Supporting the health care transition from adolescence to adulthood in the medical home

Optimising healthcare transition of adolescents and young adults to adult care: a perspective statement of the Italian Society of Obesity

The transition to adult health care (HCT, Health Care Transition), is the purposeful, planned movement of patients from paediatric to adult services. For the adolescent living with obesity (ALwO), the HCT represents a crucial window for effective intervention that can help improve body weight, adiposopathy, and metabolic complications. Nevertheless, no transition guidelines, models, and tools have been developed for these patients. The present statement of the Italian Society of Obesity examines the critical transition of ALwO from paediatric to adult healthcare. It synthesises current knowledge and identifies gaps in HCT of ALwO. Drawing on successful practices and evidence-based interventions worldwide, the paper explores challenges, including disparities and barriers, while advocating for patient and family involvement. Additionally, it discusses barriers and perspectives within the Italian health care scenario. The need for specialised training for healthcare providers and the impact of transition on healthcare policies are also addressed. The conclusions underscore the significance of well-managed transitions. The SIO recognises that without proper support during this transition, ALwOs risk facing a gap in healthcare delivery, exacerbating their condition, and increasing the likelihood of complications. Addressing this gap requires concerted efforts to develop effective transition models, enhance healthcare provider awareness, and ensure equitable access to care for all individuals affected by obesity. The document concludes by outlining avenues for future research and improvement.

Development of a Standardized Process for Transition to Adult Care in a Pediatric Colorectal Surgery Clinic

BACKGROUND

As pediatric patients with colorectal diseases grow, it is important to address transition to adult practice. We aim to describe our center's transition process and early outcomes.

METHODS

We developed a standardized process for transition to adult practice. An annual survey is given to parents and caregivers starting at age 12 that assesses knowledge of disease, independence with healthcare tasks, and confidence and interest regarding transition. After multidisciplinary review, those eligible are recommended for transition. Those not referred are provided with tools to help with areas of weakness. Outcomes were analyzed with descriptive and regression analyses (significance at p ≤ 0.05).

RESULTS

A total of 116 patients were evaluated, with 80 patients (69.0%) recommended for transition. Median age at survey was 15.5 years [IQR: 13.7-18.1], and those recommended were older (16.6 years [IQR: 14.7-19.4] vs 13.5 years [IQR: 12.5-14.9], p < 0.001)). Primary diagnosis and gender were not associated with recommendation for transition. Overall, a minority (18.1%) were able to complete healthcare tasks; this correlated strongly with transition recommendation (26.3% vs 0.0%, p < 0.0001). On regression controlling for age, diagnosis, knowledge, and confidence, age (aOR 1.98, 95% CI 1.44-2.71) and confidence (aOR 3.78, 95% CI 1.29-11.11) independently predicted transition recommendation.

CONCLUSION

A standardized approach may be effective in transitioning patients from pediatric to adult colorectal surgery practice. Patients who transition are more confident and can perform healthcare tasks independently; however, these skills are not essential prior to a recommendation of transition.

LEVEL OF EVIDENCE

III.

Resource use and costs of transitioning from paediatric to adult care for patients with chronic endocrine disease

OBJECTIVE

Structured transition of adolescents and young adults with a chronic endocrine disease from paediatric to adult care is important. Until now, no data on time and resources required for the necessary components of the transition process and the associated costs are available.

DESIGN, PATIENTS AND MEASUREMENTS

In a prospective cohort study of 147 patients with chronic endocrinopathies, for the key elements of a structured transition pathway including (i) assessment of patients' disease-related knowledge and needs, (ii) required education and counselling sessions, (iii) compiling an epicrisis and a transfer appointment of the patient together with the current paediatric and the future adult endocrinologist resource consumption and costs were determined.

RESULTS

One hundred and forty-three of 147 enroled patients (97.3%) completed the transition pathway and were transferred to adult care. The mean time from the decision to start the transition process to the final transfer consultation was 399 ± 159 days. Transfer consultations were performed in 143 patients, including 128 patients jointly with the future adult endocrinologist. Most consultations were performed by a multidisciplinary team consisting of a paediatric and adult endocrinologist, psychologist, nurse, and a social worker acting also as a case manager with a median of three team members and lasted 87.6 ± 23.7 min. The mean cumulative costs per patient of all key elements were 519 ± 206 Euros. In addition, costs for case management through the transition process were 104.8 ± 28.0 Euros.

CONCLUSIONS

Using chronic endocrine diseases as an example, it shows how to calculate the time and cost of a structured transition pathway from paediatric to adult care, which can serve as a starting point for sustainable funding for other chronic rare diseases.

The Crucial Role of Empowerment in Engaging Adolescents and Young Adults for Independence: Essential Strategies and Skills for a Successful Transition

BACKGROUND

An increasing number of pediatric solid organ transplant (SOT) recipients are surviving into adolescence and young adulthood. The transition from pediatric to adult-oriented care occurs during a unique and vulnerable period.

METHODS

Presented here is a structured approach to healthcare transition (HCT) for adolescent and young adult SOT recipients aimed at optimizing independence in order to assist young patients with adherence, self-management, and improved quality of life.

RESULTS

Close attention must be paid to neurocognitive development, mental well-being, and social determinants of health.

CONCLUSIONS

These efforts require a multidisciplinary team approach as well as collaboration between pediatric and adult providers in order to achieve these goals and patient longevity.

Gaps during pediatric to adult care transfer escalate acute resource utilization in sickle cell disease

ABSTRACT

Guidelines recommend transfer to adult health care within 6 months of completing pediatric care; however, this has not been studied in sickle cell disease (SCD). We hypothesized that longer transfer gaps are associated with increased resource utilization. Transfer gaps were defined as the time between the last pediatric and first adult visits. We estimated the association between varying transfer gaps and the rates of inpatient, emergency department (ED), and outpatient visits, using negative binomial regression. Health care utilization was evaluated in a mid-south comprehensive program for a follow-up period of up to 8 years (2012-2020) and was restricted to the first 2 years of adult health care. In total, 183 young adults (YAs) with SCD (51% male, 67% HbSS/HbSβ0-thalassemia) were transferred to adult health care between 2012 and 2018. YAs with transfer gaps ≥6 months compared with <2 months had 2.01 (95% confidence interval [CI], 1.31-3.11) times the rate of hospitalizations in the 8-year follow-up and 1.89 (95% CI, 1.17-3.04) when restricted to the first 2 years of adult health care. In the first 2 years of adult care, those with transfer gaps ≥6 months compared with <2 months, had 1.75 (95% CI, 1.10-2.80) times the rate of ED encounters. Those with gaps ≥2 to <6 months compared with <2 months had 0.71 (95 % CI, 0.53-0.95) times the rate of outpatient visits. Among YAs with SCD, a longer transfer gap was associated with increased inpatient and decreased outpatient encounters in adult health care and more ED encounters in the first 2 years of adult health care. Strategies to reduce the transfer gaps are needed.

