Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes.

BACKGROUND: There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations. OBJECTIVES: To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care. SEARCH METHODS: We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section. SELECTION CRITERIA: We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy. DATA COLLECTION AND ANALYSIS: We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available. MAIN RESULTS: We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other). AUTHORS' CONCLUSIONS: There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Alignment of patient-centredness definitions with real-life patient and clinician experiences: A qualitative study.

INTRODUCTION: Patient-centred care (PCC) has come to the forefront for many institutions, funding agencies and clinicians, and is integrated into care. Does a disconnect in understanding still exist between patients, healthcare organizations and clinicians in what PCC means and how outstanding issues might be addressed? METHODS: We conducted interviews and focus groups with self-reported chronic care patients and clinicians providing care to these patients exploring PCC experiences, expectations and practices. These data were initially analysed using inductive thematic analysis. This paper reports on the findings of a secondary analysis examining the alignment between patients and clinicians on five key predetermined dimensions of PCC. RESULTS: Eighteen patients participated, representing a range of chronic conditions. Thirty-eight clinicians participated. One thousand and three hundred patient and 1800 clinician codes were identified and grouped into 5 main topics with 140 unique themes (patients) and 9 main topics with 54 unique themes (clinicians). A total of 166 quotes (patient = 93, clinician = 73) were identified for this PCC definition alignment analysis. Partial or complete alignment of patient and clinician perspectives was seen on most dimensions. Key disconnects were observed in patient involvement, patient empowerment and clinician-patient communication. Only 18% of patients reported experiencing patient-centred communication, whereas 57% of clinicians reported using patient-focused communication approaches. CONCLUSION: Overall, study patients and clinicians endorse that many PCC elements occur. This study highlights key differences between patients and clinicians, suggesting persistent challenges. Clinician participants relayed their PCC approaches of informing and educating patients; however, patients often perceive these approaches as didactic, role-diminishing and noncollaborative. Collaborative approaches, such as shared decision-making, hold promise to bridge persistent PCC gaps and should be integrated into medical education programmes. PATIENT OR PUBLIC CONTRIBUTION: This project was conceived and executed with a co-design approach wherein patients with chronic conditions who are trained in research (i.e., see descriptions of Patient and Community Engagement Research in the text) were involved in all stages of the research project alongside other researchers on the project team. Healthcare providers were involved as participants and as principal investigators in the project.

Correction to: Methods for identifying 30 chronic conditions: application to administrative data.

Following publication of the original manuscript [1], the authors noted several errors in Table 1. Details of the requested corrections are shown below.

Intercountry Consensus Building: Lessons From Developing a Chronic-Conditions Self-Management Support Framework.

Self-management support initiatives that aim to improve the self-care of chronic conditions are considered a key part of a health promotion strategy for addressing the impacts of long-term illness. Given the growth of these activities and still evolving evidence base, thoughtful intercountry collaborations with subject matter experts can be an effective way to expedite building self-management support capacity, promoting the advancement of evidence, and developing effective policies and programs. The challenge is to find an effective consensus building process that promotes linkages between researchers and health promotion decisions makers across vast geographical boundaries and limited resources. This paper describes the international, multistage, face-to-face, and online process that was used for developing an international framework for self-management support by researchers, educators, health care providers, policy makers, program managers/directors, program planners, consultants, patient group representatives, and consumers in 16 countries. We reflect on key lessons from this international initiative and discuss how this type of process may be useful for other health promotion groups trying to exchange knowledge and build consensus on how to move a field of research, policy, and/or practice forward, and advance the evidence-base of practice and the relevance of research.

Toward consensus on self-management support: the international chronic condition self-management support framework.

