Measuring global health-related quality of life in children undergoing hematopoietic stem cell transplant: a longitudinal study

BACKGROUND

Pediatric health-related quality of life (HRQL) measures explore multiple domains of HRQL. To ease administration, burden, and implementation, we created a 7-item unidimensional global HRQL scale for children. This paper evaluates the psychometric properties of the global HRQL scale in children undergoing hematopoietic stem cell transplant (HSCT) and describes the trajectory of global HRQL scores over the 12-month course following HSCT.

METHODS

As part of two longitudinal HSCT studies, HRQL was collected on 312 parent-child dyads using the Child Health Ratings Inventories. Parents of children aged 5-18 completed the pediatric global HRQL scale about their child and 117 adolescents completed the scale themselves. Psychometric properties were compared across both raters. Two repeated measures models were built to describe trajectories of (1) global HRQL for all children based on parent proxy report and (2) global HRQL for adolescents based on adolescent self-report and parent proxy report.

RESULTS

Internal consistency reliability was high for parent proxy report and adolescent self-report (Cronbach's alpha 0.9, 0.8, respectively). Unidimensionality was verified using principal components analysis. Both models indicated decreased global HRQL in the presence of early complications related to HSCT and Model 1 further indicated decreased HRQL in the presence of later complications. Model 2 showed that parent proxies reported lower global HRQL scores than adolescent self-report.

CONCLUSIONS

This study has demonstrated the unidimensionality and strong psychometric properties of a 7-item global HRQL scale in a sample of children undergoing HSCT. Despite its brevity, scale scores vary in clinically meaningful ways. Future applications of this scale are encouraged.

Health-related quality of life (HRQL) in children with sickle cell disease and thalassemia following hematopoietic stem cell transplant (HSCT)

BACKGROUND

Little is known regarding the health-related quality of life (HRQL) trajectory of children with sickle cell disease or thalassemia ("hemoglobinopathies") following hematopoietic stem cell transplantation (HSCT).

PROCEDURES

We serially evaluated the HRQL of 13 children with hemoglobinopathies who received HSCT during two prospective multi-center studies using the Child Health Ratings Inventories (CHRIs). The HRQL scores among children with hemoglobinopathies, as reported separately by the children and their parents were compared using repeated measures models to scores of a comparison group of children receiving HSCT for malignancies or severe aplastic anemia.

RESULTS

The sample included 13 children with hemoglobinopathies (median age: 8 years, range 5-18) and 268 children in the comparison group (median age: 11 years, range 5-18). There were similar rates of early infection, chronic graft versus host disease, and all-cause mortality between the two groups. There was no significant difference in recovery to baseline scores for physical, emotional, and role functioning by 3 months for either group. Children with hemoglobinopathies had higher HRQL scores for physical (beta = 12, se = 5.5, P = 0.01) and baseline emotional functioning (beta = 11.6, se = 5.5, P = 0.03) than the comparison group. For all domains for both groups, parent reports demonstrated a nadir at 45 days with recovery to baseline by 3 months following transplant. Children's ratings were higher than those of their parents in both diagnostic groups.

CONCLUSIONS

Children with hemoglobinopathies had higher physical and emotional functioning scores prior to HSCT and experienced a similar pattern of recovery to their baseline functioning by 3 months post-HSCT when compared to children receiving HSCT for acquired conditions.

Survey of United States child and adolescent psychiatrists' cardiac screening practices prior to starting patients on stimulants

OBJECTIVE

The purpose of this study was to determine psychiatrists' barriers, attitudes, and practices regarding cardiac screening prior to initiating stimulants in children with attention-deficit/hyperactivity disorder.

BACKGROUND

Professional and federal oversight organizations recently have debated the evidence regarding sudden cardiac death (SCD) risk with stimulants, and have published guidelines recommending cardiac screening. It is not known how psychiatrists have responded.

METHODS

This study was a cross-sectional survey of 1,600 randomly-selected U.S. members of the American Academy of Child and Adolescent Psychiatry. Analyses included descriptive statistics and logistic regression.

