Caring for the Aging Patient With Adult Congenital Heart Disease: A Review of Cardiac and Noncardiac Comorbidities

As the demographics of congenital heart disease (CHD) have shifted, there are now more adults living with CHD than children in North America. This presents unprecedented challenges as patients with CHD acquire noncardiac comorbidities and seek care for a variety of reasons, including noncardiac surgery and emergency department (ED) visits. CHD shifts from a one organ problem to a multisystem disease and requires a team of specialists to maintain high-quality longitudinal care. In this review, we summarize the challenges patients with CHD and their providers face as they age. We review the demographics of CHD and health care utilization. We examine the rates of noncardiac comorbidities and the current quality of care received by adult patients with CHD.

Transition to adulthood and transfer to adult care of adolescents with congenital heart disease: a global consensus statement of the ESC Association of Cardiovascular Nursing and Allied Professions (ACNAP), the ESC Working Group on Adult Congenital Heart Disease (WG ACHD), the Association for European Paediatric and Congenital Cardiology (AEPC), the Pan-African Society of Cardiology (PASCAR), the Asia-Pacific Pediatric Cardiac Society (APPCS), the Inter-American Society of Cardiology (IASC), the Cardiac Society of Australia and New Zealand (CSANZ), the International Society for Adult Congenital Heart Disease (ISACHD), the World Heart Federation (WHF), the European Congenital Heart Disease Organisation (ECHDO), and the Global Alliance for Rheumatic and Congenital Hearts (Global ARCH)

The vast majority of children with congenital heart disease (CHD) in high-income countries survive into adulthood. Further, paediatric cardiac services have expanded in middle-income countries. Both evolutions have resulted in an increasing number of CHD survivors. Expert care across the life span is necessitated. In adolescence, patients transition from being a dependent child to an independent adult. They are also advised to transfer from paediatrics to adult care. There is no universal consensus regarding how transitional care should be provided and how the transfer should be organized. This is even more challenging in countries with low resources. This consensus document describes issues and practices of transition and transfer of adolescents with CHD, accounting for different possibilities in high-, middle-, and low-income countries. Transitional care ought to be provided to all adolescents with CHD, taking into consideration the available resources. When reaching adulthood, patients ought to be transferred to adult care facilities/providers capable of managing their needs, and systems have to be in place to make sure that continuity of high-quality care is ensured after leaving paediatric cardiology.

Patient information portal for congenital aortic and pulmonary valve disease: a stepped-wedge cluster randomised trial

BACKGROUND

In response to an increased need for patient information in congenital heart disease, we previously developed an online, evidence-based information portal for patients with congenital aortic and pulmonary valve disease. To assess its effectiveness, a stepped-wedge cluster randomised trial was conducted.

METHODS

Adult patients and caregivers of paediatric patients with congenital aortic and/or pulmonary valve disease and/or tetralogy of Fallot who visited the outpatient clinic at any of the four participating centres in the Netherlands between 1 March 2016-1 July 2017 were prospectively included. The intervention (information portal) was introduced in the outpatient clinic according to a stepped-wedge randomised design. One month after outpatient clinic visit, each participant completed a questionnaire on disease-specific knowledge, anxiety, depression, mental quality of life, involvement and opinion/attitude concerning patient information and involvement.

RESULTS

343 participants were included (221 control, 122 intervention). Cardiac diagnosis (p=0.873), educational level (p=0.153) and sex (p=0.603) were comparable between the two groups. All outcomes were comparable between groups in the intention-to-treat analyses. However, only 51.6% of subjects in the intervention group (n=63) reported actually visiting the portal. Among these subjects (as-treated), disease-specific knowledge (p=0.041) and mental health (p=0.039) were significantly better than in control subjects, while other baseline and outcome variables were comparable.

CONCLUSION

Even after being invited by their cardiologists, only half of the participants actually visited the information portal. Only in those participants that actually visited the portal, knowledge of disease and mental health were significantly better. This underlines the importance of effective implementation of online evidence-based patient information portals in clinical practice.

Do risk visualizations improve the understanding of numerical risks? A randomized, investigator-blinded general population survey

BACKGROUND

Risk visualizations are often employed to support risk communication. However, their effectiveness in communication of single absolute risks remains unclear. We investigated the effectiveness of risk visualizations in conveying verbatim knowledge of single absolute risks among the general population.