Pediatric to adult transition care in neurogastroenterology and motility: A position paper from the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility

Transition services-programs that support adolescents and young adults (AYAs) as they move from a child-centered to a more autonomous, adult-orientated healthcare system-have been associated with improved short- and long-term healthcare outcomes. Unfortunately, there is a paucity of evidence exploring transition services within the neurogastroenterology and motility (NGM) field. The overall aim of this article, endorsed by the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility, is to promote a discussion about the role of transition services for patients with NGM disorders. The AYAs addressed herein are those who have: (a) a ROME positive disorder of gut-brain interaction (DGBI), (b) a primary or secondary motility disorder (including those with motility disorders that have been surgically managed), or (c) an artificial feeding requirement (parenteral or enteral tube feeding) to manage malnutrition secondary to categories (a) or (b). The issues explored in this position paper include the specific physical and psychological healthcare needs of patients with NGM disorders; key healthcare professionals who should form part of a secondary care NGM transition service; the triadic relationship between healthcare professionals, caregivers, and patients; approaches to selecting patients who may benefit most from transition care; methods to assess transition readiness; and strategies with which to facilitate transfer of care between healthcare professionals. Key areas for future research are also addressed, including the construction of NGM-specific transition readiness questionnaires, tools to assess post-transfer healthcare outcomes, and educational programs to train healthcare professionals about transition care in NGM.

Research Trends in Family-Centered Care for Children With Chronic Disease: Keyword Network Analysis

Family-centered care is an approach to promote the health and well-being of children with chronic diseases and their families. This study aims to explore the knowledge components, structures, and research trends related to family-centered care for children with chronic conditions. We conducted the keyword network analysis in three stages using the keywords provided by the authors of each study: (1) search and screening of relevant studies, (2) keyword extraction and refinement, and (3) data analysis and visualization. The core keywords were child, adolescence, parent, and disabled. Four cohesive subgroups were identified through degree centrality. Research trends in the three phases of a recent decade have been changed. With the systematic understanding of the context of the knowledge structure, the future research and effective strategy establishment are suggested based on family-centered care for children with chronic disease.

Primary care physicians' perceptions of artificial intelligence systems in the care of adolescents' mental health

BACKGROUND

Given that mental health problems in adolescence may have lifelong impacts, the role of primary care physicians (PCPs) in identifying and managing these issues is important. Artificial Intelligence (AI) may offer solutions to the current challenges involved in mental health care. We therefore explored PCPs' challenges in addressing adolescents' mental health, along with their attitudes towards using AI to assist them in their tasks.

METHODS

We used purposeful sampling to recruit PCPs for a virtual Focus Group (FG). The virtual FG lasted 75 minutes and was moderated by two facilitators. A life transcription was produced by an online meeting software. Transcribed data was cleaned, followed by a priori and inductive coding and thematic analysis.

RESULTS

We reached out to 35 potential participants via email. Seven agreed to participate, and ultimately four took part in the FG. PCPs perceived that AI systems have the potential to be cost-effective, credible, and useful in collecting large amounts of patients' data, and relatively credible. They envisioned AI assisting with tasks such as diagnoses and establishing treatment plans. However, they feared that reliance on AI might result in a loss of clinical competency. PCPs wanted AI systems to be user-friendly, and they were willing to assist in achieving this goal if it was within their scope of practice and they were compensated for their contribution. They stressed a need for regulatory bodies to deal with medicolegal and ethical aspects of AI and clear guidelines to reduce or eliminate the potential of patient harm.

CONCLUSION

This study provides the groundwork for assessing PCPs' perceptions of AI systems' features and characteristics, potential applications, possible negative aspects, and requirements for using them. A future study of adolescents' perspectives on integrating AI into mental healthcare might contribute a fuller understanding of the potential of AI for this population.

Nationwide Survey on Transitional Care for Patients With Childhood-Onset Cardiomyopathy in Japan

Background: Individuals transitioning into adulthood require age-appropriate medical care and delegation of decision-making authority from their parents to the patients themselves. Although there have been multiple observational and interventional studies on transitional care for patients with congenital heart disease (CHD) in the cardiovascular field, transitional care specific to childhood-onset cardiomyopathy (CM) remains unaddressed. Methods and Results: A nationwide questionnaire-based survey was performed in the pediatric cardiology departments of 151 facilities in Japan. Responses were obtained from 100 (66%) facilities with low transfer rates (<5%) for childhood-onset CM cases. The comparison between CHD-transferring and non-CHD-transferring facilities revealed a significantly higher transfer rate (83.9%) for childhood-onset CM cases in the CHD-transferring facilities (P<0.001). Regarding the transition programs, 72 (72%) facilities do not offer any programs for CM, while most (92%) facilities recognize its necessity. Finally, only 19 (19%) facilities provided a transition program, 10 of which were CHD based. Conclusions: To the best of our knowledge, this is the first study to demonstrate the poor transition/transfer care status of patients with childhood-onset CM in Japan. The transfer rate of CMs was lower than that of CHDs, and transition programs were less available. Referring to the system established for CHD could help develop a successful transitional care system for CM.

Clinical practice guidelines for the care of girls and women with Turner syndrome

Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.

Transitional Care in Anorectal Malformation and Hirschsprung's Disease: A Systematic Review of Challenges and Solutions

BACKGROUND

The literature on transitional care in anorectal malformation (ARM) and Hirschsprung's disease (HD) is diverse and heterogeneous. There is a lack of standards and guidelines specific to transitional care in these conditions. We aim to establish and systematically categorize challenges and solutions related to colorectal transition care.

METHODS

Systematic review of qualitative studies from MEDLINE, EMBASE, PubMed and Scopus databases (2008-2022) was conducted to identify the challenges and solutions of healthcare transition specific to ARM and HD. Thematic analyses are reported with reference to patient, healthcare provider and healthcare system.

RESULTS

Sixteen studies from 234 unique articles were included. Fourteen themes related to challenges and solutions, each, are identified. Most challenges identified are patient related. The key challenges pertain to: (1) patient's lack of understanding of their disorder, resulting in over-reliance on the pediatric surgical team and reluctance towards transitioning to adult services; (2) a lack of education and awareness among adult colorectal surgeons in caring for pediatric colorectal conditions and inadequate communication between pediatric and adult teams; and (3) a lack of structured transition program and joint-clinic to meet the needs of the transitioning patients. The key solutions are: (1) fostering young adult patient's autonomy and independence; (2) conducting joint pediatric-adult transition clinics; and (3) ensuring a structured and coordinated transition program is available using a standardized guideline.

CONCLUSION

A comprehensive framework related to barriers and solutions for pediatric colorectal transition is established to help benchmark care quality of transitional care services.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Systematic review without meta-analysis.

Disparities in pediatric hospital use during transition to adult healthcare for young adults with childhood-onset chronic conditions

BACKGROUND

Young adults (YA) with childhood-onset chronic conditions-particularly YA with cystic fibrosis (CF), congenital heart disease (CHD), and sickle cell disease (SCD)-continue to have pediatric hospital admissions. Factors associated with this continued pediatric hospital use remain underexplored.

OBJECTIVE

To determine if pediatric hospital use by YA differed (1) across condition and (2) within each condition by sociodemographic factors.

METHODS

Conducted a cross-sectional analysis of admissions for YA 22-35 years with CF, CHD, and SCD from 2016 to 2020 in the National Inpatient Sample. Admissions for YA with CF, CHD, and SCD were identified by international classification of diseases, 10th revision-clinical modification diagnosis codes. To determine if conditions or sociodemographic factors were associated with YA pediatric hospital use, we used multivariable logistic regression with separate models for the different objectives.

