Home-based management can achieve intensification cost-effectively in type I diabetes. An economic evaluation of home care for children with newly diagnosed diabetes: results from a randomized controlled trial. Use of multisystemic therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control: a randomized controlled trial. Using telecommunication technology to manage children with diabetes: the Computer-Linked Outpatient Clinic (CLOC) Study. Comparing outpatient and inpatient diabetes education for newly diagnosed pediatric patients. Outpatient management vs in-hospital management of children with new-onset diabetes. Education and telephone case management for children with type 1 diabetes: a randomized controlled trial. Helping other mothers effectively work at raising young children with type 1 diabetes. Failure to maintain the benefits of home-based intervention in adolescents with poorly controlled type 1 diabetes.
Newly diagnosed insulin-dependent diabetic children are most often admitted to hospital for education and insulin management and subsequently followed in outpatient clinics or office settings. However, most could be managed at home, given adequate family and health care team support and subsequent follow-up facilitated by home-based nursing intervention. We conducted a randomized trial of clinical, psychosocial, and cost effects of home-based management in a 2-year follow-up study of newly diagnosed diabetic children.
                Sixty three patients were randomly assigned to traditional hospitalization and outpatient follow-up (hospital-based group) or home management (home-based group). Treatment differences between the two groups consisted of duration of initial hospital stay, site and timing of initial teaching, and nature and extent of subsequent nursing follow-up. Metabolic control was assessed by means of quarterly glycosylated hemoglobin measurements for 24 months and then at 36 months. Diabetes-related adverse events, knowledge of diabetes, adherence to the diabetes regimen, psychosocial impact, and social (total) costs incurred were assessed for 24 months.
                Glycosylated hemoglobin concentrations were significantly lower in the home-based group at 12 to 24 months and at 36 months. Both groups had comparable numbers of diabetes-related adverse events. There were no significant group differences in psychosocial impact. Parents in the home-based group spent significantly fewer hours on diabetes care and incurred significantly lower out-of-pocket expenses during the 1st month. Health care sector costs were significantly higher. Hospital costs were $889 higher, and government costs $890 higher per child. Social (total) costs were only $48 higher per case (NS) with home care when parents' time was valued at $11.88 per hour.
                Home-based management for newly diagnosed diabetic children can result in better metabolic control and similar psychosocial outcomes compared with traditional hospital- and clinic-based care without notable effects on social (total) costs. This study was undertaken to determine the health and cost effects of using home care to treat newly diagnosed Type I diabetic children rather than traditional inpatient hospital care. There had been no well-designed evaluations of home care for such children, and very few for children with other health conditions.
                Sixty-three children seen at the Montreal Children's Hospital were randomly assigned at diagnosis to home care or traditional inpatient care. The children in the former group were discharged once their metabolic condition stabilized; insulin adjustments and teaching were done in their homes by a trained nurse. The children in the latter group remained hospitalized for insulin adjustments and teaching. All were followed for 24 months. The cost effects were estimated using hospital and parental data.
                Social costs were only $48 higher with home care. It had little effect on social costs, because the increased costs of health care services with home care ($768) were largely offset by parental cost savings ($720). Home care improved the children's metabolic outcomes without adversely affecting their psychosocial outcomes.
                Using home care to reduce hospital stays for children with newly diagnosed Type I diabetes improved the children's health outcomes without significantly increasing social costs. The aim of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could improve adherence and metabolic control and decrease rates of hospital utilization among adolescents with chronically poorly controlled type 1 diabetes.
                A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and chronically poor metabolic control (HbA(1c) [A1C] > or =8% for the past year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants randomly assigned to MST received treatment for approximately 6 months. Data were collected at baseline and at 7 months posttest (i.e., treatment termination). Changes in A1C adherence, as measured by semistructured interviews and blood glucose meters and hospital admissions and emergency department visits, were assessed.
                In intent-to-treat analyses, participation in MST was associated with significant improvements in the frequency of blood glucose testing as assessed by blood glucose meter readings (F[1,125] = 16.75, P = 0.001) and 24-h recall interviews (F[1,125] = 6.70, P = 0.011). Participants in MST also had a decreasing number of inpatient admissions, whereas the number of inpatient admissions increased for control subjects (F[1,125] = 6.25, P = 0.014). Per protocol analyses replicated intent-to-treat analyses but also showed a significant improvement in metabolic control for adolescents receiving MST compared with control subjects (F[1,114] = 4.03, P = 0.047).
                Intensive, home-based psychotherapy improves the frequency of blood glucose testing and metabolic control and decreases inpatient admissions among adolescents with chronically poorly controlled type 1 diabetes. The purpose of this study was to evaluate the efficacy of using a telecommunication system to assist in the outpatient management of pediatric patients with insulin-dependent diabetes. Metabolic control, patients' psychosocial status, family functioning, perceived quality of life, patterns of parental/child responsibility for daily diabetes maintenance, and nursing time-on-task were evaluated. One hundred six pediatric patients (mean age = 13.3 years) were randomly assigned to an experimental or control outpatient clinic for 1 year. Experimental subjects transmitted self-monitoring blood glucose data by modem to the hospital every 2 weeks. Transmitted data were reviewed by nurse practitioners who telephoned subjects to discuss regimen adjustments. Control subjects received standard care with regimen adjustments made by physicians. There were no significant between-group differences for metabolic control, rates of hospitalization or emergency-room visits, psychological status, general family functioning, quality of life, or parent-child responsibility. A significant decrease was noted in nursing time-on-task for experimental subjects. The purpose of this study was to compare the efficacy of outpatient vs inpatient programs on medical, cognitive, behavioral, and psychosocial outcomes.
