The Effectiveness of a Structured Transition Programme in Improving Glycaemic Control in Type 1 Diabetes Mellitus

Posted: October 28, 2016

Introduction

The research (PICO) question is: In adolescents and young adults with Type 1 Diabetes, does a structured transition programme result in improved glycaemic control and reduced hospital admissions?

The application of evidence-based practice in the healthcare sector requires an adequate and critical appraisal of studies to ensure only the best interventions or therapies are accepted into practice. Critical appraisal involves a systematic process to recognize strengths and shortcomings of a research article to evaluate the value and validity of its findings. The role of a research consumer entails the critical appraisal of studies (Polit & Beck, 2010). The appraisal process helps determine the implication of a research findings, the merits of the design, and the correctness of implementing the recommendations or findings in nursing practice (Straus, Sackett, & Haynes, 2005). Elliot, Schneider, and Geri (2002) noted that critical appraisal of research articles forms the foundation of quality research because it ensures old quality work are incorporated into the nursing practice. Crombie (2000) noted the research studies should be evaluated in the context of their methodology including the study design and analysis strategies. Additionally,   the statistical procedure should be appropriate for the collected data and the appropriate test carried out (Greenhalgh, 2006) The following section evaluates evidence that supports or refutes the efficacy of a structured transition programme in improving glycaemic control in Type 1 Diabetes Mellitus. The appraisal seeks to identify current practice in the application of structured transition programmes and how such practices can be employed to improve the transition between paediatric diabetes services to adult diabetes services.

Characteristics of the Research Studies

Description of the Studies

The evaluation involves six studies which diverse in place where they were conducted and methodologies. Two of the studies were carried out in USA (Los Angeles and Winthrop University), two in Australia (Sydney and Westmead) with the remaining two being conducted in Spain and Italy each. Only one of the studies used randomized control trial (Steinbeck et al, 2014) while the other used non-randomized designs including prospective, nonrandomized trial (Sequeira et al., 2015), mixed method  (Egan, Corrigan, & Shurping, 2015), and retrospective examination. Steinbeck at al. (2015) recruited 26 participants who received standardized communication assistance at week 1, and three, six and 12 months after discharge from paediatric care. The intervention group was compared with standard clinical practices in which the participants were briefly contacted biannually to confirm their status.

Description of the Interventions

The studies explored various transition interventions and programmes ranging from structured transition, comprehensive transition programme, and therapeutic education programme and structured education programmes. Steinbeck et al. (2015) evaluated the effectiveness of a comprehensive transition programme (CTP) with standard clinical practices. The CTP constituted of comprehensive communication with the patient and unbroken support from a health practitioners. Sequeira et al. (2014) evaluated the effectiveness of a structured transition programme that incorporated specifically tailored diabetes instruction, case management, group meetings and admission to young ADS and diabetes education. Egan, Corrigan and Shurpin (2015) explored the structured transition process comprised of a transition coordinator who reminded the participants of their appointment and made the necessary changes when the participants were unavailable for the appointment. Cadario et al. (2009) integrated two groups, one that followed a structured shift whilst the other followed an unstructured transition process. The structured transition involved a transition plan designed by an endocrinologist at the start of the start of adult diabetes services. Attention was given to foresee or hold-up the transfer to particular conditions such as acute hypegylcaemia. Paediatrics and adult diabetes service coordinators worked together with the parents to ensure the transition was smooth as possible. A similar transition programme was investigated by Holmes-Walker, Llewellyn and Farrell (2006). Holmes-Walker, Llewellyn and Farrell (2006) investigated a transition programme that was tailored to allocate young diabetics as they transferred from PDS to ADS, to adhere to the designed programme including visiting a diabetes specialist, a primary care clinician and a diabetes instructor.  Vidal et al (2004) investigated a specifically designed programme that integrated a therapeutic education programme. The constituent element of the therapeutic education programme included a coordinated transfer visits and a baseline evaluation of the patient. The programme sought to help patients improve their self-management, glycemic management and adherence to physicians’ visits.

