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

Evaluation of the transition program at the University Hospital of Reims from 2015 to 2020

The transition of young type 1 diabetic (T1D) patients from pediatric to adult healthcare is a high-risk period of loss to follow-up. Since 2015, we have implemented a transition program, involving both pediatric and adult clinicians. The main objective was to evaluate the number of patients who had succeeded this transition program at 1 year. We found that 86% of patients underwent the complete transition program. However, adverse outcomes occurred in 19.1% of patients at 1 year but decreased to 2.9% after 3 years. In 63% of patients their HbA1c level had deteriorated 1 year after the transition day and this level stabilized at around 8% in the following 2 and 3 years. In patients who had improved HbA1c levels the body mass index was lower (P = 0.03) and they lived alone (P = 0.04). Although our program seemed to allow a better follow-up than previously described, this study highlights the importance of further supporting this transition period.

Diabetes-Focused Health Care Utilization Among Adolescents and Young Adults With Type 1 Diabetes

OBJECTIVE

To describe the current rates of health services use with various types of providers among adolescents and young adults (AYA) with type 1 diabetes (T1D) and evaluate which patient factors are associated with rates of service use from different provider types.

METHODS

Using 2012-16 claims data from a national commercial insurer, we identified 18,927 person-years of AYA with T1D aged 13 to 26 years and evaluated the frequency at which: 1) AYA skipped diabetes care for a year despite being insured; 2) received care from pediatric or non-pediatric generalists or endocrinologists if care was sought; and 3) received annual hemoglobin A1c (HbA1c) testing as recommended for AYA. We used descriptive statistics and multivariable regression to examine patient, insurance, and physician characteristics associated with utilization and quality outcomes.

RESULTS

Between ages 13 and 26, the percentage of AYA with: any diabetes-focused visits declined from 95.3% to 90.3%; the mean annual number of diabetes-focused visits, if any, decreased from 3.5 to 3.0; receipt of ≥2 HbA1c tests annually decreased from 82.3% to 60.6%. Endocrinologists were the majority providers of diabetes care across ages, yet the relative proportion of AYA whose diabetes care was endocrinologist-dominated decreased from 67.3% to 52.7% while diabetes care dominated by primary care providers increased from 19.9% to 38.2%. The strongest predictors of diabetes care utilization were younger age and use of diabetes technology (pumps and continuous glucose monitors).

CONCLUSIONS

Several provider types are involved in the care of AYA with T1D, though predominate provider type and care quality changes substantially across age in a commercially-insured population.

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.

Transition competence as an indicator of health outcomes related to transition

BACKGROUND

Adolescents and young adults (AYAs) with chronic conditions face a transfer, defined as an actual shift from paediatric to adult-oriented health care. Transition competence as the self-perceived knowledge, skills and abilities regarding the transition process was considered extremely useful.

AIM

This study was designed to investigate the impact of transition competence before and after the transfer on disease-specific quality of life (QoL) and health care satisfaction of AYAs with diabetes.

RESULTS

In total, a sample of N = 90 AYAs with diabetes self-reported their transition competence, diabetes-specific QoL and satisfaction with care. Multiple linear regressions were used to analyse the impact of transition competence on satisfaction with care and QoL. Transition competence positively influenced the outcomes of satisfaction with care and QoL.

CONCLUSION

Young adults with diabetes showed higher transition competence scores than adolescents with diabetes.

14. Children and Adolescents: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Transition From Childhood to Adult Care in Patients with Type 1 Diabetes: 20 Years of Experience From the Tübinger Transition Study

AIMS

Transition from pediatric to adult care is difficult for patients with chronic diseases. In this study, factors associated with metabolic control in childhood-onset type 1 diabetes (T1D) after transfer to adult care were analyzed.

METHODS

Overall, 224 persons with T1D were contacted yearly from 1998 to 2019. They voluntarily answered a questionnaire about their current hemoglobin A1c (HbA1c) levels, diabetes-associated complications, kind of care, living conditions, and family situation. Then, mixed longitudinal-cross-sectional analyses were carried out.

RESULTS

Overall, 190 patients answered at least once (mean age: 26.6 years). Diabetes complications were mentioned by 10 patients (5 microalbuminuria, 5 retinopathy). Most patients (92.6%) were in diabetes-specific care during the first year after transfer, with a trend to leave diabetes-specific care during the observation period. Patients in diabetes-specific care displayed lower HbA1c levels (%/mmol/mol) (7.1/54 vs. 7.5/58). An important predictor for HbA1c after transfer was HbA1c during the year before transfer (r=0.67, p <0.001). Patients living alone showed no difference in HbA1c levels from those living with their parents. Married patients had lower HbA1c levels (7.0/53 vs. 7.3/56, p<0.05) than unmarried ones. Patients with children (15.8%) presented lower HbA1c levels (6.9/52 vs. 7.3/56, p <0.01) than those without.

CONCLUSIONS

Good metabolic results are favored in patients followed-up in specialized care, are married, and are parents. We recommend transfer to a diabetologist with experience in T1D at an individual age.

[Transition of long-term ventilated children to adult medical care]

Through advances in long-term ventilation, the number of children with chronic respiratory insufficiency reaching adult age has increased tremendously. Therefore, transition of children from pediatric to adult care has become inevitable. Transition is necessary for medicolegal reasons, to increase autonomy of the young patients and because of change in the disease as a result of increasing age. Transition bears the risks of uncertainty of patients and parents, loss of the medical home or even loss of complete medical care. Good structural conditions, professional preparation of patient and parents, a comprehensive formalized transfer and patient coaching are prerequisites for a successful professional transition. This article discusses issues of transition with focus on long-term ventilated children.

