Improved results in paediatric diabetes care using a quality registry in an improvement collaborative: a case study in Sweden

An audit and feedback-based intervention to improve diabetes management in the year after transfer to adult type 1 diabetes care: A multi-center quasi-experimental study

AIM

To test whether an audit and feedback-based intervention improved HbA1c 12 months after transfer to type 1 diabetes adult care.

METHODS

Multi-centre, quasi-experimental pre-post study of an AF-based intervention targeting paediatric diabetes teams, which encouraged the implementation of an evidence-informed structured transition process at five paediatric diabetes centres in Ontario, Canada. Participants entered the study at their final paediatric visit. A parallel control cohort was ascertained using population-based administrative datasets. The primary outcome was HbA1c 12 months after transfer. The main exposure was the study period: pre-implementation (June 2018-May 2019); early-implementation (June 2019-September 2020); and late-implementation (October 2020-September 2021). Multivariable linear regression models were fit separately in each cohort.

RESULTS

There were 449 and 2844 individuals in the intervention and control cohorts, respectively. Twelve months after transfer, participants in the late-implementation intervention cohort had an HbA1c that was, on average, 0.41% lower than participants in the pre-implementation period (p = 0.016). Among the control cohort, there was no significant difference in the HbA1c 12 months after transfer between study periods.

CONCLUSIONS

We found an effect of the intervention on glycaemic management one year following transfer to adult care. Future work will focus on refining and testing the effectiveness of the intervention in an expanded number of study sites and in collaboration with adult diabetes care providers.

Using Time in Tight Glucose Range as a Health-Promoting Strategy in Preschoolers With Type 1 Diabetes

Children who develop diabetes in their first years of life risk being exposed to many decades of hyperglycemia, hence having a high risk of early complications and premature death. An additional age-dependent risk is that dysglycemia, especially hyperglycemia, negatively affects the developing brain. In evaluating the outcome of insulin treatment at an individual and group level, cutoff thresholds for glucose values are needed. Time in tight range (TITR) was defined as a measurement of time spent in a state of normoglycemia. The International Society of Pediatric and Adolescent Diabetes recommended that for preschoolers with type 1 diabetes (T1D), either >70% of time with glucose in range 70-180 mg/dL (3.9-10 mmol/L) or >50% of time in a tighter range 70-140 mg/dL (TITR) can be used as continuous glucose monitoring targets. In Sweden, over the past two decades, pediatric diabetes teams set glycemic targets to 70-140 mg/dL (3.9-7.8 mmol/L). Swedish registry data show that >50% of children <7 years old have >50% TITR. The purpose of this review is to share and discuss international knowledge and experiences of working with TITR as a health-promoting strategy in preschoolers with T1D on a structural and individual level. We conclude that as insulin treatment improves, a reasonable goal is to strive for as much time in a state of normoglycemia as possible, and this can easily be explained to families of children with diabetes. For children with access to an experienced health care team and diabetes technologies a currently realistic target can be at least half of the time in normoglycemic range, i.e., TITR >50%.

First year national Swedish paediatric Hba1c data are at the level of several intervention studies: Results from a Swedish nationwide diabetes register study

AIMS/HYPOTHESIS

To study the progression of HbA1c after diagnosis of type 1 diabetes in children and adolescents during 2010-2019 with emphasis on HbA1c nadir 3-6 months after onset.

METHODS

Partial funding was secured for this study. The Swedish paediatric diabetes quality register SWEDIABKIDS has >95 % coverage of type 1 diabetes up to 18 years. A mixed model for repeated measurements was used to estimate differences in HbA1c between onset year periods.

RESULTS

We followed 6,891 patients over two years from onset (48,292 HbA1c values). We found a gradual decrease in mean HbA1c 24 months after onset from 56.0 mmol/mol (7.28 %) in 2010/11 to 50.5 mmol/mol (6.77 %) in 2018/19, which is at the level of several recent intervention studies. The initial drop in HbA1c from onset until 3 and 6 months has become more pronounced in recent years. There was a significant positive correlation between HbA1c at 3 and 6 months with 12, 18 and 24 months. Percentage of severe hypoglycaemic coma was higher (5.1 % vs 3.4 %; p = 0.023) in 2010/2011 than 2018/2019, but the absolute risk of ketoacidosis was essentially unchanged, (1.5 % to 0.8 %, p = 0.110) CONCLUSIONS/INTERPRETATION: There was a continuous decrease in HbA1c over the study period 2010-2019, which coincides in time with an increased use of diabetes technology and lowering the HbA1c target to 48 mmol/mol (6.5 %). The decrease in 2-year HbA1c was preceded by a lower HbA1c nadir, which may set the trajectories for coming HbA1c and be a modifiable factor for a long-term improvement in metabolic control.

Benefits, implementation and sustainability of innovative paediatric models of care for children with type 1 diabetes: a systematic review

BACKGROUND AND AIM

The evidence about the acceptability and effectiveness of innovative paediatric models of care for Type 1 diabetes is limited. To address this gap, we synthesised literature on implemented models of care, model components, outcomes, and determinants of implementation and sustainability.

METHODS

A systematic review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Database searches of Medline, CINAHL, EMBASE and Scopus were conducted. Empirical studies focused on Type 1 diabetes paediatric models of care, published from 2010 to 2022 in English were included.

RESULTS

Nineteen extant studies reported on models and their associations with health and psychosocial outcomes, patient engagement with healthcare, and healthcare costs. Thirteen studies described multidisciplinary teamwork, education and capacity building that supported self-care. Four studies involved shared decision making between providers and patients, and two discussed outreach support where technology was an enabler. Fourteen studies reported improvements in health outcomes (e.g. glycaemic control), mostly for models that included multidisciplinary teams, education, and capacity building (11 studies), outreach support or shared care (3 studies). Four studies reported improvements in quality of life, three reported increased satisfaction for patients and carers and, and one reported improved communication. Four of five studies describing shared care and decision-making reported improvements in quality of life, support and motivation. Outreach models reported no negative outcomes, however, accessing some models was limited by technological and cost barriers. Eight studies reported on model sustainability, but only half reported implementation determinants; none reported applying a theoretical framework to guide their research.

CONCLUSION

Some health and psychosocial benefits were associated with newer models. To address knowledge gaps about implementation determinants and model sustainability, longitudinal studies are needed to inform future adoption of innovative models of care for children with Type 1 diabetes.

Ten Years of Improving Glycemic Control in Pediatric Diabetes Care: Data From the Norwegian Childhood Diabetes Registry

OBJECTIVE

To evaluate, from 2013 to 2022, how HbA1c, the incidence of acute complications, and use of diabetes technology changed at the national level in Norway and how glycemic control was associated with use of diabetes technology, carbohydrate counting, or participation in a quality improvement project.

RESEARCH DESIGN AND METHODS

This longitudinal observational study was based on 27,214 annual registrations of 6,775 children from the Norwegian Childhood Diabetes Registry from 2013 to 2022. Individuals aged >18 years, those with diabetes other than type 1, and those without HbA1c measurements were excluded. The outcome measure was HbA1c. The predictor variables in the adjusted linear mixed-effects model were 1) the use of diabetes technology, 2) the use of carbohydrate counting for meal bolusing, and 3) whether the patient's diabetes team participated in a quality improvement project.

RESULTS

Mean HbA1c decreased from 8.2% (2013) to 7.2% (2021), and the proportion of youth reaching an HbA1c <7.0% increased from 13% (2013) to 43% (2022). Insulin pump use increased from 65% (2013) to 91% (2022). Continuous glucose monitoring (CGM) use increased from 34% (first recorded in 2016) to 97% (2022). Insulin pump, CGM, and carbohydrate counting were associated with lower HbA1c and higher achievement of glycemic targets. Girls had a higher mean HbA1c than boys. Mean HbA1c levels were lower in clinics that participated in a quality improvement project for the following 4 years after the project.

