Medical care patterns at the onset of insulin-dependent diabetes mellitus: association with severity and subsequent complications

Socio-demographic and clinical characteristics of type 1 diabetes patients associated with emergency room visits and hospitalizations in Mexico

BACKGROUND

To describe the demographic and clinical characteristics of Type 1 diabetes (T1D) patients affiliated with the Mexican Institute of Social Security (IMSS) and ascertain the socio-demographic and clinical risk factors associated with emergency room (ER) visits and diabetes-related hospitalizations.

METHODS

We conducted secondary data analysis of a cross-sectional study. The study included T1D patients 18 years of age and older who in 2016 attended follow-up visits at the endocrinology department of two IMSS tertiary care hospitals in Mexico City. The study variables included demographics, acute and chronic complications, and healthcare services utilization. Multiple Poisson and negative binomial regressions served to determine the association between the study covariates and the dependent variables: ER visits and diabetes-related hospitalizations.

RESULTS

The study included 192 patients, of which 29.2% were men; average age was 32.3 years, with only 13.6% controlled (glycosylated hemoglobin (HbA1C) < 7%); the mean HbA1C was 9.2, and 64.6% presented chronic complications. During 2016, 39.0% visited ER services, and 33.9% were hospitalized. The common risk factors for ER visits and hospitalization were older age at the beginning of diabetes, severe acute complications, chronic microvascular and macrovascular complications, and other comorbidities. Female sex, high school education, depression, and repeated visits to the endocrinologist were associated with ER visits, whereas active smoking and the interaction between diabetes duration > 10 years and HbA1c > 9.0% were additional risk factors for hospitalization.

CONCLUSION

The poor clinical conditions of T1D patients contribute to explain the escalating demand for health services for diabetes patients at the IMSS. The identification of risk factors enables focalizing interventions to improve the health outcomes of T1D patients and reduce the proportion of ER visits and hospital admissions.

Site of initial diabetes education does not affect metabolic outcomes in children with T1DM

OBJECTIVE

To determine the difference in metabolic outcomes at 1 and 2 yr post type 1 diabetes mellitus (T1DM) diagnosis in children depending on the site of initial diabetes education: inpatient, vs. outpatient, vs. mixed locations.

PATIENTS AND METHODS

A retrospective chart review was performed for all patients with new onset antibody positive T1DM, aged 1-18 yr old, diagnosed in 2004-2009, and followed for at least 1 yr in a diabetes program at a tertiary academic health care center. Patients were divided into three groups based on the site of initial diabetes education: inpatient, outpatient, and mixed locations. The primary outcome was A1c at 1 and 2 yr.

RESULTS

We enrolled 238 children (133 boys), mean (± SD) age 9.9 (± 4.1). A1c levels did not differ among inpatient, outpatient, and mixed location groups at 1 and 2 yr post diagnosis (p = 0.85 and p = 0.69, respectively) and the long-acting insulin doses were similar at 1 and 2 yr (p = 0.18 and p = 0.15, respectively). There was no difference in the number of acute diabetes complications between the groups. At 1 yr, 21.8% of outpatient-educated children were on insulin pump therapy in contrast to 14.7% of inpatient and 2.7% of mixed educated groups (p = 0.04).

CONCLUSIONS

Families of children with new onset T1DM can be successfully and safely educated in a clinic setting. An 'education' admission for a medically stable patient is not necessary most of the time, however, clinical judgment and careful assessment of the family's coping and learning capabilities are important when determining the site of education.

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.

Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study

OBJECTIVE

The purpose of this work was to determine the prevalence and predictors of diabetic ketoacidosis at the diagnosis of diabetes in a large sample of youth from the US population.

PATIENTS AND METHODS

The Search for Diabetes in Youth Study, a multicenter, population-based registry of diabetes with diagnosis before 20 years of age, identified 3666 patients with new onset of diabetes in the study areas in 2002-2004. Medical charts were reviewed in 2824 (77%) of the patients in a standard manner to abstract the results of laboratory tests and to ascertain diabetic ketoacidosis at the time of diagnosis. Diabetic ketoacidosis was defined by blood bicarbonate <15 mmol/L and/or venous pH < 7.25 (arterial/capillary pH < 7.30), International Classification of Diseases, Ninth Revision, code 250.1, or listing of diabetic ketoacidosis in the medical chart.

