VANCOUVER, B.C. – Transitioning to adult diabetes care tripled hospital admissions for diabetic ketoacidosis in a Canadian study of 147 patients at Western University in London, Ont.
The number of diabetic ketoacidosis (DKA) admissions and emergency department visits for hypoglycemia or hyperglycemia increased from 65 during the 3 years before the subjects turned 18 to 101 during the 3 years afterward.
There were other problems, too. Mean hemoglobin A1c increased from 8.66 % to 8.89% after transition to adult care, and urine albumin creatinine ratio (ACR) testing decreased, with 47 patients (32%) tested at least once before transition, but 29 (20%) afterward.
Dr. Jennifer Huynh
“Some would say that these are teenagers, and they’ll are grow out of” it as they learn how to care for themselves as adults, “but I don’t think that’s good enough” because there’s an increased risk of acute complications. “The transition period is associated with worsening glycemic control and an increased risk of DKA admission. There is room for improved screening, as well. I think there is certainly a role for intervention,” said Dr. Jennifer Huynh, chief resident in internal medicine at Western University.
The differences in HbA1care big enough to worry about. “We know when A1c is high, even small increases or decreases” make a difference. Meanwhile, the increased risk of DKA (odds ratio, 3; 95% confidence interval, 1.19-7.5) is “very concerning,” she said at the World Diabetes Congress.
It’s been reported before that children with diabetes run into trouble when they move into adult care; the findings are a reminder of the issue, and help firm up the extent of the problem. The investigators were able to do a robust comparison of pre- and posttransition patients because the database at Western University links patients’ pediatric and adult records.
What often happens is that diabetes takes a backseat to school, work, relationships, and other pressures of emerging adulthood, and parents are no longer around to make sure kids take care of themselves. Given all that’s going on, it’s not surprising that the researchers also found there were 1,149 office visits in the 3 years before the subjects turned 18, but only 750 in the 3 years afterward.
All but three of the young adults in the study had type 1 diabetes, and just over half were women. At the baseline visit at 15 years of age, the median duration of diabetes was 5 years, mean weight was 66.4 kg, and the mean body mass index was 23.5 kg/m2. Forty-five subjects (31%) were on an insulin pump, 96 (65%) were on multiple daily injections, 3 (2%) were on premixed insulin, and 3 (2%) took oral agents.
Researchers at Western University and elsewhere are putting a lot of effort into figuring out how to improve the situation. Special transition clinics, support groups, and social media campaigns are just some of what’s being tried.
Investigators from Western University are finishing up a randomized trial to see if a transition coordinator helps. Patients were randomized to usual care or care overseen by the coordinator, a certified diabetes educator.
The coordinator stays in touch with the teenagers, sends them test results, reminds them of appointments for lab work and office visits, and, in general, serves as a sounding board, guide, and friend to help them manage the transition into adult care.
The hope is that the efforts will improves clinic attendance and glycemic control, among other things.
Western University is considering a survey of transition programs in Canada, to find out what works so “we can make some recommendations in terms of policy,” Dr. Huynh said.
The investigators have no conflicts of interest, and there was no industry funding for the work.