Condition-related predictors of successful transition from paediatric to adult care among adolescents with Type 1 diabetes

Age-based challenges to type 1 diabetes management in the pediatric population

Type 1 diabetes is rising in the pediatric population, affecting approximately 1.2 million children and adolescents globally. Its complex pathogenesis involves the interaction between genetic predisposition and environmental factors, leading to T cell-mediated destruction of insulin-producing pancreatic beta-cells. This destruction results in insulin insufficiency and hyperglycemia. Hence, managing type 1 diabetes requires a comprehensive approach that includes various aspects such as blood glucose monitoring, insulin therapy, carbohydrate counting, caloric intake monitoring, considering family habits and food preferences, planning daily schedules, and incorporating physical activity. Children with type 1 diabetes encounter age-specific challenges in disease management that may exacerbate the risk of metabolic complications and adverse health outcomes. These risk factors may be neurological, physiological, behavioral, psychological, or social, complicate management and necessitate tailored approaches for effective care. Regardless of the age group, primary caregivers have a high responsibility to maintain optimal glycemic control, including monitoring diet, daily activity, and administering insulin. By reviewing research on the challenges faced by pediatric patients with type 1 diabetes, we summarized key insights aimed at developing targeted interventions and support systems that enhance diabetes management and improve health outcomes in this vulnerable population.

From pediatric to adult care: a survey on the transition process in type 1 diabetes mellitus and the diabetes services in Italy

AIMS

The present study assessed the transitioning process of young adults with type 1 diabetes mellitus (T1D) in Italy.

MATERIALS AND METHODS

We asked Pediatric Diabetes Centers (PDC) and Adult Diabetes Centers (CAD) to fill in a web-based survey on the current state of services, the number of transitioning adolescents with T1D within the last year, observations on limitations, and future directions.

RESULTS

93 centers (46 PDCs, 47 CADs) joined the study. The total number of subjects with T1D being followed by a PDC was 16,261 (13,779 minors and 2483 young adults), while CADs had 25,500 patients. The survey showed an uneven situation. Only some services had a dedicated diabetes team (78% of PDCs, 64% of CADs). 72% of PDCs and 58% of CADs reported a protocol dedicated to transition. The median age for transition was 19 (range 16-25 years); the time required for preparing transition, indicated by both PDCs and CADs, was 5.5 months. A high percentage of CADs (80%) confirmed receiving sufficient clinical information, mainly through paper or computerized reports. The transition process is hampered by a lack of resources, logistical facilities, and communication between services. While some services have a protocol, monitoring of results is only carried out in a few cases. Most specialists expressed the need to enhance integration and continuity of treatment.

CONCLUSIONS

The current situation could be improved. Applying standard guidelines, taking into consideration both clinicians' and patients' necessities, would lead to a more successful transition process.

Lack of consideration of socioeconomic factors in transition programme of adolescents with type 1 diabetes: A systematic review

The transition of adolescents with type 1 diabetes should be organized such that loss of follow-up and deterioration of patients' metabolic control are minimized.

OBJECTIVE

Our study aimed to ascertain whether socioeconomic status is featured in the characteristics of adolescents with type 1 diabetes in transition programmes and their inclusion in transition programmes.

RESEARCH DESIGN AND METHODS

A systematic review of the literature was performed according to PRISMA recommendations. All articles published between 2010 and 2023 were considered. Studies that described a transition programme for adolescents or young adults with T1DM were included.

RESULTS

After screening, 18 studies were included. Different transition programmes were proposed (exchanges between professionals, coordinators, and transition clinics). Nine articles described socio-economic factors. The educational level was the most frequently reported. Only three studies evaluated the impact of one parameter on transition success: a lower education level was associated with more hospital visits for hyperglycaemia, and the other did not report any socioeconomic factor associated with clinic attendance.

CONCLUSIONS

The socioeconomic status of type 1 diabetes is poorly described in transition programmes, and the few that do make mention of it, offer little information about patient management.

[The value of assessing the socioeconomic context during the transition of adolescents with type 1 diabetes]

The follow-up of diabetic patients is marked by a period of transition from pediatric care to adult services. The major challenge of this transition is to ensure continuity of care under the best possible conditions. Socio-economic factors must be taken into account to ensure that care is adapted to patients' needs.

