Transition from pediatric to adult services: are we getting it right?

Transition From Pediatric to Adult Healthcare for Colorectal Conditions: A Systematic Review

BACKGROUND

Despite surgical advances for complex congenital colorectal conditions, such as anorectal malformation (ARM) and Hirschsprung disease (HD), many adolescents require transfer from specialist pediatric to adult providers for ongoing care.

METHODOLOGY

A systematic review of PubMed, MEDLINE and Embase was conducted to identify what is known about the transitional care of patients with ARM and HD (PROSPERO # CRD42022281558). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework guided our reporting of studies that focused on the transition care of 10-30-year-olds with ARM and HD.

RESULTS

Eight studies were identified that included patient and parent (n = 188), and/or clinician perspectives (n = 334). Patients and clinicians agreed that transitional care should commence early in adolescence to support transfer to adult care when a suitable level of maturation is reached. There was little evidence from patients that transfer happened in a timely or coordinated manner. Patients felt that clinicians did not always understand the significance of transfer to adult services. No models of transition care were identified. Surgeons ranked ARM and HD as the most common conditions to experience delayed transfer to adult care. Beyond pediatric surgeons, patients also highlighted the importance of general practitioners, transitional care coordinators and peer support groups for successful transition.

CONCLUSIONS

There is little research focused on transitional care for patients with ARM and HD. Given evidence of delayed transfer and poor experiences, the development of models of transitional care appears essential.

The transition process for paediatric rheumatology clinic patients at a single tertiary paediatric rheumatology centre in Australia

AIM

This study aimed to examine the transition process of paediatric rheumatology patients from the Monash Children's Hospital (MCH) in Melbourne in order to identify areas that could be improved.

METHODS

Retrospective review of clinical data from the rheumatology database of paediatric rheumatology patients eligible for transition between January 2015 and September 2020.

RESULTS

One hundred and sixty-five patients were included; 57 patients were transitioned. Of patients transitioned to an adult service, 38 (88%) were on medication and 14 (33%) had active disease. All patients transitioned to the general practitioner (GP) had inactive disease off medication. Juvenile idiopathic arthritis (JIA) (non-systemic) was the most common diagnosis in patients transitioned. The mean age at which transition was first discussed was 18.0 years; the first referral was made at a mean of 18.3 years. The mean age at the first adult appointment was 18.5 years. Thirty-nine (91%) patients had a referral completed and 8 (19%) had a transfer letter. Thirteen (93%) patients transferred to the GP had a transfer letter. Transfer documents to an adult public rheumatology service rated 4.3 for quality, compared to 5.5 to the GP. Transfer of care was confirmed in 40 (93%) patients transitioned to an adult service; however, correspondence was available for only 3 (7%).

CONCLUSION

Although the transition process at MCH was adequate, it could be improved through earlier discussion of the process and improved referrals and documentation. A readiness-to-transfer checklist and a young adult clinic have the potential to improve the process of transition to adult rheumatology care.

Kidney adolescent and young adult clinic: A transition model in Africa

Adolescents and Young Adults (AYAs) with chronic kidney disease (CKD) have challenges unique to this developmental period, with increased rates of high-risk behavior and non-adherence to therapy which may impact the progression of kidney disease and their requirement for kidney replacement therapy (KRT). Successful transition of AYA patients are particularly important in low- and middle-income countries (LMICs) where KRT is limited, rationed or not available. Kidney AYA transition clinics have the potential to improve clinical outcomes but there is a paucity of data on the clinical translational impact of these clinics in Africa. This review is a reflection of the 20-year growth and development of the first South African kidney AYA transition clinic. We describe a model of care for patients with CKD, irrespective of etiology, aged 10-25 years, transitioning from pediatric to adult nephrology services. This unique service was established in 2002 and re-designed in 2015. This multidisciplinary integrated transition model has improved patient outcomes, created peer support groups and formed a training platform for future pediatric and adult nephrologists. In addition, an Adolescent Centre of Excellence has been created to compliment the kidney AYA transition model of care. The development of this transition pathway challenges and solutions are explored in this article. This is the first kidney AYA transition clinic in Africa. The scope of this service has expanded over the last two decades. With limited resources in LMICs, such as KRT, the structured transition of AYAs with kidney disease is not only possible but essential. It is imperative to preserve residual kidney function, maximize the kidney allograft lifespan and improve adherence, to enable young individuals an opportunity to lead productive lives.

Biliary Atresia in Adolescence and Adult Life: Medical, Surgical and Psychological Aspects

Prior to 1955, when Morio Kasai first performed the hepatic portoenterostomy procedure which now bears his name, Biliary atresia (BA) was a uniformly fatal disease. Both the Kasai procedure and liver transplantation have markedly improved the outlook for infants with this condition. Although long-term survival with native liver occurs in the minority, survival rates post liver transplantation are high. Most young people born with BA will now survive into adulthood but their ongoing requirements for health care will necessitate their transition from a family-centred paediatric service to a patient-centred adult service. Despite a rapid growth in transition services over recent years and progress in transitional care, transition from paediatric to adult services is still a risk for poor clinical and psychosocial outcomes and increased health care costs. Adult hepatologists should be aware of the clinical management and complications of biliary atresia and the long-term consequences of liver transplantation in childhood. Survivors of childhood illness require a different approach to that for young adults presenting after 18 years of age with careful consideration of their emotional, social, and sexual health. They need to understand the risks of non-adherence, both for clinic appointments and medication, as well as the implications for graft loss. Developing adequate transitional care for these young people is based on effective collaboration at the paediatric-adult interface and is a major challenge for paediatric and adult providers alike in the 21st century. This entails education for patients and adult physicians in order to familiarise them with the long-term complications, in particular for those surviving with their native liver and the timing of consideration of liver transplantation if required. This article focusses on the outcome for children with biliary atresia who survive into adolescence and adult life with considerations on their current management and prognosis.

Health service use for young males and females with a mental disorder is higher than their peers in a population-level matched cohort

Background

To inform healthcare planning and resourcing, population-level information is required on the use of health services among young people with a mental disorder. This study aims to identify the health service use associated with mental disorders among young people using a population-level matched cohort.

Method

A population-based matched case-comparison retrospective cohort study of young people aged ≤ 18 years hospitalised for a mental disorder during 2005–2018 in New South Wales, Australia was conducted using linked birth, health, and mortality records. The comparison cohort was matched on age, sex and residential postcode. Adjusted rate ratios (ARR) were calculated for key demographics and mental disorder type by sex.

Results

Emergency department visits, hospital admissions and ambulatory mental health service contacts were all higher for males and females with a mental disorder than matched peers. Further hospitalisation risk was over 10-fold higher for males with psychotic (ARR 13.69; 95%CI 8.95–20.94) and anxiety (ARR 11.44; 95%CI 8.70-15.04) disorders, and for both males and females with cognitive and behavioural delays (ARR 10.79; 95%CI 9.30-12.53 and ARR 14.62; 95%CI 11.20-19.08, respectively), intellectual disability (ARR 10.47; 95%CI 8.04–13.64 and ARR 11.35; 95%CI 7.83–16.45, respectively), and mood disorders (ARR 10.23; 95%CI 8.17–12.80 and ARR 10.12; 95%CI 8.58–11.93, respectively) compared to peers.

Conclusion

The high healthcare utilisation of young people with mental disorder supports the need for the development of community and hospital-based services that both prevent unnecessary hospital admissions in childhood and adolescence that can potentially reduce the burden and loss arising from mental disorders in adult life.

Initial attendance and retention in adult healthcare as criteria for transition success among organ transplant recipients

BACKGROUND

Adolescent and young adult (AYA) solid organ transplant recipients experience worsening medical outcomes during transition to adult healthcare. Current understanding and definitions of transition success emphasize first initiation of appointment attendance in adult healthcare; however, declines in attendance over time after transfer remain possible, particularly as AYAs are further removed from their pediatric provider and assume greater independence in their care.

