medwireNews: The setting in which children with newly diagnosed type 1 diabetes initiate their care makes no significant difference to glucose control, psychologic outcomes, or the rate of adverse events, shows a UK study comparing home and hospital options.
“Given that hospitalization at diagnosis is costly for the [UK National Health Service], consideration should be given as to how the currently more intensive packages of care that are offered to the newly diagnosed might be provided in the context of early discharge to home-based care,” Julia Townson (Cardiff University) and co-investigators remark.
The Delivering Early Care in Diabetes Evaluation (DECIDE) trial included 203 children (mean age 9.8 years) with newly diagnosed type 1 diabetes from eight UK pediatric diabetes centers. Of these, 101 were randomly assigned to begin diabetes management at home, with the remaining 102 beginning treatment in hospital.
Patients in the home-based care arm were discharged home on the day of diagnosis and had no overnight stay in hospital. All of their education about diabetes and its management was provided by nurses at home or on an outpatient basis.
By contrast, patients in the hospital-based care group spent a minimum of 3 nights as inpatients during which time they and their families received similar treatment and education to that received by patients in the home-based arm.
At 24 months, there was no significant difference in mean glycated hemoglobin levels between the participants who initially received home- versus hospital-based care, at 72.1 versus 72.6 mmol/mol (8.7 vs 8.8%).
There were also no differences between the two groups in growth or psychologic outcomes at either 1 month or 24 months, with the exception of self-esteem, which was significantly higher among children in the hospital arm than the home arm at 1 month, but then significantly lower at 24 months.
The researchers also note that none of the children in the home management group were admitted to hospital during the 3-day initiation period and there were no adverse events during that time.
Overall, the serious adverse event rate was higher in the home-based arm than in the hospital-based arm (36.0 vs 26.5%), but the difference was not statistically significant. The majority of these events were either hypoglycemic or hyperglycemic in nature.
Writing in BMJ Open, Townson and co-authors say their findings “challenge established clinical practice as well as inform those responsible for the provision of health services who wish to redesign care pathways with more care provided in the community.”
They believe their results will be “generalisable across a range of healthcare systems,” but note that the use of research-funded nurses could render the home care-based system “unfeasible without additional specialist nursing resources,” in routine clinical practice.
The team therefore concludes: “It may be that a hybrid model, of a brief stay in hospital and early home management, offers a pragmatic solution to the challenges presented by both systems as has been tested in Canada, Sweden and Australia.”
By Laura Cowen
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