An integrative review of the impact of allied health student placements on current staff's knowledge and procedural skills in acute and primary care settings.

BACKGROUND: Staff shortages limit access to health services. The bidirectional benefits of allied health clinical placements are understood in the domains of student learning, health service delivery, and future workforce development. Still, the benefits to current workforce outcomes remain unknown. This review provides insights into the effects of allied health student placements in acute and primary care settings, particularly on healthcare staff's knowledge and procedural skills. METHODS: This search was based on the integrative review process established by Whittemore and Knafl in 2005. In October 2023, the first author (MH) searched five major electronic databases: Medline-EBSCO, PubMed, CINAHL, Embase, and Scopus. The CLUSTER model was used to track additional references. The first three authors (MH, SM, and SC) were involved in screening, quality appraisal, and synthesis of the studies. Data were thematically synthesised and analysed. RESULTS: MeSH headings and keywords were used in key search areas: health education, health professional training, clinical placements, and allied health professions. The systematic search yielded 12 papers on allied health student placements across various healthcare settings in rural and metropolitan areas, with no high-quality methodologies measuring student placements' impact on staff knowledge and skills. Four main themes were identified from the analysis: meaningful student integration in service delivery, targeted educational support to healthcare staff, development of staff procedural skills and confidence, and the mechanisms of why student placements work in this aspect. CONCLUSIONS: This review suggests that offering allied health student placement could be a promising approach to supporting rural healthcare staff in performing patient assessments and treatments proficiently and collaboratively. However, this requires further investigation to confirm.

The Risks of Being Tiny: The Added Risk of Low Weight for Neonates Undergoing Congenital Heart Surgery.

The aims of this study were (1) to describe the additive risk of performing cardiac surgery in neonates born ≤ 2.0 kg, after accounting for the baseline risks of low birth weight, and (2) to describe the additive risk of being born ≤ 2.0 kg in neonates undergoing cardiac surgery. We used a risk difference analysis in a retrospective cohort, 2006-2016. Neonates born ≤ 2.0 kg undergoing congenital heart surgery during initial postnatal admission were included. Data were standardized alternatingly for birth weight and cardiac surgical risk using national population data to estimate the number of deaths expected had they not required cardiac surgery or were they of normal weight. Of 105 neonates ≤ 2 kg, median birth weight was 1.6 kg (IQR 1.3-1.8 kg). Median gestational age was 33 weeks (IQR 31-35 weeks). Observed operative mortality was 14.3%; 0% for neonates ≤ 1.0 kg (CI 0-33.6%), 20.6% for neonates > 1.0-1.5 kg (CI 8.7-37.9%), and 12.9% for neonates > 1.5-2.0 kg (CI 5.7-23.9%). Among neonates ≤ 2.0 kg not undergoing cardiac surgery, expected mortality was 4.8% (CI 1.6-10.8); cardiac surgery increased the risk of mortality 9.5% (CI 1.7-17.4%). Conversely, the expected risk for normal birth weight neonates undergoing cardiac surgery was 5.7% (CI 2.1-12.0%); low birth weight increased the risk of mortality 8.6% (CI 0.5-16.6%). To continue making advancements in cardiac surgery, we must understand that the rate of mortality observed in normal weight infants is not a realistic target and that, despite advances, the risk attributable to the surgery remains higher among low birth weight patients.

Historicising the "Crisis" in Undergraduate Mental Health: British Universities and Student Mental Illness, 1944-1968.

This article explores how and why student mental health became an issue of concern in British universities between 1944 and 1968. It argues that two factors drew student mental health to the attention of medical professionals across this period: first, it argues that the post-war interest in mental illness drew attention to students, who were seen to be the luminaries of the future, investing their wellbeing with particular social importance. Second, it argues that the development of university health services made students increasingly visible, endorsing the view that higher education posed distinctive yet shared mental challenges to young people. The article charts the expansion of services and maps the implications of the visibility of student mental distress for post-war British universities. It suggests that claims that British higher education is currently in the midst of an unprecedented mental health "crisis" should be seen within this broader historical context, for while the contours of the debates around student mental health have shifted substantially, evidence that there was anxiety around student mental wellbeing in the immediate post-war years undermines accusations that contemporary students constitute a unique "snowflake generation."

