Improving transition from pediatric to adult cystic fibrosis care: lessons from a national survey of current practices

Transition of care in patients with epidermolysis bullosa: A survey study

There are little published data on the transition of care in EB. We conducted a survey study recruiting EB patients from the Dystrophic EB Research Association (debra) website and centers caring for high numbers of EB patients in the United States and internationally from Sept 17, 2019 to Nov 3, 2021. The majority of participants had not discussed the transition of care with their healthcare providers, nor the healthcare needs to be required as an adult. Ongoing pediatric subspecialty care was reported by 12% of adults, most commonly in pediatric dermatology. Identified barriers to transition included the perceived lack of adult providers' knowledge about EB patient healthcare needs. The results suggest the need for transition guidelines, early discussions with families about transition, and practical information for the adult providers accepting care.

Enabling successful transition-Evaluation of a transition to adult care program for pediatric liver transplant recipients

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.

Formal vs. informal transition in adolescents with cystic fibrosis: A retrospective comparison of outcomes

BACKGROUND

The aim of this study was to survey young adults who participated in either a formal or semi-formal transition program at one cystic fibrosis (CF) care center to compare their self-perceived transition related anxiety, transition readiness and satisfaction with transition teaching and timing.

METHODS

This retrospective cohort study was conducted from 3/1/2015 to 9/30/2016. Study participants met inclusion criteria if they had a diagnosis of CF, received pediatric care from the care center, transitioned to adult care between 1/1/2009 and 3/1/2016 and had at least six months experience in adult care. Participants completed a 43 question Likert-type survey rating their pre-transfer transition related anxiety, transition readiness, and satisfaction with the transition preparation and process.

FINDINGS

Participation in a structured transition program was associated with decreased anxiety at transition time (p < .05), increased transition readiness (p < .01) and increased self-perceived healthcare independence (p < .01). Only 48% of participants were satisfied with their chosen transition time, with 18% wishing they had moved to adult care sooner and 34% wishing they could have delayed their transfer to adult care longer.

DISCUSSION

This study supports that participation in a formalized transition program was associated with significantly lower pre-transfer anxiety and higher post-transition satisfaction in individuals with CF. Age at transfer initiation was not associated with satisfaction or perceived readiness to transfer.

PRACTICE IMPLICATIONS

Disease-specific knowledge acquisition in transition curriculum does not necessarily correlate to task-completion skills. Teams should partner with young adults to choose the right transition time.

Assessing Shared Decision-Making in Cystic Fibrosis Care Using collaboRATE: A Cross-Sectional Study of 159 Programs

There are numerous opportunities for shared decision-making (SDM) in cystic fibrosis (CF) care, yet little is known about patients’ SDM experiences. This study evaluated SDM across 159 CF care programs (4024 participants) in the United States. Shared decision-making was assessed using the patient-reported collaboRATE measure, which was included in the CF Foundation’s Patient and Family Experience of Care Survey over 18 months. Overall, 69% of respondents reported experiencing SDM. Respondents at pediatric programs were more likely to experience SDM than those at adult programs (72% vs 67%, P < .001). Multivariable logistic regression analyses showed a relationship between SDM and patient age, whereby SDM was less likely to occur with patients aged 18 to 24 years, compared to some younger and older age groups (P = .02-<.001). Shared decision-making was more likely to occur at pediatric programs when patients had better general health (P = .02-<.01), and at pediatric and adult programs when patients had better mental health (P = .02-<.001). Disparities in SDM experiences highlight a need to improve decision-making processes in CF care. Interventions tailored for improving SDM among specific patient populations may be particularly advantageous.

Transitional care of adolescents with Multiple Osteochondromas: a convergent mixed-method study 'Patients', parents' and healthcare providers' perspectives on the transfer process'

OBJECTIVES

Multiple osteochondromas (MO) is a rare hereditary disease characterised by numerous benign bone tumours. Its chronic aspect requires a well-organised transition from paediatric care to adult care; however, little is known on organising this care specific for patients with MO. This study aims to gain insight on this topic.

DESIGN

Convergent mixed-method study.

SETTING

This study was conducted at the orthopaedic and paediatrics department of an MO-expertise centre in the Netherlands.

PARTICIPANTS

12 patients, 10 parents and 10 healthcare professionals were interviewed. An additional survey was completed by 2 young adults.

PRIMARY AND SECONDARY OUTCOMES

The (1) themes on transition, identified through template analysis and (2) transfer experience and satisfaction assessed by an 18-item On Your Own Feet-Transfer Experience Scale (OYOF-TES, range: 18-90) and by Numeric Rating Scale (NRS, range: 1-10).

RESULTS

The following three key themes were identified in the qualitative analysis: (1) patient and parent in the lead can be encouraged by self-management tools, (2) successful transfers need interprofessional collaboration and communication and (3) how can we prepare patients for the transitional process? Stakeholders' insights to improve transition were listed and divided into these three themes.Several important aspects were underlined, particularly within the first theme; speaking-up was difficult for patients especially when parents were not directly involved. Moreover, the high psychological impact of the disease requires coaching of self-management and psychological counselling to facilitate stakeholders in their changing roles.Twenty patients completed the quantitative survey. Mean satisfaction score with the transfer process was poor, which was assessed with the NRS (mean=5.7±2.1; range: 1-9) and the OYOF-TES (mean=56.3±14.2; range: 32-85). The OYOF-TES only showed a negative correlation (R²=0.25; p=0.026) with the number of surgical interventions in the past.

CONCLUSION

Overall, the transfer process was found unsatisfactory. Improvement can be achieved by supporting and guiding the patients to be in the lead of their care. Moreover, preparation for transfer and a multidisciplinary approach may enhance successful transition.

TRAQ Changes: Improving the Measurement of Transition Readiness by the Transition Readiness Assessment Questionnaire

OBJECTIVE

The purpose of the current study was improving the measurement precision of the Transition Readiness Assessment Questionnaire (TRAQ 5.0-20 item) in order to gain better decimation of transition readiness skills across the 5 Stages of Change-from Precontemplation to Mastery.

