Diabetes In Canada Evaluation (The DICE Study): Impact on Family Practice Stewart B. Harris MD MPH FCFP FACPM Associate Professor Centre for Studies in Family Medicine Ian McWhinney Chair of Family Medicine Studies Schulich School of Medicine and Dentistry University of Western Ontario London, Ontario
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D iabetes I n C anada Evaluation (The DICE Study): Impact on Family Practice Stewart B. Harris MD MPH FCFP FACPM Associate Professor Centre for Studies.
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Diabetes In Canada Evaluation (The DICE Study):
Impact on Family Practice
Stewart B. Harris MD MPH FCFP FACPM
Associate Professor
Centre for Studies in Family Medicine
Ian McWhinney Chair of Family Medicine Studies
Schulich School of Medicine and Dentistry
University of Western Ontario
London, Ontario
Overview
• What is diabetes?• Epidemiology of diabetes• Revisiting the CDA guidelines• How are FPs doing?• Review of the DICE study findings
What Is Diabetes?
Type 1 diabetes (5-10%)• Body’s own immune system attacks the cells in the
pancreas that produce insulin
Type 2 diabetes (90 - 95%)The pancreas does not produce enough insulin and/or the
bodies’ tissues do not respond properly to the actions of insulin
• Caused by both genetic and environmental factors
Gestational diabetes• Diabetes with first onset or recognition during pregnancy• Puts women at higher risk for type 2 DM later in life
What Diabetes is NOT
• Diabetes is NOT “a touch of sugar”• It is a serious chronic disease that can
lead to complications such as heart attack, stroke, blindness, amputation, kidney disease, sexual dysfunction, and nerve damage
The Complications of Diabetes
Macrovascular Microvascular
Stroke
Heart disease and hypertension
Ulcers and amputation
Diabetic eye disease(retinopathy and cataracts)
Renal disease (Kidney)
Neuropathy
Foot problems
Peripheral vascular disease
Diabetes Complications
Diabetes = CVD
Up to 80% of adults with diabetes will die of cardiovascular disease.
Adapted from Barrett-Connor 2001.
Cardiovascular Disease
• Diabetes is a major risk factor for heart disease and stroke
• Acute MI (heart attack) occurs 15 to 20 years earlier in people with diabetes
• 80% of people with diabetes will die from cardiovascular disease
Diabetes in Ontario, An ICES Practice Atlas, 2002
• Diabetes is the leading cause of non- traumatic amputation
• Increases the risk of amputation by 20 fold
Diabetes in Ontario, An ICES Practice Atlas, 2002
Amputation
Macrovascular Microvascular
Stroke
Heart disease and hypertension
Ulcers and amputation
Diabetic eye disease(retinopathy and cataracts)
Renal disease (Kidney)
Neuropathy
Foot problems
Peripheral vascular disease
Diabetes Complications
• Diabetes is the leading cause of adult-onset blindness
• Prevalence of diabetic retinopathy:– 70% in people with type 1 diabetes– 40% with person with type 2 diabetes
• Increased risk of macular edema, cataracts, glaucoma
Diabetes in Ontario, An ICES Practice Atlas, 2002
Retinopathy
• Diabetes is the leading cause of kidney failure (end-stage renal disease)
• Increases the risk of developing ESRD by up to 13-fold
• Potent predictor of CVD
Parchman ML, et al Medical Care 2002; 40(2):137-144
Nephropathy
• Skin infections• Digestive problems• Thyroid problems (hypothyroidism)• Sexual dysfunction in men (50-70% of all
male diabetes patients suffer from erectile dysfunction)
• Urinary tract and vaginal infections• Carpal tunnel syndrome
Diabetes Complications:Other Problems
CDA, 2003 www.diabetes.ca
The Scope of the Problem
World-wide and Canada
The Worldwide Epidemic:Diabetes Trends
30
135177
221
300
370
0
50
100
150
200
250
300
350
400
Millions with Diabetes
1985 1995 2000 2010 2025 2030
www.who.intwww.idfZimmet P. et al Nature: 414, 13 Dec 2001
UKPDS Demonstrated Loss of Glycemic Control With All agents Studied
UKPDS Demonstrated Loss of Glycemic Control With All agents Studied
UK Prospective Diabetes Study Group. UKPDS 34. Lancet 1998; 352:854–865.
Overweight patientsCohort, median values
Treatment Paradigm
• Target euglycemia as early as possible (within 6-12 months)
• Tailor an individual regimen for each patient
• Consider initial combination therapy, especially with marked hyperglycemia (A1C >9%)
• Early and appropriate use of insulin
Polypharmacy
A reality in modern diabetes management
Diabetes Medications
In order to reach A1C, BP and lipid targets, people with diabetes typically require many medications:
• To lower blood glucose: 1-3 pills and/or insulin• To lower cholesterol: 1 or 2 pills• To lower blood pressure: 2 or 3 pills• For general vascular protection: aspirin
Adherence to complex drug regimens can be a challenge for patients.
A solution to help improve adherence…
The Pill Burger
Who is Providing DM Care?
18%
74%
1%
7%
Family MD +specialistFamily MD alone
Specialist alone
No DM care
Hux JE et al. Diabetes in Ontario, an ICES Practice Atlas, 2003
DICE: Diabetes in Canada Evaluation
DICE Study Overview• The objective of the DICE study was to examine the
management and control of type 2 diabetes in Canada.
• A national, cross-sectional patient chart audit:– Each physician asked to complete short 2-page diary
for each of their next 10 patients with type 2 diabetes.– September 2002 to January 2003
• Investigator-directed research project – Dr. Stewart Harris, University of Western Ontario,– Dr. Jean-Marie Ekoé, University of Montreal
• 243 primary-care physicians completed the entire study and contributed 2,473 patient diaries
Contact with the Healthcare System in the Past Year
Total
Mean visits to Family Practice clinic (n = 2145)
8.2
Mean visits to clinic for diabetes-related issues (n = 2136)
4.3
Percentage hospitalized or visited ER for diabetes-related complications (n = 1,944)
8%
Patients averaged eight FP visits in the past year and half of visits were for diabetes-related issues.
Glycemic Control in CanadaOne in two type 2 diabetes patients in Canada are not
at target (< 7%). Mean A1C = 7.3%
Controlled A1c
51%
Uncontrolled A1c
49%
Most recent A1C test results (n = 2,337)
Glycemic Control Over Duration of Disease
Control erodes the longer patients have type 2 diabetesand only 38% of patients who have had diabetes for 15+years are well controlled.