Adult care providers' perspectives on the transition to adult care for emerging adults with Type 1 diabetes: a cross-sectional survey

Adult endocrinologists' perspectives on transitioning adolescent patients with congenital adrenal hyperplasia

OBJECTIVES

The study aimed to evaluate adult endocrinologists' perspectives on caring for patients with congenital adrenal hyperplasia (CAH) and views on their transition from pediatric to adult care.

METHODS

An online survey was conducted among adult clinical endocrinologists at Harvard Medical School-affiliated hospitals from March to October 2022.

RESULTS

Most participants (25/34, 73.5 %) treat patients with CAH and expressed moderate to high confidence (23/32, 71.9 %) in their care. Those that did not treat or accept referrals cited insufficient expertise, knowledge, and resources as reasons. Only half of respondents correctly answered at least 50 % of standard of care questions. The main transition of care barrier identified was the absence of standardized policies (12/34, 35.3 %).

CONCLUSIONS

Participants, though involved in care of patients with CAH, had varied responses to standard of care questions and transition of care barriers, emphasizing the need for standardized transition protocols and additional training to ensure up-to-date clinical knowledge.

Transitions of care: An aerodigestive provider assessment survey

OBJECTIVE

To create, validate, and apply an aerodigestive provider assessment survey.

METHODS

A survey assessing provider knowledge and current practice in the transition of patients with chronic aerodigestive disorders from pediatric to adult care was drafted by a multidisciplinary expert panel. Once agreement of the initial survey items was obtained, the survey was distributed to a national multidisciplinary panel of aerodigestive experts for review. Responses from the national panel were systematically quantified and a content validity index (CVI) was calculated. A final survey was developed and distributed to pediatric and adult aerodigestive providers.

RESULTS

From the initial 22 items presented to the national panel, 20 of the initial questions were included in the final instrument. Two additional questions were developed as a result of feedback from the expert panel. All items included in the survey had an Item Content Validity Index (I-CVI) of >0.85. The average Scale CVI in proportion to the average proportion of relevance (S-CVI/Ave) for the tool was 0.88. The average Scale CVI in proportion to universal agreement (S-CVI/UA) was 0.52. The survey was then administered to pediatric and adult specialty providers at our institution. Twenty-two providers completed the final survey.

CONCLUSION

The content validity index measurements from this newly developed survey suggest that it is a valid tool for assessing current knowledge and practice in care transitions among patients with complex aerodigestive needs. The survey developed in this project has been used to identify knowledge gaps and process issues that can be addressed to ease the transition of adolescents from pediatric specialty care into adult specialty care.

The Health Care Transition Needs of Adolescents and Emerging Adults with Chronic Pain: A Narrative Review

The aim of this narrative review was to provide an overview of what is known about the health care transition process in pediatric chronic pain, barriers to successful transition of care, and the roles that pediatric psychologists and other health care providers can play in the transition process. Searches were run in in Ovid, PsycINFO, Academic Search Complete, and PubMed. Eight relevant articles were identified. There are no published protocols, guidelines, or assessment measures specific to the health care transition in pediatric chronic pain. Patients report many barriers to the transition process, including difficulty attaining reliable medical information, establishing care with new providers, financial concerns, and adapting to the increased personal responsibility for their medical care. Additional research is needed to develop and test protocols to facilitate transition of care. Protocols should emphasize structured, face-to-face interactions and include high levels of coordination between pediatric and adult care teams.

Incorporating the Six Core Elements of Health Care Transition in Type 1 Diabetes Care for Emerging Adults

A growing body of literature finds persistent problems in the provision of recommended health care transition services, as well as adverse outcomes associated with the lack of these services in emerging adults with type 1 diabetes. The Six Core Elements of Health Care Transition offers a structured approach to the phases of health care transition support for both pediatric and adult diabetes practices. This article reviews strategies to incorporate the Six Core Elements into ambulatory diabetes care to support successful health care transition for emerging adults with type 1 diabetes.

Research design and baseline participant characteristics of the Resilient, Empowered, Active Living with Diabetes - Telehealth (REAL-T) Study: A randomized controlled trial for young adults with type 1 diabetes

BACKGROUND

Type 1 diabetes (T1D) is a chronic condition affecting nearly 1.9 million people in the United States. Young adults (YAs) with T1D face unique challenges in managing their condition, experiencing poorer health and well-being than other age groups. The current study is evaluating the Resilient, Empowered, Active Living (REAL) intervention, previously shown to improve glucose levels and quality of life among YAs with diabetes, using telehealth delivery (REAL-T) to expand reach and accessibility. This paper reports on the methodology and baseline participant characteristics of the REAL-T study.

