The relationship of health care transition readiness to disease-related characteristics, psychosocial factors, and health care outcomes: preliminary findings in adolescents with chronic kidney disease

Improving the use of transition readiness measures in research and clinical care

Measurement of transition readiness is considered a crucial component of effective transition. It is included as one of the Six Core Elements of Transition in national transitional care guidelines. However, the current measures of transition readiness have not been found to correlate with either current or future health outcomes for youth. In addition, there are challenges in measuring transition readiness in youth with intellectual and developmental disabilities, who may not be expected to achieve skills and knowledge that are considered essential for transition in typically developing youth. These concerns make it difficult to know how best to use transition readiness measures in research and clinical care. This article highlights the appeal of measuring transition readiness in clinical and research contexts, the current barriers that prevent us from fully achieving those benefits, and potential strategies for bridging the gap. IMPACT: Transition readiness measures were developed as an attempt to identify those patients who were ready to successfully navigate the transition from pediatric to adult health care. Thus far, the measures that have been developed do not appear to be related to health outcomes such as disease control or timely attendance of the first adult appointment in adult care. We provide suggestions for how to address the current concerns with the available transition readiness measures.

Barriers to a successful healthcare transition for individuals with urea cycle disorders

The pediatric to adult healthcare transition (HCT) is a process for individuals with chronic health conditions to gradually shift from a pediatric to an adult-oriented care system. Autonomy and self-management skills required for an individual's HCT readiness can be evaluated through the transition readiness assessment questionnaire (TRAQ). Despite general HCT preparation guidelines, little is known about the HCT experience of individuals with a urea cycle disorder (UCD). This is the first study to report the parent or guardian perception of the HCT process in children with a UCD by investigating the stages of transition readiness and transition outcome. We identify barriers to HCT readiness and planning, along with deficiencies in transition outcome for individuals with a UCD. For children that received special education services compared to those that did not, significantly lower transition readiness scores were identified in the total TRAQ score (p = 0.03) and in the domains of tracking health issues (p = 0.02), talking with providers (p = 0.03), and managing daily activities (p = 0.01). There was a lack of HCT preparation as most subjects did not have a HCT discussion with their healthcare provider before age 26. Deficiencies in HCT outcome are demonstrated by individuals with a UCD reporting delays in needed medical care and dissatisfaction with their healthcare services. Considerations for facilitating a successful HCT for individuals with a UCD include providing individualized education, appointing a transition coordinator, allowing flexibility in HCT timing, and ensuring that the individual recognizes concerning UCD symptoms and knows when to seek medical care.

Transition readiness in middle and older adolescents with asthma and associated factors: a descriptive study

OBJECTIVE

Asthma is the leading chronic health condition in adolescents, yet little is known about adolescents' readiness to transition into adult-focused care. This study examines transition readiness in middle and late adolescents with asthma.

METHODS

This cross-sectional descriptive study was conducted in 2019 with 41 adolescents (16-20 years old) with asthma. Transition readiness was measured with the 20-item Transition Readiness Assessment Questionnaire (TRAQ), which comprises five subscales.

RESULTS

Slight majorities of the sample comprised females (58.5%) and minority adolescents (56%). The sample's overall mean score on the TRAQ was 3.89 (±0.63; possible range 1-5). Managing daily activities was associated with talking with providers subscale (r = 0.36; p < 0.01), but not with other TRAQ subscales. Females reported greater scores for managing medications than did males, with mean = 4.2 vs. 3.6 (t = -2.15, p = 0.04). Transition readiness did not differ by race or health insurance type. However, scores on arranging transportation to medical appointments were lower among minority adolescents than whites (4.17 vs. 4.8, t = 2.56, p = 0.01). Better asthma control was associated with higher scores on talking with providers (r = -0.42; p < 0.01), but not with other subscale domains.

CONCLUSIONS

Overall transition readiness is suboptimal in middle to late adolescents with asthma. Adolescents' capacity to manage daily activities is not a valid indicator of transition readiness in disease self-management. It is important to consider gender, race, and asthma control in understanding transition readiness in adolescents with asthma.

Defining and Measuring Resilience in Children with a Chronic Disease: a Scoping Review

More than 25% of all children grow up with a chronic disease. They are at higher risk for developmental and psychosocial problems. However, children who function resiliently manage to adapt positively to these challenges. We aim to systematically review how resilience is defined and measured in children with a chronic disease. A search of PubMed, Cochrane, Embase, and PsycINFO was performed on December 9, 2022, using resilience, disease, and child/adolescent as search terms. Two reviewers independently screened articles for inclusion according to predefined criteria. Extraction domains included study characteristics, definition, and instruments assessing resilience outcomes, and resilience factors. Fifty-five out of 8766 articles were identified as relevant. In general, resilience was characterized as positive adaptation to adversity. The included studies assessed resilience by the outcomes of positive adaptation, or by resilience factors, or both. We categorized the assessed resilience outcomes into three groups: personal traits, psychosocial functioning, and disease-related outcomes. Moreover, myriad of resilience factors were measured, which were grouped into internal resilience factors (cognitive, social, and emotional competence factors), disease-related factors, and external factors (caregiver factors, social factors, and contextual factors). Our scoping review provides insight into the definitions and instruments used to measure resilience in children with a chronic disease. More knowledge is needed on which resilience factors are related to positive adaptation in specific illness-related challenges, which underlying mechanisms are responsible for this positive adaptation, and how these underlying mechanisms interact with one another.

Supplementary Information

The online version contains supplementary material available at 10.1007/s42844-023-00092-2.

Translation and validation of the STARx questionnaire in transitioning Chinese adolescents and young adults with chronic health conditions

BACKGROUND

Adolescent/young adults (AYAs) with chronic conditions must undergo healthcare transition (HCT) preparation until their mid-twenties. Valid HCT readiness measures are lacking in China.