METHODS

Randomly sampled members of the general Dutch population completed four basic risk conversions from percentages to natural frequencies and vice versa. By random investigator-blinded allocation, these conversions were supported by either icon arrays, pie charts, bar graphs or no visualization. Verbatim risk knowledge was scored as the number of conversions completed correctly.

RESULTS

393 subjects were included. Overall, 60% of respondents answered all four questions correctly. Risk format (percentages vs. natural frequencies, p = 0.677) and risk magnitude (p = 0.532) were not associated with verbatim risk knowledge score. Younger age (p = 0.001) and higher education level (p < 0.001) were independently associated with higher scores. The use of risk visualizations was not associated with higher scores (OR = 1.08; 95% confidence interval: 0.69-1.69; p = 0.745). All three forms of risk visualization were equally ineffective. These findings held when stratifying by risk format, risk magnitude and user preference for a certain form of risk visualization. There were no significant interactions with age or education level.

CONCLUSION

Risk visualizations did not improve conveyance of verbatim knowledge of single absolute risks, irrespective of age, education level, risk magnitude, risk format and form of risk visualization. Risk visualizations may therefore be less suitable for settings in which detailed conveyance of single absolute risks is the main objective, although their effect on user experience and perception of risk communication and subsequent patient activation and participation remains to be elucidated.

Lifestyles and determinants of perceived health in Italian grown-up/adult congenital heart patients: a cross-sectional and pan-national survey

OBJECTIVES

To provide the first epidemiological lifestyle descriptions of the Italian grown-up/adult congenital heart disease (GUCH/ACHD) population by identifying the determinants of poor perceived health status.

DESIGN

Cross-sectional pan-national survey.

SETTING

Italian GUCH/ACHD patients who were members of the Italian Association of GUCH/ACHD.

PRIMARY AND SECONDARY OUTCOME MEASURES

To discuss these lifestyle descriptions through an ad hoc developed questionnaire and health perceptions (ie, mental and physical health perception) through a short form health survey (SF-12).

RESULTS

629 patients included; many investigated GUCH/ACHD lifestyles were determined similar to those of the general population - with the exception of the smoking habits, which were lower. The odds of the occurrence of inadequate physical health perceptions increased by more than two times in patients undergoing antiarrhythmic therapies (OR adjusted=2.045; 95% CI=1.201 to 3.479; p=0.008; n=629), more than 1.5 times in patients taking oral anticoagulants (OR adjusted=1.638; 95% CI=1.038 to 2.585; p=0.034; n=629) and roughly 1.7 times in patients treated with antiplatelets (OR adjusted=1.743; 95% CI=1.024 to 2.966; p=0.041; n=629). The odds of the occurrence of inadequate mental health perceptions increased by 1.7% for every year that the patients aged (OR adjusted=1.017; 95% CI=1.002 to 1.032; p=0.025; n=629).

CONCLUSION

Particular attention should be paid to these ageing patients' increasing psychological needs, and additional research is needed to identify associations between their lifestyles and clinical outcomes.

Health behaviours reported by adults with congenital heart disease across 15 countries

Background

Health behaviours are essential to maintain optimal health and reduce the risk of cardiovascular complications in adults with congenital heart disease. This study aimed to describe health behaviours in adults with congenital heart disease in 15 countries and to identify patient characteristics associated with optimal health behaviours in the international sample.

Design

This was a cross-sectional observational study.

Methods

Adults with congenital heart disease ( n = 4028, median age = 32 years, interquartile range 25–42 years) completed self-report measures as part of the Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study (APPROACH-IS). Participants reported on seven health behaviours using the Health Behaviors Scale-Congenital Heart Disease. Demographic and medical characteristics were assessed via medical chart review and self-report. Multivariate path analyses with inverse sampling weights were used to investigate study aims.

Results

Health behaviour rates for the full sample were 10% binge drinking, 12% cigarette smoking, 6% recreational drug use, 72% annual dental visit, 69% twice daily tooth brushing, 27% daily dental flossing and 43% sport participation. Pairwise comparisons indicated that rates differed between countries. Rates of substance use behaviours were higher in younger, male participants. Optimal dental health behaviours were more common among older, female participants with higher educational attainment while sports participation was more frequent among participants who were younger, male, married, employed/students, with higher educational attainment, less complex anatomical defects and better functional status.

