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Marsh AM, Treadwell MJ. Stepping Systematically Forward Toward Health Equity in Sickle Cell Disease. JAMA Pediatr 2024; 178:225. [PMID: 38190149 DOI: 10.1001/jamapediatrics.2023.5984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Affiliation(s)
- Anne M Marsh
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Marsha J Treadwell
- Department of Pediatrics, University of California San Francisco, Oakland
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Munung NS, Kamga KK, Treadwell MJ, Dennis-Antwi J, Anie KA, Bukini D, Makani J, Wonkam A. Perceptions and preferences for genetic testing for sickle cell disease or trait: a qualitative study in Cameroon, Ghana and Tanzania. Eur J Hum Genet 2024:10.1038/s41431-024-01553-7. [PMID: 38374470 DOI: 10.1038/s41431-024-01553-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/30/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024] Open
Abstract
Sickle cell disease (SCD) is a single gene blood disorder characterised by frequent episodes of pain, chronic anaemic, acute chest syndrome, severe disease complications and lifelong debilitating multi-system organ damage. Genetic testing and screening programs for SCD and the sickle cell trait (SCT) are valuable for early diagnosis and management of children living with SCD, and in the identification of carriers of SCT. People with SCT are for the most part asymptomatic and mainly identified as through genetic testing or when they have a child with SCD. This qualitative study explored perceptions towards genetic testing for SCD and SCT in Cameroon, Ghana, and Tanzania. The results show a general preference for newborn screening for SCD over prenatal and premarital/preconception testing, primarily due to its simpler decision-making process and lower risk for stigmatization. Premarital testing for SCT was perceived to be of low public health value, as couples are unlikely to alter their marriage plans despite being aware of their risk of having a child with SCD. Adolescents were identified as a more suitable population for SCT testing. In the case of prenatal testing, major concerns were centred on cultural, religious, and personal values on pregnancy termination. The study revealed a gender dimension to SCD/SCT testing. Participants mentionned that women bear a heightened burden of decision making in SCD/SCT testing, face a higher risk of rejection by potential in-laws/partners if the carriers of SCT, as well as the possibility of divorce if they have a child with SCD. The study highlights the complex cultural, ethical, religious and social dynamics surrounding genetic testing for SCD and emphasises the need for public education on SCD and the necessity of incorporating genetic and psychosocial counselling into SCD/SCT testing programs.
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Affiliation(s)
| | - Karen Kengne Kamga
- Division of Human Genetics, University of Cape Town, Capetown, South Africa
- Medical Genetic Service, Regional Hospital Limbe, Limbe, Cameroon
| | - Marsha J Treadwell
- University of California San Francisco Department of Pediatrics/Division of Hematology, Oakland, CA, USA
| | | | - Kofi A Anie
- London Northwest University HealthCare (NHS) Trust, London, UK
- Imperial College London, London, UK
| | - Daima Bukini
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Julie Makani
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ambroise Wonkam
- Division of Human Genetics, University of Cape Town, Capetown, South Africa.
- McKusick-Nathans Institute & Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Munung NS, Nnodu OE, Moru PO, Kalu AA, Impouma B, Treadwell MJ, Wonkam A. Looking ahead: ethical and social challenges of somatic gene therapy for sickle cell disease in Africa. Gene Ther 2023:10.1038/s41434-023-00429-7. [PMID: 38012299 DOI: 10.1038/s41434-023-00429-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/24/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
Somatic gene therapy will be one of the most exciting practices of genetic medicine in Africa and is primed to offer a "new life" for persons living with sickle cell disease (SCD). Recently, successful gene therapy trials for SCD in the USA have sparked a ray of hope within the SCD community in Africa. However, the high cost, estimated to exceed 1.5 million USD, continues to be a major concern for many stakeholders. While affordability is a key global health equity consideration, it is equally important to reflect on other ethical, legal and social issues (ELSIs) that may impact the responsible implementation of gene therapy for SCD in Africa. These include informed consent comprehension, risk of therapeutic misestimation and optimistic bias; priorities for SCD therapy trials; dearth of ethical and regulatory oversight for gene therapy in many African countries; identifying a favourable risk-benefit ratio; criteria for the selection of trial participants; decisional conflict in consent; standards of care; bounded justice; and genetic tourism. Given these ELSIs, we suggest that researchers, pharma, funders, global health agencies, ethics committees, science councils and SCD patient support/advocacy groups should work together to co-develop: (1) patient-centric governance for gene therapy in Africa, (2) public engagement and education materials, and (3) decision making toolkits for trial participants. It is also critical to establish harmonised ethical and regulatory frameworks for gene therapy in Africa, and for global health agencies to accelerate access to basic care for SCD in Africa, while simultaneously strengthening capacity for gene therapy.
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Affiliation(s)
- Nchangwi Syntia Munung
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Obiageli E Nnodu
- Centre of Excellence for Sickle Cell Disease Research and Training (CESRTA), University of Abuja, Abuja, Nigeria
| | - Patrick Ohiani Moru
- Centre of Excellence for Sickle Cell Disease Research and Training (CESRTA), University of Abuja, Abuja, Nigeria
| | - Akpaka A Kalu
- World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
| | - Benido Impouma
- World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
| | - Marsha J Treadwell
- Department of Pediatrics, Division of Hematology, University of California San Francisco, Oakland, CA, USA
| | - Ambroise Wonkam
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- McKusick-Nathans Institute & Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Treadwell MJ. Mental health and psychological resilience in sickle cell disease. Lancet Haematol 2023:S2352-3026(23)00166-7. [PMID: 37451306 DOI: 10.1016/s2352-3026(23)00166-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Marsha J Treadwell
- Division of Hematology, Department of Pediatrics, Sickle Cell Center of Excellence, University of California San Francisco, Oakland, CA 94609, USA.
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Treadwell MJ, Mushiana S, Badawy SM, Preiss L, King AA, Kroner B, Chen Y, Glassberg J, Gordeuk V, Shah N, Snyder A, Wun T. An evaluation of patient-reported outcomes in sickle cell disease within a conceptual model. Qual Life Res 2022; 31:2681-2694. [PMID: 35445915 PMCID: PMC9356962 DOI: 10.1007/s11136-022-03132-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To examine the relations between patient-reported outcomes (PROs) within a conceptual model for adults with sickle cell disease (SCD) ages 18 - 45 years enrolled in the multi-site Sickle Cell Disease Implementation Consortium (SCDIC) registry. We hypothesized that patient and SCD-related factors, particularly pain, and barriers to care would independently contribute to functioning as measured using PRO domains. METHODS Participants (N = 2054) completed a 48-item survey including socio-demographics and PRO measures, e.g., social functioning, pain impact, emotional distress, and cognitive functioning. Participants reported on lifetime SCD complications, pain episode frequency and severity, and barriers to healthcare. RESULTS Higher pain frequency was associated with higher odds of worse outcomes in all PRO domains, controlling for age, gender and site (OR range 1.02-1.10, 95% CI range [1.004-1.12]). Reported history of treatment for depression was associated with 5 of 7 PRO measures (OR range 1.58-3.28 95% CI range [1.18-4.32]). Fewer individual barriers to care and fewer SCD complications were associated with better outcomes in the emotion domain (OR range 0.46-0.64, 95% CI range [0.34-0.86]). CONCLUSIONS Study results highlight the importance of the biopsychosocial model to enhance understanding of the needs of this complex population, and to design multi-dimensional approaches for providing more effective interventions to improve outcomes.
