Krishnan A, Jacobs MB, Morris SA, Peyvandi S, Bhat AH, Chelliah A, Chiu JS, Cuneo BF, Freire G, Hornberger LK, Howley L, Husain N, Ikemba C, Kavanaugh-McHugh A, Kutty S, Lee C, Lopez KN, McBrien A, Michelfelder EC, Pinto NM, Schwartz R, Stern KWD, Taylor C, Thakur V, Tworetzky W, Wittlieb-Weber C, Woldu K, Donofrio MT; Fetal Heart Society. Circulation. 2021 May 25;143(21):2049-2060. doi: 10.1161/CIRCULATIONAHA.120.053062. Epub 2021 May 17.PMID: 33993718
Take Home Points:
- Lower socioeconomic quartile (SEQ), Hispanic ethnicity, and rural residence are associated with decreased prenatal detection (PND) for d-TGA
- Lower SEQ is associated with decreased PND for HLHS
- Future directives, including advanced geo-mapping to identify at risk areas, improving outreach and education of OBs to include outflow tract views, as well as use of telehealth when distance to a surgical center, may help improve PND
Commentary from Dr. Jared Hershenson (Greater Washington DC), section editor of Pediatric Cardiology Journal Watch: Prenatal detection of significant CHD such as in HLHS or d-TGA has been shown to improve morbidity and mortality. It can improve delivery planning and allow for proper coordination of care, especially if intervention is necessary soon after delivery. A focus in the fetal cardiology world is to continue to improve PND, and understanding the barriers to PND is important to create an effective strategy for prevention and improving outcomes. The purpose of this study was to determine the effect of social determinants of health on PND of CHD. This was a large, multicenter retrospective cohort study that included 21 North American centers (19 USA and 2 Canada). The study population included prenatally and postnatally diagnosed fetuses with HLHS or d-TGA. These 2 diagnoses represent the most common critical newborn CHD. The primary independent variables included SEQ, neighborhood poverty level > 20%, neighborhood race/ethnicity, rural residence, at risk geographic location, driving distance to surgical center, maternal insurance, and maternal race/ethnicity. The paper explains how SEQ and neighborhood scores were determined. Of note, insurance status was not examined for the Canadian cohort and patients without insurance were not examined in the US cohort.
1862 patients were included; 1171 with HLHS (91.8% prenatally diagnosed) and 691 (58% prenatally diagnosed) with d-TGA. See table 1. On unadjusted analysis, in the US, only lower SEQ was associated with lower PND in the d-TGA group. Adjusted analyses were performed to adjust for maternal age and accounting for hospital clustering. This showed that PND was 6% less likely among the lowest SEQ for HLHS and up to 22% in the d-TGA group with the lowest SEQ. In the US, PND was less common for Hispanic mothers and those from a rural location. In the Canadian cohort, further distance was associated with a lack of PND in the HLHS group but not the d-TGA group. See table 3. Lower SEQ was also associated with later gestational age at PND in both US/Canada, and public insurance, rural residence and longer distance to surgical center were associated with later GA at PND in the US.
In the discussion, the authors note that public insurance was not associated with decreased PND, a finding that had been seen in some previous studies. They also speculate that the difference in PND for HLHS vs d-TGA, while better than previous studies, may be due to the fact that HLHS can be more readily identified on the 4 chamber view, while d-TGA requires outflow tract views which are not always obtained on the OB sonogram. Also, given the overall high rate of detection for HLHS, access to prenatal care may not necessarily be the barrier for the small group of HLHS patients that were not detected. Another interesting finding was that universal health care did not necessarily improve PND, as overall rates were similar between the US and Canada. However, only 2 sites in Canada were studied. They recommend future directives, including advanced geo-mapping to identify at risk areas, improving outreach and education of OBs to include outflow tract views, as well as use of telehealth when distance to a surgical center is an issue.
