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Continuing Stability of Center Differences in Pediatric Diabetes Care: Do Advances in Diabetes Treatment Improve Outcome?

The Hvidoere Study Group on Childhood Diabetes

¹ DECCP, Clinique Pédiatrique/Centre Hospitalier, Luxembourg
² Department of Paediatrics, Leicester Royal Infirmary Children's Hospital Leicester, U.K
³ Department of Psychology, University of Wollongong, Wollongong, Australia
⁴ Diabetes, Center for Pediatric and Adolescent Diabetes, Rotterdam, the Netherlands
⁵ Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
⁶ Department of Endocrinology and Diabetes, Royal Children's Hospital, Parkville, Victoria, Australia
⁷ Endocrinology and Diabetes Research Group, Hospital de Cruces, Cruces, Spain
⁸ Department of Pediatrics, University of Chieti, Chieti, Italy
⁹ Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
¹⁰ Kinderkrankenhaus auf der Bult, Hannover, Germany
¹¹ Diabetology Clinic, Children's University Hospital Queen Fabiola, Brussels, Belgium
¹² Department of Paediatrics, Trinity College, National Childrens Hospital, Dublin, Ireland
¹³ Department of Paediatrics, Peijas Hospital, Vantaa, Finland
¹⁴ Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles California
¹⁵ Pediatric Clinic, Medical Faculty Department of Endocrinology and Genetics, Skopje, Republic of Macedonia
¹⁶ Paediatric Department L, Glostrup University Hospital, Glostrup, Denmark
¹⁷ Department of Pediatrics, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway
¹⁸ National Center of Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
¹⁹ Department of Paediatrics, Royal Hospital for Sick Children, Glasgow, Scotland
²⁰ Department of Paediatrics, University Childrens Hospital, Zurich, Switzerland
²¹ Department of Paediatrics, Nihon University School of Medicine, Tokyo, Japan
²² Centro di Diabetologia, University of Parma, Parma, Italy

Address correspondence and reprint requests to Dr. Carine de Beaufort, Clinique Pédiatrique, Centre Hospitalier de Luxembourg, 4, rue Barblé, 1220 Luxembourg. E-mail: debeaufort.carine{at}chl.lu

	ABSTRACT

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS-- RESULTS CONCLUSIONS-- References

 
OBJECTIVE—To reevaluate the persistence and stability of previously observed differences between pediatric diabetes centers and to investigate the influence of demography, language communication problems, and changes in insulin regimens on metabolic outcome, hypoglycemia, and ketoacidosis.

RESEARCH DESIGN AND METHODS—This was an observational cross-sectional international study in 21 centers, with clinical data obtained from all participants and A1C levels assayed in one central laboratory. All individuals with diabetes aged 11–18 years (49.4% female), with duration of diabetes of at least 1 year, were invited to participate. Fourteen of the centers participated in previous Hvidoere Studies, allowing direct comparison of glycemic control across centers between 1998 and 2005.

RESULTS—Mean A1C was 8.2 ± 1.4%, with substantial variation between centers (mean A1C range 7.4–9.2%; P < 0.001). There were no significant differences between centers in rates of severe hypoglycemia or diabetic ketoacidosis. Language difficulties had a significant negative impact on metabolic outcome (A1C 8.5 ± 2.0% vs. 8.2 ± 1.4% for those with language difficulties vs. those without, respectively; P < 0.05). After adjustement for significant confounders of age, sex, duration of diabetes, insulin regimen, insulin dose, BMI, and language difficulties, the center differences persisted, and the effect size for center was not reduced. Relative center ranking since 1998 has remained stable, with no significant change in A1C.

CONCLUSIONS—Despite many changes in diabetes management, major differences in metabolic outcome between 21 international pediatric diabetes centers persist. Different application between centers in the implementation of insulin treatment appears to be of more importance and needs further exploration.