METHODS

In stage 1, starting with the TRAQ 5.0 20-item, 5 domain subscale questionnaire, we eliminated the five lowest discriminating items using Item response theory (IRT) in MPlus v7.4,which eliminated the domain subscale Managing Daily Activities, and we e added 15 more difficult and better discriminating items. We added items to both to the remaining 4 domain subscales and created a new domain subscale entitled Future Planning. The revised 30-item TRAQ was piloted among 386 youth between 16 and 24 years old (mean = 20 years; 54% female; 87% White).

RESULTS

After examining the model fit, discrimination and difficulty coefficients, and modification indices, we eliminated 10 items and the new Future Planning domain subscale we eliminated. The resulting questionnaire has 4 domain subscales and 20 items. It exhibited good to excellent fit to the data, χ²(164) = 887.239, p < .001, CFI = 0.943, TLI = 0.93, RMSEA = 0.0942 (90% CI: 0.090, 0.114), WRMR = 1.111. All items have acceptable discrimination coefficients. Each of the 4 domain subscales have improved reliability as compared with the original TRAQ 5.0 20 item scale.

CONCLUSIONS

The revised 20-itemTRAQ 6.0 has 4 domains subscales; Managing medications, keeping appointment, tracking health issues, and Talking with providers and has good construct validity as demonstrated by model fit. By adding more difficult items to the 4 resulting domain subscales, we have demonstrated improved item discrimination and difficulty, and therefore can better measure acquisition of transition readiness skills across the five stages of change from pre-contemplation to contemplation to initiation to action and finally to mastery.

Smoothing the transition of adolescents with CF from pediatric to adult care: Pre-transfer needs

INTRODUCTION

In France, the cystic fibrosis (CF) care pathway is performed in 45 CF centers, the life expectancy of patients has steadily increased, but to date there are no national recommendations for the transition from pediatric to adult care. The transition to an adult CF center still raises questions about the relevance of its organizational arrangements. The "SAFETIM need" study aimed to identify the organizational needs both of patients and of parents before the transfer to an adult CF center.

METHODS

This was a prospective, observational, multicenter study conducted between July 2017 and December 2018, involving the three CF centers of a regional network in southeastern France. Each adolescent registered with the center and his or her parents were interviewed individually, on the same day, during the 6 months leading up to transfer. They participated in semi-structured interviews during one of their routine consultations at the CF center. The interview manual, based on literature reviews and targeting national recommendations, was tested and validated by the national CF therapeutic education group (GETheM). All interviews were transcribed and checked by two different people, and analyzed by two researchers individually. The results were classified by topic according to content categorization.

RESULTS

Overall, 43 adolescents and 41 parents were interviewed, respectively, who were followed up by CF centers: 14% (n=6) in a mixed CF center (pediatric and adult); 19% (n=8) and 67% (n=29), respectively, in two different pediatric CF centers. Adolescents were between 16 and 19 years old. For adolescents, the average interview time was 5.11min. (standard deviation [SD]: 3.8min; minimum: 2.53min; maximum: 17.14min). For parents, the average interview time was 7.99min (SD: 3.56min, minimum: 3.43min; maximum: 22.50min).

DISCUSSION

Our study enquired only about the preparation and organization of the transfer. We identified three areas of actions matching the needs of adolescents and parents before transfer. The first one is to anticipate team change to prepare follow-up in their future CF center: acquire new skills, consider the future CF center according to the adolescent's curriculum, be involved in the transition process. The second area is to accompany the upcoming change. The care team could help by providing information and support during the start of teenagers' transition toward autonomy. And parents were aware that the CF center change will reverse roles. They must provide their own knowledge and manage the ambivalence of this as well as letting go. The third one is to announce the transition process and functioning of the future adult CF center, because the transition would require time to find their place (patients and parents) with the new team.

CONCLUSION

The "SAFETIM needs" pre-transfer study results show that we can identify the main criteria to be developed and strengthened, to promote a smooth, high-quality transition from pediatric to adult CF care for patients in France. For most patients, the transition cannot be prepared at the last minute. Caregivers need to develop specific skills in adolescent and young adult care and follow-up. Each team must consider the transition as a normal part of the patient care cycle. While it must be structured, some flexibility must be allowed so as to give everyone the chance to be prepared and to personalize the care.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cystic Fibrosis

Cystic fibrosis (CF) is one of the most commonly diagnosed genetic disorders. Clinical characteristics include progressive obstructive lung disease, sinusitis, exocrine pancreatic insufficiency leading to malabsorption and malnutrition, liver and pancreatic dysfunction, and male infertility. Although CF is a life-shortening disease, survival has continued to improve to a median age of 46.2 years due to earlier diagnosis through routine newborn screening, promulgation of evidence-based guidelines to optimize nutritional and pulmonary health, and the development of CF-specific interdisciplinary care centers. Future improvements in health and quality of life for individuals with CF are likely with the recent development of mutation-specific modulator therapies. In this review, we will cover the current understanding of the disease manifestations, diagnosis, and management as well as common complications seen in individuals with CF.

Transition Planning for Chronic Illnesses in the Time of COVID-19

Transition from pediatric to adult care for those with chronic illnesses must have special considerations during the COVID-19 pandemic. The SARS-CoV-2 coronavirus has significantly disrupted social, economic, and health care practices globally. Young adults with special health care needs are at increased risk for poor outcomes during this unprecedented time. We have found that heightened anxiety, health care service disruption, and other logistical complications surrounding the new virus may further confound health care transitions. Increased communication and collaboration with young adults is necessary to provide patient-centered care and ensure they successfully cross the transition chasm.

[Cystic fibrosis, the transition to adult centres]

The transition from childhood to adulthood means physical and psychological upheaval. The Safetim study, in a multi-professional team, is looking at the ideal transition for cystic fibrosis patients. Synthesis of the literature on the subject.

