Transitioning Adolescents and Young Adults with Spina Bifida to Adult Healthcare: Initial Findings from a Model Program

Pediatric to Adult Hydrocephalus: A Smooth Transition

Introduction

Pediatric patients treated for hydrocephalus, regardless of etiology, require continuous access to care to address the long-term sequelae from the disease progression itself and from the interventions undertaken. The challenge for all pediatric neurosurgeons is providing comprehensive and coordinated care for these patients in order to achieve a smooth and seamless transition into adult health care.

Methods

A review of the literature was conducted regarding the overall concept of pediatric patients with chronic conditions transitioning to adult care. We also specifically reviewed the pediatric hydrocephalus literature to investigate the barriers of transition, models of success, and specific elements required in a transition policy.

Results

The review identified several barriers that hamper smooth and successful transition from pediatric to adult care within the hydrocephalus population. These included patient-related, cultural/society-related, healthcare provider-related, and healthcare system-related barriers. Six elements for successful transitions were noted: transition policy, tracking and monitoring, transition readiness, transition planning, transfer of care, and transition completion stemming from the Got Transition center.

Conclusions

A successful patient transition from pediatric neurosurgical care to adult neurosurgical care is very center-specific and depends on the available resources within that center's hospital, health system, and geo-economic environment. Six recommendations are made for transition policy implementation in resource-poor environments, including beginning the process early, preferably at age 14 years.

Discrepancies in Educational Needs for Transition in Adolescents and Young Adults with Spina Bifida in South Korea: Use of the Borich Needs Assessment Model

PURPOSE

Transition is an important goal for ensuring that adolescents and young adults (AYAs) with spina bifida (SB) lead autonomous lives. This study aimed to identify the educational needs of AYAs with SB based on the discrepancies between perceived importance and proficiency levels during the transition process.

DESIGN AND METHODS

A cross-sectional study was conducted through face-to-face and online surveys from Jan-Dec 2020 of AYAs aged 13-25 years who had previously been diagnosed with SB. The survey consisted of 37 transition-related questions, of which 11 pertained to healthcare environments and 26 pertained to transition education needs SPSS and Excel were used for statistical analysis. Transition educational needs were analyzed by the Borich Needs Assessment Model. Higher the mean weighted discrepancy scores, lower the proficiency as compared to the perceived importance, indicating that the educational needs were high.

RESULTS

Overall, 108 responses were analyzed, and 56 (51.9%) AYAs were diagnosed with lipomyelomeningocele. The highest ranked educational needs were for "Health insurance system", "SB related urinary system diseases management", "SB related nervous system symptoms", and "Self-catheterization management". "The demands for 'SB related work life", "Urinary incontinence management", and "Constipation management" were significantly higher in young adults than adolescents.

CONCLUSIONS

During the transition process, activities perceived as important by AYAs with SB may differ from the activities that they can actually perform proficiently. It is important to assess their needs based on these discrepancies.

PRACTICE IMPLICATIONS

Transition education programs are needed that consider the individual educational needs and developmental stage-specific characteristics of AYAs with SB.

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.

Self-management and spina bifida: A systematic review of the literature

BACKGROUND

Self-management is critical to optimizing the health of individuals with a chronic condition or disability and is, therefore, a central concept in individual and family-centered healthcare delivery. The purpose of this review is to report the state of the science of self-management for individuals with spina bifida (SB) from a lifespan perspective.

OBJECTIVE

This review will summarize the (a) development and use of self-management skills and behaviors across the life span, (b) factors related to self-management behaviors, (c) development of generic or condition-specific measures of self-management used with a spina bifida population, and (d) development and/or outcomes of interventions to improve self-management in SB.

METHODS

The search strategy was limited to primary research articles published between 2003 and 2019 and followed PRISMA guidelines. The databases searched included: PubMed, CINAHL, PsycINFO, Web of Science, Cochrane, and Google Scholar. Studies that addressed self-management concepts in individuals throughout the life span and published in English were included.

RESULTS

The search yielded 108 citations and 56 articles met inclusion/exclusion criteria. A systematic narrative synthesis was reported. The level of evidence identified was primarily Level III articles of good quality. Multiple demographic, environmental, condition and process factors were related to self-management behaviors. SB self-management instruments and intervention development and testing studies were identified.

