Unmet education and training needs of rheumatology health professionals in adolescent health and transitional care

Addressing the unmet needs of transitional care in juvenile idiopathic arthritis

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transition of patients with metabolic bone disease from paediatric to adult healthcare services: current situation and proposals for improvement

BACKGROUND

There are currently no models for the transition of patients with metabolic bone diseases (MBDs) from paediatric to adult care. The aim of this project was to analyse information on the experience of physicians in the transition of these patients in Spain, and to draw up consensus recommendations with the specialists involved in their treatment and follow-up.

METHODS

The project was carried out by a group of experts in MBDs and included a systematic review of the literature for the identification of critical points in the transition process. This was used to develop a questionnaire with a total of 48 questions that would determine the degree of consensus on: (a) the rationale for a transition programme and the optimal time for the patient to start the transition process; (b) transition models and plans; (c) the information that should be specified in the transition plan; and (d) the documentation to be created and the training required. Recommendations and a practical algorithm were developed using the findings. The project was endorsed by eight scientific societies.

RESULTS

A total of 86 physicians from 53 Spanish hospitals participated. Consensus was reached on 45 of the 48 statements. There was no agreement that the age of 12 years was an appropriate and feasible point at which to initiate the transition in patients with MBD, nor that a gradual transition model could reasonably be implemented in their own hospital. According to the participants, the main barriers for successful transition in Spain today are lack of resources and lack of coordination between paediatric and adult units.

CONCLUSIONS

The TEAM Project gives an overview of the transition of paediatric MBD patients to adult care in Spain and provides practical recommendations for its implementation.

Implementation of Rheumatology Health Care Transition Processes and Adaptations to Systems Under Stress: A Mixed-Methods Study

OBJECTIVES

Despite poor health care transition outcomes among young adults with pediatric rheumatic diseases, adoption of transition best practices is low. We sought to understand how structured transition processes were operationalized within pediatric rheumatology practices and what factors were perceived to enable adaptations during a global pandemic.

METHODS

We conducted a mixed methods study of team leaders' experiences during an interim analysis of a pilot project to implement transition policy discussions at sites in the Childhood Arthritis and Rheumatology Research Alliance Transition Learning Collaborative. We combined quantitative assessments of organizational readiness for change (9 sites) and semistructured interviews of team leaders (8 sites) using determinants in the Exploration, Preparation, Implementation, Sustainment Framework.

RESULTS

Engagement of nursing and institutional improvement efforts facilitated decisions to implement transition policies. Workflows incorporating educational processes by nonphysicians were perceived to be critical for success. When the pandemic disrupted contact with nonphysicians, capacity for automation using electronic medical record (EMR)-based tools was an important facilitator, but few sites could access these tools. Sites without EMR-based tools did not progress despite reporting high organizational readiness to implement change at the clinic level. Lastly, educational processes were often superseded by acute issues, such that youth with greater medical/psychosocial complexity may not receive the intervention.

CONCLUSION

We generated several considerations to guide implementation of transition processes within pediatric rheumatology from the perspectives of team leaders. Careful assessment of institutional and nursing support is advisable before conducting complex transition interventions. Ideally, new strategies would ensure interventions reach youth with high complexity.

Co-designed healthcare transition interventions for adolescents and young adults with chronic conditions: a scoping review

PURPOSE

To determine the scope of published literature on healthcare transition (HCT) interventions that have been co-designed with adolescents and young adults with chronic conditions, and to undertake feasibility assessments.

METHODS

Using Scopus, CINAHL, Medline-Ovid, Cochrane and PsycINFO databases, publications that included a HCT intervention to support paediatric to adult healthcare transition were included. Study location, design, population, description of the intervention, co-design methods, feasibility evidenced using Bowen and colleagues' framework, and outcome measures were extracted for review.

RESULTS

A total of 21 studies were included, relating to 17 co-designed HCT interventions that ranged across multiple medical specialties. There was no standard HCT intervention; characteristics, format and delivery mode varied. Only three studies reported a detailed description of the co-design method(s) used and none reported on the facilitators or barriers. Among the studies, five of Bowen and colleagues' eight dimensions of feasibility were measured.

CONCLUSIONS

Despite the co-design process being neither described or evaluated extensively, all co-designed HCT interventions included in this review were considered to be feasible. Nevertheless, HCT interventions varied in their format and delivery method making it difficult to compare between them. Furthermore, interventions were often condition-specific and not representative of the extensive range of chronic conditions.Implications for RehabilitationHealthcare transition interventions can improve adherence to care, health outcomes, ongoing rehabilitation, and quality of life of adolescents and young adults with chronic conditions.Healthcare transition interventions should maximise long-term functioning and prioritise rehabilitation aimed at enhancing independence and self-management skills, while reducing hospitalisations.The engagement of individuals with lived experience in the co-design of interventions has been strongly advocated as it brings unique knowledge and experience to the research process.Minimal attention has been given to the involvement of adolescents and young adults with chronic conditions in the development of healthcare transition interventions, however, healthcare transition interventions co-designed with adolescents and young adults with chronic conditions are both feasible and acceptable.

A Mixed Method Study: Defining the Core Learning Needs of Nurses Delivering Care to Children and Young People with Rheumatic Disease to Inform Paediatric Musculoskeletal Matters, a Free Online Educational Resource

Children and young people with rheumatic diseases and their families are often supported by nurses who may not have had specialist training in paediatric rheumatology. The purpose of our study was to establish the core learning needs of all nurses who may encounter these children and young people in their clinical practice and use this information to inform the content and format of Paediatric Musculoskeletal Matters Nursing (PMM-Nursing) Engagement with nurses working in different roles and with various levels of experience in musculoskeletal medicine informed these learning needs and PMM-Nursing content. Mixed methods ascertained learning needs under the following themes: (1) Need for increased awareness about rheumatic disease; (2) Impact of experience and nursing role; (3) Need for increased knowledge about rheumatic disease and management. In addition, our methods informed design components for an impactful learning and information resource. Representatives from stakeholder nursing groups, social sciences, and web development used this information to create a suitable framework for PMM-Nursing. The content of PMM-Nursing is now live and freely available.

Provider perspectives of barriers and facilitators to the transition from pediatric to adult care: a qualitative descriptive study using the COM-B model of behaviour

Objectives

Transition of care can be a complex process that involves multiple providers working together across the pediatric and adult health care system to support youth. The shift from a primarily family-centred approach to a patient-centred approach that emphasizes more personal responsibility for health care management can be challenging for youth, caregivers and providers to navigate. Despite the importance of transition, there is a lack of evidence about the best practices and types of interventions that support the transition of care process from the perspective of both pediatric and adult health care providers. An exploration of barriers and facilitators is a critical first step to identifying important behavioural determinants for designing and implementing evidence-based interventions. As such, the purpose of this study was to identify the barriers and facilitators to the transition of care from the perspective of pediatric and adult health care providers.

