Increasing pediatric to adult healthcare transition services through clinical decision supports.

2021

292-297

2021 Aug 24

1532-8449

<p><strong>PURPOSE: </strong>Despite American Academy of Pediatrics recommendations that adolescents receive healthcare transition (HCT) services starting at age 12, few do. Electronic health record-based clinical decision support (CDS) tools are effective at promoting healthcare provider adherence to clinical guidelines. This study's purpose was to increase provider HCT services engagement through implementation of a transition-specific CDS and participation in a transition-focused Learning Collaborative (LC).</p>

<p><strong>DESIGN AND METHODS: </strong>Three pediatric primary care sites of an urban, academic medical center implemented a transition CDS tool for ≥14-year-olds. Previously, one site had a version for ≥16-year-olds. Two sites participated in a LC with Plan-Do-Study-Act cycles targeting HCT services engagement, measured by CDS use and practice-level guideline implementation.</p>

<p><strong>RESULTS: </strong>From July 2018 through June 2019, providers at LC-participating sites engaged in HCT services at 8.0% (n&nbsp;=&nbsp;480) and 5.3% (n&nbsp;=&nbsp;145) of eligible patient visits compared to the control's 3.1% (n&nbsp;=&nbsp;69). Engagement was highest for ≥18-year-olds at the LC-participating sites, 26.0% (n&nbsp;=&nbsp;263) and 12.0% (n&nbsp;=&nbsp;80), compared to the control's 7.2% (n&nbsp;=&nbsp;31). After expanding from ≥16 to ≥14-year-olds, engagement decreased by 9.5% at ≥16-year-old visits. LC-participating sites reported increased HCT guideline adherence.</p>

<p><strong>CONCLUSIONS: </strong>Implementation of a transition-specific CDS with LC participation increased provider HCT services engagement and practice-level guideline implementation. Expansion to younger adolescents contributed to decreased engagement for older patients. Future research should assess opportunities to improve uptake and patient outcomes of transition CDS engagement.</p>

<p><strong>PRACTICE IMPLICATIONS: </strong>Quality improvement activities and transition clinical decision supports can improve provider engagement in recommended transition services for adolescents and young adults.</p>

10.1016/j.pedn.2021.08.012

J Pediatr Nurs

34450469

Healthcare system supports for young adult patients with pediatric onset chronic conditions: a qualitative study.

2015

126-32

2015 Jan-Feb

1532-8449

<p>Over 90% of children with chronic conditions survive into adulthood necessitating primary care teams to care for adults with pediatric-onset chronic conditions. This study explores practice supports and barriers to care for this population via qualitative techniques. Using in depth interviews with twenty-two healthcare providers practice supports identified include: formalizing intake processes, interoperable electronic medical records, and leveraging care coordination. Barriers identified included: definition of the medical team, lack of appropriate medical records, time and administrative burden, lack of training, and financial constraints. Themes may be utilized to design interventions and improve care coordination for patients with pediatric-onset chronic conditions.</p>

10.1016/j.pedn.2014.09.015

J Pediatr Nurs

25450439

International and Interdisciplinary Identification of Health Care Transition Outcomes.

2016

205-11

2016 Mar 1

2168-6211

<p><strong>IMPORTANCE: </strong>There is a lack of agreement on what constitutes successful outcomes for the process of health care transition (HCT) among adolescent and young adults with special health care needs.</p>

<p><strong>OBJECTIVE: </strong>To present HCT outcomes identified by a Delphi process with an interdisciplinary group of participants.</p>

<p><strong>DESIGN, SETTING, AND PARTICIPANTS: </strong>A Delphi method involving 3 stages was deployed to refine a list of HCT outcomes. This 18-month study (from January 5, 2013, of stage 1 to July 3, 2014, of stage 3) included an initial literature search, expert interviews, and then 2 waves of a web-based survey. On this survey, 93 participants from outpatient, community-based, and primary care clinics rated the importance of the top HCT outcomes identified by the Delphi process. Analyses were performed from July 5, 2014, to December 5, 2014.</p>

<p><strong>EXPOSURES: </strong>Health care transition outcomes of adolescents and young adults with special health care needs.</p>

<p><strong>MAIN OUTCOMES AND MEASURES: </strong>Importance ratings of identified HCT outcomes rated on a Likert scale from 1 (not important) to 9 (very important).</p>

