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Soma K, Ochiai R, Tsutsui H, Takeda N, Yao A. Nationwide Survey on Transitional Care for Patients With Childhood-Onset Cardiomyopathy in Japan. Circ Rep 2024; 6:209-216. [PMID: 38860186 PMCID: PMC11162852 DOI: 10.1253/circrep.cr-24-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/31/2024] [Accepted: 04/09/2024] [Indexed: 06/12/2024] Open
Abstract
Background: Individuals transitioning into adulthood require age-appropriate medical care and delegation of decision-making authority from their parents to the patients themselves. Although there have been multiple observational and interventional studies on transitional care for patients with congenital heart disease (CHD) in the cardiovascular field, transitional care specific to childhood-onset cardiomyopathy (CM) remains unaddressed. Methods and Results: A nationwide questionnaire-based survey was performed in the pediatric cardiology departments of 151 facilities in Japan. Responses were obtained from 100 (66%) facilities with low transfer rates (<5%) for childhood-onset CM cases. The comparison between CHD-transferring and non-CHD-transferring facilities revealed a significantly higher transfer rate (83.9%) for childhood-onset CM cases in the CHD-transferring facilities (P<0.001). Regarding the transition programs, 72 (72%) facilities do not offer any programs for CM, while most (92%) facilities recognize its necessity. Finally, only 19 (19%) facilities provided a transition program, 10 of which were CHD based. Conclusions: To the best of our knowledge, this is the first study to demonstrate the poor transition/transfer care status of patients with childhood-onset CM in Japan. The transfer rate of CMs was lower than that of CHDs, and transition programs were less available. Referring to the system established for CHD could help develop a successful transitional care system for CM.
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Affiliation(s)
- Katsura Soma
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo Tokyo Japan
| | - Ryota Ochiai
- Adult Nursing, Department of Nursing, School of Medicine, Yokohama City University Yokohama Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University Fukuoka Japan
- International University of Health and Welfare Tokyo Japan
| | - Norihiko Takeda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo Tokyo Japan
| | - Atsushi Yao
- Division for Health Service Promotion, The University of Tokyo Tokyo Japan
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2
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Ducas RA, Mao T, Beauchesne L, Silversides C, Dore A, Ganame J, Alonso-Gonzalez R, Keir M, Muhll IV, Grewal J, Williams A, Dehghani P, Siu S, Johri A, Bedard E, Therrien J, Hayami D, Kells C, Marelli A. Adult Congenital Heart Disease Care in Canada: Has Quality of Care Improved in the Last Decade? Can J Cardiol 2024; 40:138-147. [PMID: 37924967 DOI: 10.1016/j.cjca.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/12/2023] [Accepted: 08/04/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Patients with adult congenital heart disease (ACHD) are at increased risk of comorbidity and death compared with the age-matched population. Specialized care is shown to improve survival. The purpose of this study was to analyze current measures of quality of care in Canada compared with those published by our group in 2012. METHODS A survey focusing on structure and process measures of care quality in 2020 was sent to 15 ACHD centres registered with the Canadian Adult Congenital Heart Network. For each domain of quality, comparisons were made with those published in 2012. RESULTS In Canada, 36,708 patients with ACHD received specialized care between 2019 and 2020. Ninety-five cardiologists were affiliated with ACHD centres. The median number of patients per ACHD clinic was 2000 (interquartile range [IQR]: 1050, 2875). Compared with the 2012 results, this represents a 68% increase in patients with ACHD but only a 19% increase in ACHD cardiologists. Compared with 2012, all procedural volumes increased with cardiac surgeries, increasing by 12% and percutaneous intervention by 22%. Wait time for nonurgent consults and interventions all exceeded national recommendations by an average of 7 months and had increased compared with 2012 by an additional 2 months. Variability in resources were noted across provincial regions. CONCLUSIONS Over the past 10 years, ACHD care gaps have persisted, and personnel and infrastructure have not kept pace with estimates of ACHD population growth. Strategies are needed to improve and reduce disparity in ACHD care relative to training, staffing, and access to improved care for Canadians with ACHD.
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Affiliation(s)
- Robin A Ducas
- Department of Internal Medicine, Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Tony Mao
- Department of Internal Medicine, Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Luc Beauchesne
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Candice Silversides
- University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, University of Toronto, Toronto, Ontario, Canada
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Rafael Alonso-Gonzalez
- University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jasmine Grewal
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Anne Williams
- Memorial University, St John's, Newfoundland, Canada
| | - Payam Dehghani
- Prairie Vascular Research Inc, Adult Congenital Heart Disease, Regina, Saskatchewan, Canada
| | - Samuel Siu
- Western University, London, Ontario, Canada
| | - Amer Johri
- Queen's University, Kingston, Ontario, Canada
| | - Elisabeth Bedard
- Quebec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Judith Therrien
- Jewish General Hospital, McGill Adult Unit for Congenital Heart Disease (MAUDE Unit), McGill University, Montréal, Québec, Canada
| | - Doug Hayami
- Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Ariane Marelli
- Jewish General Hospital, McGill Adult Unit for Congenital Heart Disease (MAUDE Unit), McGill University, Montréal, Québec, Canada
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3
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Mao RT, Beauchesne L, Marelli A, Silversides C, Dore A, Ganame J, Keir M, Alonso-Gonzalez R, Vonder Muhll I, Grewal J, Williams A, Dehghani P, Siu S, Johri A, Bedard E, Therrien J, Hayami D, Kells C, Ducas RA. The Impact of the COVID-19 Pandemic Restrictions on the Provision of Adult Congenital Heart Disease Care Across Canada: A National Survey. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:247-252. [PMID: 37970218 PMCID: PMC10642110 DOI: 10.1016/j.cjcpc.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/05/2023] [Indexed: 11/17/2023]
Abstract
Background The COVID-19 pandemic significantly impacted health care access across Canada with the reduction in in-person evaluations. The aim of the study was to examine the effects of the COVID-19 pandemic on access to health care services among the Canadian population with adult congenital heart disease (ACHD). Methods All Canadian adult congenital heart affiliated centres were contacted and asked to collect data on outpatient clinic and procedural volumes for the 2019 and 2020 calendar years. A survey was sent detailing questions on clinic and procedural volumes and wait times before and after pandemic restrictions. Descriptive statistics were used with the Student t-test to compare groups. Results In 2019, there were 19,326 ACHD clinic visits across Canada and only 296 (1.5%) virtual clinic visits. However, during the first year of the pandemic, there were 20,532 clinic visits and 11,412 (56%) virtual visits (P < 0.0001). There were no differences in procedural volumes (electrophysiology, cardiac surgery, and percutaneous intervention) between 2019 and 2020. The mean estimated wait times (months) before the pandemic vs the pandemic were as follows: nonurgent consult 5.4 ± 2.6 vs 6.6 ± 4.2 (P = 0.65), ACHD surgery 6.0 ± 3.5 vs 7.0 ± 4.6 (P = 0.47), electrophysiology procedures 6.3 ± 3.3 vs 5.7 ± 3.3 (P = 0.72), and percutaneous intervention 4.6 ± 3.9 vs 4.4 ± 2.3 (P = 0.74). Conclusions During the pandemic and restrictions of social distancing, the use of virtual clinic visits helped to maintain continuity in ACHD clinical care, with 56% of ACHD visits being virtual. The procedural volumes and wait times for consultation and percutaneous and surgical interventions were not delayed.
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Affiliation(s)
| | - Luc Beauchesne
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease (MAUDE unit), Montreal, Québec, Canada
| | - Candice Silversides
- University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, University of Toronto, Toronto, Ontario, Canada
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | | | | | - Rafael Alonso-Gonzalez
- University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, University of Toronto, Toronto, Ontario, Canada
| | | | - Jasmine Grewal
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Anne Williams
- Memorial University, St. John’s, Newfoundland, Canada
| | - Payam Dehghani
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Samuel Siu
- Western University, London, Ontario, Canada
| | - Amer Johri
- Queen’s University, Kingston, Ontario, Canada
| | - Elisabeth Bedard
- Quebec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Judith Therrien
- McGill Adult Unit for Congenital Heart Disease (MAUDE unit), Montreal, Québec, Canada
| | - Doug Hayami
- Dalhousie University, Halifax, Nova Scotia, Canada
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4
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Daniels CJ. The development of adult congenital heart disease care in the United States. Curr Probl Pediatr Adolesc Health Care 2023:101400. [PMID: 37349150 DOI: 10.1016/j.cppeds.2023.101400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Affiliation(s)
- Curt J Daniels
- Professor Internal Medicine and Pediatrics, USA; Dottie Dohan Hepard Professsor Cardiovascular Medicine, USA; COACH Program: olumbus Ohio Adult Congenital Heart Program, USA; Heart Disease Program, USA; Schooler Family Adult Congenital Heart Disease Fellowship Program, USA; The Ohio State University Medical Center, USA; Nationwide Children's Hospital, Columbus, Ohio, USA.