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Affiliation(s)
- Marsha J Treadwell
- University of California San Francisco Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA.
| | | | - Sherif M Badawy
- Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Liliana Preiss
- Research Triangle International, Research Triangle Park, NC, USA
| | | | - Barbara Kroner
- Research Triangle International, Research Triangle Park, NC, USA
| | - Yumei Chen
- University of California San Francisco Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA
| | | | | | | | | | - Theodore Wun
- University of California Davis, Sacramento, CA, USA
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Treadwell MJ, Du L, Bhasin N, Marsh AM, Wun T, Bender MA, Wong TE, Crook N, Chung JH, Norman S, Camilo N, Cavazos J, Nugent D. Barriers to hydroxyurea use from the perspectives of providers, individuals with sickle cell disease, and families: Report from a U.S. regional collaborative. Front Genet 2022; 13:921432. [PMID: 36092883 PMCID: PMC9461276 DOI: 10.3389/fgene.2022.921432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited blood disorder that affects about 100,000 people in the U.S., primarily Blacks/African-Americans. A multitude of complications negatively impacts quality of life. Hydroxyurea has been FDA approved since 1998 as a disease-modifying therapy for SCD, but is underutilized. Negative and uninformed perceptions of hydroxyurea and barriers to its use hinder adherence and promotion of the medication. As the largest real-world study to date that assessed hydroxyurea use for children and adults with SCD, we gathered and analyzed perspectives of providers, individuals with SCD, and families. Participants provided information about socio-demographics, hospital and emergency admissions for pain, number of severe pain episodes interfering with daily activities, medication adherence, and barriers to hydroxyurea. Providers reported on indications for hydroxyurea, reasons not prescribed, and current laboratory values. We found that hydroxyurea use was reported in over half of eligible patients from this large geographic region in the U.S., representing a range of sickle cell specialty clinical settings and practices. Provider and patient/caregiver reports about hydroxyurea use were consistent with one another; adults 26 years and older were least likely to be on hydroxyurea; and the likelihood of being on hydroxyurea decreased with one or more barriers. Using the intentional and unintentional medication nonadherence framework, we found that, even for patients on hydroxyurea, challenges to taking the medicine at the right time and forgetting were crucial unintentional barriers to adherence. Intentional barriers such as worry about side effects and “tried and it did not work” were important barriers for young adults and adults. For providers, diagnoses other than HgbSS or HgbS-β0 thalassemia were associated with lower odds of prescribing, consistent with evidence-based guidelines. Our results support strengthening provider understanding and confidence in implementing existing SCD guidelines, and the importance of shared decision making. Our findings can assist providers in understanding choices and decisions of families; guide individualized clinical discussions regarding hydroxyurea therapy; and help with developing tailored interventions to address barriers. Addressing barriers to hydroxyurea use can inform strategies to minimize similar barriers in the use of emerging and combination therapies for SCD.
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Affiliation(s)
- Marsha J. Treadwell
- Division of Hematology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
- *Correspondence: Marsha J. Treadwell,
| | - Lisa Du
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Neha Bhasin
- Division of Hematology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Anne M. Marsh
- Division of Hematology/Oncology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Theodore Wun
- Division of Hematology and Oncology, Department of Internal Medicine, University of California, Davis, Davis, CA, United States
| | - M. A. Bender
- Odessa Brown Children’s Clinic, Seattle Children’s Hospital, Seattle, WA, United States
| | - Trisha E. Wong
- Division of Pediatric Hematology and Oncology and Department of Pathology, Oregon Health and Sciences University, Portland, OR, United States
| | - Nicole Crook
- Center for Inherited Blood Disorders, Orange, CA, United States
| | - Jong H. Chung
- Hematology-Oncology, Department of Pediatrics, University of California, Davis, Davis, CA, United States
| | - Shannon Norman
- Alaska Bleeding Disorders Clinic, Anchorage, AK, United States
| | - Nicolas Camilo
- St. Luke’s Children’s Cancer Institute, Boise, ID, United States
| | - Judith Cavazos
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Diane Nugent
- Center for Inherited Blood Disorders, Orange, CA, United States
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Masese RV, Bulgin D, Knisely MR, Preiss L, Stevenson E, Hankins JS, Treadwell MJ, King AA, Gordeuk VR, Kanter J, Gibson R, Glassberg JA, Tanabe P, Shah N. Sex-based differences in the manifestations and complications of sickle cell disease: Report from the Sickle Cell Disease Implementation Consortium. PLoS One 2021; 16:e0258638. [PMID: 34714833 PMCID: PMC8555833 DOI: 10.1371/journal.pone.0258638] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Sex-based clinical outcome differences in sickle cell disease (SCD) remain largely unknown despite evidence that female sex is associated with an increased lifespan. To better characterize sex-based differences in SCD, we assessed pain, treatment characteristics, laboratory measures and complications among males and females currently enrolled in the Sickle Cell Disease Implementation Consortium (SCDIC) registry. METHODS The SCDIC consists of eight comprehensive SCD centers and one data coordinating center that received funding from the National Heart Lung and Blood Institute to improve outcomes for individuals with SCD. Eligibility criteria included: 15 to 45 years of age and a confirmed diagnosis of SCD. Self-report surveys were completed and data were also abstracted from the participants' medical records. RESULTS A total of 2,124 participants were included (mean age: 27.8 years; 56% female). The majority had hemoglobin SS SCD genotype. Females had worse reports of pain severity (mean (SD) T-score 51.6 (9.6) vs 49.3 (10), p<0.001), more vaso-occlusive episodes (p = 0.01) and a higher occurrence of 3 or more hospital admissions in the past year (30.9% vs. 25.5, p = 0.03). On multivariable analysis, males had higher odds of acute chest syndrome (odds ratio (OR) 1.4, p = 0.002), cardiovascular (OR 1.70, p<0.001) and musculoskeletal (OR 1.33, p = 0.0034) complications and lower odds of depression (OR 0.77, p = 0.0381). Females had higher fetal hemoglobin levels with and without hydroxyurea use (9.6% vs 8.5%, p = 0.03 and 3% vs 2.2%, p = 0.0005, respectively). CONCLUSION Our data suggests that sex differences in clinical outcomes do occur among individuals with SCD. Future research needs to explore the mechanisms underlying these differences.
