Community-based physical and occupational therapy (PT/OT) are critical for stroke recovery but are underused. We conducted a secondary analysis of the COMPASS (Comprehensive Post-Acute Stroke Services) study, a pragmatic trial of comprehensive postacute transitional care (TC) to investigate whether TC programs increase PT/OT use. Forty hospitals were randomized to implement COMPASS-TC or maintain usual care for patients with stroke/transient ischemic attack. In a crossover phase, usual care hospitals implemented COMPASS-TC. We linked participants to administrative claims to assess PT/OT use after stroke. Adjusted generalized estimating equations compared COMPASS-TC to usual care within the trial and crossover cohorts on 30-/90-day PT/OT use, time to first visit, number of visits, and receipt of PT and OT versus single therapy. Per protocol analysis estimated complier average causal effects. COMPASS enrolled 8377 patients from July 2016 to March 2019; 5261 were linked to administrative claims. Thirty-day PT/OT ranged from 22.6% in usual care to 37.5% in COMPASS-TC. Therapy use was similar between groups in the trial cohort, and COMPASS-TC was associated with increased use in crossover analysis (9.4% [95% CI, 5.6-13.3%] at 30 days). COMPASS-TC was consistently associated with a shorter time to therapy (mean difference, -0.16 [95% CI, -0.03 to -0.29]). Per protocol results were larger for most outcomes. COMPASS-TC was associated with shorter time to PT/OT and with greater therapy receipt in the crossover, but not the trial, analysis. Inconsistencies may reflect confounding or differences in hospitals that chose to adopt the intervention in Phase 2. Implementation studies to improve care transitions after stroke are needed to enhance use of postacute rehabilitation.

The importance of transitioning care from pediatric to adult practitioners is an often overlooked aspect of chronic disease. The benefits of a planned transition in health care are that patients will learn valuable life-long lessons on healthcare maintenance, when and how to seek medical attention for new issues that may arise, and improvements on their overall well-being. The purpose of this SAGES White Paper was to summarize the available knowledge for several pediatric surgical conditions to aid in transition of care for this patient population. The members of the SAGES Pediatric Surgery Committee elected to produce this White Paper. The group choseto focus on several important gastrointestinal diseases that may require lifelong care: tracheoesophageal fistula, duodenal atresia, anorectal malformations, childhood obesity, and gastrointestinal malignancies. For each disease process a summary of long term issues facing these patients, stakeholders involved, and follow up recommendations if required were identified. Each disease process has its own unique set of long-term issues as well as multidisciplinary stakeholders and need for follow-up. However, individualized care is needed based on each patient's unique needs. To facilitate consistent transfer of care standardization is needed for surgical diseases. Key aspects of standardization include identifying a multidisciplinary team, working towards consistent quality improvement, and implementation of policy guided processes with individual treatment plans. Continued work in standardizing transition of care is required for optimal treatment of this complex patient population.

This study aimed to identify the behavioral determinants influencing the integration of physical activity into the care pathway of postmenopausal women with hormone receptor-positive breast cancer. It specifically addressed the following research question: What are the main barriers and facilitators, from both patient and healthcare professional perspectives, that influence the integration of physical activity into routine care? This qualitative study was based on the Theoretical Domains Framework and the Capability, Opportunity, Motivation - Behavior (COM-B) model. Semi-structured interviews were conducted and the analysis was guided by these frameworks, complemented by inductive thematic analysis, to capture nuanced insights in this clinical context. Barriers for patients include misconceptions, fatigue and difficulties with autonomous PA practice, while healthcare professionals emphasize the need for practical training and clear protocols. Key enablers included early physical activity assessment, personalized and playful interventions, peer support, and the emerging role of advanced practice nurses in structuring care transitions. Digital tools show promise for sustainable engagement when co-designed with patients and integrated into therapeutic relationships. The study identifies concrete levers for integrating physical activity into oncology care, combining behavioral frameworks with nursing science to better understand clinical realities. These findings provide practical guidance for developing sustainable strategies and reinforce the need for person-centered, coordinated approaches to make physical activity a fully recognized component of breast cancer care.

Application of transitional care in older adults: A bibliometric analysis.

Transition to adulthood after childhood cystoplasty: Patient perspectives.

