Sharing the care of pediatric patients with type 1 diabetes

Nutrition Research Newsletter, Nov, 2006

Research has proven the health benefits of intensive therapy for type 1 diabetes. The benefit-cost ratio for intensive therapy in adolescents was shown to be identical to that in adults, and intensive therapy for type 1 diabetes is cost-effective in comparison to treatment of other common chronic conditions. One of the many potential barriers to widespread translation of intensive diabetes therapy is the limited availability of health professionals trained in new methods, which are more complex, laborious, and costly.

Expert panels convened to analyze education needs in pediatrics' have concluded that pediatric generalists should participate in chronic disease management insofar as their own skills allow and that pediatric subspecialists should move toward the development of integrated delivery systems that facilitate interaction between specialists and generalists. Efficacy and effectiveness studies are needed that compare new models to existing models of care.

A recent investigation was designed to examine the feasibility of shared care model for delivering intensive diabetes therapy to youth with type 1 diabetes. The Cumberland Pediatric Diabetes Network (CPDN) was designed to integrate the services of primary care pediatricians and the multidisciplinary diabetes specialty team consisting of one pediatric endocrinologist, two nurses in advanced practice, and one master 's-prepared registered dietitian. The intent of the network was to also help families perceive that the diabetes specialty team was an extension of their pediatricians' offices. Key elements of the model were explicitly defined professional roles and procedures to guide the movement of patients and information within the network. Pediatricians were responsible for patient recruitment and chronic care. The specialty team was responsible for initiating therapy, completing self-management training, and serving as a resource as needed thereafter.

The diabetes specialty team developed an educational program on intensive treatment of type 1 diabetes for participating pediatricians. The program's cognitive material was provided as a 75-page printed text and was sent to the participating pediatricians prior to the special training. Two weeks following, the diabetes team presented a 4-hour workshop in the pediatricians' offices, emphasizing patient management skills, especially behavior change counseling, and network procedures. Pediatricians referred diabetes patients from their practices by explaining the health benefits of intensive therapy and the opportunity to initiate intensive therapy through the CPDN project. All patients aged six years and older were considered eligible.

The diabetes specialty team performed an assessment for initiation of intensive management and negotiated a treatment plan with the referred family. The endocrinologist saw patients only once at the first visit and then discussed each patient's status at weekly specialty team meetings. Patient visits for self-management training with the nurses and dietitian were conducted over 6 weeks to 12 weeks. There was continuity of care in that the family was seen by the registered dietitian and the same nurse in advanced practice throughout the 2-year study. In addition to self-management training, the nurses and dietitian maintained telephone contact with each family during this period, reviewed blood glucose records, and used a problem-solving paradigm to evaluate blood glucose levels outside the target range. Families returned to the care of their pediatricians when, in the judgment of the diabetes team, they had acquired basic self-management skills, whether or not blood glucose target levels had been achieved.

Patient/family satisfaction was assessed by a questionnaire adapted for the project. Pediatricians completed a similar satisfaction questionnaire with 17 items.

Twenty-nine patients accepted pediatrician referral, 25 kept initial training sessions, and 20 completed at least one year in the network. All 24 invited pediatricians participated, and 17 enrolled patients. All families who completed satisfaction surveys were highly satisfied with the network. Nine-teen pediatricians completed end-of-study questions and were also highly positive about sharing care with the specialty team. The mean A1C value was near target levels or better the first year, and it rose during the second year.

This investigation supports the feasibility of integrating general pediatric practices with diabetes specialty services for children with type 1 diabetes.

E. King, R. Gregory, M. Flannery. Feasibility Test of a Shared Care Network for Children with Type 1 Diabetes Mellitus. The Diabetes Educator, 32:723-733 (September/ October 2006). [Correspondence: Elaine Boswell King, MSN, APRN, BC, CDE, Vanderbilt Diabetes Research and Training Center, 315 Medical Arts Building, 1211 21st Avenue S, Nashville, TN 37212. E-mail: Elaine.boswell.king@vanderbilt.edu.]