Transitional care in clinical networks for young people with juvenile idiopathic arthritis: current situation and challenges

Inter-organisational collaboration enabling care delivery in a specialist cancer surgery provider network: A qualitative study

Objective

To explore the processes, challenges and strategies used to govern and maintain inter-organisational collaboration between professionals in a provider network in London, United Kingdom, which implemented major system change focused on the centralisation of specialist cancer surgery.

Methods

We used a qualitative design involving interviews with stakeholders (n = 117), non-participant observations (n = 163) and documentary analysis (n = 100). We drew on an existing model of collaboration in healthcare organisations and expanded this framework by applying it to the analysis of collaboration in the context of major system change.

Results

Network provider organisations established shared goals, maintained central figures who could create and sustain collaboration, and promoted distributed forms of leadership. Still, organisations continued to encounter barriers or challenges in relation to developing opportunities for mutual acquaintanceship across all professional groups; the active sharing of knowledge, expertise and good practice across the network; the fostering of trust; and creation of information exchange infrastructures fit for collaborative purposes.

Conclusion

Collaborative relationships changed over time, becoming stronger post-implementation in some areas, but continued to be negotiated where resistance to the centralisation remained. Future research should explore the sustainability of these relationships and further unpack how hierarchies and power relationships shape inter-organisational collaboration.

Differences in Healthcare Transition Views, Practices, and Barriers Among North American Pediatric Rheumatology Clinicians From 2010 to 2018

OBJECTIVE

Since 2010, the rheumatology community has developed guidelines and tools to improve healthcare transition. In this study, we aimed to compare current transition practices and beliefs among Childhood Arthritis and Rheumatology Research Alliance (CARRA) rheumatology providers with transition practices from a provider survey published in 2010.

METHODS

In 2018, CARRA members completed a 25-item online survey about healthcare transition. Got Transition's Current Assessment of Health Care Transition Activities was used to measure clinical transition processes on a scale of 1 (basic) to 4 (comprehensive). Bivariate analyses were used to compare 2010 and 2018 survey findings.

RESULTS

Over half of CARRA members completed the survey (202/396), including pediatric rheumatologists, adult- and pediatric-trained rheumatologists, pediatric rheumatology fellows, and advanced practice providers. The most common target age to begin transition planning was 15-17 years (49%). Most providers transferred patients prior to age 21 years (75%). Few providers used the American College of Rheumatology transition tools (31%) or have a dedicated transition clinic (23%). Only 17% had a transition policy in place, and 63% did not consistently address healthcare transition with patients. When compared to the 2010 survey, improvement was noted in 3 of 12 transition barriers: availability of adult primary care providers, availability of adult rheumatologists, and pediatric staff transition knowledge and skills (P < 0.001 for each). Nevertheless, the mean current assessment score was < 2 for each measurement.

CONCLUSION

This study demonstrates improvement in certain transition barriers and practices since 2010, although implementation of structured transition processes remains inconsistent.

Patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology: a qualitative systematic review

OBJECTIVES

We aimed to describe patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology to inform patient-centred transitional care programmes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO and CINAHL to August 2019 and used thematic synthesis to analyse the findings.

RESULTS

From 26 studies involving 451 people with juvenile-onset rheumatic conditions we identified six themes: a sense of belonging (comfort in familiarity, connectedness in shared experiences, reassurance in being with others of a similar age, desire for normality and acceptance); preparedness for sudden changes (confidence through guided introductions to the adult environment, rapport from continuity of care, security in a reliable point of contact, minimizing lifestyle disruptions); abandonment and fear of the unknown (abrupt and forced independence, ill-equipped to hand over medical information, shocked by meeting adults with visible damage and disability, vulnerability in the loss of privacy); anonymous and dismissed in adult care (deprived of human focus, sterile and uninviting environment, disregard of debilitating pain and fatigue); quest for autonomy (controlled and patronized in the paediatric environment, liberated from the authority of others, freedom to communicate openly); and tensions in parental involvement (overshadowed by parental presence, guilt of excluding parents, reluctant withdrawal of parental support).

CONCLUSION

Young people feel dismissed, abandoned, ill-prepared and out of control during transition. However, successful transition can be supported by preparing for changes, creating a sense of belonging and negotiating parental involvement and autonomy. Incorporating patient-identified priorities into transitional services may improve satisfaction and outcomes in young people with juvenile-onset rheumatic conditions.

Patient and parent perspectives on transition from paediatric to adult healthcare in rheumatic diseases: an interview study

OBJECTIVES

To describe the experiences, priorities, and needs of patients with rheumatic disease and their parents during transition from paediatric to adult healthcare.

