d iabetes i n c anada evaluation (the dice study): impact on family practice stewart b. harris md...
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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
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 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
Why the Epidemic?
• Physical Inactivity– 60% to 85% of adults are not active enough to
maintain their health
• Diet– Calorie dense; high fat
• Aging population• Urbanization
– Shift from an agricultural to an urban lifestyle means a decrease in physical activity
The Canadian Epidemic
• The Canadian population is aging– Boomer and Echo generations
• Immigration and ethnicity – High percentage (77%) of Canadian immigrants
are from ethnic groups that are at high risk for the development of diabetes
• Latino, Hispanic• South East Asian• Asian• African
- Growth in Aboriginal populations
The Canadian Epidemic:Age Distribution of Canadians with Diabetes
in 2000 & 2016
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
<5 5-9 10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
Age Group
Persons with Diabetes
2000 (n=1.4 million)2016 (n=2.5 million)
* Source: Statistics Canada
• Cost of diabetes in Canada
–2002: $13.2 billion
–2010: $15.2 billion
–2020: $19.2 billion
Cost of Diabetes
Screening and Prevention
Glycemic Management
Targets
Monitoring
Treatment paradigm
Macrovascular Complications
BP and lipid targets
Revisiting the Guidelines
A Growing Divide
Evidence Behaviour
How can we facilitate translating science to better
outcomes?
How can we facilitate translating science to better
outcomes?
-C
ell
Fu
nct
ion
(%
)*
PostprandialHyperglycemia
IGT† Type 2DiabetesPhase I Type 2
DiabetesPhase II
Type 2 DiabetesPhase III
25
100
75
0
50
-12 -10 -6 -2 0 2 6 10 14Years From Diagnosis
Patients treated with insulin, metformin, sulfonylureas‡
Lebovitz HE. Diabetes Rev. 1999;7:139-153.
UKPDS: -Cell Loss Over Time
General Principles of Care
• Multidisciplinary team approach• Care must be systematic
– Use clinical flow charts– Institute diabetes mini clinics– Computer data bases assist with
physician and patient recall• Sporadic reactive care is less effective in
preventing complications
Patients (and Physicians): “Know Your Targets”
Diabetes ABCs
A1C: ≤7.0% (or ≤6.0%)
BP: ≤130/80 mm Hg
Cholesterol: LDL-C <2.5 mmol/L
Management of diabetes requires attention to all factors that increase the risk of complications
Blood Glucose Targets*
A1C (%) FPG (mmol/L)
2hPG (mmol/L)
Target for most people with DM
≤7.0 4 - 7 5 - 10
Normal (if safely achievable)
≤6.0 4 - 6 5 - 8
* Treatment goals and strategies must be tailored to the patient, with consideration given to individual risk factors.
A1C & Complications
Per 1% A1C
Any DM endpoint: 21% (p<0.0001)
Deaths related to DM: 21% (p<0.0001)
All-cause mortality: 14% (p<0.0001)
5 6 7 8 9 10
1
4
1
4
1
4
Haz
ard
ratio
Updated mean A1C (%) Stratton et al. UKPDS 50. Diabetologia 2001;44:156-63.
+ complex insulin regimen
7
6
9
8
HbA
1c (
%)
10
Diagnosis +5 yrs +10 yrs +15 yrs
Duration of diabetes
+ OAD monotherapyDiet & Exercise
+ OAD combination
+ OAD + basal insulin
Treat to Fail:Traditional Stepwise Approach
7
6
9
8
HbA
1c (
%)
Diagnosis +5 yrs +10 yrs +15 yrs
Duration of diabetes
OAD + basal insulin
complex insulin regimen
Diet & Exercise
+ OAD combination
Treat to Succeed:Early Combination Approach
06
7
8
9
2 4 6 8 10
A1
C (
%)
Years from randomization
Upper limit of of normal = 6.2%
ConventionalGlyburideChlorpropamideMetforminInsulin
0
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
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.
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 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.
