Community based Primary Care for Adolescents and Young Adults Transitioning From Pediatric Specialty Care: Results from a Scoping Review.

BACKGROUND: Ongoing primary care during adolescence is recommended by best practice guidelines for adolescents and young adults (AYAs; ages 12-25) with chronic conditions. A synthesis of the evidence on the roles of Primary Care Physicians (PCPs) and benefits of primary care is needed to support existing guidelines. METHODS: We used Arksey and O'Malley's scoping review framework, and searched databases (MEDLINE, EMBASE, PsychINFO, CINAHL) for studies that (i) were published in English between 2004 and 2019, (ii) focused on AYAs with a chronic condition(s) who had received specialist pediatric services, and (iii) included relevant findings about PCPs. An extraction tool was developed to organize data items across studies (eg, study design, participant demographics, outcomes). RESULTS: Findings from 58 studies were synthesized; 29 (50%) studies focused exclusively on AYAs with chronic health conditions (eg, diabetes, cancer), while 19 (33%) focused exclusively on AYAs with mental health conditions. Roles of PCPs included managing medications, "non-complex" mental health conditions, referrals, and care coordination, etc. Frequency of PCP involvement varied by AYAs; however, female, non-Black, and older AYAs, and those with severe/complex conditions appeared more likely to visit a PCP. Positive outcomes were reported for shared-care models targeting various conditions (eg, cancer, concussion, mental health). CONCLUSION: Our findings drew attention to the importance of effective collaboration among multi-disciplinary specialists, PCPs, and AYAs for overcoming multiple barriers to optimal transitional care. Highlighting the need for further study of the implementation of shared care models to design strategies for care delivery during transitions to adult care.

Genetic Counseling for Men with Prostate Cancer.

Germline genetic testing is becoming more prevalent in urology clinics because of precision medicine for prostate cancer treatment. Genetic testing results can also influence cancer screening discussions for patients and/or their families. An important part of germline genetic testing is genetic counseling. This article provides an overview of the historical aspects of genetic counseling, discusses the components needed to provide proper genetic counseling, summarizes genes related to hereditary prostate cancer risk, and reviews genetic privacy and genetic discrimination concerns related to germline genetic testing.

Association of pediatric cardiac surgery-associated acute kidney injury with post-discharge healthcare utilization, mortality and kidney outcomes.

BACKGROUND: Acute kidney Injury (AKI) in children undergoing cardiac surgery (CS) is strongly associated with hospital morbidity. Post-discharge CS AKI outcomes are less clear. We evaluated associations between AKI and post-discharge (a) healthcare utilization, (b) chronic kidney disease (CKD) or hypertension and (c) mortality. METHODS: This is a retrospective two-centre cohort study of children surviving to hospital discharge after CS. Primary exposures were post-operative ≥Stage 1 AKI and ≥Stage 2 AKI defined by Kidney Disease Impoving Global Outcomes. Association of AKI with time to outcomes was determined using multivariable Cox-Proportional Hazards analysis. RESULTS: Of 350 participants included (age 3.1 (4.5) years), 180 [51.4%] developed AKI and 60 [17.1%] developed ≥Stage 2 AKI. Twenty-eight (9%) participants developed CKD or hypertension (composite outcome), and 17 (5%) died within 5 years of discharge. Post-operative ≥Stage 1 and ≥Stage 2 AKI were not associated with post-discharge hospitalizations, emergency room (ER) visits, physician visits or CKD or hypertension in adjusted analyses. A trend was observed between ≥Stage 2 AKI and mortality but was not statistically significant. In unadjusted stratified analyses, AKI was associated with post-discharge hospitalizations in children with RACHS-1 score ≥3, complex chronic disease classification and children living in urban areas. CONCLUSIONS: Post-CS AKI is not associated with post-discharge healthcare utilization, death and CKD or hypertension, though it may be associated with healthcare utilization in more complex paediatric CS children. Studies should aim to better understand post-CS healthcare utilization patterns and non-AKI risk factors for CKD, hypertension and mortality, to reduce adverse long-term outcomes after CS.

Primary care during the transition to adult care for adolescents involved with pediatric specialty services: a scoping review protocol.

BACKGROUND: Of the 15-20% of youth in North America affected by a chronic health condition (e.g., type 1 diabetes, cystic fibrosis) and/or mental health or neurodevelopmental disorder (e.g., depression, eating disorder, Attention Deficit-Hyperactivity Disorder), many often require lifelong specialist healthcare services. Ongoing primary care during childhood and into young adulthood is recommended by best practice guidelines. To date, it is largely unknown if, how, and when primary care physicians (PCPs; such as family physicians) collaborate with specialists as AYAs leave pediatric-oriented services. The proposed scoping review will synthesize the available literature on the roles of PCPs for AYAs with chronic conditions leaving pediatric specialty care and identify potential benefits and challenges of maintaining PCP involvement during transition. METHODS: Arksey and O'Malley's original scoping review framework will be utilized with guidance from Levac and colleagues and the Joanna Briggs Institute. A search of databases including MEDLINE (OVID), EMBASE, PsycINFO, and CINAHL will be conducted following the development of a strategic search strategy. Eligible studies will (i) be published in English from January 2004 onwards, (ii) focus on AYAs (ages 12-25) with a chronic condition(s) who have received specialist services during childhood, and (iii) include relevant findings about the roles of PCPs during transition to adult services. A data extraction tool will be developed and piloted on a subset of studies. Both quantitative and qualitative data will be synthesized. DISCUSSION: Key themes about the roles of PCPs for AYAs involved with specialist services will be identified through this review. Findings will inform the development and evaluation of a primary-care based intervention to improve transition care for AYAs with chronic conditions.

