ESPE Yearbook of Paediatric Endocrinology

Pediatr Diabetes. 2019;20:93–98. DOI: 10.1111/pedi.12801

• The quality and availability of pediatric diabetes management varies from setting to setting depending on the available resources.

• In this position paper, the authors propose a ‘levels of care’ concept with three tiers that stratifies the existing levels of care into minimal care, intermediate care, and comprehensive care.

This article acknowledges the reality: in many low- and middle-income countries (LMICs), diabetes care is suboptimal and is associated with high mortality and morbidity. The authors propose a “Levels of Care” framework for T1D care that can guide health authorities to focus their efforts on appropriate objectives for better diabetes care. This article builds on previous work by the first author who developed a standardized, reproducible Child Program Index of diabetes care measure that can be used to assess critical factors influencing diabetes treatment outcomes (1). Indeed, while we are all familiar with the “gold standard” approach as described in the International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines, we do not always appreciate the “next step” approach that will lead to an improvement in diabetes care.

The authors propose nine levels of diabetes care, from a “Minimal care” (characterized by poor insulin access, poor education and uncommon blood glucose testing and associated with elevated HbA1c values and high mortality) to “Intermediate care” (characterized by appropriate access to human insulin and blood glucose strips and associated with low incidence of complications) and “Comprehensive care” (characterized by access to insulin analogs or insulin pumps, multidisciplinary diabetes team and optimal blood glucose monitoring and associated with the lowest HbA1c and prevalence of long term complications). The association between the various components of diabetes care (insulin access, blood glucose monitoring, HbA1c measures, complications screening and quality of diabetes education) and the clinical outcomes (mean HbA1c and prevalence of mortality and complications) at each level of care will serve as a guide for health authorities wishing to implement additional actions for diabetes management and encourage them to reach the next level of care.

Reference: 1. Ogle GD, Middlehurst AC, Silink M. The IDF Life for a Child Program Index of diabetes care for children and youth. Pediatr Diabetes. 2016 Aug;17(5):374–84.