摘要：Objectives. We examined the association between survival of infants with severe congenital heart defects (CHDs) and community-level indicators of socioeconomic status. Methods. We identified infants born to residents of Arizona, New Jersey, New York, and Texas between 1999 and 2007 with selected CHDs from 4 population-based, statewide birth defect surveillance programs. We linked data to the 2000 US Census to obtain 11 census tract–level socioeconomic indicators. We estimated survival probabilities and hazard ratios adjusted for individual characteristics. Results. We observed differences in infant survival for 8 community socioeconomic indicators ( P < .05). The greatest mortality risk was associated with residing in communities in the most disadvantaged deciles for poverty (adjusted hazard ratio [AHR] = 1.49; 95% confidence interval [CI] = 1.11, 1.99), education (AHR = 1.51; 95% CI = 1.16, 1.96), and operator or laborer occupations (AHR = 1.54; 95% CI = 1.16, 1.96). Survival decreased with increasing numbers of indicators that were in the most disadvantaged decile. Community-level mortality risk persisted when we adjusted for individual-level characteristics. Conclusions. The increased mortality risk among infants with CHDs living in socioeconomically deprived communities might indicate barriers to quality and timely care at which public health interventions might be targeted. Advances in medical and surgical care for individuals born with congenital heart defects (CHDs) has improved survival in recent years, yet despite this progress, mortality due to CHDs remains a significant public health issue. 1,2 CHDs are the most common type of birth defect and are the leading cause of death among those born with birth defects. 3,4 CHDs necessitate medical and often surgical intervention early in life, and timely detection and quality care can improve health outcomes. 5,6 Medical factors such as low birth weight, preterm birth, severity of the condition, and the presence of comorbidities are well-established risk factors for mortality, particularly during the neonatal period. 7 Nonmedical factors (particularly race/ethnicity) also play an important role in the survival of infants with birth defects and potentially contribute significantly to unexplained survival differences. 8 Several factors that influence access to and use of care have been examined among cohorts of infants born with CHDs, but these have been limited to race/ethnicity, 2,9–16 medical insurance, 9,16–20 and distance to specialty care. 10,17,21,22 Assessment of the potential impact of socioeconomic status (SES) on survival has been challenging, largely because SES has been defined and measured in many ways and is often unavailable in large, population-based data sets. SES has been investigated as a risk factor for the occurrence of different types of birth defects, 23–28 but few published population-based studies have included SES as a risk factor for CHD-related mortality. Community-level factors related to socioeconomic conditions have been associated with decreased access to pediatric subspecialty care and early mortality of infants with low birth weight, 29,30 and they might provide evidence of contextual factors that could potentially influence the survival of infants with CHDs, who require timely medical intervention. 31–33 In this population-based study, we estimated the association of census tract–level indicators of SES with the survival of infants born with CHDs and examined the potential impact of communities on observed racial/ethnic disparities in infant survival.
