Stakeholder validation of a model of readiness for transition to adult care

Nurses' and physicians' perspectives on implementation barriers and facilitators in a transfer program for parents of adolescents with chronic illness

AIM

To identify barriers and facilitators impacting the implementation of a comprehensive transfer program aimed at parents of adolescents with chronic illness in clinical practice.

DESIGN

A real-time, qualitative process evaluation.

METHODS

Individual interviews were conducted with 10 nurses and seven physicians from paediatric and adult outpatient clinics: Nephrology, hepatology, neurology, and rheumatology. Data were analysed through the lens of normalization process theory.

RESULTS

Themes were framed within the theory's four components. (1) Coherence: Healthcare professionals' views on their core tasks and on the parents' role influenced their perception of the program. (2) Cognitive participation: A named key worker, autonomy, and collaboration impacted healthcare professionals' involvement in the program. (3) Collective action: Department prioritization and understanding of the program's aim were key factors in its successful delivery. (4) Reflective monitoring: Participants experienced that the program helped parents during transfer but questioned if the program was needed by all families.

CONCLUSION

We identified three barriers: Healthcare professionals' lack of understanding of the parental role during transfer, top-down decisions among nurses, and physicians' uncertainty about their role in joint consultations. Facilitators: Healthcare professionals' understanding of the program's purpose and expected effect, the nurses' significant role as named keyworkers, and good collaboration across paediatric and adult departments.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Implementation strategies should be developed before implementing a transfer program in clinical practice.

IMPACT

Implementing a parental transfer program in clinical practice can be challenging. Therefore, for successful implementation, it is crucial to identify barriers and facilitators. Barriers and facilitators exist at the personal, professional, and organizational levels, and it is important to understand them. The results of this qualitative study could support the implementation of transfer programs in other settings.

REPORTING METHOD

Consolidated criteria for reporting qualitative studies (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Nurses' and physicians' experiences of ownership of the transfer program is essential for successful implementation. Clinics should appoint a named keyworker, preferably a nurse, as the driving force during the implementation of a transfer program. Nurses and physicians should receive training about the purpose, justification, and expected effect of a transfer program before implementation.

Emerging Adults With Type 2 Diabetes: Understanding Illness Experience and Transition to Adult Care

PURPOSE

Youth-onset type 2 diabetes (T2D) is increasingly common and is often diagnosed shortly before transition from pediatric to adult care. Little is known about the experience of emerging adults (EAs) with T2D and the readiness, barriers, and facilitators to transition. This study sought to describe the illness experience of EAs with T2D and perceptions about transition, and explore themes by "transition readiness," measured by the Transition Readiness Assessment Questionnaire (TRAQ).

METHODS

In this mixed-methods study, we conducted semi-structured interviews with EAs with T2D using a guide grounded in the health belief model, administered the TRAQ, and collected disease metrics from the electronic medical record. We developed a coding scheme using a directed content-analysis approach and triangulated qualitative and quantitative data to compare themes stratified by mean TRAQ score.

RESULTS

Participants described modifying factors like adjusting to life with a chronic illness and coping with mental health issues as critical elements of the illness experience that influence transition. Individual beliefs emerged including the perceived risk of disease complications being informed by experience of family members, self-efficacy in diabetes care hinging on the ability to be highly organized, and transition as a daunting obstacle with numerous emotional and logistical barriers. Participants emphasized the need for support from caregivers and providers throughout transition. Themes did not vary significantly by TRAQ score.

DISCUSSION

Experiences of EAs with T2D suggest more assistance is needed in the transition period to address factors such as mental health, organizational skills, and identifying support people to facilitate care.

Perceived transition readiness among adolescents and young adults with neurofibromatosis type 1 and plexiform neurofibromas: a cross-sectional descriptive study

OBJECTIVES

Neurofibromatosis type 1 (NF1) is a genetic cancer predisposition syndrome that can impact multiple organ systems and is associated with plexiform neurofibroma tumors, requiring care from birth through adulthood. Adolescents and young adults (AYAs) with NF1 face several barriers to transition from pediatric to adult care. This cross-sectional study aimed to assess transition readiness in this population and to evaluate relationships between specific NF1 symptoms and transition readiness.

METHODS

AYAs (aged 16-24) enrolled in existing studies related to NF1 were eligible. AYAs and their parents completed measures of transition readiness (Transition Readiness Assessment Questionnaire version 4 [TRAQ-4]), and AYAs also completed a transition readiness interview (UNC TRxANSITION).

RESULTS

Thirty-eight AYAs (mean age = 19.95 ± 2.68 years) participated in the study. Average TRAQ scores indicated that AYAs were still learning Self-Management skills (M = 3.37, SD = 1.08) and Self-Advocacy skills (M = 3.98, SD = 0.67). Older AYAs had higher TRAQ scores for Self-Management (r = 0.70, p < .001) and Self-Advocacy (r = 0.41, p = .011) than younger AYAs. Parents and AYAs had similar TRAQ scores. About one third of AYAs (37.8%, n = 14) expressed uncertainty about how NF1 might affect them in the future. The remaining AYAs mostly expressed concerns regarding tumor growth, pain, or cancer.

CONCLUSIONS

In this small study, preliminary findings suggest that AYAs with NF1 express confidence in many areas of transition readiness but continue to require support, particularly with Self-Management skills. Given the gaps in understanding of future health risks, AYAs with NF1 would benefit from early assessment, psychoeducation, and support for transition readiness to adult care.

The Health Care Transition Needs of Adolescents and Emerging Adults with Chronic Pain: A Narrative Review

The aim of this narrative review was to provide an overview of what is known about the health care transition process in pediatric chronic pain, barriers to successful transition of care, and the roles that pediatric psychologists and other health care providers can play in the transition process. Searches were run in in Ovid, PsycINFO, Academic Search Complete, and PubMed. Eight relevant articles were identified. There are no published protocols, guidelines, or assessment measures specific to the health care transition in pediatric chronic pain. Patients report many barriers to the transition process, including difficulty attaining reliable medical information, establishing care with new providers, financial concerns, and adapting to the increased personal responsibility for their medical care. Additional research is needed to develop and test protocols to facilitate transition of care. Protocols should emphasize structured, face-to-face interactions and include high levels of coordination between pediatric and adult care teams.

An Updated Equitable Model of Readiness for Transition to Adult Care: Content Validation in Young People With Sickle Cell Disease

Importance

Despite elevated health risks during young adulthood, many adolescents and young adults with serious health care needs face barriers during the transfer to an adult specialty practitioner, and health disparities may occur during the transition.

Objective

To validate the content of an updated Social-Ecological Model of Adolescent and Young Adult Readiness for Transition to Promote Health Equity (SMART-E) in a group of adolescents and young adults with sickle cell disease (SCD) and their supports.

Design, Setting, and Participants

Health equity framework components were reviewed. Systems of power (eg, institutional and practitioner bias) and environments or networks (eg, peer or school support) were added as SMART-E preexisting factors, and health literacy was included within readiness factors. Adolescents and young adults aged 16 to 29 years with SCD, caregivers, and practitioners participated in this convergent, mixed-methods study within Children's Hospital of Philadelphia between January and August 2022.

Main Outcomes and Measures

Content validity was assessed through nominations of top 3 most important transition barriers prior to interviews and focus groups, ratings on importance of SMART-E factors (0-4 scale; ratings >2 support validity) after interviews and focus groups, nominations of 3 most important factors for transition and for health equity, and qualitative content analysis of interview transcripts.

Results

The study enrolled 10 pediatric adolescents and young adults (mean [SD] age, 18.6 [2.9] years; 4 female and 6 male), 10 transferred adolescents and young adults (mean [SD] age, 22.9 [2.1] years; 8 female and 2 male), 9 caregivers (mean [SD] age, 49.8 [8.7] years; 5 female and 4 male), and 9 practitioners (mean [SD] age, 45.6 [10.5] years; 8 female and 1 male). Quantitative ratings supported the content validity of SMART-E and met established criteria for validity. Systems of power was the most endorsed transition barrier (14 of 38 participants) reported prior to interviews and focus groups. After the interview, participants endorsed all SMART-E factors as important for transition, with new factors systems of power and environments and networks rated at a mean (SD) 2.8 (1.23) and 3.1 (0.90), respectively, on a 0 to 4 scale of importance. The most important factors for transition and equity varied by participant group, with all factors being endorsed, supporting the comprehensiveness of SMART-E. Qualitative data corroborated quantitative findings, further supporting validity, and minor modifications were made to definitions.

