WHAT'S KNOWN ON THIS SUBJECT:The importance of transition from pediatric to adult health care for youth with special health care needs has gained increasing attention over the past decade, but fewer than half of this population received needed transition preparation in [2005][2006]. abstract OBJECTIVE: To examine current US performance on transition from pediatric to adult health care and discuss strategies for improvement. WHAT THIS STUDY ADDS: METHODS: The 2009-2010 National Survey of Children with SpecialHealth Care Needs is a nationally representative sample with 17 114 parent respondents who have youth with special health care needs (YSHCN) ages 12 and 18. They are asked about transition to an adult provider, changing health care needs, increasing responsibility for health care needs, and maintaining insurance coverage. We analyzed the association of selected characteristics with successful transition preparation. RESULTS:Overall, 40% of YSHCN meet the national transition core outcome. Several factors are associated with transition preparation, including female gender; younger age; white race; non-Hispanic ethnicity; income $400% of poverty; little or no impact of condition on activities; having a condition other than an emotional, behavioral, or developmental condition; having a medical home; and being privately insured.CONCLUSIONS: Most YSHCN are not receiving needed transition preparation. Although most providers are encouraging YSHCN to assume responsibility for their own health, far fewer are discussing transfer to an adult provider and insurance continuity. Although changes in sample design limit trend analysis, there have been no discernible improvements since this transition outcome was measured in the 2005

Objectives To describe the natural history of frailty transitions in a large cohort of community-dwelling older men and identify predictors associated with progression to or improvement from states of greater frailty. Design Prospective cohort study. Setting Six U.S. sites. Participants 5,086 community-dwelling men aged 65 years or older. Measurements Frailty was measured at baseline and an average of 4.6 years later. Frailty was defined as ≥ 3 of the following: low lean mass, weakness, self-reported exhaustion, low activity level, and slow walking speed; prefrail as 1-2 components. Separate multivariable logistic regression models were analyzed for progression and improvement in frailty status. Results Of the 5,086 men, 8% were frail, 46% were prefrail, and 46% were robust at baseline. Between baseline and follow-up, 35% progressed in frailty status or died, 56% had no change in frailty status, and 15% of prefrail or frail participants improved. However, only 0.5% improved across two levels, from frail to robust. In multivariable models, factors associated with improvement in frailty status included greater leg power, being married, and good or excellent self-reported health, whereas presence of any instrumental activities of daily living (IADL) limitations, low albumin levels or high IL-6 levels, and presence of chronic obstructive pulmonary disease or diabetes mellitus were associated with a decreased likelihood of improvement in frailty status. Conclusions Improvement in frailty status was possible in this cohort of community-dwelling older men; however, complete remediation from frail to robust was rare. Several predictors were identified as possible targets for intervention including prevention and improved management of comorbid medical conditions, prevention of IADL disability, physical exercise, and nutritional and social support.

Background/Objectives To assess symptoms in older (age ≥65 years) intensive care unit (ICU) survivors and determine whether post-ICU frailty identifies those with the greatest palliative care needs. Design A prospective cohort study. Setting An urban tertiary-care hospital and community hospital. Participants One-hundred and twenty-five medical-ICU survivors of mechanical ventilation age ≥65 years. Measurements Baseline measurements of the Edmonton Symptom Assessment Scales (ESAS), categorized as mild (0–3), moderate (4–6), and severe (7–10), and the frailty phenotype were made during the week prior to hospital discharge. Functional recovery was defined as a return to a Katz Activities of Daily Living dependency count less than or equal to the pre-hospitalization dependency count within 3 months. In the last 29 participants, we made additional assessments of fatigue and ESAS at baseline and 1 month after discharge. Results Fatigue was the most prevalent moderate-to-severe symptom (74%), followed by dyspnea (53%), drowsiness (50%), poor appetite (47%), pain (45%), depression (42%), anxiety (36%), and nausea (17%). At 1 month follow-up, there were no significant differences in the proportions of participants with moderate-to-severe symptoms. Each increase in baseline ESAS fatigue severity category was associated with a 55% lower odds of functional recovery (OR 0.45, 95% CI 0.24–0.84), independent of age, sex, comorbidities, and critical illness severity. Compared to non-frail participants, frail participants had a higher median (IQR) baseline total ESAS symptom distress score (13 [9–22] versus 34 [23–44], p <0.001). Conclusions Older ICU survivors have a high burden of palliative care needs that persist at 1 month after discharge. Fatigue is the most prevalent symptom and may interfere with recovery. Post-ICU frailty may be both a useful palliative care consultation trigger and treatment target.

The DASI improves the construct and predictive validity of frailty assessment in adults with advanced lung disease or recent critical illness. This simple questionnaire should replace the more complex MLTA in assessing the frailty phenotype in these populations.

Background: Moral distress is a reason for burnout in healthcare professionals, but the clinical settings in which moral distress is most often experienced by medical students, and whether moral distress is associated with burnout and career choices in medical students is unknown. We assessed moral distress in medical students while caring for older patients, and examined associations with burnout and interest in geriatrics. Methods: A cross-sectional survey study of second-, third-, and fourth-year medical students at an American medical school. The survey described 12 potentially morally distressing clinical scenarios involving older adult patients. Students reported if they encountered each scenario, and whether they experienced moral distress, graded on a 1-10 scale. We conducted a principal axis factor analysis to assess the dimensionality of the survey scenarios. A composite moral distress score was calculated as the sum of moral distress scores across all 12 scenarios. Burnout was assessed using the Maslach Abbreviated Burnout Inventory, and interest in geriatrics was rated on a 7-point Likert scale. Results: Two-hundred and nine students responded (47%), of whom 90% (188/209) reported moral distress in response to ≥1 scenario with a median (IQR) score of 6 (4-7). Factor analysis suggested a unidimensional factor structure of the 12 survey questions that reliably measured individual distress (Cronbach alpha = 0.78). Those in the highest tertile of composite moral distress scores were more likely to be burnt out (51%) than those in the middle tertile of scores (34%), or lowest tertile of scores (31%) (p = 0.02). There was a trend towards greater interest in geriatrics among those in the higher tertiles of composite moral distress scores (16% lowest tertile, 20% middle tertile, 25% highest tertile, p-for-tend = 0.21). Respondents suggested that moral distress might be mitigated with didactic sessions in inpatient geriatric care, and debriefing sessions with peers and faculty on the inpatient clerkships on medicine, neurology, and surgery, where students most often reported experiencing moral distress. Conclusions: Moral distress is highly prevalent among medical students while caring for older patients, and associated with burnout. Incorporating geriatrics education and debriefing sessions into inpatient clerkships could alleviate medical student moral distress and burnout.