1
|
Thompson-Paul AM, Kraus EM, Porter RM, Pierce SL, Kompaniyets L, Sekkarie A, Goodman AB, Jackson SL. Pediatric Lipid Screening Prevalence Using Nationwide Electronic Medical Records. JAMA Netw Open 2024; 7:e2421724. [PMID: 39042409 PMCID: PMC11267408 DOI: 10.1001/jamanetworkopen.2024.21724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/07/2024] [Indexed: 07/24/2024] Open
Abstract
Importance Universal screening to identify unfavorable lipid levels is recommended for US children aged 9 to 11 years and adolescents aged 17 to 21 years (hereafter, young adults); however, screening benefits in these individuals have been questioned. Current use of lipid screening and prevalence of elevated lipid measurements among US youths is not well understood. Objective To investigate the prevalence of ambulatory pediatric lipid screening and elevated or abnormal lipid measurements among US screened youths by patient characteristic and test type. Design, Setting, and Participants This cross-sectional study used data from the IQVIA Ambulatory Electronic Medical Record database and included youths aged 9 to 21 years with 1 or more valid measurement of height and weight during the observation period (2018-2021). Body mass index (BMI) was calculated and categorized using standard pediatric BMI percentiles (9-19 years) and adult BMI categories (≥20 years). The data were analyzed from October 6, 2022, to January 18, 2023. Main Outcomes and Measures Lipid measurements were defined as abnormal if 1 or more of the following test results was identified: total cholesterol (≥200 mg/dL), low-density lipoprotein cholesterol (≥130 mg/dL), very low-density lipoprotein cholesterol (≥31 mg/dL), non-high-density lipoprotein cholesterol (≥145 mg/dL), and triglycerides (≥100 mg/dL for children aged 9 years or ≥130 mg/dL for patients aged 10-21 years). After adjustment for age group, sex, race and ethnicity, and BMI category, adjusted prevalence ratios (aPRs) and 95% CIs were calculated. Results Among 3 226 002 youths (23.9% aged 9-11 years, 34.8% aged 12-16 years, and 41.3% aged 17-21 years; 1 723 292 females [53.4%]; 60.0% White patients, 9.5% Black patients, and 2.4% Asian patients), 11.3% had 1 or more documented lipid screening tests. The frequency of lipid screening increased by age group (9-11 years, 9.0%; 12-16 years, 11.1%; 17-21 years, 12.9%) and BMI category (range, 9.2% [healthy weight] to 21.9% [severe obesity]). Among those screened, 30.2% had abnormal lipid levels. Compared with youths with a healthy weight, prevalence of an abnormal result was higher among those with overweight (aPR, 1.58; 95% CI, 1.56-1.61), moderate obesity (aPR, 2.16; 95% CI, 2.14-2.19), and severe obesity (aPR, 2.53; 95% CI, 2.50-2.57). Conclusions and Relevance In this cross-sectional study of prevalence of lipid screening among US youths aged 9 to 21 years, approximately 1 in 10 were screened. Among them, abnormal lipid levels were identified in 1 in 3 youths overall and 1 in 2 youths with severe obesity. Health care professionals should consider implementing lipid screening among children aged 9 to 11 years, young adults aged 17 to 21 years, and all youths at high cardiovascular risk.
Collapse
Affiliation(s)
- Angela M. Thompson-Paul
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- US Public Health Service Commissioned Corps, Rockville, Maryland
| | - Emily M. Kraus
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Informatics Institute, Task Force for Global Health, Decatur, Georgia
- Kraushold Consulting, Denver, Colorado
| | - Renee M. Porter
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Samantha L. Pierce
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lyudmyla Kompaniyets
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ahlia Sekkarie
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alyson B. Goodman
- US Public Health Service Commissioned Corps, Rockville, Maryland
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sandra L. Jackson
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
2
|
Huo T, Cardel MI, Thompson LA, Lemas DJ, Pearson TA, Gurka MJ. Lipid Testing among Youth in Medicaid: The Role of Social Determinants of Health and Providers. J Pediatr 2024; 274:114170. [PMID: 38944189 DOI: 10.1016/j.jpeds.2024.114170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE To assess recent temporal trends in guideline-compliant pediatric lipid testing, and to examine the influence of social determinants of health (SDoH) and provider characteristics on the likelihood of testing in youth. STUDY DESIGN In this observational, multiyear cross-sectional study, we calculated lipid testing prevalence by year among 268 627 12-year olds from 2015 through 2019 who were enrolled in Florida Medicaid and eligible for universal lipid screening during age 9 to 11, and 11 437 22-year olds (2017-2019) who were eligible for screening during age 17-21. We compared trends in testing prevalence by SDoH and health risk factors at two recommended ages and modeled the associations between patient characteristics and provider type on lipid testing using generalized estimating equations. RESULTS Testing among 12-year olds remained low between 2015 through 2019 with the highest prevalence in 2015 (8.0%) and lowest in 2017 (6.7%). Screening compliance among 22-year olds was highest in 2017 (21.1%) and fell to 17.8% in 2019. Hispanics and non-Hispanic Blacks in both age groups had about 2%-3% lower testing prevalence than non-Hispanic Whites. Testing in 12-year olds was 12.3% vs 7.7% with and without obesity, and 14.4% vs 7.6% with and without antipsychotic use. Participants who saw providers who were more likely to prescribe lipid testing were more likely to receive testing (OR = 2.3, 95% CI 2.0-2.8, P < .001). CONCLUSIONS Although lipid testing prevalence was greatest among high-risk children, overall prevalence of lipid testing in youth remains very low. Provider specialty and choices by individual providers play important roles in improving guideline-compliant pediatric lipid testing.
Collapse
Affiliation(s)
- Tianyao Huo
- IQVIA, Inc., Wayne, PA; Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL
| | - Michelle I Cardel
- Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL; WW International, Inc., New York, NY
| | | | - Dominick J Lemas
- Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL
| | - Thomas A Pearson
- Department of Epidemiology, University of Florida, Gainesville, FL
| | | |
Collapse
|
3
|
Flyer JN, Congdon E, Yeager SB, Drucker N, Giddins NG, Haxel CS, Burstein DS, O'Connor KHC, Remy HH, Terrien HE, Robinson KJ. Improvement Science Increases Routine Lipid Screening in General Pediatric Cardiology. J Pediatr 2024; 273:114118. [PMID: 38815743 DOI: 10.1016/j.jpeds.2024.114118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of patient education, physician counseling, and point-of-care (POC) testing on improving adherence to lipid screening national guidelines in a general pediatric cardiology practice (2017-2023). STUDY DESIGN Regional primary care providers were surveyed regarding lipid screening practices. Key drivers were categorized (physician, patient, and system) with corresponding interventions. Pediatric cardiologists started offering lipid screening during regular visits by providing families with preventive cardiovascular education materials and lab phlebotomy testing. System redesign included educational posters, clinical intake protocol, physician counseling, electronic health record integration, and POC testing. Run charts and statistical process control charts measured screening rates and key processes. RESULTS The primary care survey response rate was 32% (95/294); 97% supported pediatric cardiologists conducting routine lipid screening. Pediatric cardiology mean baseline lipid screening rate was 0%, increased to 7% with patient education, and to 61% after system redesign including POC testing. Screening rates among 1467 patients were similar across age groups (P = .98). More patients received lipid screening by POC (91.7%) compared with phlebotomy (8.3%). Lipid abnormalities detected did not differ by screening methodology (P = .49). CONCLUSION Patient education, counseling, and POC testing improved adherence to national lipid screening guidelines, providing a possible model for primary care implementation.
