J zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA C hro n Dis Vol. 39, No. 7, pp. 561-562, 1986 Printed in Great Britain 0021-9681/86 $3.00 + 0.00 Pergamon Journals Ltd Letters to the Editors zyxwvutsrqponmlkjihgfedcbaZYXWVU OUTPATIENT PEDIATRIC DIABETES-l. CURRENT PRACTICES I WISH TO comment on the recently published survey of outpatient pediatric diabetes practice [l]. Sampling is non-randomized, the questionnaire may be leading and is not validated, but the results are used to describe typical diabetes subspecialty practice. The suggestion that the sample included at least one subspecialist from each major academic and large private medical center in the U.S. is difficult to accept. We are not told how many were from within the same center. In our own survey of the same reference population (The Lawson Wilkins Pediatric Endocrine Society), we wound up with twice the respondents with only one representative of each center [2]. Ambiguity of the questionnaire is suggested by the data on average clinic visit which yielded a range of 12-360 minutes. These extremes suggest that people were responding to this question in quite different ways (e.g. at the upper limit including waiting time), rather than that there is a 30-fold variation in investment in patient care by this population of respondents. Compliance and control are quite different notions. Clarke et al. [l] refer to various measures of diabetic control as indicators of patient compliance with the medical manage- ment plan. This equating of compliance and control is based on the unproven assumption that if patients simply followed doctors’ orders, diabetic control would be excellent [3]. The assumption that the educational practices that were listed and commented upon are “utilized by respondents” may also not be appropriate. If I remember the questionnaire correctly from when I responded, these were professed good practices, not necessarily those that were used in the respondent’s clinic. Nor is there any attempt to assess the physician’s “compliance” with his or her professed educational practices. The authors talk about patients being on open-loop therapy when referring to insulin pump use. In a systems analytic sense, all administration of insulin without continuous feedback is open-loop. More seriously, in relation to the administration of insulin, the authors imply that “the use of combinations of regular and NPH insulins administered twice daily” is the norm, but their table only confuses on this issue. At first glance, their table indicates that 23% of patients are on single daily injection and 70% on twice daily injection; however, these are the frequencies of physicians giving these responses as an indication that more than half of their patients are in one or the other group. Thus, it is impossible to get a statistical handle, even from such a potentially biased population, of how many patients are on once vs twice a day insulin. The dating of this report is indicated by the conclusions regarding self blood glucose monitoring, for which the authors conclude, “no mass movement toward the use of HGM [home glucose monitoring] is evident.” When these authors did their survey in 1980, self blood glucose monitoring was relatively new and its acceptance by the pediatric patient population only beginning 141. Urine glucose testing is no longer even taught to new patients in many clinics, including our own. The assessment of complications included at least two exercises that have no relevance to quality practice, although they may be of interest in research, nerve conduction studies and capillary basement membrane width. 561