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Malhotra S, Hyer JM, Dalmacy D, Hayes D, Tumin D, Kirkby SE, Jonas DE, Bose-Brill S, Li SS. Preventive service utilization among adults with cystic fibrosis covered by private insurance is comparable to the general population. J Cyst Fibros 2024; 23:314-320. [PMID: 38220475 DOI: 10.1016/j.jcf.2023.11.013] [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: 05/09/2023] [Revised: 10/16/2023] [Accepted: 11/22/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND As the life expectancy of the cystic fibrosis (CF) population is lengthening with modulator therapies, diligent age-appropriate screening and preventive care are increasingly vital for long-term health and wellbeing. METHODS We performed a retrospective analysis comparing rates of receiving age- and sex-appropriate preventive services by commercially insured adult people with CF (PwCF) and adults without CF from the general population (GP) via the Truven Health MarketScan database (2012-2018). RESULTS We captured 25,369 adults with CF and 488,534 adults from the GP in the United States. Comparing these groups, we found that 43% versus 39% received an annual preventive visit, 28% versus 28% were screened for chlamydia, 38% versus 37% received pap smears every 3 years (21-29-year-old females), 33% versus 31% received pap smears every 5 years (30-64-year-old females), 55% versus 44% received mammograms, 23% versus 21% received colonoscopies, and 21% versus 20% received dyslipidemia screening (all screening rates expressed per 100 person-years). In age-stratified analysis, 18-27-year-old PwCF had a lower rate of annual preventive visits compared to adults in the same age group of the GP (27% versus 42%). CONCLUSIONS We discovered a comparable-to-superior rate of preventive service utilization in adults with CF relative to the GP, except in young adulthood from 18-27 years. Our findings establish the importance of meeting the primary care needs of adults with CF and call for development of strategies to improve preventive service delivery to young adults.
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Affiliation(s)
- Sankalp Malhotra
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - J Madison Hyer
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States; Secondary Data Core, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Djhenne Dalmacy
- Center for Biostatistics, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States; Secondary Data Core, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children's Hospital and Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Stephen E Kirkby
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Daniel E Jonas
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 3691 Ridge Mill Drive, Hilliard, Columbus, OH 43026, United States
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 3691 Ridge Mill Drive, Hilliard, Columbus, OH 43026, United States
| | - Susan S Li
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 3691 Ridge Mill Drive, Hilliard, Columbus, OH 43026, United States; Department of Internal Medicine, University of South Carolina School of Medicine Greenville, 1809 Wade Hampton Blvd, Ste. 120, Greenville, SC 29609, United States.
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Patterns of Health Insurance Coverage and Lung Disease Progression in Adolescents and Young Adults with Cystic Fibrosis. Ann Am Thorac Soc 2021; 18:290-299. [PMID: 32885982 DOI: 10.1513/annalsats.201911-839oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Rationale: Health insurance coverage has been implicated as a socioeconomic factor affecting clinical outcomes in patients with cystic fibrosis (CF), but evidence for this is mixed and varies by age.Objectives: Focusing on adolescents and young adults with CF, we examined how multiyear patterns of health insurance coverage were associated with lung function decline and related outcomes.Methods: We used data from the 2000 to 2015 CF Foundation Patient Registry to classify patients in three cohorts (ages 12-17 yr, adolescents; 18-23 yr, transitioning to adulthood; and 24-29 yr, young adults) according to health insurance coverage, as follows: continuous private, continuous public, intermittent public, and coverage gaps. The primary outcome was the percentage predicted forced expiratory volume in 1 second (FEV1pp), which was modeled using mixed-effects regression. Additional outcomes included outpatient visits, hospital days for pulmonary exacerbation treatment, bacterial colonization, and body mass index. Outcomes were assessed over a 6-year period (e.g., ages 12-17 yr), whereas exposures were assessed over the prior 6 years (e.g., ages 6-11 yr).Results: The three cohorts included 3,365, 2,800, and 1,807 patients, respectively. The highest rate of FEV1pp decline was found in the middle cohort, with the annual decline being steeper among patients with continuous public (-3.1/yr; 95% confidence interval [CI], -3.3 to -2.8) or intermittent public (-2.4/yr; 95% CI, -2.6 to -2.2) coverage compared with patients with continuous private coverage (-2.1/yr; 95% CI, -2.2 to -2.0). These differences were not explained by differences in outpatient care utilization.Conclusions: During the transition to adulthood, use of public insurance was associated with accelerated lung function decline among patients with CF. The role of insurance as a causal factor in this decline or proxy for other socioeconomic characteristics should be explored in further studies.
