Irén Tiberg

Children diagnosed with type 1 diabetes: a randomized controlled trial comparing hospital versus home-based care.

Aim:  To compare two different regimens for children diagnosed with type 1 diabetes: hospital‐based care or hospital‐based home care (HBHC), referring to specialist care in a home‐based setting.

Metabolic control, healthcare satisfaction and costs 1 month after diagnosis of type 1 diabetes: a randomised controlled trial of hospital-based care vs. hospital-based home care.

Procedures for the initial management of children newly diagnosed with diabetes vary greatly worldwide and the evidence available is insufficient for conclusively determining the best process regarding hospital‐based or home‐based care. The aim of the study was to compare two different regimens for children with newly diagnosed type 1 diabetes; hospital‐based care and hospital‐based home care (HBHC), defined as specialist care in a home‐based setting. A randomised controlled trial, including 60 children, took place at a university hospital in Sweden during the period of March 2008 to September 2011. After 2–3 d with hospital‐based care, children from 3 to 15 yr of age were randomised to either continued hospital‐based care for a total of 1–2 wk or to HBHC. This article presents results 1 month after diagnosis. No differences were shown in the daily mean glucose level or in its variability when the children received care but, after discharge, children who received HBHC showed lower mean plasma glucose values and lower variability compared to children who received hospital‐based care. Children in HBHC had fewer episodes of hypoglycaemia during the first month after diagnosis. In the HBHC group, parents were more satisfied with the healthcare received and healthcare costs for the first month were 30% lower as compared to hospital‐based care. The results 1 month after diagnosis support the HBHC programme as being a safe and cost‐effective way of providing care. A follow‐up will continue for 2 yr to evaluate which process was best for the majority of families over time.

A Methodological Description of a Randomised Controlled Trial Comparing Hospital-Based Care and Hospital-Based Home Care when a Child is Newly Diagnosed with Type 1 Diabetes

Aim and objective: To describe the study design of a randomised controlled trial with the aim of comparing two different regimes for children with newly diagnosed type 1 diabetes; hospital-based care and hospital-based home care. Background: Procedures for hospital admission and sojourn in connection with diagnose vary greatly worldwide and the existing evidence is insufficient to allow for any conclusive determination of whether hospital-based or home-based care is the best alternative for most families. Comparative studies with adequate power and outcome measurements, as well as measurements of cost-effectiveness are needed. Design: The study design was based on the Medical Research Council framework for complex interventions. After two to three days with hospital-based care, children between the ages of 3 and 16 were randomised to receive either continued hospital-based care for a total of 1-2 weeks or hospital-based home care, which refers to specialist care in a home-based setting. The trial started in March 2008 at a University Hospital in Sweden and was closed in September 2011 when a sufficient number of children according to power calculation, were included. The primary outcome was the child’s metabolic control during the following two years. Secondary outcomes were set to evaluate the family and child situation as well as the organisation of care. Discussion: Childhood diabetes requires families and children to learn to perform multiple daily tasks. Even though intervention in health care is complex with several interacting components entailing practical and methodological difficulties, there is nonetheless, a need for randomised controlled trials in order to evaluate and develop better systems for the learning processes of families that can lead to long-term improvement in adherence and outcome. Trial Registration: Trial Register NCT00804232.

Cost-effectiveness and cost-utility analyses of hospital-based home care compared to hospital-based care for children diagnosed with type 1 diabetes; a randomised controlled trial; results after two years’ follow-up

BackgroundPractices regarding hospitalisation of children at diagnosis of type 1 diabetes vary both within countries and internationally, and high-quality evidence of best practice is scarce. The objective of this study was to close some of the gaps in evidence by comparing two alternative regimens for children diagnosed with type 1 diabetes: hospital-based care and hospital-based home care (HBHC), referring to specialist care in a home-based setting.MethodsA randomised controlled trial, including 60 children aged 3–15 years, took place at a university hospital in Sweden. When the children were medically stable, they were randomised to either the traditional, hospital-based care or to HBHC.ResultsTwo years after diagnosis there were no differences in HbA1c (p = 0.777), in episodes of severe hypoglycaemia (p = 0.167), or in insulin U/kg/24 h (p = 0.269). Over 24 months, there were no statistically significant differences between groups in how parents’ reported the impact of paediatric chronic health condition on family (p = 0.138) or in parents’ self-reported health-related quality of life (p = 0.067). However, there was a statistically significant difference regarding healthcare satisfaction, favouring HBHC (p = 0.002). In total, healthcare costs (direct costs) were significantly lower in the HBHC group but no statistically significant difference between the two groups in estimated lost production (indirect costs) for the family as a whole. Whereas mothers had a significantly lower value of lost production, when their children were treated within the HBHC regime, fathers had a higher, but not a significantly higher value. The results indicate that HBHC might be a cost-effective strategy in a healthcare sector perspective. When using the wider societal perspective, no difference in cost effectiveness or cost utility was found.ConclusionsOverall, there are only a few, well-designed and controlled studies that compare hospital care to different models of home care. The results of this study provide empirical support for the safety and feasibility of HBHC when a child is diagnosed with type 1 diabetes. Our results further indicate that the model of care may have an impact on families’ daily living, not only during the initial period of care but for a longer period of time.Trial registrationClinicalTrials.gov with identity number NCT00804232, December 2008.