CONCLUSIONS

Diabetes technology, carbohydrate counting, and systematic quality improvement in pediatric departments led to improved glycemic control.

Correlation between centre size, metabolic variation and mean HbA1c in major paediatric diabetes centres

AIM

To exploit a relatively homogeneous national health care context and a national diabetes database to address the questions: Is there an optimal clinic/centre size in determining outcomes?; and Can improvement in median centre outcomes be driven by reducing variability in outcome?

METHODS

Using the Australasian Diabetes Database Network, data from seven tertiary hospital paediatric diabetes clinics for patients with type one diabetes from Australia were recorded from 6-month uploads: September 2017, March 2018, September 2018 and March 2019. Data from 25 244 patient visits included demographic variables, HbA1C, number of patient visits and insulin regimens.

RESULTS

There was no association between centre size and median HbA1C. On the other hand, there was a significant association between or median absolute deviation of HbA1C outcomes and the median HbA1C result between centres. On average every two thirds of a median absolute deviation increase in clinic HbA1C was associated with a 1.0% (10.9 mmol/mol) increase in median clinic HbA1C.

CONCLUSIONS

Our data have shown that it is likely difficult for centres to have a low median HbA1C if there is high variance of HbA1C's within centres or within centre treatment groups. This appears to be true regardless of centre size. These findings need to be carefully considered by teams who wish to lower their clinic median HbA1C.

Intensified follow-up of patients with type 1 diabetes and poor glycaemic control: a multicentre quality improvement collaborative based on data from the Norwegian Diabetes Register for Adults

BACKGROUND

Patients with type 1 diabetes mellitus (T1DM) and poor glycaemic control are at high risk of developing microvascular and macrovascular complications. The aim of this study was to determine if a quality improvement collaborative (QIC) initiated by the Norwegian Diabetes Register for adults (NDR-A) could reduce the proportion of patients with T1DM with poor glycaemic control (defined as glycated haemoglobin (HbA1c)≥75 mmol/mol) and reduce mean HbA1c at participating clinics compared with 14 control clinics.

METHOD

Multicentre study with controlled before and after design. Representatives of 13 diabetes outpatient clinics (n=5145 patients with T1DM) in the intervention group attended four project meetings during an 18-month QIC. They were required to identify areas requiring improvement at their clinic and make action plans. Continuous feedback on HbA1c outcomes was provided by NDR-A during the project. In total 4084 patients with type 1 diabetes attended the control clinics.

RESULTS

Between 2016 and 2019, the overall proportion of patients with T1DM and HbA1c≥75 mmol/mol in the intervention group were reduced from 19.3% to 14.1% (p<0.001). Corresponding proportions in the control group were reduced from 17.3% (2016) to 14.4% (2019) (p<0.001). Between 2016 and 2019, overall mean HbA1c decreased by 2.8 mmol/mol (p<0.001) at intervention clinics compared with 2.3 mmol/mol (p<0.001) at control clinics. After adjusting for the baseline differences in glycaemic control, there were no significant differences in the overall improvement in glycaemic control between intervention and control clinics.

CONCLUSIONS

The registry linked QIC did not result in a significantly greater improvement in glycaemic control at intervention clinics compared with control clinics. However, there has been a sustained improvement in glycaemic control and importantly a significant reduction in the proportion of patients with poor glycaemic control at both intervention and control clinics during and after the QIC time frame. It is possible that some of this improvement may be due to a spillover effect from the QIC.

IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation

BACKGROUND

Immigrant women's challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women's possibility to choose and initiate effective contraceptive methods post-partum.

METHODS

This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study's intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women's choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women's experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project's primary outcome involving women's choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents.

DISCUSSION

The intervention's co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services.

TRIAL REGISTRATION

NCT05521646, August 30, 2022.

To become an expert within a week: Children's and parents' experiences of the child being diagnosed with type 1 diabetes and receiving diabetes education - A qualitative interview study

PURPOSE

To explore children's and parents' experiences of the child being diagnosed with type 1 diabetes and receiving diabetes education during hospitalisation.

DESIGN AND METHODS

A qualitative interpretive design was applied. Semi-structured interviews with 15 children and their parent(s) were conducted. Data were analysed via thematic analysis.

RESULTS

The analysis revealed three themes: To be diagnosed with diabetes turns one's world upside down; It is positive to meet friendly and helpful healthcare professionals; and Diabetes education is overwhelming but required.

CONCLUSIONS

To be hospitalised and receive a diabetes diagnosis is overwhelming. The family must learn, in a short time, the basic skills to manage the condition. While learning, the child may fluctuate between being active and passive. In this vulnerable situation, it is positive to meet helpful healthcare professionals. Children find the motivation to learn, as they want to self-manage and be independent. All necessary education is given, but often the families would like to be more actively involved in the teaching. Sometimes, the teaching is also very compressed.

PRACTICE IMPLICATIONS

It is important to be aware of the vulnerable situation of the family and to adjust education to the fluctuations of the child. Teaching should be simplified and broken down stepwise, using pictures, artefacts, etc., to support the learning. More involvement may make education even more engaging and interesting. It has to be considered whether the education can be compressed into too short a time, making it difficult to transfer to the everyday lives of the families.

Temporal Changes in Hemoglobin A1c and Diabetes Technology Use in DPV, NPDA, and T1DX Pediatric Cohorts from 2010 to 2018

Objective: The German/Austrian Diabetes Patient Follow-up Registry (Diabetes-Patienten-Verlaufsdokumentation or DPV), England/Wales National Pediatric Diabetes Audit (NPDA), and Type 1 Diabetes Exchange (T1DX) in the United States investigated changes in hemoglobin A1c (HbA1c) and diabetes technology use from 2010 to 2018. Methods: Registry/audit data from 2010 to 2018 were analyzed in annual cohorts using linear regression for those <18 years of age with type 1 diabetes diagnosed at age >6 months. Time trends in HbA1c, pump, and continuous glucose monitoring (CGM) use were studied using repeated measurements linear and logistic regression models with an autoregressive covariance structure and with year and data source as independent variables. Results: A total of 1,172,980 visits among 114,264 (54,119 DPV, 43,550 NPDA, 16,595 T1DX) patients were identified. HbA1c remained clinically stable in DPV (7.7% [61 mmol/mol] to 7.6% [60 mmol/mol]), decreased in the NPDA (8.7% [72 mmol/mol] to 7.9% [63 mmol/mol]), and increased in T1DX (8.0% [64 mmol/mol] to 8.5% [69 mmol/mol] from 2010 to 2018). In all registries/audits, insulin pump and CGM use increased over time with greatest pump use in T1DX and lowest uptake reported in NPDA. Conclusions: These data reveal three different longitudinal patterns of change in registry/audit HbA1c from 2010 to 2018. Diabetes technology use increased throughout, at different rates. Quality improvement (QI) programs in DPV have been ongoing for 25 years, began in NPDA in 2009 and T1DX in 2016. We speculate that in England/Wales, development of networks, peer review, and implementation of QI measures contributed to reductions in population HbA1c. Many of these interventions had been implemented in DPV before 2010. Further efforts to understand this improvement, including the role of QI, and continued success within standardized documentation and benchmarking could inform T1DX programs to reduce HbA1c.

Developing contraceptive services for immigrant women postpartum - a case study of a quality improvement collaborative in Sweden

Background

Immigrant women use less effective contraceptive methods and have a higher risk of unintended pregnancies. Maternal health care services offer a central opportunity to strengthen contraceptive services, especially among immigrants. This study aimed to evaluate a Quality Improvement Collaborative QIC. Its objective was to improve contraceptive services for immigrant women postpartum, through health care professionals’ (HCPs) counselling and a more effective choice of contraceptive methods.

