Abstract
Objective:
To compare the incidence of and adjusted hazards for cardiometabolic morbidities among adults with and without cerebral palsy or spina bifida.
Methods:
Privately-insured beneficiaries were included if they had an ICD-9-CM diagnostic code for cerebral palsy or spina bifida (n=15,302). Adults without cerebral palsy or spina bifida were also included (n=1,935,480). Incidence estimates of common cardiometabolic morbidities were compared at 4-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident cardiometabolic morbidities.
Results:
Adults living with cerebral palsy or spina bifida had a higher 4-year incidence of any cardiometabolic morbidity (41.5% vs. 30.6%) as compared to adults without cerebral palsy or spina bifida, and differences were to a clinically meaningful extent. Fully adjusted survival models demonstrated that adults with cerebral palsy or spina bifida had a greater hazard for any cardiometabolic morbidity (Hazard Ratio [HR]: 1.52; 95%CI: 1.47, 1.57), and all but one cardiometabolic disorder (non-alcoholic fatty liver disease), and ranged from HR: 1.20 (1.15, 1.25) for hypercholesterolemia to HR: 1.86 (1.74, 1.98) for heart failure.
Conclusions:
Adults with cerebral palsy or spina bifida have a significantly higher incidence of and risk for common cardiometabolic morbidities, as compared to adults without cerebral palsy or spina bifida. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of cardiometabolic disease onset/progression in these higher risk populations.
Introduction
Cerebral Palsy is the most common pediatric-onset physical disability with an estimated prevalence ranging from 2.6–3.1 cases per 1,000 live births in the U.S.1 Cerebral palsy is caused by an insult or malformation of the developing brain which affects motor control centers, and causes alterations in growth, development, and overall health throughout the lifespan.2 Spina bifida encompasses a spectrum of birth defects (myelomeningocele, myelocele, meningocele, and rachischisis), which are the result of an incomplete closure of the spinal column and lead to exposure of or herniation to the spinal cord/meninges.3 Spina bifida occurs in approximately 3.5 cases per 10,000 live births in the U.S.,4 Although spina bifida has a lower case fatality rate than other neural tube defects, it often results in severe life-long disability and morbidity. The population of adults with cerebral palsy and spina bifida is expanding because of the steady or marginally increased prevalence5 and increases in the childhood survival rate6,7 in recent decades.
Despite the shortage of surveillance research to evaluate lifespan health and developmental trajectories in both of these populations, there is ample indication that adults living with cerebral palsy and spina bifida have significant and progressive functional decline, increased obesity, and risk for secondary chronic disease.8–16 However, there have been very few nationwide studies to examine the longitudinal trends of cardiometabolic disorders in these populations as compared to a non-cerebral palsy and non-spina bifida population. The purpose of this study was to examine the incidence of and risk for common cardiometabolic morbidities in a large sample of privately-insured adults with cerebral palsy or spina bifida, as compared to adults without.
Methods
Data Source
This study used a national, private insurance claims database, Clinformatics DataMart Database (OptumInsight, Eden Prairie, MN). This is a de-identified administrative claims database of over 80 million adults and children with commercial insurance representing those on a single, large U.S. private payer who had both medical and pharmacy coverage throughout the enrollment. Enrolled beneficiaries’ emergency department, outpatient, and inpatient encounters are captured. This study was deemed exempt by the University of Michigan Institutional Review Board at the researchers’ institution.
Sample Selection
All individuals 18 years of age and older at the time of their enrollment which could start from 2007 to 2017 were potentially eligible for this analysis. We excluded individuals with less than 12 months of continuous enrollment to require sufficient claim history. All medical claims excluding laboratory and outpatient pharmacy was considered to identify prevalence or treatment for these conditions during the enrollment period.
Identification of Patients with Cerebral palsy and Spina Bifida
All members with a diagnosis of cerebral palsy or spina bifida were identified using International Classification of Diseases, Ninth revision, Clinical Modification (ICD-9-CM) (Supplementary Table S1). Members that had cerebral palsy or spina bifida prior to 2007 were excluded due to poorer coverage of diagnosis codes during 2001 to 2006 in the database. Members without a diagnosis code in any position when they were 18 years or older during enrollment were excluded. Due to lack of clinical feasibility and different disease etiologies, a small number of members were excluded who had both cerebral palsy and spina bifida during enrollment. To allow adequate longitudinal follow up for all patients with cerebral palsy or spina bifida, only those that had four or more continuous years of enrollment following their starting date of enrollment within the study period were included.
