Predictors of timing of transfer from pediatric to adult primary care

Ensuring a smooth transfer from pediatric to adult health care is a crucial component of high quality care transition, especially for youth with chronic conditions.  However, little is known about the timing of such transfers and the factors that influence them. Our objective was to determine factors related to the time at transfer to adult primary care providers (PCPs) and to the time between last pediatric and first adult PCP visits for adolescents and young adults (AYA) while enrolled in a health plan.

We selected adolescents who were continuously enrolled in a large non-profit health plan from age 16 to at least age 18 between January 2000 and December 2012, and who had at least one pediatric PCP visit before age 18.  Multivariable Cox regression was used to model the time to first visit with an adult PCP or disenrollment. Multivariable linear regression was used to model the length of the gap between the last pediatric PCP visit and first adult PCP visit among those who transferred. Potential predictors included gender, chronic condition status, state of residence, neighborhood income, age at last pediatric PCP visit, dependent status, and year.

Of 57,565 AYA in our sample, 39.2% transferred from a pediatric PCP to an adult PCP during their enrollment, with a mean age at transfer of 20.5 years, and 88.5% of AYA had a gap of more than 12 months after their last pediatric PCP visit.  Transfer occurred at younger ages for female AYA (HR: 1.48, 95%CI: 1.44-1.52) and those with chronic conditions (HR: 1.17, 95%CI: 1.14-1.20), and at older ages for AYA in neighborhoods in the lowest income quartile (vs. highest) (HR 0.92, 95%CI: 0.89-0.96).  The gap between last pediatric and first adult PCP visit was shorter for female AYA than for males (2.8 months, 95%CI: 2.4 – 3.1 months) and those with chronic conditions than those without (1.5 months, 95%CI: 1.1 – 1.9 months), and longer for AYA in neighborhoods in the lowest income quartile than in the highest (0.8 months, 95%CI: 0.2-1.4 months).

Although it is reassuring that AYA with chronic conditions have shorter gaps than those without chronic conditions, this population may be more vulnerable to delays in primary care access and may need even shorter transfer intervals to ensure continuous care.  More work is needed to determine if AYA are experiencing clinically important lapses in care and promote optimal transfer from pediatric to adult primary care.