Self-management support (SMS) initiatives have been hampered by insufficient attention to underserved and disadvantaged populations, a lack of integration between health, personal and social domains, over emphasis on individual responsibility and insufficient attention to ethical issues. This paper describes a SMS framework that provides guidance in developing comprehensive and coordinated approaches to SMS that may address these gaps and provides direction for decision makers in developing and implementing SMS initiatives in key areas at local levels. The framework was developed by researchers, policy-makers, practitioners and consumers from 5 English-speaking countries and reviewed by 203 individuals in 16 countries using an e-survey process. While developments in SMS will inevitably reflect local and regional contexts and needs, the strategic framework provides an emerging consensus on how we need to move SMS conceptualization, planning and development forward. The framework provides definitions of self-management (SM) and SMS, a collective vision, eight guiding principles and seven strategic directions. The framework combines important and relevant SM issues into a strategic document that provides potential value to the SMS field by helping decision-makers plan SMS initiatives that reflect local and regional needs and by catalyzing and expanding our thinking about the SMS field in relation to system thinking; shared responsibility; health equity and ethical issues. The framework was developed with the understanding that our knowledge and experience of SMS is continually evolving and that it should be modified and adapted as more evidence is available, and approaches in SMS advance.

Comorbidity as a driver of adverse outcomes in people with chronic kidney disease.

Chronic kidney disease (CKD) is associated with poor outcomes, perhaps due to a high burden of comorbidity. Most studies of CKD populations focus on concordant comorbidities, which cause CKD (such as hypertension and diabetes) or often accompany CKD (such as heart failure or coronary disease). Less is known about the burden of mental health conditions and discordant conditions (those not concordant but still clinically relevant, like dementia or cancer). Here we did a retrospective population-based cohort study of 530,771 adults with CKD residing in Alberta, Canada between 2003 and 2011. Validated algorithms were applied to data from the provincial health ministry to assess the presence/absence of 29 chronic comorbidities. Linkage between comorbidity burden and adverse clinical outcomes (mortality, hospitalization or myocardial infarction) was examined over median follow-up of 48 months. Comorbidities were classified into three categories: concordant, mental health/chronic pain, and discordant. The median number of comorbidities was 1 (range 0-15) but a substantial proportion of participants had 3 and more, or 5 and more comorbidities (25 and 7%, respectively). Concordant comorbidities were associated with excess risk of hospitalization, but so were discordant comorbidities and mental health conditions. Thus, discordant comorbidities and mental health conditions as well as concordant comorbidities are important independent drivers of the adverse outcomes associated with CKD.

Methods for identifying 30 chronic conditions: application to administrative data.

BACKGROUND: Multimorbidity is common and associated with poor clinical outcomes and high health care costs. Administrative data are a promising tool for studying the epidemiology of multimorbidity. Our goal was to derive and apply a new scheme for using administrative data to identify the presence of chronic conditions and multimorbidity. METHODS: We identified validated algorithms that use ICD-9 CM/ICD-10 data to ascertain the presence or absence of 40 morbidities. Algorithms with both positive predictive value and sensitivity ≥70% were graded as "high validity"; those with positive predictive value ≥70% and sensitivity <70% were graded as "moderate validity". To show proof of concept, we applied identified algorithms with high to moderate validity to inpatient and outpatient claims and utilization data from 574,409 people residing in Edmonton, Canada during the 2008/2009 fiscal year. RESULTS: Of the 40 morbidities, we identified 30 that could be identified with high to moderate validity. Approximately one quarter of participants had identified multimorbidity (2 or more conditions), one quarter had a single identified morbidity and the remaining participants were not identified as having any of the 30 morbidities. CONCLUSIONS: We identified a panel of 30 chronic conditions that can be identified from administrative data using validated algorithms, facilitating the study and surveillance of multimorbidity. We encourage other groups to use this scheme, to facilitate comparisons between settings and jurisdictions.

Use of chronic disease management programs for diabetes: in Alberta's primary care networks.

OBJECTIVE: To determine the types of chronic disease management (CDM) programs offered for patients with diabetes in Alberta's primary care networks (PCNs). DESIGN: A survey was administered to PCNs to determine the types of CDM programs offered for patients with diabetes; CDM programs were organized into categories by their resource intensity and effectiveness. Results of the survey were reported using frequencies and percentages. SETTING: Alberta has recently created PCNs-groups of family physicians who receive additional funds to enable them to support activities that fall outside the typical physician-based fee-for-service model, but which address specified objectives including CDM. It is currently unknown what additional programs are being provided through the PCN supplemental funding. PARTICIPANTS: A survey was administered to the individual responsible for CDM in each PCN. This included executive directors, chronic disease managers, and CDM nurses. MAIN OUTCOME MEASURES: We determined the CDM strategies used in each PCN to care for patients with diabetes, whether they were available to all patients, and whether the services were provided exclusively by the PCN or in conjunction with other agencies. RESULTS: There was considerable variation across PCNs with respect to the CDM programs offered for people with diabetes. Nearly all PCNs used multidisciplinary teams (which could include nurses, dietitians, and pharmacists) and patient education. Fewer than half of the PCNs permitted personnel other than the primary physician to write or alter prescriptions for medications. CONCLUSION: Alberta's PCNs have successfully established many different types of CDM programs. Multidisciplinary care teams, which are among the most effective CDM strategies, are currently being used by most of Alberta's PCNs.

