- Email: [email protected]
Type 2 Diabetes Mellitus Management in Canada: Is It Improving?
Can J Diabetes 37 (2013) 82e89
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Original Research
Type 2 Diabetes Mellitus Management in Canada: Is It Improving? Lawrence A. Leiter MD a, d, e, *, Lori Berard RN f, C. Keith Bowering MD g, Alice Y. Cheng MD a, d, Keith G. Dawson MD h, Jean-Marie Ekoé MD i, Carl Fournier MD j, Lianne Goldin k, Stewart B. Harris MD, MPH l, Peter Lin MD k, Thomas Ransom MD, MSc m, Mary Tan MSc k, Hwee Teoh PhD a, b, Ross T. Tsuyuki PharmD, MSc n, Dana Whitham RD, MSc o, Vincent Woo MD p, Jean-François Yale MD q, Anatoly Langer MD, MSc c, d, k a
Division of Endocrinology and Metabolism, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada Division of Cardiac Surgery, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada Division of Cardiology, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada d Department of Medicine, University of Toronto, Toronto, Ontario, Canada e Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada f Diabetes Research Group, Health Science Centre, Winnipeg, Manitoba, Canada g Division of Endocrinology and Metabolism, University of Alberta, Edmonton, Alberta, Canada h Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada i Montreal Institute for Clinical Research and Centre hospitalier de l’Université de Montréal Research Center, Division of Endocrinology and Department of Nutrition, Université de Montréal, Montréal, Quebec, Canada j Department of Medicine, Université de Montréal, Montréal, Quebec, Canada k Canadian Heart Research Centre, Toronto, Ontario, Canada l Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada m Department of Endocrinology, Dalhousie University, Halifax, Nova Scotia, Canada n EPICORE Centre, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada o Diabetes Comprehensive Care Program, St. Michael’s Hospital, Toronto, Ontario, Canada p Section of Endocrinology, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada q Division of Endocrinology and Metabolism, Department of Medicine, McGill Nutrition and Food Science Centre, McGill University, Montréal, Quebec, Canada b c
a r t i c l e i n f o Article history: Received 25 January 2013 Accepted 20 February 2013
Keywords: blood pressure care gap glycemic control guidelines lipids management type 2 diabetes
a b s t r a c t Objective: To gain insight into the current management of patients with type 2 diabetes mellitus by Canadian primary care physicians. Method: A total of 479 primary care physicians from across Canada submitted data on 5123 type 2 diabetes patients whom they had seen on a single day on or around World Diabetes Day, November 14, 2012. Results: Mean glycated hemoglobin (A1C) was 7.4%, low-density lipoprotein (LDL-C) was 2.1 mmol/L and blood pressure (BP) was 128/75 mm Hg. A1C 7.0% was met by 50%, LDL-C 2.0 mmol/L by 57%, BP <130/80 mm Hg by 36% and the composite triple target by 13% of patients. Diet counselling had been offered to 38% of patients. Of the 87% prescribed antihyperglycemic agents, 18% were on 1 non-insulin antihyperglycemic agent (NIAHA) (85% of which was metformin), 15% were on 2 NIAHAs, 6% were on 3 NIAHAs, 19% were on insulin only and 42% were on insulin þ 1 NIAHA(s). Amongst the 81% prescribed lipid-lowering therapy, 88% were on monotherapy (97% of which was a statin). Among the 83% prescribed antihypertensive agents, 39%, 34%, 21% and 6% received 1, 2, 3 and >3 drugs, respectively, with 59% prescribed angiotensin-converting enzyme inhibitors and 35% angiotensin II receptor blockers. Conclusions: The Diabetes Mellitus Status in Canada survey highlights the persistent treatment gap associated with the treatment of type 2 diabetes and the challenges faced by primary care physicians to gain glycemic control and global vascular protection in these patients. It also reveals a higher use of insulin therapy in primary care practices relative to previous surveys. Practical strategies aimed at more effectively managing type 2 diabetes patients are urgently needed. Ó 2013 Canadian Diabetes Association
* Address for correspondence: Lawrence A. Leiter, St Michael’s Hospital Medical Centre, 61 Queen Street East, Suite 6-121Q, Toronto, Ontario M5C 2T2, Canada. E-mail address: [email protected] (L.A. Leiter). 1499-2671/$ e see front matter Ó 2013 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2013.02.055
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
83
r é s u m é Mots clés: pression artérielle lacunes en matière de soins maîtrise de la glycémie lignes directrices lipides prise en charge diabète de type 2
Objectif : Obtenir un aperçu de la prise en charge actuelle des patients ayant le diabète sucré de type 2 par les médecins canadiens de premiers recours. Méthodes : Un total e 479 médecins de premier recours de l’ensemble du Canada ont soumis des données sur 5123 patients ayant le diabète de type 2 chez qui ils ont observé durant une seule journée lors ou autour de la journée mondiale du diabète, le 14 novembre 2012. Résultats : L’hémoglobine glyquée moyenne (HbA1c) a été de 7,4 %, le cholestérol à lipoprotéines de basse densité (C-LDL) de 2,1 mmol/L et la pression artérielle (PA) à 128/75 mm Hg. Une HbA1c 7,0 % a été obtenue chez 50 % des patients, un C-LDL 2,0 mmol/L chez 57 %, une PA < 130/80 mm Hg chez 36 % et un critère composite triple chez 13 %. Le counseling en diététique a été offert à 38 % des patients. Parmi les 87 % prenant des agents antihyperglycémiques, 18 % ont pris 1 agent antihyperglycémique non insulinique (AAHNI; dont 85 % ont pris la metformine), 15 % ont pris 2 AAHNI, 6 % ont pris 3 AAHNI, 19 % ont seulement pris de l’insuline et 42 % ont pris de l’insuline et 1 AAHNI. Parmi les 81 % qui suivaient un traitement hypolipidémiant, 88 % ont suivi une monothérapie (dont 97 % ont pris une statine). Parmi les 83 % qui prenaient des agents antihypertensifs, 39 %, 34 %, 21 % et 6 % ont reçu respectivement 1, 2, 3 et > 3 médicaments, dont 59 % ont pris des inhibiteurs de l’enzyme de conversion de l’angiotensine et 35 % des antagonistes des récepteurs de l’angiotensine II. Conclusions : L’enquête canadienne sur le statut du diabète sucré souligne les lacunes persistantes en matière de traitement associées au traitement du diabète de type 2 et les défis à relever par les médecins de premier recours pour obtenir une maîtrise de la glycémie et une protection vasculaire globale chez ces patients. Cela révèle également une plus grande utilisation de l’insulinothérapie dans les centres de soins primaires qui concernent les enquêtes précédentes. Des stratégies pratiques dont le but est une prise en charge plus efficace des patients ayant le diabète de type 2 s’imposent de manière urgente. Ó 2013 Canadian Diabetes Association
Introduction Clinical practice guidelines (CPGs) from professional organizations around the world collectively advocate that patients with type 2 diabetes mellitus should have their risk factors managed in an aggressive and timely manner (1e5). These recommendations are largely based on seminal type 2 diabetes-focused trials demonstrating significant improvements in vascular complications and reduced mortality through comprehensive and multifactorial behavioural modification and pharmacotherapy strategies (6,7). However, despite concerted and widespread efforts to translate these evidence-based recommendations into routine clinical practice as well as increasing pharmacologic options, practice reviews conducted in different countries and settings continually indicate that optimal management of type 2 diabetes patients remains challenging (8e15). Based on data collected between September 2002 and February 2003, the Diabetes in Canada Evaluation (DICE) Study determined that 51% of patients were successful at achieving a glycated hemoglobin (A1C) of <7.0% (10). The Diabetes Registry to Improve Vascular Events (DRIVE) study, using data collected between March 2005 and March 2006, revealed that 53% of the study population had an A1C of 7.0% (8) leading the investigators to postulate that the 2003 Canadian Diabetes Association (CDA) CPGs (3) had minimal impact on glycemic control in Canada up to that point. In anticipation of the publication of the 2013 CDA CPGs in early 2013, the national cross-sectional Diabetes Mellitus Status in Canada (DM-SCAN) survey was undertaken to gain insight into the current management of type 2 diabetes patients in the Canadian primary care setting. A secondary goal was to identify management gaps that may provide directional input on how best to effectively design strategies aimed at improving the care of these patients. Methods From September to December 2012, standard letters from the DM-SCAN Steering Committee were sent to primary care physicians across Canada inviting them to participate in the DM-SCAN survey. The invitation was distributed through e-mail and facsimiles by the
Canadian Heart Research Centre (CHRC) to lists of Canadian primary care physicians, participants in prior or ongoing registries within the CHRC, through standard hard copy invitations distributed by the CDA at its annual professional session and the CHRC at continuing medical education meetings, and by representatives of the sponsoring company. Physicians were requested to first complete a 10-question survey on their practice location and setting, how many type 2 diabetes patients they typically see in a week, whether they routinely discuss the symptoms and treatment of hypoglycemia, what they consider to be the greatest barriers in type 2 diabetes management and what educational platforms they felt would benefit their patients and practice. Physicians who completed the needs assessment survey were asked to complete a 1-page anonymized data collection form on patients with the clinical diagnosis of type 2 diabetes whom they had seen on a single clinic day as part of routine clinical practice on or as close as possible to the 2012 World Diabetes Day (November 14). Patient demographics, clinical history, anthropometric and laboratory data as well as management strategies used by the physician to achieve glycemic targets and global vascular protection were documented. Physicians were reimbursed for their efforts. The final program materials were reviewed and endorsed by the CDA and Diabète Québec before ethics approval was obtained. The program synopsis was reviewed and approved before survey initiation by OPTIMUM Clinical Research, an independent central ethics review board. Data management and statistical analysis Completed physician surveys and data collection forms were submitted either electronically via a secure website or faxed to the CHRC by 19 December 2012. Faxed data were scanned into an electronic database (TELEform, Version 10.0, Cardiff Software, San Diego, CA). Point prevalence data are presented. Continuous variables are summarized as mean (standard deviation [SD]) and discrete variables are reported as counts and percentages. Categorical variables between groups were compared using the Pearson’s chi-square or Cochran-Armitage trend tests where appropriate. Multivariable logistic regression analyses, using the
84
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
generalized estimating equations (GEE) method, were carried out to determine whether insulin use was influenced by provincial and geographical locations, practice format and access to diabetes educators. Because patients treated by the same physician were more likely to be treated similarly compared to patients under the care of other physicians, the GEE approach allowed us to adjust for correlations within individual physicians. Odds ratios (ORs) and their 95% confidence interval (CIs) are reported. All analyses were carried out using SAS software version 9.2 (SAS Institute, Cary, NC). Results
Table 1 Provincial distribution of physicians and patients Province
Physicians (N¼479)
Patients (N¼5123)
Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan
29 41 19 26 17 28 270 1 45 3
233 365 249 347 208 295 2990 15 400 21
(6.1) (8.6) (4.0) (5.4) (3.5) (5.8) (56.4) (0.2) (9.4) (0.6)
(4.5) (7.1) (4.9) (6.8) (4.1) (5.8) (58.4) (0.3) (7.8) (0.4)
Physicians and their practices
Data are presented as n (%).