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Recipient Age Impacts Long-Term Survival in Adult Subjects with Cystic Fibrosis after Lung Transplantation. Ann Am Thorac Soc 2021; 18:44-50. [PMID: 32795188 DOI: 10.1513/annalsats.201908-637oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Rationale: Lung transplant is an effective treatment option providing survival benefit in patients with cystic fibrosis (CF). Several studies have suggested survival benefit in adults compared with pediatric patients with CF undergoing lung transplant. However, it remains unclear whether this age-related disparity persists in adult subjects with CF.Objectives: We investigated the impact of age at transplant on post-transplant outcomes in adult patients with CF.Methods: The United Network of Organ Sharing Registry was queried for all adult patients with CF who underwent lung transplantation between 1992 and 2016. Pertinent baseline characteristics, demographics, clinical parameters, and outcomes were recorded. The patients were divided into two groups based on age at transplant (18-29 yr old and 30 yr or older). The primary endpoint was survival time. Assessment of post-transplant survival was performed using Kaplan-Meier tests and log-rank tests with multivariable Cox proportional hazards analysis to adjust for confounding variables.Results: A total of 3,881 patients with CF underwent lung transplantation between 1992 and 2016; mean age was 31.0 (± 9.3) years. The 18-29-year-old at transplant cohort consisted of 2,002 subjects and the 30 years or older cohort had 1,879 subjects. Survival analysis demonstrated significantly higher survival in subjects in the 30 years or older cohort (9.47 yr; 95% confidence interval [CI], 8.7-10.2) compared with the 18-29-year-old cohort (5.21 yr; 95% CI, 4.6-5.8). After adjusting for confounders, survival remained higher in recipients aged 30 years or older (hazard ratio, 0.44; 95% CI, 0.2-0.9). Mortality due to allograft failure was significantly lower in patients with CF aged 30 years or older (28% vs. 36.5%; odds ratio [OR], 0.7; 95% CI, 0.6-0.8), whereas the incidence of malignancy was higher in the 30 years or older cohort (8% vs. 2.9%; OR, 3.0; 95% CI, 1.9-4.6).Conclusions: Age at transplant influences lung transplant outcomes in recipients with CF. Subjects with CF aged 30 years or older at transplant have superior survival compared with adult subjects with CF transplanted between the ages 18 and 29 years.
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Lung transplantation for cystic fibrosis. J Heart Lung Transplant 2020; 39:553-560. [PMID: 32147452 DOI: 10.1016/j.healun.2020.02.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The contribution of lung transplantation to the treatment of patients with end-stage cystic fibrosis (CF) has been debated. We aimed to describe achievable outcomes from high-volume CF and lung transplant programs. This study reports on the largest single-center experience of lung transplantation for adult and pediatric patients with CF. It also highlights the evolution of practice and outcomes over time. METHODS A retrospective analysis of the prospectively collected Toronto Lung Transplant database was carried out. Post-transplant survival in CF was calculated using the Kaplan-Meier method and analyzed with log-rank tests. RESULTS From 1983 to 2016, a total of 1,885 transplants were performed at our institution, where 364 (19.3%) were CF recipients and another 39 (2.1%) were CF retransplants. The mean age at first transplant was 29.5 ± 9.7 years where 56.6% were males and 91.5% were adults. Pre-transplantation, 88 patients (24.2%) were Burkholderia cepacia complex (BCC)-positive, 143 (39.3%) had diabetes mellitus, and the mean forced expiratory volume in one second was 26.0 ± 7.2%, as predicted at listing. The 1-, 5-, and 10-year probabilities of survival in adults who were BCC-negative were 94%, 70%, and 53%, respectively. Pediatric, BCC-positive, and retransplant recipients had worse survival than adult patients who were BCC-negative. Strategies to improve the donor pool did not affect survival but possibly reduced waitlist mortality. For the entire cohort, the most common causes of death after lung transplant were infection and chronic lung allograft dysfunction. CONCLUSIONS Lung transplantation for CF provides excellent short- and long-term outcomes. These results strongly support lung transplantation as the standard of care for patients with CF having advanced lung disease.
