Factors associated with de-hospitalization of children and adolescents with complex chronic condition / Fatores associados à desospitalização de crianças e adolescentes com condição crônica complexa

ABSTRACT Objective: To assess the factors associated with the de-hospitalization of children and adolescents with complex chronic condition. Methods: This cross-sectional and retrospective study investigated a sample of children and adolescents admitted to the Dehospitalization Training Unit, from January 2012 to December 2017. Data were collected by consulting medical records and patient record books, from November 2018 to June 2019. The length of stay in the unit, de-hospitalization, readmissions, frequency and cause of death, age, sex, diagnosis, place of residence, number of caregivers and kinship, and use of devices were studied. The chi-square test was used to verify the association between the dependent variable (de-hospitalization) and the independent variables (age, sex, place of residence, use of devices, and clinical diagnosis). Results: A total of 93 patient records were analyzed, 37.6% aged between 7 months and 2 years old, 58.1% boys, 95.7% used tracheostomy, 92.5% gastrostomy, and 71% invasive mechanical ventilation. Hypoxic-ischemic encephalopathy was the diagnosis of 40.3% of the sample. Average hospitalization time was 288 ± 265 days; 60.2% were hospitalized between 31 days and one year, representing 50% of deaths. Of those de-hospitalized, 76.3% were discharged to the Ventilatory Assistance Homecare Program. De-hospitalization was associated with the child or adolescent's place of residence (p=0.027) and use of ventriculoperitoneal shunt (p=0.021). Conclusions: This study identified that de-hospitalization may be associated with the place of residence of the child or adolescent, with the highest number of discharges to the state capital, and non-dehospitalization when using ventricular-peritoneal shunt.

RESUMO Objetivo: Avaliar os fatores associados à desospitalização de crianças e adolescentes com condição crônica complexa. Métodos: Estudo transversal e retrospectivo, que investigou a população de crianças e adolescentes internados na Unidade de Treinamento para Desospitalização (UTD), de janeiro de 2012 a dezembro de 2017. Os dados foram coletados por meio da consulta aos prontuários e livros de registros, de novembro de 2018 a junho de 2019. Foram estudados o período de internamento na UTD, a desospitalização, as reinternações, a frequência e causa dos óbitos, a idade, o sexo, o diagnóstico, o local de residência, o número de cuidadores e parentesco e o uso de dispositivos. Utilizou-se o teste do qui-quadrado para verificar a associação entre a variável dependente (desospitalização) e as variáveis independentes (idade, sexo, local de residência, uso de dispositivos e diagnóstico clínico). Resultados: O total de 93 prontuários de pacientes foi analisado, 37,6% tinham idade entre sete meses e dois anos, 58,1% eram meninos, 95,7% usavam traqueostomia, 92,5% gastrostomia e 71% ventilação mecânica invasiva. Encefalopatia hipóxico-isquêmica foi o diagnóstico de 40,3% da população. O tempo médio de hospitalização foi 288±265 dias; 60,2% ficaram internados entre 31 dias e um ano, representando 50% dos óbitos. Dos desospitalizados, 76,3% receberam alta para o Programa de Assistência Ventilatória Domiciliar (PAVD). A desospitalização foi associada ao local de procedência (p=0,027) e ao uso de derivação ventriculoperitoneal (DVP) (p=0,021). Conclusões: Identificou-se que a desospitalização esteve associada ao local de residência da criança ou adolescente e ao uso de DVP, sendo o maior número de altas para a capital do estado.

Forecasting disability-adjusted life years for chronic diseases: reference and alternative scenarios of salt intake for 2017-2040 in Japan.

BACKGROUND: In Japan, a high-sodium diet is the most important dietary risk factor and is known to cause a range of health problems. This study aimed to forecast Japan's disability-adjusted life year (DALYs) for chronic diseases that would be associated with high-sodium diet in different future scenarios of salt intake. We modelled DALY forecast and alternative future scenarios of salt intake for cardiovascular diseases (CVDs), chronic kidney diseases (CKDs), and stomach cancer (SC) from 2017 to 2040. METHODS: We developed a three-component model of disease-specific DALYs: a component on the changes in major behavioural and metabolic risk predictors including salt intake; a component on the income per person, educational attainment, and total fertility rate under 25 years; and an autoregressive integrated moving average model to capture the unexplained component correlated over time. Data on risk predictors were obtained from Japan's National Health and Nutrition Surveys and from the Global Burden of Disease Study 2017. To generate a reference forecast of disease-specific DALY rates for 2017-2040, we modelled the three diseases using the data for 1990-2016. Additionally, we generated better, moderate, and worse scenarios to evaluate the impact of change in salt intake on the DALY rate for the diseases. RESULTS: In our reference forecast, the DALY rates across all ages were predicted to be stable for CVDs, continuously increasing for CKDs, and continuously decreasing for SC. Meanwhile, the age group-specific DALY rates for these three diseases were forecasted to decrease, with some exceptions. Except for the ≥70 age group, there were remarkable differences in DALY rates between scenarios, with the best scenario having the lowest DALY rates in 2040 for SC. This represents a wide scope of future trajectories by 2040 with a potential for tremendous decrease in SC burden. CONCLUSIONS: The gap between scenarios provides some quantification of the range of policy impacts on future trajectories of salt intake. Even though we do not yet know the policy mix used to achieve these scenarios, the result that there can be differences between scenarios means that policies today can have a significant impact on the future DALYs.

