Search

BACKGROUND To date, most group-based type 2 diabetes (T2D) self-management education (DSME) programs have been delivered in-person. The rapid transition to virtual care at the outset of the COVID-19 pandemic presented opportunities to test, evaluate, and iterate a new virtual DSME program. OBJECTIVE To refine the delivery and evaluation of a multi-component virtual DSME program for adults living with T2D by examining several feasibility outcomes. METHODS Patients from a London, Canada outpatient diabetes clinic (serving high-risk, low-income adults) were recruited to participate in a six-week, single cohort feasibility study (ORBIT Phase 1b) from November 2020 to March 2021. A virtual DSME program including live video education classes, individualized physical activity (PA) prescription and counselling, as well as intermittently scanned continuous glucose and wearable PA monitoring was delivered. Several outcomes were assessed including recruitment and retention rates, program adherence, and acceptability (i.e., technology issues, exit survey feedback). PA was assessed with a FitBit Inspire 2 and estimated glycated hemoglobin (A1C) using the FreeStyle Libre. Given the small sample, data are reported descriptively and at the group and participant level. RESULTS Ten adults living with T2D were recruited (% female: 60, Age: 49.9±14.3 years, estimated A1C: 6.2±0.5%). Recruitment and retention rates were 29% and 80%, respectively. Participants attended 83% and 93% of education classes and PA counselling phone calls, respectively. There were 3.2±2.6 technology issues reported per person, mostly related to study data transfer. Exit survey responses suggest most participants (89%) were ‘satisfied’ with the program. Participants achieved 7103±2900 and 7515±3169 steps per day at baseline and Study Week 6, respectively. Estimated A1C was 6.2±0.5% and 6.2±0.6% at baseline and Study Week 6, respectively. CONCLUSIONS Though the virtual DSME program showed promise, several program and study protocol refinements are recommended before conducting a larger pilot trial (ORBIT Phase 2a). CLINICALTRIAL ClinicalTrials.gov NCT04498819

Objective Hypoglycemia can cause psychological distress in people with diabetes; however, less is understood about the emotional impact of hypoglycemia on their health care providers (HCPs). This article focuses on the experiences and emotions of HCPs caring for patients with diabetes. Methods This was a descriptive qualitative study from the InHypo-DM research program. Purposive sampling was used to recruit 20 HCPs from a variety of professions for 30- to 45-minute semi-structured interviews. An iterative analysis was conducted to identify the overarching themes. Results Three overarching themes encompassed the responses of participants when their patients experienced hypoglycemia. The first was a sense of professional responsibility, as participants felt they must have failed or inadequately fulfilled their professional duties. The second was a more personal range of emotions such as sadness and guilt. The final theme was how these emotions created a “call to action,” prompting participants to identify potential strategies to prevent future hypoglycemic events. Conclusion This qualitative study highlights the emotional impact of patients’ hypoglycemia on HCPs. Although it may have been expected that HCPs have a strong sense of professional responsibility, it was unexpected that these responses often became personal emotions. To ameliorate the negative impact of these responses on patient care, HCPs should engage in activities that enable them to anticipate and manage their own emotional responses. In addition, strategies to optimize hypoglycemia detection and prevention should be promoted.

BackgroundPatient-centred interventions to help patients with multimorbidity have had mixed results.AimTo assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work.Design and settingMixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada.MethodPatients aged 18–80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients’ experiences of the intervention.ResultsA total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, P = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes.ConclusionOverall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference’s recommendations.

Background Patients with multimorbidity often require services across different health care settings, yet team processes among settings are rarely implemented. We explored perceptions of specialists and family physicians collaborating in a telemedicine interprofessional consultation for patients with multimorbidity to better understand the value of bringing physicians together across the boundaries of health care settings. Methods This was a descriptive qualitative, interview-based study. Physicians who had previously participated in the Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (Telemedicine IMPACT Plus [TIP] Program) were invited to participate and asked to describe their experience of being a member of the program. Interviews were conducted from March to May 2016. We conducted an iterative and interpretive process using both individual and team analysis to identify themes. Results There were 15 participants, 9 specialists and 6 family physicians. Three themes emerged in the analysis: creating new perspectives on care for patients with multimorbidity by sharing knowledge, skills and attitudes; the shift from a consultant model to an interprofessional team model (allowing a window into the community, extending discussions beyond the medical model and focusing on the patient's health in context); and opportunities for learners, including learning about interprofessional collaboration and gaining exposure to a real-world model for caring for people with multimorbidity in outpatient settings. Interpretation Family physicians and specialists participating in a TIP Program believed the program improved their knowledge and skills, while also serving as an effective care delivery strategy. The findings also support that learners require more exposure to nontraditional consultant models in order to care for patients with multimorbidity effectively.

