ISPAD Clinical Practice Consensus Guidelines 2014. The delivery of ambulatory diabetes care to children and adolescents with diabetes

Brief assessment of diabetes-specific psychological flexibility in racially and income diverse youth with type 1 diabetes

OBJECTIVE

Diabetes-specific psychological flexibility (the ability to engage in valued behaviors, be open to internal experiences, with present-moment awareness, while living with diabetes) is associated with HbA1c and health-related quality of life in youth with type 1 diabetes (T1D). Having brief diabetes-specific psychological flexibility assessments that perform equivalently across diverse individuals is important for research and clinical work addressing health disparities. The present study aimed to create 9-and 3-item short forms (DAASito-9 and -3) of the Diabetes Acceptance and Action Scale (DAAS-22), and evaluate their validity, reliability, and measurement invariance (MI).

RESEARCH DESIGN AND METHODS

Youth with T1D (n = 179, M_age  = 14.64, 50% female, 56% Black/African American) completed self-report measures at an endocrinology clinic visit. HbA1c was extracted from medical records. One-half of the sample was used to develop the DAASitos with the highest reliability, McDonald's 𝜔 ≥ 0.75, and convergent validity (r ≥ 0.90 to DASS-22). Confirmatory factor analyses evaluated structural validity. MI was assessed across demographic (race, gender, grade, household income) and disease characteristic (illness duration, HbA1c) groups. Correlations with measures of psychological flexibility assessed additional convergent validity, and latent mean differences across groups were evaluated after confirming MI.

RESULTS

MI was supported. The DAASito-9 and -3 were correlated in expected directions with other psychological flexibility measures, HbA1c, and health-related quality of life.

CONCLUSIONS

The psychometric properties of the DAASito-9 and -3 support their use in research and clinical care of diverse youth with T1D. Significant differences in psychological flexibility across race, income, and glycemic health warrant further research and clinical intervention.

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.

Do children and adolescents with type 1 diabetes suffer from a lack of resources in France? Results from a benchmark study in the New Aquitaine region

BACKGROUND

A benchmark study was conducted in the southwest of France, in the New Aquitaine region, to investigate metabolic outcomes and availability of resources in pediatric diabetes units. We assessed whether the level of care was in accordance with the International Society for Pediatric and Adolescent Diabetes recommendations.

METHODS

Demographic and clinical data were collected, as were all HbA1c tests for the 2017 calendar year. Pediatricians specialized in diabetes care were invited to complete an online survey concerning means allocated to the management of type 1 diabetes in their centers.

RESULTS

Sixteen centers provided data for 1277 patients and 3873 clinical visits. A total of 1115 children suffering from diabetes for more than 1 year were studied. Median HbA1c was 8% (7.4-8.6) for the whole region. Only 29.2% of children had good metabolic control in accordance with the <7.5% target. We identified slight but significant variation in glycemic control among centers (P=0.029). The use of an insulin pump varied greatly among centers but did not explain HbA1c differences. We did not identify a correlation between medical or paramedical time dedicated to the follow-up of diabetic patients and the mean HbA1c of each center. For 100 diabetic patients, follow-up was provided by 0.42 physicians (0.23-1.50), 0.15 nurses (0-0.56), 0.12 dietitians (0-0.48), and 0.07 psychologists (0-0.30).

CONCLUSION

This study demonstrates a lack of human resources allocated to the management of type 1 diabetes in the region that is far below international recommendations. The proportion of children achieving the international glycemic target is low. There is a clear need to improve glycemic control in children, which will only be possible with improved professional practices, encouraged by benchmark studies, and by increasing the size of our multidisciplinary teams.

Food Insecurity Screening Among Families of Children With Diabetes

Little is known about screening in clinical settings for food insecurity (FI) among households of children with diabetes. This study evaluated the acceptability and feasibility of an FI screening initiative in a pediatric diabetes clinic that was implemented to help diabetes dietitian educators tailor management plans for families of children with type 1 or type 2 diabetes facing FI. The initiative comprised three validated screening questions, a care algorithm, a community resource handout, and a poster. In total, 50 families of children and adolescents aged 0-18 years with type 1 or type 2 diabetes were screened for FI. In-person semi-structured interviews combining open-ended and Likert-scale questions were conducted with 37 of the screened families and the three diabetes dietitian educators who conducted the screening. Perceived barriers and facilitators of the screening initiative were identified using content analysis, and Likert-scale questionnaires rated interviewees' comfort level with the screening questions. A reflective journal kept by an onsite research interviewer also facilitated the data interpretation process. Most families felt comfortable answering the screening questions. Families with FI appreciated the opportunity to express their concerns and learn about affordable food resources. However, ∼20% of these families described stigma and fear of judgment by clinicians if they screened positive for FI. Diabetes educators also felt comfortable with the screening questions but reported lack of time to screen all families and to follow-up with resources after a positive screen. A self-reported intake form was recommended to ensure that everyone is systematically screened. A standardized and respectful method of assessing FI could help clinicians better tailor treatment plans and support for families of children with diabetes who face FI. Based on these findings, similar FI screening initiatives should be implemented in other clinical settings as part of routine clinical practice.

