Session #2

Why Are We Here? The Diabetes Epidemic Stewart B. Harris, MD MPH FCFP FACPM Sonja Reichert, MD MSc FCFP FACPM Betty Harvey, RNEC BScN MScN

Overview • Examine current and projected estimates of diabetes prevalence • Describe factors associated with diabetes prevalence • Discuss the clinical gaps (e.g. care gaps) • Discuss why primary care is “Ground Zero” for diabetes prevention and management

Diabetes in Canada

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Some Canadian statistics Prevalence (2008/09) ~2.4 million people (6.8% of the population)

Incidence (2008/09) ~203,018 people were diagnosed

Mortality (2009) 6th leading cause of death Public Health Agency of Canada. Diabetes in Canada: Facts and Figures from a Public Health Perspective. Ottawa, ON: 2011. Statistics Canada. Leading causes of death in Canada, 2009

Increase in prevalence of diagnosed diabetes • After adjusting for differences in age distributions among the provinces between 1998/99 and 2008/09, the prevalence of diabetes: – increased by 70% – was higher in men than women – increased in every age category

• The prevalence of diabetes in Canada is expected to increase to 3.7 million by 2018/19

Public Health Agency of Canada. Diabetes in Canada: Facts and Figures from a Public Health Perspective. Ottawa, ON: 2011.

Diabetes shortens life expectancy for all ages • A 50-year-old with diabetes dies, on average, 6 years earlier than a counterpart without diabetes • Compared to people without diabetes, people with diabetes have higher mortality rates: – 20–44 years: 4 to 6 times higher – 45–79 years: 2 to 3 times higher

The Emerging Risk Factors Collaboration. N Engl J Med 2011; 364:829-841 Public Health Agency of Canada. Report from the National Diabetes Surveillance: Diabetes in Canada 2009.

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Diabetes Shortens Health-adjusted Life Expectancy (HALE) • HALE is an indicator of the average number of years that an individual is expected to live in a healthy state. • It is a summary measure that combines both quantity of life and quality of life. • Individuals with diabetes at age 55 have a loss in HALE of: – 5.8 years for women – 5.3 years for men.

Public Health Agency of Canada. Health-Adjusted Life Expectancy (HALE) in Canada 2012 .

Factors Contributing to Diabetes Prevalence and Incidence

Factors affecting diabetes prevalence & incidence in Canada • Aging population • Increasing immigration from high-risk populations • Aboriginal population growth • Increasing prevalence of childhood and adult obesity • Socioeconomic and environmental factors

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An aging Canadian population • The prevalence of diabetes increases sharply around middle age. • By 2036, the proportion of Canadians >65 years will be 23–25% — nearly double what it was in 2009

Public Health Agency of Canada. Diabetes in Canada: Facts and Figures from a Public Health Perspective. Ottawa, ON: 2011.

Immigration from high-risk populations • Of immigrants who came to Canada in 2012, ~82% were from high-risk populations: – 58% from Asia (including the Middle East) – 11% from Mexico/Central/South America/Caribbean – 13% from Africa

Statistics Canada. Canada’s population estimates, fourth quarter 2012. The Daily. March 20, 2013.

Aboriginal population growth • Aboriginal Canadians have 3 to 5 times higher rates of diabetes than the general population. • Due primarily to a high birth rate, from 1996 to 2003, the Aboriginal population grew by 45%, nearly 6 times the growth rate of nonAboriginals. • The highest concentration of Aboriginal peoples in 2001 was in the prairie provinces and the North. Harris SB, et al. Diabetes Care. 1997;20:185–187; Statistics Canada. Canada’s. Aboriginal Peoples in Canada in 2006; Inuit, Métis and First Nations; 2006 Census; Statistics Canada. Aboriginal population in 2017.

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The Prevalence of Obesity is Increasing

Canadians are too heavy • • • • •

60% of men are overweight 44% of women are overweight 18% of Canadians are obese Obesity rates highest in those 55 to 64 years Between 2003 and 2011, obesity rates rose: – from 16% to 20% in men – from 14.5% to 17% in women

Statistics Canada. Canadian Community Health Survey, 2011.

