Author's personal copy

Original Research

Type 2 Diabetes Mellitus Management in Canada: Is It Improving?

Lawrence A. Leiter MD a,d,e,*, Lori Berard RN f, C. Keith Bowering MDg, Alice Y. Cheng MD a,d,Keith G. Dawson MDh, Jean-Marie Ekoé MD i, Carl Fournier MD j, Lianne Goldin k,Stewart B. Harris MD, MPH l, Peter Lin MDk, Thomas Ransom MD, MScm, Mary Tan MSc k,Hwee Teoh PhD a,b, Ross T. Tsuyuki PharmD, MSc n, Dana Whitham RD, MSc o, Vincent Woo MDp,Jean-François Yale MDq, Anatoly Langer MD, MSc c,d,k

aDivision of Endocrinology and Metabolism, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, CanadabDivision of Cardiac Surgery, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, CanadacDivision of Cardiology, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, CanadadDepartment of Medicine, University of Toronto, Toronto, Ontario, CanadaeDepartment of Nutritional Sciences, University of Toronto, Toronto, Ontario, CanadafDiabetes Research Group, Health Science Centre, Winnipeg, Manitoba, CanadagDivision of Endocrinology and Metabolism, University of Alberta, Edmonton, Alberta, CanadahDivision of Endocrinology, University of British Columbia, Vancouver, British Columbia, CanadaiMontreal Institute for Clinical Research and Centre hospitalier de l’Université de Montréal Research Center, Division of Endocrinology and Department of Nutrition, Université deMontréal, Montréal, Quebec, CanadajDepartment of Medicine, Université de Montréal, Montréal, Quebec, CanadakCanadian Heart Research Centre, Toronto, Ontario, Canadal Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, CanadamDepartment of Endocrinology, Dalhousie University, Halifax, Nova Scotia, Canadan EPICORE Centre, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, CanadaoDiabetes Comprehensive Care Program, St. Michael’s Hospital, Toronto, Ontario, Canadap Section of Endocrinology, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, CanadaqDivision of Endocrinology and Metabolism, Department of Medicine, McGill Nutrition and Food Science Centre, McGill University, Montréal, Quebec, Canada

a r t i c l e i n f o

Article history:Received 25 January 2013Accepted 20 February 2013

Keywords:blood pressurecare gapglycemic controlguidelineslipidsmanagementtype 2 diabetes

a b s t r a c t

Objective: To gain insight into the current management of patients with type 2 diabetes mellitus byCanadian primary care physicians.Method: A total of 479 primary care physicians from across Canada submitted data on 5123 type 2diabetes patients whom they had seen on a single day on or around World Diabetes Day, November 14,2012.Results: Mean glycated hemoglobin (A1C) was 7.4%, low-density lipoprotein (LDL-C) was 2.1 mmol/L andblood pressure (BP) was 128/75 mm Hg. A1C �7.0% was met by 50%, LDL-C �2.0 mmol/L by 57%, BP<130/80 mm Hg by 36% and the composite triple target by 13% of patients. Diet counselling had beenoffered to 38% of patients. Of the 87% prescribed antihyperglycemic agents, 18% were on 1 non-insulinantihyperglycemic agent (NIAHA) (85% of which was metformin), 15% were on 2 NIAHAs, 6% were on�3 NIAHAs, 19% were on insulin only and 42% were on insulin þ �1 NIAHA(s). Amongst the 81%prescribed lipid-lowering therapy, 88% were on monotherapy (97% of which was a statin). Among the83% prescribed antihypertensive agents, 39%, 34%, 21% and 6% received 1, 2, 3 and >3 drugs, respectively,with 59% prescribed angiotensin-converting enzyme inhibitors and 35% angiotensin II receptor blockers.Conclusions: The Diabetes Mellitus Status in Canada survey highlights the persistent treatment gapassociated with the treatment of type 2 diabetes and the challenges faced by primary care physicians togain glycemic control and global vascular protection in these patients. It also reveals a higher use ofinsulin therapy in primary care practices relative to previous surveys. Practical strategies aimed at moreeffectively managing type 2 diabetes patients are urgently needed.

� 2013 Canadian Diabetes Association

* Address for correspondence: Lawrence A. Leiter, St Michael’s Hospital MedicalCentre, 61 Queen Street East, Suite 6-121Q, Toronto, Ontario M5C 2T2, Canada.

E-mail address: leiterl@smh.ca (L.A. Leiter).

Contents lists available at SciVerse ScienceDirect

Canadian Journal of Diabetesjournal homepage:

www.canadianjournalofdiabetes.com

1499-2671/$ e see front matter � 2013 Canadian Diabetes Associationhttp://dx.doi.org/10.1016/j.jcjd.2013.02.055

Can J Diabetes 37 (2013) 82e89

Author's personal copy

Mots clés:pression artériellelacunes en matière de soinsmaîtrise de la glycémielignes directriceslipidesprise en chargediabète de type 2

