Impact of multimorbidity subgroups on the health care use of early pediatric cancer survivors.

BACKGROUND: Although pediatric cancer survivors in the United States are at an increased risk of developing chronic conditions, to the authors' knowledge there is limited information regarding the types and combinations of conditions they experience in the years immediately after the completion of cancer therapy. METHODS: An observational cohort study of early pediatric cancer survivors (children who were ≥2 years from the end of therapy and aged ≤18 years) was conducted using the Truven Health MarketScan (r) Commercial Claims and Encounters database (2009-2014). Latent class analysis was used to identify comorbidity groups among the subset with ≥2 conditions. Group-level health care use was compared with survivors without chronic conditions using multivariate regression. RESULTS: A total of 3687 early survivors were identified, of whom approximately 41.2% had no chronic conditions, 22.5% had 1 chronic condition, and 36.3% had ≥2 chronic conditions. Among those with ≥2 chronic conditions, 5 groups emerged: 1) general pediatric morbidity (35.4%); 2) central nervous system (CNS) (22.4%); 3) mental health conditions (22.2%); 4) endocrine (26.2%); and 5) CNS with endocrine (3.8%). The CNS group experienced the highest expenditures, at $17,964 more per year (95% CI, $1446-$34,482) compared with survivors without chronic conditions. The CNS group also had the highest odds of an emergency department visit (adjusted odds ratio, 1.71; 95% CI, 1.15-2.56). The endocrine group had the highest odds of hospitalization (odds ratio, 2.29; 95% CI, 1.24-4.22). CONCLUSIONS: Multimorbidity is common among pediatric cancer survivors. The current study identified 5 distinct comorbidity subgroups, all of which experienced high, yet differential, rates of health care use. The results of the current study highlight the complex health care needs of early survivors and provide evidence for the design of targeted survivorship services and interventions.

Multimorbidity and healthcare utilization among early survivors of pediatric cancer.

Early survivors of pediatric cancer are at increased risk of experiencing chronic conditions; however, little is known about the morbidity burden in this population. In this observational cohort study of commercially insured pediatric cancer survivors in the United States (2009-2014), we find that 22.5% of survivors had one chronic condition, and 36.3% had multiple. Compared with survivors without chronic conditions, the presence of multiple conditions significantly increased the odds of an emergency department visit by 70% (odds ratios [OR], 1.7; 95% confidence interval [CI], 1.4-2.1) and of a hospitalization almost four-fold (OR, 3.8; 95% CI], 2.5-5.5). Findings are important for informing pediatric survivorship care plans in the years following completion of therapy.

Lifestyle-related attitudes: do they explain self-rated health and life-satisfaction?

BACKGROUND: Strategies to improve public health may benefit from targeting specific lifestyles associated with poor health behaviors and outcomes. The aim of this study was to characterize and examine the relationship between health and lifestyle-related attitudes (HLAs) and self-rated health and life-satisfaction. METHODS: Secondary analyses were conducted on data from a 2012 community wellness survey in Kirklees, UK. Using a validated HLA tool, respondents (n = 9130) were categorized into five segments: health conscious realists (33%), balanced compensators (14%), live-for-todays (18%), hedonistic immortals (10%), and unconfident fatalists (25%). Multivariate regression was used to examine whether HLAs could explain self-rated health using the EQ-5D visual analog scale (EQ-VAS) and life-satisfaction. Health conscious realists served as the reference group. RESULTS: Self-rated health differed by HLA, with adjusted mean EQ-VAS scores being significantly higher (better) among balanced compensators (1.15, 95% CI 0.27, 2.03) and lower scores among unconfident fatalists (- 9.02, 95% CI - 9.85, - 8.21) and live-for-todays (- 1.96, 95% CI - 2.80, - 1.14). Balanced compensators were less likely to report low life-satisfaction (OR 0.75, 95% CI 0.62, 0.90), while unconfident fatalists were most likely to have low life-satisfaction (OR 3.51, 95% CI 2.92, 4.23). SIGNIFICANCE: Segmentation by HLA explained differences in self-rated health and life-satisfaction, with unconfident fatalists being a distinct segment with significantly worse health perceptions and life-satisfaction. Health promotion efforts may benefit from considering the HLA segment that predominates a patient group, especially unconfident fatalists.