Pediatric Nurses' Role in Health Care Transition Planning: National Survey Findings and Practice Implications

PURPOSE

Youth and young adults (YYA) with chronic illness and/or disability (CID) face numerous challenges in transition from pediatric to adult health care. Established evidence supports interdisciplinary team approaches to preparing youth and families for transition and transfer. The purpose of this national survey was to address a gap in current knowledge specific to pediatric nursing professionals' roles and responsibilities in health care transition planning (HCTP).

METHODOLOGY

A quantitative descriptive study using a survey questionnaire validated by experts in the field investigated respondents' role in HCTP, inclusion of HCTP in job description, levels of HCTP knowledge, and ratings of importance of HCTP elements. A volunteer sample of 1814 respondents was drawn from two professional organizations.

RESULTS

Over 64% of respondents performed HCTP activities related to complex chronic illness management. Only 18% reported specialized training in HCTP. The highest-ranking items in regard to perceived importance were educating and supporting disease self-management and speaking with families about complex needs. Predictors of perceived importance were role, inclusion of transition planning in a job description, percentage of time in direct care, caring for those aged 14 years and older, and level of knowledge about HCTP.

CONCLUSIONS

The findings highlight key aspects of the pediatric nurse role in HCTP and identify specific elements that can be addressed to support future HCTP role development.

PRACTICE IMPLICATIONS

Pediatric nurses perform a vital role in HCTP for YYA with CID that may be enhanced with the inclusion of HCTP activities in job descriptions and specialized interdisciplinary HCTP training related to this emerging and growing population.

Outcomes of a Comprehensive Retention Strategy for Youth With HIV After Transfer to Adult Care in the United States

BACKGROUND

The retention of youth living with HIV (YLHIV) in adult care after transfer from pediatric care in the United States is a challenge. A targeted comprehensive retention strategy (CRS) may improve retention among YLHIV.

METHODS

A retrospective cohort study of YLHIV after transfer from pediatric to adult care for patients with at least 1 adult visit at 2 urban HIV care programs in the United States employing CRSs with internal medicine/pediatrics-trained providers, peer navigators, social workers and mental health resources. Primary outcomes were successful retention in care after transfer (≥2 provider visits in the adult clinic ≥90 days apart within 1 year of transfer) and successful transition (successful retention plus a stable HIV viral load (VL) defined as VL 1 year after transfer that was less than or equal to the VL obtained at or immediately before transfer). Logistic regression assessed factors associated with successful transition. A subgroup analysis was performed to examine rates of successful transfer and linkage from pediatric to adult clinics (attending at least 1 adult visit after transition).

RESULTS

Of the 89 patients included in the study, 79 (89%) patients had successful retention and 53 (60%) had successful transition to the adult program. Factors associated with successful transition included non-African American race [adjusted odds ratio (aOR) = 11.26, 95% confidence interval (CI): 1.32-95.51], perinatal HIV (aOR = 8.00, 95% CI: 1.39-46.02) and CD4 count > 500 cells/mm (aOR = 5.22, 95% CI: 1.54-17.70). Of those who were retained, 53/79 (67%) had stable or improved virologic control at 1 year after transition. In a subgroup analysis, 54/56 (96%) patients who were targeted to transition successfully linked to adult care.

CONCLUSIONS

Overall, YLHIV in the United States engaged in a CRS program appear to have high retention rates but suboptimal virologic control after transfer from pediatric HIV care.

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

Background:

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

[Quality criteria for the transition to adult care in French CF centers - results from the SAFETIM APP study?]

INTRODUCTION

SAFETIM-APP compiled an inventory of professional practice in the 45 French cystic fibrosis reference centres (CFRC), between February 2015 and December 2016, related to the transition of adolescents with cystic fibrosis to adult centres.

METHOD

This multicentre cross-sectional study addressed the modalities of the transition in CFRCs and proposed a list of items that could be used to establish quality criteria. Quantitative analysis of the criteria and a qualitative analysis of the transition procedure were carried out.

RESULTS

A total of 77% of the CFRCs that were contacted took part. Transition lasted 3 to 5 years and began at around 15 years of age. Nine criteria were described as fundamental, including: collaboration between teams, taking adolescence into account, having a time for adolescents to speak with the physician alone, defining a program including therapeutic education, involving the family, accompanying the parents. Seven additional criteria were noted to be important, including: re-announcing the diagnosis, identifying a common thread (caregiver) accompanying the family, scheduling adult follow-up from paediatrics onwards, visiting the adult department, organizing a formal departure/reception time, initiating the process early enough, identifying indicators to evaluate practices.

CONCLUSION

The transition processes in place in CFRCs can be improved by implementing the use of these quality criteria systematically.

Initiating transitional care for adolescents with cystic fibrosis at the age of 12 is both feasible and promising

AIM

Adolescence is a vulnerable period in cystic fibrosis, associated with declining lung function. This study described, implemented and evaluated a transition programme for adolescents.

METHODS

We conducted a single centre, nonrandomised and noncontrolled prospective programme at the cystic fibrosis centre at Copenhagen University Hospital Rigshospitalet from 2010 to 2011, assessing patients aged 12-18 at baseline and after 12 months. Changes implemented included staff training on communication, a more youth-friendly feel to the outpatient clinic, the introduction of youth consultations partly alone with the adolescent, and a parents' evening focusing on cystic fibrosis in adolescence. Lung function and body mass index (BMI) were measured monthly and adolescents were assessed for their readiness for transition and quality of life at baseline and 12 months.

RESULTS

We found that 40 (98%) of the eligible patients participated and youth consultations were successfully implemented with no dropouts. The readiness checklist score increased significantly over the one-year study period, indicating increased readiness for transfer and self-care. Overall quality of life, lung function and BMI remained stable during the study period.

CONCLUSION

A well-structured transition programme for cystic fibrosis patients as young as 12 years of age proved to be both feasible and sustainable.