Peer review of rural and tertiary Queensland paediatric diabetes services: A pilot project from the National Health Service

AIM

Peer review is one component of the improvement of diabetes care delivered by the National Health Service (NHS) in England and Wales. Queensland has a decentralised model of service provision with an established state diabetes network.

METHODS

The NHS scheme was adapted for use in Australia, and seven trained reviewers were recruited to visit 14 'hub' centres, which in turn covered 29 'spoke' units delivering care to over 95% of all public patients <16 years old in the state. Details of control as measured by glycosylated haemoglobin (HbA1c), the rate of presentation of diabetic ketoacidosis (DKA), the use of state guidance and staffing levels were recorded. Thirteen minimum standards of care were used as a basis for assessment. A report for the use of each inspected unit was produced at the end of the process.

RESULTS

Most units had not previously collected outcome data; 45% of new cases presented with DKA. The centre mean HbA1c was 9.1%, and only 21% of patients achieved the Australian recommended level of <7.5%. Only three centres met some of the internationally recommended staffing levels. Only two centres provided transitional care to adult services. Of 13 NHS minimum standards of care, a mean of 5 were achieved (range 1-8), a mean of 4.6 partially achieved (range 3-6) and a mean of 3.9 not achieved (range 0-9). The care for 68 patients with type 2 diabetes was particularly poor.

CONCLUSIONS

Paediatric diabetes care in Queensland is suboptimal. Recommended remedial actions are suggested that may be applicable to other states.

Diabetes camp still matters: Relationships with diabetes-specific distress, strengths, and self-care skills

OBJECTIVE

Prior studies suggest diabetes camps improve psychosocial well-being in youth with type 1 diabetes but these studies suffer from variable levels of rigor. The present study assessed associations between camp participation and diabetes distress, perceived independence in diabetes self-care, and diabetes strengths in a large sample of children, adolescents, and their parents across 44 camps in the United States. Analyses compared viewpoints of study participants, identified moderators of change, and assessed perceived benefits of camp participation.

METHODS

There were 2488 youth and 2563 parents consented for participation in the online survey. Participants reported diabetes distress and perceived independence in youth care, their new experiences and best parts of camp, and changes in behavior following camp. T-tests, regressions, Cohen's d, and relative frequencies were used as appropriate to assess baseline differences between reporters, pre-post outcome differences, and moderators of change.

RESULTS

Parents as compared to youth reported higher pre-camp distress and lower perception of youth independence in self-care. Youth experienced a statistically significant decrease in distress and increase in independence in self-care. Diabetes strengths did not change. Higher A1c prior to camp was associated with higher levels of distress across camp participation. Campers and their parents endorsed a high frequency of positive firsts, bests, and benefits of camp.

CONCLUSIONS

Data from a large sample youth with type 1 diabetes across multiple camps showed broad-based psychosocial benefits of camp participation.

Transition from pediatric to adult care in emerging adults with type 1 diabetes: a blueprint for effective receivership

For adolescents and emerging adults, the transition from pediatrics to adult care is fraught with challenges both inside and outside the clinical arena, including assuming independent care for diabetes, working with new adult providers, and overcoming concomitant psychosocial issues, while maintaining work/school-life balance. Not surprisingly, glycemic control in emerging adults with type 1 diabetes is amongst the worst in all age groups. Thus, new and comprehensive strategies are needed by both pediatric and adult diabetes care teams to support young adults during the transition to adult care. In this review, we focus on challenges during the transition period and provide evidence-based recommendations for a receivership model to assist adult diabetes care teams in addressing these concerns. By coordinating efforts with pediatrics providers, identifying strengths and deficiencies in self-care, establishing rapport with young adult patients, directly addressing prevalent psychosocial concerns, and developing a team-based approach to keep patients engaged, adult care teams can prioritize support for the most vulnerable transition patients. Improved strategies to propel emerging adult patients through the transition period towards habits leading to optimal glycemic control could have a major long-term impact on preventing diabetes-related complications.

Determination of Pubertal Status in Youths With Type 1 Diabetes Using Height Velocity and Trajectories

CONTEXT

Assessment of pubertal change is important for the management of chronic pediatric diseases, such as type 1 diabetes. Physical and/or laboratory assessments of pubertal status are often unavailable, impractical, or costly.

OBJECTIVE

To develop and validate a practical and objective method to assess pubertal status using longitudinal linear growth in youths with type 1 diabetes.