Acute kidney injury in critically ill children and 5-year hypertension.

BACKGROUND: To develop a pediatric-specific hypertension algorithm using administrative data and use it to evaluate the association between acute kidney injury (AKI) in the intensive care unit (ICU) and hypertension diagnosis 5 years post-discharge. METHODS: Two-center retrospective cohort study of children (≤ 18 years old) admitted to the pediatric ICU in Montreal, Canada, between 2003 and 2005 and followed until 2010. Patients with a valid healthcare number and without end-stage renal disease were included. Patients who could not be merged with the provincial database, did not survive admission, underwent cardiac surgery, had pre-existing renal disease associated with hypertension or a prior diagnosis of hypertension were excluded. AKI defined using the Kidney Disease: Improving Global Outcomes (KDIGO) definition. Using diagnostic codes and medications from administrative data, novel pediatric-specific hypertension definitions were designed. Both the evaluation of the prevalence of hypertension diagnosis and the association between AKI and hypertension occurred. RESULTS: Nineteen hundred and seventy eight patients were included (median age at admission [interquartile range] 4.3 years [1.1-11.8], 44% female, 325 (16.4%) developed AKI). Of these patients, 130 (7%) had a hypertension diagnosis 5 years after discharge. Patients with AKI had a higher prevalence of hypertension diagnosis [non-AKI: 84/1653 (5.1%) vs. AKI: 46/325 (14.2%), p < .001]. Children with AKI had a higher adjusted risk of hypertension diagnosis (hazard ratio [95% confidence interval] 2.19 [1.47-3.26]). CONCLUSIONS: Children admitted to the ICU have a high prevalence of hypertension post-discharge and children with AKI have over two times higher risk of hypertension compared to those with no AKI.

The Canadian childhood nephrotic syndrome (CHILDNEPH) study: report on mid-study feasibility, recruitment and main measures.

BACKGROUND: To assess reasons for continuing practice variation in the management of childhood nephrotic syndrome despite expert reviews and guidelines, we are conducting a longitudinal cohort study in children with glucocorticoid sensitive nephrotic syndrome. Objectives of this mid-study report are to describe patient and physician recruitment characteristics, glucocorticoid prescriptions, use of second line agents, biopsy practices, and adherence to study protocol. METHODS: Children with new onset nephrotic syndrome and providers are being recruited from all 12 pediatric nephrology centres across Canada with > 2½ years follow-up. Data collection points of observation are over a minimum 36 months. Details of prescribed glucocorticoids and of all second line agents used during treatment are being collected. All relapses are being recorded with time to urinary remission of proteinuria. RESULTS: To date, 243 patients (57.1% male) from 12 centres were included. Median number of patients per centre was 29 (range 2-45), and median age of cohort was 7.3 (IQR 4.2) at enrollment. Forty-eight physicians were recruited, median 5 (range 2-8) per site. Median number of relapses per patient year of follow-up was 2.1 (IQR 4). Cumulative dose variability of glucocorticoids prescribed per episode of proteinuria and length of treatment was observed between participating centres. CONCLUSION: The Canadian pediatric nephrology community established a longitudinal childhood nephrotic syndrome cohort study that confirms ongoing practice variability. The study will help to evaluate its impact on patient outcomes, and facilitate clinical trial implementation in nephrotic syndrome.

A Validation Study of Administrative Health Care Data to Detect Acute Kidney Injury in the Pediatric Intensive Care Unit.

BACKGROUND: Large studies evaluating pediatric acute kidney injury (AKI) epidemiology and outcomes are lacking, partially due to underuse of large administrative health care data. OBJECTIVE: To assess the diagnostic accuracy of administrative health care data-defined AKI in children admitted to the pediatric intensive care unit (PICU). DESIGN: Retrospective cohort study utilizing chart and administrative data. SETTING: Children admitted to the PICU at 2 centers in Montreal, QC. PATIENTS: Patients between 0 and 18 years old with a provincial health insurance number, without end-stage renal disease and admitted to the PICU between January 1, 2003, and March 31, 2005, were included. MEASUREMENTS: The AKI was defined from chart data using the Kidney Disease: Improving Global Outcomes (KDIGO) definition (Chart-AKI). The AKI defined using administrative health data (Admin-AKI) was based on International Classification of Disease, Ninth Revision (ICD-9) AKI codes. METHODS: Data available from retrospective chart review, including baseline and PICU patient characteristics, and serum creatinine (SCr) and urine output (UO) values during PICU admission, were merged with provincial administrative health care data containing diagnostic and procedure codes used for ascertaining Admin-AKI. Sensitivity, specificity, positive, and negative predictive value of Admin-AKI compared with Chart-AKI (reference standard) were calculated. Univariable associations between Admin-AKI and hospital mortality were evaluated. RESULTS: A total of 2051 patients (55% male, mean age at admission 6.1 ± 5.8 years, 355 cardiac surgery, 1696 noncardiac surgery) were included. The AKI defined by SCr or UO criteria occurred in 52% of cardiac surgery patients and 24% of noncardiac surgery patients. Overall, Admin-AKI detected Chart-AKI with low sensitivity, but high specificity in cardiac and noncardiac surgery patients. Sensitivity increased by 1.5 to 2 fold with each increase in AKI severity stage. Admin-AKI was associated with hospital mortality (13% in Admin-AKI vs 2% in non-AKI, P < .001). LIMITATIONS: These data were generated in a PICU population; future research should study non-PICU populations. CONCLUSIONS: Use of administrative health care data to define AKI in children leads to AKI incidence underestimation. However, for detecting more severe AKI, sensitivity is higher, while maintaining high specificity.