Trends in Selected Chronic Conditions and Related Risk Factors Among Women of Reproductive Age: Behavioral Risk Factor Surveillance System, 2011-2017.

Introduction: Chronic diseases in the United States are the leading drivers of disability, death, and health care costs. In women of reproductive age (WRA), chronic disease and related risk factors can also affect fertility and reproductive health outcomes. This analysis of trends from 2011 to 2017 adds additional indicators and updates an analysis covering 2001-2009. Methods: Data from the 2011-2017 Behavioral Risk Factor Surveillance System were analyzed for 265,544 WRA (18-44 years). To assess trends in 12 chronic conditions and related risk factors, we calculated annual prevalence estimates and adjusted prevalence ratios (APRs) with predicted marginals accounting for age, race, Hispanic ethnicity, education, and health care coverage. Results: From 2011 to 2017, prevalence decreased for current smoking (20.7%-15.9%; p < 0.001), gestational diabetes (3.1%-2.7%; p = 0.003), and high cholesterol (19.0%-16.7%; p < 0.001); prevalence increased for depression (20.4%-24.9%; p < 0.001) and obesity (24.6%-27.6%; p < 0.001). After adjustment, in 2017 WRA were more likely to report asthma (APR = 1.06; 95% confidence interval [CI] = 1.01-1.11), physical inactivity (APR = 1.08; 95% CI = 1.04-1.12), obesity (APR = 1.15; 95% CI = 1.11-1.19), and depression (APR = 1.29; 95% CI = 1.25-1.34) compared with 2011. They were less likely to report high cholesterol (APR = 0.89; 95% CI = 0.85-0.94) in 2015 compared with 2011, and current smoking (APR = 0.86; 95% CI = 0.82-0.89) and gestational diabetes (APR = 0.84; 95% CI = 0.75-0.94) in 2017 compared with 2011. Conclusions: Some chronic conditions and related risk factors improved, whereas others worsened over time. Research clarifying reasons for these trends may support the development of targeted interventions to promote improvements, potentially preventing adverse reproductive outcomes and promoting long-term health.

Trends in prevalence of comorbidities in heart failure clinical trials.

AIMS: The primary objective of this systematic review was to estimate the prevalence and temporal changes in chronic comorbid conditions reported in heart failure (HF) clinical trials. METHODS AND RESULTS: We searched MEDLINE for HF trials enrolling more than 400 patients published between 2001 and 2016.Trials were divided into HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or trials enrolling regardless of ejection fraction. The prevalence of baseline chronic comorbid conditions was categorized according to the algorithm proposed by the Chronic Conditions Data Warehouse, which is used to analyse Medicare data. To test for a trend in the prevalence of comorbid conditions, linear regression models were used to evaluate temporal trends in prevalence of comorbidities. Overall, 118 clinical trials enrolling a cumulative total of 215 508 patients were included. Across all comorbidities examined, data were reported in a mean of 35% of trials, without significant improvement during the study period. Reporting of comorbidities was more common in HFrEF trials (51%) compared with HFpEF trials (27%). Among trials reporting data, hypertension (63%), ischaemic heart disease (44%), hyperlipidaemia (48%), diabetes (33%), chronic kidney disease (25%) and atrial fibrillation (25%) were the major comorbidities. The prevalence of comorbidities including hypertension, atrial fibrillation and chronic kidney disease increased over time while the prevalence of smoking decreased in HFrEF trials. CONCLUSION: Many HF trials do not report baseline comorbidities. A more rigorous, systematic, and standardized framework needs to be adopted for future clinical trials to ensure adequate comorbidity reporting and improve recruitment of multi-morbid HF patients.

Impact of Illness on Electronic Health Use (The Seventh Tromsø Study - Part 2): Population-Based Questionnaire Study.

