Results of Diabetes Outreach Complications Screening Programs in Alberta

“RESULTS OF DIABETES OUTREACH and COMPLICATIONS SCREENING PROGRAMS IN ALBERTA”

Sandra Shade, BScNDirector of Home Care, Blood Tribe Health DepartmentEllen L Toth, MDUniversity of Alberta

Canadian Diabetes Association Meeting, Edmonton 2010

Outline

Brief description of SLICK

SLICK results

Discussion

MDSi results

Other programs

SLICK: Screening for Limbs, I-eyes, Cardiovascular and Kidneys

Launched December 2001

2 vans

44 eligible communities

Alberta

SLICK team

SLICK and MDSI: Eye photographs

Collaborative Endeavour

Alberta First Nations

University of Alberta

First Nations and Inuit Health Branch

ADI and Nursing, significant partnership and operational funding from ADI

Canadian Health Infrastructure Partnership Program (CHIPP) initial funding

Royal Alexandra Hospital

Ophthalmology and Aboriginal Diabetes Wellness Program

Capital Health Authority

Alberta Health and Wellness

Program Objectives

Reduce the complications of diabetes

Increase access to appropriate diabetes care

Increase capacity to meet the Canadian Diabetes Practice Guidelines

Foster integration and collaboration of health services across the continuum of care

Provide cost-effective care

Share lessons learned with others

SLICK: Screening for Limbs, I-eyes, Cardiovascular and Kidneys

Dr David Strong, MOHHeather Young, Director of NursingJudy Halladay, RD, promotion and

preventionFirst Nations leadership

Dr. Ellen Toth, Medical AdvisorDr Hakique Virani, Medical AdvisorDr. Matt Tennant, OphthalmologistSandra Shade, ADI coordinatorAudrey Inouye, ADI CoordinatorIris Weibel, RN, CDELorraine Trojan, RNKathleen Gibson, RD and R. photographer

SLICK: Screening for Limbs, I-eyes, Cardiovascular and Kidneys

Dr David Strong, MOHHeather Young, Director of NursingJudy Halladay, RD, promotion and

preventionFirst Nations leadership

Dr. Ellen Toth, Medical AdvisorDr Hakique Virani, Medical AdvisorDr. Matt Tennant, OphthalmologistSandra Shade, ADI coordinatorAudrey Inouye, ADI CoordinatorIris Weibel, RN, CDELorraine Trojan, RNKathleen Gibson, RD and R. photographer

Analyses in SLICK

SLICK Survey: Care providers and activitiesSatisfaction with servicesDiabetes knowledgeClinical statusComplications screening activitiesQuality of Life

SLICK activity

Clinical characteristics:

Weight/waist, A1c, Cholesterol, BP, feet, eyes

at baseline

over time

SLICK ActivitySLICK NON-SLICK

Year NewClients

per Year

PriorYear

Clients seen again

This Year

Clients seen

again

NewClients

per Year

PriorYear

Clients seen

again

This Year

Clients seen

again

Total visits

2001 11 0 0 1 0 0 122002 804 5 46 180 0 1 10362003 396 375 28 231 38 3 10712004 354 601 34 292 83 13 13772005 202 594 17 323 141 11 12882006 202 721 15 286 169 8 14012007(to end of June)

133 439 1 200 186 0 959

Totals: 2102 2735 141 1513 617 36 7144

New clients seen per year (N = 2102 Slick and 1513 Non-Slick)

0

200

400

600

800

1000

2001 2002 2003 2004 2005 2006 2007

Year

Num

ber

Non-SlickSlick

Total visits per year (N = 4978 Slick, 2166 Non Slick)

0

200

400

600

800

1000

1200

2001 2002 2003 2004 2005 2006 2007

Year

Num

ber

Non SlickSlick

Gender distribution (unique clients)

0

200400

600

800

10001200

1400

Non-SLICK Slick

Num

ber

FemalesMales

Age distribution of SLICK clients at 1st visit (N=2102)

050

100150200250300350400

0-9 10-19

20-29

30-39

40-49

50-59

60-69

70-79

80-89

90-100

Age group

Num

ber

FemalesMales

Age distribution of Non Slick clients at 1st visit (N = 1512)

0

50

100

150

200

250

300

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-100

Age groups

Num

ber

FemalesMales

Number of visits per person (2001- June 2007)

0

200

400

600

800

1000

1200

1 2 3 4 5 6 7 8 9

Number of visits

Num

ber

Non SlickSlick

Longitudinal SLICK results December 2OO1to June 2OO7

SLICK ActivityUNIQUE Clients seen SLICK Non-SLICK

Once only 905 1096X 2 458 256X 3 310 108X 4 199 36X 5 126 12X 6 85 5> 7 40 0

Total UNIQUE clients 2102 1513Total VISITS 4978 2166

Seen at least TWICE: 1218 4171218

2102

Baseline Results for SLICK clients at first visit (secular trend?)

All Clients

7.16

8.21

7.69 7.61 7.54 7.60 7.58

Mean A1c

0

1

2

3

4

5

6

7

8

9

Year

2001 2002 2003 2004 2005 2006 2007

At first visit!????