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Affiliation(s)
- Rita V. Masese
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Dominique Bulgin
- College of Nursing, University of Tennessee Knoxville, Knoxville, Tennessee, United States of America
| | - Mitchell R. Knisely
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Liliana Preiss
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Eleanor Stevenson
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Jane S. Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Marsha J. Treadwell
- Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, Oakland, California, United States of America
| | - Allison A. King
- School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Victor R. Gordeuk
- University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Julie Kanter
- University of Alabama, Birmingham, Alabama, United States of America
| | - Robert Gibson
- Department of Emergency Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | - Jeffrey A. Glassberg
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Paula Tanabe
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Nirmish Shah
- School of Nursing, Duke University, Durham, North Carolina, United States of America
- School of Medicine, Duke University, Durham, North Carolina, United States of America
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Faro EZ, Shook L, Treadwell MJ, King AA, Whiteman LN, Ivy ED, Hulihan M, Kavanagh PL, Selk S, Oyeku S, Berns SD. A National Measurement Framework to Assess and Improve Sickle Cell Care in 4 US Regions. Public Health Rep 2020; 135:442-451. [PMID: 32639897 DOI: 10.1177/0033354920935068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Coordinated measurement strategies are needed to inform collaborative approaches to improve access to and quality of care for persons with sickle cell disease (SCD). The objective of our study was to develop a multilevel measurement strategy to assess improvements in access to and quality of care for persons with SCD in 4 US regions. METHODS From 2014 through 2017, regional grantees in the Sickle Cell Disease Treatment Demonstration Program collected administrative and patient-level electronic health record (EHR) data to assess quality improvement initiatives. Four grantees-covering 29 US states and territories and an SCD population of 56 720-used a collective impact model to organize their work. The grantees collected administrative data from state Medicaid and Medicaid managed care organizations (MCOs) at multiple points during 2014-2017 to assess improvements at the population level, and local patient-level data were abstracted from site-level EHRs at regular intervals to track improvements over time. RESULTS Administrative data were an important source of understanding population-level improvements but were delayed, whereas patient-level data were more sensitive to small-scale quality improvements. CONCLUSIONS We established a shared measurement approach in partnership with Medicaid and Medicaid MCO stakeholders that can be leveraged to effectively support quality improvement initiatives for persons with SCD in the United States.
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Affiliation(s)
- Elissa Z Faro
- Albert Einstein College of Medicine, Bronx, NY, USA.,37292 Children's Hospital at Montefiore, Bronx, NY, USA
| | - Lisa Shook
- 2518 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Cincinnati Comprehensive Sickle Cell Center, Cincinnati, OH, USA
| | - Marsha J Treadwell
- 6164 Department of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Allison A King
- 12275 Washington University School of Medicine, St Louis, MO, USA
| | - Lauren N Whiteman
- 116031 Washington/Baltimore High Intensity Drug Trafficking Areas Program, George Mason University, Fairfax, VA, USA
| | - E Donnell Ivy
- 374349 Hemoglobinopathies Programs, Genetic Services Branch, Division of Services for Children With Special Health Needs, Maternal and Child Health Bureau, Health Resources and Services Administration, Washington, DC, USA
| | - Mary Hulihan
- 1242 Epidemiology and Surveillance Branch, Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Patricia L Kavanagh
- 12259 Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA.,Pediatric Emergency Department, Boston Medical Center, Boston, MA, USA
| | - Sabrina Selk
- 1854 Office of Health Equity, Massachusetts Department of Public Health, Boston, MA, USA
| | - Suzette Oyeku
- Albert Einstein College of Medicine, Bronx, NY, USA.,37292 Children's Hospital at Montefiore, Bronx, NY, USA
| | - Scott D Berns
- 50980 National Institute for Children's Health Quality, Boston, MA, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA.,Brown University School of Public Health, Providence, RI, USA
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Kayle M, Valle J, Paulukonis S, Holl JL, Tanabe P, French DD, Garg R, Liem RI, Badawy SM, Treadwell MJ. Impact of Medicaid expansion on access and healthcare among individuals with sickle cell disease. Pediatr Blood Cancer 2020; 67:e28152. [PMID: 32147964 PMCID: PMC7096276 DOI: 10.1002/pbc.28152] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/03/2019] [Accepted: 12/13/2019] [Indexed: 11/05/2022]
Abstract
PURPOSE Sickle cell disease (SCD) is associated with high acute healthcare utilization. The purpose of this study was to examine whether Medicaid expansion in California increased Medicaid enrollment, increased hydroxyurea prescriptions filled, and decreased acute healthcare utilization in SCD. METHODS Individuals with SCD (≤65 years and enrolled in Medicaid for ≥6 total calendar months any year between 2011 and 2016) were identified in a multisource database maintained by the California Sickle Cell Data Collection Program. We describe trends and changes in Medicaid enrollment, hydroxyurea prescriptions filled, and emergency department (ED) visits and hospital admissions before (2011-2013) and after (2014-2016) Medicaid expansion in California. RESULTS The cohort included 3635 individuals. Enrollment was highest in 2014 and lowest in 2016 with a 2.8% annual decease postexpansion. Although <20% of the cohort had a hydroxyurea prescription filled, the percentage increased by 5.2% annually after 2014. The ED visit rate was highest in 2014 and decreased slightly in 2016, decreasing by 1.1% annually postexpansion. Hospital admission rates were similar during the pre- and postexpansion periods. Young adults and adults had higher ED and hospital admission rates than children and adolescents. CONCLUSIONS Medicaid expansion does not appear to have improved enrollment or acute healthcare utilization among individuals with SCD in California. Future studies should explore whether individuals with SCD transitioned to other insurance plans or became uninsured postexpansion, the underlying reasons for low hydroxyurea utilization, and the lack of effect on hospital admissions despite a modest effect on ED visits.
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Affiliation(s)
| | - Jhaqueline Valle
- Sickle Cell Data Collection Program, Tracking California/ Public Health Institute, Richmond, California
| | - Susan Paulukonis
- Sickle Cell Data Collection Program, Tracking California/ Public Health Institute, Richmond, California
| | - Jane L. Holl
- Biological Sciences Division, University of Chicago, Chicago, IL
| | | | - Dustin D. French
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois USA,Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois USA,Veterans Affairs Health Services Research and Development Service, Chicago, Illinois USA
| | - Ravi Garg
- Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois USA
| | - Robert I. Liem
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL,Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Sherif M. Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL,Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Marsha J. Treadwell
- University of California San Francisco Benioff Children’s Hospital, Oakland, CA
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10
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Smith WR, Sisler IY, Johnson S, Lipato TJ, Newlin JS, Owens ZS, Morgan AM, Treadwell MJ, Polak K. Lessons Learned from Building a Pediatric-to-Adult Sickle Cell Transition Program. South Med J 2019; 112:190-197. [PMID: 30830235 DOI: 10.14423/smj.0000000000000950] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE More effective transitions and transfers of young people with sickle cell disease (SCD) into the adult healthcare setting is a focus of both primary care and specialty care medical organizations. Effective transition and transfer requires six core elements: establishing a policy, tracking progress, administering transition readiness assessments, planning for adult care, transferring to adult care, and integrating into an adult practice. We developed a program using these six core elements. The objective of our report was to assess the development and implementation of this program. METHODS We used the six core elements to develop and implement a program at Virginia Commonwealth University for children and adolescents with SCD to transition to adult health care. RESULTS We assessed individuals' differences by age and grade, their independent living skills, their feelings about moving to adult care; tallied and analyzed several assessment scales; and assessed transfer success and patient retention. CONCLUSIONS The principles and lessons we learned in developing and implementing this program over 5 years, accompanied by caring, flexible, and dedicated care team members, often can overcome even severe barriers to care transitions.
