Type 1diabetes mellitus (i.e. insulin-dependent diabetes mellitus) is one of the most prevalent chronic diseases among children in the United States . In 2010, the prevalence of type 1 diabetes in children aged 0–19 in the United States was 1.7 per 1,000 children . Among youth aged less than 10 years and 10–19 years there are 19.7 and 18.6 per 100,000 new cases of type 1 diabetes every year, respectively .
With proper education and care, type 1 diabetes can be managed throughout an individual’s life. Initial diabetes education is important for establishing successful diabetes self-management, long-term glycemic control, and complication free survival . Often, new-onset type 1 diabetic children are admitted to hospitals for metabolic stabilization and disease education, regardless of disease severity [4, 5]. While fifteen percent of newly diagnosed type 1 diabetic children require urgent insulin and fluid replacement treatment, one-third to one-half of them present with mild symptoms [6, 7]. For children with mild to moderate symptoms and who are clinically stable, there is not definite evidence as to which healthcare setting is most cost-effective for the provision of initial type 1 diabetes management education and patient care –[6, 8]–.
Previous studies compared metabolic outcomes using subsequent hemoglobin A1C (i.e. HbA1C) levels of newly diagnosed type 1 diabetic children based on initial diabetes education setting –[9, 13, 14]. Chase et al., (1992) found that HbA1C levels of newly diagnosed type 1 diabetic inpatient and outpatient children were not significantly different for any of the five follow-up years after diagnosis (p>0.05). Additionally, Simell et al. (1991) found that the length of initial stay in a hospital had no effect on metabolic control in newly diagnosed type 1 diabetic children at 2 years post- diagnosis. Dougherty, Soderstrom, & Schiffrin (1998) found that the mean HbA1C levels of the children, who received initial diabetes education in a home-based setting (6.4%; 46 mmol/mol), was not significantly different (p>0.55) from those in a hospital setting (6.1%; 43 mmol/mol) at 12 months post-diagnosis; nevertheless, HbA1C levels were significantly lower (p<0.05) in the home-based group (6.4%; 46 mmol/mol) than in the hospital group (7.1%; 54 mmol/mol) at 3 years after diagnosis. Similarly, Tiberg et al. (2012) did not find statistically significant differences (p>0.74) in the mean HbA1C levels at six months post-diagnosis of newly diagnosed type 1 diabetic children who received initial diabetes education in a home-based setting (6.0%; 42.8 mmol/mol) compared to children in a hospital setting (6.1%; 43.3 mmol/mol). Finally, Hamman et al. (1985) found no significant differences in the risk of subsequent ketoacidosis episodes among children who received their initial education in an inpatient, an outpatient, or a mixed inpatient/outpatient setting.
The United States ranked highest in the world for diabetes health expenditures per capita and as a percentage of total health expenditures . The economic burden of type 1 diabetes in the United States was estimated at $14.9 billion in 2007, including $10.5 billion in healthcare costs . The average annual type 1 diabetes healthcare cost per diabetic adult was estimated at $10,495 in 2007 . Few studies have estimated the costs of type 1 diabetes diagnosis and care in new-onset children based on initial diabetes education setting [13, 18]–. Dougherty, Soderstrom, & Schiffrin (1998) estimated that the cost of type 1 diabetes diagnosis and care in children, who received their initial diabetes education in a home-based setting, was CAN$ 48 (USD 53) higher per child (p>0.85) compared to the inpatient setting. Similarly, Spaulding & Spaulding (1976) estimated that the total average cost per patient (both children and adults) in the home-based setting was CAN$ 154 (USD 169) compared to CAN$ 1,445 (USD 1,587) average total cost per patient admitted to the hospital. Authors used the Ontario Medical Association fee schedule to compare the healthcare cost of new-onset type 1 diabetic patients managed in a home-based setting, without admission to hospital during the 6 months of continuing insulin treatment, with those patients admitted to a hospital for initiation of insulin treatment. Healthcare costs included salaries of staff, physician’s fees, laboratory costs and daily hospital bed rate. The costs of insulin, other drugs and some of the home urine-testing supplies were not included in the analysis. More recently, Tiberg et al. (2012) examined the healthcare costs one month after diagnosis of newly diagnosed type 1 diabetic children who received hospital-based care versus hospital-based home care. Authors found that total mean healthcare cost per patient was lower in the hospital-based home care group (1,501 SEK; USD 235) compared to the hospital-based care group (2,143 SEK; USD 335) (p<0.001). Authors used the Swedish southern regional healthcare pricelist as a proxy for cost of healthcare services. Healthcare services included stay at hospital and hospital-based home Family House, outpatient visits, telephone consultations and healthcare professionals’ educational time. Simell, Simell, & Sintonen (1993) compared the cost of care of the length of initial hospital stay of children with newly diagnosed type 1 diabetes. The costs of care of a child with type 1 diabetes admitted to a hospital for 23±4 days totaled £10,834 (USD 7,333) compared to £6,928 (USD 4,689) per child admitted for 9±3 days (p<0.001). Authors concluded that shortening the initial hospital stay of children with newly diagnosed type 1 diabetes decreased total costs without influencing metabolic outcome during the first 2 years of disease.
Baystate Health’s type 1 diabetes management education and care is delivered through the Pediatric Endocrinology Division at Baystate Children’s Hospital and an outpatient pediatric endocrinology clinic. Initial type 1 diabetes management and patient education is provided during 2–4 hours for two consecutive days. The initial two days of diabetes education sessions are followed by daily nurse interaction with the family over the phone, when clinically needed, and a clinic follow up visit at 1 week, 1 month, 2 months, and quarterly thereafter. The same team of specialty nurses and a dietitian provides diabetes education and insulin management training to the parents and child and covers the same content regardless of education setting (i.e. hospital and/or outpatient pediatric endocrinology clinic). The role and involvement of the pediatric endocrinologist is also similar whether the child is an inpatient at Baystate Children’s Hospital or an outpatient at the outpatient pediatric endocrinology clinic. New-onset type 1 diabetes management and patient education is initiated to clinically stable patients, either in the outpatient pediatric endocrinology clinic or on the hospital ward floor of Baystate Children’s Hospital, within a 10-day period following diagnosis.
The healthcare cost and utilization of the provision of initial type 1 diabetes education and care in a hospital compared to an outpatient pediatric clinic has not been empirically estimated. This study sought to assess differences in outcomes and costs between new-onset type 1 diabetic children who received initial education and care in a hospital and in an outpatient pediatric endocrinology clinic. The study specifically compared: 1) HbA1C levels at diagnosis and one year post-diagnosis; and 2) healthcare utilization and costs associated with the provision of type 1 diabetes education and care during the first year from date of diagnosis in both healthcare settings.