Employment and insurance for young adults with congenital heart disease

Advances in Managing Transition to Adulthood for Adolescents With Congenital Heart Disease: A Practical Approach to Transition Program Design: A Scientific Statement From the American Heart Association

It is now expected that most individuals with congenital heart disease will survive to adulthood, including those with complex heart conditions. Maintaining lifelong medical care requires those with congenital heart disease to eventually transfer from pediatric to adult-oriented health care systems. Developing health care transition skills and gaining independence in managing one's own health care is imperative to this process and to ongoing medical and psychosocial success. This scientific statement reviews the recent evidence regarding transition and provides resources, components, and suggestions for development of congenital heart disease transition programs with the goals of improving patient knowledge, self-management, and self-efficacy skills to the level they are capable to eventually integrate smoothly into adult-oriented health care. Specifically, the scientific statement updates 3 sections relevant to transition programming. First, there is a review of specific factors to consider, including social determinants of health, psychosocial well-being, and neurocognitive status. The second section reviews costs of inadequate transition including the public health burden and the impairment in individual quality of life. Finally, the last section discusses considerations and suggestions for transition program design including communication platforms, a family-centered approach, and individual models. Although this scientific statement reviews recent literature surrounding transitions of care for individuals with congenital heart disease there remain significant knowledge gaps. As a field, we have yet to determine ideal timing and methods of transition, and barriers to transition and transfer remain, particularly for the underserved populations. The consequences of poor health care transition are great and garnering outcomes and information through organized, multifaceted, collaborative approaches to transition is critical to improving the lifelong care of individuals with congenital heart disease.

Health Care Policy and Congenital Heart Disease: 2020 Focus on Our 2030 Future

The congenital heart care community faces a myriad of public health issues that act as barriers toward optimum patient outcomes. In this article, we attempt to define advocacy and policy initiatives meant to spotlight and potentially address these challenges. Issues are organized into the following 3 key facets of our community: patient population, health care delivery, and workforce. We discuss the social determinants of health and health care disparities that affect patients in the community that require the attention of policy makers. Furthermore, we highlight the many needs of the growing adults with congenital heart disease and those with comorbidities, highlighting concerns regarding the inequities in access to cardiac care and the need for multidisciplinary care. We also recognize the problems of transparency in outcomes reporting and the promising application of telehealth. Finally, we highlight the training of providers, measures of productivity, diversity in the workforce, and the importance of patient-family centered organizations in advocating for patients. Although all of these issues remain relevant to many subspecialties in medicine, this article attempts to illustrate the unique needs of this population and highlight ways in which to work together to address important opportunities for change in the cardiac care community and beyond. This article provides a framework for policy and advocacy efforts for the next decade.

Disparities in insurance coverage among hospitalized adult congenital heart disease patients before and after the Affordable Care Act

BACKGROUND

Data are lacking regarding the insurance status of adults with congenital heart disease (ACHD). We investigated whether the Affordable Care Act (ACA) impacted insurance status among hospitalized ACHD, identified associated sociodemographic factors, and compared coverage to adults with other chronic childhood conditions.

METHODS

Serial cross-sectional analysis of National Inpatient Sample hospitalizations from 2007 to 2016 was performed for patients 18-64 years old. ACHD were identified using ICD-9/10-CM codes and compared to patients with sickle cell disease (SCD), cystic fibrosis (CF), and the general population. Age was dichotomized as 18-25 years (transition aged) or 26-64 years. Groups were compared by era (pre-ACA [January 2007-June 2010]; early-ACA [July 2010-December 2013], which eliminated pre-existing condition exclusions; and full-ACA [January 2014-December 2016]) using interrupted time series and multivariable Poisson regression analyses.

RESULTS

Overall, uninsured hospitalizations decreased from pre-ACA (12.0%) to full-ACA (8.5%). After full ACA implementation, ACHD had lower uninsured rates than the general hospitalized population (6.0 vs. 8.6%, p < .01), but higher rates than those with other chronic childhood diseases (SCD [4.5%]; CF [1.6%]). Across ACA eras, transition aged ACHD had higher uninsured rates than older patients (8.9 vs. 7.6%, p < .01), and Hispanic patients remained less insured than other groups.

CONCLUSIONS

Hospitalized ACHD were better insured than the general population but less insured than those with SCD or CF. Full ACA implementation was associated with improved insurance coverage for all groups, but disparities persisted for transition aged and Hispanic patients. Ongoing evaluation of the effects of insurance and health policy on ACHD remains critical to diminish health disparities.

