Association Between Combined Anatomic and Physiologic Classification of Adults with Congenital Heart Disease and Selected Healthcare Utilization and Clinical Outcomes Público
Rink, David (Spring 2021)
Published
Abstract
Background: Classifying complexity of congenital heart disease in adults (ACHD) through native anatomy alone based on ICD codes may not identify those at risk of adverse outcomes. Incorporating physiologic comorbidities into classification may improve the ability to predict adverse outcomes using administrative data. The objective of this study is to examine the association between combined anatomic and physiologic classification of congenital heart disease (CHD) complexity with healthcare utilization and adverse clinical outcomes among adults.
Methods: Data from Georgia Medicaid claims and Emory Healthcare electronic health records (eHR) were examined for adult patients aged 18-45 years with a CHD-related diagnosis with encounters from 2008 to 2013. Anatomic complexity was examined and categorized as complex anatomy or shunt and/or valve. ACHD guideline-based physiologic comorbidities captured at one year were used to determine physiologic classification, categorized as A/B or C/D. Healthcare utilization (i.e., hospitalizations and emergency department (ED) visits) and adverse clinical outcomes (i.e., transplantation and mortality) were examined for one year. Adjusted relative risks (aRR) and 95% confidence intervals (95% CI) were estimated using multivariable logistic regression.
Results: Among 2,384 eligible patients, 34.4% had complex anatomy and 41.6% had C/D physiology. Overall, 10.2% had at least one hospitalization and 8.3% had at least one ED visit. There were 22 deaths and one transplant with no significant group differences by combined anatomic and physiologic classification status. The risk of any hospitalization for those with complex ACHD and C/D physiology was 31.2 (aRR 31.2, 95% CI: 11.9, 81.6) times higher than those with shunt and/or valve anatomy and A/B physiology over 1-year of follow-up. The risk of having any ED visit for those with complex ACHD and C/D physiology was 10.6 (aRR 10.6, 95% CI: 3.4, 33.5) times higher than those with shunt and/or valve anatomy and A/B physiology over 1-year of follow-up.
Conclusions: Physiologic comorbidities provide additional information compared to native anatomy alone in assessing outcomes in adults using healthcare administrative databases. Future analyses should examine the associations noted in this study and apply alternative study designs that may better handle influential covariates and potential confounders that inform outcomes.
Table of Contents
CHAPTER I: BACKGROUND
Congenital Heart Defects (CHD)
Prevalence of CHD in the United States
CHD Phenotypes
Natural History of CHD
Cardiac Transplantation in ACHD
Mortality in ACHD
Factors Associated with Adverse Clinical Outcomes in ACHD
Prevalence of Healthcare Utilization in ACHD
Factors Associated with Healthcare Utilization in ACHD
Anatomic CHD Complexity: Predicting Clinical Outcomes and Healthcare Utilization
CHAPTER II: METHODS
Study Design
Data Sources
Study Subjects
Outcome Variables
Predictor Variables
Covariables
Age
Gender
Race
Ethnicity
Socio-Economic Status (SES)
Statistical Analysis
CHAPTER III: RESULTS
CHAPTER IV: DISCUSSION
CHAPTER V: PUBLIC HEALTH IMPLICATIONS AND FUTURE DIRECTIONS
REFERENCES
TABLES
Table 1. Descriptive Characteristics of Adult Congenital Heart Disease Patients (2008-2013)
Table 2. Bivariate Analyses of Native Anatomy, AP Physiological Stage, and Covariates with Hospitalizations for Adults with Congenital Heart Disease (N=2384)
Table 3. Bivariate Analyses of Native Anatomy, AP Physiological Stage, and Covariates by Emergency Department Visits for Adults with Congenital Heart Disease (N=2384)
Table 4. Bivariate Analyses of Covariates by Native Anatomy for Adults with Congenital Heart Disease (N=2384)
Table 5. Bivariate Analyses of Covariates with AP Physiological Stage for Adults with Congenital Heart Disease (N=2384)
Table 6. Unadjusted Analysis – Association of Native Anatomy, AP Physiologic Stage, and Other Covariates with Any Hospitalization and Any Emergency Department Visits for Adults with Congenital Heart Disease
Table 7. Unadjusted Analysis - Association of Combined Native Anatomy and AP Physiologic Stages with Any Hospitalization and Any Emergency Department Visits for Adults with Congenital Heart Disease
Table 8. Adjusted Analysis - Association of Native Anatomy, AP Physiologic Stage, and Other Covariates with Any Hospitalization and Any Emergency Department Visits for Adults with Congenital Heart Defects
Table 9. Adjusted Analysis – Association of Combined Native Anatomy and AP Physiologic Stages with Any Hospitalization and Any Emergency Department Visits for Adults with Congenital Heart Disease
FIGURES
Figure 1. Analytic Dataset Construction: Inclusions and Exclusions
APPENDICES
Appendix A. Data Sources
Appendix B. ICD-9-CM Codes for Anatomic Complexity Classification* of Congenital Hearts Defects
Appendix C. 2018 AHA/ACC ACHD AP Classification Physiological Stages
Appendix D. Operationalization of 2018 AHA/ACC ACHD AP Classification Physiological Stages with ICD-9-CM codes
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