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Gabel ME, Gaudio RE, Shaikhkhalil AK. Improving growth in infants with CF. Pediatr Pulmonol 2024; 59 Suppl 1:S17-S26. [PMID: 39105334 DOI: 10.1002/ppul.26871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/23/2023] [Accepted: 01/11/2024] [Indexed: 08/07/2024]
Abstract
Cystic fibrosis (CF) results in chronic pulmonary infections, inflammation, pancreatic insufficiency, and multiple gastrointestinal manifestations. Malnutrition and poor growth are hallmarks of CF, and strongly associated with poor outcomes. Through newborn screening, many infants can be diagnosed within a few days of life, which allows for early initiation of nutritional counseling and close clinical follow-up. Obstacles to growth for infants with CF start in utero, as newborns with CF can have a lower birth weight than the general population. Improving infant growth has been linked to improved clinical outcomes and survival. It remains a top priority and challenge for caregivers and healthcare teams. An interdisciplinary approach, including registered dietitian and social work support, is essential to optimize health for infants with CF. Remaining barriers to normalcy include deficits in linear growth, lack of accurate nutrition biomarkers, persistence of inequities related to social determinant of health, particularly in the global CF community.
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Affiliation(s)
- Megan E Gabel
- University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Golisano Children's Hospital, Rochester, New York, USA
| | - Rachel E Gaudio
- Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ala K Shaikhkhalil
- Department of Clinical Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
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2
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Jensen CB, Jensen KJ, Pressler T, Katzenstein TL, Skov M, Qvist T, Olsen MF, Jeppesen M, Jensen-Fangel S, Olesen HV, Reuter SB, Pedersen HKR, Wang JN, Michalopoulos S, McGarry L, Wöhling H, Petersen J, Jimenez-Solem E. Education, employment, and income among people living with cystic fibrosis across three decades - A matched cohort study using Danish health registries. J Cyst Fibros 2024; 23:836-841. [PMID: 38485602 DOI: 10.1016/j.jcf.2024.03.009] [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: 12/12/2023] [Revised: 02/16/2024] [Accepted: 03/09/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND Past and ongoing advancements in cystic fibrosis (CF) care warrant long-term analysis of the societal impact of the condition. This study aims to evaluate changes in key socioeconomic factors across three decades among people living with CF (pwCF), compared with both the general population and an early-onset chronic disease population. METHODS This nationwide, registry-based, matched cohort study included all pwCF ≥ 18 years in Denmark in the years 1990, 2000, 2010, and 2018. Each person living with CF was matched to five individuals in the general population and five individuals living with type 1 diabetes or juvenile arthritis based on age, sex, and municipality. RESULTS The Danish adult CF population increased nearly fourfold from 88 in 1990 to 331 in 2018, and mean age increased by ten years. The educational level of pwCF was similar to the two comparator cohorts, while pwCF were less often in employment and more often permanently outside the labor force. Personal and household income levels of the CF cohort were higher than those of the comparator cohorts. CONCLUSIONS The disadvantage in employment for pwCF remained, but, over time, the societal profiles of the one-year CF cohorts increasingly converged with those of the comparator cohorts, indicative of improved clinical management, extended life expectancy, and the supportive role of the Danish welfare system in reducing health inequalities. Further research should be done to evaluate the effects of the newly introduced modulator therapies on employment, considering the broader societal impact and impact on quality of life.
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Affiliation(s)
- Camilla Bjørn Jensen
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, University Hospital of Copenhagen - Bispebjerg and Frederiksberg, DK, Denmark.
| | - Kristoffer Jarlov Jensen
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, University Hospital of Copenhagen - Bispebjerg and Frederiksberg, DK, Denmark
| | - Tacjana Pressler
- Department of Infectious Diseases, University Hospital of Copenhagen - Rigshospitalet, Cystic Fibrosis Centre, DK, Denmark; Department of Pediatrics and Adolescent Medicine, University Hospital of Copenhagen - Rigshospitalet, Cystic Fibrosis Centre, DK, Denmark
| | - Terese L Katzenstein
- Department of Infectious Diseases, University Hospital of Copenhagen - Rigshospitalet, Cystic Fibrosis Centre, DK, Denmark
| | - Marianne Skov
- Department of Pediatrics and Adolescent Medicine, University Hospital of Copenhagen - Rigshospitalet, Cystic Fibrosis Centre, DK, Denmark
| | - Tavs Qvist
- Department of Infectious Diseases, University Hospital of Copenhagen - Rigshospitalet, Cystic Fibrosis Centre, DK, Denmark
| | - Mette Frahm Olsen
- Department of Infectious Diseases, University Hospital of Copenhagen - Rigshospitalet, Cystic Fibrosis Centre, DK, Denmark; Department of Nutrition, Exercise and Sports, University of Copenhagen, DK, Denmark
| | - Majbritt Jeppesen
- Department of Infectious Diseases, Aarhus University Hospital, DK, Denmark
| | | | - Hanne Vebert Olesen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, DK, Denmark
| | - Simon Bertram Reuter
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, DK, Denmark
| | - Hans Kristian Råket Pedersen
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, University Hospital of Copenhagen - Bispebjerg and Frederiksberg, DK, Denmark; Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, DK, Denmark
| | - Joanna Nan Wang
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, University Hospital of Copenhagen - Bispebjerg and Frederiksberg, DK, Denmark; Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, DK, Denmark
| | | | - Lisa McGarry
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Heike Wöhling
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Janne Petersen
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, University Hospital of Copenhagen - Bispebjerg and Frederiksberg, DK, Denmark; Section of Biostatistics, Department of Public Health, University of Copenhagen, DK, Denmark
| | - Espen Jimenez-Solem
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, University Hospital of Copenhagen - Bispebjerg and Frederiksberg, DK, Denmark; Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, DK, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, DK, Denmark
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3
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Mall MA, Burgel PR, Castellani C, Davies JC, Salathe M, Taylor-Cousar JL. Cystic fibrosis. Nat Rev Dis Primers 2024; 10:53. [PMID: 39117676 DOI: 10.1038/s41572-024-00538-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2024] [Indexed: 08/10/2024]
Abstract
Cystic fibrosis is a rare genetic disease caused by mutations in CFTR, the gene encoding cystic fibrosis transmembrane conductance regulator (CFTR). The discovery of CFTR in 1989 has enabled the unravelling of disease mechanisms and, more recently, the development of CFTR-directed therapeutics that target the underlying molecular defect. The CFTR protein functions as an ion channel that is crucial for correct ion and fluid transport across epithelial cells lining the airways and other organs. Consequently, CFTR dysfunction causes a complex multi-organ disease but, to date, most of the morbidity and mortality in people with cystic fibrosis is due to muco-obstructive lung disease. Cystic fibrosis care has long been limited to treating symptoms using nutritional support, airway clearance techniques and antibiotics to suppress airway infection. The widespread implementation of newborn screening for cystic fibrosis and the introduction of a highly effective triple combination CFTR modulator therapy that has unprecedented clinical benefits in up to 90% of genetically eligible people with cystic fibrosis has fundamentally changed the therapeutic landscape and improved prognosis. However, people with cystic fibrosis who are not eligible based on their CFTR genotype or who live in countries where they do not have access to this breakthrough therapy remain with a high unmet medical need.
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Affiliation(s)
- Marcus A Mall
- Department of Paediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany.
- German Centre for Lung Research (DZL), Associated Partner Site Berlin, Berlin, Germany.
- German Center for Child and Adolescent Health (DZKJ), Partner Site Berlin, Berlin, Germany.
| | - Pierre-Régis Burgel
- Université Paris Cité and Institut Cochin, Inserm U1016, Paris, France
- Department of Respiratory Medicine and National Reference Center for Cystic Fibrosis, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, Genoa, Italy
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, London, UK
- St Thomas' NHS Trust, London, UK
- Royal Brompton Hospital, Part of Guy's & St Thomas' Trust, London, UK
| | - Matthias Salathe
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Jennifer L Taylor-Cousar
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
- Division of Paediatric Pulmonary Medicine, National Jewish Health, Denver, CO, USA
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4
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Avery M, Wolfe J, DeCourcey DD. Economic Hardship at the End of Life for Families of Children With Complex Chronic Conditions. J Pain Symptom Manage 2024; 67:e313-e319. [PMID: 38151216 DOI: 10.1016/j.jpainsymman.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/14/2023] [Accepted: 12/16/2023] [Indexed: 12/29/2023]
Abstract
CONTEXT Many children with complex chronic medical conditions (CCC), though living longer, die prematurely. Little is known about family economic hardship during end of life (EOL), nor associated differences in patterns of care. OBJECTIVES To describe the prevalence, experience, and characteristics of families of patients with CCC who report great economic hardship (GEH), and associations with end-of-life care patterns and suffering. METHODS We conducted a 183-item cross-sectional survey of bereaved parents of patients cared for at Boston Children's Hospital and chart reviews for each patient. Fifteen survey items on economic hardship related to financial and material hardships including food, housing, and utility insecurity. RESULTS A total of 114 bereaved parents completed the survey (54% response rate) and economic hardship data was analyzed for 105. Nearly a fifth reported GEH. This group was characterized by fewer two parent households. Children from families with GEH had spent more time hospitalized than those without GEH. CONCLUSION Economic burden on families of children with CCC correlates with higher health care utilization demonstrating the need for ameliorative resources and preventative measures.