r é s u m é

Objectif : Obtenir un aperçu de la prise en charge actuelle des patients ayant le diabète sucré de type 2 parles médecins canadiens de premiers recours.Méthodes : Un total e 479 médecins de premier recours de l’ensemble du Canada ont soumis des donnéessur 5123 patients ayant le diabète de type 2 chez qui ils ont observé durant une seule journée lors ouautour de la journée mondiale du diabète, le 14 novembre 2012.Résultats : L’hémoglobine glyquée moyenne (HbA1c) a été de 7,4 %, le cholestérol à lipoprotéines de bassedensité (C-LDL) de 2,1 mmol/L et la pression artérielle (PA) à 128/75 mm Hg. Une HbA1c � 7,0 % a étéobtenue chez 50 % des patients, un C-LDL � 2,0 mmol/L chez 57 %, une PA < 130/80 mm Hg chez 36 % etun critère composite triple chez 13 %. Le counseling en diététique a été offert à 38 % des patients. Parmiles 87 % prenant des agents antihyperglycémiques, 18 % ont pris 1 agent antihyperglycémique noninsulinique (AAHNI; dont 85 % ont pris la metformine), 15 % ont pris 2 AAHNI, 6 % ont pris � 3 AAHNI,19 % ont seulement pris de l’insuline et 42 % ont pris de l’insuline et � 1 AAHNI. Parmi les 81 % quisuivaient un traitement hypolipidémiant, 88 % ont suivi une monothérapie (dont 97 % ont pris unestatine). Parmi les 83 % qui prenaient des agents antihypertensifs, 39 %, 34 %, 21 % et 6 % ont reçurespectivement 1, 2, 3 et > 3 médicaments, dont 59 % ont pris des inhibiteurs de l’enzyme de conversionde l’angiotensine et 35 % des antagonistes des récepteurs de l’angiotensine II.Conclusions : L’enquête canadienne sur le statut du diabète sucré souligne les lacunes persistantes enmatière de traitement associées au traitement du diabète de type 2 et les défis à relever par les médecinsde premier recours pour obtenir une maîtrise de la glycémie et une protection vasculaire globale chez cespatients. Cela révèle également une plus grande utilisation de l’insulinothérapie dans les centres de soinsprimaires qui concernent les enquêtes précédentes. Des stratégies pratiques dont le but est une prise encharge plus efficace des patients ayant le diabète de type 2 s’imposent de manière urgente.

� 2013 Canadian Diabetes Association

Introduction

Clinical practice guidelines (CPGs) from professional organiza-tions around theworld collectively advocate that patients with type2 diabetes mellitus should have their risk factors managed in anaggressive and timely manner (1e5). These recommendations arelargely based on seminal type 2 diabetes-focused trials demon-strating significant improvements in vascular complications andreduced mortality through comprehensive and multifactorialbehavioural modification and pharmacotherapy strategies (6,7).However, despite concerted and widespread efforts to translatethese evidence-based recommendations into routine clinicalpractice as well as increasing pharmacologic options, practicereviews conducted in different countries and settings continuallyindicate that optimal management of type 2 diabetes patientsremains challenging (8e15).

Based on data collected between September 2002 and February2003, the Diabetes in Canada Evaluation (DICE) Study determinedthat 51% of patients were successful at achieving a glycatedhemoglobin (A1C) of <7.0% (10). The Diabetes Registry to ImproveVascular Events (DRIVE) study, using data collected betweenMarch2005 and March 2006, revealed that 53% of the study populationhad an A1C of �7.0% (8) leading the investigators to postulate thatthe 2003 Canadian Diabetes Association (CDA) CPGs (3) hadminimal impact on glycemic control in Canada up to that point.

In anticipation of the publication of the 2013 CDA CPGs in early2013, the national cross-sectional Diabetes Mellitus Status inCanada (DM-SCAN) survey was undertaken to gain insight into thecurrent management of type 2 diabetes patients in the Canadianprimary care setting. A secondary goal was to identify managementgaps that may provide directional input on how best to effectivelydesign strategies aimed at improving the care of these patients.

Methods

From September to December 2012, standard letters from theDM-SCAN Steering Committeewere sent to primary care physiciansacross Canada inviting them to participate in the DM-SCAN survey.The invitationwas distributed through e-mail and facsimiles by the

Canadian Heart Research Centre (CHRC) to lists of Canadianprimary care physicians, participants in prior or ongoing registrieswithin the CHRC, through standard hard copy invitations distrib-uted by the CDA at its annual professional session and the CHRC atcontinuing medical education meetings, and by representatives ofthe sponsoring company. Physicians were requested to firstcomplete a 10-question survey on their practice location andsetting, how many type 2 diabetes patients they typically see ina week, whether they routinely discuss the symptoms and treat-ment of hypoglycemia, what they consider to be the greatestbarriers in type 2 diabetes management and what educationalplatforms they felt would benefit their patients and practice.Physicians who completed the needs assessment survey wereasked to complete a 1-page anonymized data collection form onpatients with the clinical diagnosis of type 2 diabetes whom theyhad seen on a single clinic day as part of routine clinical practice onor as close as possible to the 2012 World Diabetes Day (November14). Patient demographics, clinical history, anthropometric andlaboratory data as well as management strategies used by thephysician to achieve glycemic targets and global vascular protec-tion were documented. Physicians were reimbursed for theirefforts. The final program materials were reviewed and endorsedby the CDA and Diabète Québec before ethics approval was ob-tained. The program synopsis was reviewed and approved beforesurvey initiation by OPTIMUM Clinical Research, an independentcentral ethics review board.

Data management and statistical analysis

Completed physician surveys and data collection forms weresubmitted either electronically via a secure website or faxed to theCHRC by 19 December 2012. Faxed data were scanned into anelectronic database (TELEform, Version 10.0, Cardiff Software, SanDiego, CA). Point prevalence data are presented. Continuous vari-ables are summarized as mean (standard deviation [SD]) anddiscrete variables are reported as counts and percentages.Categorical variables between groups were compared using thePearson’s chi-square or Cochran-Armitage trend tests whereappropriate. Multivariable logistic regression analyses, using the

L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89 83

Author's personal copy

generalized estimating equations (GEE) method, were carried outto determine whether insulin use was influenced by provincial andgeographical locations, practice format and access to diabeteseducators. Because patients treated by the same physician weremore likely to be treated similarly compared to patients under thecare of other physicians, the GEE approach allowed us to adjust forcorrelations within individual physicians. Odds ratios (ORs) andtheir 95% confidence interval (CIs) are reported. All analyses werecarried out using SAS software version 9.2 (SAS Institute, Cary, NC).