'A disastrous blow': psychiatric risk, social indicators and medical authority in abortion reform in post-war Britain.

The Second World War lent impetus to the creation of new models and explanatory frameworks of risk, encouraging a closer reading of the relationship between individual psychiatric disorder and social disarray. This article interrogates how conceptions of psychiatric risk were animated in debates around abortion reform to forge new connections between social conditions and psychiatric vulnerability in post-war Britain. Drawing upon the arguments that played out between medical practitioners, I suggest that abortion reform, culminating in the 1967 Abortion Act, was both a response to and a stimulus for new ideas about the interaction between social aetiologies and medical pathologies; indeed, it became a site in which the medical and social domains were recognised as mutually constitutive. Positioned in a landscape in which medical professionals were seeking to assert their authority and to defend their areas of practice, abortion reform offered new opportunities for medical professionals to intervene in the social sphere under the guise of risk to women's mental health. The debate in medical journals around the status of issues that were seen to bridge the social and the medical were entangled with increasing anxiety about patient agency and responsibility. These concerns were further underscored as conversations about psychiatric risk extended towards considerations of the potential impact on women's existing families, bringing domestic conditions and the perceived psychosocial importance of family life into relief within medical journals. This article, then, argues that conceptions of psychiatric risk, as refracted through the creation of new synapses connecting the social and the medical domains, were critical to medical debates over abortion reform in post-war Britain.

Minimum important difference of the Epworth Sleepiness Scale in obstructive sleep apnoea: estimation from three randomised controlled trials.

BACKGROUND: The Epworth Sleepiness Scale (ESS) is a widely used tool for assessing sleepiness in patients with obstructive sleep apnoea (OSA). We aimed to estimate the minimal important difference (MID) in patients with OSA. METHODS: We used individual data from three randomised controlled trials (RCTs) in patients with OSA where the preintervention to postintervention change in ESS was used as a primary outcome. We used anchor-based linear regression and responder analysis approaches to estimate the MID. For anchors, we used the change in domains of the Functional Outcomes of Sleep Questionnaire and 36-Item Short Form Health Survey. We also used the distribution-based approaches Cohen's effect size, SE of measurement and empirical rule effect size to support the anchor-based estimates. The final MID was determined by triangulating all estimates to a single MID. FINDINGS: A total of 639 patients with OSA were included in our analyses across the three RCTs with a median (IQR) baseline ESS score of 10 (6-13). The median (IQR) ESS change score overall was -2 (-5 to 1). The anchor-based estimates of the MID were between -1.74 and -4.21 points and estimates from the responder analysis were between -1 and -3 points. Distribution-based estimates were smaller, ranging from -1.46 to -2.36. INTERPRETATION: We propose an MID for the ESS of 2 points in patients with OSA with a disease severity from mild to severe. This estimate provides the means to plan trials and interpret the clinical relevance of changes in ESS. TRIAL REGISTRATION NUMBER: Provent, NCT01332175; autoCPAP trial, NCT00280800; MOSAIC,ISRCTN (3416388).

Delivering allied health services to regional and remote participants on the autism spectrum via video-conferencing technology: lessons learned.

