Diabetes care in Canada: Results from selected provinces and territory, 2005

by Claudia Sanmartin and Jason Gilmore

Diabetes in Canada
Data source
Diabetes care
Role of a regular doctor
Limitations
Conclusion
Analytical methods

Diabetes is a serious chronic disease that affects the body´s ability to produce or properly use insulin and is the underlying cause of numerous health conditions.¹ It can lead to various life threatening and disabling complications such as heart disease and stroke, high blood pressure, and premature death.² Diabetes is the single largest cause of blindness in Canada, and a leading cause of kidney failure and lower limb amputations.³ It is currently the seventh leading cause of death in Canada and accounts for 25,000 person years of life lost before age 75⁴.

Despite the increased risk of these complications , diabetes can be controlled. Appropriate care is critical for the management of diabetes and the prevention of serious complications. In 2003, the Canadian Diabetes Association published the Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada providing recommendations for appropriate diabetes care.⁵ These guidelines provide critical information regarding the type of care that should be provided to individuals with diabetes.

To determine how well the guidelines are being followed, more specific information is needed about the type of care diabetic individuals actually receive. While there is some information regarding the quality of care for diabetes in Canada ^{1, 2}, the evidence is based on small scale studies with selected samples that do not always fully represent the Canadian population with diabetes. Information is one of the key components of the Canadian Diabetes Strategy, initiated by the Government of Canada in 1999 to build on existing efforts to establish effective diabetes prevention and control strategies at the population level.⁶ While efforts such as the National Diabetes Surveillance System (NDSS) provide important information regarding the prevalence and incidence of diabetes at the national level, detailed information regarding care practices at the national level is currently limited.

The Diabetes Care Module of the Canadian Community Health Survey 3.1 (2005) was designed to fill this information gap. This set of questions, which was developed by Statistics Canada in collaboration with the Public Health Agency of Canada, collects in-depth information regarding the care practices of individuals with diabetes such as glucose testing, and foot and eye examinations at the population level. Respondents are asked both about care provided by a health care professional and care provided by themselves or a family member. Questions from the module were derived in part from the 2003 Behavioural Risk Factor Surveillance System (BRFSS) in the United States. This survey has been successfully used for reporting diabetes care indicators since 1984.⁷

Data source

Estimates in this article are based on data from the 2005 Canadian Community Health Survey (CCHS), conducted by Statistics Canada. The CCHS covers the population aged 12 or older living in private households. It does not include residents of Indian reserves, institutions, and some remote areas; full-time members of the Canadian Armed Forces; and civilian residents of military bases. The data were collected by personal and telephone interviews between January and December 2005.

All CCHS respondents were asked a series of questions regarding chronic conditions diagnosed by a health care professional and lasting for more than six months (Chronic Conditions Module). Individuals indicating that they had been diagnosed with diabetes were asked follow-up questions regarding the age of diagnosis and whether or not they were using insulin and were then asked the diabetes care module.

In 2005, the Diabetes Care module was optional content and was selected by all regions in Newfoundland and Labrador, Prince Edward Island , New Brunswick, Ontario, Manitoba and Yukon. Only respondents in health regions where the module was selected were administered the diabetes care questions. Data on individuals 18 years of age and older in these provinces were selected for analysis. (n=3,924)

Following the collection and processing of the data, the respondents´ records were weighted in order to reflect the sampling and non-response that occurred in the CCHS. Weights were also adjusted to demographic projections by age group and province.

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Diabetes in Canada

In 2005, 1.3 million Canadians, or 4.9% of the population aged 12 or older, reported having diabetes. (see Table 1). The rate varied across the country from 6.8% in Newfoundland and Labrador to 3.4% in Northwest Territories (data from Nunavut were not available due to high sampling variability). The rates in the eastern provinces, ranging from 6.0% to 6.8%, were significantly higher than the national average. The rates in Alberta (3.9%) and Northwest Territories were significantly lower than the national average.

In 2005, men were slightly more likely to report having been diagnosed with diabetes by a health professional compared with women (5.4% vs. 4.4%; see Table 2 ). Canadians under the age of 45 were much less likely to have been diagnosed by a health professional as having diabetes compared with those aged 45 and older. Overall, approximately one in five (19.9%) of individuals with diabetes in 2005 was reported using insulin.

