Opportunities To Improve Diabetes Care in the Hemodialysis Unit: A Cohort Study in Ontario, Canada

Background

Patients with diabetes receiving chronic, in-center hemodialysis face healthcare challenges. We examined the prevalence of gaps in their diabetes care, explored regional differences, and determined predictors of care gaps.

Methods

We conducted a population-based, retrospective study between January 1, 2016 and January 1, 2018 in Ontario, Canada. We included adults with prevalent diabetes mellitus receiving in-center hemodialysis as of January 1, 2018 and examined the proportion with (1) insufficient or excessive glycemic monitoring, (2) suboptimal screening for diabetes-related complications (retinopathy and cardiovascular screening), (3) hospital encounters for hypo- or hyperglycemia, and (4) hospital encounters for hypertension in the 2 years prior (January 1, 2016 to January 1, 2018). We then identified patient, provider, and health-system factors associated with more than one care gap and used multivariable logistic regression to determine predictors. Further, we used geographic information systems to explore spatial variation in gaps.

Results

There were 4173 patients with diabetes receiving in-center hemodialysis; the mean age was 67 years, 39% were women, and the majority were of lower socioeconomic status. Approximately 42% of patients had more than one diabetes care gap, the most common being suboptimal retinopathy screening (53%). Significant predictors of more than one gap included younger age, female sex, shorter duration of diabetes, dementia, fewer specialist visits, and not seeing a physician for diabetes. There was evidence of spatial variation in care gaps across our region.

Conclusions

There are opportunities to improve diabetes care in patients receiving in-center hemodialysis, particularly screening for retinopathy. Focused efforts to bring diabetes support to high-risk individuals might improve their care and outcomes.

The Impact of Migration on the Gut Metagenome of South Asian Canadians

South Asian (SA) Canadian immigrants have a higher risk of developing certain immune-mediated inflammatory diseases compared to non-migrant SAs. We sought to investigate the effect of migration on the gut metagenome and to identify microbiological associations between migration and conditions that may influence the development of immune-mediated inflammatory diseases. Metagenomic analysis of 58 first-generation (GEN1) SA immigrants and 38 unrelated Canadian born children-of-immigrants (GEN2) determined that the time lived in Canada was associated with continued changes in gut microbial communities. Migration of GEN1 to Canada early in life results in a gut community with similarities to GEN2 SA Canadians and non-SA North Americans. Conversely, GEN1 immigrants who arrived recently to Canada exhibited pronounced differences from GEN2, while displaying microbial similarities to a non-migrating SA cohort. Multivariate analysis identified that community composition was primarily influenced by high abundance taxa. Prevotella copri dominated in GEN1 and non-migrant SAs. Clostridia and functionally related Bacteroidia spp. replaced P. copri dominance over generations in Canada. Mutually exclusive Dialister species occurred at differing relative abundances over time and generations in Canada. This shift in species composition is accompanied by a change in genes associated with carbohydrate utilization and short-chain fatty acid production. Total energy derived from carbohydrates compared to protein consumption was significantly higher for GEN1 recent immigrants, which may influence the functional requirements of the gut community. This study demonstrates the associations between migration and the gut microbiome, which may be further associated with the altered risk of immune-mediated inflammatory diseases observed for SA Canadians.

Ethnic Disparity in Annual Healthcare Expenditures for Type 2 Diabetes Mellitus in Ningxia, China

BACKGROUND

The incidence of type 2 diabetes mellitus (T2DM) and its complications has been increasing worldwide with an increasing provision of long-term medications and health services. This study aimed to assess the healthcare costs for T2DM patients for vulnerable ethnic minority.

METHODS

A cross-sectional study was conducted from October 13, 2016, to June 19, 2017, in two public hospitals in Ningxia, China. Eligible Hui and Han inpatients were recruited and interviewed. Ethnic disparities in annual healthcare expenditures for T2DM measured from a societal perspective and its associations of expenditures with other factors were analyzed by linear and quantile regressions.