METHODS

The present study translated, back-translated, and adapted the Self-Management and Transition to Adulthood with Rx = Treatment (STAR_x) Questionnaire. We examined the psychometric properties of this tool in a relatively large in-patient sample of AYAs with various chronic health conditions at a Chinese tertiary general hospital.

RESULTS

We enrolled 624 AYAs aged 10-25 years (19.66 ± 3.64) with various chronic health conditions. The Chinese version of the STAR_x Questionnaire demonstrated excellent internal consistency (Cronbach's alpha = 0.83) and reliability with a two-week test-retest (ICC = 0.88, p < .001). Furthermore, the Chinese version revealed a three-factor structure (self-management, disease knowledge, and provider communication) consistent with the revised English version of the STAR_x Questionnaire. In terms of discriminant validity, the total score of the Chinese STAR_x Questionnaire showed a significant positive correlation with age but no gender differences were found. In terms of predictive validity, the Chinese STAR_x Questionnaire was significantly correlated with shorter length of hospitalization and higher frequency of emergency room visit, but the correlations became insignificant after controlling for age.

CONCLUSIONS

The results suggest that the Chinese version of the STAR_x Questionnaire is a robust HCT readiness tool in AYAs with chronic conditions and clinicians may find it useful to develop individualized interventions.

Are Mid to Late Adolescents with Asthma Ready for Transition of Care? A Qualitative Study

This qualitative descriptive study explores experiences and perspectives of mid-to-late adolescents about growing up with asthma, and the roles of parents and providers as they transition. Purposeful sampling was used to recruit and enroll adolescents aged 16-20 years with asthma. Forty-one adolescents participated in a focus group or individual interview, and content analysis was conducted to analyze the data. The mean age of participants was 17.7 years, the majority (56%) of whom were Black. Themes that emerged included concerns about becoming an adult with asthma and its self-management, parental involvement, and communication with providers. Adolescents felt burdened by asthma, few considered becoming adults with asthma, and their future outlook was pessimistic with concerns related to worsening symptoms, inadequacy in symptom self-management and limitations on career choices due to asthma. Deficiencies in self-management were noted, parents still played major roles in adolescents' asthma care, and transition of care was seldom discussed with the providers. Mid-to-late adolescents with asthma are inadequately prepared for transition of care, and parents and providers insufficiently engage adolescents in the preparation. Parent, provider, and adolescent partnership is critical to achieve adolescent readiness for independence in asthma management and to ensure proper asthma care continuity post transition.

Healthcare Transition Among Young Adults With Childhood-Onset Chronic Pain: A Mixed Methods Study and Proposed Framework

Chronic pain extends from childhood to adulthood for many young people. The transition from pediatric to adult care is a critical, yet understudied, healthcare task facing young adults with chronic pain. The aims of this observational, sequential mixed methods study were to 1) document the healthcare transition status of young adults with chronic pain (Stage 1, quantitative aim), 2) examine young adults' perspectives of barriers and facilitators of healthcare transition (Stage 2, qualitative aim), and 3) integrate findings to construct a theoretical framework of healthcare transition. A cohort was identified with childhood chronic pain and prior care in one of 15 multidisciplinary pediatric pain clinics across the United States and Canada. Approximately 6 years later, 189 young adults (M age = 21.0; age range = 18-24; 81.5% female) from this cohort with continuing chronic pain completed surveys for Stage 1, and a subsample (n = 17) completed qualitative interviews for Stage 2. Quantitative findings demonstrated that young adults may experience lapses in care, with 41.8% indicating they had not transitioned to adult pain services. Qualitative analysis revealed young adults experienced significant barriers (eg, abrupt departure from pediatric care) as well as facilitators (eg, acceptance of pain prognosis) of healthcare transition. Quantitative and qualitative findings were integrated to construct a healthcare transition framework for chronic pain, which highlights transition as a complex process involving multiple pathways, outcomes, and stakeholders. Advancements in research and practice are needed to develop transition services to bridge gaps in care and optimize health outcomes for young people with chronic pain. PERSPECTIVE: This mixed-methods study demonstrated that 41.8% of young adults with chronic pain experience lapses in adult-centered pain care and identified key barriers and facilitators to successful healthcare transition. Findings were integrated to construct the first healthcare transition framework for youth with chronic pain.

Health Care Transition in Adolescents and Young Adults With Chronic Kidney Disease: Focus on the Individual and Family Support Systems

Health care transition (HCT) from pediatric to adult-focused services is a longitudinal process driven by the collaboration and interactions of adolescent/young adult patients, their families, providers, health care agencies, and environment. Health care providers in both pediatric and adult-focused settings must collaborate, as patients' health self-management skills are acquired in the mid-20s, after they have transferred to adult-focused care. Our manuscript discusses the individual and family support systems as they relate to adolescents and young adults with chronic or end-stage kidney disease. In the individual domain, we discuss demographic/socioeconomic characteristics, disease complexity/course, cognitive capabilities, and self-management/self-advocacy. In the family domain, we discuss family composition/culture factors, family function, parenting style, and family unit factors. We provide a section dedicated to patients with cognitive and developmental disability. Furthermore, we discuss barriers for HCT preparation and offer solutions as well as activities for HCT preparation.

Transition readiness in adolescents and young adults with chronic rheumatic disease in Oman: today's needs and future challenges

INTRODUCTION

In Oman, the ""transition" of health care of adolescents to adult care occurs at a young age, like many other GCC countries for cultural reasons. In order to address this concern, this study was conducted to determine the transition readiness skills of adolescents and young adults with childhood onset rheumatic diseases using a cross-cultural adaptation of the UNC TRxANSITION scale.

METHODS

We used a professionally translated/back translated, provider-administered UNC TR_xANSITION Scale. This 32-question scale measures HCT in 10 domains including knowledge about diagnosis or treatment, diet, reproductive health, school/work, insurance, ability to self-manage and identification of new health providers. The maximum transitional score of 10, was categorized as low (1-4), moderate (4 - 7) and high (7 -10) transitional readiness scores.

