Effects of Longitudinal Coaching on Relationships and Feedback Processes in Pediatric Subspecialty Fellowships-An Interpretive Description Study.

Background: Coaching in graduate medical education provides a facilitative approach to feedback as well as opportunities for residents and fellows to engage with feedback and develop individualized improvement goals. Objective: To explore the roles and actions of successful coaches in longitudinal coaching relationships and how they enable feedback processes. Methods: Using interpretive description methodology, we performed semi-structured interviews with pediatrics fellows (n=11), faculty coaches (n=9), and program directors (n=2) from 2 pediatric subspecialty fellowship training programs at Ann and Robert H. Lurie Children's Hospital of Chicago. Both training programs had previously implemented longitudinal clinical coaching programs. Interview questions aimed to explore the roles and impacts of coaches within a longitudinal coaching program. Interviews took place in 2019 and 2020. Results: We identified 4 major actions to the coaching role in longitudinal coaching relationships: (1) establish the coach-fellow relationship; (2) prepare for the coaching conversation; (3) facilitate feedback dialogue; and (4) serve as the go-to person to raise uncomfortable issues. Additionally, nearly all participants expressed support for a longitudinal coaching program to support fellows' growth and development of personalized learning goals. Conclusions: By fulfilling these 4 key aspects to the coaching role, coaches in longitudinal relationships with coachees enable feedback processes.

Post-operative discharge education for parent caregivers of children with congenital heart disease: a needs assessment.

OBJECTIVE: Children with congenital heart disease (CHD) have complex unique post-operative care needs. Limited data assess parents' hospital discharge preparedness and education quality following cardiac surgery. The goals were to identify knowledge gaps in discharge preparedness after congenital heart surgery and to assess the acceptability of an educational mobile application to improve discharge preparedness. METHODS: Telephonic interviews with parents of children with two-ventricle physiology who underwent cardiac surgery 5-7 days post-discharge and in-person interviews with clinicians were conducted. We collected parent and clinician demographics, parent health literacy information and patient clinical data. We analysed interview transcripts using summative content analysis. RESULTS: We interviewed 26 parents and 6 clinicians. Twenty-two of the 26 (85%) parents felt ready for discharge; 4 of the 6 (67%) clinicians did not feel most parents were ready for discharge. Fifteen of the 26 parents (58%) reported receiving the majority of discharge teaching on the day of discharge. Eight parents did not feel like all of their questions were answered. Most parents (14/26, 54%) preferred visual educational learning aids and could accurately describe important aspects of care. Most parents (23/26, 88%) and all 6 clinicians felt a mobile application for post-operative care education would be helpful. CONCLUSIONS: Most parents received education on the day of discharge and could describe the information they received prior to discharge, although there were some preparedness gaps identified after discharge. Clinicians and parents varied in their perceptions of the readiness for discharge. Most responses suggest that a mobile application for discharge education may be helpful for transition to home.

Comparing Childhood Cancer Care Costs in Two Canadian Provinces.

BACKGROUND: Cancer in children presents unique issues for diagnosis, treatment and survivorship care. Phase-specific comparative cost estimates are important for informing healthcare planning. OBJECTIVE: The aim of this paper is to compare direct medical costs of childhood cancer by phase of care in British Columbia (BC) and Ontario (ON). METHODS: For cancer patients diagnosed at <15 years of age and propensity-score-matched non-cancer controls, we applied standard costing methodology using population-based healthcare administrative data to estimate and compare phase-based costs by province. RESULTS: Phase-specific cancer-attributable costs were 2%-39% higher for ON than for BC. Leukemia pre-diagnosis costs and annual lymphoma continuing care costs were >50% higher in ON. Phase-specific in-patient hospital costs (the major cost category) represented 63%-82% of ON costs, versus 43%-73% of BC costs. Phase-specific diagnostic tests and procedures accounted for 1.0%-3.4% of ON costs and 2.8%-13.0% of BC costs. CONCLUSION: There are substantial cost differences between these two Canadian provinces, BC and ON, possibly identifying opportunities for healthcare planning improvement.

Identifying qualitative differences in PPARα signaling networks in human and rat hepatocytes and their significance for next generation chemical risk assessment methods.

