Disparities in Cystic Fibrosis Care and Outcome

Cystic fibrosis in Europe: improved lung function and longevity - reasons for cautious optimism, but challenges remain

BACKGROUND

Prognosis and disease severity in cystic fibrosis (CF) are linked to declining lung function. To characterise lung function by the number of adults in countries with different levels of Gross National Income (GNI), data from the European Cystic Fibrosis Society Patient Registry were utilised.

METHODS

Annual data including age, forced expiratory volume in 1 s (FEV1), anthropometry, genotype, respiratory cultures and CF-related diabetes (CFRD) were retrieved between 2011 and 2021. All countries were stratified into GNI per capita to reflect differences within Europe.

RESULTS

A consistent improvement in FEV1 % pred and survival was observed among the 47 621 people with CF (pwCF), including subjects with chronic Pseudomonas aeruginosa infection, CFRD and/or undernutrition. Mean values of FEV1 % pred changed from 85% to 94.2% for children and from 63.6% to 74.7% for adults. FEV1 % pred further increased among those carrying the F508del mutation in 2021, when elexacaftor/tezacaftor/ivacaftor was available. The number of adult pwCF increased from 13 312 in 2011 to 21 168 in 2021, showing a 60% increase. PwCF living in European lower income countries did not demonstrate a significant annual increase in FEV1 % pred or in the number of adults.

CONCLUSION

This pan-European analysis demonstrates a consistent improvement in FEV1 % pred, number of adult pwCF and survival over the last decade only in European higher and middle income countries. Urgent action is needed in the lower income countries where such improvement was not observed. The notable improvement observed in pwCF carrying the F508del mutation emphasises the need to develop treatments for all CF mutations.

Lung function and secondhand smoke exposure among children with cystic fibrosis: A Bayesian meta-analysis

BACKGROUND

Secondhand smoke exposure, an important environmental health factor in cystic fibrosis (CF), remains uniquely challenging to children with CF as they strive to maintain pulmonary function during early stages of growth and throughout adolescence. Despite various epidemiologic studies among CF populations, little has been done to coalesce estimates of the association between secondhand smoke exposure and lung function decline.

METHODS

A systematic review was performed using PRISMA guidelines. A Bayesian random-effects model was employed to estimate the association between secondhand smoke exposure and change in lung function (measured as FEV1% predicted).

RESULTS

Quantitative synthesis of study estimates indicated that second-hand smoke exposure corresponded to a significant drop in FEV1 (estimated decrease: -5.11% predicted; 95% CI: -7.20, -3.47). The estimate of between-study heterogeneity was 1.32% predicted (95% CI: 0.05, 4.26). There was moderate heterogeneity between the 6 analyzed studies that met review criteria (degree of heterogeneity: I2=61.9% [95% CI: 7.3-84.4%] and p = 0.022 from the frequentist method.) CONCLUSIONS: Our results quantify the impact at the pediatric population level and corroborate the assertion that secondhand smoke exposure negatively affects pulmonary function in children with CF. Findings highlight challenges and opportunities for future environmental health interventions in pediatric CF care.

Demographic and Socioeconomic Factors Associated with Fungal Infection Risk, United States, 2019

Diagnosis disproportionately affected minority and low-income populations, underscoring the need for broad public health interventions.

Fungal infections cause substantial rates of illness and death. Interest in the association between demographic factors and fungal infections is increasing. We analyzed 2019 US hospital discharge data to assess factors associated with fungal infection diagnosis, including race and ethnicity and socioeconomic status. We found male patients were 1.5–3.5 times more likely to have invasive fungal infections diagnosed than were female patients. Compared with hospitalizations of non-Hispanic White patients, Black, Hispanic, and Native American patients had 1.4–5.9 times the rates of cryptococcosis, pneumocystosis, and coccidioidomycosis. Hospitalizations associated with lower-income areas had increased rates of all fungal infections, except aspergillosis. Compared with younger patients, fungal infection diagnosis rates, particularly for candidiasis, were elevated among persons >65 years of age. Our findings suggest that differences in fungal infection diagnostic rates are associated with demographic and socioeconomic factors and highlight an ongoing need for increased physician evaluation of risk for fungal infections.

