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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 From the Hvidøre Study Group

¹ Charité Children’s Hospital, Humboldt University, Berlin, Germany
² Department of Pediatrics, Glostrup University Hospital, Glostrup, Denmark
³ Department of Statistics, Novo Nordisk A/S, Bagsvaerd, Denmark
⁴ Sophia Children’s Hospital, Rotterdam, the Netherlands
⁵ Pediatric University Clinic, Chieti, Italy
⁶ The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
⁷ University Children’s Hospital "Reine Fabiola," Brussels, Belgium
⁸ Institut St. Pierre, Montpellier, France
⁹ Ninewells Hospital, Dundee, U.K.
¹⁰ University of Dublin, National Children’s Hospital, Tallaght, Ireland
¹¹ Ulm University, Ulm, Germany
¹² Department of Pediatrics, Peijas Hospital, Vantaa, Finland
¹³ University Pediatric Clinic, Skopje, Republic of Macedonia
¹⁴ Hospital de Cruces, Baracaldo, Spain
¹⁵ Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
¹⁶ Royal Hospital for Sick Children, Glasgow, U.K.
¹⁷ University Children’s Hospital, Zurich, Switzerland
¹⁸ Department of Pediatrics, Haukeland Hospital, Bergen, Norway
¹⁹ Leicester Royal Infirmary Children’s Hospital, Leicester, U.K.
²⁰ Pediatric Department, Hospital S. João, Porto, Portugal
²¹ Pediatric Clinic of Parma University, Parma, Italy
²² Örebro Regional Hospital, Örebro, Sweden

OBJECTIVE—Twenty-one international pediatric diabetes centers from 17 countries investigated the effect of simple feedback about the grand mean HbA_1c level of all centers and the average value of each center on changes in metabolic control, rate of severe hypoglycemia, and insulin therapy over a 3-year period.

RESEARCH DESIGN AND METHODS—Clinical data collection and determination of HbA_1c levels were conducted at a central location in 1995 (n = 2,780, age 0–18 years) and 1998 (n = 2,101, age 11–18 years).

RESULTS—Striking differences in average HbA_1c concentrations were found among centers; these differences remained after adjustment for the significant confounders of sex, age, and diabetes duration. They were apparent even in patients with short diabetes duration and remained stable 3 years later (mean adjusted HbA_1c level: 8.62 ± 0.03 vs. 8.67 ± 0.04 [1995 vs. 1998, respectively]). Three centers had improved significantly, four centers had deteriorated significantly in their overall adjusted HbA_1c levels, and 14 centers had not changed in glycemic control. During the observation period, there were increases in the adjusted insulin dose by 0.076 U/kg, the adjusted number of injections by 0.23 injections per day, and the adjusted BMI by 0.95 kg/m². The 1995 versus 1998 difference in glycemic control for the seven centers could not be explained by prevailing insulin regimens or rates of hypoglycemia.

CONCLUSIONS—This study reveals significant outcome differences among large international pediatric diabetes centers. Feedback and comparison of HbA_1c levels led to an intensification of insulin therapy in most centers, but improved glycemic control in only a few.

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