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Transcript of Www.dmscan.ca The DM-SCAN program has been made possible through the support of Merck Canada Inc....
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The DM-SCAN program has been made possible through the support of Merck Canada Inc. The opinions expressed in this material are those of the authors and do not necessarily reflect the views of Merck Canada Inc.
Steering Committee MembersWestern Canada:
Lori Berard, RN, CDE – Nurse and Certified Diabetes Educator – Winnipeg, MBKeith Bowering, MD – Endocrinologist – Edmonton, ABKeith Dawson, MD – Endocrinologist – Vancouver, BCRoss Tsuyuki, PharmD – Academic Pharmacist – Calgary ABVincent Woo, MD – Endocrinologist – Winnipeg, MB
Ontario:Alice Cheng, MD – Endocrinologist – Toronto, ONStewart Harris, MD – Primary Care Physician/Diabetes Expert – London, ONAnatoly Langer MD – Cardiologist – Toronto, ONLawrence Leiter, MD (Chair) – Endocrinologist – Toronto, ONPeter Lin, MD – Primary Care Physician – Toronto, ONDana Whitham, RD, MSc, CDE – Dietitian and Certified Diabetes Educator – Toronto, ON
Quebec:Jean-Marie Ekoé, MD – Endocrinologist – Montreal, QCCarl Fournier, MD – Primary Care Physician – Montreal, QC Jean-Francois Yale, MD – Endocrinologist – Montreal, QC
Atlantic Canada:Thomas Ransom, MD – Endocrinologist – Halifax, NS
Program Objectives• To evaluate and gain insight into the current
status and management of patients with Type 2 Diabetes in Canada in the primary care setting
• To highlight the public health burden of Type 2 Diabetes
• To identify management gaps to help design educational programs of practical value to primary care physicians
Program OverviewAssess the current management of
patients with type 2 diabetes by completing a simple one-page Data
Collection Form on ALL patients seen as part of routine clinical practice on or as close as possible to World Diabetes Day
(November 14, 2012)
National Physician and Patient Representation
ABMDs – n=29DCFs – n=233
BCMDs – n=41 DCFs – n=365
MBMDs – n=19 DCFs – n=249
SKMDs – n=3 DCFs – n=21
ONMDs – n=270
DCFs – n=2990
QCMDs – n =45 DCFs – n=400
NB-PEIMDs – n=27 DCFs – n=362
NSMDs – n=28 DCFs – n=295
NLMDs – n=17
DCFs – n=208
MDs – N = 479DCFs – N = 5123• Avg. number of DCF*s/MD - 11
* DCF – Data Collection Form
Practice Setting
41%
59%
Solo PracticeGroup Practice
50% of the physician participants identified being a part of a Family Health Team
Physician Practice – Geographic Setting
16%
21%63%
Inner CitySmall Town / RuralUrban / Suburban
Practice Survey Question:On average, how many patients with Type 2 Diabetes
do you see in a week?
Number of patients % - physician responses
Less than 5 1%
5 to 10 13%
10 to 20 36%
20 to 30 27%
30 to 50 16%
More than 50 7%
Percent of patients % - physician responses
None 3%
1 to 25% 56%
26 to 50% 19%
> 50% 22%
Practice Survey Question:Approximately what proportion of your patients have their type 2 diabetes co-managed by an allied health care professional (in your
office or local diabetes education centre)?
Practice Survey Question:Please identify the greatest barriers to managing
patients with diabetes:
Top Five Responses:
1. Patient non-compliance2. Patient resistance3. Constraints on physician’s time4. Financial barriers5. Lack of support for the physician
Patient Demographics
* Data presented as mean (SD)Female Sex: n=2353 Available Records 4707Age: n=5090Duration of T2DM: n=5062
46%Age* 64 (12)
Duration of T2DM* 9 (7)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Patient Ethnicity
Aboriginal Canadian 3%
Black 4%
Caucasian 61%
East / SE Asian 17%
Hispanic 2%
South Asian 11%
Other 3%
N = 4971
152 records unavailable
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Summary of Patient BMI Categories
Category Percent of Patients
Normal Weight 14%
Overweight 29%
Obese 57%
Body Mass Index (kg/m2) Mean (SD)Men 30.5 (10)Women 31.1 (11.6)
N = 5123*
N for each category was variable due to missing values, <10% in each case.