Diabetes Stigma and Clinical Outcomes in Adolescents and Young Adults: The SEARCH for Diabetes in Youth Study

OBJECTIVE

To examine the association between diabetes stigma and HbA1c, treatment plan and acute and chronic complications in adolescents and young adults (AYAs) with type 1 or type 2 diabetes.

RESEARCH DESIGN AND METHODS

The SEARCH for Diabetes in Youth study is a multicenter cohort study that collected questionnaire, laboratory, and physical examination data about AYAs with diabetes diagnosed in childhood. A five-question survey assessed frequency of perceived diabetes-related stigma, generating a total diabetes stigma score. We used multivariable linear modeling, stratified by diabetes type, to examine the association of diabetes stigma with clinical factors, adjusting for sociodemographic characteristics, clinic site, diabetes duration, health insurance, treatment plan, and HbA1c.

RESULTS

Of 1,608 respondents, 78% had type 1 diabetes, 56% were female, and 48% were non-Hispanic White. The mean (SD) age at study visit was 21.7 (5.1) years (range, 10-24.9). The mean (SD) HbA1c was 9.2% (2.3%; 77 mmol/mol [2.0 mmol/mol]). Higher diabetes stigma scores were associated with female sex and higher HbA1c (P < 0.01) for all participants. No significant association between diabetes stigma score and technology use was observed. In participants with type 2 diabetes, higher diabetes stigma scores were associated with insulin use (P = 0.04). Independent of HbA1c, higher diabetes stigma scores were associated with some acute complications for AYAs with type 1 diabetes and some chronic complications for AYAs with type 1 or type 2 diabetes.

CONCLUSIONS

Diabetes stigma in AYAs is associated with worse diabetes outcomes and is important to address when providing comprehensive diabetes care.

[Essen transition model for neuromuscular diseases]

BACKGROUND

Advances in healthcare systems with new therapeutic options improve the life expectancy of patients with neuromuscular diseases. With this, a shift in the phenotype of the diseases from the neuromuscular system towards other organs is more frequently observed, requiring closer interdisciplinary cooperation in caring for these young adults. Therefore, the transition to the adult caring system is nowadays a multilayered transfer with the need for complex care of these patients.

OBJECTIVE

How can the transitional process be efficiently structured to combine the therapeutic effort of each specialist discipline involved and improve the healthcare process and quality of life in young adults with neuromuscular diseases?

MATERIAL AND METHOD

The Departments of Neuropediatrics and Neurology of the University Medicine Essen established the Essen transition model for a structured transitional process. A concept of care was developed for the late onset Pompe's disease, Duchenne muscular dystrophy and juvenile myasthenia gravis representatively for neuromuscular diseases. It consists of four components: 1) In a standardized operational procedure (SOP), general processes, clinical diagnostic steps and guidance of treatment between the two departments are harmonized and specified. 2) The young adults and their relatives are seen in a joint consultation of both disciplines allowing a comprehensive handover for healthcare professionals. 3) In a quarterly meeting, transition conference representatives from the different specialized disciplines from pediatric and adult medicine get together for a case-related interdisciplinary exchange. 4) An interdepartmental transitional database was created to integrate all diagnostic results and parameters as a common information platform and data basis.

CONCLUSION

The Essen transition model aims to close a gap in the transition of patients with neuromuscular diseases and improve healthcare in these patients with their complex needs.

14. Children and Adolescents: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Transition From Pediatric to Adult Care for Individuals With Type 1 Diabetes: Opportunities and Challenges

OBJECTIVES

Type 1 diabetes (T1D) is a chronic disease with patients across the age spectrum that has high potential for morbidity and mortality. Unfortunately, patients transitioning from pediatric to adult care continue to demonstrate worsened glycemic control in part due to lack of understanding of transition of care best practices.

METHODS

This review highlights the impact of existing transition of care interventions, assessment tools, and other recently published strategies for providers to consider to improve care of adolescent and young adult (AYA) patients with T1D in both hospital- and clinic-based settings.

RESULTS

Many barriers impact patients with T1D during the transition period and disparities by race, sex, insurance status, and comorbid illness persist. As diabetic care continues to evolve and the prevalence of adolescents and young adults living with T1D increases, an intentional approach to transition of care is more pressing than ever. While current literature on transition of care models is limited, many show promise in improving clinic attendance and decreasing hospitalization. There are critical discussions that providers should lead with AYA patients to improve their outcomes and increase diabetes self-management, such as re-addressing carbohydrate counseling, sleep hygiene, and reproductive planning.

CONCLUSION

While further research on transition of care is needed, many care models offer the promise of improved T1D outcomes, enhancements in our approach to care, and increased value for our health care system at large.

Essen transition model for neuromuscular diseases

BACKGROUND

With the optimization of medical care structures and the rapid progress in the development of new therapeutic methods, an increase in life expectancy is observed in patients with neuromuscular diseases. This leads to an expansion of the phenotypic spectrum, whereby new or previously less relevant disease manifestations in different organ systems gain more importance. The care of adolescents and young adults with neuromuscular diseases, therefore, requires increasingly close interdisciplinary collaboration within neuromuscular centers.

RESEARCH QUESTION

How can the transition process from pediatric to adult care be structured so that the individual disciplines are efficiently integrated into the complex treatment and care process, and the patients' quality of life is improved?

