This study developed a valid and reliable transition readiness assessment tool for Thai adolescents with rheumatic disease and identified predictors for higher and lower TRAQ scores. This study may help pediatric rheumatologists and other healthcare providers assess transition readiness skills and have better transition plans for adolescents with rheumatic diseases in the future. The results demonstrated that these patients' weaknesses were health insurance coverage and financial management in the appointment keeping and tracking health issues domains. Predictors of high transition readiness were studying for a bachelor's degree and attending independent clinic visits, whereas predictors of low transition readiness were inactive disease status and dependent clinic visits.
Some questions were adapted to ensure compatibility with our healthcare system (e.g., question number 1, which is related to the prescription filling process). The process of receiving medications in Thailand is different from Western countries. In the Thai healthcare system, patients receive medications at the hospital after leaving the doctor's office. Hospital pharmacies are the only places permitted to dispense specific drugs, especially immunosuppressive medications and biologic agents. Patients cannot get these medications from outside pharmacies. Therefore, question number 1 was adapted to assess the process of obtaining medications from pharmacists at the hospital. It might be more comfortable for patients to obtain medicines in Thailand than in Western countries, but this is the first step toward patient independence and taking responsibility for their health.
Another question that was adapted was question number 9, which is related to health insurance. The majority of Thai citizens can apply for the UCS from the government at no cost, so they usually do not apply for other health insurance programs. The UCS covers most basic and immunosuppressive drugs used to treat rheumatic disease, except biologic agents. However, the UCS has a short expiration date, and the majority of patients need to reapply before attending their next clinic visits.
Patients whose parents work for the government or state enterprise are eligible for the CSMBS until they are 20 years old.
This benefit covers all immunosuppressive medications and some biologic agents. After 20 years of age, these patients need to apply for other healthcare benefits, including the UCS or other health insurance programs. Therefore, question number 9 was adapted to "Can you get the UCS or find other health care programs, if your current health care program ends?"
The results of this study show that the percentage of patients with an active disease status (78%) was similar to previous studies (60–80%), but the percentage of patients that took at least one medication (93%) was higher compared with previous studies (70–85%)[9, 25]. Because most patients in our study had JIA or SLE, they needed long-term treatment until adulthood. Thailand has only a small number of pediatric rheumatologists; thus, a delay in patient referral to pediatric rheumatologists is expected, resulting in poor outcomes and the need for long-term medications. Additionally, our patients could not access biologic therapy as soon as indicated, which is different from developed countries' situation. Thus, these patients still need DMARDs for long-term disease control.
Regarding the association between TRAQ score and specific diseases, previous studies have demonstrated that patients with mental illness or developmental disabilities tended to have lower TRAQ scores than patients with chronic diseases of physical function [15]. In the study by Sawicki et al. [15], patients were affected by physical disability and different types of rheumatic diseases but were not affected by mental illness; therefore, the TRAQ scores associated with each rheumatic disease were similar. The hypothesis that TRAQ scores were higher in patients with rheumatic disease without co-existing mental illness compared with patients with co-existing mental illness is supported by the TRAQ scores observed in the present study and Anelli et al study [40]. Both studies demonstrated higher TRAQ scores than other studies [15, 41], which assessed patients with cognitive impairment and mental health issues.
The skills related to health insurance coverage and financial management had the lowest TRAQ scores. Because most of the patients in this study were of a low socioeconomic status, most of them applied for the UCS.
Patients' parents/caregivers reapplied on their behalf, although these patients were young adults.
Differences exist between Thai culture and Western culture in terms of living status and financial management.
Most Thai children live with their parents, even as young adults, and they only leave their parents once they are married.
Furthermore, most of them do not have a part-time job and do not undertake extra work while attending university.
Therefore, health insurance and healthcare financing are managed by parents or caregivers.
The results of this study emphasize that health insurance and financial management are necessary to facilitate the transition to an adult setting. Because only 16% of patients had a prior discussion about transition processes and policies, discussing these issues as part of transition sessions is essential.
With regard to good transition readiness, studying for a bachelor's degree and independent clinic visits were predictors of high TRAQ scores in this study. These findings are different from previous studies [15, 16, 41], which showed that older age is a predictor of high TRAQ scores. As mentioned previously, parents in Thai culture always take care of their children, even as young adults. Therefore, adolescents do not necessarily have independent living skills. Instead, higher education helps adolescents learn how to become independent and manage their medications. Furthermore, our study population mainly studied at the high school level. At this age, patients have not acquired sufficient living skills; thus, they might not be able to manage their lives and finances independently.
Focusing on the lower mean scores in the domains of appointment keeping and tracking health issues, we found that inactive disease status and dependent visits were predictors of lower TRAQ scores.
It is understandable that patients with inactive disease always ignore their health status and pay no attention to taking medications and seeking medical care, resulting in failure to transition to an adult care setting.
Furthermore, the anxiety of Thai parents is another factor that affects children's dependency.
Parents always attend the clinic with their children instead of teaching their children independence.
Thus, practitioners should prepare and discuss these issues with patients during transition sessions.
To the best of our knowledge, this is the first study carried out in Thailand using the cross-cultural adapted TRAQ to assess transition readiness in adolescents with rheumatic diseases. However, this study had some limitations. First, this study was performed at a single center; thus, it might not represent the whole Thai adolescent population. Nevertheless, our hospital is the main referral center in Thailand, which receives patients from all over the country. Second, several factors associated with transition readiness, including psychological factors, strong relationships with pediatricians, and parenting style, were not assessed. Therefore, further multicenter studies with prospective cohort designs, including psychological factor assessments, are recommended.
In summary, the Thai TRAQ is a valid and reliable tool with good performance to assess transition readiness in Thai adolescents with rheumatic diseases. Patients studied for a bachelor's degree and who independently attended clinic visits have a higher chance of successful transition to adult care. Practitioners should facilitate patient transfer from pediatric to adult care settings by preparing patients for this transition and paying particular attention to two issues: health insurance coverage and financial management. Moreover, it is important to raise awareness of the disease to the patients especially during inactive disease. Parents should teach their children independent living skills. Well-planned transitional care may help adolescents to achieve a successful transition and achieve good health and wellbeing.
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