It is that time again—seniors in high school are receiving acceptances to universities all across the country (and even internationally). Our senior students with diabetes are no exception! While some of our youth with diabetes in the Washington, DC, area are dreaming of attending a university in southern California for example, their family caregivers are agonizing about who will provide medical guidance and care so far away.
It is my personal practice at Children's National Medical Center to continue to follow all college bound young adults until they graduate college. I also will care for those who choose an alternate career path until they are 22 years of age.
There are many developmental milestones that occur in children and adolescents. Adolescence is the continuum through young adulthood—some believe till age 30! Pediatricians always have a reluctance in saying goodbye to their patients when they reach a certain age. Now, a recent online publication in Pediatrics has evidenced-base data providing some support for our reluctance in transitioning to adult practitioners, especially for those with chronic illness.
Drs. Lotstein, Seidel, and Klingensmith, et al., representing the SEARCH for Diabetes in Youth group published the online report, "Transition from Pediatric to Adult Care for Youth Diagnosed with Diabetes in Adolescence," in Pediatrics DOI.10.1542/peds.2012-1450 on March 25, 2013. The purpose of the study was to describe the different correlating factors of poor diabetes control that are associated with transfer to adult providers of diabetes care. The study cohort consisted of 185 youth with the average age at diagnosis of 15. Of note, approximately 86 percent had private insurance before and after follow-up. This is important as we can't fault the lack of insurance in this cohort if there is no eventual follow-up. According to recent guidelines from the American Academy of Pediatrics and the American Diabetes suggest transition to adult providers between 18-21 years of age.
What were the results?
1. Only 57 percent of the study subjects transitioned to adult providers by the follow-up visit.
2. The median age of transition was about 20 years of age.
3. 77 percent left pediatric care by age 21.
4. Older age, lower baseline hb A1c and less parental education was associated with an increased likelihood of transitioning to adult providers.
5. The chances of poor diabetes control at follow-up were 2.5 times higher in those subjects that transitioned to adult care versus those that remained in their pediatric practice.
6. It also was noted that those participants with higher A1cs remained with their pediatric providers longer than those with lower ones. (Perhaps because pediatric providers were more concerned about their glycemic control and asked them to remain in their care)
7. Young adults from minority racial or ethnic backgrounds also were considered at increased risk for problematic transition outcomes.
Let’s go back to our graduating high school student. The statistics point to the likelihood of leaving pediatric care by 21. Is this a good idea in view of the chances of deteriorating glycemic control after leaving "the nest?" There are no clear-cut answers to these questions and further research will be necessary to determine the best route for our young adults. We do not yet know the ideal transition timeframe for these hybrid late adolescent/ young adults. What we do now know is that pediatric providers must do a better job preparing our hybrid adults when they decide to make "the leap." And then our next step will be to ensure that our patients follow-up with their new adult diabetes team. Bad things happen when our late adolescents/young adults get lost in between care providers.
Published On: April 23, 2013