Only a minority of Australian children and adults with type 1 diabetes are meeting recommended glycemic targets despite access to specialist care in tertiary diabetes centres.

The disappointing results, from almost 8,000 patients attending 11 paediatric and 7 adult diabetes centres in the Australasian Diabetes Data Network (ADDN), may also be a worrying indicator of the state of diabetes care beyond the major centres.

The study, published in the Internal Medicine Journal, found the mean HbA1c for the whole cohort was 8.2% with similar rates in males and females.

“Overall, 18% of the paediatric cohort (≤18 years) and 13% of the adult cohort met the recommended international glycaemic target of HbA1c < 53 mmol/mol (7.0%),” the study authors said.

“HbA1c increased with age; from 60 mmol/mol (7.6%) in children less than 10 years with a subsequent rise during adolescence and a peak in the 20-25 years age group (73 mmol/mol or 8.8%), before a decline to 67 mmol/mol (8.3%) in the >30 age group,” they noted

The study also showed the mean HbA1c was significantly lower in those using continuous subcutaneous insulin infusion (8.0%) compared with multiple daily injections (8.3%; p<0.0001) which was lower again than those on BD injections (8.5%; p<0.001).

In the 0-18 age group HbA1c was significantly lower in those using CGM >75% of the time for all therapy groups.

“In the 18-30 age group with CGM >75%, HbA1c was significantly lower in CSII users but not for MDI users and in the >30 age group, there was no impact of CGM on HbA1c for either CSII or MDI users.”

“The study highlights the urgent need to critically assess and evaluate the current strategies, recognise the enablers and barriers to improve diabetes care both in children and adults with T1D to reduce the acute care costs and long-term complications of the chronic disease,” said the investigators, led by A/Prof Jane Holmes-Walker, Staff Specialist in the Department of Diabetes and Endocrinology, Westmead Hospital, Sydney.

They noted that while the highest levels of HbA1c are historically reported in adolescents, the data showed 20-25 years olds were of most concern. Only 1 in 10 in this age group achieved the recommended HbA1c <7.0%.

“The finding in Australia that sub-optimal control continues through adulthood is also concerning with only 23% of adults >30 years achieving the recommended ADA glycaemic targets.”

They said their conclusions may be limited by the possible disproportionate representation of adults with T1D with advanced complications and from lower socio-economic backgrounds in the tertiary adult centres.

“On the other hand, the large tertiary centres may have access to a greater range of resources,” they said.

“While only a minority of those attending ADDN centres achieved the recommended glycaemic target; it is interesting to speculate on outcomes for those with T1D who do not have access to major centres or to technology in Australia.”

They concluded their findings warrant further efforts “…to improve equity of access to expert care as well as proven therapies with planned and effective service delivery.”

Need to find out why

One of the ADDN’S principal investigators Professor Tim Jones, from Perth Children’s Hospital, told the limbic there has to be a deeper dive into the data to find explanations and solutions for the suboptimal glycaemic outcomes.

“Other countries do better. Places like Sweden and Germany do better in the proportion of people meeting target. We’re about level with the US.”

“We need to find out why. We’ve got smart people, we’re one of the richest countries in the world … we need to dig down and find out why it is not working.”

Professor Jones said children were doing better than adults – perhaps because of access to CGM. However, the problems were more than just access to technology.

“I think CGM is a great tool and has made a lot of difference in the paediatric world. But if you give someone a CGM, they’re not going to do any better unless you show them how to use it.”

“It’s the whole package. It’s the model of care. Its education. And it’s the tools.”

He said even the visit frequency, at less than three visits per year for adults, seemed inadequate for a chronic disease that reduces life expectancy by 15 years.

“HbA1c of <7% is internationally recognised as the gold standard. Everybody aims for that. We know that if you can get that you can prevent the long term complications of diabetes. Economically it makes sense to try and put the resources in to try and achieve that.”

“Young adults are the ones that are really doing the worst. Young adults are high risk, they can’t afford health insurance, and the complications start to evolve in that younger adults group. We owe it to them to know what is going on.”

Professor Jones said there was a move to include more regional centres in the network.

“They might be doing better, they might be doing worse because there is not the expertise out there. We just don’t know.”