Passing the baton: The pediatric surgical perspective on transition

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.

Transition From Pediatric to Adult Healthcare for Colorectal Conditions: A Systematic Review

BACKGROUND

Despite surgical advances for complex congenital colorectal conditions, such as anorectal malformation (ARM) and Hirschsprung disease (HD), many adolescents require transfer from specialist pediatric to adult providers for ongoing care.

METHODOLOGY

A systematic review of PubMed, MEDLINE and Embase was conducted to identify what is known about the transitional care of patients with ARM and HD (PROSPERO # CRD42022281558). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework guided our reporting of studies that focused on the transition care of 10-30-year-olds with ARM and HD.

RESULTS

Eight studies were identified that included patient and parent (n = 188), and/or clinician perspectives (n = 334). Patients and clinicians agreed that transitional care should commence early in adolescence to support transfer to adult care when a suitable level of maturation is reached. There was little evidence from patients that transfer happened in a timely or coordinated manner. Patients felt that clinicians did not always understand the significance of transfer to adult services. No models of transition care were identified. Surgeons ranked ARM and HD as the most common conditions to experience delayed transfer to adult care. Beyond pediatric surgeons, patients also highlighted the importance of general practitioners, transitional care coordinators and peer support groups for successful transition.

CONCLUSIONS

There is little research focused on transitional care for patients with ARM and HD. Given evidence of delayed transfer and poor experiences, the development of models of transitional care appears essential.

A Survey on Enhanced Recovery After Surgery (ERAS) Elements in Cleft Palate Repair

This study aims to characterize current use, knowledge, and attitude toward ERAS protocols by academic craniofacial surgeons.

Craniofacial surgeons were provided with electronic surveys.

Electronic survey; Institutional tertiary surgeons.

102 cleft palate surgeons surveyed and 31 completed the survey (30.4%).

None.

Respondents rated their knowledge, use, and willingness to implement perioperative interventions modeled after adult ERAS protocols.

Majority (67.7%) rated they were knowledgeable about ERAS. However, 61.3% "never use" a standardized protocol for cleft palate surgery. Only 3 ERAS elements are currently implemented by a majority of cleft surgeons: avoiding prolonged perioperative fasting (67.7%), using hypothermia prevention measures (74.2%), and minimizing use of opioids (62.5%). A large majority of respondents noted they never administer bolus (71.0%) or infusion (80.6%) dosing of tranexamic acid; most of these surgeons also indicated that administering tranexamic acid "would not be a valuable addition" (67.7% and 71.0%, respectively). Short-acting sedatives are used by 12.9% and by 16.1% of surgeons in all patients during extubation and postoperative recovery, respectively. By contrast, 22.6% never use such agents during extubation and 48.4% never use it during postoperative recovery. Overall, 67.7% of respondents replied that they would be willing to implement an ERAS protocol for cleft palate repair.

Many respondents report using interventions compatible with an ERAS approach and the majority are willing to implement an ERAS protocol for cleft palate repair.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Difficulties in Transition of Care from Pediatric to Adult Gynecology Providers: Should We Maintain Care into Adulthood?

There is evidence that transfer of care for older adolescent patients to adult care is associated with a deterioration in health, especially in those with chronic conditions. Because several specific conditions in pediatric and adolescent gynecology continue into adulthood, it is important that patients have a seamless healthcare transition. In this commentary, it is argued that instead of arranging transfer, long-term retention of patients by the same physician or physician team may be the more caring, patient-centered approach.

Transition of Care in Paediatric Surgery: Current practices and perspectives of paediatric surgeons in Malaysia

Objectives

Transition of care (TOC) from paediatric to adult care is still at an early stage in Malaysia. This study aimed to explore current practices and perspectives regarding TOC among paediatric surgeons in Malaysia.

Methods

This study was carried out between June and December 2017. All 48 paediatric surgeons currently working in Malaysia were invited to participate in a questionnaire-based survey to assess demographic characteristics and practices and perspectives regarding TOC.