Hypoglycemia is one of the most common adverse events for people living with type 1 or type 2 diabetes. To gain a deeper understanding of patients’ emotions regarding hypoglycemia, we conducted a descriptive qualitative study. Purposive sampling was used to recruit participants for a 30- to 45-minute semi-structured interview. The 16 participants included both women and men with either type 1 or type 2 diabetes, with a mean age of 53 years and mean time since diagnosis of 21 years. All participants had experienced more than one hypoglycemia event in the past year, ranging from nonsevere to severe. Data collection and analysis occurred in an iterative manner. Individual and team analyses of interviews were conducted to identify overarching themes and sub-themes. Thematic analysis revealed the unique interconnection among the emotions experienced by participants, including fear, anxiety, frustration, confidence, and hope. Time, experience, and reflection helped to build participants’ confidence in their ability to manage a hypoglycemia event. Patients’ emotions regarding hypoglycemia provide valuable insights into life with diabetes. Although hypoglycemia continues to evoke feelings of fear and anxiety, the role of hope may temper these emotions. Understanding the complex interplay of emotions concerning hypoglycemia can guide health care providers in improving clinical practice and promoting patient-centered interventions. Ultimately, health care providers can build patients’ hypoglycemia-related confidence by using a strengths-based approach.

Background People with multimorbidity, who may be more vulnerable to certain social determinants of health, often require care by an interprofessional primary healthcare (PHC) team that can tailor their approach to address the multiple and complex needs of this population. This paper describes how the needs of vulnerable patients experiencing multimorbidity are identified and provided care by innovative interprofessional PHC teams during an innovative one-hour consultation, outside of usual care. Methods This was a descriptive qualitative study. Forty-eight interviews were conducted with 20 allied healthcare professionals: (e.g., social work, pharmacy); 19 physicians (e.g., psychiatry, internal medicine, family medicine); and 9 decision makers. The thematic analysis was iterative using an individual and team approach to identify the main themes and exemplar quotations for illustration. Results Participants described patients with multimorbidity who were vulnerable as those experiencing major challenges accessing and navigating the healthcare system. Mental health issues were a major contributor to being vulnerable and often linked to common social determinants of health. Cultural factors were identified as potentially causing patients to be vulnerable. Participants articulated how the collaborative nature of the team generated new ideas and facilitated creative recommendations designed to meet the specific needs of each patient. Conclusions This one-time consultation went beyond the assessment of a patient’s multimorbidity by including a psycho-social-contextual understanding of vulnerability within the healthcare system. Findings may have important clinical and policy implications in the adoption and implementation of this approach and further assist vulnerable patients with multimorbidity in having their complex needs addressed.

Objectives Hypoglycemia is a common adverse event for people with type 1 and type 2 diabetes mellitus. In this article, we explore the specific roles that individuals assume to prevent or treat hypoglycemia. Methods A descriptive qualitative study from the UnderstandINg the impact of HYPOglycemia on Diabetes Management Study (InHypo-DM) research program. A purposive sample of people with type 1 and type 2 diabetes were recruited for semistructured interviews. There were 16 participants (women and men), who were, on average, 53 years old. Average time since diagnosis was 15 (type 1) and 21 (type 2) years; all patients had at least 1 hypoglycemic event in the past year. Individual and team analysis of interviews were conducted to identify overarching themes. Results Participants articulated 4 roles in preventing or treating hypoglycemia. The first role was being a manager by assuming ownership and accountability for their own glycemic control. The second role, being a technician, used both subjective and objective information and employed specific strategies to respond to hypoglycemic events. The third role, educator, extended beyond self-management to increase others’ awareness of hypoglycemia. The fourth role, advocate, involved championing one’s own needs during a hypoglycemic event. These 4 roles were, in turn, influenced by the contexts of work, social settings, exercise and travel. Conclusions These findings demonstrate that strategies that individuals use to avoid or reduce the severity of a hypoglycemic event extend beyond merely making impromptu decisions during events. Instead, these 4 roles of manager, technician, educator and advocate, embedded in specific contexts, enhanced their mastery in managing hypoglycemia in daily life.

Minimizing hypoglycemia is a key clinical goal for healthcare providers (HCPs) in the care of patients with T1DM and T2DM as the associated morbidity and mortality of hypoglycemia is well understood. Yet, there is a paucity of literature regarding the impact of reported hypoglycemia on HCPs. Using qualitative data from the InHypo-DM Study, Canada’s largest mixed methods study of hypoglycemia to date, we explored the emotional impact of patients’ hypoglycemia on HCPs. Our research team conducted semi-structured interviews lasting 30-45 minutes. Interviews were transcribed verbatim. An iterative and interpretative process was used during both individual and team analysis to identify the main themes. A purposive sample of twenty HCPs was interviewed including endocrinologists (4), family physicians (4), nurse practitioners (3), and diabetes educators (9). Three themes emerged in the analysis: (1) a sense of professional responsibility with the subsequent feeling that the HCP must have failed or inadequately fulfilled their professional duties; (2) a mix of personal emotions including sadness, “feeling bad,” guilt and distress; and (3) the desire to act on these emotions through a “call to action” expressed as a strong desire to identify potential causes of patients’ hypoglycemia and ways in which to help prevent future events. This qualitative study highlights the emotional impact on HCPs as they care for patients at risk of hypoglycemia. While it may have been expected that HCPs have a strong sense of professional responsibility, it was unexpected to discover that these responses often became personal emotions. Clinical strategies that support HCPs in their efforts to optimize hypoglycemia detection and prevention should be promoted. Such strategies could help facilitate not only reductions in hypoglycemia among patients, but also lessen the emotional burden experienced by diabetes care providers over the span of their careers. Disclosure S.M. Reichert: Advisory Panel; Self; Abbott, AstraZeneca, Boehringer Ingelheim (Canada) Ltd., Eli Lilly and Company, Novo Nordisk Inc., Sanofi, Servier. Consultant; Self; Abbott, AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. Research Support; Self; Canadian Institutes of Health Research. Other Relationship; Self; AstraZeneca, Boehringer Ingelheim (Canada) Ltd., Novo Nordisk Inc., Sanofi. J.B. Brown: None. Y. Valliere: None. C. McLachlan: None. S. Webster-Bogaert: None. A. Ratzki-Leewing: Consultant; Self; Eli Lilly and Company, Novo Nordisk A/S. Research Support; Self; Sanofi. B.L. Ryan: None. N.H. Au: None. S.B. Harris: Advisory Panel; Self; Abbott, AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. Consultant; Self; Abbott, AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. Research Support; Self; AstraZeneca, Canadian Institutes of Health Research, Eli Lilly and Company, Health Canada/First Nations and Inuit Health Branch, Janssen Pharmaceuticals, Inc., JDRF, Lawson Foundation, Novo Nordisk Inc., Sanofi. Other Relationship; Self; AstraZeneca, Eli Lilly and Company, Novo Nordisk Inc., Sanofi. Funding Sanofi Canada