CONTEXTE: On dispose de peu d'études à grande échelle évaluant l'épidémiologie et l'évolution de l'insuffisance rénale aigüe (IRA) chez les enfants, notamment en raison d'une sous-utilisation des données administratives du système de santé. OBJECTIF: Évaluer la précision diagnostique de l'IRA définie à partir des données administratives en santé chez des enfants admis aux unités de soins intensifs pédiatriques (USIP). TYPE D'ÉTUDE: Une étude de cohorte rétrospective utilisant des données administratives et les données provenant des dossiers médicaux. CADRE: Les USIP de deux centres hospitaliers de Montréal, au Canada. SUJETS: Ont été inclus les patients âgés de 0 à 18 ans possédant un numéro d'assurance-maladie provincial qui ont été admis aux USIP entre le 1er janvier 2003 et le 31 mars 2005 avec une insuffisance rénale non terminale. MESURES: L'IRA-Dos a été définie à partir des dossiers médicaux en utilisant les critères du KDIGO (Kidney Disease: Improving Global Outcomes). L'IRA-Admin a été définie à partir des données administratives en santé avec les codes d'IRA de la neuvième révision de la Classification internationale des maladies (CIM-9). MÉTHODOLOGIE: Les données tirées de l'examen rétrospectif des dossiers médicaux, soit les valeurs de créatinine sérique (SCr) et de diurèse pendant le séjour aux USIP et les caractéristiques des patients, initiales et à l'admission, ont été fusionnées aux données administratives provinciales en santé contenant les codes de diagnostic et de procédure utilisés pour établir l'IRA-Admin. La sensibilité, la spécificité et les valeurs prédictives négative et positive de l'IRA-Admin, en comparaison à l'IRA-Dos (standard de référence), ont été calculées. L'association univariée entre l'IRA-Admin et la mortalité à l'hôpital a également été évaluée. RÉSULTATS: Un total de 2 051 patients ont été inclus (355 ayant subi une cardiochirurgie et 1 696 non opérés). L'âge moyen des sujets à l'admission était de 6,1 ± 5,8 ans et 55 % étaient des garçons. L'IRA définie par les critères de SCr et de diurèse a été diagnostiquée chez 52 % des patients opérés et chez 24 % des patients non opérés. Pour l'ensemble de la cohorte (patients opérés ou non), l'IRA-Admin a détecté l'IRA-Dos avec une faible sensibilité, mais avec une spécificité élevée. La sensibilité s'est accrue de 1,5 à 2 fois pour chaque passage à un stade supérieur de gravité de l'IRA. Enfin, l'IRA-Admin a été associée à un taux plus élevé de mortalité à l'hôpital (13 % des patients IRA-Admin contre 2 % des patients sans IRA, p<0,001). LIMITATIONS: Ces résultats concernent une population de patients hospitalisés aux USIP. Des études futures devraient inclure des populations non admises aux USIP. CONCLUSIONS: L'utilisation des données administratives en santé pour définir l'IRA chez les enfants a mené à une sous-estimation de son incidence. Cependant, la méthode montre une plus grande sensibilité dans la détection des cas plus graves d'IRA, tout en conservant une spécificité élevée.

Reducing physician voiding cystourethrogram ordering in children with first febrile urinary tract infection: evaluation of a purposefully sequenced educational intervention.

BACKGROUND: Physicians often fail to implement clinical practice guidelines. Our aim was to evaluate whether a purposefully sequenced, multifaceted educational intervention would increase physician adherence to a guideline for voiding cystourethrogram (VCUG) use following first urinary tract infection (UTI) in young children. METHODS: Using a single centre, pretest-posttest design, we compared the proportion of guideline adherent VCUG orders and the VCUG ordering rate before and after three educational interventions (interactive lecture, clinical pathway, faxed reminder) selected and sequenced according to the PRECEDE (Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation) health promotion model. RESULTS: One hundred and nine physicians ordered 219 VCUGs for 219 children. Following the interventions, there was an increase in the monthly proportion of adherent VCUGs ordered by pediatricians (analysis of variance (ANOVA) F(2,29) = 3.38, p = .048) and non-pediatricians (ANOVA F(2,28) = 14.71, p < .001). Also, pediatricians decreased their monthly VCUG ordering rate (linear trend incidence rate ratio 0.74, 95% confidence interval (CI) [0.54, 0.99]). Pediatricians were more likely to adhere with the guideline than were non-pediatricians (odds ratio 2.91, 95% CI [1.5, 5.5]). CONCLUSION: Exposure to purposefully sequenced educational interventions based on the PRECEDE model was associated with increased adherence to guideline recommendations.

Long-term Mortality After Acute Kidney Injury in the Pediatric ICU.

