Health Care Transition and Glycemic Control in Young Adults with Type 1 Diabetes

Katharine Garvey MD MPH

Children’s Hospital Boston Transition SymposiumBoston, MA

April 27, 2012

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

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

Current Diabetes Transitions??

Pediatric Care

Faith, Trust, and Pixie Dust

Adult Care

Slide courtesy of Nissa Askins

Transition in Type 1 DiabetesTransition 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

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

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

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

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

MethodsMethods• Inclusion Criteria:

– Current age 22-30 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

Results

11

Survey Sent to n = 512

Completed Surveys n = 258

Denominator n = 484

Response Rate = 53%

12 undeliverable + 16 ineligible

Respondent Characteristics

Characteristic 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%

Results

"Most Important" Reason for Transition

28

25

17 16

12

2

0

5

10

15

20

25

30

Too old forpediatrics

Providersuggestion

College Didn't like pediprovider

Moved Parent suggestion

% R

esp

ond

ents

Results

Time Lapse Between Pediatric and Adult Diabetes Care

18

47

23

84

0

10

20

30

40

50

60

≤ 3 months 4-6 months 7-12 months 13-24 months > 24 months

% R

espo

nden

ts

35% over 6 months

Results

18

40

23

116

2

19

41

1913

62

0

10

20

30

40

50

60

≤7% 7.1-8.0% 8.1-9.0% 9.1-10.0% 10.1-12.0% >12%

% R

espo

nden

ts

A1c

Respondent A1c Values

Pre-Transition A1cMost Recent A1c

ADA Target < 7%

Results

Transition Preparation

78

69

61

4946

1410 9

0

25

50

75

100

Pedi visitswithout parent

Discussscreening tests

Discussindependentmanagement

Adult providerrec

Adult providercontact info

Transitionvisit

Meet newadult provider

beforetransition

Writtentransitionmaterials

% R

espo

nden

ts

• 8 survey items were developed to assess specific transition preparation

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

Results

57

24

38

26

2

13

21

37

27

0

10

20

30

40

50

Completely Un Mostly Un Neutral Mostly Completely

% R

espo

nden

ts

Preparation and Satisfaction

PreparedSatisfied

*Mostly/Completely prepared/satisfied are highly correlated, p < 0.0001

Gaps Between Pediatric/Adult Care

Factors Associated with a Prolonged Gap > 6 months Between Pediatric and Adult CareVariable 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]

Young Adult HbA1c

* Also conducted sensitivity analysis in those who transitioned in the last 3 years

Variable Multivariate modelBeta (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 < 0.0001

Age at transition (years) -0.008 (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

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

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

Acknowledgements• Harvard Pediatric Health Services Research

Fellowship (AHRQ T32 HS000063-17)• 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