Educational and behavioral issues in transitioning from pediatric cardiology to adult-centered health care

Transition to adulthood and transfer to adult care of adolescents with congenital heart disease: a global consensus statement of the ESC Association of Cardiovascular Nursing and Allied Professions (ACNAP), the ESC Working Group on Adult Congenital Heart Disease (WG ACHD), the Association for European Paediatric and Congenital Cardiology (AEPC), the Pan-African Society of Cardiology (PASCAR), the Asia-Pacific Pediatric Cardiac Society (APPCS), the Inter-American Society of Cardiology (IASC), the Cardiac Society of Australia and New Zealand (CSANZ), the International Society for Adult Congenital Heart Disease (ISACHD), the World Heart Federation (WHF), the European Congenital Heart Disease Organisation (ECHDO), and the Global Alliance for Rheumatic and Congenital Hearts (Global ARCH)

The vast majority of children with congenital heart disease (CHD) in high-income countries survive into adulthood. Further, paediatric cardiac services have expanded in middle-income countries. Both evolutions have resulted in an increasing number of CHD survivors. Expert care across the life span is necessitated. In adolescence, patients transition from being a dependent child to an independent adult. They are also advised to transfer from paediatrics to adult care. There is no universal consensus regarding how transitional care should be provided and how the transfer should be organized. This is even more challenging in countries with low resources. This consensus document describes issues and practices of transition and transfer of adolescents with CHD, accounting for different possibilities in high-, middle-, and low-income countries. Transitional care ought to be provided to all adolescents with CHD, taking into consideration the available resources. When reaching adulthood, patients ought to be transferred to adult care facilities/providers capable of managing their needs, and systems have to be in place to make sure that continuity of high-quality care is ensured after leaving paediatric cardiology.

Patient and physician view on patient information and decision-making in congenital aortic and pulmonary valve surgery

Background

To assess the current state of patient information and decision-making in congenital aortic and pulmonary valve disease, we conducted a survey among patients, parents and physicians.

Methods

A questionnaire was sent by ground mail to 157 adults and 32 parents of children who previously underwent surgery for congenital aortic or pulmonary valve disease at 0-40 years of age between January 2005 and February 2014 at the Erasmus University Medical Center and to all paediatric and adult congenital cardiologists and congenital cardiac surgeons in the Netherlands (n=88).

Results

73 patients/parents (39% response rate, 62 adult patients, 11 parents of paediatric patients) and 35 physicians (40% response rate) responded. Median patient age at the time of surgery was 25.7 years. Basic disease-specific knowledge was adequate in 42% of patients/parents and numeracy was sufficient in 47%. Patients/parents reported that they rely heavily on their physicians for information and often experience difficulty in finding reliable information elsewhere. They lack information on psychosocial aspects of disease (29% of respondents) and risks and benefits of treatment options (26%). They feel less involved in decision-making than they would prefer to be (p=0.014). Decisional conflict at the time of surgery was experienced by 31% of patients/parents. If they had to do it again, 72% of patients/parents would want the same treatment. Quality of life is often impaired due to various valve-related anxieties and lifestyle changes. Physicians reported that they are unable to fully inform and sufficiently involve patients, due to limited patient/parent knowledge and understanding (56%) and limited time during consultations (32%). Patients/parents (98%) and physicians (97%) agree that they should have shared roles in decision-making.

Conclusion

The substantial shortcomings in our current practice of patient information and decision-making underline the need for innovative solutions, such as careful implementation of patient information tools and shared decision-making in the care path.

Development of an Online, Evidence-Based Patient Information Portal for Congenital Heart Disease: A Pilot Study

OBJECTIVES

In response to an increased need for patient information on congenital heart disease in the Netherlands, we initiated a nationwide initiative to develop an online, evidence-based patient information portal, starting with a pilot project aimed at the subgroup of patients with congenital aortic and pulmonary valve disease.

