Respiratory-associated deaths in people with intellectual disabilities: a systematic review and meta-analysis

Stakeholder perspectives of immunisation delivery for adolescents with disability in specialist schools in Victoria, Australia: 'we need a vaccination pathway'

BACKGROUND

Adolescents with disability have lower vaccination rates than the general population, including HPV vaccination. Understanding the multi-level influences on vaccination in specialist schools is crucial to achieve optimal vaccination coverage and vaccination experiences for adolescents living with disability.

OBJECTIVE

To identify and improve understanding of the facilitators and barriers of HPV vaccination among adolescents with intellectual disabilities or autism in Victorian specialist schools to inform strategies to increase vaccination acceptance and uptake.

METHODS

Qualitative interviews with key stakeholders (adolescents with disabilities, parents, school and council immunisation staff) from six specialist schools in Victoria, Australia. Data were analysed thematically. Inductively derived themes were then deductively mapped across the UNICEF 'Journey to Immunization' model.

RESULTS

32 interviews were conducted with stakeholders (2 adolescents, 7 parents, 13 school staff, 10 council staff). Trust in vaccines was high, but knowledge of the HPV vaccine was limited. Barriers included lack of accessible information for parents, the consent process, behavioural challenges and vaccine-related anxiety among students. The immunisation program in special schools was perceived as convenient, however preparing students for vaccination day and catering to individual student needs were key. Participants expressed a need for more parent information about options and additional support for vaccination outside of the school program.

CONCLUSIONS

Our study identified a range of facilitators and barriers to the school immunisation program for students with disabilities in specialist schools. The next phase of this work will use co-design workshops to build on the suggestions for improvement and opportunities that could be leveraged to improve vaccination uptake.

The association between disability and all-cause mortality in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

There are 1·3 billion people with disabilities globally. On average, they have poorer health than their non-disabled peers, but the extent of increased risk of premature mortality is unknown. We aimed to systematically review the association between disability and mortality in low-income and middle-income countries (LMICs).

METHODS

We searched MEDLINE, Global Health, PsycINFO, and EMBASE from Jan 1, 1990 to Nov 14, 2022. Longitudinal epidemiological studies in any language with a comparator group that measured the association between disability and all-cause mortality in people of any age were eligible for inclusion. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. We used a random-effects meta-analysis to calculate the pooled hazard ratio (HR) for all-cause mortality by disability status. We then conducted meta-analyses separately for different impairment and age groups.

FINDINGS

We identified 6146 unique articles, of which 70 studies (81 cohorts) were included in the systematic review, from 22 countries. There was variability in the methods used to assess and report disability and mortality. The meta-analysis included 54 studies, representing 62 cohorts (comprising 270 571 people with disabilities). Pooled HRs for all-cause mortality were 2·02 (95% CI 1·77-2·30) for people with disabilities versus those without disabilities, with high heterogeneity between studies (τ2=0·23, I2=98%). This association varied by impairment type: from 1·36 (1·17-1·57) for visual impairment to 3·95 (1·60-9·74) for multiple impairments. The association was highest for children younger than 18 years (4·46, [3·01-6·59]) and lower in people aged 15-49 years (2·45 [1·21-4·97]) and people older than 60 years (1·97 [1·65-2·36]).

INTERPRETATION

People with disabilities had a two-fold higher mortality rate than people without disabilities in LMICs. Interventions are needed to improve the health of people with disabilities and reduce their higher mortality rate.

FUNDING

UK National Institute for Health and Care Research; and UK Foreign, Commonwealth and Development Office.

The impact of comorbid psychiatric disorders on chronic obstructive pulmonary disease (COPD) hospitalizations: a nationwide retrospective study

AIMS

To characterize the register of a secondary diagnosis of mental illnesses in all chronic obstructive pulmonary disease (COPD) hospitalizations registered in Portugal from 2008 to 2015 and explore their impact on hospitalization outcomes.

METHODS

A retrospective observational study was conducted. Hospitalizations of patients with at least 40 years old, discharged between 2008 and 2015 with a primary diagnosis of COPD (ICD-9-CM codes 491.x, 492.x and 496) were retrieved from a national administrative database. Comorbid psychiatric diagnoses were identified and defined by the HCUP Clinical Classification Software (CCS) category codes 650-670 (excluding 662). Length of hospital stay (LoS), admission type, in-hospital mortality, and estimated hospital charges were analyzed according to psychiatric diagnostic categories using sex and age-adjusted models.

