Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: protocol for a multiple-methods study with a convergent parallel design.

INTRODUCTION: The growth and complexity of diabetes are exceeding the capacity of family physicians, resulting in the demand for community-based, interprofessional, primary care-led transition clinics. The Primary Care Diabetes Support Programme (PCDSP) in London, Ontario, is an innovative approach to diabetes care for high-risk populations, such as medically or socially complex and unattached patients. In this study, we will employ a quadruple-aim approach to evaluate the health system impacts of the PCDSP. METHODS AND ANALYSIS: We will use multiple methods through a convergent parallel design in this project across five unique studies: a case study, a patient study, a provider study, a complications study and a cost-effectiveness study. The project will be conducted in a dedicated stand-alone clinic specialising in chronic disease management, specifically focusing on diabetes care. Participants will include clinic staff, administrators, family physicians, specialists and patients with type 1 or type 2 diabetes who received care at the clinic between 2011 and 2023. The project design will define the intervention, support replication at other sites or for other chronic diseases and address each of the quadruple aims and equity. Following the execution of the five individual studies, we will build a business case by integrating the results. Data will be analysed using both qualitative (content analysis and thematic analysis) and quantitative techniques (descriptive statistics and multiple logistic regression). ETHICS AND DISSEMINATION: We received approval from the research ethics boards at Western University (reference ID: 2023-1 21 766; 2023-1 22 326) and Lawson Health Research Institute (reference ID: R-23-202). A privacy review was completed by St. Joseph's Healthcare Corporation. The findings will be shared among PCDSP staff and patients, stakeholders, academic researchers and the public through stakeholder sessions, conferences, peer-reviewed publications, infographics, posters, media interviews, social media and online discussions. For the patient and provider study, all participants will be asked to provide consent and are free to withdraw from the study, without penalty, until the data are combined. Participants will not be identified in any report or presentation except in the case study, for which, given the number of PCDSP providers, we will seek explicit consent to identify them.

The TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD): economic analysis.

BACKGROUND: Indigenous populations have increased risk of developing diabetes and experience poorer treatment outcomes than the general population. The FORGE AHEAD program partnered with First Nations communities across Canada to improve access to resources by developing community-driven primary healthcare models. METHODS: This was an economic assessment of FORGE AHEAD using a payer perspective. Costs of diabetes management and complications during the 18-month intervention were compared to the costs prior to intervention implementation. Cost-effectiveness of the program assessed incremental differences in cost and number of resources utilization events (pre and post). Primary outcome was all-cause hospitalizations. Secondary outcomes were specialist visits, clinic visits and community resource use. Data were obtained from a diabetes registry and published literature. Costs are expressed in 2023 Can$. RESULTS: Study population was ~ 60.5 years old; 57.2% female; median duration of diabetes of 8 years; 87.5% residing in non-isolated communities; 75% residing in communities < 5000 members. Total cost of implementation was $1,221,413.60 and cost/person $27.89. There was increase in the number and cost of hospitalizations visits from 8/$68,765.85 (pre period) to 243/$2,735,612.37. Specialist visits, clinic visits and community resource use followed this trend. CONCLUSION: Considering the low cost of intervention and increased care access, FORGE AHEAD represents a successful community-driven partnership resulting in improved access to resources.

The Determination of Diabetes Utilities, Costs, and Effects Model: A Cost-Utility Tool Using Patient-Level Microsimulation to Evaluate Sensor-Based Glucose Monitoring Systems in Type 1 and Type 2 Diabetes: Comparative Validation.

