Digital Delivery of Person-centered Transitional Care

Medical and surgical advances have significantly increased the life expectancy of individuals with congenital and pediatric-onset diseases, often resulting in chronic conditions. Effective lifetime care is crucial, especially during the transition from pediatric to adult care. Transition is a process where adolescents with chronic conditions are prepared to manage their health and life as they move to adult healthcare environments. Transition programs are designed to assist in this preparation, and over the past decade, several randomized-controlled trials (RCTs) have demonstrated the effectiveness of such programs in improving outcomes like self-management, knowledge of the condition, clinic attendance, and satisfaction with care.

In Sweden, the STEPSTONES (Swedish Transition Effects Project Supporting Teenagers with chrONic mEdical conditionS) project is evaluating a person-centered transition program tailored for young individuals with chronic conditions. The project has focused on conditions like congenital heart disease and type 1 diabetes through RCTs and is now exploring a digital adaptation called Digi-STEPSTONES, which aims to deliver the transition program remotely to improve accessibility and continuity of care.

PURPOSE AND AIMS

The main goal of this project is to evaluate the effectiveness of a digitally delivered, person-centered transition program for adolescents with asthma/allergy and those who have undergone a solid organ transplant in a real-world setting. The specific objectives are:

• To investigate the non-inferiority of the digital delivery compared to in-person delivery.
• To evaluate the implementation process of the digital transition program.

SIGNIFICANCE AND NOVELTY Digi-STEPSTONES aligns with person-centered care principles by supporting shared decision-making and empowering adolescents to actively participate in their healthcare. This project is novel as it is the first to provide evidence on the effectiveness of a digitally delivered person-centered transition program, covering multiple conditions, which enhances the generalizability of the findings.

RESEARCH DESIGN AND METHODS

To achieve the project's objectives, two studies will be conducted:

Study 1: Comparative Effectiveness Research (Non-Inferiority Trial) A two-arm, non-inferiority study using a causal inference methodology will be performed. Arm A involves a digital delivery of the transition program, while Arm B is a historical cohort from previous RCTs that received in-person delivery.

The STEPSTONES transition program includes eight components implemented in five steps, and the intervention will be delivered via the "Mitt vårdmöte" platform, already in use for digital healthcare appointments in Sweden. Assessments will be made at ages 16 and 18.5, focusing on primary outcomes like patient empowerment and secondary outcomes like transition readiness, quality of life, and health literacy.

Study 2: Evaluation of the Implementation of the Digital Transition Program A mixed methods approach will be used, combining quantitative and qualitative methods. Adolescents who participated in the digital program and healthcare providers will be included. The evaluation will focus on the intervention's reach, fidelity, perceived barriers, facilitators, usability, and user-friendliness of the digital platform.

TIMEPLAN The Digi-STEPSTONES project will be executed through six work packages, covering managerial, developmental, implementation, research, and reporting tasks, starting in 2023.

Ethical Approval The project has received ethical approval (2022-05394-01-351139, 2023-01-13).

By delivering the transition program digitally, Digi-STEPSTONES aims to reduce the burden on young patients, particularly those living in remote areas, and ensure that they receive the necessary transitional care. The project will contribute to Sweden's healthcare objectives by leveraging digital solutions to provide accessible, equitable, and high-quality care.

RESEARCH DESIGN AND METHODS

To address the specific objectives of this project, 2 studies will be conducted:

Objective 1 Study 1: Comparative effectiveness research: Non-inferiority trial Design: A two-arm, comparative, non-inferiority study, using a causal inference methodology will be performed. Arm A involves a pre-test/post-test design where individuals will participate in the digital delivery of the transition program.

Arm B is a historical comparison cohort that includes participants from two previous RCTs who received the intervention in-person.

Participants/inclusion criteria:

Arm A:

• Literate, Swedish-speaking adolescents with asthma/allergy or went through a solid organ transplantation aged minimum 15 years. Their parents will be invited to fill out a questionnaire (proxy).