Proposed method for evaluation and categorization of functional capacity of children, adolescents, and adults with cardiac diseases to bring them in existing social justice system by creating the cardiac disability criteria

INTRODUCTION

Emerging epidemiological trends in India indicate the rising burden of cardiovascular diseases (CVDs) demanding a need of a social support system. Yet, the list of 21 benchmark disabilities notified by the Department of Empowerment of Persons with Disabilities, Ministry of Social Justice and Empowerment, Government of India, does not include CVDs under the newly enacted Rights of Persons with Disabilities (RPWD) Act, 2016. While the RPWD Act 2016 has acknowledged the dynamic nature of disabilities associated with congenital diseases like thalassemia, it has also provided an opportunity to bring in "cardiac disability" under its tenets. This would allow India to adopt strategies for the benefit of cardiac patients in accordance with policies adopted by developed countries such as the United States of America (USA), the United Kingdom of Great Britain (UK), and Canada. This document is to initiate a thought process of recruitment of cardiac patients in the social justice system.

AIMS AND OBJECTIVES

(1) To define cardiac disability, (2) to categorize cardiac diseases/defects (groups A-C) according to severity and need for interventions, (3) to identify operated and unoperated patients with normal functional capacity and their eligibility to avail normal opportunities similar to their peer groups, (4) to create a comprehensive cardiac disability scoring (CCDS) system for disability certification based on subjective and objective evaluation of functional capacity and the corresponding heart disease category group, and (5) to create a reference literature for the issues of education, employability, insurability, and vocational counseling based on this document.

METHODOLOGY

The evolution of this manuscript has been discussed in view of relevant observations made by a team of cardiologists, cardiac surgeons, intensivists, pediatricians, social workers, etc.

CONCLUSION

This manuscript suggests a CCDS system to lay down criteria for disability status for eligible patients suffering from cardiovascular diseases. It intends to offer a unique scientific tool to address the psychosocial and socio-economic bias against patients with heart diseases of heterogeneous nature.

Chance of surgery in adult congenital heart disease

Background Young patients with congenital heart disease reaching adulthood face mandatory transition to adult cardiology. Their new cardiologist needs to assess the chances of major future events such as surgery. Using a large national registry, we assessed if patient characteristics at the age of 18 years could predict the chance of congenital heart surgery in adulthood. Design and methods Of 10,300 patients from the CONCOR national registry, we used general patient characteristics at age 18 years, underlying congenital heart defect, history of complications, and interventions in childhood as potential predictors of congenital heart surgery occurring from age 18 years up to age 40 and 60 years. Cox regression was used to calculate hazard ratios with 95% confidence intervals. Analyses were performed separately for all congenital heart surgery and for valvular surgery alone. Results Altogether 2427 patients underwent congenital heart surgery after age 18 years, 1389 of whom underwent valvular surgery. Underlying heart defect, male sex, multiple defects, childhood endocarditis, supraventricular arrhythmia, aortic complications and paediatric cardiovascular surgery, independently predicted adult congenital heart surgery. The mean chance of congenital heart surgery was 22% up to age 40 and 43% up to age 60 years; individual chances spanned from 9-68% up to age 40 and from 19-93% up to age 60 years. Conclusion At the time of transition from paediatric to adult cardiology, an easily obtainable set of characteristics of patients with congenital heart disease can meaningfully inform cardiologists about the patient's individual chance of surgery in adulthood. Our findings warrant validation in other cohorts.

Comprehensive Care for Adults with Congenital Heart Disease: Expanding Roles for Nurses

Adults with congenital heart disease constitute a growing patient population. Although life expectancy of these patients is increasing, they may be confronted with specific medical, psychosocial and behavioural problems throughout their life span. Special attention needs to be given to patients' illness experiences; knowledge and health behaviour; employability and insurability. Hence, comprehensive care by specialised health care professionals, addressing the multidimensional problems experienced by the patients is required. Interdisciplinary teams in which nurses guarantee the management beyond typical medical issues are promising. Key elements of nurses' involvement are facilitation of the transition process from paediatric to adult cardiology, identification of patient needs, screening and referral for psychosocial problems, and education and counselling of patients and families. In particular, an advanced practice nurse seems to be pre-eminent to optimise illness management of adult patients with congenital heart disease.