METHODS AND RESULTS

We developed an information portal that aims to (1) improve patient knowledge and involvement and to subsequently reduce anxiety and decisional conflict and improve mental quality of life and (2) to support physicians in informing and communicating with their patients. The information portal was developed according to the systematic International Patient Decision Aid Standards development process employing Delphi techniques by a multidisciplinary workgroup of pediatric and adult congenital cardiologists, a congenital cardiothoracic surgeon, a psychologist, an epidemiologist, a patient representative, and web and industrial design experts. First, patients and physicians were surveyed and interviewed to assess the current state of patient information and explore their preferences and needs to determine the focus for the development of the information portal. We found that patient knowledge and numeracy are limited, reliable information is scarce, physicians inform patients selectively and patient involvement is suboptimal, and there is a need for more reliable, tailored, and multi-faceted information. Based on the findings of these surveys and interviews, a patient-tailored information portal was designed that presents evidence-based disease- and age-specific medical and psychosocial information about diagnosis, treatment, prognosis, and impact on daily life in a manner that is comprehensible and digestible for patients and that meets the needs expressed by both patients and physicians. The effect of the website on patient outcome is currently being assessed in a multicenter stepped-wedge implementation trial.

CONCLUSION

The present pilot project succeeded in developing an online, evidence-based information portal that is supported by both patients and physicians. The information portal will be further developed and expanded to include all other major forms of congenital heart disease, translations into other languages, and a public information portal to serve patients' relatives and the general public at large.

From adolescents to adults with congenital heart disease: the role of transition

Improved surgical care during the last decades, together with advances in medical management, led to a remarkable increase in survival of patients with congenital heart disease (CHD). However, aging of the CHD population brings new challenges, and loss of follow-up of adolescents and adults with CHD is a major concern. It is crucial to optimize the transfer of patients with CHD from paediatric to adult health care services to prevent loss to follow-up. The transition process plays a central role in the future health and follow-up of the patient. The aim of this review is to explain and discuss the clinical impact of the transition process in adolescents with CHD. We will also discuss specific CHD adolescents' problems.

CONCLUSION

Adolescence is a crucial phase for the formation of the personality. Understanding and acceptance of the responsibility for health at this stage through a transition process with a multidisciplinary team will determine the quality of future medical follow-up and probably limit psychosocial issues in their adult life.

WHAT IS KNOWN

• Aging of the congenital heart disease population brings new challenges to the organisation of care. • Loss of follow-up is a major concern for patients with congenital heart disease. What is new: • The quality of a formal transition process during adolescence will determine future outcomes in patients with congenital heart disease.

Texting teens in transition: the use of text messages in clinical intervention research

BACKGROUND

The rapidly growing population of young adults living with congenital heart disease (CHD), currently challenging ill-prepared cardiac care systems, presents a novel population in which to consider the use of mHealth. This methodological study was part of a larger study that tested the effectiveness of a clinic-based nursing intervention to prepare teens for transfer from pediatric to adult cardiology care. The intervention included creation of a MyHealth Passport and subsequently SMS (short message service) text messages between the intervention nurse and study participant.

OBJECTIVE

Our aim was to determine (1) the preference of teens with CHD to be contacted via text message following the nursing intervention, (2) the effectiveness of texting to collect data regarding the use of MyHealth Passport after participation in the intervention, (3) the nature of the texting interaction, and (4) the risks and benefits of texting.

METHODS

Participants were recruited through the intervention study (n=24) by either choosing to receive information from the study coordinator through text message, or texting a question to the study nurses. Inclusion criteria were age 15-17 years, diagnosed with moderate or complex heart disease, and currently being followed by the Division of Cardiology at Stollery Children's Hospital. Exclusion criteria were heart transplantation and/or less than a 6th grade reading and comprehension ability. Text message transcripts were analyzed by qualitative inductive content analysis.

RESULTS

Two-thirds of teens (16/24, 67%) chose text messaging as their preferred contact, making them eligible for the study. Texting was effective in collecting information regarding the MyHealth Passport; all but one teen had their MyHealth Passport on them, and many reported carrying it with them wherever they went. All teens reported showing their MyHealth Passport to at least one person. Seven themes were identified in the texting transcripts: mixing formal and informal language, the passive teen, interaction with health care providers, texting teens in transition, texting as a mechanism to initiate other forms of communication, affirmation, and the nurse as an educator. Benefits of texting were identified as flexibility, ability to respond over time, information presented in byte-sized amounts, and information directly related to patient questions. Risks of texting were identified as the possibility that interactions may not be in-depth, distraction of teen and researcher, and invasiveness.

CONCLUSIONS

Text messaging was useful in collecting data regarding the use of the MyHealth Passport. Text messaging resulted in conversations with the teens that were sometimes in-depth and meaningful, especially when combined with other communication modalities. Using text messaging in a manner resulting in full conversations with the patients requires more study and may benefit from protocols and the use of solid theoretical foundations that would standardize the interaction so that more conclusions could be drawn.