SETTING

Face-to-face and telephone semistructured interviews were conducted from December 2018 to September 2019 recruited from five hospital centres in Australia.

PARTICIPANTS

Fourteen young people and 16 parents were interviewed. Young people were included if they were English speaking, aged 14-25 years, diagnosed with an inflammatory rheumatic disease (eg, juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, panniculitis, familial Mediterranean fever) before 18 years of age. Young people were not included if they were diagnosed in the adult setting.

RESULTS

We identified four themes with respective subthemes: avoid repeat of past disruption (maintain disease stability, preserve adjusted personal goals, protect social inclusion); encounter a daunting adult environment (serious and sombre mood, discredited and isolated identity, fear of a rigid system); establish therapeutic alliances with adult rheumatology providers (relinquish a trusting relationship, seek person-focused care, redefine personal-professional boundaries, reassurance of alternative medical supports, transferred trust to adult doctor) and negotiate patient autonomy (confidence in formerly gained independence, alleviate burden on patients, mediate parental anxiety).

CONCLUSIONS

During transition, patients want to maintain disease stability, develop a relationship with their adult provider centralised on personal goals and access support networks. Strategies to comprehensively communicate information between providers, support self-management, and negotiate individualised goals for independence during transition planning may improve satisfaction, and health and treatment outcomes.

Using Arts-Based Therapies to Improve Mental Health for Children and Young People With Physical Health Long-Term Conditions: A Systematic Review of Effectiveness

Background: Children with physical health long-term conditions (LTCs) have increased risk of mental health difficulties relative to healthy peers. However, availability of psychological support integrated into pediatric physical health settings is limited, and there are long waiting times for access to child mental health services. Arts-based therapies involve using creative media to develop a therapeutic relationship, and offer a potential alternative to talking-based therapies. The aim of this systematic review is to establish the effectiveness of arts-based therapies for improving the mental health of children with physical health LTCs.

Methods: The review protocol was published on PROSPERO. Four electronic databases were searched (Medline, Embase, Cinahl, and PsycINFO), plus hand searches of two key journals and relevant reviews, and forward/back citations searches of selected articles were conducted. The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess bias in selected articles. Second reviewers completed 10% of article screening and 20% of bias assessments. The findings were synthesized narratively.

Results: Sixteen studies met inclusion criteria and demonstrated some improvements on indicators of mental health and well-being including quality of life, coping behaviors, anxiety, self-concept, and mood. However, replication across interventions and outcomes was absent. Overall, the quality of evidence of effectiveness in the studies reviewed was moderate/weak. This was due to bias in study design; other limitations included a lack of detail on intervention components, e.g., use of a manual, and single recruitment sites.

Conclusions: The heterogeneity of existing research evaluating arts-based therapies for children with physical health LTCs limits conclusions about effectiveness. Suggestions are made to inform the design of future research studies to help build a robust evidence base.

The European network for care of children with paediatric rheumatic diseases: care across borders

OBJECTIVES

To provide an overview of the paediatric rheumatology (PR) services in Europe, describe current delivery of care and training, set standards for care, identify unmet needs and inform future specialist service provision.

METHODS

An online survey was developed and presented to national coordinating centres of the Paediatric Rheumatology International Trials Organisation (PRINTO) (country survey) and to individual PR centres (centre and disease surveys) as a part of the European Union (EU) Single Hub and Access point for paediatric Rheumatology in Europe project. The survey contained components covering the organization of PR care, composition of teams, education, health care and research facilities and assessment of needs.

RESULTS

Response rates were 29/35 (83%) for country surveys and 164/288 (57%) for centre surveys. Across the EU, approximately one paediatric rheumatologist is available per million population. In all EU member states there is good access to specialist care and medications, although biologic drug availability is worse in Eastern European countries. PR education is widely available for physicians but is insufficient for allied health professionals. The ability to participate in clinical trials is generally high. Important gaps were identified, including lack of standardized clinical guidelines/recommendations and insufficient adolescent transition management planning.

CONCLUSION

This study provides a comprehensive description of current specialist PR service provision across Europe and did not reveal any major differences between EU member states. Rarity, chronicity and complexity of diseases are major challenges to PR care. Future work should facilitate the development, dissemination and implementation of standards of care, treatment and service recommendations to further improve patient-centred health care across Europe.

