Rachel Bensen

Diabetes Device Use in Adults With Type 1 Diabetes: Barriers to Uptake and Potential Intervention Targets

OBJECTIVE Diabetes devices (insulin pumps, continuous glucose monitors [CGMs]) are associated with benefits for glycemic control, yet uptake of these devices continues to be low. Some barriers to device uptake may be modifiable through psychosocial intervention, but little is known about which barriers and which patients to target. RESEARCH DESIGN AND METHODS We surveyed 1,503 adult T1D Exchange participants (mean age 35.3 [SD 14.8] years, mean diagnosis duration 20.4 [SD 12.5] years) to investigate barriers to device uptake, understand profiles of device users versus nonusers, and explore differences by age and sex. Scales used were the Diabetes Distress Scale, Technology Use Attitudes (General and Diabetes-Specific), and Barriers to Device Use and Reasons for Discontinuing Devices. RESULTS Most commonly endorsed modifiable barriers were related to the hassle of wearing devices (47%) and disliking devices on one’s body (35%). CGM users (37%) were older than nonusers (mean 38.3 vs. 33.5 years), had diabetes for longer (22.9 vs. 18.8 years), had more positive technology attitudes (22.6–26.0 vs. 21.4–24.8), and reported fewer barriers to using diabetes technology than nonusers (3.3 vs. 4.3). The youngest age-group (18–25 years) had the lowest CGM (26% vs. 40–48%) and insulin pump (64% vs. 69–77%) uptake, highest diabetes distress (2.2 vs. 1.8–2.1), and highest HbA1c levels (8.3% [67 mmol/mol] vs. 7.2–7.4% [55–57 mmol/mol]). CONCLUSIONS Efforts to increase device use need to target physical barriers to wearing devices. Because young adults had the lowest device uptake rates, highest distress, and highest HbA1c compared with older age-groups, they should be the focus of future interventions to increase device use.

Better health, less spending: Redesigning the transition from pediatric to adult healthcare for youth with chronic illness

Adolescents and young adults (AYA) with serious chronic illnesses face costly and dangerous gaps in care as they transition from pediatric to adult health systems. New, financially sustainable approaches to transition are needed to close these gaps. We designed a new transition model for adolescents and young adults with a variety of serious chronic conditions. Our explicit goal was to build a model that would improve the value of care for youth 15-25 years of age undergoing this transition. The design process incorporated a review, analysis, and synthesis of relevant clinical and health services research; stakeholder interviews; and observations of high-performing healthcare systems. We identified three major categories of solutions for a safer and lower cost transition to adult care: (1) building and supporting self-management during the critical transition; (2) engaging receiving care; and (3) providing checklist-driven guide services during the transition. We propose that implementation of a program with these interventions would have a positive impact on all three domains of the triple aim - improving health, improving the experience of care, and reducing per capita healthcare cost. The transition model provides a general framework as well as suggestions for specific interventions. Pilot tests to assess the models ease of implementation, clinical effects, and financial impact are currently underway.

Transitions in Pediatric Gastroenterology: Results of a National Provider Survey.

Objectives: Transition and transfer to adult-oriented health care is an important yet challenging task for adolescents and young adults with chronic medical conditions. Transition practices vary widely, but a paucity of data makes determination of best practices difficult. We described North American pediatric gastroenterologists’ preferences and present transition practice patterns and explored whether experience affected providers’ perspectives. Methods: An online survey was distributed via e-mail to members of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition. Participation was voluntary and answers were anonymous. Quantitative and qualitative analysis was performed. Results: Almost three quarters of the 175 respondents describe providing transition or self-care management education, but only 23% use structured readiness assessments. Most respondents (88%) report having age cutoffs above which they no longer accept new referrals, with the most common age being 18 years (57%). One third report the ability to provide age-appropriate care to patients older than 21 years. Only 6% indicate that their practice or institution should provide care for individuals older than 25 years. Many (63%) indicate that their practice or institution has a policy regarding age of transfer, but most (79%) are flexible. Provider preferences for triggers to transfer to adult care diverge widely between age, milestones, and comorbidities. Overall, parent (81%) and patient (74%) attachment to pediatric health care providers are cited as the most common barriers to transition. Conclusions: Preferences and practices surrounding transition preparation and transfer to adult care vary widely, reflecting continued uncertainty regarding optimal transition strategies.

