How Adult Specialists Deal with the Principles of a Successful Transition

Methods 

Using the Web site of the Swiss Medical Association, we drew a list of all adult specialists (N=299) in cardiology, endocrinology, gastroenterology, nephrology, neurology, pulmonology, and rheumatology from four French-speaking cantons of Switzerland (Vaud, Jura, Neuchâtel, and Fribourg). These cantons were chosen because the University Hospital in Lausanne is their referring tertiary care center. Through postal mail, each specialist received a letter introducing the study and a 20-item questionnaire (available, in French, upon request) specifically designed and validated (content validity) for this study. If the specialist did not wish to answer the questionnaire, he/she was asked to return a slip indicating the reason why. The study protocol was approved by the ethics committee of the University of Lausanne's Medical School.

After three waves were sent (at monthly intervals) between May and July 2007, 209 (70%) responses were obtained. Among them, 40 adult specialists (19%) indicated that they did not wish to fill in the questionnaire. The two main reasons for not filling in the questionnaire were because they did not treat any adolescents (N=29) and because they did not have time (N=3). Of the 169 adult specialists who completed the questionnaire, only 102 indicated having received the transfer of at least one adolescent patient in the previous 2 years and were included in the analyses.

The communication level between the pediatric and the adult specialist was assessed through a combination of two questions: do you have a joint consultation with the pediatric specialist? (always/other), and does the pediatric specialist contact you personally before transferring an adolescent patient? (yes/no). A new variable (previous contact) was created: the physicians always doing a joint consultation and/or having a contact being included in the yes category, whereas those answering negatively to both questions were included in the no category.

To assess whether adult specialists comply with the basic principles of transition, it was analyzed whether (a) they had a transition protocol, (b) they addressed common concerns of young people, and (c) whether they were supportive in enhancing the adolescents' autonomy. Common concerns of young people were assessed by asking the respondents whether or not they discussed on a routine basis the following nine subjects with their young patients: nutrition, school/work, impact of disease on daily life, family issues, tobacco use, alcohol use, use of illegal drugs, sexuality, and emotional well-being. Autonomy was assessed through the question of whether they saw the patient alone (without the parents being present) at least during part of the consultation.

To determine whether adult specialists' individual characteristics such as age, gender, workplace, number of transfers, or perceived experience had an influence, a binary logistic regression was performed for each one of the four above-mentioned variables. In each regression the following independent variables were included: number of transfers in the previous 2 years (one to four, five or more); age range (≥50 years/<50 years), gender, workplace (at least part-time in a hospital/private practice only), and perceived experience with young people (fair to a lot/little or none). Data were analyzed using SPSS 15.0 (SPSS Inc., Chicago, IL).

Results 

Overall, 53% of our sample was aged 50 years or over, 84% were males, 69% worked at least part time in a hospital, less than a third considered having experience treating adolescents, and three out of every four had received one to four transfers in the previous 2 years (Table 1).

Table 1. Description of the sample (N=102)

		%	95% CI
	Number of transfers in the previous 2 years
	1 to 4	75.5%	67.1/83.8
	5 or more	24.5%	16.2/32.9
	Age range
	≥50 years	52.9%	43.3/62.6
	<50 years	47.9%	37.4/56.7
	Gender
	Female	15.7%	8.6/22.7
	Male	84.3%	77.3/91.4
	Workplace
	Hospital	68.6%	59.6/77.6
	Private practice	31.4%	22.4/40.4
	Perceived experience with adolescent patients
	Fair to a lot	30.4%	21.5/39.3
	Little or none	69.6%	60.7/78.5

CI=confidence interval.

Slightly over half (54%) of the surveyed adult specialists did not have any contact with their pediatric counterpart, and 59% did not have an established protocol. Less than half of respondents (46%) spent some time alone with their young patients. Regarding the issues routinely discussed with their young patients, although 85% of respondents talked about the impact of the disease on daily life, only one in four discussed sexuality (Table 2).

Table 2. Compliance with good transition principles (N=102)

		%	95% CI
	Topics routinely discussed with adolescent patients:
	Nutrition	47.1%	37.4/56.7
	School/work	67.6%	58.6/76.7
	Impact of disease on daily life	85.3%	78.4/92.2
	Family issues	45.1%	35.4/54.8
	Tobacco use	62.7%	53.4/72.1
	Alcohol use	52.0%	42.3/61.7
	Illegal drugs use	50.0%	40.3/59.7
	Sexuality	26.5%	17.9/35.0
	Emotional well-being	42.2%	32.6/51.7
	Parents present during the consultation
	Yes	53.9%	44.2/63.6
	No or only partially	46.1%	36.4/55.8
	Having an established protocol
	At least for some diseases	41.2%	31.6/50.7
	No	58.8%	49.3/68.4
	Previous contact with pediatric specialist
	Yes	46.1%	36.4/55.8
	No	53.9%	44.2/63.6

CI=confidence interval.