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Affiliation(s)
- Madeline Avery
- Pediatric Palliative Care (M.V., J.W.), Department of Pediatrics, Massachusetts General Hospital, Boston Massachusetts, USA.
| | - Joanne Wolfe
- Pediatric Palliative Care (M.V., J.W.), Department of Pediatrics, Massachusetts General Hospital, Boston Massachusetts, USA
| | - Danielle D DeCourcey
- Division of Medical Critical Care (D.D.D.), Department of Pediatrics, Boston Children's Hospital, Boston Massachusetts, USA
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5
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McKone EF. Socioeconomic disparities in European cystic fibrosis outcomes: time to close the gap. Eur Respir J 2024; 63:2400328. [PMID: 38453247 DOI: 10.1183/13993003.00328-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Edward F McKone
- St. Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
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Kerem E, Orenti A, Adamoli A, Hatziagorou E, Naehrlich L, Sermet-Gaudelus I. Cystic fibrosis in Europe: improved lung function and longevity - reasons for cautious optimism, but challenges remain. Eur Respir J 2024; 63:2301241. [PMID: 38302155 PMCID: PMC10918317 DOI: 10.1183/13993003.01241-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Prognosis and disease severity in cystic fibrosis (CF) are linked to declining lung function. To characterise lung function by the number of adults in countries with different levels of Gross National Income (GNI), data from the European Cystic Fibrosis Society Patient Registry were utilised. METHODS Annual data including age, forced expiratory volume in 1 s (FEV1), anthropometry, genotype, respiratory cultures and CF-related diabetes (CFRD) were retrieved between 2011 and 2021. All countries were stratified into GNI per capita to reflect differences within Europe. RESULTS A consistent improvement in FEV1 % pred and survival was observed among the 47 621 people with CF (pwCF), including subjects with chronic Pseudomonas aeruginosa infection, CFRD and/or undernutrition. Mean values of FEV1 % pred changed from 85% to 94.2% for children and from 63.6% to 74.7% for adults. FEV1 % pred further increased among those carrying the F508del mutation in 2021, when elexacaftor/tezacaftor/ivacaftor was available. The number of adult pwCF increased from 13 312 in 2011 to 21 168 in 2021, showing a 60% increase. PwCF living in European lower income countries did not demonstrate a significant annual increase in FEV1 % pred or in the number of adults. CONCLUSION This pan-European analysis demonstrates a consistent improvement in FEV1 % pred, number of adult pwCF and survival over the last decade only in European higher and middle income countries. Urgent action is needed in the lower income countries where such improvement was not observed. The notable improvement observed in pwCF carrying the F508del mutation emphasises the need to develop treatments for all CF mutations.
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Affiliation(s)
- Eitan Kerem
- Department of Paediatrics and CF Centre, Hebrew University Medical School, Hadassah Medical Center, Jerusalem, Israel
| | - Annalisa Orenti
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Biometry and Epidemiology "G.A. Maccaccaro", University of Milan, Milan, Italy
| | - Arianna Adamoli
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Biometry and Epidemiology "G.A. Maccaccaro", University of Milan, Milan, Italy
| | - Elpis Hatziagorou
- Paediatric Pulmonology and Cystic Fibrosis Unit, 3rd Paediatric Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- These authors contributed equally to the manuscript
| | - Lutz Naehrlich
- Department of Pediatrics, Justus Liebig University Giessen, Giessen, Germany
- These authors contributed equally to the manuscript
| | - Isabelle Sermet-Gaudelus
- Cystic Fibrosis National Pediatric Reference Center, Pneumo-Allergologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Paris, France
- INSERM, CNRS, Institut Necker Enfants Malades, Paris, France
- Université Paris-Cité, Paris, France
- These authors contributed equally to the manuscript
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7
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Hummel K, Ludomirsky A, Burgunder L, Lu M, Goldberg S, Sleeper L, Reichman J, Blume ED. The family burden of paediatric heart disease during the chronic phase of illness. Cardiol Young 2023:1-7. [PMID: 38014533 DOI: 10.1017/s1047951123003906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND CHD is a lifelong condition with a significant burden of disease to patients and families. With increased survival, attention has shifted to longer-term outcomes, with a focus on social determinants of health. Among children with CHD, socioeconomic status is associated with disparities in outcomes. Household material hardship is a concrete measure of poverty and may serve as an intervenable measure of socioeconomic status. METHODS A longitudinal survey study was conducted at multiple time points (at acute hospitalisation, then 12-24 months later in the chronic phase) to determine the prevalence of household material hardship among parents of children with advanced heart disease and quality of life during long-term follow-up. RESULTS The analytic cohort was 160 children with a median patient age of 1 year (IQR 1,4) with 54% of patients <2 years. During acute hospitalisation, over one-third of families reported household material hardship (37%), with significantly lower household material hardship in the chronic phase at 16% (N = 9 of 52). For parents reporting household material hardship during acute hospitalisation, 50% had resolution of household material hardship by the chronic phase. Household material hardship-exposed children were significantly more likely to be publicly insured (56% versus 20%, p = 0.03) with lower quality of life than those without household material hardship (64% versus 82%, p = 0.013). CONCLUSION The burden of heart disease during the chronic phase of illness is high. Household material hardship may serve as a target to ensure equity in the care and outcomes of CHD patients and their families.
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Affiliation(s)
- Kevin Hummel
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Intermountain Health Primary Children's Hospital, Salt Lake City, UT, USA
| | - Avital Ludomirsky
- Department of Cardiology, Childrens Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lauren Burgunder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Intermountain Health Primary Children's Hospital, Salt Lake City, UT, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Sarah Goldberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Lynn Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jeffrey Reichman
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
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8
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Peng G, Taylor-Cousar JL, Lee M, Keller A, West NE, Kazmerski TM, Goralski JL, Aitken ML, Roe AH, Hadjiliadis D, Uluer A, Flume PA, Mody S, Bray LA, Jain R. Association between unplanned pregnancies and maternal exacerbations in cystic fibrosis. J Cyst Fibros 2023; 22:796-803. [PMID: 37029015 DOI: 10.1016/j.jcf.2023.03.020] [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: 10/24/2022] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION Following availability of the highly effective cystic fibrosis (CF) transmembrane conductance regulator modulator, elexacaftor/tezacaftor/ivacaftor, there was a near doubling of pregnancies reported in the United States (US) in people with CF. We sought to determine health impacts of planned (PP) versus unplanned pregnancies (UP). METHODS We collected retrospective pregnancy data from January 2010-December 2020 from 11 US CF centers. After adjusting for potential confounding effects, we conducted multivariable, multilevel longitudinal regression analysis using mixed effect modeling to assess whether changes in percent predicted forced expiratory volume in one second (ppFEV1), body mass index (BMI), and pulmonary exacerbations (PEx) 1-year-pre- to 1-year-post-pregnancy were associated with pregnancy planning. RESULTS Our analysis included 163 people with 226 pregnancies; the cohort had a mean age at conception of 29.6 years, mean pre-pregnancy ppFEV1 of 75.4 and BMI of 22.5 kg/m2. PpFEV1 declined in both PP (adjusted decline of -2.5 (95% CI: -3.8, -1.2)) and UP (adjusted decline of -3.0 (95% CI: -4.6, -1.4)) groups, they did not differ from each other (p = 0.625). We observed a difference in change in the annual number of PEx pre- to post-pregnancy (PP: 0.8 (0.7, 1.1); UP: 1.3 (1.0, 1.7); interaction effect p = 0.029). In a subset of people with available infant data, infants resulting from UP had more preterm births, lower APGAR scores, and more intensive care unit stays. CONCLUSIONS Following UP, there is an increased trajectory for PEx and potentially for infant complications compared to PP. Clinicians should consider increased surveillance in the setting of UP.
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Affiliation(s)
- Giselle Peng
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | | | - MinJae Lee
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | - Ashley Keller
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | | | | | | | | | - Andrea H Roe
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Denis Hadjiliadis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Ahmet Uluer
- Harvard/Boston Children's Hospital and Brigham & Women's Hospital, Boston, MA, United States
| | - Patrick A Flume
- Medical University of South Carolina, Charleston, SC, United States
| | - Sheila Mody
- University of California San Diego, San Diego, CA, United States
| | - Leigh Ann Bray
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Raksha Jain
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States.
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Oates GR, Schechter MS. Aiming to Improve Equity in Pulmonary Health: Cystic Fibrosis. Clin Chest Med 2023; 44:555-573. [PMID: 37517835 PMCID: PMC10458995 DOI: 10.1016/j.ccm.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
This review summarizes the evidence of health disparities in cystic fibrosis (CF), an autosomal recessive genetic disorder with substantial variation in disease progression and outcomes. We review disparities by race, ethnicity, socioeconomic status, geographic location, gender identity, or sexual orientation documented in the literature. We outline the mechanisms that generate and perpetuate such disparities across levels and domains of influence and assess the implications of this evidence. We then recommend strategies for improving equity in CF outcomes, drawing on recommendations for the general population and considering approaches specific to people living with CF.
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Affiliation(s)
- Gabriela R Oates
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Michael S Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University and Children's Hospital of Richmond at VCU, Richmond, VA, USA
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Ziedas AC, Castle JP, Abed V, Swantek AJ, Rahman TM, Chaides S, Makhni EC. Race and Socioeconomic Status Are Associated With Inferior Patient-Reported Outcome Measures Following Rotator Cuff Repair. Arthroscopy 2023; 39:234-242. [PMID: 36208711 DOI: 10.1016/j.arthro.2022.08.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To investigate the impact social determinants of health (SDOH) have on National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test scores and postoperative health care use in patients who undergo rotator cuff repair (RCR). METHODS All patients who underwent RCR surgery by 3 shoulder and/or sports medicine fellowship-trained orthopaedic surgeons between July 2017 and January 2020 were included. The electronic medical record (EMR) was used to identify SDOH for each patient. PROMIS computer adaptive test measures of Upper Extremity function, Pain Interference, and Depression were completed preoperatively and postoperatively (6 months and 1 year). Postoperative health care use (clinical visits, virtual encounters, imaging encounters, and physical therapy visits) were recorded as well. Univariate associations, multiple linear regressions, and Wilcoxon rank-sum tests were used to analyze mean differences between patient groups based on SDOH. RESULTS Three hundred thirty-eight patients who underwent RCR were included. Patients who were Black, in lower median household income quartiles, had public insurance, and female reported lower PROMIS scores compared with their counterparts. Smokers and White patients attended fewer postoperative office visits whereas Black patients had more physical therapy and nonvisit encounters compared with their respective counterparts. CONCLUSIONS Black race and lower socioeconomic status are associated with worse function and pain outcomes post-RCR compared with White race. Similarly, Black race and positive smoking status are associated with differential use of health care following RCR. Further attention may be required for these patients to address health care disparities. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Alexander C Ziedas
- From the Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Joshua P Castle
- From the Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Varag Abed
- From the Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Alexander J Swantek
- From the Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Tahsin M Rahman
- From the Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Sarah Chaides
- From the Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Eric C Makhni
- From the Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A..