RESULTS

We enrolled 81 Omani adolescents and young adults (AYA) with chronic childhood onset rheumatic diseases. The cohort consisted of 79% females, with mean age of 15.8 years (± 3.53) and mean disease duration of 6.95 years (± 4.83). Our cohort's overall mean score is low 5.22 (±1.68). Only 14.8% of the cohort achieved a high transition score (≥7). Significant direct relationship was observed between age and the mean transition readiness score (r = .533, P < .001). The mean transition readiness score in the younger age group (10-13 years) was 4.07 (±1.29), the middle age group (14-18 years) was 5.43 (±1.27), while the older age group (19-21 year), was 6.12 (±1.81). Mean transition score of youngest age group was found to be significantly lower than the other two age groups (p = .003).

CONCLUSION

Overall, the transition readiness of AYA in Oman is low compared to other western countries indicating the need to initiate a health care transition preparation program for patients with chronic diseases across the country. In addition, we need to establish regional guidelines to address the transfer and transition policies to be in line to international recommendations. As transition continues after transfer, and is preferably guided by adolescent developmental status rather than chronological age, it would be preferable to refer to the transition and transfer policies 9rather than transitional age policy) to be in line to international recommendations.

Gaps in transition readiness measurement: a comparison of instruments to a conceptual model

Objectives

Measuring transition readiness is important when preparing young people with chronic illness for successful transition to adult care. The Expanded Socioecological Model of Adolescent and Young Adult Readiness to Transition (Expanded SMART) offers a holistic view of factors that influence transition readiness and outcomes. The aim of this study was to examine conceptual congruency of transition readiness instruments with the Expanded SMART to determine the breadth and frequency of constructs measured.

Methods

PubMed was searched to identify observational and experimental studies that measured transition readiness across chronic illnesses. Selected instruments were first evaluated on their development and psychometric properties. Next, reviewers independently mapped each instrument item to Expanded SMART constructs: knowledge, skills/self-efficacy, relationships/communication, psychosocial/emotions, developmental maturity, beliefs/expectations, goals/motivation. If items did not map to a construct, a new construct was named inductively through group discussion.

Results

Three instruments (TRAQ [20 items], STARx [18 items] and TRxANSITION Index [32 items]), reported in 74 studies, were identified. Across instruments, most items mapped to three constructs: skills/self-efficacy, developmental maturity, and knowledge. The psychosocial constructs of goals/motivation and psychosocial/emotions were underrepresented in the instruments. No instrument mapped to every model construct. Two new constructs: independent living and organization were identified.

Conclusions

Constructs representing transition readiness in three frequently used transition readiness instruments vary considerably from Expanded SMART, a holistic conceptual model of transition readiness, suggesting that conceptualization and operationalization of transition readiness is not standardized. No instrument reflected all conceptual constructs of transition readiness and psychosocial constructs were underrepresented, suggesting that current instruments may provide an incomplete measurement of transition readiness.

Transition in cardiology 1: Pediatric patients with congenital heart disease to adulthood

With advances in medical care, the majority of infants and children with chronic diseases are now able to reach adulthood. However, many of them still need special health care because of their original diseases, sequelae, and complications. The transition from the child health care system to the adult health care system is a crucial step for these patients. The goal of transitional care is to maximize the lifelong function and potential of these patients by uninterruptedly providing appropriate health-care services. To achieve this goal, we should (i) coordinate the transfer to adequate medical institutions and departments for adults, (ii) educate patients to improve self-management, and (iii) support the transition to social and welfare services for adults. Transitional care in pediatric cardiology has been a step ahead of such care in other diseases because of the relatively high incidence and the long history of adult congenital heart disease. Education of the patients to establish autonomy reduces dropping out and unexpected hospitalizations and it is the most important part of transitional care. To achieve this goal, we should provide explanations to pediatric patients according to their age and level of understanding from their first visit, rather than waiting until they reach a certain age. Tools for education and readiness checks are also being developed. To achieve a situation in which pediatric patients with chronic disease can take care of their own health and fully utilize their abilities at the growing step, transitional care plays a crucial role not only in pediatric cardiology but also in other subspecialties.

"You Just Have to Keep Going, You Can't Give Up": Coping mechanisms among young adults with lupus transferring to adult care

INTRODUCTION

Coping mechanisms and emotional regulation are important contributors to psychosocial health during stressful life events. We sought to describe the coping and emotional responses of persons with childhood-onset systemic lupus erythematosus during the transfer from pediatric to adult healthcare.

METHODS

Semi-structured in-depth one-on-one interviews were conducted with 13 young women aged 18-24 of minority background who had transferred to adult care in a public hospital system. Thematic analysis was used to identify themes motifs from the data.

RESULTS

Participants described the use of (1) problem-focused coping such as the use of clear communication and self-education, (2) adaptive emotion-focused coping such as cognitive reframing and acceptance, (3) social coping including support-seeking, (4) meaning-making coping including positive religious framing and viewing events as learning opportunities for growth, and (5) disengaged coping including denial and social isolation. A range of emotional responses associated with the transfer were described including fear, anger, loss, and feelings of empowerment and excitement.

CONCLUSION

Effective coping and emotional regulation are modifiable factors that may impact transfer-related outcomes and psychosocial health. Addressing coping mechanisms is relevant to the optimized transfer to adult care.

Exploring Health Literacy, Transition Readiness, and Healthcare Utilization in Medicaid Chronically Ill Youth

PURPOSE

Youths with special healthcare needs face challenges transitioning from pediatric to adult health care. Understanding possible mechanisms contributing to poor healthcare transition could improve care. This study explores associations between health literacy (HL), transition readiness, and healthcare utilization.

METHODS

Youths with special healthcare needs aged 12-18 years were recruited from a Medicaid accountable care organization (2012-2017). Outcome measures included transition readiness (Transition Readiness Assessment Questionnaire), and healthcare utilization (any well-check, hospitalization, emergency department [ED] visit, or ambulatory sensitive condition ED visit). Multivariate regression analyses examined whether HL (adequate vs. inadequate) predicted outcomes, after adjusting for covariates. Models were then created to examine whether the effect of HL on healthcare utilization was mediated by transition readiness.