Enrolment in primary care networks: impact on outcomes and processes of care for patients with diabetes.

BACKGROUND: Primary care networks are a newer model of primary care that focuses on improved access to care and the use of multidisciplinary teams for patients with chronic disease. We sought to determine the association between enrolment in primary care networks and the care and outcomes of patients with diabetes. METHODS: We used administrative health care data to study the care and outcomes of patients with incident and prevalent diabetes separately. For patients with prevalent diabetes, we compared those whose care was managed by physicians who were or were not in a primary care network using propensity score matching. For patients with incident diabetes, we studied a cohort before and after primary care networks were established. Each cohort was further divided based on whether or not patients were cared for by physicians enrolled in a network. Our primary outcome was admissions to hospital or visits to emergency departments for ambulatory care sensitive conditions specific to diabetes. RESULTS: Compared with patients whose prevalent diabetes is managed outside of primary care networks, patients in primary care networks had a lower rate of diabetes-specific ambulatory care sensitive conditions (adjusted incidence rate ratio 0.81, 95% confidence interval [CI] 0.75 to 0.87), were more likely to see an ophthalmologist or optometrist (risk ratio 1.19, 95% CI 1.17 to 1.21) and had better glycemic control (adjusted mean difference -0.067, 95% CI -0.081 to -0.052). INTERPRETATION: Patients whose diabetes was managed in primary care networks received better care and had better clinical outcomes than patients whose condition was not managed in a network, although the differences were very small.

How a hobby can shape cognition: visual word recognition in competitive Scrabble players.

Competitive Scrabble is an activity that involves extraordinary word recognition experience. We investigated whether that experience is associated with exceptional behavior in the laboratory in a classic visual word recognition paradigm: the lexical decision task (LDT). We used a version of the LDT that involved horizontal and vertical presentation and a concreteness manipulation. In Experiment 1, we presented this task to a group of undergraduates, as these participants are the typical sample in word recognition studies. In Experiment 2, we compared the performance of a group of competitive Scrabble players with a group of age-matched nonexpert control participants. The results of a series of cognitive assessments showed that the Scrabble players and control participants differed only in Scrabble-specific skills (e.g., anagramming). Scrabble expertise was associated with two specific effects (as compared to controls): vertical fluency (relatively less difficulty judging lexicality for words presented in the vertical orientation) and semantic deemphasis (smaller concreteness effects for word responses). These results suggest that visual word recognition is shaped by experience, and that with experience there are efficiencies to be had even in the adult word recognition system.

Enhancing Diabetes Surveillance Across Alberta by Adding Laboratory and Pharmacy Data to the National Diabetes Surveillance System Methods.