A total of 479 physicians (equivalent to a 65% participation rate of the 738 who completed the initial audit form) representing all 10 Canadian provinces completed 5123 data collection forms (54% online, 46% fax-based submission) (Table 1). Fifty-nine percent of physicians were in a group practice (2 physicians), 41% had a single-physician practice and 50% were part of a family health team. Practices were located in inner city (16%), urban/suburban (63%) or small town/rural (21%) settings. Nearly two-thirds of the physicians reported seeing 10 to 30 type 2 diabetes patients each week (1% <5/week, 13% 5e10/week, 36% 10e0/week, 27% 20e30/ week, 16% 30e50/week, 7% >50/week) and 22% indicated that >50% of their type 2 diabetes patients were co-managed by an allied health care professional.
by physicians for 4798 patients from a list of 5 choices were 3% for 6.0%, 14% for 6.5%, 71% for 7.0%, 9% for 7.5% and 4% for 8.0%. Although 4477 (87%) of patients were prescribed antihyperglycemic therapy, 10% were managed through diet only strategies (Table 3). Of the patients prescribed antihyperglycemic agents (AHAs), 18% were receiving 1 non-insulin antihyperglycemic agent (NIAHA) (85% of which was metformin), 15% on 2 NIAHAs, 6% on 3 NIAHAs, 19% on insulin only and 42% on insulin and one or more 1 NIAHA. There were significant (p<0.0001) interprovincial differences in insulin use, with the highest found in Manitoba (80.3%) and the lowest in Alberta (47.6%). Logistic analyses using the GEE model indicated that patients in urban regions (OR [95% CI]¼1.41 [0.97e2.06], p¼0.0741), from group/family health practices (OR [95% CI]¼1.57 [1.13e1.81], p¼0.0074) and with access to diabetes educators (OR [95% CI]¼1.59 [1.39e1.81], p<0.0001) were more likely to be prescribed insulin. Of the 127 patients with known insulin monotherapy regimens, 9%, 29% and 62% were receiving 1, 2 and 3 insulin injections/day, respectively. Most of the individuals on dual AHA therapy were prescribed insulin and a NIAHA; dipeptidyl peptidase-4 inhibitors (DPP-4Is) and sulfonylureas were the most common NIAHAs to be combined with metformin when dual NIAHA therapy was prescribed. Among the 2531 patients who reached an A1C 7.0%, 37% were on NIAHAs only (51% of whom were on metformin monotherapy), 20% on insulin alone and 23% on insulin þ 1 NIAHA. The management strategies used for patients who had an A1C >7.0% are shown in Figure 1B. Of
Patient characteristics The demographic, clinical history, anthropometric and laboratory data of patients reviewed by the DM-SCAN physician participants are detailed in Table 2. Mean (SD) duration of type 2 diabetes was 9.2 (7.0) years; 15% had type 2 diabetes for 2 years, 21% for 3e5 years, 22% for 6e9 years, 23% for 10e14 years and 20% for 15 years. According to the World Health Organization ethnic-specific definitions for overweight and obesity (16), 14%, 29% and 57% of patients were within the normal weight range, overweight and obese, respectively. Of those with a known smoking history (n¼4098), 12% were current smokers. According to the available data, 26% of patients had at least one macrovascular complication (22% coronary artery disease, 6% previous stroke, 8% peripheral arterial disease). At least 1 microvascular complication was recorded for 25% of patients (8% retinopathy, 15% nephropathy, 12% neuropathy). Both cancer and depression were reported for 12% of patients. Erectile dysfunction was noted for 39% of male patients. Diet management Information from 4787 records indicated that 38% of patients had been referred to or counselled by a registered dietitian or a certified diabetes educator within the last 12 months. Data from 4776 records revealed that a nutrition/exercise/weight loss plan with measurable goals had been established for 50% of patients within the same time span. Glycemic control and management Mean (SD) A1C for 5103 individuals was 7.4% (1.3%), of whom 50% had A1C results of 7.0%. Figure 1A shows the distribution of A1C values. Duration of type 2 diabetes correlated mildly but significantly with A1C increases (r¼ 0.14, p<0.0001). Duration of type 2 diabetes also showed a strong association with A1C 7.0% attainment rates: 65% for those with type 2 diabetes for 2 years, 58 % for 3e5 years, 49% for 6e9 years, 43% for 10e14 years and 37% for 15 years (p for trend <0.0001). Optimal A1C targets identified
Table 2 Demographic, clinical history, anthropometric and laboratory data of patients reviewed Patients (N¼5123) Women* Age (years)y Ethnicity* Aboriginal Canadian Black Caucasian East/Southeast Asian Hispanic South Asian Other Body mass index (kg/m2)y Men Women A1C (%)y Fasting plasma glucose (mmol/L)y LDL-C (mmol/L)y Blood pressure (mm Hg)y Systolic Diastolic Duration of type 2 diabetes (years)y Current or previous smoker*
2353 (46.1) 64 (12) 144 197 3021 851 76 529 153
(2.9) (4.0) (60.8) (17.1) (1.5) (10.6) (3.1)
30.5 31.1 7.4 7.8 2.1
(10.0) (11.6) (1.3) (2.6) (0.9)
128 75 9.2 1774
(14) (9) (7.0) (36.1)
LDL-C, low-density lipoprotein cholesterol. N for each category was variable due to missing values, <10% in each case. * Data are presented as n (%). y Data are presented as mean (SD).
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
85
Figure 1. Glycemic control and management of DM-SCAN patients. (A) Distribution of A1C levels. (B) Management strategies used for patients with A1C >7.0%. (C) Distribution of NIAHA monotherapy and dual therapy strategies prescribed to patients with A1C >7.0%. Values for (C) were determined according to the corresponding number of patients with A1C >7.0% who were known to be treated with 1 NIAHA or 2 NIAHAs. DPP-4I, dipeptidyl peptidase-4 inhibitor; GLP-1R, glucagon-like peptide 1 receptor agonists; NIAHA, noninsulin antihyperglycemic agent; SU, sulfonylurea.
the 1432 patients with an A1C of 7.1% to 8.0%, 2% were not prescribed any diet or AHA therapy, 4% were on a diet only therapeutic regimen and 27% on AHA monotherapy. Even amongst those with an A1C 9.0% (n¼523), 2% were not prescribed any diet or AHA therapy, <1% were on diet only management and 18% on AHA monotherapy. NIAHA monotherapy and dual therapy strategies prescribed are outlined in Figure 1C.
Lipid control and management Mean (SD) low-density lipoprotein cholesterol (LDL-C) level was 2.1 mmol/L (0.9 mmol/L). The target LDL-C of 2.0 mmol/L was achieved by 57% of 5069 patients (65% for those with known vascular disease vs. 54% for those without, p<0.0001). The distribution of LDL-C values is shown in Figure 2A. Amongst the 4153
86
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
Table 3 Glycemic control and management Target A1C Attainment* A1C 7.0% A1C 9.0% Management strategies* Diet only On antihyperglycemic therapy Neither diet nor antihyperglycemic therapy Antihyperglycemic therapy Monotherapy Insuliny Metforminy Other NIAHAsy Dual therapy 2 NIAHAsz Metformin þ DPP-4Ix Metformin þ sulfonylureax Insulin þ 1 NIAHAz Triple therapy 3 NIAHAs{ Insulin þ 2 NIAHAs{
Patients (N¼5103) 2531 (49.6) 523 (10.3) Patients (N¼5123) 517 (10.1) 4477 (87.4) 129 (2.5) Patients (N¼4477) 1656 854 685 117 1923 673 284 264 1250 798 241 557
(37.0) (51.2) (41.4) (7.1) (43.0) (35.0) (42.2) (39.2) (65.0) (17.8) (30.2) (69.8)
DPP-4I, dipeptidyl peptidase-4 inhibitor; NIAHA, non-insulin antihyperglycemic agent. Data are presented as *n (%). y Values were calculated against the number of patients who were on AHA monotherapy. z Values were calculated against the number of patients who were on AHA dual therapy. x Values were calculated against the number of patients who were on 2 NIAHAs. { Values were calculated against the number of patients who were on 3 AHAs.
(82%) patients who were prescribed lipid-lowering therapy, 88% were on monotherapy (of whom 97% were on a statin) and 11% on dual therapy (67% of whom were on a statin þ ezetimibe). Of the 2878 patients with LDL-C 2.0 mmol/L, 90% received statins and 8% were prescribed a statin þ ezetimibe. Figure 2B outlines how patients whose LDL-C exceeded 2.0 mmol/L were managed. Blood pressure control and management Mean (SD) blood pressure (BP) was 128/75 mm Hg (14/9 mm Hg). Blood pressure <130/80 mm Hg was met by 36% of 5099 patients. Figure 3A illustrates the BP distribution across the study population. Amongst the 4272 (83%) patients prescribed antihypertensive agents 39%, 34% and 21% and 6% were on 1, 2, 3 and 3 drugs respectively with 59% prescribed angiotensin-converting enzyme (ACE) inhibitors and 35% angiotensin II receptor blockers (ARBs). Amongst the 1852 individuals who reached the BP target of <130/80 mm Hg, 50% were on ACE inhibitors and 25% on ARBs. Figure 3B details how those with BP 130/80 mm Hg were managed. Composite A1C, LDL-C and BP outcome The composite endpoint goal of A1C 7.0%, LDL-C 2.0 mmol/l and BP <130/80 mm Hg was met by 13% of 5104 patients (16% for those with known coronary artery disease vs. 12% for those without, p¼0.0013). Barriers to successful management of type 2 diabetes Poor patient adherence (e.g. diet, physical activity, medication, blood glucose monitoring) was the most commonly cited barrier to managing type 2 diabetes patients. Other physician-identified barriers were patient resistance (e.g. reluctance to initiate/intensify antihyperglycemic therapy, poor understanding of disease, its progressive nature and the associated complications), constraints
Figure 2. Lipid control and management of DM-SCAN patients. (A) Distribution of LDL-C levels. (B) Distribution of lipid lowering therapy strategies prescribed to patients with LDL-C >2.0 mmol/L. Values for (B) were determined according to the corresponding number of patients with LDL-C >2.0 mmol/L who were known to be treated with lipid lowering agents.
on physician time (e.g. comorbidities, complex medical regimens, patient education), financial issues (e.g. insurance coverage, access to and cost of “healthy” food) and lack of support for physician (e.g. poor access to timely and sustained nutritional and exercise counselling).
