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Objective: With increased utilization of virtual care in mental health, examining its appropriateness in various clinical scenarios is warranted. This study aimed to compare the risk of adverse psychiatric outcomes following virtual versus in-person mental health follow-up care after a psychiatric emergency department (ED) visit., Methods: Using population-based health administrative data in Ontario (2021), we identified 28,232 adults discharged from a psychiatric ED visit who had a follow-up mental health visit within 14 days postdischarge. We compared those whose first follow-up visit was virtual (telephone or video) versus in-person on their risk for experiencing either a repeat psychiatric ED visit, psychiatric hospitalization, intentional self-injury, or suicide in the 15-90 days post-ED visit. Cox proportional hazard models generated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs), adjusted for age, income quintile, psychiatric hospitalization, and intentional self-injury in the 2 years prior to ED visit. We stratified by sex and diagnosis at index ED visits based on the International Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) coding., Results: About 65% ( n  = 18,354) of first follow-up visits were virtual, while 35% ( n  = 9,878) were in-person. About 13.9% and 14.6% of the virtual and in-person groups, respectively, experienced the composite outcome, corresponding to incidence rates of 60.9 versus 74.2 per 1000 person-years (aHR 0.95, 95% CI 0.89 to 1.01). Results were similar for individual elements of the composite outcome, when stratifying by sex and index psychiatric diagnosis, when varying exposure (7 days) and outcome periods (60 and 30 days), and comparing "only" virtual versus "any" in-person follow-up during the 14-day follow-up., Conclusions and Relevance: These results support virtual care as a modality to increase access to follow-up after an acute care psychiatric encounter across a wide range of diagnoses. Prospective trials to discern whether this is due to the comparable efficacy of virtual and in-person care, or due solely to appropriate patient selection may be warranted., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Mental health (MH) conditions are prevalent in adolescents with childhood-onset SLE (cSLE). Early identification is crucial in preventing poor patient outcomes; however, MH screening rates remain low., Local Problem: From July 2021-January 2022, only 15% of adolescents in a paediatric tertiary care cSLE clinic were being screened for depression and anxiety. By November 2023, we aimed to increase the percentage of patients with cSLE (≥12-18 years) screened for depression (Patient Health Questionnaire: PHQ-9) and anxiety (Generalised Anxiety Disorder-7: GAD-7) from 15% to 80%., Methods: This quality improvement project employed the Model for Improvement framework. Stakeholders included the clinic team, patients and families, and MH providers. Statistical process control charts were used to analyse the outcome measure for percentage of screened patients with cSLE. Patient and caregiver satisfaction surveys were conducted at baseline and after screening as a balancing measure., Interventions: MH screening workflow with a referral algorithm was developed with stakeholders. Additional interventions included two MH training workshops for healthcare providers and a preclinic reminder of eligible patients for screening., Results: Over 21 months, 146 patients with cSLE completed 270 MH screens, increasing the screening rate from 15%, peaking at 100%, to a median of 56%. Sixty-six individuals (45%) reported symptoms of depression and/or anxiety on their initial screen. Of 270 screens, 44 individuals (17%) reported moderate to severe symptoms meeting the screening workflow criteria for referral to a MH service; 10% of patients screened were referred and seen by the MH service within 2-12 weeks. Patients and caregivers reported satisfaction with the MH screening process and quality of MH follow-up., Conclusion: Despite not sustainably meeting the target, MH screening rates increased in the cSLE clinic by nearly fourfold, demonstrating feasibility and acceptability. Patients expressed satisfaction with their mental health follow-up, emphasising its importance in their care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The transition from pediatric to adult care poses a significant health system-level challenge impeding the delivery of quality health services for youth with chronic health conditions. In Canada and globally, the transition to adult care is regarded as a top priority in adolescent health in need of readily applicable, adaptable, and relevant national metrics to evaluate and benchmark transition success across disease populations and clinical care settings. Unfortunately, existing literature fails to account for the lack of engagement from youth and caregivers in developing indicators, and its applicability across chronic conditions, primary care involvement, and health equity considerations., Objective: Our proposed study aims to establish a consensus-driven set of quality indicators for the transition to adult care that are universally applicable across physical, developmental, and mental health conditions, clinical care settings, and health jurisdictions., Methods: Using an integrated knowledge translation (iKT) approach, a panel comprising youth, caregivers, interdisciplinary health care providers, and health system leaders will be established to collaborate with our research team to ensure that the study methodology, materials, and knowledge dissemination are suitable and reflect the perspectives of youth and their families. We will then conduct an iterative 3-round Online Modified Delphi (OMD) study (n=160) to (1) compare and contrast the perspectives of youth, caregivers, health care providers, and health system leaders on quality indicators for transition; and (2) prioritize a key set of quality indicators for transition applicable across disease populations that are the most important, useful, and feasible in the Canadian context. Using the RAND/UCLA Appropriateness Method (RAM) multistage analytic approach, data from each panel and stakeholder group will be examined separately and compared to establish a key set of indicators endorsed by both panels., Results: The study is funded by the Canadian Institutes of Health Research and Physicians Services Incorporated., Conclusions: This study will produce quality indicators to evaluate and inform action equitably to improve transition from pediatric to adult care for youth and their families in Canada., International Registered Report Identifier (irrid): PRR1-10.2196/60860., (©Alene Toulany, Dmitry Khodyakov, Sarah Mooney, Lisa Stromquist, Katherine Bailey, Claire EH Barber, Michelle Batthish, Kristin Cleverley, Gina Dimitropoulos, Jan Willem Gorter, Danijela Grahovac, Ruth Grimes, Beverly Guttman, Michèle L Hébert, Tomisin John, Lisha Lo, Dorothy Luong, Laura MacGregor, Geetha Mukerji, Jacklynn Pidduck, Vjura Senthilnathan, Rayzel Shulman, Patricia Trbovich, Sarah EP Munce. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 10.09.2024.)

Background: Youth engagement refers to the collaboration between researchers and youth to produce research. Youth engagement in health research has been shown to inform effective interventions aimed at improving health outcomes. However, limited evidence has identified promising practices to meaningfully engage youth. This synthesis aims to describe youth engagement approaches, frameworks, and barriers, as well as provide both evidence-based and youth-generated recommendations for meaningful engagement., Main Body: This review occurred in two stages: 1) a narrative review of existing literature on youth engagement and 2) a Youth Advisory Council (YAC) to review and supplement findings with their perspectives, experiences, and recommendations. The terms 'youth engagement' and 'health research' were searched in Google Scholar, PubMed, Web of Science, Scopus, and PsycINFO. Articles and non-peer reviewed research works related to youth engagement in health research were included, reviewed, and summarized. The YAC met with research team members and in separate youth-only forums to complement the narrative review with their perspectives. Types of youth engagement include participation as research participants, advisors, partners, and co-investigators. Barriers to youth engagement were organized into youth- (e.g., time commitments), researcher- (e.g., attitudes towards youth engagement), organizational- (e.g., inadequate infrastructure to support youth engagement), and system-level (e.g., systemic discrimination and exclusion from research). To enhance youth engagement, recommendations focus on preparing and supporting youth by offering flexible communication approaches, mentorship opportunities, diverse and inclusive recruitment, and ensuring youth understand the commitment and benefits involved., Conclusions: To harness the potential of youth engagement, researchers need to establish an inclusive and enabling environment that fosters collaboration, trust, and valuable contributions from youth. Future research endeavors should prioritize investigating the dynamics of power-sharing between researchers and youth, assessing the impact of youth engagement on young participants, and youth-specific evaluation frameworks., (© 2024. Crown.)

