Audit of rheumatology services for adolescents and young adults in the UK. British Paediatric Rheumatology Group

Addressing the unmet needs of transitional care in juvenile idiopathic arthritis

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Consensus evidence-based recommendations for transition of care for adolescents with juvenile idiopathic arthritis: meeting patients’, parents’, and rheumatologists’ perspectives

Background

Transition of care means the process of educating and empowering adolescents and young adults to take an active role in their own healthcare, develop decision-making skills, and eventually transition from paediatric to adult healthcare providers. Most people do not switch doctors until they are young adults, but it can be beneficial to start preparing children earlier. We aimed to develop a specific toolkit tailored to paediatric and adult rheumatologists to assist them in transitioning of care of young people with juvenile onset rheumatic musculoskeletal diseases from the paediatric to adult rheumatology care.

Results

The expert panel was confined to an online survey (n = 18), all the experts completed the two rounds. At the conclusion of round 2, a total of 10 points were gathered. The range of respondents (ranks 7–9) who agreed with the recommendations was 88.9 to 100%. All 10 clinical standards identified by the scientific committee were written in the same way. Based on the answers to the structured key questions and the literature review, a structured template was developed presenting transition of care integrated pathway.

Conclusion

The developed rheumatology-specific guideline offers adolescents and young adults a focussed, multidisciplinary transition of care approach with equity of access, quality of care and flexibility and set up standards for transitional care for young adults with juvenile rheumatological diseases.

Proceedings of the 2nd BEAT-PCD conference and 3rd PCD training school: part 1

Primary ciliary dyskinesia (PCD) is a rare heterogenous condition that causes progressive suppurative lung disease, chronic rhinosinusitis, chronic otitis media, infertility and abnormal situs. 'Better Experimental Approaches to Treat Primary Ciliary Dyskinesia' (BEAT-PCD) is a network of scientists and clinicians coordinating research from basic science through to clinical care with the intention of developing treatments and diagnostics that lead to improved long-term outcomes for patients. BEAT-PCD activities are supported by EU funded COST Action (BM1407). The second BEAT-PCD conference, and third PCD training school were held jointly in April 2017 in Valencia, Spain. Presentations and workshops focussed on advancing the knowledge and skills relating to PCD in: basic science, epidemiology, diagnostic testing, clinical management and clinical trials. The multidisciplinary conference provided an interactive platform for exchanging ideas through a program of lectures, poster presentations, breakout sessions and workshops. Three working groups met to plan consensus statements. Progress with BEAT-PCD projects was shared and new collaborations were fostered. In this report, we summarize the meeting, highlighting developments made during the meeting.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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

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

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

"Sometimes I feel like a pharmacist": identity and medication use among adolescents with juvenile arthritis

BACKGROUND

Taking medicines as intended is difficult for everybody, but young people going through adolescence have greater problems than adults and younger children. One of the most important things that happen during the teenage years is the development of individual identities, which might not remain constant during this time and can be affected deeply by the diagnosis of a long-term condition. The aim of this study was to examine the relationships between identity and medication use among young people with juvenile arthritis.

METHODS

A prospective qualitative study was undertaken to collect private online 'blog' style data from young people (aged 11-19 years) with juvenile arthritis, and their parents, to examine their views about their condition, identity, medication and use of health services. Participants were identified from a large paediatric hospital in the UK.

RESULTS

Young people (n = 21) with a median age 14 years (range 11-17 years) posted a median (range) of 8 (1-36) blogs and parents (n = 6) posted 4 (1-12) blogs. Young people gave a strong sense of both private and public identity that was intertwined with their arthritis and treatment. It was evident that young people's self-care was intrinsically linked to their attempts to maintain a sense of individually and socially constructed definitions of normality. The act of taking medication, and the consequences (positive or negative) of that act, had an impact both personally and socially.

CONCLUSIONS

Young people with juvenile arthritis reflect on their medication as a factor affecting their perception of themselves. Acknowledging the roles of both personal and social identity will be important in any strategies to support optimal medication use. This includes an understanding of the identity transformations that young people can experience and how decision-making may be affected by their attempts to retain pre-diagnosis identities and/or develop new social identities.