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Lung Transplant Index: A Quality Improvement Initiative. Pediatr Qual Saf 2019; 4:e209. [PMID: 31745512 PMCID: PMC6831041 DOI: 10.1097/pq9.0000000000000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/05/2019] [Indexed: 11/25/2022] Open
Abstract
Limited long-term survival is a recognized problem in adolescent/young adult lung transplant recipients. A quality improvement (QI) initiative included the development of a Lung Transplant Index (LTI) composed of key elements that we used as a comprehensive approach to screen and identify potential harms in this at-risk patient population. Methods A single-center, uncontrolled QI study was completed from January 2014 to February 2019. The elements of the LTI are events that should have occurred within the most recent 12 months. If an element did not occur, it was counted as a missed element of preventing harm and summated later serving as the LTI score. Implementation of the LTI occurred on January 1, 2015, with a retrospective chart review of patients seen in clinic the prior year serving as baseline measures for comparison. Results The year before implementing the LTI, numerous opportunities failed to identify preventable harm in our adolescent/young adult lung transplant population. The LTI resulted in a sustained reduction of these missed opportunities without negatively influencing patient/family satisfaction with lengthening of the clinic visit. Conclusions A single-center QI initiative identified preventable harms in an adolescent/young adult lung transplant population and reduced the number of preventable harm elements not performed. Future work is needed to determine if this type of QI initiative is associated with less healthcare utilization.
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Lung Allocation Score Thresholds Prioritize Survival After Lung Transplantation. Chest 2019; 156:64-70. [PMID: 30664859 DOI: 10.1016/j.chest.2019.01.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/02/2018] [Accepted: 01/02/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The lung allocation score (LAS) prioritizes lung transplant (LTx) candidates with poor transplant-free survival and expected survival benefit from LTx. Although patients with the highest LAS have the shortest waiting time, mortality benefit is unclear in this group, raising criticism that the LAS inappropriately prioritizes critically ill candidates. We aim to identify a threshold above which increasing LAS values do not predict increasing survival benefit. METHODS The United Network for Organ Sharing Registry was queried for first-time adult LTx candidates with LAS ≥ 30 between May 2005 and December 2016. Survival was tracked from the time of listing through the posttransplant period and compared with survival while remaining on the waitlist, using proportional hazards regression. The survival benefit of LTx was modeled as a piecewise-constant time-dependent covariate, moderated by candidate LAS. RESULTS Of the overall cohort (N = 21,157), LTx was particularly protective for 365 patients with an initial LAS of 70 to 79 (hazard ratio of death after undergoing LTx relative to remaining on the waitlist, 0.2; 95% CI, 0.1-0.3). However, the survival benefit of LTx did not meaningfully increase for 1,042 patients listed with even higher LAS. Among patients with cystic fibrosis, the survival benefit of LTx was constant above an LAS of approximately 50. CONCLUSIONS Consistent survival benefit of LTx was observed among patients with an initial LAS of 70 and greater. This result supports equalizing priority for donor lung allocation for patients with LAS ≥ 70. A lower LAS threshold for maximum priority is indicated in patients with cystic fibrosis.
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Li SS, Tumin D, Krone KA, Boyer D, Kirkby SE, Mansour HM, Hayes D. Risks associated with lung transplantation in cystic fibrosis patients. Expert Rev Respir Med 2018; 12:893-904. [PMID: 30198350 DOI: 10.1080/17476348.2018.1522254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Survival after lung transplantation lags behind outcomes of other solid organ transplants, and complications from lung transplant are the second most common cause of death in cystic fibrosis. Evolving surgical techniques, therapeutics, and perioperative management have improved short-term survival after lung transplantation, yet have not translated into significant improvement in long-term mortality. Areas covered: We review risk factors for poor long-term outcomes among patients with cystic fibrosis undergoing lung transplantation to highlight areas for improvement. This includes reasons for organ dysfunction, complications of immunosuppression, further exacerbation of extrapulmonary complications of cystic fibrosis, and quality of life. A literature search was performed using PubMed-indexed journals. Expert commentary: There are multiple medical and socioeconomic barriers that threaten long-term survival following lung transplant for patients with cystic fibrosis. An understanding of the causes of each could elucidate treatment options. There is a lack of prospective, multicenter, randomized control trials due to cost, complexity, and feasibility. Ongoing prospective studies should be reserved for the most promising interventions identified in retrospective studies in order to improve long-term outcomes.
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Affiliation(s)
- Susan S Li
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Dmitry Tumin
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Katie A Krone
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Debra Boyer
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Stephen E Kirkby
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Heidi M Mansour
- c Department of Pharmacology and Toxicology , The University of Arizona Colleges of Pharmacy and Medicine , Tucson , AZ , USA
| | - Don Hayes
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
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Ritchie AG, Clayton PA, McDonald SP, Kennedy SE. Age-specific risk of renal graft loss from late acute rejection or non-compliance in the adolescent and young adult period. Nephrology (Carlton) 2018; 23:585-591. [DOI: 10.1111/nep.13067] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/09/2017] [Accepted: 04/20/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Angus G. Ritchie
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
- Department of Nephrology; Sydney Children's Hospital; Randwick New South Wales Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Philip A. Clayton
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry; Royal Adelaide Hospital; Adelaide South Australia Australia
- Department of Renal Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Stephen P. McDonald
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry; Royal Adelaide Hospital; Adelaide South Australia Australia
- Faculty of Health Sciences; University of Adelaide; Adelaide South Australia Australia
| | - Sean E. Kennedy
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
- Department of Nephrology; Sydney Children's Hospital; Randwick New South Wales Australia
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Killian MO, Schuman DL, Mayersohn GS, Triplett KN. Psychosocial predictors of medication non-adherence in pediatric organ transplantation: A systematic review. Pediatr Transplant 2018; 22:e13188. [PMID: 29637674 DOI: 10.1111/petr.13188] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/27/2022]
Abstract
Adherence to immunosuppressant medication is critical to health and quality-of-life outcomes for children who have received a solid organ transplant. Research on the psychological and social predictors of medication adherence is essential to the advancement of pretransplant assessments and transplant psychosocial services. Despite the importance of identifying risk factors, the literature remains limited regarding psychosocial predictors of non-adherence. A systematic search was conducted to identify studies of the psychosocial predictors of post-transplant medication non-adherence in pediatric solid organ transplantation. From 1363 studies identified in searches of empirical literature, a final sample consisted of 54 publications representing 49 unique studies. Findings regarding psychosocial predictors were inconsistent with non-adherence associated largely with adolescence, racial/ethnic minority status, and presence of mental health issues. Familial predictors of non-adherence problems included single-parent households, lower socioeconomic status, lower family cohesion, presence of family conflict, and poor family communication. Several studies reported an association between non-adherence and social pressures (eg, peer social interaction, wanting to feel normal) among adolescent transplant recipients. While significant methodological and substantive gaps remain in this body of knowledge, this review synthesizes current evidence for assessment for transplant clinicians and researchers.
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Affiliation(s)
- Michael O Killian
- School of Social Work, University of Texas at Arlington, Arlington, TX, USA.,Children's Health, Children's Medical Center Dallas, Dallas, TX, USA
| | - Donna L Schuman
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | | | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, Dallas, TX, USA.,University of Texas - Southwestern Medical Center, Dallas, TX, USA
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Castellani C, Duff AJA, Bell SC, Heijerman HGM, Munck A, Ratjen F, Sermet-Gaudelus I, Southern KW, Barben J, Flume PA, Hodková P, Kashirskaya N, Kirszenbaum MN, Madge S, Oxley H, Plant B, Schwarzenberg SJ, Smyth AR, Taccetti G, Wagner TOF, Wolfe SP, Drevinek P. ECFS best practice guidelines: the 2018 revision. J Cyst Fibros 2018; 17:153-178. [PMID: 29506920 DOI: 10.1016/j.jcf.2018.02.006] [Citation(s) in RCA: 432] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/26/2018] [Accepted: 02/08/2018] [Indexed: 12/12/2022]
Abstract
Developments in managing CF continue to drive dramatic improvements in survival. As newborn screening rolls-out across Europe, CF centres are increasingly caring for cohorts of patients who have minimal lung disease on diagnosis. With the introduction of mutation-specific therapies and the prospect of truly personalised medicine, patients have the potential to enjoy good quality of life in adulthood with ever-increasing life expectancy. The landmark Standards of Care published in 2005 set out what high quality CF care is and how it can be delivered throughout Europe. This underwent a fundamental re-write in 2014, resulting in three documents; center framework, quality management and best practice guidelines. This document is a revision of the latter, updating standards for best practice in key aspects of CF care, in the context of a fast-moving and dynamic field. In continuing to give a broad overview of the standards expected for newborn screening, diagnosis, preventative treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support, this consensus on best practice is expected to prove useful to clinical teams both in countries where CF care is developing and those with established CF centres. The document is an ECFS product and endorsed by the CF Network in ERN LUNG and CF Europe.
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Affiliation(s)
- Carlo Castellani
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata Verona, Italy; Cystic Fibrosis Centre, Gaslini Institute, Genoa, Italy
| | - Alistair J A Duff
- Regional Paediatric CF Unit, Leeds General Infirmary Leeds, UK; Department of Clinical & Health Psychology, St James' University Hospital, Leeds, UK.
| | - Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Harry G M Heijerman
- Dept of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Munck
- Hopital Robert Debré Assistante publique-Hôpitaux de Paris, Université Paris 7, Pediatric CF Centre, Paris, France
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Isabelle Sermet-Gaudelus
- Service de Pneumologie et Allergologie Pédiatriques, Centre de Ressources et de Compétence de la Mucoviscidose, Institut Necker Enfants Malades/INSERM U1151 Hôpital Necker Enfants Malades, P, France
| | - Kevin W Southern
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jurg Barben
- Ostschweizer Kinderspital Sankt Gallen, Claudiusstrasse 6, 9006 St. Gallen, Switzerland
| | - Patrick A Flume
- Division of Pulmonary and Critical Care, Medical University of South Carolina, USA
| | - Pavla Hodková
- Department of Clinical Psychology, University Hospital, Prague, Czech Republic
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis Group), Federal State Budgetary Institution, Research Centre for Medical Genetics, Moscow, Russia
| | - Maya N Kirszenbaum
- Department of Pediatric Pulmunology, CRCM, Hôpital Necker-Enfants Malades, Paris, France
| | - Sue Madge
- Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK
| | - Helen Oxley
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Barry Plant
- Cork Adult CF Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Sarah Jane Schwarzenberg
- Divison of Pediatric Gastroenterology Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology (COG), University of Nottingham, Nottingham, UK
| | - Giovanni Taccetti
- Cystic Fibrosis Centre, Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Thomas O F Wagner
- Frankfurter Referenzzentrum für Seltene Erkrankungen (FRZSE), Universitätsklinikum Frankfurt am Main, Wolfgang von Goethe-Universität, Frankfurt am Main, Germany
| | - Susan P Wolfe
- Regional Paediatric CF Unit, The Leeds Children's Hospital, Leeds Teaching Hospitals, Belmont Grove, Leeds, UK
| | - Pavel Drevinek
- Department of Medical Microbiology, Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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Clinical Indices Can Standardize and Monitor Pediatric Care: A Novel Mechanism to Improve Quality and Safety. J Pediatr 2018; 193:190-195.e1. [PMID: 29212624 DOI: 10.1016/j.jpeds.2017.09.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/07/2017] [Accepted: 09/27/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The Cancer Care Index (CCI), a single metric that sums the number of undesirable patient events in a given time frame (either preventable harm events or missed opportunities to provide optimal care), resulted in a 42% improvement in performance. Our objective was to test the index concept in other service lines to determine whether similar performance improvement occurred. STUDY DESIGN Care indices were developed and introduced in 3 additional service lines: Nephrology (Chronic Kidney Disease Care Index; CKDCI), Pulmonology (Lung Transplantation Care Index; LTCI), and Otolaryngology (Tracheostomy Care Index; TCI). After reaching agreement on specific harms to be avoided and elements of optimal care that should be reliably delivered, these items were compiled into indices that were updated monthly. Reports included each element individually and the total for all elements. Baseline performance was calculated retrospectively for the previous year. RESULTS Significant improvement in performance occurred in each program following implementation of the clinical indices. The CKDCI was decreased by 63.2% (P < .001), the LTCI was decreased by 89.5% (P < .001), and the TCI was decreased by 53.0% (P < .001). Surveyed staff indicated satisfaction with use of the metric. CONCLUSIONS Clinical indices are useful for evaluating and managing the overall reliability of a program's ability to deliver optimal care, and are associated with improved clinical performance and satisfaction by service line staff when incorporated into a program's operation.
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Indications for lung resection surgery and lung transplant in South American children with cystic fibrosis. Paediatr Respir Rev 2018; 25:37-42. [PMID: 28366682 DOI: 10.1016/j.prrv.2017.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 02/03/2017] [Indexed: 11/21/2022]
Abstract
The current available literature evaluating lung resection surgery and lung transplantation in children with cystic fibrosis (CF) was reviewed through a PubMed search and references from selected studies were additionally included. Pulmonary resections, i.e. lobectomy, segmentectomy, and pneumonectomy, are seldom performed in CF. The main indications, in patients with a forced expiratory volume in 1second (FEV1) that is greater than 30% predicted, are localized bronchiectasis/atelectasis, severe hemoptysis, and bronchopleural fistula refractory to medical management. The potential benefits are decreased symptoms and pulmonary exacerbations, and an improved quality of life. Pre and postoperative intensive care is mandatory for surgical candidates. The risk of death should be taken into account when the procedure is considered. Selection for lung transplantation (LTx) candidates in children with CF in South America follows the International Society for Heart and Lung Transplantation (ISHLT) criteria. When compared to adults with CF, a poorer survival rate after LTx in children with CF has been observed in the literature, as well as in our LTx center in Brazil, reasons for which are still unknown. The main complications after LTx in children are early and late acute rejection, and infections. LTx is a therapeutic option for eligible children with CF, fulfilling the lung transplant candidacy criteria, as post-transplant survival rates are increasingly improving due to better management of the transplanted patient.
