Pediatric to Adult Care Transition: Perspectives of Young Adults With Sickle Cell Disease

Exploring the emotional impact of pain on children and adolescents: A poetic meta-ethnography

Pain in early life can go unreported and untreated. We use poems to portray findings from a systematic review of qualitative research. The overall aim of the review was to distil essential experiences across pain conditions and contexts. This report, focusing on the emotional impact of pain, is one of a series of three analyses from one systematic review of qualitative research. We used meta-ethnography to synthesise research. We identified studies in English that explored acute and/or chronic child and/or adolescent pain experience. Findings were distilled into themes and poems co-created in English and Spanish. We included 189 reports (177 unique studies) incorporating 5875 people (at least 3484 reported as female). Most studies (93%) included participants aged 11-20 years (range 2-38). The studies explored acute (24% studies), chronic (75%), and acute/chronic (1%). We report seven themes: (1) Pain can be hard to bear; (2) Pain is scary; (3) Pain is constantly at the back of my mind: (4) Pain makes me feel like I am outside alone; (5) Pain makes school a hard fit; (6) Pain can hurt me deep inside; (7) Pain has changed me. Our themes highlight the emotional impact of pain across conditions and contexts. Art and science are both integral to leaps in understanding. The contribution of the Arts is their unique ability to reach audiences on an affective level, giving the potential to underpin compassionate care and policy. We invite readers to utilise these poems to start a conversation about young people's pain experiences. This systematic review was registered on the PROSPERO database (CRD42023429027). Ethical permissions are not required for an evidence synthesis. PERSPECTIVE: The voices of young people in pain are not always heard. This article presents themes, in poetic form, from a synthesis of 189 qualitative studies. Science and art are integral to leaps in understanding and inclusive arts-based research methods have the potential to underpin compassionate pain care for young people.

Association between hospital type and length of stay and readmissions for young adults with complex chronic diseases

BACKGROUND

There is a paucity of information around whether hospital length of stay and readmission rates differ based upon hospital type for adolescents and young adults (AYA) with complex chronic diseases (CCDs).

OBJECTIVE

To measure the association between hospital type and readmission rates and index admission LOS among AYA with CCDs.

METHODS

We performed a retrospective cross-sectional study of 2017 Healthcare Cost and Utilization Project State Inpatient Databases, including patients 12-25 years old with cystic fibrosis (CF), sickle cell disease (SCD), spina bifida (SB), inflammatory bowel disease (IBD), and diabetes mellitus (DM). Index hospitalizations were categorized by hospital type (pediatric hospitals [PHs], adult hospitals with pediatric services [AHPSs], and adult hospitals without pediatric services [AHs]), CCD, and age group. We compared case-mix adjusted 30-day readmission rates and differences in index admission LOS between hospital types.

RESULTS

Adult hospitals without pediatric services exhibited higher readmission rates (25.4%) than AHPS (22.9%) and PH (15.1%). Compared to patients with CF admitted to AH, lower readmission rates were associated with longer LOS at both AHPS (relative ratio [RR]: 1.25, 95% confidence interval [CI]: 1.02-1.55) and PH (RR: 1.59, 95% CI: 1.28-1.97). Patients with DM admitted to AHPS (odds ratio [OR]: 0.75, 95% CI: 0.62-0.91) and PH (OR: 0.47, 95% CI: 0.31-0.71) also demonstrated lower readmission rates than those admitted to AH.

CONCLUSIONS

For AYA with CCD, hospital type is associated with differences in readmission rates and LOS. Lower readmission rates at hospitals with pediatric services compared to adult hospitals without pediatric services suggest hospital type has a significant impact on outcomes.

The presentation of self in everyday young lives with pain: a poetic meta-ethnography

BACKGROUND

Access to pain relief is a fundamental human right, yet child and adolescent pain can remain unheard and untreated . We aimed to understand and testify to young people's pain experiences.

METHODS

This is the first systematic review of qualitative research to present findings as poetry. We followed stages of meta-ethnography, using verbatim poetry to express the findings.

RESULTS

We included 189 studies incorporating 5875 young people with pain across a range of conditions and contexts. Our findings highlight the ambiguity of pain . This ambiguity is exacerbated by unpredictability, absence of diagnosis, and a tangle of bio-psycho-social factors.