Use of continuous subcutaneous insulin infusion versus multiple daily injections in emerging adults with type 1 diabetes is associated with better clinical engagement but not glycaemic control

BACKGROUND

Limited studies have compared outcomes between emerging adults with type 1 diabetes mellitus (T1D) attending a diabetes transition support programme using multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII).

AIMS

To assess glycaemic control and service utilisation in emerging adults with T1D on MDI or CSII attending a young adult diabetes clinic (YAC).

METHODS

A retrospective cohort analysis was conducted from January 2013 to December 2015. Data collected included clinic visits per year, after-hours mobile telephone use, diabetic ketoacidosis (DKA) admissions and all HbA1c levels. Independent t-test was used to compare continuous variables whilst Pearson's Chi-squared test was used for categorical variables. Linear mixed effects models explored mean changes in HbA1c levels over time.

RESULTS

Over 3 years, 318 youth with T1D (176 MDI, 121 CSII, 21 switched from MDI to CSII) attended our YAC. Aggregated mean HbA1c levels remained similar between modalities (CSII 9.1% vs MDI 9.3%; P = 0.23); however, mean change in HbA1c at 3 years was significantly increased in CSII users at 0.55% (95% CI 0.15-0.95; P < 0.01) compared with no significant change in MDI users. Clinic visits per year were improved in CSII users (CSII 2.8 vs MDI 2.5; P = 0.02), while DKA admissions remained similar between MDI and CSII users (3.6 admissions per 100 patient-years).

CONCLUSION

In our YAC cohort, glycaemic control in CSII and MDI users was similar but well below recommended international glycaemic targets (HbA1c level < 7.0%). Despite increased clinical engagement occurring in CSII users, glycaemic deterioration was observed over the 3 years.

Managing the unmanageable through interdependence in adolescents living with type 1 diabetes and their parents: A constructivist grounded theory

BACKGROUND

Management of T1D is complex and requires continuous care and monitoring that place many demands on adolescents with T1D and their parents. The purpose of this study was to explore the nature of interdependence with T1D management with adolescents and their parents.

METHODS

Using a constructivist grounded theory methodology, 32 open-ended interviews were conducted, transcribed, and analyzed from 11 adolescents aged 10-18 years with T1D and eight parents.

FINDINGS

The data were coded using three coding phases: initial, focused, and theroetical and this process continued until theroetical saturation was reached. The substantive theory that emerged from the data describing parents' and adolescents' main concern of Maintaining Optimal Glycemic Control was Managing the Unmanageable through Interdependence. Four related subprocesses were found: Completing T1D Tasks, Attaining Support, Balancing Independence, and Reconciling Reality. These subprocesses occurred within the context of the ever-changing, Nature of the Illness.

DISCUSSION

There is a dynamic relationship associated with interdependence between adolescents with T1D and their parents that varied situationally and by age. Participants also indicated interdependence occurs or they would like it to occur, with others beyond themselves and the health-care team to others willing to be involved.

APPLICATION TO PRACTICE

Interdependence is a dynamic process and requires ongoing evaluation by health-care professionals of its function in the daily management of T1D by parents and adolescents. Additional research into of the roles of health professionals and others in promoting interdependence is needed.

Community-based accompaniment for adolescents transitioning to adult HIV care in urban Peru: a pilot study

We piloted a community-based intervention to improve outcomes among adolescents living with HIV who were transitioning to adult-oriented care in Lima, Peru. We assessed feasibility and potential effectiveness, including within-person changes in self-reported adherence, psychosocial metrics (NIH Toolbox), and transition readiness (“Am I on TRAC” questionnaire, “Got Transition” checklist). From October 2019 to January 2020, we enrolled 30 adolescents (15–21 years). The nine-month intervention consisted of logistical, adherence and social support delivered by entry-level health workers and group sessions to improve health-related knowledge and skills and social support. In transition readiness, we observed within-person improvements relative to baseline. We also observed strong evidence of improvements in adherence, social support, self-efficacy, and stress, which were generally sustained three months post-intervention. All participants remained in treatment after 12 months. The intervention was feasible and potentially effective for bridging the transition to adult HIV care. A large-scale evaluation, including biological endpoints, is warranted.

