Using an integrated knowledge translation (iKT) approach [34], an iKT panel comprising youth, caregivers, interdisciplinary health care providers, and health system leaders will be established at the outset of the project. The iKT panel will collaborate with the research team to ensure that the study methodology and materials are appropriate and youth- and family-centered. We will then conduct a 3-round Online Modified Delphi (OMD) study to prioritize a set of quality indicators for transition across chronic physical, developmental, and mental health conditions that are most important, useful, and feasible for Canadians. Findings will be reported in accordance with the ACcurate COnsensus Reporting Document (ACCORD) reporting guideline [35].

iKT is defined as a dynamic collaboration between researchers and knowledge users, or those with the authority to enact change, in the synthesis, dissemination, and application of knowledge. An iKT panel with diverse representation will be established and comprise an equal distribution of youth, caregivers, health care providers, and health system leaders in addition to the research team. Panel members will be recruited using the research team’s pre-existing relationships with key knowledge users, including leading organizations in child and youth health in Canada. Purposive recruitment will ensure knowledge users with varied backgrounds who can represent transitional care issues that are specific to rural, remote, Francophone, Indigenous, and immigrant communities are included. We will use the best practice activities outlined in the Canadian Institutes of Health Research’s (CIHR’s) Strategy for Patient-Engagement in Research, in addition to the Ontario Brain Institute (OBI) framework to facilitate engagement with participants and to collaborate [36-38].

The iKT panel will meet on a quarterly basis and be actively engaged throughout the research process. Decision-making processes will occur through active discussion in panel meetings and written feedback. The primary activity of the iKT panel will be to work with the research team to refine the previously identified quality indicators for transition [21] (n=169) to present to the OMD participants minimizing participant burden. Further, the iKT panel will be responsible for finalizing the criteria (eg, importance, usefulness, and feasibility) used to rate quality indicator categories and determining the decision rules for achieving consensus. The panel will also help to inform participant recruitment strategies, consult on the development of supplemental materials for participants in the OMD study (eg, project goals, processes, and timeline), ensure concepts and materials used in the OMD are easily understood and methods used are appropriate for youth and caregivers, and inform the strategies for knowledge dissemination.

Once the quality indicators for transition have been refined, the rating criteria have been finalized, and the decision rules for achieving consensus have been established, we will conduct a 3-round OMD study to prioritize the quality indicators. Each category of quality indicator will be individually rated on the proposed categories of importance and feasibility. These rating scales have been adapted from a previous study aimed at developing quality indicators to evaluate health system performance [39]. The OMD process will follow the RAND guidance for conducting Delphi studies and consists of 2 concurrently run panels [40].

The OMD panels will be administered using ExpertLens, an online platform for conducting OMD studies developed by RAND, which has been instrumental in advancing consensus-building methodologies. ExpertLens has been used previously for quality indicator development in Canada [39,41] and allows for conducting RAND/UCLA Appropriateness panels (a gold standard for developing clinical guidelines and quality indicators) completely online [42]. The RAND/PPMD Patient-Centeredness Method (RPM)—a recently developed approach for engaging patients and caregivers in guideline development—also used the ExpertLens platform, which shows the feasibility and benefits of soliciting patient and caregiver input in clinical processes [43,44].

We will use a previously developed multistage analytic approach to analyzing ExpertLens data [28]. We will examine data from each panel and expert group separately and then compare the results to establish a prioritized set of proposed quality indicators using a 3-step approach described below.

First, we will use descriptive statistics (ie, medians and interquartile ranges) to identify how participants within each panel and across the 2 panels viewed each quality indicator category in rounds 1 and 3.

Second, we will use the RAND/UCLA Appropriateness Method (RAM) manual’s [47] approach to determine if consensus was reached within each expert group and panel after rounds 1 and 3. ExpertLens will automatically do this and display round 1 results to participants in rounds 2 and 3. Round 3 ratings will be used to determine the final study results and address aims. RAM [47] uses the distribution of panel responses to determine if participants agree or disagree with each other and relies on the median value to indicate if the panel’s determination is positive, negative, or uncertain.

Third, we will use round 3 data for each indicator category to determine which category is endorsed by each panel. We will identify indicator categories rated highly (median score of 6.5 and above without disagreement) on all rating criteria and automatically include them for further consideration [42].

Finally, we will determine the replicability of the final panel results by calculating a κ coefficient for each indicator category. If the κ statistic is at least moderate (0.41-0.60), we will consider the level of replicability of panel ratings to be acceptable [48]. This threshold is considered conservative. Conducting 2 concurrently run panels will not only help us identify indicators with the highest level of agreement but also increase confidence in our final study results. The final list of endorsed indicator categories will include those rated highly on importance and feasibility by both panels.

To better explain panel and expert group ratings of different indicators, we will analyze participants’ explanations of ratings and discussion comments via content analysis [44,47,49]. For each panel separately, we will group all comments for each indicator and rating criterion based on the numeric ratings to which they refer; we will also group all discussion comments by the indicator on which they focus. The coding team will review and code all qualitative comments inductively to identify themes that could be used to explain why a certain quality indicator was considered important, useful, or feasible or if experts have similar perspectives [50]. All coding results will be reviewed by DK to ensure consistency in applying the codebook; AT and other study team members will review coding results to ensure the correct clinical interpretation of comments and appropriateness of conclusions.

