Excess mortality and hospitalizations in transitional-age youths with a long-term disease: A national population-based cohort study

[The transition preparation consultation: What for?]

The transition from pediatrics to adult services represents one of the many changes experienced by adolescents with chronic illnesses between childhood and adulthood. It needs to be structured and personalized to support the young person's development and empowerment, as well as the construction of his or her overall life project. With this in mind, AD'venir offers transition preparation consultations, the details and benefits of which are described in this article.

Factors associated with hospital admission and 30-day readmission for children less than 18 years of age in 2018 in France: a one-year nationwide observational study

BACKGROUND

Nationwide data for children for short-stay hospitalisation (SSH) and associated factors are scarce. This retrospective study of children in France < 18 years of age followed after their birth or birthday in 2018 focused on at least one annual SSH, stay < 1 night or ≥ 1 night, or 30-day readmission ≥ 1 night.

METHODS

Children were selected from the national health data system (SNDS), which includes data on long-term chronic disease (LTD) status with full reimbursement and complementary universal coverage based on low household income (CMUC). Uni and multivariate quasi-Poisson regression were applied for each outcome.

RESULTS

Among 13.211 million children (94.4% population, 51.2% boys), CMUC was identified for 17.5% and at least one LTD for 4% (0-<1 year: 1.5%; 14-<18 year: 5.2%). The most frequent LTDs were pervasive developmental diseases (0.53%), asthma (0.24%), epilepsy (0.17%), and type 1 diabetes (0.15%). At least one SSH was found for 8.8%: SSH < 1 night (4.9%), SSH ≥ 1 night (4.5%), readmission (0.4%). Children with at least one SSH were younger (median 6 vs. 9 years) and more often had CMUC (21%), a LTD (12%), an emergency department (ED) visit (56%), or various primary healthcare visits than all children. Those with a SSH ≥1 night vs. < 1 night were older (median: 9 vs. 4 years). They had the same frequency of LTD (13.4%) but more often an ED visit (78% vs. 42%). Children with readmissions were younger (median 3 years). They had the highest levels of CMUC (29.3%), LTD (34%), EDs in their municipality (35% vs. 29% for the whole population) and ED visits (87%). In adjusted analysis, each outcome was significantly less frequent among girls than boys and more frequent for children with CMUC. LTDs with the largest association with SSH < 1 night were cystic fibrosis, sickle cell diseases (SCD), diabetes type 1, those with SSH ≥1 night type 1 diabetes epilepsy and SCD, and those for readmissions lymphoid leukaemia, malignant neoplasm of the brain, and SCD. Among all SSH admissions of children < 10 years, 25.8% were potentially preventable.

CONCLUSION

Higher SSH and readmission rates were found for children with certain LTD living in low-income households, suggesting the need or increase of specific policy actions and research.

[Supporting the adolescents with chronic condition during transition: Role of the transition units]

The transition of care between pediatric and adult care is a key-period for adolescents with chronic disease, because of the high risk of follow-up loss and of short-term and long-term poorer health. To support transition, platforms of transition have been created in France since several years, implemented in pediatric or adult care structures. Their common objective is to provide a physical reception of adolescents and their parents to share about transition issues, and to inform them about resources to enhance the adolescent's global health. They tend to work closely with the referent health care providers and the patients' associations. A large heterogeneity of functioning and health care supply is still observed in these recent structures. Supporting these structures and reinforcing the partnerships between pediatric and adults care remain a challenge.

[Accompanying the pediatric/adult service transition in chronically ill patients]

The transition is a key step for adolescents with chronic illnesses, as they are at risk of a disruption in care, complications and even mortality. Accompanying this process is based on two axes: autonomization of the young person (acquisition of knowledge and know-how in a perspective of empowerment) and structuring of the care pathway (transition measures, pediatric/adult service coordination).