CONCLUSIONS

This review provides a synthesis of the state of the science of self-management including factors related to self-management behaviors, preliminary evidence of instruments for use in SB, factors important to consider in the development and testing of future interventions, and gaps in the literature.

Being cross pressured-parents' experiences of the transfer from paediatric to adult care services for their young people with long term conditions: A systematic review and qualitative research synthesis

BACKGROUND

Family members of young people (13-24 years) with long-term conditions tend to experience multiple challenges when their children transfer from paediatric to adult care, as do the patients themselves.

OBJECTIVES

To identify, interpret and theoretically conceptualise the meaning of parents' experiences of the transfer from paediatric to adult care of their young people with long-term conditions.

DESIGN

A qualitative research synthesis.

DATA SOURCES

We obtained articles from Medline, CINAHL, PsycINFO, EMBASE, Scopus, and Web of Science. Unpublished theses and dissertations were searched for using Google Scholar, Mednar, and ProQuest Dissertations and Theses.

REVIEW METHODS

Based on a previously published protocol, we followed the guidelines from the Joanna Briggs Institute. Sandelowski and Barroso's qualitative research synthesis approach guided the metasynthesis. Articles published between 1999 and March 2019 were systematically searched for.

FINDINGS

Twenty-three reports from seven Western countries representing 454 parents including significant others such as aunts and grandparents of 462 young people with various diagnoses contributed to the review. 'Being cross-pressured' was the metasynthesis found to reflect parents' experiences of the transfer from paediatric to adult care of their young people with long-term conditions. The metasynthesis comprised four themes: 'Fluctuating between parental roles', 'Navigating contrasting healthcare contexts', 'Making decisions in the face of inner conflict', and 'Trusting their child's self-management ability'.

CONCLUSIONS

Our metasynthesis finding of parents' experiences of being cross-pressured provides a new way of thinking about the study phenomena which is supported by transitions theory holding that multiple transitions can take place simultaneously involving myriads of concurrent and conflicting demands. The cross pressure may overwhelm parents. The clinical implications are to recognise parents' experiences and distress in healthcare planning to promote safe and predicable transfers of their young people. Provision of healthcare to parents during transfer needs to be tailored to a collaborative decision-making process between parents, their young people, and involved practitioners across paediatric and adult healthcare services. Tweetable abstract: Parents experienced being cross-pressured when their young people with long-term conditions were transferred from paediatric to adult care.

Transition programs for adolescents and young adults with spina bifida: A mixed-methods systematic review

AIMS

To identify the components of transition programs for the successful transition of adolescents and young adults with spina bifida and to synthesize the literature findings on the transition outcomes of the programs.

DESIGN

Mixed-methods systematic review.

DATA SOURCES

PubMed, CINAHL, PsycINFO, and Web of Science (January 2010-June 2019).

REVIEW METHODS

The methodological quality was appraised using the Mixed Methods Appraisal Tool and Cochrane Risk of Bias Tool. Extracted data were summarized as tables. For data synthesis, a sequential explanatory design was used.

RESULTS

Eight studies were selected. The main components of the transition programs identified the participants' characteristics and intervention strategies. Quantitative studies reported only positive transition outcomes, including independence and satisfaction with social support and transition experience, whereas negative outcomes such as negative experiences communicating with providers and uncertainty were further reported in qualitative studies.

CONCLUSION

For development and implementation of a successful transition program, it is necessary to assess the characteristics and needs of the participants and incorporate their needs with input from parents and trained healthcare providers.

IMPACT

When planning transition programs, a comprehensive effort that encompasses program development, implementation, and evaluation, based on developmental tasks and long-term perspectives, is needed. Transition program that reflect the cultural characteristics of Eastern and developing countries are needed.

Constructing Recovery Narratives: Experiences and Expectations Following Spinal Cord Injury

PURPOSE

This study aimed to explore how married individuals construct narratives following spinal cord injury (SCI).

DESIGN

Prospective qualitative study.

METHODS

Eighteen married people with SCI were recruited during inpatient hospitalization. In-depth interviews were conducted at approximately 1, 4, and 7 months post-SCI. Interviews were analyzed using thematic analysis.

FINDINGS

Participants constructed three primary narrative types (optimistic, anxious, and stability) about their trajectories following SCI, focusing on their expectations about recovery and their past and current experiences with their spouse, peers, and health professionals. These narrative types are the foundation for understanding how people make sense of the rehabilitation experience in relation to others.

