Can J Diabetes xxx (2014) 1e2
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Commentary
Investments in Diabetes Strategies: Time to Evaluate! Stewart B. Harris MD, MPH, FCFP, FACPM, Jann Paquette-Warren MSc * Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western Centre for Public Health and Family Medicine, The University of Western Ontario, London, Ontario, Canada
a r t i c l e i n f o Article history: Received 19 February 2014 Accepted 27 February 2014 Available online xxx
Diabetes is one of the most common and preventable chronic diseases, yet an estimated 3.7 million Canadians are projected to develop the disease by 2018/2019 (1). Diabetes poses a significant burden on our economy, with a rise of $4.7 billion (nearly 70%) since 2000 to an estimated $11.7 billion in 2010 (2). Over the past decade, government investment to address the growing burden of diabetes has been significant (1,3,4). In 2005, the federal government allocated $18 million per year for the Canadian Diabetes Strategy, which focuses on the prevention and management of diabetes. In 2010/2011, $55 million were allocated to the Aboriginal Diabetes Initiative (5). In addition, the provinces and territories invested in diabetes strategies: $648 million from 2008 through 2012 for the Ontario Diabetes Strategy, which allocated $118 million (18%) for increased access to team-based care (including the Regional Coordination Centres, Diabetes Education Programs and other initiatives); $19 million (3%) for diabetes prevention initiatives; $150 million (23%) for a diabetes registry and the Baseline Diabetes Dataset Initiative (BDDI); $63 million (10%) for insulin pump therapy; $220 million (34%) for chronic kidney disease services and $78 million (12%) for bariatric centres of excellence (6). This new funding was in addition to previously endorsed diabetes services through the Ontario Ministry of Health and Long-Term Care, including the annual $335 million for health-promotion programs (6). It is regrettable that the evaluation of these initiatives was negligible (6). This was highlighted in 2 recent reports by the auditor generals of Ontario (6) and the federal government (5). The federal report (5) discussed concerns about coordination between funded activities and the lack of clear priorities, measures and deliverables to develop and establish an effective strategy or to assess its degree of success. This was said to result from the failure to engage key stakeholders and the inadequate development of a
* Address for correspondence: Jann Paquette-Warren, MSc, Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western Centre for Public Health and Family Medicine, The University of Western Ontario, 1151 Richmond St., London, Ontario N6A3K7, Canada. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2014 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.02.029
clear research plan at the outset and throughout implementation The Ontario report (6) noted that although some deliverables were met, there was duplication of services and not enough emphasis on prevention. Impact measurement requirements were set, and health system outcome indicators were identified for assessing quality of care, but reporting did not necessarily occur, and there were no performance checks by government officials. In summary, the reports concluded that to date, no substantive evidence exists to demonstrate whether investments by the government have affected the prevalence and associated costs of diabetes (5,6), and no framework exists to guide the comprehensive evaluation of diabetes prevention and management strategies systematically (7). As such, a formal evaluation strategy needs to be developed to accompany new investments and initiatives to improve the health of patients with diabetes. The purpose of evaluation and assessment of performance is to provide healthcare decision makers with appropriate information about the state of their healthcare system (5,6). To understand the multifaceted mechanisms and processes underlying care, multilevel performance indicators (including, but not limited to, clinical processes and outcomes) are required, along with assessment of causal pathways between activities and outcomes (7,8). A framework is needed to guide the evaluation of health research and initiatives and to facilitate policy innovations. Such a framework should be 1) system focused; 2) comprehensive, by including prevention, identification and management of diabetes and associated complications; and 3) flexible in its application. If this type of framework were developed and aligned with new funding strategies, stakeholders would be better able to 1) identify care gaps; 2) enhance transparency and accountability; 3) encourage policy change with economic implications and 4) provide direction for future investments and programs. The framework should be developed in collaboration with key stakeholders (e.g. diabetes, evaluation, policy, and healthcare system experts, decision makers, etc.) and should build on existing literature to capture the standards and benchmarks of diabetes care across the healthcare system and environmental contexts.
2
S.B. Harris, J. Paquette-Warren / Can J Diabetes xxx (2014) 1e2
There is a growing need to sustain the costs of managing patients with diabetes while striving for high-quality care. Making use of an evidence-based evaluation framework would facilitate the assessment of the health and economic impacts of new or previously endorsed chronic disease management programs and models of care and would facilitate policy innovations to reduce the financial and public health burden of diabetes. Investments in diabetes strategies are substantial, and now is the time to evaluate. References 1. Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective 2011. http://www.phac-aspc.gc.ca/cd-mc/publications/ diabetes-diabete/facts-figures-faits-chiffres-2011/pdf/facts-figures-faits-chiffreseng.pdf. Accessed January 30, 2012.