In this paper, we evaluate the PPARα signaling network in rats, examining transcriptional responses in primary hepatocytes exposed to a PPARα specific ligand, GW7647. These transcriptomic studies were complemented with ChIP-seq studies of PPARα binding and transcription binding motif identification for PPARα responsive genes. We also conducted a limited study of GW7647 dosing the in intact rat to examine differences in transcriptional responses for primary hepatocytes in vitro and in the intact liver. The rat network has a much larger number of down-regulated genes and pathways than we had found in the human and the PPARα binding motifs in rat differed for upregulated and down regulated genes. Based on these results and comparison with our previous work with the human PPARα signaling network, we identified qualitative differences in the transcriptional networks controlled by PPARα activation in the two species that provide an explanation of the interspecies differences in the responses of humans and rodents to GW7647 and likely to other PPARα agonists. These studies also allow some observations on the manner in which in vitro, fit-for-purpose assays in human hepatocytes could form the basis for risk assessment without recourse to in-life studies in rodents or other test species.

Resource Utilization and Costs in Adolescents Treated for Cancer in Pediatric vs Adult Institutions.

BACKGROUND: Adolescents with cancer can receive care in pediatric or adult institutions. Survival often differs by locus, but little is known about relative health care utilization and costs. We estimated these in a population-based cohort of adolescents. METHODS: All Ontario adolescents (15.0-17.9 years) diagnosed with cancer between 1995 and 2010 were identified from provincial cancer registries. We compared health care resource utilization (hospitalizations, emergency department visits, same-day surgeries, outpatient chemotherapy, radiation, diagnostic/laboratory tests, physician services, home care) and costs (2012 Canadian dollars) during four discrete care phases-prediagnosis (60 days), initial (360 days), continuing (variable), and terminal (360 days)-between adolescents treated in pediatric vs adult institutions, for the whole cohort and within seven diagnostic categories. All statistical tests were two-sided. RESULTS: Of 1356 eligible adolescents, 691 and 665 were treated in adult and pediatric institutions, respectively. Hospitalization rates were higher in pediatric institutions during prediagnosis (14.9% vs 6.9%, P < .001), initial (95.1% vs 73.3%, P < .001), and continuing phases (43.2% vs 34.4%, P = .002), but similar (96.1% vs 96.3%, P = .93) during the terminal phase. Average length of stay was higher at pediatric institutions within most diagnoses and phases. For all diagnoses, median initial phase costs were higher in pediatric than adult institutions (eg, leukemia: $153 926 vs $102 418 per 360 days, P < .001; lymphoma: $65 025 vs $19 846, P < .001, respectively). CONCLUSIONS: The costs of caring for adolescents with the same malignancy are considerably higher in pediatric than adult institutions during most phases. Resource utilization, particularly hospitalization, drives much of the cost difference, making these data applicable to other jurisdictions.

Long-term effects of cancer on earnings of childhood, adolescent and young adult cancer survivors - a population-based study from British Columbia, Canada.

BACKGROUND: The patterns and determinants of long-term income among young people surviving cancer, and differences compared to peers, have not yet been fully explored. The objectives of this paper are to describe long-term income among young survivors of cancer, the impact of socio-demographic, disease, and treatment factors on long-term income, and income relative to the general population. METHODS: Retrospective cohort study with comparison group from the general population, using linked population-based registries, clinical data, and tax-records. Multivariate random effects regression models were used to determine survivor income, compare long-term income between survivors and comparators, and assess income determinants. Subjects included all residents of British Columbia (BC), Canada, diagnosed with cancer before 25 years of age and surviving 5 years or more. Comparators were selected from the BC general population matched by gender and birth year. RESULTS: Young cancer survivors earned significantly less than the general population. In addition, survivors of central nervous system tumors have significantly lower incomes than lymphoma survivors. Survivors who received radiation therapy have significantly lower income. Results should be interpreted with caution as the comparator group was matched by gender and date of birth. CONCLUSIONS: Depending on original diagnosis, treatment, and other characteristics, survivors face significantly lower income than peers and may require supports to gain and retain paid employment. Lower income will affect their opportunity for independent living, and will reduce productivity in the labour force.

Costs of cancer care in children and adolescents in Ontario, Canada.

