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Goselink RJ, Eklund A, Olsson I, Hallböök T, Malmgren K, Reilly C. Transitioning from paediatric to adult care in epilepsy: A qualitative study of adolescent experiences. Seizure 2024; 119:92-97. [PMID: 38820675 DOI: 10.1016/j.seizure.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 05/16/2024] [Accepted: 05/16/2024] [Indexed: 06/02/2024] Open
Abstract
OBJECTIVE Transition into adulthood and adult medical care is an important step in the life of young people with epilepsy. We aimed to gain a better insight into the lived experience of the transition to adulthood and adult medical care in epilepsy in Sweden, to improve future transitional care. METHODS A cross-sectional observational study with digital focus-group meetings and interviews with young people with epilepsy (16-22 years, n = 37) prior to, or after the transfer to adult care, or their primary caregivers if they had intellectual disability. We used reflexive thematic analysis to analyse the experiences and expectations on the transition to adulthood and adult medical care. RESULTS The results of the thematic analysis included four key areas during transition to adulthood and adult care for young persons with epilepsy: (I) worries on coming changes and future, (II) transfers are not smooth and adult care is less integrated, (III) epilepsy is part of a bigger picture, and (IV) parental roles change. In those with intellectual disability, parents experienced a stressful process and had to increase their efforts to coordinate all care contacts in adult care. Here, epilepsy was often experienced as a minor part of a more complex disease picture, where neurodevelopmental issues were often the primary concern. SIGNIFICANCE Transition in epilepsy is often complex due to the large burden of co-occurring disease, specifically intellectual disability and neuropsychiatric diagnoses. Transfer to adult care is experienced as unplanned and participants experience uncertainty, indicating a need for an improved transition process. As effective interventions are known in other chronic diseases, future studies should focus on the evaluation of how these approaches can be feasible and effective in young people with epilepsy.
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Affiliation(s)
- Rianne Jm Goselink
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Section of Neurology, Department of Internal Medicine, County Hospital Ryhov, Jönköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Anna Eklund
- Section of Neurology, Department of Internal Medicine, County Hospital Ryhov, Jönköping, Sweden
| | - Ingrid Olsson
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Sweden; Member of the ERN EpiCARE, Gothenburg, Sweden
| | - Tove Hallböök
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Sweden; Member of the ERN EpiCARE, Gothenburg, Sweden
| | - Kristina Malmgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden
| | - Colin Reilly
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Sweden; Member of the ERN EpiCARE, Gothenburg, Sweden; Research Department, Young Epilepsy, Lingfield, Surrey RH7 6PW, UK
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2
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Ortiz de Zarate Z, Fonseca E, Abraira L, Santamarina E, Campos-Fernández D, Quintana M, Sánchez J, Goméz-Andrés D, Sala J, Raspall M, Felipe-Rucián A, Del Toro M, Macaya A, Toledo M. EPITRANS. Quality assessment of the epilepsy transition process. Eur J Paediatr Neurol 2024; 48:121-128. [PMID: 38241904 DOI: 10.1016/j.ejpn.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/14/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To analyze the differences in clinical management during the epilepsy transition process from pediatric to adult care and to determine the quality of life and degree of satisfaction of patients and caregivers during the transition. METHODS This is a longitudinal study including patients with epilepsy transferred from pediatric to adult epilepsy care between 2013 and 2017. Patients had a minimum follow-up of 3 years before the transition visit and at least 3 years consulting in the adults section. Clinical characteristics were retrieved from the medical chart. Quality of life and satisfaction questionnaires were administered by online access to patients and caregivers at the end of the adult follow-up period. RESULTS 99 patients (50.5 % women, mean transition age 16.5 ± 1 years old) were included. Before the transition visit, 90 % of patients received a transition discussion and 88 % had a formal clinical report. In the pediatric period, patients were visited more frequently, had more EEGs and genetic studies, and were seen by the same neuropediatrician (P<0.05). In the adult period, patients underwent a larger number of prolonged video EEGs and were prescribed polytherapy more often (P<0.05). Quality of life remained steady during the entire transition, but satisfaction with the care received was significantly higher during the pediatric period. CONCLUSIONS Significant differences were seen in epilepsy care during transition from pediatric to adult management, and this had an impact on the degree of satisfaction reported by patients and caregivers. Our results provide evidence of the potential value of development and early implementation of a protocolled transition program.