The Challenge of and Opportunities for Transitioning and Maintaining a Continuum of Care Among Adolescents and Young Adults Living with HIV in Resource Limited Settings

An unprecedented number of youth living with HIV (YLHIV) are aging into adolescence and young adulthood, increasing concerns about the possibility of these youth being lost in the transition from supported care (sometimes in pediatric settings) to more independent healthcare settings and perhaps furthering the emerging disparities in outcomes (e.g., higher nonadherence to treatment, increased morbidity and mortality). In resource-rich settings where there is likely greater recognition of adolescent cognitive and developmental challenges, transitioning YLHIV to adult healthcare has emerged as a major challenge. In resource limited settings (RLS), where the burden of HIV is significant and healthcare resources often stretched, the challenge to move toward healthcare independence and maintain a fluid continuum of care for YLHIV may be the greatest. We review key issues in transitioning YLHIV in RLS, highlighting steps in the transition process, examining evidence where available, and discussing challenges and opportunities to understanding and optimizing outcomes.

Implementing transition: Ready Steady Go

There is good evidence that morbidity and mortality increase for young persons (YP) following the move from paediatric to adult services. Studies show that effective transition between paediatric and adult care improves long-term outcomes. Many of the issues faced by young people across subspecialties with a long-term condition are generic. This article sets out some of the obstacles that have delayed the implementation of effective transition. It reports on a successful generic transition programme 'Ready Steady Go' that has been implemented within a large National Health Service teaching hospital in the UK, with secondary and tertiary paediatric services, where it is now established as part of routine care.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Paediatric rheumatology practice in the UK benchmarked against the British Society for Paediatric and Adolescent Rheumatology/Arthritis and Musculoskeletal Alliance Standards of Care for juvenile idiopathic arthritis

OBJECTIVE

To describe current clinical practice against the BSPAR/ARMA Standards of Care (SOCs) for children and young people (CYP) with incident JIA.

METHODS

Ten UK paediatric rheumatology centres (including all current centres nationally accredited for paediatric rheumatology higher specialist training) participated in a retrospective case notes review using a pretested pro forma based on the SOC. Data collected per centre included clinical service configuration and the initial clinical care for a minimum of 30 consecutive new patients seen within the previous 2 years and followed up for at least 6 months.

RESULTS

A total of 428 CYP with JIA (median age 11 years, range 1-21 years) were included, with complete data available for 73% (311/428). Against the key SOCs, 41% (175/428) were assessed ≤10 weeks from symptom onset, 60% (186/311) ≤4 weeks from referral, 26% (81/311) had eye screening at ≤6 weeks, 83% (282/341) had joint injections at ≤6 weeks, 59% (184/311) were assessed by a nurse specialist at ≤4 weeks and 45% (141/311) were assessed by a physiotherapist at ≤8 weeks. A median of 6% of patients per centre participated in clinical trials. All centres had access to eye screening and prescribed biologic therapies. All had access to a nurse specialist and physiotherapist. Most had access to an occupational therapist (8/10), psychologist (8/10), joint injection lists (general anaesthesia/inhaled analgesia) (9/10) and designated transitional care clinics (7/10).

CONCLUSION

This first description of UK clinical practice in paediatric rheumatology benchmarked against the BSPAR/ARMA SOCs demonstrates variable clinical service delivery. Considerable delay in access to specialist care is evident and this needs to be addressed in order to improve clinical outcomes.

The Longitudinal Relationship Between Satisfaction with Transitional Care and Social and Emotional Quality of Life Among Chronically Ill Adolescents

This study aimed to identify the relationship between satisfaction with transitional care and quality of life of chronically ill adolescents over time. This longitudinal study included adolescents with type I diabetes, juvenile idiopathic arthritis (JIA), and neuromuscular disorders (NMD). At baseline 138 respondents (response rate 31 %) filled in a questionnaire and 188 about 1 year later (response rate 43 %). Analysis of variance showed that adolescents with diabetes reported the highest physical quality of life, followed in order by those with NMD and JIA (p ≤ 0.01). Adolescents with diabetes reported the highest social quality of life, followed in order by those with JIA and NMD (both at p ≤ 0.001). Univariate analyses showed that satisfaction with transitional care at T0 was significantly related to emotional and physical quality of life at T1 (both at p ≤ 0.05). At T1, satisfaction with transitional care was significantly related to the emotional, physical, and social domains of quality of life (all at p ≤ 0.001). Multiple regression analyses revealed that satisfaction with transitional care at T1 was related to emotional (β -0.20; p ≤ 0.05) and social (β -0.35; p ≤ 0.01) quality of life domains over time. This indicates that lower gap scores, which measured differences between 'best care' and 'current care,' are associated with better social and emotional quality of life in this sample of adolescents. Satisfaction with transitional care and social and emotional quality of life are related over time.

