Diabetic ketoacidosis presentations in a low socio-economic area: are services suitable?

BACKGROUND: Diabetic ketoacidosis causes a significant number of hospitalisations worldwide, with rates tending to increase with remoteness and socioeconomic disadvantage. Our study aimed to explore healthcare professionals' perceptions of factors affecting presentation of people with type 1 diabetes in a low socioeconomic area of Queensland, Australia. METHODS: This was a qualitative study. Individual semi-structured face-to-face or telephone interviews were completed with patients with type 1 diabetes who had presented in diabetic ketoacidosis, and healthcare professionals who have experience in related care. Data were analysed using Gibbs's framework of thematic analysis. RESULTS: Four patients with type 1 diabetes and 18 healthcare professionals were interviewed. Restricted access was identified as a factor contributing to diabetic ketoacidosis and delayed presentation, with ketone testing supplies, continuous glucose monitoring technology and transport considered barriers. Many of these factors were arguably preventable. Opportunities to improve the care available to patients with type 1 diabetes were detailed, with particularly strong support for dedicated out of hours telephone help lines for adults with type 1 diabetes. CONCLUSIONS: Gaps in support for patient self-care to avoid diabetic ketoacidosis presentations and prevent late presentation of diabetic ketoacidosis revealed by this study require service reconfiguration to support care delivery. Until change is made, people with type 1 diabetes will continue to make both avoidable and delayed, acutely unwell, presentations to Emergency Departments.

A discussion of healthcare support for adolescents and young adults with long-term conditions: Current policy and practice and future opportunities.

BACKGROUND: Adolescence and young adulthood can be a period of significant and unique life changes in which competing demands and challenges distract from disease self-management. Specific challenges related to the way individual services are configured can also limit the support available. This paper presents a discussion of healthcare service support for adolescents and young adults, using type 1 diabetes as an exemplar. DESIGN: Discussion paper. RESULTS: A wide variety of issues at the biopsychosocial level of the individual, health services policy and practice pose challenges to effective health support for adolescents and young adults. Intersectoral, multilevel and multicomponent opportunities are available to engage and empower young people to be part of change and accountability mechanisms and to transform the support available and outcomes achievable. A priority research agenda can benefit patients, families and their communities. CONCLUSION: Future policy and practice development may assist clinicians, service providers and managers, policymakers, non-governmental organizations and community groups to deliver more effective and efficient support to vulnerable adolescent and young adult populations.

Service use of young people with Type 1 diabetes after transition from paediatric to adult-based diabetes health care.

Objective The aim of this study was to determine, in the first 2 years after the last planned appointment with paediatric diabetes services for young people with Type 1 diabetes (T1D): (1) the number of planned and unplanned healthcare contacts and HbA1c measurements made; (2) factors linked to diabetes-related service use; and (3) factors predictive of the number of planned and unplanned service contacts, and of meeting the minimum number of planned service contacts. Methods Healthcare records of a major public healthcare provider in Australia were audited for preventive and acute service use by young people with T1D transferring from paediatric to adult public healthcare services. Statistical analyses included use of t-tests and logistic regression modelling. Results Of 172 young people with T1D, 21% had no planned specialist care and 49% accessed acute services for diabetes-related matters. Residents of metropolitan areas and users of continuous subcutaneous insulin infusion therapy were more likely to access specialist care and were less likely to use acute services for unplanned care. Those achieving a minimum of nine planned care contacts in 2 years had a shorter duration between the last paediatric and first adult healthcare contact. Conclusions Lack of specialist care in early adult years and non-metropolitan relative disadvantage compromise the present and future health of young people with diabetes. What is known about the topic? Well-managed transition is thought to offer the best chance of achieving cost-effective continuing engagement with specialist services for planned preventive care, effective T1D self-management and deferral or early attention to diabetes-related vascular complications. However, transition is commonly reported as problematic. What does this paper add? The findings of this study indicate a positive trend but continuing need to improve transition care for young people with T1D, especially those living in non-metropolitan areas and those not using continuous subcutaneous insulin infusion therapy. What are the implications for practitioners? Without service innovation, suboptimal and delayed access to planned care, high use of acute services for unplanned care and poor glycaemic control will continue to threaten the future health and well-being of young people with T1D.

Readiness for diabetes prevention and barriers to lifestyle change in women with a history of gestational diabetes mellitus: rationale and study design.