OBJECTIVES: (1) To evaluate the association between acute kidney injury (AKI) in the PICU and long-term mortality and (2) to determine the extent to which adding the urine output (UO)-defined AKI alters the association. METHODS: A 2-center retrospective cohort study of children (≤18 years old) admitted to the PICU between 2003 and 2005 for noncardiac surgery, with follow-up until 2010. Patients with end stage renal disease, no provincial health insurance number, who died during hospitalization, or could not be linked to administrative data were excluded. One hospitalization per patient was included. AKI was defined by using serum creatinine criteria and/or UO criteria. Mortality was ascertained by using administrative data. Cox regression analysis was performed to evaluate the association between AKI and long-term mortality. RESULTS: The study population included 2041 patients (55.7% male, mean admission age 6.5 ± 5.8 years). Of 2041 hospital survivors, 9 (0.4%) died within 30 days, 51 (2.5%) died within 1 year, and 118 (5.8%) died within 5 to 7 years postdischarge. AKI was independently associated with 5- to 7-year mortality (adjusted hazard ratio [95% confidence interval]: 3.10 [1.46-6.57] and 3.38 [1.63-7.02], respectively). Including UO did not strengthen the association. CONCLUSIONS: AKI is associated with 5- to 7-year mortality. Because this is an observational study we cannot determine if AKI is causative of mortality or of the pathophysiology. However, patients with AKI represent a high-risk group. It is reasonable that these patients be considered for targeted follow-up until future researchers better elucidate these relationships.

Variation in estimated glomerular filtration rate at dialysis initiation in children.

BACKGROUND: Data guiding the timing of dialysis initiation in children are limited. We sought to determine current practice and secular trends in Canada with respect to the timing of dialysis initiation in children based on estimated glomerular filtration rate (eGFR). METHODS: This observational study included incident chronic dialysis patients aged ≤21 years identified from the Canadian Organ Replacement Register who started dialysis in Canada between January 2001 and December 2010 at any of the nine participating Canadian centers (n = 583). Youth were categorized utilizing CKiD Schwartz eGFR into ≥10.5 (higher) or <10.5 ml/min/1.73 m2 (lower) eGFR groups. Differences at dialysis initiation by facility and region were examined, and secular trends were determined. RESULTS: Median eGFR at dialysis initiation was 8.1 (interquartile range 5.4-11.0) ml/min/1.73 m2. Overall, 29 % of the patients started dialysis with an eGFR of ≥10.5 ml/min/1.73 m2. The proportion of children starting with higher eGFR increased from 27.3 % in 2001 to 35.4 % in 2010 (p = 0.04) and differed by treatment facility (12-70 %; p = 0.0001). Factors associated with higher eGFR at dialysis initiation in the adjusted regression model were female sex [odds ratio (OR) 1.48; 95 % confidence interval (CI) 1.02-2.14], genetic cause of end-stage kidney disease (OR 2.77; 95 % CI 1.37-5.58) and living ≥50 km from treatment facility (OR 1.47; 95 % CI 1.01-2.14). CONCLUSIONS: One-third of the children were found to have initiated dialysis with an eGFR ≥10.5 ml/min/1.73 m2, however significant practice variation exists with respect to timing of dialysis initiation by treatment facility. More data is required to evaluate the clinical implications of this practice variation.

Perceptions of pediatric nephrologists regarding timing of dialysis initiation in children in Canada.

BACKGROUND: Significant practice variation exists in Canada with respect to timing of dialysis initiation in children. In the absence of evidence to guide practice, physicians' perceptions may significantly influence decision-making. OBJECTIVE: The objectives of this study are to (1) evaluate Canadian pediatric nephrologists' perceptions regarding dialysis initiation in children with chronic kidney disease (CKD) and (2) determine the factors guiding practice that may contribute to practice variation across Canada. DESIGN: This study was a cross-sectional online survey. SETTING: This study was done in academic pediatric nephrology centers in Canada. PARTICIPANTS: The participants of this study are pediatric nephrologists. MEASUREMENTS AND METHODS: An anonymous web-based survey was administered to pediatric nephrologists in Canada to evaluate perspectives and practice patterns regarding timing of dialysis initiation. We also explored the importance of estimated glomerular filtration rate (eGFR) vs. symptoms and the role of patient and provider factors influencing decisions. RESULTS: Thirty-five nephrologists (59 %) completed the survey. Most respondents care for advanced CKD patients in a multidisciplinary clinic (86 %) and no centers have a formal policy on timing of dialysis initiation. Seventy-five percent of centers follow <20 stage 4-5 CKD patients, and 9 % follow >30 patients. Discussions about dialysis initiation are generally informal (75 %) and the decision to start is made by the nephrologist (37 %) or a team (57 %). Fifty percent agreed GFR was important when deciding when to initiate dialysis, 41 % were neutral, and 9 % disagreed. Variability exists in the threshold that nephrologists considered early (vs. late) dialysis initiation: >20 (21 %), >15 (38 %), >12 (26 %), and >10 ml/min/1.73 m(2) (12 %). Practitioners however typically start dialysis in asymptomatic patients at eGFRs of 7-9 (9 %), 10-11 (41 %), 12-14 (38 %), and 15-19 (6 %) ml/min/1.73 m(2). Patient factors important in the decision to start dialysis for >90 % of nephrologists were fatigue, >10 % weight loss, nausea, increasing missed school, and awaiting a pre-emptive transplant. Age was only a factor for 56 %. LIMITATIONS: This study has a 59 % response rate. CONCLUSIONS: Variability exists in Canada regarding the importance and threshold of eGFR guiding the decision as to when to start dialysis in children, whereas patient symptoms are almost universally important to pediatric nephrologists' decision-making. Additional studies evaluating outcomes of children starting dialysis earlier vs. later are needed to standardize decision-making and care for children with kidney failure.