CONCLUSIONS

Findings provide an initial understanding of how expectations of life with SCI as well as social interactions in the healthcare setting influence experiences of injury and recovery.

CLINICAL RELEVANCE

Findings can inform future interventions during SCI rehabilitation to ease transitions and decrease anxiety following SCI.

Needs assessment survey for children and adults with spina bifida in Georgia

PURPOSE

We conducted a needs assessment among parents/guardians of children and independent adults with spina bifida, served by the Spina Bifida Association of Georgia (SBAGA). The objective was to assess if SBAGA is adequately meeting the needs of its constituents and to identify challenges and opportunities to improve services.

METHODS

The survey targeted all members of SBAGA in 2017. Survey questions were drafted separately for parents/guardians of children, and independent adults with spina bifida. Both closed- and open-ended response options were provided. The survey was pilot-tested, and administered in English and Spanish, using email, post, or in person.

RESULTS

A total of 119 individuals completed the survey. For parents/guardians (n= 96), the most important needs were bladder and bowel education, social and communication skills education, medical support, and transition and independence training. Independent adults (n= 23) responded that they mostly needed bladder and bowel education, medical support, and transition and independence training. Location of the SBAGA events and transportation to the events were the most frequent limiting factors for both groups.

CONCLUSIONS

Our survey findings highlighted that SBAGA services are valued overall. The survey findings will be used to guide quality improvement of current programs, and develop programs addressing emerging needs and challenges.

The Role of Pediatric Psychologists in the Transition of Youth to Adult Health Care: A Descriptive Qualitative Study of Their Practice and Recommendations

Transition from pediatric to adult health care setting is a challenge for young patients because of the psychosocial issues they may present that could hinder their commitment to treatment and medical care. Psychologists play a key role in supporting these patients. They intervene with the most vulnerable ones for whom the current transitional practice does not necessarily meet their specific needs and help them to develop an appropriate level of autonomy despite medical condition. To date, few studies have described their clinical practice in this field. This study aimed to gather in-depth information about the elements that characterize their different roles in transition care. Following a semi-structured interviews with ten pediatric psychologists, we conducted a thematic content analysis to identify common themes among participants. The results indicate that the psychologists' practice focuses on four main aspects: assessment, intervention, education, and liaison. Their recommendations point towards a better organization of health care services and a reflection on the best practices in psychology. These results highlight the specific roles that pediatric psychologists play in the transition process within the health care environment.

Transitioning in hydrocephalus: Current practices in Canadian Paediatric Neurosurgery centres

Introduction

Advances in perinatal care in the developed world have resulted in more children living into adulthood with complex chronic health conditions. Transition is a process to improve and maximize the functional status of adolescents via the provision of adequate and appropriate health services in adulthood. This process is frequently disjointed, fragmented and inconsistent and inadequate transition increases morbidity, hospital admissions and urgent interventions. Ten thousand children are diagnosed with hydrocephalus annually in North America. Most survive to adulthood yet there are few transitioning programs and little research data on successful programs for this population.

Methods

An email survey of paediatric neurosurgical centres in Canada was carried out to establish current transition practices and attitudes for adolescents with hydrocephalus. Data were analyzed descriptively.

Results

Eleven out of 12 centres responded. The age of transition ranged from 16 to 18 years. Four centres have access to a dedicated Adult Hydrocephalus Clinic. Referral practices vary between centres and we highlight inconsistencies in care to this cohort of patients in Canada. There is little satisfaction among neurosurgeons with current transition arrangements in Canada. Several suggestions were made on how to improve this process.

Conclusion

We recommend research into the needs of patients with hydrocephalus in order to formalize appropriate standards for transitioning patients with a view to developing national guidelines to standardize the transition process. This will require input from patients, families and the wider medical and allied health professional groups.

The Nature of Patient- and Family-Centred Care for Young Adults Living with Chronic Disease and their Family Members: A Systematic Review

BACKGROUND AND AIM

The published literature addressing the nature of patient- and family-centred care (PFCC) among young adults (16-25 years old) living with chronic disease and their family members is diverse. The aim of this systematic review was to collect and interpretatively synthesise this literature to generate a conceptual understanding of PFCC in this age group.

