Type 2 Diabetes Mellitus Management in Canada: Is It Improving?

doi:10.1016/j.jcjd.2013.02.055

Canadian Journal of Diabetes

Volume 37, Issue 2, April 2013, Pages 82-89

https://doi.org/10.1016/j.jcjd.2013.02.055 Get rights and content

Abstract

Objective

To gain insight into the current management of patients with type 2 diabetes mellitus by Canadian primary care physicians.

Method

A total of 479 primary care physicians from across Canada submitted data on 5123 type 2 diabetes patients whom they had seen on a single day on or around World Diabetes Day, November 14, 2012.

Results

Mean glycated hemoglobin (A1C) was 7.4%, low-density lipoprotein (LDL-C) was 2.1 mmol/L and blood pressure (BP) was 128/75 mm Hg. A1C ≤7.0% was met by 50%, LDL-C ≤2.0 mmol/L by 57%, BP <130/80 mm Hg by 36% and the composite triple target by 13% of patients. Diet counselling had been offered to 38% of patients. Of the 87% prescribed antihyperglycemic agents, 18% were on 1 non-insulin antihyperglycemic agent (NIAHA) (85% of which was metformin), 15% were on 2 NIAHAs, 6% were on ≥3 NIAHAs, 19% were on insulin only and 42% were on insulin + ≥1 NIAHA(s). Amongst the 81% prescribed lipid-lowering therapy, 88% were on monotherapy (97% of which was a statin). Among the 83% prescribed antihypertensive agents, 39%, 34%, 21% and 6% received 1, 2, 3 and >3 drugs, respectively, with 59% prescribed angiotensin-converting enzyme inhibitors and 35% angiotensin II receptor blockers.

Conclusions

The Diabetes Mellitus Status in Canada survey highlights the persistent treatment gap associated with the treatment of type 2 diabetes and the challenges faced by primary care physicians to gain glycemic control and global vascular protection in these patients. It also reveals a higher use of insulin therapy in primary care practices relative to previous surveys. Practical strategies aimed at more effectively managing type 2 diabetes patients are urgently needed.

Résumé

Objectif

Obtenir un aperçu de la prise en charge actuelle des patients ayant le diabète sucré de type 2 par les médecins canadiens de premiers recours.

Méthodes

Un total e 479 médecins de premier recours de l'ensemble du Canada ont soumis des données sur 5123 patients ayant le diabète de type 2 chez qui ils ont observé durant une seule journée lors ou autour de la journée mondiale du diabète, le 14 novembre 2012.

Résultats

L'hémoglobine glyquée moyenne (HbA1c) a été de 7,4 %, le cholestérol à lipoprotéines de basse densité (C-LDL) de 2,1 mmol/L et la pression artérielle (PA) à 128/75 mm Hg. Une HbA1c ≤ 7,0 % a été obtenue chez 50 % des patients, un C-LDL ≤ 2,0 mmol/L chez 57 %, une PA < 130/80 mm Hg chez 36 % et un critère composite triple chez 13 %. Le counseling en diététique a été offert à 38 % des patients. Parmi les 87 % prenant des agents antihyperglycémiques, 18 % ont pris 1 agent antihyperglycémique non insulinique (AAHNI; dont 85 % ont pris la metformine), 15 % ont pris 2 AAHNI, 6 % ont pris ≥ 3 AAHNI, 19 % ont seulement pris de l'insuline et 42 % ont pris de l'insuline et ≥ 1 AAHNI. Parmi les 81 % qui suivaient un traitement hypolipidémiant, 88 % ont suivi une monothérapie (dont 97 % ont pris une statine). Parmi les 83 % qui prenaient des agents antihypertensifs, 39 %, 34 %, 21 % et 6 % ont reçu respectivement 1, 2, 3 et > 3 médicaments, dont 59 % ont pris des inhibiteurs de l'enzyme de conversion de l'angiotensine et 35 % des antagonistes des récepteurs de l'angiotensine II.