DESIGN, PARTICIPANTS, AND OUTCOME MEASUREMENTS

Participants (n = 123) were part of a 2-year study assessing continuous glucose monitoring in youths with type 1 diabetes at a tertiary diabetes center. Pubertal status at visits was assigned by a tiered approach using clinical Tanner staging or indicators of pubertal maturation from the electronic medical record when available. For other visits, independent evaluations of height velocities and growth chart trajectories provided data for pubertal status assignments. Sensitivity analysis confirmed the validity of the pubertal status assignments.

RESULTS

The sample (50% female, 95% white) had a mean ± SD age of 12.7 ± 2.7 years, diabetes duration of 6.0 ± 3.6 years, and hemoglobin A1c of 7.9 ± 0.8%. Of 985 study visits, 50% received a pubertal status assignment based on clinical Tanner staging, 29% on additional medical record review, and 22% on an evaluation of height velocity and growth chart trajectory. For the sensitivity analysis, pubertal status assignments based on height velocity and growth chart trajectory matched clinical Tanner staging in 87% of visits.

CONCLUSIONS

Our practical and objective method to assess pubertal status based on height velocity and growth chart trajectory highlights growth as a reliable and objective bioassay for pubertal onset, status, and progression.

Children and adolescents with type 1 diabetes in Australasia: An online survey of model of care, workforce and outcomes

AIM

To survey the model of care and workforce that manages children and adolescents with type 1 diabetes (T1D) in Australasia along with glycaemic outcomes.

METHODS

Tertiary and regional paediatric clinics in Australia and New Zealand (NZ) caring for children and adolescents with diabetes were invited to complete an online survey assessing health-care professional (HCP) workforce numbers and available clinical data for the 2016 calendar year.

RESULTS

A total of 38 sites responded - 25 Australian (10 tertiary, 15 regional), 13 NZ (4 tertiary, 8 regional) - representing 9715 children with T1D. HCP resourcing varied across sites, with overall HCP/100 patient ratios of: doctors: 0.36 (0.08-1.07), nurses: 0.72 (0-1.8), dieticians: 0.19 (0-0.49) and psychologist/social workers: 0.13 (0-0.36). Overall, 39% of patients used insulin pump therapy (CSII) (29.5% NZ, 40.8% Australia). Databases were being used locally by 26 sites. Thirty-two sites reported the mean clinic HbA1c, mean HbA1c 66 mmol/mol (8.2%) (NZ = 69 mmol/mol (8.5%), Australia = 66 mmol/mol (8.2%)), with 29% of patients attaining the recommended HbA1c target of <58 mmol/mol (7.5%) (NZ = 28%, Australia = 29%).

CONCLUSIONS

This is the largest Australasian paediatric T1D workforce survey to date. HCP to patient ratios remain well below international recommendations and have not changed over the last 5-7 years. Glycaemic outcomes in this population were below recommended levels in the majority of patients. There is an urgent need to reform models of care and workforce and to institute systematic benchmarking in both countries in order to prevent acute and chronic complications of T1D.

Management of Children With Diabetes in the School Setting

Diabetes educators are well positioned to help optimize care of the student with diabetes within the school setting.

Type 1 diabetes outcomes: Does distance to clinic matter?

BACKGROUND AND OBJECTIVES

To access care, pediatric type 1 diabetes (T1D) patients living in British Columbia (BC), Canada, travel to the sole tertiary pediatric hospital (BC Children's Hospital; BCCH), or they receive community care from pediatric endocrinologists and/or pediatricians. We sought to determine whether hemoglobin A1_C (HbA_1C ) and patient-reported outcomes were associated with (1) distance to clinic and (2) tertiary vs community care.

METHODS

Patients were recruited from T1D clinics across BC. Clinical chart review and patient surveys were completed, including the Diabetes Treatment Satisfaction Questionnaire (DTSQ). Clinic type was categorized as tertiary (BCCH) or community, and the travel time to BCCH was categorized as <1 hour, 1 to 2 hours, or >2 hours.

RESULTS

There were 189 participants. Age and duration of T1D were similar across groups. Mean number of visits/year for BCCH groups were 2.23, 2.24, and 2.05 for the <1-hour, 1- to 2-hour, and >2-hour groups, respectively, vs 3.26 for the community group. Adjusted mean difference in HbA_1C was +0.65% (95% confidence interval [CI]: 0.15, 1.15) and +0.52% (95% CI: 0.02, 1.02) for the BCCH >2-hour group compared to the BCCH <1-hour group and community groups, respectively. Child DTSQ scores were significantly lower in the BCCH >2-hour group compared to the BCCH <1-hour and community groups.

