- Email: [email protected]
Understanding Patient Care Gaps in Diabetes: Perspective of Patients, Healthcare Professionals, and Healthcare Administrators.
MONTREAL 2008 ABSTRACTS
ORAL PRESENTATIONS
61
I
62
G. MIKALACHK I*", STEWART B. HARR IS' + t , +Department of Family Medicine, University of Western Ontario, London. ON; #St. Joseph's Health Care, London, ON
HA YES' , D1L1P PA TEL " MARTIN DUPUIS', SUZANNE MUR RA y' . 'AXDEV Group In c., Brossard , QC, ' Merck Frosst Canada Limited, Kirk land , QC . Des pite changes and re fo rm s in healthca re in Canada sin ce last fe w years, critical gaps continuc to hinder optim al pati ent ca re. The objectives of thi s study were to: (I) Identif), and better un derstand key cha llen ges that impact patient ca re from m ult ip les perspect ive (pati en t, phys icians, all ied hea lthcare providers. an d hospitals and gov ernme nts admini str ators); (2) Better understand patients' ex periences \vit hin th e health care sy stem acros s multipl e di sease, inclu din g fo r d iabetes ; (3) to ide nti fy ca llses ofthc gaps and barriers to opti mal care in the current Canadi an health ca re context. An IRB approved m ixed-meth od appro ach w as employed including q ualitative and quan titati ve data collecti on techn iques. In the q ua litati ve phase, 18 foc us groups an d 122 telephone s inte rv iews were conducted across the country w ith a total of 21 0 stakeh olders . including pati en ts. healthcare professionals, and admini strators. In the quantitati ve an online survey was dep loyed based upon the findi ngs o f the qualitative phase, and was completed by 11 87 respondents (a 2.3% response rate), including patie nts (n ~422) . healthcare professionals (n~755), and administrators (n~IO).
Results of the comprehensive analysis reveal 7 key substantive patient care gaps. The data provided in-depth understanding of thc etiology o f each of those gaps that include: a) Suboptimal integration between health care professionals, b) patients disengaged and thus not being active participants in their health management, c) poor or s ubo ptimal therapeut ic re lati onships contributin g to reduced pat ient adherence, d) the strugg le for physici ans to prov ide emoti onal and psy cho log ical support to pati ents, e) ph ysician s are no t being equipped to prov ide appropriate patient education to support necessary li festy le changes, t) phys icians avo iding situati ons that co uld gene rate pati ent distress o r anxi ety, g) ph ys icians put emp hasis on curati ve care, neglecting preventi on. W ith each gap. the authors were able to deepen understa nd in g as to th e patient/ prov ider ,lnd/or system perspecti ve and co ntri bution 10 th e e.ap.
63
I Literature review on dietary factors associated with type II diabetes: a popu lation health perspective. Lise Dubois, Ottawa, ON, Wei Luo, Ottawa, ON, Marie Desmeules, Ottawa, ON Purpose of the study: The objective of this study was to cond uct a thorough literature review on the relationship between nutrition and the risk of type 11 diabetes (T2DM) at the population level. Methods: To be included in the review, studies must have been conducted among a population-based sample of adu lts, and they must have q uantify dietary intakes (dietary patterns, glycemic index , food /beverages, macronutrients, vitamins and minerals). Results: At the population level, dietary fiber, whole grains, fish and sea foods, coffee and moderate alcohol consumption are associated with a lower prevalence of T2DM, whereas read meat, processed meat and soft drinks are assoc iated with a higher prevalence of T2DM. Low vitamin D , calci um , dairy intake , magnesium and antioxida nts are also associated with an increased risk of T2DM in populations. The Med iterranean diet pattern offers protective elements against th e development of T2DM. Th is diet is characterized by a higher consumption of fruits and vegetables, legumes, fis h/seafood, who le grains, poultry and low fat dairy products . This pattern is associated with hi gher intakes of PUFA, vitam in E a nd C, fiber and beta carotene, and moderate consumption of a lcoho l. Individuals who have a hig her prudent diet pattern score are ge nerall y of older age, more physicall y active, and are more frequently non-smoke rs. The Western dietary pattern increases the risk for T2DM. T hi s diet is associated with higher intakes of butter a nd potatoes, red meat, processed meat, high-fat da iry prod ucts, French fries , refine grains, sweets and desserts, eggs, high sugar drinks, higher intakes of fat and alcohol and lower intakes of magnesium and cereal fiber. Generall y speaking, hig her conservative dietary patterns are found among individuals who are: males, of you nger age, of higher Body Mass Index , with lower levels of physical activity , and smokers. Conclusion: Nutritional factors should be at the heart of poli cies and interventions to prevent T2DM .
