Transition of Care in Type 1 Diabetes Mellitus

Improving Transition of Care in Type 1 Diabetes Mellitus: A Collaborative Approach

This research project seeks to address the question of how to improve the transition of patients with type 1 diabetes mellitus from the paediatric to the adult health service at RNSH and Mona Vale Community Health Centre (seeking the perspectives of patients, families, and staff)?

Study Overview

• Status: Enrolling by invitation
• Conditions: Type 1 Diabetes Mellitus; Transition

Detailed Description

There are significant limitations in the literature relating to transition from paediatric to adult healthcare.

In healthcare, transition describes the purposeful process of planning and moving from paediatric to adult services and usually occurs in adolescence (in itself a time of rapid physical, cognitive and psychosocial growth between childhood and adulthood). The available evidence within the literature to guide this process of transition is often limited and additional evidence to guide clinical practice is required. Although reports within the literature vary, it is known that up to 50% of young adults with an endocrine disorder are lost to follow-up after transition to adult health services. Even if the young person attends the adult service, they may have poor health outcomes related to inability to self-manage their condition, particularly if it is a chronic disease requiring significant daily intervention by the patient, such as in type 1 diabetes mellitus.

Type 1 diabetes mellitus is a life-long condition characterised by autoimmune-mediated destruction of pancreatic β-cells, almost always resulting in absolute insulin deficiency. As a result, patients are required to perform lifelong intensive glucose monitoring and insulin administration. These intensive insulin regimens require an enormous amount of attention and effort on the part of the young person with diabetes and their family, but dramatically reduce their rates of micro- and macro-vascular complications, such as blindness, kidney failure, heart attack and stroke. Evidence for this 'legacy effect' - the long-term clinical benefits of early intensive insulin treatment - are provided through studies including the EDIC (Epidemiology of Diabetes Interventions and Complications) study which undertook long-term follow up of the Diabetes Control and Complications Trial (DCCT). The DCCT, conducted from 1983-1989, randomised 1441 participants with new or recently-diagnosed type 1 diabetes to receive either intensive insulin therapy or standard therapy. The DCCT/EDIC study ultimately recommended maintaining patients' glucose levels as close to the normal range as safely possible, with intensive insulin therapy and monitoring.

Glycaemic control and transition in adolescents with type 1 diabetes mellitus has its own specific challenges. Across all age groups, adolescents are currently the farthest from achieving good glycaemic control (a HbA1c goal of <58 mmol/mol or 7.0%). The factors contributing to this may include hormonal changes during puberty, psycho-social challenges and decreased adherence to insulin therapy regimens.

Appropriate transition of patients with type 1 diabetes from paediatric to adult health care thus needs to take a holistic approach to the individual patient which addresses these factors and which is centred on individual patients' developmental stages and circumstances.

The local transition process at Royal North Shore Hospital has future potential At Royal North Shore Hospital, there is a structured transition process underpinned by the transition policy. However, initial analysis indicates that patients are missing appointments and education, and being lost to follow-up. There is accordingly a pressing need for analysis of the transition process and its outcomes.

Within the current literature, evaluation measures to assess patients' diabetes self-management and transition readiness (including glucose monitoring, insulin and food regulation, exercise, and emergency preparedness) frequently rely on patient self-report and emphasise knowledge and practical skills in diabetes care.

This research will provide additional insights from the patient's family and from treating staff as well as explore self-efficacy (the individual's belief in their capacity to execute behaviours) which are often poorly studied in transition research. It is anticipated that this will provide a comprehensive picture of areas in which patients' efficacy, transition readiness, knowledge and diabetes-related distress can have tailored support provided in an individualised way.

This research project will utilise the following questionnaires, with access for all participants via a QR code using Northern Sydney Local Health District (NSLHD) REDCap (a secure, web-based application for building and managing online surveys and databases).

1. A modified READDY tool assessing transition readiness and self-efficacy - with versions that can be answered separately by the patient, the patient's family member, and the patient's healthcare professional.
2. Diabetes knowledge questionnaire - with versions that can be answered separately by the patient and patient's family member
3. Diabetes distress questionnaire - with versions that can be answered separately by the patient and the patient's family member
4. Evaluation of the transition process - with versions that can be answered separately by patient, patient's family member and staff member

• Study Type: Observational
• Enrollment (Estimated): 80

Contacts and Locations

Study Locations

• Australia
  • New South Wales
    • Sydney, New South Wales, Australia, 2065
      • Royal North Shore Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: N/A

• Sampling Method: Non-Probability Sample

Study Population

Patients with type 1 diabetes mellitus meeting inclusion criteria, above

Description

Inclusion Criteria:

Adolescents who have an existing diagnosis of type 1 diabetes mellitus and who underwent (in 2020 to 8th June, 2023) or who are undergoing (from 9th June, 2023 and subsequent cohorts) transition from paediatric care to adult health care at Royal North Shore Hospital and Mona Vale Community Health Centre. Adolescents with type 1 diabetes will be 16 years or older

A family member or caregiver of the participant of the adolescent patient with type 1 diabetes mellitus

A staff member who is a member of the patient's treating diabetes team within the paediatric diabetes service (first study visit and second study visit) and young adult diabetes service (third study visit)

Exclusion Criteria:

There are no specific exclusion criteria

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Retrospective cohort; Patients with type 1 diabetes mellitus known to Royal North Shore Hospital, who underwent transition from paediatric to adult health care from 1st January 2020-8th June 2023
Prospective cohort; Patients with type 1 diabetes mellitus known to Royal North Shore Hospital, undergoing transition from paediatric to adult health care, from 9th June 2023 onwards

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient self-efficacy (patient, family and staff member) relating to diabetes	From prospective questionnaires, with higher scores indicative of higher self-efficacy	From 9th June, 2023, ongoing for initial period of 5 years with interim sequential reviews
Diabetes knowledge questionnaire (patient and family member)	From prospective questionnaires, with a single correct answer per question	From 9th June, 2023, ongoing for initial period of 5 years with interim sequential reviews
Diabetes-related distress (patient and family member)	From prospective questionnaires, with higher scores indicative of higher distress levels	From 9th June, 2023, ongoing for initial period of 5 years with interim sequential reviews

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient medical outcomes	HbA1c (%) over time	From 9th June, 2023, ongoing for initial period of up to 5 years with interim sequential reviews
Patient medical outcomes	Frequency (number) of emergency department presentations	From 9th June, 2023, ongoing for initial period of up to 5 years with interim sequential reviews
Patient medical outcomes	Percentage of patients developing diabetes complications	From 9th June, 2023, ongoing for initial period of up to 5 years with interim sequential reviews

Collaborators and Investigators

• Sponsor: Northern Sydney and Central Coast Area Health Service
• Investigators: Principal Investigator: Shihab Hameed, MBBS, Royal North Shore Hospital

Study record dates

Study Major Dates

• Study Start (Actual): June 9, 2023
• Primary Completion (Estimated): June 9, 2024
• Study Completion (Estimated): June 9, 2028

Study Registration Dates

• First Submitted: June 21, 2023
• First Submitted That Met QC Criteria: October 30, 2023
• First Posted (Actual): November 2, 2023

Study Record Updates

• Last Update Posted (Actual): November 2, 2023
• Last Update Submitted That Met QC Criteria: October 30, 2023
• Last Verified: October 1, 2023

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Immune System Diseases; Autoimmune Diseases; Endocrine System Diseases; Diabetes Mellitus; Diabetes Mellitus, Type 1
• Other Study ID Numbers: 2022/ETH02412

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No