MATERIAL AND METHODS

A structured transition process was established at the University Hospital in Essen, Germany. Exemplarily, a comparable care concept was developed based on Pompe disease, Duchenne muscular dystrophy, and juvenile myasthenia gravis comprising four elements: (1) With the introduction of cross-department standard operating procedures, the logistical processes, as well as the diagnostic and therapeutic measures, are uniformly coordinated, and the transition process is bindingly defined. (2) To ensure a seamless transition, young patients are seen with their parents during joint consultations before they reach their 17th birthday. This creates an opportunity for patients to get to know the subsequent department structure and build a lasting relationship of trust. (3) A quarterly "transition board" regularly brings together the participating disciplines from pediatric and adult care systems for a case-related interdisciplinary exchange and continuous optimization of the transition process. (4) A cross-department "Transition Database", in which medical findings and parameters are recorded, was implemented as a common information platform and database.

CONCLUSION

The Essen Transition Model aims to close the gap in care for young patients with neuromuscular diseases during the critical transition from pediatric to adult medicine and to create a successful continuation of treatment in adulthood.

A call for action: Recommendations to improve transition to adult care for youth with complex health care needs

Youth with complex health care needs, defined as those requiring specialized health care and services for physical, developmental, and/or mental health conditions, are often cared for by paediatricians and paediatric specialists. In Canada, the age at which provincial/territorial funders mandate the transfer of paediatric care to adult services varies, ranging between 16 and 19 years. The current configuration of distinct paediatric and adult care service boundaries is fragmentary, raising barriers to continuity of care during an already vulnerable developmental period. For youth, the lack of care integration across sectors can negatively impact health engagement and jeopardize health outcomes into adulthood. To address these barriers and improve transition outcomes, paediatric and adult care providers, as well as family physicians and other community partners, must collaborate in meaningful ways to develop system-based strategies that streamline and safeguard care for youth transitioning to adult services across tertiary, community, and primary care settings. Flexible age cut-offs for transfer to adult care are recommended, along with considering each youth's developmental stage and capacity as well as patient and family needs and circumstances. Specialized training and education in transitional care issues are needed to build capacity and ensure that health care providers across diverse disciplines and settings are better equipped to accept and care for young people with complex health care needs.

Two-Year Follow-Up of a Transition-Specific Education Program for Young People With Chronic Conditions

PURPOSE

The transition to adulthood is a challenging process for young people (YP) with chronic conditions. Patient education can help to prepare them for autonomous disease management and transfer to adult healthcare services. In a previous controlled study, participation in the youth-specific group education program ModuS-T immediately improved transition-specific knowledge, competencies, and patient activation of YP with various chronic conditions. To evaluate whether these effects are long lasting, we questioned YP from the intervention group (IG) and the control group (CG; no program) 2 years after participation.

METHODS

Standardized questionnaires were used to assess YP's transition-specific knowledge, competencies, patient activation, health-related quality of life, and medical care status at baseline and 2 years later. Repeated measurement covariance analyses were used for statistical testing.

RESULTS

A total of 181 YP (109 IG, 72 CG) completed the questionnaires (60% of previous interviewees; mean age 20 years, 46% female). Compared to the CG, the IG reported significant improvements in transition-specific knowledge, competencies, and patient activation (p < .001) and lower parents' responsibility for their condition (p = .004). The proportion of YP who had already transferred to adult health care was nearly the same (54% IG/56% CG), but the CG was more likely to lose access to medical care (6% IG/14% CG). There were no effects on health-related quality of life.

DISCUSSION

The 1.5-day ModuS-T program has long-lasting positive effects on knowledge and competencies relevant for the transition of YP. Transition-specific patient education programs close an important care gap and should be integrated into standard care.

Appel à l'action : des recommandations pour améliorer la transition des jeunes ayant des besoins de santé complexes vers les soins aux adultes

Les jeunes qui ont des besoins de santé complexes, définis comme ceux qui nécessitent des soins et services spécialisés en raison d'affections physiques, développementales ou mentales, sont souvent traités par des pédiatres et autres spécialistes en pédiatrie. Au Canada, l'âge auquel les bailleurs de fonds provinciaux et territoriaux exigent le transfert des soins pédiatriques aux soins pour adultes varie entre 16 et 19 ans. La délimitation actuelle entre les services de santé pédiatriques et aux adultes est fragmentaire, ce qui entrave la continuité des soins pendant une période déjà vulnérable du développement. Le peu d'intégration des soins entre les domaines peut nuire à l'engagement des jeunes en matière de santé et compromettre leur santé à l'âge adulte. Pour renverser ces obstacles et améliorer les résultats de la transition, les dispensateurs de soins pédiatriques et de soins aux adultes, de même que les médecins de famille et d'autres partenaires communautaires, doivent collaborer de manière satisfaisante à l'élaboration de stratégies systémiques qui rationalisent et préservent les soins aux jeunes en transition vers des soins aux adultes en milieu tertiaire, communautaire et primaire. Il est recommandé de privilégier des limites d'âge flexibles pour effectuer cette transition vers les soins aux adultes et de tenir compte de la phase de développement et de l'aptitude de chaque jeune, ainsi que des besoins et de la situation de chaque patient et de chaque famille. Une formation et un enseignement spécialisés sur les enjeux liés aux soins de transition s'imposent pour renforcer les capacités et s'assurer que les professionnels de la santé des diverses disciplines et des divers milieux soient mieux outillés pour accepter et traiter les jeunes qui ont des besoins de santé complexes.

Behandlungsverhalten und Wünsche an die Therapie aus Sicht von jungen Erwachsenen mit Diabetes mellitus Typ 1

Hintergrund Bei Jugendlichen und jungen Erwachsenen (JujE) mit Diabetes mellitus Typ 1 (DMT1) werden gehäuft Behandlungsverhaltensweisen beobachtet, die mit ungünstigen Gesundheitsoutcomes assoziiert sind. Darüber hinaus verläuft der in diesem Alter erforderliche Transitionsprozess oft problematisch. Insgesamt ist diese Altersspanne mit einem erhöhten Risiko für akute Komplikationen und langfristige Folgeschäden assoziiert. Ziel der Studie ist es, Gründe für Therapieunzufriedenheit und ungünstiges Behandlungsverhalten aus Sicht der JujE zu explorieren und den Bedarf sowie konkrete Empfehlungen für ein zusätzliches psychologisches Coaching abzuleiten.