Discussion The results of this large, national, cross-sectional observational survey suggest that still only 50% of Canadian type 2 diabetes patients met the 2008 CDA CPGs recommended A1C target of 7.0% (3). Additionally, just over 50% were successful at reaching the LDL-C 2.0 mmol/L goal recommended by the 2008 CDA CPGs (3) and the 2009 Canadian Lipid CPGs (17) and only a third the 2008 CDA and 2012 Canadian Hypertension Education Program recommended target BP of <130/80 mm Hg (3,18). Finally, it is also disappointing that only 13% of patients achieved the composite goal of A1C 7.0%, LDL-C 2.0 mmol/l and BP <130/80 mm Hg. The Canadian-based DICE and DRIVE studies previously demonstrated that CPGs-recommended glycemic control was only successfully observed in 51% and 53% of the study patients, respectively (8,10). Notwithstanding some methodological differences, the DM-SCAN survey recapitulates the persistent management gap associated with type 2 diabetes and reconfirms the earlier suggestions that glycemic and other metabolic control in Canada remains suboptimal despite continual update and dissemination of
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
87
Table 4 Temporal glycemic, lipid and blood pressure controldfrom DICE to DRIVE to DM-SCAN DICE DRIVE DM-SCAN (2002e2003) (2005e2006) NoveDec N¼2473 N¼3002 2012 N¼5123 Women Age at audit (years)* Duration of type 2 diabetes (years)* Body mass index (kg/m2)* On insulin A1C (%)* A1C <7.0%y or 7.0%z LDL-C (mmol/L)* LDL-C <2.5 mmol/Ly or 2.0 mmol/Lz Blood pressure (mm Hg)* Systolic Diastolic Blood pressure 130/80 mm Hgy or <130/80 mm Hgz Triple target achievement A1C 7.0%, LDL-C <2.5 mmol/L, BP 130/80 mm Hg A1C 7.0%, LDL-C 2.0 mmol/L, BP <130/80 mm Hg
46 63 7.8 31 12 7.3 51z NA NA
41 64 6.0 30 15 6.9 53{ 2.2 64y
46 64 9.2 31 16 7.4 50{ 2.1 57z
NA NA NA
130 78 54y
128 75 36z
NA
19
ND
NA
ND
13
LDL-C, low-density lipoprotein cholesterol; NA, not available; ND, not determined. Data are presented as %. * Mean for DICE and DM-SCAN, median for DRIVE. yz{ Targets for DICE, DRIVE and DM-SCAN were different; symbols denote corresponding targets of the individual study.
Figure 3. Lipid control and management of DM-SCAN patients. (A) Distribution of blood pressure levels. (B) Distribution of antihypertensive therapy strategies prescribed to patients with BP 130/80 mm Hg. Values for (B) were determined according to the corresponding number of patients with BP 130/80 mm Hg who were known to be treated with antihypertensive agents.
CPGs and an increasing number of AHAs. Table 4 summarizes the key findings of the DICE, DRIVE and DM-SCAN studies. Mean duration of type 2 diabetes for the DICE and DM-SCAN patient populations were 8 years and 9 years, respectively, and the median duration for DRIVE was 6 years. Although all 3 studies found that only 50% the patients were able to attain the recommended A1C target of the time, it is worth noting that despite DM-SCAN patients having a longer mean duration of type 2 diabetes than DICE patients, mean A1C was only slightly higher for the former (7.4% vs. 7.3%). This may in part be attributed to less reliance on lifestyle only management (10% for DM-SCAN vs. 16% for DICE) and greater use of insulin (both alone and in combination with NIAHAs) amongst DMSCAN patients (61% for DM-SCAN vs. 12 % for DICE). Although it would appear that glycemia was better controlled in DRIVE vs. DMSCAN patients (median A1C 6.9% vs. 7.0%; A1C 7.0% rates 53% vs. 50%), it is important that at the time of audit DRIVE patients were generally at earlier stages of the disease than DM-SCAN patients. In 81% of patients, the A1C goal set by the physicians was 7%. Therefore, the low success rate in achieving A1C levels 7% cannot be explained by patient factors that would make such a target unreasonable or physicians not knowing the recommended target. When queried, physicians suggested patient barriers as the primary causes of unsuccessful attempts to gain and sustain glycemic control. However, they also acknowledged time constraints, financial considerations and limited access to relevant diabetesassociated support personnel and services as contributory factors.
Rate of insulin usage for the DRIVE cohort was 15%. This is similar to the 12% reported by the DICE investigators but remarkably lower than the 61% noted in the DM-SCAN patient population. The greater use of insulin amongst the DM-SCAN physicians is of significant interest since it occurred despite the introduction of 2 new classes of AHAs after the release of the 2008 CDA CPGsdthe DPP-4Is and glucagon-like peptide 1 receptor agonistsdboth of which are not associated with the potential weight gain and risk of hypoglycemia of insulin. Whether these observations represent an increase in awareness and enhanced adherence to CPGs recommendations and/or a decrease in clinical inertia with regards to insulin initiation and intensification remains to be determined. The fact that insulin use was associated with greater access to diabetes educators suggests that this may have contributed. Regardless, these findings are novel, promising and warrant further investigations. The recurrent observation in the DICE, DRIVE and DM-SCAN initiatives that glycemic control is achieved in only about half of the patients is not unique to Canada. A retrospective, crosssectional analysis of data from the United Kingdom General Practice Research Database, collected between 1998 and 2002, indicated that A1C 7.0% was recorded for 34% of patients (14). The 2003e2006 data from the population-based National Health and Nutrition Examination Survey (NHANES) revealed that just 57% of adults with diabetes surveyed met the recommended A1C target of 7.0% or lower (12). After reviewing 2966 medical records of type 2 diabetes patients from primary, secondary, and tertiary hospitals in the Jiangsu province of China, Bi et al. (13) reported only 56% attained A1C <7.0%. Although only 57% of DM-SCAN patients achieved the LDL-C target of 2.0 mmol/L, it is somewhat reassuring because only 64% of DRIVE patients met the higher <2.5 mmol/L target. This suggests that physicians are aware of and are more confident at applying CPGs recommendations to immediately achieve LDL-C targets in type 2 diabetes patients. The DM-SCAN results are not as positive as those found in the Canadian arm of the recently completed DYSlipidemia International Study (DYSIS) where 63% of
88
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
all patients were at recommended or intervention target LDL-C levels (19). Neither do the DM-SCAN results appear as promising as those of the Canadian Lipid Study-Observational (CALIPSO) where only 27% of patients audited were not at the recommended LDL-C (20). It is, however, important to remember that the DYSIS and CALIPSO analyses were based on LDL-C thresholds recommended in the 2006 Canadian Cardiovascular Society (21) and the 2003 Canadian Working Group on Hypercholesterolemia and Other Dyslipidemias (22) CPGs, respectively, both of which were higher than that in the 2009 Canadian Lipid CPGs (17) The disparity between the DM-SCAN, DYSIS and CALIPSO results are also likely reflective of our subanalysis demonstrating that a greater percentage of patients with cardiovascular disorders reached the LDL-C target than those who did not present with any cardiovascular abnormalities. The apparent discrepant care between type 2 diabetes patients with and without cardiovascular disease has previously been reported by the investigators of the Analysis and Understanding of Diabetes and Dyslipidaemia: Improving Treatment (AUDIT) study (23). The AUDIT survey found that physicians tended to treat type 2 diabetes patients with cardiovascular disease more intensively than they did those without cardiovascular disease suggesting that at least at the time of the study, type 2 diabetes had yet to be recognized by physicians as a major cardiovascular risk factor. Blood pressure distribution was similar in the DM-SCAN and DRIVE studies (Table 4) as were the use of ACE inhibitors (59% DM-SCAN vs. 61% DRIVE) and ARBs (35% DM-SCAN vs. 27% DRIVE). Target BP achievement rate, although still suboptimal, was greater in the DRIVE study (54% vs. 36%) and may have resulted in part from the slightly less stringent BP target (130/80 mm Hg vs. <130/80 mm Hg for DM-SCAN). The investigators of the 2006 Ontario Survey on the Prevalence and Control of Hypertension also observed suboptimal blood pressure control in the Canadian diabetes community. They reported that 50% of individuals with type 2 diabetes had hypertension, amongst whom 97% were receiving antihypertensive treatment but only 36% had BP values <130/80 mm Hg (24). Global vascular protection is acknowledged as the cornerstone to managing type 2 diabetes patients. Only 13% of the DM-SCAN patients achieved the composite target of A1C 7.0%, LDL-C 2.0 mmol/l and BP <130/80 mm Hg. This is lower than the 19% success rate reported for the DICE patients (8) who had less intense LDL-C and BP targets but very similar to the 2003e2006 NHANES data showing 13% of type 2 diabetes patients successfully achieving all 3 primary goals for A1C (<7.0%), LDL-C (<2.6 mmol/L) and BP (<130/80 mm Hg) (12). The investigators of the International Diabetes Management Practice Study recently reported that in developing regions only 3.6% of 3896 type 2 diabetes patients met the composite goal of A1C <7.0%, LDL-C and BP (25). Clearly, greater efforts are needed to bring more patients to the triple therapeutic goal to achieve maximal vascular protection. The results of the DM-SCAN survey have important implications for the implementation of the 2013 CDA CPGs. It is evident that innovative strategies are necessary to emphasize to physicians the importance of adopting and translating evidence-based CPGs into every day clinical care. It is imperative too that a variety of easily accessible education platforms be established to provide physicians with practical means of overcoming clinical inertia and strategies to more effectively educate their patients at self-managing and selfmonitoring to enhance accountability. Initiatives aimed at encouraging greater collaboration between primary care physicians, specialists and allied healthcare personnel in a patient-centric network as well as increasing patient adherence are also warranted. For instance, in recognition of the strong evidence for better patient outcomes with nurse- and pharmacist-directed care (26,27), Hypertension Canada has expanded its audience to include nurses and pharmacists (28). Some other avenues that may be
