Association of Preexisting Heart Failure With Outcomes in Older Patients With Diffuse Large B-Cell Lymphoma.

Importance: Anthracycline-containing regimens are highly effective for diffuse large B-cell lymphoma (DLBCL); however, patients with preexisting heart failure (HF) may be less likely to receive anthracyclines and may be at higher risk of lymphoma mortality. Objective: To assess the prevalence of preexisting HF in older patients with DLBCL and its association with treatment patterns and outcomes. Design, Setting, and Participants: This longitudinal cohort study used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry from 1999 to 2016. The SEER registry is a system of population-based cancer registries, capturing more than 25% of the US population. Linkage to Medicare offers additional information from billing claims. This study included individuals 65 years and older with newly diagnosed DLBCL from 2000 to 2015 with Medicare Part A or B continuously in the year prior to lymphoma diagnosis. Data were analyzed from September 2020 to December 2022. Exposures: Preexisting HF in the year prior to DLBCL diagnosis ascertained from billing codes required one of the following: (1) 1 primary inpatient discharge diagnosis, (2) 2 outpatient diagnoses, (3) 3 secondary inpatient discharge diagnoses, (4) 3 emergency department diagnoses, or (5) 2 secondary inpatient discharge diagnoses plus 1 outpatient diagnosis. Main Outcomes and Measures: The primary outcome was anthracycline-based treatment. The secondary outcomes were (1) cardioprotective medications and (2) cause-specific mortality. The associations between preexisting HF and cancer treatment were estimated using multivariable logistic regression. The associations between preexisting HF and cause-specific mortality were evaluated using cause-specific Cox proportional hazards models with adjustment for comorbidities and cancer treatment. Results: Of 30 728 included patients with DLBCL, 15 474 (50.4%) were female, and the mean (SD) age was 77.8 (7.2) years. Preexisting HF at lymphoma diagnosis was present in 4266 patients (13.9%). Patients with preexisting HF were less likely to be treated with an anthracycline (odds ratio, 0.55; 95% CI, 0.49-0.61). Among patients with preexisting HF who received an anthracycline, dexrazoxane or liposomal doxorubicin were used in 78 of 1119 patients (7.0%). One-year lymphoma mortality was 41.8% (95% CI, 40.5-43.2) with preexisting HF and 29.6% (95% CI, 29.0%-30.1%) without preexisting HF. Preexisting HF was associated with higher lymphoma mortality in models adjusting for baseline and time-varying treatment factors (hazard ratio, 1.24; 95% CI, 1.18-1.31). Conclusions and Relevance: In this study, preexisting HF in patients with newly diagnosed DLBCL was common and was associated with lower use of anthracyclines and lower use of any chemotherapy. Trials are needed for this high-risk population.

Evaluating the role of financial navigation in alleviating financial distress among young adults with a history of blood cancer: A hybrid type 2 randomized effectiveness-implementation design.

BACKGROUND: Young adulthood (YA) is a complex phase of life, marked by key developmental goals, including educational and vocational attainment, housing independence, maintenance of social relationships, and financial stability. A cancer diagnosis during, or prior to, this phase of life can compromise the achievement of these milestones. Studies of adults with cancer have demonstrated that >70% report experiencing financial side-effects, which are associated with increased mortality, diminished health-related quality of life, and forgone medical care. The goal of this project is to evaluate financial distress of YA-aged survivors of blood cancers, and the impact of financial navigation on alleviating this distress. METHODS: This three-arm, multi-site, hybrid type 2 randomized effectiveness-implementation design (EID) study will be conducted through remote consent, remote data capture and telephone-based/virtual financial navigation. Participants will be aged 18-39, and more than three years from their blood cancer diagnosis. In this six-month intervention, the study will compare the primary outcome of financial distress in three arms: (1) usual care (2) participant-initiated, ad hoc navigation, and (3) study-directed proactive navigation. The study will be evaluated via the five-component Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) outcome strategy with a mixed-methods approach through quantitative assessment of participant-reported financial distress using the Personal Financial Wellness Scale™, as the primary outcome measure, and qualitative assessment through interviews. CONCLUSION: The study will address many unanswered questions regarding financial navigation within the YA survivor population and will inform the most successful strategies to mitigate financial distress in this vulnerable population.

