Transcript The Madison Clinic for Pediatric Diabetes at UCSF - Criss

UCSF Transition Program
The Madison Clinic for
Pediatric Diabetes at UCSF
CRISS
May 09, 2014
Goals of The Transition Program
at Madison Clinic
 provide youth with diabetes continuity of care
 a seamless transition within our clinic to young
adult-trained provider
 a successful transfer of care.
School of Medicine
The new Madison Clinic at
Mission Bay
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Transition???
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
3
Transition ???
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
4
ADA: Challenges of Transition
• Lack of empirical evidence on best approaches
• Lack of well-defined criteria for readiness
• Changing social and demographic characteristics of
young adults
• Gaps in health insurance
• Differences in learning styles
• Lack of training for HCP in care of this age group
• No studies done in emerging adults with T2DM
• Emergence of chronic complications
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
5
Transition Issues cont.
• Differences between health care delivery in the
peds and adult setting
• Deterioration of glycemic control and other risk
factors of the young adult
• Loss to follow-up
• Increased risk for acute complications
• Emergence of chronic complications
• Psychosocial issues
• Sexual and reproductive health issues
• Alcohol, smoking and drug use
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
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Transition Issues cont.
Deterioration of glycemic control and other risk
factors of the young adult
Poor control (SEARCH)
• Only 32% of youth with T1DM age 13-18 meet ADA
HbA1c goal
• Only 18% of youth over 19 meet ADA Hba1c goal
Loss to follow-up (increase morbidity/mortality)
• BDA study showed that mortality among those with
T1D is 3X in men and 6X in women compared to peer
group at ages 20-29 years old
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
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The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
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Transition Issues cont.
• Increased risk for acute complications
•
Hypoglycemia
•
DKA
• Emergence of chronic complications
•
Emergence of chronic complications
• T1DM : ~ 10 % of adol with mc-alb
• T2DM : ~ 30% of adol with mc-alb
• Discussion: What might be putting these
emerging adults at risk for severe hypo
and DKA?
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
9
Transition Issues cont.
• Differences between health care delivery in the
pediatrics and adult setting
• Deterioration of glycemic control and other risk
factors of the young adult
• Loss to follow-up
•
•
•
•
Increased risk for acute complications
Emergence of chronic complications
Psychosocial issues
Sexual and reproductive health issues
• Alcohol, smoking and drug use
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
10
Transition Issues cont.
• Psychosocial issues
•
•
•
•
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
Feelings of guilt and anxiety about getting off track with
diabetes care
Worrying about the future and the possible complications
Depressive Symptoms
• 18-20 y.o. 15-33% report depressive sxs
• Emerging adults: 23-35%
• > 20% of adolescent females (TODAY)
Eating Disorders
• 2.4 x risk of developing ED in adolescent and post-adol
females
• Associated with poor control, decreased adherence,
depression, increase DKA, increase microvascular
comps
• T2DM: 6% report binge eating and 20% reports
subclinical eating disorder
Diabetes Care for Emerging Adults: Recommendations for Transition
From Pediatric to Adult Diabetes Care Systems, Diabetes Care, November 2011
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SECTION HEADING
Transition Issues cont.
• Differences between health care delivery in the
pedeatrics and adult setting
•
Deterioration of glycemic control and other risk factors of the
young adult
•
Loss to follow-up
•
Increased risk for acute complications
•
Emergence of chronic complications
•
Psychosocial issues
• Sexual and reproductive health issues
• Alcohol, smoking and drug use
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
12
Transition Issues cont.
• Sexual and reproductive health issues
– Fewer than 1 in 4 adolescent females
aware of fetal and maternal risk of
pregnancy**
• Alcohol, smoking and drug use
– Alcohol and tobacco use similar to peers
• Alcohol increases risk of severe hypoglycemia
• Smoking increases CV risk and mc-alb
• Driving risk
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
13
TRAiD
Transition Readiness Assessment in Diabetes
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
14
Demographics
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
Characteristics
Race
White/Caucasian
Black/African-American
Hispanic/Latino
Asian
Other
Age
Age (in years)
Sex
Male
Female
Insurance
Private
Public
Unknown
n=116
%
54.4%
6.1%
23.7%
7.9%
7.9%
Mean (SD)
18.3 (2.7)
Percent
52.6%
47.4%
Percent
48.6%
36.9%
14.4%
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Transition Discussion
I have discussed eventually transferring my
care from a pediatric to adult provider
%
Yes, and we have a plan in place
11%
Yes, but we have no plan in place
38%
No
42%
I don’t know
8%
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
16
HbA1c profile for teens > 16
who took the TRAiD
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
Hemoglobin A1c (Age 16 and
over)
Overall
Race
White/Caucasian
Black/African-American
Hispanic/Latino
Asian
Other
Insurance Status
Private Insurance
Public Insurance
Age group
Age 16-19
Age 19-21
Age >21
Mean (SD)
n=116
8.9 (1.8)
8.7 (1.6)
9.8 (3.1)
8.9 (1.8)
9.3 (2.2)
9.3 (1.3)
8.2 (1.3)
10.0 (2.9)
9.1 (1.8)
8.7 (1.5)
8.3 (1.9)
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Results: TRAiD
Transition Readiness Assessment in
Diabetes
Responses
n=116
% Answering “No”
“I know what is required to stay on my health
insurance.”
“I have a plan for staying insured.”
“I know the difference between an adult
endocrinologist and an adult primary care
doctor”
“I have discussed moving to an adult diabetes
team with my family.”
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
“I have discussed moving to an adult diabetes
team with someone from my pediatric
diabetes team.”
47.4%
53.6%
37.4%
57.3%
54.6%
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Results: TRAiD
Transition Readiness Assessment in
Diabetes
Patient Autonomy Survey Questions
“I know how to get in contact with someone from
my diabetes team if I have questions.”
“I am the person who contacts my diabetes team
with questions or concerns.”
“I use MyChart to contact my diabetes team.”
Parent Involvement Questions
“Does your parent/guardian observe you checking
your blood sugar?”
Transition Readiness Score1
Score (range from 0-2)
Responses
n=116
% Answering “Yes”
75.9%
27.6%
5.2%
% Answering “No”
31.2%
Mean (SD)
0.8 (0.6)
1- Each patient’s “Transition Readiness Score” was created by averaging the responses
for all questions answered listed in Table 1 under “Transition Readiness Survey
Questions,” with “No” assigned a value of 0, “Sometimes” assigned a value of 1, and
“Yes” assigned a value of 2.
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
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Implemented Transition Programs
• Climbing Wall + DM Education and Exercise
• Back to College Night
• Decoding Health Insurance
• Game Night
• Sex, Drugs & Rock and Roll
• Psychosocial groups
• Transition Day – Collaboration with JDRF, CHO, CarbDM,
DYF
• Youth Advisory Board
The Madison Clinic for
Pediatric
School
of Diabetes
Medicine
at UCSF
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Marcela Arregui Reyes, MS, PMP
Transition Coordinator,
UCSF Benioff Children’s Hospital
Madison Clinic for Pediatric Diabetes
Maureen McGrath, MS, PNP-BC, BC-ADM
Associate Clinical Professor
Coordinator, Diabetes Minor
University of California, San Francisco
Family Health Care Nursing