# Transition from Paediatric to Adult Diabetes Care in People with Type 1 Diabetes: An Online Survey from France

Juliette Eroukhmanoff, Claire Ballot Schmit, Sabine Baron, Amar Bahloul, Jacques Beltrand, Zeina Salame, Sophie Borot, Fabienne Dalla Vale, Helen Mosnier Pudar, Marc Nicolino, et al.

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## ► To cite this version:

Juliette Eroukhmanoff, Claire Ballot Schmit, Sabine Baron, Amar Bahloul, Jacques Beltrand, et al. Transition from Paediatric to Adult Diabetes Care in People with Type 1 Diabetes: An Online Survey from France. Diabetes Therapy, 2024, 15 (10), pp.2211-2222. 10.1007/s13300-024-01630-6. hal-05084385

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ORIGINAL RESEARCH

# Transition from Paediatric to Adult Diabetes Care in People with Type 1 Diabetes: An Online Survey from France

Juliette Eroukhmanoff* · Claire Ballot Schmit · Sabine Baron · Amar Bahloul ·

Jacques Beltrand · Zeina Salame · Sophie Borot · Fabienne Dalla Vale ·

Helen Mosnier Pudar · Marc Nicolino · Alfred Penfornis · Eric Renard

Received: April 22, 2024 / Accepted: July 17, 2024 / Published online: August 10, 2024

© The Author(s) 2024

## ABSTRACT

**Introduction:** The transition from paediatric to adult diabetes care (TPA) of children/adolescents with type 1 diabetes (T1D) represents a unique challenge and remains a critical phase in the

T1D care pathway. This study aims to describe and understand the experience of the transition process from a participant's perspective in young adults who are living in France with T1D and to measure their satisfaction.

**Methods:** An online questionnaire was presented to people with T1D in France on a global online participant community platform. The questionnaire was developed by a scientific committee including paediatric and adult diabetologists and refined by a group of participants.

**Supplementary Information** The online version contains supplementary material available at https://doi.org/10.1007/s13300-024-01630-6.

J. Eroukhmanoff (✉)
Department of Diabetology-Endocrinology, Hospital Center Sud Francilien (Centre Hospitalier Sud Francilien), Corbeil-Essonnes, France
e-mail: juliette.eroukhmanoff@chsf.fr

C. Ballot Schmit
Paediatric Department, Jean Minjoz University Hospital, Besançon, France

S. Baron
Paediatric Diabetology Department, University Hospital, Nantes, France

A. Bahloul · Z. Salame
Sanofi, Gentilly, France

J. Beltrand
Department of Paediatric Endocrinology, Diabetology and Gynecology, Necker-Enfants Malades University Hospital, Public Assistance of Paris-Centre Hospitals, Paris, France

S. Borot
Department of Endocrinology, Diabetology and Nutrition, Besançon University Hospital, Besançon, France

F. Dalla Vale
Paediatric Diabetology Unit, Arnaud De Villeneuve Hospital, Montpellier University Hospital, Saint-Pierre Institute, Palavas-les-Flots, France

H. Mosnier Pudar
Department of Endocrine and Metabolic Diseases, CHU Cochin, Paris, France

M. Nicolino
Paediatric Diabetology, University Hospital, Lyon, France

A. Penfornis
Paris-Saclay University, Paris, France

E. Renard
Department of Endocrinology-Diabetology, Montpellier University Hospital, University of Montpellier, Montpellier, France
Thematic qualitative analysis was performed on the responses.

**Results:** A total of 104 respondents were included in the survey (mean age 24.4 years [95% CI 23.8–25.0]; 61.5% female). The mean age at the time of transition was 18.4 years (95% CI 17.8–18.9), and 56% of respondents had their first adult diabetology follow-up in the same institution. During TPA, of the 76 participants who experienced personal issues, 74% experienced at least one issue with their diabetes management in the months following the transition. In the following months, 61% experienced new or unexpected problems in monitoring their diabetes after transition and 44% reported unusual glycaemic imbalances, including hypoglycaemia (8%) and hyperglycaemia (9%) requiring hospitalisation. Presence of personal issues during TPA was significantly associated with occurrence of problems with diabetes management or glycaemic imbalance. Three factors identified for a successful transition were (i) early meeting with the ‘adult’ diabetes care team, (ii) letting the participants choose the right age to leave paediatric clinic and (iii) having good diabetes control at the beginning of the TPA process.