OBJECTIVES: The National Diabetes Surveillance System (NDSS) case definition, which identifies a case of diabetes using administrative health records as "two physician claims or one hospital discharge abstract record, within a 2-year period for a diagnosis bearing International Classification of Disease codes for diabetes," was compared with expanded case definitions, including pharmacy (PHARM) and laboratory (LAB) data. The PHARM definition included any therapeutic antihyperglycemic agents, and the LAB definition included thresholds of ≥1 glycated hemoglobin measurement of ≥6.5%, or 2 instances of random glucose ≥11.1 mmol/L or fasting glucose ≥7.0 mmol/L. METHODS: In this retrospective study we used administrative data from the Diabetes Infrastructure for Surveillance, Evaluation, and Research project. Descriptive statistics were used to characterize participants by several subgroups. RESULTS: The NDSS identified 291,242 diabetes cases, indicating a provincial prevalence of 6.83%. Using LAB plus PHARM identified 52,040 additional cases, so the combination of NDSS or LAB or PHARM identified the largest number of cases (n=343,282), increasing the diabetes prevalence estimate to 8.06%. These 3 sources resulted in 7 unique subsets: NDSS only (n=42,606), PHARM only (n=16,310), LAB only (n=32,202), NDSS+LAB (n=32,582), NDSS+PHARM (n=22,503), LAB+PHARM (n=3,528) and NDSS+LAB+PHARM (n=193,551). Refinement using demographic and clinical characteristics allowed presumptive cases of polycystic ovarian syndrome to be excluded. CONCLUSIONS: The widely used NDSS case definition can be enhanced by the addition of LAB and PHARM data. Including PHARM and LAB data identified subsets of the diabetes population, which can maximize the yield for detection of diabetes cases in Alberta and provide a richer understanding of this population to target interventions to improve health outcomes.

Use of Virtual Care for Glycemic Management in People With Types 1 and 2 Diabetes and Diabetes in Pregnancy: A Rapid Review.

Our objective in this study was to answer the main research question: In patients with diabetes, does virtual care vs face-to-face care provide different clinical, patient and practitioner experience or quality outcomes? Articles (2012 to 2020) describing interventions using virtual care with the capability for 2-way, individualized interactions compared with usual care were included. Studies involving any patients with diabetes and outcomes of glycated hemoglobin (A1C), quality of care and/or patient or health-care practitioner experience were included. Systematic reviews, randomized controlled studies, quasi-experimental trials, implementation trials, observational studies and qualitative analyses were reviewed. MEDLINE and McMaster Health Evidence databases searched in June 2020 identified 59 articles. Virtual care, in particular telemonitoring, combined with a means of 2-way communications provided improvement in A1C similar or superior to usual care, with the strongest evidence for type 2 diabetes. Virtual care was generally acceptable to patients, who expressed satisfaction with their care. Health-care providers recognized benefits but raised issues of technical support, workflow and compensation.

Revision of Alberta's Provincial Insulin Pump Therapy Criteria for Adults and Children With Type 1 Diabetes: Process, Rationale and Framework for Evaluation.

OBJECTIVES: Insulin pump therapy is a valuable, but costly approach, with public funding in Alberta for eligible individuals since 2013. The Provincial Insulin Pump Therapy Program Clinical Advisory Committee has revised and updated the clinical criteria, integrating current literature, best practice and feedback from clinicians. The objective was to develop criteria that would: 1) optimize safety and effectiveness of insulin pump therapy, while 2) carefully stewarding resources available to care for people with type 1 diabetes. METHODS: The Clinical Advisory Committee comprised health-care professionals with expertise in pump therapy and included adult and pediatric endocrinologists, an internist, a pediatrician, certified pump trainers, diabetes educators and clinic managers. The group meets regularly by teleconference. Decisions are made by consensus. RESULTS: Indications for insulin pump therapy for adults and children with insulin-deficient diabetes were divided into 4 hierarchical levels: 1) problematic hypoglycemia, inability to achieve acceptable control or progressive complications; 2) unpredictable activity, dawn phenomenon or children for whom use of multiple daily injections is not appropriate; 3) individual preference and 4) clinical exception, with priority given to indications with clear evidence of benefit. The criteria emphasize the importance of: 1) adequate education in diabetes self-management; 2) adequate trial of flexible insulin therapy with modern analogues and 3) evidence of active, safe diabetes self-management. Tools to facilitate effective and efficient annual review and surveillance were developed incorporating biological, behavioural evaluation and self-reflection to provide a framework for program evaluation. The recommendations were implemented in January 2019. CONCLUSIONS: The process and revised criteria may be valuable for jurisdictions considering how to develop and implement a publicly funded insulin pump program.

Validity of administrative data claim-based methods for identifying individuals with diabetes at a population level.

