1. Health Care Transition and Glycemic Control in Young Adults with Type 1 Diabetes
Katharine Garvey MD MPH
Children’s Hospital Boston Transition Symposium
Boston, MA
April 27, 2012

2. Background
Focus on U.S. health care transition for type 1 diabetes (T1D)
Recent projects
Qualitative focus group analysis of young adults with T1D currently receiving adult care at specialty clinic
Survey of young adults with T1D currently receiving adult care at specialty clinic
Focus of today’s presentation
Survey of young adults with T1D who previously received pediatric diabetes care at tertiary care center
National survey of adult endocrinologists

3.  Type 1 Diabetes
An intensive level of daily self-management is required for optimal control in type 1 diabetes (T1D)
Patient is truly at the center of his/her care
Young adults with type 1 diabetes are at high risk for poor diabetes outcomes

4. Current Diabetes Transitions??
Pediatric Care
Adult Care
Faith, Trust, and Pixie Dust
Slide courtesy of Nissa Askins 4

5. Transition in Type 1 Diabetes
Studies in Canada and Europe have shown
Significant delays in care
Decreased adult follow-up visits
Increased post-transition DM hospitalizations
Patient dissatisfaction with transition process
Emerging work in transition readiness assessment, transition coordination in pediatrics
Few data on transition quality or post-transition outcomes
Few U.S. data

6. Specific Aims – Survey Study
Describe characteristics of health care transition in a large group of young adults with type 1 diabetes
Evaluate the association between health care transition factors and glycemic control
Determine patient-related and health-care related factors associated with glycemic control

7. Hypotheses
Young adults with inadequate transition preparation are more likely to report a prolonged gap between pediatric and adult diabetes care
Young adults with inadequate transition preparation are more likely to have suboptimal current glycemic control

8. Methods
Developed an 85-item survey to evaluate the transition experiences of young adults with T1D
Survey developed based on
Extensive literature search of published transition data, both in T1D and other chronic illnesses
Qualitative data from focus groups of young adults with T1D
Conceptual model
Content validity via expert review
Cognitive testing with young adult T1D patients

9. Survey Domains Diabetes history
Characteristics of pediatric vs. adult diabetes care
Reasons for transition
Transition timing, preparation, satisfaction, barriers
Current support system, diabetes self-care
Demographics

10. Methods Inclusion Criteria:
Current age years old
T1D diagnosed at < 18 yrs old & while in pediatric care
Now followed in the Adult Clinic at the Joslin Diabetes Center
Survey sent in 3 mail waves between January and March 2011
Electronic web option, reminder phone calls
Token gift + iPad2 incentive

11. Results Response Rate = 53% Survey Sent to n = 512 Denominator n = 484
12 undeliverable + 16 ineligible
Denominator n = 484
Completed Surveys n = 258
Response Rate = 53% 11 11

12. Respondent Characteristics
Mean ± SD or %
Current age
26.7 ± 2.4 years
Male
38%
Caucasian
92%
Diabetes duration
16.7 ± 5.5 years
Age at transition to adult diabetes care
19.5 ± 2.9 years
Most recent HbA1c (measured)
8.1 ± 1.3
Highest education ≥ college
81%
Private insurance
90%

13. Results

14. Results
35% over 6 months

15. Results
ADA Target < 7%

16. Results
8 survey items were developed to assess specific transition preparation

17. Transition Preparation
“Yes” responses to all of the specific preparation items were highly correlated (p<0.05) with overall report of “mostly” or “completely” prepared
This overall question was used as a dichotomous variable in analyses

18. Results
*Mostly/Completely prepared/satisfied are highly correlated, p <

19. Gaps Between Pediatric/Adult Care
Factors Associated with a Prolonged Gap > 6 months Between Pediatric
and Adult Care
Variable
Multivariate model
Odds Ratio [95% CI]
Mostly/Completely prepared for transition
0.47 [0.25,0.88]
Pediatric A1c in year prior to transition (%)
1.18 [0.95,1.48]
Age at transition (years)
0.95 [0.86,1.06]
Education = college or greater
1.08 [0.48,2.43]
Male
0.98 [0.53,1.82]
≥ 3 pediatric visits in year prior to transition
0.35 [0.19,0.63]

20. Young Adult HbA1c Variable Multivariate model Beta (S.E.), p-value
Mostly/Completely prepared for transition
-0.18 (0.16), p = 0.27
Pediatric A1c in year prior to transition (%)
0.49 (0.06), p <
Age at transition (years)
(0.03), p = 0.77
Current Age (years)
-0.08 (0.03), p = 0.025
Education college or greater
-0.53 (0.21), p = 0.01
Male
-0.14 (0.16), p = 0.38
Married
0.06 (0.21), p = 0.77
Living with parents
-0.28 (0.23), p = 0.24
Living alone
0.13 (0.23), p = 0.56
Medicaid
0.17 (0.30), p = 0.57
* Also conducted sensitivity analysis in those who transitioned in the last 3 years

21. Limitations Non-response bias Recall bias
Generalizability – highly educated, relatively advantaged population who have found their way to JDC
Unmeasured factors associated with transition and A1c in young adulthood, e.g. self-determination, resilience

22. Conclusions
Report of suboptimal preparation for transition is associated with a prolonged > 6 month gap between pediatric and adult care
Surprisingly, in multivariate analyses, transition preparation is not significantly associated with young adult HbA1c
Strong influence of pre-transition A1c, level of education
Data suggest that “typical” transition preparation activities do not have a major positive influence
Future work should examine interventions to
Empower patients to transition more effectively
Improve provider handoffs and young adult-centered care in pediatric and adult diabetes clinic settings

23. Acknowledgements
Harvard Pediatric Health Services Research Fellowship (AHRQ T32 HS )
Jonathan Finkelstein MD, MPH
Howard Wolpert, MD
Joseph Wolfsdorf MB, BCh
Erinn Rhodes MD, MPH
Ken Kleinman PhD
Lori Laffel MD, MPH
Meg Beste, BA