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Turner EM, Cassidy AR, Rea KE, Smith-Paine JM, Wolfe KR. [Formula: see text] The multifaceted role of neuropsychology in pediatric solid organ transplant: preliminary guidelines and strategies for clinical practice. Child Neuropsychol 2024; 30:503-537. [PMID: 37291962 DOI: 10.1080/09297049.2023.2221759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/31/2023] [Indexed: 06/10/2023]
Abstract
The incidence of pediatric solid organ transplantation (SOT) has increased in recent decades due to medical and surgical advances as well as improvements in organ procurement. Survival rates for pediatric kidney, liver, and heart transplantation are above 85% but patients continue to experience complex healthcare needs over their lifetime. Long-term developmental and neuropsychological sequelae are becoming increasingly recognized in this population, although preliminary work is limited and deserves further attention. Neuropsychological weaknesses are often present prior to transplantation and may be related to underlying congenital conditions as well as downstream impact of the indicating organ dysfunction on the central nervous system. Neuropsychological difficulties pose risk for functional complications, including disruption to adaptive skill development, social-emotional functioning, quality of life, and transition to adulthood. The impact of cognitive dysfunction on health management activities (e.g., medication adherence, medical decision-making) is also an important consideration given these patients' lifelong medical needs. The primary aim of this paper is to provide preliminary guidelines and clinical strategies for assessment of neuropsychological outcomes across SOT populations for pediatric neuropsychologists and the multidisciplinary medical team, including detailing unique and shared etiologies and risk factors for impairment across organ types, and functional implications. Recommendations for clinical neuropsychological monitoring as well as multidisciplinary collaboration within pediatric SOT teams are also provided.
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Affiliation(s)
- Elise M Turner
- Department of Pediatrics, Section of Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Cassidy
- Departments of Psychiatry & Psychology and Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelly E Rea
- Division of Pediatric Psychology, Department of Pediatrics, C. S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Julia M Smith-Paine
- Division of Developmental-Behavioral Pediatrics & Psychology, Department of Pediatrics, Rainbow Babies & Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kelly R Wolfe
- Department of Pediatrics, Section of Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, CO, USA
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2
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Killian MO, Little CW, Howry SK, Watkivs M, Triplett KN, Desai DM. Demographic Factors, Medication Adherence, and Post-transplant Health Outcomes: A Longitudinal Multilevel Modeling Approach. J Clin Psychol Med Settings 2024; 31:163-173. [PMID: 37589865 DOI: 10.1007/s10880-023-09970-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
Few studies in pediatric solid organ transplantation have examined non-adherence to immunosuppressive medication over time and its associations with demographic factors and post-transplant outcomes including late acute rejection and hospitalizations. We examined longitudinal variation in patient Medication Level Variability Index (MLVI) adherence data from pediatric kidney, liver, and heart transplant recipients. Patient and administrative data from the United Network for Organ Sharing were linked with electronic health records and MLVI values for 332 patients. Multilevel mediation modeling indicated comparatively more variation in MLVI values between patients than within patients, longitudinally, over 10 years post transplant. MLVI values significantly predicted late acute rejection and hospitalization. MLVI partially mediated patient factors and post-transplant outcomes for patient age indicating adolescents may benefit most from intervention efforts. Results demonstrate the importance of longitudinal assessment of adherence and differences among patients. Efforts to promote medication adherence should be adapted to high-risk patients to increase likelihood of adherence.
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Affiliation(s)
- Michael O Killian
- College of Social Work, University Center, Florida State University, 296 Champions Way, Building C - Suite 2500, Tallahassee, FL, USA.
- College of Medicine, Florida State University, Tallahassee, FL, USA.
| | - Callie W Little
- College of Social Work, University Center, Florida State University, 296 Champions Way, Building C - Suite 2500, Tallahassee, FL, USA
| | - Savarra K Howry
- College of Social Work, University Center, Florida State University, 296 Champions Way, Building C - Suite 2500, Tallahassee, FL, USA
| | - Madison Watkivs
- College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center of Dallas, Dallas, TX, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dev M Desai
- Children's Health, Children's Medical Center of Dallas, Dallas, TX, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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3
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Bilhartz JL, Lopez MJ, Eder SJ, Magee JC, Rea K, Sturza J, Fredericks EM. Changes over time in self-efficacy and the allocation of responsibility for health management tasks in pediatric liver transplant recipients: Targets to improve the transition process. Pediatr Transplant 2024; 28:e14673. [PMID: 38059409 DOI: 10.1111/petr.14673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/03/2023] [Accepted: 11/24/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND The process of transition to adult-based care encompasses a critical period in the life of an adolescent and young adult living with a chronic illness and one that comes with an increase in the risk of poor health outcomes. As yet, there is a dearth of empirical data to help optimize this process to ensure the best long-term outcome. METHODS This study used a principal components analysis to determine specific constructs measured by a revised version of the transition readiness survey used in our clinic. We investigated changes in these constructs over time. We further investigated the relationship between the change in these constructs over time spent in a focused transition program with adherence. RESULTS The primary component underlying our transition readiness survey for patients and parents represented self-efficacy. Time spent in the transition program was an independent predictor of change in self-efficacy (rho 0.299, p = .015); however, the magnitude of that change had no relationship to adherence. Change in parent-proxy self-efficacy was found to have a statistically significant relationship with tacrolimus standard deviation (rho -0.301, p = .026). There was disagreement identified between patient and parent responses on the survey. Neither change in patient nor parent reports of self-efficacy was found to have a relationship with post-transfer adherence. CONCLUSIONS This study reaches the novel conclusion that self-efficacy and parent-proxy self-efficacy are dynamic concepts that change over time spent in a focused transition program. The patient-parent disagreement and the relationship between parent-proxy self-efficacy and adherence stress the importance of involving parents/guardians in the transition process as well.
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Affiliation(s)
- Jacob L Bilhartz
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan, USA
- University of Michigan Transplant Center, Michigan Medicine, Ann Arbor, Michigan, USA
| | - M James Lopez
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan, USA
- University of Michigan Transplant Center, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sally J Eder
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan, USA
| | - John C Magee
- University of Michigan Transplant Center, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kelly Rea
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Julie Sturza
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Emily M Fredericks
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan, USA
- University of Michigan Transplant Center, Michigan Medicine, Ann Arbor, Michigan, USA
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4
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Day J, Hames A, Earl M, Simpson A, Joshi D, Pissas E, Samyn M. Self-management skills in a UK sample of young people with chronic liver disease. Pediatr Transplant 2023; 27:e14614. [PMID: 37807641 DOI: 10.1111/petr.14614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 08/26/2023] [Accepted: 09/01/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND We aimed to assess self-management skills and adherence behaviors in young people post-liver transplant and compare these with those of young people with autoimmune liver disease and other forms of chronic liver disease. METHOD As part of our specialist multidisciplinary clinic, n = 156 young people (aged 16-25 years) completed the Liver Self-Management Questionnaire (an adaptation of the Developmentally Based Skills Checklist for adolescents post-liver transplant and modified for us across liver disease type and within the United Kingdom). Those taking medication (n = 128) also completed a service-designed questionnaire regarding adherence. The statistical significance of group differences was assessed with non-parametric analyses. RESULTS Young people post-liver transplant were less likely to report managing their condition independently than those with autoimmune liver disease or those with other forms of chronic liver disease. They also reported higher adherence (93%) compared to those with autoimmune liver disease (77%) and those with other forms of chronic liver disease (85%). However, the vast majority of self-management and adherence behaviors were comparable between young people post-transplant and those with autoimmune liver disease/other forms of chronic liver disease. CONCLUSION Our data are in line with existing data from US samples and also extend these findings to include those with other forms of chronic liver disease. These data highlight the importance of individualized care for young adults, regardless of condition type or healthcare setting, and of clinicians managing their expectations regarding what is considered appropriate condition management in early adulthood.
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Affiliation(s)
- Jemma Day
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Anna Hames
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Megan Earl
- Paediatric Liver, Gastroenterology & Nutrition Centre, King's College Hospital, London, UK
| | - Anna Simpson
- Institute of Psychiatry, Psychology & Neuroscience, King's College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Eleanna Pissas
- Paediatric Liver, Gastroenterology & Nutrition Centre, King's College Hospital, London, UK
| | - Marianne Samyn
- Paediatric Liver, Gastroenterology & Nutrition Centre, King's College Hospital, London, UK
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Badour B, Bull A, Gupta AA, Mirza RM, Klinger CA. Parental Involvement in the Transition from Paediatric to Adult Care for Youth with Chronic Illness: A Scoping Review of the North American Literature. Int J Pediatr 2023; 2023:9392040. [PMID: 38045800 PMCID: PMC10691897 DOI: 10.1155/2023/9392040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 10/23/2023] [Accepted: 11/11/2023] [Indexed: 12/05/2023] Open
Abstract
With medical advancements and improvements in medical technology, an increasing number of children with chronic conditions survive into adulthood. There is accordant growing interest toward supporting adolescents throughout the transition from paediatric to adult care. However, there is currently a paucity of research focusing on the role that these patients' parents should play during and after the transition to adult care and if maintained parental involvement is beneficial during this transition within a North American context. Accordingly, this scoping review utilized Arksey and O'Malley's five-step framework to consider parental roles during chronically ill children's transition to adult care. APA PsycInfo, CINAHL, EMBASE, MEDLINE, ProQuest, and Scopus were searched alongside advanced Google searches. Thematic content analysis was conducted on 30 articles meeting the following inclusion criteria: (1) published in English between 2010 and 2022, (2) conducted in Canada or the United States, (3) considered adolescents with chronic conditions transitioning to adult care, (4) family being noted in the title or abstract, and (5) patient populations of study not being defined by delays in cognitive development, nor mental illness. Three themes emerged from the literature: the impacts of maintaining parental involvement during transition to adult care for patients, parents experiencing feeling loss of stability and support surrounding the transition of their child's care, and significant nonmedical life events occurring for youths at the time of transition of care. Parents assuming supportive roles which change alongside their maturing child's needs were reported as being beneficial to young peoples' transition processes, while parents who hover over or micromanage their children during this time were found to hinder successful transitions. Ultimately, the majority of reviewed articles emphasized maintained parental involvement as having a net positive impact on adolescents' transitions to adult care. As such, practice and policies should be structured to engage parents throughout the transition process to best support their chronically ill children during this time of change.
