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Introduction: Transition from multidisciplinary paediatric to adult care results in a significant change in the intensity of care provided to patients with spina bifida (SB). Objective: To compare planned and unplanned health care utilization and costs of care of transitioning SB patients. Study Design: Through a retrospective population-based cohort study, patients with SB born in Ontario between 1988 and 1999 were studied using routinely collected data analysed at ICES. Patients were followed longitudinally from age 16 to 22 years with comparisons made between the paediatric baseline year (age 16) to the first 3 years of adulthood (ages 19 to 21). A composite primary outcome of unplanned emergency room (ER) visits, hospitalizations and emergency surgical procedures, was compared before and after transition. Secondary outcomes included these variables individually and estimated health care costs. Results: In the 299 patients, no significant differences were identified in the composite primary outcome between periods (P = 0.09). Unplanned ER visits (P = 0.004) and emergency surgical procedures (P = 0.02) increased after transition. Despite this, the estimated individual total cost of care declined after transition (P = 0.03). Further, multivariable analysis identified rural residence (RR 1.78, confidence interval [CI] 1.30 to 2.44) and previous urologic surgery (RR 1.91, CI 1.41 to 2.57) as significant predictors of increased need for emergent care and health care costs, respectively. Conclusion: Patients with SB in Ontario have higher rates of ER usage and unplanned surgery after the transition to adult care. While this does not drive an increase in health care costs, improvements in the care of transitioned SB patients, particularly rural patients and those with prior urologic surgery, may decrease the requirement for acute care.
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PURPOSE: Improvements in life expectancy have resulted in an increasing number of adults with cerebral palsy, of which over a third will have neurogenic lower urinary tract dysfunction (NLUTD). This review explores urinary dysfunction in adults with cerebral palsy. METHODS: Relevant literature on NLUTD in adults with cerebral palsy was identified using an unrestricted search of PubMed. RESULTS: Urinary incontinence is the most common complaint, often accompanied by frequency and urgency. Special consideration should be given to women and in those with worse motor or cognitive dysfunction as they have been shown to have more severe urologic symptoms. NLUTD can have significant morbidity and impact quality of life. Hospital admission, urinary tract infections, and hydronephrosis are common urologic complications, with poor urinary function associated with decreased quality of life (QOL). Neurogenic detrusor overactivity is the most common urodynamic abnormality, with elevated detrusor leak point pressure and reduced bladder capacity. Detrusor sphincter dyssynergy is present in some patients and maybe secondary to generalized spasticity or incomplete upper motor neuron injury. Elevated bladder capacity is also present in a portion of patients, and becomes particularly relevant in adults as a result of increased spasticity of the urinary sphincter. Conservative management like functional toileting strategies, medications, and incontinence aids are successful in most patients. Medical management with anticholinergics is well described, and frequently the only intervention required, particularly in children. Intermittent clean catheterization has mixed results with this population, as its efficacy is limited by pelvic spasticity and patient factors. Surgical intervention, while often successful, should be restricted to select patients, as it is associated with significant morbidity in this population. CONCLUSION: Management of NLUTD in adults with CP involves conservative management, medications, and in rare cases surgical intervention.