METHODS

REAL-T is a two-arm randomized controlled trial that recruited 18-30 year olds with T1D via clinics and social media advertising. Data collection, which was adapted to be fully remote due to COVID-19, occurs every three months for one year. Participants receive either usual care or a 6-month telehealth occupational therapy intervention. The primary outcome is glycated hemoglobin (A1c); secondary outcomes include diabetes distress, quality of life, and continuous glucose monitor-derived measures.

RESULTS

The study enrolled a diverse sample of 209 YAs with T1D. Analysis of baseline data indicates equivalence between the intervention and control groups. Study participants have notably higher diabetes distress and poorer mental well-being than similar populations.

CONCLUSION

The REAL-T study successfully adapted to remote implementation during the COVID-19 pandemic. By examining long-term outcomes, mediating pathways, and cost-effectiveness, the study will contribute knowledge of the impact of tailored interventions for YAs with T1D, designed to reduce disparities and improve health and well-being in this population.

Growth Hormone Deficiency following Traumatic Brain Injury in Pediatric and Adolescent Patients: Presentation, Treatment, and Challenges of Transitioning from Pediatric to Adult Services

Traumatic brain injury (TBI) is increasingly recognized, with an incidence of approximately 110 per 100,000 in pediatric populations and 618 per 100,000 in adolescent and adult populations. TBI often leads to cognitive, behavioral, and physical consequences, including endocrinopathies. Deficiencies in anterior pituitary hormones (e.g., adrenocorticotropic hormone, thyroid-stimulating hormone, gonadotropins, and growth hormone [GH]) can negatively impact health outcomes and quality of life post-TBI. This review focuses on GH deficiency (GHD), the most common post-TBI pituitary hormone deficiency. GHD is associated with abnormal body composition, lipid metabolism, bone mineral density, executive brain functions, behavior, and height outcomes in pediatric, adolescent, and transition-age patients. Despite its relatively frequent occurrence, post-TBI GHD has not been well studied in these patients; hence, diagnostic and treatment recommendations are limited. Here, we examine the occurrence and diagnosis of TBI, retrospectively analyze post-TBI hypopituitarism and GHD prevalence rates in pediatric and adolescent patients, and discuss appropriate GHD testing strategies and GH dosage recommendations for these patients. We place particular emphasis on the ways in which testing and dosage recommendations may change during the transition phase. We conclude with a review of the challenges faced by transition-age patients and how these may be addressed to improve access to adequate healthcare. Little information is currently available to help guide patients with TBI and GHD through the transition phase and there is a risk of interrupted care; therefore, a strength of this review is its emphasis on this critical period in a patient's healthcare journey.

Improving the transition from paediatric to adult healthcare: a scoping review on the recommendations of young adults with lived experience

OBJECTIVE

The goal of this review was to identify recommendations within the literature on how to improve the transition from paediatric to adult healthcare from the perspective of young adults (YAs) living with chronic conditions who have gone through the process.

DESIGN

This review was conducted in accordance with JBI methodology for scoping reviews.

SEARCH STRATEGY

We searched MEDLINE (Ovid), CINAHL (EBSCO), PsycINFO (EBSCO) and EMBASE (Elsevier) databases, and conducted a grey literature search for relevant material. The databases were searched in December 2019, and re-searched June 2020 and September 2020, while the grey literature was searched in April 2020. This scoping review focused on the recommendations of YAs with chronic conditions who have transitioned from paediatric to adult healthcare, in any setting (eg, hospital, clinic or community), and across all sectors (eg, health, education and social services).

RESULTS

Eighteen studies met inclusion criteria for this review. These studies included YAs with 14 different chronic conditions, receiving primary health services in North America (67%) and Europe (33%). YAs' recommendations for improving the transition from paediatric to adult healthcare (n=number of studies reported) included: improving continuity of care (n=12); facilitating patient-centred care (n=9); building strong support networks (n=11) and implementing transition education preparedness training (n=7).