Results

Physicians and their practices

A total of 479 physicians (equivalent to a 65% participation rateof the 738 who completed the initial audit form) representing all 10Canadian provinces completed 5123 data collection forms (54%online, 46% fax-based submission) (Table 1). Fifty-nine percent ofphysicians were in a group practice (�2 physicians), 41% hada single-physician practice and 50% were part of a family healthteam. Practices were located in inner city (16%), urban/suburban(63%) or small town/rural (21%) settings. Nearly two-thirds of thephysicians reported seeing 10 to 30 type 2 diabetes patients eachweek (1% <5/week, 13% 5e10/week, 36% 10e0/week, 27% 20e30/week, 16% 30e50/week, 7% >50/week) and 22% indicated that>50% of their type 2 diabetes patients were co-managed by anallied health care professional.

Patient characteristics

The demographic, clinical history, anthropometric and labora-tory data of patients reviewed by the DM-SCAN physician partici-pants are detailed in Table 2. Mean (SD) duration of type 2 diabeteswas 9.2 (7.0) years; 15% had type 2 diabetes for �2 years, 21% for3e5 years, 22% for 6e9 years, 23% for 10e14 years and 20% for �15years. According to the World Health Organization ethnic-specificdefinitions for overweight and obesity (16), 14%, 29% and 57% ofpatients were within the normal weight range, overweight andobese, respectively. Of those with a known smoking history(n¼4098), 12% were current smokers. According to the availabledata, 26% of patients had at least one macrovascular complication(22% coronary artery disease, 6% previous stroke, 8% peripheralarterial disease). At least 1 microvascular complication was recor-ded for 25% of patients (8% retinopathy, 15% nephropathy, 12%neuropathy). Both cancer and depression were reported for 12% ofpatients. Erectile dysfunction was noted for 39% of male patients.

Diet management

Information from 4787 records indicated that 38% of patientshad been referred to or counselled by a registered dietitian ora certified diabetes educator within the last 12 months. Data from4776 records revealed that a nutrition/exercise/weight loss planwith measurable goals had been established for 50% of patientswithin the same time span.

Glycemic control and management

Mean (SD) A1C for 5103 individuals was 7.4% (1.3%), of whom50% had A1C results of �7.0%. Figure 1A shows the distribution ofA1C values. Duration of type 2 diabetes correlated mildly butsignificantly with A1C increases (r¼ 0.14, p<0.0001). Duration oftype 2 diabetes also showed a strong association with A1C �7.0%attainment rates: 65% for those with type 2 diabetes for �2 years,58 % for 3e5 years, 49% for 6e9 years, 43% for 10e14 years and 37%for �15 years (p for trend <0.0001). Optimal A1C targets identified

by physicians for 4798 patients from a list of 5 choices were 3% for�6.0%, 14% for �6.5%, 71% for �7.0%, 9% for �7.5% and 4% for �8.0%.

Although 4477 (87%) of patients were prescribed anti-hyperglycemic therapy, 10% were managed through diet onlystrategies (Table 3). Of the patients prescribed antihyperglycemicagents (AHAs), 18% were receiving 1 non-insulin antihyperglycemicagent (NIAHA) (85% of which was metformin), 15% on 2 NIAHAs, 6%on �3 NIAHAs, 19% on insulin only and 42% on insulin and one ormore 1 NIAHA. There were significant (p<0.0001) interprovincialdifferences in insulin use, with the highest found in Manitoba(80.3%) and the lowest in Alberta (47.6%). Logistic analyses usingthe GEE model indicated that patients in urban regions (OR [95%CI]¼1.41 [0.97e2.06], p¼0.0741), from group/family health prac-tices (OR [95% CI]¼1.57 [1.13e1.81], p¼0.0074) and with access todiabetes educators (OR [95% CI]¼1.59 [1.39e1.81], p<0.0001) weremore likely to be prescribed insulin. Of the 127 patients withknown insulin monotherapy regimens, 9%, 29% and 62% werereceiving 1, 2 and �3 insulin injections/day, respectively. Most ofthe individuals on dual AHA therapy were prescribed insulin anda NIAHA; dipeptidyl peptidase-4 inhibitors (DPP-4Is) and sulfo-nylureas were the most common NIAHAs to be combined withmetformin when dual NIAHA therapy was prescribed. Among the2531 patients who reached an A1C�7.0%, 37%were onNIAHAs only(51% of whom were on metformin monotherapy), 20% on insulinalone and 23% on insulin þ �1 NIAHA. The management strategiesused for patients who had an A1C >7.0% are shown in Figure 1B. Of

Table 1Provincial distribution of physicians and patients

Province Physicians (N¼479) Patients (N¼5123)

Alberta 29 (6.1) 233 (4.5)British Columbia 41 (8.6) 365 (7.1)Manitoba 19 (4.0) 249 (4.9)New Brunswick 26 (5.4) 347 (6.8)Newfoundland 17 (3.5) 208 (4.1)Nova Scotia 28 (5.8) 295 (5.8)Ontario 270 (56.4) 2990 (58.4)Prince Edward Island 1 (0.2) 15 (0.3)Quebec 45 (9.4) 400 (7.8)Saskatchewan 3 (0.6) 21 (0.4)

Data are presented as n (%).