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Affiliation(s)
- Wally R Smith
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
| | - India Y Sisler
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
| | - Shirley Johnson
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
| | - Thokozeni J Lipato
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
| | - Jennifer S Newlin
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
| | - Zakiya S Owens
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
| | - Alma M Morgan
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
| | - Marsha J Treadwell
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
| | - Kathryn Polak
- From the Department of Internal Medicine, Division of General Internal Medicine, Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Psychology, Virginia Commonwealth University, Richmond, and Department of Hematology/Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco
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11
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Cabana MD, Kanter J, Marsh AM, Treadwell MJ, Rowland M, Stemmler P, Bardach NS. Barriers to Pediatric Sickle Cell Disease Guideline Recommendations. Glob Pediatr Health 2019; 6:2333794X19847026. [PMID: 31106244 PMCID: PMC6501475 DOI: 10.1177/2333794x19847026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/08/2019] [Accepted: 04/08/2019] [Indexed: 12/04/2022] Open
Abstract
National guidelines recommend that providers counsel all patients with sickle cell anemia about hydroxyurea (HU) therapy and screen children with sickle cell anemia annually for the risk of stroke with transcranial Doppler (TCD). We surveyed a national convenience sample of sickle cell disease clinicians to assess factors associated with low adherence. Adherence was 46% for TCD screening. Low adherence was associated with a lack of outcome expectancy (eg, a belief that there would be poor patient follow-up to TCD testing; P < .05). Adherence was 72% for HU counseling. Practice barriers (eg, lack of support staff or time) and a lack of agreement with HU recommendations were associated with low adherence (P < .05). This study demonstrates that different types of strategies are needed to improve TCD screening (to address follow-up and access to testing) versus HU counseling (to address physician agreement and practice barriers).
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Affiliation(s)
- Michael D Cabana
- University of California, San Francisco, CA, USA.,UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Julie Kanter
- Medical University of South Carolina, Charleston, SC, USA
| | - Anne M Marsh
- UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Marsha J Treadwell
- University of California, San Francisco, CA, USA.,UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Michael Rowland
- University of California, San Francisco, CA, USA.,UCSF Benioff Children's Hospital, Oakland, CA, USA
| | | | - Naomi S Bardach
- University of California, San Francisco, CA, USA.,UCSF Benioff Children's Hospital, San Francisco, CA, USA
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12
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DiMartino LD, Baumann AA, Hsu LL, Kanter J, Gordeuk VR, Glassberg J, Treadwell MJ, Melvin CL, Telfair J, Klesges LM, King A, Wun T, Shah N, Gibson RW, Hankins JS. The sickle cell disease implementation consortium: Translating evidence-based guidelines into practice for sickle cell disease. Am J Hematol 2018; 93:E391-E395. [PMID: 30203558 PMCID: PMC6503654 DOI: 10.1002/ajh.25282] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 09/05/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | - Ana A Baumann
- Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri
| | - Lewis L Hsu
- Division of Pediatric Hematology-Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Julie Kanter
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Victor R Gordeuk
- Division of Pediatric Hematology-Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Jeffrey Glassberg
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marsha J Treadwell
- University of California, San Francisco Benioff Children's Hospital Oakland, Oakland, California
| | - Cathy L Melvin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Joseph Telfair
- Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia
| | - Lisa M Klesges
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Allison King
- School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Ted Wun
- University of California, Davis School of Medicine, Sacramento, California
| | - Nirmish Shah
- Division of Hematology, Duke University School of Medicine, Durham, North Carolina
| | - Robert W Gibson
- Department of Emergency Medicine and Hospitalist Services, Augusta University, Augusta, Georgia
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
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13
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Dennis-Antwi JA, Ohene-Frempong K, Anie KA, Dzikunu H, Agyare VA, Boadu RO, Antwi JS, Asafo MK, Anim-Boamah O, Asubonteng AK, Agyei S, Wonkam A, Treadwell MJ. Relation Between Religious Perspectives and Views on Sickle Cell Disease Research and Associated Public Health Interventions in Ghana. J Genet Couns 2018; 28:10.1007/s10897-018-0296-7. [PMID: 30171429 PMCID: PMC6395545 DOI: 10.1007/s10897-018-0296-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 08/22/2018] [Indexed: 01/08/2023]
Abstract
Sickle cell disease (SCD) is highly prevalent in Africa with a significant public health burden for under-resourced countries. We employed qualitative research methods to understand the ethical, legal, and social implications of conducting genomic research in SCD under the Human Heredity and Health in Africa (H3Africa) initiative. The present study focused on religious and cultural aspects of SCD with the view to identifying beliefs and attitudes relevant to public health interventions in Ghana. Thematic analyses from individual and group interviews revealed six key areas of importance, namely, reliance on a supreme being; religion as a disruptive influence on health behaviors; role of religious leaders in information sharing and decision-making; social, religious, and customary norms; health and religious/supernatural beliefs; and need for social education and support through church and community. Findings suggest that public health programs in Ghana should not only aim at increasing knowledge and awareness about SCD and its management but also create an understanding of the relevance of genomics and alternative technological advancement to diagnosis and ethical decision-making around available options for health seeking. Future research should engage communities to help address the ethical and social implications of a persuasive religious influence on SCD-related health decisions.
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Affiliation(s)
- Jemima A Dennis-Antwi
- Ghana College of Nurses and Midwives, Accra, Ghana
- Sickle Cell Foundation of Ghana, Accra, Ghana
| | | | - Kofi A Anie
- Hematology and Sickle Cell Centre, London North West University Healthcare NHS Trust and Imperial College London, London, UK
| | | | | | | | | | - Mabel K Asafo
- Regional Health Administration, Ghana Health Services, Kumasi, Ashanti Region, Ghana
| | | | | | | | - Ambroise Wonkam
- Division of Human Genetics, Department of Clinical Laboratory Sciences, National Health Laboratory Service and University of Cape Town, Cape Town, South Africa
| | - Marsha J Treadwell
- Department of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA.
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14
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Keller S, Yang M, Treadwell MJ, Hassell KL. Sensitivity of alternative measures of functioning and wellbeing for adults with sickle cell disease: comparison of PROMIS® to ASCQ-Me℠. Health Qual Life Outcomes 2017; 15:117. [PMID: 28577358 PMCID: PMC5455105 DOI: 10.1186/s12955-017-0661-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 04/20/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Sickle Cell Disease (SCD) causes profound suffering and decrements in daily functioning. Demand is growing for valid and reliable measures to systematically document these effects, particularly in adults. The Adult Sickle Cell Quality of Life Measurement System, ASCQ-Me℠, was developed for this purpose. ASCQ-Me℠ is one of four measurement systems housed within the Person-Centered Assessment Resource (PCAR), funded by the National Institutes of Health, to support clinical research. To help users select the best of these measures for adults with SCD, we evaluated and compared two PCAR systems: one designed to be "universally applicable" (the Patient-Reported Outcome Measurement Information System, PROMIS®) and one designed specifically for SCD (ASCQ-Me℠). METHODS Respondents to PROMIS and ASCQ-Me questions were 490 adults with SCD from seven geographically-disbursed clinics within the US. Data were collected for six ASCQ-Me measures (Emotional Impact, Sleep Impact, Social Impact, Stiffness Impact, Pain Impact, SCD Pain Episode Frequency and Severity) and ten PROMIS measures (Pain Impact, Pain Behavior, Physical Functioning, Anxiety, Depression, Fatigue, Satisfaction with Discretionary Social Activities, Satisfaction with Social Roles, Sleep Disturbance, and Sleep-Related Impairment). Statistical analyses, including analysis of variance and multiple linear regression, were conducted to determine the sensitivity of measures to SCD severity. SCD severity was assessed via a checklist of associated treatments and conditions. RESULTS For those with the most severe SCD, PROMIS scores showed worse health compared to the general population for nine of ten health domains: the magnitude of the difference ranged 0.5 to 1.1 standard deviation units. The PROMIS domains most severely affected were Physical Functioning and Pain (Impact and Behavior). Significant differences by tertile of the SCD-MHC were shown for most PROMIS short forms and all ASCQ-Me short and fixed forms. In most models, ASCQ-Me measures explained statistically significant unique variance in SCD-MHC scores complementary to that explained by corresponding PROMIS measures. CONCLUSIONS Study results supported the validity of both PROMIS and ASCQ-Me measures for use in adults with SCD. Compared to comparable PROMIS scores, most ASCQ-Me scores were better predictors of SCD disease severity, as measured by a medical history checklist. The clinical implications of these results require further investigation.
