Improving the transition between paediatric and adult healthcare: a systematic review

Lessons Learned From a Retrospective Analysis of Medicolegal Risks for Physicians Treated Adolescents and Young Adults With Medical Complexity

PURPOSE

Adolescent and young adult patients occupy a clinically transitional space between pediatric and adult care. Youth with chronic conditions and special healthcare needs may have trouble accessing and receiving appropriate care in this transition, which may lead to patient safety issues and medicolegal risks for physicians. The objectives of this article were to explore patient safety issues and identify medicolegal risks for physicians.

METHODS

A national repository was retrospectively searched for medicolegal cases (MLCs) involving complaints from youth. The study included MLCs closed at the Canadian Medical Protective Association between 2013 and 2022 involving youth. The study participants were adolescents and young adults aged ≥ 15 and ≤ 21 years with medical complexity. The frequencies and proportions of patient safety events and medicolegal risks for physicians were calculated by exploring factors that contributed to each incident using established frameworks.

RESULTS

A total of 182 eligible MLCs were identified. Of 206 involved physicians, 55 were psychiatrists. The most common reasons for patient complaints were deficient assessment, diagnostic error, and communication breakdown with the patient and/or family. More than half of the cases were related to a harmful incident. Peer experts reviewed the cases and identified factors such as a deficient assessment, a failure to perform a test or intervention, failure to refer the patient, and insufficient provider knowledge/skill as contributing to the patient safety event.

DISCUSSION

The impact of our findings is to identify gaps in care delivery to youth that can inform practitioners of ways to mitigate the gaps and improve patient care and health outcomes.

Management aspects of congenital adrenal hyperplasia during adolescence and transition to adult care

The adolescent period is characterised by fundamental hormonal changes, which affect sex steroid production, cortisol metabolism and insulin sensitivity. These physiological changes have a significant impact on patients with congenital adrenal hyperplasia (CAH). An essential treatment aim across the lifespan in patients with CAH is to replace glucocorticoids sufficiently to avoid excess adrenal androgen production but equally to avoid cardiometabolic risks associated with excess glucocorticoid intake. The changes to the hormonal milieu at puberty, combined with poor adherence to medical therapy, often result in unsatisfactory control exacerbating androgen excess and increasing the risk of metabolic complications due to steroid over-replacement. With the physical and cognitive maturation of the adolescent with CAH, fertility issues and sexual function become a new focus of patient care in the paediatric clinic. This requires close surveillance for gonadal dysfunction, such as irregular periods/hirsutism or genital surgery-associated symptoms in girls and central hypogonadism or testicular adrenal rest tumours in boys. To ensure good health outcomes across the lifespan, the transition process from paediatric to adult care of patients with CAH must be planned carefully and early from the beginning of adolescence, spanning over many years into young adulthood. Its key aims are to empower the young person through education with full disclosure of their medical history, to ensure appropriate follow-up with experienced physicians and facilitate access to multispecialist teams addressing the complex needs of patients with CAH.

Living with epilepsy in adolescence and young adulthood transitioning from pediatric to adult hospital services: A systematic review and meta-synthesis of qualitative studies

BACKGROUND

Transition is characterized by developing greater self-identity and growing independence, but adolescents dealing with chronic illnesses encounter health-related and situational changes during transition. Despite the many suggestions made in recent years, the shift from pediatric to adult care continues to pose difficulties for adolescents and young adults with epilepsy (AWE). The holistic perspective of AWE's experiences and needs during transition is not as well understood.

AIM

To synthesize the qualitative evidence related to AWE's experiences and needs transitioning from pediatric to adult hospital care.

METHODS

This systematic review adhered to the rigorous Joanna Briggs methodology for qualitative evidence synthesis. A comprehensive search was conducted across multiple databases, including PubMed, CINAHL, Scopus, Embase, PsycINFO, and ProQuest Dissertations & Theses Global, from their inception to April 2024. The findings were critically appraised and aggregated using meta-synthesis.

RESULTS

The search yielded a total of 3,985 studies, and twenty-one were included in the review. Two of the included studies were undertaken in a program where a transition clinic was established. The meta-synthesis reveals that the transition experience of AWE is more than a change from one clinic to another and is interwoven into a pattern of developmental, health-illness, situational, and organizational transition issues. Five synthesized findings were developed: 1) Feeling different from others and striving to address the impact of epilepsy in everyday life; 2) the transition from pediatric to adult care - a problematic intersection point; 3) the family's role - support or parental overprotectiveness 4) seeking knowledge and being familiar with epilepsy supported by healthcare professionals and technologies, and 5) development of independence and responsibility through involvement and support from healthcare professionals and parents.

CONCLUSION

During the transition from pediatric to adult hospital care, AWEs encounter a loss of familiarity, increased responsibility, and feelings of not belonging. Therefore, it is essential to create an environment where they can thrive beyond the limitations of their illness. Understanding, acceptance, and inclusivity should characterize this environment to support AWEs in facilitating the development of responsibility, independence, and confidence as they navigate transitions.

Systematic Review: Practices and Programs in Inflammatory Bowel Disease Transition Care

BACKGROUND

Adolescents with inflammatory bowel disease (IBD) transitioning to adult care is often deemed a challenging period for patients, their carers, and practitioners. The use of structured transition programs is increasingly incorporated into standards of care, yet the optimal format remains unknown. The aim of this study is to carry out a systematic review of structured transition programs and their components to assess the impact on disease-specific and transition-related outcomes.

METHODS

A systematic review (PROSPERO ID: CRD42023380846) was performed across 4 databases (PubMed, CINAHL, CENTRAL, and EMBASE) and relevant publications up to March 2023 were reviewed. Studies evaluating either a structured transition program or targeted intervention which also measured a transition- and/or disease-related outcomes were included for evaluation in accordance with the PRISMA statement.

RESULTS

Three thousand four hundred and thirty-two articles were identified and 29 included in the final review. A structured transition program was reported in 21 studies and 8 investigated discrete transition-related interventions. The key transition-related outcomes included knowledge, self-efficacy, adherence, clinic attendance, and transition readiness which overall improved with the use of structured transition programs. Similarly, interventions consistently improved relapse/admission rates and corticosteroid use across most studies, although the benefit in hospitalization and surgical rates was less evident. Methodological limitations alongside heterogeneity in study design and outcome measures impacted on the quality of the evidence as assessed by the GRADE rating.

CONCLUSIONS

Transition- and medical-related outcomes for adolescents with IBD have been shown to benefit from structured transition programs but practices vary greatly between centers. There is no current standardized transition model for patients with IBD prompting further research to guide future development of guidelines and models of care.

Transition of patients with Gaucher disease type 1 from pediatric to adult care: results from two international surveys of patients and health care professionals

Introduction

Gaucher disease (GD) is a rare, autosomal recessive lysosomal storage disorder caused by a deficiency in the enzyme glucocerebrosidase. The most common subtype in Europe and the USA, type 1 (GD1), is characterized by fatigue, cytopenia, splenomegaly, hepatomegaly, bone disease, and rarely pulmonary disease. Increased life expectancy brought about by improved treatments has led to new challenges for adolescents and their transition to adult care. Efficient healthcare transition to adult care is essential to manage the long-term age-related complications of the disease.

Methods

This international study consisted of two online surveys: one survey for patients with GD1 and one survey for healthcare professionals (HCPs) involved in treatment of patients with GD1. The aims of this international, multi-center project were to evaluate the current transition process in various countries and to understand the challenges that both HCPs and patients experience.

Results

A total of 45 patients and 26 HCPs took part in the survey, representing 26 countries. Our data showed that a third (11/33) of patients were aware of transition clinics and most stated that the clinic involved patients with metabolic diseases or with GD. Seven patients attended a transition clinic, where most patients (5/7) received an explanation of the transition process. Approximately half of HCPs (46%; 12/26) had a transition clinic coordinator in their healthcare center, and 10 of HCPs had a transition clinic for patients with metabolic diseases in their healthcare center. HCPs reported that transition clinics were comprised of multi-disciplinary teams, with most patients over the age of 18 years old managed by hematology specialists. The main challenges of the transition process reported by HCPs included limited funding, lack of expertise and difficulty coordinating care amongst different specialties.

