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Can J Diabetes 37 (2013) 82e89

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Canadian Journal of Diabetes

journal homepage:
www.canadianjournalofdiabetes.com

Original Research

Type 2 Diabetes Mellitus Management in Canada: Is It Improving?

Lawrence A. Leiter MD a, d, e, *, Lori Berard RN f, C. Keith Bowering MD g, Alice Y. Cheng MD a, d,
Keith G. Dawson MD h, Jean-Marie Eko MD i, Carl Fournier MD j, Lianne Goldin k,
Stewart B. Harris MD, MPH l, Peter Lin MD k, Thomas Ransom MD, MSc m, Mary Tan MSc k,
Hwee Teoh PhD a, b, Ross T. Tsuyuki PharmD, MSc n, Dana Whitham RD, MSc o, Vincent Woo MD p,
Jean-Franois Yale MD q, Anatoly Langer MD, MSc c, d, k
a
Division of Endocrinology and Metabolism, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ontario, Canada
b
Division of Cardiac Surgery, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ontario, Canada
c
Division of Cardiology, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ontario, Canada
d
Department of Medicine, University of Toronto, Toronto, Ontario, Canada
e
Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
f
Diabetes Research Group, Health Science Centre, Winnipeg, Manitoba, Canada
g
Division of Endocrinology and Metabolism, University of Alberta, Edmonton, Alberta, Canada
h
Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
i
Montreal Institute for Clinical Research and Centre hospitalier de lUniversit de Montral Research Center, Division of Endocrinology and Department of Nutrition, Universit de
Montral, Montral, Quebec, Canada
j
Department of Medicine, Universit de Montral, Montral, Quebec, Canada
k
Canadian Heart Research Centre, Toronto, Ontario, Canada
l
Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
m
Department of Endocrinology, Dalhousie University, Halifax, Nova Scotia, Canada
n
EPICORE Centre, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
o
Diabetes Comprehensive Care Program, St. Michaels Hospital, Toronto, Ontario, Canada
p
Section of Endocrinology, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada
q
Division of Endocrinology and Metabolism, Department of Medicine, McGill Nutrition and Food Science Centre, McGill University, Montral, Quebec, Canada

a r t i c l e i n f o a b s t r a c t

Article history:
Received 25 January 2013 Objective: To gain insight into the current management of patients with type 2 diabetes mellitus by
Accepted 20 February 2013 Canadian primary care physicians.
Method: A total of 479 primary care physicians from across Canada submitted data on 5123 type 2
diabetes patients whom they had seen on a single day on or around World Diabetes Day, November 14,
2012.
Results: Mean glycated hemoglobin (A1C) was 7.4%, low-density lipoprotein (LDL-C) was 2.1 mmol/L and
blood pressure (BP) was 128/75 mm Hg. A1C 7.0% was met by 50%, LDL-C 2.0 mmol/L by 57%, BP
Keywords: <130/80 mm Hg by 36% and the composite triple target by 13% of patients. Diet counselling had been
blood pressure
offered to 38% of patients. Of the 87% prescribed antihyperglycemic agents, 18% were on 1 non-insulin
care gap
antihyperglycemic agent (NIAHA) (85% of which was metformin), 15% were on 2 NIAHAs, 6% were on
glycemic control
guidelines 3 NIAHAs, 19% were on insulin only and 42% were on insulin 1 NIAHA(s). Amongst the 81%
lipids prescribed lipid-lowering therapy, 88% were on monotherapy (97% of which was a statin). Among the
management 83% prescribed antihypertensive agents, 39%, 34%, 21% and 6% received 1, 2, 3 and >3 drugs, respectively,
type 2 diabetes with 59% prescribed angiotensin-converting enzyme inhibitors and 35% angiotensin II receptor blockers.
Conclusions: The Diabetes Mellitus Status in Canada survey highlights the persistent treatment gap
associated with the treatment of type 2 diabetes and the challenges faced by primary care physicians to
gain glycemic control and global vascular protection in these patients. It also reveals a higher use of
insulin therapy in primary care practices relative to previous surveys. Practical strategies aimed at more
effectively managing type 2 diabetes patients are urgently needed.
2013 Canadian Diabetes Association

* Address for correspondence: Lawrence A. Leiter, St Michaels Hospital Medical

Centre, 61 Queen Street East, Suite 6-121Q, Toronto, Ontario M5C 2T2, Canada.
E-mail address: leiterl@smh.ca (L.A. Leiter).

