Impacts of national surveillance for uncommon conditions in childhood

Rare disease: a national survey of paediatricians' experiences and needs

OBJECTIVE

To describe the experiences of Australian paediatricians while caring for children with rare diseases, and their educational and resource needs.

DESIGN

A brief online survey was developed and deployed to a representative sample of 679 paediatricians from the Australian Paediatric Surveillance Unit database.

RESULTS

Of the 679 paediatricians, 242 (36%) completed the survey. The respondents were representative of all states and territories of Australia, urban and rural regions, and hospital and private practice. Almost all respondents (93%) had seen children with one or more of >350 different rare diseases during their career; 74% had seen a new patient with rare disease in the last 6 months. The most common problems encountered while caring for patients were: diagnostic delays (65%), lack of available treatments (40%), clinical guidelines (36%) and uncertainty where to refer for peer support (35%). Few paediatricians said that rare diseases were adequately covered during university (40%) or the Fellowship of the Royal Australasian College of Physicians (50%) training, and 28% felt unprepared to care for patients with rare diseases. Paediatricians wanted lists of specialist referral services (82%) and online educational modules about rare diseases (78%) that could be accessed via one online portal that consolidated multiple resources. Smartphone applications on rare diseases were favoured by paediatricians aged <50 years and by female paediatricians.

CONCLUSIONS

An online educational portal should be developed and maintained for accuracy and currency of information to support dissemination of rare disease guidelines, referral pathways and coordination services relevant to Australian paediatricians and other health professionals who care for children with rare diseases.

Impact of three genetic musculoskeletal diseases: a comparative synthesis of achondroplasia, Duchenne muscular dystrophy and osteogenesis imperfecta

Achondroplasia, Duchenne muscular dystrophy, and osteogenesis imperfecta are among the most frequent rare genetic disorders affecting the musculoskeletal system in children. Rare genetic disorders are severely disabling and can have substantial impacts on families, children, and on healthcare systems. This literature review aims to classify, summarize and compare these non-medical impacts of achondroplasia, Duchenne muscular dystrophy and osteogenesis imperfecta.

Utilization of national patient registries by clinical nurse specialist: opportunities and implications

PURPOSE

The purpose of this article was to describe how clinical nurse specialists can be instrumental in getting involved in the process of joining a national disease registry to improve patient outcomes.

BACKGROUND

Clinical patient data registries provide longitudinal data on developmental outcomes in chronic, lifelong diseases affecting children. Recognition and application of their use have historically allowed for collection of benchmarking data, improved understanding of disease processes and patient outcomes, and improved quality of life.

DESCRIPTION OF THE PROJECT

A group of advanced practice nurses in a university-based multispecialty clinic, through evidence-based practice, embarked on the process of joining the National Spina Bifida Patient Registry sponsored by the Centers for Disease Control and Prevention.

OUTCOME

By taking the lead as project managers, this group of advanced practice nurses obtained buy-in from physicians and multispecialty team members of the Spina Bifida Clinic in the university children's hospital where they practice. An institutional review board application was submitted to their university children's hospital internal review board and currently approved.

CONCLUSION

This project demonstrates how dynamic utilization of core competencies through application of specific knowledge and skill sets supports the advanced practice nurse's instrumental role in actively initiating, promoting, and supporting participation in clinical patient data registries that seek improved patient outcomes at the national level.

IMPLICATIONS

Clinical nurse specialists quantify their role and purpose when connecting their interventions and influence to patient outcomes with utilization of resources, such as a national patient data registry.

Epidemiology of Shiga toxin producing Escherichia coli in Australia, 2000-2010

BACKGROUND

Shiga toxin-producing Escherichia coli (STEC) are an important cause of gastroenteritis in Australia and worldwide and can also result in serious sequelae such as haemolytic uraemic syndrome (HUS). In this paper we describe the epidemiology of STEC in Australia using the latest available data.

METHODS

National and state notifications data, as well as data on serotypes, hospitalizations, mortality and outbreaks were examined.