RESULTS

More than half (54%) of the patients were hospitalized at diagnosis, including 93% of those with diabetic ketoacidosis and 41% without diabetic ketoacidosis. The prevalence of diabetic ketoacidosis at the diagnosis was 25.5%. The prevalence decreased with age from 37.3% in children aged 0 to 4 years to 14.7% in those aged 15 to 19 years. Diabetic ketoacidosis prevalence was significantly higher in patients with type 1 (29.4%) rather than in those with type 2 diabetes (9.7%). After adjusting for the effects of center, age, gender, race or ethnicity, diabetes type, and family history of diabetes, diabetic ketoacidosis at diagnosis was associated with lower family income, less desirable health insurance coverage, and lower parental education.

CONCLUSION

At the time of diagnosis, 1 in 4 youth presents with diabetic ketoacidosis. Those with diabetic ketoacidosis were more likely to be hospitalized. Diabetic ketoacidosis was a presenting feature of <10% of youth with type 2. Young and poor children are disproportionately affected.

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.

Management of newly diagnosed diabetes: home or hospital?

Type 1 diabetes is one of the most common chronic childhood disorders, occurring with increasing frequency. Diabetes management involves the child and family learning how to inject insulin and monitor blood glucose, and adhere to a diet containing healthy food choices. Medical interventions necessary to stabilise newly diagnosed diabetes depend upon the clinical condition of the child at presentation. Hospital admission is necessary if intravenous therapy is required to correct dehydration, electrolyte imbalance, and ketoacidosis, with progression to oral fluids and subcutaneous insulin administration as the child's condition improves. If the child is mildly to moderately symptomatic and clinically well, subcutaneous insulin and oral diet and fluids may be begun from the time of diagnosis, and stabilisation at diagnosis does not necessarily require hospital admission. This article reviews the evidence concerning hospital or home based treatment at diagnosis for children with type 1 diabetes. The Cardiff approach to home management is briefly described, and the benefits and disadvantages of different approaches to initial management are discussed.

Childhood diabetes: parents' experience of home management and the first year following diagnosis

AIMS

To explore parents' experience of having a child diagnosed with Type 1 diabetes, managed at home, and their first year following diagnosis.

METHODS

A qualitative, longitudinal study based on 40 in-depth interviews with parents of 20 children with newly diagnosed Type 1 diabetes managed at home from diagnosis in South Wales.

RESULTS

Many parents were alarmed by the speed of diagnosis following the gradual progress of their child's symptoms. The provision of timely, adequate information was important to all parents. Although five parents had initial concerns about going home, all parents were subsequently pleased their children had not been hospitalized. Home management enabled parents to integrate diabetes management into the family's normal lifestyle from diagnosis. Professional support, particularly accessible telephone advice, was valued by and reassured parents. Parents experienced a loss of spontaneity, a continuing fear of hypoglycaemia and did not want their child to feel different to other children. Acutely aware of the seriousness of diabetes, they did their utmost to achieve optimal glycaemic control but felt that diabetes could not 'dominate' if they were to lead a 'normal' life.

CONCLUSIONS

The experience of parents in this study suggests that parents of children with newly diagnosed diabetes are able to cope successfully when given the opportunity to start treatment at home. Therefore, if children with diabetes are clinically well at diagnosis, this study supports home management as a system of care from the parents' point of view. These findings are relevant to clinicians, policy makers and health service managers involved in planning and providing paediatric diabetes care.

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.

Recent trends in hospitalization for diabetic ketoacidosis in ontario children

OBJECTIVE

To investigate trends and geographic variation in diabetic ketoacidosis (DKA) hospitalization rates among children in Ontario from 1991 to 1999.