Collapse
Affiliation(s)
- Jonathan N Flyer
- Department of Pediatrics, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Elizabeth Congdon
- Department of Pediatrics, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Scott B Yeager
- Department of Pediatrics, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Nancy Drucker
- Department of Pediatrics, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Niels G Giddins
- Department of Pediatrics, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Caitlin S Haxel
- Department of Pediatrics, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Danielle S Burstein
- Department of Pediatrics, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Kelsey H C O'Connor
- Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Heather H Remy
- Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Hannah E Terrien
- Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT
| | - Keith J Robinson
- Department of Pediatrics, The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Vermont Child Health Improvement Program, University of Vermont, Burlington, VT
| |
Collapse
|
4
|
Jones LK, Romagnoli KM, Schubert TJ, Clegg K, Kirchner HL, Hu Y, Cawley D, Norelli V, Williams MS, Gidding SS, Rahm AK. Using implementation science to develop a familial hypercholesterolemia screening program in primary care: The CARE-FH study. J Clin Lipidol 2024; 18:e176-e188. [PMID: 38228467 PMCID: PMC11069448 DOI: 10.1016/j.jacl.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/26/2023] [Accepted: 01/01/2024] [Indexed: 01/18/2024]
Abstract
BACKGROUND We designed the Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia (CARE-FH) clinical trial to improve FH screening in primary care and facilitate guideline-based care. OBJECTIVE The goal was to incorporate perspectives from end-users (healthcare system leaders, primary care clinicians, cardiologists, genetic counselors, nurses, and clinic staff) and improve translation of screening guidance into practice. METHODS We partnered with end-users to sequentially define the current state of FH screening, assess acceptability, feasibility, and appropriateness of implementing an FH screening program, and select clinically actionable strategies at the patient-, clinician-, and system-level to be deployed as a package in the CARE-FH clinical trial. Methods informed by implementation science and human centered design included: contextual inquiries, surveys, and deliberative engagement sessions. RESULTS Screening for FH occurred rarely in primary care, and then only after a cardiovascular event or sometimes due to a family history of high cholesterol or early heart attack. Surveys suggested FH screening in primary care was acceptable, appropriate, and feasible. Reported and observed barriers to screening include insufficient time at patient encounters to screen, cost and convenience of testing for patients, and knowledge regarding causes of dyslipidemia. Facilitators included clear guidance on screening criteria and new therapies to treat FH. These results led to the development of multilevel strategies that were presented to end-users, modified, and then pilot tested in one primary care clinic. CONCLUSIONS A refined implementation strategy package for FH screening was created with a goal of improving FH awareness, identification, and initiation of guideline-based care. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/study/NCT05284513?id=NCT05284513&rank=1 Unique Identifier: NCT05284513.
Collapse
Affiliation(s)
- Laney K. Jones
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA 17822, USA
- Heart and Vascular Institute, Geisinger, Danville, PA 17822, USA
| | - Katrina M. Romagnoli
- Department of Population Health Sciences, Research Institute, Geisinger, Danville, PA 17822, USA
| | - Tyler J. Schubert
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA 17822, USA
- Geisinger Commonwealth School of Medicine, Scranton, PA 18510, USA
| | - Katarina Clegg
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA 17822, USA
- Geisinger Commonwealth School of Medicine, Scranton, PA 18510, USA
| | - H. Lester Kirchner
- Department of Population Health Sciences, Research Institute, Geisinger, Danville, PA 17822, USA
| | - Yirui Hu
- Department of Population Health Sciences, Research Institute, Geisinger, Danville, PA 17822, USA
| | - Dylan Cawley
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA 17822, USA
| | - Victoria Norelli
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA 17822, USA
| | - Marc S. Williams
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA 17822, USA
| | - Samuel S. Gidding
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA 17822, USA
| | - Alanna K. Rahm
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA 17822, USA
| |
Collapse
|
5
|
Wu F, Juonala M, Jacobs DR, Daniels SR, Kähönen M, Woo JG, Sinaiko AR, Viikari JSA, Bazzano LA, Burns TL, Steinberger J, Urbina EM, Venn AJ, Raitakari OT, Dwyer T, Magnussen CG. Childhood Non-HDL Cholesterol and LDL Cholesterol and Adult Atherosclerotic Cardiovascular Events. Circulation 2024; 149:217-226. [PMID: 38014550 DOI: 10.1161/circulationaha.123.064296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Although low-density lipoprotein cholesterol (LDL-C) remains the primary cholesterol target in clinical practice in children and adults, non-high-density lipoprotein cholesterol (non-HDL-C) has been suggested as a more accurate measure of atherosclerotic cardiovascular disease (ASCVD) risk. We examined the associations of childhood non-HDL-C and LDL-C levels with adult ASCVD events and determined whether non-HDL-C has better utility than LDL-C in predicting adult ASCVD events. METHODS This prospective cohort study included 21 126 participants from the i3C Consortium (International Childhood Cardiovascular Cohorts). Proportional hazards regressions were used to estimate the risk for incident fatal and fatal/nonfatal ASCVD events associated with childhood non-HDL-C and LDL-C levels (age- and sex-specific z scores; concordant/discordant categories defined by guideline-recommended cutoffs), adjusted for sex, Black race, cohort, age at and calendar year of child measurement, body mass index, and systolic blood pressure. Predictive utility was determined by the C index. RESULTS After an average follow-up of 35 years, 153 fatal ASCVD events occurred in 21 126 participants (mean age at childhood visits, 11.9 years), and 352 fatal/nonfatal ASCVD events occurred in a subset of 11 296 participants who could be evaluated for this outcome. Childhood non-HDL-C and LDL-C levels were each associated with higher risk of fatal and fatal/nonfatal ASCVD events (hazard ratio ranged from 1.27 [95% CI, 1.14-1.41] to 1.35 [95% CI, 1.13-1.60] per unit increase in the risk factor z score). Non-HDL-C had better discriminative utility than LDL-C (difference in C index, 0.0054 [95% CI, 0.0006-0.0102] and 0.0038 [95% CI, 0.0008-0.0068] for fatal and fatal/nonfatal events, respectively). The discordant group with elevated non-HDL-C and normal LDL-C had a higher risk of ASCVD events compared with the concordant group with normal non-HDL-C and LDL-C (fatal events: hazard ratio, 1.90 [95% CI, 0.98-3.70]; fatal/nonfatal events: hazard ratio, 1.94 [95% CI, 1.23-3.06]). CONCLUSIONS Childhood non-HDL-C and LDL-C levels are associated with ASCVD events in midlife. Non-HDL-C is better than LDL-C in predicting adult ASCVD events, particularly among individuals who had normal LDL-C but elevated non-HDL-C. These findings suggest that both non-HDL-C and LDL-C are useful in identifying children at higher risk of ASCVD events, but non-HDL-C may provide added prognostic information when it is discordantly higher than the corresponding LDL-C and has the practical advantage of being determined without a fasting sample.