1499-2671/$ e see front matter 2013 Canadian Diabetes Association

http://dx.doi.org/10.1016/j.jcjd.2013.02.055

Reprinted from Canadian Journal of Diabetes - April 2013 (Vol. 37, Issue 2, Pages 82-89), with permission from Elsevier. http://
www.sciencedirect.com/science/article/pii/S1499267113001329
 Author's personal copy

L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89 83

r s u m
Mots cls:
pression artrielle Objectif : Obtenir un aperu de la prise en charge actuelle des patients ayant le diabte sucr de type 2 par
lacunes en matire de soins les mdecins canadiens de premiers recours.
matrise de la glycmie Mthodes : Un total e 479 mdecins de premier recours de lensemble du Canada ont soumis des donnes
lignes directrices sur 5123 patients ayant le diabte de type 2 chez qui ils ont observ durant une seule journe lors ou
lipides autour de la journe mondiale du diabte, le 14 novembre 2012.
prise en charge Rsultats : Lhmoglobine glyque moyenne (HbA1c) a t de 7,4 %, le cholestrol lipoprotines de basse
diabte de type 2
densit (C-LDL) de 2,1 mmol/L et la pression artrielle (PA) 128/75 mm Hg. Une HbA1c  7,0 % a t
obtenue chez 50 % des patients, un C-LDL  2,0 mmol/L chez 57 %, une PA < 130/80 mm Hg chez 36 % et
un critre composite triple chez 13 %. Le counseling en dittique a t offert 38 % des patients. Parmi
les 87 % prenant des agents antihyperglycmiques, 18 % ont pris 1 agent antihyperglycmique non
insulinique (AAHNI; dont 85 % ont pris la metformine), 15 % ont pris 2 AAHNI, 6 % ont pris  3 AAHNI,
19 % ont seulement pris de linsuline et 42 % ont pris de linsuline et  1 AAHNI. Parmi les 81 % qui
suivaient un traitement hypolipidmiant, 88 % ont suivi une monothrapie (dont 97 % ont pris une
statine). Parmi les 83 % qui prenaient des agents antihypertensifs, 39 %, 34 %, 21 % et 6 % ont reu
respectivement 1, 2, 3 et > 3 mdicaments, dont 59 % ont pris des inhibiteurs de lenzyme de conversion
de langiotensine et 35 % des antagonistes des rcepteurs de langiotensine II.
Conclusions : Lenqute canadienne sur le statut du diabte sucr souligne les lacunes persistantes en
matire de traitement associes au traitement du diabte de type 2 et les ds relever par les mdecins
de premier recours pour obtenir une matrise de la glycmie et une protection vasculaire globale chez ces
patients. Cela rvle galement une plus grande utilisation de linsulinothrapie dans les centres de soins
primaires qui concernent les enqutes prcdentes. Des stratgies pratiques dont le but est une prise en
charge plus efcace des patients ayant le diabte de type 2 simposent de manire urgente.
2013 Canadian Diabetes Association

Introduction Canadian Heart Research Centre (CHRC) to lists of Canadian

Clinical practice guidelines (CPGs) from professional organiza-
tions around the world collectively advocate that patients with type
2 diabetes mellitus should have their risk factors managed in an
aggressive and timely manner (1e5). These recommendations are
largely based on seminal type 2 diabetes-focused trials demon-
strating signicant improvements in vascular complications and
reduced mortality through comprehensive and multifactorial
behavioural modication and pharmacotherapy strategies (6,7).
However, despite concerted and widespread efforts to translate
these evidence-based recommendations into routine clinical
practice as well as increasing pharmacologic options, practice
reviews conducted in different countries and settings continually
indicate that optimal management of type 2 diabetes patients
remains challenging (8e15).
Based on data collected between September 2002 and February
2003, the Diabetes in Canada Evaluation (DICE) Study determined
that 51% of patients were successful at achieving a glycated
hemoglobin (A1C) of <7.0% (10). The Diabetes Registry to Improve
Vascular Events (DRIVE) study, using data collected between March
2005 and March 2006, revealed that 53% of the study population
had an A1C of 7.0% (8) leading the investigators to postulate that
the 2003 Canadian Diabetes Association (CDA) CPGs (3) had
minimal impact on glycemic control in Canada up to that point.
In anticipation of the publication of the 2013 CDA CPGs in early
2013, the national cross-sectional Diabetes Mellitus Status in
Canada (DM-SCAN) survey was undertaken to gain insight into the
current management of type 2 diabetes patients in the Canadian
primary care setting. A secondary goal was to identify management
gaps that may provide directional input on how best to effectively
design strategies aimed at improving the care of these patients.
Methods
From September to December 2012, standard letters from the
DM-SCAN Steering Committee were sent to primary care physicians
across Canada inviting them to participate in the DM-SCAN survey.
The invitation was distributed through e-mail and facsimiles by the
primary care physicians, participants in prior or ongoing registries
within the CHRC, through standard hard copy invitations distrib-
uted by the CDA at its annual professional session and the CHRC at
continuing medical education meetings, and by representatives of
the sponsoring company. Physicians were requested to rst
complete a 10-question survey on their practice location and
setting, how many type 2 diabetes patients they typically see in
a week, whether they routinely discuss the symptoms and treat-
ment of hypoglycemia, what they consider to be the greatest
barriers in type 2 diabetes management and what educational
platforms they felt would benet their patients and practice.
Physicians who completed the needs assessment survey were
asked to complete a 1-page anonymized data collection form on
patients with the clinical diagnosis of type 2 diabetes whom they
had seen on a single clinic day as part of routine clinical practice on
or as close as possible to the 2012 World Diabetes Day (November
14). Patient demographics, clinical history, anthropometric and
laboratory data as well as management strategies used by the
physician to achieve glycemic targets and global vascular protec-
tion were documented. Physicians were reimbursed for their
efforts. The nal program materials were reviewed and endorsed
by the CDA and Diabte Qubec before ethics approval was ob-
tained. The program synopsis was reviewed and approved before
survey initiation by OPTIMUM Clinical Research, an independent
central ethics review board.
Data management and statistical analysis
Completed physician surveys and data collection forms were
submitted either electronically via a secure website or faxed to the
CHRC by 19 December 2012. Faxed data were scanned into an
electronic database (TELEform, Version 10.0, Cardiff Software, San
Diego, CA). Point prevalence data are presented. Continuous vari-
ables are summarized as mean (standard deviation [SD]) and
discrete variables are reported as counts and percentages.
Categorical variables between groups were compared using the
Pearsons chi-square or Cochran-Armitage trend tests where
appropriate. Multivariable logistic regression analyses, using the
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84 L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89