Methods

A qualitative descriptive design was used to conduct semi-structured interviews guided by the COM-B Model of Behaviour – a theoretical model that suggests that for any behaviour to occur there must be a change in one or more of the following domains: capability, opportunity and/or motivation. The study took place in the province of Nova Scotia, Canada and focused on three common conditions: Inflammatory Bowel Disease, Diabetes, and Juvenile Idiopathic Arthritis. Participants were recruited through stratified purposeful and convenience sampling and all interviews were conducted virtually on Zoom. Interviews were audio-recorded, transcribed verbatim and imported into NVivo Qualitative Data Software for analysis. Data were first analyzed using directed content analysis, guided by the COM-B model, then further examined using inductive thematic analysis to identify barriers and facilitators within the three domains.

Results

In total, 26 health care providers participated in this study (pediatric, n=13, adult n=13) including a mix of adult and pediatric physicians, nurses, and allied health care professionals. The participants identified primarily as female (n=19.73%) and had a range of years of experience (3–39, mean = 14.84). We identified a range of interconnected barriers and facilitators across each of the COM-B Model of Behaviour domains such as, degree of formalized training (capability), facilitation and coordination responsibilities (opportunity), collaboration across providers (opportunities), securing attachment to adult care system (motivation) and time (opportunity). Findings were categorized by three overarching themes: (1) Knowledge and Skills to Support Transition of Care; (2) Navigation Role for Youth and Caregivers; and (3) System Coordination.

Conclusions

By using the COM-B Model of Behaviour, we identified key barriers and facilitators that intersect to influence the transition of care process. These findings will be used to inform and adapt initiatives and interventions in Nova Scotia to improve the transition experience, as well as may be transferrable to other jurisdictions.

The Utility of Self-Determination Theory in Predicting Transition Readiness in Adolescents With Special Healthcare Needs

PURPOSE

Adolescents and young adults with chronic health conditions must learn skills to successfully manage their health as they prepare to transition into adult-based care. Self-determination theory (SDT), an empirically based theory of human motivation, posits that competence (feeling effective), autonomy (volition to perform behaviors), and relatedness (support for autonomy from others) influence behavioral change. This study evaluates the utility of SDT constructs in predicting transition readiness among adolescents and young adults recruited into an intervention to promote successful healthcare transition.

METHODS

Baseline assessments were completed by 137 patients aged 17-23 years recruited from pediatric renal, gastroenterology, or rheumatology clinical services. Surveys measured transition readiness (Transition Readiness Assessment Questionnaire) as well as SDT constructs, including competence (Patient Activation Measure); provider relatedness and parent autonomy support (Health Care Climate Questionnaire); and health care-related autonomy (Treatment Self-Regulation Questionnaire). Relationships between SDT constructs and transition readiness were evaluated using linear regression.

RESULTS

Between 44 and 48 participants were recruited from each service. Bivariate correlation coefficients between transition readiness and SDT constructs were competence (r = .44), autonomous autonomy (r = .34), controlled autonomy (r = .27), provider relatedness (r = .46), and parental autonomy support (r = .35) (p < .01). Age positively correlated with transition readiness (r = .47, p < .001). After controlling for age, gender, and clinical service, competence (p < .001) and provider relatedness (p = .008) successfully predicted transition readiness (R² = .423; F change; p < .001).

CONCLUSIONS

Findings from this cross-sectional study support the utility of SDT constructs in promoting transition readiness among adolescents and young adults with chronic conditions, underscoring the importance of building competence and provider support for autonomy during this critical period.

Rheumatology education in India: a survey-based cross sectional study

This study aimed at understanding the perception and perspectives of rheumatology trainees about specialist training in India. Rheumatology trainees (Doctorate of Medicine, Diplomate of National Board) in Indian universities (2010 onwards) were contacted to complete a validated e-survey consisting of 41 questions to evaluate the current rheumatology training in India. Of 53 respondents (M:F 3.4:1, mean age 37 years ± 12.7), 81.1% trained at government hospitals, and 15.1% trained at private hospitals. During training period, 37.5% respondents were exposed to 6–7 h of didactics/week. They treated nearly 175 patients (175 ± 35.4) per week and reported a reasonable level of independence in management of patients with common rheumatic diseases (RDs) during their training (7.5 ± 0.7 SD). However, nearly one-third of the trainees were not exposed to basic immunology and laboratory techniques. Similarly, placement in the radiology department was not a part of the curriculum for nearly half of the trainees, 80% were not confident to manage paediatric RDs and soft tissue rheumatism. Almost 60% did not feel comfortable in addressing ancillary care including patient counselling as they had not received formal training. Among the participants, 59% were not satisfied by the current system of assessment, 86.8% suggested for multiple time point-based assessment systems and 45.3% preferred objective and subjective assessment in final examinations. Rheumatology training in India offers notable exposure to patients and independence in managing cases. However, there is an unmet need for improvement in training in the field of laboratory, radiology and ancillary care, and to overhaul assessment system by including objective evaluation.

"Improving the quality of care for adolescents and young adults on an adult medical ward"

BACKGROUND

Adolescents and young adults have health needs which are distinctly different from children and adults. A lack of education and training is reported by clinicians to be one of the main barriers to providing comprehensive developmentally appropriate care to young people, including the provision of confidential healthcare and taking a holistic approach.

AIM

This study documents the current provision of care to young people on an adult inpatient medical ward at a large tertiary teaching hospital in Auckland.

METHODS

Forty-three staff and 40 patients aged 16-24 years on an adult medical ward completed surveys, which were based on the Northern Regional Alliance, Northern Regional Youth Health Network Standards for Quality Care for Adolescents and Young Adults in Secondary or Tertiary Care.

RESULTS

Few staff (12%) had completed any specific training in looking after adolescent and young adult (AYA) patients. Confidentiality was not routinely discussed with young people by 50% of clinicians, and only 23% of staff reported that they see a young person alone as part of their consultation or admission. Less than half of young people reported receiving a comprehensive psychosocial assessment that included sexual health, mental health and suicide, and safety.

CONCLUSIONS

Key components of comprehensive developmentally appropriate healthcare were not regularly carried out by staff on an adult medical ward. These findings suggest that further education and training, and service improvements are needed in tertiary adult hospital settings. This article is protected by copyright. All rights reserved.

Patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology: a qualitative systematic review

OBJECTIVES

We aimed to describe patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology to inform patient-centred transitional care programmes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO and CINAHL to August 2019 and used thematic synthesis to analyse the findings.

RESULTS

From 26 studies involving 451 people with juvenile-onset rheumatic conditions we identified six themes: a sense of belonging (comfort in familiarity, connectedness in shared experiences, reassurance in being with others of a similar age, desire for normality and acceptance); preparedness for sudden changes (confidence through guided introductions to the adult environment, rapport from continuity of care, security in a reliable point of contact, minimizing lifestyle disruptions); abandonment and fear of the unknown (abrupt and forced independence, ill-equipped to hand over medical information, shocked by meeting adults with visible damage and disability, vulnerability in the loss of privacy); anonymous and dismissed in adult care (deprived of human focus, sterile and uninviting environment, disregard of debilitating pain and fatigue); quest for autonomy (controlled and patronized in the paediatric environment, liberated from the authority of others, freedom to communicate openly); and tensions in parental involvement (overshadowed by parental presence, guilt of excluding parents, reluctant withdrawal of parental support).