BACKGROUND: Patients who suffer from different diseases may use different electronic health (eHealth) resources. Thus, those who plan eHealth interventions should take into account which eHealth resources are used most frequently by patients that suffer from different diseases. OBJECTIVE: The aim of this study was to understand the associations between different groups of chronic diseases and the use of different eHealth resources. METHODS: Data from the seventh survey of the Tromsø Study (Tromsø 7) were analyzed to determine how different diseases influence the use of different eHealth resources. Specifically, the eHealth resources considered were use of apps, search engines, video services, and social media. The analysis contained data from 21,083 participants in the age group older than 40 years. A total of 15,585 (15,585/21,083; 73.92%) participants reported to have suffered some disease, 10,604 (10,604/21,083; 50.29%) participants reported to have used some kind of eHealth resource in the last year, and 7854 (7854/21,083; 37.25%) participants reported to have used some kind of eHealth resource in the last year and suffered (or had suffered) from some kind of specified disease. Logistic regression was used to determine which diseases significantly predicted the use of each eHealth resource. RESULTS: The use of apps was increased among those individuals that (had) suffered from psychological problems (odds ratio [OR] 1.39, 95% CI 1.23-1.56) and cardiovascular diseases (OR 1.12, 95% CI 1.01-1.24) and those part-time workers that (had) suffered from any of the diseases classified as others (OR 2.08, 95% CI 1.35-3.32). The use of search engines for accessing health information increased among individuals who suffered from psychological problems (OR 1.39, 95% CI 1.25-1.55), cancer (OR 1.26, 95% CI 1.11-1.44), or any of the diseases classified as other diseases (OR 1.27, 95% CI 1.13-1.42). Regarding video services, their use for accessing health information was more likely when the participant was a man (OR 1.31, 95% CI 1.13-1.53), (had) suffered from psychological problems (OR 1.70, 95% CI 1.43-2.01), or (had) suffered from other diseases (OR 1.43, 95% CI 1.20-1.71). The factors associated with an increase in the use of social media for accessing health information were as follows: (had) suffered from psychological problems (OR 1.65, 95% CI 1.42-1.91), working part time (OR 1.35, 95% CI 0.62-2.63), receiving disability benefits (OR 1.42, 95% CI 1.14-1.76), having received an upper secondary school education (OR 1.20, 95% CI 1.03-1.38), being a man with a high household income (OR 1.67, 95% CI 1.07-2.60), suffering from cardiovascular diseases and having a high household income (OR 3.39, 95% CI 1.62-8.16), and suffering from respiratory diseases while being retired (OR 1.95, 95% CI 1.28-2.97). CONCLUSIONS: Our findings show that different diseases are currently associated with the use of different eHealth resources. This knowledge is useful for those who plan eHealth interventions as they can take into account which type of eHealth resource may be used for gaining the attention of the different user groups.

The relationship between chronic diseases and number of sexual partners: an exploratory analysis.

BACKGROUND: We investigated sex-specific associations between lifetime number of sexual partners and several health outcomes in a large sample of older adults in England. METHODS: We used cross-sectional data from 2537 men and 3185 women aged ≥50 years participating in the English Longitudinal Study of Ageing. Participants reported the number of sexual partners they had had in their lifetime. Outcomes were self-rated health and self-reported limiting long-standing illness, cancer, coronary heart disease, and stroke. We used logistic regression to analyse associations between lifetime number of sexual partners and health outcomes, adjusted for relevant sociodemographic and health-related covariates. RESULTS: Having had 10 or more lifetime sexual partners was associated with higher odds of reporting a diagnosis of cancer than having had 0-1 sexual partners in men (OR 1.69, 95% CI 1.01 to 2.83) and women (OR 1.91, 95% CI 1.04 to 3.51), respectively. Women who had 10 or more lifetime sexual partners also had higher odds of reporting a limiting long-standing illness (OR 1.64, 95% CI 1.15 to 2.35). No other statistically significant associations were observed. CONCLUSIONS: A higher lifetime number of sexual partners is associated with increased odds of reported cancer. Longitudinal research is required to establish causality. Understanding the predictive value of lifetime number of sexual partners as a behavioural risk factor may improve clinical assessment of cancer risk in older adults.

Chronic condition risk factor change over time in a remote Indigenous community.

INTRODUCTION: This study sought to determine change in chronic condition risk factors in a remote Indigenous community following a 3-year period of community-led health promotion initiatives. METHODS: Data were compared between two cross-sectional surveys of Indigenous Australian community residents before and after health promotion activities, and longitudinal analysis of participants present at both surveys using multilevel mixed-effects regression. RESULTS: At baseline, 294 (53% women; mean age 35 years) participated and 218 attended the second survey (56% women, mean age 40 years), and 87 attended both. Body composition, blood pressure and urinary albumin-to-creatinine ratio remained stable between baseline and follow-up. After adjusting for age and sex, haemoglobin A1c significantly increased (from 57 to 63 mmol/mol (7.5% to 8.1%), p=0.021) for those with diabetes. Increases were also observed for total cholesterol (from 4.4 to 4.6 mmol/L, p=0.006) and triglycerides (from 1.5 to 1.6 mmol/L, p=0.019), and high-density lipoprotein cholesterol levels improved (from 0.98 to 1.02 mmol/L, p=0.018). Self-reported smoking prevalence was high but stable between baseline (57%) and follow-up (56%). Similar results were observed in the longitudinal analysis to the cross-sectional survey comparison. CONCLUSION: Community-led health promotion initiatives may have had some benefits on chronic condition risk factors, including stabilisation of body composition, in this remote Indigenous community. Given that less favourable trends were observed for diabetes and total cholesterol over a short time period and smoking prevalence remained high, policy initiatives that address social and economic disadvantage are needed alongside community-led health promotion initiatives.

