Successful Transition from Pediatric to Adult Care in Inflammatory Bowel Disease: What is the Key?

Patient Empowerment Among Children and Adolescents with Inflammatory Bowel Disease (IBD) and Parents of IBD Patients-Use of Counseling Services and Lack of Knowledge About Transition

Background: Children and adolescents with pediatric inflammatory bowel diseases (PIBD) face significant challenges, including emotional stress, social isolation, and interrupted education due to symptoms. Effective counseling and education empower these young patients and their families to actively participate in healthcare. This paper investigates the IBD needs analysis (CEDNA), focusing on counseling and transition services. Methods: The Study Group distributed questionnaires to PIBD patients and the parents of children and adolescents with PIBD across Germany, with all responses provided anonymously. We conducted a subgroup analysis based on patient age and time since diagnosis, as well as aspects of regional distribution and city size. Parents' responses were analyzed by corresponding age groups to facilitate comparison with the patients' responses. Results: From October 2021 to April 2022, 1158 questionnaires (patients 38.9%, n = 450; parents 61.1%, n = 708) were completed. In the group of 16-17-year-old patients, only 14.1% (n = 239) feel well informed about transition programs (parents 6.7% of n = 360). Depending on the disease duration, 2.1% to 6.9% of the patients surveyed (n = 292) feel well informed about PIBD (parents 3.3% to 7.5%, n = 361). Nutritional counseling is the most requested support service (patients 49.2%, n = 382; parents: service used for their children 41.9%, n = 578; parents: service used for themselves 46.1%, n = 575). Conclusions: PIBD patients, especially aged 12-17, lack knowledge and preparation for transition to adult care. While general PIBD management awareness is fair, targeted educational efforts are necessary. Trustworthy information sources and early, tailored counseling services could enhance transition experiences and improve long-term disease management and patient outcomes.

Effectiveness of Transitional Care in Inflammatory Bowel Disease; Development, Validation, and Initial Outcomes of a Transition Success Score

BACKGROUND AND AIMS

The effectiveness of transition programs from pediatric to adult healthcare in adolescents with inflammatory bowel disease (IBD) is not clear, as prospective studies using validated outcome measures for transition are lacking. This study aimed to develop and validate a quantitative Transition Success Score (TSS), and to apply it in a multicenter setting to assess the effectiveness of transitional care.

METHODS

The Top 10 outcome items related to a successful transition, identified through an international Delphi study with IBD stakeholders, were integrated into a generic questionnaire, the TSS. In a prospective, multicenter study, the TSS was scored by adult healthcare providers, young adult patients, and caregivers, 9-15 months after transfer of care.

RESULTS

In 7 Dutch hospitals, 160 patients completed the TSS. The mean score was 25 (range 17-27), 25.6% of patients achieving maximum score. Hypothesis testing for construct validity revealed significant associations with characteristics related to transitional care, such as knowledge, independence, and quality of life (p < 0.005). Structural validation indicated the score was most effective at discerning lower levels of transition success. Internal consistency was acceptable (0.64). High disease burden, exacerbation during or after transfer, and certain personality profiles were associated with lower scores.

CONCLUSIONS

The TSS serves as a quantitative tool to evaluate the effectiveness of transitional care interventions and to identify IBD patients at risk of encountering challenges during the transition to adult healthcare.

Detailed immune profiling in pediatric Crohn's disease using methylation cytometry

DNA methylation has been extensively utilized to study epigenetic patterns across many diseases as well as to deconvolve blood cell type proportions. This study builds upon previous studies examining methylation patterns in paediatric patients with varying stages of Crohn's disease to extend the immune profiling of these patients using a novel deconvolution approach. Compared with control subjects, we observed significantly decreased levels of CD4 memory and naive, CD8 naive, and natural killer cells and elevated neutrophil levels in Crohn's disease. In addition, Crohn's patients had a significantly elevated neutrophil-to-lymphocyte ratio. Using an epigenome-wide association approach and adjusting for potential confounders, including cell type, we observed 397 differentially methylated CpG (DMC) sites associated with Crohn's disease. The top genetic pathway associated with the DMCs was the regulation of arginine metabolic processes which are involved in the regulation of T cells.