Conclusions

Health behaviour rates vary by country. Predictors of health behaviours may reflect larger geographic trends. Our findings have implications for the development and implementation of programmes for the assessment and promotion of optimal health behaviours in adults with congenital heart disease.

Risk-Taking Behaviors in Adolescents With Chronic Cardiac Conditions: A Scoping Review

PROBLEM

Advances in treatment and therapy for children with chronic cardiac conditions have extended their life expectancy. Risk-taking behavior among adolescents requires further exploration. Researchers conducted a scoping review to address a literature gap specific to risk-taking behavior among adolescents with chronic cardiac conditions.

ELIGIBILITY CRITERIA

Sources were limited to (1) human subjects, (2) English language or translatable to English, (3) adolescents without age restrictions, (4) all research designs and (5) presence of a chronic cardiac condition.

SAMPLE

Searches of six electronic databases (CINAHL Plus Full Text, PubMed, Web of Knowledge, Scopus, ProQuest and Grey Literature Report) were conducted to verify the empirical literature between 1975 and 2018. Seventeen sources were included in this review.

RESULTS

Among the 17 sources, 12 sources examined risk-taking behavior by self-report among adolescents with chronic cardiac conditions. Tobacco, alcohol and/or other drug use and physical inactivity were the most prevalent risk-taking behaviors identified through this review.

CONCLUSIONS

Findings from this scoping review describe the types of risk-taking behaviors that adolescents with chronic cardiac conditions are engaging in, highlight similarities when compared to other types of chronic conditions, and serve as a foundation for future research among this population.

IMPLICATIONS

Discussion of risk-taking behaviors should be integrated into each healthcare encounter beginning in early adolescence and continuing through transition to adulthood and adult health care. Qualitative research studies may serve as an effective method by which to explore risk-taking behavior among adolescents with chronic cardiac conditions in greater detail.

The Effect of Oral Health Promotion Program on Early Dental Decay in Students: a Cluster Randomized Controlled Trial

Introduction: The use of different models play a significant role in health education and its promotion. Therefore, the present study aims to investigate the effect of the Theory of Planned Behavior (TPB) on early dental decay in elementary students.

Methods: This study was a single-blinded, cluster randomized controlled trial, in which 470 elementary students in the fourth, fifth and sixth grades in Saveh, Iran were participated. A demographic questionnaire and a 5-item questionnaire consisting of questions on awareness, attitude, practice, tooth brushing, diet and referring to dentist, were used to data collection. The samples of the intervention (n=234) and control (n=236) groups filled out the questionnaires before intervention (pre-test), immediately after intervention and one month after intervention. The educational intervention based on the TPB was held in three 45-minute sessions. Finally, the data were analyzed, using the SPSS version 13. For analyzing, the Independent t-test, Chi-square, and repeated measures ANOVA were used.

Results: This study showed that there is a significant difference in the mean scores obtained from knowledge, attitude, subjective norm, perceived behavioral control, behavioral intention and behavior among students in the experimental group (immediately after and one month after the intervention) and students in the control group.

Conclusion: The results of this study showed that using of TPB, as a framework for providing behavior-led training, can be effective in promoting oral and dental health of students. Nurses as an important member of the treatment team can use the results of this study in school health programs.

Patient and physician view on patient information and decision-making in congenital aortic and pulmonary valve surgery

Background

To assess the current state of patient information and decision-making in congenital aortic and pulmonary valve disease, we conducted a survey among patients, parents and physicians.

Methods

A questionnaire was sent by ground mail to 157 adults and 32 parents of children who previously underwent surgery for congenital aortic or pulmonary valve disease at 0-40 years of age between January 2005 and February 2014 at the Erasmus University Medical Center and to all paediatric and adult congenital cardiologists and congenital cardiac surgeons in the Netherlands (n=88).

Results

73 patients/parents (39% response rate, 62 adult patients, 11 parents of paediatric patients) and 35 physicians (40% response rate) responded. Median patient age at the time of surgery was 25.7 years. Basic disease-specific knowledge was adequate in 42% of patients/parents and numeracy was sufficient in 47%. Patients/parents reported that they rely heavily on their physicians for information and often experience difficulty in finding reliable information elsewhere. They lack information on psychosocial aspects of disease (29% of respondents) and risks and benefits of treatment options (26%). They feel less involved in decision-making than they would prefer to be (p=0.014). Decisional conflict at the time of surgery was experienced by 31% of patients/parents. If they had to do it again, 72% of patients/parents would want the same treatment. Quality of life is often impaired due to various valve-related anxieties and lifestyle changes. Physicians reported that they are unable to fully inform and sufficiently involve patients, due to limited patient/parent knowledge and understanding (56%) and limited time during consultations (32%). Patients/parents (98%) and physicians (97%) agree that they should have shared roles in decision-making.