<p><strong>RESULTS: </strong>The 2 waves of surveys included 117 and 93 participants as the list of outcomes was refined. Transition outcomes were refined by the 3 waves of the Delphi process, with quality of life being the highest-rated outcome with broad agreement. The 10 final outcomes identified included individual outcomes (quality of life, understanding the characteristics of conditions and complications, knowledge of medication, self-management, adherence to medication, and understanding health insurance), health services outcomes (attending medical appointments, having a medical home, and avoidance of unnecessary hospitalization), and a social outcome (having a social network). Participants indicated that different outcomes were likely needed for individuals with cognitive disabilities.</p>

<p><strong>CONCLUSIONS AND RELEVANCE: </strong>Quality of life is an important construct relevant to HCT. Future research should identify valid measures associated with each outcome and further explore the role that quality of life plays in the HCT process. Achieving consensus is a critical step toward the development of reliable and objective comparisons of HCT outcomes across clinical conditions and care delivery locations.</p>

10.1001/jamapediatrics.2015.3168

JAMA Pediatr

26619178

Variation in surgical outcomes for adolescents and young adults with inflammatory bowel disease.

2013

S81-9

2013 Mar

1098-4275

<p><strong>OBJECTIVE: </strong>To examine whether hospital type (children's hospital or generalist hospital) and surgeon specialty are associated with variations in surgical outcomes for hospitalized adolescents and young adults with inflammatory bowel disease (IBD) requiring surgery.</p>

<p><strong>METHODS: </strong>The 2007-2009 Perspective Data Warehouse was used to identify a retrospective cohort study of all inpatients 16 to 25 years old who received surgery for IBD. Multivariate regression, clustered at the hospital level, examined the association of hospital type and surgical specialty with surgical complications and 30-day readmissions.</p>

<p><strong>RESULTS: </strong>Surgery was performed in 917 hospitalizations of 598 patients across 20 children's hospitals and 198 general hospitals by 566 general surgeons, 46 pediatric surgeons, and 305 colorectal surgeons. After adjustment, children's hospitals had higher predicted probabilities of surgical complication (predicted probability [PP]: 35% [95% confidence interval (CI): 28-42]) compared with general hospitals (PP: 26% [95% CI: 23-29]). Despite higher complications among children's hospitals, pediatric surgeons had lowest predicated probabilities of surgical complication or 30-day readmission (PP: 24% [95% CI: 10-39]) compared with general surgeons (PP: 39% [95% CI: 35-43]) and colorectal surgeons (PP: 35% [95% CI: 28-42]).</p>

<p><strong>CONCLUSIONS: </strong>Disparate outcomes for adolescents and young adults receiving care in children's versus generalist hospitals and from different types of surgeons reveal the need to better understand how practice setting and surgical specialty may modify outcomes for a population that traverses a variety of health care settings.</p>

10.1542/peds.2012-1427j

Pediatrics

23457154

The health care transition research consortium health care transition model: a framework for research and practice.

2014

3-15

2014

1875-8894

<p>The body of health care transition (HCT) research is in the early stages of development. One of the major limitations of this developing field of research is the lack of theoretically-directed studies. This research limitation has hindered understanding of the variables contributing to successful HCT. The inadequate understanding of HCT is due largely to the absence of an adequate conceptual model that addresses the complexity and the relationships amongst variables that influence HCT outcomes among adolescents and emerging adults with special health care needs (AEA-SHCN). Existing conceptual models do not sufficiently address the significant interrelationships amongst variables to explain, predict and/or control AEA-SHCN's biopsychosocial HCT outcomes. This article provides a description of a health care transition theoretical model developed by the international and interdisciplinary Health Care Transition Research Consortium (HCTRC) that can be applied for testing in research and serve as a framework for clinical practice and policymaking. The HCTRC model is composed of four domains that are considered integral to the HCT phenomenon: Individual, Family/Social Support, Environment, and the Health Care System. The HCTRC model specifies the variables, processes, and potential mediators and moderators that affect the HCT outcomes.</p>

10.3233/PRM-140277

J Pediatr Rehabil Med

24919934

Transitioning Adolescents and Young Adults With Sickle Cell Disease From Pediatric to Adult Health Care: Provider Perspectives.