CONCLUSION

Young people feel dismissed, abandoned, ill-prepared and out of control during transition. However, successful transition can be supported by preparing for changes, creating a sense of belonging and negotiating parental involvement and autonomy. Incorporating patient-identified priorities into transitional services may improve satisfaction and outcomes in young people with juvenile-onset rheumatic conditions.

Patient and parent perspectives on transition from paediatric to adult healthcare in rheumatic diseases: an interview study

OBJECTIVES

To describe the experiences, priorities, and needs of patients with rheumatic disease and their parents during transition from paediatric to adult healthcare.

SETTING

Face-to-face and telephone semistructured interviews were conducted from December 2018 to September 2019 recruited from five hospital centres in Australia.

PARTICIPANTS

Fourteen young people and 16 parents were interviewed. Young people were included if they were English speaking, aged 14-25 years, diagnosed with an inflammatory rheumatic disease (eg, juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, panniculitis, familial Mediterranean fever) before 18 years of age. Young people were not included if they were diagnosed in the adult setting.

RESULTS

We identified four themes with respective subthemes: avoid repeat of past disruption (maintain disease stability, preserve adjusted personal goals, protect social inclusion); encounter a daunting adult environment (serious and sombre mood, discredited and isolated identity, fear of a rigid system); establish therapeutic alliances with adult rheumatology providers (relinquish a trusting relationship, seek person-focused care, redefine personal-professional boundaries, reassurance of alternative medical supports, transferred trust to adult doctor) and negotiate patient autonomy (confidence in formerly gained independence, alleviate burden on patients, mediate parental anxiety).

CONCLUSIONS

During transition, patients want to maintain disease stability, develop a relationship with their adult provider centralised on personal goals and access support networks. Strategies to comprehensively communicate information between providers, support self-management, and negotiate individualised goals for independence during transition planning may improve satisfaction, and health and treatment outcomes.

US Adult Rheumatologists' Perspectives on the Transition Process for Young Adults With Rheumatic Conditions

OBJECTIVE

To assess the attitudes and common practices of adult rheumatologists in the US regarding health care transition (HCT) for young adults with rheumatic diseases.

METHODS

An anonymous online survey was sent to US adult rheumatologist members of the American College of Rheumatology to collect demographic data and information on attitudes and common practices regarding the transition process.

RESULTS

Of 4,064 contacted rheumatologists, 203 (5%) completed the survey. Almost half of respondents (45.1%) were never trained in transition practices, and 74.7% were not familiar with the American Academy of Pediatrics/American Academy of Family Physicians/American College of Physicians Consensus Statement About Transitions for Youth with Special Healthcare Needs. Only 56.2% felt comfortable caring for former pediatric patients. The vast majority of respondents (90.7%) did not have a multidisciplinary transition team, and 37% did not have a plan for transitioning pediatric patients into their practice. Most adult rheumatologists were unsatisfied with the current transition process (92.9%), due to insufficient resources, personnel (91.1%), and time in clinic (86.9%). They also were unsatisfied with referral data received concerning previous treatments (48.9%), hospitalization history (48%), disease activity index (45.1%), medical history summary (43.9%), comorbidities (36.4%), medication list (34.1%), and disease classification (32.6%). Three major barriers to HCT were lack of insurance reimbursement (33.7%), knowledge about community resources (30.8%), and lapses in care between primary provider and specialist (27.8%).

CONCLUSION

This survey identified substantial gaps in knowledge and resources regarding HCT for young adults with rheumatic diseases. These may be best addressed by further training, research, dedicated resources, adequate payment, and practice guidelines.

Exposure and attitudes to adolescent health amongst Paediatric trainees in Northern Ireland: a mixed-methods study

AIMS

To determine the exposure and attitudes of paediatric trainees towards adolescent medicine.

METHODS

All paediatric trainees in the Northern Ireland deanery (n=107) were invited to participate in an online survey in March 2016. The questionnaire was based on the 'Modified Perceptions of Adolescent Issues and Resources: Care of Adolescents' questionnaire. The questions included a 5-point Likert scale (1-strongly disagree, 5-strongly agree) as well as open questions. All paediatric trainees were invited to attend focus groups to expand on themes generated from the questionnaire.

RESULTS

The response rate for the paediatric survey was 62% (n=66). Trainees identified adolescence as an area of importance similar to paediatrics and neonates; however, knowledge, confidence, skills and previous teaching in adolescent medicine were lower than for neonatal medicine and general paediatrics. Trainees who saw ≥6 adolescent patients per week were more likely to rate the importance of adolescent medicine higher. Trainees' perceived confidence, knowledge, self-rated skills and prior teaching in adolescent medicine were strongly correlated. Most (70%) respondents stated that they had not attended an adolescent transition clinic during their postgraduate training. Undergraduate and postgraduate teaching for adolescent health was rated poorly.

CONCLUSIONS

This project identified a paediatric trainee population that are aware of the importance of adolescent health but with low perceived knowledge, skills and confidence to manage them. Education is required to enhance learning and improve outcomes for adolescent patients.

Transitional Care in Rheumatology: a Review of the Literature from the Past 5 Years

PURPOSE OF REVIEW

Effective transitional care for adolescents and young adults (AYA) with rheumatic musculoskeletal disease (RMD) is fundamental to rheumatology care provision. Here we review the recent evidence from the literature on transition in rheumatology and debate why universal implementation has yet to be recognised.

RECENT FINDINGS

Evidence of need for transitional care continues to be reported. The triphasic nature of transitional care remains poorly recognised, and the third phase following transfer to adult rheumatology is particularly under-researched in spite of the recognition of the age-related trajectories of transition skill development during young adulthood. Several rheumatology-specific transitional care interventions have now been evaluated but the search for valid measures including outcome continues. Finally, the need to study transition at a health system level is increasingly recognised. Future research in this area should consider the developmental trajectories of AYA as well as the social-ecological model of transition readiness, which focuses on the interactions between AYA, caregivers and providers (and the systems they are part of) as these are the likely targets of any intervention to improve health transitions.

Adolescents and young adults (AYAs) affected by chronic immunological disease: A tool-box for success during the transition to adult care

Adolescence is a time of physical, psychological and social changes between childhood and adulthood. All adolescents and young adults (AYAs) are in transition and experience key underlying processes that will influence their later life. It is a critical period, particularly for AYAs with a chronic medical condition. Diseases can start at any point during adolescence. The transition of care will concern health care providers, as well as more unexpected actors such as social workers, teachers, business managers and the family. In this review, we focus on transition in primary immunodeficiencies (PIDs) and autoimmune diseases (AIDs). We describe the challenges and needs of transition in the field. Questions that AYAs with PID and/or AID must face during transition in their familial, professional and personal life are discussed. We expose a practical, AYA centered approach to help physicians in their daily practice, and we propose a position for the future.