RESULTS

Ethnic disparities in annual healthcare expenditures for T2DM were demonstrated, mainly reflecting differences in the cost of productivity loss. The quantile of annual healthcare expenditure showed significant ethnic disparities in T2DM patients with complications. At the 10th to 50th quantiles of healthcare expenditures, Hui patients had significantly lower expenditures than Han patients in both unadjusted and adjusted models. Non-significant difference in expenditures between Hui and Han patients was found at the 90th quantile of expenditure in the unadjusted model, but significantly higher expenditures for Hui patients were shown when adjusted for socioeconomic and clinical factors.

CONCLUSION

T2DM Hui patients faced significantly higher expenditures than Han patients when the costs of healthcare were high. Appropriate national policy considering the issue of ethnic minority should be further explored to improve health and subsidize economic burden for T2DM patients.

Examining sedentary time as a risk factor for cardiometabolic diseases and their markers in South Asian adults: a systematic review

OBJECTIVES

The objective was to systematically review the literature to determine whether sedentary time was associated with cardiometabolic diseases and their risk factors among South Asian adults.

METHODS

Six electronic databases were searched to identify all studies that examined the association between sedentary time and cardiometabolic diseases (e.g., diabetes, cardiovascular disease) and their risk factors [e.g., body mass index (BMI), waist circumference (WC), lipids, blood pressure (BP), glucose] among South Asian adults. Two independent reviewers performed abstract/full-text screening, data abstraction, and quality assessments.

RESULTS

Searching identified 1757 potential articles; 22 were used in the analysis. Greater sedentary time was associated with an increased likelihood of diabetes (n = 5), higher BMI (n = 13), WC (n = 3), BP (n = 2), and glucose (n = 4). Thirteen out of 22 studies were of higher quality.

CONCLUSION

Results identified a trend whereby greater sedentary time was associated with an increased risk for diabetes, and several other cardiometabolic risk factors among South Asian adults. High quality studies are needed to identify whether risk factors are independent of physical activity levels to inform culturally-specific interventions for South Asians.

Rethinking peer support for diabetes in Vancouver's South-Asian community: a feasibility study

AIM

To examine the feasibility and potential health impact of a diabetes self-management education and support intervention involving peer support on glycaemic control and diabetes distress.

METHODS

A total of 41 South-Asian adults with Type 2 diabetes were recruited for a 24-week diabetes self-management education and support pilot intervention involving peer support. The intervention consisted of six weekly education sessions co-facilitated by a certified diabetes educator and two peer leaders, followed by 18 weekly support sessions facilitated by two peer leaders. Education sessions were guided entirely by participants' self-management questions and also emphasized goal setting and action planning. Support sessions were based on empowerment principles and participants discussed self-management challenges, shared emotions, asked self-management questions, problem-solved in a group, set goals, and developed and evaluated action plans. Feasibility outcomes included recruitment and retention. Primary health-related outcomes included HbA1c levels and diabetes distress (measured at baseline, 6 and 24 weeks). Programme satisfaction was also assessed.

RESULTS

Pre-established criteria for recruitment and retention were met. Paired t-tests showed no changes in HbA1c and diabetes distress at 6 weeks. At 24 weeks, HbA1c levels deteriorated [54 mmol/mol (7.1%) vs 61 mmol/mol (7.7%)] while diabetes distress scores improved (2.0 vs 1.7).

CONCLUSIONS

Although feasible, findings suggest this peer-support model may have a positive impact on diabetes distress, but not on HbA1c levels. Culturally responsive modifications (e.g. intervention location) to the pilot model are needed and could lead to more favourable health outcomes for this community. Such a re-designed peer-support model will require further investigation.

Utilization of health resources in South Asian, Chinese and white patients with diabetes mellitus

AIMS

We sought to determine whether there are differences in health resource utilization among South Asian (SA), Chinese and White patients with newly diagnosed diabetes mellitus.

METHODS

We used province-wide administrative data from British Columbia, Canada (1997-2006) to determine proportion of patients with ≥2 visits/year for all outpatient and family physician (FP) visits, proportion of patients with at least one annual visit to specialists, ophthalmology/optometry and hospital admissions by ethnic group.

