White Mary, O'Connell Michele A, Cameron Fergus J
Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Melbourne, VIC, Australia; Department of Paediatric and Adolescent Endocrinology & Diabetes, Monash Children's Hospital, Clayton, VIC, Australia.
Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Melbourne, VIC, Australia.
Lancet Child Adolesc Health. 2017 Dec;1(4):274-283. doi: 10.1016/S2352-4642(17)30089-5. Epub 2017 Oct 5.
Care transition from paediatric to adult services for young adults with type 1 diabetes is frequently associated with decreased attendance at outpatient hospital clinics and increased disengagement from specialist services. We aimed to assess the effect of an appointment-management intervention on clinic attendance and disengagement after transition.
We did a randomised, open-label, controlled trial of patients aged 17-19 years with type 1 diabetes. Participants were recruited from a tertiary paediatric diabetes service at the Royal Children's Hospital (Melbourne, VIC, Australia) and had to be scheduled for transition to adult services at one of eight centres in Melbourne. We randomly assigned participants (1:1), using sequential sealed opaque envelopes, to either appointment management (intervention) or current care (control). The appointment manager acted as the point of contact between intervention group participants and the relevant adult clinics, and provided personalised pre-appointment telephone and short message service (SMS) reminders with automatic rebooking of missed appointments. No contact was initiated with the control group after recruitment, and any self-initiated contact with the investigating team was directed to the participant's previous treating paediatric physician. The intervention continued throughout the trial until at least 12 months of follow-up data were obtained for all participants. We assessed the mean frequency of adult clinic attendance and disengagement from services during 0-12 months after transition (primary outcomes) and 12-24 months after transition (secondary outcomes), analysed by intention to treat. We used regression analyses, adjusted for clinic attendance and glycated haemoglobin concentration pre-transition, to analyse the effect of the intervention. This study is registered with the Australian New Zealand Clinical Trials Registry (number ACTRN12611001012965).
Between Jan 4, 2012, and Dec 31, 2014, we randomly assigned 120 individuals, 60 to the intervention and 60 to control. During 0-12 months after transition, the mean number of clinics attended was 2·3 (SD 1·1) in the intervention group and 2·3 (1·4) in the control group (p=0·84; adjusted β 0·1, SE 0·2, p=0·88); three (6%) of 49 participants in the intervention group and six (11%) of 55 in the control group disengaged from services (p=0·38; adjusted odds ratio [OR] 0·5, 95% CI 0·1-2·3, p=0·36). At 12-24 months post-transition, mean clinic attendance was 2·5 (SD 1·3) in the intervention group and 1·4 (SD 1·8) in the control group (p=0·001; adjusted β 0·9, SE 0·4, p=0·009); two (6%) of 32 in the intervention group and 18 (49%) of 37 in the control group disengaged from services (p=0·001; adjusted OR 0·1, 95% CI 0·1-0·2, p=0·001). Neither the intervention nor pre-transition clinic attendance had an independent effect on glycated haemoglobin after transition.
Appointment management did not increase clinic attendance and did not decrease disengagement with services 0-12 months after transition to adult services, but had a positive effect during 12-24 months after transition.
Australasian Paediatric Endocrine Group and Lilly.
1型糖尿病青少年从儿科服务向成人服务的过渡，常常伴随着门诊医院就诊率下降以及与专科服务的脱离增加。我们旨在评估预约管理干预措施对过渡后门诊就诊率和服务脱离情况的影响。
我们对17 - 19岁的1型糖尿病患者进行了一项随机、开放标签、对照试验。参与者从皇家儿童医院（澳大利亚维多利亚州墨尔本）的三级儿科糖尿病服务机构招募，且必须安排在墨尔本的八个中心之一向成人服务过渡。我们使用连续密封不透明信封将参与者按1:1随机分配至预约管理组（干预组）或常规护理组（对照组）。预约管理员作为干预组参与者与相关成人诊所之间的联络点，并提供个性化的预约前电话和短信服务（SMS）提醒，以及错过预约的自动重新预约服务。招募后未与对照组进行任何主动联系，任何与研究团队的主动联系都引导至参与者之前的儿科主治医生处。干预在整个试验期间持续进行，直至获得所有参与者至少12个月的随访数据。我们评估了过渡后0 - 12个月（主要结局）和12 - 24个月（次要结局）期间成人门诊就诊的平均频率和服务脱离情况，采用意向性分析。我们使用回归分析，对过渡前的门诊就诊率和糖化血红蛋白浓度进行调整，以分析干预的效果。本研究已在澳大利亚新西兰临床试验注册中心注册（注册号ACTRN12611001012965）。
在2012年1月4日至2014年12月31日期间，我们随机分配了120人，60人至干预组，60人至对照组。在过渡后的0 - 12个月期间，干预组的平均门诊就诊次数为2.3次（标准差1.1），对照组为2.3次（1.4）（p = 0.84；调整后的β值0.1，标准误0.2，p = 0.88）；干预组49名参与者中有3人（6%）脱离服务，对照组55名中有6人（11%）脱离服务（p = 0.38；调整后的比值比[OR]0.5，95%置信区间0.1 - 2.3，p = 0.36）。在过渡后12 - 24个月时，干预组的平均门诊就诊次数为2.5次（标准差1.3），对照组为1.4次（标准差1.8）（p = 0.001；调整后的β值0.9，标准误0.4，p = 0.009）；干预组32名中有2人（6%）脱离服务，对照组37名中有18人（49%）脱离服务（p = 0.001；调整后的OR值0.1，95%置信区间0.1 - 0.2，p = 0.001）。过渡后，干预措施和过渡前的门诊就诊率对糖化血红蛋白均无独立影响。
预约管理在向成人服务过渡后的0 - 12个月内未增加门诊就诊率，也未减少服务脱离情况，但在过渡后的12 - 24个月内有积极影响。
澳大利亚和新西兰儿科内分泌学会及礼来公司。