**Conclusion:** Most young adults with T1D report experiencing issues around TPA with significant consequences on their disease management. Hence, it is necessary to identify these issues to better support them and improve diabetes management during this phase.

**Keywords:** Adult diabetes; Glycaemic control; Paediatrics; Satisfaction; Transition; Type 1 diabetes

## Key Summary Points

### Why carry out this study?

In type 1 diabetes treatment management, transition of children from paediatric clinic to adult diabetes care presents unique challenges and barriers.

Studies focused on diabetes monitoring and patient satisfaction during the transition from paediatric to adult diabetes care are limited in France.

The current survey was conducted to describe the transition process from paediatric to adult diabetes care from a participant’s perspective and to further measure and understand participants’ experiences, such as personal issues, satisfaction and their apprehension during the transition.

### What was learned from the study?

The current study identified that for most participants, the transition was triggered by a joint decision with the paediatrician and participant before the final move from the paediatric clinic. Personal concerns during the transition were significantly associated with new or unexpected issues following the transition.

Meeting the adult diabetology medical team and initiating the transition process by having diabetes under control were the most important aspects for a successful transition.

## INTRODUCTION

Type 1 diabetes (T1D) remains a global public health concern and is the most common metabolic disorder in children and adolescents. A recent modelling analysis estimated that there were 8.4 million people living with T1D at the global level in 2021 and this number is predicted to increase between 13.5 and 17.4 million by 2040 [1]. In addition, 1.5 million (18%) of individuals were less than 20 years of age, highlighting that T1D is one of the most common chronic diseases in children and adolescents, affecting more than 1 out of every 500 youths in the USA and other countries [1, 2]. Hence, for effective management of T1D, children require cooperation and regular support from parents and healthcare professionals (HCPs) [3].

In children and adolescents with T1D, transition from paediatric to adult diabetes care (TPA)

<figure><img src="image_3.png" /></figure>
can represent a major challenge to optimal care. Transition healthcare is defined as the ‘planned purposeful movement of the adolescent from child-centred to adult-orientated care’ [4]. The optimal TPA process should be uninterrupted, well-coordinated and comprehensive, yet sufficiently flexible to consider the psychological and social development of the adolescent, the complexity of the health problems for the family and their readiness for transition [5]. Although TPA among people with T1D is a day-to-day activity in clinical context, data are scarce on this topic. Recent studies showed that glycaemic control declines significantly among people with T1D in the age range of 18–25 years, i.e. during transition to adult care, with only 14% of participants meeting glycated haemoglobin (HbA1c) targets [6]. Further, in comparison with younger and older cohorts, late adolescents and early emerging adults also exhibit poorer diabetes management habits, which include declining clinic attendance and early signs of long-term problems [7]. It is important to highlight that adolescents and young adults face a high proportion of acute and chronic medical conditions and concerns, which makes the ongoing access to high-quality medical care necessary for this age group. In addition to potential treatment adherence challenges among adolescents related to decreased parental involvement in diabetes management, the achievement of optimal metabolic control is hampered by hormonal changes in this age group, which further causes transient increase in insulin resistance and corresponding insulin requirements to maintain euglycaemia [8].

Research have indicated the need for a more formal, structured transition process for adolescents with diabetes, as a helpful way to support participants' TPA [6]. According to the existing literature, planned transition care programmes could enhance patient satisfaction, visit attendance rates and glycaemic control in young adults with T1D [9]. However, findings suggest that clinical care may be disrupted by the shift from paediatric to adult-focused healthcare, which could also result in inadequate glycaemic control [10]. Maintaining a consistent relationship with a diabetes care provider across adolescence and young adulthood is required to provide

the frequent monitoring necessary to minimise diabetes-related complications. However, studies focusing on these aspects in people with T1D living in France are limited. Hence, the current survey aimed to understand the experience of people living with T1D during TPA through an online questionnaire.

