Diabetes Patient Education
Transcript of Diabetes Patient Education
-
8/9/2019 Diabetes Patient Education
1/96
Canadian Diabetes Strategy: Time For Action
DIABETESAn Epidemic of the New
Millennium
Program & Policy
Implicationsfor Canada
Dr. Stewart HarrisUniversity of Western Ontario
-
8/9/2019 Diabetes Patient Education
2/96
Canadian Diabetes Strategy: Time For Action,May 2003
Overview of Todays Talk
The Epidemiology
Current Healthcare Delivery &
Innovative Models Future Policy & Program Direction
-
8/9/2019 Diabetes Patient Education
3/96
Canadian Diabetes Strategy: Time For Action,May 2003
The World Wide Epidemic:Prevalence of Diabetes
5%
8%
14%
4%
3%
-
8/9/2019 Diabetes Patient Education
4/96
Canadian Diabetes Strategy: Time For Action,May 2003
The Worldwide Epidemic:Diabetes Trends
30
135177
221
300
370
0
50
100
150
200
250
300
350
400
MillionswithDiabetes
1985 1995 2000 2010 2025 2030
Sources: www.who.int
www.idf
Zimmet P. et al Nature: 414, 13 Dec 2001
http://www.who.int/http://www.idf/http://www.idf/http://www.who.int/ -
8/9/2019 Diabetes Patient Education
5/96
Canadian Diabetes Strategy: Time For Action,May 2003
The World Wide Epidemic:Millions with Diabetes 2000 & 2030
< 30
36 - 40
31 - 35
41 - 45
46 - 50
>50
People withDiabetes(millions)
2030
2000
-
8/9/2019 Diabetes Patient Education
6/96
Canadian Diabetes Strategy: Time For Action,May 2003
The World Wide Epidemic:Millions by Degree of Development
0
50
100
150
200
250
MillionswithDiabetes
Developed Countries Developing Countries
1995
2025
REF: www.who.int Sept 2002 Fact Sheet#236
-
8/9/2019 Diabetes Patient Education
7/96Canadian Diabetes Strategy: Time For Action
The Diabetes Epidemic
in Canada
Prevalence, Risk Factors,
andCurrent Cost Implications
-
8/9/2019 Diabetes Patient Education
8/96
Canadian Diabetes Strategy: Time For Action,May 2003
The Canadian Epidemic:Prevalence of Diabetes in Canada,1996
0.6% 0.5% 0.5%0.7% 0.7%
1.9%
2.7%
4.4%
5.9%
8.2%
9.6%
10.2%
12.6%
10.2%
0%
2%
4%
6%
8%
10%
12%
14%
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+
Age Group
Preva
lence
(%)
Overall self-reportedprevalence (15+):3.4% (n=786,000)
Source: Statistics Canada, National Population Health Survey, Public Use Microdata,
1996/97
-
8/9/2019 Diabetes Patient Education
9/96
Canadian Diabetes Strategy: Time For Action,May 2003
The Canadian Epidemic:Prevalence in Canada, 1994/95 to 2000/01, by
Province
1996 -1997
2.53.1
3.23.20
3.203.2
3.2
3.40
4.60
4.6
Prevalence (%)
1.30 to2.903.00 to3.403.50 to 3.90
4.00 to4.405.00 to
5.405.50 to5.90Nodata
3.10
1998 - 1999
3.4
4.4
3.13.13.1
3.33.6
4.0
5.2
3.1
2000 -2001
1.3
3.43.9
4.0
4.0
4.1
4.25.0
5.1 5.2
5.8
3.2
1994 -1995
2.7
2.8
2.83.0
3.13.1
3.2
3.50
3.6
3.9
0
Source: Statistics Canada: CANSIM II
-
8/9/2019 Diabetes Patient Education
10/96Canadian Diabetes Strategy: Time For Action
These numbers are anunder-representationof the true burden of
diabetes.