Methode Insgesamt wurden 15 qualitative Interviews mit JujE (Alter M=20.2; SD=3.1 Jahre; 53.3% weiblich) geführt. Zudem wurden die Soziodemographie und depressive Symptomatik (PHQ-9; Patient Health Questionnaire) erhoben.

Ergebnisse Die Ergebnisse deuten darauf hin, dass Behandlungsunzufriedenheit und ungünstiges Behandlungsverhalten mit direktiven Kommunikationsmustern sowie einer fehlenden persönlichen Bindung zu den Behandler:innen assoziiert sind. Zudem werden psychische Belastungen aus Sicht der Befragten unzureichend thematisiert. Die JujE wünschten sich insbesondere Kontinuität im Behandlungsteam sowie einen empathischen Umgang. Die Idee eines zusätzlichen Coachings wurde positiv aufgenommen. Hierbei besteht der Wunsch nach bedürfnisorientierter Ausgestaltung.

Diskussion Mögliche Barrieren von Adhärenz und psychische Belastungen sollten offen erfragt und thematisiert werden. Insbesondere bei psychisch belasteten JujE könnte das Behandlungsverhalten möglicherweise durch zusätzliche niederschwellige Coachingangebote verbessert werden. Eine randomisiert-kontrollierte Studie ist noch ausstehend.

Course of screening-based depression in young adults with a long type 1 diabetes duration: Prevalence and transition probabilities - A cohort study

AIMS

To extend the current knowledge of the prevalence and course of screening-based depression (SBD) and its predictors in emerging adults with a long type 1 diabetes duration.

METHODS

A total of 487 young adults (64.7% women, mean age 24.0 years) who participated in a nationwide cohort study provided data on SBD (Patient Health Questionnaire (PHQ-9) score ≥ 10). We estimated the overall and age- and sex-specific prevalence of SBD, identified the associated covariates, and determined the transition probabilities between SBD states using adjusted first-order Markov transition models.

RESULTS

The prevalence of SBD was 17.7% in women and 7.0% in men. A total of 70.4% (95%-CI 57.4%; 80.8%) of the participants with SBD at the first screening still had SBD at the three-year follow-up. Of the subjects without SBD at baseline, 6.9% (4.9%; 9.8%) had SBD at follow-up. The main predictor of current SBD was previous SBD (OR 39.0 (15.4; 98.6)), followed by living in one's own or in a shared apartment vs. living with both parents (OR: 2.75 (1.03; 7.36)).

CONCLUSIONS

Using an innovative analytical approach, emerging adults with a long diabetes duration demonstrated a moderate rate of incident SBD but a high rate of persistent SBD.

Aus Sicht der Diabetespraxis: erwachsen werden mit Typ-1-Diabetes

Junge Erwachsene mit Typ-1-Diabetes tragen die Verantwortung für ihre Diabetestherapie weitgehend selbst, gleichzeitig genießen sie neu gewonnene Freiheiten und sind eher risikobereit. Die eigene Wohnung, Partnerschaft, Studium, Beruf und weitere Entwicklungsaufgaben stellen hohe Anforderungen. Diese sind oft schwer mit einer qualifizierten Diabetestherapie vereinbar. Nach der langjährigen persönlichen Bindung an das Team einer Kinderklinik ist der Wechsel in eine internistische Diabetesschwerpunktpraxis nicht immer reibungslos. Individuelle psychische Belastungen und ein unzureichendes Diabetesmanagement verstärken sich dabei gegenseitig. Diabetes verkörpert in diesem Lebensabschnitt genau das Gegenteil von all dem, was altersgemäß ist. Er erfordert einen strukturierten Tagesablauf, disziplinierte Ernährung, regelmäßige Arztbesuche und vorausschauendes Denken und Handeln. Die Analyse der CGM-Daten (CGM: kontinuierliche Glukosemessung [„continuous glucose monitoring“]) in der Diabetespraxis erlaubt detaillierte Einblicke in den persönlichen Alltag, die mit Scham- und Schuldgefühlen verbunden sein können. Ziel der Langzeitbehandlung ist es, alle diese Aspekte – aktuelle Lebensqualität, persönliche Ziele, Vermeidung akuter Diabeteskomplikationen und Prävention langfristiger kardiovaskulärer Folgekomplikationen – zu beachten und daraus partizipativ ein individuelles Behandlungskonzept zu entwickeln. Die wichtigste Aufgabe der Diabetespraxis ist dabei, junge Menschen auf ihrem individuellen Weg zu unterstützen, ihre Stärken anzuerkennen und sie durch Erfolge zu motivieren.

14. Children and Adolescents: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Exploring Health Literacy, Transition Readiness, and Healthcare Utilization in Medicaid Chronically Ill Youth

PURPOSE

Youths with special healthcare needs face challenges transitioning from pediatric to adult health care. Understanding possible mechanisms contributing to poor healthcare transition could improve care. This study explores associations between health literacy (HL), transition readiness, and healthcare utilization.