A comparison cohort of controls without cerebral palsy or spina bifida were also identified using the same inclusion criteria. Additional exclusion criteria for identifying the control cohort included removal of any individual without cerebral palsy or spina bifida, but with a diagnosis of other physically disabling neurological disorders (e.g., paraplegia, quadriplegia, hemiplegia, traumatic spinal cord injury, and multiple sclerosis). Among remaining members without cerebral palsy or spina bifida, a 20% simple random sample of members was selected to represent the control group. Post-hoc analyses of demographic characteristics were compared between the 20% sample of controls and all controls to ensure no bias in control cohort attributable to random selection (Figure 1).
Figure 1.
Flow chart of subject inclusion and exclusion for final case and control cohorts.
Cardiometaboic Morbidities
Physician-diagnosed cardiometabolic health disorders were identified based on a single encounter that included at least one of pertinent ICD-9 or ICD-10 codes (in any position) (see Supplementary Table S1). The primary outcome was time in days to any incident cardiometabolic morbidity following enrollment on the plan. Secondary outcomes were component incident cardiometabolic morbidity, including: (1) cardiac dysrhythmias, (2) heart failure, (3) peripheral and visceral atherosclerosis, (4) non-alcoholic fatty liver disease, (5) chronic kidney disease, (6) type 2 diabetes, (7) hypercholesterolemia, and (8) hypertension.
Covariates
Covariates included age group split into three categories (18–44, 45–64, 65 or older), sex, race, educational attainment, household net worth, and a modified Elixhauser comorbidity index. The Elixhauser comorbidity index was modified to remove four conditions that would be correlated with incident cardiometabolic morbidity: congestive heart failure, cardiac arrhythmia, valvular disease, peripheral vascular disorders, complicated and uncomplicated hypertension, uncomplicated and complicated diabetes, and renal failure. Therefore, the revised index only considers 22 comorbidities (Supplemental Table S2).
Statistical Analysis
Bivariate analyses of baseline demographic characteristics between patients with cerebral palsy or spina bifida and controls were examined. For categorical variables, column percentages were compared between both groups using effect size calculations with Cohen’s h. The Cohen’s h effect size calculation was used since, due to large sample sizes, being statistically overpowered would not provide clinically meaningful differences in proportions between groups. For continuous variables, means and standard deviations as well as medians with upper and lower bounds on interquartile ranges were calculated. Cohen’s d standardized mean differences were calculated for continuous variables to ascertain clinically meaningful differences between groups.
Since cerebral palsy and spina bifida are congenital conditions, it is assumed that all adults already have the condition at the time of their enrollment by age 18. To capture full comorbidity history within the study period, all patients with sufficient continuous enrollment within the study period of four years were retained to enable sufficient follow-up. The cerebral palsy/spina bifida cohort, use the first year of enrollment out of the four-year enrollment to capture comorbidity history and to examine if any prevalent cardiometabolic outcomes existed.
To examine disease-free survival of individuals with cerebral palsy or spina bifida compared to controls, those patients that had no evidence of composite cardiometabolic morbidity in each group were plotted using Kaplan-Meier product limit survival curves for a three-year period. To establish incidence in claims, we used a one-year lookback period from the index date in each group to obtain evidence of any service utilization with a diagnosis of any cardiometabolic morbidity. These patients were excluded from the product-limit survival curves and other subsequent analyses.
To estimate the unadjusted and adjusted hazard of the composite and each cardiometabolic morbidity, a series of survival models were developed. For each cardiometabolic morbidity, all patients that had evidence of the specific cardiometabolic morbidity were excluded from the model. For example, if heart failure was being considered as the incident outcome, all patients with prevalent heart failure in the one year prior to the index date would be excluded from the model. Therefore, sample sizes of patients included for each outcome varied based on evidence of prevalent disease in the one year prior to the index date. Survival models were then used to quantify unadjusted and adjusted hazard ratios for each incident cardiometabolic morbidity. Appropriate survival models were based on distributional assumptions that included testing Weibull, lognormal, exponential, gamma, logistic, loglog, and Normal distribution with respect to the follow-up in days by minimizing critical model fit statistics. Critical assessment of Akaiki Information Criterion (AIC) was used as a basis for minimization amongst all candidate distributions. Use of the parametric Weibull regression for incident cardiometabolic outcome was applied stepwise. To examine the effects of incremental adjustment on the exposure variable (cerebral palsy or spina bifida), a series of models for each cardiometabolic outcome was evaluated. All patients were right censored if they did not experience the outcome in the follow-up period or disenrolled from the plan. Both unadjusted and all adjusted hazard ratios and 95% confidence intervals for the exposure to cerebral palsy/spina bifida were calculated.