Conclusion

The substantial shortcomings in our current practice of patient information and decision-making underline the need for innovative solutions, such as careful implementation of patient information tools and shared decision-making in the care path.

Frequency and Consequences of Influenza Vaccination in Adults With Congenital Heart Disease

Immunization against influenza is a critical, but perhaps underappreciated prevention of morbidity and mortality in the cardiac population. The purpose of the present study is to examine influenza vaccination rates in adults with congenital heart disease (ACHD). A secondary purpose is to explore whether there is an association between demographic, medical, and behavioral variables and receipt of the influenza vaccination. Of the 183 consecutive ACHD patients who were contacted, 123 responded to our telephone survey. Mean age was 38.4 ± 14.7, with the most common type of lesion complexity being moderate (65.3%), followed by simple (21.0%) and severe (13.7%). Overall, 53 respondents reported undergoing influenza vaccination in the previous season. Fifty-two percent of all subjects claimed they were notified of the benefits of vaccination by their physician. Univariate analysis revealed that older age (p = 0.006), female gender (p = 0.027), perceived susceptibility to influenza illness (p <0.001), perceived severity of the influenza illness (p <0.001), perceived benefits of the influenza vaccination (p <0.001), side effects from previous immunization (p = 0.006), and physician recommendation (p = 0.008) were predictors of receipt of influenza vaccination. On multivariate analyses, however, only side effects from previous immunization was a predictor (odds ratio = 0.34 [95% confidence interval 0.13 to 0.91]), whereas physician recommendation was numerically, but not statistically, significant (odds ratio 2.01 [95% confidence interval 0.85 to 4.78]). Our study demonstrated that less than 50% of ACHD population receives influenza vaccination. We believe educating both the patients about the side effects of vaccination and the physicians about their role in counseling ACHD patients will increase the vaccination rates in this high-risk population.

Development of an Online, Evidence-Based Patient Information Portal for Congenital Heart Disease: A Pilot Study

OBJECTIVES

In response to an increased need for patient information on congenital heart disease in the Netherlands, we initiated a nationwide initiative to develop an online, evidence-based patient information portal, starting with a pilot project aimed at the subgroup of patients with congenital aortic and pulmonary valve disease.

METHODS AND RESULTS

We developed an information portal that aims to (1) improve patient knowledge and involvement and to subsequently reduce anxiety and decisional conflict and improve mental quality of life and (2) to support physicians in informing and communicating with their patients. The information portal was developed according to the systematic International Patient Decision Aid Standards development process employing Delphi techniques by a multidisciplinary workgroup of pediatric and adult congenital cardiologists, a congenital cardiothoracic surgeon, a psychologist, an epidemiologist, a patient representative, and web and industrial design experts. First, patients and physicians were surveyed and interviewed to assess the current state of patient information and explore their preferences and needs to determine the focus for the development of the information portal. We found that patient knowledge and numeracy are limited, reliable information is scarce, physicians inform patients selectively and patient involvement is suboptimal, and there is a need for more reliable, tailored, and multi-faceted information. Based on the findings of these surveys and interviews, a patient-tailored information portal was designed that presents evidence-based disease- and age-specific medical and psychosocial information about diagnosis, treatment, prognosis, and impact on daily life in a manner that is comprehensible and digestible for patients and that meets the needs expressed by both patients and physicians. The effect of the website on patient outcome is currently being assessed in a multicenter stepped-wedge implementation trial.

CONCLUSION

The present pilot project succeeded in developing an online, evidence-based information portal that is supported by both patients and physicians. The information portal will be further developed and expanded to include all other major forms of congenital heart disease, translations into other languages, and a public information portal to serve patients' relatives and the general public at large.