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Affiliation(s)
- Bryn Badour
- Faculty of Arts and Science: Health Studies Program, University of Toronto, Toronto, Ontario, Canada M5S 3G3
- National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada M5S 1V4
| | - Amanda Bull
- Faculty of Arts and Science: Health Studies Program, University of Toronto, Toronto, Ontario, Canada M5S 3G3
- National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada M5S 1V4
| | - Abha A. Gupta
- Temerty Faculty of Medicine: Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada M5S 1A8
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8
- Division of Medical Oncology, University Health Network: Princess Margaret Cancer Centre, Toronto, Ontario, Canada M5G 2C1
| | - Raza M. Mirza
- Faculty of Arts and Science: Health Studies Program, University of Toronto, Toronto, Ontario, Canada M5S 3G3
- National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada M5S 1V4
- Temerty Faculty of Medicine: Translational Research Program, University of Toronto, Toronto, Ontario, Canada M5S 1A8
- Factor-Inwentash Faculty of Social Work: Institute for Life Course and Aging, University of Toronto, Toronto, Ontario, Canada M5S 1V4
| | - Christopher A. Klinger
- Faculty of Arts and Science: Health Studies Program, University of Toronto, Toronto, Ontario, Canada M5S 3G3
- National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada M5S 1V4
- Temerty Faculty of Medicine: Translational Research Program, University of Toronto, Toronto, Ontario, Canada M5S 1A8
- Factor-Inwentash Faculty of Social Work: Institute for Life Course and Aging, University of Toronto, Toronto, Ontario, Canada M5S 1V4
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Hart LC, Chisolm D. Improving the use of transition readiness measures in research and clinical care. Pediatr Res 2023; 94:926-930. [PMID: 37029237 DOI: 10.1038/s41390-023-02596-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/21/2023] [Accepted: 03/22/2023] [Indexed: 04/09/2023]
Abstract
Measurement of transition readiness is considered a crucial component of effective transition. It is included as one of the Six Core Elements of Transition in national transitional care guidelines. However, the current measures of transition readiness have not been found to correlate with either current or future health outcomes for youth. In addition, there are challenges in measuring transition readiness in youth with intellectual and developmental disabilities, who may not be expected to achieve skills and knowledge that are considered essential for transition in typically developing youth. These concerns make it difficult to know how best to use transition readiness measures in research and clinical care. This article highlights the appeal of measuring transition readiness in clinical and research contexts, the current barriers that prevent us from fully achieving those benefits, and potential strategies for bridging the gap. IMPACT: Transition readiness measures were developed as an attempt to identify those patients who were ready to successfully navigate the transition from pediatric to adult health care. Thus far, the measures that have been developed do not appear to be related to health outcomes such as disease control or timely attendance of the first adult appointment in adult care. We provide suggestions for how to address the current concerns with the available transition readiness measures.
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Affiliation(s)
- Laura C Hart
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
- Departments of Pediatrics and Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Deena Chisolm
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- College of Public Health, The Ohio State University, Columbus, OH, USA
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Kinberg S, Verma T, Kaura D, Mercer DF. Optimizing transition from pediatric to adult care in short bowel syndrome and intestinal failure. JPEN J Parenter Enteral Nutr 2023; 47:718-728. [PMID: 37004208 DOI: 10.1002/jpen.2499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 02/22/2023] [Accepted: 03/08/2023] [Indexed: 04/03/2023]
Abstract
As the majority of children with short bowel syndrome (SBS) and intestinal failure (IF) are now surviving into adulthood, there is a paradigm shift from short-term management to long-term outcomes and a growing need to focus on healthcare transition (HCT). It is imperative that adolescents and young adults with SBS and IF receive disease education, empowerment, and support as they navigate the transition from pediatric to adult care. Furthermore, both pediatric and adult healthcare providers who manage these patients should be aware of the challenges faced by this population, barriers to their HCT, and strategies to overcome them. This article reviews the literature on HCT in children with chronic illnesses, discusses barriers to HCT in SBS/IF, identifies the important constituents of the transition process in SBS/IF, and provides recommendations for the successful and smooth transition of the pediatric patient to the adult healthcare environment. Structured and multicomponent HCT programs should become the standard of care to ensure uninterrupted high-quality care across the life span for patients with SBS/IF.
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Affiliation(s)
- Sivan Kinberg
- Pediatric Intestinal Rehabilitation Center (PIRC), Columbia University Irving Medical Center, New York, New York, USA
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - Tanvi Verma
- Pediatric Intestinal Rehabilitation Center (PIRC), Columbia University Irving Medical Center, New York, New York, USA
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - Deeksha Kaura
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - David F Mercer
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Kelly D, Samyn M, Schwarz KB. Biliary Atresia in Adolescence and Adult Life: Medical, Surgical and Psychological Aspects. J Clin Med 2023; 12:1594. [PMID: 36836128 PMCID: PMC9967626 DOI: 10.3390/jcm12041594] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/06/2022] [Accepted: 12/23/2022] [Indexed: 02/19/2023] Open
Abstract
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.
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Affiliation(s)
- Deirdre Kelly
- Liver Unit, Birmingham Women’s & Children’s NHS Hospital, University of Birmingham, Birmingham B15 2TT, UK
| | - Marianne Samyn
- Paediatric Liver, Gastroenterology and Nutrition Unit, King’s College Hospital NHS Foundation Trust, London WC2R 2LS, UK
| | - Kathleen B. Schwarz
- Pediatric Liver Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Pediatric Liver Center, UCSD School of Medicine/Rady Children’s Hospital, San Diego, CA 92123, USA
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Kinch M, Kroll T, Stokes D, Somanadhan S. Interventions to support adolescents and young adults with the healthcare transition from paediatric to adult nephrology health services: A scoping review protocol. HRB Open Res 2023. [DOI: 10.12688/hrbopenres.13684.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Due to technological advancements and improved medical management of adolescents and young adults (AYAs) living with renal disease, there has been an exponential increase noted in the number of patients advancing from the paediatric to adult nephrology healthcare setting. Subsequently, more AYAs are required to undergo the process of healthcare transition from paediatric to adult healthcare services. This process is often a challenging period for young people and families and is often associated with a decline in physical and psychosocial health outcomes of AYAs with renal disorders. To ensure a successful transition, AYAs must develop the ability to manage their renal condition, including the medical and psychosocial aspects of their condition, independently. Despite significant research into the transition from paediatric to adult healthcare for this unique patient cohort, the transition period remains a challenge. The scoping review will aim to map, explore, and understand the interventions that are currently available to offer positive perceptions and experiences of transition for both AYAs living with renal disorders and their families. Methods: A systematic literature search will be conducted of PubMed, PsycInfo, CINAHL, ASSIA, EMBASE and Web of Science databases from the year 2000 to present. Two independent reviewers will screen the title and abstracts of peer-reviewed literature obtained and assess them against the inclusion criteria to determine their inclusion eligibility. Data will be extracted and synthesised using a template refined by the authors. The scoping review will be undertaken in accordance with PRISMA-ScR guidelines. Data will undergo a formal critical appraisal using recognised appraisal tools. Conclusions: Through mapping this knowledge, the scoping review will aim to identify interventions that are currently available and identify gaps within the literature. This evidence may support the development of transitional care interventions in the future, promote patient satisfaction, and improve patient outcome measures and experiences.
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Sakhuja S, Himes R, Carreker C, Guffey D, Beer S, Amin M, Hiremath G, Mysore K. Impact of psychosocial factors on medication level variability index and outcomes in pediatric liver transplant recipients. Pediatr Transplant 2023; 27:e14425. [PMID: 36325588 DOI: 10.1111/petr.14425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/20/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Caregivers play an important role in maintaining a functioning graft after pediatric liver transplantation. Therefore, the psychosocial factors of both patients and caregivers can have a critical impact on transplant outcomes. Appropriate assessment and recognition of these factors pre-transplantation may allow transplant teams to better define the needs of pediatric organ recipients and develop specific countermeasures, which may then contribute toward improving transplant outcomes. METHODS We studied 136 pediatric LT recipients followed at Texas Children's Hospital. Licensed social workers conducted comprehensive pre-transplant assessments on each patient, consisting of 22 psychosocial variables that were thought to impact adherence, which were reviewed during our study period. Non-adherence was determined using the MLVI for up to 4 years after transplantation. Biopsy-confirmed rejection episodes were assessed in the first 3 years after liver transplantation. RESULTS Factors significantly associated with non-adherence (defined as MLVI >2) included parental age and parental education level at assessment, type of insurance, and household income. The number of ACR episodes trended higher in patients with non-adherence, and these patients had a higher number of moderate to severe rejection episodes but this trend was not statistically significant. CONCLUSIONS Psychosocial characteristics such as parental age, education level, insurance, and household income may contribute significantly to suboptimal adherence to medications after transplantation. Identification of these psychosocial factors and early intervention is essential to the success and equitable care of our pediatric LT recipients.
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Affiliation(s)
- Shruti Sakhuja
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Ryan Himes
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ochsner Health, New Orleans, Louisiana, USA
| | - Colleen Carreker
- Department of Patient and Family Services, Texas Children's Hospital, Houston, Texas, USA
| | - Danielle Guffey
- Institution for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Stacey Beer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Mansi Amin
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Girish Hiremath
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Vanderbilt Children's, Nashville, Tennessee, USA
| | - Krupa Mysore
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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11
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Health Care Transition for Adolescents and Young Adults With Pediatric-Onset Liver Disease and Transplantation: A Position Paper by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2023; 76:84-101. [PMID: 35830731 DOI: 10.1097/mpg.0000000000003560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Advances in medical therapies and liver transplantation have resulted in a greater number of pediatric patients reaching young adulthood. However, there is an increased risk for medical complications and morbidity surrounding transfer from pediatric to adult hepatology and transplant services. Health care transition (HCT) is the process of moving from a child/family-centered model of care to an adult or patient-centered model of health care. Successful HCT requires a partnership between pediatric and adult providers across all disciplines resulting in a transition process that does not end at the time of transfer but continues throughout early adulthood. Joint consensus guidelines in collaboration with the American Society of Transplantation are presented to facilitate the adoption of a structured, multidisciplinary approach to transition planning utilizing The Six Core Elements of Health Care Transition TM for use by both pediatric and adult specialists. This paper provides guidance and seeks support for the implementation of an HCT program which spans across both pediatric and adult hepatology and transplant centers.
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12
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Lau NSM, Henderson P. Outcomes of paediatric patients with chronic liver disease in early adulthood: A heterogeneous, but representative, regional cohort study. J Paediatr Child Health 2022; 58:1771-1777. [PMID: 35762110 PMCID: PMC9796537 DOI: 10.1111/jpc.16091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/26/2022] [Accepted: 05/22/2022] [Indexed: 01/01/2023]
Abstract
AIM Advances in paediatric hepatology have led to the increasing survival of patients with paediatric-onset chronic hepatobiliary disease into adulthood. Data are lacking with regard to the outcomes of this heterogeneous group of patients and current transition models may be insufficient. This retrospective regional cohort study examined the outcomes of these patients cared for in a paediatric gastroenterology centre following transfer to adult services. METHODS A prospective database of paediatric patients with liver disease identified those already transferred to adult services. Following exclusions, medical notes were examined and health parameters recorded including initial diagnoses, transplant status, fertility and mortality. Descriptive statistics were used to calculate follow-up data and transplant-free survival (TFS). RESULTS Overall, 63 patients (52% male) entered the final analyses with a median follow-up of 27.5 years. The most common diagnosis was biliary atresia (19%); 27 different diagnoses were apparent within the cohort highlighting the heterogeneity within a single centre. Transplant prevalence at adult transfer was 41%; 14% of patients were lost to follow-up including 10% of transplant patients. TFS for biliary atresia was 17% after 37.4 years follow-up and was 54% for the total cohort. There were seven documented pregnancies and the prevalence of any psychological or psychiatric input was 44%. Transplant complications occurred in 38% of patients; there were two cancer diagnoses and two deaths following transfer. CONCLUSIONS Although overall mortality was low, the health-care burden of patients with paediatric-onset chronic liver disease is high. This group is also very heterogeneous, making structured transition to adult services difficult.
