TNDMS - The National Diabetes Management Strategy
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CDA Chair Diabetes Management:
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CDA Chair Diabetes Management ...

Goals for the Chair



 

Stewart B. Harris,
CM, MD, MPH, FCFP, FACPM
CDA Chair in Diabetes Management

In January 2008, Dr. Stewart B. Harris was appointed the inaugural Canadian Diabetes Association Chair (CDA) in Diabetes Management at Western University. Dr. Harris was re-appointed for another 5-year term in 2014.

In his first five year term as CDA Chair, the National Diabetes Management Strategy (TNDMS) was created to serve as the foundation for focused research in the area of diabetes in Canada. A ten-year vision for the TNDMS was strategically outlined to support and enhance the translation of scientific data from clinical practice into tangible healthcare outcomes to optimize patient management of diabetes.

Continuity and expansion are critical in progressing forward with the CDA Chair and TNDMS and are key concepts integrated in the goals, objectives and programs of research moving forward.

The revised TNDMS over-arching goal is to identify and reduce clinical care gaps and optimize the management of diabetes as a means of improving the quality of care for people living with diabetes.

The revised TNDMS objectives will guide the development and implementation of activities over the next five years:

  • To comprehensively assess the impact of innovative strategies/initiatives/models and policies on the healthcare system, healthcare professionals, communities and people living with diabetes
  • To advocate for changes in the healthcare system and related policies that consider both medical and non-medical determinants of health for enhanced diabetes prevention and management
  • To evaluate the uptake, strengthen the use of, and impact of the Canadian Diabetes Association clinical practice guidelines
  • To utilize researchable clinical and administrative databases (diabetes registries, surveillance system, electronic medical records) to identify clinical care gaps and assess cost/value of care for diabetes and related chronic diseases
  • To support student training and the professional development of diabetes health providers, researchers, and other relevant/interested stakeholders such as decision-makers
  • To establish and foster collaborative local, regional, national and international partnerships in diabetes and related chronic disease sectors to optimize knowledge translation

To meet the CDA Chair mandate and goal/objectives of the NDMS, the research program focuses on four priority research areas that fulfill the concept of continuity and expansion of the NDMS:

  1. Evaluation of Diabetes and Chronic Disease Models of Care
  2. Diabetes Research with First Nations
  3. Pragmatic Studies in Diabetes Care
  4. Clinical and Administrative Research Databases
  5. Investigator Initiated and Pharmaceutical Sponsored Clinical Trials

 

Evaluation of Diabetes and Chronic Disease Models of Care

Diabetes Evaluation Framework for Innovative National Evaluations (DEFINE)
DEFINE is a framework that will guide the comprehensive evaluation (process/formative and outcome) of initiatives/programs/models that aim to improve diabetes prevention and management in Canada and facilitate policy innovations directed to improve diabetes care and reduce the clinical and financial burden of diabetes.

The DEFINE package involves a 5-step evaluation approach, a pictorial representation of the relationships between medical and non-medical determinants of health, a list of 83 all-inclusive indicators, associated measurement tools, and a 31 priority indicator set. To show the applicability and value of DEFINE, it has been launched on the NDMS website in partnership with Sanofi Canada.  As of 2014-15, two papers have been published and one has been submitted.

Evaluation of Quality Improvement Programs
Significant investment by provincial governments has gone into establishing new models of primary care with a particular focus on chronic diseases. There has been substantial effort and funding into quality improvement activities to improve diabetes care.  Dr. Harris has led two large external evaluations of these programs carried out in Ontario. The Partnerships for Health (PFH) aimed to improve diabetes management in the family practice setting by educating health professionals, facilitating quality improvement initiatives and integrating external health professionals into the family practice group. As of 2014-15 three papers have been published and one other has been submitted.  The Quality Improvement & Innovation Partnership (QIIP) learning collaborative program aimed to support the care of diabetes patients, screening for colorectal cancer and access to care.  As of 2014-15, two papers have been published and two are in development.