CONCLUSIONS

Verbatim poetry can help us to imagine what it is like to live in someone else' shoes. Poetry can therefore contribute to compassionate and high-quality care. Future research might explore the role of poetry inmore inclusive research.

The pervasive influence of systems of power on transition readiness for adult care in sickle cell disease: A qualitative study

BACKGROUND

Adolescence and young adulthood are vulnerable developmental periods for individuals with sickle cell disease (SCD), particularly given the impact of social inequities, challenges with transitioning to adult healthcare services, and increased risk for morbidity and mortality. Systems of power, such as institutionalized and interpersonal manifestations of bias, could impact SCD transfer and engagement in adult care through their influence on healthcare transition readiness; yet research in this area is limited.

OBJECTIVE

To characterize how systems of power impact transition readiness factors described in the Social-ecological Model of AYA Readiness for Transition to Promote Health Equity (SMART-E) framework at the patient, caregiver, and practitioner levels.

METHODS

Pediatric adolescents and young adults (AYA), transferred AYA, caregivers, and practitioners participated in semi-structured focus groups and individual interviews examining health equity and systems of power during healthcare transition. Focus groups/interviews were transcribed and coded using a deductive approach via the updated SMART-E framework.

RESULTS

Ten pediatric AYA with SCD, nine transferred AYA with SCD, eight caregivers, and nine practitioners participated in a focus group or interview. Qualitative findings across reporters emphasize the impact of systems of power (e.g., racial bias and disease stigma) on knowledge, skills and self-efficacy, beliefs and expectations, goals and motivation, and emotions and psychosocial functioning at the patient, caregiver, and practitioner levels.

CONCLUSION

Systems of power are prevalent with respect to transition barriers for AYA with SCD and their supports. Structural, institutional, and individual factors with potential to reduce the influence of systems of power should be further identified and targeted for intervention.

An Updated Equitable Model of Readiness for Transition to Adult Care: Content Validation in Young People With Sickle Cell Disease

Importance

Despite elevated health risks during young adulthood, many adolescents and young adults with serious health care needs face barriers during the transfer to an adult specialty practitioner, and health disparities may occur during the transition.

Objective

To validate the content of an updated Social-Ecological Model of Adolescent and Young Adult Readiness for Transition to Promote Health Equity (SMART-E) in a group of adolescents and young adults with sickle cell disease (SCD) and their supports.

Design, Setting, and Participants

Health equity framework components were reviewed. Systems of power (eg, institutional and practitioner bias) and environments or networks (eg, peer or school support) were added as SMART-E preexisting factors, and health literacy was included within readiness factors. Adolescents and young adults aged 16 to 29 years with SCD, caregivers, and practitioners participated in this convergent, mixed-methods study within Children's Hospital of Philadelphia between January and August 2022.

Main Outcomes and Measures

Content validity was assessed through nominations of top 3 most important transition barriers prior to interviews and focus groups, ratings on importance of SMART-E factors (0-4 scale; ratings >2 support validity) after interviews and focus groups, nominations of 3 most important factors for transition and for health equity, and qualitative content analysis of interview transcripts.

Results

The study enrolled 10 pediatric adolescents and young adults (mean [SD] age, 18.6 [2.9] years; 4 female and 6 male), 10 transferred adolescents and young adults (mean [SD] age, 22.9 [2.1] years; 8 female and 2 male), 9 caregivers (mean [SD] age, 49.8 [8.7] years; 5 female and 4 male), and 9 practitioners (mean [SD] age, 45.6 [10.5] years; 8 female and 1 male). Quantitative ratings supported the content validity of SMART-E and met established criteria for validity. Systems of power was the most endorsed transition barrier (14 of 38 participants) reported prior to interviews and focus groups. After the interview, participants endorsed all SMART-E factors as important for transition, with new factors systems of power and environments and networks rated at a mean (SD) 2.8 (1.23) and 3.1 (0.90), respectively, on a 0 to 4 scale of importance. The most important factors for transition and equity varied by participant group, with all factors being endorsed, supporting the comprehensiveness of SMART-E. Qualitative data corroborated quantitative findings, further supporting validity, and minor modifications were made to definitions.

Conclusions and Relevance

SMART-E obtained initial content validation with inclusion of health equity factors for adolescents and young adults with SCD, caregivers, and practitioners. The model should be evaluated in other populations of adolescents and young adults with chronic disease.

