2010 (Oct) Canadian Diabetes Association Annual Conference, Aboriginal health Symposium facilitated by BRAID Research

1. “RESULTS OF DIABETES OUTREACH
and COMPLICATIONS SCREENING
PROGRAMS IN ALBERTA”
Sandra Shade, BScN
Director of Home Care, Blood Tribe Health Department
Ellen L Toth, MD
University of Alberta
Canadian Diabetes Association Meeting,
Edmonton 2010

2. Outline
 Brief description of SLICK
 SLICK results
 Discussion
 MDSi results
 Other programs

3. SLICK: Screening for Limbs, I-eyes,
Cardiovascular and Kidneys
 Launched December
2001
 2 vans
 44 eligible communities
Alberta

4. SLICK team

8. SLICK and MDSI:
Eye photographs

10. Collaborative
Endeavour
 Alberta First Nations
 University of Alberta
 First Nations and Inuit Health Branch
 ADI and Nursing, significant partnership and
operational funding from ADI
 Canadian Health Infrastructure
Partnership Program (CHIPP) initial
funding
 Royal Alexandra Hospital
 Ophthalmology and Aboriginal Diabetes
Wellness Program
 Capital Health Authority
 Alberta Health and Wellness

11. Program Objectives
 Reduce the complications of diabetes
 Increase access to appropriate diabetes
care
 Increase capacity to meet the Canadian
Diabetes Practice Guidelines
 Foster integration and collaboration of
health services across the continuum of
care
 Provide cost-effective care
 Share lessons learned with others

12. SLICK: Screening for Limbs, I-eyes,
Cardiovascular and Kidneys
Dr David Strong, MOH
Heather Young, Director of Nursing
Judy Halladay, RD, promotion and
prevention
First Nations leadership
Dr. Ellen Toth, Medical Advisor
Dr Hakique Virani, Medical Advisor
Dr. Matt Tennant, Ophthalmologist
Sandra Shade, ADI coordinator
Audrey Inouye, ADI Coordinator
Iris Weibel, RN, CDE
Lorraine Trojan, RN
Kathleen Gibson, RD and R.
photographer

13. SLICK: Screening for Limbs, I-eyes,
Cardiovascular and Kidneys
Dr David Strong, MOH
Heather Young, Director of Nursing
Judy Halladay, RD, promotion and
prevention
First Nations leadership
Dr. Ellen Toth, Medical Advisor
Dr Hakique Virani, Medical Advisor
Dr. Matt Tennant, Ophthalmologist
Sandra Shade, ADI coordinator
Audrey Inouye, ADI Coordinator
Iris Weibel, RN, CDE
Lorraine Trojan, RN
Kathleen Gibson, RD and R.
photographer

14. Analyses in SLICK
 SLICK Survey:
 Care providers and activities
 Satisfaction with services
 Diabetes knowledge
 Clinical status
 Complications screening activities
 Quality of Life
 SLICK activity
 Clinical characteristics:
 Weight/waist, A1c, Cholesterol, BP, feet, eyes
 at baseline
 over time

15. SLICK Activity
SLICK NON-SLICK
Year New
Clients
per
Year
Prior
Year
Clients
seen again
This
Year
Clients
seen
again
New
Clients
per
Year
Prior
Year
Clients
seen
again
This
Year
Clients
seen
again
Total
visits
2001 11 0 0 1 0 0 12
2002 804 5 46 180 0 1 1036
2003 396 375 28 231 38 3 1071
2004 354 601 34 292 83 13 1377
2005 202 594 17 323 141 11 1288
2006 202 721 15 286 169 8 1401
2007(to
end of
June)
133 439 1 200 186 0 959
Totals: 2102 2735 141 1513 617 36 7144

16. New clients seen per year
(N = 2102 Slick and 1513 Non-Slick)
0
200
400
600
800
1000
2001 2002 2003 2004 2005 2006 2007
Year
Number
Non-Slick
Slick

17. Total visits per year
(N = 4978 Slick, 2166 Non Slick)
0
200
400
600
800
1000
1200
2001 2002 2003 2004 2005 2006 2007
Year
Number
Non Slick
Slick

18. Gender distribution (unique clients)
0
200
400
600
800
1000
1200
1400
Non-SLICK Slick
Number
Females
Males

19. Age distribution of SLICK clients at 1st visit (N=2102)
0
50
100
150
200
250
300
350
400
0-9 10-
19
20-
29
30-
39
40-
49
50-
59
60-
69
70-
79
80-
89
90-
100
Age group
Number
Females
Males

20. Age distribution of Non Slick clients at 1st visit (N = 1512)
0
50
100
150
200
250
300
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-100
Age groups
Number
Females
Males

21. Number of visits per person (2001- June 2007)
0
200
400
600
800
1000
1200
1 2 3 4 5 6 7 8 9
Number of visits
Number
Non Slick
Slick

22. Longitudinal SLICK
results December 2OO1
to June 2OO7

23. SLICK Activity
UNIQUE Clients seen SLICK Non-SLICK
Once only 905 1096
X 2 458 256
X 3 310 108
X 4 199 36
X 5 126 12
X 6 85 5
> 7 40 0
Total UNIQUE clients 2102 1513
Total VISITS 4978 2166
Seen at least TWICE: 1218 4171218
2102