Conclusions and Relevance

SMART-E obtained initial content validation with inclusion of health equity factors for adolescents and young adults with SCD, caregivers, and practitioners. The model should be evaluated in other populations of adolescents and young adults with chronic disease.

Factors influencing the healthcare transition in Chinese adolescents with inflammatory bowel disease: a multi-perspective qualitative study

BACKGROUND

The development and implementation of the transition from pediatric to adult healthcare systems for adolescents with inflammatory bowel disease (IBD) should consider stakeholders' perceptions. This study aimed to explore the factors influencing the transition of Chinese adolescents with IBD from the perspectives of patients, parents, and healthcare providers.

METHODS

A descriptive qualitative research was conducted. Purposive sampling was used to recruit 36 participants, including 13 patients, 13 parents, and 10 providers, from a tertiary pediatric IBD center, a tertiary adult IBD center, and the China Crohn's & Colitis Foundation in Zhejiang Province, China. Individual semi-structured interviews were used to collect data on facilitators and barriers to the transition process. Conventional content analysis was used to analyze the interview transcripts.

RESULTS

Nine primary themes were identified. Patients with young age, prolonged disease duration, severe disease, academic pressures such as the Gaokao, low level of disease acceptance, limited transition consciousness, low self-efficacy, poor transition communication, and inadequate medical transition system serve as barriers. While patients with the mentality of guilt towards their parents; parents with low education levels and intensive work schedules, high levels of disease acceptance, and situations of parent-child separation; stakeholders with high transition consciousness, high transition self-efficacy, and effective transition communication act as facilitators. Furthermore, community support and hospital guide services were also contributing factors during the transition.

CONCLUSIONS

This study offers comprehensive insights into the factors affecting the transition of Chinese adolescent IBD patients. The process is continuously influenced by stakeholders, community, and healthcare environments and policies. Identifying these factors provides healthcare providers with a reference for developing and implementing targeted transition interventions.

Parents' views on and need for an intervention during their chronically ill child's transfer to adult care

Parents of chronically ill adolescents play a significant role during their child's transition and transfer to adult care. Parents seek help and support, but appropriate initiatives are still lacking. Thus, there is an urgent call for knowledge regarding parents' needs and views on such support. The aim of this study was to examine, in relation to parents of chronically ill adolescents: 1) views and experiences regarding their child's transfer from paediatric to adult care, and 2) which initiatives parents preferred in relation to the transfer. The study was based on the interpretive description method, and data were collected through face-to-face or telephone interviews with parents of chronically ill adolescents aged 16-19 (n = 11). We found three overall findings: 'Feeling acknowledged vs. feeling excluded', 'Perceived differences between paediatric and adult care' and 'Feeling safe vs. entering the unknown', together with three preferred initiatives: 1) Joint consultations, 2) Educational events and 3) Online support/website. In general, we found that some parents were extremely worried about the transfer, while others were not. Our results suggest that transfer initiatives targeting parents should focus on knowledge, expectations, relationships and goals in accordance with the social-ecological model of adolescent and young adult readiness to transition (SMART).

Transition of Care of Pediatric Patients with Special Needs to Adult Care Settings: Children with Diabetes Mellitus and Other Endocrine Disorders

Childhood onset endocrine disorders need long-term medical, psychological and social management. Over time, many illnesses evolve, while others may witness onset of new complications. Thus, the components of the care change as the child grows into adolescence and then adulthood. The transition of children and adolescents with chronic endocrine disorders to adult care continues to be a major challenge. Pediatric and adult healthcare teams should together design a transitional care plan that is developmentally appropriate and responsive to the needs of young adults. The preparation for transition to adult care should begin early in adolescence and involve both the adolescent and his parents. A structured and planned transitional care bridges the gap between pediatric and adult care teams, promote ongoing engagement and build trust with the new healthcare teams. Combined pediatric-adult care transition model for endocrine conditions has yielded high adherence rates and patient satisfaction.

Optimizing transition from pediatric to adult care in short bowel syndrome and intestinal failure

As the majority of children with short bowel syndrome (SBS) and intestinal failure (IF) are now surviving into adulthood, there is a paradigm shift from short-term management to long-term outcomes and a growing need to focus on healthcare transition (HCT). It is imperative that adolescents and young adults with SBS and IF receive disease education, empowerment, and support as they navigate the transition from pediatric to adult care. Furthermore, both pediatric and adult healthcare providers who manage these patients should be aware of the challenges faced by this population, barriers to their HCT, and strategies to overcome them. This article reviews the literature on HCT in children with chronic illnesses, discusses barriers to HCT in SBS/IF, identifies the important constituents of the transition process in SBS/IF, and provides recommendations for the successful and smooth transition of the pediatric patient to the adult healthcare environment. Structured and multicomponent HCT programs should become the standard of care to ensure uninterrupted high-quality care across the life span for patients with SBS/IF.

Parental Perspectives on Health Care Transition in Adolescent and Young Adult Survivors of Pediatric Cancer

The health care transition (HCT) from pediatric to adult care is pivotal for childhood cancer survivors (CCS) and their parents. However, there is little research examining parental needs during HCT, despite this being a key predictor of successful HCT. The goal of this study was to investigate the needs of parents of CCS during HCT. Using an integrative review of the literature structured around the social-ecological model (SEM) of CCS transition readiness yielded 454 articles, including three hand-searched articles. Six articles were included in the final analysis. Data were extracted into nine factors derived from SEM. Articles were published within the last decade, largely qualitative, and mainly examined parents and CCS together. Parents most frequently mentioned relationships with their practitioner and CCS as contributing to HCT readiness, while abstract factors, such as goal-setting and expectations around HCT, were not mentioned. Our results are limited by the dearth of research on this topic, the homogeneity of samples, and joint presentation of CCS and parent data. Nonetheless, our results indicate that parents do not weigh all aspects of SEM equally, with macrolevel barriers, such as sociodemographic factors being viewed as less salient for HCT readiness. Parents mostly focused on interpersonal factors, such as their relationships with practitioners and CCS, indicating that practitioners should emphasize these in preparing parents for HCT.

Pediatric Bowel Management Options and Organizational Aspects

A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.

[Crossed perspectives on pediatrics to adult health care transition in Belgium]

In Belgium, there is not yet a standardized procedure for supporting the transition of patients with chronic diseases from pediatrics to adult health care. However, the field increasingly calls for the development of multidisciplinary landmarks. By crossing perspectives of a pediatrician, two psychologists and an ethicist, we propose the key elements of a successful transition: 1. Start preparing for the transition early; 2. Promote the patient's knowledge, know-how and interpersonal skills; 3. Improve continuity of care and collaboration between patient, family, healthcare teams, patient associations and families; 4. Support parents; 5. Improve the skills of healthcare teams in the specificities of adolescent medicine; 6. Individualize the transition, respecting each person's pace and uniqueness; 7. Develop an interdisciplinary approach of the transition; 8. Develop collaboration with public authorities, national and international experts; 9. Develop research on this emerging field of study.

A comprehensive transfer program from pediatrics to adult care for parents of adolescents with chronic illness (ParTNerSTEPs): study protocol for a randomized controlled trial

BACKGROUND

Previous research shows that adolescents with a chronic illness have more successful transfers to adult care if their parents are involved during the transition. However, there is a lack of structured and evaluated transfer programs for parents. Our aim will be to test a comprehensive transfer program for parents of adolescents with chronic illness during the transfer from pediatric to adult care and to evaluate the program's effectiveness, acceptability, and costs.