-
8/9/2019 Diabetes Patient Education
11/96
Canadian Diabetes Strategy: Time For Action,May 2003
In international population based diabetesprevalence studies
American study found: 33% of all cases of diabetes were undiagnosed
Australian study found: 50% of all cases of diabetes were undiagnosed
For a total prevalence of 7.4%
The Canadian Epidemic:
Undiagnosed DM and PreDiabetes
REF: The Australian Diabetes, Obesity and Lifestyle Study, Diabetes Care, V25 5, May 200
Harris MI, Eastman RC, Diabetes Metab Res Rev 2000 Jul-Aug;16(4):230-6
-
8/9/2019 Diabetes Patient Education
12/96
Canadian Diabetes Strategy: Time For Action,May 2003
The Canadian Epidemic:Age Distribution of Canadians with Diabetes in 2000& 2016
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
-
8/9/2019 Diabetes Patient Education
13/96
Canadian Diabetes Strategy: Time For Action,May 2003
The Canadian Epidemic:Alberta Prevalence
First Nations
Social Services
Subsidy
No-Subsidy
-
8/9/2019 Diabetes Patient Education
14/96
Canadian Diabetes Strategy: Time For Action
Diabetes Risk Factors
Modifiable Risk FactorsPhysical Activity
Obesity
Diet
&
Non-Modifiable RiskFactorsEthnicity
Family History
-
8/9/2019 Diabetes Patient Education
15/96
Canadian Diabetes Strategy: Time For Action,May 2003
Diabetes Risk Factors:Modifiable
0
1
2
RelativeRisk
>7 4 to 7 2 to 4 .5 to 2
-
8/9/2019 Diabetes Patient Education
16/96
Canadian Diabetes Strategy: Time For Action,May 2003
0
0.5
1
1.5
2
relativeris
5 4 3 2 1quintiles based on fat/fibre content
Healthy Diet:
Relative Risk for Developing DM
Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.
Diabetes Risk Factors:Modifiable
-
8/9/2019 Diabetes Patient Education
17/96
Canadian Diabetes Strategy: Time For Action,May 2003
0
10
20
30
40
RelativeRis
-
8/9/2019 Diabetes Patient Education
18/96
Canadian Diabetes Strategy: Time For Action,May 2003
Relative risk for developing type 2 is cumulative. A physically inactive individual (less than 30 min/wk of
exercise)
who consumes an unhealthy diet
and is modestly overweight (BMI 25-30) would have a 30-fold increased (1.8*2*8) risk of
developing type 2 DM compared to the generalpopulation,
which would translate to a lifetime risk of nearly
100%REF: Atlas of Diabetes 2nd Ed, Part 2, JS Sklyer, Editor
Diabetes Risk Factors:Modifiable
-
8/9/2019 Diabetes Patient Education
19/96
Canadian Diabetes Strategy: Time For Action,May 2003
2000
56
58
62
6263
64
65
65
6566
59
69
40 to 49
50 to 59
60 to 69
70 to 79
2001
47
55
61
61
67
50
57
62
63
49
5959
60
47
1999
57
65
67
6162
65 65
6872
55
47
urce: www.cflri.canadian Fitness & Lifestyle Research Institute
63
69
1998
51
56
58
60
63
67
7363
63
70
68
Diabetes Risk Factors: ModifiablePhysical Inactivity in Adults by Province,1998-2001
http://www.cflri.ca/http://www.cflri.ca/ -
8/9/2019 Diabetes Patient Education
20/96
Canadian Diabetes Strategy: Time For Action,May 2003
19901985
1994
< 10%
< 10% - 14.9%
> 15%No data
1996 1998
urce: Katzmarzyk PT, CMAJ Apr. 16, 2002; 166 (8)
Diabetes Risk Factors: ModifiableObesity by Province: BMI 30
-
8/9/2019 Diabetes Patient Education
21/96
Canadian Diabetes Strategy: Time For Action,May 2003
The proportion of children andadolescents who are overweight hastripled in the past 3 decades.
