In Children With Complex Congenital Heart Disease After Open-heart Operation

Backgrounds:Previous studies have shown that there is a close correlation between lower socioeconomic status(SES)and higher mortality in patients with cardiovascular diseases.However,the impact of family SES on the prognosis of patients with congenital heart disease(CHD)is unclear,especially in newly industrialized countries(NIC).The purpose of this study was to explore the relationship between family SES and postoperative outcomes of children with complex congenital heart disease(CCHD).Methods:We conducted an observational cohort study to recruit 2555 children(age<7 years)who underwent open-heart surgery for CCHD at a single tertiary care centre(fuwai hospital,Chinese Academy of Medical Sciences)from May 1,2012 to December 31,2015.The follow-up for all patients ended until May 4,2017.During the follow-up period,the all-cause mortality and unplanned readmission events were mainly collected.The socioeconomic-related information,including household income in the past year,and occupation and education level of each parent,was collected and quantified to measure the SES,and the synthetic SES was categorised as low,middle or high.Kaplan-meier survival analyses were used to compare the differences in all-cause mortality and unplanned readmission-free survival rate across SES tertiles,and multivariable cox proportional hazards regression models were further applied to assess the association between family SES and all-cause mortality and unplanned readmission of CCHD patients.Results:The median age of participants at operation was 0.9(IQR 0.6-1.9)years.Among them,2485(97%)survived to discharge,with a median follow-up time of 32.1(IQR 19.6-44.7)months.In total,180 patients(7%)died during the follow-up period,with 1477 unplanned readmissions events occurred in 748(30%)patients.Compared with CCHD children from high(n=767)SES families,children from low(n=899)and middle(n=819)SES families had higher unadjusted all-cause mortality and lower unadjusted unplanned readmission-free survival rate:3-year survival rate of children across SES tertiles was 88.5%(95%CI 86.3-90.7),93.1%(95%CI 91.1-95.1),and 96.3%(95%CI 94.7-97.9);3-year unplanned readmission-free survival rate across SES tertiles was 56.3%(95%CI 52.8-59.8),68.4%(95%CI 64.9-71.9),and 82.4%(95%CI 79.5-85.3)(both log-rank P<0.0010).In multivariable cox proportional hazards regression models,after adjustment for demographic factors,cardiac diagnostic categories,operation types,and other characteristics,we found that compared with high family SES,hazard ratios(HRs)of all-cause mortality and unplanned readmission in families with low SES were 2.66(95%CI 1.62-4.35)and 4.17(95%CI 3.31-5.25)respectively,whereas HRs of all-cause mortality and unplanned readmission in families with middle SES were 1.95(95%CI 1.18-3.22)and 2.44(95%CI 1.94-3.07)respectively.Conclusions:Compared with CCHD patients from families with high SES,patients from low and middle SES families had worse prognosis after heart surgery.Necessary interventions are needed for children with CCHD from families with lower SES,such as measures to reduce the financial burden on children with CCHD and to provide more high-quality medical care,which may improve the surgical prognosis of these patients.Backgrounds:For children with complex congenital heart disease(CCHD),family socioeconomic status(SES)was associated with health-related quality of life(HRQOL)after cardiac surgery.However,very little evidence is from newly industrialized countries(NIC).Methods:We conducted a cross-sectional study to recruit 2037 surviving children with CCHD undergoing open-heart surgery from May 1,2012 to December 31,2015 at a single tertiary care centre(fuwai hospital,Chinese Academy of Medical Sciences).All children enrolled in the study were aged 2 to 12 years.The HRQOL was evaluated using the Pediatric Quality of Life Inventory(PedsQL)version 4.0 generic core scales and 3.0 cardiac modules.The socioeconomic-related information,including household income in the past year,and occupation and education level of each parent,was collected and quantified to measure the SES,and the synthetic SES was categorised as low,middle or high.HRQOL scores across different family SES groups were compared by one-way analysis of variance(One-way ANOVA).Other covariates were adjusted in a multivariate linear regression model to assess the impact of family SES on HRQOL scores.Results:Patients with CCHD from middle and high family SES group reported higher scores in main subscales of the PedsQL,as compared with CCHD patients from low family SES group(PedsQL 4.0 generic core scales:total scores:75.00±8.0 and 76.01±7.9 vs 71.2±7.9,P<0.0010;psychosocial functioning:74.4±8.4 and 75.3±8.4 vs 70.8±9.0,P<0.0010;physical functioning:76.0±9.7 and 77.1±9.4 vs 71.6±10.4,P<0.0010;emotional functioning:72.5±10.2 and 72.6±9.9 vs 68.4±11.3,P<0.0010;social functioning:76.3± 11.5 and 77.2± 11.4 vs 72.1 ± 11.9,P?0.0010.PedsQL 3.0 cardiac modules:heart symptoms and treatment:75.7±11.0 and 76.8±10.3 vs 71.9±11.6,P<0.0010;cognitive:69.4±12.1 and 74.6±13.6 vs 65.4±11.1,P<0.0010).After adjusting for other clinical and demographic variables in the multivariate linear regression model,it was found that family SES significantly affected almost all subscales of PedsQL 4.0 generic core scales and 3.0 cardiac modules,except for the treatment barriers,treatment anxiety,physical appearance and communication.Conclusions:Family SES is an independent determining factor for HRQOL in patients with CCHD after cardiac surgery.Clinicians should routinely evaluate the HRQOL of children after surgical treatment for CHD,especially for those from lower SES family,so that problems in the rehabilitation process can be identified in time,and targeted interventions can be conducted timely to make better use of the limited medical resources and to improve the prognosis of those patients.