Prompt Recognition of New-Onset Type 1 Diabetes Is Everyone’s Responsibility—Even on Weekends

While the complex etiopathogenesis and heterogeneity of type 1 diabetes (T1D) creates many challenges regarding disease-modifying interventions, there are ways to meaningfully reduce the morbidity (1,2), and mortality, associated with new-onset T1D when it presents with life-threatening diabetic ketoacidosis (DKA). Early diagnosis and prompt initiation of insulin can prevent DKA, as has been shown in research programs that monitor children at risk for T1D.

In theory, early recognition of T1D to prevent severe metabolic decompensation consists of a simple exchange of knowledge regarding the signs and symptoms with all stakeholders and access to specialized health care. However, we have not been able to reduce the frequency of DKA in the population despite awareness and educational campaigns. Individual efforts have reduced DKA rates within a study setting, such as in Italy through an educational program in clinics, homes, and schools (3); however, the incidence of DKA at onset continues to rise in Italy and other regions (4–6). The rate of DKA at T1D diagnosis in children and adolescents remains unacceptably high and variable across countries (25–77%) (7–9).

In a study published in this issue of Diabetes Care, Kamrath et al. (9) analyzed the German Prospective Diabetes Registry (DPV) to assess for differences in when (e.g., the day of the week) individuals were diagnosed with, and started treatment for, new-onset T1D. In addition, over the 10-year period analyzed they assessed the rate of DKA, DKA severity, and effect of the coronavirus disease 2019 (COVID-19) pandemic. These are straightforward but previously unanswered questions that have implications for families, health care systems, and payors.

In this study of the DPV registry, DKA that occurred at diagnosis in children was 1) highest (in absolute counts) on Mondays and Tuesdays , but 2) highest proportional to the number of new cases of T1D each day on Saturday and Sunday. Similarly, looking at public holidays in Germany and school vacations by region, T1D (and DKA) was less likely to be diagnosed on weekends compared with weekdays.

In 9.1% of cases, insulin was not started on the day of diagnosis. Of note, DKA occurred in 21.2% of cases where treatment initiation was delayed. While the rate of DKA was higher (28%) in children without a treatment delay, if someone were near DKA, often tell-tale signs are evident that should alert a medical provider to the urgent need for treatment, although presentations vary and laboratory studies may not be readily available on weekends. This is especially apparent with the high rate of diabetes diagnosed on public holidays (21.8%), when laboratories may be closed, for example, as opposed to weekends and school vacations (14.4% and 12.4%, respectively). In comparison to 2013–2019, during the COVID-19 pandemic (2020–2022), the proportions of DKA and severe DKA at diagnosis did rise, as seen in other reports. However, there were no significant differences when comparing the type of day (workday versus other) between these time periods.

The analysis by Kamrath et al. (9) is well designed and includes a large number of children and adolescents. The DPV receives data from the vast majority (93%) of T1D diagnoses throughout the country, increasing its generalizability. While the type of health care system varies between countries, I would still expect these differences between workdays and nonworkdays to be present in many countries. In support of this assumption, in Colorado it was found that while DKA rates in children increased from 2010 to 2017, the increase was driven by insured children (5), meaning other variables, as Kamrath et al. explore, may play a role. Direct evidence of what information families may have received from acute care clinics, general providers, and on-call answering services is not available.

This study should provide renewed motivation for specialized diabetes-specific trainings for all who care for children. In addition, we can advocate for updates to health care policy to require that all patients have access to pediatric/specialized health care services 24 h a day, 7 days a week, 365 days a year. An influx of monetary support in this area could reduce DKA and intensive care unit hospitalizations for children which may actually save health care dollars. In addition, many children requiring critical care often must be transferred to another hospital that may be far from the family’s home and support system. We can focus on the stakeholders involved in primary prevention of DKA, which include the person with T1D and their family, primary care providers, acute care providers, and on-call services. The latter two especially are used more on weekends and holidays. For children who are likely to have a more rapid metabolic decompensation, parents are a vital stakeholder, as the child may not be able to adequately express their symptoms. Each of these stakeholders interacts with a child developing T1D before a specialist does. Kamrath et al. (9) bring up valuable points about differences in care that children receive outside standard weekdays. Might we take a multipronged approach to reach these stakeholders, as depicted in Fig. 1?

Identifying T1D early, before the development of DKA, is possible, as has been shown in the U.S., Germany, Finland, Sweden, Australia, and New Zealand, where rates of DKA were ≤6% when children at risk for T1D (multiple islet autoantibodies present) were involved in monitoring (5,10–13). We, as readers of Diabetes Care, should be taking lessons from these groups as we work toward the goal of zero cases of DKA. We can affect change regarding early recognition of T1D.