The transition of young adults with lifelong urological needs from pediatric to adult services: An international children's continence society position statement

Outcomes of a newly established transitional urology outpatient clinic: a real-world experience

PURPOSE

To evaluate the demographic and clinical characteristics of patients who visited our transitional urology (TU) outpatient clinic formed by pediatric urologists with urology background within the first year upon its establishment.

METHODS

Files of 130 consecutive patients who visited our TU outpatient clinic, which was established in 01 March 2021, between 01 March 2021 and 01 March 2022 were retrospectively collected. Patients were divided into two groups: those with a previous follow-up in our pediatric urology department (Group I, n: 81, 62.3%) and those who were followed up in other clinics during childhood (Group II, n: 49, 37.7%) afterwards. Demographic characteristics, complaints at admission, previous medical history, and management plans at the recent clinical visit were noted. We defined a successful and smooth transition from childhood to adult care as not being without follow-up within the first year after the age of 18 years and not requiring extraordinary medical assistance (e.g., emergency room visits, hospitalization, intensive care unit admissions) from the last urological control to the TU outpatient clinic visits.

RESULTS

The most common diagnoses were vesicoureteral reflux (n: 32, 24.6%), neuropathic bladder accompanied by spina bifida (n: 31, 23.8%), obstructive uropathy (n: 25, 19.2%), hypospadias (n: 20, 15.3%), non-neurogenic lower urinary tract dysfunction (n: 19, 14.6%), and bladder exstrophy (n: 8, 6.1%). The distribution of primary diagnosis in the two patient groups was similar. The median time from the last pediatric urology visit to the current TU clinical visit was significantly longer in Group II (12 vs. 60 months, p < 0.001),consequently, the median patient age at admission was significantly higher in Group II (21 vs. 23 years, p = 0.020). The rate of a successful and smooth transition was 86.4% in Group I, whereas Group II had a completely unsuccessful transition period. Upon admission to TU outpatient clinic, the requirement of a surgical intervention was lower in Group I (21% vs. 38.8%, p = 0.028).Also,the need for medical treatment changes was higher in Group II (9.9% vs. 53.1%, p < 0.001).

CONCLUSION

Our findings emphasize the importance of patient referral to a TU clinic that deal with lifelong problems of congenital genitourinary diseases. Delays in receiving medical or surgical treatments during transition from childhood to adulthood may be associated with higher need for subsequent surgical interventions in this vulnerable patient population.

Unmet needs in the management of neurourological disorders within the last 50 years

PURPOSE

This abstract aims to assess the evolution of neurogenic patient management over the past century, with a focus on persistent unmet needs in the field. We reflect on the history of neurourology and its key principles, highlighting urgent needs for research and progress.

METHODS

This review is based on a non-systematic search of MEDLINE databases. We explore the historical context, innovations, and challenges in neurological patient care, using keywords such as "Neurourology", "history" and "future", as well as specific treatment modalities.

RESULT

Several unmet needs in the field of neurourology have been identified. These include the need to strike a balance between spontaneous micturition and continence, the search for solutions to restore spontaneous micturition in patients with acontractile bladders, the imperative to improve and personalize renal and bladder function monitoring, mitigation of the side effects of long-term treatments, strategies to manage recurrent urinary tract infections, and efforts to overcome organizational barriers in patient care.

CONCLUSION

The care of neurological patients has made remarkable progress over the past 50 years. However, persistent unmet needs underline the need for ongoing research and collaboration to improve the quality of care in this field.

9-Year Evaluation of a Transitional Care Program for Congenital Neurogenic Bladder Patients

OBJECTIVE

To evaluate short and long-term adherence and nonadherence patterns within a staged transition clinic developed in 2014 to assist congenital neurogenic bladder patients transfer from pediatric to adult urologic care.

METHODS

We performed a retrospective chart review of all congenital neurogenic bladder patients who had been prospectively identified in the transition clinic and adult urology clinic since 2014. Demographic and clinical data were collected and analyzed to determine patient adherence with transfer of care, to study long-term compliance with follow-up, and to identify factors that positively and negatively influenced transition clinic success.