# METHODS

## Survey Design and Participants

This was an observational, cross-sectional online survey. An online questionnaire was presented to people with T1D in France on a global online participant community platform. The questionnaire was developed by the survey sponsor and a scientific advisory board including paediatric and adult diabetologists. Three patients meeting inclusion criteria contributed to the development and validation of the questionnaire using a cognitive debriefing approach. People registered on the online T1D community in France were invited to participate in the survey via email or direct messages through the platform.

The survey was conducted online from 1 July 2022 to 26 August 2022. Participants were included in the survey if they were aged between 18 and 30 years, living in France, self-reported as T1D diagnosed by an HCP and had experienced TPA for more than 6 months. All participants provided electronic informed consent prior to their participation in the survey and had given their informed consent to the collection, processing and storage of their personal and health data. The survey was conducted online, and no HCPs were involved in participant recruitment. The survey identified and complied with the national regulations relating to ‘patients satisfaction surveys’ and no ethics committee evaluation was required. The questionnaire used in this survey is provided in Appendix I – Supplementary Document S1.

## Objectives

The main objectives of the survey were to describe the transition process from paediatric to
adult diabetes care from a participant’s perspec-
tive and to further measure and understand par-
ticipants’ experiences, such as personal issues,
satisfaction and their apprehension during the
transition.

Survey Endpoints

The survey assessed participants' perspectives on the impact of TPA process with respect to their relationship with HCPs, self-care, diabetes management, emotional and psychosocial concerns and the roles of supportive networks. The survey evaluated personal issues including fragilities of the family unit, first departure from family home, life challenge, denial of diabetes, eating disorders, psychological disorders, school or professional failure, stress related to schooling or work etc. and patients' satisfaction with the transition process.

Data Analyses

The term transition used in the survey was
defined as ‘an organised and coordinated pro-
cess of moving a participant, usually living with
a chronic disease, from paediatric care to an
adult healthcare system’. The survey included
qualitative and quantitative variables; crosso-
vers were developed on the basis of sample size
and considering their relevance to best describe
the course of transition among the participants.
Analysis was done by use of parametric (analysis
of variance (ANOVA) and Student test) and non-
parametric tests (Kruskal–Wallis, Mann–Whitney
and chi-squared test) accordingly. Correlation
analysis was done to measure the strength and
direction of a linear relationship between two
variables (–1 [strong reverse relationship] to
+1 [strong positive relationship]; 0 [no linear
relationship]). Continuous variables data were
expressed as means (±standard deviations) and
categorical variables data were expressed as num-
bers and percentages. The central limit theorem
was used to calculate the mean sample size and
standard deviation. Thematic qualitative analy-
sis was performed on respondents’ answers to
the questionnaire. In order to best describe the
course of transition among the participants, the

manuscript depicts the most relevant results. A
P value less than 0.05 was considered statistically
significant using a chi-squared test.

RESULTS

Participant Disposition

A total of 104 responders were included in the survey; of these, 64 (61.5%) participants were female. The mean age was 24.4 years (95% CI 23.8–25.0), with 53 (51%) participants 18–24 years old and 51 (49%) 25–30 years old. The mean age at the time of T1D diagnosis was 11.9 years (95% CI 10.9–12.9) and the mean time elapsed since diagnosis was 12.5 years (95% CI 11.2–13.8). The mean age at the time of transition was 18.4 years (95% CI 17.8–18.9) with 61 (59%) participants ≤ 18 years and 43 (41%) participants > 18 years of age. The mean time elapsed since transition was 6.0 years (95% CI 5.3–6.8) and the time since transition ranged between 6 months and 5 years in 49 (47%) participants and was more than 5 years in 55 (53%) participants (Table 1).

Regarding site for care, 77 (74%) partici-
pants were followed in public hospitals before
transition. For 58 (56%) participants, the first
adult diabetology department was in the same
institution. Overall, 65% of participants had
consulted a diabetologist after the transition; a
general practitioner, dietitian, pharmacist, oph-
thalmologist, nurse, podiatrist and psychologist/
psychiatrist were consulted by smaller propor-
tions of participants.

