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O’Leary JM, Siddiqi OK, de Ferranti S, Landzberg MJ, Opotowsky AR. The Changing Demographics of Congenital Heart Disease Hospitalizations in the United States, 1998 Through 2010. JAMA. 2013;309(10):984–986. doi:10.1001/jama.2013.564
Letters Section Editor: Jody W. Zylke, MD, Senior Editor.
Author Affiliations: Department of Medicine, Brigham and Women's Hospital (Dr O’Leary); Department of Medicine, Boston Medical Center (Dr Siddiqi); and Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts (Drs de Ferranti, Landzberg, and Opotowsky).
To the Editor: Congenital heart disease incidence has remained stable,1 but longevity has improved. There are more than 787 000 adults with congenital heart disease in the United States.2 Adults with congenital heart disease remain at risk for frequent hospitalizations.3 We analyzed US hospitalizations from 1998 through 2010 for children and adults with congenital heart disease.
We identified congenital heart disease admissions to acute care hospitals from 1998 through 2010 using the Nationwide Inpatient Sample, a stratified 20% sample of hospitalizations, including approximately 8 million admissions annually from approximately 1000 hospitals. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify congenital heart disease,4 which was classified as simple, complex, or unclassified.5 To minimize the effect of year-to-year variability, we compared the number of hospitalizations between the first and second halves of the study (January 1, 1998, through June 30, 2004; July 1, 2004, through December 31, 2010). The primary outcome was the change in number of admissions for all congenital heart disease diagnoses for pediatric (aged <18 years) vs adult patients; we also analyzed defect complexity for each age category.
Continuous variables were compared using 2-sided t tests and categorical variables were compared using 2-sided Rao-Scott χ2 tests. Logistic regression, with congenital heart disease as the dependent variable, was used to test for interaction between age and time. Analyses used SAS 9.3 (SAS Institute Inc) with sampling weights to produce nationally representative estimates accounting for complex survey design and hospital clustering. Statistical significance was defined as P < .05. The Brigham and Women's Hospital institutional review board determined the study did not qualify as human subjects research and was exempt from oversight.
The annual number of congenital heart disease hospitalizations among adults increased more quickly and consistently from 1998 through 2010 than pediatric hospitalizations (Figure). Adult admission volume was 87.8% higher during the second half of the study (n=622 084) compared with the first half (n=331 162), while pediatric admissions grew 32.8% (1 082 540 vs 815 471) (P < .001 for interaction between age group and period) (Table). Admissions for simple defects changed 112.8%, unclassified defects changed 52.6%, and complex defects 52.8% between the eras among adults, compared with changes in simple defects (46.3%), unclassified defects (−9.8%), and complex defects (32.4%) for children. Adults accounted for 36.5% (95% CI, 34.0%-38.9%) of congenital heart disease admissions in the latter era, up from 28.9% (95% CI, 26.6%-31.2%). The extent of medical comorbidity was greater among adults, though this increased significantly for both children and adults over the study period. Length of stay and inflation-adjusted hospital charges increased for both children and adults, but there was a modest decline in the proportion of admissions involving cardiac procedures among both groups (Table).
The frequency of hospitalizations for adults with congenital heart disease has grown at a rate more than twice that for children from 1998 through 2010. As a result, annual adult admissions are approaching those of children, accounting for 36.5% of all congenital heart disease admissions. While simple defects make up a greater percentage of adult admissions, a similar growth in admissions is seen for more complex congenital heart disease.
The observed trend is likely due to a number of independent forces including better congenital heart disease survival, an aging population, and accumulating comorbidities. Limited availability of quality outpatient services may also contribute.6 Further research is warranted to understand the forces generating admissions.
Using ICD-9 codes to define congenital heart disease has inherent limitations. For example, secundum atrial septal defects include small defects and patent foramen ovale; though these lesions are of questionable clinical relevance, they may be increasingly documented using sensitive diagnostic imaging in the context of speculation of a pathologic role in embolic events. However, the trends are not limited to simple congenital heart disease. These are hospitalization-level, not patient-level, data and will include multiple hospitalizations for a given patient. These data do not reflect the number of congenital heart disease patients, but rather the burden of congenital heart disease admissions. Because the described factors are not likely to abate, this trend may continue. Adult congenital heart disease admissions will have an increasing impact on resource utilization. Further research and focus on optimizing health care delivery is warranted to effectively care for adults with congenital heart disease.
Corresponding Author: Jared M. O’Leary, MD, Brigham and Women's Hospital, Internal Medicine, 75 Francis Street, Boston, MA 02115 (firstname.lastname@example.org).
Published Online: March 7, 2013. doi:10.1001/jama.2013.564
Author Contributions: Dr O’Leary had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: O’Leary, Landzberg, Siddiqi, Opotowsky.
Acquisition of data: Opotowsky.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: O’Leary, Opotowsky.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: O’Leary, Siddiqi, Opotowsky.
Administrative, technical, or material support: Landzberg, Siddiqi, Opotowsky.
Study supervision: Landzberg, Opotowsky.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Landzberg reported serving as a board member for the Adult Congenital Heart Association, receiving consulting fees from Actelion, and receiving grants from Gilead and the National Heart, Lung, and Blood Institute. Dr Opotowsky reported receiving research support from Actelion, Merck, Boston Children's Office of Faculty Development, Boston Children's Heart Foundation, Children's Heart Foundation of Nevada, and the National Institutes of Health. No other disclosures were reported.