Szymanski Konrad M, Cain Mark P, Hardacker Thomas J, Misseri Rosalia
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
Division of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
J Pediatr Urol. 2017 Feb;13(1):40.e1-40.e6. doi: 10.1016/j.jpurol.2016.09.020. Epub 2016 Nov 9.
Rates of successful transition from adolescent to adult spina bifida (SB) care are unknown.
We aimed to assess rates and predictors of successful transition from a multidisciplinary SB clinic to a transitional urology clinic (TUC), or a pediatric or adult urologist.
We retrospectively reviewed patients discharged from a multidisciplinary SB clinic (2006-2012), collecting demographic and clinical data. At transition, all patients/families were given instructions to arrange an appointment within 12 months. Patients who followed-up within 2 years were classified as transitioned. Logistic regression was used for analysis.
Of 77 patients discharged at a mean age of 19.1 years, 31 (40.3%) successfully transitioned (mean follow-up 4.7 years). Only 20/41 (48.8%) with prior bladder augmentation, urinary channel, and MACE transitioned. There was no significant change in patients transitioning over time or late catch-up presentations (p = 0.41 see Figure). Transitioned and non-transitioned groups were similar in age, gender, home-to-clinic distance, insurance, ambulation, shunt status, prior non-adherence, emergency room visits, neurosurgery appointments, hospitalizations, and surgeries (including genitourinary reconstruction) before discharge (p = 0.22). Transitioned patients had more pre-discharge appointments with services outside the SB clinic (p = 0.01) and radiographic studies (p < 0.001), but these were not significant on multivariate analysis (p = 0.16). Among those who did not transition, five (6.5%) presented after 2 years, rarely with new complaints (20.0%). Patients without urological follow-up were most likely to visit the emergency room (p = 0.03).
To facilitate continued care and a smooth transition, the TUC was opened across the corridor from the multidisciplinary SB clinic. To our surprise, a low percentage of patients actually transitioned to adult care over the last 7 years. It is a sobering fact that despite offering three different transition models, <50% of patients took advantage of any of them. While none of the predictors we anticipated to be important in a successful transition were statistically significant, potentially because of low statistical power, perhaps others, such as insufficient time to coordinate care, wait times, and lack of adult coordinated care programs, may be more important. We were unable to compare the urologic health of those who did and did not transition, as we relied on medical record data.
Only 40% of patients transitioned successfully from a multidisciplinary SB clinic and few presented after 2 years. Patients who transitioned tended to have more active health issues and more radiographic tests prior to discharge. Those followed by a urologist are less likely to use emergency room services.
从青少年脊柱裂（SB）护理成功过渡到成人护理的比例尚不清楚。
我们旨在评估从多学科SB诊所成功过渡到过渡性泌尿外科诊所（TUC）或儿科或成人泌尿科医生的比例及预测因素。
我们回顾性分析了从多学科SB诊所出院的患者（2006 - 2012年），收集人口统计学和临床数据。在过渡时，所有患者/家属都收到指示要在12个月内安排预约。在2年内进行随访的患者被归类为已过渡。采用逻辑回归进行分析。
77例平均年龄为19.1岁出院的患者中，31例（40.3%）成功过渡（平均随访4.7年）。先前接受膀胱扩大术、尿流改道和可控性膀胱造瘘术的患者中只有20/41（48.8%）成功过渡。随着时间推移成功过渡的患者或晚期追赶就诊患者无显著变化（p = 0.41，见图）。已过渡组和未过渡组在年龄、性别、住所到诊所的距离、保险、行走能力、分流状态、先前的不依从情况、急诊就诊、神经外科预约、住院和出院前手术（包括泌尿生殖系统重建）方面相似（p = = 0.22）。已过渡患者在出院前与SB诊所外的服务预约（p = 0.01）和影像学检查（p < 0.001）更多，但在多变量分析中这些并不显著（p = 0.16）。在未过渡的患者中，5例（6.5%）在2年后就诊，很少有新的主诉（20.0%）。未接受泌尿外科随访的患者最有可能去急诊室就诊（p = 0.03）。
为便于持续护理和平稳过渡，TUC在多学科SB诊所走廊对面开设。令我们惊讶的是，在过去7年中实际过渡到成人护理的患者比例很低。一个严峻的事实是，尽管提供了三种不同的过渡模式，但不到50%的患者利用了其中任何一种。虽然我们预期在成功过渡中重要的预测因素均无统计学意义，可能是因为统计效能低，但也许其他因素，如协调护理的时间不足、等待时间以及缺乏成人协调护理项目等可能更重要。由于我们依赖病历数据，所以无法比较已过渡和未过渡患者的泌尿健康状况。
只有40%的患者从多学科SB诊所成功过渡，2年后很少有患者就诊。已过渡的患者在出院前往往有更活跃的健康问题和更多的影像学检查。接受泌尿科医生随访的患者使用急诊室服务的可能性较小。