The transition of adolescents with juvenile idiopathic arthritis or epilepsy from paediatric health-care services to adult health-care services: A scoping review of the literature and a synthesis of the evidence

Young people with long-term health conditions (LTCs) can face challenges when making the transition to adult health services. This paper sought to identify studies that assess and explore transitional care for young people with LTCs. Two conditions were used as exemplars: juvenile idiopathic arthritis (JIA) and epilepsy. A scoping review of the literature was conducted by using search terms to search for papers in English between 2001 and 2016 concerning transitional care on four databases. Qualitative papers were reviewed and synthesized using thematic analysis. Quantitative papers using health outcomes were also synthesized. Twenty-eight papers were selected for review. Despite the wealth of literature concerning aspects of transitional care that are key to a successful transition for young people with JIA or epilepsy, there is a paucity of outcomes that define 'successful' transition and consequently a lack of reliable research evaluating the effectiveness of transitional care interventions to support young people moving to adult health services.

Successful implementation of a clinical transition pathway for adolescents with juvenile-onset rheumatic and musculoskeletal diseases

BACKGROUND

In 2008 a clinical transition pathway for young people with juvenile-onset rheumatic and musculoskeletal diseases (jRMD) aiming at improving transitional care was instituted. Historical data on drop-out rate in our clinic was 35%, one year before the implementation of the transition pathway. This study aims to I) evaluate the effectiveness of the clinical transition pathway, II) evaluate the experiences and satisfaction of YP with the transitional process and evaluate their perceived self-management skills.

METHODS

Young people with any jRMD transferred from the pediatric to the adult rheumatology department in our academic center were eligible to enroll in this quantitative cross-sectional observational study between 2009 and 2015. Notably in 2012, we created a dedicated adolescent JIA-clinic, located at the adult rheumatology department. Electronic patient records from all young people that were transferred between 2009 and 2015 were reviewed for drop-out of care. Young people were asked to rate a VAS for 'satisfaction with transition' and to complete the "on your own feet transfer experience scale" (OYOF-TES)-questionnaire regarding their experiences and satisfaction with transition. Self-management skills were measured with the "on your own feet self-efficacy scale" (OYOF-SES)-questionnaire.

RESULTS

One hundred fifty-four young people were transferred to the adult department, of which 76 were transferred to the dedicated adolescent JIA-clinic. The mean age at transfer was 17.8 years for YP transferred to the adult clinic and 15.2 years for transfer to the adolescent clinic. Drop-out of care rate one year after transfer was 5.1% in the adult clinic and 1.3% in the adolescent JIA-clinic. Response rate of the returned questionnaires was 61% for the adolescent JIA clinic and 36% for the adult clinic. There was no difference between responders and non-responders in demographics and disease type besides age (non-responders were significantly younger). Young people transferred to the adult and adolescent JIA-clinic both had high scores on the satisfaction scale (7.7 and 7.5 on the VAS-scale and 72.0 and 74.5 on the OYOF-TES). Self-efficacy scores were high for both groups, with OYOF-SES 59.7 for those transferred to the adult clinic and 58.2 for those transferred to the adolescent JIA-clinic.

CONCLUSION

The implementation of the clinical transition pathway has led to a substantial improvement of patient care during the transitional process leading to low drop-out of care rate and high scores on satisfaction with transition. High scores on the self-reported self-efficacy scale suggests confidence of young people to have achieved sufficient skills to successfully manage their disease.

Transitional care for rheumatic conditions in Europe: current clinical practice and available resources

OBJECTIVE

To assess European pediatric rheumatology providers' current clinical practices and resources used in the transition from child-centered to adult-oriented care.

METHODS

European pediatric rheumatologists were invited to complete a 17-item anonymized e-survey assessing current transition practices, transition policy awareness, and needs in advance of the publication of EULAR/PReS recommendations on transition.

RESULTS

The response rate was 121/276 (44%), including responses from 115 centers in 22 European Union countries. Although 32/121 (26%) responded that their centers did not offer transition services, the majority (99%) agreed that a formalized process in transitioning patients to adult care is necessary. A minority (<30%) of respondents stated that they have a written transition policy although 46% have an informal transition process. Designated staff to support transitional care were available in a minority of centers: nurse (35%), physiotherapist (15%), psychologist (15%), social worker (8%), and occupational therapist (2%). The existence of a designated team member to coordinate transition was acknowledged in many centers (64% of respondents) although just 36% use a checklist for young people as part of individualized transitional care.

CONCLUSION

This survey of European pediatric rheumatology providers regarding transitional care practices demonstrates agreement that transitional care is important, and wide variation in current provision of transition services exists.

'Training gap' - the present state of higher specialty training in adolescent and young adult health in medical specialties in the UK

Young people often experience worse health outcomes and more dissatisfaction with healthcare compared with other age groups. This survey sought to determine the state of adolescent and young adult health training across medical specialties in the UK. An online questionnaire was distributed to higher specialty trainees in adult medical specialties. Training in adolescent/young adult health/transition was rated as minimal/non-existent by 70/73% of respondents, respectively; 52% reported that they had received no formal training and 61% had never attended a dedicated young person's or transition clinic. The most significant barrier to delivering good adolescent and young adult healthcare was felt to be lack of training to deal with adolescent issues. This survey has identified a 'training gap'; a lack of preparation to meet the specific care needs of the adolescent and young adult population. Improved interventions are required to help drive improvement in care for young people in the UK.

Challenges in transitioning adolescents and young adults with rheumatologic diseases to adult Care in a Developing Country - the Brazilian experience

BACKGROUND

Transition guidelines and recommendations for developing countries are limited and best transition practices in young patients with chronic medical conditions have been poorly examined. This study evaluates transition practices from pediatric to adult rheumatology care in Brazil.

METHODS

Practicing pediatric rheumatologists registered in the Brazilian Society of Rheumatology were e-surveyed with SurveyMonkey® using the Chira et al. questionnaire that had been used previously to evaluate transition practices of pediatric rheumatologists from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) in the USA and Canada. The questionnaire was modified to better address specific issues pertaining to the Brazilian health care system.

RESULTS

Seventy-six of 112 (68%) pediatric rheumatologists responded. Only 13% of the respondents reported that they had a well-established transition program and only 14% were satisfied with their current transition process. Eighty percent did not use any specific tools to assess transition readiness. While 43% of respondents considered 18 as the ideal transition age, only a third effectively transitioned their patients at that age while 48% did later. Major hurdles for a successful transition cited by the respondents included emotional attachment to the patients (95%) insufficient training in transition practice (87%), lack of devoted time for transition preparation and process (80%), lack of assistance by pediatric generalists, (77%), and lack of available adult subspecialists (75%). Sixty-seven percent of respondents stated that their program would need more tools/resources to facilitate transition and 59% believed that the development of specific guidelines would be useful to standardize and help with the transition process.

CONCLUSIONS

Our study demonstrates that the identified challenges pertaining to transition in Brazilian patients are similar to those reported by pediatric rheumatologists in the United States and Canada. However, the current financial economic pressures affecting Brazil's health care system may force physicians to deprioritize non emergent care such as transition. A comprehensive understanding of transition issues specific to youth in developing countries and educating not only patients but also health care providers about the importance of a seamless transition process will support the development of transition guidelines and ensure better outcomes of pediatric subspecialty patients.