How dislocation and professional anxiety influence readiness for change during the implementation of hospital-based home care for children newly diagnosed with diabetes – an ethnographic analysis of the logic of workplace change

BackgroundIn 2013–14, the evidence based care model Hospital-based Home Care for children newly diagnosed with diabetes was implemented at a large paediatric diabetes care facility in the south of Sweden. The first step of the implementation was to promote readiness for change among the professionals within the diabetes team through regular meetings. The aim was to analyse the implicit facilitators and barriers evident on a cultural micro level in discussions during the course of these meetings. What conceptions, ideals and identities might complicate, or facilitate, implementation?MethodsA case study was conducted during the implementation process. This article draw on ethnographic observations carried out at team meetings (n = 6) during the introductory element of implementation. From a discourse theoretical perspective, the verbal negotiations during these meetings were analysed.ResultsThree aspects were significant in order to understand the dislocation during this element of implementation: an epistemological disagreement that challenged the function of information within care practice; a paradoxical understanding of the time-knowledge intersection; and expressions of professional anxiety. More concretely, the professionals exhibited an unwillingness to give up the opportunity to provide structured, age-independent information; a resistance against allowing early discharge; and a professional identity formed both by altruistic concern and occupational guardiancy. The findings suggest the necessity of increased awareness of the conceptions and ideals that constitute the basis of a certain professional practice; a deeper understanding of the cultural meaning that influences care practice within a specific logic in order to predict in what way these ideals might be challenged by the implemented evidence.ConclusionsOur main contribution is the argument that the implemented evidence in itself needs to be examined and problematized from a cultural analytical perspective before initiation in order to be able to actively counter negative connotations and resistance.

Promoting health in children and adolescents with – or at risk of – Type 2 diabetes mellitus in the United States: An interview – study of nurses’ experiences of their role

Introduction: Type 2 diabetes mellitus (T2DM) in children and adolescents is increasing throughout the world and the USA. Previous research has shown that the nurses have an important role in the management of T2DM in children and adolescents, but few studies have covered how the nurses perceive and experience their role. Aim: This paper aims to describe how nurses experience their role in the care of children and adolescents with T2DM and their families. Methods: Semi-structured interviews were used to collect the data from eight registered nurses and nurse practitioners who worked in an American university hospital area participated in the study. An inductive qualitative approach was used and the data were analysed through the content analysis. The findings were described in four categories: overcoming challenges; improving life quality; being cooperative and being committed to one’s role as a diabetes nurse forming the theme Promoting health. Conclusions: The diabetes nurse has a key role in the work of promoting health and the results elucidate the complexity of the role. To be able to plan for and to implement an evidence-based approach based on theoretical models of behaviour and consideration of the child’s needs, not only requires a commitment from health professionals but also involves education and discussions that require both commitment and managerial and economic support from leaders in children’s healthcare and managers of health services.

Health-related quality of life in children with Type 1 diabetes : an RCT of hospital-based care and hospital-based home care at diagnosis

Introduction:When a child is diagnosed with Type 1 diabetes, it involves extensive lifestyle changes for the whole family. There is limited knowledge of the impact the initial care has for children and parents over time. The aim was to compare children’s diabetes-specific health-related quality of life (HRQOL) in hospital-based care and hospital-based home care (HBHC), 12 and 24 months after the onset of Type 1 diabetes. The aim was also to compare the children’s and parents’ proxy-report of the children’s diabetes-specific HRQOL after 12 and 24 months, regardless of the form of care. Method: The trial took place at a university hospital in Sweden and had a randomised controlled design evaluating the hospital-based care and HBHC, referring to specialist care in a home-based setting. Children aged 5–16 and their parents answered the PedsQLTM 3.0 Diabetes Module, 12 months and 24 months after the onset of the illness. Results: The results showed no difference regarding the children’s diabetes-specific HRQOL. However, 12 months from diagnosis, the children and parents who received HBHC experienced more worry than those who had received hospital-based care at diagnosis (p = .012). Irrespective of the form of care, children reported more discomfort of the disease than their parents reported that the children would have (p = .017). Conclusion: Overall, the result indicates that both hospital-based care and HBHC provide equivalent outcomes in terms of the children’s diabetes-specific HRQOL. However, a more home-based model of care might put more strain on some families. Those families need to be identified and the routines should be flexible in order to meet each family’s need.

An ethnographic observation study of the facilitator role in an implementation process

BackgroundEven though the importance of a facilitator during an implementation process is well described, the facilitator’s role is rarely problematized in relation to the organizational context in terms of power and legitimacy; themes which have recently been brought to the fore when studying change in health care organizations. Therefore, in this article, we present a qualitative study with the aim of identifying key aspects of the experience of being in a facilitator role. The data collection involved ethnographic fieldwork encompassing observations and field notes, as well as two qualitative interviews with the facilitator. The data were analysed using a phenomenological hermeneutical method in order to formulate thematic aspects of the implementation process. The study was conducted in southern Sweden between January 2013 and August 2014.ResultsOne main theme, “walking a tightrope”, and four sub-themes, all of which involved balancing acts of different levels and different ways, were identified. These included: being in control, but needing to adjust; pushing for change, but forced to stand back; being accepted, but dependent; and being reasonable, but culturally sensitive.ConclusionInstead of listing the desirable qualities and conditions of a facilitator, this study shows that being a facilitator can be described more completely by applying the concept of role, thus allowing a more holistic process of reflection and analysis. This in turn makes it possible to move from the reactive stance of balancing to a more proactive stance of negotiating.