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Affiliation(s)
- Z Ortiz de Zarate
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain; Department of Pediatric Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - E Fonseca
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain; Research Group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Spain.
| | - L Abraira
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain; Research Group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Spain
| | - E Santamarina
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain; Research Group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Spain
| | - D Campos-Fernández
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain; Research Group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Spain
| | - M Quintana
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain; Research Group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Spain
| | - J Sánchez
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain; Research Group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Spain
| | - D Goméz-Andrés
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - J Sala
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - M Raspall
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - A Felipe-Rucián
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - M Del Toro
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - A Macaya
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - M Toledo
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Barcelona, Spain; Research Group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Hospital Campus, Spain
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Bailey K, Avolio J, Lo L, Gajaria A, Mooney S, Greer K, Martens H, Tami P, Pidduck J, Cunningham J, Munce S, Toulany A. Social and Structural Drivers of Health and Transition to Adult Care. Pediatrics 2024; 153:e2023062275. [PMID: 38084099 DOI: 10.1542/peds.2023-062275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 01/02/2024] Open
Abstract
CONTEXT Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition. OBJECTIVES This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth. DATA SOURCES Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022. STUDY SELECTION Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included. DATA EXTRACTION SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance. RESULTS 101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion. LIMITATIONS Studies were heterogeneous and a meta-analysis was not possible. CONCLUSIONS Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.
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Affiliation(s)
- Katherine Bailey
- Temerty Faculty of Medicine
- Institute of Health Policy, Management and Evaluation
| | | | - Lisha Lo
- Centre for Quality Improvement and Patient Safety
| | - Amy Gajaria
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Margaret and Wallace McCain Centre for Child, Youth, and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Sarah Mooney
- Stollery Children's Hospital, Alberta Health Services, Edmonton, Alberta, Canada
- Alberta Strategy for Patient Oriented Research Support Unit
- Faculty of Nursing, Grant MacEwan University, Edmonton, Alberta, Canada
| | - Katelyn Greer
- Alberta Strategy for Patient Oriented Research Support Unit
| | - Heather Martens
- Patient and Community Engagement Research (PaCER) Program, University of Calgary, Calgary, Alberta,Canada
- Alberta Health Services, Edmonton, Alberta, Canada
- KickStand, Mental Health Foundation, Edmonton, Alberta, Canada
| | - Perrine Tami
- Public Health and Preventative Medicine, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Sarah Munce
- Rehabilitation Sciences Institute
- Department of Occupational Science and Occupational Therapy
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Alene Toulany
- Temerty Faculty of Medicine
- Institute of Health Policy, Management and Evaluation
- Department of Pediatrics, Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health and Evaluative Sciences, Sickkids Research Institute, Toronto, Ontario, Canada
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Vacca M, Fernandes M, Veronese L, Ballesio A, Cerminara C, Galasso C, Mazzone L, Lombardo C, Mercuri NB, Liguori C. Clinical, Sociodemographic, and Psychological Factors Associated with Transition Readiness in Patients with Epilepsy. Brain Sci 2023; 14:21. [PMID: 38248236 PMCID: PMC10813513 DOI: 10.3390/brainsci14010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND The transition to adult care for patients with epilepsy is a complicated clinical issue associated with adverse outcomes, including non-adherence to treatment, dropout of medical care, and worse prognosis. Moreover, youngsters with epilepsy are notably prone to emotional, psychological, and social difficulties during the transition to adulthood. Transition needs depend on the type of epilepsy and the epileptic syndrome, as well as on the presence of co-morbidities. Having a structured transition program in place is essential to reduce poor health consequences. A key strategy to optimize outcomes involves the use of transition readiness and associated factors assessment to implement the recognition of vulnerability and protective aspects, knowledge, and skills of these patients and their parents. Therefore, this study aims to provide a comprehensive framework of clinical and psychosocial aspects associated with the transition from pediatric to adult medical care of patients with epilepsy. METHODS Measures examining different aspects of transition readiness and associated clinical, socio-demographic, psychological, and emotional factors were administered to 13 patients with epilepsy (Mage = 22.92, SD = 6.56) with (n = 6) or without (n = 7) rare diseases, and a respective parent (Mage = 56.63, SD = 7.36). RESULTS patients showed fewer problems in tracking health issues, appointment keeping, and pharmacological adherence as well as low mood symptoms and moderate resiliency. Moreover, they referred to a low quality of sleep. Notably, parents of patients with rare diseases reported a lower quality of sleep as compared to the other group of parents. CONCLUSIONS Increasing awareness around transition readiness is essential to promote self-management skills of patients with epilepsy and their parents. Anticipating the period of transition could be beneficial, especially to prevent problematic sleep patterns and promote independence in health care management. Parents of patients with epilepsy and rare diseases should be monitored for their mental status which can affect patients' well-being.
