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Abell B, Rodwell D, Eagleson KJ, Parsonage W, Auld B, Bora S, Kasparian NA, Justo R, McPhail SM. "It's more than just a conversation about the heart": exploring barriers, enablers, and opportunities for improving the delivery and uptake of cardiac neurodevelopmental follow-up care. Front Pediatr 2024; 12:1364190. [PMID: 38863525 PMCID: PMC11165703 DOI: 10.3389/fped.2024.1364190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/08/2024] [Indexed: 06/13/2024] Open
Abstract
Introduction Surveillance, screening, and evaluation for neurodevelopmental delays is a pivotal component of post-surgical care for children with congenital heart disease (CHD). However, challenges exist in implementing such neurodevelopmental follow-up care in international practice. This study aimed to characterise key barriers, enablers, and opportunities for implementing and delivering outpatient cardiac neurodevelopmental follow-up care in Australia. Methods an exploratory descriptive qualitative study was conducted with healthcare professionals across Australia who had lived experience of designing, implementing, or delivering neurodevelopmental care for children with CHD. Online semi-structured interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research to explore contextual influences. Interview transcripts were analysed using a rapid qualitative approach including templated summaries and hybrid deductive-inductive matrix analysis. Results fifty-two participants were interviewed. Perceived barriers and enablers were organised into six higher-order themes: factors in the broader environmental, economic, and political context; healthcare system factors; organisational-level factors; provider factors; patient and family factors; and care model factors. The largest number of barriers occurred at the healthcare system level (service accessibility, fragmentation, funding, workforce), while service providers demonstrated the most enabling factors (interprofessional relationships, skilled teams, personal characteristics). Strategies to improve practice included building partnerships; generating evidence; increasing funding; adapting for family-centred care; and integrating systems and data. Discussion Australia shares many similar barriers and enablers to cardiac neurodevelopmental care with other international contexts. However, due to unique geographical and health-system factors, care models and implementation strategies will require adaption to the local context to improve service provision.
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Affiliation(s)
- Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Facultyof Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - David Rodwell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Facultyof Health, Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Accident Research & Road Safety—Queensland (CARRS-Q), School of Psychology and Counselling, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Karen J. Eagleson
- Queensland Paediatric Cardiac Service, Queensland Children’s Hospital, South Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Facultyof Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben Auld
- Queensland Paediatric Cardiac Service, Queensland Children’s Hospital, South Brisbane, QLD, Australia
| | - Samudragupta Bora
- Health Services Research Center, University Hospitals Research & Education Institute and Department of Pediatrics, University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Nadine A. Kasparian
- Heart and Mind Wellbeing Center, Heart Institute and the Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Robert Justo
- Queensland Paediatric Cardiac Service, Queensland Children’s Hospital, South Brisbane, QLD, Australia
| | - Steven M. McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Facultyof Health, Queensland University of Technology, Brisbane, QLD, Australia
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Hennrick H, Miller E, Lai WW, Nelkin VC, Flores AM, Olson M, Kong D, Tan A. Effects of Implementing a Standardized Surveillance Program on Cardiac Neurodevelopmental Program Referral Completion. Pediatr Cardiol 2024; 45:821-828. [PMID: 38416202 DOI: 10.1007/s00246-024-03425-9] [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: 11/11/2023] [Accepted: 01/20/2024] [Indexed: 02/29/2024]
Abstract
Differences in surveillance methods have resulted in significant variability in referral volumes and referral completion rates across cardiac neurodevelopmental programs, with frequent barriers to referral completion including high no-show rates, lack of education, and inaccessibility for underrepresented populations. The purpose of this study was to describe implementation of a standardized surveillance program and investigate impact on referral volume and completion over a two-year period. Between fiscal years 2021 and 2022, a surveillance program was implemented which standardized assessment of neurodevelopmental risk via a checklist as well as family education and referral procedures. All patients referred to the cardiac neurodevelopmental program during these two fiscal years were included in the analysis, and patient referrals were categorized as complete or incomplete (due to physician-related or patient-related factors). Referral completion rates between fiscal years were compared using two sample Z test of proportions, while associations between referral completion and demographic/anatomical variables were completed using chi-square tests of independence. Implementation of the formal surveillance program resulted in a 66.7% increase in referral volume. Proportions of both incomplete referrals (z = 2.00, p < 0.05) and incomplete referrals due to physician-related factors (z = 4.34, p < 0.01) were significantly lower after implementation. A significant association was found after implementation between referral completion and race/ethnicity (x2 = 14.08, p < 0.01) due to a significantly high proportion of completed referrals for patients identifying as Hispanic/Latino within the overall distribution of patients. This study describes the successful implementation of a standardized surveillance program, including improvements to referral volume and completion rate. Findings also support implementation of methods that emphasize physician surveillance methods and improve accessibility for historically marginalized groups at greatest risk for disparities in access and quality of care.