I Results of the Team Diabetes London Pharmacy Pi lot AMANDA
Understand ing Pati ent Care Gaps in Di abetes: Perspective of Patients, He alth care Professionals, an d Health ca re A dministrators. SEAN M.
There are many barriers to accessing diabetes education: location, cost, transportation, system navigation, and physician referral. Lengthy diabetes education sessions can also be a barrier to the elderly, mentally ill , and those who are employed. Team Diabetes London Pharmacy is a pi lot study examin ing the effectiveness of a diabetes education program hosted in the community pharmacy setting. Pharmacists referred patients into the program . Referred patients, attended three, 30 minute ed ucational sessions over six months with two interim foll ow-up phone calls. A ll sess ions were held in the community pharmacy setting one on one . Clinical diabetes outcomes (i.e. A Ie, SP, waist circumference, and weight) were documented on a flow sheet at each patient interaction. The flow sheet was also used to capture changes in patient self-management strategies and med ication profile. The flow sheet fac ili tated tracking of physician response to treatment recommendations . The patient " no show" rate was also documented. Patients and pharmacists completed a post program intervention questionnaire. 66 patients from I I different pharmacies were recruited to participate. Of those participants 52% were male and 66 % were greater than 60 years old. 60% of the participants had previously sought standard diabetes education. A t baseline and post intervention the % of p<"1t ients at target CPG tar get Alc< .070
(n62)Baseline45 % at target (.07 1) (n62)post68 % at target (.067)
CPG tar get BP< 130/80
(n59)Basel ine49% at target ( 130.7174.8) (n55)PosI56%at target ( 128.7170.6) p value .491
pvalue .011
Participa nts and pharmacists eva l uated the program favorably. 94% of the participants found the pharmacy a convenient location. "No show" rate for appoi ntments was
64
I Improved Method for Evaluating the Perform ance of Blood Glucose Monitoring Systems at Very l ow Sample Vo lumes DAVI D A. PR IC E1·, JOHN M. ElLiSONl, CHRISTOPHER DAVIS \ CARO LI NE CHU l, SANTHANAGOPAl AN NAN DAGO PAl AN1, UfeScan, Inc. Milpitas, CA, United States
Bac kgro und and aim s: Sample volume requirements for blood glucose mon itorin g systems (8GM Ss) have decreased in the past deca de. Despite the use of so phisticated error detection technologies. applying insuffi~ient blood remains a common user error. Studies have shown thai underdosing can produ ce numerica l resul1s that are falsely low by more Ihan 20% in some systems . Current methods for evaluating sample volume are prone to several so urces of error as they typically involve repealed pipeHing 01 fixed microvolumes of whole blood. The purpose of this study was to evaluate the frequency and accuracy of nu merical results for 2 BGMS systems at low blood volumes using a new and improved method . Materia ls and meth ods: Three test strip lots from 2 BGMS systems were evaluated (Ascensia® Contour®. OneTouch® Ultra®2) using venous blood sam ples with gl ucose level s adjusted to 70 and 400 mg/dL (3. B and 22 2 mmoll L). A validated gravimetric method was used 10 precisely determine the volume of blood applied to each test strip. logistic regression analysis provided estimate s of (a) the probability that the BGMS will yield a numerical result across a range of six sample volumes (spanning the claimed volume of each BGMS system). and (b) the probability that numerical results obtained will be accurate with respect to YSI plasma reference values. The accuracy of meter resulis at each test vo lu me was evaluated usin g bias plots based on published ISO criteria Hesults: A total of 432 tests were performed on each BGMS system. Both systems have a volume region below the claimed volume where error messages and numerical results are possible. The new methodology shows that under these low-volume conditions. the frequency of numerical results (as opposed to error messages) was sim ilar for both systems a152% (Contour) and 58 % (Ultra2) for high glucose levels and 50 % (Contour) and 42% (Ultra2) at low glucose levels. However. the accuracy of the numerical results was quite different for the 2 systems. At high glucose levels, 59% (57197) of the Conlour BGMS results were found to be accurate as compared to 100% (34 /34 ) for Ultra2 . Similarly, at low glucose levels. 66 % (21 132 ) of the Contour BGMS resuhs were found to be accurate as compared to 100% (17/17) for Uhra2 . The inaccurate results obse rved with the Contour BGMS were falsely low. Co nclu sion: Our new method provides reliable estimates of the effects of sa mple volu me on BGMS systems . Despite having a low volum e requi re ment. the error detection method used by the Contour BGMS system may be ineffective al preventing inaccurate test results. These inaccuracies may have significa nt clin ica l implications.
