Diabetes Care Contents

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1 Diabetes Care Contents July 2010 Vol. 20 Number 2 in Nova Scotia A NEWSLETTER OF THE DIABETES CARE PROGRAM OF NOVA SCOTIA State of the Art The Diabetes Physical Activity and Exercise Toolkit, 2nd Edition...implementation of effective physical activity counseling into standard practice by diabetes care providers still remains a significant challenge in quality diabetes care. Many diabetes care providers recognize the importance of physical activity for the prevention and management of diabetes. Recent analyses have confi rmed the high effectiveness of diet and physical activity/exercise in preventing the progression to diabetes, 1 as well as the long-standing persistence of these benefits continuing for many years after the intervention period. 2-3 When combined with high cost-effectiveness, low-risk profi le, and other multi-factorial benefits beyond glucose control, lifestyle intervention (i.e., diet and physical activity) has recently been recognized as the most prudent tool to manage diabetes. 4 However, long-term adherence to physical activity and exercise by clients and implementation of effective physical activity counseling into standard practice by diabetes care providers still remains a significant challenge in quality diabetes care. Tool Kit Update The Diabetes Physical Activity and Exercise Toolkit was developed to address the lack of resources that diabetes care providers have for physical activity counseling in clinical practice. The Toolkit was originally developed and released in April 2008 and its effectiveness evaluated over the last two years in Nova Scotia. Based on what has been learned thus far, there are many positive outcomes, but also significant challenges for lifestyle management in clinical diabetes care. Issues of time, motivation, cost, and know-how are well-known barriers for patients including physical activity and exercise in daily life. What has also been discovered is that these are significant challenges for delivery of physical activity and exercise counseling by diabetes care providers in daily clinical practice. 1 State of the Art The Diabetes Physical Activity and Exercise Toolkit, 2nd Edition 4 News from the Care Program 7 Pregnancy Focus GDM Expanding Figures 8 Research to Practice What is a Healthy Waist Circumference? 9 Educator Sharing Dalhousie Health Mentors Program NEW Diabetes Guidelines for Elderly Residents in Long-Term Care Facilities (9) Family Physician Chronic Disease Management (CDM) Incentive Program (10) Self-Monitoring Blood Glucose (SMBG) - Part 2 (11) DCPNS Grant Funding (2009/10) Project Summary: - Patient Medication Improvement Project (12) - Implementing and Evaluating a Physical Activity and Exercise Program in the South West Health Diabetes Centres (13) 14 Physical Activity Corner 14 News From Around the Province Newsletter publication dates: February, June, and October. Questions or contributions should be submitted at least 3-4 weeks prior to publication South Park Street, Bethune Building, Suite 548 Halifax, NS B3H 2Y9 Tel. (902) ; Fax (902) Website:

2 con t First and foremost, many diabetes care providers lacked formal training in physical activity and exercise; therefore, reported low confidence in their ability to appropriately counsel on physical activity and prescribe exercise. 5 Diabetes educators initially reported (pre; n=124) multiple barriers to physical activity counseling in practice; and time (65%), lack of interest by the client (34%), lack of resources (30%), and lack of knowledge (30%) were identified most often. 5 As a result, less than 1/3 of educators reported providing physical activity counseling during client sessions. Given this situation, it is not surprising that only 2.4% of patients in Nova Scotia and New Brunswick initially reported (pre; n=203) meeting the CDA guidelines for both aerobic and resistance exercise (recent findings - unpublished). The Diabetes Physical Activity and Exercise Toolkit and workshops provided education and information on how to appropriately screen clients for exercise or referral, how to adopt a counseling approach that is relevant to the patient, and how to develop a physical activity or exercise plan that is suited to the client s readiness and capacity for physical activity. As a result, diabetes educators in Nova Scotia reported that confidence in physical activity counseling increased significantly (+12%; p<0.001), and the barriers of lack of knowledge and resources were reduced by half (p<0.01). One of our most important findings was in relation to the barrier reported by diabetes educators re: lack of interest by clients in physical activity and exercise. Diabetes educators reported at pre that their perception of the client s attitude toward physical activity and exercise was low (2.8/5), and confidence in the client s ability to perform physical activity was also low (38%). Interestingly, when we surveyed clients, their attitude toward physical activity and exercise was high (6.0/7); and actual confidence in their own abilities to perform physical activity was higher than that perceived by diabetes educators (58%; i.e., ~20% difference). Additionally, clients also reported high confidence in the diabetes educators to provide direction for physical activity and exercise (68%). What these data suggest is that there is the potential for clients to be interested in physical activity but not know what to do or how to do it. Because clients have high confidence in their diabetes care provider to give them appropriate direction, if physical activity or exercise is not discussed in a diabetes counseling session, or is not given similar coverage as other topics, this could be interpreted as not being important or as a low-priority in diabetes management. As a clinical practice point, the recommendation may be to guard against interpreting a lack of know-how by the client as a lack of interest. A major goal of physical activity counseling is to support and build provider confidence and the confidence of clients by bridging the awareness to action gap with concrete direction and plans for physical activity and exercise. These points highlight the importance of clientcentered care in lifestyle management, where the needs and interests of the client are considered for the plan to be engaging and effective. As a result of this approach promoted through the Toolkit project, it appears that clients report greater maintenance of seasonal physical activity (compared to controls) and greater exercise frequency (compared to pre levels) as a result of Toolkit counseling. An important aspect of the Toolkit project has been the extensive contribution from all partners into the development and delivery of the Toolkit itself. What has resulted is a state of the art resource Diabetes Physical Activity & Exercise Toolkit 2nd Edition For diabetes care providers wanting to get their clients moving in the right direction for physical activity and exercise counseling in diabetes care. The Diabetes The significant problems we face cannot be solved at the same level of thinking we were at when we created them. Albert Einstein Physical Activity and Exercise Toolkit, 2 nd Edition (released in April 2010) is a refined manual with revised text, representing current research in the field. It contains: Edited graphics and presentation style for ease of reading and review (a big thank you to Barb Patterson for her layout expertise!). New risk screening and referral sections to match up with recent CDA revisions. A new decision tree and quick reference counseling guide. Updated (and renumbered) client brochures. A resistance training video. The complete package has now been presented to diabetes care providers in Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland; and there is great interest in this resource from diabetes care providers from other parts of Canada and other countries. As a testament to the innovative nature of this project and the findings 2