Background Patients with diabetes and advanced chronic kidney disease face a high health care burden. As part of a patient-oriented research initiative to identify ways to better support patients' diabetes care, we explored their health care experience and solutions for patient-centred diabetes care. Methods We engaged 2 patients with advanced kidney disease and diabetes to join our multidisciplinary team as full research partners. They were involved in our design and conduct of the study, the analysis of the results and knowledge translation. We conducted qualitative interviews (1:1 semistructured interviews and focus groups) with patients with a history of both diabetes (type 1 or 2) and advanced kidney disease including those using dialysis. We identified overarching themes using individual and team analysis and conducted interviews until data saturation was reached. Results Twelve participants were interviewed between October 2017 and February 2018. Six people were interviewed in 2 separate focus groups (consisting of 4 and 2 participants) and 6 participated in 1:1 interviews with our team. Participants described being burdened by medical appointments, strict conflicting diets, costly diabetes therapies and fragmented, siloed health care. They indicated that self-management support, education and coordinated diabetes care might better support their diabetes care. Interpretation Patients with complex medical comorbidities face many challenges traversing a health care system organized around single diseases. Researchers and policy-makers should study and develop patient-centred diabetes care strategies to better support these high-risk patients.

The aim of this study was to estimate the real-world incidence of self-reported non-severe hypoglycemia (NSH) and its related sociodemographic and clinical risk factors in a general population of Canadian adults with type 2 diabetes mellitus (T2DM) taking insulin and/or secretagogues.Data for this study were obtained from the InHypo-DM Study. Self-reported data on the frequency of NSH (past 30 days) as well as sociodemographic and clinical characteristics were collected through an online questionnaire. Risk factors for any, daytime and nocturnal NSH were identified using multivariable negative binomial regression with backward selection.Among 432 adults with T2DM (43.8% female, mean age of 53.1 years), 53.9% (95% confidence interval [CI], 49.2% to 58.6%) reported ≥1 event of any (i.e. daytime or nocturnal) NSH in the past 30 days. The 30-day incidence rate of any NSH was 2.3 events per 30 person-days (95% CI, 2.1 to 2.4). Risk factors associated with the increased rate of any NSH were younger age, lower annual household income, being employed, longer duration of diabetes, higher glycated hemoglobin and presence of comorbidity. Risk factors were generally similar for daytime NSH (except for the exclusion of diabetes duration and addition of diabetes medication type) and nocturnal NSH (except for the exclusion of being employed).This is the largest Canadian investigation to estimate the real-world frequency and distribution of self-reported NSH in T2DM. Events were alarmingly frequent and recurrent. Numerous sociodemographic and clinical risk factors were elucidated. These results highlight the importance of identifying high-risk individuals to minimize future occurrences of hypoglycemia.

