Health priorities in adolescents with inflammatory bowel disease: physicians' versus patients' perspectives

Transitional care of adolescents with inflammatory bowel disease to adult services varies widely across Australia and New Zealand

Background and Aim

Children and adolescents account for approximately 14% of inflammatory bowel disease (IBD) diagnoses. At an appropriate age and level of development adolescents with IBD have their care transferred from the pediatric to adult clinical team during a process termed "transition". The study aim was to survey pediatric gastroenterologists throughout Australasia to identify commonality in the transition process to contribute to standardized guideline development.

Methods

A descriptive survey captured key variables: transition clinic format, process and infrastructure, transition assessments, and guidelines. The survey was distributed electronically to 59 Pediatric Gastroenterologists throughout Australasia in January 2023.

Results

Seventeen (29%) clinicians completed the survey: Australia 13 (76%). New Zealand 4 (24%). Thirteen (76%) respondents had access to a dedicated IBD transition clinic. Adolescents attended transition clinics 1-7 times, and the main processes transferred were: prescription provision, biologic appointments, and adult team contacts. Transition was first discussed age 13-15 years (53%), or 16-18 years (47%), with the main discussion topics including: continuing adherence (88%), smoking (59%), alcohol use (59%), recreational drug use (59%). Transition readiness assessments were done infrequently (24%). The minority (24%) used formal guidelines to inform the transition process, but 15 (88%) considered the development of a standardized Australasian guideline as beneficial/extremely beneficial.

Conclusions

This survey highlighted that transition care for adolescents with IBD is variable across Australasia. Australasian guideline development may optimize the transition process for adolescents with IBD and improve their longitudinal outcomes.

Understanding Perceived Stress in Adolescent Inflammatory Bowel Disease

Background

Inflammatory bowel disease (IBD) is a chronic and debilitating illness associated with psychosocial comorbidities. Adolescents are vulnerable to the additive stress of managing IBD and navigating developmental milestones. Psychosocial factors, such as catastrophizing, illness stigma, illness uncertainty, and illness-related shame, often contribute to perceived stress in chronic illnesses. However, the combination of these variables on perceived stress in adolescents with IBD has not been examined.

Methods

Participants completed a cross-sectional online self-report survey. Model 4 of PROCESS Macro in SPSS was used to test the parallel mediation model of the relationship between disease severity and perceived stress using catastrophizing, stigma, uncertainty, and shame as mediators using 10,000 bootstrap samples. T-tests were run to assess systematic differences in the dependent variable between subjects.

Results

One hundred and thirty-one adolescents (Mage = 18.95 years; 100 females) completed the survey. Females had higher stress scores than males (P =0.002), and there were no difference in stress between younger and older participants (P = 0.085), location (P = 0.484), or IBD type (P = 0.515). The total effect of disease stress on perceived stress operating through the mediators was significant, b = 0.168, SE = 0.028, 95% CI [0.112, 0.224]. Helplessness catastrophizing, illness uncertainty, and illness-related shame, but not illness stigma, were equally strong, positive mediators.

Conclusions

The present results suggest that helplessness catastrophizing, illness uncertainty, and illness-related shame are central elements to target in stress interventions for adolescents with IBD.

Explaining the Disease Management Experiences of Patients With Inflammatory Bowel Disease: A Qualitative Study

Inflammatory bowel disease is an unpredictable, chronic, recurrent gastrointestinal disorder with a wide range of social, physical, and psychological problems experienced by patients. The identification of these concerns is important to provide better healthcare. The purpose of this study was to understand the experiences and concerns of these patients. This study was conducted using a qualitative content analysis approach. The participants were 20 inflammatory bowel disease patients. Data were collected through unstructured interviews with purposive sampling and continued until data saturation. Data were comparatively analyzed continuously and simultaneously with data collection. Data analysis revealed two themes of "tension due to possible recurrence" and "fear of decline and deterioration." The integration of these concepts suggested that patients experience "sinking into the marsh of recurrence" as a major concern that disrupts their successful management of inflammatory bowel disease. Identifying the concerns of inflammatory bowel disease patients regarding their cultural and social context is of paramount importance. The integration of such concerns into treatment can improve patients' coping abilities and improve their quality of life.