A multi-center pediatric to adult care transition intervention program to improve clinic visit adherence and clinical outcomes among adolescents and emerging adults with type 1 diabetes mellitus [PATHWAY]: Protocol for a randomized controlled trial

OBJECTIVE

This multi-center randomized controlled trial aims to evaluate the effectiveness of a context-specific transition intervention program to improve clinic visit adherence and clinical outcomes among emerging adults with type 1 diabetes mellitus (T1DM) in Delhi, India.

METHODS

We will recruit patients with T1DM of duration ≥1 year and age 15-19.5 years from the participating pediatric sites. After a baseline assessment and a "basic introductory session", which apprises participants about the concept of transition, study participants (proposed sample size =156) will be randomly allocated into an intervention and control arm. Participants in the intervention arm will receive a structured transition program delivered over a period of 15 months. On the other hand, control arm participants will continue to receive usual care from the pediatric site till the time of transfer to the adult site. The study assessments will be done at baseline, at the time of transfer, and at 1 and 2 years following the transfer. The primary outcome is the difference in clinic attendance rate between intervention and control arms at the end of 1-year post-transfer.The secondary outcomes include the difference in clinic attendance rate at the end of 2 years, difference in proportion of participants with a minimum of 4 visits in the first follow-up year, and process indicators such as diabetes knowledge and self-management skills, diabetes treatment satisfaction, overall quality of life, diabetes-related distress, hospitalization for acute complications and screening for chronic diabetes complications, and HbA1c.

CONCLUSION

This study will provide important new evidence about a potential strategy to improve clinical care among adolescents and emerging adults with T1DM in lower resource contexts during the vulnerable phase of transition from pediatric to adult healthcare. The trial is registered on the Clinical Trials Registry of India (http://ctri.nic.in) under the CTRI registration number CTRI/2020/10/028379.

Patient and family perspectives of a Pre-Transition Visit in a paediatric tertiary care diabetes clinic

INTRODUCTION

The need to better prepare youth with type 1 diabetes for the transition from paediatric to adult care is evident. As part of a regional quality improvement initiative, a novel Pre-Transition (Pre-T) Visit was developed and piloted at a paediatric tertiary care centre in January 2018 for patients aged 15-18 years to capture the status of their self-management skills, introduce transition tools and identify self-care goals and knowledge gaps to be addressed prior to transition.

PURPOSE

To evaluate patient and family satisfaction, visit relevance and patient engagement with a novel Pre-T Visit.

METHODS

From May 2019 to March 2020 a survey was offered to all youth who attended a Pre-T Visit and their parent(s)/caregiver(s). Patient and family satisfaction with, relevance of and engagement with the Pre-T Visit were evaluated using a 5-point Likert scale. Multivariable regression was used to assess patient factors associated with patient level satisfaction.

RESULTS

Of the 63 youth who participated in a Pre-T Visit, 60 completed the survey. Mean age (SD) of participants was 16.7 (0.8) years; 47% were female. Mean (SD) haemoglobin A1C (A1C) was 8.2% (1.8). Patients reported high levels of satisfaction (95% quite or extremely satisfied) that were consistent across age, A1C, gender and disease duration. Visit relevance and engagement were also rated highly by youth. Parent participants (n=27) also reported high levels of satisfaction (89% quite or extremely satisfied) and relevance.

CONCLUSIONS

Pre-T Visits were rated highly by patients and their parents. Their impact on glycaemic control and health outcomes following transition requires further study.

Exploring the attitudes and experiences of adolescents with type 1 diabetes towards transition of care

Introduction

Transition from adolescence to adult care is very challenging for most patients. Without appropriate appointments and education, adolescents can get lost to follow up within one-year of transitioning to adult care (Mistry et al. Diabet Med 32(7):881–885, 2015). Loss to follow-up can increase risks of adverse short and long term diabetes-related complications, with healthcare contacts mainly limited to crisis-based management (Iversen et al. Scand J Caring Sci 33(3):723–730, 2019).

Aims

The purpose of this study was to evaluate the patient’s perspective of the process of transition from paediatric to adult-based diabetes services in the Mid-West Region of Ireland.