Transition to international classification of disease version 10, clinical modification: the impact on internal medicine and internal medicine subspecialties.

BACKGROUND: The US health care system uses diagnostic codes for billing and reimbursement as well as quality assessment and measuring clinical outcomes. The US transitioned to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) on October, 2015. Little is known about the impact of ICD-10-CM on internal medicine and medicine subspecialists. METHODS: We used a state-wide data set from Illinois Medicaid specified for Internal Medicine providers and subspecialists. A total of 3191 ICD-9-CM codes were used for 51,078 patient encounters, for a total cost of US $26,022,022 for all internal medicine. We categorized all of the ICD-9-CM codes based on the complexity of mapping to ICD-10-CM as codes with complex mapping could result in billing or administrative errors during the transition. Codes found to have complex mapping and frequently used codes (n = 295) were analyzed for clinical accuracy of mapping to ICD-10-CM. Each subspecialty was analyzed for complexity of codes used and proportion of reimbursement associated with complex codes. RESULTS: Twenty-five percent of internal medicine codes have convoluted mapping to ICD-10-CM, which represent 22% of Illinois Medicaid patients, and 30% of reimbursements. Rheumatology and Endocrinology had the greatest proportion of visits and reimbursement associated with complex codes. We found 14.5% of ICD-9-CM codes used by internists, when mapped to ICD-10-CM, resulted in potential clinical inaccuracies. CONCLUSIONS: We identified that 43% of diagnostic codes evaluated and used by internists and that account for 14% of internal medicine reimbursements are associated with codes which could result in administrative errors.

Addressing Women's Health Care Needs During Pediatric Care.

Objective: To determine if the use of a simple self-administered Postpartum Questionnaire for Mothers (PQM) at the well-baby visit (WBV) increased the proportion of women who received health care and contraception by 6 months postpartum (PP). Methods: This was a single-site, system-level, intervention. Women were recruited from the pediatric clinic when presenting with their infants for a 2-month WBV. During phase 1 of the study, a control group was enrolled, followed by an 8-week washout period; then enrollment of the intervention group (phase 2). During phase 2, the PQM was administered and reviewed by the pediatrician during the infant's visit; the tool prompted the pediatrician to make a referral for the mother's primary or contraceptive care as needed. Data were collected at baseline and at 6 months PP, and additional data were extracted from the electronic medical record. Results: We found that PP women exposed to the PQM during their infant's WBV were more likely to have had a health care visit for themselves between 2 and 6 months PP, compared with the control group (relative risk [RR] 1.66, [confidence interval (CI) 0.91-3.03]). In addition, at 6 months PP, women in the intervention group were more likely to identify a primary care provider (RR 1.84, [CI 0.98-3.46]), and more likely to report use of long-acting reversible contraception (LARC) (RR 1.24, [CI 0.99-1.58]), compared with women in the control group. Conclusion: A simple self-administered PQM resulted in an increase in women's receipt of health care and use of LARC by 6 months PP. Clinical Trial Registration: Use of a reproductive life planning tool at the pediatric well-baby visit with postpartum women, NCT03448289.

COVID-19 Precipitating Euglycaemic Diabetic Ketoacidosis with SGLT2 Inhibitor Use.

OBJECTIVE: To describe a patient who developed euglycaemic diabetic ketoacidosis (DKA) in the setting of SGLT2 inhibitor use precipitated by COVID-19. PATIENT AND METHODS: A 52-year-old male with type II diabetes on empagliflozin and no history of DKA presented with symptoms of COVID-19 as well as laboratory findings consistent with euglycaemic DKA. His hospital course was complicated by recurrent episodes of euglycaemic DKA as well as hyperglycaemic DKA. CONCLUSION: SGLT2 inhibitors should be held as early as possible in COVID-19 cases due to the risk of euglycaemic DKA. These patients should also have more intense glucose monitoring. LEARNING POINTS: COVID-19 can precipitate euglycaemic DKA in diabetic patients taking SGLT2 inhibitors.Clinicians should be cognizant that the effects of SGLT2 inhibitors can persist for more than 72 hours after the last dose.Diabetic patients with COVID-19 require closer strict glucose monitoring to reduce the risk of DKA.

