Resident and Staff Satisfaction of Pediatric Graduate Medical Education Training on Transition to Adult Care of Medically Complex Patients

Resident and Staff Satisfaction of Pediatric Graduate Medical Education Training on Transition to... Abstract Introduction This study aims to describe the quantity and satisfaction current residents and experienced pediatricians have with graduate medical education on transitioning medically complex patients to adult care. There is an increasing need for transitioning medically complex adolescents to adult care. Over 90% now live into adulthood and require transition to adult healthcare providers. The 2010 National Survey of Children with Special Health Care Needs found that only 40% of youth 12–17 yr receive the necessary services to appropriately transition to adult care. Materials and Methods Prospective, descriptive, anonymous, web-based survey of pediatric residents and staff pediatricians at Army pediatric residency training programs was sent in March 2017. Questions focused on assessing knowledge of transition of care, satisfaction with transition training, and amount of education on transition received during graduate medical education training. Results Of the 145 responders (310 potential responders, 47% response rate), transition was deemed important with a score of 4.3 out of 5. The comfort level with transition was rated 2.6/5 with only 4.2% of participants receiving formal education during residency. The most commonly perceived barriers to implementing a curriculum were time constraints and available resources. Of the five knowledge assessment questions, three had a correct response rate of less than 1/3. Conclusions The findings show the disparity between the presence of and perceived need for a formal curriculum on transitioning complex pediatric patients to adult care. This study also highlighted the knowledge gap of the transition process for novice and experienced pediatricians alike. IMPLICATIONS AND CONTRIBUTION This study describes the quantity and satisfaction residents and experienced pediatricians have with graduate medical education (GME) training on transitioning medically complex patients to adult care. Additionally, perceived barriers were assessed which is a starting point for developing a formal curriculum. INTRODUCTION Nearly 15% of children (under the age of 18 yr) have special healthcare needs1; defined as “those who have or are at an increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” Historically, the most complex of these children did not live into adulthood and remained in a pediatric medical home until death. With advances in medical care, over 90% now live into adulthood and require transition to adult healthcare providers.2 Successful transition from adult to pediatric care should be a well thought out and deliberate process that starts in early adolescence.3 Despite the importance of successfully transitioning pediatric patients with complex medical needs, the 2010 National Survey of Children with Special Health Care Needs found that only 40% of youth aged 12–17 yr receive the necessary services to make an appropriate transition to adult care. Few studies have looked at pediatric resident education regarding transitioning medically complex children to adult care, or graduate satisfaction and comfort managing transitions. A 2010 study examined pediatric resident education on medically complex children; but only queried exposure to transitioning patients.4 At a large teaching hospital implementing a curriculum on transition of care, another study compared the education of internal medicine and pediatric residents in caring for medically complex children and found that pediatric residents received disease specific education and teaching on specific childhood disease processes and were more comfortable with transition than internists in training.2 Resident preferences for timing of curriculum implementation and topics for inclusion in the development of a transition curriculum were examined; identifying a preference for teaching on transitioning throughout residency training with varied presentation modalities. As family medicine, internal medicine and pediatric residents were all surveyed desired topics for inclusion varied by residency type.5 This study fills several gaps in knowledge by addressing the military population and by assessing specifics of quality and satisfaction with transition in pediatric GME training. Despite the military having a significantly higher proportion of children with special healthcare needs (23%) than in the general population (15%), no studies have examined transition of care for this population6; illustrating the need for education and training of pediatric residents in adult care transition for these special care needs children. Unique challenges stemming from frequent relocation make education on successful transition of military children even more important and more problematic. Both active duty families and active duty medical providers change duty stations every 3–4 yr, yet local resources both on base and in the community as well as applicable state laws to aid children with special healthcare needs vary widely. Military parents frequently struggle with re-establishment of care, and military providers with familiarity accessing available local resources. This study’s focus is the perceived presence and quality of a transition curriculum and subsequent comfort with transitioning complex medical patients to adult care; an important topic as evidenced by its inclusion in the 2016 American Board of Pediatrics Content Specifications for board certification examination. METHODS An anonymous, web-based, IRB-approved (Madigan Army Medical Center Institutional Review Board) survey was sent to current pediatric residents and staff at all four Army pediatric residency training locations (Madigan Army Medical Center, Tripler