RESULTS

YA with SCD had lower odds of pediatric hospital use compared to YA with CF. Relationships between sociodemographic factors and pediatric hospital use varied. Black YA with both CF and CHD had lower odds of pediatric hospital use than white YA with CF and CHD. For YA with SCD, despite 17,810 (6.5%) having rural residence, zero (0) had pediatric hospital use; whereas YA with CF living in a rural area had greater odds of pediatric hospital use compared to urban residents.

CONCLUSION

YA with SCD used pediatric hospitals less than YA with either CF or CHD. Coupled with our findings that Black YA with CF and CHD had less pediatric hospital use, these data may reflect systematic racial differences within pediatric to adult healthcare transition programs.

A Smooth Transition: Assessing Transition Readiness in Adolescents with Inflammatory Bowel Disease

BACKGROUND

Inflammatory Bowel Disease (IBD) is an early onset condition that affects individuals of all ages. Approximately 15%-25% of patients present before the age of 20 years, with peak onset occurring during adolescence.

AIMS

To evaluate transition readiness among adolescents diagnosed with IBD and identify barriers to transition.

METHODS

We conducted a cross-sectional study of patients with IBD aged 12-21 years. Patients were stratified by age into three groups: A (12-14 years), B (14-17 years), and C (17 + years). Patients were asked to complete a questionnaire which assessed patient knowledge in three areas of transition: 'Taking Charge,' 'My Health,' and 'Using Health Care.' Fisher's Exact and Chi-Square tests were used to evaluate the associations between age and transition readiness.

RESULTS

A total of 127 participants (68 males and 59 females) with a mean age of 16.14 years were included. Transition readiness increased with age from 60.7% in Group A to 63.2% and 77.9% in Groups B and C, respectively (p < 0.001). Patient confidence and the importance of transition increased with age, with means of 5.51, 6.17, and 6.94 in Groups A, B, and C (p = 0.02). Patient-reported knowledge of their health condition was > 70%, with no statistical differences between the groups (p = 0.65). Patient knowledge regarding 'Using Health Care' increased from 52% in Group A to 79% in Group C (p < 0.001). The greatest barriers to transitioning were carrying health information for Group A (100%) and obtaining provider referrals for Groups B (75%) and C (51%).

CONCLUSION

This study demonstrated that transition readiness increases with age in adolescents with IBD.

Pediatric to Adult Transition in Inflammatory Bowel Disease: Consensus Guidelines for Australia and New Zealand

BACKGROUND

The incidence of pediatric inflammatory bowel disease (IBD) is rising, and there is an increasing need to support adolescents when they transition to adult care. Evidence supports the use of a structured transition process but there is great variation across Australasia. The study aim was to develop evidence and expert opinion-based consensus statements to guide transitional care services in IBD.

METHODS

A modified UCLA-RAND methodology was employed to develop consensus statements. An IBD expert steering committee was formed and a systematic literature review was conducted to guide the drafting of consensus statements. A multidisciplinary group was formed comprising 16 participants (clinicians, nurses, surgeons, psychologists), who anonymously voted on the appropriateness and necessity of the consensus statements using Likert scales (1 = lowest, 9 = highest) with a median ≥7 required for inclusion. Patient support groups, including direct input from young people with IBD, informed the final recommendations.

RESULTS

Fourteen consensus statements were devised with key recommendations including use of a structured transition program and transition coordinator, mental health and transition readiness assessment, key adolescent discussion topics, allied health involvement, age for transition, and recommendations for clinical communication and handover, with individualized patient considerations. Each statement reached median ≥8 for appropriateness, and ≥7 for necessity, in the first voting round, and the results were discussed in an online meeting to refine statements.

CONCLUSIONS

A multidisciplinary group devised consensus statements to optimize pediatric to adult transitional care for adolescents with IBD. These guidelines should support improved and standardized delivery of IBD transitional care within Australasia.

Parental entrustment of healthcare responsibilities to youth with chronic conditions: A concept analysis

PURPOSE

Chronic health conditions impact nearly 40% of children in the United States, necessitating parents/caregivers to entrust healthcare responsibilities to youth aging into adulthood. Understanding the parental entrustment process may lead to tailored transition support; however, the concept lacks conceptual clarity, limiting its research and practical applications.

DESIGN AND METHODS

Rodgers' evolutionary concept analysis method was used to clarify the parental entrustment of healthcare responsibilities to youth with chronic health conditions. PubMed, CINAHL, and PsycINFO databases were searched without date restrictions, including full-text, English-language, primary source articles related to parent-child healthcare transition preparation. Following title, abstract, and full-text screenings, data were analyzed using a hybrid thematic approach to identify antecedents, attributes, and consequences.

RESULTS

Forty-three studies from August 1996 to September 2023 were identified. Antecedents encompass social cues and readiness factors, while attributes involve a) responsibility transfer, support, and facilitation, b) a dynamic process, c) balancing trust and fear, d) navigating conflict, and e) parental letting go. Consequences entail shifts in parental and adolescent roles. Parental entrustment is an iterative process wherein parents guide their maturing child through responsibility transfer via facilitation, support, conflict navigation, and trust building.

CONCLUSION

The clarified concept underscores the role of parents/caregivers in empowering youth to manage their health. Introducing a working definition and conceptual model contributes to understanding the processes families navigate in the larger landscape of healthcare transition.

PRACTICE IMPLICATIONS

This clarification holds implications for clinicians and policymakers, offering insights to enhance support and guidance for families navigating healthcare transition.

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.

Kawasaki disease: patients' transition journey and recommendations for adult care

BACKGROUND

Children who develop coronary artery aneurysms after Kawasaki disease are at risk for cardiovascular morbidity, requiring health care transition and lifelong follow-up with an adult specialist. Follow-up losses after health care transition have been reported but without outcome and patient experience evaluation.

OBJECTIVE

The Theoretical Domains Framework underpinned our aim to explore the required self-care behaviours and experiences of young adults' post-health care transition.

METHODS

A qualitative description approach was used for virtual, 1:1 interviews with 11 participants, recruited after health care transition from a regional cardiac centre in Ontario. Directed content analysis was employed.

RESULTS

Health, psychosocial, and lifestyle challenges were compounded by a sense of loss. Six themes emerged within the Theoretical Domains Framework categories. Participants offered novel health care transition programme recommendations.

CONCLUSIONS

The realities of health care transition involve multiple, overlapping stressors for young adults with Kawasaki disease and coronary artery aneurysms. Our findings will inform a renewed health care transition programme and will include outcome evaluation.

Healthy transition: Roadmap for young adults with Down syndrome to adulthood

Healthcare transition is the purposeful and planned process for preparing young adults with Down syndrome for an adult oriented healthcare system. Significant gaps of a delayed, incomplete, siloed and decentered transition can be avoided when transition is approached in a longitudinal and holistic manner. Young adults with Down syndrome are specifically vulnerable to these gaps as the combination of intellectual differences and healthcare complexity leads to the need for a process that allows for appropriate preparation to develop the skills and process for an appropriate. To establish a successful transition care plan, the six core elements of policy, tracking, readiness, planning, transfer of care, and complete transition will compose the scaffolding of the transition process and address these gaps in care. A comprehensive tool kit including policy statements, healthcare transition tracking forms, the TRAQ tool, and template portable medical summaries will operationalize those elements and counteract any gaps in the transition process.

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

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

Addressing the unmet needs of transitional care in juvenile idiopathic arthritis

OBJECTIVES

We aimed to comprehensively analyse the available literature to identify the unmet requirements in transitional programs tailored specifically for patients diagnosed with JIA.