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Affiliation(s)
- Nicole SM Lau
- Child Life and HealthUniversity of EdinburghEdinburghUnited Kingdom
| | - Paul Henderson
- Child Life and HealthUniversity of EdinburghEdinburghUnited Kingdom,Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUnited Kingdom
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13
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Murray CB, Murphy LK, Jordan A, Owens MT, McLeod D, Palermo TM. Healthcare Transition Among Young Adults With Childhood-Onset Chronic Pain: A Mixed Methods Study and Proposed Framework. THE JOURNAL OF PAIN 2022; 23:1358-1370. [PMID: 35301116 DOI: 10.1016/j.jpain.2022.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 06/14/2023]
Abstract
Chronic pain extends from childhood to adulthood for many young people. The transition from pediatric to adult care is a critical, yet understudied, healthcare task facing young adults with chronic pain. The aims of this observational, sequential mixed methods study were to 1) document the healthcare transition status of young adults with chronic pain (Stage 1, quantitative aim), 2) examine young adults' perspectives of barriers and facilitators of healthcare transition (Stage 2, qualitative aim), and 3) integrate findings to construct a theoretical framework of healthcare transition. A cohort was identified with childhood chronic pain and prior care in one of 15 multidisciplinary pediatric pain clinics across the United States and Canada. Approximately 6 years later, 189 young adults (M age = 21.0; age range = 18-24; 81.5% female) from this cohort with continuing chronic pain completed surveys for Stage 1, and a subsample (n = 17) completed qualitative interviews for Stage 2. Quantitative findings demonstrated that young adults may experience lapses in care, with 41.8% indicating they had not transitioned to adult pain services. Qualitative analysis revealed young adults experienced significant barriers (eg, abrupt departure from pediatric care) as well as facilitators (eg, acceptance of pain prognosis) of healthcare transition. Quantitative and qualitative findings were integrated to construct a healthcare transition framework for chronic pain, which highlights transition as a complex process involving multiple pathways, outcomes, and stakeholders. Advancements in research and practice are needed to develop transition services to bridge gaps in care and optimize health outcomes for young people with chronic pain. PERSPECTIVE: This mixed-methods study demonstrated that 41.8% of young adults with chronic pain experience lapses in adult-centered pain care and identified key barriers and facilitators to successful healthcare transition. Findings were integrated to construct the first healthcare transition framework for youth with chronic pain.
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Affiliation(s)
- Caitlin B Murray
- Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, Washington; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington.
| | - Lexa K Murphy
- Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, Washington
| | - Abbie Jordan
- Department of Psychology & Centre for Pain Research, University of Bath, Bath, UK
| | - Michele Tsai Owens
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dorothy McLeod
- Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, Washington
| | - Tonya M Palermo
- Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, Washington; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
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14
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Howsley P, Dunkley L, Calvert R, Hawley S, Tattersall R, McMahon AM, Hawley D. Psychological/social factors associated with transfer readiness in young people with juvenile idiopathic arthritis. Clin Rheumatol 2022; 41:3777-3782. [PMID: 35896902 DOI: 10.1007/s10067-022-06237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/13/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022]
Abstract
The aim of this study is to investigate the relationships between psychological/social factors and transfer readiness from paediatric to adult rheumatology services in pre- and post-transfer young people (YP) with juvenile idiopathic arthritis (JIA). Participants completed questionnaires measuring a broad range of psychological/social factors (generalised anxiety, pain-specific anxiety, pain-related thoughts, depression, prosocial behaviours, problem behaviours, arthritis-related quality of life (QoL), social support, family functioning) and transfer readiness (transfer-related knowledge and skills, health-related self-efficacy). JIA disease activity was measured on the same day as the questionnaires. This study received all relevant ethical and regulatory approvals, and informed consent was received from or on behalf of all participants. In total, 40 pre-transfer YP with JIA aged 10-16 years (M = 13.54 years, 26 females) and their parents/guardians participated at Sheffield Children's NHS Foundation Trust, and 40 post-transfer YP with JIA aged 16-24 years (M = 20.16 years, 26 females) participated at Sheffield Teaching Hospitals NHS Foundation Trust. For both pre- and post-transfer YP, greater transfer readiness was associated with lower generalised anxiety levels, lower pain-specific anxiety levels, fewer pain-related thoughts, lower depression levels, fewer problem behaviours, better arthritis-related QoL, better social support, and better family functioning. Greater transfer readiness was also associated with less JIA disease activity for post-transfer YP only. A broad range of psychological/social factors were associated with transfer readiness in pre- and post-transfer YP with JIA. This highlights the importance of assessing and addressing YP's psychological/social well-being during their transition to adult services. Key Points • A wide range of psychological and social factors may be associated with how ready young people with juvenile idiopathic arthritis feel to move from paediatric to adult rheumatology services. • Transition outcomes may be improved by comprehensively assessing and addressing young people's psychological and social well-being.
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Affiliation(s)
- Philippa Howsley
- Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, S10 2TH, UK
| | - Lisa Dunkley
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, 2 Claremont Place, Sheffield, S10 2TB, UK
| | - Rachel Calvert
- Department of Paediatric Psychology, Sheffield Children's NHS Foundation Trust, 1 Northumberland Road, Sheffield, S10 2TH, UK
| | - Samuel Hawley
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachel Tattersall
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, 2 Claremont Place, Sheffield, S10 2TB, UK.,Department of Paediatric Rheumatology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, S10 2TH, UK
| | - Anne-Marie McMahon
- Department of Paediatric Rheumatology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, S10 2TH, UK
| | - Daniel Hawley
- Department of Paediatric Rheumatology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, S10 2TH, UK.
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15
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Culnane E, Loftus H, Peters R, Haydar M, Hodgson A, Herd L, Hardikar W. Enabling successful transition-Evaluation of a transition to adult care program for pediatric liver transplant recipients. Pediatr Transplant 2022; 26:e14213. [PMID: 34967989 DOI: 10.1111/petr.14213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/18/2021] [Accepted: 12/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study aimed to evaluate the transition to adult care program instituted for liver transplant recipients (LTRs) at a large tertiary pediatric hospital in Melbourne, Australia. Evaluation included the change in a Global Assessment Measure (GAM) before and after the transition program, satisfaction with the program, and measures of transition success including rejection rates and attendance at appointments post-transfer. We hypothesized that the introduction of our structured transition program would improve disease understanding, health system understanding, and self-care. We also hypothesized that those who had undergone the transition program would have lower failure to attend rates and lower rates of rejection than historical controls. METHODS A LTR transition program was instituted at our service from 2013 to 2015. The program involved initial assessment of competencies with a Global Assessment Measure (GAM), followed by the introduction of a personalized goal setting program addressing issues identified in dedicated transition clinics. Assessment of competencies was compared between the commencement of the program and immediately prior to transfer. Patient satisfaction with the transition process was assessed at an interview 6-12 months after transfer to the adult service. Rejection rates and failure to attend rates were compared between the intervention group and a group of LTRs who did not receive the intervention. RESULTS Twenty-eight LTRs participated in the study; 20 received the transition intervention and 8 served as controls. Within the intervention group, all domains of transition competency and reported anxiety regarding transferring had significantly improved at the conclusion of the intervention and all reported satisfaction with the transition program with most (81%) reporting readiness to transfer. There were no significant differences in rejection rates or failure to attend rates between those who did and did not receive the transition intervention. CONCLUSION A longitudinal holistic transition program has the potential to positively impact the competencies and readiness of LTRs to successful transition and transfer to adult care.
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Affiliation(s)
- Evelyn Culnane
- Transition Support Service, Department of Adolescent Medicine, The Royal Children's Hospital (RCH) Melbourne, Parkville, Victoria, Australia
| | - Hayley Loftus
- Transition Support Service, Department of Adolescent Medicine, The Royal Children's Hospital (RCH) Melbourne, Parkville, Victoria, Australia.,Health Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Rebecca Peters
- Transition Support Service, Department of Adolescent Medicine, The Royal Children's Hospital (RCH) Melbourne, Parkville, Victoria, Australia
| | - Madeleine Haydar
- Transition Support Service, Department of Adolescent Medicine, The Royal Children's Hospital (RCH) Melbourne, Parkville, Victoria, Australia
| | - Alexandra Hodgson
- Department of Gastroenterology and Hepatology, The Royal Children's Hospital (RCH) Melbourne, Parkville, Victoria, Australia
| | - Lauren Herd
- Department of Gastroenterology and Hepatology, The Royal Children's Hospital (RCH) Melbourne, Parkville, Victoria, Australia
| | - Winita Hardikar
- Department of Gastroenterology and Hepatology, The Royal Children's Hospital (RCH) Melbourne, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia.,Population Allergy, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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16
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The Development And Validation Of The Transition Readiness Assessment Instrument In Type 1 Diabetes “On TRAck”. Can J Diabetes 2022; 46:510-517. [DOI: 10.1016/j.jcjd.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 11/18/2022]
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17
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Fernandez HE, Foster BJ. Long-Term Care of the Pediatric Kidney Transplant Recipient. Clin J Am Soc Nephrol 2022; 17:296-304. [PMID: 33980614 PMCID: PMC8823932 DOI: 10.2215/cjn.16891020] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pediatric kidney transplant recipients are distinguished from adult recipients by the need for many decades of graft function, the potential effect of CKD on neurodevelopment, and the changing immune environment of a developing human. The entire life of an individual who receives a transplant as a child is colored by their status as a transplant recipient. Not only must these young recipients negotiate all of the usual challenges of emerging adulthood (transition from school to work, romantic relationships, achieving independence from parents), but they must learn to manage a life-threatening medical condition independently. Regardless of the age at transplantation, graft failure rates are higher during adolescence and young adulthood than at any other age. All pediatric transplant recipients must pass through this high-risk period. Factors contributing to the high graft failure rates in this period include poor adherence to treatment, potentially exacerbated by the transfer of care from pediatric- to adult-oriented care providers, and perhaps an increased potency of the immune response. We describe the characteristics of pediatric kidney transplant recipients, particularly those factors that may influence their care throughout their lives. We also discuss the risks associated with the transition from pediatric- to adult-oriented care and provide some suggestions to optimize the transition to adult-oriented transplant care and long-term outcomes.
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Affiliation(s)
- Hilda E. Fernandez
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Bethany J. Foster
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada,Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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18
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Sanada Y, Sakuma Y, Onishi Y, Okada N, Hirata Y, Horiuchi T, Omameuda T, Lefor AK, Sata N. Long-term outcomes in pediatric patients who underwent living donor liver transplantation for biliary atresia. Surgery 2022; 171:1671-1676. [PMID: 35027207 DOI: 10.1016/j.surg.2021.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 11/20/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is no consensus about long-term outcomes in patients with biliary atresia. We retrospectively reviewed the long-term outcomes in pediatric patients who underwent living donor liver transplantation for biliary atresia. METHODS Between May 2001 and December 2020, 221 (73%) of 302 pediatric patients who underwent living donor liver transplantation had biliary atresia. The median age at living donor liver transplantation was 1.2 (range 0.2-16.5) years, and follow-up was 10.3 ± 5.5 years. RESULTS The 10-year graft survival rates in patients with and without biliary atresia were 94% and 89%, respectively (P = .019). The 10-year graft survival was significantly poorer in patients ≥12 years of age (84%) versus those <12 years of age at living donor liver transplantation (0-2 years: 95%; 2-12 years: 96%) (P = .016). The causes of graft failure in patients with biliary atresia included late-onset refractory rejection (n = 6), bowel perforation (n = 2), and acute encephalitis (n = 2), as well as cerebral hemorrhage, hepatic vein thrombosis, and sepsis (n = 1 for all). All 7 patients with graft failure due to refractory rejection and hepatic vein thrombosis underwent repeated liver transplantation and are alive in 2021. The rates of post-transplant portal vein complications and early-onset acute cellular rejection in patients with biliary atresia were higher than in those without biliary atresia (P = .042 and P = .022, respectively). In 2021, of 60 adolescents with biliary atresia, 14 (23%) reported medication nonadherence. The rate of liver dysfunction due to late-onset acute cellular rejection and graft failure due to late-onset refractory rejection in patients with nonadherence was higher than in patients with satisfactory adherence (P = .009). CONCLUSION The long-term prognosis after living donor liver transplantation in pediatric patients with biliary atresia is quite good. However, long-term support to enhance medication adherence is required in adolescents with biliary atresia.
