Health Care System Factors Associated with Transition Preparation in Youth with Special Health Care Needs

Transition of care readiness among adolescents with chronic pain between 2021-2022 in a Nationally representative sample

Chronic pain impacts 11-33% of children and will continue into adulthood for over half of them. Transition of pain management to adult care is crucial given high risk of interruption of care which is associated with subsequent poor medical, social, and vocational outcomes. Yet the transition experience for these youth is poorly characterized. Using a sample from the 2021 and 2022 National Survey of Children's Health (conducted by parent report), we aimed to determine the prevalence of transition readiness among adolescents with chronic pain in the U.S. and estimate the association of readiness with biopsychosocial-cultural and health system characteristics. Of the 2584 adolescents aged 14-17 with chronic pain, 23.9% of adolescents met criteria for transition readiness. Using Poisson regression, we determined those more likely to meet criteria were older (PR 1.8 95%CI: 1.3, 2.6), female (PR 1.6 95% CI: 1.2, 2.2), White (Asian PR 0.4, 95% CI: 0.2, 0.9, Multi-racial PR 0.6 95% CI: 0.4, 0.9), and experienced shared decision making (aPR 1.7 95% CI: 1.1, 2.8). Fewer than half met criteria for medical home, effective care coordination, and adequate insurance. Poor mental health emerged as a concern with high levels of anxiety and/or depression (48%) and low levels of flourishing (42%). This is an important first step in demonstrating low transition readiness among adolescents with chronic pain and identifying mental health and healthcare continuity concerns. Future research should incorporate stakeholder perspectives and investigate pain specific factors relevant to transition readiness and investigate how readiness relates to transition outcomes. PERSPECTIVE: This article establishes low readiness to transition from pediatric to adult healthcare among adolescents with chronic pain and identifies disparities in readiness. Poor mental health and inadequate healthcare access were identified as factors which may impact transition intervention delivery. These findings can guide development and implementation of a transition intervention.

Transitioning to Adulthood: Pediatric Spinal Cord Injury Care and Beyond

The transition to adulthood is a complex and dynamic process for youth with spinal cord injury (SCI). A key goal of SCI rehabilitation is to develop the skillsets necessary to successfully transition to adulthood, lead a meaningful life, engage in one's community, and maintain a good quality of life. This article provides an overview of transition outcomes and interventions within a biopsychosocial framework, with regard to physiologic functioning, participation in education and employment, emotional and social well-being, and the health care system.

Health care transition rates and associated factors for adolescents with asthma

Background

Adolescents and young adults with asthma face increased risks during the health care transition (HCT) from pediatric to adult care. Despite guidelines advocating for more HCT preparedness, this does not consistently occur in clinical practice. The rates of exposure to transition preparation in adolescents with asthma are unknown.

Objectives

Our goal was to understand the rates of HCT exposure among adolescents with asthma in the United States, along with predictive characteristics associated with receiving HCT exposure, as determined by using data from a nationally representative survey.

Methods

We studied adolescents aged 12 to 17 years with asthma in the 2020-2021 National Survey of Children's Health data set. We explored associations between sociodemographic, health-related, and provider practice-related variables and HCT exposure through univariate analysis and multivariable logistic regression.

Results

Only 19% of adolescents with asthma from this cohort met criteria indicating that they had received HCT exposure. In our multivariable analysis, being older, being female, having a provider actively work with the child to make positive choices about health, having a written care plan addressing transition, having routine preventive care visits, and having a caregiver who has someone with whom to discuss health insurance into adulthood were associated with higher odds of HCT exposure. Hispanic ethnicity, lack of insurance, and residence in a metropolitan area were associated with lower odds of receiving preparation for transitional care but were not significant in the multivariable model.

Conclusions

Our findings underscore the need to improve transitional care preparation for adolescents with asthma, with attention needed to address disparities based on sociodemographic factors, including health care access.

