Challenges and obstacles in the transition process through the eyes of the gastroenterologist

Nurses' and physicians' perspectives on implementation barriers and facilitators in a transfer program for parents of adolescents with chronic illness

AIM

To identify barriers and facilitators impacting the implementation of a comprehensive transfer program aimed at parents of adolescents with chronic illness in clinical practice.

DESIGN

A real-time, qualitative process evaluation.

METHODS

Individual interviews were conducted with 10 nurses and seven physicians from paediatric and adult outpatient clinics: Nephrology, hepatology, neurology, and rheumatology. Data were analysed through the lens of normalization process theory.

RESULTS

Themes were framed within the theory's four components. (1) Coherence: Healthcare professionals' views on their core tasks and on the parents' role influenced their perception of the program. (2) Cognitive participation: A named key worker, autonomy, and collaboration impacted healthcare professionals' involvement in the program. (3) Collective action: Department prioritization and understanding of the program's aim were key factors in its successful delivery. (4) Reflective monitoring: Participants experienced that the program helped parents during transfer but questioned if the program was needed by all families.

CONCLUSION

We identified three barriers: Healthcare professionals' lack of understanding of the parental role during transfer, top-down decisions among nurses, and physicians' uncertainty about their role in joint consultations. Facilitators: Healthcare professionals' understanding of the program's purpose and expected effect, the nurses' significant role as named keyworkers, and good collaboration across paediatric and adult departments.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Implementation strategies should be developed before implementing a transfer program in clinical practice.

IMPACT

Implementing a parental transfer program in clinical practice can be challenging. Therefore, for successful implementation, it is crucial to identify barriers and facilitators. Barriers and facilitators exist at the personal, professional, and organizational levels, and it is important to understand them. The results of this qualitative study could support the implementation of transfer programs in other settings.

REPORTING METHOD

Consolidated criteria for reporting qualitative studies (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Nurses' and physicians' experiences of ownership of the transfer program is essential for successful implementation. Clinics should appoint a named keyworker, preferably a nurse, as the driving force during the implementation of a transfer program. Nurses and physicians should receive training about the purpose, justification, and expected effect of a transfer program before implementation.

Transition care to adolescent hepatology in a tertiary center for rare adult-child liver disease

AIMS

This study analyzed the results of a transition program in a patient population with a rare liver disease of pediatric onset.

METHOD

Data were collected on the clinical course of an adolescent population with a rare disease of pediatric onset and enrolled in a transition program between 1994 and 2022.

RESULTS

A total of 238 adolescents (including 34 having undergone a liver transplant on enrolling in the program) were included. Eight patients were lost to follow-up before the first transition consultation and 16 families requested follow-up in an adult hepatology department closer to their home. Overall, 214 initial transition consultations were carried out; 29 patients were subsequently lost to follow-up and 13 switched center. Overall, 15.4 % of the patients enrolled in our program were lost to follow-up. Five adult patients underwent a liver transplantation during this 28-year period. Overall mortality was 3.2 %, graft survival was 91.5 %, and posttransplant survival was 92 %. In total, the current active file represents 183 patients with a median age of 24.3 years (18-51) and a median follow-up period of 5.8 years (6 months to 28 years).

CONCLUSION

The implementation of a transition program to adult medicine for adolescents with a rare liver disease should follow the recommendations but must be adapted in line with local practice conditions. This process requires close collaboration between the pediatric and adult medicine teams based on a mutual desire to constantly improve practices and enhance knowledge.

Transition of Adolescents with Inflammatory Bowel Disease-Are the Pediatric Teams up to the Task?

Our aim was to describe the challenges of the transition process of adolescents with inflammatory bowel disease (IBD), as seen from a pediatric-care perspective, to clarify the key obstacles and propose how to move forward. Semi-structured individual interviews of pediatric gastroenterologists and nurses were analyzed and interpreted according to the principles of social science. It is a challenge for the pediatric team to continuously match, support, and gently guide the ever-changing adolescent patient. All adolescent patients should be offered guidance regardless of their starting point, and specific individual needs should be taken into consideration. Adolescents burdened by psychosocial challenges require extra support. Early and continued interdisciplinary effort is essential. Collaboration with the parents must be continuously adapted to prepare them for their new roles and responsibilities. The shift from the pediatric family-focused approach to the individualistic approach of the Adult Gastroenterology Department signifies a fundamental change. Equipping adolescents with disease-management skills remains a comprehensive task. The following crucial questions remain: Who is capable of performing the transition? Who can dedicate the necessary resources for performing the transition? A transition center led by both pediatricians and adult gastroenterologists in an interdisciplinary setting that includes transition-trained persons may be the solution.