Transition to adulthood and adult health care for patients with sickle cell disease or cystic fibrosis: Current practices and research priorities

INTRODUCTION

A growing population of adults living with severe, chronic childhood-onset health conditions has created a need for specialized health care delivered by providers who have expertise both in adult medicine and in those conditions. Optimal care of these patients requires systematic approaches to healthcare transition (HCT). Guidelines for HCT exist, but gaps in care occur, and there are limited data on outcomes of HCT processes.

METHODS

The Single Disease Workgroup of the Lifespan Domain Task Force of the National Center for Advancing Translational Sciences Clinical and Translational Science Award programs convened a group to review the current state of HCT and to identify gaps in research and practice. Using cystic fibrosis and sickle cell disease as models, key themes were developed. A literature search identified general and disease-specific articles. We summarized key findings.

RESULTS

We identified literature characterizing patient, parent and healthcare provider perspectives, recommendations for transition care, and barriers to effective transition.

CONCLUSIONS

With increased survival of patients with severe childhood onset diseases, ongoing study of effective transition practices is essential as survival increases for severe childhood onset diseases. We propose pragmatic methods to enhance transition research to improve health and key outcomes.

The transition of adolescents with juvenile idiopathic arthritis or epilepsy from paediatric health-care services to adult health-care services: A scoping review of the literature and a synthesis of the evidence

Young people with long-term health conditions (LTCs) can face challenges when making the transition to adult health services. This paper sought to identify studies that assess and explore transitional care for young people with LTCs. Two conditions were used as exemplars: juvenile idiopathic arthritis (JIA) and epilepsy. A scoping review of the literature was conducted by using search terms to search for papers in English between 2001 and 2016 concerning transitional care on four databases. Qualitative papers were reviewed and synthesized using thematic analysis. Quantitative papers using health outcomes were also synthesized. Twenty-eight papers were selected for review. Despite the wealth of literature concerning aspects of transitional care that are key to a successful transition for young people with JIA or epilepsy, there is a paucity of outcomes that define 'successful' transition and consequently a lack of reliable research evaluating the effectiveness of transitional care interventions to support young people moving to adult health services.

The Health Care Transition of Youth With Liver Disease Into the Adult Health System: Position Paper From ESPGHAN and EASL

BACKGROUND

Medical advances have dramatically improved the long-term prognosis of children and adolescents with once-fatal hepatobiliary diseases. However, there is no generally accepted optimal pathway of care for the transition from paediatric care to the adult health system.

AIM

The purpose of this position paper is to propose a transition process for young people with paediatric onset hepatobiliary diseases from child-centred to adult-centred healthcare services.

METHODS

Seventeen ESPGHAN/EASL physicians from 13 countries (Austria, Belgium, France, Germany, Hungary, Italy, the Netherlands, Norway, Poland, Spain, Sweden, Switzerland, and United Kingdom) formulated and answered questions after examining the currently published literature on transition from childhood to adulthood. PubMed and Google Scholar were systematically searched between 1980 and January 2018. Quality of evidence was assessed by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) system. Expert opinions were used to support recommendations whenever the evidence was graded weak. All authors voted on each recommendation, using the nominal voting technique.

RESULTS

We reviewed the literature regarding the optimal timing for the initiation of the transition process and the transfer of the patient to adult services, principal documents, transition multi-professional team components, main barriers, and goals of the general transition process. A transition plan based on available evidence was agreed focusing on the individual young people's readiness and on coordinated teamwork, with transition monitoring continuing until the first year of adult services.We further agreed on selected features of transitioning processes inherent to the most frequent paediatric-onset hepatobiliary diseases. The discussion highlights specific clinical issues that will probably present to adult gastrointestinal specialists and that should be considered, according to published evidence, in the long-term tracking of patients.

CONCLUSIONS

Transfer of medical care of individuals with paediatric onset hepatobiliary chronic diseases to adult facilities is a complex task requiring multiple involvements of patients and both paediatric and adult care providers.

Exploring the need for Transition Readiness Scales within cystic fibrosis services: A qualitative descriptive study

AIMS AND OBJECTIVES

To explore healthcare professionals' and patients' perceptions of the potential use of a Transition Readiness Scale in cystic fibrosis care. This included an examination of barriers and facilitators to its implementation along with the identification of key items to include in a Transition Readiness Scale.

BACKGROUND

Due to increasing life expectancy and improved quality of life, more adolescents with cystic fibrosis are transitioning from paediatric to adult health care. To assess and correctly manage this transition, a more structured approach to transition is advocated. This can be achieved using a Transition Readiness Scale to potentially identify or target areas of care in which the adolescent may have poor knowledge. These key items include education, developmental readiness taking into account relationships, reproduction, future plans and self-management skills. Existing tools to gauge readiness concentrate mainly on education and self-care needs assessment as their key items. Currently, there is no specific cystic fibrosis Transition Readiness Scale in use in Ireland or internationally.

DESIGN

The study used a descriptive qualitative design.

METHODS

Data were collected using semi-structured interviews (n = 8) and analysed using a thematic approach.

RESULTS

The findings identified the potential benefits of this tool and second the resources which need to be in place before its development and implementation into cystic fibrosis services.

CONCLUSION

Transition Readiness Scales have substantial relevance with cystic fibrosis services emphasising the importance of establishing the necessary resources prior to its implementation. These were identified as more staff, a dedicated private space and staff training and education.

RELEVANCE TO CLINICAL PRACTICE

Significant resources are needed to fully integrate Transition Readiness Scales in practice. The study findings suggest multidisciplinary collaborations, and patient engagement is pivotal in planning and easing the transition process for adolescents with cystic fibrosis.

[Adolescents with cystic fibrosis: the approach to transition from paediatric to adult care]

Because of early and effective therapies, an increasing numbers of young people with cystic fibrosis (CF) reach adulthood. Preparing for and maintaining high quality CF care in the adult healthcare is critical for prolonged survival. Because adverse health consequences occur when inadequate transition arrangements are in place, safely transferring patients from pediatric to adult care is a priority. Key features include an early preparation, planning and self-management skills, a coordinated approach and a detailed communication between patients, families, pediatric and adult teams. Formal transition protocols and audits can support the process and be helpful for multidisciplinary teams.