RESULTS

Among 417 youths with special healthcare needs, 67.1% reported adequate HL. Relative to inadequate HL, teens with adequate HL had significantly higher average Transition Readiness Assessment Questionnaire-20 scores (β = .34, p < .001). Controlling for covariates, HL was a significant predictor of having an ambulatory sensitive condition ED visit and having any ED visits neared significance. There was a positive transition readiness mediation effect on having an ED visit, with higher transition readiness being associated with higher odds of having any ED visit in the mediation analysis.

CONCLUSIONS

HL is independently associated with higher transition readiness and lower ambulatory sensitive condition ED use, but pathways of action require further study.

The Effect of Self-Efficacy, Social Support and Quality of Life on Readiness for Transition to Adult Care Among Adolescents with Cystic Fibrosis in Turkey

PURPOSE

The aim of this study is to examine the effects of self-efficacy, social support and quality of life on readiness for transition to adult care in adolescents with cystic fibrosis.

DESIGN AND METHODS

A descriptive and cross-sectional study design was used. Data were collected from 50 adolescent between 14 and 17 years old with cystic fibrosis, by using The Transition Readiness Assessment Questionnaire, Social Support Appraisals Scale for Children, Self-Efficacy Questionnaire for Children and health-related quality-of-life instrument, the KIDSCREEN-10.

RESULTS

A positive correlation was found between the readiness levels of adolescents for transition to adult care and self-efficacy levels. In path analysis, self-efficacy was found to have a significant effect on the level of readiness for transition to adult care. There was not statistically significant relationship between the level of readiness for transition to adult care and health-related quality of life and perceived social support. Path analysis revealed that health-related quality of life and perceived social support had significant effects on the self-efficacy levels of adolescents.

CONCLUSIONS

Self-efficacy were associated with readiness for the transition to adult care. Although perceived social support and quality of life were not related with transition readiness these variables had significant effects on perceived self-efficacy, which was determined as a factor affecting the readiness for the transition to adult care.

PRACTICE IMPLICATIONS

In adolescents with cystic fibrosis, self-efficacy, social support and quality of life levels should be taken into account when planning preparation programs for transition to adult care.

Psychometric properties of the 'Self-Management and Transition to Adulthood with Rx = Treatment Questionnaire' in Chinese children and young people with chronic diseases

AIMS

The aims of this work were to translate, culturally adapt and evaluate the reliability and validity of the Chinese version of the Self-Management and Transition to Adulthood with R_x = Treatment Questionnaire.

BACKGROUND

Children and young people with chronic diseases are expected to start self-managing their diseases and have a smooth and coordinated transition from paediatric- to adult-oriented care.

DESIGN

This study involved the cultural adaptation of a questionnaire into Chinese and examined its factor structure.

METHODS

This was a multicentre cross-sectional study of children and young people/adolescents (8-18 years) who were diagnosed with chronic diseases in China from June 2016 to December 2018. Exploratory and confirmatory factor analyses were performed to analyse the questionnaire's validity.

RESULTS

Four major factors were identified in the Chinese version of the questionnaire, and it had a good fit to the target population. The internal reliability was good. All factors were positively and strongly correlated with the total score. The t test revealed that the Medication Management score was not significantly different between two age groups (8-11 and 12-18 years), but the scores of the other factors and overall scale were lower in the 8-11 years age group.

CONCLUSION

The Chinese version of the questionnaire has good reliability and validity in the Chinese context.

Health literacy, nutrition knowledge, and health care transition readiness in youth with chronic kidney disease or hypertension: A cross-sectional study

This study evaluates the associations of nutrition knowledge and health literacy with health care transition (HCT) readiness and self-management in adolescents and young adults (AYAs) with chronic kidney disease (CKD) or hypertension. Chronically ill AYAs with poor HCT or self-management skills are less likely to achieve favorable health outcomes as they enter adulthood. Health literacy and nutrition knowledge, which are identified as important contributors to health outcomes, may suggest important points of interventions to improve self-management skills. For the study, we enrolled 59 consecutive patients ages 12-29, with a diagnosis of CKD or hypertension at pediatric- and adult-focused clinics in the United States. Participants completed measures of nutrition knowledge, health literacy, and the Self-management and Transition to Adulthood with R_x = treatment (STAR_x) questionnaire. Correlation tests and multivariate regressions were employed for data analysis. The findings show that health literacy was positively associated with self-management skills (p = .050), communication with providers (p = .002) and overall HCT (p = .001) after adjusting for key variables. Disease-specific nutrition knowledge positively predicted communication with providers (p = .002) and overall HCT (p < .001) after adjusting for key variables. Therefore, health literacy and nutrition knowledge predicted self-management and transition readiness. Testing for these skills should be considered in clinics and HCT preparation for AYAs with chronic conditions.

Transition readiness measures for adolescents and young adults with chronic health conditions: a systematic review

Background

Transition from pediatric to adult healthcare for adolescents with chronic health conditions has emerged as a critical period influencing health outcomes. Suitable transition readiness measures are necessary to facilitate effective planning. Currently, there is little consensus about well-validated transition readiness measures. The purpose of this systematic review was to identify best practices in transition readiness measurement for adolescents and young adults with chronic health conditions.

Data sources

Academic databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, Google Scholar and Athabasca University Library’s Discover.

Study selection

Articles were included that discussed the development and psychometric properties of transition readiness measures for adolescents and young adults (11–25 years) with chronic health conditions and/or that utilized a previously developed measure.

Data extraction

The primary and secondary reviewers extracted data from the selected articles as per the data extraction tool developed for this review.