worthwhile exploring include increased accessibility of CPGs, treatment algorithms and information on newer AHA classes through mobile applications; and novel formats for “live” and online continued medical education events. This survey has several limitations. First, the recruitment strategies used may have resulted in an overrepresentation of physicians who are more proactive at improving their management of type 2 diabetes patients and thus more open to participating in a survey such as DM-SCAN. Second, it is possible that patients with well-controlled A1C, or those treated with insulin, consult their physicians more regularly and therefore were more likely to be enrolled that may account in part for the large proportion of patients reported to be on insulin therapy. Additionally, we are unable to confirm that physicians enrolled consecutive patients and provided information for all patients seen over a single clinic day. Third, laboratory values were obtained from medical records rather than through central laboratory evaluations. Furthermore, there were no attempts to confirm the accuracy of the data provided against the source documents. Fourth, we did not request information on baseline/earlier glycemic, lipid and BP parameters and therefore cannot comment on whether patients were managed appropriately. We also therefore cannot comment on patients who have type 2 diabetes who were seen but were excluded due to the absence of an A1C reading. Fifth, although we did collect data on whether lifestyle modifications were recommended, we did not obtain details on patient lifestyle, nor on drug side effects and treatment adherence. This survey does have several strengths. First, this was a large nationwide initiative with representation from a variety of primary care settings in different geographical locations. Second, there were very few missing A1C (0.4%), SBP (0.4%), DBP (0.5%) and LDL-C (1.1%) values suggesting high accuracy of the target achievement rates calculated. Finally, the requirement that physicians report on all the type 2 diabetes patients whom they saw in the single day may have in some cases reduced the chances of patient selection and may be in these cases be more reflective of “real world” settings. Conclusions Despite widespread attempts at dissemination and implementation of practice CPGs, and advances in type 2 diabetes pharmacotherapy, the results of the DM-SCAN survey accentuate the persistent treatment gap associated with the treatment of type 2 diabetes. This survey also highlights the continual challenges faced by primary care physicians to gain and maintain glycemic control as well as achieve global vascular protection in type 2 diabetes patients. Practical strategies aimed at more aggressively managing type 2 diabetes patients and their risk factors to more effectively surmount the collective barriers in closing the ongoing care gap are urgently needed. Acknowledgments The Diabetes Mellitus Status in Canada (DM-SCAN) survey was 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. Author Disclosures LAL has received honouraria or research support from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen, Merck, Novartis, Novo Nordisk, Sanofi, Servier and Takeda. LB has received honouraria or research support from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck, Novo Nordisk and Sanofi. CKB has received honouraria or research
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Novo Nordisk, Pfizer and Sanofi. AYC has received honouraria or research support from Abbott, AstraZeneca- Bristol-Myers Squibb, Becton Dickinson, Eli Lilly, Eli Lilly, Lifescan, Merck, Novo Nordisk, Sanofi and Servier. KGD has received honouraria or research support from GlaxoSmithKline, Lifescan, Lilly, Merck, Novo Nordisk and Sanofi. J-ME has received honouraria or research support from Merck. CF has received honouraria or research support from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Forrest, Janssen, Sanofi, Takeda and Valeant. LG has no conflicts of interest to declare. SBH has received honouraria or research support from AstraZeneca- BristolMyers Squibb, Boehringer Ingelheim-Eli Lilly, Janssen, Merck, NovoNordisk, Roche, Sanofi and Takeda. PL has received honouraria or research support from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck, NovoNordisk, Sanofi and Takeda. TR has received honouraria or research support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Merck, Novartis, NovoNordisk and Sanofi. MT has no conflicts of interest to declare. HT has no conflicts of interest to declare. RTT has received honouraria or research support from Abbott, AstraZeneca, BristolMyers Squibb-AstraZeneca, Boehringer Ingelheim, Merck, PharmaSmart and Sanofi. DW has no conflicts of interest to declare. VW has received honouraria or research support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Forrest, Janssen, Merck, Novo Nordisk and Sanofi. J-FY has received honouraria or research support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck, Novo Nordisk, Sanofi and Takeda. AL has received honouraria or research support from Actelion, AstraZeneca, Aventis, Bayer, Biovail, Boston Scientific, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, Cordis, Guidant, Medtronics, Merck, Millennium Pharmaceuticals, Ortho Biotec, Oryx, Pfizer, Roche, Sanofi-Synthelabo, Schering Key Corporation, Servier, The Medicines Company and United Therapeutics. Author Contributions LAL designed the study, researched the data, contributed to the discussion, wrote the manuscript and edited the manuscript. LB contributed to the discussion and reviewed the manuscript. CKB contributed to the discussion and reviewed the manuscript. AYC contributed to the discussion and reviewed the manuscript. KGD contributed to the discussion and reviewed the manuscript. J-ME contributed to the discussion and reviewed the manuscript. CF contributed to the discussion and reviewed the manuscript. LG designed the study, researched the data, contributed to the discussion and reviewed the manuscript. SBH contributed to the discussion and reviewed the manuscript. PL contributed to the discussion and reviewed the manuscript. TR contributed to the discussion and reviewed the manuscript. MT researched the data, contributed to the discussion, and reviewed the manuscript. HT researched the data, wrote the manuscript and edited the manuscript. RTT contributed to the discussion and reviewed the manuscript. DW contributed to the discussion and reviewed the manuscript. VW contributed to the discussion and reviewed the manuscript. JFY contributed to the discussion and reviewed the manuscript. AL designed the study, researched the data, contributed to the discussion and reviewed the manuscript. References 1. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract 2011;17:287e302.
89
2. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012;55:1577e96. 3. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in canada. Can J Diabetes 2008;32:S1e201. 4. Published by National Institute for Health and Clinical Excellence, Manchester, United Kingdom. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. 2012. 5. International Diabetes Federation Clinical Guidelines Task Force. Global guideline for type 2 diabetes. 2012. http://www.idf.org/sites/default/files/IDF% 20Guideline%20for%20Type%202%20Diabetes.pdf. 6. Holman RR, Paul SK, Bethel MA, et al. Ten-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577e89. 7. Gaede P, Lund-Andersen H, Parving HH, et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580e91. 8. Braga MF, Casanova A, Teoh H, et al. Poor achievement of guidelinesrecommended targets in type 2 diabetes: findings from a contemporary prospective cohort study. Int J Clin Pract 2012;66:457e64. 9. Brown LC, Johnson JA, Majumdar SR, et al. Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis. CMAJ 2004;171:1189e92. 10. Harris SB, Ekoe JM, Zdanowicz Y, et al. Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada Evaluation Study). Diabetes Res Clin Pract 2005;70:90e7. 11. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004;291:335e42. 12. Cheung BM, Ong KL, Cherny SS, et al. Diabetes prevalence and therapeutic target achievement in the United States, 1999 to 2006. Am J Med 2009;122: 443e53. 13. Bi Y, Zhu D, Cheng J, et al. The status of glycemic control: a cross-sectional study of outpatients with type 2 diabetes mellitus across primary, secondary, and tertiary hospitals in the Jiangsu Province of China. Clin Ther 2010;32: 973e83. 14. Fox KM, Gerber RA, Bolinder B, et al. Prevalence of inadequate glycemic control among patients with type 2 diabetes in the united kingdom general practice research database: a series of retrospective analyses of data from 1998 through 2002. Clin Ther 2006;28:388e95. 15. Al Hamarneh YN, Rosenthal M, Tsuyuki RT. Glycemic control in communitydwelling patients with type 2 diabetes. Can Pharm J 2012;145:68e70. 16. World Health Organization Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157e63. 17. Genest J, McPherson R, Frohlich J, et al. 2009 Canadian Cardiovascular Society/ Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adultd2009 recommendations. Can J Cardiol 2009;25:567e79. 18. Canadian Hypertension Education Program. The 2012 CHEP recommendations for the management of hypertension. 2012. http://www.hypertension.ca/cheprecommendations. 19. Goodman SG, Langer A, Bastien NR, et al. Prevalence of dyslipidemia in statintreated patients in Canada: results of the Dyslipidemia International Study (DYSIS). Can J Cardiol 2010;26:e330e5. 20. Bourgault C, Davignon J, Fodor G, et al. Statin therapy in Canadian patients with hypercholesterolemia: the Canadian Lipid Study-Observational (CALIPSO). Can J Cardiol 2005;21:1187e93. 21. McPherson R, Frohlich J, Fodor G, et al. Canadian Cardiovascular Society position statementdrecommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease. Can J Cardiol 2006;22: 913e27. 22. Genest J, Frohlich J, Fodor G, et al. Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update. CMAJ 2003;169:921e4. 23. Leiter LA, Betteridge DJ, Chacra AR, et al. Audit study. Evidence of global undertreatment of dyslipidaemia in patients with type 2 diabetes mellitus. Can J Diabetes Vasc Dis 2006;6:31e40. 24. Leenen FH, Dumais J, McInnis NH, et al. Results of the Ontario survey on the prevalence and control of hypertension. CMAJ 2008;178:1441e9. 25. Chan JC, Gagliardino JJ, Baik SH, et al. Multifaceted determinants for achieving glycemic control: the International Diabetes Management Practice Study (IDMPS). Diabetes Care 2009;32:227e33. 26. Santschi V, Chiolero A, Paradis G, et al. Pharmacist interventions to improve cardiovascular disease risk factors in diabetes: a systematic review and meta-analysis of randomized controlled trials. Diabetes Care 2012;35: 2706e17. 27. Watts SA, Gee J, O’Day ME, et al. Nurse practitioner-led multidisciplinary teams to improve chronic illness care: the unique strengths of nurse practitioners applied to shared medical appointments/group visits. J Am Acad Nurse Pract 2009;21:167e72. 28. Campbell NR, Poirier L, Tremblay G, et al. Canadian Hypertension Education Program: the science supporting new 2011 CHEP recommendations with an emphasis on health advocacy and knowledge translation. Can J Cardiol 2011; 27:407e14.
