9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Assessment of a new home-based care pathway for children newly diagnosed with type 1 diabetes

AIM

To compare the outcomes of home-based and conventional hospital-based care for children newly diagnosed with type 1 diabetes mellitus.

METHODS

A descriptive study was conducted of all children newly diagnosed with diabetes mellitus at the Timone Hospital in Marseille, France, between November 2017 and July 2019. The patients received either home-based or in-patient hospital care. The primary outcome was the length of initial hospital stay. The secondary outcome measures were glycemic control in the first year of treatment, families' diabetes knowledge, the effect of diabetes on quality of life, and overall quality of care.

RESULTS

A total of 85 patients were included, 37 in the home-based care group and 48 in the in-patient care group. The initial length of hospital stay was 6 days in the home-based care group versus 9 days in the in-patient care group. Levels of glycemic control, diabetes knowledge and quality of care were comparable in the two groups despite a higher rate of socioeconomic deprivation in the home-based care group.

CONCLUSION

Home-based care for children with diabetes is safe and effective. This new healthcare pathway provides good overall social care, especially for socioeconomically deprived families.

Hospital-based home care for young children newly diagnosed with type 1 diabetes: Assessing expectations and obstacles in families and general practitioners

AIMS

This study aimed to evaluate whether hospital-based home care was desired by the parents of children diagnosed with type 1 diabetes (T1D) under the age of 5 years and their general practitioners, and to identify the main expectations and obstacles to its implementation.

METHODS

This descriptive bicentric study in France was performed between November 2016 and November 2017. Data were collected by interviewing 57 families of children diagnosed with diabetes before the age of 5 years and the corresponding 30 general practitioners. The primary endpoint was the families' or general practitioners' acceptance of home-based care after diagnosis.

RESULTS

A high proportion of families and physicians (86% and 93%, respectively) expressed a wish for hospital-based home care, most of whom considered it essential (79% and 87%, respectively). Low-income families were less likely to accept this care pathway (P<0.001). The families' expectations regarding home care were help with social care, the management of emergencies, and return to school. The physicians' main request was improved interprofessional collaboration.

CONCLUSION

Hospital-based home care seems to be an acceptable transition after conventional care for children just diagnosed with T1D. Multidisciplinary support, personalized social care, and access to welfare benefits may improve acceptance rates, especially among low-income families.

Home-based vs inpatient education for children newly diagnosed with type 1 diabetes

BACKGROUND

Initial management of children diagnosed with type 1 diabetes (T1D) varies worldwide with sparse high quality evidence regarding the impact of different models of care.

AIM

To compare the inpatient model of care with a hybrid home-based alternative, examining metabolic and psychosocial outcomes, diabetes knowledge, length of stay, and patient satisfaction.

SUBJECTS AND METHODS

The study design was a randomized-controlled trial. Inclusion criteria were: newly diagnosed T1D, aged 3 to 16 years, living within approximately 1 hour of the hospital, English-speaking, access to transport, absence of significant medical or psychosocial comorbidity. Patients were randomized to standard care with a 5 to 6 day initial inpatient stay or discharge after 2 days for home-based management. All patients received practical skills training in the first 48 hours. The intervention group was visited twice/day by a nurse for 2 days to assist with injections, then a multi-disciplinary team made 3 home visits over 2 weeks to complete education. Patients were followed up for 12 months. Clinical outcomes included HbA1c, hypoglycemia, and diabetes-related readmissions. Surveys measured patient satisfaction, diabetes knowledge, family impact, and quality of life.

RESULTS

Fifty patients were recruited, 25 to each group. There were no differences in medical or psychosocial outcomes or diabetes knowledge. Average length of admission was 1.9 days shorter for the intervention group. Families indicated that with hindsight, most would choose home- over hospital-based management.

CONCLUSIONS

With adequate support, children newly diagnosed with T1D can be safely managed at home following practical skills training.

