Authors: testFrancesca Valent, Laura Tonutti, Manuela Zanatta, Paola Cogo, Franco Grimaldi
Via Colugna 50 - 33100 Udine
Citation: Transfer of patients with type 1 diabetes mellitus from pediatric to adult specialist care in a Northern Italian area.Global Scientific Research Journal of Diabetes, 1(1), 2018, pp. 21-32.
Copyright: This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: Transfer of patients with type 1 diabetes mellitus (T1DM) from pediatric to adult care services may be challenging. The objective of this study was to evaluate glycemic control during pediatric and adult care among teenagers and young adult patients overall and among those who experienced transfer in the Italian area of Udine, where informal initiatives are in place to favor transition
Methods: The administrative health-related databases of the local health information system were used as source of information. Different databases (healthcare beneficiaries, drug prescriptions, ambulatory care, laboratory data, exemptions from medical charges) were linked at the individual level through an anonymous univocal stochastic key. Among patients with T1DM born between 1990 and 2005, we analyzed ambulatory visits and HbA1c from 2010 to 2017. Pediatric and adult care periods were compared in the whole cohort and subjects experiencing transfer were identified.
Results: The cohort included 84 subjects. Of them, 14 (median age: 18 years) switched from pediatric to adult care. Overall, mean HbA1c was slightly and non-significantly higher during adult care than during pediatric care. Among subjects experiencing transfer, mean HbA1c increased from 8.0 to 8.3% (p= 0.0651) whereas the interval between consecutive measurements decreased from 287 to 175 days (p= 0.0420).
Conclusions: In this Italian area, transfer to adult care services does not significantly affect either the pattern of care or glycemic control of patients with T1DM. Glycemic control is generally always acceptable. Other factors possibly influencing glycemic control in this area should be investigated.
Key words: type 1 diabetes mellitus; pediatric transition to adult care; glycated hemoglobin; Italy.
Adolescents and young adults affected by chronic illnesses, such as type 1 diabetes mellitus (T1DM), experience, at a certain point, transition and then transfer from pediatric to adult care services, where transition indicates the process of preparation of those patients to the actual transfer to adult care services [1,2]. The difficulties of achieving good glycemic control in emerging adults with T1DM and transitioning pediatric T1DM patients to adult diabetes care have been described extensively [3-5].
However, only limited evidence is available on effective strategies to improve the transition process. For example, one recent Cochrane review evaluating the effectiveness of interventions to improve the transition of adolescents from pediatric to adult health services could not draw any conclusion since only four randomized clinical trials, one of which on patients with T1DM, could be evaluated .
Transitioning itself could represent a cause of glycemic control worsening. In the USA, for example, transitioning from pediatric to adult care patients diagnosed with T1DM in adolescence was associated with increased risk of poor glycemic control . A review by Lyons et al., however, highlighted that in various observational studies, many of which were from European countries, HbA1c even improved after transferring patients to adult care.2 Evidence from one particular socio-geographical context may not be generalizable to different settings. In fact, in a recent Danish study, a decrease in glycated hemoglobin (HbA1c) was observed on average after transfer to adult care, however, social factors were strongly associated with glycemic control .
In Italy, the national standards for diabetes care  recommend that patients with T1DM should be assisted by a multidisciplinary diabetologic team, and recommend for adolescents (13-19 years of age) that HbA1c should be <7.5% as the glycemic control target. In some Italian areas, such as Brescia, a transition ambulatory for T1DM patients has been established . A survey of 137 Italian diabetology services highlighted that some kind of rules for patient transfer only existed in 26% of centers; of them, less than one third were actually structured care paths, the remaining being well-established written or verbal agreements between diabetes care professionals or even occasional agreements. Only 7% of those rules were established in the regional legislation .
In the North-Eastern Italian Region Friuli Venezia Giulia (FVG), epidemiological data on T1DM in the population 0-18 years of age indicate that incidence rate has increased from 9.8 in 1987-1990  to 15.8 new cases per 100,000 person-years in 2010-2013  and that the current prevalence of T1DM in the same age group is approximately 15 per 10,000 inhabitants, increasing with increasing age . In agreement with the 2014 national standards, the guidelines of the FVG Region on the integrated care of patients with diabetes mellitus  encourage multidisciplinary care, but do not explicitly address the issues of transition (i.e., the process of preparation) or transfer (i.e., the actual transfer to adult care). Thus, the organization and management of this process is transferred to the local Health Agencies.