RESULTS

For the 11 year period 2000 to 2010, the overall annual Australian rate of all notified STEC illness was 0.4 cases per 100,000 per year. In total, there were 822 STEC infections notified in Australia over this period, with a low of 1 notification in the Australian Capital Territory (corresponding to a rate of 0.03 cases per 100,000/year) and a high of 413 notifications in South Australia (corresponding to a rate of 2.4 cases per 100,000/year), the state with the most comprehensive surveillance for STEC infection in the country. Nationally, 71.2% (504/708) of STEC infections underwent serotype testing between 2001 and 2009, and of these, 58.0% (225/388) were found to be O157 strains, with O111 (13.7%) and O26 (11.1%) strains also commonly associated with STEC infections. The notification rate for STEC O157 infections Australia wide between 2001-2009 was 0.12 cases per 100,000 per year. Over the same 9 year period there were 11 outbreaks caused by STEC, with these outbreaks generally being small in size and caused by a variety of serogroups. The overall annual rate of notified HUS in Australia between 2000 and 2010 was 0.07 cases per 100,000 per year. Both STEC infections and HUS cases showed a similar seasonal distribution, with a larger proportion of reported cases occurring in the summer months of December to February.

CONCLUSIONS

STEC infections in Australia have remained fairly steady over the past 11 years. Overall, the incidence and burden of disease due to STEC and HUS in Australia appears comparable or lower than similar developed countries.

Disease registries and outcomes research in children: focus on lysosomal storage disorders

Assessing medicines specifically for use in children has been neglected in the past, with the majority of formal clinical studies being conducted in adults. Clinical trials are a pivotal part of the drug approval process; however, they are not always applicable to the diverse populations - including children - that receive the drug after approval. They may not be the most informative assessment tool, especially in rare (or orphan) disorders where there are few patients, due to a lack of existing natural history data and the challenges of designing appropriately powered statistical analyses. Disease registries, which can collect clinical information in larger, more heterogeneous populations than can be included in a clinical trial, are becoming increasingly valuable. Their use is particularly beneficial for diseases affecting very small patient populations, such as lysosomal storage disorders (LSDs), and for looking at specific populations, for example, children. Such disease registries can provide natural history data as well as enable the impact of therapy to be examined. Moreover, despite potential limitations of enrollment bias and unmonitored data, patient registries can play a valuable role in assuring pediatric health, providing longitudinal data that can be used to monitor developmental outcomes in chronic lifelong diseases, and assessing the effectiveness of treatment. This review describes the role of registries in drug development and regulatory approval, the impact of global registry programs on pediatric research, with some examples from the field of LSDs, and how registries are impacting the clinical care such children receive.

What do paediatricians think of the Australian Paediatric Surveillance Unit?

AIM

To explore clinicians' perceptions of the value, usefulness and limitations of the Australian Paediatric Surveillance Unit (APSU) and obtain direct feedback regarding the surveillance mechanism and suggestions for improvement.

METHODS

Anonymous postal survey of Australian paediatricians (n = 1260) in 2007.

RESULTS

Of 1260 clinicians surveyed 818 (65%) responded, a similar proportion from all states/territories and specialties. Over half had participated in surveillance for >10 years. The majority (95%), believe APSU research is valuable, for generating knowledge (81%), identifying research needs (78%), facilitating collaborative research (75%), supporting education and advocacy (74%), guiding clinical practice (70%), informing future policy (70%) and evaluating current policy (68%). Of 458 respondents who had ever reported a case (90%) had no objection to providing de-identified clinical information; and about 75% said questionnaires were easy to complete; however, one third said clinical information requested was not always readily available. Most (680, 83%) respondents believed their contribution to the APSU was appropriately acknowledged and 20% said they had personally benefited from participation. The majority (90%) were willing to report immediately by email/fax/phone in an epidemiological emergency. Lack of time and resources was the most common limitation to participation identified by clinicians: some suggested on-line reporting would improve the ease and timeliness of reporting. Clinicians also suggested better use of the APSU website to disseminate results.

CONCLUSION

Clinicians acknowledged the APSU as valuable. Improving communication with clinicians, ensuring that information requested in questionnaires is relevant and available, and developing a secure web-based reporting system are future APSU priorities.