RESEARCH DESIGN AND METHODS

Canadian Institute for Health Information (CIHI) data were used to identify 15,872 diabetes-related hospital admissions in children younger than 19 years in Ontario from 1991 to 1999. Of these, 5,008 admissions were because of DKA and 10,864 admissions were because of conditions other than DKA (non-DKA). Small area variation analysis was used to compare areas with high versus low DKA admission rates.

RESULTS

There was a 19% relative decrease in the overall diabetes admission rate over the study period. Non-DKA admissions decreased by 29%, whereas DKA admissions remained stable. Total days of care decreased by 393 days per year for non-DKA admissions and by 99 days per year for DKA admissions. The average length of hospital stay decreased from 4.9 to 3.5 days for non-DKA admissions and from 4.5 to 3.2 days for DKA admissions. The fatality rate was 0.19% for non-DKA admissions and 0.18% for DKA admissions. Variation across geographic areas remained stable for DKA over the study period (Kendall's correlation coefficient 0.64, P = 0.017) with an average 3.7-fold difference between the lowest and highest regions.

CONCLUSIONS

Increased ambulatory care efforts for children with type 1 diabetes in Ontario have successfully reduced non-DKA admission rates. However, DKA admission rates have remained stable. Geographic variation for DKA admissions is low, but the observed 3.7-fold difference is clinically important for a preventable complication with a significant potential for long-term morbidity and mortality. Prevention strategies are needed, particularly in areas identified with the highest rates.

The changing presentation of children with newly diagnosed type 1 diabetes mellitus

Although it is known that the incidence of type 1 diabetes mellitus (DM) in childhood is progressively increasing, it is less clear whether the presentation of newly diagnosed DM is changing. The aim of this study was to establish whether any biochemical or clinical presentation parameters have altered over time. A retrospective study was performed comparing newly diagnosed children with DM in two 24 month time intervals, 8 yrs apart (1988-89 and 1995-96). Fifty-seven children were diagnosed with type 1 DM in 1988-89 and 70 children in 1995-96. At presentation, children born in the later cohort had a higher pH (p < 0.001) and lower serum glucose (p < 0.05). Although the frequency of diabetic ketoacidosis (DKA) was higher in the 1988/89 cohort (63% vs. 42% in 1995/96) the absolute number of children with DKA in each time interval was similar (33 subjects in 1988-89 vs. 30 subjects in 1995/96). Islet cell antibody (ICA) levels were very different between the two cohorts; higher antibody levels were found in the 1988/89 group (p < 0.01). DKA was also associated with higher ICA titres (p < 0.05). Hospital admission stay decreased from 6.5 DS to 3.4 DS over the 8-year period (p < 0.0001). At our institution, the presentation of children with type 1 DM is changing with many more children diagnosed before developing DKA. We speculate that a new environmental factor(s) may be responsible for the absolute increase in patients presenting without DKA, while older etiologies (both genetic and environmental) are responsible for the steady, unchanging number of patients with a more severe presentation. Greater awareness of diabetes in children is not the factor contributing to earlier diagnosis before DKA develops.

Your child has diabetes: hospital or home at diagnosis?

Historically, children with diabetes have been hospitalized at diagnosis, but increasingly, newly diagnosed children are being cared for entirely at home. The management of this chronic condition usually involves the whole family, with children often taking responsibility for much of their own care. However, this article focuses specifically on the needs of parents, forming part of an extensive literature review informing a study exploring parents' experience of home management and coping over the first year with childhood diabetes. A search of the literature revealed a scarcity of evidence overall about hospitalization or home management from a parental perspective, and none in relation to childhood diabetes. This article provides a critical appraisal of the appropriateness of these two approaches to care for parents of children with newly diagnosed diabetes. First, a brief introduction to home management in childhood diabetes is followed by an examination of the small amount of research found about home management and hospitalization from the point of view of parents. Then, the possible benefits and disadvantages of both approaches are discussed and subsequently scrutinized in the context of childhood diabetes. Finally, preliminary conclusions are drawn and suggestions made for the direction of future research in this area.

