Impact of a paediatric-adult care transition programme on the health status of patients with sickle cell disease: study protocol for a randomised controlled trial (the DREPADO trial)

Sickle Cell Trevor Thompson Transition Project (ST3P-UP) protocol for managing care transitions: Methods and rationale

BACKGROUND

Emerging adults with sickle cell disease (EASCD) experience significant challenges transitioning from pediatric to adult care. Acute care utilization increases, quality of life (QOL) declines, with an increased risk of mortality. Currently, there are no practice standards to guide emerging adults through the transition process. We are creating a structured transition education (STE) based program for EASCD by customizing the Six Core Elements (6 CE) of Health Care Transition model and are evaluating the effectiveness of adding peer mentoring (PM).

METHODS

The Sickle Cell Trevor Thompson Transition Project (ST3P-UP) is an ongoing multi-site, cluster randomized clinical trial with a target enrollment of 537 EASCD aged 16 to 25 years in pediatric care. Each site (n = 14) comprises a pediatric clinic, adult clinic, and a sickle cell disease (SCD) community-based organization (CBO). Sites are randomized 1:1 to either STE or STE + PM. EASCDs are followed prospectively for 24 months. Rapid cycle plan-do-study-act quality improvement (QI) methods are used to implement the STE. The primary objective is to compare the effectiveness of STE + PM versus STE only at decreasing the number of acute care visits per year over 24 months. The secondary objectives are to compare overall healthcare utilization and patient-reported QOL outcomes at 24 months.

CONCLUSION

We aim to demonstrate the feasibility of using a QI approach to implement 6 CE-based practice standards at 14 disparate SCD clinical programs to guide EASCD through the transition process. We hypothesize that adding PM to the STE program will improve acute care reliance, QOL, and satisfaction with transition outcomes.

Exploration of barriers and facilitators to the implementation of the DREPADO randomized controlled trial: A qualitative study

PURPOSE

DREPADO is a randomized controlled trial (RCT) assessing the impact of a pediatric-adult transition program, on the health status of adolescents with sickle cell disease. Using a biopsychosocial approach with three main facets (educational, psychological and social interactions), it constitutes a complex transition program, which is quite difficult to implement. To facilitate the implementation of this complex program, the aim of this ancillary study is to explore barriers and facilitators at the early stages of this implementation.

METHODS

A qualitative study with semi-structured interviews was conducted, according to COREQ quality criteria, in patients with sickle cell disease who had already experienced the transition to adult care before DREPADO, and healthcare professionals working on the DREPADO RCT.

RESULTS

Semi-structured interviews were conducted with patients (n = 12) and healthcare professionals (n = 12) from November 2019 to May 2020. The main barriers identified by patients were time and implication required by this transition program. Healthcare professionals involved in the coordinating center mentioned changes in their working habits and also elements about the RCT regulatory procedures. Main facilitators reported by both patients and healthcare professionals were the positive perception of the transition program design, and especially the home setting for therapeutic education sessions.

CONCLUSION

This study led to the identification of main barriers and facilitators to the implementation of both the DREPADO intervention and RCT. These propositions could also be used to promote other complex public health interventions or/and other randomized controlled trials.

Impact of COVID-19 pandemic on access to online therapeutic education programs for children with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) is a lifelong disease for which outcomes may be influenced by patients' self-care knowledge. Therapeutic education (TPE) is a patient-centered teaching instrument based on patient's adaptative processes and needs. TPE was developed in the Paris area by a pediatric health network using interactive face-to-face meetings. The COVID-19 pandemic has impacted the TPE modalities by promoting online training. Our aims were to evaluate the accessibility of patients with SCD to online TPE.

METHODS

We compared sessions of TPE before and after the onset of the pandemic: the number of sessions, performed face-to-face or online, individual or in a group. We also recorded the number of participants in each session and their age, school level, and department in France.

FINDINGS

We observed an increase in the total number of trained children, but participation varied greatly according to the geographical area of residence, with a decrease from 22.4% to 4.9% in the proportion of attendees living in the most socio-economically deprived French departments.

DISCUSSION

Online TPE is feasible for patients with SCD but with unequal access according to socio-economic status.

APPLICATION TO PRACTICE

Access to TPE needs to be improved for patients living in socially disadvantaged areas.

A scoping review of transition interventions for young adults with sickle cell disease

Standardized programming for individuals with sickle cell disease (SCD) transitioning from pediatric to adult-centered care does not currently exist, resulting in high rates of mortality and morbidity. This scoping review examines and evaluates the current literature on SCD transition programs and interventions. Eligible studies described an existing program for individuals with SCD aged 12-29 years preparing to transition. The Evidence Project risk-of-bias tool was used to assess article quality. We identified 30 eligible articles, of which, only two were randomized controlled trials. Many studies have incomplete reports of feasibility information, such as completion rates, patient characteristics, and attrition; all studies were limited to a single institution; and most studies were rated high for risk of bias. Progress has been made in designing and gathering initial evaluation data for SCD transition programs; however, there is a need for higher quality studies, consistent assessment, and better dissemination of programs.

Cognitive performance as a predictor of healthcare transition in sickle cell disease

Neurocognitive deficits in sickle cell disease (SCD) may impair adult care engagement. We investigated the relationship between neurocognitive functioning and socio-environmental factors with healthcare transition outcomes. Adolescents aged 15-18 years who had neurocognitive testing and completed a visit with an adult provider were included. Transition outcomes included transfer interval from paediatric to adult care and retention in adult care at 12 and 24 months. Eighty adolescents (59% male, 64% HbSS/HbSβ⁰ -thalassaemia) were included. Mean age at adult care transfer was 18·0 (±0·3) years and transfer interval was 2·0 (±2·3) months. Higher IQ (P = 0·02; P_FDR  = 0·05) and higher verbal comprehension (P = 0·008; P_FDR  = 0·024) were associated with <2 and <6 month transfer intervals respectively. Better performance on measures of attention was associated with higher adult care retention at 12 and 24 months (P = 0·009; P_FDR  = 0·05 and P = 0·04; P_FDR  = 0·12 respectively). Transfer intervals <6 months were associated with smaller households (P = 0·02; P_FDR  = 0·06) and households with fewer children (P = 0·02; P_FDR  = 0·06). Having a working parent was associated with less retention in adult care at 12 and 24 months (P = 0·01; P = 0·02 respectively). Lower IQ, verbal comprehension, attention difficulties and environmental factors may negatively impact transition outcomes. Neurocognitive function should be considered in transition planning for youth with SCD.