The initial care when a child is diagnosed with type 1 diabetes
Sammanfattning: When a child is diagnosed with diabetes, the symptoms may be in its most severe form with ketoacidosis, to mild symptoms of diabetes, detected incidentally. Moderate and severe symptoms of diabetes presentation require infusion therapy and thereby necessitate hospitalisation for the first few days. The initial management is largely a preparation for family members to help them gain the practical understanding and skills needed for integrating the treatment in everyday life. Some units routinely admit the children to hospital, while others say they can be safely managed at home. There is no high-quality evidence concerning the consequences that the differences in the type of service might have for the child, family or health system. The overall aim of this thesis was to investigate the initial care for children newly diagnosed with type 1 diabetes, receiving conventional hospital-based care and hospital-based home care (HBHC), i.e. specialist care in a home-based setting. A further aim was to identify families where the child runs the risk of decreased metabolic control and to give these families increased support. Two studies have been carried out at Skåne University Hospital Lund in Sweden. The first had a retrospective design with the aim of assessing whether temporal changes in the initial management over a ten year period affected children’s metabolic control two years after diagnosis. The results showed that during the years 1997 up to 2006 all children, except one, were admitted to hospital. The duration of the hospital stay decreased from a mean of three weeks to two weeks. Seventy-five per cent of the children were not acutely ill (defined as pH ≥7.30) at diagnosis and 94% of the children initially received intravenous insulin treatment. Neither the length of the hospital stay nor any differences in insulin treatment were associated with children’s metabolic control over time. The second study had a randomised design with the aim of comparing two different regimes for children diagnosed with type 1 diabetes: hospital-based care and HBHC. The follow-up of the study was two years. In this thesis, results one and six months from diagnosis are presented. No adverse events or severe acute diabetes complications have occurred during the trial or during the follow-up. Results one month from diagnosis showed small advantages to HBHC in the children’s metabolic control with regards to plasma glucose values and numbers of episodes of hypoglycaemia. Parents were more satisfied with the service in HBHC, and healthcare costs were 30% lower in HBHC compared to the hospital-based service. The results six months from diagnosis showed that parents continued to be more satisfied with the service in HBHC. Furthermore, the results showed that there were no differences in the children’s HbA1c, in the arrangement of the parents’ working hours after the child’s diagnosis or in the amount of absence from work related to the child’s diagnosis. The categorical risk for families’ psychosocial distress, assessed by professionals at the time of diagnosis, was associated with subsequent resource use, although not HbA1c. Families that received HBHC had less use of healthcare resources, compared to families having received hospital-based care. When summarising the first month and the period from 1-6 months, the total healthcare costs were 27% lower in HBHC compared to hospital-based care. In summary, for children diagnosed with type 1 diabetes, the length of the hospital stay has decreased significantly over a ten year period. During this time, children have usually been routinely admitted to hospital irrespective of their medical condition. The results support the suggestion that an HBHC programme is just as safe for the child as hospital-based care. The results further indicate equivalence in the efficacy of the services. These results, in combination with a high degree of acceptance by those to whom the HBHC service was offered and lower healthcare costs, could suggest that the HBHC service is more effective as compared to the conventional hospitalbased care. As a whole, there are not many well-designed and controlled studies that have compared hospital services with different models of home care. This thesis, although limited in answers by power and knowledge stability, provides empirical support for the safety and effectiveness of healthcare services when a child is diagnosed with type 1 diabetes. The evaluation will continue to assess the consequences, of both HBHC and hospital-based care, for the child, family and health services over time and from different perspectives.
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