Adult congenital heart disease nurse coordination: Essential skills and role in optimizing team-based care a position statement from the International Society for Adult Congenital Heart Disease (ISACHD)

BACKGROUND

Founded in 1992, the International Society for Adult Congenital Heart Disease (ISACHD) is the leading global organization of professionals dedicated to pursuing excellence in the care of adults with congenital heart disease (CHD) worldwide. Among ISACHD's objectives is to "promote a holistic team-based approach to the care of the adult with CHD that is comprehensive, patient-centered, and interdisciplinary" (http://www.isachd.org). This emphasis on team-based care reflects the fact that adults with CHD constitute a heterogeneous population with a wide spectrum of disease complexity, frequent association with other organ involvement, and varied co-morbidities and psychosocial issues.

METHODS

Recognizing the vital role of the adult CHD (ACHD) nurse coordinator (ACHD-NC) in optimizing team-based care, ISACHD established a task force to elucidate and provide guidance on the roles and responsibilities of the ACHD-NC. Acknowledging that nursing roles can vary widely from region to region based on factors such as credentials, scopes of practice, regulations, and local culture and tradition, an international panel was assembled with experts from North America, Europe, East Asia, and Oceania. The writing committee was tasked with reviewing key aspects of the ACHD-NC's role in team-based ACHD care.

RESULTS/CONCLUSION

The resulting ISACHD position statement addresses the ACHD-NC's role and skills required in organizing, coordinating, and facilitating the care of adults with CHD, holistic assessment of the ACHD patient, patient education and counseling, and support for self-care management and self-advocacy.

Associations among Depression Symptoms with Alcohol and Smoking Tobacco Use in Adult Patients with Congenital Heart Disease

BACKGROUND

Adult congenital heart disease (ACHD) patients have high rates of untreated depression and anxiety disorders. We evaluated associations among self-reported depression symptoms and alcohol/smoking tobacco use.

METHODS

From 2009 to 2013, 202 ACHD patients (45% male) completed questionnaires on depressive symptoms, anxiety symptoms, and substance use as part of routine clinical care. Data were collected by retrospective chart review.

RESULTS

Mean age was 31 ± 10 years, 21% reported often feeling depressed and 33% reported feeling nervous or anxious. Sixty-one percent of patients reported some alcohol intake; 25% reported current or previous smoking tobacco use. Patients with depressive symptoms were 3× as likely to report drinking alcohol (OR 2.89; 95% CI 1.29-6.5) and 5× more likely to report smoking tobacco use (OR 5.17; 95% CI 1.49-17.87). Fourteen percent of patients were prescribed antidepressant/antianxiety medications; 43% of patients on medication reported depressive symptoms. In patients reporting symptoms, those who consumed alcohol were less likely to be on antidepressant/antianxiety medications (21%) than those who did not consume alcohol (56%).

CONCLUSION

Self-reported depressive symptoms are associated with increased alcohol and smoking tobacco use by ACHD patients. Alcohol use may be a means of self-medicating for untreated depression, but further investigation is needed. Risk factors, including depressive symptoms and substance use, should be routinely assessed and addressed in ACHD patients.

Effectiveness of structured education on knowledge and health behaviors in patients with congenital heart disease

OBJECTIVE

To investigate whether a single educational session increased the level of knowledge and changed the prevalence of health risk behaviors in young people with congenital heart disease (CHD).

STUDY DESIGN

We conducted a longitudinal study of patients transferred to adult CHD care who received a single educational session (n = 201) at a tertiary care center. Their knowledge level and prevalence of health risk behaviors were assessed via the Leuven Knowledge Questionnaire CHD and the Health Behavior Scale CHD, respectively. A general linear model for longitudinal measurements was used to analyze the natural progression of patients' knowledge during a 27-month period and the effect of one educational session on outcomes.

RESULTS

Participating in an educational session resulted in a small-to-moderate, but significant, increase in total knowledge level and better understanding of deterioration symptoms, and rationale and frequency of follow-up; however, it did not improve patients' health behaviors.

CONCLUSIONS

This type of education did improve knowledge but did not improve the patients' tendency to engage in better health behaviors. Future studies should assess the effect of repetitive exposure to educational sessions dealing with CHD.

A retrospective study of judicial encounters of young adults with congenital heart disease

Young people with congenital heart disease are often marginalised and may compensate for restricted physical and social abilities by substance abuse or risk-taking behaviour. We report on the judicial encounters of patients in an Adult Congenital Heart unit. Fifteen patients had court appearances and all were male. Seven served jail sentences, including four indigenous adolescents. All had multiple interventions for their cardiac conditions and four are now deceased. The majority of patients had mental health issues and substance misuse. These patients need psychological and medical support, and help with judicial authorities. Recommendations for ongoing care are provided.