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Affiliation(s)
- Yukihiro Sanada
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan.
| | - Yasunaru Sakuma
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Yasuharu Onishi
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Noriki Okada
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Yuta Hirata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Toshio Horiuchi
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Takahiko Omameuda
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
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19
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Teh KL, Hoh SF, Chan SWB, Gao X, Das L, Book YX, Arkachaisri T. Transition readiness assessment in adolescents and young adults with rheumatic diseases: The Singapore experience. Int J Rheum Dis 2022; 25:344-352. [PMID: 34989472 DOI: 10.1111/1756-185x.14277] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transition from pediatric to adult care is a challenging time for adolescents and young adults (AYA) with rheumatic diseases. Validated tools have been developed to assess transition readiness. AIM To evaluate transition readiness among AYA with rheumatic diseases and to identify factors associated with transition readiness. METHODS Patients ≥15 years old were enrolled into our transition program and administered a Transition Readiness Assessment Tool (TRAT) from July 2017. The TRAT consists of 3 components: (a) patient's perception on importance of transition and confidence toward transition on a Likert scale 0-10; (b) assessment of knowledge on medical and healthcare usage using a set of 23 questions; (c) transition readiness using the Transition Readiness Assessment Questionnaire (TRAQ). Differences between groups were compared to identify factors associated with transition readiness. RESULTS Transition readiness assessment was performed in 152 patients. The median score for perception on transition importance was 7.0 (5.0-8.8) and the median score for confidence in transition was 7.0 (5.0-9.0). Majority of the patients (>50%) lack knowledge in health insurance, carrying health information, healthcare privacy changes and making own healthcare decision. Patients <20 years old were also deficient in knowledge in navigating healthcare systems. TRAQ scores were lowest in areas pertaining to healthcare insurance and obtaining financial help. CONCLUSION Healthcare insurance literacy and self-management skills were lacking in the assessment of transition readiness in AYA with rheumatic diseases. Targeted intervention in these areas will improve transition readiness and promote successful transition processes.
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Affiliation(s)
- Kai Liang Teh
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Sook Fun Hoh
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
| | - Su-Wan Bianca Chan
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Xiaocong Gao
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
| | - Lena Das
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yun Xin Book
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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20
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Rea KE, Cushman GK, Quast LF, Stolz MG, Mee LL, George RP, Blount RL. Specific healthcare responsibilities and perceived transition readiness among adolescent solid organ transplant recipients: Adolescent and caregiver perspectives. PATIENT EDUCATION AND COUNSELING 2021; 104:2089-2097. [PMID: 33549384 DOI: 10.1016/j.pec.2021.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/28/2020] [Accepted: 01/22/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Adolescents and young adults (AYAs) with solid organ transplants must attain responsibility for healthcare tasks during transition to adult healthcare. However, healthcare systems often initiate transfer based on age and not independence in care. This study examines specific responsibilities distinguishing AYA organ transplant recipients reporting readiness to transfer. METHODS 65 AYAs (ages 12-21) with heart, kidney, or liver transplants and 63 caregivers completed questionnaires assessing AYA's transition readiness, healthcare responsibility, and executive functioning. Categorizations included mostly/completely ready versus not at all/somewhat ready to transition; responsibility was compared between groups. RESULTS 42% of AYAs and 24% of caregivers reported AYAs as mostly/completely ready to transition. AYAs mostly/completely ready reported similar routine healthcare responsibility (e.g., medication taking, appointment attendance), but greater managerial healthcare responsibility (e.g., knowing insurance details, appointment scheduling), compared to AYAs not at all/somewhat ready to transition. CONCLUSIONS All AYAs should be competent in routine healthcare skills foundational for positive health outcomes. However, the managerial tasks distinguish AYAs perceived as ready to transfer to adult healthcare. PRACTICE IMPLICATIONS Emphasis on developing responsibility for managerial tasks is warranted. The Hierarchy of Healthcare Transition Readiness Skills is a framework by which AYA responsibility can be gradually increased in preparation for transfer.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology University of Georgia, Athens, USA.
| | | | - Lauren F Quast
- Department of Psychology University of Georgia, Athens, USA
| | | | - Laura L Mee
- Emory/Children's Pediatric Institute, Atlanta, USA
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21
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Dattilo TM, Roberts CM, Fisher RS, Traino KA, Edwards CS, Pepper-Davis M, Chaney JM, Mullins LL. The Role of Avoidance Coping and Illness Uncertainty in the Relationship Between Transition Readiness and Health Anxiety. J Pediatr Nurs 2021; 59:125-130. [PMID: 33878537 DOI: 10.1016/j.pedn.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE The transition to college is associated with numerous stressors, including environmental changes, increased academic expectations, and changes in social support, all of which may be exacerbated by the added responsibility of managing a chronic medical condition. Huang (2019) proposed a model examining the relationships between coping styles, transition readiness, and health anxiety, and suggested that greater transition readiness is associated with adaptive coping strategies and less health anxiety. However, there are limited findings as to how poor transition readiness relates to health anxiety. Therefore, the current study tested a serial mediation model (i.e., poor transition readiness → avoidance coping → illness uncertainty → health anxiety). DESIGN AND METHODS College students (N = 194) with a chronic medical condition completed self-report questionnaires. RESULTS Results indicated several direct effects among the modeled variables and a significant poor transition readiness → avoidance coping → illness uncertainty → health anxiety serial mediation (path a1d21b2 = 0.438, 95% CI = 0.153 to 0.913). CONCLUSIONS Worse transition readiness was associated with increased avoidance as a coping mechanism, which in turn is associated with increased illness uncertainty, and ultimately health anxiety. The current findings identified possible drivers of health anxiety in college students with a chronic medical condition. PRACTICE IMPLICATIONS These findings highlight that good transition readiness skills may buffer against maladaptive avoidance, illness uncertainty, and health anxiety. Modules aimed at improving healthcare management, avoidance, and illness uncertainty may be beneficial additions to interventions to reduce health anxiety.
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Affiliation(s)
- Taylor M Dattilo
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University, Stillwater, OK, USA.
| | - Caroline M Roberts
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University, Stillwater, OK, USA
| | - Rachel S Fisher
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University, Stillwater, OK, USA
| | - Katherine A Traino
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University, Stillwater, OK, USA
| | - Clayton S Edwards
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University, Stillwater, OK, USA
| | - Morgan Pepper-Davis
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University, Stillwater, OK, USA
| | - John M Chaney
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University, Stillwater, OK, USA
| | - Larry L Mullins
- Center for Pediatric Psychology, Department of Psychology, Oklahoma State University, Stillwater, OK, USA
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22
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Ryan JL, Dandridge LM, Fischer RT. Adherence to laboratory testing in pediatric liver transplant recipients. Pediatr Transplant 2021; 25:e13899. [PMID: 33131187 DOI: 10.1111/petr.13899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 09/08/2020] [Accepted: 10/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The objectives of this retrospective cohort study are to describe rates of adherence to laboratory testing 6 months to 3 years post-liver transplantation and to examine demographic and clinical factors related to lab non-adherence and the association with medication adherence and clinical outcomes. METHODS Medical chart review was conducted for 54 youth (mean age = 5.0 years) transplanted between 2003 and 2014. Lab adherence (≥80%) was measured as the proportion of completed labs out of the number expected. Immunosuppressant drug-level variability was used as a proxy for medication adherence. Clinical outcomes included LAR, viral infection, hospitalization, and non-routine clinic visit ≥12 months after transplant. RESULTS Lab adherence decreased substantially over time. Single-parent household (aOR 5.86; 95% CI: 1.38-24.93) and no history of early rejection (aOR 3.96; 95% CI: 1.04-15.24) were independently associated with non-adherence. Lab non-adherence was significantly associated with medication non-adherence (P < .05), LAR (P = .02), and non-routine clinic visits (P = .03). CONCLUSIONS Systematic monitoring of lab adherence may help in identifying pediatric LT recipients at increased risk for excessive healthcare use and adverse outcomes possibly due to poor disease management.
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Affiliation(s)
- Jamie L Ryan
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO, USA.,Division of Developmental and Behavioral Health, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Laura M Dandridge
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO, USA.,Division of Developmental and Behavioral Health, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Ryan T Fischer
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO, USA
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23
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Hart LC, Díaz-González de Ferris M, Nazareth M, Faldowski RA, Rak E, Hooper SR, Ndugga M, van Tilburg MAL. Evaluation of the TRxANSITION Index-Parent Version for Assessment of Readiness to Transition to Adult Care Among Youth with Chronic Conditions. J Pediatr Nurs 2021; 58:1-8. [PMID: 33278706 DOI: 10.1016/j.pedn.2020.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To develop and evaluate a parent-proxy measure of youth HCT readiness: the TRxANSITION Index-Parent Version. DESIGN AND METHODS We recruited parents (77% female) and youth (ages 12 to 25) to complete transition readiness measures during outpatient clinic visits. The TRxANSITION Index-Parent Version contains two domains: the Parent Knowledge Domain assessing a parent's knowledge of their youth's illness, and the Parent Proxy Domain, which provides a parental perspective regarding a youth's transition readiness skills. We evaluated the TRxANSITION Index - Parent Version for differences between parent and youth reports of HCT readiness, associations between parent's score and youth's characteristics, and item-category, item-sub-index, and sub-index category correlations. RESULTS Data from 93 parents-youth dyads were analyzed. Parents scored significantly higher than youth in the Parent Knowledge Domain and similarly in the Parent Proxy Domain. Parents of daughters had significantly higher scores in the Parent Knowledge Domain than parents of sons and reported similar scores to Parents of sons in the Parent Proxy Domain. Only the self-management sub-index significantly correlated with youth's age. The sub-index-domain, item-sub-index, and item-domain correlations assessed were generally large in magnitude (r > 0.5). CONCLUSIONS The TRxANSITION Index-Parent Version shows promise as a means of assessing parent knowledge of a youth's illness and may provide an accurate proxy assessment of a youth HCT readiness skills. PRACTICE IMPLICATIONS Obtaining parental perspective on a youth's HCT readiness may provide useful clinical information during the transition process.