Table 2Demographic, clinical history, anthropometric and laboratory data of patientsreviewed

Patients (N¼5123)

Women* 2353 (46.1)Age (years)y 64 (12)Ethnicity*

Aboriginal Canadian 144 (2.9)Black 197 (4.0)Caucasian 3021 (60.8)East/Southeast Asian 851 (17.1)Hispanic 76 (1.5)South Asian 529 (10.6)Other 153 (3.1)

Body mass index (kg/m2)y

Men 30.5 (10.0)Women 31.1 (11.6)

A1C (%)y 7.4 (1.3)Fasting plasma glucose (mmol/L)y 7.8 (2.6)LDL-C (mmol/L)y 2.1 (0.9)Blood pressure (mm Hg)y

Systolic 128 (14)Diastolic 75 (9)

Duration of type 2 diabetes (years)y 9.2 (7.0)Current or previous smoker* 1774 (36.1)

LDL-C, low-density lipoprotein cholesterol.N for each category was variable due to missing values, <10% in each case.

* Data are presented as n (%).y Data are presented as mean (SD).

L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e8984

Author's personal copy

the 1432 patients with an A1C of 7.1% to 8.0%, 2% were notprescribed any diet or AHA therapy, 4% were on a diet only thera-peutic regimen and 27% on AHAmonotherapy. Even amongst thosewith an A1C �9.0% (n¼523), 2% were not prescribed any diet orAHA therapy, <1% were on diet only management and 18% on AHAmonotherapy. NIAHA monotherapy and dual therapy strategiesprescribed are outlined in Figure 1C.

Lipid control and management

Mean (SD) low-density lipoprotein cholesterol (LDL-C) level was2.1 mmol/L (0.9 mmol/L). The target LDL-C of �2.0 mmol/L wasachieved by 57% of 5069 patients (65% for those with knownvascular disease vs. 54% for those without, p<0.0001). The distri-bution of LDL-C values is shown in Figure 2A. Amongst the 4153

Figure 1. Glycemic control and management of DM-SCAN patients. (A) Distribution of A1C levels. (B) Management strategies used for patients with A1C >7.0%. (C) Distribution ofNIAHA monotherapy and dual therapy strategies prescribed to patients with A1C >7.0%. Values for (C) were determined according to the corresponding number of patients withA1C >7.0% who were known to be treated with 1 NIAHA or 2 NIAHAs. DPP-4I, dipeptidyl peptidase-4 inhibitor; GLP-1R, glucagon-like peptide 1 receptor agonists; NIAHA, non-insulin antihyperglycemic agent; SU, sulfonylurea.

L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89 85

Author's personal copy

(82%) patients who were prescribed lipid-lowering therapy, 88%were on monotherapy (of whom 97% were on a statin) and 11% ondual therapy (67% of whom were on a statin þ ezetimibe). Of the2878 patients with LDL-C�2.0 mmol/L, 90% received statins and 8%were prescribed a statin þ ezetimibe. Figure 2B outlines howpatients whose LDL-C exceeded 2.0 mmol/L were managed.

Blood pressure control and management

Mean (SD) blood pressure (BP) was 128/75 mm Hg (14/9 mmHg). Blood pressure <130/80 mm Hg was met by 36% of 5099patients. Figure 3A illustrates the BP distribution across the studypopulation. Amongst the 4272 (83%) patients prescribed antihy-pertensive agents 39%, 34% and 21% and 6% were on 1, 2, 3 and �3drugs respectively with 59% prescribed angiotensin-convertingenzyme (ACE) inhibitors and 35% angiotensin II receptor blockers(ARBs). Amongst the 1852 individuals who reached the BP target of<130/80 mm Hg, 50% were on ACE inhibitors and 25% on ARBs.Figure 3B details how those with BP �130/80 mm Hg weremanaged.

Composite A1C, LDL-C and BP outcome

The composite endpoint goal of A1C �7.0%, LDL-C �2.0 mmol/land BP <130/80 mm Hg was met by 13% of 5104 patients (16% forthosewith known coronary artery disease vs.12% for thosewithout,p¼0.0013).

Barriers to successful management of type 2 diabetes

Poor patient adherence (e.g. diet, physical activity, medication,blood glucose monitoring) was the most commonly cited barrier tomanaging type 2 diabetes patients. Other physician-identifiedbarriers were patient resistance (e.g. reluctance to initiate/inten-sify antihyperglycemic therapy, poor understanding of disease, itsprogressive nature and the associated complications), constraints

on physician time (e.g. comorbidities, complex medical regimens,patient education), financial issues (e.g. insurance coverage, accessto and cost of “healthy” food) and lack of support for physician (e.g.poor access to timely and sustained nutritional and exercisecounselling).

Discussion

The results of this large, national, cross-sectional observationalsurvey suggest that still only 50% of Canadian type 2 diabetespatients met the 2008 CDA CPGs recommended A1C target of�7.0%(3). Additionally, just over 50% were successful at reaching theLDL-C �2.0 mmol/L goal recommended by the 2008 CDA CPGs (3)and the 2009 Canadian Lipid CPGs (17) and only a third the 2008CDA and 2012 Canadian Hypertension Education Program recom-mended target BP of <130/80 mm Hg (3,18). Finally, it is alsodisappointing that only 13% of patients achieved the composite goalof A1C �7.0%, LDL-C �2.0 mmol/l and BP <130/80 mm Hg.

The Canadian-based DICE and DRIVE studies previouslydemonstrated that CPGs-recommended glycemic control was onlysuccessfully observed in 51% and 53% of the study patients,respectively (8,10). Notwithstanding some methodological differ-ences, the DM-SCAN survey recapitulates the persistent manage-ment gap associatedwith type 2 diabetes and reconfirms the earliersuggestions that glycemic and other metabolic control in Canadaremains suboptimal despite continual update and dissemination of

Figure 2. Lipid control and management of DM-SCAN patients. (A) Distribution ofLDL-C levels. (B) Distribution of lipid lowering therapy strategies prescribed to patientswith LDL-C >2.0 mmol/L. Values for (B) were determined according to the corre-sponding number of patients with LDL-C >2.0 mmol/L who were known to be treatedwith lipid lowering agents.

