Rethinking Transfers of Pediatric Orthopedic Patients to Adult Care

By Kaitlin Gunter
Sunday, January 1, 2017

Pediatric orthopedic providers treat some patients well into adulthood, and guidelines for transitioning those patients to adult care need revisiting, according to recent research in the Journal of Pediatric Orthopaedics.

A study by Laurie N. Fishman, MD, and other researchers associated with Boston Children’s Hospital analyzed data from a survey to assess perspectives of providers from the Pediatric Orthopaedic Society of North America and the Pediatric Orthopaedic Practitioner Society.

Roughly 70 percent of the more than 300 providers who responded treat patients older than age 25, and more than one-third treat patients over age 40. They treat mostly neuromuscular or congenital disorders.

The providers often acknowledged basing transitions on triggers such as institutional policy regarding age restrictions, as well as adult comorbidities — cardiac disease, for example — and differences in levels of autonomy between pediatric and adult patients.

“There is a consensus nationally that transition is important and people should do it,” says Dr. Fishman, attending physician at Boston Children’s Hospital and Assistant Professor of Pediatrics at Harvard Medical School. “But there are not a lot of guidelines as to exactly what age and exactly the best way to do it and exactly what patients need to go to full, adult-centered care and which can have more mixed care, or which should be seen in pediatric settings with adult specialists coming in.”

A Culture Change?

One barrier to transitions is a shortage of adult-care providers with expertise regarding certain rare neuromuscular or congenital pediatric-onset conditions, Dr. Fishman says. However, adults with such conditions are living longer, healthier lives and at a certain point need more age-appropriate care, she adds. She urges providers to view patients’ needs in their totality in order to determine the optimal care setting.

“As pediatric providers, we forget that there are both advantages and disadvantages of each culture,” Dr. Fishman says. “Instead of positioning our culture as being wonderful and better-suited to the patients we treat, consider what aspects they will lose and gain as they transition ... . Think of it as green and blue, instead of losing the light and going into the dark.”

Surgical and medical expertise is important but is only part of the equation, Dr. Fishman adds.

“There are other aspects of care in these different cultures that play a role,” she says, “so think of the whole patient and consider the advantages offered them, like different access to pain management or physical therapy or nutritional rehabilitation.”

Collaboration is key, says Laurel C. Blakemore, MD, UF Orthopaedics and Sports Medicine Institute, Chief and Associate Professor of Pediatric Orthopaedics, University of Florida College of Medicine.

“Everyone agrees there is a lot of variability in how we transition from pediatric to adult care for these children,” Dr. Blakemore says. “We need to involve adult-care providers in the decision-making process and establish better resources for them after transfer of care to establish a smoother transition that is more consistent across care models.”