Elsevier

The Journal of Pediatrics

Volume 131, Issue 5, November 1997, Pages 727-733
The Journal of Pediatrics

Consequences of irregular versus continuous medical follow-up in children and adolescents with insulin-dependent diabetes mellitus,☆☆,

https://doi.org/10.1016/S0022-3476(97)70101-XGet rights and content

Abstract

Objectives: To study the social and family characteristics of patients with insulin-dependent diabetes mellitus with irregular versus continuous clinical follow-up and to study the medical outcomes of patients with these follow-up patterns.

Methods: An onset cohort of 61 children and adolescents with insulin-dependent diabetes mellitus and their parents were studied. Aspects of their social and family environment were assessed at study inception and examined in relation to frequency of follow-up early in the course of the illness. Follow-up was dichotomized so that patients with continuous follow-up were compared with patients with irregular follow-up, who were defined as those missing 1 full year of planned medical appointments during the second through fourth years after diagnosis. Patients with irregular and continuous follow-up were compared in terms of acute metabolic complications, glycemic control, and retinopathy status during a 10-year period.

Results: Compared with individuals with continuous follow-up, patients with irregular clinical visits were more likely to be from families of lower socioeconomic class levels, have a parental history of separation and divorce, and were members of families that reported being least openly expressive of positive emotions. Poor glycemic control in year 1 was associated with irregular follow-up in years 2 through 4. Patients with irregular follow-up continued to have worse glycemic control in years 2 through 4 than patients with continuous follow-up. However, in years 7 and 10 their glycemic control no longer differed from patients with continuous follow-up. More episodes of diabetic ketoacidosis occurred in the irregular follow-up group. Finally, retinopathy occurred more frequently among those in the irregular follow-up group.

Conclusion: Early irregular clinical follow-up should be considered a risk factor for complications of insulin-dependent diabetes mellitus. (J Pediatr 1997;131:727-33)

Section snippets

Subjects

Table I presents the demographic and medical characteristics of the patients enrolled in the study. The patients were selected within 1 year of onset of IDDM. All patients between the ages of 9 and 16 years who were seen at the Joslin Diabetes Center’s Pediatric Unit were invited to participate in the study. No patients were excluded on the basis of psychologic characteristics. Of those recruited, 76% (N = 61) agreed to participate. All subjects except one were white children; the remaining

Clinic Attendance and Year 1 Demographic, Family, and Medical Characteristics

Twelve (20%) of the 61 patients did not have appointments in at least 1 year during years 2 through 4. We compared these patients with irregular follow-up with the 49 patients with continuous follow-up (Table II) . Two demographic dimensions distinguished the groups: socioeconomic class and parent marital history. Patients from the two higher SES groups were least likely to have irregular follow-up, whereas those from the three lower SES groups were most likely to have an irregular pattern of

Discussion

Retinopathy 10 years after diagnosis of IDDM was more commonly found among those with early irregular follow-up. The logistic regression analyses are consistent with the interpretation that medical care exerts its influence on complications development through its relation with glycemic control. The hopeful finding of improved glycemic control by years 7 and 10 among those with early irregular follow-up may lead to a decrease in relative risk later in the course of diabetes. It is not clear to

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    Supported by National Institutes of Health grant No. DK27845, and National Institute of Mental Health Research Scientist Award 5K-02-MH70178 (S.T.H.).

    ☆☆

    Reprint requests: Alan M. Jacobson, MD, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215.

    0022-3476/97/$5.00 + 0 9/21/80749

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