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5
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Bassareo PP, Mcmahon CJ, Prendiville T, James A, Roberts P, Oslizlok P, Walsh MA, Kenny D, Walsh KP. Planning Transition of Care for Adolescents Affected by Congenital Heart Disease: The Irish National Pathway. Pediatr Cardiol 2023; 44:24-33. [PMID: 35737012 DOI: 10.1007/s00246-022-02955-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/08/2022] [Indexed: 01/24/2023]
Abstract
At some point in their life, adolescent patients with a congenital heart disease (CHD) transition from paediatric services to adult care facilities. The process is not without any risks, as it is often linked with a significantly progressive deterioration in adolescents' health and loss of follow-up. In fact, transition patients often encounter troubles in finding a care giver who is comfortable managing their condition, or in re-establishing trust with the new care provider. Planning the rules of transition is pivotal in preventing these risks. Unfortunately, the American and European guidelines on CHD provide just generic statements about transition. In a recently published worldwide inter-societies consensus document, a hybrid model of transition, which should be adapted for use in high- and low- resource settings, has been suggested. Currently, in literature there are a few models of transition for CHD patients, but they are by far local models and cannot be generalized to other regions or countries. This paper describes the Irish model for transition of care of CHD patients. Due to the peculiarity of the healthcare organization in the Republic of Ireland, which is centralized with one main referral centre for paediatric cardiology (in Dublin, with a few smaller satellite centres all around, according to the "hub and spoke" model) and one centre for adult with CHD (in Dublin), the model can be considered as a national one and the first to be released in the old continent.
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Affiliation(s)
- Pier Paolo Bassareo
- School of Medicine, University College of Dublin, Dublin, Republic of Ireland. .,Mater Misericordiae University Hospital, Eccles St, Inns Quay, Dublin 7, Dublin, D07 R2WY, Republic of Ireland. .,Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland.
| | - Colin Joseph Mcmahon
- School of Medicine, University College of Dublin, Dublin, Republic of Ireland.,Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland
| | - Terence Prendiville
- School of Medicine, University College of Dublin, Dublin, Republic of Ireland.,Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland
| | - Adam James
- Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland
| | - Phil Roberts
- Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland
| | - Paul Oslizlok
- Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland
| | - Mark Anthony Walsh
- School of Medicine, University College of Dublin, Dublin, Republic of Ireland.,Mater Misericordiae University Hospital, Eccles St, Inns Quay, Dublin 7, Dublin, D07 R2WY, Republic of Ireland.,Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland
| | - Damien Kenny
- Mater Misericordiae University Hospital, Eccles St, Inns Quay, Dublin 7, Dublin, D07 R2WY, Republic of Ireland.,Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland.,Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Kevin Patrick Walsh
- School of Medicine, University College of Dublin, Dublin, Republic of Ireland.,Mater Misericordiae University Hospital, Eccles St, Inns Quay, Dublin 7, Dublin, D07 R2WY, Republic of Ireland.,Children's Health Ireland (CHI) at Crumlin, Dublin, Republic of Ireland
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Ohuchi H, Kawata M, Uemura H, Akagi T, Yao A, Senzaki H, Kasahara S, Ichikawa H, Motoki H, Syoda M, Sugiyama H, Tsutsui H, Inai K, Suzuki T, Sakamoto K, Tatebe S, Ishizu T, Shiina Y, Tateno S, Miyazaki A, Toh N, Sakamoto I, Izumi C, Mizuno Y, Kato A, Sagawa K, Ochiai R, Ichida F, Kimura T, Matsuda H, Niwa K. JCS 2022 Guideline on Management and Re-Interventional Therapy in Patients With Congenital Heart Disease Long-Term After Initial Repair. Circ J 2022; 86:1591-1690. [DOI: 10.1253/circj.cj-22-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Masaaki Kawata
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi
| | - Hideki Uemura
- Congenital Heart Disease Center, Nara Medical University
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Atsushi Yao
- Division for Health Service Promotion, University of Tokyo
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Morio Syoda
- Department of Cardiology, Tokyo Women’s Medical University
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University
| | | | - Syunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomoko Ishizu
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yumi Shiina
- Cardiovascular Center, St. Luke’s International Hospital
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital
| | - Aya Miyazaki
- Division of Congenital Heart Disease, Department of Transition Medicine, Shizuoka General Hospital
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiko Mizuno
- Faculty of Nursing, Tokyo University of Information Sciences
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital
| | - Ryota Ochiai
- Department of Adult Nursing, Yokohama City University
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Koichiro Niwa
- Department of Cardiology, St. Luke’s International Hospital
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Effect of post-ICU follow-up by a rapid response team after congenital heart surgery. Sci Rep 2022; 12:5633. [PMID: 35379889 PMCID: PMC8980095 DOI: 10.1038/s41598-022-09683-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
Patients with congenital heart disease who have a variety of cardiac/extracardiac problems are at high risk for deterioration. This study aimed to determine the effectiveness of post-intensive care unit (ICU) follow-up by a rapid response team (RRT) after congenital heart surgery. This before-and-after study was conducted at an urban regional tertiary hospital. We enrolled 572 consecutive patients who underwent congenital heart surgery and were transferred alive from the paediatric ICU (PICU) between April 2015 and March 2020. Post-ICU follow-up for 48 h was started in April 2018. The primary and secondary endpoints were unplanned ICU readmission and clinical outcomes at ICU readmission, respectively. Overall, 346 and 226 patients were analysed pre- and post-intervention, respectively. Patient demographics were similar between groups, but in the post-intervention group, patients tended to have had more complicated surgery. Unplanned ICU readmission rates within 30 days were similar between groups. Regarding the demographics and outcomes at ICU readmission, patients in the post-intervention group had lower predicted mortality rates (1.7% vs 5.3%, P = 0.001), required less ventilator days (median, 0.5 days [interquartile range (IQR) 0–1] vs median, 3 days [IQR 0.5–4], P = 0.02), and had a shorter ICU stay (median, 3 days [IQR 2–4] vs median, 6 days [IQR 3–9], P = 0.03), but there was no significant between-group difference in ICU mortality. Post-ICU follow-up by a RRT after congenital heart surgery did not decrease unplanned ICU readmission but improved several outcomes at ICU readmission.
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Skogby S, Bratt EL, Johansson B, Moons P, Goossens E. Discontinuation of follow-up care for young people with complex chronic conditions: conceptual definitions and operational components. BMC Health Serv Res 2021; 21:1343. [PMID: 34911550 PMCID: PMC8672472 DOI: 10.1186/s12913-021-07335-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 11/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background A substantial proportion of young people with Complex Chronic Conditions (CCCs) experience some degree of discontinuation of follow-up care, which is an umbrella term to describe a broken chain of follow-up. Discontinuation of follow-up care is not clearly defined, and the great plethora of terms used within this field cannot go unnoticed. Terms such as “lost to follow-up”, “lapses in care” and “care gaps”, are frequently used in published literature, but differences between terms are unclear. Lack of uniformity greatly affects comparability of study findings. The aims of the present study were to (i) provide a systematic overview of terms and definitions used in literature describing discontinuation of follow-up care in young people with CCC’s; (ii) to clarify operational components of discontinuation of follow-up care (iii); to develop conceptual definitions and suggested terms to be used; and (iv) to perform an expert-based evaluation of terms and conceptual definitions. Methods A systematic literature search performed in PubMed was used to provide an overview of current terms used in literature. Using a modified summative content analysis, operational components were analysed, and conceptual definitions were developed. These conceptual definitions were assessed by an expert panel using a survey. Results In total, 47 terms and definitions were retrieved, and a core set of operational components was identified. Three main types of discontinuation of follow-up care emerged from the analysis and expert evaluation, conceptually defined as follows: Lost to follow-up care: “No visit within a defined time period and within a defined context, and the patient is currently no longer engaged in follow-up care”;Gap in follow-up care: “Exceeded time interval between clinic visits within a defined context, and the patient is currently engaged in follow-up care”; andUntraceability: “Failure to make contact due to lack of contact information”. Conclusion By creating a common vocabulary for discontinuation of follow-up care, the quality of future studies could improve. The conceptual definitions and operational components provide guidance to both researchers and healthcare professionals focusing on discontinuation of follow-up care for young people with CCCs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07335-x.
