Failure to maintain the benefits of home-based intervention in adolescents with poorly controlled type 1 diabetes

Physicians' Explanatory Models of Pediatric Inflammatory Bowel Disease: A Qualitative Interview Study

Explanatory models are culturally informed representations of illness that convey understandings of the etiology and expected course of disease. Substantial research has explored lay explanatory models, but examining physicians' clinical explanatory models can also provide insight into patients' understandings of illness because physicians are a foundational source of authoritative knowledge that shapes lay concepts of illness and disease. This study characterized the explanatory models used by pediatric gastroenterologists when explaining inflammatory bowel disease (IBD) to children. We conducted semi-structured qualitative interviews with 20 pediatric gastroenterologists across the United States about their clinical communication and explanatory models. We identified two primary explanatory models used to describe immune dysregulation in pediatric IBD: the defense and protection model, which characterizes the immune system as an army that erroneously sees the body as "non-self" and attacks it; and the switch model, which conceptualizes treatment as activating a switch that turns off a faulty immune response. We also identified two models used by some physicians to describe inflammation: the scratch and scrape model, which compares IBD inflammation to scratches or scrapes on the skin; and the bonfire model, which compares inflammation to a fire in need of extinguishing. While the use of militaristic metaphors is pervasive in medicine, describing autoimmunity as a battle against the self may lead children to perceive their body as the enemy. This may be compounded by describing the immune system as "confused" while noting its ongoing protective function. Use of these explanatory models may nevertheless improve patient disease-related knowledge.

The perception of patients, mothers and healthcare professionals regarding introduction of home visits for adolescents with type 1 diabetes

BACKGROUND AND OBJECTIVES

Despite advancements in diabetes management, a subgroup of patients does not achieve an acceptable level of metabolic control. To achieve treatment goals for high-risk patients, a higher frequency of contact with healthcare professionals is essential. However, socioeconomic challenges often lead to nonattendance at the outpatient clinic. Therefore, home visits were introduced as a supplement/an alternative to consultations at the paediatric diabetes clinic. The aim of this study was to uncover the perception of patients, mothers and healthcare professionals regarding home visits versus consultations at the outpatient clinic in order to being able to improve the services offered.

METHODS

Semistructured interviews with patients, mothers and healthcare professionals were conducted to explore the experiences and perspectives of the concept at two paediatric diabetes clinics in Denmark. Paired t tests were used to compare the glycated hemoglobin A1c (HbA1c) levels at the start of the intervention with HbA1c 1 year before and HbA1c at the end of the intervention.

RESULTS

Both patients, mothers and healthcare professionals found consultations in familiar surroundings to result in stronger relationships between healthcare professionals and families, creating greater opportunities to discuss personal issues aimed at improving the outcome of diabetes. Furthermore, home visits facilitated finding alternative methods of helping patients and the families integrating diabetes into everyday life.

CONCLUSION

Overall, home visits were found to contribute toward creating a more constructive relationship. However, it was still a challenge to keep the scheduled appointments, and during this short study, no improvement in metabolic control could be observed.

Comparing the effects of home visits and telenursing on blood glucose control: A systematic review of randomized controlled trials

BACKGROUND

Home visits have often been performed for diabetes management, but with the increased use of the internet and smartphones, people are opting for telenursing as the main method for monitoring and controlling diabetes.

OBJECTIVE

This study compares the effects of home visits and telenursing on diabetes management.

METHODS

Four electronic databases (MEDLINE, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature) were used as data sources. Glycated hemoglobin (HbA1c), fasting blood sugar, and two-hour post-prandial glucose levels were used as outcome measures. A subgroup analysis was performed based on the type of diabetes and follow-up.

RESULTS

Of 1890 studies, 24 (2801 participants) were selected and meta-analyzed. The nursing interventions provided during nursing visits or telenursing mainly included education on diabetes and blood sugar control. It was seen that HbA1c decreased with a weighted mean difference of -0.66 (95 % confidence interval -0.82 to -0.51, p < .001) % in home visits and -0.56 (95 % confidence interval -0.81 to -0.31, p < .001) % in telenursing. The fasting blood sugar reported only in telenursing was reduced by a weighted mean difference of -14.23 (95 % confidence interval 27.59 to -0.88, p = .04) mg/dL and two-hour post-prandial glucose was reduced with a mean difference of -15.84 (95 % confidence interval -24.45 to -7.24, p = .003) mg/dL. Furthermore, low heterogeneity was found among the studies. In a subgroup analysis of diabetes type, HbA1c in home visits was reduced by -0.86 % in type 1 diabetes and -0.62 % in type 2 diabetes, while in telenursing, the reductions were -0.65 % and -0.53 %, respectively. Fasting blood glucose was reduced by -6.08 mg/dL and -18.50 mg/dL, respectively, whereas two-hour postprandial blood sugar was reduced by -14.49 mg/dL and -30.30 mg/dL, respectively, in telenursing. In the subgroup analysis of the follow-up period, HbA1c during home visits decreased by -0.63 % at 10 to 16 weeks, -0.73 % at 24 to 36 weeks, and -0.64 % at 52 weeks or more, while in telenursing, the reductions were -0.80 %, -0.44 %, and -0.07 %, respectively. Home visits were not statistically significant between 10 and 16 weeks, whereas telenursing was not significant at 52 weeks or more.