RESULTS

Of 66,661 COPD hospitalizations, 25,869 (38.8%) were episodes with a registered psychiatric comorbidity. These were more likely to correspond to younger inpatients (OR = 2.16, 95%CI 2.09-2.23; p < 0.001), to stay longer at the hospital (aOR = 1.08, 95%CI 1.05-1.12; p < 0.001), to incur in higher estimated hospital charges (aOR = 1.37, 95%CI 1.33-1.42; p < 0.001) and to be urgently admitted (aOR = 1.33, 95%CI 1.23-1.44; p < 0.001). After adjustment for age, in-hospital mortality was lower for episodes with psychiatric diagnoses (aOR = 0.90; 95%CI 0.84-0.96; p < 0.001), except for organic and neurodegenerative diseases category and developmental disorders, intellectual disabilities and disorders usually diagnosed in infancy, childhood, or adolescence category.

DISCUSSION

These findings corroborate the additional burden placed by psychiatric disorders on COPD hospitalizations, highlighting the importance of individualizing care to address these comorbidities and minimize their impact on treatment outcomes.

Parental home-based pulse oximetry monitoring for adults with intellectual disabilities at risk of serious respiratory problems including COVID-19: a brief report

BACKGROUND

People with intellectual disabilities (ID) are at high risk of developing respiratory health issues. The COVID-19 pandemic has compounded this, with serious consequences, and for some, death. Despite home-based oxygen saturation monitoring being recommended for people with ID, there is a stark lack of evidence in the literature on its feasibility.

METHOD

We conducted 3-day baseline home-based oxygen saturation monitoring, using pulse oximeters, with eight parents of nine adults with ID in Scotland. Two eligible parents also completed a further 2 weeks of monitoring, and returned an evaluation questionnaire on its feasibility.

RESULTS

Baseline mean readings for eight adults with ID were within the normal range (%Sp0₂  ≥ 95), and for another one 94%. Fluctuations over the 3-day assessment period were experienced by six of these individuals. However, these variations were within limits which are not dangerous (lowest reading 92%), implying that parental home-based pulse oximetry monitoring is likely to be safe for adults with ID. The two parents who completed the evaluation found home-based pulse oximetry monitoring to be easy/very easy to do, and effective/very effective.

CONCLUSIONS

This is the first research study, albeit with a very small sample, to report on the potential feasibility of parental home-based pulse oximetry monitoring for adults with ID. Home-based pulse oximetry monitoring appears to be safe in adults with ID at risk of developing serious respiratory problems, and not difficult for their parents to do. There is an urgent need to replicate this work, using a larger sample, to promote home-based respiratory health monitoring more widely for people with ID.

Mortality in residential care facilities for people with disability: a descriptive cross-sectional analysis of statutory notifications in Ireland

OBJECTIVES

To determine incidence of death in residential care facilities for people with disability in Ireland, primary cause of death, associations of facility characteristics and deaths, and to compare characteristics of deaths reported as expected and unexpected.

DESIGN

Descriptive cross-sectional study.

SETTING

All residential care facilities for people with disability operational in Ireland in 2019 and 2020 (n=1356).

PARTICIPANTS

n=9483 beds.

MAIN OUTCOME MEASURES

All expected and unexpected deaths notified to the social services regulator. Cause of death as reported by the facility.

RESULTS

395 death notifications were received in 2019 (n=189) and 2020 (n=206). 45% (n=178) were for unexpected deaths. Incidence of death per 1000 beds per year was 20.83 for all, 11.44 for expected and 9.39 for unexpected deaths. Respiratory disease was the most common cause of death, accounting for 38% (n=151) of all deaths. In adjusted negative binomial regression analysis, congregated settings versus non-congregated (incidence rate ratio (95% CI): 2.59 (1.80 to 3.73)) and higher bed numbers (highest vs lowest quartile) (4.02 (2.19 to 7.40)) were positively associated with mortality. There was also a positive n-shaped association with category of nursing staff-to-resident ratio when compared with zero nurses. Emergency services were contacted for 6% of expected deaths. Of the deaths reported as unexpected, 29% were receiving palliative care and 10.8% had a terminal illness.

CONCLUSION

Although incidence of death was low, residents of congregated and larger settings had higher incidence of death than residents of other settings. This should be a consideration for practice and policy. Given the high contribution of respiratory diseases to deaths and the potential avoidability of these, there is a need for improved respiratory health management in this population. Nearly half of all deaths were reported as unexpected; however, overlap in the characteristics of expected and unexpected deaths highlights the need for clearer definitions.

A scoping review of the evidence for the use of screening tools in people with intellectual disabilities with dysphagia

BACKGROUND

Dysphagia can have serious health implications including choking and respiratory infection leading to poorer quality of life. People with intellectual disabilities are at higher risk of dysphagia related health complications and early death. Robust dysphagia screening tools are vital for this population.

METHOD

A scoping review and appraisal of the evidence for dysphagia and feeding screening tools for use with people with intellectual disabilities was undertaken.

RESULTS

Seven studies (using six screening tools) met the review inclusion criteria. Mostly studies were limited by no defined dysphagia criteria, no verification of tools with a gold reference standard (e.g., videofluoroscopic examination) and lack of participant diversity (small samples, narrow age range, severity of intellectual disability or limited settings).