In the multivariate analysis (Table 3), discussing on a regular basis nutrition, impact of the disease on daily life, tobacco use, illegal drugs use, sexuality, parents being present during the consultation, not having an established protocol, and having a previous contact with the pediatric specialist were independent of the physician's characteristics. Discussing school/work showed a trend towards being more frequent among experienced specialists (p=.051). Discussing family issues was significantly associated with perceived experience, whereas alcohol use was less frequently dealt with by those working in a hospital. Experienced physicians and females were more likely to talk about emotional well-being, whereas those in the upper age range were less likely to tackle the issue.

Table 3. Multivariate analysis of successful transition principles (N=102)

	Independent variables/Dependent variables	Number of transfers (1-4)	Age range (≥50 years)	Gender (female)	Workplace (hospital)	Perceived experience (fair to a lot)
	Parents present (yes)	1.24 [0.46/3.35]	1.37 [00.56/3.35]	2.35 [0.74/7.47]	0.85 [0.35/2.08]	2.22 [0.82/5.97]
	Established protocol (no)	1.42 [0.52/3.90]	0.86 [0.34/2.15]	1.96 [0.63/6.08]	0.73 [0.30/1.77]	2.53 [0.93/6.91]
	Previous contact (yes)	0.76 [0.29/2.00]	1.01 [0.41/2.46]	0.95 [0.30/3.02]	1.59 [0.64/3.94]	2.47 [0.91/6.68]
	Discussed routinely
	Nutrition	1.13 [0.43/2.92]	0.66 [0.28/1.59]	1.03 [0.34/3.13]	0.83 [0.35/1.97]	1.08 [0.41/2.84]
	School/work	0.87 [0.29/2.56]	0.45 [0.17/1.17]	0.70 [0.20/2.45]	0.36 [0.12/1.06]	3.14 [0.99/9.91]∗
	Impact of the disease	2.95 [0.85/10.29]	00.61 [0.18/2.11]	0.75 [0.17/3.22]	1.75 [0.53/5.83]	2.35 [0.55/10.09]
	Family issues	1.04 [0.39/2.75]	0.42 [0.17/10.8]	1.04 [0.33/3.24]	0.82 [0.33/1.99]	3.15 [1.12/8.84]
	Tobacco use	1.10 [0.41/2.95]	0.59 [0.24/1.47]	1.54 [0.43/5.45]	0.44 [0.17/1.17]	1.03 [0.38/2.83]
	Alcohol use	1.05 [0.40/2.79]	1.27 [0.52/3.09]	1.46 [0.46/4.68]	0.39 [0.16/0.98]	1.14 [0.42/3.08]
	Illegal drugs use	0.80 [0.30/2.13]	0.75 [0.30/1.83]	1.44 [0.45/4.56]	0.43 [0.17/1.06]	1.88 [0.69/5.11]
	Sexuality	0.61 [0.21/1.73]	0.52 [0.18/1.51]	1.52 [0.47/4.99]	0.75 [0.28/2.00]	2.19 [0.72/6.68]
	Emotional well-being	1.57 [0.55/4.47]	0.34 [0.12/0.92]	3.71 [1.08/12.81]	1.25 [0.49/3.23]	4.37 [1.43/13.32]

Data are expressed as adjusted odds ratio with [95% confidence intervals]. Statistically significant results are in bold type.

∗ p=.051.

Discussion 

Taken as a whole, our findings indicate that the principles of a good transition are not applied well enough among adult specialists and that the level of communication between pediatric and adult specialists is insufficient. As noted by Soanes and Timmons [5], the transition from pediatric to adult care for adolescents with chronic illness seems to occur more by default than design.

More than half of our sample did not spend time alone with their young patients, even though it is considered a good way to encourage self-management skills [16], [17], an opportunity to establish independence from family [5], and is correlated with a successful transfer [18]. In fact, adolescents with chronic illness feel comfortable seeing the provider without their parents [17]. This result is quite surprising when one of the main differences between pediatric and adult units is that the former are family centered, whereas the latter are patient centered [17], [19]. This finding could also explain why sensitive topics are often not tackled, given that when patients are seen together with their parents it is difficult to discuss such issues.