METHODS

Youths with special healthcare needs aged 12-18 years were recruited from a Medicaid accountable care organization (2012-2017). Outcome measures included transition readiness (Transition Readiness Assessment Questionnaire), and healthcare utilization (any well-check, hospitalization, emergency department [ED] visit, or ambulatory sensitive condition ED visit). Multivariate regression analyses examined whether HL (adequate vs. inadequate) predicted outcomes, after adjusting for covariates. Models were then created to examine whether the effect of HL on healthcare utilization was mediated by transition readiness.

RESULTS

Among 417 youths with special healthcare needs, 67.1% reported adequate HL. Relative to inadequate HL, teens with adequate HL had significantly higher average Transition Readiness Assessment Questionnaire-20 scores (β = .34, p < .001). Controlling for covariates, HL was a significant predictor of having an ambulatory sensitive condition ED visit and having any ED visits neared significance. There was a positive transition readiness mediation effect on having an ED visit, with higher transition readiness being associated with higher odds of having any ED visit in the mediation analysis.

CONCLUSIONS

HL is independently associated with higher transition readiness and lower ambulatory sensitive condition ED use, but pathways of action require further study.

[When people with type 1 diabetes become adults - Diabetes technology and transition - do we need new models?]

Approximately 40 % of adolescents with type 1 diabetes lose contact with specialty care at transfer to adult care, with a marked increase in risk for poor outcomes. Adolescents showed a 2,5-fold increased risk of an HbA_1c level > 9 % after transfer, compared with adolescents who remained in pediatric care. While the use of modern technologies is rapidly increasing in pediatric diabetology, fewer resources are available to address the rapidly changing digital transformation of type 1 diabetes therapy in adult diabetology, not least because of the large number of patients with type 2 diabetes who require care. Therefore, in the transition from children with type 1 diabetes to adult medicine, disparities in resource provision for training and interpretation of new diabetes technologies now add to the problems that have been known for many years. One possible solution would be the creation of regional treatment centers with pediatric and internal medicine care for people with intensive diabetes therapy and use of diabetes technology, as well as the use of telemedicine capabilities. International comparisons show that in centers where pediatric and internal medicine diabetes teams provide age-appropriate care within the same treatment facility, the transition is much less complicated and people with type 1 diabetes benefit from shared experience in the use of diabetes technologies across the lifespan. However, the implementation of such concepts under the framework of the German health care system requires a rethinking among the involved stakeholders and does not seem promising without pressure from the affected people with type 1 diabetes.

Transition von Jugendlichen mit Diabetes in die Erwachsenenbetreuung – eine Expertenbefragung

Einleitung Der Transitionsprozess für Jugendliche mit chronischen Erkrankungen ist vielerorts noch ungeregelt, eine fachärztliche Weiterbetreuung ist oftmals nicht gesichert. Ziel der Studie war es, das derzeitige Vorgehen und mögliche Defizite bei der Transition von Jugendlichen mit Diabetes zu evaluieren und das Interesse und die Bereitschaft zur flächendeckenden Einführung von strukturierten Transitionsprogrammen in Deutschland zu erfragen.

Methode Eine anonymisierte Onlinebefragung der Mitglieder der „Arbeitsgemeinschaft für Pädiatrische Diabetologie e. V.“ (AGPD) wurde im Zeitraum von Oktober 2019 bis April 2020 durchgeführt.

Ergebnisse 60 der 492 über den strukturierten E-Mail-Newsletter kontaktierten Mitglieder der AGPD nahmen an der Befragung teil. 81,1 % der Studienteilnehmer gaben an, die Transition im Rahmen von regulären Ambulanzterminen mit den Patienten zu besprechen. 25,8 % nutzen ein intern erarbeitetes oder extern unterstütztes strukturiertes Transitionsprogramm. Die Befragten schätzen, dass 50 % der Patienten eine intensive Unterstützung bei der Transition benötigen und 20 % im Transitionsprozess den Kontakt zur spezialisierten medizinischen Betreuung verlieren. Fast alle Befragten (91,4 %) sahen Verbesserungsbedarf im aktuellen Transitionsprozedere. Im Vordergrund stehen dabei insbesondere eine engere Zusammenarbeit von Kinderdiabetologen und Erwachsenendiabetologen, die Einführung eines strukturierten, standardisierten Vorgehens sowie eine Optimierung der Vorbereitung und Motivation der Jugendlichen. Die Einführung von strukturierten Transitionsprogrammen mit externer Unterstützung wird von der überwiegenden Zahl der Befragten als dringend notwendig (27,6 %) bzw. wichtig (41,4 %) bewertet.

Schlussfolgerung Die Nutzung standardisierter strukturierter Transitionsprogramme in der Behandlung von Jugendlichen mit Diabetes ist in Deutschland bisher noch gering, aber notwendig, um eine kontinuierliche fachärztliche Betreuung zu gewährleisten. Die flächendeckende Einführung geeigneter und finanzierter Programme kann den Transitionsprozess und damit auch das langfristige Outcome der Patienten verbessern. Gerade in der Umbruchphase der Adoleszenz ist ein zuverlässiger Ansprechpartner erforderlich, der die Übernahme der Selbstverantwortung für den Diabetes begleitet.

Psychische Komorbiditäten bei Jugendlichen und jungen Erwachsenen mit Typ-1-Diabetes

Jugendliche und junge Erwachsene mit Typ-1-Diabetes sind häufig von komorbiden psychischen Störungen betroffen. Dabei zeigt die Studienlage zur Verbreitung ein heterogenes und inkonsistentes Bild. Diagnose und Behandlung der somatopsychischen Begleiterkrankungen beeinflussen den Behandlungs- und Krankheitsverlauf sowie die Lebensqualität der Betroffenen. Trotzdem wird dies in der klinischen Praxis selten frühzeitig berücksichtigt. Das multizentrische Verbundprojekt COACH verfolgt das Ziel, die Erkennung und Behandlung psychischer Komorbidität für diese Zielgruppe in der bundesweiten Routineversorgung zu optimieren.

