Case Manager Assures Continuity of Diabetes Care for Adolescents

Direct intervention with an assigned appointment specialist dramatically improved retention rates and better disease outcomes among pediatric patients with type 1 Diabetes as they were transitioned to adult care.

With Mary White, MD, and Olga Kordonouri, MD

When transitioning to adult care, adolescents with type 1 diabetes showed improved rates for follow-up care after 12 months of a personalized intervention,1 according to a study published in Lancet

The randomized controlled trial of 60 Australian teenagers with type 1 diabetes explored the value of a personalized appointment management intervention to smooth subjects’ transition from pediatric to adult care.1 The intervention and control groups had equivalent outcomes during the 12-month study period. However, during the second year, essentially half (49%) of the control group disengaged from medical services while only 6% of the intervention group dropped out.

“We know that transition to adult care can be a challenging time, and one that is associated with increased losses to follow up and declining hospital attendance rates,” said Mary White, MD, a clinical research fellow in endocrinology at the Murdoch Children’s Research Institute at the Royal Children’s Hospital in Melbourne, Australia.

Without Non-Parental Involvement, Care Falls Off

Prior studies have shown that prolonged gaps in medical care between the time of pediatric and adult review is particularly important for young adults with type 1 diabetes.2,3 The Lancet study protocol employed an individual point of contact person whose function was to call each patient with pre-appointment telephone reminders and to automatically rebooked any missed appointments.

“Regular attendance at specialist clinics has been associated with a reduced risk of hospitalization and diabetic ketoacidosis which is potentially life-threatening,” Dr. White told EndocrineWeb, “And so disengagement from specialist care, which is the extreme end of this spectrum is clearly a very high-risk situation, where medical input is sought only in crisis situations.”

In addition, young adults with type 1 diabetes may have microvascular complications, such as retinopathy and renal impairment that will typically develop as they enter their third decade of life. 

“These complications are progressive over time and may be identified early on annual screening tests which allow appropriate management when indicated. However, for the individual who is not regularly coming to the clinic for scheduled medical care it is likely that inadequate screening for these complications may result in potentially devastating effects,” said Dr. White.

Reminder Calls to Teen Improves Compliance

A variety of interventions have been suggested in an attempt to increase the chance of a successful transition from pediatric to adult care, including the role of a transition or appointment coordinator. However, this had not previously been tested in a formal trial setting, and so we sought to address this question to provide an evidence basis,” Dr. White said.

“We had expected that the disengagement rates would be in the order of 30% based on a previous follow-up study of young adults who had transitioned to adult services.3 So in that respect, we had not anticipated that the disengagement rates would be much lower than this in the first 12 months following the transition in both the intervention and control groups and that the effect of the intervention would not be seen until the second year after making the transition,” said Dr. White.

“The study also confirmed that post-transition attendance and glycemic control may be predicted by pretransition factors,4 which has been reported previously,” she said.

Assignment of a Case Manager Assures Continuity of Care

Professor Olga Kordonouri, MD, of the Diabetes Center for Children and Adolescents, Kinder und Jugendkrankenhaus Auf der Bult in Hannover, Germany agreed that the findings have practical, clinical applications.

“The establishment of a case or appointment management could help to structure the transition from pediatric to adult care,” Dr. Kordonouri told EndocrineWeb, “The crucial issue is the financial one. Who pays for that? In case there is an established transition program (like the healthcare system in Germany), it would be wise to join it and convince the patients to accept it. This is not always an easy job.”

The findings suggest constructive disease management directions for managing pediatric patients with other chronic diseases, as well.

“Treatment of most thyroid diseases sounds easy as the patients have only to take one pill per day. However, even in that case, the treatment adherence is not optimal,” said Dr. Kordonouri. “Taking  this together with missed lab controls through the specialists, patients may face complications due to hypo- or hyperfunctioning of the thyroid gland.” She also said that youngsters with T2D are at high risk for getting lost in follow-up.

“Their treatment adherence is poor even during the pediatric care. Social economic factors are more problematic in obese children with T2D, which probably means less familial support and supervision of a successful transition than in an average kid with T1D. Therefore, the support through a structured transition program is essential for young people with T2D.”

However, Dr. White cautioned against generalizing her findings to all pediatric populations.

“The data relating to transition in type 2 diabetes and thyroid conditions are very limited, and we do not have data with which to make an assessment of how current practice may affect post-transition outcomes [in these populations],” said Dr. White, “Particularly for thyroid disease, many young adults may be transitioned to the primary care or to a general practitioner and thus their transition requirements are likely to be very different from individuals with type 1 diabetes.”

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