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Affiliation(s)
- Sandra Skogby
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden. .,Department of Paediatric Cardiology, Queen Silvia Children's Hospital, Gothenburg, Sweden. .,KU Leuven Department of Public Health and Primary Care, Leuven, Belgium.
| | - Ewa-Lena Bratt
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Department of Paediatric Cardiology, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Bengt Johansson
- Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Philip Moons
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,KU Leuven Department of Public Health and Primary Care, Leuven, Belgium.,Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Eva Goossens
- KU Leuven Department of Public Health and Primary Care, Leuven, Belgium.,Research Foundation Flanders, Brussels, Belgium.,Center for Research and Innovation in Care, Faculty of Nursing, University of Antwerp, Antwerp, Belgium.,Department of Patient Care Services, Antwerp University Hospital, Antwerp, Belgium
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9
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Skogby S, Goossens E, Johansson B, Moons P, Bratt EL. Qualitative study of facilitators and barriers for continued follow-up care as perceived and experienced by young people with congenital heart disease in Sweden. BMJ Open 2021; 11:e049556. [PMID: 34706951 PMCID: PMC8552172 DOI: 10.1136/bmjopen-2021-049556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
UNLABELLED In-depth understanding of factors perceived by young people with congenital heart disease (CHD) to affect continued follow-up care is needed to tailor preventive strategies for discontinuation of follow-up care. To identify facilitating factors, low-prevalence settings in terms of discontinuation should be investigated. OBJECTIVE This qualitative study describes factors affecting continued follow-up as perceived and experienced by young adults with CHD. PARTICIPANTS Using a mixed purposive sampling technique, 16 young adults with CHD were included. Three participants had discontinued follow-up care and 13 had continued follow-up care after transfer. SETTING Participants were recruited from all seven university hospitals in Sweden, which is considered a low-prevalence setting in terms of discontinuation. DESIGN Individual interviews were performed and subjected to qualitative content analysis. RESULTS The analysis resulted in three main categories, illuminating factors affecting continued follow-up: (1) motivation for follow-up care; (2) participation in care and sense of connectedness with healthcare provider (HCP) and (3) care accessibility. The choice of continuing follow-up or not was multifactorial. Knowledge of your CHD and the importance of continuing follow-up care was a central factor, as well as experiencing CHD-related symptoms and having ongoing or planned medical treatment or interventions. Sensing a clear purpose with follow-up care was facilitating, as was feeling well treated and cared for by HCPs. Practical aspects, such as travel distance was also stressed, as well as active invitations and reminders for visits. CONCLUSION Factors on both patient, hospital and healthcare system level were raised by participants, stressing the importance of holistic approaches when developing preventive strategies for discontinuation. There is a need for improved skills and competencies among HCPs, as well as a person-centred approach to follow-up care. In addition, specific healthcare needs and remaining transitional needs after transfer to adult care require careful consideration to prevent discontinuation.
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Affiliation(s)
- Sandra Skogby
- University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden
- KU Leuven Department of Public Health and Primary Care, Leuven, Flanders, Belgium
| | - Eva Goossens
- KU Leuven Department of Public Health and Primary Care, Leuven, Flanders, Belgium
- Center for Research and Innovation in Care, Faculty of Nursing, University of Antwerp, Antwerp, Belgium
| | - Bengt Johansson
- Heart Centre and Department of Surgery and Perioperative Sciences, Umeå University, Umea, Sweden
| | - Philip Moons
- University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden
- KU Leuven Department of Public Health and Primary Care, Leuven, Flanders, Belgium
| | - Ewa-Lena Bratt
- University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden
- Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Gothenburg, Sweden
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10
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Goossens E, van Deyk K, Budts W, Moons P. Are missed appointments in an outpatient clinic for adults with congenital heart disease the harbinger for care gaps? Eur J Cardiovasc Nurs 2021; 21:127-134. [PMID: 34235534 DOI: 10.1093/eurjcn/zvab012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/26/2021] [Accepted: 02/11/2021] [Indexed: 01/10/2023]
Abstract
AIMS Life-long follow-up is vital for patients with congenital heart disease (CHD) to safeguard longevity. Missing scheduled appointments might be prodromal to subsequent care gaps, but our understanding of their occurrence and impact is limited. This study determined the occurrence and predictors of missed appointments (MA), assess its predictive value for care gaps, and explored if MA or care gaps are associated with increased mortality. METHODS AND RESULTS From 2007 to 2009, the occurrence of MA in 2075 CHD patients was documented at an adult CHD clinic. The frequency of outpatient visits in 1363 adults with moderate to complex CHD was calculated from 2009 to 2012. Patients without a visit were considered to have a care gap. Data on mortality were collected from 2013 to 2017. Missed appointments occurred in 11% of patients and were more common in men [odds ratio (OR) = 1.57; 95% confidence interval (CI): 1.18-2.08], without a history of cardiac procedures (OR = 1.46; 95% CI: 1.08-1.97), and for morning visits (OR = 1.45; 95% CI: 1.10-1.92). Care gaps were identified in 6% of moderate to complex CHD. A MA was significantly associated with an increased likelihood of care gaps (OR = 19.55; 95% CI: 11.92-32.07; R2 = 26.5%). In moderate to complex CHD, no difference in mortality rates was related to the occurrence of discontinued care. CONCLUSION The occurrence of MA was related to patients' gender, no history of cardiac interventions, and time of day of the outpatient visits. Care gaps were associated by the preceding MA. No association with increased mortality rates was observed. Interventions reducing missed appointments, such as SMS-reminders prior to visits, need investigation.
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Affiliation(s)
- Eva Goossens
- Faculty of Medicine and Health Sciences, Division of Nursing and Midwifery, Centre for Research and Innovation in Care, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium.,KU Leuven Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Research Foundation Flanders, Brussels, Belgium.,Department of Patient Care, Antwerp University Hospital, Antwerp, Belgium
| | - Kristien van Deyk
- Department of Cardiovascular Sciences, Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, KU, Belgium
| | - Werner Budts
- Department of Cardiovascular Sciences, Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, KU, Belgium
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
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11
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Patient-Reported Outcomes in Adults With Congenital Heart Disease Following Hospitalization (from APPROACH-IS). Am J Cardiol 2021; 145:135-142. [PMID: 33460605 DOI: 10.1016/j.amjcard.2020.12.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/14/2020] [Accepted: 12/29/2020] [Indexed: 01/07/2023]
Abstract
In this international study, we (1) compared patient-reported outcomes (PROs) in adults with congenital heart disease (CHD) who had versus had not been hospitalized during the previous 12 month, (2) contrasted PROs in patients who had been hospitalized for cardiac surgery versus nonsurgical reasons, (3) assessed the magnitude of differences between the groups (i.e., effect sizes), and (4) explored differential effect sizes between countries. APPROACH-IS was a cross-sectional, observational study that enrolled 4,028 patients from 15 countries (median age 32 years; 53% females). Self-report questionnaires were administered to measure PROs: health status; anxiety and depression; and quality of life. Overall, 668 patients (17%) had been hospitalized in the previous 12 months. These patients reported poorer outcomes on all PROs, with the exception of anxiety. Patients who underwent cardiac surgery demonstrated a better quality of life compared with those who were hospitalized for nonsurgical reasons. For significant differences, the effect sizes were small, whereas they were negligible in nonsignificant comparisons. Substantial intercountry differences were observed. For various PROs, moderate to large effect sizes were found comparing different countries. In conclusion, adults with CHD who had undergone hospitalization in the previous year had poorer PROs than those who were medically stable. Researchers ought to account for the timing of recruitment when conducting PRO research as hospitalization can impact results.
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12
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Characteristics of Patients With Congenital Heart Disease Requiring ICU Admission From Japanese Emergency Departments. Pediatr Crit Care Med 2020; 21:e1106-e1112. [PMID: 32769701 DOI: 10.1097/pcc.0000000000002440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the characteristics of patients with congenital heart disease requiring ICU admission from emergency departments and determine the associations between the reasons for emergency department visits and specific congenital heart disease types or cardiac procedures. DESIGN Retrospective observational study using data from a Japanese multicenter database. SETTING Twelve PICUs and 11 general ICUs in Japan. PATIENTS All patients requiring ICU admission from an emergency department during 2013-2018, divided into two groups: with congenital heart disease and without congenital heart disease groups. INTERVENTIONS None for this analysis. MEASUREMENTS AND MAIN RESULTS Of the 297 patients with congenital heart disease (9.2% of a total of 3,240 patients), more than half had moderate-to-high complexity congenital heart disease; most of them were pediatric patients who had visited specialized congenital heart disease centers. All the patients' clinical outcomes were similar. Regarding the reasons for emergency department admission, seizure was significantly associated with a single ventricle anatomy (odds ratio, 3.3; 95% CI, 1.1-10.0), post-Glenn shunt placement (odds ratio, 5.6; 95% CI, 1.1-29.4), and a Fontan-type operation status (odds ratio, 6.3; 95% CI, 1.5-25.5). Sepsis and gastrointestinal bleeding were associated with asplenia (odds ratio, 21.1; 95% CI, 4.3-104 and odds ratio, 21.0; 95% CI, 3.1-141, respectively); gastrointestinal bleeding was also associated with systemic-to-pulmonary artery shunt placement (odds ratio, 18.8; 95% CI, 2.8-125) and a Fontan-type operation status (odds ratio, 17.0; 95% CI, 2.6-112). Arrhythmia was associated with a single ventricle anatomy (odds ratio, 21.0; 95% CI, 3.1-141), systemic-to-pulmonary artery shunt placement (odds ratio, 18.8; 95% CI, 2.8-125), and a Fontan-type operation status (odds ratio, 17.0; 95% CI, 2.6-112). CONCLUSIONS Classification of the reasons for emergency department admission by congenital heart disease type and surgical stage may guide clinicians in the selection of appropriate treatments in such settings.
