International benchmarking in type 1 diabetes: Large difference in childhood HbA1c between eight high-income countries but similar rise during adolescence-A quality registry study.

OBJECTIVES: To identify differences and similarities in HbA1c levels and patterns regarding age and gender in eight high-income countries. SUBJECTS: 66 071 children and adolescents below18 years of age with type 1 diabetes for at least 3 months and at least one HbA1c measurement during the study period. METHODS: Pediatric Diabetes Quality Registry data from Austria, Denmark, England, Germany, Norway, Sweden, the United States, and Wales were collected between 2013 and 2014. HbA1c, gender, age, and duration were used in the analysis. RESULTS: Distribution of gender and age groups was similar in the eight participating countries. The mean HbA1c varied from 60 to 73 mmol/mol (7.6%-8.8%) between the countries. The increase in HbA1c between the youngest (0-9 years) to the oldest (15-17 years) age group was close to 8 mmol/mol (0.7%) in all countries (P < .001). Females had a 1 mmol/mol (0.1%) higher mean HbA1c than boys (P < .001) in seven out of eight countries. CONCLUSIONS: In spite of large differences in the mean HbA1c between countries, a remarkable similarity in the increase of HbA1c from childhood to adolescence was found.

The establishment of a new national network leads to quality improvement in childhood diabetes: implementation of the ISPAD Guidelines.

AIMS: To investigate whether implementation of International Society for Pediatric and Adolescent Diabetes (ISPAD) Guidelines and the establishment of a system for nationwide anonymous comparison, between treatment centres, of quality indicators for childhood diabetes could lead to improvement in diabetes care. METHODS: Children and adolescents with type-1 diabetes in Norway are treated at the public hospitals. Data were collected prospectively yearly according to standardized written instructions. Quality indicators were defined and benchmarked. HbA1c was measured at a central national Diabetes Control and Complications Trial (DCCT) standardized laboratory. RESULTS: The participation increased with 454 type-1 diabetes patients from eight clinics included in 2001 and 1658 patients from 25 clinics in 2005. The adherence rate in 2005 was 85% of all eligible patients from 25 of 26 pediatric clinics. The mean HbA1c of all clinics improved (8.6% in 2001 and 8.1% in 2005) and this was statistically significant (p < 0.01). The use of intensive insulin treatment increased from 56% to 78% (p < 0.01) and pumps from 8% to 37% (p < 0.01). The incidence of diabetes ketoacidosis (DKA) remained constant. The incidence of severe hypoglycemia declined insignificantly. The proportion of patients not screened yearly for microalbuminuria and retinopathy, according to ISPAD guidelines, decreased from 12% to 2% (p < 0.01) and from 42% to 27% (p < 0.01), respectively. All changes occurred gradually from 2001 to 2005. CONCLUSIONS: During the establishment of a system for benchmarking of diabetes treatment in Norway the outcomes showed significant improvements associated with changes in management and the quality of screening assessments. Benchmarking combined with organized quality meetings and discussions was effective to improve outcome on a national level.

Exploring Variation in Glycemic Control Across and Within Eight High-Income Countries: A Cross-sectional Analysis of 64,666 Children and Adolescents With Type 1 Diabetes.

OBJECTIVE: International studies on childhood type 1 diabetes (T1D) have focused on whole-country mean HbA1c levels, thereby concealing potential variations within countries. We aimed to explore the variations in HbA1c across and within eight high-income countries to best inform international benchmarking and policy recommendations. RESEARCH DESIGN AND METHODS: Data were collected between 2013 and 2014 from 64,666 children with T1D who were <18 years of age across 528 centers in Germany, Austria, England, Wales, U.S., Sweden, Denmark, and Norway. We used fixed- and random-effects models adjusted for age, sex, diabetes duration, and minority status to describe differences between center means and to calculate the proportion of total variation in HbA1c levels that is attributable to between-center differences (intraclass correlation [ICC]). We also explored the association between within-center variation and children's glycemic control. RESULTS: Sweden had the lowest mean HbA1c (59 mmol/mol [7.6%]) and together with Norway and Denmark showed the lowest between-center variations (ICC ≤4%). Germany and Austria had the next lowest mean HbA1c (61-62 mmol/mol [7.7-7.8%]) but showed the largest center variations (ICC ∼15%). Centers in England, Wales, and the U.S. showed low-to-moderate variation around high mean values. In pooled analysis, differences between counties remained significant after adjustment for children characteristics and center effects (P value <0.001). Across all countries, children attending centers with more variable glycemic results had higher HbA1c levels (5.6 mmol/mol [0.5%] per 5 mmol/mol [0.5%] increase in center SD of HbA1c values of all children attending a specific center). CONCLUSIONS: At similar average levels of HbA1c, countries display different levels of center variation. The distribution of glycemic achievement within countries should be considered in developing informed policies that drive quality improvement.