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11
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Ziedas A, Castle JP, Abed V, Swantek A, Chaides S, Elhage K, Fife J, Moutzouros V, Makhni EC. Associating Social Determinants of Health With PROMIS CAT Scores and Health Care Utilization After ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671221139350. [PMID: 36683912 PMCID: PMC9850131 DOI: 10.1177/23259671221139350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 01/18/2023] Open
Abstract
Background The term "social determinants of health" (SDOH) refers to social and economic factors that influence a patient's health status. The effect of SDOH on the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test (CAT) scores and postoperative resource utilization in patients with anterior cruciate ligament reconstruction (ACLR) have yet to be thoroughly studied. Purpose To investigate the impact SDOH have on PROMIS CAT outcomes and postoperative resource utilization in patients with ACLR. Study Design Cohort study; Level of evidence, 3. Methods The electronic medical record was used to identify the SDOH for patients who underwent ACLR by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons between July 2017 and April 2020. PROMIS CAT measures of Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), and Depression (PROMIS-D) were completed at the preoperative, 6-month postoperative, and 12-month postoperative time points. Postoperative health care utilization was recorded as well. Independent 2-group t tests and Wilcoxon rank-sum tests were used to analyze mean differences between patient groups based on SDOH. Results Two-hundred and thirty patients who underwent ACLR were included (mean age, 27 years; 59% male). Compared with White patients, Black patients were represented more frequently in the lowest median household income (MHI) quartile (63% vs 23%, respectively; P < .001). White patients were represented more frequently in the highest area deprivation index (ADI) quartile when compared with Black patients (67% vs 12%, respectively; P = .006). Significantly worse PROMIS-PF, PROMIS-PI, and PROMIS-D scores at all 3 time points were found among patients who were Black, female, smokers, and in the lower MHI quartiles, with higher ADI and public health care coverage. In terms of resource utilization, Black patients attended significantly fewer postoperative physical therapy visits when compared with their respective counterparts. Those in the lower MHI quartiles attended significantly fewer postoperative imaging encounters, and female patients attended significantly more postoperative virtual encounters than male patients. Conclusion Specific SDOH variables, particularly those that reflect racial and socioeconomic disparities, were associated with differences in postoperative health care utilization and ACLR outcomes as measured by PROMIS CAT domains.
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Affiliation(s)
| | | | - Varag Abed
- Henry Ford Health System, Detroit, Michigan, USA
| | | | | | | | | | | | - Eric C. Makhni
- Henry Ford Health System, Detroit, Michigan, USA.,Eric C. Makhni, MD, MBA, Henry Ford Health System, 2799 W Grand
Boulevard, Detroit, MI 48202, USA (
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12
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McColley SA, Martiniano SL, Ren CL, Sontag MK, Rychlik K, Balmert L, Elbert A, Wu R, Farrell PM. Disparities in first evaluation of infants with cystic fibrosis since implementation of newborn screening. J Cyst Fibros 2023; 22:89-97. [PMID: 35871976 DOI: 10.1016/j.jcf.2022.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/04/2022] [Accepted: 07/13/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE We evaluated whether implementation of cystic fibrosis (CF) newborn screening (NBS) leads to equitable timeliness of initial evaluation. We compared age at first event (AFE, age at sweat test, encounter and/or care episode) between infants categorized as Black/African American, American Indian/ Native Alaskan, Asian, and/or Hispanic and/or other (Group 1) to White and not Hispanic infants (Group 2). METHODS This retrospective cohort study from the Cystic Fibrosis Foundation Patient Registry (CFFPR) included infants born 2010-2018. Race and ethnicity categories followed US Census definitions. The primary outcome was AFE; the secondary outcome was weight for age (WFA) z-score averaged 12 to < 24 months. We compared distributions by Wilcoxon rank-sum test and proportions by Chi-square or Fisher's exact tests. A nested cohort study used a linear mixed effects model of variables that affect WFA, chosen a priori, to evaluate associations with 1-year WFA z-score. RESULTS Among 6354 infants, 21% were in Group 1. Group 1 median AFE was 31 days (IQR 19, 49) and Group 2 was 22 days (IQR 14,36) (p< .001). Median WFA z-score at 1-2 years was lower in Group 1. In 3017 infants with complete data on variables of interest, AFE, Black race, CFTR variant class I-III, prematurity and public insurance were associated with lower 1-year WFA z-score. CONCLUSIONS Differences in AFE for infants with CF from historically marginalized groups may exacerbate long standing health disparities. We speculate that inequitable identification of CFTR gene variants and/or bias may influence timeliness of evaluation after an out-of-range NBS.
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Affiliation(s)
- Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States.
| | - Stacey L Martiniano
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Children's Hospital Colorado, Aurora, CO, United States
| | - Clement L Ren
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Marci K Sontag
- Center for Public Health Innovation, CI International, Littleton, CO, United States
| | - Karen Rychlik
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States
| | - Lauren Balmert
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | | | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, MD, United States
| | - Philip M Farrell
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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13
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Jennings D, List R, Bruschwein H, Compton M, Somerville L, Williamson L, Murray R, Evangelista B, Albon D. Social determinants of health screening and intervention: A cystic fibrosis quality improvement process. Pediatr Pulmonol 2022; 57:3035-3043. [PMID: 36039394 PMCID: PMC9826285 DOI: 10.1002/ppul.26131] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/09/2022] [Accepted: 08/23/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Lower socioeconomic status is associated with significantly poorer outcomes in weight, lung function, and pulmonary exacerbation rates in people with cystic fibrosis (PwCF). GLOBAL AIM We aim to reduce health disparities and inequities faced by PwCF by screening for and addressing unmet social needs. SPECIFIC AIMS We aimed to increase routine social determinants of health (SDoH) screening of eligible PwCF from 0% to 95% and follow-up within 2 weeks for those PwCF who screened positive and requested assistance from 0% to 95% by December 31, 2021. METHODS The Model for Improvement methodology was used. A process map and a simplified failure mode effects analysis chart were created for the screening and SDoH follow-up process. For those who screened positive for SDoH and requested assistance, follow-up contact was made to offer intervention. INTERVENTION Adult PwCF who had at least one UVA Clinic encounter in 2021 were screened for SDoH. The SDoH screening tool included eight domains: housing, food, transportation, utilities, health-care access, medication access, income/employment, and education. Follow-up was completed with all PwCF who screened positive for SDoH. RESULTS A total of 132 of 142 (93.0%) PwCF eligible for screening completed the SDoH screening. Of the PwCF who completed screening, 56 (42.4%) screened positive for SDoH. A follow-up rate of 100% was achieved in June 2021 and maintained through December 2021. CONCLUSION Implementing screening for SDOH and follow-up to mitigate social difficulties in adult PwCF at UVA was successful and could be reproduced at other CF care centers.
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Affiliation(s)
- Deirdre Jennings
- Department of Social Work, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Rhonda List
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Heather Bruschwein
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Martina Compton
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Lindsay Somerville
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Lauren Williamson
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Rachel Murray
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Brielle Evangelista
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dana Albon
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, Virginia, USA
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14
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Oates GR, Schechter MS. Socioeconomic determinants of respiratory health in patients with cystic fibrosis: implications for treatment strategies. Expert Rev Respir Med 2022; 16:637-650. [PMID: 35705523 DOI: 10.1080/17476348.2022.2090928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Great variation exists in the progression and outcomes of cystic fibrosis (CF) lung disease, due to both genetic and environmental influences. Social determinants mediate environmental exposures and treatment success; people with CF from socioeconomically disadvantaged backgrounds have worse health and die younger than those in more advantaged positions. AREAS COVERED This paper reviews the literature on the mechanisms that are responsible for generating and sustaining disparities in CF health, and the ways by which social determinants translate into health advantages or disadvantages in people with CF. The authors make recommendations for addressing social risk factors in CF clinical practice. EXPERT OPINION Socioeconomic factors are not dichotomous and their impact is felt at every step of the social ladder. CF care programs need to adopt a systematic protocol to screen for health-related social risk factors, and then connect patients to available resources to meet individual needs. Considerations such as daycare, schooling options, living and working conditions, and opportunities for physical exercise and recreation as well as promotion of self-efficacy are often overlooked. In addition, advocacy for changes in public policies on health insurance, environmental regulations, social welfare, and education would all help address the root causes of CF health inequities.
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Affiliation(s)
- Gabriela R Oates
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael S Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University and Children's Hospital of Richmond at VCU, USA
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15
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McGarry ME, Gibb ER, Oates GR, Schechter MS. Left behind: The potential impact of CFTR modulators on racial and ethnic disparities in cystic fibrosis. Paediatr Respir Rev 2022; 42:35-42. [PMID: 35277357 PMCID: PMC9356388 DOI: 10.1016/j.prrv.2021.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/16/2021] [Indexed: 12/16/2022]
Abstract
The advent of CFTR modulators, a genomic specific medication, revolutionized the treatment of CF for many patients. However, given that these therapeutics were only developed for specific CFTR mutations, not all people with CF have access to such disease-modifying drugs. Racial and ethnic minority groups are less likely to have CFTR mutations that are approved for CFTR modulators. This exclusion has the potential to widen existing health disparities.
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Affiliation(s)
- Meghan E. McGarry
- Division of Pulmonary Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Elizabeth R. Gibb
- Division of Pulmonary Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Gabriela R. Oates
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Michael S. Schechter
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Virginia Commonwealth University and Children’s Hospital of Richmond at VCU, Richmond, VA
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16
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McBennett KA, Davis PB, Konstan MW. Increasing life expectancy in cystic fibrosis: Advances and challenges. Pediatr Pulmonol 2022; 57 Suppl 1:S5-S12. [PMID: 34672432 PMCID: PMC9004282 DOI: 10.1002/ppul.25733] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 01/14/2023]
Abstract
Since the first description of cystic fibrosis in 1938, there have been significant advances in both quality of life and longevity for people living with this disease. In this article we describe the milestones of the last 80 years and what we perceive to be the remaining barriers to normalcy for this population.
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Affiliation(s)
- Kimberly A McBennett
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Pamela B Davis
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael W Konstan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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17
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Telehealth use in cystic fibrosis during COVID-19: Association with race, ethnicity, and socioeconomic factors. J Cyst Fibros 2021; 20 Suppl 3:49-54. [PMID: 34930543 PMCID: PMC8683127 DOI: 10.1016/j.jcf.2021.09.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/31/2021] [Accepted: 09/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Due to the COVID-19 pandemic, there was an uptake of telehealth in cystic fibrosis care. Previous studies show disparities in telehealth use based on socioeconomic status (SES). We aimed to: (1) understand telehealth use and perceptions and (2) identify the facilitators and barriers to telehealth use among people with CF and their families (PwCF) from diverse racial/ethnic and socioeconomic backgrounds. METHODS We conducted an analysis of the 2020 Cystic Fibrosis State of Care surveys completed by PwCF (PFSoC), CF Care Programs (SoC1) and the CF Foundation Patient Registry (CFFPR). RESULTS A total of 424 PwCF and 286 programs responded to the PFSoC and SoC1. Among PwCF, 90% self-identified as White, 6% as Hispanic/Latino, and 2% as Black. Racial/ethnic minorities were less likely to have had a telehealth visit (p=.015). This difference was pronounced among the Hispanic/Latino population (p<.01). Telehealth use did not differ by health insurance and was similarly offered independent of financial status. Compared to PwCF who denied financial constraints, those who reported financial difficulties found telehealth more difficult to use (p=.018) and were less likely to think that their concerns (p=.010) or issues that mattered most to them (p=.020) were addressed during telehealth. Programs perceived lack of technology, language barriers, and home conditions as barriers to telehealth in vulnerable populations. CONCLUSION PFSoC and SoC1 identified differences in telehealth use and care perceptions by ethnicity, race, and socioeconomic characteristics. Further studies are needed to understand how telehealth can change access to CF care in diverse subpopulations.