Developing a transition workshop for adolescents with sickle cell disease

Background

The transfer from paediatric to adult care presents a significant challenge for adolescents and young adults (AYA) with sickle cell disease (SCD). Disease self-management skills have been recognized as important mediators of poor health outcomes, but transition-related skills such as scheduling appointments and understanding the shift in health care responsibilities remain under taught in the healthcare system. The purpose of this quality improvement (QI) study was to (1) understand the areas of disease self-management that AYA patients felt underprepared for, and (2) design and evaluate an educational program addressing the top unmet skills.

Methods

The Plan-Do-Study-Act (PDSA) model was implemented in a tertiary outpatient clinic between September 2020 and July 2021. Patients were surveyed during regular clinic visits to identify their priorities on disease self-management skills. Based on the results, a virtual workshop was created and administered three separate times. Feedback was collected using an electronic survey.

Results

'Navigating the adult health care system' was the top self-management skill that AYA patients (n = 39) identified needing more support with. The majority of participants (79%, n = 14) reported that the virtual workshop was excellent, with 'appointment management' being the most useful topic discussed. Participants also reported feeling more confident (71%) and aware (86%) of how to navigate adult care.

Conclusion

This QI study showed that delivering a virtual workshop on transition skills was well received by AYA participants with SCD. The PDSA framework was useful for identifying specific knowledge gaps in transition aged AYA to help improve patient education in a well-established transition program.

Sickle cell disease and adolescents' perspectives on self-care management resources

Background

Adolescents with sickle cell disease (SCD) face unique challenges, especially during the critical health care transition from pediatric to adult care. The purpose of this study was to gather the perspectives of adolescents living with SCD and to describe their self-care management experiences prior to their move into the adult health care system.

Methods

Guided by the Theory of Self-Care Management for Sickle Cell Disease, this qualitative descriptive study used semi-structured interviews with 11 adolescents with SCD (M = 16.63 years, SD = 1.15). In addition to a demographic survey, adolescents answered interview questions about their perceptions of their self-care management, health care transition readiness, support, and spiritual well-being. Data were analyzed using a template analysis style.

Results

Four major themes were identified: attaining vocational aspirations, maintaining effective self-care management strategies, managing and maintaining social support, and building resilience through spirituality and religion. Maintaining, effective self-care management strategies had three threads: coping behaviors, health care transition needs, and self-care management strengths.

Discussion

Identifying self-care management resources and areas where further attention is needed can be helpful for health care providers when developing age specific plans. A tailored approach to care during this critical health care transition period can also build capacity for a successful transition for adolescents.

Health literacy correlates with abbreviated full-scale IQ in adolescent and young adults with sickle cell disease

INTRODUCTION

Sickle cell disease (SCD) is a chronic condition with progressive neurocognitive deficits. Health literacy (HL) is essential during adolescence and young adulthood, as the transition to adult care requires healthcare decisions. HL is known to be low in SCD; however, relation between general cognitive ability and HL has not been investigated.

METHODS

This cross-sectional study included adolescent and yound adults (AYAs) with SCD from two institutions. Logistic regression measured the association between HL, measured by the Newest Vital Sign tool, and general cognitive ability, measured with abbreviated full-scale intelligence quotient (FSIQ) on the Wechsler Abbreviated Scale of Intelligence.

RESULTS

Our cohort contained 93 participants at two sites: 47 (51%) at Memphis, TN and 46 (49%) at St. Louis, MO, ranging from ages 15-45 years (mean = 21 years) and with a majority (70%) possessing a high school education or greater. Only 40/93 participants (43%) had adequate HL. Lower abbreviated FSIQ (p < .0001) and younger age at assessment (p = .0003) were associated with inadequate HL. For every standard score point increase in abbreviated FSIQ, the odds of having adequate HL compared to limited or possibly limited HL increase by 1.142 (95% confidence interval [CI]: 1.019-1.322) and 1.116 (95% CI: 1.045-1.209), respectively, after adjusting for age, institution, income, and educational attainment.

CONCLUSIONS

Understanding and addressing HL is imperative in improving self-management and health outcomes. Among AYA with SCD, low HL was prevalent and influenced by abbreviated FSIQ. Routine screening for neurocognitive deficits and HL should be performed to guide development of interventions to adapt to the HL of AYA with SCD.