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Affiliation(s)
- Laura C Hart
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, United States of America.
| | - Maria Díaz-González de Ferris
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, 231 MacNider Building, NC, United States of America
| | - Meaghan Nazareth
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, 231 MacNider Building, NC, United States of America
| | - Richard A Faldowski
- Department of Allied Health Sciences, University of North Carolina at Chapel Hill, NC, United States of America
| | - Eniko Rak
- Division of Clinical Rehabilitation and Mental Health Counseling, Department of Allied Health Sciences, University of North Carolina at Chapel Hill, NC, United States of America
| | - Stephen R Hooper
- Department of Allied Health Sciences, University of North Carolina at Chapel Hill, NC, United States of America
| | - Maggwa Ndugga
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, 231 MacNider Building, NC, United States of America
| | - Miranda A L van Tilburg
- Department of Medicine, University of North Carolina at Chapel Hill, NC, United States of America; College of Pharmacy and Health Sciences, Campbell University, NC, United States of America; School of Social Work, University of Washington, NC, United States of America
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24
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Shapiro JM, Himes R, Khaderi S, Economides J, El-Serag HB. A multidisciplinary approach to improving transition readiness in pediatric liver transplant recipients. Pediatr Transplant 2021; 25:e13839. [PMID: 32997866 DOI: 10.1111/petr.13839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 11/29/2022]
Abstract
The Six Core Elements of Transition have been advocated to guide transition, but little is published about their use with liver transplant patients. We started a liver transplant transition program in August 2015 using quality improvement (QI) methods and by linking the Six Core Elements of Transition to process measures. Eligible patients completed baseline transition readiness assessments (Readiness for Transition Questionnaire, RTQ), interviews with a psychologist, received focused education, and completed follow-up RTQs before transfer to adult care. Our QI goal was to improve RTQ scores by 20% prior to transfer to adult care. We also assessed continuity of care, tacrolimus levels, rejection, and retransplantation as balancing measures. Of the 24 patients who completed the transition program and were transferred to adult care, RTQ scores were available for 11 patients. Overall RTQ scores improved from 23.7 to 30.5 (+28.7%, P = .009) prior to transfer. Nearly two-thirds (63%) of patients were seen by adult transplant hepatology within 6 months, and one patient was lost to follow-up after the first adult visit. Tacrolimus-level standard deviations were <2.0 in 45% of patients in pediatric care and 72% of patients in adult care. Three patients had undergone immunosuppression withdrawal in pediatric care, with one restarted on immunosuppression prior to transfer to adult care due to late acute rejection. The Six Core Elements of Transition can be translated into patient- and system-level transition milestones to serve as potential quality metrics in the implementation of transition programs.
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Affiliation(s)
- Jordan M Shapiro
- U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service at the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ryan Himes
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ochsner Health System, New Orleans, LA, USA
| | - Saira Khaderi
- Division of Abdominal Transplantation, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Julie Economides
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Hashem B El-Serag
- U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service at the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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25
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Vernon-Roberts A, Frampton C, Gearry RB, Day AS. Development and Validation of a Self-management Skills Assessment Tool for Children With Inflammatory Bowel Disease: The Inflammatory Bowel Disease-Skills Tasks and Abilities Record (IBD-STAR). J Pediatr Gastroenterol Nutr 2021; 72:67-73. [PMID: 32804909 DOI: 10.1097/mpg.0000000000002905] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES For children with inflammatory bowel disease (IBD), the development of self-management skills has the potential to improve disease outcomes. No assessment tools are aimed at measuring self-management skills in this population. A tool was developed called the IBD-Skills Tasks and Abilities Record (IBD-STAR) which measures children's allocation of responsibility for specific skills. IBD-STAR contains 18 items, scored whether completed independently (score 2), with help (score 1) or not at all (score 0). METHODS Children with IBD completed IBD-STAR; one parent and a gastroenterologist completed a series of visual analogue scales that corresponded with each IBD-STAR section. Children's IBD-STAR scores were examined against independent variables and compared with the parent and clinician visual analogue scale scores. Reliability was calculated using Cronbach's alpha. RESULTS Twenty-five Cronbach's alpha with IBD participated, mean age 14 years (standard deviation (SD) 1.7), 14 (56%) were boys, and 21 (84%) had Crohn's disease. The mean IBD-STAR score was 27.1 (SD 5.7), equivalent to a score of 75%. Age was the only independent variable significantly associated with scores (P = 0.017). Parents consistently underestimated their children in all sections, but clinician assessments were more closely aligned. Reliability for IBD-STAR was good with an overall Cronbach's alpha of 0.84. CONCLUSION IBD-STAR reports the allocation of responsibility for self-management skills with good agreement between children and clinician, and with comprehensible differences with their parents. Such a tool may be used to identify children with IBD in need of support or to measure the efficacy of targeted interventions.
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Affiliation(s)
| | - Chris Frampton
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
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26
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Health Care Transition: A Time of Increased Vulnerability for Pediatric Liver Transplant Recipients. J Pediatr Gastroenterol Nutr 2020; 71:704-706. [PMID: 32925552 DOI: 10.1097/mpg.0000000000002938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Improvements in pediatric liver transplantation (LT) have led to an increased number of patients reaching young adulthood. Young adult LT recipients transferring from pediatric to adult models of care have increased rates of rejection, graft loss, and medical complications. The goal of a health care transition program is to optimize health and assist youth in reaching their full potential. The means to achieve this goal requires an organized transition process to support youth in acquiring independent health care skills, preparing for an adult model of care, and transferring to new providers without disruption in treatment. This can only be achieved through a multidisciplinary approach to transition planning. This is often a labor and resource-intensive undertaking, which may not receive the necessary support from local institutions. Widespread implementation requires the assistance and endorsement from governing organizations at the national and international level.
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27
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Chu MC, Smith PJ, Reynolds JM, Palmer SM, Snyder LD, Gray AL, Blumenthal JA. Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients. Int J Psychiatry Med 2020; 55:421-436. [PMID: 32052665 DOI: 10.1177/0091217420906637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Posttransplant depression has been linked to increased risk for adverse outcomes in lung transplant patients. Maintaining target serum immunosuppressant levels is also essential for optimal lung transplant clinical outcome and may be a crucial predictor of outcomes. Because depression could affect medication nonadherence, resulting in out-of-range immunosuppressant levels, we examined the relationship between posttransplant depression, immunosuppressant medication trough level variability, indexed by out-of-range values on clinical outcomes and coefficient of variability, and clinical outcomes. METHOD A consecutive series of 236 lung transplant recipients completed the Center for Epidemiological Studies-Depression two-month posttransplant. Immunosuppressant trough levels (i.e., tacrolimus or cyclosporine) within the range of individualized immunosuppressant targets were obtained at three-, six-, nine-month follow-up clinic visits. Clinical outcomes including hospitalizations and mortality were obtained from medical records. RESULTS Fourteen percent of patients were classified as depressed (Center for Epidemiological Studies-Depression ≥16), 144 (61%) of patients had at least 25% out-of-range immunosuppressant values, and the average coefficient of variability was 36%. Over a median of 2.6 years (interquartile range = 1.2), 32 participants died (14%) and 144 (61%) had at least one unplanned, transplant-related hospitalization. Both depression (hazard ratio = 1.45 (1.19, 1.76), p < . 01) and immunosuppressant variation (immunosuppressant out-of-range: hazard ratio = 1.41 (1.10, 1.81), p < .01) independently predicted more frequent hospitalizations and higher mortality. CONCLUSIONS Early posttransplant depression was associated with significantly worse clinical outcomes. While immunosuppressant level variability is also related to adverse outcomes, such variability does not account for increased risk observed with depression.
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Affiliation(s)
- Michael C Chu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - John M Reynolds
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alice L Gray
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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28
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Kelly D, Wray J. Non-adherence and transition clinics. Best Pract Res Clin Gastroenterol 2020; 46-47:101687. [PMID: 33158474 DOI: 10.1016/j.bpg.2020.101687] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 02/07/2023]
Abstract
The majority of children who undergo liver transplantation now survive into adulthood and their requirement for life-long follow-up means that they will need to transition from paediatric to adult services. Poor transition is a risk factor for poor clinical and psychosocial outcomes and one of the barriers to effective transition is vulnerability to risk-taking behaviours, and specifically non-adherence. This chapter focuses on practical considerations for transitioning young people from paediatric to adult services, with a particular focus on the risk factors associated with non-adherence and examples of interventions for managing it.
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Affiliation(s)
- Deirdre Kelly
- Liver Unit, Birmingham Women's & Children's Hospital, University of Birmingham, UK.
| | - Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK.
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29
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Ma J, Yu Q, Ding W, Zhang T, Zhang Y. Psychometric properties of the 'Self-Management and Transition to Adulthood with R x = Treatment Questionnaire' in Chinese children and young people with chronic diseases. Int J Nurs Pract 2020; 27:e12880. [PMID: 32935431 DOI: 10.1111/ijn.12880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 05/26/2020] [Accepted: 07/16/2020] [Indexed: 11/30/2022]
Abstract
AIMS The aims of this work were to translate, culturally adapt and evaluate the reliability and validity of the Chinese version of the Self-Management and Transition to Adulthood with Rx = Treatment Questionnaire. BACKGROUND Children and young people with chronic diseases are expected to start self-managing their diseases and have a smooth and coordinated transition from paediatric- to adult-oriented care. DESIGN This study involved the cultural adaptation of a questionnaire into Chinese and examined its factor structure. METHODS This was a multicentre cross-sectional study of children and young people/adolescents (8-18 years) who were diagnosed with chronic diseases in China from June 2016 to December 2018. Exploratory and confirmatory factor analyses were performed to analyse the questionnaire's validity. RESULTS Four major factors were identified in the Chinese version of the questionnaire, and it had a good fit to the target population. The internal reliability was good. All factors were positively and strongly correlated with the total score. The t test revealed that the Medication Management score was not significantly different between two age groups (8-11 and 12-18 years), but the scores of the other factors and overall scale were lower in the 8-11 years age group. CONCLUSION The Chinese version of the questionnaire has good reliability and validity in the Chinese context.
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Affiliation(s)
- Jiali Ma
- Shanghai Jiao Tong University School of Nursing, Shanghai, China
| | - Qinglin Yu
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, Shanghai, China
| | - Wenwen Ding
- Neonatal Intensive Care Unit, Zhejiang University School of Medicine Sir Run Shaw Hospital, Hangzhou, China
| | - Taomei Zhang
- Shanghai Jiao Tong University School of Nursing, Shanghai, China
| | - Ying Zhang
- Shanghai Jiao Tong University School of Nursing, Shanghai, China.,Nursing Management Research Center of China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
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30
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Cushman GK, Rich KL, Rea KE, Quast LF, Stolz MG, Gutierrez-Colina AM, Eaton CK, Lee JL, Mee LL, George R, Blount RL. Caregivers' Barriers to Facilitating Medication Adherence in Adolescents/Young Adults With Solid Organ Transplants: Measure Development and Validation. J Pediatr Psychol 2020; 45:498-508. [PMID: 32374379 DOI: 10.1093/jpepsy/jsaa023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 03/29/2020] [Accepted: 04/08/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate the factor structure, validity, and reliability of the Caregiver Medication Barriers to Adherence Scale (CMBAS), which assesses caregivers' barriers to facilitating medication adherence in adolescent and young adults (AYAs) with solid organ transplants. METHODS The sample included 93 caregivers of AYAs ages 12-22 years who received a liver, kidney, or heart transplant. Caregivers completed the CMBAS and surveys to assess its validity, including internalizing symptoms, personality traits (i.e., neuroticism, conscientiousness), and AYAs' nonadherence to immunosuppressant medications. AYA nonadherence to tacrolimus was objectively assessed via the Medication Level Variability Index (MLVI). RESULTS Confirmatory factor analyses of the CMBAS revealed a two-factor model: Caregiver Emotional Distress and Caregiver Cognitive Burden/Responsibility. Higher CMBAS scores were related to higher levels of caregiver internalizing symptoms (rs = .28 to .30), neuroticism (r = .27), and caregiver proxy-reported immunosuppressant nonadherence (r = .27), as well as lower levels of caregiver conscientiousness (rs = -.25 to -.26). The CMBAS was not associated with the MLVI (rs = -.13 to -.16). CONCLUSIONS The CMBAS demonstrated reliability and validity for caregivers of AYAs with solid organ transplants. Findings support the use of the CMBAS as a brief clinical screening tool to identify caregivers' barriers to facilitating AYA medication adherence.
