Insights (Essays)

Insights (Essays) December 2020

Comprehensive Care and Prevention of Diabetes in Ontario: The Need of the Hour

Harpreet Bajaj, Kimberley Hanson, David Kaplan, Terrence Sullivan and Catharine Whiteside

Diabetes 

As the COVID-19 pandemic forges through the globe, clear evidence points to worse outcomes experienced by persons with chronic conditions. Coupled with susceptibility to infection and commonly associated risk factors such as hypertension, cardiovascular disease, and obesity, diabetes carries at least twice the risk of severe disease or death related to COVID-19 (Apicella et al. 2020). Diabetes is a key health inequality indicator in Canada. Those at the greatest risk for adverse health outcomes are disproportionately represented by persons living in poverty, isolated older adults, Indigenous peoples, refugees and new immigrants and especially women in these groups (Public Health Agency of Canada 2018). The highest risk for infection with COVID-19 follows the same pattern in Canada and across the globe (Chan et al. 2020; Government of Canada 2020).

Diabetes or pre-diabetes affects one in three Canadians and is on the rise. Prior to COVID-19, prevention of diabetes (type 2) and its related complications (for both type 1 and type 2 diabetes) were already among our most pressing unmet public health challenges. Diabetes is the most common cause of preventable blindness in working-aged Canadians, kidney failure requiring dialysis and lower limb amputations caused by diabetic foot ulcers and peripheral vascular disease. Once a person has diabetes, outcomes worsen for any coincident chronic condition, including cancer and mental health conditions (Diabetes Canada 2018).

Fortunately, several health data and technology-enabling tools are available to create new effective models of care. The opportunity to build on adopting and adapting virtual care for persons with chronic conditions during the pandemic has already accelerated implementation of Ontario’s Digital First for Health strategy (Hein n.d.). The focus on integrating community-based and acute care by Ontario Health Teams has led to the creation of a framework for designing solutions toward improved quality outcomes and reduced cost for the management of complex chronic conditions (Government of Ontario n.d.)

The Diabetes 360 National Strategy created by Diabetes Canada is a comprehensive framework for the prevention and management of diabetes but it can be applied to all chronic conditions. It describes achieving the following 90/90/90/90 targets for all Canadians:  90% living in an environment that prevents the development of diabetes; 90% aware of their diabetes status; 90% achieving improved health outcomes; and 90% engaged in preventing their diabetes-related complications (Diabetes Canada 2018).

Preventing Type 2 Diabetes as a High Priority Public Health and Societal Goal

The prevalence of type 2 diabetes is rising in Canada in every age group. This tide can only be turned by effectively influencing lifestyle at the earliest age and sustaining these measures throughout one’s lifespan. Combined efforts from public health, community and primary care and specialist services along with policy decision-makers are necessary to achieve this. Examples include access to a safe neighbourhood for physical activity, food security, local social services support and tax on sugar-laden foods. Health education and health coaching for individuals at a high risk of developing diabetes are essential (Wayne et al. 2015). A good example of such a comprehensive approach is the Canadian Diabetes Prevention Program – a 12-month digital coaching program that empowers persons with pre-diabetes, or otherwise at high risk of developing diabetes, to engage successfully in a healthier lifestyle to prevent type 2 diabetes (Canadian Diabetes Prevention Program 2020).

Identify High-Risk Persons with Diabetes and Complex Chronic Conditions

To align current health and social services with the needs of individuals at the highest risk of poor health outcomes, Ontario Health Teams must be provided with the necessary digital health tools and ability to share health information. Moreover, they need change management support to properly implement these tools to drive improvement (Chan et al. 2020). By linking primary care electronic medical records and provincial administrative data, persons with diabetes and multiple chronic conditions in regions across Ontario can be identified. Those regions, served by Community Health Centres and Aboriginal Health Centres that assist a disproportionate number of high-needs populations, should be prioritized for access to these digital health tools and services. The tracking of quality indicators and health outcomes that matter most to persons with chronic conditions should be used as a measure of successful patient-centered care and prevention.

Establish Data-Informed Virtual Collaborative Care Services

Building on the concept of the effective Smoking Treatment for Ontario Patients (STOP) program at the Centre for Addiction and Mental Health, a model of managed collaborative virtual diabetes care could be established within each Ontario Health Team (Selby et al. 2018). Central to this model is a care manager who evaluates the complex needs of patients and directly connects them to members of a virtual healthcare team of multiple practitioners (e.g., registered dietitian, pharmacist, diabetologist) for timely diagnosis and intervention. The care manager also acts as a health coach and communicates with the local primary care provider and necessary social services. Re-organizing and standardizing regional diabetes education and care would enable re-alignment and better utilization of current resources to establish this comprehensive virtual model.

