Transition experiences and health care utilization among young adults with type 1 diabetes

Barriers and Facilitators Impacting Disease and Symptom Management Among College Students With Type 1 Diabetes: A Qualitative Study

PURPOSE

This study aimed to explore barriers and facilitators impacting disease and symptom management among college students living with Type 1 Diabetes (T1D).

DESIGN

A qualitative, phenomenological approach using semi-structured, one-on-one interviews.

SETTING

Interviews conducted on Zoom (n = 28) and in-person (n = 3).

PARTICIPANTS

Purposive sample of 31 college students living with T1D for at least 2 years who attended large, 4-year public universities in the Southeastern United States.

METHOD

This study was theoretically informed using the Middle-Range Theory of Self-Care of Chronic Illness Integration of Symptoms to develop interview questions. Interviews were transcribed verbatim and uploaded in NVivo. Data were analyzed thematically using a codebook developed by the research team using the theory as a framework. Trustworthiness was established using an audit trail, memos, and negative case analysis.

RESULTS

Four themes described barriers: diabetes burnout, challenges adjusting to a college lifestyle, difficulty receiving medical supplies, and insurance limitations. Five themes explained facilitators: years of experience managing T1D, tangible support with medical supplies, informational support for disease management, and emotional/technological support for disease and symptom management.

CONCLUSION

Barriers and facilitators in this study should be addressed in future T1D interventions for college students. Findings can also guide healthcare professionals, health promotion practitioners, family, friends, and significant others on how to better support college students as they manage T1D.

The role and need for psychological support in the treatment of adolescents and young people suffering from type 1 diabetes

Psychological support might be perceived as one of the most important factors in the treatment of people suffering from type 1 diabetes, particularly among vulnerable groups such as adolescents and young people. Problems arising from extreme pressure put on young patients, high expectations, and specific limitations associated with diabetes often reflect in negative wellbeing and affect patients' behavior, resulting in lower self-esteem, mood swings, depression, or even eating disorders. Therefore, the need for a more holistic approach to the treatment of diabetes and caring about psychological support can be observed, which may contribute to better functioning and management of the disease. Differentiation of certain approach methods such as the positive approach (PA) discussed in the text may help young patients in motivation and coping with their disease as well as accepting limitations caused by type 1 diabetes. This would decrease the risk of potential revolt against medical recommendations, common for patients at the mentioned age, and help raise awareness of the problem. Maintaining life balance through undertaking regular physical activities and being open to new strategies such as telenursing can also result in the improvement of glycemic control. The studies presented have proven the great effectiveness of personalized care adjusted to the patient with psychological support, as well as the invaluable role of education in diabetes, which includes not only standard procedures such as calculating an appropriate insulin dose but also the invention of effective coping mechanisms, which influence patients' performance and wellbeing.

Patient-Reported Outcomes Among Transition-Age Young Adults With Juvenile Idiopathic Arthritis in the Childhood Arthritis and Rheumatology Research Alliance Registry

OBJECTIVE

To evaluate patient-reported care utilization and outcomes among young adults with juvenile idiopathic arthritis (JIA), including factors associated with complete transfer to adult rheumatology.

METHODS

We included young adults with JIA enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from 2015 to 2019 with age ≥ 18 years at their last clinical site visit. We used data from the CARRA Registry Long-term Follow-up program, which follows inactive CARRA Registry patients and collects patient-reported information through phone surveys. We compared the characteristics of respondents with complete and incomplete transfer to adult rheumatology care at their first Long-term Follow-up phone survey.

RESULTS

We identified 540 young adults with JIA; 187 (35%) responded to the Long-term Follow-up phone survey. The 54% of respondents with complete transfer to adult rheumatology were slightly older and reported more self-assessed disease activity, morning stiffness, and pain compared to those with incomplete transfer. Biologic use was high at both timepoints and did not differ by transfer status. Patients who completed the transfer were more likely to have private insurance and be actively pursuing postsecondary education compared to those with an incomplete transfer. Across the cohort, 65% reported problems with pain or discomfort and 45% with anxiety or depression.

CONCLUSION

Young adult respondents with JIA in the CARRA Registry commonly report persistent medication use, but still report more problems with pain as compared to population norms. Additional work is needed to understand how best to address comorbid pain around the period of transition to adult care.

