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Nagy DK, Bresee LC, Eurich DT, Simpson SH. Are Guideline-concordant Processes of Care Consistent Across the Rural-Urban Continuum? A Retrospective Cohort Study of Adults Newly Treated for Type 2 Diabetes. Can J Diabetes 2024:S1499-2671(24)00065-0. [PMID: 38583767 DOI: 10.1016/j.jcjd.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/07/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVES Our aim in this study was to identify the association between place of residence (metropolitan, urban, rural) and guideline-concordant processes of care in the first year of type 2 diabetes management. METHODS We conducted a retrospective cohort study of new metformin users between April 2015 and March 2020 in Alberta, Canada. Outcomes were identified as guideline-concordant processes of care through the review of clinical practice guidelines and published literature. Using multivariable logistic regression, the following outcomes were examined by place of residence: dispensation of a statin, angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB), eye examination, glycated hemoglobin (A1C), cholesterol, and kidney function testing. RESULTS Of 60,222 new metformin users, 67% resided in a metropolitan area, 10% in an urban area, and 23% in a rural area. After confounder adjustment, rural residents were less likely to have a statin dispensed (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.79 to 0.87) or undergo cholesterol testing (aOR 0.86, 95% CI 0.83 to 0.90) when compared with metropolitan residents. In contrast, rural residents were more likely to receive A1C and kidney function testing (aOR 1.14, 95% CI 1.08 to 1.21 and aOR 1.17, 95% CI 1.11 to 1.24, respectively). ACEi/ARB use and eye examinations were similar across place of residence. CONCLUSIONS Processes of care varied by place of residence. Limited cholesterol management in rural areas is concerning because this may lead to increased cardiovascular outcomes.
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Affiliation(s)
- Danielle K Nagy
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Lauren C Bresee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dean T Eurich
- School of Public Health, Li Ka Shing Centre for Research, University of Alberta, Edmonton, Alberta, Canada
| | - Scot H Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada.
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Houlden RL, Thayalan N, Shi S, Kukaswadia A, Mau G, Liu A. Identifying Ontarians with Type 2 Diabetes Mellitus in Administrative Data: A Comparison of Two Case Definitions. Diabetes Ther 2024; 15:677-689. [PMID: 38340280 PMCID: PMC10942959 DOI: 10.1007/s13300-024-01535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/16/2024] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION This study compared two previously validated sensitive and specific diabetes case definitions to explore the impact of different classification methods in Ontario ICES administrative data. METHODS This study included patients captured by the Ontario Diabetes Database with type 2 diabetes using either the sensitive cohort definition (≥ 2 physician visits for diabetes within 1 year or ≥ 1 drug claim for diabetes or ≥ 1 hospitalization with diabetes), or the specific cohort definition (≥ 3 physician visits for diabetes within 1 year), between October 1, 2013 to September 30, 2015. Each cohort's demographic and clinical features were described using descriptive analysis. RESULTS Using sensitive and specific definitions, 1,093,812 and 783,228 patients with type 2 diabetes were identified, respectively. Overall, the demographic and clinical characteristics were similar between cohorts. Patients in the sensitive cohort had mean age of 64.1 years and were 52.4% male, compared to 64.8 years and 53.6% male in the specific cohort. In the sensitive and specific cohorts respectively, 64.4% and 55.7% of patients reported one-year mean HbA1c of < 7% (53 mmol/mol) and 25.3% and 31.5% reported levels between 7.0-8.5% (53-69 mmol/mol). CONCLUSIONS Although sample sizes were different between sensitive and specific cohorts, demographic and clinical characteristics were similar.
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Affiliation(s)
- Robyn L Houlden
- Division of Endocrinology, Queen's University, Kingston, ON, Canada.
