Health care transition from pediatric to adult care: an evidence-based guideline
Open accessAbstract
For consistent quality of treatment of young people with chronic health care needs, a structured health care transition (HCT) from pediatric medicine to adult medical care is essential. Currently, most countries have no guidelines on HCT based on systematic evidence research. To close this gap, guidance to support HCT was developed in Germany. Twenty-two experts in the management of adolescents and young adults with different chronic conditions and three patient representatives were invited to take part in the guideline group. Based on a systematic literature search recommendations for HCT were drafted. Where evidence was lacking, recommendations were developed using collective expert consensus. The consensus process was independently moderated using a Delphi approach. The final draft was reviewed and endorsed by all major German medical societies. The clinical recommendations provide guidance for all chronic somatic diseases. After assessment of HCT readiness, an individualized plan for HCT should be drawn up. Key elements here are a responsible coordinator, age-adapted patient education, involvement of caregivers, web-based interventions, joint visits, and a structured summary for the receiving physician. The aim is the gradual transfer of responsibility for disease management to the young person themselves. Conclusion: As only a few randomized controlled studies on HCT are available, evidence-based statements are possible for some but not all areas of HCT. However, this guideline may help to develop globally accepted standards. These standards should be established and implemented. The aim should be a reimbursement by individual national health systems to allow appropriate support for young people. What is Known: • Health care transition from pediatric to adult care is primarily organized in local settings, partly based on disease-specific guidelines. •There have been no national guidelines in Germany until now. What is New: • Here we present the general evidence-based guidelines of the German Association of Scientific Medical Societies for health care transition. • These might serve as a blueprint for further national or international health care transition guidelines.
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Structured transition in AYA with chronic health care needs is shown to be beneficial in a number of specific situations, though data are mixed.
“Structured transition in AYA with chronic health care needs is shown to be beneficial in a number of specific situations,532,533 though data are mixed.534-536”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [533]
Developmental age is likely more relevant than chronological age in individuals with TS given the increased neurocognitive and psychosocial differences.
“General guidelines recommend that transition begin between 12 and 14 years of age, yet developmental age is likely more relevant than chronological age in individuals with TS given the increased neurocognitive and psychosocial differences.424,532,533”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [533]
General guidelines recommend that transition begin between 12 and 14 years of age.
“General guidelines recommend that transition begin between 12 and 14 years of age, yet developmental age is likely more relevant than chronological age in individuals with TS given the increased neurocognitive and psychosocial differences.424,532,533”
From Clinical practice guidelines for the care of girls and women with Turner syndrome. (2024) · cites this paper as [533]
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Clinical practice guidelines for the care of girls and women with Turner syndrome.
Gravholt, C. H., Andersen, N. H., Christin-Maitre, S., Davis, S. M., Duijnhouwer, A., Gawlik, A., Maciel-Guerra, A. T., Gutmark-Little, I., Fleischer, K., Hong, D., et al. (2024) · European Journal of Endocrinology · doi:10.1093/ejendo/lvae050 · Cited by 224 · see citing works
- Authors
- Pape, L., & Ernst, G.
- Affiliations
- Essen University Hospital (DE)
- Medizinische Hochschule Hannover (DE)
- Corresponding author
- Pape, Lars
- Venue
- European Journal of Pediatrics
- Published
- 2022-01-27
- Volume
- 181
- Issue
- 5
- Pages
- 1951-1958
- ISSN
- 0340-6199 (ISSN-L)
- 1432-1076
- PMC
- PMC9056438
- OpenAlex
- W4220675053
- Cited by
- 86
- References
- 48
- Citations by year
- 2026: 26 · 2025: 26 · 2024: 13 · 2023: 13 · 2022: 7 · 2018: 1
- FWCI
- 18.58
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- European Journal of Pediatrics (publishedVersion, cc-by)
- Research Square (acceptedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Universitätsbibliographie, Universität Duisburg-Essen (submittedVersion)
- Funders
- Society of Transition Medicine
- Universität Duisburg-Essen
- Topics
- Health Sciences › Health Professions › Speech and Hearing › Adolescent and Pediatric Healthcare
- Health Sciences › Health Professions › General Health Professions › Child and Adolescent Health
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Keywords
- care transitions, transition to adult care, adolescents and young adults, chronic somatic diseases, transition readiness, patient education, caregiver involvement, online intervention, transfer of responsibility, transition coordinator, clinical guidelines
- MeSH terms
- Adolescent, Child, Chronic Disease, Germany, Humans, Patient Transfer, Practice Guidelines as Topic, Consensus, Young Adult, Transition to Adult Care
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