Megumi J. Okumura

Prevalence and Determinants of Insulin Resistance Among U.S. Adolescents A population-based study

OBJECTIVE—We sought to examine the distribution of insulin and homeostasis model assessment of insulin resistance (HOMA-IR) and associations of HOMA-IR with sex, race/ethnicity, age, and weight status, as measured by BMI, among U.S. adolescents. RESEARCH DESIGN AND METHODS—Of 4,902 adolescents aged 12–19 years who participated in the National Health and Nutrition Examination Survey 1999–2002, analysis was performed for a nationally representative subsample of 1,802 adolescents without diabetes who had fasting laboratory measurements. The main outcome measure was HOMA-IR, calculated from fasting insulin and glucose and log transformed for multiple linear regression analyses. RESULTS—In adjusted regression models that included age and weight status, girls had higher HOMA-IR than boys and Mexican-American children had higher HOMA-IR levels than white children. There were no significant differences in adjusted HOMA-IR between black and white children. Obese children (BMI ≥95th percentile) had significantly higher levels of HOMA-IR compared with children of normal weight (BMI <85th percentile) in adjusted comparisons (mean HOMA-IR 4.93 [95% CI 4.56–5.35] vs. 2.30 [2.21–2.39], respectively). Weight status was by far the most important determinant of insulin resistance, accounting for 29.1% of the variance in HOMA-IR. The prevalence of insulin resistance in obese adolescents was 52.1% (95% CI 44.5–59.8). CONCLUSIONS—Obesity in U.S. adolescents represents the most important risk factor for insulin resistance, independent of sex, age, or race/ethnicity. The prevalence of insulin resistance in obese children foreshadows a worrisome trend for the burden of type 2 diabetes in the U.S.

Comfort of general internists and general pediatricians in providing care for young adults with chronic illnesses of childhood.

BackgroundAs an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about how comfortable physicians are caring for this population.ObjectivesTo assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses originating in childhood as well as the factors associated with comfort.Participants In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate = 53%).MethodsWe measured respondents’ comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis (CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics.ResultsFifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF (p < .001) and 35% for SCD (p > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult patients with CF and SCD.ConclusionsA majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the transition to adult-focused care for the growing numbers of young adults with complex chronic conditions.

Understanding Factors Associated With Work Loss for Families Caring for CSHCN

OBJECTIVE: Parents of children with special health care needs (CSHCN) are at risk for work loss as a result of the complex health needs of their children. Our objective was to determine how child- and family-level factors and the medical home are associated with work loss for these families. METHODS: We performed secondary data analyses of the National Survey of Children With Special Health Care Needs (NS-CSHCN) 2005–2006. This is a nationally representative sample of CSHCN in the United States. The primary outcome measure was having any family member report work loss to care for a CSHCN. We calculated survey-weighted unadjusted and adjusted odds ratios by using independent variables that included child demographic factors, functional limitation, condition stability, insurance status/type, family income, and criteria of the medical home. RESULTS: Overall, 23.7% of the parents of CSHCN reported work loss as a result of their childs health care needs. Greater functional limitation and condition instability were associated with increased odds of family work loss. The presence of a medical home in the multivariate model was associated with a 50% reduction in the odds of reported family work loss. CONCLUSIONS: Approximately 24% of families with CSHCN have experienced work loss to meet the medical needs of their child. Availability of a system of care support, such as the medical home, is associated with lower work loss reported by families. Therefore, improved systems of care for CSHCN may have the potential to optimize work productivity for families.

Trends in Hospitalizations for Diabetes Among Children and Young Adults: United States, 1993–2004

OBJECTIVE—The purpose of this study was to examine national trends in hospitalizations associated with diabetes for U.S. children and young adults. RESEARCH DESIGN AND METHODS—The study included hospital discharges for individuals aged 0–29 years with a diagnosis of diabetes (250.xx) in the Nationwide Inpatient Sample (1993–2004). Outcomes were weighted, nationally representative estimates of the frequency of population-adjusted hospital discharges and hospital charges (2004

Change in Health Status and Access to Care in Young Adults With Special Health Care Needs: Results From the 2007 National Survey of Adult Transition and Health

U.S.). RESULTS—Among individuals aged 0–29 years, population-adjusted rates of hospitalizations associated with diabetes over the 12-year period increased by 38% (99.1 of 100,000 in 1993 and 136.4 of 100,000 in 2004; P < 0.001 for curvilinear trend). Age-specific increases in annual hospitalizations for diabetes occurred primarily among individuals aged 20–24 years (152.6 of 100,000 in 1993 and 222.2 of 100,000 in 2004) and 25–29 years (224.9 of 100,000 in 1993 and 331.2 of 100,000 in 2004). Trends in hospitalizations among younger individuals showed no significant patterns. Hospitalization rates were consistently higher for females than for males, with a greater rate of increase for females (42%) than for males (29%) (P < 0.001). Inflation-adjusted total charges for diabetes hospitalizations increased 130%, from

