Adolescent diabetes and emerging adulthood: effectiveness of a robust and staged joint-care transition pathway

Lakshminarayanan Varadhan; Laura Lambert; Joanne Hankey; Tracy Fallows; Julie Wilkins; George Varughese; Parakkal Raffeeq

Background: An effective care pathway is required for the smooth ‘transition’ (rather than swift ‘transfer’ of care) from the paediatric to adult diabetes clinic. Engaging the patient in the service, with a clear, smooth and robust pathway, is required to bridge this very challenging period. The aim of our study was to assess the effectiveness of a staged transition process based on a shared-care protocol that has been existent over the last 3 years at our centre.

Materials and methods: The transition care happens in a two staged process

Joint transition clinic (JTC)

– Paediatric team identify patients ready for transition

– Patients seen in JTC over 3–4 appointments over a year

– Adult diabetologist and diabetes specialist nurse (DSN) sit in

– Paediatric team lead first two clinics; adult team lead subsequent clinics and transfer to the young adult clinic

Young adult clinic (YAC)

– Same adult team conduct this clinic at the same site

– Longer duration of appointments, open access to service with immediate appointments, named DSN to stay in telephonic contact

– Telephone reminder service 3 days prior to the clinic, to improve attendance rates at appointments

– Seen 1–4 times/year for up to 3 years based on clinical needs, then transfer to adult diabetes clinic

– Transition empowerment evenings: organized by both teams on an annual basis for patients/families going through the transition

– YAC also caters to young patients with new onset of diabetes (17–30 years)

The last HbA1c from paediatric clinic, JTC and YAC were taken for statistics.

Results: JTC:

31 clinics; 90 patients

266 patient appointments; 1–8/patient; 72.2% attendance rates

YAC:

35 clinics; 143 patients so far (65 from JTC, rest new referrals to the service)

254 patient appointments; 1–5/patient; 75.2% attendance rates

Transition care:


	Clinic parameters
n=65	Joint transition clinic (JTC)	Young adult clinic (YAC)
Mean age at entry	17.1 years (15.6–19.0)	18.5 years (16.7–20.5)
Number of appointments/patient	2.9 (1–8)	2.7 (1–7)
Attendance rates	72%	67%
No. of patients with failure to attend at least 1 appointment	52% (20 – once, 10 – twice, 2 – thrice, 2 – four)	49% (17 – once, 7 – twice, 7 – thrice, 1 – four)
Failure to attend any appointment	12% (1–4 appointments)	6% (2–3 appointments)
Mean change in HbA1c	−0.1% (−4.7 to +9.9%)	+0.2% (−4.4 to +4.3%)
Proportion of patients with HbA1c worsening by >1%	25%	19%
Mean duration of follow up	453 days (49–1323)	326 days (0–763)
		(n=25)
Mean HbA1c at entry	9.8% (5–17.5%)	9.7% (5.3–15.5%)
Mean HbA1c at exit/ last appointment	9.7% (5.3–15.5%)	9.8% (6.7–15.6%)
Proportion of patients with overall improved HbA1c	49.2%	50.8%

65 patients have been through joint transitional care

39 on-going care in YAC; 25 transferred to other services (1 for insulin pump; 2 to pregnancy clinic; 15 to adult care; 7 to primary care (4 for repeated non-attendance)); 1 died (non-diabetic complication).

Conclusion: The attendance rates in the transitional care pathway clinics are high (72% in comparison to previous adolescent diabetes clinic attendance rates of 45% prior to the introduction of this pathway), with majority getting sustained improvement in glycemic control. Our care pathway provides an effective, patient-centred, coordinated, multi-professional team based staged approach to deliver transitional care to this at-risk vulnerable group of patients.

Endocrine Abstracts

P19