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Affiliation(s)
| | - Kristin Loiselle Rich
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati School of Medicine
| | | | | | | | - Ana M Gutierrez-Colina
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | | | - Jennifer L Lee
- Emory University School of Medicine.,Children's Healthcare of Atlanta
| | - Laura L Mee
- Emory University School of Medicine.,Children's Healthcare of Atlanta
| | - Roshan George
- Emory University School of Medicine.,Children's Healthcare of Atlanta
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31
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Thompson FM, Ferguson JW, Kelly DA, Hirschfield GM. Liver disease in the young adult: the challenges and rewards. Lancet Gastroenterol Hepatol 2020; 4:248-254. [PMID: 30739664 DOI: 10.1016/s2468-1253(18)30244-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/18/2018] [Accepted: 07/23/2018] [Indexed: 01/08/2023]
Abstract
Increasing numbers of children are surviving into adulthood with a diagnosis of liver disease or having undergone liver transplantation. This population presents some challenges for the adult hepatologist, and a formal transition service clearly improves outcomes for patients in this group. Evidence of ongoing neurological development in young people up to the age of 25 years exists, and understanding these physiological processes is important in overcoming some of the challenges that caring for this population presents. A well designed transition service is key to maximising potential for these patients, and should enable young people to take control of their illness and achieve their life goals.
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Affiliation(s)
- Fiona M Thompson
- Centre for Rare Diseases, Institute for Translational Medicine, University Hospitals Birmingham, Birmingham, UK.
| | - James W Ferguson
- Centre for Rare Diseases, Institute for Translational Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Deirdre A Kelly
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Gideon M Hirschfield
- Centre for Rare Diseases, Institute for Translational Medicine, University Hospitals Birmingham, Birmingham, UK; National Institute for Health Research Birmingham Biomedical Research Centre, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, ON, Canada
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32
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Parrish C, Bartolini E, Song Y, Hernandez E, Green K, Ostrander R. Pediatric medical psychology. Int Rev Psychiatry 2020; 32:284-297. [PMID: 32091271 DOI: 10.1080/09540261.2019.1705258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Paediatric medical psychology is a specialised field within clinical health psychology focussed on the behavioural, developmental, and psychological needs of children, adolescents, and families in healthcare contexts. Paediatric medical psychologists address a myriad of problems by employing evidence-based evaluations and interventions in order to support the well-being of paediatric patients and their families. In this paper, we provide an overview of paediatric medical psychology including the education and training required to be a paediatric psychologist followed by common problems addressed by paediatric psychology, the settings paediatric psychologists work in, and the services they provide. Discussion concludes with future application of integrating paediatric psychology throughout the continuum of care to optimise adjustment and health of paediatric patients.
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Affiliation(s)
- Carisa Parrish
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Ellen Bartolini
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Youlim Song
- Department of Psychological and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Emily Hernandez
- College of Social and Behavioral Sciences, California State University Northridge, Northridge, CA, USA
| | - Katerina Green
- The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rick Ostrander
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
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33
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Reyes JD, Dick AA, Hendele JB, Perkins JD, Hsu EK. Adults transplanted as children as retransplant candidates: Analysis of outcomes support optimism in a population mislabeled as high risk. Clin Transplant 2020; 34:e13880. [PMID: 32282089 DOI: 10.1111/ctr.13880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jorge D Reyes
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington
| | - Andre A Dick
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington
| | - James B Hendele
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington
| | - James D Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, Washington
| | - Evelyn K Hsu
- Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, Washington.,Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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34
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Willis E, McDonagh JE. Shifting the mindset-adolescent and young adult rheumatology in transition. THE LANCET. RHEUMATOLOGY 2020; 2:e236-e244. [PMID: 38268158 DOI: 10.1016/s2665-9913(19)30163-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/12/2019] [Accepted: 12/20/2019] [Indexed: 01/26/2024]
Abstract
Almost 30 years have passed since publication of the first reports acknowledging the crucial importance of transitional care for adolescents and young adults with chronic disease, but universal implementation has yet to be achieved. Progress has undoubtedly been made, with increasing evidence for best practice in transitional care. However, translation of research and guidance into clinical practice continues to be challenging. Neuroscience advances in understanding the changes occurring in the adolescent brain demand that the third phase of transition (ie, post-transfer to adult services) is given further attention, with recognition that transfer itself is not the end of the transition process. The complex, often unwieldy health systems delivering care must also be considered. Paediatric and adult rheumatology practitioners need to collaborate not only with each other, but also with practitioners in other disciplines, specialties, and agencies, to plan and commission rheumatology services that are responsive to adolescents and young adults. A shift in approach from focusing on health transition towards developmentally appropriate health care has the potential to improve the care provided during this vulnerable life stage, increasing the likelihood of continuing engagement of patients in their own health care into adulthood and thereby improving health outcomes.
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Affiliation(s)
- Emily Willis
- Department of Paediatric and Adolescent Rheumatology, Royal Manchester Children's Hospital, Manchester University Hospitals NHS Trust, Manchester, UK
| | - Janet E McDonagh
- Department of Paediatric and Adolescent Rheumatology, Royal Manchester Children's Hospital, Manchester University Hospitals NHS Trust, Manchester, UK; Versus Arthritis Centre for Epidemiology, and Centre for Musculoskeletal Research, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester, UK.
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35
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Adherence, Medical Outcomes, and Health Care Costs in Adolescents/Young Adults Following Pediatric Liver Transplantation. J Pediatr Gastroenterol Nutr 2020; 70:183-189. [PMID: 31978014 DOI: 10.1097/mpg.0000000000002553] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Improved outcomes after pediatric liver transplantation (LT) have led to increasing numbers of adolescent and young adult recipients entering into adult health care systems. The aim of this study was to evaluate the impact of transition from pediatric to adult health care models on medical outcomes, measures of adherence, and health care utilization for pediatric LT recipients. METHODS We evaluated the course of patients who received an LT while followed in pediatrics and transferred to an adult care provider within our institution. Data were collected from 2 years preceding and 2 years following transfer of care. RESULTS A total of 32 patients were eligible for analysis. Median age at time of transfer was 22.9 years (interquartile range 21.7-23.6). Nine patients (28%) died following transfer of care. There was a significant decrease in office visit adherence following transfer of care (P = 0.02). Although not achieving significance, an increase in alanine aminotransferase values, episodes of acute cellular rejection, progression to cirrhosis, evolution to chronic rejection, and hospital admission rates post transfer were found. These findings were associated with an increase in health care costs related to required interventions. CONCLUSIONS Our study demonstrates trends toward worse health outcomes, decreased adherence, and increased health care utilization following transfer of care. These findings and poor patient survival suggest that the time around transition from pediatric to adult health care models represents a period of increased vulnerability for pediatric LT recipients. Larger, multicenter, prospective studies are needed to identify factors and interventions that affect adolescent and young adult to improve the transition process.
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36
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Campagna BR, Weatherley K, Shemesh E, Annunziato RA. Adherence to Medication During Transition to Adult Services. Paediatr Drugs 2020; 22:501-509. [PMID: 32889685 PMCID: PMC7474320 DOI: 10.1007/s40272-020-00414-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The transition from childhood and adolescence to adulthood is often tumultuous. For individuals with a chronic medical condition, this progression also includes a gradual transition to independence in healthcare management as well as a transfer in care location at some set point. As adolescents navigate these sometimes challenging processes, there is a significant risk for a decline in adequate health behaviors, which can have dire consequences. One of the most vital components of the transfer to adult care is medication adherence. Poor medication adherence puts patients at risk for worse outcomes, with the most profound being increased mortality for many conditions. In recent years, acknowledgment of the need to create evidence-based methods to aid patients during the transition period has been growing. This paper seeks to provide an overview of current research and recommendations for interventions to increase adherence to medication regimens during this period.
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Affiliation(s)
- Bianca R. Campagna
- grid.256023.0000000008755302XDepartment of Psychology, Fordham University, 441 E. Fordham Road, Bronx, NY 10458 USA ,grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Kristen Weatherley
- grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Eyal Shemesh
- grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Rachel A. Annunziato
- grid.256023.0000000008755302XDepartment of Psychology, Fordham University, 441 E. Fordham Road, Bronx, NY 10458 USA ,grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
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Triplett KN, El-Behadli AF, Masood SS, Sullivan S, Desai DM. Digital medicine program with pediatric solid organ transplant patients: Perceived benefits and challenges. Pediatr Transplant 2019; 23:e13555. [PMID: 31328842 DOI: 10.1111/petr.13555] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 05/06/2019] [Accepted: 06/18/2019] [Indexed: 11/28/2022]
Abstract
Given the complexity of the pediatric post-transplant medication regimen and known medication adherence difficulties within the solid organ transplant population, interventions to improve adherence continue to be explored and fine-tuned. Advances in technology have led to the development of new programs aimed at improving medication adherence and the overall care of transplant patients. This manuscript describes implementation of a DMP where transplant patients' medications were co-encapsulated with ingestible sensors, and adherence was monitored via a patient mobile application and a provider portal. The benefits and challenges of the DMP as reported by patients, caregivers, and medical providers are explored in this manuscript. Participant feedback regarding best practices highlighted these benefits: ease of use/intuitive technology, sense of improved communication with medical team, increased knowledge and motivation around treatment regimen, and positive self-reports of medication adherence. Challenges included reluctance to participate (n = 43, 54.43% of patients approached declined participation) and patch wearability difficulties reported by participants (n = 20; 68.97%). Other notable challenges included the following: limited drug profile compatibility with the DMP technology and concerns about privacy and electronic data sharing for patients who chose not to participate. DMP implementation highlighted how technological advances offer novel methods to assess adherence, enhance medical decision-making, and can potentially improve clinical outcomes. Although numerous benefits of the program were recognized by participants, challenges were identified and the DMP technology and medication panel continues to be refined; further investigation of such programs continues to be warranted.
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Affiliation(s)
- Kelli N Triplett
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ana F El-Behadli
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Saba S Masood
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sarah Sullivan
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas
| | - Dev M Desai
- Solid Organ Transplant Department, Children's Health - Children's Medical Center, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
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Varty M, Popejoy LL. A Systematic Review of Transition Readiness in Youth with Chronic Disease. West J Nurs Res 2019; 42:554-566. [PMID: 31530231 DOI: 10.1177/0193945919875470] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The transition of chronically ill adolescents and young adults to adult health care is poorly managed, leading to poor outcomes due to insufficient disease knowledge and a lack of requisite skills to self-manage their chronic disease. This review analyzed 33 articles published between 2009 and 2019 to identify factors associated with transition readiness in adolescents and young adults with chronic diseases, which can be used to design effective interventions. Studies were predominantly cross-sectional survey designs that were guided by interdisciplinary research teams, assessed adolescents and young adults ages 12-26 years, and conducted in the outpatient setting. Modifiable factors, including psychosocial and self-management/transition education factors, and non-modifiable factors, including demographic/ecological and disease factors, associated with transition readiness were identified. Further research is necessary to address gaps identified in this review prior to intervention development, and there is a need for additional longitudinal studies designed to provide perspective on how transition readiness changes over time.
