4 WORLD GASTROENTEROLOGY NEWS NOVEMBER 2016 Editorial | Expert Point of View | Gastro 2016: EGHS-WGO | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events higher risk for steroid dependence6,7. All of these factors suggest more ag-gressive disease phenotype in pediatric patients. The risk for surgery among adolescents is about 35% within the first five years of time of diagnosis7. Adolescents are also more likely to have upper gastrointestinal and extraintestinal manifestations7. Nu-tritional impairment and weight loss occur in nearly 85% of children with IBD8, and the highest levels of mental health disorders including depression and anxiety are found among adoles-cents with IBD compared to other chronic conditions9. The first period of adult life from age 18 to 25 has been described as an unstable period between adolescence and full adulthood, and as with other chronic diseases, this period may be longer in IBD3. The ‘emerging adults with IBD’ or EAI3 have an increased risk for disease progression and other complications of disease10, higher economic burden of all-cause total health care costs, highest utilization of emergency services, and poorer adher-ence to treatment11-14. Because of these differences, in-cluding more severe disease pheno-type, need for chronic medications, increased risks for anxiety, depres-sion and other co-morbidities, and increased healthcare costs and poorer adherence, in an effort to improve outcomes, it is imperative for uninter-rupted care and management of IBD in these young adults. Resources for Evaluation of Patient Readiness and Adherence for Transition of Care: The North American Society for Pe-diatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) has published recommendations regarding the transition of patients with child-hood onset of IBD to adult care15. The NASPGHAN recommendations to the pediatric gastroenterologist are to begin the process of transition when the patient enters early to middle adolescence and: (1) See the adolescent patient without their parents or caregivers in order to build independence and self-reliance. (2) Discuss and introduce the subject and the benefits of a transition to an adult gastroenterologist early on to the patient and family. (3) Select an experienced adult gas-troenterologist knowledgeable and interested in the unique needs of young adults with IBD. (4) Provide all appropriate medical re-cords and summaries to the adult gastroenterologist in advance, to ensure confidence in the patient and family that the pediatric and adult providers are work-ing together. The NASPGHAN Medical Summary Form can be found in Appendix A of the medi-cal position statement15. NASPGHAN has also created a ‘Healthcare Provider Transitioning Checklist’ which can be utilized as early as age 12-14 years, to evalu-ate the readiness of the adolescents to transitional care http://www. naspghan.org/files/documents/pdfs/ medical resources/ibd/Checklist_Pa-tientandHealthcareProdiver_ Transi-tionfromPedtoAdult. pdf 15 There are also other clinical instru-ments available to perform regular as-sessments of the EAI or young adult’s readiness and potential areas for early intervention, to best achieve tran-sition- relevant skills. Although the evaluation of readiness is difficult to measure, tools such as the Transition Readiness Assessment Questionnaire (TRAQ)16 and the portable medical record called MyHealth Passport for IBD17 are both available online and be utilized by patients and providers in clinic. The Morisky Adherence Scale18 is another clinical instrument tool used to identify and intervene early in any potential adherence problems. And lastly, the PHQ-9 Depression Screening Tool19 incorporates DSM-IV diagnostic criteria for depression and can be incorporated with the other transition readiness and adher-ence tools to evaluate all patients prior to transition of care. Organizing a Transition of Care in IBD: The key players involved in a tran-sitional care program should always center around the patient. Parents/ caregivers, pediatric and adult gastro-enterologists, IBD nurse specialists, psychologists or counselors, dietician and pharmacists should all be part of this multidisciplinary team to ensure best delivery of care and improved patient outcomes. Three goals in the process of transi-tion in IBD were identified by JC Escher: “(1) to get the patient ready for transfer, having attained specific skills and knowledge; (2) to get the parents ready for transfer; (3) to get the adult gastroenterologist ready and well informed at the time of transfer.”20 Although there are several suggested timelines for the transition process, it is important to understand that this still requires special attention and tailoring based on the young adult’s developmental abilities, which is more based on competency and emotional and cognitive maturity rather than a chronological age alone21. In a survey of adult gastroenterologists caring for young adults with IBD, it was report-ed that young adults need improved education about their medical history and treatment/medications, and pe-diatric gastroenterologists need better communication with referring adult providers. Lastly, the study concluded that adult providers would benefit from formalized adolescent training5. Similar results were described in a UK study22 of adult and pediatric gastro-enterologists, which also concluded that pediatric providers were more likely to consider the need for a struc- Continued from first page.
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