The transition of adolescents with juvenile idiopathic arthritis or epilepsy from paediatric health-care services to adult health-care services: A scoping review of the literature and a synthesis of the evidence

Young people with long-term health conditions (LTCs) can face challenges when making the transition to adult health services. This paper sought to identify studies that assess and explore transitional care for young people with LTCs. Two conditions were used as exemplars: juvenile idiopathic arthritis (JIA) and epilepsy. A scoping review of the literature was conducted by using search terms to search for papers in English between 2001 and 2016 concerning transitional care on four databases. Qualitative papers were reviewed and synthesized using thematic analysis. Quantitative papers using health outcomes were also synthesized. Twenty-eight papers were selected for review. Despite the wealth of literature concerning aspects of transitional care that are key to a successful transition for young people with JIA or epilepsy, there is a paucity of outcomes that define 'successful' transition and consequently a lack of reliable research evaluating the effectiveness of transitional care interventions to support young people moving to adult health services.

Development of a clinical transition pathway for adolescents in the Netherlands

AIMS

To explore how young people with juvenile-onset rheumatic and musculoskeletal diseases (jRMDs) and their parent(s) experience care during preparation for the upcoming transfer to adult services, and to develop a clinical transition pathway.

METHOD

A survey was conducted with 32 young people aged between 14 and 20 years with jRMDs, and their parents ( n =33), treated at the department of paediatric rheumatology in a tertiary care children's hospital in the Netherlands.

RESULTS

More than 30% of young people would have liked to discuss topics such as educational and vocational choices in a clinic, but did not get the opportunity. Preparation for transition was poor as was training in self-management skills. One third of parents had feelings of anxiety about the upcoming transfer. Results from the survey and evidence-based principles of transitional care were used to develop the clinical transition pathway. The pathway focuses on starting transition early, developing self-management skills, joint consultations and supporting parents in giving young people control of their clinical care.

CONCLUSION

Care does not currently meet the needs of young people in the process of transition to adult rheumatology services. The clinical transition pathway developed as a result of the study is a tool that may improve this process.

Transition to adult rheumatology care is necessary to maintain DMARD therapy in young people with juvenile idiopathic arthritis

OBJECTIVE

To evaluate the outpatient health service utilisation of young people (YP) with juvenile idiopathic arthritis (JIA) during transfer from paediatric to adult care in Germany.

METHODS

Based on claims data of a large German statutory health fund (BARMER GEK) we conducted a cohort study of 2008-2014. Insured YP with diagnosis of JIA (ICD: M08 or M09.0) in two quarters at the age of 16 and continuous insurance until the age of 20 were included. Outpatient health care utilisation, prescribed antirheumatic drugs and diagnosis maintenance were analysed over four consecutive years for all YP with JIA and for the subgroup on disease-modifying antirheumatic drugs (DMARDs) at the age of 16.

RESULTS

A total of 256 YP with JIA (67% female) were followed during the transfer period, 115 of them received (DMARDs) at the age of 16. At the age of 20, 30% of all 256 YP utilised adult specialty care, 59% still had a JIA diagnosis and 30% were treated with DMARDs. Of those 115 YP, treated with DMARDs at the age of 16 and in need of follow-up, 49% had visited an adult rheumatologist at the age of 20, 75% had a JIA diagnosis and 56% were on DMARDs. Those 49% YP with successful transfer to adult specialty care had a JIA diagnosis in 93% and were treated with DMARDs in 80%. YP, who were only seen by general practitioners, had a JIA diagnosis in 54% and received DMARDs in 27%.

CONCLUSIONS

One in two YP with JIA and a clear need for ongoing follow-up do not utilise adult rheumatologic care. The maintenance of JIA diagnosis and DMARD therapy depend on the utilisation of specialised care services.

EULAR/PReS standards and recommendations for the transitional care of young people with juvenile-onset rheumatic diseases

To develop standards and recommendations for transitional care for young people (YP) with juvenile-onset rheumatic and musculoskeletal diseases (jRMD). The consensus process involved the following: (1) establishing an international expert panel to include patients and representatives from multidisciplinary teams in adult and paediatric rheumatology; (2) a systematic review of published models of transitional care in jRMDs, potential standards and recommendations, strategies for implementation and tools to evaluate services and outcomes; (3) setting the framework, developing the process map and generating a first draft of standards and recommendations; (4) further iteration of recommendations; (5) establishing consensus recommendations with Delphi methodology and (6) establishing standards and quality indicators. The final consensus derived 12 specific recommendations for YP with jRMD focused on transitional care. These included: high-quality, multidisciplinary care starting in early adolescence; the integral role of a transition co-ordinator; transition policies and protocols; efficient communications; transfer documentation; an open electronic-based platform to access resources; appropriate training for paediatric and adult healthcare teams; secure funding to continue treatments and services into adult rheumatology and the need for increased evidence to inform best practice. These consensus-based recommendations inform strategies to reach optimal outcomes in transitional care for YP with jRMD based on available evidence and expert opinion. They need to be implemented in the context of individual countries, healthcare systems and regulatory frameworks.