title: Continuing stability of center differences in pediatric diabetes care: do advances in diabetes treatment improve outcome? The Hvidoere Study Group on Childhood Diabetes.
abstract: 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.
  
  
  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.
authors.affiliation: DECCP, Clinique Pédiatrique/Centre Hospitalier, Luxembourg. debeaufort.carine@chl.lu
authors.forename: Carine E
authors.initials: CE
authors.lastname: de Beaufort
authors.forename: Peter G F
authors.initials: PG
authors.lastname: Swift
authors.forename: Chas T
authors.initials: CT
authors.lastname: Skinner
authors.forename: Henk J
authors.initials: HJ
authors.lastname: Aanstoot
authors.forename: Jan
authors.initials: J
authors.lastname: Aman
authors.forename: Fergus
authors.initials: F
authors.lastname: Cameron
authors.forename: Pedro
authors.initials: P
authors.lastname: Martul
authors.forename: Francesco
authors.initials: F
authors.lastname: Chiarelli
authors.forename: Dennis
authors.initials: D
authors.lastname: Daneman
authors.forename: Thomas
authors.initials: T
authors.lastname: Danne
authors.forename: Harry
authors.initials: H
authors.lastname: Dorchy
authors.forename: Hilary
authors.initials: H
authors.lastname: Hoey
authors.forename: Eero A
authors.initials: EA
authors.lastname: Kaprio
authors.forename: Francine
authors.initials: F
authors.lastname: Kaufman
authors.forename: Mirjana
authors.initials: M
authors.lastname: Kocova
authors.forename: Henrik B
authors.initials: HB
authors.lastname: Mortensen
authors.forename: Pal R
authors.initials: PR
authors.lastname: Njølstad
authors.forename: Moshe
authors.initials: M
authors.lastname: Phillip
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Robertson
authors.forename: Eugen J
authors.initials: EJ
authors.lastname: Schoenle
authors.forename: Tatsuhiko
authors.initials: T
authors.lastname: Urakami
authors.forename: Maurizio
authors.initials: M
authors.lastname: Vanelli
mesh_terms: D000293:Adolescent; D002648:Child; D003144:Communication Barriers; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D016883:Diabetic Ketoacidosis / Q000453:epidemiology / Q000209:etiology; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007003:Hypoglycemia / Q000209:etiology; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D015203:Reproducibility of Results
chemical_list: D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; C517652:hemoglobin A1c protein, human