Treating Newly Diagnosed Diabetes Patients in the Ambulatory Setting

The Children's Mercy Diabetes Center is making a change to the way it cares for the 250 to 300 type 1 and 2 diabetes patients newly diagnosed each year, transitioning them from inpatient to outpatient treatment.

Patients over 5 years old and their families will receive the education and training needed to maintain healthy blood glucose levels in three outpatient visits over the course of 1 month. Children under 5 or those who present with diabetic ketoacidosis will continue to be admitted to the hospital. This change is being made to enhance the patient experience in receiving and retaining education related to their new diabetes diagnosis.

Hear from Ryan McDonough, DO, as he discuss this new clinic model and the benefits it will offer to patients newly diagnosed with diabetes.
Treating Newly Diagnosed Diabetes Patients in the Ambulatory Setting
Featured Speaker:
Ryan J. McDonough, DO
Ryan McDonough, DO, FAAP is a Pediatric Endocrinologist at Children’s Mercy Kansas City. He also serves as the Co-Medical Director of the Children’s Diabetes Center at Children’s Mercy.

Dr. McDonough earned his Bachelor of Arts degree in Psychology from Creighton University, Omaha, NE in 2006. He earned his Doctor of Osteopathic Medicine from Des Moines University, Des Moines, IA in 2010. He completed his General Pediatrics Residency and Pediatric Endocrinology & Diabetes Fellowship at Children’s Mercy, Kansas City, MO.

Dr. McDonough has a particular interest in the care and management of children and adolescents with Type 1 Diabetes. His research interests include the effects of sleep and education on adherence to self-management behaviors in T1DM and quality improvement projects such as decreasing unnecessary lab utilization.

Learn more about Ryan McDonough, DO

Dr. Michael Smith (Host): So, our title today is “Treating Newly Diagnosed Diabetes Patients in the Ambulatory Setting”. My guest is Dr. Ryan McDonough. He is the pediatric endocrinologist at Children’s Mercy Kansas City, and he also serves as the Co-medical Director of the Children’s Diabetes Center at Children’s Mercy. Dr. McDonough, welcome to the show.

Dr. Ryan McDonough (Guest): Hi. Thank you so much.

Dr. Mike: Tell me first a little bit about the Children’s Mercy Diabetes Center.

Dr. McDonough: So, we are a very big diabetes center, actually. We take care of around 2,400 kids across the Kansas City Metro and beyond that have some form of diabetes-- the vast majority Type 1. We have about 20 endocrinologists between our Kansas City and Wichita locations. We’re blessed to have very big diabetes support staff with psychologists and social workers, nurses and dietician educators that are a part of our term.

Dr. Mike: So, I'm looking at your bio here and I see that your research interests include the effects of sleep and education on adherence to self-management behaviors in Type 1 diabetes. Tell us a little bit about how you became interested in that.

Dr. McDonough: So, my interest in diabetes stemmed from an experience in college that I had with one of my good friends who, at the time, I didn’t know had diabetes. She was very private about her diabetes but we were studying for a physics test and it turns out she started to have a low blood sugar reaction that, at the time, I was not very familiar with what that meant or what to do with it. I ended up having to call her mom, and her mom walked me through step-by-step how to treat a low blood sugar, and from that moment on, I really started being very interested in diabetes, the path of physiology and how someone can live successfully with such a long-lasting, lifelong medical problem that impacts pretty much every part of their day. It was her that really gave me my inspiration to be an endocrinologist and to be a pediatric endocrinologist. Then, from there, my interest in diabetes just blossomed. And one of the things I really like to do is find out how we can help people take care of their diabetes better.

Dr. Mike: Yes, that’s great, and that’s what you’re doing obviously at the Children’s Mercy Diabetes Center but I understand that you’re going to be making a change in the way that the center cares for, I think, what you have up to maybe 300 Type 1 Type 2 patients? Tell us a little bit about what change is happening for next year.