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Abstract
Cystic fibrosis (CF) is a common indication for lung transplantation (LTx) in children and adults with severe and irreversible lung disease. In the setting of LTx in the CF population, immunosuppressive medications are used to prevent allograft rejection despite the majority of these patients being chronically infected with numerous, and often antibiotic-resistant, pathogens. There is limited evidence for the optimal post-LTx immunosuppression regimen in patients with CF, particularly in children. This article provides a review of immunosuppression regimens in the pediatric and adult CF post-LTx population, investigating drug dosing and monitoring, and medication combinations. Currently used immunosuppressive medications and related systemic adverse effects are reviewed. With limitations of data in the pediatric population, future research should address immunosuppression in these children to help guide pediatric drug management as a means to optimize clinical outcomes after LTx.
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Reported Nonadherence to Immunosuppressive Medication in Young Adults After Heart Transplantation: A Retrospective Analysis of a National Registry. Transplantation 2017; 101:421-429. [PMID: 26950728 DOI: 10.1097/tp.0000000000001152] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Young adult heart transplantation (HTx) recipients experience high mortality risk attributed to increased nonadherence to immunosuppressive medication in this age window. This study sought to test whether a high-risk age window in HTx recipients persisted in the absence of reported nonadherence. METHODS Heart transplantation recipients aged 2 to 40 years, transplanted between October 1999 and January 2007, were identified in the United Network for Organ Sharing database. Multivariable survival analysis was used to estimate influences of age at transplantation and attained posttransplant age on mortality hazard among patients stratified by center report of nonadherence to immunosuppression that compromised recovery. RESULTS Three thousand eighty-one HTx recipients were included, with univariate analysis demonstrating peak hazards of mortality and reported nonadherence among 567 patients transplanted between ages 17 and 24 years. Multivariable analysis adjusting for reported nonadherence demonstrated lower mortality among patients transplanted at younger (hazards ratio, 0.813; 95% confidence interval, 0.663-0.997; P = 0.047) or older (hazards ratio, 0.835; 95% confidence interval, 0.701-0.994; P = 0.042) ages. Peak mortality hazard at ages 17 to 24 years was confirmed in the subgroup of patients with no nonadherence reported during follow-up. This result was replicated using attained age after HTx as the time metric, with younger and older ages predicting improved survival in the absence of reported nonadherence. CONCLUSIONS Late adolescence and young adulthood coincide with greater mortality hazard and greater chances of nonadherence to immunosuppressive medication after HTx, but the elevation of mortality hazard in this age range persists in the absence of reported nonadherence. Other causes of the high-risk age window for post-HTx mortality should be demonstrated to identify opportunities for intervention.
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Stephenson AL, Sykes J, Berthiaume Y, Singer LG, Chaparro C, Aaron SD, Whitmore GA, Stanojevic S. A clinical tool to calculate post-transplant survival using pre-transplant clinical characteristics in adults with cystic fibrosis. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12950] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Anne L. Stephenson
- Adult CF Program; St. Michael's Hospital; Toronto ON Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's Hospital; Toronto ON Canada
- Department of Medicine; University of Toronto; Toronto ON Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto ON Canada
| | - Jenna Sykes
- Adult CF Program; St. Michael's Hospital; Toronto ON Canada
| | - Yves Berthiaume
- IRCM and Department of medicine; CHUM University of Montreal; Montreal QC Canada
| | - Lianne G. Singer
- Department of Medicine; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; Toronto ON Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto ON Canada
| | - Cecilia Chaparro
- Adult CF Program; St. Michael's Hospital; Toronto ON Canada
- Department of Medicine; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; Toronto ON Canada
| | - Shawn D. Aaron
- The Ottawa Hospital Research Institute; University of Ottawa; Ottawa ON Canada
| | - George Alex Whitmore
- The Ottawa Hospital Research Institute; University of Ottawa; Ottawa ON Canada
- Desautels Faculty of Management; McGill University; Montreal Canada
| | - Sanja Stanojevic
- Division of Respiratory Medicine; The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto ON Canada