The evolution of IBD perceived engagement and care needs across the life-cycle: a scoping review

Background

The chronic and progressive evolution of Inflammatory Bowel Diseases (IBD), with its prototypical fluctuating trend, creates a condition of psycho-social discomfort, impacting the quality of life in terms of personal, working, and interpersonal.

Aims

In this article, we want to identify the nature and extent of the research evidence on the life experiences, the perceived engagement, the psychological, social care and welfare needs of people affected by IBD across the lifecycle.

Methods

Following the approach set out by Arksey and O’Malley and the PRISMA extension for scoping reviews, we conducted a scoping review in March 2019 and closed the review with an update in October 2019. It was performed using electronic databases covering Health and Life Sciences, Social Sciences and Medical Sciences, such as PubMed, Medline, Embase, Scopus, Cochrane, Web of Science, PsycInfo.

Results

We identified 95 peer-reviewed articles published from 2009 to 2019, that allowed to detection the main needs in children (psychological, need to be accepted, physical activity, feeding, parent style, support, social needs), adolescents (to understand, physical and psychological needs, protection, relational, gratitude, respect, and engagement) and adults (information, medical, psychological, social, work-related, practical, future-related, engagement). Although the literature confirms that the majority of the IBD units have planned provision for the different types of transitions, the quality and appropriateness of these services have not been assessed or audited for all the kinds of challenges across the life cycle.

Conclusions

The literature shows the relevance of organizing a flexible, personalized health care process across all the critical phases of the life cycle, providing adequate benchmarks for comparison in a multidisciplinary perspective and ensuring continuity between hospital and territory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01850-1.

The IBD-disk Is a Reliable Tool to Assess the Daily-life Burden of Patients with Inflammatory Bowel Disease

BACKGROUND AND AIM

The inflammatory bowel disease [IBD]-disk is a 10-item self-questionnaire that is used to assess IBD-related disability. The aim of the present study was to evaluate this tool in the assessment of IBD daily-life burden.

METHODS

A 1-week cross-sectional study was conducted in 42 centres affiliated in France and Belgium. Patients were asked to complete the IBD-disk [best score: 0, worst score: 100] and a visual analogue scale [VAS] of IBD daily-life burden [best score: 0, worst score: 10]. Analyses included internal consistency, correlation analysis, and diagnostic performance assessment.

RESULTS

Among the 2011 IBD outpatients who responded to the survey [67.8% of the patients had Crohn's disease], 49.9% were in clinical remission. The IBD-disk completion rate was 73.8%. The final analysis was conducted in this population [n = 1455 patients]. The mean IBD-disk score and IBD daily-life burden VAS were 39.0 ± 23.2 and 5.2 ± 2.9, respectively. The IBD-disk score was well correlated with the IBD daily-life burden VAS [r = 0.67; p <0.001]. At an optimal IBD-disk cut-off of 40, the area under the receiver operating characteristic curve [AUROC] for high IBD daily-life burden [VAS >5] was 0.81 (95% confidence interval [CI]: 0.79-0.83; p <0.001).

CONCLUSIONS

In a large cohort of patients, the IBD-disk score was well correlated with IBD daily-life burden, and it could be used in clinical practice.

Inflammatory Bowel Disease Nurses' Perspectives: Prioritizing Adolescent Transition Readiness Factors

PURPOSE

Despite the wealth of knowledge and expertise that Inflammatory Bowel Disease (IBD) nurses bring to the transition process, health literature lacks nurses' perspectives on transition readiness. The purpose of study was to ask IBD nurses to prioritize care transition readiness factors for adolescents living with IBD.

