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How Does Transfer from Pediatric to Adult Health Care Affect Diabetes Outcomes?

Glycemic control, diabetes care visit attendance, and acute diabetes-related complications assessed…. 

The transfer from pediatric care to adult care typically occurs between the ages of 18 and 25, a period some refer to as "emerging adulthood". Several articles exist looking at how this transition affects diabetes management in type 1 diabetics. One thing that many of these articles have found is that poor glycemic control and loss of clinical follow-up often occurs with the transition to adult care. There is little empirical evidence however to support these observations, and health care providers practice primarily using their own clinical experience or expert consensus. This review looks to examine the empirical evidence that is available for this transition of care with focus on the following outcomes: glycemic control, diabetes care visit attendance, and acute complication rates.

The authors of this study did a search of available literature on this topic using Pubmed and Embase. The search terms T1D, transition, transfer, adolescents, and emerging adults were used to find articles. Studies that were included were required to report measures of A1c, diabetes care visit attendance, and/or complication rates among those recently transferred to adult care. Any study that used patient reported values or information were excluded. A total of 18 studies were included in this analysis.

Of the studies included, eight studies examined A1c before and after transfer to adult care, and five of these studies found A1c to be significantly improved in adult care. The remaining 3 studies did not detect a change in A1c from pediatric to adult care. Two recent studies, however, looked at the association between A1c of emerging adult patients and the type of provider and found that early transfer from pediatric care was associated with worse glycemic control. High school students changing to adult care before their senior year had a significantly higher A1c than their peers who waited until after graduation to transfer. Five studies examined the frequency of diabetes care visits before and after transfer to adult care. All five studies showed a decline in visit frequency after transition to adult care. These findings are somewhat difficult to assess, though, as the number of clinic visits recommended for pediatric patients may have been different than the number of visits recommended for adults. Regarding complication rates, one study found that screening for retinopathy did not differ in the two care settings. Another study showed that retinopathy rates significantly increased from age 18 to 24, though these changes were not tied to pediatric vs. adult care. Both of these studies also looked at diabetes-related hospitalization rates before and after transition and did not find a difference between those in pediatric care and those is adult care.

The application of the conclusions found in many of these observational studies is limited because these studies do not have a comparison group, and the differences between the two study groups could also be due to other factors such as the type of care chosen, the process of the change in care, or pubertal and psychosocial maturation that occurs in this age group. Also, the comparison of glycemic control pre- and post- transfer to adult care can only be made in those patients that attend their diabetes care visits regularly enough to have their A1c measured consistently. These studies also primarily looked at pediatric care centers and adult clinics that were within the same health system, and therefore patients who leave that health care setting may have worse attendance.

Though A1c is often considered to be the "gold standard" for measuring diabetes outcomes, the growing concern that patients are going to drop out of health care upon transition to adult care facilities may make diabetes care attendance a better marker of outcomes for this age group. That being said, future research should focus on examining predictors of clinic attendance. Also, identifying barriers to care for both pediatric and adult care such as lack of finances can help to find ways to increase attendance to these visits. Many physicians already employ transition programs as a way to help patients transition into adult care. A linking of pediatric providers to adult providers is one such method, and has been shown effective in one study that found clinic attendance was higher for those who had already met the adult care physician before transferring from pediatric care. Future research identifying the differences between care provided by pediatric and adult providers will help us to develop interventions that can better prepare patients for this change and facilitate this transition.

Practice Pearls:
  • A decline in diabetes care visit attendance often occurs following the transition to adult care.
  • Most studies do not show a worsening in A1c following change to adult care, but a deterioration in glycemic control has been shown for emerging adults who transferred to adult care when compared to their peers that remained in pediatric care.

Lyons, SK. et al. "Transfer from pediatric to adult health care: effects on diabetes outcomes" Pediatric Diabetes. 2014;15:10-17.