RESULTS

157 patients participated in the transition clinic. 76/79 (96.2%) patients ready to transition successfully transferred to adult care. 55/76 (72.4%) remain active. Greater number of visits between transition stages was significant among patients who maintained active follow-up after transition (P = .006). 171 patients initiated care in our adult urology clinic without transition. Irrespective of nontransitioned patients longer follow-up, formally transitioned adult patients had higher yearly participation rates, with 55 (72.4%) transitioned patients compared to 63 (36.8%) nontransitioned patients remaining active (P < .001).

CONCLUSION

Congenital neurogenic bladder patients who participated in a transition clinic were successful transferring from pediatric to adult care, with improved clinic adherence in adulthood, compared to patients who initiated adult care without structured transition. Early introduction to adult providers and increased number of visits positively impacted adherence upon transition to adult care. Noncompliance with pediatric provider visits negatively impacted transition adherence.

Pediatric Bowel Management Options and Organizational Aspects

A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.

Updates of Overactive Bladder in Pediatrics

Overactive bladder (OAB) is clinically defined as urinary urgency with or without urinary incontinence. It is associated with daytime frequency or constipation and has a prevalence of approximately 5%-12% among 5- to 10-year-olds. The appropriate functional exchange between the pontine micturition center, periaqueductal gray matter, and prefrontal cortex is important for proper micturition control. Several studies on pediatric cases observed a link between OAB and neuropsychiatric problems, such as anxiety, depression, and attention deficit, and treatment of these comorbidities improved patient symptoms. In this review, we present the pathophysiology of OAB, its associated conditions, and aspects related to updates in OAB treatment, and we propose a step-by-step treatment approach following this sequence: behavioral therapy, medical treatment, and invasive treatment. Although anticholinergic drugs are the mainstay of OAB medical treatment, beta-3 agonists and alpha-blockers are now recommended as a result of significant advancements in pharmacologic treatment in the last 10 years. Electrical stimulation techniques and botulinum toxin are also effective and can be used, especially in conventional treatment-refractory cases.

Pediatric Psychology in a Urology Division: Unifying Complex Medical and Mental Health Treatment

PURPOSE OF REVIEW

Although pediatric psychology is heavily involved in many medical divisions, its involvement in a urology division is still relatively new and its role continuously evolving and growing.

RECENT FINDINGS

This article reviews the limited research on the use of psychology in a urology division, including psychosocial struggles across urology diagnoses, dysfunctional voiding, and anxiety surrounding medical procedures and surgery. Urinary diagnoses and presenting problems seen by pediatric psychologists and medical providers at an urban children's hospital are also included. Based on the complex conditions and varied presenting concerns in a urology division, potential assessments and future research are suggested to help gather data for this population moving forward and expand the literature on urology psychology.

Nurses' and Doctors' Experiences of Transferring Adolescents or Young Adults With Long-Term Health Conditions From Pediatric to Adult Care: A Metasynthesis

The transfer of adolescents and young adults (AYA) with long-term health conditions from pediatric to adult care is a multidisciplinary enterprise where nurses and doctors play an important role. This review aimed to identify and synthesize evidence from qualitative primary reports on how nurses and doctors experience the transfer of AYA aged 13 to 24 years with long-term health conditions to an adult hospital setting. We systematically searched seven electronic databases for reports published between January 2005 and November 2021 and reporting nurses' and doctors' experiences. We meta-summarized data from 13 reports derived from 11 studies published worldwide. Using qualitative content analysis, we metasynthesized nurses' and doctors' experiences into the theme "being boosters." Boosting AYA's transfer was characterized by supporting AYA's and their parents' changing roles, smoothening AYA's transition from pediatric to adult care, and handling AYA's encounters with a different care culture.

Scoping review of neurogenic bladder patient-reported readiness and experience following care in a transitional urology clinic

OBJECTIVE

To generate a scoping review that summarizes thematically on all reported patient perceptions on readiness and experiences during transitional urologic care for patients with neurogenic bladder and or congenital genitourinary conditions that require continuity of care into adulthood.

METHODS

A systematic literature search was performed in October 2021. Records were screened and identified for studies relevant to reported readiness and experience in urologic transitional care among patients needing life-long urologic care. The methodological quality of the cross-sectional studies was assessed using AXIS. The included studies were clustered according to patient readiness in transition and patient experience-satisfaction in the urologic transition process. This scoping review was part of a systematic review registered on PROSPERO CRD42022306229 and was conducted in compliance with the PRISMA extension for scoping reviews.