This study will be heavily influenced by patient and public involvement. Key knowledge users in transition to adult care—youth, caregivers, multidisciplinary health care providers, and health system leaders—will form an iKT panel. This iKT panel will collaborate with the research team to help inform patient facing study materials, recruitment and knowledge dissemination strategies of this research. This is particularly important as the perspectives of youth and caregiver knowledge users are paramount. These youth and caregiver knowledge users will be essential for developing plain language summaries of the research findings that are relevant and accessible to the public.

Ethics approval has been obtained from The Hospital of Sick Children (1000080241). The study has been reviewed and considered to be exempt by the RAND’s Human Subjects Protection Committee. Informed consent will be obtained before the start of the OMD study.

The study is supported by funding from the CIHR through the Transitions in Care (TiC) Team Grant (funding reference number TRC 184533) and Physicians Services Incorporated (PSI; grant number 22-20). A 16-member iKT panel has been established to be actively involved in the preparation for the OMD. Enrollment will begin in September 2024 and the first round of the OMD will commence in October 2024. The study results are expected to be published in late 2026.

We will leverage our partnerships with key knowledge users to promote rapid knowledge mobilization of the key quality indicators, with a primary focus on national-level knowledge dissemination to multiple relevant knowledge users. Our knowledge users have a proven track record of mobilizing knowledge to guide policy decisions and influence clinical practice. We will also engage primary care and community leaders through provincial- and national-level workshops, webinars, and media releases on the findings and implications for practice. Many members of the research team are affiliated or situated within pediatric and adult tertiary care and community clinics providing transition support and care to patients. As such, our results will be translated directly and immediately into these services.

Our study findings will be shared at national and international conferences and published in leading open access journals with youth and caregivers as coauthors. Together with our iKT panel, we will explore the information needs of our youth and families and ensure voices from diverse communities and populations are heard to realize a flexible and clear communication plan. Plain-language summaries with messages that are clear, simple, and individualized for each knowledge user group will be developed to augment the accessibility of the information.

Our innovative and equity-focused approach will reveal the differences and similarities in perceptions among youth, caregivers, health care providers, and health system leaders or decision makers on priority quality indicators for transition. The formation of an iKT panel that includes the most important knowledge users, the youth with chronic health conditions and caregivers, will allow the view of youth and caregivers to have significant weight in the study findings.

This study will define a candidate set of quality indicators for transition to adult care that are relevant, feasible to implement, and have the potential to improve the quality of care for Canadian youth and families. This work will respond to the lack of standardized quality indicators for transition from pediatric to adult care in Canada, which has been a major bottleneck toward achieving high quality care for young adults with chronic health conditions.

This study will contribute readily applicable, adaptable, and relevant metrics to evaluate and benchmark transition outcomes nationally, addressing 3 major gaps in transition care and research. First, to reflect the needs and priorities of those receiving care, delivering services, and developing health care policies, we will engage with knowledge users involved in the continuum of transition care, including youth (ie, ages 18-24 years), caregivers, health care providers and health system leaders or decision makers. Using an iKT approach, we will appropriately engage and build collaborations with knowledge users throughout the research process [36]. Second, we will ensure demographic and sociocultural diversity among participants [45]. Nationally relevant benchmarks require representation from diverse geographical areas and practice settings [45]. To date, transition research has placed little emphasis on identifying the health system level practices that lead to inequitable transition care and subsequent negative health outcomes [47]. Our strong collaborations with key knowledge ensure that we are well positioned to recruit participants with diverse biological and sociocultural characteristics and lived experiences, including sex, gender, race or ethnicity, immigrant and refugee status, chronic disease, geography, and socioeconomic status [41], helping us to secure representation of diverse transition experiences from marginalized populations. Third, we will also focus on primary care integration. Adolescents with chronic health conditions should engage primary care services to meet their routine health care needs and maintain a continuous patient-provider relationship during the transition period to adult care [46]. An Ontario population–based cohort study by Toulany et al demonstrated youth with severe mental illness receiving no primary care during transition experienced an increased rate of mental health–related hospitalizations in young adulthood [48,49,51]. Despite this, transition research continues to focus on specialist providers [26,47].

This research study has several notable strengths that contribute to the field of transition care. One strength of the OMD is to define a key of consensus-derived quality indicators that are not only meaningful to youth and families but also useful and applicable for use by health care providers and decision makers. Secondly, the iKT approach will foster collaborations with key knowledge users to ensure the needs and priorities of those receiving care, delivering services, and developing health care policies are reflected throughout the research and dissemination process. Finally, the online approach will allow for a large number of participants with wide geographical distribution and the anonymity of discussions will help promote equal participation without the influence of perceived hierarchy, ensuring that all voices are heard and valued.

This study is not without some potential limitations. While we recognize that internet accessibility may pose a barrier for some potential participants specifically in rural areas, choosing ExpertLens will allow greater participation across the country. This platform allows participants to connect to the platform using any basic internet-connected devices, including mobile phones and tablets, addressing some technological barriers that may arise. Using a mixed panel of different expert groups may pose a challenge. To address this issue, all study materials will be written in clear and concise language that is easily comprehensible for both youth and caregivers. Attrition is a potential limitation within a 3-round Delphi as participants may drop out after round 1. To encourage engagement in all 3 rounds, incentives will only be provided at the end.

This study will produce a key set of quality indicators to evaluate and inform action to improve transition from pediatric to adult care for youth and their families equitably in Canada. Determining the most beneficial metrics from the perspectives of various knowledge users, most importantly youth and caregivers, is a fundamental step to identifying areas for improvement in transition, evaluating current processes, benchmarking across jurisdictions, and optimizing health outcomes for youth with chronic conditions into young adulthood.