METHODS

The overall design for this protocol will be a randomized controlled trial. A total of 62 dyads consisting of an adolescent (age 16.5-17.5) and at least one parent will be recruited from one of four pediatric outpatient clinics (nephrology, hepatology, neurology, or rheumatology) at Copenhagen University Hospital - Rigshospitalet, Denmark. The dyads will be randomized to receive the transfer program in addition to usual care or to receive usual care only. The program includes an informative website, bi-annual online educational events, and transfer consultations across pediatric and adult care. Outcome measures will include transition readiness, allocation of responsibility, parental uncertainty level, and transfer satisfaction. Data will be collected from participants at baseline, every 6 months until transfer, at transfer, and 3 months after transfer. The parents' acceptance of and satisfaction with the program will be explored through semi-structured interviews. Cost, barriers, and facilitators affecting future implementation will be identified in interviews with health care professionals, using the Normalization Process Theory as a framework for the process analysis.

DISCUSSION

To our knowledge, this transfer program is one of the first interventions for parents of adolescents with a chronic illness during their child's transfer to adult care. Our trial will include parental and adolescent measures allowing us to examine whether a transfer program for parents will improve transfer to adult care for both parents and adolescents. We believe that results from our trial will be helpful in forming recommendations to ensure better involvement of parents in transitional care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04969328 . Retrospectively registered on 20 July 2021.

Parents' experiences with health care transition of their adolescents and young adults with medically complex conditions: A scoping review

BACKGROUND

Health care transition (HCT) has become increasingly important as adolescents and young adults (AYAs) with complex medical conditions now live well into adulthood but little attention has been given to parents of AYAs preparing for HCT.

OBJECTIVE

This scoping review aimed to identify and synthesize information on parental facilitators and barriers to health care transition readiness.

ELIGIBILITY CRITERIA

English-language, peer-reviewed original studies focused on the parents' experience of HCT were included. Studies were excluded if AYAs were not anticipated to be independent or if AYAs had only mental health disorders.

CHARTING METHODS

Parent-reported facilitators and barriers were identified in each study and then categorized to identify common themes.

RESULTS

Themes related to parental facilitators included evidence of coordination between pediatric and adult levels of care, healthcare provider guidance for HCT, and parental awareness and acceptance of natural seasons of life. Themes related to parental barriers included relationship loss, loss of parental role, lack of knowledge and/or skills, and concerns related to the health care system in general.

CONCLUSION

Common facilitators and barriers were found across studies, regardless of medical diagnosis. Relationships and role change figure prominently in parents' perceptions of the HCT experience and their readiness for their AYA children to transition. These findings suggest potential areas for future research inquiry as well as potential nursing interventions designed to aid parents through HCT.

Healthcare Transition Among Young Adults With Childhood-Onset Chronic Pain: A Mixed Methods Study and Proposed Framework

Chronic pain extends from childhood to adulthood for many young people. The transition from pediatric to adult care is a critical, yet understudied, healthcare task facing young adults with chronic pain. The aims of this observational, sequential mixed methods study were to 1) document the healthcare transition status of young adults with chronic pain (Stage 1, quantitative aim), 2) examine young adults' perspectives of barriers and facilitators of healthcare transition (Stage 2, qualitative aim), and 3) integrate findings to construct a theoretical framework of healthcare transition. A cohort was identified with childhood chronic pain and prior care in one of 15 multidisciplinary pediatric pain clinics across the United States and Canada. Approximately 6 years later, 189 young adults (M age = 21.0; age range = 18-24; 81.5% female) from this cohort with continuing chronic pain completed surveys for Stage 1, and a subsample (n = 17) completed qualitative interviews for Stage 2. Quantitative findings demonstrated that young adults may experience lapses in care, with 41.8% indicating they had not transitioned to adult pain services. Qualitative analysis revealed young adults experienced significant barriers (eg, abrupt departure from pediatric care) as well as facilitators (eg, acceptance of pain prognosis) of healthcare transition. Quantitative and qualitative findings were integrated to construct a healthcare transition framework for chronic pain, which highlights transition as a complex process involving multiple pathways, outcomes, and stakeholders. Advancements in research and practice are needed to develop transition services to bridge gaps in care and optimize health outcomes for young people with chronic pain. PERSPECTIVE: This mixed-methods study demonstrated that 41.8% of young adults with chronic pain experience lapses in adult-centered pain care and identified key barriers and facilitators to successful healthcare transition. Findings were integrated to construct the first healthcare transition framework for youth with chronic pain.

The current state of adult metabolic medicine in the United States: Results of a nationwide survey

PURPOSE

Patients with inherited metabolic disorders (IMDs) now have improved health outcomes and increased survival into adulthood. There is scant evidence on managing adults with IMDs. We present an analysis of current care practices for adults with IMDs in the United States.

METHODS

We created and distributed an online survey to US members of the Society of Inherited Metabolic Disorders. The survey addressed ambulatory care, acute management, and health care transition (HCT) practices of adults with IMDs.

RESULTS

The survey was completed by 91 providers from 73 institutions. Most adult patients with IMDs receive lifelong care from a single metabolic clinician, predominantly in pediatric clinic settings. Adults receive comprehensive ambulatory metabolic care, but fewer trainees participate compared with pediatric visits. Most acute IMD management occurs in pediatric hospitals. Clinician comfort with HCT increased the frequency of HCT planning. Overall, all respondents felt that providing specialized care to adults with IMDs is high value.

CONCLUSION

Our survey demonstrates the paucity of clinical resources dedicated to adult metabolic medicine. Care is fragmented and varies by medical system. Interest in HCT is robust but would benefit from standardized practices. Our findings reinforce the need for greater focus on adult metabolic medicine in the United States.

Development of a complex intervention to support parents of adolescents with chronic illness transferring from pediatrics to adult care (ParTNerSTEPs)

BACKGROUND

Transition from pediatric to adult care for adolescents with chronic illness is associated with outpatient non-attendance and low treatment adherence in adolescents, and with anxiety and concerns among parents. Recent studies have shown that parent involvement results in better transitions. The aim of this paper was to describe the development, through participatory design, of a comprehensive transfer program targeted to parents of adolescents with chronic illness.

METHODS

The study was based on the UK Medical Research Council's (MRC) framework on developing and testing complex interventions. To increase the program's feasibility and relevance, participatory design was chosen as the overall method. A collaboration group of parents, young people and health care professionals (HCP) were actively involved in the development of the program. The program was developed in three development stages, in accordance with the MRC framework: 1) identifying the evidence base, 2) identifying theory, and 3) modelling process and outcomes.

RESULTS

Together with the collaboration group, we developed a comprehensive transfer program targeting parents, by undertaking an iterative process, involving a literature review, individual interviews, workshops and online brainstorms. The program, called ParTNerSTEPs (Parents in Transition - a Nurse-led Support and Transfer Educational Program) comprised three components: 1) an informative website, 2) online educational events for parents, and 3) transfer consultations with providers from both pediatrics and adult care.

CONCLUSIONS

The MRC framework was successfully applied to develop a comprehensive transfer program targeting parents of adolescents with chronic ilness. By incorporating the principles of participatory design in the development phase, we ensured that both parents' and adolescents' needs were represented and addressed in the program.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT04969328.

Canadian Consensus Statements on the Transition of Adolescents and Young Adults with Inflammatory Bowel Disease from Pediatric to Adult Care: A Collaborative Initiative Between the Canadian IBD Transition Network and Crohn’s and Colitis Canada

Objectives

With the increased prevalence of childhood-onset inflammatory bowel disease (IBD), there is a greater need for a planned transition process for adolescents and young adults (AYA). The Canadian IBD Transition Network and Crohn’s and Colitis Canada joined in collaborative efforts to describe a set of care consensus statements to provide a framework for transitioning AYA from pediatric to adult care.

Methods

Consensus statements were drafted after focus group meetings and literature reviews. An expert panel consisting of 20 IBD physicians, nurses, surgeon, adolescent medicine physician, as well as patient and caregiver representatives met, discussed and systematically voted. The consensus was reached when greater than 75% of members voted in agreement. When greater than 75% of members rated strong support, the statement was rendered a strong recommendation, suggesting that a clinician should implement the statement for all or most of their clinical practice.

