Gap in mean HbA1c values growing between US, European nations
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Mean HbA1c for people with type 1 diabetes increased in the U.S. from 2011 to 2017, whereas Sweden saw decreases in HbA1c among all age groups, and Germany and Austria reported a decline among children, according to study data.
“HbA1c levels were already higher for people with type 1 diabetes in the United States in 2011 when compared with those in Germany, Austria and Sweden, and the gap widened when the HbA1c data from 2017 were analyzed,” Anastasia Albanese-O'Neill, PhD, APRN, CDCES, director of community screening and clinical trial education at JDRF, faculty member at the University of Florida College of Nursing, and an Endocrine Today Editorial Board Member, told Healio. “Data collection, benchmarking and quality improvement collaboratives are well-established practices in these European countries, and collectively have contributed to improvements in diabetes outcomes. Clinicians in the United States have the opportunity, where applicable, to learn from processes already implemented across the Atlantic.”
Albanese-O’Neill and colleagues collected data from four type 1 diabetes registries; the Diabetes Patienten Verlaufsdokumentation in Germany and Austria, the Swedish pediatric diabetes quality registry for children with type 1 diabetes and the Swedish National Diabetes Register for adults in Sweden, and the T1D Exchange clinic registry in the U.S. HbA1c values were collected for 2011 and 2017 for all people with type 1 diabetes in each registry. Mean HbA1c was calculated for seven age groups: younger than 6 years, 6 to 12 years, 13 to 17 years, 18 to 24 years, 25 to 44 years, 45 to 64 years, and at least 65 years.
The findings were published in Diabetes Technology & Therapeutics.
There were 86,323 total registry participants in 2011, including 25,651 from Germany and Austria, 44,474 from Sweden and 16,198 from the U.S. In 2017, there were 100,219 people in the four registries, with 29,442 from Germany and Austria, 53,690 from Sweden and 17,087 from the U.S.
HbA1c values increasing in U.S.
In Germany and Austria, the mean overall HbA1c was 7.8% in both 2011 and 2017. Sweden had a decrease in HbA1c from 8% in 2011 to 7.6% in 2017 (P < .001). Mean HbA1c in the U.S. increased from 8.1% in 2011 to 8.3% in 2017 (P < .001).
In Germany and Austria, adults aged 25 years and older had an increase in HbA1c from 2011 to 2017, teens aged 13 to 17 years had a decrease in HbA1c, and no significant changes were observed in other age groups. All age groups in Sweden had a significant decrease in HbA1c. In the U.S., all age groups had an increase in HbA1c except for children younger than 6 years and adults aged 45 to 64 years, where no significant changes were observed.
“What was particularly striking in this study was that from 2011 to 2017, as HbA1c levels rose among U.S. teenagers, HbA1c fell slightly in this same age group in Germany and Austria, and the mean fell by 0.6% in Sweden,” Albanese-O’Neill said. “By 2017, the mean HbA1c among teenagers aged 13 to 17 years was 9.1% in the U.S., 8.2% in Germany and Austria, and 7.6% in Sweden.”
In an analysis of mean HbA1c for children, adolescents and young adults, values were about 0.5% higher in the U.S. than the three European nations in 2011. In 2017, Sweden had a mean HbA1c in those age groups about 0.5% lower than in Germany and Austria and about 0.8% to 1.5% lower than in the U.S.
Among adults in 2011, HbA1c was lowest in Germany, Austria and the U.S. and highest in Sweden. In 2017, HbA1c among middle-aged adults was lowest in Sweden and in the U.S. There were no differences between the four countries in HbA1c among older adults in 2017.
Quality improvement initiatives needed
Albanese-O’Neill said some steps can be taken to reverse the increasing HbA1c trajectory in the U.S., such as expanding benchmarking in type 1 diabetes and launching quality improvement initiatives to improve outcomes and reduce disparities. Some initiatives could include improving access to continuous glucose monitors and insulin delivery systems with training and education to support their sustained use, finding more efficient ways to get objective glucose and insulin delivery data transferred to electronic medical records, and improving processes for identifying diabetes-related distress and supporting providers in behavioral health.
However, for many of these initiatives to work, Albanese-O’Neill said, the U.S. must find a way to lower health care costs, which are substantially higher than in the other countries in the study.
“Americans face high personal out-of-pocket costs for medications and diabetes technologies,” Albanese-O’Neill said. “Insulin, which is essential to sustain life for people living with type 1 diabetes, has unfortunately become the most well-known example of skyrocketing list drug prices in the U.S. Some of our most populous states have high numbers of uninsured, with rates in Florida at 13.2% and in Texas at 18.4%. And this doesn’t address the underinsured in the United States, who may have health care coverage but experience prohibitively high out-of-pocket costs for medications and supplies. While we engage in quality improvement, we must also be willing to advocate for universal access to health insurance.”
For more information:
Anastasia Albanese-O'Neill, PhD, APRN, RN, CDCES can be reached at aalbanese@bellsouth.net.
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