generalized estimating equations (GEE) method, were carried out Table 1

to determine whether insulin use was inuenced by provincial and Provincial distribution of physicians and patients

geographical locations, practice format and access to diabetes Province Physicians (N479) Patients (N5123)
educators. Because patients treated by the same physician were Alberta 29 (6.1) 233 (4.5)
more likely to be treated similarly compared to patients under the British Columbia 41 (8.6) 365 (7.1)
care of other physicians, the GEE approach allowed us to adjust for Manitoba 19 (4.0) 249 (4.9)
New Brunswick 26 (5.4) 347 (6.8)
correlations within individual physicians. Odds ratios (ORs) and
Newfoundland 17 (3.5) 208 (4.1)
their 95% condence interval (CIs) are reported. All analyses were Nova Scotia 28 (5.8) 295 (5.8)
carried out using SAS software version 9.2 (SAS Institute, Cary, NC). Ontario 270 (56.4) 2990 (58.4)
Prince Edward Island 1 (0.2) 15 (0.3)
Results Quebec 45 (9.4) 400 (7.8)
Saskatchewan 3 (0.6) 21 (0.4)

Physicians and their practices Data are presented as n (%).

A total of 479 physicians (equivalent to a 65% participation rate by physicians for 4798 patients from a list of 5 choices were 3% for
of the 738 who completed the initial audit form) representing all 10 6.0%, 14% for 6.5%, 71% for 7.0%, 9% for 7.5% and 4% for 8.0%.
Canadian provinces completed 5123 data collection forms (54% Although 4477 (87%) of patients were prescribed anti-
online, 46% fax-based submission) (Table 1). Fifty-nine percent of hyperglycemic therapy, 10% were managed through diet only
physicians were in a group practice (2 physicians), 41% had strategies (Table 3). Of the patients prescribed antihyperglycemic
a single-physician practice and 50% were part of a family health agents (AHAs), 18% were receiving 1 non-insulin antihyperglycemic
team. Practices were located in inner city (16%), urban/suburban agent (NIAHA) (85% of which was metformin), 15% on 2 NIAHAs, 6%
(63%) or small town/rural (21%) settings. Nearly two-thirds of the on 3 NIAHAs, 19% on insulin only and 42% on insulin and one or
physicians reported seeing 10 to 30 type 2 diabetes patients each more 1 NIAHA. There were signicant (p<0.0001) interprovincial
week (1% <5/week, 13% 5e10/week, 36% 10e0/week, 27% 20e30/ differences in insulin use, with the highest found in Manitoba
week, 16% 30e50/week, 7% >50/week) and 22% indicated that (80.3%) and the lowest in Alberta (47.6%). Logistic analyses using
>50% of their type 2 diabetes patients were co-managed by an the GEE model indicated that patients in urban regions (OR [95%
allied health care professional. CI]1.41 [0.97e2.06], p0.0741), from group/family health prac-
tices (OR [95% CI]1.57 [1.13e1.81], p0.0074) and with access to
Patient characteristics diabetes educators (OR [95% CI]1.59 [1.39e1.81], p<0.0001) were
more likely to be prescribed insulin. Of the 127 patients with
The demographic, clinical history, anthropometric and labora- known insulin monotherapy regimens, 9%, 29% and 62% were
tory data of patients reviewed by the DM-SCAN physician partici- receiving 1, 2 and 3 insulin injections/day, respectively. Most of
pants are detailed in Table 2. Mean (SD) duration of type 2 diabetes the individuals on dual AHA therapy were prescribed insulin and
was 9.2 (7.0) years; 15% had type 2 diabetes for 2 years, 21% for a NIAHA; dipeptidyl peptidase-4 inhibitors (DPP-4Is) and sulfo-
3e5 years, 22% for 6e9 years, 23% for 10e14 years and 20% for 15 nylureas were the most common NIAHAs to be combined with
years. According to the World Health Organization ethnic-specic metformin when dual NIAHA therapy was prescribed. Among the
denitions for overweight and obesity (16), 14%, 29% and 57% of 2531 patients who reached an A1C 7.0%, 37% were on NIAHAs only
patients were within the normal weight range, overweight and (51% of whom were on metformin monotherapy), 20% on insulin
obese, respectively. Of those with a known smoking history alone and 23% on insulin 1 NIAHA. The management strategies
(n4098), 12% were current smokers. According to the available used for patients who had an A1C >7.0% are shown in Figure 1B. Of
data, 26% of patients had at least one macrovascular complication
(22% coronary artery disease, 6% previous stroke, 8% peripheral Table 2
Demographic, clinical history, anthropometric and laboratory data of patients
arterial disease). At least 1 microvascular complication was recor-
reviewed
ded for 25% of patients (8% retinopathy, 15% nephropathy, 12%
neuropathy). Both cancer and depression were reported for 12% of Patients (N5123)
patients. Erectile dysfunction was noted for 39% of male patients. Women* 2353 (46.1)
Age (years)y 64 (12)
Ethnicity*
Diet management Aboriginal Canadian 144 (2.9)
Black 197 (4.0)
Information from 4787 records indicated that 38% of patients Caucasian 3021 (60.8)
had been referred to or counselled by a registered dietitian or East/Southeast Asian 851 (17.1)
Hispanic 76 (1.5)
a certied diabetes educator within the last 12 months. Data from
South Asian 529 (10.6)
4776 records revealed that a nutrition/exercise/weight loss plan Other 153 (3.1)
with measurable goals had been established for 50% of patients Body mass index (kg/m2)y
within the same time span. Men 30.5 (10.0)
Women 31.1 (11.6)
A1C (%)y 7.4 (1.3)
Glycemic control and management Fasting plasma glucose (mmol/L)y 7.8 (2.6)
LDL-C (mmol/L)y 2.1 (0.9)
Mean (SD) A1C for 5103 individuals was 7.4% (1.3%), of whom Blood pressure (mm Hg)y
50% had A1C results of 7.0%. Figure 1A shows the distribution of Systolic 128 (14)
Diastolic 75 (9)
A1C values. Duration of type 2 diabetes correlated mildly but
Duration of type 2 diabetes (years)y 9.2 (7.0)
signicantly with A1C increases (r 0.14, p<0.0001). Duration of Current or previous smoker* 1774 (36.1)
type 2 diabetes also showed a strong association with A1C 7.0%
LDL-C, low-density lipoprotein cholesterol.
attainment rates: 65% for those with type 2 diabetes for 2 years, N for each category was variable due to missing values, <10% in each case.
58 % for 3e5 years, 49% for 6e9 years, 43% for 10e14 years and 37% * Data are presented as n (%).
for 15 years (p for trend <0.0001). Optimal A1C targets identied y
Data are presented as mean (SD).
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L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89 85

