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Objectives For most patients with diabetes, routine use of blood glucose test strips (BGTS) has not been shown to be beneficial, yet the economic implications of broad publicly funded reimbursement for BGTS are substantial. We assessed the potential impact of BGTS quantity limits on utilization and costs for 6 publicly funded drug plans across Canada. Methods A cross-sectional analysis was conducted in 6 provinces (Alberta, Saskatchewan, Manitoba, Nova Scotia, Newfoundland and Labrador and Prince Edward Island) for patients who received at least 1 prescription for BGTS in 2014 through the public drug program. We determined the number of BGTS that would have exceeded the quantity limits and the associated costs to the provincial drug program. Results A total of $38,051,026 was spent on BGTS reimbursed through public drug programs among the 6 provinces. In provinces where BGTS use is largely restricted to patients using insulin, the potential annual savings were minimal, ranging from 0.4% to 2.3%, whereas in provinces with more liberal listings, potential savings ranged from 12.4% to 19.8%. Combining these results with data from a previous analysis in Ontario and British Columbia, the cost savings associated with BGTS quantity limits for 8 provinces across Canada (capturing approximately three-quarters of the Canadian population) is estimated to be $30.3 million annually. Conclusions The national implementation of a quantity limit policy for BGTS that aligns with evidence of efficacy, optimal prescribing and patient safety can lead to considerable savings for most public drug plans across Canada.

To examine the concordance between testosterone replacement therapy (TRT) use and established reimbursement criteria, as well as compare the persistence of use among available formulations (injectable, oral, topical gel, transdermal patch) among elderly men in Ontario, Canada.We conducted a retrospective cohort study of men aged 66 years or older in Ontario newly treated with testosterone between 1 January 2009 and 31 December 2012 using linked health administrative data. Continuous use was defined on the basis of prescription refills issued within 180 days of the preceding prescription. We studied men who received at least two consecutive TRT prescriptions. We estimated the prevalence of hypogonadism, human immunodeficiency virus, specialist visits and lab tests for serum testosterone prior to initiation of TRT to investigate concordance with prescribing criteria. We also performed a Kaplan-Meier analysis to test for differences in the median time to discontinuation among formulations.Among the 4797 men who received at least two TRT prescriptions, only 38.7% met the reimbursement criteria for use prior to initiating therapy. The median time to discontinuation differed significantly among formulations and was longest among recipients of oral TRT products (383 days), and lower for recipients of topical gels (319 days), injectable (283 days) and transdermal patches (160 days; Log-rank test p 0.001).A large proportion of older men in Ontario do not appear to meet reimbursement criteria prior to commencing therapy, and many discontinue TRT within a year of initiation. Copyright © 2016 John WileySons, Ltd.

Background Compared to Caucasians, Chinese achieve a higher blood concentration of statin for a given dose. It remains unknown whether this translates to increased risk of serious statin-associated adverse events amongst Chinese patients. Methods We conducted a population-based retrospective cohort study of older adults (mean age, 74 years) newly prescribed a statin in Ontario, Canada between 2002 and 2013, where 19,033 Chinese (assessed through a validated surname algorithm) were matched (1:3) by propensity score to 57,099 non-Chinese. This study used linked healthcare databases. Findings The follow-up observation period (mean 1.1, maximum 10.8 years) was similar between groups, as were the reasons for censoring the observation period (end of follow-up, death, or statin discontinuation). Forty-seven percent (47%) of Chinese were initiated on a higher than recommended statin dose. Compared to non-Chinese, Chinese ethnicity did not associate with any of the four serious statin-associated adverse events assessed in this study [rhabdomyolysis hazard ratio (HR) 0.61 (95% CI 0.28 to 1.34), incident diabetes HR 1.02 (95% CI 0.80 to 1.30), acute kidney injury HR 0.90 (95% CI 0.72 to 1.13), or all-cause mortality HR 0.88 (95% CI 0.74 to 1.05)]. Similar results were observed in subgroups defined by statin type and dose. Conclusions We observed no higher risk of serious statin toxicity in Chinese than matched non-Chinese older adults with similar indicators of baseline health. Regulatory agencies should review available data, including findings from our study, to decide if a change in their statin dosing recommendations for people of Chinese ethnicity is warranted.

Introduction: South Asians have earlier cardiovascular disease onset and higher stroke mortality than non-South Asians, but disparities in long-term outcomes after stroke in patients with diabetes are not well described. We compared risk of cardiovascular outcomes after first ischemic stroke between South Asian and non-South Asian patients with diabetes. Hypothesis: We hypothesized that South Asian stroke patients with diabetes were younger and had higher stroke recurrence, even accounting for competing risk of death. Methods: Using population-based health care databases in Ontario, Canada, we selected all patients with diabetes hospitalized with first ischemic stroke between April 1, 2002 and March 31, 2012, and assigned South Asian vs. non-South Asian ethnicity using a validated surname algorithm. Kaplan-Meier survival analysis and competing risk models estimated risk of death, stroke, and myocardial infarction. The primary predictor was ethnicity; models were adjusted for demographics and vascular risk factors. Sensitivity analysis including adjustment for medication use was performed in those aged >=65 years. Results: There were 25495 diabetics with first ischemic stroke; 840 were South Asian and were younger, more often male, had lower income, and had shorter Ontario residency compared to non-South Asians. South Asians had higher incidence and cumulative risk of recurrent stroke (Figure). In adjusted competing risk models, recurrent stroke risk was increased among South Asians compared to non-South Asians (HR 1.17 [95% CI 1.00-1.38]) in the whole cohort and in those aged >=65 years, both with adjustment for medication use (HR 1.23 [1.01-1.50]) and without (1.27 [1.04-1.54]). Conclusions: In this large population-based study, South Asian stroke patients with diabetes had higher recurrent stroke risk compared to non-South Asians, despite younger age. Further research and targeted interventions are needed to reduce stroke burden in South Asians.

Diabet. Med. 29, 1524–1528 (2012) Abstract Aims Sulphonylureas promote insulin release by inhibiting pancreatic potassium channels. Older sulphonylureas such as glyburide (glibenclamide), but not newer ones such as gliclazide, antagonize similar channels in myocardium, interfering with the protective effects of ischaemic preconditioning. Whether this imparts a higher risk of adverse cardiac events is unknown. Methods We conducted a population-based cohort study of patients aged 66 years and older who were hospitalized for acute myocardial infarction or who underwent percutaneous coronary intervention between 1 April 2007 and 31 March 2010 while receiving either glyburide or gliclazide. We used a high-dimensional propensity score matching process to ensure similarity of glyburide- and gliclazide-treated patients. The primary outcome was a composite of death or hospitalization for myocardial infarction or heart failure. Results During the 2-year study period, we matched 1690 patients treated with glyburide to 984 patients treated with gliclazide at the time of hospitalization for acute myocardial infarction or percutaneous coronary intervention. We found no difference in the risk of the composite outcome among patients receiving glyburide (adjusted hazard ratio 1.01; 95% CI 0.86–1.18). We found similar results in secondary analyses of each outcome individually, and in two supplementary analyses (haemorrhage and pneumonia) in which we anticipated no difference between the two patient groups. Conclusions Among older patients hospitalized for acute myocardial infarction or percutaneous coronary intervention, treatment with glyburide is not associated with an increased risk of future adverse cardiovascular events relative to gliclazide, suggesting that the effect of glyburide on ischaemic preconditioning is of little clinical relevance.

