An audit and feedback-based intervention to improve diabetes management in the year after transfer to adult type 1 diabetes care: A multi-center quasi-experimental study

Rayzel Shulman^{1

2

3

4

5

6}, Ian Zenlea^{2

7}, Noah Ivers^{4

6

8

9}, Peter C Austin⁶, Ping Li⁶, Cheril Clarson^{10

11}, Alanna Landry¹², Jennifer Harrington¹³, Geetha Mukerji^{14

15

16}, Mark R Palmert^{1

17}, Janet Parsons^{18

19}, Zubin Punthakee²⁰, Baiju R Shah^{6

16

21}

Affiliations

¹ Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada.
² Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
³ SickKids Research Institute, Toronto, Ontario, Canada.
⁴ Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
⁵ Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada.
⁶ ICES, Toronto, Ontario, Canada.
⁷ Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada.
⁸ Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.
⁹ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
¹⁰ Children's Hospital, London Health Sciences Centre, London, Ontario, Canada.
¹¹ Lawson Health Research Institute, London, Ontario, Canada.
¹² Oak Valley Health, Markham Stouffville Hospital, Markham, Ontario, Canada.
¹³ Division of Endocrinology, Women's and Children's Health Network, University of Adelaide, Adelaide, South Australia, Australia.
¹⁴ Division of Endocrinology, Women's College Hospital, Toronto, Ontario, Canada.
¹⁵ Institute of Health Systems Solutions and Virtual care, Women's College Hospital, Toronto, Ontario, Canada.
¹⁶ Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
¹⁷ Department of Pediatrics and Physiology, University of Toronto, Toronto, Ontario, Canada.
¹⁸ Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
¹⁹ Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.
²⁰ Department of Medicine and Pediatrics, McMaster University, Hamilton, Ontario, Canada.
²¹ Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

PMID: 39473047
PMCID: PMC11635587
DOI: 10.1111/dme.15444

Multicenter Study

An audit and feedback-based intervention to improve diabetes management in the year after transfer to adult type 1 diabetes care: A multi-center quasi-experimental study

Rayzel Shulman et al. Diabet Med. 2025 Jan.

. 2025 Jan;42(1):e15444.

doi: 10.1111/dme.15444. Epub 2024 Oct 29.

Authors

Affiliations

¹ Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada.
² Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
³ SickKids Research Institute, Toronto, Ontario, Canada.
⁴ Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
⁵ Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada.
⁶ ICES, Toronto, Ontario, Canada.
⁷ Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada.
⁸ Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.
⁹ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
¹⁰ Children's Hospital, London Health Sciences Centre, London, Ontario, Canada.
¹¹ Lawson Health Research Institute, London, Ontario, Canada.
¹² Oak Valley Health, Markham Stouffville Hospital, Markham, Ontario, Canada.
¹³ Division of Endocrinology, Women's and Children's Health Network, University of Adelaide, Adelaide, South Australia, Australia.
¹⁴ Division of Endocrinology, Women's College Hospital, Toronto, Ontario, Canada.
¹⁵ Institute of Health Systems Solutions and Virtual care, Women's College Hospital, Toronto, Ontario, Canada.
¹⁶ Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
¹⁷ Department of Pediatrics and Physiology, University of Toronto, Toronto, Ontario, Canada.
¹⁸ Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
¹⁹ Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.
²⁰ Department of Medicine and Pediatrics, McMaster University, Hamilton, Ontario, Canada.
²¹ Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

PMID: 39473047
PMCID: PMC11635587
DOI: 10.1111/dme.15444

Abstract

Aim: To test whether an audit and feedback-based intervention improved HbA1c 12 months after transfer to type 1 diabetes adult care.

Methods: Multi-centre, quasi-experimental pre-post study of an AF-based intervention targeting paediatric diabetes teams, which encouraged the implementation of an evidence-informed structured transition process at five paediatric diabetes centres in Ontario, Canada. Participants entered the study at their final paediatric visit. A parallel control cohort was ascertained using population-based administrative datasets. The primary outcome was HbA1c 12 months after transfer. The main exposure was the study period: pre-implementation (June 2018-May 2019); early-implementation (June 2019-September 2020); and late-implementation (October 2020-September 2021). Multivariable linear regression models were fit separately in each cohort.

Results: There were 449 and 2844 individuals in the intervention and control cohorts, respectively. Twelve months after transfer, participants in the late-implementation intervention cohort had an HbA1c that was, on average, 0.41% lower than participants in the pre-implementation period (p = 0.016). Among the control cohort, there was no significant difference in the HbA1c 12 months after transfer between study periods.

Conclusions: We found an effect of the intervention on glycaemic management one year following transfer to adult care. Future work will focus on refining and testing the effectiveness of the intervention in an expanded number of study sites and in collaboration with adult diabetes care providers.

Keywords: adolescent; health services research; quality improvement; transition to adult care; type 1 diabetes mellitus; young adult.

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Conflict of interest statement

Rayzel Shulman has received speakers and advisory board fees from Dexcom Canada. Ian Zenlea received advisory board fees from Novo Nordisk Canada, Dexcom and Abbot Diabetes Care. Zubin Punthakee has received speakers and advisory board fees from Dexcom, Eli Lilly, NovoNordisk and Sanofi.

Figures

**FIGURE 2**
Summary of significant difference in HbA1c 12 months after final paediatric visit within and between intervention and control cohorts.

See this image and copyright information in PMC

References

1. Lotstein DS, Seid M, Klingensmith G, et al. Transition from pediatric to adult care for youth diagnosed with type 1 diabetes in adolescence. Pediatrics. 2013;131(4):e1062‐e1070. - PMC - PubMed
1. Garvey KC, Wolpert HA, Rhodes ET, et al. Health care transition in patients with type 1 diabetes: young adult experiences and relationship to glycemic control. Diabetes Care. 2012;35(8):1716‐1722. - PMC - PubMed
1. Arnett JJ. Emerging adulthood: a theory of development from the late teens through the twenties. Am Psychol. 2000;55(5):469‐480. - PubMed
1. Garvey KC, Foster NC, Agarwal S, et al. Health care transition preparation and experiences in a U.S. National Sample of Young adults with type 1 diabetes. Diabetes Care. 2017;40(3):317‐324. - PMC - PubMed
1. Nakhla M, Bell LE, Wafa S, Dasgupta K. Improving the transition from pediatric to adult diabetes care: the pediatric care provider's perspective in Quebec, Canada. BMJ Open Diabetes Res Care. 2017;5(1):e000390. - PMC - PubMed

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An audit and feedback-based intervention to improve diabetes management in the year after transfer to adult type 1 diabetes care: A multi-center quasi-experimental study

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An audit and feedback-based intervention to improve diabetes management in the year after transfer to adult type 1 diabetes care: A multi-center quasi-experimental study

Authors

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Conflict of interest statement

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