Treating the Most Vulnerable and Costly in Diabetes

Abstract

Diabetic ketoacidosis (DKA) is associated with negative health outcomes and high costs for patients, families, and communities. Interventions developed to effectively reduce DKA and related costs should target the multiple risk factors associated with DKA and adherence difficulties. Certain demographic, psychological, and family factors are associated with increased risk for adherence problems and DKA. Individuals with a combination of risk factors (e.g., mental health problems, low socioeconomic status, high family conflict) may be particularly vulnerable to DKA. Although several different interventions have demonstrated promise in improving adherence and/or decreasing the risk of DKA, the generalizability of treatment results to those individuals most vulnerable to DKA is limited. Approaches which include multiple evidence-based components of care, are flexible in treatment delivery (e.g., home- and community-based, utilize technology), and target the multiple risk factors across relevant systems (e.g., individual, family, school, medical) are warranted to effectively reduce DKA in vulnerable populations.

An Evaluation of Recurrent Diabetic Ketoacidosis, Fragmentation of Care, and Mortality Across Chicago, Illinois

“…Although these are pediatric interventions, they could be adapted for care in adults as well. These interventions involve patient and family education, coordination of care, cognitivebehavioral intervention, and family systems approaches (18). Newer approaches using newer technologies involving video conferencing and text messaging have also been advocated (18).…”

“…These interventions involve patient and family education, coordination of care, cognitivebehavioral intervention, and family systems approaches (18). Newer approaches using newer technologies involving video conferencing and text messaging have also been advocated (18). In addition, members of our group have previously reported use of regional informatics/health information exchanges for improved care coordination in the area of antibiotic-resistant infections (19,20).…”

Type 1 Diabetes in Children and Adolescents

“…Risk is increased in children with poor metabolic control or previous episodes of DKA, peripubertal and adolescent girls, children on CSII or long-acting basal insulin analogues, ethnic minorities, and children with psychiatric disorders and those with difficult family circumstances (72)(73)(74)(75). The frequency of DKA in established diabetes can be decreased with education, behavioural intervention and family support (76,77), as well as access to 24-hour telephone services or telemedicine for parents of children with diabetes (78)(79)(80).…”

Outpatient Care Preceding Hospitalization for Diabetic Ketoacidosis

“…Similarly, missed visits to endocrinology should activate less urgent case management strategies to prevent DKA, such as renewed education, care coordination, and patientor family-focused behavioral interventions. 26 At a population level, outpatient care utilization should be incorporated into predictive analytic models so that programs like CCS can focus limited human and financial resources on patients during the time when they are at highest risk. In addition, our findings that a large percentage of type 1 patients with diabetes may be receiving diabetes care from nonendocrinologists and that method of care delivery (eg, managed care) is associated with odds of DKA deserve further exploration, given the implications for health policy and system redesign.…”