Results

The Canadian expert panel generated 15 consensus statements (9 strong and 6 weak recommendations). Areas of focus of the statements included: transition program implementation, key stakeholders, areas of potential need and gaps in the research.

Conclusions

These consensus statements provide a framework for the transition process. The quality of evidence for these statements was generally low, highlighting the need for further controlled studies to investigate and better define effective strategies for transition in pediatric to adult IBD care.

Gaps in transition readiness measurement: a comparison of instruments to a conceptual model

Objectives

Measuring transition readiness is important when preparing young people with chronic illness for successful transition to adult care. The Expanded Socioecological Model of Adolescent and Young Adult Readiness to Transition (Expanded SMART) offers a holistic view of factors that influence transition readiness and outcomes. The aim of this study was to examine conceptual congruency of transition readiness instruments with the Expanded SMART to determine the breadth and frequency of constructs measured.

Methods

PubMed was searched to identify observational and experimental studies that measured transition readiness across chronic illnesses. Selected instruments were first evaluated on their development and psychometric properties. Next, reviewers independently mapped each instrument item to Expanded SMART constructs: knowledge, skills/self-efficacy, relationships/communication, psychosocial/emotions, developmental maturity, beliefs/expectations, goals/motivation. If items did not map to a construct, a new construct was named inductively through group discussion.

Results

Three instruments (TRAQ [20 items], STARx [18 items] and TRxANSITION Index [32 items]), reported in 74 studies, were identified. Across instruments, most items mapped to three constructs: skills/self-efficacy, developmental maturity, and knowledge. The psychosocial constructs of goals/motivation and psychosocial/emotions were underrepresented in the instruments. No instrument mapped to every model construct. Two new constructs: independent living and organization were identified.

Conclusions

Constructs representing transition readiness in three frequently used transition readiness instruments vary considerably from Expanded SMART, a holistic conceptual model of transition readiness, suggesting that conceptualization and operationalization of transition readiness is not standardized. No instrument reflected all conceptual constructs of transition readiness and psychosocial constructs were underrepresented, suggesting that current instruments may provide an incomplete measurement of transition readiness.

Mobile Phone-Based Intervention Among Adolescents Living With Perinatally Acquired HIV Transitioning from Pediatric to Adult Care: Protocol for the Interactive Transition Support for Adolescents Living With HIV using Social Media (InTSHA) Study

BACKGROUND

Adolescents living with perinatally acquired HIV often have poor retention in care and viral suppression during the transition from pediatric to adult-based care.

OBJECTIVE

The aim of this study is to evaluate a mobile phone-based intervention, Interactive Transition Support for Adolescents Living With HIV using Social Media (InTSHA), among adolescents living with perinatally acquired HIV as they transition from pediatric to adult care in South Africa.

METHODS

InTSHA uses encrypted, closed group chats delivered via WhatsApp (Meta Platforms Inc) to develop peer support and improve communication between adolescents, their caregivers, and health care providers. The intervention is based on formative work with adolescents, caregivers, and health care providers and builds on several existing adolescent support programs as well as the Social-ecological Model of Adolescent and Young Adult Readiness for Transition (SMART). The final InTSHA intervention involves 10 modules conducted weekly through moderated WhatsApp group chats with adolescents and separately with their caregivers. We will randomly assign 80 South African adolescents living with perinatally acquired HIV who are aware of their HIV status and aged between 15 and 19 years to receive either the intervention (n=40) or standard of care (n=40).

RESULTS

We will measure acceptability of the intervention as the primary outcome and evaluate feasibility and preliminary effectiveness for retention in care and viral suppression after completion of the intervention and at least 6 months after randomization. In addition, we will measure secondary outcomes evaluating the impact of the InTSHA intervention on peer support, self-esteem, depression, stigma, sexual education, connection to health care providers, and transition readiness. Enrollment began on April 15, 2021. As of December 31, 2021 a total of 78 out of expected 80 participants have been enrolled.

CONCLUSIONS

If successful, the intervention will be evaluated in a fully powered randomized controlled trial with a larger number of adolescents from urban and rural populations to further evaluate the generalizability of InTSHA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03624413; https://clinicaltrials.gov/ct2/show/NCT03624413.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35455.

Development and design of the first structured clinic-based program in lower resource settings to transition emerging adults with type 1 diabetes from pediatric to adult care

INTRODUCTION

Type 1 diabetes (T1D) is increasing in young people worldwide and more children in resource limited settings are living into adulthood. There is a need for rigorous testing and reporting of evidence-based and stakeholder-informed strategies that transition individuals with T1D from pediatric to adult care. We present the development of and design of the first structured transition program in Delhi, India, to inform similar efforts in India and resource limited settings.

METHODS

The intervention development team included clinicians and researchers with expertise in T1D and the implementation context. To select intervention outcomes, establish intervention targets, and design session modules, we drew upon formative research conducted at prospective intervention implementation sites, consensus guidelines, and previous care transition and behavior change research conducted in developed settings. We used the Template for Intervention Description and Replication and GUIDance for the rEporting of intervention Development checklists to report the intervention and development process.

RESULTS

The 15-month program ("PATHWAY") includes five quarterly ~30 minute sessions delivered predominantly by diabetes educators at pediatric and adult clinics, which coincide with routine care visits. Primary program components include educational and behavioral sessions that address psychosocial drivers of clinic attendance and self-management, diabetes educators as transition coordinators and counselors, and a one-year "overlap period" of alternating visits between pediatric and adult providers.

CONCLUSIONS

We followed a systematic and transparent process to develop PATHWAY, which facilitated rich description of intervention context, guiding principles, targets, and components. Dependence on previously published program examples to design PATHWAY may have introduced challenges for program feasibility and effectiveness, underscoring the importance of input gathering from prospective intervention actors at multiple points in the development process. This detailed report in combination with future evaluations of PATHWAY support efforts to increase rigorous development and testing of strategies to improve outcomes among emerging adults with T1D.

Promoting High-Quality Health Communication Between Young Adults With Diabetes and Health Care Providers

Young adults with diabetes assume increasing responsibility for communicating with their health care providers, and engaging in high-quality health communication is an integral component of overall diabetes self-management. This article provides an overview of the main features of health communication, factors that may influence communication quality, interventions to promote communication skills, and practical strategies for clinicians working with young adults with diabetes. The review concludes with a comprehensive summary of future directions for health communication research.

Feasibility of computerized clinical decision support for pediatric to adult care transitions for patients with special healthcare needs

The objective of this study was to determine the feasibility of a computerized clinical decision support (cCDS) tool to facilitate referral to adult healthcare services for children with special healthcare needs. A transition-specific cCDS was implemented as part of standard care in a general pediatrics clinic at a tertiary care academic medical center. The cCDS alerts providers to patients 17-26 years old with 1 or more of 15 diagnoses that may be candidates for referral to an internal medicine adult transition clinic (ATC). Provider responses to the cCDS and referral outcomes (e.g. scheduled and completed visits) were retrospectively analyzed using descriptive statistics. One hundred and fifty-two patients were seen during the 20-month observation period. Providers referred 87 patients to the ATC using cCDS and 77% of patients ≥18 years old scheduled a visit in the ATC. Transition-specific cCDS tools are feasible options to facilitate adult care transitions for children with special healthcare needs.

Coping, Anxiety, and Health Care Transition Readiness in Youth with Chronic Conditions

PURPOSE

To explore the relationship between coping and health care transition readiness, and to examine whether anxiety is a mediator between coping and health care transition readiness.

DESIGN AND METHODS

A sample of 174 youths with various chronic conditions (age 13.03 ± 2.02 years, 48.3% male) attending the 2018 Victory Junction Camp and their parents participated. Youths and parents completed measures to assess coping (Kidcope Checklist), anxiety symptoms (PROMIS Anxiety scale), and transition readiness (STARx Questionnaire) through Qualtrics online surveys.

RESULTS

Positive coping was positively related to transition readiness in both youth and parent-proxy reports, while negative coping was negatively related to transition readiness in youth reports. Anxiety mediated the relationship of positive coping and transition readiness in parent-proxy reports, and the relationship of negative coping and transition readiness in both youth self-reports and parent-reports.