Condições de saúde e mudança de peso de idosos em dez anos do Estudo SABE / Condiciones de salud y cambio de peso de personas mayores en diez años del Estudio SABE / Health conditions and weight change among the older adults over ten years of the SABE Survey

Objetivo: Analisar a relação das condições de saúde com a mudança de peso entre idosos em um período de dez anos em São Paulo/SP. Métodos: Estudo longitudinal que acompanhou (2000-baseline, 2006 e 2010) a mudança do peso corporal (variável desfecho) e condições de saúde associadas (variáveis de exposição) em idosos (n=571); análises de regressão logística multinomial foram empregadas. Resultados: O aumento médio de peso no período foi de 29,0%. Perderam peso 34,0% (2006) e 12,5% (2010); e ganharam peso 18,2% (2006) e 39,9% (2010). A prevalência de doenças crônicas aumentou de 34,1% (2000) para 51,9% (2006) e 60,1% (2010). Idosos com aumento de peso avaliaram pior sua saúde geral em 2006 (RR:3,15; IC95% 1,21;8,17) e 2010 (RR:2,46; IC95% 1,02;5,94). Maior número de doenças (RR:2,12; IC95% 1,00;4,46) e internações (RR:3,50; IC95% 1,40;8,72) associaram-se a diminuição de peso em 2010. Conclusão: Mudanças de peso estão relacionadas a um pior estado de saúde entre idosos.

Objetivo: Analizar la relación entre las condiciones de salud y el cambio de peso entre adultos mayores durante un período de diez años en São Paulo/SP. Métodos: Estudio longitudinal (2000-baseline, 2006 y 2010) que siguió el cambio en el peso corporal (variable de resultado) y las condiciones de salud asociadas (variables de exposición) en adultos mayores (n=571); se emplearon análisis de regresión logística multinomial. Resultado: El aumento de peso promedio en el período evaluado fue del 29,0%. Un 34,0% (2006) y 12,5% (2010) perdieron peso; 18,2% (2006) y 39,9% (2010) ganaron peso. La prevalencia de enfermedades crónicas aumentó del 34,1% (2000) para 51,9% (2006) y 60,1% (2010). Las personas mayores con aumento de peso calificaron su salud general peor en 2006 (RR:3,15; IC95% 1,21;8,17) y 2010 (RR:2,46; IC95% 1,02;5,94). El mayor número de enfermedades (RR:2,12; IC95% 1,00;4,46) y hospitalizaciones (RR:3.50; IC95% 1,40;8,72) se asociaron con una disminución del peso en 2010. Conclusión: Los cambios de peso están relacionados con un peor estado de salud entre los adultos mayores.

Objective: To analyze the relationship between health conditions and weight changes among elderly people monitored by the SABE Survey over a ten-year period in São Paulo/SP. Methods: This was a longitudinal study that followed (2000-baseline, 2006 and 2010) change in body weight (outcome variable) and associated health conditions (exposure variables) in the elderly (n=571); multinomial logistic regression analyses were employed. Results: Average weight increase in the evaluated period was 29.0%. 34.0% (2006) and 12.5% (2010) lost weight and 18.2% (2006) and 39.9% (2010) gained weight. Prevalence of chronic diseases increased from 34.1% (2000) to 51.9% (2006) and 60.1% (2010). Older people with weight gain also rated their overall health as poorer in 2006 (RR:3.15; 95%CI 1.21;8.17) and 2010 (RR:2.46; 95%CI 1.02;5.94). The higher numbers of diseases (RR:2.12; 95%CI 1.00;4.46) and hospitalizations (RR:3.50; 95%CI 1.40;8.72) were associated with a decrease in weight in 2010. Conclusion: Weight changes are related to poorer health status among the elderly.

Nurse as an integrator in healthcare management of children with chronic condition / Enfermero como integrador en la gestión del cuidado al niño con condición crónica / Enfermeiro como integrador na gestão do cuidado à criança com condição crônica

ABSTRACT Objectives: to understand the practice of the nurse in healthcare management of children with chronic condition in the hospital setting. Methods: analytical study of qualitative approach with theoretical and methodological reference of institutional ethnography. Developed in the pediatric unit of a university hospital, in a municipality in Northeastern Brazil. Data collections techniques were: participant observation, documentary analysis and semi-structured interview. Participants of the study totaled twenty professionals, including nurses, social workers, psychologists, pharmacists, nutritionists, physiotherapists, and doctors. For data analysis, it was used the Bardin's Content Analysis with interface of the Atlas.ti software. Results: categories of analysis were "Nurse as mediator of healthcare management"; "Nursing process as a mechanism of healthcare management". Final considerations: the nurse proved to be essential for healthcare management of the child with chronic condition, acting as mediator of the relationship between the doctor, the members of the health team, the user and their family.

RESUMEN Objetivos: comprender la práctica del enfermero en la gestión del cuidado al niño con condición crónica en el contexto hospitalário. Métodos: estudio analítico de abordaje cualitativo, con referencial teórico y metodológico de la etnografía institucional. Desarrollado en la unidad pediátrica de un hospital universitario, en un municipio del Nordeste brasileño. Se utilizaron técnicas de recolección de datos, como observación participante, análisis documental y entrevista semiestructurada. Participaron del estudio un total de veinte profesionales, siendo ellos enfermeros, asistentes sociales, psicólogos, farmacéuticos, nutricionistas, fisioterapeutas y médicos. Para el análisis de los datos, se utilizó el Análisis de Contenido de Bardin con interfaz del software Atlas.ti Resultados: las categorías de análisis fueron "enfermero como mediador de la gestión del cuidado"; "Proceso de enfermería como mecanismo de gestión del cuidado". Consideraciones finales: el enfermero se reveló fundamental para la gestión del cuidado al niño con condición crónica, actuando como mediador de la relación entre el médico, los integrantes del equipo de salud, el usuario y su família.

