Transition of care for patients with type 1 diabetes mellitus from pediatric to adult health care systems

The transfer of care experience in young adults with type 1 diabetes

OBJECTIVES

To explore the experiences and perceptions of young adults with type 1 diabetes (T1D) after they transferred care from a pediatric to an adult clinic, utilizing an organized transfer process that included a Diabetes Transition Clinic (DTC) and a transfer letter (TL).

METHODS

This retrospective study used a semi-structured interview 1-1.5 years after transfer of care, which gathered both quantitative and qualitative data of young adults (n=12) who transferred care at an average age of 19.6 years, within a Midwest academic medical center. Descriptive statistics and thematic analysis were used to analyze the data and to identify emerging themes.

RESULTS

Most participants were worried about their transfer of care and found attending a DTC valuable. Most found the TL helpful in summarizing their diabetes care. Emerging themes demonstrated the importance of preparing the young adult for change, supporting their emotional journey, and developing connections with their new diabetes team.

CONCLUSIONS

For young adults with diabetes, the transfer of care from pediatric to adult is a time of apprehension. Incorporating a DTC and TL can facilitate this journey by preparing patients for change and developing ways to deepen connections with new providers.

Dynamic assessment of a transition process for patients with diabetes

Introduction

Adolescence can be defined as the period during which all individuals move from childhood to adulthood, including in the healthcare system, creating a need for a healthcare transition process. Children's of Alabama provides four transition education sessions during clinic visits for adolescents with type 1 diabetes (T1D). We aimed to assess baseline patient data and patient perspectives of our current transition education process to guide our efforts to improve this process.

Methods

We used a mixed methods design comprised of a quantitative analysis of baseline data in our adolescents with T1D and qualitative analysis of provide and patient perspectives. We queried the electronic medical record to obtain baseline characteristics of adolescent adolescents with T1D seen at our center from January 2022 to May 2022 and sought input via anonymous surveys of adult and pediatric endocrinology attendings, fellows, and nurse practitioners at our institution and of adolescents with T1D who had completed the final education session via an electronic secure database.

Results

Electronic Medical review of adolescents with T1D transitioning to adult care at our center revealed most of our adolescents with T1D had a gap in care of four months or greater between last pediatric visit and first adult visit. Pediatric provider surveys emphasized barriers for adolescents with T1D with appointment scheduling and challenges navigating the adult health care system. Adult surveys emphasized lack of communication with the adult health care team. Adolescents with T1D overall reported transition education prepared them well for adult care, but only 35.3 % had identified an adult provider after completing transition education.

Conclusions

Our findings outline additional areas for improvement in our transition process for adolescents with T1D. Based on feedback from the pediatric team, we are working to initiate transition education by age 16, standardize document discussions around transition, document date of planned transition, and document planned accepting adult provider. We are working to streamline record transfer based on feedback from adult providers. Based on patient feedback and our documented gaps in care, we are working to place referrals for adult care to minimize gaps in diabetes care.

Transitioning From Pediatric to Adult Psychiatric Care for ADHD in Sweden: A Nationwide Study

OBJECTIVE

To evaluate care transition and medication use in young adults with ADHD in Sweden.

METHOD

Observational retrospective study of patients with ADHD from the Swedish National Patient Register, Prescribed Drug Register, and Cause of Death Register (2018-2020). Last contact with pediatric psychiatric care, first contact with adult psychiatric care, and medication use were described for ages 18 to 21 years, inclusive.

RESULTS

Of 19,233 patients who had dispensed ADHD treatment, 85.8% had received adult psychiatric care by 21 years of age. The proportion of patients on medication was highest at age 18 years (80.1%), decreasing to 36.1% by age 21 years. By 21 years, there were significantly more patients on versus off ADHD medication who had received healthcare for autism, been prescribed selective serotonin re-uptake inhibitors, and received adult psychiatric outpatient visits (all p < .0001).

CONCLUSION

This study demonstrates declining ADHD medication use during the pediatric-to-adult care transition for patients in Sweden.

Nurse-led therapeutic patient education program on glycemic control and emotional wellbeing in adolescents with type 1 diabetes mellitus during hospital transition

INTRODUCTION

The transition of adolescents from pediatric to adult hospitals is a planned and guided process that involves changes in the focus, style, and location of care. During this period, complications are common in those with type 1 diabetes mellitus (T1DM). The objective of this study was to understand the influence of a nurse-led structured therapeutic education program on maintaining glycemic control and emotional wellbeing in these adolescents.

MATERIALS AND METHODS

Monocentric quasi-experimental clinical trial of a single group. SPSS and R-Commander were used for statistical analysis, including Student's t-test, Wilcoxon test, Cohen's d, Rosenthal's r, and multivariate linear regression analysis.