3 con t presented, we recently received further funding from the Lawson Foundation for a continuation and expansion of the project for another two years. Primary objectives will be to implement the Toolkit as standard practice to diabetes care providers throughout all of Atlantic Canada, to translate the materials into French, and to provide enhanced support for physical activity initiatives through Diabetes Centres in Nova Scotia. The enhanced support in Nova Scotia is being piloted this summer and will begin in earnest next winter and spring (2011). We hope to work with diabetes care providers over the next two years to develop solutions to address the challenges of lifestyle management in clinical practice. We will explore time-effective and resource-efficient strategies to further support physical activity and exercise counseling and delivery such as exploring web-based materials, phone follow-up, kinesiologist involvement, referral, and other forms of monitoring. The recent release of the Diabetes Physical Activity and Exercise Toolkit, 2 nd Edition represents one the most complete packages for clinical physical activity counseling in the field. The Toolkit project in Nova Scotia is being looked upon as one of the leading programs in the country to support implementation of physical activity counseling into standard practice. We thank all those who have contributed to the project and continue to support physical activity counseling in clinical practice. We will invite more input and involvement in the research component of the project in the near future and always welcome feedback regarding physical activity and exercise in diabetes management. Jonathon Fowles, PhD Associate Professor in Exercise Physiology, Acadia University CSEP-Certified Exercise Physiologist Submitted on behalf of the Tool-kit team: Chris Shields, PhD; Matt Durant, PhD RDt; Rene Murphy, PhD Brittany Barron, BKinH CSEP-CEP (candidate) References: 1. Gillies CL, Abrams KR, Lambert PC, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ. 2007;334(7588): Diabetes Prevention Program Research Group, Knowler WC, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702): Li G, Zhang P, Wang J, Gregg EW, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Lancet. 2008;371(9626): Nathan DM, Buse JB, Davidson MB, et al. American Diabetes Association; European Association for Study of Diabetes. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32(1): Dillman C, Shields C, Fowles JR, et al. Including Physical Activity and Exercise in Diabetes Management: Diabetes Educators Perceptions of their own Abilities and the Abilities of their Clients. Can. J. Diabetes. Sept (In press) Practice Point Q: At the DCPNS Annual Workshop 2010, information was shared from the DCPNS Registry that indicated there is missing information about DM complications/ comorbidities, especially retinopathy. How would you suggest we improve this type of data capture? A: At the time of the presentation, Pam Talbot and Ian MacInnis issued a challenge to all the attending DC staffs to collect up-to-date information about diabetic retinopathy for their attending clients. We would like to renew and expand that challenge to all DC staff. For the next six months (July to December 31), make a point to update retinopathy status for each DC patient you see not only the date of the eye examination, but was there any mention of diabetic retinopathy background or proliferative? This type of information is critical for understanding the burden of DM at the local, DHA, and provincial levels. 3

4 News from the Care Program With only three issues of this newsletter a year, it seems even harder to stay on task and time. Our apologies as this June issue now reaches you in July! It has been an extremely busy spring with a number of pressing projects and deadlines. We want to take this opportunity to acknowledge and thank Jonathon Fowles for his continued commitment to physical activity and exercise in the diabetes population. The State of the Art article reminds us of the importance of this work and the success of his many endeavors and partnerships. It is truly exciting to think that diabetes care providers in all of Atlantic Canada will have ready access to much needed tools, resources, and expertise as a result of his team s work and the continued support of the Lawson Foundation. Hats off to the Lawson Group as its support has helped to change the face of diabetes care in Canada. When projects such as the Toolkit reach beyond a single community and takes on a life of its own, there should be great celebration. Hope you all have a wonderful summer with family and friends relax and enjoy! Advisory Council, Subcommittees, and Working Groups The DCPNS is pleased to welcome four new Council members - Dr. Lesley Ruggles, General Practitioner, GASHA; Darla MacPherson, VP Community Health, CHA (DHA 5); Shonda Jeffery, SWNHA (DHA 2) and Wendie Christoff, CBDH (DHA 8), diabetes nurse educator representatives. On July 8 th, the Advisory Councils from three provincial programs - DCPNS, Cardiovascular Health Nova Scotia, and the Nova Scotia Renal Program - came together to identify and prioritize opportunities for collaborative work. This is an exciting time for the programs as current joint initiatives (hypertension prevention, identification, and management as well as efforts to help guide interest and activities around integrated chronic disease management) are recognized and supported. The Councils will also engage in broad-based discussions around the need for improved surveillance to better describe the true burden of chronic diseases across Nova Scotia as well as other potential joint projects. These initiatives will help enrich work across programs and to ensure improved disease management/ prevention in Nova Scotia. The Diabetic Foot in Nova Scotia: Challenges and Opportunities Working Group Activities We are thrilled to report that the uptake of these tools by various provider groups in different settings is going extremely well. Family Practice Nurses, VON (in specific DHAs), individual Family Practice offices, the Division of Endocrinology (QEII), Capital Health Dialysis Unit, and First Nations organizations (CMM and UNSI), are but a few that have requested and received packets of the resource materials. We were also pleased to learn that Dalhousie University Faculty of Medicine will be using the Foot Risk Assessment form in the teaching of all medical students starting this fall. The DCPNS website is home to the complete set of foot resources to download free of charge. Care of the Elderly with Diabetes Residing in Long-Term Care (LTC) Facilities The Diabetes Guidelines for Elderly Residents in Long-Term Care Facilities Pocket Reference was launched on April 1, 2010 with the help of a Telehealth session linked to 18 sites across Nova Scotia. Drs. Laurie Mallery and Lynne Harrigan presented the background, developmental process (it was a long one), and the science behind the guidelines. Case studies were used to illustrate application in practice. The Pocket Reference and accompanying materials (background and FAQ) as well as the Telehealth presentation slides have been posted on the DCPNS website ( Video clips from the Telehealth session will be available on the DCPNS website later this summer. The guidelines and related materials have been directly distributed to long-term care and residential facilities in Nova Scotia (117 in total), Diabetes Centres, and others that have been waiting for the release. We encourage diabetes educators to share the guidelines with other health professionals in their community. Please see page 9 for an example of how one long-term care facility has adopted the guidelines in daily practice. In the fall, the DCPNS will start development of guidelines related to frequency of blood glucose and other testing in the frail elderly residing in LTC facilities. 4