CONCLUSIONS

Despite telenursing reducing HbA1c slightly less than home visits, evidence from this systematic review suggests that telenursing is a similarly effective approach for controlling blood glucose levels in patients with diabetes. Telenursing is a nursing intervention that can be used as an alternative to home visits for patients requiring diabetes management.

Is there an optimal approach to elective stabilisation of glycaemic control in children and adolescents with type 1 diabetes mellitus?

AIM

To investigate the effectiveness of inpatient and outpatient interventions in attaining improved glycaemic control in children/adolescents with type 1 diabetes mellitus and persistently high/deteriorating HbA1c.

METHODS

A retrospective study at a tertiary paediatric centre. Admitted individuals who had prior attempts at ambulatory stabilisation were matched with intervention naïve controls who underwent outpatient intervention. The mean age was 14.6 years in the admitted group and 14.7 years in the ambulatory group. Mean duration of diabetes was 6.1 years in the admitted group and 7.3 years in the ambulatory group. Change in HbA1c from baseline was assessed to 12 months.

RESULTS

Mean baseline HbA1c was 11.3% (100 mmol/mol), with 11.4% in the admitted group and 11.2% in the ambulatory group. Sustained reduction in HbA1c at 12 months was seen in both groups (n = 35 in each): mean (standard deviation) 10.1% (1.5) in admitted (mean reduction in HbA1c 1.4%) and 9.7% (1.4) in ambulatory (mean reduction in HbA1c 1.5%). Proportions achieving delta HbA1c ≥2% (22 mmol/mol) at 12 months were 25 and 31% in admitted and ambulatory groups, respectively. A sustained reduction in HbA1c of ≥2% (22 mmol/mol) after 12 months was more likely in those who attained this reduction by 6 months (17/24 who achieved this at 6 months vs. 3/41 who had not).

CONCLUSIONS

Both inpatient and outpatient stabilisation strategies achieved sustained improvements in HbA1c. We recommend an individualised approach to stabilisation, with review of the intervention's success at 6 months with further intensification as needed.

The Effectiveness of Conducting Home Visits by Medical Students among Malaysians with Type 2 Diabetes: A Retrospective Analysis

Background

Medical students at the International Medical University (IMU), Seremban, Malaysia were required to assess patients at home over a period of two years as a part of their curriculum. The students conducted six visits to educate their patients and help them utilize available resources to manage their disease.

This study aims to examine whether patients with diabetes visited improve their control of their disease, specifically in terms of their HbA1c measurement.

Methodology

We used a retrospective, matched before and after study design to prevent biased levels of effort by students conducting the home visits over two years. Information was obtained through reports written by IMU students. Convenient sampling was used to select outpatients undergoing treatment ‘as usual’ from a health clinic and were subsequently matched as controls.

Results

There was a significant decrease in the mean HbA1c among 57 patients with diabetes who were CFCS subjects [from 8.4% (68 mmol/mol) to 7.3% (57 mmol/mol) p<0.001], while the mean HbA1c levels among 107 matched control subjects rose significantly from 7.9% (63 mmol/mol) to 8.3% (67 mmol/mol) (p=0.019) over a similar period. The two groups were controlled for most biological and socioeconomic variables except for comorbidities, diabetic complications and medication dose changes between groups.

Conclusion

Behavioural intervention in the form of home visits conducted by medical students is an effective tool with a dual purpose, first as a student educational initiative, and second as a strategy to improve outcomes for patients with diabetes.

Are home visits an effective method for diabetes management? A quantitative systematic review and meta-analysis

AIMS/INTRODUCTION

Previous reviews have revealed uncertainty regarding the effectiveness of home visit interventions for managing diabetes. Therefore, we carried out a quantitative systematic review and meta-analysis to evaluate the effects of home visit interventions among patients with diabetes.

MATERIALS AND METHODS

We searched various electronic databases (PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, Wanfang and Chinese scientific full-text databases) from their inception until March 2016. We included randomized controlled trials that included patients with diabetes, and evaluated the effects of home visit programs on glycated hemoglobin concentrations. Two reviewers independently used the Cochrane Collaboration methods to assess the included studies' risk of bias and quality.

RESULTS

We included seven randomized controlled trials with 686 participants. Compared with the usual care, the home visit group showed a greater reduction in glycated hemoglobin concentrations (mean difference -0.79% [-9 mmol/mol], 95% confidence interval [CI]: -0.93 to -0.25% [11 to -3 mmol/mol]; P < 0.05; I²  = 0%), systolic blood pressure (mean difference -5.94 mmHg, 95% confidence interval -11.34 to -0.54 mmHg) and diastolic blood pressure (mean difference -6.32 mmHg, 95% confidence interval -12.00 to -0.65 mmHg). Furthermore, home visits improved quality of life, high-density lipoprotein, low-density lipoprotein, total triglycerides and self-management. However, there were no significant differences between the two groups in their bodyweight, total cholesterol, body mass index and self-efficacy.

CONCLUSION

Home visits were associated with improved glycemic control and reduced cardiovascular risk factors, which shows that it is an effective method for diabetes management.

Behavioral Programs for Type 1 Diabetes Mellitus: A Systematic Review and Meta-analysis

BACKGROUND

Whether behavioral approaches for self-management programs benefit individuals with type 1 diabetes mellitus is unclear.