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Affiliation(s)
- San Keller
- American Institutes for Research, 100 Europa Drive, Suite 315, Chapel Hill, NC 27517-2357 USA
| | - Manshu Yang
- American Institutes for Research, 100 Europa Drive, Suite 315, Chapel Hill, NC 27517-2357 USA
| | - Marsha J. Treadwell
- Children’s Hospital & Research Center Oakland, 747 52nd Street, Oakland, CA 94609 USA
| | - Kathryn L. Hassell
- Division of Hematology, University of Colorado, 12700 E. 19th Avenue, Rm 9122 RC 2/MS B170, Aurora, CO 80045 USA
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15
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Paulukonis ST, Feuchtbaum LB, Coates TD, Neumayr LD, Treadwell MJ, Vichinsky EP, Hulihan MM. Emergency department utilization by Californians with sickle cell disease, 2005-2014. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26390. [PMID: 28000344 PMCID: PMC5403550 DOI: 10.1002/pbc.26390] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/14/2016] [Accepted: 10/31/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Clinical care for children and adults living with sickle cell disease (SCD) is often provided in the emergency department (ED). Population-based surveillance data can be used to describe the ED utilization patterns of this patient population. PROCEDURE A cohort of pediatric and adult California patients with SCD was identified from multiple data sources, and 10 years (2005-2014) of their treat-and-release ED utilization data were analyzed. RESULTS Among a cohort of 4,636 patients with SCD, 4,100 (88%) had one or more treat-and-release ED visits. There were 2.1 mean annual visits per person for the cohort (median 0.7; range 0-185). In a single year (2005), 53% had 0 treat-and-release ED visits, 35% had 1-3 visits, 9% had 4-10 visits, and 3% had 11 or more visits; this highest utilization group accounted for 45% of all patients' ED visits. ED utilization in this cohort was highest among young adults and also higher among older adults than pediatric patients. CONCLUSION The majority of identified patients in each of the 10 years did not go to the ED, but nearly all had one or more such visits over the full span of time. This study highlights the power and utility of a multisource longitudinal data collection effort for SCD. Further study of the segment of the population with highest ED utilization may highlight areas where changes in healthcare and health policy could improve and extend the lives of patients with SCD.
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Affiliation(s)
- Susan T. Paulukonis
- California Rare Disease Surveillance Program, Public Health Institute, Richmond, California
| | - Lisa B. Feuchtbaum
- Genetic Disease Screening Program, California Department of Public Health, Richmond, California
| | - Thomas D. Coates
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Lynne D. Neumayr
- Division of Hematology/Oncology, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, California
| | - Marsha J. Treadwell
- Division of Hematology/Oncology, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, California
| | - Elliott P. Vichinsky
- Division of Hematology/Oncology, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, California
| | - Mary M. Hulihan
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
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16
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Treadwell MJ, Makani J, Ohene-Frempong K, Ofori-Acquah S, McCurdy S, de Vries J, Bukini D, Dennis-Antwi J, Kamga KK, Mbekenga C, Wonkam ET, Tangwa G, Royal CD, Wonkam A. Stakeholder Perspectives on Public Health Genomics Applications for Sickle Cell Disease: A Methodology for a Human Heredity and Health in Africa (H3Africa) Qualitative Research Study. OMICS 2017; 21:323-332. [PMCID: PMC5488382 DOI: 10.1089/omi.2017.0047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Advances in omics technologies alone are not a guarantee that science will translate to robust responsible innovation that is firmly grounded in societal values. This study aimed to identify best practices for Ethical, Legal, and Social Implications (ELSI) research in Africa that allows for optimal integration of community perspectives into the design and implementation of genomics research. In a large sample of 346 stakeholders in Cameroon, Ghana, and Tanzania (59% women), we used a qualitative study design with a phenomenological approach and conducted 32 group and 74 individual interviews (25% rural). We imported interview recordings into NVivo software for analysis. We created a “concept map” to organize the coded information, with Perspectives on Genomics and Sickle Cell Disease (SCD) Public Health Interventions as the central themes. We found that (1) analyses of major subthemes across and within countries revealed differential knowledge and experiences of SCD, and perspectives on various aspects of research and genomics; (2) we were able to gather empirical data efficiently from urban and rural stakeholders, to study the issues related to sample sharing, consent processes, and return of clinical and genomic study results; (3) the concept of nondirectiveness in modern genetic medicine practice can be challenged by the views of stakeholders in the context of a high-burden disease such as SCD; and (4) linking community views to current and proposed public health interventions could be understood within the context of each specific country. Our work informs future qualitative social science and technology policy research designs on genomics applications in Africa.
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Affiliation(s)
- Marsha J. Treadwell
- Department of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Julie Makani
- Sickle Cell Disease Programme, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Solomon Ofori-Acquah
- Center for Translational and International Hematology, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sheryl McCurdy
- Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, Houston, Texas
| | - Jantina de Vries
- Bioethics Centre, University of Cape Town, Cape Town, South Africa
| | - Daima Bukini
- Sickle Cell Disease Programme, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Karen Kengne Kamga
- University of Yaoundé 1, Faculty of Medical and Biomedical Sciences, Yaoundé, Cameroon
| | - Columba Mbekenga
- Sickle Cell Disease Programme, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Edmond Tingang Wonkam
- University of Yaoundé 1, Faculty of Medical and Biomedical Sciences, Yaoundé, Cameroon
| | - Godfrey Tangwa
- University of Yaoundé 1, Faculty of Medical and Biomedical Sciences, Yaoundé, Cameroon
| | - Charmaine D. Royal
- Center on Genomics, Race, Identity, Difference (GRID), Duke University, Durham
| | - Ambroise Wonkam
- Division of Human Genetics, Department of Medicine, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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17
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Evensen CT, Treadwell MJ, Keller S, Levine R, Hassell KL, Werner EM, Smith WR. Quality of care in sickle cell disease: Cross-sectional study and development of a measure for adults reporting on ambulatory and emergency department care. Medicine (Baltimore) 2016; 95:e4528. [PMID: 27583862 PMCID: PMC5008546 DOI: 10.1097/md.0000000000004528] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Documented deficiencies in adult sickle cell disease (SCD) care include poor access to knowledgeable providers and inadequate treatment in emergency departments (EDs).The aim of this study was to create patient-reported outcome measures of the quality of ambulatory and ED care for adults with SCD.We developed and pilot tested SCD quality of care questions consistent with Consumer Assessments of Healthcare Providers and Systems surveys. We applied psychometric methods to develop scores and evaluate reliability and validity.The participants of this study were adults with SCD (n = 556)-63% aged 18 to 34 years; 64% female; 64% SCD-SS-at 7 US sites.The measure used was Adult Sickle Cell Quality of Life Measurement information system Quality of Care survey.Most participants (90%) reported at least 1 severe pain episode (pain intensity 7.8 ± 2.3, 0-10 scale) in the past year. Most (81%) chose to manage pain at home rather than the ED, citing negative ED experiences (83%). Using factor analysis, we identified Access, Provider Interaction, and ED Care composites with reliable scores (Cronbach α 0.70-0.83) and construct validity (r = 0.32-0.83 correlations with global care ratings). Compared to general adult Consumer Assessments of Healthcare Providers and Systems scores, adults with SCD had worse care, adjusted for age, education, and general health.Results were consistent with other research reflecting deficiencies in ED care for adults with SCD. The Adult Sickle Cell Quality of Life Measurement Quality of Care measure is a useful self-report measure for documenting and tracking disparities in quality of SCD care.