RESULTS

A total of 15 adolescents with a 5-to-17-year history of the disease participated in the study. They had a BMI of 18-26.3kg/m2 and were on basal-bolus therapy. No significant differences were found in glycemic control and emotional wellbeing between baseline values and at 3 months. A significant difference in self-care was observed at 12 months. Family function and eating disorders were positively associated at baseline, 3 months, and 12 months.

CONCLUSIONS

The structured therapeutic education program for adolescents with T1DM transitioning from pediatric to adult care maintains glycemic control and emotional wellbeing.

Transition from pediatric to adult care system in patients with complex epilepsies: Necker model for transition evaluated on 70 consecutive patients

OBJECTIVE

Complex epilepsies such as epileptic and developmental encephalopathies require multidisciplinary care throughout life. A coordinated transition program is therefore essential to provide optimal support for patients leaving pediatric for adult care. The aim of this study is to describe and evaluate our transition program for complex epilepsies, focusing on the last step in this program, that is, the multidisciplinary transition day hospital (MTDH).

METHODS

We performed a retrospective observational study including patients with complex epilepsies who underwent the full steps of the transition program at Necker-Enfants Malades Hospital between May 2021 and June 2023, with a follow-up until February 2024. We described the cohort and detailed the interventions performed during the MTDH including medical, medicosocial, educational, daily life abilities, and laboratory and imaging assessments with the participation of one member of the adult team. We evaluated two indicators of our program: (1) the "adult first clinic attendance rate," defined by the percentage of patients attending their first adult clinic; and (2) the "return rate," defined by the percentage of patients who requested a pediatric encounter after their transfer.

RESULTS

Our cohort included 70 patients with a mean age of 19.1 years (interquartile range = 16.3-19.5). Eighty percent had an epilepsy syndrome diagnosis; 72.8% were treated with three or more antiseizure medications. All patients had their appointment at the adult clinic within 6 months of the day hospital, and only two families requested a pediatric encounter after the transfer.

SIGNIFICANCE

The transition program is key for an optimal transfer of patients with complex epilepsies to adult care. It requires a comprehensive multidisciplinary approach and provides a complete summary of the medical record. Our program secures a smooth landing in adult care and is a promising model to better manage the challenging transition process, especially in patients with complex epilepsy.

Strategies to Guide Paediatric Type 1 Diabetes Management and Transition of Care: A State-Of-The-Art Review

AIM

The aim of the study was to synthesise current evidence on the transition of type 1 diabetes management responsibility from caregiver to child.

DESIGN

A state-of-the-art review was conducted.

METHODS

Using Rayyan software, two authors independently performed the study selection.

DATA SOURCES

CINAHL, PubMed and Web of Science databases were searched to identify relevant articles that focused on children ages 1-19 who were transitioning care of paediatric type 1 diabetes. The last search was performed on 17 October 2023.

RESULTS

Thirty-seven studies conducted in four different countries were included following abstract screening, full-text review and assessment for risk of bias-23 quantitative, 13 qualitative and one mixed method. One study examined early childhood transition, five studies examined middle childhood and 31 studies examined transition strategies utilised in later childhood. Themes in clinician and caregiver transition interventions were identified.

CONCLUSION

Findings can inform the development and refinement of transition interventions to help clinicians and caregivers ensure a successful transition of type 1 diabetes management to the paediatric patient.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

A rigorous investigation to validate strategies for different age groups is needed. To support this process and improve type 1 diabetes mellitus outcomes for paediatric patients, research and recommendations should be further reviewed to assist in tailoring interventions accordingly.

IMPACT STATEMENT

Effective transition management strategies to shift responsibility from caregiver to child are increasingly important to ensuring safe self-management of paediatric type 1 diabetes. Reviews on type 1 diabetes transition management strategies for youth are needed. In this systematic review, we highlight transition strategies for children ages 1-19 who were transitioning care of paediatric type 1 diabetes. Findings offer insight on long-term diabetes management to improve patient outcomes in paediatric patients with type 1 diabetes.

REPORTING METHOD

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was required in this review.