RESULTS

There were 9529 South Asian, 14,084 Chinese and 143,630 White patients with newly diagnosed diabetes in the study. Over 90% of each of the ethnic groups visited their FP ≥2 visits/year. Chinese patients were less likely to visit FP, ophthalmology/optometrists and specialists compared to White patients. SA patients had fewer ophthalmology/optometry visits compared to White populations. White patients had higher rates of hospitalization.

CONCLUSION

Although all groups had high proportion of patients with appropriate frequency of FP visits, other aspects of health care utilization varied significantly by ethnicity.

Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial

OBJECTIVE

To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities, including American Indian/Alaska Natives.

SUBJECTS AND METHODS

We conducted a multicenter, randomized controlled trial and assigned diabetic participants to one of two groups: (1) telemedicine with a nonmydriatic camera or (2) traditional surveillance with an eye care provider. For those receiving telemedicine, the criteria for requiring follow-up with an eye care provider were (1) moderate nonproliferative diabetic retinopathy or higher, (2) presence of clinically significant macular edema, or (3) "unable to grade" result for diabetic retinopathy or macular edema.

RESULTS

The telemedicine group (n=296) was more likely to receive a diabetic retinopathy screening examination within the first year of enrollment compared with the traditional surveillance group (n=271) (94% versus 56%, p<0.001). The overall prevalence of diabetic retinopathy at baseline was 21.4%, and macular edema was present in 1.4% of participants. In the telemedicine group, 20.5% would require further evaluation with an eye care provider, and 86% of these referrals were because of poor-quality digital images.

CONCLUSIONS

Telemedicine using nonmydriatic cameras increased the proportion of participants who obtained diabetic retinopathy screening examinations, and most did not require follow-up with an eye care provider. Telemedicine may be a more effective way to screen patients for diabetic retinopathy and to triage further evaluation with an eye care provider. Methods to decrease poor quality imaging would improve the effectiveness of telemedicine for diabetic retinopathy screening examinations.

Cardiovascular complications and mortality after diabetes diagnosis for South Asian and Chinese patients: a population-based cohort study

OBJECTIVE

Many non-European ethnic groups have an increased risk for diabetes; however, the published literature demonstrates considerable uncertainty about the rates of diabetes complications among minority populations. The objective of this study was to determine the risks of cardiovascular complications and of mortality after diabetes diagnosis for South Asian and Chinese patients, compared with European patients.

RESEARCH DESIGN AND METHODS

A population-based cohort study identified all 491,243 adults with newly diagnosed diabetes in Ontario, Canada, between April 2002 and March 2009. Subjects were followed until March 2011 for the first occurrence of any cardiovascular complication of diabetes (coronary artery disease, stroke, or lower-extremity amputation) and for all-cause mortality. Median follow-up was 4.7 years.

RESULTS

The crude incidence of cardiovascular complications after diabetes diagnosis was 17.9 per 1,000 patient-years among European patients, 12.0 among South Asian patients, and 7.7 among Chinese patients. After adjusting for baseline characteristics, the cause-specific hazard ratios (HRs) for cardiovascular complications relative to European patients were 0.95 (95% CI 0.90-1.00; P = 0.056) and 0.50 (0.46-0.53; P < 0.001) for South Asian and Chinese patients, respectively. Mortality was lower for both minority groups (adjusted HR for South Asian patients 0.56 [95% CI 0.52-0.60]; P < 0.001; for Chinese patients 0.58 [0.55-0.62]; P < 0.001).

CONCLUSIONS

Chinese patients were at substantially lower risk than European patients for cardiovascular complications after diabetes diagnosis, whereas South Asian patients were at comparable risk. Mortality after diabetes diagnosis was markedly lower for both minority populations.

A systematic literature review of diabetes self-management education features to improve diabetes education in women of Black African/Caribbean and Hispanic/Latin American ethnicity

OBJECTIVE

This systematic literature review aims to identify diabetes self-management education (DSME) features to improve diabetes education for Black African/Caribbean and Hispanic/Latin American women with Type 2 diabetes mellitus.