INTRODUCTION A significant body of research exists on the impact of the social determinants of health (SDoHs) on diabetes care and general health outcomes. However, less is known about health care practitioners' (HCPs') perspectives and experiences regarding the impact of the SDoHs on their patients with Type I and Type 2 diabetes mellitus and how this affects the prevention and treatment of hypoglycemia. METHOD A descriptive qualitative study, derived from the InHypo-DM (Canada) research program. A purposive sampling technique was used to recruit participants residing in southwestern Ontario, Canada, for a 30- to 45-min semistructured interview. Individual and team analysis of interviews was conducted to identify overarching and subthemes. Twenty HCP participants, including endocrinologists, family physicians, and allied health care practitioners, were recruited. Seven were Certified Diabetes Educators. RESULTS Participants articulated 2 overarching components of the SDoHs: patients' socioeconomic issues and psychosocial issues. They highlighted two socioeconomic issues: occupation type and poverty. Participants also emphasized 3 areas pertaining to patients' psychosocial issues: stage in the life cycle (e.g., elderly), social isolation, and mental health. DISCUSSION This study emphasizes the need for conducting detailed and comprehensive social histories during clinical diabetes assessments, as well as the necessity of adequate clinical time and resources for HCPs and patients to address these issues in the context of hypoglycemia management. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Impaired awareness of hypoglycemia (IAH) has been linked to an increased rate of severe hypoglycemia (SH) in T1DM. Yet, few investigations have focused on quantifying this relationship in the context of T2DM, particularly from a pragmatic epidemiological lens. This study leverages the value of self-reported SH data to explore the real-world, population-based effect of IAH severity on SH rates in T2DM. A validated questionnaire (InHypo-DMPQ) was administered online to a nationally representative panel comprising Canadians (≥18 years) with T2DM using insulin and/or secretagogues. Data were collected on respondents’ socio-demographic/clinical traits; self-reported incidence of SH (in the past year); and IAH severity, trisected by no, moderate, and severe impairment. Multivariable negative binomial regression (NBR) analysis was used to isolate the effect of IAH on SH. A directed acyclic graph was devised to identify the minimally sufficient adjustment set. Of the 452 complete respondents (mean age: 53.2 (SD: 14.7) years; male: 56%), 6% were classified with severe IAH, 67% with moderate IAH, and 27% with no IAH. Those with severe IAH had the highest crude annual SH rate (5.89 events/person-year, 95% CI: 5.01-6.88), which over doubled and tripled the SH rate in people with moderate IAH (p This real-world, population-based study provides timely insight into the high prevalence of moderate and severe IAH in people with T2DM using insulin and/or secretagogues. The marked impact of IAH on increased SH rates underscores a pressing need for the clinical prioritization of IAH assessment and management in T2DM. Disclosure A. Ratzki-Leewing: None. S.B. Harris: Advisory Panel; Self; AstraZeneca, Janssen Pharmaceuticals, Inc., Lilly/Boehringer Ingelheim, Merck & Co., Inc., Novo Nordisk A/S, Sanofi. Consultant; Self; AstraZeneca, Janssen Pharmaceuticals, Inc., Lilly/Boehringer Ingelheim, Merck & Co., Inc., Novo Nordisk Inc., Sanofi. Research Support; Self; Abbott, AstraZeneca, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk A/S, Sanofi. Other Relationship; Self; Canadian Diabetes Association, Canadian Institutes of Health Research, The Lawson Foundation. N.H. Au: None. S. Webster-Bogaert: None. J.B. Brown: None. S.M. Reichert: Advisory Panel; Self; Abbott, AstraZeneca, Novo Nordisk Inc., Sanofi, Servier. Research Support; Self; Canadian Institutes of Health Research. Speaker's Bureau; Self; Abbott, AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. B.L. Ryan: None. Funding Sanofi Canada

Background: Patients with diabetes and chronic kidney disease (CKD) are at high risk of diabetes-related complications. Diabetes care can support these individuals, but outpatient clinic appointments can be difficult to attend, given their already high burden of multimorbidity. Methods: We systematically searched the medical and grey literature for studies that evaluated the effect of nonconventional diabetes care strategies on diabetes-related outcomes in adults with stages 2–5 CKD or using dialysis (end of search December 30, 2017). We included both randomized-controlled trials and observational studies. Study selection and data extraction were completed by two independent reviewers. Diabetes-related outcomes included glycemic, blood pressure, and lipid control, along with microvascular complications, macrovascular complications, and death. Results: After screening 2177 relevant citations, we identified 34 studies which met inclusion. The majority were observational studies. Studies were frequently small, single-centered, and excluded patients with more advanced CKD. Nonconventional diabetes care strategies included community-based care, unique self-management and education programs, nurse-led care clinics, dialysis-based diabetes programs, telemedicine, and interdisciplinary care clinics. Programs were most often developed by study investigators. Although there were limitations to several of the included studies, programs were described to have modest effects on physiologic outcomes, and in some cases, diabetes-related complications and death. Conclusions: Nonconventional diabetes-related care might be helpful to patients with CKD. Prior to developing and implementing programs, however, it will be important to study them more rigorously, understand their acceptability to patients, and evaluate their costs and feasibility in a real-world setting.

While sulfonylureas (SUs) are known to induce hypoglycemia, their low cost and ease-of-use has made them a mainstay therapy for T2DM. Second-generation SUs (SGSUs), compared to first-generation SUs (FGSUs), have been successful at reducing these events. Pragmatic evidence substantiating this association remains limited; this study leverages data from the population-based InHypo-DM study to describe the real-world patterns of SU use and impact on hypoglycemia incidence in Canada. A validated questionnaire (InHypo-DMPQ) was administered online to a nationwide panel consisting of adults with SU-treated T2DM. Questions related to respondents’ past hypoglycemia events, as well as socio-demographic and clinical traits. Negative binomial regression (NBR) was used to test the effect of SU type (FGSUs (chlorpropamide/tolbutamide) vs. SGSUs (glyburide/gliclazide/glimepiride)) on the annual rate of any hypoglycemia. A directed acyclic graph was constructed to identify the adjustment set. Of the 255 adults with SU-treated T2DM (56% male, mean age: 53.1 (SD: 14.4) years), 10.6% were on FGSUs (chlorpropamide: 7.5%, tolbutamide: 3.1%) and 89.5% on SGSUs (glyburide: 27.5%, gliclazide: 54.9%, glimepiride: 7.1%). Annualized crude event frequencies revealed that those on FGSUs, vs. SGSUs, were 1.57 times as likely to have ≥1 event; this group also experienced an average of 2.70 more events/person-year. Based on the NBR, FGSUs vs. SGSUs was associated with a 2.76 (95% CI: 1.07-7.11, p=0.035) factor increase in the rate of hypoglycemia, adjusting for drug coverage, T2DM duration, income, and clinician type. These results confirm that FGSUs induce a dangerous, real-world risk for hypoglycemia. It exposes a worrying trend for the continued use of outdated SUs for T2DM, despite the availability of safer alternatives in Canada. Our study serves as a pressing call-to-action to ensure that clinicians provide the safest and most effective therapeutic management for patients with T2DM. Disclosure N.H. Au: None. A. Ratzki-Leewing: None. B.L. Ryan: None. S. Mequanint: None. J.E. Black: None. S.M. Reichert: Other Relationship; Self; Novo Nordisk Inc., Sanofi, Abbott, AstraZeneca. Advisory Panel; Self; Servier. Speaker's Bureau; Self; Eli Lilly and Company. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Speaker's Bureau; Self; Merck & Co., Inc., Janssen Pharmaceuticals, Inc.. J.B. Brown: None. S. Harris: Advisory Panel; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Amgen Inc., Lilly/Boehringer Ingelheim, Abbott, Janssen. Consultant; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Lilly/Boehringer Ingelheim, Abbott, Janssen. Research Support; Self; Novo Nordisk A/S, Sanofi, Merck, Abbott, AstraZeneca, Janssen. Other Relationship; Self; CIHR, CDA, The Lawson Foundation.