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Original Research
Type 2 Diabetes Mellitus Management in Canada: Is It Improving? Lawrence A. Leiter MD a, d, e, *, Lori Berard RN f, C. Keith Bowering MD g, Alice Y. Cheng MD a, d, Keith G. Dawson MD h, Jean-Marie Ekoé MD i, Carl Fournier MD j, Lianne Goldin k, Stewart B. Harris MD, MPH l, Peter Lin MD k, Thomas Ransom MD, MSc m, Mary Tan MSc k, Hwee Teoh PhD a, b, Ross T. Tsuyuki PharmD, MSc n, Dana Whitham RD, MSc o, Vincent Woo MD p, Jean-François Yale MD q, Anatoly Langer MD, MSc c, d, k a
Division of Endocrinology and Metabolism, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada Division of Cardiac Surgery, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada Division of Cardiology, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada d Department of Medicine, University of Toronto, Toronto, Ontario, Canada e Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada f Diabetes Research Group, Health Science Centre, Winnipeg, Manitoba, Canada g Division of Endocrinology and Metabolism, University of Alberta, Edmonton, Alberta, Canada h Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada i Montreal Institute for Clinical Research and Centre hospitalier de l’Université de Montréal Research Center, Division of Endocrinology and Department of Nutrition, Université de Montréal, Montréal, Quebec, Canada j Department of Medicine, Université de Montréal, Montréal, Quebec, Canada k Canadian Heart Research Centre, Toronto, Ontario, Canada l Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada m Department of Endocrinology, Dalhousie University, Halifax, Nova Scotia, Canada n EPICORE Centre, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada o Diabetes Comprehensive Care Program, St. Michael’s Hospital, Toronto, Ontario, Canada p Section of Endocrinology, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada q Division of Endocrinology and Metabolism, Department of Medicine, McGill Nutrition and Food Science Centre, McGill University, Montréal, Quebec, Canada b c
a r t i c l e i n f o Article history: Received 25 January 2013 Accepted 20 February 2013
Keywords: blood pressure care gap glycemic control guidelines lipids management type 2 diabetes
a b s t r a c t Objective: To gain insight into the current management of patients with type 2 diabetes mellitus by Canadian primary care physicians. Method: A total of 479 primary care physicians from across Canada submitted data on 5123 type 2 diabetes patients whom they had seen on a single day on or around World Diabetes Day, November 14, 2012. Results: Mean glycated hemoglobin (A1C) was 7.4%, low-density lipoprotein (LDL-C) was 2.1 mmol/L and blood pressure (BP) was 128/75 mm Hg. A1C 7.0% was met by 50%, LDL-C 2.0 mmol/L by 57%, BP <130/80 mm Hg by 36% and the composite triple target by 13% of patients. Diet counselling had been offered to 38% of patients. Of the 87% prescribed antihyperglycemic agents, 18% were on 1 non-insulin antihyperglycemic agent (NIAHA) (85% of which was metformin), 15% were on 2 NIAHAs, 6% were on 3 NIAHAs, 19% were on insulin only and 42% were on insulin þ 1 NIAHA(s). Amongst the 81% prescribed lipid-lowering therapy, 88% were on monotherapy (97% of which was a statin). Among the 83% prescribed antihypertensive agents, 39%, 34%, 21% and 6% received 1, 2, 3 and >3 drugs, respectively, with 59% prescribed angiotensin-converting enzyme inhibitors and 35% angiotensin II receptor blockers. Conclusions: The Diabetes Mellitus Status in Canada survey highlights the persistent treatment gap associated with the treatment of type 2 diabetes and the challenges faced by primary care physicians to gain glycemic control and global vascular protection in these patients. It also reveals a higher use of insulin therapy in primary care practices relative to previous surveys. Practical strategies aimed at more effectively managing type 2 diabetes patients are urgently needed. Ó 2013 Canadian Diabetes Association
* Address for correspondence: Lawrence A. Leiter, St Michael’s Hospital Medical Centre, 61 Queen Street East, Suite 6-121Q, Toronto, Ontario M5C 2T2, Canada. E-mail address: [email protected] (L.A. Leiter). 1499-2671/$ e see front matter Ó 2013 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2013.02.055
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
83
r é s u m é Mots clés: pression artérielle lacunes en matière de soins maîtrise de la glycémie lignes directrices lipides prise en charge diabète de type 2
Objectif : Obtenir un aperçu de la prise en charge actuelle des patients ayant le diabète sucré de type 2 par les médecins canadiens de premiers recours. Méthodes : Un total e 479 médecins de premier recours de l’ensemble du Canada ont soumis des données sur 5123 patients ayant le diabète de type 2 chez qui ils ont observé durant une seule journée lors ou autour de la journée mondiale du diabète, le 14 novembre 2012. Résultats : L’hémoglobine glyquée moyenne (HbA1c) a été de 7,4 %, le cholestérol à lipoprotéines de basse densité (C-LDL) de 2,1 mmol/L et la pression artérielle (PA) à 128/75 mm Hg. Une HbA1c 7,0 % a été obtenue chez 50 % des patients, un C-LDL 2,0 mmol/L chez 57 %, une PA < 130/80 mm Hg chez 36 % et un critère composite triple chez 13 %. Le counseling en diététique a été offert à 38 % des patients. Parmi les 87 % prenant des agents antihyperglycémiques, 18 % ont pris 1 agent antihyperglycémique non insulinique (AAHNI; dont 85 % ont pris la metformine), 15 % ont pris 2 AAHNI, 6 % ont pris 3 AAHNI, 19 % ont seulement pris de l’insuline et 42 % ont pris de l’insuline et 1 AAHNI. Parmi les 81 % qui suivaient un traitement hypolipidémiant, 88 % ont suivi une monothérapie (dont 97 % ont pris une statine). Parmi les 83 % qui prenaient des agents antihypertensifs, 39 %, 34 %, 21 % et 6 % ont reçu respectivement 1, 2, 3 et > 3 médicaments, dont 59 % ont pris des inhibiteurs de l’enzyme de conversion de l’angiotensine et 35 % des antagonistes des récepteurs de l’angiotensine II. Conclusions : L’enquête canadienne sur le statut du diabète sucré souligne les lacunes persistantes en matière de traitement associées au traitement du diabète de type 2 et les défis à relever par les médecins de premier recours pour obtenir une maîtrise de la glycémie et une protection vasculaire globale chez ces patients. Cela révèle également une plus grande utilisation de l’insulinothérapie dans les centres de soins primaires qui concernent les enquêtes précédentes. Des stratégies pratiques dont le but est une prise en charge plus efficace des patients ayant le diabète de type 2 s’imposent de manière urgente. Ó 2013 Canadian Diabetes Association
Introduction Clinical practice guidelines (CPGs) from professional organizations around the world collectively advocate that patients with type 2 diabetes mellitus should have their risk factors managed in an aggressive and timely manner (1e5). These recommendations are largely based on seminal type 2 diabetes-focused trials demonstrating significant improvements in vascular complications and reduced mortality through comprehensive and multifactorial behavioural modification and pharmacotherapy strategies (6,7). However, despite concerted and widespread efforts to translate these evidence-based recommendations into routine clinical practice as well as increasing pharmacologic options, practice reviews conducted in different countries and settings continually indicate that optimal management of type 2 diabetes patients remains challenging (8e15). Based on data collected between September 2002 and February 2003, the Diabetes in Canada Evaluation (DICE) Study determined that 51% of patients were successful at achieving a glycated hemoglobin (A1C) of <7.0% (10). The Diabetes Registry to Improve Vascular Events (DRIVE) study, using data collected between March 2005 and March 2006, revealed that 53% of the study population had an A1C of 7.0% (8) leading the investigators to postulate that the 2003 Canadian Diabetes Association (CDA) CPGs (3) had minimal impact on glycemic control in Canada up to that point. In anticipation of the publication of the 2013 CDA CPGs in early 2013, the national cross-sectional Diabetes Mellitus Status in Canada (DM-SCAN) survey was undertaken to gain insight into the current management of type 2 diabetes patients in the Canadian primary care setting. A secondary goal was to identify management gaps that may provide directional input on how best to effectively design strategies aimed at improving the care of these patients. Methods From September to December 2012, standard letters from the DM-SCAN Steering Committee were sent to primary care physicians across Canada inviting them to participate in the DM-SCAN survey. The invitation was distributed through e-mail and facsimiles by the
Canadian Heart Research Centre (CHRC) to lists of Canadian primary care physicians, participants in prior or ongoing registries within the CHRC, through standard hard copy invitations distributed by the CDA at its annual professional session and the CHRC at continuing medical education meetings, and by representatives of the sponsoring company. Physicians were requested to first complete a 10-question survey on their practice location and setting, how many type 2 diabetes patients they typically see in a week, whether they routinely discuss the symptoms and treatment of hypoglycemia, what they consider to be the greatest barriers in type 2 diabetes management and what educational platforms they felt would benefit their patients and practice. Physicians who completed the needs assessment survey were asked to complete a 1-page anonymized data collection form on patients with the clinical diagnosis of type 2 diabetes whom they had seen on a single clinic day as part of routine clinical practice on or as close as possible to the 2012 World Diabetes Day (November 14). Patient demographics, clinical history, anthropometric and laboratory data as well as management strategies used by the physician to achieve glycemic targets and global vascular protection were documented. Physicians were reimbursed for their efforts. The final program materials were reviewed and endorsed by the CDA and Diabète Québec before ethics approval was obtained. The program synopsis was reviewed and approved before survey initiation by OPTIMUM Clinical Research, an independent central ethics review board. Data management and statistical analysis Completed physician surveys and data collection forms were submitted either electronically via a secure website or faxed to the CHRC by 19 December 2012. Faxed data were scanned into an electronic database (TELEform, Version 10.0, Cardiff Software, San Diego, CA). Point prevalence data are presented. Continuous variables are summarized as mean (standard deviation [SD]) and discrete variables are reported as counts and percentages. Categorical variables between groups were compared using the Pearson’s chi-square or Cochran-Armitage trend tests where appropriate. Multivariable logistic regression analyses, using the
84
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
generalized estimating equations (GEE) method, were carried out to determine whether insulin use was influenced by provincial and geographical locations, practice format and access to diabetes educators. Because patients treated by the same physician were more likely to be treated similarly compared to patients under the care of other physicians, the GEE approach allowed us to adjust for correlations within individual physicians. Odds ratios (ORs) and their 95% confidence interval (CIs) are reported. All analyses were carried out using SAS software version 9.2 (SAS Institute, Cary, NC). Results
Table 1 Provincial distribution of physicians and patients Province
Physicians (N¼479)
Patients (N¼5123)
Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan
29 41 19 26 17 28 270 1 45 3
233 365 249 347 208 295 2990 15 400 21
(6.1) (8.6) (4.0) (5.4) (3.5) (5.8) (56.4) (0.2) (9.4) (0.6)
(4.5) (7.1) (4.9) (6.8) (4.1) (5.8) (58.4) (0.3) (7.8) (0.4)
Physicians and their practices
Data are presented as n (%).