METHODS

The current study assessed health-care utilization, medical outcomes, and transition success among 49 AYA heart, kidney, or liver recipients recently transferred to adult healthcare. Differences in outcomes were examined along two transition success criteria: (1) initial engagement in adult healthcare within 6 or 12 months of last pediatric appointment and (2) retention in adult healthcare over 3 years following last pediatric appointment. Growth curve modeling examined change in attendance over time.

RESULTS

Successful retention in adult healthcare was significantly related to more improved clinical outcomes, including decreased number and duration of hospitalizations and greater medication adherence, as compared to initial engagement. Significant declines in appointment attendance over 3 years were noted, and individual differences in declines were not accounted for by age at transfer or time since transplant.

CONCLUSIONS

Findings underscore support for AYAs after transfer, as significant declines in attendance were noted after initiating adult care. Clinical care teams should examine transition success longitudinally to address changes in health-care utilization and medical outcomes. Attention to interventions and administrative support aimed at maintaining or increasing attendance and identifying risk factors and intervention for unsuccessful transition is warranted.

Transition of Chronic Pediatric Nephrological Patients to Adult Care Excluding Patients on Renal Replacement Therapy with Literature Review

(1) Background: The transition of children with chronic kidney disease to adult care has become a well-handled issue. However, other patients with normal or mildly decreased renal function also requiring further management and transition are neglected. (2) Methods: A questionnaire was sent to patients with kidney pathology, aged 17 years and older.(3) Results: The patients were mostly high-school (55%) or college students (39%), living with their parents (94%). One third did not know how their disease affected their choice of profession and reproductive health. Furthermore, 46% of the respondents did not know who would continue with their care, and 44% still had a primary pediatrician. (4) Conclusions: A review of the literature on the topic was performed and summarized here. Regular education is the key for successful transfer, not only in chronic kidney and transplant patients, but also in others in whom a decline in renal function can be expected in the future.

Understanding of the transition to adult healthcare services among individuals with VACTERL association in Sweden: A qualitative study

Current knowledge of transitional care from the perspective of individuals with congenital malformations is scarce. Their viewpoints are required for the development of follow-up programs and transitional care corresponding to patients’ needs. The study aimed to describe expectations, concerns, and experiences in conjunction with transfer to adult health care among adolescents, young adults, and adults with VACTERL association, (i.e. vertebral defects, anorectal malformations (ARM), cardiac defects (CHD), esophageal atresia (EA), renal, and limb abnormalities). Semi-structured telephone interviews were performed and analyzed with qualitative content analysis. Of 47 invited individuals, 22 participated (12 males and 10 females). An overarching theme emerged: Leaving the safe nest of pediatric health care for an unfamiliar and uncertain follow up yet growing in responsibility and appreciating the adult health care. The participants described expectations of qualified adult health care but also concerns about the process and transfer to an unfamiliar setting. Individuals who were transferred described implemented or absence of preparations. Positive and negative experiences of adult health care were recounted including being treated as adults. The informants described increasing involvement in health care but were still supported by their parents. Ongoing follow up of health conditions was recounted but also uncertainty around the continuation, missing follow up and limited knowledge of how to contact health care. The participants recommended information ahead of transfer and expressed wishes for continued health care with regular follow up and accessibility to a contact person. Based on the participants’ perspective, a transitional plan is required including early information about transfer and follow up to prepare the adolescents and reduce uncertainty concerning future health care. Meetings with the pediatric and adult team together with the patient and the parents are essential before transfer. Follow up should be centralized to centers with multi-professional teams well-experienced with the condition. Further studies are warranted to evaluate the transition process for adolescents and young adults with complex congenital health conditions.

Transition to adult care of young patients with neurofibromatosis type 1 and cognitive deficits: a single-centre study

BACKGROUND

The transition of adolescents to adult care is known to be challenging. Studies indicate that patients with a chronic disease and cognitive deficits are at risk of inadequate transition to adult care, which eventually may result in disease deterioration. This study investigated the transition process for patients with neurofibromatosis type 1 (NF1) and discussed whether patients with NF1 and cognitive deficits should receive additional attention in their transitional period.

METHOD

A self-reported online questionnaire assessing disease severity, cognitive deficits, psychiatric diagnoses as well as transition experiences was completed by patients with NF1 aged 15-25-years. Patients were assigned to a national NF1 expert centre covering the western part of Denmark. Furthermore, a retrospective medical chart review was performed, and data were collected to estimate the prevalence of psychiatric diagnoses.

RESULTS

The questionnaire was completed by 41/103 (39%), median age 20 [range 15; 25] years. Medical chart review was performed in 103 patients, median age 20 [range 15; 25]. Participants reporting the transition as difficult all received special needs education, six reported executive function deficits and three out of seven had a psychiatric diagnosis. Fifteen (37%) questionnaire participants reported a wish for more information about the natural history and the prognosis of NF1. The prevalence of psychiatric diagnoses was 24% in the questionnaire survey and 30% in the medical chart review.

CONCLUSION

This study suggests a need of additional care for patients with NF1 and cognitive deficits including psychiatric disorders during their transition to adult care. In addition, it suggests a need for more information on and education in long-term prospects and mental health issues for patients with NF1.

Transitioning from paediatric to adult services with cystic fibrosis or bronchiectasis: What is the impact on engagement and health outcomes?

AIM

To determine whether the transfer of young people with cystic fibrosis (CF) or bronchiectasis from paediatric to adult services is associated with changes in service engagement and/or health outcomes.

METHODS

Young people aged ≥15 years of age with CF or bronchiectasis who transferred from the Auckland-based paediatric service (Starship Children's Hospital) to one of three Auckland-based District Health Boards between 2005 and 2012 were identified and included if they had 3 years care both pre-transfer and post-transfer care. Transfer preparation, service engagement (clinics scheduled, clinics attended) and health outcomes (lung function, hospitalisations) were collected per annum.

RESULTS

Fifty-seven young people transferred in this period with 46 meeting inclusion criteria (CF n = 20, bronchiectasis n = 26). The CF group had better transfer documentation, were transferred at an older age (11 months older P < 0.0001 95%CI: 6.7 months, 14.7 months), were 20 times more likely to attend clinics (P < 0.0001, 95%CI: 7.8, 66.1) and had 3-4 more clinics scheduled pre-transfer (P < 0.0001, 95%CI: 3.4, 4.9) and post-transfer (P < 0.0001, 95%CI: 2.4, 3.8) despite having less severe respiratory disease as measured by FEV1 for each year (P < 0.01, 95%CI: 0.34, 1.22).

CONCLUSION

The transfer of young people with CF to adult services did not affect health engagement or outcomes, in contrast to those with bronchiectasis. Use of a formalised transfer process, more clinic appointments offered and greater resources for CF may be responsible for this difference. Comprehensive transition with purposeful, planned movement and developmentally appropriate care is a key goal.

The Effect of Self-Efficacy, Social Support and Quality of Life on Readiness for Transition to Adult Care Among Adolescents with Cystic Fibrosis in Turkey

PURPOSE

The aim of this study is to examine the effects of self-efficacy, social support and quality of life on readiness for transition to adult care in adolescents with cystic fibrosis.

DESIGN AND METHODS

A descriptive and cross-sectional study design was used. Data were collected from 50 adolescent between 14 and 17 years old with cystic fibrosis, by using The Transition Readiness Assessment Questionnaire, Social Support Appraisals Scale for Children, Self-Efficacy Questionnaire for Children and health-related quality-of-life instrument, the KIDSCREEN-10.

RESULTS

A positive correlation was found between the readiness levels of adolescents for transition to adult care and self-efficacy levels. In path analysis, self-efficacy was found to have a significant effect on the level of readiness for transition to adult care. There was not statistically significant relationship between the level of readiness for transition to adult care and health-related quality of life and perceived social support. Path analysis revealed that health-related quality of life and perceived social support had significant effects on the self-efficacy levels of adolescents.

CONCLUSIONS

Self-efficacy were associated with readiness for the transition to adult care. Although perceived social support and quality of life were not related with transition readiness these variables had significant effects on perceived self-efficacy, which was determined as a factor affecting the readiness for the transition to adult care.