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18
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Martiniano SL, Elbert AA, Farrell PM, Ren CL, Sontag MK, Wu R, McColley SA. Outcomes of infants born during the first 9 years of CF newborn screening in the United States: A retrospective Cystic Fibrosis Foundation Patient Registry cohort study. Pediatr Pulmonol 2021; 56:3758-3767. [PMID: 34469079 DOI: 10.1002/ppul.25658] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/05/2021] [Accepted: 08/08/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Newborn screening (NBS) for cystic fibrosis (CF) was implemented in all US states and DC by 2010. This hypothesis-generating study was designed to form the basis of additional analyses and to plan quality improvement initiatives. The aims were to describe the outcomes of infants with CF born during the first 9 years of universal NBS. METHODS We included participants in the CF Foundation Patient Registry born 2010-2018 with age of recorded CF diagnosis 0-365 days old. We compared the age of center-reported diagnosis, age at first CF event (defined as earliest sweat test, clinic visit, or hospitalization), demographics, and outcomes between three cohorts born between 2010-2012, 2013-2015, and 2016-2018. RESULTS In 6354 infants, the median age at first CF event decreased from the first to the third cohort. Weight-for-age (WFA) was < 10th percentile in about 40% of infants at the first CF Center visit. Median WFA z-score at 1-2 years was more than 0 but height-for-age (HFA) z-score was less than 0 through age 5-6 years. The second cohort had a higher HFA z-score than the first cohort at age 5-6 years. Pseudomonas aeruginosa infection was less common in later cohorts. About 1/3 of infants were hospitalized in the first year of life with no changes over time. CONCLUSION Over 9 years of CF NBS, median age at first CF event decreased. CF NBS had positive health impacts, but early life nutritional deficits and a high rate of infant hospitalizations persist.
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Affiliation(s)
- Stacey L Martiniano
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.,Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Clement L Ren
- Division of Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Marci K Sontag
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.,Center for Public Health Innovation at CI International, USA
| | | | - Susanna A McColley
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Pulmonary and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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19
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Taufique ZM, Escher PJ, Gathman TJ, Nickel AJ, Lee DB, Roby BB, Chinnadurai S. Demographic Risk Factors for Malnutrition in Patients With Cleft Lip and Palate. Laryngoscope 2021; 132:1482-1486. [PMID: 34665463 DOI: 10.1002/lary.29899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/21/2021] [Accepted: 10/05/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Patients with cleft lip and/or palate (CLP) are at increased risk of malnutrition. Acute and chronic malnutrition have been associated with elevated risk of postsurgical wound complications, adding morbidity and cost to patients and their families. To study the association between demographic factors, including insurance type, race, and median neighborhood income (MNI), and malnutrition in patients with CLP. STUDY DESIGN Retrospective cohort study. METHODS Retrospective review was performed in patients undergoing their first cleft-related surgery at a large tertiary pediatric hospital from 2006 to 2018. Demographic data, weight and height at surgery, type of insurance, race, and primary residential address were collected. Geocoded information on MNI was generated using patient address. World Health Organization Z-scores for weight-for-age (WFA) and height-for-age (HFA) were used as proxies for acute and chronic malnutrition, respectively. Linear regression models were generated to analyze the relationship of insurance type, race, and MNI on WFA and HFA Z-scores. RESULTS About 313 patients met inclusion criteria. Increasing MNI predicted increasing WFA Z-score (0.05 increase in WFA per $1,000 increase, P = .047) as well as HFA Z-score (0.09 increase in HFA per $1,000 increase, P = .011). The effect of MNI was not independently modified by race for either WFA (P = .841) nor HFA (P = .404). Race and insurance type did not predict WFA or HFA. CONCLUSIONS Lower MNI is a significant independent risk factor for acute and chronic malnutrition in children with CLP. Combined with previous investigation linking malnutrition to surgical outcomes in this population, this offers a target area for intervention to improve patient outcomes. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Zahrah M Taufique
- ENT and Facial Plastic Surgery, Children's Minnesota, Minneapolis, Minnesota, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Paul J Escher
- University of Minnesota School of Medicine, Minneapolis, Minnesota, U.S.A
| | - Tyler J Gathman
- University of Minnesota School of Medicine, Minneapolis, Minnesota, U.S.A
| | - Amanda J Nickel
- Children's Research Institute, Children's Minnesota, Minneapolis, Minnesota, U.S.A
| | - Daniel B Lee
- Amherst H. Wilder Foundation, Saint Paul, Minnesota, U.S.A
| | - Brianne B Roby
- ENT and Facial Plastic Surgery, Children's Minnesota, Minneapolis, Minnesota, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Sivakumar Chinnadurai
- ENT and Facial Plastic Surgery, Children's Minnesota, Minneapolis, Minnesota, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
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20
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Albon D, Bruschwein H, Soper M, List R, Jennings D, Gettle L, Compton M, Bailey M, Starheim E, Murray R, Kalmanek J, Somerville L. Impact of COVID-19 on social determinants of health for adults with cystic fibrosis. Ther Adv Respir Dis 2021; 15:17534666211037459. [PMID: 34420457 PMCID: PMC8381410 DOI: 10.1177/17534666211037459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction: Outcomes in cystic fibrosis are influenced by multiple factors, including
social determinants of health. Low socioeconomic status has been shown to be
associated with lung function decline, increased exacerbation rates,
increased health care utilization, and decreased survival in cystic
fibrosis. The COVID-19 pandemic disrupted the US economy, placing people
with cystic fibrosis at risk for negative impacts due to changes in social
determinants of health. Methods: To characterize the impact of COVID-19-related changes in social determinants
of health in the adult cystic fibrosis population, a social determinants of
health questionnaire was designed and distributed to patients as part of a
quality improvement project. Results: Of 132 patients contacted, 76 (57.6%) responses were received. Of these
responses, 22 (28.9%) answered yes to at least one question that indicated
an undesired change in social determinants of health. Patients with stable
employment prior to COVID-19 were more likely to endorse undesired change in
all domains of the questionnaire, and the undesired changes were most likely
to be related to employment, insurance security, and access to medications.
Patients receiving disability were more likely to report hardship related to
utilities and food security compared with patients previously employed or
unemployed. Of patients endorsing risk of socioeconomic hardship, 21 (95.5%)
were contacted by a social worker and provided resources. Conclusion: Utilizing a social determinants of health questionnaire to screen for social
instability in the context of COVID-19 is feasible and beneficial for
patients with cystic fibrosis. Identifying social issues early during the
pandemic and implementing processes to provide resources may help patients
with cystic fibrosis mitigate social hardship and maintain access to health
care and medications.
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Affiliation(s)
- Dana Albon
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, VA, USA
| | - Heather Bruschwein
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia Health System, PO Box 800223, Charlottesville, VA 22908, USA
| | - Morgan Soper
- Department of Social Work, University of Virginia Health System, Charlottesville, VA, USA
| | - Rhonda List
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, VA, USA
| | - Deirdre Jennings
- Department of Social Work, University of Virginia Health System, Charlottesville, VA, USA
| | - Lucy Gettle
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, VA, USA
| | - Martina Compton
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, VA, USA
| | - Molly Bailey
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, VA, USA
| | - Elissa Starheim
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, VA, USA
| | - Rachel Murray
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, VA, USA
| | - John Kalmanek
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Lindsay Somerville
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Virginia Health System, Charlottesville, VA, USA
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21
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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: 12] [Impact Index Per Article: 4.0] [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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22
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DiMango E, Simpson K, Menten E, Keating C, Fan W, Leu CS. Health Disparities among adults cared for at an urban cystic fibrosis program. Orphanet J Rare Dis 2021; 16:332. [PMID: 34332588 PMCID: PMC8325847 DOI: 10.1186/s13023-021-01965-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence is conflicting regarding differential health outcomes in racial and ethnic minorities with cystic fibrosis (CF), a rare genetic disease affecting approximately 28,000 Americans. We performed a cross-sectional analysis of health outcomes in Black/Latinx patients compared with non-Hispanic Caucasian patients cared for in a CF center in New York City. Adult patients enrolled in the CF Foundation Patient Registry at the Columbia University Adult CF Program and seen at least once during 2019 were included. Health metrics were compared between Black/Latinx and non-Hispanic Caucasian patients. RESULTS 262 patients were eligible. 39 patients (15%) identified as Black/Latinx or non-Hispanic Caucasian. Descriptive statistics are reported with mean (standard deviation). Current age was 35.9 (13.3) years for non-Hispanic Caucasian and 32.0 (9.3) years for Black/Latinx patients (p = 0.087). Age of diagnosis did not differ between groups; 9.56 (15.96) years versus 11.59 (15.8) years for non-Hispanic Caucasian versus Black/Latinx respectively (p = 0.464). Pulmonary function, measured as mean forced expiratory volume in one second (FEV1) was 70.6 (22.5) percent predicted in non-Hispanic Caucasian versus 59.50 (27.9) percent predicted in Black/Latinx patients (p = 0.010). Number of visits to the CF clinic were similar between groups. When controlled for age, gender, co-morbidities, median income, and insurance status, there was a continued association between minority status and lower FEV1. CONCLUSIONS Minorities with CF have significantly lower pulmonary function, the major marker of survival, than non-Hispanic Caucasians, even when controlled for a variety of demographic and socioeconomic factors that are known to affect health status in CF. Significant health disparities based on race and ethnicity exist at a single CF center in New York City, despite apparent similarities in access to guideline based care at an accredited CF Center. This data confirms the importance of design of culturally appropriate preventative and management strategies to better understand how to direct interventions to this vulnerable population with a rare disease.