Incidence Trends of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes in British Columbia, Canada

OBJECTIVES

To estimate the 11-year incidence trend of diabetic ketoacidosis (DKA) at and after the diagnosis of type 1 diabetes.

STUDY DESIGN

A retrospective cohort study using a population-based administrative cohort diagnosed with type 1 diabetes at <20 years of age from 2002 to 2012 in British Columbia, Canada. DKA at (1 episode per individual) and DKA after (multiple episodes per individual) the diagnosis of diabetes were defined as DKA occurring ≤14 days or >14 days, respectively, from diagnosis, identified using International Classification of Diseases,9th and 10theditions codes. Incidence rate ratios were estimated using Poisson regression and DKA trends using Joinpoint regression analyses.

RESULTS

There were 1519 individuals (mean age at first-DKA, 12.6 ± 5.9 years; 50% male) with ≥1 DKA episode identified. Of 2615 incident cases of type 1 diabetes, there were 847 (32.4%; mean age, 9.9 ± 4.8 years; 52% male) episodes of DKA at the diagnosis of diabetes. Among prevalent cases of type 1 diabetes (1790 cases in 2002 increasing to 2264 in 2012), there were 1886 episodes of DKA after the diagnosis of diabetes (mean age at first DKA, 15.7 ± 5.2 years). The rates per 100 person-years of DKA at diabetes diagnosis (ranging from 24.1 in 2008 to 37.3 in 2006) and DKA after diabetes diagnosis (ranging from 4.9 in 2002 to 7.7 in 2008) remained stable. Females showed a 67% higher rate of incidence of DKA after the diagnosis of diabetes compared with their male counterparts (incidence rate ratio, 1.67; 95% CI, 1.50-1.86; P < .001), adjusted for the temporal trend by fiscal year. Younger age at diagnosis (<5 years) was associated with a greater risk of DKA at the time of diabetes diagnosis and older children (≥10 years) had a greater risk of DKA after the diagnosis of diabetes.

CONCLUSIONS

The risk of DKA at the time of diagnosis of diabetes was greater with younger age and the risk of DKA after the diagnosis of diabetes was higher in females and older children and youth.

The Transatlantic HbA1c gap: differences in glycaemic control across the lifespan between people included in the US T1D Exchange Registry and those included in the German/Austrian DPV registry

AIM

To compare HbA_1c levels across the lifespan in people with type 1 diabetes in the USA with those in Germany/Austria, and to examine potential differences in HbA_1c levels between sexes, insulin delivery methods and minority status.

METHODS

Data were extracted from the US T1D Exchange Registry (n=18 381 participants from 73 sites) and from the German/Austrian Prospective Diabetes Follow-up Registry, the DPV (n=32 643 participants from 362 sites). Mean HbA_1c was calculated for each year of age for individuals aged ≤25 years, and at 2-year age intervals for individuals aged >25 years. Curves for mean HbA_1c by age were estimated using locally weighted scatterplot smoothing. HbA_1c differences between registries, sexes, insulin delivery methods, and minority status were assessed by age group using multiple linear regression.

RESULTS

In both registries, mean HbA_1c increased by ~11 mmol/mol (1.0%) between the ages of 9 and 18 years, although at quite different absolute levels: from 66 mmol/mol (8.2%) to 77 mmol/mol (9.2%) in the T1D Exchange Registry, and from 56 mmol/mol (7.3%) to 66 mmol/mol (8.2%) in the DPV. Sex differences were observed in the DPV only. In the T1D Exchange Registry, injection users had higher mean HbA_1c than pump users across the lifespan, whereas in the DPV higher HbA_1c levels in injection users were observed in the age groups 6 to <12 years, 12 to <18 years, and 30 to <50 years (P < 0.001). Minority status was significantly associated with higher HbA_1c in most age groups in both registries.

CONCLUSIONS

Significant differences in HbA_1c were noted between the USA and Germany/Austria, with disparities more pronounced in early childhood through to young adulthood. Further studies should identify causes for these disparities.

Somatic outcomes of young people with chronic diseases participating in transition programs: a systematic review

Introduction

There is growing evidence that the health of young people with chronic health conditions deteriorates during the transfer from child-centred to adult-oriented health care. Risks include not only the deterioration of health status in general but also the occurrence of secondary diseases and adverse events. Transition programs have been implemented. However, there is a lack of evidence about whether they reduce these risks and which interventions should be principally included. Evidence-based guidelines for the transition of young people should be introduced. In this study we therefore aim to summarise actual evidence on somatic outcomes during the transition period.

Methods

A systematic literature review was conducted. Two independent reviewers searched in electronic databases (Cochrane, Embase, PubMed, Web of Science) for intervention studies that aimed to improve transition. Last update of search was October 31st 2018. Grey literature was also searched. Studies were included if they examined participants aged 11 years or older suffering from a chronic health condition and evaluated interventions aimed to improve somatic outcomes after transition. Controlled trials or studies with a measurement before and after intervention were considered. The certainty of evidence was assessed using the GRADE approach. Additionally, each study was graded using a modified grading scale based on GRADE.

Results

28 studies met the inclusion criteria. Patients suffered from different chronic conditions such as type 1 diabetes, solid organ transplantation, inflammatory bowel disease or cystic fibrosis. Interventions had different components such as transition checklists, workshops, web-based interventions, transition plans, joint visits or transition coordinators. Outcomes included mortality and morbidity. They varied according to chronic condition. Thirteen studies showed beneficial effects in the intervention group or in post-intervention measurements. The certainty of evidence was very low.