Dr. McDonough: So, starting in January, we are making a fairly big initiative change in the way that we take care of those newly diagnosed kids--those 250 to 300 kids every year that come to us with newly diagnosed diabetes. Historically, we had admitted those kids to the hospital. They spend 48 to 72 hours with us, and we teach them the basics of diabetes care in the hospital setting. We realized that that really causes a lot of anxiety for families. It causes a lot of stress. It’s an overwhelming experience to not only have this new diagnoses, but then to be separated from your family, to be separated from your home, and your area that you’re comfortable with. To top that all off, this new diagnosis is a lot of information that we’re giving them. It is so much that they have to digest over the course of a 48-hour period that we know that we can't pick up everything. So, what we’re doing is shifting that and deciding that what would be best for our patients is instead of spending that 48 to 72 hours in the hospital, let’s start doing this education in a clinic setting. Let’s do it in the ambulatory space where people are going to be able to get that knowledge in a more comfortable location and then be able to go home that night and be able to spend that night back in their own home with the basics of diabetes care. One of the biggest pieces of this is that we’re spreading the education out. Instead of condensing it all into that 48 hours where these kids and these families were, really, we’re asking them to take a drink of water from a fire hydrant worth of knowledge, we’re going to spread it out and, instead, have them come back over several visits over the course of a month to really give them an opportunity to learn the basics, go home and live with those basics, come back to get some higher level skills, and then do that again. Hopefully, this will really enhance their educational experience.

Dr. Mike: So, this is rolling out for next year. So, did you test this out in a smaller setting to show that there is benefit in approaching it this way?

Dr. McDonough: So, we have done a few kids over the course of the last year who just under different circumstances were able to do ambulatory type education, so we have some experience with it. Then, also, the co-directors of the diabetes center, we’ve gone to other locations to really experience how it’s being practiced elsewhere and see it in action, knowing that it works. So, we feel very comfortable, very confident this is going to be a great transition for our community, for our diabetes center and for the patients that we serve.

Dr. Mike: So, obviously, in this education of the patients and the family, you focus a lot on this self-management of the disease. Tell us what are some of the barriers that you see to helping families and the patient take better care of themselves, and what are some of the things you specifically teach to improve self-management behaviors?

Dr. McDonough: So, the foundation of diabetes care is self-management, and not just knowing the basic skills but being able to advance those skills, to be able to essentially take care of your diabetes when you’re at home and with interaction with your diabetes team as you need. The amount of education that you get is variable depending on the person. Everyone needs a little bit different focus and attention but what we find is that it is the foundation of being able to take care of yourself. The big hurdles are there’s a lot of technical skill that’s involved. You have to learn how to do an insulin injection. You have to learn how to count the carbohydrates of the food that you’re eating. You need to know what to do with blood sugars that are high and what to do when they’re low. What we do in our self-management education is address each of those topics and custom tailor it to the child that we’re seeing. We want our families to be able to look at a meal and know what to do with it when it comes to their child. We want them to be able to take into account the activity that’s going to be coming up or changes to school or family routines that may impact diabetes care. At the end of the day, what we want is for them to be able to make those adjustments and feel confident making those adjustments.

Dr. Mike: Yes. So, when you look at the self-management behaviors that you’re trying to teach, how has the diabetes center at Children’s Mercy utilized technology in teaching these behaviors?

Dr. McDonough: So, diabetes is a very technology-driven disease. One of the biggest technologies that we rely on is the use of insulin pumps. About 80% to 85% of our Type 1 patient population uses that insulin pump technology to manage their diabetes. It offers so much more flexibility to their everyday diabetes care. It makes a lot less injections for kids, which they tend to really enjoy, and it gives the ability to titrate and to adjust things a little bit more tightly than we would be able to do with injections. Then, there’s, of course, just a myriad of different technology options for ways that families can communicate back with us. We can see from remotely what the blood sugar trend is doing. We can help manage and help make adjustments to insulin regimens because the families can give us that information over the internet or remotely which has been a huge benefit to our patients and to our diabetes center.

Dr. Mike: Yes. So, looking at the whole program that you’re about to start for 2017, just give us a synopsis of what you hope to achieve with this new approach to your Type 1 and Type 2 diabetes patients.

Dr. McDonough: So, our biggest initiative, our biggest goal is to try and make the new onset experience a little less stressful for families, to make it a little bit easier to digest, to be able to get them to where they need to be without causing a lot of undue burden, undue anxiety, that we find can happen in the hospitalized setting. Our goal is to make sure that our patients getting ambulatory education are getting the same metabolic and glycemic outcomes that we see in our patients who are admitted, and to make sure that we are helping our families just really adjust to diabetes as easily as possible.

Dr. Mike: Yes. Well, Dr. McDonough, I want to thank you for the work that you’re doing, and I really do wish you the best of luck. My gut feeling is that you are on the right track on this and I think you are going to be very successful.

Dr. McDonough: Really appreciate that.

Dr. Mike: And, of course, thanks for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to That’s I’m Dr. Mike Smith. Thanks for listening.