OBJECTIVES: This study assessed the validity of a widely-accepted administrative data surveillance methodology for identifying individuals with diabetes relative to three laboratory data reference standard definitions for diabetes. METHODS: We used a combination of linked regional data (hospital discharge abstracts and physician data) and laboratory data to test the validity of administrative data surveillance definitions for diabetes relative to a laboratory data reference standard. The administrative discharge data methodology includes two definitions for diabetes: a strict administrative data definition of one hospitalization code or two physician claims indicating diabetes; and a more liberal definition of one hospitalization code or a single physician claim. The laboratory data, meanwhile, produced three reference standard definitions based on glucose levels +/- HbA1c levels. RESULTS: Sensitivities ranged from 68.4% to 86.9% for the administrative data definitions tested relative to the three laboratory data reference standards. Sensitivities were higher for the more liberal administrative data definition. Positive predictive values (PPV), meanwhile, ranged from 53.0% to 88.3%, with the liberal administrative data definition producing lower PPVs. CONCLUSIONS: These findings demonstrate the trade-offs of sensitivity and PPV for selecting diabetes surveillance definitions. Centralized laboratory data may be of value to future surveillance initiatives that use combined data sources to optimize case detection.

The impact of the use of video-based educational interventions on patient outcomes in hospital settings: A scoping review.

OBJECTIVE: To summarize the literature on the impact of video-based educational interventions on patient outcomes in inpatient settings as compared to standard education techniques. METHODS: This review followed a scoping review methodology. English language articles were searched in Pubmed, Medline, Cochrane, and CINAHL databases. Inclusion criteria were: use of video-based educational interventions, and inpatient hospital settings. Abstracts were reviewed and selected according to predetermined criteria, followed by full-text scrutiny. RESULTS: Sixty-two empirical studies were identified, with 38 (61%) reporting a significant positive effect of video-based educational interventions on patient outcomes, compared to control groups (i.e., standard education). Three different types of video-based educational intervention formats were identified: animated presentations, professionals in practice, and patient narratives. Outcome types included: knowledge-based, clinical, emotional, and behavioral, with knowledge-based most prevalent. CONCLUSION: Video-based educational interventions are common in the hospital setting. These interventions are effective at improving short-term health literacy goals, but their impact on behavior or lifestyle modifications is unclear. Their effectiveness also depends on presentation format, timing, and the patient's emotional well-being. PRACTICE IMPLICATIONS: Video-based educational delivery is effective for improving short-term health literacy, however a combination of approaches delivered over an extended period of time may support improving longer-term health outcomes.

Clinical and medication profiles stratified by household income in patients referred for diabetes care.

BACKGROUND: Low income individuals with diabetes are at particularly high risk for poor health outcomes. While specialized diabetes care may help reduce this risk, it is not currently known whether there are significant clinical differences across income groups at the time of referral. The objective of this study is to determine if the clinical profiles and medication use of patients referred for diabetes care differ across income quintiles. METHODS: This cross-sectional study was conducted using a Canadian, urban, Diabetes Education Centre (DEC) database. Clinical information on the 4687 patients referred to the DEC from May 2000 - January 2002 was examined. These data were merged with 2001 Canadian census data on income. Potential differences in continuous clinical parameters across income quintiles were examined using regression models. Differences in medication use were examined using Chi square analyses. RESULTS: Multivariate regression analysis indicated that income was negatively associated with BMI (p < 0.0005) and age (p = 0.023) at time of referral. The highest income quintiles were found to have lower serum triglycerides (p = 0.011) and higher HDL-c (p = 0.008) at time of referral. No significant differences were found in HBA1C, LDL-c or duration of diabetes. The Chi square analysis of medication use revealed that despite no significant differences in HBA1C, the lowest income quintiles used more metformin (p = 0.001) and sulfonylureas (p < 0.0005) than the wealthy. Use of other therapies were similar across income groups, including lipid lowering medications. High income patients were more likely to be treated with diet alone (p < 0.0005). CONCLUSION: Our findings demonstrate that low income patients present to diabetes clinic older, heavier and with a more atherogenic lipid profile than do high income patients. Overall medication use was higher among the lower income group suggesting that differences in clinical profiles are not the result of under-treatment, thus invoking lifestyle factors as potential contributors to these findings.

Convenient analogies for an inconvenient truth.

