Using Metrics to Improve the Delivery of Optimal Care for Children With Type 1 Diabetes

Manmohan Kamboj, MD

Manmohan Kamboj, MD, is division and section chief of the Division of Endocrinology at Nationwide Children’s Hospital.

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Despite the traditional use of hemoglobin A1c (HbA1c) as the standard metric for diabetes control, it has its shortcomings, such as an incomplete picture of blood sugar variability and hypoglycemia risk. To gain a more holistic sense of diabetes management, the endocrinology team at Nationwide Children’s Hospital developed the first-ever Type 1 Diabetes Composite Score: a broad metric comprised of numerous lab test results and risk indicators. 

“HbA1c is important, but it’s not everything when it comes to understanding how well a person’s diabetes is controlled,” says Manmohan Kamboj, MD, chief of Endocrinology at Nationwide Children’s and senior author on the publication detailing the team’s quality improvement (QI) initiative to create the score. 

“We can make anyone’s HbA1c lower but that leads to greater hypoglycemia risks and parents lying awake at night worrying about their child developing a scary low blood sugar,” adds Justin Indyk, MD, PhD, pediatric endocrinologist at Nationwide Children’s and lead author on the publication. “We wanted to find a better way to capture how a patient is doing in a global sense.”


Dr. Indyk and the QI team compiled key diabetes surveillance measures recommended by the American Diabetes Association and the International Society for Pediatric and Adolescent Diabetes, including blood pressure, urine screening and lipid profiles and added other known outcomes-related factors, such as wellness visit attendance, hypoglycemia and hospitalization episodes, use of continuous glucose monitoring (CGM) devices and more. The new process- and outcomes-driven composite measure includes nine components and has a scoring system of 0 to 18, with higher numbers representing better diabetes management.

They worked with hospital information science experts to build a diabetes registry for the clinic in 2017. This patient registry, which now includes more than 1,900 patients, was then used to develop the framework and clinician “dashboard” showing patient- and population-level T1DCS data. The team tested the scoring tool in 2018 and continued applying it clinic-wide using periodic assessments of 2019 data. Since implementing the T1DCS as a tool in the electronic medical record system, the clinic has tracked steady improvements in population-level scores driven, they believe, by visibility of these metrics as well as a push for increased CGM use and patient-specific education.

While the broad use of the composite score depends on fairly high-tech integration with a clinic’s electronic records system, Dr. Indyk is hopeful that future iterations of standard EMR programs could be built with this module included. He also believes elements can also be adopted on a smaller, less computer-driven scale.

Indyk JA, Buckingham D, Obrynba KS, Servick C, Gandhi KK, Kramer A, Kamboj MK. The Type 1 Diabetes Composite Score: An innovative metric for measuring patient care outcomes beyond HbA1c. Pediatric Quality and Safety. 2020 Sep-Oct; 5(5): e354.