Collapse
Affiliation(s)
- Feitong Wu
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (F.W., A.J.V., T.D., C.G.M.)
- Baker Heart and Diabetes Institute, Melbourne, Australia (F.W., C.G.M.)
- Baker Department of Cardiometabolic Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia (F.W.)
| | - Markus Juonala
- Department of Medicine, University of Turku, Finland (M.J., J.S.J.V.)
- Division of Medicine, Turku University Hospital, Finland (M.J., J.S.J.V.)
| | - David R Jacobs
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (D.R.J.)
| | - Stephen R Daniels
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora (S.R.D.)
| | - Mika Kähönen
- Faculty of Medicine and Health Technology, Tampere University, Finland (M.K.)
- Department of Clinical Physiology, Tampere University Hospital, Finland (M.K.)
| | - Jessica G Woo
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, OH (J.G.W.)
| | - Alan R Sinaiko
- University of Minnesota Medical School, Minneapolis (A.R.S.)
| | - Jorma S A Viikari
- Department of Medicine, University of Turku, Finland (M.J., J.S.J.V.)
- Division of Medicine, Turku University Hospital, Finland (M.J., J.S.J.V.)
| | - Lydia A Bazzano
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (L.A.B.)
| | - Trudy L Burns
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City (T.L.B.)
| | - Julia Steinberger
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (J.S.)
| | - Elaine M Urbina
- The Heart Institute, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, OH (E.M.U.)
| | - Alison J Venn
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (F.W., A.J.V., T.D., C.G.M.)
| | - Olli T Raitakari
- Centre for Population Health Research, University of Turku and Turku University Hospital, Finland (O.T.R., C.G.M.)
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Finland (O.T.R., C.G.M.)
- Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Finland (O.T.R.)
- InFLAMES Research Flagship, University of Turku, Finland (O.T.R.)
| | - Terence Dwyer
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (F.W., A.J.V., T.D., C.G.M.)
- The Nuffield Department of Women's & Reproductive Health, University of Oxford, UK (T.D.)
- Murdoch Children's Research Institute, Melbourne, Australia (T.D.)
| | - Costan G Magnussen
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (F.W., A.J.V., T.D., C.G.M.)
- Baker Heart and Diabetes Institute, Melbourne, Australia (F.W., C.G.M.)
- Centre for Population Health Research, University of Turku and Turku University Hospital, Finland (O.T.R., C.G.M.)
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Finland (O.T.R., C.G.M.)
| |
Collapse
|
6
|
Alshammri F, Geddie H, Sawalha N, Kim G, McAssey K, Morrison KM. Factors Associated With the Development of Dyslipidemia Among Pediatric Patients With Diabetes: A Single-centre-based Study. Can J Diabetes 2023; 47:611-617. [PMID: 37392858 DOI: 10.1016/j.jcjd.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/02/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVES The prevalence of pediatric diabetes is increasing. Dyslipidemia is an important modifiable cardiovascular disease risk factor often present in children with diabetes. In this study, we evaluated the adherence to Diabetes Canada 2018 lipid screening guidelines in a pediatric diabetes program to determine the prevalence of dyslipidemia in youth with diabetes and to identify risk factors related to dyslipidemia. METHODS This retrospective chart review included patients at McMaster Children's Hospital with diabetes (types 1 and 2), who were at least 12 years of age as of January 1, 2019. Extracted data included age, sex, family history of diabetes or dyslipidemia, date of diagnosis, body mass index, glycemia monitoring system used, lipid profile, glycated hemoglobin (A1C), and thyroid-stimulating hormone values at the time the lipid profile was measured. Statistical methods included descriptive statistics and logistic regression modelling. RESULTS Of the 305 patients included, 61% had a lipid profile measured according to guidelines, 29% had lipid screening completed outside of the recommended window, and 10% had no lipid profile on record. Among screened patients, 45% had dyslipidemia, most commonly hypertriglyceridemia (35%). Dyslipidemia was highest amongst those with type 2 diabetes, obesity, older age, short duration of diabetes, higher A1C, and those who used capillary blood glucose for monitoring (p<0.05). CONCLUSIONS A high proportion of patients were screened for dyslipidemia, but many outside the recommended window. Dyslipidemia is highly prevalent in this patient population and was associated with the presence of obesity, but 44% of patients without obesity also had dyslipidemia.
Collapse
Affiliation(s)
- Fahd Alshammri
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Hannah Geddie
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Noor Sawalha
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Gloria Kim
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Karen McAssey
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Katherine M Morrison
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
7
|
Christian S, Ridsdale R, Lin M, Khoury M. Evaluating the prevalence of lipid assessments in children in Alberta, Canada. CMAJ Open 2023; 11:E820-E825. [PMID: 37726114 PMCID: PMC10516684 DOI: 10.9778/cmajo.20220163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Familial hypercholesterolemia is a common, inherited, life-threatening and treatable condition that is characterized by marked elevations of low-density lipoprotein cholesterol (LDL-C), resulting in a high risk of cardiovascular disease, but treatment starting in childhood dramatically reduces this risk. We sought to evaluate the prevalence of pediatric lipid assessments among children in Alberta. METHODS We reviewed laboratory and administrative data from Alberta Health between Apr. 1, 2012, and Dec. 31, 2021. We evaluated 2 pediatric cohorts (children aged 2-10 yr and children aged 9-17 yr) to allow for longitudinal assessments throughout the pediatric period. We also reviewed annual frequencies of lipid assessment for all children between 2013 and 2021. RESULTS Pediatric lipid assessments were performed for 1972 (4.3%) of 46 170 children aged 2-10 years and for 8158 (19.9%) of 40 926 children aged 9-17 years. Female children (aged 2-10 yr) and those living in rural communities were significantly less likely to have a lipid assessment, compared with male children and those in nonrural communities. Among those with lipid assessments, 23 (1.2%) and 86 (1.1%) children aged 2-10 years and 9-17 years, respectively, had an LDL-C level suggestive of probable familial hypercholesterolemia (≥ 4.0 mmol/L). Statin therapy was prescribed in 16 children during the study period. The frequency of lipid assessments was relatively stable, with the exception of a decrease in 2020. INTERPRETATION Rates of pediatric lipid assessment in Alberta are suboptimal. These findings highlight the need to increase awareness of the benefits of early diagnosis and treatment of familial hypercholesterolemia with regard to long-term health and identify and overcome barriers to diagnosis and treatment.
