Routine hospital admission versus out-patient or home care in children at diagnosis of type 1 diabetes mellitus

 

Abstract

Background

In many places, children newly diagnosed with type 1 diabetes mellitus are admitted to hospital for metabolic stabilisation and training, even if they are not acutely ill. Out-patient or home based management of these children could avoid the stress associated with a hospital stay, could provide a more natural learning environment for the child and its family, and might reduce costs for both the health care system and the families.

Objectives

To assess the effects of routine hospital admission compared to out-patient or home-based management in children newly diagnosed with type 1 diabetes mellitus.

Search methods

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, and the British Nursing Index. Additionally, we searched reference lists of relevant studies identified and contacted one of the trialists about further studies.

Selection criteria

Comparative studies of initial hospitalisation compared to home-based and/or out-patient management in children with newly diagnosed type 1 diabetes.

Data collection and analysis

Studies were independently selected by two reviewers. Data extraction and quality assessment of trials were done independently by two reviewers. Authors of included studies were contacted for missing information. Results were summarised descriptively, using tables and text.

Main results

Seven studies were included in the review, including a total of 298 children in the out-patient/home group. The one high quality trial identified suggested that home-based management of children with newly diagnosed type 1 diabetes may lead to slightly improved long term metabolic control (at two and three years follow-up). No differences between comparison groups were found in any of the psychosocial and behavioural variables assessed or in rates of acute diabetic complications within two years. Parental costs were found to be decreased, while health system costs were increased, leaving total social costs virtually unchanged. None of the other studies assessing metabolic control found a difference between the comparison groups. There seemed to be no differences in hospitalisations or acute diabetic complications between the out-patient/home groups and the hospital groups.

Authors' conclusions

Due to the generally low quality or limited applicability of the studies identified, the results of this review are inconclusive. On the whole, the data seem to suggest that where adequate out-patient/home management of type 1 diabetes in children at diagnosis can be provided, this does not lead to any disadvantages in terms of metabolic control, acute diabetic complications and hospitalisations, psychosocial variables and behaviour, or total costs.

 

Plain language summary

Routine hospital admission versus outpatient or home care in children at diagnosis of type 1 diabetes mellitus

Traditionally, children newly diagnosed with type 1 diabetes have been admitted to hospital to make sure that blood sugar and symptoms of the disease are well controlled and to teach the child and his/her family how to manage the diabetes. In some cases, the child is acutely ill and needs hospital admission to receive intravenous fluids, but in many cases the child is not acutely ill. Being in hospital is often stressful for children and their families and home-based care may provide a more natural environment for the children and families to learn how to deal with the diabetes. This review asked the question whether there are any benefits or dangers of using this type of care. We found only data of limited quality and or applicability, so no clear answers are possible. The seven studies we looked at suggested that home management of children newly diagnosed with type 1 diabetes does not lead to any disadvantages in terms of blood glucose, acute diabetic complications and hospitalisations, psychological variables and behaviour, or total costs. This would be particularly relevant for children not acutely ill, but also for children who require a short period of initial treatment in the hospital.

 

摘要

背景

比較第一型糖尿病兒童初診斷時之常規住院與門診治療或居家照護之影響

在許多地方,新診斷出為第一類型糖尿病的兒童,即使沒有急性病徵或不適,仍為達到新陳代謝的安定和訓練的目的而住院。以門診或家庭照護為基礎的照顧能讓這些兒童免於因住院而產生的壓力,為病童與其家庭提供一個較自然的學習環境,或許亦能因此而減少健康照護系統和家庭的開支。

目標

評估常規住院與以門診治療或家庭照護為基礎的照顧對初診斷為第一型糖尿病兒童的影響。

搜尋策略

搜尋的資料庫包括The Cochrane Library, MEDLINE, EMBASE, CINAHL, and the British Nursing Index.此外,也搜尋相關研究的參考資料,並與試驗者之一就更進深入的研究作接觸.

選擇標準

對於新診斷第一型糖尿病兒之初始治療為住院治療,居家照護或門診治療的比較研究。

資料收集與分析

二位審查者獨立地選擇研究。此外,對資料收集和試驗品質的評估亦由兩位審查者獨立完成。若資訊有缺漏,則會聯繫參與在內的作者。研究結果使用圖表和文字做描述總結。

主要結論

一共檢閱了了七項研究,包括298個在門診/家庭照護組的兒童。其中只有一個高品質試驗指出,在新診斷出為第一型糖尿病的兒童,以家庭為基礎的照護,對長期新陳代謝的控制(在二和三年後續追蹤)有輕微地改善;在心理社會,行為,或糖尿病急性併發症的發生率方面,在二年的追蹤期間內,兩組之間沒有顯著差異;雖然雙親的花費減少,但健康系統的花費增加了,整體社會成本實際上並未改變。其餘的研究則指出,在長期新陳代謝的控制方面,未發現兩組有所區別。在住院與糖尿病急性併發症發生率也沒有差異。

作者結論

由於多數的研究為低品質或適用性有限, 此一回顧研究的結果是無法定論的。總體上,這些資料傾向於建議,對於初被診斷為第一型糖尿病的兒童提供適切的門診/居家照護,並不會不利於新陳代謝控制、急性糖尿病併發症、住院治療、心理社會、行為或總支出。

翻譯人

本摘要由臺灣大學附設醫院張涵軒翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於初被診斷為第一型糖尿病的兒童,以家庭為基礎的照護也許和以醫院為基礎的照護一樣安全。傳統上,初被診斷為第一型糖尿病的兒童必須住院以確保血糖與疾病症狀得到控制,並且需要教導患童與其家屬如何處理糖尿病。某些情況下,患童確實是有急性病徵需要入院接受靜脈輸液,但在許多情形下,患童並無急性病徵。待在醫院經常令兒童及其家屬感到有壓力,而以家庭為基礎的照護也許能為兒童及其家庭提供一個較自然的環境來學習如何處理糖尿病。這個回顧研究提出這個問題:以此種方式為基礎的照護,是否有任何的好處或危險性。 我們只找到唯一一個有限品質及適用性的資料,因此並沒有明確的答復。在找到的七個研究中建議:對於初被診斷為第一型糖尿病的兒童,以居家為基礎的照護,不論是在血糖控制,急性糖尿病併發症,住院,心理與行為層面,或是總支出等方面,並不會有任何的不利。對那些沒有糖尿病急性病徵的兒童如此,對需要短暫住院治療的病童也是如此。