The experience of men and women with cystic fibrosis who have become a parent: A qualitative study

AIMS AND OBJECTIVES

To explore the experiences of men and women with cystic fibrosis in becoming parents.

BACKGROUND

As lifespan for people with cystic fibrosis increases, and reproductive technology advances, having a child of their own becomes a possibility.

DESIGN

This study used a phenomenological framework.

METHODS

Seven Australian adults with cystic fibrosis were invited to describe their experiences of becoming parents in the context of a semi-structured interview. Analysis of the data involved highlighting recurrent phrases and isolating emergent themes.

RESULTS

Two overarching themes characterised the participants' experience: Counting the cost, as they recalled Concentric communication and Pathways to pregnancy; and Living the dream, as they cast a retrospective view over this, their major achievement, in the light of their Reaction: a dream comes true, Coping: a question of balance, Conjecture: the future redefined and Confidence: recalibrating.

CONCLUSIONS

While advances in cystic fibrosis care and reproductive technology have increased the possibility of individuals with cystic fibrosis becoming parents, the passage to becoming a parent is a complex process.

RELEVANCE TO CLINICAL PRACTICE

These findings can inform health professionals to support the adaptive work necessary for families that include members with cystic fibrosis. A contemporary understanding of this phenomenon is necessary for facilitating clinically relevant communication.

Evaluation of spina bifida transitional care practices in the United States

PURPOSE

Recent studies have revealed that the lack of continuity in preparing patients with spina bifida to transition into adult-centered care may have detrimental health consequences. We sought to describe current practices of transitional care services offered at spina bifida clinics in the US.

METHODS

Survey design followed the validated transitional care survey by the National Cystic Fibrosis center. Survey was amended for spina bifida. Face validity was completed. Survey was distributed to registered clinics via the Spina Bifida Association. Results were analyzed via descriptive means.

RESULTS

Total of 34 clinics responded. Over 90 characteristics were analyzed per clinic. The concept of transition is discussed with most patients. Most clinics discuss mobility, bowel and bladder management, weight, and education plans consistently. Most do not routinely evaluate their process or discuss insurance coverage changes with patients. Only 30% communicate with the adult providers. Sexuality, pregnancy and reproductive issues are not readily discussed in most clinics. Overall clinics self-rate themselves as a 5/10 in their ability to provide services for their patients during transition.

CONCLUSIONS

Characteristics of current transitional care services and formal transitional care programs at US clinics show wide variances in what is offered to patients and families.

Overcoming barriers to a successful transition from pediatric to adult care

As life expectancy for people with cystic fibrosis (CF) has increased dramatically, so has the need for a guided, structured transition from pediatric to adult-focused care. A formalized transition program allows for seamless transfer of patients between providers, helping to ensure continuity of care, and avoid potential declines associated with inconsistent medical care. New CF Center guidelines issued by the CFF strongly recommend that each center establish a transition program for age-appropriate transition to an adult CF clinic. In this article, we explore the remaining barriers to establishing a transition program in a CF Center and offer examples of several successful models. We describe CFF-sponsored and other initiatives that exist to support centers in establishing a transition program and discuss the need for ongoing research in this area.

Improving transition to adult healthcare for young people with cystic fibrosis: A systematic review

As survival increases worldwide, large numbers of young people will need to transition from child to adult cystic fibrosis (CF) services. Little is known about the best method for transitioning patients with CF and which transition programmes yield better outcomes. This paper provides a systematic review of the empirical literature on the outcomes and experiences of transition for young people with CF. Outcomes data were subject to a narrative synthesis and a thematic synthesis of experiences data. Structured transition programmes were associated with increased satisfaction, discussions about transition, self-care and self-advocacy skills, more independence, lower anxiety, and increased self-management and parent management of physiotherapy and nutritional supplementation. Young people's concerns included leaving behind previous caregivers, differences in care provision and infection risks. Lack of preparation was a consistent theme. The two most useful aspects of transition programmes were meeting the adult doctors/CF specialist nurse/team and visiting the adult centre. Young people want education about the differences between services, implications of their condition and self-care management. Structured transition programmes appear to impact positively on experiences but the contribution of the different components of transition programmes is unclear. The absence of high-quality studies indicates the need for more well-designed research.

Evidence Supporting the Effectiveness of Transition Programs for Youth With Special Health Care Needs

More than 90% of adolescents and young adults with chronic medical conditions will survive into adulthood. Transitioning from pediatric to adult health care services for these individuals has often times been associated with deterioration of their health and Quality of Life. Separation from their pediatric provider and lack of preparedness of the adult health care system has been identified as major barriers in preventing the successful transition of these individuals. The purpose of this review is to summarize the available data related to transitioning adolescents and young adults (AYA) with special health care needs into the adult health care system.

Transition structures and timing of transfer from paediatric to adult-based care after kidney transplantation in Germany: a qualitative study

OBJECTIVES

It is known that transition, as a shift of care, marks a vulnerable phase in the adolescents' lives with an increased risk for non-adherence and allograft failure. Still, the transition process of adolescents and young adults living with a kidney transplant in Germany is not well defined. The present research aims to assess transition-relevant structures for this group of young people. Special attention is paid to the timing of the process.

SETTING

In an observational study, we visited 21 departments of paediatric nephrology in Germany. Participants were doctors (n=19), nurses (n=14) and psychosocial staff (n=16) who were responsible for transition in the relevant centres. Structural elements were surveyed using a short questionnaire. The experiential viewpoint was collected by interviews which were transcribedverbatim before thematic analysis was performed.

RESULTS

This study highlights that professionals working within paediatric nephrology in Germany are well aware of the importance of successful transition. Key elements of transitional care are well understood and mutually agreed on. Nonetheless, implementation within daily routine seems challenging, and the absence of written, structured procedures may hamper successful transition.