CONCLUSION

Review findings can benefit service delivery by addressing important barriers to health, education, and social services for youth transitioning to adult healthcare.

Parental Relationships, Patient-Centered Communication With Healthcare Providers, and Diabetes Management Across Emerging Adulthood

OBJECTIVE

To examine whether yearly fluctuations in acceptance from and disclosure to parents were associated with fluctuations in perceptions of patient-centered communication (PCC) with the healthcare provider and whether fluctuations in PCC were associated with self-efficacy, type 1 diabetes self-care, and HbA1c across four annual assessments during early emerging adulthood (EA).

METHODS

A total of 228 high school seniors (M age = 17.76 years at time 1) reported on mothers' and fathers' acceptance and diabetes-related disclosure to parents, diabetes self-care, and PCC once per year for 4 years. HbA1c was collected from assay kits.

RESULTS

Multilevel models revealed within-person associations such that in years when individuals reported greater maternal acceptance than their average, they reported higher PCC. In addition, between-person differences indicated that individuals who reported more maternal acceptance on average relative to others also perceived greater PCC. Similar associations were found for EAs' reports of fathers. No significant effects were found for disclosure to either mother or father. Yearly fluctuations in PCC were associated with self-efficacy such that in years when perceived PCC was higher, self-efficacy was higher. Between person-effects were found for self-efficacy, self-care, and HbA1c such that individuals who reported more PCC on average relative to others reported higher self-efficacy, better self-care, and lower HbA1c.

CONCLUSIONS

Aspects of EA's relationships with parents fluctuate with perceptions of PCC with healthcare providers. Perceived PCC with the healthcare provider may be important in higher self-efficacy, diabetes self-care, and lower HbA1c across the early EA years.

Toward a better understanding of transition from paediatric to adult care in type 1 diabetes: A qualitative study of adolescents

AIMS

Type 1 diabetes is associated with significant morbidity, with an increasing risk of acute diabetes-related complications in adolescence and emerging adulthood. Purposeful transition from paediatric to adult-oriented care could mitigate this risk but is often lacking. Detailed understanding of the perspectives of adolescents in their final year of paediatric care is essential to inform delivery of transition care programs.

METHODS

We conducted semi-structured interviews with adolescents (aged 17 years) with type 1 diabetes at an academic institution from April 2017 to May 2018. Participants were recruited through convenience sampling. Sixty-one interviews were transcribed for analysis. Coding followed the principles of thematic analysis.

RESULTS

Thirty-six percent of participants were male, and participants were from diverse socioeconomic backgrounds. We found three overarching themes in our analysis: first, difficulties navigating changing relationships with parents and healthcare teams; second, the need to increase type 1 diabetes self-management and differing comfort levels based on age of diagnosis; and third, perceived responsibilities for transition care preparation (for both the paediatric team and adolescents themselves) focused not only on type 1 diabetes-specific skills but also on healthcare system structures.

CONCLUSIONS

Our findings suggest that novel transition programs addressing changing inter-personal relationships, disease-specific self-management (adapted for age of diagnosis), and healthcare system navigation, supported by parents and peers, may be needed to improve transition care for adolescents with type 1 diabetes.

A Guide for Adult Nephrologists and Hematologists to Managing Atypical Hemolytic Uremic Syndrome and C3 Glomerulopathy in Teens Transitioning to Young Adults

Atypical hemolytic uremic syndrome and C3 glomerulopathy/immune complex membranoproliferative glomerulonephritis are ultra-rare chronic, complement-mediated diseases with childhood manifestation in a majority of cases. Transition of clinical care of patients from pediatric to adult nephrologists-typically with controlled disease in native or transplant kidneys in case of atypical hemolytic uremic syndrome and often with chronic progressive disease despite treatment efforts in case of C3 glomerulopathy/immune complex membranoproliferative glomerulonephritis-identifies a challenging juncture in the journey of these patients. Raising awareness for the vulnerability of this patient cohort; providing education on disease pathophysiology and management including the use of new, high-precision complement antagonists; and establishing an ongoing dialog of patients, families, and all members of the health care team involved on either side of the age divide will be inevitable to ensure optimal patient outcomes and a safe transition of these patients to adulthood.

The four I's of adolescent transition in type 1 diabetes care: A qualitative study

AIMS

To explore adolescent perspectives on programme design in the transition to adult care.