Pat
ien
ts a
t ta
rget
(%
) (
A1c
< 7
%)
100
80
60
40
20
015+ years(n = 310)
10-14 years(n = 364)
6-9 years(n = 455)
≤ 2 years(n = 449)
3-5 years(n = 591)
38%33%
47%
69%
58%
Glycemic Management
Total
Sample 2,473
Lifestyle only 15%
1 oral agent - no insulin 36%
2 oral agents - no insulin 30%
3+ oral agents - no insulin 8%
Insulin only - No oral agents 6%
1 oral agent + insulin 3%
2+ oral agents + insulin 2%
51% of patients
using lifestyle
modifications or
one oral agent
only
Glycemic Management:Drug Class
0 20 40 60 80 100
61%
48%
15%
4%
12%
15%
Patients currently taking medication (%)Base: Patients (n = 2,473)Sulfonylureas include: Glimepiride, glyburide, chloropropamide, gliclazide, tolbutamide.TZDs include: Pioglitazone, rosiglitazone.Other oral agents include: Repaglinide, acarbose, nateglinide.
Most patients are managed with traditional agents.
Metformin
Sulfonylureas net
TZDs net
Other oral agents
net
Insulin
Lifestyle only
Major Challenges to Improving A1c For Patients Not at Target
Total
Sample 1,128
Compliance with diet 72%
Compliance with exercise 71%
Lack of interest 37%
Comorbid conditions 35%
Compliance with glucose monitoring 35%
Compliance with medications 24%
Knowledge 21%
Multiple medications 16%
Cultural 14%
Drug coverage 13%
No challenges 6%
Non-compliance with lifestyle modifications are the major barriers to achieving A1c targets.
Patients with
most recent
A1c ≥ 7.0
and have
target A1c
Total
Sample 1,128
No action 5%
Reinforce lifestyle 79%
More aggressive treatment plans (NET) 56%
• Increase dose oral antihyperglycemic agents 28%
• Add oral antihyperglycemic agents 18%
• Refer to specialist 13%
• Increase insulin dose 10%
• Add insulin 6%
Plans to Achieve TargetMore aggressive treatment is planned for only half of these patients.
Patients with most recent A1c ≥ 7.0 and have target A1c
Glycemic Control and Disease Burden
0
10
20
30
40
50
60
70
80
90
100
Treatment strategies may not be aggressive enough to control all patients, particularly those who have had the disease the longest.
≤ 2 years 3 - 5 years 6 - 9 years 10 - 14 years 15+ years
Macrovascular
complications
Microvascular
complications
Pat
ien
ts (
%)
A1C ≥ 7%
17%21%
31%
22%
32%
42%
25%
42%
53%
32%
44%
67%
52%
62%62%
High Disease Burden
0
10
20
30
40
50
60
70
80
90
100
The burden associated with type 2 diabetes in Canada is high for patients and physicians managing this complex disease.
Base: Patients (n = 2,473)Macrovascular conditions include stable angina, MI, CHF, prior stroke, peripheral vascular disease, left ventricular hypertrophyMicrovascular conditions include microalbuminuria, cataracts neuropathy, diabetic retinopathy, nephropathy, diabetic foot disease, prior amputation * Among men
63%59%
28%
38%
Hypertension Dyslipidemia Macrovascular
Conditions
Microvascular
Conditions
Other Medications(non-antihyperglycemic agents)
0 20 40 60 80 100
Base: Patients (n = 2,473)Antihypertensive agents = ACE inhibitors, diuretics, CCBs, beta-blockers, ARBs.Choleserol-lowering agents = Statins, fibrates, niacin.Other heart-related agent = ASA, coronary vasodilator, antiplatelet, anticoagulant.Other medications = Thyroid replacement therapy, antidepressant, HRT therapy, anti-obesity.
Taking multiple medications may be a complex burden
for the type 2 diabetic patient.
Anti-hypertensive
agents**
Cholesterol-lowering
agents**
Other heart-related
agents**
Other medications
73%
51%
56%
24%
Patients currently taking medication (%)
DICE Summary• In Canada, 1 in 2 patients with type 2 patients are not at
target, suggesting that current treatment approaches in family practice are not intensive enough.
• Type 2 diabetes is a complex disease with a high disease burden even within the first 2 years of diagnosis.
• DICE suggests that with duration of diabetes, glycemic control erodes and morbidity increases among Canadian patients.
• Physicians are cognizant of Clinical Practice Guideline glycemic targets, but this knowledge does not necessarily translate into action.
• To help delay or even prevent complications earlier aggressive treatment is needed for type 2 diabetes patients in Canada.