METHODS

According to published guidance on narrative reviews, a systematic review of the literature on transitional care in rheumatology was conducted. Pertinent documents were collected from reputable databases, such as Web of Science, Scopus, and MEDLINE/PubMed. The search encompassed literature published from the inception of each database until January 2023.

RESULTS

In this study, a comprehensive analysis of the findings of 34 studies was conducted. Among these, 12 studies focused on assessing the readiness of adolescents and young adults diagnosed with JIA. Additionally, 18 studies examined the effectiveness of structured transition programs in terms of adherence and satisfaction. Finally, 4 studies investigated disease-related outcomes in this population.

CONCLUSION

The need for transitioning children with rheumatic diseases to adult rheumatology services for continued care is clearly evident. However, the absence of established best practice guidelines presents a challenge in facilitating this transition effectively. Although several scoring systems have been proposed to ensure organized and seamless transfers, a consensus has not yet been reached. Furthermore, the socio-economic and cultural variations across countries further complicate the development of universal guidelines for transitioning children with rheumatic diseases. To address these concerns, our objective in conducting this literature review was to emphasize the significance of this issue and identify the specific requirements based on the unmet needs in the transition process.

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

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

Resource utilization and costs of transitioning from pediatric to adult care for patients with chronic autoinflammatory and autoimmune disorders

BACKGROUND

A structured transition of adolescents and young adults with chronic autoinflammatory and autoimmune disorders from the pediatric to the adult health care system is important. To date, data on the time, processes, outcome, resources required for the necessary components of the transition process and the associated costs are lacking.

METHODS

Evaluation of resource use and costs in a prospective cohort study of 58 adolescents with chronic autoinflammatory and autoimmune disorders, for the key elements of a structured transition pathway including (i) compilation of a summary of patient history, (ii) assessment of patients' disease-related knowledge and needs, (iii) required education and counseling sessions, (iv) and a transfer appointment of the patient with the current pediatric and the future adult rheumatologist.

RESULTS

Forty-nine of 58 enrolled patients (84.5%) completed the transition pathway and were transferred to adult care. The mean time from the decision to start the transition process to the final transfer consultation was 315 ± 147 days. Transfer consultations were performed in 49 patients, including 10 patients jointly with the future adult rheumatologist. Most consultations were performed by the multidisciplinary team with a median of three team members and lasted 65.5 ± 21.3 min. The cumulative cost of all consultation and education sessions performed including the transfer appointment was 283 ± 164 Euro per patient. In addition, the cost of coordinating the transition process was 57.3 ± 15.4 Euro.

CONCLUSIONS

A structured transition pathway for patients with chronic autoinflammatory and autoimmune disorders is resource and time consuming and should be adequately funded.

Transition From Pediatric to Adult Rheumatology Care: An Exploratory Study From Latin America

BACKGROUND/PURPOSE

Adequate transition from pediatric to adult care is associated with better adherence to treatment and better outcomes in pediatric patients with chronic diseases. There are little data on transition programs, outcomes, use of transition guidelines, and available tools in pediatric rheumatology centers from Latin America (LATAM). In this study, we described the characteristics of transition programs from 3 pediatric rheumatology centers. We also introduced results of the first survey examining the transition experience in countries from LATAM.

METHODS

The experience and implementation process of transition programs from 3 pediatric rheumatology centers were described. A survey based on a questionnaire created by Chira et al (J Rheumatol. 2014;41:768-779) from the Childhood Arthritis and Rheumatology Research Alliance was also administrated to pediatric rheumatology centers from LATAM.

RESULTS

A total of 49 (68%) pediatric rheumatologists answered the survey. Most centers do not have an official and written transition program and reported a need for more tools and resources in their services to facilitate the transition experience.

CONCLUSIONS

Transition guidelines culturally tailored to developing countries are needed in LATAM.

Towards a standardized program of transitional care for adolescents with juvenile idiopathic arthritis for Turkey: a national survey study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a prevalent childhood chronic arthritis, often persisting into adulthood. Effective transitional care becomes crucial as these patients transition from pediatric to adult healthcare systems. Despite the concept of transitional care being recognized, its real-world implementation remains inadequately explored. This study aims to evaluate the thoughts and practices of healthcare providers regarding transitional care for JIA patients.

METHODS

A cross-sectional survey was conducted among pediatric and adult rheumatologists in Turkey. Based on the American Academy of Pediatrics' six core elements of transitional care, the survey included 86 questions. The respondents' demographic data, attitudes towards transitional care, and practical implementation were assessed.

RESULTS

The survey included 48 rheumatologists, with 43.7% having a transition clinic. The main barriers to establishing transition programs were the absence of adult rheumatologists, lack of time, and financial constraints. Only 23.8% had a multidisciplinary team for transition care. Participants agreed on the importance of coordination and cooperation between pediatric and adult healthcare services. The timing of the transition process varied, with no consensus on when to initiate or complete it. Participants advocated for validated questionnaires adapted to local conditions to assess transition readiness.

CONCLUSIONS

The study sheds light on the challenges and perspectives surrounding transitional care for JIA patients in Turkey. Despite recognized needs and intentions, practical implementation remains limited due to various barriers. Cultural factors and resource constraints affect the transition process. While acknowledging the existing shortcomings, the research serves as a ground for further efforts to improve transitional care and ensure better outcomes for JIA patients transitioning into adulthood.

Diabetes-Focused Health Care Utilization Among Adolescents and Young Adults With Type 1 Diabetes

OBJECTIVE

To describe the current rates of health services use with various types of providers among adolescents and young adults (AYA) with type 1 diabetes (T1D) and evaluate which patient factors are associated with rates of service use from different provider types.

METHODS

Using 2012-16 claims data from a national commercial insurer, we identified 18,927 person-years of AYA with T1D aged 13 to 26 years and evaluated the frequency at which: 1) AYA skipped diabetes care for a year despite being insured; 2) received care from pediatric or non-pediatric generalists or endocrinologists if care was sought; and 3) received annual hemoglobin A1c (HbA1c) testing as recommended for AYA. We used descriptive statistics and multivariable regression to examine patient, insurance, and physician characteristics associated with utilization and quality outcomes.

RESULTS

Between ages 13 and 26, the percentage of AYA with: any diabetes-focused visits declined from 95.3% to 90.3%; the mean annual number of diabetes-focused visits, if any, decreased from 3.5 to 3.0; receipt of ≥2 HbA1c tests annually decreased from 82.3% to 60.6%. Endocrinologists were the majority providers of diabetes care across ages, yet the relative proportion of AYA whose diabetes care was endocrinologist-dominated decreased from 67.3% to 52.7% while diabetes care dominated by primary care providers increased from 19.9% to 38.2%. The strongest predictors of diabetes care utilization were younger age and use of diabetes technology (pumps and continuous glucose monitors).

CONCLUSIONS

Several provider types are involved in the care of AYA with T1D, though predominate provider type and care quality changes substantially across age in a commercially-insured population.

Lack of consideration of socioeconomic factors in transition programme of adolescents with type 1 diabetes: A systematic review

The transition of adolescents with type 1 diabetes should be organized such that loss of follow-up and deterioration of patients' metabolic control are minimized.

OBJECTIVE

Our study aimed to ascertain whether socioeconomic status is featured in the characteristics of adolescents with type 1 diabetes in transition programmes and their inclusion in transition programmes.