OBJECTIVES: To assess the accuracy and validity of the Determination of Diabetes Utilities, Costs, and Effects (DEDUCE) model, a Microsoft-Excel-based tool for evaluating diabetes interventions for type 1 and type 2 diabetes. METHODS: The DEDUCE model is a patient-level microsimulation, with complications predicted based on the Sheffield and Risk Equations for Complications Of type 2 diabetes models for type 1 and type 2 diabetes, respectively. For this tool to be useful, it must be validated to ensure that its complication predictions are accurate. Internal, external, and cross-validation was assessed by populating the DEDUCE model with the baseline characteristics and treatment effects reported in clinical trials used in the Fourth, Fifth, and Ninth Mount Hood Diabetes Challenges. Results from the DEDUCE model were evaluated against clinical results and previously validated models via mean absolute percentage error or percentage error. RESULTS: The DEDUCE model performed favorably, predicting key outcomes, including cardiovascular disease in type 1 diabetes and all-cause mortality in type 2 diabetes. The model performed well against other models. In the Mount Hood 9 Challenge comparison, error was below the mean reported from comparator models for several outcomes, particularly for hazard ratios. CONCLUSIONS: The DEDUCE model predicts diabetes-related complications from trials and studies well when compared with previously validated models. The model may serve as a useful tool for evaluating the cost-effectiveness of diabetes technologies.

Use of the FreeStyle Libre system and diabetes treatment progression in T2DM: Results from a retrospective cohort study using a Canadian private payer claims database.

BACKGROUND: Up to one-third of Canadians are estimated to be living with prediabetes or diabetes. A retrospective study using Canadian private drug claims data was conducted to investigate whether flash glucose monitoring using the FreeStyle Libre system (FSL) among people with type 2 diabetes mellitus (T2DM) in Canada can be associated with changes in treatment intensification when compared with blood glucose monitoring (BGM) alone. MATERIALS AND METHODS: Using a Canadian national private drug claims database comprising approximately 50% coverage of insured individuals in Canada, cohorts of people with T2DM using FSL or BGM were identified algorithmically based on treatment history and followed over a 24-month study period, tracking their progression in diabetes treatment therapy. The Andersen-Gill model for recurrent time-to-event data was used to evaluate whether the rate of treatment progression differs between the FSL and BGM treatment cohorts. The survival function was used to calculate comparative treatment progression probabilities between the cohorts. RESULTS: In total, 373 871 people with T2DM met the inclusion criteria. Across treatment (FSL) and control (BGM) groups, people using FSL had a higher probability of treatment progression compared with BGM alone, with a relative risk ranging between 1.86 and 2.81 (p < .001). A higher probability of treatment progression was independent of the diabetes treatment at the enrolment date (index date) or the patient status, and independent of whether patients were treatment naïve or on established diabetes therapy. Assessment of the ending treatment relative to the starting therapy indicated that dynamic treatment changes were most evident for patients in the FSL cohort and that the FSL cohort had a much greater portion of patients who ended with insulin treatment (when they started with non-insulin treatment) compared with the BGM cohort. CONCLUSIONS: People with T2DM using FSL had a greater probability for treatment progression compared with BGM alone, irrespective of the starting therapy, which may suggest that FSL can be used to support escalation of diabetes therapy to improve therapeutic inertia in T2DM.

National Survey of Indigenous primary healthcare capacity and delivery models in Canada: the TransFORmation of IndiGEnous PrimAry HEAlthcare delivery (FORGE AHEAD) community profile survey.

BACKGROUND: There is a significant deficiency of national health information for Indigenous peoples in Canada. This manuscript describes the Community Profile Survey (CPS), a community-based, national-level survey designed to identify and describe existing healthcare delivery, funding models, and diabetes specific infrastructure and programs in Indigenous communities. METHODS: The CPS was developed collaboratively through FORGE AHEAD and the First Nations and Inuit Health Branch of Health Canada. Regional and federal engagement and partnerships were built with Indigenous organizations to establish regionally-tailored distribution of the 8-page CPS to 440 First Nations communities. Results were collected (one survey per community) and reported in strata by region, with descriptive analyses performed on all variables. Results were shared with participating communities and regional/federal partners through tailored reports. RESULTS: A total of 84 communities completed the survey (19% response rate). The majority of communities had a health centre/office to provide service to their patients with diabetes, with limited on-reserve hospitals for ambulatory or case-sensitive conditions. Few healthcare specialists were located on-site, with patients frequently travelling off-site (> 40 km) for diabetes-related complications. The majority of healthcare professionals on-site were Health Directors, Community Health Nurses, and Home Care Nurses. Many communities had a diabetes registry but few reported a diabetes surveillance system. Regional variation in healthcare services, diabetes programs, and funding models were noted, with most communities engaging in some type of innovative strategy to improve care for patients with diabetes. CONCLUSIONS: The CPS is the first community-based, national-level survey of its kind in Canada. Although the response rate was low, the CPS was distributed and successfully administered across a broad range of First Nations communities, and future considerations would benefit from a governance structure and leadership that strengthens community engagement, and a longitudinal research approach to increase the representativeness of the data. This type of information is important for communities and regions to inform decision making (maintain successes, and identify areas for improvement), strengthen health service delivery and infrastructure, increase accessibility to healthcare personnel, and allocate funding and/or resources to build capacity and foster a proactive chronic disease prevention and management approach for Indigenous communities across Canada. TRIAL REGISTRATION: Current ClinicalTrial.gov protocol ID NCT02234973 . Registered: September 9, 2014.

