Creating a national register of childhood type 1 diabetes using routinely collected hospital data

Childhood type 1 diabetes: an environment-wide association study across England

AIMS/HYPOTHESIS

Type 1 diabetes is an autoimmune disease affecting ~400,000 people across the UK. It is likely that environmental factors trigger the disease process in genetically susceptible individuals. We assessed the associations between a wide range of environmental factors and childhood type 1 diabetes incidence in England, using an agnostic, ecological environment-wide association study (EnWAS) approach, to generate hypotheses about environmental triggers.

METHODS

We undertook analyses at the local authority district (LAD) level using a national hospital episode statistics-based incident type 1 diabetes dataset comprising 13,948 individuals with diabetes aged 0-9 years over the period April 2000 to March 2011. We compiled LAD level estimates for a range of potential demographic and environmental risk factors including meteorological, land use and environmental pollution variables. The associations between type 1 diabetes incidence and risk factors were assessed via Poisson regression, disease mapping and ecological regression.

RESULTS

Case counts by LAD varied from 1 to 236 (median 33, interquartile range 24-46). Overall type 1 diabetes incidence was 21.2 (95% CI 20.9, 21.6) per 100,000 individuals. The EnWAS and disease mapping indicated that 15 out of 53 demographic and environmental risk factors were significantly associated with diabetes incidence, after adjusting for multiple testing. These included air pollutants (particulate matter, nitrogen dioxide, nitrogen oxides, carbon monoxide; all inversely associated), as well as lead in soil, radon, outdoor light at night, overcrowding, population density and ethnicity. Disease mapping revealed spatial heterogeneity in type 1 diabetes risk. The ecological regression found an association between type 1 diabetes and the living environment domain of the Index of Multiple Deprivation (RR 0.995; 95% credible interval [CrI] 0.991, 0.998) and radon potential class (RR 1.044; 95% CrI 1.015, 1.074).

CONCLUSIONS/INTERPRETATION

Our analysis identifies a range of demographic and environmental factors associated with type 1 diabetes in children in England.

Emerging Approaches in Surveillance of Type 1 Diabetes

PURPOSE OF REVIEW

Surveillance of type 1 diabetes provides an opportunity to address public health needs, inform etiological research, and plan health care services. We present issues in type 1 diabetes surveillance, review previous and current methods, and present new initiatives.

RECENT FINDINGS

Few diabetes surveillance systems distinguish between type 1 and type 2 diabetes. Most worldwide efforts have focused on registries and ages < 15 years, resulting in limited information among adults. Recently, surveillance includes use of electronic health information and national health surveys. However, distinguishing by diabetes type remains a challenge. Enhancing and improving surveillance of type 1 diabetes across all age groups could include validating questions for use in national health surveys. In addition, validated algorithms for classifying diabetes type in electronic health records could further improve surveillance efforts and close current gaps in our understanding of the epidemiology of type 1 diabetes.

Associations between birthweight, gestational age at birth and subsequent type 1 diabetes in children under 12: a retrospective cohort study in England, 1998-2012

AIMS/HYPOTHESIS

With genetics thought to explain only 40-50% of the total risk of type 1 diabetes, environmental risk factors in early life have been proposed. Previous findings from studies of type 1 diabetes incidence by birthweight and gestational age at birth have been inconsistent. This study aimed to investigate the relationships between birthweight, gestational age at birth and subsequent type 1 diabetes in England.

METHODS

Data were obtained from a population-based database comprising linked mother-infant pairs using English national Hospital Episode Statistics from 1998 to 2012. In total, 3,834,405 children, categorised by birthweight and gestational age at birth, were followed up through record linkage to compare their incidence of type 1 diabetes through calculation of multivariable-adjusted HRs.

RESULTS

Out of 3,834,405 children, 2969 had a subsequent hospital diagnosis of type 1 diabetes in childhood. Children born preterm (<37 weeks) or early term (37-38 weeks) experienced significantly higher incidence of type 1 diabetes than full term children (39-40 weeks) (HR 1.19 [95% CI 1.03, 1.38] and 1.27 [95% CI 1.16, 1.39], respectively). Children born at higher than average birthweight (3500-3999 g or 4000-5499 g) after controlling for gestational age experienced higher incidence of type 1 diabetes than children born at medium birthweight (3000-3499 g) (HR 1.13 [95% CI 1.03, 1.23] and 1.16 [95% CI 1.02, 1.31], respectively), while children at low birthweight (<2500 g) experienced lower incidence (0.81 [95% CI 0.67, 0.98]), signifying a statistically significant trend (p trend 0.001).

CONCLUSIONS/INTERPRETATION

High birthweight for gestational age and low gestational age at birth are both independently associated with subsequent type 1 diabetes. These findings help contextualise the debate about the potential role of gestational and early life environmental risk factors in the pathogenesis of type 1 diabetes, including the potential roles of insulin sensitivity and gut microbiota.

