Development of a clinical pathway for ambulatory management of poorly controlled type 1 diabetes mellitus in children and adolescents

C. L. Link, M. A. Patterson, T. M. McGee, A. Fjone, D. L. Donaldson

Research output: Contribution to journalArticle

Abstract

Background: Poor metabolic control and diabetic ketoacidosis can be prevented in children and adolescents with Type 1 diabetes mellitus. We used home health case management for patients with worsening glycemic control due to non-adherence and/or hospitalizations for DKA. A clinical pathway was developed including education, clinical support and other care management services for such patients based upon several patterns of response to home health intervention. Methods: A retrospective chart review was performed for 21 patients referred to home health for non-adherence to their recommended diabetes regimen, including 11 patients who had one or more hospitalizations for DKA. Hemoglobin A1C (Hb1C) levels and rates of hospitalization and emergency room visits for at least one year prior to and six months after home health referral were determined. Interviews were conducted with the home health nurse to identify the approach taken and the responses of these patients and their families to this intervention. Results: After referral to home health the mean HbA1C levels of these patients decreased from 11.4±1.7% to 10.9±1.8% (p=0.45). The mean change for patients with an increasing HbA1C was +0.95% (p=0.315) with the mean change for patients with a decreasing HbA1C was -1.4% (p=0.097). The mean rate of hospitalization for patients with RDKA dropped from 13.1±8.8 hospitalizations per 100 patient-months prior to referral to 0.7+2.2 (p=0.0008) after referral, while the mean ER visit rate dropped from 9.2±15.2 to 4.3±6.5 (p=0.35) visits per 100 patient months. A clinical pathway was developed describing the responses that were observed when a patient was referred to home case management Conclusion: Home health care decreased HbA1C level in only a subgroup of patients with diabetes adherence. Those that displayed an increase did not increase a clinically significant amount, while those patents experiencing a decrease did display a clinically significant improvement. Home care did significantly reduce the rate of hospitalizations for DKA.

Original languageEnglish (US)
JournalJournal of Investigative Medicine
Volume47
Issue number2
StatePublished - Feb 1999

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