All analyses were conducted using SAS 9.4 (SAS Institute, Cary, NC). Statistical testing was two-tailed with a significance level of 0.05 and effect sizes used a 0.2 meaningful difference cutoff.
Results
The median time in the plan for eligible enrollees was 7.0 (25th Percentile: 5.1; 75th Percentile: 9.7) and 6.7 (25th Percentile: 5.0; 75th Percentile: 9.3) years for patients with cerebral palsy or spina bifida vs controls respectively. Adults living with cerebral palsy or spina bifida had a higher 4-year incidence of any cardiometabolic morbidity (41.5% vs. 30.6%) as compared to adults without cerebral palsy or spina bifida, and differences were to a clinically meaningful extent. Moreover, adults with cerebral palsy or spina bifida had significantly higher incidence of all but one (non-alcoholic fatty liver disease) cardiometabolic outcomes, including cardiac dysrhythmias (20.2% vs. 12.5%), heart failure (6.4% vs. 3.4%), peripheral and visceral atherosclerosis (9.6% vs. 5.7%), chronic kidney disease (6.4% vs. 4.4%), type 2 diabetes (10.8% vs. 7.5%), hypercholesterolemia (16.0% vs. 7.5%), and hypertension (27.0% vs. 20.8%), as compared to adults without cerebral palsy or spina bifida (all P<.01 and SMD≥0.2) (Table 2).
Table 2.
Incidence of any and all cardiometabolic morbidities among adults with and without cerebral palsy or spina bifida with one-year clean enrollment period.
| †No Outcome at Baseline | ||
|---|---|---|
| Case/Denominator | Control/Denominator | |
| Any Cardiometabolic Morbidity | 3626/8730 (41.5%)* | 379360/1241712 (30.6%) |
| Cardiac dysrhythmias | 2768/13717 (20.2%)* | 225811/1804627 (12.5%) |
| Heart Failure | 943/14767 (6.4%)* | 64789/1901060 (3.4%) |
| Peripheral and visceral atherosclerosis | 1389/14462 (9.6%)* | 107557/1884626 (5.7%) |
| Non-Alcoholic Fatty Liver Disease | 491/15096 (3.3%) | 47373/1920273 (2.5%) |
| Chronic kidney disease | 950/14814 (6.4%)* | 83479/1895572 (4.4%) |
| Type 2 Diabetes | 1448/13410 (10.8%)* | 129400/1731190 (7.5%) |
| Hypercholesterolemia | 2158/13486 (16.0%)* | 237590/1719293 (13.8%) |
| Hypertension | 2798/10364 (27.0%)* | 290792/1395989 (20.8%) |
P<.01 and standard mean difference (SMD) ≥0.2
Denominators for both cases and controls reflect a one-year clean period during their enrollment for the specific condition. For instance, among cases (cerebral palsy/spina bifida), there exist 13,717 patients whose first year of enrollment had no evidence of Cardiac dysrhythmias; therefore, inferred incident Cardiac dysrhythmias could be estimated for this subset of the full cerebral palsy/spina bifida cohort. As a result, all patient cohorts’ denominators dynamically change conditional on the incident outcome being measured to ensure a clean period in the first year of enrollment.
