Gradually transferring diabetes care responsibilities from the parent to the teenager is among the recommendations for helping young people with diabetes make an effective, smooth transition from pediatric to adult care that are included in a position statement released by the American Diabetes Association.
But the bulk of prep work falls to pediatric health care providers, who should also start preparing teenagers and their families for this transition at least 1 year before they switch to an adult clinician, according to the statement "Diabetes Care for Emerging Adults."
The statement is a result of the ADA Transitions Working Group, which includes representatives of the American Academy of Pediatrics, American Association of Clinical Endocrinologists, Endocrine Society, Pediatric Endocrine Society, and other associations. The multidisciplinary group of experts and people with diabetes reviewed the issues related to the transition from pediatric to adult care that affect health care professionals as well as people with diabetes. The statement focuses on people aged 18-30 years, described as "emerging adults," and includes people with type 1 and type 2 diabetes.
This transition "represents a high-risk period for a person with diabetes, a perfect storm during which interruption of care is likely for multiple reasons," wrote the authors of the statement, Dr. Anne Peters of the University of Southern California, Los Angeles, and Dr. Lori Laffel of the Joslin Diabetes Center and Harvard University, Boston. "This is a critical time when patients not only assume responsibility for their diabetes self-care and interactions with the health care system but when they become more independent," and may move out of their parent’s home to go to college or start work, they wrote (Diabetes Care 2011;34:2477-85).
Tens of thousands of people in this age group with type 1 or type 2 diabetes are transitioning from pediatric to adult care every year in the United States, based on current estimates of young people with diabetes, according to the statement.
The statement points out that there are many challenges to making this transition, including gaps in health insurance coverage and gaps in health care professional training in how best to deliver care for this age group. More research is needed in this area, as well as in the training of providers who attend to the medical and psychosocial needs of young adults with diabetes.
Eight areas relevant to people in this age group are summarized in the statement. They are: differences between pediatric and adult diabetes care; poor glycemic control and other risk factors; loss to follow-up; increased risk of acute complications; psychosocial issues; sexual and reproductive health issues; alcohol, smoking, and drug abuse; and emergence of signs of chronic diabetes complications.
The statement points out that older teens and young adults are at a high risk for being disengaged from health care and, as a result, are at an increased risk for short-term complications such as hypoglycemia and long-term complications such as nephropathy and retinopathy. Interruptions in care explain some of the adverse outcomes in this age group, including an increased relative risk of death among young adults with diabetes, compared with those without diabetes. Fewer medical visits for diabetes, loss of parental supervision, and other factors such as increased alcohol consumption can also increase the risk of acute complications, they said.
Pediatric providers should give transitioning patients a written summary for them and their future adult health care provider that includes information on medications, past glycemic control, assessment of their diabetes self-care skills, and diabetes-related comorbidities, the statement said. Preparing patients for the transition should include individualized, developmentally appropriate care that gives the patient responsibilities in not only self-monitoring glucose but scheduling their own appointments. The transferring provider also should ensure that patients have a supply of medication, educate them about health insurance, evaluate and treat them for eating disorders, and provide mental health referrals.
"It is particularly important to create effective and translatable processes for the transition in care from pediatric to adult providers in order to optimize well-being and health for the near term," the authors concluded. Over the next decade, they expect to see "the emergence of evidence-based strategies that support best practice for the growing numbers of young adults with type 1 and type 2 diabetes who will be making this important transition."
The meeting of the writing group was supported with an unrestricted grant from the Jonas Brothers’ Change for the Children Foundation. Both Dr. Peters and Dr. Laffel disclosed ties to makers of diabetes drugs.