RESULTS

A total of 12 articles were included that assessed patients with neurogenic bladder that reported either readiness or patient experience following the transitional care process. The patient readiness was assessed in six studies, determined using the TRAQ score with a range of 3-4/5. Older age, high health literacy, and parental or families' transition process awareness were associated with readiness. Generally, patients experience better satisfaction with pediatric care than with adult care facilities. Most patients felt that sexuality and fertility were not adequately tackled during the transition. The reported barriers to successful transition were patient, provider, and system factors, including lack of insurance coverage/financial management, patient preference, long-term bond with the pediatric providers, and communication by the adult provider. Based on AXIS, all of the studies identified for this scoping review did not determine the sample size, and most of the studies did not categorize the responders, which could introduce bias to the interpretation of their results.

CONCLUSION

This scoping review summarizes the readiness and experience of neurogenic bladder patients who underwent the urologic transitional process. Overall, understanding the patient, provider, and system factors associated with better readiness and enhancing the patient experience will ensure a better transition process.

Transition of Chronic Pediatric Nephrological Patients to Adult Care Excluding Patients on Renal Replacement Therapy with Literature Review

(1) Background: The transition of children with chronic kidney disease to adult care has become a well-handled issue. However, other patients with normal or mildly decreased renal function also requiring further management and transition are neglected. (2) Methods: A questionnaire was sent to patients with kidney pathology, aged 17 years and older.(3) Results: The patients were mostly high-school (55%) or college students (39%), living with their parents (94%). One third did not know how their disease affected their choice of profession and reproductive health. Furthermore, 46% of the respondents did not know who would continue with their care, and 44% still had a primary pediatrician. (4) Conclusions: A review of the literature on the topic was performed and summarized here. Regular education is the key for successful transfer, not only in chronic kidney and transplant patients, but also in others in whom a decline in renal function can be expected in the future.

Barriers in transitioning urologic patients from pediatric to adult care

As the advances in medicine continue to emerge, more children with congenital or pediatric-onset chronic urologic conditions are surviving well into adulthood. This imposes an ever rising there is a need for adequate transition of these patients from pediatric to adult care. Despite position statements from multiple heath care organizations and several models proposed in literature, different issues and gaps in urologic transition continue to exist. Major barriers in this transition are adolescence, a challenging time that is characterized by impulsive behavior and risk taking, and the longstanding relation between both patients and paediatric providers. Both pediatric and adult care providers need to be aware of the special needs of maturing youth with chronic care problems related to education, self-management, legal issues and psychological support during care transition. Furthermore, they need to understand and address the currently existing obstacles for adequate transition. There is need for active communication with each other and the patient to develop sustainable relationships that can support the transitioning process. It is therefore in the greatest interest of the care provider to make this transition as smooth as possible. This paper aims to point out the currently perceived barriers in care transition within the urological context, reflect on previous implemented models for care transition and present proposals for improvement.

The need for specialized training for adults with congenital urologic conditions: differences in opinion among specialties

Introduction

The aim of this study was to survey pediatric urology fellowship directors (PFD) and adult reconstruction fellowship directors (AFD) to assess who they believe has sufficient training to care for adults with congenital urologic conditions (ACUC).

Material and methods

An online survey was created to assess attitudes towards specific training to care for ACUC. The survey was administered to 27 PFD and 26 AFD [16 from genitourinary reconstructive surgery (GURS) and 10 from female pelvic medicine and reconstructive surgery (FPMRS)]. Both groups were asked if specific training is warranted, and if general urologists, pediatric urologists or adult reconstructive urologists were sufficiently trained to care for ACUC.

Results

A total of 26 (96%) PFD and 10 (39%) AFD completed the survey. All PFD were fellowship trained in pediatrics. Of the AFD, 5 were GURS trained, 4 were FPMRS trained and 1 was not fellowship trained. The majority (65% PFD, 90% AFD) believed specific training is warranted. Few believed general urologists have sufficient training (8% PFD, 20% AFD). Most PFD believed pediatric urologists have sufficient training (85%), but a minority believed those with adult reconstructive training do (40%). Conversely, a minority of AFD believed that pediatric urologists have sufficient training (40%), while those with adult reconstructive training do (FPMRS: 67%, GURS: 60%).