MISE EN CONTEXTE: Des différences significatives existent dans la pratique au Canada quant au moment où des traitements de dialyse devraient être entrepris chez les enfants souffrant d'insuffisance rénale. En absence de données probantes pour guider leur pratique, les différentes approches des néphrologues exerçant auprès de cette population jouent probablement un rôle majeur dans leur prise de décision. OBJECTIFS DE L'ÉTUDE: Dans un premier temps, l'étude visait à évaluer la perception des néphrologues canadiens en regard de l'amorce de traitements de dialyse chez les enfants atteints d'insuffisance rénale chronique (IRC). Ensuite, on a voulu déterminer les facteurs qui guident la pratique et qui font en sorte que des variations subsistent à cet égard dans la pratique en néphrologie pédiatrique à travers le Canada. CADRE ET TYPE D'ÉTUDE: Il s'agit d'un sondage transversal mené en ligne auprès des néphrologues pratiquant dans les unités pédiatriques des centres hospitaliers universitaires dans tout le Canada. MÉTHODOLOGIE: Un sondage accessible par le web, auquel les participants répondaient de façon anonyme, a été distribué aux spécialistes canadiens pratiquant en néphrologie pédiatrique. Ce sondage avait pour objectif d'évaluer les perceptions et les schémas de pratique relativement au moment le plus propice pour amorcer la dialyse. Le sondage explorait aussi l'importance du débit de filtration glomérulaire estimé (DFGe) par rapport aux symptômes ressentis par le patient dans la prise de décision. Finalement, nous avons tenté d'identifier les facteurs pouvant influencer le patient et son médecin traitant au moment de décider d'entreprendre des traitements de dialyse. RÉSULTATS: Tous les pédiatres-néphrologues pratiquant au Canada ont reçu le questionnaire. Toutefois, seulement 35 d'entre eux, soit un peu plus de la moitié (59 %), l'ont complété et renvoyé. La grande majorité des répondants (86 %) exerçaient au sein de cliniques multidisciplinaires, auprès de cas sévères d'IRC. Aucun des centres de soins où ces spécialistes pratiquent ne possédait de politique formelle quant au moment d'entreprendre des traitements de dialyse chez les patients suivis en néphrologie pédiatrique. Les trois quarts des centres de soins cités (75 %) suivaient moins de 20 cas d'IRC de stade 4 ou 5, alors que 9 % en suivaient plus de 30. Les répondants ont indiqué dans une proportion de 75 % que la discussion concernant l'amorce de la dialyse se déroulait de façon informelle. De plus, le sondage révèle que la décision d'amorcer la dialyse est prise par le néphrologue soignant seulement (37 % des cas) ou par une équipe (57 % des cas). La moitié des répondants (50 %) s'accordait pour dire que le DFGe était important dans leur prise de décision d'amorcer des traitements de dialyse chez leurs patients, 41 % avaient une opinion neutre à ce sujet alors que 9 % ne jugeaient pas cet élément important. Les pédiatres-néphrologues répondants sont partagés quant à la valeur seuil de DFGe qu'ils considèrent comme une amorce « hâtive ¼ de dialyse. Pour 21 % des répondants, cette valeur se situe à 20 ml/min/1,73 m2; pour 38 % elle se situe plutôt à 15 ml/min/1,73 m2; 26 % l'établissent à 12 ml/min/1,73 m2; alors que 12 % des répondants jugent l'amorce d'une dialyse dite « hâtive ¼ à un DFGe de 10 ml/min/1,73 m2. De façon générale, chez les patients asymptomatiques, la dialyse est amorcée lorsque le DFGe se situe entre 7 et 9 ml/min/1,73 m2 (9 % des cas), entre 10 et 11 ml/min/1,73 m2 (41 % des cas), entre 12 et 14 ml/min/1,73 m2 (38 % des cas) ou entre 15 et 19 ml/min/1,73 m2 (6 % des cas). Enfin, parmi les facteurs motivant les patients à entreprendre des traitements de dialyse, tels que rapportés par les répondants dans une proportion de plus de 90 %, on trouve : une sensation de fatigue, une perte de poids de plus de 10 %, des nausées, les absences répétées à l'école et l'attente d'une greffe rénale préventive. L'âge n'a été mentionné comme facteur que dans 56 % des cas. LIMITES DE L'ÉTUDE: Le taux de réponse au sondage relativement faible (59 %) limite la portée des résultats. CONCLUSIONS: En néphrologie pédiatrique, alors que les symptômes ressentis par les patients sont considérés de façon universelle dans la décision d'entreprendre une dialyse, les pédiatres-néphrologues canadiens ont des perceptions très différentes quant à la valeur seuil de DFGe qui devrait guider cette décision et à l'importance du rôle que ce paramètre devrait y jouer. Des études supplémentaires comparant les résultats chez les patients qui amorcent une dialyse dite hâtive par rapport à ceux de patients l'amorçant plus tard s'avèrent nécessaires pour établir des pratiques standardisées en matière de soins pour les enfants atteints d'insuffisance rénale.

The association between individual counselling and health behaviour change: the See Kidney Disease (SeeKD) targeted screening programme for chronic kidney disease.