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy, offering durable responses and prolonged survival. However, these therapies also present unique challenges, particularly with the onset of immune-related adverse events (irAEs), which can manifest during treatment either acutely and/or become chronic or emerge long after treatment cessation. Delayed, chronic, and re-emergent irAEs often require tailored survivorship care, including coordination across multiple disciplines focused on oncology, specialty care, and primary care. Despite the increased usage of ICIs, there is limited longitudinal data guiding the surveillance, diagnosis, attribution, and management of irAEs after ICI treatment. To address these gaps, the Society for Immunotherapy of Cancer convened an Expert Panel to deliberate best practices and identify research opportunities for improving post-treatment care. This paper outlines these expert insights into irAE surveillance, coordination and continuity across care transitions and settings, and clinical management strategies. The paper also underscores the importance of clinicians' understanding of irAE onset patterns, multidisciplinary coordination, and the urgent need in the field for the development of a comprehensive irAE registry. By addressing these critical gaps, the oncology community can better support the growing population of ICI-treated cancer survivors, ensuring improved quality of life and care outcomes.

Many older adults living in a seniors' residence (SR), especially those living with dementia, will have to be relocated in long-term care (LTC) despite the negative impact of these care transitions on physical and psychological well-being. Using a living lab methodology and focus group methods, a care approach was co-developed in collaboration with a SR and public home care services, to promote aging-in-place and delay relocations in LTC. Outcomes were assessed using Interrupted Time Series Analysis. Integrating best practices like staff training, care reorganization, personalized care based on the residents' life stories, and stronger collaborations with the home care services, this approach allowed older adults with higher assistance needs to remain within their home. Relocations to LTC were delayed by approximately 3months. Ultimately, aging-in-place was found to be relevant in providing evolving care to older adults living in a SR, though further studies are needed to document its financial impact.

A0195 STREAMWAY – perceptions and barriers to transition in urological care among adolescents – intermediate analysis

Adapting complex healthcare interventions for use across diverse healthcare systems requires balancing fidelity to core components with responsiveness to local contexts. The Pal-Cycles project aims to support transitions in care for patients with advanced cancer across seven European countries. Understanding the multilevel factors that influence adaptation is essential to ensure contextual fit while maintaining intervention integrity. To explore the multilevel factors that influenced the adaptation of the Pal-Cycles intervention across seven European countries. A qualitative study was conducted with purposively sampled country lead team members from all participating countries. Data were derived from focus groups, in which participants reflected on and discussed their experiences of cross-country adaptation meetings, and were analysed using framework analysis. Fourteen country lead team members participated in the study. Analysis identified five areas reflecting multilevel factors that influenced the adaptation of the Pal-Cycles intervention: (1) Organisational variability as a barrier to adapting the Pal-Cycles intervention, (2) Disparities in training and shared motivation to improve palliative care communication, (3) Multidisciplinary collaboration shaped by organisational and cultural contexts, (4) Balancing optimism and practical constraints: stakeholder views on the Pal-Cycles intervention, (5) Working together to adapt the Pal-Cycles intervention across cultures. Organisational variability influenced service availability, integration between oncology and palliative care, and communication pathways. Disparities in previous training and shared motivation shaped clinicians' engagement with the intervention's training component. Multidisciplinary collaboration varied across settings, affecting role clarity and coordination among healthcare professionals. Stakeholder perspectives, including those of cancer clinicians, general practitioners, and consortium members, informed decisions about which elements of the intervention were most relevant in each context. Finally, working together to adapt the intervention across diverse cultural and organisational settings involved iterative discussions that balanced flexibility with preservation of the intervention's core components. The adaptation of Pal-Cycles was shaped by interrelated organisational, professional, and cultural factors. Recognising how local contexts influence the prioritisation and operationalisation of intervention components is essential for achieving a balance between standardisation and flexibility in cross-national healthcare interventions.