Transition to adult rheumatology care is necessary to maintain DMARD therapy in young people with juvenile idiopathic arthritis

OBJECTIVE

To evaluate the outpatient health service utilisation of young people (YP) with juvenile idiopathic arthritis (JIA) during transfer from paediatric to adult care in Germany.

METHODS

Based on claims data of a large German statutory health fund (BARMER GEK) we conducted a cohort study of 2008-2014. Insured YP with diagnosis of JIA (ICD: M08 or M09.0) in two quarters at the age of 16 and continuous insurance until the age of 20 were included. Outpatient health care utilisation, prescribed antirheumatic drugs and diagnosis maintenance were analysed over four consecutive years for all YP with JIA and for the subgroup on disease-modifying antirheumatic drugs (DMARDs) at the age of 16.

RESULTS

A total of 256 YP with JIA (67% female) were followed during the transfer period, 115 of them received (DMARDs) at the age of 16. At the age of 20, 30% of all 256 YP utilised adult specialty care, 59% still had a JIA diagnosis and 30% were treated with DMARDs. Of those 115 YP, treated with DMARDs at the age of 16 and in need of follow-up, 49% had visited an adult rheumatologist at the age of 20, 75% had a JIA diagnosis and 56% were on DMARDs. Those 49% YP with successful transfer to adult specialty care had a JIA diagnosis in 93% and were treated with DMARDs in 80%. YP, who were only seen by general practitioners, had a JIA diagnosis in 54% and received DMARDs in 27%.

CONCLUSIONS

One in two YP with JIA and a clear need for ongoing follow-up do not utilise adult rheumatologic care. The maintenance of JIA diagnosis and DMARD therapy depend on the utilisation of specialised care services.

Educational needs of health professionals working in rheumatology in Europe

Objective

To explore the availability of postgraduate education for health professionals (HPs) working in rheumatology in Europe, and their perceived educational needs and barriers for participation in current educational offerings.

Methods

Structured interviews were conducted with national representatives of rheumatology HPs' organisations and an online survey among individual HPs was disseminated through existing European League Against Rheumatism (EULAR) networks (10 languages including English). These comprised questions on: availability of postgraduate education, familiarity with EULAR and its educational offerings, unmet needs regarding the contents and mode of delivery and potential barriers to participate in education (0–10 scales).

Results

According to 17 national representatives, postgraduate rheumatology education was most common for nurses, physical and occupational therapists. There were 1041 individuals responding to the survey, of whom 48% completed all questions. More than half (56%) were familiar with EULAR as an organisation, whereas <25% had attended the EULAR congress or were familiar with EULAR online courses. Educational needs regarding contents were highest for ‘inflammatory arthritis’ and ‘connective tissue diseases’ and regarding modes of delivery for ‘courses organised in own country’ and ‘online courses’. Important barriers to participation included lack of ‘resources’, ‘time’ and ‘English language skills’. Overall, there was considerable variation in needs and barriers among countries.

Conclusions

There is a lack of postgraduate rheumatology education for HPs in most countries. There are opportunities to raise awareness regarding EULAR educational offerings and to develop courses provided in HPs' own country, tailored to national needs and barriers and taking language barriers into consideration.

The Prevocational and Early Employment Needs of Adolescents with Juvenile Idiopathic Arthritis: The Occupational Therapy Perspective

The purpose of the study was to explore the prevocational needs of adolescents with juvenile idiopathic arthritis (JIA) from the perspective of occupational therapists and to examine the role of occupational therapy in addressing these. A questionnaire was distributed to members of occupational therapy organisations (n = 494) to assess the perceived importance of addressing prevocational issues for adolescents with JIA and the respondents' knowledge, confidence and perceived role. The questionnaire was completed by 175 (35.4%) individuals.

The results showed that although the occupational therapists felt that they were an appropriate profession to address the vocational needs of adolescents, they reported limited knowledge and confidence to do so. Significant unmet training needs were highlighted. This study echoes previous calls for vocational issues to be addressed within adolescent rheumatology and provides evidence that occupational therapy is well placed to coordinate this area of need.

The Prevocational and Early Employment Needs of Adolescents with Juvenile Idiopathic Arthritis: The Adolescent Perspective

The purpose of this study was to explore the prevocational needs of adolescents with juvenile idiopathic arthritis (JIA) from their own perspectives.

A focus group discussion was undertaken with eight adolescents with JIA (14.2–16.6 years) attending one United Kingdom hospital. The topics of interest were (i) attitudes towards education, prevocational readiness and employment in relation to JIA; (ii) perceived barriers; (iii) coping strategies; and (iv) preferred sources of support. The data were analysed according to standardised procedures that included data reduction, data display, conclusion drawing and conclusion verifying.

The provision of vocational support for young people with JIA was reported to be uncoordinated, limited and unresponsive to individual needs. A recurrent theme was that professionals generally underestimated adolescents' educational and vocational potential. This was felt to be true of teachers, careers advisers, admissions personnel at colleges and universities and potential employers. Most adolescents worried about discrimination and those in whom the JIA was not visible felt a dilemma about disclosure to potential employers.

The current framework of careers advice appeared to have failed the adolescents in this study who, in the absence of satisfactory support, found themselves consulting health professionals instead. Greater careers advice support for adolescents and professionals is warranted.

Integrating Adolescents and Young Adults into Adult-Centered Care for IBD

Planned healthcare transition, initiated in pediatric care, is a gradual process aimed at fostering the adolescent patient's disease knowledge and skills with the ultimate objective of preparing patients and families for adult-centered care. The process is critical in inflammatory bowel diseases (IBD) where there is an increased risk of non-adherence, hospitalizations, and emergency department use as young adult patients graduate from pediatric to adult-centered care. While evidence for healthcare transition in IBD is mounting, important gaps remain in the understanding of this process from the perspective of the adult gastroenterologist. This paper summarizes what is known about healthcare transition in IBD and explores the unanswered questions-a conceptual and methodological framework for transition interventions, relevant outcomes that define successful transition, and key stakeholder perspectives. For the adult gastroenterologist managing the young adult patient population, this paper presents the paradigm of "care integration"-a process of ongoing, multi-modality support for the patient, initiated in the adult care setting, with the goal of improving self-management skills and active participation in medical decision-making.

