The impact of a diabetes management team on the metabolic control and prevalence of complications in paediatric patients with type 1 diabetes mellitus

[摘要] ENGLISH ABSTRACT : BACKGROUND: In various centres a diabetes management team (DMT) wasfound to have an impact on glycaemic control.HYPOTHESIS: A DMT improves HbA1c levels, decreases the diabeticketoacidosis (DKA) and recurrent DKA (rDKA) rates, reduces admissions,shortens the length of hospital stay, improves clinic attendance rate, leads toa reduced dose of insulin per patient, facilitates the use of an intensive insulinregimen and decreases the prevalence of complications of type 1 diabetic(T1DM) paediatric and adolescent patients attending Tygerberg Children'sHospital (TCH).STUDY DESIGN: Retrospective cohort study (a time series) with crosssectionalelements.METHODS: 190 T1DM patients attending the paediatric diabetic clinic at TCHbetween August 2004 and July 2011 were reviewed. Data extracted: HbA1clevels, DKA and rDKA admissions, total number of admissions, length ofhospital stay, clinic attendances, insulin regimen and dose, and complications.4 time periods were compared: P1 (paediatric endocrinologist only), P2(introduction of DMT after a period when no paediatric endocrinologist wasavailable), P3 [introduction of diabetes nurse educator (DNE)], and P4(substitution of DNE).RESULTS: HbA1c increased from 9% (95% CI 7.85-10.15) in P1 to 10.9%(95% CI 9.6-12.2) in P2, and decreased to 9.25% (95% CI 8.75-9.75) in P4(p=0.01818). DKA rate improved from 32.5 (P1) to 23.5 /100 patient years(P4). Recurrent DKA rate improved from 18.8% (P1) to 9.6% (P4).Admissions decreased from 0.79 (95% CI 0.46-1.12) in P1 to 0.18 (95% CI0.02-0.34) in P4 (p=0.00127). Patients hospitalised for longer than 30 daysdecreased from 30% (P2) to 15.1 % (P4). Number of insulin injectionsincreased from 2.97 (95% CI 2.91-3.03) in P1, to 3.06 (95% CI 2.97-3.14) inP2 but remained constant thereafter (p=0.0015). Few complications weredocumented in P1. Prevalence of microalbuminuria was similar (95% CI 26.9-46.2%) in all periods, as was retinopathy (95% CI 10.3-13.3%). Prevalence oflimited joint mobility (LJM) increased from 26% (P2) to 42.9% (P4). Levels oftriglycerides were similar in all periods, low-density lipoprotein cholesterol(LDLC) decreased to 2.6mmol/l (95% CI 2.38-2.81) in P3 and high-densitylipoprotein cholesterol (HDLC) decreased to 1.38mmol/l (95% CI 1.27-1.49) in CONCLUSIONS: After introduction of the full DMT (including the DNE),HbA1c decreased and showed less variation, DKA and rDKA rate decreased,hospital stay shortened, number of insulin injections/day increased andcomplications were more readily identified. Decreased clinic attendancecorresponded to poorer glycaemic control and the period where inexperiencedpersonnel were responsible for diabetes care. There was an increase inusage of both the modified conventional regimen as well as the basal bolusregimen as time progressed. It is therefore recommended that the services ofthe DMT, which includes a DNE, should continue.

[发布机构] Stellenbosch University