The rates of cardiovascular disease and hypertension are higher among Canadians diagnosed with diabetes. Results from the CCHS 3.1 indicate that 19.8% of individuals with diabetes also have heart disease, compared with 4.0% among those without diabetes. Similarly, 60.3% of individuals with diabetes in Canada had also been diagnosed with high blood pressure, compared with 17.4% among those without diabetes.

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Diabetes care

The following analysis is based on data from the Diabetes Care module of CCHS Cycle 3.1 (2005). In 2005, the module was available as optional content to health regions across Canada and was selected by all health region in Newfoundland and Labrador, Prince Edward Island, New Brunswick, Ontario, Manitoba and Yukon.

Haemoglobin A1C testing

Management of glycemic levels is a critical part of diabetes care. Studies have shown that glycemic control, as measured by haemoglobin A1C, is associated with the reduced risk of developing long term complications. The current Canadian Diabetes Association Clinical Practice Guidelines (CPG) recommend that measurement of this indicator be undertaken approximately every 3 months to ensure that glycemic goals are being met or maintained.

In 2005, almost three-quarters (74%) of diabetic respondents reported having had their haemoglobin A1C checked at least once by a health care professional in the previous 12 months (Table 3). One in five (20%) indicated they had not had the test in the previous 12 months. Diabetic respondents who had been tested, were tested on average of 3.4 times during the 12 month period or about one every three and a half months. The participation rates were similar for males and females and across age groups (Table 3). Diabetics using insulin were more likely to have been tested (83%) than those not using insulin (74%).

Foot care

Individuals with diabetes often experience foot problems such as ulcers, lesions and infections. These conditions, if not appropriately cared for, may lead to more serious health issues such as gangrene and the need for amputation. In an effort to reduce the risk of serious complications, the CPG recommends annual foot examinations for all individuals with diabetes with more frequent exams for those at high risk, to reduce the likelihood of amputations and improve quality of life. The Guidelines also recommend that individuals at high risk receive proper foot care instruction to facilitate appropriate self-care.

In 2005, almost half (48%) of diabetics respondents indicated having had their feet checked by a health care professional at least once during the previous 12 months (Table 3). On average, individuals had had their feet checked 3.7 times over a 12 month period. The participation rates were similar for males and females, and across age groups and socio-economic status (Table 3). Individuals using insulin were more likely to have had their feet checked (68%) compared with those who were not using insulin (45%). After adjusting for other factors, diabetics respondents using insulin were 2.7 times more likely to have had their feet examined by a health professional in the previous year than those not using insulin. ¹

Respondents were also asked about foot care provided by themselves or a family member or friend. The majority of respondents (65%) indicated that they, or a family member or friend, had checked their feet for sores or irritations at least once in the previous 12 months – 37% checked daily and 17% checked weekly Table 4). On the other hand, almost one-third of respondents indicated that they never checked their feet.

Eye exams

Diabetic patients are at risk of developing retinopathy – a disease of the blood vessels of the eye. High blood sugar levels cause the blood vessels in the eye to weaken and leak tiny amounts of blood or fluid, causing swelling of the retina. Vision may become blurred and in some cases blindness may result. " The CPG recommends that all people with diabetes be screened and examined for retinopathy either at the time of diagnosis (for those with Type 2) or within 5 years of diagnosis after age 15 (for those with Type 1).¹⁴

Most of those responding to the Diabetes Care module (68%) indicated that they had had an eye test where their pupils were dilated at least once. Diabetics aged 18 to 44 were less likely to have had a dilation eye exam in the past 12 months compared with older diabetics (Table 3). As with other types of diabetes care, those using insulin were more likely to have had an eye exam (82%) compared with those not using insulin (66%). After adjusting for other factors, diabetics respondents using insulin were 2.7 times more likely to have received an eye dilation examination compared with those not using insulin.¹

Among all those who reported having had an exam, 14% reported having an exam within the last month, 58% between one month and one year ago; and 17% one to two years ago (Table 5).