Link between obesity and type 2 diabetes: Harvard Nurses’ Health Study

Ageadjusted relative risk for diabetes

120 100 80 60 40 20 0 35.0 22.9 23.8 24.9 26.9 28.9 30.9 32.9 34.9

BMI (kg/m2)

Colditz GA, et al. Ann Intern Med. 1995;122:481-486.

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Projected prevalence of overweight (BMI ≥25 kg/m2): Women age ≥30, 2005

Look at the red 

Projected prevalence of overweight (BMI ≥25 kg/m2): Women age ≥30, 2015

Look at the red 

Our lifestyle puts us at risk • Inactivity increases insulin resistance, which is intimately linked to type 2 diabetes. • Every 2 hours per day of television watching has been shown to be associated with a 14% increase in the risk of type 2 diabetes. • Only 54% of Canadian adults are at least moderately active during their leisure time. • Every hour of brisk walking per day has been associated with a 34% decrease in the risk of type 2 diabetes. Statistics Canada. Canadian Community Health Survey, 2011 Hu FB, et al. JAMA. 2003;289:1785-1791.

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Childhood obesity in Canada • Almost one-third of 5- to 17-year-olds are – overweight (19.8%), or – obese (11.7%)

• Obese children tend to remain obese as adults.

Statistics Canada. Health Reports. 2012;23(3)

Socioeconomic factors: A disease of the poor • High income is protective against diabetes • Diabetes is disproportionately clustered: – in lower socioeconomic status quintiles; and – in neighborhoods with lower average household incomes, high proportions of visible minorities and/or recent immigrants.

• People in lower income brackets and with fewer years of education also report: – higher rates of smoking; – less physical activity; and – higher rates of overweight.

All modifiable risk factors for DM

Hux JE, et al. Diabetes in Ontario: An ICES Practice Atlas; 2003; Glazier RH, et al. ICES Atlas; 2007; Willi C, et al. JAMA. 2007;298:2675-2676; Statistics Canada. National Population Health Survey – Household Component Longitudinal, 1998–1999; Raphael D. Heart Health Network; 2001.

Our environment matters • Researchers conducted a study to assess the impact of neighborhood walkability on diabetes incidence. • Adults aged 30–64 years who were free of diabetes and living in Toronto were followed from March 2005 until March 2010 for the development of diabetes. • Neighborhood walkability was inversely associated with the development of diabetes, particularly among recent immigrants living in low-income areas. Booth GL, et al. Diabetes Care. 2013;36:302-308.

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Impact on the Healthcare System

A strain on global healthcare budgets Canada: Total costs are currently $12.2. billion, and are expected to increase to $16.9 billion by 2020. Accounts for ~3.5% of public healthcare spending.2

Global: In 2012, at least $471 billion USD.1

United States: In 2012, total costs were $245 billion.3

1. IDF Diabetes Atlas Update 2012. Available at:

http://www.idf.org/diabetesatlas/5e/Update2012. 2. Canadian Diabetes Association. An economic tsunami, the cost of diabetes. 2009. 3. American Diabetes Association. Diabetes Care. 2013; doi:10.2337/dc12-2625

A strain on outpatient resources Anxiety (~40%) and depression (~15%) Diabetic retinopathy (~40%) Obesity (80−90%) Erectile dysfunction (34−45%) Neuropathy (40−50%) PHAC. Diabetes in Canada: Highlights from the National Diabetes Surveillance System 2004– 2005; Can J Diabetes. 2008;32(suppl 1):S1S201; Statistics Canada. Sequelae of diabetes; 2005.

Foot ulcers (15%)

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A strain on inpatient resources • Compared to people without diabetes, people with diabetes were hospitalized at higher rates for:

Stroke x 3 Heart attack x 3 Hypertension or heart failure x 4 Chronic kidney disease x 7 Lower limb amputations x 24

PHAC. Diabetes in Canada: Highlights from the National Diabetes Surveillance System 2004– 2005.