A total of 479 physicians (equivalent to a 65% participation rate of the 738 who completed the initial audit form) representing all 10 Canadian provinces completed 5123 data collection forms (54% online, 46% fax-based submission) (Table 1). Fifty-nine percent of physicians were in a group practice (2 physicians), 41% had a single-physician practice and 50% were part of a family health team. Practices were located in inner city (16%), urban/suburban (63%) or small town/rural (21%) settings. Nearly two-thirds of the physicians reported seeing 10 to 30 type 2 diabetes patients each week (1% <5/week, 13% 5e10/week, 36% 10e0/week, 27% 20e30/ week, 16% 30e50/week, 7% >50/week) and 22% indicated that >50% of their type 2 diabetes patients were co-managed by an allied health care professional.
by physicians for 4798 patients from a list of 5 choices were 3% for 6.0%, 14% for 6.5%, 71% for 7.0%, 9% for 7.5% and 4% for 8.0%. Although 4477 (87%) of patients were prescribed antihyperglycemic therapy, 10% were managed through diet only strategies (Table 3). Of the patients prescribed antihyperglycemic agents (AHAs), 18% were receiving 1 non-insulin antihyperglycemic agent (NIAHA) (85% of which was metformin), 15% on 2 NIAHAs, 6% on 3 NIAHAs, 19% on insulin only and 42% on insulin and one or more 1 NIAHA. There were significant (p<0.0001) interprovincial differences in insulin use, with the highest found in Manitoba (80.3%) and the lowest in Alberta (47.6%). Logistic analyses using the GEE model indicated that patients in urban regions (OR [95% CI]¼1.41 [0.97e2.06], p¼0.0741), from group/family health practices (OR [95% CI]¼1.57 [1.13e1.81], p¼0.0074) and with access to diabetes educators (OR [95% CI]¼1.59 [1.39e1.81], p<0.0001) were more likely to be prescribed insulin. Of the 127 patients with known insulin monotherapy regimens, 9%, 29% and 62% were receiving 1, 2 and 3 insulin injections/day, respectively. Most of the individuals on dual AHA therapy were prescribed insulin and a NIAHA; dipeptidyl peptidase-4 inhibitors (DPP-4Is) and sulfonylureas were the most common NIAHAs to be combined with metformin when dual NIAHA therapy was prescribed. Among the 2531 patients who reached an A1C 7.0%, 37% were on NIAHAs only (51% of whom were on metformin monotherapy), 20% on insulin alone and 23% on insulin þ 1 NIAHA. The management strategies used for patients who had an A1C >7.0% are shown in Figure 1B. Of
Patient characteristics The demographic, clinical history, anthropometric and laboratory data of patients reviewed by the DM-SCAN physician participants are detailed in Table 2. Mean (SD) duration of type 2 diabetes was 9.2 (7.0) years; 15% had type 2 diabetes for 2 years, 21% for 3e5 years, 22% for 6e9 years, 23% for 10e14 years and 20% for 15 years. According to the World Health Organization ethnic-specific definitions for overweight and obesity (16), 14%, 29% and 57% of patients were within the normal weight range, overweight and obese, respectively. Of those with a known smoking history (n¼4098), 12% were current smokers. According to the available data, 26% of patients had at least one macrovascular complication (22% coronary artery disease, 6% previous stroke, 8% peripheral arterial disease). At least 1 microvascular complication was recorded for 25% of patients (8% retinopathy, 15% nephropathy, 12% neuropathy). Both cancer and depression were reported for 12% of patients. Erectile dysfunction was noted for 39% of male patients. Diet management Information from 4787 records indicated that 38% of patients had been referred to or counselled by a registered dietitian or a certified diabetes educator within the last 12 months. Data from 4776 records revealed that a nutrition/exercise/weight loss plan with measurable goals had been established for 50% of patients within the same time span. Glycemic control and management Mean (SD) A1C for 5103 individuals was 7.4% (1.3%), of whom 50% had A1C results of 7.0%. Figure 1A shows the distribution of A1C values. Duration of type 2 diabetes correlated mildly but significantly with A1C increases (r¼ 0.14, p<0.0001). Duration of type 2 diabetes also showed a strong association with A1C 7.0% attainment rates: 65% for those with type 2 diabetes for 2 years, 58 % for 3e5 years, 49% for 6e9 years, 43% for 10e14 years and 37% for 15 years (p for trend <0.0001). Optimal A1C targets identified
Table 2 Demographic, clinical history, anthropometric and laboratory data of patients reviewed Patients (N¼5123) Women* Age (years)y Ethnicity* Aboriginal Canadian Black Caucasian East/Southeast Asian Hispanic South Asian Other Body mass index (kg/m2)y Men Women A1C (%)y Fasting plasma glucose (mmol/L)y LDL-C (mmol/L)y Blood pressure (mm Hg)y Systolic Diastolic Duration of type 2 diabetes (years)y Current or previous smoker*
2353 (46.1) 64 (12) 144 197 3021 851 76 529 153
(2.9) (4.0) (60.8) (17.1) (1.5) (10.6) (3.1)
30.5 31.1 7.4 7.8 2.1
(10.0) (11.6) (1.3) (2.6) (0.9)
128 75 9.2 1774
(14) (9) (7.0) (36.1)
LDL-C, low-density lipoprotein cholesterol. N for each category was variable due to missing values, <10% in each case. * Data are presented as n (%). y Data are presented as mean (SD).
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
85
Figure 1. Glycemic control and management of DM-SCAN patients. (A) Distribution of A1C levels. (B) Management strategies used for patients with A1C >7.0%. (C) Distribution of NIAHA monotherapy and dual therapy strategies prescribed to patients with A1C >7.0%. Values for (C) were determined according to the corresponding number of patients with A1C >7.0% who were known to be treated with 1 NIAHA or 2 NIAHAs. DPP-4I, dipeptidyl peptidase-4 inhibitor; GLP-1R, glucagon-like peptide 1 receptor agonists; NIAHA, noninsulin antihyperglycemic agent; SU, sulfonylurea.
the 1432 patients with an A1C of 7.1% to 8.0%, 2% were not prescribed any diet or AHA therapy, 4% were on a diet only therapeutic regimen and 27% on AHA monotherapy. Even amongst those with an A1C 9.0% (n¼523), 2% were not prescribed any diet or AHA therapy, <1% were on diet only management and 18% on AHA monotherapy. NIAHA monotherapy and dual therapy strategies prescribed are outlined in Figure 1C.
Lipid control and management Mean (SD) low-density lipoprotein cholesterol (LDL-C) level was 2.1 mmol/L (0.9 mmol/L). The target LDL-C of 2.0 mmol/L was achieved by 57% of 5069 patients (65% for those with known vascular disease vs. 54% for those without, p<0.0001). The distribution of LDL-C values is shown in Figure 2A. Amongst the 4153
86
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
Table 3 Glycemic control and management Target A1C Attainment* A1C 7.0% A1C 9.0% Management strategies* Diet only On antihyperglycemic therapy Neither diet nor antihyperglycemic therapy Antihyperglycemic therapy Monotherapy Insuliny Metforminy Other NIAHAsy Dual therapy 2 NIAHAsz Metformin þ DPP-4Ix Metformin þ sulfonylureax Insulin þ 1 NIAHAz Triple therapy 3 NIAHAs{ Insulin þ 2 NIAHAs{
Patients (N¼5103) 2531 (49.6) 523 (10.3) Patients (N¼5123) 517 (10.1) 4477 (87.4) 129 (2.5) Patients (N¼4477) 1656 854 685 117 1923 673 284 264 1250 798 241 557
(37.0) (51.2) (41.4) (7.1) (43.0) (35.0) (42.2) (39.2) (65.0) (17.8) (30.2) (69.8)
DPP-4I, dipeptidyl peptidase-4 inhibitor; NIAHA, non-insulin antihyperglycemic agent. Data are presented as *n (%). y Values were calculated against the number of patients who were on AHA monotherapy. z Values were calculated against the number of patients who were on AHA dual therapy. x Values were calculated against the number of patients who were on 2 NIAHAs. { Values were calculated against the number of patients who were on 3 AHAs.
(82%) patients who were prescribed lipid-lowering therapy, 88% were on monotherapy (of whom 97% were on a statin) and 11% on dual therapy (67% of whom were on a statin þ ezetimibe). Of the 2878 patients with LDL-C 2.0 mmol/L, 90% received statins and 8% were prescribed a statin þ ezetimibe. Figure 2B outlines how patients whose LDL-C exceeded 2.0 mmol/L were managed. Blood pressure control and management Mean (SD) blood pressure (BP) was 128/75 mm Hg (14/9 mm Hg). Blood pressure <130/80 mm Hg was met by 36% of 5099 patients. Figure 3A illustrates the BP distribution across the study population. Amongst the 4272 (83%) patients prescribed antihypertensive agents 39%, 34% and 21% and 6% were on 1, 2, 3 and 3 drugs respectively with 59% prescribed angiotensin-converting enzyme (ACE) inhibitors and 35% angiotensin II receptor blockers (ARBs). Amongst the 1852 individuals who reached the BP target of <130/80 mm Hg, 50% were on ACE inhibitors and 25% on ARBs. Figure 3B details how those with BP 130/80 mm Hg were managed. Composite A1C, LDL-C and BP outcome The composite endpoint goal of A1C 7.0%, LDL-C 2.0 mmol/l and BP <130/80 mm Hg was met by 13% of 5104 patients (16% for those with known coronary artery disease vs. 12% for those without, p¼0.0013). Barriers to successful management of type 2 diabetes Poor patient adherence (e.g. diet, physical activity, medication, blood glucose monitoring) was the most commonly cited barrier to managing type 2 diabetes patients. Other physician-identified barriers were patient resistance (e.g. reluctance to initiate/intensify antihyperglycemic therapy, poor understanding of disease, its progressive nature and the associated complications), constraints
Figure 2. Lipid control and management of DM-SCAN patients. (A) Distribution of LDL-C levels. (B) Distribution of lipid lowering therapy strategies prescribed to patients with LDL-C >2.0 mmol/L. Values for (B) were determined according to the corresponding number of patients with LDL-C >2.0 mmol/L who were known to be treated with lipid lowering agents.
on physician time (e.g. comorbidities, complex medical regimens, patient education), financial issues (e.g. insurance coverage, access to and cost of “healthy” food) and lack of support for physician (e.g. poor access to timely and sustained nutritional and exercise counselling).