Conclusions

L'enquête canadienne sur le statut du diabète sucré souligne les lacunes persistantes en matière de traitement associées au traitement du diabète de type 2 et les défis à relever par les médecins de premier recours pour obtenir une maîtrise de la glycémie et une protection vasculaire globale chez ces patients. Cela révèle également une plus grande utilisation de l'insulinothérapie dans les centres de soins primaires qui concernent les enquêtes précédentes. Des stratégies pratiques dont le but est une prise en charge plus efficace des patients ayant le diabète de type 2 s'imposent de manière urgente.

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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Cardiovascular disease (CVD) is a major cause of morbidity and mortality in people with type 1 diabetes (PWT1D). We assessed cardiovascular risk factors and pharmacologic treatment in a large Canadian cohort of PWT1D.
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Most PWT1D received recommended pharmacologic cardiovascular protection, but specific subgroups required special attention. Target achievement for key risk factors remains suboptimal.
Les maladies cardiovasculaires (MCV) sont la principale cause de morbidité et de mortalité chez les personnes atteintes du diabète de type 1 (PDT1). Nous avons évalué les facteurs de risque des MCV et le traitement pharmacologique au sein d’une vaste cohorte canadienne de PDT1.
La présente étude transversale reposait sur les données de PDT1 adultes du registre BETTER (n = 974). Les participants auto-déclaraient par questionnaire en ligne les facteurs de risque des MCV, les complications liées au diabète et les traitements (qui servaient d’indicateurs de la pression artérielle et de la dyslipidémie). Des données objectives étaient disponibles pour un sous-groupe de PDT1 (23 %, n = 224).
Les participants étaient des adultes (43,9 ± 14,8 ans) qui avaient le diabète depuis 23,3 ± 15,2 ans; 34,8 % déclaraient une hémoglobine glyquée (A1c) ≤ 7 %, 67,2 % déclaraient un risque de maladies cardiovasculaires très élevé, et 27,2 % déclaraient au moins 3 facteurs de risque des MCV. La plupart des participants recevaient le traitement pharmacologique recommandé (score médian de 75,0 %) pour une MCV conformément aux lignes directrices de pratique clinique de Diabète Canada (LDPC-DC). Toutefois, les 3 sous-groupes qui avaient une plus faible adhésion aux LDPC-DC (< 70 %) étaient les suivants : les participants (1) qui avaient des complications microvasculaires et qui recevaient un traitement par statines (60,8 %, n = 208/342) ou un traitement néphroprotecteur (axe rénine-angiotensine) (52,6 %, n = 180/342); (2) qui étaient âgés de ≥ 40 ans et qui recevaient un traitement par statines (67,1 %, n = 369/550); (3) qui étaient âgés de ≥ 30 ans, avaient le diabète depuis ≥ 15 ans et recevaient un traitement par statines (58,9 %, n = 344/584). Dans le sous-groupe de participants qui avaient des résultats de laboratoire récents, seule 24.5% de PDT1 (n = 26/106) avait atteint les valeurs cibles de l’A1c et du cholestérol à lipoprotéines de faible densité.
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Participants aged 18–79 years, devoid of CVD but treated with antihypertensive and/or lipid-lowering and/or antidiabetic therapy were interviewed >6 months and <2 years after medication initiation. Information regarding dietary management was collected by questionnaire.
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Although national diabetes guidelines recommend targets for various health parameters, studies have demonstrated a gap between recommendations and real-life practice. The objectives of the present study were to 1) assess measurements in type 2 diabetes (T2DM) care performed by diabetologists in tertiary care, 2) determine whether these measurements were within recommended targets by Canadian guidelines, and 3) identify how these measurements compare with previously published Canadian studies.
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The percentages of patients with recent screening of A1C, LDL-C, blood pressure and uACR were higher compared with the earlier studies. The calculated means for A1C, LDL-C and blood pressure were comparable with those studies. The percentage of measurements achieving target was comparable with subspecialty care data but differed from primary care data.
