Digital Delivery of Person-centered Transitional Care (DigiStep)

February 7, 2025 updated by: Göteborg University

Evaluation of the Digital Delivery of Person-centered Transitional Care to Empower Adolescents With Chronic Childhood-onset Diseases: The Digi-STEPSTONES Study

Advances in medical care have extended the life expectancy of individuals with congenital and pediatric-onset diseases, leading to an increased need for effective transition programs as these individuals move from pediatric to adult healthcare. The STEPSTONES project in Sweden is designed to evaluate the effectiveness of a person-centered transition program to support teenagers with chronic conditions during this transition. The project's innovative digital adaptation, Digi-STEPSTONES, seeks to address challenges related to accessibility and continuity of care by delivering the program remotely. This study will assess the non-inferiority of the digital program compared to traditional, in-person care, focusing on outcomes such as patient empowerment, transition readiness, and quality of life. Additionally, the project will explore the implementation and scalability of the digital transition model across various chronic conditions. Preliminary studies have highlighted the importance of structured, person-centered care in improving empowerment and other outcomes in adolescents with chronic illnesses. The Digi-STEPSTONES project aims to provide crucial evidence for the digital delivery of transition programs, potentially enhancing the accessibility and effectiveness of care for young people with chronic conditions in Sweden.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Detailed Description

Medical and surgical advances have significantly increased the life expectancy of individuals with congenital and pediatric-onset diseases, often resulting in chronic conditions. Effective lifetime care is crucial, especially during the transition from pediatric to adult care. Transition is a process where adolescents with chronic conditions are prepared to manage their health and life as they move to adult healthcare environments. Transition programs are designed to assist in this preparation, and over the past decade, several randomized-controlled trials (RCTs) have demonstrated the effectiveness of such programs in improving outcomes like self-management, knowledge of the condition, clinic attendance, and satisfaction with care.

In Sweden, the STEPSTONES (Swedish Transition Effects Project Supporting Teenagers with chrONic mEdical conditionS) project is evaluating a person-centered transition program tailored for young individuals with chronic conditions. The project has focused on conditions like congenital heart disease and type 1 diabetes through RCTs and is now exploring a digital adaptation called Digi-STEPSTONES, which aims to deliver the transition program remotely to improve accessibility and continuity of care.

PURPOSE AND AIMS

The main goal of this project is to evaluate the effectiveness of a digitally delivered, person-centered transition program for adolescents with asthma/allergy and those who have undergone a solid organ transplant in a real-world setting. The specific objectives are:

  • To investigate the non-inferiority of the digital delivery compared to in-person delivery.
  • To evaluate the implementation process of the digital transition program.

SIGNIFICANCE AND NOVELTY Digi-STEPSTONES aligns with person-centered care principles by supporting shared decision-making and empowering adolescents to actively participate in their healthcare. This project is novel as it is the first to provide evidence on the effectiveness of a digitally delivered person-centered transition program, covering multiple conditions, which enhances the generalizability of the findings.

RESEARCH DESIGN AND METHODS

To achieve the project's objectives, two studies will be conducted:

Study 1: Comparative Effectiveness Research (Non-Inferiority Trial) A two-arm, non-inferiority study using a causal inference methodology will be performed. Arm A involves a digital delivery of the transition program, while Arm B is a historical cohort from previous RCTs that received in-person delivery.

The STEPSTONES transition program includes eight components implemented in five steps, and the intervention will be delivered via the "Mitt vårdmöte" platform, already in use for digital healthcare appointments in Sweden. Assessments will be made at ages 16 and 18.5, focusing on primary outcomes like patient empowerment and secondary outcomes like transition readiness, quality of life, and health literacy.

Study 2: Evaluation of the Implementation of the Digital Transition Program A mixed methods approach will be used, combining quantitative and qualitative methods. Adolescents who participated in the digital program and healthcare providers will be included. The evaluation will focus on the intervention's reach, fidelity, perceived barriers, facilitators, usability, and user-friendliness of the digital platform.

TIMEPLAN The Digi-STEPSTONES project will be executed through six work packages, covering managerial, developmental, implementation, research, and reporting tasks, starting in 2023.

Ethical Approval The project has received ethical approval (2022-05394-01-351139, 2023-01-13).

By delivering the transition program digitally, Digi-STEPSTONES aims to reduce the burden on young patients, particularly those living in remote areas, and ensure that they receive the necessary transitional care. The project will contribute to Sweden's healthcare objectives by leveraging digital solutions to provide accessible, equitable, and high-quality care.