24. Baseline Results for SLICK
clients at first visit (secular
trend?)

25. All Clients
7.16
8.21
7.69 7.61 7.54 7.60 7.58
MeanA1c
0
1
2
3
4
5
6
7
8
9
Year
2001 2002 2003 2004 2005 2006 2007

26. At first
visit!????
Slope = -0.143
p-value=<.0001
(N=2091 Slick clients at 1st
MeanA1c
4
5
6
7
8
9
10
11
12
13
14
year
2001 2002 2003 2004 2005 2006 2007
A1c by Year
(N=2091 Slick clients at 1st visit)

27. Slope = -0.158
p-value <.0001
(N = 1704)
MeanCholesterol
1
2
3
4
5
6
7
8
9
10
11
year
2001 2002 2003 2004 2005 2006 2007
Total Cholesterol by Year
(N=1704 Slick clients at 1st visit)

29. Longitudinal results for
RETURNING SLICK
clients over time(average
improvement of
individuals)

30. For the longitudinal analysis, univariate general linear mixed
effect models with random client effect and fixed time (year)
effect were used for continuous outcome variables.
Logit general linear mixed effect models (binary or
multinomial) with random client effect and fixed time effect
were used for categorical (binary) outcome variables.
Longitudinal analyses for baseline clinical parameters per year
were adjusted for duration of diabetes.
Statistical Methodology

33. SLICK summary

34. Summary
 Seeing improvements:
A1c (secular and longitudinal)
Weight
Total cholesterol (secular and
longitudinal)
Blood pressure
 LIMITATIONS
No control group

35. Thank You
Sandra Shade BscN
sshade@onehealth.ca
Dr Ellen Toth: 780 - 407-3636
ellen.toth@ualberta.ca
www.braiddm.ca
ACADRE

36. Discussion
 Seeing improvements:
Unable to attribute to SLICK
 SLICK update
 ADI funding insecure, but recently
confirmed and increased
 SLICK screeners in Communities
 Comparison to Circle results
 Provincial surveillance

37. The CIRCLE Study
The Canadian First Nations Diabetes Clinical Management
Epidemiologic Study
Principal Investigator:
Dr. Stewart Harris
Coordinating Centre:
Mariam Naqshbandi, Program Coordinator
Jim Esler, Research Assistant
Marnie Orcutt, Administrative Assistant

38. Complications of Diabetes - Screening at
Recommended Intervals
39%
22%
26%
16%
46%
28%
72%
14%
27%
18%
22% 22%
85%
44%
74%
86%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
%of
participants
Foot exam(annual, 2007) Eye (retinopathy) - (every
1-2 years, 2006-2007)
Nerve (neuropathy) -
(annual, 2007)
Kidney (nephropathy) -
(annual, 2007)
National
A
B
C

39. Diet Alone
Oral
Insulin
Insulin+Oral
percentage
0
10
20
30
40
50
60
70
80
90
100
<7 7-9 9-12 >=12

40. Treatment of Diabetes - Insulin and
Oral Anti-Diabetes Medications
0%
5%
10%
15%
20%
25%
30%
35%
%of
participants
National A B C
No insulin or OADs
Insulin alone
1 OAD
2 OADs
3 or more OADs
Insulin + 1 OAD
Insulin + 2 OADs
Insulin + 3 or more OADs

41. ABC comparisons
CIRCLE ALBERTA
CIRCLE
Communities
Canadian
chart audit,
Harris,
2005
DOVE
study
SLICK
baseline
Mean A1c ? 8.2 -8.3 8.2-8.3 7.3 7.4 8.2
A1c < 7.0 37% 32-42% 49% 50% 30 or 43%
Blood
pressure too
high
53% 44-60% 63% 55% 61%
Cholesterol
too high
40% 37-61% 59% 60% 39%
Microvascular
complications
(eyes,
kidneys,
nerves)
40% 2-54% 39% 31-39%
Heart disease
and stroke
20% 6-16% 28% ?30%

42. ADSS 2009
Authors: Oster, Hemmelgarn, Toth, King, Crowshoe, Campbell

44. Other Aboriginal diabetes
programs
“TOP”
SLICK: federally funded, 9000 visits since 2001
(~947/yr)
ADI
MDSi: provincially funded, 5000 visits since 2003
(~769/yr)
ADWP: ?~ 700 visits per year for last 10 yrs?

46. Mobile Diabetes Screening
Initiative:
“… provide resources for screening for
diabetes and its complications in
Aboriginal off-reserve and remote
Alberta communities”
(part of the 10 year Alberta Diabetes Strategy,
2003-2013)

47. KNOWNS and
UNKNOWNS
MDSi
KNOWNS:
- have diabetes
- visits take longer
- need foot and eye exams
UNKNOWNS:
screen for risk of
diabetes and
cardiovascular risk
30
%
80%

48. MDSi baseline results

49. Returning subjects with
diabetes, N = 18O
BMI
Waist
A1c
Systolic BP
Diastolic BP
MAP
Cholesterol
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2
BMI
Waist
A1c
Systolic BP
Diastolic BP
MAP
Cholesterol

50. -1.5 -1 -0.5 0 0.5 1 1.5
Returning “unknowns”, subjects at
diabetes risk, N = 629
BMI
Waist
A1c
Systolic BP
Diastolic BP
MAP
Cholesterol

51. Thank You
Sandra Shade BscN
sshade@onehealth.ca
Dr Ellen Toth: 780 - 407-3636
ellen.toth@ualberta.ca
www.braiddm.ca
ACADRE