Download Diabetes In Canada Evaluation (The DICE Study)

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
The Complications of
Diabetes
Diabetes Complications
Macrovascular
Stroke
Microvascular
Diabetic eye disease
(retinopathy and cataracts)
Heart disease
and hypertension
Renal disease (Kidney)
Peripheral
vascular disease
Neuropathy
Ulcers and
amputation
Foot problems
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
Amputation
• Diabetes is the leading cause of nontraumatic amputation
• Increases the risk of amputation by 20 fold
Diabetes in Ontario, An ICES Practice Atlas, 2002
Diabetes Complications
Macrovascular
Stroke
Heart disease
and hypertension
Microvascular
Diabetic eye disease
(retinopathy and
cataracts)
Renal disease
(Kidney)
Peripheral
vascular disease
Neuropathy
Ulcers and
amputation
Foot problems
Retinopathy
• 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
Nephropathy
• 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
Diabetes Complications:
Other Problems
•
•
•
•
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
CDA, 2003 www.diabetes.ca
The Scope of the Problem
World-wide and Canada
The Worldwide Epidemic:
Diabetes Trends
Millions with Diabetes
400
370
350
300
300
250
221
177
200
135
150
100
50
30
0
1985
1995 2000
2010
www.who.int
www.idf
Zimmet P. et al Nature: 414, 13 Dec 2001
2025 2030
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
400,000
Persons with Diabetes
350,000
2000 (n=1.4 million)
2016 (n=2.5 million)
300,000
250,000
200,000
150,000
100,000
50,000
0
<5
5-9
10- 1514 19
2024
25- 30- 3529 34 39
4044
45- 5049 54
Age Group
* Source: Statistics Canada
5559
60- 6564 69
70- 75- 80+
74 79
Cost of Diabetes
• Cost of diabetes in Canada
–2002:
–2010:
–2020:
$13.2 billion
$15.2 billion
$19.2 billion
Portion Size: 1950s to 2000
The Economist,
December 13th-19th,
2003
Millions of years
< 30 years
Revisiting the Guidelines
Screening and
Prevention
Glycemic Management
Targets
Monitoring
Treatment paradigm
Macrovascular
Complications
BP and lipid targets
A Growing Divide
Evidence
Behaviour
How can we facilitate
translating science to better
outcomes?
UKPDS: -Cell Loss Over Time
-Cell Function (%)*
100
75
Patients treated
with insulin,
metformin,
sulfonylureas‡
50
25
IGT†
0
-12 -10
Type 2
Postprandial
Diabetes
Hyperglycemia
Phase I
-6
-2 0
Type 2
Diabetes
Phase II
2
6
Years From Diagnosis
Lebovitz HE. Diabetes Rev. 1999;7:139-153.
Type 2 Diabetes
Phase III
10
14
Diabetes Management
(It’s Not Just About Blood Glucose)
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:
BP:
Cholesterol:
≤7.0% (or ≤6.0%)
≤130/80 mm Hg
LDL-C <2.5 mmol/L
Management of diabetes requires attention to all
factors that increase the risk of complications
Glycemic Management
Blood Glucose Targets*
A1C (%)
Target for
≤7.0
most
people with
DM
Normal (if
≤6.0
safely
achievable)
FPG
(mmol/L)
2hPG
(mmol/L)
4-7
5 - 10
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
4
Any DM endpoint: 21% 
Hazard ratio
1
(p<0.0001)
4
Deaths related to DM: 21% 
(p<0.0001)
1
4
All-cause mortality: 14% 
(p<0.0001)
1
5
6
7
8
9
10
Updated mean A1C (%)
Stratton et al. UKPDS 50. Diabetologia
2001;44:156-63.
Treat to Fail:
Traditional Stepwise Approach
+ OAD
Diet & Exercise monotherapy
+ OAD
combination
+ OAD
+ complex insulin
+ basal insulin
regimen
HbA1c (%)
10
9
8
7
6
Diagnosis
+5 yrs
+10 yrs
Duration of diabetes
+15 yrs
Treat to Succeed:
Early Combination Approach
Diet & Exercise
+ OAD combination
OAD + basal insulin
HbA1c (%)
9
complex insulin regimen
8
7
6
Diagnosis
+5 yrs
+10 yrs
Duration of diabetes
+15 yrs
UKPDS Demonstrated Loss of Glycemic
Control With All agents Studied
A1C (%)
9
8
Conventional
Glyburide
Chlorpropamide
Metformin
Insulin
7
Upper limit of of normal = 6.2%
6
0
0
2
4
6
8
Years from randomization
UK Prospective Diabetes Study Group. UKPDS 34. Lancet 1998; 352:854–865.