Evaluating Differences in the Disease Experiences of Minority Adults With Cystic Fibrosis

Extensive research has demonstrated disparities in health outcomes and survival between non-Hispanic Caucasian (NHC) and non-Caucasian or Hispanic (minority) persons with cystic fibrosis (CF) in the United States (US). However, very little research has been done to explore the disease experiences of racial and ethnic minority persons with CF. Adult subjects with CF were approached for study participation and to characterize their experiential disease perceptions. Survey data were analyzed using Chi-Square tests and Mann-Whitney U-test for basic categorical and continuous variables, and Kruskal-Wallis one-way ANOVA using ranks for Likert scales. Minority persons reported significantly lower scores (more negative experience) when comparing themselves to others with CF (15.18 ± 2.89 vs 18.40 ± 3.18, P < .01), particularly in the areas of representation in research, experience, and support. We were able to identify the unique experiences of minority persons with CF, including perceived lower disease understanding and poorer representation compared to most others with CF. Further large studies are needed to develop and assess interventions that may be useful for serving these diverse populations.

Social Disparities in Benign Lung Diseases

The many socioeconomic disparities in the myriad of diagnoses that make up benign lung diseases are unfortunately a global issue that was most recently highlighted by the COVID-19 pandemic of 2020. In this chapter, we will be reviewing the socioeconomic disparities in benign lung disease from both a United States perspective as well as a global perspective. We will cover the spectrum of infectious, obstructive, and restrictive lung disease and review the evidence on how social disparities affect these populations and their access to medical care.

Disparities in cystic fibrosis survival in Mexico: Impact of socioeconomic status

BACKGROUND

Median survival age in cystic fibrosis (CF) has increased in developed countries. Scarce literature exists about survival in Latin America, especially in Mexico. The aim of our study was to assess the median age of survival in CF patients and the impact of risk factors in Mexico over a 20-year period.

METHODS

We conducted a retrospective study with all patients registered and followed in the CF Center in Monterrey, Mexico from 2000 to 2020. Median survival age was the primary outcome, assessed with Kaplan-Meier analysis. The influence of clinical, biological, and demographic factors on survival was analyzed with Cox regression model.

RESULTS

Two-hundred five patients were included. Median survival for the cohort was 21.37 years (95% confidence interval [CI], 17.20-25.55). In the multivariate Cox regression model, low socioeconomic status (hazard ratio [HR], 4.21; 95% CI, 2.43-7.27), chronic Pseudomonas aeruginosa infection at 6 years (HR, 10.45; 95% CI, 5.66-19.28), and pancreatic insufficiency (HR, 3.13; 1.38-7.13) were independent risk factors for mortality.

CONCLUSION

Median survival in Mexican patients with CF is lower than in high-income countries, and socioeconomic status plays a conspicuous role in the disparity. To increase patient survival for those residing in low-middle income countries, public health authorities must design policies that fully cover diagnosis and treatment strategies for the CF population.

Cystic fibrosis in low and middle-income countries (LMIC): A view from four different regions of the world

Cystic fibrosis (CF) has been shown to affect people all over the world. While life expectancy for people with CF has increased substantially, CF is still associated with death in infants and young children in many regions, particularly in low and middle-income countries (LMIC). These countries face significant challenges to promote CF diagnosis and improvements to CF care due to financial constraints and a significant burden of other diseases. In this review, we describe the status of CF diagnosis and care in different LMIC settings, from four different parts of the world (Brazil, South Africa, Israel and India). We highlight challenges and opportunities for CF practitioners in LMIC to improve CF care and outcomes. While early CF diagnosis is the key to optimising outcomes, newborn screening may not be feasible for countries with lower CF incidence and higher birth rates, such as India or South Africa. CF therapies and care in LMIC need to be adapted to available resources of these countries. Collaboration initiatives of the global CF community with LMIC may improve CF care in these countries. Most individuals with CF in LMIC are not benefiting from CFTR modulator treatments due to the prohibitive cost of these drugs.

Transitioning from paediatric to adult services with cystic fibrosis or bronchiectasis: What is the impact on engagement and health outcomes?

AIM

To determine whether the transfer of young people with cystic fibrosis (CF) or bronchiectasis from paediatric to adult services is associated with changes in service engagement and/or health outcomes.

METHODS

Young people aged ≥15 years of age with CF or bronchiectasis who transferred from the Auckland-based paediatric service (Starship Children's Hospital) to one of three Auckland-based District Health Boards between 2005 and 2012 were identified and included if they had 3 years care both pre-transfer and post-transfer care. Transfer preparation, service engagement (clinics scheduled, clinics attended) and health outcomes (lung function, hospitalisations) were collected per annum.