Genetic knowledge and attitudes of parents of children with congenital heart defects

Clinical genetic testing for specific isolated congenital heart defects (CHD) is becoming standard of care in pediatric cardiology practice. Both genetic knowledge and attitudes toward genetic testing are associated with an increased utilization of genetic testing, but these factors have not been evaluated in parents of children with CHD. We mailed a survey to measure the demographics, genetic knowledge, and attitudes towards genetic testing of parents of children with CHD who previously consented to participate in a separate research study of the genetic etiology of left ventricular outflow tract malformations (LVOT). Of the 378 eligible families, 190 (50%) returned surveys with both parents completing surveys in 97 (51%) families, resulting in 287 participants. Genetic knowledge was assessed on an adapted measure on which the mean percent correct was 73.8%. Educational attainment and household income were directly and significantly associated with genetic knowledge (P < 0.001). Attitudes about the health effects of genetic testing were favorable with at least 57% agreeing that genetic testing would be used for managing health care and finding cures for disease. Conversely, a minority of participants found it likely that genetic testing would be used for insurance (up to 39.9%), employment (15.8%), or racial/social discrimination (up to 11.2%). Parents of younger children were less likely to endorse employment or racial/social discrimination. Genetic knowledge was not correlated with specific attitudes. Among parents of children with CHD, genetic knowledge was directly associated with household income and education, but additional research is necessary to determine what factors influence attitudes towards genetic testing.

Caring for a teen with congenital heart disease

Adolescents with congenital heart disease (CHD) are a rapidly growing population with complex medical needs and psychosocial challenges. Identity formation is an important developmental task accomplished during the teenage years. This article reviews different aspects of ongoing care that pertain to teenagers with CHD, with a particular focus on primary care issues and a summary of recommendations from various scientific societies. A successful smooth transition to the adult health care setting should achieve 2 important goals: to prevent loss of follow-up and to foster and encourage self-care behaviors.

Personality traits, quality of life and perceived health in adolescents with congenital heart disease

This study investigated how the big five personality traits were related to quality of life and perceived health in adolescents with congenital heart disease (CHD). Adolescents with CHD were selected from the database of paediatric and congenital cardiology of the University Hospitals Leuven. A total of 366 adolescents (15-20 years) participated; 364 were matched on sex and age with community controls. Adolescents' personality was assessed using the quick big five, quality of life was measured using a linear analogue scale and several domains of perceived health were assessed using the paediatric quality of life inventory. Adolescents with CHD displayed similar big five levels as controls, except for a lower score on extraversion. Whereas disease-specific domains of perceived health were mainly related to emotional stability, several traits contributed to patients' quality of life and generic perceived health. Hence, the present findings demonstrate that the Big Five is a valuable framework for examining linkages between personality and disease adaptation in chronic disease populations. Moreover, these findings underscore the importance of examining patients' personality to shed light on their daily functioning. Future research should explore potential mechanisms detailing how personality influences disease adaptation over time in these patients.

Longer-term issues for young adults with hypoplastic left heart syndrome: contraception, pregnancy, transition, transfer, counselling, and re-operation

Hypoplastic left heart syndrome remained a largely untreated lesion until the 1980s. In the current era, 75-80% of patients who are managed at "centres of excellence" can be expected to survive into young adulthood after staged palliation. This improved survival has led to an emerging population of patients now entering adulthood with a new set of concerns. We discuss the realised and potential issues that will be faced by these patients, including family planning, transition, and re-operation.

R1 version, self-concept in Taiwanese adolescents with congenital heart disease

BACKGROUND

  The objectives of this study were to evaluate and compare differences in self-concept between male and female adolescents with congenital heart disease, and to compare the self-concepts of these adolescents to that of the general adolescent population using normative data.

METHODS

  A total of 300 adolescents, 143 male and 157 female, from two medical centers in Taiwan completed the Tennessee Self-Concept Scales and the scores of male and female subjects were compared. The scores of adolescents with congenital heart disease were also compared with normative data of healthy Taiwanese adolescents.