5 con t Special Initiatives DCPNS Provincial Workshop We had another very successful provincial workshop. Held on April 15 and 16, 2010, over 100 diabetes care providers (predominantly diabetes educators) from 36 of the 39 Diabetes Centres (DCs) attended and provided positive feedback on the program content, speakers, and workshop logistics. Overall, 99% of the respondents rated the workshop as good to excellent. On a scale of 1-5, where 5 is strongly agree, respondents rated the workshop at 4.7 for met expectations, held interest, and allowed opportunity for networking ; 99% enjoyed the opportunity to view/ interact with industry representatives. All speakers were well received with most ratings in the mid to high 4 s. Celebrating 20 Years as a Provincial Program Next year, 2011, the DCPNS will celebrate its 20th anniversary as a provincial program. Can you imagine! See page 15 for more information and to help us plan for this year-long event. SMBG Working Group/Workshop See page 11 for Part 2 of SMBG Working Group activities. DCPNS Insulin Dose Adjustment Polices & Guidelines Manual Work continues on the review and revision of this manual. With the recent focused assistance of Lois Ferguson, Brenda Cook, Christine Borgel, and Barb Patterson, the revised version has been sent to specialist physicians for review and comment. It is our plan that the revised guidelines be ready for distribution/ release later this summer. A huge thank you to Bev Harpell, Alice Veinotte, Lois Ferguson, Janice Smith, Viviane Wright, Wendie Christoff, Bev Harris, and Darlene Miller-Cash (Working Group members) for their work on this project it was a far, far greater job than we ever expected; but the fi nal product will be well worth the wait. DCPNS Pump Half-Day Representatives from the nine DHAs and the IWK attended a half-day session hosted by the DCPNS on June 18th. This session was intended to engage a multidisciplinary group of diabetes health care professionals (pediatricians and diabetes educators) in preliminary discussions around a consistent approach to initiating pump therapy in our child/ adolescent population in Nova Scotia. We explored standardized materials including pre-requisites for pump use, forms, and readiness assessment tools, as well as possible efficiencies through shared learning and approaches, group introductions to pump therapy, etc. We are pleased to report that all of those in attendance expressed interest in working together to standardize materials and approaches and to continue to share best practices. Thanks to all who made this day such a success! DCPNS Diabetes Centre Grants The call for project proposals has been postponed. Look for information on the priority areas and the application process early in the fall. In the meantime, take advantage of this extra time to gather your ideas, form your partnerships, and prepare for the call with a few potential projects in your back pocket. Diabetes Care in Nova Scotia Volume 20 Number 2 July 2010 Registry & Website Enhancements The revised Physician/Nurse Practitioner Patient List is just about ready to launch. We are awaiting fi nal comments from the DHA that has been piloting the form with a small group of family physicians. This revised Physician/Nurse Practitioner Report now reports smoking status, date of last eye exam, and last annual flu vaccine in support of the Province s Chronic Disease Management Incentive Program. Please see page 10 for information on this incentive program for physicians. The wait times feature of the Registry will be piloted during the summer in SSH DCs. Remember, the DCPNS is offering on-site refresher courses on use of the DCPNS Registry and Registry reports. Please contact the DCPNS office to obtain an overview of the training session and to arrange a session for your DHA. Partnership Projects Provincial Programs Hypertension Initiative A number of activities are currently underway under the guidance of the three provincial programs (Cardiovascular, Diabetes, and Renal) to improve the prevention, identification, and management of hypertension in Nova Scotia. These include: The successful completion of a Hypertension Stakeholder Forum in March 2010 and the posting of this report on the Renal Program s web site ( ialprogramspartnerships). 5

