Transition Care: Future Directions in Education,Health Policy,and Outcomes Research

All youth must transition from pediatric to adult-centered medical care. This process is especially difficult for youth with special health care needs. Many youth do not receive the age-appropriate medical care they need and are at risk during this vulnerable time. Previous research has identified barriers that may prevent effective transition, and protocols have been developed to improve the process. Health outcomes related to successful transition have yet to be fully defined.Health care transition can also be influenced by education of providers, but there are gaps in medical education at the undergraduate, graduate, and postgraduate levels. Current changes in federal health policy allow improved health care coverage, provide some new financial incentives, and test new structures for transitional care, including the evolution of accountable care organizations (ACO). Future work must test how these systems changes will affect quality of care. Finally, transition protocols exist in various medical subspecialties; however, national survey results show no improvement in transition readiness, and there are no consistent measures of what constitutes transition success.In order to advance the field of transition, research must be done to integrate transition curricula at the undergraduate, graduate, and postgraduate levels; to provide advance financial incentives and pilot the ACO model in centers providing care to youth during transition; to define outcome measures of importance to transition; and to study the effectiveness of current transition tools on improving these outcomes.     

Family Impacts Among Children With Autism Spectrum Disorder: The Role of Health Care Quality

ObjectiveTo compare health care quality and family employment and financial impacts among children with special health care needs (CSHCN) with autism spectrum disorder (CSHCN + ASD), CSHCN with functional limitations (CSHCN + FL), and CSHCN lacking these conditions (other CSHCN); to test whether high health care quality was associated with reduced family impacts among CSHCN + ASD.MethodsData from the 2009–2010 National Survey of CSHCN were used to compare 3025 CSHCN + ASD, 6505 CSHCN + FL, and 28,296 other CSHCN. Weighted multivariate logistic regression analyses examined 6 age-relevant, federally defined health care quality indicators and 5 family financial and employment impact indicators. Two composite measures were additionally used: 1) receipt of care that met all age-relevant quality indicators; and 2) had ≥2 of the 5 adverse family impacts.ResultsAcross all health care quality indicators, CSHCN + ASD fared poorly, with only 7.4% meeting all age-relevant indicators. CSHCN + ASD had worse health care quality than other CSHCN, including CSHCN + FL. CSHCN + ASD also had high rates of adverse family impact, with over half experiencing ≥2 adverse impacts. Rates of adverse family impact were higher in CSHCN + ASD than other CSHCN, including CSHCN + FL. Among CSHCN + ASD, those whose health care that met federal quality standards were less likely to have multiple adverse family impacts than CSHCN + ASD whose health care did not meet federal quality standards.ConclusionsCSHCN + ASD are more prone to experience poor health care quality and family impacts than other CSHCN, even CSHCN + FL. Receipt of care meeting federal quality standards may potentially lessen adverse family impacts for CSHCN + ASD.     

The Connection between Psychosocial Health, Health Behaviors and the Environment In Rural Children

Overweight and obesity is a concern for child populations in many countries. Due to a high prevalence of sedentary activity, low physical activity, and unhealthy diet, many children are at serious risk for health complications. Overweight and obesity seem to be of particular concern for Canadian children living in rural environments. A recent pilot study examined the physical and emotional health status of children in grades 4, 5, and 6 from four rural schools in Saskatchewan. Quantitative data was collected using four validated instruments: the Piers Harris 2, the Faces Scale, the Youth/Adolescent Questionnaire (Food Frequency), and the Physical Activity Questionnaire, as well as measured heights and weights. Qualitative data was collected using Photovoice, a research methodology that encourages expression through photography. This was used to explore the children’s perception of the rural environment, and whether they felt it helped or hindered their abilities to maintain health. Results revealed a high proportion of overweight and obesity. There were no significant differences in weight status between girls and boys. However, most children indicated that they were happy living in the rural environment. Three themes emerged from the Photovoice component: satisfaction, wide-open spaces, and a sense of safety. The rural environment appears to contribute to children’s health and happiness and thus should be fully utilized in interventions and health promotion activities that promote health and healthy behaviours in children.     

小儿总肝管狭窄的外科治疗──Champeau手术

采用法国Ｃｈａｍｐｅａｕ肝脏切开，肝内深部胆管－肠道吻合术治疗３例总肝管狭窄伴阻塞性黄疸患儿。随访时间最长为８年，效果满意。手术关键：肝脏切开，选用正中裂径路，即从胆囊床底走向下腔静脉左缘，由前向后自上而下将肝脏象一本书似的切开；最后，在肝内足够的范围内完成肝管－肠道吻合。该术方便、可靠。     

Identifying Priorities to Improve the System of Care for Children With Complex Health Needs in North Carolina: Process and Outcomes of Systematic Stakeholder Engagement

ObjectiveChildren with complex health needs (CCHN) have both medical (eg, chronic conditions) and health-related social needs (eg, potentially adverse social determinants of health) that require ongoing health care and support from multiple community service providers. National standards developed for populations defined by health needs (CYSHCN) provide a framework for stakeholders to plan system-level improvements in care delivery for CCHN, but improvement efforts should reflect the priorities of their families and providers. This article describes a process of prioritizing system-level efforts to improve the health and well-being of CCHN and families in North Carolina (NC), using systematic stakeholder engagement and modified Delphi expert ratings.MethodsWe surveyed stakeholders with experience caring for CCHN using an open-ended, 3-item instrument to identify opportunities to improve systems of care. Using directed qualitative content analysis, we synthesized responses into a master list of potential improvement topics. Using a modified Delphi approach, a 16-member advisory committee rated all topics for importance and urgency, on 9-point Likert scales over 2 rounds; then ratings for each topic were ranked (low, medium, high) to establish relative priority.ResultsForty seven individuals from 31 counties around NC provided survey responses, yielding 59 improvement topics in 10 domains. Through the modified Delphi method process, 21 topics (36%) received the highest rankings, largely representing access to community- and home-based services, equity, and enhancement of the pediatric workforce.ConclusionsPriorities identified by stakeholders will inform advocacy, policy, and improvement efforts. Next steps for the coalition include developing improvement projects to implement stakeholder-recommended actions for the highest-priority topics.