Army Medical Center, Walter Reed National Military Medical Center, and the San Antonio Military Medical Center). The survey consisted of 19 total questions. Seven questions identified basic demographic information while the remainder were either multiple choice or Likert scale questions assessing knowledge of transition of care, satisfaction with transition training in residency, and amount of education on transition received during GME training. For each Likert scale question, participants responded on a scale from 0 to 5 with 0 indicating little satisfaction or comfort with transitioning patients and an answer of 5 indicating a high level of satisfaction or comfort with transitioning patients to adult care. No incentives or compensation were offered or provided for participation in the survey. After 2 wk, the survey link was again sent via email to the group of prospective participants. The survey was closed 2 wk after the second request. RESULTS The survey was distributed through established departmental email lists for providers at the training locations (potential responders = 310). A total of 145 people responded to the survey for a total response rate of 47%. Of the 145 respondents, 50 were current residents (34%) and more than half (54.5%) were staff physicians with 3 or more yr’ experience. The majority of respondents work in an outpatient setting at least part of the time (92.4%). Complete demographics are reflected in Table I. Table I. Demographics of Responders to Health Care Transition Survey (n = 145) T = 145  Number  %  Gender   Male  66  45.5   Female  79  54.5  Training level   PGY-1  17  11.7   PGY-2  17  11.7   PGY-3  16  11  Graduated in last 3 yr  16  11  Staff with more than 3 yr’ experience  79  54.5  Number of residents in their respective program (at time of GME training)   <15  12  8.3   15–24  42  29   >24  91  62.8  Outpatient work setting       Yes  133  92.4   No  11  7.6  Patients in provider’s panel with complex medical needs (provider’s best estimate)   <10%  47  32.9   10–20%  45  31.5   >20%  51  35.7  T = 145  Number  %  Gender   Male  66  45.5   Female  79  54.5  Training level   PGY-1  17  11.7   PGY-2  17  11.7   PGY-3  16  11  Graduated in last 3 yr  16  11  Staff with more than 3 yr’ experience  79  54.5  Number of residents in their respective program (at time of GME training)   <15  12  8.3   15–24  42  29   >24  91  62.8  Outpatient work setting       Yes  133  92.4   No  11  7.6  Patients in provider’s panel with complex medical needs (provider’s best estimate)   <10%  47  32.9   10–20%  45  31.5   >20%  51  35.7  Table I. Demographics of Responders to Health Care Transition Survey (n = 145) T = 145  Number  %  Gender   Male  66  45.5   Female  79  54.5  Training level   PGY-1  17  11.7   PGY-2  17  11.7   PGY-3  16  11  Graduated in last 3 yr  16  11  Staff with more than 3 yr’ experience  79  54.5  Number of residents in their respective program (at time of GME training)   <15  12  8.3   15–24  42  29   >24  91  62.8  Outpatient work setting       Yes  133  92.4   No  11  7.6  Patients in provider’s panel with complex medical needs (provider’s best estimate)   <10%  47  32.9   10–20%  45  31.5   >20%  51  35.7  T = 145  Number  %  Gender   Male  66  45.5   Female  79  54.5  Training level   PGY-1  17  11.7   PGY-2  17  11.7   PGY-3  16  11  Graduated in last 3 yr  16  11  Staff with more than 3 yr’ experience  79  54.5  Number of residents in their respective program (at time of GME training)   <15  12  8.3   15–24  42  29   >24  91  62.8  Outpatient work setting       Yes  133  92.4   No  11  7.6  Patients in provider’s panel with complex medical needs (provider’s best estimate)   <10%  47  32.9   10–20%  45  31.5   >20%  51  35.7  While deemed important by respondents with a score of 4.3 out of 5 (Table II), providers do not feel comfortable with transitioning medically complex patients with only 4.2% of respondents receiving formal transition instruction during residency and most reporting no informal instruction. The two most commonly perceived barriers (Fig. 1) to implementing a transition curriculum were time constraints (nearly 60%) and lack of available transition resources (73%). The most common “other” write-in barrier cited was the absence of trained providers willing to assume care for these complex patients. Table II. Responses to Questions About Residency Experience of Transition   Average Likert Score (Range)    Provider’s response to how important the topic of transition is to GME  4.3 (0.2–5)    (0 = not important, 5 = very important)      Provider’s level of comfort transitioning complex patients to adult care  2.6 (0–5)    (0 = not comfortable, 5 = very comfortable)      Provider’s perception on quantity of education received on transition  1.2 (0–4.5)    (0 = none, 5 = sufficient)      Provider’s satisfaction with residency’s training on transition  1.4 (0–4.5)    (0 = not satisfied, 5 = very satisfied)      Provider’s overall satisfaction with their medication “education” training  4 (0–5)    (0 = not satisfied, 5 = very satisfied)      Presence of formal education/curriculum on transition in residency  Responses  %   Yes  6  4.2   No  136  95.8    Average Likert Score (Range)    Provider’s response to how important the topic of transition is to GME  4.3 (0.2–5)    (0 = not important, 5 = very important)      Provider’s level of comfort transitioning complex patients to adult care  2.6 (0–5)    (0 = not comfortable, 5 = very comfortable)      Provider’s perception on quantity of education received on transition  1.2 (0–4.5)    (0 = none, 5 = sufficient)      Provider’s satisfaction with residency’s training on transition  1.4 (0–4.5)    (0 = not satisfied, 5 = very satisfied)      Provider’s overall satisfaction with their medication “education” training  4 (0–5)    (0 = not satisfied, 5 = very satisfied)      Presence of formal education/curriculum on