Discussion The results of this large, national, cross-sectional observational survey suggest that still only 50% of Canadian type 2 diabetes patients met the 2008 CDA CPGs recommended A1C target of 7.0% (3). Additionally, just over 50% were successful at reaching the LDL-C 2.0 mmol/L goal recommended by the 2008 CDA CPGs (3) and the 2009 Canadian Lipid CPGs (17) and only a third the 2008 CDA and 2012 Canadian Hypertension Education Program recommended target BP of <130/80 mm Hg (3,18). Finally, it is also disappointing that only 13% of patients achieved the composite goal of A1C 7.0%, LDL-C 2.0 mmol/l and BP <130/80 mm Hg. The Canadian-based DICE and DRIVE studies previously demonstrated that CPGs-recommended glycemic control was only successfully observed in 51% and 53% of the study patients, respectively (8,10). Notwithstanding some methodological differences, the DM-SCAN survey recapitulates the persistent management gap associated with type 2 diabetes and reconfirms the earlier suggestions that glycemic and other metabolic control in Canada remains suboptimal despite continual update and dissemination of
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
87
Table 4 Temporal glycemic, lipid and blood pressure controldfrom DICE to DRIVE to DM-SCAN DICE DRIVE DM-SCAN (2002e2003) (2005e2006) NoveDec N¼2473 N¼3002 2012 N¼5123 Women Age at audit (years)* Duration of type 2 diabetes (years)* Body mass index (kg/m2)* On insulin A1C (%)* A1C <7.0%y or 7.0%z LDL-C (mmol/L)* LDL-C <2.5 mmol/Ly or 2.0 mmol/Lz Blood pressure (mm Hg)* Systolic Diastolic Blood pressure 130/80 mm Hgy or <130/80 mm Hgz Triple target achievement A1C 7.0%, LDL-C <2.5 mmol/L, BP 130/80 mm Hg A1C 7.0%, LDL-C 2.0 mmol/L, BP <130/80 mm Hg
46 63 7.8 31 12 7.3 51z NA NA
41 64 6.0 30 15 6.9 53{ 2.2 64y
46 64 9.2 31 16 7.4 50{ 2.1 57z
NA NA NA
130 78 54y
128 75 36z
NA
19
ND
NA
ND
13
LDL-C, low-density lipoprotein cholesterol; NA, not available; ND, not determined. Data are presented as %. * Mean for DICE and DM-SCAN, median for DRIVE. yz{ Targets for DICE, DRIVE and DM-SCAN were different; symbols denote corresponding targets of the individual study.
Figure 3. Lipid control and management of DM-SCAN patients. (A) Distribution of blood pressure levels. (B) Distribution of antihypertensive therapy strategies prescribed to patients with BP 130/80 mm Hg. Values for (B) were determined according to the corresponding number of patients with BP 130/80 mm Hg who were known to be treated with antihypertensive agents.
CPGs and an increasing number of AHAs. Table 4 summarizes the key findings of the DICE, DRIVE and DM-SCAN studies. Mean duration of type 2 diabetes for the DICE and DM-SCAN patient populations were 8 years and 9 years, respectively, and the median duration for DRIVE was 6 years. Although all 3 studies found that only 50% the patients were able to attain the recommended A1C target of the time, it is worth noting that despite DM-SCAN patients having a longer mean duration of type 2 diabetes than DICE patients, mean A1C was only slightly higher for the former (7.4% vs. 7.3%). This may in part be attributed to less reliance on lifestyle only management (10% for DM-SCAN vs. 16% for DICE) and greater use of insulin (both alone and in combination with NIAHAs) amongst DMSCAN patients (61% for DM-SCAN vs. 12 % for DICE). Although it would appear that glycemia was better controlled in DRIVE vs. DMSCAN patients (median A1C 6.9% vs. 7.0%; A1C 7.0% rates 53% vs. 50%), it is important that at the time of audit DRIVE patients were generally at earlier stages of the disease than DM-SCAN patients. In 81% of patients, the A1C goal set by the physicians was 7%. Therefore, the low success rate in achieving A1C levels 7% cannot be explained by patient factors that would make such a target unreasonable or physicians not knowing the recommended target. When queried, physicians suggested patient barriers as the primary causes of unsuccessful attempts to gain and sustain glycemic control. However, they also acknowledged time constraints, financial considerations and limited access to relevant diabetesassociated support personnel and services as contributory factors.
Rate of insulin usage for the DRIVE cohort was 15%. This is similar to the 12% reported by the DICE investigators but remarkably lower than the 61% noted in the DM-SCAN patient population. The greater use of insulin amongst the DM-SCAN physicians is of significant interest since it occurred despite the introduction of 2 new classes of AHAs after the release of the 2008 CDA CPGsdthe DPP-4Is and glucagon-like peptide 1 receptor agonistsdboth of which are not associated with the potential weight gain and risk of hypoglycemia of insulin. Whether these observations represent an increase in awareness and enhanced adherence to CPGs recommendations and/or a decrease in clinical inertia with regards to insulin initiation and intensification remains to be determined. The fact that insulin use was associated with greater access to diabetes educators suggests that this may have contributed. Regardless, these findings are novel, promising and warrant further investigations. The recurrent observation in the DICE, DRIVE and DM-SCAN initiatives that glycemic control is achieved in only about half of the patients is not unique to Canada. A retrospective, crosssectional analysis of data from the United Kingdom General Practice Research Database, collected between 1998 and 2002, indicated that A1C 7.0% was recorded for 34% of patients (14). The 2003e2006 data from the population-based National Health and Nutrition Examination Survey (NHANES) revealed that just 57% of adults with diabetes surveyed met the recommended A1C target of 7.0% or lower (12). After reviewing 2966 medical records of type 2 diabetes patients from primary, secondary, and tertiary hospitals in the Jiangsu province of China, Bi et al. (13) reported only 56% attained A1C <7.0%. Although only 57% of DM-SCAN patients achieved the LDL-C target of 2.0 mmol/L, it is somewhat reassuring because only 64% of DRIVE patients met the higher <2.5 mmol/L target. This suggests that physicians are aware of and are more confident at applying CPGs recommendations to immediately achieve LDL-C targets in type 2 diabetes patients. The DM-SCAN results are not as positive as those found in the Canadian arm of the recently completed DYSlipidemia International Study (DYSIS) where 63% of
88
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
all patients were at recommended or intervention target LDL-C levels (19). Neither do the DM-SCAN results appear as promising as those of the Canadian Lipid Study-Observational (CALIPSO) where only 27% of patients audited were not at the recommended LDL-C (20). It is, however, important to remember that the DYSIS and CALIPSO analyses were based on LDL-C thresholds recommended in the 2006 Canadian Cardiovascular Society (21) and the 2003 Canadian Working Group on Hypercholesterolemia and Other Dyslipidemias (22) CPGs, respectively, both of which were higher than that in the 2009 Canadian Lipid CPGs (17) The disparity between the DM-SCAN, DYSIS and CALIPSO results are also likely reflective of our subanalysis demonstrating that a greater percentage of patients with cardiovascular disorders reached the LDL-C target than those who did not present with any cardiovascular abnormalities. The apparent discrepant care between type 2 diabetes patients with and without cardiovascular disease has previously been reported by the investigators of the Analysis and Understanding of Diabetes and Dyslipidaemia: Improving Treatment (AUDIT) study (23). The AUDIT survey found that physicians tended to treat type 2 diabetes patients with cardiovascular disease more intensively than they did those without cardiovascular disease suggesting that at least at the time of the study, type 2 diabetes had yet to be recognized by physicians as a major cardiovascular risk factor. Blood pressure distribution was similar in the DM-SCAN and DRIVE studies (Table 4) as were the use of ACE inhibitors (59% DM-SCAN vs. 61% DRIVE) and ARBs (35% DM-SCAN vs. 27% DRIVE). Target BP achievement rate, although still suboptimal, was greater in the DRIVE study (54% vs. 36%) and may have resulted in part from the slightly less stringent BP target (130/80 mm Hg vs. <130/80 mm Hg for DM-SCAN). The investigators of the 2006 Ontario Survey on the Prevalence and Control of Hypertension also observed suboptimal blood pressure control in the Canadian diabetes community. They reported that 50% of individuals with type 2 diabetes had hypertension, amongst whom 97% were receiving antihypertensive treatment but only 36% had BP values <130/80 mm Hg (24). Global vascular protection is acknowledged as the cornerstone to managing type 2 diabetes patients. Only 13% of the DM-SCAN patients achieved the composite target of A1C 7.0%, LDL-C 2.0 mmol/l and BP <130/80 mm Hg. This is lower than the 19% success rate reported for the DICE patients (8) who had less intense LDL-C and BP targets but very similar to the 2003e2006 NHANES data showing 13% of type 2 diabetes patients successfully achieving all 3 primary goals for A1C (<7.0%), LDL-C (<2.6 mmol/L) and BP (<130/80 mm Hg) (12). The investigators of the International Diabetes Management Practice Study recently reported that in developing regions only 3.6% of 3896 type 2 diabetes patients met the composite goal of A1C <7.0%, LDL-C and BP (25). Clearly, greater efforts are needed to bring more patients to the triple therapeutic goal to achieve maximal vascular protection. The results of the DM-SCAN survey have important implications for the implementation of the 2013 CDA CPGs. It is evident that innovative strategies are necessary to emphasize to physicians the importance of adopting and translating evidence-based CPGs into every day clinical care. It is imperative too that a variety of easily accessible education platforms be established to provide physicians with practical means of overcoming clinical inertia and strategies to more effectively educate their patients at self-managing and selfmonitoring to enhance accountability. Initiatives aimed at encouraging greater collaboration between primary care physicians, specialists and allied healthcare personnel in a patient-centric network as well as increasing patient adherence are also warranted. For instance, in recognition of the strong evidence for better patient outcomes with nurse- and pharmacist-directed care (26,27), Hypertension Canada has expanded its audience to include nurses and pharmacists (28). Some other avenues that may be