A qualitative enquiry of hypoglycemia and the social determinants of health: The InHypo-DM study, Canada.

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).

Canadian Alliance for Healthy Hearts and Minds: First Nations Cohort Study Rationale and Design.

BACKGROUND: This is the first national indigenous cohort study in which a common, in-depth protocol with a common set of objectives has been adopted by several indigenous communities across Canada. OBJECTIVES: The overarching objective of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to investigate how the community-level environment is associated with individual health behaviors and the presence and progression of chronic disease risk factors and chronic diseases such as cardiovascular disease (CVD) and cancer. METHODS: CAHHM aims to recruit approximately 2,000 First Nations indigenous individuals from up to nine communities across Canada and have participants complete questionnaires, blood collection, physical measurements, cognitive assessments, and magnetic resonance imaging (MRI). RESULTS: Through individual- and community-level data collection, we will develop an understanding of the specific role of the socioenvironmental, biological, and contextual factors have on the development of chronic disease risk factors and chronic diseases. CONCLUSIONS: Information collected in the indigenous cohort will be used to assist communities to develop local management strategies for chronic disease, and can be used collectively to understand the contextual, environmental, socioeconomic, and biological determinants of differences in health status in harmony with First Nations beliefs and reality.

Call to action: A new path for improving diabetes care for Indigenous peoples, a global review.

Diabetes has reached epidemic proportions in Indigenous populations around the globe, and there is an urgent need to improve the health and health equity of Indigenous peoples with diabetes through timely and appropriate diabetes prevention and management strategies. This review describes the evolution of the diabetes epidemic in Indigenous populations and associated risk factors, highlighting gestational diabetes and intergenerational risk, lifestyle risk factors and social determinants as having particular importance and impact on Indigenous peoples. This review further describes the impact of chronic disease and diabetes on Indigenous peoples and communities, specifically diabetes-related comorbidities and complications. This review provides continued evidence that dramatic changes are necessary to reduce diabetes-related inequities in Indigenous populations, with a call to action to support programmatic primary healthcare transformation capable of empowering Indigenous peoples and communities and improving chronic disease prevention and management. Promising strategies for transforming health services and care for Indigenous peoples include quality improvement initiatives, facilitating diabetes and chronic disease registry and surveillance systems to identify care gaps, and prioritizing evaluation to build the evidence-base necessary to guide future health policy and planning locally and on a global scale.

The power of two: an update on fixed-dose combinations for type 2 diabetes.

INTRODUCTION: Patients with type 2 diabetes mellitus (T2DM) are unlikely to maintain glycemic control with monotherapy, and will eventually require therapy with multiple antihyperglycemic agents (AHAs). Combination therapy regimens with multiple AHAs may be complex and negatively impact patient adherence. Fixed-dose combinations (FDCs) are used successfully for management of numerous chronic diseases. Areas covered: This article includes a brief overview of the add-on approach of current treatment guidelines for T2DM and reviews the evidence supporting the utility of oral FDCs in the treatment of T2DM, including recently developed oral FDCs (2010-2016). Benefits regarding safety and tolerability, adherence and cost are also discussed. Finally, the barriers limiting the use of FDCs and how these barriers may be overcome are addressed. Expert commentary: Therapeutic strategies including FDCs need to be implemented on a larger scale. FDCs have the potential to simplify treatment regimens, improve adherence and provide long-term glycemic control.