Abbreviations: CSII, continuous subcutaneous insulin infusion • DCCT, Diabetes Control and Complications Trial • DKA, diabetic ketoacidosis

	INTRODUCTION

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS-- RESULTS CONCLUSIONS-- References

 
The Hvidoere Study Group on Childhood Diabetes has investigated metabolic control in large cohorts of adolescents from >20 pediatric diabetes centers worldwide. Studies have shown that although the mean A1C was not much higher than in the intensively treated adolescent group in the Diabetes Control and Complications Trial (DCCT), few of the adolescents achieved A1C levels in an optimal range (29% < 8.0%) (1). Better metabolic control was associated with better quality of life with no increased rate of hypoglycemia (2,3), contrary to the results of the DCCT for adolescents (4,5). However, the Hvidoere Study Group also revealed substantial and persistent differences between the centers for which no clear explanations were found (2,6).

With the introduction of newer insulins, increased implementation of basal- bolus multiple-dose injection regimens, reentry of continuous subcutaneous insulin infusion (CSII) treatment, and the general trend toward intensification of insulin treatment into pediatric diabetes, a new study was initiated (7–10). The aims of this study were to investigate whether demographic and ethnic factors, or the substantial regimen changes and information exchange between centers, had resulted in improved glycemic control in adolescents and reduced the differences between centers.

	RESEARCH DESIGN AND METHODS—

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS-- RESULTS CONCLUSIONS-- References

 
An observational, multicenter, cross-sectional study involving 21 pediatric diabetes departments from 19 countries in Europe, Japan, Australia, and North America was performed between March and October 2005. Fourteen centers had participated in the 1998 Hvidoere Study. Adolescents (aged 11–18 years; diabetes duration >12 months), parents, and health care professionals were invited to participate. Each center was limited to a maximum of 200 adolescent participants. If a center had >200 eligible adolescents, only the patients seen by one Hvidoere member were invited.

The case report form included information on sex, age, height, weight, duration of diabetes, number of severe hypoglycemic events (defined as seizures or loss of consciousness in the 3 months preceding blood sampling), and number of episodes of diabetic ketoacidosis (DKA) necessitating hospital admission in the last year. The number of insulin injections, type of insulin, and injection device were recorded. Information on concomitant medical conditions (celiac disease, thyroid disease, epilepsy, asthma, or other) was obtained. As a marker for ethnicity/minority group status, the case report form recorded whether there were language difficulties leading to communication problems with the diabetes team. All members of the diabetes teams were asked what changes had been made "to improve diabetes care and outcomes in your clinic during the last 5 years. Include clinical, administrative, organizational, resource and any other changes."

A capillary blood sample was provided by participants and analyzed at Steno Diabetes Center, Gentofte, Denmark. A1C was DCCT aligned (normal range 4.4–6.3%, mean 5.4%, and interassay SD 0.15%, Tosoh method). For comparisons with 1998 data (A1C assayed by the Bio-Rad method), we used the correction equation for equivalence evaluated by the Steno laboratory (A1C_BioRad = 0.590 + 0.971 A1C_Tosoh) (11). Details of transportation and stability of specimens have been published (1). The study was performed according to the criteria of the Helsinki II Declaration and was approved by the local ethics committee at each center.

Statistical analysis
Data were all double entered at a central administration center, and ambiguous data on the case report form were resolved by direct contact with participating centers. Bivariate relationships with A1C, DKA, and hypoglycemic episodes were tested using ANOVA for categorical variables and Pearson's product moment correlation for continuous variables. The effect of center on A1C was tested by adding confounding demographic and medical characteristics as covariates, with categorical covariates dummy coded. Comparisons between the 1998 and 2005 studies were conducted, after ensuring comparable age range for participants, using repeated-measures ANOVA, with subsequent analysis controlling for all confounding variables with categorical covariates dummy coded.

