Transitional care in pediatric neurosurgical patients

Pediatric to Adult Hydrocephalus: A Smooth Transition

Introduction

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

Methods

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

Results

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

Conclusions

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

A Pilot Project: Improving the Transition Care Process for Neurosurgical Adolescent Patients with Indwelling Shunts to Adult Care

BACKGROUND

A formal transition program has not been described for neurosurgical adolescent patients with an indwelling shunt device. Transitioning from pediatric neurosurgical care to adult care without transition guidance has caused abrupt transfer of care at this institution. The goal of this pilot transition program was to help patients and caregivers feel informed and prepared for transition.

METHODS

The Got Transition®, Six Core Elements of Transition, were used to create this program. Both a policy and a registry to track and monitor patients were created. A validated questionnaire for transition readiness was measured. Education was provided based on the results of the questionnaire to prepare the adolescent for transfer of care. A smartphone application was used to promote health care independence. Transfer to adult neurosurgical care included hand-off between the pediatric and adult teams, child life and social work involvement, and scheduled follow up with an adult neurosurgical provider.

FINDINGS

All patients 14 to 18 years with indwelling shunts were enrolled in the pilot program. Eight patients completed a baseline transition readiness assessment, received education and anticipatory guidance, and downloaded the smartphone application. At the end of the six month pilot, three patients were successfully transferred to adult care.

DISCUSSION

The integration of a transition readiness questionnaire and smart phone application during this pilot program was feasible and continues to be used at this institution. Adolescent patients with shunts require gradual and carefully planned transition services.

Living with the cerebellar mutism syndrome: long-term challenges of the diagnosis

BACKGROUND

After posterior fossa tumour surgery, up to 39% of children experience postoperative cerebellar mutism syndrome (CMS) characterized by mutism and other motor and cognitive impairments. There is a lack of knowledge on the patient-reported challenges and long-term needs. Consequently, no specific recommendations exist for rehabilitative and supportive interventions for patients with CMS. The aims of this study were to explore the patients' experiences related to the sequelae of CMS, to identify challenges and needs regarding support and rehabilitation in the period of growing from child to adult and to add perspectives for future developments of supportive care and rehabilitative guidelines.

METHODS

Ten semi-structured interviews were conducted with young adults diagnosed with CMS as children. A thematic analysis identified four themes describing challenges impacting aspects of the participants' lives.

RESULTS

Four main themes were identified and highlight the rehabilitative need for focus on verbal and non-verbal communication skills in addition to the physical impairments. We found that brain tumour survivors with CMS can benefit from social and educational rehabilitation, straightforward and truthful information, support in structuring their everyday lives and increased public knowledge of CMS.

CONCLUSION

Children with CMS face a variety of challenges affecting many aspects of their everyday lives. They should be entitled to the elements of a current rehabilitation initiative for childhood cancer to support patients' social disability and educational decline. Finally, we identified a need for an official information publication.

Transition to Adulthood for Pediatric Moyamoya Patients

Moyamoya is a progressive arteriopathy of the intracranial vasculature, predominantly affecting the terminal branches of the internal carotid artery. Treatment is predicated on surgical revascularization to reduce the risk of stroke. For patients diagnosed and treated as children, it is important to recognize the long-term implications of the disease, for example, that moyamoya is treatable, but not curable. Pediatric moyamoya patients face unique challenges as they transition to adulthood as a consequence of the chronic nature of this disorder. Successful long-term care requires a strategy that incorporates ongoing longitudinal disease monitoring, coordination of care between physician teams, and anticipation of socioeconomic factors that change over time. This article provides an approach to transition care to adult caregivers for pediatric moyamoya patients with a specific focus on the three key stakeholders in the process: the neurosurgeon, the primary care physician, and the individual patient.

Transition of Care of the Spina Bifida Patient from Childhood to Adulthood

Spina bifida is a complex disease process, the care of which involves multiple physicians and other healthcare providers in several disciplines. As our treatment of this disorder has improved over time, thus has survival of these patients into adulthood. Consideration in the care of young adults and adults with spina bifida poses significant challenges that parallel many other disease processes of childhood where medical advances have improved survival. We attempt to discuss the complex disorder that is spina bifida and some of the challenges associated with transition of care of these patients into adulthood.

Therapeutic Pitfalls in the Transition of Neurologic Patients from Pediatric to Adult Health Care Providers

Transitions of care from the pediatric to adult setting are fraught with difficulty. For patients whose neurologic problems began in childhood, there is often a lack of organized multidisciplinary care with the desired neurologic expertise in the adult setting. This monograph highlights those difficulties, reviewing disease-specific instances of the problems with transition from pediatric to adult neurologic care. The use of an arbitrary chronologic age cutoff for transition from pediatric to adult expertise in specific disease state may be a disservice in provision of care, and the disease-specific expertise of providers may outweigh the benefit of an age-related provider focus.