DESIGN AND METHODS

The cross-sectional exploratory survey was researcher-developed and distributed online to IBD nurses across Canada. The survey was divided into nine transition topic categories.

RESULTS

Fifty-six female registered nurses from six Canadian provinces participated in the study. Overall, nurses rated all items within each transition topic category to be very important in facilitating adolescent transition to adult healthcare. The highest individual mean scores and the highest prioritized categories were within the Knowing IBD and Healthcare Provider Relationships categories, emphasizing the importance for adolescents to understand their disease and feel comfortable communicating their needs and questions to healthcare providers.

CONCLUSIONS

The transition process needs to be individualized and comprehensive addressing a multitude of biopsychosocial factors in order to support IBD patients and families to achieve healthy adult self-care behaviours that can foster positive health outcomes.

PRACTICE IMPLICATIONS

Healthcare providers, adolescents, and parents must work collaboratively to achieve identified transition goals so that the transition process is a mutually satisfying experience. A comprehensive readiness assessment tool is suggested to assist in the transition process. Transition readiness assessment must start early, be ongoing, be age-appropriate, and be individualized to the patient needs.

Perceptions of IBD within patient and community samples: a systematic review

Objective: Inflammatory bowel disease (IBD) is a chronic, gastrointestinal condition that involves a range of debilitating bowel symptoms. Adjustment to living with IBD can be negatively impacted by maladaptive cognitive and behavioural factors (e.g. negative illness representations and repressing emotions). Patient samples also report negative reactions from the general public and such perceptions can further negatively impact people living with IBD. Therefore, we aimed to systematically review literature investigating the illness perceptions, perceived stigmatisation, and negative emotional reactions toward IBD within patient and community samples. We also aimed to review how these factors impact those living with IBD (i.e. adjustment, psychological health). Design: A range of databases (e.g. Psych INFO, PubMed) were searched over two years. One reviewer individually screened titles and abstracts using the specified inclusion criteria, and this process was repeated by a second reviewer. Subsequently, the full text articles were screened and data were extracted for the 82 articles that satisfied the inclusion criteria. Following data extraction, a narrative synthesis was conducted.Results: The review of 82 studies suggested that negative illness perceptions are linked to poorer psychosocial outcomes, that patient samples frequently anticipate stigmatisation, fear relating to bowel accidents was the most common emotion reported, and that the general public direct little enacted stigma towards IBD.Conclusion: For people living with IBD: (i) poorer psychological adjustment was reported by those who held more negative perceptions and reactions toward their illness; and (ii) their concerns regarding public perceptions of IBD warrants further empirical attention. Results emphasise the importance of targeting perceptions, and facilitating education and adaptive responding during treatment.

The Role of Shared Decision-Making in Shaping Intent to Access Services for Adolescents in Protective Custody

Including children in protective custody (e.g., foster care) in legal decisions positively impacts their perceptions of the legal system, with giving youth a voice being particularly important. Studies have primarily focused on including young people in legal processes; however, for adolescents in protective custody, decisions about living arrangements, education, and long-term planning are made outside the courtroom, with ramifications for young people and their perceptions of both legal and child protection systems. This study looks at such decision making using existing data from 151 adolescents who were ages 16-20 and had been in child welfare protective custody for at least 12 months. During in-person interviews we assessed their desired amount of involvement in a recent decision and their perceptions of their actual involvement. Youth named other individuals involved in decision-making. Data were coded and analysed to identify discrepancies in young people's perceptions of desired and actual levels of involvement. Results indicate that while the majority of adolescents (96%) are participating in decision-making, they generally desire more involvement in decisions made (64%). Only 7% of youth reported that their level of personal involvement and the involvement of others matched what they desired. The most common individuals identified in a decision made were child protection workers, legal professionals, and caregivers or family members. These findings enhance the existing literature by highlighting the unique issues related to giving young people in protective custody a voice, and provide an empirical foundation for guiding policies around who to involve in every-day decisions made for young people preparing for emancipation from protective custody.

