Children and adolescents with type 1 diabetes in Aotearoa New Zealand: An online survey of workforce and outcomes 2021

To survey the national workforce that manages children and adolescents with type 1 diabetes (T1D) in Aotearoa New Zealand and compare with glycaemic outcomes for 2021.

2][3] In well-resourced countries, complications of T1D should be delayed or prevented entirely. 4][7][8][9] In countries such as Aotearoa New Zealand, comprehensive and accessible care should be available to all in need, and HbA1c levels should align with The International Society of Paediatric and Adolescent Diabetes (ISPAD) guidelines. 4The ISPAD recommendation for optimal resource allocation of multidisciplinary team members per 100 patients is: 0.75-1.00doctors, 1.00-1.25 diabetes nurses, 0.5 dietitians and 0.3 social workers/psychologists. 10Recent analyses of the Aotearoa New Zealand workforce responsible for providing care for children and adolescents with T1D have consistently shown under-resourcing for the past decade, falling well below ISPAD recommendations. 2,3,11An under-resourced workforce may contribute to data demonstrating most young people in Aotearoa New Zealand with T1D do not reach healthy glycaemic levels that reduce the risk of micro and macrovascular complications. 12,13espite technological advancements in glucose testing, monitoring and insulin delivery that have transformed outpatient diabetes care, challenges persist in delivering comprehensive, guidelines-based care to all people with T1D, especially those in rural areas and from diverse socio-economic and ethnic backgrounds.Pacific and M aori (the Indigenous people of Aotearoa New Zealand) ethnicities, and those of lower socio-economic status, have been shown to have higher HbA1cs, placing them at high risk of developing complications. 12Ensuring adequate workforce resourcing and preventing the widening of health inequities have become critical priorities to diabetes management in Aotearoa New Zealand.

Methods
A representative from each paediatric diabetes centre in Aotearoa New Zealand was invited to complete a short online survey in August 2022.The survey asked representatives to calculate departmental workforce data with respect to the 2021 calendar year.
In evaluating public sector workforce full-time-equivalent (FTE) to compare to ISPAD optimal resource allocation, a halfday clinic was calculated as equivalent to 0.2 FTE as per previous specialty physician practice in Aotearoa New Zealand. 14On this basis, participants were asked to calculate the amount of healthcare professional (HCP) FTE provided by the entire diabetes services.Specialist paediatricians and specialist endocrinologists working in diabetes centres were pooled under 'Doctor'.Psychology and social workers were pooled to align with the International Society of Paediatric and Adolescent Diabetes (ISPAD).Certain district health boards (DHBs) have combined regional diabetes centres and were pooled as a single site (e.g.Auckland and Canterbury & West Coast).Regions with a patient number <30 were excluded from median FTE/100 patient calculations.
The survey contained skip logic, and the full survey is included as Appendix S1 (Supporting Information).The survey questions were designed to ensure that only the proportion of work dedicated to T1D by any HCP was included.During the analysis of the results, data outliers were identified and then verified or corrected by contacting the diabetes centre concerned.
Glycaemic data from all regional diabetes centres in Aotearoa New Zealand with children <15 years with T1D has previously been reported by Burnside et al. 12 Socioeconomic status was ascertained indirectly from address of domicile, coded to small area units (meshblocks, about the size of a city block), which were matched to the Aotearoa New Zealand Index of Deprivation 2018 (NZDep).NZDep, a validated area-based measure of socioeconomic position in Aotearoa New Zealand, combines the following census data: communication, income, employment, qualifications, owned home, support, living space and living condition. 15NZDep is displayed as deciles with each decile containing about 10% of the Aotearoa New Zealand population. 15Decile 1 represents areas with the least socioeconomically deprived scores, and decile 10 represents areas with the most socioeconomically deprived scores.NZDep data were categorised into quintiles for analysis where quintile 5 represents the 20% most socioeconomically deprived areas in Aotearoa New Zealand based on meshblocks.
Patient's urban-rural status was determined using the Geographic Classification for Health (GCH). 16Patients were classified as 'urban' if they lived within 20-25 min of a large or major urban centre (≥30 000 population), 'semi-rural' if they lived within 50-60 min of a large or major urban centre or within 25 min of a medium urban centre (>10 000 population), or rural otherwise.

Statistical analysis
Workforce FTE per 100 patients were calculated and tabulated by worker role and DHB.Restricted maximum likelihood linear mixed effect models were used to investigate the potential causes of variation between DHB in the mean observed HbA1c of their patients.The HbA1c of individual patients were entered as the dependent variable in the models, and DHB as a random effect.Covariates were added to models to adjusted for differences between DHB in patient-level and workforce-level factors.Patient-level factors included use of intermittent CGM (isCGM) or real-time CGM (rtCGM), NZDep score, of M aori and/or Pacific ethnicity, and urban-rural status.The Workforce-level factors were FTE per 100 patients of doctors, nurses, and dietitians.Heterogeneity in HbA1c across DHB was explored by estimating the standard deviation of the random effects for each model.Analysis was undertaking using R (version 4.2.2) 17 and the lme4 package (version 1.1-31). 17