transition in residency  Responses  %   Yes  6  4.2   No  136  95.8  Table II. Responses to Questions About Residency Experience of Transition   Average Likert Score (Range)    Provider’s response to how important the topic of transition is to GME  4.3 (0.2–5)    (0 = not important, 5 = very important)      Provider’s level of comfort transitioning complex patients to adult care  2.6 (0–5)    (0 = not comfortable, 5 = very comfortable)      Provider’s perception on quantity of education received on transition  1.2 (0–4.5)    (0 = none, 5 = sufficient)      Provider’s satisfaction with residency’s training on transition  1.4 (0–4.5)    (0 = not satisfied, 5 = very satisfied)      Provider’s overall satisfaction with their medication “education” training  4 (0–5)    (0 = not satisfied, 5 = very satisfied)      Presence of formal education/curriculum on transition in residency  Responses  %   Yes  6  4.2   No  136  95.8    Average Likert Score (Range)    Provider’s response to how important the topic of transition is to GME  4.3 (0.2–5)    (0 = not important, 5 = very important)      Provider’s level of comfort transitioning complex patients to adult care  2.6 (0–5)    (0 = not comfortable, 5 = very comfortable)      Provider’s perception on quantity of education received on transition  1.2 (0–4.5)    (0 = none, 5 = sufficient)      Provider’s satisfaction with residency’s training on transition  1.4 (0–4.5)    (0 = not satisfied, 5 = very satisfied)      Provider’s overall satisfaction with their medication “education” training  4 (0–5)    (0 = not satisfied, 5 = very satisfied)      Presence of formal education/curriculum on transition in residency  Responses  %   Yes  6  4.2   No  136  95.8  FIGURE 1. View largeDownload slide Perceived barriers to implementing graduate medical education training on transition. FIGURE 1. View largeDownload slide Perceived barriers to implementing graduate medical education training on transition. Sub-group analysis unsurprisingly demonstrated increasing comfort with the topic of transition with increasing experience, although even experienced staff only achieved an aggregate score of 3.2 suggesting marginal comfort. While the overwhelming majority of providers endorsed transition as an important topic, post graduate year (PGY)-3 providers endorsed it most strongly. This likely reflects anxiety with the subject as these providers anticipate completion of training and relocation away from the supports of the medical center. Table III displays the results of the transition knowledge assessment. These were broad questions targeting a variety of transition topics to include: the AAP’s recommended age to start discussing the transition process (age 12–13). the IDEA Act of 2004, required age for inclusion of formal IEP goals for transitioning(age 16). the maximum age students may remain in high school on an IEP(age 21). the age to submit a Department of Defense application for secondary dependence(age 21). the agency providing support for residential living services, the Administration on Developmental Disabilities. Table III. Knowledge Assessment on Transition   % Correct  AAP’s recommendation to discuss transition with patients  25.9  Age when IEP should include transition goals per IDEA  35.2  Age at which a child can remain in school on IEP  69  In DoD at what age does application for secondary dependence occur  51.4  Which agency listed assists with residential services and support  24.5    % Correct  AAP’s recommendation to discuss transition with patients  25.9  Age when IEP should include transition goals per IDEA  35.2  Age at which a child can remain in school on IEP  69  In DoD at what age does application for secondary dependence occur  51.4  Which agency listed assists with residential services and support  24.5  AAP, American Academy of Pediatrics; IEP, Individualized Education Program; IDEA, Individuals with Disabilities Education Improvement Act; DoD, Department of Defense. Table III. Knowledge Assessment on Transition   % Correct  AAP’s recommendation to discuss transition with patients  25.9  Age when IEP should include transition goals per IDEA  35.2  Age at which a child can remain in school on IEP  69  In DoD at what age does application for secondary dependence occur  51.4  Which agency listed assists with residential services and support  24.5    % Correct  AAP’s recommendation to discuss transition with patients  25.9  Age when IEP should include transition goals per IDEA  35.2  Age at which a child can remain in school on IEP  69  In DoD at what age does application for secondary dependence occur  51.4  Which agency listed assists with residential services and support  24.5  AAP, American Academy of Pediatrics; IEP, Individualized Education Program; IDEA, Individuals with Disabilities Education Improvement Act; DoD, Department of Defense. The results of these questions highlight the clear deficit in knowledge and understanding on the topic of transition. Three of the five questions had a correct response by 1/3 or fewer respondents including the question aimed at the AAP recommended age to start the transition process. DISCUSSION The successful transition of medically complex pediatric patients to adult care providers is critical, as illustrated by the publication of a specific AAPs policy statement and the establishment of a Center for Health Care Transition Improvement team by the Maternal and Child Health Bureau. While pediatricians care for the majority of children with medically complex needs, pediatric residents rarely receive specific training on how to successfully transition these complex patients as they age into adulthood. With movement towards the patient centered medical home, the role of the general pediatrician becomes pivotal in transitioning these patients out of the pediatric system. Non-involvement by the general pediatrician results in these complex patients