Figure 1. Glycemic control and management of DM-SCAN patients. (A) Distribution of A1C levels. (B) Management strategies used for patients with A1C >7.0%. (C) Distribution of
NIAHA monotherapy and dual therapy strategies prescribed to patients with A1C >7.0%. Values for (C) were determined according to the corresponding number of patients with
A1C >7.0% who were known to be treated with 1 NIAHA or 2 NIAHAs. DPP-4I, dipeptidyl peptidase-4 inhibitor; GLP-1R, glucagon-like peptide 1 receptor agonists; NIAHA, non-
insulin antihyperglycemic agent; SU, sulfonylurea.

the 1432 patients with an A1C of 7.1% to 8.0%, 2% were not
prescribed any diet or AHA therapy, 4% were on a diet only thera-
peutic regimen and 27% on AHA monotherapy. Even amongst those
with an A1C 9.0% (n523), 2% were not prescribed any diet or
AHA therapy, <1% were on diet only management and 18% on AHA
monotherapy. NIAHA monotherapy and dual therapy strategies
prescribed are outlined in Figure 1C.
Lipid control and management
Mean (SD) low-density lipoprotein cholesterol (LDL-C) level was
2.1 mmol/L (0.9 mmol/L). The target LDL-C of 2.0 mmol/L was
achieved by 57% of 5069 patients (65% for those with known
vascular disease vs. 54% for those without, p<0.0001). The distri-
bution of LDL-C values is shown in Figure 2A. Amongst the 4153
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86 L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89

Table 3
Glycemic control and management

Target A1C Attainment* Patients (N5103)

A1C 7.0% 2531 (49.6)
A1C 9.0% 523 (10.3)

Management strategies* Patients (N5123)

Diet only 517 (10.1)
On antihyperglycemic therapy 4477 (87.4)
Neither diet nor antihyperglycemic therapy 129 (2.5)

Antihyperglycemic therapy Patients (N4477)

Monotherapy 1656 (37.0)
Insuliny 854 (51.2)
Metforminy 685 (41.4)
Other NIAHAsy 117 (7.1)
Dual therapy 1923 (43.0)
2 NIAHAsz 673 (35.0)
Metformin DPP-4Ix 284 (42.2)
Metformin sulfonylureax 264 (39.2)
Insulin 1 NIAHAz 1250 (65.0)
Triple therapy 798 (17.8)
3 NIAHAs{ 241 (30.2)
Insulin 2 NIAHAs{ 557 (69.8)

DPP-4I, dipeptidyl peptidase-4 inhibitor; NIAHA, non-insulin antihyperglycemic

agent.
Data are presented as *n (%).
y
Values were calculated against the number of patients who were on AHA
monotherapy.
z
Values were calculated against the number of patients who were on AHA dual
therapy.
x
Values were calculated against the number of patients who were on 2 NIAHAs.
{
Values were calculated against the number of patients who were on 3 AHAs.