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Affiliation(s)
- Mariacarolina Vacca
- Department of Psychology, Sapienza University of Rome, 00185 Rome, Italy; (M.V.); (A.B.); (C.L.)
| | - Mariana Fernandes
- Department of Systems Medicine, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy; (M.F.); (L.V.); (C.G.); (L.M.); (N.B.M.)
| | - Lorenzo Veronese
- Department of Systems Medicine, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy; (M.F.); (L.V.); (C.G.); (L.M.); (N.B.M.)
| | - Andrea Ballesio
- Department of Psychology, Sapienza University of Rome, 00185 Rome, Italy; (M.V.); (A.B.); (C.L.)
| | - Caterina Cerminara
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Hospital, Viale Oxford 81, 00133 Rome, Italy;
| | - Cinzia Galasso
- Department of Systems Medicine, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy; (M.F.); (L.V.); (C.G.); (L.M.); (N.B.M.)
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Hospital, Viale Oxford 81, 00133 Rome, Italy;
| | - Luigi Mazzone
- Department of Systems Medicine, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy; (M.F.); (L.V.); (C.G.); (L.M.); (N.B.M.)
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Hospital, Viale Oxford 81, 00133 Rome, Italy;
| | - Caterina Lombardo
- Department of Psychology, Sapienza University of Rome, 00185 Rome, Italy; (M.V.); (A.B.); (C.L.)
| | - Nicola Biagio Mercuri
- Department of Systems Medicine, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy; (M.F.); (L.V.); (C.G.); (L.M.); (N.B.M.)
- Epilepsy Center, Neurology Unit, University Hospital of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Claudio Liguori
- Department of Systems Medicine, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy; (M.F.); (L.V.); (C.G.); (L.M.); (N.B.M.)
- Epilepsy Center, Neurology Unit, University Hospital of Rome “Tor Vergata”, 00133 Rome, Italy
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Kanhere S, Joshi SM. Transition of Care in Adolescents with Epilepsy: Perspective of Pediatric Neurologists in India. Indian J Pediatr 2023; 90:1149-1151. [PMID: 37140836 DOI: 10.1007/s12098-023-04579-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/17/2023] [Indexed: 05/05/2023]
Abstract
This cross-sectional study was designed to determine the current status of transition of care for adolescents with epilepsy to adult neurological services in India and to understand pediatric neurologists' perspectives. After approval from the appropriate Ethics Committee, a pre-designed questionnaire was distributed electronically. Twenty-seven pediatric neurologists from 11 cities across India responded. Pediatric care ended under 15 y for 55.4% responders and at 18 y in another 40.7%. Eighty nine percent introduced the concept of transition or had transition discussions with their patients and parents. Majority of providers did not have a formal plan for transferring the children with epilepsy to an adult neurologist, and very few had transition clinics. Communication with adult neurologists was also variable. Several pediatric neurologists followed patients after transfer for varying periods of time. This study demonstrates increasing awareness regarding the importance of transition of care in this population.
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Affiliation(s)
- Sujata Kanhere
- Division of Pediatric Neurology, Department of Pediatrics, K.J. Somaiya Medical College, Hospital & Research Centre, Sion, Mumbai, Maharashtra, 400022, India.
| | - Sucheta M Joshi
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, USA
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Abstract
Transition of care is the planned, coordinated movement from a child and family environment of pediatrics to a patient centered adult care setting. Epilepsy is a common neurological condition. While seizures remit in a proportion of children, in around 50% of children seizures persist into adulthood. Also, with advances in diagnostics and therapeutics, more children with epilepsy survive into adulthood, and need services of adult neurologists. Clinical guidelines from the American Academy of Pediatrics, American College of Family Physicians and American College of Physicians called for "supporting the healthcare transition from adolescence to adulthood", but this occurs in a minority of patients. There are several challenges to implementing transition of care at the level of the patient and family, pediatric and adult neurologist and with systems of care. Transition needs vary based on the type of epilepsy and epilepsy syndrome and presence of co-morbidities. Transition clinics are essential to effective transfer of care, but implementation remains extremely variable, with a variety of clinics or program structures in countries around the world. There is a need to develop multidisciplinary transition clinics, enhance physician education and establish national guidelines for this important process to be put into practice. Further studies are also needed to develop best practices and assess outcomes of well executed transition programs on epilepsy.