experiencing significant delays in transition; or worse never transitioning to adult care providers as pediatricians are neither trained in adult medicine nor adequately equipped to treat the adult medical concerns. While satisfied with their overall graduate medical education (score 4.0), the majority of surveyed providers were dissatisfied with both the quantity and quality of their education on transitions (scores 1.2 and 1.4, respectively). The stark contrast between these scores suggests both a need and desire by pediatric providers for more training on transitioning. Despite consideration as an important topic and reported increased comfort with experience, the educational gap approaches canyon proportion with less than a third of respondents having knowledge of AAP policy surrounding transitions and less than a quarter with knowledge regarding available supports and resources. It is only mildly more heartening to know that most of these military providers did know the ages for continued eligibility for educational services and secondary military dependence. This study did have several limitations. First, this study was conducted at only Army pediatric residency training program locations and therefore may not be generalizable to pediatric GME education as a whole. The other major limitation is that a major portion of the responders were staff with greater than 3 yr’ experience. Transition has been a more recent focus over the past 10 yr and the experiences of staff that are further from their graduate medical training may not accurately reflect the current state of GME training on the topic. Finally, this study only looked at pediatric trainees and pediatricians. Other healthcare providers take care of medically complex children that will require transition to adult care however their training experiences are not reflected in his cohort. CONCLUSIONS With the recent advances to healthcare over the last two decades and the majority of medically complex patients reaching adult age, there are clear needs to improve upon the skill and comfort level pediatric providers have with transitioning patients to adult care. The topic of transition requires dedicated instruction, much like other topics in pediatric medicine. Ideally, this should start during the graduate medical education years when interns and residents are first learning to care for these medically complex patients; and when more experienced providers are available to lend their expertise on the topic. While there are many competing requirements during residency education, transition is becoming an increasingly important topic. With significant implications to patient overall health if not successfully transitioned to adult care; greater emphasis on this topic with a formal curriculum is recommended during residency education. While state laws and local resources vary significantly between different duty stations, creating significant challenges for the families of children with special healthcare needs; the military healthcare system provides unique challenges and opportunities for a transition curriculum and the actual act of transitioning these children. When constructing a curriculum to educate residents and staff alike, identification of a champion to maintain and regularly update a listing of resources available in the community is critical. Frequent moves affecting active duty medical staff increase potential for vital updates to fall through the cracks, making civilian staff ideally suited to this role within the military healthcare system as their stability maintains institutional memory. Although identification of community resources and local providers willing to assume care for young adults with chronic medical is a daunting task, selection of a champion would significantly enhance the formulation of a curriculum and education of trainees on how to successfully transition these children. Despite the challenges inherent to military service, as a single payer with access to the medical record across all locations, there is potential to mitigate educational shortfalls by flagging the records of children with conditions likely to persist into adulthood and establish prompts to aid in transitioning. Supplementary Material Supplementary material is available at Military Medicine online. References 1 McPheeters M, Davis AM, Taylor JL, Brown RF, Potter SA, Epsein RA. Transition Care for Children With Special Health Needs. Technical Brief No. 15. AHRQ Publication No. 14-ECH027-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2014. 2 Patel MS, O’Hare K.: Residency training in transition of youth with childhood-onset chronic disease. Pediatrics  2010; 126( Suppl 3): S190– 193. Google Scholar CrossRef Search ADS PubMed  3 Cooley WC, Sagerman PJ.: Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics  2011; 128( 1): 182– 200. Google Scholar CrossRef Search ADS PubMed  4 Nazarian BL, Glader L, Choueiri R, Shipman DL, Sadof M.: Identifying what pediatric residents are taught about children and youth with special health care needs and the medical home. Pediatrics  2010; 126( Suppl 3): S183– 189. Google Scholar CrossRef Search ADS PubMed  5 Mennito S.: Resident preferences for a curriculum in healthcare transitions for young adults. South Med J  2012; 105( 9): 462– 466. Google Scholar CrossRef Search ADS PubMed  6 Williams TV, Schone EM, Archibald ND, Thompson JW.: A national assessment of children with special health care needs: prevalence of special needs and use of health care services among children in the military health system. Pediatrics  2004; 114( 2): 384– 393. Google Scholar CrossRef Search ADS PubMed  Author notes The views expressed are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government. The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR, Part 46. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Resident and Staff Satisfaction of Pediatric Graduate Medical Education Training on Transition to Adult Care of Medically Complex Patients

