Background/Purpose: Young adults with chronic health conditions deserve an intentional transition from pediatric to adult care. We have developed a longitudinal process to standardize transfer of care of patients from pediatric to adult rheumatology providers. Elements of the process include utilization of a Transition Planning Tool (TPT)—an electronic medical record (EMR)-based flowsheet with 13 core components designed to assess patients’ knowledge, skills and ability to manage their own health—and a novel transition success score. Here, we assess if there is correlation between application of the TPT and successful transition.

Methods: We retrospectively reviewed the EMRs of a cohort of patients that transitioned out of our pediatric rheumatology clinic between 2017-2024. We ascertained TPT utilization rates, identified attainment of any TPT components, and calculated transition success scores. Our transition success score, created internally, includes four factors related to attendance at adult visits, medication refills with the new adult provider, and the absence of rheumatology-related emergency department visits/admissions in the first year after the final pediatric appointment. Patients must achieve all 4 components to have successful transition. GraphPad Prism was used for statistical analysis (Mann-Whitney).

Results: From 2017-2024 we identified 198 patients able to be scored for transition success. The average age at transition was 18.7±1 years, and the most common diagnoses were lupus (84/198, 47%) and juvenile arthritis (68/198, 34%). Pediatric providers utilized the TPT at least once with 178/198 (90%) of transitioned patients. In these 178, the TPT was utilized a median of 5 times per patient, however, there was a broad range as the TPT was only used once with 21, but more than 10x with 15 (IQR 3-7). Among the 157/178 (88%) patients with at least two TPT uses, TPT use spanned across a median of 2.6 (IQR 1.6-4.1) years. While 83/178 (47%) patients had the TPT used at the final pediatric rheumatology visit, among the other 95 patients the TPT was last used a median of 8.5 months prior to transfer of care, and actually ranged up to 4.1 years prior. Providers indicated that patients accomplished a median of 8 (IQR 4-11) of the 13 core TPT components (range 0-13) at any point during their pediatric rheumatology care. There were no differences in the average number of times the TPT was used (5.6 v 5.4, p=0.87) or in the number of TPT components fulfilled (7.6 v 7.1, p=0.35) between patients who were scored as transitioning successfully or not.

Conclusion: We have developed a structured transition process that incorporates a TPT to guide intentional transition planning for young adults with rheumatic disease. Providers are encouraged, but not required, to use the TPT. In this initial evaluation, there was no significant association between TPT use or accomplishment of TPT components and transition success. Future analyses will evaluate whether particular TPT components are predictive of transition success and if regular use of the TPT across time can improve transition outcomes.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/evaluating-the-relationship-between-an-electronic-transition-planning-tool-and-transition-success-in-a-pediatric-rheumatology-clinic/