There is no gap if we manage diabetes care transition appropriately: Holmes-Walker

Recognising and addressing the obstacles as young people with diabetes transition to adult care is the key to developing a successful service for youth with diabetes, Associate Professor Jane Holmes-Walker, Staff Specialist in the Department of Diabetes and Endocrinology at Westmead Hospital told delegates at the ADS-ADEA Annual Scientific Meeting on Wednesday.

Speaking at the ADS Symposium: Clinical Challenges of T1 Diabetes, Professor Holmes-Walker, who has been running a service looking after young people with diabetes for 15 years, explained that their service began in order to address the loss to follow-up that typically occurs after transition and to reduce admission rates for diabetic ketoacidosis (DKA) for youth, which she had noted were significantly higher than in older age groups.

International experience has put loss to follow-up  at around 50%, two years after transition from a paediatric service, and high rates of admission for DKA (5-15 per 100 patient years) in this group, Professor Holmes-Walker told delegates.

In particular, studies have found that of those lost to follow-up, 90% attended only one appointment.

“So that was our focus” Professor Holmes-Walker told the audience, “making sure they get back to the second”.

Quoting a paper by Wolpert and Anderson on youth transition, she noted that one of the key priorities in the care of youth with diabetes is “to develop a strong relationship that will ensure continued follow-up and that over time could be translated into influence to promote change in self-care behaviour”.

Among other things, Professor Holmes-Walker said, building these relationships has been a key part of the youth service at Westmead.

Understanding the different stages of young adult development and receptiveness to change at each stage is also important, she told the audience.

Professor Holmes-Walker and her team designed their service around the key factors they had identified as being important to successful transition – elements consistent with the findings from an International Delphi Study (Key Elements for, and Indicators of, a Successful Transition) published last year.

Their service provides:

  • Review within 3 months of their last pediatric visit
  • Direct phone contact with the young person or their primary carers
  • A central mobile contact to access the service
  • SMS reminders for appointments and rebooking missed appointments
  • Extended hours to allow for appointments outside of work and study time
  • Telephone support for sick day management
  • Desktop HbA1c and all complications screening within the clinic

The success of the service is evident by the fact they now service 10 times the number of youth with diabetes than when they started, largely due to increased retention, Professor Holmes-Walker told delegates. In fact, only 8% are lost to follow-up and 90% have had at least one appointment in the last 12 months.

Rates of DKA have also been significantly reduced – to 25% of baseline.

“Rates are the lowest published results for DKA admissions in the literature for this age group – 5 admissions per 100 youth with diabetes”, she said.

They have also found that offering phone support at the time of illness can prevent hospital admissions.

“Admission rates with DKA are almost 4-fold higher in youth with diabetes not attending a dedicated transition service,” she informed the audience.

Speaking with the limbic, Professor Holmes-Walker had this take home message for those working with young people with diabetes: “There is no gap if we manage transition appropriately by preventing loss to follow up, preventing DKA admissions and preventing deterioration in control as measured by Hb1c. This in turn improves the quality of life for youth with diabetes”.


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