Objective: Our objective was to characterize adolescent health and psychosocial issues in patients with childhood-onset systemic lupus erythematosus (cSLE) and evaluate demographic and disease characteristics associated with adolescent health., Methods: We retrospectively examined adolescents aged 12 to 18 years with cSLE seen at the Hospital for Sick Children meeting the American College of Rheumatology/Systemic Lupus International Collaborating Clinics classification criteria, assessed by adolescent medicine in the cSLE clinic between 2018 and 2020. Adolescent health issues were characterized using the Home, Education/Employment, Activities, Diet/Drugs, Sexuality, Suicide/mood (HEADDSS) framework. Issues were classified as presenting and/or identified; adolescent health burden was tabulated as the number of distinct adolescent issues per patient. Multiple Poisson regression models examined associations between patient and disease characteristics (age, sex, material deprivation, disease activity, disease damage, and high-dose glucocorticoid exposure) and adolescent health issues., Results: A total of 108 (60%) of 181 adolescents with cSLE were seen by adolescent medicine, with a median of 2 (interquartile range [IQR] 1-3) visits and a median of 2 (IQR 1-5) adolescent health issues during the study period. Common issues were mood (presenting in 21% vs identified in 50%), sleep (27% vs 2%), school and education (26% vs 1%), and nonadherence (23% vs 8%). Psychoeducation was provided by adolescent medicine to 54% of patients. High-dose glucocorticoids (risk ratio [RR] 1.82, 95% confidence interval [CI] 1.41-2.35, P < 0.001), material deprivation (RR 1.17, 95% CI 1.04-1.30, P = 0.007), and lower SLE Disease Activity Index scores (RR 0.95, 95% CI 0.92-0.98, P = 0.004) were associated with higher adolescent health burden., Conclusion: Adolescents with cSLE experience many adolescent issues, especially low mood. High-dose glucocorticoids and social marginalization are associated with greater adolescent health burden. This study highlights the importance of addressing adolescent health needs as part of routine care., (© 2024 American College of Rheumatology.)

Introduction: Patient engagement and integrated knowledge translation (iKT) processes improve health outcomes and care experiences through meaningful partnerships in consensus-building initiatives and research. Consensus-building is essential for engaging a diverse group of experienced knowledge users in co-developing and supporting a solution where none readily exists or is less optimal. Patients and caregivers provide invaluable insights for building consensus in decision-making around healthcare, policy and research. However, despite emerging evidence, patient engagement remains sparse within consensus-building initiatives. Specifically, our research has identified a lack of opportunity for youth living with chronic health conditions and their caregivers to participate in developing consensus on indicators/benchmarks for transition into adult care. To bridge this gap and inform our consensus-building approach with youth/caregivers, this scoping review will synthesise the extent of the literature on patient and other knowledge user engagement in consensus-building healthcare initiatives., Methods and Analysis: Following the scoping review methodology from Joanna Briggs Institute, published literature will be searched in MEDLINE, EMBASE, CINAHL and PsycINFO databases from inception to July 2023. Grey literature will be hand-searched. Two independent reviewers will determine the eligibility of articles in a two-stage process, with disagreements resolved by a third reviewer. Included studies must be consensus-building studies within the healthcare context that involve patient engagement strategies. Data from eligible studies will be extracted and charted on a standardised form. Abstracted data will be analysed quantitatively and descriptively, according to specific consensus methodologies, and patient engagement models and/or strategies., Ethics and Dissemination: Ethics approval is not required for this scoping review protocol. The review process and findings will be shared with and informed by relevant knowledge users. Dissemination of findings will also include peer-reviewed publications and conference presentations. The results will offer new insights for supporting patient engagement in consensus-building healthcare initiatives., Protocol Registration: https://osf.io/beqjr., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives: Coronavirus disease 2019 (COVID-19) posed a significant threat to adolescents' sexual and reproductive health. In this study, we examined population-level pregnancy and sexual health-related care utilization among adolescent females in Ontario, Canada during the pandemic and evaluated relationships between these outcomes and key sociodemographic characteristics., Methods: This was a population-based, repeated cross-sectional study of >630 000 female adolescents (12-19 years) during the prepandemic (January 1, 2018-February 29, 2020) and COVID-19 pandemic (March 1, 2020-December 31, 2022) periods. Primary outcome was pregnancy; secondary outcomes were contraceptive management visits, contraception prescription uptake, and sexually transmitted infection (STI) management visits. Poisson models with generalized estimating equations for clustered count data were used to model pre-COVID-19 trends and forecast expected rates during the COVID-19 period. Absolute rate differences between observed and expected outcome rates for each pandemic month were calculated overall and by urbanicity, neighborhood income, immigration status, and region., Results: During the pandemic, lower-than-expected population-level rates of adolescent pregnancy (rate ratio 0.87; 95% confidence interval [CI]:0.85-0.88), and encounters for contraceptive (rate ratio 0.82; 95% CI:0.77-0.88) and STI management (rate ratio 0.52; 95% CI:0.51-0.53) were observed. Encounter rates did not return to pre-pandemic rates by study period end, despite health system reopening. Pregnancy rates among adolescent subpopulations with the highest pre-pandemic pregnancy rates changed least during the pandemic., Conclusions: Population-level rates of adolescent pregnancy and sexual health-related care utilization were lower than expected during the COVID-19 pandemic, and below-expected care utilization rates persist. Pregnancy rates among more structurally vulnerable adolescents demonstrated less decline, suggesting exacerbation of preexisting inequities., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: Studies have highlighted significant challenges associated with the transition from pediatric to adult health and social care services for youth living with childhood-acquired disabilities and their caregivers. Patient navigation has been proposed as an effective transitional care intervention. Better understanding of how patient navigation may support youth and their families during pediatric to adult care transitions is warranted., Objective: This study aims to describe the preferred adaptations of an existing web-based platform from the perspectives of youth with childhood-onset disabilities and their family caregivers to develop a web-based peer-patient navigation program, Compassionate Online Navigation to Enhance Care Transitions (CONNECT)., Methods: A qualitative descriptive design was used. Participants included youth living with childhood-acquired disabilities (16/23, 70%) and their caregivers (7/23, 30%). Semistructured interviews and focus groups were conducted, digitally recorded, and transcribed. Thematic analysis was used to analyze the data and was facilitated through NVivo software (Lumivero)., Results: Participants desired a program that incorporated (1) self-directed learning, (2) a library of reliable health and community resources, and (3) emotional and social supports. On the basis of participants' feedback, CONNECT was deemed satisfactory, as it was believed that the program would help support appropriate transition care through the provision of trusted health-related information. Participants highlighted the need for options to optimize confidentiality in their health and social care and the choice to remain anonymous to other participants., Conclusions: Web-based patient navigation programs such as CONNECT may deliver peer support that can improve the quality and experience of care for youth, and their caregivers, transitioning from pediatric to adult care through personalized support, health care monitoring, and health and social care resources. Future studies are needed to test the feasibility, acceptability, usability, use, and effectiveness of CONNECT among youth with childhood-onset disabilities., (©Kristina Marie Kokorelias, Tin-Suet Joan Lee, Mark Bayley, Emily Seto, Alene Toulany, Michelle L A Nelson, Gina Dimitropoulos, Melanie Penner, Robert Simpson, Sarah E P Munce. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org), 07.02.2024.)

Importance: Understanding the evolving characteristics of pediatric patients hospitalized for eating disorders is important to ensure that services and treatments align with patient needs., Objective: To examine temporal trends in the rates of hospitalizations for pediatric eating disorders by clinical and demographic characteristics in Ontario, Canada, over a 17-year period., Design, Setting, and Participants: This population-based, repeated, cross-sectional study used linked health administrative and demographic databases in Ontario, Canada, to identify individuals aged 5 to 17 years hospitalized with eating disorder diagnoses from April 1, 2002, to March 31, 2020. Data analyses were performed from May 2021 to June 2023., Exposure: Fiscal year (April 1-March 31) of eating disorder hospitalization., Main Outcomes and Measures: Outcomes of interest were absolute and relative changes in pediatric eating disorder hospitalization rates overall and stratified by patient sex, age groups, and eating disorder diagnostic groups., Results: Over the study period, there were 11 654 pediatric eating disorder hospitalizations, of which 5268 (45.2%) were for anorexia nervosa and 1374 (11.8%) were for bulimia nervosa. There were a total of 10 648 hospitalizations (91.4%) among female patients, and the median (IQR) age was 15.0 (14-0-16.0) years. Hospitalization rates increased 139% from 2002 to 2019, from 2.0 per 10 000 population to 4.8 per 10 000 population. The largest relative changes were observed among male patients (416%; from 0.2 per 10 000 population to 1.1 per 10 000 population), individuals aged 12 to 14 years (196%; from 2.2 per 10 000 population to 6.6 per 10 000 population), and individuals with eating disorders other than anorexia or bulimia nervosa (255%; from 0.6 per 10 000 population to 2.1 per 10 000 population). Male patients, younger adolescents, and individuals with other eating disorders also represented larger proportions of hospitalizations by fiscal 2019., Conclusions and Relevance: In this cross-sectional study of eating disorder hospitalizations, pediatric hospitalizations increased over time, particularly among populations traditionally considered atypical. Existing eating disorder programs must adapt to accommodate changing patient presentations and increased volumes to ensure effective care delivery.