Context and issues: The introduction of individualised funding under the National Disability Insurance Scheme in Australia aimed to increase individual choice and control over how people received disability supports. An increase in the allied health disability workforce was anticipated; however, disability workforce sector reports have consistently indicated difficulties in attracting and retaining sufficient allied health staff to satisfy current and future demand. Autism spectrum disorder is the most prevalent primary diagnosis of participants receiving individualised funding to date and requires support staff to have specialised skills and experience. Given that overall staff attraction and retention issues are reported to be exacerbated in regional and remote areas of Australia, it is important to seek innovative ways of supporting individuals on the autism spectrum in their local communities. Technology has the potential to provide a timely and low-cost alternative that extends access to specialist services for people in remote locations. The current project aimed to identify the feasibility, essential requirements and potential barriers in delivering therapy support to regional and remote participants on the autism spectrum via video-conferencing technology. Lessons learned: A multidisciplinary team (speech pathologist, occupational therapist, psychologist and a special educator) were recruited and trained to deliver tele-therapy services to 16 participants on the autism spectrum, in collaboration with their families and local support teams. Participants resided in two northern, nine western and one southern regional area in New South Wales (NSW), Australia. There were three sets of siblings. One participant resided on remote Lord Howe Island off the coast of northern NSW. Researchers used semi-structured telephone interviews to gain insight into the program from key stakeholder groups including parents, education staff, allied health professionals and tele-therapists. A general inductive approach to data analysis was used under five project evaluation areas. The evaluation focused on five areas including: development of the tele-health delivery team, understanding the role of collaboration, examining the need for autism-specific support, establishing the need for in-person contact and identifying barriers to success. The project evaluation found that investment in staff training and support was key to building a competent tele-therapy team and delivering successful tele-therapy services under a sustainable model. For many families and support team members, collaboration was reported as an important part of the tele-therapy program, with families and teachers finding it helpful to work together with the same information. The evaluation confirmed that access to autism-specific knowledge and support was novel and regarded as beneficial for families and support teams living in regional and remote areas. There were mixed responses to the inclusion of in-person support as part of a tele-therapy service. While some families felt a tele-therapy service was no different to in-person services, other families and tele-therapists indicated that the addition of at least one in-person session would help to increase rapport. Barriers within the tele-therapy model included scheduling and local staff changes, as well as the delivery of intervention requiring physical support. Technology was not seen as a barrier in the current study. This research adds to the growing body of information supporting the use of tele-practice for geographically isolated regions. Ideally, tele-therapy should not replace in-person services; however, it is necessary when no other comparable service option is available locally. Larger scale research is needed to compare blended, online and in-person models so that an optimal ratio can be established.

A multicentre validation of the 1-min sit-to-stand test in patients with COPD.

Our aim was to comprehensively validate the 1-min sit-to-stand (STS) test in chronic obstructive pulmonary disease (COPD) patients and explore the physiological response to the test.We used data from two longitudinal studies of COPD patients who completed inpatient pulmonary rehabilitation programmes. We collected 1-min STS test, 6-min walk test (6MWT), health-related quality of life, dyspnoea and exercise cardiorespiratory data at admission and discharge. We assessed the learning effect, test-retest reliability, construct validity, responsiveness and minimal important difference of the 1-min STS test.In both studies (n=52 and n=203) the 1-min STS test was strongly correlated with the 6MWT at admission (r=0.59 and 0.64, respectively) and discharge (r=0.67 and 0.68, respectively). Intraclass correlation coefficients (95% CI) between 1-min STS tests were 0.93 (0.83-0.97) for learning effect and 0.99 (0.97-1.00) for reliability. Standardised response means (95% CI) were 0.87 (0.58-1.16) and 0.91 (0.78-1.07). The estimated minimal important difference was three repetitions. End-exercise oxygen consumption, carbon dioxide output, ventilation, breathing frequency and heart rate were similar in the 1-min STS test and 6MWT.The 1-min STS test is a reliable, valid and responsive test for measuring functional exercise capacity in COPD patients and elicited a physiological response comparable to that of the 6MWT.

Prediction of long-term clinical outcomes using simple functional exercise performance tests in patients with COPD: a 5-year prospective cohort study.

The 1-min sit-to-stand (1-min STS) test and handgrip strength test have been proposed as simple tests of functional exercise performance in chronic obstructive pulmonary disease (COPD) patients. We assessed the long-term (5-year) predictive performance of the 1-min sit-to-stand and handgrip strength tests for mortality, health-related quality of life (HRQoL) and exacerbations in COPD patients. In 409 primary care patients, we found the 1-min STS test to be strongly associated with long-term morality (hazard ratio per 3 more repetitions: 0.81, 95% CI 0.65 to 0.86) and moderately associated with long-term HRQoL. Neither test was associated with exacerbations. Our results suggest that the 1-min STS test may be useful for assessing the health status and long-term prognosis of COPD patients. This study was registered at http://www.clinicaltrials.gov/ (NCT00706602, 25 June 2008).

Investigation of training and support needs in rural and remote disability and mainstream service providers: implications for an online training model.