Diabet. Med. 29, 1134–1141 (2012) Abstract Aims There are limited validated methods to ascertain comorbidities for risk adjustment in ambulatory populations of patients with diabetes using administrative health-care databases. The objective was to examine the ability of the Johns Hopkins’ Aggregated Diagnosis Groups to predict mortality in population-based ambulatory samples of both incident and prevalent subjects with diabetes. Methods Retrospective cohorts constructed using population-based administrative data. The incident cohort consisted of all 346 297 subjects diagnosed with diabetes between 1April 2004 and 31 March 2008. The prevalent cohort consisted of all 879 849 subjects with pre-existing diabetes on 1 January, 2007. The outcome was death within 1 year of the subject’s index date. Results A logistic regression model consisting of age, sex and indicator variables for 22 of the 32 Johns Hopkins’ Aggregated Diagnosis Group categories had excellent discrimination for predicting mortality in incident diabetes patients: the c-statistic was 0.87 in an independent validation sample. A similar model had excellent discrimination for predicting mortality in prevalent diabetes patients: the c-statistic was 0.84 in an independent validation sample. Both models demonstrated very good calibration, denoting good agreement between observed and predicted mortality across the range of predicted mortality in which the large majority of subjects lay. For comparative purposes, regression models incorporating the Charlson comorbidity index, age and sex, age and sex, and age alone had poorer discrimination than the model that incorporated the Johns Hopkins’ Aggregated Diagnosis Groups. Conclusions Logistical regression models using age, sex and the John Hopkins’ Aggregated Diagnosis Groups were able to accurately predict 1-year mortality in population-based samples of patients with diabetes.

Diabet. Med. 29, e180–e183 (2012) Abstract Aims To compare the prevalence of diabetes in pregnancy, pregnancy care and adverse pregnancy outcomes in on-reserve First Nations women vs. non-First Nations women in Ontario, Canada. Methods A retrospective population-based cohort study was performed. All 487 368 live singleton hospital deliveries between 1 April 2002 and 31 March 2010 were identified. Outcomes were defined by linking mothers and infants to provincial healthcare administrative databases. Results Diabetes in pregnancy was more prevalent in First Nations women (10.3 vs. 6.0%). They received less pregnancy care and had higher rates of adverse outcomes than non-First Nations women with diabetes. Conclusions First Nations women are at a higher risk of diabetes in pregnancy and adverse outcomes. This highlights the need for increased care for pregnant First Nations women.

Objectives Childhood type 2 diabetes (T2D) is increasing and may present differently across various populations. This study compares clinical features of T2D at diagnosis in Aboriginal children with Caucasian children and children from other high-risk ethnic groups. Patients and methods This retrospective observational study used data from a Canadian surveillance study where newly diagnosed cases of childhood T2D were reported (n = 227). Using descriptive statistics, clinical features at diagnosis of T2D were compared across different ethnic groups including Aboriginal (n = 100), Caucasian (n = 57), and other high-risk ethnic groups (n = 64). Comparisons were made between Aboriginal children living in central Canada (Manitoba/northwestern Ontario) (n = 74) and Aboriginal children from other regions of Canada (n = 26). Results Aboriginal children were younger, less obese, and less likely to have polycystic ovarian syndrome and dyslipidemia when compared to Caucasian children and children from other high-risk ethnic groups (p < 0.05). Aboriginal children from central Canada vs. those from other regions of Canada did not differ in age, body mass index z-score, family history of T2D, or presence of acanthosis nigricans. Those from central Canada had lower hemoglobin A1c levels (p < 0.05) and were less likely to have dyslipidemia than Aboriginal children from other regions (p < 0.05). Conclusions Clinical features and rates of comorbidity in children with newly diagnosed T2D differ across various populations (Caucasian, Aboriginal, and children who belong to other high-risk ethnic groups) and across distinct Aboriginal populations (those living in central Canada vs. those living in other regions of Canada). Future research should determine specific genetic and environmental factors that contribute to these differences.

Please cite this paper as: Shah B, Lipscombe L, Feig D, Lowe J. Missed opportunities for type 2 diabetes testing following gestational diabetes: a population-based cohort study. BJOG 2011;118:1484–1490. Objectives Few women with gestational diabetes (GDM) are tested for type 2 diabetes in the postpartum period. Whether women are having physician visits that could be an opportunity to improve testing rates is unknown. This study sought to evaluate population-level trends in postpartum diabetes testing after GDM, and to evaluate postpartum physician care for these women. Design Population-based cohort study. Setting Ontario, Canada. Population Women who delivered between 1994 and 2008. Methods Using population-level healthcare databases, we identified 47 691 women with GDM. They were matched to women without GDM. Main outcome measures An oral glucose tolerance test (OGTT) within 6 months postpartum, the specialty of the physician ordering the test, and ambulatory care visits with physicians from various specialties within 6 months postpartum were recorded. Results Most women with GDM did not receive an OGTT, although testing rates increased slowly over the 14 years of the study, compared with no change in testing for women who had not had GDM. Virtually all women with GDM had postpartum visits with a family physician or obstetrician, but few OGTTs were ordered by physicians from these specialties. Conclusions Despite a slow increase in testing over time and high rates of postpartum visits to family physicians and obstetricians, few women with GDM received the recommended diabetes test. This represents a missed opportunity in a high-risk population. Interventions to change test ordering that target family physicians and obstetricians are most likely to increase the proportion of women with GDM who receive postpartum diabetes testing.

To compare the prevalence of risk factors in children aged18 years diagnosed with medication-induced diabetes mellitus versus those diagnosed with type 2 diabetes.This retrospective observational study used data from a Canadian prospective surveillance study in which clinical features of new cases of type 2 diabetes (n = 225) and medication-induced diabetes (n = 58) were reported over a 2-year period. The presence of risk factors for type 2 diabetes (eg, obesity, family history of type 2 diabetes, ethnicity, acanthosis nigricans, hypertension, polycystic ovarian syndrome) was compared in the 2 groups using descriptive statistics and logistic regression.Compared with the children with type 2 diabetes, the children with medication-induced diabetes were more likely to be Caucasian (P.0001) and less likely to be obese (P.0001), to have a positive family history of type 2 diabetes (P = .0001), to have acanthosis nigricans (P.0001) on clinical examination, and to have an obesity-related comorbidity, such as polycystic ovarian syndrome (P = .04), dyslipidemia (P = .02), hypertension (P = .04), or an elevated alanine aminotransferase level (P = .05).Evaluating for the typical risk factors for type 2 diabetes is not sufficient to identify all children at risk for developing medication-induced diabetes. Further studies are needed to help inform guidelines on screening for and prevention of medication-induced diabetes in children.