Objective: We sought to evaluate the relationship between social determinants of health and physician-based mental healthcare utilization and virtual care use among children and adolescents in Ontario, Canada, during the COVID-19 pandemic., Methods: This population-based repeated cross-sectional study of children and adolescents (3-17 years; N  = 2.5 million) used linked health and demographic administrative data in Ontario, Canada (2017-2021). Multivariable Poisson regressions with generalized estimating equations compared rates of outpatient physician-based mental healthcare use during the first year of the COVID-19 pandemic with expected rates based on pre-COVID patterns. Analyses were conducted by socioeconomic status (material deprivation quintiles of the Ontario Marginalization index), urban/rural region of residence, and immigration status., Results: Overall, pediatric physician-based mental healthcare visits were 5% lower than expected (rate ratio [RR] = 0.95, 95% confidence interval [CI], 0.92 to 0.98) among those living in the most deprived areas in the first year of the pandemic, compared with the least deprived with 4% higher than expected rates (RR = 1.04, 95% CI, 1.02 to 1.06). There were no differences in overall observed and expected visit rates by region of residence. Immigrants had 14% to 26% higher visit rates compared with expected from July 2020 to February 2021, whereas refugees had similarly observed and expected rates. Virtual care use was approximately 65% among refugees, compared with 70% for all strata., Conclusion: During the first year of the pandemic, pediatric physician-based mental healthcare utilization was higher among immigrants and lower than expected among those with lower socioeconomic status. Refugees had the lowest use of virtual care. Further work is needed to understand whether these differences reflect issues in access to care or the need to help inform ongoing pandemic recovery planning., Competing Interests: Declaration of Conflicts of InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: N. Saunders reported receiving personal fees from the Archives of Diseases in Childhood, grants from the Canadian Institutes for Health Research and the Ontario Ministry of Health, grants from the Centre for Addiction and Mental Health, and grants from The Hospital for Sick Children outside the submitted work. S. Vigod reported receiving royalties from UpToDate Inc. for authorship of materials related to depression and pregnancy unrelated to the submitted work. No other disclosures were reported.

Objective: To assess physician-based mental health care utilization during the COVID-19 pandemic among children and adolescents new to care and those already engaged with mental health services, and to evaluate differences by sociodemographic factors., Study Design: We performed a population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada among all children and adolescents 3-17 years. We examined outpatient visit rates per 1,000 population for mental health concerns for those new to care (no physician-based mental healthcare for ≥1 year) and those with continuing care needs (any physician-based mental healthcare <1 year) following onset of the pandemic., Results: Among ~2.5 million children and adolescents (48.7% female, mean age 10.1 ± 4.3 years), expected monthly mental health outpatient visits were 1.5/1,000 for those new to mental health care and 5.4/1,000 for those already engaged in care. Following onset of the pandemic, visit rates for both groups were above expected [adjusted rate ratio (aRR) 1.22, 95% CI 1.17, 1.27; aRR 1.10, 95% CI 1.07, 1.12] for new and continuing care, respectively. The greatest increase above expected was among females (new: aRR 1.33, 95% CI 1.25, 1.42; continuing: aRR 1.22 95% CI 1.17, 1.26) and adolescents ages 13-17 years (new: aRR 1.31, 95% CI 1.27, 1.34; continuing: aRR 1.15 95% CI 1.13, 1.17). Mood and anxiety concerns were prominent among those new to care., Conclusion: In the 18 months following onset of the pandemic, outpatient mental health care utilization increased for those with new and continuing care needs, especially among females and adolescents., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Toulany, Vigod, Kurdyak, Stukel, Strauss, Fu, Guttmann, Guan, Cohen, Chiu, Hepburn, Moran, Gardner, Cappelli, Sundar and Saunders.)

Background: Increased rates of pediatric eating disorders have been observed during the COVID-19 pandemic, but little is known about trends among adults. We aimed to evaluate rates of emergency department visits and hospital admissions for eating disorders among adolescents and adults during the pandemic., Methods: We conducted a population-based, repeated cross-sectional study using linked health administrative data for Ontario residents aged 10-105 years during the prepandemic (Jan. 1, 2017, to Feb. 29, 2020) and pandemic (Mar. 1, 2020, to Aug. 31, 2022) periods. We evaluated monthly rates of emergency department visits and hospital admissions for eating disorders, stratified by age., Results: Compared with expected rates derived from the prepandemic period, emergency department visits for eating disorders increased during the pandemic among adolescents aged 10-17 years (7.38 v. 3.33 per 100 000; incidence rate ratio [IRR] 2.21, 95% confidence interval [CI] 2.17-2.26), young adults aged 18-26 years (2.79 v. 2.46 per 100 000; IRR 1.13, 95% CI 1.10-1.16) and older adults aged 41-105 years (0.14 v. 0.11 per 100 000; IRR 1.15, 95% CI 1.07-1.24). Hospital admissions for eating disorders increased during the pandemic for adolescents (8.82 v. 5.74 per 100 000; IRR 1.54, 95% CI 1.54-1.54) but decreased for all adult age groups, especially older adults aged 41-105 years (0.21 v. 0.30 per 100 000; IRR 0.72, 95% CI 0.64-0.80)., Interpretation: Emergency department visits for eating disorders increased among adolescents, young adults and older adults during the pandemic, but hospital admissions increased only for adolescents and decreased for all adult groups. Differential rates of acute care use for eating disorders by age have important implications for allocation of inpatient mental health resources., Competing Interests: Competing interests: Natasha Saunders reports receiving personal fees from The BMJ Group’s Archives of Diseases in Childhood and grants from the Canadian Institutes of Health Research (CIHR), the Ontario Ministry of Health, the Centre for Addiction and Mental Health and The Hospital for Sick Children. Astrid Guttmann reports funding from CIHR. No other competing interests were reported., (© 2023 CMA Impact Inc. or its licensors.)

