The Journal of Pediatrics
Volume 149, Issue 2 , Pages 154-156, August 2006

How low can we go…safely?: Factors affecting intensive diabetes management

  • Steven M. Willi, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Steven M. Willi, MD, Division of Endocrinology/Diabetes, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Suite 8C09, Philadelphia, PA 19104.

Director, Diabetes Center for Children, Children’s Hospital of Philadelphia, Associate Professor of Pediatrics, University of Pennsylvania, Philadelphia, PA

Article Outline

 

Although there is little doubt that the Diabetes Control and Complications Trial (DCCT) was a landmark in the history of diabetes care, pediatric diabetes centers have been understandably cautious in adopting intensive management regimens. Diabetes centers eager to take this approach have seen a consistent decline in HbA1c among their patients but were also faced with an increased occurrence of severe hypoglycemic reactions.1 However, in more recent years, hypoglycemia has been curtailed with the introduction of continuous subcutaneous insulin infusion (CSII)2 and insulin analogues.3 In addition, the flexibility that these advancements offer has been shown to decrease the perceived burden of diabetes care.4 This enthusiasm for intensive diabetes management must be tempered, however, with the reality that this approach is more costly and may not be appropriate for every child.

See related article, p 227

The DCCT enrolled more than 1400 subjects (195 were children) and is the largest study to examine whether strict blood glucose control could delay or prevent the long-term complications of type 1 diabetes.5 Although the past 10 years have seen remarkable advancements in diabetes technologies (continuous glucose sensors, insulin analogues, and so forth), the results of the DCCT were achieved with the same basic tools available since the early 1980s (regular, neutral protamine Hagedorn [NPH], ultralente insulin, and self-monitored blood glucose). Even the insulin pump, which was used by about one third of the intensively treated DCCT subjects, was only chosen by 8 children at the time of randomization. Rather than technology, this trial placed its emphasis on the importance of improved education of patients and frequent contact with a skilled diabetes treatment team. The close temporal relation between the publication of the DCCT’s results and the achievement of these goals in the clinical setting,6 despite the absence of significant technological advancement, suggests that the adoption of a multidisciplinary diabetes treatment model is the single most significant predictor of improved diabetes outcomes. In the “pay for performance” days that seem destined to come, we can anticipate even greater pressures to achieve more aggressive blood glucose targets. Effective application of diabetes technologies, offers the hope for improved achievement of these lower glycemic targets without severe hypoglycemia.

In this issue of The Journal, Springer et al7 examine the numerous factors associated with the achievement of optimal diabetes control in children with type 1 diabetes. They found that a number of factors (for example, age and diabetes duration) contributed, but low socioeconomic status (SES) was the single strongest predictor of poor diabetes outcome. This question was also recently examined in a study of 155 children at the Oregon Health Sciences Center.8 Similarly, the authors found that older age and longer diabetes duration predicted poorer diabetes outcomes but also found that single-parent households and a reduced number of blood glucose checks (a marker of compliance) had the same effect. These authors were careful to exclude patients in their first year after diagnosis but concluded little with regard to SES. Other markers of compliance and diabetes self-management skills (for example, frequency of diabetes clinic visits) have also been shown to predict HbA1c.9 At least one report suggests that increasing the frequency of visits beyond DCCT recommendations can facilitate the achievement of even better control.10

Springer’s finding that most children with good compliance who are regularly in contact with a competent treatment team can achieve HbA1c targets is not unique. Yet, this study has a number of significant implications toward the future of type 1 diabetes treatment. Although their study was somewhat limited by its relatively homogeneous, affluent cohort, the authors clearly found a strong association between diabetes outcome (specifically HbA1c) and SES. It is unclear what particular aspects of high socioeconomic status predicted better outcomes, but the authors were careful to control for differences in sex, age, diabetes duration, insulin pump use, and body mass index. It seems likely that patients with low SES may struggle with the financial burdens of diabetes care. The relative paucity of subjects with low SES in their cohort may have limited their ability to identify whether the use of CSII (which costs approximately $1800 per year more than insulin injections)6 might have mitigated some of these differences.

Another critical factor that limits the generalizability of their results is the relative availability of pediatric diabetes services in urban Connecticut versus much of the United States. For their 667 patients, they have two physicians and six nurse practitioners, which yields a patient-to-practitioner ratio of less than 85:1, compared with a ratio of greater than 150:1, as would be calculated from manpower data from the DCCT.11 The increasing number of pediatric patients with diabetes, the emergence of type 2 diabetes in children, and the limited number of skilled pediatric endocrinologists and nurse practitioners dedicated to the care of children with diabetes combine to make these ratios difficult to achieve across the country. Recent estimates from the Centers for Disease Control suggest that more than 200,000 children in the United States are affected by diabetes, with only 633 full time equivalents (FTE) of clinical pediatric endocrinologists (many of whom provide a limited amount of diabetes care).

