ESPE Abstracts (2018) 89 P-P2-293

What is the Impact of a Structured Healthcare Pathway Dedicated to Patients in Transition on Their Long-term Follow-up?

Florence Menesguena, Isabelle Tejedorb, Sabine Malivoira, Pauline Faucherc, Marine Halbrond, Marc Popelierd, Juliane Legere, Irene Netchinef, Michel Polakg, Eric Bruckerth, Christine Poitouc & Philippe Tourainea,i


aDepartment of Endocrinology and Reproductive Medicine Pitie Salpetriere Hospital, Paris, France; bDepartment of Endocrinology and Reproductive Medicine Pitie Salpetriere Hospital Department of Endocrinology and Reproductive Medicine Pitie Salpetriere Hospital, Paris, France; cDepartment of Nutrition Pitie Salpetriere Hospital, Paris, France; dDepartment of Diabetology Pitie Salpetriere Hospital, Paris, France; eDepartment of Pediatric Endocrinology Robert Debre Hospital, Paris, France; fDepartment of Pediatric Endocrinology Trousseau Hospital, Paris, France; gDepartment of Pediatric Endocrinology Necker Hospital, Paris, France; hDepartment of Endocrinology and Metabolism Pitie Salpetriere Hospital, Paris, France; iCenter for Rare Endocrine Disorders, Paris, France


Management of patients presenting a chronic endocrine or metabolic disease during transition period is a challenge for multiple reasons. The department of Adult Endocrinology and Reproductive Medicine in Pitie Salpêtrière Hospital, Paris has been involved in the management of such patients for many years. However, in our own experience, 81% of patients are still followed-up after 1 year, 71% after 3 years and only 49% after 5 years. Based on such experience, we decided to set up a structured healtcacare pathway dedicated to patients in transition. We built up this program with the Department of Nutrition, the Department of Diabetology and the Department of Endocrinology and Metabolism, all located in the same building in Pitie Salpêtrière Hospital. We associated to this program among others nurses, dieteticians, psychologists and more recently a coordinator dedicated to this healthcare pathway. Since september 2016, 273 patients have been included at a mean age of 19 yrs. These patients were mostly referred from Necker Hospital, Robert Debré and Trousseau Hospitals located in Paris and managing children with endocrine disorders. The most frequent chronic diseases were brain tumours (15%), obesity (14%), DSD (11%), Diabetes (10%) and Pituitary deficiencies (9%). Among this population we studied the follow-up pf patients included between September 2016 and February 2017 and analyzed their management after one year, by the end of march 2018. Seventy-none patients were followed-up during this one-year period; seventy-four patients (93.6%) have been currently managed in in-door or out-door clinics. Even if this appears as a very important number of patients, we have to notice that such result depends on the strong involvement of the educative team dedicated to this pathway. In conclusion, this structured healthcare pathway appears potentially helpful for the management of young adults during transition period. The benefits and the limits of this program will be discussed.