TY - JOUR
T1 - Exploring Variation in Glycemic Control Across and Within Eight High-Income Countries
T2 - A Cross-sectional Analysis of 64,666 Children and Adolescents With Type 1 Diabetes
AU - Charalampopoulos, Dimitrios
AU - Hermann, Julia M
AU - Svensson, Jannet
AU - Skrivarhaug, Torild
AU - Maahs, David M
AU - Akesson, Karin
AU - Warner, Justin T
AU - Holl, Reinhard W
AU - Birkebæk, Niels H
AU - Drivvoll, Ann K
AU - Miller, Kellee M
AU - Svensson, Ann-Marie
AU - Stephenson, Terence
AU - Hofer, Sabine E
AU - Fredheim, Siri
AU - Kummernes, Siv J
AU - Foster, Nicole
AU - Hanberger, Lena
AU - Amin, Rakesh
AU - Rami-Merhar, Birgit
AU - Johansen, Anders
AU - Dahl-Jørgensen, Knut
AU - Clements, Mark
AU - Hanas, Ragnar
N1 - © 2018 by the American Diabetes Association.
PY - 2018/6/1
Y1 - 2018/6/1
N2 - OBJECTIVE International studies on childhood type 1 diabetes (T1D) have focused on wholecountrymean 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-effectsmodels 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 lowestmeanHbA1c (59mmol/mol [7.6%]) and togetherwithNorway andDenmark 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 withmore variable glycemic results had higher HbA1c levels (5.6mmol/mol [0.5%] per 5mmol/mol [0.5%] increase in centerSD of HbA1c values of all children attending a specific center). CONCLUSIONS Atsimilaraveragelevels ofHbA1c, countriesdisplaydifferentlevelsofcentervariation. The distribution of glycemic achievement within countries should be considered in developing informed policies that drive quality improvement.
AB - OBJECTIVE International studies on childhood type 1 diabetes (T1D) have focused on wholecountrymean 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-effectsmodels 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 lowestmeanHbA1c (59mmol/mol [7.6%]) and togetherwithNorway andDenmark 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 withmore variable glycemic results had higher HbA1c levels (5.6mmol/mol [0.5%] per 5mmol/mol [0.5%] increase in centerSD of HbA1c values of all children attending a specific center). CONCLUSIONS Atsimilaraveragelevels ofHbA1c, countriesdisplaydifferentlevelsofcentervariation. The distribution of glycemic achievement within countries should be considered in developing informed policies that drive quality improvement.
KW - Adolescent
KW - Austria/epidemiology
KW - Blood Glucose/metabolism
KW - Child
KW - Cross-Sectional Studies
KW - Denmark/epidemiology
KW - Developed Countries/economics
KW - Diabetes Mellitus, Type 1/blood
KW - England/epidemiology
KW - Female
KW - Germany/epidemiology
KW - Glycated Hemoglobin A/analysis
KW - Humans
KW - Income/statistics & numerical data
KW - Male
KW - Minority Groups/statistics & numerical data
KW - Norway/epidemiology
KW - Sweden/epidemiology
KW - Wales/epidemiology
U2 - 10.2337/dc17-2271
DO - 10.2337/dc17-2271
M3 - Journal article
C2 - 29650804
SN - 0149-5992
VL - 41
SP - 1180
EP - 1187
JO - Diabetes Care
JF - Diabetes Care
IS - 6
ER -
