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

Thesis (MSc)--Stellenbosch University, 2015ENGLISH ABSTRACT : BACKGROUND: In various centres a diabetes management team (DMT) was found to have an impact on glycaemic control. HYPOTHESIS: A DMT improves HbA1c levels, decreases the diabetic ketoacidosis (DKA) and recurrent DKA (rDKA) rates, reduces admissions, shortens the length of hospital stay, improves clinic attendance rate, leads to a reduced dose of insulin per patient, facilitates the use of an intensive insulin regimen and decreases the prevalence of complications of type 1 diabetic (T1DM) paediatric and adolescent patients attending Tygerberg Children’s Hospital (TCH). STUDY DESIGN: Retrospective cohort study (a time series) with crosssectional elements. METHODS: 190 T1DM patients attending the paediatric diabetic clinic at TCH between August 2004 and July 2011 were reviewed. Data extracted: HbA1c levels, DKA and rDKA admissions, total number of admissions, length of hospital 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 was available), 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% CI 0.02-0.34) in P4 (p=0.00127). Patients hospitalised for longer than 30 days decreased from 30% (P2) to 15.1 % (P4). Number of insulin injections increased from 2.97 (95% CI 2.91-3.03) in P1, to 3.06 (95% CI 2.97-3.14) in P2 but remained constant thereafter (p=0.0015). Few complications were documented 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 of limited joint mobility (LJM) increased from 26% (P2) to 42.9% (P4). Levels of triglycerides 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-density lipoprotein 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 and complications were more readily identified. Decreased clinic attendance corresponded to poorer glycaemic control and the period where inexperienced personnel were responsible for diabetes care. There was an increase in usage of both the modified conventional regimen as well as the basal bolus regimen as time progressed. It is therefore recommended that the services of the DMT, which includes a DNE, should continue.AFRIKAANSE OPSOMMING : AGTERGROND: Verskeie sentrums het vantevore bevind dat 'n diabetiese bestuurspan (DBS) 'n impak op glukemiese beheer het. HIPOTESE: ʼn DBS verlaag HbA1c vlakke, verminder diabetiese ketoasidose (DKA) en herhalende DKA (hDKA) episodes, verminder hospitaal toelatings, verkort hospitaal verblyf, verbeter kliniek bywoning, lei tot 'n verminderde dosis insulien gebruik per pasiënt, fasiliteer die gebruik van 'n intensiewe insulien skedule en, verminder die voorkoms van komplikasies van tipe 1-diabetes (T1DM) in pediatriese en adolessente pasiënte wat Tygerberg Kinder Hospitaal (TKH) besoek. STUDIE-ONTWERP: Terugwerkende Kohort studie ('n tyd reeks) met deursneeelemente. METODE: Die bywoning van 190 T1DM pasiënte by die pediatriese diabetese kliniek by TKH tussen Augustus 2004 en Julie 2011 is nagegaan. Die volgende data is versamel: HbA1c vlakke, DKA en hDKA opnames, die totale aantal opnames, die lengte van hospitaal verblyf, kliniek bywoning, insulien skedule, insulien dosis,en komplikasies. Vier tydperke is met mekaar vergelyk: P1 (net pediatriese endokrinoloog), P2 (bekendstelling van DBS na ‘n periode waar daar geen pediatriese endokrinoloog was nie), P3 [bekendstelling van diabetiese verpleegster opvoeder (DVO)], en P4 (vervanging van DVO). RESULTATE: HbA1c het toegeneem van 9% (95% CI 7,85-10,15) in P1 tot 10.9% (95% CI 9,6-12,2) in P2, en het verminder na 9,25% (95% CI 8,75-9,75) in P4 (p = 0,01818). DKA voorkoms het verbeter van 32.5 (P1) na 23.5 / 100 pasiënt jare (P4). HDKA het verbeter van 18,8% (P1) tot 9.6% (P4). Toelatings het afgeneem van 0,79 (95% CI 0,46-1,12) in P1 tot 0,18 (95% CI 0,02-0,34) in P4 (p = 0,00127). Die aantal pasiënte wat gehospitaaliseer was vir langer as 30 dae het verminder van 30% (P2) na 15,1% (P4). Die hoeveelheid insulien inspuitings het toegeneem van 2,97 (95% CI 2.91-3.03) in P1, na 3,06 (95% CI 2,97-3,14) in P2, maar het daarna konstant gebly (p=0,0015). Min komplikasies is gedokumenteer vir P1. Die voorkoms van mikroalbuminurie was soortgelyk (95% CI 26,9-46,2%) in al die tydperke, asook retinopatie (95% CI 10,3-13,3%). Voorkoms van beperkte gewrigsmobiliteit het verhoog vanaf 26% (P2) na 42,9% (P4). Vlakke van trigliseriede was soortgelyk in al die tydperke, lae-digtheid lipoproteïen cholesterol het afgeneem na 2.6mmol / l (95% CI 2,38-2,81) in P3 en hoë-digtheid lipoproteïen cholesterol het afgeneem na 1.38mmol / l (95% CI 1,27-1,49) in P4. GEVOLGTREKKING: Na bekendstelling van die volle DBS (insluitend die DVO), het HbA1c verlaag en meer konstant vertoon, DKA en hDKA syfers het gedaal, hospitaal verblyf het verkort, die hoeveelheid van insulieninspuitings per dag het verhoog en komplikasies is makliker geïdentifiseer. Verminderde kliniek bywonings korrespondeer met slegte glukemiese beheer en met die periode waar onervare personeel verantwoorelik was vir diabetiese sorg. Daar was ‘n toeneming in die gebruik van albei die gemodifiseerde konvensionele regimen en die basale bolus regimen. Ons beveel dus aan dat die dienste van die DBS, insluitend ‘n DVO moet voortgaan