Predictors of timing of transfer from pediatric- to adult-focused primary care

Abstract

Importance: A timely, well-coordinated transfer from pediatric- to adult-focused primary care is an important component of high-quality health care, especially for youths with chronic health conditions. Current recommendations suggest that primary-care transfers for youths occur between 18 and 21 years of age. However, the current epidemiology of transfer timing is unknown.

Objective: To examine the timing of transfer to adult-focused primary care providers (PCPs), the time between last pediatric-focused and first adult-focused PCP visits, and the predictors of transfer timing.

Design, setting, and participants: Retrospective cohort study of patients insured by Harvard Pilgrim Health Care (HPHC), a large not-for-profit health plan. Our sample included 60 233 adolescents who were continuously enrolled in HPHC from 16 to at least 18 years of age between January 2000 and December 2012. Pediatric-focused PCPs were identified by the following provider specialty types, but no others: pediatrics, adolescent medicine, or pediatric nurse practitioner. Adult-focused PCPs were identified by having any provider type that sees adult patients. Providers with any specialty provider designation (eg, gastroenterology or gynecology) were not considered PCPs.

Main outcomes and measures: We used multivariable Cox proportional hazards regression to model age at first adult-focused PCP visit and time from the last pediatric-focused to the first adult-focused PCP visit (gap) for any type of office visit and for those that were preventive visits.

Results: Younger age at transfer was observed for female youths (hazard ratio [HR], 1.32 [95% CI, 1.29-1.36]) who had complex (HR, 1.06 [95% CI, 1.01-1.11]) or noncomplex (HR, 1.08 [95% CI, 1.05-1.12]) chronic conditions compared with those who had no chronic conditions. Transfer occurred at older ages for youths who lived in lower-income neighborhoods compared with those who lived in higher-income neighborhoods (HR, 0.89 [95% CI, 0.83-0.95]). The gap between last pediatric-focused to first adult-focused PCP visit was shorter for female youths than male youths (HR, 1.57 [95% CI, 1.53-1.61]) and youths with complex (HR, 1.35 [95% CI, 1.28-1.41]) or noncomplex (HR, 1.24 [95% CI, 1.20-1.28]) chronic conditions. The gap was longer for youths living in lower-income neighborhoods than for those living in higher-income neighborhoods (HR, 0.80 [95% CI, 0.75-0.85]). Multivariable models showed an adjusted median age at transfer of 21.8 years for office visits and 23.1 years for preventive visits and an adjusted median gap length of 20.5 months for office visits and 41.6 months for preventive visits.

Conclusions and relevance: Most youths are transferring care later than recommended and with gaps of more than a year. While youths with chronic conditions have shorter gaps, they may need even shorter transfer intervals to ensure continuous access to care. More work is needed to determine whether youths are experiencing clinically important lapses in care or other negative health effects due to the delayed timing of transfer.

Figure 1. Multivariable-Adjusted Age at Transfer

Modified box plots depicting the adjusted 25th, 50th (median), and 75th percentiles for age at transfer to first adult office visit (A) and first adult preventive visit (B) for the overall sample and by primary predictors. Multivariable Cox models were used to construct the adjusted survival functions, from which these percentiles were obtained. The inset table on the left describes the sample size for each subgroup and the adjusted median age at transfer (also identified by the thick black bar within each box plot). For the provider network variable, subgroup totals do not sum to the total sample because individuals could contribute person-time to both categories of this time-varying covariate. HMO indicates health maintenance organization; POS, point of service; and PPO, preferred provider organization.

Figure 2. Multivariable-Adjusted Gap Length

Modified box plots depicting the adjusted 25th, 50th (median), and 75th percentiles for transfer/gap length to first adult office visit (A) and first adult preventive visit (B) for the overall sample and by primary predictors. Multivariable Cox models were used to construct the adjusted survival functions, from which these percentiles were obtained. The inset table on the left describes the sample size for each subgroup and the adjusted median gap length (also identified by the thick black bar within each box plot). For the provider network variable, subgroup totals do not sum to the total sample because individuals could contribute person-time to both categories of this time-varying covariate. HMO indicates health maintenance organization; POS, point of service; and PPO, preferred provider organization.