How do we organize smooth, effective transfer from paediatric to adult diabetes care?
Transition from paediatric to adult care is a major milestone in the life of a young person with diabetes, yet it is commonly poorly done. This finding is supported by the dearth of publications in the literature that particularly relate to transition in diabetes care. Other transitions occur at this time of life, for example: from parental supervision to growing independence and from secondary school to post-school options. Health professionals know, from anecdotal evidence, that this is the period when young people with diabetes 'drop out' of the system. They often have no specialist follow-up and attend only the primary care physician for insulin prescriptions. Then, inevitably, a problem occurs that cannot be managed by the family doctor, such as diabetic ketoacidosis or pregnancy, and the patient is finally referred to an adult unit. There are many contributing factors to poor transition but two major reasons are that members of this age group are classic non-attenders and, importantly, they have not been well prepared for the transition. Preparation is the key to success and this must include parents as well as the young person. Components of transition preparation include: self-advocacy, independent health care behaviours, sexual health, psychosocial support, education and vocational planning, and health and lifestyle (drugs, alcohol, etc.). Considerable differences exist between many of the paediatric and adult services, and this cultural shift has significant impact on the success or otherwise of transition. Paediatric care is often multidisciplinary, family focused, prescriptive and requires parental direction and consent. Adult care is often provided by a single doctor, is patient focused, more investigational and requires autonomous, independent skills on the part of the user. Young people and their families, unless well prepared, become confused and disillusioned with the adult system. To avoid this situation, there is a variety of solutions, including adolescent transition clinics attended by both paediatric and adult teams, a transition coordinator who is responsible for making the transfer as smooth as possible, etc. Unfortunately, the very nature of the group in question means that none of these solutions is perfect. In reality, transition is a process that takes place over a number of years and should not be considered an event. The transition process needs to begin in early adolescence, to foster independence and communication skills, and to incorporate health education.