RESULTS

Response rate was 40%; 96% met eligibility criteria. Barriers to identifying cardiac disorders in general included ability to perform a routine physical examination (74%) and care coordination with primary care providers (35%). Only 27% agreed that SCD risk warranted cardiac assessment. Prior to starting a patient on stimulants, 95% of psychiatrists obtained a routine history. The majority either conducted (9%), or relied on primary care providers to conduct (67%) a physical examination; 26% did not obtain a physical examination. Nineteen percent of psychiatrists ordered an electrocardiogram (ECG), of those, non-mutually exclusive reasons for ordering an ECG included standard practice procedure (62%), clinical findings (27%), medicolegal considerations (25%), and guideline adherence (24%). On multivariate modeling, psychiatrists were less likely to conduct cardiac screening themselves if in private practice (referent: academic medical center), if >50% of their patients had private insurance, or if they believed their ability to perform a physical examination to be a barrier. When modeling cardiac screening performed by any healthcare professional (e.g., psychiatrist, primary care practitioner), screening was less likely if the psychiatrist was practicing in a community mental health center (referent: academic medical center), was male, or if >50% of that psychiatrist's patients had private insurance.

CONCLUSION

Findings suggest the tacit interplay between primary care and psychiatry for the assessment and management of medical risks associated with psychotropic medications should be improved, and solutions prioritized.

Costs and benefits of targeted screening for causes of sudden cardiac death in children and adolescents

BACKGROUND

Sudden cardiac death in children is a rare but devastating event. Experts have debated the merits of community-based screening programs using an ECG and targeting 2 potential high-risk groups: school-aged children initiating stimulant medications to treat attention-deficit/hyperactivity disorder and adolescents participating in sports.

METHODS AND RESULTS

Simulation models incorporating detailed prevalence, sensitivity and specificity, and treatment algorithms were built to determine the cost-effectiveness of targeted sudden cardiac death screening. Clinical care algorithms were constructed for asymptomatic children initiating stimulants for attention-deficit/hyperactivity disorder (8 years of age) or participating in sports (14 years of age) and presenting with a positive ECG finding suggestive of 1 of the 3 most common pediatric disorders causing sudden cardiac death and identifiable by ECG. Information to develop simulation model assumptions was drawn from the existing literature, Medicaid fees, and expert judgment. Sensitivity analyses examined parameter ranges to identify influential sources of uncertainty. Outcomes included costs and lost life-years caused by condition-related mortality. Our models estimate that screening for all 3 conditions simultaneously would reduce sudden death risk by 3.6 to 7.5 × 10(-5) with projected life expectancy increases of 0.8 to 1.6 days per screened individual. The incremental cost-effectiveness of screening is $91,000 to $204,000 per life-year. Sensitivity analysis showed that assumed disease prevalence, baseline mortality, and the relative risk of mortality resulting from stimulant medication use and sports participation had the greatest impact on estimated cost-effectiveness.

CONCLUSION

Results based on assumptions favoring sudden cardiac death screening indicated that its cost is high relative to its health benefits.

Parental caregiving of children prior to hematopoietic stem cell transplant

Using the Caregiver Reaction Assessment (CRA), we assessed positive reactions and burdens of the caregiving experience among parental caregivers (n = 189) of children scheduled to undergo hematopoietic stem cell transplant. Although widely used in non-parental caregivers, the CRA has not been used in parents of pediatric patients. Reliability (Cronbach's alpha: .72-.81 vs. .63) and concurrent validity (correlation: .41-.61 vs. .28) were higher for negatively framed than positively framed subscales. Results indicate that the caregiving experience is complex. The parents experienced high caregiver's esteem and moderate family support, but also negative impacts on finances and schedule, and to a lesser degree, health. Compared to non-parental caregivers, parental caregivers experienced higher esteem and more impact on finances and schedule.

