BMJ  2003;327:260-261 (2 August), doi:10.1136/bmj.327.7409.260

Paper

Retrospective review of care and outcomes in young adults with type 1 diabetes

¹ Queen's Medical Centre, Nottingham NG7 2UH, ² Derbyshire Royal Infirmary, Derby DE1 2QY, ³ Leicester Royal Infirmary, Leicester LE1 5WW, ⁴ Northern General Hospital, Sheffield S5 7AU

Introduction

The national service framework for diabetes includes standards to improve care and outcomes for young people.¹ Good glycaemic control delays the onset and progression of microvascular complications, but control can be difficult to achieve, particularly in young people.²

Participants, methods, and results

We did this study in four of the important centres for the care of people with diabetes—Derbyshire Royal Infirmary; University Hospital, Nottingham; Northern General Hospital, Sheffield; and Leicester Royal Infirmary. Each centre has a dedicated clinic for young people.

We searched for people aged 16 to 25 who were being followed up for type 1 diabetes. We collected data retrospectively from case notes and computer records on glycaemic control, completeness of screening for and prevalence of complications of diabetes, hypertension, and clinic attendance.

Of the 397 patients included, mean HbA_1c concentration was 9.5% (SD 2.0%). (The assay was standardised to that used in the diabetes control and complications trial²; the upper limit of the reference range for people without diabetes is about 6%.) Glycaemic control was similar in 31 patients who had not had a recent measurement of HbA_1c concentration—their mean fructosamine concentration was 404.9 (93.9) µmol/l (reference range 230-280 µmol/l).

Screening rates and the prevalence of complications varied between centres (table). The low prevalence of retinopathy in centre 2 was confirmed by an independent review of case notes.

View this table: [in this window] [in a new window]   Care and outcomes of 16-25 year olds with type 1 diabetes in four centres in Trent, United Kingdom

 

Thirty four patients (15% of those tested) were hypertensive (systolic blood pressure was at least 140 mm Hg or diastolic blood pressure was at least 85 mm Hg). Of these, 24 (71%) had been tested for excretion of protein by the kidneys. Ten (42%) had proteinuria or microalbuminuria and eight of these were taking angiotensin converting enzyme inhibitors.

Comment

For young adults with type 1 diabetes in this study, glycaemic control is generally poor, attendance at the clinic and screening for complications are suboptimal, and microvascular complications are common. Achieving good glycaemic control in youth yields future health, quality of life, and cost benefits but is difficult for many psychological and social reasons. Cooperation between paediatricians and diabetologists should provide a smooth transition of care from childhood to adulthood; many centres have clinics for young adults. Previous studies of young adults in the United kingdom found poor glycaemic control.³ In our study, control was comparable to that of conventionally treated adolescents in the diabetes control and complications trial.²

Some European cohorts have lower mean concentrations of glycated haemoglobin,⁴ perhaps due to structured programmes teaching self management. The dose adjustment for normal eating (DAFNE) programme, based on a programme used in Germany, was a success in the United Kingdom and is being evaluated on a wider scale.⁵

Each 1% fall in HbA_1c concentration leads to an estimated fall of 30% in the risk of microvascular complications.² Patients in our centres are at more risk than patients in centres with lower mean HbA_1c concentrations. Also, the prevalence of complications in our study concerns us. Screening for complications is suboptimal, partly because of poor attendance rates. Young adults may have difficulty complying with traditional clinic systems, and non-attenders are at greatest risk of complications. The attendance rate was highest in the centre that offered appointments in the evening and reminded patients by letter or telephone. All centres in this study had limited resources, with inadequate access to dietetic and psychological services in particular.

We are failing to achieve high standards of care for young adults with diabetes—a problem which is likely to affect the entire United Kingdom. To improve standards of care, we need to evaluate and share outcomes of practice, examine reasons for poor outcomes, and learn from (European) centres that achieve better results.

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We thank K Price, Northern General Hospital, Sheffield, and D Kitchener, Leicester Royal Infirmary, for help with data collection.

Contributors: CJW, AS, MJD, and ADRM collected data. CJW constructed the joint database. All authors prepared the manuscript. AS and PM designed the study. CJW is guarantor.

Funding: No additional funding.

Competing interests: None declared.

References

1. Department of Health. National service framework for diabetes: standards. London: Department of Health, 2001.
2. The diabetes control and complications trial research group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329: 977-86.[Abstract/Free Full Text]
3. Bryden KS, Peveler RC, Stein A, Neil A, Mayou RA, Dunger DB. Psychological course of diabetes from adolescence to young adulthood. Diabetes Care 2001;24: 1536-40.[Abstract/Free Full Text]
4. Dorchy H. What level of HbA1c can be achieved in young diabetic patients beyond the honeymoon period? Diabetes Care 1993;16: 1311-3.
5. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ 2002;325: 746-9.[Abstract/Free Full Text]

(Accepted May 23, 2003)

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