What Puts Adolescent Patients With IBD at Risk for Suboptimal Transitions?

However, pediatric facilities often lack the time, money or staffing to develop and implement successful transition processes. While many programs have made efforts to improve the transition process for patients with chronic conditions, the implementation is inconsistent.

Suboptimal transitions put adolescent patients, particularly those with chronic diseases like inflammatory bowel disease (IBD), at risk of adverse health outcomes.

In a recent Journal of Pediatric Gastroenterology and Nutrition publication, Jennifer Dotson, MD, MPH, and her research team sought to identify the risk factors for suboptimal transitions in adolescent patients with IBD.

“The study’s data support that, for adolescent patients with IBD, psychosocial-related factors increase the risk of a suboptimal transition,” says Dr. Dotson, co-director of the Pediatric and Adolescent Inflammatory Bowel Disease Center at Nationwide Children’s Hospital.

Dr. Dotson and her team retrospectively reviewed the medical charts of 104 pediatric patients with IBD at Nationwide Children’s. These patients transitioned to adult gastroenterology care between 2016 and 2017. Data collected included baseline and disease-specific data and mental health diagnoses.

Using these data, the research team developed a model to identify factors predictive of suboptimal transition, defined by the team as care escalation within one year of transition and increased health care utilization at Nationwide Children’s (“bounce back”). Bounce back included increased numbers of post-transition emergency department and IBD outpatient visits.

Of the 104 patients, 37 (36%) had suboptimal transitions. Psychosocial-related factors—mental health diagnoses, public insurance and medication nonadherence — most strongly predicted suboptimal transition.

“Depression and anxiety are common mental health diagnoses in patients with pediatric IBD,” says Dr. Dotson. Depression could decrease adherence or motivation to schedule appointments, while anxiety could cause considerable discomfort when working with new caregivers at an adult care facility.

Public insurance is a common proxy for socioeconomic status. Pediatric patients using public insurance tend to have a lower socioeconomic status, experience health disparities and are typically less ready to transition than their counterparts with private insurance.

Greater disease severity also predicted suboptimal transition. Patients with active disease would benefit from a delayed transition, allowing time to achieve disease control.

Age was not associated with suboptimal transition, potentially because there are fewer developmental differences between ages 18 and 22 in this study, Dr. Dotson explains.

Dr. Dotson and her team are developing a structured transition program in Nationwide Children’s IBD clinic. Currently, the clinic has a multidisciplinary educational curriculum that begins working with patients aged 12 and 13. In the program, patients practice skill-building for a successful transition, including simple meal preparation and problem-solving (e.g., what to do when they are low on refills or there is a delay in receiving prescriptions).

The program is also focused on developing partnerships with excellent adult IBD physicians, such as those at The Ohio State University. “We want to make sure that we’re leaving our patients in good hands,” says Dr. Dotson.

She emphasizes that adolescent patients with IBD should have satisfactory psychosocial readiness and adequate disease control at the time of transition.

For patients at higher risk for a suboptimal transition, Dr. Dotson advises care providers to proactively follow up to ensure that adult care has been established. “Closing the loop can prevent patients from experiencing a suboptimal transition and being lost to follow up,” she says.

Reference

Pearlstein H, Bricker J, Michel HK, Afzali A, Donegan AM, Maltz RM, Boyle BM, Dotson JL. Predicting sub-optimal transitions in adolescents with inflammatory bowel disease. Journal of Pediatric Gastroenterology and Nutrition. 2020 Nov 30.

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