Racial Disparities in Mental Health Disorders in Youth with Chronic Medical Conditions.

OBJECTIVE: To evaluate the association between race/ethnicity, poverty, and mental health in youth with chronic conditions. STUDY DESIGN: A cross-sectional comparative study was performed using the records of a tertiary care center from 2011 to 2015. INCLUSION CRITERIA: children aged 4-17 years with ≥1 hospitalization or emergency department visit. Exclusion criteria were those with arrhythmias or treatment with clonidine/benzodiazepines. The primary outcome variable was diagnosis or medication for anxiety, depression, or attention deficit hyperactivity disorder. The primary predictor variable was diagnosis of cystic fibrosis (CF), sickle cell disease (SCD), or congenital heart disease (CHD). RESULTS: We identified 112 313 patients, 0.2% with CF, 0.4% with SCD, and 1.0% with CHD. Patients with CF had the highest prevalence (23%) and odds (OR, 4.21; 95% CI, 3.07-5.77) of anxiety or depression, whereas patients with SCD had the lowest prevalence (7%) and odds (OR, 1.54; 95% CI, 1.11-2.14). Those with CHD had a prevalence of up to 17%, with 3-4 times higher odds of anxiety or depression (OR, 3.70; 95% CI, 2.98-4.61). All non-White participants were less likely to be diagnosed or treated for anxiety or depression and attention deficit hyperactivity disorder. Although poverty increased the probability of anxiety or depression in patients with CHD, this finding was not seen in patients with CF or SCD. CONCLUSIONS: Children with CF, SCD, and CHD are at increased risk of anxiety or depression; however non-White patients are likely being underdiagnosed and undertreated. Increased screening and recognition in minority children are needed to decrease disparities in mental health outcomes.

Hope is No Plan: Uncovering Actively Missing Transition-Aged Youth with Congenital Heart Disease.

Studies describing gaps in care for youth with congenital heart disease (CHD), focus on those who have returned to care, but rarely those actively missing from care. Our objective was to determine barriers for young adults with CHD actively missing from cardiac care and to re-engage them in care. Retrospective single-center cohort study of cardiology clinic patients ages 15-21 years with CHD between 2012 and 2019 for patients actively missing from care (≥ 12 months beyond requested clinic follow-up). We conducted prospective interviews, offered clinic scheduling information, and recorded cardiac follow-up. Data analyzed using descriptive statistics, univariable, and multivariable logistic regression. Of 1053 CHD patients, 33% (n = 349) were actively missing. Of those missing, 58% were male and median age was 17 years (IQR 16-19). Forty-six percent were Non-Hispanic White, 33% Hispanic, and 9% Black. Moderately complex CHD was in 71%, and 62% had private insurance. Patients with simple CHD, older age at last encounter (18-21), and scheduled follow-up > 12 months from last encounter were more likely to be actively missing. Interviews were completed by 125 patients/parents (36%). Lack of cardiac care was reported in 52%, and common barriers included: insurance (33%), appointment scheduling (26%), and unknown ACHD center care (15%). Roughly half (55%) accepted appointment information, yet only 3% successfully returned. Many patients require assistance beyond CHD knowledge to maintain and re-engage in care. Future interventions should include scheduling assistance, focused insurance maintenance, understanding where to obtain ACHD care, and educating on need for lifelong care.

Mental Health Disorders in Children With Congenital Heart Disease.

BACKGROUND: Data on anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) are lacking for youth with congenital heart disease (CHD), particularly those with simple CHD. This study aims to characterize these disorders in youth with CHD compared to those without CHD. METHODS: A comparative cross-sectional study was conducted by using the electronic medical records of a large tertiary care hospital between 2011 and 2016. Inclusion criteria were youth aged 4 to 17 years with >1 hospitalization or emergency department visits. Exclusion criteria were patients with arrhythmias or treatment with clonidine and/or benzodiazepines. The primary predictor variable was CHD type: simple, complex nonsingle ventricle, and complex single ventricle. The primary outcome variable was a diagnosis and/or medication for anxiety and/or depression or ADHD. Data were analyzed by using logistic regression (Stata v15; Stata Corp, College Station, TX). RESULTS: We identified 118 785 patients, 1164 with CHD. Overall, 18.2% (n = 212) of patients with CHD had a diagnosis or medication for anxiety or depression, compared with 5.2% (n = 6088) of those without CHD. All youth with CHD had significantly higher odds of anxiety and/or depression or ADHD. Children aged 4 to 9 years with simple CHD had ∼5 times higher odds (odds ratio: 5.23; 95% confidence interval: 3.87-7.07) and those with complex single ventricle CHD had ∼7 times higher odds (odds ratio: 7.46; 95% confidence interval: 3.70-15.07) of diagnosis or treatment for anxiety and/or depression. Minority and uninsured youth were significantly less likely to be diagnosed or treated for anxiety and/or depression or ADHD, regardless of disease severity. CONCLUSIONS: Youth with CHD of all severities have significantly higher odds of anxiety and/or depression and ADHD compared to those without CHD. Screening for these conditions should be considered in all patients with CHD.

Typed versus voice recognition for data entry in electronic health records: emergency physician time use and interruptions.