10
Overweight patients
Cohort, 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
Polypharmacy
A reality in modern diabetes
management
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.
A solution to help improve
adherence…
The Pill Burger
Who is Providing DM Care?
7%
1%
18%
Family MD +
specialist
Family MD alone
Specialist alone
No DM care
74%
Hux JE et al. Diabetes in Ontario, an ICES Practice Atlas, 2003
DICE:
Diabetes in Canada Evaluation
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
Patients averaged eight FP visits in the past year and
half of visits were for diabetes-related issues.
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%
Glycemic Control in Canada
One in two type 2 diabetes patients in Canada are not
at target (< 7%). Mean A1C = 7.3%
Most recent A1C test results (n = 2,337)
Uncontrolled A1c
49%
Controlled A1c
51%
Glycemic Control
Over Duration of Disease
Control erodes the longer patients have type 2 diabetes
and only 38% of patients who have had diabetes for 15+
years are well controlled.
Patients at target (%)
(A1c < 7%)
100
80
69%
58%
60
47%
38%
40
33%
20
0
≤ 2 years
(n = 449)
3-5 years
(n = 591)
6-9 years
(n = 455)
10-14 years
(n = 364)
15+ years
(n = 310)
Glycemic Management
Sample
Total
2,473
Lifestyle only
1 oral agent - no insulin
15%
36%
2 oral agents - no insulin
3+ oral agents - no insulin
30%
8%
Insulin only - No oral agents
1 oral agent + insulin
2+ oral agents + insulin
6%
3%
2%
51% of patients
using lifestyle
modifications
or one oral
agent only
Glycemic Management:
Drug Class
Most patients are managed with traditional agents.
Metformin
61%
Sulfonylureas net
48%
15%
TZDs net
Other oral agents
net
Insulin
Lifestyle only
0
4%
12%
15%
20
40
60
80
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.
100
Major Challenges to Improving A1c
For Patients Not at Target
Non-compliance with lifestyle modifications are the major
barriers to achieving A1c targets.
Total
Sample
Patients
with most
recent A1c
≥ 7.0 and
have target
A1c
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%
Plans to Achieve Target
More aggressive treatment is planned for only half of
these patients.
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%
Patients with most recent A1c ≥ 7.0 and have target A1c
Glycemic Control and Disease Burden
Treatment strategies may not be aggressive
enough to control all patients, particularly those
who have had the disease the longest.
Patients (%)
100
90
80
70
67%
60
50
40
31%
30
21%
20 17%
53%
42%
32%
22%
62% 62%
52%
44%
42%
32%
25%
10
0
≤ 2 years
3 - 5 years
Macrovascular
complications
6 - 9 years
Microvascular
complications
10 - 14 years
15+ years
A1C ≥ 7%
High Disease Burden
The burden associated with type 2 diabetes in Canada is high
for patients and physicians managing this complex disease.
100
90
80
70
60
63%
59%
38%
50
40
30
20
10
0
28%
Hypertension
Dyslipidemia
Macrovascular
Conditions
Microvascular
Conditions
Base: Patients (n = 2,473)
Macrovascular conditions include stable angina, MI, CHF, prior stroke, peripheral vascular disease, left ventricular hypertrophy
Microvascular conditions include microalbuminuria, cataracts neuropathy, diabetic retinopathy, nephropathy, diabetic foot disease,
prior amputation
* Among men
Other Medications
(non-antihyperglycemic agents)
Taking multiple medications may be a complex burden
for the type 2 diabetic patient.
Anti-hypertensive
agents**
73%
Cholesterol-lowering
agents**
51%
Other heart-related
agents**
56%
Other
medications
24%
0
20
40
60
80
Patients currently taking medication (%)
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.
100
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.