PRACTICE IMPLICATIONS

In adolescents with cystic fibrosis, self-efficacy, social support and quality of life levels should be taken into account when planning preparation programs for transition to adult care.

Adults transplanted as children as retransplant candidates: Analysis of outcomes support optimism in a population mislabeled as high risk

Adult liver transplant programs have heretofore been hesitant to perform liver retransplantation in adult patients who underwent primary liver transplantation as a child (P_A). Areas of concern include: (a) potential disruption in care when transferring from a pediatric to an adult transplant center; (b) generally inferior outcomes of retransplantation; (c) reputation of young adults for non-adherence to post-transplant regimen; and (d) potential higher work effort for equivalent outcomes. To examine these concerns, we reviewed data on all US liver adult retransplants from 10/01/1987 to 9/30/2017. We propensity matched the P_A patients to patients who received both primary and retransplantation as adults (A_A), with ≥550 days between transplants. A mixed Cox proportional hazards model with program size and time period of transplantation as random variables revealed that retransplantation of P_A patients produced no significantly different graft survival or patient survival rates than retransplantation of the matched A_A patients. Therefore, inferior rates of liver retransplantation in these patients and concerns about continuity of care in changing transplant programs are not as believed in the wider liver transplant community. In conclusion, liver transplant centers should be optimistic about retransplanting adults who received their primary transplants as children.

Paediatric to adult transition care for patients with sickle cell disease: a global perspective

Sickle cell disease is a life-threatening inherited condition designated as a public health priority by WHO. Increased longevity of patients with sickle cell disease in high-income, middle-income, and low-income countries present unprecedented challenges for all settings; however, a globally standardised solution for patient transition from paediatric to adult sickle cell disease health care is unlikely to address the challenges. We established a task force of experts from a multicountry (the USA, Europe, Middle East, and Africa) consortium. We combined themes from the literature with viewpoints from members of the task force and invited experts to provide a global overview of transition care practice, highlighting barriers to effective transition care and provide baseline recommendations that can be adapted to local needs. We highlighted priorities to consider for any young person with sickle cell disease transitioning from paediatric to adult health care: skills transfer, increasing self-efficacy, coordination, knowledge transfer, linking to adult services, and evaluating readiness (the SICKLE recommendations). These recommendations aim to ensure appropriate benchmarking of transition programming, but multisite prospective studies are needed to address this growing public health need.

Lost in transition: resident and fellow training and experience caring for young adults with chronic conditions in a large United States' academic medical center

BACKGROUND

The transition from pediatric to adult healthcare is a vulnerable time for adolescents and young adults (AYA), especially those with chronic conditions. Successful transition requires communication and coordination amongst providers, patients, and families. Unfortunately, multiple studies have demonstrated that the majority of practicing providers do not feel prepared to help AYA patients through health care transition, but little is known about the transition/transfer aptitudes of physician trainees.

OBJECTIVES

The purpose of this study was to establish the transition/transfer training that residents and fellows from different fields receive - and determine what training factors are associated with increased confidence in core transition/transfer skills.

DESIGN

A 20-item electronic survey regarding experiences caring for AYA patients was sent to all 2014-2015 graduate medical education (GME) trainees at our institution.

RESULTS

Forty-nine percent (479/985) of trainees responded: 60 pediatric, 387 non-pediatric, and 32 'combined' (e.g., Medicine/Pediatrics or Family Medicine). Trainees from all three categories of programs reported similar exposure to AYA patients with chronic conditions, with a median of 1-3 encounters per month. A quarter of trainees rated themselves as 'not at all prepared' to speak with a counterpart provider about a transferring patient, while nearly half of trainees considered themselves 'not at all prepared' to speak with a patient and family about transition. Trainee confidence in performing these two skills was strongly predicted by three factors: increased exposure to AYA with chronic conditions, education (training or role modeling) in transition skills, and experience practicing transition skills. Of these, the strongest association with trainee confidence was experience practicing the skills of communicating with other providers (OR = 13.0) or with patients/families (OR = 14.5).

CONCLUSION

Despite at least monthly encounters with AYA with chronic conditions, most residents and fellows have very little experience communicating across the pediatric-to-adult healthcare divide, highlighting training opportunities in graduate medical education.

Be on TRAQ – Cross-cultural adaptation of the Transition Readiness Assessment Questionnaire (TRAQ 5.0) and pilot testing of the German Version (TRAQ-GV-15)

Objective

Transfer from pediatric care into the adult health care system is known to be a vulnerable phase in the lives of youth with special health care needs (YSHCN). Recommendations from the literature favor assessment of transition readiness rather than simply pass over YSHCN from pediatric to adult-centered care by the age of 18. Nevertheless, no validated and disease neutral assessment instrument in German exists to date. Hence, our aim was to cross-culturally adapt and to pilot-test a German version of the Transition Readiness Assessment Questionnaire (TRAQ 5.0). We wanted to provide a tool that can be applied broadly during the health care transition (HCT) process of YSHCN.

Methods

The development included translating and adapting TRAQ 5.0 to German and conducting a pilot-study with 172 YSHCN between the ages of 14 and 23.

Results

Cross-cultural adaptation resulted in the TRAQ-GV-15. Exploratory factor analysis led to a 3 factor-structure. Internal consistency for the overall score was good with a Cronbach’s alpha of 0.82. Age, in contrast to sex, had a significant effect on the TRAQ scoring. The administration of the TRAQ-GV-15 was well received and demonstrated good feasibility.

Conclusion

The TRAQ-GV-15 is an easily applicable and clinically usable instrument for assessing transition readiness in German speaking YSHCN prior to HCT.

Changes in Clinical Markers During A Short-Term Transfer Program of Adult Cystic Fibrosis Patients from Pediatric to Adult Care

Background:

Transition from child-oriented to adult-oriented health care in Cystic Fibrosis (CF) has become more important over recent decades as the survival of people with this disease has increased. The transition process usually begins in adolescence, with full transfer completed in early adulthood.

Objective:

This study investigated the impact of a short-term transfer program on clinical markers in an adult CF cohort still being managed by pediatricians.

Methods:

Clinically relevant data from the year before (T-1), the time of Transfer (T) and the year after the transfer (T+1) were analysed retrospectively.

Results:

39 patients (median age 29.0 years; 64% male) were transferred between February and December 2016. Lung function had declined significantly in the year before transfer (in % predicted: Forced Expiratory Volume in 1 second (FEV), 62.8 vs. 57.7, p <0.05; Forced Vital Capacity (FVC), 79.9 vs. 71.1, p<0.05), but remained stable in the year after transfer (in % predicted: FEV: 56.3; FVC 68.2). BMI was stable over the whole observational period. There was no relevant change in chronic lung infection with P. aeruginosa, Methicillin-Resistant Staphylococcus aureus (MRSA) and Burkholderia sp. during the observation period. The number of patient contacts increased significantly in the year after versus the year before transfer (inpatient: 1.51 vs. 2.51, p<0.05; outpatient: 2.67 vs. 3.41, p<0.05).

Conclusions:

Our data show that, within the framework of a structured transfer process, it is possible to transfer a large number of adult CF patients, outside a classic transition program, from a pediatric to an adult CF center in a short period of time, without any relevant changes in clinical markers and, stability.

Patients' association programs for adolescents and young adults: The JAP study

INTRODUCTION

A dozen innovative care clinics have recently opened in France to support the transition of adolescents with chronic conditions between pediatric and adult healthcare units through various interventions. Some patients' associations have set up specific programs for adolescents and young adults (AYAs) in order to facilitate the transition process, but they are not well-known among healthcare professionals. Our aim was to describe these programs and to evaluate the quality of their implementation and transferability into transition clinics.

MATERIEL AND METHODS

We conducted semistructured interviews with representatives of associations that proposed interventions dedicated to AYAs with chronic conditions. We collected quantitative and qualitative data to describe these interventions. Descriptive statistics were run on quantitative data and a thematic analysis of the qualitative data was made.

