Comparing outpatient and inpatient diabetes education for newly diagnosed pediatric patients

Assessment of a new home-based care pathway for children newly diagnosed with type 1 diabetes

AIM

To compare the outcomes of home-based and conventional hospital-based care for children newly diagnosed with type 1 diabetes mellitus.

METHODS

A descriptive study was conducted of all children newly diagnosed with diabetes mellitus at the Timone Hospital in Marseille, France, between November 2017 and July 2019. The patients received either home-based or in-patient hospital care. The primary outcome was the length of initial hospital stay. The secondary outcome measures were glycemic control in the first year of treatment, families' diabetes knowledge, the effect of diabetes on quality of life, and overall quality of care.

RESULTS

A total of 85 patients were included, 37 in the home-based care group and 48 in the in-patient care group. The initial length of hospital stay was 6 days in the home-based care group versus 9 days in the in-patient care group. Levels of glycemic control, diabetes knowledge and quality of care were comparable in the two groups despite a higher rate of socioeconomic deprivation in the home-based care group.

CONCLUSION

Home-based care for children with diabetes is safe and effective. This new healthcare pathway provides good overall social care, especially for socioeconomically deprived families.

Diabetes education in pediatrics: How to survive diabetes

Diabetes mellitus is the most common abnormal carbohydrate metabolism disorder affecting millions of people worldwide. It is characterized by hyperglycemia as a result of ß-cell destruction or dysfunction by both genetic and environmental factors. Over time chronic hyperglycemia leads to microvascular (i.e., retinopathy, nephropathy and neuropathy) and macrovascular (i.e., ischemic heart disease, peripheral vascular disease, and cerebrovascular disease) complications of diabetes. Diabetes complication trials showed the importance of achieving near-normal glycemic control to prevent and/or reduce diabetes-related morbidity and mortality. There is a staggering rate of increased incidence of diabetes in youth, raising concerns for future generations' health, quality of life and its enormous economic burden. Despite advancements in the technology, diabetes management remains cumbersome. Training individuals with diabetes to gain life-long survival skills requires a comprehensive and ongoing diabetes education by a multidisciplinary team. Diabetes education and training start at the time of diagnosis of diabetes and should be continuous throughout the course of disease. The goal is to empower the individuals and families to gain diabetes self-management skills. Diabetes education must be individualized depending on the individual's age, education, family dynamics, and support. In this article, we review the history of diabetes, etiopathogenesis and clinical presentation of both type 1 and type 2 diabetes in children as well as adolescents. We then focus on diabetes management with education methods and materials.

Designing and implementing an outpatient management pathway for patients with newly diagnosed insulin-dependent diabetes mellitus

OBJECTIVE

Recently, our team transitioned to an outpatient diabetes education model for patients with newly diagnosed insulin-dependent diabetes mellitus (IDDM) after concerns arose regarding inconsistent education provided in the hospital, as well as additional emotional stress attributed to hospitalization. To optimize this model, an improvement initiative was implemented to redesign the outpatient care processes, refine patient education content and identify ideal educational strategies. Specific aims were to (a) achieve family self-management, (b) reduce stress and (c) ensure family and provider satisfaction with the outpatient pathway.

RESEARCH DESIGN AND METHODS

Using a multidisciplinary team and formal quality improvement (QI) methods, we redesigned content and format of the pathway based on results from key measures and Plan-Do-Study-Act (PDSA) cycles. Primary outcome measures included self-efficacy, stress and satisfaction.

RESULTS

We achieved our goal self-management skills, while maintaining high satisfaction for patients and providers throughout the implementation and refinement of the pathway. Key pathway components include refined education content, interactive educational tools and close collaboration with social work. Multiple PDSA cycles and pathway modifications were completed, including early social work involvement and simplification of education resources; however, we found modifying the stress experienced by parents to be a challenge. The majority of the stress relates to factors that are difficult to modify, specifically emotional burden and interpersonal distress, and is rarely attributed to regimen- or physician-related distress.