METHODS

We conducted five focus groups on adolescents with type 1 diabetes nearing the age of transition to adult care. Study participants also completed an embedded survey where they rated a wide range of potential transition interventions. Focus group transcripts were analysed with three iterations of line-by-line coding to triangulate themes and subthemes.

RESULTS

Four themes were identified: Individualization-how to personalize the transition experience (having choices in the transition experience, meeting adult provider before transition and specific transition preparation); Identity-how the world relates to my diabetes (stigma of type 1 diabetes, confusion with type 2 diabetes, diagnosis disclosure and resilience); Interconnection-how my support system can help me with my diabetes (peer support, near peer support, parental support, loss of bond with paediatric team and fear of not having a bond with adult team); and Impediment-how my diabetes limits me (self-care takes work and time, unpredictability and restrictiveness, and emotional burden). Highly rated interventions from the survey included: good communication between the paediatric and adult teams, medical summary of past diabetes care, and having paediatric and adult teams in the same building.

CONCLUSIONS

The design of future transition interventions for adolescents with type 1 diabetes should address the issues of Individualization, Identity, Interconnection and Impediment. Collaborative processes between paediatric and adult providers were also rated as important strategies to facilitate the transition to adult care.

Adult Provider Perspectives on Transition and Transfer to Adult Care: A Multi-Specialty, Multi-Institutional Exploration

PURPOSE

To identify barriers that transcend multiple adult care specialties and identify potential solutions.

DESIGN AND METHODS

Twenty-one adult care providers practicing in the specialty areas of internal medicine, family medicine, gastroenterology, endocrinology, and neurology participated in one of six semi-structured focus group interviews. Data were coded and analyzed according to the Socio-ecological Model of Adolescent/Young Adult Readiness for Transition (SMART).

RESULTS

Three themes and one subtheme emerged from the data. These fell within the beliefs/expectations, knowledge, access/insurance, and relationships (subtheme) domains of the SMART model. Family beliefs/expectations regarding the provider role, difficulty accessing reliable information, and limited access to mental health and behavioral providers reportedly affect providers' ability to provide optimal health care.

CONCLUSIONS

Adult providers identified several barriers affecting their ability to care for newly transferred patients. Increased education of families and improved methods of communication between providers were recommended. Barriers related to access and insurance are common and require larger systems-level collaborations between health care systems and payor sources.

PRACTICAL IMPLICATIONS

Some recommendations (e.g., educating families on the distinct roles of the PCP vs. specialist, highlighting new treatment opportunities in adult care, conveying trust and endorsing the new provider), represent concrete steps pediatric providers can immediately take to improve transfer. Other steps will require forging bridges across the pediatric and adult care world to expand patient access to medical, mental health, and behavioral services.

Bridge study protocol: an international, observational cohort study on the transition of healthcare for adolescents with chronic conditions

INTRODUCTION

More than 10% of adolescents live with a chronic disease or disability that requires regular medical follow-up as they mature into adulthood. During the first 2 years after adolescents with chronic conditions are transferred to adult hospitals, non-adherence rates approach 70% and emergency visits and hospitalisation rates significantly increase. The purpose of the Bridge study is to prospectively examine associations of transition readiness and care experiences with transition success: young patients' health, health-related quality of life (HRQoL) and adherence to medical appointments as well as costs of care. In addition, we will track patients' growing independence and educational and employment pathways during the transition process.

METHODS AND ANALYSIS

Bridge is an international, prospective, observational cohort study. Study participants are adolescents with a chronic health condition or disability and their parents/guardians who attended the New Children's Hospital in Helsinki, Finland, or the Royal Children's Hospital (RCH) in Melbourne, Australia. Baseline assessment took place approximately 6 months prior to the transfer of care and follow-up data will be collected 1 year and 2 years after the transfer of care. Data will be collected from patients' hospital records and from questionnaires completed by the patient and their parent/guardian at each time point. The primary outcomes of this study are adherence to medical appointments, clinical health status and HRQoL and costs of care. Secondary outcome measures are educational and employment outcomes.

ETHICS AND DISSEMINATION

The Ethics Committee for Women's and Children's Health and Psychiatry at the Helsinki University Hospital (HUS/1547/2017) and the RCH Human Research Ethics Committee (38035) have approved the Bridge study protocol. Results will be published in international peer-reviewed journals and summaries will be provided to the funders of the study as well as patients and their parents/guardians.

