Suboptimal Transitions: Pediatric to Adult Care

Two recent articles delve into the topic of Pediatric to Adult Care Transition.

M Katz et al. J Pediatr (Epub head of publication) 2021. African American Pediatric Liver Transplant Recipients Have an Increased Risk of Death After Transferring to Adult Healthcare (Thanks to a friend who shared this reference & congratulations to my Emory colleagues and senior author Nitika Gupta on this publication)

This retrospective study examined 101 patients between 1990 and 2015. 64 had long-term followup data available.

Key findings:

  • African Americans had higher rates of death after transfer than patients of other races (44% mor-
    tality vs 16%, representing 67% of all cases of death; P = .032)
  • 18 of the 64 (28%) died. Of those 18 deaths, 4 (22%) occurred within the first 2 years after transfer, and 10 (55%)
    within 5 years of transfer.
  • There was a high rate of medication nonadherence in patients who died. ” Death in our cohort was typically caused by chronic rejection and graft failure, with a high frequency of severe infections or bleeding events ultimately causing a patient to die.”
  • The average age of transplant in deceased patients was 15. Transplantation in teenage years could be a risk factor as well.
  • The authors note that “the years directly after transfer of care from pediatrics to adult medicine are high risk for death and poor patient outcomes. Racial disparities seen in pediatric medicine also hold true after transfer to adulthood.”

H Pearlstein et al. JPGN 2021; 72: 563-568. Predicting Suboptimal Transitions in Adolescents with Inflammatory Bowel Disease

This retrospective study with 104 subjects defined suboptimal transition as “either a return to pediatric care or requiring care escalation within 1 year of transfer.

Key findings:

  • 37 (36%) were determined to have a suboptimal transition.
  • Risk factors: mental health diagnosis (OR 4.15), medication non-adherence (OR 5.15), public insurance (OR 6.60), and higher Physician Global Assessment score at time of transition (OR 6.64).

Comments: This is a small study and included only 26 patients receiving public insurance, which the authors considered as a proxy measure of socioeconomic status.

My take: These studies show the difficulties and potential deadly outcomes that face these young adults during transition from pediatrics to adult care. In many cases, medication non-adherence is a key factor and can be affected by access to care, insurance coverage, and mental health. Most young adults with serious medical problems probably would benefit from keeping their parents actively involved in their care.

Related blog posts:

March 30,2021. Washington D.C. Thanks to Seth for this picture.

“Aging Elephant in the Room”

Happy New Year!

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“Adults are just obsolete children” –Theodor Seuss Geisel

So, begins an interesting commentary (B Kinnear. JAMA pediatrics 2015; 169: 1081-2 -thanks to Ben Gold for this reference).

This editorial discusses a growing problem of patients older than 21 years of age seeking care in pediatric institutions.  Currently, ~15,000 admissions occur annually in the U.S..  At the author’s institution (Cincinnati Children’s), the average daily hospital census was 15.7 patients between 2012-2014.  In fact, at Cincinnati, which has an adult care hospital across the street, they have developed a team to care for these patients: “the Hospital Medicine Adult Care team.” In addition, they have established protocols to recognize and initiate treatment on problems like acute coronary syndrome, pulmonary embolism, and acute stroke.

The author argues that age should not be the only factor determining which institution would offer the best care.  Some cognitively impaired adults with cerebral palsy may be better-suited at a pediatric facility and some obese teenagers with type 2 diabetes and hypertension may fit better at an adult care hospital.

Common barriers to transitioning to adult care hospitals:

  • Lack of adult health care professional knowledge and comfort by adult health care physicians
  • Poor communication between pediatric and adult care providers
  • Families fear of leaving established care settings

These adults in pediatric care settings do have increased length of stays and greater odds of mortality than adolescents, even when adjusting for  the increased number of chronic conditions.  Thus, it is not entirely clear that outcomes will be improved by retaining this vulnerable population at pediatric institutions.  Much of this question will be determined by the institutional resources available for their care.

My take: I worry that keeping adults (patients >21 years) in pediatric institutions is a mistake.  There are increasing numbers of vulnerable patients and their needs should be addressed by adult care providers.

Isle of Palms, SC

Isle of Palms, SC