I 317
ORAL PRESENTATIONS
61
I
62
G. MIKALACHK I*", STEWART B. HARR IS' + t , +Department of Family Medicine, University of Western Ontario, London. ON; #St. Joseph's Health Care, London, ON
HA YES' , D1L1P PA TEL " MARTIN DUPUIS', SUZANNE MUR RA y' . 'AXDEV Group In c., Brossard , QC, ' Merck Frosst Canada Limited, Kirk land , QC . Des pite changes and re fo rm s in healthca re in Canada sin ce last fe w years, critical gaps continuc to hinder optim al pati ent ca re. The objectives of thi s study were to: (I) Identif), and better un derstand key cha llen ges that impact patient ca re from m ult ip les perspect ive (pati en t, phys icians, all ied hea lthcare providers. an d hospitals and gov ernme nts admini str ators); (2) Better understand patients' ex periences \vit hin th e health care sy stem acros s multipl e di sease, inclu din g fo r d iabetes ; (3) to ide nti fy ca llses ofthc gaps and barriers to opti mal care in the current Canadi an health ca re context. An IRB approved m ixed-meth od appro ach w as employed including q ualitative and quan titati ve data collecti on techn iques. In the q ua litati ve phase, 18 foc us groups an d 122 telephone s inte rv iews were conducted across the country w ith a total of 21 0 stakeh olders . including pati en ts. healthcare professionals, and admini strators. In the quantitati ve an online survey was dep loyed based upon the findi ngs o f the qualitative phase, and was completed by 11 87 respondents (a 2.3% response rate), including patie nts (n ~422) . healthcare professionals (n~755), and administrators (n~IO).
Results of the comprehensive analysis reveal 7 key substantive patient care gaps. The data provided in-depth understanding of thc etiology o f each of those gaps that include: a) Suboptimal integration between health care professionals, b) patients disengaged and thus not being active participants in their health management, c) poor or s ubo ptimal therapeut ic re lati onships contributin g to reduced pat ient adherence, d) the strugg le for physici ans to prov ide emoti onal and psy cho log ical support to pati ents, e) ph ysician s are no t being equipped to prov ide appropriate patient education to support necessary li festy le changes, t) phys icians avo iding situati ons that co uld gene rate pati ent distress o r anxi ety, g) ph ys icians put emp hasis on curati ve care, neglecting preventi on. W ith each gap. the authors were able to deepen understa nd in g as to th e patient/ prov ider ,lnd/or system perspecti ve and co ntri bution 10 th e e.ap.
63
I Literature review on dietary factors associated with type II diabetes: a popu lation health perspective. Lise Dubois, Ottawa, ON, Wei Luo, Ottawa, ON, Marie Desmeules, Ottawa, ON Purpose of the study: The objective of this study was to cond uct a thorough literature review on the relationship between nutrition and the risk of type 11 diabetes (T2DM) at the population level. Methods: To be included in the review, studies must have been conducted among a population-based sample of adu lts, and they must have q uantify dietary intakes (dietary patterns, glycemic index , food /beverages, macronutrients, vitamins and minerals). Results: At the population level, dietary fiber, whole grains, fish and sea foods, coffee and moderate alcohol consumption are associated with a lower prevalence of T2DM, whereas read meat, processed meat and soft drinks are assoc iated with a higher prevalence of T2DM. Low vitamin D , calci um , dairy intake , magnesium and antioxida nts are also associated with an increased risk of T2DM in populations. The Med iterranean diet pattern offers protective elements against th e development of T2DM. Th is diet is characterized by a higher consumption of fruits and vegetables, legumes, fis h/seafood, who le grains, poultry and low fat dairy products . This pattern is associated with hi gher intakes of PUFA, vitam in E a nd C, fiber and beta carotene, and moderate consumption of a lcoho l. Individuals who have a hig her prudent diet pattern score are ge nerall y of older age, more physicall y active, and are more frequently non-smoke rs. The Western dietary pattern increases the risk for T2DM. T hi s diet is associated with higher intakes of butter a nd potatoes, red meat, processed meat, high-fat da iry prod ucts, French fries , refine grains, sweets and desserts, eggs, high sugar drinks, higher intakes of fat and alcohol and lower intakes of magnesium and cereal fiber. Generall y speaking, hig her conservative dietary patterns are found among individuals who are: males, of you nger age, of higher Body Mass Index , with lower levels of physical activity , and smokers. Conclusion: Nutritional factors should be at the heart of poli cies and interventions to prevent T2DM .
