Size matters: Influence of center size on quality of diabetes control in children and adolescents with type 1 diabetes—A longitudinal analysis of the DPV cohort

Abstract

Background Treatment of patients with type 1 diabetes requires experience and a specific infrastructure. Therefore, center size might influence outcome in diabetes treatment. Objective To analyze the influence of center size on the quality of diabetes treatment in children and adolescents in Germany and Austria. Patients and methods In 2009 and 2018, we analyzed metabolic control, acute complications, and rates of recommended screening tests in the DPV cohort. Diabetes centers were classified according to the number of patients from “XS” to “XL” (<20 [XS], ≥20 to <50 [S], ≥50 to <100 [M], ≥100 to <200 [L], ≥200 [XL]). Results Over the 10‐year period, metabolic control improved significantly in “M”, “L” and “XL” diabetes centers. Treatment targets are best achieved in “M” centers, while “XS” centers have the highest mean hemoglobin A1c. The relation between hemoglobin A1c and center size follows a “v‐shaped” curve. In 2009, conventional insulin therapy was most frequently used in “XS” centers, but in 2018, there was no difference in mode of insulin therapy according to center size. Use of CSII and sensor augmented CSII/hybrid closed loop increased with center size. Patients cared for in “XS” diabetes centers had the fewest follow‐up visits per year. The rates of severe hypoglycemia and DKA were lowest in “XL” diabetes centers, and the rate of DKA was highest in “XS” centers. Conclusion Center size influences quality of care in pediatric patients with type 1 diabetes. Further investigations regarding contributing factors such as staffing and financial resources are required.

Does size matter? Hospital volume and resource use in paediatric diabetes care

“…Our results are in concordance with a previous study from the national DPV Registry in Germany and Austria, showing the lowest number of consultations in the smallest hospitals 10 . All‐cause hospitalisation in relation to hospital volume has not been studied previously.…”

“…All‐cause hospitalisation in relation to hospital volume has not been studied previously. However, the previous study revealed that diabetic ketoacidosis (DKA) occurred most in extra‐small centres (<20 patients), while DKA and hypoglycaemia rates were lowest in extra‐large centres (≥200 patients) 10 . This indicates a similar hospitalisation pattern that aligns with our results.…”

“…However, the previous study revealed that diabetic ketoacidosis (DKA) occurred most in extra-small centres (<20 patients), while DKA and hypoglycaemia rates were lowest in extra-large centres (≥200 patients). 10 This indicates a similar hospitalisation pattern that aligns with our results. Furthermore, the DPV study reported no differences in pump therapy between volume categories, yet they did find that the use of sensor-augmented pumps increases with centre size.…”

“…Our results are in concordance with a previous study from the national DPV Registry in Germany and Austria, showing the lowest number of consultations in the smallest hospitals. 10 All-cause hospitalisation in relation to hospital volume has not been studied previously. However, the previous study revealed that diabetic ketoacidosis (DKA) occurred most in extra-small centres (<20 patients), while DKA and hypoglycaemia rates were lowest in extra-large centres (≥200 patients).…”

“…Several studies have shown an association between hospital features, particularly hospital size, and clinical patient outcomes such as glycaemic control 10–12 . In previous studies conducted in the Netherlands, unexpectedly higher diabetes expenditures were observed in larger hospitals and diabetes technology use was found to play an important role in the costs of paediatric diabetes care 13,14 .…”