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Abstract

Abstract Introduction This study aims to describe the quantity and satisfaction current residents and experienced pediatricians have with graduate medical education on transitioning medically complex patients to adult care. There is an increasing need for transitioning medically complex adolescents to adult care. Over 90% now live into adulthood and require transition to adult healthcare providers. The 2010 National Survey of Children with Special Health Care Needs found that only 40% of youth 12–17 yr receive the necessary services to appropriately transition to adult care. Materials and Methods Prospective, descriptive, anonymous, web-based survey of pediatric residents and staff pediatricians at Army pediatric residency training programs was sent in March 2017. Questions focused on assessing knowledge of transition of care, satisfaction with transition training, and amount of education on transition received during graduate medical education training. Results Of the 145 responders (310 potential responders, 47% response rate), transition was deemed important with a score of 4.3 out of 5. The comfort level with transition was rated 2.6/5 with only 4.2% of participants receiving formal education during residency. The most commonly perceived barriers to implementing a curriculum were time constraints and available resources. Of the five knowledge assessment questions, three had a correct response rate of less than 1/3. Conclusions The findings show the disparity between the presence of and perceived need for a formal curriculum on transitioning complex pediatric patients to adult care. This study also highlighted the knowledge gap of the transition process for novice and experienced pediatricians alike. IMPLICATIONS AND CONTRIBUTION This study describes the quantity and satisfaction residents and experienced pediatricians have with graduate medical education (GME) training on transitioning medically complex patients to adult care. Additionally, perceived barriers were assessed which is a starting point for developing a formal curriculum. INTRODUCTION Nearly 15% of children (under the age of 18 yr) have special healthcare needs1; defined as “those who have or are at an increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” Historically, the most complex of these children did not live into adulthood and remained in a pediatric medical home until death. With advances in medical care, over 90% now live into adulthood and require transition to adult healthcare providers.2 Successful transition from adult to pediatric care should be a well thought out and deliberate process that starts in early adolescence.3 Despite the importance of successfully transitioning pediatric patients with complex medical needs, the 2010 National Survey of Children with Special Health Care Needs found that only 40% of youth aged 12–17 yr receive the necessary services to make an appropriate transition to adult care. Few studies have looked at pediatric resident education regarding transitioning medically complex children to adult care, or graduate satisfaction and comfort managing transitions. A 2010 study examined pediatric resident education on medically complex children; but only queried exposure to transitioning patients.4 At a large teaching hospital implementing a curriculum on transition of care, another study compared the education of internal medicine and pediatric residents in caring for medically complex children and found that pediatric residents received disease specific education and teaching on specific childhood disease processes and were more comfortable with transition than internists in training.2 Resident preferences for timing of curriculum implementation and topics for inclusion in the development of a transition curriculum were examined; identifying a preference for teaching on transitioning throughout residency training with varied presentation modalities. As family medicine, internal medicine and pediatric residents were all surveyed desired topics for inclusion varied by residency type.5 This study fills several gaps in knowledge by addressing the military population and by assessing specifics of quality and satisfaction with transition in pediatric GME training. Despite the military having a significantly higher proportion of children with special healthcare needs (23%) than in the general population (15%), no studies have examined transition of care for this population6; illustrating the need for education and training of pediatric residents in adult care transition for these special care needs children. Unique challenges stemming from frequent relocation make education on successful transition of military children even more important and more problematic. Both active duty families and active duty medical providers change duty stations every 3–4 yr, yet local resources both on base and in the community as well as applicable state laws to aid children with special healthcare needs vary widely. Military parents frequently struggle with re-establishment of care, and military providers with familiarity accessing available local resources. This study’s focus is the perceived presence and quality of a transition curriculum and subsequent comfort with transitioning complex medical patients to adult care; an important topic as evidenced by its inclusion in the 2016 American Board of Pediatrics Content Specifications for board certification examination. METHODS An anonymous, web-based, IRB-approved (Madigan Army Medical Center Institutional Review Board) survey was sent to current pediatric residents and staff at all four Army pediatric residency training locations (Madigan Army Medical Center, Tripler Army Medical Center, Walter Reed National Military Medical Center, and