Slope = -0.143p-value=<.0001

(N=2091 Slick clients at 1stMean A1c

4

5

6

7

8

9

10

11

12

13

14

year

2001 2002 2003 2004 2005 2006 2007

A1c by Year(N=2091 Slick clients at 1st visit)

Slope = -0.158

p-value <.0001

(N = 1704)

Mean Cholesterol

1

2

3

4

5

6

7

89

10

11

year2001 2002 2003 2004 2005 2006 2007

Total Cholesterol by Year(N=1704 Slick clients at 1st visit)

Longitudinal results for RETURNING SLICK clients over time(average improvement of individuals)

For the longitudinal analysis, univariate general linear mixed effect models with random client effect and fixed time (year) effect were used for continuous outcome variables.

Logit general linear mixed effect models (binary or multinomial) with random client effect and fixed time effect were used for categorical (binary) outcome variables.

Longitudinal analyses for baseline clinical parameters per year were adjusted for duration of diabetes.

Statistical Methodology

SLICK summary

Summary

Seeing improvements:A1c (secular and longitudinal)WeightTotal cholesterol (secular and

longitudinal)Blood pressure

LIMITATIONSNo control group

Thank You

Sandra Shade BscNsshade@onehealth.ca

Dr Ellen Toth: 780 - 407-3636ellen.toth@ualberta.ca

www.braiddm.ca

ACADRE

Discussion

Seeing improvements:Unable to attribute to SLICK

SLICK update ADI funding insecure, but recently

confirmed and increased SLICK screeners in Communities

Comparison to Circle results

Provincial surveillance

The CIRCLE StudyThe Canadian First Nations Diabetes Clinical Management Epidemiologic Study

Principal Investigator: Dr. Stewart Harris

Coordinating Centre: Mariam Naqshbandi, Program CoordinatorJim Esler, Research AssistantMarnie Orcutt, Administrative Assistant

Complications of Diabetes - Screening at Recommended Intervals

39%

22%26%

16%

46%

28%

72%

14%

27%18%

22% 22%

85%

44%

74%

86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% of participants

Foot exam (annual, 2007) Eye (retinopathy) - (every1-2 years, 2006-2007)

Nerve (neuropathy) -(annual, 2007)

Kidney (nephropathy) -(annual, 2007)

National

A

B

C

Diet AloneOralInsulinInsulin+Oralp

ercentage

0

10

20

30

40

50

60

70

80

90

100

<7 7-9 9-12 >=12

Treatment of Diabetes - Insulin and Oral Anti-Diabetes Medications

0%

5%

10%

15%

20%

25%

30%

35%

% of participants

National A B C

No insulin or OADsInsulin alone1 OAD2 OADs3 or more OADsInsulin + 1 OADInsulin + 2 OADsInsulin + 3 or more OADs

ABC comparisonsCIRCLE ALBERTA

CIRCLE Communities

Canadian chart audit,

Harris, 2005

DOVE study

SLICK baseline

Mean A1c ? 8.2 -8.3 8.2-8.3 7.3 7.4 8.2A1c < 7.0 37% 32-42% 49% 50% 30 or 43%Blood pressure too high

53% 44-60% 63% 55% 61%

Cholesterol too high

40% 37-61% 59% 60% 39%

Microvascular complications (eyes, kidneys, nerves)

40% 2-54% 39% 31-39%

Heart disease and stroke

20% 6-16% 28% ?30%

ADSS 2009

Authors: Oster, Hemmelgarn, Toth, King, Crowshoe, Campbell

Other Aboriginal diabetes programs

“TOP”

SLICK: federally funded, 9000 visits since 2001(~947/yr)

ADI

MDSi: provincially funded, 5000 visits since 2003 (~769/yr)

ADWP: ?~ 700 visits per year for last 10 yrs?

Mobile Diabetes Screening Initiative:“… provide resources for screening for diabetes and its complications in Aboriginal off-reserve and remote Alberta communities” (part of the 10 year Alberta Diabetes Strategy, 2003-2013)

KNOWNS and UNKNOWNS

MDSi

KNOWNS: - have diabetes - visits take longer - need foot and eye exams

UNKNOWNS: screen for risk of diabetes and cardiovascular risk

30 %

80%

MDSi baseline results

Returning subjects with diabetes, N = 18O

BMI

Waist

A1c

Systolic BP

Diastolic BP

MAP

Cholesterol-2 -1.5 -1 -0.5 0 0.5 1 1.5 2

BMI

Waist

A1c

Systolic BP

Diastolic BP

MAP

Cholesterol

-1.5 -1 -0.5 0 0.5 1 1.5

Returning “unknowns”, subjects at diabetes risk, N = 629

BMI

Waist

A1c

Systolic BP

Diastolic BP

MAP

Cholesterol

Thank You

Sandra Shade BscNsshade@onehealth.ca

Dr Ellen Toth: 780 - 407-3636ellen.toth@ualberta.ca

www.braiddm.ca

ACADRE