3 areas of T1D care that fall short of guideline recommendations

Most care of children with type 1 diabetes mellitus is in keeping with clinical practice guidelines but there is room for improvement in areas such as screening for psychological disorders, an Australian study has found.

An audit of 35 indicators of guideline-recommended care provided to 251 children with T1D in three states found that the overall level of adherence to recommendation was 80%.

However the review of care provided in hospital inpatient settings, emergency departments and by community paediatricians found that only 38% of children who had suboptimal glycaemic control were assessed for co-occurrence of psychological disorders.

Other aspects of care with poor adherence to recommendations included having a sick-day emergency plan in the medical record with ketone measurement (51%) and provision of written guidelines and details on 24 hours access to clinical advice (57%).

Similarly, only about half (54%) of children who presented with signs of DKA had their level of dehydration recorded.

The CareTrack Kids investigative team also found there was room for improvement in provision of education by a dietician on carbohydrate counting, where there was only two thirds (68%) adherence to guideline recommendation.

Overall adherence by care type was 86% for diagnosis, 79% for routine care and 84% for emergency care.

Writing in BMJ Open Diabetes Research and Care, the study investigators led by Dr Richard McGee of the University of Newcastle, NSW, said it was reassuring to see generally high levels of adherence to clinical practice guidelines across different care settings and in both rural and metropolitan areas.

But they said it was disappointing to see that only a third of children with suboptimal glycemic control were screened for psychological disorders, given that children with T1D have an increased prevalence of behavioural and psychological disorders and these disorders are predictive of worse long‐term outcomes and decreased quality of life.

“Few clinicians would challenge the importance of mental health, or the need for screening, but this study highlights it is one of the areas where there is a possible evidence-practice gap,” they wrote.

“Similarly, few would argue against the provision of sick-day emergency plans but this too was an area where the selected professional groups underperformed, with roughly half having a documented plan. This group of indicators may be promising targets for local quality improvement activities.”

They acknowledged that the lower levels of dietician education on carbohydrate counting might reflect “the diversity of views on appropriate insulin management within the specialty.”

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