Predictors of Timing of Transfer From Pediatric- to Adult-Focused Primary Care

Abstract

IMPORTANCE A timely, well-coordinated transfer from pediatric-to adult-focused primary care is an important component of high-quality health care, especially for youths with chronic health conditions. Current recommendations suggest that primary-care transfers for youths occur between 18 and 21 years of age. However, the current epidemiology of transfer timing is unknown.OBJECTIVE To examine the timing of transfer to adult-focused primary care providers (PCPs), the time between last pediatric-focused and first adult-focused PCP visits, and the predictors of transfer timing. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients insured byHarvard Pilgrim Health Care (HPHC), a large not-for-profit health plan. Our sample included 60 233 adolescents who were continuously enrolled in HPHC from 16 to at least 18 years of age between January 2000 and December 2012. Pediatric-focused PCPs were identified by the following provider specialty types, but no others: pediatrics, adolescent medicine, or pediatric nurse practitioner. Adult-focused PCPs were identified by having any provider type that sees adult patients. Providers with any specialty provider designation (eg, gastroenterology or gynecology) were not considered PCPs. MAIN OUTCOMES AND MEASURESWe used multivariable Cox proportional hazards regression to model age at first adult-focused PCP visit and time from the last pediatric-focused to the first adult-focused PCP visit (gap) for any type of office visit and for those that were preventive visits.RESULTS Younger age at transfer was observed for female youths (hazard ratio [HR], 1.32 [95% CI, 1.29-1.36]) who had complex (HR, 1.06 [95% CI, 1.01-1.11]) or noncomplex (HR, 1.08 [95% CI, 1.05-1.12]) chronic conditions compared with those who had no chronic conditions. Transfer occurred at older ages for youths who lived in lower-income neighborhoods compared with those who lived in higher-income neighborhoods (HR, 0.89 [95% CI, 0.83-0.95]). The gap between last pediatric-focused to first adult-focused PCP visit was shorter for female youths than male youths (HR, 1.57 [95% CI, 1.53-1.61]) and youths with complex (HR, 1.35 [95% CI, 1.28-1.41]) or noncomplex (HR, 1.24 [95% CI, 1.20-1.28]) chronic conditions. The gap was longer for youths living in lower-income neighborhoods than for those living in higher-income neighborhoods (HR, 0.80 [95% CI, 0.75-0.85]). Multivariable models showed an adjusted median age at transfer of 21.8 years for office visits and 23.1 years for preventive visits and an adjusted median gap length of 20.5 months for office visits and 41.6 months for preventive visits. CONCLUSIONS AND RELEVANCEMost youths are transferring care later than recommended and with gaps of more than a year. While youths with chronic conditions have shorter gaps, they may need even shorter transfer intervals to ensure continuous access to care. More work is needed to determine whether youths are experiencing clinically important lapses in care or other negative health effects due to the delayed timing of tr...

Expectancy and Achievement Gaps in Educational Attainment and Subsequent Adverse Health Effects Among Adolescents With and Without Chronic Medical Conditions

“…This opportunity is precarious: College overlaps the period when transition from pediatric to adult-focused care is recommended, 29 and when youth are most likely to fall out of contact with their healthcare provider. 30 Movement away from established care relationships and supports, common for college attending youth, may undermine self-management and expose YCMC to environments conducive of risk behaviors; 31–33 yet, evidence suggests that many colleges are not well equipped to identify and support the medical needs of YCMC. 34,35 Lacking access to preventive and specialty care during college may explain the observed lower graduation rates among the YCMC who make it to college.…”

Substance Use Patterns Through Early Adulthood

“…YCMC’s risk of substance use was most consistently elevated during older adolescence and early adulthood, periods when transition from pediatric to adult-focused care is recommended, 20 but when youth are most likely to fall out of contact with a healthcare provider. 28 Healthcare interactions may help stimulate health-promoting behaviors and improve detection/reduction of risky ones, making it particularly important to develop strategies that support continued healthcare engagement throughout the transition period.…”

Management of Cardiac Involvement Associated With Neuromuscular Diseases: A Scientific Statement From the American Heart Association

“…[356][357][358][359][360] It is recommended that education through accurate dissemination of information begin at an early stage in the patient healthcare process and directly involve caregivers, providers, support staff, and the patient. 351,[361][362][363] Patients with NMDs are likely to benefit from a coordinator-directed, multidisciplinary team approach, which can provide important support in negotiating communication gaps between providers and enable a systematic clinical transition and education process on health, adult care providers, facilities, and financial and medical resources. 351,353,358,364,365 …”