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13
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Nitta M, Ochiai R, Nakano S, Nakashima R, Matsumoto K, Sugano T, Ishigami T, Ishikawa T, Tamura K, Nakano Y, Watanabe S, Hokosaki T, Machida D, Masuda M, Kimura K. Characteristics of patients with adult congenital heart disease treated by non-specialized doctors: The potential loss of follow-up. J Cardiol 2020; 77:17-22. [PMID: 33317801 DOI: 10.1016/j.jjcc.2020.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/22/2020] [Accepted: 06/08/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND In the treatment of adult congenital heart disease (ACHD), the transfer of patients from pediatric cardiologists to ACHD cardiologists is of relevance. However, little is known about the clinical courses of ACHD patients that have been referred by non-CHD-specialized doctors (n-CSDs). METHODS This retrospective cohort study included 230 patients (average age: 37 ± 15.2 years, male: 97) who were referred to a single specialized ACHD center between April 2016 and July 2019. We compared the characteristics and clinical courses between patients referred by n-CSDs and those referred by CHD-specialized-doctors (CSDs). RESULTS Overall, 121 (53%) patients were referred by n-CSDs. Among them, 91 (75%) patients were referred by adult cardiologists. Univariate analysis showed that the patients referred by n-CSDs were older than those referred by CSDs (41.6 ± 16.3 vs. 32.0 ± 12.0 years, p < 0.01), were more likely to have simple CHD, and less likely to have severe CHD (27.0% vs. 12.8% and 16.5% vs. 40.4%, respectively, p < 0.01). Patients referred by n-CSDs were also more likely to have a history of loss of follow-up (16.5% vs. 3.7%, p < 0.01) and to require invasive treatments after referral, including cardiac surgeries and transcatheter interventions (47.9% vs. 26.6 %, p < 0.01). Notably, unintended invasive treatments that were not designated by the referring doctors were more frequently required in patients with moderate complexity referred by n-CSDs (50.0% vs. 23.3%, p = 0.02). CONCLUSIONS Patients with moderate CHD complexity referred by n-CSDs are more likely to require unintended invasive treatments. Referrals to specialized ACHD centers may be most beneficial for these patients.
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Affiliation(s)
- Manabu Nitta
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Ryota Ochiai
- Cancer/Advanced Adult Nursing, Department of Nursing, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Rie Nakashima
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Katsumi Matsumoto
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Teruyasu Sugano
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tomoaki Ishigami
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yusuke Nakano
- Department of Pediatric Cardiology, Yokohama City University Hospital, Yokohama, Japan
| | - Shigeo Watanabe
- Department of Pediatric Cardiology, Yokohama City University Hospital, Yokohama, Japan
| | - Tatsunori Hokosaki
- Department of Pediatric Cardiology, Yokohama City University Hospital, Yokohama, Japan
| | - Daisuke Machida
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kazuo Kimura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Oliver Ruiz JM, Dos Subirá L, González García A, Rueda Soriano J, Ávila Alonso P, Gallego P. Cardiopatías congénitas del adulto en España: estructura, actividad y características clínicas. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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15
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Fernandes SM, Marelli A, Hile DM, Daniels CJ. Access and Delivery of Adult Congenital Heart Disease Care in the United States. Cardiol Clin 2020; 38:295-304. [DOI: 10.1016/j.ccl.2020.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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16
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Oliver Ruiz JM, Dos Subirá L, González García A, Rueda Soriano J, Ávila Alonso P, Gallego P. Adult congenital heart disease in Spain: health care structure and activity, and clinical characteristics. ACTA ACUST UNITED AC 2020; 73:804-811. [PMID: 32249097 DOI: 10.1016/j.rec.2019.09.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/12/2019] [Indexed: 01/27/2023]
Abstract
INTRODUCTION AND OBJECTIVES To assess the structure of health care delivery and the clinical characteristics of adults with congenital heart disease (ACHD) attending specialized centers in Spain. METHODS A survey was conducted among 32 Spanish centers in 2014. The centers were classified into 2 levels based on their resources. In 2017, a clinical dataset was collected of all consecutive patients attended for a 2-month period at these centers. RESULTS A total of 31 centers (97%) completed the survey. Seven centers without specialized ACHD clinics were excluded from the analysis. In 2005, only 5 centers met the requirements for specific care. In 2014, there were 10 level 1 and 14 level 2 centers, with a total of 19 373 patients under follow-up. Health care structure was complete in most centers but only 33% had ACHD nurse specialists on staff and 29% had structured transition programs. Therapeutic procedures accounted for 99% and 91% of those reported by National Registries of Cardiac Surgery and Cardiac Catheterization, respectively. Among attended patients, 48% had moderately complex lesions and 24% had highly complex lesions. Although 46% of patients attending level 2 centers had simple lesions, 17% had complex lesions. CONCLUSIONS The structure for ACHD health care delivery in Spain complies with international recommendations and is similar to that of other developed countries. Congenital heart diseases under specialized care consist mostly of moderately and highly complex lesions, even in level 2 centers. It would be desirable to reorganize patient follow-up according to international recommendations in clinical practice.
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Affiliation(s)
- José María Oliver Ruiz
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain.
| | - Laura Dos Subirá
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, CIBERCV, Barcelona, Spain
| | - Ana González García
- Servicio de Cardiología, Hospital Universitario La Paz y CIBERCV, Madrid, Spain
| | - Joaquín Rueda Soriano
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, CIBERCV, Valencia, Spain
| | - Pablo Ávila Alonso
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain
| | - Pastora Gallego
- Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Instituto BioMedicina (IBIS), CIBERCV, Sevilla, Spain
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Mondal TK, Muddaluru V, Jaafar A, Gupta-Bhatnagar S, Greville LJ, Gorter JW. Transition of adolescents with congenital heart disease from pediatric to adult congenital cardiac care: lessons from a retrospective cohort study. JOURNAL OF TRANSITION MEDICINE 2020. [DOI: 10.1515/jtm-2019-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractBackgroundThe transfer from pediatric to adult care is a key milestone for adolescents living with chronic health conditions. Over the past few decades, pediatric cardiac care has witnessed outstanding advancements leading to a dramatic increase in the number of children with congenital heart disease (CHD) surviving into adulthood. Successful transfer from pediatric to adult congenital cardiac care is critical because many adults with CHD require regular long-term cardiac care for optimal health outcomes.ObjectivesThis study aims to (1) determine the rate of successful transfer of adolescents with CHD from pediatric to adult congenital cardiac care at the McMaster University Medical Centre (MUMC), a tertiary care level centre, and (2) to explore available patient- and context-related factors associated with unsuccessful transfer. MUMC includes both the McMaster Children’s Hospital, which offers Pediatric Cardiology services, and Adult Outpatient Services, which offers the Adult Congenital Cardiac Clinic (ACCC).MethodsThis is a retrospective cohort study in which all patients eligible for transfer from pediatric to adult congenital cardiac care from January 2006 to December 2012 were identified from the McMaster Children’s Hospital database. Successful transfer was defined as attendance at the ACCC within 2 years of discharge from Pediatric Cardiology. Patient and context-related variables include gender, severity of the CHD diagnosis, years since pediatric follow-up, and distance from the patient’s home to MUMC. The relationship between patient- and context-related variables available at baseline and unsuccessful transfer was assessed by univariate analysis.ResultsA total of 279 patients were identified, of which, 269 patients (96.4%) were successfully transferred to adult congenital cardiac care. Out of the 10 patients (3.6%) who were lost to follow-up, 8 had mild, 1 had moderate, and 1 had severe CHD. Based on the point estimates expressed as odds ratio (OR), factors that are potentially associated with a higher risk for loss to follow-up were: male gender (OR 1.8, 95% CI 0.5–7.3) and travel distance greater than 200 km to MUMC (OR 7.7, 95% CI 0.7–81.5), while moderate and severe CHD could potentially be a protective factor against loss to follow up when compared to mild CHD (OR 0.2, 95% CI 0–1.1).DiscussionThe medical and administrative practices that may be contributing to the high transfer rate of 96.4% include early and developmentally appropriate discussions, engaging patients and their families in cardiac care, proximity of the pediatric and adult congenital cardiac clinics, and an information pamphlet regarding the transition process, amongst others. Learning from our retrospective study we now work with the patients identified as potential high risk for loss to follow-up to understand and eliminate barriers and to implement sustainable methods that will ensure a successful transition to adult health care for all patients with CHD.
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Affiliation(s)
- Tapas K. Mondal
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Varun Muddaluru
- Graduate Entry Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ahmad Jaafar
- Department of Pediatrics, McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | | | | | - Jan Willem Gorter
- Department of Pediatrics, McMaster Children’s Hospital, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
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Skogby S, Moons P, Johansson B, Sunnegårdh J, Christersson C, Nagy E, Winberg P, Hanséus K, Trzebiatowska-Krzynska A, Fadl S, Fernlund E, Kazamia K, Rydberg A, Zühlke L, Goossens E, Bratt EL. Outpatient volumes and medical staffing resources as predictors for continuity of follow-up care during transfer of adolescents with congenital heart disease. Int J Cardiol 2020; 310:51-57. [PMID: 31959410 DOI: 10.1016/j.ijcard.2020.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/06/2019] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Providing continuous follow-up care to patients with congenital heart disease (CHD) remains a challenge in many settings. Previous studies highlight that patients with CHD experience discontinuation of follow-up care, but mainly describe a single-centre perspective, neglecting inter-institutional variations. Hospital-related factors above and beyond patient-related factors are believed to affect continuity of care. The present multicentre study therefore investigated (i) proportion of "no follow-up care"; (ii) transfer destinations after leaving paediatric cardiology; (iii) variation in proportions of no follow-up between centres; (iv) the association between no follow-up and outpatient volumes, and (v) its relationship with staffing resources at outpatient clinics. METHODS An observational, multicentre study was conducted in seven university hospitals. In total, 654 adolescents with CHD, born between 1991 and 1993, with paediatric outpatient visit at age 14-18 years were included. Transfer status was determined 5 years after the intended transfer to adult care (23y), based on medical files, self-reports and registries. RESULTS Overall, 89.7% of patients were receiving adult follow-up care after transfer; 6.6% had no follow-up; and 3.7% were untraceable. Among patients in follow-up care, only one remained in paediatric care and the majority received specialist adult CHD care. Significant variability in proportions of no follow-up were identified across centres. Higher outpatient volumes at paediatric outpatient clinics were associated with better continued follow-up care after transfer (OR = 1.061; 95% CI = 1.001 - 1.124). Medical staffing resources were not found predictive. CONCLUSION Our findings support the theory of hospital-related factors influencing continuity of care, above and beyond patient-related characteristics.