PURPOSE

To determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate effect.

DATA SOURCES

6 electronic databases (1993 to June 2015), trial registries and conference proceedings (2011 to 2014), and reference lists.

STUDY SELECTION

36 prospective, controlled studies involving participants of any age group that compared behavioral programs with usual care, active controls, or other programs.

DATA EXTRACTION

One reviewer extracted and another verified data. Two reviewers assessed quality and strength of evidence (SOE).

DATA SYNTHESIS

Moderate SOE showed reduction in glycated hemoglobin (HbA1c) at 6 months after the intervention compared with usual care (mean difference, -0.29 [95% CI, -0.45 to -0.13] percentage points) and compared with active controls (-0.44 [CI, -0.69 to -0.19] percentage points). At the end of the intervention and 12-month follow-up or longer, there were no statistically significant differences in HbA1c (low SOE) for comparisons with usual care or active control. Compared with usual care, generic quality of life at program completion did not differ (moderate SOE). Other outcomes had low or insufficient SOE. Adults appeared to benefit more for glycemic control at program completion (-0.28 [CI, -0.57 to 0.01] percentage points) than did youth (-0.12 [CI, -0.43 to 0.19] percentage points). Program intensity appeared not to influence effectiveness; some individual delivery appears beneficial.

LIMITATIONS

All studies had medium or high risk of bias. There was scarce evidence for many outcomes.

CONCLUSION

Behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up, but improvement for other outcomes has not been shown. (PROSPERO registration number: CRD42014010515).

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERD registration number: CRD42014010515).

Preventing Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a major cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM). This article examines the factors associated with DKA in children with T1DM, both at first presentation and in recurrent cases. The challenge for future research is to find effective ways to improve primary care physician and general community awareness of T1DM to reduce DKA at presentation and develop practical, cost-effective programs to reduce recurrent DKA.

Costs and effects of new professional roles: Evidence from a literature review

One way in which governments are seeking to improve the efficiency of the health care sector is by redesigning health services to contain labour costs. The aim of this study was to investigate the impact of new professional roles on a wide range of health service outcomes and costs. A systematic literature review was performed by searching in different databases for evaluation papers of new professional roles (published 1985-2013). The PRISMA checklist was used to conduct and report the systematic literature review and the EPHPP-Quality Assessment Tool to assess the quality of the studies. Forty-one studies of specialist nurses (SNs) and advanced nurse practitioners (ANPs) were selected for data extraction and analysis. The 25 SN studies evaluated most often quality of life (10 studies), clinical outcomes (8), and costs (8). Significant advantages were seen most frequently regarding health care utilization (in 3 of 3 studies), patient information (5 of 6), and patient satisfaction (4 of 6). The 16 ANP studies evaluated most often patient satisfaction (8), clinical outcomes (5), and costs (5). Significant advantages were seen most frequently regarding clinical outcomes (5 of 5), patient information (3 of 4), and patient satisfaction (5 of 8). Promoting new professional roles may help improve health care delivery and possibly contain costs. Exploring the optimal skill-mix deserves further attention from health care professionals, researchers and policy makers.

How standard is standard care? Exploring control group outcomes in behaviour change interventions for young people with type 1 diabetes

OBJECTIVE

Poor descriptions of standard care may compromise interpretation of results in randomised controlled trials (RCTs) of health interventions. We investigated quality of standard care in RCTs of behaviour change interventions for young people with type 1 diabetes and consider implications for evaluating trial outcomes.

DESIGN

We conducted systematic searches for articles published between 1999 and 2012. We extracted standard care descriptions and contacted trial authors to complete a checklist of standard care activities. The relationship between standard care quality and outcomes was examined via subgroup meta-analyses and meta-regression.

MAIN OUTCOME MEASURES

Standard care descriptions, standard care quality, and relationships between standard care quality with medical and psychological outcomes.

RESULTS

We identified 20 RCTs described across 26 articles. Published descriptions of standard care were limited to service-level features. Author responses indicated standard care provision extended beyond published accounts. Subgroup analyses suggested control groups receiving higher standard care quality showed larger improvements in both medical and psychological outcomes, although standard care quality did not predict outcomes significantly.

CONCLUSION

The quality of care delivered to control group participants can influence outcomes of RCTs. Inadequate reporting exacerbates this issue by masking variations between trials. We argue for increased clarity in reporting standard care in future trials.

Development and validation of a pediatric IBD knowledge inventory device: the IBD-KID

OBJECTIVES

Questionnaires exist to assess inflammatory bowel disease (IBD)-related knowledge of adults. Owing to wording and content concerns, these were believed to be inappropriate for use in pediatric patients. The aim of this study was to develop a questionnaire to assess disease-related knowledge of pediatric patients with IBD and their parents.

METHODS

Following a formal process of item generation and reduction, the IBD-Knowledge Inventory Device was developed and pilot tested. It was administered to 10- to 17-year-old patients with IBD, and to 1 of each of their parents. To evaluate its discriminatory validity, pediatric residents, nurses, and ward clerks completed the questionnaire.