(82%) patients who were prescribed lipid-lowering therapy, 88%

were on monotherapy (of whom 97% were on a statin) and 11% on
dual therapy (67% of whom were on a statin ezetimibe). Of the
2878 patients with LDL-C 2.0 mmol/L, 90% received statins and 8%
were prescribed a statin ezetimibe. Figure 2B outlines how
patients whose LDL-C exceeded 2.0 mmol/L were managed.
Blood pressure control and management
Figure 2. Lipid control and management of DM-SCAN patients. (A) Distribution of
LDL-C levels. (B) Distribution of lipid lowering therapy strategies prescribed to patients
with LDL-C >2.0 mmol/L. Values for (B) were determined according to the corre-
sponding number of patients with LDL-C >2.0 mmol/L who were known to be treated
with lipid lowering agents.

Mean (SD) blood pressure (BP) was 128/75 mm Hg (14/9 mm
Hg). Blood pressure <130/80 mm Hg was met by 36% of 5099
patients. Figure 3A illustrates the BP distribution across the study
population. Amongst the 4272 (83%) patients prescribed antihy-
pertensive agents 39%, 34% and 21% and 6% were on 1, 2, 3 and 3
drugs respectively with 59% prescribed angiotensin-converting
enzyme (ACE) inhibitors and 35% angiotensin II receptor blockers
(ARBs). Amongst the 1852 individuals who reached the BP target of
<130/80 mm Hg, 50% were on ACE inhibitors and 25% on ARBs.
Figure 3B details how those with BP 130/80 mm Hg were
managed.
Composite A1C, LDL-C and BP outcome
The composite endpoint goal of A1C 7.0%, LDL-C 2.0 mmol/l
and BP <130/80 mm Hg was met by 13% of 5104 patients (16% for
those with known coronary artery disease vs. 12% for those without,
p0.0013).
Barriers to successful management of type 2 diabetes
Poor patient adherence (e.g. diet, physical activity, medication,
blood glucose monitoring) was the most commonly cited barrier to
managing type 2 diabetes patients. Other physician-identied
barriers were patient resistance (e.g. reluctance to initiate/inten-
sify antihyperglycemic therapy, poor understanding of disease, its
progressive nature and the associated complications), constraints
on physician time (e.g. comorbidities, complex medical regimens,
patient education), nancial issues (e.g. insurance coverage, access
to and cost of healthy food) and lack of support for physician (e.g.
poor access to timely and sustained nutritional and exercise
counselling).
Discussion
The results of this large, national, cross-sectional observational
survey suggest that still only 50% of Canadian type 2 diabetes
patients met the 2008 CDA CPGs recommended A1C target of 7.0%
(3). Additionally, just over 50% were successful at reaching the
LDL-C 2.0 mmol/L goal recommended by the 2008 CDA CPGs (3)
and the 2009 Canadian Lipid CPGs (17) and only a third the 2008
CDA and 2012 Canadian Hypertension Education Program recom-
mended target BP of <130/80 mm Hg (3,18). Finally, it is also
disappointing that only 13% of patients achieved the composite goal
of A1C 7.0%, LDL-C 2.0 mmol/l and BP <130/80 mm Hg.
The Canadian-based DICE and DRIVE studies previously
demonstrated that CPGs-recommended glycemic control was only
successfully observed in 51% and 53% of the study patients,
respectively (8,10). Notwithstanding some methodological differ-
ences, the DM-SCAN survey recapitulates the persistent manage-
ment gap associated with type 2 diabetes and reconrms the earlier
suggestions that glycemic and other metabolic control in Canada
remains suboptimal despite continual update and dissemination of
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L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89 87

Table 4
Temporal glycemic, lipid and blood pressure controldfrom DICE to DRIVE to
DM-SCAN

DICE DRIVE DM-SCAN

(2002e2003) (2005e2006) NoveDec
N2473 N3002 2012
N5123
Women 46 41 46
Age at audit (years)* 63 64 64
Duration of type 2 diabetes (years)* 7.8 6.0 9.2
Body mass index (kg/m2)* 31 30 31
On insulin 12 15 16
A1C (%)* 7.3 6.9 7.4
A1C <7.0%y or 7.0%z 51z 53{ 50{
LDL-C (mmol/L)* NA 2.2 2.1
LDL-C <2.5 mmol/Ly or 2.0 mmol/Lz NA 64y 57z
Blood pressure (mm Hg)*
Systolic NA 130 128
Diastolic NA 78 75
Blood pressure 130/80 mm Hgy or NA 54y 36z
<130/80 mm Hgz
Triple target achievement
A1C 7.0%, LDL-C <2.5 mmol/L, NA 19 ND
BP 130/80 mm Hg
A1C 7.0%, LDL-C 2.0 mmol/L, NA ND 13
BP <130/80 mm Hg

LDL-C, low-density lipoprotein cholesterol; NA, not available; ND, not determined.
Data are presented as %.
* Mean for DICE and DM-SCAN, median for DRIVE.
yz{
Targets for DICE, DRIVE and DM-SCAN were different; symbols denote corre-
sponding targets of the individual study.