A Kaplan-Meier curve for the unadjusted disease-free survival for any cardiometabolic morbidity in adults with cerebral palsy or spina bifida and controls are demonstrated in Figure 2. Unadjusted survival models demonstrated a robust increased hazard ratio (HR) for each of the incident cardiometablic morbidities among adults with cerebral palsy or spina bifida, and ranged from HR: 1.17 (1.13, 1.23) for hypercholesterolemia to HR: 1.90 (1.79, 2.03) for heart failure (all p<0.001). Fully adjusted survival models demonstrated that adults with cerebral palsy or spina bifida had a greater hazard for any cardiometabolic morbidity (HR: 1.52; 95%CI: 1.47, 1.5) (Supplemental Table S3), and all but one cardiometabolic disorder (non-alcoholic fatty liver disease), and ranged from HR: 1.20 (1.15, 1.25) for hypercholesterolemia, to HR: 1.86 (1.74, 1.98) for heart failure (Table 3).
Figure 2.
Disease-free survival and Kaplan-Meier product-limit survival curves (3-year) for adults with cerebral palsy or spina bifida (blue) and without cerebral palsy or spina bifida (red), for any cardiometabolic morbidity.
Table 3.
Survival models with parametric Weibull regression was completed stepwise for each incident cardiometabolic outcome to examine the effects of incremental adjustment on the exposure variable (cerebral palsy or spina bifida).
| Model 1 | Model 2 | Model 3 | Model 4 | |
|---|---|---|---|---|
| Any Cardiometabolic Morbidity | 1.48 (1.43, 1.53)*** | 1.73 (1.68, 1.79)*** | 1.53 (1.48, 1.58)*** | 1.52 (1.47, 1.57)*** |
| Cardiac dysrhythmias | 1.69 (1.62, 1.75)*** | 1.84 (1.77, 1.91)*** | 1.53 (1.47, 1.59)*** | 1.52 (1.47, 1.58)*** |
| Heart Failure | 1.90 (1.79, 2.03)*** | 2.48 (2.32, 2.65)*** | 1.94 (1.82, 2.07)*** | 1.86 (1.74, 1.98)*** |
| Peripheral and visceral atherosclerosis | 1.72 (1.63, 1.81)*** | 2.28 (2.16, 2.40)*** | 1.85 (1.76, 1.95)*** | 1.80 (1.70, 1.89)*** |
| Non-Alcoholic fatty liver disease | 1.32 (1.21, 1.45)*** | 1.40 (1.28, 1.53)*** | 0.97 (0.89, 1.06) | 0.96 (0.88, 1.05) |
| Chronic kidney disease | 1.47 (1.38, 1.57)*** | 1.88 (1.76, 2.00)*** | 1.58 (1.48, 1.68)*** | 1.53 (1.43, 1.63)*** |
| Type 2 Diabetes | 1.47 (1.40, 1.55)*** | 1.68 (1.59, 1.77)*** | 1.49 (1.41, 1.57)*** | 1.45 (1.38, 1.53)*** |
| Hypercholesterolemia | 1.17 (1.13, 1.23)*** | 1.32 (1.26, 1.37)*** | 1.20 (1.15, 1.25)*** | 1.20 (1.15, 1.25)*** |
| Hypertension | 1.35 (1.30, 1.40)*** | 1.64 (1.58, 1.70)*** | 1.50 (1.44, 1.56)*** | 1.46 (1.40, 1.51)*** |
Model 1: Unadjusted
Model 2: Model 1 + Demographic variables (age, sex, race, geographic region).
Model 3: Model 1 + Model 2 + Modified Elixhauser Comorbidity Index
Model 4: Model 1 + Model 2 + Model 3 + Education + Income
As with incidence estimates (Table 2), all survival models used cases (cerebral palsy/spina bifida) and control cohorts consistent with Table 2, which required a one-year clean period with no evidence of the condition being
P<0.001
Discussion
The primary finding of this study was that adults living with cerebral palsy or spina bifida had a higher incidence of and adjusted hazard for any and all cardiometabolic morbidities than adults without cerebral palsy or spina bifida. We determined that the incidence of cardiac dysrhythmias, heart failure, atherosclerosis, non-alcoholic fatty liver disease, chronic kidney disease, type 2 diabetes, hypercholesterolemia, and hypertension were between 3.3% (non-alcoholic fatty liver disease) to 27% (hypertension) in adults with cerebral palsy and spina bifida within a nationwide claims database. Importantly, these diseases are occurring at a young age in individuals with cerebral palsy or spina bifida, with 80% of our study population being less than 65 years old and approximately 40% between the ages of 18–44. These findings raise critical questions about preventable cardiometabolic health complications in cerebral palsy and spina bifida across the lifespan. We and others have proposed rationale for development of registries to better understand and prevent age-related chronic disease risk in the cerebral palsy population;17–19 however, this is the first and largest study to examine the longitudinal trends and disease-free survival of primary cardiometabolic diseases among adults with cerebral palsy and spina bifida. Based on these findings and those of other recent reports showing increased risk of chronic noncommunicable diseases among adults with cerebral palsy and spina bifida,8–15,20,21 as well as recent work showing an increased risk of death due to diseases of the circulatory and respiratory systems in adults with cerebral palsy,22 future efforts are needed to facilitate the development of appropriate clinical screening algorithms and design of early behavioral interventions to reduce risk of cardiometabolic disease onset/progression in these populations.