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Affiliation(s)
- Maureen Varty
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Lori L Popejoy
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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Abstract
PURPOSE OF REVIEW Effective transitional care for adolescents and young adults (AYA) with rheumatic musculoskeletal disease (RMD) is fundamental to rheumatology care provision. Here we review the recent evidence from the literature on transition in rheumatology and debate why universal implementation has yet to be recognised. RECENT FINDINGS Evidence of need for transitional care continues to be reported. The triphasic nature of transitional care remains poorly recognised, and the third phase following transfer to adult rheumatology is particularly under-researched in spite of the recognition of the age-related trajectories of transition skill development during young adulthood. Several rheumatology-specific transitional care interventions have now been evaluated but the search for valid measures including outcome continues. Finally, the need to study transition at a health system level is increasingly recognised. Future research in this area should consider the developmental trajectories of AYA as well as the social-ecological model of transition readiness, which focuses on the interactions between AYA, caregivers and providers (and the systems they are part of) as these are the likely targets of any intervention to improve health transitions.
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Affiliation(s)
- Janet E McDonagh
- Versus Arthritis Centre for Epidemiology, Centre for MSK Research, University of Manchester and NIHR Biomedical Research Centre, Manchester University Hospital NHS Trust, Manchester, UK.
| | - Albert Farre
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK
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Ekong UD, Gupta NA, Urban R, Andrews WS. 20- to 25-year patient and graft survival following a single pediatric liver transplant-Analysis of the United Network of Organ Sharing database: Where to go from here. Pediatr Transplant 2019; 23:e13523. [PMID: 31211487 DOI: 10.1111/petr.13523] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/20/2019] [Indexed: 12/19/2022]
Abstract
To understand factors contributing to liver graft loss and patient death, we queried a national database designed to follow pediatric patients transplanted between 1987 and 1995 till adulthood. A comparison was made to a cohort transplanted between 2000 and 2014. The 5-, 10-, 15-, 20-, and 25-year patient survival and graft survival were 95.5%, 93.7%, 89.1%, 80.8%, and 73.1%, and 92.5%, 86.7%, 77.6%, 68.7%, and 62.2%, respectively. The twenty-year patient/graft survival was significantly worse in those transplanted between 5 and 17 years of age compared to those transplanted at <5 years of age (P < 0.001). For the modern era cohort, the 3-year patient survival was significantly lower in children transplanted at 16-17 years of age compared to those transplanted at <5 and 11-15 years of age (P ≤ 0.02). The 3-year graft survival was similarly lower in children transplanted at 16-17 years of age compared to those transplanted at <5, 5-10, and 11-15 years of age (P ≤ 0.001). Infection as a cause of death occurred either early or >15 years post-transplant. Chronic rejection remained the leading cause of graft loss in both cohorts and the commonest indication for retransplantation 20-25 years following primary transplant. Further research is required to identify modifiable factors contributing to development of chronic rejection.
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Affiliation(s)
- Udeme D Ekong
- Section of Pediatric Gastroenterology and Hepatology, Yale University School of Medicine, New Haven, Connecticut
| | - Nitika A Gupta
- Division of Pediatric Gastroenterology and Hepatology, Emory University, Atlanta, Georgia
| | - Read Urban
- United Network for Organ Sharing, Richmond, Virginia
| | - Walter S Andrews
- Section of Transplant Surgery, Children's Mercy Hospitals & Clinics, Kansas City, Missouri
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41
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Preferences for cancer survivorship care among adolescents and young adults who experienced healthcare transitions and their parents. J Cancer Surviv 2019; 13:620-631. [DOI: 10.1007/s11764-019-00781-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/26/2019] [Indexed: 11/26/2022]
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Danziger-Isakov L, Frazier TW, Worley S, Williams N, Shellmer D, Dharnidharka VR, Gupta NA, Ikle D, Shemesh E, Sweet SC. Perceived barriers to medication adherence remain stable following solid organ transplantation. Pediatr Transplant 2019; 23:e13361. [PMID: 31332928 PMCID: PMC6652201 DOI: 10.1111/petr.13361] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 11/30/2018] [Accepted: 01/04/2019] [Indexed: 12/29/2022]
Abstract
Perceived barriers to adherence have previously been investigated in SOT to identify plausible intervention targets to improve adherence and transplant outcomes. Fifteen centers in CTOTC enrolled patients longitudinally. Patients >8 years completed Adolescent Scale(AMBS) at two visits at least 6 months apart in the first 17 months post-transplant while their guardians completed PMBS. Differences over time for pre-identified AMBS/PMBS factors were analyzed. Perceived barrier reporting impact on subsequent TAC levels was assessed. A total of 123 patients or their guardians completed PMBS or AMBS. Twenty-six were 6-11 years and 97 were ≥12. The final cohort consisted of kidney (66%), lung (19%), liver (8%), and heart (7%) recipients. Unadjusted analysis showed no statistically significant change in reported barriers from visit 1 (median 2.6 months, range 1.2-3.7 post-transplant) to visit 2 (median 12, range 8.9-16.5). Of 102 patients with TAC levels, 74 had a single level reported at both visits. The factor of "Disease frustration" was identified through the PMBS/AMBS questions about fatigue around medication and disease. Each point increase in "disease frustration" at visit 1 on the AMBS/PMBS doubled the odds of a lower-than-threshold TAC level at visit 2. No clear change in overall level of perceived barriers to medication adherence in the first year post-transplant was seen in pediatric SOT. However, disease frustration early post-transplant was associated with a single subtherapeutic TAC levels at 12 months. A brief screening measure may allow for early self-identification of risk.
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Affiliation(s)
| | | | | | - Nikki Williams
- National Institute for Allergy and Infectious Diseases, Bethesda, MD
| | - Diana Shellmer
- University of Pittsburgh, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Vikas R. Dharnidharka
- Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO
| | | | | | - Eyal Shemesh
- Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Stuart C. Sweet
- Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO
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Haarbauer-Krupa J, Alexander NM, Mee L, Johnson A, Wise J, Arora Gupta N, Schechter MS, Wasilewski-Masker K, Gilleland Marchak J. Readiness for transition and health-care satisfaction in adolescents with complex medical conditions. Child Care Health Dev 2019; 45:463-471. [PMID: 30836446 DOI: 10.1111/cch.12656] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 02/27/2019] [Accepted: 03/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study is to examine contributions to patient perceptions of transition readiness and satisfaction with care amongst adolescents and young adults (AYAs) with complex health conditions engaging in paediatric care. METHODS Participants included 94 patients aged 14-20 years (M = 16.41, SD = 1.56) with cystic fibrosis (n = 31), sickle cell disease (n = 27), and solid organ transplants (n = 36). Participants completed self-report questionnaires and medical providers completed measures of their medication regimen complexity. One-way analysis of variance compared differences between disease groups on study variables. Pearson product-moment correlation coefficients and linear regression models evaluated factors associated with AYA reported transition readiness and satisfaction with health care. RESULTS There were no significant differences between disease groups on patient-reported transition readiness, barriers to medication adherence, health care self-management, or satisfaction. Patient age, self-reported health-care responsibility, medication barriers, and academic performance predicted a large portion of the variance in AYA perceptions of transition readiness (R2 = 0.27, F (4, 83) = 7.74, p < 0.001, Cohen's f2 = 0.37). Patient gender, self-reported health-care responsibility, and medication barriers predicted a medium portion of the variance in AYA satisfaction with health care (R2 = 0.23, F (3, 88) = 8.56, p < 0.001, Cohen's f2 = 0.30). CONCLUSIONS Patient perceptions of health care self-management and barriers to medication adherence are important predictors of readiness for transition and satisfaction with care. Considering a holistic approach that includes these factors allows for improved understanding of individual needs for transition interventions that can improve adult outcomes for individuals with complex health conditions.
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Affiliation(s)
| | | | - Laura Mee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, GA
| | - Alcuin Johnson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, GA
| | - Justin Wise
- Department of Psychology, Oglethorpe University, Atlanta, Georgia
| | - Nitika Arora Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, GA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, Georgia
| | - Michael S Schechter
- Division of Pulmonary Medicine and Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia.,Children's Hospital of Richmond at VCU, Richmond, Virginia
| | - Karen Wasilewski-Masker
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jordan Gilleland Marchak
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, GA
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Digital Wings: Innovations in Transition Readiness for Adolescent and Young Adult Transplant Recipients [corrected]. Transplantation 2019; 103:1970-1974. [PMID: 30985578 DOI: 10.1097/tp.0000000000002749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The Johns Hopkins University School of Medicine organized 2 multistakeholder symposia on February 2, 2018 and January 11, 2019 to address the problem of high graft failure in adolescent and young adult (AYA) solid organ transplant (SOT) recipients. Participants included international experts in transplantation, behavioral psychology, patient/parent advocacy, and technology. The objectives of the symposia were as follows: (1) to identify and discuss the barriers to and facilitators of effective transfer of care for AYA SOT recipients; (2) to actively explore strategies and digital solutions to promote their successful transfer of care; and (3) to develop meaningful partnerships for the successful development, evaluation, implementation, and dissemination of these digital solutions. Additionally, data were collected from 152 AYA SOT recipients demonstrating a substantial gap in how this population uses technologies for health-related activities, alongside an increased interest in an app to help them manage their transplant.
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van den Brink G, van Gaalen MA, Zijlstra M, de Ridder L, van der Woude CJ, Escher JC. Self-efficacy did not predict the outcome of the transition to adult care in adolescents with inflammatory bowel disease. Acta Paediatr 2019; 108:333-338. [PMID: 29926962 PMCID: PMC6585705 DOI: 10.1111/apa.14471] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 04/22/2018] [Accepted: 06/19/2018] [Indexed: 01/08/2023]
Abstract
AIM It can be difficult for adolescents with inflammatory bowel disease (IBD) to make the transition from paediatric to adult care. We studied the outcomes of this process and defined what constituted a successful transition. METHODS In 2008, 50 adolescents who attended our IBD transition clinic completed IBD-yourself, a self-efficacy questionnaire that we had previously developed and validated. We approached the subjects in 2014, two to six years after they transferred to adult care, and 35 agreed to take part in the current study. The outcome of transition was assessed by our newly developed Transition Yourself Score. In addition, the relationship between self-efficacy and the outcome of the transition was measured. RESULTS The mean age of the patients was 21.8 years, and 69% suffered from Crohn's disease. The transition process was successful in 63% of cases, moderately successful in 31% and failed in 6%. A successful transition was associated with effective use of medication and clinical remission at the time of transfer, but could not be predicted by self-efficacy. The Transition Yourself Score will be validated in future studies. CONCLUSION Nearly two-thirds (63%) of the adolescents who attended the IBD transition clinic had a successful transition to adult care.