Purpose: To measure trends in the rates and costs of hospitalizations over a 15-year period among young adults with physical and/or psychiatric disorders., Methods: This population-based, repeated cross-sectional study identified all 18- to 26- year-olds hospitalized in Ontario, Canada from April 1, 2003 and March 31, 2018 (fiscal years 2003-2017). Using discharge diagnoses, we assigned hospitalizations to one of four categories: 1) psychiatric disorder only; 2) primary psychiatric disorder with comorbid physical illness; 3) primary physical with comorbid psychiatric disorder; and 4) physical illness only. We compared health service utilization and changes in rates of hospitalizations over time using restricted cubic spline regression. Secondary outcome measures included change in hospital costs for each hospitalization category over the study period., Results: Of 1,076,951 hospitalizations in young adults (73.7% female), 195,726 (18.2%) had a psychiatric disorder (either primary or comorbid). There were 129,676 hospitalizations (12.0%) with psychiatric disorders only, 36,287 (3.4%) with primary psychiatric and comorbid physical disorders, 29,763 (2.8%) with primary physical and comorbid psychiatric disorders, and 881,225 (81.8%) with physical disorders only. Rates of hospitalization for psychiatric disorders only increased 81% from 4.32 to 7.84/1,000 population, and those with physical health disorders with comorbid psychiatric disorders increased 172% from 0.47 to 1.28/1,000 population. Substance-related disorders were the most common comorbid psychiatric disorders among youth hospitalized for physical illness and increased 260% from 0.9 to 3.3/1,000 population., Discussion: Hospitalizations among young adults with primary and comorbid psychiatric disorders have increased significantly over the past 15 years. Health system resources should be adequately directed to meet the shifting and complex needs of hospitalized young adults., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Youth have reported worsening mental health during the COVID-19 pandemic. We sought to evaluate rates of pediatric acute care visits for self-harm during the pandemic according to age, sex and mental health service use., Methods: We conducted a population-based, repeated cross-sectional study using linked health administrative data sets to measure monthly rates of emergency department visits and hospital admissions for self-harm among youth aged 10-17 years between Jan. 1, 2017, and June 30, 2022, in Ontario, Canada. We modelled expected rates of acute care visits for self-harm after the pandemic onset based on prepandemic rates. We reported relative differences between observed and expected monthly rates overall and by age group (10-13 yr and 14-17 yr), sex and mental health service use (new and continuing)., Results: In this population of about 1.3 million children and adolescents, rates of acute care visits for self-harm during the pandemic were higher than expected for emergency department visits (0.27/1000 population v. 0.21/1000 population; adjusted rate ratio [RR] 1.29, 95% confidence interval [CI] 1.19-1.39) and hospital admissions (0.74/10 000 population v. 0.43/10 000 population, adjusted RR 1.72, 95% CI 1.46-2.03). This increase was primarily observed among females. Rates of emergency department visits and hospital admissions for self-harm were higher than expected for both those aged 10-13 years and those aged 14-17 years, as well as for both those new to the mental health system and those already engaged in care., Interpretation: Rates of acute care visits for self-harm among children and adolescents were higher than expected during the first 2 and a half years of the COVID-19 pandemic, particularly among females. These findings support the need for accessible and intensive prevention efforts and mental health supports in this population., Competing Interests: Competing interests: Rachel Mitchell reports receiving grants from the American Foundation for Suicide Prevention, the TD Pooler Fund and the Sunnybrook Foundation, as well as an Academic Scholar Award from the Department of Psychiatry at Sunnybrook Health Sciences Centre and the University of Toronto and an honourarium from Medscape. Eyal Cohen is a member of the Committee to Evaluate Drugs. Rachel Strauss reports consulting fees from Canadian Doctors for Prevention from Guns. Simone Vigod reports receiving authorship royalties from UpToDate. Kimberly Moran receives salary support from the Ontario College of Family Physicians. Astrid Guttmann reports receiving grants from the Canadian Institutes for Health Research. Paul Kurdyak is Vice President, Clinical at the Mental Health and Addictions Centre of Excellence at Ontario Health. Natasha Saunders reports receiving grants from the Canadian Institutes for Health Research, the Ontario Ministry of Health, the Centre for Addiction and Mental Health and The Hospital for Sick Children, as well as personal fees from the BMJ Group for her role as associate editor for the Archives of Diseases in Childhood. She is a member of the Canadian Paediatric Society Mental Health and Developmental Disabilities committee. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Objective: To examine physician factors associated with practice-level uptake of virtual mental healthcare for children and adolescents., Design, Setting and Participants: A population-based data linkage study of a cohort of all physicians (n=12 054) providing outpatient mental healthcare to children and adolescents (aged 3-17 years, n=303 185) in a single-payer provincial health system in Ontario, Canada from 1 July 2020 to 31 July 2021., Exposures: Physician characteristics including gender, age, specialty, location of training, practice region, practice size and overall and mental health practice size., Main Outcomes: Practice-level proportion of outpatient virtual care provided: (1) mostly in-person (<25% virtual care), (2) hybrid (25%-99% virtual care) or (3) exclusively virtual (100% virtual care). Multinomial logistic regression models tested the association between practice-level virtual care provided and physician characteristics., Results: Among physicians, 1589 (13.2%) provided mostly in-person mental healthcare with 8714 (67.8%) providing hybrid care, and 2291 (19.0%) providing exclusively virtual care. The provision of exclusive virtual care (vs mostly in-person) was associated with female sex (adjusted OR (aOR) 1.97, 95% CI 1.70 to 2.27 (ref: male)), foreign training (aOR 1.27, 95% CI 1.07 to 1.50 (ref: Canadian-trained)), family physicians (aOR 2.05, 95% CI 1.56 to 2.69 (ref: psychiatrist)) and reversely associated with large practice size (aOR 0.32, 95% CI 0.25 to 0.40 (ref smallest quintile)). Mostly in-person care was associated with older age physicians (71+ years) and practice outside the Toronto region., Conclusions and Relevance: In a single-payer universal healthcare system that remunerates physicians using the same fee structure for in-person and virtual outpatient care, there is heterogeneity in utilisation of virtual care that is associated with provider factors. This practice variation, with limited evidence on effectiveness and appropriate contexts for virtual care use, suggests there may be opportunity for further outcomes research and guidance on appropriate context for paediatric virtual mental healthcare delivery., Competing Interests: Competing interests: NRS reported receiving personal fees from the Archives of Diseases in Childhood, grants from the Canadian Institutes for Health Research and the Ontario Ministry of Health, grants from the Centre for Addiction and Mental Health and grants from The Hospital for Sick Children outside the submitted work. SV reported receiving royalties from UpToDate for authorship of materials related to depression and pregnancy outside the submitted work. No other disclosures were reported., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This research examined longitudinal associations between youth physical-mental multimorbidity and psychological distress before and during the COVID-19 pandemic; assessed the contextual impact of the pandemic on these associations; and, investigated potential moderating factors. The Multimorbidity in Youth across the Life-course, an ongoing study of youth aged 2-16 years (mean 9.4; 46.9% female) with physical illness, was used as the sampling frame for this COVID-19 sub-study, in which 147 parent-youth dyads participated. Psychological distress was measured using the Kessler-6 (K6). Multimorbidity was associated with higher pre-pandemic, but not with intra-pandemic distress. Disability moderated pre-pandemic distress-multimorbidity was associated with higher K6 among youth with high disability, but not among youth with low disability. Age moderated intra-pandemic distress-multimorbidity was associated with higher K6 in older youth, but not among younger youth., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

A hallmark of delivering quality adolescent health care services is the provision of confidential care. Key tenets when providing confidential care for adolescents include time alone with a health care provider, maintaining the privacy of health information, and securing informed consent for services without permission from a parent, guardian, or caregiver. While confidentiality is a basic principle for all health care encounters regardless of age, the unique considerations for capable adolescent patients are not always realized or appreciated. By ensuring appropriate quantity and quality of confidential care for adolescents, clinicians are better equipped to elicit a comprehensive history and physical examination, while empowering the adolescent involved to develop agency, autonomy, trust, and responsibility for their own health care decision-making and management., Competing Interests: All authors: No reported conflicts of interest., (© Canadian Paediatric Society 2023. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: We developed a multicomponent, family-based intervention for young children with obesity consisting of parent group sessions, home nursing visits, and multidisciplinary clinical encounters. Our objective was to assess intervention feasibility, acceptability, and implementation. Methods: From 2017 to 2020, we conducted a multiple methods study in the obesity management clinic at a tertiary children's hospital (Toronto, Canada). We included 1-6 year olds with a body mass index ≥97th percentile and their parents; we also included health care providers (HCPs) who delivered the intervention. To assess feasibility, we performed a pilot randomized controlled trial (RCT) comparing the intervention to usual care. To explore acceptability, we conducted parent focus groups. To explore implementation, we examined contextual factors with HCPs using the Consolidated Framework for Implementation Research. Results: There was a high level of ineligibility ( n  = 34/61) for the pilot RCT. Over 21 months, 11 parent-child dyads were recruited; of 6 randomized to the intervention, 3 did not participate in group sessions or home visits. In focus groups, themes identified by parents ( n  = 8) related to information provided at referral; fit between the intervention and patient needs; parental gains from participating in the intervention; and feasibility of group sessions. HCPs ( n  = 10) identified contextual factors that were positively and negatively associated with intervention implementation. Conclusions: We encountered challenges related to intervention feasibility, acceptability, and implementation. Lessons learned from this study will inform the next iteration of our intervention and are relevant to intervention development and implementation for young children with obesity. Clinical Trial Registration number: NCT03219658.