RESEARCH DESIGN AND METHODS

A systematic review of the literature was performed according to PRISMA recommendations. All articles published between 2010 and 2023 were considered. Studies that described a transition programme for adolescents or young adults with T1DM were included.

RESULTS

After screening, 18 studies were included. Different transition programmes were proposed (exchanges between professionals, coordinators, and transition clinics). Nine articles described socio-economic factors. The educational level was the most frequently reported. Only three studies evaluated the impact of one parameter on transition success: a lower education level was associated with more hospital visits for hyperglycaemia, and the other did not report any socioeconomic factor associated with clinic attendance.

CONCLUSIONS

The socioeconomic status of type 1 diabetes is poorly described in transition programmes, and the few that do make mention of it, offer little information about patient management.

Resource use and costs of transitioning from pediatric to adult care for patients with chronic kidney disease

BACKGROUND

The structured transition of adolescents and young adults with chronic kidney disease (CKD) from pediatric to adult care is important, but data on the time and resources required for the necessary components of the transition process and the associated costs are lacking.

METHODS

In a prospective single-center cohort study of 52 patients with pre-transplant CKD (CKD stage 1, n = 10; stage 2, n = 6; stage 3, n = 5; stage 4 and 5, 1 patient each) or kidney transplant recipients (KTR), resource use and costs were evaluated for the key elements of a structured transition pathway, including (i) assessment of patients' disease-related knowledge and needs, (ii) required education and counseling sessions, and (iii) compiling an epicrisis and a transfer appointment of the patient with the current pediatric and the future adult nephrologist.

RESULTS

Forty-four of 52 enrolled patients (84.6%) completed the transition pathway and were transferred to adult care. The mean time from the decision to start the transition process until the final transfer consultation was 514 ± 204 days. The process was significantly longer for KTR (624 ± 150 [range, 307-819] days) than for patients with pre-transplant CKD (365 ± 172 [range, 1-693] days; P < 0.0001). The cumulative costs of all counseling and education sessions performed including the transfer appointment were 763 ± 473 Euro; it was significantly higher in KTR (966 ± 457 Euro) than in patients with pre-transplant CKD (470 ± 320 Euro; P < 0.0001).

CONCLUSIONS

A structured transition pathway for patients with CKD is resource and time-consuming due to the complexity of the disease and should be sufficiently funded. A higher-resolution version of the Graphical abstract is available as Supplementary information.

Racial and ethnic disparities in early mortality among patients with inborn errors of immunity

BACKGROUND

Racial and ethnic disparities in life expectancy in the United States have been widely documented. To date, there remains a paucity of similar data in patients with inborn errors of immunity (IEIs).

OBJECTIVE

Our aim was to examine racial and ethnic differences in mortality due to an IEI in the United States.

METHODS

We analyzed National Center for Health Statistics national mortality data from 2003 to 2018. We quantified age-adjusted death rate and age-specific death rate as a result of an IEI for each major racial and ethnic group in the United States and examined the association of race and ethnicity with death at a younger age.

RESULTS

From 2003 to 2018, IEIs were reported as the underlying or contributing cause of death in 14,970 individuals nationwide. The age-adjusted death rate was highest among Black patients (4.25 per 1,000,000 person years), compared with 2.01, 1.71, 1.50, and 0.92 per 1,000,000 person years for White, American Indian/Alaska Native, Hispanic, and Asian/Pacific Islander patients, respectively. The odds of death before age 65 years were greatest among Black patients (odds ratio [OR] = 5.15 [95% CI = 4.61-5.76]), followed by American Indian/Alaska Native patients (OR = 3.58 [95% CI = 2.30-5.82]), compared with White patients. The odds of death before age 24 years were greater among Hispanic patients than among non-Hispanic patients (OR = 3.60 [95% CI = 3.08-4.18]).

CONCLUSION

Our study highlights racial and ethnic disparities in mortality due to an IEI and the urgent need to further identify and systematically remove barriers in care for historically marginalized patients with IEIs.

A commentary on the healthcare transition policy landscape for youth with disabilities or chronic health conditions, the need for an inclusive and equitable approach, and recommendations for change in Canada

There is a growing number of youth with healthcare needs such as disabilities or chronic health conditions who require lifelong care. In Canada, transfer to the adult healthcare system typically occurs at age 18 and is set by policy regardless of whether youth and their families are ready. When the transition to adult services is suboptimal, youth may experience detrimental gaps in healthcare resulting in increased visits to the emergency department and poor healthcare outcomes. Despite the critical need to support youth with disabilities and their families to transition to the adult healthcare system, there is limited legislation to ensure a successful transfer or to mandate transition preparation in Canada. This advocacy and policy planning work was conducted in partnership with the Patient and Family Advisory Council (PFAC) within the CHILD-BRIGHT READYorNot™ Brain-Based Disabilities (BBD) Project and the CHILD-BRIGHT Policy Hub. Together, we identified the need to synthesize and better understand existing policies about transition from pediatric to adult healthcare, and to recommend solutions to improve healthcare access and equity as Canadian youth with disabilities become adults. In this perspective paper, we will report on a dialogue with key informants and make recommendations for change in healthcare transition policies at the healthcare/community, provincial and/or territorial, and/or national levels.

[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.

Association between clinician specialty and prescription of preventive medication for young adults with migraine: A retrospective cohort study

OBJECTIVE

We aimed to compare the prescribing patterns of preventive medications between pediatric and adult neurologists for young adults with migraine.

BACKGROUND

Although preventive medications are effective for adults with migraine, studies in children have failed to demonstrate similar efficacy. As a result, lifestyle modifications and non-pharmacological interventions are often emphasized in children. It is not known whether young adults are prescribed preventive medications at different rates according to whether they are cared for by an adult or pediatric neurologist.

METHODS

We performed a multicenter retrospective cohort analysis of patients with migraine aged 18-25 years who were seen by a pediatric or adult neurologist at Mass General Brigham Hospital between 2017 and 2021. The primary outcome was whether the patient received a prescription for any preventive medication during the study period.

RESULTS

Among the 767 included patients, 290 (37.8%) were seen by a pediatric neurologist. Preventive medications were prescribed for 131/290 (45.2%; 95% confidence interval [CI]: 39.5%, 51.0%) patients seen by a pediatric neurologist and 206/477 (43.2%; 95% CI: 39.0%, 47.7%) patients seen by an adult neurologist (p = 0.591). In the mixed effects logistic regression model, clinician specialty was not associated with preventive medication use (adjusted odds ratio [AOR] 1.20, 95% CI: 0.62, 2.31). Female sex (AOR 1.69, 95% CI: 1.07, 2.66) and number of visits during the study period (AOR 1.64, 95% CI: 1.49, 1.80) were associated with receiving preventive medication.

CONCLUSION

Approximately two fifths of young adults with migraine were prescribed preventive medications, and this proportion did not differ according to clinician specialty. Although these findings suggest that pediatric and adult neurologists provide comparable care, both specialties may be underusing preventive medications in this patient population.

State of the Art Bowel Management for Pediatric Colorectal Problems: Spinal Anomalies

BACKGROUND

Patients with spinal abnormalities often struggle with fecal and/or urinary incontinence (up to 87 and 92%, respectively) and require a collaborative approach to bowel management in conjunction.

METHODS

To define existing approaches and propose state-of-the-art bowel management, a literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published July 2013 and July 2023.