the San Antonio Military Medical Center). The survey consisted of 19 total questions. Seven questions identified basic demographic information while the remainder were either multiple choice or Likert scale questions assessing knowledge of transition of care, satisfaction with transition training in residency, and amount of education on transition received during GME training. For each Likert scale question, participants responded on a scale from 0 to 5 with 0 indicating little satisfaction or comfort with transitioning patients and an answer of 5 indicating a high level of satisfaction or comfort with transitioning patients to adult care. No incentives or compensation were offered or provided for participation in the survey. After 2 wk, the survey link was again sent via email to the group of prospective participants. The survey was closed 2 wk after the second request. RESULTS The survey was distributed through established departmental email lists for providers at the training locations (potential responders = 310). A total of 145 people responded to the survey for a total response rate of 47%. Of the 145 respondents, 50 were current residents (34%) and more than half (54.5%) were staff physicians with 3 or more yr’ experience. The majority of respondents work in an outpatient setting at least part of the time (92.4%). Complete demographics are reflected in Table I. Table I. Demographics of Responders to Health Care Transition Survey (n = 145) T = 145  Number  %  Gender   Male  66  45.5   Female  79  54.5  Training level   PGY-1  17  11.7   PGY-2  17  11.7   PGY-3  16  11  Graduated in last 3 yr  16  11  Staff with more than 3 yr’ experience  79  54.5  Number of residents in their respective program (at time of GME training)   <15  12  8.3   15–24  42  29   >24  91  62.8  Outpatient work setting       Yes  133  92.4   No  11  7.6  Patients in provider’s panel with complex medical needs (provider’s best estimate)   <10%  47  32.9   10–20%  45  31.5   >20%  51  35.7  T = 145  Number  %  Gender   Male  66  45.5   Female  79  54.5  Training level   PGY-1  17  11.7   PGY-2  17  11.7   PGY-3  16  11  Graduated in last 3 yr  16  11  Staff with more than 3 yr’ experience  79  54.5  Number of residents in their respective program (at time of GME training)   <15  12  8.3   15–24  42  29   >24  91  62.8  Outpatient work setting       Yes  133  92.4   No  11  7.6  Patients in provider’s panel with complex medical needs (provider’s best estimate)   <10%  47  32.9   10–20%  45  31.5   >20%  51  35.7  Table I. Demographics of Responders to Health Care Transition Survey (n = 145) T = 145  Number  %  Gender   Male  66  45.5   Female  79  54.5  Training level   PGY-1  17  11.7   PGY-2  17  11.7   PGY-3  16  11  Graduated in last 3 yr  16  11  Staff with more than 3 yr’ experience  79  54.5  Number of residents in their respective program (at time of GME training)   <15  12  8.3   15–24  42  29   >24  91  62.8  Outpatient work setting       Yes  133  92.4   No  11  7.6  Patients in provider’s panel with complex medical needs (provider’s best estimate)   <10%  47  32.9   10–20%  45  31.5   >20%  51  35.7  T = 145  Number  %  Gender   Male  66  45.5   Female  79  54.5  Training level   PGY-1  17  11.7   PGY-2  17  11.7   PGY-3  16  11  Graduated in last 3 yr  16  11  Staff with more than 3 yr’ experience  79  54.5  Number of residents in their respective program (at time of GME training)   <15  12  8.3   15–24  42  29   >24  91  62.8  Outpatient work setting       Yes  133  92.4   No  11  7.6  Patients in provider’s panel with complex medical needs (provider’s best estimate)   <10%  47  32.9   10–20%  45  31.5   >20%  51  35.7  While deemed important by respondents with a score of 4.3 out of 5 (Table II), providers do not feel comfortable with transitioning medically complex patients with only 4.2% of respondents receiving formal transition instruction during residency and most reporting no informal instruction. The two most commonly perceived barriers (Fig. 1) to implementing a transition curriculum were time constraints (nearly 60%) and lack of available transition resources (73%). The most common “other” write-in barrier cited was the absence of trained providers willing to assume care for these complex patients. Table II. Responses to Questions About Residency Experience of Transition   Average Likert Score (Range)    Provider’s response to how important the topic of transition is to GME  4.3 (0.2–5)    (0 = not important, 5 = very important)      Provider’s level of comfort transitioning complex patients to adult care  2.6 (0–5)    (0 = not comfortable, 5 = very comfortable)      Provider’s perception on quantity of education received on transition  1.2 (0–4.5)    (0 = none, 5 = sufficient)      Provider’s satisfaction with residency’s training on transition  1.4 (0–4.5)    (0 = not satisfied, 5 = very satisfied)      Provider’s overall satisfaction with their medication “education” training  4 (0–5)    (0 = not satisfied, 5 = very satisfied)      Presence of formal education/curriculum on transition in residency  Responses  %   Yes  6  4.2   No  136  95.8    Average Likert Score (Range)    Provider’s response to how important the topic of transition is to GME  4.3 (0.2–5)    (0 = not important, 5 = very important)      Provider’s level of comfort transitioning complex patients to adult care  2.6 (0–5)    (0 = not comfortable, 5 = very comfortable)      Provider’s perception on quantity of education received on transition  1.2 (0–4.5)    (0 = none, 5 = sufficient)      Provider’s satisfaction with residency’s training on transition  1.4 (0–4.5)    (0 = not satisfied, 5 = very satisfied)      Provider’s overall satisfaction with their medication “education” training  4 (0–5)    (0 = not satisfied, 5 = very satisfied)      Presence of formal education/curriculum on transition in residency  Responses  %   Yes  6  4.2   No  136  95.8  Table