CONCLUSIONS

There is urgent need for development and rigorous appraisal of existing dysphagia screening tools to meet the needs of a wider range of people with intellectual disabilities (particularly mild-to-moderate severity) and in wider settings.

Rates, causes and predictors of all-cause and avoidable mortality in 163 686 children and young people with and without intellectual disabilities: a record linkage national cohort study

OBJECTIVES

To investigate mortality rates and associated factors, and avoidable mortality in children/young people with intellectual disabilities.

DESIGN

Retrospective cohort; individual record-linked data between Scotland's 2011 Census and 9.5 years of National Records for Scotland death certification data.

SETTING

General community.

PARTICIPANTS

Children and young people with intellectual disabilities living in Scotland aged 5-24 years, and an age-matched comparison group.

MAIN OUTCOME MEASURES

Deaths up to 2020: age of death, age-standardised mortality ratios (age-SMRs); causes of death including cause-specific age-SMRs/sex-SMRs; and avoidable deaths.

RESULTS

Death occurred in 260/7247 (3.6%) children/young people with intellectual disabilities (crude mortality rate=388/100 000 person-years) and 528/156 439 (0.3%) children/young people without intellectual disabilities (crude mortality rate=36/100 000 person-years). SMRs for children/young people with versus those without intellectual disabilities were 10.7 for all causes (95% CI 9.47 to 12.1), 5.17 for avoidable death (95% CI 4.19 to 6.37), 2.3 for preventable death (95% CI 1.6 to 3.2) and 16.1 for treatable death (95% CI 12.5 to 20.8). SMRs were highest for children (27.4, 95% CI 20.6 to 36.3) aged 5-9 years, and lowest for young people (6.6, 95% CI 5.1 to 8.6) aged 20-24 years. SMRs were higher in more affluent neighbourhoods. Crude mortality incidences were higher for the children/young people with intellectual disabilities for most International Statistical Classification of Diseases and Related Health Problems, 10th Revision chapters. The most common underlying avoidable causes of mortality for children/young people with intellectual disabilities were epilepsy, aspiration/reflux/choking and respiratory infection, and for children/young people without intellectual disabilities were suicide, accidental drug-related deaths and car accidents.

CONCLUSION

Children with intellectual disabilities had significantly higher rates of all-cause, avoidable, treatable and preventable mortality than their peers. The largest differences were for treatable mortality, particularly at ages 5-9 years. Interventions to improve healthcare to reduce treatable mortality should be a priority for children/young people with intellectual disabilities. Examples include improved epilepsy management and risk assessments, and coordinated multidisciplinary actions to reduce aspiration/reflux/choking and respiratory infection. This is necessary across all neighbourhoods.

Risk factors for excess all-cause mortality during the first wave of the COVID-19 pandemic in England: A retrospective cohort study of primary care data

BACKGROUND

The COVID-19 pandemic's first wave in England during spring 2020 resulted in an approximate 50% increase in all-cause mortality. Previously, risk factors such as age and ethnicity, were identified by studying COVID-related deaths only, but these were under-recorded during this period.

OBJECTIVE

To use a large electronic primary care database to estimate the impact of risk factors (RFs) on excess mortality in England during the first wave, compared with the impact on total mortality during 2015-19.

METHODS

Medical history, ethnicity, area-based deprivation and vital status data were extracted for an average of 4.8 million patients aged 30-104 years, for each year between 18-March and 19-May over a 6-year period (2015-2020). We used Poisson regression to model total mortality adjusting for age and sex, with interactions between each RF and period (pandemic vs. 2015-19). Total mortality during the pandemic was partitioned into "usual" and "excess" components, assuming 2015-19 rates represented "usual" mortality. The association of each RF with the 2020 "excess" component was derived as the excess mortality ratio (EMR), and compared with the usual mortality ratio (UMR).

RESULTS

RFs where excess mortality was greatest and notably higher than usual were age >80, non-white ethnicity (e.g., black vs. white EMR = 2.50, 95%CI 1.97-3.18; compared to UMR = 0.92, 95%CI 0.85-1.00), BMI>40, dementia, learning disability, severe mental illness, place of residence (London, care-home, most deprived). By contrast, EMRs were comparable to UMRs for sex. Although some co-morbidities such as cancer produced EMRs significantly below their UMRs, the EMRs were still >1. In contrast current smoking has an EMR below 1 (EMR = 0.80, 95%CI 0.65-0.98) compared to its UMR = 1.64.

CONCLUSIONS

Studying risk factors for excess mortality during the pandemic highlighted differences from studying cause-specific mortality. Our approach illustrates a novel methodology for evaluating a pandemic's impact by individual risk factor without requiring cause-specific mortality data.