I Results of the Team Diabetes London Pharmacy Pi lot AMANDA
Understand ing Pati ent Care Gaps in Di abetes: Perspective of Patients, He alth care Professionals, an d Health ca re A dministrators. SEAN M.
There are many barriers to accessing diabetes education: location, cost, transportation, system navigation, and physician referral. Lengthy diabetes education sessions can also be a barrier to the elderly, mentally ill , and those who are employed. Team Diabetes London Pharmacy is a pi lot study examin ing the effectiveness of a diabetes education program hosted in the community pharmacy setting. Pharmacists referred patients into the program . Referred patients, attended three, 30 minute ed ucational sessions over six months with two interim foll ow-up phone calls. A ll sess ions were held in the community pharmacy setting one on one . Clinical diabetes outcomes (i.e. A Ie, SP, waist circumference, and weight) were documented on a flow sheet at each patient interaction. The flow sheet was also used to capture changes in patient self-management strategies and med ication profile. The flow sheet fac ili tated tracking of physician response to treatment recommendations . The patient " no show" rate was also documented. Patients and pharmacists completed a post program intervention questionnaire. 66 patients from I I different pharmacies were recruited to participate. Of those participants 52% were male and 66 % were greater than 60 years old. 60% of the participants had previously sought standard diabetes education. A t baseline and post intervention the % of p<"1t ients at target CPG tar get Alc< .070
(n62)Baseline45 % at target (.07 1) (n62)post68 % at target (.067)
CPG tar get BP< 130/80
(n59)Basel ine49% at target ( 130.7174.8) (n55)PosI56%at target ( 128.7170.6) p value .491
pvalue .011
Participa nts and pharmacists eva l uated the program favorably. 94% of the participants found the pharmacy a convenient location. "No show" rate for appoi ntments was
64
I Improved Method for Evaluating the Perform ance of Blood Glucose Monitoring Systems at Very l ow Sample Vo lumes DAVI D A. PR IC E1·, JOHN M. ElLiSONl, CHRISTOPHER DAVIS \ CARO LI NE CHU l, SANTHANAGOPAl AN NAN DAGO PAl AN1, UfeScan, Inc. Milpitas, CA, United States
Bac kgro und and aim s: Sample volume requirements for blood glucose mon itorin g systems (8GM Ss) have decreased in the past deca de. Despite the use of so phisticated error detection technologies. applying insuffi~ient blood remains a common user error. Studies have shown thai underdosing can produ ce numerica l resul1s that are falsely low by more Ihan 20% in some systems . Current methods for evaluating sample volume are prone to several so urces of error as they typically involve repealed pipeHing 01 fixed microvolumes of whole blood. The purpose of this study was to evaluate the frequency and accuracy of nu merical results for 2 BGMS systems at low blood volumes using a new and improved method . Materia ls and meth ods: Three test strip lots from 2 BGMS systems were evaluated (Ascensia® Contour®. OneTouch® Ultra®2) using venous blood sam ples with gl ucose level s adjusted to 70 and 400 mg/dL (3. B and 22 2 mmoll L). A validated gravimetric method was used 10 precisely determine the volume of blood applied to each test strip. logistic regression analysis provided estimate s of (a) the probability that the BGMS will yield a numerical result across a range of six sample volumes (spanning the claimed volume of each BGMS system). and (b) the probability that numerical results obtained will be accurate with respect to YSI plasma reference values. The accuracy of meter resulis at each test vo lu me was evaluated usin g bias plots based on published ISO criteria Hesults: A total of 432 tests were performed on each BGMS system. Both systems have a volume region below the claimed volume where error messages and numerical results are possible. The new methodology shows that under these low-volume conditions. the frequency of numerical results (as opposed to error messages) was sim ilar for both systems a152% (Contour) and 58 % (Ultra2) for high glucose levels and 50 % (Contour) and 42% (Ultra2) at low glucose levels. However. the accuracy of the numerical results was quite different for the 2 systems. At high glucose levels, 59% (57197) of the Conlour BGMS results were found to be accurate as compared to 100% (34 /34 ) for Ultra2 . Similarly, at low glucose levels. 66 % (21 132 ) of the Contour BGMS resuhs were found to be accurate as compared to 100% (17/17) for Uhra2 . The inaccurate results obse rved with the Contour BGMS were falsely low. Co nclu sion: Our new method provides reliable estimates of the effects of sa mple volu me on BGMS systems . Despite having a low volum e requi re ment. the error detection method used by the Contour BGMS system may be ineffective al preventing inaccurate test results. These inaccuracies may have significa nt clin ica l implications.
I 317