6 con t The My Blood Pressure Card initiative. This is modeled after the successful Blue Card project in the Valley Regional Hospital DC that resulted in statistically significant improvements in blood pressure in the DC population. A provincial roll out of this project is being planned. The Drug Evaluation Unit at Capital Health has been engaged to review Canadian hypertension guidelines for recommendations related to medications. These recommendations will facilitate the development of common messaging, across diseases, related to medications for hypertension. The programs are actively promoting use of The Canadian Hypertension Education Program (CHEP) comprehensive set of tools for the public, patients, and providers. Stay tuned for activities related to, and resulting from, this work. Development of a Nova Scotia Diabetes Dataset (Repository) We are happy to report that the DCPNS (Pam Talbot and Zlatko Karlovic) just presented a poster detailing this work at the Canadian Public Health Association Conference in Toronto (June 13-16, 2010). Currently, there are plans to meet with the Nova Scotia Department of Health to discuss transitioning the NSDR from a provisional repository to a sustainable, ongoing diabetes/chronic Disease surveillance tool. Pilot Project - Upstream Screening and Community Intervention for Prediabetes and Undiagnosed Type 2 Diabetes In April 2010, we submitted a draft manuscript, describing the Nova Scotia experience as part of this national initiative, to the Public Health Agency of Canada (PHAC) for review. Ultimately, this article will appear as part of a larger series to be published later this year in the peer reviewed journal Chronic Diseases in Canada. In May 2010, Annapolis Valley Health (AVH) completed the first phase of their PHAC-funded project to develop a district-wide, integrated, communitybased lifestyle program for adults with prediabetes and other at risk populations. We are pleased to report that AVH received a second year of funding that will enable them to deliver and evaluate the lifestyle program at five sites throughout the District. The DCPNS will continue to serve in an advisory capacity for the second phase of this important work. Quantifying the Burden of Diabetes: Time to Comorbidity and Time to Death Although this project officially came to a close on March 22, 2010, we are working to tie up a few loose ends before truly finishing the study. We used three data sources for this project: the DCPNS Registry, the National Diabetes Surveillance System (NDSS), and administrative health records (i.e., physician billing claims and hospital records). Overall, the number of diabetes cases classified as having hypertension (HTN) was not that different between the sources; however, the actual people classified as having HTN were very different. A significant proportion of known HTN cases in the DCPNS Registry were not identified in the NDSS or administrative health records, while cases identified as having HTN in the NDSS or administrative health records were not identified as having HTN in the Registry. For diabetic retinopathy (RET), the discordance between data sources was much greater. According to the DCPNS Registry, the prevalence of RET was only 3% versus 23% for the administrative health records. Of course, the only Registry field that picks up RET is the medical problems field on the physician referral form. Unless this field is updated, there is no way to know if a patient develops RET after the initial DC referral. See page 3 for a challenge that should result in much better capture of RET rates. The Diabetes Physical Activity and Exercise Toolkit The State of the Art article (pages 1-3)reminds us about the importance of physical activity and exercise in our diabetes population, while providing us with an update on the next phase of the Toolkit work. Peggy Dunbar Provincial Program Manager, DCPNS 6

7 Pregnancy Focus GDM: Expanding Figures In April 2009, I attended the DCPNS Spring Workshop. I was asked how many patients with gestational diabetes (GDM) needed insulin in the IWK Health Centre Pregnancy and Diabetes Clinic. Sadly, I had to admit that I did not have the answer. Instead, I estimated at least 30% were starting insulin and that the number might actually be 40%. Saying this out loud was shocking to me, but not to the person inquiring. She had seen similar numbers during a recent local chart review. In May 2009, I reviewed our stats for April-December I recorded each patient with a diagnosis of GDM or impaired glucose tolerance of pregnancy (IGTP) and noted if they started insulin. The table below shows the results. Diagnosis Total Insulin Therapy % Requiring Insulin GDM IGTP In total, there were 111 new patients in 9 months with either GDM or IGTP, with 54% of the total requiring insulin. I was surprised at the results, but it explained quite clearly why we seemed to be so busy! In 2004, our team decided to manage women with IGTP as intensively as women with GDM, as best practice. 1 As expected, this change increased our workload. In 2008, we moved to group education to better manage our growing population. Women are seen initially in a group (up to four new patients) by the dietitian, followed by instruction on blood glucose monitoring with the nurse educator. Written materials on GDM are also provided. A week later the dietitian provides one-on-one counseling to follow-up on personal issues and assess if the meal plan and activity program are working. Recently, we have increased our classes to twice a week rather than once a week, as increasing numbers continue to challenge our resources. Initiating insulin teaching is also most often done in small groups. A new challenge may be on the horizon. Analysis of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study clearly shows that adverse maternal and fetal outcomes increase as hyperglycemia increases. 2 Unfortunately, there was no one glycemic threshold identified above which these risks would be increased. Therefore, even with this international study including 25,000 participants and a strict protocol, it fell to expert consensus to recommend new diagnostic criteria for GDM. The experts have included previous studies and input from the International Association of Diabetes and Pregnancy Study Groups (IADPSG), including Canada, over the past 2 years to help formulate their recommendations. The recommendations are as follows: 1) Eliminate the 50 gram carbohydrate challenge test in favour of a 1-step diagnostic test; i.e., 75 gram oral glucose tolerance test (OGTT). 2) Eliminate the diagnosis of IGTP. GDM would be diagnosed if any one (1) value on OGTT meets or exceeds the diagnostic thresholds. 3) New diagnostic thresholds for 75 gram OGTT for pregnancy: - Fasting plasma glucose (FPG) 5.1 mmol/l - 1-hour plasma glucose (PG) 10.0 mmol/l - 2-hour PG 8.5 mmol/l Present thresholds are 5.3 mmol/l, 10.6 mmol/l, and 8.9 mmol/l. 4) Diagnosis of overt diabetes if: - A1C 6.5 at any point in pregnancy - FPG 7.0 mmol/l - Random PG 11.1 mmol/l if confi rmed by A1C or FPG It is important to note that these recommendations for the diagnosis of GDM have not been adopted by the Canadian Diabetes Association (CDA) to date. However, those of us in clinical practice need to prepare for probable changes to our present diagnostic criteria as well as the challenges of increased workload. References: Lois Ferguson, RN CDE Pregnancy and Diabetes Program IWK Health Centre 1) Ferguson L. Impaired Glucose Tolerance of Pregnancy. Diabetes Care in Nova Scotia. 2005;15(3):5-6. 2) International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classifi cation of hyperglycemia in pregnancy. Diabetes Care. 2010; 33:

8 Research to Practice What is a Healthy Waist Circumference? You, like most of your North American counterparts, probably use 40 inches/102 cm for men and 35 inches /88 cm for women as the cut-point for a healthy versus unhealthy waist circumference. Have you ever wondered how these values were selected? Why is a waist circumference below 40/35 inches (102/88 cm) considered to be healthy and one above these measures considered to be unhealthy? Surely these cut-points are the product of extensive research into obesity and its effects on health. The answer is not quite so straight forward. In 1995, researchers hypothesised that waist circumference could be used as a summary measure for overweight and central fat distribution, both of which increase one s risk for adverse health outcomes. 1 In the beginning, two cut points were identified: 1-2 Males Females Males Females > 37 inches (94 cm) > 31.5 inches (80 cm) > 40 inches (102 cm) > 35 inches (88 cm) Increased health risk, especially among young men; e.g., 1.5-2x prevalence of cardiovascular risk factors compared to whole population Appearance of symptoms such as breathlessness and arthritis, increased health risk; e.g., 2.5-3x prevalence of cardiovascular risk factors compared to whole population Action should be taken to reduce weight In 1999, the European Group for the Study of Insulin Resistance proposed that a waist circumference above 37 inches (94 cm) for men and 31.5 inches (80 cm) for women be considered as one of the four optional diagnostic criteria for metabolic syndrome (individual must exhibit insulin resistance or hyperinsulinaemia and two of the four optional criteria). 3 In 2006, a consensus group of the International Diabetes Federation formally recommended that these same cut-points become an essential part of the metabolic syndrome defi nition. 4 circumference above 40 inches (102 cm) for men and 35 inches (88 cm) for women be included as one of fi ve optional diagnostic criteria for metabolic syndrome. 5 These values are used in the US today, despite the IDF s recommendation to use 37/31.5 inches (94/80 cm). It appears that Canada is following our neighbours to the south. References: Pam Talbot Diabetes Surveillance/Project Consultant 1. Lean ME, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. BMJ. 1995;311(6998): Han TS, van Leer EM, Seidell JC, Lean ME. Waist circumference action levels in the identifi cation of cardiovascular risk factors: prevalence study in a random sample. BMJ. 1995;311(7017): Balkau B, Charles MA. Comment on the provisional report from the WHO consultation. European Group for the Study of Insulin Resistance (EGIR). Diabet Med. 1999;16(5): International Diabetes Federation. The IDF Consensus Worldwide De finition of the Metabolic Syndrome [Online]. Belgium 2006 [cited 2010 June 10]. Available from: webdata/docs/idf_meta_def_fi nal.pdf 5. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285(19): So, why are we using 40 inches (102 cm) for men and 35 inches (88 cm) for women as the cut point for healthy versus unhealthy waist circumference? In 2001, the National Cholesterol Education Program s Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol recommended that a waist 8

9 Educator Sharing Dalhousie Health Mentors Program There is an exciting new program being launched at Dalhousie in September 2010 that puts people at the centre by recognizing their expertise about themselves and their health and acknowledging the unique contribution they can make to health professional education. The Dalhousie Health Mentors Program provides an innovative, collaborative approach for health professional students to learn about patient/client-centered care, interprofessional teamwork, long-term relationships, and chronic conditions and disabilities. The program, sponsored by the Faculties of Medicine, Dentistry, Health Professions, Science, and Computer Science, encompasses 17 professions and will include 550 students in its pilot year. Health Mentors are adult volunteers with a chronic condition and/or disability who are willing to share their experience of living with their condition and navigating the healthcare system with a small interprofessional team of 4 5 students. Student teams do not provide care, treatment, or medical advice; rather, listen to and learn from the Health Mentors who share their distinct perspective. Students will be asking questions about the Health Mentor s life story and their client journey, developing a picture of the whole person. Students will share their learnings with the Mentor to make sure that they have understood the Mentor s experience. The students will finish up the first year by reflecting on what they have learned and identifying learning objectives for the future. During the first year, student teams meet with their Mentor four times and continue the relationship in the fall term of the following year. Recruitment of Health Mentors is just getting underway, but already it is clear that they are drawn by a keen interest in working with students and a firm belief that by sharing their experiences with today s students, they can play a part in creating a better healthcare system for the future. They are eager to help the students to learn how important it is for individuals to be at the center of their own care, how to work well on a team, and how healthcare providers can better support people with chronic conditions. The program is seeking Health Mentors who live in the Halifax metro area. Perhaps you know someone who has a chronic condition, or you have one yourself, and are intrigued by the opportunity to participate in this innovative program. If so, Susan Nasser, RSW, Coordinator of the Dalhousie Health Mentors Program, would like to hear from you at or dal.ca. Susan Nasser, RSW, Coordinator Dalhousie Health Mentors Program NEW Diabetes Guidelines for Elderly Residents in Long-Term Care Facilities Providing safe care to the frail elderly in long-term care facilities presents many risk management challenges. Thanks to the new Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities Pocket Reference, recently released by the DCPNS, the risk for elderly persons with diabetes can be reduced and better managed to improve quality of life. The delivery of these guidelines to my desk two weeks ago was a welcome coincidence because they arrived just as the Nursing Department was developing a new Diabetes Management Policy. Simply put, we really like the new guidelines because they take the guesswork out of managing diabetes in frail elderly residents by providing clear standardized targets for glycemic control and treatment of hypoglycemia. The guidance in the Pocket Reference is specific and clear and presented in a user-friendly format. The Nursing Department has integrated the guidelines into the new Diabetes Management Policy and reviewed both the guidelines and policy with nursing staff. To further support consistent implementation at the organization level, copies of this new policy and the new Pocket Reference have been distributed to the dietician, the medical advisor, and attending physicians. The response thus far has been overwhelmingly positive. I would like to thank the DCPNS LTC Committee for their excellent work with the goal to achieve consistent care of elderly residents with diabetes in long-term care facilities. The DCPNS work will enable our team to do their part in implementing these guidelines. Indeed, the timely release of these guidelines has already enabled us to develop and implement a more meaningful policy. As an accredited long-term care facility, we are always alert to opportunities to advance resident safety and to improve the quality of resident care. To that end, DCPNS has made a significant contribution to support us in improving quality of care for elderly residents with diabetes. Carolyn Moore, RN, MScN Director of Nursing, Wolfville Nursing Homes Ltd. 9

