Diabetes Care Program of Nova Scotia (DCPNS) Projects and Priorities Highlights April 24, 2009

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1 Diabetes Care Program of Nova Scotia (DCPNS) Projects and Priorities Highlights April 24, 2009

2 Session Overview Current Projects (quick overview) Highlights: Prediabetes Pilot Screening Project Pam Talbot Guidelines for Elderly Residents of Long-Term Care Facilities Brenda Cook Hypertension Initiatives Peggy Dunbar

3 Current Projects Strategic Plan: Collaborative network across Provincial Programs (explore integrated CDM models) Develop Referral pathways for DM/PreDM Develop and Pilot test Refined case management approach for complex cases Establish new partnerships in multiple settings Refine performance indicators Routine review of diabetes services Encourage data use evaluate

4 Current Projects Forms revision Guidelines revision Working Groups: pediatric to adult care foot care resources and tools Information gathering: pump programs and approaches DCPNS communication modes/methods hand-held records use of diabetes data sources Partnership Projects PreDM Pilot Enhanced Surveillance Exercise Tool-Kit SMBG

5 A DCPNS Partnership Project Annapolis Valley Health Guysborough Antigonish Strait Health Authority Funded by the Public Health Agency of Canada & the NS Department of Health

6 First P/T meeting for PreDM in Canada Nov/06 Got the ball rolling PHAC call for proposals Dec/06 Explore practical aspects of screening for PreDM and undx T2DM among adults 40-74yrs Three waves to date Wave 1: NB, PE, SK Funded Mar 2007 Wave 2: NS, MB Funded Oct 2007 Wave 3: Vancouver, Winnipeg, Mississauga Pending

Central Coordination/Advisory Project Advisory Committee DoH, HPP, CVHNS, DCPNS, Dalhousie Family Medicine, local reps Project Manager Coordinate between sites share learnings/materials REBs Data

7 Central Coordination/Advisory Project Advisory Committee DoH, HPP, CVHNS, DCPNS, Dalhousie Family Medicine, local reps Project Manager Coordinate between sites share learnings/materials REBs Data collection tools Local Coordination/Advisory Local Advisory Committee VP Community Health, Primary Health, Lab Director, Diabetes Centres, local physician champions Local Project Manager Day-to-day running of project

8 18 month timeline

9 Sex 31% male (n=129) 69% female (n=289) Average Age Males: 58yr Females: 56yr Norm/DM: 57yr PreDM: 58yr Ethnicity 97% had a White ancestry Education 38% of sample have post-2 degree

10 Note: 418 cases n=19 based on FPG only

13 5 Sessions: PreDM Education Goal Setting Stress Management Physical Activity Nutrition 35% participation rate (19/55)

14 42% (n=106) heard about study prior to r/cv pkg 53% (n=134) knew about PreDM b/f study 2% (n=4) needed help w/canrisk 99% (n=244) found OGTT instructions easy-vy easy to understand Reasons for taking part in study 49% (n=123) Wanted to be tested 41% (n=103) Wanted to help study 41% (n=102) Family history

15 Impact of project on workload 44% no impact, 48% minimal impact Opportunity to talk about + lifestyle changes Identify more cases of PreDM/Dm More office visits Should CANRISK be used for as screening tool yes/no spilt: 52%/48% Alter prognosis Effective screening tool Aware of community resources to promote healthy lifestyle 84% were aware of resources & recommended them to their patients

16 12-month funding window unrealistic Not long enough to... Develop necessary partnership Develop study materials Develop LS programme Personnel mix PDt & Lab technician complimentary skills Partnerships are key Local & Provincial advisory committees Physician champions Lab support (both Local Lab Directors)

17 Research Ethics 7pg Info & Consent is a barrier OGTT protocol Std preparation & protocol a real asset Despite variable practice across province Weekend screening was well received CANRISK items Family history of DM often left blank Probably b/c response was NO, but cannot be sure GDM screening not applicable for older age groups Universal GDM screening started in 1994

Build on work with existing partners Engage new partners Possibilities More screening w/revised CANRISK Now single 11 17 page folded in centre Additional item re smoking status Include additional

18 Build on work with existing partners Engage new partners Possibilities More screening w/revised CANRISK Now single page folded in centre Additional item re smoking status Include additional blood tests (e.g., A1c, lipids) Expanded Lifestyle Programme Integrated CD approach Disease-specific education session Combined sessions for goal setting, nutrition, physical activity, & stress management Combination of both