Development and validation of a prediction model for 1-year mortality among older adults with Hodgkin Lymphoma who receive dose-intense chemotherapy.

BACKGROUND: Older adults with Hodgkin Lymphoma (HL) have poorer outcomes than younger patients. There are little data about which baseline patient and disease factors inform prognosis among older patients. We sought to create a prediction model for 1-year mortality among older patients with new HL who received dose-intense chemotherapy. METHODS: We included adults ≥65 years old with a new diagnosis of classical HL between 2000-2013 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset who received full-regimen chemotherapy. Through a non-random 2:1 split, we created development and validation cohorts. Multiple imputation was used for missing data. Using stepwise selection and logistic regression, we identified predictive variables for 1-year mortality. The model was applied to the validation cohort. A final model was then fit in the full cohort. RESULTS: We included 1315 patients. In the development cohort (n = 813), we identified significant predictors of 1-year mortality including age, Charlson comorbidity index (CCI), B symptoms at diagnosis, and advanced stage at diagnosis. The c-statistic was 0.70. When this model was applied to the validation cohort (n = 502), the c-statistic was 0.65. Predictors of 1-year mortality in the final model were CCI (OR = 1.41), B symptoms (OR = 1.54), advanced stage (OR = 1.44), and older age at diagnosis (OR = 1.33). CONCLUSION: We present a prediction model for use among older adults with HL who receive intensive chemotherapy. We identify risk factors for death within 1 year of diagnosis. Future work will build upon prognostication and shared decision-making after diagnosis for this population.

Assessment of patients' understanding of and adherence to oral anticancer medication (OAM): Results of a cross-sectional institutional pilot study.

BACKGROUND: Although oral anticancer medications (OAM) provide opportunity for treatment at home, challenges include prescription filling, monitoring side effects, safe handling, and adherence. We assessed understanding of and adherence to OAM in vulnerable patients. METHODS: This 2018 pilot study defined vulnerable patients based on Chinese language, older age (≥65 years), and subsidized insurance. All participants had a cancer diagnosis and were taking an OAM filled through the hospital's specialty pharmacy. Participants reported on OAM taking (days per week, times per day, special instructions) and handling (handling, storage, disposal). The specialty pharmacist classified patient-reported responses about OAM taking and handling as adequate or inadequate. OAM regimens were classified by complexity. RESULTS: Of 61 eligible patients, 55 participated. Mean age was 68 years (standard deviation [SD] = 12) and 53% were female. Patient subgroups were: 27% Chinese, 64% ≥65 years, and 9% subsidized insurance. Forty-nine percent were on frontline therapy and median time on OAM was 1 year (Quartile 1 = 0.4, Quartile 3 = 1.7). Adequacy of OAM taking (30%) and handling (15%) were low; 15% had adequacy in both. Adequacy of OAM taking and handling did not vary by patient subgroup or regimen complexity. Mean patient-reported adherence was high (5.4, SD = 1, possible range 1-6) and did not vary by adequacy of OAM taking or handling. CONCLUSIONS: Understanding of OAM taking and handling in this group of vulnerable patients was low and did not align with patient-reported adherence. Future interventions should ensure that patients understand how to safely take and handle OAM, thereby optimizing their therapeutic potential.

First-line treatment in older patients with Hodgkin lymphoma: a Surveillance, Epidemiology, and End Results (SEER)-Medicare population-based study.