Table 3Glycemic control and management

Target A1C Attainment* Patients (N¼5103)

A1C �7.0% 2531 (49.6)A1C �9.0% 523 (10.3)

Management strategies* Patients (N¼5123)

Diet only 517 (10.1)On antihyperglycemic therapy 4477 (87.4)Neither diet nor antihyperglycemic therapy 129 (2.5)

Antihyperglycemic therapy Patients (N¼4477)

Monotherapy 1656 (37.0)Insuliny 854 (51.2)Metforminy 685 (41.4)Other NIAHAsy 117 (7.1)

Dual therapy 1923 (43.0)2 NIAHAsz 673 (35.0)Metformin þ DPP-4Ix 284 (42.2)Metformin þ sulfonylureax 264 (39.2)Insulin þ 1 NIAHAz 1250 (65.0)

Triple therapy 798 (17.8)3 NIAHAs{ 241 (30.2)Insulin þ 2 NIAHAs{ 557 (69.8)

DPP-4I, dipeptidyl peptidase-4 inhibitor; NIAHA, non-insulin antihyperglycemicagent.Data are presented as *n (%).

y Values were calculated against the number of patients who were on AHAmonotherapy.

z Values were calculated against the number of patients who were on AHA dualtherapy.

x Values were calculated against the number of patients who were on 2 NIAHAs.{ Values were calculated against the number of patients who were on 3 AHAs.

L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e8986

Author's personal copy

CPGs and an increasing number of AHAs. Table 4 summarizes thekey findings of the DICE, DRIVE and DM-SCAN studies. Meanduration of type 2 diabetes for the DICE and DM-SCAN patientpopulations were 8 years and 9 years, respectively, and the medianduration for DRIVE was 6 years. Although all 3 studies found thatonly 50% the patients were able to attain the recommended A1Ctarget of the time, it is worth noting that despite DM-SCAN patientshaving a longer mean duration of type 2 diabetes than DICEpatients, mean A1C was only slightly higher for the former (7.4% vs.7.3%). This may in part be attributed to less reliance on lifestyle onlymanagement (10% for DM-SCAN vs.16% for DICE) and greater use ofinsulin (both alone and in combinationwith NIAHAs) amongst DM-SCAN patients (61% for DM-SCAN vs. 12 % for DICE). Although itwould appear that glycemia was better controlled in DRIVE vs. DM-SCAN patients (median A1C 6.9% vs. 7.0%; A1C �7.0% rates 53% vs.50%), it is important that at the time of audit DRIVE patients weregenerally at earlier stages of the disease than DM-SCAN patients.

In 81% of patients, the A1C goal set by the physicians was �7%.Therefore, the low success rate in achieving A1C levels �7% cannotbe explained by patient factors that would make such a targetunreasonable or physicians not knowing the recommended target.When queried, physicians suggested patient barriers as the primarycauses of unsuccessful attempts to gain and sustain glycemiccontrol. However, they also acknowledged time constraints,financial considerations and limited access to relevant diabetes-associated support personnel and services as contributory factors.

Rate of insulin usage for the DRIVE cohort was 15%. This issimilar to the 12% reported by the DICE investigators but remark-ably lower than the 61% noted in the DM-SCAN patient population.The greater use of insulin amongst the DM-SCAN physicians is ofsignificant interest since it occurred despite the introduction of 2new classes of AHAs after the release of the 2008 CDA CPGsdtheDPP-4Is and glucagon-like peptide 1 receptor agonistsdboth ofwhich are not associated with the potential weight gain and risk ofhypoglycemia of insulin. Whether these observations represent anincrease in awareness and enhanced adherence to CPGs recom-mendations and/or a decrease in clinical inertia with regards toinsulin initiation and intensification remains to be determined. Thefact that insulin use was associated with greater access to diabeteseducators suggests that this may have contributed. Regardless,these findings are novel, promising and warrant furtherinvestigations.

The recurrent observation in the DICE, DRIVE and DM-SCANinitiatives that glycemic control is achieved in only about half ofthe patients is not unique to Canada. A retrospective, cross-sectional analysis of data from the United Kingdom GeneralPractice Research Database, collected between 1998 and 2002,indicated that A1C �7.0% was recorded for 34% of patients (14). The2003e2006 data from the population-based National Health andNutrition Examination Survey (NHANES) revealed that just 57% ofadults with diabetes surveyed met the recommended A1C target of7.0% or lower (12). After reviewing 2966 medical records of type 2diabetes patients from primary, secondary, and tertiary hospitals inthe Jiangsu province of China, Bi et al. (13) reported only 56%attained A1C <7.0%.

Although only 57% of DM-SCAN patients achieved the LDL-Ctarget of �2.0 mmol/L, it is somewhat reassuring because only64% of DRIVE patients met the higher <2.5 mmol/L target. Thissuggests that physicians are aware of and are more confident atapplying CPGs recommendations to immediately achieve LDL-Ctargets in type 2 diabetes patients. The DM-SCAN results are notas positive as those found in the Canadian arm of the recentlycompleted DYSlipidemia International Study (DYSIS) where 63% of

Figure 3. Lipid control and management of DM-SCAN patients. (A) Distribution ofblood pressure levels. (B) Distribution of antihypertensive therapy strategiesprescribed to patients with BP �130/80 mm Hg. Values for (B) were determinedaccording to the corresponding number of patients with BP �130/80 mm Hg who wereknown to be treated with antihypertensive agents.