RESULTS

Patients with spinal anomalies have impaired innervation of the rectum and anal canal, decreasing the success rate from laxatives and rectal enemas. Thus, transanal irrigations and antegrade flushes are widely utilized in this group of patients. Based on spinal MRI, the potential for bowel control in these children depends on age, type, and lesion level. On referral for bowel management, a contrast study is performed to assess colonic motility and evacuation of stool, followed by a series of abdominal X-rays to define colonic emptying and adjust the regimen. The options for management include laxatives, rectal enemas, transanal irrigations, antegrade flushes, and the creation of a stoma. Approximately 22-71% of patients achieve social continence dependent on the type and level of the lesion.

CONCLUSION

Patients with spinal anomalies require a thorough assessment for continence potential and stool burden prior to initiation of bowel management. The optimal treatment option is defined according to the patient's age, anatomy, and mobility. The likelihood of independent bowel regimen administration should be discussed with the patients and their caregivers.

Improving the use of transition readiness measures in research and clinical care

Measurement of transition readiness is considered a crucial component of effective transition. It is included as one of the Six Core Elements of Transition in national transitional care guidelines. However, the current measures of transition readiness have not been found to correlate with either current or future health outcomes for youth. In addition, there are challenges in measuring transition readiness in youth with intellectual and developmental disabilities, who may not be expected to achieve skills and knowledge that are considered essential for transition in typically developing youth. These concerns make it difficult to know how best to use transition readiness measures in research and clinical care. This article highlights the appeal of measuring transition readiness in clinical and research contexts, the current barriers that prevent us from fully achieving those benefits, and potential strategies for bridging the gap. IMPACT: Transition readiness measures were developed as an attempt to identify those patients who were ready to successfully navigate the transition from pediatric to adult health care. Thus far, the measures that have been developed do not appear to be related to health outcomes such as disease control or timely attendance of the first adult appointment in adult care. We provide suggestions for how to address the current concerns with the available transition readiness measures.

Transition of Kidney Care at 18: Challenges and Practical Solutions for India

Health-care transition (HCT) from pediatric-centered to adult-oriented health-care setting is more than a simple transfer of care. It is a carefully planned movement specially tailored for the needs of adolescents and young adults (AYAs). Similar to other chronic diseases, the need for HCT for AYAs with kidney disease has been well established by the International Society of Nephrology (ISN) and the International Pediatric Nephrology Association (IPNA) consensus statements since 2011. However, successful HCT in India and other low- and middle-income countries (LMICs) has been limited. Undertaking the HCT program in India requires involvement of many stakeholders, that is, AYAs, parents/caregivers, health-care providers, and the health-care system. In this article, we discuss the need for HCT, the challenges faced during the transition, and the recommended models for HCT in kidney care. We focus on the unique challenges faced in India and conclude with practical suggestions to implement HCT in our setting.

The Design and Testing of the Psychometric Properties of the Adolescent Capacity to Engage Index Instrument to Measure an Adolescent's Capacity to Engage in Healthcare

Background and Purpose: Engagement in one's healthcare is paramount to improving health outcomes. As adolescents begin their journey into adulthood and increase involvement in their health-care decision-making, it is critical to understand their ability to be involved in their healthcare. The purpose of this instrumentation study was to develop and evaluate the psychometric properties and underlying factors of the Adolescent Capacity to Engage Index (ACEI) tool which measures the construct of an adolescent's capacity to engage in their healthcare. Methods: This study had a two-phase approach. Phase 1 consisted of the pilot and cognitive testing of the items developed based on the literature and content expertise. Phase 2 was the testing of the final 21 item revised instrument among 15- to 17-year-old online teen panel (n = 226). Results: Psychometric testing revealed a valid and reliable 21 item scale with a four-factor solution. The Cronbach's alpha for the total scale was .901. The four subscales and each subscale Cronbach's alpha were: (a) Active Participation In Healthcare with Psychosocial Support to Aid/Foster Good Healthcare Choices, (.826); (b) Transition Readiness to Self-Management with Family Support to Guide/Foster Health/Healthcare Decisions, (.825); (c) Proactivity and Empowerment to Have a Say in Health/Healthcare, (.747); and (d) Technology Use to Seek Health/Healthcare Information (.648). Conclusions: This study demonstrated the ACEI is a psychometrically sound instrument with good internal consistency for the overall scale and subscales. The ACEI can be implemented in clinical practice to measure adolescents' engagement capacity in their healthcare and identify appropriate interventions based on ACEI score. Further research to determine engagement capacity among teens of various populations is warranted.

Just TRAC it! Transitioning Responsibly to Adult Care Using Smart Phone Technology

PURPOSE

There is little evidence on whether smartphone technology influences transition readiness among adolescents with heart disease. Just TRAC it! is a method of using existing smartphone features (Notes, Calendar, Contacts, Camera) to manage personal health. We evaluated the impact of Just TRAC it! on self-management skills.

METHODS

Randomized clinical trial of 16-18 year-olds with heart disease. Participants were randomly allocated 1:1 to either usual care (education session) or intervention (education session including Just TRAC it!). The primary outcome was change in TRANSITION-Q score between baseline, 3 and 6 months. Secondary outcomes were frequency of use and perceived usefulness of Just TRAC it! Analysis was intention-to-treat.

RESULTS

We enrolled 68 patients (41% female, mean age 17.3 years), 68% having previous cardiac surgery and 26% had cardiac catheterization. TRANSITION-Q scores were similar at baseline and increased over time in both groups but were not significantly different between groups. Each additional point at the baseline score brought, on average, a 0.7-point increase in TRANSITION-Q score (95% CI 0.5-0.9) at each of 3 and 6 months. The Camera, Calendar and Notes apps were reported as most useful. All intervention participants would recommend Just TRAC it! to others.

DISCUSSION

A nurse-led transition teaching with versus without Just TRAC it! improved transition readiness, with no significant difference between groups. Higher baseline TRANSITION-Q scores were associated with greater increase in scores over time. Participants had a positive reception to Just TRAC it! and would recommend it to others. Smartphone technology may be useful in transition education.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Mental Health and Inflammatory Bowel Disease

Psychiatric disorders are 1.5 to 2 times more prevalent in persons with inflammatory bowel disease (IBD) than in the general population, with pooled prevalence estimates of 21% for clinical anxiety and 15% for depression. Rates are even higher when considering mental health symptoms, as nearly one-third of persons with IBD experience elevated anxiety symptoms and one-quarter experience depression symptoms. Rates of these symptoms were much higher during periods of disease activity, more common in women than men, and more common in Crohn's disease than ulcerative colitis. There is robust evidence of the detrimental effects of comorbid depression and anxiety on the subsequent course of IBD based on longitudinal studies tracking outcomes over time. However, psychiatric disorders and IBD have bidirectional effects, with each affecting risk of the other. Elevated mental health concerns have been consistently associated with greater healthcare utilization and costs related to IBD. There is some signal that low resilience in adolescence could be a risk factor for developing IBD and that enhancing resilience may improve mental health and intestinal disease outcomes in IBD. Psychological therapies used to treat anxiety and depression occurring in the context of IBD have been shown to significantly improve the quality of life for persons with IBD and reduce anxiety and depression. There is less evidence in regard to the impact of psychotropic medications on mental health or disease outcomes in persons with IBD. There is consensus, however, that mental health must be addressed as part of comprehensive IBD care for children and adults.