	RESULTS

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS-- RESULTS CONCLUSIONS-- References

 
Descriptives and demographics
A total of 2,269 eligible individuals attended clinics during the recruitment period. Demographic characteristics are summarized (Table 1). Of these, 2,093 (92%) adolescents completed a questionnaire and 2,036 (89%) provided a blood sample for assay. There were no significant differences in age, BMI, and frequency of DKA between those who provided A1C sample and those who did not. Those not providing A1C samples had a shorter duration of diabetes (with A1C, duration 6.1 ± 3.5 years; without A1C, duration 4.8 ± 2.8 years; P < 0.001).

The majority of individuals (85.3%) were on one of five insulin regimens (Table 1). The remaining 309 (14.7%) individuals were on regimens that could not be classified into any obvious category with meaningful numbers. This unclassified group had A1C 8.2% (not significantly different from other groups) but a significantly lower mean insulin dose (F = 9.4; df = 4; P < 0.001) than the classified groups. Those on thrice-daily injections had significantly higher doses than all other groups. There was a significant relationship between insulin regimen and A1C (F = 6.629; df = 5; P < 0.001), with post hoc analysis indicating individuals on twice-daily free-mix regimens (varying the quantity of short/analogue and intermediate insulin) having significantly lower A1C than those on basal-bolus, pumps, or twice-daily premixed/insulin regimens. Adolescents on twice-daily premixed insulin regimens had significantly higher A1C than all other regimens except thrice daily (Table 2). There was no significant relationship between insulin regimen and BMI, hypoglycemia, or the occurrence of DKA.

Assessment of center differences
A1C in the 21 centers ranged between 7.4 and 9.2%. ANOVA indicated that there were significant differences between centers for A1C (F = 12.88; df = 20; P < 0.001) but not for frequency of hypoglycemia nor DKA. Six centers had a mean A1C significantly below the sample mean and six centers significantly above the sample mean (Fig. 1). However, there were also significant differences between centers for age of participants (F = 3.4; df = 20; P < 0.001), duration of diabetes (F = 1.80; df = 20; P < 0.05), insulin regimens (² = 2,300; df = 80; P < 0.001), daily insulin dosage (F = 6.40; df = 20; P < 0.001), and BMI (F = 2.91; df = 20; P < 0.005). Two centers had more participants with language difficulties than the overall mean, and four centers had less than the mean (² = 114; df = 2; P < 0.001). When the analysis of center differences was repeated adding these variables as covariates, the significant differences in A1C between centers remained, with the effect size remaining largely unaffected by the inclusion of any/all these covariates (F = 13.61; df = 20; P < 0.001).

View larger version (15K): [in this window] [in a new window]   Figure 1— Mean and SE of A1C (Tosoh method) for participating centers in rank order after controlling for confounding variables.

Controlling for demographic differences between cohorts, two centers showed a significant reduction (0.5%) in A1C from 1998 to 2005 and one center had a significant increase in A1C from 1998 to 2005 (Fig. 2). Although those centers that showed improved metabolic outcomes had increased the use of basal- bolus/CSII regimens (from 3 to 52% for center 3 and from 3 to 82% for center 14), this increase did not differ significantly from the other 12 centers (e.g., center 2 from 13 to 93%, center 5 from 4 to 60%). Some centers reported a decrease in basal bolus regimens with no detrimental effect on metabolic control (e.g., center 1 from 21 to 7%, with 93% of the patients being on twice-daily free mix).

View larger version (22K): [in this window] [in a new window]   Figure 2— Mean corrected A1C in 1998 and 2005 for centers in both studies after controlling for confounding variables.

	CONCLUSIONS—

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS-- RESULTS CONCLUSIONS-- References

 
The management of children and adolescents with type 1 diabetes has undergone many changes over the past decade (7–10), aiming to improve glycemic control and reduce risks of vascular complications, without sacrificing quality of life (12). These have included increased usage of insulin analogues, basal- bolus regimens, and CSII (9,13–16).

