Diabetes Mellitus (diabetes) is a chronic illness that affects 706,500 people, or 7.5 per cent of Ontario's population. In the last decade, the number of people with diabetes in Ontario has doubled and could reach 1.2 million by 2010.

Significant lifestyle changes are required to manage not only diabetes, but also other co-existing conditions associated with diabetes, such as hypertension and dyslipidemia, as well as to prevent the complications of diabetes including cardiovascular disease. Diabetes and its complications contribute significantly to the burden of illness :

• life expectancy of people with diabetes is 13 years less than people without diabetes;
• almost one quarter of people who died in Ontario in 1997 had diabetes;
• the risk of end stage renal disease (kidney disease) is 13 times higher in people with diabetes compared with people without diabetes;
• 70 percent of lower extremity amputations are performed on people with diabetes;
• cardiovascular disease accounts for about 70 per cent of deaths among people with diabetes;
• hospitalizations for stroke are approximately 3-fold higher in people with diabetes compared to people without diabetes;
• diabetic retinopathy is the leading cause of blindness in Canadians aged 30 to 69;
• the age at which acute myocardial infarction (AMI) is seen is 15 to 20 years earlier for people with diabetes;
• on average, people with diabetes receive surgical treatment for vascular disease 20 years earlier than people without diabetes.

Tight control of blood glucose (glycemic) levels has been shown to significantly reduce the risk of developing complications of diabetes. It has been shown that every 1 per cent drop in the hemoglobin A1C, an index of averaged blood glucose levels, is associated with a 14 per cent decrease in the incidence of acute myocardial infarction and a 16 per cent decrease in heart failure rates. Studies have also shown that complications of diabetes can be reduced by optimizing blood pressure and lipid levels and by having regular foot and eye care. Dietary modifications, increased physical activity and smoking cessation are also positively associated with better outcomes for people with diabetes.

The current health system is geared towards addressing acute episodes of care of persons with diabetes. However, comprehensive diabetes management including effective blood glucose control, management of co-existing cardiovascular risk factors such as hypertension and dyslipidemia and screening for complications cannot be effectively delivered in such a context.

Evidence from Diabetes in Ontario: An ICES Practice Atlas illustrates numerous gaps between current care delivery and evidence-based practice as well as high levels of avoidable complications. For example, over a seven year period from 1992 to 1999, 87,425 Ontarians with diabetes had at least one hospitalization or emergency room visit for abnormally high or low blood glucose even though such hospitalizations should be largely avoidable with effective out-patient diabetes management. Screening and early treatment of diabetic eye disease has been proven to prevent blindness, yet only 51 per cent of persons with newly-diagnosed diabetes received recommended screening within one year of diagnosis of type 2 diabetes. Selected medications have been repeatedly demonstrated to reduce the risk of diabetes complications, yet these drugs are consistently under-prescribed. In 1999, over 900 Ontarians with diabetes underwent a major amputation and over 500 lost a portion of a foot even though the risk of such events can be reduced substantially with effective foot care and aggressive management of vascular risk factors. Diabetes now accounts for more than half of new cases of end-stage kidney disease and has become the major contributor to the growing demand for dialysis. The numbers of dialysis starts increased by 84 per cent among persons with diabetes between 1995 and 2000 while increasing by less than 10 per cent in the non-diabetic population a trend in part related to the under-use of appropriate blood pressure medication in persons at risk.

In acknowledgment of the startling figures of the growing pervasive nature of diabetes, and its dramatic impact on the health of Ontario's population, as reported in Diabetes in Ontario: An ICES Practice Atlas (2003) , the Ontario Ministry of Health and Long-Term Care established the Task Force in 2003 to advise the Ministry of the best methods for reducing the burden of diabetes on the Ontario population. Concerns were raised that Ontario's health care services might not be effectively directed at improving treatment for persons suffering from diabetes.

The aim of the Task Force was not to provide comprehensive recommendations covering all aspects of diabetes prevention and care, but to focus on priority areas deemed by the Task Force to be the most pressing issues which would achieve maximum impact in improving outcomes for people with diabetes and the population as a whole. As such, the Task Force has made twelve high-level recommendations:

1. Reduce waiting times for structured diabetes education and care in the province by improving access from the present level of 28 per cent of people diagnosed with diabetes to at least 50 per cent, over the next three years progressing to 100 per cent thereafter.
2. Ensure that access to high-quality, provincially standardized and integrated, structured diabetes education and care is provided in Ontario based on a provincial framework.
3. Improve patient outcomes for people with diabetes by providing high-quality, integrated care within a provincial framework and provide structured diabetes education and care predominantly through multidisciplinary, community-based, primary care services.
4. Improve access to eye exams and treatment of retinal complications.
5. Implement hospital-based diabetes resource teams for complex inpatient care.
6. Develop comprehensive, rational, long-term funding strategies that are fair to all people with diabetes and demonstrate downstream improvements in patient outcomes.
7. Improve access to insulin, insulin needles, insulin pumps, glucose testing strips and lancets.
8. Fund studies to determine the barriers to accessing anti-hyperglycemic agents, lipid-lowering drugs, anti-hypertensives and ACE inhibitors for people with diabetes and ways in which removing these barriers could improve compliance and patient outcomes.
9. Provide direct research funding to enhance the level of evidence for clinical care and delivery of diabetes care.
10. Use the newly-developed, Ontario-specific economic model to help the government make decisions regarding new interventions.
11. Ensure that a comprehensive strategy is developed to support an enabling environment to increase physical activity and healthy eating.
12. Provincial and federal governments should consider implementing new policies that provide incentives and facilitate access (including affordability) to healthy foods, such as fruits and vegetables.

Members of the Task Force feel privileged that they were asked to make this contribution to addressing one of the most important chronic diseases facing the people of Ontario. The Task Force recommends that an implementation committee be appointed as soon as possible, if the recommendations are acceptable to the Minister.

The full report is available for download in PDF format, below :

FULL REPORT

Diabetes Task Force Report to the Ministry of Health and Long-Term Care 78 pages | 277 kb | PDF format

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