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Health Behaviours
38% of patients had been referred to or counselled by a registered dietitian or a certified diabetes educator within the last 12 months (n=4787)
50% of patients had a nutrition / exercise / weight loss plan with measurable goals established in the past 12 months (n=4776)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Glycemic and Renal Profile
Measure N Mean + SD Guideline Recommendations
A1C (%) 5103 7.4 + 1.3 <7.0%
Fasting Plasma Glucose (mmol/L) 4761 7.8 + 2.6 4.0 – 7.0
Creatinine (µmol/L) 4890 86 + 124 N / A
eGFR (mL/min) 4615 75.2 + 44.1 N / A
Urine Albumin Creatinine Ratio (mg/mmol) 3957 10.7 + 48.4 <2.0 (men) <2.8 (women)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Insulin Use by Number of Injections per Day
1 Injection / day 2 injections / day 3 injections / day 4 injections / day > 4 injections / day0%
20%
40%
60%
9%
29%
15%
40%
7%
28% 28%
13%
27%
5%
Insulin Only Insulin + NIAHA*
% o
f pati
ents
* NIAHA – Non Insulin Antihyperglycemic Agent
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Glycemic Management
N = 4477
Medical Management N % of Patients
1 NIAHA* - 85% treated with Metformin 802 18%
2 NIAHAs 673 15%
≥ 3 NIAHAs 261 6%
Insulin alone 854 19%
Insulin + ≥ 1 NIAHAs 1887 42%
* NIAHA - non-insulin antihyperglycemic agent
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
A1C Values AchievedN = 5103
Target Achieved ≤6.5%
Target Achieved ≤7.0%
≤7.5% ≤8% ≤8.5% ≤ 9.0%0%
20%
40%
60%
80%
100%
28%
50%
67%
78%
86%91%
% o
f pati
ents
A1C (%)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
In 81% of patients, the A1C goal set by the physicians was ≤7%.
A1C <7% Attainment Rates based on Duration of Diabetes
≤2 years 3-5 years 6-9 years 10-14 years >15 years0%
20%
40%
60%
80%
65%
58%
49%
43%
37%
Duration of Diabetes (years)
% o
f pati
ents
– A
1C <
7%
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Lipid Profile
N = 5069
Measure Mean + SD Guideline Recommendations
LDL 2.1 + 0.9 <2.0 mmol/L
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Lipid Management
Management % of Patients
Monotherapy 88%
Statin alone 85%
2 Lipid Lowering Agents 11%
Statin + Cholesterol Absorption Inhibitor 8%
> 2 Lipid Lowering Agents <1%
N = 4153
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
LDL-C Values Achieved
N = 5069
Target Achieved ≤2.0 ≤2.5 ≤3.0 ≤3.50%
20%
40%
60%
80%
100%
57%
75%
86%
93%
% o
f pati
ents
LDL-C (mmol/L)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
LDL-C Values Achieved – Presence and Absence of Vascular Disease
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Lipid Control and Management of DM-SCAN Patients
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Blood Pressure Profile
Systolic Blood Pressure: N = 5103, Diastolic Blood Pressure: N = 5099
Measure Mean + SD Guideline Recommendations
SBP 128 + 14 < 130 mm Hg
DBP 75 + 9 < 80 mm Hg
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Blood Pressure Management
N = 4946Management % of Patients
BP recorded (Nov / Dec 2012) 70%
Not treated with BP medication 17%
N = 4272Monotherapy 39%
2 Agents 34%
3 Agents 21%
3+ Agents 6%
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Blood Pressure Values AchievedN = 5099
Target Achieved SBP < 130 / DBP < 80
<135 / <85 <140 / <90 <145 / <95 <150 / <1000%
20%
40%
60%
80%
100%
36%
69%
79%
90%93%
% o
f pati
ents
SBP / DBP (mm Hg)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Distribution of Antihypertensive Therapy Strategies Prescribed to Patients with Blood
Pressure >130/80 mmHg
N = 1494
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Guideline Targets Achieved for A1C, LDL-C and Blood Pressure
A1C (≤7%) (n=5103) LDL-C (≤2.0 mmol/L) (n=5069)
SBP/DBP (<130/80 mm HG) (n=5099)
All 3 Endpoints (A1C, LDL-C,
BP) (n=5104)
0%
20%
40%
60%
50%
57%
36%
13%
% o
f pati
ents
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Patient Comorbidities
Depression
Cancer
Erectile Dysfunction (n=2313)
Neuropathy
Nephropathy
Retinopathy
Atrial Fibrillation
PAD
Stroke / TIA
CAD
0% 20% 40% 60%
12%
12%
39%
12%
15%
8%
7%
8%
6%
22%
% of patients
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Has glycemic management improved over the last decade?
DICE(2002-2003)
N = 2473
DRIVE(2005-2006)
N = 3002
DM-SCAN(Nov-Dec 2012)
N=5123
Age at audit, years 62.7 63 64
Time since diagnosis, years 7.8 8.1 9.2
Female, % 46 41 46
BMI, kg/m2 31 31 31
A1C, % 7.3 7.2 7.4
A1C >7.0%, proportion of patients 49 47 50
1Harris S, et al. Diabetes Res Clin Prac. 2005;70(1):90-97.2Braga M, et al. Can J Cardiol. 2010;26(6):297-302.
Note: All data reported as mean