Healthcare Transition in Pediatrics and Young Adults With Inflammatory Bowel Disease: A Scoping Review

The incidence of inflammatory bowel disease has steadily increased in children within the last decade. As young adults transition into the adult healthcare system, lack of support can lead to disease exacerbations and disease-related complications. The purpose of this scoping review was to examine the current healthcare transition literature in pediatrics and young adults with inflammatory bowel disease, with a particular focus on assessment or screening tools to evaluate healthcare transition readiness. Five most relevant databases were searched. Of these, 22 articles met the inclusion criteria and key findings from these are summarized. The majority of articles focused on adolescents or young adults with inflammatory bowel disease and were primarily published in the United States. Since 2008, there has been a growing trend in publications of inflammatory bowel disease healthcare transition literature. Articles were often described as healthcare transition readiness assessment tools, patient outcomes following transition, or transition experiences and barriers. An understanding of the current literature on the readiness assessment and support strategies is required to promote an improved quality of life for pediatric and young adult patients living with inflammatory bowel disease.

Identifying Needs in Young Adults With Inflammatory Bowel Disease: A Qualitative Study

Successful transitional care for young adults entails that healthcare teams recognize and understand the attitudes, perspectives, and developmental maturity of young adults. The aim of this study was to identify the needs of young adults with inflammatory bowel disease. Young adults 18-30 years of age were recruited from the McMaster University Medical Centre adult inflammatory bowel disease (IBD) clinic between July 2012 and May 2013. Semistructured interviews were audio taped, transcribed verbatim, and coded using a constant comparative method. QSR NVivo10 software was used to manage the data. Twenty-one young adults, including 15 subjects diagnosed as adolescents (younger than 18 years) and 6 subjects diagnosed as young adults, were interviewed. Four broad categories of needs were identified: psychosocial, informational, self-advocacy, and daily living needs. The most commonly reported needs were psychosocial and the least common were daily living needs. Results from this study may be used to inform clinical practitioners of potential needs that may be important to the overall quality of patient health during young adulthood. In addition, these findings may be used to evaluate existing transition and self-management tools to measure success of transition interventions more effectively.

Multi-Site Comparison of Patient, Parent, and Pediatric Provider Perspectives on Transition to Adult Care in IBD

PURPOSE

This multi-site study examines patient, parent, and pediatric provider perspectives on what is most important for successful transition.

DESIGN AND METHODS

Using the Transition Readiness Assessment Questionnaire, 190 participants recruited from two pediatric IBD centers selected the top five skills they considered "most important for successful transition." Rankings were summarized and compared by group.

RESULTS

While patients, parents, and clinicians all identified "calling the doctor about unusual changes in health" and "taking medications correctly and independently" as being important, each stakeholder group qualitatively and statistically differed in terms of transition readiness skills emphasized. Patients endorsed "calling the doctor about unusual changes in health" and "being knowledgeable about insurance coverage," as being most important to successful transition while parents emphasized health monitoring and problem solving. Pediatric providers emphasized adherence to treatment and reporting unusual changes in health. There were statistically significant differences in endorsement rates across participants for seven transition readiness skills. Patients agreed with providers 80% of the time and with their parents 40% of the time. Parent-provider agreement was 60%.

CONCLUSIONS

Although there was some overlap across groups, areas of emphasis differed by informant. Patients emphasized skills they need to learn, parents emphasized skills they most likely manage for their children, and providers emphasized skills that directly impact their provision of care.

PRACTICE IMPLICATIONS

Patient, parent, and provider beliefs all need to be considered when developing a comprehensive transition program. Failure to do so may result in programs that do not meet the needs of youth with IBD.

European Crohn's and Colitis Organisation Topical Review on Transitional Care in Inflammatory Bowel Disease

BACKGROUND

This European Crohn's and Colitis Organisation [ECCO] topical review focuses on the transition of adolescents with inflammatory bowel disease [IBD] from child-centred to adult-oriented care. The aim was to provide evidence-supported, expert consensus for health professionals taking part in the transition.