BACKGROUND: Health behaviour change is an important component of management for patients with chronic kidney disease (CKD); however, the optimal method to promote health behaviour change for self-management of CKD is unknown. The See Kidney Disease (SeeKD) targeted screening programme screened Canadians at risk for CKD and promoted health behaviour change through individual counselling and goal setting. OBJECTIVES: The objectives of this study are to determine the effectiveness of individual counselling sessions for eliciting behaviour change and to describe participant characteristics associated with behaviour change. DESIGN: This is a cross-sectional, descriptive study. SETTING: The study setting is the National SeeKD targeted screening programme. PATIENTS: The participants are all 'at risk' patients who were screened for CKD and returned a follow-up health behaviour survey (n = 1129). MEASUREMENTS: Health behaviour change was defined as a self-reported change in lifestyle, including dietary changes or medication adherence. METHODS: An individual counselling session was provided to participants by allied healthcare professionals to promote health behaviour change. A survey was mailed to all participants at risk of CKD within 2-4 weeks following the screening event to determine if behaviour changes had been initiated. Descriptive statistics were used to describe respondent characteristics and self-reported behaviour change following screening events. Results were stratified by estimated glomerular filtration rate (eGFR) (< 60 and ≥ 60 mL/min/1.73 m(2)). Log binomial regression analysis was used to determine the predictors of behaviour change. RESULTS: Of the 1129 respondents, the majority (89.8 %) reported making a health behaviour change after the screening event. Respondents who were overweight (body mass index [BMI] 25-29.9 kg/m(2)) or obese (BMI ≥ 30.0 kg/m(2)) were more likely to report a behaviour change (prevalence rate ratio (PRR) 0.66, 95 % confidence interval (CI) 0.44-0.99 and PRR 0.49, 95 % CI 0.30-0.80, respectively). Further, participants with a prior intent to change their behaviour were more likely to make a behaviour change (PRR 0.58, 95 % CI 0.35-0.96). Results did not vary by eGFR category. LIMITATIONS: We are unable to determine the effectiveness of the behaviour change intervention given the lack of a control group. Potential response bias and social desirability bias must also be considered when interpreting the study findings. CONCLUSIONS: Individual counselling and goal setting provided at screening events may stimulate behaviour change amongst individuals at risk for CKD. However, further research is required to determine if this behaviour change is sustained and the impact on CKD progression and outcomes.

MISE EN CONTEXTE: Les changements dans les habitudes de vie sont une composante majeure dans la prise en charge des patients atteints d'insuffisance rénale chronique (IRC). Malgré cela, la méthode pour promouvoir efficacement ces changements auprès de cette clientèle particulière n'est pas connue. Le programme de dépistage précoce et ciblé See Kidney Disease (SeeKD) a permis d'identifier les Canadiens à risque de développer une IRC. Ce programme a aussi servi à promouvoir l'adoption de changements d'habitudes bénéfiques pour la santé, par le biais de consultations individuelles et par l'établissement d'objectifs. OBJECTIFS DE L'ÉTUDE: Cette étude avait pour objectif de mesurer l'efficacité de séances de consultation individuelle offertes aux patients en vue de susciter des changements comportementaux. L'étude visait également à établir les caractéristiques des patients associées à ces changements de comportement. CADRE DE L'ÉTUDE: Il s'agit d'une étude transversale descriptive qui s'est tenue dans le cadre du programme national de dépistage ciblé SeeKD. PARTICIPANTS: La cohorte était constituée de tous les patients identifiés « à risque de développer une IRC ¼ par le programme SeeKD, et ayant retourné le questionnaire de suivi au sujet des changements dans leurs habitudes de vie, soit un total de 1129 participants. MESURES: Une séance de consultation individuelle ayant pour but de promouvoir l'intégration de nouvelles d'habitudes de vie a été offerte aux participants par les professionnels de la santé à la suite de l'activité de dépistage. Entre deux et quatre semaines plus tard, les participants ont également reçu un questionnaire par la poste à l'aide duquel on a pu vérifier s'ils avaient entamé les changements de comportement proposés. Des statistiques descriptives ont été utilisées pour établir les caractéristiques des répondants ainsi que les changements de comportement que ces derniers ont rapporté avoir adoptés à la suite de l'activité de dépistage. Les résultats ont été stratifiés en deux groupes selon les valeurs de DFGe des participants (< 60 mL/min/1.73 m2 et ≥ 60 mL/min/1.73 m2). L'analyse par régression logistique binomiale a été utilisée pour identifier les indicateurs de changement de comportement chez les patients. RÉSULTATS: La grande majorité (89,8 %) des 1129 participants ont rapporté avoir adopté de nouveaux comportements en matière de santé après avoir été déclarés à risque de développer une IRC. Les répondants souffrant d'embonpoint (indice de masse corporelle [IMC] entre 25 et 29,9 kg/m2) ou obèses (IMC ≥ 30,0 kg/m2) se sont avérés plus ouverts à l'idée d'adopter de nouveaux comportements en regard de leur santé (rapport du taux de prévalence [RTP] : 0,66 ; intervalle de confiance à 95 % [I.C. à 95 %] : entre 0,44 et 0,99 et RTP : 0,49 ; I.C. à 95 % : entre 0,30 et 0,80 respectivement). Par ailleurs, les répondants qui avaient déjà l'intention d'adopter de nouveaux comportements avant même d'être dépistés ont été les plus enclins à le faire (RTP : 0,58 ; I.C. à 95 % : entre 0,35 et 0,96). Aucune variation significative de ces résultats n'a été observée selon le DFGe. LIMITES DE L'ÉTUDE: Nous n'avons pu déterminer avec précision l'efficacité des changements de comportement adoptés en raison de l'absence d'un groupe contrôle. De plus, un biais dû aux réponses des participants ou par désirabilité sociale est à considérer dans l'interprétation des résultats. CONCLUSIONS: L'établissement d'objectifs ainsi que le counselling individuel fourni à la suite de l'activité de dépistage pourraient stimuler l'adoption de nouvelles habitudes de vie chez les patients à risque de développer une IRC. Toutefois, des recherches supplémentaires sont requises afin de déterminer si ces changements de comportement sont maintenus par les patients et s'ils ont une réelle influence sur le pronostic de la maladie.