Results

A total of 38 paediatric surgeons participated in the survey (response rate: 79.2%). Overall, 97.4% did not have an organised TOC model in their institution, with most (65.8%) caring for paediatric patients with complex surgical conditions until adulthood. Although the majority (86.8%) felt that care should be transitioned to adult surgeons with appropriate credentials, most surgeons (84.2%) nevertheless preferred to be involved in the management of adolescent patients after transition. However, there was no consensus regarding the most suitable age to begin the transition. Years of experience as a paediatric surgeon and place of practice did not affect overall TOC practice scores (P >0.050 each). The presence of adult comorbidities was considered the most common reason to initiate TOC (81.6%), while the lack of TOC guidelines was perceived to be the greatest barrier (84.2%).

Conclusion

This study provides a better understanding of TOC from the point of view of paediatric surgeons in Malaysia. However, further studies involving other stakeholders (i.e. patients and adult surgeons) are needed to help formulate a suitable and successful TOC model in this setting.

Systematic review of study designs and methods in health transition research for young people with intellectual disabilities

Background

Transition for young people with intellectual disabilities from paediatric or adolescent services into adult health care services remains a difficult process for all stakeholders. The study assessed the type of interventions, the methodological approaches, study designs and location of existing published evidence in health care transitions.

Methods

A systematic review utilising the PRISMA protocol with an amended quality appraisal tool to explore the nature of published evidence on health care transitions for young people.

Results

Findings demonstrate that health transition research for this population lacks a robust evidence base and researchers favour exploratory studies investigating the experiential dimension of transition. The lack of involvement of young people in the studies indicates a problematic absence of genuinely participatory research.

Conclusion

The study is the first systematic review of empirical studies in health transition of young people with intellectual disabilities exploring the nature of existing evidence. The results will support setting priorities for future research.

Transition of patients with mucopolysaccharidosis from paediatric to adult care

Mucopolysaccharidoses (MPS) are rare disorders associated with enzyme deficiencies, resulting in glycosaminoglycan (GAG) accumulation in multiple organ systems. As patients increasingly survive to adulthood, the need for a smooth transition into adult care is essential. Using case studies, we outline strategies and highlight the challenges of transition, illustrating practical solutions that may be used to optimise the transition process for patients with MPS disorders.

Seven MPS case studies were provided by four European inherited metabolic disease centres; six of these patients transferred to an adult care setting and the final patient remained under paediatric care. Of the patients who transferred, age at the start of transition ranged between 14 and 18 years (age at transfer ranged from 16 to 19 years).

While there were some shared features of transition strategies, they varied in duration, the healthcare professionals involved and the management of adult patients with MPS. Challenges included complex symptoms, patients' unwillingness to attend appointments with unfamiliar team members and attachment to paediatricians. Challenges were resolved by starting transition at an early age, educating patients and families, and providing regular communication with and reassurance to the patient and family. Sufficient time should be provided to allow patients to understand their responsibilities in the adult care setting while feeling assured of continued support from healthcare professionals. The involvement of a coordinated multidisciplinary team with expertise in MPS is also key. Overall, transition strategies must be comprehensive and individualised to patients' needs.

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

Risk and vulnerability encompass many dimensions of the transition from adolescence to adulthood. Transition from pediatric, parent-supervised health care to more independent, patient-centered adult health care is no exception. The tenets and algorithm of the original 2011 clinical report, "Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home," are unchanged. This updated clinical report provides more practice-based quality improvement guidance on key elements of transition planning, transfer, and integration into adult care for all youth and young adults. It also includes new and updated sections on definition and guiding principles, the status of health care transition preparation among youth, barriers, outcome evidence, recommended health care transition processes and implementation strategies using quality improvement methods, special populations, education and training in pediatric onset conditions, and payment options. The clinical report also includes new recommendations pertaining to infrastructure, education and training, payment, and research.