CONCLUSIONS

Children traveling >2 hours to T1D clinic at BCCH had significantly higher HbA_1C values and lower satisfaction with care vs those traveling <1 hour to BCCH and those receiving community care. Access to care closer to home may benefit glycemic control in children with T1D and improve treatment satisfaction. Future research should determine whether these findings can be replicated in other regions.

Pediatric endocrine society survey of diabetes practices in the United States: What is the current state?

BACKGROUND

The Practice Management Committee (PMC) of the Pediatric Endocrine Society (PES) conducted a survey of its membership in February/March, 2016 to assess the current state of pediatric diabetes care delivery across multiple practice types in the United States.

METHODS

The PES distributed an anonymous electronic survey (Survey Monkey) via email to its membership and requested that only one survey be completed for each practice.

RESULTS

Ninety-three unique entries from the US were entered into analysis. Care is predominantly delivered by multidisciplinary teams, based at academic institutions (65.6%), with >85% of the provider types being physicians. Each 1.0 full time equivalent certified diabetes educators serves on average 367 diabetic youth. Fee-for-service remains the standard method of reimbursement with 57% of practices reporting financial loss. Survey respondents identified under-reimbursement as a major barrier to improving patient outcomes and lack of behavioral health (BH) providers as a key gap in services provided.

CONCLUSIONS

Our survey reveals wide variation in all aspects of pediatric diabetes care delivery in the United States. Pediatric Endocrinologists responding to the survey identified a lack of resources and the current fee for service payment model as a major impediment to practice and the lack of integrated BH staff as a key gap in service. The respondents strongly support its organizations' involvement in the dissemination of standards for care delivery and advocacy for a national payment model aligned with chronic diabetes care in the context of our emerging value-based healthcare system.

Comparable glycemic outcomes for pediatric type 1 diabetes patients in metropolitan and non-metropolitan regions of Western Australia: A population-based study

BACKGROUND

Pediatric patients diagnosed with type 1 diabetes (T1D) in Western Australia (WA) are managed by a single, specialist multidisciplinary diabetes service based at a central tertiary hospital in the capital city, Perth, which provides outreach care in regional centers.

OBJECTIVE

To investigate the hypothesis that outcomes for a contemporary, population-based pediatric T1D cohort, managed by a single tertiary service are similar for metropolitan and non-metropolitan patients using this model of care. To confirm that the cohort is indeed population based, a secondary aim of the study was to determine the case ascertainment of the Western Australian Children's Diabetes Database (WACDD).

METHODS

Data for all T1D patients aged <18 years, who attended the diabetes clinics (metropolitan and non-metropolitan), at least once in 2014, were extracted from the WACDD and outcomes including HbA1c and severe hypoglycemia (SH) rates analyzed.

RESULTS

In 2014, a total of 1017 patients (492 females, 525 males) attended the diabetes clinics (54% metropolitan and 46% non-metropolitan). After adjusting for age, sex, diabetes duration, and insulin regimen, region of clinic was not a significant predictor of mean HbA1c or SH rate. The case ascertainment of the WACDD was estimated to be 99.9% complete for children diagnosed with T1D aged <15 years between 2002 and 2012.

CONCLUSIONS

This study reports similar glycemic outcomes for patients attending diabetes clinics in metropolitan and non-metropolitan areas of WA, suggesting that a model of care provided as outreach from a specialized diabetes service is effective in achieving equitable glycemic outcomes.

Strengths-Based Behavioral Intervention for Parents of Adolescents With Type 1 Diabetes Using an mHealth App (Type 1 Doing Well): Protocol for a Pilot Randomized Controlled Trial

Background

Supportive parent involvement for adolescents’ type 1 diabetes (T1D) self-management promotes optimal diabetes outcomes. However, family conflict is common and can interfere with collaborative family teamwork. Few interventions have used explicitly strengths-based approaches to help reinforce desired management behaviors and promote positive family interactions around diabetes care.

Objective

The aim of this protocol was to describe the development of a new, strengths-based behavioral intervention for parents of adolescents with T1D delivered via a mobile-friendly Web app called Type 1 Doing Well.

Methods

Ten adolescent-parent dyads and 5 diabetes care providers participated in a series of qualitative interviews to inform the design of the app. The 3- to 4-month pilot intervention will involve 82 parents receiving daily prompts to use the app, in which they will mark the diabetes-related strength behaviors (ie, positive attitudes or behaviors related to living with or managing T1D) their teen engaged in that day. Parents will also receive training on how to observe diabetes strengths and how to offer teen-friendly praise via the app. Each week, the app will generate a summary of the teen’s most frequent strengths from the previous week based on parent reports, and parents will be encouraged to praise their teen either in person or from a library of reinforcing text messages (short message service, SMS).