Fat kids become fat adults
More fat kids means more fat adultsdown the road
Diabetes Risk Factors: ModifiableObesity
-
8/9/2019 Diabetes Patient Education
22/96
Canadian Diabetes Strategy: Time For Action,May 2003
The Canadian Epidemic:Future Implications
Two major demographics are at playin Canada:
Boomer and Echo Generation
Immigration and Ethnicity
High percentage of Canadianimmigrants are from ethnic groups that
are at high risk for the development ofDM
-
8/9/2019 Diabetes Patient Education
23/96
Canadian Diabetes Strategy: Time For Action
The Epidemic:Non-Modifiable Risk
Factors
Ethnicity
AgeFamily History / Genetics
-
8/9/2019 Diabetes Patient Education
24/96
Canadian Diabetes Strategy: Time For Action
The Epidemic:Ethnic Groups at High Risk for
DM
AboriginalLatino
South East Asian
Asian
African Descent
-
8/9/2019 Diabetes Patient Education
25/96
Canadian Diabetes Strategy: Time For Action,May 2003
Diabetes Risk Factors: Non-ModifiableAboriginal Peoples in Canada & the World
-
8/9/2019 Diabetes Patient Education
26/96
Canadian Diabetes Strategy: Time For Action,May 2003
Type 2 Diabetes Prevalence Rates:NPHS, Sandy Lake to the Canadian Population,age adjusted prevalence (%) by sex
3.3
11
24.2
7.1
3.2
16.9
28
19.8
0
5
10
15
20
25
30
Male Female
Canadian
NPHS
Sandy Lake (DM)
Sandy Lake (IGT)
S a n
d y
L a
k e
( D M
)
Sandy
Lake(DM)
Sandy
Lake(IGT)
NPHS
(DM)
NPHS
(DM)
REF: Harris SB et al Diabetes Care 1997;20:185-187 & NPHS
-
8/9/2019 Diabetes Patient Education
27/96
Canadian Diabetes Strategy: Time For Action,May 2003
Age-Standardized Prevalence of Obesity by GlucoseTolerance Status (BMI>27): Canada and Sandy Lake
35
50.9
63.9
73.1
27
64.6
77.575.1
0
10
20
30
40
50
60
70
80
Men Women
Canada Sandy Lake (Norm) Sandy Lake (IGT) Sandy Lake (DM
Both measures of obesity(BMI and WHR) wereassociated withincreasing glucoseintolerance for both sexes
REF: Hanley AJG, Harris SB et al Diabetes Care 1997;20:185-187.
-
8/9/2019 Diabetes Patient Education
28/96
Canadian Diabetes Strategy: Time For Action,May 2003
Prevalence of Abdominal Obesity (WHR) by GlucoseTolerance Status: Canada and Sandy Lake (Age-Standardized)
50
81.8
93.693.4
34
91.9
98.799.1
0
20
40
60
80
100
Men Women
Canada Sandy Lake (Norm)Sandy Lake (IGT) Sandy Lake (DM)
WHR was shownto be asignificantpredictor for
diabetes
REF: Harris SB et al Diabetes Care 1997;20:185-187.
-
8/9/2019 Diabetes Patient Education
29/96
Canadian Diabetes Strategy: Time For Action,May 2003
Pediatric Obesity Study:Sandy Lake and NHANES III Males, age 2-19
Di b t Ri k F t N
-
8/9/2019 Diabetes Patient Education
30/96
Canadian Diabetes Strategy: Time For Action,May 2003
77.1% of Canadas immigrantpopulation are coming frompopulations which from high risk
ethnic groups 7.3% Latinos
Central and South America, 7.3%
57.0% Asian
12.8% African Decent
Caribbean and Bermuda, 5.5%
Africa, 7.3%
Diabetes Risk Factors:Non-ModifiableOther High-risk Groups in Canada
REF: Statistics Canada, 1996 Census
-
8/9/2019 Diabetes Patient Education
31/96
Canadian Diabetes Strategy: Time For Action
Diabetes Complications
Macrovascular
Heart Disease and Stroke
Microvascular
KidneysEyes
Feet
-
8/9/2019 Diabetes Patient Education
32/96
Canadian Diabetes Strategy: Time For Action
Macrovascular
ComplicationsThe management of macrovascular
disease is estimated to be the
largest component of diabetes-related complications costs,
accounting for 52% of the costs
REF: Caro JJ, Diabetes Care 2002 Mar;25(3):476-81
-
8/9/2019 Diabetes Patient Education
33/96
Canadian Diabetes Strategy: Time For Action,May 2003
Diabetes Complications:Macrovascular
DM is a major risk factor for cardiacdisease
Acute MI occurs 15-20 years earlierin those with DM
Heart disease accounts forapproximately 50% of all deaths
among people with diabetes inindustrialized countries
REF: Diabetes in Ontario, An ICES Practice Atlas,2002
-
8/9/2019 Diabetes Patient Education
34/96
Canadian Diabetes Strategy: Time For Action,May 2003
Several large epidemiological studieshave found a strong relationshipbetween
glucose level and subsequent coronaryevents, even at pre-diabetes levels (IGTand IFG)
glucose levels that are only modestlyelevated place patients at risk.
REF: Coutiho M. et al Diabetes Care 1999;22:233-240.
& DECODE Study Group. Arch Intern Med 2001;161:397-404.