Reality check: What happens when patients with anorectal malformations grow up? A pilot study of medical care transition from the adult patient perspective

BACKGROUND

There has been an increased focus on transition of pediatric and adolescent patients to adult centered care. For patients with rare and complex conditions, such as anorectal malformations (ARM), difficulties are compounded by the absence of structured transition protocols and lack of adult provider expertise. We sought to explore the actual experiences of adult patients with ARM and distinguish if there are factors that influence the ability to achieve satisfactory transition to adult centered medical care.

METHODS

Patients older than 18years with ARM were identified through a hospital database and social support networks, and invited to participate in an anonymous questionnaire. Patients were asked to describe their transition experience as well as report their demographics, and functional outcomes (bowel and bladder function).

RESULTS

Twenty-six surveys were completed. Comparison of those respondents (53%) who had transitioned to adult providers to those that had not yet transferred care demonstrated no difference in satisfaction with bowel and bladder function, presence of ostomy, and education level. There was a slight trend for patients with more complex malformations to seek further medical care with adult providers. Of those who transitioned, 67% reported no discussion prior to their transition and 71% received no recommendations for follow-up providers.

CONCLUSIONS

This pilot project suggests that a significant number of adult patients with ARM lack transition preparation and fail to find adult providers with expertise. Future studies will need to find optimal ways to address these issues.

TYPE OF STUDY

Survey. Retrospective Study LEVELS OF EVIDENCE: Level II.

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.

A survey of pediatric surgeons' practices with enhanced recovery after children's surgery

PURPOSE

Enhanced Recovery After Surgery (ERAS) protocols have been shown to improve outcomes in adult abdominal surgical populations. Our purpose was to survey pediatric surgeons' opinions regarding applicability of individual ERAS elements to children's surgery.

METHODS

A survey of the American Pediatric Surgical Association was conducted electronically. Using a 5-point Likert scale, respondents rated their willingness to implement 21 adult ERAS elements in an adolescent undergoing elective colorectal surgery.

RESULTS

Of an estimated 1052 members, 257 completed the survey (24%). The majority of the respondents (n=175, 68.4%) rated their familiarity with ERAS as "moderately", "very", or "extremely familiar". However only 19.2% (n=49) replied that they were "already implementing" an ERAS protocol in their practice. Most respondents replied that they were "already doing" or "definitely willing" to implement 14 of the 21 (67%) ERAS elements. For the remaining 7 elements, >10% of surgeons answered that they were only "somewhat willing" to, "uncertain" about or "unwilling" to implement these interventions.

CONCLUSIONS

Most respondents were willing to implement the majority of adult ERAS concepts in children undergoing abdominal surgery. However, we identified 7 elements that remain contentious. Further investigation regarding the safety and feasibility of these elements is warranted before applying them to children's surgery.

LEVEL OF EVIDENCE

Level V.

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.

Transition of care in patients with anorectal malformations: Consensus by the ARM-net consortium

OBJECTIVES

To develop the first consensus to standardize the management of patients with Anorectal Malformations (ARMs) transitioning from childhood to adulthood.

METHODS

A dedicated task force of experts performed an extensive literature review and multiple meetings to define the most important aspects of transition of care. The findings were discussed with all ARM-net consortium members and a set of practical recommendations agreed upon at the annual meeting in 2016.

RESULT

We defined seven domains that are essential to provide an effective and practical transition process. Within each domain we have developed a set of key recommendations that are important to be considered for ARM patients entering the age of transition.

CONCLUSIONS

It is crucial that transition begins at an early age with regular and well-structured follow-up. Cooperation with a selected multidisciplinary team of pediatric and adult practitioners is required to prepare patients and families for effective transition to adult care and to reduce long term morbidity.

TYPE OF STUDY

Review/Consensus paper.

LEVEL OF EVIDENCE

III.

Transitions in Pediatric Gastroenterology: Results of a National Provider Survey

OBJECTIVES

Transition and transfer to adult-oriented health care is an important yet challenging task for adolescents and young adults with chronic medical conditions. Transition practices vary widely, but a paucity of data makes determination of best practices difficult. We described North American pediatric gastroenterologists' preferences and present transition practice patterns and explored whether experience affected providers' perspectives.