Despite these substantial changes, it has been difficult to demonstrate significant improvements in metabolic outcome (2,6,7,10) This study in 21 international centers was initiated to investigate the impact of treatment changes on glycemic control and to establish whether the previously reported differences between centers were diminishing. The results confirm that that there has been no improvement in glycemic control over a decade, with mean A1C levels of 8.6% (1995), 8.7% (1998), and 8.6% (2005) (1), and the substantial differences between centers have remained stable.

Only two centers significantly improved glycemic control compared with 1998. This could not be explained by intensification of insulin regimens or attributed to major changes in their team approach, compared with other centers. However, the range of changes made suggests that the two centers may have undergone a more fundamental restructuring of care rather than just tinkering with service provision. Increased numbers of diabetes nurses, weekly staff meetings, written patient information, and increased visits may have lead to improved education and/or treatment adherence (17). In comparison, the DCCT/Epidemiology of Diabetes Interventions and Complications results in adolescents show that in both DCCT intensive and nonintensive groups the mean A1C levels of 8.4% suggest that this age-group requires a fundamentally different approach to obtain a significant improvement in metabolic outcome (18).

The A1C achieved by individuals using twice-daily free mixing of insulin, most often using mixtures of soluble/regular plus NPH insulins, was lower than any other group. This suggests that the so-called conventional insulin regimens may be superior to more modern intensive regimens. However, this successful outcome seems to be the result of more optimal use of this regimen in specific centers. Those centers with lower mean A1C also have individuals with lower mean A1C using other regimens. In other words, as demonstrated previously (2,6), we cannot show that one insulin regimen is superior to another but only where and how that regimen is implemented. One should not assume that a multiple-injection basal-bolus regimen automatically represents an intensified insulin therapy and that a "conventional" twice-daily injection regimen is nonintensive. A multiple injection regimen not associated with intensified comprehensive education may be associated with deteriorating glycemic control. In contrast, a twice-daily injection regimen, with intensive consistent education, adjusted food intake, and appropriate adjustments of insulin doses, may lead to better metabolic outcome (14,19,20).

There were 309 (14.7%) individuals whose insulin regimen could not be easily classified into specific categories (e.g., unusual insulin combinations, multiple doses of different insulins, etc.). It is reassuring that this group's mean A1C was no different from the total cohort despite having perhaps more individualized insulin regimens. The explanation for individualized regimens is uncertain. For example, individuals in this group may have been more difficult to control, but the result strengthens the conclusion that center differences are not strongly influenced by a particular insulin regimen. This applies also to the increased access to CSII in some centers. The A1C for individuals on CSII was not significantly different from the total group, and in centers where considerable numbers of patients were on pumps, metabolic control was not significantly different. Numerous audits have found that CSII reduces glycated hemoglobin when switching from one modality to another, especially in clinics where enthusiasm is high (16,21,22), but randomized controlled trials of CSII in adolescents have had too small sample sizes or too short a duration of study to be statistically relevant (23). These criticisms could also be leveled at reported studies of basal-bolus therapy (20,24). The effects of new therapies on glycemia alone may be exaggerated, and there is a need for new tools to assess the behavioral and psychosocial outcomes (23).

The study attempted to review the influence on glycemic control of ethnic differences both at an individual level and between centers. Previously, we reported a weak negative association between ethnic minority status and A1C (2). This area of investigation has proven to be one of the most controversial, especially in centers where ethnic groups are diverse and well established. Using language difficulties as a marker for recent ethnic diversification, we have shown that when there are problems in communication between the adolescent or parents and the team, A1C is significantly higher. However, this finding does not influence the differences between centers. Some ethnically diverse centers seem able to achieve excellent metabolic control perhaps because there are minimal language and communication difficulties.

In conclusion, we have shown that despite major and continuing changes in the use of newer insulin regimens (including CSII), modes of administration, and attempts to improve service provision, glycemic control has not improved over a decade in 21 international centers. Significant and stable differences between centers remain, which cannot be explained by demography, ethnic issues, or insulin regimens. Certain centers are able to implement different insulin regimens more successfully than others. Further analysis of this implementation as well as other factors influencing center differences require further exploration.

