Racial Disparities in Hospital Mortality Among Pediatric Cardiomyopathy and Myocarditis Patients.

Olsen J, Tjoeng YL, Friedland-Little J, Chan T.Pediatr Cardiol. 2020 Oct 6. doi: 10.1007/s00246-020-02454-4. Online ahead of print.PMID: 33025028

Take Home Points

• Racial differences in health care outcomes exist for multiple illnesses in the adult population, this appears to also be true in the pediatric population with the diagnosis of myocarditis and cardiomyopathy.
• African American race and Hispanic ethnicity were independent risk factors for mortality.
• African American race was also associated with use of ECMO, mortality while on ECMO, and cardiac arrest. However, when adjusting the model for ECMO and arrest reduced the impact of African American race.
• Hispanic ethnicity was still associated with mortality even after controlling for variables.

Commentary from Dr. Clifford Cua (Columbus Ohio USA), section editor of Pediatric/Fetal Cardiology Journal Watch: This was a retrospective cross-sectional study using the Kids’ Inpatient Database (KID). This is a national administrative database produced every 3 years with a random sampling of pediatric patients that have been discharged from a hospital. The goal of this study was to determine if any associations existed between race/ethnicity and hospital outcomes of pediatric patients diagnosed with cardiomyopathy or myocarditis.

Patients < 18 years of with an ICD-9 code of cardiomyopathy or myocarditis with no other cardiac diagnosis were identified. Data from 2003, 2006, 2009, and 2009 were used. Race/ethnicity (non-Hispanic white, non-Hispanic African American, Hispanic, and other), demographic data, hospital procedures, and hospital mortality were collected. Associations between ethnicity/race and mortality were evaluated and subsequent models incorporated cardiac arrest, ECMO, VAD, or transplant in the analysis.

Total of 34,617 patients were evaluated (white = 38.6%, African American = 20.4%, Hispanic = 15.4%, and other = 7.9%). Patients were mostly > 1 year of age (88.7%), male, 59.9%), had cardiomyopathy (70.8%), and were treated at non-pediatric hospitals (73.7%). Non-white patients were more likely to have the diagnosis of cardiomyopathy, use government insurance, live in lower income neighborhoods, and undergo fewer transplants. Rate of cardiac arrest, ECMO, and VAD did not differ between ethnicities.

Overall mortality was 4.6% with white patients having significantly lower rates (4.1%) than African Americans (4.7%), Hispanic (5.4%), and other (5.8%). Other significant variables associated with mortality are presented in Table 3. Initial statistical multivariate model showed increased odds for mortality for African American (OR 1.25 [1.01 – 1.53]) and Hispanic (OR 1.29 [1.03 – 1.60]) patients. When ECMO, VAD, or transplant was included in the model, the mortality associations were no longer present for African Americans, but persisted for Hispanic patients. African American race was associated with use of ECMO (OR 1.46 [1.04 – 2.05]) and cardiac arrest (OR 1.23 [1.02 – 1.48]). African American and “other” race had higher mortality when ECMO was utilized. In patients that did not undergo ECMO, Hispanic race was associated with mortality.

Adult studies have shown differences in health care outcomes based on race/ethnicity. This paper also documents decreased overall survival in African American and Hispanic patients compared to white patients with the diagnosis of cardiomyopathy or myocarditis. The reasons for these differences are multifactorial. By controlling for certain variables, the authors suggest that at least hospital selection and referral patterns are not the main reasons for these differences. They suggest pre-hospital and in-hospital factors or possibly intrinsic factors may be the key drivers. Limitations of the study include its retrospective nature. The lack of granular data and incomplete or incorrect data entry in the database are also shortcomings. Despite this, the large descriptive “n” allows for starting point to further evaluate why these differences exist.