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Current methods of transfer of young people with Type 1 diabetes to adult services

We read with interest the recent paper [1] on transfer of people with diabetes from paediatric (PDS) to adult (ADS) services. We have undertaken a similar study in a single centre, to evaluate the outcome of transfer and to identify factors associated with success or failure of the process. Individuals transferred aged 17 years from an evening paediatric clinic staffed by paediatric and adult physicians to an adult clinic within the same teaching hospital or to one of two neighbouring district general hospitals (DGHs), or at the subject’s request, to their GP. Patients transferred from the PDS in the preceding 5 years were identified. An ADS hospital clinic attendance rate of 75% (known to be associated with lower serum HbA 1c concentrations [2]) was used to define ‘attenders’ (gross attendance rates > 75%) and ‘defaulters’ (attendance rates < 75%). Hospital case records were reviewed for demographic, diabetes-related and clinic-related data. Patients were invited by letter to a structured interview, either in person or by telephone, based on two questionnaires: 1 The Experience of Diabetes Care Questionnaire (EDCQ)— a measure developed for this study, to address individual’s experience of the diabetes clinics and of living with diabetes. 2 The Personal Model of Diabetes Interview (PMDI)—an abbreviated version of Personal Model of Diabetes Questionnaire [3] which addresses individual’s beliefs about the seriousness of the condition and treatment effectiveness. Of 92 patients transferred, records were available for 84 (91%) and 43 were interviewed. Half were transferred to the ADS in the same hospital, 28% to their local DGH ADS and 22% to their GP. There were no significant differences between attendance groups in gender, age of diagnosis or transfer, family history of diabetes, presence of retinopathy, injection regimen, diabetes-related admissions, attendance in the PDS in the last year or HbA 1c at transfer. As previously reported [1], administrative arrangements for transfer were generally good, with transfer letters and appointments given for the ADS in all but three cases. There were more missed appointments during the first year in the ADS than the last year in the PDS (median (range) 2 (0–5) and 0 (0–5), respectively; P < 0.001). Although the prior definition of the groups would predict more ‘attenders’ than ‘defaulters’ would attend the first appointment in the ADS, the difference was large, with 96% of ‘attenders’ keeping that first appointment compared with 33% of ‘defaulters’. ‘Defaulters’ lived further ( P < 0.001) from the clinic than ‘attenders’. There were no significant differences between ‘attender’ and ‘defaulter’ groups in their perceptions of the adequacy or effectiveness of self-care. Both rated the importance of managing diabetes similarly. However, ‘attenders’ were more confident ( P < 0.05) in their ability to manage their diabetes well. Although not statistically significant, defaulters tended to be more troubled by having diabetes and regarded treatment as less effective. In terms of changes to the ADS, 62% said they would prefer a clinic for under 30-year-olds, 40% would prefer different clinic times, in particular an evening clinic, and 27% wanted more frequent appointments. The main findings of this study were the importance of geographical distance between the patient’s home and clinic, the possible longer-term impact of failure to attend the first ADS appointment, and the ‘attenders’ confidence in their ability to manage diabetes well. Whereas this confidence may be engendered by the ADS, this finding also suggests that it is confidence which assists in the transition. Factors such as distance to clinic, familiarity with staff and hospital setting may impact on this confidence. Given these findings, we have developed a ‘handover’ clinic physically located in the ADS clinic. This ‘handover’ clinic is staffed by nurse specialists and doctors from both services, but responsibility for ensuring attendance is delegated to the paediatric team. Individuals with diabetes are seen once in this clinic before follow-up in a new ADS clinic designed specifically for those who have previously attended the ‘handover’ clinic, with the focus of effort being to help the young adult develop confidence in the management of their diabetes.