Transition of care for adolescents from paediatric services to adult health services

BACKGROUND

There is evidence that the process of transition from paediatric (child) to adult health services is often associated with deterioration in the health of adolescents with chronic conditions.Transitional care is the term used to describe services that seek to bridge this care gap. It has been defined as 'the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centred to adult-oriented health care systems'. In order to develop appropriate services for adolescents, evidence of what works and what factors act as barriers and facilitators of effective interventions is needed.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve the transition of care for adolescents from paediatric to adult health services.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials 2015, Issue 1, (including the Cochrane Effective Practice and Organisation of Care Group Specialised Register), MEDLINE, EMBASE, PsycINFO, and Web of Knowledge to 19 June 2015. We also searched reference lists of included studies and relevant reviews, and contacted experts and study authors for additional studies.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled before- and after-studies (CBAs), and interrupted time-series studies (ITSs) that evaluated the effectiveness of any intervention (care model or clinical pathway), that aimed to improve the transition of care for adolescents from paediatric to adult health services. We considered adolescents with any chronic condition that required ongoing clinical care, who were leaving paediatric services and going on to receive services in adult healthcare units, and their families. Participating providers included all health professionals responsible for the care of young people.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from included papers, assessed the risk of bias of each study, and assessed the certainty of the evidence for the main comparisons using GRADE. Discrepancies were resolved by discussion. Authors were contacted for missing data. We reported the findings of the studies as pre- and post-intervention means and calculated the unadjusted absolute change from baseline with 95% confidence intervals (CI).

MAIN RESULTS

We included four RCTs (N = 238 participants) that explored: a two-day workshop-based transition preparation training for adolescents with spina bifida; a nurse-led, one-on-one, teaching session with the additional support of a 'health passport' for adolescents with heart disease; a web- and SMS-based educational intervention for adolescents with a range of different conditions; and a structured comprehensive transition programme with a transition co-ordinator for adolescents with type 1 diabetes.One study evaluating a one-on-one nurse-led intervention, and one evaluating a technology-based intervention suggested that these interventions may lead to slight improvements in transitional readiness and chronic disease self-management measured at six- to eight-month follow-ups (low certainty evidence). Results with the TRAQ self-management tool were: MD 0.20; 95% CI -0.16 to 0.56 and MD 0.43; 95% CI; -0.09 to 0.95; with the TRAQ self-advocacy tool: MD 0.37; 95% CI -0.06 to 0.80; and with the PAM tool were: MD 10; 95% CI 2.96 to 17.04. In contrast, transition-preparation training delivered via a two-day workshop for patients with spina bifida may lead to little or no difference in measures of self-care practice and general health behaviours when measured using the DSCPI-90©.Two studies evaluated the use of health services. One study evaluated a technology-based intervention and another a comprehensive transition programme; these interventions may lead to slightly more young people taking positive steps to initiate contact with health professionals themselves (Relative risk (RR): 4.87; 95% CI 0.24 to 98.12 and RR 1.50; 95% CI 0.32 to 6.94, respectively; low certainty evidence.Young people's knowledge of their disease may slightly improve with a nurse-led, one-on-one intervention to prepare young people for transition to an adult congenital heart programme (MD 14; 95% CI 2.67 to 25.33; one study; low certainty evidence).Disease-specific outcome measures were reported in two studies, both of which led to little or no difference in outcomes (low certainty evidence). One study found little or no difference between intervention and control groups. A second study found that follow-up HbA1c in young people with type 1 diabetes mellitus increased by 1.2% for each percentage increase in baseline HbA1c, independent of treatment group (1.2%; 95% CI 0.4 to 1.9; P = 0.01).Transition interventions may lead to little or no difference in well-being or quality of life as measured with the PARS III or PedsQ (two studies; low certainty evidence). Both the technology-based intervention and the two-day workshop for young people with spina bifida found little or no difference between intervention and control groups (MD 1.29; 95% CI -4.49 to 7.07). One study did not report the data.Four telephone support calls from a transition co-ordinator may lead to little or no difference in rates of transfer from paediatric to adult diabetes services (one study; low certainty evidence). At 12-month follow-up, there was little or no difference between groups of young people receiving usual care or a telephone support (RR 0.80; 95% CI 0.59 to 1.08)). They may slightly reduce the risk of disease-related hospital admissions at 12-month follow-up (RR 0.29; 95% CI 0.03 to 2.40).

AUTHORS' CONCLUSIONS

The available evidence (four small studies; N = 238), covers a limited range of interventions developed to facilitate transition in a limited number of clinical conditions, with only four to 12 months follow-up. These follow-up periods may not be long enough for any changes to become apparent as transition is a lengthy process. There was evidence of improvement in patients' knowledge of their condition in one study, and improvements in self-efficacy and confidence in another, but since few studies were eligible for this review, and the overall certainty of the body of this evidence is low, no firm conclusions can be drawn about the effectiveness of the evaluated interventions. Further research is very likely to have an important impact on our confidence in the intervention effect and likely could change our conclusions. There is considerable scope for the rigorous evaluation of other models of transitional care, reporting on clinical outcomes with longer term follow-up.

Uncharted Territory: Systematic Review of Providers' Roles, Understanding, and Views Pertaining to Health Care Transition

BACKGROUND

Health care transition (HCT) for adolescents and emerging adults (AEA) with special health care needs is an emerging field of interdisciplinary field of practice and research that is based upon an intergenerational approach involving care coordination between pediatric and adult systems of health care. Informed understanding of the state of the HCT science pertaining to this group of providers is needed in order to develop and implement service programs that will meet the comprehensive needs of AEA with special health care needs.

METHODS

The authors conducted a systematic review of the literature on the transition from child to adult care for adolescents and emerging adults (AEA) with special health care needs from 2004 to 2013. Fifty-five articles were selected for this review. An adaptation of the PRISMA guidelines was applied because all studies in this review used descriptive designs.

RESULTS

Findings revealed lack of evidence due to the limitations of the research designs and methodology of the studies included in this systematic review. Study findings were categorized the following four types: adult provider competency, provider perspectives, provider attitudes, and HCT service models. The discipline of medicine was predominant; interdisciplinary frameworks based upon integrated care were not reported. Few studies included samples of adult providers.

CONCLUSIONS

Empirical-based data are lacking pertaining to the role of providers involved in this specialty area of practice. Evidence is hampered by the limitations of the lack of rigorous research designs and methodology.

Disability and Discussions of Health-Related Behaviors Between Youth and Health Care Providers

PURPOSE

The purpose of this study was to examine the likelihood of discussing health-related behaviors with health care providers (HCPs), comparing youth with and without mobility limitations (MLs).

METHODS

Analyses were conducted using baseline data from the MyPath study. Adolescents and young adults between the ages of 16 and 24 years completed a survey about their health care and health-related experiences. Analyses assessed the relationship between mobility status and discussing health-related behaviors with an HCP. Secondary analyses examined the extent to which adolescents and young adults' engagement in these behaviors was associated with these discussions.

RESULTS

Overall, we found low rates of discussions about the following topics: substance use, sexual and reproductive health, healthy eating, weight, and physical activity. Adolescents and young adults with MLs were less likely to report discussing substance use and sexual and reproductive health, but were more likely to discuss healthy eating, weight, and physical activity than peers without MLs. Those adolescents and young adults who reported substance use had higher odds of discussing this topic and those who reported having sexual intercourse had higher odds of discussing sexual and reproductive health.

CONCLUSIONS

Results suggest mobility status and a young person's engagement in health risk and promoting behaviors are associated with the likelihood of discussing these behaviors with an HCP. It is important that HCPs view adolescents and young adults with MLs as needing the same counseling and guidance about health-related behaviors as any young person presenting him/herself for treatment.