Patients with T2DM at the MUHC receive guideline-based measurements of health parameters more frequently than at other institutions. Achievement of target values was closer to that seen by Canadian specialists than by primary care. Although further analyses are necessary to help implement effective strategies for improvement, quality assurance is nonetheless an essential part of ensuring the standards of tertiary care.
Bien que les lignes directrices nationales sur le diabète fournissent des recommandations sur les valeurs cibles des divers paramètres de santé, des études ont démontré un écart entre les recommandations et la pratique réelle. Les objectifs de la présente étude visaient à : 1) évaluer les mesures de soins liés au diabète de type 2 (DT2) réalisées par les diabétologues en soins tertiaires; 2) déterminer si ces mesures se trouvaient dans les valeurs cibles recommandées; 3) préciser de quelle façon ces mesures sont comparables aux études canadiennes publiées antérieurement.
Une revue rétrospective de dossiers a permis d’analyser les dossiers médicaux électroniques des patients vus par des spécialistes en diabète au Centre universitaire de santé McGill (CUSM). Les patients qui avaient de 18 à 75 ans et un diagnostic de DT2 ont été évalués pour savoir s’ils avaient une pression artérielle < 130/80 mmHg, un cholestérol à lipoprotéines de faible densité (cholestérol LDL) ≤ 2 mmol/L et une hémoglobine glyquée (A1c) ≤ 7 %. Le rapport albumine/créatinine urinaire (RACu) a aussi été évalué. Des comparaisons ont été faites avec les données de la littérature existante.
Les pourcentages de patients qui avaient récemment eu un dépistage de l’A1c, du cholestérol LDL, de la pression artérielle et du RACu étaient plus élevés que les pourcentages des études précédentes. Les moyennes calculées de l’A1c, du cholestérol LDL et de la pression artérielle étaient comparables aux moyennes de ces études. Le pourcentage des mesures atteignant les valeurs cibles était comparable aux données des soins de sous-spécialités, mais différait des données des soins primaires.
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A Cross-sectional Survey to Assess Reasons for Therapeutic Inertia in People With Type 2 Diabetes Mellitus and Preferred Strategies to Overcome It From the Perspectives of Persons With Diabetes and General/Family Practitioners: Results From the MOTION Study
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Although multiple causes of therapeutic inertia in type 2 diabetes mellitus (T2DM) have been identified, few studies have addressed the behavioural aspects of treatment-intensification decisions among persons with type 2 diabetes (PwT2DM) and general practitioners/family practitioners (GPFPs).
A quantitative online survey was developed to capture from 300 PwT2DM and 100 GPFPs the following information: 1) perspectives on shared decision-making (SDM) related to treatment intensification, using the 9-item Shared Decision Making Questionnaire and the Shared Decision Making Questionnaire---physician version; 2) intentions to intensify treatments, using the Theory of Planned Behaviour (TPB); and 3) preferred strategies to overcome causes of therapeutic inertia in T2DM. Regression methods were applied post hoc to examine correlations with SDM scores, behavioural intentions and behaviours.
SDM scores showed a significantly lower level of perceived involvement in decision-making related to treatment intensification among PwT2DM compared with GPFPs. The TPB identified that, for PwT2DM, attitudes, perceived behavioural control and age were associated with variation in intention to intensify treatment and, for GPFPs, perceived behavioural control and not being in a shared/group practice were associated with intentions to intensify treatment. PwT2DM behaviour, measured as hesitancy to intensify treatment, was associated with age. PwT2DM want more information to become more comfortable with the treatment decision-making process, whereas GPFPs desired support from other health professionals, and more time to address issues among PwT2DM.
Strategies directed at providing GPFPs with tools/approaches to increase PwT2DM involvement in the decision-making process, such as behavioural coaching, decision aids and goal setting, may increase acceptance of treatment intensification, leading to a reduction in therapeutic inertia in T2DM.
Bien que plusieurs causes de l’inertie thérapeutique dans la prise en charge du diabète sucré de type 2 (DST2) aient été cernées, peu d’études ont porté sur les aspects comportementaux des décisions relatives à l’intensification du traitement des personnes atteintes du diabète sucré de type 2 (PDST2) et des médecins généralistes/médecins de famille (MGMF).
