Kailash Jindal and Peter Senior
Leading up to World Diabetes Day on November 14, the University of Alberta recognizes the importance of raising awareness about the effects of diabetes on our communities, and the efforts of health professionals to improve patients' lives and find a definitive cure.
Peter Senior and Kailash Jindal could be viewed as "big city specialists." They are leading experts in diabetes, and nephropathy (kidney disease) and its prevention.
But good as they are, they can't take on the three per cent of the Alberta population that might need their specialized expertise, nor would it help patients if they could, says Senior, a professor of medicine with the University of Alberta's Faculty of Medicine & Dentistry and member of the Alberta Diabetes Institute. "Having specialists managing chronic care is not the best use of resources."
Successful management of diabetes requires an equal emphasis on lifestyle targets and biology, he says. "Following the program is the key." He likens it to an aspiring golfer taking a one-hour lesson with Tiger Woods. One hour is unlikely to change a swing developed over a lifetime. The golfer might be better off with the local pro for an hour a week.
"Diabetes management requires developing new habits and ongoing coaching," he says. "It's not really a diagnostic dilemma."
The local team includes a registered nurse and registered dietician, with local general practitioners linked in through education sessions.
Thanks to a flexible academic alternate relationship funding plan (A-ARP), the two specialists are able to participate in regional diabetic kidney disease prevention clinics and extend their knowledge to some 2,000 patients annually instead of the 300 each they might otherwise see in a year. Their patients have the benefit of ongoing coaching, in their local community, from a multidisciplinary team trained in best-practice protocols.
Why this research matters
To patients:
Patients diagnosed with diabetes face serious threats to their health if their condition isn't well managed, including loss of kidney function that could lead to dialysis, and life-threatening cardiovascular disease.
Tight control of blood sugar and blood pressure, however, is shown to cut the dangerous risks by up to 61 per cent. This community-based multidisciplinary team approach ensures patients are surrounded by a coordinated and highly educated network of health professionals who consistently implement best practice guidelines to ensure their risk is reduced. Patients report higher levels of satisfaction with a reduction in wait times and access to local service.
To Albertans:
More than 205,000 people living in Alberta have diabetes. That's about one in every 20 people. (Source: Alberta Diabetes Surveillance System) As trained, multidisciplinary, community teams of professionals support more of these patients, fewer patients and families will experience the major life disruptions and economic impacts of serious complications.
To the health care system:
The burden of diabetes on Alberta's health care system is growing as the population ages. (Albertans over the age of 65 have a three-fold greater prevalence of diabetes.)
In 2007, the total average costs (physician, hospital and emergency department costs) for people with diabetes were three to four times higher than costs for people without diabetes. Diabetes is the leading cause in 40 per cent of end-stage renal disease cases. (CIHI 2001)
Successful prevention of the major diabetes complications reduces physician visits, emergency department visits, hospital stays and mortality. It is a key strategy towards maintaining a sustainable health care system.
The clinics began with a pilot project in 2004 based on evidence from a Danish study that showed coordinated, multidisciplinary care, surrounding the patient, led to significant reductions in heart attacks, strokes and kidney failures.
Clinics were established in Hinton, Edson, Vermilion, Edmonton, Wetaskiwin, and Red Deer. While Red Deer no longer participates, clinics have expanded to Fort McMurray and Wood Buffalo, Grande Prairie, Westlock, St. Paul and Peace River.
The centralized team educating the local community clinic includes a project manager, pharmacist and social worker in addition to Jindal and Senior. The local team includes a registered nurse and registered dietician, with local general practitioners linked in through education sessions.
The team holds education sessions every six months in person, or by Telehealth. "The clinic staff members become experts," says Jindal, director of the Faculty of Medicine & Dentistry's Division of Nephrology and Alberta Diabetes Institute scholar. "Their competency to tackle a broad range in diabetes care is quite striking."
"Local clinics magnify the impact of the specialists," says Senior. "We are good at doing the one-off assessments. We can't look constantly into how much sodium [patients] are ingesting, how smoking cessation is going...and the conversations they have with a nurse or dietitian that they would never have with us."
The other benefit, says Jindal, is that those who do suffer kidney failure get transitioned into advanced care more quickly. "They are already in the system, followed and monitored." There is no need to wait for a referral from a family doctor.
Senior and Jindal would like to build on the success of the clinics. Their dreams for the future include diabetes education centres with a specialist link. In these imagined centres, local staff wouldn't refer a patient, but would be able to consult with a specialist on what they should do next. They would also like to work towards better linkages with Primary Care Networks (PCNs) and to increase the breadth of knowledge of staff in the renal insufficiency clinics, so patients are not taking backward steps.
Both doctors credit Alberta's A-ARP funding plan with their ability to increase their impact. "Initiatives like these can only be done if you have a payment system which is not based [solely] on face-to-face consultations and services," says Senior.