Transition Readiness Into Adult Health Care in Children With Inflammatory Bowel Disease

Background and aim Approximately 25% of inflammatory bowel disease (IBD) cases are diagnosed before the age of 18 years. Compared to adults, pediatric IBD is more aggressive and progresses rapidly. It is important to have a well-structured transition process in place when patients are transferred from pediatric to adult care. We aimed to evaluate the readiness of Saudi adolescents with IBD to be transitioned from pediatric to adult care using the Transition Readiness Assessment Questionnaire (TRAQ). Materials and methods This cross-sectional study was carried out at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, between January and December 2021. Pediatric patients aged between 12-18 with confirmed IBD were recruited. The mean TRAQ component and the overall scores were calculated and analyzed. Results A total of 54 patients with IBD were included. The overall mean TRAQ scores were moderately high (3.60±0.78), including high mean values for individual domains of the TRAQ. In terms of components of TRAQ, no significant differences between males and females were encountered; however, there was a trend for males having higher scores than females in tracking health issues (P=0.07). Patients older than 15 years had higher overall scores than younger patients (P=0.04). The level of child education was found to be the only independent variable that correlated with higher overall scores (P=0.005). Conclusions In this cohort of Saudi adolescents with IBD, patients showed moderately high overall mean TRAQ scores reflecting high readiness for transitioning. While males demonstrated a trend for higher scores compared to females in tracking health issues, patients older than 15 had higher total scores relative to younger patients. More studies are needed to examine the impact of better transition readiness on the long-term outcome of IBD.

Validation and Reference Scores of the Transition Readiness Assessment Questionnaire in Adolescent and Young Adult IBD Patients

OBJECTIVES

Transition readiness can predict a successful transition from pediatric to adult care. This study aimed to validate and develop age-dependent reference scores for the (Dutch version of) Transition Readiness Assessment Questionnaire (TRAQ), in adolescents and young adults (AYAs) with inflammatory bowel disease (IBD).

METHODS

TRAQ has 20 items (score 1-5) distributed over 5 domains (total sum score 100) and is completed by AYAs. Following the COnsensus-based Standards for the selection of health Measurement INstruments methodology, we conducted the translation, back-to back translation, pretesting, and validation of the final Dutch version of TRAQ (TRAQ-NL) questionnaire. We used a Rasch model for structural validation, hypothesis testing for construct validity, and Cronbach alpha to demonstrate reliability. Reference scores were calculated using percentiles.

RESULTS

Two hundred fifty TRAQ questionnaires were evaluated in 136 AYAs with IBD [56% Crohn disease, 58% male, median age 17.5 years (range 15.7-20.4)]. The overall mean item score was 3.87 (range 1.45-5). With good reliability (Cronbach alpha 0.87), TRAQ-NL discriminated well between knowledge levels, especially in the lower levels. Transition readiness was defined as low, moderate, adequate, or excellent in patients with TRAQ percentile scores (PC) <25th (<3.375 mean item score), 25th-50th (3.375-3.9), 50th-90th (3.91-4.7), or >90th (>4.7). Younger patients, concomitant illness, fewer visits to the transition clinic, and parental dependence were associated with significantly lower TRAQ scores.

CONCLUSION

TRAQ(-NL) is reliable and valid, with age-dependent PC to identify (in)adequate transfer readiness. TRAQ can now be more easily used as a patient-reported outcome measure to monitor transition readiness longitudinally in routine care for AYAs IBD patients.

Characteristics and Treatment Outcomes of Transition among Patients with Inflammatory Bowel Disease

PURPOSE

This study aimed to assess disease characteristics and outcomes of transition in patient care among adolescent patients with inflammatory bowel disease (IBD).

