Lost in transition? Access to and uptake of adult health services and outcomes for young people with type 1 diabetes in regional New South Wales

Objective: To document diabetes health services use and indices of glycaemic management of young people with type 1 diabetes from the time of their first contact with adult services, for those living in regional areas compared with those using city and state capital services, and compared with clinical guideline targets. Design, setting and subjects: Case note audit of 239 young adults aged 18-28 years with type 1 diabetes accessing five adult diabetes services before 30 June 2008 in three geographical regions of New South Wales: the capital (86), a city (79) and a regional area (74). Main outcome measures: Planned (routine monitoring) and unplanned (hospital admissions and emergency department attendance for hypoglycaemia or hyperglycaemia) service contacts; recorded measures of glycated haemoglobin (HbA(1c)), body mass index (BMI), and blood pressure (BP). Results: Routine preventive service uptake during the first year of contact with adult services was significantly higher in the capital and city. Fewer regional area patients had records of complications assessment and measurements of HbA(1c), BMI and BP across all audited years of contact (HbA(1c): 73% v 94% city, 97% capital; P<0.001). Across all years, regional area patients had the highest proportion of HbA(1c) values >8.0% (79% v 62% city, 56% capital) and lowest proportion <7% (4% v 7%, 22%) (both P < 0.001). Fewer young people made unplanned use of acute services for diabetes crisis management in the capital (24% v 49% city, 50% regional area; P<0.001). In the regional area, routine review did not occur reliably even annually, with marked attrition of patients from adult services after the first year of contact. Conclusion: Inadequate routine specialist care, poor diabetes self-management and frequent use of acute services for crisis management, particularly in regional areas, suggest service redesign is needed to encourage young people's engagement. MJA 2010; 193: 444-449