Collapse
Affiliation(s)
- Susan Christian
- Department of Medical Genetics (Christian, Risdale) and Department of Pediatrics (Khoury), University of Alberta; Alberta SPOR Support Unit and Provincial Research Data Services (Lin), Alberta Health Services, Edmonton, Alta.
| | - Ross Ridsdale
- Department of Medical Genetics (Christian, Risdale) and Department of Pediatrics (Khoury), University of Alberta; Alberta SPOR Support Unit and Provincial Research Data Services (Lin), Alberta Health Services, Edmonton, Alta
| | - Mu Lin
- Department of Medical Genetics (Christian, Risdale) and Department of Pediatrics (Khoury), University of Alberta; Alberta SPOR Support Unit and Provincial Research Data Services (Lin), Alberta Health Services, Edmonton, Alta
| | - Michael Khoury
- Department of Medical Genetics (Christian, Risdale) and Department of Pediatrics (Khoury), University of Alberta; Alberta SPOR Support Unit and Provincial Research Data Services (Lin), Alberta Health Services, Edmonton, Alta
| |
Collapse
|
8
|
Lin TK, Dispenza TC. Cholesterol Screening in Children: Is a Universal Approach Working? Curr Atheroscler Rep 2023; 25:579-590. [PMID: 37594601 DOI: 10.1007/s11883-023-01129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE OF REVIEW Ample evidence supports that an individual's lifetime risk of atherosclerotic cardiovascular disease correlates to long-term, cumulative exposure to circulating cholesterol levels, beginning in childhood. Selective screening strategies based on family history fail to identify many children with hypercholesterolemia. Universal cholesterol screening in childhood is a worthwhile goal. However, cholesterol screening rates through childhood remain low. RECENT FINDINGS Mounting evidence clarifies the barriers to cholesterol screening in children. Specific strategies to foster universal screening in childhood have been proposed. SUMMARY We present an overview of the present state of childhood cholesterol screening, summarizing historical and contemporary guidelines and collating evidence of low adherence to current guidelines. We contend that novel approaches to universal cholesterol screening in childhood are warranted, and we present potential opportunities for improvement. We call for new and universal pediatric cholesterol screening guidelines.
Collapse
Affiliation(s)
- Tracie K Lin
- Penn State Health Children's Hospital, Division of Pediatric Cardiology, 600 University Drive, Hershey, PA, 17033, USA
| | - Thomas C Dispenza
- Penn State Health Children's Hospital, Division of Pediatric Cardiology, 600 University Drive, Hershey, PA, 17033, USA.
| |
Collapse
|
9
|
Kim GK, Yee JK, Bansal N. Algorithms for Treating Dyslipidemia in Youth. Curr Atheroscler Rep 2023; 25:495-507. [PMID: 37523052 DOI: 10.1007/s11883-023-01122-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW The goal of this article is to review algorithms for treating dyslipidemia in youth, discuss pitfalls, propose enhanced algorithms to address pitfalls, and consider future directions. RECENT FINDINGS The presence of modifiable and non-modifiable cardiovascular disease (CVD) risk factors during childhood is associated with CVD-related events in adulthood. Recent data has shown that childhood initiation of statin therapy in youth < 18 years of age with familial hypercholesterolemia reduces the risk of adult CVD. However, pediatric dyslipidemia remains undertreated in part due to a lack of primary health care providers with adequate understanding of screening guidelines and pediatric lipidologists with experience in treatment and follow-up of this unique population. Management algorithms have been published by the National Heart, Lung, and Blood Institute and American Heart Association as tools to empower clinicians to manage dyslipidemia. We propose enhanced algorithms, which incorporate recently approved pharmacotherapy to address the management gaps. Future algorithms based upon clinical risk scores may enhance treatment and improve outcomes. Algorithms for dyslipidemia management which target youth < 18 years of age are tools which empower clinicians to manage dyslipidemia in this unique population. Enhanced algorithms may help address pitfalls. We acknowledge the need for further risk assessment tools in pediatrics for tailored dyslipidemia management.
Collapse
Affiliation(s)
- Grace K Kim
- Division of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin St. Ste 1020, Houston, TX, 77030, USA
| | - Jennifer K Yee
- Division of Endocrinology, Department of Pediatrics, Harbor-UCLA Medical Center, The Lundquist Institute of Biomedical Innovation at Harbor-UCLA, Torrance, CA, 90509, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, 90509, USA
| | - Nidhi Bansal
- Division of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin St. Ste 1020, Houston, TX, 77030, USA.
| |
Collapse
|
10
|
O'Byrne ML, Wilensky R, Glatz AC. Incorporating economic analysis in interventional cardiology research. Catheter Cardiovasc Interv 2023; 101:122-130. [PMID: 36480805 DOI: 10.1002/ccd.30506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
Evaluative research in interventional cardiology has focused on clinical and technical outcomes. Inclusion of economic data can enhance evaluative research by quantifying the relative economic burden incurred by different therapies. When combined with clinical outcomes, cost data can provide a measure of value (e.g., marginal cost-effectiveness). In some select situations, cost data can also be used as surrogates for complexity of care and morbidity. In this narrative review, we aim to provide a framework for the application of cost data in clinical trials and observational research, detailing how to incorporate this kind of data into interventional cardiology research.