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Affiliation(s)
- Heather Hennrick
- Department of Psychology and Neuropsychology, Children's Hospital of Orange County, 1120 West La Veta Avenue, Suite 470, Orange, CA, 92868, USA
| | - Elizabeth Miller
- Heart Institute, Children's Hospital of Orange County, Orange, CA, USA
| | - Wyman W Lai
- Heart Institute, Children's Hospital of Orange County, Orange, CA, USA
- Department of Pediatrics, University of California Irvine, Irvine, CA, USA
| | - Viannae Carmona Nelkin
- Department of Psychology and Neuropsychology, Children's Hospital of Orange County, 1120 West La Veta Avenue, Suite 470, Orange, CA, 92868, USA
| | - Ana-Mercedes Flores
- Department of Psychology and Neuropsychology, Children's Hospital of Orange County, 1120 West La Veta Avenue, Suite 470, Orange, CA, 92868, USA
| | - Marissa Olson
- Heart Institute, Children's Hospital of Orange County, Orange, CA, USA
| | - Dianne Kong
- Department of Psychology and Neuropsychology, Children's Hospital of Orange County, 1120 West La Veta Avenue, Suite 470, Orange, CA, 92868, USA
| | - Alexander Tan
- Department of Psychology and Neuropsychology, Children's Hospital of Orange County, 1120 West La Veta Avenue, Suite 470, Orange, CA, 92868, USA.
- Heart Institute, Children's Hospital of Orange County, Orange, CA, USA.
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Abell BR, Eagleson K, Auld B, Bora S, Justo R, Parsonage W, Sharma P, Kularatna S, McPhail SM. Implementing neurodevelopmental follow-up care for children with congenital heart disease: A scoping review with evidence mapping. Dev Med Child Neurol 2024; 66:161-175. [PMID: 37421232 PMCID: PMC10953404 DOI: 10.1111/dmcn.15698] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/04/2023] [Accepted: 06/07/2023] [Indexed: 07/10/2023]
Abstract
AIM To identify and map evidence describing components of neurodevelopmental follow-up care for children with congenital heart disease (CHD). METHOD This was a scoping review of studies reporting components of neurodevelopmental follow-up programmes/pathways for children with CHD. Eligible publications were identified through database searches, citation tracking, and expert recommendations. Two independent reviewers screened studies and extracted data. An evidence matrix was developed to visualize common characteristics of care pathways. Qualitative content analysis identified implementation barriers and enablers. RESULTS The review included 33 studies. Twenty-one described individual care pathways across the USA (n = 14), Canada (n = 4), Australia (n = 2), and France (n = 1). The remainder reported surveys of clinical practice across multiple geographical regions. While heterogeneity in care existed across studies, common attributes included enrolment of children at high-risk of neurodevelopmental delay; centralized clinics in children's hospitals; referral before discharge; periodic follow-up at fixed ages; standardized developmental assessment; and involvement of multidisciplinary teams. Implementation barriers included service cost/resourcing, patient burden, and lack of knowledge/awareness. Multi-level stakeholder engagement and integration with other services were key drivers of success. INTERPRETATION Defining components of effective neurodevelopmental follow-up programmes and care pathways, along with enhancing and expanding guideline-based care across regions and into new contexts, should continue to be priorities. WHAT THIS PAPER ADDS Twenty-two different neurodevelopmental follow-up care pathways/programmes were published, originating from four countries. Twelve additional publications described broad practices for neurodevelopmental follow-up across regions Common attributes across eligibility, service structure, assessment processes, and care providers were noted. Studies reported programme acceptability, uptake, cost, and effectiveness. Implementation barriers included service cost/resourcing, patient burden, and lack of knowledge/awareness.