II. Responses to Questions About Residency Experience of Transition   Average Likert Score (Range)    Provider’s response to how important the topic of transition is to GME  4.3 (0.2–5)    (0 = not important, 5 = very important)      Provider’s level of comfort transitioning complex patients to adult care  2.6 (0–5)    (0 = not comfortable, 5 = very comfortable)      Provider’s perception on quantity of education received on transition  1.2 (0–4.5)    (0 = none, 5 = sufficient)      Provider’s satisfaction with residency’s training on transition  1.4 (0–4.5)    (0 = not satisfied, 5 = very satisfied)      Provider’s overall satisfaction with their medication “education” training  4 (0–5)    (0 = not satisfied, 5 = very satisfied)      Presence of formal education/curriculum on transition in residency  Responses  %   Yes  6  4.2   No  136  95.8    Average Likert Score (Range)    Provider’s response to how important the topic of transition is to GME  4.3 (0.2–5)    (0 = not important, 5 = very important)      Provider’s level of comfort transitioning complex patients to adult care  2.6 (0–5)    (0 = not comfortable, 5 = very comfortable)      Provider’s perception on quantity of education received on transition  1.2 (0–4.5)    (0 = none, 5 = sufficient)      Provider’s satisfaction with residency’s training on transition  1.4 (0–4.5)    (0 = not satisfied, 5 = very satisfied)      Provider’s overall satisfaction with their medication “education” training  4 (0–5)    (0 = not satisfied, 5 = very satisfied)      Presence of formal education/curriculum on transition in residency  Responses  %   Yes  6  4.2   No  136  95.8  FIGURE 1. View largeDownload slide Perceived barriers to implementing graduate medical education training on transition. FIGURE 1. View largeDownload slide Perceived barriers to implementing graduate medical education training on transition. Sub-group analysis unsurprisingly demonstrated increasing comfort with the topic of transition with increasing experience, although even experienced staff only achieved an aggregate score of 3.2 suggesting marginal comfort. While the overwhelming majority of providers endorsed transition as an important topic, post graduate year (PGY)-3 providers endorsed it most strongly. This likely reflects anxiety with the subject as these providers anticipate completion of training and relocation away from the supports of the medical center. Table III displays the results of the transition knowledge assessment. These were broad questions targeting a variety of transition topics to include: the AAP’s recommended age to start discussing the transition process (age 12–13). the IDEA Act of 2004, required age for inclusion of formal IEP goals for transitioning(age 16). the maximum age students may remain in high school on an IEP(age 21). the age to submit a Department of Defense application for secondary dependence(age 21). the agency providing support for residential living services, the Administration on Developmental Disabilities. Table III. Knowledge Assessment on Transition   % Correct  AAP’s recommendation to discuss transition with patients  25.9  Age when IEP should include transition goals per IDEA  35.2  Age at which a child can remain in school on IEP  69  In DoD at what age does application for secondary dependence occur  51.4  Which agency listed assists with residential services and support  24.5    % Correct  AAP’s recommendation to discuss transition with patients  25.9  Age when IEP should include transition goals per IDEA  35.2  Age at which a child can remain in school on IEP  69  In DoD at what age does application for secondary dependence occur  51.4  Which agency listed assists with residential services and support  24.5  AAP, American Academy of Pediatrics; IEP, Individualized Education Program; IDEA, Individuals with Disabilities Education Improvement Act; DoD, Department of Defense. Table III. Knowledge Assessment on Transition   % Correct  AAP’s recommendation to discuss transition with patients  25.9  Age when IEP should include transition goals per IDEA  35.2  Age at which a child can remain in school on IEP  69  In DoD at what age does application for secondary dependence occur  51.4  Which agency listed assists with residential services and support  24.5    % Correct  AAP’s recommendation to discuss transition with patients  25.9  Age when IEP should include transition goals per IDEA  35.2  Age at which a child can remain in school on IEP  69  In DoD at what age does application for secondary dependence occur  51.4  Which agency listed assists with residential services and support  24.5  AAP, American Academy of Pediatrics; IEP, Individualized Education Program; IDEA, Individuals with Disabilities Education Improvement Act; DoD, Department of Defense. The results of these questions highlight the clear deficit in knowledge and understanding on the topic of transition. Three of the five questions had a correct response by 1/3 or fewer respondents including the question aimed at the AAP recommended age to start the transition process. DISCUSSION The successful transition of medically complex pediatric patients to adult care providers is critical, as illustrated by the publication of a specific AAPs policy statement and the establishment of a Center for Health Care Transition Improvement team by the Maternal and Child Health Bureau. While pediatricians care for the majority of children with medically complex needs, pediatric residents rarely receive specific training on how to successfully transition these complex patients as they age into adulthood. With movement towards the patient centered medical home, the role of the general pediatrician becomes pivotal in transitioning these patients out of the pediatric system. Non-involvement by the general pediatrician results in these complex patients experiencing significant delays in transition; or worse never transitioning to