Results
The survey was completed by 17 sites (including all 4 tertiary centres), collectively managing a total of 1609 children and >99% of children and adolescents with T1D in Aotearoa New Zealand (Table S1). 18
Doctor HCP/100 patient ratios were only met for one region, which had the smallest number of patients.Nurse allocations were met in 11 regions (65%), and dietitian allocations in 3 regions (18%).No region met the allocations recommended for social worker/psychologists, and eight (50%) of the regions surveyed had no FTE allocated at all.
Of the national diabetes nursing workforce, 42% were prescribing, (7.15/17.05FTE), 2% (0.4/17.05 FTE) were nurse practitioners.Psychologist/social worker services were available in eight regions.Paediatric dietitian services were available in all regions except Taranaki.No region had mental health nurse, exercise physiologist, or podiatry services embedded within the diabetes team.

Glycaemia and DHB
Glycaemic data were reported from all sites and were available for 1585 of 1609 children and adolescents.Only 15.1% (240 out of 1585) of patients had an HbA1c less than 53 mmol/mol.The mean patient (as opposed to clinic) HbA1c was 67.8 mmol/mol (8.4%).On average, patients had a lower HbA1c if they lived in an area of low deprivation, lived in or near a large urban centre, were using CGM especially real-time CGM, and were of Asian or European ethnicity (Table 2).
There were marked differences between DHB in the risk profiles of their population (Fig. 1).DHBs in the lower North Island and South Island tended to have less deprived populations, and for the South Island a higher proportion of patients of European or Asian ethnicity.Whilst 78% of patients lived in or near urban centres, Northland DHB was notable for having a large proportion of rural patients.Use of CGM was variable across the country, with the Auckland region having the highest proportion of patients using self-monitoring of blood glucose (SMBG).
The mean HbA1c differed across DHB with an unadjusted standard deviation estimated at 2.8 mmol/mol. 16Adjustment for differences in the case-mix of patients decreased the standard deviation across DHBs to 2.0 mmol/mol.No further reduction in standard deviation across DHB was evident when models were adjusted for the workforce allocation of a DHB (Fig. 2), nor were workforce allocation variables found to improve model fit after adjustment for patient-level factors (P = 0.98).As further adjustment for DHB, or FTE, made little difference to the estimated effects of ethnicity and SES on HbA1c, these results have not been presented.

Discussion
This study examined the workforce managing children and adolescents with T1D in Aotearoa New Zealand.Most children attended paediatric centres at tertiary centres staffed with multidisciplinary teams.Despite regional variability, the median health-care professional ratios were lower than the optimal resource allocation recommended by the International Society of Paediatric and Adolescent Diabetes (ISPAD).The median FTE/100 patients for doctors and dietitians were nearly two-fold lower, and nearly 8-fold lower for social worker/psychologists, with only nursing approaching ISPAD recommendations.There was minimal change in the median FTE/100 patients between   2012 and 2021, which may reflect a difference in sampling or minimal improvement in workforce. 2It is worth noting that this is despite the Aotearoa New Zealand Ministry of Health quality standards for diabetes care acknowledging that young people with T1D must have access to experienced multidisciplinary teams including development expertise, youth health, health psychology, social work and dietetics. 19he inadequate HCP/100 patient ratios for psychologists and social workers in multidisciplinary teams is concerning, given the high rate of local mental health comorbidity and the recommendation by ISPAD to screen for relevant psychosocial factors and provide education and strategies to manage these concerns. 10,20Evidence suggests that physical and psychosocial comorbidities presenting in adulthood originate in childhood and their prevalence can be reduced through appropriate interventions. 6Outsourcing of this expertise is not conducive to a multidisciplinary approach and fails to facilitate cohesive teamwork and consistent messaging to patients and their families.It also neglects the opportunity to enhance the expertise of other team members regarding the standard practices for diabetes care that they should be aware of.
Effective management of T1D demands a high level of training for all HCP involved, and previous studies have shown that access to intensive therapy may vary based on locality, which could be related to diabetes specialists' comfort and support for new technologies. 21With minimal change in workforce resourcing, the proportion of children and adolescents meeting international glycaemic targets in Aotearoa New Zealand remains low at 15%, and is worse than 2010 (27%), while noting a change in goalpost with a lower HbA1c of 52 mmol/mol or less, is likely the main reason this proportion is lower. 2lthough this study assessed the optimal health-care professional workforce allocation for diabetes services in Aotearoa New Zealand, it found no correlation between FTE and HbA1c outcomes.This finding suggests that social determinants of health significantly influence the ability of children and adolescents with diabetes achieving target glycaemic control.Discrepancies in HbA1c outcomes among regions may primarily result from variations in patient deprivation levels, as district health board ceased to predict HbA1c outcomes after adjusting for patient-level factors.Furthermore, factors such as access to diabetes therapeutics and workforce constraints may also be influential. 1,13espite the advent of continuous glucose monitoring revolutionising diabetes care in the past decade, inequity in access to care continues to a be significant challenge in achieving glycaemic targets.A recent analysis of access to continuous glucose monitoring in the Aotearoa New Zealand paediatric T1D population found ethnicity to be an independent factor associated with HbA1c levels, indicating that ethnicity-based treatment bias or unique ethnicity and cultural factors lead to disparities in health outcomes.Use of real-time glucose monitoring has the highest benefit in lowering HbA1c levels and its use has the potential to mitigate ethnicity-based and socio-economic deprivation-based HbA1c disparities should it be funded in Aotearoa New Zealand. 18To provide comprehensive care for children and adolescents with T1D, it is important to assess the applicability of ISPAD guidelines to Aotearoa New Zealand, particularly regarding culturally appropriate care for M aori and Pacific populations who experience non-trivial burden of complications associated with diabetes. 18,22Further research is needed to understand how to utilise M aori models of health to ensure culturally safe approach to diabetes management.
This study also assessed the dynamics of the T1D workforce by comparing the ratio of HCP FTE per 100 patients to the most deprived T1D patient populations.We observed that sites in the South Island of Aotearoa New Zealand had patient populations of comparatively less deprivation.As such, by comparison, North Island sites had HCP to patient ratios that did not account for the additional complexity and resource required to care for patient groups with higher needs based on socio-economic determinants of health. 18Social determinants significantly impact glycaemic outcomes in this population, with deprivation impacting HbA1c levels and continuous glucose monitoring use. 12Indeed our data show that these factors predict glycaemic measures, rather than which region you live in per se.Policy makers and workforce planners should utilise these workforce findings, in conjunction with recent prevalence and incidence data, to ensure comprehensive care for T1D regardless of their locality. 13,18With this in mind, the recent centralisation of Aotearoa New Zealand's health-care system may be an opportunity to reorientate and facilitate health equity for marginalised populations and address existing locality disparities. 23