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Hayes D, Sweet SC, Benden C, Kopp BT, Goldfarb SB, Visner GA, Mallory GB, Tobias JD, Tumin D. Transplant center volume and outcomes in lung transplantation for cystic fibrosis. Transpl Int 2017; 30:371-377. [DOI: 10.1111/tri.12911] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 09/22/2016] [Accepted: 12/19/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Don Hayes
- Department of Pediatrics; The Ohio State University; Columbus OH USA
- Department of Internal Medicine; The Ohio State University; Columbus OH USA
- Department of Surgery; The Ohio State University; Columbus OH USA
- Center for Epidemiology of Organ Failure and Transplantation; Nationwide Children's Hospital; Columbus OH USA
- Section of Pulmonary Medicine; Nationwide Children's Hospital; Columbus OH USA
| | - Stuart C. Sweet
- Department of Pediatrics; Washington University School of Medicine; St. Louis MO USA
| | - Christian Benden
- Department of Pediatrics; Pereleman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | - Benjamin T. Kopp
- Department of Pediatrics; The Ohio State University; Columbus OH USA
- Center for Epidemiology of Organ Failure and Transplantation; Nationwide Children's Hospital; Columbus OH USA
- Section of Pulmonary Medicine; Nationwide Children's Hospital; Columbus OH USA
| | - Samuel B. Goldfarb
- Department of Pediatrics; Pereleman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
- Division of Pulmonary Medicine; Children's Hospital of Philadelphia; Philadelphia PA USA
| | - Gary A. Visner
- Department of Pediatrics; Harvard Medical School; Boston MA USA
- Division of Pulmonary and Respiratory Diseases; Boston Children's Hospital; Boston MA USA
| | - George B. Mallory
- Department of Pediatrics; Baylor College of Medicine; Houston TX USA
- Division of Pulmonary Medicine; Texas Children's Hospital; Houston TX USA
| | - Joseph D. Tobias
- Department of Anesthesiology; The Ohio State University; Columbus OH USA
- Center for Epidemiology of Organ Failure and Transplantation; Nationwide Children's Hospital; Columbus OH USA
- Department of Anesthesiology & Pain Medicine; Nationwide Children's Hospital; Columbus OH USA
| | - Dmitry Tumin
- Department of Pediatrics; The Ohio State University; Columbus OH USA
- Center for Epidemiology of Organ Failure and Transplantation; Nationwide Children's Hospital; Columbus OH USA
- Department of Anesthesiology & Pain Medicine; Nationwide Children's Hospital; Columbus OH USA
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Hayes D, Glanville AR, McGiffin D, Tobias JD, Tumin D. Age-related survival disparity associated with lung transplantation in cystic fibrosis: An analysis of the registry of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2016; 35:1108-15. [DOI: 10.1016/j.healun.2016.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/19/2016] [Accepted: 04/21/2016] [Indexed: 01/26/2023] Open
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Hayes D, Tumin D, Daniels CJ, McCoy KS, Mansour HM, Tobias JD, Kirkby SE. Pulmonary Artery Pressure and Benefit of Lung Transplantation in Adult Cystic Fibrosis Patients. Ann Thorac Surg 2016; 101:1104-9. [DOI: 10.1016/j.athoracsur.2015.09.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 09/02/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
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Blatter J, Sweet S. Lung Transplantation in Cystic Fibrosis: Trends and Controversies. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2015; 28:237-243. [PMID: 26697265 DOI: 10.1089/ped.2015.0564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article is not an overview of all facets of lung transplantation in cystic fibrosis (CF), but rather it is intended as a review of current allocation controversies, as well as of trends in diagnostics and management in lung transplant recipients and in patients with end-stage lung disease. Despite changes in donor and recipient selection, long-term survival in pediatric lung transplant has continued to be limited by chronic lung allograft dysfunction (CLAD). Due to, in part, this short survival benefit, transplant continues to be an appropriate option for only a subset of pediatric patients with CF. The feasibility of transplant as a therapeutic option is also affected by the limited pediatric organ supply, which has moreover contributed to controversy over lung allocation. Debates over the allocation of this scarce resource, however, may also help to drive innovation in the field of lung transplant. Longer pretransplant survival-as aided by new lung bypass technologies, for example-could help to alleviate organ shortages, as well as facilitate the transport of organs to suitable pediatric recipients. Improved diagnosis and treatment for CLAD and for antibody-mediated rejection have the potential to extend survival in pediatric lung transplant. Regardless, the relative rarity of transplant could pose future challenges for pediatric lung transplant programs, which require adequate numbers of patients to maintain proper expertise.