Main Clinical Findings

Steinbeck et al. (2015) conducted a randomized controlled trial of after discharge programme to help paediatrics with type 1 diabetes transition from PDS to ADS. Using appointment and retention in the adult services as the primary outcome, and haemoglobin A1c, diabetes-related hospitalization and, global self-worth as the derivative outcome, Steinbeck et al. (2014) reported that CTP impact positively haemoglobin A1c. However, the study reported no noteworthy difference in the retention of patients in adult services. Additionally, the small sample did not allow for the stratification of the randomization by HbA1c. As such, the failure to record any significant difference between CTP and SCP can be attributed to the slow recruitment process that led to a small sample size and skewed representativeness of the target group. Although the study conducted in Australia provided fundamental feasibility data, it was the first randomized control experiment and due challenges in recruitment, it failed to meet recruitment goals thus its results could not be evaluated. Consequently, most of the studies including Sequeira et al. (2014), Egan, Corrigan, and Shurping, (2015), and Cadario et al. (2009) use non-randomized methods.

Structured Transition Programmes with Positive Effect

A prospective, non-randomized, a study and control group, experimental research reported that a structured transition programme facilitates the transition to adult services without decreasing clinical follow-up (Sequeira et al., 2014). Although limits in the follow-up group hampered straightforward comparison of adult care visit with the intervention group, the study indicated that participants in the intervention group had improved glycaemic control (-0.40% vs. 0.42% p=0.01). The structured transition programme that incorporated specifically programmed diabetes education, group education classes, individualized case management and ease access to young ADS and diabetes education also reduced  the episodes of severe hypoglycaemia (0.0% vs. 0.16% p = 0.02) and the well-being of the participants within twelve months of the intervention.  However, it is essential to interpret Sequeira et al. (2014) findings with caution due to the undersized sample size (n = 81), the small follow-up time and lack of randomization. 

However, Egan, Corrigan and Shurpin (2015) reported that the use of a structured programme coupled with appointment and transition facilitator’s support improves observance to follow-up and minimizes diabetes-related stress. The participants participated in 1 or 2 joint visits with the paediatric diabetes educator and the adult educator to discuss the uniqueness of the participants and address identified issues in the follow-up.  The mixed-method prospective, longitudinal investigation that recruited 29 participants, and incorporated parent s’ support, indicated that a structured transition process that involves paediatric and adult diabetes educator, and the parent, reduces diabetes-related stress during the transition and improve the quality of life. The prospective study was conducted at Winthrop University Hospital whose Paediatric Diabetes Programme serves over 1200 diabetic. A Health Care Climate Questionnaire (HCCQ) was used to examine the participants’ perceptions of the extent to which the health care professional support independence while The Diabetes Quality of Life Youth–Short Form (DQOLY-SF) was used to investigate the quality of life during the transition. One of the most interest elements of the intervention is the promotion of coordination involving paediatric and adult service care providers to ensure the success of the transition process. Egan, Corrigan and Shurpin (2015) concluded that the presence of a multidisciplinary team during the cooperative transition appointment was critical to the success of the programme. Additionally, the study incorporated the participation of the parent which contributed to observance of the follow-up. Vidal et al. (2004) had conducted a similar study exploring the effect of a specially programmed transition therapeutic education strategy on self-management, management of glycaemic levels and quality of eighty young type 1 diabetics. The transition programme included a harmonized transfer between paediatric and ADS, and parent involvement. The eight young adults were moved from a paediatric diabetes unit to an ADS clinic during which the participants received education from a multidisciplinary team and routine appointments. Vidal et al (2004) reported that the use of such a multidisciplinary team and coordinated transition process has the capacity to improve metabolic control and self-management with little effects on the quality of life. The study reported that the special transition programme decreased the rate of hypoglycaemic attacks (0.39 vs. 0.14 incidences per year) and improved metabolic control (HbA1c vs 7.4 p<0.0010). A structured transition process is obligatory for a successful transition (Cadario et al., 2009). Cadario et al. (2009) provides one of the few long-term (1994-2004) follow-up retrospective study that investigated participants discharged from paediatric diabetes service. A control group of 32 patients were transferred to an adult diabetes system with an unstructured programme while 30 patients were transferred to a structured programme. Using clinical attendance rate, levels of glycated haemoglobin and the worth of life, the study compared the impact of a structured and an unstructured transition procedure.  An unstructured programme adversely prolonged the transfer process and contributed significantly to failure of the participants to seek medical assistance. Cadario et al. (2009) reported that a structured transition programme improves HbA1c after one year of intervention and clinical attendance. The findings underscore the importance of structured transfer in promote clinic attendance.  However, the results are also limited regarding the sample size but it present fundamental insights on the need to coordinate the transition using a team of multispecialty. Holmes-Walker, Llewelly and Farrel (2006) underscored the importance of attending specialist clinic after the transition. The aim of the research was to examine whether a transition support process for young adults can sustain attendance at a professional clinic. The study of one hundred and ninety-one participants recorded a significant improvement in HbA1c from 9.3% to 8.8% (p<0.001) after five visits to a specialist clinic. Additionally, the attending group had reduced DKA admissions, readmissions and extent of hospital stay.