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Affiliation(s)
- Bridget R. Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
| | - Karen Eagleson
- Queensland Paediatric Cardiac ServiceQueensland Children's HospitalBrisbaneQLDAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
| | - Benjamin Auld
- Queensland Paediatric Cardiac ServiceQueensland Children's HospitalBrisbaneQLDAustralia
| | - Samudragupta Bora
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
- University Hospitals Rainbow Babies & Children's HospitalCase Western Reserve University School of MedicineClevelandOHUSA
| | - Robert Justo
- Queensland Paediatric Cardiac ServiceQueensland Children's HospitalBrisbaneQLDAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
- Royal Brisbane and Women's HospitalMetro North HealthBrisbaneQLDAustralia
| | - Pakhi Sharma
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
| | - Steven M. McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
- Digital Health and Informatics Directorate, Metro South HealthBrisbaneQLDAustralia
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Cassidy AR, Neumann AA. [Formula: see text] Optimizing neurodevelopmental outcomes following fetal diagnosis of congenital heart disease: a call for primary prevention neuropsychology. Child Neuropsychol 2023; 29:1155-1177. [PMID: 36942716 DOI: 10.1080/09297049.2023.2190966] [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] [Received: 07/08/2022] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
Critical congenital heart disease (CHD) presents a lasting threat to quality of life through its adverse impact on neurodevelopmental and psychosocial outcomes. As recognition of this threat has increased, so too has an appreciation for the role of pediatric neuropsychologists in supporting families affected by CHD. But there is more to offer these families than traditional neuropsychological services, which tend to focus on secondary/tertiary forms of prevention. Now that many children with CHD are diagnosed prenatally, it may be possible to begin mitigating CHD-related risks and promoting positive outcomes earlier than ever before. Through primary prevention-oriented fetal neuropsychological consultation, as well as close collaboration with allied specialists, pediatric neuropsychology has an opportunity to re-envision its typical borders and more familiar practice models; to forge early and enduring partnerships with families; and to help promote the best possible neurodevelopmental trajectories, beginning before children are even born. In this conceptual review, we survey and integrate evidence from developmental science, developmental origins of health and disease, maternal-fetal medicine, and cardiac neurodevelopmental literatures, along with current practice norms, arriving ultimately at two central conclusions: 1) there is an important role to fill on multidisciplinary teams for the pediatric neuropsychologist in fetal cardiac care and 2) role expansion (e.g., through valuing broader-based training, flexing more generalist skills) can likely improve neuropsychological outcomes earlier than has been standard for pediatric neuropsychologists. Such a reimagining of our practice may be considered primary prevention neuropsychology. Implications for care in various settings and pragmatic barriers to implementation are discussed.