RESEARCH DESIGN AND METHODS

To address the specific objectives of this project, 2 studies will be conducted:

Objective 1 Study 1: Comparative effectiveness research: Non-inferiority trial Design: A two-arm, comparative, non-inferiority study, using a causal inference methodology will be performed. Arm A involves a pre-test/post-test design where individuals will participate in the digital delivery of the transition program.

Arm B is a historical comparison cohort that includes participants from two previous RCTs who received the intervention in-person.

Participants/inclusion criteria:

Arm A:

- Literate, Swedish-speaking adolescents with asthma/allergy or went through a solid organ transplantation aged minimum 15 years. Their parents will be invited to fill out a questionnaire (proxy).

Arm B:

  • Literate, Swedish-speaking adolescents with asthma/allergy or went through a solid organ transplantation aged minimum 15 years. Their parents will be invited to fill out a questionnaire (proxy).

Sample size calculation:

Arm A: approximately 100 patients will be recruited consecutively Arm B: the approximate sample for individuals who received the intervention in-person is of approximately 120.

Exclusion criteria:

  • Non literate
  • Not Swedish speaking
  • Cognitive impairment

Intervention: The STEPSTONES transition program is a multi-component intervention comprising 8 components: a) a transition coordinator (TC); b) information and education about the condition and treatment, health behavior, dealing with school and friends; c) availability by telephone; d) information about and contact with the adult program; e) guidance of parents; f) meeting with peers; g) person-centered transition plan; and h) the actual transfer to the adult program 15,16. These components are implemented in five steps: (1) first outpatient visit with TC; (2) second outpatient visit with TC; (3) information and peer-to-peer session for adolescents and their parents; (4) individualized transfer plan; and (5) actual transfer (Figure 2). The intervention will be delivered through the "Mitt vård mote" platform, which is currently being used across Sweden to undertake digital healthcare appointments. The HEADDDSS (home, education, activity, diet, drugs, depression, sex, safety) adolescent health interview is a cornerstone of the intervention. The intervention will be performed by specialized nurses of the respective pediatric care units, after being trained to become TC. The core of the STEPSTONES transition program remains the same for the present project, except that the delivery will be digital.

Variables and measurement: Assessments are planned at the age of 16 years (Time 0 - baseline ) and 18.5 years (Time 1- endpoint). The primary outcome is Patient Empowerment, using the Gothenburg Young Persons Empowerment Scale. Secondary outcomes are transition readiness; quality of life; and satisfaction with transition. In parents, the proxy transition readiness is measured.

Procedure of patient recruitment, data collection and data management: Patients who are eligible for inclusion will be approached by letter at the age of 16 years. In a subsequent telephone call, both the adolescents and their parents will be informed verbally about the study. Patients will only be included if the adolescent, who is a minor at the time of inclusion, provides written informed assent, and the parents/guardians provide written informed consent.

Patients will be asked to complete a set of online questionnaires (eCRF) online. To increase the response rate, a modified Dillman procedure will be used to minimize non-response, same procedure as in prior STEPSTONES trials. Reminders will be sent after three, five and seven weeks.

Statistical analysis: Propensity score weighting will be used as a method of causal inference. It mimics an RCT design and reduces comparative bias. After propensity weighting, the groups are compared by applying a linear model with doubly robust estimations. A one-sided p<0.025 will be used as the cutoff for statistical significance, because non-inferiority is hypothesized.

Objective 2 Study 2: Evaluation of the implementation of the digital transition program Design: for this evaluation, a mixed methods approach will be used, meaning a combination of quantitative and qualitative methods will be used.

Participants: adolescents who participated in the digital transition program as well as the nurses in charge of delivering the transition program (i.e., transition coordinators) will be included in this section. Additionally, personal from the adult healthcare unit will be interviewed.

Sample size: all participants from study 1 will be included in the quantitative assessment of this study. In the qualitative assessment, between 10-15 adolescents and around 10 healthcare providers will be interviewed.

Data collection: to describe the intervention's reach and fidelity, information on the number of participants that took part in the different components will be monitored. To identify perceived barriers and facilitators, as well as intervention fidelity, both the adolescents and healthcare providers will be interviewed individually. To evaluate the usability and user friendliness of the digital platform, a questionnaire will be answered. This questionnaire will be answered once they have finalized the transition program, meaning it will be included in the set of questionnaires the participants answer in study when they are 18,5 years. Lastly, a percentage of the digital meetings will be audio recorded and the care plans related to the intervention will be studied to understand the mechanism of delivery.