METHODS

An online survey determined the areas of importance for health professionals involved in the transition of adolescents with IBD. Thereafter an expert panel of nine paediatric and five adult gastroenterologists was formed to identify the critical elements of the transition programme, and to prepare core messages defined as 'current practice points'. There is limited literature about transition, therefore this review is mainly based on expert opinion and consensus, rather than on specific evidence.

RESULTS

A total of 21 practice points were generated before the first [online] voting round. Practice points that reached >80% agreement were accepted, while those that did not reach 80% agreement were refined during a consensus meeting and subjected to voting. Ultimately, 14 practice points were retained by this review.

CONCLUSION

We present a consensus-based framework for transitional care in IBD that provides a guidance for clinical practice.

Transition of pediatric to adult care in inflammatory bowel disease: Is it as easy as 1, 2, 3?

Inflammatory bowel disease (IBD) is a heterogeneous group of chronic diseases with a rising prevalence in the pediatric population, and up to 25% of IBD patients are diagnosed before 18 years of age. Adolescents with IBD tend to have more severe and extensive disease and eventually require graduation from pediatric care toadult services. The transition of patients from pediatric to adult gastroenterologists requires careful preparation and coordination, with involvement of all key players to ensure proper collaboration of care and avoid interruption in care. This can be challenging and associated with gaps in delivery of care. The pediatric and adult health paradigms have inherent differences between health care models, as well as health care priorities in IBD. The readiness of the young adult also influences this transition of care, with often times other overlaps in life events, such as school, financial independence and moving away from home. These patients are therefore at higher risk for poorer clinical disease outcomes. The aim of this paper is to review concepts pertinent to transition of care of young adults with IBD to adult care, and provides resources appropriate for an IBD pediatric to adult transition of care model.

Transition from pediatric to adult medical care - A survey in young persons with inflammatory bowel disease

Background

Transition to adult health services is a vulnerable phase in young persons with chronic disease. We describe how young persons with inflammatory bowel disease in Germany and Austria experience care during the transitional age, focusing on differences by type of provider (pediatric vs. adult specialist, no specialist).

Methods

This was a follow up survey in patients previously registered with a pediatric IBD registry. Patients aged 15 to 25 received a postal questionnaire, including a measure of health care experience and satisfaction. Descriptive analyses were stratified by age. Sub-analyses in the 18–20 year age group compared health care experience by type of provider. Determinants of early or late transfer were examined using multinomial logistic regression.

Results

619 patients responded to the survey; 605 questionnaires were available for analysis. Usual age of completing transition was 18. Earlier transfer was more common with low parental SES (OR 1.8, 95% CI 0.7 to 4.6), and less common with advanced schooling (OR 0.5, 95% CI 0.2 to 1.2). Structured transition was uncommon. 48% of the respondents had not received any preceding transition advice. Overall satisfaction with IBD care was high, especially with respect to interpersonal aspects, but less so in aspects of continuity of care.

Conclusions

Despite high overall patient satisfaction, relevant deficiencies in transitional care were documented. Some of these were associated with lower parental social status. Differences in health care satisfaction by type of provider (adult vs. pediatric) were small.

Development of the IBD Disk: A Visual Self-administered Tool for Assessing Disability in Inflammatory Bowel Diseases

BACKGROUND

The Inflammatory bowel disease (IBD) Disability Index is a validated tool that evaluates functional status; however, it is used mainly in the clinical trial setting. We describe the use of an iterative Delphi consensus process to develop the IBD Disk-a shortened, self-administered adaption of the validated IBD Disability Index-to give immediate visual representation of patient-reported IBD-related disability.

