Deja Vu: Glycemic Control in Children with Diabetes Mellitus

I was dismayed by an article in the June 2018 issue of Diabetes Care (unfortunately you can’t read the article unless you have a subscription to the journal, have a friend who has a subscription, or go to a medical school library).   The article was entitled: “Exploring variation in glycemic control across and within eight high-income countries: a cross-sectional analysis of 64,666 children and adolescents with type 1 diabetes,” and was written by Chadalampopoulos et. al.  I have thought long and hard whether to get into the disturbing issues raised by this article, given that I have already written a number of entries on the subject. In the end, I decided that I had to say something, rather than “sit on my hands.”

In previous entries I have discussed the extraordinary range of mean HbA1c levels in children and adolescents with diabetes in different countries and different clinics. I have discussed in detail, the concept of a “bell curve” as so well discussed by Professor Atul Gawande, in which some sophisticated medical centers provide far better medical care than other presumably sophisticated medical centers. In short, some doctors do much better caring for their patients than other doctors do for their patients.

The current study shows exactly what several previous similar studies have shown; that some countries achieve far better outcomes for their children and adolescents with type 1 diabetes than other countries.  This study looked at 8 countries: The U.S., England, Wales, Germany, Sweden, Denmark, Austria, and Norway. HbA1c levels were far better in the “best” country (Sweden) than the “worst” country or region (a virtual tie between the U.S., England, and Wales  In Sweden the mean HbA1c was about 7.5%; in the U.S., England, and Wales, the mean HbA1c was close to 9%. That difference is about the same as the difference in mean HbA1cs in the Diabetes Control and Complications trial (DCCT) between the intensive and standard treatment groups (if you don’t know what the DCCT was all about, please go to my blog index and find one of many earlier entries on the subject).  The investigators try to make a big deal out of the fact that there are significant HbA1c differences, even within the individual countries, but that only strengthens the argument that the reason for the huge range of HbA1c averages is not because of inter-country differences in medical costs or demographics or anything else other than diabetes management skills.

Furthermore, and perhaps most disturbing, is that the data in the current study show that absolutely no progress has been made over the last 25 years in improving diabetes care in children and adolescents with diabetes. The very same centers and countries that had low HbA1cs in the 1990s, still had the low HbA1cs; the very same centers and countries that had high HbA1cs in the 1990s, still had high HbA1cs.

In my opinion, the most appalling thing about the article, was that the investigators did not offer any thoughts as to why there were such striking discrepancies in HbA1c levels among the various countries and individual centers. Isn’t it time to stand up and just tell it like it really is- that some diabetes docs, know how to take care of children and adolescents with diabetes better than others. It is Atul Gwande’s “bell curve” all over again (if you haven’t read Dr. Gawande’s article or read about the bell curve in one of his excellent books, I urge you to do so).

I hope this article will prompt some of my colleagues in the U.S. to rethink their diabetes management skills and do like the cystic fibrosis docs in Dr. Gawande’s bell curve article did; they set the big egos aside and said: “Golly, we can do better.”  Let’s see if we pediatric endocrine docs can toss our egos aside, and learn from those diabetes care teams that give better care than we do.

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