clinical practice guidelines dissemination strategy

abstract

involves multiple and demanding aspects related to self-monitoring of blood glucose, medical therapy often requiring adjustments, diet, lifestyle modification and continuous education and follow-up, compounds challenges for the homeless population. Effective and appropriate strategies are needed to address the complex health needs of this marginalized population. Project aim: Since 2008, Calgary area, Alberta Health Services, in partnership with the Calgary Drop-In & Rehab Centre has developed an innovative diabetes prevention and management project for people experiencing homelessness and poverty. The specific objectives are: to develop strong partnerships with homeless people and multiple stakeholders; to identify barriers experienced by homeless people and appropriate strategies for delivery of effective diabetes programs for homeless populations; to increase chances for early detection of diabetes and diabetes prevention and management skills. Further, the project aims to improve the external factors often impacting homeless people’s access to effective diabetes care. Methods: Using the Wagner Chronic Care Model as the guiding principal, the project provides innovative and accessible diabetes screening, prevention and management programs. In order to fully understand the complex needs of the target population, both homeless population and community partners are actively engaged in all stages of the project. All project activities are provided by a multidisciplinary team at the settings where homeless people congregate - Calgary DropIn & Rehab Centre. The project team is actively involved in improving the availability of diabetes medications and healthy foods to homeless people. results: More than 50% of the homeless people were identified atrisk for diabetes, 15-30% had elevated blood glucose and 10% had physician diagnosed diabetes. Access to appropriate primary care, prescription coverage, healthy food and housing were identified as major barriers to effective diabetes care. Innovative diabetes care approaches have resulted in enhanced awareness, access and patient outcomes. Stakeholders have become more responsive to the unique needs of the homeless population. conclusions: Active engagement of the homeless people and organizations serving the homeless and dealing with the “whole person” and “their world” are critical in identifying the barriers, needs and best strategies for effective diabetes care. This initiative could serve as a model for delivery of effective diabetes interventions for marginalized populations worldwide. Discrimination and diabetes No conflict of interest O-0259 organizing a strategic public health approach to addressing diabetes during disasters A. Albright1, P. Allweiss1, K. Ernst1, B. Rodriguez1 Centers for Disease Control & Prevention, Division of Diabetes Translation, Atlanta, USA

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aims: The need to treat chronic conditions is especially magnified when there are catastrophic disruptions of the medical infrastructure, when access to medical care and medications is severely compromised or completely cut-off, and when large-scale evacuations of the population occur. Since diabetes has reached epidemic proportions and has so many related co-morbidities, the need to prepare this vulnerable population at times of disasters has increased. Multiple sectors are involved in responding to emergencies so an integrated approach is necessary for developing preparedness plans. Plans need to address pre, during, and post disaster issues. Methods/results: The U.S. Centers for Disease Control and Prevention (CDC) has organized a work group in the Division of Diabetes Translation (DDT) to facilitate and provide leadership to enhance a public health response to diabetes during disasters. The areas of focus are: (1) Educating personnel dedicated to emergency preparedness