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Affiliation(s)
- Adam R Cassidy
- Departments of Psychiatry & Psychology and Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alyssa A Neumann
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
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Ortinau CM, Wypij D, Ilardi D, Rofeberg V, Miller TA, Donohue J, Reichle G, Seed M, Elhoff J, Alexander N, Allen K, Anton C, Bear L, Boucher G, Bragg J, Butcher J, Chen V, Glotzbach K, Hampton L, Lee CK, Ly LG, Marino BS, Martinez-Fernandez Y, Monteiro S, Ortega C, Peyvandi S, Raiees-Dana H, Rollins CK, Sadhwani A, Sananes R, Sanz JH, Schultz AH, Sood E, Tan A, Willen E, Wolfe KR, Goldberg CS. Factors Associated With Attendance for Cardiac Neurodevelopmental Evaluation. Pediatrics 2023; 152:e2022060995. [PMID: 37593818 PMCID: PMC10530086 DOI: 10.1542/peds.2022-060995] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neurodevelopmental evaluation of toddlers with complex congenital heart disease is recommended but reported frequency is low. Data on barriers to attending neurodevelopmental follow-up are limited. This study aims to estimate the attendance rate for a toddler neurodevelopmental evaluation in a contemporary multicenter cohort and to assess patient and center level factors associated with attending this evaluation. METHODS This is a retrospective cohort study of children born between September 2017 and September 2018 who underwent cardiopulmonary bypass in their first year of life at a center contributing data to the Cardiac Neurodevelopmental Outcome Collaborative and Pediatric Cardiac Critical Care Consortium clinical registries. The primary outcome was attendance for a neurodevelopmental evaluation between 11 and 30 months of age. Sociodemographic and medical characteristics and center factors specific to neurodevelopmental program design were considered as predictors for attendance. RESULTS Among 2385 patients eligible from 16 cardiac centers, the attendance rate was 29.0% (692 of 2385), with a range of 7.8% to 54.3% across individual centers. In multivariable logistic regression models, hospital-initiated (versus family-initiated) scheduling for neurodevelopmental evaluation had the largest odds ratio in predicting attendance (odds ratio = 4.24, 95% confidence interval, 2.74-6.55). Other predictors of attendance included antenatal diagnosis, absence of Trisomy 21, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category, longer postoperative length of stay, private insurance, and residing a shorter distance from the hospital. CONCLUSIONS Attendance rates reflect some improvement but remain low. Changes to program infrastructure and design and minimizing barriers affecting access to care are essential components for improving neurodevelopmental care and outcomes for children with congenital heart disease.
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Affiliation(s)
- Cynthia M. Ortinau
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - David Wypij
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States; Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia, United States
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, United States
| | - Thomas A. Miller
- Division of Cardiology, Maine Medical Center, Portland, Maine, United States
| | - Janet Donohue
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Garrett Reichle
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Mike Seed
- Department of Paediatrics, Division of Paediatric Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Justin Elhoff
- Department of Pediatrics, Division of Critical Care Medicine, Baylor School of Medicine, Houston, Texas, United States
| | - Nneka Alexander
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Kiona Allen
- Department of Pediatrics, Division of Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
| | - Corinne Anton
- Department of Cardiology, Children’s Health, Dallas, Texas, United States; Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Laurel Bear
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Gina Boucher
- Phoenix Children’s Hospital Heart Center, Phoenix, Arizona, United States
| | - Jennifer Bragg
- Department of Pediatrics, Mount Sinai Hospital, New York, New York, United States
| | - Jennifer Butcher
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Victoria Chen
- Department of Pediatrics, Division of Developmental-Behavioral Pediatrics, Cohen Children’s Medical Center, New Hyde Park, New York, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Kristi Glotzbach
- Department of Pediatrics, Division of Critical Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Lyla Hampton
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Caroline K. Lee
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Linh G. Ly