Transition in endocrinology: the challenge of maintaining continuity

OBJECTIVE

Transition from child to adult status is a crucial stage in young people's lives. It is important that young people continue to receive appropriate endocrine care throughout and following transfer from paediatric to adult services. This study examined indicators of patient loss to follow-up at initial transfer from paediatric care to identify implications for transitional care practice and research.

METHODS

A retrospective analysis of patient data following transfer from paediatric services to a young person's transition clinic was conducted. Attendance data from 103 patients transferred to the Young Person's Clinic were analysed to determine the factors affecting nonattendance 1-year post-transfer.

RESULTS

We found that overall one quarter of patients did not attend the young person's clinic in the first year after transfer. Those with poor attendance prior to transfer were likely to be poor attenders post-transfer. Further, those without an appointment scheduled in the first 6 months of their final paediatric transfer appointment were less likely to attend in the first year.

CONCLUSIONS

Young people are at risk of losing contact during the transfer from paediatric to the young person's clinic. Measures that promote continuity of contact could reduce the risk of long-term disengagement with care. Further development and research is required to identify the best ways to help young people with endocrine conditions in the transition from child to adult status.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychological factors impacting transition from paediatric to adult care by childhood cancer survivors

PURPOSE

Childhood cancer survivors require life-long care focused on the specific late effects that may arise from their cancer and its treatment. In many centers, survivors are required to transition from follow-up care in a paediatric cancer center, to care provided in an adult care setting. The purpose of this study was to identify the psychological factors involved in this transition to adult care long-term follow-up clinics.

METHODS

Qualitative interviews were conducted with ten paediatric survivors still in paediatric care, as well as 28 adult survivors of whom 11 had transitioned successfully to adult care (attended three long-term follow-up (LTFU) appointments consecutively); ten who failed to transition (attended at least one LTFU appointment as an adult, but were inconsistent with subsequent attendance); and seven who had never transitioned (did not attend any LTFU care as an adult). Line-by-line coding was used to establish categories and themes. Constant comparison was used to examine relationships within and across codes and categories.

RESULTS

Two overall categories and four subthemes were identified: (1) Identification with being a cancer survivor included the subthemes of 'cancer identity' and 'cancer a thing of the past' and; (2) Emotional components included the subthemes of 'fear and anxiety' and 'gratitude and gaining perspective'. The analysis revealed that the same factor could act as either a motivator or a hindrance to successful transition in different survivors (e.g., fear of recurrence of cancer might be a barrier or a facilitator depending on the survivor's life experience).

CONCLUSIONS

Psychological factors are an important consideration when preparing cancer survivors for transition to adult long-term follow-up care. Identifying and addressing the individual psychological needs of childhood cancer survivors may improve the likelihood of their successful transition to adult care.

AN EXPLORATORY STUDY OF FUTURE PLANS AND EXTRACURRICULAR ACTIVITIES OF TRANSITION-AGE YOUTH AND YOUNG ADULTS

A descriptive profile of the health related concerns, school-related and extracurricular activities, employment-related activities, social relationships and future plans of 25 transition-aged youth and young adults (ages 14 to 21 years) were conducted. The findings of this exploratory study provide insight on the impact their chronic condition had upon all aspects of their lives. Sixty percent of respondents indicated they had missed school due to their condition and a third of the respondents had not completed high school. Health care professionals usually were not identified as participatory in youth transition planning. The majority of these transition-aged youth and young adults had positive feelings towards their school experience, although most of the respondents were not involved in school projects or clubs, which suggests their participation in school-related extra-curricular activities was limited. Nearly all of the respondents had some form of employment experience. Most of their work experiences were nonpaying jobs such as serving as a volunteer and participating in school-based employment training. Nearly all of the respondents expressed desires for sustainable employment and fiscal and social independence. Most of the respondents reported having social relationships with just less than half reporting seeing friends outside of school.

From childhood to adult life with juvenile idiopathic arthritis (JIA): A pilot study

PURPOSE

To explore the experiences of the health service provision in the transition process from childhood to adult life from the perspective of young patients with juvenile idiopathic arthritis (JIA) and health professionals working in this field.

