Multisystemic therapy for adolescents with poorly controlled type 1 diabetes: reduced diabetic ketoacidosis admissions and related costs over 24 months

Self-management skills in a UK sample of young people with chronic liver disease

BACKGROUND

We aimed to assess self-management skills and adherence behaviors in young people post-liver transplant and compare these with those of young people with autoimmune liver disease and other forms of chronic liver disease.

METHOD

As part of our specialist multidisciplinary clinic, n = 156 young people (aged 16-25 years) completed the Liver Self-Management Questionnaire (an adaptation of the Developmentally Based Skills Checklist for adolescents post-liver transplant and modified for us across liver disease type and within the United Kingdom). Those taking medication (n = 128) also completed a service-designed questionnaire regarding adherence. The statistical significance of group differences was assessed with non-parametric analyses.

RESULTS

Young people post-liver transplant were less likely to report managing their condition independently than those with autoimmune liver disease or those with other forms of chronic liver disease. They also reported higher adherence (93%) compared to those with autoimmune liver disease (77%) and those with other forms of chronic liver disease (85%). However, the vast majority of self-management and adherence behaviors were comparable between young people post-transplant and those with autoimmune liver disease/other forms of chronic liver disease.

CONCLUSION

Our data are in line with existing data from US samples and also extend these findings to include those with other forms of chronic liver disease. These data highlight the importance of individualized care for young adults, regardless of condition type or healthcare setting, and of clinicians managing their expectations regarding what is considered appropriate condition management in early adulthood.

Interventions Across the Translational Research Spectrum: Addressing Disparities Among Racial and Ethnic Minoritized Youth with Type 1 Diabetes

Racial and ethnic minoritized youth with type 1 diabetes (T1D) are at elevated risk for health disparities. Few intervention studies have been conducted for these youth and evidence to support best practices to address their needs is lacking. Existing evidence supports the use of brief trials of diabetes technology with structured support from clinic staff, culturally tailored interventions such as language-congruent clinical care, and use of community health workers as promising directions to improve health outcomes. Clinicians and researchers should work collaboratively with community members to improve the quality of T1D intervention science for racial and ethnic minoritized youth.

Clinical and biochemical determinants of length of stay, readmission and recurrence in patients admitted with diabetic ketoacidosis

BACKGROUND

The increasing prevalence of diabetic ketoacidosis (DKA) related admissions poses a significant burden on the healthcare systems globally. However, data regarding the predictors of healthcare resource utilization in DKA is limited and inconsistent. This study aimed to identify key predictors of hospital length of stay (LOS), readmission and recurrent DKA episodes.

METHODS

We undertook a retrospective cross-sectional analysis of all DKA admissions from 2015 to 2021 across four hospitals in Qatar. The primary outcomes were the length of stay (LOS), 90-day readmission and 6-month and 1-year DKA recurrence.

RESULTS

We included 922 patients with a median age of 35 years (25-45). 62% were males with type-1 diabetes-mellitus (T1DM) and type-2 DM (T2DM), present in 52% and 48% of patients. The median LOS was 2.6 days (IQR 1.1-4.8), and the median DKA resolution time was 18 h (10.5-29). Male-gender, new-onset DM, higher Charlson Comorbidity Index (CCI), lower haemoglobin, sodium and potassium, higher urea, longer DKA duration and MICU admission predicted a longer LOS in a multivariate regression analysis. None of the factors were significantly associated with 90-day readmission. Patients with pre-existing T1DM were more likely to have a six-month DKA recurrence than pre-existing T2DM. Patients with a 6-month DKA recurrence, female gender and T1DM had higher odds of 12-month recurrence, whereas a consult with a diabetes educator at the index admission was associated with decreased odds of recurrence.

CONCLUSIONS/INTERPRETATION

This is the most extensive study from the Middle-East region reporting on LOS, readmissions and the recurrence of DKA. Results from this study with a diverse population may be valuable for physicians and healthcare systems to decrease the diabetes-related healthcare burden in DKA patients.

Research Review: Integrated healthcare for children and young people in secondary/tertiary care - a systematic review

BACKGROUND

Children and young people (CYP) with comorbid physical and/or mental health conditions often struggle to receive a timely diagnosis, access specialist mental health care, and more likely to report unmet healthcare needs. Integrated healthcare is an increasingly explored model to support timely access, quality of care and better outcomes for CYP with comorbid conditions. Yet, studies evaluating the effectiveness of integrated care for paediatric populations are scarce.

AIM AND METHODS

This systematic review synthesises and evaluates the evidence for effectiveness and cost-effectiveness of integrated care for CYP in secondary and tertiary healthcare settings. Studies were identified through systematic searches of electronic databases: Medline, Embase, PsychINFO, Child Development and Adolescent Studies, ERIC, ASSIA and British Education Index.

FINDINGS

A total of 77 papers describing 67 unique studies met inclusion criteria. The findings suggest that integrated care models, particularly system of care and care coordination, improve access and user experience of care. The results on improving clinical outcomes and acute resource utilisation are mixed, largely due to the heterogeneity of studied interventions and outcome measures used. No definitive conclusion can be drawn on cost-effectiveness since studies focused mainly on costs of service delivery. The majority of studies were rated as weak by the quality appraisal tool used.

CONCLUSIONS

The evidence of on clinical effectiveness of integrated healthcare models for paediatric populations is limited and of moderate quality. Available evidence is tentatively encouraging, particularly in regard to access and user experience of care. Given the lack of specificity by medical groups, however, the precise model of integration should be undertaken on a best-practice basis taking the specific parameters and contexts of the health and care environment into account. Agreed practical definitions of integrated care and associated key terms, and cost-effectiveness evaluations are a priority for future research.

Reducing Diabetic Ketoacidosis Readmissions with a Hospital-School-Based Improvement Partnership

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in pediatric type 1 diabetes mellitus (T1D). Baseline data showed 139 of 182 DKA readmissions (76.4%) were due to missed basal insulin dosing. The team used quality improvement tools to implement a process change around basal insulin. The project utilized insulin degludec and school-based nurses when missed basal insulin was noted as a main driver for readmission. The DKA readmission rate averaged 5.25 per month from January 2017 to April 2019. The rate decreased to 3.64 per month during the intervention from May 2019 to March 2020, a 31% reduction over 11 months. This standardized approach for patients with T1D readmitted with DKA, using a school-based intervention and insulin degludec, reduced the number of DKA readmissions. This method is safe and effective for lowering DKA readmissions due to missed basal insulin in areas with reliable school nursing.

Psychosocial Staffing and Implementation of the International Society for Pediatric and Adolescent Diabetes Psychological Care Guidelines in U.S. Pediatric Diabetes Clinics

Background

Few studies have examined the implementation of the International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines for the Psychological Care of Children and Adolescents with Type 1 Diabetes.

Objective

To collect benchmark data on psychosocial staffing and implementation of the ISPAD guidelines across U.S. pediatric diabetes clinics.

Methods

Medical (n = 95; 77 endocrinologists and 18 advance practice providers) and psychosocial (n = 86; 43 social workers and 43 psychologists) providers from 98 of 115 contacted clinics completed an online survey (85% response rate). Providers reported the number of psychosocial staff and rated the adequacy of psychosocial staffing, quality of psychosocial care, and adherence to the ISPAD guidelines in their clinics. χ2 Tests and ANOVA were used to examine differences across clinic size and across medical and psychosocial providers.

Results

Clinics averaged a total of ∼4 hours per week of psychosocial provider time per 100 patients with type 1 diabetes. Only 27% of providers agreed that psychosocial staffing was adequate, and 35% described their psychosocial care as comprehensive. Implementation of the ISPAD guidelines varied across clinics, with minimal differences across clinic size. Medical providers reported that evidence-based psychological assessment and interventions were delivered consistently by <55% of clinics. Psychosocial, compared with medical, providers were more likely to report frequent implementation of psychosocial assessment and intervention guidelines.