Electrocardiogram screening for disorders that cause sudden cardiac death in asymptomatic children: a meta-analysis

BACKGROUND AND OBJECTIVES

Pediatric sudden cardiac death (SCD) occurs in an estimated 0.8 to 6.2 per 100 000 children annually. Screening for cardiac disorders causing SCD in asymptomatic children has public appeal because of its apparent potential to avert tragedy; however, performance of the electrocardiogram (ECG) as a screening tool is unknown. We estimated (1) phenotypic (ECG- or echocardiogram [ECHO]-based) prevalence of selected pediatric disorders associated with SCD, and (2) sensitivity, specificity, and predictive value of ECG, alone or with ECHO.

METHODS

We systematically reviewed literature on hypertrophic cardiomyopathy (HCM), long QT syndrome (LQTS), and Wolff-Parkinson-White syndrome, the 3 most common disorders associated with SCD and detectable by ECG.

RESULTS

We identified and screened 6954 abstracts, yielding 396 articles, and extracted data from 30. Summary phenotypic prevalences per 100 000 asymptomatic children were 45 (95% confidence interval [CI]: 10-79) for HCM, 7 (95% CI: 0-14) for LQTS, and 136 (95% CI: 55-218) for Wolff-Parkinson-White. The areas under the receiver operating characteristic curves for ECG were 0.91 for detecting HCM and 0.92 for LQTS. The negative predictive value of detecting either HCM or LQTS by using ECG was high; however, the positive predictive value varied by different sensitivity and specificity cut-points and the true prevalence of the conditions.

CONCLUSIONS

Results provide an evidence base for evaluating pediatric screening for these disorders. ECG, alone or with ECHO, was a sensitive test for mass screening and negative predictive value was high, but positive predictive value and false-positive rates varied.

Cardiac screening prior to stimulant treatment of ADHD: a survey of US-based pediatricians

OBJECTIVES

To determine pediatricians' attitudes, barriers, and practices regarding cardiac screening before initiating treatment with stimulants for attention-deficit/hyperactivity disorder.

METHODS

A survey of 1600 randomly selected, practicing US pediatricians with American Academy of Pediatrics membership was conducted. Multivariate models were created for 3 screening practices: (1) performing an in-depth cardiac history and physical (H & P) examination, (2) discussing potential stimulant-related cardiac risks, and (3) ordering an electrocardiogram (ECG).

RESULTS

Of 817 respondents (51%), 525 (64%) met eligibility criteria. Regarding attitudes, pediatricians agreed that both the risk for sudden cardiac death (SCD) (24%) and legal liability (30%) were sufficiently high to warrant cardiac assessment; 75% agreed that physicians were responsible for informing families about SCD risk. When identifying cardiac disorders, few (18%) recognized performing an in-depth cardiac H & P as a barrier; in contrast, 71% recognized interpreting a pediatric ECG as a barrier. When asked about cardiac screening practices before initiating stimulant treatment for a recent patient, 93% completed a routine H & P, 48% completed an in-depth cardiac H & P, and 15% ordered an ECG. Almost half (46%) reported discussing stimulant-related cardiac risks. Multivariate modeling indicated that ≥1 of these screening practices were associated with physicians' attitudes about SCD risk, legal liability, their responsibility to inform about risk, their ability to perform an in-depth cardiac H & P, and family concerns about risk.

CONCLUSIONS

Variable pediatrician attitudes and cardiac screening practices reflect the limited evidence base and conflicting guidelines regarding cardiac screening. Barriers to identifying cardiac disorders influence practice.

Children's psychological distress during pediatric HSCT: parent and child perspectives

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) can be challenging to pediatric recipients and their families. Little is known about the recipients' psychological status as they initiate treatment and in the year afterwards. The purpose of this study is to describe the psychological status of 107 pediatric HSCT recipients from their parents' perspective, and to compare reports from parents and children in a subset of 55 children. We hypothesized that there would be discrepancies between parent and child report of child distress.

PROCEDURE

Multi-site, prospective study of eligible child participants and their parents who completed selected modules from the Structured Clinical Interview for DSM-IV-TR, Childhood Version (KID-SCID) the month before and one year after HSCT. Diagnoses were threshold or subthreshold.