adult care providers as pediatricians are neither trained in adult medicine nor adequately equipped to treat the adult medical concerns. While satisfied with their overall graduate medical education (score 4.0), the majority of surveyed providers were dissatisfied with both the quantity and quality of their education on transitions (scores 1.2 and 1.4, respectively). The stark contrast between these scores suggests both a need and desire by pediatric providers for more training on transitioning. Despite consideration as an important topic and reported increased comfort with experience, the educational gap approaches canyon proportion with less than a third of respondents having knowledge of AAP policy surrounding transitions and less than a quarter with knowledge regarding available supports and resources. It is only mildly more heartening to know that most of these military providers did know the ages for continued eligibility for educational services and secondary military dependence. This study did have several limitations. First, this study was conducted at only Army pediatric residency training program locations and therefore may not be generalizable to pediatric GME education as a whole. The other major limitation is that a major portion of the responders were staff with greater than 3 yr’ experience. Transition has been a more recent focus over the past 10 yr and the experiences of staff that are further from their graduate medical training may not accurately reflect the current state of GME training on the topic. Finally, this study only looked at pediatric trainees and pediatricians. Other healthcare providers take care of medically complex children that will require transition to adult care however their training experiences are not reflected in his cohort. CONCLUSIONS With the recent advances to healthcare over the last two decades and the majority of medically complex patients reaching adult age, there are clear needs to improve upon the skill and comfort level pediatric providers have with transitioning patients to adult care. The topic of transition requires dedicated instruction, much like other topics in pediatric medicine. Ideally, this should start during the graduate medical education years when interns and residents are first learning to care for these medically complex patients; and when more experienced providers are available to lend their expertise on the topic. While there are many competing requirements during residency education, transition is becoming an increasingly important topic. With significant implications to patient overall health if not successfully transitioned to adult care; greater emphasis on this topic with a formal curriculum is recommended during residency education. While state laws and local resources vary significantly between different duty stations, creating significant challenges for the families of children with special healthcare needs; the military healthcare system provides unique challenges and opportunities for a transition curriculum and the actual act of transitioning these children. When constructing a curriculum to educate residents and staff alike, identification of a champion to maintain and regularly update a listing of resources available in the community is critical. Frequent moves affecting active duty medical staff increase potential for vital updates to fall through the cracks, making civilian staff ideally suited to this role within the military healthcare system as their stability maintains institutional memory. Although identification of community resources and local providers willing to assume care for young adults with chronic medical is a daunting task, selection of a champion would significantly enhance the formulation of a curriculum and education of trainees on how to successfully transition these children. Despite the challenges inherent to military service, as a single payer with access to the medical record across all locations, there is potential to mitigate educational shortfalls by flagging the records of children with conditions likely to persist into adulthood and establish prompts to aid in transitioning. Supplementary Material Supplementary material is available at Military Medicine online. References 1 McPheeters M, Davis AM, Taylor JL, Brown RF, Potter SA, Epsein RA. Transition Care for Children With Special Health Needs. Technical Brief No. 15. AHRQ Publication No. 14-ECH027-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2014. 2 Patel MS, O’Hare K.: Residency training in transition of youth with childhood-onset chronic disease. Pediatrics  2010; 126( Suppl 3): S190– 193. Google Scholar CrossRef Search ADS PubMed  3 Cooley WC, Sagerman PJ.: Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics  2011; 128( 1): 182– 200. Google Scholar CrossRef Search ADS PubMed  4 Nazarian BL, Glader L, Choueiri R, Shipman DL, Sadof M.: Identifying what pediatric residents are taught about children and youth with special health care needs and the medical home. Pediatrics  2010; 126( Suppl 3): S183– 189. Google Scholar CrossRef Search ADS PubMed  5 Mennito S.: Resident preferences for a curriculum in healthcare transitions for young adults. South Med J  2012; 105( 9): 462– 466. Google Scholar CrossRef Search ADS PubMed  6 Williams TV, Schone EM, Archibald ND, Thompson JW.: A national assessment of children with special health care needs: prevalence of special needs and use of health care services among children in the military health system. Pediatrics  2004; 114( 2): 384– 393. Google Scholar CrossRef Search ADS PubMed  Author notes The views expressed are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government. The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR, Part 46. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Military MedicineOxford University Press

Published: Apr 11, 2018

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