TRIAL REGISTRATION NUMBER

NCT04631965.

Psychiatric disorders in emerging adults with diabetes transitioning to adult care: A retrospective cohort study

AIMS

During transition from paediatric to adult diabetes care, adolescents with diabetes are at increased risk of psychiatric disorders compared with those without diabetes. Prolonged gaps between the last paediatric and first adult diabetes care visit are associated with higher perceived stress and lower life satisfaction. We assessed the effect of a gap (>180 days) in establishing adult diabetes care on the risk of psychiatric disorders and determined other risk factors associated with psychiatric disorders during the transfer to adult care.

METHODS

Using provincial health administrative databases, we conducted a retrospective cohort study of individuals from Québec, Canada, diagnosed with diabetes between ages 1 and 15 years in 1997-2015. These individuals were followed from 6 months after their last paediatric visit until age 25 years. We used multivariable Cox proportional hazard models to determine the association of gap in care with psychiatric disorders risk.

RESULTS

Among 1772 youth with diabetes, 740 (42%) had a gap in care. There was a non-statistically significant association between gap in care and mood disorders diagnosed in the emergency department or hospital (hazard ratio [HR] 1.38, 95% confidence interval [CI]: [0.92, 2.07]). Older age at transfer, recent birth year and higher number of all-cause emergency department visits in the year before transfer increased the risks of psychiatric disorders.

CONCLUSIONS

Prolonged gaps in care during transfer to adult care are common and may be associated with increased psychiatric disorder risk. Developmental factors associated with adolescence and emerging adulthood may further amplify this risk.

A Provider-Facing eHealth Tool for Transitioning Youth With Special Health Care Needs From Pediatric to Adult Care: Mixed Methods, User-Engaged Usability Study

BACKGROUND

There is a need for medical education on health care transitions for youth with special health care needs. The Texas Transition Toolkit (the tool) supports providers through a one-stop shop for researching literature on care transitions, a catalog of care transition tools, and guides for developing care transition programs.

OBJECTIVE

This study aims to assess the functionality and usability of the tool with providers working with transition-aged children and youth with special health care needs (representative users).

METHODS

The tool was evaluated using a triangulated mixed methods case study approach consisting of a concurrent think-aloud phase, a satisfaction survey, and a survey of problem relevance and task performance to operationalize and capture functionality and usability. Our mixed methods deep dive into the functionality and usability of the tool focused on 10 representative users from one medical home in Texas and 5 website design experts.

RESULTS

Representative users found the tool to be highly relevant, as demonstrated by the satisfaction score for relevance (138/150, 92%). According to the users, the tool provided comprehensive information related to health care transitions for youth with special health care needs, with a satisfaction score of 87.3% (131/150) for comprehensive. Overall satisfaction with the tool was high at 81.92% (1065/1300) with a cutoff score of 73.33% (953.4/1300) indicating high satisfaction, but users reported relatively lower satisfaction with search (114/150, 76%) and navigation (ease of use: 114/150, 76%; hyperlinks: 163/200, 81.5%; structure: 159/200, 79.5%). They experienced search- and navigation-related problems (total problems detected: 21/31, 68%) and, based on quality checks, had a relatively low task completion rate for tasks involving finding information (60/80, 75%), which required searching and navigation. The problems identified around search and navigation functionality were relevant (relevance scores ranging from 14.5 to 22, with a cutoff score of 11.7 indicating relevance).

CONCLUSIONS

The tool may help bridge the gaps in training on health care transitions for youth with special health care needs in US medical education. The tool can be used to create structured protocols to help improve provider knowledge, collaboration across pediatric and adult care providers, and the continuity of care as youth with special health care needs transition from pediatric to adult care. The results provided a road map for optimizing the tool and highlighted the importance of evaluating eHealth technologies with representative users.

Association of Self-Efficacy, Transition Readiness and Diabetes Distress With Glycemic Control in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care

OBJECTIVES

Adolescence and emerging adulthood are associated with inadequate medical follow up, suboptimal glycemic control and higher risk for adverse outcomes. Our aim in this study was to determine whether self-efficacy, transition readiness or diabetes distress is associated with glycemic control (glycated hemoglobin [A1C]) among adolescents with type 1 diabetes (T1D) preparing to transition to adult care.

