Critical analysis and systematic examination of rheumatic transitional care programmes

Author(s): Kiyoshi Sekiya


Identify current transitional care models for rheumatic and musculoskeletal illnesses (RMD), analyse their benefits and drawbacks, and promote a consensus initiative to provide transitional care guidelines.


To find papers describing transition programmes in RMD, a systematic review was done. For inclusion, a thorough description of the programme was necessary. Descriptive data was gathered, including the country of the project, the target diseases and patient ages, the resources, the transition process's components, and, when specified, the outcomes and quality measures. The following criteria were used to evaluate the programmes' quality: level of definition, program's evidence base, accessibility of quality indicators, and efficacy evidence.


In total, 27 papers from 8 programmes in 6 countries were found and analysed. Of these, 4 covered all RMDs, 3 were tailored specifically for patients with juvenile idiopathic arthritis (JIA), and 1 plan was general for chronic diseases and modified for RMD. A written transition policy, patientindividualized

planning and flexible transitional care, the designation of a transition coordinator role, the acquisition of knowledge and skills in self-management of care, decision-making, shared care, and communication between teams of paediatric and adult health care providers, and a planned transfer to adult rheumatology were all essential components of these transition programmes. Only two demonstrated effectiveness based on the predetermined outcome metrics.


RMD transitional care plans vary in terms of their organisational setup, personnel, and operational procedures. There are no established metrics for effectiveness or outcome. This data offers crucial perceptions and methods for creating transitional care in RMD.