Peggy Dunbar

Evidence-Informed Guidelines for Treating Frail Older Adults With Type 2 Diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) Program

Clinical practice guidelines specific to the medical care of frail older adults have yet to be widely disseminated. Because of the complex conditions associated with frailty, guidelines for frail older patients should be based on careful consideration of the characteristics of this population, balanced against the benefits and harms associated with treatment. In response to this need, the Diabetes Care Program of Nova Scotia (DCPNS) collaborated with the Palliative and Therapeutic Harmonization (PATH) program to develop and disseminate guidelines for the treatment of frail older adults with type 2 diabetes. The DCPNS/PATH guidelines are unique in that they recommend the following: 1. Maintain HbA1c at or above 8% rather than below a specific level, in keeping with the conclusion that lower HbA1c levels are associated with increased hypoglycemic events without accruing meaningful benefit for frail older adults with type 2 diabetes. The guideline supports a wide range of acceptable HbA1c targets so that treatment decisions can focus on whether to aim for HbA1c levels between 8% and 9% or within a higher range (ie, >9% and <12%) based on individual circumstances and symptoms. 2. Simplify treatment by administering basal insulin alone and avoiding administration of regular and rapid-acting insulin when feasible. This recommendation takes into account the variations in oral intake that are commonly associated with frailty. 3. Use neutral protamine Hagedorn (NPH) insulin instead of long-acting insulin analogues, such as insulin glargine (Lantus) or insulin detemir (Levemir), as insulin analogues do not appear to provide clinically meaningful benefit but are significantly more costly. 4. With acceptance of more liberalized blood glucose targets, there is no need for routine blood glucose testing when oral hypoglycemic medications or well-established doses of basal insulin (used alone) are not routinely changed as a result of blood glucose testing.Although these recommendations may appear radical, they are based on careful review of research findings.

Determinants of lifestyle behavior in type 2 diabetes: results of the 2011 cross-sectional survey on living with chronic diseases in Canada.

BackgroundLifestyle behavior modification is an essential component of self-management of type 2 diabetes. We evaluated the prevalence of engagement in lifestyle behaviors for management of the disease, as well as the impact of healthcare professional support on these behaviors.MethodsSelf-reported data were available from 2682 adult respondents, age 20 years or older, to the 2011 Survey on Living with Chronic Diseases in Canada’s diabetes component. Associations with never engaging in and not sustaining self-management behaviors (of dietary change, weight control, exercise, and smoking cessation) were evaluated using binomial regression models.ResultsThe prevalence of reported dietary change, weight control/loss, increased exercise and smoking cessation (among those who smoked since being diagnosed) were 89.7%, 72.1%, 69.5%, and 30.6%, respectively. Those who reported not receiving health professional advice in the previous 12 months were more likely to report never engaging in dietary change (RR = 2.7, 95% CI 1.8 – 4.2), exercise (RR = 1.7, 95% CI 1.3 – 2.1), or weight control/loss (RR = 2.2, 95% CI 1.3 – 3.6), but not smoking cessation (RR = 1.0; 95% CI: 0.7 – 1.5). Also, living with diabetes for more than six years was associated with not sustaining dietary change, weight loss and smoking cessation.ConclusionHealth professional advice for lifestyle behaviors for type 2 diabetes self-management may support individual actions. Patients living with the disease for more than 6 years may require additional support in sustaining recommended behaviors.

Hypertension and type 2 diabetes: What family physicians can do to improve control of blood pressure - an observational study

BackgroundThe prevalence of type 2 diabetes is rising, and most of these patients also have hypertension, substantially increasing the risk of cardiovascular morbidity and mortality. The majority of these patients do not reach target blood pressure levels for a wide variety of reasons. When a literature review provided no clear focus for action when patients are not at target, we initiated a study to identify characteristics of patients and providers associated with achieving target BP levels in community-based practice.MethodsWe conducted a practice- based, cross-sectional observational and mailed survey study. The setting was the practices of 27 family physicians and nurse practitioners in 3 eastern provinces in Canada. The participants were all patients with type 2 diabetes who could understand English, were able to give consent, and would be available for follow-up for more than one year. Data were collected from each patients medical record and from each patient and physician/nurse practitioner by mailed survey. Our main outcome measures were overall blood pressure at target (< 130/80), systolic blood pressure at target, and diastolic blood pressure at target. Analysis included initial descriptive statistics, logistic regression models, and multivariate regression using hierarchical nonlinear modeling (HNLM).ResultsFifty-four percent were at target for both systolic and diastolic pressures. Sixty-two percent were at systolic target, and 79% were at diastolic target. Patients who reported eating food low in salt had higher odds of reaching target blood pressure. Similarly, patients reporting low adherence to their medication regimen had lower odds of reaching target blood pressure.ConclusionsWhen primary care health professionals are dealing with blood pressures above target in a patient with type 2 diabetes, they should pay particular attention to two factors. They should inquire about dietary salt intake, strongly emphasize the importance of reduction, and refer for detailed counseling if necessary. Similarly, they should inquire about adherence to the medication regimen, and employ a variety of patient-oriented strategies to improve adherence.

