# A region-wide hub and spoke approach to standardize and decentralize type 1 diabetes management

## TL;DR

A new healthcare model for type 1 diabetes in Italy improved patient outcomes and reduced costs and environmental impact.

## Contribution

Implementation and evaluation of a Hub and Spoke model for decentralized diabetes care in a region with fragmented services.

## Key findings

- Glycemic control improved significantly, with increased time in range and time in target range after one year.
- Adoption of diabetes technologies like AID increased, especially among newly acquired patients.
- The model reduced travel distance, CO₂ emissions, and healthcare costs by over €25,000 annually.

## Abstract

Type 1 diabetes (T1D) requires specialized, multidisciplinary, and technology-driven care, which can be difficult to guarantee across regions with fragmented services. In July 2023, the Liguria region (Italy) reorganized pediatric diabetes care into a Hub and Spoke model, coordinated by the Gaslini Institute (hub) and three peripheral pediatric departments (spokes). This study aimed to evaluate the first year of application of this model in terms of clinical, technological, and environmental outcomes.

This retrospective observational study included T1D patients aged less than 35 years in follow-up at the new regional Hub and Spoke system. Patients were categorized as transferred (previously followed at the hub), acquired (previously followed at a local center), and new onset (followed from the beginning at the Hub and Spoke system). The primary outcome was the change in time in range 70–180 mg/dL after 12 months. Secondary outcomes were additional indicators of glycemic control (CGM metrics), adoption of technologies (rtCGM and AID), and economic and environmental impact (travel distance, costs, and CO₂ emissions).

129 patients were referred to the new Hub and Spoke system during the first 2 years of its implementation. Among them, 88 (50 transferred, 38 acquired) had available data at baseline and completed the 1-year follow up period and were included in the study. In this cohort, TIR increased from 57.2 to 65.1% and TITR from 35.1 to 41.7% (p < 0.001), with improvement in other CGM metrics. Improvements were more pronounced in acquired patients, whose TIR rose from 53.9 to 65.7% (+11.2%, p < 0.001). AID use increased significantly with a larger rise among acquired (from 26.3 to 60.5%, +34.2%) compared with transferred patients (+26%). The program generated environmental and economic benefits, with estimated 70,192 km of travel, 11,932 kg CO₂, and € 25,760 saved yearly.

The Hub and Spoke model proved feasible and effective, leading to more standardized care delivery, broader adoption of diabetes technologies, improved glycemic control, and significant reductions in travel-related costs and environmental impact. This approach may offer a scalable and sustainable solution for managing T1D, particularly in regions with complex geography and variable healthcare infrastructures.