METHODS

We conducted a cross-sectional study of adolescents (age 17 years) with T1D followed at the Montreal Children's Hospital Diabetes Clinic 1 year before transferring to adult care. Participants completed validated questionnaires on self-efficacy (Self-Efficacy for Diabetes Self-Management Measure [SEDM], score 1 to 10), transition readiness (Am I ON TRAC? For Adult Care questionnaire [TRAC], score ≥8 indicates readiness) and diabetes distress (Diabetes Distress Scale for Adults with Type 1 Diabetes [T1-DDS], score ≥3 indicates distress). The primary outcome was A1C (%) 1 year before transfer. We examined associations of self-efficacy, transition readiness and diabetes distress with A1C using multivariate linear and logistic regression models adjusted for sex, age at diagnosis and socioeconomic status.

RESULTS

Of 74 adolescents with T1D (29 males, 39.1%), 27 (36.4%) had suboptimal glycemic control (A1C ≥9.0%). Less than half were transition-ready (TRAC questionnaire score ≥8) and 14% had diabetes distress (T1-DDS score ≥3). SEDM was not associated with A1C. Adolescents considered ready for transition were less likely to have suboptimal glycemic control (odds ratio, 0.30; 95% confidence interval, 0.09 to 0.99), whereas adolescents with diabetes distress were more likely to have suboptimal glycemic control (odds ratio, 6.24; 95% confidence interval, 1.06 to 36.75).

CONCLUSIONS

Improving health-care transition within pediatric care should focus on both transition readiness and diabetes distress to help improve adolescents' glycemic control and prepare them for adult care.

Transition von Jugendlichen mit Diabetes in die Erwachsenenbetreuung – eine Expertenbefragung

Einleitung Der Transitionsprozess für Jugendliche mit chronischen Erkrankungen ist vielerorts noch ungeregelt, eine fachärztliche Weiterbetreuung ist oftmals nicht gesichert. Ziel der Studie war es, das derzeitige Vorgehen und mögliche Defizite bei der Transition von Jugendlichen mit Diabetes zu evaluieren und das Interesse und die Bereitschaft zur flächendeckenden Einführung von strukturierten Transitionsprogrammen in Deutschland zu erfragen.

Methode Eine anonymisierte Onlinebefragung der Mitglieder der „Arbeitsgemeinschaft für Pädiatrische Diabetologie e. V.“ (AGPD) wurde im Zeitraum von Oktober 2019 bis April 2020 durchgeführt.

Ergebnisse 60 der 492 über den strukturierten E-Mail-Newsletter kontaktierten Mitglieder der AGPD nahmen an der Befragung teil. 81,1 % der Studienteilnehmer gaben an, die Transition im Rahmen von regulären Ambulanzterminen mit den Patienten zu besprechen. 25,8 % nutzen ein intern erarbeitetes oder extern unterstütztes strukturiertes Transitionsprogramm. Die Befragten schätzen, dass 50 % der Patienten eine intensive Unterstützung bei der Transition benötigen und 20 % im Transitionsprozess den Kontakt zur spezialisierten medizinischen Betreuung verlieren. Fast alle Befragten (91,4 %) sahen Verbesserungsbedarf im aktuellen Transitionsprozedere. Im Vordergrund stehen dabei insbesondere eine engere Zusammenarbeit von Kinderdiabetologen und Erwachsenendiabetologen, die Einführung eines strukturierten, standardisierten Vorgehens sowie eine Optimierung der Vorbereitung und Motivation der Jugendlichen. Die Einführung von strukturierten Transitionsprogrammen mit externer Unterstützung wird von der überwiegenden Zahl der Befragten als dringend notwendig (27,6 %) bzw. wichtig (41,4 %) bewertet.

Schlussfolgerung Die Nutzung standardisierter strukturierter Transitionsprogramme in der Behandlung von Jugendlichen mit Diabetes ist in Deutschland bisher noch gering, aber notwendig, um eine kontinuierliche fachärztliche Betreuung zu gewährleisten. Die flächendeckende Einführung geeigneter und finanzierter Programme kann den Transitionsprozess und damit auch das langfristige Outcome der Patienten verbessern. Gerade in der Umbruchphase der Adoleszenz ist ein zuverlässiger Ansprechpartner erforderlich, der die Übernahme der Selbstverantwortung für den Diabetes begleitet.

