Multisystemic Therapy for Adolescents With Poorly Controlled Type 1 Diabetes

Abstract

OBJECTIVE -The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated. RESEARCH DESIGN AND METHODS-A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care.RESULTS -Youth who received MST had significantly fewer hospital admissions than control subjects ( 2 ϭ 11.77, 4 d.f., n ϭ 127; P ϭ 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P ϭ 0.004), 12-month (P ϭ 0.021), 18-month (P ϭ 0.046), and 24-month follow-up (P ϭ 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions.CONCLUSIONS -The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance. Diabetes Care 31:1746-1747, 2008W e have previously reported on multisystemic therapy (MST), an intensive home-based family therapy, for youth with chronically poor metabolic control (CPMC). MST produced improvements in metabolic control and reducted indicators of serious nonadherence (DKA hospital admissions) at treatment termination (1,2). Reductions in admissions were maintained 6 months later (2). The present study investigated the effects of MST on DKA admissions at the conclusion of the trial and related cost savings. RESEARCH DESIGN ANDMETHODS -A total of 127 adolescents with CPMC and their families were recruited from endocrinology clinics at Children's Hospital of Michigan between 1999 and 2004. Eligible youth were diagnosed with type 1 diabetes for at least 1 year, had an average A1C of Ն8% during the year before study entry, and were aged 10 -17 years. Mean Ϯ SD A1C at study entry was 11.3 Ϯ 2.3%. A total of 92% of the subjects used injected insulin, and 8% used insulin pumps. Mean Ϯ SD age was 13.2 Ϯ 2.0 years, and 63% of participants were African American.A total of 64 participants were randomly assigned to MST and 63 to a control group. All families received quarterly visits with a multidisciplinary diabetes team. MST-treatment families also received 6 months of therapy (mean 5.7 months). Families were followed for 24 months total. MST targeted adherence-related problems within the family and broader community systems (1,3). These systems included family (e.g., poor parental supervision and oversight of the youth's diabetes care completion), school (e.g., inadequate communication between parents and school personnel regarding the youth's health needs), and health care system factors (e.g., barriers to keeping clinic appointments due to problems with transportation or family disorganization).The number of DKA admissions was obtained from the treating hospital's information system for the 6-month window before study entry (ba...

Preventing Diabetic Ketoacidosis

“…T1DM is an ambulatory-care sensitive condition, defined as a group of medical conditions typically managed in an ambulatory setting, whereby an admission to hospital indicates a potentially avoidable complication and is an indirect indicator of access and overall quality of outpatient care. 40,41 DKA is generally avoidable and its occurrence in children and adolescence with established T1DM may indicate poor outpatient diabetes mellitus care and could be prevented with comprehensive multidisciplinary outpatient care and improved adherence to diabetes management. Table 2 outlines the risk factors for DKA among youth with established T1DM.…”

“…In a randomized controlled trial in 127 adolescents with poorly controlled T1DM, intensive home-based psychotherapy over 2 years was associated with sustained reduction in hospital admissions compared with baseline or to controls over the full period. 41 This intensive intervention was expensive ($6934 per patient), but this cost was offset by reduced admissions for DKA. A subsequent trial in 146 adolescents with T1DM or type 2 diabetes mellitus showed that this approach was superior to telephone support in improving glycemic control over 12 months.…”

Evidence-based behavioral interventions to promote diabetes management in children, adolescents, and families.

“…The intervention content and format varied based on individual needs and barriers to T1D management, and drew from other empirically supported approaches such as behavioral contingencies, cognitive–behavioral therapy, and case management. MST for diabetes has demonstrated increased adherence to diabetes management tasks, fewer hospitalizations, lower health care costs, and improved glycemic control up to 24 months postintervention compared with standard care or a telephone support intervention (Ellis et al, 2012; Ellis et al, 2008). …”

Behavioral medicine interventions in diabetes

“…In addition, families in the intervention group received a 6-month therapy that included adherence-related problem-solving training within the family, school, and health systems, as well as communication training and a social support intervention. As the primary outcome variable, significantly fewer hospital admissions occurred among adolescents of the MST intervention compared with controls [55].…”