Discussion

Our study demonstrates the lack of a standardized process, the need to raise awareness of transition clinics amongst patients and the differences between the transition process in different countries. Both patients and HCPs expressed the need for a specialist individual responsible for transition, efficient coordination between pediatricians and adult specialists and for patient visits to the adult center prior to final transition of care.

Patient and carer transition outcomes and experiences at the Westmead Centre for Adolescent and Young Adult Health, Westmead, Australia: protocol for a longitudinal cohort study

INTRODUCTION

The Westmead Centre for Adolescent and Young Adult Health is a purpose-built facility supporting integrated care for young patients with a variety of long-term health conditions transitioning from paediatric services at the Children's Hospital at Westmead to adult services at Westmead Hospital, Australia.

METHODS AND ANALYSIS

This protocol outlines a prospective, within-subjects, repeated-measures longitudinal cohort study to measure self-reported experiences and outcomes of patients (12-25 years) and carers accessing transition care at the Centre for Adolescent and Young Adult Health. Longitudinal self-report data will be collected using Research Electronic Data Capture surveys at the date of service entry (recruitment baseline), with follow-ups occurring at 6 months, 12 months, 18 months and after transfer to adult services. Surveys include validated demographic, general health and psychosocial questionnaires. Participant survey responses will be linked to routinely recorded data from hospital medical records. Hospital medical records data will be extracted for the 12 months prior to service entry up to 18 months post service entry. All young people accessing services at the Centre for Adolescent and Young Adult Health that meet inclusion criteria will be invited to join the study with research processes to be embedded into routine practices at the site. We expect a sample of approximately 225 patients with a minimum sample of 65 paired responses required to examine pre-post changes in patient distress. Data analysis will include standard descriptive statistics and paired-sample tests. Regression models and Kaplan-Meier method for time-to-event outcomes will be used to analyse data once sample size and test requirements are satisfied.

ETHICS AND DISSEMINATION

The study has ethics approval through the Sydney Children's Hospitals Network Human Research Ethics Committee (2021/ETH11125) and site-specific approvals from the Western Sydney Local Health District (2021/STE03184) and the Sydney Children's Hospitals Network (2039/STE00977). Patients under the age of 18 will require parental/carer consent to participate in the study. Patients over 18 years can provide informed consent for their participation in the research. Dissemination of research will occur through publication of peer-reviewed journal reports and conference presentations using aggregated data that precludes the identification of individuals. Through this work, we hope to develop a digital common that can be shared with other researchers and clinicians wanting to develop a standardised and shared approach to the measurement of patient outcomes and experiences in transition care.

Transition of care from adolescence to early adulthood in severe asthmatic patients treated with omalizumab in real life

Half of severely asthmatic adolescents treated with omalizumab transitioning to adulthood discontinue the treatment, suggesting insufficient asthma control. However, most of the other half have low rates of HCRU markers, their asthma being under control. https://bit.ly/49ixpxt.

No one really plans to have multiple sclerosis: Transition readiness and quality of life in paediatric multiple sclerosis

AIM

We sought to explore the experiences and perceptions of the quality of life of adolescents with pediatric-onset multiple sclerosis and assess their readiness for academic, employment and/or health care-related transitions.

BACKGROUND

Adolescents with pediatric-onset multiple sclerosis face unique challenges in managing a chronic illness while navigating future scholastic, social and occupational goals. We conducted a qualitative study with in-depth, semi-structured interviews from July 2017 to March 2019. Adolescents with pediatric-onset multiple sclerosis were recruited from a pediatric neurology subspeciality practice until reaching data saturation. A total of 17 interviews were completed via telephone with participants ages 15 through 26.

RESULTS

Through content analysis of the interviews, we identified five major themes: (1) receiving a new diagnosis; (2) adapting to life with pediatric-onset multiple sclerosis; (3) evaluating education/career transition preparedness; (4) adjusting within family life and establishing support systems; and (5) assessing current medical services and preparedness for adult medical care.

CONCLUSIONS

Autonomy in health care management, adequate control of physical symptoms and sufficient family support impacted perceptions of quality of life. Implementing a dedicated transition visit, including the parent(s) of those with pediatric-onset multiple sclerosis, early in adolescence may provide an avenue for appropriate anticipatory guidance regarding available services, independent medical management and continuity of care.

Being an adolescent with epilepsy during the transition from pediatric to adult hospital care: A qualitative descriptive study

BACKGROUND

The transition from pediatric to adult care is challenging for adolescent patients despite numerous recommendations in recent decades. However, the perspective of the patients is sparsely investigated.

AIM

To explore the experiences and needs of adolescents with epilepsy (AWE) during the transition from pediatric to adult hospital care.

METHODS

We conducted 15 semi-structured interviews with AWEs aged 13-20 years and 10 h of field observations of consultations. Interviews were audio-recorded, transcribed, anonymized, and entered into NVivo (version 12, QSR International) with the transcribed field notes. Data were analyzed using systematic text condensation.

RESULTS

Three themes were identified: (1) Navigating epilepsy in everyday life; (2) The difficult balance between concealment and openness about epilepsy; and (3) Being seen as an individual and not an illness. AWEs' needs in transition are closely associated with their experiences and perceptions of illness, treatment, consultations, and seizures. Notably, AWEs reveal a significant concern about being overlooked beyond their medical condition in appointments.

CONCLUSIONS

This study highlights the vulnerability and challenges of AWEs transitioning to adult care. Overall, AWEs seek understanding, acceptance, and autonomy in managing their epilepsy and transitioning to adult care. Their experiences underscore the importance of holistic support and communication in healthcare settings. A concerted effort from healthcare professionals (HCP) is necessary to foster the recognition of AWEs as individuals with distinct personalities, needs, and capabilities.

Transition is associated with lower disease activity, fewer relapses, better medication adherence, and lower lost-to-follow-up rate as opposed to self-transfer in pediatric-onset inflammatory bowel disease patients: results of a longitudinal, follow-up, controlled study

Background

Despite the continuously rising rate of pediatric-onset inflammatory bowel diseases (PIBD), there are no consensus transitional guidelines or standardized practices.

Objectives

We aimed to examine: (1) the determinants of a successful transfer, (2) the effects of the transfer versus transition on the disease course and patient compliance, (3) the unique characteristics of PIBD patients, that need special attention in adult care.

Design

Longitudinal, follow-up, controlled study conducted between 2001 and 2022, with retrospective data collection until 2018, thence prospective.

Methods

Three hundred fifty-one PIBD patients enrolled in the study, of whom 152 were moved to adult care, with a mean post-transfer follow-up time of 3 years. Seventy-three patients took part in structured transition, whereas 79 self-transferred to adult care. The main outcome measures were disease activity (defined by PCDAI, PUCAI, CDAI, and Mayo-scores) and course, hospitalizations, surgeries, IBD-related complications, including anthropometry and bone density, patient compliance, medication adherence, and continuation of medical care.

Results

Patients who underwent structured transition spent significantly more time in remission (83.6% ± 28.5% versus 77.5% ± 29.7%, p = 0.0339) and had better adherence to their medications (31.9% versus 16.4% non-adherence rate, p = 0.0455) in adult care, with self-transferred patients having a 1.59-fold increased risk of discontinuing their medical care and a 1.88-fold increased risk of experiencing a relapse. Post-transfer the compliance of patients deteriorated (38.5% versus 29%, p = 0.0002), with the highest lost-to-follow-up rate during the changing period between the healthcare systems (12.7%), in which female gender was a risk factor (p = 0.010). PIBD patients had experienced IBD-related complications (23.4%) and former surgeries (15%) upon arriving at adult care, with high rates of malnutrition, growth impairment, and poor bone health.

Conclusion

Structured transition plays a key role in ensuring the best disease course and lowering the lost-to-follow-up rate among PIBD patients.

Brief summary

Structured transition plays a key role in ensuring the best disease outcome among PIBD patients, as in our study it was associated with lower disease activity, fewer relapses, better medication adherence, and lower lost-to-follow-up rate as opposed to self-transfer.

COCCOS study: Developing a transition program for adolescents with chronic conditions using Experience-Based Co-Design. A study protocol

BACKGROUND

During adolescence, adolescents and young adults (AYAs) are expected to transfer their care from the pediatric environment towards an adult-focused setting. To prevent an abrupt transfer of care, it is recommended to provide AYAs with chronic conditions an adequate transition program. The aim of this paper is to describe the study protocol for the development of a transition program for AYAs with common chronic conditions (COCCOS study), using the Experience-Based Co-Design (EBCD) methodology.