Home-based management can achieve intensification cost-effectively in type I diabetes

BACKGROUND

Newly diagnosed insulin-dependent diabetic children are most often admitted to hospital for education and insulin management and subsequently followed in outpatient clinics or office settings. However, most could be managed at home, given adequate family and health care team support and subsequent follow-up facilitated by home-based nursing intervention. We conducted a randomized trial of clinical, psychosocial, and cost effects of home-based management in a 2-year follow-up study of newly diagnosed diabetic children.

METHODS

Sixty three patients were randomly assigned to traditional hospitalization and outpatient follow-up (hospital-based group) or home management (home-based group). Treatment differences between the two groups consisted of duration of initial hospital stay, site and timing of initial teaching, and nature and extent of subsequent nursing follow-up. Metabolic control was assessed by means of quarterly glycosylated hemoglobin measurements for 24 months and then at 36 months. Diabetes-related adverse events, knowledge of diabetes, adherence to the diabetes regimen, psychosocial impact, and social (total) costs incurred were assessed for 24 months.

FINDINGS

Glycosylated hemoglobin concentrations were significantly lower in the home-based group at 12 to 24 months and at 36 months. Both groups had comparable numbers of diabetes-related adverse events. There were no significant group differences in psychosocial impact. Parents in the home-based group spent significantly fewer hours on diabetes care and incurred significantly lower out-of-pocket expenses during the 1st month. Health care sector costs were significantly higher. Hospital costs were $889 higher, and government costs $890 higher per child. Social (total) costs were only $48 higher per case (NS) with home care when parents' time was valued at $11.88 per hour.

INTERPRETATION

Home-based management for newly diagnosed diabetic children can result in better metabolic control and similar psychosocial outcomes compared with traditional hospital- and clinic-based care without notable effects on social (total) costs.

Illness characteristics and psychosocial and demographic correlates of illness severity at onset of insulin-dependent diabetes mellitus among school-age children

To verify empirically the most prevalent physical signs and symptoms of diabetes at onset among school-age children, document the distribution of illness-severity, and examine psychosocial and demographic correlates of initial illness severity, the authors analyzed data on 95 school-age children whose diabetes had been newly diagnosed. The most common presenting symptoms were generally consistent with descriptions in the clinical literature. Only 22% of the children presented with severe illness on admission. Children who lived in single-parent households tended to be more ill on admission than children who lived in two-parent households.

A longitudinal study of biomedical and psychosocial predictors of multiple hospitalizations among young people with insulin-dependent diabetes mellitus

The aim of the present study was to estimate the cumulative probability of multiple diabetes-related hospitalizations and identify associated risk factors in a sample of 92 school-age children, newly diagnosed with insulin-dependent (Type 1) diabetes mellitus, who were followed longitudinally for up to 14 years (mean: 9 years). 'Multiple hospitalizations' as a variable was defined as three or more admissions. Altogether 26 young patients (28%) had multiple admissions (with a total of 158 hospitalizations), yielding an estimated cumulative probability for this outcome of 0.33 by 10 years after onset of diabetes. Multivariate longitudinal analyses revealed that at any given point in time, four variables significantly increased the risk of multiple admissions: higher levels of glycosylated haemoglobin reflecting poorer metabolic control, higher levels of externalizing symptoms reflecting greater behaviour problems, younger age at diagnosis, and lower socio-economic status. According to the results of post hoc analyses, however, the aforementioned risk factors do not appear to be specific to multiple hospitalizations, and can serve to identify groups that are generally vulnerable to-readmissions.

Biomedical and psychosocial predictors of early rehospitalization among children with insulin-dependent diabetes mellitus: a longitudinal study

The purpose of the present study was to determine the cumulative probability of the first diabetes-related rehospitalization within the initial 2.5 years after the onset of insulin-dependent diabetes mellitus (IDDM) among newly diagnosed children, and to identify risk factors that can be determined shortly after IDDM-onset. The sample consisted of 88 children, 8 to 13 years old at the onset of IDDM, who had been participating in a longitudinal study. In this sample, there was a 0.25 cumulative probability of an early readmission. Poor control was the most frequent reason for readmissions. Four variables significantly increased the risk of early rehospitalization: severity of child's externalizing symptoms at IDDM-onset, lower socio-economic status, younger age at onset of IDDM, and higher levels of glycosylated haemoglobin, reflecting poorer metabolic control. Because externalizing symptoms and poor control are amenable to change, some early rehospitalizations can potentially be prevented. Furthermore, information about the risk of early rehospitalization should be part of initial diabetes education in order to better prepare families for the possibility of such an event.