Introduction Dans le cadre des soins de santé courants, les femmes ayant des antécédents de diabète sucré gestationnel (DSG) subissent rarement au cours de la période postnatale le test recommandé de dépistage du diabète de type 2, c’est-à-dire l’épreuve d’hyperglycémie provoquée par voie orale (HGPO) de 2 heures. Cette étude a pour objet de déterminer si la mise en œuvre d’un système de rappel permet d’accroître les taux de dépistage. Méthodologie À la suite de notre essai comparatif randomisé (ECR) antérieur, nous avons intégré un protocole de rappel postnatal (par la poste ou par téléphone) aux pratiques des soins courants dans deux des trois sites cliniques. Nous avons vérifié dans quelle mesure les tests postnatals étaient réalisés en consultant les bases de données de laboratoire des hôpitaux et la base de données provinciale de facturation des services médicaux. Le paramètre primaire mesuré était la proportion de patientes soumises à une épreuve d’HGPO au cours des 6 mois ayant suivi l’accouchement. Résultats Les femmes ayant reçu des soins dans un établissement où était utilisé un système de rappel étaient plus nombreuses à subir une épreuve d’HGPO au cours des 6 mois suivant leur accouchement (28 %) que celles n’ayant pas bénéficié de ce système (14 %). Pour les deux groupes ayant reçu un rappel, le taux d’HGPO (28 %) était inférieur à celui obtenu dans le cadre de notre ECR (60 %). Conclusion Le système de rappel postnatal a permis de doubler les taux de dépistage par l’épreuve d’HGPO recommandée, ceux-ci demeurant néanmoins faibles.

Introduction During regular care, women with previous gestational diabetes mellitus (GDM) rarely receive the recommended screening test for type 2 diabetes, a 2-hour oral glucose tolerance test ( OGTT), in the postpartum period. The current study examined whether the implementation of a reminder system improved screening rates. Methods Based on our previous randomized control trial, we implemented a postpartum reminder (letter or phone call) protocol into routine care at two of three clinical sites. We verified postpartum testing by searching hospital laboratory databases and by linking to the provincial physician service claims database. The primary outcome was the proportion of patients who underwent an OGTT within 6 months of delivery. Results Women who received care in a setting using a reminder system were more likely to receive an OGTT within 6 months postpartum (28%) compared with usual care (14%). The OGTT rates for both reminder groups were lower than that found in our randomized control trial (28% vs. 60%). Conclusion Although the screening rates remain low, postpartum reminders doubled screening rates using the recommended test, the OGTT.

Objectives To determine whether attending diabetes education is associated with blood glucose self-monitoring among unselected older adults in routine clinical care. Method A cross-sectional population-based study was carried out on 15 190 people with diabetes aged 65–79 years. Subjects were identified using a registry of doctor-diagnosed diabetes derived from administrative data, and attendance at diabetes education centres (DECs) was determined from a separate registry of DEC utilization for 2006. Outcomes were derived using administrative data. The primary outcome was prescriptions filled for glucose self-monitoring supplies. The secondary outcomes were prescriptions for antihypertensive drugs, prescriptions for lipid-lowering drugs and eye examinations. Results DEC attendance was associated with glucose self-monitoring, after adjusting for baseline differences between attendees and non-attendees (adjusted odds ratio 6.45, 95% confidence interval 5.61 to 7.42). All of the secondary outcomes were also independently associated with DEC attendance. Conclusions This study suggests that diabetes education is associated with self-management behaviour in real-world clinical care. These findings support the effectiveness of self-management education programmes to increase self-care behaviours.

OBJECTIVE To determine in Canadian children aged RESEARCH DESIGN AND METHODS This Canadian prospective national surveillance study involved a network of pediatricians, pediatric endocrinologists, family physicians, and adult endocrinologists. Incidence rates were calculated using Canadian Census population data. Descriptive statistics were used to illustrate demographic and clinical features. RESULTS From a population of 7.3 million children, 345 cases of non–type 1 diabetes were reported. The observed minimum incidence rates of type 2, medication-induced, and monogenic diabetes were 1.54, 0.4, and 0.2 cases per 100,000 children aged CONCLUSIONS This is the first prospective national surveillance study in Canada to report the incidence of type 2 diabetes in children and also the first in the world to report the incidence of medication-induced and monogenic diabetes. Rates of type 2 diabetes were higher than expected with important regional variation. These results support recommendations that screening for comorbidity should occur at diagnosis of type 2 diabetes.

Background: Recent evidence suggests that, despite widespread use, self-monitoring of blood glucose levels has little clinical benefit in many patients with diabetes. The impact of more focused public-payer policies for the use of blood glucose test strips may be substantial. Methods: We conducted a cross-sectional analysis of annual prescription claims for test strips between 1997 and 2008 for patients in Ontario aged 65 and older with diabetes. Patients were stratified into 1 of 4 hierarchical groups according to the most intensive glucose-lowering treatment received during each calendar year. Test strip use was calculated annually for each group over the study period, and the effects of 5 hypothetical policy scenarios of more selective test strip use were assessed. Results: Test strip use increased by almost 250% from 1997 to 2008, with 52.6% ( n = 263 513) of included patients receiving a prescription during 2008. Almost half of these patients were at low risk for drug-induced hypoglycemia. In 2008, over 117 million test strips were dispensed in Ontario; however, more focused policy scenarios could have reduced this number by between 9.5 million and 74.5 million test strips. Interpretation: Many people who self-monitor their blood glucose are at relatively low risk for drug-induced hypoglycemia. The economic benefits associated with more selective testing could be redirected to more effective interventions for patients with diabetes.

The aim of this study was to examine the association between educational attainment and utilization of the health care system and self-care behavior by individuals with diabetes. The Barriers to Diabetes Care Survey asked indi- viduals with diabetes about their care. The questionnaire was completed using computer-assisted telephone interviewing techniques. Participants were found by random digit dialing across Ontario, Canada (eligible n = 1,031). We dichotomized educational attainment at high school. We examined the relationship of educational attainment with measures of health care system utilization and of self-care behavior. We adjusted for age, sex, income, health insurance status, and diabetes type, duration and treatment regimen. Individuals with high educational attainment were more likely to have had an oph- thalmologic examination during the previous year (odds ratio 1.37, 95% confidence interval 1.04-1.82), and were more likely to report having a specialist (OR 2.08, 95% CI 1.31-3.31) or other paramedical professional (OR 1.91, 95% CI 1.19-3.07) as their most responsible provider of care, rather than a family doctor. Smoking (OR 0.64, 95% CI 0.45-0.90) and blood sugar monitoring (OR 0.70, 95% CI 0.50-0.98) were associated with low educational attainment, while follow- ing a meal plan was associated with high educational attainment (OR 1.39, 95% CI 1.07-1.80). Since appropriate utiliza- tion of the health care system and self-care behavior are essential for diabetes management, our findings suggest that peo- ple with low educational attainment are independently at risk for worse diabetes care. Health care providers should ensure that their communications, teaching materials and instructions are suitable for these higher-risk patients.