METHOD

Two groups of young persons with JIA and two groups of health professionals were interviewed in focus groups. The data were analysed according to approved guidelines for qualitative analysis.

RESULTS

'Capability to lead a meaningful adult life' emerged as a core category; capability as a consequence of 'being enabled' from the youths' point of view, and 'enabling the young patients' from the health professionals' perspective. Preparation for the transition and transfer process was perceived as inadequate and seemed dependent on enthusiastic health professionals both in the children's and adult wards. Suggestions for formal improvements were required in four main areas.

CONCLUSION

This pilot study has identified inadequacies in the transition management provided for young people with JIA. Acceptance of the young persons as active participants in their own transition process might strengthen these young persons' experience of an autonomous identity and enable participation socially and in society, thus enhancing the ability to achieve a meaningful adult life. Further investigations should focus on adults living with JIA, how they lead their lives physically and psychosocially.

Preparing for adulthood: health care transition counseling for youth with arthritis

OBJECTIVE

To determine the proportion of adolescents with arthritis who receive health care transition services and to compare the rates with those reported for adolescents with other special health care needs and adolescents with diabetes.

METHODS

We used data from the 2005-2006 National Survey of Children with Special Health Care Needs. A parent/guardian identified youth ages 12-17 years with arthritis (n = 1,052), diabetes (n = 389), and special health care needs (n = 18,189). Four questions examined the extent to which providers discussed health care transition issues, including 1) transfer of care to adult providers, 2) health care needs of adults, 3) acquiring health insurance, and 4) encouraging self-care responsibility. Bivariate comparisons assessed the associations between sociodemographic characteristics and health care transition services, and multivariate regression models compared outcomes between conditions.

RESULTS

Many adolescents with arthritis are being encouraged to assume self-care responsibilities (74.8%); fewer discussed how health needs will change in adulthood (52.1%), acquiring insurance (22.5%), or transferring care to a provider who sees adults (19.0%). These results are similar to youth with other special health care needs, but behind youth with diabetes.

CONCLUSION

Among this sample of US adolescents, many report discussions about health care needs and self-management, but few are addressing critical aspects of the transition to adult-oriented health care.

The constancy of work-related empowerment

OBJECTIVE

This study describes experiences of work empowerment among staff members at the Rheumatism Foundation Hospital in Helsinki, Finland.

METHODS

The data were collected on two occasions in 2004 and 2005 using a structured questionnaire with background variables and items concerning verbal, behavioural and outcome empowerment. The questionnaires were sent to all (n1=115, n2=112) members of multidisciplinary teams at the Rheumatism Foundation Hospital, with the exception of physicians, departmental secretaries and administrative personnel. The response rate at both data collections was 58%. The data were analysed by statistical methods.

RESULTS

No statistically significant differences were seen in work empowerment between the two data collections. Perceptions of work-related empowerment were relatively strong.

CONCLUSIONS

Work-related empowerment appears to be relatively constant and independent of changes in the organization. Indeed there is good reason to ask whether work empowerment is primarily a function of the individual employee's strengths and competencies.

Transition of care from paediatric to adult rheumatology

The origin of paediatric rheumatology in the UK mainly lies in adult rheumatology and this has proved invaluable in terms of transition provision, education and training, and collaborative research. The last 5 years have seen adolescent rheumatology gather momentum with the creation of an objective evidence base, a sound foundation for future work addressing the many unanswered questions and hypotheses in the area of transitional care. The aim of this paper is to review the evidence supporting the recent developments in transitional care within rheumatology. Acknowledging the non-categorical nature of transition, the author will also refer to evidence from other chronic illnesses which has informed these developments.

Young people's satisfaction of transitional care in adolescent rheumatology in the UK

BACKGROUND

To examine the quality of transitional health care from the perspectives of young people with juvenile idiopathic arthritis (JIA) and their parents.

METHODS

Adolescents with JIA and their parents were recruited from 10 major UK rheumatology centres. Satisfaction with health-care delivery was measured prior to, and 12 months after, the implementation of a structured and co-ordinated programme of transitional care using self-completed questionnaires designed for this study.

RESULTS

Of 359 families invited to participate, 308 (86%) adolescents with JIA and 303 (84%) parents/guardians accepted. A fifth of adolescents had persistent oligoarthritis. Median age was 14.2 (11-18) years with median disease duration of 5.7 (0-16) years. Young people and their parents rated provider characteristics more important than aspects of the physical environment or process issues. Staff honesty and knowledge were rated as the most essential aspects of best practice. Prior to implementing the programme of transitional care, parents rated service delivery for all items significantly worse than best practice. Overall satisfaction improved 12 months after entering the programme. However, while parent satisfaction improved for 70.4% of items, significant improvements were only observed for three (13.6%) items rated by adolescents.