Methods

We implemented a new transition clinic at University Hospital Limerick with the collaboration of paediatric and adult endocrinology teams. Eighteen patients opted to attend the clinic, but only 17 patients consented to participate in a qualitative assessment study and completed questionnaires before and after the transition clinic.

Results and conclusion

In terms of medical management, patients had a good understanding of hypoglycaemia and insulin dose adjustment principles, but were least comfortable with carbohydrate counting. Patients self-ranked their knowledge on driving and sexual health with a diagnosis of diabetes as poor, in comparison to understanding effects of alcohol and smoking on diabetes. Overall, a majority of the respondents felt more confident in moving to adult-care after attending the transition clinic.

Risk Factors for Adverse Outcomes in Adult and Pediatric Patients With Hyperglycemia Presenting to the Emergency Department: A Systematic Review

Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes. This review aimed to identify predictors of adverse outcomes, such as repeated hospital visits, hospitalization or death, in patients presenting to the emergency department (ED) with hyperglycemia. Electronic searches of Medline and EMBASE were conducted for studies in English of patients presenting to the ED with hyperglycemia. Both adult and pediatric populations were included, with and without diabetes. Two reviewers independently screened all titles and abstracts for relevance. If consensus was not reached, full-length manuscripts were reviewed. For discrepancies, a third reviewer was consulted. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were extracted and presented descriptively. Eight observational studies were reviewed; they included a total of 96,970 patients. Predictors of adverse outcomes included age, lowest income quintile, urban dwellers, presence of comorbidities, coexisting hyperlactatemia, having a family physician, elevated serum creatinine level, diabetes managed with insulin, sentinel visit for hyperglycemia in the past month, and high blood glucose level measured in the ED. Conflicting evidence was found for whether known history of diabetes was associated with risk. Factors associated with favourable outcomes included systolic blood pressure of 90 to 150 mmHg and tachycardia. This systematic review found 12 factors associated with adverse outcomes, and 2 factors associated with more favourable outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of patients at higher risk for adverse outcomes to guide management and follow up.

Diabetes transition care and adverse events: a population-based cohort study in Ontario, Canada

AIMS

To describe patterns of primary and diabetes care during transition age (17 to < 19 years) into early adulthood (age 19 to 26 years), and to evaluate the association of primary and diabetes care patterns during transition age with the risk of adverse events in early adulthood.

METHODS

We conducted a population-based cohort study of individuals in Ontario, Canada who were diagnosed with diabetes aged < 15 years and who turned 17 between November 2006 and March 2011, followed until March 2015 (n = 2525). Using linked administrative databases, we examined healthcare use during: 'pre-transition-age' (15 to < 17 years), 'transition-age' (17 to < 19 years), and 'early adulthood' (19 to 26 years). The main outcomes were time to death or ketoacidosis and rate of diabetes-related admissions. The main exposures were the gap in diabetes care and primary care visits during transition age.

RESULTS

There were < 6 deaths and 446 individuals (17.7%) had at least one admission for ketoacidosis during early adulthood. In all, 1188 individuals (47.0%) had a > 12-month gap in diabetes care and 241 (9.5%) had no primary care visits during transition age. A gap in diabetes care of > 12 months and no primary care visits during transition age were associated with an increased risk of ketoacidosis or death (adjusted hazard ratio 1.31, 95% CI 1.04-1.66 and adjusted hazard ratio 1.42, 95% CI 1.02-1.97, respectively).

CONCLUSIONS

In Ontario, Canada, where physician and hospital-based services are universally covered, a high proportion of young adults with diabetes have insufficient care during transition age and this is associated with a higher risk of important adverse outcomes in early adulthood. Ensuring primary care involvement during transition may be a strategy to reduce morbidity.

Who, where, and why are patients lost to follow-up? A 20-year study of bladder exstrophy patients at a single institution

INTRODUCTION

Individuals with bladder and cloacal exstrophy are at increased risk for kidney disease, renal failure, and bladder complications. Given the social implications and sensitive nature of the disease, these patients are also at risk for psychosocial problems. Lack of regular medical follow-up visits may pose serious risks to their long-term health status. The aim of this study is determine what factors place an affected individual at risk for limited long term follow up.