Conclusions

Both pediatric and adult reconstructive urologists believe specific training to care for adults with congenital urologic conditions is warranted. Neither group considers the other to be ideally suited to care for this complex patient group. This suggests both groups may have something to learn from each other.

Long-term sexual outcomes in patients with exstrophy-epispadias complex

Exstrophy-epispadias complex (EEC) is a spectrum of genitourinary malformations that ranges in severity and affects external genitalia and the lower urinary tract. The aim of this study was to determine the long-term sexual outcomes of patients with EEC. Sexual outcomes were hypothesized to be related to those of urinary ones. A retrospective database including all patients with EEC who had surgery at a tertiary referral institution from 1990 to 2019 was created. Data based on patient's charts were collected: demographics, surgeries, sexual outcomes, urinary outcomes. Fifty-eight patients with EEC had surgery at tertiary referral institution and entered our database. For this analysis of sexual outcomes, a sub-set of the whole population was selected: patients being 14 years old and older, having at least one surgery at our institution and having at least 12 months of follow-up. Applying this selection criteria to our database resulted in a series of 29 patients. High rates of sexual activity were observed in pubertal and post-pubertal men (96%) and women (75%). Seventy-nine percent of men and 67% of women reported sexual satisfaction; 63% of men reported normal ejaculation. To achieve these rates, 96% of men required surgery (84% penoplasty, 52% phalloplasty), and 25% of women required introitoplasty. Fertility was achieved in 67% of men and 100% of women. Assisted reproductive technology was needed in one man. Continence rates were high (diurnal continence in 83% and nocturnal continence in 93%). However, 76% required multiple continence procedures. Men and women with EEC can have good long-term sexual and urinary outcomes, but this may require multiple surgeries. Good sexual outcomes seem to be related to good urinary and continence outcome.

The basics of transition in congenital lifelong urology

PURPOSE

Transition in urology is defined by the process that allows an adolescent or a young adult with a congenital or acquired urogenital anomaly to assume increasing responsibility for their own health care and to become the primary decision maker in their care.

METHODS

A review of the literature regarding transitional care for lifelong urologic congenital anomalies was performed with the aim of reporting expert opinion when data are non-existent. This review focuses on special considerations for adolescents and young adults with spina bifida, bladder exstrophy, anorectal malformations and differences of sexual development.

RESULTS

Urologic goals during the transition from childhood to adulthood continue to include attention to the preservation of renal function and optimization of lower urinary tract function. Additional concerns include care to decrease long-term surgical complications (especially after augmentation cystoplasty), to monitor for malignancy, to prepare for sex activity and fertility, and to help the adult patient in decision making. Transition aims to maximize quality of life and independence by ensuring uninterrupted appropriate care through a multidisciplinary approach which varies by geographical location and healthcare setting. Barriers include patient and family factors as well as provider and system related factors. A dedicated team is an important element of successful transition.

Factors impacting transition readiness in young adults with neuropathic bladder

INTRODUCTION

Patients with spina bifida (SB) often have cognitive impairments making the difficult transition process to adult care even more challenging.

OBJECTIVE

The objective of this study was to identify what patient factors impact transition readiness in this population. It is hypothesized that young adults with SB with more healthcare exposure were more likely to report readiness to transition.

METHODS

Consecutive patients ≥18 years old in the adult SB clinic were evaluated using the validated Transition Readiness Assessment Questionnaire (TRAQ, 8/17-5/18). Five TRAQ domains assess 20 skills necessary to transition. Responses are 1 No, I do not know how"; 2 No, but I want to learn"; 3 No, but I am learning how to do this"; 4 Yes, I have started doing this"; 5 Yes, I always do this when I need to" (considered "fully transitioned"). Demographics, ambulatory status, shunt status, shunt revisions, number of medications, and prior bladder augmentation were assessed. Domain and total TRAQ scores were analyzed using non-parametric statistics and linear regression.