Prevalence of and Factors Associated With Receiving a Pelvic Examination or Pap Testing Under the Age of 21 Years.

PURPOSE: Current guidelines recommend that individuals receive their first Pap test at age 21 years and only receive a pelvic examination before age 21 years for clinical indications. We sought to determine the prevalence and associated covariates of receiving a pelvic examination or Pap test before 21 years of age. METHODS: We analyzed the 2013-2015 National Survey of Family Growth. We conducted bivariate analyses comparing individuals who had and had not had a pelvic examination or Pap test and multivariable logistic regression to identify factors associated with having a pelvic examination or Pap test under 21 years. RESULTS: This study included 1,170 individuals. Of respondents, 30.8% received a pelvic examination and 25.1% received a Pap test before 21 years of age. Receiving a pelvic examination was associated with being sexually active (adjusted odds ratio [aOR]: 6.6, 95% confidence interval [CI]: 3.8-11.7), having ever taken contraceptive pills (aOR: 2.6, 95% CI: 1.6-4.1) compared with no contraceptive method, and being screened for sexually transmitted infections in the past 12 months (aOR: 12.6, 95% CI: 7.3-21.8). Receiving a Pap test was also associated being sexually active (aOR: 7.2, 95% CI: 3.7-14.0), having ever taken contraceptive pills (aOR: 3.0, 95% CI: 1.9-4.7) compared with no contraceptive method, and being screened for sexually transmitted infections in the past 12 months (aOR: 8.94, 95% CI: 5.12-15.61). CONCLUSIONS: Contrary to contemporary guidelines, a notable proportion of individuals under the age of 21 years continues to receive pelvic examinations and Pap testing.

Work-Sampling Study of an Innovative Care Coordination Program Aimed at Children With Chronic Health Conditions.

PURPOSE OF STUDY: To estimate time allocation and labor cost for care coordinators (CCs), community health workers (CHWs), and mental health workers (MHWs) to conduct care coordination tasks in a pediatric care coordination program. PRIMARY PRACTICE SETTING: A public tertiary academic medical center in Chicago, IL. METHODOLOGY AND SAMPLE: A work-sampling study was conducted using a text message-based survey on 5 CCs, 20 CHWs, and 4 MHWs who volunteered to participate. Workers were randomly sampled within working hours to collect information on who was the subject of interaction and what service was being delivered over a 6-month period. Time allocation of workers to different subjects and services was summarized using descriptive statistics. RESULTS: Care coordinators allocated 41% of their time to managing CHW teams. Community health workers allocated 37% of time providing services directly to children and 26% to the parent/caregiver. Mental health workers allocated 16% of time providing services to children and 29% to the parent/caregiver. The care coordination program serviced 5,965 patients, with a total annual labor cost of $1,455,353. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Community health workers spent the majority of time working with patients and their families to conduct assessments. Mental health workers primarily addressed children's needs through their caregivers. Care coordinators primarily supported CHWs in coordinating care. Results may be used to inform development of such programs by determining services most often utilized, and labor cost may be used to inform program implementation and reimbursement.

Cost-effectiveness analysis of lumacaftor and ivacaftor combination for the treatment of patients with cystic fibrosis in the United States.

