www.dmscan.ca
The DM-SCAN program has been made possible through the support of Merck Canada Inc.
The opinions expressed in this material are those of the authors and do not necessarily reflect the views of Merck Canada Inc.
Steering Committee Members
Western Canada:
Lori Berard, RN, CDE – Nurse and Certified Diabetes Educator – Winnipeg, MB
Keith Bowering, MD – Endocrinologist – Edmonton, AB
Keith Dawson, MD – Endocrinologist – Vancouver, BC
Ross Tsuyuki, PharmD – Academic Pharmacist – Calgary AB
Vincent Woo, MD – Endocrinologist – Winnipeg, MB
Ontario:
Alice Cheng, MD – Endocrinologist – Toronto, ON
Stewart Harris, MD – Primary Care Physician/Diabetes Expert – London, ON
Anatoly Langer MD – Cardiologist – Toronto, ON
Lawrence Leiter, MD (Chair) – Endocrinologist – Toronto, ON
Peter Lin, MD – Primary Care Physician – Toronto, ON
Dana Whitham, RD, MSc, CDE – Dietitian and Certified Diabetes Educator – Toronto, ON
Quebec:
Jean-Marie Ekoé, MD – Endocrinologist – Montreal, QC
Carl Fournier, MD – Primary Care Physician – Montreal, QC
Jean-Francois Yale, MD – Endocrinologist – Montreal, QC
Atlantic Canada:
Thomas Ransom, MD – Endocrinologist – Halifax, NS
Program Objectives
• To evaluate and gain insight into the current
status and management of patients with
Type 2 Diabetes in Canada in the primary
care setting
• To highlight the public health burden of Type
2 Diabetes
• To identify management gaps to help design
educational programs of practical value to
primary care physicians
Program Overview
Assess the current management of
patients with type 2 diabetes by
completing a simple one-page Data
Collection Form on ALL patients seen as
part of routine clinical practice on or as
close as possible to World Diabetes Day
(November 14, 2012)
National Physician and Patient Representation
MDs – N = 479
DCFs – N = 5123
•
Avg. number of DCF*s/MD - 11
NL
MDs – n=17
DCFs – n=208
SK
MB
MDs – n=3 MDs – n=19
DCFs – n=21 DCFs – n=249
QC
ON
MDs – n=270
DCFs – n=2990
MDs – n =45
DCFs – n=400
NS
MDs – n=28
DCFs – n=295
NB-PEI
MDs – n=27
DCFs – n=362
* DCF – Data Collection Form
Practice Setting
41%
59%
Solo Practice
Group Practice
50% of the physician participants identified being a part of a Family Health Team
Physician Practice –
Geographic Setting
16%
Inner City
21%
63%
Small Town / Rural
Urban / Suburban
Practice Survey Question:
On average, how many patients with Type 2 Diabetes
do you see in a week?
Number of patients
% - physician
responses
Less than 5
1%
5 to 10
13%
10 to 20
36%
20 to 30
27%
30 to 50
16%
More than 50
7%
Practice Survey Question:
Approximately what proportion of your patients have their type 2
diabetes co-managed by an allied health care professional (in your
office or local diabetes education centre)?
Percent of patients
% - physician responses
None
3%
1 to 25%
56%
26 to 50%
19%
> 50%
22%
Practice Survey Question:
Please identify the greatest barriers to managing
patients with diabetes:
Top Five Responses:
1.
2.
3.
4.
5.
Patient non-compliance
Patient resistance
Constraints on physician’s time
Financial barriers
Lack of support for the physician
Patient Demographics
46%
Age*
Duration of T2DM*
Female Sex: n=2353 Available Records 4707
Age: n=5090
Duration of T2DM: n=5062
64 (12)
9 (7)
* Data presented as mean (SD)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Patient Ethnicity
N = 4971
Aboriginal Canadian
3%
Black
4%
Caucasian
61%
East / SE Asian
17%
Hispanic
2%
South Asian
11%
Other
3%
152 records unavailable
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Summary of Patient BMI
Categories
N = 5123*
Body Mass Index (kg/m2)
Mean (SD)
30.5 (10)
31.1 (11.6)
Men
Women
Category
Percent of Patients
Normal Weight
14%
Overweight
29%
Obese
57%
N for each category was variable due to missing values, <10% in each case.