A Qualitative Systematic Review of Pediatric Patient and Caregiver Perspectives on Pain Management for Vaso-Occlusive Episodes in the Emergency Department

OBJECTIVES

The primary objective of this study is to describe the experiences of pediatric patients with sickle cell disease (SCD) and their caregivers who have presented to the emergency department (ED) for management of vaso-occlusive pain events.

METHODS

We conducted a qualitative systematic review. The search protocol was developed to identify both published and unpublished literature that met inclusion/exclusion criteria. Included articles were primary hospital-based research with study populations that included (but were not limited to) pediatric patients aged 21 years or younger and qualitative or mixed-method analysis.

RESULTS

Four themes were identified: (1) patients and caregivers perceive the ED as the last resort; (2) health care professionals in the ED lacked knowledge about SCD but rejected patients' and caregiver's attempts to share experience or advocate for their needs; (3) patients' accounts of pain are doubted because they do not always have "typical" signs of pain; and (4) caregivers identify racism as a reason for suboptimal care in the ED.

CONCLUSIONS

There are multiple opportunities to improve management for vaso-occlusive pain events in the ED, including education of health care providers about SCD and complications, partnership between patients/caregivers and providers, and efforts to reduce the impact of systemic racism on health care delivery.

Navigating liminal spaces together: a qualitative metasynthesis of youth and parent experiences of healthcare transition

Transition from pediatric to adult care for adolescents and young adults (AYAs) with chronic illness affects the entire family. However, little research has compared AYA and parent experiences of transition. Using Sandelowski and Barroso's method, the aim of this metasynthesis was to summarize findings of qualitative studies focusing on the transition experiences of AYAs and their parents across different chronic physical illnesses. PubMed, EMBASE and CINAHL were searched followed by forward and backward citation searching. Two authors completed a two-step screening process. Quality was appraised using Guba's criteria for qualitative rigor. Study characteristics and second order constructs were extracted by two authors and an iterative codebook guided coding and data synthesis. Of 1,644 records identified, 63 studies met inclusion criteria and reflect data from 1,106 AYAs and 397 parents across 18 diagnoses. Three themes were synthesized: transition is dynamic and experienced differently (differing perceptions of role change and growth during emerging adulthood), need for a supported and gradual transition (transition preparation and the factors which influence it) and liminal space (feeling stuck between pediatric and adult care). While AYAs and parents experience some aspects of transition differently, themes were similar across chronic illnesses which supports the development of disease agnostic transition preparation interventions. Transition preparation should support shifting family roles and responsibilities and offer interventions which align with AYA and family preferences.

Transitioning Adolescents With Sickle Cell Disease From Pediatric to Adult Care: Results From a New Survey of Health Care Professionals

Transition from pediatric to adult care for adolescents and young adults (AYA) with sickle cell disease (SCD) comes at a time when a range of biopsychosocial issues occur simultaneously. A new survey sought information from physicians who treat AYA with SCD about their practices in how they transition pediatric patients to adult care. An online survey to physicians who treat SCD was conducted using SurveyMonkey between November 2019 and January 2020. Of 209 physicians who were contacted, 58 completed the survey; 62.1% treated primarily pediatric patients and 37.9% treated adults. Patient education on transition was regarded as "important" or "very important" by 94.2% of the physicians. Patients' knowledge about their disease and their ability to navigate the health care system were identified as 2 primary barriers to transition (mean 1.30 and 1.67 on a 3-point scale, respectively). Most physicians employ established models to facilitate the transition, including Got Transition (41.3%) and a biopsychosocial model (34.8%), with 34.8% using a mix of models and 23.9% not using an established model. Fewer than half (34.8%) rated their program as "very successful" or "successful." Transition protocols from pediatric to adult care should be re-examined to facilitate successful transition for AYA with SCD.

Transition for Adolescents and Young Adults With Sickle Cell Disease in a US Midwest Urban Center: A Multilevel Perspective on Barriers, Facilitators, and Future Directions

BACKGROUND

Sickle cell disease (SCD), an inherited red blood cell disorder, primarily affects African Americans in the United States. Adolescents and young adults with SCD (AYA-SCD) are at risk of high morbidity and mortality when transitioning from pediatric to adult care. The goal of this qualitative study was to understand factors associated with optimal implementation of the AYA-SCD transition.