2015

577-83

2015 Nov

1536-3678

<p>The transition from pediatric to adult health care is often challenging for adolescents and young adults with sickle cell disease (SCD). Our study aimed to identify (1) measures of success for the transition to adult health care; and (2) barriers and facilitators to this process. We interviewed 13 SCD experts and asked them about their experiences caring for adolescents and young adults with SCD. Our interview guide was developed based on Social-Ecological Model of Adolescent and Young Adult Readiness to Transition framework, and interviews were coded using the constant comparative method. Our results showed that transition success was measured by health care utilization, quality of life, and continuation on a stable disease trajectory. We also found that barriers to transition include negative experiences in the emergency department, sociodemographic factors, and adolescent skills. Facilitators include a positive relationship with the provider, family support, and developmental maturity. Success in SCD transition is primarily determined by the patients' quality of relationships with their parents and providers and their developmental maturity and skills. Understanding these concepts will aid in the development of future evidence-based transition care models.</p>

10.1097/MPH.0000000000000427

J. Pediatr. Hematol. Oncol.

26492583

Barriers and facilitators to successful transition from pediatric to adult inflammatory bowel disease care from the perspectives of providers.

2014

2083-91

2014 Nov

1536-4844

<p><strong>BACKGROUND: </strong>For adolescents and young adults (AYA) with inflammatory bowel disease (IBD), the transition from pediatric to adult care is often challenging and associated with gaps in care. Our study objectives were to (1) identify outcomes for evaluating transition success and (2) elicit the major barriers and facilitators of successful transition.</p>

<p><strong>METHODS: </strong>We interviewed pediatric and adult IBD providers from across the United States with experience caring for AYAs with IBD until thematic saturation was reached after 12 interviews. We elicited the participants' backgrounds, examples of successful and unsuccessful transition of AYAs for whom they cared, and recommendations for improving transition using the Social-Ecological Model of Adolescent and Young Adult Readiness to Transition framework. We coded interview transcripts using the constant comparative method and identified major themes.</p>

<p><strong>RESULTS: </strong>Participants reported evaluating transition success and failure using health care utilization outcomes (e.g., maintaining continuity with adult providers), health outcomes (e.g., stable symptoms), and quality of life outcomes (e.g., attending school). The patients' level of developmental maturity (i.e., ownership of care) was the most prominent determinant of transition outcomes. The style of parental involvement (i.e., helicopter parent versus optimally involved parent) and the degree of support by providers (e.g., care coordination) also influenced outcomes.</p>

<p><strong>CONCLUSIONS: </strong>IBD transition success is influenced by a complex interplay of patient developmental maturity, parenting style, and provider support. Multidisciplinary IBD care teams should aim to optimize these factors for each patient to increase the likelihood of a smooth transfer to adult care.</p>

10.1097/MIB.0000000000000136

Inflamm. Bowel Dis.

25137417

Association of hospital and provider types on sickle cell disease outcomes.

2013

854-61

2013 Nov

1098-4275

<p><strong>OBJECTIVES: </strong>Adolescents and young adults (A/YA) with sickle cell disease (SCD) are hospitalized in both children's and general hospitals. We determined the effect of hospital type and provider specialty on outcomes of hospitalized A/YA with SCD and acute chest syndrome (ACS).</p>

<p><strong>METHODS: </strong>This retrospective cohort study used the 2007-2009 Premier Database, a large multi-institutional database, to identify 1476 patients ages 16 to 25 years with 2299 admissions with SCD and ACS discharged from 256 US hospitals from 2007 to 2009. Multilevel logistic regression and zero-truncated negative binomial regression were performed after adjustment for patient demographic, clinical, and hospital characteristics to test the association of hospital type and provider specialty on death, endotracheal intubation, simple or exchange transfusion, length of stay (LOS), and 30-day readmission.</p>

<p><strong>RESULTS: </strong>Of all admissions, 14 died and 45% were intubated. General hospitals had 13 deaths and were associated with higher intubation rates (predicted probability [PP], 48% [95% confidence interval (CI), 43%-52%]) and longer LOS (predicted mean LOS, 7.6 days [95% CI, 7.2-7.9]) compared with children's hospitals (PP of intubation, 24% [95% CI, 5%-42%]; and predicted mean LOS, 6.8 days [95% CI, 5.6-5.8]). There was no difference by hospital type or provider specialty in PP of simple or exchange transfusion, or 30-day readmission.</p>

<p><strong>CONCLUSIONS: </strong>General hospitals carry higher intubation risks for A/YA with SCD and ACS compared with children's hospitals. We need to better understand the drivers of these differences, including the role of staff expertise, hospital volume, and quality of ongoing SCD care.</p>

10.1542/peds.2013-0089

Pediatrics

24167173