An innovative model of diabetes care and delivery: the St. Joseph's Primary Care Diabetes Support Program (SJHC PCDSP).

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.

Prevalence and epidemiology of diabetes in Canadian primary care practices: a report from the Canadian Primary Care Sentinel Surveillance Network.

OBJECTIVE: The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is a large, validated national primary care Electronic Medical Records (EMR)-based database. Our objective was to describe the epidemiology of diabetes in this Canadian sample. METHODS: We analyzed the records of 272 469 patients10 years of age and older, with at least 1 primary care clinical encounter between January 1, 2011, and December 31, 2012. We calculated the age-gender standardized prevalence of diabetes. We compared health care utilization and comorbidities for 7 selected chronic conditions in patients with and without diabetes. We also examined patterns of medication usage. RESULTS: The estimated population prevalence of diabetes was 7.6%. Specifically, we studied 25 425 people with diabetes who had at least 1 primary care encounter in 2 years. On average, patients with diabetes had 1.42 times as many practice encounters as patients without diabetes (95% CI 1.42 to 1.43, p<0.0001). Patients with diabetes had 1.29 times as many other comorbid conditions as those without diabetes (95% CI 1.27 to 1.31, p<0.0001). We found that 85.2% of patients taking hypoglycemic medications were taking metformin, and 51.8% were taking 2 or more classes of medications. CONCLUSIONS: This study is the first national Canadian report describing the epidemiology of diabetes using primary care EMR-based data. We found significantly higher rates of primary care use, and greater numbers of comorbidities in patients with diabetes. Most patients were on first-line hypoglycemic medications. Data routinely recorded in EMRs can be used for surveillance of chronic diseases such as diabetes in Canada. These results can enable comparisons with other national EMR-based datasets.

Room for improvement in diabetes care among First Nations in northern Quebec (Eeyou Istchee): reasonable management of glucose but poor management of complications.

OBJECTIVES: To evaluate the clinical management of type 2 diabetes in the Eeyou Istchee communities of northern Quebec. STUDY DESIGN: Retrospective quality assurance audit. METHODS: Patients with diabetes were identified using the Cree Diabetes Information System. Charts of eligible patients were audited for healthcare visits, glycemic control, blood pressure, lipid profile, pharmacological treatment and complications for the 2006 calendar year. Analyses were performed to assess the association of disease duration, age, target glycemic and blood pressure control with diabetes complications. RESULTS: Half of the patients (49.7%) achieved target HbA1c, 53.6% had a blood pressure of ≤130/80 and 58.7% had an LDL of ≤2.5 mmol/L. The proportion of patients meeting all 3 targets was low at 17.1%. The mean number of diabetes-related clinic visits was high, with an average of 3.9 visits to a physician and an average of 8.7 visits to a registered nurse. Of patients with a documented diabetic complication, 39.4% of patients were not being managed with an ACE/ARB and 48.2% of patients were not prescribed a statin. CONCLUSIONS: These findings suggest a possible treatment gap for risk factors and complications management. To circumvent further increases in diabetes-related complications, emphasis should be placed on improved healthcare worker training, greater use of clinical management and patient education tools and improved communication during the diabetes-related clinical visits. Development of a culturally appropriate multidisciplinary approach towards improved understanding of diabetes and multifactorial risk management for diabetic patients is essential for the prevention of diabetic complications.

Providers' perceptions of barriers to the management of type 2 diabetes in remote Aboriginal settings.