Considerations for Alternative Decision-Making When Transitioning to Adulthood for Youth With Intellectual and Developmental Disabilities: Policy Statement

With advances in medical care, more youth with intellectual and/or developmental disabilities (IDD) are transitioning into adulthood. Patient- and family-centered, integrated care is warranted around this time of transition. Support teams (including the youth, caregivers, teachers, and pediatricians) should engage in transition planning, ideally starting between 12 and 14 years of age, to identify and develop resources to support the maturing youth's capacity for independent decision-making. Care teams should consider the varied levels of alternative decision-making support, which may include supported decision-making, medical proxy decision-making, power of attorney, and/or establishment of legal guardianship arrangements, to support the youth's health and well-being optimally. Ultimately, if independent decision-making is not appropriate, the goal for youth with IDD should be the least restrictive alternative, while preserving human rights and human dignity and promoting their autonomy. These considerations review alternative decision-making support, concepts, and legal requirements available for youth with IDD and their care teams. Pediatricians can support youth with IDD and their families in the transition process and decision-making autonomy by actively engaging the youth in care decisions, supporting needs for augmentative communication, fostering their expression of preferences and understanding of care decisions, and linking them to resources such as the medical-legal partnership model.

Social and Structural Drivers of Health and Transition to Adult Care

CONTEXT

Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition.

OBJECTIVES

This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth.

DATA SOURCES

Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022.

STUDY SELECTION

Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included.

DATA EXTRACTION

SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance.

RESULTS

101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion.

LIMITATIONS

Studies were heterogeneous and a meta-analysis was not possible.

CONCLUSIONS

Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends and Disparities in Health Care Transition Preparation from 2016 to 2019: Findings from the US National Survey of Children's Health

OBJECTIVES

To evaluate national trends in health care transition preparation over a 4-year period using the National Survey of Children's Health (NSCH) and to identify and examine disparities in receipt of health care transition preparation over the study period.

STUDY DESIGN

Data from the NSCH, an annual serial cross-sectional survey conducted from 2016 to 2019, were examined. Caregivers answered questions regarding one of their children within each of a random sample of households across the US. The primary analysis examined trends in health care transition preparation based on the year of survey completion. A secondary analysis examined the associations of race/ethnicity, primary household language, insurance type, and children with special health care needs (CSHCN) with receipt of health care transition preparation.

RESULTS

We included data from 54 434 youths (20 708 in 2016, 8909 in 2017, 12 587 in 2018, and 12 230 in 2019) aged 12-17 years whose caregivers completed the NSCH between 2016 and 2019. The sample was weighted to be nationally representative based on weights provided by the NSCH. The proportion of youths receiving necessary health care transition preparation increased over the study period, from 14.8% in 2016 to 20.5% in 2019 (P < .001). Multivariable logistic regression demonstrated increased odds of receiving health care transition preparation in 2018 and 2019, as well as for White non-Hispanic youths, those with English or Spanish as a primary household language, those with private insurance, and CSHCN.

CONCLUSIONS

Although the proportion of youths receiving health care transition preparation has increased since 2016, the need for ongoing improvement and elimination of disparities in health care transition preparation remains.

Measuring health care transition: Across time and into the future

PROBLEM

Youth with special health care needs often experience significant difficulty transitioning into adult health care services and adult life. Services supporting youths' transition from pediatric to adult health care (Health Care Transition (HCT)) have been a priority for nearly 30 years to improve this transition process. The Health Resources and Service Administration, Maternal and Child Health Bureau have measured HCT service provision since 2001 but the longitudinal use of this measure has never been examined (Blumberg, 2003; Maternal and Child Health Bureau, n.d.).

ELIGIBILITY CRITERIA

This manuscript highlights the consistent and inconsistent uses of HCT constructs in two prominent national surveys (the National Survey of Children with Special Health Care Needs (NS-CSHCN) and the National Survey of Children's Health (NSCH)) between 2001 and 2019. All studies utilizing an HCT measure within a national survey between the 18 years were included in this examination.

RESULTS

Significant changes have been made to the measurement of HCT service provision resulting in inconsistencies over the last 18 years. Measurement criteria and survey questions have changed substantially from the NS-CSHCN and NSCH limiting one's ability to examine trends in HCT since 2001. Since 2016, few changes have been made, allowing for analysis of trends over time. Importantly, the NSCH includes added questions pertaining to HCT that are not included in the composite HCT outcome measure.

CONCLUSION

Future work should include a validation study of the HCT outcome in the National Survey of Children's Health and inclusion of additional HCT questions to promote continued and extensive use of a measure that more fully represents the needs of youth and their families.