Objectives It is known that there are difficulties in recruiting and retaining practitioners in rural and remote communities and that access to support and professional development can be key in breaking this cycle. Technology provides a possible solution not only for increasing access to these opportunities, but also in building community capacity to support children with autism. The aim of the present study was to investigate the current learning and support needs within rural and remote professionals prior to setting up a model of support. Methods An online survey was used to gather information from service providers in rural and remote communities on their demographics, current skills and confidence in working with clients on the autism spectrum, current supervision and professional development, identified learning and support needs, and the availability and uptake of technology for accessing professional development. Results Respondents reported below average levels of perceived confidence and skills when working with children with autism, most notably children with challenging behaviour. Half the respondents do not currently attend supervision sessions, with only 15% receiving regular supervision (fortnightly or more often), and 66% of respondents had travelled more than 3h to access professional development workshops. The majority of participants had access to technology and over half had already used this for online training. Conclusion Overall, service providers in rural and remote areas are generally not currently meeting their needs in terms of frequency of supervision and professional development. The present needs analysis identifies key areas for learning, the ideal frequency of support and the acceptability of using technology to deliver this support. This information will guide future researchers in the development of an evidence-based model that will be accessible and meaningful to its participants. What is known about the topic? It is known that there are difficulties in recruiting and retaining practitioners in rural and remote communities and that access to support and professional development can be key in breaking this cycle, which may be triggered by geographical isolation. Technology-delivered intervention and support, also known as eHealth or Telehealth, has been used successfully in the disability sector for medical rehabilitation, direct intervention, employment support and support groups, but there is little evidence as to how technology is received by and implemented with disability and mainstream service providers supporting children with autism living in remote regions. What does this paper add? This paper provides an insight into the current skills and confidence of a broad range of service providers, including educators, allied health therapists and therapy and community support workers, in working with children with autism. This paper also investigates the experience, feasibility and potential uptake of a technology-driven program of support and professional development in rural and remote Australia. Finally, this paper provides an insight into the desired frequency of training and support, as well as identified learning support needs. What are the implications for practitioners? These findings have and will continue to guide practitioners in the development of an evidence-based, technology-driven model of supporting rural and remote staff working with children with autism. Technology has the potential to provide practitioners in geographically isolated areas with access to more responsive, collaborative and individualised professional support and training. Such practice may improve the skills of practitioners and the level of support they can provide their clients with autism, with the added potential of increasing staff retention in rural and remote areas of Australia.

Managing Caesarean Scar Pregnancy in low Resource Settings: 2 Case Reports and a Description of Transrectal Ultrasound guided Surgical Approach (TRUGA).

Caesarean scar pregnancy (CSP) occurs when an embryo implants in a previous caesarean section scar. It has a reported incidence of 1 in 1800. Various surgical and medical techniques have been described in case reports for the management of CSP. These techniques are usually undertaken in tertiary level units with significant resource availability. In this paper, we present a new clinical perspective for the management of CSP in low resource settings and describe the steps involved in a transrectal ultrasound guided approach with dilatation of uterine cervix and subsequent evacuation of uterine contents (TRUGA with D&C).

Race/ethnicity and socioeconomic status affect the assessment of lipoprotein(a) levels in clinical practice.

Background and Objective: High Lp(a) levels are a risk factor for ASCVD, however Lp(a) ordering in clinical practice is low. This study examines how race/ethnicity and socioeconomic status influence Lp(a) ordering. Methods: This is a single center, retrospective study (2/1/2020-6/30/2023) using electronic medical records of adults with at least one ICD-10 diagnosis of ASCVD or resistant hyperlipidemia (LDL-C >160 mg/dL on statin therapy). We evaluated Lp(a) level differences among racial/ethnic groups and sexes. We also assessed associations between diagnosis type, diagnosis number, age at diagnosis, race, socioeconomic score (based on zip codes), public health coverage and presence of Lp(a) orders. Results: 4% of our cohort (N=56,833) had an Lp(a) order (17.3% Hispanic, 8.7% non-Hispanic Black, 47.5% non-Hispanic White and, 27% Asian/others). Non-Hispanic Black and Hispanic patients had lower rates of Lp(a) orders (0.17%, 0.28%, respectively) when compared to non-Hispanic White patients (2.35%), p<0.001, however, their median Lp(a) levels were higher. Individuals belonging to deprived socioeconomic groups or on Medicaid, were less likely to have an Lp(a) order (RR=0.39, p<0.001 and RR=0.40, p<0.001 respectively). Certain diagnoses (carotid stenosis, family history of ASCVD and FH) and multiple diagnoses (>2) resulted in more Lp(a) orders compared to those with only one diagnosis (p<0.001). Conclusions: Lp(a) ordering is low in patients with ASCVD. Non-Hispanic Black and Hispanic patients at risk are less likely to have an Lp(a) order. Individuals residing in socioeconomically deprived neighborhoods and on Medicaid are also less like have Lp(a) order. Lp(a) orders depend on the type and number of patients' diagnoses.