ERS statement on transition of care in childhood interstitial lung diseases

Interstitial lung diseases (ILD) are a heterogeneous group of rare diffuse diseases affecting the lung parenchyma in children and adults. Childhood interstitial lung diseases (chILD) are often diagnosed at very young age, affect the developing lung, and can have different presentations and prognosis compared to adult forms of these diseases. In addition, chILD in many cases may apparently remit, and have a better response to therapy and better prognosis than adult ILD. Many affected children will reach adulthood with minimal activity or clinical remission of the disease. They need continuing care and follow-up from childhood to adulthood if the disease persists and progresses over time, but also if they are asymptomatic and in full remission. Therefore, for every chILD patient an active transition process from paediatric to adult care should be guaranteed. This European Respiratory Society (ERS) statement provides a review of the literature and current practice concerning transition of care in chILD. It draws on work in existing transition care programmes in other chronic respiratory diseases, disease-overarching transition-of-care programmes, evidence on the impact of these programmes on clinical outcomes, current evidence regarding long-term remission of chILD as well as the lack of harmonisation between the current adult ILD and chILD classifications impacting on transition of care. While the transition system is well established in several chronic diseases, such as cystic fibrosis or diabetes mellitus, we could not find sufficient published evidence on transition systems in chILD. This statement summarises current knowledge, but cannot yet provide evidence-based recommendations for clinical practice.

Young Adults with Type 1 Diabetes

Young adults experience multiple developmental transitions across social, educational, vocational, residential, and financial life domains. These transitions are potential competing priorities to managing a chronic condition such as type 1 diabetes and can contribute to poor psychosocial and medical outcomes. In this narrative review, we describe population outcomes of young adult populations and the unique considerations associated with managing type 1 diabetes in young adulthood. We provide an overview of the current evidence-based strategies to improve care for young adults with type 1 diabetes and recommendations for future directions in the field.

Experiences of young people living with type 1 diabetes in transition to adulthood: The importance of care provider familiarity and support

BACKGROUND

During the developmental transition from childhood to adulthood, young people living with type 1 diabetes (T1D) are more likely to take less care of their chronic disease. Alongside the developmental transition, young people with T1D also experience an organisational transition in which the care responsibility changes from a family-based approach in paediatric care to an individualised approach in adult care. Little is known from the perspective of the young people about what their interactions with the healthcare providers mean during these transitions.

AIM

The aim of this study is to explore how young people living with T1D experience interactions with their care providers, and what it means for their developmental transition.

METHOD

Semi-structured interviews with 10 respondents aged 18-20 living with T1D who were recruited from a youth outpatient diabetes clinic in Denmark. Recorded audio data were transcribed and analysed using an interpretative phenomenological analysis approach.

RESULTS

Young people experience continuity in the relationship with the diabetes nurse from the paediatric clinic and a personal patient-provider relationship with their well-known and new care providers. This creates a feeling of familiarity and contributes to a seamless transition. The young people express that becoming more involved in diabetes treatment increases their willingness to take more responsibility for their own health. They also express that care providers should support them in managing their diabetes and talk about sensitive topics.

CONCLUSION

Continuity in the relationship with the diabetes nurse makes the transition from paediatric to adult care more satisfying and seamless. To support the developmental transition, care providers should gradually involve young people more in diabetes management and be supportive as they become more independent during the developmental transition.

Incorporating the Six Core Elements of Health Care Transition in Type 1 Diabetes Care for Emerging Adults

A growing body of literature finds persistent problems in the provision of recommended health care transition services, as well as adverse outcomes associated with the lack of these services in emerging adults with type 1 diabetes. The Six Core Elements of Health Care Transition offers a structured approach to the phases of health care transition support for both pediatric and adult diabetes practices. This article reviews strategies to incorporate the Six Core Elements into ambulatory diabetes care to support successful health care transition for emerging adults with type 1 diabetes.

Assessing the readiness to transition to adult care, perceived medication barriers, and glycemic control among teens with type 1 diabetes

AIM

This study assessed the readiness to transition (RT) from pediatric to adult care, perceived medication barriers (PMB), and glycemic control in teens with type one diabetes (T1D).

BACKGROUND

During the transition from pediatric to adult care, teens with T1D are at risk of long-term complications related to impaired adherence. With the increasing prevalence of T1D in Saudi Arabia, research is required to identify the challenges facing teens with T1D during their transition.

METHODS

This was a cross-sectional study with a convenient sample of 83 adolescents (12-17 years old) diagnosed with T1D for ≥6 months, their parents, and their pediatric endocrinologists from the pediatric endocrinology clinic in a tertiary hospital in Riyadh. The RT Questionnaire was used to measure RT, and the Medication Barriers Scale was used to measure PMB. Glycemic control was measured using hemoglobin A1c (HbA1c).

RESULTS

About 96 % of teens had HbA1c > 7 %. Male teens had higher HbA1c than female teens. Teens and their parents reported high PMB and low RT. PMB (teens), disease duration, family history of diabetes mellitus, and comorbidity were significant predictors of RT (parents). PMB (teens), teens' age, and having a family history of diabetes mellitus were significant predictors of RT (providers). RT (parents) and RT (providers) were the only significant predictors of HbA1c, with RT (providers) being the strongest predictors of HbA1c.