Presentation and progress of childhood diabetes mellitus: a prospective population-based study. The Bart's-Oxford Study Group

We surveyed the clinical presentation, initial management and subsequent course of a prospectively registered, population-based cohort of 230 patients with Type 1 (insulin-dependent) diabetes mellitus diagnosed before age 21 years in the Oxford Regional Health Authority area in 1985 and 1986. Clinical details from the time of diagnosis were available on 219 patients. Thirty-four (16%) were in severe ketoacidosis with pH less than 7.10 or plasma bicarbonate less than 10 mmol/l, and 21 (10%) had mild to moderate ketoacidosis with pH 7.10-7.35 or plasma bicarbonate 10-21 mmol/l. One child died in ketoacidosis. Presentation in severe ketoacidosis was most common in children under age 5 years (p < 0.05), and ketoacidosis of any degree was less frequent in older children (0.05 < p < 0.01) and those with a parent or sibling with diabetes (p < 0.01). Within 4 years of diagnosis, 55 of 211 patients (26%) experienced severe hypoglycaemia, which in 31 (15%) led to one or more admissions. Readmission for unstable glycaemic control excluding acute hypoglycaemia occurred at least once within 1 year of diagnosis in 13% and within 4 years in 28%, and was more common in girls, in children aged less than 10 years at diagnosis, and those with a history of severe hypoglycaemia. A second cohort of 97 similar patients was recruited in 1990. The rates of admission at diagnosis (79%), severe ketoacidosis (13%) and mild to moderate ketoacidosis (13%) did not differ from the 1985/1986 cohort.(ABSTRACT TRUNCATED AT 250 WORDS)

The first two years of type 1 diabetes in children: length of the initial hospital stay affects costs but not effectiveness of care

The long-term costs of care and the effects of the length of the initial hospital stay on costs and effectiveness of the care of children with Type 1 diabetes are largely unexplored. A randomized prospective study was carried out wherein we shortened the length of the initial hospital stay from 23 +/- 4 days to 9 +/- 3 days in half of 61 consecutive children with newly diagnosed Type 1 diabetes. Metabolic control, psychosocial adjustment, and direct and indirect costs of care were compared during a 2-year follow-up. Having confirmed similar metabolic and psychosocial outcomes, we now report the costs of the two treatment modes. The costs of care of a child with Type 1 diabetes totalled 10,834 pounds and 6928 pounds in the long-term and short-term alternatives, respectively, during the 2-year follow-up (p < 0.001, one-way ANOVA). Direct costs accounted for 83% of the expenses in the long-term and 82% of the expenses in the short-term group; 73% and 56% of the direct and 78% and 72% of the indirect costs were incurred during the first month in the two groups, respectively. The first month's expenses were twice as high in the long-term than in the short-term group. Consumed hospital days and the parents' lost work time were the largest cost items in both groups. There were no significant differences in the cost items during the following 23 months. We conclude that the greater part of both the direct and the indirect expenditures were associated with the initial hospital stay.(ABSTRACT TRUNCATED AT 250 WORDS)

Outpatient management vs in-hospital management of children with new-onset diabetes

The long-term results of outpatient management of subjects with newly diagnosed insulin-dependent diabetes mellitus (IDDM) are unknown. The longest follow-up described to date is for only one year, a time when most children with IDDM still make endogenous insulin. In this study, 41 young subjects with IDDM, treated and educated in the outpatient setting (1980 to 1984), were compared to a group of 80 similar subjects who received their initial education as hospital inpatients. Long-term glycemic control, as measured by longitudinal glycohemoglobin (HbA1) values was not different in the two groups (p greater than .05). We conclude that outpatient education and management of newly diagnosed subjects with IDDM is as safe and effective as inpatient treatment.