CONCLUSIONS

While professionals aim for an individual timing of transfer based on medical, social, emotional and structural aspects, rigid regulations on transfer age as given by the relevant health authorities add on to the challenge.

TRIAL REGISTRATION NUMBER

ISRCTN Registry no 22988897; results (phase I) and pre-results (phase II).

A Review of Interventions Aimed at Facilitating Successful Transition Planning and Transfer to Adult Care Among Youth with Chronic Illness

This article reviews studies that developed interventions aimed at facilitating the transition process and/or the transfer of youth with chronic illness to adult programs during the past decade. Three key intervention approaches have been studied. Data assessing the impact of transition coordinators suggest that the most successful outcomes occur when coordinators meet with patients prior to the transfer of care, support them as they negotiate the adult programs, and facilitate appointment keeping. Data assessing the impact of transition clinics suggest that the key to positive outcomes is helping patients develop a trusting relationship with the adult providers before fully transferring their care to the adult clinic. Similar conclusions can be drawn for transition programs, where it appears that the opportunity to discuss and plan transition with a pediatric provider over time and to meet with both the pediatric and adult providers simultaneously are beneficial for facilitating successful transfer to adult care. Although aspects of these care processes appear promising for improving transition success, this review identifies areas that need further study. We argue that studies are needed that examine individual patient and family-focused interventions as well as looking at other potential interventions in the health care system. [Pediatr Ann. 2017;46(5):e182-e187.].

Current Concepts of Transition of Care in Cystic Fibrosis

Over the past 6 decades, advances in cystic fibrosis (CF) diagnosis and management have extended the life expectancy of patients far beyond childhood; therefore, all pediatric CF patients must prepare for transition to adult care. Readiness assessment, knowledge and skill education, and support structures are all elements of ideal transition. Transition should begin early in life with teaching skills and knowledge for disease care, and in adolescence the readiness to transition should be addressed. Transition is a gradual process of increasing responsibilities in self-care and disease management, an improvement in the understanding of CF, and an iterative process of self-assessment with knowledge acquisition. Communication and collaboration between pediatric and adult providers is necessary to ensure a smooth and successful transition with minimum effect on outcomes. Although there is increased knowledge of successful transition practices, this area presents many opportunities for advancement of care for the patient with CF. [Pediatr Ann. 2017;46(5):e188-e192.].

Evaluation of Medication-related Self-care Skills in Patients With Cystic Fibrosis

BACKGROUND: As the life expectancy of patients with cystic fibrosis (CF) increases, the focus on ensuring success with medication therapies is increasingly important. The ability of patients to autonomously manage medications and related therapies is poorly described in the literature. OBJECTIVE: The goal of this project was to assess the level of medication-related knowledge and self-care skills in patients with CF. METHODS: This project took place in a Cystic Fibrosis Foundation accredited affiliate center. Eighty-nine patients between the ages of 6 and 60 were eligible to participate based on inclusion and exclusion criteria. Pharmacists administered a 16-item questionnaire and detailed medication history during clinic visits from January through May 2014. RESULTS: Forty-five patients 6 to 41 years old participated in the study. The skills most often performed independently were preparing nebulizer treatments (85%) and telling someone if they feel their medicines are causing a problem (89%). Skills least often performed were carrying a medication list (82%) and bringing a medication list to appointments (76%). In respondents 21 years of age and older, less than 75% of respondents were involved with obtaining financial resources, maintaining equipment, carrying a medication list, or rinsing their mouth after using inhaled medicines. Participants were able to provide drug name, dose, and frequency of use for pancreatic enzymes and azithromycin 37% and 24% of the time, respectively. CONCLUSIONS: In the population surveyed, many medication-related skills had not been acquired by early adulthood. Assessing and providing education for medication-related self-care skills at all ages are needed.

Transitions in Health Care: What Can We Learn from Our Experience with Cystic Fibrosis

Numerous individuals with chronic disease age into adulthood each year, necessitating transition from a pediatric to an adult medical care team. Transition should start early in adolescence and occur gradually over years, preparing the individual for the transfer to the adult team. Cystic fibrosis (CF) has a growing population of adults, as survival over the past several decades has increased. The CF Foundation has implemented guidelines for the transition process. The transition process for individuals with CF provides an example that could be adapted into other chronic disease populations, to provide a successful and meaningful transition into adult care.

Evaluating outpatient transition clinics: a mixed-methods study protocol

INTRODUCTION

To support young people in their transition to adulthood and transfer to adult care, a number of interventions have been developed. One particularly important intervention is the transition clinic (TC), where paediatric and adult providers collaborate. TCs are often advocated as best practices in transition care for young people with chronic conditions, but little is known about TC models and effects. The proposed study aims to gain insight into the added value of a TC compared with usual care (without a TC).

METHODS AND ANALYSIS

We propose a mixed-methods study with a retrospective controlled design consisting of semistructured interviews among healthcare professionals, observations of consultations with young people, chart reviews of young people transferred 2-4 years prior to data collection and questionnaires among the young people included in the chart reviews. Qualitative data will be analysed through thematic analysis and results will provide insights into structures and daily routines of TCs, and experienced barriers and facilitators in transitional care. Quantitatively, within-group differences on clinical outcomes and healthcare use will be studied over the four measurement moments. Subsequently, comparisons will be made between intervention and control groups on all outcomes at all measurement moments. Primary outcomes are 'no-show after transfer' (process outcome) and 'experiences and satisfaction with the transfer' (patient-reported outcome). Secondary outcomes consider clinical outcomes, healthcare usage, self-management outcomes and perceived quality of care.

ETHICS

The Medical Ethical Committee of the Erasmus Medical Centre approved the study protocol (MEC-2014-246).

DISSEMINATION

Study results will be disseminated through peer-reviewed journals and conferences. The study started in September 2014 and will continue until December 2016. The same study design will be used in a national study in 20 diabetes settings (2016-2018).