Diabetes mellitus is a chronic condition that requires complex management; however, the time of health care providers is limited and patient motivation varies. How can health care providers design realistic treatment plans and establish priorities that maximize health benefits for patients? The 2008

Background Diabetes is a common chronic disease, which results in significant morbidity and mortality. Although ethnic variations in disease prevalence are known, variations in the utilization of physician services for the disease (particularly in publicly funded health care systems) are uncertain. Methods Self-reported ethnicity was determined from two population health surveys in Ontario, Canada. These data were linked to administrative data sources, including an administrative data-derived disease registry. Diabetes prevalence was determined for each ethnic group. Utilization of physician services for primary care, diabetes specialist care and eye examinations was compared among ethnic groups, adjusting for age, sex, socioeconomic status and diabetes duration. Results There were 20 788 eligible survey respondents. Standardized diabetes prevalence was elevated for the South Asian and Black populations (11.1 and 11.0%, respectively) compared with that for the White population (5.9%). Ethnic minorities with diabetes were less likely to receive an eye examination compared with White patients (adjusted OR, 0.63; 95% CI, 0.46‐0.85). The use of primary care and diabetes specialist care did not differ. Conclusion Ethnic minorities with diabetes are less likely to receive eye examinations. This disparity in quality of care could lead to worse clinical

The quality of diabetes care delivered to patients falls below the expectations of practice guidelines and clinical trial evidence. Studies in many jurisdictions with varying health care systems have shown that recommended processes of care occur less often than they should; hence, outcomes of care are inadequate. Many studies comparing care between specialists and generalists have found that specialists are more likely to implement processes of care. However, this provides little insight into improving quality of care, as the difference between specialists and generalists in these studies is small compared to the overall deficiency in quality. Therefore, future research should instead focus on ways to implement high quality care, regardless of specialty. To date, few methodologically rigorous studies have uncovered interventions that can improve quality of care. The development of such interventions to help all physicians implement better quality care could greatly benefit people with diabetes.

Introduction: Despite growing interest in the built environment and its impact on cardiovascular health, little is known about whether moving to a neighborhood more conducive to walking influences one’s risk of hypertension, a key risk factor of cardiovascular diseases. Objective: To conduct the first cohort study examining the association between moving to a highly walkable neighborhood and the risk of incident hypertension among a population-based sample of adults in Ontario, Canada. Methods: From the Canadian Community Health Survey (2001-2010), we identified a propensity-score matched cohort of 1057 pairs of Canadian adults who moved from a low (Walk Score Results: We observed a 42% lower risk of incident hypertension among those who moved from a low to high walkability neighborhood vs. those who moved from a low to another low walkability neighborhood (p=0.03) (Figure below). The incidence rate of hypertension was 8.6 per 1,000 person-years among the low to high walkability movers compared to 14.9 per 1,000 person-years among the low to low walkability movers. There were no significant differences in the control event rates between the two mover groups. Conclusions: Moving to a highly walkable neighborhood was associated with a significant protective effect on hypertension incidence, suggesting that the built environment can positively influence cardiovascular health.

How do we improve the lives of people with diabetes? Developing new interventions (such as new medications) to manage their glucose control and other risk factors is clearly important. However, we must also strive to deliver existing treatments more effectively, more efficiently and more equitably. Innovative ways of delivering diabetes care could have a profound impact on quality of care and health outcomes for people with diabetes. In fact, improving the delivery of care may lead to greater health impacts than incremental advances in the efficacy of therapy (1). This issue of Canadian Journal of Diabetes focuses on innovative models of care. The majority of diabetes care is delivered in primary care settings; indeed, a recent themed issue of the journal focused on the delivery of primary diabetes care (2). In this issue, Gucciardi et al. (3) explore the integration of specialized diabetes care teams in primary care settings. Through in-depth qualitative interviews with patients, diabetes educators and primary care physicians, they found that situating diabetes education teams within primary care practices was perceived as useful, but clear communication channels and a delineation of provider roles was necessary to facilitate implementation. With the growing prevalence of diabetes, the ability to integrate specialized healthcare providers focused on diabetes within primary care practices could become a useful model to improve quality of and access to care. Incorporating new technologies into clinical care can lead to improved communication, more and better data for decision making and greater patient engagement in self-management. Although e-mail is an integral part of many people’s day-to-day communications, its adoption in the healthcare sector in Canada has been slow, despite the many ways in which it could facilitate patientprovider communication. Popeski et al. (4) found that allied health professionals communicate with diabetes patients via e-mail regularly, but few physicians used it and most were uncertain about its potential to improve clinical care. The authors suggest that policies for the use of e-communications, including appropriate safeguards for privacy and security, could lead to improved efficiency and better access to diabetes care. Care transitions between healthcare sectors or between prac

Evidence from large, population-based studies about the association between neighbourhood walkability and the prevalence of obesity is limited.The study population consisted of 106,337 people aged 20 or older living in urban and suburban Ontario, who participated in the National Population Health Survey and the Canadian Community Health Survey from 1996/1997 to 2008. Based on their postal code, individuals were grouped into one of five walkability categories, ranging from very car-dependent to "Walker's Paradise," according to the Street Smart Walk Score®, a composite measure of neighbourhood walkability. Logistic regression models, adjusted for demographic, socioeconomic and lifestyle characteristics, were used to estimate odds ratios relating neighbourhood walkability to overweight/obesity and physical activity.Compared with residents of "Walker's Paradise" areas, those in very car-dependent areas had significantly higher odds of being overweight or obese. Despite similar levels of leisure physical activity among residents of all walkability areas, those in "Walker's Paradise" areas reported more utilitarian walking and weighed, on average, 3.0 kg less than did those in very car-dependent areas.Living in a low-walkability area is associated with a higher prevalence of overweight/obesity. Neighbourhood walkability is related to the frequency of utilitarian walking.

It has recently emerged that carrying a male fetus is associated with poorer maternal β-cell function in pregnancy and an increased risk of gestational diabetes mellitus (GDM). β-cell dysfunction is the central pathophysiologic defect underlying both GDM and subsequent postpartum progression to type 2 diabetes mellitus (T2DM).This was a retrospective cohort study that aimed to determine whether fetal sex influences the natural history of maternal risk of diabetes after delivery and in a subsequent pregnancy.The study was conducted using population-based administrative databases in Ontario, Canada.All women with a singleton live-birth first pregnancy between April 2000 and March 2010 (n = 642 987) were included.Fetal sex was the exposure of interest (313 280 delivered a girl; 329 707 delivered a boy).Development of T2DM or a second pregnancy were the main outcome measures. Glucose tolerance in each pregnancy was classified as either GDM or non-GDM.The population was followed for a median of 3.8 years. Carrying a boy yielded a higher risk of GDM in both the first pregnancy (odds ratio [OR] =1.03; 95% confidence interval [CI], 1.0002-1.054) and second pregnancy (OR =1.04, 95% CI, 1.01-1.08). For women with GDM in the first pregnancy, the likelihood of developing T2DM before a second pregnancy was higher if they delivered a girl (OR = 1.07; 95% CI, 1.01-1.12). Recurrence of GDM was not affected by fetal sex (P = .7). However, among women with a non-GDM first pregnancy while carrying a girl, having a boy in their second pregnancy predicted an increased risk of GDM (OR = 1.07, 95% CI, 1.01-1.14).Fetal sex is a previously unrecognized factor that is associated with maternal diabetic risk both after delivery and in a subsequent pregnancy.