METHODS

In the preparatory phase, the IBD CONNECT group (30 health care professionals) ranked IBD Disability Index items in the perceived order of importance. The Steering Committee then selected 10 items from the IBD Disability Index to take forward for inclusion in the IBD Disk. In the consensus phase, the items were refined and agreed by the IBD Disk Working Group (14 gastroenterologists) using an online iterative Delphi consensus process. Members could also suggest new element(s) or recommend changes to included elements. The final items for the IBD Disk were agreed in February 2016.

RESULTS

After 4 rounds of voting, the following 10 items were agreed for inclusion in the IBD Disk: abdominal pain, body image, education and work, emotions, energy, interpersonal interactions, joint pain, regulating defecation, sexual functions, and sleep. All elements, except sexual functions, were included in the validated IBD Disability Index.

CONCLUSIONS

The IBD Disk has the potential to be a valuable tool for use at a clinical visit. It can facilitate assessment of inflammatory bowel disease-related disability relevant to both patients and physicians, discussion on specific disability-related issues, and tracking changes in disease burden over time.

Patient-Reported Outcomes Measurement Information System in Children with Crohn's Disease

OBJECTIVES

To assess the criterion validity and responsiveness of Patient-Reported Outcomes Measurement Information System (PROMIS) in a web-based cohort of children with Crohn's disease.

STUDY DESIGN

We recruited children with Crohn's disease (ages 9-17 years) and their parents from the web-based Crohn's and Colitis Foundation of America Kids and Teens Study cohort. Upon entry into the cohort and 6 months later, children self-reported Crohn's disease activity, health-related quality of life, and PROMIS domains of pain interference, anxiety, depression, fatigue, and peer relationships.

RESULTS

Mean PROMIS scores for the 276 participating patients were worse among those with worse self-reported Crohn's disease activity (per Short Crohn's Disease Activity Index, P < .005 for all), Crohn's disease activity in the prior 6 months (per Manitoba Index, P < .01 for all), and health-related quality of life (per IMPACT-35, P < .001 for all). One hundred forty-three patients and their parents completed follow-up questionnaires, 75% of whom reported stable disease activity. Those with improved Crohn's disease activity reported improved PROMIS scores, and those with worsened Crohn's disease activity reported worse PROMIS scores for all domains except anxiety. All participants reported improved anxiety from baseline, but those with stable or worsened Crohn's disease activity reported less improvement (P = .07).

CONCLUSIONS

PROMIS scores were significantly associated with Crohn's disease activity in a linear and clinically meaningful manner, and responded to change in Crohn's disease activity over a 6-month period. This supports the criterion validity and responsiveness of pediatric PROMIS.

Concerns and worries in people living with inflammatory bowel disease (IBD): A mixed methods study

OBJECTIVE

This mixed-methods study aimed to explore concerns and worries related to living with inflammatory bowel disease (IBD).

METHODS

Overall, 294 patients with a clinically established diagnosis of IBD were enrolled in this cross-sectional study. Concerns and worries were measured with one open-ended question. Measures of anxiety and depressive symptoms and disease activity were also administered. A thematic analysis was conducted and thematic map created. Spearman's rho was used to identify univariate correlations between predictors and the main themes. Binary logistic regression was used to test the predictors of the main themes.

RESULTS

Despite the majority of study participants being in IBD remission (74%, n=217), all but 11 reported significant IBD-related concerns. Twenty two percent reported symptoms of depression and 41% of anxiety. Four themes were identified: Quality of life (51%); Unpredictability (35%); Symptoms (34%) and Treatments (19%). Males and older people were less concerned about Quality of life (OR=.597, 95% CI: .363-.980 and OR=.980, 95% CI: .965-.995, respectively). Those in remission were less concerned about Symptoms (OR=.510, 95% CI: .281- .926) while those with longer disease duration worried more about the Symptoms (OR=1.035, 95% CI: 1.010-1.061). Males were less concerned about Treatments (OR=.422, 95% CI: .229-.777).

CONCLUSION

IBD patients report significant disease-related concerns even when in remission. Further exploration of what predicts patient concerns may help in shaping health-care delivery so that it better addresses patient needs.