Collapse
Affiliation(s)
- Michael L O'Byrne
- Department of Pediatrics, Division of Cardiology and Clinical Futures, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute For Healthcare Economics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Wilensky
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Internal Medicine, Division of Cardiology, The Hospital of The University of Pennsylvania, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, and St. Louis Children's Hospital, St. Louis, Missouri, USA
| |
Collapse
|
11
|
Schipper HS, de Ferranti S. Cardiovascular Risk Assessment and Management for Pediatricians. Pediatrics 2022; 150:189891. [PMID: 36321395 DOI: 10.1542/peds.2022-057957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 12/05/2022] Open
Abstract
Childhood and adolescence provide a unique window of opportunity to prevent atherosclerotic cardiovascular disease later in life, especially for pediatric groups at risk. The growing list of pediatric groups at risk includes individuals with chronic inflammatory disorders, organ transplants, familial hypercholesterolemia, endocrine disorders, childhood cancer, chronic kidney diseases, congenital heart diseases, and premature birth, as well as increasing numbers of children and adolescents with traditional risk factors such as obesity, hypertension, hyperlipidemia, and hyperglycemia. Here, we focus on recent advances in cardiovascular risk assessment and management and their implications for pediatric practice. First, hyperlipidemia and hyperglycemia are highly prevalent in the young, with hyperlipidemia occurring in 14.6% and hyperglycemia in 16.4% of children and adolescents with a normal weight. Implementation of nonfasting lipid and glycated hemoglobin screening in youth at risk is emerging as a promising avenue to improve testing compliance and lipid and glucose management. Second, blood pressure, lipid, and glucose management in youth at risk are reviewed in depth. Third, multisite and multimodal assessment of early atherosclerosis is discussed as a way to capture the complexity of atherosclerosis as a systemic disease. In addition to conventional carotid intima-media thickness measurements, the measurement of aortic pulse wave velocity and peripheral arterial tonometry can advance the assessment of early atherosclerosis in pediatrics. Finally, we make a plea for lifetime atherosclerotic cardiovascular disease risk stratification that integrates disease-associated risk factors and traditional risk factors and could facilitate tailored cardiovascular risk management in growing numbers of children and adolescents at risk.
Collapse
Affiliation(s)
- Henk S Schipper
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital and University Medical Center Utrecht, The Netherlands.,Center for Translational Immunology, University Medical Center Utrecht, The Netherlands
| | - Sarah de Ferranti
- Department of Cardiology, Boston Children's Hospital, and Harvard University Medical School, Boston, Massachusetts
| |
Collapse
|
12
|
Scott L, Dunn L, Oliver J. Increasing lipid screenings in children 9-11 years old at a federally qualified health center - A quality improvement project. J Pediatr Nurs 2022; 67:1-6. [PMID: 35870386 DOI: 10.1016/j.pedn.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/28/2022] [Accepted: 07/08/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) remains the leading cause of death in the U.S. Atherosclerotic changes leading to CAD begin in early childhood. Universal lipid screenings remain low nationwide despite the 2011 National Heart, Lung, and Blood Institute's (NHLBI) Expert Panel Guidelines. LOCAL PROBLEM The aim of this quality improvement project was to examine the benefit of an educational intervention on the implementation of universal lipid screening guidelines within a federally qualified health center tasked with providing care to a high-risk population. INTERVENTION An educational intervention was offered detailing the 2011 NHLBI guidelines. A total of seven medical providers participated in the intervention. METHOD Following the intervention, a pre- and post- knowledge survey was given to assess improvement in knowledge. A retrospective chart review was performed to evaluate application to practice. RESULTS The number of lipid screenings improved from 7.8% (n = 384) pre-intervention to 39.2% (n = 74) post intervention. There was a statistically significant increase in screenings post-intervention t (456) = 7.842, p = .000, two-tailed). CONCLUSION More studies are needed to adequately identify the impact of universal screening guidelines on the health of both children and adults alike. PRACTICE IMPLICATIONS Universal lipid screenings remain promising in early identification of CAD in the pediatric population. Interventions related to expanding the knowledge of healthcare providers, patients, and families are key to decreasing CAD morbidity and mortality.
Collapse
Affiliation(s)
- Letisha Scott
- Capstone College of Nursing, The University of Alabama, 650 University Blvd, Tuscaloosa, AL 35487, USA.
| | - Linda Dunn
- Capstone College of Nursing, The University of Alabama, 650 University Blvd, Tuscaloosa, AL 35487, USA.
| | - JoAnn Oliver
- Capstone College of Nursing, The University of Alabama, 650 University Blvd, Tuscaloosa, AL 35487, USA.
| |
Collapse
|
13
|
Mietus-Snyder M, Suslovic W, Delaney M, Playford MP, Ballout RA, Barber JR, Otvos JD, DeBiasi RL, Mehta NN, Remaley AT. Changes in HDL cholesterol, particles, and function associate with pediatric COVID-19 severity. Front Cardiovasc Med 2022; 9:1033660. [PMID: 36312284 PMCID: PMC9597312 DOI: 10.3389/fcvm.2022.1033660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background Myriad roles for high-density lipoprotein (HDL) beyond atheroprotection include immunologic functions implicated in the severity of coronavirus disease-2019 (COVID-19) in adults. We explored whether there is an association between HDL and COVID-19 severity in youth. Methods A pediatric cohort (N = 102), who tested positive for COVID-19 across a range of disease manifestations from mild or no symptoms, to acute severe symptoms, to the multisystem inflammatory syndrome of children (MIS-C) was identified. Clinical data were collected from the medical record and reserve plasma aliquots were assessed for lipoproteins by NMR spectroscopy and assayed for HDL functional cholesterol efflux capacity (CEC). Findings were compared by COVID-19 status and symptom severity. Lipoprotein, NMR spectroscopy and CEC data were compared with 30 outpatient COVID negative children. Results Decreasing HDL cholesterol (HDL-c), apolipoprotein AI (ApoA-I), total, large and small HDL particles and HDL CEC showed a strong and direct linear dose-response relationship with increasing severity of COVID-19 symptoms. Youth with mild or no symptoms closely resembled the uninfected. An atypical lipoprotein that arises in the presence of severe hepatic inflammation, lipoprotein Z (LP-Z), was absent in COVID-19 negative controls but identified more often in youth with the most severe infections and the lowest HDL parameters. The relationship between HDL CEC and symptom severity and ApoA-I remained significant in a multiply adjusted model that also incorporated age, race/ethnicity, the presence of LP-Z and of GlycA, a composite biomarker reflecting multiple acute phase proteins. Conclusion HDL parameters, especially HDL function, may help identify youth at risk of more severe consequences of COVID-19 and other novel infectious pathogens.
