Factors associated with age at operation for children with congenital heart disease.

OBJECTIVE: Previous studies have shown that children with congenital heart disease (CHD) who live in nonurban areas or who do not have private insurance are at risk for delayed referral to a pediatric cardiologist. However, the effect of these factors on the age at which cardiac surgery is performed has not been evaluated. This study is designed to evaluate the factors that influence the age at which definitive surgical repair is performed.
METHODS: Data on hospital discharges for 1995 and 1996 in California were obtained from the Office of Statewide Health Planning and Development database. Children <18 years who underwent surgical repair for atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), or atrioventricular canal (AVC) were included in the study. Age at surgery was evaluated using type of CHD, gender, race, type of insurance, surgical centers, urban or rural home location, and distance between home and surgical center as independent variables.
RESULTS: In 1995-1996, 666 children underwent ASD closure (mean age: 5.1 years; median: 4.0 years), 582 VSD closure (mean age: 2.8; median: 1.1 years), 394 TOF repair (mean age: 1.7; median:.9 years), and 177 AVC repair (mean age: 1.1; median:.6 years). Comparing median and mean age at surgery, we found: AVC<TOF<VSD<ASD (< indicates younger than). A consistent trend for all 4 types of CHD was seen indicating that for median age at operation: private insurance<managed care<Medicaid. Gender or race had no effect on age at operation, although Asians tended to be older at surgery for all 4 types of CHD. There is a significant negative correlation between the case volume of surgical centers and median age at operation for ASD (r = -.37), VSD (r = -.49), TOF (r = -.63), and AVC (r = -.17). In addition, significant positive correlation was found between degree of urbanization of home locations (measured by population density) and median age at operation for ASD (r =.50), VSD (r =.77), and TOF (r =.18). No significant correlation was found between distance to surgical center and age at operation.
CONCLUSIONS: Many medical and nonmedical variables play important roles in determining age for definitive repair of CHD in children. Type of insurance, a recognized surrogate for access to care, may play an important role. In addition, centers with higher surgical case volume were more likely to operate at a younger age. Finally, children in urban areas tend to be older at the time of surgery for ASD, VSD, and TOF.