Structured Transition Programmes not Researched Effective

83% (5 out 6) studies evaluated gave positive evidence on the effectiveness of the structured transition programme. However, the first randomized control trail reported that such studies should be considered with a lot caution due to the small sample sizes, lack of randomization, and limitations in sustaining prolonged follow-up.

Strengths and Limitations of Included Studies:

Macnee and McCabe (2008) noted that it is critical to evaluate the sampling procedure and methodology to understand some common uncertainties in research. Holmes-Walker, Llewelly and Farrel (2006) sampling procedures are non-random and participants are from the same group making the study group highly homogenous. However, the study contribution is essential and the retrospective strategy permitted a long-term study of the participants. Gerrish and Lacey (2010), hold that an optimal research design minimizes bias and anticipates confounding variables. Vidal et al. (2004) minimizes biases by striving to ensure the sample is as representative as possible. However, considering that the sample limitations, the generalization of the findings is limited. Similar to most non-randomized studies, Egan, Corrigan and Shurpin (2015) trial was underpowered due to the small sample and the sample was highly homogenous (from a single diabetes programme). These factors reduce the generalization of the findings and call for future studies that incorporate participants from heterogeneous samples from different socioeconomic backgrounds (LoBiondo-Wood, & Haber, 1994). Grove, Burns, and Gray (2014) noted that randomized controlled trials (RCT) are ideal for evaluating the effectiveness of an intervention or treatment because it limits the prospective for bias. Subjects in such studies are randomized to the treatment and control groups to reduce the selection bias. When these elements are absent, the validity of a study testing the effectiveness of an intervention is reduced and as such, Sequeira et al. (2014) findings should be regarded as highly introductory. Additionally, the admission of research into evidence-based practice requires that a research provides a new approach to an existing problem. As such, the studies need to describe the research question extensively to highlight a gap in knowledge. These studies sought to address a critical issue in the management of one of the commonest chronic diseases.

Conclusion

There is a great importance to ensure an on-going and adequate metabolic control, adherence to clinic attendance, self-management and quality of life during and after the transition from paediatric diabetes services to adult services. As such collaboration between paediatric and adult diabetes service is critical in ensuring the adult diabetes service coordinator has baseline information regarding the uniqueness of each patient. The transition should involve a resolute, planned shift of patients from paediatric to ADS with the aim of maximising health and wellbeing and ensuring adherence to clinical therapies. A derisory transition process may lead o delayed or inapt care, unwarranted emotional stress for the patients and families and inappropriate timing of transfer.  It improves glycaemic control and the number of admissions to hospital due to comorbidities such as ketoacidosis (DKA) and severe hypoglycaemia. It also reduces the chances of readmission and the extent of stay in the hospital. Support from the literature indicates some common themes regarding the characteristics of successfully structured transition processes. First, the programmes incorporated a multidisciplinary team of paediatric and adult diabetes professionals. The most advantageous goal of transition between services is to provide health care that is continuous, harmonized and developmentally suitable. As such, the inclusion and coordination between paediatric and adult diabetic services professionals are critical in ensuring there is continuity of care. Collaboration between these professionals and the incorporation of inputs from other stakeholders has been shown to yield positive results about adherence to clinic attendance.  The collaboration creates a sense of corporation and joint effort which is manifested during the transition. Involving members of the paediatric and adult programmes ensure the delivery of comprehensive and empathetic care to the emerging adult by incorporating the concerns of the paediatric members with ideas of the adult diabetes services. The Cooperation between the practitioners is likely to contribute to the reception of the transition (Egan, Corrigan, & Shurpin, 2015; Sequeira et al., 2014). Secondly, the integration of education and effective communication improved the outcome of the transition process. Comprehensive communication with the patient and continuous support from a health professional improves patients’ glycaemic control and adherence to appointments. 

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