METHODS

Participants were recruited from a large hospital system and the community. Interview guides included topics on access to primary and specialized care, beliefs and practices related to pain control, transition from pediatric to adult care, and patient experiences in the emergency department. Data were coded and analyzed using an inductive thematic coding approach in combination with a deductive coding approach using domains from the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Fifty-nine participants, including 21 AYA-SCD from both the pediatric and adult clinics, 17 caregivers, 9 pediatric SCD providers, 6 adult SCD providers, and 6 emergency department providers, completed 11 focus groups and 5 semistructured interviews. Results identified multiple factors within the domains of CFIR including the outer setting, inner setting, individual characteristics, and intervention characteristics. Results were incorporated into a transition framework to inform local practice improvement.

CONCLUSION

Our study highlights the importance of multilevel barriers and facilitators for AYA-SCD transition from pediatric to adult care. Future studies could use implementation science frameworks to understand local context and identify strategies and intervention characteristics to improve transition programming. These efforts will ultimately reduce health disparities and ensure health equity.

Pediatric-Adult Care Transition: Perceptions of Adolescent and Young Adult Patients with Sickle Cell Disease and Their Healthcare Providers

INTRODUCTION

The pediatric-adult care transition, which takes place during adolescence, is a high-risk period for medical care adherence in chronic diseases, this encompasses treatment adherence, attending medical consultations and following healthcare advice. Studying perceptions is needed to get a more comprehensive picture of this care transition and to propose interventions to address the gaps. The authors analyzed perceptions from patients and caregivers in adolescents with sickle cell disease. Although this is the first step to improving the actual care management, to our knowledge, no study has explored perceptions from healthcare providers and compared it to patients' perceptions. The purpose of this study was to provide an insight on the experience of adolescent and adult patients, pediatric and adult healthcare providers in the context of pediatric to adult care transition, and analyze those concerns in order to better understand medical care adherence and improve patient care.

MATERIAL AND METHODS

Semi-structured interviews were conducted with adolescent and adult patients, as well as healthcare professionals (HCPs) in pediatric and adult departments. These interviews were audiotaped and transcribed before manual inductive content analysis.

RESULTS

A total of 15 adolescent patients, 10 adult patients, 9 pediatric HCPs and 13 adult HCPs - including 12 nurses - were interviewed. Patients and healthcare providers all agreed that the pediatric-adult care transition was poorly experienced. This was mainly due to various changes in habits, physicians, and care organization. Anticipating this transition and acquiring new skills both for patients and HCPs are essential steps for improving medical care adherence during this challenging pediatric-adult care transition.

CONCLUSION

Propositions emerged from patients and healthcare providers to improve care and subsequently to improve medical care adherence in patients with sickle cell disease during and after the pediatric to adult care transition.

Biopsychosocial factors related to transition among adolescents and young adults with sickle cell disease: A systematic review

It is critical to support adolescents and young adults (AYAs) with sickle cell disease (SCD) during transition to adult healthcare. We provide a systematic review of literature related to biopsychosocial influences on transition among AYAs with SCD. Data sources included studies published between January 2010 and May 2020. Forty-four studies were included. Biopsychosocial factors related to improved transition outcomes included older AYA age, greater disease severity, intact neurocognitive functioning, and greater pain coping skills. Financial and insurance barriers were noted. The importance of cultural considerations and provider communication were noted across two qualitative studies. Ten studies assessed efficacy of transition interventions, with 80 % resulting in improvements; however, retention in programs was low and gaps in knowledge and skills remained. Incorporation of early, ongoing assessments of transition readiness and barriers into culturally-tailored interventions aimed at improving transition outcomes is recommended. Examination of longitudinal relationships and interactions across biopsychosocial influences is needed.

Mortality and Causes of Death From Sickle Cell Disease in The Netherlands, 1985-2017

In the Netherlands, between 1985 and 2007 secular changes in the health care of patients with sickle cell disease (SCD) have taken place, such as penicillin prophylaxis, vaccination programs and stroke prevention. We investigated the number and causes of death in a cohort of 298 SCD patients, established in 2007, before introduction of neonatal screening, to determine preventable deaths. All patients were diagnosed with SCD before the age of 18 (median age at diagnosis 5.1 y). Their vital status was determined up to January 2017. After a total follow-up period of 4565 patient years and a median time of follow-up of 15 years for all patients, 230 patients (77%) were still alive, 45 patients (15%) were lost to follow-up and a total of 23 patients (8%) had died. Estimated survival to 18 years was 92% with a global mortality rate of 0.48 deaths/100 patient years. Leading causes of death were infection (35%) followed by neurologic complications (22%) and death in the course of a painful episode (13%). Nine of the 20 known causes of death were preventable. These results strongly suggest the benefit of comprehensive care measures for patients with SCD in the Netherlands to further prevent morbidity and mortality.