Methods

The pilot study was designed as an organisational case study including both qualitative and quantitative data collection and analysis. Midwives at three maternal health clinics (MHCs) in Stockholm, Sweden participated in a QIC during 2018–2019. In addition, two recently pregnant women and a couple contributed user feedback. Data on women’s choice of contraceptive method at the postpartum visit were registered in the Swedish Pregnancy Register over 1 year.

Results

The participating midwives decided that increasing the proportion of immigrant women choosing a more effective contraceptive method postpartum would be the goal of the QIC. Evidence-based changes in contraceptive services, supported by user feedback, were tested in clinical practice during three action periods. During the QIC, the proportion of women choosing a more effective contraceptive method postpartum increased at an early stage of the QIC. Among immigrant women, the choice of a more effective contraception increased from 30 to 47% during the study period. Midwives reported that their counselling skills had developed due to participation in the QIC, and they found using a register beneficial for evaluating women’s choice of contraceptive methods.

Conclusions

The QIC, supported by a register and user feedback, helped midwives to improve their contraceptive services during the pregnancy and postpartum periods. Immigrant women’s choice of a more effective contraceptive method postpartum increased during the QIC. This implies that a QIC could increase the choice of a more effective contraception of postpartum contraception among immigrants.

Center differences in diabetes treatment outcomes among children with type 1 diabetes: A nationwide study of 3866 Danish children

OBJECTIVE

Mean differences in HbA_1c across centers are well established, but less well understood. The aim was to assess whether differences in patient case-mix can explain the variation in mean HbA_1c between pediatric diabetes centers in Denmark. The association between HbA_1c , frequency of blood glucose monitoring (BGM), treatment modality, and center visits was investigated.

RESEARCH DESIGN AND METHODS

This longitudinal nationwide study included 3866 Danish children with type 1 diabetes from 2013 to 2017 (n = 12,708 child-year observations) from 16 different pediatric diabetes centers. Mean HbA_1c , proportion of children reaching HbA_1c treatment target (HbA_1c  ≤ 58 mmol/mol [7.5%]) were compared across centers using linear regression models. This was done with and without adjustment for socioeconomic characteristics (patient case-mix).

RESULTS

The mean difference in HbA_1c during follow-up was 11.6 mmol/mol (95% CI 7.9, 15.3) (1.1% [95% CI 0.7, 1.4]) when comparing the centers with the lowest versus highest mean HbA_1c . The difference was attenuated and remained significant after adjustment for the patient case-mix (difference: 10.5 mmol/mol [95% CI 6.8, 14.2] (1.0% [95% CI 0.6, 1.3])). Overall, 6.8% of the differences in mean HbA_1c across centers were explained by differences in the patient case-mix. Across centers, more frequent BGM was associated with lower HbA_1c . The proportion of insulin pump users and number of visits was not associated with HbA_1c .

CONCLUSION

In a setting of universal health care, large differences in HbA_1c across centers were found, and could not be explained by patient background, number of visits or use of technology. Only BGM was associated with center HbA_1c .

Trends in Glycemia between 2002 and 2016 among Incident Youth Cohorts Early in the Course of Type 1 Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVE

Hyperglycemia early in the course of type 1 diabetes (T1D) may increase the risk of cardiometabolic complications later in life. We tested the hypothesis that there were temporal trends in population-level glycemia and insulin pump use near T1D diagnosis among incident youth cohorts diagnosed between 2002 and 2016.

METHODS

Weighted and adjusted regression models were applied to data from the SEARCH for Diabetes in Youth study to analyze trends in hemoglobin A1c (HbA1c), suboptimal glycemia (HbA1c > 9% or not), and insulin pump use among youth with T1D within 30 months of diagnosis. We tested the interaction of year with race and ethnicity, sex, and insulin regimen to assess potential disparities.

RESULTS

Among the 3,956 youth with T1D, there was a small, clinically insignificant reduction in HbA1c between 2002 (7.9% ± 1.5) and 2016 (7.8% ± 2.4) (fully adjusted change by year (-0.013% [95% CI -0.026, -0.0008], p = 0.04). The proportion of youth with suboptimal glycemia increased with each year, but the adjusted odds did not change. Insulin pump use increased more than fivefold. Although interaction effects of time with race and ethnicity, sex, and insulin regimen were not detected, in 2016, suboptimal glycemia was 4.3 and 1.8 times more prevalent among Black and Hispanic than among non-Hispanic White youth, respectively.

CONCLUSIONS

There was not a clinically significant population-level improvement in glycemia across incident youth cohorts early in the course of T1D, despite severalfold increases in insulin pump use. Comprehensive clinical interventions to improve glycemia early in the T1D course and address disparities are urgently needed.

Changes in HbA1c Between 2011 and 2017 in Germany/Austria, Sweden, and the United States: A Lifespan Perspective

Aims: This study assessed hemoglobin A1c (HbA1c) across the lifespan in people with type 1 diabetes (T1D) in Germany/Austria, Sweden, and the United States between 2011 and 2017 to ascertain temporal and age-related trends. Methods: Data from the Diabetes-Patienten-Verlaufsdokumentation (DPV) (n = 25,651 in 2011, n = 29,442 in 2017); Swedish Pediatric Diabetes Quality Registry (SWEDIABKIDS)/National Diabetes Register (NDR), (n = 44,474 in 2011, n = 53,690 in 2017); and T1D Exchange (n = 16,198 in 2011, n = 17,087 in 2017) registries were analyzed by linear regression to compare mean HbA1c overall and by age group. Results: Controlling for age, sex, and T1D duration, HbA1c increased in the United States between 2011 and 2017, decreased in Sweden, and did not change in Germany/Austria. Controlling for sex and T1D duration, mean HbA1c decreased between 2011 and 2017 in all age cohorts in Sweden (P < 0.001). In the United States, HbA1c stayed the same for participants <6 years and 45 to <65 years and increased in all other age groups (P < 0.05). In Germany/Austria, HbA1c stayed the same for participants <6 to <13 years and 18 to <25 years; decreased for participants ages 13 to <18 years (P < 0.01); and increased for participants ≥25 years (P < 0.05). Conclusions: The comparison of international trends in HbA1c makes it possible to identify differences, explore underlying causes, and share quality improvement processes. National quality improvement initiatives are well accepted in Europe but have yet to be implemented systematically in the United States. However, disparities created by the lack of universal access to health care coverage, unequal access to diabetes technologies (e.g., continuous glucose monitoring) regardless of insurance status, and high out-of-pocket cost for the underinsured ultimately limit the potential of quality improvement initiatives.

Aligning quality improvement with better child health for the 21st century

Quality improvement (QI) has tremendous potential to tackle the shortcomings of health services. But health professionals have not yet fully embraced QI as part of their day-to-day concerns. Indeed, QI is sometimes experienced as a brake on quality rather than a catalyst for improvement. This can happen, for example, if there is too much emphasis on meeting short-term institutional goals rather than on addressing long-term health needs. This emphasis also risks equating quality with safety and efficiency measures while neglecting patient-centredness and equity. QI does not have to be like this. We suggest that the conscientious and critical engagement of health professionals in QI can lead to genuinely better and more far-reaching outcomes for child health. We also distinguish between QI projects that repair the status quo and those that seek to reform it, arguing that there is an important place for both.

Quality Improvement in Diabetes Care: A Review of Initiatives and Outcomes in the T1D Exchange Quality Improvement Collaborative

Despite immense strides in therapeutic advances, clinical outcomes continue to be less than ideal for people with type 1 diabetes. This discrepancy has prompted an outpouring of quality improvement (QI) initiatives to address the medical, psychosocial, and health equity challenges that complicate ideal type 1 diabetes care and outcomes. This article reviews a framework for QI in diabetes care that guided the development of the T1D Exchange Quality Improvement Collaborative to improve care delivery and health outcomes in type 1 diabetes. Evaluation of the methodology, outcomes, and knowledge gained from these initiatives will highlight the importance of continued QI initiatives in diabetes care.