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Affiliation(s)
| | - Marsha J. Treadwell
- Department of Hematology/Oncology, University of California San Francisco Benioff Children's Hospital Oakland, Oakland, CA
- Correspondence: Marsha J. Treadwell, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA 94609 (e-mail: )
| | - San Keller
- American Institutes for Research, Chapel Hill, NC
| | | | | | - Ellen M. Werner
- Blood Epidemiology and Clinical Therapeutics Branch, Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Wally R. Smith
- Division of General Internal Medicine, Virginia Commonwealth University, Richmond, VA
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18
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Anie KA, Treadwell MJ, Grant AM, Dennis-Antwi JA, Asafo MK, Lamptey ME, Ojodu J, Yusuf C, Otaigbe A, Ohene-Frempong K. Community engagement to inform the development of a sickle cell counselor training and certification program in Ghana. J Community Genet 2016; 7:195-202. [PMID: 27090687 DOI: 10.1007/s12687-016-0267-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 04/10/2016] [Indexed: 12/22/2022] Open
Abstract
Sickle cell disease (SCD) and sickle cell trait (SCT) are highly prevalent in Africa. Despite public health implications, there is limited understanding of community issues for implementing newborn screening and appropriate family counseling. We conducted a 3-day workshop in Kumasi, Ghana, with community leaders as lay program development advisors to assist the development and implementation of a Sickle Cell Counselor Training and Certification Program. We employed qualitative methods to understand cultural, religious, and psychosocial dimensions of SCD and SCT, including the advisors' attitudes and beliefs in relation to developing a culturally sensitive approach to family education and counseling that is maximally suited to diverse communities in Ghana. We collated advisors' discussions and observations in order to understand community issues and potential challenges and guide strategies for advocacy in SCD family education and counseling. Results from the workshop revealed that community leaders representing diverse communities in Ghana were engaged constructively in discussions about developing a culturally sensitive counselor training program. Key findings included the importance of improved knowledge about SCD among the public and youth in particular, the value of stakeholders such as elders and religious and traditional leaders, and government expectations of reduced SCD births. We submitted a report to the Ministry of Health in Ghana with recommendations for the next steps in developing a national sickle cell counselor training program. We named the program "Genetic Education and Counseling for Sickle Cell Conditions in Ghana" (GENECIS-Ghana). The first GENECIS-Ghana Training and Certification Program Workshop was conducted from June 8 to 12, 2015.
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Affiliation(s)
- Kofi A Anie
- Haematology and Sickle Cell Centre, London North West Healthcare NHS Trust, Central Middlesex Hospital, London, NW10 7NS, UK. .,Imperial College London, London, UK.
| | - Marsha J Treadwell
- University of California San Francisco Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Althea M Grant
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jemima A Dennis-Antwi
- International Confederation of Midwives Investing in Midwives Program, Accra, Ghana.,Sickle Cell Foundation of Ghana, Kumasi, Ghana
| | - Mabel K Asafo
- Ashanti Region Health Promotion Office, Kumasi, Ghana
| | - Mary E Lamptey
- Sickle Cell Foundation of Ghana, Kumasi, Ghana.,National Newborn Screening Program for Sickle Cell Disease, Accra, Ghana
| | - Jelili Ojodu
- Association of Public Health Laboratories, Silver Spring, MD, USA
| | - Careema Yusuf
- Association of Public Health Laboratories, Silver Spring, MD, USA
| | - Ayo Otaigbe
- Sickle Cell Foundation Nigeria, Lagos, Nigeria
| | - Kwaku Ohene-Frempong
- Sickle Cell Foundation of Ghana, Kumasi, Ghana.,National Newborn Screening Program for Sickle Cell Disease, Accra, Ghana.,Children's Hospital of Philadelphia, Philadelphia, PA, USA
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20
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Treadwell MJ, Anie KA, Grant AM, Ofori-Acquah SF, Ohene-Frempong K. Using formative research to develop a counselor training program for newborn screening in Ghana. J Genet Couns 2014; 24:267-77. [PMID: 25193810 DOI: 10.1007/s10897-014-9759-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 08/13/2014] [Indexed: 10/24/2022]
Abstract
Sickle cell disease (SCD), sickle cell trait (SCT) and related conditions are highly prevalent in sub-Saharan Africa. Despite the public health implications, there is limited understanding of the unique needs regarding establishing and implementing extensive screening for newborns and appropriate family counseling. We sought to gain understanding of community attitudes and beliefs about SCD/SCT from counselors and potential counselors in Ghana; obtain their input about goals for counseling following newborn screening; and obtain guidance about developing effective counselor education. Five focus groups with 32 health care providers and health educators from 9 of 10 regions in Ghana were conducted by trained facilitators according to a structured protocol. Qualitative data were coded and categorized to reflect common themes. Saturation was achieved in themes related to genetics/inheritance; common complications of SCD; potential for stigmatization; marital strain; and emotional stress. Misconceptions about SCT as a form of SCD were prevalent as were cultural and spiritual beliefs about the causes of SCD/SCT. Potential positive aspects included affected children's academic achievement as compensation for physical limitations, and family cohesion. This data informed recommendations for content and structure of a counselor training program that was provided to the Ministry of Health in Ghana.
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Affiliation(s)
- Marsha J Treadwell
- Hematology/Oncology Department, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA,
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21
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Treadwell MJ, Bell M, Leibovich SA, Barreda F, Marsh A, Gildengorin G, Morris CR. A Quality Improvement Initiative to Improve Emergency Department Care for Pediatric Patients with Sickle Cell Disease. J Clin Outcomes Manag 2014; 21:62-70. [PMID: 26412961 PMCID: PMC4580258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To determine whether a quality improvement (QI) initiative would result in more timely assessment and treatment of acute sickle cell-related pain for pediatric patients with sickle cell disease (SCD) treated in the emergency department (ED). METHODS We created and implemented a protocol for SCD pain management in the ED with the goals of improving (1) mean time from triage to first analgesic dose; (2) percentage of patients that received their first analgesic dose within 30 minutes of triage, and (3) percentage of patients who had pain assessment performed within 30 minutes of triage and who were re-assessed within 30 minutes after the first analgesic dose. RESULTS Significant improvements were achieved between baseline (55 patient visits) and post order set implementation (165 visits) in time from triage to administration of first analgesic (decreased from 89.9 ± 50.5 to 35.2 ± 22.8 minutes, P < 0.001); percentage of patient visits receiving pain medications within 30 minutes of triage (from 7% to 53%, P < 0.001); percentage of patient visits assessed within 30 minutes of triage (from 64% to 99.4%, P < 0.001); and percentage of patient visits re-assessed within 30 minutes of initial analgesic (from 54% to 86%, P < 0.001). CONCLUSIONS Implementation of a QI initiative in the ED led to expeditious care for pediatric patients with SCD presenting with pain. A QI framework provided us with unique challenges but also invaluable lessons as we address our objective of decreasing the quality gap in SCD medical care.