While Hodgkin lymphoma (HL) is highly curable in younger patients, older patients have higher relapse and death rates, which may reflect age-related factors, distinct disease biology and/or treatment decisions. We described the association between patient, disease and geographic factors and first-line treatment in older patients (≥65 years) with incident HL using Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1999 to 2014 (n = 2825). First-line treatment initiated at ≤4 months after diagnosis was categorised as: full chemotherapy regimen (n = 699, 24·7%); partial chemotherapy regimen (n = 1016, 36·0%); single chemotherapy agent or radiotherapy (n = 382, 13·5%); and no treatment (n = 728, 25·8%). Among the fully treated, ABVD [doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine]/AVD was most common (n = 635, 90·8%). Adjusted multinomial logistic regression identified factors associated with treatment. Older age, Medicaid dual eligibility, not married, frailty, cardiac comorbidity, prior cancer, earlier diagnosis date, histology, advanced disease Stage, B symptoms and South region were independently associated with increased odds of not receiving full chemotherapy regimens. In conclusion, we found variability in first-line HL treatment for older patients. Treatment differences by Medicaid and region may indicate disparities. Even after adjusting for frailty and cardiac comorbidity, age was associated with treatment, suggesting factors such as end-of-life care or shared decision-making may influence treatment in older patients.

Assessment of health-related quality of life among adults hospitalized with sickle cell disease vaso-occlusive crisis.

Sickle cell disease (SCD) is characterized by painful vaso-occlusive crises (VOCs). Self-reported pain intensity is often assessed with the Numeric Rating Scale (NRS), whereas newer patient-reported outcome measures (PROMs) assess multidimensional pain in SCD. We describe pain experiences among hospitalized adults with VOCs, using 2 PROMs: the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health and the Adult Sickle Cell Quality of Life Measurement System (ASCQ-Me). Adults with SCD hospitalized with VOCs at 2 academic centers in Boston, Massachusetts, from April 2016 to October 2017 were eligible. Participants completed the NRS and PROMs at admission and 7 days postdischarge. PROM scores were described and compared with population norms. Length of stay (LOS) and 30-day readmission rates were assessed. Forty-two (96%) of 44 eligible patients consented and completed admission assessments. Mean age was 30.2 years (standard deviation, 9.1), 60% were women, 76% were non-Hispanic black, and 64% had hemoglobin SS. Twenty-seven participants (64%) completed postdischarge assessments. Sixty percent had ≥4 VOCs in the last year. Nearly all PROMIS Global Health and ASCQ-Me scores were worse than population norms. NRS and PROMIS Global Physical Health scores improved after discharge, the latter driven principally by improvements in pain. Overall median LOS was 7 days, and 30-day readmission rate was 40.5%. Administration of PROMs among adults with SCD hospitalized for VOCs is feasible and demonstrates participants experienced recurrent, prolonged, and severe VOCs. PROMIS Global and ASCQ-Me scores indicated substantial suffering, and the striking 30-day readmission rate highlights the vulnerability of these patients.

Risk factors for length of stay and charge per day differ between older and younger hospitalized patients with AML.

Acute myeloid leukemia (AML) is associated with frequent hospitalizations. We evaluated factors associated with length of stay (LOS) and charge per day (CPD) for admissions in older (≥60 years) and younger patients (<60 years). We identified patients with ICD-9-CM codes for AML or myeloid sarcoma in the 2012 HCUP-NIS. In separate models based on age, we examined patient (sex, race, income, insurance payer, chronic conditions, chemotherapy administration, death) and hospital (type, geography) characteristics. Multivariable negative binomial regression estimated factor effects on LOS and CPD using rate ratios, with HCUP-NIS weights. In 43,820 discharges, LOS was longer in patients <60 than ≥60 (6.8 vs. 5.4 days). For patients <60, longer LOS was seen with more chronic conditions (RR = 1.10), Black race (RR = 1.16), chemotherapy (RR = 2.27), and geography; shorter LOS was associated with older age (RR = 0.93), Medicare (RR = 0.83), and hospital type. For patients ≥60, longer LOS associated with chronic conditions (RR = 1.07) and Asian race (RR = 1.33). Shorter LOS associated with older age (RR = 0.86), higher income (RR = 0.93), and hospital type. For patients <60, higher CPD associated with chronic conditions (RR = 1.05), death (RR = 1.93), and geography; lower CPD associated with increasing age (RR = 0.96), Medicaid (RR = 0.93), and rural hospitals (RR = 0.65). For patients ≥60, higher CPD associated with Medicare (RR = 1.05), more chronic conditions (RR = 1.02), younger age (RR = 1.1), west geography (RR = 1.37), death (RR = 1.45), and Hispanic race (RR = 1.15). We identify predictors for increased healthcare utilization in hospitalized patients with AML, which differ within age groups. Future efforts are needed to link utilization outcomes with clinical treatments and response.