Conclusion

Psychological care in U.S. pediatric type 1 diabetes clinics does not consistently meet the ISPAD guidelines, and many clinics lack adequate psychosocial staff. These benchmark data are a foundational step to improve psychosocial care for pediatric patients with type 1 diabetes.

Perceptions of diabetes management among adolescents with type 1 diabetes and their caregivers: development and validation of the Japanese version of the diabetes family responsibility questionnaire

The shift in diabetes management responsibility is critical for adolescents with type 1 diabetes (T1D). Currently, in Japan, there is insufficient progress in the development of scales for evaluating diabetes management responsibility. We developed the Japanese version of the Diabetes Family Responsibility Questionnaire (DFRQ), a scale to evaluate diabetes management responsibility, and verified its reliability and validity. We recruited 12-18-year-old adolescents with T1D and their caregivers. The DFRQ questionnaires (DFRQ-A for adolescents and DFRQ-C for caregivers) were distributed. The responses of 31 pairs were analyzed (adolescents: 9 males, 22 females; mean age: 14.8 ± 1.5 years). The median total DFRQ scores of adolescents (30.0) and caregivers (32.0) were not significantly different (p = 0.269). The internal consistencies (Cronbach's α) were 0.784 and 0.687 for DFRQ-A and DFRQ-C, respectively. DFRQ-A scores and adolescent age demonstrated a weak statistically significant negative correlation (r =  - 0.397, p = 0.027), whereas DFRQ-C scores and adolescent age demonstrated a weak negative correlation not statistically significant (r =  - 0.311, p = 0.089). Both scores were significantly negatively correlated with self-efficacy for diabetes self-management scores (r =  - 0.390, p = 0.030; r =  - 0.478, p = 0.006, respectively). Furthermore, a significantly moderate positive correlation was found between these scores (r = 0.624, p < 0.001). We confirmed the reliability and validity of the Japanese version of DFRQ. DFRQ is expected to be used as a dyadic scale to evaluate the status of diabetes management responsibility and its transition during adolescence in Japan.

Intensive sick day rules to prevent recurrent diabetic ketoacidosis- An intervention that exemplifies health disparities

OBJECTIVE

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). In established T1D patients, DKA is frequently a result of insulin omission or inadequate insulin administration during illness or stress. Ethnic minorities and patients with lower socioeconomic status are affected disproportionately. We hypothesized that implementation of intensive sick day rules with frequent reinforcement would reduce hospitalizations secondary to DKA in T1D youth irrespective of their demographics.

METHODS

Intensive sick day rules were implemented beginning January 2016. All T1D patients seen in the pediatric endocrinology clinic or hospital between January 1^st 2015 through December 31^st 2017 were included for chart review. Categorical variables were analyzed with Chi-square test. For the continuous variables, t test was used. Episodes of DKA per 100 patients were compared using the trends test over the three-year period. Patients who had DKA in 2015 were analyzed as a subgroup.

RESULTS

The frequency of DKA episodes per 100 patient years for 2015 was 19.1, for 2016 was 15.2 and was 12.4 for 2017. This decrease was statistically significant (p=0.006). The decline was also statistically significant for the subgroup of patients who developed DKA in 2015 and followed longitudinally. The decline was not uniform across all patient groups and DKA episodes remained associated with African- American race, Medicaid insurance status and higher HbA1c throughout the years.

CONCLUSION

Implementation of intensive sick day rules led to a decrease in total number of DKA admissions in our population with T1D youth. However, this intervention did not reduce the health disparity in this population and African-Americans on Medicaid insurance continued to form the disproportionate majority of admissions with DKA. This study highlights the need for further research into interventions that can improve outcomes across racial and socio-economic barriers.

Previous diabetic ketoacidosis as a risk factor for recurrence in a large prospective contemporary pediatric cohort: Results from the DPV initiative

OBJECTIVE

To assess the role of previous episodes of diabetic ketoacidosis (DKA) and their time-lag as risk factors for recurring DKA in youth with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

In a population-based analysis, data from 29,325 children and adolescents with T1D and at least 5 years of continuous follow-up were retrieved from the "Diabetes Prospective Follow-up" (DPV) multi-center registry in March 2020. Statistical analyses included unadjusted comparisons, logistic and negative binomial regression models.

RESULTS

Among 29,325 patients with T1D, 86.0% (n = 25,219) reported no DKA, 9.7% (n = 2,833) one, and 4.3% (n = 1,273) more than one episode, corresponding to a DKA rate of 4.4 [95% CI: 4.3-4.6] per 100 patient-years. Female sex, migratory background, higher HbA1c values, higher daily insulin doses, a lower glucose monitoring frequency, and less CGM usage were associated with DKA. In patients with a previous episode, the DKA rate in the most recent year was significantly higher than in patients with no DKA (17.6 [15.9-19.5] vs. 2.8 [2.7-3.1] per 100 patient-years; p < 0.001). Multiple DKAs further increased the recurrence rate. The risk for DKA in the most recent year was higher in patients with an episode in the preceding year than in patients with no previous DKA (OR: 10.0 [95% CI: 8.6-11.8]), and remained significantly elevated 4 years after an episode (OR: 2.3 [1.6-3.1]; p < 0.001).

CONCLUSIONS

Each episode of DKA is an independent risk factor for recurrence, even 4 years after an event, underlining the importance of a close follow-up after each episode.

Predicting healthcare utilization in youth with type 1 diabetes: The importance of family level variables

OBJECTIVE

Little is known about how family factors impacting treatment adherence in type 1 diabetes are directly associated with unplanned healthcare utilization (e.g., emergency room visits and hospital admissions). Given the substantial financial burden of diabetes, understanding predictors of healthcare utilization in particular is important to inform behavioral interventions aimed toward improving adherence.

RESEARCH DESIGN AND METHODS

The current study examined the relationship between family-level variables and healthcare utilization in a sample of 239 youth with type 1 diabetes and their parents. Healthcare utilization was determined via parent report and chart review. Parent- and youth-reports regarding levels of family conflict, youth autonomy, and parent support related to diabetes management were obtained via questionnaire, and negative reciprocity was obtained by coding observations of parent and youth interactions. Generalized Estimating Equations were used to examine the longitudinal association between healthcare utilization and family-level factors.

RESULTS

Higher levels of observed negative reciprocity were associated with more frequent hospital admissions, while higher levels of youth-reported parent involvement in diabetes management were associated with fewer hospital admissions and ED visits.

CONCLUSIONS

These findings highlight how family-level factors are directly related to healthcare utilization and point to the continued importance of integrating family-focused behavioral interventions in routine medical care for improving type 1 diabetes outcomes and reducing healthcare costs.

Psychological interventions for adherence, metabolic control, and coping with stress in adolescents with type 1 diabetes: a systematic review

BACKGROUND

The aim of this review was to summarize and identify the variations in the effectiveness of psychological interventions on adherence, metabolic control, and coping with stress in adolescents with type 1 diabetes (T1D).

METHODS

An electronic search of literature was performed using PubMed (NLM), Embase (Ovid), CINAHL Plus (EBSCOhost), PsycINFO (Ovid), and Google Scholar. The search was limited to include articles reported the effect of one of the psychological interventions: cognitive behavioral therapy (CBT), coping skills training (CST), stress management, or psychotherapy intervention. The report included peer-reviewed articles published in English from January 1990 until May 2019 in adolescents with T1D, and summarizes the results of 24 studies that met the inclusion criteria.