Collapse
Affiliation(s)
- Michele Mietus-Snyder
- Children's National Hospital, Washington, DC, United States
- The Children's National Clinical and Translational Science Institute, Washington, DC, United States
- Division of Cardiology, School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
| | | | - Meghan Delaney
- Children's National Hospital, Washington, DC, United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
- Division of Clinical and Laboratory Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
| | - Martin P. Playford
- Cardiovascular and Pulmonary Branch, National Institutes of Health, Bethesda, MD, United States
| | - Rami A. Ballout
- Lipoprotein Metabolism Section, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - John R. Barber
- The Children's National Clinical and Translational Science Institute, Washington, DC, United States
| | - James D. Otvos
- Lipoprotein Metabolism Section, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Roberta L. DeBiasi
- Children's National Hospital, Washington, DC, United States
- The Children's National Clinical and Translational Science Institute, Washington, DC, United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
- Division of Infectious Diseases, School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
- Department of Microbiology, Immunology and Tropical Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
| | - Nehal N. Mehta
- Cardiovascular and Pulmonary Branch, National Institutes of Health, Bethesda, MD, United States
| | - Alan T. Remaley
- Lipoprotein Metabolism Section, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
- Clinical Center, Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, United States
| |
Collapse
|
14
|
Nash D, Katcoff H, Faerber J, Iyer VR, Shah MJ, O'Byrne ML, Janson C. Impact of Device Miniaturization on Insertable Cardiac Monitor Use in the Pediatric Population: An Analysis of the MarketScan Commercial and Medicaid Databases. J Am Heart Assoc 2022; 11:e024112. [PMID: 35929446 PMCID: PMC9496290 DOI: 10.1161/jaha.121.024112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Insertable cardiac monitors (ICMs) are effective in the detection of paroxysmal arrhythmias. In 2014, the first miniaturized ICM was introduced with a less invasive implant technique. The impact of this technology on ICM use in pediatric patients has not been evaluated. We hypothesized an increase in annual pediatric ICM implants starting in 2014 attributable to device miniaturization. Methods and Results A retrospective observational study was conducted using administrative claims from MarketScan Medicaid and commercial insurance claims databases. Use of ICM between January 2013 and December 2018 was measured (normalized to the total enrolled population ≤18 years) and compared with balancing measures (Holter ambulatory monitors, cardiac event monitors, encounters with syncope diagnosis, implantation of implantable cardioverter‐defibrillator/pacemaker). Secondary analyses included evaluations of subsequent interventions and complications. The study cohort included 33 532 185 individual subjects, of which 769 (0.002%) underwent ICM implantation. Subjects who underwent ICM implantation were 52% male sex, with a median age of 16 years (interquartile range, 10–17 years). A history of syncope was present in 71%, palpitations in 43%, and congenital heart disease in 28%. Following release of the miniaturized ICM, use of ICMs increased from 5 procedures per million enrollees in 2013 to 11 per million between 2015 and 2018 (P<0.001), while balancing measures remained static. Of 394 subjects with ≥1 year of follow‐up after implantation, interventions included catheter ablation in 24 (6%), pacemaker implantation in 15 (4%), and implantable cardioverter‐defibrillator implantation in 7 (2%). Conclusions Introduction of the miniaturized ICM was followed by a rapid increase in pediatric use. The effects on outcomes and value deserve further attention.
Collapse
Affiliation(s)
- Dustin Nash
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Jennifer Faerber
- Data Science and Biostatistics Unit The Children's Hospital of Philadelphia PA
| | - V Ramesh Iyer
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Maully J Shah
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
| | - Christopher Janson
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| |
Collapse
|
15
|
Sharifi M, Goodman AB, Chua KP. Assessment of Underuse and Overuse of Screening Tests for Co-occurring Conditions Among Children With Obesity. JAMA Netw Open 2022; 5:e2222101. [PMID: 35834247 PMCID: PMC9284328 DOI: 10.1001/jamanetworkopen.2022.22101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE The American Academy of Pediatrics (AAP) recommends laboratory screening for diabetes, dyslipidemia, and liver disease every 2 years among children aged 10 years and older with obesity. Routine screening for hypothyroidism or hyperinsulinemia is not recommended. National data on rates of adherence to AAP-recommended screening and rates of potentially unnecessary endocrine testing are unavailable. OBJECTIVE To assess rates of AAP-adherent screening and potentially unnecessary endocrine testing among privately and publicly insured children diagnosed with obesity at well-child visits. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the 2018-2019 IBM MarketScan Commercial Database (which contains claims from privately insured patients across the US) and the 2018-2019 IBM MarketScan Multi-State Medicaid Database (which contains claims from Medicaid patients in multiple states). A total of 156 773 children aged 10 to 18 years with obesity diagnosis codes at a well-child visit from December 1, 2018, through November 30, 2019, were included. Analysis was performed from May 1 to October 31, 2021. MAIN OUTCOMES AND MEASURES Primary outcomes were the proportion of children who received AAP-adherent screening during the 729 days before to 30 days after a well-child visit and the proportion of children who received 1 or more potentially unnecessary thyroid or insulin tests during the same period. Proportions of children by payer type were compared using logistic regression models adjusted for age and sex. To assess screening that was potentially ordered by primary care clinicians, the proportion of children without AAP-adherent screening before visits who received this screening within 30 days was calculated. RESULTS Of 156 773 children, the mean (SD) age was 13.5 years (2.5) years; 83 305 (53.1%) were male, and 97 595 (62.3%) were publicly insured. Among publicly insured children, 13 167 (13.5%) were Hispanic or Latino, 34 792 (35.6%) were non-Hispanic Black, 42 029 (43.1%) were non-Hispanic White, 3850 (3.9%) were of other race and/or ethnicity (specific races and ethnicities were not available in the database), and 3757 (3.8%) were of unknown race and ethnicity. Race and ethnicity were not available for privately insured children because these data are not reported in the commercial claims database. During the 729 days before to 30 days after well-child visits, 42 849 patients (27.3%) received AAP-adherent screening, including 13 939 (23.6%) of 59 178 privately insured children and 28 910 (29.6%) of 97 595 publicly insured children (average marginal effect for public insurance: 6.8 [95% CI, 6.3-7.2] percentage points). In addition, 46 592 children (29.7%) received potentially unnecessary thyroid or insulin tests, including 12 834 (21.7%) of 59 178 privately insured children and 23 198 (23.8%) of 97 595 publicly insured children (average marginal effect for public insurance: 2.4 [95% CI, 2.0-2.8] percentage points). Among 129 104 children who did not receive AAP-adherent screening before visits, 15 090 (11.7%) received this screening within 30 days. CONCLUSIONS AND RELEVANCE In this cross-sectional study, similar proportions of children diagnosed with obesity at well-child visits received recommended and nonrecommended screening tests for obesity-related co-occurring conditions, suggesting that specific actionable guidelines and interventions are needed to prevent overuse and underuse of screening tests among children with obesity.
