Transition

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					The Transition of Chronic-Care Patients from Pediatric to Adult Providers
(focusing on Heme/Onc)

Meg Browning Med/Peds group seminar series November, 2004

Assumption: This must happen
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Are there rules about this? Is it appropriate to have 30-year-olds and 4-year-olds in the same clinic? The same hospital? Are pediatricians (however specialized) competent to provide care to 30somethings? How about 50-somethings? (Let’s get back to that later.)

What is standing in the way?
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Patient/provider attachment Neurocognitive ability of the patient Perceived poor compensation for care of chronic issues (adult hospitals may not wish to open that sickle cell clinic) Parent roles/wishes The “patient role” – habit of being cared for Availability of trained providers (the bit where the lifespans are really different than they were 10 years ago)

Goals to be met
(there is a WEALTH of this on the Internet – timetables, checklists, etc.)
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Self-advocacy Independent health care Sexual health Psychosocial support Educational and vocational planning Health and lifestyle issues

Social hurdles
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Being seen without parents Taking “ownership” of illness, meds, etc. Insurance Employment Lack of services

Moral: Chronic care programs for adult patients are in every bit as great a need of good social workers as the peds programs.

2nd moral:

Vote.

Medical care
(that Pediatricians may not do as well)
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PAP smears, Mammograms/screening Family planning / (contraception) Prostate health Colon cancer screening (Tobacco/alcohol use) / lifestyle issues Heart/vascular disease

HgSS: late complications
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Retinal hemorrhage Sequellae of stroke Osteonecrosis Renal and Cardiac dysfunction Reproductive problems (esp. males) Pain, pain, pain Drug addiction?

Hemophilia: late complications
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Hepatitis (chronic) Bleeds (kind of never goes away) Joint damage Pain and pain meds

Procoagulant disorders
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Ongoing care Increased risks with hormone Rx Implications for pregnancy
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Fetal losses Teratogenic medications

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Family planning (hereditary)

Onc/Transplant: late effects
(highly disease- and therapy-specific)
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Assuming that the basics like growth, nutrition, and thyroid are already covered Sterility Cataracts Cardiac and renal dysfunction Osteopenia/osteoporosis Second malignancies (skin, breast, marrow, other radiation field)

Sterility
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Males: sperm bank before making them that way. Everything else is a bit more iffy. Females
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GnRH analog during chemo Other hormone Rx during chemo (other benefits) Egg harvest Ovarian tissue harvest

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A few words on the protocol here for that last one

Suggestions
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Have defined “steps” Have providers meet (all that info we don’t write in the chart, such as “knowledge of the family”) 1st new visit while well Help get med and imz records Start early in giving patient ownership of disease New provider first sees patient in old setting


				
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