Study Type

Interventional

Enrollment (Estimated)

100

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Sweden
      • Gothenburg, Sweden, 41674
        • Not yet recruiting
        • Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg
    • Vastra Gotalandsregionen
      • Gothenburg, Vastra Gotalandsregionen, Sweden, 416 50
        • Recruiting
        • Queen Silvia Childrens hospital, Sahlgrenska university hospital
        • Contact:
        • Contact:
        • Principal Investigator:
          • Ewa-Lena Bratt, Professor

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult

Accepts Healthy Volunteers

No

Description

Participants:

Arm A - Literate and Swedish-speaking adolescents with asthma/allergy or went through a solid organ transplantation aged minimum 15 years. Their parents will be asked to fill out one questionnaire (proxy).

Arm B:

- Literate and Swedish-speaking adolescents with asthma/allergy or went through a solid organ transplantation aged minimum 15 years. Their parents will be asked to fill out one questionnaire (proxy).

Sample size calculation:

Arm A: approximately100 patients will be recruited consecutively. Arm B: the approximate sample for individuals who received the intervention in-person is of

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Supportive Care
  • Allocation: Non-Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Arm A
Arm A involves a pre-test/post-test design where individuals will participate in the digital delivery of the transition program.
Behavioral: Stepstones transition program
The STEPSTONES transition program is an 8-component intervention designed to support adolescents with chronic conditions transitioning to adult care. It includes: a transition coordinator (TC), education about the condition, phone support, guidance on transitioning to adult care, parental guidance, peer meetings, a personalized transition plan, and the actual transfer to adult care. The intervention is implemented in five steps, starting with outpatient visits and culminating in the transfer to adult care. Delivered via the "Mitt vårdmöte" digital platform, the program includes the HEADDDSS adolescent health interview and is conducted by trained specialized nurses.
Other: Arm B
Arm B is a historical comparison cohort that includes participants from two previous RCTs who received the intervention (the transition program) in-person.
Behavioral: Stepstones transition program
The STEPSTONES transition program is an 8-component intervention designed to support adolescents with chronic conditions transitioning to adult care. It includes: a transition coordinator (TC), education about the condition, phone support, guidance on transitioning to adult care, parental guidance, peer meetings, a personalized transition plan, and the actual transfer to adult care. The intervention is implemented in five steps, starting with outpatient visits and culminating in the transfer to adult care. Delivered via the "Mitt vårdmöte" digital platform, the program includes the HEADDDSS adolescent health interview and is conducted by trained specialized nurses.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Patient empowerment
Time Frame: At baseline T0 when the participant is 16 years with follow up at T1 when the participants are 18.5 years
Gothenburg Young Persons Empowerment Scale (GYPES)
At baseline T0 when the participant is 16 years with follow up at T1 when the participants are 18.5 years

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Satisfaction with transition
Time Frame: 18.5y
Transitional care EXPeriences Questionnaire
18.5y
Transition readiness
Time Frame: At baseline T0 when the participant is 16 years with follow up at T1 when the participants are 18.5 years
Readiness for Transition Questionnaire (RTQ)- adolescent version
At baseline T0 when the participant is 16 years with follow up at T1 when the participants are 18.5 years

Other Outcome Measures

Outcome Measure
Measure Description
Time Frame
Transition readiness
Time Frame: Parents fills out the questionnaire at baseline T0 when their adolescent (participant) is 16 years with follow up at T1 when the participant are 18.5 years
Readiness for Transition Questionnaire (RTQ)-parent version PROXY
Parents fills out the questionnaire at baseline T0 when their adolescent (participant) is 16 years with follow up at T1 when the participant are 18.5 years

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Göteborg University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

October 1, 2024

Primary Completion (Estimated)

December 31, 2027

Study Completion (Estimated)

September 30, 2028

Study Registration Dates

First Submitted

September 12, 2024

First Submitted That Met QC Criteria

February 7, 2025

First Posted (Actual)

March 25, 2025

Study Record Updates

Last Update Posted (Actual)

March 25, 2025

Last Update Submitted That Met QC Criteria

February 7, 2025

Last Verified

February 1, 2025

More Information

Terms related to this study

Keywords

Other Study ID Numbers

  • Digi Stepstones

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

UNDECIDED

IPD Plan Description

ethical considerations

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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