within CDC about diabetes and other chronic diseases; (2) Forming partnerships with and training first responders, shelter personnel, health care providers, and pharmaceutical/device companies to increase capability for emergency response; (3) Providing diabetes-related educational tools and data to prepare for and respond to emergencies. Discussion/conclusion: The CDC’s mission is collaborating to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats. As part of fulfilling this mission, DDT is actively working to improve the emergency response for those with diabetes and other chronic conditions during disasters. Prevalence of diabetes at the county level is being introduced to several groups to aid in preparing for emergencies and is being used in preparedness drills at CDC. Training and educational materials for various audiences have been developed by CDC and several partners are available for use. Efforts are underway to hold a meeting to discuss medication/supply distribution and stockpile issues to be more effectively prepared for disasters. Strategies used, lessons learned, materials developed and future plans will be discussed. Disasters and diabetes No conflict of interest O-0360 clinical practice guidelines dissemination strategy I. Blumer2, A. Cheng4, M. Clement5, M. Beatty1, J. Guimond1, S. Zeiler1, C. Mulholland3 1 Canadian Diabetes Association, Research Professional Education and Government Affairs, Toronto, Canada 2 Charles H. Best, Diabetes Centre, Ajax, Canada 3 Canadian Diabetes Association, Marketing and Communications, Toronto, Canada 4 St. Michael’s Hospital, Division of Endocrinology and Metabolism, Toronto, Canada 5 Vernon Jubilee Hospital, Diabetes Education, Vernon, Canada background: The Canadian Diabetes Association developed the 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, an internationally recognized evidence-based set of clinical recommendations for the prevention of type 2 diabetes and management of type 1 and type 2 diabetes. An expert committee of 99 volunteers from various healthcare professions across Canada developed the Guidelines. The Dissemination and Implementation Committee, a volunteer group of various healthcare professionals and people living with diabetes developed the dissemination strategy. aims: The Association’s goal in developing the Guidelines is to improve the quality of care for people with or at risk of diabetes by translating evidence-based knowledge into recommendations of care for healthcare professionals and encouraging the incorporation into practice. Methods: The dissemination strategy included a media release with the launch of the Guidelines to raise the profile and communicate key recommendations. The strategy also includes rolling out key themes from the Guidelines, every 6 months for the next three years. Each theme consists of clinically orientated, practical information and accompanying tools to help integrate diabetes prevention and management strategies from the Guidelines into practice. results:The first theme, cardiovascular disease (CV), resulted in the creation of several innovative ‘tools’ distributed to over 100,000 healthcare providers including physicians, diabetes educators, and allied health care professionals. The first is a branded portfolio designed as an information repository for health professionals to store essential content of the Guidelines. The second is a synopsis of key information on CV disease and diabetes. The third is a clinical assessment tool providing an algorithm for

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cardiovascular risk assessment. The fourth is self-assessment tool for lay individuals to keep and perform a self- analysis of their CV risk and to inform them of the key measures to lower this risk. This tool is expected to reach over one million Canadians with diabetes. Lastly, the ‘What’s up?’ document is a conversational newsletter apprising health care providers of the key elements of the 2008 Guidelines and important changes from the previous Guidelines. conclusion: The development of the 2008 Clinical Practice Guidelines, along with these dissemination and implementation strategies, will effectively contribute to knowledge translation for health professionals to improve their care of people with diabetes. The Association intends to evaluate the effectiveness of the Guidelines and the dissemination and implementation strategies on behavior change, patient care and empowerment as these strategies unfold over the next 3 years. Guidelines, clincal care No conflict of interest O-0362 comparison of the clinical management of type 2 diabetes in canada’s First Nations peoples to national guidelines: the cIrcLE study S.B. Harris1, M. Naqshbandi1, A.J.G. Hanley2, O.K. Bhattacharyya3, J.G. Esler1, B. Zinman4 1 Centre for Studies in Family Medicine The University of Western Ontario, Family Medicine, London, Canada 2 University of Toronto, Nutritional Sciences, Toronto, Canada 3 Li Ka Shing Knowledge Institute St. Michael’s Hospital University of Toronto, Family and Community Medicine, Toronto, Canada 4 University of Toronto, Medicine, Toronto, Canada Introduction: Diabetes mellitus (T2DM) is one of the most common causes of morbidity and mortality in developed nations, with much of the burden due to complications of T2DM. In Canada, approximately 7% of the population has T2DM with rates up to 5 times higher in Aboriginal peoples. Despite the “epidemic” status of T2DM in Canada’s First Nations (FN) peoples, there is no national data about diabetes care delivery and adherence to published national clinical practice guidelines (CPGs) for T2DM. aim: The aim of the Canadian First Nations Diabetes Clinical Management Epidemiologic (CIRCLE) study was to examine the degree to which the clinical status of T2DM in FN peoples across Canada was in accordance with the Canadian Diabetes Association 2003 CPGs. Methods: A random chart audit for T2DM care during the 2007 calendar year was completed for 733 consenting patients (>= 18 years) from 15 FN communities using systematic computerized data collection. Metabolic status, prevalence of complications and treatment were documented. results: Results are compared to the key CPG recommendations for the treatment and management of T2DM and the degree to which patients surveyed met these CPGs. Results indicate that 33.2% [95% CI 29.0-37.4] had an A1C of 7.0-8.9% and 27.1% [19.1-35.1] had an A1C of 9.0% or greater. Of the 27.1% of patients with an A1C of 9.0% or greater, 87.6% [83.6-91.5] were not receiving insulin. Blood pressure was above the target 130/80 mmHg in 51.3% [44.7-57.9] of patients with 13.4% [10.3-16.4] of those not on an ACE or ARB at the time of audit. LDL cholesterol was above the 2.0 mmol/L target for 65.8% [58.9-72.7] of patients with 37.7% [28.9-46.4] not on a statin. Overweight, defined as a BMI of 25-29.9 was prevalent in 24.3% [18.6-30.0] of patients, 25.7% [19.4-31.9] were obese with a BMI of 30-34.9 and 30.3% [19.6-40.9] were morbidly obese with a BMI of 35 or greater. The prevalence of current smokers was 39.4% [19.0-49.9]. conclusion and Discussion: The CIRCLE study demonstrates that a considerable proportion of T2DM FN patients in Canada are not well controlled and that disease burden is high. The percentage of patients not at A1C target is higher than in a similar study carried out with