19 LONG-TERM CARE GUIDELINES, 2009

21 DCPNS Guidelines for Elderly Residents in Long- Term Care Facilities Targets for Glycemic Control

22 TARGETS FOR GLYCEMIC CONTROL (cont) The goal is: to avoid the acute complications of poor glycemic control including hypoglycemia and to avoid prolonged hyperglycemia. If random BG: < 7 mmol/l : notify MD to DM tx 7.0 to 9.9 mmol/l: safe (some risk of Hypoglycemia) 10.0 to 20.0 mmol/l: acceptable if no reversible symptoms > 20 mmol/l: notify MD to DM tx > 33 mmol/l (with stupor or coma): notify MD

23 TARGETS FOR GLYCEMIC CONTROL (cont) When the health care team discusses an individual s overall health status and prognosis with either the patient or family, a review of the glycemic targets and the importance of avoiding hypoglycemia would be beneficial. If glycemic targets are different from the diabetes guidelines, this should be clearly documented and include the rationale.

24 Hypoglycemia rationale, assessment, and treatment

25 HYPERTENSION IN NOVA SCOTIA I

26 Source: NDSS v209, March 2009 Estimated Overall Crude Rate = 27.7%

27 Source: NDSS v209, March 2009

28 Crude Diabetes Cases with Hypertension Prevalence Rates Nova Scotia Residents, Aged Prevalence (%) Male Female Combined / / / / / / / / /07 Male Female Combined Fiscal Year

29 Diabetes Prevalence in NS (with and without Hypertension) by Age Group and Gender, Aged 20+, 2005/06 Prevalence Rate (%) Total Male Female Combined M with Hyp F with Hyp C with Hyp Age Group Male Female Combined M with Hyp F with Hyp C with Hyp

30 Blood Pressure Initiatives 1991: Implementation of Regular Blood Pressure Measurements in DCs 1997: Release Surveying and Preventing the Complications of Diabetes in Nova Scotia : audit 17 DCs for BP and other clinical indicators CDA abstract : Meeting with DEANS (23% within target <130/85) 2002: Partnership Project Hypertension in Persons with Diabetes: A qualitative Inquiry. PI: Peter Twohig 2004: Guidelines for Blood Pressure Monitoring and Education in NS DCs includes hypertension education module (in revision/09) (CDA abstract 05) DC Grants initiated 2005/06(quality improvement initiatives) 2007: Outcomes Study Routine review and reporting on BP by DC, DHA, and Province Business Plan reporting and targets (each of the last 4 yrs)

Clinical Indicators (% within target) NS < 0.001 < 0.

31 Clinical Indicators (% within target) NS < < < < < 7% < 130/80 < 4 < 2.5 < 2.0 < 2.0 < 1.5

32 Blood Pressure Changes 1998 to 2007 P < P < 0.001

33 Mean Blood Pressure (Systolic / Diastolic) S: P-value < D: P-value < 0.001

34 Putting It All Together DCPNS Annual Population Report--Blood Pressure DC #1 Compares Population Figures DC Runs Quality Indicator Report Criteria: BP > 130/80 mmhg Initiates 9 mos Intervention: DCPNS DC Grant Quality Improvement Example: VRH Initiative Produce Family Physician Patient List--q 3 months Letter to all MDs Implement patient BP card (allows comparison between--dr. and DC) Use alert letter from DC Pre-post analysis

35 Valley Regional: Clinical Indicators (% within target) N = < 7% < 130/80 < 4 < 2.5 < 2.0 *2006 (12 mos): (12 mos): (6 mos): individuals 808 individuals 673 individuals

36 HYPERTENSION INITIATIVES: The Potential for Nova Scotia (March 23, 2009) Target Audience: Key staff from the NS Departments of Health and Health Promotion and Protection Key staff from the 3 DoH provincial programs Cardiovascular Health Nova Scotia, DCPNS, and Nova Scotia Renal Program (Program Managers, Clinical Managers, Consultants) Key note speaker: Dr. Norm Campbell leading the effort to prevent and control hypertension in Canada as the CIHR Canadian Chair in Hypertension Prevention and Control

37 HYPERTENSION INITIATIVES: The Potential for Nova Scotia (March 23, 2009) Objectives: To increase awareness of local hypertension research/ initiatives To increase awareness of the burden of hypertension To better understand programs that have been successfully implemented nationally and in other parts of Canada To initiate discussion within the Departments of Health and Health Promotion and Protection related to possible initiatives in NS.

38 Next Steps Blood pressure continues to be a DCPNS priority, and now, across provincial programs priority Blood pressure values in DCs are improving, but there is still a ways to go DC-specific guidelines are in place for monitoring, recording, & reporting, as well as routine auditing (in revision) Patient education module is intended for community use Provincial targets have been set using DC data and CEOs expect to see this data DCs are encouraged to set local targets DC Grants encourage use of data and interventions to be determined locally Partnership projects have been established we will be looking for new opportunities messaging, pilot work, etc.