RESULTS

A questionnaire was sent to 55 associations, 19 (36%) of them had established programs and were contacted; interviews were conducted with 16 of them. Thirteen were national associations, 11 focused on a specific chronic disease, three supported multiple chronic conditions, and two were available to any AYA with chronic disease. Programs were mainly camps (n=5; from 2days to 3weeks) and workshops (n=5). Educational considerations and hobbies were more frequently discussed when peers were directly involved in the program. Stakeholders were mainly other patients and peers (9/16). Fourteen out of 16 were perceived as successful (perceived improvement in AYA quality of life and/or positive feedback). Twelve out of 16 associations thought that their program could be transferable to transition clinics and all were interested in collaboration.

DISCUSSION

This work highlights five key points to be considered in the clinical care setting before building programs: unique tailoring and customization, complementarity with existing programs in patients' associations, viability based on peer involvement and evaluation, a common main goal, and using transition clinics' assets to direct AYAs towards the most suitable program.

Childhood-onset growth hormone deficiency and the transition to adulthood: current perspective

Childhood-onset growth hormone deficiency (CO-GHD) is an endocrine condition associated with a broad range of health issues from childhood through to adulthood, which requires particular attention during the transition period from adolescence to young adulthood. There is uncertainty in the clinical practice of the management of CO-GHD during transition regarding the clinical assessment and management of individual patients during and after transition to obtain optimal follow-up and improved health outcomes. Despite the availability of clinical guidelines providing the framework for transition of young adults with CO-GHD, there remains substantial variation in approaching transitional care among pediatric and adult services. A well-structured and coordinated transitional plan with clear communication and direct collaboration between pediatric and adult health care to ensure optimal management of adolescents with CO-GHD during transition is needed.

Pediatric to adult healthcare transitioning for adolescents living with HIV in Nigeria: A national survey

Introduction

The period of transition from pediatric to adult care has been associated with poor health outcomes among 10–19 year old adolescents living with HIV (ALHIV). This has prompted a focus on the quality of transition services, especially in high ALHIV-burden countries. Due to lack of guidelines, there are no healthcare transition standards for Nigeria’s estimated 240,000 ALHIV. We conducted a nationwide survey to characterize routine transition procedures for Nigerian ALHIV.

Materials and methods

This cross-sectional survey was conducted at public healthcare facilities supported by five local HIV service implementing partners. Comprehensive HIV treatment facilities with ≥1 year of HIV service provision and ≥20 ALHIVs enrolled were selected. A structured questionnaire assessed availability of treatment, care and transition services for ALHIV. Transition was defined as a preparatory process catering to the medical, psychosocial, and educational needs of adolescents moving from pediatric to adult care. Comprehensive transition services were defined by 6 core elements: policy, tracking and monitoring, readiness evaluation, planning, transfer of care, and follow-up.

Results

All 152 eligible facilities were surveyed and comprised 106 (69.7%) secondary and 46 (30.3%) tertiary centers at which 17,662 ALHIV were enrolled. The majority (73, 48.3%) of the 151 facilities responding to the “clinic type” question were family-centered and saw all clients together regardless of age. Only 42 (27.8%) facilities had an adolescent-specific HIV clinic; 53 (35.1%) had separate pediatric/adolescent and adult HIV clinics, of which 39 (73.6%) reported having a transfer/transition policy. Only 6 (15.4%) of these 39 facilities reported having a written protocol. There was a bimodal peak at 15 and 18 years for age of ALHIV transfer to adult care. No surveyed facility met the study definition for comprehensive transition services.

Conclusions

Facilities surveyed were more likely to have non-specialized HIV treatment services and had loosely-defined, abrupt transfer versus transition practices, which lacked the core transition elements. Evidence-based standards of transitional care tailored to non-specialized HIV treatment programs need to be established to optimize transition outcomes among ALHIV in Nigeria and in similar settings.

The New Old (and Old New) Medical Model: Four Decades Navigating the Biomedical and Psychosocial Understandings of Health and Illness

The importance of how disease and illness are conceptualised lies in the fact that such definition is paramount to understand the boundaries and scope of responsibility associated with medical work. In this paper, we aim to provide an overview of the interplay of these understandings in shaping the nature of medical work, philosophically, and in practice. We first discuss the emergence of the biopsychosocial model as an attempt to both challenge and broaden the traditional biomedical model. Then, we outline the main criticisms associated with the biopsychosocial model and note a range of contributions addressing the shortcomings of the model as initially formulated. Despite recurrent criticisms and uneven uptake, the biopsychosocial model has gone on to influence core aspects of medical practice, education, and research across many areas of medicine. One of these areas is adolescent medicine, which provides a particularly good exemplar to examine the contemporary challenges associated with the practical application of the biopsychosocial model. We conclude that a more optimal use of existing bodies of evidence, bringing together evidence-based methodological advances of the biopsychosocial model and existing evidence on the psychosocial needs associated with specific conditions/populations, can help to bridge the gap between philosophy and practice.

Helping Health Services to Meet the Needs of Young People with Chronic Conditions: Towards a Developmental Model for Transition

The transition to adult healthcare has been the subject of increased research and policy attention over many years. However, unmet needs of adolescent and young adults (AYAs) and their families continue to be documented, and universal implementation has yet to be realised. Therefore, it is pertinent to re-examine health transition in light of the principles of adolescent medicine from which it emerged, and consider this particular life transition in terms of a developmental milestone rather than a negotiation of structural boundaries between child and adult services. Health transitions are an integral part of AYA development and as such, occur alongside, and in connection with, a range of other important transitions that affect many other areas of life. In this paper, we discuss the interrelated nature of health transitions and AYA development; outline the underpinnings of a developmentally appropriate approach to transitional care; and consider the outcome measurement of such care based on existing evidence. A developmental approach has the potential to refocus transition on the fundamental principles of adolescent medicine, enabling health transition to be integrated along with other life transitions into routine AYA developmental assessments rather than being limited to the geographies of different healthcare settings and a potential health crisis.

Youth friendly communication in a transition clinic aimed at adolescents with chronic illness

Background Good communication skills are considered a cornerstone in a "youth friendly approach". However, research in the field as well as transition guidelines only sparsely explain what doctor-patient communication involves. Furthermore, only few guidelines exist regarding concrete communication skills for health professionals who want to apply a youth friendly communication approach to their practice. Objective To examine how health professionals trained in adolescent medicine practise a youth friendly approach when communicating with adolescents with chronic illness. Methods Data from 10 non-participation observations of transition consultations with adolescents with juvenile idiopathic arthritis (JIA) were analysed using a qualitative positioning analysis approach focusing on the health professionals' reflexive and interactive positionings as well as the décor of the consultation room. Results The health professionals in the transition clinic positioned the adolescent patients as independent interlocutors, children, and adolescents, and they positioned themselves as imperfect/untraditional, appreciative and non-judgmental. The positionings were based on a number of linguistic tools such as affirmation, recognition, examples, asking for the adolescents' own expert knowledge and the décor. The health professionals actively negotiated power. Conclusion Positionings and linguistic tools were inspired by youth friendly tools including the HEADS (Home Education/Eating Activities Drugs Sex/Safety/Self harm) interview, motivational interviewing, and an adolescent medicine practice. A central component was negotiating of power. Limitations of the study include a risk of too positive interpretations of data, i.e. because of the presence of the observer, who could have affected the health professionals' positionings.