RESULTS

Psychological interventions showed differential effects on adherence, metabolic control, and coping with stress in adolescents with T1D. Behavioral interventions using principles of CBT appear to have a superior positive effect on regimen adherence compared with other types of psychological protocols. In contrast, metabolic control was significantly improved with the implementation of CST and some forms of CBT. Stress management and psychotherapy interventions showed significant promises for adolescents to cope with their diabetes-related daily stressors.

CONCLUSIONS

However, the findings may add some promises to diabetes management in adolescents, additional research to understand the effect of these interventions is needed.

Psychological care in children and adolescents with type 1 diabetes in a real-world setting and associations with metabolic control

BACKGROUND

International guidelines recommend psychosocial care for children and adolescents with type 1 diabetes.

OBJECTIVE

To assess psychological care in children and adolescents with type 1 diabetes in a real-world setting and to evaluate associations with metabolic outcome.

METHODS

Delivery of psychological care, HbA1c, and rates of severe hypoglycemia and diabetic ketoacidosis (DKA) in children and adolescents with type 1 diabetes from 199 diabetes care centers participating in the German diabetes survey (DPV) were analyzed.

RESULTS

Overall, 12 326 out of 31 861 children with type 1 diabetes were supported by short-term or continued psychological care (CPC). Children with psychological care had higher HbA1c (8.0% vs 7.7%, P<.001) and higher rates of DKA (0.032 vs 0.021 per patient-year, P<.001) compared with children without psychological care. In age-, sex-, diabetes duration-, and migratory background-matched children, HbA1c stayed stable in children supported by CPC during follow-up (HbA1c 8.5% one year before psychological care started vs 8.4% after two years, P = 1.0), whereas HbA1c was lower but increased significantly by 0.3% in children without psychological care (HbA1c 7.5% vs 7.8% after two years, P <.001). Additional HbA1c-matching showed that the change in HbA1c during follow-up was not different between the groups, but the percentage of children with severe hypoglycemia decreased from 16.3% to 10.7% in children receiving CPC compared with children without psychological care (5.5% to 5.8%, P =.009).

CONCLUSIONS

In this real-world setting, psychological care was provided to children with higher HbA1c levels. CPC was associated with stable glycemic control and less frequent severe hypoglycemia during follow-up.

The Role of Caregiver-Reported Risks in Predicting Adverse Pediatric Outcomes

OBJECTIVE

Certain social risk factors (e.g., housing instability, food insecurity) have been shown to directly and indirectly influence pediatric health outcomes; however, there is limited understanding of which social factors are most salient for children admitted to the hospital. This study examines how caregiver-reported social and medical characteristics of children experiencing an inpatient admission are associated with the presence of future health complications.

METHODS

Caregivers of children experiencing an inpatient admission (N = 249) completed a predischarge questionnaire designed to capture medical and social risk factors across systems (e.g., patient, caregiver, family, community, healthcare environment). Electronic health record (EHR) data were reviewed for child demographic data, chronic disease status, and subsequent emergency department visits or readmissions (i.e., acute events) 90 days postindex hospitalization. Associations between risk factors and event presence were estimated using odds ratios (ORs) and confidence intervals (CI), both unadjusted and adjusted OR (aOR) for chronic disease and age.

RESULTS

Thirty-three percent (N = 82) of children experienced at least one event. After accounting for child age and chronic disease status, caregiver perceptions of child's health being generally "poor" or "not good" prior to discharge (aOR = 4.7, 95% CI = 2.3, 9.7), having high care coordination needs (aOR = 3.2, 95% CI = 1.6, 6.1), and experiencing difficulty accessing care coordination (aOR = 2.5, 95% CI = 1.4, 4.7) were significantly associated with return events.

CONCLUSIONS

Caregiver report of risks may provide valuable information above and beyond EHR records to both determine risk of future health problems and inform intervention development.

Management of Diabetic Ketoacidosis in Adults: A Narrative Review

Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency and causes the greatest risk for death in patients with diabetes mellitus. DKA more commonly occurs among those with type 1 diabetes, yet almost a third of the cases occur among those with type 2 diabetes. Although mortality rates from DKA have declined to low levels in general, it continues to be high in many developing countries. DKA is characterized by hyperglycemia, metabolic acidosis and ketosis. Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states. The most common precipitating causes for DKA include infections, new diagnosis of diabetes and nonadherence to insulin therapy. Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors. Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA. Future episodes of DKA can be reduced through patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers. New approaches such as extended availability of phone services, use of telemedicine and utilization of public campaigns can provide further support for the prevention of DKA.

THR1VE! Positive psychology intervention to treat diabetes distress in teens with type 1 diabetes: Rationale and trial design

Adolescents with type 1 diabetes (T1D) experience high rates of diabetes distress, which negatively influence self-management and glycemic control. Building on effective positive psychology interventions to improve adherence in adults, as well as our pilot work to adapt these interventions for adolescents, we developed a positive psychology intervention for adolescents with T1D. The goal of THR1VE! is to reduce diabetes distress in adolescents with T1D and improve their diabetes outcomes. This multi-site randomized controlled trial compares a Diabetes Education + text-message-based Positive Affect intervention, to a Diabetes Education control condition. In the ongoing trial, we are evaluating the effects of the intervention on adolescents' diabetes distress, self-management, and glycemic control. This paper describes the rationale, trial design, and methodology of the THR1VE! Study.

Health Care Utilization and Spending for Children With Mental Health Conditions in Medicaid

OBJECTIVE

To examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups.

METHODS

This retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3 to 17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total health care spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group.

RESULTS

Children with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (P <.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total health care spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group.

CONCLUSIONS

Among children with MH conditions, mental and physical health comorbidities were common and spending for general health care outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical health care services and investigate whether current spending on MH services supports high-quality MH care.

Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes

Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA_1c, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.

Adaptation of an Evidence-Based Diabetes Management Intervention for Delivery in Community Settings: Findings From a Pilot Randomized Effectiveness Trial

Objective

To adapt an evidence-based intervention targeting diabetes management in adolescents with poorly controlled type 1 diabetes for use in a community setting by community health workers (CHWs) and to conduct pilot testing of the new intervention, REACH for Control (RFC). The study was conducted as a collaboration between university researchers and a federally qualified health center. Methods In a pilot effectiveness trial, feasibility and acceptability of RFC were evaluated based on participant enrollment, treatment dose, and consumer satisfaction. RFC effects on adolescent adherence, health outcomes, and quality of life were also assessed. The trial used a parallel group design. Families were randomized to 6 months of RFC plus standard medical care (n = 26) or standard care (SC) only (n = 24). Data were collected at baseline and 7-month posttest. A mixed-methods approach was used to analyze data.

Results

Qualitative analyses suggested that caregivers viewed RFC and delivery of a home-based intervention by CHWs positively. Furthermore, adolescents who received RFC had statistically significant (p = .05) and clinically meaningful improvements in hemoglobin A1c (HbA1c) (0.7%) and reported significant improvements in quality of life from baseline to follow-up (p = .001). No significant changes were found for adolescents in standard medical care. However, while dose of primary intervention session delivered was acceptable, dose of follow-up sessions used for skills practice was low.

Conclusions

Results provide preliminary support for RFC's acceptability and effectiveness to improve health status and quality of life when used in community settings serving high-risk, low-income families. Additional testing in a full-scale effectiveness trial appears warranted.

Integrated Care Models and Child Health: A Meta-analysis

CONTEXT

Integrated care models may improve health care for children and young people (CYP) with ongoing conditions.

OBJECTIVE

To assess the effects of integrated care on child health, health service use, health care quality, school absenteeism, and costs for CYP with ongoing conditions.

DATA SOURCES

Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library databases (1996-2018).

STUDY SELECTION

Inclusion criteria consisted of (1) randomized controlled trials, (2) evaluating an integrated care intervention, (3) for CYP (0-18 years) with an ongoing health condition, and (4) including at least 1 health-related outcome.