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Affiliation(s)
- Sandra Skogby
- Institute of Health and Care Sciences, University of Gothenburg, Arvid Wallgrens Backe, Box 457, 405 30 Gothenburg, Sweden; Department of Paediatric Cardiology, Queen Silvia's Children's Hospital, Rondvägen 10, 416 50 Gothenburg, Sweden; KU Leuven Department of Public Health and Primary Care, Kapucijnenvoer 35, PB 7001, 3000 Leuven, Belgium
| | - Philip Moons
- Institute of Health and Care Sciences, University of Gothenburg, Arvid Wallgrens Backe, Box 457, 405 30 Gothenburg, Sweden; KU Leuven Department of Public Health and Primary Care, Kapucijnenvoer 35, PB 7001, 3000 Leuven, Belgium; Department of Paediatrics and Child Health, University of Cape Town, Klipfrontein Road Mowbray, Cape Town 7700, South Africa
| | - Bengt Johansson
- Department of Public Health and Clinical Medicine, Umeå University, 90185 Umeå, Sweden
| | - Jan Sunnegårdh
- Department of Paediatric Cardiology, Queen Silvia's Children's Hospital, Rondvägen 10, 416 50 Gothenburg, Sweden
| | - Christina Christersson
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 753 09 Uppsala, Sweden
| | - Edit Nagy
- Heart and Vascular Theme, Congenital Heart Disease Group, Karolinska University Hospital, Stockholm, 171 76 Solna, Sweden
| | - Per Winberg
- Department of Paediatric Cardiology, Karolinska University Hospital, Eugeniavägen 23 C8:34, 17176 Stockholm, Sweden
| | - Katarina Hanséus
- Department of Paediatric Cardiology, Skåne University Hospital, Barnhjärtcentrum avd 67, 221 85 Lund, Sweden
| | - Aleksandra Trzebiatowska-Krzynska
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Sjukhusvägen, 581 85 Linköping, Sweden; Department of Cardiology, Department of Medical and Health Sciences, Linköping University, Sjukhusvägen, 58185 Linköping, Sweden
| | - Shalan Fadl
- Department of Paediatric and Women's Health Care, Örebro University Hospital, 701 85 Örebro, Sweden
| | - Eva Fernlund
- Department of Clinical and Experimental Medicine, Division of Paediatrics, Crown Princess Victoria Children's Hospital, Linköping University, 581 85 Linköping, Sweden; Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Department of Paediatric Cardiology, 221 85 Lund, Sweden
| | - Kalliopi Kazamia
- Department of Paediatric Cardiology, Uppsala University, Sjukhusvägen 85, 75185 Uppsala, Sweden
| | - Annika Rydberg
- Department of Clinical Sciences, Unit of Paediatrics, Umeå University, Umeå University Hospital, 90185 Umeå, Sweden
| | - Liesl Zühlke
- Division of Paediatric Cardiology, Department of Paediatric and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Klipfrontein Road Mowbray, Cape Town 7700, South Africa; Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Anzio Road Mowbray, Cape Town 7700, South Africa
| | - Eva Goossens
- KU Leuven Department of Public Health and Primary Care, Kapucijnenvoer 35, PB 7001, 3000 Leuven, Belgium; Research Foundation Flanders (FWO), Egmontstraat 5, 1030 Brussels, Belgium
| | - Ewa-Lena Bratt
- Institute of Health and Care Sciences, University of Gothenburg, Arvid Wallgrens Backe, Box 457, 405 30 Gothenburg, Sweden; Department of Paediatric Cardiology, Queen Silvia's Children's Hospital, Rondvägen 10, 416 50 Gothenburg, Sweden.
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Empowering Young Persons with Congenital Heart Disease: Using Intervention Mapping to Develop a Transition Program - The STEPSTONES Project. J Pediatr Nurs 2020; 50:e8-e17. [PMID: 31669495 DOI: 10.1016/j.pedn.2019.09.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE Describe the implementation of intervention mapping in the development of a transition program that aims to empower adolescents with congenital heart disease. DESIGN AND METHODS To gain a better understanding of the problem, we conducted a literature review, focus group and individual interviews, and a cross-sectional survey. This information helped us decide on the scope of the intervention, relevant theories, determinants, formulate performance and change objectives and identify adequate evidence-based change methods. Once the transition program had been designed, effectiveness and process evaluation studies were planned. RESULTS Young persons with congenital heart disease have insufficient disease-related knowledge, self-management skills and high parental involvement. The transition program involves three meetings with a trained transition coordinator over a two-and-a-half-year period and targets young persons with congenital heart disease and their parents. The transition coordinators use change techniques such as goal-setting, modeling and active learning in order to target three personal determinants (knowledge, self-efficacy and self-management). CONCLUSIONS The use of intervention mapping may lead to designing interventions tailored to the needs of the targeted population. The transition program described in this paper is currently being evaluated in a hybrid experimental design with simultaneous undertaking of the process evaluation. PRACTICE IMPLICATIONS This transition program can lead to the empowerment of young persons with congenital heart disease and help them in the process of becoming more responsible for their care. If proven effective, it can be implemented for other chronic conditions.
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Mizuno A, Niwa K, Ochiai R, Shiraishi I, Sumita Y, Daida H, Fukuda T, Miyamoto Y, Nishimura K, Ogawa H, Yasuda S. Impact of facilities accredited by both adult and pediatric cardiology societies on the outcome of patients with adult congenital heart disease. J Cardiol 2020; 75:105-109. [DOI: 10.1016/j.jjcc.2019.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/16/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022]
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Thomet C, Moons P, Budts W, De Backer J, Chessa M, Diller G, Eicken A, Gabriel H, Gallego P, Giamberti A, Roos-Hesselink J, Swan L, Webb G, Schwerzmann M. Staffing, activities, and infrastructure in 96 specialised adult congenital heart disease clinics in Europe. Int J Cardiol 2019; 292:100-105. [DOI: 10.1016/j.ijcard.2019.04.077] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/06/2019] [Accepted: 04/25/2019] [Indexed: 11/26/2022]
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Real-world healthcare utilization in adult congenital heart disease: a systematic review of trends and ratios. Cardiol Young 2019; 29:553-563. [PMID: 31046858 DOI: 10.1017/s1047951119000441] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND As a result of medical advances, the adult congenital heart disease population is rapidly expanding. Nonetheless, most patients remain prone to increased morbidity and mortality. Therefore, long-term medical resource use is required. This systematic review aims to present the trends over the past decades of medical resource utilization in adult congenital heart disease as well as its current status, with a focus on hospitalizations, emergency department visits, outpatient cardiology visits, and visits to other healthcare professionals. METHODS MEDLINE (Pubmed), Embase, and Web of Science were searched for retrospective database research publications. The ISPOR checklist for retrospective database research was used for quality appraisal. Trends over time are explored. RESULTS Twenty-one articles met the inclusion criteria. All but one of the studies was conducted in Western Europe and North America. The absolute number of hospitalizations has been increasing over the last several decades. This increase is highest in patients with mild lesions, although these numbers are largely driven by hospitalizations of patients with an atrial septal defect or a patent foramen ovale. Meanwhile, outpatient cardiology visits are increasing at an even higher pace, and occur most often in geriatric patients and patients with severe lesions. Conversely, the number of hospitalizations per 100 patients is decreasing over time. Literature is scarce on other types of healthcare use. CONCLUSION A strong rise in healthcare utilization is noticed, despite the mitigating effect of improved efficiency levels. As the population continues to grow, innovative medical management strategies will be required to accommodate its increasing healthcare utilization.
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Ochiai R, Kato H, Misaki Y, Kaneko M, Ikeda Y, Niwa K, Shiraishi I. Preferences Regarding Transfer of Patients With Congenital Heart Disease Who Attend Children’s Hospital. Circ J 2019; 83:824-830. [DOI: 10.1253/circj.cj-18-1144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ryota Ochiai
- Department of Adult Nursing/Palliative Care Nursing, Graduate School of Medicine, The University of Tokyo
| | - Hitoshi Kato
- Division of Cardiology, National Center for Child Health and Development
| | - Yasushi Misaki
- Division of Cardiology, National Center for Child Health and Development
| | - Masahide Kaneko
- Division of Cardiology, National Center for Child Health and Development
| | | | - Koichiro Niwa
- Cardiovascular Center, St. Luke’s International Hospital
| | - Isao Shiraishi
- Department of Education and Research Promotion, Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
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Saur P, Haller C. Bedeutung des rechten Ventrikels bei Erwachsenen mit angeborenen Herzfehlern. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nursing Research and Quality Improvement Initiatives for Patients with Congenital Heart Disease. CONGENIT HEART DIS 2019. [DOI: 10.1007/978-3-319-78423-6_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Abstract
Congenital heart disease (CHD) is the most common birth defect, occurring in approximately 0.8% to 1.0% of neonates. Advances in medical and surgical therapies for children with CHD have resulted in a growing population of patients reaching adulthood, with survival rates exceeding 85%. Many of these patients, especially if managed inappropriately, face the prospect of future complications including heart failure and premature death. For adults with uncorrected or previously palliated CHD, percutaneous therapies have become the primary treatment for many forms of CHD. In this article, we discuss the role of transcatheter interventions in the treatment of adults with CHD.