Transition-Triggering Event

The main event that triggered the transition was
a jointly made decision with the paediatrician in
36% of participants; the remaining participants
initiated the transition because of reasons such
as the decision was made by the paediatrician
alone, wish of parents, own wish, relocation,
and paediatrician relocation or retirement and
miscellaneous. Moreover, the transition started
naturally at the age of 18 years in 30% of partici-
pants and lasted mostly between 2 and 6 months
<table><caption>**Table 1** Baseline characteristics</caption><thead><tr><th>Parameters</th><th>Proportion of participants, n (%)</th></tr></thead><tbody><tr><td>Age (n = 104)</td><td></td></tr><tr><td>18–24 years</td><td>53 (51)</td></tr><tr><td>25–30 years</td><td>51 (49)</td></tr><tr><td>Female participants</td><td>64 (61.5)</td></tr><tr><td>Male participants</td><td>40 (38.5)</td></tr><tr><td>Age at diagnosis (n = 95)</td><td></td></tr><tr><td>Less than 5 years</td><td>12 (13)</td></tr><tr><td>Between 6 and 10 years</td><td>24 (25)</td></tr><tr><td>Between 11 and 15 years</td><td>34 (36)</td></tr><tr><td>More than 15 years</td><td>25 (26)</td></tr><tr><td>Time elapsed since diagnosis (n = 95)</td><td></td></tr><tr><td>Less than 3 years</td><td>6 (6)</td></tr><tr><td>Between 4 and 10 years</td><td>32 (34)</td></tr><tr><td>More than 10 years</td><td>57 (60)</td></tr><tr><td>Age at the time of transition (n = 104)</td><td></td></tr><tr><td>Less than or equal to 18 years</td><td>61 (59)</td></tr><tr><td>More than 18 years</td><td>43 (41)</td></tr><tr><td>Time elapsed since transition (n = 104)</td><td></td></tr><tr><td>Between 6 months and 5 years</td><td>49 (47)</td></tr><tr><td>More than 5 years</td><td>55 (53)</td></tr></tbody></table>

(33%) or less than 2 months (28%). Overall, for 72% of transitions, the adult diabetologists were consulted within a short period before the final departure from the paediatric department. The participants declared that they had one or more consultations with the adult diabetologist (47%) and/or with the paramedical team (specialized nurse, dietitian, psychologist, etc.) (45%).

## Insulin Treatment Regimen Before and After Transition

Among the responders, 49% changed their insulin treatment regimen after the transition. The insulin treatment regimen with use of classic injectable pens decreased with an increase in the use of the latest-generation devices.

## Treatment and Glucose Monitoring

Six months after the transition, participants tended to change their insulin administration device from the classic pen (47 to 29%) and to one of the latest-generation devices (6 to 28%) and their glucose monitoring from self-monitoring of blood glucose (48 to 32%) to intermittently scanned continuous glucose monitoring (is-CGM) (14 to 30%). However, from national care insurance coverage of is-CGM in 2017, much more participants in paediatrics had used this monitoring mode prior to transition (9% transition before 2017 vs. 21% transition after 2017). Participants who changed treatment soon after transition were more likely to change their glucose monitoring device as well versus participants who had no change of treatment (78% vs. 34%; P<0.001).

## Participant Insights: Personal Issues Faced During Transition

Almost three quarters of participants declared having experienced personal issues at the time of transition (mean of the number of issues 1.6). Moreover, one out of four participants mentioned the stress was related to school. Overall, female participants experienced slightly more issues than male participants (2.3 vs. 2.0 average mean). For the majority of participants (93%), the transition did not delay or disrupt a life plan, while for the rest of the participants (7%), the main life projects impacted were studies and travels.

## Diabetes Monitoring Issues After Transition

Of the 76 participants who experienced personal issues at the time of transition, 74% experienced at least one issue with their diabetes
management in the months following the transition. Personal concerns during the transition were significantly associated with new or unexpected issues in the months following the transition (*P* < 0.001) as presented in Fig. 1.

Overall, 61% of participants experienced new or unexpected issues in monitoring their diabetes after the transition. Twenty percent of all respondents identified two or more issues, which commonly included feeling alone (29%) and loss of motivation (25%) (Fig. 2).

Among participants who transitioned to a different institution, the feeling of loneliness after the transition was reported more often (43%) than other issues. Also, respondents who had no issues in the months following their transition

reported higher mean scores for diabetes team expertise (8.8 vs. 7.6; *P* < 0.001), diabetes team support (8.1 vs. 7.3; *P* = 0.001) and relatives' support (8.7 vs. 7.9; *P* < 0.001) than respondents who had issues.