Intermittently scanned continuous glucose monitoring is associated with high satisfaction but increased HbA1c and weight in well-controlled youth with type 1 diabetes

OBJECTIVE

We undertook a 24-month prospective observational single-center real-world trial to study impact of access to intermittently scanned continuous glucose monitoring (isCGM) on quality of life (QOL) and glycemic control of youth with type 1 diabetes (T1D).

METHODS

Between September 2016 and November 2017, 138 children and adolescents with T1D were recruited. Demographic, metabolic, and QOL data were collected during 24 months of routine follow-up. Primary endpoint was the evolution of QOL, with secondary outcomes change in HbA1c, occurrence of acute diabetes complications, and school absenteeism.

RESULTS

Ninety-two percent of participants found isCGM more user-friendly than capillary finger-stick tests and had high treatment satisfaction, without change in diabetes-specific QOL. HbA1c significantly increased from 7.2% (7.0-7.3) (55 mmol/mol [53-56]) at baseline to 7.6% (7.4-7.8) (60 mmol/mol [57-62]) at 12 months (P < .0001) and was unchanged up to 24 months. Overall increase was mainly driven by children with baseline HbA1c <7.0% (<53 mmol/mol). Additionally, BMI adjusted for age was higher at study end. In year before isCGM, 228 days per 100 patient-years of school absenteeism were reported, which dramatically decreased to 13 days per 100 patient-years (P = .016) after 24 months. Parents of children also reported less work absenteeism (P = .011).

CONCLUSION

The use of isCGM by T1D pediatrics is associated with high treatment satisfaction and fewer days of school absence. However, increased HbA1c and weight may reflect a looser lifestyle, with less attention to diet and more avoidance of hypoglycemia. Intensive education specifically focusing on these points may mitigate these issues.

International benchmarking in type 1 diabetes: Large difference in childhood HbA1c between eight high-income countries but similar rise during adolescence-A quality registry study

OBJECTIVES

To identify differences and similarities in HbA1c levels and patterns regarding age and gender in eight high-income countries.

SUBJECTS

66 071 children and adolescents below18 years of age with type 1 diabetes for at least 3 months and at least one HbA1c measurement during the study period.

METHODS

Pediatric Diabetes Quality Registry data from Austria, Denmark, England, Germany, Norway, Sweden, the United States, and Wales were collected between 2013 and 2014. HbA1c, gender, age, and duration were used in the analysis.

RESULTS

Distribution of gender and age groups was similar in the eight participating countries. The mean HbA1c varied from 60 to 73 mmol/mol (7.6%-8.8%) between the countries. The increase in HbA1c between the youngest (0-9 years) to the oldest (15-17 years) age group was close to 8 mmol/mol (0.7%) in all countries (P < .001). Females had a 1 mmol/mol (0.1%) higher mean HbA1c than boys (P < .001) in seven out of eight countries.

CONCLUSIONS

In spite of large differences in the mean HbA1c between countries, a remarkable similarity in the increase of HbA1c from childhood to adolescence was found.

Therapeutic Inertia in Pediatric Diabetes: Challenges to and Strategies for Overcoming Acceptance of the Status Quo

Despite significant advances in therapies for pediatric type 1 diabetes, achievement of glycemic targets remains elusive, and management remains burdensome for patients and their families. This article identifies common challenges in diabetes management at the patient-provider and health care system levels and proposes practical approaches to overcoming therapeutic inertia to enhance health outcomes for youth with type 1 diabetes.

Testing an audit and feedback-based intervention to improve glycemic control after transfer to adult diabetes care: protocol for a quasi-experimental pre-post design with a control group

BACKGROUND

When young adults transfer from pediatric to adult diabetes care they are at risk for deterioration of glycemic control, putting them at an increased risk of developing both acute and chronic complications. Despite increased awareness of these risks, there are gaps in care delivery during this vulnerable time and variability in the implementation of recommended transition practice. Audit and feedback (AF) interventions have a positive but variable effect on implementation of best practices. An expert group identified specific suggestions for optimizing the effectiveness of AF interventions. We aim to test an AF-based intervention incorporating these specific suggestions to improve transition practices and glycemic control in the first year after transfer from pediatric to adult diabetes care.

METHODS

This is a pragmatic quasi-experimental study; a series of three cohort studies (pre-implementation, early-implementation, and post-implementation) to compare the baseline adjusted hemoglobin A1c (HbA1c) in the 12 months after the final pediatric visit in five pediatric diabetes centres within the Ontario Pediatric Diabetes Network in Ontario, Canada. The intervention includes three components: 1) centre-level feedback reports compiling data from chart abstraction, linked provincial administrative datasets, and patient-reported experience measures; 2) webinars for facilitated conversations/coaching about the feedback; and 3) online repository of curated transition resources for providers. The primary outcome will be analyzed using a multivariable linear regression model. We will conduct a qualitative process evaluation to understand intervention fidelity and to provide insight into the mechanisms of action of our results.

DISCUSSION

There is a need to develop an innovative system-level approach to improve outcomes and the quality of care for young adults with type 1 diabetes during the vulnerable time when they transfer to adult care. Our research team, a collaboration of health services, implementation science, and quality improvement researchers, are designing, implementing, and evaluating an AF-based intervention using recommendations about how to optimize effectiveness. This knowledge will be generalizable to other care networks that aim to deliver uniformly high-quality care in diverse care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03781973. Registered 13 December 2018. Date of enrolment of the first participant to the trial: June 1, 2019.

The Educational Impact of Implementing National Quality Registries in Sweden-A National Collaboration Project

BACKGROUND AND OBJECTIVES

There is a need for improved clinical outcomes, and a useful tool in this endeavor is the use of National Quality Registries (NQRs). To learn more about the impact of NQRs, a National Collaboration Project was formed. This follow-up study had 2 aims: first, to describe the value and learning of a National Collaboration Project focusing on the use of NQRs in collaboration between universities, health care organizations, and the regional registry centers; and, second, to describe what activities are still ongoing.

METHOD

A qualitative design was used to obtain a detailed description of the extent to which project leaders perceived that the goals had been achieved after participation in the national project. A qualitative descriptive content analysis was performed.

RESULTS

Four main categories were found. The context proved to be crucial for how the local projects were formed and developed. Networking was highlighted as an important part of learning. Another mentioned part of learning was the change planned and implemented in the curriculum to promote the use of NQRs. Finally, the importance of anchoring and spreading the lessons learned was also stressed.

CONCLUSION

Using NQRs in multidisciplinary education is successful in many ways, but this study shows that certain factors need to be in place to make it work in practice.

In-depth comparison of two quality improvement collaboratives from different healthcare areas based on registry data-possible factors contributing to sustained improvement in outcomes beyond the project time

BACKGROUND

Quality improvement collaboratives (QICs) are widely used to improve healthcare, but there are few studies of long-term sustained improved outcomes, and inconsistent evidence about what factors contribute to success. The aim of the study was to open the black box of QICs and compare characteristics and activities in detail of two differing QICs in relation to their changed outcomes from baseline and the following 3 years.

METHODS

Final reports of two QICs-one on heart failure care with five teams, and one on osteoarthritis care with seven teams, including detailed descriptions of improvement projects from each QIC's team, were analysed and coded by 18 QIC characteristics and four team characteristics. Goal variables from each team routinely collected within the Swedish Heart Failure Registry (SwedeHF) and the Better Management of Patients with OsteoArthritis Registry (BOA) at year 2013 (baseline), 2014, 2015 and 2016 were analysed with univariate statistics.