Impact of Social Determinants of Health on Predictive Models for Outcomes After Congenital Heart Surgery.

BACKGROUND: Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors. OBJECTIVES: The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance. METHODS: Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model. RESULTS: Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers. CONCLUSIONS: Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.

Safety and efficacy of vemurafenib in end stage renal failure.

BACKGROUND: Serine-threonine inhibitors, such as vemurafenib, are being used increasingly in cancer treatment, and the toxicity and therapeutic benefit need to be balanced carefully both before and during treatment. CASE PRESENTATION: A patient with metastatic melanoma and end stage renal failure who was on peritoneal dialysis was treated with the serine-threonine kinase inhibitor, vemurafenib. After 5 months of treatment, a substantial response to vemurafenib was observed using imaging, but when he developed a prolonged QTc interval (common toxicity criteria (CTC) grade 3), treatment was interrupted. Vemurafenib was restarted at a reduced dose when the QTc interval returned to normal. The patient has had a significant response to vemurafenib and continued on treatment for 12 months after beginning the therapy. CONCLUSION: This is the first reported case of end stage renal failure in a patient who is taking vemurafenib. Although the patient developed QTc prolongation, it appears to be asymptomatic, and was managed with dose reduction. This case highlights the need for closer QTc monitoring at the start and during treatment.

Efficacy of a Commercial Physical Activity Monitor in Longitudinal Tracking of Patients With Pulmonary Hypertension: A Pilot Study.

BACKGROUND: Patients with pulmonary arterial hypertension have quality-of-life limitations, decreased exercise capacity, and poor prognosis if the condition is left untreated. Standard exercise testing is routinely performed to evaluate patients with pulmonary arterial hypertension but may be limited in its ability to monitor activity levels in daily living. OBJECTIVE: To evaluate the validity of the commercial Fitbit Charge HR as a tool to assess real-time exercise capacity as compared with standard exercise testing. METHODS: Ambulatory pediatric and adult patients were enrolled and given a Fitbit with instructions to continuously wear the device during waking hours. Patients underwent a 6-minute walk test, cardiopulmonary exercise test, and a 36-Item Short Form Health Survey on the day of enrollment and follow-up. Twenty-seven ambulatory patients with pulmonary arterial hypertension were enrolled, and 21 had sufficient data for analyses (median age, 25 years [range, 13-59 years]; 14 female participants). RESULTS: Daily steps measured by the Fitbit had a positive correlation with 6-minute walk distance (r = 0.72, P = .03) and an inverse trend with World Health Organization functional class. On the 36-Item Short Form Health Survey, 77% of patients reported improvement in vitality (P = .055). At follow-up, there was a strong correlation between number of steps recorded by Fitbit and role limitations because of physical problems (r = 0.88, P = .02) and weaker correlations with other quality-of-life markers. CONCLUSION: The findings of this pilot study suggest activity monitors may have potential as a simple and novel method of assessing longitudinal exercise capacity and activity levels in patients with pulmonary hypertension. Further study in larger cohorts of patients is warranted to determine which accelerometer measures correlate best with outcomes.

Adjusting for Congenital Heart Surgery Risk Using Administrative Data.