Diabetes Complications:Macrovascular
-
8/9/2019 Diabetes Patient Education
35/96
Canadian Diabetes Strategy: Time For Action,May 2003
Diabetes Complications:Macrovascular
Relationship between FPG and CHD
REF: Coutinho et al. Diabetes Care 1999;22:233-40.
Metaregression - 20 prospective studies
n = 95,783 - follow-up 12.4 yrs
FPG > 6 mmol/L: RR 1.38 (1.06-1.67)
Fasting glucose (mmol/L)
Relative
Risk
2.5
2
1.5
1
4 5 6 7 8 9
-
8/9/2019 Diabetes Patient Education
36/96
Canadian Diabetes Strategy: Time For Action,May 2003
Men with DM
Male No DMWomen with DM
Women No DM
Diabetes Complications:Macrovascular
-
8/9/2019 Diabetes Patient Education
37/96
Canadian Diabetes Strategy: Time For Action,May 2003
Increasing Morbidity from IschaemicHeart Disease in Sandy Lake, Ontario
0
20
40
6080
100
120
IHDadmissions
per 10,000
persons
1983-1987 1988-1992 1993-1997
REF: Hanley AJG, Harris SB et al Diabetes Care 1997;20:185-187.
-
8/9/2019 Diabetes Patient Education
38/96
Canadian Diabetes Strategy: Time For Action,May 2003
Rates of Acute MI Admissions: 1980-1996Native Communities, Northern Ontario, All of Ontario
0
10
20
30
40
50
60
1980 1982 1984 1986 1988 1990 1992 1994 1996
AcuteMIsper10,0
00population
Native Communities Northern Ontario All Ontario
REF: Baiju R. Shah, Arch Intern Med V160, 2000
-
8/9/2019 Diabetes Patient Education
39/96
Canadian Diabetes Strategy: Time For Action,May 2003
98,925
158,056
228,214
0
50,000
100,000
150,000
200,000
250,000
CVDHospitalizations
1996 2006 2016
REF: Blanchard J. Unpublished
Projected Number of Cardiovascular Disease (CVD)Hospitalizations Among Persons with Diabetes, Canada
Diabetes Complications:Macrovascular
-
8/9/2019 Diabetes Patient Education
40/96
Canadian Diabetes Strategy: Time For Action
Microvascular
ComplicationsNeuropathy accounts for 17%,
retinopathy for 10%, and
nephrology 21% of the costs of DMcomplications
REF: Caro JJ, Diabetes Care 2002 Mar;25(3):476-81
-
8/9/2019 Diabetes Patient Education
41/96
Canadian Diabetes Strategy: Time For Action,May 2003
Diabetes.
Is the leading cause of non traumaticamputation
Increases the risk of amputation by 20fold
those living in the north or in low incomeneighborhoods and those with poor accessto physician services are at particular riskfor amputation.
REF: Diabetes in Ontario, An ICES Practice Atlas, 2002
Diabetes Complications:Microvascular Amputation
-
8/9/2019 Diabetes Patient Education
42/96
Canadian Diabetes Strategy: Time For Action,May 2003
First Nations
General Population
Diabetes Complications:Microvascular Amputation
-
8/9/2019 Diabetes Patient Education
43/96
Canadian Diabetes Strategy: Time For Action,May 2003
6,602
10,573
15,275
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
Amputation
1996 2006 2016
Projected Number of Lower Limb Amputations Among
Persons with Diabetes, Canada
REF: Blanchard J, Unpublished
Diabetes Complications:Microvascular - Amputation
-
8/9/2019 Diabetes Patient Education
44/96
Canadian Diabetes Strategy: Time For Action,May 2003
Diabetes
Is a leading cause of adult-onsetblindness
Prevalence of diabetic retinopathy is ~ 70% inpersons with type 1 and 40% with person withtype 2 diabetes.
REF: Diabetes in Ontario, An ICES Practice Atlas, 2002
Diabetes Complications:Microvascular Retinopathy
-
8/9/2019 Diabetes Patient Education
45/96
Canadian Diabetes Strategy: Time For Action,May 2003
Diabetes
Is the leading cause of ESRD
Increases the risk of developing ESRD
by up to 13-fold
Refs: Meltzer S, et al CMAJ 1998; 159 (8 suppl):S1-S29, &
Parchman ML, et al Medical Care 2002; 40(2):137-144.