RESULTS

A total of 99 patients (mean 42, Crohn disease 46, age 14(±2) years) and 99 parents completed the IBD-Knowledge Inventory Device. Parent knowledge scores, 15(±4), were higher than those of patients, 11(±4), P < 0.001. Patient and parent knowledge scores were strongly correlated (r = 0.62, P < 0.001). Patient knowledge score was significantly related to disease type (Crohn disease scored higher than ulcerative colitis, P = 0.004) and to perceived knowledge level (P < 0.001) by regression analysis. Similarly, parent knowledge score was significantly related to sex (girls scored higher, P = 0.014), postsecondary education (P < 0.001), and perceived knowledge level (P = 0.002). The questionnaire scores of 23 were 19, 16, and 10, respectively, for residents, nurses, and ward clerks. Both residents and nurses scored significantly higher than ward clerks (P = 0.001 for both).

CONCLUSIONS

A valid IBD-related knowledge assessment questionnaire was developed for use in older children and adolescents with IBD and their parents.

Metabolic control in children and adolescents with insulin-dependent diabetes mellitus at King Abdul-Aziz University Hospital

OBJECTIVE

Preventing long-term diabetic complications requires good metabolic control, especially in type 1 diabetes mellitus (T1DM). We describe the metabolic control of T1DM and the factors affecting it among children and adolescents attending the Pediatric Clinic at King Abdul-Aziz University Hospital.

METHODS

A retrospective cross-sectional study was conducted on T1DM children and adolescents who had attended the Pediatric Clinic at King Abdul-Aziz University Hospital from 2006 to 2010. Both clinical and laboratory data were reviewed for the enrolled cases. The mean age of the patients was 12.5 ± 4.1 years. Ages ranged from 1 to 18 years (n = 484: male = 213, female = 271). 38.6% of the patients were pre-pubertal and 61.4%-- pubertal. The patients were categorized into 3 age groups as 1-6 years (10.3%), 7-12 years (33.5%) and 13-18 years (56.2%).

RESULTS

The overall mean HbA1c was 9.4 ± 2.4% and the duration of patient follow-up was 26 ± 17 months. 10.3% of the patients were on conventional insulin regimens and 89.7%--on intensive insulin therapy. 31.4% had satisfactory HbA1c according to the American Diabetes Association guidelines. The duration of T1DM was 2.9 ± 1.4 years. The patients with diabetes duration ≤ 2 years (45%) had a mean HbA1c of 8.7 ± 1.8% and those with diabetes duration > 2 years (55%) had a mean HbA1c value of 9.8 ± 2.3% (p < 0.001).

CONCLUSIONS

The metabolic control of T1DM children in our cohort was less satisfactory than in other studies. We recommend the promotion of physical exercise and family educational programs to improve the metabolic control of T1DM pediatric patients in our population.

A pilot project for improving paediatric diabetes outcomes using a website: the Pediatric Diabetes Education Portal

We created a website for patients and families that allowed them to review clinic test results, review educational materials related to these results and post questions to their diabetes educator. Fingerstick haemoglobin A(1c) (HbA(1c)) testing and periodic use of a continuous glucose monitoring system (CGMS) were offered to all patients. The HbA(1c) and CGMS results were posted to the website after each clinic visit. A total of 52 patients with type 1 diabetes were enrolled in the study. There were 16 patients with HbA(1c) values within ADA guidelines and 16 with HbA(1c) values above guidelines; 20 patients were excluded for various reasons. Users of the website were defined as families who logged in four or more times over the six-month study period. For patients whose HbA(1c) started above ADA guidelines, the mean HbA(1c) for website users decreased from 10.5% (SD 2.2) at baseline to 9.1% (SD 1.2) after six months. In the non-users, the mean HbA(1c) increased from 9.5% (SD 1.5) at baseline to 10.4% (SD 2.5). However, these changes were not significant. A between groups comparison (users versus non-users) showed a significant improvement in HbA(1c) for website users (P = 0.03). This change in HbA(1c) was clinically relevant. Further studies with more patients are needed to see if these improvements can be sustained over a longer period.

Improving glycaemic control in children and adolescents: which aspects of therapy really matter?

In paediatric diabetes, the concept of intensive therapy in the post-Diabetes Control and Complications Trial period has become subverted by a pharmaco-technological paradigm at the expense of other aspects of care such as goal-setting and psychosocial support. This review examines which patients benefit most from intensive therapy in terms of glycaemic control (HbA1c). It also reviews published controlled trial and observational data relating to the impact of various insulin types and delivery systems on glycaemic control and canvasses the literature dealing with the impact of patient support, philosophy of care, goal setting and treating team dynamic on HbA1c. Taking into account the characteristics of those patients who benefit most from intensive therapy, the quantum of HbA1c change and the persistence of changes that have been reported in selected and non-selected patient groups, it appears that there is a clear hierarchy in aspects of therapy that improve glycaemic control for children and adolescents with Type 1 diabetes. Prime issues appear to be patient support, team cohesion and goal setting. The reported glycaemic benefits achieved by an isolated emphasis upon a pharmaco-technological paradigm are limited in children and adolescents. It appears that only after the prime issues have been first considered will the potential benefits of the insulin types and regimens then be realized.