Executive Functioning Predicts Adaptive Functioning and Self-Care Independence in Pediatric Sickle Cell Disease

OBJECTIVE

This study examined the impact of executive functioning (EF) on adaptive functioning and self-care independence in pre-transition youth with sickle cell disease (SCD).

METHODS

Thirty-four youth with SCD (ages 12-18 years) completed a brief neuropsychological battery and their caregivers completed questionnaires assessing adaptive functioning, EF behaviors, and independence in completing self-care tasks, including disease management. Hierarchical linear regression analyses were utilized to investigate if EF predicted significantly more variability in adaptive functioning and self-care independence than what is accounted for by socioeconomic status (SES), disease knowledge, and estimated intellectual functioning.

RESULTS

Mean performance on standardized measures assessing working memory, processing speed, and EF skills fell in the low average range. Performance-based EF and caregiver-reported EF behaviors predicted variance in adaptive functioning and self-care independence above and beyond that accounted for by SES, disease knowledge, and intelligence, with moderate to large effect sizes.

CONCLUSIONS

EF skills may support the ability of youth with SCD to adequately achieve independence in self-care, including medical self-care, and other adaptive skills, which may increase the likelihood of successful transition to young adulthood. These findings provide support for the role of neuropsychological screening and individualized intervention in interdisciplinary transition programs.

Progression of central nervous system disease from pediatric to young adulthood in sickle cell anemia

Silent cerebral infarcts and arteriopathy are common and progressive in individuals with sickle cell anemia. However, most data describing brain lesions in sickle cell anemia are cross-sectional or derive from pediatric cohorts with short follow-up. We investigated the progression of silent cerebral infarct and cerebral vessel stenosis on brain MRI and MRA, respectively, by describing the incidence of new or worsening lesions over a period of up to 25 years among young adults with sickle cell anemia and explored risk factors for progression. Forty-four adults with sickle cell anemia (HbSS or HbSβ⁰thalassemia), exposed to chronic transfusions (n = 12) or hydroxyurea (n = 32), median age 19.2 years (range 18.0-31.5), received a screening brain MRI/MRA and their results were compared with a clinical exam performed during childhood and adolescence. We used exact log-rank test to compare MRI and MRA progression among any two groups. The hazard ratio (HR) and 95% confidence interval (CI) were calculated from Cox regression analyses. Progression of MRI and MRA occurred in 12 (27%) and 4 (9%) young adults, respectively, relative to their pediatric exams. MRI progression risk was high among participants with abnormal pediatric exams (HR: 11.6, 95% CI: 2.5-54.7) and conditional or abnormal transcranial Doppler ultrasound velocities (HR: 3.9, 95% CI: 1.0-15.1). Among individuals treated with hydroxyurea, high fetal hemoglobin measured in childhood was associated with lower hazard of MRI progression (HR: 0.86, 95% CI: 0.76-0.98). MRA progression occurred more frequently among those with prior stroke (HR: 8.6, 95% CI: 1.2-64), abnormal pediatric exam (P = 0.00084), and elevated transcranial Doppler ultrasound velocities (P = 0.004). Brain MRI/MRA imaging in pediatrics can identify high-risk patients for CNS disease progression in young adulthood, prompting consideration for early aggressive treatments.

The Health Care of Adults with Differences in Sex Development or Intersex Traits Is Changing: Time to Prepare Clinicians and Health Systems

Historically, the majority of differences in sex development or intersex trait (dsd/I)-specific medical care has been provided by pediatric clinicians, leading to a dearth of adult clinicians qualified to care for this vulnerable population, and pediatricians reticent to transition patients to adult care. Recent changes in routine care of children and infants with dsd/I, including reconsidering the role of early genital surgeries, highlight the critical need to address the gaps in adult dsd/I health care. In this perspective, we describe three key educational and research approaches that can be implemented to build competency to care for adults with dsd/I and improve care across the lifespan.