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Affiliation(s)
- Sujata Kanhere
- Division of Pediatric Neurology, Department of Pediatrics, K.J. Somaiya Medical College, Hospital & Research Centre, Mumbai, Maharashtra, India.
| | - Sucheta M Joshi
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, USA
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Yüksel Yılmaz D, Yardımcı F, Erdemir F, Karabudak R. Defining the experiences of adolescent patients with multiple sclerosis in transition from pediatric care to adult care. Mult Scler Relat Disord 2022; 68:104123. [PMID: 36058194 DOI: 10.1016/j.msard.2022.104123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/14/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the experiences of patients aged 18-24 years who were diagnosed with multiple sclerosis before the age of eighteen, during the transition from pediatric care to adult care. METHODS This research was in the type of phenomenological qualitative research. Focus group interviews were conducted between December 2020 and October 2021 with seventeen participants who had been diagnosed with multiple before the age of eighteen, aged 18-24, voluntarily having agreed to participate in the study. The views of the participants were analyzed with Maxqda Plus v10 data analysis software, and thematic coding was created by the researchers. RESULTS Of the participants, 58.9% were female, 76.5% had their first attack after the age of 13, and it was determined that 64.7% of them took oral tablets for therapeutic purposes. As a result of the content analysis; four thematic codes emerged: (a) Perceptions of the Illness and Pediatric Clinic Before Transition, (b) Perceptions of the Disease and Adult Clinic After Transition to the Adult Clinic, (c) Expectations from the Clinic They Received Service from During Their Childhood, (d) Expectations from the Clinic They Used in Adulthood. CONCLUSION This study revealed that individuals with multiple sclerosis did not receive any medical care regarding the transition from pediatric clinics to adult clinics. Describing the experiences of young adult patients with multiple sclerosis in pediatric clinics and their experiences in the transition to adult clinics allows for the definition of comprehensive, individualized and transitional nursing interventions.
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Affiliation(s)
- Didem Yüksel Yılmaz
- Research Assistant, RN, Ufuk University, School of Nursing, Mevlana Boulevard (Konya Yolu) No:86-88 Balgat, Ankara, Turkey.
| | - Figen Yardımcı
- Associate Professor, Ege University, Faculty of Nursing, Department of Child Health and Diseases, Izmir, Turkey
| | - Firdevs Erdemir
- Professor, Near East University, Faculty of Nursing, Department of Child Health and Diseases, Nicosia, Cyprus
| | - Rana Karabudak
- Professor, Hacettepe University Faculty of Medicine, Department of Neurology, Ankara, Turkey
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Tschamper MK, Systad S. Rare, epilepsy-related disorder including intellectual disability - A scoping review of caregivers' identified information needs. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2022; 26:704-717. [PMID: 33998344 PMCID: PMC9442773 DOI: 10.1177/17446295211002348] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 06/12/2023]
Abstract
AIMS The aims of this review were: (1) to obtain an overview of caregiver-reported information needs; and (2) to investigate if there are information needs that are unique for caregivers of persons with rare epilepsies. METHOD We followed the scoping review framework outlined by Arksey and O'Malley and the preferred reporting items outlined by PRISMA. RESULTS Among the 17 articles that met the inclusion criteria, 5 included caregivers of persons with rare epilepsies. Categories of information needs: (1) Medical information; (2) Information on how to cope with emotional distress; (3) Experiential information from peers; and (4) Interdisciplinary information exchange. The need for disorder-specific information seemed particularly important for caregivers of persons with rare epilepsies. CONCLUSION There is a need for further studies, particularly on formal caregivers' information needs.
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Affiliation(s)
- Merete Kristin Tschamper
- Merete Kristin Tschamper, National Center for Rare
Epilepsy-Related Disorders, Department of Rare Disorders, Oslo University Hospital, 0316
Oslo, Norway.
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Joshi CN, Miller JS, Silveira LJ, Nelson JA, Walleigh DJ, Joshi SM, Patel AD. A Multicenter Study of Adherence to Best Practices and Application of Epilepsy Quality Metrics in a Pediatric Telemedicine Encounter. J Child Neurol 2022; 37:744-748. [PMID: 35656770 DOI: 10.1177/08830738221099730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To assess Epilepsy Quality Metrics (EQM) and guideline implementation in new pediatric patients seen in telemedicine. Methods: Multicenter, cross sectional, retrospective analysis. Results: Patients were similar across 3 centers for age, gender, and insurance type. Eighty-one percent presented for spells. One hundred sixty patients with epilepsy formed the EQM cohort. Results: Seizures described: 95%; frequency: 67%, last seizure documented: 81%, epilepsy syndrome documented: 67%; epilepsy diagnosis: 77%, medications reviewed: 56%, adverse events discussed: 73%. Quality of life discussed: 3%. Anticipatory guidance was described as follows: seizure safety, 57%; driving, 47%; SUDEP, 11%; vitamin D discussion, 19%; pregnancy and folic acid counseling, 4% and 10%. Epileptologists were 4 times as likely as generalists in discussing driving safety (odds ratio 3.93, 95% confidence interval 1.7-8.9; P = .001) for all ages. Significance: Performance on EQM and guideline implementation in pediatric epilepsy telemedicine encounters can be improved.