## Diabetes Imbalance After Transition

Overall, 56 (54%) participants did not experience any unexpected diabetes imbalance after transition. Further analysis revealed that, out of 44% of participants who experienced unusual diabetes imbalance after the transition, 8 (8%) were hospitalised because of unusual

<figure><img src="image_4.png" /></figure>

Note: Personal concerns during the transition were significantly associated with new or unexpected issues in the months following the transition (*P* < 0.001)

<figure><img src="image_5.png" /><figcaption>Fig. 2 Diabetes monitoring difficulties after transition in overall population (n = 104)</figcaption></figure>
hypoglycaemia and 9 (9%) as a result of unusual hyperglycaemia, as shown in Fig. 3.

Amongst participants who had one or more consultations with the diabetologists (n = 35), 17 (49%) did not experience any unexpected diabetes imbalance, while among participants who did not have any consultations with the diabetologists (n = 69), 24 (35%) did not experience any unexpected diabetes imbalance.

Participants who experienced personal issues during the transition were likely to remember having an unusual diabetes imbalance compared to those who did not experience personal issues (54% vs. 20%) in the months following the transition.

Respondents who had an unexpected diabetes imbalance gave a significantly lower score (7.6 vs. 8.5; *P* < 0.05) to the expertise of the adult diabetes team than those who did not have any diabetes imbalance.

## Unmet Needs and Satisfaction

Overall, half of the participants who received information about transition did so from their medical team and half through other means.

Overall, 17% of respondents wished they had information about diabetes management at work or school.

On average, participants used mean number of services (1.8) or tools to help them in their transition. The most used were apps (32%) and specialised websites (31%) in diabetes care. In total, 70% of respondents had a smooth transition or had no suggestions how to improve the transition process. The remaining participants (30%) identified support, good listening (8.6%) and communication between the paediatric and adult diabetes teams (5.7%) as the primary causes to improve the transition.

## Participants’ Experience, Benefits and Main Concerns with the Transition

A quarter (24%) of respondents expected more autonomy from their transition. Half of the respondents (52%) expected no benefits (Table 2). The risk of less involvement of the medical team was the biggest concern of the participants about transition (ranked in top three by 43% of the respondents). The second most reported concern was having a different

<figure><img src="image_6.png" /><figcaption>Fig. 3 Diabetes imbalance after the transition (n = 104)</figcaption></figure>
organisation and 10% had no apprehension (Fig. 4).

## Satisfaction with the Transition

Overall, 41% reported that they were very satisfied, although some participants (8%) were rather dissatisfied with the way their transition was prepared. Participants who had a prepared transition (< 2 months or between 2 and 6 months) seemed to be more satisfied with their

<table><caption>**Table 2** Benefits of transition (n = 104)</caption><thead><tr><td>Parameters</td><td>Proportion of participants (n %)</td></tr></thead><tbody><tr><td>More autonomy</td><td>24</td></tr><tr><td>Less narrow and more suited follow-up</td><td>8.6</td></tr><tr><td>Better follow-up, new treatments</td><td>4.8</td></tr><tr><td>Less parental involvement</td><td>1.9</td></tr><tr><td>Help and support</td><td>5.7</td></tr><tr><td>More information</td><td>1.9</td></tr><tr><td>More participant involvement</td><td>1.0</td></tr><tr><td>Meet experienced participants</td><td>1.0</td></tr><tr><td>Less infantilising behaviour</td><td>6.7</td></tr><tr><td>No benefit</td><td>52</td></tr></tbody></table>

transition. Importantly, total satisfaction was reported in only 26% of those who reported at least one personal issue.

## Key Aspects of the Transition

Meeting the adult diabetology medical team and initiating the transition process by having their diabetes under control were ranked as the two most important aspects for a successful transition by 40% and 38% participants, respectively. The main concern related to the transition was losing the benefit from relatives' support throughout the process (14.4% of participants) (Fig. 5). Compared to participants who transitioned to another institution (47%), significantly more participants (66%) who transitioned in the same hospital believed that staying in the same hospital through transition was important (P < 0.001).

