Across Europe, the incidence of type 1 diabetes in children younger than 15 years is predicted to rise by 70% between 2005 and 2020. In some areas of the UK, between 1999 and 2003, the incident rate of newly diagnosed cases ranged from 22.4 - 29.8 per 100,000. Traditionally, most children diagnosed with diabetes have been admitted to hospital as part of their initial management but over recent years there has been a move towards carrying out initial care from diagnosis in the home.
How children should be managed when newly diagnosed with diabetes is still strongly debated. Some units routinely admit all children to hospital, whilst others routinely manage children at home [2, 3]. For some children, it is necessary to admit them to hospital due to clinical presentation, for example, for intravenous therapy if acidotic, (approximately 25% of children are acidotic at diagnosis). However, if children are not acutely ill at diagnosis, they can be managed safely in the community [3, 4].
There is no high quality evidence concerning whether hospital admission or home management from diagnosis in children who are clinically well is different in terms of physical, psychological, social, and economic outcomes [5, 6]. Indeed, a recent Cochrane Review of this topic could draw no conclusions due to the very small number and low quality, or limited applicability, of studies. Although home management is supported as a safe, effective alternative to hospitalisation [3, 8–10] studies have commonly been retrospective  with little account taken of any biases that may affect outcomes , and based on relatively small samples often from single centres .
There are also differing interpretations of home management, ranging from complete avoidance of hospitalisation  to 72 hours in hospital . The study by Dougherty et al  was the only quality trial identified in the Cochrane review of home versus hospital management of type 1 diabetes in children  but did not strictly address the research question as children in the intervention group (n = 32) were also hospitalised for a total of 70 days. Studies examining cost effectiveness, mainly in the USA and Canada, suggest either cost reduction from outpatient management or no significant difference in costs between home and hospital management  but other outcomes need to be taken into account. For example, if either arm is found to reduce subsequent readmissions and result in improved glycaemic control, if sustained, this will have positive implications in relation to the reduced risk of diabetes related complications in later life. These issues need to be examined over time, not merely to assess cost effectiveness but, more importantly, to determine the effect of home management and hospitalisation on patients' long term health and well being.
A recent empirical qualitative study  explored parents' experience of having their child managed at home from diagnosis and identified that, although parents experienced an initial grief response to the diagnosis similar to that usually associated with bereavement , they had a positive experience of home management. Parents believed that, because home management allowed them to deal with situations that occurred within the framework of their everyday life, the relative normality of this helped them feel more 'in control' of the situation to enable them to cope more effectively and feel less anxious. Surprisingly, although parents of children hospitalised at diagnosis have been found to experience, for example, remarkably high rates of post-traumatic stress symptoms  or distress due to their child's hospitalisation , no work has explored parents' experiences of initial hospitalisation or children's experiences of either approach.
Furthermore, little emphasis has been placed on psychosocial outcomes  or comparison of psychological outcomes from home management and hospitalisation. Improved pyschological well-being of parents and their affected child from diagnosis could also have a positive impact on diabetes control and subsequent engagement with the diabetes team. As Clar et al  emphasised, there is a need for a large, well- designed RCT to investigate whether there are significant differences in comprehensive short and long-term outcomes between the two approaches. The DECIDE multi-centred RCT will address these gaps in the current knowledge base by building on the programme of work by Lowes et al [2, 11, 12], providing high quality evidence on which to base decisions about the environment (home or hospital) where treatment should be initiated for children with newly diagnosed type 1 diabetes, potentially making a difference to the lives of children with type 1 diabetes and their parents.