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Affiliation(s)
- Joshua Blatter
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine , St. Louis, Missouri
| | - Stuart Sweet
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine , St. Louis, Missouri
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Remarkable long-term survival post–lung transplantation among Canadian patients with cystic fibrosis. J Heart Lung Transplant 2015; 34:1131-3. [DOI: 10.1016/j.healun.2015.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 05/28/2015] [Indexed: 11/22/2022] Open
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22
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Hayes D, Auletta JJ, Whitson BA, Black SM, Kirkby S, Tobias JD, Mansour HM. Human leukocyte antigen mismatching and survival after lung transplantation in adult and pediatric patients with cystic fibrosis. J Thorac Cardiovasc Surg 2015; 151:549-57.e1. [PMID: 26414151 DOI: 10.1016/j.jtcvs.2015.08.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 08/03/2015] [Accepted: 08/10/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The influence of human leukocyte antigen (HLA) mismatching on survival in adult and pediatric patients with cystic fibrosis (CF) after lung transplantation (LTx) is unknown. METHODS The United Network for Organ Sharing database was queried from 1987 to 2013 to determine the influence of HLA mismatching on survival in adult and pediatric CF LTx recipients by assessing the association of HLA mismatching with survival in first-time adult (aged ≥ 18 years) and pediatric (aged <18 years) recipients. RESULTS Of 3149 adult and 489 pediatric patients with CF, 3145 and 489 were used for univariate Cox analysis, 2687 and 363 for Kaplan-Meier survival analysis, and 2073 and 257 for multivariate Cox analysis, respectively. Univariate analyses in adult and pediatric patients with CF demonstrated conflicting associations between HLA mismatching and survival (adult hazard ratio [HR], 1.0; 95% confidence interval [CI], 0.97-1.1; P = .45 vs pediatric HR, 0.87; 95% CI, 0.77-0.99; P = .032). Multivariate Cox models including both pediatric and adult patients confirmed that HLA mismatching had an initially protective effect at young ages (HR, 0.85; 95% CI, 0.73-0.99; P = .044) and that this protective effect diminished at older ages and was no longer associated with survival at P < .05 beyond age 10 years. CONCLUSIONS HLA mismatching has significantly different implications for survival after LTx in adult compared with pediatric patients with CF.
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Affiliation(s)
- Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio; Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio.
| | - Jeffery J Auletta
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Host Defense Program, Nationwide Children's Hospital, Columbus, Ohio; Section of Hematology/Oncology and Bone Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio; Section of Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sylvester M Black
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Stephen Kirkby
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio; Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Heidi M Mansour
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, Tucson, Ariz
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Abstract
Cardiothoracic transplantation has significantly impacted the lives of pediatric patients with advanced cardiopulmonary failure. The current state of lung transplantation in children as well as its ongoing and future challenges are discussed.
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Abstract
BACKGROUND The influence of diabetes mellitus (DM) on survival in patients with cystic fibrosis (CF) before and after lung transplantation is not well studied. METHODS To determine the influence of DM in patients with CF, the United Network for Organ Sharing database (2005-2013) was queried for 2 cohorts: first-time lung transplant candidates who were not transplanted and first-time transplant recipients. RESULTS A total of 679 patients with CF had data on DM status at listing and did not undergo transplantation. In this cohort, DM was associated with significant increase in mortality hazard as shown by an adjusted multivariate Cox model fitted to the whole cohort (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.1-1.8; P = .012) and by a Cox model stratified on pairs of DM and non-DM patients matched on the propensity of having DM at listing (HR, 1.9; 95% CI, 1.2-2.9; P = .003). In comparison, a total of 1464 patients with CF had data on DM status at listing and received a transplant, but DM at listing was not associated with posttransplant survival. The lack of association between DM and mortality hazard was evident in a multivariate Cox regression model fitted to the whole sample (HR, 1.0; 95% CI, 0.82-1.2; P = .98) and a Cox regression model stratified on matched pairs of DM and non-DM patients (HR, 1.1; 95% CI, 0.82-1.5; P = .56). CONCLUSIONS The presence of DM is associated with significantly increased risk for death in patients with CF on the wait list before lung transplantation, but does not influence survival after transplantation.
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Sweet SC, Liou TG. Adolescents with cystic fibrosis: take the door, not the window. Pediatr Transplant 2015; 19:133-5. [PMID: 25620082 PMCID: PMC6545115 DOI: 10.1111/petr.12427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Stuart C. Sweet
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| | - Theodore G. Liou
- Departments of Internal Medicine and Pediatrics, University of Utah, Salt Lake City, UT, USA
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