worthwhile exploring include increased accessibility of CPGs, treatment algorithms and information on newer AHA classes through mobile applications; and novel formats for “live” and online continued medical education events. This survey has several limitations. First, the recruitment strategies used may have resulted in an overrepresentation of physicians who are more proactive at improving their management of type 2 diabetes patients and thus more open to participating in a survey such as DM-SCAN. Second, it is possible that patients with well-controlled A1C, or those treated with insulin, consult their physicians more regularly and therefore were more likely to be enrolled that may account in part for the large proportion of patients reported to be on insulin therapy. Additionally, we are unable to confirm that physicians enrolled consecutive patients and provided information for all patients seen over a single clinic day. Third, laboratory values were obtained from medical records rather than through central laboratory evaluations. Furthermore, there were no attempts to confirm the accuracy of the data provided against the source documents. Fourth, we did not request information on baseline/earlier glycemic, lipid and BP parameters and therefore cannot comment on whether patients were managed appropriately. We also therefore cannot comment on patients who have type 2 diabetes who were seen but were excluded due to the absence of an A1C reading. Fifth, although we did collect data on whether lifestyle modifications were recommended, we did not obtain details on patient lifestyle, nor on drug side effects and treatment adherence. This survey does have several strengths. First, this was a large nationwide initiative with representation from a variety of primary care settings in different geographical locations. Second, there were very few missing A1C (0.4%), SBP (0.4%), DBP (0.5%) and LDL-C (1.1%) values suggesting high accuracy of the target achievement rates calculated. Finally, the requirement that physicians report on all the type 2 diabetes patients whom they saw in the single day may have in some cases reduced the chances of patient selection and may be in these cases be more reflective of “real world” settings. Conclusions Despite widespread attempts at dissemination and implementation of practice CPGs, and advances in type 2 diabetes pharmacotherapy, the results of the DM-SCAN survey accentuate the persistent treatment gap associated with the treatment of type 2 diabetes. This survey also highlights the continual challenges faced by primary care physicians to gain and maintain glycemic control as well as achieve global vascular protection in type 2 diabetes patients. Practical strategies aimed at more aggressively managing type 2 diabetes patients and their risk factors to more effectively surmount the collective barriers in closing the ongoing care gap are urgently needed. Acknowledgments The Diabetes Mellitus Status in Canada (DM-SCAN) survey was 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. Author Disclosures LAL has received honouraria or research support from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen, Merck, Novartis, Novo Nordisk, Sanofi, Servier and Takeda. LB has received honouraria or research support from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck, Novo Nordisk and Sanofi. CKB has received honouraria or research
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Novo Nordisk, Pfizer and Sanofi. AYC has received honouraria or research support from Abbott, AstraZeneca- Bristol-Myers Squibb, Becton Dickinson, Eli Lilly, Eli Lilly, Lifescan, Merck, Novo Nordisk, Sanofi and Servier. KGD has received honouraria or research support from GlaxoSmithKline, Lifescan, Lilly, Merck, Novo Nordisk and Sanofi. J-ME has received honouraria or research support from Merck. CF has received honouraria or research support from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Forrest, Janssen, Sanofi, Takeda and Valeant. LG has no conflicts of interest to declare. SBH has received honouraria or research support from AstraZeneca- BristolMyers Squibb, Boehringer Ingelheim-Eli Lilly, Janssen, Merck, NovoNordisk, Roche, Sanofi and Takeda. PL has received honouraria or research support from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck, NovoNordisk, Sanofi and Takeda. TR has received honouraria or research support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Merck, Novartis, NovoNordisk and Sanofi. MT has no conflicts of interest to declare. HT has no conflicts of interest to declare. RTT has received honouraria or research support from Abbott, AstraZeneca, BristolMyers Squibb-AstraZeneca, Boehringer Ingelheim, Merck, PharmaSmart and Sanofi. DW has no conflicts of interest to declare. VW has received honouraria or research support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Forrest, Janssen, Merck, Novo Nordisk and Sanofi. J-FY has received honouraria or research support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck, Novo Nordisk, Sanofi and Takeda. AL has received honouraria or research support from Actelion, AstraZeneca, Aventis, Bayer, Biovail, Boston Scientific, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, Cordis, Guidant, Medtronics, Merck, Millennium Pharmaceuticals, Ortho Biotec, Oryx, Pfizer, Roche, Sanofi-Synthelabo, Schering Key Corporation, Servier, The Medicines Company and United Therapeutics. Author Contributions LAL designed the study, researched the data, contributed to the discussion, wrote the manuscript and edited the manuscript. LB contributed to the discussion and reviewed the manuscript. CKB contributed to the discussion and reviewed the manuscript. AYC contributed to the discussion and reviewed the manuscript. KGD contributed to the discussion and reviewed the manuscript. J-ME contributed to the discussion and reviewed the manuscript. CF contributed to the discussion and reviewed the manuscript. LG designed the study, researched the data, contributed to the discussion and reviewed the manuscript. SBH contributed to the discussion and reviewed the manuscript. PL contributed to the discussion and reviewed the manuscript. TR contributed to the discussion and reviewed the manuscript. MT researched the data, contributed to the discussion, and reviewed the manuscript. HT researched the data, wrote the manuscript and edited the manuscript. RTT contributed to the discussion and reviewed the manuscript. DW contributed to the discussion and reviewed the manuscript. VW contributed to the discussion and reviewed the manuscript. JFY contributed to the discussion and reviewed the manuscript. AL designed the study, researched the data, contributed to the discussion and reviewed the manuscript. References 1. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract 2011;17:287e302.
89
2. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012;55:1577e96. 3. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in canada. Can J Diabetes 2008;32:S1e201. 4. Published by National Institute for Health and Clinical Excellence, Manchester, United Kingdom. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. 2012. 5. International Diabetes Federation Clinical Guidelines Task Force. Global guideline for type 2 diabetes. 2012. http://www.idf.org/sites/default/files/IDF% 20Guideline%20for%20Type%202%20Diabetes.pdf. 6. Holman RR, Paul SK, Bethel MA, et al. Ten-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577e89. 7. Gaede P, Lund-Andersen H, Parving HH, et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580e91. 8. Braga MF, Casanova A, Teoh H, et al. Poor achievement of guidelinesrecommended targets in type 2 diabetes: findings from a contemporary prospective cohort study. Int J Clin Pract 2012;66:457e64. 9. Brown LC, Johnson JA, Majumdar SR, et al. Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis. CMAJ 2004;171:1189e92. 10. Harris SB, Ekoe JM, Zdanowicz Y, et al. Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada Evaluation Study). Diabetes Res Clin Pract 2005;70:90e7. 11. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004;291:335e42. 12. Cheung BM, Ong KL, Cherny SS, et al. Diabetes prevalence and therapeutic target achievement in the United States, 1999 to 2006. Am J Med 2009;122: 443e53. 13. Bi Y, Zhu D, Cheng J, et al. The status of glycemic control: a cross-sectional study of outpatients with type 2 diabetes mellitus across primary, secondary, and tertiary hospitals in the Jiangsu Province of China. Clin Ther 2010;32: 973e83. 14. Fox KM, Gerber RA, Bolinder B, et al. Prevalence of inadequate glycemic control among patients with type 2 diabetes in the united kingdom general practice research database: a series of retrospective analyses of data from 1998 through 2002. Clin Ther 2006;28:388e95. 15. Al Hamarneh YN, Rosenthal M, Tsuyuki RT. Glycemic control in communitydwelling patients with type 2 diabetes. Can Pharm J 2012;145:68e70. 16. World Health Organization Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157e63. 17. Genest J, McPherson R, Frohlich J, et al. 2009 Canadian Cardiovascular Society/ Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adultd2009 recommendations. Can J Cardiol 2009;25:567e79. 18. Canadian Hypertension Education Program. The 2012 CHEP recommendations for the management of hypertension. 2012. http://www.hypertension.ca/cheprecommendations. 19. Goodman SG, Langer A, Bastien NR, et al. Prevalence of dyslipidemia in statintreated patients in Canada: results of the Dyslipidemia International Study (DYSIS). Can J Cardiol 2010;26:e330e5. 20. Bourgault C, Davignon J, Fodor G, et al. Statin therapy in Canadian patients with hypercholesterolemia: the Canadian Lipid Study-Observational (CALIPSO). Can J Cardiol 2005;21:1187e93. 21. McPherson R, Frohlich J, Fodor G, et al. Canadian Cardiovascular Society position statementdrecommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease. Can J Cardiol 2006;22: 913e27. 22. Genest J, Frohlich J, Fodor G, et al. Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update. CMAJ 2003;169:921e4. 23. Leiter LA, Betteridge DJ, Chacra AR, et al. Audit study. Evidence of global undertreatment of dyslipidaemia in patients with type 2 diabetes mellitus. Can J Diabetes Vasc Dis 2006;6:31e40. 24. Leenen FH, Dumais J, McInnis NH, et al. Results of the Ontario survey on the prevalence and control of hypertension. CMAJ 2008;178:1441e9. 25. Chan JC, Gagliardino JJ, Baik SH, et al. Multifaceted determinants for achieving glycemic control: the International Diabetes Management Practice Study (IDMPS). Diabetes Care 2009;32:227e33. 26. Santschi V, Chiolero A, Paradis G, et al. Pharmacist interventions to improve cardiovascular disease risk factors in diabetes: a systematic review and meta-analysis of randomized controlled trials. Diabetes Care 2012;35: 2706e17. 27. Watts SA, Gee J, O’Day ME, et al. Nurse practitioner-led multidisciplinary teams to improve chronic illness care: the unique strengths of nurse practitioners applied to shared medical appointments/group visits. J Am Acad Nurse Pract 2009;21:167e72. 28. Campbell NR, Poirier L, Tremblay G, et al. Canadian Hypertension Education Program: the science supporting new 2011 CHEP recommendations with an emphasis on health advocacy and knowledge translation. Can J Cardiol 2011; 27:407e14.