Youths' Experiences of Transition from Pediatric to Adult Care: An Updated Qualitative Metasynthesis

PROBLEM

Improvements in chronic disease management has led to increasing numbers of youth transitioning to adult healthcare. Poor transition can lead to high risks of morbidity and mortality. Understanding adolescents and young adults (AYA) perspectives on transition is essential to developing effective transition preparation. The aim of this metasynthesis was to synthesize qualitative studies assessing the experiences and expectations of transition to adult healthcare settings in AYAs with chronic diseases to update work completed in a prior metasynthesis by Fegran, Hall, Uhrenfeldt, Aagaard, and Ludvigsen (2014).

ELIGIBILITY CRITERIA

A search of PubMed, Medline, PsycINFO, and CINAHL was conducted to gather articles published after February 2011 through June 2019.

SAMPLE

Of 889 articles screened, a total of 33 articles were included in the final analysis.

RESULTS

Seven main themes were found: developing transition readiness, conceiving expectations based upon pediatric healthcare, transitioning leads to an evolving parent role, transitioning leads to an evolving youth role, identifying barriers, lacking transition readiness, and recommendations for improvements.

CONCLUSIONS

Findings of this metasynthesis reaffirmed previous findings. AYAs continue to report deficiencies in meeting the Got Transition® Six Core Elements. The findings highlighted the need to create AYA-centered transition preparation which incorporate support for parents.

IMPLICATIONS

Improvements in transition preparation interventions need to address deficiencies in meeting the Got Transition® Six Core Elements. More research is needed to identify and address barriers implementing the transition process.

Paediatric to adult transition care for patients with sickle cell disease: a global perspective

Sickle cell disease is a life-threatening inherited condition designated as a public health priority by WHO. Increased longevity of patients with sickle cell disease in high-income, middle-income, and low-income countries present unprecedented challenges for all settings; however, a globally standardised solution for patient transition from paediatric to adult sickle cell disease health care is unlikely to address the challenges. We established a task force of experts from a multicountry (the USA, Europe, Middle East, and Africa) consortium. We combined themes from the literature with viewpoints from members of the task force and invited experts to provide a global overview of transition care practice, highlighting barriers to effective transition care and provide baseline recommendations that can be adapted to local needs. We highlighted priorities to consider for any young person with sickle cell disease transitioning from paediatric to adult health care: skills transfer, increasing self-efficacy, coordination, knowledge transfer, linking to adult services, and evaluating readiness (the SICKLE recommendations). These recommendations aim to ensure appropriate benchmarking of transition programming, but multisite prospective studies are needed to address this growing public health need.

In-Depth Interviews to Assess the Relevancy and Fit of a Peer-Mentored Intervention for Transition-Age Youth with Chronic Medical Conditions

STUDY PURPOSE

The purpose of this study is to evaluate the relevancy and fit of a proposed group-based, peer-mentored intervention, based on the principles of Self-Determination Theory (SDT), to facilitate the development of health self-management skills needed to transition from pediatric to adult-based healthcare.

DESIGN AND METHODS

Individual in-depth interviews with 28 transition-age youth (TAY) ages 17-22 and 24 caregivers (parents) from Gastroenterology, Renal and Rheumatology clinical services assessed interests in and preferred content, timing of and format for an intervention to help youth build self-management skills. Descriptive statistics were used for short answer questions and rating scales. Thematic analysis was used to analyze transcripts.

RESULTS

>90% of TAY and all caregivers thought the proposed group-based transition skills-building intervention was a good idea. TAY expressed wanting someone with lived experience to lead it and a desire to meet other youth with chronic conditions. All caregivers would want their TAY to participate if given the opportunity. Both TAY and caregivers voiced the importance of mental health topics as many TAY experienced anxiety or depression over managing their illness. Nearly 50% of TAY and caregivers thought parents should attend some or all group sessions, though TAY and caregivers within the same family did not always agree.

CONCLUSIONS

Findings establish the relevancy and fit of a peer-mentored intervention focused on skill development to successfully transition to adult healthcare.

PRACTICE IMPLICATIONS

The group intervention designed using a SDT framework may be particularly relevant as autonomy, competence, and relatedness undergo major developmental changes during adolescence.