Effects of rural status on health outcomes in pediatric liver transplantation: A single center analysis of 388 patients

Park KT, Nanda P, Bensen R, Strichartz D, Esquivel C, Cox K. Effects of rural status on health outcomes in pediatric liver transplantation: A single center analysis of 388 patients.
Pediatr Transplantation 2011: 15: 300–305.

Geographical Rural Status and Health Outcomes in Pediatric Liver Transplantation: An Analysis of 6 Years of National United Network of Organ Sharing Data

OBJECTIVE To determine whether children in rural areas have worse health than children in urban areas after liver transplantation (LT). STUDY DESIGN We used urban influence codes published by the US Department of Agriculture to categorize 3307 pediatric patients undergoing LT in the United Network of Organ Sharing database between 2004 and 2009 as urban or rural. Allograft rejection, patient death, and graft failure were used as primary outcome measures of post-LT health. Pediatric end-stage liver disease/model of end-stage liver disease scores >20 was used to measure worse pre-LT health. RESULTS In a multivariate analysis, we found greater rates of allograft rejection within 6 months of LT (OR 1.27; 95% CI 1.05-1.53) and a lower occurrence of posttransplantation lymphoproliferative disorder (OR 0.64; 95% CI 0.41-0.99) in patients in rural areas. The difference in allograft rejection was eliminated at 1 year of LT (OR 1.18; 95% CI 0.98-1.42). Rural location did not impact other outcome measures. CONCLUSION We conclude that rural location makes a negative impact on patient health within the first 6 months of LT by increasing the risk for allograft rejection, although patients in rural areas may have lower rates of developing posttransplantation lymphoproliferative disorder. Long-term adverse health effects were not seen.

Legislative Advocacy: Evaluation of a Grand Rounds Intervention for Pediatricians

OBJECTIVE To evaluate the impact of a Grand Rounds Action Alert (GRAA) intervention on the behaviors, knowledge, and attitudes of pediatric grand rounds (GR) attendees; and to assess its acceptability. METHODS A cross-sectional, quasi-experimental study was performed at a freestanding childrens hospital. GRAA on child health legislative topics were presented in the first 2 minutes of the pediatric GR session as well as posted outside. Each session included an action item, such as writing/signing letters to elected officials or informational sheets with legislator contact information. Main outcome measures included self-reported behavior, advocacy knowledge, attitudes, and acceptability. RESULTS One year after GRAA implementation, GR attendees with high exposure to the intervention were more likely to have written/signed a letter to a legislator compared to those with low/no exposure (60% vs 35%, P = .016). Those with high exposure were also more knowledgeable regarding financing of health care for low-income children (20% vs 5%, P = .027). Attitudes toward advocacy at baseline were positive: respondents agreed it is important to remain informed about (98%) and advocate for (94%) legislation favorable to childrens health. Implementing this program was challenging, but the intervention was accepted favorably: 93% of respondents agreed that GRAA should continue. CONCLUSIONS GRAA facilitated participation in legislative advocacy behaviors while improving self-perceived knowledge of legislative issues relating to childrens health. They were well received in a large tertiary childrens hospital.