Develop Effective Care Paths to Prevent Diabetes-Related Lower Limb Amputations

Prior to COVID-19, a lower limb amputation occurred every four hours in Ontario mainly due to poorly managed diabetic foot ulcers and peripheral vascular disease. This amputation rate has increased over the past decade because of the rising prevalence of diabetes in an aging population (Hussain et al. 2019). The lack of timely intervention for these conditions during COVID-19 is increasing the risk of lower limb amputations, particularly for the most vulnerable. Establishing effective care pathways for early diagnosis and intervention for persons at a high risk of developing diabetic foot ulcers is overdue. A bundled care solution could include the following: funded community chiropody/podiatry preventative services; standardized wound home care; education of primary care practitioners; and expert care managers tracking the most vulnerable to provide timely referrals to collaborative specialist services, such as vascular surgery. Based on data from countries that have successfully instituted effective prevention and early treatment of diabetic foot ulcers, the cost savings to Ontario would be a least $500million per year (Diabetes Canada n.d.; Rasmussen 2016).

Conclusion

Given the major burden of disease that diabetes and its complications are having on our society and our healthcare system, particularly during the COVID-19 pandemic, and the significant opportunities for reducing that burden as described above, the time for implementing a systematic approach to diabetes – such as is provided by Diabetes 360° – is now.

About the Author(s)

Harpreet Bajaj, MD, MPH, ECNU, FACE, is an endocrinologist and the director of Late-Phase Research, LMC Healthcare in Toronto, ON.

Kimberley Hanson, BA MBA, is the executive director, Federal Affairs at Diabetes Canada in Toronto, ON.

David Kaplan, MD, MSc, CCFP, FCCP, is an associate professor in Family and Community Medicine at the University of Toronto in Toronto, ON.

Terrence Sullivan, PhD, is a part-time professor and senior fellow at IHPME in the University of Toronto, Toronto, ON.

Catharine Whiteside, CM, MD PhD FRCPC, is an emeritus professor and former dean of the Faculty of Medicine at the University of Toronto in Toronto, ON.

References

Apicella M., M.C. Campopiano, M. Mantuano, L. Mazoni, A. Coppelli and S.D. Prato.. 2020. COVID-19 in People with Diabetes: Understanding the Reasons for Worse Outcomes. The Lancet Diabetes & Endocrinology 8(9); 782–92. doi: 10.1016/S2213-8587(20)30238-2.

Canadian Diabetes Prevention Program. 2020. A Healthier Life Starts Here. Retrieved December 10, 2020. <https://www.lmc.ca/diabetes-prevention/>.

Chan, J.C.N., Lim L.-L., N. J. Wareham, J. E. Shaw, T. J. Orchard, P. Zhang et al. 2020. The Lancet Commission on Diabetes: Using Data to Transform Diabetes Care and Patient Lives. The Lancet. doi: 10.1016/S0140-6736(20)32374-6.

Diabetes Canada. 2018, July. Diabetes 360o: A Framework for a Diabetes Strategy for Canada. Recommendations for Governments.  Retrieved December 10, 2020. <https://diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Diabetes-360-Recommendations.pdf>.

Diabetes Canada. n.d. The Economic Impact of Offloading Devices for the Prevention of Amputations in Ontario. Retrieved December 10, 2020. <https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Advocacy%20Reports/Economic-Impact-of-Offloading-Devices-on-DFU-Costs-in-Ontario_FINAL.pdf>.

Government of Ontario. n.d. Ontario Health Teams: Guidance for Health Care Providers and Organizations. Retrieved December 10, 2020. <http://health.gov.on.ca/en/pro/programs/connectedcare/oht/docs/guidance_doc_en.pdf>.

Government of Canada. October 2020. From Risk to Resilience: An Equity Approach to COVID-19. The Chief Public Health Office of Canada’s Report on the State of Public Health in Canada 2020. Retrieved December 10, 2020 <https://www.canada.ca/content/dam/phac-aspc/documents/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/from-risk-resilience-equity-approach-covid-19/cpho-covid-report-eng.pdf> .

Hein, G. n.d. Digital First for Health. Ontario Ministry of Health. Retrieved December 17, 2020. <https://www.ontariomd.ca/documents/events%20info/esc-toronto-2019-presentations/digital%20first%20for%20health.pdf>.

Hussain M.A., M. Al-Omran, K. Salata, A. Sivaswamy, T.L. Forbes, N. Sattar et al. 2019. Population-Based Secular Trends in Low- Extremity Amputation for Diabetes and Peripheral Artery Disease.CMAJ 191(35): e955–61. doi: 10.1503/cmaj.190134. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/science-research/key-health-inequalities-canada-national-portrait-executive-summary/key_health_inequalities_full_report-eng.pdf>.

Rasmussen B.S.B., K.B. Yderstraede, B. Carstensen, O. Skov, H. H. Beck-Nielsen. 2016. Substantial Reduction in the Number of Amputations Among Patients with Diabetes: A Cohort Study Over 16 Years. Diabetologia 59(1): 121–29. doi: 10.1007/s00125-015-3781-7.

Selby P., S. Voci, L. Zawertailo, D. Baliunas, R. Dragonetter and S. Hussain.2018. Public Health Impact of a Novel Smoking Cessation Outreach Program in Ontario, Canada. BMC Public Health18(1117). doi: 10.1186/s12889-018-6012-6.

Wayne N., D. F. Perez, D. M. Kaplan and P. Ritvo. 2015. Health Coaching Reduces HbA1c in Type 2 Diabetic Patients from Lower-Socioeconomic Status Community: A Randomized Controlled Trial2015. Journal of Medical Internet Research17(10): e224. doi: 10.2196/jmir.4871.  

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