Dr. Joel Lavine on Transitions of Adolescents and Young Adults with Chronic Liver and Digestive Diseases from Pediatric to Adult Digestive Health Specialists at Columbia University Medical Center
Children with chronic digestive diseases who require care for ongoing monitoring and treatment of their condition often suffer setbacks in their well-being when transitioning from their primary pediatric gastroenterologist or hepatologist to designated adult providers. Dr. Joel Lavine, Professor of Pediatrics at Columbia University, developed initiatives at his Medical Center while serving as Chief of the Division of Pediatric Gastroenterology, Hepatology and Nutrition; to enable a smooth transition that maintains the health of the patients cared for by his team of specialists.
The conditions that require a transitional program include inflammatory bowel disease, chronic liver diseases that have required or will require a liver transplant, celiac disease, chronic functional motility disorders, and those with short gut syndrome.
Dr. Joel Lavine states that instituting programs for adolescents and young adults in these circumstances requires a flexible time of transition to ensure or enhance adherence to medical regimens for drug maintenance, clinic attendance, procedure scheduling and monitoring. The timing of transition may be variable, given the particular diagnosis and situation that relates to frequency of clinic attendance, laboratory evaluations, and psychosocial maturity and understanding for compliance.
Most adolescents make the transition to adult providers who are experts in the germane condition around the time they are finishing high school if they are going to attend university, or leave their parents’ home to travel or take on a job after finishing their education. Their capability to successfully transition usually depends on their degree of understanding of their disease process and the reason for maintaining surveillance and compliance, their psychological and emotional foundation, their degree of independence while still under the care of their parents, their lifestyle, future health concerns, and their readiness and need to incorporate thinking about their sexuality and reproduction.
In order to enhance the transition, Dr. Joel Lavine notes that special attention needs to be made for a standardized, evidence-based and informed transition clinic in the relevant chronic disease area. A multi-disciplinary team must be instituted, such as the ones in his Division at Columbia University Medical Center.
This team, which may overlap at a specific time and place on a scheduled basis for those specific patients undergoing transition to adult care, generally includes the pediatric digestive health specialist, his or her adult counterpart preparing to take on the patient, surgeons, and conjoint social workers, dietitians, and nurse practitioners/ physician assistants. In some instances, a joint psychologist may be involved, particularly for complex functional GI motility disorders. Health care providers involved in the management of these problems should receive appropriate training in transition of care, as Dr. Joel Lavine assures.
Monitoring of the program is important. Dr. Lavine maintains that a regular review of outcomes of patients involved in transition programs be performed. This review ideally assesses compliance with clinic attendance schedules and follows through with prescription pick-up and utilization of needed medications. Data on hospitalizations, maintenance of employment, success and attendance at University, and continuing quality of life assessments. Patients should be increasingly knowledgeable about their disease process, disease location, medications, payment for services, and health resources. This disease-specific education program should be uniform, albeit the time difference aspects that are instituted may vary by individual’s sophistication and ability to comply and understand.
Dr. Joel Lavine has overseen the set-up of such programs in celiac disease, inflammatory bowel disease, liver transplantation, congenital GI birth defects (esophageal atresia, diaphragmatic hernia, imperforate anus), fatty liver disease, and eosinophilic esophagitis at Columbia. Each of these programs undergo a scheduled review of guidelines and monitoring of success. Dr. Lavine hopes that all centers caring for such patients are aware of the need for such programs in transition, and have the resources to adequately address this critical issue.