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 insuran ce are at risk for delayed referral to a pediatric cardiologist. However, t he 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 tha t influence the age at which definitive surgical repair is performed. Methods. Data on hospital discharges for 1995 and 1996 in California were o btained from the Office of Statewide Health Planning and Development databa se. Children <18 years who underwent surgical repair for atrial septal defe ct (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), or at rioventricular canal (AVC) were included in the study. Age at surgery was e valuated using type of CHD, gender, race, type of insurance, surgical cente rs, urban or rural home location, and distance between home and surgical ce nter as independent variables. Results. In 1995-1996, 666 children underwent ASD closure (mean age: 5.1 ye ars; 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 (mea n 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 fo r 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 ag e at operation, although Asians tended to be older at surgery for all 4 typ es of CHD. There is a significant negative correlation between the case vol ume 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 p ositive correlation was found between degree of urbanization of home locati ons (measured by population density) and median age at operation for ASD (r = .50), VSD (r = .77), and TOF (r = .18). No significant correlation was f ound 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 ope rate at a younger age. Finally, children in urban areas tend to be older at the time of surgery for ASD, VSD, and TOF.