The Hvidoere Study Group is to be commended for their efforts to elucidate demographic, ethnic, and treatment factors associated with disparities in mean A1C that persisted between participating pediatric diabetes clinics despite similar treatment goals and management techniques (1). It was disheartening that none of the evaluated factors, with the possible exception of language difficulties, yielded an easy-to-implement way to improve mean A1C levels within clinics or reduce A1C differences between clinics.
The authors mention that two clinics markedly improved their mean clinic A1C and hint that improvement may have been due to an increased number of staff. Workforce issues, such as increasing the number of staff members devoted to patient care, may be an essential factor in improving overall A1C. From 1997 onward, we tracked the relationship between yearly mean clinic A1C and the number of staff from all disciplines devoted to patient care per 100 diabetes patients at the Children’s Hospital of New Orleans. We found a trend for higher staff number being associated with lower A1C. Extrapolation of our regression curve suggested that a mean clinic A1C <8% might be achievable with a ratio of ∼3–4 staff per 100 patients. Regrettably, in 2005, hurricane Katrina prematurely ended data collection for this survey. By comparison, we estimate that the Diabetes Control and Complications Trial (DCCT) (2), from which current glycemic goals have evolved, had an overall staff-to-patient ratio of ∼5–6 to 100. As most DCCT staff time was devoted to patients in the intensive-treatment half of the study, the effective ratio might have been closer to 7–10 staff per 100 patients. The highly favorable staff-to-patient ratio in the DCCT was undoubtedly essential to achieving A1C goals in the intensive treatment group. Because there was considerable selection diversity of subjects between Hvidoere centers, it is possible that unmeasured differences in staff number, training, specialization, experience, and élan may have influenced A1C levels.
Published glycemic goals for children and adolescents were established without regard to staffing needs required for their achievement in general diabetes clinic populations (3). If the mission of diabetes management teams is to help patients achieve and maintain optimal glycemic control, it would be of considerable help in the design, funding, and staffing of programs to understand the functional relationship between staff number and composition and mean program or clinic A1C. The impressively low mean A1C levels achieved at a few of the Hvidoere centers may be unattainable at the majority of pediatric diabetes clinics without substantial increase in the number and specializations of staff members devoted to patient care. Thus, it would be highly valuable if the Hvidoere Study Group or other consortiums of pediatric diabetes clinics were able to use their resources to evaluate the relationship between workforce issues and A1C outcomes.