BACKGROUND: Lumacaftor/ivacaftor was approved by the Food and Drug Administration (FDA) as a combination treatment for Cystic Fibrosis (CF) patients who are homozygous for the F508del mutation. The objective of this study was to assess the cost-effectiveness of lumacaftor/ivacaftor combination for the treatment of CF homozygous for F508del CF Transmembrane Conductance Regulator (CFTR) mutation. METHODS: A Markov-state transition model following a cohort of 12 year-old CF patients homozygous for F508del CFTR mutation in the United States (US) over two, four, six, eight and ten years from a payer's perspective was developed using TreeAge Pro 2016. Markov states included: mild (percentage of predicted forced expiratory volume in 1 s or FEV1 > 70%), moderate (FEV1 40-70%), severe (FEV1 < 40%) disease, post-transplant, and death. Pulmonary exacerbation and lung transplant were included as transition states. All the input parameters were estimated from the literature. A 1-year cycle length and 3% discount rate were applied. To assess uncertainty in long-term treatment effects, several scenarios were modelled: 100% long-term effectiveness (base-case), defined as improvement in FEV1 in the first year followed by no annual FEV1 decline and a constant reduction in pulmonary exacerbations throughout, 75%, 50%, 25% and 0% (worst case) long-term effectiveness, where treatment effects were intermediate from the second year of treatment until the end of the time horizon. Other scenarios included changing the starting age of the cohort to 6 and 25 years. Primary outcome included incremental cost-effectiveness ratio (ICER) in terms of cost per quality adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were performed to determine uncertainty. RESULTS: Under the base-case, Lumacaftor/ivacaftor resulted in higher QALYs (7.29 vs 6.84) but at a very high cost ($1,778,920.88) compared to usual care ($116,155.76) over a 10-year period. The ICER for base-case and worst-case scenarios were $3,655,352 / QALY, and $8,480,265/QALY gained, respectively. In the base-case, lumacaftor/ivacaftor was cost-effective at a threshold of $150,000/QALY-gained when annual drug costs were lower than $4153. The results were not substantially affected by the sensitivity analyses. CONCLUSIONS: The intervention produces large QALY gains but at an extremely high cost, resulting in an ICER that would not typically be covered by any insurer. Lumacaftor/ivacaftor's status as an orphan drug complicates coverage decisions.

Medicaid Managed Care: Unanswered Impact on School-Located Immunization Services.

Managed care coordination for Medicaid beneficiaries is being implemented in states across the country. Recently, 1.5 million Medicaid beneficiaries in five regions of Illinois began this transition. This article presents the findings of a study to learn if immunizations would continue to be a reimbursable service if provided to beneficiaries outside of the designated primary care setting. The findings revealed a lack of clarity among health plan representatives and billing personnel in how to obtain coverage information. Five contacted plans (25%) stated they were unable to verify coverage and unclear where to acquire this information. Similarly, six (30%) representatives could not answer the question and recommended calling the Illinois Department of Healthcare and Family Services hot line. Despite the potential benefit of improved coordination of care gained by transitioning to managed care entity model, this infrastructure change may inadvertently introduce barriers to services obtained outside the medical home, like school-located immunization.

Emergency Department-Based Care Transitions for Pediatric Patients: A Systematic Review.

CONTEXT: Successful care transitions between emergency departments (EDs) and outpatient settings have implications for quality, safety, and cost of care. OBJECTIVE: To investigate the effectiveness of ED-based care transition interventions in achieving outpatient follow-up among pediatric patients. DATA SOURCES: Medline, Embase, CINAHL, Cochrane Library, trial registers, and reference lists of relevant articles. STUDY SELECTION AND DATA EXTRACTION: Eligible studies included randomized controlled trials of ED-based care transition interventions involving pediatric patients (aged ≤18 years). Study selection, data extraction, and risk of bias assessment were performed in duplicate and independent manner. Study results were pooled for meta-analysis by using a random effects model. RESULTS: Sixteen randomized controlled trials, comprising 3760 patients, were included in the study. Most interventions were single-site (n = 14), multicomponent (n = 12), and focused on patients with asthma (n = 8). Pooling data from 10 studies (n = 1965 patients) found moderate-quality evidence for a relative increase of 29% in outpatient follow-up with interventions compared with routine care (odds ratio, 1.58 [95% confidence interval, 1.08-2.31]). Successful interventions included structured telephone reminders, educational counseling on follow-up, and appointment scheduling assistance. There was low-quality evidence when pooling data from 5 studies (n = 1609 participants) that exhibited little or no beneficial effect of interventions on ED readmissions (risk ratio, 1.02 [95% confidence interval, 0.91-1.15]). LIMITATIONS: All studies were conducted in urban US hospitals which makes generalization of the results to rural settings and other countries difficult. CONCLUSIONS: ED-based care transition interventions are effective in increasing follow-up but do not seem to reduce ED readmissions. Further research is required to investigate the mechanisms that affect the success of these interventions.