CONCLUSION

The perceived quality of health care for young people with JIA and their parents was significantly lower than what they would like. Satisfaction with many aspects of care during transition from paediatric to adult services can be improved through the implementation of a structured, co-ordinated programme of transitional care.

Development and preliminary validation of the 'Mind the Gap' scale to assess satisfaction with transitional health care among adolescents with juvenile idiopathic arthritis

BACKGROUND

To develop a scale to assess satisfaction with transitional health care among adolescents with a chronic illness and their parents.

METHODS

The 'Mind the Gap' scale was developed using evidence from a previous needs assessment, in three stages: (1) definition of the construct; (2) design of the scale items, response options and instructions; (3) full administration of the scale, item analysis and dimensionality analysis. The scale was administered to 308 adolescents with juvenile idiopathic arthritis (JIA) and 303 parents/guardians, prior to and 12 months after the implementation of an evaluation of a structured and co-ordinated programme of transitional care. The patient population involved adolescents with JIA and their parents recruited from 10 major UK rheumatology centres.

RESULTS

A total of 301 (97.7%) adolescents and 286 (95.0%) parents chose to complete the questionnaire, with median item completion rates of 100.0% (0-100%) for both adolescents and parents thus confirming feasibility. Face and content validity were confirmed. Factor analyses revealed a three-factor structure which explained 49.5% and 56.1% of the variation in adolescent and parent scores respectively. The internal consistency of each subscale ('management of environment', 'provider characteristics' and 'process issues') was indicated by Cronbach's alphas of 0.71, 0.89 and 0.89 for adolescents, respectively, and 0.83, 0.91 and 0.92 for parents respectively. Cronbach's alphas for the entire scales were 0.91 and 0.94 for the adolescent and parent forms respectively.

CONCLUSION

These preliminary results report the potential of the 'Mind the Gap' scale in evaluating transitional care for adolescents with JIA. In view of the generic nature of transitional care reflected in the scale, this scale has wider potential for use with adolescents with other chronic illness in view of the generic nature of transition. This development is particularly timely in the context of transitional care developments in the UK and further validation of the scale is in progress.

Overview of the psychosocial concerns of young adults with juvenile arthritis

Young adults who develop juvenile idiopathic arthritis in childhood have a significant risk of long-term morbidity and continuing disease activity in adulthood. The impact of a physically restricting and painful chronic illness can make the transition from adolescence to adulthood more challenging. In this overview of the psychological and social impact of juvenile arthritis on young adults, particular attention is given to those areas that are of concern to this age group. The transition from adolescence to adulthood can be detrimentally affected not only by the attitudes of peers and parents, but also by the attitudes of the individual with arthritis. Chronic arthritis, including juvenile arthritis, is related to increased rates of anxiety and depression. In the face of functional restriction, pain, and poor body image, social and sexual relationships may be harder to develop and maintain. The family of the young adult may also be affected on many levels. Employment and financial security are common and well-founded concerns of young disabled adults.

When should young people with chronic rheumatic disease move from paediatric to adult-centred care?

Many young people with childhood-onset diseases, including rheumatic diseases, continue to require medical care into adult life. There are many differences between paediatric and adult health care which can make this change a dramatic and difficult one for young people and their families. Transitional care services aim to equip young people with the appropriate knowledge and skills to cope with this change. This chapter will describe the differences between transition and transfer, and the different perspectives of those involved in the transition process, and will discuss the determinants of a successful transfer. Transition models currently used in practice will also be described, as will the evolving evidence base that is contributing to the further development of transitional care services.

Principles of management of musculoskeletal conditions in children and young people

Musculoskeletal symptoms and rheumatic conditions are common throughout childhood and adolescence. Age- and development-appropriate care and management of children and young people with such conditions is vital, acknowledging that they are NOT small adults! The major aspect of both paediatric and adolescent rheumatology care which differentiates it from adult care is the fact that children and young people are still growing, in contrast to the ageing and senescence which characterizes adult rheumatology. Growth must be considered in the global sense, incorporating cognitive and psychosocial growth as well as physical growth. Likewise, the reciprocal influences of growth and a chronic rheumatic condition should be considered when caring for young people with childhood-onset rheumatic disease. This chapter will detail the general principles of management of such symptomatology with primary reference to chronic conditions.