DATA EXTRACTION

Descriptive data were synthesized. Data for quality of life (QoL) and emergency department (ED) visits allowed meta-analyses to explore the effects of integrated care compared to usual care.

RESULTS

Twenty-three trials were identified, describing 18 interventions. Compared with usual care, integrated care reported greater cost savings (3/4 studies). Meta-analyses found that integrated care improved QoL over usual care (standard mean difference = 0.24; 95% confidence interval = 0.03-0.44; P = .02), but no significant difference was found between groups for ED visits (odds ratio = 0.88; 95% confidence interval = 0.57-1.37; P = .57).

LIMITATIONS

Included studies had variable quality of intervention, trial design, and reporting. Randomized controlled trials only were included, but valuable data from other study designs may exist.

CONCLUSIONS

Integrated care for CYP with ongoing conditions may deliver improved QoL and cost savings. The effects of integrated care on outcomes including ED visits is unclear.

Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention

Pharmacological, technological and educational approaches have advanced the treatment of Type 1 diabetes in the last four decades and yet diabetic ketoacidosis (DKA) continues to be a leading cause of admission in Type 1 diabetes. This article begins by reviewing the contemporary epidemiological evidence in DKA. It highlights a rise in DKA episodes in the last two decades, with DKA continuing to be the leading cause of death in young people with Type 1 diabetes, and that DKA episodes are a marker for subsequent all-cause mortality. It also summarizes the limited evidence base for DKA prevention and associations with psychopathology. To emphasize the importance of this group with high-risk Type 1 diabetes and the degree to which they have been overlooked in the past two decades, the article summarizes the research literature of recurrent DKA during 1976-1991 when it was extensively investigated as part of the phenomenon of 'brittle diabetes'. This period saw numerous basic science studies investigating the pathophysiology of recurrent DKA. Subsequently, research centres published their experiences of brittle diabetes research participants manipulating their treatment under research conditions. Unfortunately, the driver for this behaviour and whether it was indicative of other people with ketoacidosis was not pursued. In summary, we suggest there has been a stasis in the approach to recurrent DKA prevention, which is likely linked to historical cases of mass sabotage of brittle diabetes research. Further investigation is required to clarify possible psychological characteristics that increase the risk of DKA and thereby targets for DKA prevention.

An individualized inpatient diabetes education and hospital transition program for poorly controlled hospitalized patients with diabetes

OBJECTIVE

To evaluate predictors of outcomes associated with an inpatient diabetes education and discharge support program for hospitalized patients with poorly controlled diabetes (glycated hemoglobin [HbA1c]>9%).

METHODS

Patients participated in individualized diabetes education conducted by a certified diabetes educator (CDE) that included an exploration of barriers and goal setting during hospitalization with telephone follow-up and communication with primary providers at discharge. Predictors of HbA1c reduction, successful follow-up, and readmission were analyzed.

RESULTS

There were 82 subjects, and 48% were insulin naïve. Patients with type 2 diabetes (T2D, n = 58) had a significant decrease in HbA1c at follow-up (-2.8%, P<.0001), while those with type 1 diabetes (T1D, n = 19) did not (+0.02%, P = .96). However, after adjustment for other factors, only increasing age, higher baseline HbA1c, earlier education, and initiation of basal insulin were significant predictors of reduction in HbA1c. Higher area level income and empowerment and earlier education were significant predictors of outpatient follow-up within 30 days. While 28% were admitted for severe hyperglycemia, only 1 patient was readmitted with severe hyperglycemia. Successful phone contact was 77% and 57% with and without the support of non-CDE assistants respectively, but all outcomes were similar.

CONCLUSION

The study suggests that an individualized inpatient diabetes education and transition program is associated with a significant reduction in HbA1c that is dependent on baseline HbA1c, older age, initiation of insulin, and earlier enrollment. Additional interventions are needed to ensure better continuity of care.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies for parents of children and adolescents with chronic illness aim to improve parenting behavior and mental health, child functioning (behavior/disability, mental health, and medical symptoms), and family functioning.This is an updated version of the original Cochrane Review (2012) which was first updated in 2015.

OBJECTIVES

To evaluate the efficacy and adverse events of psychological therapies for parents of children and adolescents with a chronic illness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and trials registries for studies published up to July 2018.

SELECTION CRITERIA

Included studies were randomized controlled trials (RCTs) of psychological interventions for parents of children and adolescents with a chronic illness. In this update we included studies with more than 20 participants per arm. In this update, we included interventions that combined psychological and pharmacological treatments. We included comparison groups that received either non-psychological treatment (e.g. psychoeducation), treatment as usual (e.g. standard medical care without added psychological therapy), or wait-list.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and outcomes post-treatment and at first available follow-up. Primary outcomes were parenting behavior and parent mental health. Secondary outcomes were child behavior/disability, child mental health, child medical symptoms, and family functioning. We pooled data using the standardized mean difference (SMD) and a random-effects model, and evaluated outcomes by medical condition and by therapy type. We assessed risk of bias per Cochrane guidance and quality of evidence using GRADE.

MAIN RESULTS

We added 21 new studies. We removed 23 studies from the previous update that no longer met our inclusion criteria. There are now 44 RCTs, including 4697 participants post-treatment. Studies included children with asthma (4), cancer (7), chronic pain (13), diabetes (15), inflammatory bowel disease (2), skin diseases (1), and traumatic brain injury (3). Therapy types included cognitive-behavioural therapy (CBT; 21), family therapy (4), motivational interviewing (3), multisystemic therapy (4), and problem-solving therapy (PST; 12). We rated risk of bias as low or unclear for most domains, except selective reporting bias, which we rated high for 19 studies due to incomplete outcome reporting. Evidence quality ranged from very low to moderate. We downgraded evidence due to high heterogeneity, imprecision, and publication bias.Evaluation of parent outcomes by medical conditionPsychological therapies may improve parenting behavior (e.g. maladaptive or solicitous behaviors; lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.28, 95% confidence interval (CI) -0.43 to -0.13; participants = 664; studies = 3; SMD -0.21, 95% CI -0.37 to -0.05; participants = 625; studies = 3; I2 = 0%, respectively, low-quality evidence), chronic pain post-treatment and follow-up (SMD -0.29, 95% CI -0.47 to -0.10; participants = 755; studies = 6; SMD -0.35, 95% CI -0.50 to -0.20; participants = 678; studies = 5, respectively, moderate-quality evidence), diabetes post-treatment (SMD -1.39, 95% CI -2.41 to -0.38; participants = 338; studies = 5, very low-quality evidence), and traumatic brain injury post-treatment (SMD -0.74, 95% CI -1.25 to -0.22; participants = 254; studies = 3, very low-quality evidence). For the remaining analyses data were insufficient to evaluate the effect of treatment.Psychological therapies may improve parent mental health (e.g. depression, anxiety, lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.21, 95% CI -0.35 to -0.08; participants = 836, studies = 6, high-quality evidence; SMD -0.23, 95% CI -0.39 to -0.08; participants = 667; studies = 4, moderate-quality evidence, respectively), and chronic pain post-treatment and follow-up (SMD -0.24, 95% CI -0.42 to -0.06; participants = 490; studies = 3; SMD -0.20, 95% CI -0.38 to -0.02; participants = 482; studies = 3, respectively, low-quality evidence). Parent mental health did not improve in studies of children with diabetes post-treatment (SMD -0.24, 95% CI -0.90 to 0.42; participants = 211; studies = 3, very low-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent mental health.Evaluation of parent outcomes by psychological therapy typeCBT may improve parenting behavior post-treatment (SMD -0.45, 95% CI -0.68 to -0.21; participants = 1040; studies = 9, low-quality evidence), and follow-up (SMD -0.26, 95% CI -0.42 to -0.11; participants = 743; studies = 6, moderate-quality evidence). We did not find evidence for a beneficial effect for CBT on parent mental health at post-treatment or follow-up (SMD -0.19, 95% CI -0.41 to 0.03; participants = 811; studies = 8; SMD -0.07, 95% CI -0.34 to 0.20; participants = 592; studies = 5; respectively, very low-quality evidence). PST may improve parenting behavior post-treatment and follow-up (SMD -0.39, 95% CI -0.64 to -0.13; participants = 947; studies = 7, low-quality evidence; SMD -0.54, 95% CI -0.94 to -0.14; participants = 852; studies = 6, very low-quality evidence, respectively), and parent mental health post-treatment and follow-up (SMD -0.30, 95% CI -0.45 to -0.15; participants = 891; studies = 6; SMD -0.21, 95% CI -0.35 to -0.07; participants = 800; studies = 5, respectively, moderate-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent outcomes.Adverse eventsWe could not evaluate treatment safety because most studies (32) did not report on whether adverse events occurred during the study period. In six studies, the authors reported that no adverse events occurred. The remaining six studies reported adverse events and none were attributed to psychological therapy. We rated the quality of evidence for adverse events as moderate.