AIMS: Women with gestational diabetes mellitus (GDM) have a high risk of future diabetes, which can be prevented with lifestyle modification. Prior diabetes prevention programmes in this population have been limited by lack of adherence. The aim of this study is to evaluate readiness for behaviour change at different time points after GDM diagnosis and identify barriers and facilitators, to inform a lifestyle modification programme specifically designed for this group. The objective of this paper is to present the rationale and methodological design of this study. METHODS: The ongoing prospective cohort study has recruited a multi-ethnic cohort of 1353 women with GDM from 7 Ontario, Canada hospitals during their pregnancy. A questionnaire was developed to evaluate stage of readiness for behaviour change, and sociodemographic, psychosocial, and clinical predictors of healthy diet and physical activity. Thus far, 960 women (71%) have completed a baseline survey prior to delivery. Prospective postpartum follow-up is ongoing. We are surveying women at 2 time-points after delivery: 3-12 months postpartum, and 13-24 months postpartum. Survey data will be linked to health care administrative databases for long-term follow-up for diabetes. Qualitative interviews were conducted in a subset of women to gain a deeper understanding of barriers and facilitators to lifestyle change. CONCLUSIONS: Our study is a fundamental first step in effectively addressing diabetes prevention in women with GDM. Our findings will aid in the design of a diabetes prevention intervention specifically targeted to women with recent GDM, which can then be evaluated in a clinical trial.

Screening for the high-risk diabetic foot: a 60-second tool (2012).

People with diabetes mellitus will develop lower-limb complications, such as neuropathy, peripheral vascular disease, foot ulcers, and lower-leg amputations. Resources to control elevated hemoglobin A1c and blood pressure, along with the standardized approach using the 60-second tool (2012), can detect the high-risk diabetic foot and help prevent complications.

Lost in transition? Access to and uptake of adult health services and outcomes for young people with type 1 diabetes in regional New South Wales.

OBJECTIVE: To document diabetes health services use and indices of glycaemic management of young people with type 1 diabetes from the time of their first contact with adult services, for those living in regional areas compared with those using city and state capital services, and compared with clinical guideline targets. DESIGN, SETTING AND SUBJECTS: Case note audit of 239 young adults aged 18-28 years with type 1 diabetes accessing five adult diabetes services before 30 June 2008 in three geographical regions of New South Wales: the capital (86), a city (79) and a regional area (74). MAIN OUTCOME MEASURES: Planned (routine monitoring) and unplanned (hospital admissions and emergency department attendance for hypoglycaemia or hyperglycaemia) service contacts; recorded measures of glycated haemoglobin (HbA(1c)), body mass index (BMI), and blood pressure (BP). RESULTS: Routine preventive service uptake during the first year of contact with adult services was significantly higher in the capital and city. Fewer regional area patients had records of complications assessment and measurements of HbA(1c), BMI and BP across all audited years of contact (HbA(1c): 73% v 94% city, 97% capital; P < 0.001). Across all years, regional area patients had the highest proportion of HbA(1c) values > 8.0% (79% v 62% city, 56% capital) and lowest proportion < 7% (4% v 7%, 22%) (both P < 0.001). Fewer young people made unplanned use of acute services for diabetes crisis management in the capital (24% v 49% city, 50% regional area; P < 0.001). In the regional area, routine review did not occur reliably even annually, with marked attrition of patients from adult services after the first year of contact. CONCLUSION: Inadequate routine specialist care, poor diabetes self-management and frequent use of acute services for crisis management, particularly in regional areas, suggest service redesign is needed to encourage young people's engagement.

Description of an early discharge post-acute care program: length of hospital stay, patient and carer needs and cost.

The objective of the project was to evaluate a pilot Post Acute Community Care (PACC) program for orthopaedic patients. A series of cross-sectional surveys elicited responses of patient and home carer needs and GP and hospital staff acceptability while a cost-minimisation analysis compared the average cost of the PACC program with general orthopaedic hospital care. Patients were classified according to Australian National Diagnosis Related Groups (DRGs). Average length of hospital stay in 1998/99 for PACC patients was 7.7 days compared to 12.3 for general orthopaedic patients. Only 3% of patients had an unplanned readmission to hospital. Patients and carers expressed a number of unmet needs. This study confirms the popularity of early discharge schemes with patients, and provides little evidence of adverse health outcomes or that the burden of care is shifted to carers in a way that is unacceptable for this older population.

Reorganisation of an ailing aged care service.

This paper evaluates the impact of reorganisation of geriatric and general medical services in a tertiary referral hospital. The patients involved were predominantly elderly with multiple medical problems. We used an iterative process of bed utilisation review, stakeholder consultation and service remodelling to improve bed management. Reduced length of stay and increased throughput allowed closure of between 22 and 30 beds and generated recurrent cost savings of $900,000 annually. Even under pressure it is possible to describe and evaluate the process of change. Such description and evaluation may help to avoid expensive mistakes.