Results

The major outcomes of this pilot study will include intervention feasibility and satisfaction data. Clinical and behavioral outcomes will include glycemic control, regimen adherence, family relationships and conflict, diabetes burden, and health-related quality of life.

Conclusions

This strengths-based, mobile health (mHealth) intervention aims to help parents increase their awareness of and efforts to support their adolescents’ engagement in positive diabetes-related behaviors. If efficacious, this intervention has the potential to reduce the risk of family conflict, enhance collaborative family teamwork, and ultimately improve diabetes outcomes.

Trial Registration

ClinicalTrials.gov NCT02877680; https://clinicaltrials.gov/ct2/show/NCT02877680 (Archived by WebCite at http://www.webcitation.org/6xTAMN5k2)

Diabetes in Childhood and Adolescence

BACKGROUND

The incidence of type 1 diabetes mellitus in childhood and adolescence is steadily rising and now stands at 22.9 new cases per year per 100 000 persons up to age 15.

METHODS

This review is based on pertinent publications retrieved by a selective literature search, with special attention to the current German S3 guideline on diabetes in childhood and adolescence.

RESULTS

Polydipsia, polyuria, and weight loss are the characteristic presenting symptoms of diabetes mellitus. The acutely presenting patient needs immediate stabilization because of the danger of rapid metabolic decompensation (risk of keto - acidosis, 21.1%). Long-term insulin therapy can be delivered either by subcutaneous injection or by an insulin pump. The goals of treatment are the near-normalization of glucose metabolism (HbA1c <7.5%), the avoidance of acute complications (hypoglycemia and ketoacidosis), the reduction of diabetes-specific sequelae (retinopathy, nephropathy, neuropathy, hypertension, and hyperlipidemia), unrestricted participation in age-appropriate everyday activities, and normal physical and psychosocial development. Children and adolescents with diabetes need individualized treatment with frequent adjustments and holistic overall care so that these goals can be effectively met.

CONCLUSION

Every physician must be able to diagnose the initial presentation of diabetes and to initiate the first steps in its management. The patient should be referred as soon as possible to a diabetes team that has experience in the treatment of children and adolescents.

Management of Children With Diabetes in the School Setting

Diabetes educators are well positioned to help optimize care of the student with diabetes within the school setting.

Improving the Care of Youth With Type 1 Diabetes With a Novel Medical-Legal Community Intervention: The Diabetes Community Care Ambassador Program

Purpose The purpose of this study was to examine the feasibility and efficacy of the Diabetes Community Care Ambassador (DCCA) Program, a novel medical-legal community intervention designed to support high-risk youth with type 1 diabetes. Methods Study eligibility criteria: ages 3-19 years, A1C ≥8.5% (≥69 mmol/mol) and/or recent diabetic ketoacidosis hospitalization, type 1 diabetes duration ≥1 year, and English- or Spanish-speaking. Eighty-nine youth and their caregivers participated in the 9- to 12-month intervention, which included diabetes education and support through 3 home visits, 1 to 2 school visits, and phone support from a lay health worker, as well as legal support from a medical-legal partnership attorney. Feasibility was assessed; change in A1C was compared in a linear mixed model. Results Of the 89 DCCA Program participants, 80% completed the program, with the majority of participants rating their DCCA favorably. Sixty-two percent reported ≥1 unmet legal need, of whom 29% accepted legal counsel. Youth enrolled in the DCCA Program demonstrated an improvement in glycemic control as their mean A1C decreased from 9.71% (83 mmol/mol) at the start of the program to 9.40% (79 mmol/mol) at the end of the intervention period ( P = .03). Participants with public health insurance experienced the greatest differential A1C reduction (9.79% to 9.11%, 83 mmol/mol to 76 mmol/mol). Conclusions The DCCA Program represents a promising intervention for improving care of high-risk youth with type 1 diabetes. A significant proportion of caregivers of youth reported having an unmet legal need. Participants remained highly engaged and demonstrated improved glycemic control, particularly youth with public health insurance.

The impact of outpatient telehealth compared to standard care on emergency room visits and hospital admissions in pediatric diabetes patients: a systematic review protocol

REVIEW QUESTION

What is the effectiveness of outpatient telehealth compared to standard care on emergency room and hospital admissions in patients aged 0 to 18 years with type 1 or type 2 diabetes?

Diabetes camp matters: Assessing families' views of their diabetes camp experience

BACKGROUND

Camp offers a safe and fun environment for learning new information about diabetes care and for trying new self-care skills. It is a place where children and teens are able to meet with others who also have diabetes and who share their experiences.

MATERIALS AND METHODS

This study assessed self-reports before and after attending diabetes camp on diabetes-specific emotional distress, diabetes-specific quality of life, and self-care behaviors by surveying campers and their parents from over 42 diabetes-specific summer camps across the United States. Parents (N = 413), Teenagers (N = 154), and Children (N = 116) completed both pre- and post-camp surveys.