Congenital Hypothyroidism: A 2020-2021 Consensus Guidelines Update-An ENDO-European Reference Network Initiative Endorsed by the European Society for Pediatric Endocrinology and the European Society for Endocrinology

Background: An ENDO-European Reference Network (ERN) initiative was launched that was endorsed by the European Society for Pediatric Endocrinology and the European Society for Endocrinology with 22 participants from the ENDO-ERN and the two societies. The aim was to update the practice guidelines for the diagnosis and management of congenital hypothyroidism (CH). A systematic literature search was conducted to identify key articles on neonatal screening, diagnosis, and management of primary and central CH. The evidence-based guidelines were graded with the Grading of Recommendations, Assessment, Development and Evaluation system, describing both the strength of recommendations and the quality of evidence. In the absence of sufficient evidence, conclusions were based on expert opinion. Summary: The recommendations include the various neonatal screening approaches for CH as well as the etiology (also genetics), diagnostics, treatment, and prognosis of both primary and central CH. When CH is diagnosed, the expert panel recommends the immediate start of correctly dosed levothyroxine treatment and frequent follow-up including laboratory testing to keep thyroid hormone levels in their target ranges, timely assessment of the need to continue treatment, attention for neurodevelopment and neurosensory functions, and, if necessary, consulting other health professionals, and education of the child and family about CH. Harmonization of diagnostics, treatment, and follow-up will optimize patient outcomes. Lastly, all individuals with CH are entitled to a well-planned transition of care from pediatrics to adult medicine. Conclusions: This consensus guidelines update should be used to further optimize detection, diagnosis, treatment, and follow-up of children with all forms of CH in the light of the most recent evidence. It should be helpful in convincing health authorities of the benefits of neonatal screening for CH. Further epidemiological and experimental studies are needed to understand the increased incidence of this condition.

Transition of children with life-limiting conditions to adult care and healthcare use: a systematic review

BACKGROUND

Improved survival has led to increasing numbers of children with life-limiting conditions transitioning to adult healthcare services. There are concerns that transition may lead to a reduction in care quality and increases in emergency care. This review explores evidence for differences in health or social care use post- versus pre-transition to adult services.

METHODS

MEDLINE, EMBASE, CINAHL, PsychINFO and Social Science Citation Index were searched. Studies published in English since 1990 including individuals with any life-limiting condition post- and pre-transition and reporting a health or social care use outcome were included. Data were extracted and quality assessed by one reviewer with 30% checked by an independent reviewer.

RESULTS

Nineteen papers (18 studies) met the inclusion criteria. There was evidence for both increases and decreases (post- versus pre-transition) in outpatient attendance, inpatient admissions, inpatient bed days and health service costs; for increases in Emergency Department visits and for decreases in individuals receiving physiotherapy.

CONCLUSIONS

Evidence for changes in healthcare use post- versus pre-transition is mixed and conflicting, although there is evidence for an increase in Emergency Department visits and a reduction in access to physiotherapy. More high-quality research is needed to better link changes in care to the transition.

IMPACT

Evidence for changes in healthcare use associated with transition to adult services is conflicting. Emergency Department visits increase and access to physiotherapy decreases at transition. There are marked differences between care patterns in the United States and Canada.

Factors Affecting Loss to Follow-Up in Children and Adolescents with Chronic Endocrine Conditions

OBJECTIVE

Most children with endocrine diseases require long-term continuity of care. We investigated the prevalence of loss to follow-up (LTFU) in pediatric patients with chronic endocrine diseases and the risk factors associated with LTFU.

METHODS

This observational cohort study included all children with chronic endocrine diseases included in the database of a single academic pediatric care center over a period of 8 years. LTFU was defined as a lack of attendance at clinical visits for over 2 years, for unknown reasons.

RESULTS

LTFU was recorded for 154 of the 1,067 patients included (14%). Median age at diagnosis was 5.8 (0.3-11.8) vs. 1.2 (0.0-6.9) years, and age at last visit was 14.1 (9.7-16.1) vs. 11.7 (6.1-15.8) years, for the LTFU and no-LTFU groups, respectively. In multivariate analysis, the risk of LTFU increased with age at diagnosis (OR 1.18; 95% CI 1.12-1.24) and was higher for patients diagnosed before 2006 (vs. after 2006; OR 4.80; 95% CI 3.00-7.66), with fewer visits in the last 3 years (OR 0.72; 95% CI 0.65-0.80; p < 0.0001) and a lower health insurance classification (OR 1.79; 95% CI 1.10-2.89; p = 0.02). The risk of LTFU was higher for patients with isolated growth hormone deficiency than for those with other endocrine conditions, such as multiple pituitary deficiencies, hypogonadotropic hypogonadism, Turner syndrome, or thyroid, adrenal, or gonadal disorders (OR 5.24; 95% CI 1.13-24.37; p = 0.03).