This must be initiated through intense intervention and education of the patient around physical activity and other healthy lifestyles. Early detection (e.g., regular lipid panels, cardiac stress tests, fasting glucose, etc.) is critical to risk stratify individuals on the basis of need for specialty services and care coordination. Moreover, appropriate body composition screening is necessary to take into consideration more sensitive assessments of abdominal adiposity (e.g., waist circumference), as many individuals with physical disabilities are risk for normal weight obesity.23 Perhaps most importantly, habitual activity behaviors are known to track from adolescence into adulthood,24 and moreover, that physical inactivity is a modifiable risk factor for various cardiometabolic diseases, cancer and early all-cause mortality, evaluating the contributing factors of participation among individuals with cerebral palsy and spina bifida may help to inform viable public health interventions. Individuals with cerebral palsy and spina bifida have much higher levels of sedentary behavior and lower levels of physical activity as compared to the general population25. The 2018 Physical Activity Guidelines (PAG) for Americans provides recommendations on amount and intensity of physical activity for the general population to decrease risk for cardiovascular disease. The PAG recommendations for individuals living with chronic disease or disability are similar, with suggestions to adjust to the individual’s ability26. Guidelines developed for individuals with cerebral palsy recommend a two pronged approach, including breaking up sedentary time and starting a regular physical activity program at a lower level and building slowly25. Due to the large amounts of sedentary time of many individuals with cerebral palsy and spina bifida, the recommendation to break up sedentary time can be an intervention that may be more easily implemented and start to provide some reduction in metabolic risk. Encouraging physical activity at any level continues to remain an important educational intervention and the link between physical activity and improved cardiovascular health must be emphasized.
Limitations and Strengths
We were unable to determine the severity of cerebral palsy or spina bifida through claims-based data. It is likely that our sample is more reflective of a healthier, higher functioning, and potentially more affluent segment of the cerebral palsy or spina bifida population, as they had to be enrolled in private insurance, either by purchasing their own insurance, or by being covered through employment or marriage to someone who had private insurance. Therefore, results and comparisons to adults without cerebral palsy or spina bifida could be conservative estimates, and the true extent of cardiometabolic morbidity may be underestimated in this study. Secondly, we cannot rule out time-varying confounding since baseline measurements of all covariates were included in our final models. Thus, whether having cerebral palsy or spina bifida “causes” an elevated risk for earlier-onset cardiometabolic disease, or if changes in other health parameters (e.g., increased sedentary behavior, a known predictor of cardiometabolic disease risk) themselves, are a cause of poor cardiometabolic health, is an interesting topic. Unmeasured confounding could also be within proxy variables of appropriate care which might mitigate cardiometabolic morbidity risk (and were not considered). This would lend credence to additional follow-up work to understand the care pathway to success for these patients. Lastly, administrative claims data may be prone to inaccurate coding of medical diagnoses, such as cerebral palsy or spina bifida, as well as chronic diseases, which may have an effect on our incidence estimates. While validation studies have shown that using >1 claim for a medical condition improves the ability to identify beneficiaries with that medical condition,27,28 single claim-based algorithms have been reported to have moderate-to-high positive predictive value (~80%) or specificity (up to 96%).27,29,30 However, the accuracy of identifying medical conditions using claims data depends on the number of years for the study period29 and the medical condition examined.27,29–31
A strength of this study is the large and longitudinal sample of adults with cerebral palsy or spina bifida. It can be challenging to gather data on these clinical sub-populations, and very little is known about health outcomes among individuals with cerebral palsy or spina bifida as they transition throughout adulthood. Moreover, most large administrative claims databases do not contain some socioeconomic indicators such as net worth, race, and location (division). Lastly, while clinical trials may be considered the “gold standard” in clinical research, cohort studies are less expensive, include broader patient populations, and are more efficient. In fact, there is little evidence to support the superiority of clinical trials over observational studies.32
Conclusion
Adults with cerebral palsy or spina bifida have an elevated risk of developing a variety of cardiometabolic morbidities compared to the general adult population of privately insured beneficiaries, and these elevated risks occur at a relatively young age. Individuals with disabilities infrequently utilize healthcare services as part of their routine clinical care. Increasing clinical awareness of cardiometabolic health disorders among adults with cerebral palsy and spina bifida, improving clinical screening strategies and early preventive health interventions, and developing efficient referral resources for coordinated care may help reduce the burden of cardiometabolic health disorders in these population.