Pediatric Specialty Care Model for Management of Chronic Respiratory Failure: Cost and Savings Implications and Misalignment With Payment Models.

OBJECTIVE: To describe program design, costs, and savings implications of a critical care-based care coordination model for medically complex children with chronic respiratory failure. DESIGN: All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data. SETTING: Tertiary children's hospital. SUBJECTS: Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2-2 million or $407/pt/mo net of program costs. CONCLUSIONS: Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established.

Patient-Reported Health-Related Quality-of-Life Assessment at the Point-of-Care with Adolescents and Young Adults with Cancer.

PURPOSE: Advances in health-related quality-of-life (HRQL) measurement enable point-of-care assessments. We incorporated the Patient-Reported Outcomes Measurement Information System (PROMIS®) Global Health Scale in routine outpatient evaluations of adolescent and young adult (AYA) oncology patients and survivors at two geographically distinct U.S. institutions. METHODS: AYAs (18-39 years old) completed the 10-question PROMIS Global. Summary subscale scores for Global Physical Health (GPH) and Global Mental Health (GMH) were produced using established scoring algorithms (standardized mean = 50, standard deviation = 10). In addition to comparisons by treatment status, associations between lower subscale scores (<45, previously defined as clinically meaningful) and patient characteristics were assessed using two-sample t-tests among those off treatment. RESULTS: Of 147 patients approached, 142 consented. Mean age was 24.6 ± 5.3 years; 53.5% were male; and 61.3% had hematologic malignancies. Most (76%) were off treatment; 43.0% had treatment complications. While mean GPH and GMH scores did not differ from the standardized population mean (GPH, 49.7 ± 8.8, p = 0.73; GMH, 50.5 ± 9.3, p = 0.55), mean GPH scores were lower among those on treatment (44.3 ± 9.0) than off treatment (51.5 ± 8.1, p < 0.0001). There was no difference in GMH scores by treatment status. Among those off treatment, 26.9% of GPH and 22.2% of GMH scores were <45. The only factor associated with lower GPH scores was treatment complications; no factors were associated with lower GMH scores. CONCLUSION: Point-of-care HRQL assessment with AYAs is feasible. Among patients off treatment, GPH scores were lower for patients with treatment complications. Further research is needed to understand factors associated with lower GMH scores in this AYA oncology population.

Predicting Health Care Utilization for Children With Respiratory Insufficiency Using Parent-Proxy Ratings of Children's Health-Related Quality of Life.

INTRODUCTION: Children with chronic respiratory insufficiency and mechanical ventilation often experience acute illnesses requiring unscheduled hospitalizations. Health-related quality of life (HRQL) may predict future health care utilization. METHODS: Participants were 30 days to 22 years old with chronic respiratory insufficiency (N = 120). Parent-proxies completed global HRQL and general health measures. Outcomes were total health care (emergency department, outpatient, inpatient) and inpatient days over 6 months. Adjusted negative binomial regression estimated the effects of global HRQL and general health on utilization. RESULTS: Three quarters of children had any utilization; 32% had hospitalizations. Children with poor/fair global HRQL had 3.7 times more health care days than those with very good/excellent global HRQL. Children with poor/fair global HRQL had 6.3 times more inpatient days than those with very good/excellent global HRQL. Similar relationships existed between general health and utilization. DISCUSSION: HRQL was associated with health care and inpatient days. Clinical teams can use HRQL as a marker for utilization risk, enabling potentially earlier intervention, better outcomes, and lower costs.

Cholesterol Screening and Treatment Practices and Preferences: A Survey of United States Pediatricians.