Health care transition in pediatric neurosurgery: a consensus statement from the American Society of Pediatric Neurosurgeons

OBJECTIVE

The number of children with complex medical conditions surviving to adulthood is increasing. A planned transition to adult care systems is essential to the health maintenance of these patients. Guidance has been established for the general health care transition (HCT) from adolescence to adulthood. No formal assessment of the performance of pediatric neurosurgeons in HCT has been previously performed. No "best practice" for this process in pediatric neurosurgery currently exists. The authors pursued two goals in this paper: 1) define the current state of HCT in pediatric neurosurgery through a survey of the membership of the American Society of Pediatric Neurosurgeons (ASPN) on current methods of HCT, and 2) develop leadership-endorsed best-practice guidelines for HCT from pediatric to adult neurosurgical health care.

METHODS

Completion of the Current Assessment of Health Care Transition Activities survey was requested of 178 North American pediatric neurosurgeons by using a web-based questionnaire to capture HCT practices of the ASPN membership. The authors concurrently conducted a PubMed/MEDLINE-based literature review of HCT for young adults with special health care needs, surgical conditions, and/or neurological conditions for the period from 1990 to 2018. Selected articles were assembled and reviewed by subject matter experts and members of the ASPN Quality, Safety, and Advocacy Committee. Best-practice recommendations were developed and subjected to peer review by external expert groups.

RESULTS

Seventy-six responses to the survey (43%) were received, and 62 respondents (82%) answered all 12 questions. Scores of 1 (lowest possible score) were recorded by nearly 60% of respondents on transition policy, by almost 70% on transition tracking, by 85% on transition readiness, by at least 40% on transition planning as well as transfer of care, and by 53% on transition completion. Average responses on all core elements were < 2 on the established 4-point scale. Seven best-practice recommendations were developed and endorsed by the ASPN leadership.

CONCLUSIONS

The majority of pediatric neurosurgeons have transition practices that are poor, do not meet the needs of patients and families, and should be improved. A structured approach to transition, local engagement with adult neurosurgical providers, and national partnerships between pediatric and adult neurosurgery organizations are suggested to address current gaps in HCT for patients served by pediatric neurosurgeons.

Improving health care transition and longitudinal care for adolescents and young adults with hydrocephalus: report from the Hydrocephalus Association Transition Summit

The health care needs of children with hydrocephalus continue beyond childhood and adolescence; however, pediatric hospitals and pediatric neurosurgeons are often unable to provide them care after they become adults. Each year in the US, an estimated 5000-6000 adolescents and young adults (collectively, youth) with hydrocephalus must move to the adult health care system, a process known as health care transition (HCT), for which many are not prepared. Many discover that they cannot find neurosurgeons to care for them. A significant gap in health care services exists for young adults with hydrocephalus. To address these issues, the Hydrocephalus Association convened a Transition Summit in Seattle, Washington, February 17-18, 2017.The Hydrocephalus Association surveyed youth and families in focus groups to identify common concerns with HCT that were used to identify topics for the summit. Seven plenary sessions consisted of formal presentations. Four breakout groups identified key priorities and recommended actions regarding HCT models and practices, to prepare and engage patients, educate health care professionals, and address payment issues. The breakout group results were discussed by all participants to generate consensus recommendations.Barriers to effective HCT included difficulty finding adult neurosurgeons to accept young adults with hydrocephalus into their practices; unfamiliarity of neurologists, primary care providers, and other health care professionals with the principles of care for patients with hydrocephalus; insufficient infrastructure and processes to provide effective HCT for youth, and longitudinal care for adults with hydrocephalus; and inadequate compensation for health care services.Best practices were identified, including the National Center for Health Care Transition Improvement's "Six Core Elements of Health Care Transition 2.0"; development of hydrocephalus-specific transition programs or incorporation of hydrocephalus into existing general HCT programs; and development of specialty centers for longitudinal care of adults with hydrocephalus.The lack of formal HCT and longitudinal care for young adults with hydrocephalus is a significant health care services problem in the US and Canada that professional societies in neurosurgery and neurology must address. Consensus recommendations of the Hydrocephalus Association Transition Summit address 1) actions by hospitals, health systems, and practices to meet local community needs to improve processes and infrastructure for HCT services and longitudinal care; and 2) actions by professional societies in adult and pediatric neurosurgery and neurology to meet national needs to improve processes and infrastructure for HCT services; to improve training in medical and surgical management of hydrocephalus and in HCT and longitudinal care; and to demonstrate the outcomes and effectiveness of HCT and longitudinal care by promoting research funding.

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

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