Diabetes Research with First Nations

First Nations continue to have the highest rates of diabetes in Canada. Unfortunately, the care of First Nations individuals with diabetes is often fractionated, resulting in inconsistent application of CDA clinical practice guidelines which contributes to the alarmingly high rate of diabetes-related complications. An information gap exists with little current, systematic, validated Canadian data available on the prevalence, incidence, morbidity and mortality rates due to type 2 diabetes in First Nations.

Dr. Harris’ leadership and efforts to build strategic alliances and seek out new funding have been successful to support collaborative research and training with a population that has the highest rates of diabetes and related complications in Canada.  

 

Transformation of Indigenous Primary Healthcare Delivery (FORGE AHEAD)
To develop and evaluate community-driven, culturally relevant, primary healthcare models that enhance chronic disease management and appropriate access to available services in First Nations communities in Canada, Dr. Harris, worked collaboratively as principal investigator with a group of over 20 co-investigators from 9 institutions and provinces, 9 collaborators/decision-makers, and 14 First Nations community leaders to plan, develop and obtain funding for a comprehensive research program entitled -  TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD): Community-driven Innovations and Strategic Scale-up Toolkits; this is a five-year program (2013 – 2018) funded $2,500,000 by CIHR’s Signature Initiative in Community-Based Primary Health Care (CBPHC): CBPHC Innovation Teams.

FORGE AHEAD is founded in participatory action research principles that simultaneously ensure culturally appropriate implementation and integrate knowledge translation by involving relevant stakeholders throughout the entire program. The activities in FORGE AHEAD are linked to the Expanded Chronic Care Model and revolve around five key research objectives: (1) Assess the current healthcare delivery, funding models and best practices used in First Nations communities in Canada; (2) Assess community and clinical readiness to address and adopt chronic disease care; (3) Enhance patient access to available community resources for chronic disease care; (4) Implement, evaluate, and cost community and clinic quality improvement initiatives to improve chronic disease management, including community diabetes registries, a web-based surveillance system, and a community-driven quality improvement intervention; (5) Develop sustainment strategies and scale-up toolkits for improved chronic disease management in First Nations communities.

The use of readiness assessments and diabetes registry and surveillance data, the program is in a significant position to identify care gaps, train diabetes healthcare professionals and researchers, and build evidence related to diabetes prevention and management models and clinical process and outcomes measures. The scale-up tool-kits of tested strategies that can be successfully implemented, sustained and used for other chronic diseases in First Nations communities across Canada is a defining example of knowledge translation to advocate for healthcare policy and healthcare delivery The outcomes of this research program, its related cost and the subsequent policy recommendations, will have the potential to significantly affect future policy decisions pertaining to diabetes and chronic disease care in First Nations communities. Work is underway and will continue from 2014 to 2018 The CDA Chair will support efforts to leverage funding to continue this work beyond 2018.

Leveraged funding from the Chair and FORGE AHEAD for 2 additional peer reviewed grants from  Lawson Foundation ($200,00) and CIHR Planning ($25,000), an unrestricted grant from Astra Zeneca ($500,000), and a contract Health Canada ($109,056)

Gestational Diabetes Mellitus – Healthy Moms, Healthy Babies
Gestational diabetes increases the risk of developing type 2 diabetes in both mothers and babies in the future thus making its prevention and management an important component in the fight against diabetes. The Healthy Moms, Healthy Babies program was a partnership between researchers and First Nations communities and included an epidemiological assessment, healthy community lifestyle program and implementing a pilot project of continuous glucose monitoring technology. This innovative program ended in late 2014. A manuscript has been published and one more is planned.

 

Pragmatic Studies in Diabetes Care

Understanding the impact of Hypoglycemia on diabetes management: A survey of Perspectives and Practices (InHYPO-DM)
Hypoglycemia is the most common diabetes-related adverse event.  The aim of this study is to develop a survey that will explores Canadians’ clinical and personal perspectives and practices related to hypoglycemia and its impact on the management of diabetes. The survey will be founded on the Theoretical Domains Framework, and the Diabetes Evaluation Framework for Innovative National Evaluations (DEFINE) and will be administered to people with diabetes, their family members, and care providers. A review of the literature and interviews with these key stakeholders will inform the design and content of the survey. The survey will be piloted then distributed nationwide. This methodological approach to survey development ensures the comprehensiveness and appropriateness of the survey tool.  This study is the first of its kind in the Canadian context.