RESULTS

The two QICs differed greatly in design. The SwedeHF-QIC involved eight experts and ran for 12 months, whereas the BOA-QIC engaged three experts and ran for 6 months. There were about twice as many activities in the SwedeHF-QIC as in the BOA-QIC and they ranged from standardisation of team coordination to better information and structured follow-ups. The outcome results were heterogeneous within teams and across teams and QICs. Both QICs were highly appreciated by the participants and contributed to their learning, e.g. of improvement methods; however, several teams had already reached goal values when the QICs were launched in 2013.

CONCLUSIONS

Even though many QI activities were carried out, it was difficult to see sustained improvements on outcomes. Outcomes as specific measurable aspects of care in need of improvement should be chosen carefully. Activities focusing on adherence to standard care programmes and on increased follow-up of patients seemed to lead to more long-lasting improvements. Although earlier studies showed that data follow-up and measurement skills as well as well-functioning data warehouses contribute to sustained improvements, the present registries' functionality and QICs at this time did not support those aspects sufficiently. Further studies on QICs and their impact on improvement beyond the project time should investigate the effect of those elements in particular.

Children and adolescents with type 1 diabetes in Australasia: An online survey of model of care, workforce and outcomes

AIM

To survey the model of care and workforce that manages children and adolescents with type 1 diabetes (T1D) in Australasia along with glycaemic outcomes.

METHODS

Tertiary and regional paediatric clinics in Australia and New Zealand (NZ) caring for children and adolescents with diabetes were invited to complete an online survey assessing health-care professional (HCP) workforce numbers and available clinical data for the 2016 calendar year.

RESULTS

A total of 38 sites responded - 25 Australian (10 tertiary, 15 regional), 13 NZ (4 tertiary, 8 regional) - representing 9715 children with T1D. HCP resourcing varied across sites, with overall HCP/100 patient ratios of: doctors: 0.36 (0.08-1.07), nurses: 0.72 (0-1.8), dieticians: 0.19 (0-0.49) and psychologist/social workers: 0.13 (0-0.36). Overall, 39% of patients used insulin pump therapy (CSII) (29.5% NZ, 40.8% Australia). Databases were being used locally by 26 sites. Thirty-two sites reported the mean clinic HbA1c, mean HbA1c 66 mmol/mol (8.2%) (NZ = 69 mmol/mol (8.5%), Australia = 66 mmol/mol (8.2%)), with 29% of patients attaining the recommended HbA1c target of <58 mmol/mol (7.5%) (NZ = 28%, Australia = 29%).

CONCLUSIONS

This is the largest Australasian paediatric T1D workforce survey to date. HCP to patient ratios remain well below international recommendations and have not changed over the last 5-7 years. Glycaemic outcomes in this population were below recommended levels in the majority of patients. There is an urgent need to reform models of care and workforce and to institute systematic benchmarking in both countries in order to prevent acute and chronic complications of T1D.

A systematic review of non-genetic predictors and genetic factors of glycated haemoglobin in type 1 diabetes one year after diagnosis

Type 1 diabetes (T1D) results from autoimmune destruction of the pancreatic βcells. Although all T1D patients require daily administration of exogenous insulin, their insulin requirement to achieve good glycaemic control may vary significantly. Glycated haemoglobin (HbA1c) level represents a stable indicator of glycaemic control and is a reliable predictor of long-term complications of T1D. The purpose of this article is to systematically review the role of non-genetic predictors and genetic factors of HbA1c level in T1D patients after the first year of T1D, to exclude the honeymoon period. A total of 1974 articles published since January 2011 were identified and 78 were finally included in the analysis of non-genetic predictors. For genetic factors, a total of 277 articles were identified and 14 were included. The most significantly associated factors with HbA1c level are demographic (age, ethnicity, and socioeconomic status), personal (family characteristics, parental care, psychological traits...) and features related to T1D (duration of T1D, adherence to treatment …). Only a few studies have searched for genetic factors influencing HbA1c level, most of which focused on candidate genes using classical genetic statistical methods, with generally limited power and incomplete adjustment for confounding factors and multiple testing. Our review shows the complexity of explaining HbA1c level variations, which involves numerous correlated predictors. Overall, our review underlines the lack of studies investigating jointly genetic and non-genetic factors and their interactions to better understand factors influencing glycaemic control for T1D patients.

Interventions using pediatric diabetes registry data for quality improvement: A systematic review

BACKGROUND

Diabetes registries contain vast amounts of data that can be used for quality improvement (QI) and are foundational elements of learning health systems; infrastructure to share data, create knowledge rapidly and inform decisions to improve health outcomes. QI interventions using adult diabetes registries are associated with improved glycemic control, complication screening rates, and reduced hospitalizations; pediatric data are limited.

OBJECTIVE

To evaluate the effects of QI strategies that use pediatric diabetes registry data on care processes, organization of care, and patient outcomes.

METHODS

We searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Google, Google Scholar, Directory of Open Access Journals, and diabetes registry websites for studies that evaluated the impact of QI interventions on diabetes care processes, care organization, or patient outcomes, using pediatric diabetes registry data. Two reviewers independently assessed eligibility, extracted data and assessed the risk of bias.

RESULTS

Twelve studies were included. Most interventions targeted health-care providers and evaluated effects on patient outcomes. Five of nine studies that evaluated hemoglobin A1c found improvements of 0.26% to 0.85% (2.8-9.3 mmol/mol) while four found no difference. Many report positive effects on care processes or organization. Study data could not be combined because of variable study design and outcome measures. Included studies represent a minority of existing registries.

CONCLUSIONS

Pediatric diabetes registries are underused for QI and may facilitate improved care and outcomes. Existing vast amount of pediatric registry data could be used to foster the development of learning health systems and to improve diabetes care and outcomes.

Enhancing policy implementation to improve healthcare practices: The role and strategies of hybrid national-local support structures

BACKGROUND

In this study, we followed a national initiative to enhance the use of quality indicators gathered in national quality registries (NQRs) for improvement of clinical practices in Swedish healthcare, more specifically by investigating the support strategies of regional support centers with national and local missions. The aim was to increase knowledge on the role, challenges, and strategies of support structures with mixed and complex missions in the healthcare system.

METHODS

Documents and 25 semistructured interviews with staff at 6 regional support centers, ie, quality registry centers, formed this multiple case study. Data were analyzed using conventional content analysis.

RESULTS

The centers' strategies varied from developing the NQRs to become more suitable for improvement to supporting healthcare's use of NQRs, from the use of task to process-oriented support strategies, and from taking on national responsibilities to responding to local initiatives. All quality registry centers engaged in initiatives inspired by the Breakthrough Series approach. Some used preexisting change concepts or collaborated with local development units. A main challenge was to overcome a lack of formal mandate to act in the healthcare organizations they served.

CONCLUSIONS

Support functions with mixed and complex missions have to use a variation of strategies to reach relevant actors and achieve changes. This study provides valuable input for policy and decision-makers on the support strategies used and challenges of support functions with complex missions situated in-between national and local levels of the healthcare system, here denoted hybrid national-local support structures.

Type 1 diabetes during adolescence: International comparison between Germany, Austria, and Sweden

OBJECTIVES

By using pediatric diabetes quality registries in Austria, Germany, and Sweden treatment of type 1 diabetes and the outcome of care during the vulnerable adolescence period were compared.

METHODS

Data in DPV, broadly used in Austria and Germany, and Swediabkids used in Sweden, from clinical visits in the year 2013 on 14 383 patients aged 11 to 16 years regarding hemoglobin A1c (HbA1c), insulin regimen, body mass index (BMI)-SD score (SDS), blood pressure, hypoglycemia, ketoacidosis, and smoking habits were analyzed.

RESULTS

Patients in Sweden had fewer clinical visits per year (P < .05), lower insulin dose per kg (P < .001), and lower proportion of fast acting insulin compared with Germany and Austria (P < .001). The proportion of pump users was higher in Sweden (P < .001). Patients in Sweden had lower mean HbA1c levels (Austria: 64 mmol/mol, Germany: 63 mmol/mol, and Sweden: 61 mmol/mol [8.0%, 7.9%, and 7.7%, respectively]; P < .001). The frequency of severe hypoglycemia was higher in Sweden while it was lower for ketoacidosis (3.3% and 1.1%, respectively) than in Austria (1.1% and 5.3%) and Germany (2.0% and 4.4%) (P < .001). Girls in all 3 countries had higher HbA1c and BMI-SDS than boys.

