Medical Care Patterns at the Onset of Insulin-dependent Diabetes Mellitus: Association with Severity and Subsequent Complications

Abstract

The hospitalization of a child at the onset of insulin-dependent diabetes mellitus (IDDM) has become routine in many parts of the world, although controversy exists about its necessity. We examined the patterns of medical care use and the prognosis for acute complications after diagnosis for children with newly diagnosed IDDM in Colorado from 1978 to 1982. We reasoned that if children cared for entirely in outpatient settings at diagnosis had no more frequent acute complications after diagnosis than hospitalized children, we would be encouraged to further explore other potential benefits of outpatient care at onset. Twelve percent of 305 children studied statewide received only outpatient care during the first 2 wk after diagnosis, and, prognostically, their subsequent hospitalization and ketoacidosis rates were 2-3.7 times lower than those of children who received any inpatient care. No differences were noted for severe insulin reaction rates. Children classified as "severe" at onset, or with parents of lower education and income, or aged 10-14 yr at onset, regardless of care setting, had 2-4 times higher subsequent acute complication rates after onset than children without these characteristics. These findings, together with data on nights hospitalized and average length of stay in hospital at onset, suggest that a 42% reduction in total nights hospitalized could occur if children with "mild" or "normal" severity at onset were treated largely in the outpatient setting.

Presentation and progress of childhood diabetes mellitus: a prospective population-based study

“…The proportion of patients admitted at diagnosis varied from 48-100 % between districts, and two of the eight districts accounted for 48 % of all those not admitted. Our study confirmed that admission at diagnosis does not affect subsequent outcome measures such as readmission or episodes of severe hypoglycaemia, even when the groups were matched for severity of disease at presentation [6,15]. A survey of British paediatricians found that 87 % admitted more than 80 % of all new cases, but that 47 % would change this policy if better community facilities became available [16].…”

“…Girls are more likely to be readmitted than boys but the relationship with age at diagnosis is inconsistent. We found younger children to be at highest risk whereas Haman et al [6] found the risk highest in adolescence, and Hardie et al [3] found no relationship with age.…”

“…In addition, medical records were reviewed on a sample of 33 of the 96 (34 %) whose parents reported admission but no intravenous therapy, and on 57 of the 69 members of the 1985/1986 cohort who had not been included in the Bart's-Oxford study or who did not respond to the questionnaire. [6]. Venous bicarbonate was recorded in 82 of the 115 patients from both cohorts in whom acid-base data were available, and arterial puncture was performed in the remaining 33 patients.…”

Hospitalization among diabetic children and adolescents and non-diabetic control subjects: a prospective population-based study

“…It is conceivable that structured education in the first course after diabetes onset results in lower complication events and will lead to lower hospitalization in the following [17,29,30,31,32,33]. Nevertheless, it has to be discussed whether educational programmes can be performed in outpatient settings.…”

High Risk of IDDM in African-American and Hispanic Children in Chicago, 1985–1990

“…Although no similar information exists for U.S. Hispanics, these race differences are presumably due in large part to differences in socioeconomic conditions. In Colorado, the rate of rehospitalization among Hispanic IDDM patients was greater than that among non-Hispanic white patients (22), and those whose mothers had <12 years schooling had twice the risk of rehospitalization than those with mothers who had some college education. These statistics are particularly compelling in light of recent findings that strict attention to diabetes management can cause postponement or avoidance of chronic microvascular complications (23).…”