Youth with complex health care needs, defined as those requiring specialized health care and services for physical, developmental, and/or mental health conditions, are often cared for by paediatricians and paediatric specialists. In Canada, the age at which provincial/territorial funders mandate the transfer of paediatric care to adult services varies, ranging between 16 and 19 years. The current configuration of distinct paediatric and adult care service boundaries is fragmentary, raising barriers to continuity of care during an already vulnerable developmental period. For youth, the lack of care integration across sectors can negatively impact health engagement and jeopardize health outcomes into adulthood. To address these barriers and improve transition outcomes, paediatric and adult care providers, as well as family physicians and other community partners, must collaborate in meaningful ways to develop system-based strategies that streamline and safeguard care for youth transitioning to adult services across tertiary, community, and primary care settings. Flexible age cut-offs for transfer to adult care are recommended, along with considering each youth's developmental stage and capacity as well as patient and family needs and circumstances. Specialized training and education in transitional care issues are needed to build capacity and ensure that health care providers across diverse disciplines and settings are better equipped to accept and care for young people with complex health care needs., (© Canadian Paediatric Society 2022. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Les jeunes qui ont des besoins de santé complexes, définis comme ceux qui nécessitent des soins et services spécialisés en raison d'affections physiques, développementales ou mentales, sont souvent traités par des pédiatres et autres spécialistes en pédiatrie. Au Canada, l'âge auquel les bailleurs de fonds provinciaux et territoriaux exigent le transfert des soins pédiatriques aux soins pour adultes varie entre 16 et 19 ans. La délimitation actuelle entre les services de santé pédiatriques et aux adultes est fragmentaire, ce qui entrave la continuité des soins pendant une période déjà vulnérable du développement. Le peu d'intégration des soins entre les domaines peut nuire à l'engagement des jeunes en matière de santé et compromettre leur santé à l'âge adulte. Pour renverser ces obstacles et améliorer les résultats de la transition, les dispensateurs de soins pédiatriques et de soins aux adultes, de même que les médecins de famille et d'autres partenaires communautaires, doivent collaborer de manière satisfaisante à l'élaboration de stratégies systémiques qui rationalisent et préservent les soins aux jeunes en transition vers des soins aux adultes en milieu tertiaire, communautaire et primaire. Il est recommandé de privilégier des limites d'âge flexibles pour effectuer cette transition vers les soins aux adultes et de tenir compte de la phase de développement et de l'aptitude de chaque jeune, ainsi que des besoins et de la situation de chaque patient et de chaque famille. Une formation et un enseignement spécialisés sur les enjeux liés aux soins de transition s'imposent pour renforcer les capacités et s'assurer que les professionnels de la santé des diverses disciplines et des divers milieux soient mieux outillés pour accepter et traiter les jeunes qui ont des besoins de santé complexes., (© Société canadienne de pédiatrie 2022. Publié par Oxford University Press pour le compte de la Société canadienne de pédiatrie. Tous droits réservés. Pour obtenir une autorisation, écrivez à journals.permissions@oup.com.)

Background and Objective: Transition from pediatric to adult care is associated with adverse health outcomes for many adolescents with chronic illness. We identified quality indicators for transition to adult care that are broadly applicable across chronic illnesses and health systems., Methods: Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature were searched, covering earliest available date to July 2021. The Gray Matters framework was used to search gray literature. Two independent reviewers screened articles by title and abstract, followed by full-text review. Disagreements were resolved by a third reviewer. Studies were included that identified quality indicators developed via consensus-building methods. Indicators were organized into a framework categorized by illness specificity, level of care, Donabedian model, and Institute of Medicine quality domain. Appraisal of Guidelines for Research and Evaluation tool was used for critical appraisal., Results: The search identified 4581 articles, of which 321 underwent full-text review. Eight peer-reviewed studies and 1 clinical guideline were included, identifying 169 quality indicators for transition. Of these, 56% were illness specific, 43% were at the patient level of care, 44% related to transition processes, and 51% were patient centered and 0% equity focused. Common indicator themes included education (12%), continuity of care (8%), satisfaction (8%), and self-management/self-efficacy (7%). The study was limited by quality indicators developed through consensus-building methodology., Conclusions: Although most quality indicators for transition were patient-centered outcomes, few were informed by youth and parents/caregivers, and none focused on equity. Further work is needed to prioritize quality indicators across chronic illness populations while engaging youth and parents/caregivers in the process.

Objective: To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization., Method: Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1-18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization., Results: In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P  < 0.001)] or hospitalizations [10.2% pre vs. 8.7% post (test statistic 11.96, P  < 0.001)] declined in the year following tele-mental health consultation, while local psychiatry visits increased [8.4% pre vs. 17.0% post (test statistic 298.69, P  < 0.001)]. In the second cohort ( n  = 84,033), only 1.5% received tele-mental health services, 40.7% saw a psychiatrist in-person, and 32.5% received no MHA-related outpatient care in follow-up., Conclusions: Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

Objectives: With the increased prevalence of childhood-onset inflammatory bowel disease (IBD), there is a greater need for a planned transition process for adolescents and young adults (AYA). The Canadian IBD Transition Network and Crohn's and Colitis Canada joined in collaborative efforts to describe a set of care consensus statements to provide a framework for transitioning AYA from pediatric to adult care., Methods: Consensus statements were drafted after focus group meetings and literature reviews. An expert panel consisting of 20 IBD physicians, nurses, surgeon, adolescent medicine physician, as well as patient and caregiver representatives met, discussed and systematically voted. The consensus was reached when greater than 75% of members voted in agreement. When greater than 75% of members rated strong support, the statement was rendered a strong recommendation, suggesting that a clinician should implement the statement for all or most of their clinical practice., Results: The Canadian expert panel generated 15 consensus statements (9 strong and 6 weak recommendations). Areas of focus of the statements included: transition program implementation, key stakeholders, areas of potential need and gaps in the research., Conclusions: These consensus statements provide a framework for the transition process. The quality of evidence for these statements was generally low, highlighting the need for further controlled studies to investigate and better define effective strategies for transition in pediatric to adult IBD care., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.)

