A Learner-Centered Diabetes Management Curriculum

OBJECTIVE Diabetes errors, particularly insulin administration errors, can lead to complications and death in the pediatric inpatient setting. Despite a lecture-format curriculum on diabetes management at our children’s hospital, resident diabetes-related errors persisted. We hypothesized that a multifaceted, learner-centered diabetes curriculum would help reduce pathway errors. RESEARCH DESIGN AND METHODS The 8-week curricular intervention consisted of 1) an online tutorial addressing residents’ baseline diabetes management knowledge, 2) an interactive diabetes pathway discussion, 3) a learner-initiated diabetes question and answer session, and 4) a case presentation featuring embedded pathway errors for residents to recognize, resolve, and prevent. Errors in the 9 months before the intervention, as identified through an incident reporting system, were compared with those in the 10 months afterward, with errors classified as relating to insulin, communication, intravenous fluids, nutrition, and discharge delay. RESULTS Before the curricular intervention, resident errors occurred in 28 patients (19.4% of 144 diabetes admissions) over 9 months. After the intervention, resident errors occurred in 11 patients (6.6% of 166 diabetes admissions) over 10 months, representing a statistically significant (P = 0.0007) decrease in patients with errors from before intervention to after intervention. Throughout the study, the errors were distributed into the categories as follows: insulin, 43.8%; communication, 39.6%; intravenous fluids, 14.6%; nutrition, 0%; and discharge delay, 2.1%. CONCLUSIONS An interactive learner-centered diabetes curriculum for pediatric residents can be effective in reducing inpatient diabetes errors in a tertiary children’s hospital. This educational model promoting proactive learning has implications for decreasing errors across other medical disciplines

Outpatient Management of Pediatric Type 1 Diabetes.

The incidence of both type 1 and type 2 diabetes (T1DM and T2DM) continues to rise within the pediatric population. However, T1DM remains the most prevalent form diagnosed in children. It is critical that health-care professionals understand the types of diabetes diagnosed in pediatrics, especially the distinguishing features between T1DM and T2DM, to ensure proper treatment. Similar to all individuals with T1DM, lifelong administration of exogenous insulin is necessary for survival. However, children have very distinct needs and challenges compared to those in the adult diabetes population. Accordingly, treatment, goals, and age-appropriate requirements must be individually addressed. The main objectives for the treatment of pediatric T1DM include maintaining glucose levels as close to normal as possible, avoiding acute complications, and preventing long-term complications. In addition, unique to pediatrics, facilitating normal growth and development is important to comprehensive care. To achieve these goals, a careful balance of insulin therapy, medical nutrition therapy, and exercise or activity is necessary. Pharmacological treatment options consist of various insulin products aimed at mimicking prior endogenous insulin secretion while minimizing adverse effects. This review focuses on the management of pediatric T1DM in the outpatient environment, highlighting pharmacotherapy management strategies

Affective Communication in Routine Diabetes Care for Adolescents and Young Adults

High quality communication between health care providers (HCPs) and adolescents and young adults (AYAs) with type 1 diabetes (T1D) may contribute to better diabetes self-care and health outcomes. Health communication reflects both informational content and how information is conveyed, including affect and tone. The aim of this study was to assess HCP affective communication and the relationship between HCP affective communication and glycemic control in AYAs with T1D. As part of a larger study of AYA-HCP health communication, routine clinic visits for 69 AYAs with T1D (M age 17.81 yrs; 56.5% female) and 8 HCPs (88% female) were audiorecorded. Clinic visits were coded using the Roter Interaction Analysis System (RIAS), a validated coding structure assessing verbal and non-verbal exchanges in a medical encounter. HCP global affective ratings were used to create two composite variables – positive HCP affect (e.g. attentiveness; respectfulness; Cronbach’s α = 0.82) and negative HCP affect (e.g. anger; dominance; Cronbach’s α = 0.75). Hemoglobin A1c (A1c) was taken from the medical chart. The mean A1c was 8.97% (±2.30). Descriptive analyses of positive and negative HCP affect indicated that HCPs expressed a high level of positive affect (M = 4.21) and a relatively low level of negative affect (M = 2.80). Negative affect was positively associated with HbA1c. After controlling for salient covariates (e.g., HCP, race, regimen), A1c accounted for a significant portion of the variance in negative affect during the clinic visit (Adj R2 = .36, β = 0.57, p \u3c 0.001). This sample of HCPs predominantly exhibited positive affect during routine T1D visits. Glycemic control was not associated with positive affect, but higher A1c was associated with more negative affect. This finding suggests elevated A1c levels may elicit more negative affect in routine diabetes care. Future research should examine these associations over time, including how AYA-HCP health communication quality predicts long-term glycemic control