The Emerging Adult with Inflammatory Bowel Disease: Challenges and Recommendations for the Adult Gastroenterologist

Incidence of pediatric inflammatory bowel disease (IBD) is rising. Adult gastroenterologists are seeing increasing numbers of young adults with IBD, a subpopulation with unique needs and challenges that can impair their readiness to thrive in an adult healthcare system. Most adult gastroenterologists might not have the training or resources to address these needs. “Emerging adulthood” is a useful developmental lens through which this group can be studied. With complex disease phenotype and specific concerns of medication side effects and reproductive health, compounded by challenges of geographical and social flux and lack of adequate health insurance, emerging adults with IBD (EAI) are at risk of disrupted care with lack of continuity. Lessons learned from structured healthcare transition process from pediatric to adult services can be applied towards challenges in ongoing care of this population in the adult healthcare system. This paper provides an overview of the challenges in caring for the post transition EAI from the perspective of adult gastroenterologists and offers a checklist of provider and patient skills that enable effective care. This paper discusses the system-based challenges in care provision and search for meaningful patient-oriented outcomes and presents a conceptual model of determinants of continuity of care in this unique population.

Consensus of the Spanish society of pediatric rheumatology for transition management from pediatric to adult care in rheumatic patients with childhood onset

To develop recommendations on the transition from pediatric care to adult care in patients with chronic inflammatory rheumatic diseases with childhood onset based. Recommendations were generated following nominal group methodology and Delphi technique. A panel of 16 experts was established. A systematic literature review (on transitional care) and a narrative review were performed and presented to the panel in the first panel meeting to be discussed. A first draft of recommendations was generated and circulated. Focal groups with adolescents, young adults and parents were organized. In a second meeting, the focus group results along with the input from invited psychologist were used to establish definitive recommendations. Then, a Delphi process (two rounds) was carried out. A group of 72 pediatric and adult rheumatologists took part. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70 % voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford center for evidence-based medicine levels of evidence. Transition care was defined as a purposeful, planned process that addresses the medical, psychosocial and educational/vocational needs of adolescents and young adults with chronic inflammatory rheumatic diseases with childhood onset as they move from child-centered to adult-oriented healthcare systems. The consensus covers: transition needs, barriers and facilitators, transitional issues (objectives, participants, content, phases, timing, plans, documentation and responsibilities), physicians' and other health professionals' knowledge and skill requirements, models/programs, and strategies and guideline for implementation. Preliminary recommendations and agreement grade are shown in the Table (first Delphi round). These recommendations are intended to provide health professionals, patients, families and other stakeholders with a consensus on the transition process from pediatric to adult care.

Transitioning youth with rheumatic conditions: perspectives of pediatric rheumatology providers in the United States and Canada

OBJECTIVE

To assess North American pediatric rheumatology providers' perspectives on practices, barriers, and opportunities concerning the transition from pediatric-centered to adult-centered care.

METHODS

Childhood Arthritis and Rheumatology Research Alliance (CARRA) members completed a 25-item survey assessing current transition practices, transition policy awareness, and transitional care barriers and needs. Results were compared to the American Academy of Pediatrics (AAP) 2008 survey on transitional care.

RESULTS

Over half (158/288, 55%) of CARRA members completed the survey. Fewer than 10% are very familiar with AAP guidelines about transition care for youth with special healthcare needs. Eight percent have a formal written transition policy, but 42% use an informal approach. Patient request (75%) most frequently initiates transfer to adult care. Two major barriers to transition are fragmented adult medical care and lack of sufficient time to provide services. Compared with AAP survey participants, pediatric rheumatology providers are significantly more likely to help youth find an adult specialist (63% vs 45%) and discuss confidentiality and consent before age 18 (45% vs 33%), but are less likely to help with medical summary creation (16% vs 27%) or find a primary care provider (25% vs 47%). Outcomes ranked as "very important" in defining a successful transition are survival (76%), seeing an adult rheumatologist within 6 months of final pediatric rheumatology visit (66%), and maintaining insurance coverage (57%).

CONCLUSION

This comprehensive survey of North American pediatric rheumatology providers regarding transitional care practices demonstrates deficiencies in education, resources, and a formalized process. Respondents support development of standardized rheumatology-specific transition practices.

Rationale, design and baseline data of a mixed methods study examining the clinical impact of a brief transition programme for young people with juvenile idiopathic arthritis: the DON'T RETARD project

OBJECTIVES

To describe (1) the content of a transition programme for young people with juvenile idiopathic arthritis (JIA) designed as a brief intervention, (2) the rationale and design of a mixed-methods study evaluating the clinical impact of this transition programme and (3) to provide baseline data of the intervention group.

DESIGN

An 'embedded experimental' design is used for the evaluation of the transition programme. A 'one-group pretest-posttest, with a non-equivalent posttest-only comparison group design' is used to quantitatively evaluate the impact of the transition programme, applying both longitudinal and comparative analyses. Subsequently, experiences of adolescents and their parents who participated in the experimental group will be analysed qualitatively using content analysis.

SETTING

Participants in the intervention are recruited at a tertiary care centre in Belgium. The comparison group participants are recruited from one tertiary and three secondary care centres in Belgium.

PARTICIPANTS

The intervention group consists of 33 young people (25 females; 8 males) with a median age of 16 years. Main diagnoses are persistent or extended oligoarticular JIA (33%), polyarticular JIA (30%), enthesitis-related JIA (21%) or systemic arthritis (15%).

INTERVENTION

The transition programme comprises eight key components: (1) transition coordinator; (2) providing information and education; (3) availability by telephone; (4) information about and contact with an adult care programme; (5) guidance of parents; (6) meeting with peers; (7) transfer plan; and (8) actual transfer to adult care.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome is health status, as perceived by the adolescents. Secondary outcomes are health status, as perceived by the parents; medication adherence; illness-related knowledge; quality of life; fatigue; promotion of independence; support of autonomy; behavioural control and psychological control.

RESULTS

At baseline, the median score was 69.2 (Q1=60.0;Q3=92.9) on psychosocial health and 68.8 (Q1=56.3; Q3=89.1) on physical health. Rheumatic-specific health scores ranged from 62.5 to 100.

CONCLUSIONS

We present the rationale and design of a study intended to evaluate a transition programme for adolescents with JIA as a brief intervention.

'Everybody's business': transition and the role of adult physicians

The outcome of transition from paediatric to adult care is often judged by what happens after transfer. Young people at the point of transfer are reported to have low levels of knowledge and independence. These observations could be interpreted in one of two ways: either that the transition process before transfer is inadequate or that the transition process needs to continue into young adulthood and therefore adult care. The second interpretation is further supported by brain development continuing into the third decade. There is also growing evidence for the effectiveness of young adult clinics in the process of transition. To optimise transition, adult physicians need not only to work with paediatricians to achieve continuity during transfer, but also to look critically at their service as to how it can be changed to meet the needs of young people. In addition, they need to develop knowledge, skills and attitudes to communicate effectively and address a young person's developmental and health needs.