- Department of Paediatrics, Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children’s, Cleveland, Ohio, United States
| | | | - Sonia Monteiro
- Department of Pediatrics, Baylor School of Medicine, Houston, Texas, United States
| | - Christina Ortega
- Department of Psychology, Joe DiMaggio Children’s Hospital, Hollywood, Florida, United States
| | - Shabnam Peyvandi
- University of California San Francisco Benioff Children’s Hospital, San Francisco, California, United States
| | | | - Caitlin K. Rollins
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Neurology, Harvard Medical School, Boston, Massachusetts, United States
| | - Anjali Sadhwani
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Renee Sananes
- Department of Psychology, Division of Cardiology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Jacqueline H. Sanz
- Division of Neuropsychology, Children’s National Hospital; Departments of Psychiatry and Behavioral Sciences & Pediatrics, The George Washington University School of Medicine, Washington D.C., United States
| | - Amy H. Schultz
- Division of Cardiology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, United States
| | - Erica Sood
- Nemours Cardiac Center, Nemours Children’s Health, Wilmington, Delaware, United States; Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Alexander Tan
- Department of Neuropsychology, Children’s Health Orange County, Orange, California, United States
| | - Elizabeth Willen
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, United States
| | - Kelly R. Wolfe
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Caren S. Goldberg
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
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Neurodevelopmental Outcomes in Children with Congenital Heart Disease: Ten Years After the American Heart Association Statement. Clin Perinatol 2023; 50:53-66. [PMID: 36868713 DOI: 10.1016/j.clp.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Even before birth, children with congenital heart disease (CHD) are at risk for neurodevelopmental concerns, with additional insults occurring as part of their treatment course and from subsequent exposures to socioeconomic stressors. With multiple affected neurodevelopmental domains, individuals with CHD face lifelong cognitive, academic, psychological, and quality-of-life difficulties. Early and repeated neurodevelopmental evaluation is key to receiving appropriate services. However, obstacles at the level of the environment, provider, patient, and family can make the completion of these evaluations difficult. Future neurodevelopmental endeavors should aim to evaluate CHD-specific programs, their effectiveness, and barriers to access.
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Lee FT, Sun L, Freud L, Seed M. A guide to prenatal counseling regarding neurodevelopment in congenital heart disease. Prenat Diagn 2022; 43:661-673. [PMID: 36575573 DOI: 10.1002/pd.6292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 12/07/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022]
Abstract
Advances in cardiac surgical techniques taking place over the past 50 years have resulted in the vast majority of children born with congenital cardiac malformations now surviving into adulthood. As the focus shifts from survival to the functional outcomes of our patients, it is increasingly being recognized that a significant proportion of patients undergoing infant cardiac repair experience adverse neurodevelopmental (ND) outcomes. The etiology of abnormal brain development in the setting of congenital heart disease is poorly understood, complex, and likely multifactorial. Furthermore, the efficacy of therapies available for the learning disabilities, attention deficit, and hyperactivity disorders and other ND deficits complicating congenital heart disease is currently uncertain. This situation presents a challenge for prenatal counseling as current antenatal testing does not usually provide prognostic information regarding the likely ND trajectories of individual patients. However, we believe it is important for parents to be informed about potential issues with child development when a new diagnosis of congenital heart disease is disclosed. Parents deserve a comprehensive and thoughtful approach to this subject, which conveys the uncertainties involved in predicting the severity of any developmental disorders encountered, while emphasizing the improvements in outcomes that have already been achieved in infants with congenital heart disease. A balanced approach to counseling should also discuss what local arrangements are in place for ND follow-up. This review presents an up-to-date overview of ND outcomes in patients with congenital heart disease, providing possible approaches to communicating this information to parents during prenatal counseling in a sensitive and accurate manner.