Conclusion

A considerable number of studies evaluating transition interventions was identified. Transition interventions had some beneficial effects. Workshops, joint visits and longer or multidisciplinary appointments may be particularly effective components. Transition guidelines could be based on these results. However, due to the limitations of the included studies it is difficult to draw firm conclusions. More research is needed to further evaluate the effectiveness of transition interventions. It should address the deficits identified from prior studies, such as poor study design, short follow-up time or small sample sizes.

Acute diabetes complications across transition from pediatric to adult care in Ontario and Newfoundland and Labrador: a population-based cohort study

BACKGROUND

Transition to adult diabetes care is a high-risk period for acute complications, yet the optimal transition care model is unknown. To gain insight into the impact on health outcomes of system-level transition processes that reflect resourcing differences, we examined acute complications in youth with diabetes across transition in 2 Canadian provinces with different transition care models.

METHODS

We used linked provincial health administrative data for Ontario and Newfoundland and Labrador to create 2 parallel cohorts of youth with diabetes diagnosed before age 15 years who turned 17 between 2006 and 2011. Participants were followed until 2015 (maximum age 21 yr). We described rates of and proportion of participants with at least 1 diabetes-related hospital admission at age 15-17 years and 18-20 years, standardized according to material deprivation based on the 2006 Canadian Marginalization Index. We compared diabetes-related admissions at age 15-17 years and 18-20 years in the Ontario cohort.

RESULTS

The cohorts consisted of 2525 youth in Ontario and 93 in Newfoundland and Labrador. In Newfoundland and Labrador, 39 participants (42.0%) were in the lowest socioeconomic quintile, versus 326 (12.9%) in Ontario. The standardized rate of diabetes-related hospital admissions per 100 person-years was 13.5 (95% confidence interval [CI] 12.6-14.4) at age 15-17 years and 14.4 (95% CI 13.5-15.3) at age 18-20 years in Ontario, and 11.4 (95% CI 7.0-15.8) at age 15-17 years and 10.5 (95% CI 6.4-14.6) at age 18-20 years in Newfoundland and Labrador. In Ontario, there was no association between the rate (adjusted rate ratio 1.10, 95% CI 0.94-1.28) or occurrence (adjusted odds ratio 1.03, 95% CI 0.91-1.17) of diabetes-related admissions across transition.

INTERPRETATION

Although posttransition care is delivered differently in the 2 provinces, rates of adverse events across transition were stable in both. Coordinated support during transition is needed to help mitigate adverse events for young adults in both provinces. Delivery of other health care and social services, including primary care, may be influencing the risk of adverse events after transition to adult care.

Hypoglycaemia unawareness in young people with type 1 diabetes transferred to an adult center

OBJECTIVE

To evaluate frequency of hypoglycaemia unawareness (HU) in patients with type 1 diabetes (T1D) transferred from Paediatrics following a specific therapeutic education programme (TEP) in an adult hospital.

PATIENTS AND METHODS

Young patients transferred from 2009-2011 were evaluated. The TEP included a coordinated transfer process, individual appointments and a group course. At baseline and at 12 months we evaluated glycated haemoglobin (HbA1c) frequency of severe (SH) hypoglycaemia/patient/year and non severe hypoglycaemia (NSH). The patients were classified into two groups and compared: hypoglycaemia awareness (HA) and HU according to the Clarke Test <3R or>3R respectively.

RESULTS

Fifty-six patients (age 18.1±0.3 years, 46% females, HbA_1c 8.0±1.2%) underwent the TEP. In the baseline evaluation 16% presented HU. The number of SH was higher in the HU Group (0.33±0.50 vs. 0.09±0.28 P<.05). The percentage of patients with>2 NSH/week was higher, albeit not significantly, in the HU group (66% vs. 34%, p=0.06). At 12 months 11% of the patients continued to present HU. The number of SH remained higher in the HU group (0.38±1.06 vs. 0.02±0.15 P=.04).

CONCLUSIONS

The percentage of young people with T1D with HU is quite high at transfer. Although the TEP improves hypoglycaemia awareness it does not solve this important problem. Patients with HU more frequently present SH. It is necessary to identify HU in order to reduce SH which continues to be a problem in people with T1D.

The 3i Conceptual Framework for Recognizing Patient Perspectives of Type 1 Diabetes During Emerging Adulthood

IMPORTANCE

Early emerging adulthood, the developmental life stage roughly spanning between the ages of 18 and 24 years, can be a challenging time for individuals living with type 1 diabetes, being associated with an increased risk of acute complications, loss to follow-up, and the emergence of long-term diabetes complications. Few evidence-based interventions exist, and practice guidelines instead emphasize the importance of delivering individualized, developmentally appropriate care.

OBJECTIVE

To inform the provision of tailored care and education by illuminating the individual lived experiences of emerging adults with type 1 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used in-depth interviews conducted with 33 emerging adults living with type 1 diabetes between October 14, 2016, and May 16, 2017. Participants were recruited from 2 urban Young Adult Diabetes Clinics in the city of Toronto, Ontario, Canada, using a convenience sampling approach. Narrative analysis of participants' accounts was conducted inductively to define story typology.

MAIN OUTCOMES AND MEASURES

Participant accounts of type 1 diabetes during childhood, adolescence, and emerging adulthood.

