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Central Surgical Association

49th Annual Meeting

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Neighborhood Socioeconomic Status Predicts Early and Late Outcomes following the Norwood Procedure – Analysis of Consecutive Operations over 20 Years
Aditya Sengupta1, Emily M. Bucholz2, Kimberlee Gauvreau2, Jane W. Newburger2, *Pedro J. del Nido1, *Meena Nathan1
1Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, United States, 2Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, United States

OBJECTIVE: The Norwood operation remains one of the highest risk procedures in congenital cardiac surgery. While various predictors of adverse postoperative outcomes have been identified, the role of socioeconomic status (SES) remains incompletely characterized.

METHODS: This was a single-center, retrospective review of consecutive patients who underwent the Norwood procedure (the index operation) from 01/1997-11/2017. Outcomes of interest included early mortality or transplant (prior to discharge from the index hospitalization), postoperative hospital length-of-stay (PHLOS), and post-discharge (late) mortality or transplant. The primary predictor was neighborhood SES, assessed using a United States census-based composite score derived from six census-block group measures related to wealth, income, education, and occupation. Associations between SES tertile and outcomes were assessed using logistic regression (early mortality/transplant), zero-truncated negative binomial regression (PHLOS), and Cox proportional hazards models (late mortality/transplant), adjusting for baseline patient-related and procedural factors.

RESULTS: Of 478 patients who underwent the Norwood operation, there were 62 (13.0%) early deaths or transplants. Patients in the lowest SES tertile had a significantly higher adjusted risk of early mortality or transplant (odds ratio 4.5, 95% confidence interval [CI] 1.9-11, p=0.001), compared to those in the highest tertile (Table 1). Of 416 transplant-free survivors who were discharged from the index hospitalization, median PHLOS was 24 days (interquartile range [IQR]: 15-43 days) (Figure 1). Patients in the lowest SES tertile had a greater number of postoperative days of hospitalization (adjusted incidence rate ratio 1.4, 95% CI 1.2-1.6, p<0.001), versus those in the highest tertile (Table 2). At a median post-discharge follow-up of 6.2 years (IQR: 1.6-12.5 years; range: 1 day-21.3 years), there were 97 (23.3%) late deaths or transplants. Lower SES tertile was significantly associated with worse late transplant-free survival (Figure 2). On multivariable analysis, lowest SES tertile (hazard ratio [HR] 2.1, 95% CI 1.2-3.5, p=0.008), genetic syndrome or non-cardiac anomaly (HR 1.8, 95% CI 1.1-3.0, p=0.016), and preoperative moderate or severe atrioventricular valve regurgitation (HR 2.3, 95% 1.1-4.8, p=0.024) were significantly associated with late death or transplant (Table 3).

CONCLUSIONS: Low SES is independently associated with adverse early and late outcomes following the Norwood operation. Children with single-ventricle heart disease from resource-limited settings thus constitute an especially high-risk cohort that warrants closer surveillance and tailored interventions.

Univariable and Multivariable Logistic Regression Models of Early Mortality or Transplant

Figure 1. Hospital length of stay following the Norwood operation is depicted for each SES tertile. Only data from transplant-free survivors of hospital discharge are shown. There was a significant association between postoperative hospital length of stay and SES. The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. Whiskers mark the adjacent values, defined as the largest and smallest values not more 1.5 times the interquartile range above and below the 75th and 25th percentiles. The circles indicate outliers. *Comparison by the Kruskal-Wallis test. SES, socioeconomic status.

Zero-Truncated Negative Binomial Regression Models of Postoperative Hospital Length-of-Stay

Figure 2. Kaplan-Meier estimates of post-discharge freedom from mortality or transplant by SES tertile are shown here. Lower SES tertile was significantly associated worse transplant-free survival. The number of patients at risk for each SES tertile are provided below the graph. The dashed lines indicated the 95% confidence interval. SES, socioeconomic status.

Univariable and Multivariable Cox Proportional Hazards Models of Post-Discharge Mortality or Transplant


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