10 10 Family Physician Chronic Disease Management (CDM) Incentive Program A Family Physician CDM Incentive Program was implemented in Nova Scotia in 2009 and recently expanded on April 1, The new program is intended to recognize the additional work family physicians are doing beyond office visits to provide and/or ensure access to guidelines-based care for patients with specific chronic diseases. Unlike other provinces that have taken a disease-centered approach, the Nova Scotia program is patient-centered and recognizes that individuals may have multiple chronic diseases with risk factors in common. One set of agreed-upon clinical guidelines is used per chronic disease as the basis for determining the priority indicators. These are normally selected from the accepted guidelines currently in use in Nova Scotia by provincial programs. Eligible family physicians are paid a base incentive amount once per fiscal year for managing an annual cycle of care and addressing the required indicators/risk factors for each patient with one qualifying chronic disease. An additional incentive amount is paid if the patient is managed for a second qualifying chronic condition. Starting April 1, 2010, the chronic diseases that qualify under the CDM Incentive Program include: Type 1 and Type 2 Diabetes as evidenced by FPG 7.0 mmol/l or Casual PG 11.1 mmol/l plus symptoms or 2hPG in a 75-g OGTT 11.1 mmol/l.³ Ischaemic Heart Disease (IHD) as characterized by reduced blood supply to the myocardium, most often due to coronary atherosclerosis, and as evidenced by a failed stress test, abnormal EKG compatible with IHD, wall motion study, abnormal smibi, abnormal myocardial perfusion scan, abnormal cardiac catheterization, and/ or abnormal stress echocardiogram. This patient population includes the 2009/10 program population of patients receiving post-mi care for up to 5 years. In order to claim the 2010/11 CDM incentive, the following indicators/risk factors are required to be addressed and documented as part of the annual cycle of care for diabetes and/or IHD. The required indicators include all common indicators plus the indicators for diabetes only, IHD only, or diabetes and IHD, if both chronic diseases are present. Common Indicators for Either Diabetes or IHD Blood pressure 2 times a year Smoking cessation once a year if smoker (document smoker or nonsmoker) Lipids once a year Weight/nutrition counseling once a year Plus either or both of the following: Indicators for Diabetes only: HbA1C ordered 2 times a year Renal function ACR or egfr ordered once a year Foot exam with monofilament or 128hz tuning fork referred or completed once a year Eye exam discussed and/or referred once a year for routine dilated eye exam Indicators for IHD only: ASA/Anti-platelet therapy considered/ reviewed once a year Beta-blocker considered/reviewed once a year ACEI/ARB considered/reviewed once a year Discuss Nitroglycerin Consider further cardiac investigations Under the program, the family physician is expected to act as case manager to ensure care based on the selected key guidelines is provided for patients with the qualifying chronic diseases. The physician may or may not provide all of this care directly and is not held responsible if patients do not follow through on recommendations or referrals. The patients must be seen a minimum of two times per year by a licensed healthcare provider in relation to their chronic disease(s), including at least one visit with the family physician claiming the CDM incentive fee. Every required CDM indicator does not necessarily have to be addressed at each visit, but the indicators should be addressed at the frequency required for claiming the annual CDM incentive. A Family Physician Chronic Disease Management Flow Sheet is available for physicians to use if they wish. The flow sheet has recently been updated to reflect the program changes for 2010/11 and continues to be optional. The CDM incentive can be claimed by family physicians once per patient per fiscal year by March 31 of that year. For the period April 1, 2010 to March 31, 2011, the CDM incentive can be claimed providing: The patient is seen by the family physician in relation to his/her chronic disease(s) at least once in the 2010/11 fiscal year. The patient has had at least one other appointment with the physician or another licensed health care provider in relation to his/her chronic disease(s) in the previous 12 months. The CDM indicators required for the CDM incentive payment have been addressed at the required frequency and documented in the clinical record or optional flow sheet at/or before the time of billing. Doctors Nova Scotia