Using Community-based Participatory Research (CBPR) To Target Health Disparities in Families

Community-based participatory research (CBPR) is an action research approach that emphasizes collaborative partnerships between community members, community organizations, health care providers, and researchers to generate knowledge and solve local problems. Although relatively new to the field of family social science, family and health researchers have been using CBPR for over a decade. This paper will introduce CBPR methods, illustrate the usefulness of CBPR methods in families and health research, describe two CBPR projects related to diabetes, and conclude with lessons learned and strengths and weaknesses of CBPR.

A transition care programme which improves diabetes control and reduces hospital admission rates in young adults with Type 1 diabetes aged 15-25 years

AIMS

To determine if a transition support programme for young adults with diabetes could maintain attendance at a specialist clinic, improve diabetes control and reduce acute hospital admissions with diabetic ketoacidosis (DKA) in 15-25-year-olds with Type 1 diabetes.

METHODS

A transition coordinator/diabetes educator arranged booking and rebooking of appointments for a young adult diabetes clinic based in an adult hospital between July 2001 and March 2006. An after-hours phone support service was initiated. Data collected included source of referral, frequency of clinic attendance and HbA1c at each visit. Numbers of admissions and readmissions with DKA, length of stay and HbA1c on admission were recorded.

RESULTS

One hundred and ninety-one young adults were referred. HbA1c at initial referral was 9.3 +/- 2.17%. HbA1c significantly improved to 8.8 +/- 1.9% (P < 0.001) after a median of five visits with a statistically significant fall in HbA1c of 0.13% per visit (P = 0.01). The greatest improvements were seen in those with starting HbA1c > 11% (-2.5 +/- 2.3%, P < 0.001). Eighty-two percent had attended appointments in the last 6 months. There was a significant reduction in DKA admissions falling by 1/3 (P = 0.05), and in readmissions a significant reduction in length of stay (-3.6 days, P = 0.02), over 3.5 years.

CONCLUSIONS

If young adults are appropriately supported in adult services, clinic attendance is maintained, diabetes control is improved and hospital admission rates with DKA are reduced. The cost savings from reduced admissions covered the costs of the programme.

A randomized controlled trial of telephone calls to young patients with poorly controlled type 1 diabetes

OBJECTIVE

To determine if scheduled telephone calls from a pediatric diabetes educator to children who have type 1 diabetes improve hemoglobin A1c (HbA1c) level, hospital admissions, diabetes knowledge, compliance, and psychological well-being.

RESEARCH DESIGN AND METHODS

A randomized controlled trial of 123 young subjects (mean age 11.9 yr, 69 male) with type 1 diabetes (mean duration 3.65 yr). For 7 months, the intervention group held bimonthly 15-30 min scheduled supportive telephone discussions. The primary outcome was change in the HbA1c level. Admission rates and changes in diabetes knowledge, psychological parameters, compliance, and patient perception were measured.

RESULTS

There was no significant difference between the treatment and control groups either before or after the intervention. The mean HbA1c level in the control group increased from 8.32 to 8.82% and in the intervention group from 8.15 to 8.85% (p = 0.24). Both groups showed an increase in admissions of 0.2 per yr (p = 0.57). There was no improvement in diabetes knowledge (p = 0.34), compliance, or psychological function. The intervention group viewed their contact with the clinic as more helpful (p = 0.003). Analysis of family function did not reveal subgroups with statistically significant differences. A mean of 13 calls was made to each subject at a cost of 36 Australian dollars per child per month.

CONCLUSIONS

Scheduled bimonthly phone support does not improve the HbA1c level, admission rates, diabetes knowledge, psychological function, or self-management but is perceived by patients as helpful. Further study into the effects of more frequent but shorter periods of support for patients experiencing specific difficulties is needed.

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.

Insulin pump therapy in youth with type 1 diabetes: a retrospective paired study

OBJECTIVE

To compare by age and glycemic control continuous subcutaneous insulin infusion with multiple daily injections in youth with type 1 diabetes.

METHODS

The files of 279 patients who had type 1 diabetes and switched from multiple daily injections to continuous subcutaneous insulin infusion between 1998 and 2003 were reviewed for glycemic control, body mass index standard deviation score, and adverse events. Patients were divided by age as follows: 23 prepubertal (median age: 5.4; range: 1.6-8.6 years), 127 adolescent (median age: 13.7; range 9-17 years), and 129 young adult (median age: 22.8; range: 17-40 years). The data were compared between the 12 months of multiple daily injections that preceded continuous subcutaneous insulin infusion and the period after the start of continuous subcutaneous insulin infusion for the whole cohort and by age group.

RESULTS

A significant decrease in hemoglobin A1c was demonstrated after the start of continuous subcutaneous insulin infusion use for the entire cohort (-0.51%) and for the prepubertal (-0.48%), adolescent (-0.26%), and young adult (-0.76%) groups. There was a significant interaction between the change in hemoglobin A1c level and hemoglobin A1c value at initiation of pump therapy (-1.7% for patients with hemoglobin A1c > or = 10%; 0.2% for patients with hemoglobin A1c < or = 7%). The rate of severe hypoglycemic episodes decreased significantly in the adolescent group, from 36.5 to 11.1 events per 100 patient-years, and in the young adult group, from 58.1 to 23.3. There was no significant change in the rate of diabetic ketoacidosis between the 2 periods. The young adults showed a significant decrease in body mass index standard deviation scores (-0.08 +/- 0.37).