                Using three large, tertiary medical centers in the United States, the sample of 32 children newly diagnosed with diabetes and their parents were recruited. Children and parents who received outpatient education were compared with those who received inpatient education. The following outcome variables were compared: (1) rates of hospital readmissions and/or emergency room visits for either severe hypoglycemia or ketoacidosis, (2) knowledge, (3) sharing of responsibilities, (4) adherence, (5) family functioning, (6) coping, and (7) quality of life.
                In general, no statistically significant differences were found between the groups. A trend was noted in the outpatient group with regard to improved use of emergency precautions on the adherence measure, roles on the family functioning measure, maintaining family integration on the parental coping measure, and disposition on the children's coping instrument.
                Findings support the safety and efficacy of the outpatient program method. The long-term results of outpatient management of subjects with newly diagnosed insulin-dependent diabetes mellitus (IDDM) are unknown. The longest follow-up described to date is for only one year, a time when most children with IDDM still make endogenous insulin. In this study, 41 young subjects with IDDM, treated and educated in the outpatient setting (1980 to 1984), were compared to a group of 80 similar subjects who received their initial education as hospital inpatients. Long-term glycemic control, as measured by longitudinal glycohemoglobin (HbA1) values was not different in the two groups (p greater than .05). We conclude that outpatient education and management of newly diagnosed subjects with IDDM is as safe and effective as inpatient treatment. The purpose of the study was to compare three nursing interventions and their impact on glycemic control among children with type I diabetes. The 75 subjects' mean +/- SD age was 12.5 +/- 3.4 years, 55% were boys, and 55% were White. Subjects were randomly assigned to a standard care (SC), an education (ED), or an education and telephone case management (ED + TCM) group. The primary outcome measure was glycemic control (hemoglobin A1c, or HbA1c). Secondary outcome measures were diabetes knowledge (KNOW), parent-child teamwork (TEAM), and adherence (ADH). After 6 months of follow-up, results demonstrated no significant differences among groups in HbA1c. KNOW and TEAM scores improved slightly in the ED and ED + TCM groups, but no statistically significant differences were found among the three groups. Significant improvement in ADH scores among ED + TCM groups was reported when compared with the ED and SC groups. This change may represent a move toward improved adherence to diabetes care and subsequent improvement in diabetes control. The challenges of recruitment and retention of subjects in this study will also be discussed. This study examined the feasibility of a postdiagnosis parent mentoring intervention for mothers of young children (1-10 years old) newly diagnosed with type 1 diabetes.
                A mixed-method, prospective, randomized, controlled clinical trial design was used. Parent mentors (experienced mothers who have successfully raised young children with type 1 diabetes) and mother participants with young children newly diagnosed with type 1 diabetes were recruited from 2 regional pediatric diabetes centers. The mentors were trained to provide informational, affirmational, and emotional support using Ireys' modified parent mentor curriculum. During a 6-month trial, mentors provided home visits and phone call support to the mothers who were randomized to the experimental group. The control group had the option of receiving the intervention after the 6-month trial.
                Mothers in the experimental group had fewer concerns, more confidence, identified more resources, and perceived diabetes having less of a negative impact on their family compared with mothers in the control group. Parent mentors provided important, practical day-to-day management information, reassurance, and emotional support during times of crises.
                A postdiagnosis parent mentoring intervention for mothers of children with diabetes appears to be feasible and potentially effective. To determine whether a 6-month home-based intervention program in adolescents with poorly controlled diabetes improves metabolic control and whether benefits are maintained after the intervention.
                Adolescents with a mean HbA1c of > 9.0% over the preceding 12 months received either routine care in a diabetes clinic and an ambulatory intervention for 6 months (n = 37) or routine care only (n = 32). A diabetes educator provided monthly home visits and weekly phone contact to educate and support the adolescents in setting goals for insulin adjustment, blood glucose monitoring, and target blood glucose range. There was no systematic change in the frequency of insulin injections. After the intervention, there was a 12-month follow-up when the intervention and control groups both received only routine care. Outcome measures were HbA1c and Diabetes Knowledge Assessment (DKN).
                During the intervention, mean HbA1c fell (baseline: 11.1 +/- 1.3%, 6 months: 9.7 +/- 1.6%; P = 0.0001) and mean knowledge scores increased (P = 0.0001) in the intervention group but not in control subjects. However, this improvement in HbA1c and increase in knowledge was not maintained in the intervention group at 12- and 18-month follow-up assessments. Parents' knowledge scores also improved significantly from baseline levels in the intervention group at 6 and 12 months (P = 0.001, P = 0.005, respectively).
                An ambulatory program improves metabolic control and knowledge in adolescents with poorly controlled type 1 diabetes; however, it is effective only while the intervention is maintained.
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.