Predictors of Patient Return to a Tertiary Neurofibromatosis Subspecialty Clinic

OBJECTIVE

To evaluate sociodemographic and medical predictors of patient return to a neurofibromatosis subspecialty clinic.

STUDY DESIGN

Data were collected from the Washington University Neurofibromatosis Clinical Program electronic medical records. A total of 713 subjects with initial visits to the Washington University Neurofibromatosis Clinical Program between July 1, 2005 and December 18, 2020 were included. Variables collected included sex, race, ethnicity, age, date of first visit, place of residence, diagnosis, insurance payer, physician recommendation for return, and subject return. Return rates for each demographic group were calculated. Bivariate analyses were performed to inform variable inclusion in the model, and a binary logistic regression model was calculated to predict subject return.

RESULTS

The overall return rate was 76%. The binary logistic regression model was statistically significant (χ²₉ = 131.094; P < .001) and showed that subjects who self-identified as Black and/or African American, presented with or received a diagnosis of café-au-lait macules at their initial visit, were from a rural area, were older, or who lived farther from the Washington University Neurofibromatosis Clinical Program were less likely to return to clinic.

CONCLUSIONS

These findings support the implementation of tailored communication and monitoring interventions to improve the care for children with neurofibromatosis type 1.

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.

The added value of transition programs in Dutch diabetes care: A controlled evaluation study

PURPOSE

The desirability of evaluating transition programs is widely acknowledged. This study aimed to explore the added value of transitional care investments for young adults with type 1 diabetes mellitus.

DESIGN AND METHODS

Based on qualitative data, two groups of diabetes teams were created through cluster analysis: paying more (HI-ATT) versus less attention (LO-ATT) to transitional care. Retrospective controlled evaluation included chart reviews on healthcare use and clinical outcomes; and a survey on young adults' experiences, satisfaction with care, and self-management skills.

RESULTS

Data from 320 patients in fifteen diabetes teams were collected; 123 young adults (38.4%) completed a questionnaire. Self-reported outcomes showed that young adults treated by a HI-ATT team felt better prepared for transfer (p < .05). Self-management outcomes did not differ between groups. HI-ATT teams had more scheduled consultations in the year after transfer (p < .05); only 10.6% of all measurements had reached targeted HbA1c scores.

CONCLUSIONS

Current transitional care investments in Dutch diabetes care did not lead to notable improvements in experiences and outcomes, except for preparation for transfer. The period after transfer, however, is just as important. Attention is required for parent involvement.

PRACTICE IMPLICATIONS

Transitional care investments should extend beyond the transfer. By educating young adults about the importance of regular clinic attendance and introducing additional person-centered consultations in adult care, nurses may help ensure continuity of care. Nurses could also introduce support programs for parents to prepare for the transition and their change in role, taking into account their continuing partnership.

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.

TRAQ Changes: Improving the Measurement of Transition Readiness by the Transition Readiness Assessment Questionnaire

OBJECTIVE

The purpose of the current study was improving the measurement precision of the Transition Readiness Assessment Questionnaire (TRAQ 5.0-20 item) in order to gain better decimation of transition readiness skills across the 5 Stages of Change-from Precontemplation to Mastery.

METHODS

In stage 1, starting with the TRAQ 5.0 20-item, 5 domain subscale questionnaire, we eliminated the five lowest discriminating items using Item response theory (IRT) in MPlus v7.4,which eliminated the domain subscale Managing Daily Activities, and we e added 15 more difficult and better discriminating items. We added items to both to the remaining 4 domain subscales and created a new domain subscale entitled Future Planning. The revised 30-item TRAQ was piloted among 386 youth between 16 and 24 years old (mean = 20 years; 54% female; 87% White).

RESULTS

After examining the model fit, discrimination and difficulty coefficients, and modification indices, we eliminated 10 items and the new Future Planning domain subscale we eliminated. The resulting questionnaire has 4 domain subscales and 20 items. It exhibited good to excellent fit to the data, χ²(164) = 887.239, p < .001, CFI = 0.943, TLI = 0.93, RMSEA = 0.0942 (90% CI: 0.090, 0.114), WRMR = 1.111. All items have acceptable discrimination coefficients. Each of the 4 domain subscales have improved reliability as compared with the original TRAQ 5.0 20 item scale.