CONCLUSIONS

Continuous subcutaneous insulin infusion improves glycemic control in youth with type 1 diabetes, especially in those with a history of poor glycemic control. This improvement is associated with a decrease in the rate of severe hypoglycemia in the absence of weight gain.

Reinforced follow-up for children and adolescents with type 1 diabetes and inadequate glycaemic control: a randomized controlled trial intervention via the local pharmacist and telecare

AIM

To evaluate the effectiveness and feasibility of reinforced follow-up via telecare mediated by the local pharmacist in contact with the hospital team to improve glycaemic control in children and adolescents with type 1 diabetes (DT1).

METHODS

One hundred patients, aged 8 to 17 years, with a history of DT1 of more than 1 year, with HbA(1c) >=8%, were randomly assigned to either the "reinforced follow-up" group (RFG) or the "usual follow-up" group (UFG). The intervention consisted in downloading and then printing data stored in a glucometer every two weeks, by the local pharmacist. Printouts were faxed to the hospital team which then communicated adapted instructions for better glycemic control directly to the family.

RESULTS

Fifty patients were assigned to each group. The two groups were comparable at the beginning. 71 children had a doctor's visit at 6 +/- 1 months (36 in RFG and 35 in UFG). At this date, there was no significant difference between the average HbA(1c) levels of the two groups (9.12 +/- 1.46 in RFG versus 9.27 +/- 1.20 in UFG). We had various difficulties setting up and gaining compliance with the intervention procedure, which explains why only 33 children in the RFG transmitted at least one fax.

CONCLUSION

At this stage, the reinforced follow-up has not proved to be superior to the usual follow-up. However, it would be possible to make numerous improvements in order to make the former more feasible and probably more efficient.

Glycemic Relapse in Type 2 Diabetes

OBJECTIVE

To characterize the occurrence of glycemic relapse after initial improvement in blood glucose levels and to describe predictors of relapse in patients with type 2 diabetes.

METHODS

Occurrence of glycemic relapse was analyzed in 393 consecutive patients with type 2 diabetes after participation in a 3-month intensive outpatient intervention. All patients had hemoglobin A1c (A1C) values (3)7% before the intervention and had achieved adequate glycemic control (nadir A1C<7%) afterward. The median follow-up time was 26.5 months. Relapse was defined as a subsequent increase in A1C to (3)7%.

RESULTS

The probability of glycemic relapse was 45% at 1 year after the intervention and was 76% at 3 years. The median time to relapse was 15.2 months. Cox multivariate regression analysis indicated that treatment with insulin was associated with a greater risk of relapse-- hazard ratio=1.5 (95% confidence interval, 1.1 to 2.2), after controlling for the patient's age, sex, race, body mass index, duration of diabetes, weight change during the intervention, and nadir A1C value. Among those patients not treated with insulin at the end of the intervention, a shorter duration of diabetes and weight loss during the intervention period were significantly associated with decreased risk of relapse.

CONCLUSION

The majority of study patients with type 2 diabetes who attained satisfactory glycemic control after intensive outpatient intervention had a relapse after the end of the intervention period. Patients receiving insulin therapy were at particular risk of glycemic relapse. Therefore, such patients should receive high priority for continuation of intensive care or for other relapse prevention measures.

Social ecological model of illness management in high-risk youths with type 1 diabetes

In this study, the authors tested a social ecological model of illness management in high-risk, urban adolescents with Type 1 diabetes. It was hypothesized that management behaviors would be associated with individual adolescent characteristics as well as family, peer, and provider relationships. Questionnaires were collected from 96 adolescents in poor metabolic control and their primary caregivers. Variables in each system were correlated with illness management. Multiple regression demonstrated that higher externalizing symptoms, poorer family relationships, lower satisfaction with providers, and greater age contributed to the variance in illness management. Internalizing symptoms and peer relationships were no longer significant in the model. Results support a social ecological model of illness management in high-risk youths. Interventions grounded in social ecological theory are discussed.

The psychologic context of pediatric diabetes

During the past few decades, there has been an explosion of behavioral science research on family management of pediatric diabetes. This article distills the major conclusions from that literature, emphasizing how primary care providers can apply these findings in clinical practice.

Use of multisystemic therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control: a randomized controlled trial

OBJECTIVE

The aim of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could improve adherence and metabolic control and decrease rates of hospital utilization among adolescents with chronically poorly controlled type 1 diabetes.

RESEARCH DESIGN AND METHODS

A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and chronically poor metabolic control (HbA(1c) [A1C] > or =8% for the past year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants randomly assigned to MST received treatment for approximately 6 months. Data were collected at baseline and at 7 months posttest (i.e., treatment termination). Changes in A1C adherence, as measured by semistructured interviews and blood glucose meters and hospital admissions and emergency department visits, were assessed.

RESULTS

In intent-to-treat analyses, participation in MST was associated with significant improvements in the frequency of blood glucose testing as assessed by blood glucose meter readings (F[1,125] = 16.75, P = 0.001) and 24-h recall interviews (F[1,125] = 6.70, P = 0.011). Participants in MST also had a decreasing number of inpatient admissions, whereas the number of inpatient admissions increased for control subjects (F[1,125] = 6.25, P = 0.014). Per protocol analyses replicated intent-to-treat analyses but also showed a significant improvement in metabolic control for adolescents receiving MST compared with control subjects (F[1,114] = 4.03, P = 0.047).