AUTHORS' CONCLUSIONS

Psychological therapy may improve parenting behavior among parents of children with cancer, chronic pain, diabetes, and traumatic brain injury. We also found beneficial effects of psychological therapy may also improve parent mental health among parents of children with cancer and chronic pain. CBT and PST may improve parenting behavior. PST may also improve parent mental health. However, the quality of evidence is generally low and there are insufficient data to evaluate most outcomes. Our findings could change as new studies are conducted.

An Effective Diabetic Ketoacidosis Prevention Intervention in Children With Type 1 Diabetes

The objective of this study was to evaluate the effectiveness of a brief, office-based educational intervention to increase parent or patient recognition of the early warning signs and symptoms of diabetic ketoacidosis (DKA). Forty-two patients aged > 13 years and 34 parents of children aged ≤ 13 years were given a pretest questionnaire about their knowledge of signs and symptoms of DKA and sick day management practices. They received a brief refresher course on sick day management specific to their treatment modality (pump vs. injection) and were given a take-home flow sheet of guidelines for diabetes sick day management. Subjects were retested with the same knowledge questionnaire after 6 to 12 months. Patients or parents scored higher on the posttest than the pretest and called the emergency line for assistance more frequently (p = .032) following the intervention. Emergency department visits were significantly reduced in adolescents (p = .024). A short educational intervention and printed management tool is effective in improving sick day and DKA knowledge and appears to be effective in reducing emergency department visits by increasing utilization of a diabetes emergency line for early outpatient intervention.

Comprehensive Community-Based Intervention and Asthma Outcomes in African American Adolescents

: media-1vid110.1542/5804911922001PEDS-VA_2017-3737Video Abstract BACKGROUND: African American adolescents appear to be the most at risk for asthma morbidity and mortality even compared with other minority groups, yet there are few successful interventions for this population that are used to target poorly controlled asthma.

METHODS

African American adolescents (age 12-16 years) with moderate-to-severe persistent asthma and ≥1 inpatient hospitalization or ≥2 emergency department visits in 12 months were randomly assigned to Multisystemic Therapy-Health Care or an attention control group (N = 167). Multisystemic Therapy-Health Care is a 6-month home- and community-based treatment that has been shown to improve illness management and health outcomes in high-risk adolescents by addressing the unique barriers for each individual family with cognitive behavioral interventions. The attention control condition was weekly family supportive counseling, which was also provided for 6 months in the home. The primary outcome was lung function (forced expiratory volume in 1 second [FEV₁]) measured over 12 months of follow-up.

RESULTS

Linear mixed-effects models revealed that compared with adolescents in the comparison group, adolescents in the treatment group had significantly greater improvements in FEV₁ secondary outcomes of adherence to controller medication, and the frequency of asthma symptoms. Adolescents in the treatment group had greater reductions in hospitalizations, but there were no differences in reductions in emergency department visits.

CONCLUSIONS

A comprehensive family- and community-based treatment significantly improved FEV₁, medication adherence, asthma symptom frequency, and inpatient hospitalizations in African American adolescents with poorly controlled asthma. Further evaluation in effectiveness and implementation trials is warranted.

Health Care Utilization and Burden of Diabetic Ketoacidosis in the U.S. Over the Past Decade: A Nationwide Analysis

OBJECTIVE

Diabetes is one of the most common chronic diseases and a leading cause of morbidity and mortality in the U.S. Although our ability to treat diabetes and its associated complications has significantly improved, presentation with uncontrolled diabetes leading to ketoacidosis remains a significant problem.

RESEARCH DESIGN AND METHODS

We aimed to determine the incidence and costs of hospital admissions associated with diabetic ketoacidosis (DKA). We reviewed the National Inpatient Sample database for all hospitalizations in which DKA (ICD-9 codes 250.10, 250.11, 250.12, and 250.13) was the principal discharge diagnosis during 2003-2014 and calculated the population incidence by using U.S. census data. Patients with ICD-9 codes for diabetic coma were excluded because the codes do not distinguish between hypoglycemic and DKA-related coma. We then analyzed changes in temporal trends of incidence, length of stay, costs, and in-hospital mortality by using the Cochrane-Armitage test.

RESULTS

There were 1,760,101 primary admissions for DKA during the study period. In-hospital mortality for the cohort was 0.4% (n = 7,031). The total number of hospital discharges with the principal diagnosis of DKA increased from 118,808 in 2003 to 188,965 in 2014 (P < 0.0001). The length of stay significantly decreased from an average of 3.64 days in 2003 to 3.24 days in 2014 (P < 0.01). During this period, the mean hospital charges increased significantly from $18,987 (after adjusting for inflation) per admission in 2003 to $26,566 per admission in 2014. The resulting aggregate charges (i.e., national bill) for diabetes with ketoacidosis increased dramatically from $2.2 billion (after adjusting for inflation) in 2003 to $ 5.1 billion in 2014 (P < 0.001). However, there was a significant reduction in mortality from 611 (0.51%) in 2003 to 620 (0.3%) in 2014 (P < 0.01).

CONCLUSIONS

Our analysis shows that the population incidence for DKA hospitalizations in the U.S. continues to increase, but the mortality from this condition has significantly decreased, indicating advances in early diagnosis and better inpatient care. Despite decreases in the length of stay, the costs of hospitalizations have increased significantly, indicating opportunities for value-based care intervention in this vulnerable population.

Family-Based Interventions Targeting Improvements in Health and Family Outcomes of Children and Adolescents with Type 1 Diabetes: a Systematic Review

PURPOSE OF REVIEW

A systematic review was conducted of family-based interventions to improve glycemic control, adherence, and psychosocial outcomes in children and adolescents with type 1 diabetes (T1D). Electronic databases were searched for randomized controlled trials (RCTs) published since the seminal Diabetes Control and Compliance Trial (DCCT). Interventions are summarized and findings reviewed to help guide clinical practice and future research.

RECENT FINDINGS

Twenty-five RCTs are reviewed. The majority of studies (n = 15) focused on interventions targeting both children and adolescents and their caregivers and were delivered in diabetes clinics, outpatient settings, mental health clinics, or participants' homes. Family-based interventions for youth with T1D appear effective at improving diabetes and family-centered outcomes. Additional research is needed to examine the pathways to improvement in glycemic control, as outcomes were mixed. Future research should also involve measures beyond HbA1c given new markers for sustained health improvement and outcomes are being explored.

Mental health issues in children and adolescents with chronic illness

Purpose

The purpose of this paper is to consider mental health issues in children and adolescents with chronic illness or health conditions, including their treatment, and issues related to delivery of services.

Design/methodology/approach

A selective review of the literature was conducted to highlight significant mental health issues and their treatment in youth with various types of chronic illness.

