Background:
The management of diabetes in emerging adulthood (19-25 years) can be particularly challenging for the person with diabetes (PWD) and healthcare professional (HCP). For the PWD, these are the years of growing independence, exploration and life-changing experiences. The challenge for the HCP is to continue to engage the PWD with the clinical service, improve clinical outcomes and reduce complications.
In December 2015, the Young Adult Diabetes Clinic underwent a restructure at our hospital. This involved joint clinic appointments with a multi-disciplinary team (doctor, diabetes specialist nurse and dietitian), a clear clinic pathway based on National Institute of Clinical Excellence (NICE) NG17 guidance, the availability of drop-in appointments, use of pre-clinic questionnaires for highlighting areas of concern, and glucometer data download analysis. In addition, a clinic database was created to measure outcomes and provide alerts on impending investigations. Furthermore, the team set-up the first peer-support group for adults with type 1 diabetes in Liverpool.

Aims: 
The aim of this study was to perform a comparative analysis of clinical and demographic data before (2015) and after (2016) the clinic restructure.

Method:
We performed a retrospective, comparative analysis, using information from 2015 and 2016 in the newly created clinic database, regarding:
1.	Population demographics.
2.	Clinic attendance rates.
3.	HbA1c, Albumin-Creatinine ratio (ACR), BMI, Thyroid Stimulating Hormone (TSH).
4.	Hypoglycaemia awareness and frequency of self-reported hypoglycaemia. 
5.	Admission to hospital for diabetic ketoacidosis (DKA) and severe hypoglycaemia (SH).

Results:
123 patients (n=123) were identified from the clinic database (age range 19-25 years). Diabetes diagnosis of all patients included type 1 diabetes (92%), type 2 diabetes (7%) and MODY (1%), with mean duration of diabetes of 13.7 ± 6.6 years. Majority of these patients (85%) were on a basal-bolus insulin regime.
In 2016, 89 patients (versus 76 in 2015) attended appointments and 55% (v. 58%) were female. Additionally, 65% (v. 42%, p=0.001) of patients attended 2 or more clinic appointments and the ‘missed appointment rate’ for the clinic was reduced to 32% (v. 47%, p=0.03). Mean HbA1c for the clinic was 8.9 ± 4.2% (v. 9.1 ± 4.0%) and 25% (v. 14%, p=0.03) of patients had an HbA1c <7.5%. Mean ACR was 2.5mg/mmol (v. 6.5 mg/mmol) and 86% of patients (v. 81%) had an ACR <2.5mg/mmol. Mean BMI was 25.3 ± 4.8 (v. 24.7 ± 4.7) and 20% of the patients (v. 13%) were obese. TSH was checked in 67% patients (v. 43.4%). Admissions rates for DKA and SH in 2016 were 8% (v. 15%, 0.12) and 2% (v. 4%, p=0.40), respectively. 
87% of all patients in the database had hypoglycaemia awareness and majority (82%) reported a hypoglycaemia frequency of up to 5 episodes per month.

Discussion:
Restructuring the young adult clinical service towards a more flexible, patient-centered and multi-disciplinary approach has brought about improvements in the clinic attendance rate, HbA1c, prevalence of microalbuminuria and admission rates of diabetes-related emergencies amongst our clinic cohort. The rising incidence of obesity in this age group is concerning and a sign of a paradigm shift. Further development of the clinic database to include other clinical and demographic parameters for analysis is needed for continuing improvement.

Outcomes before and after the Young Adult Diabetes Clinic restructure at a tertiary hospital in the UK