CONCLUSION

During the transition to an outpatient pathway, we achieved our satisfaction and self-management goals but were unsuccessful in achieving our goals for minimizing stress associated with a new diagnosis of a chronic illness.

Hospital admission in children and adolescents with or without type 1 diabetes from Germany: An analysis of statutory health insurance data on 12 million subjects

OBJECTIVE

To compare the chance of hospital admissions in children and adolescents with type 1 diabetes (T1D) to that without T1D from Germany.

METHODS

Data were provided by the German information system for health care data which contains information on all patients with a statutory health insurance. The years 2009 and 2011 were considered. Children and adolescents (0 to ≤19 years of age; n = 12 030 242) were included. Unadjusted odds ratios (ORs) with 95% confidence interval (95% CI) were used to compare the hospitalization rate for patients with (n = 26 444) or without T1D (12 003 798). T1D was identified by documented insulin treatment and by ICD-code E10/14. Results were stratified by age-group (0-5; >5-10; >10-15, >15-19 years) and gender.

RESULTS

In all age-groups, the hospitalization chance in patients with T1D was higher compared to that of their peers (database 2011). The highest OR was observed in >5 to 10-year-old patients (OR 8.1; 95% CI: 7.7-8.5), followed by patients >10 to 15 years (OR 7.4; 95% CI: 7.1-7.7) and patients ≤5 years (OR 5.3; 95% CI: 4.8-5.7). The lowest OR was present in patients >15 to 19 years (OR 4.0; 95% CI: 3.9-4.2). Overall, OR for hospital admission were higher in girls with T1D compared to boys. The most frequent reasons for hospitalization in T1D were "T1D without complications" (68.4%) and "T1D with ketoacidosis" (18.6%).

CONCLUSIONS

Children and adolescents with T1D in Germany had a 4 to 8 times higher hospitalization chance compared to children without T1D. The OR in T1D patients compared to peers were higher in girls than in boys. High rates of elective hospital admission in Germany may contribute to these results.

Home-based vs inpatient education for children newly diagnosed with type 1 diabetes

BACKGROUND

Initial management of children diagnosed with type 1 diabetes (T1D) varies worldwide with sparse high quality evidence regarding the impact of different models of care.

AIM

To compare the inpatient model of care with a hybrid home-based alternative, examining metabolic and psychosocial outcomes, diabetes knowledge, length of stay, and patient satisfaction.

SUBJECTS AND METHODS

The study design was a randomized-controlled trial. Inclusion criteria were: newly diagnosed T1D, aged 3 to 16 years, living within approximately 1 hour of the hospital, English-speaking, access to transport, absence of significant medical or psychosocial comorbidity. Patients were randomized to standard care with a 5 to 6 day initial inpatient stay or discharge after 2 days for home-based management. All patients received practical skills training in the first 48 hours. The intervention group was visited twice/day by a nurse for 2 days to assist with injections, then a multi-disciplinary team made 3 home visits over 2 weeks to complete education. Patients were followed up for 12 months. Clinical outcomes included HbA1c, hypoglycemia, and diabetes-related readmissions. Surveys measured patient satisfaction, diabetes knowledge, family impact, and quality of life.

RESULTS

Fifty patients were recruited, 25 to each group. There were no differences in medical or psychosocial outcomes or diabetes knowledge. Average length of admission was 1.9 days shorter for the intervention group. Families indicated that with hindsight, most would choose home- over hospital-based management.

CONCLUSIONS

With adequate support, children newly diagnosed with T1D can be safely managed at home following practical skills training.

Cost-effectiveness and cost-utility analyses of hospital-based home care compared to hospital-based care for children diagnosed with type 1 diabetes; a randomised controlled trial; results after two years' follow-up

Background

Practices regarding hospitalisation of children at diagnosis of type 1 diabetes vary both within countries and internationally, and high-quality evidence of best practice is scarce. The objective of this study was to close some of the gaps in evidence by comparing two alternative regimens for children diagnosed with type 1 diabetes: hospital-based care and hospital-based home care (HBHC), referring to specialist care in a home-based setting.