BACKGROUND: Congenital heart surgery (CHS) encompasses a heterogeneous population of patients and surgeries. Risk standardization models that adjust for patient and procedural characteristics can allow for collective study of these disparate patients and procedures. OBJECTIVES: We sought to develop a risk-adjustment model for CHS using the newly developed Risk Stratification for Congenital Heart Surgery for ICD-10 Administrative Data (RACHS-2) methodology. METHODS: Within the Kids' Inpatient Database 2019, we identified all CHSs that could be assigned a RACHS-2 score. Hierarchical logistic regression (clustered on hospital) was used to identify patient and procedural characteristics associated with in-hospital mortality. Model validation was performed using data from 24 State Inpatient Databases during 2017. RESULTS: Of 5,902,538 total weighted hospital discharges in the Kids' Inpatient Database 2019, 22,310 pediatric cardiac surgeries were identified and assigned a RACHS-2 score. In-hospital mortality occurred in 543 (2.4%) of cases. Using only RACHS-2, the mortality mode had a C-statistic of 0.81 that improved to 0.83 with the addition of age. A final multivariable model inclusive of RACHS-2, age, payer, and presence of a complex chronic condition outside of congenital heart disease further improved model discrimination to 0.87 (P < 0.001). Discrimination in the validation cohort was also very good with a C-statistic of 0.83. CONCLUSIONS: We created and validated a risk-adjustment model for CHS that accounts for patient and procedural characteristics associated with in-hospital mortality available in administrative data, including the newly developed RACHS-2. Our risk model will be critical for use in health services research and quality improvement initiatives.

Management of systemic to pulmonary shunts and elevated pulmonary vascular resistance.

Background: Repair of systemic to pulmonary shunts is timed to prevent the development of irreversible pulmonary vascular disease, including in patients with other factors contributing to pulmonary hypertension. This study assessed outcomes of an individualised strategy for managing patients with mild-moderately elevated pulmonary vascular resistance (PVR) deemed borderline eligible for repair. Methods: A retrospective chart review was conducted of patients with systemic to pulmonary shunts and baseline indexed PVR (PVRi) ≥3 WU·m2 treated at a single centre from 1 January 2005 to 30 September 2019. Data included demographics, World Health Organization functional class (WHO FC), medications and haemodynamic data at baseline and serial follow-up. Results: 30 patients (18 females) met criteria for inclusion. Median age at diagnosis of pulmonary arterial hypertension was 1.3 years (range 0.03-54 years) and at surgery was 4.1 years (range 0.73-56 years). Median follow-up time was 5.8 years (range 0.2-14.6 years) after repair. Most patients received at least one targeted pulmonary arterial therapy prior to repair and the majority (80%) underwent fenestrated shunt closure. There was a significant decrease in mean pulmonary arterial pressure (mPAP) (p<0.01), PVRi (p=0.0001) and PVR/systemic vascular resistance (p<0.01) between baseline and preoperative catheterisation and a decrease in PVRi (p<0.005), mPAP (p=0.0001) and pulmonary to systemic flow ratio (p<0.03) from baseline to most recent catheterisation. WHO FC improved from FC II-III at baseline to FC I post repair in most patients (p<0.003). Conclusions: In carefully selected patients with systemic to pulmonary shunts and elevated PVR considered borderline for operability, the use of preoperative targeted therapy in conjunction with fenestrated or partial closure of intracardiac shunts is associated with improvement in WHO FC and clinical outcomes.

Right Ventricular Strain in Patients With Ductal-Dependent Tetralogy of Fallot.

BACKGROUND: Right ventricular (RV) dysfunction is an independent predictor of poor outcomes in patients with tetralogy of Fallot (TOF), and global longitudinal strain (GLS) is a well-validated echocardiographic technique to measure RV function. Although trends in RV GLS have been examined in patients with TOF, they have not been studied specifically in those with ductal-dependent TOF, a group in which there is not a clear consensus on the best surgical strategy. The aim of this study was to assess the midterm trajectory of RV GLS in patients with ductal-dependent TOF, drivers of this trajectory, and differences in RV GLS between repair strategies. METHODS: This was a retrospective two-center cohort study of patients with ductal-dependent TOF who underwent repair. Ductal dependence was defined as being initiated on prostaglandin therapy and/or undergoing surgical intervention on or before 30 days of life. RV GLS was measured on echocardiography preoperatively, early after complete repair, and at 1 and 2 years of age. RV GLS was trended over time and compared between surgical strategies and with control subjects. Mixed-effects linear regression models were used to evaluate the factors associated with changes in RV GLS over time. RESULTS: Forty-four patients with ductal-dependent TOF were included in the study, of whom 33 (75%) underwent primary complete repair and 11 (25%) underwent staged repair. Complete TOF repair was performed at a median of 7 days in the primary-repair group and 178 days in the staged-repair group. RV GLS improved over time from post-complete repair echocardiography through 2 years of age (-17.4% [interquartile range, -15.5% to -18.9%] vs -21.5% [interquartile range, -18.0% to -23.3%], P < .001). However, compared with age-matched control subjects, patients had worse RV GLS at all time points. There was no difference in RV GLS between the staged and primary complete repair groups at 2-year follow-up. Shorter intensive care unit length of stay after complete repair was independently associated with improvement in RV GLS over time. Strain improved by 0.07% (95% CI, 0.01 to 0.12) for each fewer day in the intensive care unit (P = .03). CONCLUSIONS: RV GLS improves over time among patients with ductal-dependent TOF, though it is consistently reduced compared with control subjects, suggesting an altered deformation pattern in patients with ductal-dependent TOF. There was no difference in RV GLS between the primary- and staged-repair groups at midterm follow-up, suggesting that repair strategy is not a risk factor for worse RV strain in the mid postoperative period. A shorter complete-repair intensive care unit length of stay is associated with an improved trajectory of RV GLS.

Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid.

BACKGROUND: Understanding the longitudinal burden of health care expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities. OBJECTIVES: The purpose of this study was to describe and identify predictors of health care expenditures and utilization for Medicaid-insured pediatric cardiac surgical patients. METHODS: All Medicaid enrolled children age <18 years undergoing cardiac surgery in the New York State CHS-COLOUR database, from 2006 to 2019, were followed in Medicaid claims data through 2019. A matched cohort of children without cardiac surgical disease was identified as comparators. Expenditures and inpatient, primary care, subspecialist, and emergency department utilization were modeled using log-linear and Poisson regression models to assess associations between patient characteristics and outcomes. RESULTS: In 5,241 New York Medicaid-enrolled children, longitudinal health care expenditures and utilization for cardiac surgical patients exceeded noncardiac surgical comparators (cardiac surgical children: $15,500 ± $62,000 per month in year 1 and $1,600 ± $9,100 per month in year 5 vs noncardiac surgical children: $700 ± $6,600 per month in year 1 and $300 ± $2,200 per month in year 5). Children after cardiac surgery spent 52.9 days in hospitals and doctors' offices in the first postoperative year and 90.5 days over 5 years. Being Hispanic, compared with non-Hispanic White, was associated with having more emergency department visits, inpatient admissions, and subspecialist visits in years 2 to 5, but fewer primary care visits and greater 5-year mortality. CONCLUSIONS: Children after cardiac surgery have significant longitudinal health care needs, even among those with less severe cardiac disease. Health care utilization differed by race/ethnicity, although mechanisms driving disparities should be investigated further.

Chronic Medication Burden After Cardiac Surgery for Pediatric Medicaid Beneficiaries.

BACKGROUND: Congenital heart defects are the most common and resource-intensive birth defects. As children with congenital heart defects increasingly survive beyond early childhood, it is imperative to understand longitudinal disease burden. OBJECTIVES: The purpose of this study was to examine chronic outpatient prescription medication use and expenditures for New York State pediatric Medicaid enrollees, comparing children who undergo cardiac surgery (cardiac enrollees) and the general pediatric population. METHODS: This was a retrospective cohort study of all Medicaid enrollees age <18 years using the New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources database (2006-2019). Primary outcomes were total chronic medications per person-year, enrollees per 100 person-years using ≥1 and ≥3 medications, and medication expenditures per person-year. We described and compared outcomes between cardiac enrollees and the general pediatric population. Among cardiac enrollees, multivariable regression examined associations between outcomes and clinical characteristics. RESULTS: We included 5,459 unique children (32,131 person-years) who underwent cardiac surgery and 4.5 million children (22 million person-years) who did not. More than 4 in 10 children who underwent cardiac surgery used ≥1 chronic medication compared with approximately 1 in 10 children who did not have cardiac surgery. Medication expenditures were 10 times higher per person-year for cardiac compared with noncardiac enrollees. Among cardiac enrollees, disease severity was associated with chronic medication use; use was highest among infants; however, nearly one-half of adolescents used ≥1 chronic medication. CONCLUSIONS: Children who undergo cardiac surgery experience high medication burden that persists throughout childhood. Understanding chronic medication use can inform clinicians (both pediatricians and subspecialists) and policymakers, and ultimately the value of care for this medically complex population.