Improving the health of individuals and populations while assuring the sustainability of modern healthcare systems requires a greater commitment to chronic disease prevention and management. In Canada, national challenges in the management of health care systems, such as prolonged wait times, have benefited from targeted federal investment, with provincial and territorial collaboration in the development and implementation of local strategies. The lead paper "An Inconvenient Truth: A Sustainable Healthcare System Requires Chronic Disease Prevention and Management Transformation," makes a sound argument for a similar investment toward the epidemic of chronic disease. Any strategy that might emerge from such a federal commitment ought to recognize two fundamentally important issues. First, as chronic disease prevention and management activities are largely community-based (rather than hospital or facility-based), Canada has an opportunity to move beyond a potentially disparate collection of provincial and territorial approaches to a truly national strategy. Second, and more important, effective chronic disease prevention and management will only be achievable if we reframe the challenge as a societal issue, not simply a health system concern. This reframing exercise might benefit from a greater understanding of how societal responses to other crises, such as global warming, have been triggered or accelerated.

How Attending Physician Preceptors Negotiate Their Complex Work Environment: A Collective Ethnography.

PURPOSE: To generate an empiric, detailed, and updated view of the attending physician preceptor role and its interface with the complex work environment. METHOD: In 2013, the authors conducted a modified collective ethnography with observations of internal medicine medical teaching unit preceptors from two university hospitals in Canada. Eleven observers conducted 32 observations (99.5 hours) of 26 preceptors (30 observations [93.5 hours] of 24 preceptors were included in the analysis). An inductive thematic approach was used to analyze the data with further axial coding to identify connections between themes. Four individuals coded the main data set; differences were addressed through discussion to achieve consensus. RESULTS: Three elements or major themes of the preceptor role were identified: (1) competence or the execution of traditional physician competencies, (2) context or the extended medical teaching unit environment, and (3) conduct or the manner of acting or behaviors and attitudes in the role. Multiple connections between the elements emerged. The preceptor role appeared to depend on the execution of professional skills (competence) but also was vulnerable to contextual factors (context) independent of these skills, many of which were unpredictable. This vulnerability appeared to be tempered by preceptors' use of adaptive behaviors and attitudes (conduct), such as creativity, interpersonal skills, and wellness behaviors. CONCLUSIONS: Preceptors not only possess traditional competencies but also enlist additional behaviors and attitudes to deal with context-driven tensions and to negotiate their complex work environment. These skills could be incorporated into role training, orientation, and mentorship.

Multimorbidity, dementia and health care in older people:a population-based cohort study.

BACKGROUND: Little is known about how multimorbidity, dementia and increasing age combine to influence health outcomes or utilization. Our objective was to examine the joint associations between age, dementia and burden of morbidity with mortality and other clinical outcomes. METHODS: We did a retrospective population-based cohort study of all adults aged 65 years and older residing in Alberta, Canada, between 2002 and 2013. We used validated algorithms applied to administrative and laboratory data from the provincial health ministry to assess the presence/absence of dementia and 29 other morbidities, and their associations with mortality (our primary outcome), other clinical outcomes (emergency department visits, all-cause hospital admissions) and a proxy for loss of independent living (discharge to long-term care). Cox and Poisson models were adjusted for year-varying covariates. A 3-way interaction was modelled for dementia, the number of comorbidities, and age. RESULTS: There were 610 457 adults aged 65 years and older living in Alberta over the study period. Over median follow-up of 6.8 years, 153 125 (25.1%) participants died and 5569 (0.9%) were discharged to long-term care. The prevalence of people with at least 3 morbidities was 33.7% in 2003 and 50.2% in 2012. The prevalence of dementia rose from 6.2% in fiscal year 2003 to 8.3% in fiscal year 2012, representing a net increase of approximately 13 700 people. The likelihood of all 4 outcomes increased with age and with greater burden of morbidity; the presence of dementia further increased these risks. For example, the risk of mortality increased by 1.54 to 6.38 in the presence of dementia, depending on age and morbidity burden. The risk associated with dementia was attenuated by increasing comorbidity. INTERPRETATION: Older age, multimorbidity and dementia are all strongly correlated with adverse health outcomes as well as a proxy for loss of independent living. The increasing prevalences of dementia and multimorbidity over time suggest the need for coordinated national strategies aimed at mitigating the health challenges associated with the aging of the population.