RESULTS

Parents reported higher levels of diabetes-specific emotional distress than their campers did. Both parents and children reported significant improvements in their own distress after camp. Teens reported improvements in distress but they were not statistically significant. Youth report higher levels of self-care skills than parents believe their children possess. Parents, Teens, and Children all reported significant improvements in the camper's self-care skills after camp. First time campers' and their parents' perspectives regarding self-care skills are consistent with veteran campers after attending camp. Self-reports post-camp reveals that campers and their parents see camp as a place where youth feel they are with others who really understand what it is like to live with diabetes. Respondents also report that camp is a place where youth are exposed to new technologies and where campers can try new self-care tasks.

Diabetes conflict outstrips the positive impact of self-efficacy on youth adherence and glycemic control in type 1 diabetes

OBJECTIVE

To examine whether self-efficacy buffers the deleterious consequences of diabetes-specific family conflict on self-monitoring blood glucose (SMBG) and glycated hemoglobin (HbA1c) in youth with type 1 diabetes mellitus (T1DM).

METHODS

A total of 129 youth with T1DM (aged 10-16 years) completed measures of diabetes-specific family conflict and self-efficacy for diabetes management, and their blood glucose meter data and HbA1c were extracted from the electronic medical record. We preformed moderation analyses to examine whether self-efficacy moderated the association that diabetes-specific family conflict had with SMBG and HbA1c. We used simple slopes analyses to probe significant interactions.

RESULTS

Our results indicated that self-efficacy moderated the association that diabetes-specific family conflict had with SMBG and HbA1c. The pattern of these findings showed that high self-efficacy buffered the negative impact of diabetes conflict on HbA1c. However, benefits of high self-efficacy for more frequent SMBG was only apparent in the context of low diabetes-specific family conflict.

CONCLUSIONS

Study findings highlight the interactive relationship between diabetes-specific family conflict and self-efficacy in relation to SMBG and glycemic control. These findings suggest that family functioning and youth's self-efficacy are promising intervention targets for families having trouble with SMBG and HbA1c.

Perspectives on care for young adults with type 1 diabetes transitioning from pediatric to adult health systems: A national survey of pediatric endocrinologists

BACKGROUND

Healthcare transition from pediatric to adult care for young adults (YA) with type 1 diabetes (T1D) is associated with risk of adverse outcomes. Consensus recommendations exist from US professional societies on transition care for YA with T1D, but it is not known whether they have been widely adopted. We describe experiences, barriers, and provider characteristics associated with transition care in a national sample of pediatric endocrinologists.

METHODS

US pediatric endocrinologists identified through the American Medical Association Physician Masterfile were sent an electronic survey.

RESULTS

Response rate was 16% (164/1020) representing 32 states. The majority of pediatric endocrinologists (age 44 ± 10; years in practice 12 ± 11) were female (67%) and worked in academic centers (75%). Main reasons for transfer were age (49%) and glycemic control (18%). Barriers to transition included ending long-therapeutic relationships with patients (74%), lack of transition protocols (46%), and perceived deficiencies in adult care (42%). The majority of pediatric endocrinologists reported lack of transition training (68%); those who received training were less likely to have difficulty ending patient relationships [odds ratio (OR) = 0.39, P = .03], more likely to perform patient record transfer to adult systems (OR=1.27, P = .006), and less likely to report patient returns to pediatric care after transfer (OR=0.49, P = .01), independent of endocrinologist gender, years in practice, or practice type.

CONCLUSIONS

There is wide variation in transition care for YA with T1D among US pediatric endocrinologists despite consensus recommendations. Dissemination of educational programming on transition care and provision of actionable solutions to overcome local health system and perceived barriers is needed.

Improved diabetes management in Swedish schools: results from two national surveys

BACKGROUND

Support in diabetes self-care in school is essential to achieve optimal school performance and metabolic control. Swedish legislation regulating support to children with chronic diseases was strengthened 2009.

OBJECTIVE

To compare the results of a national survey conducted 2008 and 2015 measuring parents' and diabetes specialist teams' perceptions of support in school.

METHOD

All pediatric diabetes centers in Sweden were invited to participate in the 2015 study. In each center, families with a child being treated for T1DM and attending preschool class or compulsory school were eligible. The parents' and the diabetes teams' opinions were collected in two separate questionnaires.

RESULTS

Forty-one out of 42 eligible diabetes centers participated and 568 parents answered the parental questionnaire in 2015. Metabolic control had improved since the 2008 survey (55.2 ± 10.6 mmol/mol, 7.2% ± 1.0%, in 2015 compared with 61.8 ± 12.4 mmol/mol, 7.8% ± 1.1% in 2008). The proportion of children with a designated staff member responsible for supporting the child's self-care increased from 43% to 59%, (P < .01). An action plan to treat hypoglycemia was present for 65% of the children in 2015 compared with 55% in 2008 (P < .01). More parents were satisfied with the support in 2015 (65% compared with 55%, P < .01).

