We appreciate Dr. Chalew's comments in his letter (1) regarding our recent study (2). Modification of the levels of staffing may have contributed to improved metabolic outcome in two of the Hvidoere study centers that achieved reductions in mean clinic A1C levels in contrast to the lack of improvement seen in other centers without staffing changes. Most would agree that comprehensive, structured (intensive) education is a key factor in metabolic outcome; and therefore, it would not be surprising that a sufficient number of trained experienced staff is a necessity and not a luxury in managing diabetes successfully. However, several centers have achieved excellent outcomes in previous Hvidoere Study Group (HSG) studies and have maintained their high standards without changes in staff (3). Criteria for choosing the type of insulin therapy and for insulin dose alteration and different personal and team characteristics are probably important, but other services (availability of a 24-h hotline, possible differences in background population, frequency of clinic attendance) have been suggested as influential (4,5). Also, in this most recent HSG study, more frequent visits to the doctor by adolescents were reported to be associated with better metabolic control, whereas more frequent visits to the nurse/educator or the psychologist were significantly related to poorer metabolic control (4). We have found, however, that not only the number of health care professionals involved in the delivery of care but also the treatment targets identified by the team members may influence metabolic outcome. It appears that identification of consistent A1C targets by team members has a major impact on outcome, as does the perception of the treatment goals by adolescents and parents (4).

We acknowledge the significance of Dr. Chalew's question regarding staffing levels. Various national bodies have tried to estimate acceptable ratios of specialist staff to patients, and there has been some attempt to measure outcomes in terms of the availability of specialist teams (6). Although the Diabetes Control and Complications Trial provided evidence that good metabolic control reduces the risk for late complications, achieving optimal metabolic control in different cultures and environments remains a major challenge. At the end of the day, small numbers of motivated, organized, and effective staff may achieve excellent outcomes, whereas well-resourced but poorly functioning teams may produce the opposite. Further in- depth analysis of the twenty-one HSG centers with respect to center structure, staffing arrangements, and targeting is ongoing and may provide answers to Dr. Chalew's questions.

Chalew S: Continuing stability of center differences in pediatric diabetes care: do advances in diabetes treatment improve outcome? The Hvidoere Study Group on Childhood Diabetes.
Diabetes Care
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de Beaufort CE, Swift PG, Skinner CT, Aanstoot HJ, Aman J, Cameron F, Martul P, Chiarelli F, Daneman D, Danne T, Dorchy H, Hoey H, Kaprio EA, Kaufman F, Kocova M, Mortensen HB, Njølstad PR, Phillip M, Robertson KJ, Schoenle EJ, Urakami T, Vanelli M, the Hvidoere Study Group on Childhood Diabetes 2005: Continuing stability of center differences in pediatric diabetes care: do advances in diabetes treatment improve outcome? The Hvidoere Study Group on Childhood Diabetes.
Diabetes Care
Danne T, Mortensen HB, Hougaard P, Lynggaard H, Aanstoot HJ, Chiarelli F, Daneman D, Dinesen B, Dorchy H, Garandeau P, Greene SA, Hoey H, Holl RW, Kaprio EA, Kocova M, Martul P, Matsuura N, Robertson KJ, Schoenle EJ, Sovik O, Swift PGF, Tsou RM, Vanelli M, Aman J, the Hvidøre Study Group on Childhood Diabetes: Persistent center differences over 3 years in glycemic control and hypoglycemia in a study of 3,805 children and adolescents with type 1 diabetes.
Diabetes Care
Swift PGF, de Beaufort CE, Skinner TC, the Hvidoere Study Group on Childhood Diabetes: Services provided by the diabetes team: do they affect glycemic outcome?
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Dorchy H, Roggemans MP, Willems D: Glycated hemoglobin and related factors in diabetic children and adolescents under 18 years of age: a Belgian experience.
Diabetes Care
Edge JA, Swift PGF, Anderson W, Turner B: Diabetes services in the UK: fourth national survey; are we meeting NSF standards and NICE guidelines?
Arch Dis Child