METHODS AND ANALYSIS

A qualitative, participatory study is conducted in Flanders (Belgium). Study participants are AYAs (n≥15, 14-25 years old, diagnosed with type 1 diabetes, asthma, or obesity), their families, and healthcare providers (n≥15). The study is composed of eight EBCD stages: clinical site observations, in-depth interviews, trigger film, healthcare providers' feedback event, AYAs' feedback event, joint event, co-design workshops, and a celebration event. Photovoice will take place as a starting point of EBCD. Data will be analyzed using thematic analysis.

RESULTS

Data collection has started in January 2023 and is expected to be completed in May 2024. As of August 2023, over 15 clinical site observations have been conducted. A total of 18 AYAs, two parents, six healthcare providers have been enrolled and a total of 20 interviews have been conducted.

CONCLUSION

Advancing transitional care is essential for tackling negative health outcomes. Applying the innovative participatory EBCD methodology will reveal key elements of transitional care for AYAs with common chronic conditions in the development of a person-centered transition program.

PRACTICE IMPLICATIONS

Study findings will apply key elements of transitional care of AYAs with chronic conditions in the development of an adequate transition program.

'I don't know exactly what that means to do check-ups': understanding and experiences of primary care among resettled young adult refugees

Young adult refugees have suboptimal primary care use, including having a regular provider and engaging with a regular source of care for primary and preventive healthcare needs. Our purpose was to understand how young adult refugees (ages 18-29 years) resettled to the United States understand and experience primary care. We conducted 23 semi-structured interviews with young adult refugees and explored their ideas about and experiences of key characteristics of primary care. Emergent themes were synthesized. Young adult refugees reported a lack of an understanding of the idea of primary care. However, they also described the lack of accepted key components of primary care, such as being the first contact and providing continuity, coordination and comprehensiveness. The importance of developing an ability to ask questions, get answers and feel empowered was a facilitator of primary care successes. Young refugees lack access to healthcare that exemplifies quality primary care. Improving understanding of the primary care model and its value as well as increasing access and ease of engagement could improve primary care engagement for young adult refugees.

An Updated Equitable Model of Readiness for Transition to Adult Care: Content Validation in Young People With Sickle Cell Disease

Importance

Despite elevated health risks during young adulthood, many adolescents and young adults with serious health care needs face barriers during the transfer to an adult specialty practitioner, and health disparities may occur during the transition.

Objective

To validate the content of an updated Social-Ecological Model of Adolescent and Young Adult Readiness for Transition to Promote Health Equity (SMART-E) in a group of adolescents and young adults with sickle cell disease (SCD) and their supports.

Design, Setting, and Participants

Health equity framework components were reviewed. Systems of power (eg, institutional and practitioner bias) and environments or networks (eg, peer or school support) were added as SMART-E preexisting factors, and health literacy was included within readiness factors. Adolescents and young adults aged 16 to 29 years with SCD, caregivers, and practitioners participated in this convergent, mixed-methods study within Children's Hospital of Philadelphia between January and August 2022.

Main Outcomes and Measures

Content validity was assessed through nominations of top 3 most important transition barriers prior to interviews and focus groups, ratings on importance of SMART-E factors (0-4 scale; ratings >2 support validity) after interviews and focus groups, nominations of 3 most important factors for transition and for health equity, and qualitative content analysis of interview transcripts.

Results

The study enrolled 10 pediatric adolescents and young adults (mean [SD] age, 18.6 [2.9] years; 4 female and 6 male), 10 transferred adolescents and young adults (mean [SD] age, 22.9 [2.1] years; 8 female and 2 male), 9 caregivers (mean [SD] age, 49.8 [8.7] years; 5 female and 4 male), and 9 practitioners (mean [SD] age, 45.6 [10.5] years; 8 female and 1 male). Quantitative ratings supported the content validity of SMART-E and met established criteria for validity. Systems of power was the most endorsed transition barrier (14 of 38 participants) reported prior to interviews and focus groups. After the interview, participants endorsed all SMART-E factors as important for transition, with new factors systems of power and environments and networks rated at a mean (SD) 2.8 (1.23) and 3.1 (0.90), respectively, on a 0 to 4 scale of importance. The most important factors for transition and equity varied by participant group, with all factors being endorsed, supporting the comprehensiveness of SMART-E. Qualitative data corroborated quantitative findings, further supporting validity, and minor modifications were made to definitions.

Conclusions and Relevance

SMART-E obtained initial content validation with inclusion of health equity factors for adolescents and young adults with SCD, caregivers, and practitioners. The model should be evaluated in other populations of adolescents and young adults with chronic disease.

Transition readiness and anxiety among adolescents with a chronic condition and their parents: A cross-sectional international study

AIMS

To evaluate associations of age, transition readiness and anxiety in adolescents with chronic conditions and to compare perceptions of adolescents and their parents regarding health self-management and transition readiness.

DESIGN

Cross-sectional international study, reported following STROBE guidelines.

METHODS

Adolescents and young adults (N = 512, mean age 17.7) with a chronic medical condition and their parents (N = 322) from Finland and Australia. Data were collected through surveys (between September 2017 and December 2020). Adolescents reported the duration of their condition. Age at survey was defined by the response date of the questionnaires. Validated questionnaires were used to measure transition readiness (Am I ON TRAC? for Adult Care) and anxiety related to transition of care (State-Trait Anxiety Inventory short form). Perceptions of health self-management and transition readiness were compared in adolescent/parent dyads. Associations were explored using Spearman's correlation.

RESULTS

Duration of condition and age at survey correlated weakly with transition readiness knowledge and behaviour. Higher transition readiness knowledge scores correlated with higher behaviour scores. Higher transition readiness behaviour scores were associated with lower levels of anxiety. Adolescents were less anxious than their parents and adolescents and parents mostly agreed about health self-management and transition readiness.

CONCLUSION

Transition readiness should be determined by an assessment of knowledge, self-management and psychosocial skills instead of age alone. Further research should address how well transition readiness predicts positive health outcomes after the transfer of care.

IMPLICATIONS FOR PATIENT CARE

Transition readiness and self-management skills should be formally assessed because positive feedback may decrease the anxiety of both adolescents and their parents regarding the transfer of care.

REPORTING METHOD

We have adhered to the STROBE statement, using STROBE checklist for cross-sectional studies.

PATIENT OR PUBLIC INVOLVEMENT STATEMENT

No patient or public involvement.

TRIAL AND PROTOCOL REGISTRATION

ClinicalTrials.org NCT04631965.

Health care management adequacy among French persons with severe profound intellectual and multiple disabilities: a longitudinal study

BACKGROUND

The care organization of persons with profound intellectual and multiple disabilities (PIMD) varies by country according to the health care system. This study used a large sample of French individuals with severe PIMD/polyhandicap to assess: 1) the adequacy of care setting over a 5-year period and 2) health care consumption.

METHODS

The longitudinal study used data from the French EVALuation PoLyHandicap (EVAL-PLH) cohort of persons with severe PIMD/polyhandicap who were receiving managed in specialized care centres and residential facilities. Two assessments were performed: wave 1 (T1) in 2015-2016 and wave 2 (T2) in 2020-2021. The inclusion criteria were as follows: age > 3 years at the time of inclusion; age at onset of cerebral lesion younger than 3 years old; and severe PIMD. The adequacy of the care setting was based on the following: i) objective indicators, i.e., adequacy for age and adequacy for health status severity; ii) subjective indicators, i.e., self-perception of the referring physician about medical care adequacy and educational care adequacy. Health care consumption was assessed based on medical and paramedical care.

RESULTS

Among the 492 persons assessed at the 2 times, 50% of individuals at T1 and 46% of individuals at T2 were in an inadequate care setting based on age and severity. Regarding global subjective inadequacy, the combination of medical adequacy and educational adequacy, 7% of individuals at T1 and 13% of individuals at T2 were in an inadequate care setting. At T2, a majority of individuals were undermonitored by medical care providers (general practitioners, physical medicine rehabilitation physicians, neurologists, orthopaedists, etc.). Important gaps were found between performed and prescribed sessions of various paramedical care (physiotherapy, occupational therapy, psychomotor therapy, etc.).