Profiling Health and Health-Related Services for Children With Special Health Care Needs With and Without Disabilities

1.05 billion in 1993 to

The health care transition research consortium health care transition model: A framework for research and practice

2.42 billion in 2004. CONCLUSIONS—The number of young adults hospitalized with diabetes in the U.S. has increased significantly over the last decade. Sex-specific differences in hospitalization rates and trends in obesity among U.S. children may amplify future trends in diabetes hospitalizations and corresponding rapid growth in associated health care expenditures.

Self-management skills in adolescents with chronic rheumatic disease: A cross-sectional survey

BACKGROUND Despite over 500,000 adolescents with special health care needs transitioning to adulthood each year, limited information is available on their health status or their access to care after transition. OBJECTIVE To describe the change in health status and access to care of a nationally sampled, longitudinal cohort of young adults with special health care needs (ASHCN). METHODS We analyzed follow-up data collected in the 2007 Survey of Adult Transition and Health on young adults who were 14-17 years of age when their parents participated in the 2001 National Survey of Children with Special Health Care Needs. We describe changes in access to care and health status over time, and used logistic regression to identify characteristics that were associated with declining health status in this cohort. RESULTS 1,865 participants, aged 19-23 years, completed the Survey of Adult Transition and Health. Between 2001 and 2007, there was a 3.6 fold increase in the proportion experiencing delayed or forgone care; 10% reported a decline in health status. There was a 7.7-fold increase in the proportion reporting no insurance. In regression analysis, factors associated with declining health status between 2001 and 2007 included underlying disease severity and delayed or forgone care in young adulthood. CONCLUSIONS We found significant deterioration in insurance coverage, usual source of care and receiving timely health care as ASHCN aged into adulthood, and that this was associated with decline in health status. Our findings suggest that further population-based analyses of health outcomes are needed to plan for interventions to assist this vulnerable population.

Improving transition from paediatric to adult cystic fibrosis care: programme implementation and evaluation

OBJECTIVE The aims of this study were to profile and compare the health and health services characteristics for children with special health care needs (CSHCN), with and without disabilities, and to determine factors associated with unmet need. METHODS Secondary data analysis of the 2005-2006 National Survey of Children with Special Health Care Needs was conducted. The sociodemographics, health, and health services of CSHCN with and without disabilities were compared. Multivariable logistic regression was employed to examine factors associated with unmet need for health services. RESULTS Children from minority racial and ethnic groups and children living in or near poverty were over-represented among CSHCN with disabilities, compared with other CSHCN. Statistically higher percentages of CSHCN with disabilities had behavioral problems (39.6% vs 25.2%), anxiety/depressed mood (46.1% vs 24.0%), and trouble making/keeping friends (38.1% vs 15.6%) compared with other CSHCN. Thirty-two percent of CSHCN with disabilities received care in a medical home compared with 51% of other CSHCN. CSHCN with disabilities had higher rates of need and unmet need than other CSHCN for specialty care, therapy services, mental health services, home health, assistive devices, medical supplies, and durable medical equipment. The adjusted odds of unmet need for CSHCN with disabilities were 71% higher than for other CSHCN. CONCLUSION CSHCN with disabilities had more severe health conditions and more health services need, but they less commonly received care within a medical home and had more unmet need. These health care inequities should be amenable to policy and health service delivery interventions to improve outcomes for CSHCN with disabilities.

Peripheral muscle weakness in RASopathies

The body of health care transition (HCT) research is in the early stages of development. One of the major limitations of this developing field of research is the lack of theoretically-directed studies. This research limitation has hindered understanding of the variables contributing to successful HCT. The inadequate understanding of HCT is due largely to the absence of an adequate conceptual model that addresses the complexity and the relationships amongst variables that influence HCT outcomes among adolescents and emerging adults with special health care needs (AEA-SHCN). Existing conceptual models do not sufficiently address the significant interrelationships amongst variables to explain, predict and/or control AEA-SHCNs biopsychosocial HCT outcomes. This article provides a description of a health care transition theoretical model developed by the international and interdisciplinary Health Care Transition Research Consortium (HCTRC) that can be applied for testing in research and serve as a framework for clinical practice and policymaking. The HCTRC model is composed of four domains that are considered integral to the HCT phenomenon: Individual, Family/Social Support, Environment, and the Health Care System. The HCTRC model specifies the variables, processes, and potential mediators and moderators that affect the HCT outcomes.