Many patients fail to report severe hypoglycemia (SH) events to their healthcare provider (HCP). This limits the ability of HCPs to adjust treatment regimens and optimize glycemia. This study aimed to explore the independent association between patients’ disclosure of SH events to their HCP and self-reported rates of SH. Data were obtained from the InHypo-DM population-based study, Canada’s largest hypoglycemia-specific survey. To indicate SH disclosure, patients at risk for hypoglycemia rated how often they reported their SH events (using ADA definitions) to their HCP on a scale from Never to Always. Univariable analyses identified significant clinical or demographic confounders (p≤0.2). Based on the distribution of SH events, zero-inflated negative binomial (ZINB) regression was used to test the relationship between hypoglycemia disclosure and the retrospective incidence of SH events. A total of 552 people with T1DM (17%) or T2DM (83%) completed the InHypo-DM survey. Forty percent of respondents reported at least one or more SH events. The overall incidence rate of SH was 2.45 events/person-year. Thirty-four percent of respondents indicated that they always report SH events. Results of the ZINB model showed that the odds of experiencing any event was not significantly associated with disclosure behaviour (p=0.86). However, the rate of repeated events was almost double (IRR=1.9, 95% CI: 1.2 to 3.0, p=0.004) among individuals who under-reported their SH as compared to those who did not. These results persisted after adjusting for age, medication type, income, most recent HbA1c, and presence of comorbidities. This population-based study revealed a nearly two-fold higher rate of SH among those who under-report to their HCP. Thus, HCPs should be aware that patient reporting may not be a true reflection of SH events and make efforts to elicit accurate information regarding SH events from their patients, especially for those at risk for repeated SH. Disclosure A. Ratzki-Leewing: None. J.E. Black: None. S. Mequanint: None. N.H. Au: None. B.L. Ryan: None. S.M. Reichert: Other Relationship; Self; Novo Nordisk Inc., Sanofi, Abbott, AstraZeneca. Advisory Panel; Self; Servier. Speaker's Bureau; Self; Eli Lilly and Company. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Speaker's Bureau; Self; Merck & Co., Inc., Janssen Pharmaceuticals, Inc.. J.B. Brown: None. S. Harris: Advisory Panel; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Amgen Inc., Lilly/Boehringer Ingelheim, Abbott, Janssen. Consultant; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Lilly/Boehringer Ingelheim, Abbott, Janssen. Research Support; Self; Novo Nordisk A/S, Sanofi, Merck, Abbott, AstraZeneca, Janssen. Other Relationship; Self; CIHR, CDA, The Lawson Foundation.

Insight into the self-reported frequency of third-party assisted severe hypoglycemia (SH) is critical for the therapeutic optimization of type 2 diabetes (T2D). This study presents real-world epidemiological evidence on the self-reported incidence and related risk indicators of SH. A validated questionnaire (InHypo-DMPQ) was administered to a population-based panel of adult Canadians with T2D treated with insulin and/or secretagogues. Questions pertained to respondents’ past hypoglycemia events as well as socio-demographic and clinical characteristics, including hypoglycemia unawareness. Univariable analyses (p≤0.20) followed by a multivariable zero-inflated negative binomial (ZINB) analysis were performed to explore the influence of potential risk indicators on the occurrence of any and repeated SH events. The current evaluation is based on a cohort of 436 respondents (mean age: 53 years; male: 54%). Among these individuals, 37.8% (95% CI: 33.3%-42.4%) self-reported at least one SH event in the past year; the incidence rate was 2.4 events (95% CI: 2.26-2.55) per person-year. Based on the ZINB analysis, only non-severe (NH) hypoglycemia was independently associated with SH, holding other indicators constant. Among respondents who reported ≥1 (vs. zero) NH events, the odds of never experiencing an SH event decreased by 82% (95% CI: 39.3%-94.7%, p=0.006). Likewise, a history of NH, among those who had a chance of experiencing SH, increased the expected rate of SH by a factor of 4.29 (95% CI: 2.25-8.17, p Real-world estimates of SH in T2D are often limited by sub-optimal reporting and gaps in clinical practice. To help clarify the true frequency of SH, this large, population-based study leveraged the value and clinical relevance of self-reported hypoglycemia data. The results of this study suggest that the burden of third-party assisted SH is substantial in people with T2D. Clinical strategies to prevent NH may reduce the risk of any/repeated SH events and resulting sequelae. Disclosure A. Ratzki-Leewing: None. S. Harris: Advisory Panel; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Amgen Inc., Lilly/Boehringer Ingelheim, Abbott, Janssen. Consultant; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Lilly/Boehringer Ingelheim, Abbott, Janssen. Research Support; Self; Novo Nordisk A/S, Sanofi, Merck, Abbott, AstraZeneca, Janssen. Other Relationship; Self; CIHR, CDA, The Lawson Foundation. S. Mequanint: None. N.H. Au: None. J.E. Black: None. S.M. Reichert: Other Relationship; Self; Novo Nordisk Inc., Sanofi, Abbott, AstraZeneca. Advisory Panel; Self; Servier. Speaker's Bureau; Self; Eli Lilly and Company. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Speaker's Bureau; Self; Merck & Co., Inc., Janssen Pharmaceuticals, Inc.. J.B. Brown: None. B.L. Ryan: None.

