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Continuing Stability of Center Differences in Pediatric Diabetes Care: Do Advances in Diabetes Treatment Improve Outcome?

The Hvidoere Study Group on Childhood Diabetes

¹ DECCP, Clinique Pédiatrique/Centre Hospitalier, Luxembourg
² Department of Paediatrics, Leicester Royal Infirmary Children's Hospital Leicester, U.K
³ Department of Psychology, University of Wollongong, Wollongong, Australia
⁴ Diabetes, Center for Pediatric and Adolescent Diabetes, Rotterdam, the Netherlands
⁵ Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
⁶ Department of Endocrinology and Diabetes, Royal Children's Hospital, Parkville, Victoria, Australia
⁷ Endocrinology and Diabetes Research Group, Hospital de Cruces, Cruces, Spain
⁸ Department of Pediatrics, University of Chieti, Chieti, Italy
⁹ Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
¹⁰ Kinderkrankenhaus auf der Bult, Hannover, Germany
¹¹ Diabetology Clinic, Children's University Hospital Queen Fabiola, Brussels, Belgium
¹² Department of Paediatrics, Trinity College, National Childrens Hospital, Dublin, Ireland
¹³ Department of Paediatrics, Peijas Hospital, Vantaa, Finland
¹⁴ Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles California
¹⁵ Pediatric Clinic, Medical Faculty Department of Endocrinology and Genetics, Skopje, Republic of Macedonia
¹⁶ Paediatric Department L, Glostrup University Hospital, Glostrup, Denmark
¹⁷ Department of Pediatrics, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway
¹⁸ National Center of Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
¹⁹ Department of Paediatrics, Royal Hospital for Sick Children, Glasgow, Scotland
²⁰ Department of Paediatrics, University Childrens Hospital, Zurich, Switzerland
²¹ Department of Paediatrics, Nihon University School of Medicine, Tokyo, Japan
²² Centro di Diabetologia, University of Parma, Parma, Italy

Address correspondence and reprint requests to Dr. Carine de Beaufort, Clinique Pédiatrique, Centre Hospitalier de Luxembourg, 4, rue Barblé, 1220 Luxembourg. E-mail: debeaufort.carine{at}chl.lu

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.

RESEARCH DESIGN AND 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.

Abbreviations: CSII, continuous subcutaneous insulin infusion • DCCT, Diabetes Control and Complications Trial • DKA, diabetic ketoacidosis

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