RESULTS

Ninety-six patients (60.4% females, 70.8% shunted) participated at median age 25.5 years. Overall median TRAQ score was 4.0/5.0, indicating that patients were starting to transition. On univariate analysis, age >25 years was associated with higher TRAQ scores across every domain and overall (P ≤ 0.01). Female gender was also associated with higher TRAQ scores for "Appointment Keeping," "Tracking Health Issues" and overall (P ≤ 0.03). Race, ambulatory status, shunt status, number of shunt revisions, number of medications, and prior bladder augmentation were not associated with TRAQ scores (P ≥ 0.12). After adjusting for gender on bivariate analysis, age >25 years was associated with higher TRAQ scores for "Appointment Keeping," "Tracking Health Issues," "Talking with Providers," and "Managing Daily Activities" domains and overall (P ≤ 0.03), but not the "Managing Medications" domain (P = 0.07). Female gender was not independently associated with higher domain or overall TRAQ scores (P≥0.10).

DISCUSSION

The transition readiness of young adults with SB compared based on demographic factors and factors increasing healthcare exposure is described. Limitations include the small sample size, potentially limiting generalizability, as well as cross-sectional nature.

CONCLUSION

Transitioning adults with SB had TRAQ scores indicating that they were not yet fully transitioned in terms of their healthcare-related behavior. Older age was the only factor associated with transition readiness, which was not impacted by other demographics. Increased attention to transition readiness and consideration of a longer transition process in this population is necessary.

Transitioning young adults with neurogenic bladder-Are providers asking too much?

INTRODUCTION

Significant numbers of young adults with chronic health conditions fail to transition.

OBJECTIVE

The aim of the study was to evaluate how ready transitioned urologic patients were for that process. Owing to the cognitive impairments frequently seen with spina bifida (SB), it is hypothesized that these individuals will be less prepared to transition their medical care to adult providers compared with their healthy counterparts.

METHODS

Participants included consecutive patients in the transitional SB clinic at the study institution and controls (college students without obvious physical disability or interest in healthcare-related fields aged 18-25 years). Both groups were administered the Transition Readiness Assessment Questionnaire (TRAQ) over a nine-month period. Five TRAQ domains assess 20 skills necessary to transition. Likert scale responses range from 1 "no, I do not know how" to 5 "yes, I always do this when I need to" (which the authors considered appropriate for transitioned patients). Demographics and the number of daily medications taken were collected. Patients and healthy controls were compared using (1) total and domain TRAQ scores, (2) the proportion of non-transitioned skills ("1"), and (3) fully transitioned skills ("5"). Non-parametric statistics were used.

RESULTS

Forty-three unique SB patients (30.8% shunted, 46.5% female) and 100 controls were enrolled. Patients with SB were older than controls (21 vs 20 years, p < 0.001). There was no gender difference between groups (p = 0.33). Transitioned patients and college students were fully transitioned only in the "Talking with Providers" domain (Figure). College students performed significantly better than patients in the domains of "Appointment Keeping" (p = 0.04) and "Tracking Health Issues" (p = 0.02). Transitioned patients were less likely to be interested in learning how to perform skills in the domains of "Appointment Keeping" and "Tracking Health Issues" (p < 0.001 for both domains).

DISCUSSION

The transition readiness of young adults with SB compared to healthy controls and other youths with chronic health conditions is described. The limitations include the small sample size, potentially limiting generalizability, and cross-sectional nature.

CONCLUSION

"Transitioned" patients with SB had lower TRAQ scores in some domains compared to healthy college students, who themselves had scores indicating that they were not fully ready for transition. Increased attention to transition readiness in people with SB is necessary, as even healthy young adults struggle with these tasks and are poorly prepared for transition.

Lifelong Congenital Urology: The Challenges for Patients and Surgeons

CONTEXT

Patients born with complex congenital genitourinary anomalies (including bladder exstrophy, cloacal exstrophy, epispadias, neurogenic bladder, hypospadias and posterior urethral valves) often require major reconstructive surgery in childhood. These conditions, their treatment and sequelae require lifelong follow-up. This has created the need for adult urologists to provide care as these patients grow into adults.

OBJECTIVE

To evaluate current strategies for transition and provide a current position statement with examples of the challenges faced by patients and their health care teams as a result of these conditions and their treatment.

EVIDENCE ACQUISITION

Each of the authors was asked to provide a 500-word synthesis, based on current literature; to highlight the challenges faced in an area of their expertise.

EVIDENCE SYNTHESIS

The authors assembled in March 2018 to form a consensus based on the data gathered. The aforementioned sections were reviewed and following the consensus discussion the paper was formulated and reviewed.