METHOD

From an initial pool of 10,615 papers, 51 were systematically identified as relevant to the research question and appraised using the Critical Appraisal Skills Programme tools. A total of 24 papers passed the quality appraisal and proceeded to a qualitative meta-synthesis.

RESULTS

The qualitative meta-synthesis revealed three major elements of PFCC relevant to young adults living with chronic disease and their family members: (1) patients and practitioners felt able to engage with each other on an emotional and social level; (2) patients and families felt empowered to be part of the care process; and (3) patients and families experienced care as effective at addressing their individual needs.

CONCLUSION

There is agreement among young adult patients and families about what constitutes PFCC in a chronic disease setting, independent of the aetiology of the pathological process. Patients and families also have strong feelings about how practitioners can achieve PFCC in practice. These findings have implications for the delivery of health services to young adults living with chronic disease and their family members.

Pediatric Nurse Practitioners' Perspectives on Health Care Transition From Pediatric to Adult Care

INTRODUCTION

This study examined the perspectives of pediatric nurse practitioners (PNPs) regarding the needs of adolescents, parents/caregivers, clinicians, and institutions in the health care transition (HCT) process for adolescents/young adults.

METHODS

PNPs (N = 170) participated in a luncheon for those interested in transition at an annual conference. Small groups discussed and recorded their perspectives related to health care transition from adolescent to adult services. Content analysis was used to analyze responses (Krippendorff, 2013).

RESULTS

Four themes, Education, Health care system, Support, and Communication, emerged from the data analysis. PNPs identified health care informatics and adolescents' use of technology as additional critical aspects to be considered in health care transition.

DISCUSSION

Opportunities and challenges identified by the PNPs are discussed to improve the quality and process of transitioning adolescents to adult services. This report will help National Association of Pediatric Nurse Practitioners formulate a new Health Care Transition Policy Statement for the organization.

The development of a lifetime care model in comprehensive spina bifida care

PURPOSE

To describe the development and implementation of the Children's of Alabama (COA) Spina Bifida (SB) Lifetime-Care-Model, including standardized care protocols and transition plan.

METHODS

In 2010, members of the pediatric team at COA began to evaluate limitations in access to care for patients with SB at various stages of life. Through clinic surveys, observations, and caregiver report, a Lifetime-Care-Model was developed and implemented. Partnerships were made with adult medicine colleagues to create an interdisciplinary model at each stage. Since developing this program, it has evolved to include standardized care protocols.

RESULTS

Since 2011, there have been 42 prenatal clinics; 114 families received counseling and prenatal care. Of these, 106 have delivered at our center and established care in our pediatric clinic. There are currently 474 patients in the pediatric and 218 in the adult clinics.

CONCLUSIONS

Our institutional experience suggests that patients with SB benefit from continuity of care throughout their lifetime. This article describes early failures which led to an evolution in approach and implementation of a Lifetime-Care-Model which results in a smooth transition between all phases of life. We hope that other institutions may adapt and build upon it to create programs unique to their specific patient needs.

Youth and parents' experiences of a new inter-agency transition model for spina bifida compared to youth who did not take part in the model

BACKGROUND

Young adults with spina bifida are underserved in health care and are at risk as they transition to adult health care. A pediatric rehabilitation hospital and an adult community health center partnered to help address this gap. Although some research has explored general transition experiences of youth with disabilities, little is known about their experiences in a transition model that involves an inter-agency partnership, continuous, age-appropriate, and client-centered care.

OBJECTIVE

To explore youth and parent experiences of a new transition model for youth with spina bifida, compared to the experiences of young adults with spina bifida who did not participate in the model.

METHODS

Using a descriptive, qualitative design involving a thematic analysis we conducted semi-structured interviews with 32 participants (9 youth, 11 parents, 12 young adults).

RESULTS

Most youth and parents in our sample who took part in the new model felt supported by pediatric providers and benefitted from gradually transferring responsibility from parents to youth. They also reported experiencing challenges, including lack of support from primary care providers and lack of clarity about the new model. Many young adults who did not take part in the model reported receiving some transition-related thought support from pediatric specialists, parents, and in some cases, primary care providers. However, they also reported experiencing gaps in their continuity of care and needed more support with employment, relationships, finances, and housing.

CONCLUSIONS

Our findings show the new transition model for youth with spina bifida can help enhance participants' transition experiences and preparation for adulthood. However, the model needs further development to address the varied abilities and support needs of youth with spina bifida.