MATERIALS AND METHODS

We identified all patients with bladder or cloacal exstrophy seen by the pediatric urology department at the Oklahoma University Health Sciences Center (OUHSC) between January 1996 and August 2016. Patient data included demographics, insurance coverage, distance from patient's home to the clinic, medical and surgical history, and the date of their last clinic visit. Two groups for comparison were (1) those that had been seen within the last 2 years, and (2) those that were counted as failing to maintain follow-up because 2 or more years had passed since their last clinic visit. These groups were compared using the Student t-test, the chi-square test, or the Fisher exact test and p < 0.05 was treated as significant for the purposes of discussion.

RESULTS AND DISCUSSION

Ninety-one patients with bladder or cloacal exstrophy were seen by the pediatric urology department between January 1996 and August 2016. Of the 91 patients, 24 left the clinic for known reasons thus leaving 67 patients that were considered for analyses: 51 had been seen within the last 2 years while 16 were counted as lost to follow-up. These two groups (active and lost to follow-up) did not differ significantly for age at last clinic visit, distance between family's home and clinic, history of bladder reconstruction, sex, or insurance status. There was a significant difference between the two groups in the medical complexity of their condition. The group active in urological care had more patients with cloacal exstrophy and additional anomalies than the group lost to follow-up.

CONCLUSIONS

Patients with bladder exstrophy and cloacal exstrophy are less likely to maintain annual follow-up visits with their urologist if they have a simpler diagnosis requiring fewer surgical interventions. For patients with exstrophy, regular clinic visits prioritizing education and psychosocial support may prevent hospitalizations, emergency interventions, and poor overall health outcomes. To maintain contact with the medical team and promote optimal health outcomes, a social worker or care coordinator/educator may play an integral part in addressing the unique needs of this population.

Transition to adult diabetes care in Germany-High risk for acute complications and declining metabolic control during the transition phase

OBJECTIVE

There is evidence that transition from pediatric to adult health care is frequently associated with deterioration of health in youths with type 1 diabetes (T1D). The aim of this study was to compare metabolic control, acute complications and microvascular complications in adolescents and young adults before and after transfer to an adult treatment center with respect to the time between first visit in the adult center and last visit in pediatric treatment.

METHODS

All data were collected during routine care and retrieved from the German/Austrian DPV database. We analyzed data as of March 2017.

RESULTS

We found 1283 young adults with available data of the last pediatric treatment year and the first year after transition to adult care. HbA1c increased significantly from 8.95% (74 mmol/mol) before to 9.20% (77 mmol/mol) in the first year after transition. Frequency of DKA with hospitalization (0.10-0.191 per annum, P < .0001) and severe hypoglycemia (0.23-0.46 per annum, P = .013) doubled during transition. Microvascular complications increased dramatically depending on the time between first visit in adult treatment and last visit in pediatric care. We could not find a significant correlation of this rise of microvascular complications to the duration of transition (short or long).

CONCLUSION

This phase of life bears a high risk for detrimental outcome in young adults with T1D. Structured transition programs with case management are therefore needed to improve the transition process and outcomes.

Clinic attendance and disengagement of young adults with type 1 diabetes after transition of care from paediatric to adult services (TrACeD): a randomised, open-label, controlled trial

BACKGROUND

Care transition from paediatric to adult services for young adults with type 1 diabetes is frequently associated with decreased attendance at outpatient hospital clinics and increased disengagement from specialist services. We aimed to assess the effect of an appointment-management intervention on clinic attendance and disengagement after transition.

METHODS

We did a randomised, open-label, controlled trial of patients aged 17-19 years with type 1 diabetes. Participants were recruited from a tertiary paediatric diabetes service at the Royal Children's Hospital (Melbourne, VIC, Australia) and had to be scheduled for transition to adult services at one of eight centres in Melbourne. We randomly assigned participants (1:1), using sequential sealed opaque envelopes, to either appointment management (intervention) or current care (control). The appointment manager acted as the point of contact between intervention group participants and the relevant adult clinics, and provided personalised pre-appointment telephone and short message service (SMS) reminders with automatic rebooking of missed appointments. No contact was initiated with the control group after recruitment, and any self-initiated contact with the investigating team was directed to the participant's previous treating paediatric physician. The intervention continued throughout the trial until at least 12 months of follow-up data were obtained for all participants. We assessed the mean frequency of adult clinic attendance and disengagement from services during 0-12 months after transition (primary outcomes) and 12-24 months after transition (secondary outcomes), analysed by intention to treat. We used regression analyses, adjusted for clinic attendance and glycated haemoglobin concentration pre-transition, to analyse the effect of the intervention. This study is registered with the Australian New Zealand Clinical Trials Registry (number ACTRN12611001012965).