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Affiliation(s)
- Gertrude van den Brink
- Department of Paediatric Gastroenterology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Martha A.C. van Gaalen
- Department of Paediatric Gastroenterology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Marieke Zijlstra
- Department of Paediatric Gastroenterology; Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | | | - Johanna C. Escher
- Department of Paediatric Gastroenterology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
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Jones MR, Frey SM, Riekert K, Fagnano M, Halterman JS. Transition Readiness for Talking With Providers in Urban Youth With Asthma: Associations With Medication Management. J Adolesc Health 2019; 64:265-271. [PMID: 30389202 PMCID: PMC6339852 DOI: 10.1016/j.jadohealth.2018.08.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Teen readiness assessments may provide a developmental indicator of the transfer of responsibility for health self-management from caregivers to teens. Among urban adolescents with asthma, we aimed to describe teen readiness for talking with providers and identify how readiness relates to responsibility for asthma management, medication beliefs, and clinical outcomes. METHODS Teens and caregivers enrolled in the school-based asthma care for teen's trial in Rochester, NY completed in-home surveys. We classified ready teens as those reporting a score of five on both items of the transition readiness assessment questionnaire talking with providers subscale. We performed bivariate analyses to detect differences between ready teens and other teens in teen- and caregiver-reported responsibility, teen medication beliefs, and clinical outcomes (medication adherence over the past 2 weeks, and healthcare use over the past year). RESULTS Among this sample of 251 adolescents (mean age: 13.4 years), 35% were classified as "Ready." Ready teens were more likely than other teens to want to use a controller medication independently (7.6 vs. 6.5 out of 10, p < .01) and to have confidence in this ability (8.4 vs. 7.6 out of 10, p = .02). Teens reported poor adherence (missed 52.9% of prescribed controller doses), with no differences in responsibility or clinical outcomes based on level of teen readiness for talking with providers. CONCLUSIONS In urban adolescents with poorly controlled asthma, a higher level of teen readiness for talking with providers is associated with higher perceptions of independence in medication taking, but does not appear to relate to clinical outcomes.
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Affiliation(s)
| | - Sean M. Frey
- University of Rochester Medical Center, Division of General Pediatrics, 601 Elmwood Ave, Box 777, Rochester, NY 14642,
| | - Kristin Riekert
- Johns Hopkins School of Medicine, Division of Pulmonary and Critical Care Medicine, 5501 Hopkins Bayview Circle, JHAAC 3B37, Baltimore, MD,
| | - Maria Fagnano
- University of Rochester Medical Center, Division of General Pediatrics, 601 Elmwood Ave, Box 777, Rochester, NY 14642,
| | - Jill S. Halterman
- University of Rochester Medical Center, Division of General Pediatrics, 601 Elmwood Ave, Box 777, Rochester, NY 14642,
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Meng X, Gao W, Wang K, Han C, Zhang W, Sun C. Adherence to medical regimen after pediatric liver transplantation: a systematic review and meta-analysis. Patient Prefer Adherence 2019; 13:1-8. [PMID: 30587939 PMCID: PMC6301298 DOI: 10.2147/ppa.s181195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Adherence to the medical regimen after pediatric liver transplantation is crucial for good clinical outcomes. However, the existing literature provides inconsistent evidence regarding the prevalence of and risk factors for nonadherence to the medical regimen after pediatric liver transplantation. This study aimed to investigate such nonadherence after pediatric liver transplantation and risk factors associated with this nonadherence using findings of reported studies. METHODS The electronic databases of Excerpta Medica, Ovid Technologies, PubMed and WanFang Data were searched using the keywords "adherence", "liver transplant" and "paediatric". Additionally, relevant references cited in related studies were used to obtain original articles. Using 22 original articles, data regarding nonadherence to the medical regimen after pediatric liver transplantation were quantitatively combined, and risk factors associated with nonadherence were qualitatively identified. Average rates of nonadherence in four areas of medical regimens were calculated. The heterogeneity of the included original articles was also analyzed. When I 2>50 and P<0.05, a random effects model was used; otherwise, a fixed effects model was used. Moreover, Egger's and Begg's tests were used to evaluate publication bias, if any, and original articles with P>0.05 were considered to have no publication bias. RESULTS The clinical attendance nonadherence rate was 45% (95% confidence interval [CI]: 39-51), global nonadherence rate was 17% (95% CI: 13-21) and immunosuppression non-adherence rates were 39% (95% CI: 26-52) and 34% (95% CI: 30-39) for cyclosporine and tacrolimus, respectively. Risk factors included older age of the pediatric patient, low family cohesion, poor social functioning, poor mental health and single-parent family. CONCLUSIONS The nonadherence rate in pediatric liver transplantation is high. Therefore, intervention on the basis of risk factors, such as mental health and family function, may be necessary. Moreover, a standard technique for assessing nonadherence to the medical regimen after pediatric liver transplantation, comprising as many dimensions as possible, is required in order to be more objective and comprehensive when assessing nonadherence.
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Affiliation(s)
- Xingchu Meng
- Department of Organ Transplantation, Tianjin First Center Hospital, Tianjin, China,
| | - Wei Gao
- Department of Organ Transplantation, Tianjin First Center Hospital, Tianjin, China,
| | - Kai Wang
- Department of Organ Transplantation, Tianjin First Center Hospital, Tianjin, China,
| | - Chao Han
- Department of Organ Transplantation, Tianjin First Center Hospital, Tianjin, China,
| | - Wei Zhang
- Department of Organ Transplantation, Tianjin First Center Hospital, Tianjin, China,
| | - Chao Sun
- Department of Organ Transplantation, Tianjin First Center Hospital, Tianjin, China,
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Hoegy D, Bleyzac N, Robinson P, Bertrand Y, Dussart C, Janoly-Dumenil A. Medication adherence in pediatric transplantation and assessment methods: a systematic review. Patient Prefer Adherence 2019; 13:705-719. [PMID: 31123396 PMCID: PMC6511245 DOI: 10.2147/ppa.s200209] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Medication adherence is a major concern in public health. It is fully established that immunosuppressive therapy (IT) and concomitant medications affect transplant outcomes in the pediatric population, showing interest in adherence to this therapy. The aim of the present review was to report on medication adherence in pediatric population post-transplantation. This will enable us to know the situation in this particular population. Methods: A literature search was performed using the MEDLINE database. Studies that were published from January 1999 to January 2016 in English language and which investigated medication adherence in pediatric transplantation were included. The type of organ and the methods used to assess medication adherence were studied. Results: A total of 281 records were identified, from which 34 studies were selected: 38% (n=13) on kidney transplantation, 32% (n=11) on liver transplantation, and 23% (n=10) on the transplantation of other organs. Medication adherence was found to be lower than 80% in two-thirds of the studies (64%), and varied from 22% to 97%. This wide range was explained in part by the important heterogeneity of assessment methods among studies. The methods used were objective, non-objective, or combined both types. Most studies did not fully describe the data collected: the time since transplantation, the period over which adherence was assessed, the population, the medications, and the threshold discriminating adherence and non-adherence. Conclusion: The present study found poor medication adherence in the pediatric population post-transplantation. There was a wide range of medication adherence, explained largely by the heterogeneity of assessment methods. Future studies must consider the characteristics of each methodology, but also the threshold defining adherence should be chosen on the basis of clinical outcomes, and describe all data collected to gain precision. To improve adherence in this population, it is essential to identify factors influencing medication (IT and concomitant medications) adherence.
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Affiliation(s)
- Delphine Hoegy
- EA 4129 P2S Parcours Santé Systémique – Univ Claude Bernard Lyon 1, Univ Lyon 1, Lyon, France
- Pharmacy, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Correspondence: Delphine HoegyP2S, EA 4129, universités Lyon I & III, 5 place d’Arsonval, 69003, Lyon, FranceEmail
| | - Nathalie Bleyzac
- Institut d’Hématologie et d’Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
- EMR 3738, PK/PD Modeling in Oncology, université Lyon-Sud, Lyon, France
| | - Philip Robinson
- Direction de la Recherche Clinique et de l’Innovation, Hospices Civils de Lyon, Lyon, France
| | - Yves Bertrand
- Institut d’Hématologie et d’Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
- U1111-CNRS UMR 5308, University of Lyon I, ENS Lyon, Lyon, France
| | - Claude Dussart
- EA 4129 P2S Parcours Santé Systémique – Univ Claude Bernard Lyon 1, Univ Lyon 1, Lyon, France
- Central Pharmacy, Hospices Civils de Lyon, Lyon, France
| | - Audrey Janoly-Dumenil
- EA 4129 P2S Parcours Santé Systémique – Univ Claude Bernard Lyon 1, Univ Lyon 1, Lyon, France
- Pharmacy, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
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Longitudinal Self-Management and/or Transition Readiness per the TR xANSITION Index among Patients with Chronic Conditions in Pediatric or Adult Care Settings. J Pediatr 2018; 203:361-370.e1. [PMID: 30201183 DOI: 10.1016/j.jpeds.2018.06.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/26/2018] [Accepted: 06/15/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate the roles of key individual, family, and illness characteristics on the levels of and gains in longitudinal healthcare transition (HCT) readiness in the pediatric setting and/or self-management skills (SMS) in the adult-focused setting, we used a large dataset with longitudinal measurements from 2006 to 2015. STUDY DESIGN This longitudinal observational study followed 566 adolescents and young adults with chronic conditions at University of North Carolina Hospitals. TRxANSITION Index measurements, which represent learning outcomes rather than health outcomes, were collected multiple times per patient and analyzed using a novel application of an education-based approach. RESULTS Levels of and gains in HCT/SMS scores increased with age (P < .001) with smaller increases at older ages. Mastery of skills varied by age with self-management achieved after 20 years of age. Scores varied positively by father's education and negatively by mother's education and duration of diagnosis. Gains in scores further varied positively with private insurance and negatively with mother's education and duration of diagnosis. CONCLUSIONS We found diminishing positive increases in HCT/SMS scores as patients become older and smaller levels of and gains in readiness among younger patients with more educated mothers. Risk factors for absolute level of HCT/SMS readiness and inadequate longitudinal gains are not always the same, which motivates a deeper understanding of this dynamic process through additional research. This information can guide providers to focus HCT/SMS preparation efforts on skills mastered at particular ages and to identify patients at risk for inadequate development of HCT/SMS skills.
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Shneider C, Dunphy C, Shemesh E, Annunziato RA. Assessment and Treatment of Nonadherence in Transplant Recipients. Gastroenterol Clin North Am 2018; 47:939-948. [PMID: 30337042 DOI: 10.1016/j.gtc.2018.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Stable intake of an immunosuppressant medication regimen is essential for posttransplant survival in the vast majority of cases. And yet, many patients are nonadherent (do not take their medications as prescribed), and suffer consequences ranging from rejection to morbidity and mortality. We review the evidence related to monitoring of adherence to medications, and intervention strategies. Our aim is to provide a baseline from which readers may approach behavioral aspects of posttransplant care. This review may also help readers in designing clinical programs for routine monitoring of adherence, and inform the choice of intervention when adherence falls below a certain threshold.
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Affiliation(s)
- Caitlin Shneider
- Center for Translational Science, Children's National Medical Center, 111 Michigan Avenue Northwest, 5th Floor Main, Suite 5500, Office 5533, Washington, DC 20010, USA
| | - Claire Dunphy
- Clinical Psychology, Department of Psychology, Fordham University, 441 East Fordham Road, Dealy Hall, Bronx, NY 10458, USA
| | - Eyal Shemesh
- Division of Behavioral and Developmental Health, The Department of Pediatrics, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, Box 1198, 1 Gustave L Levy Place, New York, NY 10029, USA.
| | - Rachel A Annunziato
- Psychology, Fordham College at Rose Hill, Fordham University, 441 East Fordham Road, Dealy Hall, Bronx, NY 10458, USA
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