Insulin therapy in children and adolescents with type 1 diabetes

Treatment of type 1 diabetes mellitus (T1DM) requires lifelong administration of exogenous insulin. The primary goal of treatment of T1DM in children and adolescents is to maintain near-normoglycemia through intensive insulin therapy, avoid acute complications, and prevent long-term microvascular and macrovascular complications, while facilitating as close to a normal life as possible. Effective insulin therapy must, therefore, be provided on the basis of the needs, preferences, and resources of the individual and the family for optimal management of T1DM. To achieve target glycemic control, the best therapeutic option for patients with T1DM is basal-bolus therapy either with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Many formulations of insulin are available to help simulate endogenous insulin secretion as closely as possible in an effort to eliminate the symptoms and complications of hyperglycemia, while minimizing the risk of hypoglycemia secondary to therapy. When using MDI, basal insulin requirements are given as an injection of long- or intermediate-acting insulin analogs, while meal-related glucose excursions are controlled with bolus injections of rapid-acting insulin analogs. Alternatively, CSII can be used, which provides a 24-h preselected but adjustable basal rate of rapid-acting insulin, along with patient-activated mealtime bolus doses, eliminating the need for periodic injections. Both MDI treatment and CSII therapy must be supported by comprehensive education that is appropriate for the individual needs of the patient and family before and after initiation. Current therapies still do not match the endogenous insulin profile of pancreatic β-cells, and all still pose risks of suboptimal control, hypoglycemia, and ketosis in children and adolescents. The safety and success of a prescribed insulin regimen is, therefore, dependent on self-monitoring of blood glucose and/or a continuous glucose monitoring system to avoid critical hypoglycemia and glucose variability. Regardless of the mode of insulin therapy, doses should be adapted on the basis of the daily pattern of blood glucose, through regular review and reassessment, and patient factors such as exercise and pubertal status. New therapy options such as sensor-augmented insulin pump therapy, which integrates CSII with a continuous glucose sensor, along with emerging therapies such as the artificial pancreas, will likely continue to improve safe insulin therapy in the near future.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Representations and coverage of non-English-speaking immigrants and multicultural issues in three major Australian health care publications

BACKGROUND

No recent Australian studies or literature, provide evidence of the extent of coverage of multicultural health issues in Australian healthcare research. A series of systematic literature reviews in three major Australian healthcare journals were undertaken to discover the level, content, coverage and overall quality of research on multicultural health. Australian healthcare journals selected for the study were The Medical Journal of Australia (MJA), The Australian Health Review (AHR), and The Australian and New Zealand Journal of Public Health (ANZPH). Reviews were undertaken of the last twelve (12) years (1996-August 2008) of journal articles using six standard search terms: 'non-English-speaking', 'ethnic', 'migrant', 'immigrant', 'refugee' and 'multicultural'.

RESULTS

In total there were 4,146 articles published in these journals over the 12-year period. A total of 90 or 2.2% of the total articles were articles primarily based on multicultural issues. A further 62 articles contained a major or a moderate level of consideration of multicultural issues, and 107 had a minor mention.

CONCLUSIONS

The quantum and range of multicultural health research and evidence required for equity in policy, services, interventions and implementation is limited and uneven. Most of the original multicultural health research articles focused on newly arrived refugees, asylum seekers, Vietnamese or South East Asian communities. While there is some seminal research in respect of these represented groups, there are other communities and health issues that are essentially invisible or unrepresented in research. The limited coverage and representation of multicultural populations in research studies has implications for evidence-based health and human services policy.