MATERIALS AND METHODS

Data from patients younger than 18 years who were diagnosed with IBD (Crohn's disease, ulcerative colitis, or intestinal Behçet's disease) were investigated. We categorized the patients into two groups: transition IBD group (Group A, diagnosed in pediatric care followed by transfer to/attendance in adult IBD care) and non-transition group (Group B, diagnosed and followed up in pediatric care or adult IBD care without transfer).

RESULTS

Data from a total of 242 patients [Group A (n=29, 12.0%), Group B (n=213, 88.0%)] were analyzed. A significantly higher number of patients was diagnosed at an earlier age in Group A than in Group B (p<0.001). Group A patients had more severe disease in terms of number of disease flare ups (p=0.011) and frequency of bowel-related complications (p<0.001). Multiple linear regression analysis showed that Group B patients had more medical non-compliance than Group A patients (β=2.31, p=0.018). After transition, IBD-related admission frequency, emergency admission frequency, disease flare frequency, and medical non-compliance were significantly improved.

CONCLUSION

The transition IBD group had more severe disease. Medical non-compliance was lower in the transition IBD group. Clinical outcomes improved after transition.

Building a Self-Management Toolkit for Patients with Pediatric Inflammatory Bowel Disease: Introducing the resilience 5

Transition from pediatric to adult health care is a complex process that calls for complex interventions and collaboration between health care teams and families. However, many inflammatory bowel disease (IBD) clinical care teams do not have the resources to implement rigorous transition programs for youth. This review provides a description of the Resilience5: self-efficacy, disease acceptance, self-regulation, optimism, and social support. The Resilience5 represents teachable skills to support IBD self-management, offset disease interfering behaviors, and build resilience in adolescents and young adults transitioning to adult health care systems. These skills can also be encouraged and reinforced during routine IBD clinical care.

Barriers to and requirements for a successful transition in inflammatory bowel disease from pediatric to adult care in Greece

Background

The incidence of pediatric-onset inflammatory bowel disease (IBD) is rising, while the relapsing and often severe nature of IBD, and its impact on emotional and pubertal development and social maturation underline the need for a successful transition from pediatric to adult care.

Methods

A web-based survey was distributed via the Hellenic Group for the Study of IBD, the Hellenic Society of Gastroenterology Department of North Greece, and the Hellenic Society of Pediatric Gastroenterology, Hepatology, and Nutrition.

Results

The questionnaire was answered by 98 individuals (78 adult and 20 pediatric gastroenterologists, out of 357 and 30, respectively). The response rate was 25.3%. A higher response rate was found among pediatric (66.6%) vs. adult gastroenterologists 21.8% (P<0.001). Pediatric gastroenterologists believed that the appropriate age for transition was either 16-17 or 17-18 years, whereas 59% of the adult gastroenterologists chose the age group of 16-17 years. Both adult and pediatric gastroenterologists stated that the most significant initiators for a successful transition process were cognitive maturity and patients' ability to manage their disease independently. The lack of communication and collaboration between pediatric and adult gastroenterologists was the main barrier to the transition process, as identified by adult gastroenterologists (27.7%). In contrast, 43.5% of pediatric gastroenterologists suggested that differences in the follow up of patients with IBD between pediatric and adult clinics were the main restrictions.

Conclusion

These results highlight the need for a transitional education program for pediatric IBD patients, and the importance of improving collaboration among adult and pediatric gastroenterologists.

Transition from pediatric to adult care among patients with epilepsy: Cross-sectional surveys of experts and patients in Korea

Objectives

Many pediatric patients with epilepsy require treatment beyond the pediatric age. These patients require transition to an adult epilepsy center. Currently, many centers worldwide run epilepsy transition programs. However, a standardized protocol does not exist in Korea. The basic data required to establish a transition program are also unavailable. We aimed to assess the status and perceptions of patients and epilepsy care providers on transition.

Methods

To assess the status of epilepsy transition, we retrospectively collected data from patients with epilepsy older than 18 years who visited our pediatric epilepsy clinic between March 1990 and July 2019. To assess the perception of transition, we surveyed patients, parents, pediatric neurologists (PN), and adult epileptologists (AE).