CONCLUSIONS

This study revealed key elements of inadequate care management for persons with severe PIMD/polyhandicap in France. Based on these important findings, healthcare workers, familial caregivers, patients experts, and health decision-makers should develop appropriate care organizations to optimize the global care management of these individuals.

TRIAL REGISTRATION

NCT02400528, registered 27/03/2015.

[State of play of adolescent-adult transition platforms]

Transition support is an integral part of the care of adolescents in clinical services. To avoid disruptions in the care pathway, transition spaces in pediatric and adult hospitals are emerging. There are currently fifteen in France. The professionals working there and the tools and methods used are heterogeneous, but with a common challenge which is the reduction of the major risk of disruption of the care pathway and support for the life course.

Mirror meetings as a tool to enhance professionals' awareness of the lived experiences of young people with inflammatory bowel disease

During mirror meetings, professionals were confronted with the experiences of young people (YP) with inflammatory bowel disease to encourage them to improve their transitional care arrangements. The mirror meetings were held under guidance of an independent moderator. YP conversed about their transition experiences, while health care providers listened without interfering. Meetings were audio-recorded and summarized. Qualitative thematic analysis was conducted. Thirty-two YP participated in six mirror meetings with 26 professionals from paediatric and adult care. Professionals received concrete suggestions for improving their transitional care arrangements. These were about holistic care, tailored to individual needs and preferences, attention for mental health and the role of parents and peers. Advice given by YP matched transitional care guidelines' recommendations. Mirror meetings are a powerful tool to enhance professionals' awareness of YP's needs.

Exploring the transition experiences of young adults with cerebral palsy

BACKGROUND

It is important that young adults with a chronic health condition or developmental disability, such as cerebral palsy, receive adequate healthcare transition preparation and support to optimise the transition period and transfer from paediatric to adult health services. Understanding the healthcare experiences of young adults during and after the transition period will provide valuable insights into what enables a positive healthcare experience for young adults in the adult health setting.

METHODS

Eleven young adults with cerebral palsy who had their last appointment at the Royal Children's Hospital between 2016 and 2018 were purposively recruited for this study. Ten participants completed one-on-one telephone interviews, and one participant provided written responses to interview questions. Five participated via parent proxy. Interviews were recorded, transcribed verbatim, and analysed using the Braun and Clarke six-step thematic analysis to create an interpretive description of participants' transition experiences.

RESULTS

Three themes were generated: (1) "preparedness of the young adult and parent," which discussed the preparation for adult healthcare, with subthemes (a) expectations of adult care and (b) development of self-management skills during transition; (2) "coordination of transfer process and continuity of care," which illustrated the impact of transfer coordination on continuity of care; and (3) "adjusting to adult services," which highlighted experiences of care in the adult setting, with subthemes (a) differences between paediatric and adult services, (b) availability and accessibility of adult and community services to meet needs, and (c) autonomy and agency.

CONCLUSION

Dedicated transition support for young adults and their parents during transition from paediatric to adult healthcare plays an important role in ensuring a supportive and well-coordinated transition and transfer of care. Experience of care in the adult setting is influenced by a combination of both transition experience and the capacity of adult services to cater for young adults' needs.

Transition of care in inborn errors of immunity

PURPOSE OF REVIEW

This review outlines the principles of transition, summarizes current information about transition practices in inborn errors of immunity (IEI) and highlights general and specific considerations for transition of patients with these conditions.

RECENT FINDINGS

Recent surveys demonstrate the variability in access to and transition practices in IEI. Key challenges of transition in IEI from the perspective of healthcare professionals include lack of adult subspecialists, lack of access to holistic care and fragmentation of adult services. Limited research focused on IEI patient and carer perspectives highlight information gaps, poor coordination and difficulty adapting to adult healthcare structures as important challenges for smooth transition.

SUMMARY

Local policies and practices for transition in IEI are highly variable with limited assessment of outcomes or patient experience. There is a need for IEI-focused transition research and for development of national and international consensus statements to guide improved transition in IEI.

Transition from Paediatric to adult health services: Aspirations and practices of human flourishing

BACKGROUND

Transition from paediatric to adult care is challenging for youths with a chronic condition. Most transition programmes place high value in autonomy and independence. We undertook a qualitative study to: (1) identify the needs and aspirations of youths and (2) better understand the well-being and flourishing of youths.

METHODS

Semi-structured interviews were conducted with youths, parents of youths and healthcare professionals recruited from four clinics. Thematic analysis focused on: (1) perceptions of transition; (2) key aspects of human flourishing during transition; and (3) salient concerns with respect to the transition and dimensions of human flourishing.

RESULTS

54 interviews were conducted. Perceptions of transition clustered around: (1) apprehension about adult care; (2) lack of clarity about the transition process; (3) emotional attachment to paediatric healthcare professionals; (4) the significance of the coinciding transition into adulthood. Fourteen salient concerns (e.g., Knowledge and information about the transition, Parental involvement in healthcare) were identified with corresponding recommendations. Salient concerns related to important dimensions of human flourishing (e.g., environmental mastery, autonomy).

DISCUSSION AND CONCLUSION

The flourishing of youths is affected by suboptimal transition practices. We discuss the implications of our findings for environmental mastery, contextual autonomy, and the holistic and humanistic aspects of transition.

Barriers to weight management in adolescence: Measure adaptation among adolescents presenting to an interdisciplinary weight management clinic

A range of barriers may negatively impact adolescents' ability to successfully alter or sustain healthy weight-related behaviors. However, there is a lack of validated measures to empirically assess these barriers. This study developed a measure of adolescent-reported barriers to healthy weight-related behaviors by adapting the previously validated parent-report Barriers to Child Weight Management. Adolescents (N = 154) ages 11-17 presenting to a tertiary weight management program completed Barriers to Weight Management in Adolescence (BWMA). This measure assessed adolescents' perspectives of barriers to healthy weight-related behaviors. Confirmatory factor analysis was used to examine model fit, with four hypothesized subscales-Parental Disengagement, Cost, Lack of Family Support, and Adolescent Disengagement. Overall, good model fit was model demonstrated, χ2 (98) = 130.44, p = .02, CFI = .92, RMSEA = .05, SRMR = .06, supporting a four-factor structure. A final 16-item measure demonstrated good initial psychometric properties. As hypothesized, BWMA was significantly associated with general healthy habits [r = -.25, 95% CI(-.46, -.12)] and parent-reported barriers [r = .40, 95% CI (.264, .586)]. This study adapted and tested preliminary validation of a quantitative measure of adolescent-reported barriers to weight-related behaviors. Identification of barriers may prompt providers to adequately assess, and in turn address, factors impeding adolescents' success in modifying eating and physical activity patterns.

Parental Involvement in the Transition from Paediatric to Adult Care for Youth with Chronic Illness: A Scoping Review of the North American Literature

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.

[The transition preparation consultation: What for?]

The transition from pediatrics to adult services represents one of the many changes experienced by adolescents with chronic illnesses between childhood and adulthood. It needs to be structured and personalized to support the young person's development and empowerment, as well as the construction of his or her overall life project. With this in mind, AD'venir offers transition preparation consultations, the details and benefits of which are described in this article.

[History and challenges of the transition from pediatrics to adult care]

Transition from pediatrics to adult care involves a growing number of young people living with chronic health conditions. Now a field of study and practice, transition has been built up in successive stages, the nature of which informs us about its evolution and current issues.

Transitioning from paediatric to adult healthcare: Exploring the practices and experiences of care providers

Complex paediatric health conditions are increasingly associated with survival into adulthood resulting in more youth with complex care needs (CCN) transitioning from paediatric to adult healthcare. Current transition practices, when present, are disorganized, resulting in health status deterioration and complications due to unmet needs. The aim of this qualitative descriptive study is to develop a broader understanding of the current transition practices and experiences, as well as recommendations of care providers who support youth with CCN in the transition from paediatric to adult healthcare. Fifteen care providers from two Eastern Canadian provinces were interviewed using a semi-structured interview guide. The data collected were analyzed using inductive thematic analysis following the six phases outlined by Braun and Clarke (2006). The findings from this research demonstrate (1) a shortage of care providers, (2) inconsistent timing for transition initiation, and (3) lack of available community resources and services. Participant recommendations include (1) a designated transition coordinator; (2) transition policy implementation; (3) improved collaboration between and across care teams; and (4) the integration of virtual care to facilitate the transition process. The results of this study can potentially improve transition practices and policies and guide future research in this area.