BACKGROUND: Cancer in children and adolescents presents unique issues regarding treatment and survivorship, but few studies have measured economic burden. We estimated health care costs by phase of cancer care, from the public payer perspective, in population-based cohorts. METHODS: Children newly diagnosed at ages 0 days-14.9 years and adolescents newly diagnosed at 15-19.9 years, from January 1, 1995 to June 30, 2010, were identified from Ontario cancer registries, and each matched to three noncancer controls. Data were linked with administrative records describing resource use for cancer and other health care. Total and net (patients minus controls) resource-specific costs ($CAD2012) were estimated using generalized estimating equations for four phases of care: prediagnosis (60 days), initial (360 days), continuing (variable), final (360 days). RESULTS: Mean ages at diagnosis were 6 years for children (N = 4,606) and 17 years for adolescents (N = 2,443). Mean net prediagnosis phase 60-day costs were $6,177 for children and $1,018 for adolescents. Costs for initial, continuing, and final phases were $138,161, $15,756, and $316,303 per 360 days for children, and $62,919, $7,071, and $242,008 for adolescents. The highest initial phase costs were for leukemia patients ($156,225 per 360 days for children and $171,275 for adolescents). The final phase was the most costly ($316,303 per 360 days for children and $242,008 for adolescents). CONCLUSIONS: Costs for children with cancer are much higher than for adolescents and much higher than those reported in adults. Comprehensive population-based long-term estimates of cancer costs are useful for health services planning and cost-effectiveness analysis.

The Simulation-Based Assessment of Pediatric Rapid Response Teams.

OBJECTIVE: To create scenarios of simulated decompensating pediatric patients to train pediatric rapid response teams (RRTs) and to determine whether the scenario scores provide a valid assessment of RRT performance with the hypothesis that RRTs led by intensivists-in-training would be better prepared to manage the scenarios than teams led by nurse practitioners. STUDY DESIGN: A set of 10 simulated scenarios was designed for the training and assessment of pediatric RRTs. Pediatric RRTs, comprising a pediatric intensive care unit (PICU) registered nurse and respiratory therapist, led by a PICU intensivist-in-training or a pediatric nurse practitioner, managed 7 simulated acutely decompensating patients. Two raters evaluated the scenario performances and psychometric analyses of the scenarios were performed. RESULTS: The teams readily managed scenarios such as supraventricular tachycardia and opioid overdose but had difficulty with more complicated scenarios such as aortic coarctation or head injury. The management of any particular scenario was reasonably predictive of overall team performance. The teams led by the PICU intensivists-in-training outperformed the teams led by the pediatric nurse practitioners. CONCLUSIONS: Simulation provides a method for RRTs to develop decision-making skills in managing decompensating pediatric patients. The multiple scenario assessment provided a moderately reliable team score. The greater scores achieved by PICU intensivist-in-training-led teams provides some evidence to support the validity of the assessment.

Costs for Childhood and Adolescent Cancer, 90 Days Prediagnosis and 1 Year Postdiagnosis: A Population-Based Study in Ontario, Canada.

BACKGROUND: Childhood and adolescent cancers are uncommon, but they have important economic and health impacts on patients, families, and health care systems. Few studies have measured the economic burden of care for childhood and adolescent cancers. OBJECTIVES: To estimate costs of cancer care in population-based cohorts of children and adolescents from the public payer perspective. METHODS: We identified patients with cancer, aged 91 days to 19 years, diagnosed from 1995 to 2009 using cancer registry data, and matched each to three noncancer controls. Using linked administrative health care records, we estimated total and net resource-specific costs (in 2012 Canadian dollars) during 90 days prediagnosis and 1 year postdiagnosis. RESULTS: Children (≤14 years old) numbered 4,396: 36% had leukemia, 21% central nervous system tumors, 10% lymphoma, and 33% other cancers. Adolescents (15-19 years old) numbered 2,329: 28.9% had lymphoma. Bone and soft tissue sarcoma, germ cell tumor, and thyroid carcinoma each comprised 12% to 13%. Mean net prediagnosis costs were $5,810 and $1,127 and mean net postdiagnosis costs were $136,413 and $62,326 for children and adolescents, respectively; the highest were for leukemia ($157,764 for children and $172,034 for adolescents). In both cohorts, costs were much higher for patients who died within 1 year of diagnosis. Inpatient hospitalization represented 69% to 74% of postdiagnosis costs. CONCLUSIONS: Treating children with cancer is costly, more costly than treating adolescents or adults. Substantial survival gains in children mean that treatment may still be very cost-effective. Comprehensive age-specific population-based cost estimates are essential to reliably assess the cost-effectiveness of cancer care for children and adolescents, and measure health system performance.