Work-related empowerment of the multidisciplinary team at the Rheumatism Foundation Hospital

Carried out as part of a staff development project, this study describes the experiences of work-related empowerment within a multidisciplinary team at the Rheumatism Foundation Hospital in Finland. The data were collected using a structured questionnaire consisting of background variables and questions concerning verbal, behavioural and outcome empowerment. The questionnaire was sent to all members of the multidisciplinary team at the Rheumatism Foundation Hospital, with the exception of physicians, departmental secretaries and administrative personnel. The response rate was 58%. The data were examined using statistical methods. The multidisciplinary team felt quite strong verbal and behavioural empowerment, but was less confident in terms of outcome empowerment. Several factors were found to be associated with the different fields of empowerment. In conclusion, the multidisciplinary team felt quite strong work-related empowerment.

Growing up and moving on. A multicentre UK audit of the transfer of adolescents with juvenile idiopathic arthritis from paediatric to adult centred care

OBJECTIVE

To assess the provisions made for the transfer of adolescents with juvenile idiopathic arthritis to adult rheumatology clinics in the UK and the impact of a transitional care programme.

METHODS

An audit of the documentation of the provisions made for transfer in 10 centres participating in a controlled trial of transitional care. Each centre conducted a retrospective case note audit of the recent patients transferred to adult care before and 12-24 months after the start of the trial. Demographic details, age when transition was first discussed, age at transfer, transitional issues, multidisciplinary team involvement, adolescent self advocacy, and readiness were documented.

RESULTS

There were improvements at follow up in documentation of transitional issues, disease specific educational needs, adolescent readiness, and parental needs with the exception of dental care, dietary calcium, and home exercise programmes. The age at which the concept of an independent clinic visit was introduced was lower (mean (SD): 16.8 (1.06) v 15.8 (1.46) years, p = 0.01) but there were no other changes in age related transitional milestones. Significantly more participants had preparatory visits to the adult clinic, had a transition plan, and had joint injections while awake at follow up.

CONCLUSIONS

The improvement in documentation suggests that involvement in the research project increased awareness of transitional issues. The difficulty of changing policy into practice was highlighted, with room for improvement, particularly at the paediatric/adult interface. The reasons for this are likely to be multiple, including resources and lack of specific training.

Growing up and moving on in rheumatology: a multicentre cohort of adolescents with juvenile idiopathic arthritis

OBJECTIVES

To define the transitional care workload of a multicentre cohort of adolescents with juvenile idiopathic arthritis (JIA) including disease, self-advocacy and vocational issues prior to the implementation of a transitional care programme.

METHODS

Data were collected using questionnaires completed by senior clinicians, patients and parents in 10 UK paediatric rheumatology centres. Entry criteria for patients included a confirmed diagnosis of JIA for at least 6 months and an age of 11, 14 or 17 yr.

RESULTS

Of 359 families invited to participate, 308 (85.79%) adolescents with JIA and 303 parents/guardians accepted. Of these, 19.5% had persistent oligoarthritis. Despite their imminent transfer to adult care, ongoing transitional issues were identified in the 17-yr-old cohort: 55.8% were still seeing the rheumatologists with their parent, 20% were not self-medicating, 68.5% had not had intra-articular injections under local anaesthetic and 14% had received no careers counselling. This age group also had significant disease-related issues; 54.6% had moderate to severe functional disability, 67.5% were still on disease-modifying anti-rheumatic drugs and, as a group, they had significantly greater pain than younger patients.

CONCLUSIONS

This study has objectively identified the transitional care workload facing paediatric and adult rheumatologists in terms of disease-related, self-advocacy and vocational issues. Outcome data following the implementation of a coordinated transitional care programme are awaited.

User perspectives of transitional care for adolescents with juvenile idiopathic arthritis

OBJECTIVES

To gain insight into the transitional needs of adolescents with juvenile idiopathic arthritis (JIA) and to examine how these needs may be addressed within a structured programme of transitional care.

METHODS

A qualitative study using focused group discussions was performed. Groups comprised (i) adolescents with JIA aged 12-18 yr, (ii) young adults with JIA aged 19-30 yr, (iii) parents of adolescents with JIA, and (iv) parents of young adults with JIA.