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Affiliation(s)
- Hussam S Suradi
- Interventional Cardiology, Structural Heart & Valve Center, St. Mary Medical Center, 1500 South Lake Park Avenue, Suite 100, Hobart, IN 46342, USA; Department of Cardiology, Community Hospital, Munster, IN 46321, USA; Rush Center for Structural Heart Disease, Rush University Medical Center, Chicago, IL 60612, USA.
| | - Ziyad M Hijazi
- Sidra Cardiac Program, Department of Pediatrics, Sidra Medical & Research Center, Weill Cornell Medicine, PO Box 26999, Doha, Qatar
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Burström Å, Acuna Mora M, Öjmyr-Joelsson M, Sparud-Lundin C, Rydberg A, Hanseus K, Frenckner B, Nisell M, Moons P, Bratt EL. Parental uncertainty about transferring their adolescent with congenital heart disease to adult care. J Adv Nurs 2018; 75:380-387. [PMID: 30209810 PMCID: PMC7379976 DOI: 10.1111/jan.13852] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/05/2018] [Accepted: 08/17/2018] [Indexed: 11/27/2022]
Abstract
Aims To study parent's levels of uncertainty related to the transfer from pediatric to adult care in adolescents with congenital heart disease (CHD) and to identify potentially correlating factors. Background Parents acknowledge that during transition they struggle with finding ways of feeling secure in handing over the responsibility and letting go of control. Well‐prepared and informed parents who feel secure are most likely better skilled to support their adolescent and to hand over the responsibility. Design A cross‐sectional study. Methods Overall, 351 parents were included (35% response rate). Parental uncertainty was assessed using a Linear Analogue Scale (0–100). Data were collected between January ‐ August 2016. Potential correlates were assessed using the readiness for transition questionnaire and sociodemographic data. Results The mean parental uncertainty score was 42.5. Twenty‐four percent of the parents had a very low level of uncertainty (score 0–10) and 7% had a very high level (score 91–100). Overall, 26% of the mothers and 36% of the fathers indicated that they had not started thinking of the transfer yet. The level of uncertainty was negatively associated with the level of perceived overall readiness. Adolescents' age, sex, CHD complexity, and parental age were not related to uncertainty. Conclusion A wide range in the levels of uncertainty was found. Parents who were less involved in the care, or perceived their adolescent as readier for the transition, felt less uncertain. Still, thirty percent of the parents had not started to think about the transfer to adult care.
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Affiliation(s)
- Åsa Burström
- Institution for Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Cardiology, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Mariela Acuna Mora
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,KU Leuven Department of Public Health and Primary Care, Leuven, Belgium
| | - Maria Öjmyr-Joelsson
- Institution for Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Carina Sparud-Lundin
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Annika Rydberg
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Katarina Hanseus
- Department of Pediatric Cardiology, Skåne University Hospital, Lund, Sweden
| | - Björn Frenckner
- Institution for Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Margret Nisell
- Institution for Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,The Red Cross University College, Stockholm, Sweden
| | - Philip Moons
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,KU Leuven Department of Public Health and Primary Care, Leuven, Belgium
| | - Ewa-Lena Bratt
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Department of Pediatric Cardiology, The Queen Silvia Children's Hospital, Gothenburg, Sweden
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28
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Abstract
Purpose of the Review The purpose of this review is to illustrate specific challenges and opportunities in the building of an adult congenital heart disease (ACHD) program and to highlight critical components and important allies. Recent Findings With more than 1.4 million adults with congenital heart disease in the USA alone, access to specialized, compassionate, high-quality comprehensive care requires a shift toward more aggressive expansion of ACHD care, especially in the context of sparse ACHD provider representation in the vast majority of adult medical centers. Summary The effective build of an ACHD program requires measured escalation in management of ACHD complexity matched with cultivation of key resources and clinical services ranging from congenital cardiac surgery and interventional cardiology to acquired heart disease as well as partnerships with non-cardiac specialists. By reframing ACHD care as a shared goal between patients, providers, hospitals, pharmaceutical and device industry, and payers, a potent business model can be built around the developing ACHD program to facilitate acquisition of these key resources.
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Kratzert WB, Boyd EK, Schwarzenberger JC. Management of the Critically Ill Adult With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2017; 32:1682-1700. [PMID: 29500124 DOI: 10.1053/j.jvca.2017.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Indexed: 02/01/2023]
Abstract
Survival of adults with congenital heart disease (CHD) has improved significantly over the last 2 decades, leading to an increase in hospital and intensive care unit (ICU) admissions of these patients. Whereas most of the ICU admissions in the past were related to perioperative management, the incidence of medical emergencies from long-term sequelae of palliative or corrective surgical treatment of these patients is rising. Intensivists now are confronted with patients who not only have complex anatomy after congenital cardiac surgery, but also complex pathophysiology due to decades of living with abnormal cardiac anatomy and diseases of advanced age. Comorbidities affect all organ systems, including cognitive function, pulmonary and cardiovascular systems, liver, and kidneys. Critical care management requires an in-depth understanding of underlying anatomy and pathophysiology in order to apply contemporary concepts of adult ICU care to this population and optimize patient outcomes. In this review, the main CHD lesions and their common surgical management approaches are described, and the sequelae of CHD physiology are discussed. In addition, the effects of chronic comorbidities on the management of critically ill adults are explored, and the adjustments of current ICU management modalities and pharmacology to optimize care are discussed.
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Affiliation(s)
- Wolf B Kratzert
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA.
| | - Eva K Boyd
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA
| | - Johanna C Schwarzenberger
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA
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30
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Frankfurter C, Asgar AW, Webb JG, Cantor WJ, Velianou JL, Gobeil F, Chan AW, Welsh RC, Love MP, Wood DA, McKenzie K, Horlick EM. Adult Congenital Heart Disease Intervention: The Canadian Landscape. Can J Cardiol 2017; 33:1201-1205. [DOI: 10.1016/j.cjca.2017.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 05/23/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022] Open
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Acar P. How best to train doctors in adult congenital heart disease? Arch Cardiovasc Dis 2017; 110:277-280. [DOI: 10.1016/j.acvd.2016.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/03/2016] [Indexed: 12/01/2022]
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32
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Transitioning from pediatric to adult care after thoracic transplantation. J Heart Lung Transplant 2017; 36:823-829. [PMID: 28342709 DOI: 10.1016/j.healun.2017.02.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 01/24/2017] [Accepted: 02/24/2017] [Indexed: 11/23/2022] Open
Abstract
With improving outcomes after thoracic transplantation, more children are surviving to adulthood and requiring specialized adult care. A systematic and effective program is essential to transition these patients from a pediatric to adult health care setting. In this review, we discuss the concept of transition and the factors leading to an effective transfer to an adult care provider, including administrative support, patient/provider preparation, and the navigation of potential barriers. Notably, there is a paucity of data for many details of transition, making this a significant opportunity for future research.
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33
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Moons P, De Geest S, Budts W. Comprehensive Care for Adults with Congenital Heart Disease: Expanding Roles for Nurses. Eur J Cardiovasc Nurs 2016; 1:23-8. [PMID: 14622863 DOI: 10.1016/s1474-5151(01)00014-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Adults with congenital heart disease constitute a growing patient population. Although life expectancy of these patients is increasing, they may be confronted with specific medical, psychosocial and behavioural problems throughout their life span. Special attention needs to be given to patients' illness experiences; knowledge and health behaviour; employability and insurability. Hence, comprehensive care by specialised health care professionals, addressing the multidimensional problems experienced by the patients is required. Interdisciplinary teams in which nurses guarantee the management beyond typical medical issues are promising. Key elements of nurses' involvement are facilitation of the transition process from paediatric to adult cardiology, identification of patient needs, screening and referral for psychosocial problems, and education and counselling of patients and families. In particular, an advanced practice nurse seems to be pre-eminent to optimise illness management of adult patients with congenital heart disease.
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Affiliation(s)
- Philip Moons
- Centre for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35/4, B-3000, Leuven, Belgium.