Understanding Whether and How a Digital Health Intervention Improves Transition Care for Emerging Adults Living With Type 1 Diabetes: Protocol for a Mixed Methods Realist Evaluation

BACKGROUND

Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to an increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from pediatric to adult care with sufficient self-management capability. While digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which groups of individuals.

OBJECTIVE

This study aims to evaluate the design and implementation of a multicomponent SMS text message-based digital health intervention to support emerging adults living with T1D in real-world settings. The objectives are to identify the intervention components and associated mechanisms that support user engagement and T1D health care transition experiences and determine the individual characteristics that influence the implementation process.

METHODS

We used a realist evaluation embedded alongside a randomized controlled trial, which uses a sequential mixed methods design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and realist interviews. In step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships among "individual-level contextual factors, intervention components and features, mechanisms, and outcomes," with special attention paid to user engagement. Among them, intervention components and features depict 10 core characteristics such as transition support information, problem-solving information, and real-time interactivity. The proximal outcomes of interest include user engagement, self-efficacy, and negative emotions, whereas the distal outcomes of interest include transition readiness, self-blood glucose monitoring behaviors, and blood glucose. In step 2, we plan to conduct semistructured realist interviews with the randomized controlled trial's intervention-arm participants to test the hypothesized "context-intervention-mechanism-outcome" configurations. In step 3, we plan to triangulate all sources of data using a coincidence analysis to identify the necessary combinations of factors that determine whether and how the desired outcomes are achieved and use these insights to consolidate the program theory.

RESULTS

For step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for this realist evaluation was anticipated to start in July 2023 and continue until we reached thematic saturation or achieved informational power.

CONCLUSIONS

Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46115.

Challenges, Complexity, and Developments in Transition Services for Young People with Disabilities, Mental Health, and Long-Term Conditions: An Integrative Review

Transition to adulthood for young people is complex and multi-faceted, with additional hurdles for young people who have disabilities, long-term, or life-limiting conditions or mental health problems. The challenges in providing effective transition support are not new; researchers, policymakers, commissioners, and service providers have been grappling with the problem for several decades, with varying degrees of success. The aims of this integrative review were firstly to build on previous research to synthesize and evaluate recently published evidence. Secondly to provide an overview of the effectiveness of interventions (in one or a combination of health, social care, and education transitions) designed to support transition to adulthood in these groups of young people. A search of a range of databases retrieved published literature from January 2015 to January 2021 demonstrating global interest in the topic. Fifty-one articles were included following an appraisal of quality and eligibility. Qualitative, quantitative, mixed methods studies, and evidence synthesis were included. Some studies were clinically orientated whilst others examined the impact of the transition process, or utilized participatory approaches which give young service-users and families a voice. Transition between children's and adult health or care services as well as other life-course trajectories, such as life-skills development, education transitions, social inclusion and employability were evaluated. Thematic analysis and synthesis of articles retrieved in this review highlighted themes identified in previous reviews: timing of, and preparation for transition; perceptions and experience of transition; barriers and facilitators; transition outcomes. Additional themes included special considerations; dealing with complexity; advocacy, participation, autonomy, aspirations, and young people's rights; future work, research, and evaluation. Novel perspectives and diverse data sources contributed to holistic understanding of an ongoing priority for international policy, service development, and research: the complexity of providing effective transition support and achieving positive outcomes for young people with long-term and life-limiting health conditions, disabilities, and mental health difficulties.

Health Care Transition: The Struggle to Define Itself

Health care transition is an expanding field of health care practice and research focused on facilitating adolescents and emerging adults with long-term conditions to transfer uninterruptedly from pediatric to adult health care services and to transition successfully into adulthood and beyond. There is a widespread need to develop and implement service models as approximately one million adolescents and emerging adults with long-term conditions transfer their care into the adult system and enter adulthood. The purpose of this article is to explore major issues associated with the current state of health care transition practice, research and ultimately policymaking and systems change. The prominent issues addressed in this article include the following. Defining clearly what constitutes models of health care transition practice as ambiguity exists with terminology used with concepts integral to health care transition. The indistinct meanings of health care transition terminology commonly used, such as transition, transfer, readiness, and preparation, need to be operationalized for widespread application. Furthermore, questions remain as to what goal-directed outcomes are expected within this field of practice and science.

An investigation of vascular anomalies centers' transition of care practices

This study aims to examine transition of care (TOC) practices of multidisciplinary vascular anomalies centers (VACs). Thirty-seven of 71 VAC leaders to whom the survey was sent completed the questionnaire. TOC and transfer practices varied with only 16% of VACs having TOC programs. The most frequently cited barriers to developing a TOC program were lack of resources and difficulty finding expert adult providers.

Transition of patients with metabolic bone disease from paediatric to adult healthcare services: current situation and proposals for improvement

BACKGROUND

There are currently no models for the transition of patients with metabolic bone diseases (MBDs) from paediatric to adult care. The aim of this project was to analyse information on the experience of physicians in the transition of these patients in Spain, and to draw up consensus recommendations with the specialists involved in their treatment and follow-up.

METHODS

The project was carried out by a group of experts in MBDs and included a systematic review of the literature for the identification of critical points in the transition process. This was used to develop a questionnaire with a total of 48 questions that would determine the degree of consensus on: (a) the rationale for a transition programme and the optimal time for the patient to start the transition process; (b) transition models and plans; (c) the information that should be specified in the transition plan; and (d) the documentation to be created and the training required. Recommendations and a practical algorithm were developed using the findings. The project was endorsed by eight scientific societies.

RESULTS

A total of 86 physicians from 53 Spanish hospitals participated. Consensus was reached on 45 of the 48 statements. There was no agreement that the age of 12 years was an appropriate and feasible point at which to initiate the transition in patients with MBD, nor that a gradual transition model could reasonably be implemented in their own hospital. According to the participants, the main barriers for successful transition in Spain today are lack of resources and lack of coordination between paediatric and adult units.

CONCLUSIONS

The TEAM Project gives an overview of the transition of paediatric MBD patients to adult care in Spain and provides practical recommendations for its implementation.

Fact-finding survey of doctors at the departments of pediatrics and pediatric surgery on the transition of patients with childhood-onset chronic disease from pediatric to adult healthcare

BACKGROUND

The number of adult patients with childhood-onset chronic diseases is increasing. However, the process of transitioning these patients from child- to adult-centered medical services faces many difficulties. Despite the key role that doctors in the pediatric field are considered to play in transition, few fact-finding surveys about transition have been conducted among these doctors.

OBJECTIVE

The aim of this study was to demonstrate the current status and challenges in the transition of patients with childhood-onset chronic diseases by a fact-finding survey of pediatricians and pediatric surgeons at a university hospital.

METHODS

A cross-sectional survey was performed using an anonymous self-administered questionnaire. Seventy-six doctors of pediatrics and pediatric surgery (excluding junior residents) in a university hospital were asked to answer an anonymous self-report questionnaire. A multidisciplinary research team selected items related to the transitional process.

RESULTS

Sixty (79%) doctors participated, of whom 52 (87%) showed awareness of transition. No doctor answered that "Transition is conducted smoothly." Doctors with shorter pediatric department experience had lower awareness and poorer experience with transition. In contrast to pediatric surgeons, pediatricians explained "job-seeking activities" and "contraceptive methods" to the patient, and reported a higher patient age at which to initiate explanation of transition to the patient and his/her family. Among factors inhibiting transition, 39 (65%) respondents selected "The patient's family members do not desire transition" and 34 (57%) selected "Although a relevant adult healthcare department is available, it will not accept the patient." The medical providers most frequently considered to have responsibility for playing a central role in the transition process were "pediatrician/pediatric surgeon," "medical social worker," and "regional medical liaison office."

DISCUSSION

To promote transition, pediatric and adult healthcare departments should share concerns about and cooperate in the establishment of more effective methods of transition, and provide multidisciplinary collaboration to support patients and their families.