Cost-effectiveness of neonatal surgery: first greeted with scepticism, now increasingly accepted

Mortality rates in neonatal surgery have dropped markedly, illustrating the enormous progress made. Yet, new questions have arisen. To mention one, health care budgets have tightened. It follows that the effects of medical interventions should be weighted against their costs. As evidence was particularly sparse, we set out to analyse cost-effectiveness of neonatal surgery. The purpose of this article is to summarise our findings and to review recent studies. Moreover, this article explains the relevance of cost-effectiveness analysis and explores how cost-effectiveness interacts with other determinants of health care priority setting. Our research revealed that treatments for two common diagnostic categories in neonatal surgery (congenital anorectal malformations and congenital diaphragmatic hernia) produce good cost-effectiveness. Other groups also published cost-effectiveness studies in the field of neonatal surgery, although their number is still small. Contemporaneously, the economic aspects of health care have captured the interest of policy makers. Importantly, this is not to say that there are no other factors playing a role in priority setting, foremost among which are ethical questions and arguments of equity. This article concludes that, according to present evidence, neonatal surgery yields good value for money and contributes to equity in health.

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

BACKGROUND

In many places, children newly diagnosed with type 1 diabetes mellitus are admitted to hospital for metabolic stabilisation and training, even if they are not acutely ill. Out-patient or home based management of these children could avoid the stress associated with a hospital stay, could provide a more natural learning environment for the child and its family, and might reduce costs for both the health care system and the families.

OBJECTIVES

To assess the effects of routine hospital admission compared to out-patient or home-based management in children newly diagnosed with type 1 diabetes mellitus.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, and the British Nursing Index. Additionally, we searched reference lists of relevant studies identified and contacted one of the trialists about further studies.

SELECTION CRITERIA

Comparative studies of initial hospitalisation compared to home-based and/or out-patient management in children with newly diagnosed type 1 diabetes.

DATA COLLECTION AND ANALYSIS

Studies were independently selected by two reviewers. Data extraction and quality assessment of trials were done independently by two reviewers. Authors of included studies were contacted for missing information. Results were summarised descriptively, using tables and text.

MAIN RESULTS

Seven studies were included in the review, including a total of 298 children in the out-patient/home group. The one high quality trial identified suggested that home-based management of children with newly diagnosed type 1 diabetes may lead to slightly improved long term metabolic control (at two and three years follow-up). No differences between comparison groups were found in any of the psychosocial and behavioural variables assessed or in rates of acute diabetic complications within two years. Parental costs were found to be decreased, while health system costs were increased, leaving total social costs virtually unchanged. None of the other studies assessing metabolic control found a difference between the comparison groups. There seemed to be no differences in hospitalisations or acute diabetic complications between the out-patient/home groups and the hospital groups.

AUTHORS' CONCLUSIONS

Due to the generally low quality or limited applicability of the studies identified, the results of this review are inconclusive. On the whole, the data seem to suggest that where adequate out-patient/home management of type 1 diabetes in children at diagnosis can be provided, this does not lead to any disadvantages in terms of metabolic control, acute diabetic complications and hospitalisations, psychosocial variables and behaviour, or total costs.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Psycho-educational interventions for children and young people with Type 1 diabetes

BACKGROUND

A systematic review of the literature in 2000 revealed numerous methodological shortcomings in education research, but in recent years progress has been made in the quantity and quality of psycho-educational intervention studies.

SUMMARY OF CONTENTS

This review focuses on diabetes education programmes developed for children, young people and their families in the past 5 years. A comprehensive review of the literature identified 27 articles describing the evaluation of 24 psycho-educational interventions. Data summary tables compare the key features of these, and comparisons are made between individual, group and family-based interventions. Effect sizes are calculated for nine of the randomized studies. Three research questions are posed: firstly has the recent literature addressed the problems highlighted in the previous review; secondly is there sufficient evidence to recommend adaptation of a particular programme; and, finally, what do we still need to do?

CONCLUSIONS

Progress in the quality and quantity of educational research has not resulted in improved effectiveness of interventions. There is still insufficient evidence to recommend adaptation of a particular educational programme and no programme that has been proven effective in randomized studies for those with poor glycaemic control. To develop a range of effective educational interventions, further research involving larger sample sizes with multicentre collaboration is required.