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.

Consensus evidence-based recommendations for transition of care for adolescents with juvenile idiopathic arthritis: meeting patients’, parents’, and rheumatologists’ perspectives

Background

Transition of care means the process of educating and empowering adolescents and young adults to take an active role in their own healthcare, develop decision-making skills, and eventually transition from paediatric to adult healthcare providers. Most people do not switch doctors until they are young adults, but it can be beneficial to start preparing children earlier. We aimed to develop a specific toolkit tailored to paediatric and adult rheumatologists to assist them in transitioning of care of young people with juvenile onset rheumatic musculoskeletal diseases from the paediatric to adult rheumatology care.

Results

The expert panel was confined to an online survey (n = 18), all the experts completed the two rounds. At the conclusion of round 2, a total of 10 points were gathered. The range of respondents (ranks 7–9) who agreed with the recommendations was 88.9 to 100%. All 10 clinical standards identified by the scientific committee were written in the same way. Based on the answers to the structured key questions and the literature review, a structured template was developed presenting transition of care integrated pathway.

Conclusion

The developed rheumatology-specific guideline offers adolescents and young adults a focussed, multidisciplinary transition of care approach with equity of access, quality of care and flexibility and set up standards for transitional care for young adults with juvenile rheumatological diseases.

A Patient Portal Intervention to Promote Adolescent and Young Adult Self-Management Skills

OBJECTIVE

Failure to transfer care to adult medicine is associated with gaps in health care access and poor health outcomes among young adults. We examined whether a patient portal educational intervention is acceptable and can improve adolescent and young adult (AYA) self-management skills toward transition readiness to adult care.

METHODS

We conducted a single site feasibility study using a mixed research method consisting of 1) a patient portal one-on-one educational intervention with pre- and postsurveys adapted from the Transition Readiness Assessment Questionnaire to assess participant self-management skills and portal user activity; 2) portal user experience was assessed through semistructured interviews until thematic saturation was reached. Study participants were 13 to 25 years old and received care at an academic-affiliated community pediatric clinic. Descriptive statistics were used to describe participant characteristics, paired t tests, or Wilcoxon signed-rank tests to assess outcomes of survey response changes pre- versus postintervention.

RESULTS

Sixty percent of enrolled participants (N = 78) completed the surveys. Following the educational intervention, we observed an increase in participants self-reporting knowing how to access their protected health information P < .0001, (95%, confidence interval [CI], 1-2) and in the proportion of participants self-reporting to strongly agree to know their medication P = .025 (95%, CI 0-1). We also observed an increase in portal user access at 3 weeks; the median number of logins was 2 per participant (range 1-36, P < .0001). The Portal user experience was strongly positive.

CONCLUSION

Our patient portal educational intervention suggests that AYAs welcome a patient portal to access protected health information and is associated with an increase in the proportion of participants self-reporting to strongly agree with knowing their medication. While these results are encouraging, this is a quasiexperimental study designed on the frame of feasibility. Our study was not adequately powered, limiting our findings' significance. Future interventions would benefit from a larger sample size with a comparison group to ascertain the effect of a patient portal on self-management skills in a diverse AYA population and inform best practices.

[Transition of long-term ventilated children to adult medical care]

Through advances in long-term ventilation, the number of children with chronic respiratory insufficiency reaching adult age has increased tremendously. Therefore, transition of children from pediatric to adult care has become inevitable. Transition is necessary for medicolegal reasons, to increase autonomy of the young patients and because of change in the disease as a result of increasing age. Transition bears the risks of uncertainty of patients and parents, loss of the medical home or even loss of complete medical care. Good structural conditions, professional preparation of patient and parents, a comprehensive formalized transfer and patient coaching are prerequisites for a successful professional transition. This article discusses issues of transition with focus on long-term ventilated children.

Associations of Diabetes-related and Health-related Quality of Life With Glycemic Levels in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care

OBJECTIVES

As adolescents with type 1 diabetes (T1D) progress to adulthood, they assume responsibility for diabetes self-management while dealing with competing life demands, decreasing parental support, and the transfer to adult care. Lower perceived quality of life (QOL) may hamper diabetes management, which is associated with suboptimal glycemic levels. Our objective was to determine associations of diabetes- and health-related QOL with glycemic management (glycated hemoglobin [A1C]) in adolescents with T1D before their transfer to adult care.

METHODS

We conducted a cross-sectional analysis of baseline data from the Group Education Trial to Improve Transition (GET-IT- T1D) in adolescents with T1D (16 to 17 years of age). Participants completed validated questionnaires measuring diabetes-related QOL (PedsQL 3.2 Diabetes Module) and health-related QOL (PedsQL 4.0 Generic Core Scales). Associations of QOL Total and subscale scores with A1C were assessed using linear regression models adjusted for sex, diabetes duration, socioeconomic status, insulin pump use, and mental health comorbidity.

RESULTS

One hundred fifty-three adolescents with T1D were included (mean age, 16.5 [standard deviation, 0.3] years). Diabetes-related QOL Total scores (adjusted β=-0.04; 95% confidence interval [CI], -0.05 to -0.02) as well as subscale scores for Diabetes Symptoms (adjusted β=-0.02; 95% CI, -0.04 to -0.00) and Diabetes Management (adjusted β=-0.04; 95% CI, -0.05 to -0.02) were inversely associated with A1C. Health-related QOL Total scores were not associated with A1C, but Psychosocial Health subscale scores were (adjusted β=-0.01; 95% CI, -0.03 to -0.00).

CONCLUSION

Our results suggest that strategies focussing on diabetes-related QOL and psychosocial health may help prepare adolescents for the increasing responsibility of diabetes self-care.

Transition readiness of adolescents to adult health care

Background

Transition in health care is a process wherein adolescents gradually prepare for and shift towards care in the adult system. An initial assessment of the readiness of these adolescents is fundamental in providing appropriate health services for them. This paper aims to determine the readiness of adolescent patients towards transitioning to adult care.

Methods

This is a prospective cross-sectional study utilizing an interviewer-guided modified Transition Readiness Assessment Questionnaire (TRAQ). Sixty-three adolescents ages 15 to 18 years seen in the Pediatric Outpatient Department (OPD) of a tertiary hospital in Baguio City from July 1 to October 31, 2020 were enrolled. Frequency and percentages were used to describe the demographic data; while mean score and standard deviation determined readiness based on a Likert scale. One-way ANOVA was utilized to determine association between factors and readiness to transition.

Results

For all domains of TRAQ, the mean score was 3.64, implying that they are not yet ready to transition. 49.2% belong to General Pediatrics. 44.4% belong to the Igorot ethnic groups. Most are still in High school, and majority of their parents finished High School level. Furthermore, the P-values were more than 0.05 for all variables suggesting no association between readiness to transition and the identified factors in this study.

Discussion

This study showed that adolescents who had both acute and chronic illnesses, were not yet ready to transition. Provision of a platform for assisting the adolescents in their assumption of bigger roles/responsibilities for their own health care is necessary to ensure proper transitioning to adult health care.

Transition practice for primary immunodeficiency diseases in Southeast Asia: a regional survey

Introduction

With increased diagnostic capabilities and treatment modalities in the field of primary immunodeficiencies (PID), many pediatric patients survive beyond childhood and experience a change of care to the adult-oriented healthcare system. Unfortunately, the transition pathways for PID are less clearly defined, resulting in deterioration of quality of care in adulthood. Hence, this is the first regional study to address PID clinicians' opinions on practices and challenges of transition care in 7 Southeast Asia (SEA) countries.