What Does it Mean to Live with a Congenital Heart Disease? A Qualitative Study on the Lived Experiences of Adult Patients

Background: Adults with congenital heart disease constitute a relatively new and continuously growing patient population. In addition to medical problems, patients perceive specific psychosocial concerns that influence their lived experiences and quality of life.

Aim: This study aimed to explore the lived experiences of adult congenital heart disease patients.

Methods: Unstructured, in-depth interviews were performed with 12 patients, aged between 25 and 40 years and suffering from moderate or severe heart defect (tetralogy of Fallot, transposition of the great arteries). Interviews were tape recorded and transcribed verbatim. Data were analyzed using Grounded Theory procedures.

Results: Feeling different was the central theme of the patients’ lived experience, as they are faced with physical limitations and visible signs due to the heart defect. The experienced discordance between their world and healthy individuals’ world implies that patients struggle constantly with themselves and with their environment to be accepted as normal. The feeling of being different was influenced by attitudes of the environment, health care, and patient's personality. Moreover, it determined the perceived impact of the disease on the patient's daily life.

Conclusion: This study shows that normalisation is the most important process when dealing with patients suffering from a congenital heart disease.

Style of coping and its determinants in adults with congenital heart disease in a developing country

OBJECTIVE

The objective of this study is to compare coping strategies between adults with and without congenital heart disease and to scrutinize the associations between different available resources (e.g., social support) and adoption of certain coping strategies.

DESIGN

The study has a cross-sectional case-control design.

SETTING

The study was conducted in two university-affiliated heart hospitals in Tehran, Iran.

PATIENTS

The participants comprised 347 persons (18-64 years) with and 353 individuals without congenital heart disease, matched by gender and age.

OUTCOME MEASURES

Coping strategies, assessed with the Utrecht Coping List-short form, were compared between both groups. Block-wise multiple regression analyses were conducted to scrutinize the associations between different independent variables (e.g., demographic/socioeconomic statuses) and adoption of certain styles of coping (dependent variables) among all participants and separately for each group.

RESULTS

The styles of coping in the patients were comparable with those of the control group. Multivariate analyses revealed that congenital heart disease per se was not associated with style of coping except for palliative reaction pattern. The active problem-solving coping style was associated with never married marital status, parenthood, unemployment, higher level of anxiety/somatic symptoms, lower level of depressive symptoms, and better social support. The avoidance behavior style was associated with having a low income, whereas the expression of emotion style was associated with higher anxiety symptoms, experience of financial strain, and income. None of the adopted coping strategies was related to the heart disease variables.

CONCLUSIONS

The adults with congenital heart disease coped as well as adults without congenital heart disease. Marital status, parenthood, annual income, financial strain, psychological adjustment, and perceived social support were important explanatory factors in adopting a certain style of coping among adults with congenital heart disease. However, longitudinal studies with repeated measures are warranted.

Anxiety, depressive and somatic symptoms in adults with congenital heart disease

OBJECTIVE

Despite the improvement in life-expectancy of adults with congenital heart disease, they may experience unique medical and social challenges that could impact on their psychological functioning. The aims of this study were to address the experience of anxiety, depressive and somatic symptoms among adults with congenital heart disease in comparison with that of non-heart diseased persons considering the role of various factors (e.g. socio-economic).

METHODS

In cross-sectional case-control study, the participants consisted of 347 patients with congenital heart disease (18-64 years, 52.2% female) and 353 matched (by sex/age) non-heart diseased persons. The participants completed a questionnaire. The data were analyzed with bivariate and multivariate methods.

RESULTS

In bivariate analyses, scores in anxiety and somatic symptoms were higher among patients than the healthy controls (both at p≤0.001), whereas the groups did not differ in depressive symptoms. Following multiple-linear-regression-analyses, only the association between congenital heart disease and somatic symptoms was confirmed. Among the patients, perceived financial strain was significantly related to anxiety, depressive and somatic symptoms; lower perceived social support to anxiety and depression; and low annual income to somatic symptoms. Additionally, somatic symptoms were associated with anxiety and depressive symptoms, and vice versa. And no medical variables were related to anxiety, depressive and somatic symptoms.