	Acknowledgments

 
We thank Novo Nordisk for their continuous support of this project.

	Footnotes

 
Published ahead of print at http://care.diabetesjournals.org on 31 May 2007. DOI: 10.2337/dc07-0475.

C.E.B. has received travel grant support and speaking honoraria from Medtronic and Roche. F.Ca. has received research funding support, travel support, and honoraria from Medtronic, Eli Lilly, Aventis, and Animas. K.J.R. has received travel expenses and speaking fees from NovoNordisk.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C Section 1734 solely to indicate this fact.

Received for publication March 24, 2007. Accepted for publication May 24, 2007.

	References

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS-- RESULTS CONCLUSIONS-- References

 

1. Mortensen HB, Hougaard P: Comparison of metabolic control in a cross-sectional study of 2,873 children and adolescents with insulin-dependent diabetes from 18 countries. Diabetes Care 20:714–720, 1997[Abstract]
   
2. Danne T, Mortensen HB, Hougaard P, Lynggaard H, Aanstoot HJ, Chiarelli F, Daneman D, Dorchy H, Garandeau P, Greene SA, Hoey H, Holl RW, Kaprio EA, Kocova M, Martul P, Matsuura N, Robertson KJ, Schoenle EJ, Søvik O, Swift PG, Tsou RM, Vanelli M, Aman J, the Hvidøre Study Group on Childhood Diabetes: Persistent differences among centers over 3 years in glycemic control and hypoglycemia in a study of 3,805 children and adolescents with type 1 diabetes. Diabetes Care 24:1342–1347, 2001[Abstract/Free Full Text]
   
3. Hoey H, Aanstoot HJ, Chiarelli F, Daneman D, Danne T, Dorchy H, Fitzgerald M, Garandeau P, Greene S, Holl R, Hougaard P, Kaprio E, Kocova M, Lynggaard H, Martul P, Matsuura N, McGee HM, Mortensen HB, Robertson K, Schoenle E, Sovik O, Swift P, Tsou RM, Vanelli M, Aman J: Good metabolic control is associated with better quality of life in 2,101 adolescents with type 1 diabetes. Diabetes Care 24:1923–1928, 2001[Abstract/Free Full Text]
   
4. Diabetes Control and Complications Trial Research Group: Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus. J Pediatr 125:177–188, 1994[Medline]
   
5. White NH, Cleary PA, Dahms W, Goldstein D, Malone J, Tamborlane WV, the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group: Beneficial effects of intensive therapy of diabetes during adolescence: outcomes after the conclusion of the Diabetes Control and Complications Trial (DCCT). J Pediatr 139:804–812, 2001[Medline]
   
6. Holl RW, Swift PG, Mortensen HB, Lynggaard H, Hougaard P, Aanstoot HJ, Chiarelli F, Daneman D, Danne T, Dorchy H, Garandeau P, Greene S, Hoey HM, Kaprio EA, Kocova M, Martul P, Matsuura N, Robertson KJ, Schoenle EJ, Sovik O, Tsou RM, Vanelli M, Aman J: Insulin injection regimens and metabolic control in an international survey of adolescents with type 1 diabetes over 3 years: results from the Hvidoere Study Group. Eur J Pediatr 162:22–29, 2003[Medline]
   
7. Tamborlane WV, Bonfig W, Boland E: Recent advances in treatment of youth with type 1 diabetes: better care through technology. Diabet Med 18:864–870, 2001[Medline]
   
8. Brink SJ, Miller M, Moltz KC: Education and multidisciplinary team care concepts for pediatric and adolescent diabetes mellitus. J Pediatr Endocrinol Metab 15:1113–1130, 2002[Medline]
   