39 Moving Blood Pressure Management Forward in Nova Scotia Small Group Work Interactive Session Dr. Lynne Harrigan

40 Work at hand. Each table will have one of three case studies to discuss. Quickly assign a recorder/reporter. Record your discussion points (in response to the questions) for the table on a single page. This will be collected by DCPNS staff for collation and distribution following the workshop. After 15 mins, we will start the large group discussion with feedback from the first tables that volunteer.

41 HYPERTENSION POTPORRI DISCUSSION

42 Case Study # 1 Mrs. Jones: 65 year old female with a 10-yr history of type 2 DM is seen in the DC. She has had intermittent follow-up in the DC. She is on Glicazide 80mg BID and Metformin 500mg BID. A1C is 7.5%. BMI is 30, and she is inactive. When asked about her diet, her response is I don t eat sweets, dear. TC 5.2 mmol/l, LDL 3.5 mmol/l BP values at last two DC visits were: - 143/95 mmhg and 145/91 mmhg. She takes Altace 10 mg, once daily. Task: Write out a care plan for Mrs. Jones. Be very specific.

43 Case Study # 1 (cont d) Part 2: Mrs. Jones is in for a follow-up visit 6 months later. BP is 145/95 with no change in medication. Questions: What other plans would you implement now? What is the responsibility of the diabetes educator(s)?

44 What s New for 2009 The Hypertensive Diabetic Patients with diabetes are at high cardiovascular risk Up to 80% of diabetic patients die of cardiovascular disease Most patients with diabetes have hypertension Between 35 and 75% of diabetic complications have been attributed to hypertension. Treatment of hypertension in patients with diabetes reduces total mortality, myocardial infarction, stroke, retinopathy and progressive renal failure rates. More intensive reduction in blood pressure reduces major cardiovascular events and total mortality by 25% Treating hypertension in the diabetic patient reduces death and disability and reduces health care system costs TARGET <130 systolic and <80 mmhg diastolic

45 What s New for 2009 The Hypertensive Diabetic 2/3 rds of hypertensive diabetic patients have uncontrolled hypertension (> 130/80 mmhg) There is underutilization of diuretic therapy in treating hypertension in diabetic patients. In general a diuretic is required for blood pressure control in multi drug regimes. A combination of lifestyle changes and 3 or more medications are often required. More intensive reduction in blood pressure in the hypertensive diabetic is one a few medical interventions where the cost of treatment is less than the cost of the complications prevented Treating hypertension in the diabetic patient reduces death and disability and reduces health care system costs TARGET <130 systolic and <80 mmhg diastolic

46 II. Goals of Therapy Blood pressure target values for treatment of hypertension Condition Target SBP and DBP mmhg Isolated systolic hypertension <140 Systolic/Diastolic Hypertension Systolic BP Diastolic BP Diabetes or Chronic Kidney Disease Systolic Diastolic <140 <90 <130 <80

47 Lifestyle Recommendations for Prevention and Treatment of Hypertension To reduce the possibility of becoming hypertensive, Reduce sodium intake to less than 2300 mg / day Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and sodium in accordance with Canada's Guide to Healthy Eating. Regular physical activity: accumulation of minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk) 4-7 days/week in addition to routine activities of daily living Low risk alcohol consumption ( 2 standard drinks/day and less than 14/ week for men and less than 9/week for women) Maintenance of ideal body weight (BMI kg/m 2 ) Waist Circumference Men Women -Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm -South Asian, Chinese <90 cm <80 cm Smoke free environment

Lifestyle Recommendations for Hypertension: Dietary High in dietary and soluble fibre High in fresh fruits High in fresh vegetables High in low fat dairy products High in plant protein Low in

48 Lifestyle Recommendations for Hypertension: Dietary High in dietary and soluble fibre High in fresh fruits High in fresh vegetables High in low fat dairy products High in plant protein Low in saturated fat and cholesterol Low in sodium Dietary Sodium Less than 2300mg / day (Most of the salt in food is hidden and comes from processed food) Dietary Potassium Daily dietary intake >80 mmol Calcium supplementation No conclusive studies for hypertension Magnesium supplementation No conclusive studies for hypertension

49 Recommendations for Daily Salt Intake Less than: 2,300 mg sodium (Na) 100 mmol sodium (Na) 5.8 g of salt (NaCl) 1 teaspoon of table salt 2,300 mg sodium = 1 level teaspoon of table salt however, 80% of average sodium intake is in processed foods and only 10% is added at the table or in cooking

50 Lifestyle Recommendations for Hypertension: Physical Activity F Should be prescribed to reduce blood pressure Frequency - Four to seven days per week I T T Intensity - Moderate Time minutes Type cardiorespiratory activity - Walking, jogging - Cycling - Non-competitive swimming Exercise should be prescribed as adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension: Alcohol Low risk alcohol consumption 0-2 standard drinks/day Men: maximum of 14 standard drinks/week Women: maximum of

51 Lifestyle Recommendations for Hypertension: Alcohol Low risk alcohol consumption 0-2 standard drinks/day Men: maximum of 14 standard drinks/week Women: maximum of 9 standard drinks/week A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 ml or 12 oz of beer (5% alcohol) 43 ml or 1.5 oz of spirits (40% alcohol).

