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

An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents

Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.

Socioeconomic Deprivation, Household Education, and Employment are Associated With Increased Hospital Admissions and Poor Glycemic Control in Children With Type 1 Diabetes Mellitus

BACKGROUND

Socioeconomic deprivation, obesity, and emotional discomfort are important determinants of health inequalities and poor glycemic control in children and young people with type 1 diabetes mellitus (T1D).

OBJECTIVES

The aims of this study were to evaluate the incidence of hospital admissions of T1D children in relation to socioeconomic deprivation, and to determine the effects of social deprivation, body mass index (BMI), and patient-reported emotional well-being on glycemic control.

METHODS

All hospital admissions of T1D patients aged 1-18 years were identified during 2007 and 2012. Admission cause and glycemic control were related to social deprivation, BMI, and psychological, emotional well-being. Indices of Multiple Deprivation (IMD) 2010 were applied to the United Kingdom data. The associations were calculated using the Spearman's rank correlation coefficient.

RESULTS

A significant correlation was found between hospital admission rates and overall deprivation scores (r = -0.18, p = 0.04). Patients living in deprived areas were more likely to selfpresent to the accident and emergency department (r = -0.24, p = 0.02). Poor glycemic control (n = 124) was significantly associated with lower levels of education (r = -0.22, p = 0.02) and unemployment (r = -0.19, p = 0.04). Significance was not reached for level of income (r = -0.16, p = 0.07) and overall deprivation (r = -0.17, p = 0.06). Glycemic control was not found to be associated with BMI, standard deviation scores (SDS), or emotional well-being.

CONCLUSION

Early intervention and education from primary care and specialist diabetes teams within the community in deprived areas may be effective in reducing hospital admissions for diabetes-related problems and improving glycemic control.

Delivering early care in diabetes evaluation (DECIDE): a protocol for a randomised controlled trial to assess hospital versus home management at diagnosis in childhood diabetes

BACKGROUND

There is increased incidence of new cases of type 1 diabetes in children younger than 15 years. The debate concerning where best to manage newly diagnosed children continues. Some units routinely admit children to hospital whilst others routinely manage children at home. A Cochrane review identified the need for a large well-designed randomised controlled trial to investigate any significant differences in comprehensive short and long-term outcomes between the two approaches. The DECIDE study will address these knowledge gaps, providing high quality evidence to inform national and international policy and practice.

METHODS/DESIGN

This is a multi-centre randomised controlled trial across eight UK paediatric diabetes centres. The study aims to recruit 240 children newly diagnosed with type 1 diabetes and their parents/carers. Eligible patients (aged 0-17 years) will be remotely randomised to either 'hospital' or 'home' management. Parents/carers of patients will also be recruited. Nursing management of participants and data collection will be co-ordinated by a project nurse at each centre. Data will be collected for 24 months after diagnosis; at follow up appointments at 3, 12 and 24 months and every 3-4 months at routine clinic visits.The primary outcome measure is patients' glycosylated haemoglobin (HbA1c) at 24 months after diagnosis. Additional measurements of HbA1c will be made at diagnosis and 3 and 12 months later. HbA1c concentrations will be analysed at a central laboratory.Secondary outcome measures include length of stay at diagnosis, growth, adverse events, quality of life, anxiety, coping with diabetes, diabetes knowledge, home/clinic visits, self-care activity, satisfaction and time off school/work. Questionnaires will be sent to participants at 1, 12 and 24 months and will include a questionnaire, developed and validated to measure impact of the diagnosis on social activity and independence. Additional qualitative outcome measures include the experience of both approaches by a subgroup of participants (n = 30) and health professionals. Total health service costs will be evaluated. A cost effectiveness analysis will assess direct and indirect health service costs against the primary outcome (HbA1c).

DISCUSSION

This will be the first randomised controlled trial to evaluate hospital and home management of children newly diagnosed with type 1 diabetes and the findings should provide important evidence to inform practice and national guidelines.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN78114042.

Starting subcutaneous insulin doses in a paediatric population with newly diagnosed type 1 diabetes

BACKGROUND

Starting subcutaneous insulin doses in children with newly diagnosed type 1 diabetes vary widely from 0.2 units/kg/day to 0.8 units/kg/day.

AIM

To determine whether there are correlations between starting insulin dose and diabetes-related outcomes.

METHODS

By reviewing the charts of children newly diagnosed with type 1 diabetes, the prevalence of hypoglycemia in the first 48 h was compared between those who received low (0.5 units/kg/day or less) and those who received high (greater than 0.5 units/kg/day) starting insulin doses.

RESULTS

Forty-two children were initially prescribed a low dose of insulin, and 55 children were given a high dose. Approximately one-third of children (36.4%) younger than six years of age who received a high starting dose of insulin had mild hypoglycemia within 48 h of subcutaneous insulin initiation, compared with 16.0% of children six to 10 years of age and 5.3% of children older than 10 years of age.

CONCLUSIONS

Hypoglycemia was not more frequent among children given high-insulin starting doses. However, children younger than six years of age remained at increased risk for hypoglycemia.

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.

Persistent social disparities in the risk of hospital admission of paediatric diabetic patients in Germany-prospective data from 1277 diabetic children and adolescents

BACKGROUND

Reduction of social inequality in health care is a major target in many countries. The risk of hospital admission is thought to be higher in diabetic children from socially deprived families but actual data are lacking.

METHODS

Based on a nationwide prospective computer-based documentation program (DPV), we determined the association between three social parameters (parental professional education, one-parent family vs. complete family, migration background) and the risk for post-onset hospital admission, as well as the number of hospital admission days in children and adolescents < 20 years of age with diabetes onset in 2002-2005 [n = 1277, 56% male, mean age at onset 8.5 (4.1) years]. We estimated relative risks with 95% confidence intervals, adjusting for age, sex, and diabetes centre (cluster), using random effect models.

RESULTS

Forty-two per cent of the study subjects were admitted to hospital at least once during follow-up. The incidence of hospital admissions was 0.46 (0.43-0.49) per person year, and there were 2.72 (2.65-2.80) hospital days per person year. Hospital admissions and hospital days were higher in girls than in boys (significant for hospital days, P < 0.05), and significantly lower in adolescents aged 15-19 compared with children aged 0-4 years (P < 0.05 in all models). Hospital admission rates were significantly higher in children from lower-educated parents, single-parent families, and families with a migration background (all P < 0.05).

DISCUSSION

We found post-onset hospital admission rates to be higher in diabetic children and adolescents from socially deprived families. In comparison with an analysis in the 1990s, no decrease in social disparity in hospital admission risk was found.

Twenty years of a multidisciplinary paediatric diabetes home care unit

As only a minority of patients with type 1 diabetes are unwell at diagnosis, these patients could be managed at home if appropriate facilities were available. A multidisciplinary diabetes home care service was established over 20 years ago at Birmingham Children's Hospital, to support children with diabetes mellitus within the home environment from diagnosis, reducing emotional upset and separation. Despite increase in the size and distribution of the unit over this time (from 230 to 400 patients (now spread over two hospitals)), the proportion of newly diagnosed children managed wholly at home (median 43%; range 31-67%), and the reduction in number and duration of admissions has been sustained (readmission rate with diabetic ketoacidosis 4.1 bed-days per 100 patients/year; range 2.9-7.1), with no deterioration in overall blood glucose control. In this way the savings achieved by reductions in expensive hospital bed occupancy have more than offset the costs of maintaining the unit.