One of the Health Agencies of the FVG Region is the “Azienda Sanitaria Universitaria Integrata di Udine” (ASUIUD), serving 37 municipalities in the area around the city of Udine. In this area, a 1000-bed Academic Hospital is the cornerstone of healthcare services for the approximately 250,000 inhabitants of the greater Udine catchment area. The Pediatrics. Department of the University Hospital of Udine includes a Diabetology Ambulatory which is in charge of the diagnosis and follow-up of diabetes mellitus in children. Thus, in this area, children with diabetes mellitus are usually managed by pediatricians devoted to diabetes care within that ambulatory. In the same Hospital, the Diabetology Ambulatory is in charge of taking care of patients with special needs, including those transitioning from the Pediatric services, although this activity is not explicitly addressed in the Ambulatory patient information sheet . Despite the lack of a written document regulating the transition and transfer of T1DM patients from pediatric to adult care, in the Hospital of Udine , the health professionals from both ambulatories cooperate and organize periodical educational camps and shared patients visits for mutual acquaintance and favor visits with one single diabetologist throughout the first year of adult care, following the principles stated in the consensus document on transition published by the Italian scientific societies dealing with diabetes care .
We conducted a research to evaluate glycemic control in teenagers and young adults with T1DM living in the area of Udine, comparing HbA1c levels during pediatric and adult diabetes care overall and in subjects who experienced transfer from pediatric to adult care services in the years 2010-2017.
MATERIAL AND METHODS
For this population-based study, we used as the source of information the administrative health-related databases of ASUIUD. Different databases were linked at the individual level through an anonymous univocal stochastic key: the database of potential healthcare beneficiaries, including demographic and residential information; the drug prescription database, including prescriptions filled by all public physicians in the Region; the ambulatory care database, containing information on outpatient visits at public and private accredited hospitals and clinics of the Region; the laboratory database, including results of all laboratory tests conducted at public hospitals in the Region; the database of exemptions from medical charges (in Italy, potential healthcare beneficiaries may be entitled, because of low income, age, or chronic diseases, to receive free medications and outpatient specialist care. The Italian Ministry of Health assigned codes to all the diseases which entitle patients to exemptions. Currently, they include many chronic and disabling diseases , including diabetes mellitus, as well as rare diseases ). Since the most recent of those databases (i.e., the laboratory) has been available since 2010, all the analyses on transfers regarded the years 2010-2017.
We identified patients with an exemption from medical charges because of diabetes mellitus (national exemption code 013), assuming the date of exemption as the date of diagnosis of diabetes mellitus. From that pool, we selected subjects <15 years of age at the time of diagnosis, born between 1990 and 2005, still resident in the area of Udine in 2017 who received during their lives any prescriptions of insulin (ATC codes A10Axxx) and no prescriptions of oral antidiabetic drugs (ATC codes A10Bxxx). Thus, we obtained a cohort of patients with probable type 1 diabetes mellitus (T1DM), living in the study area, who were supposed to experience transfer from pediatric to adult care in the years 2010-2017.
For those patients, we analyzed all the ambulatory care visits from 2010 to 2017 and assessed those taking place at a pediatric ambulatory (“pediatric care”) or at an adult diabetes-related ambulatory, e.g., endocrinology, diabetology, medicine (“adult care”). The cohort was divided into 4 groups: a) patients with pediatric visits only; b) patients with adult care visits only; d) patients transferred from pediatric to adult care; d) patients with no visits at specialist public ambulatories, who were assumed to receive diabetes care by their general practitioner (GP) or by private specialists. For subjects switching from pediatric to adult care between 2010 and 2017, we identified the transfer date as the date of the first adult care visit. Such date was used to calculate age at transfer.
For subjects who only attended pediatric ambulatories, age at last visit was calculated. On the other hand, for those who only attended adult or private ambulatories, age at the earliest visit was calculated.
1. Hanna KM, Woodward J. The transition from pediatric to adult diabetes care services. Clin NurseSpec2013;27:132-45https:// - doi.org/10.1097/NUR.0b013e31828c8372.
2. Lyons SK, Becker DJ, Helgeson VS. Transfer from pediatric to adult health care: effects on d i a b e t e s o u t c o m e s . P e d i a t r D i a b e t e s 2014;15:10-7.https://doi.org/10.1111/pedi.12106.
3. Garvey KC, Markowitz JT, Laffel LM. Transition to adult care for youth with type 1 diabetes. Curr Diab Rep 2012;12:533-41. https://- doi.org/10.1007/s11892-012-0311-6.
4. Ritholz MD, Wolpert H, Beste M, Atakov-Castillo A, Luff D, Garvey KC. Patient-provider relationships across the transition from pediatric to adult diabetes care: a qualitative study. DiabetesEduc2014;40:40-7.https:// - doi.org/10.1177/0145721713513177.
5. Lyons SK, Libman IM, Sperling MA. Clinical review: Diabetes in the adolescent: transitional issues JCli Endocrinol Metab 2013;98:4639-45. https://doi.org/10.1210/jc.2013-2890.
6. Campbell F, Biggs K, Aldiss SK, O'Neill PM, Clowes M, McDonagh J, While A, Gibson F. Transition of care for adolescents from paediatric services to adult health services. Cochrane Database Syst Rev 2016;4:CD009794. https://- doi.org/10.1002/14651858.CD009794.pub2.