CONCLUSION

This study provides the first epidemiological data for LTFU in children and adolescents with chronic endocrine diseases. It should facilitate the targeting of interventions to improve adherence to medical care and healthcare organization during the pediatric period.

COMPLEXITY OF PEDIATRIC CHRONIC DISEASE: CROSS-SECTIONAL STUDY WITH 16,237 PATIENTS FOLLOWED BY MULTIPLE MEDICAL SPECIALTIES

Objective:

To assess demographic data and characteristics of children and adolescents with pediatric chronic diseases (PCD), according to the number of specialties/patient.

Methods:

We performed a cross-sectional study with 16,237 PCD patients at outpatient clinics in one year. Data were analyzed by an electronic data system, according to the number of physician appointments for PCD. This study assessed: demographic data, follow-up characteristics, types of medical specialty, diagnosis (International Statistical Classification of Diseases and Related Health Problems - ICD-10), number of day hospital clinic visits, and acute complications.

Results:

Patients followed by ≥3 specialties simultaneously showed a significantly higher duration of follow-up compared to those followed by ≤2 specialties [2.1 (0.4-16.4) vs. 1.4 (0.1-16.2) years; p<0.001] and a higher number of appointments in all specialties. The most prevalent medical areas in patients followed by ≥3 specialties were: Psychiatry (Odds Ratio - OR=8.0; confidence interval of 95% - 95%CI 6-10.7; p<0.001), Palliative/Pain Care (OR=7.4; 95%CI 5.7-9.7; p<0.001), Infectious Disease (OR=7.0; 95%CI 6.4-7.8; p<0.001) and Nutrology (OR=6.9; 95%CI 5.6-8.4; p<0.001). Logistic regressions demonstrated that PCD patients followed by ≥3 specialties were associated with high risk for: number of appointments/patient (OR=9.2; 95%CI 8.0-10.5; p<0.001), day hospital clinic visits (OR=4.8; 95%CI 3.8-5.9; p<0.001), emergency department visits (OR=3.2; 95%CI 2.9-3.5; p<0.001), hospitalizations (OR=3.0; 95%CI 2.7-3.3; p<0.001), intensive care admissions (OR=2.5; 95%CI 2.1-3.0; p<0.001), and deaths (OR=2.8; 95%CI 1.9-4.0; p<0.001). The diagnosis of asthma, obesity, chronic pain, and transplant was significantly higher in patients followed by ≥3 specialties.

Conclusions:

The present study showed that PCD patients who required simultaneous care from multiple medical specialties had complex and severe diseases, with specific diagnoses.

[Bringing paediatrics into the home]

In-home hospital care provides a good vantage point from which to understand the evolution of paediatric care. It is in fact in line with the main ambitions of paediatrics today, by ensuring that children can remain with their parents in their familiar environment. The model may seem ideal. There are however constraints, such as the risk of confinement for the children and their parents and the difficulty, for the caregivers, of entering a private space which has not been designed for healthcare ergonomics.

Transitions in Rheumatic Disease: Pediatric to Adult Care

Although it has been widely acknowledged for more than two decades that transition from pediatric to adult care is a vulnerable time for adolescents and young adults with rheumatic diseases, current primary and subspecialty care transition and transfer processes remain inadequate. Barriers to improving transition include complex health care systems, neurodevelopmental challenges of adolescents and young adults, and insufficient transition-related education and resources for health care providers. Standardized, evidence-based transition interventions are sorely needed to establish best practices. Quality improvement approaches such as the Six Core Elements of Health Care Transition offer opportunities to improve transition care for teens and young adults.