Results

Forty-eight articles, representing 19 tools, were included in the review. Ten of the tools were disease-specific; nine were disease-neutral. According to the Cohen criteria, eight measures were “well-established assessments”. The Transition Readiness Assessment Questionnaire was deemed the best measure of transition readiness available. The literature search included only articles published in peer-reviewed journals; measures nearing completion or awaiting publication were not included. In addition, only English manuscripts were included, many from North America.

Conclusions

Despite national practice guidelines and ongoing policy development, there is slow movement towards achieving a gold standard or best-practice measure of transition readiness.

Shifting the mindset-adolescent and young adult rheumatology in transition

Almost 30 years have passed since publication of the first reports acknowledging the crucial importance of transitional care for adolescents and young adults with chronic disease, but universal implementation has yet to be achieved. Progress has undoubtedly been made, with increasing evidence for best practice in transitional care. However, translation of research and guidance into clinical practice continues to be challenging. Neuroscience advances in understanding the changes occurring in the adolescent brain demand that the third phase of transition (ie, post-transfer to adult services) is given further attention, with recognition that transfer itself is not the end of the transition process. The complex, often unwieldy health systems delivering care must also be considered. Paediatric and adult rheumatology practitioners need to collaborate not only with each other, but also with practitioners in other disciplines, specialties, and agencies, to plan and commission rheumatology services that are responsive to adolescents and young adults. A shift in approach from focusing on health transition towards developmentally appropriate health care has the potential to improve the care provided during this vulnerable life stage, increasing the likelihood of continuing engagement of patients in their own health care into adulthood and thereby improving health outcomes.

Examination of Transition Readiness, Medication Adherence, and Resilience in Pediatric Chronic Illness Populations: A Pilot Study

The present study assessed the relationship between resilience, adherence, and transition readiness in adolescents/young adults with chronic illness. Participants included 50 patients (Mean age, Mage = 17.3 ± 2.1 years) diagnosed with an oncology disorder (n = 7; 12.1%), hematology disorder (n = 5; 8.6%), nephrology disorder (n = 31; 53.4%), or rheumatology disorder (n = 7; 12.1%). Patients were administered questionnaires assessing resilience (Conner–Davidson Resilience Scale 25-item questionnaire, CD-RISC-25), transition readiness (Self-Management and Transition to Adulthood with Rx=Treatment, STARx), and self-reported medication adherence (Medication Adherence Module, MAM). Medical chart reviews were conducted to determine objective medication adherence rates based on pharmacy refill history (medication adherence ratios). A multivariate correlation analysis was used to examine the relationship between resilience, transition readiness, and adherence. There was a moderate relationship (r = 0.34, p ≤ 0.05) between resilience (M = 74.67 ± 13.95) and transition readiness (M = 67.55 ± 8.20), such that more resilient patients reported increased readiness to transition to adult care. There also was a strong relationship (r = 0.80, p ≤ 0.01) between self-reported medication adherence (M = 86.27% ± 15.98) and pharmacy refill history (Mean Medication Adherence Ratio, M_MAR = 0.75 ± 0.27), which indicated that self-reported adherence was consistent with prescription refill history across pediatric illness cohorts. Our findings underscore the importance of assessing resilience, transition readiness, and adherence years before transitioning pediatric patients to adult providers to ensure an easier transition to adult care.

Transition Readiness Not Associated With Measures of Health in Youth With IBD

BACKGROUND

It remains unclear how transition readiness is associated with various domains of health in children and young adults. Our objective was to describe the transition readiness of children and young adults with inflammatory bowel disease (IBD) and examine its associations with demographic factors, IBD activity, and measures of physical, psychological, and social health.

METHODS

We recruited children ages 12 to 17 and young adults ages 18 to 20 from 2 internet-based cohorts sponsored by the Crohn's & Colitis Foundation. Participants self-reported demographics, IBD activity, transition readiness, health-related quality of life, and Patient-Reported Outcomes Information Systems domains of physical, psychological, and social health.

RESULTS

Among 361 pediatric and 119 adult participants, age and female sex were associated with transition readiness. The association was greater in the pediatric cohort. Having IBD in remission was associated with worse transition readiness in the pediatric cohort only (beta = 0.3; P = 0.003). Health-related quality of life and Patient-Reported Outcomes Information Systems measures of fatigue, pain interference, and sleep disturbance were not associated with transition readiness in either children or adults. We observed few small associations between psychological or social health and transition readiness. Better transition readiness was associated with greater anxiety in adults (beta = -0.02; P = 0.02) and greater peer relationships among children (beta = 0.01; P = 0.009).

CONCLUSIONS

In children and young adults with IBD, transition readiness was associated with older age and female sex. Associations between transition readiness and physical, psychological, and social health were either small, inconsistent across age groups, or nonexistent.

Validation of the Japanese Transition Readiness Assessment Questionnaire

BACKGROUND

For patients with childhood-onset chronic illnesses, the transition to adult care requires an understanding of transition readiness and the effectiveness of evaluation methods. However, no such psychometrically verified scales exist in Japan. This study aimed to develop a Japanese version of the Transition Readiness Assessment Questionnaire (TRAQ) and verify its validity and reliability.

METHODS

The Japanese TRAQ was developed in accordance with international guidelines, followed by a preliminary survey to verify face validity among six participants who fulfilled the inclusion criteria. For the main survey 107 patients who fulfilled the same inclusion criteria were asked to complete the questionnaire and provide basic information. After descriptive statistics analysis, the construct validity of the Japanese TRAQ was tested using the t-test and Pearson's correlation coefficients. Cronbach's alpha coefficients were calculated to assess reliability.

RESULTS

In the main survey, 76 participants with no missing data were included in the complete data analysis (40 males 36 females; mean age, 17.8 and 18.2 years, respectively). The mean total Japanese TRAQ score was 3.9. Cronbach's alpha coefficients were 0.94 overall and 0.8-0.96 for each of the four domains. The known-groups analysis revealed that older participants (r = 0.23, P = 0.044), those having knowledge of the disease name (yes [4.0] vs no [3.4]; P < 0.001), and making unaccompanied hospital visits (with parent/others [3.7] vs alone [4.4]; P < 0.001) had significantly higher total TRAQ scores.

