The establishment of a new national network leads to quality improvement in childhood diabetes: Implementation of the ISPAD Guidelines

Aims: To investigate whether implementation of International Society for Pediatric and Adolescent Diabetes (ISPAD) Guidelines and the establishment of a system for nationwide anonymous comparison, between treatment centres, of quality indicators for childhood diabetes could lead to improvement in diabetes care. Methods: Children and adolescents with type-1 diabetes in Norway are treated at the public hospitals. Data were collected prospectively yearly according to standardized written instructions. Quality indicators were defined and benchmarked. HbA1c was measured at a central national Diabetes Control and Complications Trial (DCCT) standardized laboratory. Results: The participation increased with 454 type-1 diabetes patients from eight clinics included in 2001 and 1658 patients from 25 clinics in 2005. The adherence rate in 2005 was 85% of all eligible patients from 25 of 26 pediatric clinics. The mean HbA1c of all clinics improved (8.6% in 2001 and 8.1% in 2005) and this was statistically significant (p < 0.01). The use of intensive insulin treatment increased from 56% to 78% (p < 0.01) and pumps from 8% to 37% (p < 0.01). The incidence of diabetes ketoacidosis (DKA) remained constant. The incidence of severe hypoglycemia declined insignificantly. The proportion of patients not screened yearly for microalbuminuria and retinopathy, according to ISPAD guidelines, decreased from 12% to 2% (p < 0.01) and from 42% to 27% (p < 0.01), respectively. All changes occurred gradually from 2001 to 2005. Conclusions: During the establishment of a system for benchmarking of diabetes treatment in Norway the outcomes showed significant improvements associated with changes in management and the quality of screening assessments. Benchmarking combined with organized quality meetings and discussions was effective to improve outcome on a national level.