Health risk behaviors in adolescents and young adults with special health care needs

PURPOSE OF REVIEW

Adolescents and young adults with special health care needs (SHCN) are uniquely vulnerable to health risk behaviors including smoking, alcohol and illicit drug use, and sexual risk-taking. Their likelihood of experiencing adverse health outcomes because of these behaviors may be beyond that experienced by their healthier peer group. Pediatric providers are responsible for appropriately counseling these patients about healthy lifestyles. This review provides some background regarding these health risks among adolescents and young adults with SHCN with particular focus on three populations: childhood cancer survivors, congenital heart disease patients, and those with intellectual disability.

RECENT FINDINGS

Young adults and adolescents with chronic medical conditions are as likely - and perhaps more likely - to engage in health risk behaviors. However, these behaviors are not fully addressed by primary care providers.

SUMMARY

Pediatric providers are encouraged to ask adolescents and young adults with SHCN about their understanding of, and engagement in, health risk behaviors. A multidisciplinary approach to encourage a healthy lifestyle within this population may have significant health benefits.

Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study (APPROACH-IS): rationale, design, and methods

BACKGROUND

Data on patient-reported outcomes (PROs) in adults with congenital heart disease (CHD) are inconsistent and vary across the world. Better understanding of PROs and their differences across cultural and geographic barriers can best be accomplished via international studies using uniform research methods. The APPROACH-IS consortium (Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study) was created for this purpose and investigates PROs in adults with CHD worldwide. This paper outlines the project rationale, design, and methods.

METHODS/DESIGN

APPROACH-IS is a cross-sectional study. The goal is to recruit 3500-4000 adults with CHD from 15 countries in five major regions of the world (Asia, Australia, Europe, North and South America). Self-report questionnaires are administered to capture information on PRO domains: (i) perceived health status (12-item Short-form Health Survey & EuroQOL-5D); (ii) psychological functioning (Hospital Anxiety and Depression Scale); (iii) health behaviors (Health-Behavior Scale-Congenital Heart Disease); and (iv) quality of life (Linear Analog Scale & Satisfaction With Life Scale). Additionally, potential explanatory variables are assessed: (i) socio-demographic variables; (ii) medical history (chart review); (iii) sense of coherence (Orientation to Life Questionnaire); and (iv) illness perceptions (Brief Illness Perception Questionnaire). Descriptive analyses and multilevel models will examine differences in PROs and investigate potential explanatory variables.

DISCUSSION

APPROACH-IS represents a global effort to increase research understanding and capacity in the field of CHD, and will have major implications for patient care. Results will generate valuable information for developing interventions to optimize patients' health and well-being.

REGISTRATION

ClinicalTrials.gov: NCT02150603.

Obesity and perceived severity of obstructive sleep apnea-related conditions

This study examined risk factors and perceived severity of obstructive sleep apnea-related conditions among college students based on weight categories. Data collected from 1399 college students were analyzed using multinomial and binary logistic regressions. Overweight and obese participants were more likely to snore and report familial risk for cardiovascular disease compared with their normal weight counterparts. Relative to normal weight participants, obese participants perceived snoring (odds ratio [OR] = 1.10), irritability (OR = 1.16), and high blood pressure (OR = 1.21) as more severe; they perceived erectile dysfunction (OR = 0.89) and cardiovascular disease (OR = 0.71) as less severe. Efforts are needed to identify obstructive sleep apnea risk and create systems for weight loss interventions, screening, and diagnosis.

Caring for a teen with congenital heart disease

Adolescents with congenital heart disease (CHD) are a rapidly growing population with complex medical needs and psychosocial challenges. Identity formation is an important developmental task accomplished during the teenage years. This article reviews different aspects of ongoing care that pertain to teenagers with CHD, with a particular focus on primary care issues and a summary of recommendations from various scientific societies. A successful smooth transition to the adult health care setting should achieve 2 important goals: to prevent loss of follow-up and to foster and encourage self-care behaviors.

Transition and transfer of adolescents and young adults with pediatric onset chronic disease: the patient and parent perspective

PURPOSE

To determine patients' and parents' perceptions regarding the delivery of transition education and perceived barriers to transfer to adult oriented care.

METHODS

A self-report survey was administered to a convenience sample of patients (16-25 years old) with various childhood onset chronic diseases. A similar survey was administered to their parents/guardians.