The See Kidney Disease Targeted Screening Program for CKD.

BACKGROUND AND OBJECTIVES: The effectiveness of targeted screening for identification of CKD is largely unknown. The See Kidney Disease (SeeKD) targeted screening project aimed to determine the prevalence of unrecognized CKD in Canada. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The SeeKD project was conducted across Canada using a convenience sample approach and events to identify adults with risk factors for CKD (i.e., diabetes, hypertension, vascular disease, family history of kidney problems, etc.). Participants with at least one risk factor received a point-of-care creatinine measurement to identify unrecognized CKD (CKD-Epidemiology Collaboration eGFR <60 ml/min per 1.73 m(2)). Baseline information included clinical characteristics, sociodemographics, and health knowledge. Semistructured telephone interviews were conducted with each Kidney Foundation of Canada branch (regionalized locations) after the screening events to characterize local screening strategies, which were subsequently categorized as individual-targeted (specifically targeting individuals at risk of CKD) and community-targeted (event in a community location in proximity to a high-risk population). We calculated the prevalence of unrecognized CKD overall, and by screening strategy. RESULTS: Between January 2011 and February 2014, 6329 Canadians participated in SeeKD screening events. Participants were predominantly female (65.3%), middle-aged (mean, 58.5 years), and the majority (88.9%) self-reported at least one risk factor for CKD. Of participants with at least one risk factor, 92.3% (n=5194) were screened, of whom 18.8% (95% confidence interval [95% CI], 17.8 to 19.9) had unrecognized CKD; the majority (13.8%) had stage 3a CKD (eGFR=45-60 ml/min per 1.73 m(2)). The prevalence of unrecognized CKD was higher for branches with individual versus community-targeted events (21.9% [95% CI, 20.5 to 23.4] versus 14.7% [95% CI, 13.2 to 16.2]). CONCLUSIONS: Targeted screening identified a high proportion of individuals with risk factors for CKD and a high prevalence of unrecognized CKD. Future research will evaluate the ability of targeted screening to promote self-management behaviors addressing priorities for people with CKD.

Statewide Administration of the CRAFFT Screening Tool: Highlighting the Spectrum of Substance Use.

BACKGROUND: Adolescent alcohol and drug use in the United States are associated with negative consequences spanning multiple domains. Much of the public health surveillance of these behaviors relies on self-report survey data. These data frequently takes the form of frequency or prevalence data for specific substances, which may not provide a complete picture of use. OBJECTIVES: This study analyzes a state-level survey that includes the CRAFFT screening tool. The study's goal is to elucidate the spectrum of substance use severity across a large segment of substance-using adolescents attending schools in the state of Indiana and to assess the contribution of a variety of predictor variables to the variance between users falling into each category of use severity. METHODS: Data were collected in 2011 from 168,801 adolescents, of whom 25,204 met the inclusion criteria for this study. The authors utilize multinomial logit analyses to highlight variables, including sociodemographic data, poly-drug use, and risk/protective behavior scales, associated with each category of use. RESULTS: Seriousness of use is not uniform across substance-using adolescents; 49% were categorized as nonproblem users, 33% as problem users, and 18% as dependent users. Risk and protective factors predict adolescents' severity of substance use, but do not do so uniformly. Poly-drug use is a significant predictor of problem use and dependent use as well. CONCLUSIONS: The CRAFFT may provide a more nuanced perspective of adolescent substance use than frequency/prevalence data alone; the authors describe the implications derived from these data and analyses to the adolescent prevention and treatment systems.

Exploring physician specialist response rates to web-based surveys.

BACKGROUND: Survey research in healthcare is an important tool to collect information about healthcare delivery, service use and overall issues relating to quality of care. Unfortunately, physicians are often a group with low survey response rates and little research has looked at response rates among physician specialists. For these reasons, the purpose of this project was to explore survey response rates among physician specialists in a large metropolitan Canadian city. METHODS: As part of a larger project to look at physician payment plans, an online survey about medical billing practices was distributed to 904 physicians from various medical specialties. The primary method for physicians to complete the survey was via the Internet using a well-known and established survey company (www.surveymonkey.com). Multiple methods were used to encourage survey response such as individual personalized email invitations, multiple reminders, and a draw for three gift certificate prizes were used to increase response rate. Descriptive statistics were used to assess response rates and reasons for non-response. RESULTS: Overall survey response rate was 35.0%. Response rates varied by specialty: Neurology/neurosurgery (46.6%); internal medicine (42.9%); general surgery (29.6%); pediatrics (29.2%); and psychiatry (27.1%). Non-respondents listed lack of time/survey burden as the main reason for not responding to our survey. CONCLUSIONS: Our survey results provide a look into the challenges of collecting healthcare research where response rates to surveys are often low. The findings presented here should help researchers in planning future survey based studies. Findings from this study and others suggest smaller monetary incentives for each individual may be a more appropriate way to increase response rates.