CONCLUSIONS

Intensive, home-based psychotherapy improves the frequency of blood glucose testing and metabolic control and decreases inpatient admissions among adolescents with chronically poorly controlled type 1 diabetes.

Pediatric parenting stress among parents of children with type 1 diabetes: the role of self-efficacy, responsibility, and fear

OBJECTIVE

Parents of children with type 1 diabetes are crucial to promoting positive disease adaptation and health outcomes among these youngsters, yet this success may come at some consequence to parents' own well-being. Little research has examined the stress faced by parents, or explored the psychological and behavioral correlates of their stress.

METHODS

One hundred and thirty-four parents of children with type 1 diabetes completed measures of diabetes self-efficacy, responsibility for diabetes management, fear of hypoglycemia, and a recently developed measure of pediatric parenting stress (the Pediatric Inventory for Parents [PIP]; R. Streisand, S. Braniecki, K. P. Tercyak, & A. E. Kazak, 2001).

RESULTS

Bivariate analyses suggest that pediatric parenting stress is multifaceted; the frequency of parenting stress is negatively related to child age and family socioeconomic status and positively related to single parent status and regimen status (injections vs. insulin pump). Difficulty of parenting stress is negatively related to child age and positively related to regimen status. In multivariate analyses, a significant portion of the variance in stress frequency (32%) and difficulty (19%) are associated with parent psychological and behavioral functioning, including lower self-efficacy, greater responsibility for diabetes management, and greater fear of hypoglycemia.

CONCLUSIONS

Each area of parent functioning associated with pediatric parenting stress is amenable to behavioral intervention aimed at stress reduction or control and improvement of parent psychological and child-health outcomes.

Improved diabetes control by using 'close adjustment algorithms'

BACKGROUND

Intensive insulin therapy increases the frequency of severe hypoglycemia despite markedly improved glycemic control in patients with type 1 diabetes mellitus. To determine the optimal dose of insulin, the authors designed algorithms based on self-monitored blood glucose levels.

METHODS

Each dose of insulin was composed of two components: a basal dose determined on the basis of blood glucose levels over the previous two days and an additional dose determined on the basis of blood glucose level just before insulin injection. The patients were instructed to adjust each dose according to the algorithms. The authors investigated the effects of using algorithms on glycemic control, anthropometric data, body composition, and lipid profile in seven females with type 1 diabetes 12-20 years old.

RESULTS

After 3 months, the daily dose of insulin increased significantly from 0.93 +/- 0.18 to 1.16 +/- 0.26 units/kg of body weight, and haemoglobin A(1C) decreased significantly from 8.27 +/- 1.33 to 6.50 +/- 0.64%. Severe hypoglycemia, however, did not occur. Body mass index increased significantly from 21.7 +/- 2.7 to 22.7 +/- 2.9 kg/m(2) with no increase in the percentage of body fat. All lipid-profile data showed a decreasing trend.

CONCLUSIONS

Algorithms developed on the basis of self-monitored blood glucose levels are useful in determining the optimal dose of insulin and can improve glycemic control and lipid metabolism.

A randomized, controlled study of insulin pump therapy in diabetic preschoolers

OBJECTIVE

To compare glycemic control, safety, and parental satisfaction in preschool-aged diabetic children randomized to treatment either with continuous subcutaneous insulin infusion (CSII) or intensive insulin injection therapy.

STUDY DESIGN

This clinical trial enrolled 42 patients <5 years of age who had been diagnosed with diabetes for at least 12 months. Children were randomly assigned to CSII (n = 21) or intensive insulin injection therapy (n = 21). Hemoglobin A1c (HbA1c) level was measured at baseline, 3, and 6 months. Secondary outcomes included severe hypoglycemic events, meter-detected hypoglycemia, blood sugar variability, body mass index (BMI), and satisfaction with therapy.

RESULTS

Thirty-seven patients completed 6 months of therapy. There was a significant decrease in HbA1c during the study period for both groups (from 8.9% +/- 0.6% to 8.6% +/- 0.6% at 3- and 6-month visits). At 3 months, children using pumps had a significantly lower HbA1c than the injection group (8.4% vs 8.8%); however, by 6 months the two groups were similar (8.5% vs 8.7%). No differences in pre-meal blood sugar variabilities were seen between groups. Children on pumps had increases in the number of meter-detected episodes of hypoglycemia. Pump therapy was safe and well tolerated. No episodes of ketoacidosis occurred in either group, whereas one hypoglycemic seizure occurred in each group. Parents reported satisfaction with CSII, with 95% of families continuing on CSII beyond the 6-month study period.

CONCLUSION

Pump therapy in preschool-aged children was not associated with clinically significant differences in glycemic control as compared with intensive injection therapy. The rationale for initiating CSII in this age group should be based on patient selection and lifestyle preference.

Comparison of continuous subcutaneous insulin infusion and multiple daily injection regimens in children with type 1 diabetes: a randomized open crossover trial

OBJECTIVE

To compare the efficacy and feasibility of continuous subcutaneous insulin infusion (CSII) with multiple daily insulin injections (MDI) in children with type 1 diabetes.