CONCLUSIONS

The revised 20-itemTRAQ 6.0 has 4 domains subscales; Managing medications, keeping appointment, tracking health issues, and Talking with providers and has good construct validity as demonstrated by model fit. By adding more difficult items to the 4 resulting domain subscales, we have demonstrated improved item discrimination and difficulty, and therefore can better measure acquisition of transition readiness skills across the five stages of change from pre-contemplation to contemplation to initiation to action and finally to mastery.

The role of parental support for emerging adults with type 1 diabetes: A scoping review

BACKGROUND

Emerging adults with type 1 diabetes often have poor diabetes self-care and pose a considerable therapeutic challenge. They simultaneously handle a life phase characterized by instability, identity exploration, and transitions and manage a chronic illness that demands structure, self-discipline, and repeated health care contacts. Relation to parents is often ambivalent but typically remains the most stable social support, so parental support could potentially be helpful for diabetes self-care and wellbeing.

METHOD

This scoping review aimed to identify, summarize and analyze empirical studies (for instance interview studies, questionnaire studies and intervention studies) exploring parental support for emerging adults with type 1 diabetes. Studies were identified in PsycInfo, PubMed, Scopus, and Google Scholar. Data were extracted by one author and checked by another. Study results were synthesized by a convergent mixed methods approach and qualitative thematic analysis.

RESULTS

We included 26 studies (2829 participants), 16 interview studies, 10 questionnaire studies, and no intervention studies. Five overarching themes were identified: self-care and glycemic control, diabetes-related emotional wellbeing, support characteristics, ambivalence and harms, and core support providers. Parents tended to contribute positively to diabetes self-care, glycemic control, and psychological wellbeing. However, emerging adults did not want to be too dependent on their parents and family, and family could also act unsupportively; when absent, disinterested in diabetes or controlling.

CONCLUSION

This review underlines that parental support still plays a role for diabetes self-care and wellbeing in emerging adults with type 1 diabetes. Age-appropriate parental support therefore seems a promising path to investigate further.

Parental Stress as a Child With Diabetes Transitions From Adolescence to Emerging Adulthood

This study examined parental and caregiver distress among families caring for children with type 1 diabetes as the child transitions into Emerging Adulthood. More than 96 hours of semistructured interviews were conducted with 19 adult caregivers including parents, grandparents, and other adult family members of 10 children. Each research partner participated in multiple face-to-face, 1- to 1.5-hour long-evolving interviews over the course of 4.5 years. Paradoxically, caregivers were found to experience significant increase in distress as their child with diabetes entered the developmental stage of Emerging Adulthood, 18 to 25 years old, by which time they should be masters of self-care, and parental distress should begin to decline. This increase in familial distress was associated with the emerging adults leaving the home, being unable to maintain an acceptable level of self-care, and experiencing declining health, frequent visits to the emergency department, and repeated hospitalizations. These findings suggest that parental distress from caring for a child with diabetes continues as the child ages, matures, and transitions into adulthood and may be exacerbated when the emerging adult with type 1 diabetes leaves the home and the direct observation and care of the parent.

The impact of type 1 diabetes on young adults' health-related quality of life

BACKGROUND

Young adulthood is a challenging period for people with diabetes mellitus type 1 (T1DM) as they are facing multiple life transitions while managing a demanding disease. This poses a risk for impaired health-related quality of life (HRQOL). We assessed HRQOL in a cohort of young adults with T1DM in the Netherlands, and compared outcomes with those of Dutch norm groups of healthy young adults and young adults with a chronic disease.

METHODS

We analyzed data collected in a larger evaluation study on transitional care for young adults with T1DM in a nationwide sample in the Netherlands, including twelve participating hospitals. These data had been obtained from online questionnaires completed by young adults with T1DM after they had transferred to adult care. HRQOL was self-reported with the Pediatric Quality of Life Inventory for young adults (PedsQL-YA).

RESULTS

One hundred and sixty-five young adults with T1DM participated (44.2% response); and they scored significantly worse than did healthy peers on all domains of HRQOL, except social functioning. Particularly, functioning at school or work was worse than that of the norm group. The study group's HRQOL-scores were comparable to norm scores of young adults with chronic diseases, although the physical and social functioning of young people with T1DM was better. One quarter (26.1%) of all young adults with T1DM reported fatigue.