Strengths and limitations
This survey has the strength of encompassing all centres that manage children and adolescents with T1D in Aotearoa New Zealand and provides the last workforce data prior to centralisation of the health-care system.It is the first Australasian children and adolescent T1D workforce survey to provide identified regional data, allowing for targeted improvements.While potential biases and some 'best-estimates' for FTE allocations may exist due to the identification of regions, the study identifies areas of national shortage in resourcing care for children and adolescents with T1D.
The ISPAD suggested guide on optimal resource allocation does not delineate the scope of a 1.0 FTE allocation for health clinicians in terms of clinic hours.Drawing from the practice of specialty physicians in Aotearoa New Zealand, the authors propose that five half-day clinics equate to 1.0 FTE, although this may differ internationally.This study is limited in its failure to include cultural support workers or health navigators in FTE calculations or capture the ethnicities of our workforce.Future surveys should investigate whether our workforce reflects the population needs.Furthermore, this study fails to evaluate workforce resources dedicated to children and adolescents with type 2 diabetes mellitus, a group which is likely cared for by the same workforce and where disparities may be even greater.A limitation of the survey is that it did not capture access to allied health services that are not embedded within the team but are available to the service.Finally, our study utilises small area units (meshblock) to ascertain socioeconomic status and the Geographic Classification for Health to determine rurality status which have their own limitations. 15,16

Conclusions
In conclusion, our study highlights consistent under-resourcing of care for children and adolescents with T1D in Aotearoa New Zealand.Despite aiming to meet the comprehensive care targets set by The International Society of Pediatric and Adolescent Diabetes, the country falls short in terms of health-care professional resource allocation.Increased workforce, particularly in areas with a high proportion of low socio-economic patients, is needed to achieve equity in outcomes for all patients with T1D in Aotearoa New Zealand.

FIGURE 1
FIGURE 1 Distribution of patient-level risk factors by District Health Board (DHB).Levels to the left of the figures are associated with lower mean HbA1c (NZDep 1-3, Urban, Non-M aori non-Pacific ethnicity, use of rtCGM), whereas those on the right (NZDep 4 & 5, Rural, M aori or Pacific ethnicity, use of SMBG) are associated with higher mean HbA1c.isCGM, intermittent CGM; rtCGM, real time CGM; SMBG, self-monitoring of blood glucose.

Table 2
Association between HbA1c and patient-level risk factors Unadjusted differences were estimated by fitting each variable to a separate linear regression model.Adjusted differences were estimated by including all four variables in a single linear regression model.CGM, continuous glucose monitoring; GCH, geographic classification for health; isCGM, intermittent CGM; NZDep, New Zealand Deprivation Index quintile; Ref, reference category; rtCGM, real time CGM; SMBG, self-monitoring of blood glucose.
Variation in glycaemic control across DHB, with or without adjustment for patient-level risk factors and workforce allocation.The estimated HbA1c for a DHB versus the national average was estimated using restricted maximum-likelihood linear mixed effects models, with DHB fitted as a random effect.Subject-level adjustment included patient SES (NZDep), urban-rural status (GCH), ethnicity, and use of CGM (rtCGM or isCGM) as fixed effects.Adjustment for workforce allocation also included DHB FTE per 100 patients for Doctors, Nurses and Dietitians.