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Affiliation(s)
- Emily DiMango
- Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA.
| | - Kaitlyn Simpson
- Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Elizabeth Menten
- Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Claire Keating
- Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Weijia Fan
- Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
| | - Cheng-Shiun Leu
- Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
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23
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Bustamante AE, Fernández LT, Rivas LC, Mercado-Longoria R. Disparities in cystic fibrosis survival in Mexico: Impact of socioeconomic status. Pediatr Pulmonol 2021; 56:1566-1572. [PMID: 33656284 DOI: 10.1002/ppul.25351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/10/2021] [Accepted: 02/27/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Median survival age in cystic fibrosis (CF) has increased in developed countries. Scarce literature exists about survival in Latin America, especially in Mexico. The aim of our study was to assess the median age of survival in CF patients and the impact of risk factors in Mexico over a 20-year period. METHODS We conducted a retrospective study with all patients registered and followed in the CF Center in Monterrey, Mexico from 2000 to 2020. Median survival age was the primary outcome, assessed with Kaplan-Meier analysis. The influence of clinical, biological, and demographic factors on survival was analyzed with Cox regression model. RESULTS Two-hundred five patients were included. Median survival for the cohort was 21.37 years (95% confidence interval [CI], 17.20-25.55). In the multivariate Cox regression model, low socioeconomic status (hazard ratio [HR], 4.21; 95% CI, 2.43-7.27), chronic Pseudomonas aeruginosa infection at 6 years (HR, 10.45; 95% CI, 5.66-19.28), and pancreatic insufficiency (HR, 3.13; 1.38-7.13) were independent risk factors for mortality. CONCLUSION Median survival in Mexican patients with CF is lower than in high-income countries, and socioeconomic status plays a conspicuous role in the disparity. To increase patient survival for those residing in low-middle income countries, public health authorities must design policies that fully cover diagnosis and treatment strategies for the CF population.
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Affiliation(s)
- Adriana E Bustamante
- Pneumology Department, Hospital Universitario Dr. José E. González, Monterrey, Nuevo León, México
| | - Lucía T Fernández
- Internal Medicine Department, Hospital Universitario Dr. José E. González, Monterrey, Nuevo León, México
| | - Lissette C Rivas
- Pneumology Department, Hospital Universitario Dr. José E. González, Monterrey, Nuevo León, México
| | - Roberto Mercado-Longoria
- Pneumology Department, Hospital Universitario Dr. José E. González, Monterrey, Nuevo León, México
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Oates G, Rutland S, Juarez L, Friedman A, Schechter MS. The association of area deprivation and state child health with respiratory outcomes of pediatric patients with cystic fibrosis in the United States. Pediatr Pulmonol 2021; 56:883-890. [PMID: 33258546 PMCID: PMC8035176 DOI: 10.1002/ppul.25192] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Differences in socioenvironmental exposures influence overall child health, but their association with pediatric cystic fibrosis (CF) outcomes is less clear. This observational study investigated the relationship between area-level socioeconomic deprivation, state child health, and CF respiratory outcomes in a national cohort. METHODS We assessed relationships between the 2015 area deprivation index, a composite measure of socioeconomic disadvantage; the 2016 child health index, a state-specific measure of overall child health; and CF respiratory outcomes in the 2016 CF Foundation Patient Registry. RESULTS The sample included 9934 individuals with CF, aged 6-18 years. In multiple regression analysis adjusted for demographic and clinical covariates, those residing in the worst tertile for area deprivation had 2.8% lower percent predicted forced expiratory volume in 1 s (ppFEV1 ; 95% confidence interval [CI]: -4.1 to -1.5), 1.2 more intravenous (IV) treatment nights (CI: 0.1-2.4), and 20% higher odds of ≥2 pulmonary exacerbations (odds ratio [OR]: 1.2, CI: 1.0-1.5) than best-tertile counterparts. Children with CF in states at the worst tertile for child health had 2.3% lower ppFEV1 (CI: -4.5 to -0.2), 2.2 more IV treatment nights (CI: 0.5-3.6), and 40% higher odds of ≥2 exacerbations (OR: 1.4, CI: 1.1-1.8) than best-tertile counterparts. State child health accounted for the association between area deprivation and multiple exacerbations and more IV treatment nights. CONCLUSIONS Both area socioeconomic characteristics and state child health play a role in pediatric CF outcomes. The residual association of the state child health with CF outcomes after controlling for area deprivation reflects the ability of state programs to mitigate the effect of poverty.
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Affiliation(s)
- Gabriela Oates
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sarah Rutland
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lucia Juarez
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Annabelle Friedman
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael S Schechter
- Department of Pediatrics, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia, USA
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25
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McKone EF, Ariti C, Jackson A, Zolin A, Carr SB, Orenti A, van Rens JG, Lemonnier L, Macek M, Keogh RH, Naehrlich L. Survival estimates in European cystic fibrosis patients and the impact of socioeconomic factors: a retrospective registry cohort study. Eur Respir J 2021; 58:13993003.02288-2020. [PMID: 33678607 DOI: 10.1183/13993003.02288-2020] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 02/12/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Median survival for cystic fibrosis (CF) patients in Europe is unknown and is likely to be influenced by socioeconomic factors. Using the European CF Society Patient Registry (ECFSPR), median survival estimates were obtained for CF patients across Europe and the impact of socioeconomic status on survival was examined. METHODS CF subjects known to be alive and in the ECFSPR between 2010 and 2014 were included. Survival curves were estimated using the Kaplan-Meier method. Differences in the survival curves were assessed using the log-rank test. Cox regression was used to estimate the association between socioeconomic factors and the age-specific hazard of death, with adjustment for sex, age at diagnosis, CF transmembrane conductance regulator (CFTR) genotype and transplant status. RESULTS The final analysis included 13 countries with 31 987 subjects (135 833 person-years of follow-up) and 1435 deaths. Median survival age for these patients in the ECFSPR was 51.7 (95% CI 50.0-53.4) years. After adjusting for potential confounders age at diagnosis, sex, CFTR genotype and transplant status, there remained strong evidence of an association between socioeconomic factors and mortality (p<0.001). Countries in the highest third of healthcare spending had a 46% lower hazard of mortality (HR 0.54, 95% CI 0.45-0.64) than countries in the lowest third of healthcare spending. CONCLUSIONS Median survival for patients with CF in Europe is comparable to that reported in other jurisdictions and differs by socioeconomic factors.
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Affiliation(s)
- Edward F McKone
- St Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Cono Ariti
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Anna Zolin
- Dept of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Epidemiology and Biometry "G.A. Maccacaro", University of Milan, Milan, Italy
| | - Siobhán B Carr
- Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Annalisa Orenti
- Dept of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Epidemiology and Biometry "G.A. Maccacaro", University of Milan, Milan, Italy
| | - Jacqui G van Rens
- European Cystic Fibrosis Society Patient Registry, Karup, Denmark.,University Hospital Leuven, Leuven, Belgium
| | | | - Milan Macek
- Dept of Biology and Medical Genetics, Faculty of Medicine of Charles University and Motol University Hospital, Prague, Czechia
| | - Ruth H Keogh
- London School of Hygiene and Tropical Medicine, London, UK
| | - Lutz Naehrlich
- Dept of Paediatrics, Justus Liebig University Giessen, Giessen, Germany
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Kabir S, Farrokhvar L, Russell MW, Forman A, Kamali B. Regional socioeconomic factors and length of hospital stay: a case study in Appalachia. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-020-01418-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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27
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Reddy AR, Badolato GM, Chamberlain JM, Goyal MK. Disparities Associated with Sepsis Mortality in Critically Ill Children. J Pediatr Intensive Care 2020; 11:147-152. [DOI: 10.1055/s-0040-1721730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022] Open
Abstract
AbstractDisparities in health care related to socioeconomic status and race/ethnicity are well documented in adult and neonatal sepsis, but they are less characterized in the critically ill pediatric population. This study investigated whether socioeconomic status and/or race/ethnicity is associated with mortality among children treated for sepsis in the pediatric intensive care unit (PICU). A retrospective cohort study was conducted using information from 48 children's hospitals included in the Pediatric Health Information System database. We included visits by children ≤ 21 years with All Patients Refined Diagnosis-Related Groups (APR-DRG) diagnosis codes of septicemia and disseminated infections that resulted in PICU admission from 2010 to 2016. Multivariable logistic regression was used to measure the effect of race/ethnicity and socioeconomic status (insurance status and median household income for zip code) on mortality after adjustment for age, gender, illness severity, and presence of complex chronic condition. Among the 14,276 patients with sepsis, the mortality rate was 6.8%. In multivariable analysis, socioeconomic status, but not race/ethnicity, was associated with mortality. In comparison to privately insured children, nonprivately insured children had increased odds of mortality (public: adjusted odds ratio [aOR]: 1.2 [1.0, 1.5]; uninsured: aOR: 2.1 [1.2, 3.7]). Similarly, children living in zip codes with the lowest quartile of annual household income had higher odds of mortality than those in the highest quartile (aOR: 1.5 [1.0, 2.2]). These data suggest the presence of socioeconomic, but not racial/ethnic, disparities in mortality among children treated for sepsis. Further research is warranted to understand why such differences exist and how they may be addressed.
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Affiliation(s)
- Anireddy R. Reddy
- Department of Pediatrics, Children’s National Medical Center, Washington, District of Columbia, United States
| | - Gia M. Badolato
- Department of Pediatric Emergency Medicine, Children’s National Medical Center, Washington, District of Columbia, United States
| | - James M. Chamberlain
- Department of Pediatric Emergency Medicine, Children’s National Medical Center, Washington, District of Columbia, United States
| | - Monika K. Goyal
- Department of Pediatric Emergency Medicine, Children’s National Medical Center, Washington, District of Columbia, United States
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28
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McGettrick M, McCaughey P, MacLellan A, Brewis M, Church AC, Johnson MK. Social deprivation in Scottish populations with pulmonary hypertension secondary to connective tissue disease and chronic thromboembolic disease. ERJ Open Res 2020; 6:00297-2019. [PMID: 33263038 PMCID: PMC7682671 DOI: 10.1183/23120541.00297-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 08/12/2020] [Indexed: 11/20/2022] Open
Abstract
Socioeconomic factors have been shown to have an adverse impact on survival in some respiratory diseases. Studies from the USA and China have suggested worse survival in idiopathic pulmonary arterial hypertension in low socioeconomic groups. We looked at the effect of deprivation on the outcomes in patients with connective tissue disease-associated pulmonary hypertension (CTDPH) and chronic thromboembolic pulmonary hypertension (CTEPH) in a retrospective observational study. Data were obtained from 232 patients with CTDPH and 263 with CTEPH who were under the care of the Scottish Pulmonary Vascular Unit, Glasgow, UK. We used Cox proportional hazards regression to assess for a relationship between deprivation and survival. We found no difference in survival across deprivation quintiles in the CTDPH (p=0.26) or CTEPH cohorts (p=0.18). We constructed multivariate models using enrolment time, age, sex and body mass index, with no significant change in findings. There was no difference between expected and observed population distribution of CTDPH (p=0.98) and CTEPH (p=0.36). Whilst there was no difference in presenting functional class in the CTDPH group, the CTEPH patients in more deprived quintiles presented in a worse functional class (p=0.032). There was no difference between quintiles of CTEPH patients who had distal or proximal disease (p=0.75), or who underwent surgery (p=0.5). Increased social deprivation is not associated with worse survival in patients with CTDPH and CTEPH managed in the Scottish National Health Service. Whilst there is no evidence of referral barriers in CTDPH, this may not be the case in CTEPH, as lower deprivation was associated with worse functional class at presentation. Increased social deprivation is not associated with worse survival in patients with connective tissue disease-associated pulmonary hypertension or chronic thromboembolic pulmonary hypertension managed in the Scottish NHShttps://bit.ly/32KbzSv
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Affiliation(s)
- Michael McGettrick
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Paul McCaughey
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Alexander MacLellan
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Melanie Brewis
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - A Colin Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
| | - Martin K Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
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29
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Naehrlich L. The Changing Face of Cystic Fibrosis and Its Implications for Screening. Int J Neonatal Screen 2020; 6:54. [PMID: 33123635 PMCID: PMC7570194 DOI: 10.3390/ijns6030054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/30/2020] [Indexed: 12/27/2022] Open
Abstract
Early diagnosis, multidisciplinary care, and optimized and preventive treatments have changed the face of cystic fibrosis. Life expectancy has been expanded in the last decades. Formerly a pediatric disease, cystic fibrosis has reached adulthood. Mutation-specific treatments will expand treatment options and give hope for further improvement of quality of life and life expectancy. Newborn screening for CF fits perfectly into these care structures and offers the possibility of preventive treatment even before symptoms occur. Especially in countries without screening, newborn screening will fulfill that promise only with increased awareness and new care structures.