OBJECTIVES: To examine providers' perspectives of the barriers to providing diabetes care in remote First Nation communities in the Sioux Lookout Zone (SLZ) of Northwestern Ontario, Canada. STUDY DESIGN: A qualitative study involving key informant interviews and focus groups was conducted with health care providers working in remote First Nation communities in SLZ. METHODS: Twenty-four nurses, doctors, diabetes educators and community health representatives (CHRs) participated in qualitative interviews and focus groups. Data collected from the interviews and focus groups was coded and thematically analysed using NVIVO software. RESULTS: Barriers to diabetes care were grouped into patient, clinic and system factors. Providers' perceptions of patient factors were divided between those advocating for a patient-provider partnership and those advocating for greater patient responsibility. Clinic-related barriers such as short staffing, staff turnover and system fragmentation were discussed, but were often overshadowed by a focus on patient factors and a general sense of frustration among providers. Cultural awareness and issues with clinic management were not mentioned, though they are both within the providers' control. CONCLUSIONS: This study characterizes a range of barriers to diabetes care and shows that patient-related factors are of primary concern for many providers. We conclude that patient-focused interventions and cultural competence training may help improve patient-provider partnerships. Funding and supporting quality improvement initiatives and clinic reorganization may increase the providers' knowledge of the potential for clinical strategies to improve patient outcomes and focus attention on those factors that providers can change. Future research into the factors driving quality of care and strategies that can improve care in Aboriginal communities should be a high priority in addressing the rising burden of diabetes and related complications.

Investigating concordance in diabetes diagnosis between primary care charts (electronic medical records) and health administrative data: a retrospective cohort study.

BACKGROUND: Electronic medical records contain valuable clinical information not readily available elsewhere. Accordingly, they hold important potential for contributing to and enhancing chronic disease registries with the goal of improving chronic disease management; however a standard for diagnoses of conditions such as diabetes remains to be developed. The purpose of this study was to establish a validated electronic medical record definition for diabetes. METHODS: We constructed a retrospective cohort using health administrative data from the Institute for Clinical Evaluative Sciences Ontario Diabetes Database linked with electronic medical records from the Deliver Primary Healthcare Information Project using data from 1 April 2006-31 March 2008 (N = 19,443). We systematically examined eight definitions for diabetes diagnosis, both established and proposed. RESULTS: The definition that identified the highest number of patients with diabetes (N = 2,180) while limiting to those with the highest probability of having diabetes was: individuals with ≥2 abnormal plasma glucose tests, or diabetes on the problem list, or insulin prescription, or ≥2 oral anti-diabetic agents, or HbA1c ≥6.5%. Compared to the Ontario Diabetes Database, this definition identified 13% more patients while maintaining good sensitivity (75%) and specificity (98%). CONCLUSIONS: This study establishes the feasibility of developing an electronic medical record standard definition of diabetes and validates an algorithm for use in this context. While the algorithm may need to be tailored to fit available data in different electronic medical records, it contributes to the establishment of validated disease registries with the goal of enhancing research, and enabling quality improvement in clinical care and patient self-management.

Patient age, ethnicity, medical history, and risk factor profile, but not drug insurance coverage, predict successful attainment of glycemic targets: Time 2 Do More Quality Enhancement Research Initiative (T2DM QUERI).

OBJECTIVE: To identify factors in patients with type 2 diabetes and A1C >7.0% associated with attainment of A1C ≤ 7.0%. RESEARCH DESIGN AND METHODS: We used a prospective registry of 5,280 Canadian patients in primary care settings enrolled in a 12-month glycemic pharmacotherapy optimization strategy based on national guidelines. RESULTS: At close out, median A1C was 7.1% (vs. 7.8% at baseline) with 48% of subjects achieving A1C ≤ 7.0% (P < 0.0001). Older patients of Asian or black origin, those with longer diabetes duration, those with lower baseline A1C, BMI, LDL cholesterol, and blood pressure, and those on angiotensin receptor blockers and a lower number of antihyperglycemic agents, were more likely to achieve A1C ≤ 7.0% at some point during the study (all P < 0.0235). Access to private versus public drug coverage did not impact glycemic target realization. CONCLUSIONS: Patient demography, cardiometabolic health, and ongoing pharmacotherapy, but not access to private drug insurance coverage, contribute to the care gap in type 2 diabetes.