RESULTS

According to parents, nearly 30% of children had anxiety disorder both before and after HSCT; approximately half of these met threshold criteria. Agreement between parents and children for anxiety disorders was poor at baseline (κ = -0.18, 95%CI = -0.33, -0.02) and fair at 12 months (κ  = 0.31, 95%CI  = -0.04, 0.66). Agreement about mood disorders was fair at baseline (10% prevalence, κ =  0.39, 95%CI = -0.02, 0.79) and moderate at 12 months (14% prevalence, κ = 0.41, 95%CI =  0.02, 0.80).

CONCLUSIONS

Anxiety (30%) and mood (10-14%) symptoms are common in children both before and after HSCT; parent and child reports of these symptoms do not agree. Input from parents and children is recommended to identify more accurately children who may need additional intervention during and following HSCT.

Factors associated with parental activation in pediatric hematopoietic stem cell transplant

Patient activation, the extension of self-efficacy into self-management, is an essential component of effective chronic care. In pediatric populations, caregiver activation is also needed for proper disease management. This study investigates the relationships between parental activation and other characteristics of parent-child dyads (N = 198) presenting for pediatric hematopoietic stem cell transplant. Parental activation concerning their child's health was assessed using the Parent Patient Activation Measure (Parent-PAM), a modified version of the well-validated Patient Activation Measure (PAM). Using hierarchical linear regression and following the Belsky process model for determining parenting behaviors, a multivariate model was created for parental activation on behalf of their child that showed that the parent's age, rating of their own general health, self-activation, and duration of the child's illness were significantly related to Parent-PAM score. Our findings characterize a potentially distinct form of activation in a parent-child cohort preparing for a demanding clinical course.

Public health emergency preparedness at the local level: results of a national survey

OBJECTIVE

To study the relationship between elements of public health infrastructure and local public health emergency preparedness (PHEP).

DATA SOURCES/STUDY SETTING

National Association of County and City Health Officials 2005 National Profile of Local Health Departments (LHDs).

STUDY DESIGN

Cross-sectional.

PRINCIPAL FINDINGS

LHDs serving larger populations are more likely to have staff, capacities, and activities in place for an emergency. Adjusting for population size, the presence of a local board of health and the LHDs' experience in organizing PHEP coalitions were associated with better outcomes.

CONCLUSIONS

The results of this study suggest that more research should be conducted to investigate the benefit of merging small health departments into coalitions to overcome the inverse relationship between preparedness and population size of the jurisdiction served by the LHD.

Public health systems research in emergency preparedness: a review of the literature

BACKGROUND

Despite the acknowledged promise of developing a public health systems research (PHSR) agenda for emergency preparedness, there has been no systematic review of the literature in this area. The purpose of this study was to conduct a systematic literature review in order to identify and characterize the PHSR literature produced in the U.S. in the past 11 years in the field of public health emergency preparedness.

EVIDENCE ACQUISITION

Articles were searched in MEDLINE and EMBASE, as well as in the gray literature. Two independent reviewers classified the articles according to study design and IOM public health emergency preparedness (PHEP) research goal areas.

EVIDENCE SYNTHESIS

From January 1, 1997, through December 31, 2008, there were 547 articles that met the inclusion criteria that were published. It was possible to classify 314 (57%) articles into at least one of the four IOM PHEP research goal areas. Of these, 61 (11%) addressed Research Area 1 (usefulness of training); 39 (7%) addressed Research Area 2 (communications in preparedness and response); 193 (35%) addressed Research Area 3 (sustainable preparedness and response systems); and 39 (7%) addressed Research Area 4 (criteria and metrics to measure effectiveness and efficiency). Twenty-one studies (4%) could be classified into more than one category. The majority of the articles (81%), including commentaries/reviews and case studies, were based on qualitative analysis. Commentaries/review articles were the most common study types (62%).

CONCLUSIONS

Since 2001, the PHSR literature on PHEP issues has grown at about 33% per year. However, most studies lack a rigorous design, raising questions about the validity of the results.