CONCLUSIONS

Health policy reform is required to develop national RT programs to prepare teens with T1D to take full responsibility for managing their medical conditions while ensuring adherence.

Prevalence and factors associated with school failure in children with type 1 diabetes

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is a health problem that can be difficult for young people to accept. The aim of this study is to determine the prevalence and characteristics of school failure in children with T1DM and to identify the associated factors.

MATERIAL AND METHODS

This is a retrospective study conducted in the endocrinology department of the Farhat Hached Hospital in Sousse, regarding T1DM patients, by analysing their school and career paths according to their clinicobiological and social data. School failure was defined in our study by the presence of at least one year's repetition and/or exclusion from school.

RESULTS

Our study included 70 patients. School failure was recorded in 71.4% of cases. School drop-out was observed in 47.1% of patients. The reasons for school drop-out were iterative hospitalizations in 31.4% of cases and glycaemic instability with hyper/hypoglycaemic fluctuations in 17.1%. Multivariate analysis showed that the risk factors significantly associated with school failure were, respectively, number of hospitalizations for ketosis ≥ 5 (p = 0.037) and higher mean HbA1c at the last consultations (p = 0.001). Use of functional insulin therapy (p = 0.031) and use of insulin analogue (p = 0.004) were significantly protective factors.

CONCLUSIONS

The risk of school failure in T1DM is real and should not be underestimated. Socioeconomic factors such as lack of financial resources, limited family support, and an unfavourable social environment can contribute to school avoidance.

Factors underlying a disproportionate increase in hospital admissions for adrenal insufficiency in women aged 20-29 years

Since the year 2000, admissions for adrenal insufficiency (AI) and adrenal crises (AC) have shown a particular increase in young adult females. We examined data on acute non-surgical hospitalisations for AI/AC from New South Wales, Australia, to determine relevant factors that may have contributed to this increase. Data were analysed to ascertain associations between various comorbid psychosocial issues, identified by relevant ICD-10-AM codes in each record, and ACs. From 2005 to 2021. There were 877 admissions for an acute non-surgical illness in this age group. The average admission rate for females [63.5/million/year] was almost twice that for males [34.0/million/year] (p<0.01), as was the average female AC admission rate [14.7/million/year] relative to that in males [6.75/million/year] (p=NS). Infection was present in 41.6% (n=365) of the admissions and Type 1 diabetes mellitus was present in 12.2% (n=107). Overall, psychosocial factors were considered by the senior clinician to have contributed to the illness episode in 22.1% of all admissions and 29.0% of AC admissions. Having one or more psychosocial problems was associated with an AC in females (37.4%, n=49, in those having an AC, p<0.001) but not males. Females with an AC also had a higher mean composite psychosocial, psychiatric and drug/alcohol score [0.47 (0.67)] than females without an AC [0.32 (0.62) p<0.05]. No comparable associations were found in male patients. An increase in the rates of hospitalisations that included a code for at least one psychosocial problem was highly correlated with increases in admission rates for both ACs (r=0.82, p<0.001) and all AI (r=0.98, p<0.001) in females but there was no such relationship in males. This new evidence suggests that psychosocial factors may play an important role in ongoing rates of ACs in treated AI (incidence approximately 6-8 ACs/100PY) particularly in young adult females. In order to minimize AC episodes, all barriers to self-management need exploration on an individual patient basis and with regard to the patient population as a whole.

Internet-Based Recruitment and Retention of Young Adults With Type 1 Diabetes: Cross-Sectional Study

BACKGROUND

Multiple research strategies are required to recruit and engage a representative cohort of young adults in diabetes research. In this report, we describe an approach for internet-based recruitment for a repeated-measures descriptive study.

OBJECTIVE

The objective of this cross-sectional study was to determine whether internet-based recruitment through multiple social media platforms, a clinical research platform, and cooperation with community partnerships-College Diabetes Network and Beyond Type 1-would serve as an effective way to recruit a representative sample of young adults aged 18-25 years with type 1 diabetes (T1D).

METHODS

We conducted a repeated-measures descriptive study. We captured enrollment rates and participant characteristics acquired from each social media platform through survey data and Facebook analytics. This study was advertised via paid postings across a combination of different social media platforms (eg, Facebook, Instagram, Twitter, and Reddit). We used quarterly application postings, quarterly newsletters, and participation in the ResearchMatch registry to identify potentially eligible participants from February 3, 2021, to June 6, 2022.

