Advancing Transition in Resource-Constrained Settings.

The critical importance of transitioning children and young people (CYP) with chronic conditions from pediatric to adult-based services is increasingly recognized. Whilst improved therapeutics such as biologic agents have allowed for greater survival into adulthood, there remains an ongoing risk of disease flares, lifelong potential for disability, as well as a psychosocial impact of these chronic conditions that needs to be monitored and managed throughout adolescence and into adulthood [1]. A disorganized execution of transition to adult services can lead to treatment noncompliance, lack of healthcare awareness, loss to follow-up, and overall poor disease outcomes [2].

Whilst the need for effective transition is well established in developed nations, it remains an emerging concept in many under-resourced countries [3]. Of the published studies examining health outcomes before and after transition in rheumatology, all were based in Europe or North America [1]. García-Rodríguez et al. describe the first transitional care model for adolescents with rheumatic disease in Mexico, providing a framework for developing transition services in resource-constrained settings [4]. The authors outline the development of their model, which ultimately involves a three-stage transition process. They propose a goal-based rather than age- or time-based approach, with patients assessed for their readiness to progress to the next stage of transition at each three-monthly visit. Patients are reviewed by a multidisciplinary team, which includes 3 pediatric rheumatologists, 2 adult rheumatologists, 2 nutritionists, 2 physiatrists, 1 adolescent psychiatry specialist, 1 clinical psychologist, 1 nurse, and 1 social worker. The authors acknowledge that this current study only outlines the design process, with actual results from the intervention to follow in future publications. Furthermore, they note that clinical outcomes, such as disease activity, are not being considered.

The strength of this design lies in its highly commendable comprehensiveness and multidisciplinary approach. The authors have rightly identified the decisive impact of mental health in chronic disease and are well equipped with allied health support to empower adolescents to navigate this challenging life stage [4]. However, such a wide-ranging service may be unattainable in even many developed settings, let alone those that are resource constrained [5].

Consideration could be given to how transition can still effectively occur with a more streamlined approach. The availability of allied health providers to support transition has been highlighted as a major barrier to holistic transitional care [2]. One solution may include the use of telemedicine. Through the course of the COVID-19 pandemic, as health care universally moved towards a digital delivery model, clinicians (and patients) became accustomed to conducting consults online [5]. With the knowledge that smartphones are increasingly affordable and commonplace, and that adolescents interact with technology more than any other age group, telemedicine may offer an enticing avenue to enable holistic transition, including in under-resourced settings [5].

A high-quality, effective transition is paramount to enabling CYP to successfully gain ownership of their chronic condition and health journey. Whilst ideal service design and delivery is specific to the resources, infrastructure, policy, and societal influences of each site, ongoing research into the design and outcomes of programs will strengthen and enhance these fledgling pathways.