CONCLUSIONS

Coping is an important factor in transition readiness. Furthermore, anxiety is an important mediator, and may be more influential in the relationship of negative coping and transition readiness.

PRACTICE IMPLICATIONS

Practitioners and health care providers can use these findings to promote the use of positive coping and reduce the use of negative coping, which in turn may improve outcomes for youth with chronic health conditions who are transitioning to adult health care services.

Preconception and Interconception Pediatric Primary Care Utilization of Pregnant and Parenting Teens

PURPOSE

Gaps in preventive care may contribute to adverse outcomes among pregnant teens. This study quantified teen preventive care utilization before and after pregnancy.

METHODS

A continuous retrospective cohort identified 150 teens with a positive pregnancy test (July 2015 to May 2017) at two pediatric primary care sites. Chart review assessed office visits for 18 months before and after the pregnancy test. We also assessed contraceptive counseling, pregnancy outcomes (live birth, miscarriage, termination), and continuity with a single clinician. Demographic factors included age, race, ethnicity, primary insurance, and residential zip code. Logistic regression identified factors associated with visits after pregnancy. Separately, for a cohort of 47 parenting teens who received primary care at the same site as their infants, we assessed teen-infant care after birth.

RESULTS

Teens were predominantly non-Latina black (91%) and Medicaid insured (71%). Before pregnancy, most teens had preventive visits (66%) and reported contraceptive use (65%). After pregnancy, 52% discussed pregnancy decisions within a month, 55% reported contraceptive use, and 64% had any primary care visit. Postpregnancy visits were associated with teen age (<18 vs. ≥18 years odds ratio 2.84, 95% confidence interval 1.17-6.90) and pregnancy outcome (termination vs. live birth odds ratio 4.02, 95% confidence interval 1.47-11.01). Among parenting teens, there were more infant visits than teen visits, and continuity was higher for infants.

CONCLUSION

In a primary care cohort of pregnant teens, gaps persisted in pediatric clinical follow-up after pregnancy. Particularly in situations where pregnancy led to a birth, pregnancy frequently prompted a transition away from pediatric care.

TRAQ Changes: Improving the Measurement of Transition Readiness by the Transition Readiness Assessment Questionnaire

OBJECTIVE

The purpose of the current study was improving the measurement precision of the Transition Readiness Assessment Questionnaire (TRAQ 5.0-20 item) in order to gain better decimation of transition readiness skills across the 5 Stages of Change-from Precontemplation to Mastery.

METHODS

In stage 1, starting with the TRAQ 5.0 20-item, 5 domain subscale questionnaire, we eliminated the five lowest discriminating items using Item response theory (IRT) in MPlus v7.4,which eliminated the domain subscale Managing Daily Activities, and we e added 15 more difficult and better discriminating items. We added items to both to the remaining 4 domain subscales and created a new domain subscale entitled Future Planning. The revised 30-item TRAQ was piloted among 386 youth between 16 and 24 years old (mean = 20 years; 54% female; 87% White).

RESULTS

After examining the model fit, discrimination and difficulty coefficients, and modification indices, we eliminated 10 items and the new Future Planning domain subscale we eliminated. The resulting questionnaire has 4 domain subscales and 20 items. It exhibited good to excellent fit to the data, χ²(164) = 887.239, p < .001, CFI = 0.943, TLI = 0.93, RMSEA = 0.0942 (90% CI: 0.090, 0.114), WRMR = 1.111. All items have acceptable discrimination coefficients. Each of the 4 domain subscales have improved reliability as compared with the original TRAQ 5.0 20 item scale.

CONCLUSIONS

The revised 20-itemTRAQ 6.0 has 4 domains subscales; Managing medications, keeping appointment, tracking health issues, and Talking with providers and has good construct validity as demonstrated by model fit. By adding more difficult items to the 4 resulting domain subscales, we have demonstrated improved item discrimination and difficulty, and therefore can better measure acquisition of transition readiness skills across the five stages of change from pre-contemplation to contemplation to initiation to action and finally to mastery.

Health Care Utilization, Transition Readiness, and Quality of Life: A Latent Class Analysis

OBJECTIVE

To identify possible subgroups of health care utilization (HCU) patterns among adolescents and young adults (AYAs) with a chronic medical condition (CMC), and examine how these patterns relate to transition readiness and health-related quality of life (HRQoL).

METHODS

Undergraduates (N = 359; Mage=19.51 years, SD = 1.31) with a self-reported CMC (e.g., asthma, allergies, irritable bowel syndrome) completed measures of demographics, HCU (e.g., presence of specialty or adult providers, recent medical visits), transition readiness, and mental HRQoL (MHC) and physical HRQoL (PHC). Latent class analysis identified four distinct patterns of HCU. The BCH procedure evaluated how these patterns related to transition readiness and HRQoL outcomes.

RESULTS

Based on seven indicators of HCU, a four-class model was found to have optimal fit. Classes were termed High Utilization (n = 95), Adult Primary Care Physician (PCP)-Moderate Utilization (n = 107), Family PCP-Moderate Utilization (n = 81), and Low Utilization (n = 76). Age, family income, and illness controllability predicted class membership. Class membership predicted transition readiness and PHC, but not MHC. The High Utilization group reported the highest transition readiness and the lowest HRQoL, while the Low Utilization group reported the lowest transition readiness and highest HRQoL.

CONCLUSIONS

The present study characterizes the varying degrees to which AYAs with CMCs utilize health care. Our findings suggest poorer PHC may result in higher HCU, and that greater skills and health care engagement may not be sufficient for optimizing HRQoL. Future research should examine the High Utilization subgroup and their risk for poorer HRQoL.

The Transition to Adult Health Care in Youth With Spina Bifida: Theory, Measurement, and Interventions

PURPOSE

This article focuses on the transition to adult health care in youth with spina bifida (SB) from the perspective of theory, measurement, and interventions.

METHODS

The purpose of this article is to discuss (a) a theory of linkages between the transfer of medical responsibility from parent to child and the transition from pediatric to adult health care, as mediated by transition readiness; (b) measurement issues in the study of self-management and the transition to adult health care; and (c) U.S.-based and international interventions focused on the transition to adult health care in young adults with SB.

FINDINGS

Individuals with SB must adhere to a complex multicomponent treatment regimen while at the same time managing a unique array of cognitive and psychosocial challenges and comorbidities that hinder self-management, medical adherence, and the transition to adult health care. Moreover, such youth endure multiple transitions to adult health care (e.g., in the areas of urology, orthopedics, neurosurgery, and primary care) that may unfold across different time frames. Finally, three transition-related constructs need to be assessed, namely, transition readiness, transition completion, and transition success.

CONCLUSIONS

SB provides an important exemplar that highlights the complexities of conducting research on the transition to adult health care in youth with chronic health conditions. Many transition trajectories are possible, depending on the functioning level of the child and a host of other factors. Also, no single transition pathway is optimal for all patients with SB.

CLINICAL RELEVANCE

The success of the process by which a child with SB transitions from pediatric to adult health care can have life-sustaining implications for the patient.

"It was not okay because you leave your friends behind": A prospective analysis of transition to adult care for adolescents living with perinatally-acquired HIV in South Africa

OBJECTIVE

To determine facilitators and barriers to successful transition to adult care for adolescents living with perinatally-acquired HIV in South Africa.

METHODS

We prospectively enrolled 30 adolescents living with perinatally-acquired HIV after their pediatrician deemed them ready for transition to adult care but prior to their transition. Eighteen months after enrollment, we measured transition status, engagement in care (i.e., viral load within 12 months of transition), and viral suppression (<200 copies/ml). Additionally, we conducted in-depth interviews with adolescents before and after transition to explore facilitators and barriers to successful transition.

RESULTS

A total of 19/30 (63%) adolescents transitioned to adult care. Of those who transitioned, 11 (58%) were retained in care and 7 (37%) were virally suppressed one year after transition to adult care. Insufficient staff training, lack of availability of pediatric ART formulations in adult clinics, and insufficient clinical monitoring contributed to delayed transition. Rigid clinical scheduling that interfered with school and loss of clinic relationships with peers and clinical staff were major factors in contributing to poor engagement in care after transition. Maturity of the adolescent, reduced distance to clinic, and reduced length of time in the clinic were seen as facilitators to transition to adult care.