RESULTS

  Girls with congenital heart disease showed significantly lower mean scores in Physical Self, Social Self, Personal Self, Academic Self and Overall Self domains on the Tennessee Self-Concept Scales when compared to boys with congenital heart disease. When compared to the average value of normative data, adolescent boys with congenital heart disease had significantly higher mean T-scores on Physical Self, Family Self, Social Self, Personal Self, Academic Self and Overall Self, and adolescent girls had significantly higher mean T-scores in Moral-ethical Self, Social Self, Personal Self, Academic Self and Overall Self domains. There were weak negative correlations between severity of congenital heart disease and Physical Self T-scores, and between the number of heart operations and Academic T-scores.

CONCLUSIONS

  Self-concept in adolescents with congenital heart disease is similar to or even higher than that of their normal counterparts. More holistic views of adolescents with congenital heart disease, including their self-concept, appear warranted, especially for adolescent girls with congenital heart disease.

Adolescents' understanding of their congenital heart disease on transfer to adult-focused care

Adolescents with congenital heart disease (CHD) must take responsibility for their life and care. This requires that they have sufficient knowledge about their heart disease, treatment, and preventive measures. Thus, CHD-related education should be directed to adolescents. Research on adolescents' understanding and knowledge of CHD is limited. It is unknown what adolescents with CHD know about their heart defect, treatment, and preventive measures necessary to avoid complications. We addressed these questions in a descriptive cross-sectional study of 91 adolescents with CHD (53% males; median age 17 years). In the present study, we assessed the subjects' knowledge of CHD using the Leuven Knowledge Questionnaire for Congenital Heart Disease. The results showed that the patients had adequate knowledge (>80% correct answers) about the need for regular follow-up, their required diet, past treatment, and dental practices. They had moderate knowledge (50% to 80% correct answers) about the frequency of follow-up, occupational choices, medication regimen, and sexual activities. However, the patients had poor knowledge (<50% correct answers) of the name of their heart defect; the reasons for follow-up; the effects of competitive sports; the symptoms that reflect deterioration of their heart disease; the definition, characteristics, and risk factors of endocarditis; the possibility of recurrent episodes of endocarditis during their lifetime; the effect of smoking and alcohol on their heart disease; the hereditary nature of their condition; the suitability of intrauterine devices as contraceptives; the appropriateness of oral contraceptives; and the risks of pregnancy. In conclusion, the results of the present study have showed that the level of knowledge of adolescents with CHD has significant gaps.

Attitude toward and current practice of transfer and transition of adolescents with congenital heart disease in the United States of America and Europe

The objective of this study was to explore the current practice and attitudes of pediatric cardiologists in the United States and Europe on the transfer and transition of children with congenital heart disease (CHD). A survey among pediatric cardiology programs in the United States and Europe was undertaken. Sixty-nine centers completed and returned the 61-item questionnaire that was specifically devised for this survey. Of 69 participating centers, 74% reported that they transfer their patients to adult-focused care. When a center transfers its patients, 80% transfer them to a formalized Adult Congenital Heart Disease Program. The median age of transfer is 18 years. Comorbidities, pregnancy, and patient/family request to leave pediatric cardiology were identified as initiators for transfer. Complexity of the heart defect was relatively less important when deciding whether to transfer patients. Only one-third of the centers that transfer their patients provide a structured preparation for patients and family. Development of a formal transition program is planned at 59% of the centers that transfer patients. In conclusion, timely transfer and a structured transition process of children with CHD are not implemented in all pediatric cardiology programs. Health-care providers working in pediatric cardiology should make their transfer policies explicit and transition programs ought to be developed.

Children and adults with congenital heart disease lost to follow-up: who and when?

BACKGROUND

Many patients with congenital heart disease (CHD) require lifelong care. However, the duration of cardiology follow-up in children and adults with CHD is unknown. We sought to determine the proportion of children and young adults with CHD receiving outpatient cardiology care and to identify predictors of lack of follow-up.

METHODS AND RESULTS

The study population consisted of individuals born in 1983 and alive at age 22 years who were diagnosed with CHD in Quebec, Canada, before 6 years of age (n=643). Patients and outpatient visits were identified with the use of the provincial physician's claims database. Three age groups were examined for the presence of outpatient cardiology follow-up: 6 to 12, 13 to 17, and 18 to 22 years. CHD lesions were classified as severe (n=84; 13%), simple shunts (n=390; 61%), and "other" lesions (n=169; 26%). Failure to receive cardiac follow-up after the 6th, 13th, and 18th birthday occurred in 28%, 47%, and 61%, respectively. Among those with severe lesions, only 79% were seen after the 18th birthday. However, the majority of subjects visited primary care physicians in all age groups, and 93% remained in contact with the healthcare system into early adulthood. Predictors of lack of cardiology follow-up in adulthood included male sex, a nonsevere lesion, and a history of follow-up outside a university hospital setting.