RESULTS

A total of 155 patients and 104 parents participated in the study. The mean age of patients was 18.8 ± 2.3 years; 57% were female. Although most patients and parents reported receiving information and training about their medical condition, significant gaps in other aspects of transition education were identified. These included stated deficiencies in education regarding unprotected intercourse, health of future offspring, birth control, pregnancy, illicit drug use, and future career or vocation counseling. Commonly cited barriers to transfer were emotional attachments and lack of adult medicine specialty providers; however, the majority anticipated being ready to transfer to adult oriented care by age 25 years.

CONCLUSION

There are significant gaps in the delivery of transition education as perceived by patients and their parents. Standardization of transition education may help ensure that patients acquire the knowledge and skills for health care self-management in adulthood and successful transfer to adult oriented care.

Substance use, dental hygiene, and physical activity in adult patients with single ventricle physiology

OBJECTIVES

The study aims to describe substance use, dental hygiene, and physical activity in adult survivors with single ventricle physiology (SVP) and to compare the behaviors with matched controls, while the patients are particularly at risk for general health problems.

DESIGN

The present study is part of a larger research project on long-term outcomes in adult patients with SVP. A cross-sectional, case-control study including 59 patients out of 83 eligible patients participated in the study (response rate 71%). The patients were matched to 172 healthy controls. A questionnaire was mailed to the patients. Nonresponders did not differ significantly from the included participants on age, gender, or physical function.

SETTING

The study was conducted at the Heart Center of Copenhagen University Hospital or the Department of Cardiology, Aarhus University Hospital.

RESULTS

In these patients, 85% report alcohol consumption (92% in controls; odds ratio [OR] = 0.91; P = 0.575); 26% admit "binge drinking" (41% in controls; OR = 0.56; P = 0.041); 20% are cigarette smokers (36% in controls; OR = 0.59; P = 0.100); 12% have used cannabis over the past year (15% in controls; OR = 0.80; P = 0.596); 20% have had no dental visits during the last year (25% in controls; OR = 1.07; P = 0.684); 46% are not flossing their teeth (32% in controls; OR = 1.32; P = 0.239); and 39% are not physically active (24% in controls; OR = 1.63; P = 0.069).

CONCLUSIONS

While in general there was no significant differences in overall health behaviors between SVP patients and controls, SVP patients are less physically active and are less likely to binge drink.

Social burden and lifestyle in adults with congenital heart disease

We aimed to evaluate how the presence and severity of congenital heart disease (CHD) influence social life and lifestyle in adult patients. A random sample (n = 1,496) from the CONgenital CORvitia (n = 11,047), the Dutch national registry of adult patients with CHD, completed a questionnaire on educational attainment, employment and marital statuses, and lifestyle (response 76%). The Utrecht Health Project provided a large reference group (n = 6,810) of unaffected subjects. Logistic regression models were used for subgroup analyses and to adjust for age, gender, and socioeconomic status where appropriate. Of all patients 51.5% were men (median age 39 years, interquartile range 29 to 51) with mild (46%), moderate (44%), and severe (10%) CHD. Young (<40-year-old) patients with CHD were more likely to have achieved a lower education (adjusted odds ratios [ORs] 1.6 for men and 1.9 for women, p <0.05 for the 2 comparisons), significantly more often unemployed (adjusted ORs 5.9 and 2.0 for men and women, respectively), and less likely to be in a relationship compared to the reference group (adjusted ORs 8.5 for men and 4.5 for women). These poorer outcomes were seen in all severity groups. Overall, the CHD population smoked less (adjusted OR 0.5, p <0.05), had more sports participation (adjusted OR 1.2, p <0.05), and had less obesity (adjusted OR 0.7, p <0.05) than the reference group. In conclusion, there was a substantial social disadvantage in adult patients with CHD, which was seen in all severity groups and primarily in young men. In contrast, adults with CHD had healthier lifestyles compared to the reference group.

Healthcare needs of adults with congenital heart disease: study of the patient perspective

BACKGROUND

More than 90% of infants born with congenital heart disease reach adulthood. International medical recommendations outline patient care needs in an effort to optimize patient health. There are, however, limited data focusing on the patient perspective.

OBJECTIVES

This study investigated adult congenital heart disease patient-reported (1) barriers to medical care, (2) healthcare behaviors, and (3) concerns regarding medical, psychosocial, and lifestyle matters.