CONCLUSIONS

During transition to adulthood, young adults with T1DM struggle to maintain a balance between the demands of managing a disease and their life. Many of them encounter problems at work or school, and suffer from fatigue. These findings underscore the need to regularly assess HRQOL, and to discuss work- and education-related issues in clinical practice.

Analysis of factors influencing the frequency of primary care visits among diabetic patients in two provinces in China

BACKGROUND

Community health services have played an important role in the prevention and control of diabetes in China. The aims of this study were to examine the frequency of visits to community clinics for diabetic care services, to assess factors correlated with infrequent primary care visits and to identify barriers to regular follow-up visits for urban and rural patients.

METHODS

Between October 2014 and November 2014, data were collected from 17 communities in two cities and four townships located in Shandong and Jiangsu Provinces in China. A total of 1598 diabetic patients aged 18 years or older who were registered with a primary health station in local communities were selected by simple random sampling. Each participant was required to complete an interviewer-led questionnaire. Univariate and multivariate analyses were used to identify significant factors for infrequent visitor status using multivariable logistic regression analysis.

RESULTS

After being clearly informed of the study protocol, 1508/1598 (94.4%) patients agreed to participate in this survey. Among the 1508 subjects (mean age 64.4 ± 10.6), 683 (45.3%) were classified as infrequent visitors. The following were significant factors determining infrequent visitor status: urban residence, lack of health insurance, per-capita household income< 20,000 (yuan), lack of telephone follow-up and lack of household visit. From the patients' perspectives, the reasons for infrequent visits among urban patients included drug scarcity and longer travel time to clinics. For rural patients, worries about medical expenses and drug scarcity were the most common barriers to clinic visits.

CONCLUSION

Determinants of infrequent community visits in diabetes patients include urban residence, lower household income, lack of health insurance, lack of telephone follow-up and lack of household visit services. Strategies aimed at enhancing the utilization of community health care should be implemented in China.

Longitudinal Self-Management and/or Transition Readiness per the TRxANSITION Index among Patients with Chronic Conditions in Pediatric or Adult Care Settings

OBJECTIVE

To evaluate the roles of key individual, family, and illness characteristics on the levels of and gains in longitudinal healthcare transition (HCT) readiness in the pediatric setting and/or self-management skills (SMS) in the adult-focused setting, we used a large dataset with longitudinal measurements from 2006 to 2015.

STUDY DESIGN

This longitudinal observational study followed 566 adolescents and young adults with chronic conditions at University of North Carolina Hospitals. TR_xANSITION Index measurements, which represent learning outcomes rather than health outcomes, were collected multiple times per patient and analyzed using a novel application of an education-based approach.

RESULTS

Levels of and gains in HCT/SMS scores increased with age (P < .001) with smaller increases at older ages. Mastery of skills varied by age with self-management achieved after 20 years of age. Scores varied positively by father's education and negatively by mother's education and duration of diagnosis. Gains in scores further varied positively with private insurance and negatively with mother's education and duration of diagnosis.

CONCLUSIONS

We found diminishing positive increases in HCT/SMS scores as patients become older and smaller levels of and gains in readiness among younger patients with more educated mothers. Risk factors for absolute level of HCT/SMS readiness and inadequate longitudinal gains are not always the same, which motivates a deeper understanding of this dynamic process through additional research. This information can guide providers to focus HCT/SMS preparation efforts on skills mastered at particular ages and to identify patients at risk for inadequate development of HCT/SMS skills.

Young people's experiences of managing Type 1 diabetes at university: a national study of UK university students

AIM

Little is known about the challenges of transitioning from school to university for young people with Type 1 diabetes. In a national survey, we investigated the impact of entering and attending university on diabetes self-care in students with Type 1 diabetes in all UK universities.

METHODS

Some 1865 current UK university students aged 18-24 years with Type 1 diabetes, were invited to complete a structured questionnaire. The association between demographic variables and diabetes variables was assessed using logistic regression models.

