PRIMARY CARE DIABETES: ISSUES FACING FAMILY DOCTORS

Background: Developing and testing effective strategies to screen for and detect diabetes in the community is an important population health issue. The Community Health Awareness Diabetes (CHAD) program was designed to be a community program to identify high-risk individuals for subsequent diabetes screening by their family doctors. Objectives: This paper describes the CHAD program and evaluates its success. Methods: Participants, who were residents of Grimsby, Ontario and over 40 years old, were invited to self risk-assess for diabetes using a validated questionnaire and 2 near patient blood tests (capillary blood glucose and glycosylated hemoglobin). Some participants were self-selected, having seen advertising for the program, and others had been invited by a letter from their family doctor. No participants had pre-existing diabetes. The outcomes examined were the numbers and characteristics of participants, numbers found at risk and satisfaction of participants. Results: There were 588 participants in CHAD; of these, the majority had received invitation letters, were seniors and females; 526 did not have pre-existing diabetes; and 16% of participants (n= 84/526) were identified as being at high risk PhD Thesis – G. Agarwal McMaster University – Family Medicine 76 for diabetes. Those at high risk of diabetes had significantly more modifiable risk factors, including higher fat, fast food and salt intake, and higher systolic blood pressure. Satisfaction with the program was high. Conclusion: Use of a two-stage screening process may be useful in identifying community-based individuals who are at risk of diabetes or pre-diabetes. PhD Thesis – G. Agarwal McMaster University – Family Medicine 77 Introduction Alarmingly, adult diabetes-prevalence in Ontario rose by 80%, from 5% in 1995, to 9% in 2005(1). Current estimates suggest that people with diabetes use five-times as many health resources as those without(2). Therefore, developing and testing effective strategies to increase detection of diabetes in the community, is an important primary care and population health issue. An effectively screened population will have diabetes diagnosed 5–6 years earlier than a population without an organized screening program(3), offering opportunities for delaying diabetes and related complications(4). Hence, the Canadian Diabetes Association recommends that all Canadians over 40 years old should be screened for diabetes with fasting plasma glucose (FPG) or oral glucose tolerance tests (OGTT) every 3 years, or annually in the presence of risk factors(5). These current screening tests are too costly and inconvenient to be offered at a population level in the form of a screening program. Furthermore, the organization of primary care in Canada is poorly designed to cope with the initiation and management of comprehensive diabetes screening for everyone over 40 years of age(6). Existing diabetes prevention and lifestyle programs, designed for research and not community application, have unrealistic program costs, since they require all participants to have OGTTs(7,8). However, sequential and selective screening of high-risk groups could increase efficiency(9) and reduce workload and screening costs for the healthcare system by reducing the PhD Thesis – G. Agarwal McMaster University – Family Medicine 78 number of individuals requiring a ‘gold standard’ diagnostic test, as compared to universal screening(10,11). The Community Health Awareness Diabetes (CHAD) Program was designed to be a practical, feasible, low-cost community program to increase awareness of diabetes and identify high-risk individuals to be targeted for subsequent diabetes-screening by their family doctors. The objective of this paper is to describe and evaluate the CHAD program, focusing on characteristics of the attendees, numbers found to be at risk of diabetes and participants’ satisfaction with the program. This report does not describe the effectiveness of the intervention at detecting diabetes, which is described elsewhere. Methods Participants, setting and program description Participants of the CHAD program were residents of Grimsby, Ontario and the surrounding areas, who were over 40 years old. Participants were invited to the program in two separate ways. Firstly, a local media campaign (local paper advertisements, radio announcements and local news television appearances) advertized the program and listed the eligibility criteria. Secondly, family physicians (recruited to the program by personal contact from the principal investigator) agreed to either hand out advertisements/invitations to suitable patients for risk assessment sessions opportunistically, or to send invitations through the mail to all patients over 40 years old without diabetes. All participants PhD Thesis – G. Agarwal McMaster University – Family Medicine 79 were instructed, by letter or advertising, not to eat or drink anything other than water for 8 hours prior to risk-assessment attendance to allow valid blood testing. Each CHAD session took place in one of 5 local pharmacies and consisted of a 3 hour period accommodating 15 30 people. All attendees consented to participation and then completed a diabetes risk-assessment questionnaire with the assistance of a volunteer peer health educator (PHE). The risk-assessment questionnaire included questions (shown in Table 1) which had been previously validated(12,13). Scores for each individual risk score were interpreted as high risk for diabetes if they were > 15 for the Finnrisk or >0.199 for the Cambridge risk score. Following this, two near patient tests were self-administered by participants (the capillary blood glucose CBG and glycosylated-hemoglobin HbA1c). Performance characteristics of these screening tests compared to the gold standard are presented in Table 2. After the session, participants received a simplified copy of the assessment, and, if warranted by the assessment, were invited to attend a session for counseling, provided locally, around modifiable risk factors. Upon consent, a risk- assessment result was also sent to participants’ family doctors. These results were formatted to resemble a laboratory test and included attendance date, and a risk- assessment for diabetes described as low, moderate or high according to the literature. An algorithm which combined the Finnrisk Questionnaire scoring(12), the Cambridge Diabetes risk assessment questionnaire(13), HbA1c lab cutoff values(14) and FBG values(15) was used to report on these results, which also PhD Thesis – G. Agarwal McMaster University – Family Medicine 80 suggested further management and follow-up strategies using the adapted CDA guidelines(5) (see Table 3). Formal screening was suggested for those individuals scoring at a ‘high risk’ of developing or having diabetes. All sessions were delivered by volunteer PHEs who had been recruited from a pool of interested older adults, who had already participated in a similar community health awareness program focused on hypertension. All were older individuals (55 years of age and older) and included some ex-healthcare professionals. They were trained in 2 two-hour long sessions by a public health nurse and family physician (GA), including hands-on experience with the risk- assessment questionnaire and CBG and HbA1c testing. The PHEs assisted attendees in self-completing the risk-assessment questionnaire, and guided attendees through the process of the CBG and HbA1c self-testing. PHEs were not required to touch the attendees’ soiled lancets or blood-stained items at any time, as they instructed attendees to dispose of their own biological waste in appropriate containers that were provided.