Effect of physician specialist alternative payment plans on administrative health data in Calgary: a validation study.

BACKGROUND: There are concerns that alternate payment plans for physicians may be associated with erosion of data quality, given that physicians are paid regardless of whether claims are submitted. Our objective was to determine the proportion of claims submitted by physician specialists using fee-for-service and alternative payment plans, and to identify and compare the validity of information coded in physician billing claims submitted by these specialists in Calgary. METHODS: We conducted a survey of physician specialists to determine their plan status and obtained consent to use physicians' claims data from 4 acute care hospitals in Calgary. Inpatient and emergency department services were identified from the Discharge Abstract Database for Alberta (Canadian Institute for Health Information) and the Alberta Ambulatory Care Classification System database. We linked services to claims by Alberta physicians from 2002 to 2009 by using unique patient and physician identifiers. After identifying the proportion of claims submitted, we reviewed inpatient charts to determine the completeness of submissions as defined by positive predictive value. RESULTS: Of 182 physicians who responded to the survey, 94 (51.6%) used fee-for-service plans exclusively and 51 (28.0%) used alternative payment plans exclusively. Overall completeness of physician submissions for claims was 91.8% for physicians using fee-for-service plans and 90.0% for physicians using alternative payment plans. Submission rate varied by medical specialty (surgery: 92.4% for fee for service v. 88.6% for alternative payment; internal medicine: 94.1% v. 91.3%; neurology: 95.1% v. 91.0%; and pediatrics: 95.1% v. 89.3%). Among claims submitted, the physician accuracies for billing of medical conditions were 87.8% for fee-for-service and 85.0% for alternative payment. INTERPRETATION: Overall submission rates and accuracy in recording diagnoses by physicians who used both plans were high. These findings show that the implementation of alternative payment plan programs in Alberta may not have an impact on the quality of physician claims data.

Kidney stones and cardiovascular events: a cohort study.

BACKGROUND AND OBJECTIVES: Kidney stones are common in general clinical practice, and their prevalence is increasing. Kidney stone formers often have risk factors associated with atherosclerosis, but it is uncertain whether having a kidney stone is associated with higher risk of cardiovascular events. This study sought to assess the association between one or more kidney stones and the subsequent risk of cardiovascular events. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Cohort study of 3,195,452 people aged≥18 years registered in the universal health care system in Alberta, Canada, between 1997 and 2009 (median follow-up of 11 years). People undergoing dialysis or with a kidney transplant at baseline were excluded. The primary outcome was the first acute myocardial infarction (AMI) during follow-up. We also considered other cardiovascular events, including death due to coronary heart disease, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass grafting (CABG), and stroke. RESULTS: In total, 25,532 (0.8%) participants had at least one kidney stone, and 91,465 (3%) individuals had at least one cardiovascular event during follow-up. Compared with people without kidney stones and after adjustment for cardiovascular risk factors and other potential confounders, people who had at least one kidney stone had a higher risk of subsequent AMI (adjusted hazard ratio [HR], 1.40; 95% confidence interval [95% CI], 1.30 to 1.51), PTCA/CABG (HR, 1.63; 95% CI, 1.51 to 1.76), and stroke (HR, 1.26; 95% CI, 1.12 to 1.42). The magnitude of the excess risk associated with a kidney stone appeared more pronounced for younger people than for older people (P<0.001) and for women than men (P=0.01). CONCLUSIONS: The occurrence of a kidney stone is associated with a higher risk of cardiovascular events, including AMI, PTCA/CABG, and stroke.

Substantial practice variation exists in the management of childhood nephrotic syndrome.

BACKGROUND: Practice variation is common for nephrotic syndrome (NS) treatment. METHODS: A cross-sectional, web-based survey on NS treatment was administered to 58 Canadian pediatric nephrologists with the aim to document existing practice variation and compare practice with the recommendations of the Kidney Disease Improving Global Outcomes Clinical Practice Guideline for NS. RESULTS: Of the 58 nephrologists asked to participate in the survey, 40 (69 %) responded. Among these, 62 % prescribed initial daily glucocorticoid (GC) therapy for 6 weeks, 26 % for 4 weeks by 26 %, and 10 % prescribed 'other'. Alternate-day GC was continued for 6 weeks by 63 % of respondents and for >6 and <6 weeks by 32 and 6 %, respectively. For biopsy-confirmed minimal change disease, 65 and 46 % of respondents chose oral cyclophosphamide for frequently relapsing and steroid-dependent phenotypes, respectively; calcineurin inhibitors or mycophenolate were the second most popular choices. Kidney biopsy was 'always' performed by 16, 39, and 97 % of respondents for frequently relapsing, steroid-dependent, and steroid-resistant patients, respectively. Rituximab had been administered by 60 % of respondents; 22, 56, and 72 % reported that they would consider rituximab for frequently relapsing, steroid-dependent, and steroid-resistant patients, respectively. Most notable differences between practice and Guideline recommendations were first presentation GC duration, GC-sparing agent choices in frequently relapsing and steroid-dependent patients, and biopsy practices. CONCLUSIONS: There is substantial Canadian practice variation in NS treatment. Assessment of factors driving variation and strategies to implement Guideline recommendations are needed.