Results

In a retrospective chart review, 39 of 267 (14.6%) patients visited the adult epilepsy clinic after consulting a pediatric neurologist, and three patients returned to the pediatric center. The average patient age at transition was 23.29 ± 5.10 years. A total of 94 patients or their guardians and 100 experts participated in the survey. About half of the patients or guardians (44.7%) did not want to transition and emotional dependence was the commonest reason. Most patients (52.1%) thought that the appropriate age of transition was above 20 years. PNs had greater concerns about patients' compliance than AEs. Regarding the age of transition, AEs believed that a younger age (18 years) was more appropriate than PNs (20 years).

Significance

This study describes difficulties in the transition from pediatric to adult epilepsy centers without appropriate support. There were differences in perspectives among patients, parents, and adult and pediatric epilepsy care providers. This study can assist in creating a standardized protocol in Korea.

Rotterdam Transition Test: A Valid Tool for Monitoring Disease Knowledge in Adolescents With Inflammatory Bowel Disease

OBJECTIVES

Disease knowledge is important in adolescents with inflammatory bowel disease (IBD) transitioning to adult care. We developed an IBD-specific knowledge questionnaire, the Rotterdam Transition Test (RTT), and aimed to validate this tool.

METHODS

This is a prospective longitudinal validation study. The RTT has 25 open questions on IBD, medication, lifestyle, and transition to adult care. A scoring model was developed, and inter-rater agreement was assessed. Using a Rasch model, we determined the difficulty and performance of the questions. Cronbach alpha was used to demonstrate reliability. Patient factors (age, disease, education, medication use, illness acceptance, and independence) were correlated to RTT score.

RESULTS

A total of 207 RTTs were evaluated in 111 adolescent IBD patients. The scoring model showed a kappa score of >0.61 for all questions. Reliability with Cronbach alpha was good (0.81). Mean total result of the RTT was 58% (girls) and 55% (boys) of maximal score.The RTT discriminated well between the different levels of knowledge. Knowledge scores increased in patients who did repeated RTTs during the transition period. Male sex, low educational level, disease acceptance issues, and dependence on parents associated with a significantly lower total RTT score. Prednisone use within 3 months and treatment without biologics associated with significantly higher RTT scores. Disease activity was not a significant factor.

CONCLUSIONS

The RTT is a reliable and valid tool to assess IBD knowledge. The RTT can be used to detect and discuss knowledge gaps in adolescents with IBD transitioning to adult healthcare.

Health Care Transition for Children with Medical Complexity: Challenges and Lessons Learned

BACKGROUND

Transition from pediatric to adult health care is a pivotal process for young adults, especially those with complex medical needs. Despite advancements in the medical care provided to children with medical complexity (CMC), there is a lack of systematic approaches and guidance for patients and families transitioning from pediatric to adult health care.

METHODS

Health care providers and nurse case managers in the Complex Care Program (CCP) evaluated health care transition practices prior to 2019, and initiated quality improvement efforts to standardize transition guidance, planning, and documentation from 2019 to 2020 within the CCP.

FINDINGS

Challenges identified with transitioning CMC include: 1) Varied approaches and timelines for health care providers, 2) Documentation in the EMR, and 3) Connecting to adult health care systems. Throughout this work, CCP staff have learned lessons to effectively transition CMC. Themes included: 1) Transition from a pediatric to an adult primary care provider first, 2) Start transition conversations early, 3) Identify a universal location to document transition planning, and 4) Importance of family involvement.

IMPLICATIONS FOR PRACTICE

To effectively transition CMC, health care staff must start conversations early, engaging all primary and specialty providers, patients, and families to create safe transition plans.

'Adulting' with IBD: Efficacy of a Novel Virtual Transition Workshop for Pediatric Inflammatory Bowel Disease

PURPOSE

The rising prevalence of IBD in children corresponds with a need for patient education on transition to adult care. The objective of this study was to design, implement and evaluate a novel transitions program for adolescents with Inflammatory Bowel Disease and their parents, and to assess the impact of this program on transition readiness skills, self-efficacy and participant satisfaction.