Type 2 diabetes mellitus (T2DM) imparts an increased risk for cognitive decline, specifically executive function, which is important to maintain for diabetes self-management. There is evidence to suggest that exercise improves cognition in healthy older adults; however, the literature in adults with T2DM is lacking. This commentary is in complement to Podolski et al.'s systematic review evaluating the effects of physical activity on cognitive function in adults with T2DM. We have included eight additional studies and further highlight their conclusions on the heterogeneity of the literature thus far. Three current issues with the literature are as follows: (1) variability in interventions (e.g., aerobic, resistance, lifestyle, and yoga), (2) variability in cognitive outcome measures, and (3) lack of detailed description of the population studied, for example, baseline glycated hemoglobin (A1C) values. Overall, making it difficult to compare these studies and draw final conclusions. Thus, the efficacy for exercise to improve cognition in adults with T2DM is not yet well understood. Potential ways to mitigate these limitations could be for future studies that (1) use robust methodology whenever possible, that is, randomized controlled trials, (2) to follow current guideline-derived exercise recommendations for adults with T2DM, and (3) utilize cognitive outcome measures that are consistent across studies. The hope is that these consistencies in turn will help to determine the efficacy of exercise on cognitive function in adults with T2DM and therefore, allow national organizations to develop recommendations and guidelines for healthcare practitioners to follow.

ObjectiveVery few real-world studies have been conducted to assess the incidence of diabetes-related hypoglycemia. Moreover, there is a paucity of studies that have investigated hypoglycemia among people taking secretagogues as a monotherapy or in combination with insulin. Accordingly, our research team developed and validated the InHypo-DM Person with Diabetes Mellitus Questionnaire (InHypo-DMPQ) with the aim of capturing the real-world incidence of self-reported, symptomatic hypoglycemia. The questionnaire was administered online to a national sample of Canadians (≥18 years old) with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) treated with insulin and/or insulin secretagogues.Research design and methodsSelf-report data obtained from the InHypo-DMPQ were descriptively analyzed to ascertain the crude incidence proportions and annualized incidence densities (rates) of 30-day retrospective non-severe and 1-year retrospective severe hypoglycemia, including daytime and nocturnal events.ResultsA total of 552 people (T2DM: 83%; T1DM: 17%) completed the questionnaire. Over half (65.2%) of the total respondents reported experiencing at least one event (non-severe or severe) at an annualized crude incidence density of 35.1 events per person-year. The incidence proportion and rate of non-severe events were higher among people with T1DM versus T2DM (77% and 55.7 events per person-year vs 54% and 28.0 events per person-year). Severe hypoglycemia was reported by 41.8% of all respondents, at an average rate of 2.5 events per person-year.ConclusionsThe results of the InHypo-DMPQ, the largest real-world investigation of hypoglycemia epidemiology in Canada, suggest that the incidence of hypoglycemia among adults with diabetes taking insulin and/or insulin secretagogues is higher than previously thought.

Quality improvement (QI) programs are frequently implemented to support primary healthcare (PHC) team development and to improve care outcomes. In Ontario, Canada, the Quality Improvement and Innovation Partnership (QIIP) offered a learning collaborative (LC) program to support the development of interdisciplinary team function and improve chronic disease management, disease prevention, and access to care. A qualitative study using a phenomenological approach was conducted as part of a mixed-method evaluation to explore the influence of the program on team functioning in participating PHC teams. A purposive sampling strategy was used to identify PHC teams (n = 10), from which participants of different professional roles were selected through a purposeful recruitment process to reflect maximum variation of team roles. Additionally, QI coaches working with the interview participants and the LC administrators were also interviewed. Data were collected through semistructured telephone interviews that were audiotaped and transcribed verbatim. Thematic analysis was conducted through an iterative and interpretive approach. The shared experience of participating in the program appeared to improve team functioning. Participants described increased trust and respect for each other's clinical and administrative roles and were inspired by learning about different approaches to interdisciplinary care. This appeared to enhance collegial relationships, collapse professional silos, improve communication, and increase interdisciplinary collaboration. Teamwork involves more than just physically grouping healthcare providers from multiple disciplines and mandating them to work together. The LC program provided opportunities for participants to learn how to work collaboratively, and participation in the LC program appeared to enhance team functioning.