Diabetes is a frequent reason for physician visits Top 10 reasons* for patient visits¶ to physicians in Canada, 2010 1. Hypertension

2. Diabetes (without complications) 3. Health check-up (Routine Child Health Check-up [V20.2] and Routine General Medical Exam and Health Check-up [V70.0])

4. Depression 5. Anxiety 6. Acute upper respiratory infection 7. Normal pregnancy supervision 8. Hyperlipidemia 9. Esophagitis 10. Hypothyroidism * Based on ICD-9 classifications. ¶ Visits made to Canadian office-based physicians – physicians maintaining an office outside hospitals

People with diabetes are frequent flyers • Compared to people without diabetes, adults with diabetes in Canada have 2 to 2.4 times more visits to their family doctors and specialists • Study in general Cdn population with diabetes: see their family doctor a mean of 8.3 times per year (mean of 4.3 diabetes-related visits) • Study in First Nations: mean of 14.7 healthcare visits (mean of 8.7 diabetes-related visits)

Harris S, et al. Diabetes Res Clin Prac. 2005;70(1):90-97 Harris SB, et al. Diabetes Res Clin Pract. 2011;92(2):272-279.

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Diabetes treatments are among the top 10 most frequently dispensed therapeutic classes in Canada Therapeutic class

Prescriptions* dispensed in 2010 (in millions)

1

Cardiovasculars

77,130

2

Psychotherapeutics

64,853

3

Gastrointestinal/genitourinary

36,283

4

Cholesterol agents

34,214

5

Hormones

26,650

Rank

6

Analgesics

25,232

7

Anti-infectives (systemic)

24,532

8

DIABETES THERAPIES

21,348

9

Neurological disorders

22,773

10

Diuretics

17,835

*Estimated prescriptions dispensed in Canadian retail pharmacies. Includes new and refills IMS Brogan; CompuScript, 2010.

The 3rd most frequently dispensed (and one of the fasting growing) therapeutic classes in the world Rank

Therapeutic class

Percentage growth, 2011

1

Oncologics

5.5%

2

Respiratory agents

7.3%

3

Anti-diabetics

11.4%

4

Lipid regulators

3.7%

5

Anti-psychotics

9.4%

6

Angiotensin II antagonists

-0.7%

7

Anti-ulcerants

-6.4%

8

Auto-immune agents

14.1%

9

Anti-depressants

-1.5%

10

HIV anti-virals

9.5%

IMS Health MIDAS, December 2011

Top 10 drugs in Canada (by active ingredient) Rank (2012)

Active Ingredient (indication)

1

Atorvastatin (cholesterol agent)

2

Levothyroxine (thyroid hormone)

3

Rosuvastatin (cholesterol agent)

4

Metformin (diabetes agent)

5

Pantaprazole (anti-GERD agent)

6

Amlodipine (anti-hypertensive agent)

7

Ramipril (anti-hypertensive agent)

8

Metoprolol (anti-hypertensive agent)

9

Furosemide (anti-hypertensive agent)

10

Lorazepam (anti-anxiety agent)

Source: IMS Brogan, Canadian CompuScript, 2012

Boot Camp materials are the sole property of the authors and may not be adapted or reproduced in any way without the express consent of the authors

Top 10 drugs in Canada (by active ingredient) Rank, 2012

Active Ingredient (indication)

1

Atorvastatin (cholesterol agent)

2

Levothyroxine (thyroid hormone)

3

Rosuvastatin (cholesterol agent)

4

Metformin (diabetes agent)

5

Pantaprazole (anti-GERD agent)

6

Amlodipine (anti-hypertensive agent)

7

Ramipril (anti-hypertensive agent)

8

Metoprolol (anti-hypertensive agent)

9

Furosemide (anti-hypertensive agent)