CONCLUSIONS

Lifelong care of congenital problems is challenging and essential for many but not all. Expertise is needed to provide the best care for patients and make the best use of resources. Specialist centres appear to be the most effective and safe model. In the long term it would be ideal to establish an evidence base focused on the common long-term problems with these conditions to ensure excellent care with appropriate expertise.

PATIENT SUMMARY

Patients born with complex congenital anomalies of the genitourinary system require specialist care in childhood. Many will need lifelong care to manage their condition and the treatment of it. There is growing interest in this area of medicine and this consensus statement addresses the need for lifelong care in this group. The aim is to ensure that all patients that need care at any age are able to find what they need.

Transitions in care from pediatric to adult general surgery: Evaluating an unmet need for patients with anorectal malformation and Hirschsprung disease

BACKGROUND

The provision of timely and comprehensive transition of care from pediatric to adult surgical providers for patients who have undergone childhood operations remains a challenge. Understanding the barriers to transition from a patient and family perspective may improve this process.

METHODS

A cross-sectional survey was conducted of patients with a history of anorectal malformation (ARM) or Hirschsprung Disease (HD) and their families. The web-based survey was administered through two support groups dedicated to the needs of individuals born with these congenital abnormalities. Categorical variables were compared using Chi-squared and Fisher's exact test with Student's t test and ANOVA for continuous variables.

RESULTS

A total of 118 surveys were completed (approximately 26.2% response). The average age of patients at time of survey was 12.3years (SD 11.6) with 64.5% less than 15years old. The primary diagnosis was reported for 78.8% patients and included HD (29.0%), ARM (61.3%), and cloaca (9.7%). The average distance traveled for ongoing care was 186.6miles (SD 278.3) with 40.9% of patients traveling ≥30miles; the distance was statistically significantly greater for patients with ARM (p<0.001). With regards to ongoing symptoms, 44.1% experience constipation, 40.9% experience diarrhea, and approximately 40.9% require chronic medication for management of bowel symptoms; only 3 respondents (3.2%) reported fecal incontinence. The majority of patients, 52.7% reported being seen by a provider at least twice per year and the majority continued to be followed by a pediatric provider, consistent with the majority of the cohort being less than 18years of age. Conversations with providers regarding transitioning to an adult physician had occurred in fewer than 13% of patients. The most commonly cited barrier to transition was the perception that adult providers would be ill-equipped to manage the persistent bowel symptoms.

CONCLUSION

Patients undergoing childhood procedures for ARM or HD have a high prevalence of ongoing symptoms related to bowel function but very few have had conversations regarding transitions in care. Early implementation of transitional care plans and engagement of adult providers are imperative to transitions and may confer long-term health benefits in this patient population.

LEVEL OF EVIDENCE

Level IV, case series with no comparison group.

Caring for urologic transition patients: Current practice patterns and opinions

INTRODUCTION

Congenitalism is an emerging field that recognizes the complex needs of adult patients with congenital urologic issues. Despite the onset of transitional care clinics, these patients remain difficult to care for due to resource availability, insurance coverage, and multi-disciplinary needs.

OBJECTIVE

The current study sought to characterize practice patterns and opinions regarding care for urologic transition patients.

DESIGN

An anonymous 20-question survey was sent to members of the Society of Pediatric Urology listserv. Questions pertained to physician background, practice demographics, clinic structure, and quality. Five-point Likert scales were used to assess quality markers (5 = most/best). Data were analyzed in R, and subgroup analyses were performed. Subgroups included presence of formal transition clinic, city size, and practice type.

RESULTS

The response rate was 53%, with 124 respondents. A formal transition clinic was reported by 32%. Those with formal clinics reported higher enthusiasm (3.9 vs 3.4, P < 0.01) for care of these patients and believed they provided better care compared to other institutions (P < 0.001) Summart Table. There was no significant difference in perceived quality between respondents in academic vs other practices. There was a small trend towards higher-quality ratings in smaller cities (3.8 vs 3.5, P = 0.13). The majority (64%) felt that transition patients are best cared for by specialized adult providers; however, these formalized clinics found to be staffed primarily by pediatric providers (54%).

DISCUSSION

This study supported the general consensus in the literature that transition clinics improve care for urologic transition patients, while underlining discordance between current practice patterns and recommendations for optimal care.