Table 4Temporal glycemic, lipid and blood pressure controldfrom DICE to DRIVE toDM-SCAN

DICE(2002e2003)N¼2473

DRIVE(2005e2006)N¼3002

DM-SCANNoveDec2012N¼5123

Women 46 41 46Age at audit (years)* 63 64 64Duration of type 2 diabetes (years)* 7.8 6.0 9.2Body mass index (kg/m2)* 31 30 31On insulin 12 15 16A1C (%)* 7.3 6.9 7.4A1C <7.0%y or �7.0%z 51z 53{ 50{

LDL-C (mmol/L)* NA 2.2 2.1LDL-C <2.5 mmol/Ly or �2.0 mmol/Lz NA 64y 57z

Blood pressure (mm Hg)*

Systolic NA 130 128Diastolic NA 78 75

Blood pressure �130/80 mm Hgy or<130/80 mm Hgz

NA 54y 36z

Triple target achievementA1C �7.0%, LDL-C <2.5 mmol/L,

BP �130/80 mm HgNA 19 ND

A1C �7.0%, LDL-C �2.0 mmol/L,BP <130/80 mm Hg

NA ND 13

LDL-C, low-density lipoprotein cholesterol; NA, not available; ND, not determined.Data are presented as %.

* Mean for DICE and DM-SCAN, median for DRIVE.yz{ Targets for DICE, DRIVE and DM-SCAN were different; symbols denote corre-sponding targets of the individual study.

L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89 87

Author's personal copy

all patients were at recommended or intervention target LDL-Clevels (19). Neither do the DM-SCAN results appear as promisingas those of the Canadian Lipid Study-Observational (CALIPSO)where only 27% of patients audited were not at the recommendedLDL-C (20). It is, however, important to remember that the DYSISand CALIPSO analyses were based on LDL-C thresholds recom-mended in the 2006 Canadian Cardiovascular Society (21) and the2003 CanadianWorking Group on Hypercholesterolemia and OtherDyslipidemias (22) CPGs, respectively, both of which were higherthan that in the 2009 Canadian Lipid CPGs (17) The disparitybetween the DM-SCAN, DYSIS and CALIPSO results are also likelyreflective of our subanalysis demonstrating that a greaterpercentage of patients with cardiovascular disorders reached theLDL-C target than those who did not present with any cardiovas-cular abnormalities. The apparent discrepant care between type 2diabetes patients with and without cardiovascular disease haspreviously been reported by the investigators of the Analysis andUnderstanding of Diabetes and Dyslipidaemia: Improving Treat-ment (AUDIT) study (23). The AUDIT survey found that physicianstended to treat type 2 diabetes patients with cardiovascular diseasemore intensively than they did those without cardiovasculardisease suggesting that at least at the time of the study, type 2diabetes had yet to be recognized by physicians as a majorcardiovascular risk factor.

Blood pressure distribution was similar in the DM-SCAN andDRIVE studies (Table 4) as were the use of ACE inhibitors (59%DM-SCAN vs. 61% DRIVE) and ARBs (35% DM-SCAN vs. 27% DRIVE).Target BPachievement rate, although still suboptimal,was greater intheDRIVE study (54%vs. 36%) andmayhave resulted inpart fromtheslightly less stringent BP target (�130/80mmHgvs.<130/80mmHgfor DM-SCAN). The investigators of the 2006 Ontario Survey on thePrevalence and Control of Hypertension also observed suboptimalblood pressure control in the Canadian diabetes community. Theyreported that 50% of individuals with type 2 diabetes had hyper-tension, amongst whom 97% were receiving antihypertensivetreatment but only 36% had BP values <130/80 mm Hg (24).

Global vascular protection is acknowledged as the cornerstoneto managing type 2 diabetes patients. Only 13% of the DM-SCANpatients achieved the composite target of A1C �7.0%, LDL-C�2.0 mmol/l and BP <130/80 mm Hg. This is lower than the 19%success rate reported for the DICE patients (8) who had less intenseLDL-C and BP targets but very similar to the 2003e2006 NHANESdata showing 13% of type 2 diabetes patients successfully achievingall 3 primary goals for A1C (<7.0%), LDL-C (<2.6 mmol/L) and BP(<130/80 mm Hg) (12). The investigators of the InternationalDiabetes Management Practice Study recently reported that indeveloping regions only 3.6% of 3896 type 2 diabetes patients metthe composite goal of A1C<7.0%, LDL-C and BP (25). Clearly, greaterefforts are needed to bring more patients to the triple therapeuticgoal to achieve maximal vascular protection.

The results of the DM-SCAN survey have important implicationsfor the implementation of the 2013 CDA CPGs. It is evident thatinnovative strategies are necessary to emphasize to physicians theimportance of adopting and translating evidence-based CPGs intoevery day clinical care. It is imperative too that a variety of easilyaccessible education platforms be established to provide physicianswith practical means of overcoming clinical inertia and strategies tomore effectively educate their patients at self-managing and self-monitoring to enhance accountability. Initiatives aimed at encour-aging greater collaboration between primary care physicians,specialists and allied healthcare personnel in a patient-centricnetwork as well as increasing patient adherence are alsowarranted. For instance, in recognition of the strong evidence forbetter patient outcomes with nurse- and pharmacist-directed care(26,27), Hypertension Canada has expanded its audience to includenurses and pharmacists (28). Some other avenues that may be

worthwhile exploring include increased accessibility of CPGs,treatment algorithms and information on newer AHA classesthrough mobile applications; and novel formats for “live” andonline continued medical education events.