The Role of Internal Medicine-Pediatric Programs and Transition Champions in Graduate Medical Trainee Health Care Transition Development

OBJECTIVE

Transition to adult health care for adolescents and young adults (AYAs), especially those with chronic conditions, is a critical time. Medical trainees lack competency in providing transition care, but little is known about the factors contributing to the development of health care transition (HCT) knowledge, attitudes, and practice. This study examines how Internal Medicine-Pediatrics (Med-Peds) programs and institutional HCT champions influence trainee HCT knowledge, attitudes, and practices.

STUDY DESIGN

A 78-item electronic survey regarding the knowledge, attitudes, and practices of caring for AYA patients was sent to trainees from 11 graduate medical institutions.

RESULTS

A total of 149 responses were analyzed, including 83 from institutions with Med-Peds programs and 63 from institutions without Med-Peds programs. Trainees with an institutional Med-Peds Program were more likely to identify an institutional HCT champion (odds ratio, 10.67; 95% confidence interval, 2.40-47.44; p = .002). The mean HCT knowledge scores and use of a routine, standardized HCT tools were higher in trainees with an institutional HCT champion. Trainees without an institutional Med-Peds program experienced more barriers to HCT education. Trainees with institutional HCT champions or Med-Peds programs reported greater comfort in providing transition education and using validated, standardized transition tools.

DISCUSSION

The presence of a Med-Peds residency program was associated with a greater likelihood of a visible institutional HCT champion. Both factors were associated with increased HCT knowledge, positive attitudes, and HCT practices. Both clinical champions and adoption of Med-Peds program curricula will enhance HCT training within graduate medical education.

Patient education interventions for adolescent and young adult kidney transplant recipients- a scoping review

BACKGROUND

Adolescence and young adulthood are high risk periods for kidney transplant recipients. The reasons for this are complex; but are predominantly thought to be due to poor adherence to immunosuppressive medications. Patient education can help support young recipients to reduce their risk of behaviour-related transplant loss. The aim of this review was to understand what is known about education interventions targeted at adolescent and young adult kidney transplant recipients.

METHODS

Systematic scoping review methodology was utilised. Six online databases were searched for suitable articles. Articles were selected for full text review following title and abstract screening. Articles deemed eligible to be included in the review had data extracted, which were qualitatively analysed using thematic analysis. Findings were validated through a consultation exercise with both young recipients and healthcare professionals.

RESULTS

29 studies were eligible for inclusion in the review. There was a high level of heterogeneity in the content, mode, design, and measurement of efficacy of interventions in the selected studies. Traditional face-to-face education and transition clinics were the most common educational interventions. Using technology to enhance patient education was also a major theme identified. Few studies reported using educational theory or involving patients in intervention design.

DISCUSSION

Four key research gaps were identified. 1.) Lack of educational theory in intervention design 2.) Lack of patient/ stakeholder involvement 3.) Identifying best way to measure efficacy 4.) identifying novel future research questions within already well established paediatric and educational frameworks. Addressing these gaps in future research will help inform best-practice in this vulnerable population.

A survey of Canadian adult rheumatologists' knowledge, comfort level, and barriers in assessing psychosocial needs of young adults with rheumatic diseases

To assess adult rheumatologists' comfort level, current practices, and barriers to provision of optimal care in supporting young adults with pediatric-onset rheumatic conditions in Canada. Survey questions were informed by literature review, a needs assessment, and using milestones listed by the Royal College of Physicians and Surgeons of Canada for the entrustable professional activities (EPAs) applicable to care for rheumatology patients transitioning to adult practice. The electronic survey was distributed to adult rheumatology members of the Canadian Rheumatology Association over 4 months. Four hundred and fifty-one rheumatologists received the survey, with a response rate of 15.2%. Most respondents were from Ontario and had been in practice ≥ 10 years. Three quarters reported a lack of training in transition care although the same proportion were interested in learning more about the same. Approximately 40% felt comfortable discussing psychosocial concerns such as gender identity, sexuality, contraception, drug and alcohol use, vaping, and mental health. Despite this, 45-50% reported not discussing vaping or gender identity at all. The most frequently reported barriers to providing transition care were lack of primary care providers, allied health support, and training in caring for this age group. Most adult rheumatologists lack formal training in transition care and view it as a barrier to providing care for this unique patient population. Future educational initiatives for adult rheumatology trainees should include issues pertaining to adolescents and young adults. More research is needed to assess the effectiveness of resources such as transition navigators in ensuring a successful transition process.

Transition in endocrinology: predictors of drop-out of a heterogeneous population on a long-term follow-up

PURPOSE

To evaluate: (1) clinical and epidemiological characteristics of outpatients transitioned from Pediatrics Endocrine (PED) to Adult Endocrine Department (AED) in a tertiary center; (2) transition process features, and predictors of drop-out.

METHODS

Demographic, clinical, and transition features of 170 consecutive patients with pediatric onset of chronic endocrine or metabolic disease (excluded type 1 diabetes) who transitioned from PED to AED (2007-2020) were retrospective evaluated.

RESULTS

The age at transition was 18.4 ± 4 years (F:M = 1.2: 1), and mean follow-up 2.8 years. The population was heterogeneous; the most (69.4%) was affected by one, 24.1% by two or more endocrine diseases, 6.5% were followed as part of a cancer survivor's surveillance protocol. The comorbidity burden was high (37, 20.6, and 11.2% of patients had 2, 3, 4, or more diseases). The number of visits was associated with the number of endocrine diseases and the type of them. Adherent subjects had a higher number of comorbidities. Thyroid disorders and more than one comorbidity predicted the adherence to follow-up. Having performed one visit only was predictive of drop-out, regardless of the pathology at diagnosis.

CONCLUSION

This is the first study that analyzed a specific transition plan for chronic endocrine diseases on long-term follow-up. The proposed "one-size-fits-all model" is inadequate in responding to the needs of patients. A structured transition plan is an emerging cornerstone.

Transition of pediatric patients with bronchiectasis to adult medical care in the Northern Territory: A retrospective chart audit

Background

Bronchiectasis is increasingly being recognized to exist in all settings with a high burden of disease seen in First Nations populations. With increasing numbers of pediatric patients with chronic illnesses surviving into adulthood, there is more awareness on examining the transition from pediatric to adult medical care services. We undertook a retrospective medical chart audit to describe what processes, timeframes, and supports were in place for the transition of young people (≥14 years) with bronchiectasis from pediatric to adult services in the Northern Territory (NT), Australia.

Methods

Participants were identified from a larger prospective study of children investigated for bronchiectasis at the Royal Darwin Hospital, NT, from 2007 to 2022. Young people were included if they were aged ≥14 years on October 1, 2022, with a radiological diagnosis of bronchiectasis on high-resolution computed tomography scan. Electronic and paper-based hospital medical records and electronic records from NT government health clinics and, where possible, general practitioner and other medical service attendance were reviewed. We recorded any written evidence of transition planning and hospital engagement from age ≥14 to 20 years.

Results

One hundred and two participants were included, 53% were males, and most were First Nations people (95%) and lived in a remote location (90.2%). Nine (8.8%) participants had some form of documented evidence of transition planning or discharge from pediatric services. Twenty-six participants had turned 18 years, yet there was no evidence in the medical records of any young person attending an adult respiratory clinic at the Royal Darwin Hospital or being seen by the adult outreach respiratory clinic.

Conclusion

This study demonstrates an important gap in the documentation of delivery of care, and the need to develop an evidence-based transition framework for the transition of young people with bronchiectasis from pediatric to adult medical care services in the NT.

Supporting the parent-to-child transfer of self-management responsibility for chronic kidney disease: A qualitative study

INTRODUCTION

As children with long-term conditions (LTCs) mature, they are usually expected to assume responsibility from their parents for self-management of their condition. Little is known about what supports families with this handover of responsibility, including the role of healthcare professionals (HCPs). This study aimed to explore what supports young people with chronic kidney disease (CKD) to assume self-management responsibility and parents to relinquish control.

METHODS

A qualitative study, using a grounded theory approach was conducted. Individual and dyadic interviews and focus groups were carried out with 16 young people aged 13-17 years old with CKD, 13 parents, and 20 HCPs. Participants were recruited from two UK children's renal units.