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Affiliation(s)
- Fu-Tsuen Lee
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Liqun Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay Freud
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mike Seed
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Neukomm A, Ehrler M, Feldmann M, Chaouch A, Knirsch W, Hagmann C, Jakab A, Latal B. Perioperative Course and Socioeconomic Status Predict Long-Term Neurodevelopment Better Than Perioperative Conventional Neuroimaging in Children with Congenital Heart Disease. J Pediatr 2022; 251:140-148.e3. [PMID: 35948191 DOI: 10.1016/j.jpeds.2022.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/17/2022] [Accepted: 07/23/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE The objective of the study was to compare the use of neonatal conventional brain magnetic resonance imaging (MRI) with that of clinical factors and socioeconomic status (SES) to predict long-term neurodevelopment in children with severe congenital heart disease (CHD). STUDY DESIGN In this prospective cohort study, perioperative MRIs were acquired in 57 term-born infants with CHD undergoing cardiopulmonary bypass surgery during their first year of life. Total brain volume (TBV) was measured using an automated method. Brain injury severity (BIS) was assessed by an established scoring system. The neurodevelopmental outcome was assessed at 6 years using standardized test batteries. A multiple linear regression model was used for cognitive and motor outcomes with postoperative TBV, perioperative BIS, CHD complexity, length of hospital stay, and SES as covariates. RESULTS CHD diagnoses included univentricular heart defect (n = 15), transposition of the great arteries (n = 33), and acyanotic CHD (n = 9). Perioperative moderate-to-severe brain injury was detected in 15 (26%) patients. The total IQ was similar to test norms (P = .11), whereas the total motor score (P < .001) was lower. Neither postoperative TBV nor perioperative BIS predicted the total IQ, but SES (P < .001) and longer hospital stay (P = .004) did. No factor predicted the motor outcome. CONCLUSION Although the predictive value of neonatal conventional MRIs for long-term neurodevelopment is low, duration of hospital stay and SES better predict the outcome in this CHD sample. These findings should be considered in initiating early therapeutic support.
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Affiliation(s)
- Astrid Neukomm
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Melanie Ehrler
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland
| | - Maria Feldmann
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Aziz Chaouch
- Division of Biostatistics, Center of Primary Care and Public Health (Unisanté) Lausanne, Lausanne, Switzerland
| | - Walter Knirsch
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland; Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Cornelia Hagmann
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; Department of Neonatology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Andras Jakab
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; Center for MR Research, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland
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Monteiro S, Serrano F, Guffey D, Lopez KN, De Thomas EM, Voigt RG, Shekerdemian L, Morris SA. Factors affecting rates of neurodevelopmental follow-up in infants with congenital heart disease. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Gallegos FN, Woo JL, Anderson BR, Lopez KN. Disparities in surgical outcomes of neonates with congenital heart disease across regions, centers, and populations. Semin Perinatol 2022; 46:151581. [PMID: 35396037 PMCID: PMC9177851 DOI: 10.1016/j.semperi.2022.151581] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To summarize existing literature on neonatal disparities in congenital heart disease surgical outcomes and identify potential policies to address these disparities. FINDING Disparities in outcomes for neonatal congenital heart surgery were largely published under four domains: race/ethnicity, insurance type, neighborhood/socioeconomic status, and cardiac center characteristics. While existing research identifies associations between these domains and mortality, more nuanced analyses are emerging to understand the mediators between these domains and other non-mortality outcomes, as well as potential interventions and policies to reduce disparities. A broader look into social determinants of health (SDOH), prenatal diagnosis, proximity of birth to a cardiac surgical center, and post-surgical outpatient and neurodevelopmental follow-up may accelerate interventions to mitigate disparities in outcomes. CONCLUSION Understanding the mechanisms of how SDOH relate to neonatal surgical outcomes is paramount, as disparities research in neonatal congenital heart surgery continues to shift from identification and description, to intervention and policy.