CONCLUSION

Improved preparation for transition by pediatric and adult clinical staff, including restructuring of care delivery, may improve successful transition of adolescents living with perinatally acquired HIV to adult care. Transition readiness assessments are needed to determine optimal timing of transition and which adolescents are ready to transition to adult care.

Late Effects After Haematopoietic Stem Cell Transplantation in ALL, Long-Term Follow-Up and Transition: A Step Into Adult Life

Haematopoietic stem cell transplant (HSCT) can be a curative treatment for children and adolescents with very-high-risk acute lymphoblastic leukaemia (ALL). Improvements in supportive care and transplant techniques have led to increasing numbers of long-term survivors worldwide. However, conditioning regimens as well as transplant-related complications are associated with severe sequelae, impacting patients' quality of life. It is widely recognised that paediatric HSCT survivors must have timely access to life-long care and surveillance in order to prevent, ameliorate and manage all possible adverse late effects of HSCT. This is fundamentally important because it can both prevent ill health and optimise the quality and experience of survival following HSCT. Furthermore, it reduces the impact of preventable chronic illness on already under-resourced health services. In addition to late effects, survivors of paediatric ALL also have to deal with unique challenges associated with transition to adult services. In this review, we: (1) provide an overview of the potential late effects following HSCT for ALL in childhood and adolescence; (2) focus on the unique challenges of transition from paediatric care to adult services; and (3) provide a framework for long-term surveillance and medical care for survivors of paediatric ALL who have undergone HSCT.

Ongoing care for the patient with an anorectal malfromation; transitioning to adulthood

Planned health care transition can improve the ability of young adults to manage their own health care to effecively use health services and ultimately maximize life-long functioning and well-being. Transitional care is a purposeful, planned process that addresses the medical, psychosocial and educational needs of adolescents and young adults with chronic physical and medical conditions as they move from child-centered to adult-oriented healthcare systems. Unsuccessful surgical transtion may result in physical and mental health implications for young patients, negative long-term outcomes and suboptimal use of health care resources. Anorectal malformation and Hirschsprung patients are an especially vulnerable patient population with ongoing surgical, physiologic and pyschosocial challenges.

Validation of the Healthcare Transition Outcomes Inventory for Young Adults With Type 1 Diabetes

OBJECTIVE

We recently developed and content validated the Healthcare Transition Outcomes Inventory (HCTOI), a stakeholder vetted, multidimensional measure of the outcomes of the transition from pediatric to adult healthcare for young adults (YA) with type 1 diabetes (T1D). In this study, we aimed to evaluate the psychometric properties of the HCTOI.

METHODS

We collected and analyzed cross-sectional data from 128 YA (18-25 years old) with T1D to evaluate the psychometric properties of the HCTOI. We conducted confirmatory factor analysis (CFA), item analysis, and examined reliability and validity in relation to measures of quality of life, diabetes distress, regimen adherence, and glycemic control.

RESULTS

CFA supported a five-factor solution: integration of T1D into emerging adult roles, balance of parental support with T1D autonomy, establishing and maintaining continuity of care, forming a collaborative patient-provider relationship, and ownership of T1D. We reduced the HCTOI from 54 to 34 items. The HCTOI demonstrated adequate internal consistency (α's = 0.62-0.87) and significant correlations demonstrated construct (quality of life, diabetes distress) and criterion validity (adherence, glycemic control).

CONCLUSIONS

The HCTOI demonstrated promising initial psychometric properties. As the first measure of the multiple dimensions of healthcare transition outcomes, the HCTOI provides a means to examine longitudinal relations between transition readiness and outcomes and to assess the efficacy or effectiveness of interventions and programs designed to improve the transition process for YA with T1D.

Transition from pediatric to adult follow-up care in childhood cancer survivors-a systematic review

PURPOSE

The successful transition of childhood cancer survivors from pediatric- to adult-focused long-term follow-up care is crucial and can be a critical period. Knowledge of current transition practices, especially regarding barriers and facilitators perceived by survivors and health care professionals, is important to develop sustainable transition processes and implement them into daily clinical practice. We performed a systematic review with the aim of assessing transition practices, readiness tools, and barriers and facilitators.

METHODS

We searched three databases (PubMed, Embase/Ovid, CINAHL) and included studies published between January 2000 and January 2020. We performed this review according to the PRISMA guidelines and registered the study protocol on PROSPERO; two reviewers independently extracted the content of the included studies.

RESULTS

We included 26 studies: six studies described current transition practices, six assessed transition readiness tools, and 15 assessed barriers and facilitators to transition.

CONCLUSION

The current literature describing transition practices is limited and overlooks adherence to follow-up care as a surrogate marker of transition success. However, the literature provides deep insight into barriers and facilitators to transition and theoretical considerations for the assessment of transition readiness. We showed that knowledge and education are key facilitators to transition that should be integrated into transition practices tailored to the individual needs of each survivor and the possibilities and limitations of each country's health care system.

IMPLICATIONS FOR CANCER SURVIVORS

The current knowledge on barriers and facilitators on transition should be implemented in clinical practice to support sustainable transition processes.

Transition of care in pediatric oncohematology: a systematic literature review

BACKGROUND

The transition of medical care from a pediatric to an adult environment is a psychological change, a new orientation that requires a self-redefinition of the individual, to understand that changes are taking place in his life. Up to 60 percent of pediatric patients who transition to adult services will experience one or more disease or treatment-related complication as they become adults. A nurse who knows how to recognize potential barriers at an early stage can play a pivotal role in the educational plan for the transition process.

MATERIALS AND METHODS

A literature search was undertaken of PUBMED, CINAHL and The Cochrane Library, with specific inclusion and exclusion criteria, including articles published in the lasts ten years.This literature review has been performed according to the PRISMA statement.

RESULTS

Using the keywords in different combination 38 articles were found in The Cochrane Library, 5877 in PUBMED, 274 in CINAHL. 88 articles were selected after the abstract screening. 31 after removing the duplicates and reading the full text.

DISCUSSION

The main themes surrounding transition of care that emerged from the synthesis are the organization of care within common models of transition, innovative clinical approaches to transition, and the experience of patients and caregivers. The transition from pediatric to adult care of cancer or SCD survivors is an emerging topic in pediatric nursing. The organization of care is affected by the lack of clear and well-structured organizational models. Further research is needed to deepen the understanding of some aspects of the transition.

Longitudinal Youth in Transition Study (LYiTS): protocol for a multicentre prospective cohort study of youth transitioning out of child and adolescent mental health services at age 18

INTRODUCTION

Transition between health services is widely recognised as a problematic hurdle. Yet, the factors necessary for successful transition out of child and adolescent mental health services (CAMHS) as youth reach the service boundary at age 18 are poorly understood. Further, fragmentation and variability among the services provided by mental health organisations serve to exacerbate mental illness and create unnecessary challenges for youth and their families. The primary aim of the Longitudinal Youth in Transition Study (LYiTS) is to describe and model changes in psychiatric symptoms, functioning and health service utilisation at the transition out of CAMHS at age 18 and to identify key elements of the transition process that are amendable to interventions aimed at ensuring continuity of care.

METHODS AND ANALYSIS

A prospective longitudinal cohort study will be conducted to examine the association between psychiatric symptoms, functioning and mental health and health service use of youth aged 16-18 as they transition out of child mental health services at age 18. We will recruit a sample of (n=350) participants from child and adolescent psychiatric programmes at two hospital and two community mental health sites and conduct assessments annually for 3 years using standardised measures of psychiatric symptoms, functioning and health service utilisation.

ETHICS AND DISSEMINATION

Ethics approval has been obtained at all four recruitment sites. We will disseminate the results through conferences, open access publications and webinars.