Aims To evaluate the relationship between gestational diabetes (GDM) and incidence of cancer in women within the first decade postpartum. Methods This population-based retrospective cohort study compared the risk of cancer in women with GDM with that of a matched control group comprising pregnant women without diabetes. We included women from Ontario, Canada aged 20–50 years with no history of cancer who had given birth between 1995 and 2008 (N = 149 049). Women with GDM (N = 49 684) were matched on age and year of giving birth, in a ratio of 1:2, to pregnant women without diabetes (N = 99 365). Results Over a median 8-year follow-up, there were a total of 2927 (1.5%) cancers. After adjustment for covariates, we found no significant difference in overall risk of cancer between women with GDM and matched control subjects; however, GDM was associated with a significantly greater risk of thyroid cancer (adjusted hazard ratio 1.24, 95% CI 1.05, 1.46) and a significantly lower risk of premenopausal breast cancer (hazard ratio 0.86, 95% CI 0.75, 0.98) compared with matched control subjects. Conclusions This large population-based study did not find a greater risk of cancers among women with GDM during the first decade postpartum; however, GDM was associated with a higher risk of thyroid cancer and a lower risk of premenopausal breast cancer. Further studies are needed to confirm these findings.

Breast cancer stage at diagnosis is an important predictor of survival. Our goal was to compare breast cancer stage at diagnosis (by American Joint Committee on Cancer criteria) in Chinese and South Asian women with stage at diagnosis in the remaining general population in Ontario. We used the Ontario population-based cancer registry to identify all women diagnosed with breast cancer during 2005&ndash, 2010, and we applied a validated surname algorithm to identify South Asian and Chinese women. We used logistic regression to compare, for Chinese or South Asian women and for the remaining general population, the frequency of diagnoses at stage ii compared with stage i and stages ii&ndash, iv compared with stage i. The registry search identified 1304 Chinese women, 705 South Asian women, and 39,287 women in the remaining general population. The Chinese and South Asian populations were younger than the remaining population (mean: 54, 57, and 61 years respectively). Adjusted for age, South Asian women were more often diagnosed with breast cancer at stage ii than at stage i [odds ratio (or): 1.28, 95% confidence interval (ci): 1.08 to 1.51] or at stages ii&ndash, iv than at stage i (or: 1.27, 95% ci: 1.08 to 1.48), Chinese women were less likely to be diagnosed at stage ii than at stage i (or: 0.82, 95% ci: 0.72 to 0.92) or at stages ii&ndash, iv than at stage i (or: 0.73, 95% ci: 0.65 to 0.82). Breast cancers were diagnosed at a later stage in South Asian women and at an earlier stage in Chinese women than in the remaining population. A more detailed analysis of ethnocultural factors influencing breast screening uptake, retention, and care-seeking behavior might be needed to help inform and evaluate tailored health promotion activities.

The efficacy of diabetes self-management education on glycaemic control, self-care behaviour and knowledge has been established by short-term studies in experimental settings. The objective of this study was to assess its effectiveness to improve quality of care and reduce the risk of long-term diabetes complications in unselected older patients with recently diagnosed diabetes in routine clinical care.Using population-level health care administrative databases and registries, all patients aged ≥66 years in Ontario, Canada with diabetes for5 years were identified. Self-management education programme attendees (n = 8485) in 2006 were matched with non-attendees using high-dimensional propensity scores, creating extremely well-balanced study arms. Quality of care measures and the long-term risk of diabetes complications were compared.Self-management programme attendees were more likely than non-attendees to achieve process measures of quality of care such as retinal screening examinations (75.3% versus 70.3%, adjusted relative risk 1.05, 99% confidence interval 1.03-1.08), and ≥2 glycated haemoglobin tests (57.5% versus 53.3%, adjusted relative risk 1.08, 99% confidence interval 1.05-1.11). However, with a median follow-up of 5.3 years, diabetes complications and mortality were not different between arms.In real-world clinical care, self-management education for older patients with recently diagnosed diabetes was associated with modest improvements in quality of care, but no reductions in long-term clinical events.

Aims Although heart disease and stroke are the underlying causes of death in most people with diabetes, vascular risk modification targets are frequently not met. This study examined whether vascular risk-modifying medication utilization for diabetic patients differed among physician specialties. Methods A population-based study using administrative data from 105 715 people aged ≥ 65 years with newly diagnosed diabetes in Ontario between 1994 and 2001. The receipt of antihypertensive and lipid-lowering drugs was compared between patients who had regular care from endocrinologists, internists/geriatricians and family physicians. Hierarchical logistic regression adjusted for patient-level differences, physician-level differences and patient clustering within physicians. Results Only two-thirds of patients received antihypertensive drugs and about one-quarter received lipid-lowering drugs. Compared with patients of family physicians, the adjusted odds ratios for antihypertensive drug use were 1.27 [95% confidence interval (CI) 1.16, 1.38] for patients of internists/geriatricians and 1.03 (95% CI 0.94, 1.12) for patients of endocrinologists. For lipid-lowering drugs, the odds ratios were 1.20 (95% CI 1.11, 1.30) for patients of internists/geriatricians and 1.58 (95% CI 1.42, 1.76) for patients of endocrinologists. Conclusions Despite recommendations to use vascular risk-modifying medication for most older people with diabetes, many patients were not receiving these medications. Medication utilization differed between physician specialties, with family physicians having the lowest rates of use. Notably, although blood pressure control has the greatest evidence of benefit and is cost-saving, endocrinologists did not use antihypertensive drugs more often than family physicians after adjustment for other differences.