FINDINGS

Building and maintaining trust, fostering positivity, learning from mistakes, forming partnerships and individualized support, facilitated the transfer of self-management responsibility. However, HCPs' focus on developing partnerships with young people meant some parents felt excluded, highlighting uncertainty around whether support should be child- or family-centred. Although tailored support was identified as critical, aspects of local service provision appeared to impact on HCPs' capacity to implement individualized approaches.

CONCLUSION

This study has identified what supports the handover of responsibility, and, importantly, HCPs' current, and potential role in helping young people to assume responsibility for managing their LTC. Further research is needed to explore how HCPs' involvement balances child- and family-centred care, and how HCPs can adopt personalized, strengths-based approaches to help ensure the support that families receive is tailored to their individual needs.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public involvement was integrated throughout the study, with young adults with CKD and parents who had a child with CKD actively involved in the study's design and delivery.

The role and the composition of a liaison team to facilitate the transition of adolescents and young adults: an umbrella review

Adolescents and young adults (AYAs) benefit from healthcare transition (HCT) programs. Despite the well-established literature reviewing HCT, a considerable heterogeneity exists on the involved healthcare professionals. This review aims to explore systematic reviews on the practices and recommendations on which disciplines of professionals should be involved in HCT. An umbrella review was performed using the MEDLINE, EMBASE, and Web of Science databases. To be eligible, systematic reviews had to report on the composition and/or the rationale of members of a transition team. Seventeen reviews were included in this systematic review. A healthcare professional that coordinates HCT was identified as a key caregiver in all reviews. Other reported members of a HCT team were nurses (75% of the reviews), social workers (44%), and peers/mentors (35%). The reported key responsibilities of a HCT team were to (i) manage communication, (ii) ensure continuity of care, and (iii) maintain contact with community services.  Conclusions: A team responsible for HCT should be active on the organizational, medical, and social levels. Key members of a HCT team vary little between diseases and included a coordinator, social worker, and nurse. A coordinating physician could facilitate transition in complex conditions. At all times, the condition and needs of the AYA should determine who should be involved as caregiver. What is Known: • The psychosocial needs of adolescents and young adults during healthcare transition are largely similar between chronic diseases. What is New: • Coordinators, nurses and social workers were the most involved, independent of the condition. • A liaison team should be active on organizational-, medical- and social-levels.

Young adults with eating disorders perspectives on educational resources to support the transition into adult medicine: a thematic analysis

Background

Eating disorders (EDs) commonly develop in adolescence and can be a chronic condition. Once patients reach the age when it is no longer permitted or appropriate for them to be seen in a children’s healthcare setting, they will need to transition into adult-focused care. This transition period can be challenging, with increased risks of negative health outcomes and disruptions in care. Appropriate educational resources could be an effective support for patients during this transition. Our objectives were to engage patients about the value of developing educational supports and determine how these supports should be structured to be most useful to young adults with EDs.

Methods

Patients who had transitioned out of a hospital-based ED program between 2017 and 2020 were invited to participate in a semi-structured interview. Data were analyzed using thematic analysis and qualitative description.

Results

Six young adults (5 females and 1 male) with EDs were interviewed. All participants thought it would be helpful to have an educational resource. Three main themes and seven subthemes were identified. Themes identified related to the unique challenges of transition for ED patients given the age of onset and cycle of symptoms; issues in adult care related to comorbidities and new level of autonomy; and the value of educational resources as both a connection tool and a benchmark. Participants also thought it would be useful to include in any educational resource a summary of their previous treatments, information regarding the transition process, a list of main healthcare providers they saw for their ED, a description of the differences and expectations of the adult system, a list of their follow up appointments, and a list of community and emergency mental health resources.

Conclusions

Participants said that educational supports can play a useful role for young adults with EDs during their transition into adult care. They also provided valuable insights into the desired contents of such supports and expanded on the roles that educational resources could serve for ED patients.

Most adolescents who have an eating disorder will reach an age when it is no longer appropriate for them to receive care in a children’s health program. They will then need to transition to an adult-focused program. This transition period can be challenging, with increased risks of negative health outcomes and disruptions in care. One approach for better supporting patients during transition is through the development of appropriate educational resources. Before developing these resources, it is important to hear from patients about how they should be structured to be as useful as possible. We interviewed six patients who had recently transitioned out of a pediatric eating disorder program about the value of an educational transition resource and what should be included in it. Patients identified several unique transition issues for young adults with eating disorders. We identified valuable insights and seven key themes from these interviews. While all patients recognized the value of educational resources, rather than being just a static source of information, they envisioned a resource that could also be a dynamic record of their previous care and a tool for engaging with their new adult-focused health care providers.

Readiness for transition to adult health care among US adolescents, 2016-2020

OBJECTIVE

Adolescence is a critical period of transition from paediatric to adult health care, but readiness for this transition has been described as low in the general adolescent population. We aimed to investigate whether transition readiness improved over time among US adolescents and to examine associations between demographic and clinical characteristics and transition readiness over time.

METHODS

Deidentified caregiver-reported repeated cross-sectional data from the 2016-2020 National Survey of Children's Health were analysed for caregiver-reported measures of transition readiness among adolescents age 12-17 years. Logistic regression was used to identify trends in transition readiness and change over time in factors associated with this outcome.

RESULTS

Among 55 022 adolescents represented in the five survey years, the proportion meeting a composite definition of transition readiness increased from 15% (95% confidence interval [CI]: 14%, 16%) in 2016 to 19% (95% CI: 17%, 20%) in 2020. After multivariable adjustment, each additional year was associated with 12% greater odds of caregiver-reported transition readiness (95% CI: +8%, +15%; P < 0.001), and transition readiness was more likely for girls, older adolescents and adolescents with special health care needs. Associations between adolescent characteristics and transition readiness did not change over the study period.

CONCLUSIONS

Population-level caregiver-reported transition readiness among US adolescents has increased but remains low. Factors previously associated with transition readiness (age, sex, race and ethnicity, family income and presence of special health care needs) have persisted over recent years.

Sickle Cell Trevor Thompson Transition Project (ST3P-UP) protocol for managing care transitions: Methods and rationale

BACKGROUND

Emerging adults with sickle cell disease (EASCD) experience significant challenges transitioning from pediatric to adult care. Acute care utilization increases, quality of life (QOL) declines, with an increased risk of mortality. Currently, there are no practice standards to guide emerging adults through the transition process. We are creating a structured transition education (STE) based program for EASCD by customizing the Six Core Elements (6 CE) of Health Care Transition model and are evaluating the effectiveness of adding peer mentoring (PM).

METHODS

The Sickle Cell Trevor Thompson Transition Project (ST3P-UP) is an ongoing multi-site, cluster randomized clinical trial with a target enrollment of 537 EASCD aged 16 to 25 years in pediatric care. Each site (n = 14) comprises a pediatric clinic, adult clinic, and a sickle cell disease (SCD) community-based organization (CBO). Sites are randomized 1:1 to either STE or STE + PM. EASCDs are followed prospectively for 24 months. Rapid cycle plan-do-study-act quality improvement (QI) methods are used to implement the STE. The primary objective is to compare the effectiveness of STE + PM versus STE only at decreasing the number of acute care visits per year over 24 months. The secondary objectives are to compare overall healthcare utilization and patient-reported QOL outcomes at 24 months.

CONCLUSION

We aim to demonstrate the feasibility of using a QI approach to implement 6 CE-based practice standards at 14 disparate SCD clinical programs to guide EASCD through the transition process. We hypothesize that adding PM to the STE program will improve acute care reliance, QOL, and satisfaction with transition outcomes.

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

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

Predicting the Need for Transition from Pediatric to Adult Pain Services: A Retrospective, Longitudinal Study Using the Electronic Persistent Pain Outcome Collaboration (ePPOC) Databases

A proportion of youth with chronic pain do not respond to interdisciplinary pain management and may require transition to adult pain services. This study sought to characterize a cohort of patients referred to pediatric pain services who subsequently required referral to an adult pain service. We compared this transition group with pediatric patients eligible by age to transition but who did not transition to adult services. We sought to identify factors predicting the need to transition to adult pain services. This retrospective study utilized linkage data from the adult electronic Persistent Pain Outcomes Collaboration (ePPOC) and the pediatric (PaedePPOC) data repositories. The transition group experienced significantly higher pain intensity and disability, lower quality of life, and higher health care utilization relative to the comparison group. Parents of the transition group reported greater distress, catastrophizing, and helplessness relative to parents in the comparison group. Three factors significantly predicted transition: compensation status (OR = 4.21 (1.185-15)), daily anti-inflammatory medication use (OR = 2 (1.028-3.9)), and older age at referral (OR = 1.6 (1.3-2.17)). This study demonstrated that patients referred to pediatric pain services who subsequently need transition to adult services are a uniquely disabled and vulnerable group beyond comparative peers. Clinical applications for transition-specific care are discussed.

