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Clinic variation in glycaemic control for children with Type 1 diabetes in England and Wales: a population-based,
D Charalampopoulos1, R Amin1, J T Warner2
1University College London Great Ormond Street Institute of Child Health, London, UK.
Insights
Most variation in children's Type 1 diabetes control (HbA1c) occurs within clinics, not between them. Improving national outcomes requires raising overall clinic quality, not just targeting underperforming centers.
Area of Science:
- Pediatric Endocrinology
- Diabetes Management
- Health Services Research
Background:
- Glycaemic control in children with Type 1 diabetes (T1D) can vary significantly.
- Understanding variation between clinics is crucial for improving pediatric diabetes care outcomes.
Purpose of the Study:
- To assess the potential for enhancing glycaemic outcomes in pediatric T1D by reducing inter-clinic variation.
- To investigate the influence of insulin regimens and clinic characteristics on glycaemic control.
Main Methods:
- Cross-sectional analysis of National Paediatric Diabetes Audit data (2012-2013).
- Involved 21,773 children (<19 years) with T1D across 176 clinics in England and Wales.
- Multilevel models were used to analyze HbA1c variation, calculating the intraclass correlation coefficient (ICC).
Main Results:
- 39% of clinics showed significantly different glycaemic performance (HbA1c) after case-mix adjustment.
- Inter-clinic differences accounted for only 4.7% of total HbA1c variation.
- Accounting for within-clinic HbA1c variation reduced the ICC to 2.4%; insulin regimen and clinic factors had minor impacts.
Conclusions:
- Most HbA1c variation in pediatric T1D is within-clinic, not between clinics.
- National improvements in glycaemic control may be best achieved by elevating the quality of all clinics, rather than solely focusing on underperforming ones.
Aim:
To understand the scope for improving children's glycaemic outcomes by reducing variation between clinics and examine the role of insulin regimen and clinic characteristics.
Methods:
Cross-sectional analysis of 2012-2013 National Paediatric Diabetes Audit data from 21 773 children aged < 19 years with Type 1 diabetes cared for at 176 clinics organized into 11 regional diabetes networks in England and Wales. Variation in HbA1c was explored by multilevel models with a random effect for clinic. The impact of clinic context was quantified by computing the per cent of total variation in HbA1c which occurs between clinics (intraclass correlation coefficient; ICC).
Results:
Overall, 69 of the 176 diabetes clinics (39%) had a glycaemic performance that differed significantly from the national average after adjusting for patient case-mix with respect to age, gender, diabetes duration, deprivation and ethnicity. However, differences between clinics accounted for 4.7% of the total variation in HbA1c . Inclusion of within-clinic HbA1c standard deviation led to a substantial reduction in ICC to 2.4%. Insulin regimen, clinic volume and diabetes networks had a small or moderate impact on ICC.
Conclusions:
Differences between diabetes clinics accounted for only a small portion of the total variation in glycaemic control because most of the variation was within clinics. This implies that national glycaemic improvements might best be achieved not only by targeting poor centres but also by shifting the whole distribution of clinics to higher levels of quality.
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