Impact of Social Determinants of Health on Predictive Models for Outcomes After Congenital Heart Surgery

Sarah Crook; Kacie Dragan; Joyce L Woo; Matthew Neidell; Katherine A Nash; Pengfei Jiang; Yun Zhang; Chantal M Sanchez; Stephen Cook; Edward L Hannan; Jane W Newburger; Marshall L Jacobs; Christopher J Petit; Andrew Goldstone; Robert Vincent; Kathleen Walsh-Spoonhower; Ralph Mosca; T K Susheel Kumar; Neil Devejian; Ben Biddix; George M Alfieris; Michael F Swartz; David Meyer; Erin A Paul; John Billings; Brett R Anderson; New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes & Utilization of Resources (CHS-COLOUR)

doi:10.1016/j.jacc.2024.03.430

Impact of Social Determinants of Health on Predictive Models for Outcomes After Congenital Heart Surgery

J Am Coll Cardiol. 2024 Jun 18;83(24):2440-2454. doi: 10.1016/j.jacc.2024.03.430.

Authors

Sarah Crook¹, Kacie Dragan², Joyce L Woo³, Matthew Neidell⁴, Katherine A Nash⁵, Pengfei Jiang⁶, Yun Zhang⁷, Chantal M Sanchez⁸, Stephen Cook⁹, Edward L Hannan¹⁰, Jane W Newburger¹¹, Marshall L Jacobs¹², Christopher J Petit⁷, Andrew Goldstone¹³, Robert Vincent¹⁴, Kathleen Walsh-Spoonhower¹⁵, Ralph Mosca¹⁶, T K Susheel Kumar¹⁶, Neil Devejian¹⁷, Ben Biddix¹⁸, George M Alfieris¹⁹, Michael F Swartz²⁰, David Meyer²¹, Erin A Paul²², John Billings²³, Brett R Anderson²⁴; New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes & Utilization of Resources (CHS-COLOUR)

Affiliations

¹ Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
² New York University, Wagner Graduate School of Public Service, New York, New York, USA; Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts, USA.
³ Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
⁴ Department of Health Policy and Management; Mailman School of Public Health, Columbia University, New York, New York, USA.
⁵ Division of Pediatric Critical Care and Hospital Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
⁶ Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁷ Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
⁸ Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
⁹ Department of Pediatrics, Internal Medicine, and Center for Community Health, University of Rochester Medical Center, Rochester, New York, USA; New York State Department of Health; Offices of Health Insurance Programs, Albany, New York, USA.
¹⁰ University at Albany School of Public Health, Rensselaer, New York, USA.
¹¹ Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.
¹² Division of Cardiac Surgery; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
¹³ Department of Cardiothoracic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center & Weill Cornell Medical Center, New York, New York, USA.
¹⁴ Division of Pediatric Cardiology, Westchester Medical Center, Valhalla, New York, USA.
¹⁵ Division of Pediatric Cardiology, Stony Brook Children's Hospital, Stony Brook, New York, USA.
¹⁶ Department of Cardiothoracic Surgery, New York University, New York, New York, USA.
¹⁷ Division of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA.
¹⁸ Division of Pediatric Cardiology, Albany Medical College, Albany, New York, USA.
¹⁹ Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgery, State University of New York Upstate Medical Center, Syracuse, New York, USA.
²⁰ Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA.
²¹ Departments of Cardiothoracic Surgery and Pediatrics, Hofstra-Northwell School of Medicine, Uniondale, New York, USA.
²² Division of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
²³ New York University, Wagner Graduate School of Public Service, New York, New York, USA.
²⁴ Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA; Division of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address: [email protected].

PMID: 38866447
DOI: 10.1016/j.jacc.2024.03.430

Abstract

Background: Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors.

Objectives: The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance.

Methods: Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model.

Results: Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers.

Conclusions: Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.

Keywords: congenital; outcomes; risk model; social determinants; surgery.

MeSH terms

Cardiac Surgical Procedures* / mortality
Child
Child, Preschool
Female
Heart Defects, Congenital* / mortality
Heart Defects, Congenital* / surgery
Humans
Infant
Infant, Newborn
Male
New York / epidemiology
Risk Assessment / methods
Social Determinants of Health*