Findings

A significant portion of youth experience mental health problems related to their chronic health conditions. While evidence-based treatments are available to address these problems, significant barriers exist that impede the delivery of psychological and behavioral interventions for many youth.

Research limitations/implications

More controlled studies are needed to demonstrate the effectiveness and cost offset of delivering psychological and behavioral interventions for the population of youth with various types of chronic health conditions, particularly in clinical and community settings.

Social implications

Policy reform can ensure that mental health issues are effectively addressed for children with chronic illness. Policy is needed that promotes integrated health care, whereby psychological and behavioral interventions are delivered in health care settings along with medical interventions to reduce barriers to care.

Originality/value

Significant numbers of children and adolescents have chronic health conditions and many experience mental health problems related to their conditions. While evidence-based treatments are available to address these problems, significant barriers impede the delivery of psychological and behavioral interventions for many youth. Health care policy promoting integrated health care to deliver psychological and behavioral interventions in health care settings along with medical interventions should reduce barriers to care and improve both physical and mental health outcomes for youth.

Delay discounting and parental monitoring in adolescents with poorly controlled type 1 diabetes

In a sample of adolescents with poorly controlled type 1 diabetes, this study examined if delay discounting, the extent to which individuals prefer immediate over delayed rewards, was associated with severity of non-adherence and poor glycemic control, and if parental monitoring of diabetes management moderated those associations. Sixty-one adolescents (M _age = 15.08 years, SD 1.43) with poorly controlled type 1 diabetes completed a delayed discounting task and an HbA1c blood test. Adherence was assessed via self-monitoring of blood glucose (SMBG) data from adolescents' glucometers. Parents completed a parental monitoring questionnaire. Greater delay discounting was associated with higher HbA1c, but not SMBG. Direct parent observation of diabetes tasks, but not indirect parental monitoring, moderated the link between greater delay discounting and higher HbA1c, with higher direct parent observation buffering the link between greater discounting and poorer glycemic control. Delay discounting may be a target for future interventions to improve HbA1c in youth with type 1 diabetes.

Treating Mental Illness Among Diabetic Black Male Adolescents: A Review

OBJECTIVE

To examine randomized controlled trials (RCTs) for treatment evidence for Black male adolescents suffering from comorbid mental illness and diabetes mellitus.

METHOD

A review of the studies published in English-language journals was conducted.

RESULTS

We found no RCT focused on Black males with diabetes mellitus Type 2 (DMT2). However, we found RCT inclusive of Black male adolescents with diabetes mellitus Type 1 (DMT1). Multisystemic therapy appears to be the best supported overall treatment for DMT1 management and psychosocial functioning followed by an enhanced form of behavioral family systems therapy for diabetics. Metformin was the only treatment in this review noted for use within DMT2. Metformin and a nursing-based telephone case management intervention realized utility as secondary services.

CONCLUSIONS

There are gaps present for what effectively treats comorbid mental illness and DMT2 in Black male adolescents. For comorbid mental illness and DMT1, there are gaps in additional efficacious treatments, effectiveness across conditions, and effect duration beyond 24 months.

Evidence-based behavioral interventions to promote diabetes management in children, adolescents, and families

As members of multidisciplinary diabetes care teams, psychologists are well-suited to support self-management among youth with Type 1 diabetes (T1D) and Type 2 diabetes (T2D) and their families. Psychological and behavioral interventions can promote adherence to the complex and demanding diabetes care regimen, with the goals of promoting high quality of life, achieving optimal glycemic control, and ultimately preventing disease-related complications. This article reviews well-researched contemporary behavioral interventions to promote optimal diabetes family- and self-management and health outcomes in youth with T1D, in the context of key behavioral theories. The article summarizes the evidence base for established diabetes skills training programs, family interventions, and multisystemic interventions, and introduces emerging evidence for technology and mobile health interventions and health care delivery system interventions. Next steps in behavioral T1D intervention research include tailoring interventions to meet individuals' and families' unique needs and strengths, and systematically evaluating cost-effectiveness to advocate for dissemination of well-developed interventions. Although in its infancy, this article reviews observational and intervention research for youth with T2D and their families and discusses lessons for future research with this population. Interventions for youth with T2D will need to incorporate family members, consider cultural and family issues related to health behaviors, and take into account competing priorities for resources. As psychologists and behavioral scientists, we must advocate for the integration of behavioral health into routine pediatric diabetes care in order to effectively promote meaningful change in the behavioral and medical well-being of youth and families living with T1D and T2D. (PsycINFO Database Record

New directions for diabetes prevention and management in behavioral medicine

Accelerating diabetes rates have resulted in a global public health epidemic. Lifestyle change is a cornerstone of care, yet regimen demands may result in adherence difficulties. Distress, depression, and other psychosocial concerns are higher in those with diabetes. While interventions, such as the Diabetes Prevention Program appear to be effective, further research is needed to support the translation of interventions to prevent diabetes. Studies assessing optimal approaches to promoting effective decision making, coping and adherence are needed. More information is needed to evaluate the influence and potential of emerging technologies on intervention delivery and quality of life in children and adults with diabetes. Theoretically informed, interdisciplinary studies that consider ecological models are needed to develop a roadmap for policies and diabetes management recommendations. Reduction of diabetes-related health disparities is a critical area for future studies. Behavioral medicine scientists and practitioners are poised to address these and other proposed future research directions to advance diabetes prevention and management.

An Evaluation of Recurrent Diabetic Ketoacidosis, Fragmentation of Care, and Mortality Across Chicago, Illinois

OBJECTIVE

A portion of patients with diabetes are repeatedly hospitalized for diabetic ketoacidosis (DKA), termed recurrent DKA, which is associated with poorer clinical outcomes. This study evaluated recurrent DKA, fragmentation of care, and mortality throughout six institutions in the Chicago area.

RESEARCH DESIGN AND METHODS

A deidentified Health Insurance Portability and Accountability Act-compliant data set from six institutions (HealthLNK) was used to identify 3,615 patients with DKA (ICD-9 250.1x) from 2006 to 2012, representing 5,591 inpatient admissions for DKA. Demographic and clinical data were queried. Recurrence was defined as more than one DKA episode, and fragmentation of health care was defined as admission at more than one site.

RESULTS

Of the 3,615 patients, 780 (21.6%) had recurrent DKA. Patients with four or more DKAs (n = 211) represented 5.8% of the total DKA group but accounted for 26.3% (n = 1,470) of the encounters. Of the 780 recurrent patients, 125 (16%) were hospitalized at more than one hospital. These patients were more likely to recur (odds ratio [OR] 2.96; 95% CI 1.99, 4.39; P < 0.0001) and had an average of 1.88-times the encounters than nonfragmented patients. Although only 13.6% of patients died of any cause during the study period, odds of death increased with age (OR 1.06; 95% CI 1.05, 1.07; P < 0.001) and number of DKA encounters (OR 1.28; 95% CI 1.04, 1.58; P = 0.02) after adjustment for age, sex, insurance, race, fragmentation, and DKA visit count. This study was limited by lack of medical record-level data, including comorbidities without ICD-9 codes.

CONCLUSIONS

Recurrent DKA was common and associated with increased fragmentation of health care and increased mortality. Further research is needed on potential interventions in this unique population.

Multisystemic Therapy Improves the Patient-Provider Relationship in Families of Adolescents with Poorly Controlled Insulin Dependent Diabetes

The purpose of this study was to determine if multisystemic therapy (MST), an intensive, home and community-based family treatment, significantly improved patient-provider relationships in families where youth had chronic poor glycemic control. One hundred forty-six adolescents with type 1 or 2 diabetes in chronic poor glycemic control (HbA1c ≥8 %) and their primary caregivers were randomly assigned to MST or a telephone support condition. Caregiver perceptions of their relationship with the diabetes multidisciplinary medical team were assessed at baseline and treatment termination with the Measure of Process of Care-20. At treatment termination, MST families reported significant improvement on the Coordinated and Comprehensive Care scale and marginally significant improvement on the Respectful and Supportive Care scale. Improvements on the Enabling and Partnership and Providing Specific Information scales were not significant. Results suggest MST improves the ability of the families and the diabetes treatment providers to work together.