RESULTS

Interviews were conducted with 33 participants aged 18 to 24 years (mean [SD] age at interview, 20.6 [1.7] years); 17 (51%) were women. Duration of diabetes ranged from 3 to 20 years (mean [SD] duration, 12.0 [4.8] years). Narrative analysis identified 3 distinct story types, or lenses, termed ingrained (n = 14), intrusive (n = 12), and inconspicuous (n = 7). Ingrained narratives portrayed an active integration of diabetes self-management into daily life. Intrusive narratives were characterized by stories of struggles for acceptance and striving for control. Inconspicuous narratives were differentiated by descriptions of a willingness to ignore diabetes and its attendant daily tasks with the goals of preserving normalcy and limiting distress. Mean levels of hemoglobin A1c were higher in participants conveying an intrusive lens narrative (mean [SD], 9.3% [1.6%]) than those conveying an ingrained lens (mean [SD], 7.4% [0.7%]) (difference between intrusive and ingrained, 1.9%; 95% CI, 0.8%-2.9%; P = .007) or an inconspicuous lens (mean [SD], 8.6% [1.5%]).

CONCLUSIONS AND RELEVANCE

Although every person is unique, there are commonalities in how emerging adults perceive and depict their experiences living with type 1 diabetes. Among the emerging adults interviewed in the present study, the 3i conceptual framework of ingrained, intrusive, and inconspicuous lenses encapsulated these commonalities. Recognition of the different psychosocial contexts surrounding type 1 diabetes during emerging adulthood may help health care professionals individualize their care accordingly.

Experiences of College Students Who Are Newly Diagnosed With Type 1 Diabetes Mellitus

PURPOSE

To gain insight and understanding of emerging adult experiences after a diagnosed with type 1 diabetes mellitus (T1DM) and prior to or during college life experiences.

DESIGN AND METHODS

A qualitative research design using a focus group was conducted with 12 college students recently diagnosed with T1DM during emerging adulthood. The focus group took place during a College Diabetes Network retreat. Using Braun and Clarke's six phase process, two researchers independently conducted a thematic analysis from the transcribed, verbatim audiotaped narratives.

RESULTS

The 12 participants attended colleges in 11 different states. The mean age was 21 years (SD = 6.3) and the majority were female (n = 7). Qualitative analysis revealed four themes: 1) diabetes affects all aspects of life and complicates college living; 2) college environment affects diabetes management; 3) diabetes diagnosis facilitates growth and maturity; and 4) strategies used for diabetes management in college.

CONCLUSION

T1DM is complex to manage in the college environment. However, these emerging adults newly diagnosed with T1DM highlight strategies for diabetes management while in college and the pivotal role of pediatric providers play in the successful management of T1DM.

PRACTICE IMPLICATIONS

Diabetes education for emerging adults in college requires an adaptive focus that supports the developmental needs of this population. Nurses should focus on teaching healthy, modifiable behaviors of sleep, physical activity, and nutrition to improve glycemic control as well as adapting to the college life choices.

Disparities in Care Delivery and Outcomes in Young Adults With Diabetes

PURPOSE OF REVIEW

This review summarizes the literature on care and outcome disparities in young adults (YA) with type 1 and type 2 diabetes, and outlines remaining needs and suggestions to reduce disparities and improve care.

RECENT FINDINGS

Despite well-documented disparities and data from large national and international diabetes populations, the role that social determinants of health play in disease management is largely unstudied. Further, mechanisms of how these risk factors interact with the unique developmental needs of racial-ethnic minority and economically vulnerable young adults with diabetes remain unknown. Little intervention research has focused on improving outcomes in this vulnerable population. More research needs to focus on identifying and addressing risk factors in racial-ethnic minority and economically vulnerable young adults with diabetes. Interventions need to be adapted and developed to meet the unique needs of this high-risk population. Clinicians and healthcare systems must recognize the inequity in care and outcomes for this group and structure clinical programs and policies to promote their optimal care.

Needs Assessment in Care of Adults With Anorectal Malformations and Exstrophy-Epispadias Complex in Germany

Introduction: Medical needs of adults with anorectal malformations (ARM) and the exstrophy-epispadias complex (EEC) are not fully understood. Therefore, the aim of the study was to evaluate how affected individuals get along with the current national medical care and what their medical or social long-term requirements are. Patients and Methods: Between 11/2014-07/2016 all adult members (≥18 years, ARM n = 113, EEC n = 126) of the German self-help organizations SoMA e.V. and Blasenekstrophie/Epispadie e.V. were contacted via email or post and asked to fill out an anonymous online questionnaire regarding medical requirements, treatment satisfaction, daily life impairment and expectations regarding physicians soft skills. The results were compared between both groups and male and female participants. Results: 56 participants with ARM (median age 26 years, IQR 19-38) and 52 participants with EEC (median age 31 years, IQR 22-37) filled in the questionnaire completely. Forty-five percent of the ARM and 67% of the EEC participants contacted an urologist. A general surgeon was visited by 23% of the ARM individuals, a peadiatric surgeon by 20%. Although 60% of the females with ARM and 82% of the females with EEC assessed gynecological counseling as helpful or neutral, a small subgroup of ARM females (n = 6, 16%; 70% non-isolated ARM or ARM with Hirschsprung disease and additional associated anomalies) were not satisfied. The majority of both groups reported no or only minor daily life impairment (p = 0.38). Professional knowledge, paying attention to patients' concerns, having empathy and taking enough time was important for over 90% of all participants. Thirty-eight percent of the ARM and 27% of the EEC individuals needed psychological support. Most medical consultations were judged to be helpful. Conclusion: Although adults with ARM and EEC being a self-help organization member and thus well informed and generally cope well, participants expressed their wish for expert counseling regarding family planning, reconstructive procedures, continence management, urological care and social welfare issues. Furthermore, specific expert consultations for gynecological issues in a subgroup of ARM females, mainly non-isolated, might be required. Actual needs of adults with rare conditions must be better clarified to improve medical care beyond childhood and adolescence.