A new transition model benefits teenagers and young adults with Type 1 diabetes who are moving from pediatric to adult care, researchers say.
Professional societies offer recommendations for guiding adolescents through that transition, and individual pediatric practices have tailored their own approaches. However, no standardized national guidelines exist, compounding the challenges of continuity of care.
“It is especially difficult to know how to prepare these youths as they transition because insurance changes [when they move for work] ... and they can’t necessarily go to the provider their pediatrician recommended,” says Shivani Agarwal, MD, MPH, Director of the Diabetes Transition Clinic at the University of Pennsylvania’s Rodebaugh Diabetes Center. “There’s research on patient perspective from before and after the transition ... that shows that there are very different aspects of transition care that patients wish they had gotten, depending on whether they are anticipating transfer or they have actually transferred. Those who have transferred really just wanted very basic things — the name of an adult provider [and an explanation of] differences of the adult care system.”
A Cost-effective Model
The lack of a standardized transition system prompted Dr. Agarwal and colleagues to create and test a new and easily adoptable model, which they reported on recently in The Diabetes Educator. The study included 72 participants — all of whom have Type 1 diabetes — between the ages of 18 and 25. It essentially ran as a clinical program, tracking factors such as blood glucose monitoring frequency and glycemic control. While most clinical transition programs are based on the pediatric side of care, this model is based on the adult care system and is run by endocrinologists who treat adults.
The model, called the Pediatric to Adult Diabetes Transition Clinic (PADTC), utilized a multidisciplinary team that included adult diabetes physicians, nurse practitioners, diabetes nurses, a diabetes educator, a dietitian and a part-time social worker. Patients were provided continuing education to improve their self-management of the disease and were encouraged to set goals to keep them engaged with their own care.
“If we can move the needle on this hemoglobin A1C value [with this model], we really have done something remarkable.”
— Shivani Agarwal, MD, MPH, Director of the Diabetes Transition Clinic at the Rodebaugh Diabetes Center at the University of Pennsylvania
One significant advantage of the program is that it utilized only resources already available, rather than relying on outside funding. Thus, other facilities can more easily replicate the model.
“If you look at some of the resources that many of the pediatric transition programs have had in the past, there are definitely ... funding barriers that come up, and that may dissuade people from attempting something like this,” says Serena Cardillo, MD, Associate Professor of Clinical Medicine and Director of Graduate Diabetes Education at the Rodebaugh Diabetes Center. “[We] just utilized our amazing staff of educators and nutritionists and were able to really demonstrate a significant improvement.”
Dr. Agarwal and Dr. Cardillo’s findings come from only a six-month period and are a preliminary look at something the research team wants to dive into more deeply. Among their most significant findings:
- Mean A1C decreased by 0.7 percent from baseline, with improvement in some patients ranging up to almost 2 percent.
- Frequency of blood glucose monitoring increased by one check per day.
- Almost 90 percent of participants attended two or more healthcare provider visits during the study.
Regarding the first metric, Dr. Agarwal says, “It’s really important to show an improvement in this hard outcome, because all of the large population studies show that the hemoglobin A1C level is linked with long-term diabetes-related complications and mortality.”
There appears to be significant recognition of the challenges of transitioning pediatric patients to adult care. Recently, researchers at Rush University in Chicago also developed a new model for that process.
The approach Jeanne Little, DNP, CPNP-AC/PC, faculty with the Rush University College of Nursing, and fellow researchers took was to create a tool within their EHR that automatically sorts their target patient population: those age 14 or older with a diagnosis of diabetes on their problem list. They discussed their efforts earlier this year in the Journal of Pediatric Health Care, though full results are not yet available.
“The registry contains key health information of this targeted population, so it was an easy way to see how many patients we have who should be transitioning and we should be planning with,” Little says. “It gives us specifics on their age and date of birth. It also provides their most recent hemoglobin A1C so we can see quickly how their glycemic control is.”
Little and her colleagues also utilized the Transition Readiness Assessment Questionnaire (TRAQ), which was administered to patients in their target population at each clinic visit. It measures five domains: managing medications, keeping appointments, tracking health issues, talking with providers and managing daily activities. Tracking a patient’s responses allowed the team to know what areas required the most attention, where goals should be set and where the patient was improving visit to visit.
Looking ahead, Dr. Agarwal and Dr. Cardillo hope to dig deeper into socioeconomic factors affecting access to care. Their program serves both patients with strong familial and financial support, as well as those who lack those advantages.
“While this is a very small and early study, we are starting to tease out some of those differences, and I think that under-resourced population is at particularly high risk for poor control and challenges in this transition,” Dr. Cardillo says. “Identifying what aspects of this program work well for this population, what the deficiencies are in terms of what we’re offering, and how we fill those gaps and needs for that particular population ... is going to be the next step.”