Self-Management Strategies in Emerging Adults With Type 1 Diabetes

INTRODUCTION: This study examined changes in self-management behaviors after high school graduation in a cohort of emerging adults with type 1 diabetes. METHODS: Sixty-four emerging adults reported on diabetes self-management behaviors at three time points over a one year period. Glycemic control and blood glucose monitoring frequency were collected from medical chart review. RESULTS: Collaboration with parents decreased, diabetes problem-solving and communication increased, and glycemic control worsened over the first year post-high school (ps<.05). Problem solving appeared to be protective against worsening glycemic control; higher baseline diabetes problem solving significantly predicted better glycemic control at the one year follow-up. DISCUSSION: Emerging adults demonstrate increased independence in diabetes problem solving and communication with health care providers in the year post-high school. Problem-solving skills may help emerging adults adapt type 1 diabetes self-care in response to unpredictable schedules post high-school, and promoting these skills may prevent deteriorations in glycemic control during this risky period

The impact of parents\u27 sleep quality and hypoglycemia worry on diabetes self-efficacy

Parents of young children with type 1 diabetes (T1D) may experience poor sleep quality possibly impacting their confidence in T1D management. This study investigated sleep characteristics among parents of children with T1D and relationships amongst parents’ sleep quality, hypoglycemia worry, and diabetes self-efficacy. As part of baseline assessment for a randomized clinical trial (RCT) to promote parental management of T1D, 134 parents of children ≤ age 6 reported on demographics, parent sleep characteristics, hypoglycemia worry, and diabetes self-efficacy. Parents reported they slept less time than recommended by the National Sleep Foundation and endorsed greater global sleep problems than standardized norms of healthy adults; 1/3 of parents reported their overall sleep quality was “fairly bad” or “very bad.” Hypoglycemia worry and parents’ sleep quality were both significantly related to diabetes self-efficacy, but parents’ sleep quality did not mediate the relationship of hypoglycemia worry and diabetes self-efficacy. Many parents experience disrupted sleep that impacts their perceived ability to perform T1D management. Interventions designed to improve parental T1D self-efficacy should consider sleep and concerns about children’s hypoglycemia

Sleep behaviors and parent functioning in young children with type 1 diabetes

This study evaluates sleep characteristics among young children with type 1 diabetes and associations with parent sleep and emotional functioning and diabetes care. Study participants included twenty-four parents of young children with type 1 diabetes (ages 2–5) enrolled in a pilot study of a randomized-controlled trial. Child sleep characteristics were within normal limits. However, increased child bedtime resistance and behavioral insomnia were related to greater parent stress, anxiety, and depression and use of an intensive insulin regimen. Type 1 diabetes management may impact child and parent sleep as well as parent emotional functioning. Implications for practice are presented

Health Communication Experiences of Youth with Type 1 Diabetes

Background: Effective communication between adolescents/young adults (AYAs) with type 1 diabetes (T1D) and healthcare providers (HCPs) is essential to optimize health outcomes. Understanding AYA preferences for healthcare interactions can help HCPs more effectively engage AYA patients. Objective: To gain insight into AYA-HCP communication and identify factors that AYAs with T1D value when working with HCPs. Methods: As part of a longitudinal study, 20 AYAs (M age=18.8±1.5 yrs; 70% female; 65% Caucasian) with T1D receiving care in a pediatric diabetes clinic (n=5 HCPs) participated in a qualitative interview and completed the Patient Assessment of Chronic Illness Care (PACIC). Interviews (M length=13.9±5.1 min) were recorded, transcribed, and coded by two independent coders to identify themes. Hemoglobin A1c (M=8.5±1.7%) was taken from medical records. Results: Themes emerged related to HCP interaction style, support for autonomy, comfort with disclosure, and difficulties when glycemic control was poor. AYAs valued a straightforward approach to T1D care, with HCPs who encouraged shared decision-making and were directed towards AYAs instead of parents. AYAs perceived higher quality communication when HCPs took interest in their lives beyond T1D. Most AYAs were comfortable disclosing risky behavior (e.g. sexual activity, alcohol use) but preferred HCPs to initiate these conversations. Most participants had not discussed transition to adult care with their HCP but reported general confidence in planning for transition. AYAs with A1c \u3e8.5% endorsed external stressors affecting T1D management and some felt HCPs were less supportive when glycemic control was poor. On the PACIC, participant satisfaction with T1D care was generally high (M PACIC score=3.57±.57). Higher A1c was associated with lower decision support by HCPs (r=-.49, p\u3c.05). Participants who changed HCPs during the study (n=4) also reported lower decision support (p\u3c.05) and were more likely to describe their HCP as impersonal or punitive. Conclusions: Results suggest AYAs desire collaborative, consistent HCP relationships, but need HCPs to initiate discussions about risky behavior and healthcare transition. Given low decision support among AYAs with higher A1cs or HCP inconsistency, HCPs working with these patients should encourage self-efficacy and promote organization of care. Results should be replicated in a more diverse sample of AYAs with T1D to further inform key themes related to HCP relationships in youth