CONCLUSION

We confirmed preliminarily the validity and reliability of the Japanese TRAQ.

Adherence to Medication During Transition to Adult Services

The transition from childhood and adolescence to adulthood is often tumultuous. For individuals with a chronic medical condition, this progression also includes a gradual transition to independence in healthcare management as well as a transfer in care location at some set point. As adolescents navigate these sometimes challenging processes, there is a significant risk for a decline in adequate health behaviors, which can have dire consequences. One of the most vital components of the transfer to adult care is medication adherence. Poor medication adherence puts patients at risk for worse outcomes, with the most profound being increased mortality for many conditions. In recent years, acknowledgment of the need to create evidence-based methods to aid patients during the transition period has been growing. This paper seeks to provide an overview of current research and recommendations for interventions to increase adherence to medication regimens during this period.

A Systematic Review of Transition Readiness in Youth with Chronic Disease

The transition of chronically ill adolescents and young adults to adult health care is poorly managed, leading to poor outcomes due to insufficient disease knowledge and a lack of requisite skills to self-manage their chronic disease. This review analyzed 33 articles published between 2009 and 2019 to identify factors associated with transition readiness in adolescents and young adults with chronic diseases, which can be used to design effective interventions. Studies were predominantly cross-sectional survey designs that were guided by interdisciplinary research teams, assessed adolescents and young adults ages 12-26 years, and conducted in the outpatient setting. Modifiable factors, including psychosocial and self-management/transition education factors, and non-modifiable factors, including demographic/ecological and disease factors, associated with transition readiness were identified. Further research is necessary to address gaps identified in this review prior to intervention development, and there is a need for additional longitudinal studies designed to provide perspective on how transition readiness changes over time.

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.

Healthcare Transition Readiness, Family Support, and Self-management Competency in Korean Emerging Adults with Type 1 Diabetes Mellitus

PURPOSE

The current study investigated factors related to healthcare transition readiness, including family support and self-management competency, in emerging adults with Type 1 diabetes mellitus (T1DM).

DESIGN AND METHODS

A cross-sectional survey was conducted with 87 individuals, aged 16-24 years. Participants were recruited both from the outpatient clinic of Severance Children's Hospital, and an online self-help group for emerging adults with T1DM in South Korea. Participants reported perceived levels of family support, self-management competency, and healthcare transition readiness through a structured questionnaire.

RESULTS

Healthcare transition readiness was positively correlated with family support (r = 0.257, p = .016) and self-management competency (r = 0.606, p < .001). Multivariate linear regression analyses revealed that only self-management competency was a significant factor associated with healthcare transition readiness (β = 0.699, p < .001).

CONCLUSIONS

For emerging adults with T1DM, ongoing family involvement in diabetes care and enhanced self-management competency can strengthen their healthcare transition readiness. Furthermore, primary factors associated with healthcare transition readiness in the present study were identified as self-management competency and participants' age.

PRACTICE IMPLICATIONS

Healthcare providers should assess and enhance healthcare transition readiness in emerging adults with T1DM. A primary method of addressing transition readiness is helping people strengthen their self-management competency.

Association of youth health care transition readiness to role overload among parents of children with chronic illness

BACKGROUND

A parent's level of role overload, a situation in which the demands of an individual's roles are beyond their capacity to perform adequately, has been associated with poor outcomes in adolescents. It is unknown if role overload in parents is associated with less health care transition (HCT) readiness in their children with chronic conditions. We sought to assess this relationship.

METHODS

Youth with chronic conditions attending a therapeutic camp and their parents completed online consents/assents and de-identified surveys. Parents reported on parental role overload using the Reilly Role Overload Scale and a proxy assessment of the youth's HCT readiness using the STAR_x -Parent Questionnaire. Youth self-reported on their HCT readiness using the STAR_x Questionnaire. Linear regression measured the relationship between parent role overload and HCT readiness, controlling for youth's age, sex, and degree of youth's educational support.

RESULTS

One hundred fifty-two parents and 50 youth completed the measures. Greater parental role overload was associated with less overall HCT readiness on the parent proxy measure (β = -.12, P ≤ .008) and a lower level in the self-management domain on the parent proxy measure (β = -.20, P ≤ .001). We found no associations between parent role overload and youth self-report of HCT readiness.

CONCLUSION

Parent's level of role overload had no association with youth's self-report of HCT readiness but was negatively associated with parent proxy report of their youth's HCT readiness, suggesting that parents with high levels of role overload may perceive their youth as less ready to transition to adult-focused care.

Transition Readiness for Talking With Providers in Urban Youth With Asthma: Associations With Medication Management

PURPOSE

Teen readiness assessments may provide a developmental indicator of the transfer of responsibility for health self-management from caregivers to teens. Among urban adolescents with asthma, we aimed to describe teen readiness for talking with providers and identify how readiness relates to responsibility for asthma management, medication beliefs, and clinical outcomes.

METHODS

Teens and caregivers enrolled in the school-based asthma care for teen's trial in Rochester, NY completed in-home surveys. We classified ready teens as those reporting a score of five on both items of the transition readiness assessment questionnaire talking with providers subscale. We performed bivariate analyses to detect differences between ready teens and other teens in teen- and caregiver-reported responsibility, teen medication beliefs, and clinical outcomes (medication adherence over the past 2 weeks, and healthcare use over the past year).

RESULTS

Among this sample of 251 adolescents (mean age: 13.4 years), 35% were classified as "Ready." Ready teens were more likely than other teens to want to use a controller medication independently (7.6 vs. 6.5 out of 10, p < .01) and to have confidence in this ability (8.4 vs. 7.6 out of 10, p = .02). Teens reported poor adherence (missed 52.9% of prescribed controller doses), with no differences in responsibility or clinical outcomes based on level of teen readiness for talking with providers.