Transition of care in pediatric oncohematology: a systematic literature review

BACKGROUND

The transition of medical care from a pediatric to an adult environment is a psychological change, a new orientation that requires a self-redefinition of the individual, to understand that changes are taking place in his life. Up to 60 percent of pediatric patients who transition to adult services will experience one or more disease or treatment-related complication as they become adults. A nurse who knows how to recognize potential barriers at an early stage can play a pivotal role in the educational plan for the transition process.

MATERIALS AND METHODS

A literature search was undertaken of PUBMED, CINAHL and The Cochrane Library, with specific inclusion and exclusion criteria, including articles published in the lasts ten years.This literature review has been performed according to the PRISMA statement.

RESULTS

Using the keywords in different combination 38 articles were found in The Cochrane Library, 5877 in PUBMED, 274 in CINAHL. 88 articles were selected after the abstract screening. 31 after removing the duplicates and reading the full text.

DISCUSSION

The main themes surrounding transition of care that emerged from the synthesis are the organization of care within common models of transition, innovative clinical approaches to transition, and the experience of patients and caregivers. The transition from pediatric to adult care of cancer or SCD survivors is an emerging topic in pediatric nursing. The organization of care is affected by the lack of clear and well-structured organizational models. Further research is needed to deepen the understanding of some aspects of the transition.

Development and content validation of the Healthcare Transition Outcomes Inventory for young adults with type 1 diabetes

Background

The literature on the specification and measurement of the outcomes of the healthcare transition from pediatric to adult centered-care is scarce and methodologically weak. To address these gaps, we conducted a series of studies to develop a multidimensional, multi-informant (young adults, parents, and healthcare providers) measure of healthcare transition outcomes for young adults with type 1 diabetes (T1D), the Healthcare Transition Outcomes Inventory (HCTOI). The current study describes the development and refinement of the HCTOI item pool.

Methods

Following Patient Reported Outcomes Measurement Information System (PROMIS) standards, the research team conducted qualitative interviews to define six content domains of healthcare transition outcomes from the perspectives of multiple stakeholders, developed an initial item pool of the HCTOI based on the six domains, analyzed expert item ratings and feedback for content validation, and conducted cognitive interviews with informants (patients, parents, and healthcare providers) for further item pool refinement.

Results

Qualitative findings revealed six healthcare transition outcome domains: 1) Biomedical markers of T1D control; 2) Navigation of a new health care system; 3) Possession of T1D self-management skills and knowledge; 4) Integration of T1D care into emerging adult roles; 5) Balance of parental involvement with autonomy; and 6) Attainment of T1D “ownership.” An initial pool of 88 items focused on the extent to which a young adult with T1D is successful on each of the six domains. Experts rated all content domains and all but six items as relevant. In addition to suggesting additional items, experts were concerned about the length of the measure, response burden, and whether every informant type would have sufficient knowledge to rate items in particular content domains. Cognitive interviews resulted in retaining all six content domains, but dropping some items and yielded fewer items for the healthcare provider version (47 items versus 54 items for the young adult- and parent-versions).

Conclusions

Expert review and cognitive interviews confirmed that all six domains of HCT outcomes were relevant and both procedures resulted in retaining a sufficient number of clear and representative items for each content domain. The HCTOI represents the first multi-informant, rigorously developed item pool that comprehensively measures the multiple components of the transition from pediatric to adult specialty healthcare.

The role of resilience in healthcare transitions among adolescent kidney transplant recipients

PURPOSE

AYAs with KTs experience high rates of premature allograft loss during the HCT. There is a critical need to identify protective factors associated with stable HCT. Resilience-the ability to adapt and thrive in the setting of adversity-has known positive impact on health outcomes. This study explored the novel role of resilience constructs as protective factors in securing stable HCT among AYA with KT.

METHODS

We conducted semi-structured interviews of adolescents and young adults who transitioned from a single pediatric transplant center to multiple adult nephrology centers between 2010 and 2017. Interviews explored the role of key resilience constructs in participants' lives around the time of HCT. Participants were stratified into stable or unstable HCT groups based on biological markers of allograft function and clinical data from chart review. Content analyses of interview transcripts were reviewed and compared among HCT groups.

RESULTS

Thirty-two participants enrolled (17 stable; 15 unstable). Key resilience constructs more salient in the stable versus unstable HCT group were confidence in and connection to one's healthcare team. Reports of healthcare self-management competencies were similar across both HCT groups.

CONCLUSIONS

Confidence in and connection to one's healthcare team appear to be linked with a stable HCT among AYA with KT. This suggests that interdependence, the ability to foster connections with and elicit support from healthcare providers, as opposed to complete independence or autonomy, which is often advised in the HCT process, is a critical component of resilience linked to stable HCT.

Impact of Service User Involvement from the Perspective of Adolescents and Young Adults with Cancer Experience

Purpose: Knowledge of the impact of participating in service user involvement within a health care setting among adolescents and young adults (AYAs) with cancer is limited, and it is unclear as to what AYAs with cancer gain from their participation. Therefore, the purpose of this study was to investigate the impact of participating in service user involvement initiatives from the perspective of AYA cancer patients and AYA cancer survivors. Methods: Individual semistructured interviews were performed with 12 AYAs aged 16-29 who had been or were in current treatment for cancer. Participants were recruited from Kræftværket, a youth support center and social organization for AYAs with cancer, where they had participated in one or more service user involvement initiatives. Data were analyzed by using thematic analysis. Results: The following main themes were found (presented with subthemes in brackets): Achieving professional skills (Strengthening of the Curriculum Vitae, Inspiration for own profession, Handling new working procedures), Being considerate to others (Understanding different perspectives, Altruism), Increasing well-being (Insights into life with cancer, Social community, Giving meaning to life, Everyday life and normalcy). Conclusion: Participating in service user involvement initiatives made the AYAs feel more empowered during their illness course and complied with the personal needs and wishes of AYAs with cancer, including additional support from likeminded individuals. The participants experienced a range of benefits from participating, such as a greater sense of normalcy and increased well-being, allowing for a greater sense of control throughout their illness course.

Transitional care practices, services, and delivery in childhood cancer survivor programs: A survey study of U.S. survivorship providers

PURPOSE

There are limited reports describing transition of young adult childhood cancer survivors (CCS) from pediatric to adult-focused survivorship care. The purpose of this study was to characterize current transitional care practices in the United States.

PROJECT DESCRIPTION

An online survey was sent to one preselected respondent at 163 Children's Oncology Group member institutions in the United States. Data were collected about (i) the availability and type of long-term follow-up services for adult CCS and (ii) policies and procedures for transitioning. Logistic regression was used to evaluate factors related to care for CCS.

RESULTS

The response rate was 60% (97/163). Eighty-one respondents (84%) represented centers with specialized pediatric-focused CCS programs. Thirty-nine percent (38/97) of programs delivered specialized transitional care for adult CCS. Adult-centered care was delivered in both pediatric (39%, 15/38) and adult oncology clinics (39%, 15/38). The most common perceived transition barriers were lack of available partnering adult providers and adult providers' lack of knowledge regarding CCS. The larger the program in terms of new diagnoses, the more likely they were to offer formal transitional care (<50 vs >200: odds ratios [OR] 20.0; 95% CI 3.2, 100.0, P = 0.004).

CONCLUSIONS

A variety of models are utilized for delivering care to adult CCS. Our results suggest that interventions to establish effective partnerships with adult providers on appropriate care of CCS may facilitate expanded availability of these services.

Integrating multiple community perspectives in intervention development

We offer a framework and exemplify how to integrate multiple community perspectives in research to develop breast cancer screening interventions among Latinas non-adherent to national guidelines. We leverage members of an academic institution's community consultative service [community engagement advisory board (CEAB) members]; study team members [community health workers (CHWs)] and study-eligible individuals (non-adherent Latinas). First, we asked what was needed from CEAB members (N=17), CHWs (N=14) and non-adherent Latinas (N=20) in one-time semi-structured group consultations and focus groups. Second, we drafted materials. Third, we conducted group consultations and focus groups with a new set of CEAB members (N=13), CHWs (N=17) and non-adherent Latinas (N=16) to reflect on our initial analysis and draft materials. Fourth, we finalized interventions. Certain recommendations were shared across stakeholders and simple to integrate (e.g. costs → access to free services). Some recommendations varied, but complementary integration was possible (e.g. location versus recruitment → multiple recruitment in multiple community areas). Others were distinct across stakeholders and resulted in strategies to recognize participants' agency and inform their choices about breast cancer screening (e.g. differences in preferred information about screening → personalized information and evidence about all screening options).

