ESPE Abstracts (2015) 84 P-2-285

Implementation of Effective Transition from Paediatric to Adult Diabetes Care: Epidemiological and Clinical Characteristics - A Pioneering Experience in North Africa

Essaddam Leïlaa, Turki Zinetb, Fitouri Zohraa, Ben Slama Claudeb, Matoussi Nadiaa & Ben Becher Saaydaa


aPUC Department, Children Hospital of Tunis, Tunis, Tunisia; bC Department, National Institute of Nutrition, Tunis, Tunisia


Background: Diabetes mellitus (DM) is a chronic metabolic disorder requiring daily care to prevent both acute and chronic complications. Healthcare providers are challenged to manage the transition of adolescents from paediatric to adult diabetes services. Until recent date, this change of the medical team was lived by teenagers as a tearing and a discontinuity of the medical care.

Objective and hypotheses: While centres providing structured integrated paediatric and adult care seem optimal, diabetic teenagers suffered from an unsuitable care. These patients are in need of transition programs to prevent discontinuities in specialized care.

Method: In collaboration with an adult endocrinology department, we developed a transition program for adolescents with DM. A meeting of transition is organised with the whole paediatric team and the adult one in which patients meet their new medical staff, ask their questions and express their fears. DM related issues are recorded in a specially developed ‘diabetes health passport’ used by the patient. This ‘passport’ accompanies the patient through the transition process, providing anticipatory guidance, ongoing assessment of psychosocial issues and promotes self-care in collaboration with both paediatric and adult healthcare providers. After this meeting, patients benefit from an outpatient transition in the endocrinology adult department.

Results: 44 DM teenagers (23 females/21 males) have been successfully transitioned from paediatric to adult care after five meetings of transition from 2012 to 2014 in which 52% of them went accompanied by their mothers The mean age at the onset of their DT1 is 7.5 years with an average paediatric follow up time of 9 years (2–15 years). The mean age during transition is 14.9 years (14–23 years). 13% had a familial DM. 40% have switched to an intensive insulin therapy. Regarding their chronic complications, we noticed no diabetic retinopathy or cardiac disease, two cases of nephropathy and two cases of distal neuropathy. Associated auto-immune diseases are three cases of celiac disease and one case of hypothyroidism. All the teenagers developed a spontaneous puberty. Five teenagers have left their schooling. Those meetings of transition were determinant for 56.5% of the teenagers who attend them.

Conclusion: We report on the successful implementation of a structured program for adolescents with DM transitioning from paediatric to adult care. Our systematic approach is pioneering in North Africa and appears to provide a structure for ensuring continuity of care and effective transition.

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