RESULTS

ResearchMatch proved to be the most cost-effective strategy overall, yielding the highest gender and racial diversity compared to other internet platforms (eg, Facebook, Instagram, Twitter, and Reddit), application postings (eg, Beyond Type 1), and newsletters (eg, College Diabetes Network and a local area college). However, we propose that the combination of these approaches yielded a larger, more diverse sample compared to any individual strategy. Our recruitment cost was US $16.69 per eligible participant, with a 1.27% conversion rate and a 30% eligibility rate.

CONCLUSIONS

Recruiting young adults with T1D across multiple internet-based platforms was an effective strategy to yield a moderately diverse sample. Leveraging various recruitment strategies is necessary to produce a representative sample of young adults with T1D. As the internet becomes a larger forum for study recruitment, participants from underrepresented backgrounds may continue engaging in research through advertisements on the internet and other internet-based recruitment platforms.

Use of expert consensus to improve the diagnosis and management of type 1 diabetes mellitus

BACKGROUND

Although type 1 diabetes mellitus (T1DM) is recognized as a catastrophic disease among the different types of diabetes, it is often confusedly diagnosed in clinical practice and difficult in care. The objective of this study is to reach a multidisciplinary consensus for the establishment of clinical recommendations on T1DM to optimize its undoubtedly diagnostic evaluation and transitional care.

METHODS

Scientific evidence was reviewed by a committee of researchers, based on which recommendations related to T1DM diagnosis were formulated. A two-round method was conducted to compare the opinions of a panel of 32 specialists (adult endocrinologists [53.1%], pediatric endocrinologists [43.8%], a diabetes educator for child and adolescent [3.1%]) on these issues.

RESULTS

The panel reached consensus on two of the six items discussed. The four items on which no consensus was reached were related to autoantibody detection and age of onset. Up to 80% of the panelists favored items related to the glucagon test and diabetic ketoacidosis history for T1DM diagnosis. Consensus regarding transitional care through diabetes educators was established.

CONCLUSION

The assessment conducted by experts on T1DM showed a high level of professional agreement regarding the proposed diagnostic and transitional care recommendations. A comprehensive analysis of the latest evidence is warranted for the items on which consensus was not established.

Health Care Transition From Pediatric- to Adult-Focused Care in X-linked Hypophosphatemia: Expert Consensus

CONTEXT

X-linked hypophosphatemia (XLH) is an inherited skeletal disorder that can lead to lifelong deleterious musculoskeletal and functional consequences. Although often perceived as a childhood condition, children and adults both experience the negative effects of XLH. Adolescents and young adults (AYAs) benefit from effective health care transition (HCT) preparation to support the transfer from pediatric- to adult-focused care. Whereas transition timelines, milestones, and educational tools exist for some chronic conditions, they do not meet the unique needs of patients with XLH.

EVIDENCE ACQUISITION

To produce the first expert recommendations on HCT preparation for AYAs with XLH developed by clinical care investigators and transition experts, a formal literature search was conducted and discussed in an advisory board meeting in July 2020. A modified Delphi method was used to refine expert opinion and facilitate a consensus position.

EVIDENCE SYNTHESIS

We identified the need for psychosocial and access-related resources for disease education, genetic counseling, family planning, and AYA emancipation from caregiver-directed care. Additionally, we recognized that it is necessary to facilitate communication with patients through channels familiar and accessible to AYAs and teach patients to advocate for their health care/access to specialists.

CONCLUSION

Clear HCT preparation guidelines and treatment-related goals are defined. Individualized timelines and practical strategies for HCT preparation are proposed to optimize health outcomes resulting from continuous clinical care throughout the patient lifecycle. We provide an expert consensus statement describing a tailored HCT preparation program specifically for AYAs with XLH to aid in the effective transfer from pediatric- to adult-focused health care.

Trend of Diabetes-Related Hospital Admissions During the Transition Period From Adolescence to Adulthood in the State of California

OBJECTIVE

This study examined the incidence of diabetes-related hospital admissions and described the characteristics among youth and emerging adults with type 1 (T1D) and type 2 diabetes (T2D) in California.

RESEARCH DESIGN AND METHODS

A retrospective study was conducted using the statewide inpatient database during the years 2014-2018. Individuals aged 13-24 years hospitalized with diabetic ketoacidosis (DKA) or severe hypoglycemia (SH) were recorded. Demographic characteristics and health measures among youth (ages 13-18) and young adults (ages 19-24) were compared.