Gatifloxacin has been associated with both hypoglycemia and hyperglycemia. We examined dysglycemia-related health outcomes associated with various antibiotics in a population of approximately 1.4 million Ontario, Canada, residents 66 years of age or older.We conducted two population-based, nested case-control studies. In the first, case patients were persons treated in the hospital for hypoglycemia after outpatient treatment with a macrolide, a second-generation cephalosporin, or a respiratory fluoroquinolone (gatifloxacin, levofloxacin, moxifloxacin, or ciprofloxacin). In the second, case patients were persons who received hospital care for hyperglycemia. For each case patient, we identified up to five controls matched according to age, sex, the presence or absence of diabetes, and the timing of antibiotic therapy.Between April 2002 and March 2004, we identified 788 patients treated for hypoglycemia within 30 days after antibiotic therapy. As compared with macrolide antibiotics, gatifloxacin was associated with an increased risk of hypoglycemia (adjusted odds ratio, 4.3; 95 percent confidence interval, 2.9 to 6.3). Levofloxacin was also associated with a slightly increased risk (adjusted odds ratio, 1.5; 95 percent confidence interval, 1.2 to 2.0), but no such risk was seen with moxifloxacin, ciprofloxacin, or cephalosporins. We then identified 470 patients treated for hyperglycemia within 30 days after antibiotic therapy. As compared with macrolides, gatifloxacin was associated with a considerably increased risk of hyperglycemia (adjusted odds ratio, 16.7; 95 percent confidence interval, 10.4 to 26.8), but no risk was noted with the other antibiotics. Risks were similar in the two studies regardless of the presence or absence of diabetes.As compared with the use of other broad-spectrum oral antibiotics, including other fluoroquinolones, the use of gatifloxacin among outpatients is associated with an increased risk of in-hospital treatment for both hypoglycemia and hyperglycemia.

Objective For various reasons, people of Chinese (China, Hong Kong or Taiwan) and South Asian (Indian subcontinent) ancestry (the two largest ethnic minority groups in Ontario, Canada) may be less likely to register for deceased organ donation than the general public, and their families may be less likely to consent for deceased organ donation at the time of death. Methods We conducted two population-based studies: (1) a cross-sectional study of deceased organ donor registration as of May 2013, and (2) a cohort study of the steps in proceeding with deceased organ donation for patients who died in hospital from October 2008 to December 2012. Results A total of 49 938 of 559 714 Chinese individuals (8.9%) and 47 774 of 374 291 South Asians (12.8%) were registered for deceased organ donation, proportions lower than the general public (2 676 260 of 10 548 249 (25.4%). Among the 168 703 Ontarians who died in a hospital, the families of 33 of 81 Chinese (40.1%; 95% CI: 30.7%-51.6%) and 39 of 72 South Asian individuals (54.2%; 95% CI: 42.7-65.2%) consented for deceased organ donation, proportions lower than the general public (68.3%; 95% CI: 66.4%-70.0%). Conclusions In Ontario, Canada Chinese and South Asian individuals are less likely to register and their families are less likely to consent to deceased organ donation compared to the remaining general public. There is an opportunity to build support for organ and tissue donation in these two large ethnic communities in Canada.

Objective To compare glycaemic control, as reflected in the A1c level, of diabetic patients with primary care vs. with specialist care. Methods The study used administrative data from eastern Ontario, Canada, and a database containing the results of all A1c tests from this region between 1 September 1999 and 1 September 2000. To avoid referral bias, diabetic patients with an index specialist visit were selected and separated into those with exclusively primary care previously (n = 974) and those with prior specialist care (n = 3533). We compared A1c levels measured within 30 days of the index visit and hence attributable to the prior care. To control for confounding between the groups, both multiple linear regression and propensity score-based matching were used. Results After controlling for confounders, patients with prior specialist care had significantly lower A1c levels (P

OBJECTIVE—Diabetic patients with inadequate glycemic control ought to have their management intensified. Failure to do so can be termed “clinical inertia.” Because data suggest that specialist care results in better control than primary care, we evaluated whether specialists demonstrated less clinical inertia than primary care physicians. RESEARCH DESIGN AND METHODS—Using administrative data, we studied all non-insulin-requiring diabetic patients in eastern Ontario aged 65 or older who had A1c results >8% between September 1999 and August 2000. Drug intensification was measured by comparing glucose-lowering drug regimens in 4-month blocks before and after the elevated A1c test and was defined as 1) the addition of a new oral drug, 2) a dose increase of an existing oral drug, or 3) the initiation of insulin. Propensity score-based matching was used to control for confounding between groups. RESULTS—There were 591 patients with specialist care and 1,911 with exclusively primary care. In the matched cohorts, 45.1% of patients with specialist care versus 37.4% with primary care had drug intensification (P = 0.009). Most of this difference was attributed to specialists’ more frequent initiation of insulin in response to elevated A1c. CONCLUSIONS—Fewer than one-half of patients with high A1c levels had intensification of their medications, regardless of specialty of their physician. Specialists were more aggressive with insulin initiation than primary care physicians, which may contribute to the lower A1c levels seen with specialist care. Interventions assisting patients and physicians to recognize and overcome clinical inertia should improve diabetes care in the population.

OBJECTIVE To examine trends in diabetes incidence among Ontario residents with Chinese and European origins. RESEARCH DESIGN AND METHODS Respondents to population-based health surveys in 1996, 2001, 2003, and 2005 who were aged ≥30 years, who did not have diabetes, and who self-identified as having European (n = 76,285) or Chinese (n = 1,041) origins were followed for diabetes incidence through a validated administrative data–derived diabetes registry. RESULTS Age- and sex-standardized diabetes incidence increased from 1.3 to 19.6 per 1,000 person-years in the Chinese population and from 7.8 to 10.0 in the European population. Relative to the 1996 European population, the adjusted hazard ratio for diabetes was 4.50 (95% CI 1.89–7.49) for the 2005 Chinese population and 1.22 (1.05–1.39) for the 2005 European population. CONCLUSIONS Diabetes incidence increased much more rapidly between 1996 and 2005 in the Chinese population than in the European population, independent of age, obesity, and other risk factors.

Pancreatic β-cell dysfunction is the central pathophysiological defect underlying both gestational diabetes mellitus (GDM) and the subsequent postpartum progression to type 2 diabetes mellitus (T2DM) (1). It has recently emerged that, in singleton pregnancies, carrying a boy is associated with poorer maternal β-cell function and hence an increased risk of GDM (1,2). Moreover, women who develop GDM while carrying a girl have a higher risk of postpartum progression to T2DM than those who develop GDM with a boy (3,4), possibly reflecting comparatively poorer β-cell function in the former (as they developed GDM in the absence of the adverse impact of the male fetus). It thus emerges that the sex of the fetus is associated with maternal risk of diabetes during and after a singleton pregnancy. In this context, we sought to evaluate the impact of twin gestation and the sex of both fetuses on maternal risk of diabetes during and after pregnancy. Using population-based administrative databases, we identified …

OBJECTIVE To examine whether quality of diabetes care is equitable for South Asian and Chinese patients in an urban Canadian setting. RESEARCH DESIGN AND METHODS Process and intermediate measures of quality of care were compared between 246 South Asians, 170 Chinese, and 431 patients from the general population with type 2 diabetes selected from 45 family physicians’ practices. RESULTS A total of 61% of Chinese achieved A1C ≤7.0% versus 45% of South Asians and 49% of the general population (P < 0.05). They were also more likely to achieve LDL cholesterol ≤2.0 mmol/L, while South Asians were more likely to achieve blood pressure ≤130/80. There was only one significant process of care deficiency: fewer foot examinations among South Asians (34 vs. 49% for the general population, P < 0.01). CONCLUSIONS Quality of diabetes care in a Canadian urban setting was equitable, with ethnic minorities somewhat more likely to achieve recommended targets than the general population.