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Affiliation(s)
- Charuta N Joshi
- Children's Hospital Colorado, Anschutz Medical Campus, 2932University of Colorado, Denver, CO, USA
| | - Joseph S Miller
- Ohio University Heritage College of Osteopathic Medicine, 43973Ohio University, Athens, OH, USA
| | - Lori J Silveira
- Children's Hospital Colorado, Anschutz Medical Campus, 2932University of Colorado, Denver, CO, USA
| | - Julie A Nelson
- Children's Hospital Colorado, Anschutz Medical Campus, 2932University of Colorado, Denver, CO, USA
| | - Diana J Walleigh
- Children's Hospital Colorado, Anschutz Medical Campus, 2932University of Colorado, Denver, CO, USA
| | | | - Anup D Patel
- 2650Nationwide Children's Hospital, Center for Clinical Excellence, The Ohio State University College of Medicine, Division of Neurology
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Goselink RJM, Olsson I, Malmgren K, Reilly C. Transition to adult care in epilepsy: A systematic review. Seizure 2022; 101:52-59. [PMID: 35901664 DOI: 10.1016/j.seizure.2022.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/08/2022] [Accepted: 07/10/2022] [Indexed: 11/29/2022] Open
Abstract
The transfer from paediatric to adult care can be a complex process in children with epilepsy. Inadequate care during this phase can affect long-term medical and psychosocial outcomes. The aim of this study was to review studies on transitional care from paediatric to adult healthcare for young persons with epilepsy in order to synthesize evidence for best practice. We undertook a systematic review following PRISMA guidelines and employed narrative synthesis. A total of 36 articles were included, of which 11 were interventional studies and 25 observational studies. Study quality was rated as 'good' for only four studies. Interventions included joint or multidisciplinary clinics, education (patient and health professional education) and extended service provision (Saturday clinics, peer-groups). All studies observed a positive effect experienced by the participants, regardless of intervention type. Observational studies showed that transition plans/programmes are asked for but frequently not existing or not adapted to subgroups with intellectual disability or other neurodevelopmental conditions. The results of this systematic review on transitional care in epilepsy suggest that a planned transition process likely enhances medical and psychosocial outcomes for young people with epilepsy, but the body of evidence is limited and there are significant gaps in knowledge of what efficacious transition constitutes. More studies are needed employing qualitative and quantitative methods to further explore the needs of young people with epilepsy and their families but also robust study designs to investigate the impact of interventions on medical and psychosocial outcomes.
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Affiliation(s)
- Rianne J M Goselink
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Section of Neurology, Department of Internal Medicine, County Hospital Ryhov, Jönköping, Sweden; Division of Neurobiology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Ingrid Olsson
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neuropaediatrics, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden.
| | - Kristina Malmgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, SE-413 45, Sweden.
| | - Colin Reilly
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neuropaediatrics, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden; Research Department, Young Epilepsy, Lingfield, Surrey RH7 6PW, United Kingdom.
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11
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Pieters H, Watson M, Baca CM. Pediatric and adult epileptologist perspectives and experiences of pediatric to adult epilepsy care transition: "Saying goodbye and opening a door.". Epilepsy Behav 2021; 120:107981. [PMID: 33962252 DOI: 10.1016/j.yebeh.2021.107981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/05/2021] [Indexed: 11/28/2022]
Abstract
We aimed to describe perspectives of transition and transfer of adolescents and young adults with childhood-onset epilepsy from pediatric to adult care from the viewpoints of both pediatric and adult epileptologists. Telephone semi-structured interviews with pediatric (n = 15) and adult (n = 11) epileptologists at leading U.S. epilepsy centers were used to collect data about the transition process. Interviews were audio-recorded, transcribed, systematically coded using thematic analysis by two independent researchers, and subsequently checked for agreement during regular meetings. Participants were on average 46 years old (SD = 7.4), 50% male, 91% Non-Hispanic and 85% Caucasian; all had completed a formal epilepsy or clinical neurophysiology fellowship (mean = 11 years since terminal training) and were employed at a comprehensive epilepsy center. Three interrelated themes regarding epileptologists' perspectives of epilepsy transition and transfer of care were evident: (1) the process is unnatural and disruptive, (2) clinicians make the best of challenges, and (3) the epilepsy transition process includes a spectrum of broad needs some of which are unique to epilepsy care while others are common to other chronic diseases. Despite challenges, epilepsy clinicians spontaneously expressed stress, empathy, and commitment to providing the best possible care.
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Affiliation(s)
- Huibrie Pieters
- School of Nursing, University of California Los Angeles, Los Angeles, CA, United States
| | - Meagan Watson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Christine M Baca
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States.