the non-Aboriginal population in Canada. Major care gaps exist in the management and treatment of T2DM patients in FN communities. Further research into alternate models of diabetes health care delivery in FN communities is urgently required. Guidelines, clincal care No conflict of interest O-0369 cardiovascular function in type 1 diabetes: the Dcct/EDIc research Group S.M. Genuth2, P.A. Cleary1, J.C. Backlund1, J.A.C. Lima3, D.A. Bluemke4 The George Washington University, The Biostatistics Center, Rockville, USA 2 Case Western Reserve University, Biomedical Research, Cleveland, USA 3 Johns Hopkins Medical Institutions, Russel H. Morgan Dept of Radiology, Baltimore, USA 4 Johns Hopkins Medical Institutions, Radiology and Imaging Sciences, Bethesda, USA

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background: The EDIC observational follow-up of the Diabetes Control and Complications Trial (DCCT) has reported benefit of prior intensive therapy on retinopathy, nephropathy, neuropathy and cardiovascular disease (CVD) events. Using Cardiac MRI (CMRI), we evaluated cardiac function in former DCCT intensive (INT) and conventional (CON) therapy subjects 14 to 15 years after DCCT closeout. Methods: CMRI was performed in 28 clinics and read centrally using MASS software. Six functional outcomes were evaluated: end diastolic volume (EDV) and systolic volume (ESV), stroke volume (SV), cardiac output (CAROUT) and left ventricular end diastolic mass (LVDM), adjusting for body surface area, and ejection fraction (EF). results: Of 1211 active EDIC subjects asked to participate, 90% agreed. A total of 850 scans (~75% of the consented participants) have been performed. Fifty-one patients with CVD were excluded from this analysis. On a quality control scale of 0,1,2, the mean score was 1.77 with only 2% unacceptable (0 score) examinations. Reproducibility was high for all measures (intra-class correlations > 0.91). Normal EF (50-70%) was prevalent (>85%) in both INT and CON treatment group. Least Square Means by Gender (adjusting for basic covariates (BC) reader, machine type and attained age) and by Group (adjusting for BC and gender) Females

Males

INt

coN

EDV (ml/m2)

outcome

66.4

74.0

70.3

70.1

ESV (ml/m2)

24.2

28.8

26.4

26.6

SV (ml/m2)

42.2

45.2

43.9

43.5

EF (%)

63.7

61.4

62.7

62.4

CAROUT (L/ min/m2)

3.1

3.2

3.1

3.1

LVDM (g/m )

66.5

80.2

73.4

73.2

2

*All p-values < 0.01 between genders. No significant differences between INT and CON conclusion: A large multicenter study of CVD in type 1 diabetes is feasible, attractive to participants and yields new information. After excluding patients with clinical CVD events, 89% of the subjects had normal EF; least square mean differences between men and women were statistically significant on all the functional outcomes; no differences were detected between the INT and CON treatment groups. Complications - cardiovascular disease No conflict of interest