DESIGN AND METHODS

Sixteen adolescent-parent dyads participated in the virtual transition workshop. Workshop programming was designed utilizing a biopsychosocial and multidisciplinary approach to IBD management and engagement with healthcare resources. The impact of the workshop was measured utilizing validated self- and parent-report measures of transition readiness (TRAQ), self-efficacy (IBD-SES), depression (PHQ8) and anxiety (GAD7).

RESULTS

Over 60% of participants found the workshop helpful and 92% would recommend it to other teens with IBD. The average adolescent transition readiness score (TRAQ) significantly increased by 5.00 points following the workshop (SD = 7.49, p = 0.04), while total parent scores increased by 10.55 points (SD = 11.15, p = 0.011). As was expected, this demonstrates increased transition readiness skills. The average total adolescent IBD-SES score decreased by 6.75 (SD = 8.95, p = 0.024).

CONCLUSION

This novel transition program resulted in increased participant transition readiness, as reported by adolescent and parents, indicating the workshop's utility in promoting tangible skill development. Self-efficacy scores did not increase; self-efficacy is a delayed measure of program success and is tied to disease status and other stressors which also changed across time points.

PRACTICE IMPLICATIONS

Future directions include continuing the virtual program for increased participation and dissemination, integrating feedback and increasing interdisciplinary involvement.

Management of paediatric IBD after the peak of COVID-19 pandemic in Italy: A position paper on behalf of the SIGENP IBD working group

Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2, spreading in Italy during the first months of 2020, abruptly changed the way of practicing medicine in this country. As a consequence of the lockdown, the diagnostic and therapeutic management of paediatric chronic conditions, such as inflammatory bowel disease (IBD) has been affected. During the peak of COVID-19 pandemic, elective visits, endoscopies and infusions have been postponed, with potential clinical and psychological impact on disease course and a high likelihood of increasing waiting lists. While slowly moving back towards normality, clinicians need to recognize the best ways to care for patients with IBD, carefully avoiding risk factors for new potential epidemic outbreaks. In this uncertain scenario until the development and spread of COVID-19 vaccine, it is necessary to continue to operate with caution. Hereby we provide useful indications for a safer and gradual restarting of routine clinical activities after COVID-19 peak in Italy.

Development of Entrustable Professional Activities and Standards in Training in Pediatric Neurogastroenterology and Motility: North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and American Neurogastroenterology and Motility Society Position Paper

Neurogastroenterology and motility (NGM) disorders are common in childhood and are often very debilitating. Although pediatric gastroenterology fellows are expected to obtain training in the diagnosis and management of patients with these disorders, there is an ongoing concern for unmet needs and lack of exposure and standardized curriculum. In the context of tailoring training components, outcome and expressed needs of pediatric gastroenterology fellows and programs, members of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and American Neurogastroenterology and Motility Society (ANMS) developed guidelines for NGM training in North America in line with specific expectations and goals of training as delineated through already established entrustable professional activities (EPAs). Members of the joint task force applied their expertise to identify the components of knowledge, skills, and management, which are expected of NGM consultants. The clinical knowledge, skills and management elements of the NGM curriculum are divided into domains based on anatomic regions including esophagus, stomach, small bowel, colon and anorectum. In addition, dedicated sections on pediatric functional gastrointestinal (GI) disorders, research and collaborative approach, role of behavioral health and surgical approaches to NGM disorders and transition from pediatric to adult neurogastroenterology are included in this document. Members of the NASPGHAN-ANMS task force anticipate that this document will serve as a resource to break existing barriers to pursuing a career in NGM and provide a framework towards uniform training expectations at 3 hierarchical tiers corresponding to EPA levels.

Knowledge of disease and self-management of adolescents with inflammatory bowel diseases

AIM

To describe factors that might affect successful transition in young adult patients with inflammatory bowel disease (IBD).