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Affiliation(s)
- Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, D-35392 Giessen, Germany; ; Tel.: +49-641-9857621
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30
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Oates GR, Harris WT, Gutierrez HH, Mims C, Rutland SB, Ott C, Niranjan SJ, Scarinci IC, Walley SC. Tobacco smoke exposure in pediatric cystic fibrosis: A qualitative study of clinician and caregiver perspectives on smoking cessation. Pediatr Pulmonol 2020; 55:2330-2340. [PMID: 32511883 PMCID: PMC7686064 DOI: 10.1002/ppul.24879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Tobacco smoke exposure has negative impacts on the lung health of children with cystic fibrosis (CF), yet evidence-based strategies for smoking cessation have not been tested with or tailored to CF caregivers. This qualitative study identified barriers and facilitators of smoking cessation in this population and outlined potential interventional approaches. METHODS We conducted semi-structured interviews with CF familial caregivers who were current or former smokers, and with members of the CF care team. We asked about experiences, practices, and prerequisites for a successful program. Interviews were recorded, transcribed verbatim, and coded by two investigators. Analysis used a thematic approach guided by the PRECEDE model, which identifies predisposing (intrapersonal), reinforcing (interpersonal), and enabling (structural) factors relevant to health behaviors and programs. RESULTS Seventeen interviews were conducted-eight with familial caregivers and nine with CF team members. Whereas caregivers provided greater insight into internal difficulties and motivators to quit smoking, clinicians offered more extensive input on barriers and solutions related to the clinical environment. Based on study recommendations, a successful tobacco cessation program should include (a) family education about the harms of smoke exposure for children with CF; (b) screening for exposure, ideally with biochemical verification; (c) access to trained tobacco counselors; (d) affordable pharmacotherapy; and (e) outpatient follow-up of those undergoing tobacco treatment. CONCLUSION This qualitative study revealed intrapersonal, interpersonal, and structural barriers to eliminating tobacco smoke exposure in children with CF, outlined opportunities to address these barriers, and made recommendations for a comprehensive tobacco cessation strategy.
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Affiliation(s)
- Gabriela R Oates
- Pediatric Pulmonary and Sleep Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - William T Harris
- Pediatric Pulmonary and Sleep Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hector H Gutierrez
- Pediatric Pulmonary and Sleep Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cathy Mims
- Children's of Alabama, Birmingham, Alabama
| | - Sarah B Rutland
- Pediatric Pulmonary and Sleep Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Corilyn Ott
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Soumya J Niranjan
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama
| | - Isabel C Scarinci
- Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Susan C Walley
- Pediatric Hospital Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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31
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Garcia B, Christon L, Gray S. In the south, if you give us lemons, we will make you lemonade. J Cyst Fibros 2020; 19:842-843. [PMID: 32546432 PMCID: PMC7269958 DOI: 10.1016/j.jcf.2020.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Bryan Garcia
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine. Medical University of South Carolina, Charleston SC, United States of America.
| | - Lillian Christon
- Department of Psychiatry and Behavioral Sciences, Division of Biobehavioral Medicine. Medical University of South Carolina, Charleston SC, United States of America
| | - Sue Gray
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine. Medical University of South Carolina, Charleston SC, United States of America
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32
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Szczesniak R, Rice JL, Brokamp C, Ryan P, Pestian T, Ni Y, Andrinopoulou ER, Keogh RH, Gecili E, Huang R, Clancy JP, Collaco JM. Influences of environmental exposures on individuals living with cystic fibrosis. Expert Rev Respir Med 2020; 14:737-748. [PMID: 32264725 DOI: 10.1080/17476348.2020.1753507] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Natural, social, and constructed environments play a critical role in the development and exacerbation of respiratory diseases. However, less is known regarding the influence of these environmental/community risk factors on the health of individuals living with cystic fibrosis (CF), compared to other pulmonary disorders. AREAS COVERED Here, we review current knowledge of environmental exposures related to CF, which suggests that environmental/community risk factors do interact with the respiratory tract to affect outcomes. Studies discussed in this review were identified in PubMed between March 2019 and March 2020. Although the limited data available do not suggest that avoiding potentially detrimental exposures other than secondhand smoke could improve outcomes, additional research incorporating novel markers of environmental exposures and community characteristics obtained at localized levels is needed. EXPERT OPINION As we outline, some environmental exposures and community characteristics are modifiable; if not by the individual, then by policy. We recommend a variety of strategies to advance understanding of environmental influences on CF disease progression.
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Affiliation(s)
- Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Jessica L Rice
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University School of Medicine , Baltimore, MD, USA
| | - Cole Brokamp
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Patrick Ryan
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Teresa Pestian
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Yizhao Ni
- Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | | | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine , London, UK
| | - Emrah Gecili
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Rui Huang
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Mathematical Sciences, University of Cincinnati , Cincinnati, OH, USA
| | - John P Clancy
- Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA.,Department of Clinical Research, Cystic Fibrosis Foundation , Bethesda, MD, USA
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University School of Medicine , Baltimore, MD, USA
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33
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Leung GJ, Cho TJ, Kovesi T, Hamid JS, Radhakrishnan D. Variation in lung function and nutritional decline in cystic fibrosis by genotype: An analysis of the Canadian cystic fibrosis registry. J Cyst Fibros 2020; 19:255-261. [DOI: 10.1016/j.jcf.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/04/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
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Health Disparities. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_3] [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: 10/24/2022]
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35
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Meldau JE, Borowsky P, Blanchett J, Stephens J, Muh S, Moutzouros V, Makhni EC. Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery. Orthop J Sports Med 2019; 7:2325967119884543. [PMID: 31803791 PMCID: PMC6876178 DOI: 10.1177/2325967119884543] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear. Purpose/Hypothesis: The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship–trained orthopaedic surgeons were included in the study. Preoperative PROMIS–Upper Extremity (PROMIS-UE), PROMIS–Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors. Results: Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI (R = –0.61; P < .001), and a negligible correlation was found between the PROMIS-UE and PROMIS-D (R = –0.28; P < .001). When stratified by patient demographic factors, the correlation between the PROMIS-UE and PROMIS-PI was stronger in female patients compared with male patients (R = –0.77 vs –0.46, respectively; P < .001 for both), stronger in black patients compared with white patients (R = –0.72 vs –0.56, respectively; P < .001 for both), and highest in current tobacco users (R = –0.80; P < .001). Conclusion: Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups.
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Affiliation(s)
- Jason E Meldau
- Henry Ford West Bloomfield Hospital, Henry Ford Health System, West Bloomfield, Michigan, USA
| | - Peter Borowsky
- Henry Ford West Bloomfield Hospital, Henry Ford Health System, West Bloomfield, Michigan, USA
| | - Jacob Blanchett
- Henry Ford West Bloomfield Hospital, Henry Ford Health System, West Bloomfield, Michigan, USA
| | | | - Stephanie Muh
- Henry Ford West Bloomfield Hospital, Henry Ford Health System, West Bloomfield, Michigan, USA
| | - Vasilios Moutzouros
- Henry Ford West Bloomfield Hospital, Henry Ford Health System, West Bloomfield, Michigan, USA
| | - Eric C Makhni
- Henry Ford West Bloomfield Hospital, Henry Ford Health System, West Bloomfield, Michigan, USA
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36
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McGarry ME, Williams WA, McColley SA. The demographics of adverse outcomes in cystic fibrosis. Pediatr Pulmonol 2019; 54 Suppl 3:S74-S83. [PMID: 31715087 PMCID: PMC6857719 DOI: 10.1002/ppul.24434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/16/2019] [Indexed: 01/08/2023]
Abstract
Understanding variability in cystic fibrosis (CF) health outcomes requires an understanding of factors that go far beyond Cystic Fibrosis Transmembrane Receptor (CFTR) function caused by different gene mutations. Social and environmental factors that influence health have a significant influence on the trajectory of health in CF and in other chronic diseases. In this article, we review demographic factors associated with poorer health outcomes in CF, known and postulated biological mechanisms of these outcomes, and interventions that healthcare teams can implement that may reduce outcome disparities.
