Opportunities to improve diabetes prevention and care in Canada

The prevalence of diabetes in Canada is expected to more than double by 2030. Additionally, the costs associated with diabetes have nearly doubled between 2000 and 2010 and will continue to rise unless improvements are made. Fortunately, more effective policies and programs can reduce both the prevalence of diabetes and the complications associated with the disease. We used responses from the Canadian Community Health Survey to assess whether Canadians with diabetes report (1) receiving from healthcare professionals the recommended tests to screen for complications, (2) performing sufficient self-care for their diabetes and, (3) for those in lower-income households, receiving less recommended care. The results show that only one in three (32%) Canadian adults with diabetes reported having received all four recommended tests during the previous year. Lower-income Canadians were more likely to report having diabetes and less likely to report receiving the four diabetes care tests. Only half of adults with diabetes reported checking their blood sugar levels daily, and only two in five reported checking their feet for injuries and ulcers. Improvements to adherence to diabetes care guidelines are needed to reduce the likelihood that Canadians, especially lower-income Canadians, will develop complications from diabetes. Bending the cost curve downward is possible through more effective policies and programs that prevent diabetes in the first place and that ensure Canadians with diabetes get both recommended care from their healthcare providers and enough support for effective self-care.     

Using RE-AIM metrics to evaluate diabetes self-management support interventions

BACKGROUND: Current healthcare evidence relies on relatively narrow efficacy data to make decisions about program impact. This paper illustrates the application of impact indices derived from the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework that takes a broader perspective and includes issues important to decision makers, such as reach, adoption, and cost. METHODS: Composite RE-AIM indices that summarize impact and cost efficiency at the individual participant and setting levels are used to compare two different diabetes self-management support approaches. One study, the Diabetes Priority (DP) program, involved 886 diabetes patients from 30 primary care offices, and relied on usual clinical staff for program implementation. The other study, Diabetes Health Connection (DHC), involved 335 diabetes patients in both HMO and fee-for-service settings, and used health education staff. RESULTS: The DP performed better on the setting-level impact index, but the programs produced similar results on individual-level impact. The DP had a greater reach (50% vs 38%); was more effective at the initial follow-up (median effect size [ES]=0.23 vs 0.17); and had greater impact consistency across various populations. The DHC performed better on several indices, including higher physician office adoption (20% vs 6%) and staff adoption (79% vs 70%), and there was less variability among intervention staff on protocol implementation (median ES=0.0 vs 0.50). CONCLUSIONS: Greater use of indices focused on public health and external validity criteria could help identify programs most likely to have a meaningful impact on population health and to fit local settings and priorities.     

Using computer simulations to compare pertussis vaccination strategies in Australia

High levels of notified pertussis in adolescents and adults, persisting severe disease (hospitalization and deaths) in infants despite high childhood immunization coverage, together with the availability of adult-formulated pertussis vaccines, have made alternate strategies for vaccine control of pertussis an important issue in Australia. An age-structured computer simulation model was used to compare the likely effects of adopting different vaccination strategies in Australia on pertussis transmission by age group over a 50 year time period. Epidemiological parameters and vaccination coverage in Australia were estimated from previous pertussis modeling studies and existing data. In the simulations, replacing the pertussis booster at 18 months with a booster dose for adolescents at an age between 12 and 17 years, assuming 80% coverage, led to decreases in pertussis cases of 30% in children of ages 0-23 months (who have the highest complication rates) and of 25% in adolescents, but an increase of 15% in cases in 2-4-year-old children. The simulations did not suggest any shift of pertussis cases into the adult child-bearing years. Varying parameter values in the simulations in a series of sensitivity analyses showed the model predictions to be robust over a plausible range. The results of these simulations suggest that the recent change in the Australian pertussis vaccination schedule, replacing the 18 month dose with a pertussis booster in 15-17-year-old adolescents, is very likely to reduce overall pertussis incidence in Australia without increasing the cost of the current vaccine program.     

Towards an economic model of the Dutch health care sector

This paper describes the construction of a model of the Dutch health care sector. It discusses the behaviour of patients, general practitioners, medical specialists and hospital managers. It also analyses the various ways the actors interact, such as general practitioners supplying the services demanded by patients, specialists dispatching referrals made by general practitioners or hospital managers boosting output to match an increasing amount of specialist services. Numerical simulations illustrate the various mechanisms in the model. © 1997 John Wiley & Sons, Ltd.     

