title: Predictors of timing of transfer from pediatric- to adult-focused primary care.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts2Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Ma.
authors.forename: Lauren E
authors.initials: LE
authors.lastname: Wisk
authors.affiliation: Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts2Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Ma.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Finkelstein
authors.affiliation: Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts4Division of Pulmonary and Respiratory Diseases, Boston Children's Hospital, B.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Sawicki
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.
authors.forename: Matthew
authors.initials: M
authors.lastname: Lakoma
authors.affiliation: Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
authors.forename: Sara L
authors.initials: SL
authors.lastname: Toomey
authors.affiliation: Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Schuster
authors.affiliation: Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts2Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Ma.
authors.forename: Alison A
authors.initials: AA
authors.lastname: Galbraith
mesh_terms: D000293:Adolescent; D000367:Age Factors; D001900:Boston; D002908:Chronic Disease / Q000628:therapy*; D015331:Cohort Studies; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration / Q000706:statistics & numerical data; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D011203:Poverty; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012737:Sex Factors; D060305:Transition to Adult Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D055815:Young Adult