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Affiliation(s)
| | - Michael Bell
- Children's Hospital & Research Center Oakland, Oakland, CA
| | | | | | - Anne Marsh
- Children's Hospital & Research Center Oakland, Oakland, CA
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22
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Taylor LEV, Stotts NA, Humphreys J, Treadwell MJ, Miaskowski C. A biopsychosocial-spiritual model of chronic pain in adults with sickle cell disease. Pain Manag Nurs 2013; 14:287-301. [PMID: 24315252 PMCID: PMC3857562 DOI: 10.1016/j.pmn.2011.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 06/04/2011] [Accepted: 06/06/2011] [Indexed: 01/30/2023]
Abstract
Chronic pain in adults with sickle cell disease (SCD) is a complex multidimensional experience that includes biologic, psychologic, sociologic, and spiritual factors. To date, three models of pain associated with SCD (i.e., biomedical model, biopsychosocial model for SCD pain, and Health Beliefs Model) have been published. The biopsychosocial multidimensional approach to chronic pain developed by Turk and Gatchel is a widely used model of chronic pain. However, this model has not been applied to chronic pain associated with SCD. In addition, a spiritual/religious dimension is not included in this model. Because spirituality/religion is central to persons affected by SCD, that dimension needs to be added to any model of chronic pain in adults with SCD. In fact, data from one study suggest that spirituality/religiosity is associated with decreased pain intensity in adults with chronic pain from SCD. A biopsychosocial-spiritual model is proposed for adults with chronic pain from SCD, because it embraces the whole person. This model includes the biologic, psychologic, sociologic, and spiritual factors relevant to adults with SCD based on past and current research. The purpose of this paper is to describe an adaptation of Turk and Gatchel's model of chronic pain for adults with SCD and to summarize research findings that support each component of the revised model (i.e., biologic, psychologic, sociologic, spiritual). The paper concludes with a discussion of implications for the use of this model in research.
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Affiliation(s)
- Lou Ella V Taylor
- Department of Physiological Nursing University of California, San Francisco.
| | - Nancy A Stotts
- Department of Physiological Nursing University of California, San Francisco
| | - Janice Humphreys
- Department of Family Health Care Nursing University of California, San Francisco
| | - Marsha J Treadwell
- Sickle Cell Center, Children's Hospital and Research Center, Oakland, California
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Neumayr L, Pringle S, Giles S, Quirolo KC, Paulukonis S, Vichinsky EP, Treadwell MJ. Chart Card: feasibility of a tool for improving emergency department care in sickle cell disease. J Natl Med Assoc 2011; 102:1017-23. [PMID: 21141289 DOI: 10.1016/s0027-9684(15)30728-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with sickle cell disease (SCD) are concerned with emergency department care, including time to treatment and staff attitudes and knowledge. Providers are concerned about rapid access to patient information and SCD treatment protocols. A software application that stores and retrieves encrypted personal medical information on a plastic credit card-sized Chart Card was designed. OBJECTIVE To determine the applicability and feasibility of the Chart Card on patient satisfaction with emergency department care and provider accessibility to patient information and care protocols. METHODS One-half of 44 adults (aged -18 years) and 50 children with SCD were randomized to either the Chart Card or usual care. Patient satisfaction was surveyed pre and post implementation of the Chart Card program, and emergency department staff was surveyed about familiarity with SCD treatment protocols. CONCLUSION Patient satisfaction with emergency department care and efficacy in health care increased post Chart Card implementation. Providers valued immediate access to patient information and SCD treatment guidelines. The technology has potential for application in the treatment of other illnesses in other settings.
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Affiliation(s)
- Lynne Neumayr
- Children's Hospital and Research Center Oakland, 747 52nd St, Oakland, CA 94609, USA
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Taylor LEV, Stotts NA, Humphreys J, Treadwell MJ, Miaskowski C. A review of the literature on the multiple dimensions of chronic pain in adults with sickle cell disease. J Pain Symptom Manage 2010; 40:416-35. [PMID: 20656451 PMCID: PMC2989986 DOI: 10.1016/j.jpainsymman.2009.12.027] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 12/08/2009] [Accepted: 01/19/2010] [Indexed: 11/24/2022]
Abstract
Sickle cell disease (SCD) is a major health care and societal problem that affects millions of people worldwide. In Nigeria, 45,000 to 90,000 babies are born each year with SCD. In the United States, SCD is the most common genetic disorder, affecting more than 80,000 people, the majority of whom are African American. Sickle cell pain is the hallmark feature of SCD. Most of the research on pain from SCD has focused on children with acute pain associated with sickle cell crisis. Consequently, very little is known about the occurrence and characteristics of chronic pain, especially in adults with SCD. Individuals with SCD who experience chronic pain are often underserved, and their pain is undertreated. This undertreatment may result in millions of dollars per year spent on emergency room visits, hospitalizations, and lost work productivity. The primary purpose of this literature review was to summarize the findings from studies that evaluated the characteristics of chronic pain in adults with SCD. Each of the studies included in this review was evaluated to determine if it provided data on the following multidimensional characteristics of chronic pain: occurrence, number of pain episodes, duration, pattern, quality, location, intensity, aggravating factors, relieving factors, and impact of pain on function. A secondary purpose was to identify gaps in knowledge and directions for future research on the multiple dimensions of chronic pain in adults with SCD.
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Affiliation(s)
- Lou Ella V Taylor
- Department of Physiological Nursing, University of California at San Francisco, San Francisco, California 94143-0610, USA.
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Gold JI, Johnson CB, Treadwell MJ, Hans N, Vichinsky E. Detection and assessment of stroke in patients with sickle cell disease: neuropsychological functioning and magnetic resonance imaging. Pediatr Hematol Oncol 2008; 25:409-21. [PMID: 18569843 DOI: 10.1080/08880010802107497] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Sickle cell disease (SCD) is associated with increased risk of stroke and cognitive impairment. This study describes a retrospective review of 65 patients who underwent routine neuropsychological testing and MRI during treatment at a comprehensive sickle cell center. It was hypothesized that (1) children with no evidence of CVA would perform lower than expected on cognitive tasks compared to population-based normative data, (2) children with strokes and children with silent infarcts would perform lower on cognitive tasks and motor skills as compared to patients with no evidence of CVA, and (3) children with evidence of silent infarcts would perform better than children with known overt strokes. This final hypothesis has not been studied previously, as children with known overt stroke and silent infarct were grouped together. Sixty-five children with SCD who were sent for routine neuropsychological testing and brain MRI were identified via retrospective chart review. Patients had been administered neuropsychological tests to assess cognitive, executive and motor function. Brain MRI was obtained from each patient and was analyzed for evidence of cerebrovascular accident (CVA). Based on MRI analysis, 27% of patients with SCD had experienced a stroke and 13% a silent infarct. The majority (59%) of patients diagnosed with stroke or infarct sustained cortical damage to the frontal lobe. Patients with SCD and no evidence of CVA functioned normally on tests of cognitive ability and achievement, but patients with CVA displayed impairments in cognitive function and comparatively lower scores on verbal and performance scales. Neuropsychological testing can identify impairments in patients with SCD with no known cerebrovascular accident. Investigations of neurocognitive functioning will help characterize patterns of deficits and can inform the ability to implement comprehensive care strategies for patients with SCD and cognitive impairment.