Insulin is the most effective therapy for achieving optimal glycemic control; however, many patients with type 2 diabetes on an intensified treatment regimen fail to achieve the recommended HbA1c target (1,2) and face the risk of adverse effects such as hypoglycemia and weight gain (3). The addition of sodium–glucose cotransporter 2 (SGLT2) inhibitors to a regimen of insulin therapy in this patient population has the potential to mitigate insulin-related weight gain and risk of hypoglycemia, with the added benefit of insulin dose reduction (4). Randomized controlled trials (RCTs) have shown improved clinical outcomes of SGLT2 inhibitors as monotherapy and as an add-on to oral and insulin therapy, but there is a paucity of real-world (RW) studies evaluating similar outcomes. Data extracted from WebDR (5) was used to evaluate the RW clinical impact of SGLT2 inhibitors (initiation of canagliflozin or dapagliflozin between February 2014 and December 2016) as an add-on to insulin therapy in patients with type 2 diabetes not achieving glycemic targets (those with HbA1c >7% [>53 mmol/mol]). Empagliflozin was excluded because of inadequate sample size. Ethical approval …

The majority of diabetes care in Canada is provided within the primary healthcare setting. It is delivered in a variety of models ranging from the physician working in a solo fee-for-service practice to an interprofessional team setting with specialist collaboration. To augment diabetes-related health services, the Ontario government has provided substantial funding to support community diabetes education programs. These models and initiatives are improving diabetes outcomes, and continued evolution of these programs can provide even greater outcomes. The St. Joseph's Primary Care Diabetes Support Program (SJHC PCDSP) is an innovative model that incorporates multidisciplinary allied health professionals together with physician support to provide care for more than 3000 patients in London, Ontario, Canada. It embodies the Canadian Diabetes Association (CDA)'s Organizations of Care recommendations to combine patient education and self-management with active medical support at each clinic encounter, all while embodying the tenets of primary care. A brief review of primary healthcare reform is provided to explain how the SJHC PCDSP combines features of current models in a unique format so as to deliver exceptional patient care. By providing a detailed description of the services delivered at the SJHC PCDSP, it is hoped that both specialists and primary care providers consider using and adapting approaches to diabetes management based on this innovative model to optimize their practices.

Square-stepping exercise (SSE) is a visuospatial working memory task with a cued stepping response that improves mobility and cognition in older adults.PURPOSE: To determine if a SSE intervention improves cognitive and mobility in older adults with chronic disease (i.e., knee osteoarthritis [KOA]; t

Objectives: B-type natriuretic peptides are biomarkers of heart failure (HF) that can decrease following treatment. We sought to determine whether B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) concentration changes occurred in parallel to changes in other measures of heart failure following treatment. Methods: We conducted a systematic review of the literature for studies that assessed B-type natriuretic peptide measurements in treatment monitoring of patients with stable chronic heart failure. Selected studies had to include at least three consecutive measurements of BNP or NT-proBNP. Results: Of 4338 citations screened, only 12 met all of the selection criteria. The selected studies included populations with a wide range of heart failure severity and therapy. BNP and NT-proBNP decreased following treatment in nine studies and was associated with improvement in clinical measures of HF. Conclusions: There was limited data to support using BNP or NT-proBNP to monitor therapy in patients with HF.

Quaternary Prevention is defined as the action taken to identify patients at risk of overtreatment, to protect them from additional medical treatments, and to suggest interventions that are ethically acceptable. Many countries and organizations have joined in the efforts to practice quaternary prevention. These countries started a campaign called Choosing Wisely that implements recommendations in order to avoid harming patients.To determine the attitudes, perceptions and awareness towards Quaternary Prevention and the practice of “Choosing Wisely Canada Recommendations” among family doctors working in the Social Security System in Peru.A questionnaire was developed after reviewing the literature and contacting experts in the field and was sent by email to all 64 family physicians in the Social Security System (Essalud) in Lima Peru. Responses were received from 40 participants.The response rate was 64%. Approximately 95% reported that they understand the concept of quaternary prevention. Agreement with all the recommendations was 90% or higher. In most of the recommendations the applicability was more than 80%. The most important barriers perceived for the practice of Quaternary Prevention were patients’ expectations (33%).There are positive perceptions towards Quaternary Preventions and Choosing Wisely recommendations in the family doctors of social security in Lima Peru.La prevención cuaternaria se define como la acción llevada a cabo para identificar pacientes en riesgo de sobretratamiento, a fin de protegerlos de una nueva intervención médica y para recomendar intervenciones que son éticamente aceptables. Muchos países y organizaciones han unido esfuerzos para la práctica de la prevención cuaternaria. Estos países iniciaron una campaña llamada Choosing Wisely, que implementa recomendaciones para evitar hacer daño a los pacientes.Determinar las actitudes, percepciones y preocupaciones hacia la prevención cuaternaria y la práctica de las recomendaciones Choosing Wisely Canadá entre médicos de familia que trabajan en el Seguro Social del Perú.Se desarrolló un cuestionario después de revisar la literatura y consultar expertos en el tema. Éste fue enviado por correo electrónico a todos los médicos de familia (64) del Seguro Social del Perú (EsSalud) en Lima, Perú. Se recibieron respuestas de 40 participantes.La tasa de respuesta fue del 64%. Aproximadamente, 95% reportó que comprende el concepto de prevención cuaternaria. La concordancia con las recomendaciones fue del 90% o superior. En la mayoría de las recomendaciones, la aplicabilidad fue mayor del 80%. La barrera percibida como más importante para la práctica de prevención cuaternaria fue la expectativa de los pacientes (33%).Existen percepciones positivas hacia la prevención cuaternaria y las recomendaciones Choosing Wisely entre los médicos de familia de la Seguridad Social del Perú.