Figure 3. Lipid control and management of DM-SCAN patients. (A) Distribution of
blood pressure levels. (B) Distribution of antihypertensive therapy strategies
prescribed to patients with BP 130/80 mm Hg. Values for (B) were determined
according to the corresponding number of patients with BP 130/80 mm Hg who were
known to be treated with antihypertensive agents.
CPGs and an increasing number of AHAs. Table 4 summarizes the
key ndings of the DICE, DRIVE and DM-SCAN studies. Mean
duration of type 2 diabetes for the DICE and DM-SCAN patient
populations were 8 years and 9 years, respectively, and the median
duration for DRIVE was 6 years. Although all 3 studies found that
only 50% the patients were able to attain the recommended A1C
target of the time, it is worth noting that despite DM-SCAN patients
having a longer mean duration of type 2 diabetes than DICE
patients, mean A1C was only slightly higher for the former (7.4% vs.
7.3%). This may in part be attributed to less reliance on lifestyle only
management (10% for DM-SCAN vs. 16% for DICE) and greater use of
insulin (both alone and in combination with NIAHAs) amongst DM-
SCAN patients (61% for DM-SCAN vs. 12 % for DICE). Although it
would appear that glycemia was better controlled in DRIVE vs. DM-
SCAN patients (median A1C 6.9% vs. 7.0%; A1C 7.0% rates 53% vs.
50%), it is important that at the time of audit DRIVE patients were
generally at earlier stages of the disease than DM-SCAN patients.
In 81% of patients, the A1C goal set by the physicians was 7%.
Therefore, the low success rate in achieving A1C levels 7% cannot
be explained by patient factors that would make such a target
unreasonable or physicians not knowing the recommended target.
When queried, physicians suggested patient barriers as the primary
causes of unsuccessful attempts to gain and sustain glycemic
control. However, they also acknowledged time constraints,
nancial considerations and limited access to relevant diabetes-
associated support personnel and services as contributory factors.
Rate of insulin usage for the DRIVE cohort was 15%. This is
similar to the 12% reported by the DICE investigators but remark-
ably lower than the 61% noted in the DM-SCAN patient population.
The greater use of insulin amongst the DM-SCAN physicians is of
signicant interest since it occurred despite the introduction of 2
new classes of AHAs after the release of the 2008 CDA CPGsdthe
DPP-4Is and glucagon-like peptide 1 receptor agonistsdboth of
which are not associated with the potential weight gain and risk of
hypoglycemia of insulin. Whether these observations represent an
increase in awareness and enhanced adherence to CPGs recom-
mendations and/or a decrease in clinical inertia with regards to
insulin initiation and intensication remains to be determined. The
fact that insulin use was associated with greater access to diabetes
educators suggests that this may have contributed. Regardless,
these ndings are novel, promising and warrant further
investigations.
The recurrent observation in the DICE, DRIVE and DM-SCAN
initiatives that glycemic control is achieved in only about half of
the patients is not unique to Canada. A retrospective, cross-
sectional analysis of data from the United Kingdom General
Practice Research Database, collected between 1998 and 2002,
indicated that A1C 7.0% was recorded for 34% of patients (14). The
2003e2006 data from the population-based National Health and
Nutrition Examination Survey (NHANES) revealed that just 57% of
adults with diabetes surveyed met the recommended A1C target of
7.0% or lower (12). After reviewing 2966 medical records of type 2
diabetes patients from primary, secondary, and tertiary hospitals in
the Jiangsu province of China, Bi et al. (13) reported only 56%
attained A1C <7.0%.
Although only 57% of DM-SCAN patients achieved the LDL-C
target of 2.0 mmol/L, it is somewhat reassuring because only
64% of DRIVE patients met the higher <2.5 mmol/L target. This
suggests that physicians are aware of and are more condent at
applying CPGs recommendations to immediately achieve LDL-C
targets in type 2 diabetes patients. The DM-SCAN results are not
as positive as those found in the Canadian arm of the recently
completed DYSlipidemia International Study (DYSIS) where 63% of
 Author's personal copy
88 L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
all patients were at recommended or intervention target LDL-C
levels (19). Neither do the DM-SCAN results appear as promising
as those of the Canadian Lipid Study-Observational (CALIPSO)
where only 27% of patients audited were not at the recommended
LDL-C (20). It is, however, important to remember that the DYSIS
and CALIPSO analyses were based on LDL-C thresholds recom-
mended in the 2006 Canadian Cardiovascular Society (21) and the
2003 Canadian Working Group on Hypercholesterolemia and Other
Dyslipidemias (22) CPGs, respectively, both of which were higher
than that in the 2009 Canadian Lipid CPGs (17) The disparity
between the DM-SCAN, DYSIS and CALIPSO results are also likely
reective of our subanalysis demonstrating that a greater
percentage of patients with cardiovascular disorders reached the
LDL-C target than those who did not present with any cardiovas-
