Background New-onset diabetes after transplantation (NODAT) is a major post-transplant complication associated with lower allograft and recipient survival. Our objective was to determine if metabolic syndrome pre-transplant is independently associated with NODAT development. Methods We recruited 640 consecutive incident non-diabetic renal transplant recipients from 3 academic centers between 1999 and 2004. NODAT was defined as use of hypoglycemic medication, a random plasma glucose >200 mg/dL, or 2 fasting glucose levels ≥126 mg/dL beyond 30 days post-transplant. Results Metabolic syndrome was common pre-transplant (57.2 %). NODAT developed in 31.4% of recipients one year post-transplant. Participants with metabolic syndrome were more likely to develop NODAT compared to recipients without metabolic syndrome (34.4% v. 27.4%, p=0.057). Recipients with increasing number of positive metabolic syndrome components were more likely to develop NODAT (metabolic syndrome score-prevalence at 1 year: 0-0.0%, 1-24.2, 2-29.3%, 3-31.0%, 4-34.8%, and 5-73.7%, p=0.001). After adjustment for demographics, age by decade (HR-1.34 (1.20-1.50), p<0.0001), African American race (HR-1.35 (1.01-1.82), p=0.043), cumulative prednisone dosage (HR-1.18 (1.07-1.30), p=0.001), and metabolic syndrome (HR-1.34 (1.00-1.79), p=0.047) were independent predictors of development of NODAT at 1 year post-transplant. In a multivariable analysis incorporating the individual metabolic syndrome components themselves as covariates, the only pre-transplant metabolic syndrome component to remain an independent predictor of NODAT was low HDL (HR-1.37 (1.01-1.85), p=0.042). Conclusions Metabolic syndrome is an independent predictor for NODAT and is a possible target for intervention to prevent NODAT. Future studies to evaluate if modification of metabolic syndrome factors pre-transplant reduces NODAT development are needed.
OBJECTIVES:The mental health of parents of children with medical complexity (CMC) is poorly understood, yet it drives child and family health outcomes. For parents of CMC, compared with parents of noncomplex children with special health care needs (CSHCN) and children without special health care needs (non-CSHCN), we examined self-reported mental health, knowledge of community sources for help, and emotional support.METHODS: Using parent-reported data from the combined 2016-2017 National Survey of Children's Health, we divided the population into 3 groups: households with CMC, noncomplex CSHCN, and non-CSHCN. We compared these groups regarding the following: (1) parents' risks for poor or fair mental health and knowledge of where to go for community help and (2) parent-reported sources of emotional support.RESULTS: Of 63 955 588 parent-child dyads (weighted from a sample of 65 204), parents of CMC had greater adjusted odds of reporting poor or fair mental health compared with parents of noncomplex CSHCN (adjusted odds ratio [aOR] 2.0; 95% confidence interval [CI] 1.1-3.8) and non-CSHCN (aOR 4.6; 95% CI 2.5-8.6). Parents of CMC had greater odds of not knowing where to find community help compared with parents of noncomplex CSHCN (aOR 2.1; 95% CI 1.4-3.1) and non-CSHCN (aOR 2.9; 95% CI 2.0-4.3). However, parents of CMC were most likely to report receiving emotional support from health care providers and advocacy groups (P < .001).CONCLUSIONS: Among all parents, those with CMC were at the highest risk to report suboptimal mental health. They more often reported that they do not know where to find community help, but they did say that they receive emotional support from health care providers and advocacy groups. Future researchers should identify ways to directly support the emotional wellness of parents of CMC.