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Claessens P, Moons P, de Casterlé BD, Cannaerts N, Budts W, Gewillig M. What Does it Mean to Live with a Congenital Heart Disease? A Qualitative Study on the Lived Experiences of Adult Patients. Eur J Cardiovasc Nurs 2016; 4:3-10. [PMID: 15718186 DOI: 10.1016/j.ejcnurse.2004.12.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Revised: 12/14/2004] [Accepted: 12/21/2004] [Indexed: 11/23/2022]
Abstract
Background: Adults with congenital heart disease constitute a relatively new and continuously growing patient population. In addition to medical problems, patients perceive specific psychosocial concerns that influence their lived experiences and quality of life. Aim: This study aimed to explore the lived experiences of adult congenital heart disease patients. Methods: Unstructured, in-depth interviews were performed with 12 patients, aged between 25 and 40 years and suffering from moderate or severe heart defect (tetralogy of Fallot, transposition of the great arteries). Interviews were tape recorded and transcribed verbatim. Data were analyzed using Grounded Theory procedures. Results: Feeling different was the central theme of the patients’ lived experience, as they are faced with physical limitations and visible signs due to the heart defect. The experienced discordance between their world and healthy individuals’ world implies that patients struggle constantly with themselves and with their environment to be accepted as normal. The feeling of being different was influenced by attitudes of the environment, health care, and patient's personality. Moreover, it determined the perceived impact of the disease on the patient's daily life. Conclusion: This study shows that normalisation is the most important process when dealing with patients suffering from a congenital heart disease.
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Affiliation(s)
- Patricia Claessens
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Belgium
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35
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Ochiai R, Kato H, Akiyama N, Ichida F, Yao A, Inuzuka R, Niwa K, Shiraishi I, Nakanishi T. Nationwide Survey of the Transfer of Adults With Congenital Heart Disease From Pediatric Cardiology Departments to Adult Congenital Heart Disease Centers in Japan. Circ J 2016; 80:1242-50. [DOI: 10.1253/circj.cj-15-0937] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ryota Ochiai
- School of Nursing, Tokyo Women’s Medical University
| | - Hitoshi Kato
- National Center for Child Health and Development
| | - Naomi Akiyama
- Department of Nursing, Tokyo Women’s Medical University Hospital
| | - Fukiko Ichida
- Department of Pediatrics, Faculty of Medicine, University of Toyama
| | - Atsushi Yao
- Division of Health Service Promotion, The University of Tokyo
| | - Ryo Inuzuka
- Department of Pediatrics, The University of Tokyo
| | - Koichiro Niwa
- Department of Cardiology, St Luke’s International Hospital
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Toshio Nakanishi
- Department of Pediatric Cardiology, Tokyo Women’s Medical University
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36
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Hays L. Transition to Adult Congenital Heart Disease Care: A Review. J Pediatr Nurs 2015; 30:e63-9. [PMID: 25704989 DOI: 10.1016/j.pedn.2015.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 01/21/2015] [Accepted: 01/23/2015] [Indexed: 01/07/2023]
Abstract
The population of adults with congenital heart disease (ACHD) has grown due to recent advances in surgical procedures. The survival rate to adulthood is now more than 95%. This review identifies current recommendations and status of ACHD management and treatment in the United States by examining comprehensive guidelines for management and transition and comparing them to the current state of the science. Successful transition from pediatric to adult care begins during the adolescent years, and prepares patients for management at an ACHD regional center utilizing multidisciplinary teams of ACHD specialists. Advocacy and research needs for the ACHD population persist.
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Affiliation(s)
- Laura Hays
- Arkansas Children's Hospital, Little Rock, AR.
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37
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Goossens E, Fernandes SM, Landzberg MJ, Moons P. Implementation of the American College of Cardiology/American Heart Association 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Am J Cardiol 2015; 116:452-7. [PMID: 26092269 DOI: 10.1016/j.amjcard.2015.04.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 04/21/2015] [Accepted: 04/21/2015] [Indexed: 11/25/2022]
Abstract
Although different guidelines on adult congenital heart disease (ACHD) care advocate for lifetime cardiac follow-up, a critical appraisal of the guideline implementation is lacking. We investigated the implementation of the American College of Cardiology/American Heart Association 2008 guidelines for ACHD follow-up by investigating the type of health care professional, care setting, and frequency of outpatient visits in young adults with CHD. Furthermore, correlates for care in line with the recommendations or untraceability were investigated. A cross-sectional observational study was conducted, including 306 patients with CHD who had a documented outpatient visit at pediatric cardiology before age 18 years. In all, 210 patients (68.6%) were in cardiac follow-up; 20 (6.5%) withdrew from follow-up and 76 (24.9%) were untraceable. Overall, 198 patients were followed up in tertiary care, 1/4 (n = 52) of which were seen at a formalized ACHD care program and 3/4 (n = 146) remained at pediatric cardiology. Of those followed in formalized ACHD and pediatric cardiology care, the recommended frequency was implemented in 94.2% and 89%, respectively (p = 0.412). No predictors for the implementation of the guidelines were identified. Risk factors for becoming untraceable were none or lower number of heart surgeries, health insurance issues, and nonwhite ethnicity. In conclusion, a significant number of adults continue to be cared for by pediatric cardiologists, indicating that transfer to adult-oriented care was not standard practice. Frequency of follow-up for most patients was in line with the ACC/AHA 2008 guidelines. A considerable proportion of young adults were untraceable in the system, which makes them vulnerable for discontinuation of care.
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Moceri P, Goossens E, Hascoet S, Checler C, Bonello B, Ferrari E, Acar P, Fraisse A. From adolescents to adults with congenital heart disease: the role of transition. Eur J Pediatr 2015; 174:847-54. [PMID: 25957970 DOI: 10.1007/s00431-015-2557-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 03/29/2015] [Accepted: 04/27/2015] [Indexed: 11/26/2022]
Abstract
UNLABELLED Improved surgical care during the last decades, together with advances in medical management, led to a remarkable increase in survival of patients with congenital heart disease (CHD). However, aging of the CHD population brings new challenges, and loss of follow-up of adolescents and adults with CHD is a major concern. It is crucial to optimize the transfer of patients with CHD from paediatric to adult health care services to prevent loss to follow-up. The transition process plays a central role in the future health and follow-up of the patient. The aim of this review is to explain and discuss the clinical impact of the transition process in adolescents with CHD. We will also discuss specific CHD adolescents' problems. CONCLUSION Adolescence is a crucial phase for the formation of the personality. Understanding and acceptance of the responsibility for health at this stage through a transition process with a multidisciplinary team will determine the quality of future medical follow-up and probably limit psychosocial issues in their adult life. WHAT IS KNOWN • Aging of the congenital heart disease population brings new challenges to the organisation of care. • Loss of follow-up is a major concern for patients with congenital heart disease. What is new: • The quality of a formal transition process during adolescence will determine future outcomes in patients with congenital heart disease.
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Affiliation(s)
- Pamela Moceri
- Cardiology Department, Pasteur University Hospital, Nice, France,
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39
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Maul TM, Zaidi A, Kowalski V, Hickey J, Schnug R, Hindes M, Cook S. Patient Preference and Perception of Care Provided by Advance Nurse Practitioners and Physicians in Outpatient Adult Congenital Clinics. CONGENIT HEART DIS 2015; 10:E225-9. [PMID: 26010340 DOI: 10.1111/chd.12273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Nurse practitioners (NPs) have an established role for delivering competent care to patients in the primary care setting. The aim of this study was to compare satisfaction of patients managed by NPs vs. physicians in the outpatient adult congenital heart disease (CHD) clinic. DESIGN A prospective study conducted in two outpatient adult CHD clinics to assess patient satisfaction through standardized surveys. Demographic data included CHD diagnosis, age, and New York Heart Association functional class. All patients completed a Short-Form-12 to assess health status. RESULTS Of the 371 patients recruited (52% men; median age 29 years, severe CHD complexity 31.5%) and seen by NP (n = 187) or physician (n = 184), physician-managed practices had higher perceived: overall experience, courtesy of provider (P < 0.05) and confidence (trust) in provider (P < 0.1). Overall, patients reported satisfaction with an NP providing care (98%), the NP was able to effectively deal with illness/CHD (95%), and an increased chance (94%) or willingness to see an NP at a future visit. Only 73% reported an understanding of NP training and how an NP differed from a registered nurse. There was a stronger perception of how an NP differed from a physician (83%). CONCLUSION Patient satisfaction was high regardless of whether care was provided by physicians or NPs. However, patients appear to make distinctions in what they believe the type of care each practitioner is best at providing. Patient education regarding competence of the different health care providers may continue to improve patient satisfaction.
