Continuing stability of center differences in pediatric diabetes care: do advances in diabetes treatment improve outcome? The Hvidoere Study Group on Childhood Diabetes.
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.
de Beaufort
Carine E
CE
DECCP, Clinique Pédiatrique/Centre Hospitalier, Luxembourg. debeaufort.carine@chl.lu
Swift
Peter G F
PG
Skinner
Chas T
CT
Aanstoot
Henk J
HJ
Aman
Jan
J
Cameron
Fergus
F
Martul
Pedro
P
Chiarelli
Francesco
F
Daneman
Dennis
D
Danne
Thomas
T
Dorchy
Harry
H
Hoey
Hilary
H
Kaprio
Eero A
EA
Kaufman
Francine
F
Kocova
Mirjana
M
Mortensen
Henrik B
HB
Njølstad
Pal R
PR
Phillip
Moshe
M
Robertson
Kenneth J
KJ
Schoenle
Eugen J
EJ
Urakami
Tatsuhiko
T
Vanelli
Maurizio
M
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
D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; C517652:hemoglobin A1c protein, human