Factors determining diabetes care outcomes in patients with type 1 diabetes after transition from pediatric to adult health care: a systematic review
Authors: Farrell Kaye , Griffiths Rhonda , Fernandez Ritin 
Published: December 2014

Executive summary

Background
The transition of young adults with type 1 diabetes from pediatric to adult health care usually takes place at the end of secondary schooling, at a time when they are also experiencing multiple life transitions. Diabetes self-care management will often be of low priority for young people as they adjust to new routines involved with further study, employment and relationships. Failure to transition successfully may result in loss to medical follow-up, deterioration in diabetes control and development of short and long term diabetes complications.

Objectives
The primary focus of this systematic review was to identify the best available evidence of factors that determine diabetes care outcomes for young adults with type 1 diabetes after transition from pediatric to adult health care services.

Inclusion criteria

Types of participants

Studies involving people aged 15-19 years inclusive with a diagnosis of type 1 diabetes who have transitioned from pediatric to adult health care services.

Types of intervention(s)

Any intervention which identified factors that influenced the transition of young people with type 1 diabetes from pediatric to adult health care.

Types of studies

All clustered trials, descriptive studies, pre-and post-test studies, and other designs with a control group and case studies evaluating factors which influence the transition from pediatric to adult health care of patients with type 1 diabetes were included in the review.

Types of outcomes

Primary outcomes: Diabetes control as measured by HbA1c at follow-up, loss to follow-up, adherence to insulin therapy, incidence of hospital admission for acute complications, and frequency and regularity of clinic attendance
Secondary outcomes: Uptake of screening for long term diabetes complications, cost effectiveness of intervention, health-related quality of life and patient satisfaction

Search strategy
Seven databases were searched and the reference list of all included studies was searched for additional studies. There was no time limitation to the search.

Methodological quality
The methodological quality of eligible trials was assessed independently by two reviewers using the Joanna Briggs Institute (JBI) quality assessment tool.

Data collection
Data extraction from the included trials was undertaken and summarized independently by two reviewers using the JBI data extraction tool which was modified in order to extract detailed data from the study.

Data synthesis
Where data were available, it has been pooled and presented as a forest plot in the review results. Studies with textual data results or where synthesis is inappropriate are presented as a narrative summary.

Results
Forty-one studies that potentially met the criteria for inclusion in the review were identified by the search strategy, of which 13 met the inclusion criteria. Factors identified to assist transition in the review studies related to either structured or unstructured interventions. The results of this review demonstrate that when a structured program is in place to assist the transition from pediatric to adult diabetes services, young people are less likely to require hospitalization for acute diabetes complications and more likely to attend appointments at the adult diabetes service.

Conclusions
The evidence identified from this review is suggestive that a structured transition intervention employing a dedicated health professional to support and coordinate the process is more likely to prevent loss to follow-up, maintain clinic attendance, have a positive impact on diabetes control, reduce hospital admissions, and be a more cost effective and positive experience for patients than an unstructured or usual care model.

Implications for practice

The unique needs of these patients demand services distinctly different to the general adult patient with diabetes and adult clinicians should take an active role in ensuring follow-up in this vulnerable group.

Implications for research

Due to the relatively small numbers in this patient cohort one suggestion for future research would be to conduct multi-center randomized controlled trials which may then provide more meaningful evidence of diabetes transition and outcome measures.