METHODS

We conducted a literature search in six health databases for randomized controlled trials and comparative studies. Success rates of intervention features were calculated based on effectiveness in improving glycosolated hemoglobin (HbA1c), anthropometrics, physical activity, or diet outcomes. Calculations of rate differences assessed whether an intervention feature positively or negatively affected an outcome.

RESULTS

From 13 studies included in our analysis, we identified 38 intervention features in relation to their success with an outcome. Five intervention features had positive rate differences across at least three outcomes: hospital-based interventions, group interventions, the use of situational problem-solving, frequent sessions, and incorporating dietitians as interventionists. Six intervention features had high positive rate differences (i.e. ≥50%) on specific outcomes.

CONCLUSION

Different DSME intervention features may influence broad and specific self-management outcomes for women of African/Caribbean and Hispanic/Latin ethnicity.

PRACTICAL IMPLICATIONS

With the emphasis on patient-centered care, patients and care providers can consider options based on DSME intervention features for its broad and specific impact on outcomes to potentially make programming more effective.

Evaluating a diabetes self-management support peer leader training programme for the English- and Punjabi-speaking South-Asian community in Vancouver

AIMS

The purpose of this single-cohort study was to implement and evaluate a programme that trains peers to deliver a diabetes self-management support programme for South-Asian adults with Type 2 diabetes and to assess the perceived efficacy of and satisfaction with this programme.

METHODS

We recruited eight South-Asian adults who completed a 20-h peer-leader training programme conducted over five sessions (4 h per session). The programme used multiple instructional methods (quizzes, group brainstorming, skill building, group sharing, role-play and facilitation simulation) and provided communication, facilitation, and behaviour change skills training. To graduate, participants were required to achieve the pre-established competency criteria in four training domains: active listening, empowerment-based facilitation, five-step behavioural goal-setting, and self-efficacy. Participants were given three attempts to pass each competency domain.

RESULTS

On the first attempt six (75%), eight (100%), five (63%) and five (63%) participants passed active listening, empowerment-based facilitation, five-step behavioural goal-setting, and self-efficacy, respectively. Those participants who did not pass a competency domain on the first attempt were successful in passing on the second attempt. As a result, all eight participants graduated from the training programme and became peer leaders. Satisfaction ratings for programme length, balance between content and skills development, and preparation for leading support activities were uniformly high. Ratings for the instructional methods ranged between effective and very effective.

CONCLUSION

Findings suggest it is feasible to train and graduate peer leaders with the necessary skills to facilitate a diabetes self-management support intervention.

Age- and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada

BACKGROUND

The majority of immigrants to Canada originate from the developing world, where the most rapid increase in prevalence of diabetes mellitus is occurring. We undertook a population-based study involving immigrants to Ontario, Canada, to evaluate the distribution of risk for diabetes in this population.

METHODS

We used linked administrative health and immigration records to calculate age-specific and age-adjusted prevalence rates among men and women aged 20 years or older in 2005. We compared rates among 1,122,771 immigrants to Ontario by country and region of birth to rates among long-term residents of the province. We used logistic regression to identify and quantify risk factors for diabetes in the immigrant population.

RESULTS

After controlling for age, immigration category, level of education, level of income and time since arrival, we found that, as compared with immigrants from western Europe and North America, risk for diabetes was elevated among immigrants from South Asia (odds ratio [OR] for men 4.01, 95% CI 3.82-4.21; OR for women 3.22, 95% CI 3.07-3.37), Latin America and the Caribbean (OR for men 2.18, 95% CI 2.08-2.30; OR for women 2.40, 95% CI: 2.29-2.52), and sub-Saharan Africa (OR for men 2.31, 95% CI 2.17-2.45; OR for women 1.83, 95% CI 1.72-1.95). Increased risk became evident at an early age (35-49 years) and was equally high or higher among women as compared with men. Lower socio-economic status and greater time living in Canada were also associated with increased risk for diabetes.

INTERPRETATION

Recent immigrants, particularly women and immigrants of South Asian and African origin, are at high risk for diabetes compared with long-term residents of Ontario. This risk becomes evident at an early age, suggesting that effective programs for prevention of diabetes should be developed and targeted to immigrants in all age groups.