Methods

We adopted a cross-sectional study design through an online survey platform to enquire opinions of transition practices from expert representatives in 7 SEA countries.

Results

Regionally, 3 out 7 countries reported having no practice of transition care. Among cited challenges were reluctant adaptation by patients and caregivers to unfamiliarized adult healthcare systems, inadequate ratio of adult immunologists to patients and lack of facilities for transfer.

Discussion and conclusion

Our study provides evidence to advocate policy makers on the importance of standardized integration of transition practice towards betterment of transiting PID patients into adulthood.

Transition of Care to Adult Neuroimmunology

A structured health care transition is essential for adolescents with chronic disease to ensure continuity of care without treatment lapse. Though rare, multiple sclerosis is diagnosed in children and adolescents and these patients will eventually require transition to adult care in late adolescence and early adulthood. Some barriers to transition include limited independence of the adolescent, fear of an unknown adult care model, and difficulty ending close relationships with longstanding pediatric providers. For optimal success, transition planning should be started in the early teenage years, and graduated independence and self-management skills should be fostered over time. Providers should also be aware of the developmental evolution of adolescents when assessing transition readiness and should screen for barriers during routine clinic visits to ensure that these are addressed prior to the time of transfer.

Barriers to a successful healthcare transition for individuals with urea cycle disorders

The pediatric to adult healthcare transition (HCT) is a process for individuals with chronic health conditions to gradually shift from a pediatric to an adult-oriented care system. Autonomy and self-management skills required for an individual's HCT readiness can be evaluated through the transition readiness assessment questionnaire (TRAQ). Despite general HCT preparation guidelines, little is known about the HCT experience of individuals with a urea cycle disorder (UCD). This is the first study to report the parent or guardian perception of the HCT process in children with a UCD by investigating the stages of transition readiness and transition outcome. We identify barriers to HCT readiness and planning, along with deficiencies in transition outcome for individuals with a UCD. For children that received special education services compared to those that did not, significantly lower transition readiness scores were identified in the total TRAQ score (p = 0.03) and in the domains of tracking health issues (p = 0.02), talking with providers (p = 0.03), and managing daily activities (p = 0.01). There was a lack of HCT preparation as most subjects did not have a HCT discussion with their healthcare provider before age 26. Deficiencies in HCT outcome are demonstrated by individuals with a UCD reporting delays in needed medical care and dissatisfaction with their healthcare services. Considerations for facilitating a successful HCT for individuals with a UCD include providing individualized education, appointing a transition coordinator, allowing flexibility in HCT timing, and ensuring that the individual recognizes concerning UCD symptoms and knows when to seek medical care.

Associations between peer experiences and health outcomes among adolescents and young adults with asthma

OBJECTIVE

Although peer relationships become increasingly important across adolescence and early adulthood, research examining links between peer relationships and the health outcomes of young people with asthma is scarce. Using a large sample of adolescents and young adults (AYAs) with asthma, the current study assessed whether positive and negative peer experiences are associated with AYAs' asthma control, asthma self-efficacy, and internalizing symptoms.

METHODS

In this cross-sectional study, a national sample of 440 diverse adolescents and young adults with asthma completed an online survey. Questionnaires assessed general and asthma-specific peer experiences (i.e. peer victimization; peer support; asthma-related peer problems) and health indicators (i.e. asthma control; asthma self-efficacy; internalizing symptoms). Regression analyses were performed to examine associations between peer experiences and health while controlling for participant age, gender, race/ethnicity, and age of asthma diagnosis.

RESULTS

Results from separate regression models indicated that adolescents who experienced greater peer victimization, less peer support, and more asthma-related peer problems also reported worse asthma control, lower asthma self-efficacy, and more severe internalizing symptoms. Follow-up exploratory analyses indicated that peer victimization and asthma-related peer problems were the strongest predictors of asthma control and internalizing, whereas peer support and asthma-related peer problems were the strongest predictors of asthma self-efficacy.

CONCLUSIONS

This study underscores connections between peer relationships and health outcomes among AYAs with asthma. Interventions that leverage peer support and mitigate peer stress may offer a developmentally appropriate approach for mitigating physical and psychological distress among adolescents and young adults with asthma.

Individualized Education Programs and Transition Planning for Adolescents With Autism

OBJECTIVES

The study objectives were to examine the contents of individualized education programs (IEPs) of adolescents with autism spectrum disorder (ASD), including postsecondary transition goals, services, and changes in special education classification over time.

METHODS

This study involved a longitudinal population-based surveillance cohort from the Autism Developmental Disabilities Monitoring Network from 2002 to 2018 in 3 catchment areas in the United States. The sample included 322 adolescents who were born in 2002, identified with ASD, and had an IEP available for review at ages 15-16 years.

RESULTS

We found that 297 (92%) adolescents with ASD had an IEP including a transition plan. Those without intellectual disability (ID) were more likely to have postsecondary education and employment goals and have those goals be to pursue higher education or competitive employment compared with those with ID. Forty-one percent of adolescents with ASD had a postsecondary living arrangement goal. Although 28% of adolescents with ASD received school-based mental health services, none of these adolescents were Black; additionally, 15% of those with ID received mental health services compared with 34% without ID. The percentage of adolescents with ASD served under an autism classification increased from 44% at age 8 years to 62% by age 16.

CONCLUSIONS

We identified gaps and disparities in school-based postsecondary transition planning. Working with education partners, families, and adolescents will be important to identify what challenges contribute to these findings and what supports are needed to improve the equity and quality of the transition planning process for adolescents with ASD so they are prepared for adulthood.

Depressive Symptoms, Cannabis Use, and Transition Readiness among College Students with and without Chronic Medical Conditions

Background: College students experience increased responsibility for healthcare transition. They are at increased risk for depressive symptoms and cannabis use (CU), potentially modifiable predictors of successful healthcare transition. This study investigated how depressive symptoms and CU related to transition readiness, and if CU moderated the association between depressive symptoms and transition readiness for college students. Methods: College students (N = 1,826, Mage=19.31, SD = 1.22) completed online measures of depressive symptoms, healthcare transition readiness, and past-year CU. Regression identified 1) the main effects of depressive symptoms and CU on transition readiness and 2) examined if CU moderated the relationship between depressive symptoms and transition readiness with chronic medical conditions (CMC) status as a covariate. Results: Higher depressive symptoms were correlated with past-year CU (r=.17, p<.001) and lower transition readiness (r=-0.16, p<.001). In the regression model, higher depressive symptoms were related to lower transition readiness (ß=-0.02, p<.001); CU was not related to transition readiness (ß=-0.10, p=.12). CU moderated the relationship between depressive symptoms and transition readiness (B=.01, p=.001). The negative relationship between depressive symptoms and transition readiness was stronger for those with no past-year CU (B=-0.02, p<.001) relative to those with a past-year CU (ß=-0.01, p<.001). Finally, having a CMC was related to CU and higher depressive symptoms and transition readiness. Conclusions: Findings highlighted that depressive symptoms may hinder transition readiness, supporting the need for screening and interventions among college students. The finding that the negative association between depressive symptoms and transition readiness was more pronounced among those with past-year CU was counterintuitive. Hypotheses and future directions are provided.