NP, RHG and ADP were supported as Clinician Scientists by the Department of Family and Community Medicine at the University of Toronto and at St Michael's Hospital. NP is supported by a fellowship from Physicians Services Incorporated Foundation. KT was supported as a Clinician Scientist by the Department of Family and Community Medicine at the University of Toronto and at Toronto Western Hospital. ML received salary support through a Canada Research Chair and a Michael Smith Foundation for Health Research Scholar Award. Introduction : Cost-related non-adherence to medicines is common in low-income, middle-income and high-income countries such as Canada. Medicine non-adherence is associated with poor health outcomes and increased mortality. This randomised trial will test the impact of a carefully selected list of essential medicines at no charge (compared with usual medicine access) in primary care patients reporting cost-related non-adherence. Methods and analysis : This is an open-label, parallel two-arm, superiority, individually randomised controlled trial conducted in three primary care sites (one urban, two rural) in Ontario, Canada, that was codesigned by a community guidance panel. Adult patients (≥18 years) who report cost-related non-adherence to medicines are eligible to participate in the study. Participants will be randomised to receive free and convenient access to a carefully selected list of 125 essential medicines (based on the WHO's Model List of Essential Medicines) or usual means of medicine access. Care for patients in both groups will otherwise be unchanged. The primary outcome of this trial is adherence to appropriately prescribed medicines. Secondary outcomes include medicine adherence, appropriate prescribing, blood pressure, haemoglobin A1c, low-density lipoprotein cholesterol, patient-oriented outcomes and healthcare costs. All participants will be followed for at least 12 months. Ethics and dissemination : Ethics approval was obtained in all three participating sites. Results of the main trial and secondary outcomes will be submitted for publication in a peer-reviewed journal and discussed with members of the public and decision makers. Trial registration number : NCT02744963. Publisher PDF

BACKGROUND: The South Asian and Chinese populations represent a significant portion of the population of Ontario; however, little is known about the burden of respiratory diseases in these populations.OBJECTIVE: To investigate the prevalence of asthma and the associated health care burden among South Asian and Chinese populations living in Ontario.METHODS: Using administrative health data for Ontario, the authors identified individuals of South Asian and Chinese descent using a validated surname algorithm and compared the prevalence of asthma in these groups with the general population using an established asthma case definition for the period 2002 to 2010. Also compared were the rates of asthma-specific emergency department visits and hospitalizations among the ethnic groups.RESULTS: In 2010, the prevalence of asthma in South Asians residing in Ontario was similar to that of the general population (12.1% versus 12.4%), and was increasing at a faster rate than in the general population (0.51%/year versus 0.34%/year). Compared with the general population, the South Asian population had fewer emergency department visits for asthma, whereas the asthma-related hospitalization rate was greatest among the South Asian population (0.45 per 100 person-years). The Chinese population had the lowest asthma prevalence and associated health care use.CONCLUSION: The burden of asthma among South Asians in Ontario is increasing and warrants further investigation to determine the reasons for this rise.

Aims To determine whether sharing the same ethnicity as their family physician influenced the quality of diabetes care for Chinese and South Asian patients in Ontario, Canada. Methods We conducted two related studies: a population-based cohort study of Chinese and South Asian patients with incident diabetes using health care administrative data ( n =49,484), and a cross-sectional study of Chinese and South Asian patients with established diabetes using data collected directly from their family physicians' clinical records ( n =416). In both studies, quality of care measures were compared between patients whose family physicians were or were not from the same ethnic group. Results In the cohort study, Chinese patients whose family physicians were also Chinese were more likely to have a diabetes-related family physician visit and appropriate HbA1c and cholesterol testing. In the cross-sectional study, they were more likely to have foot examinations, to have microalbuminuria testing, and to achieve recommended treatment targets for HbA1c and for LDL-cholesterol. In contrast, for South Asian patients, most quality measures in either study did not differ by physician ethnicity. Conclusions Having a family physician from the same ethnic group was associated with better quality of diabetes care for Chinese but not for South Asian patients.

OBJECTIVE: Self-management education, supported by multidisciplinary health care teams, is essential for optimal diabetes management. We sought to determine whether acute diabetes complications or quality of care differed for patients in routine clinical care when their self-management education was delivered through group diabetes education classes versus individual counselling. METHODS: With the use of population-level administrative and primary data, all diabetic patients in Ontario who attended a self-management education program in 2006 were identified and grouped according to whether they attended group classes (n=12,234), individual counselling (n=55,761) or a mixture of both (n=9,829). Acute complications and quality of care in the following year were compared among groups. RESULTS: Compared with those attending individual counselling, patients who attended group classes were less likely to have emergency department visits for hypo/hyperglycemia (odds ratio 0.54, 95% confidence interval [CI]: 0.42–0.68), hypo/hyperglycemia hospitalizations (OR 0.49, CI: 0.32–0.75) or foot ulcers/cellulitis (OR 0.64, CI: 0.50–0.81). They were more likely to have adequate HbA1c testing (OR 1.10, CI: 1.05–1.15) and lipid testing (OR 1.25, CI: 1.19–1.32), and were more likely to receive statins (OR 1.22, CI: 1.07–1.39). CONCLUSION: Group self-management education was associated with fewer acute complications and some improvements in processes of care. Group sessions can offer care to more patients with reduced human resource requirements. With increased pressure to find efficiencies in health care delivery, group diabetes education may provide an opportunity to deliver less resource-intensive care that simultaneously improves patient care.

We wish to thank Tillin et al. (1) for their comments on our study (2). We agree that the absence of information on smoking status from population-level health care administrative data limits our ability to adjust for this important cardiovascular risk factor, and that this and other unmeasured risk factors could confound the relationships we found between ethnicity and cardiovascular complications or mortality. However, as noted in the article, we conducted …

Most published data on ethnic variations in diabetes care and outcomes come from the United States, and their generalizability to inform clinical care and policy making in Canada is limited. As a result, the Institute for Clinical Evaluative Sciences (ICES) has conducted several studies examining the burden of diabetes for and the quality of care received by visible minority populations in Ontario compared with the general population.

A relationship between higher patient volume and both better quality of care and better outcomes has been shown for many acute care conditions. Whether a volume-quality relationship exists for the outpatient management of chronic diseases is uncertain.To explore the association between primary care physician volume and quality of diabetes care.Cohort study.The study was conducted using linked population-based health care administrative data in Ontario, Canada.1 018 647 adults with diabetes in 2011 who received care from 9014 primary care physicians. Two measures of volume were ascertained for each physician: overall ambulatory volume (representing time available to devote to chronic disease management during patient encounters) and diabetes-specific volume (representing disease-specific expertise).Quality of care was measured over a 2-year period using 6 indicators: disease monitoring (eye examination, hemoglobin A1c testing, and low-density lipoprotein cholesterol testing), prescribing appropriate medications (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and statins), and adverse clinical outcomes (emergency department visits for hypoglycemia or hyperglycemia).Higher overall ambulatory volume was associated with lower rates of appropriate disease monitoring and medication prescription. In contrast, higher diabetes-specific volume was associated with better quality of care across all 6 indicators.Only a select set of quality indicators and potential confounders could be ascertained from available data.Primary care physicians with busier ambulatory patient practices delivered lower-quality diabetes care, but those with greater diabetes-specific experience delivered higher-quality care. These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care. Health policies or programs to support physicians with a low volume of patients with diabetes may improve care.Canadian Institutes of Health Research.