Methods

A randomised controlled trial, including 60 children aged 3–15 years, took place at a university hospital in Sweden. When the children were medically stable, they were randomised to either the traditional, hospital-based care or to HBHC.

Results

Two years after diagnosis there were no differences in HbA1c (p = 0.777), in episodes of severe hypoglycaemia (p = 0.167), or in insulin U/kg/24 h (p = 0.269). Over 24 months, there were no statistically significant differences between groups in how parents’ reported the impact of paediatric chronic health condition on family (p = 0.138) or in parents’ self-reported health-related quality of life (p = 0.067). However, there was a statistically significant difference regarding healthcare satisfaction, favouring HBHC (p = 0.002). In total, healthcare costs (direct costs) were significantly lower in the HBHC group but no statistically significant difference between the two groups in estimated lost production (indirect costs) for the family as a whole. Whereas mothers had a significantly lower value of lost production, when their children were treated within the HBHC regime, fathers had a higher, but not a significantly higher value. The results indicate that HBHC might be a cost-effective strategy in a healthcare sector perspective. When using the wider societal perspective, no difference in cost effectiveness or cost utility was found.

Conclusions

Overall, there are only a few, well-designed and controlled studies that compare hospital care to different models of home care. The results of this study provide empirical support for the safety and feasibility of HBHC when a child is diagnosed with type 1 diabetes. Our results further indicate that the model of care may have an impact on families’ daily living, not only during the initial period of care but for a longer period of time.

Trial registration

ClinicalTrials.gov with identity number NCT00804232, December 2008.

Healthcare cost of type 1 diabetes mellitus in new-onset children in a hospital compared to an outpatient setting

Background

Type 1 diabetes is among the most prevalent chronic childhood diseases in the US. Initial type 1 diabetes management education and care can take place in different clinical settings. This study assessed metabolic outcomes (i.e. hemoglobin A1C), healthcare utilization and costs among new-onset type 1 diabetic children who received initial diabetes education and care in a hospital compared to those children in an outpatient pediatric endocrinology clinic.

Methods

A retrospective cross-sectional study was conducted from the payer’s perspective. New-onset type 1 diabetic children, aged 1–18, presented at Baystate Children’s Hospital (Massachusetts) from 2008–2009 were included in the study if lab test confirmed diagnosis and there was one year of follow-up. Inpatients spent at least one night in the hospital during a 10-day diagnosis period and received all or part of diabetes education there. Outpatients were diagnosed and received all diabetes education in a pediatric endocrinology clinic. Metabolic outcomes were measured at diagnosis and at one year post-diagnosis. Healthcare charges and electronic medical records data were reviewed from 2008–2010. Healthcare costs components included diagnostic test, pediatric, endocrinology and hospitalists care, critical and emergency care, type 1 diabetes related supplies, prescription drugs, and IV products.

Results

Study sample included 84 patients (33 inpatient and 51 outpatients). No statistically significant differences in patient demographic characteristics were found between groups. There were no statistically significant differences in metabolic outcomes between groups. Total cost at one year post-diagnosis per new-onset type 1 diabetic child was $12,332 and $5,053 in the inpatient and outpatient groups, respectively. The average healthcare cost for pediatric endocrinology care was $4,080 and $3,904 per child in the inpatient and outpatient groups, respectively.

Conclusion

Provision of initial type 1 diabetes education and care to new-onset non-critically ill children in a hospital setting increases healthcare costs without improving patient’s glycemic control in the first year post-diagnosis.

Long-term glycemic control as a result of initial education for children with new onset type 1 diabetes: does the setting matter?

PURPOSE

The purpose of this study was to examine the role of initial diabetes education delivery at an academic medical center (AMC) versus non-AMCs on long-term glycemic control.

METHODS

We performed a retrospective study of children with type 1 diabetes referred to an AMC after being educated at non-AMCs. These children were matched to a group of children diagnosed and educated as inpatients at an AMC. The A1C levels at 2, 3, and 5 years from diagnosis were compared between the 2 groups of children.