RESULTS

In total, 584 (31%) students from 64 hospitals and 37 university medical practices completed the questionnaire. Some 62% had maintained routine diabetes care with their home team, whereas 32% moved to the university provider. Since starting university, 63% reported harder diabetes management and 44% reported higher HbA_1c levels than before university. At university, 52% had frequent hypoglycaemia, 9.6% reported one or more episodes of severe hypoglycaemia and 26% experienced diabetes-related hospital admissions. Female students and those who changed healthcare provider were approximately twice as likely to report poor glycaemic control, emergency hospital admissions and frequent hypoglycaemia. Females were more likely than males to report stress [odds ratio (OR) 4.78, 95% confidence interval (CI) 3.19-7.16], illness (OR 3.48, 95% CI 2.06-5.87) and weight management issues (OR 3.19, 95% CI 1.99-5.11) as barriers to self-care. Despite these difficulties, 91% of respondents never or rarely contacted university support services about their diabetes.

CONCLUSION

The study quantifies the high level of risk experienced by students with Type 1 diabetes during the transition to university, in particular, female students and those moving to a new university healthcare provider.

Health Communication Experiences of Emerging Adults with Type 1 Diabetes

Objective

In an effort to refine a model of clinical care identifying effective communication with health care providers (HCPs) as a key skill for successful transition to adult medical care, this study explored the perspectives of emerging adults with type 1 diabetes (T1D) about factors that impact the quality and content of communication with their HCPs.

Methods

Twenty emerging adults with T1D were interviewed about health communication experiences with their pediatric HCP and readiness for transition to adult diabetes care. Interviews were recorded and transcribed; three raters coded transcripts using conventional content analysis for broad themes.

Results

Five themes emerged from the data capturing factors that influence emerging adult-HCP communication: HCP interaction style, HCP consistency, HCP support for autonomy, parental involvement in medical care, and emerging adult comfort with disclosure. Most emerging adults had not discussed transition to adult diabetes care with their HCP; some expressed confidence in their ability to transition while others expressed anxiety about the transition process.

Conclusions

Findings support the conceptual model of communication and inform clinical implications for working with emerging adults with T1D. Continuity of care should be prioritized with transition-age patients. Additionally, HCPs should initiate conversations about engagement in risky behaviors and transition to adult medical care and ensure emerging adults have time without parents to discuss these sensitive topics. Psychologists can enhance the transition process by facilitating effective patient-HCP communication and coaching both patients and HCPs to ask questions about risky behaviors and transition to adult medical care.

Outcome Evidence for Structured Pediatric to Adult Health Care Transition Interventions: A Systematic Review

OBJECTIVE

To identify statistically significant positive outcomes in pediatric-to-adult transition studies using the triple aim framework of population health, consumer experience, and utilization and costs of care.

STUDY DESIGN

Studies published between January 1995 and April 2016 were identified using the CINAHL, Ovid MEDLINE, PubMed, Scopus, and Web of Science databases. Included studies evaluated pre-evaluation and postevaluation data, intervention and comparison groups, and randomized clinic trials. The methodological strength of each study was assessed using the Effective Public Health Practice Project Quality Assessment Tool.

RESULTS

Out of a total of 3844 articles, 43 met our inclusion criteria. Statistically significant positive outcomes were found in 28 studies, most often related to population health (20 studies), followed by consumer experience (8 studies), and service utilization (9 studies). Among studies with moderate to strong quality assessment ratings, the most common positive outcomes were adherence to care and utilization of ambulatory care in adult settings.

CONCLUSIONS

Structured transition interventions often resulted in positive outcomes. Future evaluations should consider aligning with professional transition guidance; incorporating detailed intervention descriptions about transition planning, transfer, and integration into adult care; and measuring the triple aims of population health, experience, and costs of care.

Evaluating Continuity During Transfer to Adult Care: A Systematic Review

CONTEXT

Appropriate outcomes are required to evaluate transition programs' ability to maintain care continuity during the transfer to adult care of youths with a chronic condition.

OBJECTIVE

To identify the outcomes used to measure care continuity during transfer, and to analyze current evidence regarding the efficacy of transition programs.

DATA SOURCES

PubMed (1948-2014), Web of Science (1945-2014), Embase (1947-2014), and the reference lists of the studies identified.

STUDY SELECTION

Screening on titles and abstracts; full-text assessment by 2 reviewers independently.

DATA EXTRACTION

By 2 reviewers independently, by using a Cochrane form adapted to observational studies, including bias assessment.

