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2010 (Oct) Canadian Diabetes Association Annual Conference, Aboriginal health Symposium facilitated by BRAID Research
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“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 [email protected]
Dr Ellen Toth: 780 - [email protected]
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 [email protected]
Dr Ellen Toth: 780 - [email protected]
www.braiddm.ca
ACADRE