INTRODUCTION: Use of electronic health record (EHR) systems can place a considerable data entry burden upon the emergency department (ED) physician. Voice recognition data entry has been proposed as one mechanism to mitigate some of this burden; however, no reports are available specifically comparing emergency physician (EP) time use or number of interruptions between typed and voice recognition data entry-based EHRs. We designed this study to compare physician time use and interruptions between an EHR system using typed data entry versus an EHR with voice recognition. METHODS: We collected prospective observational data at 2 academic teaching hospital EDs, one using an EHR with typed data entry and the other with voice recognition capabilities. Independent raters observed EP activities during regular shifts. Tasks each physician performed were noted and logged in 30 second intervals. We compared time allocated to charting, direct patient care, and change in tasks leading to interruptions between sites. RESULTS: We logged 4,140 minutes of observation for this study. We detected no statistically significant differences in the time spent by EPs charting (29.4% typed; 27.5% voice) or the time allocated to direct patient care (30.7%; 30.8%). Significantly more interruptions per hour were seen with typed data entry versus voice recognition data entry (5.33 vs. 3.47; p=0.0165). CONCLUSION: The use of a voice recognition data entry system versus typed data entry did not appear to alter the amount of time physicians spend charting or performing direct patient care in an ED setting. However, we did observe a lower number of workflow interruptions with the voice recognition data entry EHR. Additional research is needed to further evaluate the data entry burden in the ED and examine alternative mechanisms for chart entry as EHR systems continue to evolve.

Cost analysis of isolated mitral valve surgery in the United States.

BACKGROUND: Within the field of cardiac surgery, several strategies have been adopted in an effort to address contributors to increasing health care costs. Limited data are available on cost analysis within the field of mitral valve surgery. The purpose of our investigation was to analyze cost differences between mitral valve repair and replacement. METHODS: The analysis was based on the subset of patients with isolated mitral valve repair or replacement (International Classification of Diseases, ninth revision, clinical codes 35.12, 35.23, and 35.24) using data from the 2005 to 2008 Nationwide Inpatient Sample database, which is the largest all-payer database in the United States. We examined the selective contribution of patient demographics, hospital characteristics, and postoperative complications to cost by using hierarchical linear mixed models. We used mixed effects logistic regression models to identify factors that influence extreme cost expenditures in patients undergoing mitral valve surgery. RESULTS: Independent predictors of increased cost for both repair and replacement on multivariable analysis included increased age, prior myocardial infarction, heart failure, neurologic deficit, renal disease, emergent status, and Medicare or Medicaid insurance type. The presence of postoperative complications also predicted increased costs. However, the model for repair only yielded a reduction in variability of 13%, while the model for replacement produced a reduction of 22%. CONCLUSIONS: In this analysis, the most important contributors to cost for mitral valve repair and replacement are preoperative patient comorbidities, most notably history of myocardial infarction and heart failure, emergent admission status, and postoperative complications. The variables in our model failed to account for a large proportion of the variability in cost. This would suggest that future analyses exploring differential procedure costs between hospitals must look for factors beyond patient baseline characteristics and postoperative outcomes.

Morgagni hernia presenting as a right middle lobe compression.

A 25-year-old woman with a history of chronic bronchitis since age 12 and 3-4 previous episodes of pneumonia presented to the emergency room with cough and shortness of breath. A CT scan of her chest revealed findings consistent with Morgagni hernia with herniation of omental fat, causing near complete compressive atelectasis of the right middle lobe. The diaphragmatic defect was successfully treated with a laparoscopic repair. The patient was discharged home on the first postoperative day after tolerating regular diet.

Tricuspid valve surgery: the past 10 years from the Nationwide Inpatient Sample (NIS) database.

OBJECTIVES: The purpose of this study was to examine the trends in tricuspid valve surgery over time. METHODS: We used 10 years (1999-2008) of NIS data to examine the population of patients undergoing tricuspid valve repair or replacement (ICD-9-CM codes 35.14, 35.27, and 35.28). RESULTS: We identified 28,726 admissions for tricuspid valve surgery. The total number of tricuspid procedures more than doubled over the 10- year period (1712 cases in 1999 vs 4072 cases in 2008). Although the absolute number of repairs and replacements increased over time, the tricuspid repair rate increased whereas there was a corresponding decrease in tricuspid replacement rate. Isolated tricuspid valve surgery accounted for 20% of the total tricuspid cases, whereas tricuspid surgery as a concomitant procedure to other cardiac operations accounted for the remaining 80%. There was a trend toward increased use of tissue over mechanical valves for tricuspid replacement. Overall hospital mortality was 10.6%. Over time, mortality decreased significantly for both repair and replacement. Concomitant tricuspid replacement was associated with significantly higher hospital mortality than was isolated tricuspid replacement (16.1% vs 10.1%; P = .0001). CONCLUSIONS: There has been a dramatic increase in tricuspid interventions over time. This has been associated with an increase in tricuspid repair rates as well as use of bioprostheses for tricuspid replacement. The majority of tricuspid operations are performed concomitantly to other cardiac procedures. Mortality for tricuspid valve surgery remains considerable and significantly higher for replacement than for repair.

Repair of left atrial-esophageal fistula following percutaneous radiofrequency ablation for atrial fibrillation.

Atrial-esophageal fistula is a rare but often fatal complication of percutaneous radiofrequency ablation for atrial fibrillation. We present a patient who was diagnosed with this complication in a delayed fashion and successfully treated with primary repair via left thoracotomy. The details of the surgical approach are discussed.