Diabetes Complications:Microvascular - Nephropathy
-
8/9/2019 Diabetes Patient Education
46/96
Canadian Diabetes Strategy: Time For Action,May 2003
First NationsSocial Services
Subsidy
No-Subsidy
Diabetes Complications:Microvascular - Nephropathy
-
8/9/2019 Diabetes Patient Education
47/96
Canadian Diabetes Strategy: Time For Action,May 2003
REF: Blanchard J,
Unpublished.
1,574
2,494
3,533
0
500
1000
1500
2000
2500
3000
3500
4000
New
Personsw
ithDiabe
teson
Dial
1996 2006 2016
Projected Number of New Persons withDiabetes on Dialysis, Canada
Diabetes Complications:Microvascular - Nephropathy
-
8/9/2019 Diabetes Patient Education
48/96
Canadian Diabetes Strategy: Time For Action
Current Canadian Costs
The Financial Impact of
Diabetes
Cost of Diabetes:
-
8/9/2019 Diabetes Patient Education
49/96
Canadian Diabetes Strategy: Time For Action,May 2003
Cost of Diabetes:Impact of Diabetes on Health CareCosts
General Population Status Population
Diabetes No
Diabetes
Diabetes No
Diabetes
Hospital $1196 $479 $2362 $893
PCH $340 $251 $195 $156
Professional $519 $271 $606 $267
Dialysis $114 $10 $493 $43
Total $2169 $1011 $3656 $1359
REF: Blanchard J, Unpublished, 2001
Estimated Selected Direct HealthCare Costs, Manitoba 1995/96
-
8/9/2019 Diabetes Patient Education
50/96
Canadian Diabetes Strategy: Time For Action,May 2003
The total economic burden (in US dollars) of diabetes andits chronic complications in Canada for 1998 was likely tobe between $4.76 and $5.73 billion.
In those people just with diagnosed diabetes, the directmedical costs associated with diabetes care, beforeconsidering complications, were $573 million.
Of the costs associated with the complications of
diabetes, cardiovascular disease was by far the greatestat $673 million.
Cost of Diabetes:The Cost in Canada, 1998
REF: Dawson KG et al. Diabetes Care 2002 Aug;25(8):1303-7
-
8/9/2019 Diabetes Patient Education
51/96
Canadian Diabetes Strategy: Time For Action,May 2003
In 2002, the direct and indirect expenditures attributableto diabetes were estimated at $132 billion up from 1998 estimate of $92 billion
The estimated $132 billion cost likely underestimates the
true burden because it omits intangibles, such as pain and suffering, care provided by non-paid caregivers,
and several areas of health care spending where people with diabetesprobably use services at higher rates than people without diabetes (eg.dental care, optometry care, and the use of licensed dieticians).
Likely underestimating the growth of high risk populations
Cost of Diabetes:The Cost in United States, 2002
REF: ADA, Diabetes Care, V26, 3 March
2003
-
8/9/2019 Diabetes Patient Education
52/96
Canadian Diabetes Strategy: Time For Action,May 2003
$24.6* billion
ChronicComplications
$44.1* billionGeneralMedical
Conditions
$23.2* billionDiabetes Care
$40.1 billion
Indirect
*DirectCosts
REF: Diabetes Care Vol. 26, No. 3 March
2003
Total Cost$132 billion
Cost of Diabetes:The Cost in United States, 2002
Cost of Diabetes:
-
8/9/2019 Diabetes Patient Education
53/96
Canadian Diabetes Strategy: Time For Action,May 2003
Cost of Diabetes:The Cost in United States & Canada,2002 Cost projections for the United States
Annual cost, in 2002 dollars,
$132 billion, 2002
$156 billion by 2010
$192 billion by 2020 Cost projections for Canada
Cost estimates based 10% of population base
Annual cost, in 2002 dollars,
$13.2 billion, 2002
$15.6 billion by 2010
$19.2 billion by 2020
REF: Diabetes Care Vol. 26, No. 3 March
2003
C t f Di b t
-
8/9/2019 Diabetes Patient Education
54/96
Canadian Diabetes Strategy: Time For Action,May 2003
Health care system can choose to investnow to help manage it properly
OR
the alternative is to wait, AND spend.
$50,000/yr for kidney dialysis
$74,000 for the cost of a leg amputation
Etc.