BACKGROUND AND OBJECTIVES: Children with neurologic impairment (NI) are a growing subset of children who frequently use health care. We examined health care use and spending trends across services for children with NI during their first 5 years of life. METHODS: This was a retrospective study of 13 947 children with NI in the multistate IBM Medicaid MarketScan Database (2009–2017). We established birth cohorts of children with NI and analyzed claims from birth to 5 years. NI, identified by using International Classification of Diseases, 9th Revision, diagnosis codes, was defined as ≥1 neurologic diagnosis that was associated with functional and/or intellectual impairment. We measured annual health care use and per-member-per-year spending by inpatient, emergency department (ED), and outpatient services. Population trends in use and spending were assessed with logistic and linear regression, respectively. RESULTS: During their first versus fifth year, 66.8% vs 5.8% of children with NI used inpatient services, and 67.8% vs 44.4% used ED services. Annual use in both categories decreased over 0–5 years (inpatient odds ratio: 0.35, 95% confidence interval: 0.34 to 0.36; ED odds ratio: 0.78, 95% confidence interval: 0.77 to 0.79). The use of outpatient services (primary care, specialty care, home health) decreased gradually. Per-member-per-year spending on inpatient services remained the largest spending category: $83 352 (90.2% of annual spending) in the first year and $1944 (25.5%) in the fifth year. CONCLUSIONS: For children with early-onset NI from 0–5 years, use and spending on inpatient services decreased dramatically; ED and outpatient service use decreased more gradually. These findings may help systems, clinicians, and families optimize care by anticipating and adjusting for shifting use of health care services.
OBJECTIVES For hospitalized children and their families, laboratory study collection at night and in the early morning interrupts sleep and increases the stress of a hospitalization. To change this practice, our quality improvement (QI) study developed a rounding checklist aimed at increasing the percentage of routine laboratory studies ordered for and collected after 7 am. METHODS Our QI study was conducted on the pediatric hospital medicine service at a single-site urban children’s hospital over 28 months. Medical records from 420 randomly selected pediatric inpatients were abstracted, and 5 plan-do-study-act cycles were implemented during the intervention. Outcome measures included the percentage of routine laboratory studies ordered for and collected after 7 am. The process measure was use of the rounding checklist. Run charts were used for analysis. RESULTS The percentage of laboratory studies ordered for after 7 am increased from a baseline median of 25.8% to a postintervention median of 75.0%, exceeding our goal of 50% and revealing special cause variation. In addition, the percentage of laboratory studies collected after 7 am increased from a baseline median of 37.1% to 76.4% post intervention, with special cause variation observed. CONCLUSIONS By implementing a rounding checklist, our QI study successfully increased the percentage of laboratory studies ordered for and collected after 7 am and could serve as a model for other health care systems to impact provider ordering practices and behavior. In future initiatives, investigators should evaluate the effects of similar interventions on caregiver and provider perceptions of patient- and family-centeredness, satisfaction, and the quality of patient care.
In this study, we evaluated whether caregivers preferred to be called "Mom" and "Dad" or by name in the inpatient pediatric setting and how often caregivers reported that residents, attending physicians, and nurses greeted them as they preferred. METHODS: We measured caregivers' greeting preferences and perceptions of how residents, attending physicians, and nurses greeted them by surveying caregivers on 1 unit at a large urban children's hospital from October 2017 to April 2018. The 27-item survey consisted of multiple choice, Likert scale, and demographic measures. A member of the study team enrolled caregivers at the patient's bedside to complete the written survey anonymously. RESULTS: A total of 114 caregivers completed the survey (51% of 223 enrolled caregivers); 63% (95% confidence interval [CI] 53%-74%) of mothers and 57% (95% CI 36%-77%) of fathers preferred to be greeted as Mom and Dad, respectively; the rest preferred greetings by name. Caregiver preferences did not significantly vary on the basis of relationship to the child (mother or father), age, race, or education level (P. .05). Caregivers reported that 48% (95% CI 35%-62%) of residents, 43% (95% CI 29%-57%) of attending physicians, and 63% (95% CI 49%-75%) of nurses always or usually addressed them as they preferred. CONCLUSIONS: Approximately half of mothers and fathers preferred to be called Mom and Dad, respectively, whereas the rest preferred to be greeted by name. Caregiver preferences did not differ on the basis of demographics. Caregivers reported that residents, attending physicians, and nurses were inconsistent in following their greeting preferences.
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