CONCLUSIONS

Sharing data between diabetes registries and nations enables us to better understand differences in diabetes outcome between countries. In this particular comparison, pediatric patients with diabetes in Sweden were more often treated with insulin pump, had lower HbA1c levels and a higher rate of severe hypoglycemia. Patients in Austria and Germany used rapid acting insulin analogs more often and had a lower rate of ketoacidosis.

Targets and teamwork: Understanding differences in pediatric diabetes centers treatment outcomes

OBJECTIVE

The reason for center differences in metabolic control of childhood diabetes is still unknown. We sought to determine to what extent the targets, expectations, and goals that diabetes care professionals have for their patients is a determinant of center differences in metabolic outcomes.

RESEARCH DESIGN AND METHODS

Children, under the age of 11 with type 1 diabetes and their parents treated at the study centers participated. Clinical, medical, and demographic data were obtained, along with blood sample for centralized assay. Parents and all members of the diabetes care team completed questionnaires on treatment targets for hemoglobin A1c (HbA1c) and recommended frequency of blood glucose monitoring.

RESULTS

Totally 1113 (53% male) children (mean age 8.0 ± 2.1 years) from 18 centers in 17 countries, along with parents and 113 health-care professionals, participated. There were substantial differences in mean HbA1c between centers ranging from 7.3 ± 0.8% (53 mmol/mol ± 8.7) to 8.9 ± 1.1% (74 mmol/mol ± 12.0). Centers with lower mean HbA1c had (1) parents who reported lower targets for their children, (2) health-care professionals that reported lower targets and more frequent testing, and (3) teams with less disagreement about recommended targets. Multiple regression analysis indicated that teams reporting higher HbA1c targets and more target disagreement had parents reporting higher treatment targets. This seemed to partially account for center differences in Hb1Ac.

CONCLUSIONS

The diabetes care teams' cohesiveness and perspectives on treatment targets, expectations, and recommendations have an influence on parental targets, contributing to the differences in pediatric diabetes center outcomes.

Diabetes technology: improving care, improving patient-reported outcomes and preventing complications in young people with Type 1 diabetes

With the evolution of diabetes technology, those living with Type 1 diabetes are given a wider arsenal of tools with which to achieve glycaemic control and improve patient-reported outcomes. Furthermore, the use of these technologies may help reduce the risk of acute complications, such as severe hypoglycaemia and diabetic ketoacidosis, as well as long-term macro- and microvascular complications. In addition, diabetes technology can have a beneficial impact on psychosocial health by reducing the burden of diabetes. Unfortunately, diabetes goals are often unmet and people with Type 1 diabetes too frequently experience acute and long-term complications of this condition, in addition to often having less than ideal psychosocial outcomes. Increasing realization of the importance of patient-reported outcomes is leading to diabetes care delivery becoming more patient-centred. Diabetes technology in the form of medical devices, digital health and big data analytics have the potential to improve clinical care and psychosocial support, resulting in lower rates of acute and chronic complications, decreased burden of diabetes care, and improved quality of life.

Reducing post-tonsillectomy haemorrhage rates through a quality improvement project using a Swedish National quality register: a case study

Purpose

Tonsillectomy (TE) is one of the most frequently performed ENT surgical procedures. Post-tonsillectomy haemorrhage (PTH) is a potentially life-threatening complication of TE. The National Tonsil Surgery Register in Sweden (NTSRS) has revealed wide variations in PTH rates among Swedish ENT centres. In 2013, the steering committee of the NTSRS, therefore, initiated a quality improvement project (QIP) to decrease the PTH incidence. The aim of the present study was to describe and evaluate the multicentre QIP initiated to decrease PTH rates.

Methods

Six ENT centres, all with PTH rates above the Swedish average, participated in the 7-month quality improvement project. Each centre developed improvement plans describing the intended changes in clinical practice. The project’s primary outcome variable was the PTH rate. Process indicators, such as surgical technique, were also documented. Data from the QIP centres were compared with a control group of 15 surgical centres in Sweden with similarly high PTH rates. Data from both groups for the 12 months prior to the start of the QIP were compared with data for the 12 months after the QIP.

Results

The QIP centres reduced the PTH rate from 12.7 to 7.1% from pre-QIP to follow-up; in the control group, the PTH rate remained unchanged. The QIP centres also exhibited positive changes in related key process indicators, i.e., increasing the use of cold techniques for dissection and haemostasis.

Conclusions

The rates of PTH can be reduced with a QIP. A national quality register can be used not only to identify areas for improvement but also to evaluate the impact of subsequent improvement efforts and thereby guide professional development and enhance patient outcomes.

Continued improvement of metabolic control in Swedish pediatric diabetes care

BACKGROUND

To prospectively investigate if the grand mean HbA1c and the differences in mean HbA1c between centers in Sweden could be reduced, thereby improving care delivered by pediatric diabetes teams.

METHODS

We used an 18-month quality improvement collaborative (QIC) together with the Swedish pediatric diabetes quality registry (SWEDIABKIDS). The first program (IQ-1), started in April 2011 and the second (IQ-2) in April 2012; together they encompassed 70% of Swedish children and adolescents with diabetes.

RESULTS

The proportion of patients in IQ-1 with a mean HbA1c <7.4% (57 mmol/mol) increased from 26.4% before start to 35.9% at 36 months (P < .001), and from 30.2% to 37.2% (P < .001) for IQ-2. Mean HbA1c decreased in both participating and non-participating (NP) centers in Sweden, thereby indicating an improvement by a spatial spill over effect in NP centers. The grand mean HbA1c decreased by 0.45% (4.9 mmol/mol) during 36 months; at the end of 2014 it was 7.43% (57.7 mmol/mol) (P < .001). A linear regression model with the difference in HbA1c before start and second follow-up as dependent variable showed that QIC participation significantly decreased mean HbA1c both for IQ-1 and IQ-2. The proportion of patients with high HbA1c values (>8.7%, 72 mmol/mol) decreased significantly in both QICs, while it increased in the NP group.

CONCLUSIONS

The grand mean HbA1c has decreased significantly in Sweden from 2010 to 2014, and QICs have contributed significantly to this decrease. There seems to be a spatial spill-over effect in NP centers.

Sensemaking and cognitive shifts - learning from dissemination of a National Quality Register in health care and elderly care

Purpose The purpose of this study is to examine and establish how sensemaking develops among a group of external change agents (ECAs) engaged to disseminate a national quality register nationwide in Swedish health care and elderly care. To study the emergent sensemaking, the theoretical concept of cognitive shift has been used. Design/methodology/approach The data collection method included individual semi-structured interviews, and two sets of interviews (initial sensemaking and renewed sensemaking) have been conducted. Based on a typology describing how ECAs interpret their work, structural analyses and comparisons of initial and renewed sensemaking are made and illuminated in spider diagrams. The data are then analyzed to search for cognitive shifts. Findings The ECAs' sensemaking develops. Three cognitive shifts are identified, and a new kind of issue-related cognitive shift, the outcome-related cognitive shift, is suggested. For the ECAs to customize their work, they need to be aware of how they interpret their own work and how these interpretations develop over time. Originality/value The study takes a novel view of the interrelated concepts of sensemaking and sensegivers and points out the cognitive shifts as a helpful theoretical concept to study how sensemaking develops.

Are quality improvement collaboratives effective? A systematic review

Background

Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness.

Method

We searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards.

Results

Of the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study’s primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.

Conclusions

QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.