Call for a national plan for rare diseases

Australia requires a national plan, similar to plans developed internationally, to address the impacts of rare diseases on individuals, the community and health services. Rare diseases often present in childhood, many are chronic, some life threatening and others associated with significant disability. However, diagnosis is often delayed, because of lack of knowledge and experience of health professionals and uncertainty about where to refer. Specialised health services are frequently lacking and specific therapies are often not available, partly because of lack of research funding directed towards rare diseases. A national plan would facilitate a coordinated response to service development, carer support, and health professional and community education, and would promote research and advocacy for affected children and their families.

Evaluation of a national resource to identify and study rare diseases: the Australian Paediatric Surveillance Unit

AIMS

To evaluate the Australian Paediatric Surveillance Unit (APSU).

METHODS

We used criteria recommended by the Centres for Disease Control and Prevention (CDC) for evaluating surveillance systems and reviewed productivity, response rates, completeness of the mailing list and impacts of APSU studies. Anonymous evaluation questionnaires were sent to 1260 reporting clinicians, 42 researchers and 86 public health professionals to seek their feedback as users of the APSU.

RESULTS

APSU provides national epidemiological and clinical data about rare childhood conditions that inform public health policy and clinical practice. Between 2000 and 2007, APSU data were disseminated in 106 journal articles, 207 scientific presentations and 85 media items. Of paediatricians and paediatric sub-specialists actively practicing in Australia and listed as Fellows of the Royal Australasian College of Physicians, 92% participate in APSU surveillance. An average 96% of monthly report cards were returned per annum since 2000. Sensitivity of case ascertainment was difficult to calculate for many conditions because alternative sources of ascertainment do not exist. Evaluation questionnaires were returned by 818 (65%) reporting clinicians, who believe APSU is valuable for generating knowledge 665 (81%), identifying research priorities 635 (78%), guiding clinical practice 572 (70%) and informing public health policy 575 (70%). Similar responses were received from researchers and public health professionals.

CONCLUSIONS

The APSU fulfils its objectives and meets relevant CDC criteria for usefulness, simplicity, acceptability and representativeness, sensitivity and timeliness of data quality. However, stability is threatened by lack of continuing core funding. APSU is highly productive and valued by child health clinicians, researchers and public health professionals.

Burden of eating disorders in 5-13-year-old children in Australia

OBJECTIVE

To collect nationally representative epidemiological data on early-onset eating disorders (EOEDs) in children.

DESIGN

Prospective, active surveillance using the Australian Paediatric Surveillance Unit with key informant design.

SETTING

Child health specialists in Australia (July 2002 to June 2005).

PATIENTS

Incident cases of EOEDs in children aged 5-13 years.

MAIN OUTCOME MEASURES

Disease rates, demographic characteristics, clinical features and complications, hospitalisation, psychological comorbidity, and concordance of clinical features with Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) criteria.

RESULTS

We identified 101 children aged 5-13 years with EOEDs (median age, 12.2 years; range, 5.5-13.9 years), of whom one in four were boys. Most were hospitalised (78%), and the mean duration of hospitalisation was 24.7 days (range, 1-75 days). More than 70% of inpatients were admitted to specialised eating disorder units in paediatric teaching hospitals. Among inpatients, 37% met DSM-IV diagnostic criteria for anorexia nervosa; although 61% had life-threatening complications of malnutrition, only 51% met weight criteria. Psychological symptoms were similar to those in adults with anorexia nervosa: 67% of inpatients met both psychological diagnostic criteria for anorexia nervosa (fear of weight gain/fatness and misperception of body shape). Of 19 postmenarchal girls, 18 had secondary amenorrhoea. Nasogastric feeding was used in 58% of inpatients, and 34% received psychotropic medications.

CONCLUSIONS

This is the first prospective national study of EOEDs. It demonstrates the limitations of applying DSM-IV diagnostic criteria for anorexia nervosa to young children; the high proportion of boys affected by EOEDs; and the significant psychological comorbidity and high frequency of hospitalisation associated with EOEDs. Potentially life-threatening medical complications are common at presentation, suggesting possible missed diagnoses and a need for education of health professionals. The study underlines the severity of EOEDs and the need for joint medical and psychiatric specialist management.