cular abnormalities. The apparent discrepant care between type 2
diabetes patients with and without cardiovascular disease has
previously been reported by the investigators of the Analysis and
Understanding of Diabetes and Dyslipidaemia: Improving Treat-
ment (AUDIT) study (23). The AUDIT survey found that physicians
tended to treat type 2 diabetes patients with cardiovascular disease
more intensively than they did those without cardiovascular
disease suggesting that at least at the time of the study, type 2
diabetes had yet to be recognized by physicians as a major
cardiovascular risk factor.
Blood pressure distribution was similar in the DM-SCAN and
DRIVE studies (Table 4) as were the use of ACE inhibitors (59%
DM-SCAN vs. 61% DRIVE) and ARBs (35% DM-SCAN vs. 27% DRIVE).
Target BP achievement rate, although still suboptimal, was greater in
the DRIVE study (54% vs. 36%) and may have resulted in part from the
slightly less stringent BP target (130/80 mm Hg vs. <130/80 mm Hg
for DM-SCAN). The investigators of the 2006 Ontario Survey on the
Prevalence and Control of Hypertension also observed suboptimal
blood pressure control in the Canadian diabetes community. They
reported that 50% of individuals with type 2 diabetes had hyper-
tension, amongst whom 97% were receiving antihypertensive
treatment but only 36% had BP values <130/80 mm Hg (24).
Global vascular protection is acknowledged as the cornerstone
to managing type 2 diabetes patients. Only 13% of the DM-SCAN
patients achieved the composite target of A1C 7.0%, LDL-C
2.0 mmol/l and BP <130/80 mm Hg. This is lower than the 19%
success rate reported for the DICE patients (8) who had less intense
LDL-C and BP targets but very similar to the 2003e2006 NHANES
data showing 13% of type 2 diabetes patients successfully achieving
all 3 primary goals for A1C (<7.0%), LDL-C (<2.6 mmol/L) and BP
(<130/80 mm Hg) (12). The investigators of the International
Diabetes Management Practice Study recently reported that in
developing regions only 3.6% of 3896 type 2 diabetes patients met
the composite goal of A1C <7.0%, LDL-C and BP (25). Clearly, greater
efforts are needed to bring more patients to the triple therapeutic
goal to achieve maximal vascular protection.
The results of the DM-SCAN survey have important implications
for the implementation of the 2013 CDA CPGs. It is evident that
innovative strategies are necessary to emphasize to physicians the
importance of adopting and translating evidence-based CPGs into
every day clinical care. It is imperative too that a variety of easily
accessible education platforms be established to provide physicians
with practical means of overcoming clinical inertia and strategies to
more effectively educate their patients at self-managing and self-
monitoring to enhance accountability. Initiatives aimed at encour-
aging greater collaboration between primary care physicians,
specialists and allied healthcare personnel in a patient-centric
network as well as increasing patient adherence are also
warranted. For instance, in recognition of the strong evidence for
better patient outcomes with nurse- and pharmacist-directed care
(26,27), Hypertension Canada has expanded its audience to include
nurses and pharmacists (28). Some other avenues that may be
worthwhile exploring include increased accessibility of CPGs,
treatment algorithms and information on newer AHA classes
through mobile applications; and novel formats for live and
online continued medical education events.
This survey has several limitations. First, the recruitment strat-
egies used may have resulted in an overrepresentation of physi-
cians who are more proactive at improving their management of
type 2 diabetes patients and thus more open to participating in
a survey such as DM-SCAN. Second, it is possible that patients with
well-controlled A1C, or those treated with insulin, consult their
physicians more regularly and therefore were more likely to be
enrolled that may account in part for the large proportion of
patients reported to be on insulin therapy. Additionally, we are
unable to conrm that physicians enrolled consecutive patients and
provided information for all patients seen over a single clinic day.
Third, laboratory values were obtained from medical records rather
than through central laboratory evaluations. Furthermore, there
were no attempts to conrm the accuracy of the data provided
against the source documents. Fourth, we did not request infor-
mation on baseline/earlier glycemic, lipid and BP parameters and
therefore cannot comment on whether patients were managed
appropriately. We also therefore cannot comment on patients who
have type 2 diabetes who were seen but were excluded due to the
absence of an A1C reading. Fifth, although we did collect data on
whether lifestyle modications were recommended, we did not
obtain details on patient lifestyle, nor on drug side effects and
treatment adherence. This survey does have several strengths. First,
this was a large nationwide initiative with representation from
a variety of primary care settings in different geographical loca-
tions. Second, there were very few missing A1C (0.4%), SBP (0.4%),
DBP (0.5%) and LDL-C (1.1%) values suggesting high accuracy of the