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Affiliation(s)
- Meghan E McGarry
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Wadsworth A Williams
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois
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37
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McGarry ME, Neuhaus JM, Nielson DW, Ly NP. Regional variations in longitudinal pulmonary function: A comparison of Hispanic and non-Hispanic subjects with cystic fibrosis in the United States. Pediatr Pulmonol 2019; 54:1382-1390. [PMID: 31144477 PMCID: PMC6702095 DOI: 10.1002/ppul.24377] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 05/08/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hispanic subjects with cystic fibrosis (CF) have increased morbidity and mortality than non-Hispanic white subjects. The ethnic disparity in mortality varies by region. Factors influencing pulmonary function vary by both ethnicity and region. OBJECTIVE To determine if the ethnic difference in pulmonary function varies by region. METHODS This retrospective cohort study compared differences in longitudinal pulmonary function (percent-predicted forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1 ], forced expiratory flow at 25% to 75% [FEF25-75 ], FEV1 /FVC, and FEV1 decline) between Hispanic and non-Hispanic white subjects with CF by Census region of the United States (West, South, Midwest, and Northeast). Subjects were of ages 6 to 25 years and in the CF Foundation Patient Registry from 2008 to 2013. We used linear mixed effects models with subject-specific slopes and intercepts, adjusting for 14 demographic and clinical variables. RESULTS Of 14 932 subjects, 1433 (9.6%) were Hispanic and 13 499 (90.4%) were non-Hispanic white. Hispanic subjects' FEV1 was 9.0% (8.3%-9.8%) lower than non-Hispanic white subjects in the West, while Hispanic subjects' FEV1 was only 4.0% (3.0%-5.0%) lower in the Midwest, 4.4% (3.1%-5.7%) lower in the Northeast, and 4.4% (3.2%-5.5%) lower in the South. Similarly, FVC and FEF25-75 were lower among Hispanic subjects compared to non-Hispanic white subjects in all US regions, with the biggest differences in the West. Only in the West was FEV1 /FVC significantly lower in Hispanic subjects (-0.019; -0.022 to -0.015). FEV1 decline was not significantly different between ethnicities in any region. CONCLUSIONS In CF, Hispanic subjects have lower pulmonary function than non-Hispanic white subjects in all geographic regions with the largest difference in occurring in the West.
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Affiliation(s)
- Meghan E McGarry
- Department of Pediatrics, University of California, San Francisco, California
| | - John M Neuhaus
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Dennis W Nielson
- Department of Pediatrics, University of California, San Francisco, California
| | - Ngoc P Ly
- Department of Pediatrics, University of California, San Francisco, California
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Parkins MD, Ramos KJ, Goss CH, Somayaji R. Cytomegalovirus: an unrecognised potential contributor to cystic fibrosis disease progression? Eur Respir J 2019; 53:13993003.01727-2018. [PMID: 30956206 DOI: 10.1183/13993003.01727-2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/10/2019] [Indexed: 12/30/2022]
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Lanzkron S, Sawicki GS, Hassell KL, Konstan MW, Liem RI, McColley SA. Transition to adulthood and adult health care for patients with sickle cell disease or cystic fibrosis: Current practices and research priorities. J Clin Transl Sci 2018; 2:334-342. [PMID: 30828476 PMCID: PMC6390387 DOI: 10.1017/cts.2018.338] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION A growing population of adults living with severe, chronic childhood-onset health conditions has created a need for specialized health care delivered by providers who have expertise both in adult medicine and in those conditions. Optimal care of these patients requires systematic approaches to healthcare transition (HCT). Guidelines for HCT exist, but gaps in care occur, and there are limited data on outcomes of HCT processes. METHODS The Single Disease Workgroup of the Lifespan Domain Task Force of the National Center for Advancing Translational Sciences Clinical and Translational Science Award programs convened a group to review the current state of HCT and to identify gaps in research and practice. Using cystic fibrosis and sickle cell disease as models, key themes were developed. A literature search identified general and disease-specific articles. We summarized key findings. RESULTS We identified literature characterizing patient, parent and healthcare provider perspectives, recommendations for transition care, and barriers to effective transition. CONCLUSIONS With increased survival of patients with severe childhood onset diseases, ongoing study of effective transition practices is essential as survival increases for severe childhood onset diseases. We propose pragmatic methods to enhance transition research to improve health and key outcomes.
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Affiliation(s)
- Sophie Lanzkron
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Kathryn L. Hassell
- Department of Medicine, Division of Hematology, Colorado Sickle Cell Treatment and Research Center, University of Colorado, Aurora, CO, USA
| | - Michael W. Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert I. Liem
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susanna A. McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Ilowite MF, Al-Sayegh H, Ma C, Dussel V, Rosenberg AR, Feudtner C, Kang TI, Wolfe J, Bona K. The relationship between household income and patient-reported symptom distress and quality of life in children with advanced cancer: A report from the PediQUEST study. Cancer 2018; 124:3934-3941. [PMID: 30216416 DOI: 10.1002/cncr.31668] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/15/2018] [Accepted: 06/11/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Children with advanced cancer experience high symptom distress, which negatively impacts their health-related quality of life (HRQOL). To the authors' knowledge, the relationship between income and symptom distress and HRQOL is not well described. METHODS The Pediatric Quality of Life and Symptoms Technology (PediQUEST) multisite clinical trial evaluated an electronic patient-reported outcome system to describe symptom distress and HRQOL in children with advanced cancer via repeated surveys. The authors performed a secondary analysis of PediQUEST data for those children with available parent-reported household income (dichotomized at 200% of the Federal Poverty Level and categorized as low income [<$50,000/year] or high income [≥$50,000/year]). The prevalence of the 5 most commonly reported physical and psychological symptoms was compared between groups. Multivariable generalized estimating equation models were used to test the association between household income and symptom distress and HRQOL. RESULTS A total of 78 children were included in the analyses: 56 (72%) in the high-income group and 22 (28%) in the low-income group. Low-income children were more likely to report pain than high-income children (64% vs 42%; P=.02). In multivariable models, children from low-income families demonstrated a uniform trend toward higher total (βlow-high =3.1; 95% confidence interval [95% CI], -0.08 to 6.2 [P=.06]), physical (β=3.8; 95% CI, -0.4 to 8.0 [P=.09]), and psychological (β=3.46; 95% CI, -1.91 to 8.84 [P=.21]) symptom distress compared with children from high-income families. Low income was associated with a uniform trend toward lower total (β=-7.9; 95% CI, -14.8, to -1.1 [P=.03]), physical (β=-11.2; 95% CI, -21.2 to -1.2 [P=.04]), emotional (β=-5.8; 95% CI, -13.6 to 2.0 [P=.15]), social (β=-2.52; 95% CI, -9.27 to 4.24 [P=.47]), and school (β=-9.8; 95% CI, -17.8 to -1.8 [P=.03]) HRQOL. CONCLUSIONS In this cohort of children with advanced cancer, children from low-income families were found to experience higher symptom burden and worse QOL.
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Affiliation(s)
- Maya F Ilowite
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Clement Ma
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Veronica Dussel
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Center for Research and Implementation in Palliative Care, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Abby R Rosenberg
- Seattle Children's Hospital Cancer and Blood Disorders Center, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - Chris Feudtner
- The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tammy I Kang
- Section of Palliative Care, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Joanne Wolfe
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kira Bona
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
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Oud L, Chan YM. Predictors and variation of routine home discharge in critically ill adults with cystic fibrosis. Heart Lung 2018; 47:511-515. [PMID: 29866586 DOI: 10.1016/j.hrtlng.2018.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/21/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The short-term outcomes of patients with cystic fibrosis (CF) surviving critical illness were not examined systematically. OBJECTIVES To determine the factors associated with and variation in rates of routine home discharge among ICU-managed adult CF patients. METHODS Predictors of routine home discharge and its hospital-level variation were examined in ICU-managed adults with cystic fibrosis in Texas during 2004-2013. RESULTS Older age, rural residence, and severity of illness decreased odds of routine home discharge, while hospitalization in facilities accredited as part of the Cystic Fibrosis Foundation Care Center Network nearly doubled the odds of routine home discharge. The median (interquartile) adjusted rate of routine home discharge was 62.0% (31.5-82.5). CONCLUSIONS The identified determinants of routine home discharge can inform clinical decision-making, while the demonstrated wide variation in adjusted across-hospital rates of routine home discharge of ICU-managed adults with CF can provide benchmark data for future quality improvement efforts.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, Texas, 79763, USA.
| | - Yiu Ming Chan
- Mathematics and Computer Science Department, University of Texas at the Permian Basin, 4901 East University, Odessa, Texas, 79762, USA
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McCarthy C, Lara Gallego B, Trapnell BC, McCormack FX. Epidemiology of Rare Lung Diseases: The Challenges and Opportunities to Improve Research and Knowledge. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1031:419-442. [PMID: 29214586 DOI: 10.1007/978-3-319-67144-4_24] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Rare lung diseases encompass a broad spectrum of conditions and affect an estimated 1.2-2.5 million people in North America and 1.5-3 million people in Europe. While individual rare lung diseases affect less than 1 in 2000 individuals, collectively they have a significant impact upon the population at large. Hence it is vital to understand firstly the epidemiology and subsequently the pathogenesis and clinical course of these disorders. Through a greater understanding of these aspects of disease, progress can be made in reducing symptoms, containing healthcare costs and utilizing resources efficiently. Furthermore, a greater understanding of the pathobiology of rare lung diseases can inform both the pathogenesis and management of more common pulmonary disorders.In this chapter we review how epidemiological approaches and the utilization of patient registries has improved the knowledge and management of rare lung diseases. We further focus on the epidemiology of several of the more widely known rare pulmonary disorders, including idiopathic pulmonary fibrosis (IPF), cystic fibrosis (CF) and alpha-1 antitrypsin deficiency (AATD). To conclude we describe how patient advocacy groups and foundations have driven advances in research and management of ultra-rare lung diseases, namely, the major strides made in the management and understanding of lymphangioleiomyomatosis (LAM) and pulmonary alveolar proteinosis (PAP).We conclude that the models used to study some of the rarest of diseases may be successfully adopted by other rare and common disease communities, leading to improved care and the possibility of novel therapeutic options.