As patients with intestinal failure reach adulthood, transitioning to adult care remains challenging because of a lack of specialized programs. This study evaluated outcomes of patients who transitioned care from a pediatric intestinal rehabilitation program. A retrospective cohort study was conducted of intestinal failure patients who turned 20 years old between 2013 and 2022 with follow-up through February 2025. Patient characteristics, including demographics, anatomy, nutrition, and comorbidities, were collected for all patients at the age of 18 years. Patients were classified into exposure groups based on whether they transitioned to adult care or continued follow-up at our institution. Univariate analysis comparing groups was performed with Mann-Whitney U test or chi-square/Fisher's exact test, with P < 0.05 being significant. Forty-six patients were included, with 68% having short bowel syndrome. Nine patients (20%) had an ostomy and 14 of 46 (30%) continued to receive parenteral nutrition. Twenty-seven patients (59%) transitioned to adult care at a median age of 20.8 (interquartile range [IQR], 3.8) years. No demographic, nutrition, or comorbidity differences were observed between groups. Higher mortality rates occurred among patients who transitioned care compared with patients continuing care at our institution (33% vs 5%; P = 0.02). The median time duration to death was 12 months (IQR, 43.5). Patients transitioned to adult care have a higher mortality rate, despite no obvious difference in medical complexity based on medical devices or comorbidities. Additional studies are needed to understand this difference. Increased awareness and structured transition programs are essential to ensuring optimal long-term outcomes.

Days alive and at home (DAH) is a validated outcome measure that captures health care transitions between time spent at home vs various nonhome care settings, offering a more nuanced patient-centered understanding of recovery. We aimed to (1) characterize long-term recovery trajectories for adults with moderate-to-severe traumatic brain injury (msTBI) using DAH and (2) develop and internally validate a clinical prediction model for favorable vs unfavorable recovery. This multicenter retrospective population-based cohort study was performed in Ontario, Canada; we identified adults hospitalized with isolated msTBI between 2009 and 2021 that survived beyond 72 hours postadmission. DAH was calculated in 30-day intervals from index admission through 3 years postinjury. Latent class mixed modeling identified unique recovery trajectories. Sociodemographic, clinical, and injury variables were then evaluated as candidate predictors. Logistic regression, penalized regression, and machine learning approaches were compared for discrimination of favorable (early, intermediate, or late recovery) vs unfavorable (delayed deterioration or poor recovery) trajectories. Model performance was evaluated in a held-out test set using area under the receiver operating characteristic curve (AUC) with 95% CIs. There were 3,004 adults included in the cohort with an overall male predominance (n = 2,284, 76.1%), and the average age was 49.6 years (SD 21.4). Latent class mixed modeling revealed 5 distinct DAH trajectories: early recovery (38.6%), intermediate recovery (27.5%), and late recovery (3.2%) groups were characterized by return to the community at varying time intervals; by contrast, delayed deterioration (3.4%) and poor recovery (27.3%) groups experienced limited time at home at final follow-up. Patients in the unfavorable recovery trajectory groups were older, frailer, and more likely to sustain fall-related injuries. Radiographic predictors of poor outcome included subdural hematoma, large intraparenchymal hematoma, diffuse axonal injury, and cerebral edema. Using various demographic, injury and radiographic characteristics, a prediction model (DAH-TBI calculator) could discriminate trajectories with an AUC of 0.812 (95% CI 782-0.842) on a held-out internal validation data set. Our findings emphasize a longer period of postinjury outcome observation may be necessary to capture societal reintegration after msTBI. We developed and internally validated the DAH-TBI calculator to predict long-term postinjury outcomes.

Outpatient physical therapy often marks the final stage of formal rehabilitation and is punctuated by discharge to community-based wellness or home exercise program. Despite its critical role in care continuity, the outpatient discharge process remains underexplored, specifically those discharges that are more difficult or challenging. This exploratory study examined the prevalence, contributing factors, and clinician-perceived impact of difficult discharges in outpatient physical therapy to inform early conceptual and operational definition development. A cross-sectional study was conducted using an Qualtrics survey that incorporated both quantitative and qualitative components. Three hundred and twenty four licensed physical therapists (PTs) practicing in United States (US) outpatient settings who primarily treated adults completed the survey. Quantitative data were analyzed descriptively and with regression modeling to examine clinician and practice characteristics associated with self-reported discharge difficulty, while qualitative responses to four open-ended questions were analyzed thematically to identify recurrent concepts and contextual factors influencing difficult discharges. The median self-reported prevalence of difficult discharges was 20% (interquartile range [IQR] 10-31%). Physical therapist age was inversely associated with reported discharge difficulty, with younger clinicians (<34-years-old) and those treating neurological populations reporting higher rates and emotional burden. Thematic analysis helped generate a preliminary working definition of the difficult discharge. Six qualitative themes were identified: early communication and education, knowledge gaps, chronic condition complexity, behavioral compliance, financial barriers, and interdisciplinary collaboration. These themes illustrated the multifactorial nature of difficult discharges and their impact on care transitions and clinician well-being. Difficult discharges are common in outpatient physical therapy and arise from interconnected patient, provider, and system factors. Younger clinicians and those working in neurological practice may experience greater emotional strain. Early, consistent discharge planning and improved support systems may be associated with smoother care transitions and help sustain clinician well-being.

