Racial Disparities in Health Outcomes Among Neonates Hospitalized for Necrotizing Enterocolitis Open Access

Ching, Lance Kaeo (2014)

Permanent URL: https://etd.library.emory.edu/concern/etds/b2773w45d?locale=en
Published

Abstract

Objectives: Necrotizing enterocolitis (NEC) is an inflammatory bowel disease of newborn infants and a leading cause of significant morbidity and mortality during the neonatal period. The objective of this pilot study is to investigate the relationship between race and two NEC outcomes, case-fatality and length of hospitalization (LOS) among NEC survivors.

Methods: A retrospective cohort study was designed. We utilized data collected on all neonatal inpatient admissions to Children's Healthcare of Atlanta (CHOA) between 1 January 2009 and 31 December 2010. Multiple logistic regression analysis was performed to identify independent risk factors for NEC case-fatality. Cox proportional hazard models were used to estimate time-to-hospital-discharge by race.

Results: We identified 108 neonates with NEC. Fatality associated with an NEC diagnosis was high at 32.4%, and LOS among NEC survivors averaged 70 + 59 days. No significant association was observed between race and survival due to the study's limited statistical power. However, we cannot exclude the possibility of clinically important reductions or increases in either outcome by race. Hispanic infants with NEC had a 3.99 higher odds of death compared to white infants (95% CI: 0.76, 21.00), controlling for gestational age, sex, and payer type. Adjusted estimates for black babies (OR=1.6, 95% CI: 0.57, 4.96) and other race infants (OR=1.7, 95% CI: 0.40, 6.07) were also greater (albeit non-significant) compared to white infants. We did not detect a statistically significant difference in LOS by race in either crude (p=0.3422) or adjusted Cox proportional hazard models (p=0.3860), controlling for gestational age, sex, and payer type. However, the hazard ratio comparing non-Hispanic black neonates to non-Hispanic white infants was 0.85 (95% CI: 0.47, 1.56), indicating slower times to discharge (i.e. longer hospital stays).

Conclusions: Our findings are consistent with elevated mortality and LOS for racial minorities. These pilot data provide information on important confounders such as gestational age and birth weight as well as potential modifiable and non-modifiable risk factors. These data will help inform the design of future studies focused on identifying and explaining disparities in both the incidence and outcomes of NEC.

Table of Contents

List of Figures. x

List of Tables. xi

Abbreviations. xii

CHAPTER I: INTRODUCTION.. 1

CHAPTER II: LITERATURE REVIEW... 4

  • A BRIEF HISTORY.. 5
    • Early Reports. 5
    • 20th Century to Present 6
  • NEC CLASSIFICATION.. 7
    • Bell Modified Staging Criteria. 7
    • Alternate Classification System.. 9
    • NEC Reductionism.. 10
  • EPIDEMIOLOGY.. 10
    • Incidence, Prevalence, & Mortality. 10
    • Pre- & Post-Surfactant Eras. 11
    • Economic Costs. 11
  • NEC RISK FACTORS. 13
    • Prenatal Risk Factors. 14
    • Infant-Specific Characteristics. 18
    • Clinical Course Factors. 21
  • DISEASE MANAGEMENT. 28
    • Medical Management 28
    • Surgical Management 28
  • NEC MORBIDITIES. 31
    • Short-Bowel Syndrome. 31
    • Intestinal Strictures. 32
    • Neurodevelopmental & Growth Outcomes. 32
  • SUMMARY.. 33

CHAPTER III: METHODOLOGY.. 34

  • STUDY DESIGN.. 35
    • Study Type & Data Source. 35
    • Study Population. 35
    • NEC Outcomes. 36
  • ANALYSIS PLAN.. 37
    • Descriptive and Bivariate Analyses. 37
    • Logistic Regression Analysis. 37
    • Model Selection. 37
    • Test for Multicollinearity. 38
    • Tests for Effect Modification & Confounding. 39
    • Survival Analysis. 39
    • Data Analysis. 39

CHAPTER IV: RESULTS. 40

  • DESCRIPTIVE & BIVARIATE ANALYSES. 41
  • NEC SURVIVAL. 43
  • LENGTH OF HOSPITAL STAY (LOS) 52

CHAPTER V: CONCLUSIONS. 56

  • SUMMARY & OVERVIEW... 57
  • STUDY LIMITATIONS. 60
  • FUTURE DIRECTIONS. 62

SUPPLEMENTAL TABLES. 64

SAS CODING.. 66

REFERENCES. 77

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