Purpose: Anecdotal reports suggest a significant increase in acute presentations of eating disorders among children and adolescents. Our objective was to compare the rates of emergency department visits and hospitalizations for pediatric eating disorders before and during the first 10 months of the COVID-19 pandemic., Methods: Using linked health administrative databases, we conducted a population-based repeated cross-sectional study of emergency department visits and hospitalizations for eating disorders among all children and adolescents aged 3-17 years, residing in Ontario, Canada. We defined the pre-COVID period from January 1, 2017, to February 29, 2020, and the post-COVID period from March 1, 2020, to December 26, 2020. Poisson generalized estimating equations were used to model 3-year pre-COVID trends to predict expected post-COVID trends and estimate the relative change from expected rates., Results: In our population of almost 2.5 million children and adolescents, acute care visits for eating disorders increased immediately after the onset of the pandemic, reaching a 4-week peak annualized rate of 34.6 (emergency department visits) and 43.2 per 100,000 population (hospitalizations) in October 2020. Overall, we observed a 66% (adjusted relative rate: 1.66, 95% confidence interval: 1.41-1.96) and 37% (adjusted relative rate: 1.37, 95% confidence interval: 1.25-1.50) increase in risk for emergency department visit and hospitalization, respectively., Conclusions: Acute care visits for pediatric eating disorders increased significantly in Ontario after the onset of COVID-19 pandemic and remained well above expected levels during the first 10 months of the pandemic. Further research is needed to understand the social and neurobiological mechanisms underlying the observed changes in health system utilization., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Adolescents with severe obesity and comorbid mental health issues are the most resistant to traditional weight management approaches and have poor treatment outcomes. Our objective was to implement and evaluate a pilot day hospital treatment program for adolescents with severe obesity, or risk for severe obesity, and significant mental health comorbidities. Methods: This was a prospective cohort study of adolescents 12-18 years of age with severe obesity (BMI >99th percentile), or at risk for severe obesity, and comorbid mental health issues. The intervention, focused on healthy lifestyle and mental health support, was implemented within an existing psychiatric day hospital at a pediatric quaternary care hospital. Anthropometric and mental health measures were analyzed pre- and postintervention. Results: Thirty-two adolescents with a mean age of 14.9 years [standard deviation (SD) 1.6] participated in the pilot integrative day hospital program for a mean duration of 5.2 months (SD 2.3). Eleven participants had primary severe obesity and comorbid mental health conditions (obesity subgroup) and 21 participants had primary mental illness and were at risk for obesity (psychiatry subgroup). We did not observe a significant difference between BMI pre- and postprogram among adolescents in both subgroups. In other words, adolescents in both subgroups achieved weight maintenance. Fear in losing control of overeating and/or being seen by others when eating decreased significantly in the obesity subgroup [mean difference (MD) 0.99; 95% confidence interval (CI): 0.27 to 1.71]. There was a significant decrease in participant-reported depression symptom severity, both overall and within program subgroups. Quality-of-life scores of study participants improved significantly within the obesity subgroup (MD -12.31; 95% CI: -21.69 to -2.93), but not within the psychiatry subgroup (MD -6.35; 95% CI: -13.37 to 0.67). Conclusions and Implications: A day hospital model of care may result in weight maintenance, decreased eating concerns, and improved mental health in adolescents with severe obesity or risk for severe obesity, and significant mental health comorbidities.

Introduction: Bariatric surgery, an established weight-loss tool, may be offered to some adolescents with severe obesity. However, few studies explore adolescents' postoperative experiences beyond physical and metabolic outcomes and quality-of-life measures., Methods: Between 2016 and 2021, 45 semi-structured interviews were conducted with adolescents (16-20 years) at 6 months (N = 15), 12 months (N = 15), and 24 months (N = 15) following bariatric surgery. A deductive thematic analysis framework was applied by two independent coders (Cronbach's α = 0.84). Themes were identified and refined iteratively, and discrepancies were resolved through discussion., Results: Five major themes emerged related to: (1) weight-loss expectations vs. reality, (2) social landscape, (3) body image, (4) eating and moving, and (5) challenges for long-term success. The pace of and satisfaction with weight loss and side effects was heterogenous among participants, with most changes occurring early and stabilizing by 24 months. Adolescents adapted over time to their new social landscapes (e.g., relationships) and reported improved body image and confidence, yet persistently struggled to reconcile their internal identity with evolving external perceptions and discomfort with new attention. Participants experienced changes to lifestyle routines after surgery (e.g., eating, moving, habits), which introduced distress at 6 months but resolved over time. Life transitions in early adulthood (e.g., moving away, university/college, employment), concurrent with their evolving and increasing autonomy, physical, social, and financial independence, imposed unexpected challenges to postoperative routines and support systems. Participants unanimously reaffirmed that bariatric surgery is a lifelong journey and that they were committed to long-term success., Conclusion: Our findings provide insight into optimizing adolescent selection for bariatric surgery and perioperative support. Specifically, important life transitions during this developmental period impact postoperative experiences and outcomes and adolescents may benefit from postoperative counseling focused on managing weight-loss expectations and adapting to evolving nutritional needs and changing social circumstances., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: The extent to which heightened distress during the COVID-19 pandemic translated to increases in severe mental health outcomes is unknown. We examined trends in psychiatric presentations to acute care settings in the first 12 months after onset of the pandemic., Methods: This was a trends analysis of administrative population data in Ontario, Canada. We examined rates of hospitalizations and emergency department visits for mental health diagnoses overall and stratified by sex, age and diagnostic grouping (e.g., mood disorders, anxiety disorders, psychotic disorders), as well as visits for intentional self-injury for people aged 10 to 105 years, from January 2019 to March 2021. We used Joinpoint regression to identify significant inflection points after the onset of the pandemic in March 2020., Results: Among the 12 968 100 people included in our analysis, rates of mental health-related hospitalizations and emergency department visits declined immediately after the onset of the pandemic (peak overall decline of 30% [hospitalizations] and 37% [emergency department visits] compared to April 2019) and returned to near prepandemic levels by March 2021. Compared to April 2019, visits for intentional self-injury declined by 33% and remained below prepandemic levels until March 2021. We observed the largest declines in service use among adolescents aged 14 to 17 years (55% decline in hospitalizations, 58% decline in emergency department visits) and 10 to 13 years (56% decline in self-injury), and for those with substance-related disorders (33% decline in emergency department visits) and anxiety disorders (61% decline in hospitalizations)., Interpretation: Contrary to expectations, the abrupt decline in acute mental health service use immediately after the onset of the pandemic and the return to near prepandemic levels that we observed suggest that changes and stressors in the first 12 months of the pandemic did not translate to increased service use. Continued surveillance of acute mental health service use is warranted., Competing Interests: Competing interests: Natasha Saunders reports receiving an editorial honorarium from Archives of Diseases in Childhood and an honorarium from the M.S.I. Foundation, outside the submitted work. Simone Vigod reports receiving royalties from Up To Date, outside the submitted work., (© 2021 CMA Joule Inc. or its licensors.)

Introduction: Transition from paediatric to adult care is a complex process, which poses significant challenges for adolescents with chronic physical and mental illnesses. For many, transfer to adult care is associated with poor health and psychosocial outcomes. Quality indicators to evaluate transition to adult care are needed to benchmark and compare performance across conditions and health systems. This systematic review aims to identify quality indicators for successful transition to adult care which can be applied across chronic physical and/or mental illnesses., Methods: Published literature will be searched using MEDLINE, Embase and CINHAL from earliest available date to July 2021. Grey literature will be searched using the Grey Matters tool. Using a set of inclusion/exclusion criteria, two independent reviewers will screen titles and abstracts, followed by full-text review. Disagreements will be resolved by a third reviewer. Study selection and data extraction will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Study appraisal will be completed using the Appraisal of Guidelines for Research and Evaluation for Quality Indicators instrument. Extracted quality indicators will be categorised into a conceptual framework., Ethics and Dissemination: Results from this review will offer novel insights into quality indicators that may be used to measure and evaluate transition success across conditions, which will be disseminated via a Canadian transition collaborative, workshops and peer-reviewed publication. Extracted quality indicators will be further prioritised in a Delphi study with patients, caregivers and providers. This is a critical step in developing a core set of metrics to evaluate transitions to adult care. Ethics approval is not required as this review will identify and synthesise findings from published literature., Prospero Registration Number: CRD42020198030., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Transitional care interventions have the potential to optimize continuity of care, improve health outcomes and enhance quality of life for adolescents and young adults living with chronic childhood-onset disabilities, including neurodevelopmental disorders, as they transition to adult health and social care services. The paucity of research in this area poses challenges in identifying and implementing interventions for research, evaluation and implementation. The purpose of this project was to advance this research agenda by identifying the transitional care interventions from the scientific literature and prioritize interventions for study. A modified-Delphi approach involving two rounds of online surveys followed by a face-to-face consensus meeting with knowledge users, researchers and clinician experts in transitional care (n = 19) was used. A subsequent virtual meeting concluded the formulation of next steps. Experts rated 16 categories of interventions, derived from a systematic review, on importance, impact, and feasibility. Seven of the 16 interventions categories received a mean score rating of ≥7 (out of 10) on all three rating categories. Participants then rank ordered the reduced list of seven interventions in order of priority and the top four ranked interventions advanced for further discussion at a consensus meeting. Using the Template for Intervention Description and Replication (TIDieR) checklist as a guide, the participants identified that a study of a peer system navigator was worthy of future evaluation. This study highlighted that transitional care interventions are complex and multifaceted. However, the presence of a peer to support system navigation, advocacy and individual and family education was considered the most ideal intervention addressing the current gap in care. Future research, which aims to engage patients and families in a co-design approach, is recommended to further develop this intervention., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Duncan, Luong, Perrier, Bayley, Andrew, Arbour-Nicitopoulos, Chan, Curran, Dimitropoulos, Hartman, Huang, Kastner, Kingsnorth, McCormick, Nelson, Nicholas, Penner, Thompson, Toulany, Woo, Zee and Munce.)