10

Lorazepam (anti-anxiety agent)

Source: IMS Brogan, Canadian CompuScript, 2012

Cost of testing strips • The total Canadian expenditure on blood glucose test strips in 2006 was conservatively estimated at $330 million • In many drug plans in Canada, testing strips are among the top 5 classes in terms of total expenditure • Testing strips are the most expensive component in the intensive management of glycemic control • More money is spent on testing strips than all oral antihyperglycemic agents combined Cameron C, et al. Can J Diabetes. 2010;34:34-40. ; Ministry of Health and Long-Term Care. 2006. Utilization of oral antiglycemics in Canada. Ottawa, ON: Brogan,Inc.; 2008.;CADTH 2009 (Optimal therapy report; vol. 3, no. 4).

Out-of-pocket expenses • Out-of-pocket expenses vary depending on provincial formularies and on whether people have supplementary insurance. • Typical annual out-of-pocket costs [2009] for a patient with type 2 diabetes varied from $250 (Yukon) to $3427 (New Brunswick). • National average was $1800

CDA. Diabetes-Canada at the Tipping Point. Charting a New Path.

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Diabetes Care in Canada: Room for Improvement

Not making the grade • Studies of Canadian patients with type 2 diabetes in the primary care setting demonstrated: – A1C: 47% to 49% were above target of 7.0%1,2 – BP: 46% were above target of 130/80 mm Hg2 – Cholesterol: 36% were above the LDL-C target of 2.5 mmol/L (2003 CDA guideline-recommended target). – 63% would have been above 2008 CDA target of 2.0 mmol/L2 – Only 21% achieved all three key targets1 1. Braga MFB, et al. Can J Cardiol. 2010;26(6):297-302. 2. Harris SB, et al. Diabetes Res Clin Prac. 2005;70(1):90-07.

Lifestyle changes: Easier said than done

Sedentary lifestyle

Weight and waist circumference above target

Percentage of patients

Reinforcing lifestyle is typically identified by healthcare professionals as their strategy to achieve targets, but …

Smoker

Harris S. Diabetes Res Clin Pract. 2005;70:90-97. Braga M. Can J Cardiol. 2010;26:297-302.

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Time for a New Approach

National prevention plan needed • In 2007, the IDF released its Consensus of Type 2 Diabetes Prevention, upon As of calling 2013, governments of all nations to implement a Canada hasPlan nofor: National Diabetes Prevention

diabetes prevention strategy in place

1) the population at large 2) those at high risk of developing type 2 diabetes - identify those at high risk - measure the risk . - intervene to delay/prevent type 2 diabetes using predominantly health behaviour strategies

The shifting burden of illness from acute care (disease-oriented) to chronic (health promotion-oriented) care is threatening the sustainability of our healthcare system ... prompting efforts to improve clinical output and efficiency.

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Increase in diabetes coinciding with a decrease in availability of physicians • Increasing demands on the time of family physicians providing primary care in Canada: – – – –

Increasing complexity of patient caseload Patient expectations Workload/paperwork Management of chronic disease in the aging population

• Canadian FP/GPs were able to see 6% fewer patients per week in 2010, compared to 2007. • 63% of family physicians are either not accepting or are limiting new patients. • 27% of family physicians plan to reduce their weekly work hours over the next 2 years. 2010 National Physician Survey. http://nationalphysiciansurvey.ca/result/2010-fp/

High prevalence of disease in family practice • The Diabetes Screening in Canada (DIASCAN) study demonstrated that: – 16.4% had known diabetes – 2.2% had undiagnosed diabetes – 3.5% had glucose intolerance

• 1 in 5 adults visiting their family physician will have diabetes or prediabetes.

Leiter LA. Diabetes Care. 2001;24:1038-1043.

Family physicians provide 92% of diabetes care 92%

Jaakkimainen L. Institute for Clinical Evaluative Sciences; 2003.