From child to grown up in a medical world: developing an adolescent transition programme at a Norwegian University hospital

Background Akershus University Hospital has since 2012 worked systematically towards improving the process of transfer for adolescents from the Department for Paediatric and Adolescent Medicine (DPAM) to adult services in our hospital. Objective To improve the transfer process of adolescents we aimed at moving from a more administrative focus on transfers to a transition programme. The aim was both short-term and long-term gains, namely quality improvement of the healthcare we are providing and valued health promotion outcomes. Methods A guided transition programme for adolescents was developed, piloted and introduced. It was developed in close collaboration with our youth council. An e-learning programme and a handbook for health care professionals were developed for implementation. Results Data from the pilot testing the transition programme show that the adolescent participants found the information material to be relevant. They reported that it was used actively by the health professionals in their consultations and that they found this to be helpful. It was crucial that the management acknowledged and took responsibility for the programme. We experienced that a shared understanding of the adolescent patient in both sending and receiving departments was crucial. Conclusion Adolescent medicine should include competence and professionalism. Health care personnel must possess knowledge, skills and attitude that enable good, health promoting encounters. Further evaluation of pre- and post-implementation clinical outcomes, of patient empowerment and of satisfaction among employees will need to follow for evaluation of the effectiveness of this transition programme.

Measurable Outcomes After Transfer From Pediatric to Adult Providers in Youth With Chronic Illness

Children with chronic medical conditions are requiring transition services to prepare for transfer of care. There has been little data on what qualifies as a successful transition or how to measure this goal. The purpose of this review was to identify measurable patient-level outcomes for transitioning youth with chronic illness from pediatric to adult health care. An integrative literature search was conducted using CINAHL and OVID Medline. Key words included transition to adult care and health transition. Research articles published between 2002 and 2015 and reported on measurable patient-level outcomes in youth with chronic illnesses were included. The initial search yielded 556 articles and 19 articles were selected. Most of the research reporting on outcomes after transfer is nonexperimental using secondary data. Additionally, there is inconsistency in the use of term transition. In the specific outcomes identified, there is little uniformity in measurement both in terms of timing and standardization of measurement. Further research is needed on outcomes after transfer that includes standardized measures and time intervals in order to evaluate successful transition services. This research is essential for health care providers who are instrumental in supporting young people during this high risk period.

Adolescents with congenital heart disease: their opinions about the preparation for transfer to adult care

The aim of the study was to explore what adolescents with congenital heart disease (CHD) view as important in the preparation for the transfer to adult care. We performed interviews in four focus groups with adolescents (14-18 years old) at four university hospitals in Sweden. Data was analysed using qualitative content analysis. The analysis revealed one main category; Becoming a manager of the condition and four subcategories; Sufficient knowledge about the health, Be a participant in the care, Parental support, and Communicate with others about the health. The adolescents' ages differentiated the discussion in the groups. The older adolescents seemed to have more interest in transition planning, information and transfer. The younger described more frustrations about communication and handling the disease.

CONCLUSION

To become a manager of the CHD in daily life, the adolescents want disease specific knowledge, which should be communicated in a developmentally appropriate way. Adolescents want to participate and be involved in the transition process. They need support and guidance in how to communicate their CHD. Parental support is fundamental but it change over time. Moreover, peer-support is becoming more significant during the transition process. What is Known: • Transition during adolescence and transfer to adult care for adolescents with CHD is complex, and there is a shift in roles. • Adolescents often have poor knowledge and understanding about their heart condition and the consequences. What is New: • Adolescents call for disease specific information regarding health issues of importance for them in daily life. • Communicating the disease with other is a challenge- peer support from other adolescents with CHD could be a facilitator.

Views of Young People With Chronic Conditions on Transition From Pediatric to Adult Health Services

PURPOSE

This study sought to identify and describe the views of young people with chronic conditions about the transition from pediatric to adult services.

METHODS

Q methodology was used to identify young people's views on transition. A set of 39 statements about transition was developed from an existing literature review and refined in consultation with local groups of young people. Statements were printed onto cards and a purposive sample of 44 young people with chronic health conditions was recruited, 41 remaining in the study. The young people were asked to sort the statement cards onto a Q-sort grid, according to their opinions from "strongly disagree" to "strongly agree." Factor analysis was used to identify shared points of view (patterns of similarity between individual's Q-sorts).

RESULTS

Four distinct views on transition were identified from young people: (1) "a laid-back view of transition;" (2) "anxiety about transition;" (3) "wanting independence and autonomy during transition;" and (4) "valuing social interaction with family, peers, and professionals to assist transition."

CONCLUSIONS

Successful transition is likely to be influenced by how young people view the process. Discussing and understanding young people's views and preferences about transition should help clinicians and young people develop personalized planning for transition as a whole, and more specifically the point of transfer, leading to effective and efficient engagement with adult care.

An e-health intervention to support the transition of young people with long-term illnesses to adult healthcare services: Design and early use

OBJECTIVE

Co-design information and website to support adolescents and young adults with long-term illnesses in their transition to adult healthcare.

METHODS

A participatory iterative process involving a survey (n=207), twenty-one interviews, six participatory workshops, six video recordings, two advisory groups, and a co-design group to identify needs and preferences for e-health and information provision, was used to develop an appropriate intervention.

RESULTS

Adolescents and young people expressed preferences for information that was trustworthy, empowering, colorful, easily downloaded online and written using non-patronizing language. They desired video testimonials of experiences from young adults who had transitioned to adult healthcare and wanted advice about becoming more independent, managing their condition, preparing for the transition, and information about medications and the differences between child and adult healthcare. They also wanted information about the location and configuration of adult healthcare, key hospital personnel, and frequently asked questions.

CONCLUSION

The participatory iterative process led to the development of an online resource specifically tailored to the adolescents and young people's transition needs and information preferences. Preliminary feedback indicates that it is a valued resource.

PRACTICE IMPLICATIONS

The www.SteppingUP.ie website has the potential to help prepare its target population group for the transition to adult healthcare.

Factors influencing transitional care from adolescents to young adults with cancer in Taiwan: A population-based study

Background

To investigate the progress of transition from paediatric to adult health care for patients with cancer in Taiwan’s medical system.

Methods

The data were retrieved from the Longitudinal Health Insurance Database (LHID), which contains the original inpatient and outpatient medical claims data for 1,000,000 enrollees randomly sampled from the NHIRD between 1997 and 2010.

Results

Among the 1,411 cancer patients selected for this study, 98.09 % received adult-oriented therapy before the age of 18. In addition, only 1.91 % of the patients received paediatric-oriented therapy during adolescence. The primary factors that determine whether these patients would receive paediatric-oriented therapy or adult-oriented therapy at an early age were as follows: the age of the patient at the first visit and the performance-level of the hospital (p < 0.001).

Conclusions

Previous studies conducted in developed countries have demonstrated that the unwillingness of patients to switch from paediatric-oriented therapy to adult-oriented therapy being the major obstacle that hinders the transition process. However, this study revealed a different result: the implementation of the National Health Insurance system in Taiwan makes healthcare affordable for the adolescent patients who may not possess adequate knowledge about paediatric health care and may not appreciate paediatric-oriented therapy, thereby hindering the transition process.

Quality Improvement Targeting Adherence During the Transition from a Pediatric to Adult Liver Transplant Clinic

The transition from pediatric to adult transplant care is a high risk period for non-adherence and poor health outcomes. This article describes a quality improvement initiative integrated into a pediatric liver transplant program that focused on improving outcomes following the transfer from pediatric to adult liver transplant care. Using improvement science methodology, we evaluated the impact of our center's transition readiness skills (TRS) program by conducting a chart review of 45 pediatric liver transplant recipients who transferred to adult transplant care. Medication adherence, clinic attendance, and health status variables were examined for the year pre-transfer and first year post-transfer. 19 recipients transferred without participating in the TRS program (control group) and 26 recipients participated in the program prior to transferring to the adult clinic (TRS group). The TRS group was significantly older at the time of transfer, more adherent with medications, and more likely to attend their first adult clinic visit compared to the control group. Among the TRS group, better adolescent and parent regimen knowledge were associated with greater adherence to post-transfer clinic appointments. Transition planning should focus on the gradual shift in responsibility for health management tasks, including clinic attendance, from parent to adolescent. There may be support for extending transition support for at least 1 year post-transfer to promote adherence.

[Therapeutic education programme for patients with chronic endocrine conditions: Transition from paediatric to adult services]

The purpose of this study is to contribute to better identifying the transition of patients with chronic endocrine conditions from paediatric to adult department. The aim was to specify the means and the competences that must be used by patients and health care teams and which could be help to the best quality care.