RESULTS

Fifty-seven young people transferred in this period with 46 meeting inclusion criteria (CF n = 20, bronchiectasis n = 26). The CF group had better transfer documentation, were transferred at an older age (11 months older P < 0.0001 95%CI: 6.7 months, 14.7 months), were 20 times more likely to attend clinics (P < 0.0001, 95%CI: 7.8, 66.1) and had 3-4 more clinics scheduled pre-transfer (P < 0.0001, 95%CI: 3.4, 4.9) and post-transfer (P < 0.0001, 95%CI: 2.4, 3.8) despite having less severe respiratory disease as measured by FEV1 for each year (P < 0.01, 95%CI: 0.34, 1.22).

CONCLUSION

The transfer of young people with CF to adult services did not affect health engagement or outcomes, in contrast to those with bronchiectasis. Use of a formalised transfer process, more clinic appointments offered and greater resources for CF may be responsible for this difference. Comprehensive transition with purposeful, planned movement and developmentally appropriate care is a key goal.

Promoting emotional wellness in children with cystic fibrosis, Part I: Child and family resilience

Attention should be given to individual and family well-being from a child's first interaction with the medical team and continuing throughout development, especially for families who experience chronic illnesses, such as cystic fibrosis (CF). While much attention has been given to the mental health of people with CF 12 years and older, this paper explores various areas for CF teams to assess and provide additional resources during the first 12 years of a child's life to promote child and family wellness. In this paper, we discuss parental mental health, social determinants of health, adherence/self-care, nutrition, attention to family lifestyle factors, engagement with school and peers, and modulator therapy for this age group of people with CF. This is the first of two companion papers which examines emotional wellness of children during the early years. The second paper examines mental health assessment and intervention for children under 12. Both encourage teams to strive to promote optimal child and family emotional health and wellness, emphasizing holistic health promotion and prevention, early identification, and intervention.

Cystic Fibrosis Kidney Disease: 10 Tips for Clinicians

Increased longevity in people with cystic fibrosis (CF) means that more people are surviving long enough to develop kidney complications. Nephrologists and their colleagues now face a steep learning curve as many of them encounter patients with CF related kidney disease (CFKD) for the first time. This article presents perspectives from a medical sociologist with CF on what renal health professionals should know about people with CFKD. It outlines challenges that people with CFKD as they age, framing these struggles as opportunities for clinicians to help these unique patients achieve and maintain their best possible quality of life.

Socioeconomic Status, Smoke Exposure, and Health Outcomes in Young Children With Cystic Fibrosis

BACKGROUND

Lower socioeconomic status (SES) and environmental tobacco smoke (ETS) exposure are both associated with poorer disease outcomes in cystic fibrosis (CF), and children with low SES are disproportionately exposed to ETS. We analyzed a large cohort of young children with CF to distinguish the impact of SES and ETS on clinical outcomes.

METHODS

The Early Pseudomonas Infection Control Observational study enrolled Pseudomonas-negative young children with CF <13 years of age. An enrollment survey assessed SES and ETS exposures. Forced expiratory volume in 1 second (FEV₁), crackles and wheezes, and weight-for-age percentile were assessed at each clinical encounter over at least 4 years. Repeated measures analyses estimated the association of SES and ETS exposures with longitudinal clinical outcomes, adjusting for confounders.

RESULTS

Of 1797 participants, 1375 were eligible for analysis. Maternal education was high school or less in 28.1%, 26.8% had household income <$40 000, and 43.8% had Medicaid or no insurance. Maternal smoking after birth was present in 24.8%, more prevalent in household with low SES. In separate models, lower SES and ETS exposure were significantly associated with lower FEV₁% predicted, presence of crackles or wheezes, and lower weight percentile. In combined models, effect estimates for SES changed minimally after adjustment for ETS exposures, whereas estimates for ETS exposures were attenuated after adjusting for SES.

CONCLUSIONS

ETS exposure was disproportionately high in low SES families in this cohort of children with CF. Lower SES and ETS exposure had independent adverse effects on pulmonary and nutritional outcomes. Estimated effect of SES on FEV₁ decreased minimally after ETS adjustment, suggesting health disparity risks independent of ETS exposure.