Transitional care models in adolescent kidney transplant recipients-a systematic review

BACKGROUND

Adolescence is a time of significant change for patients, guardians and clinicians. The paediatrician must ensure patients develop the necessary skills and knowledge required to transition and to function as an independent entity, with autonomy over their own care. The transfer from paediatric to adult care carries an increased risk of graft-related complications attributable to a multitude of reasons, particularly non-adherence to immunosuppressive medicines and poor attendance at scheduled appointments. This systematic review was conducted to ascertain the transitional care models available to clinicians caring for kidney transplant recipients and to compare the approach in each respective case.

METHODS

A systematic review was performed, in a methodology outlined by the PRISMA guidelines. OVID MEDLINE and EMBASE databases were searched for studies that outlined valid, replicable models pertaining to transitional care of paediatric kidney transplant recipients between 1946 and Quarter 3 of 2021. The reference lists of selected articles were also perused for further eligible studies and experts in the field were consulted for further eligible articles. Two investigators assessed all studies for eligibility and independently performed data extraction. Any discrepancies were settled by consensus.

RESULTS

A total of 1121 abstracts were identified, which was reduced to 1029 upon removal of duplicates. A total of 51 articles were deemed appropriate for full-text review and critical appraisal. A total of 12 articles that described models for transition pertaining to kidney transplant patients were included in qualitative synthesis. Every paper utilized a different transition model. All but one model included a physician and nurse at minimum in the transition process. The involvement of adult nephrologists, medical social work, psychology and psychiatry was variable. The mean age for the initiation of transition was 13.4 years (range: 10-17.5 years). The mean age at transfer to adult services was 18.3 years (range: 16-20.5 years).

CONCLUSIONS

Despite the well-established need for good transitional care for paediatric solid-organ transplant recipients, models tailored specifically for kidney transplant recipients are lacking. Further research and validation studies are required to ascertain the best method of providing effective transitional care to these patients. Transitional care should become a standardized process for adolescents and young adults with kidney transplants.

Management of Adults With Esophageal Atresia

Esophageal atresia (EA) with or without trachea-esophageal fistula is relatively common congenital malformation with most patients living into adulthood. As a result, care of the adult patient with EA is becoming more common. Although surgical repair has changed EA from a fatal to a livable condition, the residual effects of the anomaly may lead to a lifetime of complications. These include effects related to the underlying deformity such as atonicity of the esophageal segment, fistula recurrence, and esophageal cancer to complications of the surgery including anastomotic stricture, gastroesophageal reflux, and coping with an organ transposition. This review discusses the occurrence and management of these conditions in adulthood and the role of an effective transition from pediatric to adult care to optimize adult care treatment.

Defining the experiences of adolescent patients with multiple sclerosis in transition from pediatric care to adult care

BACKGROUND

The aim of this study was to evaluate the experiences of patients aged 18-24 years who were diagnosed with multiple sclerosis before the age of eighteen, during the transition from pediatric care to adult care.

METHODS

This research was in the type of phenomenological qualitative research. Focus group interviews were conducted between December 2020 and October 2021 with seventeen participants who had been diagnosed with multiple before the age of eighteen, aged 18-24, voluntarily having agreed to participate in the study. The views of the participants were analyzed with Maxqda Plus v10 data analysis software, and thematic coding was created by the researchers.

RESULTS

Of the participants, 58.9% were female, 76.5% had their first attack after the age of 13, and it was determined that 64.7% of them took oral tablets for therapeutic purposes. As a result of the content analysis; four thematic codes emerged: (a) Perceptions of the Illness and Pediatric Clinic Before Transition, (b) Perceptions of the Disease and Adult Clinic After Transition to the Adult Clinic, (c) Expectations from the Clinic They Received Service from During Their Childhood, (d) Expectations from the Clinic They Used in Adulthood.

CONCLUSION

This study revealed that individuals with multiple sclerosis did not receive any medical care regarding the transition from pediatric clinics to adult clinics. Describing the experiences of young adult patients with multiple sclerosis in pediatric clinics and their experiences in the transition to adult clinics allows for the definition of comprehensive, individualized and transitional nursing interventions.

Factors related to the readiness of Brazilian chronic pediatric patients to transition to care in adult clinics

OBJECTIVE

Advances in medicine have increased the life expectancy of pediatric patients with chronic illnesses, and challenges with the guided transition of adolescents and young adults from pediatric clinics to adult clinics have grown. The aim of this study was to better understand readiness and factors related to this transition process in Brazil.

METHOD

In this cross-sectional study of 308 patients aged from 16 to 21 years under follow-up in pediatric specialties, the degree of readiness for transition was assessed using the Transition Readiness Assessment Questionnaire (TRAQ) and its domains. Associations with demographic data, clinical data, socio-economic level, medication adherence, family functionality, and parental satisfaction with health care were evaluated.

RESULTS

The median TRAQ score was 3.7 (3.2 - 4.2). Better readiness was associated with female patients, socio-economic class A-B, current active employment, higher level of education, not failing any school year, attending medical appointments alone, functional family, and a good knowledge of disease and medications. A low correlation was observed between TRAQ and age. TRAQ presented good internal consistency (alpha-Cronbach 0.86). In the multiple linear regression, TRAQ score showed a significant association with female gender, advanced age, socio-economic class A-B, better knowledge of disease and medications, and independence to attend appointments alone.

CONCLUSION

TRAQ instrument can guide healthcare professionals to identify specific areas of approach, in order to support adolescents with chronic disease to set goals for their own personal development and improve their readiness to enter into the adult healthcare system. In this study, some factors were related to better TRAQ scores.

Barriers, goals, and enablers of transition of care in pediatric dermatology

Adolescent patients with complex skin disorders may require ongoing care for their conditions as they "age out" of the pediatric setting into adult care. Yet despite consensus from the Canadian Paediatric Society and American Academy of Pediatrics on the importance of dedicated transition programs for these patients, there is a scarcity of such programs worldwide, and no formal programs in Canada. This paper explores several barriers, goals, and potential enablers of transition programs in this discipline and proposes principles of transition versus transfer in the context of pediatric dermatology.

Adult healthcare is associated with more emergency healthcare for young people with life-limiting conditions

BACKGROUND

Children with life-limiting conditions receive specialist paediatric care in childhood, but the transition to adult care during adolescence. There are concerns about transition, including a lack of continuity in care and that it may lead to increases in emergency hospital visits.

METHODS

A retrospective cohort was constructed from routinely collected primary and hospital care records for young people aged 12-23 years in England with (i) life-limiting conditions, (ii) diabetes or (iii) no long-term conditions. Transition point was estimated from the data and emergency inpatient admissions and Emergency Department visits per person-year compared for paediatric and adult care using random intercept Poisson regressions.

RESULTS

Young people with life-limiting conditions had 29% (95% CI: 14-46%) more emergency inpatient admissions and 24% (95% CI: 12-38%) more Emergency Department visits in adult care than in paediatric care. There were no significant differences associated with the transition for young people in the diabetes or no long-term conditions groups.

CONCLUSIONS

The transition from paediatric to adult healthcare is associated with an increase in emergency hospital visits for young people with life-limiting conditions, but not for young people with diabetes or no long-term conditions. There may be scope to improve the transition for young people with life-limiting conditions.

IMPACT

There is evidence for increases in emergency hospital visits when young people with life-limiting conditions transition to adult healthcare. These changes are not observed for comparator groups - young people with diabetes and young people with no known long-term conditions, suggesting they are not due to other transitions happening at similar ages. Greater sensitivity to changes at transition is achieved through estimation of the transition point from the data, reducing misclassification bias.