Audit of diabetes care by caseload

To investigate the relationship between clinic provision, consultant and nursing caseload, and processes and outcomes of diabetes care in children.

Retrospective audit in the South Western region of England of 801 children and young people with diabetes; 701 were seen in a designated clinic. Seven of 21 consultants fulfilled the British Paediatric Association (BPA) criteria for a specialist in childhood diabetes. Seventeen nurses provided specialist care.

Glycated haemoglobin, admissions to hospital clinic attendance rates, contacts with a dietitian, measurements of height and weight, and screening rates for hypertension, microalbuminuria, and retinopathy.

Children under the care of 'non-specialists' had higher admission rates to hospital with all diabetes related problems and for hypoglycaemia and lower screening rates for microalbuminuria than those under 'specialists'. Children under the care of the two tertiary hospital consultants and lowest glycated haemoglobin results, spent least time in hospital at diagnosis, were most likely to have their heights and weights plotted, and to be screened for microalbuminuria and retinopathy, had higher admission rates, lower clinic attendance rates, and fewer dietitian consultations. Higher nursing caseloads were associated with longer periods of admission at diagnosis, better clinic attendance rates, reduced rates of admission after diagnosis, and less likelihood of having blood pressure measured and being screened for microalbuminuria. Children attending general paediatric clinics were less likely to be seen by a dietitian and to have their height and weight plotted.

The results are consistent with the recommendation of a BPA working party in 1990 that children with diabetes should be cared for by specialist paediatricians with a caseload of more than 40 children, and that children should be seen in a designated diabetic clinic.