The Australasian Diabetes Data Network: first national audit of children and adolescents with type 1 diabetes

OBJECTIVES

To assess glycaemic control, anthropometry and insulin regimens in a national sample of Australian children and adolescents with type 1 diabetes.

DESIGN

Cross-sectional analysis of de-identified, prospectively collected data from the Australasian Diabetes Data Network (ADDN) registry.

SETTING

Five paediatric diabetes centres in New South Wales, Queensland, South Australia, Victoria and Western Australia.

PARTICIPANTS

Children and adolescents (aged 18 years or under) with type 1 diabetes of at least 12 months' duration for whom data were added to the ADDN registry during 2015.

MAIN OUTCOME MEASURES

Glycaemic control was assessed by measuring haemoglobin A1c (HbA1c) levels. Body mass index standard deviation scores (BMI-SDS) were calculated according to the CDC-2000 reference; overweight and obesity were defined by International Obesity Task Force guidelines. Insulin regimens were classified as twice-daily injections (BD), multiple daily injections (MDI; at least three injection times per day), or continuous subcutaneous insulin infusion (CSII).

RESULTS

The mean age of the 3279 participants was 12.8 years (SD, 3.7), mean diabetes duration was 5.7 years (SD, 3.7), and mean HbA1c level 67 mmol/mol (SD, 15); only 27% achieved the national HbA1c target of less than 58 mmol/mol. The mean HbA1c level was lower in children under 6 (63 mmol/mol) than in adolescents (14-18 years; 69 mmol/mol). Mean BMI-SDS for all participants was 0.6 (SD, 0.9); 33% of the participants were overweight or obese. 44% were treated with CSII, 38% with MDI, 18% with BD.

CONCLUSIONS

Most Australian children and adolescents with type 1 diabetes are not meeting the recognised HbA1c target. The prevalence of overweight and obesity is high. There is an urgent need to identify barriers to achieving optimal glycaemic control in this population.

Longitudinal Analysis of Quality of Diabetes Care and Relational Climate in Primary Care

OBJECTIVE

To assess the influence of relational climate on quality of diabetes care.

DATA SOURCES/STUDY SETTING

The study was conducted at the Department of Veterans Affairs (VA). The VA All Employee Survey (AES) was used to measure relational climate. Patient and facility characteristics were gathered from VA administrative datasets.

STUDY DESIGN

Multilevel panel data (2008-2012) with patients nested into clinics.

DATA COLLECTION/EXTRACTION METHODS

Diabetic patients were identified using ICD-9 codes and assigned to the clinic with the highest frequency of primary care visits. Multiple quality indicators were used, including an all-or-none process measure capturing guideline compliance, the actual number of tests and procedures, and three intermediate continuous outcomes (cholesterol, glycated hemoglobin, and blood pressure).

PRINCIPAL FINDINGS

The study sample included 327,805 patients, 212 primary care clinics, and 101 parent facilities in 2010. Across all study years, there were 1,568,180 observations. Clinics with the highest relational climate were 25 percent more likely to provide guideline-compliant care than those with the lowest relational climate (OR for a 1-unit increase: 1.02, p-value <.001). Among insulin-dependent diabetic veterans, this effect was twice as large. Contrary to that expected, relational climate did not influence intermediate outcomes.

CONCLUSIONS

Relational climate is positively associated with tests and procedures provision, but not with intermediate outcomes of diabetes care.

Glycated hemoglobin A1c as a risk factor for severe hypoglycemia in pediatric type 1 diabetes

OBJECTIVE

To assess the risk of severe hypoglycemia related to glycated hemoglobin A1c (HbA1c) levels in a population-based cohort of pediatric type 1 diabetes patients during two time periods since 1995.

METHODS

The association between HbA1c levels and severe hypoglycemia (defined as requiring assistance from another person) or hypoglycemic coma (loss of consciousness or seizures) was analyzed by multivariable regression analysis in children and adolescents with type 1 diabetes from the DPV Diabetes Prospective Follow-up in Germany and Austria in 1995-2003 (n = 15 221 patients) and 2004-2012 (n = 22 318 patients).

RESULTS

Mean adjusted rates of severe hypoglycemia and hypoglycemic coma decreased from 19.18 [95% confidence interval (CI), 17.95-20.48] and 4.36 (3.93-4.83) per 100 patient-years in 1995-2003 to 15.01 (14.18-15.88) and 2.15 (1.94-2.39) in 2004-2012, respectively (p < 0.001). From the first to the second period, the relative risk (RR) for severe hypoglycemia and hypoglycemic coma per 1% lower HbA1c decreased from 1.22 (1.15-1.30) to 1.06 (1.01-1.12) and from 1.27 (1.15-1.40) to 1.04 (0.94-1.16), respectively. Risk of severe hypoglycemia and coma declined most in patients with HbA1c levels of 6-6.9% (RR 0.70 and 0.43, respectively) and with HbA1c of 7-7.9% (RR 0.63 and 0.38, respectively). Mean HbA1c levels fell from 8.4% in 1995-2003 to 8.2% in 2004-2012, while the use of insulin pumps, short- and long-acting insulin analogs, and glucose monitoring increased (p < 0.001).

CONCLUSIONS

In contrast to 1995-2003, low HbA1c has become a minor risk factor for severe hypoglycemia and coma in pediatric patients with type 1 diabetes in the 2004-2012 period.

Incidence of severe hypoglycemia in children with type 1 diabetes in the Nordic countries in the period 2008-2012: association with hemoglobin A 1c and treatment modality

OBJECTIVE

Treatment of type 1 diabetes has been intensified aiming at normalizing blood glucose, which may increase the risk of severe hypoglycemia (SH). We aimed to compare the incidence of SH events in the four Nordic countries Denmark, Iceland, Norway and Sweden, and to assess the influence of hemoglobin A1c (HbA_1c) and treatment modalities on the frequency of SH; particularly, to explore if a HbA_1c target ≤6.7% (50 mmol/mol) is feasible.

RESEARCH DESIGN AND METHODS

Data on children below 15 years with a diabetes duration more than 1 year, registered in the national childhood diabetes databases in the four Nordic countries from 2008 to 2012, were compiled. Data completeness was more than 95%.

RESULTS

Totally 8806 (48% females) patients with 29 715 person years were included, mean age and diabetes duration were 11 years and 5.1 years, respectively. The overall rate of SH was 6.0 per 100 patient-years, and did not change during the study period. The Swedish population constantly had the lowest SH incidence while it decreased significantly in the Danish population. HbA_1c decreased significantly over time (p<0.01), while the number of pump users increased (p<0.01). Stratifying for HbA_1c levels showed the lowest risk of SH in patients with HbA_1c ≤6.7% (≤50 mmol/mol), but in the statistical models adjusting for possible confounders the difference between the HbA_1c groups disappeared. Pump users had the lowest SH risk, also after adjusting for possible confounders.

CONCLUSIONS

Risk of SH differs between the Nordic countries with the lowest risk in Sweden. Pump therapy was associated with decreased risk of SH. The low HbA_1c group had the same or a lower risk of SH compared with the highest HbA_1c groups. A target HbA_1c ≤6.7% (≤50 mmol/mol) seems achievable without increasing the risk of SH.

Possibilities and challenges of a large international benchmarking in pediatric diabetology-The SWEET experience

AIM

Despite the existence of evidence-based guidelines for the care of children with diabetes, widespread gaps in knowledge, attitude, and practice remain. The purpose of this paper is to present a review of benchmarking practices and results of this process within SWEET, moreover focusing on current challenges and future directions.

METHODS

Biannually, members electronically transfer de-identified clinic data for 37 parameters to the SWEET database. Each center receives benchmarking and data validation reports.