RESULTS

Among the 23 studies retrieved, all but 5 were monocentric, 16 were cohorts (15 retrospective), 6 cross-sectional studies, and 1 randomized trial. The principal disease studied was diabetes (n = 11). We identified 24 indicators relating to 2 main aspects of continuity of care: engagement and retention in adult care. As designed, most studies probably overestimated engagement. A lack of adjustment for confounding factors was the main limitation of the few studies evaluating the efficacy of transition programs.

LIMITATIONS

The assessment of bias was challenging, due to the heterogeneity and observational nature of the studies.

CONCLUSIONS

This review highlights the paucity of knowledge about the efficacy of transition programs for ensuring care continuity during the transfer from pediatric to adult care. The outcomes identified are relevant and not specific to a disease. However, the prospective follow-up of patients initially recruited in pediatric care should be encouraged to limit an overestimation of care continuity.

Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services - an integrative review

AIMS AND OBJECTIVES

This paper aims to provide an updated comprehensive review of the research-based evidence related to the transitions of care process for adolescents and young adults with chronic illness/disabilities since 2010.

BACKGROUND

Transitioning adolescent and young adults with chronic disease and/or disabilities to adult care services is a complex process, which requires coordination and continuity of health care. The quality of the transition process not only impacts on special health care needs of the patients, but also their psychosocial development. Inconsistent evidence was found regarding the process of transitioning adolescent and young adults.

DESIGN

An integrative review was conducted using a five-stage process: problem identification, literature search, data evaluation, data analysis and presentation.

METHODS

A search was carried out using the EBSCOhost, Embase, MEDLINE, PsycINFO, and AustHealth, from 2010 to 31 October 2014. The key search terms were (adolescent or young adult) AND (chronic disease or long-term illness/conditions or disability) AND (transition to adult care or continuity of patient care or transfer or transition).

RESULTS

A total of 5719 records were initially identified. After applying the inclusion criteria a final 61 studies were included. Six main categories derived from the data synthesis process are Timing of transition; Perceptions of the transition; Preparation for the transition; Patients' outcomes post-transition; Barriers to the transition; and Facilitating factors to the transition. A further 15 subcategories also surfaced.

CONCLUSIONS

In the last five years, there has been improvement in health outcomes of adolescent and young adults post-transition by applying a structured multidisciplinary transition programme, especially for patients with cystic fibrosis and diabetes. However, overall patients' outcomes after being transited to adult health care services, if recorded, have remained poor both physically and psychosocially. An accurate tracking mechanism needs to be established by stakeholders as a formal channel to monitor patients' outcomes post- transition.

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

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

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

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

A Systematic Review of Transitional Care for Emerging Adults with Diabetes

The prevalence of diabetes and prediabetes in adolescents is increasing. A systematic review of 31 research articles focusing on transitional care for adolescents or emerging adults with diabetes or prediabetes was completed. Studies focused on those with type 1 diabetes, not type 2 diabetes or prediabetes, and were primarily descriptive. Major findings and conclusions include differences in pediatric versus adult care delivery and the importance of structured transitional programs using established recommendations of leading national organizations. Implications include future research on program development, implementation, and evaluation that is inclusive of adolescents and emerging adults, regardless of diabetes type, or prediabetes.

Family Perspectives of Components of a Diabetes Transition Program

PURPOSE

To evaluate the perspectives of adolescent/parent dyads about a diabetes program on: (1) perception of knowledge, self-efficacy, importance of transition behaviors and ability to self-manage diabetes, (2) the congruency of knowledge and skills important for transition, (3) program specifics families determined helpful for transition, and (4) the relationship of adolescents' self-efficacy to self-management behaviors (SMB) and Hemoglobin A1C (HbA1C).

METHODS

The individual and family self-management theory guided this prospective cross-sectional study. Sample included 45 dyads from a pediatric diabetes program. Dyads independently completed questionnaires related to knowledge, self-efficacy, the importance of specific diabetes knowledge and skills, and behaviors helpful for self-management and transition readiness. Analysis included frequencies, correlations, Cronbach's alpha, and paired t-tests.