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12
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Smith AW, Gutierrez-Colina AM, Roemisch E, Hater B, Combs A, Shoulberg AM, Modi AC. Modifiable factors related to transition readiness in adolescents and young adults with epilepsy. Epilepsy Behav 2021; 115:107718. [PMID: 33440273 DOI: 10.1016/j.yebeh.2020.107718] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/25/2020] [Accepted: 12/14/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To characterize transition readiness in adolescents and young adults (AYAs) with epilepsy and validate the social-ecological model of AYA readiness to transition (SMART) in a sample of AYAs with epilepsy. METHODS This cross-sectional study included typically developing youth with epilepsy 13-25 years old seen in a comprehensive epilepsy center. Adolescents and young adults completed measures of transition readiness (Transition Readiness Assessment Questionnaire; TRAQ), epilepsy knowledge, epilepsy self-management, developmental factors, and emotional and behavioral functioning. Adolescents and young adults also completed a measure of their relationship quality with healthcare providers. Caregiver report was included when available. RESULTS Participants included 82 AYAs (Mage = 17.3 ± 2.8; 86.6% White Non-Hispanic, 53.7% females) with epilepsy. Transition Readiness Assessment Questionnaire scores (M = 3.33, SD = 0.86) were correlated with modifiable and non-modifiable factors: age (r = 0.66, p < 0.001), income (r = -0.23, p = 0.04), AYA cognitive problems (r = 0.24, p = 0.03), AYA knowledge (r = 0.31, p = 0.005), AYA expectations (r = 0.26, p ≤ 02), AYA inattention (r = -0.24, p = 0.03), AYA executive dysfunction (r = 0.25, p = 0.02), caregiver-reported AYA odd behaviors (r = -0.25, p = 0.036), and caregiver-reported AYA communication problems (r = 0.25, p = 0.04). Transition Readiness Assessment Questionnaire scores were higher in AYAs who had seen adult providers for general healthcare issues (e.g., primary care), but were not related to other demographic (e.g., minority status, insurance), medical (years since diagnosis, type of epilepsy, polytherapy, seizure frequency), developmental (e.g., adaptive skills, cognitive functioning) or emotional/behavioral factors (e.g., skills, relationship with the provider, psychosocial functioning). Linear regression including variables significantly correlated with the outcome of transition readiness (F (7, 59) = 9.70, p < 0.001) explained 54% of the variance. Specifically, age was the only significant model predictor. SIGNIFICANCE Transition readiness in AYAs with epilepsy was predicted by non-modifiable (e.g., age) and correlated with modifiable factors (e.g., knowledge, psychosocial/cognitive functioning). Providers must better prepare patients prior to transfer, and future research should use an epilepsy-specific measure of transition readiness to identify targets for intervention.
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Affiliation(s)
| | | | | | | | | | | | - Avani C Modi
- Cincinnati Children's Hospital Medical Center, United States
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13
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Wenger JK, Niemann M. Continue the Conversation: A Complex Care Pediatrician's Perspective on Improving Healthcare Transitions for Pediatric Neurology Patients. Semin Pediatr Neurol 2020; 36:100854. [PMID: 33308518 DOI: 10.1016/j.spen.2020.100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inadequate preparation for transition to adult-oriented systems of care leads to gaps in treatment and can result in poor health outcomes for youth with special healthcare needs. Coordination between primary care and specialists must occur at multiple levels of organizations to improve transition for youth with neurological disorders. This review focuses on the transition process from the pediatrician's perspective, highlights common obstacles, addresses the unique needs of youth with intellectual disabilities, reviews relevant guidelines, and discusses emerging transition strategies. Key recommendations include defining the roles of the different healthcare providers and using multidisciplinary collaboration to overcome limited resources.
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Affiliation(s)
- Jodi K Wenger
- Department of pediatrics, Boston University School of Medicine, Boston, MA.
| | - Madeline Niemann
- Department of Pediatrics, Division of Pediatric Neurology, Boston Medical Center, Boston, MA
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14
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Nurre ER, Smith AW, Rodriguez MG, Modi AC. Patient, Caregiver, and Provider Perceptions of Transition Readiness and Therapeutic Alliance during Transition from Pediatric to Adult Care in Epilepsy. JOURNAL OF PEDIATRIC EPILEPSY 2020. [DOI: 10.1055/s-0040-1716914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractTransition from pediatric to adult health care is a time of high risk for adolescents and young adults (AYAs) with epilepsy. Our aims are to examine patient, caregiver, and provider perceptions of transition readiness and the influence of patient-provider alliance in the context of transition readiness. Our cross-sectional study included 82 AYAs with epilepsy prior to transition. Patients, caregivers, and providers completed questionnaires (e.g., transition readiness and working alliance). Statistical analyses included independent samples and paired t-tests. Participants were 17.3 ± 2.8 years on average, 54% were females, 84% were White (non-Hispanic), and 38% had generalized epilepsy. Caregivers reported significantly higher transition readiness than their AYAs (t (72) = −10.6, p < 0.001). AYAs and providers reported similar alliance scores. Providers who felt patients were ready to transition had higher patient-reported transition readiness and provider-reported alliance scores. These data suggest that patients and providers are well aligned in the transition process, and providers appropriately perceive key areas necessary for transition. Caregivers and patients had discrepant perceptions of transition readiness, highlighting the importance of assessing both unique transition perspectives. Dedicated transition programs are likely to be beneficial in improving transition readiness and increase alignment across patients, caregivers, and providers.