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Affiliation(s)
- Flora Nuñez Gallegos
- Stanford University School of Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Division of Pediatric Cardiology, Palo Alto, CA
| | - Joyce L. Woo
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital, Department of Pediatrics, Division of Pediatric Cardiology, Chicago, IL
| | - Brett R. Anderson
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Department of Pediatrics, Division of Pediatric Cardiology, New York, NY
| | - Keila N. Lopez
- Baylor College of Medicine Texas Children’s Hospital Department of Pediatrics, Division of Pediatric Cardiology, Houston TX,Corresponding Author:
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11
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Glotzbach KL, Ward JJ, Marietta J, Eckhauser AW, Winter S, Puchalski MD, Miller TA. The Benefits and Bias in Neurodevelopmental Evaluation for Children with Congenital Heart Disease. Pediatr Cardiol 2020; 41:327-333. [PMID: 31865442 DOI: 10.1007/s00246-019-02260-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
Neurodevelopmental (ND) impairment is common in children with congenital heart disease (CHD). While routine ND surveillance and evaluation of high-risk patients has become the standard-of-care, capture rate, barriers to referral, and potential patient benefits remain incompletely understood. Electronic data warehouse records from a single center were reviewed to identify all eligible and evaluated patients between July 2015 and December 2017 based on current guidelines for ND screening in CHD. Diagnoses, referring provider, and payor were considered. Potential benefit of the evaluation was defined as receipt of new diagnosis, referral for additional evaluation, or referral for a new service. Contingencies were assessed with Fisher's exact test. In this retrospective, cohort study, of 3434 children identified as eligible for ND evaluation, 135 were evaluated (4%). Appropriate evaluation was affected by diagnostic bias against coarctation of the aorta (CoArc) and favoring hypoplastic left heart syndrome (HLHS) (1.8 vs. 11.9%, p<0.01). Referrals were disproportionally made by a select group of cardiologists, and the rate of ND appointment non-compliance was higher in self-pay compared to insured patients (78% vs 27%, p<0.01). Potential benefit rate was 70-80% amongst individuals with the three most common diagnoses requiring neonatal surgery (CoArc, transposition of the great arteries, and HLHS). Appropriate ND evaluation in CHD is impacted by diagnosis, provider, and insurance status. Potential benefit of ND evaluation is high regardless of diagnosis. Strategies to improve access to ND evaluations and provider understanding of the at-risk population will likely improve longitudinal ND surveillance and clinical benefit.
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Affiliation(s)
- Kristi L Glotzbach
- Department of Pediatrics, Division of Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.
| | - John J Ward
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jennifer Marietta
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Aaron W Eckhauser
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Sarah Winter
- Department of Pediatrics, Division of General Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Michael D Puchalski
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Thomas A Miller
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
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12
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Fourdain S, Caron-Desrochers L, Simard MN, Provost S, Doussau A, Gagnon K, Dagenais L, Presutto É, Prud'homme J, Boudreault-Trudeau A, Constantin IM, Desnous B, Poirier N, Gallagher A. Impacts of an Interdisciplinary Developmental Follow-Up Program on Neurodevelopment in Congenital Heart Disease: The CINC Study. Front Pediatr 2020; 8:539451. [PMID: 33123502 PMCID: PMC7573208 DOI: 10.3389/fped.2020.539451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 08/18/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study investigates the impact of an early systematic interdisciplinary developmental follow-up and individualized intervention program on the neurodevelopment of children with complex congenital heart disease (CHD) who required cardiac surgery. Study Design: We prospectively enrolled 80 children with CHD: 41 were already followed at our neurocardiac developmental follow-up clinic from the age of 4 months, while 39 were born before the establishment of the program and therefore received standard health care. We conducted cognitive, motor, and behavioral assessments at 3 years of age. We used one-way multivariate analyses of variance to compare the neurodevelopmental outcome of both groups. Results: Between-group analyses revealed a distinct neurodevelopmental profile with clinically significant effect size (P < 0.001, partial η2 = 0.366). Children followed at our clinic demonstrated better receptive language performances (P = 0.048) and tended to show higher scores on visuo-constructive tasks (P = 0.080). Children who received standard health care exhibited greater performances in working memory tasks (P = 0.032). We found no group differences on global intellectual functioning, gross and fine motor skills, and behaviors. Referral rates for specific remedial services were higher in patients followed at our neurocardiac clinic compared to the historical cohort (P < 0.005). Conclusions: Overall, the impact of the developmental follow-up and individualized intervention program on neurodevelopmental outcomes remains subtle. Nevertheless, results, although limited by several factors, point toward an advantage for the children who took part in the program regarding receptive language skills over children who received standard health care. We hypothesize that group differences may be greater with growing age. Further research involving larger cohorts is needed to clearly assess the effectiveness of neurocardiac developmental follow-up programs at school age.