CONCLUSIONS

In urban adolescents with poorly controlled asthma, a higher level of teen readiness for talking with providers is associated with higher perceptions of independence in medication taking, but does not appear to relate to clinical outcomes.

The reliability and validity of a newly developed spina bifida-specific Transition Readiness Assessment Questionnaire: Transition Readiness Assessment Questionnaire-supplement (TRAQ-SB)

PURPOSE

The purpose of this study is to report preliminary evidence to support a new condition-specific measure of transition readiness that is theoretically grounded in the Stages of Changes framework. The Transition Readiness Assessment Questionnaire-Spina Bifida (TRAQ-SB) supplement is a newly developed tool used to measure independence and skill acquisition related to spina bifida. Similar to the Transition Readiness Assessment Questionnaire (TRAQ), the TRAQ-SB uses a 5-point Likert response set.

METHODS

Working with a multi-disciplinary team with expertise in the care of children with spina bifida, the authors developed twelve items pertaining to main aspects of SB self-management. The items were reviewed and revised through several iterations by the team and patients. The items were then fielded at a spina bifida Specialty Clinic, where 93 consecutive patients 12-25 years of age were approached to participate and 90 were administered the 20-item TRAQ and a 12-item TRAQ-SB questionnaire. A principal component analysis (PCA) was conducted on the twelve items with oblique rotation (promax). Criterion validity was also assessed by examining the correlation of the TRAQ-SB supplement with the TRAQ and with age.

RESULTS

Results of the factor analysis revealed that eleven of the twelve items loaded onto one factor with factor loadings ranging from 0.46 to 0.84. The scale yielded excellent internal reliability with a Cronbach alpha of 0.90. Correlations of the TRAQ-SB supplement scale score with the TRAQ overall scale score demonstrated good criterion validity (r= 0.74, p< 0.01). In addition, it was highly correlated with the TRAQ subscales, varying from 0.68 to 0.74 (all p< 0.01). Lastly, the TRAQ-SB was significantly correlated with age (r= 0.25, p< 0.01).

CONCLUSIONS

Results of our analyses indicated that the TRAQ-SB demonstrated good internal reliability and criterion validity as evidenced by strong correlation with age and the validated TRAQ measure. The TRAQ-SB tool can be useful to incorporate transition readiness assessment and self-management training into routine care for adolescents with spina bifida.

Moving on: transitioning young people with chronic kidney disease to adult care

Advances in the care of children mean that adolescents with chronic kidney disease (CKD) are surviving to adulthood and requiring transition to adult care. The transition phase is well-recognised to be associated with considerable excess morbidity and graft loss, but these outcomes may be avoidable through a structured transition programme. This review will discuss the (1) challenges encountered by patients with CKD, caregivers and clinicians during transition; (2) predictors and outcomes of transition; (3) current guidelines on transition from paediatric to adult renal services; (4) interventions and research directions that may help to improve the care and outcomes for young people with CKD in transition. In spite of the substantial improvement in health gains required for this disadvantaged population, there is to date only limited evidence on the effects of current transition programmes.

Younger Adults Initiating Hemodialysis: Antidepressant Use for Depression Associated With Higher Health Care Utilization

OBJECTIVE

To examine associations between antidepressant use and health care utilization in young adults beginning maintenance hemodialysis (HD) therapy.

PATIENTS AND METHODS

Antidepressant use, hospitalizations, and emergency department (ED) visits were examined in young adults (N=130; age, 18-44 years) initiating HD (from January 1, 2001, through December 31, 2013) at a midwestern US institution. Primary outcomes included hospitalizations and ED visits during the first year.

RESULTS

Depression diagnosis was common (47; 36.2%) at HD initiation, yet only 28 patients (21.5%) in the cohort were receiving antidepressant therapy. The antidepressant use group was more likely to have diabetes mellitus (18 [64.3%] vs 33 [32.4%]), coronary artery disease (8 [28.6%] vs 12 [11.8%]), and heart failure (9 [32.1%] vs 15 [14.7%]) (P<.05 for all) than the untreated group. Overall, 68 (52.3%) had 1 or more hospitalizations and 33 (25.4%) had 1 or more ED visits in the first year. The risk of hospitalization during the first year was higher in the antidepressant use group (hazard ratio, 2.35; 95% CI, 1.39-3.96; P=.001), which persisted after adjustment for diabetes, coronary artery disease, and heart failure (hazard ratio, 1.94; 95% CI, 1.22-3.10; P=.006). Emergency department visit rates were similar between the groups.

CONCLUSION

Depression and antidepressant use for mood indication are common in young adult incident patients initiating HD and and are associated with higher hospitalization rates during the first year. Further research should determine whether antidepressants are a marker for other comorbidities or whether treated depression affects the increased health care use in these individuals.

(Health-related) quality of life and psychosocial factors in adolescents with chronic disease: a systematic literature review

Background Research on living with a chronic disease (CD) in adolescence is increasing. However, studies on the relevance of psychosocial factors are still needed. The present review, focuses on the impact of living with a CD in adolescence on on quality of life (QoL), health-related quality of life (HRQoL) and psychosocial factors. Methods A literature review of articles identified through PubMed, PsycINFO and PsycARTICLES (these last two ones comprise the Ebsco Host platform) and original peer-reviewed research papers, published between 2010 and 2015, with no restrictions regarding the format/source of interventions, randomized controlled trials (RCTs) or types of comparisons were included. Results Eighteen papers met the inclusion criteria and contradictory results were found: the majority showed a significantly higher risk of impairment on QoL/HRQoL and psychosocial factors, whereas others reported a significantly lower risk of impairment (highlighting possible protective factors), or no significant differences. Heterogeneity in the assessment procedures and substantial difficulties in considering adolescence as a single and independent age group, were also noted. Conclusion The higher risk of impairment and the heterogeneity observed between cohorts, reinforce the need to work towards consensual procedures, which allow for more accurate comparisons among studies. Additionally, it conveys the challenge to find more effective interventions. Furthermore, it is highly suggested to routinely assess HRQoL/psychosocial factors within an individualized framework, to considerer adolescents as a single/independent group, to emphasize potential protective factors, and, to increase youth's participation in their own adaptation process and in health promotion in general. These are possible future directions that could enable multidisciplinary responses to improve HRQoL and psychosocial care in adolescents with a CD.