CONCLUSIONS

Lack of cardiology follow-up begins during childhood, even among those with severe lesions. This occurs despite patients being in contact with other healthcare providers. Improved communication with primary care physicians may reduce the proportion of patients lost to cardiac follow-up.

Expectations and experiences of adolescents with congenital heart disease on being transferred from pediatric cardiology to an adult congenital heart disease program

PURPOSE

To investigate the expectations and experiences of adolescents on transferring from a pediatric cardiology program to an adult congenital heart disease program.

METHODS

A qualitative, phenomenologic study was conducted, in which semi-structured, in-depth interviews were performed with 14 adolescents (aged 15-17 years) with congenital heart disease. Interviews were tape-recorded and transcribed verbatim. Data were analyzed using procedures described by Colaizzi.

RESULTS

The study identified six themes that characterized adolescents' views of the transfer process: leaving pediatric cardiology was viewed as normal; leaving behind familiar surroundings; a positive wait-and-see attitude toward the adult congenital heart disease program; adjusting to a new environment; a need for better information; and a shift in roles between the adolescent and his parents.

CONCLUSION

Although adolescents with congenital heart disease have a positive attitude toward transferring to an adult congenital heart disease program, they identified aspects of the transfer that healthcare professionals need to address. Patients and their families should be prepared for the transfer by informing them about the adult program and its healthcare providers. A formal transition program can play a role in this respect.

Implementation of transition programs can prevent another lost generation of patients with congenital heart disease

Congenital heart disease is the most frequently occurring birth defect. To date, more than 90% of the children born with a heart defect reach adulthood. Since many patients are prone to residua and sequelae, lifelong specialized care is required. However, studies indicate that about one-half to three-quarters of the patients are lost to follow-up when they have grown up. This has resulted in a virtual lost generation. Lapse of care is associated with significant morbidity. Therefore, implementation of strategies to prevent patients from failing to continue regular follow-up is critical. It is argued that transition programs that inform patients about the rationale for ongoing follow-up and that teach them how to navigate the medical system can avoid another lost generation.

Health-promoting behavior of adolescents with congenital heart disease

PURPOSE

To evaluate and compare the health-promoting behavior of adolescents with congenital heart disease (CHD) to that of adolescents without CHD.

METHODS

Cross-sectional data were collected from pediatric cardiology outpatient departments at two medical centers in Taiwan. A total of 1209 adolescents, including 316 with various forms of CHD and 893 without CHD, completed the Adolescent Health Promotion (AHP) scale. Of those with CHD, 162 were female, and 12-18 years old. The scores of adolescents with CHD were compared with published normative adolescent data.

RESULTS

No significant differences were found between those adolescents with CHD and those without in terms of dimensions of the AHP, which consisted of nutrition, social support, health responsibility, life appreciation, exercise, stress management, and overall health-promoting behavior. The three highest and lowest mean scores of scale items between these two groups were identified. Factors among adolescents with CHD, such as age, gender, parental educational level, and cardiac function were significantly associated with at least one dimension of the AHP. Such significant associations were not indicated when comparing body mass index, medical diagnoses, and whether they had undergone heart surgery.

CONCLUSIONS

Adolescents with CHD practice health-promoting behavior similar to that of their counterparts without CHD. Health-promotion counseling for adolescents with CHD should be encouraged to improve lifestyle habits, especially to ensure that they engage in adequate and vigorous exercise and practice good dental hygiene.

Transition to adulthood in congenital heart disease: missed adolescent milestones

PURPOSE

To determine whether adults with congenital heart disease (CHD) are better adjusted than adults with acquired heart disease (AHD).

METHODS

Twenty-five adults with CHD completed the Patient Adjustment to Illness Self Report (PAIS-SR).

RESULTS

CHD patients had good adjustment for Heath Care Orientation and Family Relations, but poorer adjustment for Vocational, Social and Domestic Environment, Sexual Relations, and Psychological Distress.

CONCLUSIONS

The needs of CHD patients are not being met.