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Affiliation(s)
- Timothy M Maul
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ali Zaidi
- Cardiology, The Columbus Ohio Adult Congenital Heart Program (COACH), Columbus, OH, USA
| | - Vanessa Kowalski
- The Adult Congenital Heart Disease Center, Heart Institute Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jenne Hickey
- Cardiology, The Columbus Ohio Adult Congenital Heart Program (COACH), Columbus, OH, USA
| | - Renee Schnug
- Cardiology, The Columbus Ohio Adult Congenital Heart Program (COACH), Columbus, OH, USA
| | - Morgan Hindes
- The Adult Congenital Heart Disease Center, Heart Institute Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen Cook
- The Adult Congenital Heart Disease Center, Heart Institute Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bhatt AB, Foster E, Kuehl K, Alpert J, Brabeck S, Crumb S, Davidson WR, Earing MG, Ghoshhajra BB, Karamlou T, Mital S, Ting J, Tseng ZH. Congenital Heart Disease in the Older Adult. Circulation 2015; 131:1884-931. [DOI: 10.1161/cir.0000000000000204] [Citation(s) in RCA: 158] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fernandes SM, Chamberlain LJ, Grady S, Saynina O, Opotowsky AR, Sanders L, Wise PH. Trends in utilization of specialty care centers in California for adults with congenital heart disease. Am J Cardiol 2015; 115:1298-304. [PMID: 25765587 DOI: 10.1016/j.amjcard.2015.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 02/03/2015] [Accepted: 02/03/2015] [Indexed: 02/04/2023]
Abstract
The American College of Cardiology and American Heart Association guidelines recommend that management of adult congenital heart disease (ACHD) be coordinated by specialty ACHD centers and that ACHD surgery for patients with moderate or complex congenital heart disease (CHD) be performed by surgeons with expertise and training in CHD. Given this, the aim of this study was to determine the proportion of ACHD surgery performed at specialty ACHD centers and to identify factors associated with ACHD surgery being performed outside of specialty centers. This retrospective population analysis used California's Office of Statewide Health Planning and Development's discharge database to analyze ACHD cardiac surgery (in patients 21 to 65 years of age) in California from 2000 to 2011. Designation as a "specialty ACHD center" was defined on the basis of a national ACHD directory. A total of 4,611 ACHD procedures were identified. The proportion of procedures in patients with moderate and complex CHD delivered at specialty centers increased from 46% to 71% from 2000 to 2011. In multivariate analysis among those discharges for ACHD surgery in patients with moderate or complex CHD, performance of surgery outside a specialty center was more likely to be associated with patients who were older, Hispanic, insured by health maintenance organizations, and living farther from a specialty center. In conclusion, although the proportion of ACHD surgery for moderate or complex CHD being performed at specialty ACHD centers has been increasing, 1 in 4 patients undergo surgery at nonspecialty centers. Increased awareness of ACHD care guidelines and of the patient characteristics associated with differential access to ACHD centers may help improve the delivery of appropriate care for all adults with CHD.
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Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot ND, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA. PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Can J Cardiol 2014; 30:e1-e63. [PMID: 25262867 DOI: 10.1016/j.cjca.2014.09.002] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Adult Congenital Heart Disease: A Growing Epidemic. Can J Cardiol 2014; 30:S410-9. [DOI: 10.1016/j.cjca.2014.07.749] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 07/08/2014] [Accepted: 07/23/2014] [Indexed: 11/23/2022] Open
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Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot ND, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA. PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Heart Rhythm 2014; 11:e102-65. [PMID: 24814377 DOI: 10.1016/j.hrthm.2014.05.009] [Citation(s) in RCA: 371] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 02/07/2023]
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Abstract
Adults with congenital heart disease must be managed by a new generation of subspecialist cardiologists, says John Deanfield.
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Affiliation(s)
- Jennifer Taylor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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47
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Affiliation(s)
- Gary Webb
- Cincinnati Adolescent and Adult Congenital Heart Disease Program, The Heart Institute at Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical School, Cincinnati, OH (G.W.); Boston Adult Congenital Heart (BACH) Group, Departments of Cardiology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.J.L.); and Columbus Ohio Adult Congenital Heart Disease Program, Nationwide Children's Hospital, Columbus, The Ohio State College of Medicine, Columbus, OH (C.J.D.)
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Diller GP, Kempny A, Piorkowski A, Grübler M, Swan L, Baumgartner H, Dimopoulos K, Gatzoulis MA. Choice and Competition Between Adult Congenital Heart Disease Centers. Circ Cardiovasc Qual Outcomes 2014; 7:285-91. [DOI: 10.1161/circoutcomes.113.000555] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gerhard-Paul Diller
- From the Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Münster, Germany (G.-P.D., H.B.); National Heart Institute, Imperial College of Science and Medicine, London, UK (G.-P.D., A.K., L.S., K.D., M.A.G.); Royal Brompton Hospital, London, UK (G.-P.D., A.K., M.G., L.S., K.D., M.A.G.); and Department of Geoinformatics and Applied Computer Science, AGH University of Science and Technology, Cracow, Poland (A.P.)
| | - Aleksander Kempny
- From the Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Münster, Germany (G.-P.D., H.B.); National Heart Institute, Imperial College of Science and Medicine, London, UK (G.-P.D., A.K., L.S., K.D., M.A.G.); Royal Brompton Hospital, London, UK (G.-P.D., A.K., M.G., L.S., K.D., M.A.G.); and Department of Geoinformatics and Applied Computer Science, AGH University of Science and Technology, Cracow, Poland (A.P.)
| | - Adam Piorkowski
- From the Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Münster, Germany (G.-P.D., H.B.); National Heart Institute, Imperial College of Science and Medicine, London, UK (G.-P.D., A.K., L.S., K.D., M.A.G.); Royal Brompton Hospital, London, UK (G.-P.D., A.K., M.G., L.S., K.D., M.A.G.); and Department of Geoinformatics and Applied Computer Science, AGH University of Science and Technology, Cracow, Poland (A.P.)
| | - Martin Grübler
- From the Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Münster, Germany (G.-P.D., H.B.); National Heart Institute, Imperial College of Science and Medicine, London, UK (G.-P.D., A.K., L.S., K.D., M.A.G.); Royal Brompton Hospital, London, UK (G.-P.D., A.K., M.G., L.S., K.D., M.A.G.); and Department of Geoinformatics and Applied Computer Science, AGH University of Science and Technology, Cracow, Poland (A.P.)
| | - Lorna Swan
- From the Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Münster, Germany (G.-P.D., H.B.); National Heart Institute, Imperial College of Science and Medicine, London, UK (G.-P.D., A.K., L.S., K.D., M.A.G.); Royal Brompton Hospital, London, UK (G.-P.D., A.K., M.G., L.S., K.D., M.A.G.); and Department of Geoinformatics and Applied Computer Science, AGH University of Science and Technology, Cracow, Poland (A.P.)
| | - Helmut Baumgartner
- From the Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Münster, Germany (G.-P.D., H.B.); National Heart Institute, Imperial College of Science and Medicine, London, UK (G.-P.D., A.K., L.S., K.D., M.A.G.); Royal Brompton Hospital, London, UK (G.-P.D., A.K., M.G., L.S., K.D., M.A.G.); and Department of Geoinformatics and Applied Computer Science, AGH University of Science and Technology, Cracow, Poland (A.P.)
| | - Konstantinos Dimopoulos
- From the Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Münster, Germany (G.-P.D., H.B.); National Heart Institute, Imperial College of Science and Medicine, London, UK (G.-P.D., A.K., L.S., K.D., M.A.G.); Royal Brompton Hospital, London, UK (G.-P.D., A.K., M.G., L.S., K.D., M.A.G.); and Department of Geoinformatics and Applied Computer Science, AGH University of Science and Technology, Cracow, Poland (A.P.)
| | - Michael A. Gatzoulis
- From the Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Münster, Germany (G.-P.D., H.B.); National Heart Institute, Imperial College of Science and Medicine, London, UK (G.-P.D., A.K., L.S., K.D., M.A.G.); Royal Brompton Hospital, London, UK (G.-P.D., A.K., M.G., L.S., K.D., M.A.G.); and Department of Geoinformatics and Applied Computer Science, AGH University of Science and Technology, Cracow, Poland (A.P.)
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[Recommendations on the structure of the care of adults with congenital heart disease (GUCH patients) in Austria -- update 2011th]. Wien Klin Wochenschr 2013; 125:755-8. [PMID: 24343043 DOI: 10.1007/s00508-013-0479-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Indexed: 10/25/2022]
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Brown NM, Maul TM, Reed H, Clayton S, Cook SC. Obstacles encountered in developing an adult congenital heart disease program. Am J Cardiol 2013; 112:1953-7. [PMID: 24063838 DOI: 10.1016/j.amjcard.2013.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/06/2013] [Accepted: 08/06/2013] [Indexed: 11/28/2022]
Abstract
More adults than children are now living in the United States with congenital heart disease (CHD). To accommodate the needs of this burgeoning population, there are an increasing number of centers providing care for adults with CHD. We sought to identify pertinent obstacles encountered in the development of a newly established adult CHD program. A survey regarding CHD knowledge, insurance, and cardiovascular counseling was provided to new clinic patients aged ≥18 years. Crosstab correlations were performed to identify relations among categorical variables. Of 145 subjects (54% women; mean age 31 ± 11 years), 84% had at least moderately complex CHD. Household income was <$40,000 for 51% of subjects. There were a significantly greater number of adults, aged 30 to 54 years, with public insurance compared with the national average (p = 0.005). Of 83% of subjects reporting CHD knowledge, 71% correctly identified their defect. Self-reported CHD knowledge correlated positively with higher education (p = 0.019), higher income (p = 0.036), health maintenance organization or preferred provider organization insurance (p = 0.01), and higher level of CHD complexity (p = 0.012); however, none of these factors significantly affected correct identification of one's CHD. In fact, patients with the most complex disease were the least likely to correctly identify their defects. In general, cardiovascular and sexual health screening was lacking. In conclusion, adult patients with CHD require robust ancillary services and special attention to lifelong insurance and counseling. Implementation of a health-care strategy to identify patients' needs can help to overcome socioeconomic obstacles and contribute to the success of the newly established adult CHD program.
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Affiliation(s)
- Nicole M Brown
- Adolescent and Young Adult Congenital Heart Disease Center, Department of Pediatric Cardiology and The Heart Institute at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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