METHOD

We propose group sessions and individual interviews. A thematic analysis of the sessions and the responses to questionnaires have enabled the development of individual educational diagnosis and assess the autonomy of young adolescents.

RESULTS

Fifty of 214 patients from paediatric services participated to therapeutic education program (TEP) in the last four years. This program is based on the psychic movements of adolescence. One year after the therapeutic education program session, 48 patients came to all the medical consultations and we observed a greater autonomy in adolescent patients.

CONCLUSION

However, we must improve the modalities for including patients in this "transition program".

Transition of care for adolescents from paediatric services to adult health services

BACKGROUND

There is evidence that the process of transition from paediatric (child) to adult health services is often associated with deterioration in the health of adolescents with chronic conditions.Transitional care is the term used to describe services that seek to bridge this care gap. It has been defined as 'the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centred to adult-oriented health care systems'. In order to develop appropriate services for adolescents, evidence of what works and what factors act as barriers and facilitators of effective interventions is needed.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve the transition of care for adolescents from paediatric to adult health services.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials 2015, Issue 1, (including the Cochrane Effective Practice and Organisation of Care Group Specialised Register), MEDLINE, EMBASE, PsycINFO, and Web of Knowledge to 19 June 2015. We also searched reference lists of included studies and relevant reviews, and contacted experts and study authors for additional studies.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled before- and after-studies (CBAs), and interrupted time-series studies (ITSs) that evaluated the effectiveness of any intervention (care model or clinical pathway), that aimed to improve the transition of care for adolescents from paediatric to adult health services. We considered adolescents with any chronic condition that required ongoing clinical care, who were leaving paediatric services and going on to receive services in adult healthcare units, and their families. Participating providers included all health professionals responsible for the care of young people.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from included papers, assessed the risk of bias of each study, and assessed the certainty of the evidence for the main comparisons using GRADE. Discrepancies were resolved by discussion. Authors were contacted for missing data. We reported the findings of the studies as pre- and post-intervention means and calculated the unadjusted absolute change from baseline with 95% confidence intervals (CI).

MAIN RESULTS

We included four RCTs (N = 238 participants) that explored: a two-day workshop-based transition preparation training for adolescents with spina bifida; a nurse-led, one-on-one, teaching session with the additional support of a 'health passport' for adolescents with heart disease; a web- and SMS-based educational intervention for adolescents with a range of different conditions; and a structured comprehensive transition programme with a transition co-ordinator for adolescents with type 1 diabetes.One study evaluating a one-on-one nurse-led intervention, and one evaluating a technology-based intervention suggested that these interventions may lead to slight improvements in transitional readiness and chronic disease self-management measured at six- to eight-month follow-ups (low certainty evidence). Results with the TRAQ self-management tool were: MD 0.20; 95% CI -0.16 to 0.56 and MD 0.43; 95% CI; -0.09 to 0.95; with the TRAQ self-advocacy tool: MD 0.37; 95% CI -0.06 to 0.80; and with the PAM tool were: MD 10; 95% CI 2.96 to 17.04. In contrast, transition-preparation training delivered via a two-day workshop for patients with spina bifida may lead to little or no difference in measures of self-care practice and general health behaviours when measured using the DSCPI-90©.Two studies evaluated the use of health services. One study evaluated a technology-based intervention and another a comprehensive transition programme; these interventions may lead to slightly more young people taking positive steps to initiate contact with health professionals themselves (Relative risk (RR): 4.87; 95% CI 0.24 to 98.12 and RR 1.50; 95% CI 0.32 to 6.94, respectively; low certainty evidence.Young people's knowledge of their disease may slightly improve with a nurse-led, one-on-one intervention to prepare young people for transition to an adult congenital heart programme (MD 14; 95% CI 2.67 to 25.33; one study; low certainty evidence).Disease-specific outcome measures were reported in two studies, both of which led to little or no difference in outcomes (low certainty evidence). One study found little or no difference between intervention and control groups. A second study found that follow-up HbA1c in young people with type 1 diabetes mellitus increased by 1.2% for each percentage increase in baseline HbA1c, independent of treatment group (1.2%; 95% CI 0.4 to 1.9; P = 0.01).Transition interventions may lead to little or no difference in well-being or quality of life as measured with the PARS III or PedsQ (two studies; low certainty evidence). Both the technology-based intervention and the two-day workshop for young people with spina bifida found little or no difference between intervention and control groups (MD 1.29; 95% CI -4.49 to 7.07). One study did not report the data.Four telephone support calls from a transition co-ordinator may lead to little or no difference in rates of transfer from paediatric to adult diabetes services (one study; low certainty evidence). At 12-month follow-up, there was little or no difference between groups of young people receiving usual care or a telephone support (RR 0.80; 95% CI 0.59 to 1.08)). They may slightly reduce the risk of disease-related hospital admissions at 12-month follow-up (RR 0.29; 95% CI 0.03 to 2.40).

AUTHORS' CONCLUSIONS

The available evidence (four small studies; N = 238), covers a limited range of interventions developed to facilitate transition in a limited number of clinical conditions, with only four to 12 months follow-up. These follow-up periods may not be long enough for any changes to become apparent as transition is a lengthy process. There was evidence of improvement in patients' knowledge of their condition in one study, and improvements in self-efficacy and confidence in another, but since few studies were eligible for this review, and the overall certainty of the body of this evidence is low, no firm conclusions can be drawn about the effectiveness of the evaluated interventions. Further research is very likely to have an important impact on our confidence in the intervention effect and likely could change our conclusions. There is considerable scope for the rigorous evaluation of other models of transitional care, reporting on clinical outcomes with longer term follow-up.

Health Literacy in Adolescents and Young Adults: An Updated Review

PURPOSE

Health literacy is important for health outcomes in adults. However, little is known about the health literacy of adolescents and young adults (AYAs). The purpose of this study was to provide an updated systematic review examining health literacy among AYAs with and without chronic illness. Specifically, the review considered (1) what sources of health information AYAs use; (2) how well AYAs are able to understand, communicate, and critically evaluate health-related information; and (3) whether health literacy is associated with health behaviors and outcomes.

METHODS

A systematic search was conducted for literature published in peer-reviewed journals using Medline, Embase, and PsycINFO databases.

RESULTS

Of 603 articles reviewed, 14 studies met the inclusion criteria, six of which examined health literacy in a chronic illness population. Studies reported high usage for information sources, though no clear links between source type and health literacy emerged. Adequate health literacy was reported in at least 60% of participants, though poor functional literacy was reported. Few studies explored communicative or critical health literacy; those that did indicated that AYAs experience challenges in these domains. Poorer health literacy was associated with some adverse health outcomes, such as obesity and smoking. For AYAs with a chronic illness, there were mixed findings between health literacy and medication adherence.

CONCLUSION

Understanding the challenges AYAs face with regards to complex developing communicative and critical health literacy skills is crucial. Due to the paucity of research in this field, addressing health literacy across all AYAs will provide a valuable step in guiding research in AYAs with cancer.

The experiences of family carers in the delivery of invasive clinical interventions for young people with complex intellectual disabilities: policy disconnect or policy opportunity?

AIMS AND OBJECTIVES

To explore the experiences of family carers in the delivery of invasive clinical interventions within community settings.

BACKGROUND

Many young people with intellectual disabilities present with complex health needs and require clinical interventions to sustain life. As the population lives into older age there is growing demand for the delivery of these interventions within the community setting.

DESIGN

An interpretivist qualitative design.

METHODS

Ten family carers of children with intellectual disabilities and complex care needs requiring invasive clinical interventions participated in semi-structured interviews.

RESULTS

There are barriers identified regarding the delivery of invasive clinical interventions in the home setting by social care support workers. These include a reluctance to carry out invasive clinical interventions both for family carers and staff, anxiety, a lack of knowledge and training and difficulties in recruiting appropriate staff.

CONCLUSIONS

There needs to be strategic policy developments focusing on this population who are cared for in the community and require invasive clinical interventions.