CONCLUSIONS

Congenital heart disease was only independently associated with somatic symptoms. Financial strain, social support and co-existence of emotional distress with somatic symptoms should be considered in developing appropriate interventions to improve the well-being of patients with congenital heart disease. However, longitudinal research is warranted to clarify causality.

Educational Needs of Adults With Congenital Heart Disease

Adults with congenital heart disease represent a new and growing population of patients who pose a challenge to both medicine and nursing. The purpose of this study was to identify the educational needs of adults with congenital heart disease. The study used a prospective, cross-sectional, case-control study design and enrolled 124 adults with congenital heart disease and 124 matched healthy controls. Adults with congenital heart disease were more likely to report living at home with parents and less likely to be employed compared with healthy controls. When those adults with acyanotic and cyanotic congenital heart disease were compared, acyanotic adults were twice as likely to be employed. Additionally, several areas of educational needs were identified in this study for adults with congenital heart disease.

Employment and advice regarding careers for adults with congenital heart disease

AIMS

To compare the rates of employment, and advice offered concerning careers, in adults with congenital heart disease and controls. To assess the impact of the severity of the congenital cardiac malformation on the chances for employment.

METHODS

We solicited responses from 299 adults with congenitally malformed hearts, asking them to answer questions from a questionnaire posed at interview by a trained nurse. The adults were asked to give an identical questionnaire to a friend to act as a control. We received responses from 177 of the controls.

RESULTS

The responses showed that 51 of 156 (33 per cent) adults with congenital heart disease were unemployed, and 37 of 151 (25 per cent) had been unemployed for more than a year. This is significantly more than 25 of 156 (16 per cent) matched controls unemployed, and 5 of 151 (3 per cent) controls unemployed for more than a year. Almost one-fifth of the adults with congenital heart disease (19 per cent) had received advice regarding their career which they found helpful, which is significantly fewer than the 31 per cent of controls. More (42 per cent) had been given advice against certain occupations than controls (11 per cent). Receiving career advice was significantly associated with employment in the population with congenitally malformed hearts, with almost three-quarters (73 per cent) of those given advice being employed compared to 46 per cent of those not given advice. This pattern was not seen in controls. The severity of the congenital cardiac malformation did not significantly affect the rates of unemployment.

CONCLUSIONS

Whatever the severity of their disease, adults with congenitally malformed hearts are more likely to be unemployed than matched controls. They are less likely to receive useful advice regarding potential careers, and find the advice given less helpful, than controls, although receiving suitable advice is associated with being employed in the population with congenital cardiac disease.

Educational and behavioral issues in transitioning from pediatric cardiology to adult-centered health care

It is assumed that when they begin growing up, a child with congenital heart disease will take personal responsibility for his or her care. For this purpose, patients need sufficient knowledge on the heart defect, treatment,and measures to prevent complications. However, empirical studies indicated that the levels of knowledge and understanding of both parents and children with congenital heart disease are poor. Therefore, sound patient education is imperative, particularly when patients are transitioned from pediatric cardiology to adult congenital cardiology. In this respect, the focus of communication shifts from the parent to the young patient; moreover, education should be tailored according to the developmental level of the patient. Issues that should typically be covered by educational programs for adolescents with congenital heart disease are information on the heart defect, treatment, endocarditis, sexuality and reproduction, sports, employability and insurability, and cardiovascular risk factor. International guidelines indicate that advanced practice nurses are key in developing and implementing patient education programs during the transition from pediatric cardiology to adult-centered health care.

Styles of coping and social support in a cohort of adults with congenital heart disease

OBJECTIVE

To determine styles of coping, that is personal ways of dealing with problems, and social support, or support from the social environment, in a cohort of adults with congenital heart disease.

METHODS

We subjected 362 patients with congenital heart disease, aged from 20 to 46 years, belonging to five diagnostic groups, to extensive medical and psychological examination from 20 to 33 years after their first open heart surgical procedure. During psychological examination, 342 patients filled in questionnaires concerning styles of coping, specifically the Utrecht Coping List, and social support, using the Social Support List.

RESULTS

Overall, styles of coping in the total sample are comparable to those of peers in the general population, except for lower active problem solving, which can be attributed to female patients. Males with congenital heart disease showed more favourable styles of coping compared to their peers, such as higher seeking of social support, lower passive reaction patterns, and lower expression of negative emotions. Compared to the reference group, the total cohort of patients reported to receive less social support, but also to experience less discrepancies between desired and received social support, indicating feelings of independence in these adults. Females with congenital heart disease were found to seek and receive more social support compared to their male counterparts.