52 Lifestyle Recommendations for Hypertension: Stress Management Stress management Hypertensive patients in whom stress appears to be an important issue Behaviour Modification Individualized cognitive behavioural interventions are more likely to be effective when relaxation techniques are employed.

53 Lifestyle Recommendations for Hypertension: Weight Loss and WC Height, weight, and waist circumference (WC) Hypertensive should and be all measured patients and BMI over 25 body mass index (BMI) - Encourage weight reduction calculated - Healthy BMI: for all kg/madults. 2 Waist Circumference Men Women - Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm - South Asian, Chinese, Japanese <90 cm <80 cm For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behaviour modification CMAJ 2007;176:1103-6

54 Lifestyle Therapies in Hypertensive Adults: Summary Intervention Reduce foods with added sodium < 2300 mg /day Weight loss BMI <25 kg/m 2 Alcohol restriction Physical activity Dietary patterns Smoking cessation < 2 drinks/day Target minutes 4-7 days/week DASH diet Smoke free environment Waist Circumference - Europid - South Asian, Chinese Men Women <94 cm <80 cm <90 cm <80 cm

55 Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults Intervention Intervention SBP/DBP Reduce foods with added sodium mg/day sodium Hypertensive -5.1 / -2.7 Weight loss -1 kg -1.1 / -0.9 Alcohol intake -3.6 drinks/day -3.9 / -2.4 Aerobic exercise min/week -4.9 / -3.7 Dietary patterns DASH diet Hypertensive Normotensive / / -1.8 Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ SEPT. 27, 2005; 173 (7)

56 What else is critical? Inquire about medication compliance Communicate with the Family Physician Report findings? Blue card system Focus on self management Follow-up: 2 months? Stress test

57 6 months later Suggest home BP monitoring if not already done so Impress upon the patient the need for escalation of therapy Consult with your DC Medical Advisor

58 CASE 2 When is BP an emergency?

59 Case Study # 2 Mr. Smith: 49 year-old laborer with a two-yr history of diet controlled type 2 DM Family history of premature CAD Patient feels well and is seeing the physician for his annual assessment. He has not seen his physician for one year. A1C 7.0%; LDL 2.3 mmol/l. BP (three separate measurements with automatic BP machine): - 175/108 mmhg, 168/105 mmhg, and 185/110 mmhg. Task: 1. Write out a care plan for Mrs. Jones. Be very specific.

60 Controversy In a true hypertensive emergency: Patient has evidence of acute end organ damage: LV failure Encephalopathy In this group, there is good evidence that early/ immediate treatment is beneficial Rare

61 Otherwise: No evidence that early/immediate intervention is beneficial May be harmful No absolute value of systolic or diastolic value that defines hypertensive urgency In fact, the longer your BP is elevated, the better tolerated higher values are

62 So Same as in Case 1: Lifestyle recommendation BP module Needs to see Family Physician within a 2 weeks -one month Do not panic!!!!

63 Case 3 Is it a numbers game?

64 Case Study #3 Your district has received its annual indicators report from the DCPNS. Your DC s BP values show that 38% of your follow-up patients are at target (130/80 mmhg) for BP control. Provincial target is approximately 45%. Your numbers have been stable for the last 3 years. Task: What would you do with this information?

65 POPULATION HEALTH Discuss your concerns with the DC manager, appropriate VP, and Medical advisor Develop an action plan that would include an eventual evaluation of your initiative( did it make a difference?) Implement hypertension module Consider quality improvement initiative

66 Population Health Consider the use of a patient card Consider CME for the Physicians

67 Informal Poll How many of your centers routinely look at your numbers? Whose responsibility is this? Should your centre set targets? Should your district set targets? Should DCPNS set targets?

GUIDELINES FOR DYSLIPIDEMIA MANAGEMENT AND EDUCATION THROUGH NOVA SCOTIA DIABETES CENTRES

GUIDELINES FOR DYSLIPIDEMIA MANAGEMENT AND EDUCATION THROUGH NOVA SCOTIA DIABETES CENTRES Prepared by DCPNS Action Committee Dr. Lynne Harrigan Brenda Cook Peggy Dunbar Bev Harpell with the assistance