RELEVANCE TO CLINICAL PRACTICE

Registered Nurses have a key role in educating and preparing families and social care support workers to safely deliver invasive clinical interventions in community settings for both children and adults with intellectual disabilities.

Benefits of a transfer clinic in adolescent and young adult kidney transplant patients

Background

Adolescent and young adult kidney transplant recipients have worse graft outcomes than older and younger age groups. Difficulties in the process of transition, defined as the purposeful, planned movement of adolescents with chronic health conditions from child to adult-centered health care systems, may contribute to this. Improving the process of transition may improve adherence post-transfer to adult care services.

Objective

The purpose of this study is to investigate whether a kidney transplant transfer clinic for adolescent and young adult kidney transplant recipients transitioning from pediatric to adult care improves adherence post-transfer.

Methods

We developed a joint kidney transplant transfer clinic between a pediatric kidney transplant program, adult kidney transplant program, and adolescent medicine at two academic health centers. The transfer clinic facilitated communication between the adult and pediatric transplant teams, a face-to-face meeting of the patient with the adult team, and a meeting with the adolescent medicine physician. We compared the outcomes of 16 kidney transplant recipients transferred before the clinic was established with 16 patients who attended the clinic. The primary outcome was a composite measure of non-adherence. Non-adherence was defined as either self-reported medication non-adherence or displaying two of the following three characteristics: non-attendance at clinic, non-attendance for blood work appointments, or undetectable calcineurin inhibitor levels within 1 year post-transfer.

Results

The two groups were similar at baseline, with non-adherence identified in 43.75 % of patients. Non-adherent behavior in the year post-transfer, which included missing clinic visits, missing regular blood tests, and undetectable calcineurin inhibitor levels, was significantly lower in the cohort which attended the transfer clinic (18.8 versus 62.5 %, p = 0.03). The median change in estimated glomerular filtration rate (eGFR) in the year following transfer was smaller in the group that attended the transition clinic (−0.9 ± 13.2 ml/min/1.73 m²) compared to those who did not (−12.29 ± 14.9 ml/min/1.73 m²), p = 0.045.

Conclusions

Attendance at a single kidney transplant transfer clinic was associated with improved adherence and renal function in the year following transfer to adult care. If these changes are sustained, they may improve long-term graft outcomes for adolescent kidney transplant recipients.

Experiences with and Outcomes of Two Interventions to Maximize Engagement of Chronically Ill Adolescents During Hospital Consultations: A Mixed Methods Study

Improving patient-provider communication during hospital consultations is advocated to enhance self-management planning and transition readiness of adolescents with chronic conditions. This longitudinal mixed methods study evaluates the implementation and the outcomes of independent split-visit consultations and individual transition plans by 22 hospital teams participating in the Dutch Action Program 'On Your Own Feet Ahead!'. The interventions raised awareness in adolescents and professionals, improved adolescents' display of independent behaviors and led to more discussions about non-medical issues. Successful implementation required a team-based approach and clear explanation to parents and adolescents. Pediatric nurses played a pivotal role in improving transitional care.

Pediatric Liver Transplant Recipients Who Undergo Transfer to the Adult Healthcare Service Have Good Long-Term Outcomes

Liver transplantation has transformed survival for children with liver disease necessitating the transfer of a growing number of patients to the adult healthcare service. The impact of transfer on outcomes remains unclear. The aim of this single-center study of 137 consecutive pediatric liver transplant recipients was to examine the effect of transfer on patient and graft survival. The median time from transplant to transfer was 10.4 years and the median age of the patients at transfer was 18.6 years. After transfer, there were 5 re-transplants and 12 deaths in 14 patients. The estimated posttransfer 10-year patient and graft survival was 89.9% and 86.2%, respectively. Overall, 4 patients demonstrated graft loss as a consequence of chronic rejection. Graft loss was associated with older age at first transplant (p = 0.008). When compared to young adult patients transplanted in the adult center, the transferred patients did not have inferior graft survival from the point of transfer (HR 0.28; 95% CI 0.10-0.77, p = 0.014). This suggests that transfer did not impact significantly on graft longevity. In conclusion, pediatric liver transplant recipients who undergo transfer to the adult service have good long-term outcomes.

School Performance and Disease Interference in Adolescents with Sickle Cell Disease

Sickle cell disease (SCD) results in neuropsychological complications that place adolescents at higher risk for limited educational achievement. A first step to developing effective educational interventions is to understand the impact of SCD on school performance. The current study assessed perceptions of school performance, SCD interference and acceptability of educational support strategies in adolescents with SCD. To identify potential risk factors, the relationship between school performance, SCD interference and demographics were also examined. Thirty adolescents aged 12 to 20 completed demographics and SCD school performance questionnaires. Approximately 37% of participants reported receiving special education services, but more than 60% reported that SCD interfered with their school performance. Females reported that SCD impacted their schooling more than males (X² (1, N = 30) = 5.00, p < .05). Study findings provide important insights into demographic risk factors and support the need for individualized health and educational plans for adolescents with SCD.

Developmentally appropriate healthcare for young people: a scoping study

BACKGROUND

There is increasing recognition of the importance of providing quality healthcare to meet the biopsychosocial needs of young people. 'Developmentally appropriate healthcare' (DAH) for young people is one term used to explain what these services consist of. However, this term remains ill defined.

AIMS

(i) To analyse the use of the term DAH in the scientific literature and (ii) to identify and explore the range of meanings attributed to the term in relation to young people.

METHODS

A scoping review was conducted to map the presence of the term DAH in the literature. To analyse the use and meanings attributed to the DAH terminology, data underwent qualitative content analysis using a summative approach.

RESULTS

62 papers were selected and subjected to content analysis. An explicit definition of DAH was provided in only 1 of the 85 uses of the term DAH within the data set and in none of the 58 uses of the prefix 'developmentally appropriate'. A link between the use of the term DAH and the domains of adolescent medicine, young people, chronic conditions and transitional care was identified; as were the core ideas underpinning the use of DAH.

CONCLUSIONS

There is a need for consistency in the use of the term DAH for young people, the related stage-of-life terminology and age range criteria. Consensus is now needed as to the content and range of a formal conceptual and operational definition.

Evaluation of a multidimensional cystic fibrosis transition program: a quality improvement initiative

The adequate preparation of cystic fibrosis (CF) youth for the transfer from pediatric to adult-based health care services is essential to meet the needs of this changing population. This paper describes the evolution of a transition clinic for patients with CF into a multidimensional quality improvement transition initiative. Three transition interventions (a patient transition clinical pathway; collaboration with the adult clinic; and a tool to measure transfer readiness) were sequentially implemented and evaluated. Each was found to be a valuable addition to a comprehensive transition protocol and today are endorsed as part of transition best practices.

Young adults' experiences and satisfaction with the transfer of care

PURPOSE

Transition of care of adolescents with chronic conditions is a critical area for clinicians. Patient-reported outcomes may provide important information on the quality of services. This cohort study examines young adults' experiences and satisfaction with the transfer to adult care and explores associations with patient characteristics.

METHODS

Follow-up of 518 young adults (18-25 years) with various chronic conditions who completed a Web-based survey in 2006 (response rate, 52%). Outcome measures were the 18-item On Your Own Feet Transfer Experiences Scale (α = .93) and satisfaction with the transfer process (visual analog scale). Associations with demographic and health care-related variables, health-related quality of life, and self-management were explored with stepwise multivariate modeling, using past (2006-T0) and current (2012-T1) variables.

RESULTS

Of the respondents, 315 (65%) had transferred, while 10% was still in pediatric care and 25% was not in treatment anymore. Twenty percent rated their transfer as unsatisfactory, 50% felt prepared at the time of transfer, and 24% had met their adult-centered provider in advance. Men were more positive about their experiences and rated satisfaction higher than did women. Patient-centeredness of the adult health-care provider was the most important determinant for experiences (β = .29). Higher self-efficacy at T1 was associated with more positive experiences but not with higher satisfaction. The latter was higher for those transferred within the same hospital (β = .28).