Starting Young: Trends in Opioid Therapy Among US Adolescents and Young Adults With Inflammatory Bowel Disease in the Truven MarketScan Database Between 2007 and 2015

Background Opioids are commonly prescribed for relief in inflammatory bowel disease (IBD). Emerging evidence suggests that adolescents and young adults are a vulnerable population at particular risk of becoming chronic opioid users and experiencing adverse effects. Objectives This study evaluates trends in the prevalence and persistence of chronic opioid therapy in adolescents and young adults with IBD in the United States. Method A longitudinal retrospective cohort analysis was conducted with the Truven MarketScan Database from 2007 to 2015. Study subjects were 15-29 years old with ≥2 IBD diagnoses (Crohns: 555/K50; ulcerative colitis: 556/K51). Opioid therapy was identified with prescription claims within the Truven therapeutic class 60: opioid agonists. Persistence of opioid use was evaluated by survival analysis for patients who remained in the database for at least 3 years following index chronic opioid therapy use. Results In a cohort containing 93,668 patients, 18.2% received chronic opioid therapy. The annual prevalence of chronic opioid therapy increased from 9.3% in 2007 to 10.8% in 2015 (P < 0.01), peaking at 12.2% in 2011. Opioid prescriptions per patient per year were stable (approximately 5). Post hoc Poisson regression analyses demonstrated that the number of opioid pills dispensed per year increased with age and was higher among males. Among the 2503 patients receiving chronic opioid therapy and followed longitudinally, 30.5% were maintained on chronic opioid therapy for 2 years, and 5.3% for all 4 years. Conclusion Sustained chronic opioid use in adolescents and young adults with IBD is increasingly common, underscoring the need for screening and intervention for this vulnerable population.

Market share and costs of biologic therapies for inflammatory bowel disease in the USA

Real‐world data quantifying the costs of increasing use of biologics in inflammatory bowel disease (IBD) are unknown.

Spanish and English Language Symposia to Enhance Activation in Pediatric Inflammatory Bowel Disease

Objectives: Patient activation is an important consideration for improved health outcomes in the management of chronic diseases. Limited English proficiency among patients and primary care providers has been shown to be a predictor for worse health across disease states. We aimed to determine the baseline patient activation measure (PAM) among Spanish-speaking (SP) and English-speaking (ES) pediatric patients with IBD and parents, and to describe the feasibility and efficacy of a novel peer-group education symposium designed to enhance patient activation as measured with the PAM. Methods: Two separate half-day educational symposia in either Spanish or English were presented and moderated by 2 native SP physicians. Content for each of the presentations were highly standardized and interactive, designed to address each of the activation domains (self-management, collaboration with a health care provider, maintenance of function and prevention of disease exacerbation, and appropriate access to high-quality care). Descriptive statistics were used to describe changes between pre- and postsymposium PAM trends. Results: Eleven primarily SP and 21 ES families participated in their respective symposium. Paired pre- and post-PAM scores were available from 24 pediatric patients with IBD (8 SP, 16 ES) and 41 parents (15 SP, 26 ES). The mean age for SP and ES patients was 11.6 and 12.0 years, and female sex in 80% and 62%, respectively. Paired pre- and post-PAM scores for all participants (n = 65) were analyzed. PAM scores uniformly increased in all 4 groups after the symposia (SP patients 59.1–70.3, P = 0.05; SP parents 69.8–75.2, P = 0.2; ES patients 59.9–64.0, P = 0.08; ES parents 61.9–69.1, P = 0.002), although only the ES-parents group had sufficient sample size (n = 26) to achieve statistical significance. The overall cohort had an aggregate increase from pre-PAM of 62.9 (SD 14.5) to post-PAM of 69.4 (SD 13.9) (<0.001). Conclusions: We describe a novel peer-group educational symposium presented in Spanish and English languages to increase patient and parent activation in pediatric patients with IBD and their caregiving parents. The use of PAM to assess levels of activation appears to be feasible and effective in these groups.

Depression and Healthcare Utilization in Patients with Inflammatory Bowel Disease

Background Depression frequently co-occurs in patients with inflammatory bowel disease [IBD] and is a driver in health care costs and use. Aim This study examined the associations between depression and total health care costs, emergency department [ED] visits, computed tomography [CT] during ED/inpatient visits, and IBD-related surgery among IBD patients. Methods Our sample included 331772 IBD patients from a national administrative claims database [Truven Health MarketScan® Database]. Gamma and Poisson regression analyses assessed differences related to depression, controlling for key variables. Results Approximately 16% of the IBD cohort was classified as having depression. Depression was associated with a