Length of stay (LOS) is an important issue for many healthcare organizations. In-patients with extreme LOS account for a disproportionately large percentage of hospital costs. Our analysis of over 15,000 pediatric hospital discharges at The Hospital for Sick Children (Toronto, Canada) between 2015 and 2016 revealed that the vast majority of patients with extreme LOS were discharged directly home, with only a minority receiving home-based services. Patients with the greatest LOS were accounted for by primarily four subspecialty services. Although this report outlines an analysis of pediatric in-patients, our findings and implications are relevant for all jurisdictions and populations as many acute care hospitals often "hold" patients with complex, chronic illness as in-patients for extended periods because alternate appropriate services may not exist or be available. Our case study highlights three key areas to improve quality of care for patients with extreme LOS: alternate levels of care, system resources and transitions to home., (Copyright © 2020 Longwoods Publishing.)

Introduction: Positive airway therapy (PAP) adherence rates are suboptimal among adolescents with obstructive sleep apnea (OSA) and strategies to increase PAP adherence is a clinical priority. This study evaluates if caregiver support is associated with PAP adherence rates among adolescents with OSA., Methods: We conducted a retrospective study and evaluated PAP adherence rates among adolescents with OSA from 2012 to 2017. Adherence was measured as continuous variables: average PAP usage (minutes per night) and average PAP usage >4 hours/night (% of all nights). We evaluated if adolescents with OSA who were receiving practical caregiver support with PAP had higher adherence than adolescents with OSA without caregiver support., Results: One hundred and seven adolescents with OSA (mean age=14.1±2.5 years, 64.5% male, mean BMI percentile=89.0±21.8) seen between January 2012 and August 2017 at our institution were included. In this study, 60.7% (n=65) of adolescents with OSA were receiving practical caregiver support with PAP therapy. Adolescents with OSA receiving practical caregiver support with PAP used therapy for a significantly greater duration each night compared to adolescents who were not receiving practical caregiver support (298.5±206.7 versus 211.9±187.2 minutes; P=0.02). Greater time since the initial PAP prescription was independently associated with PAP adherence., Conclusion: Focusing on PAP adherence early may help adolescents with OSA incorporate therapy into their nightly routine, which may improve adherence and lead to improved health outcomes in adolescents with OSA. Practical caregiver support may be an essential component of ensuring optimal PAP adherence among adolescents with OSA., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Evidence suggests that metabolic adaptation occurs after bariatric surgery such that resting energy expenditure (REE) declines more than accounted for by body weight or body composition changes in adults. Little is known about REE and metabolic adaptation among adolescents after bariatric surgery., Objective: To examine changes in REE and metabolic adaptation among adolescents at 12 months (12M) after bariatric surgery., Setting: Pediatric hospital, Canada., Methods: Adolescents undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were followed. Bioelectrical impedance analysis and indirect calorimetry were completed to measure body composition and REE, respectively. Predicted REE was calculated using the Mifflin equation before and after bariatric surgery and a predictive equation using preoperative data., Results: Among 20 patients (15 girls), the mean age and body mass index at surgery were 17.2 ± 0.8 years and 48.7 ± 7.4 kg/m2, respectively. REE had decreased by 548.3 kcal/d at 12M postoperatively (P < 0.001). Metabolic adaptation, determined by two procedures, was negative and significantly different from baseline (P < 0.05). When stratified by surgery type, REE change at 12M was not significantly different (RYGB, -494.0 ± 260.9 kcal/d, n = 11; SG, -614.6 ± 344.4 kcal/d, n = 9; P = 0.384). Among 13 patients with REE data at 6 and 12M, no statistically significant difference was found (P = 0.368)., Conclusions: Predicted and measured REE was 19% and 25% lower at 12M, respectively, irrespective of bariatric surgery type. Metabolic adaptation might predispose adolescents to weight regain after bariatric surgery and warrants careful nutritional management and counseling., (Copyright © 2019 Endocrine Society.)

Background: Paediatric obesity management remains generalised to dietary and exercise modifications with an underappreciation for the contributions of eating behaviours and appetitive traits in the development of obesity., Objectives: To determine whether treatment-seeking children and adolescents with obesity cluster into phenotypes based on known eating behaviours and appetitive traits ("eating correlates") and how socio-demographic and clinical characteristics associate with different phenotypes., Methods: A cross-sectional, multi-centre questionnaire was administered between November 2015 and March 2017 examining correlates of eating in children and adolescents attending weight-management programmes in Canada. Latent profile analysis was used to cluster participants based on seven eating correlate scores obtained from questionnaires. Analysis of variance (ANOVA) was used to determine phenotype differences on socio-demographic and clinical characteristics. Multinomial logistic regression models assessed relative risk of specific characteristics associating with a disordered eating phenotype., Results: Participants were 247 children and adolescents (45.3% male, mean BMI z-score = 3.4 ± 1.0 kg/m 2 ) from six paediatric weight management centres in Canada. Seven eating correlates clustered into three distinct phenotypes: (1) loss of control eating, emotional eating, external eating, hyperphagia, impulsivity ("Mixed-Severe"; n = 42, 17%), (2) loss of control eating, emotional eating, external eating, hyperphagia ("Mixed-Moderate"; n = 138, 55.9%), and (3) impulsivity ("Impulsive"; n = 67; 27.1%). Social functioning scores and body esteem were significantly different across groups, with the Mixed-Severe participants having the poorest social functioning and lowest body esteem. Low body esteem indicated a greater risk of being in a multi-correlate group compared to the Impulsive group, while poor social function had a greater risk of clustering in the Mixed-Severe than Impulsive phenotype., Conclusions: Distinct eating phenotypes were found in treatment-seeking children and adolescents with obesity. Empirical evidence is needed, but these data suggest that tailored treatment approaches could be informed by these classifications to improve weight-management outcomes.

Purpose: An interdisciplinary obesity management program was established in 2007 at our quaternary hospital, including bariatric surgery for selected adolescent patients. We report the evolution of surgical management within the program and outcomes following bariatric surgery., Methods: This was a retrospective review of adolescents who underwent bariatric surgery between 2007 and 2017. All cases were performed by a pediatric surgeon and an adult bariatric surgeon. Baseline demographics, BMI, co-morbidities, and post-operative outcomes were recorded., Results: Thirty-eight patients underwent bariatric surgery. Median age at entrance into the program was 16.5 (range, 12.1-17.4) years and at time of surgery was 17.4 (range, 13.6-18.8) years. Eight patients had laparoscopic adjustable gastric banding (LAGB) from 2007 to 10. Between 2011 and 2017, 18 had laparoscopic sleeve gastrectomy (LSG), and 12 had laparoscopic Roux-en-Y gastric bypass (RYGB). There were no intraoperative complications or conversions. Postoperative complications included wound infection, bleeding requiring transfusion and re-exploration, and internal hernia. Of patients who had LAGB, 2 required surgical revision, and 3 underwent subsequent removal., Conclusions: Adolescent bariatric surgery in the context of a multidisciplinary obesity management program is safe and effective. RYGB and sleeve gastrectomy are associated with superior weight loss in the immediate post-operative period and at most recent follow-up and lower reoperation rates than gastric banding., Level of Evidence: III., (Copyright © 2019. Published by Elsevier Inc.)