Patient Characteristics Associated with Differences in Admission Frequency for Diabetic Ketoacidosis in United States Children's Hospitals

OBJECTIVES

To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children's hospitals.

STUDY DESIGN

Multicenter retrospective cohort analysis of 12,449 children 2-18 years of age with a diagnosis of DKA in 42 US children's hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals.

RESULTS

In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥ 12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively.

CONCLUSIONS

Across children's hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.

The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management

The prognosis of diabetic ketoacidosis has undergone incredibly remarkable evolution since the discovery of insulin nearly a century ago. The incidence and economic burden of diabetic ketoacidosis have continued to rise but its mortality has decreased to less than 1% in good centers. Improved outcome is attributable to a better understanding of the pathophysiology of the disease and widespread application of treatment guidelines. In this review, we present the changes that have occurred over the years, highlighting the evidence behind the recommendations that have improved outcome. We begin with a discussion of the precipitants and pathogenesis of DKA as a prelude to understanding the rationale for the recommendations. A brief review of ketosis-prone type 2 diabetes, an update relating to the diagnosis of DKA and a future perspective are also provided.

Recruitment and retention in obesity prevention and treatment trials targeting minority or low-income children: a review of the clinical trials registration database

Background

Efforts to recruit and retain participants in clinical trials are challenging, especially in studies that include minority or low-income children. To date, no studies have systematically examined recruitment and retention strategies and their effectiveness in working successfully with this population. We examined strategies employed to recruit or retain minority or low-income children in trials that included an obesity-related behavior modification component.

Methods

First, completed home-, community-, and school-based trials involving minority or low-income children aged 2–17 years were identified in a search of the ClinicalTrials.gov registry. Second, a PubMed search of identified trials was conducted to locate publications pertinent to identified trials. Recruitment and retention rates were calculated for studies that included relevant information.

Results

Our final analytic sample included 43 studies. Of these, 25 studies reported recruitment or retention strategies, with the amount of information varying from a single comment to several pages; 4 published no specific information on recruitment or retention; and 14 had no publications listed in PubMed. The vast majority (92 %) of the 25 studies reported retention rates of, on average, 86 %. Retention rates were lower in studies that: targeted solely Hispanics or African Americans (vs. mixed races of African Americans, whites, and others); involved children and parents (vs. children only); focused on overweight or obese children (vs. general children), lasted ≥1 year (vs. <1 year), were home or community-based (vs. school-based), included nutrition and physical activity intervention (vs. either intervention alone), had body mass index or other anthropometrics as primary outcome measures (vs. obesity-related behavior, insulin sensitivity, etc.). Retention rates did not vary based on child age, number of intervention sessions, or sample size.

Conclusions

Variable amounts of information were provided on recruitment and retention strategies in obesity-related trials involving minority or low-income children. Although reported retention rates were fairly high, a lack of reporting limited the available information. More and consistent reporting and systematic cataloging of recruitment and retention methods are needed. In addition, qualitative and quantitative studies to inform evidence-based decisions in the selection of effective recruitment and retention strategies for trials including minority or low-income children are warranted.

Health-system-based interventions to improve care in pediatric and adolescent type 1 diabetes

Despite significant advances in pharmacology and technology, glycemic targets are difficult to achieve for patients with type 1 diabetes (T1D) and management remains burdensome for patients and their families. Quality improvement (QI) science offers a methodology to identify an aim, evaluate complex contributors to the goal, and test potential interventions to achieve outcomes of interest. Day-to-day management of diabetes is often an iterative process but interventions exist at all care levels: individual patient and family, clinic, and larger population and health system. This article reviews current literature and proposes novel QI interventions for enhancing health outcomes, with attention to essential determinants or drivers of improved glycemic control and patient experience for pediatric T1D in the context of the Chronic Care Model. In-depth consideration of key drivers of successful T1D care, including self-management and integration of technology, are explored, and examples of larger health systems with improved outcomes, including Learning Health Systems are highlighted.

Effectiveness of a multidisciplinary team approach to the prevention of readmission for acute glycaemic events

AIMS

To describe the effect of a combined diabetes specialist/mental health team approach to prevent readmissions for acute glycaemic events among patients with diabetes.

METHODS

Consecutive patients with diabetes, readmitted to a single hospital for an acute glycaemic condition, were offered one or more diabetes (including assessment, education, medication, technology use and intensive support) and mental health (including assessment, training and therapies) interventions. The pilot service took place over 11 months, with the preceding 24 months and subsequent 8 months serving as control periods.

RESULTS

Of the 58 patients admitted, 50 had Type 1 diabetes and were from within the hospital catchment area, and were discharged home. Of these, 32 (64%) had a pre-existing mental health issue and 14 (28%) had a complex social situation. In all, 96% of patients were met as an inpatient by a team member, and 94% accepted at least one intervention. The mean ±sd number of admissions per patient/month dropped from 0.12 ± 0.10 to 0.05 ± 0.10 (P < 0.001) during the intervention, increasing, once the intervention ended, to 0.16 ± 0.36 (P = 0.002). The mean ± sd length of stay similarly decreased and increased (0.6 ± 0.9 to 0.2 ± 0.7 days; P < 0.001 to 0.006) to 0.6 ± 1.4 days (P = 0.003) per patient/month) across the three periods, as did the mean ±sd tariff paid per patient/month (₤258.0 ± 374.0 vs ₤92.1 ± 245.0 vs ₤287.3 ± 563.8; P < 0.001 and P = 0.018, respectively). The mean ± sd HbA1c level dropped from 99 ± 22 to 92 ± 24 mmol/mol (11.2 ± 4.2% vs 10.6 ± 4.3%; P = 0.014) but did not increase after the intervention [89 ± 26 mmol/mol (10.4 ± 4.5%)].

CONCLUSIONS

The cost and long-term risks of hospitalization among patients with Type 1 diabetes and recurrent admissions can be reduced by a combined specialist diabetes/mental health team approach.

Preventing Diabetic Ketoacidosis

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

Treating the most vulnerable and costly in diabetes

Diabetic ketoacidosis (DKA) is associated with negative health outcomes and high costs for patients, families, and communities. Interventions developed to effectively reduce DKA and related costs should target the multiple risk factors associated with DKA and adherence difficulties. Certain demographic, psychological, and family factors are associated with increased risk for adherence problems and DKA. Individuals with a combination of risk factors (e.g., mental health problems, low socioeconomic status, high family conflict) may be particularly vulnerable to DKA. Although several different interventions have demonstrated promise in improving adherence and/or decreasing the risk of DKA, the generalizability of treatment results to those individuals most vulnerable to DKA is limited. Approaches which include multiple evidence-based components of care, are flexible in treatment delivery (e.g., home- and community-based, utilize technology), and target the multiple risk factors across relevant systems (e.g., individual, family, school, medical) are warranted to effectively reduce DKA in vulnerable populations.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies have been developed for parents of children and adolescents with a chronic illness. Such therapies include interventions directed at the parent only or at parent and child/adolescent, and are designed to improve parent, child, and family outcomes. This is an updated version of the original Cochrane review published in Issue 8, 2012, (Psychological interventions for parents of children and adolescents with chronic illness).