RESULTS

A total of 34,749 admission encounters for T1D and 3,304 for T2D were analyzed. Hospitalization rates significantly increased with age during the transition to adulthood, from 70/100,000 California population at age 17 to 132/100,000 at age 19 in T1D. Higher hospitalization rates were demonstrated in young adults than in youth in T1D, and the rate was significantly higher in Black young adults (23.9%) than in youth (12.0%) among the age-adjusted population with diabetes (P < 0.0001). More young adults admitted were on public insurance, and approximately half were from the lowest income quartile. No difference was observed in hospital length of stay; however, hospital charges were higher among young adults. Young adults were three times more likely to be admitted for severe conditions.

CONCLUSIONS

We demonstrated a significant rise in hospital admission during the transition period in individuals with T1D. There were significantly more Black young adults who were on public insurance and had lower socioeconomic status. Our findings suggest that the health care system fails many emerging adults with diabetes, particularly for people of color, and that improving medical transition is crucial.

Competing Demands of Young Adulthood and Diabetes: A Discussion of Major Life Changes and Strategies for Health Care Providers to Promote Successful Balance

Young adults (YAs) are often faced with many new transitions and major milestones specific to their life stage. For YAs with diabetes, it can be particularly difficult to balance diabetes management with the age-typical demands of young adulthood. Clinicians can play an important role in helping YAs navigate major life changes and find balance in the competing demands of young adulthood, while protecting their health and well-being.

Benchmarking care outcomes for young adults with type 1 diabetes in Australia after transition to adult care

AIM

To determine advantages conferred by a youth-specific transition clinic model for young adults with type 1 diabetes (T1D) at Westmead Hospital (WH) as compared with Australian registry data.

METHODS

Prospectively collected data included age, diabetes duration, visit frequency, post code, BMI, mode of insulin delivery, continuous glucose monitoring, HbA1c, albumin creatinine ratio, BP, retinopathy and diabetic ketoacidosis (DKA) for all WH T1D clinic attendees aged 16-25 between January 2017 and June 2018 (n = 269). Results were compared with data collected during the same time period from 2 separate Australian data registries, one longitudinal (Australasian Diabetes Data Network, ADDN) and one a spot survey (the Australian National Diabetes Audit, ANDA).

RESULTS

Across the three cohorts, HbA1c was similar (respectively, WH, ADDN, ANDA; 8.7%[72mmol/mol], 8.7%[72mmol/mol], 8.5%[69mmol/mol]) and HbA1c was significantly higher in young adults <21 years (8.7-8.9%[73-75mmol/mol]) as compared with ≥21 years (8.5%[69mmol/mol], p < .002). In the WH cohort, median interval between visits was shorter than in ADDN (4.5 vs. 9.0 months) and DKA was lower (respectively, 3.6 and 9.2/100 patient years; p < .001).

CONCLUSIONS

While suboptimal HbA1c was recorded in all centres, the WH model of care saw increased attendance and reduced admissions with DKA as compared with other Australian adult centres.

Financial stress in emerging adults with type 1 diabetes in the United States

OBJECTIVE

To describe the relationships among financial stress factors (perceived stress, financial stress, and financial independence) and psychological factors (depressive symptoms, trait anxiety, and diabetes distress) on self-management outcomes (HbA1c and diabetes-related quality of life) in emerging adults with type 1 diabetes.

RESEARCH DESIGN AND METHODS

A descriptive, correlational, cross-sectional study examined 413 emerging adults, ages 18-25, from the Type 1 Diabetes Exchange Clinic Registry. Data were collected via REDCap surveys using the Personal Financial Well-Being Scale, Willingness to Pay Scale, Financial Independence Visual Analog Scale, Center for Epidemiological Studies-Depression Inventory, State-Trait Anxiety Inventory, The Type 1 Diabetes Distress Scale, and Diabetes Quality of Life Measure. Hierarchical Multiple Regression analyses explored significant barriers to self-management outcomes.

RESULTS

Hierarchical Multiple Regression analyses revealed that 20.6% of variance in HbA1c (F = 15.555, p < 0.001) was explained by greater financial stress (β = -0.197, p < 0.001), willingness to pay (β = -0.220, p < 0.001), disease duration (β = 0.119, p = 0.014), and diabetes distress (β = 0.181, p < 0.001); 64.5% of the variance in diabetes-related quality of life (F = 148.469, p < 0.001) was significantly explained by greater financial stress (β = -0.112, p = 0.002), diabetes distress (β = 0.512, p < 0.001), trait anxiety (β = 0.183, p = 0.001) and depressive symptoms (β = 0.162, p = 0.001).

CONCLUSIONS

Greater financial stress and psychological factors have detrimental impacts on self-management outcomes during emerging adulthood. Diabetes providers need to identify and address these factors in routine care and advocate for policy changes to support improved self-management outcomes.

