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Evid Based Nurs 9:14 doi:10.1136/ebn.9.1.14
  • Treatment

Multisystemic therapy improved adherence to blood glucose testing in adolescents with type 1 diabetes


 
 Q Does multisystemic therapy increase adherence to blood glucose testing and insulin use, improve metabolic control, and reduce hospital use in adolescents with type 1 diabetes and chronically poor metabolic control?

METHODS

GraphicDesign:

randomised controlled trial.

GraphicAllocation:

{concealed}.*

GraphicBlinding:

blinded (assessor of reason for hospital visit, {data collectors, and data analysts}*).

GraphicFollow up period:

7 months.

GraphicSetting:

a diabetes clinic in a tertiary care children’s hospital in Detroit, Michigan, USA.

GraphicPatients:

127 English speaking adolescents who were 10–17 years of age (mean age 13 y, 51% girls, 63% African-American) and had type 1 diabetes for ⩾1 year (mean 5 y), an average HbA1c concentration ⩾8% in the previous year, and a most recent HbA1c concentration ⩾8%. Adolescents with moderate to severe mental retardation or psychosis were excluded.

GraphicIntervention:

64 adolescents were allocated to multisystemic therapy plus standard medical care (quarterly medical visits to a diabetes clinic, with care from a multidisciplinary team). Multisystemic therapy consisted of intensive, family centred, community based treatment originally designed for adolescents with serious antisocial behaviour. A trained therapist tailored treatment goals and interventions to adherence problems within the family system, peer network, and community systems. Intervention techniques were selected from an evidence-based menu that included cognitive behaviour therapy, parent training, and behavioural family systems therapy. The therapist met with the family 2–3 times per week until treatment goals were met (approximately 6 mo). 63 adolescents were allocated to standard medical care alone. Randomisation was stratified by baseline HbA1c concentration.

GraphicOutcomes:

change from baseline in HbA1c concentration; frequency of blood glucose testing (based on average daily blood glucose meter use from the previous 14 d and 24 Hour Recall Interview); insulin and dietary adherence (24 Hour Recall Interview); and diabetes related emergency department visits and hospital admissions in the previous 6 months (from hospital records).

GraphicPatient follow up:

87% of patients completed the follow up assessment; all patients were included in the intention to treat analysis, assuming no change from baseline for those without follow up.

MAIN RESULTS

At 7 months, the multisystemic therapy group had more improvement than the standard care group in frequency of blood glucose monitoring based on the 24 Hour Recall Interview (p = 0.01 for group × time interaction) and blood glucose meter readings (p = 0.001); and a greater reduction in hospital admissions (p = 0.01). The groups did not differ for changes in HbA1c concentrations (p = 0.09), insulin adherence (p = 0.17), dietary adherence (p = 0.85), or emergency department visits (p = 0.10).

CONCLUSION

Multisystemic therapy plus standard care improved adherence to blood glucose testing and reduced hospital admissions more than standard care alone in adolescents with type 1 diabetes and chronically poor metabolic control; it did not improve metabolic control.

Commentary

  1. Barbara L Paterson, RN, PhD
  1. University of New Brunswick
 Fredericton, New Brunswick, Canada

      The few existing intervention studies aimed at improving metabolic control in adolescents with diabetes have been limited by focusing only on the individual and his/her behaviour. The study by Ellis et al is one of few such studies to consider contextual factors that can support adolescents’ attempts to achieve metabolic control in diabetes management.

      The intervention was based on multisystemic therapy. It included trained counsellors, quality assurance monitoring, consideration of mental health issues, and education/counselling of adolescents and their families. Although the intervention appears intensive and expensive in the short term, it significantly improved the frequency of blood glucose monitoring and decreased hospital admissions.

      The study has several implications for nurses in the fields of diabetes, chronic illness, and adolescent health. Firstly, it points to the need to consider how external systems, such as peers and school, can support or negate an adolescent’s illness management goals. This means that nurses who counsel adolescents with chronic illness should be prepared to discuss the influence of their families, schools, and the broader community in achieving effective self management of the disease. Interviews of adolescents with diabetes can help nurses to identify those at risk of inadequate metabolic control who lack sufficient system-wide support. Secondly, the researchers described the intervention in such a way as to provide practical advice to clinicians wishing to engage family, school, and community in the support of an adolescent’s illness related goals. For example, they proposed that clinicians work with school personnel to identify a private location in the school for adolescents with diabetes to check their blood glucose concentrations. Finally, the study provides evidence that interventions to promote healthy practices among adolescents with chronic disease must be based within the context of the real world of adolescents.

      Footnotes

      • * Information provided by author.

      • For correspondence: Dr D A Ellis, Department of Child Psychiatry and Psychology, Children’s Hospital of Michigan, Detroit, MI, USA. dellis{at}med.wayne.edu

      • Source of funding: National Institute of Diabetes and Digestive and Kidney Diseases.

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