METHODS

An online survey was distributed via e-mail to members of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition. Participation was voluntary and answers were anonymous. Quantitative and qualitative analysis was performed.

RESULTS

Almost three quarters of the 175 respondents describe providing transition or self-care management education, but only 23% use structured readiness assessments. Most respondents (88%) report having age cutoffs above which they no longer accept new referrals, with the most common age being 18 years (57%). One third report the ability to provide age-appropriate care to patients older than 21 years. Only 6% indicate that their practice or institution should provide care for individuals older than 25 years. Many (63%) indicate that their practice or institution has a policy regarding age of transfer, but most (79%) are flexible. Provider preferences for triggers to transfer to adult care diverge widely between age, milestones, and comorbidities. Overall, parent (81%) and patient (74%) attachment to pediatric health care providers are cited as the most common barriers to transition.

CONCLUSIONS

Preferences and practices surrounding transition preparation and transfer to adult care vary widely, reflecting continued uncertainty regarding optimal transition strategies.

Pediatric Orthopaedic Providers' Views on Transition From Pediatric to Adult Care

BACKGROUND

Surgical specialties are underrepresented in the discussions regarding transition and transfer of patients to adult care. We sought the pediatric orthopaedic perspective on types of patients seen into adulthood, age cut-offs, triggers for transfer, and barriers to transition. We examined provider demographic factors that may influence perspectives.

METHODS

An internet-based survey was sent to all members of the Pediatric Orthopaedic Society of North America and the Pediatric Orthopaedic Practitioner Society. Responses were voluntary and anonymous.

RESULTS

Response rates were 27% for the Pediatric Orthopaedic Society of North America and 24% for the Pediatric Orthopaedic Practitioner Society. Most respondents (70%) care for patients over the age of 25 years and many (35%) for patients over the age of 40. The most common conditions cared for were neuromuscular and congenital disorders. Respondents who worked in a fully salaried model reported caring for fewer of these adult patients compared with those working in other types of payment structure (P<0.001). Respondents working in free-standing children's hospitals reported fewer patients over 30 years old compared with nonchildren's hospital settings (P<0.001). There were no significant differences between profit-based and nonprofit settings. The top triggers for transfer to adult providers were: (1) adult comorbidities; (2) transition to medical specialist; and (3) institutional policy. The top barriers to transfer were: (1) lack of qualified adult providers; (2) institutional policy; and (3) on-going surgical issues.

CONCLUSIONS

Many providers care for older patients, often using external triggers for transfer to adult care. Financial considerations may need to be further explored. Variation in care may be aided by national society guidelines.

LEVEL OF EVIDENCE

Level III-survey research.

Long term follow-up and transition of care in anorectal malformations: An international survey

BACKGROUND

The aim of the study was to assess current international practice in the long term follow-up, in managing active problems and transition of care for teenagers born with anorectal malformations (ARM).

METHODS

An original survey was administered to delegates attending two large colorectal surgical meetings in 2015. The 21 questions covered long term follow-up, specific issues for teenagers and transition of care.

RESULTS

96/236 delegates completed the survey. Follow-up was routinely suspended before 10 year of age by 33% of respondents. 90% of them did not use a scoring system to assess or risks stratify patients, despite 81% stating that an objective score would be beneficial. 40% of respondents felt that >30% of their teenagers had ongoing active medical or psychosocial issues. 42% thought their patients were not ready to be transitioned. The process of transition should start around 13-16 years according to 54% of respondents. 72% had no protocol for transition and 82% did not hold multidisciplinary meetings with adult practitioners before transition.

CONCLUSIONS

International consensus on the following aspects of the care in ARM is needed: structured long term follow-up, objective assessment and risk stratification scores, pathways of transition and methods to prepare patients, parents and adult practitioners.

Transitional care and paediatric surgery

Merits urgent attention