Collapse
Affiliation(s)
- Mona Sharifi
- Department of Pediatrics, Section of General Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Biostatistics, Health Informatics, Yale School of Public Health, New Haven, Connecticut
| | - Alyson B. Goodman
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| |
Collapse
|
16
|
Berger JH, Faerber JA, Chen F, Lin KY, Brothers JA, O'Byrne ML. Adherence With Lipid Screening Guidelines in Children With Acquired and Congenital Heart Disease: An Observational Study Using Data From The MarketScan Commercial and Medicaid Databases. J Am Heart Assoc 2022; 11:e024197. [PMID: 35301862 PMCID: PMC9075474 DOI: 10.1161/jaha.121.024197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Universal lipid screening in children provides an opportunity to mitigate the lifetime risk of atherosclerosis, particularly in children with chronic conditions that are predisposed to early atherosclerosis. In response, national guidelines recommend additional early screening in a subset of cardiac conditions. The penetration of such guidelines has not been evaluated. Methods and Results We performed a retrospective study of a geographically representative sample of US children using the MarketScan Commercial and Medicaid claims databases. The study population was children with cardiac disease between ages 2 and 18 years and ≥3 years of continuous coverage from January 1, 2013, to June 30, 2018, divided into 4 major strata of heart disease. We assessed the likelihood of screening between these classifications and compared with healthy children and calculated multivariate models to identify patient factors associated with screening likelihood. Of the eligible 8.4 million children, 155 000 children had heart disease, of which 1.8% (31 216) had high‐risk conditions. Only 17.5% of healthy children underwent lipid screening. High‐risk children were more likely to be screened (odds ratio [OR], 2.1; 95% CI, 2.09–2.19; P<0.001) than standard‐risk children, but that likelihood varied depending on strata of cardiac disease (22%–77%). Timing of screening also varied, with most occurring between ages 9 and 11 years. Among cardiac conditions, heart transplantation (OR, 16.8; 95% CI, 14.4–19.7) and cardiomyopathy (OR, 2.9; 95% CI, 2.8–3.1) were associated with the highest likelihood of screening. Conclusions Children with cardiac disease are more likely to undergo recommended lipid screening than healthy children, but at lower rates and later ages than recommended, highlighting the importance of quality improvement and advocacy for this vulnerable population.
Collapse
Affiliation(s)
- Justin H Berger
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Jennifer A Faerber
- Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Feiyan Chen
- Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Kimberly Y Lin
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Julie A Brothers
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Data Science and Biostatistics Unit The Children's Hospital of Philadelphia Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA.,Leonard Davis Institute for Health Economics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| |
Collapse
|
17
|
O'Byrne ML, Faerber JA, Katcoff H, Huang J, Edelson JB, Finkelstein DM, Lemley BA, Janson CM, Avitabile CM, Glatz AC, Goldberg DJ. Prevalent pharmacotherapy of US Fontan survivors: A study utilizing data from the MarketScan Commercial and Medicaid claims databases. Am Heart J 2022; 243:158-166. [PMID: 34582777 PMCID: PMC8819625 DOI: 10.1016/j.ahj.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/23/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Survivors of Fontan palliation are at life-long risk of thrombosis, arrhythmia, and circulatory failure. To our knowledge, no studies have evaluated current United States pharmaceutical prescription practice in this population. METHODS A retrospective observational study evaluating the prevalent use of prescription medications in children and adolescents with hypoplastic left heart syndrome or tricuspid atresia after Fontan completion (identified using ICD9/10 codes) was performed using data contained in the MarketScan Commercial and Medicaid databases for the years 2013 through 2018. Cardiac pharmaceuticals were divided by class. Anticoagulant agents other than platelet inhibitors, which are not uniformly a prescription medication, were also studied. Associations between increasing age and the likelihood of a filled prescription for each class of drug were evaluated. Annualized retail costs of pharmaceutical regimens were calculated. RESULTS A cohort of 4,056 subjects (median age 12 years [interquartile range: 8-16], 61% male, 60% commercial insurance) was identified. Of the cohort, 50% received no prescription medications. Angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (38%), diuretics (15%), and mineralocorticoid receptor antagonists (8%) were prescribed with the highest frequency. Pulmonary vasodilators were received by 6% of subjects. Older age was associated with increased likelihood of filled prescriptions for anticoagulants (P = .008), antiarrhythmic agents, digoxin, ACEi/ARB, and beta blockers (each P < .0001), but also lower likelihood of filled prescriptions for pulmonary vasodilators, conventional diuretics (both P < .0001), and mineralocorticoid receptor antagonists (P = .02). CONCLUSIONS Pharmaceuticals typically used to treat heart failure and pulmonary hypertension are the most commonly prescribed medications following Fontan palliation. While the likelihood of treatment with a particular class of medication is associated with the age of the patient, determining the optimal regimen for individual patients and the population at large is an important knowledge gap for future research.
Collapse
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness at The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA.
| | - Jennifer A Faerber
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan B Edelson
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA
| | - David M Finkelstein
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Bethan A Lemley
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christopher M Janson
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Catherine M Avitabile
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness at The Children's Hospital of Philadelphia, Philadelphia, PA
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
18
|
Cooper DM, Zulu MZ, Jankeel A, Ibraim IC, Ardo J, Kasper K, Stephens D, Meyer A, Stehli A, Condon C, Londoño ME, Schreiber CM, Lopez NV, Camplain RL, Weiss M, Golden C, Radom-Aizik S, Boden-Albala B, Chau C, Messaoudi I, Ulloa ER. SARS-CoV-2 acquisition and immune pathogenesis among school-aged learners in four diverse schools. Pediatr Res 2021; 90:1073-1080. [PMID: 34304252 PMCID: PMC8308070 DOI: 10.1038/s41390-021-01660-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/07/2021] [Accepted: 06/11/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Understanding SARS-CoV-2 infection in children is necessary to reopen schools safely. METHODS We measured SARS-CoV-2 infection in 320 learners [10.5 ± 2.1 (sd); 7-17 y.o.] at four diverse schools with either remote or on-site learning. Schools A and B served low-income Hispanic learners; school C served many special-needs learners, and all provided predominantly remote instruction. School D served middle- and upper-income learners, with predominantly on-site instruction. Testing occurred in the fall (2020), and 6-8 weeks later during the fall-winter surge (notable for a tenfold increase in COVID-19 cases). Immune responses and mitigation fidelity were also measured. RESULTS We found SARS-CoV-2 infections in 17 learners only during the surge. School A (97% remote learners) had the highest infection (10/70, 14.3%, p < 0.01) and IgG positivity rates (13/66, 19.7%). School D (93% on-site learners) had the lowest infection and IgG positivity rates (1/63, 1.6%). Mitigation compliance [physical distancing (mean 87.4%) and face-covering (91.3%)] was remarkably high at all schools. Documented SARS-CoV-2-infected learners had neutralizing antibodies (94.7%), robust IFN-γ + T cell responses, and reduced monocytes. CONCLUSIONS Schools can implement successful mitigation strategies across a wide range of student diversity. Despite asymptomatic to mild SARS-CoV-2 infection, children generate robust humoral and cellular immune responses. IMPACT Successful COVID-19 mitigation was implemented across a diverse range of schools. School-associated SARS-CoV-2 infections reflect regional rates rather than remote or on-site learning. Seropositive school-aged children with asymptomatic to mild SARS-CoV-2 infections generate robust humoral and cellular immunity.