Hypertension control: results from the Diabetes Care Program of Nova Scotia registry and impact of changing clinical practice guidelines

BackgroundThe objective of this study was to determine the rate of blood pressure control according to 4 sets of Canadian guidelines published over a decade in patients with diabetes mellitus attending Diabetes Centres in the province of Nova Scotia.MethodsOne hundred randomly selected charts from each of 13 Diabetes Centres audited between 1997 and 2001 were extracted from the Diabetes Care Program of Nova Scotia Registry. Multivariate logistic regression analyses examined the relationship between individual characteristics and self-reported antihypertensive use. Included were 1132 adults, mean age 63 years (48% male), with 9 years mean time since diagnosis of diabetes.ResultsAccording to the 1992 guidelines, 63% of the patients and according to the 2003 guidelines, 84% of patients were above target blood pressure or receiving antihypertensive medications. Forty-seven percent of patients are considered to be hypertensive and not on treatment according to 2003 guidelines. The results of the multivariate analyses showed that the only factors independently associated with anti-hypertensive use was oral anti-hyperglycemic use.ConclusionHypertension is an additional risk factor in those with diabetes mellitus for macrovascular and microvascular complications. The health and budgetary impacts of addressing the treatment gap need to be further explored.

Profile of adults with type 2 diabetes and uptake of clinical care best practices: Results from the 2011 Survey on Living with Chronic Diseases in Canada – Diabetes component

AIMS This study aimed to (1) describe the profile of adults with type 2 diabetes (T2D) in Canada and (2) assess the uptake of clinical care best practices, as defined by the Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CPGs). METHODS We used data from the 2011 Survey on Living with Chronic Diseases in Canada - Diabetes component. Participants were aged 20 years and older, living in the 10 Canadian provinces, with self-reported T2D. Descriptive analyses present the prevalence of complications and comorbidities, as well as the level of clinical monitoring and self-monitoring/lifestyle management recommendations participants received. RESULTS We included 2335 participants with T2D, a mean age of 62.9 years, and high prevalence of complications/comorbidities and prescription medication use. Most participants reported being monitored as recommended for eye disease (73.9%), weight (81.0%), blood pressure (89.0%) and blood cholesterol levels (94.3%), but only 65.5% reported having at least two HbA1c tests during the last year and 46.5% reported an annual foot examination by a health professional. About two-thirds of the participants reported having received recommendations on weight management (59.9%) and physical activity (64.7%) from a health professional in the previous year; only 47.8% of the participants reported having received diet counseling to improve diabetes control. CONCLUSION Although the uptake of CDA CPGs for clinical and self-monitoring was high, with the majority of the participants reporting meeting most indicators, it was lower for HbA1c measurement and foot examination. Uptake of lifestyle management recommendations provided by health professionals was also significantly lower.

Development of Clinical Indicators for Type 2 Diabetes

Background/Objective:Preventable drug-related morbidity in patients with type 2 diabetes is a major concern. Our objective was to develop a set of Canadian clinical indicators of preventable drug-related morbidity (PDRM) and preventable care-related morbidity (PCRM) for type 2 diabetes.Methods:Each study partner (Dalhousie University, Nova Scotia Department of Health, Diabetes Care Program of Nova Scotia, and Sobeys Pharmacy Group) was asked to identify the priorities of medication-related diabetes care from the Canadian Diabetes Association 2003 clinical practice guidelines using the nominal group technique. Based on the priorities identified, a survey was constructed listing the clinical outcome and pattern of care related to a number of possible PDRMs/PCRMs in patients with type 2 diabetes. Using the Delphi technique, an interdisciplinary panel of 10 experts scored each clinical indicator in an attempt to achieve consensus.Results:Education/reinforcement of targets was identified by the nominal group t...

The Physical Activity and Exercise Tool-kit: Effectiveness of a new resource for diabetes educators

Physical activity and exercise (PAE) are essential in the prevention and management of diabetes. Diabetes educators (DEs) are often looked to as the primary source of information for those living with diabetes and are well positioned to provide counselling on PAE. However, DEs often receive little training in exercise prescription and do not feel adequately prepared to effectively counsel patients regarding PAE. While DEs’ personal perceptions (e.g., self-efficacy) have been shown to be key determinants of their behaviour, their beliefs in their clients’ abilities (e.g., other efficacy, perceived attitudes) have received little attention. The present study examined the effectiveness of the ‘Physical Activity and Exercise Tool-kit” in increasing both DEs’ perceptions surrounding PAE counselling and of their clients’ abilities in, and attitudes towards PAE. Using a 2 (group) by 2 (time) quasi-experimental design, DEs (N = 121) were assigned to either an intervention or standard care condition. The intervention group was provided with training on PAE counselling including the “Physical Activity and Exercise Tool-kit,” a theory driven, evidence based resource specifically designed for DEs. The standard care group was referred to Canada’s Physical Activity Guide. Measures of counselling efficacy, referral efficacy, attitudes, and perceived difficulty, as well as other efficacy, and perceived client attitudes were administered at baseline and 6 months. To examine the effectiveness of the ‘Tool-kit’ three separate repeated measures MANOVAs were conducted. Examination of DEs’ efficacy beliefs revealed a significant group by time interaction (p = .03). Follow-up tests indicated that the interaction was significant for counselling efficacy (p = .02) such that participants in the intervention group were more confident about PAE counselling at 6 months (M6mo = 68.3) as compared to baseline (Mbase = 54.0) and as compared to the standard care group at both time point (Mbase = 48.9, M6mo = 50.4). In addition, there were multiple significant main effects for time across the separate analyses. Follow-up tests revealed significant increases over time in DEs’ counselling efficacy (p = .01), perceived difficulty (p < .001) and confidence in their clients’ ability to manage PAE (p = .001). These findings suggest that the ‘Tool-kit’ represents an effective training resource for DEs in the area of PAE counselling. While there is the need for examination of the effectiveness of the ‘Tool-kit’ over the longer term, and on the translation of increased counselling efficacy to improved PAE counselling, the present study suggests that incorporation of the ‘Tool-kit’ may have best practice implications for the way in which PAE is promoted in diabetes care.