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Prevalence and Correlates of Successful Transfer From Pediatric to Adult Health Care Among a Cohort of Young Adults With Complex Congenital Heart Defects

Graham J. Reid, PhD^*,,,||,¶, M. Jane Irvine, PhD^,||,#, Brian W. McCrindle, MD^**,, Renee Sananes, PhD^,, Paul G. Ritvo, PhD^,||,,, Samuel C. Siu, MD^,||,¶ and Gary D. Webb, MD^,||,¶

^* Department of Psychology and Family Medicine, University of Western Ontario, London, Ontario, Canada
Department of Public Health Science, University of Toronto, Toronto, Ontario, Canada
Department of Medicine, University of Toronto, Toronto, Ontario, Canada
^|| University Health Network, Toronto, Ontario, Canada
^** Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
^# Department of Psychology, York University, Toronto, Ontario, Canada
Hospital for Sick Children, Toronto, Ontario, Canada
School of Kinesiology and Health Sciences, York University, Toronto, Ontario, Canada
^¶ Toronto Congenital Cardiac Centre for Adults, Toronto, Ontario, Canada

Objectives. More than 85% of children born today with chronic medical conditions will live to adulthood, and many should transfer from pediatric to adult health care. The numbers of adults with congenital heart defects (CHDs) are increasing rapidly. Current guidelines recommend that just over half of adult CHD patients should be seen every 12 to 24 months by a cardiologist with specific CHD expertise at a regional CHD center, because they are at risk for serious complications (eg, reoperation and/or arrhythmias) and premature mortality. The present study aimed to determine the percent of young adults with CHDs who successfully transferred from pediatric to adult care and examine correlates of successful transfer.

Design. Cross-sectional study with prevalence data from an entire cohort.

Setting and Patients. All patients (n = 360) aged 19 to 21 years with complex CHDs who, according to current practice guidelines, should be seen annually at a specialized adult CHD center were identified from the database of the cardiology program at the Hospital for Sick Children in Toronto, Canada, a pediatric tertiary care center. Of these patients, 234 completed measures about health beliefs, health behaviors, and medical care since age 18 years.

Main Outcome Measure. All 15 specialized adult CHD centers in Canada formed the Canadian Adult Congenital Heart (CACH) Network. Attendance for at least 1 follow-up appointment at a CACH center before the age of 22 years was ascertained for all eligible patients. Attendance at a CACH center provides a clear criterion for successful transfer.

Results. In the total cohort, 47% (95% confidence interval [CI]: 42–52) had transferred successfully to adult care. There was no difference in rates of successful transfer between patients consenting to complete questionnaires (48%) and those who declined (47%). More than one quarter (27%) of the patients reported having had no cardiac appointments since 18 years.

In multivariate analyses of the entire cohort, successful transfer was significantly associated with more pediatric cardiovascular surgeries (odds ratio [OR]: 2.47; 95% CI: 1.40–4.37), older age at last visit to the Hospital for Sick Children (OR: 1.29; 95% CI: 1.10–1.51), and documented recommendations in the medical chart for follow-up at a CACH center. In multivariate analyses of the patients completing questionnaires, successful transfer was significantly related to documented recommendations and patient beliefs that adult CHD care should be at a CACH center (OR: 3.64; 95% CI: 1.34–9.90). Comorbid conditions (OR: 3.13; 95% CI: 1.13–8.67), not using substances (eg, binge drinking; OR: 0.18; 95% CI: 0.07–0.50), using dental antibiotic prophylaxis (OR: 4.23; 95% CI: 1.48–12.06), and attending cardiac appointments without parents or siblings (OR: 6.59; 95% CI: 1.61–27.00) also correlated with successful transfer.

Conclusions. This is the first study to document the percent of young adults with a chronic illness who successfully transfer to adult care in a timely manner. Patients were from an entire birth cohort from the largest pediatric cardiac center in Canada, and outcome data were obtained on all eligible patients. Similar data should be obtained for other chronic illnesses. There is need for considerable improvement in the numbers of young adults with CHDs who successfully transfer to adult care. At-risk adolescents with CHDs should begin the transition process before their teens, should be educated in the importance of antibiotic prophylaxis, should be contacted if a follow-up appointment is missed, and should be directed to a specific CHD cardiologist or program, with the planned timing being stated explicitly.

Adult care needs to be discussed in the pediatric setting, and patients must acquire appropriate beliefs about adult care well before transfer. Developmentally appropriate, staged discussions involving the patient, with and without parents, throughout adolescence may help patients acquire these beliefs and an understanding of the need for ongoing care. Improved continuity of pediatric care and provision of clear details for adult follow-up might be sufficient to cause substantive improvements in successful transfer. An understanding of why patients drop out of pediatric care may be needed to improve the continuity of care throughout adolescence.

Almost one quarter of the patients believed adult care should be somewhere other than at a CACH center despite opposite recommendations. For these patients, a single discussion of adult care during the final pediatric visit may be too little, too late. In addition to earlier discussions, multiple mechanisms such as referral letters and transition clinics are needed. Similarly, patients engaging in multiple risky or poor health behaviors such as substance use may need more intensive programs to make substantial changes in these behaviors, which hopefully would lead to successful transfer.

Overall, these data support the view that transition to adult care (a planned process of discussing and preparing for transfer to an adult health center) is important and should begin well before patients are transferred. The future health of adults with chronic conditions may depend on our ability to make these changes.

Key Words: congenital heart defects • transition • transfer • continuity of care • adolescent • young adult

Abbreviations: CHD, congenital heart defect • CACH, Canadian Adult Congenital Heart • HSC, Hospital for Sick Children • TCCCA, Toronto Congenital Cardiac Center for Adults • CI, confidence interval • OR, odds ratio

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