## DISCUSSION

For adolescents and young adults, the transition from paediatric to adult diabetology is an important step in controlling the risk of a break in the diabetes continuum of care. This includes participants' self-management of diabetes, working with new adult care HCPs and managing concomitant psychosocial issues. In the present survey conducted in France, participant/

<figure><img src="image_7.png" /><figcaption>**Fig. 4** Participants’ main concerns about transition (n = 104)</figcaption></figure>
<figure><img src="image_8.png" /><figcaption>**Fig. 5** Aspects of transition from paediatric to adult diabetes care (n = 104)</figcaption></figure>

family request was one of the reasons for TPA. However, lack of adult specialists in T1D care and long-lasting therapeutic relationship with participant/family were the main impediments to transition of care. For an effective TPA, development of structured guidelines for transition remains an important factor. Further, the most important aspects for a smooth transition, such as meeting with the adult diabetology medical team prior to the departure from paediatrics, and the aspects most related to apprehension of the transition, such as an organisation different from adult diabetology compared to paediatrics, should be anticipated.

Participants in this survey reported unanticipated disparities between the adult and paediatric teams such as differences in follow-up establishments, healthcare professionals, insulin treatment regimens, blood glucose monitoring devices etc., as well as issues connected to insufficient diabetes follow-up in adult care similar to findings reported by Garvey et al. highlighting the shortcomings in the T1D transition process and the importance of a planned transition by paediatric clinics to adult care [11]. The type of adult care provided should be considered when evaluating studies that look at how transition affects glycaemic control. Studies that evaluated HbA1c pre- and post-transition from paediatric and adult clinics have mentioned that the clinics were located within the same healthcare system, which was beneficial for the management

of diabetes [9]. Findings from the studies conducted by Helgeson et al. and Lotstein et al. found that compared with late transition or longer time in paediatric care, early transition from paediatric to adult care was associated with deterioration in glycaemic control [12–14]. Further, a 2008 study by Van Walleghem et al. [15] reported clinical outcomes with the Maestro Project, a systems navigator service for patients transitioning from paediatric to adult care. The study showed that although there was a marginal decrease in the participants continuing at least one medical visit per year before and after transition (95.3–89.1%), assistance from the Maestro project during transition was associated with a lower rate of dropout from adult care (11%) compared with those who enrolled after transition (40%).

A 2007 study by Weissberg-Benchell et al. suggested that families, participants and healthcare professionals can together create written transition plans 2 years prior to the actual intended transition. A UK study showed that using a two-stage transition process, first year in a combined transition clinic followed by transfer to young adult evening clinic, reduced HbA1c over 8 months [16]. A study conducted in Norway using semi-structured interviews showed that in contrast to paediatric care, young adults felt that adult care was less individualized and that they were not treated like whole individuals [17]. According to this study, the current protocols
for transferring young adults from paediatric to adult care were not optimal, and hence, the individuals with diabetes were not well prepared for the transition [7, 17]. Moreover, it has been reported that young adults having T1D who were satisfied with their access to health services were likely to have a satisfying clinical outcome which was unrelated to HbA1c levels or with the routine clinical plans [18]. Moreover, during the first stage of early adolescence, there exists a lack of openness to suggestions for diabetes therapy and management. Whereas the second stage of the young adulthood (25–30-year-old) is frequently marked by an increasing awareness of the significance of aiming for improved glycaemic control and an openness to enhancing self-care practices [19, 20]. It is important to note that the formation of some lifelong habits and conduct may present opportunities for medical interventions.

The main strength of this survey was the development of the questionnaire by top experts of paediatric endocrinology and diabetology. The questionnaire was additionally validated by individuals with T1D. Moreover, the survey data were obtained from a large proportion of individuals with T1D in France. One of the key limitations was the declarative type of survey and responses were based on an online survey, which might have introduced bias in the survey. There might be a recall bias associated with the survey, wherein participants were more or less likely to recall information on transition depending on the duration post transition. However, such bias commonly occurs in systematic participants surveys. The current survey highlights the importance of implementing an individualised transition process, considering the psychological aspects and fragility of the adolescent person so that the person can regain satisfaction. Thus, support in the adult diabetes transition is necessary for the autonomous management of diabetes, while considering the existing resources.

