Among adolescents and young adults with type 1 diabetes, having a dedicated certified diabetes educator and using a continuous glucose monitor (CGM) can help smooth the transition from pediatric to adult specialist practice, new research finds.
“The period of emerging adulthood is challenging for youth with type 1 diabetes. We want [them] to have continuous access to care. The gaps in diabetes care can result in worse glycemic control, an increase in complications, and also emotional challenges…A team-based approach with diabetes educators can help keep the youth engaged in their care,” said Diana Soliman, MD, when presenting the findings from her single-center retrospective analysis at the American Association of Clinical Endocrinology (AACE) Virtual Annual Meeting 2021.
Recent studies have also shown that use of real-time CGM is associated with better glycemic control, said Soliman, an endocrinology fellow at Duke University, Durham, North Carolina.
But she noted that although the device may reflect greater engagement in self-care, “the diabetes educator being associated with a shorter gap is important in intervention programs.”
Diabetes educators are now officially called “certified diabetes care and education specialists”, but in this particular context they’re often termed “transition coordinators,” Soliman noted.
Asked to comment, session moderator Jad G. Sfeir, MD, told Medscape Medical News: “I think the power of this study is that…they were able to identify very concrete variables that impacted transitioning…You have to start somewhere when creating such a program so that you can reduce the gaps.”
Although the study only looked at patients who transitioned to adult endocrinologists within Duke’s system, Sfeir noted that a successful “transition program” from a pediatric diabetes clinic could also involve transitioning to other systems or private practice adult clinicians.
“It doesn’t have to be a transition within your system. It could be a transition to an adult diabetologist outside of the system…There’s a handover that happens from one system to another, keeping that patient in touch with the health system in general without the gap,” added Sfeir, of the Mayo Clinic, Rochester, Minnesota.
“This part is challenging to capture in a study like the one they designed because they’re not able to catch those who migrated out. But any transitional program should also focus on that part.”
And, he said, such a program could work even if the patient moves to another location for school or a job. “When you create a strong program, you may be able to retain those patients even though they move out of your system, especially now that we have telemedicine. They don’t really need to migrate out…at least for the few early transitional years until they establish themselves somewhere else,” he explained.
Of a total of 1615 patients with type 1 diabetes seen at least twice at Duke’s pediatric endocrine clinic, 214 had an adult endocrine clinic appointment within the subsequent 3 years. Those individuals were 54% female and 73% White, and had a mean A1c of 9.4%.
The median time to transition to adult care was 7.9 months. After adjustments for sociodemographic and clinical factors, the gap in care was extended by 1.68-fold (P = .03) for those not seen by a certified diabetes educator and 1.86-fold (P < .01) for those who did not have a CGM prior to transfer. No other factors were found to be significantly associated with a gap in care, including A1c, insulin pump use, comorbidities, emergency visits, and hospitalizations prior to transfer.
Sfeir cautioned that the findings could be system specific.
“What applies at Duke may not apply somewhere else. Other systems should conduct similar studies to see what’s applicable…75% of this cohort is White. Do the same things apply and to the same extent in other racial groups? It could be but could be not.”
“It’s very important to know what works in other communities and other systems. But it looks like this is what happened at Duke, and others should probably replicate that.”
Soliman and Sfeir have reported no financial relationships.
AACE Virtual Annual Meeting 2021. Presented May 29, 2021. Abstract 1038612.
Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR’s Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.
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