Arm B:

• Literate, Swedish-speaking adolescents with asthma/allergy or went through a solid organ transplantation aged minimum 15 years. Their parents will be invited to fill out a questionnaire (proxy).

Sample size calculation:

Arm A: approximately 100 patients will be recruited consecutively Arm B: the approximate sample for individuals who received the intervention in-person is of approximately 120.

Exclusion criteria:

• Non literate
• Not Swedish speaking
• Cognitive impairment

Intervention: The STEPSTONES transition program is a multi-component intervention comprising 8 components: a) a transition coordinator (TC); b) information and education about the condition and treatment, health behavior, dealing with school and friends; c) availability by telephone; d) information about and contact with the adult program; e) guidance of parents; f) meeting with peers; g) person-centered transition plan; and h) the actual transfer to the adult program 15,16. These components are implemented in five steps: (1) first outpatient visit with TC; (2) second outpatient visit with TC; (3) information and peer-to-peer session for adolescents and their parents; (4) individualized transfer plan; and (5) actual transfer (Figure 2). The intervention will be delivered through the "Mitt vård mote" platform, which is currently being used across Sweden to undertake digital healthcare appointments. The HEADDDSS (home, education, activity, diet, drugs, depression, sex, safety) adolescent health interview is a cornerstone of the intervention. The intervention will be performed by specialized nurses of the respective pediatric care units, after being trained to become TC. The core of the STEPSTONES transition program remains the same for the present project, except that the delivery will be digital.

Variables and measurement: Assessments are planned at the age of 16 years (Time 0 - baseline ) and 18.5 years (Time 1- endpoint). The primary outcome is Patient Empowerment, using the Gothenburg Young Persons Empowerment Scale. Secondary outcomes are transition readiness; quality of life; and satisfaction with transition. In parents, the proxy transition readiness is measured.

Procedure of patient recruitment, data collection and data management: Patients who are eligible for inclusion will be approached by letter at the age of 16 years. In a subsequent telephone call, both the adolescents and their parents will be informed verbally about the study. Patients will only be included if the adolescent, who is a minor at the time of inclusion, provides written informed assent, and the parents/guardians provide written informed consent.

Patients will be asked to complete a set of online questionnaires (eCRF) online. To increase the response rate, a modified Dillman procedure will be used to minimize non-response, same procedure as in prior STEPSTONES trials. Reminders will be sent after three, five and seven weeks.

Statistical analysis: Propensity score weighting will be used as a method of causal inference. It mimics an RCT design and reduces comparative bias. After propensity weighting, the groups are compared by applying a linear model with doubly robust estimations. A one-sided p\<0.025 will be used as the cutoff for statistical significance, because non-inferiority is hypothesized.

Objective 2 Study 2: Evaluation of the implementation of the digital transition program Design: for this evaluation, a mixed methods approach will be used, meaning a combination of quantitative and qualitative methods will be used.

Participants: adolescents who participated in the digital transition program as well as the nurses in charge of delivering the transition program (i.e., transition coordinators) will be included in this section. Additionally, personal from the adult healthcare unit will be interviewed.

Sample size: all participants from study 1 will be included in the quantitative assessment of this study. In the qualitative assessment, between 10-15 adolescents and around 10 healthcare providers will be interviewed.

Data collection: to describe the intervention's reach and fidelity, information on the number of participants that took part in the different components will be monitored. To identify perceived barriers and facilitators, as well as intervention fidelity, both the adolescents and healthcare providers will be interviewed individually. To evaluate the usability and user friendliness of the digital platform, a questionnaire will be answered. This questionnaire will be answered once they have finalized the transition program, meaning it will be included in the set of questionnaires the participants answer in study when they are 18,5 years. Lastly, a percentage of the digital meetings will be audio recorded and the care plans related to the intervention will be studied to understand the mechanism of delivery.