METHODS

In this cross-sectional study, a questionnaire was distributed to all patients who attended a patient education conference.

RESULTS

There were 123 adult congenital heart disease participants (58% female; mean age, 37 [SD, 13] years). The most common self-reported cardiac diagnoses were tetralogy of Fallot and transposition of the great arteries. Most patients did not report transportation or financial barriers to care, but did report the following: not wanting further surgery even if it was recommended (18%), not liking to think or talk about one's heart (17%), and not understanding doctors' information; 8% of patients inaccurately considered themselves to be "cured." With regard to healthcare behaviors, more than 80% of patients reported annual family physician and dentist visits, but 34% of patients were unaware when to seek urgent medical attention. Patients reported moderate to extreme concern about the following medical topics: heart rhythm problems (82%), infections (74%), and understanding treatment options (71%). Patients most often reported moderate to extreme concern about the following lifestyle and psychosocial topics: physical activity (77%), insurance (72%), assuming increased health responsibility (73%), diet (71%), mental health (60%), and death and dying (57%).

CONCLUSIONS

This study provides important information about 3 specific areas. First, there are potential barriers to care beyond financial and transportation challenges. Second, many patients require education regarding when to seek urgent medical attention. Third, the concerns of this patient population are not limited to medical information. A patient-centered educational program is recommended.

Caring for teens with chronic illness: risky business?

PURPOSE OF REVIEW

With advances in medicine, more children with chronic illness are reaching adolescence and young adulthood. Research has shown that this group is not immune to the behavioral risks endorsed by healthy adolescents. Recent literature exploring the etiology of risk behaviors and their impact on chronic illness is presented.

RECENT FINDINGS

Risk taking may be the result of differential maturation of two distinct parts of the adolescent brain. Risk taking can be considered normal in adolescents with chronic illness, but there is some evidence that chronic illness affects normal psychosocial development. Moreover, evidence supports that chronic illness can lead to disparities in risk education and assessment because of disease focused management rather than a more comprehensive approach.

SUMMARY

Youth living with chronic illnesses face unique challenges in accomplishing the developmental tasks of adolescence. These challenges include risk behaviors, which jeopardize current and future health. The reasons for risk taking are multifactorial and require providers to make the adolescent and not the illness the center of management. More research is needed on how to improve developmentally appropriate and relevant interventions to aid in safe passage into adulthood.

Identity formation in adolescents with congenital cardiac disease: a forgotten issue in the transition to adulthood

Identity formation is a core developmental task in adolescence and functions as a key resource for transitioning to adulthood. This study investigated how adolescents with congenital cardiac disease form their identity and how it relates to demographic and medical parameters, quality of life, perceived health, depressive symptoms, and loneliness. A total of 429 adolescents aged 14-18 years with congenital cardiac disease and 403 matched controls completed questionnaires on identity and all outcome variables. There were five meaningful identity statuses, similar to those obtained in the control sample, which were found in the patient sample. Of them, two statuses--achievement and foreclosure--were characterised by a strong sense of identity; one status--diffused diffusion--especially was characterised by a weak sense of identity combined with high scores on worry about the future. These identity statuses were differentially related to outcome variables, with individuals in diffused diffusion especially scoring highest on depressive symptoms, problems in school, treatment anxiety, and communication problems with clinicians, and lowest on quality of life. Having a strong sense of personal identity was found to protect against such maladaptive outcomes. In sum, most adolescents with congenital cardiac disease moved through their identity formation process in a similar manner to other adolescents. Adolescents with a diffused identity were particularly at risk of experiencing maladjustment and problems in treatment adherence. Hence, developing intervention strategies to provide continuity of care on the road to adulthood involves paying attention to core developmental tasks, such as identity formation in adolescents with congenital cardiac disease.

Transition and transfer from pediatric to adult care of young adults with complex congenital heart disease

Many children with complex congenital heart disease are now surviving childhood with the potential to live meaningful and productive adult lives. The process of transitioning or preparing patients and families for transfer from pediatric to adult care is challenging and rarely implemented properly. An inadequate transition process results in delayed and inappropriate care, improper timing of transfer, and undue emotional and financial stress on the patients, their families, and the health care system. At worst, patients are lost to appropriate follow-up. This article discusses the general principles of transition and transfer for young adults with chronic illness, highlights the needs of young adults with congenital heart disease, discusses the barriers to transition, and proposes goals and key elements of a formal transition program.