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Role of a regular medical doctor

The CPGs recommend that people with diabetes be cared for by a multidisciplinary team. Primary care physicians play a critical role in the delivery of appropriate health care services for diabetic patients. In general, having a regular doctor or regular source of care is associated with improved access to primary care services including those required to manage chronic conditions such as diabetes.^{8, 9, 10, 11} Evidence suggests, for example, that family physicians who provide appropriate care for foot problems including addressing wounds and prescribing appropriate shoes, can reduce the rate of lower extremity amputations by half.¹²

Overall, 97% of diabetic respondents aged 18 and over in Newfoundland and Labrador, Prince Edward Island, New Brunswick, Ontario, Manitoba and Yukon had a regular medical doctor, compared with 86% of all Canadians aged 18 and over (data not shown). Results from the CCHS indicate that having a regular medical doctor matters for specific types of diabetes care. For example, diabetic patients with a regular medical doctor are approximately two times more likely to get their haemoglobin A1C checked compared with those who did not have a regular doctor at the time of the survey.¹

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Limitations

The Diabetes Care module is optional content and therefore, the results only represent diabetes care practices in the participating health regions. In the 2005 CCHS, the module was selected by all health regions in Newfoundland and Labrador , Prince Edward Island , New Brunswick , Ontario, Manitoba and Yukon. The ability to generalize these results to other non-participating provinces and territory is limited.

The information provided by respondents regarding their diabetic status and health care practices is based on self-reported data. The information has not been clinically validated

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Conclusions

The Canadian Community Health Survey collects national level information regarding diabetes in Canada. Overall, 4.9% of Canadians aged 12 or older reported had been diagnosed with diabetes. The rate of diabetes varies by geographic region, age and gender. The results indicate that the rate of diabetes is higher in the eastern provinces and among males and increases with age.

Information from the Diabetes Care module provides important insights regarding the care practices of diabetic patients in the participating provinces and territory – specifically the proportion of diabetic repondents meeting the CPG recommendations for appropriate diabetes care. Overall, the proportion of diabetic respondents meeting the CPG guidelines varies by type of care. The findings indicate that most diabetic patients (74%) have had their haemoglobin A1C checked by a health care professional at least once in the previous year and that, on average, those who have received the test are close to meeting the CPG recommended frequency of every 3 months. One in five diabetics in the participating provinces and territory did not receive a test in the previous year. The results also indicate that one of the key factors contributing to regular haemoglobin A1C testing is access to a regular medical doctor. This provides further evidence of the important role primary care physicians play in the delivery of diabetes care.

The results also indicate that the majority of diabetic respondents in the participating provinces and territory are meeting the CPG requirements for eye dilation examinations but only half are meeting the annual foot examination recommendations. The majority of respondents (68%) indicated that they had at least one dilated eye examination. However, approximately one in three indicated that they had never had such an eye examination. The Canadian rates are slightly higher than those reported in the U.S. in 2001 where only 66% indicated that they had had an eye examination.¹³ Only half of all diabetic respondents indicated that they were meeting the CPG requirements for annual foot examinations. The Canadian rates are lower than those reported in 2001 in the U.S., where approximately 60% of diabetics received annual foot examinations.

The results clearly indicate that diabetic individuals using insulin were more likely to receive diabetes care compared with those not using insulin. In some cases, insulin use may be a marker for a more progressed or advanced disease or may reflect poor glycemic control.

This report represents a first look at the health care practices for diabetics in five Canadian provinces and one territory. In the near future, many organisations with an interest in diabetes and diabetes care, including Statistics Canada, the Public Health Agency of Canada and the Canadian Institute for Health Information, will be collaborating on more in-depth analysis. This is required to better understand the health practices of  Canadians with diabetes and the factors that affect the receipt of appropriate diabetes care.

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Analytical methods

Weighted distributions and frequencies were produced. Partial or item non-responses accounted for less than 5% of the totals in most analyses; records with item non-responses were excluded from the calculations. The bootstrap technique was used to estimate the variance and confidence intervals to properly account for the complex survey design. This technique fully adjusts for the design effects of the survey. Confidence intervals were established at the level of p = 0.05.

Multivariate logistic regression models were used to analyze the relationship between having a regular medical doctor and receiving diabetes care from a health care professional. The models were run separately for the three types of care provided by a health care professional: haemoglobin A1C testing, feet examination and eye examination. The models were adjusted for demographic factors (age, sex), severity of disease (uses insulin or not) and socio-economic status (income and education). The bootstrap technique was used to determine the significance of the odds ratios (ORs) and to estimate 95% confidence intervals.

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