REF: CDA, 2003 www.diabetes.ca
Cost of Diabetes:Pay Now or. Pay Later
-
8/9/2019 Diabetes Patient Education
55/96
-
8/9/2019 Diabetes Patient Education
56/96
Canadian Diabetes Strategy: Time For Action,May 2003
Provisions in CDS Blueprint
Primary Prevention
Prevent diabetes through reduction of modifiablerisk factors in general population
Secondary Prevention
Screening those at high-risk for diabetes
Tertiary Prevention
Upon diagnosis of diabetes, prevention ofcomplications morbidity, and mortality
REF: Diabetes Blueprint
-
8/9/2019 Diabetes Patient Education
57/96
Canadian Diabetes Strategy: Time For Action
Primary Prevention
Population Health Model
-
8/9/2019 Diabetes Patient Education
58/96
Canadian Diabetes Strategy: Time For Action,May 2003
Primary Prevention Model
Goal
Reducing modifiable risk factors for diabetes
Target
General population & high-risk groups Messages
Healthy lifestyle choices
Current Delivery Models of Primary
Prevention Population Health
Primary Care
P i P ti M d l
-
8/9/2019 Diabetes Patient Education
59/96
Canadian Diabetes Strategy: Time For Action,May 2003
REF: Health
Canada
Primary Prevention Model:Population Health National
CDS
Health Canada
NADA
P i P ti M d l
-
8/9/2019 Diabetes Patient Education
60/96
Canadian Diabetes Strategy: Time For Action,May 2003
Despite population health initiatives Obesity is increasing
Diabetes is increasing
Are these models and strategies under-funded and maximally coordinated?
Are the models and strategies effective?
Are the models and strategies evaluated?
Are these models well suited for many high-risk groups
Specific innovative models are needed
Primary Prevention Model:Population Health
-
8/9/2019 Diabetes Patient Education
61/96
Canadian Diabetes Strategy: Time For Action
Primary Prevention
Primary Care Model
Primary Prevention: Primary Care
-
8/9/2019 Diabetes Patient Education
62/96
Canadian Diabetes Strategy: Time For Action,May 2003
Primary Prevention:Primary CareModelRole of Primary Care Physician
First contact of patients with healthcare system is with family doctors
Role is
to promote healthy lifestyle
Healthy diet
Physical activity
Healthy body weight
Primary Prevention: Primary Care
-
8/9/2019 Diabetes Patient Education
63/96
Canadian Diabetes Strategy: Time For Action,May 2003
Large national sample of familyphysicians on lifestyle management 96% of FPs believe that lifestyle
interventions have a role in preventingand managing type 2 diabetes
86% believe that FPs should assesslifestyle
But.96% think lifestylecounseling and programsshould be provided by others
Primary Prevention:Primary CareModelCurrent Status
REF: Harris SB, Petrella RJ et al submitted Canadian Family Physician, 2003
-
8/9/2019 Diabetes Patient Education
64/96
Canadian Diabetes Strategy: Time For Action
Secondary Prevention
Screening Those at HighRisk
-
8/9/2019 Diabetes Patient Education
65/96
Canadian Diabetes Strategy: Time For Action,May 2003
Goal
Early identification of those withdysglycemia
Target High-risk individuals and groups
Messages
Diabetes awareness Current delivery model of secondary
prevention relies on primary care
Secondary Prevention
-
8/9/2019 Diabetes Patient Education
66/96
Secondary Prevention:
-
8/9/2019 Diabetes Patient Education
67/96
Canadian Diabetes Strategy: Time For Action,May 2003
Secondary Prevention:Challenges
Health care system focuses onacute care Preventive measures difficult to achieve
with this model Screening measures difficult to achieve
with this model
No systems to track and facilitate
preventative practices Physician shortages
Secondary Prevention:
-
8/9/2019 Diabetes Patient Education
68/96
Canadian Diabetes Strategy: Time For Action,May 2003
REF: Chan, CIHI, 2002
Secondary Prevention:Challenges
Secondary Prevention: Strategies
-
8/9/2019 Diabetes Patient Education
69/96
Canadian Diabetes Strategy: Time For Action,May 2003
Secondary Prevention: StrategiesClinical Practice Guidelines
Our strategy hasbeen to developclinical practice
guidelines to assistproviders on howto screen patientsfor diabetes
-
8/9/2019 Diabetes Patient Education
70/96
Canadian Diabetes Strategy: Time For Action
Tertiary Prevention
Diabetes Management
-
8/9/2019 Diabetes Patient Education
71/96
Canadian Diabetes Strategy: Time For Action,May 2003
Tertiary Prevention
Goals
Glucose, blood pressure, and lipidcontrol to reduce the development of
complications Complication screening for early
identification and management
Tertiary Prevention:
-
8/9/2019 Diabetes Patient Education
72/96
Canadian Diabetes Strategy: Time For Action,May 2003
Tertiary Prevention:Is it Effective?