As reported among pediatric and adult physicians [20], [21], [22], sensitive issues such as sexuality and substance use were not widely discussed with adolescent patients. Zack et al [23] found similar results among patients with cystic fibrosis and indicated that more patients wanted to discuss these issues than actually had the opportunity to do so. In fact, patients also indicated that the information they received on sensitive topics is usually poor [5]. It could be hypothesized that, as these patients are often cared for both by a primary care physician and a specialist, the latter may consider that such issues are discussed with the former, even though chronically ill youth seem to consider their specialist as their primary source of healthcare [24]. Also, in a study among general internists [13], over half of them reported that adolescents with chronic illness should be treated by specialists. Although it is clear that the process of transition must involve primary care physicians [25], a good coordination between specialists and primary care providers may facilitate opportunities for adolescent patients to discuss sensitive issues [23]. Unfortunately, only 4 out of every 10 adult specialists in our study had an established transition protocol with their pediatric colleagues, albeit the literature indicates that having a transition plan is an important issue for healthcare professionals [11] and one of the key elements for a successful transition [26], [27]. Although this figure is higher than previously reported [28], [29], it is still very low, and having an established protocol would most probably enhance the collaboration between specialists.

The collaboration between pediatric and adult specialists was considered sporadic in previous publications [16], and our results seem to confirm this. Even though ongoing communication and documentation are two of the core elements for a successful transition identified both by healthcare professionals [11] and patients [23], less than half of our sample reported having had any personal contact with the pediatric specialist before or during the transfer from pediatric to adult healthcare. This result in is line with previous publications [28].

In our sample, feeling experienced seemed to play a certain role in the way adult specialists approach young patients. The literature [13] indicates that internists, as well as pediatricians, with experience in treating adolescent patients with chronic diseases feel more comfortable with the management of these patients. However, it may well be that they are comfortable with the way they care medically for their patients but not necessarily in addressing psychosocial issues, as it is easier for providers to concentrate on the chronic condition alone than to give anticipatory guidance [30]. Age, gender, workplace, or the number of transfers do not seem to play a significant role either.

The lack of training could be a global explanation to our results. In their study comparing general internists and general pediatricians, Okumura et al [13] described that internists were more likely than pediatricians to report that insufficient training limited their ability to provide care to chronically ill young patients. In fact, their conclusion was that general internists are not comfortable treating this specific age group. The fact that the patient population of adult services is aging [6], [31], and that many internal medicine curricula do not include aspects of care for chronically ill young patients could explain the difficulty in dealing with these patients. Actually, in the adult healthcare system these patients are extremely young compared to the average patient [6]. Nonetheless, a research on Swiss physicians' training needs in adolescent medicine [32] found that only 43% of general practitioners and 29% of internists reported being interested in issues related to better communicating with adolescents and 48% and 40% of them, respectively, in the management of chronic conditions.

Overall, the characteristics of the adult specialists had little influence on the their application of successful transition principles. Contrary to our results, Telfair et al [15] found that female providers were significantly more likely to demonstrate transition. However, in their study of primary care pediatricians, Burke et al [28] also found that age, gender, and practice setting were not associated to the experiences of the pediatricians in their sample.

Our research has some limitations that need to be mentioned. First, although larger than in previously published research [6], [11], [12], our sample is still relatively small, mainly because we decided to only include adult specialists who had had at least one transfer in the previous 2 years. Nevertheless, if we take into account that “not seeing adolescent patients” was the main reason for the adult specialists not wanting to answer the questionnaire, it could be assumed that absence of adolescent patients in the consultation may also be the reason for an important percentage of nonrespondents and that, in fact, we have gathered data on the majority of adult specialists dealing with adolescent patients. Second, we did not collect any information about the adult specialists' relationship with the primary care providers of their patients. Therefore, it is possible that some of the analyzed principles of a successful transition are taken care of by primary care physicians.

In our sample of adult specialists, transition from pediatric to adult healthcare for adolescents with chronic illness seems to be limited to a simple transfer. Applying simple but basic principles such as providing an age-appropriate consultation style, establishing communication pathways, and good coordination of management duties would probably improve the quality of care of these chronically ill young patients. Transition protocols may be helpful in putting these necessities into action. The final outcome would be a better care for these young patients and their families.