CONCLUSIONS

The On Your Own Feet Transfer Experiences Scale is a useful instrument to measure transfer experiences. The importance young adults attach to good relations with their new provider stresses the necessity of early involvement of and good collaboration with adult care.

Youth with special health care needs: transition to adult health care services

Transition to adult services for children and youth with special health care needs (CYSHCN) has emerged as an important event in the life course of individuals with disabilities. Issues that interfere with efficient transition to adult health care include the perspectives of stakeholders, age limits on pediatric service, complexity of health conditions, a lack of experienced healthcare professionals in the adult arena, and health care financing for chronic and complex conditions. The purposes of this study were to develop a definition of successful transition and to identify determinants that were associated with a successful transition. The 2007 Survey of Adult Transition and Health dataset was used to select variables to be considered for defining success and for identifying predictors of success. The results showed that a small percentage of young adults who participated in the 2007 survey had experienced a successful transition from their pediatric care.

Transition Planning for Youth With Special Health Care Needs (YSHCN) in Illinois Schools

“Transition Planning for Youth with Special Health Care Needs (YSHCN)” chronicles the research and work completed by agencies in Illinois to provide examples of best practice in transition planning. Increasing numbers of YSHCN survive into adulthood creating a need for focus on the transition to adult life for these young people, including meeting health care needs. As a part of the Transitions project, the Illinois Chapter of the American Academy of Pediatrics and the University of Illinois at Chicago Division of Specialized Care for Children surveyed Illinois public high schools to identify transition planning efforts, staff training needs and used those results to develop and implement training. A natural way to organize health services is by integration with school transition services. The credentialed school nurse would be the ideal person to contribute to the development of the health care transition plans based on the student’s heath care provider’s medical management plan.

Reducing bottlenecks: professionals' and adolescents' experiences with transitional care delivery

BACKGROUND

The purpose of this study was to describe the interventions implemented in a quality improvement programme to improve transitional care and evaluate its effectiveness in reducing bottlenecks as perceived by professionals and improving chronically ill adolescents' experiences with care delivery.

METHODS

This longitudinal study was undertaken with adolescents and professionals who participated in the Dutch 'On Your Own Feet Ahead!' quality improvement programme. This programme followed the Breakthrough Series improvement and implementation strategy.A total of 102/128 (79.7%) professionals from 21 hospital teams filled out a questionnaire at the start of the programme (T0), and 79/123 (64.2%; five respondents had changed jobs) professionals completed the same questionnaire 1 year later (T1). Seventy-two (58.5%) professionals from 21 teams returned questionnaires at both time points. Of 389 and 430 participating adolescents, 36% and 41% returned questionnaires at T0 and T1, respectively. We used descriptive statistics and two-tailed, paired t-tests to investigate improvements in bottlenecks in transitional care (perceived by professionals) and care delivery (perceived by adolescents).

RESULTS

Professionals observed improvement in all bottlenecks at T1 (vs. T0; p < 0.05), especially in the organisation of care, such as the presence of a joint mission between paediatric and adult care, coordination of care, and availability of more resources for joint care services. Within a 1-year period, the transition programme improved some aspects of patients' experiences with care delivery, such as the provision of opportunities for adolescents to visit the clinic alone (p < 0.001) and to decide who should be present during consultations (p < 0.05).

CONCLUSIONS

This study demonstrated that transitional care interventions may improve the organisation and coordination of transitional care and better prepare adolescents for the transition to adult care within a 1-year period. By setting specific goals based on experiences with bottlenecks, the breakthrough approach helped to improve transitional care delivery for adolescents with chronic conditions.

Cystic fibrosis adolescent transition care in Canada: A snapshot of current practice

Cystic fibrosis (CF) adolescent transition is not a new health care issue, yet progress in many areas associated with the transition process has been slow. In Canada, the status of CF transition has not been previously reported. The aim of the present study was to describe the transition from paediatric to adult health care for CF patients in Canada, specifically: availability of adult CF clinic services; average age of transfer from paediatric to adult CF health care; and existing CF transition practices. Results show that access to appropriate adult CF health care in Canada is universal; however, the availability, quantity and quality of CF transition care vary among CF clinics. Over a four-year period, the number of CF clinics using formal transition protocols almost doubled, but more work remains to be performed.

The Postpediatrician Transition

A variety of factors impacts the transition from childhood to adulthood for persons with special health care needs or disabilities. Among these are the barriers in care coordination associated with our bifurcated health care delivery system in which pediatric medicine does not smoothly link up with the medical care received by adults. After reviewing the literature, we discuss the strong case to be made for reconceptualizing the medical home model, introducing a life span perspective to resolve the postpediatrician transition. Rather than a “hand off” from pediatrician to adult provider, this approach provides a pathway to fully integrating this patient population into our evolving health care system.

Up against the System: A Case Study of Young Adult Perspectives Transitioning from Pediatric Palliative Care

Advances in pediatric care have not provided the interdisciplinary support services required by those young adults with pediatric life-threatening conditions (pedLTCs) who live beyond childhood but have limited expectations to live past early adulthood. These young adults, the first generation to live into adulthood, face multiple challenges transitioning from a plethora of pediatric palliative services to scant adult health services. In a case study, using an innovative bulletin board focus group, we describe the complex interplay of the health, education, and social service sectors in this transition. Our descriptions include system deficits and strengths and the young adults' resilience and coping strategies to overcome those deficits and move forward with their lives. Young adults with pedLTC need knowledgeable providers, coordinated and accessible services, being respected and valued, and services and supports that promote independence. We recommend implementation of multidisciplinary solutions that are focused on young adult priorities to ensure seamless access to resources to support these young adults' health, educational, vocational, and social goals. The input and voice of young adults in the development of these services are imperative to ensure that multisystem services support their needs and life goals.

The SPLIT research agenda 2013

This review focuses on active clinical research in pediatric liver transplantation with special emphasis on areas that could benefit from studies utilizing the SPLIT infrastructure and data repository. Ideas were solicited by members of the SPLIT Research Committee and sections were drafted by members of the committee with expertise in those given areas. This review is intended to highlight priorities for clinical research that could successfully be conducted through the SPLIT collaborative and would have significant impact in pediatric liver transplantation.

Study protocol: longitudinal study of the transition of young people with complex health needs from child to adult health services

BACKGROUND

Young people with complex health needs have impairments that can limit their ability to carry out day-to-day activities. As well as coping with other developmental transitions, these young people must negotiate the transfer of their clinical care from child to adult services. The process of transition may not be smooth and both health and social outcomes may suffer.Increasingly, policy-makers have recognised the need to ensure a smoother transition between children's and adult services, with processes that are holistic, individualised, and person-centred; however, there is little outcome data to support proposed models of care. This study aims to identify the features of transitional care that are potentially effective and efficient for young people with complex health needs making their transition.

METHODS/DESIGN

Longitudinal cohort study. 450 young people aged 14 years to 18 years 11 months (with autism spectrum disorder and an additional mental health problem, cerebral palsy or diabetes) will be followed through their transition from child to adult services and will contribute data at baseline, 12, 24 and 36 months. We will collect data on: health and wellbeing outcomes (participation, quality of life, satisfaction with services, generic health status (EQ-5D-Y) and condition specific measure of disease control or management); exposure to proposed beneficial features of services (such as having a key worker, appropriate involvement of parents); socio-economic characteristics of the sample; use of condition-related health and personal social services; preferences for the characteristics of transitional care.We will us regression techniques to explore how outcomes vary by exposure to service features and by characteristics of the young people. These data will populate a decision-analytic model comparing the costs and benefits of potential alternative ways of organising transition services.In order to better understand mechanisms and aid interpretation, we will undertake qualitative work with 15 young people, including interviews, non-participant observation and diary collection.

DISCUSSION

This study will evaluate the effect of service components of transitional care, rather than evaluation of specific models that may be unsustainable or not generalisable. It has been developed in response to numerous national and international calls for such evaluation.