Supplementary Material
Supplemental Table S1. Diagnostic codes for cerebral palsy, spina bifida, and all cardiometabolic morbidities using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.
Supplemental Table S2. Modified Elixhauser Index.
Supplemental Table S3. Fully adjusted survival model for any cardiometabolic morbidity.
Table 1.
Descriptive characteristics among adults with CP or SB (case) or without cerebral palsy or spina bifida (control).
| Case | Control | |
|---|---|---|
| Overall | 15,302 (100%) | 1,935,480 (100%) |
| Full Enrollment Length | ||
| Mean (SD) | 7.8 (3.3) | 7.6 (3.3) |
| Median (Q1-Q3) | 7.0 (5.1–9.7) | 6.7 (5.0–9.3) |
| Years Post Eligibility Start Date † | ||
| Mean (SD) | 5.8 (2.2) | 5.5 (2.2) |
| Median (Q1-Q3) | 5.3 (4.0–7.3) | 5.0 (3.7–6.8) |
| Age Group | ||
| 18–44 | 7055 (46.1%) | 798257 (41.2%) |
| 45–64 | 5255 (34.3%) | 617997 (31.9%) |
| 65 or Older | 2992 (19.6%) | 519226 (26.8%) |
| Gender | ||
| Female | 8666 (56.6%) | 1012200 (52.3%) |
| Male | 6636 (43.4%) | 923280 (47.7%) |
| Race | ||
| Asian | 300 (2.0%) | 75437 (3.9%) |
| Black | 1496 (9.8%) | 155609 (8.0%) |
| Hispanic | 1268 (8.3%) | 175966 (9.1%) |
| Unknown/Missing | 3161 (20.7%) | 379802 (19.6%) |
| White | 9077 (59.3%) | 1148666 (59.3%) |
| Education | ||
| <High School Diploma | 86 (0.6%) | 10761 (0.6%) |
| High School Diploma | 4465 (29.2%) | 469829 (24.3%) |
| <Bachelor Degree | 8107 (53.0%) | 1021803 (52.8%) |
| Bachelor Degree | 2238 (14.6%) | 371346 (19.2%) |
| Unknown/Missing | 406 (2.7%) | 61741 (3.2%) |
| Net Worth | ||
| Unknown | 3334 (21.8%) | 346012 (17.9%) |
| <$25K | 3234 (21.1%) | 302790 (15.6%) |
| $25K-$149K | 2695 (17.6%) | 340966 (17.6%) |
| $150K-$249K | 1379 (9.0%) | 196032 (10.1%) |
| $250K-$499K | 2088 (13.6%) | 313883 (16.2%) |
| ≥$500K | 2572 (16.8%) | 435797 (22.5%) |
All adults with cerebral palsy and spina bifida have their Index Date set the same as start of eligibility date (start of 2007, year when turned 18, or enrollment start date, whichever was the latest)
Acknowledgments
Funding/Support:
This research was developed in part under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR #90RTHF0001-01-00).
Footnotes
Conflict of Interest Statement:
Mark D. Peterson: none
Paul Lin: none
Neil Kamdar: none
Elham Mahmoudi: none
Mary M. Schmidt: none
Heidi Haapala: none
Edward A. Hurvitz: none
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Table S1. Diagnostic codes for cerebral palsy, spina bifida, and all cardiometabolic morbidities using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.
Supplemental Table S2. Modified Elixhauser Index.
Supplemental Table S3. Fully adjusted survival model for any cardiometabolic morbidity.