CONCLUSIONS

This study shows that staff support has increased and that more parents were satisfied with the support for self-care in school in 2015 compared with 2008. More efforts are needed to implement the national legislation to achieve equal support in all Swedish schools.

Insulin pump use and discontinuation in children and teens: a population-based cohort study in Ontario, Canada

OBJECTIVE

To describe insulin pump use by youth since introduction of universal funding in Ontario, Canada and to explore the relationship between pump use and pediatric diabetes center characteristics and the relationship between discontinuation and center and patient characteristics.

RESEARCH DESIGN AND METHODS

Observational, population-based cohort study of youth with type 1 diabetes (<19 yr) who received pump funding from 2006 to 2013 (n = 3700). We linked 2012 survey data from 33 pediatric diabetes centers to health administrative databases. We tested the relationship between center-level pump uptake and center characteristics (center type, physician model, and availability of 24-h support) using an adjusted negative binomial model; we studied center- and patient-level factors (socioeconomic status and baseline glycemic control) associated with discontinuation using a Cox proportional hazards model with generalized estimating equations.

RESULTS

Pump users were more likely to be in the highest income quintile than non-pump users (29.6 vs. 19.1%, p < 0.0001). In 2012, mean percent pump use was 38.0% with variability across centers. There was no association between uptake and center characteristics. Discontinuation was low (0.42/100 person-yr) and was associated with being followed at a small community center [hazard ratio (HR): 2.24 (1.05-4.76)] and being more deprived [HR: 2.36 (1.14-1.48)]. Older age was associated with a lower rate of discontinuation [HR: 0.31 (0.14-0.66)].

CONCLUSIONS

Rates of pump use have increased since 2006 and discontinuation is rare. Large variation in uptake across centers was not explained by the factors we examined but may reflect variation in patient populations or practice patterns, and should be further explored.

Management of Children With Diabetes in the School Setting

Diabetes educators are well positioned to help optimize care of the student with diabetes within the school setting.

Is the incidence of type 1 diabetes in children and adolescents stabilising? The first 6 years of a National Register

The Irish Childhood Diabetes National Register (ICDNR) was established in 2008 to define accurately the incidence and monitor the epidemiology of type 1 diabetes (T1D) in the Irish population. Here, we report data from the first 6 years of the National Register and compare with previous national data. Prospective national incident data regarding T1D in those under 15 years resident in Ireland were collected from 2008 to 2013 and national incidence rates (IRs) calculated. Ascertainment completeness was assessed using capture-recapture methodology. The period identified 1566 new cases of T1D, ascertainment reached 96.8 % in 2013. The standardised incidence rate was 27.5 in 2008 stabilising at 28.7 and 28.8 cases /100,000/year in 2012 and 2013. There was no evidence that the incidence changed significantly in the 6-year period either overall or for each age group and gender. There was evidence of a difference in the incidence of T1D across the age groups with the overall incidence highest in the 10-14 year age category. A strong seasonal association was demonstrated.

CONCLUSIONS

This study confirms Ireland as a high-incidence country for type 1 diabetes whilst demonstrating that the previous marked increase in IR from 16.3 cases/100,000/year in 1997 has not continued. Ongoing monitoring through the robust mechanism of the ICDNR is required to clarify whether this is a fluctuation or if the incidence of T1D diabetes has stopped rising in our population. Alternatively, this apparent stabilisation may reflect a shift to a later age at diagnosis. "What is known :" • The incidence of Type 1 diabetes (T1D) is increasing in most populations worldwide although in certain high-incidence populations, it may be stabilising • There was a marked increase in T1D in Ireland between 1997 and 2008 • T1D incidence increases with affluence "What is New:" • The high incidence of T1D in Ireland has been confirmed at 28.8 cases/100,000/year in 2013 and has been effectively stable in the period 2008-2013 • Incidence is highest in Irish 10-14 year olds • Changes in incidence possibly reflecting life style and economic climate • Marked seasonality of diagnosis confirmed.

Contribution of SWEET to improve paediatric diabetes care in developing countries

Diabetes affects many children living in developing countries. Through an informal survey, five SWEET (Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) centers from developing countries (Mali, Costa Rica, Argentina and two from India) share their perspective on caring for children with diabetes. Each center provides a description of the population of children with diabetes they serve, the organization of care, and the challenges encountered on a daily basis in the provision of this care. In the second part, we summarize the anticipated benefits and challenges associated with participation in SWEET. This resulting article is a testimony of the reality of managing diabetes by dynamic teams striving to achieve recommended standards of care for pediatric diabetes in an environment with limited resources.