Patient and Care Provider Perceptions and Experience Using a Decision Aid Tool for Self-Monitoring of Blood Glucose

Diabetes self-management includes self-monitoring of blood glucose (SMBG) readings, taking medication, exercise, dietary management, and foot care. Evidence suggests that SMBG alone may be of limited clinical effectiveness. This may be because patients are unable to interpret results and make adjustments to their care plan. By providing patients with the tools needed to review, interpret data, and receive feedback, a blood glucose meter with built-in algorithms could facilitate and improve the acceptance of SMBG. Putting the limited use of titration algorithms in the context of escalating diabetes prevalence rates, strategies and tools are urgently needed to help both patients and primary care providers efficiently initiate and continue basal insulin therapy. Basel insulin is considered to be the appropriate strategy after oral diabetic agent failure. This project could set the stage for the need for a blood glucose meter with built-in algorithms designed to support decision making by patients as well as care providers. The project will evaluate the uptake and use of the newly developed blood-glucose meter (FreeStyle Precision Neo meter), and its impact on primary care diabetes consultation. FreeStyle Precision Neo has a built-in basal insulin dose calculator developed by Abbott Diabetes Care.


Clinical and Administrative Research Databases

 

The Web-based Diabetes RecordWebDR is a web-based diabetes electronic medical record (EMR) used in 12 diabetes outpatient referral clinics for clinical encounters and as a comprehensive researchable database. WebDR currently contains the largest diabetes cohort in Canada of demographic and clinical information for more than 16,000 patients with diabetes and their visit information since 2000.

The WebDR researchable database includes de-identified patient demographic and longitudinal clinical information stored in a secure hospital server and is available to researchers based upon Western University Research Ethics Board and WebDR data committee review and approval. This researchable database has been utilized for generating ministry reports, identifying patients for clinical trials, and more than six research projects including medical and graduate student research and dissertations.  It has led to a number of successfully leveraged funded studies. Once such project Data Gaps & Cost Evaluation in Diabetes Care used a cohort derived from the researchable database to assess and measure costs of diabetes and its complications. The objective of the project will be fulfilled through a stepwise process that includes identifying cost related variables captured in the cohort dataset, identifying potential resource utilization data sources, linking the cohort data to cost related information obtained from another source(s) to allow economic evaluation, and assessing and analyzing the potential relationships between glycemic levels, diabetes-related hospitalizations, and hospital costs among adult patients. A manuscript presenting the impact of prescription drug coverage on diabetes outcome is in progress.

Global Registry and Surveillance System for Diabetes (GRAND)
GRAND, a web-based sentinel surveillance tool, registers and tracks individuals with diabetes and their relevant diabetes clinical parameters over time. GRAND was developed to be used globally by different countries with data stored in one central database server. A manuscript has been published describing the tool and clinical data.

Investigator Initiated and Pharmaceutical Sponsored Clinical Trials

The Chair continues to participate in international multi-center clinical trials evaluating new treatments/compounds or the safety and efficacy of improving blood sugar control in patients with diabetes and evaluating strategies to reduce cardiovascular disease in high risk individuals with type 2 diabetes.

Support the Development of Training for Diabetes Healthcare Professionals and Researchers

As part of his mandate, the Chair continued to offer diabetes research experience to undergraduate, medical and graduate students. In 2014-15, Dr. Harris advised a second year medical student in the Schulich Research Opportunities Program (SROP), a physician Masters of Clinical Sciences student affiliated with the Department of Family Medicine and a PhD candidate in Nursing. He also acted as a faculty mentor to an undergraduate student through Western’s Scholar’s Electives Program. Other undergraduate students had the opportunity to support NDMS program activities through work study positions. Dr. Harris supported the successful applications of a PhD student in Epidemiology & Biostatistics and a Masters student in the Health Information Science program and will act as their advisor in the coming years.

 

 

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