Original ResearchType 2 Diabetes Mellitus Management in Canada: Is It Improving?
Introduction
Clinical practice guidelines (CPGs) from professional organizations around the world collectively advocate that patients with type 2 diabetes mellitus should have their risk factors managed in an aggressive and timely manner 1, 2, 3, 4, 5. These recommendations are largely based on seminal type 2 diabetes-focused trials demonstrating significant improvements in vascular complications and reduced mortality through comprehensive and multifactorial behavioural modification and pharmacotherapy strategies 6, 7. However, despite concerted and widespread efforts to translate these evidence-based recommendations into routine clinical practice as well as increasing pharmacologic options, practice reviews conducted in different countries and settings continually indicate that optimal management of type 2 diabetes patients remains challenging 8, 9, 10, 11, 12, 13, 14, 15.
Based on data collected between September 2002 and February 2003, the Diabetes in Canada Evaluation (DICE) Study determined that 51% of patients were successful at achieving a glycated hemoglobin (A1C) of <7.0% (10). The Diabetes Registry to Improve Vascular Events (DRIVE) study, using data collected between March 2005 and March 2006, revealed that 53% of the study population had an A1C of ≤7.0% (8) leading the investigators to postulate that the 2003 Canadian Diabetes Association (CDA) CPGs (3) had minimal impact on glycemic control in Canada up to that point.
In anticipation of the publication of the 2013 CDA CPGs in early 2013, the national cross-sectional Diabetes Mellitus Status in Canada (DM-SCAN) survey was undertaken to gain insight into the current management of type 2 diabetes patients in the Canadian primary care setting. A secondary goal was to identify management gaps that may provide directional input on how best to effectively design strategies aimed at improving the care of these patients.
Section snippets
Methods
From September to December 2012, standard letters from the DM-SCAN Steering Committee were sent to primary care physicians across Canada inviting them to participate in the DM-SCAN survey. The invitation was distributed through e-mail and facsimiles by the Canadian Heart Research Centre (CHRC) to lists of Canadian primary care physicians, participants in prior or ongoing registries within the CHRC, through standard hard copy invitations distributed by the CDA at its annual professional session
Physicians and their practices
A total of 479 physicians (equivalent to a 65% participation rate of the 738 who completed the initial audit form) representing all 10 Canadian provinces completed 5123 data collection forms (54% online, 46% fax-based submission) (Table 1). Fifty-nine percent of physicians were in a group practice (≥2 physicians), 41% had a single-physician practice and 50% were part of a family health team. Practices were located in inner city (16%), urban/suburban (63%) or small town/rural (21%) settings.
Discussion
The results of this large, national, cross-sectional observational survey suggest that still only 50% of Canadian type 2 diabetes patients met the 2008 CDA CPGs recommended A1C target of ≤7.0% (3). Additionally, just over 50% were successful at reaching the LDL-C ≤2.0 mmol/L goal recommended by the 2008 CDA CPGs (3) and the 2009 Canadian Lipid CPGs (17) and only a third the 2008 CDA and 2012 Canadian Hypertension Education Program recommended target BP of <130/80 mm Hg 3, 18. Finally, it is
Conclusions
Despite widespread attempts at dissemination and implementation of practice CPGs, and advances in type 2 diabetes pharmacotherapy, the results of the DM-SCAN survey accentuate the persistent treatment gap associated with the treatment of type 2 diabetes. This survey also highlights the continual challenges faced by primary care physicians to gain and maintain glycemic control as well as achieve global vascular protection in type 2 diabetes patients. Practical strategies aimed at more
Acknowledgments
The Diabetes Mellitus Status in Canada (DM-SCAN) survey was made possible through the support of Merck Canada Inc. The opinions expressed in this material are those of the authors and do not necessarily reflect the views of Merck Canada Inc.
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