7. Lotstein DS1, Seid M, Klingensmith G, Case D, Lawrence JM, Pihoker C, Dabelea D, Mayer-Davis EJ, Gilliam LK, Corathers S, Imperatore G, Dolan L, Anderson A, Bell RA, Waitzfelder B; SEARCH for Diabetes in Youth Study Group. Transition from pediatric to adult care for youth diagnosed with type 1 diabetes in adolescence. Pediatrics2013;131:e1062-70.https: // - doi.org/10.1542/peds.2012-1450.
8. Castensøe-Seidenfaden P, Jensen AK, Smedegaard H, Hommel E, Husted GR, Pedersen-Bjergaard U, Teilmann G. Clinical, behavioural and social indicators for poor glycaemic control around the time of transfer to adult care: a longitudinal study of 126 young people with diabetes. Diabet Med 2017;34:667-75. https://- doi.org/10.1111/dme.13318.
9. Associazione Medici Diabetologi (AMD) - Società Italiana di Diabetologia (SID) [Internet]. Standard italiani per la cura del diabete mellito 2014.http://www.standarditaliani.it/skin/www.snaraianiit/pdf/STANDARD_2014_May28.pdf [accessed 16 August 2018].
10. Agosti B, Zarra E, Bonfadini S, Prandi E, Felappi B, Plebani A, Valentini U. La transizione del paziente affetto da diabete di tipo 1 dal centro pediatrico al team multidisciplinare dell’adulto: criticità e outcome. G It Diabetol Metab 2015;35:303-7.
11. Tonutti L, Gentile L, De Riu S, Visalli N, Gentile S, Giorda CB, Ceriello A. Transizione del paziente giovane diabetic nell’ambulatorio dell’adulto. Il Giornale di AMD 2014;17:152-8.
12. Pocecco M, Nassimbeni G. Distribution of new cases of insulin-dependent diabetes mellitus (IDDM) by age, sex, seasonality, and clinical characteristics at onset in youngsters from the Friuli Venezia Giulia region from 1987 to 1990]. Pediatr Med Chir 1993;15:489-92.
13. Valent F, Candido R, Faleschini E, Tonutti L, Tortul C, Zanatta M, Zanette G, Zanier L. The incidence rate and prevalence of pediatric type 1 diabetes mellitus (age 0-18) in the Italian region Friuli Venezia Giulia: population-based estimates through the analysis of health admini s t r a t i v e d a t a b a s e s . A c t a D i a b e t o l 2016;53:629-35.https:// - doi.org/10.1007/s00592-016-0854-0.
14. Regione Friuli Venezia Giulia. Documento di indirizzo regionale sull’Assistenza Integrata alla Persona con Diabete http://mtom.regione.fvg.it/storage//2015_1676/Allegato%202%20alla%20Delibera%201676-2015.pdf [accessed 16 August 2018].
15. Azienda Sanitaria Universitaria Integrata di Udine. Informazioni utili. Diabetologia Ambulatorieda hospital.https://asuiud.sanita.fvg.it/distretti/dipartimen - ti-ospedalieri/ospedale-smm/medicina-interna/ endocrinologia-e-malattie-del-metabolismo/dia betologia/diabetologia-e-day-hospital-informazi oni-utili-brochure/diabetologia-e-day-hospital-in formazioni-utili; 2011 [accessed 16 August 2018].
16. Gruppo di studio SIEDP - AMD – SID. Transizione dei giovani con diabete mellito verso l’età adulta. Il Giornale di AMD 2010;13:159-68.
17. Ministero della Salute. Elenco malattie e condizioni croniche e invalidanti. http://www.trovanorme.salute.gov.it/norme/renderPdf.spring?seriegu=SG&datagu=18/03/2017&r edaz=17A02015&artp=13&art=1&subart=1&su bart1=10&vers=1&prog=001; 2017 [accessed 16 August 2018].
18. Ministero della Salute. Elenco malattie rare esentate dalla partecipazione al costo. http://www.trovanorme.salute.gov.it/norme/renderPdf.spring?seriegu=SG&datagu=18/03/2017&r edaz=17A02015&artp=12&art=1&subart=1&su bart1=10&vers=1&prog=001; 2017 [accessed 16 August 2018].
19. Crocetti E, Meeus W. "Family Comes First!" Relationships with family and friends in Italian emerging adults. J Adolesc 2014;37:1463-73. https://doi.org/10.1016/j.adoles - cence.2014.02.012.
20. American Diabetes Association 12. Children and Adolescents: Standards of Medical Care in Diabetes-2018. Diabetes Care 2018;41(Suppl 1)126-S136https://doi.org/10.2337/dc18-S012.
21. van Esdonk MJ, Tai B, Cotterill A, Charles B, Hennig S. Prediction of glycaemic control in young children and adolescents with type 1 diabetes mellitus using mixed-effects logistic r e g r e s s i o n m o d e l i n g . P L o S O n e 2017;12:e0182181. https://doi.org/10.1371/- journal.pone.0182181.