The geography of diabetes in London, Canada: the need for local level policy for prevention and management.

Recent reports aimed at improving diabetes care in socially disadvantaged populations suggest that interventions must be tailored to meet the unique needs of the local community-specifically, the community's geography. We have examined the spatial distribution of diabetes in the context of socioeconomic determinants of health in London (Ontario, Canada) to characterize neighbourhoods in an effort to target these neighbourhoods for local level community-based program planning and intervention. Multivariate spatial-statistical techniques and geographic information systems were used to examine diabetes rates and socioeconomic variables aggregated at the census tract level. Creation of a deprivation index facilitated investigation across multiple determinants of health. Findings from our research identified 'at risk' neighbourhoods in London with socioeconomic disadvantage and high diabetes. Future endeavours must continue to identify local level trends in order to support policy development, resource planning and care for improved health outcomes and improved equity in access to care across geographic regions.

Childhood overweight and obesity management: A national perspective of primary health care providers' views, practices, perceived barriers and needs.

BACKGROUND: Obesity and overweight in children are an escalating problem in Canada and worldwide. Currently, little is known about the manner in which primary health care providers are responding to Canada's obesity epidemic. OBJECTIVE: To determine the views, practices, challenges/barriers, and needs of a national sample of family physicians (FPs) and community paediatricians (CPs) with respect to paediatric obesity identification and management. METHODS: A self-administered questionnaire was mailed to a random sample of 1200 FPs and 1200 CPs across Canada between 2005 and 2006. RESULTS: A total of 464 FPs and 396 CPs participated. The majority of practitioners viewed paediatric obesity as an 'important'/'very important' issue. Although the majority reported providing dietary (more than 85%) and exercise (98%) advice to their overweight/obese patients, practitioners' perceived success rate in treating paediatric obesity was limited (less than 22%). Approximately 30% of FPs and 60% of CPs (P<0.05) used the recommended method to identify paediatric obesity. At least 50% of practitioners indicated that too few government-funded dietitians, a lack of success in controlling paediatric patients' weight, time constraints and limited training were key barriers to their success. To support efforts to identify or manage paediatric obesity, practitioners identified the need for office tools, patient educational materials and system-level changes. DISCUSSION: Canadian primary health care providers are not adequately equipped to deal with the paediatric obesity epidemic. Effective assessment tools and treatment resources, dissemination of clinical practice guidelines, enhanced undergraduate medical education and postgraduate continuing medical education, and system-level changes are urgently needed to address this health problem.

Treatment satisfaction of diabetic patients: what are the contributing factors?

BACKGROUND: Treatment satisfaction is an important factor of quality of care, especially in treating chronic diseases such as diabetes mellitus. Identifying factors that independently influence treatment satisfaction may help in improving clinical outcomes. OBJECTIVE: To find the relationship between treatment satisfaction of diabetic patients and socio-demographic, clinical, adherence, treatment and health perception factors. METHODS: Patients were interviewed by telephone about their socio-demographic parameters, health status, clinical data and treatment factors. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) was used to measure satisfaction and adherence. This is a cross-sectional study, as part of a larger study of chronic patients in Israel. Subjects were randomly selected diabetes patients. The main outcome measures were DTSQ levels. A multivariate linear regression model was constructed to identify factors independently associated with patients' satisfaction. RESULTS: In all, 630 patients were included in the study. Multivariate analysis indicated that demographic parameters (e.g. female gender, P = 0.036), treatment factors (e.g. type of medication, P < 0.001), adherence factors (e.g. difficulty attending follow-up or taking medications, P < 0.001) and clinical factors (e.g. diabetes complications, P < 0.01) were independently associated with lower treatment satisfaction. CONCLUSIONS: Treatment satisfaction is lower among diabetic patients who have a lower educational level, who are insulin treated or have a diabetic complication and is related to difficulties in taking medications and coming to follow-up visits. Addressing the specific needs of these patients might be effective in improving their satisfaction, thus having a positive influence on other clinical outcomes.