FINDINGS

Between Jan 4, 2012, and Dec 31, 2014, we randomly assigned 120 individuals, 60 to the intervention and 60 to control. During 0-12 months after transition, the mean number of clinics attended was 2·3 (SD 1·1) in the intervention group and 2·3 (1·4) in the control group (p=0·84; adjusted β 0·1, SE 0·2, p=0·88); three (6%) of 49 participants in the intervention group and six (11%) of 55 in the control group disengaged from services (p=0·38; adjusted odds ratio [OR] 0·5, 95% CI 0·1-2·3, p=0·36). At 12-24 months post-transition, mean clinic attendance was 2·5 (SD 1·3) in the intervention group and 1·4 (SD 1·8) in the control group (p=0·001; adjusted β 0·9, SE 0·4, p=0·009); two (6%) of 32 in the intervention group and 18 (49%) of 37 in the control group disengaged from services (p=0·001; adjusted OR 0·1, 95% CI 0·1-0·2, p=0·001). Neither the intervention nor pre-transition clinic attendance had an independent effect on glycated haemoglobin after transition.

INTERPRETATION

Appointment management did not increase clinic attendance and did not decrease disengagement with services 0-12 months after transition to adult services, but had a positive effect during 12-24 months after transition.

FUNDING

Australasian Paediatric Endocrine Group and Lilly.

Clinical, behavioural and social indicators for poor glycaemic control around the time of transfer to adult care: a longitudinal study of 126 young people with diabetes

AIMS

To describe and compare changes in glycaemic control in young people with Type 1 diabetes over time between the last 2 years in paediatric care and the first 2 years in adult care and to identify risk factors for poor glycaemic control.

METHODS

Our retrospective cohort study followed participants aged 14-22 years from 2 years before to 2 years after transfer from paediatric to adult care. Changes in glycaemic control were calculated using repeated measurements. We adjusted for gender, age at diabetes onset, age at transfer, duration of diabetes at transfer, gap (amount of time) between last paediatric and first adult visit, comorbidity, learning disability and/or mental health conditions and family structure. We examined associations between acute hospital admissions, low visit attendance rate, loss to follow-up and baseline HbA_1c level.

RESULTS

Among 126 participants, the mean HbA_1c level was 80 mmol/mol (9.4%) pre-transfer but decreased by an average of 3 mmol/mol (0.3%) each year post-transfer (P = 0.005). Young people with a learning disability and/or a mental health condition had worse glycaemic control (P = 0.041) and the mean HbA_1c of those with divorced parents was 14 mmol/mol (1.2%) higher (P = 0.014). Almost one-third of participants were admitted to the hospital for acute diabetes care. Low visit attendance rate, high baseline HbA_1c level, learning disability and/or mental health conditions and divorced parents predicted acute hospital admissions.

CONCLUSIONS

Glycaemic control improved significantly after transfer to adult care, but the mean HbA_1c level remained high. Future interventions should focus on young people with divorced parents, those with a learning disability and/or mental health condition and those who do not attend clinical visits to improve HbA_1c levels and thereby reduce hospitalization rates.

Evaluating outpatient transition clinics: a mixed-methods study protocol

INTRODUCTION

To support young people in their transition to adulthood and transfer to adult care, a number of interventions have been developed. One particularly important intervention is the transition clinic (TC), where paediatric and adult providers collaborate. TCs are often advocated as best practices in transition care for young people with chronic conditions, but little is known about TC models and effects. The proposed study aims to gain insight into the added value of a TC compared with usual care (without a TC).