Yes
Strong evidence for tertiary preventionparticularly for microvascular disease
DCCT, UKPDS How to translate this evidence into
practice?
Tertiary Prevention: Current Status
-
8/9/2019 Diabetes Patient Education
73/96
Canadian Diabetes Strategy: Time For Action,May 2003
Conclusions From a National Study(GPDM)
Patients are seen frequently by theirfamily physicians
Acceptable performance for
macrovascular disease complicationscreening (BP, lipids)
Major deficiencies were identified inmicrovascular disease complicationscreening (retinopathy,nephropathy, neuropathy, foot)
REF: Harris SB, et al Diabetes 2001
Tertiary Prevention: Challenges
-
8/9/2019 Diabetes Patient Education
74/96
Canadian Diabetes Strategy: Time For Action,May 2003
Tertiary Prevention: ChallengesThe Canadian Health Care System
Structure of system designed foracute care not chronic disease
Healthcare under-funding is a
barrier to diabetes care
Challenges to keep up withcomplications management
growing need for dialysis, costs formedications, hospital restructuring andphysician remuneration
Tertiary Prevention: Challenges
-
8/9/2019 Diabetes Patient Education
75/96
Canadian Diabetes Strategy: Time For Action,May 2003
Reduced funding and increaseddemand
Funding mechanism is problematic
No formal evaluation oneffectiveness
Limited flexibility in adapting to newcultural and linguistic realities inCanada
Tertiary Prevention: ChallengesHospital Based Model (DECs)
Primary Secondary Tertiary
-
8/9/2019 Diabetes Patient Education
76/96
Canadian Diabetes Strategy: Time For Action,May 2003
Primary, Secondary, TertiaryPrevention: Status
In Summary
The models and funding have notkept pace with the burden of disease
Prevalence of diabetes increasing
Recognition of new disease in IGT/IFG
Models are not adequately designed to
prevent and care for people withdiabetes
-
8/9/2019 Diabetes Patient Education
77/96
Canadian Diabetes Strategy: Time For Action
Future Policy & Program
DirectionsRecommendations
Future Directions:
-
8/9/2019 Diabetes Patient Education
78/96
Canadian Diabetes Strategy: Time For Action,May 2003
Future Directions:Wake Up Call!
We know that diabetes is a world-wide epidemic
Are we, in Canada, going tobe proactive and meet thechallenge?
or be passive and pay thecost?
Future Directions:
-
8/9/2019 Diabetes Patient Education
79/96
Canadian Diabetes Strategy: Time For Action,May 2003
We CAN act on modifiable risk factors Aging population
Immigration from high-risk populations
Growth in aboriginal population
We CAN effectively target high-riskpopulations
Obesity
Physical inactivity Calorie-dense/high-fat diet
Future Directions:Take Action!
Future Directions: Cost to Act
-
8/9/2019 Diabetes Patient Education
80/96
Canadian Diabetes Strategy: Time For Action,May 2003
Cost of diabetes in Canada 2002 $13.2 billion
2010 $15.2 billion
2020 $19.2 billion
We CAN have an impact on the costby effective implementation and
utilization at all three levels ofprevention
Future Directions: Cost to ActPay NowPay Later
-
8/9/2019 Diabetes Patient Education
81/96
Future Directions:
-
8/9/2019 Diabetes Patient Education
82/96
Canadian Diabetes Strategy: Time For Action,May 2003
Future Directions:Complexity of the Model
-
8/9/2019 Diabetes Patient Education
83/96
Canadian Diabetes Strategy: Time For Action
So
What should a CanadianDiabetes Strategy address?
What should the priorities be?