RESUMO Objetivos: compreender a prática do enfermeiro na gestão do cuidado à criança com condição crônica no contexto hospitalar. Métodos: estudo analítico de abordagem qualitativa, com referencial teórico e metodológico da etnografia institucional. Desenvolvido na unidade pediátrica de um hospital universitário, em um município do Nordeste brasileiro. Foram utilizadas técnicas de coleta de dados, como observação participante, análise documental e entrevista semiestruturada. Participaram do estudo vinte profissionais, sendo eles enfermeiros, assistentes sociais, psicólogos, farmacêuticos, nutricionistas, fisioterapeutas e médicos. Para análise dos dados, utilizou-se a Análise de Conteúdo de Bardin com interface do software Atlas.ti. Resultados: categorias de análise, bem como "Enfermeiro como mediador da gestão do cuidado"; "Processo de enfermagem como mecanismo de gestão do cuidado". Considerações finais: o enfermeiro revelou-se fundamental para gestão do cuidado à criança com condição crônica, atuando como mediador da relação entre o médico, os integrantes da equipe de saúde, o usuário e sua família.

Can integration reduce inequity in healthcare utilization? Evidence and hurdles in China.

BACKGROUND: Integration of medical insurance schemes has been prioritized as one of the key strategies to address inequity in China's health system. The first pilot attempt to integrate started in 2003 and later expanded nationwide. This study aims to assess its intended impact on inequity in inpatient service utilization and identify the main determinants contributing to its ineffectiveness. METHODS: A total of 49,365 respondents in the pilot integrated area and 77,165 respondents in the non-integration area were extracted from the Fifth National Health Services Survey. A comparative analysis was conducted between two types of areas. We calculate a concentration index (CI) and horizontal inequity index (HI) in inpatient service utilization and decompose the two indices. RESULTS: Insurance integration played a positive role in reducing inequality in inpatient service utilization to some extent. A 13.23% lower in HI, a decrease in unmet inpatient care and financial barriers to inpatient care in the pilot integrated area compared with the non-integration area; decomposition analysis showed that the Urban-Rural Residents Basic Medical Insurance, a type of integrated insurance, contributed 37.49% to reducing inequality in inpatient service utilization. However, it still could not offset the strong negative effect of income and other insurance schemes that have increased inequality. CONCLUSIONS: The earlier pilot attempt for integrating medical insurance was not enough to counteract the influence of factors which increased the inequality in inpatient service utilization. Further efforts to address the inequality should focus on widening access to financing, upgrading the risk pool, reducing gaps within and between insurance schemes, and providing broader chronic disease benefit packages. Social policies that target the needs of the poor with coordinated efforts from various levels and agencies of the government are urgently needed.

Hospital Readmission of Adolescents and Young Adults With Complex Chronic Disease.

Importance: Adolescents and young adults (AYA) who have complex chronic disease (CCD) are a growing population that requires hospitalization to treat severe, acute health problems. These patients may have increased risk of readmission as demands on their self-management increase and as they transfer care from pediatric to adult health care practitioners. Objective: To assess variation across CCDs in the likelihood of readmission for AYA with increasing age. Design, Setting, and Participants: Retrospective 1-year cross-sectional study of the 2014 Agency for Healthcare Research and Quality Nationwide Readmissions Database for all US hospitals. Participants were 215 580 hospitalized individuals aged 15 to 30 years with cystic fibrosis (n = 15 213), type 1 diabetes (n = 86 853), inflammatory bowel disease (n = 48 073), spina bifida (n = 7819), and sickle cell anemia (n = 57 622) from January 1, 2014, to December 1, 2014. Exposures: Increasing age at index admission. Main Outcomes and Measures: Unplanned 30-day hospital readmission. Readmission odds were compared by patients' ages in 2-year epochs (with age 15-16 years as the reference) using logistic regression, accounting for confounding patient characteristics and data clustering by hospital. Results: Of 215 580 participants, 115 982 (53.8%) were female; the median (interquartile range) age was 24 (20-27) years. Across CCDs, multimorbidity was common; the percentages of index hospitalizations with 4 or more coexisting conditions ranged from to 33.4% for inflammatory bowel disease to 74.2% for spina bifida. Thirty-day hospital readmission rates varied significantly across CCDs: 20.2% (cystic fibrosis), 19.8% (inflammatory bowel disease), 20.4% (spina bifida), 22.5% (type 1 diabetes), and 34.6% (sickle cell anemia). As age increased from 15 to 30 years, unadjusted, 30-day, unplanned hospital readmission rates increased significantly for all 5 CCD cohorts. In multivariable analysis, age trends in the adjusted odds of readmission varied across CCDs. For example, for AYA who had cystic fibrosis, the adjusted odds of readmission increased to 1.9 (95% CI, 1.5-2.3) by age 21 years and remained elevated through age 30 years. For AYA who had type 1 diabetes, the adjusted odds of readmission peaked at ages 23 to 24 years (odds ratio, 2.3; 95% CI, 2.1-2.6) and then declined through age 30 years. Conclusions and Relevance: These findings suggest that hospitalized AYA who have CCDs have high rates of multimorbidity and 30-day readmission. The adjusted odds of readmission for AYA varied significantly across CCDs with increasing age. Further attention is needed to hospital discharge care, self-management, and prevention of readmission in AYA with CCD.