| | - Nilasha Thayalan
- Division of Endocrinology, Queen's University, Kingston, ON, Canada
| | - Scott Shi
- IQVIA Solutions Canada Inc, Mississauga, ON, Canada
| | | | - Godfrey Mau
- Novo Nordisk Canada Inc, Mississauga, ON, Canada
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Hartmann-Boyce J, Highton P, Rees K, Onakpoya I, Suklan J, Curtis F, O'Mahoney L, Morris E, Kudlek L, Morgan J, Lynch R, Marpadga S, Seidu S, Khunti K. The impact of the COVID-19 pandemic and associated disruptions in health-care provision on clinical outcomes in people with diabetes: a systematic review. Lancet Diabetes Endocrinol 2024; 12:132-148. [PMID: 38272607 DOI: 10.1016/s2213-8587(23)00351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 01/27/2024]
Abstract
The COVID-19 pandemic triggered disruptions to health care and lifestyles that could conceivably impact diabetes management. We set out to identify the impact of disruptions caused by COVID-19 on clinical outcomes in people with diabetes. We performed a systematic review of the available literature in the MEDLINE and OVID databases from Jan 1, 2020, to June 7, 2023, and included 138 studies (n>1 000 000 people). All but five studies were judged to be at some risk of bias. All studies compared prepandemic with pandemic periods. All-cause mortality (six studies) and diabetes-related mortality (13 studies) showed consistent increases, and most studies indicated increases in sight loss (six studies). In adult and mixed samples, data generally suggested no difference in diabetic ketoacidosis frequency or severity, whereas in children and adolescents most studies showed increases with some due to new-onset diabetes (69 studies). Data suggested decreases in hospital admissions in adults but increases in diabetes-related admissions to paediatric intensive care units (35 studies). Data were equivocal on diabetic foot ulcer presentations (nine studies), emergency department admissions (nine studies), and overall amputation rates (20 studies). No studies investigated renal failure. Where reported, the impact was most pronounced for females, younger people, and racial and ethnic minority groups. Further studies are needed to investigate the longer-term impact of the pandemic and the on potential differential impacts, which risk further exacerbating existing inequalities within people with diabetes.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Department of Health Promotion and Policy, University of Massachusetts Amherst, Amherst, MA, USA; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | | | | | - Igho Onakpoya
- Department for Continuing Education, University of Oxford, Oxford, UK
| | - Jana Suklan
- National Institute for Health and Care Research Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle, UK
| | - Ffion Curtis
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | | | - Elizabeth Morris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Laura Kudlek
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Jessica Morgan
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Rosie Lynch
- Medical Sciences Division, University of Oxford, Oxford, UK
| | | | - Samuel Seidu
- Diabetes Research Centre, University of Leicester, UK
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4
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Beamish P, McNeill K, Arnaout A, Malcolm J. Patient Perspectives on Virtual Care for Diabetes Management in the Era of COVID-19. Can J Diabetes 2023; 47:636-642. [PMID: 37437840 DOI: 10.1016/j.jcjd.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/28/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE The aim of this study was to characterize patient perspectives on the quality of diabetes care at The Ottawa Hospital Endocrinology and Metabolism multidisciplinary clinic delivered virtually during the COVID-19 pandemic. METHODS An online survey was developed to collect quantitative and qualitative data on patients' experiences with virtual diabetes clinic visits between March 2020 and April 2021. RESULTS A total of 333 patients were included in this study; 45% were female and had a mean age of 60 years. Seventy-nine percent were born in Canada and 87% identified as Caucasian. Thirty-six percent were treated for type 1 diabetes and 62% for type 2 diabetes. Eighty-seven percent of virtual visits occurred by phone, with 12% of these on Zoom. Overall, 83% were "very satisfied" or "satisfied" with their virtual care experience. Most respondents perceived all treatment-related factors to be equally well addressed virtually as in person, except for physical examination. Auxiliary factors like travel, cost, and time spent were rated more favourably with virtual care. Qualitative findings provided further contextualization and identified gaps in virtual care delivery. For future visits, 44% wanted in-person visits only as needed, 36% wanted a hybrid of in-person and virtual appointments, and 11% preferred in-person appointments only. CONCLUSIONS Patients perceive that virtual care provides high-fidelity diabetes management while reducing their pandemic risks as well as minimizing travel and time associated with in-person care. Virtual care is an important medium for diabetes care delivery that should be used according to patient preference and intermixed with in-person appointments.