The four I's of adolescent transition in type 1 diabetes care: A qualitative study

AIMS

To explore adolescent perspectives on programme design in the transition to adult care.

METHODS

We conducted five focus groups on adolescents with type 1 diabetes nearing the age of transition to adult care. Study participants also completed an embedded survey where they rated a wide range of potential transition interventions. Focus group transcripts were analysed with three iterations of line-by-line coding to triangulate themes and subthemes.

RESULTS

Four themes were identified: Individualization-how to personalize the transition experience (having choices in the transition experience, meeting adult provider before transition and specific transition preparation); Identity-how the world relates to my diabetes (stigma of type 1 diabetes, confusion with type 2 diabetes, diagnosis disclosure and resilience); Interconnection-how my support system can help me with my diabetes (peer support, near peer support, parental support, loss of bond with paediatric team and fear of not having a bond with adult team); and Impediment-how my diabetes limits me (self-care takes work and time, unpredictability and restrictiveness, and emotional burden). Highly rated interventions from the survey included: good communication between the paediatric and adult teams, medical summary of past diabetes care, and having paediatric and adult teams in the same building.

CONCLUSIONS

The design of future transition interventions for adolescents with type 1 diabetes should address the issues of Individualization, Identity, Interconnection and Impediment. Collaborative processes between paediatric and adult providers were also rated as important strategies to facilitate the transition to adult care.

Health Literacy and Quality of Life in Young Adults From The Belgian Crohn's Disease Registry Compared to Type 1 Diabetes Mellitus

Background and Aims: The management of chronic inflammatory bowel diseases in youth is challenging. We aimed to determine health literacy (HL), quality of life (QoL) and clinical outcomes in young adults from the BELgian CROhn's disease registry (BELCRO) in comparison to type 1 diabetes mellitus (DM) as a control. Methods: In this prospective and observational study, young adults with Crohn's disease (CD) diagnosed < 18 years and with > 5 years disease duration and a comparable group of patients with DM completed validated HL, QoL and work productivity and activity impairment questionnaires (HLS-EU-Q16, EQ-5D-5L and WPAI). HL was scored as sufficient (13-16), problematic (9-12) or inadequate (0-8). QoL was dichotomized into "no problems" (EQ-5D level 1) or "problems" (EQ-5D levels 2 to 5). Non-parametric (Mann-Whitney U) analyses and Spearman correlations were performed. Results: A total of 52 CD (median [IQR] age of 25.0 [23.8-27.0], 64% male) and 50 DM (age 20.0 [19.0-22.0], 50% male) patients were included. HL was 14.0 [11.0-16.0] for CD and 14.0 [11.3-14.8] for DM (p = 0.6) with similar proportions of sufficient (60 vs. 68%, p = 0.4), problematic (34 vs. 26%, p = 0.3) and inadequate HL (both 6%, p = 1). Although QoL was comparable for CD and DM (77.0 [68.8-82.0] vs. 75.0 [65.0-80.0] %, p =0.4), CD had a trend for higher pain/discomfort (50 vs. 32%, p = 0.06). HL and QoL correlated in CD (r = 0.6, p < 0.001) and DM patients (r = 0.6, p < 0.001). Fewer CD patients with recent hospitalization/surgery had sufficient HL (31 vs. 69%, p = 0.01) and had lower QoL (70.0 [60.0-77.0] vs. 80.0 [70.0-85.0], p = 0.04) compared to those without. Conclusions: Selected young Belgian adults suffering from CD for >5 years have similar and sufficient HL compared to DM patients. However, CD patients requiring hospitalization/surgery have lower HL, which indicates the need for targeted educational programs.

Transition from pediatric to adult follow-up care in childhood cancer survivors-a systematic review

PURPOSE

The successful transition of childhood cancer survivors from pediatric- to adult-focused long-term follow-up care is crucial and can be a critical period. Knowledge of current transition practices, especially regarding barriers and facilitators perceived by survivors and health care professionals, is important to develop sustainable transition processes and implement them into daily clinical practice. We performed a systematic review with the aim of assessing transition practices, readiness tools, and barriers and facilitators.

METHODS

We searched three databases (PubMed, Embase/Ovid, CINAHL) and included studies published between January 2000 and January 2020. We performed this review according to the PRISMA guidelines and registered the study protocol on PROSPERO; two reviewers independently extracted the content of the included studies.

RESULTS

We included 26 studies: six studies described current transition practices, six assessed transition readiness tools, and 15 assessed barriers and facilitators to transition.