Association between nighttime-daytime sleep patterns and chronic diseases in Chinese elderly population: a community-based cross-sectional study.

BACKGROUND: This study aimed to assess the relationship between specific nighttime-daytime sleep patterns and prevalence of different chronic diseases in an elderly population. METHODS: We conducted a community-based cross-sectional study in 4150 elderly Chinese, with an average age of 74 years. Sleep-related variables (nighttime sleep duration, daytime napping and duration) and chronic disease status, including diabetes, cardiovascular diseases (CVD), dyslipidemia cancer and arthritis were collected for the study. Multivariable logistic regression models were used to analyze the relationship between nighttime-daytime sleep patterns and prevalence of chronic diseases. RESULTS: Overall prevalence of any of chronic diseases was 83.8%. Nighttime-daytime sleep patterns were defined according to nighttime sleep duration and habitual nappers/non-nappers. Taking the nighttime-daytime sleep pattern "short nighttime sleep with daytime napping" as reference, those with "long nighttime sleep without daytime napping" had higher prevalence of diabetes [OR and 95% CI, 1.35 (1.01-1.80)] and lower prevalence of arthritis [OR and 95% CI, 0.46 (0.33-0.63)]. And those with "long nighttime sleep with daytime napping" had higher prevalence of diabetes [OR and 95% CI, 1.36 (1.05-1.78)] while lower prevalence of cancer [OR and 95% CI, 0.48 (0.26-0.85)] and arthritis [OR and 95% CI, 0.67 (0.51-0.86)]. Further, in habitual nappers, subjects were classified according to duration of nighttime sleep and daytime naps. Compared to "short nighttime sleep with long daytime napping", individuals with "long nighttime sleep with short daytime napping" had significantly positive association with diabetes prevalence [OR and 95% CI, 1.73 (1.15-2.68)] while border-significantly and significantly negative association with cancer [OR and 95% CI, 0.49 (0.23-1.07)] and arthritis [OR and 95% CI, 0.64 (0.44-0.94)], respectively. CONCLUSIONS: Elderly individuals with chronic diseases had different nighttime-daytime sleep patterns, and understanding these relationships may help to guide the management of chronic diseases.

Disparities in Inpatient Intensity of End-of-Life Care for Complex Chronic Conditions.

BACKGROUND: Children with complex chronic conditions (CCCs) require a disproportionate share of health care services and have high mortality rates, but little is known about their end-of-life care. METHODS: We performed a retrospective population-based analysis using a California State administrative database of children aged 1 to 21 years with a CCC who died of disease-related causes between 2000 and 2013. Rates of and sociodemographic and clinical factors associated with previously defined inpatient end-of-life intensity indicators were determined. The intensity indicators included: (1) hospital death, (2) receipt of a medically intense intervention within 30 days of death (ICU admission, cardiopulmonary resuscitation, hemodialysis, and/or intubation), and (3) having ≥2 intensity markers (including hospital death). RESULTS: There were 8654 children in the study population with a mean death age of 11.8 years (SD 6.8). The 3 most common CCC categories were neuromuscular (47%), malignancy (43%), and cardiovascular (42%). Sixty-six percent of the children died in the hospital, 36% had a medically intense intervention in the last 30 days of life, and 35% had ≥2 intensity markers. Living in a low-income neighborhood was associated with increased odds of hospital death, a medically intense intervention, and ≥2 intensity markers. Hispanic and "other" race and/or ethnicity were associated with hospital death and ≥2 intensity markers. Age 15 to 21 years was associated with hospital death, a medically intense intervention, and ≥2 intensity markers. CONCLUSIONS: Sociodemographic disparities in the intensity of end-of-life care for children with CCCs raise concerns about whether all children are receiving high-quality and goal-concordant end-of-life care.

Trends in Chronic Diseases Reported by Refugees Originating from Burma Resettling to the United States from Camps Versus Urban Areas During 2009-2016.