Low socioeconomic status is associated with adverse events in children and teens on insulin pumps under a universal access program: a population-based cohort study

OBJECTIVE

To describe adverse events in pediatric insulin pump users since universal funding in Ontario and to explore the role of socioeconomic status and 24-hour support.

RESEARCH DESIGN AND METHODS

Population-based cohort study of youth (<19 years) with type 1 diabetes (n=3193) under a universal access program in Ontario, Canada, from 2006 to 2013. We linked 2012 survey data from 33 pediatric diabetes centers to health administrative databases. The relationship between patient and center-level characteristics and time to first diabetic ketoacidosis (DKA) admission or death was tested using a Cox proportional hazards model and the rate of diabetes-related emergency department visits and hospitalizations with a Poisson model, both using generalized estimating equations.

RESULTS

The rate of DKA was 5.28/100 person-years and mortality 0.033/100 person-years. Compared with the least deprived quintile, the risk of DKA or death for those in the most deprived quintile was significantly higher (HR 1.58, 95% CI 1.05 to 2.38) as was the rate of diabetes-related acute care use (RR 1.60, 95% CI 1.27 to 2.00). 24-hour support was not associated with these outcomes. Higher glycated hemoglobin, prior DKA, older age, and higher nursing patient load were associated with a higher risk of DKA or death.

CONCLUSIONS

The safety profile of pump therapy in the context of universal funding is similar to other jurisdictions and unrelated to 24-hour support. Several factors including higher deprivation were associated with an increased risk of adverse events and could be used to inform the design of interventions aimed at preventing poor outcomes in high-risk individuals.

Valuing technology: A qualitative interview study with physicians about insulin pump therapy for children with type 1 diabetes

Insulin pumps for children with type 1 diabetes have been broadly adopted despite equivocal evidence about comparative effectiveness. To understand why and inform policy related to public funding for new technologies, we explored how physicians interpret the value of pumps. We conducted open-ended, semi-structured interviews with 16 physicians from a pediatric diabetes network in Ontario, Canada, and analyzed the data using interpretive description. Respondents recognized that pumps fell short of expectations because they required hard work, as well as family and school support. Yet, pumps were valued for their status as new technologies and as a promising step in developing future technology. In addition, they were valued for their role within a therapeutic relationship, given the context of chronic childhood disease. These findings identify the types of beliefs that influence the adoption and diffusion of technologies. Some beliefs bear on hopes for new technology that may inappropriately hasten adoption, creating excess cost with little benefit. On the other hand, some beliefs identify potential benefits that are not captured in effectiveness studies, but may warrant consideration in resource allocation decisions. Still others suggest the need for remediation, such as those bearing on disparity in pump use by socioeconomic status. Understanding how technologies are valued can help stakeholders decide how to address such beliefs and expectations in funding decisions and implementation protocols.

A Minority of Patients with Type 1 Diabetes Routinely Downloads and Retrospectively Reviews Device Data

BACKGROUND

In type 1 diabetes (T1D), periodic review of blood glucose and insulin dosing should be performed, but it is not known how often patients review these data on their own. We describe the proportion of patients with T1D who routinely downloaded and reviewed their data at home.

MATERIALS AND METHODS

A cross-sectional survey of 155 adults and 185 caregivers of children with T1D at a single academic institution was performed. "Routine Downloaders" (downloaded four or more times in the past year) were also considered "Routine Reviewers" if they reviewed their data most of the time they downloaded from devices. Logistic regression was used to identify factors associated with being a Routine Reviewer.

RESULTS

Only 31% of adults and 56% of caregivers reported ever downloading data from one or more devices, whereas 20% and 40%, respectively, were considered Routine Downloaders. Only 12% of adults and 27% of caregivers were Routine Reviewers. Mean hemoglobin A1c was lower in Routine Reviewers compared with non-Routine Reviewers (7.2±1.0% vs. 8.1±1.6% [P=0.03] in adults and 7.8±1.4% vs. 8.6±1.7% [P=0.001] in children). In adjusted analysis of adults, the odds ratio of being a Routine Reviewer of one or more devices for every 10-year increase in age was 1.5 (95% confidence interval, 1.1, 2.1 [P=0.02]). For every 10 years since diabetes diagnosis, the odds ratio of being a Routine Reviewer was 1.7 (95% confidence interval, 1.2, 2.4 [P=0.01]). For caregivers, there were no statistically significant factors associated with being a Routine Reviewer.

CONCLUSIONS

A minority of T1D patients routinely downloads and reviews data from their devices on their own. Further research is needed to understand obstacles, provide better education and tools for self-review, and determine if patient self-review is associated with improved glycemic control.