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Affiliation(s)
- Emily R. Nurre
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Aimee W. Smith
- Department of Psychology, East Carolina University, Greenville, North Carolina, United States
| | - Marie G. Rodriguez
- Department of Psychology, East Carolina University, Greenville, North Carolina, United States
| | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
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15
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Twanow JDE, Maturu S, Khandker N. Pediatric to Adult Epilepsy Transition in Ambulatory Care: Benefits of a Multidisciplinary Epilepsy Transition Clinic. JOURNAL OF PEDIATRIC EPILEPSY 2020. [DOI: 10.1055/s-0040-1716827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractChildren with epilepsy comprise 3.2% of the estimated 500,000 youth with special medical needs who move from the pediatric to adult care model annually. These 16,000 children who require transfer each year represent a challenging subset of 470,000 youth living with epilepsy in the United States. Transition and transfer of care are complex and require gradual processes. This period for youth with epilepsy is often associated with inadequate follow-up and increased risk of nonadherence. Furthermore, youth and adults with epilepsy are known to have suboptimal social and emotional outcomes compared with peers, with high rates of under education, underemployment, poverty, and struggles with mental health. The goal of improving social determinants and continuity of care prompted the development of formal epilepsy transition clinics. Multiple clinic models exist, sharing the overarching goal of supporting youth while building self-management skills, tailored to age and developmental level. Early evidence shows that transition discussion leads to statistically significant increases in transfer readiness and self-efficacy in young adults with epilepsy. Our center boasts a 100% attendance rate at our transition and transfer clinic and 78% compliance with follow-up, further demonstrating that patients and families value quality transition programming.
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Affiliation(s)
- Jaime-Dawn E. Twanow
- Division of Neurology, Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University, Columbus, Ohio, United States
| | - Sarita Maturu
- Division of Epilepsy, Department of Neurology, Nationwide Children’s Hospital, Ohio State University, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Nabil Khandker
- Division of Epilepsy, Department of Neurology, Nationwide Children’s Hospital, Ohio State University, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
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16
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Becker J, Ravens E, Pape L, Ernst G. Somatic outcomes of young people with chronic diseases participating in transition programs: a systematic review. JOURNAL OF TRANSITION MEDICINE 2020. [DOI: 10.1515/jtm-2020-0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractIntroductionThere is growing evidence that the health of young people with chronic health conditions deteriorates during the transfer from child-centred to adult-oriented health care. Risks include not only the deterioration of health status in general but also the occurrence of secondary diseases and adverse events. Transition programs have been implemented. However, there is a lack of evidence about whether they reduce these risks and which interventions should be principally included. Evidence-based guidelines for the transition of young people should be introduced. In this study we therefore aim to summarise actual evidence on somatic outcomes during the transition period.MethodsA systematic literature review was conducted. Two independent reviewers searched in electronic databases (Cochrane, Embase, PubMed, Web of Science) for intervention studies that aimed to improve transition. Last update of search was October 31st 2018. Grey literature was also searched. Studies were included if they examined participants aged 11 years or older suffering from a chronic health condition and evaluated interventions aimed to improve somatic outcomes after transition. Controlled trials or studies with a measurement before and after intervention were considered. The certainty of evidence was assessed using the GRADE approach. Additionally, each study was graded using a modified grading scale based on GRADE.Results28 studies met the inclusion criteria. Patients suffered from different chronic conditions such as type 1 diabetes, solid organ transplantation, inflammatory bowel disease or cystic fibrosis. Interventions had different components such as transition checklists, workshops, web-based interventions, transition plans, joint visits or transition coordinators. Outcomes included mortality and morbidity. They varied according to chronic condition. Thirteen studies showed beneficial effects in the intervention group or in post-intervention measurements. The certainty of evidence was very low.ConclusionA considerable number of studies evaluating transition interventions was identified. Transition interventions had some beneficial effects. Workshops, joint visits and longer or multidisciplinary appointments may be particularly effective components. Transition guidelines could be based on these results. However, due to the limitations of the included studies it is difficult to draw firm conclusions. More research is needed to further evaluate the effectiveness of transition interventions. It should address the deficits identified from prior studies, such as poor study design, short follow-up time or small sample sizes.