Social and Psychological Factors Associated With Health Care Transition for Young Adults Living With Sickle Cell Disease

Introduction: Due to advances in disease management, mortality rates in children with sickle cell disease (SCD) have decreased. However, mortality rates for young adults (YA) increased, and understanding of social and psychological factors is critical. The aim of this study was to explore factors associated with health care transition experiences for YA with SCD. Method: This was a qualitative descriptive study. A 45-minute semistructured interview was conducted with 13 YA (M = 21.5 years, SD = 1.73). Results: Results suggest that social and psychological factors and self-management experiences influence health care transition. Eight themes emerged: "need for accessible support"; "early assistance with goal setting"; "incongruence among expectations, experiences, and preparation"; "spiritual distress"; "stigma"; "need for collaboration"; "appreciation for caring providers"; and "feeling isolated." Discussion: Consideration of cultural contexts will guide nurses in supporting health care transition. Designing culturally relevant interventions that address unique needs for YA living with SCD is warranted.

Pediatric to Adult Transition in Sickle Cell Disease: Survey Results from Young Adult Patients

BACKGROUND/AIMS

We surveyed sickle cell disease (SCD) patients who transitioned from pediatric care at Texas Children's Hematology Center (TCHC) to adult care to determine the characteristics of patients with an adult SCD provider, continuation rates of pre-transition therapies, and patient perceptions of the transition process.

METHODS

A cross-sectional study was conducted by telephone survey of 44 young adults with SCD, aged 19-29 years, who transitioned from TCHC to adult care within the last 15 years.

RESULTS

Findings of the 23-item questionnaire revealed that transitioned patients with current adult providers (68.2%) were more likely to have seen a provider within 6 months of transition (p = 0.023) and to have been on hydroxyurea and/or monthly blood transfusions pre-transition (p = 0.021) than transitioned patients without a provider; 83% of patients on pre-transition hydroxyurea reported continuing hydroxyurea after transition. Transition challenges included inadequate preparation, difficulty finding knowledgeable adult providers, and lack of healthcare insurance/coverage.

CONCLUSION

Transition to adult providers is predicted by establishing care with an adult SCD provider within 6 months of transition and being on pre-transition disease-modifying therapy. Transition may be improved if pediatric hematology centers assist and verify adult provider contact within 6 months of transition and engage patients of all disease severity during transition.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sickle Cell Clinical Research and Intervention Program (SCCRIP): A lifespan cohort study for sickle cell disease progression from the pediatric stage into adulthood

BACKGROUND

Previous natural history studies have advanced the understanding of sickle cell disease (SCD), but generally have not included sufficient lifespan data or investigation of the role of genetics in clinical outcomes, and have often occurred before the widespread use of disease-modifying therapies, such as hydroxyurea and chronic erythrocyte transfusions. To further advance knowledge of SCD, St. Jude Children's Research Hospital established the Sickle Cell Clinical Research and Intervention Program (SCCRIP), to conduct research in a clinically evaluated cohort of individuals with SCD across their lifetime.

PROCEDURES

Initiated in 2014, the SCCRIP study prospectively recruits patients diagnosed with SCD and includes retrospective and longitudinal collection of clinical, neurocognitive, geospatial, psychosocial, and health outcomes data. Biological samples are banked for future genomics and proteomics studies. The organizational structure of SCCRIP is based upon organ/system-specific working groups and is opened to the research community for partnerships.

RESULTS

As of August 2017, 1,044 (92.3% of eligible) patients with SCD have enrolled in the study (860 children and 184 adults), with 11,915 person-years of observation. Population demographics included mean age at last visit of 11.3 years (range 0.7-30.1), 49.8% females, 57.7% treated with hydroxyurea, 8.5% treated with monthly transfusions, and 62.9% hemoglobin (Hb) SS or HbSB⁰ -thalassemia, 25.7% HbSC, 8.4% HbsB⁺ -Thalassemia, 1.7% HbS/HPFH, and 1.2% other.

CONCLUSIONS

The SCCRIP cohort will provide a rich resource for the conduct of high impact multidisciplinary research in SCD.

Introduction to the Special Issue on Adolescent and Young Adult Health: Why We Care, How Far We Have Come, and Where We Are Going

This special issue on adolescent and young adult (AYA) health comprises 15 original articles. The special issue recognizes the importance of AYA-focused research, highlights unique issues across the AYA period, and showcases cutting-edge research focused on AYAs. We describe the rationale for focusing on the AYA population, themes of the special issue, and future directions.