Transcript Fishman LN

Provider Perspectives and
Patient Abilities
Laurie Fishman, M.D.
PAS Symposium
April 27, 2012
Children’s Hospital Boston
What are the clinician’s beliefs and perceptions regarding transition and
transfer
at
Children’s Hospital, Boston?
Susan M. Fernandes, M.H.P., P.A.-C.; Laurie Fishman, M.D.;
Joanne O’Sullivan-Oliveira, Ph.D., F.N.P.,B.C.; Sonja Ziniel, Ph.D;
Patrice Melvin, M.P.H; Paul Khairy, M.D., Ph.D.; Rebecca O’Brien, M.D.; Romi Webster, M.P.H., M.D.; Michael J.
Landzberg, M.D.; Gregory Sawicki, M.P.H., M.D.
From the Departments of Cardiology, Medicine and Surgery, Children’s Hospital Boston, the Department of
Pediatrics, Harvard Medical School, Boston, MA.
CHB Provider Survey
• Cross sectional web based multiple-choice survey
• Outpatient clinicians at CHB (care for pts >11 years of
age) across all specialties
–
–
–
–
Staff physicians
Nurses
Physician assistants
Social workers
• IRB approved study
• Response rate overall 76% (72-100%)
Provider Demographics
Providers differ in triggers for
transfer to adult care
Combined
MD
PA
RN
SW
P value
Age
79
73
74
82
90
NS
Adult Co-morbidities
77
80
74
80
71
NS
College graduation
77
55
74
74
78
.002
Pregnancy
58
53
70
64
49
NS
Marriage
56
53
60
65
36
.013
Alcohol/illicit drugs
29
21
35
39
20
.036
High School
Graduation
16
5
48
20
20
.001
Percentage of each provider group responding to whether the characteristic should
require transfer to adult centered provider
MD
PA
RN
SW
P value
Parents attachment 96/95
to hospital/ provider
98/95
91/100
96/95
92/92
ns
Pt attachment to
provider
95
94
95
95
97
ns
Pt cognitive delay
86
86
86
85
84
ns
Provider attachment 79
to pt/family
78
57
78
92
.018
Family noncompliance with
transfer
78
72
71
83
84
ns
Unstable medical
condition
68
68
77
61
87
.015
Lack of qualified
adult providers
66
75
29
63
67
.006
Insurance issues
37
32
23
42
42
ns
BARRIERS
Combined
Percentage of providers reporting witnessing or experiencing these barriers to transfer
of care to adult care providers
Age Appropriate Care
• 43% of clinicians felt they could provide age
appropriate care to pts >25 years of age
• 23% of clinicians felt they could provide age
appropriate care to pts >50 years of age
• Additional analyses of those clinician without
adult internal medicine training
– 20% felt they could provide age appropriate care to pts
>30 years of age
– 12% thought they could provide age appropriate care
to pts >40 years of age
Of the 58% who assess skills
95% assess informally
At what age do your patients start transitioning (self management) skills
assessment and or education?
70%
% of respondents
60%
50%
Combined
40%
MD
PA
30%
RN
SW
20%
10%
0%
< 11 years
11-16 years
17-18 years
Age
19-21 years
>21 years
Don't know
Do We Know Adult Provider
Expectations?
• Pediatric providers had differing ideas regarding
knowledge, independence
• Patients move to other parts of the country –
perhaps other providers differ from our local
colleagues
Hait JPGN 2009
Format
• 1134 adult GI providers identified by AGA
membership directory
• Solicited by email - electronic survey
• Questions regarding young adult patients
transferring INTO practice
• Asked if issue was important (1 to 5)
and if often problematic (yes/no)
Demographics of adult GI responders
N=363 (34%)
Most problems reported in:
% of subjects
that reported
a problem
Issue
Mean
importance
(± SD)
Patients should know the name, dose and major
side effects of each medication they are taking.
4.6
(± .65)
55%
Patients should be able to relate highlights of
their medical history, such as onset, surgeries
and procedures.
4.5
(± .62)
53%
It is important that the pediatric
gastroenterologist provide a medical summary
prior to first visit with an adult provider.
4.6
(± .80)
Patients should have knowledge of the impact of
smoking, drugs and alcohol on their health.
4.6
(± .64)
68%
52%
Least problems reported in:
% of subjects
that reported
a problem
Issue
Mean
importance
(± SD)
Patients should be able to research their
illness outside the office visit.