HPV vaccine acceptance among adolescent males and their parents in two suburban pediatric practices.

PURPOSE: To measure HPV vaccine acceptance among unvaccinated adolescent males and parents and correlate acceptance with knowledge, awareness, and personal experience. METHODS: Adolescent males ages 11-21 years old and their parents completed questionnaires measuring attitudes and knowledge about HPV vaccination and personal experience. Acceptance was defined as wanting the vaccine and conditional acceptance as wanting the vaccine if it would protect against genital warts or cervical cancer. RESULTS: Adolescent (n=154) and parent (n=121) vaccine acceptance was low (16% and 34%, respectively); however, conditional acceptance was higher. While adolescents had similar conditional acceptance for a vaccine against genital warts and cervical cancer, parents reported higher conditional acceptance for protection against genital warts. Independent predictors of acceptance included personal experience and demographic variables. CONCLUSIONS: HPV vaccine acceptance among adolescents and parents was low. Conditional acceptance levels highlight the importance of education about a few important benefits of HPV vaccination, which may increase vaccination rates.

Infant male circumcision: healthcare provider knowledge and associated factors.

BACKGROUND AND OBJECTIVES: The emerging science demonstrates various health benefits associated with infant male circumcision and adult male circumcision; yet rates are declining in the United States. The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend that healthcare providers present evidence-based risk and benefit information for infant male circumcision to parent(s) and guardian(s). The purpose of this study was to assess providers' level of infant male circumcision knowledge and to identify the associated characteristics. METHODS: An online survey was administered to healthcare providers in the family medicine, obstetrics, and pediatrics medical specialties at an urban academic health center. To assess infant male circumcision knowledge, a 17 point summary score was constructed to identify level of provider knowledge within the survey. RESULTS: Ninety-two providers completed the survey. Providers scored high for the following knowledge items: adverse event rates, protects against phimosis and urinary tract infections, and does not prevent hypospadias. Providers scored lower for items related to more recent research: protection against cervical cancer, genital ulcer disease, bacterial vaginosis, and reduction in HIV acquisition. Two models were constructed looking at (1) overall knowledge about male circumcision, and (2) knowledge about male circumcision reduction in HIV acquisition. Pediatricians demonstrated greater overall infant male circumcision knowledge, while obstetricians exhibited significantly greater knowledge for the HIV acquisition item. CONCLUSION: Providers' knowledge levels regarding the risks and benefits of infant male circumcision are highly variable, indicating the need for system-based educational interventions.

Drugs associated with adverse events in children and adolescents.

OBJECTIVE: To describe the suspected medications, types of reactions, and outcomes of adverse events (AEs) most commonly reported to the United States Food and Drug Administration (FDA) in children by age group. METHODS: All case reports submitted to the FDA Adverse Event Reporting System (FAERS) between January 1, 2007, and August 27, 2012, for children (1 to < 12 yrs) and adolescents (12 to < 18 yrs) were examined. The most commonly reported suspected drugs were ranked. The corresponding AEs with serious outcome were compared and described between age groups. RESULTS: We identified a total of 78,623 reports in the FAERS database (53.8% in children and 46.2% in adolescents). Serious outcomes were noted in 40% of the children and 43% of the adolescents. The proportion of all case reports for central nervous system stimulants (lisdexamfetamine, 69.8%; methylphenidate, 68.0%) and analgesics (ibuprofen, 72.3%; acetaminophen, 68.6%) was higher in children, whereas tumor necrosis factor blockers (infliximab, 78.2%; adalimumab, 77.1%), atypical antipsychotics (aripiprazole 52.7%; risperidone 58.3%; quetiapine 72.1%) and oral contraceptives (levonogrestrel, 99.2%; drospirenone and ethinyl estradiol, 97.9%) were more commonly reported in adolescents. For most drugs, the types of reactions reported were similar but had different rank order across age groups, with the most dissimilar profiles being observed for isotretinoin and aripiprazole. CONCLUSIONS: This study highlights high-risk medications and their AE profiles in children and adolescents. Our findings underscore the need for further confirmation of particular drug and AE pairs and the heterogeneity of AEs by age.