9. Mohn A, Dunger DB, Chiarelli F: .The potential role of insulin analogues in the treatment of children and adolescents with type 1 diabetes mellitus. Diabetes Nutr Metab 14:349–357, 2001[Medline]
   
10. Betts PR, Jefferson IG, Swift PGF: Diabetes care in childhood and adolescence. Diabet Med 19 (Suppl. 4):61–65, 2002
    
11. Carstensen B: Comparing and predicting between several methods of measurement. Biostatistics 5:399–413, 2004[Abstract]
    
12. Silverstein J, Klingensmith G, Copeland K, Plotnick L, Kaufman F, Laffel L, Deeb L, Grey M, Anderson B, Holzmeister LA, Clark N, the American Diabetes Association: Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care 28:186–212, 2005[Free Full Text]
    
13. Rachmiel M, Perlman K, Daneman D: Insulin analogues in children and teens with type 1 diabetes: advantages and caveats. Pediatr Clin North Am 52:1651–1675, 2005[Medline]
    
14. Dorchy H: Rational use of insulin analogues in the treatment of type 1 diabetic children and adolescents: personal experience. Arch Pediatr 13:1275–1282, 2006[Medline]
    
15. Plank J, Siebenhofer A, Berghold A, Jeitler K, Horvath K, Mrak P, Pieber TR: Systematic review and meta-analysis of short-acting insulin analogues in patients with diabetes mellitus. Arch Intern Med 165:1337–1344, 2005[Abstract/Free Full Text]
    
16. Battelino T: Risk and benefits of continuous subcutaneous insulin infusion (CSII) treatment in school children and adolescents. Pediatr Diabetes 4 (Suppl. 7):20–24, 2006[Medline]
    
17. Dyrlov K, Povlsen L, Solvkaer, Marinelli K,. Olsen BS, Hougaard P, Mortensen HB: Improving the outcome for children and adolescents with type 1 diabetes: results of a changing service in Copenhagen. Pract Diab Int 17:217–225, 2000
    
18. White NH, Cleary PA, Dahms W, Goldstein D, Malone J, Tamborlane WV, the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group: Beneficial effects of intensive therapy of diabetes during adolescence: outcomes after the conclusion of the Diabetes Control and Complications Trial (DCCT). J Pediatr 139:804–812, 2001[Medline]
    
19. Dorchy H, Roggemans MP, Willems D: Glycated hemoglobin and related factors in diabetic children and adolescents under 18 years of age: a Belgian experience. Diabetes Care 20:2–6, 1997[Abstract]
    
20. Nordfeldt S, Ludvigsson J: Severe hypoglycemia in children with IDDM: a prospective population study, 1992– 1994. Diabetes Care20: 497–503, 1997[Abstract]
    
21. Boland EA, Grey M, Oesterle A, Fredrickson L, Tamborlane WV: Continuous subcutaneous insulin infusion: a new way to lower risk of severe hypoglycemia, improve metabolic control and enhance coping in adolescents with type 1 diabetes. Diabetes Care 22:1779–1784, 1999[Abstract/Free Full Text]
    
22. Danne T, von Schütz W, Lange K, Nestoris C, Datz N, Kordonouri O: Current practice of insulin pump therapy in children and adolescents. Pediatr Diabetes 7 (Suppl. 4):25–31, 2006
    
23. Danne T, Tamborlane WV: Insulin pumps in pediatrics: we have the technology. We have the evidence. Why are so few kids using it? Pediatric Diabetes 7 (Suppl. 4):2–3, 2006
    
24. Dose Adjustment For Normal Eating Study Group: Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: Dose Adjustment For Normal Eating (DAFNE) randomised controlled trial. BMJ 325:746–749, 2002.[Abstract/Free Full Text]
    

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This Article Abstract Full Text (PDF) All Versions of this Article: dc07-0475v1 30/9/2245    most recent Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by de Beaufort, C. E. Search for Related Content PubMed PubMed Citation Articles by de Beaufort, C. E. Social Bookmarking                What's this?