3.6
(± .98)
Patients should be able to identify persons
involved in their health care (both family
and professionals)
4.4
(± .66)
16%
Patients should be able to attend the visit
by themselves.
3.1
(± 1.1)
13%
Patients should be able to undergo
procedures under conscious sedation.
3.8
(± 1.1)
21%
19%
Specific issues in adolescents
Yes
Do you feel it is important for an adult gastroenterologist to have
knowledge of medical aspects (i.e. growth) in IBD in
adolescents?
93%
Do you feel you have that knowledge?
70%
Do you feel it is important for an adult gastroenterologist to have
knowledge of developmental issues in adolescents?
86%
Do you feel you have that knowledge?
42%
Patient Surveys
• Ambulatory setting, age >9
• 294 surveys (82%) returned
• Medication name, dose, side effect
(fill in before seeing provider)
Fishman JPGN 2011
Patients tended to know name and dose of
medication (78% overall)
When do patients take over care from
their parents?
Health Maintenance behaviors
regarding medication, during
clinic visit, between visit
1 my parents only
2 mostly my parents
3 we share equally
4 mostly me
5 I totally do it myself
van Groningen IBD 2012
Children's Responsibility by Age
Medication-Related Behaviors
100%
80%
60%
40%
20%
0%
10-
13-
16-
19-
12
15
18
21
Order Refills
>21
10-
13-
16-
19-
12
15
18
21
Remember To Take
>21
10-
13-
16-
19-
12
15
18
21
>21
Go To Pharmacy
Medications
Percentage of patients of each reporting “mostly me” or “I totally do it myself” when
asked who usually does these tasks
Percentage of patients of each age reporting “mostly me” or” I totally do it myself” when
asked who usually contact the doctor if there is a problem between visits, who schedules
appointments, who remembers appointments, and who gets you to the appointments.
Children's Responsibility by Age
Visit-Related Behaviors
100%
80 %
60%
40%
20%
Prepares
Questions
Main Talking
Answers
Asks Questions
Questions
Percentage of patients of each reporting “mostly me” or “I totally do it myself” when
asked who usually does these tasks
>21
19-
16-
13-
10-
>21
19-
16-
13-
10-
>21
19-
16-
13-
10-
>21
19-
16-
13-
10-
0%
Concluding thoughts
Helpful to have evidence that includes:
• Input from all stakeholders
– Adult providers
– Parents
– Post transition patients
– Pediatric providers
• Baseline information
• Specific information
References
Hait EJ, Barendse RM, Arnold JH, Valim C, Sands BE, Korzenik JR, Fishman LN.
Transition of adolescents with IBD from pediatric to adult care: a survey of adult
gastroenterologists. J Pediatr Gastroenterol Nutr. 2009; 48:61-65.
Fernandes S, Fishman LN, O’Sullivan-Oliveira J, Ziniel S, Melvin P, Khairy P, O’Brien R,
Webster R, Landzberg M, Sawicki G. Current practices for the transition and transfer
of patients with a wide spectrum of pediatric-onset chronic diseases: Results of a
clinician survey at a free-standing pediatric hospital. Int J Child Adol Health 2010 3(4):
507-517.
Fishman, LN, Houtman D, van Groningren JT, Arnold J Ziniel S. Medication Knowledge:
an Initial Step in Self-management for Adolescents and Young Adults with
Inflammatory Bowel Disease. JPGN 2011 53(6):641-5.
Ref cont.
Fernandes SM, Lanzberg MJ, Fishman LN, Khairy P, Sawicki GS, Ziniel S, Melvin P,
OSullivan-Oliveira J, Greenspan P, Bhatt AB. Clinician perceptions of transition of
patients with pediatric-onset chronic disease to adult medical care: Comparing a
pediatric facility integrated within an adult institution with a free-standing pediatric
hospital. Int J Child Adolesc Health 2012;5(3): in press.
van Groningen J, Ziniel S, Arnold J, Fishman LN. When independent health care
behaviors develop in adolescents with inflammatory bowel disease. Inflamm Bowel
Dis 2012: in press
O’Sullivan-Oliveira J, Fernandes SM, Borges LF, Fishman LN. Transition of Pediatric
Patients to Adult Care: An Analysis of Provider Opinion Across Discipline and Role. Ped
Nurs 2012: in press