Nous avons élaboré une enquête quantitative en ligne auprès de 300 PDST2 et de 100 MGMF pour recueillir les informations suivantes : 1) les points de vue sur la prise de décision partagée relative à l’intensification du traitement à l’aide du questionnaire sur la prise de décision partagée à 9 questions (SDM-Q-9, de l’anglais 9-item Shared Decision Making Questionnaire et du questionnaire sur la prise de décision partagée — version médecin; 2) les intentions en matière d’intensification du traitement à l’aide de la théorie du comportement planifié (TCP); 3) les stratégies privilégiées pour surmonter les causes de l’inertie thérapeutique dans la prise en charge du DST2. Nous avons ensuite appliqué les méthodes de régression pour examiner les corrélations entre les scores au SDM-Q-9, les intentions comportementales et les comportements.
Les scores au SDM-Q-9 ont montré un degré de participation perçue significativement plus faible dans la prise de décision relative à l’intensification du traitement des PDST2 par rapport aux MGMF. La TCP a permis de déterminer que pour les PDST2 les attitudes, la maîtrise comportementale perçue et l’âge étaient associés à la variabilité des intentions en matière d’intensification du traitement et que pour les MGMF la maîtrise comportementale perçue et le fait de ne pas être en cabinet partagé/de groupe étaient associés aux intentions en matière d’intensification du traitement. Le comportement des PDST2, qui a été évalué en fonction de l’hésitation à intensifier le traitement, était associé à l’âge. Les PDST2 voulaient plus d’informations pour se sentir plus à l’aise dans le processus de prise de décision du traitement, alors que les MGMF souhaitaient obtenir l’aide d’autres professionnels de la santé, et avoir plus de temps pour répondre aux préoccupations des PDST2.
Les stratégies qui visaient à fournir aux MGMF les outils/approches pour accroître la participation des PDST2 dans le processus de prise de décision tels que le coaching comportemental, l’aide à la décision et la détermination des objectifs, peut accroître l’acceptation de l’intensification du traitement et ainsi permettre de diminuer l’inertie thérapeutique dans la prise en charge du DST2.
Family Physician Clinical Inertia in Managing Hypoglycemia
2022, Primary Care Diabetes
Clinical inertia behaviour affects family physicians managing chronic disease such as diabetes. Literature addressing clinical inertia in the management of hypoglycemia is scarce. The objectives of this study were to create a measurement for physician clinical inertia in managing hypoglycemia (ClinInert_InHypoDM), and to determine physicians’ characteristics associated with clinical inertia.
The study was a secondary analysis of data provided by family physicians from the InHypo-DM Study, applying exploratory factor analysis. Principal axis factoring with an Oblimin rotation was employed to detect underlying factors associated with physician behaviors. Multiple linear regression was used to determine association between the ClinInert_InHypoDM scores and physician characteristics.
Factor analysis identified a statistically sound 12-item one-factor scale for clinical inertia behavior. No statistically significant differences in clinical inertia score for the studied independent variables were found.
This study provides a scale for assessing clinical inertia in the management of hypoglycemia. Further testing this scale in other family physician populations will provide deeper understanding about the characteristics and factors that influence clinical inertia. The knowledge derived from better understanding clinical inertia in primary care has potential to improve outcomes for patients with diabetes.

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Original ResearchType 2 Diabetes Mellitus Management in Canada: Is It Improving?

Abstract

Objective

Method

Results

Conclusions

Résumé

Objectif

Méthodes

Résultats

Conclusions

Introduction

Section snippets

Methods

Physicians and their practices

Discussion

Conclusions

Acknowledgments

Endocr Pract

Diabetes Res Clin Pract

Am J Med

Clin Ther

Clin Ther

Can J Cardiol

Can J Cardiol

Can J Cardiol

Can J Cardiol

Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

Diabetologia

Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in canada

Can J Diabetes

Ten-year follow-up of intensive glucose control in type 2 diabetes

N Engl J Med

Original Research
Type 2 Diabetes Mellitus Management in Canada: Is It Improving?