Simulation-Based Assessment of ECMO Clinical Specialists.

OBJECTIVE: The aims of the study were (1) to create multiple scenarios that simulate a range of urgent and emergent extracorporeal membrane oxygenation (ECMO) events and (2) to determine whether these scenarios can provide reliable and valid measures of a specialist's advanced skill in managing ECMO emergencies. DESIGN: Multiscenario simulation-based performance assessment was performed. SETTING: The study was conducted in the Saigh Pediatric Simulation Center at St. Louis Children's Hospital. SUBJECTS: ECMO clinical specialists participated in the study. MEASUREMENTS AND MAIN RESULTS: Twenty-five ECMO specialists completed 8 scenarios presenting acute events in simulated ECMO patients. Participants were evaluated by 2 separate reviewers for completion of key actions and for global performance. The scores were highest for the hemodilution scenario, whereas the air entrainment scenario had the lowest scores. Psychometric analysis demonstrated that ECMO specialists with more than 1 year of experience outperformed the specialists with less than 1 year of experience. Participants endorsed these sessions as important and representative of events that might be encountered in practice. CONCLUSIONS: The scenarios could serve as a component of an ECMO education curriculum and be used to assess clinical specialists' readiness to manage ECMO emergencies.

Advancing Cardiac Critical Care: A Call for Training, Collaboration, and Family Engagement.

The evolution and development of pediatric cardiac critical care as a distinct subspecialty have occurred rapidly over the past 20 years. As the field has grown, models for education, training, and care delivery have changed as well. This review will highlight the current state of education, training, and parental involvement in care delivery for pediatric cardiac critical care as initially.

A qualitative focus group study to identify the needs of survivors of stage II and III colorectal cancer.

BACKGROUND: Prior survivorship research has largely focused on issues faced by survivors of childhood tumors, breast cancers, or hematologic malignancies. Relatively little is known about the needs of other prevalent survivor groups. Our aim was to identify the specific concerns of colorectal cancer (CRC) survivors in the key domains of physical functioning, psychological wellbeing, and social relationships. METHODS: We conducted focus groups with stage II and III CRC survivors who had completed their primary active anti-cancer treatments. Patients were asked to describe how their diagnosis and treatment impacted their lives, to outline deficiencies in the care that they received, and to suggest ways of addressing any unmet needs. A content analysis was subsequently conducted to identify major themes. RESULTS: Thirty CRC survivors participated in six focus groups. Individuals reported some degree of dissatisfaction with the amount and type of diagnostic and treatment information they received at their initial clinic visit. Distress from toxicities, such as peripheral neuropathy, was also common among the survivors. Similarly, the majority faced challenges adjusting to their lives and daily activities, especially in caring for their colostomy. Having survived CRC, many survivors expressed an interest in advocacy and health promotion of CRC. CONCLUSIONS: CRC survivors face many barriers after their cancer treatment. Issues with colostomy are unique to this survivor group. Interventions to improve CRC survivorship care should also incorporate opportunities for patient advocacy. Copyright © 2015 John Wiley & Sons, Ltd.

Adverse Outcome Pathways for Regulatory Applications: Examination of Four Case Studies With Different Degrees of Completeness and Scientific Confidence.

Adverse outcome pathways (AOPs) offer a pathway-based toxicological framework to support hazard assessment and regulatory decision-making. However, little has been discussed about the scientific confidence needed, or how complete a pathway should be, before use in a specific regulatory application. Here we review four case studies to explore the degree of scientific confidence and extent of completeness (in terms of causal events) that is required for an AOP to be useful for a specific purpose in a regulatory application: (i) Membrane disruption (Narcosis) leading to respiratory failure (low confidence), (ii) Hepatocellular proliferation leading to cancer (partial pathway, moderate confidence), (iii) Covalent binding to proteins leading to skin sensitization (high confidence), and (iv) Aromatase inhibition leading to reproductive dysfunction in fish (high confidence). Partially complete AOPs with unknown molecular initiating events, such as 'Hepatocellular proliferation leading to cancer', were found to be valuable. We demonstrate that scientific confidence in these pathways can be increased though the use of unconventional information (eg, computational identification of potential initiators). AOPs at all levels of confidence can contribute to specific uses. A significant statistical or quantitative relationship between events and/or the adverse outcome relationships is a common characteristic of AOPs, both incomplete and complete, that have specific regulatory uses. For AOPs to be useful in a regulatory context they must be at least as useful as the tools that regulators currently possess, or the techniques currently employed by regulators.

