Abstract
Increasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres. This cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels. Mean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p <0.001), but location and patient volume were not. Associated patient-level factors associated with increases in HbA1c included past hyperglycaemic emergencies (type 1 and type 2, p<0.001) and Aboriginal and Torres Strait Islander status (type 2, p<0.001). Being a non-smoker was associated with reductions in HbA1c (type 1 and type 2, p<0.001). Centre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself.
Highlights
The rising incidence of diabetes is increasing the burden for patients and healthcare systems, in terms of both resource allocation and healthcare utilisation [1]
For people with type 1 diabetes, volume of patients was associated with increases in haemoglobin A1c (HbA1c) (p = 0.019)
For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p
Summary
The rising incidence of diabetes is increasing the burden for patients and healthcare systems, in terms of both resource allocation and healthcare utilisation [1]. People with diabetes face added financial burden and the complexity of living with a chronic condition that often includes concomitant complications including psychological distress, retinopathy, neuropathy, nephropathy, amputation and increased risk of cardiovascular disease [2–4]. Optimal diabetes control requires people to self-manage multiple disease-influencing factors. These factors include diet, physical activity and long-term maintenance of blood glucose levels [5,6]. Measured by a blood test, HbA1C is commonly used as a measure of average glucose control over the few months prior to testing [7]. While self-blood glucose monitoring (SBGM) is used as a part of day to day self-management, HbA1c is the gold standard for evaluating overall diabetes control [8,9] with the literature recommending a HbA1c target of
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