We examined changes in the prevalence of chronic health conditions among US-bound refugees originating from Burma resettling over 8 years by the type of living arrangement before resettlement, either in camps (Thailand) or in urban areas (Malaysia). Using data from the required overseas medical exam for 73,251 adult (≥ 18 years) refugees originating from Burma resettling to the United States during 2009-2016, we assessed average annual percent change (AAPC) in proportion ≥ 45 years and age- and sex-standardized prevalence of obesity, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and musculoskeletal disease, by camps versus urban areas. Compared with refugees resettling from camps, those coming from urban settings had higher prevalence of obesity (mean 18.0 vs. 5.9%), diabetes (mean 6.5 vs. 0.8%), and hypertension (mean 12.7 vs. 8.1%). Compared with those resettling from camps, those from urban areas saw greater increases in the proportion with COPD (AAPC: 109.4 vs. 9.9) and musculoskeletal disease (AAPC: 34.6 vs. 1.6). Chronic conditions and their related risk factors increased among refugees originating from Burma resettling to the United States whether they had lived in camps or in urban areas, though the prevalence of such conditions was higher among refugees who had lived in urban settings.

Subgroups of High-Cost Medicare Advantage Patients: an Observational Study.

BACKGROUND: There is a growing focus on improving the quality and value of health care delivery for high-cost patients. Compared to fee-for-service Medicare, less is known about the clinical composition of high-cost Medicare Advantage populations. OBJECTIVE: To describe a high-cost Medicare Advantage population and identify clinically and operationally significant subgroups of patients. DESIGN: We used a density-based clustering algorithm to group high-cost patients (top 10% of spending) according to 161 distinct demographic, clinical, and claims-based variables. We then examined rates of utilization, spending, and mortality among subgroups. PARTICIPANTS: Sixty-one thousand five hundred forty-six Medicare Advantage beneficiaries. MAIN MEASURES: Spending, utilization, and mortality. KEY RESULTS: High-cost patients (n = 6154) accounted for 55% of total spending. High-cost patients were more likely to be younger, male, and have higher rates of comorbid illnesses. We identified ten subgroups of high-cost patients: acute exacerbations of chronic disease (mixed); end-stage renal disease (ESRD); recurrent gastrointestinal bleed (GIB); orthopedic trauma (trauma); vascular disease (vascular); surgical infections and other complications (complications); cirrhosis with hepatitis C (liver); ESRD with increased medical and behavioral comorbidity (ESRD+); cancer with high-cost imaging and radiation therapy (oncology); and neurologic disorders (neurologic). The average number of inpatient days ranged from 3.25 (oncology) to 26.09 (trauma). Preventable spending (as a percentage of total spending) ranged from 0.8% (oncology) to 9.5% (complications) and the percentage of spending attributable to prescription medications ranged from 7.9% (trauma and oncology) to 77.0% (liver). The percentage of patients who were persistently high-cost ranged from 11.8% (trauma) to 100.0% (ESRD+). One-year mortality ranged from 0.0% (liver) to 25.8% (ESRD+). CONCLUSIONS: We identified clinically distinct subgroups of patients within a heterogeneous high-cost Medicare Advantage population using cluster analysis. These subgroups, defined by condition-specific profiles and illness trajectories, had markedly different patterns of utilization, spending, and mortality, holding important implications for clinical strategy.

Does global drug innovation correspond to burden of disease? The neglected diseases in developed and developing countries.

Although it is commonly argued that there is a mismatch between drug innovation and disease burden, there is little evidence on the magnitude and direction of such disparities. In this paper, we measure inequality in innovation, by comparing research and development activity with population health and gross domestic product data across 493 therapeutic indications to globally measure: (a) drug innovation, (b) disease burden, and (c) market size. We use concentration curves and indices to assess inequality at two levels: (a) broad disease groups and (b) disease subcategories for both 1990 and 2010. For some top burden disease subcategories (i.e., cardiovascular and circulatory diseases, neoplasms, and musculoskeletal disorders), innovation is disproportionately concentrated in diseases with high disease burden and large market size, whereas for others (i.e., mental and behavioral disorders, neonatal disorders, and neglected tropical diseases) innovation is disproportionately concentrated in low burden diseases. These inequalities persisted over time, suggesting inertia in pharmaceutical research and development in tackling the global health challenges. Our results confirm quantitatively assertions about the mismatch between disease burden and pharmaceutical innovation in both developed and developing countries and highlight the disease areas for which morbidity and mortality remain unaddressed.

Socioeconomic inequality in non-communicable diseases in Europe between 2004 and 2015: evidence from the SHARE survey.

Background: The scope of this work was to investigate socioeconomic inequalities among European adults aged 50 or older in chronic diseases and behavioural risk factors for these diseases, namely, smoking habits, obesity and physical inactivity, between 2004 and 2015. Methods: Data for this study were drawn from the Survey of Health, Ageing and Retirement (SHARE) in Europe, which is a panel database of microdata on health, socioeconomic status and social and family networks of people aged 50 years or older, covering most of the European Union. The predicted number of non-communicable diseases (NCDs) was used to estimate the concentration index and to find the contributions of determinants to socioeconomic inequalities in chronic diseases. Results: The inequality disfavoured the poor in both years, but the effect was stable from 2004 (C = -0.071) to 2015 (C = -0.081). Inequality was shown to be attributed mostly to physical inactivity and obesity and this contribution increased during the study period. Among socioeconomic status (SES) determinants, education and marital status were the most concentrated in both years, while physical inactivity and obesity were the most concentrated behavioural risk factors in both years. Conclusions: To prevent chronic diseases, health policy should aim not only to improve individual health behaviours in the population, but also to reduce socioeconomic inequality. Our study suggests promoting a healthy lifestyle in the most disadvantaged socioeconomic classes as a strategy to improve the health conditions of the whole population.