Using cost-effectiveness analysis to evaluate targeting strategies: the case of vitamin A supplementation

Given the demonstrated efficacy of vitamin A supplements in reducing childhood mortality, health officials now have to decide whether it would be efficient to target the supplements to high risk children. Decisions about targeting are complex because they depend on a number of factors; the degree of clustering of preventable deaths, the cost of the intervention, the side-effects of the intervention, the cost of identifying the high risk group, and the accuracy of the 'diagnosis' of risk. A cost-effectiveness analysis was used in the Philippines to examine whether vitamin A supplements should be given universally to all children 6-59 months, targeted broadly to children suffering from mild, moderate, or severe malnutrition, or targeted narrowly to pre-schoolers with moderate and severe malnutrition. The first year average cost of the universal approach was US$67.21 per death averted compared to $144.12 and $257.20 for the broad and narrow targeting approaches respectively. When subjected to sensitivity analysis the conclusion about the most cost-effective strategy was robust to changes in underlying assumptions such as the efficacy of supplements, clustering of deaths, and toxicity. Targeting vitamin A supplements to high risk children is not an efficient use of resources. Based on the results of this cost-effectiveness analysis and a consideration of alternate strategies, it is apparent that vitamin A, like immunization, should be provided to all pre-schoolers in the developing world. Issues about targeting public health interventions can usefully be addressed by cost-effectiveness analysis.     

Primary prevention of type 2 diabetes: integrative public health and primary care opportunities, challenges and strategies

Type 2 diabetes imposes a large and growing burden on the public's health. This burden, combined with the growing evidence for primary prevention from randomized controlled trials of structured lifestyle programs leads to recommendations to include caloric reduction, increased physical activity and specific assistance to patients in problem solving to achieve modest weight loss as well as pharmacotherapy. These recommendations demand exploration of new ways to implement such primary prevention strategies through more integrated community organization, medical practice and policy. The US experience with control of tobacco use and high blood pressure offers valuable lessons for policy, such as taxation on products, and for practice in a variety of settings, such as coordination of referrals for lifestyle supports. We acknowledge also some notable exceptions to their generalizability. This paper presents possible actions proposed by an expert panel, summarized in Table 1 as recommendations for immediate action, strategic action and research. The collaboration of primary care and public health systems will be required to make many of these recommendations a reality. This paper also provides information on the progress made in recent years by the Division of Diabetes Translation at the US Centers for Disease Control and Prevention (CDC) to implement or facilitate such integration of primary care and public health for primary prevention.     

Using an implementation science approach to implement and evaluate patient-reported outcome measures (PROM) initiatives in routine care settings

Quality of Life Research - Patient-reported outcome and experience measures (PROMs/PREMs) are well established in research for many health conditions, but barriers persist for implementing them in...     

The handling of uncertainty in economic evaluations of health care strategies

BACKGROUND: The recent development of prospective economic evaluations in association with randomized controlled clinical trials has provided clinical and economic data allowing a statistical analysis of uncertainty. Pertinent comparison of alternative medical strategies in the cost-effectiveness analysis requires analysis of the incremental cost-effectiveness ratio. In this work, we were interested in developing confidence regions of the cost-effectiveness ratio in order to take into consideration its uncertainty which creates a certain number of problems when the denominator approaches zero. Our objectives were to conduct a critical analysis of the different estimations used and examine their application in the decision making process. METHODS: There are two kinds of methods: those based on the density of the estimated ratio (Taylor method, parametric and non-parametric bootstrap methods such as percentile, percentile-t and bias-corrected and accelerated methods) and those based on the bivariate density of the variable pair: difference of average costs, difference of average effects (box method, ellipse method, and Fieller method). RESULTS: We showed that methods based on the density of the ratio become unstable and inapplicable when the statistical difference of average effects tends towards zero. In practice however, data often take on such a pattern. We give an example of an economic evaluation as an illustration. Bivariate density methods do not have this drawback. Moreover, the "mirror decision" phenomenon requires that the region of confidence be a directed single confidence sector for valid decision making. CONCLUSIONS: Uncertainty must be taken into account for all economic evaluations but the use of undirected confidence regions is inappropriate as a decision-making tool.     

Using relaxation strategies in child and youth care practice

Competent child and youth care counselors, given adequate support and consultation, can successfully, integrate relaxation training into their repertoire of skills and strategies. This paper is intended to provide a practical guide for those who wish to use relaxation strategies in a thoughtful and informed manner. Relaxation strategies are defined and described, the findings of research into relaxation training are examined, and important procedural variables associated with successful outcomes are listed. Two case examples that suggest possible application in child care settings are provided. Finally, some readily available resource materials are described.I would like to thank Bryan Hiebert, Department of Educational Psychology, University of Calgary; Betty Reiter, Calgary Board of Education; and Sandra Snape, Wood's Homes, Calgary, for their helpful feedback on an earlier version of this article.     

Using importance-performance analysis to develop health care marketing strategies.

Importance-performance analysis is a useful marketing research technique that can be easily and effectively applied in the health care sector to suggest successful marketing strategies. This article describes how this procedure was used to develop marketing strategies for hospital obstetric services in a southwestern community.