a total of 127 adolescents with cpmc and their families were recruited from endocrinology clinics at children 's hospital of michigan between 1999 and 2004 . eligible youth were diagnosed with type 1 diabetes for at least 1 year , had an average a1c of 8% during the year before study entry , and were aged 1017 years . a total of 92% of the subjects used injected insulin , and 8% used insulin pumps . mean  sd age was 13.2  2.0 years , and 63% of participants were african american . a total of 64 participants were randomly assigned to mst and 63 to a control group . mst - treatment families also received 6 months of therapy ( mean 5.7 months ) . mst targeted adherence - related problems within the family and broader community systems ( 1,3 ) . these systems included family ( e.g. , poor parental supervision and oversight of the youth 's diabetes care completion ) , school ( e.g. , inadequate communication between parents and school personnel regarding the youth 's health needs ) , and health care system factors ( e.g. , barriers to keeping clinic appointments due to problems with transportation or family disorganization ) . the number of dka admissions was obtained from the treating hospital 's information system for the 6-month window before study entry ( baseline [ t1 ] ) and for the follow - up periods ( baseline to 6 months [ t2 ] , 612 months [ t3 ] , 1218 months [ t4 ] , and 1824 months [ t5 ] ) . criteria used to diagnose dka were hyperglycemia ( blood glucose > 16.65 mmol / l ) , serum acetone positive at greater than 1:2 dilution of serum , acidosis ( ph < 7.30 and bicarbonate < 15 mmol / l ) , ketonuria , and glucosuria . as decreases in a1c at treatment termination for mst - treated youth were not maintained at 6 months ( 2 ) , cost - effectiveness evaluation was not appropriate . a total of 45 youth ( 21 mst - treated and 24 control subjects ) had at least one admission during the study . costs were estimated by obtaining direct hospital costs and revenues from the hospital financial database and calculating an average cost for dka admissions during the study . costs of mst for youth with cpmc were estimated from mst costs in the  real world  rather than costs in the trial , which might underestimate true implementation costs . because mst as originally developed for delinquent youth is widely disseminated , real - world estimates could be calculated . costs included salary and benefits ; overhead for therapists , supervisors , and program staff ; therapist mileage ; travel for training ; mst licensing fees ; and quality assurance costs . change in admission frequency over the 24-month trial was evaluated using repeated - measures poisson regression . analyses were performed with generalized estimating equations by specifying the poisson distribution for the response variable ( 4,5 ) ; this accounted for correlated error . time effects were partitioned into time - ordered contrasts comparing t1 with each follow - up period ( t2t5 ) . the effects of mst were evaluated by the group  time interaction , followed by simple effect tests of mst within - group changes from baseline . single - parent status was used as a covariate due to its relatedness to outcome in prior studies . , n = 127 ; p = 0.019 ) , indicating mst - treated youth had significantly fewer admissions than control subjects . simple effect contrasts showed that mst youth had significantly fewer dka admissions relative to baseline frequency at t2 ( p = 0.004 ) , t3 ( p = 0.021 ) , t4 ( p = 0.046 ) , and t5 ( p = 0.034 ) . drops in admissions per youth were obtained over constant 6-month intervals and , hence , are measures of effect size when expressed as rates . the rates were 0.31 ( 95% ci 0.090.54 ) , 0.27 ( 0.030.50 ) , 0.23 ( 0.010.47 ) , and 0.23 ( 0.010.47 ) for t2t5 , respectively . control subjects had fewer admissions only at t5 ( p = 0.026 ) ; rate 0.24 ( 0.020.45 ) . hence , dka admissions resulted in 360,145 and 190,665 usd in hospital costs and 462,910 and 245,070 usd in third - party payor costs for control and mst - treated youth , respectively . costs to provide mst for 21 youth were estimated at 145,614 usd ( 21  6,943 ) . therefore , mst was estimated to potentially save a total of 23,886 ( institutional perspective ) or 72,226 ( third - party payor perspective ) usd . mst produced lasting reductions in postdiagnostic dka hospital admissions , which occur most commonly due to insulin noncompliance ( 6,7 ) . reduced admissions rates in the mst group at follow - up were consistent with those reported in recent general population studies of youth with diabetes ( 8) . the only other intervention with effects on dka in youth with cpmc is residential psychiatric treatment ( 9 ) , a costly intervention with unknown long - term impact . however , preliminary evaluation suggests that control youth with dka admissions accumulated sufficient costs over 24 months and that expenditures on mst may be justified by potential for savings . mst could produce cost savings for the subset of youth with cpmc and a recent history of dka admissions if admissions are occurring frequently . the study demonstrates the potential for intensive behavioral interventions to reduce serious consequences of medication noncompliance in high - risk youth .
objective  the study aim was to determine if multisystemic therapy ( mst ) , an intensive home - based psychotherapy , could reduce hospital admissions for diabetic ketoacidosis ( dka ) in youth with poorly controlled type 1 diabetes over 24 months . 
 potential cost savings from reductions in admissions were also evaluated.research design and methods  a total of 127 youth were randomly assigned to mst or control groups and also received standard medical care.resultsyouth who received mst had significantly fewer hospital admissions than control subjects ( 2 = 11.77 , 4 d.f . 
 , n = 127 ; p = 0.019 ) . 
 mst - treated youth had significantly fewer admissions versus their baseline rate at 6-month ( p = 0.004 ) , 12-month ( p = 0.021 ) , 18-month ( p = 0.046 ) , and 24-month follow - up ( p = 0.034 ) . 
 cost to provide mst was 6,934 usd per youth ; however , substantial cost offsets occurred from reductions in dka admissions.conclusionsthe study demonstrates the value of intensive behavioral interventions for high - risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance .