How to start or change a daily insulin regimen without a specialist in diabetes. Effectiveness and RAND assessment of practical schemes for in-hospital or hospital-based home care services use.

When the diabetic patient is hospitalised or assisted by a hospital-based home care service, as a rule he/she is not cared for by a diabetologist all day long. The aim of the present work was to perform a RAND assessment of practical schemes to start or change a daily insulin regimen without a diabetologist. We created an expert panel of seven internists and two diabetologists. They judge the appropriateness of each practical scheme using the RAND method. We produced 21 clinical scenarios divided into two groups. The first group of 9 clinical scenarios-i.e., for diabetic patients who 'eat/not-always-eat' and are 'normal-weight/obese/underweight' or with 'renal failure' or 'defedated/end-of-life' or 'vomiting' or on 'parenteral nutrition'-useful for starting a daily insulin regimen without a diabetologist had a median RAND score of 8 (range 7-9). The second one-formed by 12 clinical scenarios useful to change the daily insulin dosage without a diabetologist based on low or high capillary glucose level monitoring-had a median RAND score of 9 (range 7-9). There was a high level of agreement between panellists in judging 'appropriate' the practical schemes to start or change a daily insulin regimen without a diabetologist.