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Affiliation(s)
- Cormac McCarthy
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, 45267-0564, USA. .,Translational Pulmonary Science Center Cincinnati Children's Hospital, 3333 Burnet Avenue, CCRF S4621, 45229-3039, Cincinnati, OH, USA. .,Rare Lung Diseases Clinical (RLDC), Cincinnati, OH, USA.
| | - Beatriz Lara Gallego
- Respiratory Medicine Department, Coventry University Hospital, Third Floor, East wing. Clifford Bridge Road, Coventry, CV2 2DX, Warwickshire, UK
| | - Bruce C Trapnell
- Translational Pulmonary Science Center Cincinnati Children's Hospital, 3333 Burnet Avenue, CCRF S4621, 45229-3039, Cincinnati, OH, USA.,Rare Lung Diseases Clinical (RLDC), Cincinnati, OH, USA.,Medicine and Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, CCRF R4029, 45229-3039, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, 45267-0564, USA
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Li SS, Hayes D, Tobias JD, Morgan WJ, Tumin D. Health insurance and use of recommended routine care in adults with cystic fibrosis. CLINICAL RESPIRATORY JOURNAL 2018; 12:1981-1988. [DOI: 10.1111/crj.12767] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/14/2017] [Accepted: 01/09/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Susan S. Li
- Department of Pediatrics; Nationwide Children's Hospital; Columbus Ohio
- Department of Internal Medicine; The Ohio State University College of Medicine; Columbus Ohio
| | - Don Hayes
- Department of Pediatrics; Nationwide Children's Hospital; Columbus Ohio
- Department of Internal Medicine; The Ohio State University College of Medicine; Columbus Ohio
- Department of Surgery; The Ohio State University College of Medicine; Columbus Ohio
- Section of Pulmonary Medicine; Nationwide Children's Hospital; Columbus Ohio
| | - Joseph D. Tobias
- Department of Pediatrics; Nationwide Children's Hospital; Columbus Ohio
- Section of Pulmonary Medicine; Nationwide Children's Hospital; Columbus Ohio
- Department of Anesthesiology; The Ohio State University College of Medicine; Columbus Ohio
| | - Wayne J. Morgan
- Department of Pediatrics; University of Arizona; Tucson Arizona
| | - Dmitry Tumin
- Department of Pediatrics; Nationwide Children's Hospital; Columbus Ohio
- Department of Anesthesiology & Pain Medicine; Nationwide Children's Hospital; Columbus Ohio
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Pellino K, Kerridge S, Church C, Peacock AJ, Crowe T, Jayasekera G, Johnson MK, MacKenzie A. Social deprivation and prognosis in Scottish patients with pulmonary arterial hypertension. Eur Respir J 2018; 51:51/2/1700444. [DOI: 10.1183/13993003.00444-2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 11/05/2017] [Indexed: 11/05/2022]
Abstract
Several demographic and clinical factors have prognostic significance in idiopathic pulmonary arterial hypertension (IPAH). Studies in China and the USA have suggested an association between low socioeconomic status and reduced survival. The impact of social deprivation on IPAH survival in the UK is not known.280 patients with IPAH and hereditary PAH (HPAH) attending the Scottish Pulmonary Vascular Unit (Glasgow, UK) were assigned to social deprivation quintiles using the Scottish Index of Multiple Deprivation database. The association between survival and social deprivation quintile was assessed using Cox proportional hazards regression analysis.The distribution of IPAH/HPAH patients was more socially deprived than would be expected based on Scottish citizenry as a whole (Chi-squared 16.16, p=0.003), suggesting referral and access to care is not impeded by socioeconomic status. Univariate analysis demonstrated no significant association between social deprivation and survival (p=0.81), and this association failed to reach significance with inclusion of time, sex and age as covariates in the model (p=0.23). There were no statistically significant correlations between social deprivation and baseline clinical variables of prognostic importance except for age, sex and quality of life.Social deprivation is not a significant referral barrier or prognostic factor for IPAH and HPAH in Scotland.
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Bilodeau M, Ma C, Al-Sayegh H, Wolfe J, Bona K. Household material hardship in families of children post-chemotherapy. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26743. [PMID: 28941160 PMCID: PMC6042835 DOI: 10.1002/pbc.26743] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 12/19/2022]
Abstract
Poverty is an important patient-reported outcome of therapy and a potential predictor of outcome disparities in pediatric cancer. We previously identified that nearly 30% of pediatric cancer families experience household material hardship (HMH), a concrete measure of poverty including food, energy, or housing insecurity, during the first 6 months of chemotherapy. We conducted a follow-up survey in a subcohort of these families at least 1 year off-therapy and found that 32% reported HMH in early survivorship. Persistently high concrete resource needs off-therapy may have significance for child health and quality of life, and thus represent targets for future investigation.
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Affiliation(s)
- Madeline Bilodeau
- Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Clement Ma
- Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kira Bona
- Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Fink AK, Loeffler DR, Marshall BC, Goss CH, Morgan WJ. Data that empower: The success and promise of CF patient registries. Pediatr Pulmonol 2017; 52:S44-S51. [PMID: 28910520 DOI: 10.1002/ppul.23790] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/30/2017] [Indexed: 12/17/2022]
Abstract
In this article, we describe existing CF registries with a focus on US registry data collected through the CF Foundation Patient Registry (CFFPR) and the Epidemiologic Study of CF (ESCF); highlight what registries have taught us regarding epidemiology of CF; showcase the impact of registries on research and clinical care; and discuss future directions. This manuscript complements the plenary address given by Dr Wayne Morgan at the 2016 North American CF Conference by summarizing the key points from the presentation and providing additional detail and information.
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Affiliation(s)
| | | | | | - Christopher H Goss
- Department of Medicine and Pediatrics, University of Washington, Seattle, Washington
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona
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McColley SA, Schechter MS, Morgan WJ, Pasta DJ, Craib ML, Konstan MW. Risk factors for mortality before age 18 years in cystic fibrosis. Pediatr Pulmonol 2017; 52:909-915. [PMID: 28436621 DOI: 10.1002/ppul.23715] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/31/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Understanding early-life risk factors for childhood death in cystic fibrosis (CF) is important for clinical care, including the identification of effective interventions. METHODS Data from the Epidemiologic Study of Cystic Fibrosis (ESCF) collected 1994-2005 were linked with the Cystic Fibrosis Foundation Patient Registry (CFFPR) demographic and mortality data from 2013. Inclusion criteria were ≥1 visit annually at age 3-5 years and ≥1 FEV1 measurement at age 6-8 years. Demographic data, nutritional parameters, pulmonary signs and symptoms, microbiology, and FEV1 were evaluated as risk factors for death before age 18 years. Multivariable Cox proportional hazards regression was used to model the simultaneous effects of risk factors associated with death before age 18 years. RESULTS Among 5365 patients enrolled in ESCF who met inclusion criteria, 3880 (72%) were linked to the CFFPR. Among these, 191 (5.7%) died before age 18 years; median age at death was 13.4 ± 3.1 years. Multivariable regression showed clubbing, crackles, female sex, unknown CFTR genotype, minority race or ethnicity, Medicaid insurance (a proxy of low socioeconomic status), Pseudomonas aeruginosa on 2 or more cultures, and weight-for-age <50th percentile were significant risk factors for death regardless of inclusion of FEV1 at age 6-8 years in the model. CONCLUSION We identified multiple risk factors for childhood death of patients with CF, all of which remained important after incorporating FEV1 at age 6-8 years. Among the factors identified were the presence of clubbing or crackles at age 3-5 years, signs which are not routinely collected in registries.
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Affiliation(s)
- Susanna A McColley
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael S Schechter
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | | | | | | | - Michael W Konstan
- Case Western Reserve University School of Medicine and Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Stephenson AL, Stanojevic S, Sykes J, Burgel PR. The changing epidemiology and demography of cystic fibrosis. Presse Med 2017; 46:e87-e95. [PMID: 28554720 DOI: 10.1016/j.lpm.2017.04.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/05/2017] [Indexed: 01/26/2023] Open
Abstract
Once considered a pediatric disease with a poor prognosis, individuals born with cystic fibrosis (CF) today can expect to live well into adulthood. The implementation of multidisciplinary care, novel treatments and newborn screening has resulted in the rapid evolution in the demographics of the CF population. The purpose of this review is to highlight the evolving epidemiology and demographics of the CF population internationally.
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Affiliation(s)
- Anne L Stephenson
- University of Toronto, St-Michael's hospital, Li Ka Shing knowledge institute, Keenan research centre, department of medicine, adult CF program, 30, Bond street, 6th floor, Bond Wing, M5B 1W8 Toronto, ON, Canada; University of Toronto, institute of health policy, management and evaluation, Toronto, ON, Canada.
| | - Sanja Stanojevic
- The hospital for sick children, division of respiratory medicine, Toronto, ON, Canada; University of Toronto, institute of health policy, management and evaluation, Toronto, ON, Canada
| | - Jenna Sykes
- University of Toronto, St-Michael's hospital, Li Ka Shing knowledge institute, Keenan research centre, department of medicine, adult CF program, 30, Bond street, 6th floor, Bond Wing, M5B 1W8 Toronto, ON, Canada
| | - Pierre-Regis Burgel
- Sorbonne Paris Cité, université Paris Descartes, 75014 Paris, France; Assistance publique-Hôpitaux de Paris, hôpital Cochin, 75014 Paris, France
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Ong T, Schechter M, Yang J, Peng L, Emerson J, Gibson RL, Morgan W, Rosenfeld M. Socioeconomic Status, Smoke Exposure, and Health Outcomes in Young Children With Cystic Fibrosis. Pediatrics 2017; 139:peds.2016-2730. [PMID: 28093464 PMCID: PMC5260155 DOI: 10.1542/peds.2016-2730] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Lower socioeconomic status (SES) and environmental tobacco smoke (ETS) exposure are both associated with poorer disease outcomes in cystic fibrosis (CF), and children with low SES are disproportionately exposed to ETS. We analyzed a large cohort of young children with CF to distinguish the impact of SES and ETS on clinical outcomes. METHODS The Early Pseudomonas Infection Control Observational study enrolled Pseudomonas-negative young children with CF <13 years of age. An enrollment survey assessed SES and ETS exposures. Forced expiratory volume in 1 second (FEV1), crackles and wheezes, and weight-for-age percentile were assessed at each clinical encounter over at least 4 years. Repeated measures analyses estimated the association of SES and ETS exposures with longitudinal clinical outcomes, adjusting for confounders. RESULTS Of 1797 participants, 1375 were eligible for analysis. Maternal education was high school or less in 28.1%, 26.8% had household income <$40 000, and 43.8% had Medicaid or no insurance. Maternal smoking after birth was present in 24.8%, more prevalent in household with low SES. In separate models, lower SES and ETS exposure were significantly associated with lower FEV1% predicted, presence of crackles or wheezes, and lower weight percentile. In combined models, effect estimates for SES changed minimally after adjustment for ETS exposures, whereas estimates for ETS exposures were attenuated after adjusting for SES. CONCLUSIONS ETS exposure was disproportionately high in low SES families in this cohort of children with CF. Lower SES and ETS exposure had independent adverse effects on pulmonary and nutritional outcomes. Estimated effect of SES on FEV1 decreased minimally after ETS adjustment, suggesting health disparity risks independent of ETS exposure.
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Affiliation(s)
- Thida Ong
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington;
| | - Michael Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University, Children’s Hospital of Richmond at VCU, Richmond, Virginia
| | - Jing Yang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia; and
| | - Limin Peng
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia; and
| | - Julia Emerson
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ronald L. Gibson
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Wayne Morgan
- Departments of Pediatrics and Physiology, Pediatric Pulmonary Center, University of Arizona, Tucson, Arizona
| | - Margaret Rosenfeld
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
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Cystic Fibrosis. Respir Med 2017. [DOI: 10.1007/978-3-319-43447-6_9] [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: 10/20/2022]
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