A framework for assessing outcomes from newborn screening: on the road to measuring its promise

Newborn screening (NBS) is intended to identify congenital conditions prior to the onset of symptoms in order to provide early intervention that leads to improved outcomes. NBS is a public health success, providing reduction in mortality and improved developmental outcomes for screened conditions. However, it is less clear to what extent newborn screening achieves the long-term goals relating to improved health, growth, development and function. We propose a framework for assessing outcomes for the health and well-being of children identified through NBS programs. The framework proposed here, and this manuscript, were approved for publication by the Secretary of Health and Human Services' Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC). This framework can be applied to each screened condition within the Recommended Uniform Screening Panel (RUSP), recognizing that the data elements and measures will vary by condition. As an example, we applied the framework to sickle cell disease and phenylketonuria (PKU), two diverse conditions with different outcome measures and potential sources of data. Widespread and consistent application of this framework across state NBS and child health systems is envisioned as useful to standardize approaches to assessment of outcomes and for continuous improvement of the NBS and child health systems.

SIGNIFICANCE

Successful interventions for newborn screening conditions have been a driving force for public health newborn screening for over fifty years. Organizing interventions and outcome measures into a standard framework to systematically assess outcomes has not yet come into practice. This paper presents a customizable outcomes framework for organizing measures for newborn screening condition-specific health outcomes, and an approach to identifying sources and challenges to populating those measures.

The Youth Health Care measure-satisfaction, utilization, and needs (YHC-SUN)-development of a self-report version of the Child Health Care (CHC-SUN) proxy-measure

BACKGROUND

The transition of health care of youth (age 15-25) with chronic conditions requires the assessment of adolescents' access, use and needs as well as satisfaction with the health services they use. The aim of this study was to test the adolescent adaptation of the parent version "Child Health Care Questionnaire - Satisfaction, Utilization and Needs" (CHC-SUN) concerning its psychometric performance and appropriateness for adolescents and young adults.

METHODS

The Youth Health Care Measure (YHC-SUN) was designed to allow self-report of youth and it was pilot-tested in a small sample using cognitive debriefing. A cross-sectional survey in a sample of youth with chronic conditions in the transition period was carried out.

RESULTS

One hundred eighty-two ambulatory care patients with three conditions participated in the survey. The subscales of the section on satisfaction with care showed excellent internal consistencies, uni-dimensionality and fit to the model of the parent version. There was no impact of gender and education on satisfaction with care. Associations with age, diagnosis, experiences with care and health literacy affecting the satisfaction with care indicate discriminatory and content validity.

CONCLUSIONS

Potential applications of the new instrument are evaluations of health care services for adolescents and young adults using self-reports and evaluations of transition programs and interventions such as patient education.

Preparing Patients for Transfer of Care: Practices of Primary Care Pediatricians

Comprehensive transition planning by pediatric providers is essential for successful transition into adulthood and transfer to adult medical health care settings. Yet, little is known about the level and type of transition planning and preparation provided by pediatric primary care providers. This study examined the range of transition services provided in primary care pediatric centers. Primary care pediatricians across two states in the Midwest were mailed an anonymous survey designed to examine the transition practices of community pediatricians. A response rate of 38.4% was obtained. Most endorsed transferring patients to adult care at age 18 or older, and using patient chronological age, health status, and patient relationship with pediatric provider as criteria to gauge transfer time. About 60% of responders provide preparation to patients before transition, usually by providing a list of adult providers or by transferring medical records. Few responders provide additional type of transition or transfer planning. Many primary care pediatricians provide transition planning, yet there is high variability in the degree of transition planning provided and 40% of pediatricians provide no such support to their patients. Transition planning is also largely limited to providing referrals and transferring medical records. Study findings support the need for outreach efforts so that all youth receive the needed education and resources to successfully transition and transfer to adult health care.

[Transition from paediatric to adult cystic fibrosis care centre]

The number of adolescents and young adults with chronic diseases has increased dramatically over the last decade. This led paediatric teams to organize the transition to adult centres with the aim to ensure the quality of care and prognosis, adherence to survey and treatment. To promote a good work and family life is also a challenge. Several studies have shown the importance of a successful transition in cystic fibrosis (CF) in order to prevent complications and loss monitoring and to improve the perception of patients and their families. In France in 2003, cystic fibrosis centres (CRCM) have been identified and among them of adult CF centres. The regular increase of the adult centre's active file requires improving the transition process. It is necessary to improve the transition process and to prepare the young patient and their family early during adolescence. The process in place should concern the whole aspects of care, i.e., medical, psychological and educational. The transition to adulthood will be successful if it results in a stable state of the disease allowing family and career plans.

Cystic Fibrosis Transitions of Care: Lessons Learned and Future Directions for Cystic Fibrosis

Advances in cystic fibrosis (CF) care transformed the condition from one considered lethal by age 7 into a chronic illness (median lifespan, >40 years). With the growing numbers of adults with CF voicing their preference for care in age appropriate settings, the CF community met the challenge by developing an adult-focused care system modeled on the highly successful pediatric CF centers. Adult CF programs ensure lifelong CF specialty care. Preparation for transfer occurs in a process of "transition." This article reviews progress in transition-related care and provides recommendations for research and clinical practice to improve the transition process.

Transition of respiratory technology dependent patients from pediatric to adult pulmonology care

OBJECTIVE

Recent advances in medicine have allowed children with chronic life-threatening disorders to survive longer than ever before with the use of complex medical device technology (e.g., mechanical ventilation, dialysis, etc.). The care of children with chronic pulmonary disorders and respiratory-technology dependence is often complex, involving a high level of ongoing interaction between caregivers and the health care team. Unmanaged, non-standardized transition of respiratory technology dependent (RTD) patients to adult care potentially increases the risk of adverse outcomes. Pediatric Pulmonary programs at US children's hospitals were surveyed to ascertain whether a standardized process is utilized for transitioning RTD patients from pediatric to adult subspecialty pulmonology care.

METHODOLOGY

Pediatric pulmonology programs with Accreditation Council for Graduate Medical Education certification were invited to participate in an electronic survey inquiring about practices and processes used to transition RTD patients from pediatric to adult pulmonology.