Integration of eHealth Into Pediatric Inflammatory Bowel Disease Care is Safe: 3 Years of Follow-up of Daily Care

OBJECTIVES

The aim of the study was to evaluate integration of an eHealth solution, www.young.constant-care.com, into daily care (I-eHealth).

METHODS

The I-eHealth solution was offered to inflammatory bowel disease (IBD) patients ages 10 to 17 years old in nonbiological treatment. The application was used monthly and in case of flare-ups. Blood and fecal calprotectin (FC) were tested every 3 months and during flare-ups. A total inflammation score (based on symptoms and FC) was visualized for the patient in a traffic light curve. An IBD nurse followed up on the registrations every 2 weeks. Patients had 1 yearly planned visit at the hospital. On-demand visits were arranged depending on the total inflammation. I-eHealth results were compared with data from a previous randomized clinical trial (RCT)-eHealth study (the control group of which had 4 planned annual visits).

RESULTS

Thirty-six IBD patients were followed by I-eHealth, mean age 14.7 years (SD 7.75). The median (interquartile range [IQR]) duration of using I-eHealth was 1.9 years (0.29-2.51), equal to 66.11 patient-years, compared with 40.45 in the RCT-eHealth group and 46.49 in the RCT-control group. On-demand visits per patient-year did not differ between the groups: 1.13 (I-eHealth), 1.16 (RCT-eHealth), and 0.84 (RCT-control) (P = 0.84/0.85). Hospitalizations and acute outpatient visits per patient-year did not differ between the groups: 0.11 and 0.11 (I-eHealth), 0.05 and 0.02 (RCT-eHealth), 0.11 and 0.11 (RCT-control) (P = 0.17/0.81 and 0.12/0.81). Time to first escalation of medication, and time to first on-demand visit, did not differ between the I-eHealth group and data from the clinical trial (Log rank: P = 0.25 and P = 0.61).

CONCLUSIONS

I-eHealth is comparably with results from eHealth under RCT supervision.

A Personalized eHealth Transition Concept for Adolescents With Inflammatory Bowel Disease: Design of Intervention

BACKGROUND

Transfer from pediatric to adult care is a crucial period for adolescents with inflammatory bowel disease (IBD).

OBJECTIVE

Our aim was to develop a personalized transition-transfer concept including relevant tools in an established eHealth (electronic health) program.

METHODS

Required transition skills and validated patient-reported outcome measures (PROMs) were identified via bibliographic search and clinical experience and were implemented into an existing eHealth program.

RESULTS

The following skills were identified: disease knowledge, social life, disease management, and making well-informed, health-related decisions. The PROMs included the following: self-efficacy (the IBD Self-Efficacy Scale-Adolescents), resilience (the 10-item Connor-Davidson Resilience Scale), response to stress (the Child Self-Report Responses to Stress-IBD), and self-management and health care transition skills (the Self-Management and Transition to Adulthood with Treatment questionnaire). Starting at age 14, the patient will be offered a 1-hour annual transition consultation with an IBD-specialized nurse. The consultation will be based on the results of the PROMs and will focus on the patient's difficulties. Patients will complete the PROMs on the eHealth program at home, allowing nurses and patients to prepare for the meeting. Symptom scores and medication will be filled out on the eHealth program to support disease self-management. The consultation will be a topic-centered dialogue with practical exercises. During routine outpatient visits with the provider, parents will be left out of half of the consultation when the patient is 16 years old; at 17 years old, the parents will not be present. At the transfer consultation, the pediatric provider, the adult gastroenterologist, the pediatric nurse, the patient, and the parents will be present to ensure a proper transfer.

CONCLUSIONS

We have conducted a personalized eHealth transition concept consisting of basic elements that measure, train, and monitor the patients' transition readiness. The concept can be implemented and adjusted to local conditions.