CONCLUSION

The majority of practices appeared to lack a formal transition clinic, and there was variation in their structure. Those with formal clinics tended to rate themselves as providing higher-quality care. The majority of respondents believed that adult specialists in either reconstructive or neuro-urology are best suited to care for these complex patients.

Challenges in Transition of Care for Patients With Anorectal Malformations: A Systematic Review and Recommendations for Comprehensive Care

BACKGROUND

Anorectal malformations are one of the most common congenital intestinal anomalies affecting newborns. Despite advances in neonatal care and surgical techniques, many patients with a history of anorectal malformations are affected by long-term challenges involving bowel and bladder dysfunction, sexual dysfunction, and psychosocial issues. These outcomes or challenges are additionally exacerbated by the lack of a structured transition of care from the pediatric to the adult setting.

OBJECTIVE

The purpose of this review is to describe the long-term outcomes affecting patients with a history of anorectal malformations, review the current literature on transition of care, and make recommendations for developing a standardized program for transitioning care for a select group of colorectal surgical patients.

DATA SOURCES

An extensive PubMed review of articles in English was performed to evaluate current best practices for chronic illnesses of childhood with residual symptoms or need for medical care into adulthood.

STUDY SELECTION

Meta-Analysis of Observational Studies in Epidemiology group guidelines were followed.

MAIN OUTCOME MEASURES

The primary outcome for this review was the existence of transitional services for patients with a history of anorectal malformations and evaluations of long-term outcomes affecting patients with a history of anorectal malformations.

RESULTS

Systematic review revealed improved results in transition programs as determined by patient follow-up, medication adherence, and patient and family satisfaction through the use of multidisciplinary teams. Standardized tools for assessing all aspects of patient outcomes and quality of life are essential for describing the burden of disease affecting a transitioning population.

LIMITATIONS

This is a retrospective review of the current status of a complex and rapidly evolving field of delivery of care. More work is needed to apply uniform approaches and assess the impact, patient outcomes, and quality of life.

CONCLUSIONS

Patients who undergo childhood procedures for anorectal malformations often experience chronic symptoms related to the bowel, bladder, and reproductive organs, as well as psychosocial disturbances. This population will benefit from appropriate engagement in transitional care plans. See Video Abstract at http://links.lww.com/DCR/A543.

Age trends in 30 day hospital readmissions: US national retrospective analysis

OBJECTIVE

To assess trends in and risk factors for readmission to hospital across the age continuum.

DESIGN

Retrospective analysis.

SETTING AND PARTICIPANTS

31 729 762 index hospital admissions for all conditions in 2013 from the US Agency for Healthcare Research and Quality Nationwide Readmissions Database.

MAIN OUTCOME MEASURE

30 day, all cause, unplanned hospital readmissions. Odds of readmission were compared by patients' age in one year epochs with logistic regression, accounting for sex, payer, length of stay, discharge disposition, number of chronic conditions, reason for and severity of admission, and data clustering by hospital. The middle (45 years) of the age range (0-90+ years) was selected as the age reference group.

RESULTS

The 30 day unplanned readmission rate following all US index admissions was 11.6% (n=3 678 018). Referenced by patients aged 45 years, the adjusted odds ratio for readmission increased between ages 16 and 20 years (from 0.70 (95% confidence interval 0.68 to 0.71) to 1.04 (1.02 to 1.06)), remained elevated between ages 21 and 44 years (range 1.02 (1.00 to 1.03) to 1.12 (1.10 to 1.14)), steadily decreased between ages 46 and 64 years (range 1.02 (1.00 to 1.04) to 0.91 (0.90 to 0.93)), and decreased abruptly at age 65 years (0.78 (0.77 to 0.79)), after which the odds remained relatively constant with advancing age. Across all ages, multiple chronic conditions were associated with the highest adjusted odds of readmission (for example, 3.67 (3.64 to 3.69) for six or more versus no chronic conditions). Among children, young adults, and middle aged adults, mental health was one of the most common reasons for index admissions that had high adjusted readmission rates (≥75th centile).

CONCLUSIONS

The likelihood of readmission was elevated for children transitioning to adulthood, children and younger adults with mental health disorders, and patients of all ages with multiple chronic conditions. Further attention to the measurement and causes of readmission and opportunities for its reduction in these groups is warranted.