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Affiliation(s)
- Solène Fourdain
- Sainte-Justine University Hospital Research Center, Montreal, QC, Canada.,Department of Psychology, Université de Montréal, Montreal, QC, Canada
| | - Laura Caron-Desrochers
- Sainte-Justine University Hospital Research Center, Montreal, QC, Canada.,Department of Psychology, Université de Montréal, Montreal, QC, Canada
| | - Marie-Noëlle Simard
- Sainte-Justine University Hospital Research Center, Montreal, QC, Canada.,School of Rehabilitation, Université de Montréal, Montreal, QC, Canada.,Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | - Sarah Provost
- Sainte-Justine University Hospital Research Center, Montreal, QC, Canada.,Department of Psychology, Université de Montréal, Montreal, QC, Canada
| | - Amélie Doussau
- Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | - Karine Gagnon
- Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | - Lynn Dagenais
- Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | - Émilie Presutto
- Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | - Joëlle Prud'homme
- Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
| | | | - Ioana Medeleine Constantin
- Sainte-Justine University Hospital Research Center, Montreal, QC, Canada.,Department of Psychology, Université de Montréal, Montreal, QC, Canada
| | - Béatrice Desnous
- Division of Neurology, Department of Pediatrics, La Timone Hospital, Marseille, France
| | - Nancy Poirier
- Sainte-Justine University Hospital Research Center, Montreal, QC, Canada.,Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Anne Gallagher
- Sainte-Justine University Hospital Research Center, Montreal, QC, Canada.,Department of Psychology, Université de Montréal, Montreal, QC, Canada.,Clinique d'Investigation Neurocardiaque (CINC), Sainte-Justine University Hospital Center, Montreal, QC, Canada
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13
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Neuromotor performance in infants before and after early open-heart surgery and risk factors for delayed development at 6 months of age. Cardiol Young 2019; 29:100-109. [PMID: 30352635 DOI: 10.1017/s1047951118001622] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Early identification of infants with CHD at heightened risk of developmental delays can inform surveillance priorities. This study investigated pre-operative and post-operative neuromotor performance in infants undergoing open-heart surgery, and their developmental status at 6 months of age, to identify risk factors and inform care pathways. METHODS Infants undergoing open-heart surgery before 4 months of age were recruited into a prospective cohort study. Neuromotor performance was assessed pre-operatively and post-operatively using the Test of Infant Motor Performance and Prechtl's Assessment of General Movements. Development was assessed at 6 months of age using the Ages and Stages Questionnaire third edition. Pre-operative and post-operative General Movements performance was compared using McNemar's test and test of infant motor performance z-scores using Wilcoxon's signed rank test. Risk factors for delayed development at 6 months were explored using logistic regression. RESULTS Sixty infants were included in this study. In the 23 (38%) infants. A total of 60 infants were recruited. In the 23 (38%) infants assessed pre-operatively, there was no significant difference between pre- and post-operative performance on the GMs (p=0.63) or TIMP (p=0.28). At discharge, 15 (26%) infants presented with abnormal GMs, and the median TIMP z-score was -0.93 (IQR: -1.4 to -0.69). At 6 months, 28 (52.8%) infants presented with gross motor delay on the ASQ-3, significantly negatively associated with gestational age (p=0.03), length of hospital stay (p=0.04) and discharge TIMP score (p=0.01). CONCLUSIONS Post-operative assessment using the GMs and TIMP may be useful to identify infants requiring individualised care and targeted developmental follow-up. Long-term developmental surveillance beyond 6 months of age is recommended.
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