Rationale: Low adherence to positive airway pressure (PAP) treatment for adolescents with obstructive sleep apnea (OSA) can have long-term cardiometabolic and developmental impact., Objectives: To explore the facilitators and barriers to PAP use in adolescents with OSA., Methods: We conducted a qualitative study using a descriptive thematic analysis approach. A total of 21 interviews were conducted in the clinical setting with adolescents prescribed PAP to treat OSA within the previous 12 months. Interview audio recordings were transcribed verbatim for analysis. Transcripts were reviewed, and data were categorized using a coding framework developed by the research team. Codes were structured into themes related to the barriers and facilitators to using PAP., Results: Participants described numerous challenges with the physical design of the PAP machine, including the restriction of the tubing, the discomfort of the mask, and concerns with its size and weight. A period of adjustment to wearing and preparing the PAP machine was described whereby participants had to develop their own strategies to improve comfort. After initiating the therapy, the challenges experienced by participants were cited more often than the perceived benefits, particularly for those who were less adherent. Finally, the unique needs of adolescents were highlighted, which impacted the amount of family support desired in using PAP., Conclusions: This study identifies factors affecting PAP adherence when prescribed in adolescence and highlights the need for ongoing dialogue between adolescents and their clinical team with respect to challenges encountered, troubleshooting, adherence strategies, and parental engagement.

A 13-year-old biological female patient presented with gender dysphoria while receiving treatment for obesity. Body distress and a desired masculine phenotype motivated his engagement with various therapies. We describe body image concerns in an obese adolescent with gender dysphoria to highlight the importance of assessing gender in adolescents., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To determine effective interventions to improve primary care provider involvement in transitioning youth with chronic conditions from paediatric to adult care., Design: Systematic review. Multiple electronic databases were searched including Ovid MEDLINE, EMBASE and Web of Science (from 1 January 1947 to 5 August 2015). Evidence quality was assessed using a 36-point scoring system for disparate study designs., Setting: Studies with paediatric-to-adult transition programmes and interventions involving primary care providers or in primary care settings., Participants: Youth aged 16 years and over., Outcomes: Relevant outcomes were grouped into 3 main domains based on the Triple Aim Framework: experience of care, population health, cost., Results: A total of 1888 unique citations were identified, yielding 3 studies for inclusion. Overall, primary care provider roles were not well defined. 2 studies used case managers to facilitate referrals to primary care, and the remaining study was the only 1 situated in a primary care setting. None of the studies examined transition in all 3 Triple Aim Framework domains. The most commonly reported outcomes were in the cost domain., Conclusions: There is limited empiric evidence to guide primary care interventions to improve transition outcomes for youth with chronic conditions. Future research and policy should focus on developing and evaluating coordinated transition interventions to better integrate primary care for high need populations., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Adolescent and young adult kidney transplant recipients have worse graft outcomes than older and younger age groups. Difficulties in the process of transition, defined as the purposeful, planned movement of adolescents with chronic health conditions from child to adult-centered health care systems, may contribute to this. Improving the process of transition may improve adherence post-transfer to adult care services., Objective: The purpose of this study is to investigate whether a kidney transplant transfer clinic for adolescent and young adult kidney transplant recipients transitioning from pediatric to adult care improves adherence post-transfer., Methods: We developed a joint kidney transplant transfer clinic between a pediatric kidney transplant program, adult kidney transplant program, and adolescent medicine at two academic health centers. The transfer clinic facilitated communication between the adult and pediatric transplant teams, a face-to-face meeting of the patient with the adult team, and a meeting with the adolescent medicine physician. We compared the outcomes of 16 kidney transplant recipients transferred before the clinic was established with 16 patients who attended the clinic. The primary outcome was a composite measure of non-adherence. Non-adherence was defined as either self-reported medication non-adherence or displaying two of the following three characteristics: non-attendance at clinic, non-attendance for blood work appointments, or undetectable calcineurin inhibitor levels within 1 year post-transfer., Results: The two groups were similar at baseline, with non-adherence identified in 43.75 % of patients. Non-adherent behavior in the year post-transfer, which included missing clinic visits, missing regular blood tests, and undetectable calcineurin inhibitor levels, was significantly lower in the cohort which attended the transfer clinic (18.8 versus 62.5 %, p = 0.03). The median change in estimated glomerular filtration rate (eGFR) in the year following transfer was smaller in the group that attended the transition clinic (-0.9 ± 13.2 ml/min/1.73 m(2)) compared to those who did not (-12.29 ± 14.9 ml/min/1.73 m(2)), p = 0.045., Conclusions: Attendance at a single kidney transplant transfer clinic was associated with improved adherence and renal function in the year following transfer to adult care. If these changes are sustained, they may improve long-term graft outcomes for adolescent kidney transplant recipients.

Background: Admission to hospital is the treatment of choice for anorexia nervosa in adolescent patients who are medically unstable; however, stays are often prolonged and frequently disrupt normal adolescent development, family functioning, school and work productivity. We sought to determine the costs of inpatient treatment in this population from a hospital and caregiver perspective, and to identify determinants of such costs., Methods: We used micro-costing methods for this cohort study involving all adolescent patients (age 12-18 yr) admitted for treatment of anorexia nervosa at a tertiary care child and adolescent eating disorder program in Toronto, between Sept. 1, 2011, and Mar. 31, 2013. We used hospital administrative data and Canadian census data to calculate hospital and caregiver costs., Results: We included 73 adolescents in our cohort for cost-analysis. We determined a mean total hospital cost in 2013 Canadian dollars of $51 349 (standard deviation [SD] $26 598) and a mean total societal cost of $54 932 (SD $27 864) per admission, based on a mean length of stay of 37.9 days (SD 19.7 d). We found patient body mass index (BMI) to be the only significant negative predictor of hospital cost (p < 0.001). For every unit increase in BMI, we saw a 15.7% decrease in hospital cost. In addition, we found higher BMI (p < 0.001) and younger age (p < 0.05) to be significant negative predictors of caregiver costs., Interpretation: The economic burden of inpatient treatment for adolescents with anorexia nervosa on hospitals and caregivers is substantial, especially among younger patients and those with lower BMI. Recognizing the symptoms of eating disorders early may preclude the need for admission to hospital altogether or result in admissions at higher BMIs, thereby potentially reducing these costs.

Objective: We sought to determine the potential additive usefulness of Doppler tissue imaging (DTI), strain (epsilon), and epsilon rate (SR) imaging in assessing systolic function in pediatric patients with Alström syndrome., Methods: We conducted a case-control study at a pediatric hospital with 5 patients (age 5-18 years) with Alström syndrome living in Atlantic Canada and 21 age- and sex-matched healthy control subjects. Standard echocardiographic examination was followed by DTI of the interventricular septum (IVS) and left ventricle (LV) lateral wall, longitudinal epsilon, and SR at the basal, mid, and apical segments of the LV lateral, inferior, and anterior walls, and the IVS. We also imaged radial epsilon and SR of the interventricular posterior wall., Results: For patients versus control subjects, conventional ejection fraction (0.65 vs 0.72) and fractional shortening (0.30 vs 0.35) did not distinguish between groups. DTI-derived s-waves consistently demonstrated significant differences in systolic function (LV lateral wall 0.073 vs 0.100; IVS 0.064 vs 0.080; LV anterior wall 0.066 vs 0.096; LV inferior wall 0.069 vs 0.092 [P < .05 in all positions]). Epsilon differences were observed in the movement of the mid-LV lateral (-10.4 vs -15.2, P = .035), basal LV anterior wall (-16.3 vs -22.9, P = .004), and the apical IVS (-6.3 vs -13.8, P = .015). SR at the midposition of the LV lateral wall (-0.7 vs -1.4, P = .000) also differed between the groups. Substantial diastolic function differences were also observed between patients and control subjects., Conclusion: Detection of systolic and diastolic function abnormalities in patients with Alström syndrome can potentially be enhanced by the use of DTI, epsilon, and SR imaging.