Long-term implications of structured transition of adolescents with inflammatory bowel disease into adult health care: a retrospective study

Background

We aimed to evaluate the long-term clinical and socioeconomic outcome of structured transition care in adolescents with inflammatory bowel disease (IBD).

Methods

We compared the clinical long-term course of 24 patients with and 11 patients without structured transition care within 24 months before and 24 months after transfer from paediatric to adult health care. Socio-economic parameters and quality of life were assessed by IBD Questionnaire (IBDQ-32) and additional items. Treatment costs were calculated for medication, surgery and hospitalisation.

Results

The percentage of transfer group patients with an IBD-related intestinal complication was higher compared to the transition group (64% vs. 21%, p = 0.022). We also found a tendency towards a higher number of IBD-related surgery in the transfer group compared to the transition group (46% vs. 13%, p = 0.077). Transfer group patients received higher mean cumulated doses of radiation compared with the transition group (4.2 ± 5.3 mSv vs. 0.01 ± 0.01 mSv, p = 0.036). Delayed puberty was only noted in the transfer group (27%, p = 0.025). Mean expenditures for surgeries and hospitalisation tended to be lower in the transition group compared to transfer group patients (744 ± 630€ vs. 2,691 ± 4,150€, p = 0.050). Sexual life satisfaction was significantly higher (p = 0.023) and rates of loose bowel movements tended to be lower (p = 0.053) in the transition group.

Conclusions

Structured transition of adolescents with IBD from paediatric into adult health care can lead to important clinical and economic benefits.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-1046-5) contains supplementary material, which is available to authorized users.

Readiness for transition and health-care satisfaction in adolescents with complex medical conditions

BACKGROUND

The purpose of this study is to examine contributions to patient perceptions of transition readiness and satisfaction with care amongst adolescents and young adults (AYAs) with complex health conditions engaging in paediatric care.

METHODS

Participants included 94 patients aged 14-20 years (M = 16.41, SD = 1.56) with cystic fibrosis (n = 31), sickle cell disease (n = 27), and solid organ transplants (n = 36). Participants completed self-report questionnaires and medical providers completed measures of their medication regimen complexity. One-way analysis of variance compared differences between disease groups on study variables. Pearson product-moment correlation coefficients and linear regression models evaluated factors associated with AYA reported transition readiness and satisfaction with health care.

RESULTS

There were no significant differences between disease groups on patient-reported transition readiness, barriers to medication adherence, health care self-management, or satisfaction. Patient age, self-reported health-care responsibility, medication barriers, and academic performance predicted a large portion of the variance in AYA perceptions of transition readiness (R²  = 0.27, F (4, 83) = 7.74, p < 0.001, Cohen's f2 = 0.37). Patient gender, self-reported health-care responsibility, and medication barriers predicted a medium portion of the variance in AYA satisfaction with health care (R²  = 0.23, F (3, 88) = 8.56, p < 0.001, Cohen's f2 = 0.30).

CONCLUSIONS

Patient perceptions of health care self-management and barriers to medication adherence are important predictors of readiness for transition and satisfaction with care. Considering a holistic approach that includes these factors allows for improved understanding of individual needs for transition interventions that can improve adult outcomes for individuals with complex health conditions.

Text Message Responsivity in a 2-Way Short Message Service Pilot Intervention With Adolescent and Young Adult Survivors of Cancer

Background: Text message interventions hold promise for adolescents and young adults (AYAs) with chronic health conditions, including childhood cancer survivors; however, engagement is often suboptimal. Limited research has studied mobile health intervention outcomes beyond efficacy. Understanding responsivity to different types of text messages (ie, when a participant texts back) can provide practical, actionable information to optimize engagement in future projects.

Iterative Development of a Tailored mHealth Intervention for Adolescent and Young Adult Survivors of Childhood Cancer

Objectives

Methods for developing mobile health (mHealth) interventions are not well described. To guide the development of future mHealth interventions, we describe the application of the agile science framework to iteratively develop a mHealth intervention for adolescent and young adult (AYA) survivors of childhood cancer.

Methods

We created the AYA STEPS mobile app (AYA Self-management via Texting, Education, and Plans for Survivorship) by modifying and integrating two existing programs: an online survivorship care plan (SCP) generator and a text messaging self-management intervention for AYA off treatment. The iterative development process involved three stages of agile science: 1) Formative work, 2) Obtaining feedback about the first AYA STEPS prototype, and 3) Pilot testing and finalization of a prototype. We determined preferences of AYA stakeholders as well as discovered and addressed technology problems prior to beginning a subsequent randomized controlled trial.

Results

AYA survivors reported that the app and the embedded tailored messages related to their health and SCP, were easy to use and generally satisfying and beneficial. Usage data supported that AYA were engaged in the app. Technology glitches were discovered in the pilot and addressed.

Conclusions

The iterative development of AYA STEPS was essential for creating a consistent and acceptable end user experience. This study serves as one example of how behavioral scientists may apply agile science to their own mHealth research.

The reliability and validity of a newly developed spina bifida-specific Transition Readiness Assessment Questionnaire: Transition Readiness Assessment Questionnaire-supplement (TRAQ-SB)

PURPOSE

The purpose of this study is to report preliminary evidence to support a new condition-specific measure of transition readiness that is theoretically grounded in the Stages of Changes framework. The Transition Readiness Assessment Questionnaire-Spina Bifida (TRAQ-SB) supplement is a newly developed tool used to measure independence and skill acquisition related to spina bifida. Similar to the Transition Readiness Assessment Questionnaire (TRAQ), the TRAQ-SB uses a 5-point Likert response set.

METHODS

Working with a multi-disciplinary team with expertise in the care of children with spina bifida, the authors developed twelve items pertaining to main aspects of SB self-management. The items were reviewed and revised through several iterations by the team and patients. The items were then fielded at a spina bifida Specialty Clinic, where 93 consecutive patients 12-25 years of age were approached to participate and 90 were administered the 20-item TRAQ and a 12-item TRAQ-SB questionnaire. A principal component analysis (PCA) was conducted on the twelve items with oblique rotation (promax). Criterion validity was also assessed by examining the correlation of the TRAQ-SB supplement with the TRAQ and with age.

RESULTS

Results of the factor analysis revealed that eleven of the twelve items loaded onto one factor with factor loadings ranging from 0.46 to 0.84. The scale yielded excellent internal reliability with a Cronbach alpha of 0.90. Correlations of the TRAQ-SB supplement scale score with the TRAQ overall scale score demonstrated good criterion validity (r= 0.74, p< 0.01). In addition, it was highly correlated with the TRAQ subscales, varying from 0.68 to 0.74 (all p< 0.01). Lastly, the TRAQ-SB was significantly correlated with age (r= 0.25, p< 0.01).

CONCLUSIONS

Results of our analyses indicated that the TRAQ-SB demonstrated good internal reliability and criterion validity as evidenced by strong correlation with age and the validated TRAQ measure. The TRAQ-SB tool can be useful to incorporate transition readiness assessment and self-management training into routine care for adolescents with spina bifida.

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

Risk and vulnerability encompass many dimensions of the transition from adolescence to adulthood. Transition from pediatric, parent-supervised health care to more independent, patient-centered adult health care is no exception. The tenets and algorithm of the original 2011 clinical report, "Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home," are unchanged. This updated clinical report provides more practice-based quality improvement guidance on key elements of transition planning, transfer, and integration into adult care for all youth and young adults. It also includes new and updated sections on definition and guiding principles, the status of health care transition preparation among youth, barriers, outcome evidence, recommended health care transition processes and implementation strategies using quality improvement methods, special populations, education and training in pediatric onset conditions, and payment options. The clinical report also includes new recommendations pertaining to infrastructure, education and training, payment, and research.