METHODS AND ANALYSIS

We propose a mixed-methods study with a retrospective controlled design consisting of semistructured interviews among healthcare professionals, observations of consultations with young people, chart reviews of young people transferred 2-4 years prior to data collection and questionnaires among the young people included in the chart reviews. Qualitative data will be analysed through thematic analysis and results will provide insights into structures and daily routines of TCs, and experienced barriers and facilitators in transitional care. Quantitatively, within-group differences on clinical outcomes and healthcare use will be studied over the four measurement moments. Subsequently, comparisons will be made between intervention and control groups on all outcomes at all measurement moments. Primary outcomes are 'no-show after transfer' (process outcome) and 'experiences and satisfaction with the transfer' (patient-reported outcome). Secondary outcomes consider clinical outcomes, healthcare usage, self-management outcomes and perceived quality of care.

ETHICS

The Medical Ethical Committee of the Erasmus Medical Centre approved the study protocol (MEC-2014-246).

DISSEMINATION

Study results will be disseminated through peer-reviewed journals and conferences. The study started in September 2014 and will continue until December 2016. The same study design will be used in a national study in 20 diabetes settings (2016-2018).

Technology Use in Transition-Age Patients With Type 1 Diabetes: Reality and Promises

Youth with chronic illnesses have the greatest risk for a decline in their health management during transition-age. Because of this demonstrated and well-known issue, research has focused on how to improve the transition of care process. Despite the increasing number of technological devices on the market and the advances in telemedicine modalities available to patients with type 1 diabetes (T1D), the utilization of technology is still suboptimal among patients of transition-age (ages 13-25). This article reviews the available resources, patterns of use in transition-age youth, and explores opportunities to advance technology use in transitioning patients with T1D from pediatric to adult care.

Type 1 diabetes: addressing the transition from pediatric to adult-oriented health care

Adolescents and young adults with type 1 diabetes are at risk for poor health outcomes, including poor glycemic control, acute and chronic complications, and emergency department admissions. During this developmental period, adolescent and young adult patients also experience significant changes in living situation, education, and/or health care delivery, including transferring from pediatric to adult health care. In recent years, professional and advocacy organizations have proposed expert guidelines to improve the process of preparation for and transition to adult-oriented health care. However, challenges remain and evidence-based practices for preparing youth for adult health care are still emerging. Qualitative research suggests that adolescent and young adult patients rely on health care providers to guide them through the transition process and appreciate a gradual approach to preparing for adult-oriented health care, keeping parents in supportive roles into young adulthood. Patients also benefit from specific referrals and contact information for adult care providers. Promising models of transition care include provision of transition navigators, attendance at a young adult bridge clinic, or joint visits with pediatric and adult care providers. However, much of this research is in its early stages, and more rigorous trials need to be conducted to evaluate health outcomes during transition into adult health care. The purpose of this review is to provide an overview of the transition process, patient and health care provider perceptions of transition care, and emerging evidence of successful models of care for engagement in adult-oriented health care. Recommendations and resources for health care providers are also presented.

Improving the Transition from Pediatric to Adult Diabetes Healthcare: A Literature Review

Effective transition to adult care is a significant component of an emerging adult's diabetes care. Poor transition places them at risk for disengagement with the health care system and for poor diabetes-related outcomes. The purpose of this paper was to review the literature to date on existing methods of transition care delivery for emerging adults with diabetes. We conducted a literature review using MEDLINE via OvidSP and searching the grey literature. Papers published in English between January 1, 2000 and March 25, 2015 that evaluated transition care programs for emerging adults with diabetes were included. 16 original studies, 1 study protocol and 1 technical brief describing transition programs were reviewed. Common components of care included transition care coordination, young adult clinics, transition preparation, familiarity with adult health care providers and support groups. Overall, when emerging adults are supported during the transition period, clinic attendance and glycemic control can be maintained or improved, and diabetes-related complications reduced. Despite widespread support in the literature for the need for structured transition care delivery, methodologically strong research evaluating transition care services remains limited. The literature to date encompasses a variety of care models that lack consistency in outcome measurements as well as lacking frameworks describing the interventions, which impedes comparison across studies. Further research, using a consistent framework for transition care program design, delivery and evaluation as well as reporting of outcomes, is needed to inform how best to deliver transition care services to this vulnerable population.