RESULTS

Knowledge was high and self-efficacy even higher in the dyads. However, they did not agree on behaviors important for transition such as, knowing what the HbA1C should be, accurately counting carbohydrates, how to check ketones, how alcohol and drugs affect diabetes, or consistent documentation of blood sugar, carbohydrates and insulin doses. Adolescents indicated talking with providers and program materials as helpful, but attending regular visits and talking with parents as most helpful for transition. Adolescent and parent assessment of adolescent self-efficacy and self-management behaviors were strongly correlated. Family dyad's perceptions of adolescent self-efficacy were similar but not related to HbA1C.

CONCLUSION

A diabetes transition program has the opportunity to impact an adolescent's ability to self-manage their chronic illness by increasing self-efficacy and recognizing the strengths of the parent, adolescent and provider in the transition process.

The experiences and impact of transition from child to adult healthcare services for young people with Type 1 diabetes: a systematic review

INTRODUCTION

Despite the transition between child and adult services for young people with Type 1 diabetes mellitus being a high-risk period, little is known about the impact of healthcare transition upon young people.

METHODS

A systematic review was conducted using PubMed, PsycINFO, CINAHL and EMBASE. Papers published between January 2001 and June 2014 that examined the impact or experiences of healthcare transition in young people with Type 1 diabetes were included. Data were extracted by two independent reviewers and integrated by narrative synthesis.

RESULTS

A total of 8990 citations were reviewed and 43 studies were included in the review, 24 of which explored the impact of transition and 24 examined experiences of transition. There were mixed results in terms of the change in glycaemic control and diabetes-related hospitalizations, but all studies assessing attendance found worse attendance post-transition. Data regarding experiences reported that young people and parents experienced greater difficulty in accessing and maintaining diabetes health care. Young people were required to develop independent self-management and self-advocacy skills to navigate the transition and adult health care, but some were inadequately prepared for this.

CONCLUSIONS

Although the impact of healthcare transition on outcomes for young people with Type 1 diabetes is unclear due to the paucity of high-quality studies, transition appears to be associated with decreased clinic attendance. There is some preliminary evidence of a positive impact of structured transition programmes. Experiences of healthcare transition illuminate the barriers to smooth transitions and the need for better integration and continuity of care.

Type 1 diabetes in young adulthood

Type 1 diabetes has traditionally been studied as a chronic illness of childhood. However, young adulthood is a critical time for the development and integration of lifelong diabetes management skills, and research is starting to identify unique challenges faced by youth with diabetes as they age into adulthood. Most young adults experience multiple transitions during this unstable developmental period, including changes in lifestyle (e.g., education, occupation, living situation), changes in health care, and shifting relationships with family members, friends, and intimate others. Young adults with type 1 diabetes must navigate these transitions while also assuming increasing responsibility for their diabetes care and overall health. Despite these critical health and psychosocial concerns, there is a notable lack of evidence-based clinical services and supports for young adults with type 1 diabetes. We review relevant evolving concerns for young adults with type 1 diabetes, including lifestyle considerations, health care transitions, psychosocial needs, and changes in supportive networks, and how type 1 diabetes impacts and is impacted by these key developmental considerations. Specific avenues for intervention and future research are offered.

Clinical review: Diabetes in the adolescent: transitional issues

CONTENT

Orchestrating a seamless transition from pediatric to adult care can be a daunting task in caring for youth with diabetes mellitus. This clinical review focuses on physical and psychosocial aspects affecting the care of adolescents and young adults with diabetes, evaluates how these aspects can be barriers in the process of transitioning these patients to adult diabetes care, and provides clinical approaches to optimizing the transition process in order to improve diabetes care and outcomes.

EVIDENCE ACQUISITION AND SYNTHESIS

A PubMed search identified articles related to transition to adult diabetes care and physical and psychosocial assessment of adolescents with diabetes. An Internet search for transition of diabetes care identified online transition resources. The synthesis relied on the cumulative experience of the authors. We identify barriers to successful transition and provide a checklist for streamlining the process.

CONCLUSIONS

Key points in the transition to adult diabetes care include: 1) starting the process at least 1 year before the anticipated transition; 2) assessing individual patients' readiness and preparedness for adult care; 3) providing guidance and education to the patient and family; 4) utilizing transition guides and resources; and 5) maintaining open lines of communication between the pediatric and adult providers. No current single approach is effective for all patients. Challenges remain in successful transition to avoid short- and long-term complications of diabetes mellitus.