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Affiliation(s)
- Paul Beamish
- Division of Endocrinology and Metabolism, Department of Medicine, The Ottawa Hospital Riverside Campus, The University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Kylie McNeill
- Department of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Amel Arnaout
- Division of Endocrinology and Metabolism, Department of Medicine, The Ottawa Hospital Riverside Campus, The University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Janine Malcolm
- Division of Endocrinology and Metabolism, Department of Medicine, The Ottawa Hospital Riverside Campus, The University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
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Fikree S, Hafid S, Lawson J, Agarwal G, Griffith LE, Jaakkimainen L, Mangin D, Howard M. The association between patients' frailty status, multimorbidity, and demographic characteristics and changes in primary care for chronic conditions during the COVID-19 pandemic: a pre-post study. Fam Pract 2023; 40:523-530. [PMID: 37624946 DOI: 10.1093/fampra/cmad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The purpose of this study was to assess the impact of SARS-COV-2 (Severe acute respiratory syndrome coronavirus 2) pandemic on primary care management (frequency of monitoring activities, regular prescriptions, and test results) of older adults with common chronic conditions (diabetes, hypertension, and chronic kidney disease) and to examine whether any changes were associated with age, sex, neighbourhood income, multimorbidity, and frailty. METHODS A research database from a sub-set of McMaster University Sentinel and Information Collaboration family practices was used to identify patients ≥65 years of age with a frailty assessment and 1 or more of the conditions. Patient demographics, chronic conditions, and chronic disease management information were retrieved. Changes from 14 months pre to 14 months since the pandemic were described and associations between patient characteristics and changes in monitoring, prescriptions, and test results were analysed using regression models. RESULTS The mean age of the 658 patients was 75 years. While the frequency of monitoring activities and prescriptions related to chronic conditions decreased overall, there were no clear trends across sub-groups of age, sex, frailty level, neighbourhood income, or number of conditions. The mean values of disease monitoring parameters (e.g. blood pressure) did not considerably change. The only significant regression model demonstrated that when controlling for all other variables, patients with 2 chronic conditions and those with 4 or more conditions were twice as likely to have reduced numbers of eGFR (Estimated glomerular filtration rate) measures compared to those with only 1 condition ((OR (odds ratio) = 2.40, 95% CI [1.19, 4.87]); (OR = 2.19, 95% CI [1.12, 4.25]), respectively). CONCLUSION In the first 14 months of the pandemic, the frequency of common elements of chronic condition care did not notably change overall or among higher-risk patients.
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Affiliation(s)
- Shireen Fikree
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Shuaib Hafid
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Jennifer Lawson
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Gina Agarwal
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Liisa Jaakkimainen
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, Canada
- Department of General Practice and Clinical Skills, University of Otago Christchurch, New Zealand
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Canada
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Cheng AY, Harris S, Krawchenko I, Tytus R, Hahn J, Liu A, Millson B, Golden S, Goldenberg R. Impact of the COVID-19 Pandemic on Adults With Type 2 Diabetes Care and Clinical Parameters in a Primary Care Setting in Ontario, Canada: A Cross-sectional Study. Can J Diabetes 2023:S1499-2671(23)00001-1. [PMID: 36828737 PMCID: PMC9829439 DOI: 10.1016/j.jcjd.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Diabetes requires ongoing monitoring and care to prevent long-term adverse health outcomes. In Canada, quarantine restrictions were put into place to address the coronavirus-2019 (COVID-19) pandemic in March 2020. Primary care diabetes clinics limited their in-person services and were advised to manage type 2 diabetes (T2D) through virtual visits and reduce the frequency of routine diabetes-related lab tests and screening. METHODS This retrospective cross-sectional study used de-identified patient records from a primary care electronic medical records database in Ontario, Canada, to identify people with T2D who had at least 1 health-care touchpoint between March 1, 2018, and February 28, 2021. Outcomes were described on a monthly or yearly basis: 1) number of people with primary care visits (in-person vs virtual); 2) number of people with referrals; 3) number of people with each of the vital/lab measures; and 4) results of the vital/lab measures. RESULTS A total of 16,845 individuals with T2D were included. Compared with the pre-pandemic period, the COVID-19 period had a 16.8% reduction in the T2D population utilizing any primary care and an increase of 330.4% in the number of people with at least 1 virtual visit. Compared with the pre-pandemic period, fewer people had vital/lab measures in the pandemic period. However, among the people with the test results available, the average values for all tests were similar in the pre- and pandemic periods. CONCLUSION Further research is needed to understand the impact of the reduction of in-person clinical care on the entire population with T2D.
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Affiliation(s)
- Alice Y.Y. Cheng
- Trillium Health Partners & Unity Health Toronto, Mississauga, Ontario, Canada,Address for correspondence: Alice Y.Y. Cheng MD, FRCPC, Trillium Health Partners & Unity Health Toronto, 507-2300 Eglinton Avenue West, Mississauga, Ontario L5M 2V8, Canada
| | - Stewart Harris
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | | | - Jina Hahn
- Novo Nordisk Canada, Inc, Mississauga, Ontario, Canada
| | - Aiden Liu
- Novo Nordisk Canada, Inc, Mississauga, Ontario, Canada
| | - Brad Millson
- Real World Solutions, IQVIA Solutions Canada Inc, Ottawa, Ontario, Canada
| | - Shane Golden
- Real World Solutions, IQVIA Solutions Canada Inc, Ottawa, Ontario, Canada
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