target achievement rates calculated. Finally, the requirement that
physicians report on all the type 2 diabetes patients whom they
saw in the single day may have in some cases reduced the chances
of patient selection and may be in these cases be more reective of
real world settings.
Conclusions
Despite widespread attempts at dissemination and imple-
mentation of practice CPGs, and advances in type 2 diabetes
pharmacotherapy, the results of the DM-SCAN survey accentuate
the persistent treatment gap associated with the treatment of type
2 diabetes. This survey also highlights the continual challenges
faced by primary care physicians to gain and maintain glycemic
control as well as achieve global vascular protection in type 2
diabetes patients. Practical strategies aimed at more aggressively
managing type 2 diabetes patients and their risk factors to more
effectively surmount the collective barriers in closing the ongoing
care gap are urgently needed.
Acknowledgments
The Diabetes Mellitus Status in Canada (DM-SCAN) survey was
made possible through the support of Merck Canada Inc. The
opinions expressed in this material are those of the authors and do
not necessarily reect the views of Merck Canada Inc.
Author Disclosures
LAL has received honouraria or research support from Amgen,
AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly,
GlaxoSmithKline, Janssen, Merck, Novartis, Novo Nordisk, Sano,
Servier and Takeda. LB has received honouraria or research support
from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck,
Novo Nordisk and Sano. CKB has received honouraria or research
 Author's personal copy
L.A. Leiter et al. / Can J Diabetes 37 (2013) 82e89
support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers
Squibb, Eli Lilly, Merck, Novartis, Novo Nordisk, Pzer and Sano.
AYC has received honouraria or research support from Abbott,
AstraZeneca- Bristol-Myers Squibb, Becton Dickinson, Eli Lilly, Eli
Lilly, Lifescan, Merck, Novo Nordisk, Sano and Servier. KGD has
received honouraria or research support from GlaxoSmithKline,
Lifescan, Lilly, Merck, Novo Nordisk and Sano. J-ME has received
honouraria or research support from Merck. CF has received hon-
ouraria or research support from Amgen, AstraZeneca, Boehringer
Ingelheim, Bristol-Myers Squibb, Forrest, Janssen, Sano, Takeda
and Valeant. LG has no conicts of interest to declare. SBH has
received honouraria or research support from AstraZeneca- Bristol-
Myers Squibb, Boehringer Ingelheim-Eli Lilly, Janssen, Merck,
NovoNordisk, Roche, Sano and Takeda. PL has received honouraria
or research support from AstraZeneca, Boehringer Ingelheim, Eli
Lilly, Merck, NovoNordisk, Sano and Takeda. TR has received
honouraria or research support from AstraZeneca, Boehringer
Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Merck,
Novartis, NovoNordisk and Sano. MT has no conicts of interest to
declare. HT has no conicts of interest to declare. RTT has received
honouraria or research support from Abbott, AstraZeneca, Bristol-
Myers Squibb-AstraZeneca, Boehringer Ingelheim, Merck, Phar-
maSmart and Sano. DW has no conicts of interest to declare. VW
has received honouraria or research support from AstraZeneca,
Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Forrest,
Janssen, Merck, Novo Nordisk and Sano. J-FY has received
honouraria or research support from AstraZeneca, Boehringer
Ingelheim, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck, Novo
Nordisk, Sano and Takeda. AL has received honouraria or research
support from Actelion, AstraZeneca, Aventis, Bayer, Biovail, Boston
Scientic, Bristol-Myers Squibb/Sano Pharmaceuticals Partner-
ship, Cordis, Guidant, Medtronics, Merck, Millennium Pharmaceu-
ticals, Ortho Biotec, Oryx, Pzer, Roche, Sano-Synthelabo,
Schering Key Corporation, Servier, The Medicines Company and
United Therapeutics.
Author Contributions
LAL designed the study, researched the data, contributed to the
discussion, wrote the manuscript and edited the manuscript. LB
contributed to the discussion and reviewed the manuscript. CKB
contributed to the discussion and reviewed the manuscript. AYC
contributed to the discussion and reviewed the manuscript. KGD
contributed to the discussion and reviewed the manuscript. J-ME
contributed to the discussion and reviewed the manuscript. CF
contributed to the discussion and reviewed the manuscript. LG
designed the study, researched the data, contributed to the
discussion and reviewed the manuscript. SBH contributed to the
discussion and reviewed the manuscript. PL contributed to the
discussion and reviewed the manuscript. TR contributed to the
discussion and reviewed the manuscript. MT researched the data,
contributed to the discussion, and reviewed the manuscript. HT
researched the data, wrote the manuscript and edited the manu-
script. RTT contributed to the discussion and reviewed the manu-
script. DW contributed to the discussion and reviewed the
manuscript. VW contributed to the discussion and reviewed the
manuscript. JFY contributed to the discussion and reviewed the
manuscript. AL designed the study, researched the data, contrib-
uted to the discussion and reviewed the manuscript.
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