Use of the pen delivery system for intensive insulin therapy in college-age students with type I diabetes

The present report describes our experience with 16 adolescents and young adults with insulin-dependent diabetes mellitus (IDDM; Type I) who switched from two injections of insulin per day to the NovolinPen and four insulin injections a day. Their mean age at the initiation of therapy was 19.2 years with a duration of diabetes of 8.9 years. Sixteen random computer-matched (for age, sex, and duration of diabetes) controls who remained on two insulin injections a day were evaluated for comparison. Most subjects were preparing to leave home for college. After a minimum of 1 year of using the pen, the mean weight gain of the test subjects was significantly greater (P less than .05) than for the computer-matched controls. Glycemic control, as monitored by mean HbA1c values, were similar for the NovolinPen and the control groups (10.8 versus 10.9, respectively) after almost 2 years. The main advantage to the pen expressed by the users was a sense of freedom of lifestyle.

Randomised prospective study of short-term and long-term initial stay in hospital by children with diabetes mellitus

To assess how an isolated change in the pattern of care influences outcome of care and hospital use, a randomised prospective 2-year study was done in which 31 of 61 consecutive children with newly diagnosed insulin-dependent diabetes mellitus (IDDM) were admitted to hospital at disease onset for about a week and compared with the other 30 children who were admitted for about 4 weeks. Insulin treatment and education about diabetes were similar in the two groups. Duration of initial stay in hospital had no effect on metabolic control during the 2 years but time since diagnosis was significant with respect to effect on haemoglobin A1 (p = 0.001), haemoglobin A1c (p = 0.004), and insulin dose (p less than 0.001). At 2 years, 45% of the children in the short-term group and 29% in the long-term group were C-peptide positive (p = NS); C-peptide positivity correlated with age. A change in the pattern of care of children with IDDM, led to a pronounced decrease in hospital use by this patient group. Irrespective of the length of initial stay in hospital, equally good metabolic control was obtained in both groups for 2 years.

A trial of nicotinamide in newly diagnosed patients with type 1 (insulin-dependent) diabetes mellitus

Various agents have been tried in subjects with newly diagnosed Type 1 (insulin-dependent) diabetes mellitus in an attempt to preserve Beta-cell function. In this double-blind study, nicotinamide or placebo were given for one year to 35 children and adolescents with newly-diagnosed Type 1 diabetes. All subjects were within six weeks of diagnosis and were between the ages of 6 and 18 years. Nicotinamide, a poly-(ADP-ribose) synthetase inhibitor, was given in a dose of 100 mg/year of age up to a maximum of 1.5 g/day. There were no initial differences between the 17 control and the 18 test subjects in relation to mean age, sex distribution, or severity at onset. Mean insulin dosages and HbA1 values were similar for the two groups during the year of study. Fasting and glucagon-stimulated C-peptide levels were similar for the control and nicotinamide treated groups at the beginning and after 4 and 12 months. There were no differences in remission rates between the two groups. Nicotinamide, at this dosage, does not preserve residual insulin secretion in subjects with newly diagnosed Type 1 diabetes.

Length of hospitalization of children with diabetes: effect of a clinical nurse specialist

Expeditious discharge of children with newly diagnosed diabetes is desirable for both psychological and financial reasons. Does length of hospitalization depend upon who is educating the child and family? This study compares the length of stay in newly diagnosed diabetic children educated by staff nurses (SN) with the length of stay of children educated by a clinical nurse specialist plus staff nurses (CNS/SN). The length of hospitalization of the CNS/SN group was significantly shorter (x = 6.2 days) than the SN group (x = 8.4 days; P<0.01). The two groups were not significantly different in age, admission serum pH, or admission blood glucose level, nor were they different in socioeconomic status or criteria for discharge. The ulitization of a CNS as a diabetes educator may significantly decrease the length of hospitalization of children with newly diagnosed diabetes.