Post-operative infections and obstacles to care for pediatric cardiac surgery patients in Hyderabad, India
Kunapareddy, Srujana Vuyyuru
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BACKGROUND: In India, an estimated 200,000 congenital heart defects are diagnosed each year but only 50 pediatric cardiac health centers exist with capacity to perform pediatric cardiac surgeries (PCS). Majority of the centers are private and have high cost of care. Hrudaya Foundation, a non-profit, was started to cover in-hospital costs of pediatric cardiac surgery for poor families. For the study, risk factors of post-operative infection (major outcome of PCS) were evaluated and gaps in care faced by Hrudaya Foundation patients were identified. METHODS: To identify risk factors associated with POI, retrospective cohort study was conducted. Medical records and foundation notes of 1028 interventional CATH and open heart surgery patients were examined. Chisq tests and logistic regressions on socio-economic and clinical factors were run to identify risk factors of POI for open heart surgery patients. The study also tested associations of patients’ community characteristics with pre-operative conditions and POI, like lack of access to improved latrines, distance to hospital, under & unemployment rate, and maternal illiteracy rates. To identify gaps in care, the study collected and analyzed interviews with 11 staff and 27 parents. The semi-structured interviews focused on care pathway from birth to post-discharge follow-up, financial obstacles, and an asset assessment. RESULTS: Pediatric open heart surgery patients had a 19% post-operative infection rate and a 5% mortality rate. Post-operative infections were significantly associated with age of 12 months and under, severely underweight, history of prior cardiac intervention, high risk surgery (RACHS-1 score 3 & 4), delayed sternal closure, and re-operation within same admission when the other risk factors were kept constant. POI did not have a statistically significant correlation with community level characteristics. The study found several gaps in care. Parents had difficulty getting a referral to affordable specialty cardiac care after diagnosis. Even after a referral to Hrudaya Foundation, parents still had to borrow large sums of money due to travel, lodging, and follow-up expenses. Financial constraints created barriers to maintain wellness before and after intervention. Most parents did not have consistent income and they were not aware of many assets in their communities. CONCLUSION: Patients with significant risk factors for POI should have more aggressive infection management. Though close to 41% of the sample were severely underweight, the risk factor was not recognized as actionable. Patients should get nutrition supplementation prior to surgery admission and parents should be notified of their child’s malnutrition status at discharge. Additionally, BPL parents need additional resource and system navigation assistance to reduce financial constraints and maintain their child’s follow-up care and nutrition.
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