RESULTS

Records were identified from 138 children. Glycemic control was comparable in the non-AMC-educated versus AMC-educated patients at 2, 3, and 5 years from diagnosis. The A1C was also highly consistent in each patient over time.

CONCLUSIONS

Long-term glycemic control was independent of whether initial education was delivered at an AMC or non-AMC. Formal education and location at time of diagnosis do not appear to play a significant role in long-term glycemic control. Novel educational constructs, focusing on developmental stages of childhood and reeducation over time, are likely more important than education at time of diagnosis.

Diabetes education in hospitalized children: developmental and situational concerns

When a child is diagnosed with diabetes and admitted to the pediatric intensive care unit for metabolic stabilization, there is little time to provide survival skills and education, much less support the family through the impact of the diagnosis. Yet, critical care nurses can begin the family's adaptation and recovery. This article explores the educational and support needs of the newly diagnosed child and the child who is admitted repeatedly. A model of survival topics is presented and the role of the critical care nurse is emphasized with tips for returning the family to a new normal.

A Methodological Description of a Randomised Controlled Trial Comparing Hospital-Based Care and Hospital-Based Home Care when a Child is Newly Diagnosed with Type 1 Diabetes

AIM AND OBJECTIVE

To describe the study design of a randomised controlled trial with the aim of comparing two different regimes for children with newly diagnosed type 1 diabetes; hospital-based care and hospital-based home care.

BACKGROUND

Procedures for hospital admission and sojourn in connection with diagnose vary greatly worldwide and the existing evidence is insufficient to allow for any conclusive determination of whether hospital-based or home-based care is the best alternative for most families. Comparative studies with adequate power and outcome measurements, as well as measurements of cost-effectiveness are needed.

DESIGN

The study design was based on the Medical Research Council framework for complex interventions. After two to three days with hospital-based care, children between the ages of 3 and 16 were randomised to receive either continued hospital-based care for a total of 1-2 weeks or hospital-based home care, which refers to specialist care in a home-based setting. The trial started in March 2008 at a University Hospital in Sweden and was closed in September 2011 when a sufficient number of children according to power calculation, were included. The primary outcome was the child's metabolic control during the following two years. Secondary outcomes were set to evaluate the family and child situation as well as the organisation of care.

DISCUSSION

Childhood diabetes requires families and children to learn to perform multiple daily tasks. Even though intervention in health care is complex with several interacting components entailing practical and methodological difficulties, there is nonetheless, a need for randomised controlled trials in order to evaluate and develop better systems for the learning processes of families that can lead to long-term improvement in adherence and outcome.

TRIAL REGISTRATION

Trial Register NCT00804232.

Routine hospital admission versus out-patient or home care in children at diagnosis of type 1 diabetes mellitus

BACKGROUND

In many places, children newly diagnosed with type 1 diabetes mellitus are admitted to hospital for metabolic stabilisation and training, even if they are not acutely ill. Out-patient or home based management of these children could avoid the stress associated with a hospital stay, could provide a more natural learning environment for the child and its family, and might reduce costs for both the health care system and the families.

OBJECTIVES

To assess the effects of routine hospital admission compared to out-patient or home-based management in children newly diagnosed with type 1 diabetes mellitus.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, and the British Nursing Index. Additionally, we searched reference lists of relevant studies identified and contacted one of the trialists about further studies.

SELECTION CRITERIA

Comparative studies of initial hospitalisation compared to home-based and/or out-patient management in children with newly diagnosed type 1 diabetes.

DATA COLLECTION AND ANALYSIS

Studies were independently selected by two reviewers. Data extraction and quality assessment of trials were done independently by two reviewers. Authors of included studies were contacted for missing information. Results were summarised descriptively, using tables and text.