The requirements and barriers to successful transition of adolescents with inflammatory bowel disease: differing perceptions from a survey of adult and paediatric gastroenterologists

BACKGROUND AND AIM

Preliminary data highlight the importance of appropriate transition for successful transfer of adolescents with IBD from paediatric to adult care. The aim of this study was to identify both the perceived needs of adolescent IBD patients and the barriers to successful transition from the perspective of professionals involved in their care.

METHODS

A postal questionnaire was distributed to UK adult and paediatric gastroenterologists with an interest in IBD. The questionnaire utilised closed questions as well as ranked items on the importance of the various competencies of adolescents with IBD required for successful transition.

RESULTS

Response rate of 62% and 49% for paediatric and adult gastroenterologists respectively was achieved. A structured transition service was perceived as very important by 80% paediatric compared to 47% adult gastroenterologists (p=0.001). A higher proportion of adult than paediatric gastroenterologists identified inadequacies in the preparation of adolescents for transfer (79% and 42%, p=0.001). The main areas of perceived deficiency in preparation identified were patient lack of knowledge about the condition and treatment, lack of self advocacy and co-ordination of care. Lack of resources, clinical time, and a critical mass of patients were the factors ranked highest by both groups as barriers to transition care. Both adult (65%) and paediatric gastroenterologists (62%) highlighted suboptimal training in adolescent medicine for adult gastroenterologists.

CONCLUSIONS

This survey highlights differences in the perception of adult and paediatric gastroenterologists in the management of transition care and perceived competencies for adolescents with IBD. Lack of training and inadequate resources are the main barriers identified for development of a successful transition service.

Transitions in care: support group for young adults with Type 1 diabetes

AIMS

Young adulthood is a challenging period for patients with Type 1 diabetes as developmental changes complicate Type 1 diabetes management and gaps in care may arise as patients transition from paediatric to adult providers. This period has been associated with worsening diabetes outcomes. One approach to aid young adults during this transition period could entail professionally led support groups to enhance self-motivation and facilitate peer-to-peer interactions. We implemented and evaluated a support group for young adults with Type 1 diabetes as a pilot project.

METHODS

Young adults with Type 1 diabetes (18-30 years) participated in monthly, professionally led support groups for 5 months. Questionnaires were completed pre- and post-group and chart review data were collected regarding glycaemic control and visit frequency in the year before and after group participation.

RESULTS

Participation in the group was associated with improvement in HbA(1c) and decreased self-reported diabetes burden, along with a trend for an increase in diabetes-related self-care behaviours. Frequency of visits did not vary from pre- to post-group. Discussion topics identified by participants included managing diabetes in day-to-day life, experiences and interactions with others who do not have diabetes and emotions related to diabetes. Participants identified that they sought a diabetes care team that offers knowledge, support and a multidisciplinary team.

CONCLUSIONS

Professionally led support groups may have utility for increasing social support and optimizing diabetes outcomes in young adults with Type 1 diabetes.

A social-ecological model of readiness for transition to adult-oriented care for adolescents and young adults with chronic health conditions

BACKGROUND

Policy and research related to transition to adult care for adolescents and young adults (AYAs) has focused primarily on patient age, disease skills and knowledge.

OBJECTIVE

In an effort to broaden conceptualization of transition and move beyond isolated patient variables, a new social-ecological model of AYA readiness for transition (SMART) was developed.

METHODS

SMART development was informed by related theories, literature, expert opinion and pilot data collection using a questionnaire developed to assess provider report of SMART components with 100 consecutive patients in a childhood cancer survivorship clinic.

RESULTS

The literature, expert opinion and pilot data collection support the relevance of SMART components and a social-ecological conceptualization of transition. Provider report revealed that many components, representing more than age, disease knowledge and skills, related to provider plans for transferring patients.

CONCLUSIONS

SMART consists of inter-related constructs of patients, parents and providers with emphasis on variables amenable to intervention. Results support SMART's broadened conceptualization of transition readiness and need for assessment of multiple stakeholders' perspectives of patient transition readiness. A companion measure of SMART, which will be able to be completed by patients, parents and providers, will be developed to target areas of intervention to facilitate optimal transition readiness. Similar research programmes to establish evidence-based transition measures and interventions are needed.

Systems thinking perspectives applied to healthcare transition for youth with disabilities: a paradigm shift for practice, policy and research

BACKGROUND

Healthcare transition (HCT) for youth with disabilities is a complex phenomenon influenced by multiple interacting factors, including health, personal and environmental factors. Current research on the transition to adulthood for disabled youth has primarily focused on identifying these multilevel factors to guide the development of interventions to improve the HCT process. However, little is known about how this complex array of factors interacts and contributes to successful HCT. Systems thinking provides a theoretically informed perspective that accounts for complexity and can contribute to enhanced understanding of the interactions among HCT factors. The objective of this paper is to introduce general concepts of systems thinking as applied to HCT practice and research.

METHODS

Several systems thinking concepts and principles are introduced and a discussion of HCT as a complex system is provided. Systems dynamics methodology is described as one systems method for conceptualizing HCT. A preliminary systems dynamics model is presented to facilitate discourse on the application of systems thinking principles to HCT practice, policy and research.

CONCLUSIONS

An understanding of the complex interactions and patterns of relationships in HCT can assist health policy makers and practitioners in determining key areas of intervention, the impact of these interventions on the system and the potential intended and unintended consequences of change. This paper provides initial examination of applying systems thinking to inform future research and practice on HCT.

Transitioning the adolescent inflammatory bowel disease patient: guidelines for the adult and pediatric gastroenterologist

Twenty percent of inflammatory bowel disease (IBD) patients present in the pediatric years, with recent reports suggesting a rising incidence in the pediatric age group. This highlights the need for both pediatric and adult gastroenterologists to better understand issues related to the process of transition from pediatric to adult care. Research from other disciplines outside of IBD provide evidence that the transition period can be associated with poorer health outcomes and that a structured transition program may improve patient compliance and disease control. Recent data from the IBD literature support a need for transition clinics. The ideal model of a transition program has not been established. Controlled trials are not available to measure the impact of a structured transition program on clinically relevant endpoints such as disease control and hospital admissions. As local resources and availability of staffing and funding are highly variable, we have summarized some practical guidelines for the adult and pediatric gastroenterologist that can be used as an aid to help adolescents through the transition process even without the support of an established transition clinic.

The place of pediatric rheumatology in India

Rheumatology is a relatively new specialty in the field of Pediatrics in India where there are only a few centres of excellence. Awareness about these conditions in childhood is lacking and patients are often referred late resulting in poor long term outcomes. This article highlights the needs of the paediatric rheumatology patients which are complex and should encompass both acute and chronic care and also plan a smooth transition to the adult rheumatology world. In the year 2010, attaining remission is the goal for every child with a rheumatologic disorder, which is seldom achieved for the Indian pediatric rheumatologic patient. The article discusses the reasons for poor awareness, the current outcome for these patients and details the burden of disease in India. The health care delivery system and finally the way forward have been discussed.