## CONCLUSIONS

The survey highlights the well-being of participants and their satisfaction with the provided

transition services, which is critical for young adults with diabetes and their clinicians. Further, the findings suggest that bridging paediatric and adult care settings for participants with T1D is a crucial aspect in the management of diabetes, and consistent engagement with diabetes care throughout young adulthood will promote health and welfare for youth and help them prevent diabetes-related complications. Thus, a focus on an effective approach with a structured transition programme towards the transition from paediatric centre to adult diabetes care is required. Providing an individualised transition process highlighting the common problems and solutions regarding transition would be beneficial. Glycaemic control to prevent long-term complications and to maximise lifelong functioning is essential. Also, there is a need for continued training and identification of adult providers (or advocates) versed not only in the medical care but also in the psychosocial needs of the young adult with diabetes.

## ACKNOWLEDGEMENTS

The authors would like to thank the survey respondents for participating in this survey. The authors would also thank Hela Ammar (Caretty) for her contribution in data acquisition and in developing methodology of this survey.

**Medical Writing/Editorial Assistance.** Manuscript writing assistance was provided by Tanya Debnath and Amol Gujar, both employees of Sanofi, and was funded by Sanofi.

**Author Contributions.** Juliette Eroukhmanoff, Claire Ballot Schmit, Sabine Baron, Amar Bahloul, Jacques Beltrand, Zeina Salame, Sophie Borot, Fabienne Dalla Vale, Helen Mosnier Pudar, Marc Nicolino, Alfred Penfornis, and Eric Renard were involved in the conception and design of the survey. All authors substantially contributed to the data analysis/interpretation of the results, critically reviewed, and approved the final version for submission, and are accountable for the accuracy and integrity of this manuscript. All named authors meet the
International Committee of Medical Journal
Editors (ICMJE) criteria for authorship for this
article, take responsibility for the integrity of the
work and have given their approval for this ver-
sion to be published.

**Funding.** This survey and the journal's Rapid Service Fee were funded by Sanofi.

**Data Availability.** Qualified researchers may request access to participants-level data and related survey documents, including the survey report, survey protocol with any amendments, blank case report form, statistical analysis plan and dataset specifications. The datasets generated and/or analysed during the current survey are available from the corresponding author upon reasonable request.

**Ethical Approval.** The survey was conducted online from 1 July 2022 to 26 August 2022. The people taking part in the survey have given their informed consent to the collection, processing and storage of their personal and health data. The survey was conducted online, and no HCPs were involved in participants recruitment. The survey identified and complied with the national regulations relating to ‘patients satisfaction surveys’. No ethics committee evaluation was required. Specifically, the following national guidelines were observed to assess the need for ethical evaluation: Article 1121–1 of the Public Health Code.

**Conflict of Interest.** Juliette Eroukhmanoff, Claire Ballot Schmit, Sabine Baron, Jacques Beltrand, Fabienne Dalla Vale, and Marc Nicolino were part of Sanofi's scientific committee and had no other activities to disclose. Amar Bahloul and Zeina Salame are employees of Sanofi. Alfred Penfornis is advisory panel member for AstraZeneca, MSD, and Novo Nordisk, and speaker for Abbott, Amgen, Bayer MSD, Sanofi, Novo Nordisk, Eli Lilly, and Medtronic. Eric Renard received consultancy/speaker's fees from A. Menarini Diagnostics, Abbott, Air Liquide SI, AstraZeneca, BD, Boehringer Ingelheim, Cellnovo, DexCom, Eli Lilly and Company, Hillo, Insulet, Johnson & Johnson (Animas, LifeScan),

Medtronic, Medirio, Novo Nordisk, Roche and Sanofi-Aventis and research support from Abbott, DexCom, Insulet, Roche and Tandem Diabetes Care. Sophie Borot received fees for participation in scientific meetings from Medtronic, Novo Nordisk, Insulet, DexCom, Sanofi, Eli Lilly and Company and VitalAire. Helen Mosnier Pudar received speaker invitations from Abbott, AstraZeneca, BD, Eli Lilly and Company, Novo Nordisk and Sanofi-Aventis; conferences invitations as an auditor (travel and accommodation costs covered by a company) by Novo Nordisk, Abbott and Sanofi; worked for clinical trials as principal investigator, coordinator or principal investigator for Abbott and Novartis; and regular activities in a company – SEFor.

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