MAIN RESULTS

Seven studies were included in the review, including a total of 298 children in the out-patient/home group. The one high quality trial identified suggested that home-based management of children with newly diagnosed type 1 diabetes may lead to slightly improved long term metabolic control (at two and three years follow-up). No differences between comparison groups were found in any of the psychosocial and behavioural variables assessed or in rates of acute diabetic complications within two years. Parental costs were found to be decreased, while health system costs were increased, leaving total social costs virtually unchanged. None of the other studies assessing metabolic control found a difference between the comparison groups. There seemed to be no differences in hospitalisations or acute diabetic complications between the out-patient/home groups and the hospital groups.

AUTHORS' CONCLUSIONS

Due to the generally low quality or limited applicability of the studies identified, the results of this review are inconclusive. On the whole, the data seem to suggest that where adequate out-patient/home management of type 1 diabetes in children at diagnosis can be provided, this does not lead to any disadvantages in terms of metabolic control, acute diabetic complications and hospitalisations, psychosocial variables and behaviour, or total costs.

Feasibility test of a shared care network for children with type 1 diabetes mellitus

PURPOSE

The purpose of this feasibility study was to examine primary care pediatricians and a diabetes specialty team sharing the care of children with type 1 diabetes in a structured network.

METHODS

A diabetes specialty team and 3 pediatric practice groups participated in training and shared care of patients with type 1 diabetes. The diabetes team-consisting of 1 pediatric endocrinologist, 2 nurses in advanced practice, and 1 master's-prepared registered dietitian-initiated therapy and self-management training for families; pediatricians implemented maintenance therapy. Role definitions, specially developed records, and a communication framework guided the interaction of providers. Satisfaction of families and pediatricians was assessed by questionnaire. The A1C level was used to assess patients' metabolic control.

RESULTS

Twenty-nine patients accepted pediatrician referral, 25 kept initial training sessions, and 20 completed at least 1 year in the network. All 24 invited pediatricians participated, and 17 enrolled patients. All families who completed satisfaction surveys were highly satisfied with the network. Nineteen pediatricians completed end-of-study questions and were also highly positive about sharing care with the specialty team. The mean A1C value was near target levels or better the first year, and it rose during the second year.

CONCLUSIONS

The study supports the feasibility of integrating general pediatrician and diabetes specialty services for children with type 1 diabetes. Larger studies are justified to assess the efficacy and effectiveness of shared care.

Psycho-educational interventions for children and young people with Type 1 diabetes

BACKGROUND

A systematic review of the literature in 2000 revealed numerous methodological shortcomings in education research, but in recent years progress has been made in the quantity and quality of psycho-educational intervention studies.

SUMMARY OF CONTENTS

This review focuses on diabetes education programmes developed for children, young people and their families in the past 5 years. A comprehensive review of the literature identified 27 articles describing the evaluation of 24 psycho-educational interventions. Data summary tables compare the key features of these, and comparisons are made between individual, group and family-based interventions. Effect sizes are calculated for nine of the randomized studies. Three research questions are posed: firstly has the recent literature addressed the problems highlighted in the previous review; secondly is there sufficient evidence to recommend adaptation of a particular programme; and, finally, what do we still need to do?

CONCLUSIONS

Progress in the quality and quantity of educational research has not resulted in improved effectiveness of interventions. There is still insufficient evidence to recommend adaptation of a particular educational programme and no programme that has been proven effective in randomized studies for those with poor glycaemic control. To develop a range of effective educational interventions, further research involving larger sample sizes with multicentre collaboration is required.

Measuring diabetes self-care: a psychometric analysis of the Self-Care Inventory-Revised with adults

OBJECTIVE

To examine psychometric properties of the Self-Care Inventory-revised (SCI-R), a self-report measure of perceived adherence to diabetes self-care recommendations, among adults with diabetes.

RESEARCH DESIGN AND METHODS

We used three data sets of adult type 1 and type 2 diabetic patients to examine psychometric properties of the SCI-R. Principal component and factor analyses examined whether a general factor or common factors were present. Associations with measures of theoretically related concepts were examined to assess SCI-R concurrent and convergent validity. Internal reliability coefficients were calculated. Responsiveness was assessed using paired t tests, effect size, and Guyatt's statistic for type 1 patients who completed psychoeducation.