This survey has several limitations. First, the recruitment strat-egies used may have resulted in an overrepresentation of physi-cians who are more proactive at improving their management oftype 2 diabetes patients and thus more open to participating ina survey such as DM-SCAN. Second, it is possible that patients withwell-controlled A1C, or those treated with insulin, consult theirphysicians more regularly and therefore were more likely to beenrolled that may account in part for the large proportion ofpatients reported to be on insulin therapy. Additionally, we areunable to confirm that physicians enrolled consecutive patients andprovided information for all patients seen over a single clinic day.Third, laboratory values were obtained frommedical records ratherthan through central laboratory evaluations. Furthermore, therewere no attempts to confirm the accuracy of the data providedagainst the source documents. Fourth, we did not request infor-mation on baseline/earlier glycemic, lipid and BP parameters andtherefore cannot comment on whether patients were managedappropriately. We also therefore cannot comment on patients whohave type 2 diabetes who were seen but were excluded due to theabsence of an A1C reading. Fifth, although we did collect data onwhether lifestyle modifications were recommended, we did notobtain details on patient lifestyle, nor on drug side effects andtreatment adherence. This survey does have several strengths. First,this was a large nationwide initiative with representation froma variety of primary care settings in different geographical loca-tions. Second, there were very few missing A1C (0.4%), SBP (0.4%),DBP (0.5%) and LDL-C (1.1%) values suggesting high accuracy of thetarget achievement rates calculated. Finally, the requirement thatphysicians report on all the type 2 diabetes patients whom theysaw in the single day may have in some cases reduced the chancesof patient selection and may be in these cases be more reflective of“real world” settings.

Conclusions

Despite widespread attempts at dissemination and imple-mentation of practice CPGs, and advances in type 2 diabetespharmacotherapy, the results of the DM-SCAN survey accentuatethe persistent treatment gap associated with the treatment of type2 diabetes. This survey also highlights the continual challengesfaced by primary care physicians to gain and maintain glycemiccontrol as well as achieve global vascular protection in type 2diabetes patients. Practical strategies aimed at more aggressivelymanaging type 2 diabetes patients and their risk factors to moreeffectively surmount the collective barriers in closing the ongoingcare gap are urgently needed.

Acknowledgments

The Diabetes Mellitus Status in Canada (DM-SCAN) survey wasmade possible through the support of Merck Canada Inc. Theopinions expressed in this material are those of the authors and donot necessarily reflect the views of Merck Canada Inc.

Author Disclosures

LAL has received honouraria or research support from Amgen,AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly,GlaxoSmithKline, Janssen, Merck, Novartis, Novo Nordisk, Sanofi,Servier and Takeda. LB has received honouraria or research supportfrom AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck,Novo Nordisk and Sanofi. CKB has received honouraria or research

L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e8988

Author's personal copy

support from AstraZeneca, Boehringer Ingelheim, Bristol-MyersSquibb, Eli Lilly, Merck, Novartis, Novo Nordisk, Pfizer and Sanofi.AYC has received honouraria or research support from Abbott,AstraZeneca- Bristol-Myers Squibb, Becton Dickinson, Eli Lilly, EliLilly, Lifescan, Merck, Novo Nordisk, Sanofi and Servier. KGD hasreceived honouraria or research support from GlaxoSmithKline,Lifescan, Lilly, Merck, Novo Nordisk and Sanofi. J-ME has receivedhonouraria or research support from Merck. CF has received hon-ouraria or research support from Amgen, AstraZeneca, BoehringerIngelheim, Bristol-Myers Squibb, Forrest, Janssen, Sanofi, Takedaand Valeant. LG has no conflicts of interest to declare. SBH hasreceived honouraria or research support from AstraZeneca- Bristol-Myers Squibb, Boehringer Ingelheim-Eli Lilly, Janssen, Merck,NovoNordisk, Roche, Sanofi and Takeda. PL has received honourariaor research support from AstraZeneca, Boehringer Ingelheim, EliLilly, Merck, NovoNordisk, Sanofi and Takeda. TR has receivedhonouraria or research support from AstraZeneca, BoehringerIngelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Merck,Novartis, NovoNordisk and Sanofi. MT has no conflicts of interest todeclare. HT has no conflicts of interest to declare. RTT has receivedhonouraria or research support from Abbott, AstraZeneca, Bristol-Myers Squibb-AstraZeneca, Boehringer Ingelheim, Merck, Phar-maSmart and Sanofi. DW has no conflicts of interest to declare. VWhas received honouraria or research support from AstraZeneca,Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Forrest,Janssen, Merck, Novo Nordisk and Sanofi. J-FY has receivedhonouraria or research support from AstraZeneca, BoehringerIngelheim, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck, NovoNordisk, Sanofi and Takeda. AL has received honouraria or researchsupport from Actelion, AstraZeneca, Aventis, Bayer, Biovail, BostonScientific, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partner-ship, Cordis, Guidant, Medtronics, Merck, Millennium Pharmaceu-ticals, Ortho Biotec, Oryx, Pfizer, Roche, Sanofi-Synthelabo,Schering Key Corporation, Servier, The Medicines Company andUnited Therapeutics.

Author Contributions

LAL designed the study, researched the data, contributed to thediscussion, wrote the manuscript and edited the manuscript. LBcontributed to the discussion and reviewed the manuscript. CKBcontributed to the discussion and reviewed the manuscript. AYCcontributed to the discussion and reviewed the manuscript. KGDcontributed to the discussion and reviewed the manuscript. J-MEcontributed to the discussion and reviewed the manuscript. CFcontributed to the discussion and reviewed the manuscript. LGdesigned the study, researched the data, contributed to thediscussion and reviewed the manuscript. SBH contributed to thediscussion and reviewed the manuscript. PL contributed to thediscussion and reviewed the manuscript. TR contributed to thediscussion and reviewed the manuscript. MT researched the data,contributed to the discussion, and reviewed the manuscript. HTresearched the data, wrote the manuscript and edited the manu-script. RTT contributed to the discussion and reviewed the manu-script. DW contributed to the discussion and reviewed themanuscript. VW contributed to the discussion and reviewed themanuscript. JFY contributed to the discussion and reviewed themanuscript. AL designed the study, researched the data, contrib-uted to the discussion and reviewed the manuscript.

References

1. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of ClinicalEndocrinologists Medical Guidelines for clinical practice for developing a dia-betes mellitus comprehensive care plan. Endocr Pract 2011;17:287e302.

2. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia intype 2 diabetes: a patient-centered approach. Position statement of theAmerican Diabetes Association (ADA) and the European Association for theStudy of Diabetes (EASD). Diabetologia 2012;55:1577e96.

3. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee.Canadian Diabetes Association 2008 clinical practice guidelines for the preven-tion and management of diabetes in canada. Can J Diabetes 2008;32:S1e201.

4. Published by National Institute for Health and Clinical Excellence, Manchester,United Kingdom. Preventing type 2 diabetes: risk identification and interven-tions for individuals at high risk. 2012.

5. International Diabetes Federation Clinical Guidelines Task Force. Globalguideline for type 2 diabetes. 2012. http://www.idf.org/sites/default/files/IDF%20Guideline%20for%20Type%202%20Diabetes.pdf.

6. Holman RR, Paul SK, Bethel MA, et al. Ten-year follow-up of intensive glucosecontrol in type 2 diabetes. N Engl J Med 2008;359:1577e89.

7. Gaede P, Lund-Andersen H, Parving HH, et al. Effect of a multifactorial inter-vention on mortality in type 2 diabetes. N Engl J Med 2008;358:580e91.

8. Braga MF, Casanova A, Teoh H, et al. Poor achievement of guidelines-recommended targets in type 2 diabetes: findings from a contemporaryprospective cohort study. Int J Clin Pract 2012;66:457e64.

9. Brown LC, Johnson JA, Majumdar SR, et al. Evidence of suboptimal managementof cardiovascular risk in patients with type 2 diabetes mellitus and symp-tomatic atherosclerosis. CMAJ 2004;171:1189e92.

10. Harris SB, Ekoe JM, Zdanowicz Y, et al. Glycemic control and morbidity in theCanadian primary care setting (results of the diabetes in Canada EvaluationStudy). Diabetes Res Clin Pract 2005;70:90e7.

11. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular diseaseamong adults with previously diagnosed diabetes. JAMA 2004;291:335e42.

12. Cheung BM, Ong KL, Cherny SS, et al. Diabetes prevalence and therapeutictarget achievement in the United States, 1999 to 2006. Am J Med 2009;122:443e53.

13. Bi Y, Zhu D, Cheng J, et al. The status of glycemic control: a cross-sectionalstudy of outpatients with type 2 diabetes mellitus across primary, secondary,and tertiary hospitals in the Jiangsu Province of China. Clin Ther 2010;32:973e83.

14. Fox KM, Gerber RA, Bolinder B, et al. Prevalence of inadequate glycemic controlamong patients with type 2 diabetes in the united kingdom general practiceresearch database: a series of retrospective analyses of data from 1998 through2002. Clin Ther 2006;28:388e95.

15. Al Hamarneh YN, Rosenthal M, Tsuyuki RT. Glycemic control in community-dwelling patients with type 2 diabetes. Can Pharm J 2012;145:68e70.

16. World Health Organization Expert Consultation. Appropriate body-mass indexfor Asian populations and its implications for policy and intervention strate-gies. Lancet 2004;363:157e63.

17. Genest J, McPherson R, Frohlich J, et al. 2009 Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia andprevention of cardiovascular disease in the adultd2009 recommendations.Can J Cardiol 2009;25:567e79.

18. Canadian Hypertension Education Program. The 2012 CHEP recommendationsfor the management of hypertension. 2012. http://www.hypertension.ca/chep-recommendations.

19. Goodman SG, Langer A, Bastien NR, et al. Prevalence of dyslipidemia in statin-treated patients in Canada: results of the Dyslipidemia International Study(DYSIS). Can J Cardiol 2010;26:e330e5.

20. Bourgault C, Davignon J, Fodor G, et al. Statin therapy in Canadian patients withhypercholesterolemia: the Canadian Lipid Study-Observational (CALIPSO). CanJ Cardiol 2005;21:1187e93.

21. McPherson R, Frohlich J, Fodor G, et al. Canadian Cardiovascular Societyposition statementdrecommendations for the diagnosis and treatment ofdyslipidemia and prevention of cardiovascular disease. Can J Cardiol 2006;22:913e27.

22. Genest J, Frohlich J, Fodor G, et al. Recommendations for the management ofdyslipidemia and the prevention of cardiovascular disease: summary of the2003 update. CMAJ 2003;169:921e4.

23. Leiter LA, Betteridge DJ, Chacra AR, et al. Audit study. Evidence of globalundertreatment of dyslipidaemia in patients with type 2 diabetes mellitus. CanJ Diabetes Vasc Dis 2006;6:31e40.

24. Leenen FH, Dumais J, McInnis NH, et al. Results of the Ontario survey on theprevalence and control of hypertension. CMAJ 2008;178:1441e9.

25. Chan JC, Gagliardino JJ, Baik SH, et al. Multifaceted determinants for achievingglycemic control: the International Diabetes Management Practice Study(IDMPS). Diabetes Care 2009;32:227e33.

26. Santschi V, Chiolero A, Paradis G, et al. Pharmacist interventions to improvecardiovascular disease risk factors in diabetes: a systematic review andmeta-analysis of randomized controlled trials. Diabetes Care 2012;35:2706e17.

27. Watts SA, Gee J, O’Day ME, et al. Nurse practitioner-led multidisciplinary teamsto improve chronic illness care: the unique strengths of nurse practitionersapplied to shared medical appointments/group visits. J Am Acad Nurse Pract2009;21:167e72.

28. Campbell NR, Poirier L, Tremblay G, et al. Canadian Hypertension EducationProgram: the science supporting new 2011 CHEP recommendations with anemphasis on health advocacy and knowledge translation. Can J Cardiol 2011;27:407e14.

L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89 89