Hypoglycemia is the major limiting factor to the implementation of intensive glycemic control. A variety of ingenious devices with the potential to improve control and decrease morbidity (including CSII and continuous glucose monitoring systems) have only recently been introduced at a select number of pediatric institutions on a large scale. The linking of these compact devices represents an “artificial pancreas,” which has the potential to revolutionize diabetes care in the very near future. Perhaps because of the novelty of these devices and the complexity of their implementation in children, technology has only slowly made its way into pediatric diabetes practices. The advanced age of pediatric endocrinologists in this country (median age, 52.8 years; data from American Medical Association Masterfile, 2003) may play a role as well. A survey of the diabetes literature will show that except for the noteworthy efforts of the Diabetes Research in Children Network (DirecNet, of which Yale is a constituent), the application of advanced technologies has been largely limited to adults and older children in good control with few behavioral issues and strong family support systems. However, recent reports have suggested that very young children12 and those with limited diabetes management skills10 have the most to gain from a technological approach to intensive treatment.

Therefore, the reader should not interpret the results of Springer et al7 to imply that disadvantaged families are not worthy of the best efforts of a diabetes treatment team. Rather, it may be access to these specialized services, which was not systematically evaluated in this report, that presents the major obstacle for many families (and perhaps disproportionately those of low SES) to overcome. The shorter duration of diabetes in black and Hispanic children (and presumably those of low SES) in this report remains unexplained, and, in fact, might reflect a higher rate of attrition from care for these families who are stretched beyond their means by intensive treatment.

Despite the fact that intensive diabetes management has been shown to be cost-effective (even over the short term),13 reimbursement for diabetes care remains poor. As a result, the vast majority of pediatric diabetes treatment teams are situated at large academic medical centers, which limits their availability. Unless manpower limitations in pediatric diabetes care can be overcome, these trends are unlikely to change. More creative strategies to disseminate needed services (such as telemedicine)14 have been developed primarily in countries with socialized medicine, but are currently being piloted in the United States. These strategies seem destined to fail in a medical system such as ours, which does not reimburse health care providers for the time devoted to data analysis without the patient being present.

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References 

  1. Bulsara MK , Holman CD , Davis EA , Jones TW . The impact of a decade of changing treatment on rates of severe hypoglycemia in a population-based cohort of children with type 1 diabetes . Diabetes Care . 2004;27:2293–2298
  2. Willi SM , Planton J , Egede L , Schwarz S . Benefits of continuous subcutaneous insulin infusion in children with type 1 diabetes . J Pediatr . 2003;143:796–801
  3. Alemzadeh R , Berhe T , Wyatt DT . Flexible insulin therapy with glargine insulin improved glycemic control and reduced severe hypoglycemia among preschool-aged children with type 1 diabetes mellitus . Pediatrics . 2005;115:1320–1324
  4. Fox L , Buckloh LM , Smith SD , Wysocki T , Mauras N . A randomized controlled trial of insulin pump therapy in young children with type 1 diabetes . Diabetes Care . 2005;28:1277–1281
  5. Diabetes Control and Complications Trial Research Group . Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus . J Pediatr . 1994;125:177–188
  6. Tamborlane WV , Bonfig W , Boland E . Recent advances in treatment of youth with type 1 diabetic (better care through technology) . Diabetic Med . 2001;18:864–870
  7. Springer D, Dzieura J, Tamborlane WV, Steffen AT, Ahearn JH, Vincent M, et al. Optimal control of type 1 diabetes in youth receiving intensive treatment . J Pediatr . 2006;149:227–232
  8. Urbach SL , LaFranchi S , Lambert L , Lapidus JA , Daneman D , Becker TM . Predictors of glucose control in children and adolescents with type 1 diabetes mellitus . Pediatr Diabetes . 2005;6:69–74
  9. Kaufman FR , Halvorson M , Carpenter S . Association between diabetes control and visits to a multidisciplinary pediatric diabetes clinic . Pediatrics . 1999;103:948–951
  10. Wysocki T , Harris MA , Wilkinson K , Sadler M , Mauras N , White NH . Self-management competence as a predictor of outcomes of intensive therapy or usual care in youth with type 1 diabetes . Diabetes Care . 2003;26:2043–2047
  11. Diabetes Control and Complications Trial Research Group . Resource utilization and costs of care in the diabetes control and complications trial . Diabetes Care . 1995;18:1468–1478
  12. Jeha GS, Karaviti LP, Anderson D, Smith EO, Donaldson S, McGirk TS, et al. Continuous glucose monitoring and the reality of metabolic control in preschool children with type 1 diabetes . Diabetes Care . 2004;27:2881–2886
  13. Beck JK , Logan KJ , Hamm RM , Sproat SM , Musser KM , Everhart PD , et al.   Reimbursement for pediatric diabetes intensive case management (a model for chronic diseases?) . Pediatrics . 2004;113:47–50
  14. Montori VM, Helgemoe PK, Guyatt GH, Dean DS, Leung TW, Smith SA, et al. Telecare for patients with type 1 diabetes and inadequate glycemic control (a randomized controlled trial and meta-analysis) . Diabetes Care . 2004;27:1088–1094

PII: S0022-3476(06)00495-1

doi:10.1016/j.jpeds.2006.06.002

Refers to article:

  • Optimal control of type 1 diabetes mellitus in youth receiving intensive treatment

    Dena Springer, James Dziura, William V. Tamborlane, Amy T. Steffen, JoAnn H. Ahern, Miranda Vincent, Stuart A. Weinzimer
    The Journal of Pediatrics August 2006 (Vol. 149, Issue 2, Pages 227-232)

The Journal of Pediatrics
Volume 149, Issue 2 , Pages 154-156, August 2006

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