CONCLUSION

The current literature describing transition practices is limited and overlooks adherence to follow-up care as a surrogate marker of transition success. However, the literature provides deep insight into barriers and facilitators to transition and theoretical considerations for the assessment of transition readiness. We showed that knowledge and education are key facilitators to transition that should be integrated into transition practices tailored to the individual needs of each survivor and the possibilities and limitations of each country's health care system.

IMPLICATIONS FOR CANCER SURVIVORS

The current knowledge on barriers and facilitators on transition should be implemented in clinical practice to support sustainable transition processes.

Poor metabolic control in childhood strongly correlates to diabetes-related premature death in persons <30 years of age-A population-based cohort study

BACKGROUND/OBJECTIVE

The importance of metabolic control in childhood regarding excess risk of death in young persons has not been well studied. This registry-based study aimed to investigate mortality rates and cause of death related to metabolic control in young persons (≤29 years) in Sweden with type 1 diabetes.

METHODS

All 12 652 subjects registered in the Swedish pediatric diabetes quality register, from 2006 to 2014, were included. Data were merged with the Swedish Cause of Death Register. Standardized mortality rates were calculated using the official Swedish population register.

RESULTS

Of 68 deaths identified, 38.2% of the deaths were registered as being due to diabetes whereof the major cause of death was acute complications. Overall standardized mortality ratio was 2.7 (2.1-3.4, 95% CI). Subjects who died from diabetes had a mean HbA1c of 74 ± 19 mmol/mol (8.9 ± 1.7%) during childhood vs 62 ± 12 mmol/mol (7.8 ± 1.1%) in those still alive (P < .001).

CONCLUSIONS

In this nationwide cohort of young subjects with type 1 diabetes, there was a high mortality rate compared to the general population. Mean HbA1c in childhood was significantly higher in those who died from diabetes, compared to subjects who were still alive. To decrease mortality in young persons with type 1 diabetes it is essential not only to achieve but also to maintain a good metabolic control during childhood and adolescence.

Transition from paediatric to adult care: a qualitative study of the experiences of young adults with type 1 diabetes

AIM

The aim of the present study was to explore how young adults with type 1 diabetes (T1D) experienced the transition from paediatric to adult health care services.

DESIGN

A qualitative, explorative design was used.

METHODS

Eleven young adults with T1D receiving adult diabetes care at a hospital in western Norway participated in semi-structured interviews. Data were analysed using Interpretive Description, an inductive approach inspired by grounded theory, ethnography and phenomenology, and specifically designed to explore phenomena in clinical practice aiming to generate new knowledge and skills.

RESULTS

Four main themes regarding the adolescents' experiences of the transfer from paediatric to adult care emerged: (i) limited information about the transition; (ii) transition from frequent, thorough and personal follow-up to a less comprehensive and less personal follow-up; (iii) the importance of being seen as a whole person; (iv) limited expectations of how the health care services were organised.

CONCLUSIONS

The study showed that the existing routines for transfer between paediatric and adult care are not optimal. The participants expressed that they were not prepared for the dissimilarities in follow-up and were predominantly less pleased with the adult care follow-up.

RELEVANCE TO CLINICAL PRACTICE

The findings support a need for structured transition programmes, that is programmes that contribute to young adults with T1D receiving a safe and positive transition at an otherwise demanding life phase. Young peoples' individual needs for the transition to and follow-up in adult care may be promoted by an approach based on person-centred care.

[Diabetes mellitus at the interface between pediatric and adult medicine]

Patients with chronic diseases manifesting in childhood, such as type 1 diabetes, need to make an optimal transition from pediatric to adult medical care. This or transitionis a challenge for patients and their treatment teams, since metabolic control is often unstable at this time of life. Additional factors like the social environment, as well as concomitant diseases, also need to be taken into account and often represent hurdles to optimal therapy. Transition is an important process to guarantee good self-management of diabetes therapy and good outcomes in the long term. This review provides an overview and recommendations on the topic of transition in diabetes.

College-Bound: Transition Planning Strategies for Students With Type 1 Diabetes

Transition planning is mandated for students who receive special education services; however, it is not required for students with chronic conditions. Students with chronic conditions nearing graduation would benefit from more intensive attention to their post-high school self-care needs and responsibilities. Students with type 1 diabetes must be able to understand the necessary self-care of one of the most complicated and intensive chronic conditions yet there are no evidence-based strategies for how to help students transition from the support provided at school to independence at graduation. The need for a student with type 1diabetes to independently manage their diabetes is even greater as the student leaves home for college. School nurses, who are also certified diabetes educators, created a support group for seniors with type 1 diabetes. The group focused on life after high school and provided the students with a detailed checklist to help improve knowledge and prepare students for the transition to college. Participants felt better prepared to move on to college armed with their checklist and other resources to help when away from home.