Assessing the Relationship Between Well-Care Visit and Emergency Department Utilization Among Adolescents and Young Adults

PURPOSE

To investigate the association between adolescent and young adult (AYA) well-care visits and emergency department (ED) utilization.

METHODS

Vermont's all-payer claims data were used to evaluate visits for 49,089 AYAs (aged 12-21 years) with a health-care claim from January 1 through December 31, 2018. We performed multiple logistic regression analyses to determine the association between well-care visits and ED utilization, investigating potential moderating effects of age, insurance type, and medical complexity.

RESULTS

Nearly half (49%) of AYAs who engaged with the health-care system did not attend a well-care visit in 2018. AYAs who did not attend a well-care visit had 24% greater odds (95% confidence interval [CI]: 1.19-1.30) of going to the ED at least once in 2018, controlling for age, sex, insurance type, and medical complexity. Older age, female sex, Medicaid insurance, and greater medical complexity independently predicted greater ED utilization in the adjusted model. In stratified analyses, late adolescents and young adults (aged 18-21 years) who did not attend a well-care visit had 47% greater odds (95% CI: 1.37 - 1.58) of ED visits, middle adolescents (aged 15-17 years) had 9% greater odds (95% CI: 1.01-1.18), and early adolescents (aged 12-14 years) had 16% greater odds (95% CI: 1.06 - 1.26).

CONCLUSIONS

Not attending well-care visits is associated with greater ED utilization among AYAs engaged in health care. Focus on key quality performance metrics such as well-care visit attendance, especially for 18- to 21-year-olds during their transition to adult health care, may help reduce ED utilization.

Transitioning to Adulthood with a Rheumatic Disease: A Case-Based Approach for Rheumatology Care Teams

Both pediatric and adult rheumatology care teams play a central role in health care transition, the shift from child- and family-centered to adult-oriented health care. Components of transition preparation include readiness assessment, setting self-management goals, and spending time in clinical visits without a parent present. Pediatric providers and families should work together to create a transfer plan, identifying a new adult rheumatology care provider, providing a medical summary before transfer, and anticipating changes in health insurance. For high-risk transfers, direct communication between providers is recommended. Finally, adult rheumatologists need to build rapport with young adults to support future engagement in care.

Social Resources for Transplanted Children and Families in European Union Hospitals of ERN TransplantChild

Social well-being is an intrinsic part of the current concept of health. In the context of chronic disease, there are many challenges we face in order to provide social well-being to patients and their families, even more if we talk about rare diseases. TransplantChild, a European Reference Network (ERN) in paediatric transplantation, works to improve the quality of life of transplanted children. It is not possible to improve the quality of life if the human and material resources are not available. With this study, we want to identify the economic aids, facilities, services, and financed products that are offered to families in different European centres. We also want to find out who provides these resources and the accessibility to them. We designed an ad hoc survey using the EU Survey software tool. The survey was sent to representatives of the 26 ERN members. In this article we present the results obtained in relation to two of the aspects analysed: long-term financial assistance and drugs, pharmaceuticals and medical devices. Some resources are equally available in all participating centres but there are significant differences in others, such as education aids or parapharmacy product financing. A local analysis of these differences is necessary to find feasible solutions for equal opportunities for all transplanted children in Europe. The experience of centres that already provide certain solutions successfully may facilitate the implementation of these solutions in other hospitals.

Creating a Pharmacotherapy Collaborative Practice Network to Manage Medications for Children and Youth: A Population Health Perspective

Children with special health care needs (CSHCN) use relatively high quantities of healthcare resources and have overall higher morbidity than the general pediatric population. Embedding clinical pharmacists into the Patient-Centered Medical Home (PCMH) to provide comprehensive medication management (CMM) through collaborative practice agreements (CPAs) for children, especially for CSHCN, can improve outcomes, enhance the experience of care for families, and reduce the cost of care. Potential network infrastructures for collaborative practice focused on CSHCN populations, common language and terminology for CMM, and clinical pharmacist workforce estimates are provided. Applying the results from the CMM in Primary Care grant, this paper outlines the following: (1) setting up collaborative practices for CMM between clinical pharmacists and pediatricians (primary care pediatricians and sub-specialties, such as pediatric clinical pharmacology); (2) proposing various models, organizational structures, design requirements, and shared electronic health record (EHR) needs; and (3) outlining consistent documentation of CMM by clinical pharmacists in CSHCN populations.