Differences in Healthcare Transition Views, Practices, and Barriers Among North American Pediatric Rheumatology Clinicians From 2010 to 2018

OBJECTIVE

Since 2010, the rheumatology community has developed guidelines and tools to improve healthcare transition. In this study, we aimed to compare current transition practices and beliefs among Childhood Arthritis and Rheumatology Research Alliance (CARRA) rheumatology providers with transition practices from a provider survey published in 2010.

METHODS

In 2018, CARRA members completed a 25-item online survey about healthcare transition. Got Transition's Current Assessment of Health Care Transition Activities was used to measure clinical transition processes on a scale of 1 (basic) to 4 (comprehensive). Bivariate analyses were used to compare 2010 and 2018 survey findings.

RESULTS

Over half of CARRA members completed the survey (202/396), including pediatric rheumatologists, adult- and pediatric-trained rheumatologists, pediatric rheumatology fellows, and advanced practice providers. The most common target age to begin transition planning was 15-17 years (49%). Most providers transferred patients prior to age 21 years (75%). Few providers used the American College of Rheumatology transition tools (31%) or have a dedicated transition clinic (23%). Only 17% had a transition policy in place, and 63% did not consistently address healthcare transition with patients. When compared to the 2010 survey, improvement was noted in 3 of 12 transition barriers: availability of adult primary care providers, availability of adult rheumatologists, and pediatric staff transition knowledge and skills (P < 0.001 for each). Nevertheless, the mean current assessment score was < 2 for each measurement.

CONCLUSION

This study demonstrates improvement in certain transition barriers and practices since 2010, although implementation of structured transition processes remains inconsistent.

Health Care Transition in Type 1 Diabetes: Perspectives of Diabetes Care and Education Specialists Caring for Young Adults

PURPOSE

The purpose of the study was to describe experiences reported by diabetes care and education specialists caring for young adults with type 1 diabetes and to assess perceived deficiencies in clinical resources and barriers to care delivery.

METHODS

A 60-item electronic survey was fielded through email to members of the Association of Diabetes Care and Education Specialists (ADCES). Respondents completed a survey consisting of: (1) clinical practice characteristics and respondents' demographics; (2) health care transition components (eg, referrals) and their perceived importance; (3) framework of current clinical diabetes care delivery and perceived need for additional support; and (4) perceived barriers regarding clinical care delivery. Statistical analyses included descriptive statistics, chi-square tests, and logistic regression.

RESULTS

Respondents (N = 531, 96% female, median years in practice = 13; interquartile range = 7-20) represented 49 states plus the District of Columbia. Although 88% of respondents reported reviewing pediatric records as important/very important, only 22% often/always reviewed them. Although 58% of respondents noted easy access to mental health care providers for young adults, 50% stated a need for additional resources. Furthermore, diabetes care and education specialists without easy access to mental health professionals were significantly more likely to report barriers to diabetes management for young adults with depression, substance abuse, eating disorders, and developmental disabilities.

CONCLUSION

Study findings highlight modifiable factors that may improve diabetes care coordination for transitioning young adults. Uniform approaches and increased access to trained mental health professionals may help support diabetes care and education specialists in their care of young adults with type 1 diabetes.

Methods for Measuring the Time of Transfer from Pediatric to Adult Care for Chronic Conditions Using Administrative Data: A Scoping Review

PURPOSE

To describe methods used to identify the timing of transfer from pediatric to adult care within health administrative data and to identify the advantages and limitations of each method to guide future research.

STUDY DESIGN AND SETTINGS

We conducted a scoping review to identify studies, summarized challenges of identifying the timing of transfer, and proposed methodological approaches for each.

RESULTS

Studies use the following approaches to capture individuals who transfer from pediatric to adult care by 1) defining the timing of transfer by the last pediatric and first adult care visit last and 2) defining transfer to adult care based on a specific age.

CONCLUSION

There are important limitations of administrative data that must be recognized in designing studies examining the transfer to adult care.

Self-Management of Health Care Among Youth: Implications for Policies on Transitions of Care

PURPOSE

Transitions from pediatric to adult health care are important milestones for youth. In surveys, providers report that youth lack the motivation or skills to manage their care independently, a prerequisite for successful transitions. To assess the validity of this belief, we surveyed youth regarding their current and desired level of involvement in their care.