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Primary care is “Ground Zero” High care volume Estimated number of diabetes-related visits per year for a practice of 2,000 patients Surveillance

69% of adult >2 risk factors (n = 1,380) will need annual diabetes risk review

Prediabetes

10% (n = 200) will need q3 month review and risk management support

1,380 800

Type 2 diabetes 80% (n = 180) of patients with diabetes will be under your care and have an average of 8 visits per year 3% (n = 120) incidence = newly diagnosed patients per year

1,380

Estimated visits per year

3,560

Calculations based on data from ICES, 2005

Primary healthcare reform • In 2000, the First Ministers agreed to promote the establishment of primary healthcare teams with a focus on: – health promotion; – disease prevention; and – chronic diseases.

• Access to primary health care teams reduces: – – – –

Unmet needs Uncoordinated care Risk of hospitalisation ER visits

Khan S. Statistics Canada. 2008.

Quality improvement strategies that may improve glycemic control • • • • • • • • • •

Promotion of self-management Team changes Disease (case) management Patient education Facilitated relay of clinical information Electronic patient registries Patient reminders Audit and feedback Clinician education Clinical reminders (with or without decision support)

CDA 2013 Clinical Practice Guidelines. Can J Diabetes. 2013;37 (Suppl 1):S1-S212.

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What are the care delivery features that support high-performing diabetes care teams?

Care delivery features that support team performance • Promotion of self-management1, 2 – active role in problem-solving and goal-setting

• Provider role change1, 2 – Use of algorithms to optimize treatment

• Targeted case/care management1,2 – Ongoing/proactive treatment adjustment, care coordination and coaching

• Targeted facilitated relays2,3 – Telecommunication support between patient and provider

• Patient reminders1,2

1. 2. 3.

Shojiania, KG et al . JAMA. 2006:296-440. Tricco AC, et al. Lancet. 2012;379 Verhoeven, F et al, J Diabetes Sci Tech 2010:4:666-84:2252-2261

Care delivery features of highperforming teams • Coordinated patient flow strategies – Triaging, multiple access points, advanced access, EMR registry recall, case management

• “Batched” clinics – Mini clinics

• Integration of specialist care1 • Longer consultations2,3 – Translate into better care for chronically ill patients

1. McMurchy D. Canadian Health Services Research Foundation; 2010. 2. Enhancing Interdisciplinary Collaboration in Primary Health Care. Available at: http://www.eicp.ca. 3. Kirsh S, et al. Qual Saf Health Care. 2007;16:349-353.

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Helpful hints for organization of care • Recognize: Consider diabetes risk factors in all patients and screen appropriately • Registry: Develop a registry of all diabetes patients • Resources: Engage other team members such as educators, nurses, dietitians, and pharmacists to support the patient in self-management • Relay: Facilitate information sharing between the patient and the team for coordinated care and timely management changes. • Recall: Develop a system to remind patients and caregivers of recall and review CDA 2013 Clinical Practice Guidelines. Can J Diabetes. 2013;37 (Suppl 1):S1-S212.

Diabetes care should ideally... • Be focused on the person living with diabetes, who is practicing self-management • Be structured, evidence-based, and supported by a clinical information system that includes decision support, audit and feedback. • Be managed by an interprofessional team including individuals: – With expertise and training in diabetes – Who work collaboratively with the primary care provider – Who are appropriately supported by specialist input.

• Allow the enhanced roles for the nurse, pharmacist or dietitian. • Incorporate telehealth technologies as appropriate

CDA 2013 Clinical Practice Guidelines. Can J Diabetes. 2013;37 (Suppl 1):S1-S212.

To summarize … • Diabetes is increasing in both incidence and prevalence. • These trends are being driven by corresponding increases in risk factors, especially obesity. • Physicians/NPs will be caring for increasing numbers of patients with diabetes who will be living longer and with more advanced stages of the disease. • Access to physicians has decreased • CDPM is a priority for the primary care sector (Ground Zero for the prevention and management of diabetes).

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Recruits take a break!

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