Geospatial disparities in pediatric heart failure care in China: a multicenter cohort study

Background: Pediatric heart failure (PHF) is a lethal syndrome with a distinct pathophysiology from adult heart failure, posing a significant public health challenge in China. However, the impact of the nation's profound geospatial healthcare disparities on this vulnerable population remains unquantified. This national multicenter cohort study aimed to systematically examine the association between geographic location and PHF patient profiles, management, and survival outcomes. Methods: We conducted a retrospective analysis of 2,903 pediatric inpatients (≤18 years) with a primary HF diagnosis from 30 centers (2013-2022). Patients with >20% missing data were excluded. Geospatial analysis stratified cohorts into Eastern, Western, and Central China. The primary outcome was in-hospital mortality, analyzed using multivariable logistic regression adjusted for key clinical confounders including age, etiology, and disease severity. Length of stay (LOS) was analyzed using a Gamma generalized linear model. All analyses were performed using Python (version 3.12). Results: Profound geospatial disparities were identified. Western patients presented significantly younger (median 6.93 months) with a higher prevalence of complex congenital heart disease (39.2%) and more severe clinical status (85.9% ROSS Class III-IV). In contrast, cardiomyopathy was the dominant etiology in the East (42.2%). Utilization of guideline-directed medical therapy (GDMT) was lowest in non-Eastern regions. Critically, geographic region was independently associated with mortality. Compared to the East, the adjusted odds of death were 2.58-fold higher in the West (95% CI: 1.5-4.45) and 3.54-fold higher in the Central region (95% CI: 2.11-5.94). Conclusion: This study provides robust, national-level evidence that geographic location in China is a potent independent predictor of survival for children with heart failure, revealing a tiered healthcare landscape. These findings underscore an urgent public health imperative for targeted interventions to mitigate these disparities and establish equitable care systems through regional capacity building and standardized referral pathways.