Objective Primary healthcare (PHC) quality improvement (QI) initiatives are designed to improve patient care and health outcomes. We evaluated the Quality Improvement and Innovation Partnership (QIIP), an Ontario-wide PHC QI program on access to care, diabetes management and colorectal cancer screening. This manuscript highlights the impact of QIIP on diabetes outcomes and associated vascular risk factors. Research design and methods A cluster matched-control, retrospective prechart and postchart audit was conducted. One physician per QIIP-PHC team (N=34) and control (N=34) were recruited for the audit. Eligible charts were reviewed for prespecified type 2 diabetes mellitus clinical process and outcome data at baseline, during (intervention range: 15–17.5 months) and post. Primary outcome measures were the A1c of patients above study target and proportion of patients with an annual foot exam. Secondary outcome measures included glycemic, hypertension and lipid outcomes and management, screening for diabetes-related complications, healthcare utilization, and diabetes counseling, education and self-management goal setting. Results More patients in the QIIP group achieved statistically improved lipid testing, eye examinations, peripheral neuropathy exams, and documented body mass index. No statistical differences in A1c, low-density lipoprotein or systolic/diastolic blood pressure values were noted, with no significant differences in medication prescription, specialist referrals, or chart-reported diabetes counseling, education or self-management goals. Patients of QIIP physicians had significantly more PHC visits. Conclusion The QIIP-learning collaborative program evaluation using stratified random selection of participants and the inclusion of a control group makes this one of the most rigorous and promising efforts to date evaluating the impact of a QI program in PHC. The chart audit component of this evaluation highlighted that while QIIP improved some secondary diabetes measures, no improvements in clinical outcomes were noted. This study highlights the importance of formalized evaluation of QI initiatives to provide an evidence base to inform future program planning and scale-up.

Purpose Rigorous comprehensive evaluations of primary healthcare (PHC) quality improvement (QI) initiatives are lacking. This article describes the evaluation of the Quality Improvement and Innovation Partnership Learning Collaborative (QIIP-LC), an Ontario-wide PHC QI program targeting type 2 diabetes management, colorectal cancer (CRC) screening, access to care, and team functioning. Methods This article highlights the primary outcome results of an external retrospective, multi-measure, mixed-method evaluation of the QIIP-LC, including: (1) matched-control pre-post chart audit of diabetes management (A1c/foot exams) and rate of CRC screening; (2) post-only advanced access survey (third-next available appointment); and (3) post-only semi-structured interviews (team functioning). Results Chart audit data was collected from 34 consenting physicians per group (of which 88% provided access data). Between-group differences were not statistically significant (A1c [p = 0.10]; foot exams [p = 0.45]; CRC screening [p = 0.77]; advanced access [p = 0.22]). Qualitative interview (n = 42) themes highlighted the success of the program in helping build interdisciplinary team functioning and capacity. Conclusion The rigorous design and methodology of the QIIP-LC evaluation utilizing a control group is one of the most significant efforts thus far to demonstrate the impact of a QI program in PHC, with improvements over time in both QIIP and control groups offering a likely explanation for the lack of statistically significant primary outcomes. Team functioning was a key success, with team-based chronic care highlighted as pivotal for improved health outcomes. Policy makers should strive to endorse QI programs with proven success through rigorous evaluation to ensure evidence-based healthcare policy and funding.

s / Can J Diabetes 37 (2013) S13eS84 S27 improvement (QI) learning collaborative (LC) program to interdisciplinary primary healthcare teams to support team collaboration and improve diabetes management, colorectal cancer screening and access to care. The QI program consisted of 3 learning sessions and supportive program activities utilizing the CDPM framework and IHI-BTS methodologies. A pre-post cluster matched control design with chart audit was used to determine the effectiveness of this program on diabetes management. Sixtyeight (34 physicians per group) randomly selected QIIP physicians and matched controls consented. Charts of patients with type 2 diabetes were randomly selected. Primary outcomes were annual foot exam and mean A1C of patients with A1C 7.3%. A generalized linear model was used to compare change in diabetes outcome measures from baseline between QIIP physicians and the control group accounting for clustering and baseline measures. The QIIP group significantly improved process outcomes compared to the control for eye (p1⁄40.03) and neuropathy exams (p1⁄40.01). Mean A1C was significantly lower in the QIIP group during the program (p1⁄40.01); however, these improvements were not sustained 1-year afterwards (p1⁄40.10). More patients in the QIIP group achieved target LDL (p1⁄40.03). No difference between groups was observed for foot exam (p1⁄40.15), mean systolic BP (p1⁄40.72), mean diastolic BP (p1⁄40.92), LDL (p1⁄40.32), percentage of patients achieving target A1C (p1⁄40.75) and percent of patients achieving target BP (p1⁄40.50). In conclusion, the QI program had modest improvements on diabetes process and clinical outcomes.