Temporal patterns in the risk of chronic health conditions in survivors of childhood cancer diagnosed 1970-99: a report from the Childhood Cancer Survivor Study cohort.

BACKGROUND: Treatments for childhood cancer have evolved over the past 50 years, with the goal of maximising the proportion of patients who achieve long-term survival, while minimising the adverse effects of therapy. We aimed to assess incidence patterns of serious chronic health conditions in long-term survivors of childhood cancer across three decades of diagnosis and treatment. METHODS: We used data from the Childhood Cancer Survivor Study, a retrospective cohort with longitudinal follow-up of 5-year survivors of common childhood cancers (leukaemia, tumours of the CNS, Hodgkin lymphoma, non-Hodgkin lymphoma, Wilms tumour, neuroblastoma, soft tissue sarcoma, or bone tumours) who were diagnosed before the age of 21 years and from 1970 to 1999 in North America. We examined the cumulative incidence of severe to fatal chronic health conditions occurring up to 20 years post-diagnosis among survivors, compared by diagnosis decade. We used multivariable regression models to estimate hazard ratios per diagnosis decade, and we added treatment variables to assess whether treatment changes attenuated associations between diagnosis decade and chronic disease risk. FINDINGS: Among 23 601 survivors with a median follow-up of 21 years (IQR 15-25), the 20-year cumulative incidence of at least one grade 3-5 chronic condition decreased significantly from 33·2% (95% CI 32·0-34·3) in those diagnosed 1970-79 to 29·3% (28·4-30·2; p<0·0001) in 1980-89, and 27·5% (26·4-28·6; p=0·012 vs 1980-89) in 1990-99. By comparison, the 20-year cumulative incidence of at least one grade 3-5 condition in 5051 siblings was 4·6% (95% CI 3·9-5·2). The 15-year cumulative incidence of at least one grade 3-5 condition was lower for survivors diagnosed 1990-99 compared with those diagnosed 1970-79 for Hodgkin lymphoma (17·7% [95% CI 15·0-20·5] vs 26·4% [23·8-29·1]; p<0·0001), non-Hodgkin lymphoma (16·9% [14·0-19·7] vs 23·8% [19·9-27·7]; p=0.0053), astrocytoma (30·5% [27·8-33·2] vs 47·3% [42·9-51·7]; p<0·0001), Wilms tumour (11·9% [9·5-14·3] vs 17·6% [14·3-20·8]; p=0·034), soft tissue sarcoma (28·3% [23·5-33·1] vs 36·5% [31·5-41·4]; p=0·021), and osteosarcoma (65·6% [60·6-70·6] vs 87·5% [84·1-91·0]; p<0·0001). By contrast, the 15-year cumulative incidence of at least one grade 3-5 condition was higher (1990-99 vs 1970-79) for medulloblastoma or primitive neuroectodermal tumour (58·9% [54·4-63·3] vs 42·9% [34·9-50·9]; p=0·00060), and neuroblastoma (25·0% [21·8-28·2] vs 18·0% [14·5-21·6]; p=0·0045). Results were consistent with changes in treatment as a significant mediator of the association between diagnosis decade and risk of grade 3-5 chronic conditions for astrocytoma (HR per decade without treatment in the model = 0·77, 95% CI 0·64-0·92; HR with treatment in the model=0·89, 95% CI 0·72-1·11; pmediation=0·0085) and Hodgkin lymphoma (HR without treatment=0·75, 95% CI 0·65-0·85; HR with treatment=0·91, 95% CI 0·73-1·12; pmediation=0·024). Temporal decreases in 15-year cumulative incidence comparing survivors diagnosed 1970-79 to survivors diagnosed 1990-99 were noted for endocrinopathies (5·9% [5·3-6·4] vs 2·8% [2·5-3·2]; p<0·0001), subsequent malignant neoplasms (2·7% [2·3-3·1] vs 1·9% [1·6-2·2]; p=0·0033), musculoskeletal conditions (5·8% [5·2-6·4] vs 3·3% [2·9-3·6]; p<0·0001), and gastrointestinal conditions (2·3% [2·0-2·7] vs 1·5% [1·3-1·8]; p=0·00037), while hearing loss increased (3·0% [2·6-3·5] vs 5·7% [5·2-6·1]; p<0·0001). INTERPRETATION: Our results suggest that more recently treated survivors of childhood cancer had improvements in health outcomes, consistent with efforts over the same time period to modify childhood cancer treatment regimens to maximise overall survival, while reducing risk of long-term adverse events. Continuing advances in cancer therapy offer promise of further reducing the risk of long-term adverse events in childhood cancer survivors. However, achieving long-term survival for childhood cancer continues to come at a cost for many survivors, emphasising the importance of long-term follow-up care for this population. FUNDING: National Cancer Institute and the American Lebanese-Syrian Associated Charities.