X-linked hypophosphatemic rickets (XLH) requires lifelong, coordinated, and multidisciplinary care, and the transition from pediatric to adult services represents a particularly vulnerable period often accompanied by reduced treatment adherence and a greater risk of loss to follow-up. This review aims to provide a clear, practical framework for supporting the transition of adolescents and young adults with XLH by synthesizing international guidelines, consensus statements, and clinical practice reports published up to August 2025. Current recommendations highlight the importance of early assessment of transition readiness, structured and developmentally appropriate education for patients and their families, close collaboration between pediatric and adult endocrinology teams, and the continuation of therapy with standardized monitoring protocols. A well-designed yet flexible transition pathway may support adherence, ensure continuity of care, and contribute to improved long-term outcomes. By summarizing existing evidence and identifying areas where data remain limited, this review underscores the need for prospective studies to better define optimal management strategies for adults living with XLH.

BackgroundAdvances in targeted cancer therapies have transformed the management of pediatric malignancies. Tyrosine kinase inhibitors (TKIs), a specific class of targeted agents, inhibit signaling pathways essential to cancer cell survival. TKIs have improved outcomes in specific pediatric cancers. However, TKIs are associated with acute and long-term cardiotoxicities. Supportive care management aimed at prevention, early detection, and timely intervention is necessary to mitigate cardiotoxicity associated with TKIs.MethodThis rapid review examined the supportive care management used in children with cancer and childhood cancer survivors who received TKIs as part of their treatment. TKIs were selected due to their frequent use in pediatric oncology. Eligible studies, published between 2019 and 2025, included patients aged 0-21 years. From 206 citations, 30 duplicates were removed, and 176 records were screened in Rayyan. Fifteen full texts were reviewed, and two additional studies were hand-searched, yielding eight studies for inclusion. Data extraction, synthesis, and PRISMA documentation were completed collaboratively by the review team.ResultsFive key categories in supportive care management emerged: surveillance strategies, preventive strategies, cardiac medication use, collaboration between pediatric oncology and cardiology, and transition of care for childhood cancer survivors.ConclusionTKIs are associated with significant cardiotoxic risk in pediatric oncology. This review identified five supportive care categories that may inform future interdisciplinary research and guide the development of evidence-based supportive care recommendations aimed at optimizing cardiovascular outcomes in this patient population.

PurposeHospice care is a patient- and family-centered approach to end-of-life care that prioritizes comfort, symptom management, and psychosocial support while foregoing curative treatment. Hospice care improves quality of life and care at the end of life. Despite its benefits, hospice remains underutilized by racially and ethnically diverse people, sexual and gender minorities, and socioeconomically marginalized populations.FindingsGuided by the Social Ecological Model, the objectives of this narrative review are to (a) discuss disparities in hospice care use, (b) explore multidimensional levels and factors contributing to such disparities, and (c) outline implications and imperatives for improving access to and use of hospice care. This review revealed that hospice care disparities are shaped by interacting factors across societal, structural, healthcare system, interpersonal, and individual levels. Historical context, policy design, geographic and socioeconomic constraints, clinician communication, and cultural beliefs collectively influence patterns of access, timing, and utilization of hospice care. System-level solutions include integrating hospice referrals into routine care workflows, improving hospice-related policies, strengthening partnerships with community organizations, and transitional care research. Clinicians are uniquely positioned to identify care preferences, advocate for timely referrals and support the hospice transition, and build trust with patients and families at the end of life.ConclusionsEfforts across clinical settings, policy, and research are critical to improving hospice care use, and ensuring that all seriously ill individuals benefit from goal-concordant, high-quality hospice care. Reducing hospice care disparities will require coordinated, multilevel interventions that address policy and healthcare system factors while strengthening hospice-related communication and care.