OBJECTIVES

To evaluate the efficacy of psychological therapies that include parents of children and adolescents with chronic illnesses including painful conditions, cancer, diabetes mellitus, asthma, traumatic brain injury (TBI), inflammatory bowel diseases (IBD), skin diseases, or gynaecological disorders. We also aimed to evaluate the adverse events related to implementation of psychological therapies for this population. Secondly, we aimed to evaluate the risk of bias of included studies and the quality of outcomes using the GRADE assessment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO for randomised controlled trials (RCTs) of psychological interventions that included parents of children and adolescents with a chronic illness. Databases were searched to July 2014.

SELECTION CRITERIA

Included studies were RCTs of psychological interventions that delivered treatment to parents of children and adolescents with a chronic illness compared to an active control, waiting list, or treatment as usual control group.

DATA COLLECTION AND ANALYSIS

Study characteristics and outcomes were extracted from included studies. We analysed data using two categories. First, we analysed data by each individual medical condition collapsing across all treatment classes at two time points. Second, we analysed data by each individual treatment class; cognitive behavioural therapy (CBT), family therapy (FT), problem solving therapy (PST) and multisystemic therapy (MST) collapsing across all medical conditions. For both sets of analyses we looked immediately post-treatment and at the first available follow-up. We assessed treatment effectiveness for two primary outcomes: parent behaviour and parent mental health. Five secondary outcomes were extracted; child behaviour/disability, child mental health, child symptoms, family functioning, and adverse events. Risk of bias and quality of evidence were assessed.

MAIN RESULTS

Thirteen studies were added in this update, giving a total of 47 RCTs. The total number of participants included in the data analyses was 2985, 804 of whom were added to the analyses in the update. The mean age of the children was 14.6 years. Of the 47 RCTs, the studies focused on the following paediatric conditions: n = 14 painful conditions, n = 13 diabetes, n =10 cancer, n = 5 asthma, n = 4 TBI, and n = 1 atopic eczema. We did not identify any studies treating parents of children with gynaecological disorders or IBD. Risk of bias assessments of included studies were predominantly unclear. Evidence quality, assessed using the GRADE criteria, was judged to be of low or very low quality.Analyses of separate medical conditions, across all treatment types, revealed two beneficial effects of psychological therapies for our primary outcomes. First, psychological therapies led to improved adaptive parenting behaviour in parents of children with cancer post-treatment (standardised mean difference (SMD) -0.20, 95% confidence interval (CI) -0.36 to -0.04, Z = 2.44, p = 0.01). In addition, therapies also improved parent mental health at follow-up in this group (SMD = -0.18, 95% CI -0.32 to -0.04, Z = 2.58, p = 0.01). We did not find any effect of therapies for parent behaviour for parents of children with a painful condition post-treatment or at follow-up, or for parent mental health for parents of children with cancer, diabetes, asthma, or TBI post-treatment. For all other primary outcomes, no analysis could be conducted due to lack of data.Across all medical conditions, three effects were found for the primary outcomes of psychological therapies. PST had a beneficial effect on parent adaptive behaviour (SMD = -0.25, 95% CI -0.39 to -0.11, Z = 3.59, p < 0.01) and parent mental health (SMD= -0.24, 95% CI -0.42 to -0.05, Z = 2.50, p = 0.01) immediately post-treatment and this effect was maintained at follow-up for parent mental health (SMD= -0.19, 95% CI -0.34 to -0.04, Z = 2.55, p = 0.01). The remaining analysis for PST on parent behaviour found no effect. No effects were found for CBT post-treatment or at follow-up for either parent outcome. For FT, only one analysis could be run on parent mental health and no effect was found. Due to lack of data, the remaining analyses of primary outcomes could not be run. For MST, no parent outcomes could be analysed due to lack of data.Secondary outcome analyses are presented in the Results section. Five studies reported that there were no adverse events during the trial. The remaining 42 studies did not report adverse events.

AUTHORS' CONCLUSIONS

This update includes 13 additional studies, although our conclusions have not changed from the original version. There is little evidence for the efficacy of psychological therapies that include parents on most outcome domains of functioning, for a large number of common chronic illnesses in children. However, psychological therapies are efficacious for some outcomes. CBT that includes parents is beneficial for reducing children's primary symptoms, and PST that includes parents improved parent adaptive behaviour and parent mental health. There is evidence that the beneficial effects can be maintained at follow-up for diabetes-related symptoms in children, and for the mental health of parents of children with cancer and parents who received PST.

Psoriasis in childhood: effective strategies to improve treatment adherence

Psoriasis is a relatively common chronic inflammatory skin disease in children for which there is no cure. Most children have mild disease that can be managed with topical therapy as opposed to phototherapy or systemic therapy. Despite the mild presentation of psoriasis in most children, the disease can have a significant impact on quality of life due to the need for ongoing treatment, the frequently visible nature of the cutaneous manifestations, and the social stigma that is associated with psoriasis. Adherence to treatment, in particular topical therapy, is often poor in adults and compromises response to therapy and medical provider management strategies. Multiple factors that may contribute to nonadherence in adults with psoriasis have been identified, including lack of education on the disease and expectations for management, issues related to ease of use and acceptability of topical medications, and anxiety regarding possible medication side effects. There is currently no published data on adherence in the pediatric psoriasis population; however, poor adherence is often suspected when patients fail to respond to appropriate therapy. General strategies used to assess adherence in other pediatric disease populations can be applied to children with psoriasis, and interventions that reflect experience in other chronic dermatologic disorders such as atopic dermatitis may also be helpful for medical providers caring for children with psoriasis.

Novel Interventions in Children's Healthcare for Youth Hospitalized for Chronic Pain

The purpose of this study was to pilot the implementation of the Novel Interventions in Children's Healthcare (NICH) program for youth with chronic pain who utilized a disproportionate amount of health care. Three youth (2 males and 1 female, aged 11 to 15 years) participated. The intervention consisted of a combination of family-based problem-solving, care coordination, and case management, with the inclusion of technology-assisted treatment delivery (e.g., text messages, video chat) to reduce costs. Both objective (i.e., hospitalization records) and subjective (e.g., interventionist reports) outcomes were examined to assess changes over the course of treatment. Two of the three youth demonstrated reductions in the number of days hospitalized and associated costs. In addition, interventionist reports indicated improved quality of life for family and youth served. Although further research is needed, NICH appears to be a promising intervention for youth with chronic pain and high health care utilization and shows the potential to result in improved youth health and reduced monetary costs for families, providers, and the healthcare system.

Effects of family treatment on parenting beliefs among caregivers of youth with poorly controlled asthma

OBJECTIVE

Caregiver involvement is critical in ensuring optimal adolescent asthma management. The study investigated whether multisystemic therapy (MST), an intensive home-based family therapy, was superior to family support for changing beliefs regarding asthma-related positive parenting among caregivers of African-American youth with poorly controlled asthma. The relationship between parenting beliefs and asthma management at the conclusion of the intervention was also assessed.

METHODS

A randomized controlled trial was conducted with 167 adolescents with moderate-to-severe, persistent, poorly controlled asthma and their primary caregivers. Families were randomly assigned to MST or family support (FS), a home-based family support condition. Data were collected at baseline and 7-month posttest. Changes in caregiver ratings of importance and confidence for engaging in asthma-related positive parenting were assessed through questionnaire. Illness management was assessed by the Family Asthma Management System Scale.

RESULTS

Participation in MST was associated with more change in caregiver beliefs as compared with FS for both importance (t = 2.39, p = .02) and confidence (t = 2.04, p = .04). Caregiver beliefs were also significantly related to youth controller medication adherence at the conclusion of treatment (importance: r = .21, p = .01; confidence: r = .23, p = .004).

CONCLUSION

Results support the effectiveness of MST for increasing parental beliefs in the value of asthma-related positive parenting behaviors and parental self-efficacy for these behaviors among families of minority adolescents with poorly controlled asthma.