Collapse
Affiliation(s)
- Dan M Cooper
- Institute for Clinical and Translational Science, University of California Irvine, Irvine, CA, USA
- Department of Pediatrics, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Michael Z Zulu
- Center for Virus Research, University of California Irvine, School of Biological Sciences, Irvine, CA, USA
| | - Allen Jankeel
- Center for Virus Research, University of California Irvine, School of Biological Sciences, Irvine, CA, USA
| | - Izabela Coimbra Ibraim
- Center for Virus Research, University of California Irvine, School of Biological Sciences, Irvine, CA, USA
| | - Jessica Ardo
- Children's Hospital of Orange County, Orange, CA, USA
| | | | - Diana Stephens
- Institute for Clinical and Translational Science, University of California Irvine, Irvine, CA, USA
| | - Andria Meyer
- Institute for Clinical and Translational Science, University of California Irvine, Irvine, CA, USA
| | - Annamarie Stehli
- Department of Pediatrics, Pediatric Exercise and Genomics Research Center, University of California Irvine, Irvine, CA, USA
| | - Curt Condon
- Orange County Health Care Agency, Santa Ana, CA, USA
| | - Mary E Londoño
- University of California Irvine School of Medicine, Irvine, CA, USA
| | - Casey M Schreiber
- Children's Hospital of Orange County, Orange, CA, USA
- University of California Irvine Health, Orange, CA, USA
| | - Nanette V Lopez
- Department of Health Sciences, Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ, USA
| | - Ricky L Camplain
- Department of Health Sciences, Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ, USA
| | - Michael Weiss
- Children's Hospital of Orange County, Orange, CA, USA
| | | | - Shlomit Radom-Aizik
- Department of Pediatrics, Pediatric Exercise and Genomics Research Center, University of California Irvine, Irvine, CA, USA
| | | | - Clayton Chau
- Orange County Health Care Agency, Santa Ana, CA, USA
| | - Ilhem Messaoudi
- Center for Virus Research, University of California Irvine, School of Biological Sciences, Irvine, CA, USA
| | - Erlinda R Ulloa
- Department of Pediatrics, University of California Irvine School of Medicine, Irvine, CA, USA.
- Children's Hospital of Orange County, Orange, CA, USA.
| |
Collapse
|
19
|
Alfaifi AA, Lai L, Althemery AU. Barriers in utilizing lipid-lowering agents in non-institutionalized population in the U.S.: Application of a theoretical framework. PLoS One 2021; 16:e0255729. [PMID: 34352007 PMCID: PMC8341603 DOI: 10.1371/journal.pone.0255729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/22/2021] [Indexed: 11/18/2022] Open
Abstract
Cardiovascular diseases are a major cause of death globally. Epidemiological evidence has linked elevated levels of blood cholesterol with the risk of coronary heart disease. However, lipid-lowering agents, despite their importance for primary prevention, are significantly underused in the United States. The objective of this study was to explore associations among socioeconomic factors and the use of antihyperlipidemic agents in 2018 in U.S. patients with hyperlipidemia by applying a theoretical framework. Data from the 2018 Medical Expenditure Panel Survey were used to identify the population of non-institutionalized U.S. civilians diagnosed with hyperlipidemia. This cross sectional study applied the Andersen Behavioral Model to identify patients' predisposing, enabling, and need factors. Approximately 43 million non-institutionalized adults were diagnosed with hyperlipidemia. With the exception of gender and race, predisposing factors indicated significant differences between patients who used antihyperlipidemic agents and those who did not. The relation between income level and use of antihyperlipidemic agents was significant: X2 (4, N = 3,781) = 7.09, p <.001. Hispanic patients were found to be less likely to receive treatment (OR: 0.62; 95% CI: 0.43-0.88), as observed using a logistic model, with controls for predisposing, enabling, and need factors. Patients without health insurance were less likely to use lipid-lowering agents (OR: 0.33; 95% CI: 0.14-0.77). The present study offers essential data for prioritizing interventions by health policy makers by identifying barriers in utilizing hyperlipidemia therapy. Non-adherence to treatment may lead to severe consequences and increase the frequency of fatal cardiac events in the near future.
Collapse
Affiliation(s)
- Abdullah A. Alfaifi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Kingdom of Saudi Arabia
- * E-mail:
| | - Leanne Lai
- Department of Sociobehavioral and Administrative Pharmacy, College of Pharmacy, NOVA Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Abdullah U. Althemery
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Kingdom of Saudi Arabia
| |
Collapse
|
20
|
Cooper DM, Zulu MZ, Jankeel A, Ibraim IC, Ardo J, Kasper K, Stephens D, Meyer A, Stehli A, Condon C, Londoño ME, Schreiber CM, Lopez NV, Camplain RL, Weiss M, Golden C, Aizik S, Boden-Albala B, Chau C, Messaoudi I, Ulloa ER. SARS-CoV-2 Acquisition and Immune Pathogenesis Among School-Aged Learners in Four Diverse Schools. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 33791712 DOI: 10.1101/2021.03.20.21254035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background Understanding SARS-CoV-2 infection in children is necessary to reopen schools safely. Methods We measured SARS-CoV-2 infection in 320 learners [10.5 ± 2.1(sd); 7-17 y.o.] at four diverse schools with either remote or on-site learning. Schools A and B served low-income Hispanic learners; school C served many special-needs learners; and all provided predominantly remote instruction. School D served middle- and upper-income learners, with predominantly on-site instruction. Testing occurred in the fall (2020), and 6-8 weeks later during the fall-winter surge (notable for a tenfold increase in COVID-19 cases). Immune responses and mitigation fidelity were also measured. Results We found SARS-CoV-2 infections in 17 learners only during the surge. School A (97% remote learners) had the highest infection (10/70, 14.3%, p<0.01) and IgG positivity rates (13/66, 19.7%). School D (93% on-site learners) had the lowest infection and IgG positivity rates (1/63, 1.6%). Mitigation compliance [physical distancing (mean 87.4%) and face covering (91.3%)] was remarkably high at all schools. Documented SARS-CoV-2-infected learners had neutralizing antibodies (94.7%), robust IFN-γ+ T cell responses, and reduced monocytes. Conclusion Schools can implement successful mitigation strategies across a wide range of student diversity. Despite asymptomatic to mild SARS-CoV-2 infection, children generate robust humoral and cellular immune responses. Key Points Successful COVID-19 mitigation was implemented across a diverse range of schools.School-associated SARS-CoV-2 infections reflect regional rates rather than remote or on-site learning.Seropositive school-aged children with asymptomatic to mild SARS-CoV-2 infections generate robust humoral and cellular immunity.
Collapse
|