RESULTS

Transitional needs included aspects of participants' physical, social, psychological and vocational lives. Participants (n = 55) called for developmentally appropriate care based upon shared decision-making, continuity of health professionals, and wider access to information and community services. Suggestions for improved care included individualized assessment of patient's holistic needs and increased transfer preparation.

CONCLUSIONS

These results provide a useful guide to transitional care and suggest an approach that is adolescent-focused and evidence-based.

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

OBJECTIVES

To determine the perceived education and training needs of health professionals involved in transitional care for adolescents with juvenile idiopathic arthritis (JIA).

METHODS

Two distinct questionnaires to identify transitional issues in JIA were distributed to key health professionals (n = 908) and clinical personnel involved in the implementation of a transitional care programme (n = 22).

RESULTS

The first survey was completed by 263 professionals. Education needs were reported by 114 (43%) of health professionals. Transition issues and informational resources were the most frequently reported areas of need. The second survey was completed by 22 clinical personnel who rated 'lack of training', 'lack of teaching materials geared towards adolescents' and 'limited clinic time' as the main barriers to providing developmentally appropriate care to adolescents.

CONCLUSION

Unmet education and training needs of health care professionals exist in key areas of transitional care and provide useful directions for the development of future training programmes.

Chronically ill adolescents' experiences of communicating with doctors: a qualitative study

PURPOSE

To explore the experiences of chronically ill adolescents in communicating with health professionals, including the identification of factors which hinder or facilitate their use of health professionals as an information source.

METHODS

63 adolescents (11-16 years) with a chronic condition (cystic fibrosis, diabetes, epilepsy, juvenile chronic arthritis, or Duchenne muscular dystrophy) were interviewed, and subsequently took part in two group discussion meetings with other adolescents of a similar age with the same condition. Data were analyzed using the framework method involving data reduction, data display, and conclusion-drawing and verification.

RESULTS

Factors affecting the openness and effectiveness of communication included: duration and frequency of contact; gender; perceived attitudes towards adolescents; the communication skills of the adolescent and health professional; and the presence of parents and medical students/trainee doctors. The type of information needed also affected whether the adolescents felt able to discuss an issue with a health professional. Adolescents were reluctant to raise personal or sensitive issues or to ask questions that revealed poor adherence. A perceived lack of interest in the wider impacts of having a chronic condition on day-to-day life was also a barrier to adolescents discussing difficulties at school and socio-emotional problems.

CONCLUSIONS

Communication and information provision are key roles for health professionals, yet this study highlights a population with potentially high levels of information need who are facing considerable barriers to addressing these needs. Steps taken to improve adolescent-health professional communication need to address a range of practical, attitudinal and behavioral factors.

Outcome in adults with juvenile idiopathic arthritis: a quality of life study

OBJECTIVE

To evaluate quality of life (QOL) in adults with juvenile idiopathic arthritis (JIA), using validated measures of functional disability and generic health status, and to quantify their educational attainment and employment status.

METHODS

The adult rheumatology departmental database was used to identify patients. Functional disability and generic health status/QOL were assessed by the Health Assessment Questionnaire (HAQ) and the Short Form 36-item health profile (SF-36), respectively. Educational achievement and employment status were assessed by questionnaire.

RESULTS

Complete data were available for 82 of the 101 patients identified. The median age of patients was 30 years, and the median disease duration was 21 years. No deaths were recorded. All subtypes of JIA were represented. Thirty-nine percent of patients had active disease (based on the physician global assessment scale score). The median HAQ score was 1.125 (range 0-3). SF-36 scores for bodily pain, general health, physical functioning, vitality, emotion, and social isolation were significantly worse in patients compared with controls, and this trend increased with increasing age of the patients and disease duration. The SF-36 mental summation scores of patients were low compared with those of controls, for all subtypes of JIA, and this finding was independent of the degree of functional disability (by HAQ and SF-36 physical summation scores). The educational attainment of patients was comparable to that of local controls, but unemployment rates for patients were 3-fold higher than those for controls.

CONCLUSION

This is the largest study in which the SF-36 was used to assess generic health status and QOL in adults with JIA. Many patients had active disease in adulthood, and although the physical outcome of adults with JIA is relatively good, a profound effect on generic health status and QOL was demonstrated for all types of JIA. Furthermore, despite excellent educational attainment, there was a high rate of unemployment among patients.