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Affiliation(s)
- Jeffrey I Gold
- Department of Anesthesiology Critical Care Medicine, Keck School of Medicine, University of Southern California, and Childrens Hospital Los Angeles, Los Angeles, California 90027, USA.
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Treadwell MJ, McClough L, Vichinsky E. Using qualitative and quantitative strategies to evaluate knowledge and perceptions about sickle cell disease and sickle cell trait. J Natl Med Assoc 2006; 98:704-10. [PMID: 16749645 PMCID: PMC2569269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
OBJECTIVES To evaluate knowledge, perceptions and the effectiveness of different sources of information about sickle cell trait (SCT) and sickle cell disease (SCD); to determine individual knowledge of SCT status. METHODS 28 individuals participated in three focus groups (healthcare providers, people affected by SCD or SCT, and community members). Surveyors interviewed 282 respondents within their neighborhoods. RESULTS Common themes across the focus groups included the limited general awareness of SCD and SCT, the emphasis on the benign nature of SCT rather than on future implications, and the need for public health education campaigns about SCD and SCT involving media strategies. The majority of community survey respondents (n = 243, 86.2%) had correct general knowledge about the genetic basis and severity of SCD, but only 16% (n = 45) knew their own trait status. When respondents had received information about SCD from friends and acquaintances, they were three times more likely to know their SCT status, compared with respondents who had not received information from a personal source (p < 0.01). CONCLUSIONS Despite a screening history in the 1970s fraught with controversy, sickle cell disease management and detection can be a model for the empowerment of communities in making informed decisions about theirs and their families' futures, given the burgeoning of genetic information.
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Affiliation(s)
- Marsha J Treadwell
- Children's Hospital and Research Center at Oakland, 747 52nd St., Oakland, CA, USA.
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Treadwell MJ, Law AW, Sung J, Hackney-Stephens E, Quirolo K, Murray E, Glendenning GA, Vichinsky E. Barriers to adherence of deferoxamine usage in sickle cell disease. Pediatr Blood Cancer 2005; 44:500-7. [PMID: 15602707 DOI: 10.1002/pbc.20290] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND We hypothesized that child cognitive disability would be a significant risk factor for non-adherence with home deferoxamine (DFO) administration and that a factor that would contribute to improved adherence would be sharing of responsibilities for chelation between parents and patients. We explored the influences on adherence of behavioral and psychological adjustment; family stress; perceived convenience of and satisfaction with the DFO regimen; and parent and patient knowledge about DFO. PROCEDURE Fifteen pediatric patients with sickle cell disease (SCD) who had evidence of excessive iron stores, and their parents, were interviewed about adherence and responsibility for chelation therapy. A neuropsychological assessment battery was administered to the patients. Family stress, the child's emotional and behavioral status, knowledge about chelation and iron overload were explored. Adherence was rated objectively using pharmacy refill patterns and observable signs of chelation. RESULTS Sharing of responsibilities for chelation between parents and children was related to better adherence while neuropsychological status bore a complex relation to adherence. Of the exploratory variables, low family stress were related to better adherence while satisfaction with the home care regimen and convenience ratings were not useful in predicting adherence. No one element of adherence, even objective measures, was capable of classifying adherence, while a multifactorial scheme categorizing adherent, partially adherent and non-adherent groups demonstrated good face validity. CONCLUSIONS Supporting developmentally appropriate sharing of responsibilities for self-care is critical, taking patient neurocognitive status into consideration. Clinicians should evaluate adherence using a multifactorial model that highlights the most salient targets for intervention.
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Affiliation(s)
- Marsha J Treadwell
- Children's Hospital and Research Center at Oakland, Oakland, California 94609, USA.
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Abstract
OBJECTIVE To evaluate the impact of a quality improvement approach to implementing developmentally appropriate pain assessment guidelines for pediatric inpatients. Patient and staff satisfaction with pain assessment and management, and staff documentation were evaluated one year following the implementation of the revised pain assessment guidelines. DESIGN Quasi-experimental design. SETTING The pediatric hematology/oncology unit of a regional children's hospital. Study participants. A convenience sample of 36 children and 68 staff at time 1 (TI) and 49 children and 82 staff at time 2 (T2). INTERVENTIONS Staff were educated on the use of pediatric pain assessment tools and a standardized pain assessment protocol was put into practice. Children or their primary caregivers were interviewed, using a questionnaire modified from the American Pain Society quality assurance guidelines, regarding their experiences with pain assessment and management on the unit at T1, just prior to the staff education, and one year later at T2. Multidisciplinary unit staff completed a parallel questionnaire at T1 and T2. MAIN OUTCOME MEASURES Patient and staff satisfaction with pain assessment and management, and chart audit of compliance with pain assessment documentation. RESULTS Patients, family members, and staff reported increased pain assessment, improved staff responsiveness to patients' pain and greater satisfaction with assessment tools between TI and T2. Increased compliance with the assessment guidelines was confirmed by chart audit. CONCLUSIONS Improved pain assessment and management practices with resultant increase in patient and staff satisfaction can be achieved and sustained over time using quality improvement strategies.
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Abstract
We designed a study to obtain follow-up on behavioral aspects of compliance with home deferoxamine administration, explore social factors that might influence compliance, and evaluate the effectiveness of a pilot intervention program for patients with thalassemia or sickle cell disease who were receiving chronic transfusion therapy. Thirty-one patients between the ages of 6 and 21 years and their primary caregivers were administered a 24-hour recall Interview about home care. Fifteen went on to participate in a Desferal Day Camp, which combined educational strategies with peer support. Behavioral measures of treatment adherence were similar for most patients with sickle cell disease and thalassemia. Patient compliance with days of deferoxamine administration at follow-up was associated with initial compliance, perceived support, and patient and caregiver knowledge. Increased sharing of responsibilities for home care by patients and caregivers and caregiver knowledge were associated with lower ferritin and liver iron levels. A subsample of 3 patients who were extremely noncompliant with days of deferoxamine administration was examined separately; these patients were found to be moderately compliant with the number of hours and amount of deferoxamine administered and to share fewer home care tasks with primary caregivers. Participation in Desferal Day Camp did not result in increases in knowledge or peer support, suggesting that future interventions should focus on family support and on improving self-regulatory skills. The crucial role of collaboration among patients, families, and health care providers in developing interventions to enhance adherence was emphasized.
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Affiliation(s)
- M J Treadwell
- Northern California Comprehensive Sickle Cell and Thalassemia Centers, Oakland, USA
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