OBJECTIVES: To determine pediatricians' practices, attitudes, and barriers regarding screening for and treatment of pediatric dyslipidemias in 9- to 11-year-olds and 17- to 21-year-olds. STUDY DESIGN: American Academy of Pediatrics (AAP) 2013-2014 Periodic Survey of a national, randomly selected sample of 1627 practicing AAP physicians. Pediatricians' responses were described and modeled. RESULTS: Of 614 (38%) respondents who met eligibility criteria, less than half (46%) were moderately/very knowledgeable about the 2008 AAP cholesterol statement; fewer were well-informed about 2011 National Heart, Lung, and Blood Institute Guidelines or 2007 US Preventive Service Task Force review (both 26%). Despite published recommendations, universal screening was not routine: 68% reported they never/rarely/sometimes screened healthy 9- to 11-year-olds. In contrast, more providers usually/most/all of the time screened based on family cardiovascular history (61%) and obesity (82%). Screening 17- to 21-year-olds was more common in all categories (P?

Impact of patient navigation in eliminating economic disparities in cancer care.

BACKGROUND: Patient navigation may reduce cancer disparities associated with socioeconomic status (SES) and household factors. This study examined whether these factors were associated with delays in diagnostic resolution among patients with cancer screening abnormalities and whether patient navigation ameliorated these delays. METHODS: This study analyzed data from 5 of 10 centers of the National Cancer Institute's Patient Navigation Research Program, which collected SES and household data on employment, income, education, housing, marital status, and household composition. The primary outcome was the time to diagnostic resolution after a cancer screening abnormality. Separate adjusted Cox proportional hazard models were fit for each SES and household factor, and an interaction between that factor and the intervention status was included. RESULTS: Among the 3777 participants (1968 in the control arm and 1809 in the navigation intervention arm), 91% were women, and the mean age was 44 years; 43% were Hispanic, 28% were white, and 27% were African American. Within the control arm, the unemployed experienced a longer time to resolution than those employed full-time (hazard ratio [HR], 0.85; P = .02). Renters (HR, 0.81; P = .02) and those with other (ie, unstable) housing (HR, 0.60; P < .001) had delays in comparison with homeowners. Never married (HR, 0.70; P < .001) and previously married participants (HR, 0.85; P = .03) had a longer time to care than married participants. There were no differences in the time to diagnostic resolution with any of these variables within the navigation intervention arm. CONCLUSIONS: Delays in diagnostic resolution exist by employment, housing type, and marital status. Patient navigation eliminated these disparities in the study sample. These findings demonstrate the value of providing patient navigation to patients at high risk for delays in cancer care.

The health care and productivity costs of back and neck pain in a multi-employer sample of utility industry employees.

OBJECTIVE: To determine the cost of back and/or neck (B/N) pain among predominantly rural employees insured through an employee benefits trust. METHODS: Eligible employees had 1 year or more of medical coverage and completed a survey subsequently linked to their claims data. B/N pain costs consisted of medical and pharmacy claims, over-the-counter expenses, and presenteeism and absenteeism costs valued according to median occupational earnings. RESULTS: Of 1342 eligible employees, 52.7% currently had B/N pain of which 87.9% was chronic. The average annualized cost of B/N pain per employee was $1727; 56.1% was due to lost productivity. Covered medical care was utilized by 35.6% of employees, 55.7% used pharmacy care, and 71.6% purchased uncovered over-the-counter pain medication. CONCLUSIONS: Many covered employees did not use formal care. The effect of care choices on productivity costs requires closer scrutiny.

Family-centered assessment and function for children with chronic mechanical respiratory support.