METHODS

In 2017-2018, we conducted a national text message survey of youth aged 14-24 years. The survey included three open-ended questions assessing participants' independence on three health care tasks (scheduling appointments, attending appointments, and picking up prescriptions) and one open-ended question assessing their desire to be more, less, or equally involved in their care as they are now. We qualitatively analyzed free-text responses to identify themes.

RESULTS

Among 1,214 eligible participants, 805 (66.3%) completed all four questions and were included in the sample. Forty-one percent of youth reported wanting to be more involved in their care. Among young adults aged 18-24 years, 22% were not fully independent on the three health care tasks and reported wanting to be less involved or equally as involved as they are currently.

CONCLUSION

Many youth should be viewed as partners in health care transitions instead of as barriers, but some youth are at high risk for failed transitions. Policymakers and providers should promote routine screening of youth for their current levels of engagement in care and desire to be more involved.

Risk of Psychiatric Disorders and Suicide Attempts in Emerging Adults With Diabetes

OBJECTIVE

To determine the longitudinal risks of psychiatric disorders in adolescents and emerging adults with versus without diabetes.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study in Quebec, Canada, using linked health administrative databases of adolescents (age 15 years) with and without diabetes and without prior psychiatric disorders between 1997 and 2015, followed to age 25 years.

RESULTS

Our cohort included 3,544 individuals with diabetes and 1,388,397 without diabetes. Individuals with diabetes were more likely to suffer from a mood disorder (diagnosed in the emergency department or hospital) (adjusted hazard ratio 1.33 [95% CI 1.19-1.50]), attempt suicide (3.25 [1.79-5.88]), visit a psychiatrist (1.82 [1.67-1.98]), and experience any type of psychiatric disorder (1.29 [1.21-1.37]) compared with their peers without diabetes.

CONCLUSIONS

Between the ages of 15 and 25 years, the risks of psychiatric disorders and suicide attempts were substantially higher in adolescents and emerging adults with versus without diabetes.

A Practice in Maturation: Current Perspectives on the Transition from Pediatric to Adult Care for Young Adults with Diabetes

PURPOSE OF REVIEW

This review of available literature and resources highlights the challenges in transition from pediatric to adult care for young adults with diabetes, summarizes practical recommendations for facilitating the process, and identifies areas for improvement in current transition practice.

RECENT FINDINGS

Observational studies highlight suboptimal transition preparation counseling, gaps between pediatric and adult care, and increased post-transition hemoglobin A1c and acute care utilization. Studies showing improved outcomes with later age at transition allows for an extended focus on transition preparation with an eye toward developmental maturity. Interventional studies suggest varying benefits of transition coordinators and support programs. The period of transition from pediatric to adult care is a time of in which patients are at high risk for adverse outcomes and loss to follow-up; however, careful attention to planning the process and tracking patient readiness along with skilled care coordination can contribute to transition success. The durability of interventional models, as well as generalizability to varied clinical settings, must be further tested.

Transition of patients with mucopolysaccharidosis from paediatric to adult care

Mucopolysaccharidoses (MPS) are rare disorders associated with enzyme deficiencies, resulting in glycosaminoglycan (GAG) accumulation in multiple organ systems. As patients increasingly survive to adulthood, the need for a smooth transition into adult care is essential. Using case studies, we outline strategies and highlight the challenges of transition, illustrating practical solutions that may be used to optimise the transition process for patients with MPS disorders.

Seven MPS case studies were provided by four European inherited metabolic disease centres; six of these patients transferred to an adult care setting and the final patient remained under paediatric care. Of the patients who transferred, age at the start of transition ranged between 14 and 18 years (age at transfer ranged from 16 to 19 years).

While there were some shared features of transition strategies, they varied in duration, the healthcare professionals involved and the management of adult patients with MPS. Challenges included complex symptoms, patients' unwillingness to attend appointments with unfamiliar team members and attachment to paediatricians. Challenges were resolved by starting transition at an early age, educating patients and families, and providing regular communication with and reassurance to the patient and family. Sufficient time should be provided to allow patients to understand their responsibilities in the adult care setting while feeling assured of continued support from healthcare professionals. The involvement of a coordinated multidisciplinary team with expertise in MPS is also key. Overall, transition strategies must be comprehensive and individualised to patients' needs.