CONCLUSION

Overall, few differences in styles of coping were found between the patients and their reference groups. Perceived social support in the sample of patients was favourable.

A European perspective on the management of hypoplastic left heart syndrome

Recently, the well-known American political commentator, Robert Kagan, reapplied an existing populist statement in describing Americans as being from Mars, and Europeans from Venus.1He said “they agree on little and understand one another less and less”. In general, it would be churlish to say that this applied to the medical fraternity, but it has great resonance with intercontinental differences in the management of hypoplastic left heart syndrome. In this review, I offer a personal view of those differences, potential explanations for them, and consider how the situation may change in coming years.

Quality of life experienced by adults with congenital heart disease

Adults with congenital heart disease (CHD) represent a growing population of patients. Medical and surgical advances have increased the number of CHD adult survivors, which may create quality-of-life (QOL) issues not previously considered. Quality-of-life issues pertinent to this patient population involve health and life insurance acquisition, birth control, genetic counseling, pregnancy concerns, employment, and independent living arrangements. The purpose of this study was to describe the QOL of adults with CHD. The study used a prospective cross-sectional case-control design to examine QOL using the Sickness Impact Profile (SIP). The study participants were a sample of 124 adults with CHD from an outpatient cardiology clinic in a metropolitan university-affiliated teaching hospital in the Northeast and 124 matched healthy control subjects. Between the participants and the matched control subjects, there was a significant difference in the total mean SIP score, the physical and psychosocial dimension scores, and all the category scores (P < 0.05). The areas of life the adults with CHD reported as lacking in quality involved the categories of work (SIP of 11.1, moderate disability) and sleep and rest (SIP of 9.03, mild disability). The results of this study indicate that the SIP can be used for quantitative and subjective QOL assessment of adults with CHD. It is suggested that cardiac advanced practice nurses use the results of this study to develop appropriate information, counseling, and anticipatory guidance for this patient population.

Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK

This report addresses the needs and problems of grown-up congenital heart (GUCH) patients and makes recommendations on organisation of national medical care, training of specialists, and education of the profession. The size of the national population of patients with grown-up congenital heart disease (GUCH) is uncertain, but since 80-85% of patients born with congenital heart disease now survive to adulthood (age 16 years), an annual increase of 2500 can be anticipated according to birth rate. Organisation of medical care is haphazard with only three of 18 cardiac surgical centres operating on over 30 cases per annum and only two established specialised units fully equipped and staffed. Not all grown-ups with congenital heart disease require the same level of expertise; 20-25% are complex, rare, etc, and require life long expert supervision and/or intervention; a further 35-40% require access to expert consultation. The rest, about 40%, have simple or cured diseases and need little or no specialist expertise. The size of the population needing expertise is small in comparison to coronary and hypertensive disease, aging, and increasing in complexity. It requires expert cardiac surgery and specialised medical cardiology, intensive care, electrophysiology, imaging and interventions, "at risk" pregnancy services, connection to transplant services familiar with their basic problem, clinical nurse specialist advisors, and trained nurses. An integrated national service is described with 4-6 specialist units established within adult cardiology, ideally in relation or proximity to university hospital/departments in appropriate geographic location, based in association with established paediatric cardiac surgical centres with designated inpatient and outpatient facilities for grown-up patients with congenital heart disease. Specialist units should accept responsibility for educating the profession, training the specialists, cooperative research, receiving patients "out of region", sharing particular skills between each other, and they must liaise with other services and trusts in the health service, particularly specified outpatient clinics in district and regional centres. Not every regional cardiac centre requires a full GUCH specialised service since there are too few patients. Complex patients need to be concentrated for expertise, experience, and optimal management. Transition of care from paediatric to adult supervision should be routine, around age 16 years, flexibly managed, smooth, and explained to patient and family. Each patient should be entered into a local database and a national registry needs to be established. The Department of Health should accept responsibility of dissemination of information on special needs of such patients. The GUCH Patients' Association is active in helping with lifestyle and social problems. Easy access to specialised care for those with complex heart disease is crucial if the nation accepts, as it should, continued medical responsibility to provide optimal medical care for GUCH patients.

Survivors of coarctation repair: fixed but not cured

While often considered to be cured, patients with repaired coarctation of the aorta frequently have premature morbidity and even mortality.