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Diabetes Care. 2018 Jun;41(6):1180-1187. doi: 10.2337/dc17-2271. Epub 2018 Apr 12.

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.

Author information

1
UCL Great Ormond Street Institute of Child Health, University College London, London, U.K. d.charalampopoulos@ucl.ac.uk.
2
Institute of Epidemiology and Medical Biometry, Zentralinstitut für Biomedizinische Technik, Ulm University, Ulm, Germany.
3
German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany.
4
CPH-Direct, Pediatric Department, Herlev University Hospital, Herlev, Denmark.
5
Norwegian Childhood Diabetes Registry, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
6
Department of Pediatrics, Stanford University, Stanford, CA.
7
Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
8
Department of Paediatric Endocrinology and Diabetes, Children's Hospital for Wales, Cardiff, U.K.
9
Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark.
10
Jaeb Center for Health Research, Tampa, FL.
11
Centre of Registers in Region Västra Götaland, Gothenburg, Sweden.
12
UCL Great Ormond Street Institute of Child Health, University College London, London, U.K.
13
Department of Pediatrics 1, Medical University of Innsbruck, Innsbruck, Austria.
14
Division of Nursing, Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden.
15
Department of Pediatric and Adolescent Medicine, Medical University Vienna, Wien, Austria.
16
Department of Growth and Reproduction, Copenhagen University, Rigshospitalet, Copenhagen, Denmark.
17
Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
18
Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
19
Children's Mercy Hospital, Kansas City, MO.
20
University of Missouri-Kansas City, Kansas City, MO.
21
University of Kansas Medical Center, Kansas City, KS.
22
Department of Pediatrics, NU Hospital Group, Uddevalla, Sweden.
23
Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Abstract

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.

PMID:
29650804
PMCID:
PMC5961394
DOI:
10.2337/dc17-2271
[Indexed for MEDLINE]
Free PMC Article

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