11 Self-Monitoring Blood Glucose (SMBG) - Part 2 In the February issue of this newsletter, we shared the approach used in the DCPNS workshop (January 2010) focused on SMBG in non-insulin using type 2 diabetes. This second article on the same topic is intended to take you beyond the January 22 nd meeting to where we are to-date with the planned launch of the DCPNS Decision Tool for SMBG and related resources. Immediately following the face-to-face meeting in January, participants completed two activities via and offered additional feedback on the draft tool introduced during the workshop. The responses have been used to support and plan Nova Scotia s approach to this very important topic. Consensus questions feedback: 1. Do all people with non-insulin using type 2 DM need to test? Thirteen (13) of 15 respondents said no; and 2 said not routinely, but periodically. 2. Should testing frequency be reduced in non-insulin using type 2 diabetes? All respondents said yes (case by case basis and purposeful). This response was supported by the evidence and casework presented at the workshop, while participants recognized it will take time to adjust and process the change. 3. For education (self-management purposes), should all people test at diagnosis? The responses here were more varied with 5 saying no, 6 yes, and 4 supporting testing as an option, based on individual interest, blood glucose values, willingness, and planned use of the numbers. 4. Is a maximum allowance for strips in the type 2 diabetes non-insulin using population feasible? Fourteen respondents said yes (with additional qualifiers on an extra allowance during times when more frequent testing may be required; i.e., illness); only one said no. 5. Initial self-management education, if appropriate, should focus on staggered, limited SMBG for a specified period of time. Please provide your views (what would this look like - how many, for how long ). Reponses varied from not possible to standardize as so many variables, to 1-2 weeks (variable testing times and frequencies within), to months. This exercise highlights the power of evidence and thoughtful dialogue in coming to consensus on broad questions, and the much more difficult task of reaching agreement on standardized approaches (specifics) due to individual patient and provider differences. In our Needs and Wants exercise, participants were asked, What do we need to help make the changes as discussed today a reality in your practice setting? The question was to be considered for each of the three categories noted below. Participants were prompted to consider any and all supports, inclusive of educational materials, educational opportunities, common messaging, etc. 1. The person with diabetes (those new to diabetes and those who may have had diabetes for years). Education on why/when to test (include rationale and recommendations). Handouts with consistent messaging (when to test and for how long) for distribution at point of sale. For newly diagnosed, more emphasis on other aspects of diabetes self-management such as diet and exercise. A multi-dimensional campaign for promotion through major stakeholders CDA, Diabetes Centres, doctor s offices, pharmacies, etc. Information in the CDA patient publication Diabetes Dialogue. 2. Health care providers (physicians, nurses, nurse practitioners, diabetes educators, pharmacists, etc.) Consistent guidelines (all on the same page ) with the same messages and approach clear recommendations on when and how to test. An edited, improved decision tool. Education through a variety of media to all health disciplines (inter-professional education would be ideal). Handout for patients explaining the reasons for the change in practice related to monitoring. More information on prevention (how to approach, encourage, and support necessary change). Policies and education for other diabetes care providers, including VON, long-term care, and teaching providers - Nova Scotia Community College, health discipline university programs. Academic detailing on this topic. Articles in the DCPNS newsletter, Pharmacare newsletter, etc. 3. Other (could be specific organizations/ agencies; e.g., CDA, DoH, Medavie BlueCross, etc.) New guidelines (CDA) based on evidence. CDA should play a key 11

12 con t role in supporting and disseminating key messages regarding changes through Diabetes Dialogue, professional and public sections on the website, etc. Collaboration between agencies. Mail out to clients who use Phamacare services, Medavie Blue Cross. Distribute best practice information to agencies as listed above. Education about SMBG and how to access these programs/services. All of this information has influenced where the DCPNS has gone with the topic of SMBG. The decision tool Non-Insulin Using Type 2 Diabetes: Decision Tool for Self-Monitoring of Blood Glucose (SMBG) has been finalized. After many iterations and valued feedback from working group members and others, the tool has been printed and will be officially launched this September. Since mid-may, the tool has been introduced to physicians, pharmacists, and diabetes educators through Academic Detailing (Dalhousie University CME) and will be the focus of inter-professional workshops that are being planned across Nova Scotia throughout the fall. The tool will be accompanied by a short video that will serve to introduce the topic of SMBG in non-insulin using type 2 diabetes (why the change in usual practice) and how to use the Decision Tool specifically. Key opinion leaders will provide their thoughts on SMBG in this population, reasoning/rationale for change, the opportunities this change creates for patients and providers, and the value of a decision tool to reduce subjectivity and promote a more thoughtful approach to SMBG. Case studies will be used to help providers work through scenarios for those newly diagnosed with diabetes as well as individuals with long standing diabetes that would benefit from reduced (or even no) SMBG. These materials will be hosted on the DCPNS website with easy access to view and download. A tool is also in the draft stage for persons with diabetes to address some of the suggestions provided above through the needs and wants activity. This tool will explain why the current change in recommended SMBG practices among providers and includes a quick self-test to assist the individual in determining if testing is still needed in their specific situation. For those needing to test, simple guidelines will be provided on when and how frequently (in attempts to standardize safe messages). We are exited by this continued work and the valued partnerships that have provided not only support and encouragement, but a much needed perspective from a variety of stakeholder groups. This is not just a diabetes educator issue; in fact, this is an issue that affects all providers, in multiple settings, who interact with people who have diabetes. Ultimately, both individuals with diabetes and the health system will benefit from a more reasoned approach to SMBG in non-insulin using type 2 diabetes. Stay tuned for our launch! Peggy Dunbar Provincial Program Manager, DCPNS DCPNS Grant Funding (2009/10) Project Summary Patient Medication Improvement Project Cora Lee Joudrey and Loralee Holman, CDHA Tri-Facilities DCs - (902) The best practice of the Diabetes Centre (DC) is to maintain an up-to-date list of patients current medications. This accurate assessment of current medications improves care delivery for patients within the DC. Since the initiation of the on-site DCPNS Registry in 2008, we have made an effort to update our patient medication records. During this process, we noted that many patients could not recall their current medications or the specifics around dose and timing of these medications. Our intent was to provide a useful form for our patients to document their medications. Patients attending or receiving service from the DC, hospital Emergency Department, community pharmacy, or Home Care Nova Scotia, were surveyed to determine if they carry a list of current medications. This list is important when care is delivered in a variety of clinical areas. Those who did not have a list were educated on the importance and provided a sample of either a medication record book, obtained through the program Knowledge is the Best Medicine ( org), or a smaller medication record developed by the DC staff in consultation with other health providers. Patients were 12