Analysis of counts with two latent classes, with application to risk assessment based on physician-visit records of cancer survivors.

Motivated by a cancer survivorship program, this paper explores event counts from two categories of individuals with unobservable membership. We formulate the counts using a latent class model and consider two likelihood-based inference procedures, the maximum likelihood estimation (MLE) and a pseudo-MLE procedure. The pseudo-MLE utilizes additional information on one of the latent classes. It yields reduced computational intensity and potentially increased estimation efficiency. We establish the consistency and asymptotic normality of the proposed pseudo-MLE, and we present an extended Huber sandwich estimator as a robust variance estimator for the pseudo-MLE. The finite-sample properties of the two-parameter estimators along with their variance estimators are examined by simulation. The proposed methodology is illustrated by physician-claim data from the cancer program.

Patterns of physician follow-up among young cancer survivors: report of the Childhood, Adolescent, and Young Adult Cancer Survivors (CAYACS) research program.

OBJECTIVE: To describe the frequency and pattern of physician visits in 1998 to 2000 among childhood and adolescent cancer survivors in British Columbia (BC), to compare their use of physician services with use in the general population, and to examine the effects of clinical and sociodemographic factors on care. DESIGN: Retrospective, observational, population-based cohort study, with a comparison group. Cohort records from population registries were linked to physician claim data and oncology visit records for 1998 to 2000. SETTING: Outpatient physician care in BC. PARTICIPANTS: All (N = 1157) survivors of cancer diagnosed before age 20 years in BC between 1970 and 1992 who survived at least 5 years after diagnosis, and an age-sex frequency-matched population sample of 11 570 individuals. MAIN OUTCOME MEASURES: Probability of a physician visit and frequency of physician visits. RESULTS: Approximately 97% of survivors saw at least 1 physician in the 3-year period, compared with 50% of the general population sample. The probability of a GP visit was 96% higher (adjusted 95% confidence interval [CI] 1.8 to 2.1), and the likelihood of a specialist visit was 157% higher (adjusted 95% CI 2.4 to 2.8) than for the general population. Survivors were more than twice as likely to see GPs at least 10 times (adjusted relative risk 2.23, 95% CI 2.0 to 2.4) and had 49% more visits than the general population. Cancer diagnosis and treatment affected visit patterns, but socioeconomic status and rural residency did not significantly affect the probability of a visit. CONCLUSION: Demand for physician care among childhood and adolescent cancer survivors is considerably greater than for the general population, and this need persists many years after diagnosis. Physicians need information on the unique health care requirements of this patient group in order to provide appropriate care.

Simulation in pediatrics: the reliability and validity of a multiscenario assessment.

OBJECTIVE: The goal of this study was to develop an inventory of simulated scenarios that mimic pediatric crises and determine if the resident scores could be used to establish the reliability and validity of a multiple-scenario assessment. The long-term objective is to provide pediatric residents with experiences in the recognition, diagnosis, and management of a range of simulated acute conditions. METHODS: Twenty scenarios were constructed. Each resident participated in 10 scenarios that were scored by 2 independent raters using an action-item checklist and a global score. Debriefing occurred after each scenario. Several analyses were performed to investigate the psychometric adequacy of the scores. RESULTS: Twenty-nine residents participated. The residents' scores in both sets of 10 scenarios were reliable when using either the checklist or global scoring method (>0.79). Generalizability analyses indicated that the major source of variance in scores was attributable to the scenario and scenario-resident interaction. The variance attributable to the rater was low, yielding high interrater reliability values. The more-experienced residents who participated in the study outperformed the less-experienced interns. CONCLUSIONS: An inventory of critical events was designed to assess pediatric residents' diagnostic and management skills. A reliable measure of ability could be obtained, provided the residents managed multiple scenarios. The residents outscored the interns, providing evidence to support the construct validity of the scores. Additional validity evidence is needed, including studies to determine if this type of training improves physicians' management of real-life critical events.