Challenges to school-located vaccination: lessons learned.

School-located vaccination (SLV) has a long history in the United States and has successfully contributed to lower morbidity and mortality due to vaccine-preventable diseases.(1) Historically, SLV efforts, which tended to be single-vaccine programs intended to provide catch-up immunization to a defined school-age cohort or were implemented in response to an outbreak, were unfunded, funded by local health department, or were funded by industry or federal grants. The growing palette of vaccines recommended for routine use in adolescents along with limited success of office-based adolescent immunization create a compelling argument for the creation of financially sustainable SLV programs. An arguably significant barrier to both office-based and school-located adolescent immunization is the modest reimbursement rates afforded to immunizers. Because the immunization promotion and consent process is expensive, these costs must be reduced to a minimum to reach financial viability. Although there are challenges to creating a financially sustainable SLV program coordinated by an academic medical center, (AMC), the ability of AMCs to bill private and public insurers, the nonprofit status of medical centers, the allowances for faculty for academic pursuit, and the substantial infrastructure already present make AMCs a potentially practical site for the administration of SLV programs. Alternatively, as health departments throughout the nation continue to explore methods for billing private insurance, we may find health departments to be uniquely suited for coordinating the administration and billing of these services.

A School-Located Vaccination Adolescent Pilot Initiative in Chicago: Lessons Learned.

BACKGROUND: Many adolescents underutilize preventive services and are underimmunized. METHODS: To promote medical homes and increase immunization rates, we conceptualized and implemented a 3-year, 8-school pilot school-located vaccination collaborative program. We sought community, parent, and school nurse input the year prior to implementation. We selected schools with predominantly Medicaid-enrolled or Medicaid-eligible students to receive Vaccines For Children stock vaccines. Nurses employed by a mass immunizer delivered these vaccines at participating schools 3 times a year. RESULTS: Over 3 years, we delivered approximately 1800 vaccines at schools. School administrators, health centers, and neighboring private physicians generally welcomed the program. Parents did not express overt concerns about school-located vaccination. School nurses were not able to participate because of multiple school assignments. Obtaining parental consent via backpack mail was an inefficient process, and classroom incentives did not increase consent form return rate. The influenza vaccine had the most prolific uptake. The optimal time for administering vaccines was during regular school hours. CONCLUSIONS: Although school-located vaccination for adolescents is feasible, this is a paradigm shift for community members and thus accompanies challenges in implementation. High principal or school personnel turnover led to a consequent lack of institutional memory. It was difficult to communicate directly with parents. Because we were uncertain about the proportion of parents who received consent forms, we are exploring Internet-based and back-to-school registration options for making the consent form distribution and return process more rigorous. Securing an immunization champion at each school helped the immunization processes. Identifying a financially sustainable school-located vaccination model is critical for national expansion of school-located vaccination.

Early lessons learned from extramural school programs that offer HPV vaccine.

BACKGROUND: There has been little evaluation of school-located vaccination programs that offer human papillomavirus (HPV) vaccine in US schools without health centers (ie, extramural programs). This article summarizes lessons learned from such programs. METHODS: In July to August 2010, 5 programs were identified. Semistructured, in-depth telephone interviews were conducted with program representatives about practical aspects of planning and implementation, including configuration and effectiveness. RESULTS: Most programs offered HPV vaccine as part of a broader effort to increase uptake of adolescent vaccines. Respondents stressed the importance of building partnerships with local school systems throughout all aspects of the planning and implementation phases. All programs offered HPV vaccine at no cost to students. Most did not have a mechanism to bill private insurance, and some found Medicaid reimbursements to be a challenge. Programs achieved modest rates of initiation of the 3-dose HPV vaccine series (median 10%); however, among those who initiated the series, completion rates were high (median 78%). HPV vaccine uptake was lowest for a program that offered only HPV vaccine. CONCLUSIONS: Extramural programs may increase uptake of vaccines and decrease absenteeism due to noncompliance with vaccine requirements for school entry. Until extramural programs in the US receive better access to billing private insurers and Medicaid, sustainability of these programs relies on grant funding. Better integration of extramural school-located vaccine programs with existing local healthcare and other programs at schools is an area for growth.