METHODS

The study sample included 23 children (10 males) aged 9.4 to 13.9 years with type 1 diabetes. An open randomized crossover design was used to compare 3.5 months of CSII to 3.5 months of MDI therapy for the following variables: diabetic control, incidence of adverse events, daily insulin requirement, body mass index standard deviation scores, treatment satisfaction, and quality of life.

RESULTS

The changes in HbA(1c) and fructoseamine values were similar in the 2 arms over time. At the end of the study, mean HbA(1c) level measured 8.05 +/- 0.78%. There were no differences between the treatment modes in frequency of symptomatic hypoglycemic or hyperglycemic events. There was 1 event of severe hypoglycemia during pump therapy and 3 during MDI, yielding a rate of 0.26 events per patient-year. There were no episodes of diabetic ketoacidosis. Body mass index standard deviation scores decreased during CSII and increased during MDI, as did mean insulin dose. Patients expressed a higher treatment satisfaction from CSII than MDI, although there was no difference in quality of life between the 2 modes.

CONCLUSIONS

Intensive insulin therapy by either insulin pump or MDI is safe in children and young adolescents with type 1 diabetes, with similar diabetes control and a very low rate of adverse events. We suggest that both modes be available to the diabetic team to better tailor therapy.

Specialist nurses in diabetes mellitus

BACKGROUND

The patient with diabetes has many different learning needs relating to diet, monitoring, and treatments. In many health care systems specialist nurses provide much of these needs, usually aiming to empower patients to self-manage their diabetes. The present review aims to assess the effects of the involvement of specialist nurse care on outcomes for people with diabetes, compared to usual care in hospital clinics or primary care with no input from specialist nurses.

OBJECTIVES

To assess the effects of diabetes specialist nurses / nurse case manager in diabetes on the metabolic control of patients with type 1 and type 2 diabetes mellitus.

SEARCH STRATEGY

We carried out a comprehensive search of databases including the Cochrane Library, MEDLINE and EMBASE to identify trials. Bibliographies of relevant papers were searched, and hand searching of relevant publications was undertaken to identify additional trials (Date of last search November 2002).

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trials of the effects of a specialist nurse practitioner on short and long term diabetic outcomes were included in the review.

DATA COLLECTION AND ANALYSIS

Three investigators performed data extraction and quality scoring independently; any discrepancies were resolved by consensus.

MAIN RESULTS

Six trials including 1382 participants followed for six to 12 months were included. Two trials were in adolescents. Due to substantial heterogeneity between trials a meta-analysis was not performed. Glycated haemoglobin (HbA1c) in the intervention groups was not found to be significantly different from the control groups over a 12 month follow up period. One study demonstrated a significant reduction in HbA1c in the presence of the diabetes specialist nurse/nurse case manager at 6 months. Significant differences in episodes of hypoglycaemia and hyperglycaemia between intervention and control groups were found in one trial. Where reported, emergency admissions and quality of life were not found to be significantly different between groups. No information was found regarding BMI, mortality, long term diabetic complications, adverse effects, or costs.

REVIEWER'S CONCLUSIONS

The presence of a diabetes specialist nurse / nurse case manager may improve patients' diabetic control over short time periods, but from currently available trials the effects over longer periods of time are not evident. There were no significant differences overall in hypoglycaemic episodes, hyperglycaemic incidents, or hospital admissions. Quality of life was not shown to be affected by input from a diabetes specialist nurse/nurse case manager.

Increasing problem solving in adolescents with type 1 diabetes: the choices diabetes program

The purpose of this pilot study was to test the hypothesis that adolescents with type 1 diabetes can learn to become better problem solvers in diabetes self-care and thereby improve their metabolic control.

METHODS

Fifty-three adolescents aged 13 to 17 with type 1 diabetes were randomly assigned to either a 6-week problem-solving diabetes education program or to a control group (usual care). A1C levels were obtained as well as assessments of problem solving, frequency of behavior, level of responsibility, and 24-hour behavior recall at baseline and 6 months.

RESULTS

The experimental group participants showed significantly improved problem-solving test scores and A1C values from baseline to 6 months, changes not evident in the control group. At 6 months, the experimental group participants were doing blood glucose testing more often than those in the control group. However, there was no significant difference in problem-solving test scores or A1C values.

CONCLUSIONS

This 6-week intervention for adolescents with diabetes resulted in better problem-solving skills, more frequent blood glucose testing, and improved A1C values. The results suggest that a diabetes problem-solving program for adolescents can be effective in improving metabolic control.

Psychosocial issues in pediatric diabetes

Although the majority of diabetic patients exhibit mild depression, anxiety, and somatic complaints at the time of diagnosis, these symptoms are usually temporary and resolve within 6 to 9 months. However, in some patients, depressive symptoms may increase with the duration of diabetes. Anxiety seems to increase and to be more prevalent in girls than in boys. Depression and self-esteem problems have a negative impact on the adaptation to diabetes and metabolic control. Patients' adjustment to diabetes shortly after diagnosis seems to predict adjustment later on. Family characteristics have major implications in the patient's adjustment to diabetes, self-management, and quality of life. Children and adolescents living in families with a high degree of conflict or that are less caring appear to have poorer metabolic control. Thus, the goal of achieving metabolic and psychological stability requires a diabetes team equipped to provide social and psychological support in addition to the development of technical skills. This includes very early assessment of family dynamics and psychological intervention.