摘要：Objectives. We examined the association between health insurance and survival of infants with congenital heart defects (CHDs), and whether medical insurance type contributed to racial/ethnic disparities in survival. Methods. We conducted a population-based, retrospective study on a cohort of Florida resident infants born with CHDs between 1998 and 2007. We estimated neonatal, post-neonatal, and infant survival probabilities and adjusted hazard ratios (AHRs) for individual characteristics. Results. Uninsured infants with critical CHDs had 3 times the mortality risk (AHR = 3.0; 95% confidence interval = 1.3, 6.9) than that in privately insured infants. Publicly insured infants had a 30% reduced mortality risk than that of privately insured infants during the neonatal period, but had a 30% increased risk in the post-neonatal period. Adjusting for insurance type reduced the Black–White disparity in mortality risk by 50%. Conclusions. Racial/ethnic disparities in survival were attenuated significantly, but not eliminated, by adjusting for payer status. Major health care reform efforts have sought to improve access to health care by reducing barriers associated with the lack of or insufficient insurance coverage. 1,2 Although literature exists on the impact of insurance coverage on health care utilization, there is a relative dearth of population-based evidence on whether insurance coverage is associated with significant health outcomes, particularly among the most medically vulnerable groups, which includes children with birth defects. Infants born with congenital heart defects (CHDs), the most common birth defect and leading cause of death among those born with birth defects, often require timely specialized surgical and medical care 3–5 ; therefore, access to care and service utilization may be important predictors of survival. Although recent advances in surgical interventions have resulted in improved survival rates among infants born with CHDs, mortality remains a significant public health problem, and unexplained racial/ethnic disparities add health equity concerns. 6–9 These racial/ethnic disparities in survival suggest that identification of contributing factors could potentially lead to effective strategies to reduce CHD-related infant and childhood mortality, which has been identified as a national public health priority by Healthy People 2020 . 10 Some hospital-based studies have found positive associations between insurance type and postoperative mortality of infants with CHDs. 6,8,11–14 Population-based birth defects surveillance programs provide the most complete ascertainment of infants born with major birth defects in a population that, when linked with vital records, provide a more complete source of case data for survival studies. However, most published population-based studies have had only a limited ability to examine factors associated with survival. 15–22 Despite the high sensitivity and accuracy of surveillance data, 23 payer information is not typically available beyond that reported on the birth certificate. We used population-based birth defects surveillance data, which were linked with data for each hospitalization, to obtain information on the type of health insurance used for hospitalizations initiated during the first year of life. Using these unique data, we examined the association between survival and health insurance type, and the association of health insurance type on racial/ethnic disparities in survival of infants born with CHDs.