Outcomes and metrics: measuring the impact of a comprehensive adolescent and young adult cancer program.

Against a background of poorly coordinated provision of holistic care to the adolescent and young adult (AYA) cancer population, the Canadian National Task Force on Adolescent and Young Adult Oncology, which is supported by the Canadian Partnership Against Cancer and the C17 network, convened a workshop to formulate the components of a systematic approach to care for this age group. Because such a program will deflect scarce resources, it must be validated and justified by reproducible metrics. A subgroup of experts was convened, comprising attendees at the AYA workshop, including AYA cancer survivors. A substantial number of key, feasible, and consistent metrics were identified and are systematized, justified, and presented in this article. Prioritization from within this range will be necessary.

Recall bias in the assessment of exposure to mobile phones.

Most studies of mobile phone use are case-control studies that rely on participants' reports of past phone use for their exposure assessment. Differential errors in recalled phone use are a major concern in such studies. INTERPHONE, a multinational case-control study of brain tumour risk and mobile phone use, included validation studies to quantify such errors and evaluate the potential for recall bias. Mobile phone records of 212 cases and 296 controls were collected from network operators in three INTERPHONE countries over an average of 2 years, and compared with mobile phone use reported at interview. The ratio of reported to recorded phone use was analysed as measure of agreement. Mean ratios were virtually the same for cases and controls: both underestimated number of calls by a factor of 0.81 and overestimated call duration by a factor of 1.4. For cases, but not controls, ratios increased with increasing time before the interview; however, these trends were based on few subjects with long-term data. Ratios increased by level of use. Random recall errors were large. In conclusion, there was little evidence for differential recall errors overall or in recent time periods. However, apparent overestimation by cases in more distant time periods could cause positive bias in estimates of disease risk associated with mobile phone use.

Assessment of selection bias in the Canadian case-control study of residential magnetic field exposure and childhood leukemia.

The authors evaluated the role of selection bias in the 1999 Canadian case-control study of residential magnetic field exposure and childhood leukemia. They included cases, participating controls, and first-choice nonparticipating controls in their analyses. Exposure was assessed by wire coding, a classification system based on the distribution line characteristics near homes. Although an imperfect measure of magnetic field exposure, wire coding is the only method applicable to nonparticipating subjects. First-choice nonparticipant controls tended to be of lower socioeconomic status than their replacements (non-first-choice participant controls), and lower socioeconomic status was related to higher wire code categories. The odds ratios for developing childhood leukemia in the highest exposure category were 1.6 (95% confidence interval: 1.0, 2.6) when the actual participating controls were used and 1.3 (95% confidence interval: 0.8, 2.1) when the first-choice ideal controls were used, regardless of their participation. Overall, the authors conclude that, although there is some evidence for control selection or participation bias in the Canadian study, it is unlikely to explain entirely the observed association between magnetic field exposure and childhood leukemia. Inherent problems in exposure assessment for nonparticipating subjects, however, limit the interpretations of these results, and the role of selection bias cannot entirely be dismissed on the basis of these results alone.

Impact of childhood cancer on parental employment and sources of income: a Canadian pilot study.

BACKGROUND: Loss of income and out of pocket expenses related to childhood cancer care can account for over 25% of a family's total disposable income, adding to the stress of facing a life-threatening disease. The objective of this pilot study was to assess the impact of childhood cancer on employment and sources of income within families. PROCEDURE: A retrospective postal-administered questionnaire was used to collect information from parents of children diagnosed with cancer before 20 years of age between 1990 and 1996 in the province of British Columbia (n = 111). RESULTS: Among full or part-time employed parents, 64% of mothers and 16% of fathers left their job after their child's diagnosis. The large majority of parents who left their jobs were away for less than 1 year (65% of mothers; 78% of fathers) and nearly all were able to return to the same job if they chose to do so (80% of mothers; 89% of fathers). Parents with children <10 years of age at diagnosis and those with leukemia were most likely to take leave from their jobs. There was considerable change in sources of income between the time of diagnosis and survey with more families relying on employment insurance, social assistance or other financial support at diagnosis. Reliance on sources of income other than salary decreased with time since diagnosis. CONCLUSIONS: It appears that the diagnosis of childhood cancer may cause an important but short-term impact on the employment and income sources of affected families.