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Health Behaviours
38% of patients had been referred to or counselled by a registered dietitian
or a certified diabetes educator within the last 12 months (n=4787)
50% of patients had a nutrition / exercise / weight loss plan with
measurable goals established in the past 12 months (n=4776)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Glycemic and Renal Profile
N
Mean + SD
Guideline
Recommendations
A1C (%)
5103
7.4 + 1.3
<7.0%
Fasting Plasma Glucose (mmol/L)
4761
7.8 + 2.6
4.0 – 7.0
Creatinine (µmol/L)
4890
86 + 124
N/A
eGFR (mL/min)
4615
75.2 + 44.1
N/A
Urine Albumin Creatinine Ratio (mg/mmol)
3957
10.7 + 48.4
<2.0 (men)
<2.8 (women)
Measure
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Insulin Use by Number of
Injections per Day
60%
% of patients
Insulin Only
Insulin + NIAHA*
40%
40%
28%
29%
28%
27%
20%
15%
13%
9%
7%
5%
0%
1 Injection / day
2 injections / day
3 injections / day
4 injections / day
> 4 injections / day
* NIAHA – Non Insulin Antihyperglycemic Agent
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Glycemic Management
N = 4477
Medical Management
N
% of Patients
1 NIAHA* - 85% treated with Metformin
802
18%
2 NIAHAs
673
15%
≥ 3 NIAHAs
261
6%
Insulin alone
854
19%
Insulin + ≥ 1 NIAHAs
1887
42%
* NIAHA - non-insulin antihyperglycemic agent
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
A1C Values Achieved
N = 5103
100%
91%
86%
80%
% of patients
78%
67%
60%
50%
40%
20%
28%
0%
Target Achieved Target Achieved
≤6.5%
≤7.0%
≤7.5%
≤8%
≤8.5%
≤ 9.0%
A1C (%)
In 81% of patients, the A1C goal set by the physicians was ≤7%.
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
A1C <7% Attainment Rates based on
Duration of Diabetes
80%
65%
58%
% of patients – A1C <7%
60%
49%
43%
37%
40%
20%
0%
≤2 years
3-5 years
6-9 years
10-14 years
>15 years
Duration of Diabetes (years)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Lipid Profile
N = 5069
Measure
Mean + SD
Guideline Recommendations
LDL
2.1 + 0.9
<2.0 mmol/L
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Lipid Management
N = 4153
Management
Monotherapy
Statin alone
2 Lipid Lowering Agents
Statin + Cholesterol Absorption Inhibitor
> 2 Lipid Lowering Agents
% of Patients
88%
85%
11%
8%
<1%
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
LDL-C Values Achieved
N = 5069
100%
93%
86%
% of patients
80%
60%
75%
57%
40%
20%
0%
Target Achieved ≤2.0
≤2.5
≤3.0
≤3.5
LDL-C (mmol/L)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
LDL-C Values Achieved –
Presence and Absence of Vascular Disease
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Lipid Control and Management
of DM-SCAN Patients
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Blood Pressure Profile
Systolic Blood Pressure: N = 5103, Diastolic Blood Pressure: N = 5099
Measure
Mean + SD
Guideline Recommendations
SBP
128 + 14
< 130 mm Hg
DBP
75 + 9
< 80 mm Hg
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Blood Pressure Management
N = 4946
% of Patients
Management
BP recorded (Nov / Dec 2012)
70%
Not treated with BP medication
17%
N = 4272
Monotherapy
39%
2 Agents
34%
3 Agents
21%
3+ Agents
6%
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Blood Pressure Values Achieved
N = 5099
100%
90%
93%
79%
80%
% of patients
69%
60%
40%
36%
20%
0%
Target Achieved
SBP < 130 / DBP < 80
<135 / <85
<140 / <90
<145 / <95
<150 / <100
SBP / DBP (mm Hg)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Distribution of Antihypertensive Therapy
Strategies Prescribed to Patients with Blood
Pressure >130/80 mmHg
N = 1494
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Guideline Targets Achieved for
A1C, LDL-C and Blood Pressure
60%
57%
% of patients
50%
40%
36%
20%
13%
0%
A1C (≤7%) (n=5103)
LDL-C (≤2.0 mmol/L) (n=5069) SBP/DBP (<130/80 mm HG)
(n=5099)
All 3 Endpoints
(A1C, LDL-C, BP) (n=5104)
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Patient Comorbidities
CAD
22%
Stroke / TIA
6%
PAD
8%
Atrial Fibrillation
7%
Retinopathy
8%
Nephropathy
15%
Neuropathy
12%
Erectile Dysfunction (n=2313)
39%
Cancer
12%
Depression
12%
0%
20%
40%
60%
% of patients
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82-89
Has glycemic management improved
over the last decade?
DICE
(2002-2003)
N = 2473
DRIVE
(2005-2006)
N = 3002
DM-SCAN
(Nov-Dec 2012)
N=5123
Age at audit, years
62.7
63
64
Time since diagnosis, years
7.8
8.1
9.2
Female, %
46
41
46
BMI, kg/m2
31
31
31
A1C, %
7.3
7.2
7.4
A1C >7.0%, proportion of patients
49
47
50
Note: All data reported as mean
1Harris
S, et al. Diabetes Res Clin Prac. 2005;70(1):90-97.
M, et al. Can J Cardiol. 2010;26(6):297-302.
2Braga