METHODS

Questionnaires regarding the personal disease history, treatment and diseases specific knowledge and patients' self-efficacy were completed by teenaged patients with IBD aged 14-18 years, during routine clinic visits. Patient answers were then compared with information obtained from the medical records and information provided by treating physician.

RESULTS

The study included 80 patients with IBD, 54 (67.5%) with Crohn's disease. Patients demonstrated good knowledge in their personal disease history and current treatment. Knowledge gaps were observed in medication dosages, knowledge of potential side effects and effects of smoking on disease, with only 53/80 (66%), 12/80 (15%) and 6/36 (16.7%) of patients providing correct answers. Only 25/36 (69.4%) of the patients aged 16-18 had read about their disease. All patients in 16-18 age group reported needing assistance to schedule a gastroenterologist appointment.

CONCLUSION

Knowledge and self-efficacy skills of IBD teenagers are suboptimal regarding medications, smoking and appointment management. Medical providers should work with parents and teenaged patients with IBD to allow them to attain missing information and promote self-efficacy skills, in order to reinforce readiness towards transition.

The Management Approach to the Adolescent IBD Patient: Health Maintenance and Medication Considerations

PURPOSE OF REVIEW

Inflammatory bowel disease (IBD) is often diagnosed during adolescence and can have a deep impact on the physical, hormonal, developmental, and psychosocial changes associated with this life period. The purpose of this review is to address the particular manifestations of IBD (such as growth and pubertal delay), health maintenance issues, and treatment considerations in the adolescent.

RECENT FINDINGS

The need for a multidisciplinary approach to recognize and address growth and pubertal delay, bone health, as well as the psychosocial impact of IBD on the adolescent has been increasingly recognized as an integral part of IBD care in this population. Vaccinations schedule, preventive health measures, and promoting compliance with care are particularly important during adolescence. Replacing nutrients deficits is also crucial: in particular, vitamin D has been shown to play a role in the gut immune system, and adequate vitamin D levels might promote IBD remission. Iron replacement should be done by intravenous route since oral iron is poorly absorbed in chronic inflammatory states. Finally, recent data have shed light on the increased risk of particular types of lymphoma in adolescent on thiopurines, whereas biologic therapies, in particular, anti-TNF, now are positioned as a preferred and effective steroid-sparing agents in moderate to severe IBD. Management of adolescents with IBD is not without significant challenges. An early implementation of steroid-sparing therapies, a multidisciplinary treatment approach, and a dynamic physician-patient relationship are essential to achieve remission, prevent disease-related complications but also optimize developmental, physical, and psychosocial health, and encourage compliance and transition to adult care.

Transition clinics: an observational study of themes important to young people with inflammatory bowel disease

BACKGROUND

Transition from paediatric to adult services can be stressful and potentially disruptive for adolescents diagnosed with inflammatory bowel disease (IBD). This study aimed to ascertain transition-related factors relevant to young people in New Zealand.

METHODS

Adolescents diagnosed with IBD prior to their 16th birthday were asked to participate in focus groups to generate transition-related themes. These themes were used to develop a questionnaire, which was then administered to a second group of young patients.

RESULTS

Initial focus groups discussions generated several key themes: these included concerns about meeting new people in unfamiliar surroundings, the importance of shared clinics and assessments for transition readiness. The subsequent transition questionnaire was completed by 53 young people (28 female and 48 with Crohn's disease). The most commonly reported difficulty by those entering transition was meeting a new doctor. This and building a new relationship/trust were the main concerns of respondents who were preparing for or within a transition process. Parental assessment of illness and readiness to transition were not thought to be as important as other factors for determining readiness for transition. The character of their new adult gastroenterologist was the factor felt most likely to make transition easy.

CONCLUSIONS

The main concerns of these young patients with IBD, at various stages of transition, were about meeting a new team and building new relationships. Planning and conducting a structured transition process should consider these factors to optimise the process.