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. Thomas Danne, MD1,
  2. Henrik B. Mortensen, DR MED SCI2,
  3. Philip Hougaard, PHD, DSC3,
  4. Helle Lynggaard, MSC3,
  5. Henk-Jan Aanstoot, MD, PHD4,
  6. Francesco Chiarelli, MD5,
  7. Denis Daneman, MB BCH, FRCPC6,
  8. Harry Dorchy, MD, PHD7,
  9. Patrick Garandeau, MD8,
  10. Stephen A. Greene, MD9,
  11. Hilary Hoey, MD, FRCPI10,
  12. Reinhard W. Holl, MD11,
  13. Eero A. Kaprio, MD12,
  14. Mirjana Kocova, MD, PHD13,
  15. Pedro Martul, MD, PHD14,
  16. Nobuo Matsuura, MD, PHD15,
  17. Kenneth J. Robertson, MD16,
  18. Eugen J. Schoenle, MD, PHD17,
  19. Oddmund Søvik, MD18,
  20. Peter G.F. Swift, MD, FRCP19,
  21. Rosa M. Tsou, MD20,
  22. Maurizio Vanelli, MD21,
  23. Jan Åman, MD, PHD22 and
  24. for the Hvidøre Study Group on Childhood Diabetes
  1. 1Charité Children’s Hospital, Humboldt University, Berlin, Germany
  2. 2Department of Pediatrics, Glostrup University Hospital, Glostrup, Denmark
  3. 3Department of Statistics, Novo Nordisk A/S, Bagsvaerd, Denmark
  4. 4Sophia Children’s Hospital, Rotterdam, the Netherlands
  5. 5Pediatric University Clinic, Chieti, Italy
  6. 6The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  7. 7University Children’s Hospital “Reine Fabiola,” Brussels, Belgium
  8. 8Institut St. Pierre, Montpellier, France
  9. 9Ninewells Hospital, Dundee, U.K.
  10. 10University of Dublin, National Children’s Hospital, Tallaght, Ireland
  11. 11Ulm University, Ulm, Germany
  12. 12Department of Pediatrics, Peijas Hospital, Vantaa, Finland
  13. 13University Pediatric Clinic, Skopje, Republic of Macedonia
  14. 14Hospital de Cruces, Baracaldo, Spain
  15. 15Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
  16. 16Royal Hospital for Sick Children, Glasgow, U.K.
  17. 17University Children’s Hospital, Zurich, Switzerland
  18. 18Department of Pediatrics, Haukeland Hospital, Bergen, Norway
  19. 19Leicester Royal Infirmary Children’s Hospital, Leicester, U.K.
  20. 20Pediatric Department, Hospital S. João, Porto, Portugal
  21. 21Pediatric Clinic of Parma University, Parma, Italy
  22. 22Örebro Regional Hospital, Örebro, Sweden

    Abstract

    OBJECTIVE—Twenty-one international pediatric diabetes centers from 17 countries investigated the effect of simple feedback about the grand mean HbA1c 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 HbA1c 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 HbA1c 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 HbA1c 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 HbA1c 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 HbA1c levels led to an intensification of insulin therapy in most centers, but improved glycemic control in only a few.

    Footnotes

    • Address correspondence and reprint requests to Dr. Thomas Danne, Diabetes-Zentrum für Kinder- und Jugendliche, Kinderkrankenhaus auf der Bult, Janusz-Korczak-Allee 12, 30173 Hannover, Germany. E-mail: danne{at}hka.de.

      Received for publication 28 September 2000 and accepted in revised form 17 April 2001.

      R.W.H. has received a grant and other funds from Novo Nordisk; K.J.R. has received funds for research from Novo Nordisk; and P.H. and H.L. hold stock in Novo Nordisk.

      A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

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    1. doi: 10.2337/diacare.24.8.1342 Diabetes Care August 2001 vol. 24 no. 8 1342-1347
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