The effect of peer support in adults with insulin pump-treated type 1 diabetes: a pilot study of a flexible and participatory intervention

AIM

The aim of this study was to explore the effects of a flexible and participatory peer support intervention in a clinical setting for adults with type 1 diabetes treated with an insulin pump, focusing on enhancing diabetes-specific social capital. The key questions were as follows: 1) what effects are appropriate to expect, according to participants? and 2) to what extent did these effects occur?

METHODS

Two peer support intervention programs were conducted in a diabetes specialist clinic (N=30). A participatory and adaptable approach allowed flexibility in the content of peer support meetings, which were facilitated by a diabetes nurse. Individual interviews explored participants' perception of effects of the intervention. Interview data were analyzed qualitatively. Participants (n=27) completed a baseline and postintervention questionnaire that included items assessing diabetes empowerment, diabetes distress, diabetes-specific social support, and diabetes loneliness. HbA1c levels were compared before and after the intervention.

RESULTS

Participants experienced enhanced diabetes-specific social capital, diabetes motivation, awareness of personal diabetes practices, and serenity and openness in life with diabetes. They also became more aware of treatment and support possibilities. Negative effects included feeling sad or upset after the meetings or feeling different than and not as well-controlled as other participants. Quantitative analyses showed enhanced social support, decreased eating distress and trends toward enhanced diabetes empowerment, decreased diabetes loneliness, and decreased diabetes distress (powerlessness). We found fewer positive and/or negative outcomes among participants who felt no need for peer support or felt that the group was not a unit or that important issues were not addressed.

CONCLUSION

The study indicated that flexible and participatory peer support can strengthen diabetes-specific social capital and improve participants' well-being and diabetes empowerment. Awareness of participants' incentives for attending peer support, as well as the risk of people feeling isolated within peer support groups, is essential to creating effective diabetes-specific social support.

Incidence of Type 1 Diabetes among Children and Adolescents in Italy between 2009 and 2013: The Role of a Regional Childhood Diabetes Registry

BACKGROUND

Surveillance represents a key strategy to control type 1 diabetes mellitus (T1DM). In Italy, national data are missing. This study aimed at evaluating the incidence of T1DM in subjects <18 year olds in Apulia (a large southeastern region, about 4,000,000 inhabitants) and assessing the sensitivity of the regional Registry of Childhood-Onset Diabetes (RCOD) in the 2009-2013 period.

METHODS

We performed a retrospective study matching records from regional Hospital Discharge Registry (HDR), User Fee Exempt Registry (UFER), and Drugs Prescription Registry (DPR) and calculated T1DM incidence; completeness of each data source was also estimated. In order to assess the RCOD sensitivity we compared cases from the registry to those extracted from HDR-UFER-DPR matching.

RESULTS

During 2009-2013, a total of 917 cases (about 184/year) in at least one of the three sources and an annual incidence of 25.2 per 100,000 were recorded, lower in infant, increasing with age and peaked in 5- to 9-year-olds. The completeness of DPR was 78.7%, higher than that of UFER (64.3%) and of HDR (59.6%). The RCOD's sensitivity was 39.05% (360/922; 95% CI: 34.01%-44.09%).

CONCLUSIONS

Apulia appeared as a high-incidence region. A full, active involvement of physicians working in paediatric diabetes clinics would be desirable to improve the RCOD performance.

Validation of administrative health data for the pediatric population: a scoping review

BACKGROUND

The purpose of this research was to perform a scoping review of published literature on the validity of administrative health data for ascertaining health conditions in the pediatric population (≤20 years).

METHODS

A comprehensive search of OVID Medline (1946 - present), CINAHL (1937 - present) and EMBASE (1947 - present) was conducted. Characteristics of validation studies that were abstracted included the study population, health condition, topic of the validation (e.g., single diagnosis code versus case-finding algorithm), administrative and validation data sources. Inter-rater agreement was measured using Cohen's κ. Extracted data were analyzed using descriptive statistics.

RESULTS

A total of 37 articles met the study inclusion criteria. Cohen's κ for study inclusion/exclusion and data abstraction was 0.88 and 0.97, respectively. Most studies validated administrative data from the USA (43.2%) and Canada (24.3%), and focused on inpatient records (67.6%). Case-finding algorithms (56.7%) were more frequently validated than diagnoses codes alone (37.8%). Five conditions were validated in more than one study: diabetes mellitus, inflammatory bowel disease, asthma, rotavirus infection, and tuberculosis.

CONCLUSIONS

This scoping review identified a number of gaps in the validation of administrative health data for pediatric populations, including limited investigation of outpatient populations and older pediatric age groups.