INTRODUCTION: The purpose of this study was to assess health-related quality of life (HRQL) when managing severe, chronic respiratory insufficiency (CRI) at home. METHODS: Families enrolled in a comprehensive program for CRI completed the Child Health Ratings Inventories with (a) parent-proxy ratings of the child's HRQL and (b) the parent's own HRQL. Psychometrics and known groups comparisons were reported. Linear regressions models assessed the effect of the parent's HRQL on proxy ratings. RESULTS: Eighty-six parents (67%) completed the measures. The child global HRQL score was low (63.1, SD = 24.9), although ratings of "family life" were higher (73.8, SD = 26.5). The parent global HRQL and emotional functioning (EF) scores were low, despite preserved physical and role function. Having a child with a congenital versus an acquired disability was associated with higher parental EF (p = .004). Higher parental EF correlated with a higher global child HRQL (p < .001). DISCUSSION: Families of children with CRI experience reduced HRQL. The Child Health Ratings Inventories is a valid tool for this assessment, identifying emotional distress and potential gaps in support.

Evaluation of the economic burden of diseases associated with poor nutrition status.

BACKGROUND: Geriatric acutely ill patients may frequently have insufficient nutrition intake, leading to malnutrition and increased susceptibility to additional morbidity. This compromised health status can increase costs by extending length of stay in the hospital, promoting the development of comorbidities, and requiring more intensive care. Understanding the value of measures improving the health of these patients depends in part on estimating the costs of prevented adverse outcomes. Because clinical trials often do not record these costs, it is difficult to assess the value of nutrition interventions. MATERIALS AND METHODS: This article comprehensively reviews 15 years of clinical trials of nutrition interventions to identify salient diseases and complications measured by previous clinical trials and then estimates costs corresponding with these conditions associated with poor nutrition status. RESULTS: The most costly complication associated with poor nutrition status is acute respiratory infections ($13,350-$19,530 per hospitalization), while institutional long-term care is the greatest chronic cost contributor across many diseases ($77,000 per year of care). CONCLUSION: This review can facilitate imputation of nutrition intervention benefits for acutely ill patients by characterizing the costs of clinical outcomes often reported in trials.

A systematic review of the evidence concerning the economic impact of employee-focused health promotion and wellness programs.

OBJECTIVE: To assess the evidence regarding the economic impact of worker health promotion programs. OBJECTIVE: Peer-reviewed research articles were identified from a database search. Included articles were published between January 2000 and May 2010, described a study conducted in the United States that used an experimental or quasi-experimental study design and analyzed medical, pharmacy (direct), and/or work productivity (indirect) costs. A multidisciplinary review team, following specific criteria, assessed research quality. RESULTS: Of 2030 retrieved articles, 44 met study inclusion criteria. Of these, 10 were of sufficient quality to be considered evidentiary. Only three analyzed direct and indirect costs. CONCLUSIONS: Evidence regarding economic impact is limited and inconsistent. Higher-quality research is needed to demonstrate the value of specific programs.

Community-engaged pedagogy: a strengths-based approach to involving diverse stakeholders in research partnerships.

BACKGROUND: To help build community capacity to partner in translational research partnerships, new approaches to training that incorporate both adult learning models and community-based participatory research (CBPR) are needed. OBJECTIVES: This article describes the educational approach-"community-engaged pedagogy"-used in a capacity-building training program with community partners in Boston. Drawing from adult learning theory and CBPR community-engaged pedagogy embraces co-learning and is rooted in a deep respect for the prior knowledge and experiences that community partners bring to the conversation around CBPR. This approach developed iteratively over the course of the first year of the program. Participating community partners drove the development of this educational approach, as they requested the application of CBPR principles to the educational program. METHODS: The dimensions of community-engaged pedagogy include (1) a relational approach to partnership building, (2) establishment of a learning community, (3) organic curriculum model, (4) collaborative teaching mechanism with diverse faculty, and (5) applied learning. CONCLUSIONS: Using a community-engaged pedagogical approach helps to model respect, reciprocity, and power sharing, core principles of CBPR. Although community partners appreciate this approach, traditionally trained academics may find this method unfamiliar and uncomfortable.

Costs and benefits of targeted screening for causes of sudden cardiac death in children and adolescents.