Future Directions:i l i b S ill
-
8/9/2019 Diabetes Patient Education
84/96
Canadian Diabetes Strategy: Time For Action,May 2003
1. National Diabetes SurveillanceStrategy
One of the gems of CDS to date hasbeen the establishment of NationalDiabetes Surveillance System
We need to continue and expanddata collection in other jurisdictions,
and generate quality data includingcost on an ongoing basis
Future Directions: Primary Prevention
-
8/9/2019 Diabetes Patient Education
85/96
Canadian Diabetes Strategy: Time For Action,May 2003
2. National Strategies for Prevention &Promotion
Need increased effort on a national leveltargeting the general populations and
high risk groups Boomers
Aboriginals
Other high risk immigrant groups
for modifiable risk factors Obesity
Physical inactivity
Unhealthy diets
Future Directions:
-
8/9/2019 Diabetes Patient Education
86/96
Canadian Diabetes Strategy: Time For Action,May 2003
Future Directions:3. CDS National Coordination
Continued and enhanced effort toensure effective coordination withexisting federal and provincial
health promotionNutrition
Obesity prevention
prevention programs
Future Directions:TertiaryP ti
-
8/9/2019 Diabetes Patient Education
87/96
Canadian Diabetes Strategy: Time For Action,May 2003
Prevention4. Diabetes Education Centres
Existing Diabetes Care Models need tobe formally evaluated
We need to know.
who they are serving? how long are the waiting lists?
are they effective in addressing needs ofpatients with diabetes and pre-
diabetes? are they cost effective?
are the funding schemes appropriate?
Future Directions:
-
8/9/2019 Diabetes Patient Education
88/96
Canadian Diabetes Strategy: Time For Action,May 2003
Future Directions:5. Innovative Program Fund
We need a a program to fund and evaluatenew, innovative diabetes care models
Current care models are stale and in need ofinnovation
Best practice model
Target primary and secondary preventionaccording to regional needs (i.e. Latinos in ON, Asians inBC, lower SES geographic areas)
Should support 50-100 innovative programs
Future Directions:6 T l ti f E id i t
-
8/9/2019 Diabetes Patient Education
89/96
Canadian Diabetes Strategy: Time For Action,May 2003
6. Translation of Evidence intoPractice
CDS should be supporting efforts toimplement the evidence-basedclinical practice guidelines
Work to reduce the barriers tochronic care management.
Facilitate improved data collectionat primary and tertiary care level
Implement prospective, regionalregistry for diabetes
Future Directions:
-
8/9/2019 Diabetes Patient Education
90/96
Canadian Diabetes Strategy: Time For Action,May 2003
Future Directions:7. Aboriginal Diabetes Initiative
Need to fund two corollary programs, bothon and off reserve
1) Primary Prevention
MAJOR expansion of community-baseddiabetes prevention programs needed
2) Secondary & Tertiary Prevention
Establishment of a basic clinical diabetes and
complications prevention programs
-
8/9/2019 Diabetes Patient Education
91/96
Canadian Diabetes Strategy: Time For Action
ResearchCanada has always been a
world-wide leader in
diabetes researchinnovations
From the discovery of
insulinto the Edmonton protocol
for islet transplants
Future Directions:
-
8/9/2019 Diabetes Patient Education
92/96
Canadian Diabetes Strategy: Time For Action,May 2003
8. Enhanced Research
The establishment ofNutrition,Metabolism, and Diabetes and the
Aboriginal Peoples Health Institutes
with increased funding was a majorimprovement in diabetes research.
We need to continue to expand thisfunding base
Future Directions:
-
8/9/2019 Diabetes Patient Education
93/96
Canadian Diabetes Strategy: Time For Action,May 2003
Research Priorities should include:
Pathophysiology of diabetes
Translation of evidence to practice
Health services
Prevention
Populations at risk (i.e. Aboriginal)
Canadian Diabetes Strategy 2005-2010
-
8/9/2019 Diabetes Patient Education
94/96
Canadian Diabetes Strategy: Time For Action,May 2003
2010New Component Costs for CDS ($millions)
National Diabetes Surveillance System $12 (up from $10.8)
Prevention and Promotion-National $50 (up from $41.8)
National Coordination $25 (up from $4.4)
Evaluation of Current Models $10
Innovation Funds $100
Translation $25
Aboriginal Diabetes Initiative
Primary Prevention
Clinical
$75 (up from $58)
$250
Research $50
TOTAL $597 million(Up from $115
million)
-
8/9/2019 Diabetes Patient Education
95/96
Canadian Diabetes Strategy: Time For Action
Is this a worthwhile
investment ? remember the cost of
diabetes in Canada nowand over the next 20
years.
2002 $13.2 billion
2010 $15.6 billion
2020 $19.2 billion
-
8/9/2019 Diabetes Patient Education
96/96
$600 million for the
Canadian DiabetesStrategy
less than 4% of whatthis disease will cost us
by 2010