RESULTS

The majority of respondents, 78.1% (25/32), reported that they do not utilize a standard protocol for transition while 41.4% (12/29) have no process in place. No program surveyed uses a designated transition leader. Referral to an adult pulmonologist within the same health system occurs more frequently than referral to private practice. Forty-three percent are not satisfied with involvement from the adult pulmonology care team. Coordination of care with other specialty services such as adult otolaryngology is provided by 31% of respondents. Of respondents, 13.8% assessed "readiness to transition" to adult pulmonary for RTD patients. Pediatric pulmonary providers are not satisfied with their current practices or involvement from the adult team, and only 24% track the transition process until the first visit with the adult pulmonologist.

CONCLUSION

The survey results highlight a lack of standardized transition programs at US children's hospitals for the transfer of RTD patients from a pediatric to an adult care setting. Improvement in the standardized management of transitions of complex RTD patients from pediatric to adult care may decrease the risk for adverse health outcomes and the stresses associated with changing the health care setting.

Uncharted Territory: Systematic Review of Providers' Roles, Understanding, and Views Pertaining to Health Care Transition

BACKGROUND

Health care transition (HCT) for adolescents and emerging adults (AEA) with special health care needs is an emerging field of interdisciplinary field of practice and research that is based upon an intergenerational approach involving care coordination between pediatric and adult systems of health care. Informed understanding of the state of the HCT science pertaining to this group of providers is needed in order to develop and implement service programs that will meet the comprehensive needs of AEA with special health care needs.

METHODS

The authors conducted a systematic review of the literature on the transition from child to adult care for adolescents and emerging adults (AEA) with special health care needs from 2004 to 2013. Fifty-five articles were selected for this review. An adaptation of the PRISMA guidelines was applied because all studies in this review used descriptive designs.

RESULTS

Findings revealed lack of evidence due to the limitations of the research designs and methodology of the studies included in this systematic review. Study findings were categorized the following four types: adult provider competency, provider perspectives, provider attitudes, and HCT service models. The discipline of medicine was predominant; interdisciplinary frameworks based upon integrated care were not reported. Few studies included samples of adult providers.

CONCLUSIONS

Empirical-based data are lacking pertaining to the role of providers involved in this specialty area of practice. Evidence is hampered by the limitations of the lack of rigorous research designs and methodology.

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

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

Young adults' experiences and satisfaction with the transfer of care

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Transition of young people with chronic conditions: a cross-sectional study of patient perceptions before and after transfer from pediatric to adult health care

The aim of this study was to compare perceived barriers to and the most preferred age for successful transition to adult health care between young people with chronic disorders who had not yet transferred from pediatric to adult health care (pre-transfer) and those who had already transferred (post-transfer). In a cross-sectional study, we compared 283 pre-transfer with 89 post-transfer young people, using a 28-item questionnaire that focused on perceived barriers to transition and beliefs about the most preferred age to transfer. Feeling at ease with the pediatrician was the most important barrier to successful transition in both groups, but was rated significantly higher in the pre-transfer compared to the post-transfer group (OR = 2.03, 95 %CI 1.12-3.71). Anxiety and lack of information were the next most important barriers, rated equally highly by the two groups (OR = 0.67, 95 %CI 0.35-1.28 and OR = 0.71, 95 %CI 0.36-1.38, respectively). More than 80 % of the respondents in both groups reported that 16-19 years was the most preferred age to transfer; more than half of all the respondents reported 18-19 years and older as the most preferred age.

CONCLUSION

Better transition planning through the provision of regular and more detailed information about adult health-care providers and the transition process could reduce anxiety and contribute to a more positive attitude to overcome perceived barriers to transition from young people's perspective. Young people's preferences about transferring to adult health care provide a challenge to those children's hospitals that transfer to adult health care at a younger age.

Comparison of emergency care delivered to children and young adults with complex chronic conditions between pediatric and general emergency departments

OBJECTIVES

Increasing attention is being paid to medically complex children and young adults, such as those with complex chronic conditions, because they are high consumers of inpatient hospital days and resources. However, little is known about where these children and young adults with complex chronic conditions seek emergency care and if the type of emergency department (ED) influences the likelihood of admission. The authors sought to generate nationwide estimates for ED use by children and young adults with complex chronic conditions and to evaluate if being of the age for transition to adult care significantly affects the site of care and likelihood of hospital admission.

METHODS

This was a cross-sectional study using discharge data from the 2008 Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality to evaluate visits to either pediatric or general EDs by pediatric-aged patients (17 years old or younger) and transition-aged patients (18 to 24 years old) with at least one complex chronic condition. The main outcome measures were hospital admission, ED charges for treat-and-release visits, and total charges for admitted patients.

RESULTS

In 2008, 69% of visits by pediatric-aged and 92% of visits by transition-aged patients with multiple complex chronic conditions occurred in general EDs. Not surprisingly, pediatric age was the strongest predictor of seeking care in a pediatric ED (odds ratio [OR] = 15.86; 95% confidence interval [CI] = 12.3 to 20.5). Technology dependence (OR = 1.56; 95% CI =1.2 to 2.0) and presence of multiple complex chronic conditions (OR = 1.39; 95% CI = 1.2 to 1.6) were also associated with higher odds of seeking care in a pediatric ED. When controlling for patient and hospital characteristics, type of ED was not a significant predictor of admission (p = 0.87) or total charges (p = 0.26) in either age group.

CONCLUSIONS

Overall, this study shows that, despite their complexity, the vast majority of children and young adults with multiple complex chronic conditions are cared for in general EDs. When controlling for patient and hospital characteristics, the admission rate and total charges for hospitalized patients did not differ between pediatric and general EDs. This result highlights the need for increased attention to the care that these medically complex children and young adults receive outside of pediatric-specialty centers. These results also emphasize that any future performance metrics developed to evaluate the quality of emergency care for children and young adults with complex chronic conditions must be applicable to both pediatric and general ED settings.