BACKGROUND: Sudden cardiac death in children is a rare but devastating event. Experts have debated the merits of community-based screening programs using an ECG and targeting 2 potential high-risk groups: school-aged children initiating stimulant medications to treat attention-deficit/hyperactivity disorder and adolescents participating in sports. METHODS AND RESULTS: Simulation models incorporating detailed prevalence, sensitivity and specificity, and treatment algorithms were built to determine the cost-effectiveness of targeted sudden cardiac death screening. Clinical care algorithms were constructed for asymptomatic children initiating stimulants for attention-deficit/hyperactivity disorder (8 years of age) or participating in sports (14 years of age) and presenting with a positive ECG finding suggestive of 1 of the 3 most common pediatric disorders causing sudden cardiac death and identifiable by ECG. Information to develop simulation model assumptions was drawn from the existing literature, Medicaid fees, and expert judgment. Sensitivity analyses examined parameter ranges to identify influential sources of uncertainty. Outcomes included costs and lost life-years caused by condition-related mortality. Our models estimate that screening for all 3 conditions simultaneously would reduce sudden death risk by 3.6 to 7.5 × 10(-5) with projected life expectancy increases of 0.8 to 1.6 days per screened individual. The incremental cost-effectiveness of screening is $91,000 to $204,000 per life-year. Sensitivity analysis showed that assumed disease prevalence, baseline mortality, and the relative risk of mortality resulting from stimulant medication use and sports participation had the greatest impact on estimated cost-effectiveness. CONCLUSION: Results based on assumptions favoring sudden cardiac death screening indicated that its cost is high relative to its health benefits.

Parental caregiving of children prior to hematopoietic stem cell transplant.

Using the Caregiver Reaction Assessment (CRA), we assessed positive reactions and burdens of the caregiving experience among parental caregivers (n = 189) of children scheduled to undergo hematopoietic stem cell transplant. Although widely used in non-parental caregivers, the CRA has not been used in parents of pediatric patients. Reliability (Cronbach's alpha: .72-.81 vs. .63) and concurrent validity (correlation: .41-.61 vs. .28) were higher for negatively framed than positively framed subscales. Results indicate that the caregiving experience is complex. The parents experienced high caregiver's esteem and moderate family support, but also negative impacts on finances and schedule, and to a lesser degree, health. Compared to non-parental caregivers, parental caregivers experienced higher esteem and more impact on finances and schedule.

Cardiac screening prior to stimulant treatment of ADHD: a survey of US-based pediatricians.

OBJECTIVES: To determine pediatricians' attitudes, barriers, and practices regarding cardiac screening before initiating treatment with stimulants for attention-deficit/hyperactivity disorder. METHODS: A survey of 1600 randomly selected, practicing US pediatricians with American Academy of Pediatrics membership was conducted. Multivariate models were created for 3 screening practices: (1) performing an in-depth cardiac history and physical (H & P) examination, (2) discussing potential stimulant-related cardiac risks, and (3) ordering an electrocardiogram (ECG). RESULTS: Of 817 respondents (51%), 525 (64%) met eligibility criteria. Regarding attitudes, pediatricians agreed that both the risk for sudden cardiac death (SCD) (24%) and legal liability (30%) were sufficiently high to warrant cardiac assessment; 75% agreed that physicians were responsible for informing families about SCD risk. When identifying cardiac disorders, few (18%) recognized performing an in-depth cardiac H & P as a barrier; in contrast, 71% recognized interpreting a pediatric ECG as a barrier. When asked about cardiac screening practices before initiating stimulant treatment for a recent patient, 93% completed a routine H & P, 48% completed an in-depth cardiac H & P, and 15% ordered an ECG. Almost half (46%) reported discussing stimulant-related cardiac risks. Multivariate modeling indicated that ≥1 of these screening practices were associated with physicians' attitudes about SCD risk, legal liability, their responsibility to inform about risk, their ability to perform an in-depth cardiac H & P, and family concerns about risk. CONCLUSIONS: Variable pediatrician attitudes and cardiac screening practices reflect the limited evidence base and conflicting guidelines regarding cardiac screening. Barriers to identifying cardiac disorders influence practice.