Follow-up care for traumatic brain injury (TBI) in the United States ranges from inconsistent, at best, to non-existent most predominantly. The present study aimed to gather patient perspectives on acute and post-acute TBI care using a phenomenological approach guided by the Patient Experience Framework, Chronic Care Model, and Health Literacy Framework. Using a pre-defined, semi-structured interview guide, including four groups of 35 diverse people diagnosed by a medical provider with "mild" TBI within 24 months, the study qualitatively explored their patient care experience, the care they received, and the care they felt they needed. Participants were 57% male, 43% female, 59% Caucasian, 28% African American, and 13% Latino, with a mean age of 43 years (range: 24-67). Four interconnected themes emerged representing critical failure points in the patient experience continuum: (1) foundational knowledge deficits that created barriers to care engagement; (2) critical touchpoint failures in acute care that minimized injury significance; (3) care transition failures and educational inadequacy during discharge; and (4) absence of longitudinal care and support systems. Participants possessed minimal brain injury knowledge and held fatalistic beliefs about recovery. Health care interactions consistently minimized TBI significance, with the term "concussion" conveying insignificance. Discharge occurred when cognitive capacity was most compromised, representing failed transitions rather than effective handoffs. Follow-up care was virtually absent, leaving participants to navigate complex symptom patterns without professional guidance. Psychological trauma remained unaddressed, and community support emerged as a critical unmet need. Current TBI care delivery fails patients at multiple touchpoints across the care continuum. When interpreted through established theoretical frameworks, these failures represent systemic breakdowns requiring comprehensive solutions rather than isolated improvements. Effective TBI care requires reframing TBI, including mild TBI, as a chronic condition that may require sustained support, implementing systematic education approaches that account for cognitive impairments, providing proactive follow-up care, and addressing the full spectrum of patient experience challenges including psychological sequelae and community support needs.

To understand regular medication management processes in the postoperative period for patients having major cancer surgery, and to evaluate whether medication discrepancies were associated with postoperative adverse drug events (ADEs). A prospective cohort of 500 adult patients, undergoing planned major cancer surgery at a Melbourne specialist cancer hospital, was followed from surgery to day 30 postoperatively. Regular medication discrepancies were assessed across transitions of care up to five days postoperatively and at discharge. Adverse drug events were monitored up to 30 days after surgery. Multivariable logistic regression was used to identify predictors of medication discrepancies and ADEs. Among 7254 medication orders for 500 patients, 12.5% (n = 905) of orders resulted in unintentional medication discrepancies. Polypharmacy (OR = 1.32; 95%CI: 1.21-1.44; p < 0.001) and length of stay (OR = 1.07; 95%CI: 1.03-1.12; p = 0.001) were significant predictors of unintentional medication discrepancies. ADEs occurred in 16.4% of patients (n = 82). In multivariable analysis, the odds of experiencing an ADE were significantly higher among patients who had unintentional discrepancies (vs. those with intentional discrepancies; OR = 3.06; 95%CI: 1.66-5.64; p < 0.001), older age (OR = 1.05; 95%CI: 1.02-1.08; p < 0.001), polypharmacy (OR = 1.20; 95%CI: 1.08-1.33; p < 0.001), higher acuity care admission (OR = 2.46; 95%CI: 1.33-4.54; p = 0.004) and prolonged hospital length of stay (OR = 1.07; 95%CI: 1.02-1.12; p = 0.002). Cardiovascular and alimentary tract medications were most commonly implicated in both discrepancies and ADEs. Unintentional medication discrepancies are associated with postoperative ADEs in patients having cancer surgery. Targeted strategies-especially for older patients, those with polypharmacy, and extended hospital stays-are essential to enhance medication safety across perioperative transitions.