RESULTS

In 2015, 48 centers have contributed data for 20 165 unique patients (51.6% male). After exclusion for missing data 19 131 patients remain for further analysis. The median age is 14.2 years, with a median diabetes duration 4.8 years; 96.0% of patients have type 1, 1.1% type 2, and 2.9% other diabetes types. Data completeness has increased over time. In 2015, median HbA1c of all patients' (diabetes type 1) medians was 7.8% (61.7 mmol/mol) with 39.1%, 41.4%, and 19.4% of patients having HbA1c < 7.5% (58 mmol/mol), 7.5%-9% (58-75 mmol/mol) and >9% (75 mmol/mol), respectively. Although HbA1c has been stable over time [7.7%-7.8% (60.7-61.7 mmol/mol)], there remains wide variation between centers. Fourteen centers achieve a median HbA1c <7.5% (58 mmol/mol).

CONCLUSIONS

Our vision is that the participation in SWEET is encouraging members to deliver increasingly accurate and complete data. Dissemination of results and prospective projects serve as further motivation to improve data reporting. Comparing processes and outcomes will help members identify weaknesses and introduce innovative solutions, resulting in improved and more uniform care for patients with diabetes.

Hypertransaminasemia in Newly Diagnosed Pediatric Patients With Celiac Disease

OBJECTIVES

The aim of the present study was to determine the proportion of pediatric patients with celiac disease (CD) who had transaminases obtained at diagnosis and to determine the proportion with hypertransaminasemia.

METHODS

Data from newly diagnosed patients with CD at Nationwide Children's Hospital from February 2007 to March 2014 were retrospectively reviewed. Alanine transaminase (ALT) and aspartate transaminase (AST) values at diagnosis and after initiation of a gluten-free diet (GFD) were assessed.

RESULTS

Of 388 patients (mean age 10.1 ± 4.4 years, 235 girls), 185 (47.7%) had transaminases obtained at the time of diagnosis. Twenty-eight of one hundred eighty-five (15.1%) had an elevated ALT and/or AST level with an average ALT 2.52 × upper limit of normal (ULN) and AST 1.87 × ULN. Those with hypertransaminasemia were younger than those with normal levels (6.31 ± 4.75 vs 11.00 ± 4.28 years, P < 0.0001). Sex, symptoms at diagnosis, and weight, height, and body mass index z scores were not predictive of elevated transaminases. Of the 21 patients with hypertransaminasemia at diagnosis who had repeat laboratory test results after starting the GFD, 15 (71.4%) normalized whereas 6 (28.6%) remained elevated.

CONCLUSIONS

There is variation in practice among pediatric gastroenterologists in the assessment of transaminases in children with CD. Hypertransaminasemia is present at diagnosis in a significant proportion of children with CD although at a lower frequency than previously reported. Younger patients are more likely to have an elevation in transaminases. Abnormal transaminases normalize in the majority of patients within 1 year after initiation of a GFD.

Resources and population served: a description of the Ontario Paediatric Diabetes Network

BACKGROUND

The Network of Ontario Pediatric Diabetes Programs was established in 2001 to provide access to specialized pediatric diabetes care. Universal funding for pediatric insulin pump therapy has been available in Ontario since 2006. The objective of this study was to describe the distribution of patients, resources and insulin pump use across centres within the network, now called the Ontario Paediatric Diabetes Network.

METHODS

We conducted a cross-sectional survey in 2012 of the 35 pediatric diabetes centres in Ontario to measure centre characteristics, patient volume and available clinical and social resources. We used health administrative data from the provincial Assistive Devices Program to describe patients aged 18 years or less using insulin pumps by centre as a measure of technology uptake.

RESULTS

All 35 centres participated, reporting a total of 6676 children with type 1 diabetes and 368 with type 2 diabetes. Most (> 80%) children with type 1 diabetes were followed at tertiary (n = 5) or large community (n = 14) centres. Nursing patient load was similar between centre types, but there was a large range across centres within any type. Overall, percent insulin pump use was 38.1% and varied widely across centres (5.3%-66.7%). Funded 24-hour support for pump users was available at 5 (36%) small community centres, 3 (19%) large community centres and 2 (40%) tertiary centres.

INTERPRETATION

Our study showed differences in access to specialized and after-hours care for children with diabetes in Ontario. Pump use varied widely across centres. Further research is needed to assess the impact of these observed differences on quality of care and outcomes.

Health-system-based interventions to improve care in pediatric and adolescent type 1 diabetes

Despite significant advances in pharmacology and technology, glycemic targets are difficult to achieve for patients with type 1 diabetes (T1D) and management remains burdensome for patients and their families. Quality improvement (QI) science offers a methodology to identify an aim, evaluate complex contributors to the goal, and test potential interventions to achieve outcomes of interest. Day-to-day management of diabetes is often an iterative process but interventions exist at all care levels: individual patient and family, clinic, and larger population and health system. This article reviews current literature and proposes novel QI interventions for enhancing health outcomes, with attention to essential determinants or drivers of improved glycemic control and patient experience for pediatric T1D in the context of the Chronic Care Model. In-depth consideration of key drivers of successful T1D care, including self-management and integration of technology, are explored, and examples of larger health systems with improved outcomes, including Learning Health Systems are highlighted.

Nationwide reduction in the frequency of severe hypoglycemia by half

AIMS

To examine contemporary rates of severe hypoglycemia (SH) and identify the effect of predictors of SH in a pediatric type 1 diabetes population.

METHODS

The national diabetes register provided data on children residing in Denmark from 2008 to 2013 in this register-based population study. Robust Poisson regression models were applied.

RESULTS

The study population [n = 2,715 (50.9 % boys), mean (SD) age at onset; 8.1 (4.0) years, diabetes duration; 5.6 (4.9) years] comprised 7,390 person-years of data and 561 events of SH. The overall incidence of SH was 7.6 per 100 person-years. The incidence rate peaked with 16.0 per 100 person-years in 2008 reaching a nadir of 4.9 in 2011. Overall, insulin pump reduced the rate of SH with 27 % compared to any pen treatment (P = 0.003). When stratifying pen treatment, premixed insulin increased the rate of SH by 1.9-fold (P = 0.0015) and NPH increased the rate by 1.6-fold (P = 0.003) versus pump treatment, whereas long-acting insulin analogues were comparable with pump treatment (P = 0.1485). We found no association of SH with glycemic control (P > 0.05).

CONCLUSIONS

A nationwide halving in rates of severe hypoglycemia was observed during the study period independent of the prevailing average HbA1c level. Changes in diabetes care and successful educational programs may have influenced the lower incidence rate of severe hypoglycemia.

HypoDE: Research Design and Methods of a Randomized Controlled Study Evaluating the Impact of Real-Time CGM Usage on the Frequency of CGM Glucose Values <55 mg/dl in Patients With Type 1 Diabetes and Problematic Hypoglycemia Treated With Multiple Daily Injections

Systems for continuous glucose monitoring (CGM) have been available for a number of years, and numerous clinical studies have been performed with them. Interestingly, in many of these studies patients with an increased risk of hypoglycemic events were excluded. In addition, in most studies subjects were using a pump for insulin delivery. Therefore our knowledge about the benefit of CGM in patients employing multiple daily injections (MDI) of insulin is limited, especially when it comes to a reduction in the risk of low glucose events in high-risk individuals. We are planning to run a 26-week randomized controlled study in Germany (HypoDE, Hypoglycemia in Deutschland) that is focused on evaluating if such a reduction can be observed in patients on MDI with an increased risk of low glucose events. In all, 160 patients will participate in the study, randomized into the intervention group and control group. Ideally one would study if the frequency of severe hypoglycemic events is different between both groups. However, this would require such a large sample size and study duration, so for pragmatic reasons we will use low glucose levels <55 mg/dl (measured by CGM) for at least 20 minutes as a risk marker for severe hypoglycemic events. The results from the HypoDE study shall help determine the advantage of using CGM in subjects with type 1 diabetes with an increased risk of low glucose events treated with MDI.