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Affiliation(s)
- Johanna Becker
- Department of Paediatric Nephrology, Hannover Medical School, Hannover, Germany
- Institute of Medical Psychology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany, Phone: +49 511 532-4439
| | - Esther Ravens
- Department of Paediatric Nephrology, Hannover Medical School, Hannover, Germany
- Institute of Medical Psychology, Hannover Medical School, Hannover, Germany
| | - Lars Pape
- Department of Paediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Gundula Ernst
- Institute of Medical Psychology, Hannover Medical School, Hannover, Germany
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17
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Chabrol B, Milh M. Transition from paediatric to adult care in adolescents with neurological diseases and handicap. Rev Neurol (Paris) 2020; 176:37-42. [DOI: 10.1016/j.neurol.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/16/2019] [Accepted: 09/03/2019] [Indexed: 11/16/2022]
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18
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Fantaneanu TA, Jacobs CS, De Gusmao C, Bergin AM, Milligan TA, Pearl PL, Dworetzky BA. Pediatric and adult neurologist perspectives on the challenges of sustaining a transfer clinic. Neurol Clin Pract 2019; 10:356-361. [PMID: 32983616 DOI: 10.1212/cpj.0000000000000727] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/02/2019] [Indexed: 11/15/2022]
Abstract
We present a novel epilepsy fellow-driven transfer clinic model and discuss the challenges experienced in finding sustainability; this is timely as many pioneering transition clinics are dissolving across North America. The goal of this clinic was to improve patient care and satisfaction, as measured by a post-visit telephone survey. Unfortunately, our transfer clinic model proved unsustainable due to several factors, broadly categorized as (1) cultural-societal differences between the pediatric and adult health care environments, (2) staffing issues, (3) lack of an established standardized process for transfer of care, and (4) financial and administrative barriers. We suggest potential solutions to these challenges, but the fate of transition and transfer of care clinics may ultimately depend on implementation of practice, policy, and/or financial guidelines.
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Affiliation(s)
- Tadeu A Fantaneanu
- Department of Neurology (TAF), The Ottawa Hospital, Ontario, Canada; Department of Neurology (CSJ), Massachusetts General Hospital; Department of Neurology (CDG, AMB, PLP), Boston Children's Hospital; and Department of Neurology (CDG, TAM, BAD), Brigham and Women's Hospital, Boston, MA
| | - Claire S Jacobs
- Department of Neurology (TAF), The Ottawa Hospital, Ontario, Canada; Department of Neurology (CSJ), Massachusetts General Hospital; Department of Neurology (CDG, AMB, PLP), Boston Children's Hospital; and Department of Neurology (CDG, TAM, BAD), Brigham and Women's Hospital, Boston, MA
| | - Claudio De Gusmao
- Department of Neurology (TAF), The Ottawa Hospital, Ontario, Canada; Department of Neurology (CSJ), Massachusetts General Hospital; Department of Neurology (CDG, AMB, PLP), Boston Children's Hospital; and Department of Neurology (CDG, TAM, BAD), Brigham and Women's Hospital, Boston, MA
| | - Ann M Bergin
- Department of Neurology (TAF), The Ottawa Hospital, Ontario, Canada; Department of Neurology (CSJ), Massachusetts General Hospital; Department of Neurology (CDG, AMB, PLP), Boston Children's Hospital; and Department of Neurology (CDG, TAM, BAD), Brigham and Women's Hospital, Boston, MA
| | - Tracey A Milligan
- Department of Neurology (TAF), The Ottawa Hospital, Ontario, Canada; Department of Neurology (CSJ), Massachusetts General Hospital; Department of Neurology (CDG, AMB, PLP), Boston Children's Hospital; and Department of Neurology (CDG, TAM, BAD), Brigham and Women's Hospital, Boston, MA
| | - Phillip L Pearl
- Department of Neurology (TAF), The Ottawa Hospital, Ontario, Canada; Department of Neurology (CSJ), Massachusetts General Hospital; Department of Neurology (CDG, AMB, PLP), Boston Children's Hospital; and Department of Neurology (CDG, TAM, BAD), Brigham and Women's Hospital, Boston, MA
| | - Barbara A Dworetzky
- Department of Neurology (TAF), The Ottawa Hospital, Ontario, Canada; Department of Neurology (CSJ), Massachusetts General Hospital; Department of Neurology (CDG, AMB, PLP), Boston Children's Hospital; and Department of Neurology (CDG, TAM, BAD), Brigham and Women's Hospital, Boston, MA
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