13 con t surveyed by telephone to determine the usage within one month of the dissemination of the medication cards. The results are as follows: Total patients polled regarding carrying up-to-date medication record = 35. Knowledge is the Best Medicine Cards Provided n=12/35 or 34% Completed and In Use n=5/12 or 42% Diabetes Centre Medication Records Provided n=11/35 or 32% Completed and In Use n=7/11 or 64% Percentage of patients using medication record pre distribution = 12/35 or 34% Percentage of patients using medication record post distribution = 24/35 or 69% Our data, although small in numbers, still seems to support the higher use of the cards versus the medication record books. The improved accuracy of patient information should result in a more up-to-date registry system as well as improved assessment of appropriate treatment. Making clients more aware of their medication may lead to increased self-management. Since people with diabetes are at increased risk of other health issues, this medication record should prove useful when they are seen by other services; e.g., ER or other medical appointments. In the near future, we plan to work with other departments (physician offices, ER, clinics, Central Registration) to develop a poster emphasizing the importance of medication records. Project Summary Implementing and Evaluating a Physical Activity and Exercise Program in the South West Health Diabetes Centres Rita Fitzgerald, Yarmouth DC - (902) In 2009, the South West Health Diabetes Centres (DCs) received a grant from DCPNS to help facilitate the planning, delivery, and evaluation of a Physical Activity and Exercise Program in the Yarmouth, Digby, and Shelburne DCs. Plans were to use the DCPNS Diabetes Physical Activity and Exercise Toolkit as the main resource, build community partnership, and promote community awareness to increase sustainability. DCs across the province that already implemented the use of the DCPNS Toolkit were contacted to discuss their program and obtain input regarding what worked well. The South West Health Rehab Services had been involved in physical activity and exercise education at the Yarmouth DC in the past and, therefore, were seen as strong partners. Plans were to start a pilot program in Shelburne, evaluate, and then implement across the three DCs. In June 2009, a meeting was held in Shelburne with various stakeholders to receive input as to what would work in this community. Information regarding the Shelburne Move More Program and various activities organized by the Shelburne area Parks and Recreation were discussed. A common theme was the need to increase community awareness and participation in various activities promoting active living. The Move More Program is now regularly promoted by the Shelburne DC; but unfortunately, this program is not presently run in the Digby and Yarmouth area. The District s Rehab Services reviewed the DCPNS Toolkit and the various instruction pamphlets. Presently, the Rehab staff is unable to participate directly in DC client education. A physiotherapist attended a District DC meeting in early December 2009 to provide tips on how to use the physical activity tools. The plan is for Rehab Services to provide a written guide to help DC staff educate clients. Rehab Services also created a Powerpoint presentation that will be adapted by the DCs for group education when promoting the benefits of physical activity and exercise. In 2010, plans are to have regularly scheduled group education sessions for clients at all three DCs in the District using the Powerpoint presentation, some of the tools in the Toolkit, and a simple guide for exercise instructions. Recognizing that clients have various needs and interest and DCs have limited time and resources, it will continue to be imperative for DCs to be aware and promote what already exists in the community. A handout promoting various active living programs specific to each communities will be used and regularly updated. 13

14 Physical Activity Corner The Canadian Diabetes Association (CDA) recommended in its 2008 Clinical Practice Guidelines that individuals with diabetes achieve at least 150 minutes of moderate intensity physical activity a week and to include resistive activities three times a week in the regular routine. From recent data collected through the Lawson-funded research on exercise in diabetes, we have identified that very few individuals with diabetes are able to achieve these exercise guidelines initially; and this can be a barrier to actually starting a regular physical activity program. The good news, however, is that new research from the Canadian Society for Exercise Physiology (CSEP) indicates that measurable health benefits can be achieved at lower activity thresholds than previously thought. The research has recently been published as a thematic series in the International Journal of Behavioral Nutrition and Physical Activity (May 2010), and highlights the very strong relationship between physical activity and premature all cause mortality due to seven major chronic conditions, including type 2 diabetes. 1 This research supports recent recommendations by the CDA and also identifies that accumulating small bouts of activity (of at least 10 minutes at a time) can have health benefits. What does this mean for health care practitioners trying to promote physical activity? It is helpful to know that encouraging patients to be physically active for even small bouts at a time can help them achieve important health benefits. More benefits can be achieved by increasing the frequency, duration, intensity and variety of physical activity. Jonathon Fowles, PhD Associate Professor in Exercise Physiology, Acadia University CSEP-Certified Exercise Physiologist Reference: 1. Warburton DE, Charlesworth S, Ivey A, Nettlefold L, Bredin SS. A systematic review of the evidence for Canada s Physical Activity Guidelines for Adults. Int J Behav Nutr Phys Act. 2010;7: News From Around the Province New Faces Welcome to: Marilyn Snell, RN. Marilyn joins the staff of St. Martha s Regional Hospital DC on a part-time basis. Heather Hopkins, PDt. Heather returns to part-time work with the Fishermen s Memorial Hospital DC. Congratulations to: Maureen Topley, RN CDE, and Karen MacLeod, RN CDE, on successfully passing the CDE recertifcation. Please remember if you have a change in any staff (professional or clerical) to let the DCPNS office know ASAP to ensure our contact list remains current. Thanks! What s New at the CDA Diabetes Summer Surge This summer, join the CDA in the fight against diabetes! Be part of the Diabetes Summer Surge a coast-to-coast movement in support of the CDA. Friends, family, volunteers, and health professionals are asked to join the fun by hosting a surge event or making a donation. For more information, visit www. diabetessummersurge.ca or phone the Nova Scotia Regional office at (902) Take action and sign up today. Team Diabetes Join Team Diabetes in Honolulu this Dec. 12/10! Marathon Date: December 12, 2010 Distances Available: Full Marathon & 10k Call Tom at (902) or

15 DCPNS CELEBRATING 20 YEARS IN 2011!! Help us celebrate. We welcome your thoughts on the following: What do you see as the DCPNS s biggest, most significant accomplishments? As we plan for activities during the year, we would like to profile one idea per month for the full 12 months. - Submit your idea with brief supporting rationale (why and what difference did it make). - Contributors will have their name entered into a draw for a gift certificate to a restaurant of their choice. In planning for a celebratory gathering, who should attend (from the past, present, and possibly the future)? This could include attendees, invited special guests, etc. Our 2011 newsletters will feature a Remember When section. What do you think has changed most in diabetes education and/or care over the past 20 years? We ll provide a then and now perspective. We will be seeking nominations for a few awards. Keep your eye on the DCPNS website (www. diabetescareprogram.ns.ca) for the categories and the criteria. Forward suggestions directly to THANK YOU! 15

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