ABSTRACT Adolescents and young adults living with HIV (AYAH) face significant challenges when transitioning from adolescent to adult HIV services. Up to 50% of AYAH do not remain engaged in care after transition, which may result in virological failure. We sought to understand challenges to clinic transitions and youth-identified solutions to optimize health outcomes. We conducted three focus group discussions (FGDs) (n = 33) and a 4-day participatory, human-centered design (HCD) workshop as part of this qualitative sub study. AYAH recruited for FGDs between October and November 2020 were from health facilities in Kisumu County, Kenya. A subset of FGD participants and peer navigators were recruited for the HCD workshop. Participants were purposefully recruited to obtain diversity based on various demographic variables. We used a semi-structured guide covering HIV retention and clinic transition domains. The resultant audio files were transcribed, and transcripts analyzed inductively to identify emerging themes. During the HCD workshops, AYAH presented transition as a priority and engaged in journey mapping, story-telling and brainstorming to describe how transition happens, the challenges they experience and possible solutions. HCD analysis involved insight documentation, dialogue and rapid thematic analysis. AYAH who were between 14 and 24 years and were majority (56%) female, identified transition challenges including: limited knowledge about the transition process among providers; poor preparation for transition; complex organization and clinic flow in the adult HIV clinic; privacy and stigma concerns; challenging client–provider relationship dynamics; and concern for loss of relationships with peers. AYAH proposed approaches to improve the transition experience including early transition planning, peer transition support groups, peer-led transition, ongoing relevant health education during clinic visits and active support for acceptance of one's HIV status. AYA highlighted individual, provider and facility-level challenges with care transition. The solutions identified by AYAH can guide interventions to enhance HIV treatment engagement, including adherence and retention, during the critical transition period. Trial registration: ClinicalTrials.gov identifier: NCT04432571.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored a scientific workshop in 2024, titled "Preparing for Kidney Precision Medicine Clinical Trials." The purpose of the workshop was to gain a better understanding of the therapeutic journey of patients with kidney disease and define candidate indicators for precision medicine strategies, targets, and trial readiness. Workshop participants were tasked with identifying best practices, opportunities and barriers to kidney precision medicine clinical trials, with a shared goal to optimize the design and conduct of these trials. The patient perspective served as a foundation for the meeting. Trial design should be flexible, dynamic, responsive to transitions in patient care and minimize fragmentation of care. The value of understanding mechanisms and defining endophenotypes and targets to facilitate new therapeutic approaches was discussed with examples presented for acute and chronic kidney diseases. The importance of biomarkers for diagnosis and evaluation of therapeutic response was emphasized. Laboratory and assay considerations for precision medicine trials were discussed with examples of successful large precision medicine trials supported by laboratory networks presented. There was discussion of the barriers to precision trials in nephrology, including suboptimal patient engagement, precision trial expertise, infrastructure and financial resources. Engagement in demonstration projects to test the ability of various approaches to expedite the right treatment to the right patient was highlighted. Of utmost importance is the better design of clinical trials which consider differences in genetics and status of disease mechanisms to validate individual patient-focused innovative and effective precision therapeutic approaches.

Long-term follow-up (LTFU) outpatient clinics play a primary role in screening, preventing, and addressing late effects after hematopoietic cell transplantation (HCT). Following the 2018 nationwide survey, which led to the development of standardized nationwide tools to deliver information to HCT survivors, we re-evaluated changes in the current status of LTFU clinics. We targeted 267 HCT centers certified by the Japanese society for transplantation and cellular therapy. Several questionnaire categories were retained from the 2018 survey to compare results (e.g., LTFU clinic establishment and institutional practices for late-effect screening). The response rate was high in both adult (90%) and pediatric HCT centers (88%), and the establishment rate of post-HCT LTFU clinics increased to 82% (adult, 90%; pediatric, 64%). Pediatric centers were more likely to continue follow-up of patients who received HCT beyond 5 years post-HCT. Regarding transitional medical care for long-term survivors at non-HCT institutions, only a few HCT centers conducted routine transitions to specific referral facilities. We observed significant changes in recommendations for secondary cancer screenings compared to 2018, with a substantial decrease in the proportions of "not routinely included as a screening issue." In the future, it is essential to create a sustainable follow-up system, establish networks with non-HCT facilities, and educate patients to encourage behavioral changes for lifelong health screenings.