Background Canadians of Chinese descent, represent one of the fastest growing visible minority groups in Canada, (as well as the second largest), but relatively little is known about the clinical features of heart failure (HF) in Chinese-Canadian versus non-Chinese Canadian patients. Methods We conducted a population-based analysis of urban patients hospitalized in Ontario, Canada for the first time with a most responsible diagnosis of HF between April 1, 1995 and March 31, 2008. Among the 99,278 patients, 1,339 (1.3%) were classified as Chinese using a previously validated list of Chinese surnames. Through linkage to other administrative databases, we compared the clinical characteristics, pharmacological management, and outcomes of Chinese versus non-Chinese HF patients. Results Ischemic heart disease was identified as the possible etiology of HF in a greater proportion of non-Chinese patients (47.7% vs. 35.3%; p Conclusion There are important differences in the causes and medical management of HF in Chinese and non-Chinese patients residing in Canada. Despite these differences, the long-term outcomes of HF patients were similar.

Background Audit and feedback to physicians is a commonly used quality improvement strategy, but its optimal design is unknown. This trial tested the effects of a theory-informed worksheet to facilitate goal setting and action planning, appended to feedback reports on chronic disease management, compared to feedback reports provided without these worksheets. Methods A two-arm pragmatic cluster randomized trial was conducted, with allocation at the level of primary care clinics. Participants were family physicians who contributed data from their electronic medical records. The ‘usual feedback’ arm received feedback every six months for two years regarding the proportion of their patients meeting quality targets for diabetes and/or ischemic heart disease. The intervention arm received these same reports plus a worksheet designed to facilitate goal setting and action plan development in response to the feedback reports. Blood pressure (BP) and low-density lipoprotein cholesterol (LDL) values were compared after two years as the primary outcomes. Process outcomes measured the proportion of guideline-recommended actions (e.g., testing and prescribing) conducted within the appropriate timeframe. Intention-to-treat analysis was performed. Results Outcomes were similar across groups at baseline. Final analysis included 20 physicians from seven clinics and 1,832 patients in the intervention arm (15% loss to follow up) and 29 physicians from seven clinics and 2,223 patients in the usual feedback arm (10% loss to follow up). Ten of 20 physicians completed the worksheet at least once during the study. Mean BP was 128/72 in the feedback plus worksheet arm and 128/73 in the feedback alone arm, while LDL was 2.1 and 2.0, respectively. Thus, no significant differences were observed across groups in the primary outcomes, but mean haemoglobin A1c was lower in the feedback plus worksheet arm (7.2% versus 7.4%, p

Background Care of patients with diabetes often occurs in the context of other chronic illness. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient. Guideline implementation interventions to date do not acknowledge these intricacies of clinical practice. As a result, patients and providers are left overwhelmed and paralyzed by the sheer volume of recommendations and tasks. An individualized approach to the patient with diabetes and multiple comorbid conditions using shared decision-making (SDM) and goal setting has been advocated as a patient-centred approach that may facilitate prioritization of treatment options. Furthermore, incorporating interprofessional integration into practice may overcome barriers to implementation. However, these strategies have not been taken up extensively in clinical practice. Objectives To systematically develop and test an interprofessional SDM and goal-setting toolkit for patients with diabetes and other chronic diseases, following the Knowledge to Action framework. Methods 1. Feasibility study: Individual interviews with primary care physicians, nurses, dietitians, pharmacists, and patients with diabetes will be conducted, exploring their experiences with shared decision-making and priority-setting, including facilitators and barriers, the relevance of a decision aid and toolkit for priority-setting, and how best to integrate it into practice. 2. Toolkit development: Based on this data, an evidence-based multi-component SDM toolkit will be developed. The toolkit will be reviewed by content experts (primary care, endocrinology, geriatricians, nurses, dietitians, pharmacists, patients) for accuracy and comprehensiveness. 3. Heuristic evaluation: A human factors engineer will review the toolkit and identify, list and categorize usability issues by severity. 4. Usability testing: This will be done using cognitive task analysis. 5. Iterative refinement: Throughout the development process, the toolkit will be refined through several iterative cycles of feedback and redesign. Discussion Interprofessional shared decision-making regarding priority-setting with the use of a decision aid toolkit may help prioritize care of individuals with multiple comorbid conditions. Adhering to principles of user-centered design, we will develop and refine a toolkit to assess the feasibility of this approach.

To determine whether demographic, community or health status disparities in cardioprotective medication utilization by diabetes patients exist under a universal drug insurance programme, and whether they narrow or widen during periods of increasing drug utilization.We examined all prescriptions filled by all people with diabetes aged ≥65 years in Ontario, Canada in annual cohorts from 1996 (n = 175 345) to 2010 (n = 504 093). We ascertained whether any disparities in use of three classes of cardioprotective medication (statins, all antihypertensives and renin-angiotensin-aldosterone system inhibitors) existed, and whether disparities changed over time.Utilization of all three cardioprotective medication classes increased substantially over time, particularly statins (rate ratio per year: 1.13, 95% confidence interval 1.11-1.15). We found no disparities associated with many of the demographic or community characteristics examined (including sex, income or rural residence). Use of statins was lower in those aged ≥80 compared with younger age groups, although this disparity narrowed during the study. Persistently lower use of antihypertensives by minorities and by recent immigrants may be due to lower quality of care, barriers to access, or other patient or provider factors, which highlights the need for ongoing monitoring for disparities even in populations with universal drug insurance. Differences in medication utilization based on health status characteristics such as previous cardiovascular disease were medically indicated.Although a universal drug insurance programme was reasonably successful in ensuring few disparities in cardioprotective medication use by older patients with diabetes, disparities persisted for some subpopulations, so additional interventions continue to be needed to ensure equitable care.

Aims To assess the combined impact of socio-economic status and gender on the risk of diabetes-related lower extremity amputation within a universal healthcare system. Methods We conducted a population-based cohort study using administrative health databases from Ontario, Canada. Adults with pre-existing or newly diagnosed diabetes (N = 606 494) were included and the incidence of lower extremity amputation was assessed for the period 1 April 2002 to 31 March 2009. Socio-economic status was based on neighbourhood-level income groups, assigned to individuals using the Canadian Census and their postal code of residence. Results Low socio-economic status was associated with a significantly higher incidence of lower extremity amputation (27.0 vs 19.3 per 10,000 person-years in the lowest (Q1) vs the highest (Q5) socio-economic status quintile. This relationship persisted after adjusting for primary care use, region of residence and comorbidity, and was greater among men (adjusted Q1:Q5 hazard ratio 1.41, 95% CI 1.30–1.54; P