Common Elements in Rare Kidney Diseases: Conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Rare kidney diseases encompass at least 150 different conditions, most of which are inherited. Although individual rare kidney diseases raise specific issues, as a group these rare diseases can have overlapping challenges in diagnosis and treatment. These challenges include small numbers of affected patients, unidentified causes of disease, lack of biomarkers for monitoring disease progression, and need for complex care. To address common clinical and patient issues among rare kidney diseases, the KDIGO Controversies Conference entitled, Common Elements in Rare Kidney Diseases, brought together a panel of multidisciplinary clinical providers and patient advocates to address five central issues for rare kidney diseases. These issues encompassed diagnostic challenges, management of kidney functional decline and progression of chronic kidney disease, challenges in clinical study design, translation of advances in research to clinical care, and provision of practical and integrated patient support. Thus, by a process of consensus, guidance for addressing these challenges was developed and is presented here.

Cluster analysis for family management of Chinese children with chronic kidney diseases

This study aimed to identify patterns of family management and its predictors based on the perception of the care experience from 339 caregivers of Chinese children with chronic kidney disease in multiple medical centers. Each caregiver completed the Family Management Measure questionnaires. Cluster analysis generated five patterns: effective (12.7%), impaired (14.5%), burdensome (21.2%), disorganized (27.7%), and concerning (23.9%). Multinomial logistic regression indicated that child's age, disease duration, family income, and paternal employment predicted cluster membership. Findings assist healthcare providers to distinguish families that need more help and the areas in which to intervene to promote families' overall coping and adaptation.

Female Adolescents with Chronic or End-Stage Kidney Disease and Strategies for their Care

The prevalence of chronic or end-stage kidney disease in pediatric girls is lower than in boys, however, girls have unique morbidities that can have great effect on their quality of life. For female adolescents, creatinine excretion peaks at approximately 14 years of age and is significantly less than males, owing to lower muscle mass. Females have higher nitric oxide activity, and estrogens may contribute to lower blood pressure. Females excrete less growth hormone during the prepubertal and pubertal years. Females between the ages of 8 and 10 years show increased levels of parathyroid hormone and vitamin D, however, female adolescents with chronic kidney disease have less estrogen and loss of the luteinizing hormone pulsatile pattern. These biological, hormonal, and physical changes affect the psychosocial aspects of female adolescents with chronic kidney disease/end-stage kidney disease, and they must learn to manage their health to achieve good outcomes. Patients and their parents must learn disease management through a customized health care transition preparation in both the pediatric- and adult-focused settings. Clinical strategies are suggested for the care of these special patients.

Validation of the UNC TRxANSITION Scale™Version 3 Among Mexican Adolescents With Chronic Kidney Disease

BACKGROUND

There is a lack of valid health care transition readiness (HCT) scales in Spanish.

OBJECTIVE

To provide initial validation of the UNC TRxANSITION Scale™ among Mexican adolescents and young adults (youth) with chronic kidney disease (CKD).

METHODS

We used the professionally translated/back translated, provider-administered UNC TRxANSITION Scale™ (Ferris et al., 2012). This 33-question scale measures HCT in ten sub-scales including knowledge about diagnosis or treatment, diet, reproductive health, school/work, insurance, ability to self-manage and looking for new health providers. Its maximum score is 10. We enrolled 163 Mexican adolescents (48.5% females) with CKD stage≥3, mean age of 15.1years (±2.1) and whose primary language is Spanish. There were 15 patients on hemodialysis (9.2%) and 30 transplant recipients (18.4%). Results were compared to those reported in adolescents with chronic conditions from the USA.

RESULTS

Our cohort's overall median total score was 5.9. Patients≥16years old had a median total score of 6.4, whereas younger patients had median score of 5.6 (p<0.05). Transplant patients had greater scores in the total and the sub-scales of medication knowledge, issues of reproduction, insurance, trade/work and adherence (p<0.05). When comparing the total score (by age), results from our Mexican youth were similar to those reported in youth from the USA.

CONCLUSIONS

In our Mexican cohort of youth with CKD, health care transition readiness is greater in older patients and in transplant recipients. Our cohort's overall score is low, indicating the need for a health care transition preparation program. The UNC TRxANSITION Scale™ results in Mexican youth with CKD are comparable to findings in youth from the USA.

Self-Management and Transition Readiness Assessment: Development, Reliability, and Factor Structure of the STARx Questionnaire

INTRODUCTION

The Self-Management and Transition to Adulthood with Rx=Treatment (STARx) Questionnaire was developed to collect information on self-management and health care transition (HCT) skills, via self-report, in a broad population of adolescents and young adults (AYAs) with chronic conditions.

METHODS

Over several iterations, the STARx questionnaire was created with AYA, family, and health provider input. The development and pilot testing of the STARx Questionnaire took place with the assistance of 1219 AYAs with different chronic health conditions, in multiple institutions and settings over three phases: item development, pilot testing, reliability and factor structuring.

RESULTS

The three development phases resulted in a final version of the STARx Questionnaire. The exploratory factor analysis of the third version of the 18-item STARx identified six factors that accounted for about 65% of the variance: Medication management, Provider communication, Engagement during appointments, Disease knowledge, Adult health responsibilities, and Resource utilization. Reliability estimates revealed good internal consistency and temporal stability, with the alpha coefficient for the overall scale being .80. The STARx was developmentally sensitive, with older patients scoring significantly higher on nearly every factor than younger patients.

CONCLUSION

The STARx Questionnaire is a reliable, self-report tool with adequate internal consistency, temporal stability, and a strong, multidimensional factor structure. It provides another assessment strategy to measure self-management and transition skills in AYAs with chronic conditions.