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.
