Transition from pediatric to adult care for adolescents living with HIV in South Africa: A natural experiment and survival analysis.

OBJECTIVE: To determine rates of retention and viral suppression among adolescents living with perinatally-acquired HIV who remained in pediatric care compared to those who transitioned to adult care. METHODS: We evaluated a natural experiment involving adolescents living with perinatally-acquired HIV who were attending a government-supported antiretroviral clinic in KwaZulu-Natal, South Africa. Prior to 2011, all adolescents transitioned to adult care at 12 years of age. Due to a policy change, all adolescents were retained in pediatric care after 2011. We analyzed adolescents two years before and two years after this policy change. Outcomes were retention in care and HIV viral suppression one year after transition to adult care or the 13th birthday if remaining in pediatric care. RESULTS: In the natural experiment, 180 adolescents who turned 12 years old between 2011 and 2014 were evaluated; 35 (20%) transitioned to adult care under the old policy and 145 (80%) remained in pediatric care under the new policy. Adolescents who transitioned to the adult clinic had lower rates of retention in care (49%; 17/35) compared to adolescents remaining in the pediatric clinic (92%; 134/145; p<0.001). Retention in care was lower (ARR 0.59; 95%CI 0.43-0.82; p = 0.001) and viral suppression was similar (ARR = 1.06, 95%CI 0.89-1.26; p = 0.53) for adolescents who transitioned to adult care compared to adolescents remaining in pediatric care. CONCLUSION: Adolescents living with perinatally-acquired HIV appear to have higher retention in care when cared for in pediatric clinics compared to adult clinics. Longer-term follow-up is needed to fully assess viral suppression.

Discussing Future Goals and Legal Aspects of Health Care: Essential Steps in Transitioning Youth to Adult-Oriented Care.

Discussing realistic future goals with the adolescent alone and with family, and reviewing legal aspects of health care transition (HCT), are essential steps in the transition from pediatric to adult-oriented care. Secondary analysis of datasets from 2 studies related to HCT assessed differences in provider practice for youth with and without special health care needs (SHCNs). Across both datasets, between 57% and 68.6% of providers reported some discussion of future goals with adolescent or with family. However, only 28.6% to 31% of providers reported discussing future goals with youth with SHCNs alone. It was rare for providers to report discussing legal aspects of HCT with any youth. Findings identify a gap in discussing future goals and legal aspects of HCT, as part of routine care for adolescents. Additional research to understand barriers and improve likelihood of these steps within HCT is needed.

Transition of gastroenterological patients from paediatric to adult care: A position statement by the Italian Societies of Gastroenterology.

In 2013, four Italian Gastroenterological Societies (the Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition, the Italian Society of Hospital Gastroenterologists and Endoscopists, the Italian Society of Endoscopy, and the Italian Society of Gastroenterology) formed a joint panel of experts with the aim of preparing an official statement on transition medicine in Gastroenterology. The transition of adolescents from paediatric to adult care is a crucial moment in managing chronic diseases such as celiac disease, inflammatory bowel disease, liver disease and liver transplantation. Improved medical treatment and availability of new drugs and surgical techniques have improved the prognosis of many paediatric disorders, prolonging survival, thus making the transition to adulthood possible and necessary. An inappropriate transition or the incomplete transmission of data from the paediatrician to the adult Gastroenterologist can dramatically decrease compliance to treatment and prognosis of a young patient, particularly in the case of severe disorders. For these reasons, the Italian gastroenterological societies decided to develop an official shared transition protocol. The resulting document discusses the factors influencing the transition process and highlights the main points to accomplish to optimize compliance and prognosis of gastroenterological patients during the difficult transition from childhood to adolescence and adulthood.

A Life of One's Own: Challenges in the Transition from Childhood to Adulthood with Autism Spectrum Disorder.

This is a very delicate age for Cameron, with his eighteenth birthday looming like a big exit sign. Should I establish guardianship? Am I limiting his independence if I do? Am I putting him at risk if I don't? Will he be able to earn a meaningful living and be able to support himself? If not, are there supports available for him, aside from me? These questions weigh heavy on my mind, as time seems to speed up the older Cameron gets. I am encouraged by the pride Cameron shows in his independence, and hope that pride continues to grow, along with his independence.

Federal policy supporting improvements in transitioning from pediatric to adult surgery services.

For children with complex medical conditions that require ongoing surgical intervention, planning for the transition from pediatric to adult surgical care is essential. Services that support healthcare transition from specialty pediatric practices into adult practices are often inadequate, and the healthcare policy process has been slow to respond to the call to action by both professional and patient organizations. However, The Patient Protection and Affordable Care Act of 2010 (PPACA), arguably the most significant healthcare reform legislation since the enactment of Medicaid and Medicare in the mid-1960s, includes several provisions with direct influence on access to care and quality for adolescents transitioning to adult surgical care. We present a brief background on the rationale for improving surgical transition plans, the challenges of enacting the plans, and the relevance of PPACA in shaping health policy change around transition to adult services.

Transition care: future directions in education, health policy, and outcomes research.

All youth must transition from pediatric to adult-centered medical care. This process is especially difficult for youth with special health care needs. Many youth do not receive the age-appropriate medical care they need and are at risk during this vulnerable time. Previous research has identified barriers that may prevent effective transition, and protocols have been developed to improve the process. Health outcomes related to successful transition have yet to be fully defined. Health care transition can also be influenced by education of providers, but there are gaps in medical education at the undergraduate, graduate, and postgraduate levels. Current changes in federal health policy allow improved health care coverage, provide some new financial incentives, and test new structures for transitional care, including the evolution of accountable care organizations (ACO). Future work must test how these systems changes will affect quality of care. Finally, transition protocols exist in various medical subspecialties; however, national survey results show no improvement in transition readiness, and there are no consistent measures of what constitutes transition success. In order to advance the field of transition, research must be done to integrate transition curricula at the undergraduate, graduate, and postgraduate levels; to provide advance financial incentives and pilot the ACO model in centers providing care to youth during transition; to define outcome measures of importance to transition; and to study the effectiveness of current transition tools on improving these outcomes.