RESULTS

Principal component and factor analyses identified a general factor but no consistent common factors. Internal consistency of the SCI-R was alpha = 0.87. Correlation with a measure of frequency of diabetes self-care behaviors was r = 0.63, providing evidence for SCI-R concurrent validity. The SCI-R correlated with diabetes-related distress (r = -0.36), self-esteem (r = 0.25), self-efficacy (r = 0.47), depression (r = -0.22), anxiety (r = -0.24), and HbA(1c) (r = -0.37), supporting construct validity. Responsiveness analyses showed SCI-R scores improved with diabetes psychoeducation with a medium effect size of 0.62 and a Guyatt's statistic of 0.85.

CONCLUSIONS

The SCI-R is a brief, psychometrically sound measure of perceptions of adherence to recommended diabetes self-care behaviors of adults with type 1 or type 2 diabetes.

Routine hospital admission versus out-patient or home care in children at diagnosis of type 1 diabetes mellitus

BACKGROUND

In many places, children newly diagnosed with type 1 diabetes mellitus are admitted to hospital for metabolic stabilisation and training, even if they are not acutely ill. Out-patient or home based management of these children could avoid the stress associated with a hospital stay, could provide a more natural learning environment for the child and its family, and might reduce costs for both the health care system and the families.

OBJECTIVES

To assess the effects of routine hospital admission compared to out-patient or home-based management in children newly diagnosed with type 1 diabetes who are not acutely ill, on metabolic control, wellbeing and self-efficacy of the patient and his/her family.

SEARCH STRATEGY

We searched the Cochrane Library (including the Cochrane Controlled Trials Register), Medline, Embase, Cinahl, and the British Nursing Index. Additionally, we searched reference lists of relevant studies identified and contacted one of the trialists about further studies. Date of latest search: February 2003.

SELECTION CRITERIA

Comparative studies of initial hospitalisation compared to home-based and/or out-patient management in children with newly diagnosed type 1 diabetes.

DATA COLLECTION AND ANALYSIS

Studies were independently selected by two reviewers. Data extraction and quality assessment of trials were done independently by two reviewers. Any differences in opinion were resolved by discussion. Authors of included studies were contacted for missing information. Results were summarised descriptively, using tables and text.

MAIN RESULTS

Six studies were included in the review, including a total of 237 children in the out-patient/home group. Two studies were randomised controlled trials, three were retrospective cohort studies, and one was a prospective cohort study. Except for one randomised controlled trial that included children in the intervention group who were initially hospitalised for a brief period, studies were of low quality. The one high quality trial identified suggested that home-based management of children with newly diagnosed type 1 diabetes may lead to slightly improved long term metabolic control (at two and three years follow-up). No differences between comparison groups were found in any of the psychosocial and behavioural variables assessed or in rates of acute diabetic complications within two years. Parental costs were found to be decreased, while health system costs were increased, leaving total social costs virtually unchanged. None of the other studies assessing metabolic control found a difference between the comparison groups. There seemed to be no differences in hospitalisations or acute diabetic complications between the out-patient/home groups and the hospital groups. Results with respect to psychosocial and behavioural variables were inconclusive, with only one study finding significant results on some selected subscales of tests used. In another study, the out-patient/home group did significantly better on the assessments of treatment adherence, familial relationship and sociability, but upon further analysis this only seemed to apply to selected socioeconomic subgroups, with no clear explanations offered.

REVIEWER'S CONCLUSIONS

Due to the generally low quality or limited applicability of the studies identified, the results of this review are inconclusive. On the whole, the data seem to suggest that out-patient/home management of type 1 diabetes in children at diagnosis does not lead to any disadvantages in terms of metabolic control, acute diabetic complications and hospitalisations, psychosocial variables and behaviour, or total costs. Primary research, ideally a high quality randomised controlled trial, is required.