2. Canadian Diabetes Association. Diabetes: Canada at the tipping point 2011. http://www.diabetes.ca/documents/get-involved/WEB_Eng.CDA_Report_.pdf. Accessed May 29, 2013. 3. Glazier RH, Kopp A, Schultz SE, et al. All the right intentions but few of the desired results: Lessons on access to primary care from Ontario’s patient enrolment models. Healthcare Q 2012;15:17e21. 4. Hutchison B, Levesque JF, Strumpf E, et al. Primary health care in Canada: Systems in motion. Milbank Q 2011;89:256e88. 5. Office of the Auditor General of Canada. 2013 Spring report of the Auditor General of Canada. Promoting diabetes prevention and control. http://www.oag-bvg.gc.ca/ internet/English/parl_oag_201304_05_e_38190.html. Accessed May 22, 2013. 6. Office of the Auditor General of Ontario. 2012 Annual report. Reports on valuefor-money audits and reviews, section 3.03, Diabetes management strategy 2012;82e106). http://www.auditor.on.ca/en/reports_en/en12/2012ar_en.pdf. Accessed March 27, 2013. 7. Borgermans LA, Goderis G, Ouwens M, et al. Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework? Int J Integr Care 2008;8:1e15. 8. Hulscher ME, Laurant MG, Grol RP. Process evaluation on quality improvement interventions. Qual Saf Health Care 2003;12:40e6.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Commentary
Investments in Diabetes Strategies: Time to Evaluate! Stewart B. Harris MD, MPH, FCFP, FACPM, Jann Paquette-Warren MSc * Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western Centre for Public Health and Family Medicine, The University of Western Ontario, London, Ontario, Canada
a r t i c l e i n f o Article history: Received 19 February 2014 Accepted 27 February 2014 Available online xxx
Diabetes is one of the most common and preventable chronic diseases, yet an estimated 3.7 million Canadians are projected to develop the disease by 2018/2019 (1). Diabetes poses a significant burden on our economy, with a rise of $4.7 billion (nearly 70%) since 2000 to an estimated $11.7 billion in 2010 (2). Over the past decade, government investment to address the growing burden of diabetes has been significant (1,3,4). In 2005, the federal government allocated $18 million per year for the Canadian Diabetes Strategy, which focuses on the prevention and management of diabetes. In 2010/2011, $55 million were allocated to the Aboriginal Diabetes Initiative (5). In addition, the provinces and territories invested in diabetes strategies: $648 million from 2008 through 2012 for the Ontario Diabetes Strategy, which allocated $118 million (18%) for increased access to team-based care (including the Regional Coordination Centres, Diabetes Education Programs and other initiatives); $19 million (3%) for diabetes prevention initiatives; $150 million (23%) for a diabetes registry and the Baseline Diabetes Dataset Initiative (BDDI); $63 million (10%) for insulin pump therapy; $220 million (34%) for chronic kidney disease services and $78 million (12%) for bariatric centres of excellence (6). This new funding was in addition to previously endorsed diabetes services through the Ontario Ministry of Health and Long-Term Care, including the annual $335 million for health-promotion programs (6). It is regrettable that the evaluation of these initiatives was negligible (6). This was highlighted in 2 recent reports by the auditor generals of Ontario (6) and the federal government (5). The federal report (5) discussed concerns about coordination between funded activities and the lack of clear priorities, measures and deliverables to develop and establish an effective strategy or to assess its degree of success. This was said to result from the failure to engage key stakeholders and the inadequate development of a
* Address for correspondence: Jann Paquette-Warren, MSc, Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western Centre for Public Health and Family Medicine, The University of Western Ontario, 1151 Richmond St., London, Ontario N6A3K7, Canada. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2014 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.02.029
clear research plan at the outset and throughout implementation The Ontario report (6) noted that although some deliverables were met, there was duplication of services and not enough emphasis on prevention. Impact measurement requirements were set, and health system outcome indicators were identified for assessing quality of care, but reporting did not necessarily occur, and there were no performance checks by government officials. In summary, the reports concluded that to date, no substantive evidence exists to demonstrate whether investments by the government have affected the prevalence and associated costs of diabetes (5,6), and no framework exists to guide the comprehensive evaluation of diabetes prevention and management strategies systematically (7). As such, a formal evaluation strategy needs to be developed to accompany new investments and initiatives to improve the health of patients with diabetes. The purpose of evaluation and assessment of performance is to provide healthcare decision makers with appropriate information about the state of their healthcare system (5,6). To understand the multifaceted mechanisms and processes underlying care, multilevel performance indicators (including, but not limited to, clinical processes and outcomes) are required, along with assessment of causal pathways between activities and outcomes (7,8). A framework is needed to guide the evaluation of health research and initiatives and to facilitate policy innovations. Such a framework should be 1) system focused; 2) comprehensive, by including prevention, identification and management of diabetes and associated complications; and 3) flexible in its application. If this type of framework were developed and aligned with new funding strategies, stakeholders would be better able to 1) identify care gaps; 2) enhance transparency and accountability; 3) encourage policy change with economic implications and 4) provide direction for future investments and programs. The framework should be developed in collaboration with key stakeholders (e.g. diabetes, evaluation, policy, and healthcare system experts, decision makers, etc.) and should build on existing literature to capture the standards and benchmarks of diabetes care across the healthcare system and environmental contexts.
2
S.B. Harris, J. Paquette-Warren / Can J Diabetes xxx (2014) 1e2
There is a growing need to sustain the costs of managing patients with diabetes while striving for high-quality care. Making use of an evidence-based evaluation framework would facilitate the assessment of the health and economic impacts of new or previously endorsed chronic disease management programs and models of care and would facilitate policy innovations to reduce the financial and public health burden of diabetes. Investments in diabetes strategies are substantial, and now is the time to evaluate. References 1. Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective 2011. http://www.phac-aspc.gc.ca/cd-mc/publications/ diabetes-diabete/facts-figures-faits-chiffres-2011/pdf/facts-figures-faits-chiffreseng.pdf. Accessed January 30, 2012.
2. Canadian Diabetes Association. Diabetes: Canada at the tipping point 2011. http://www.diabetes.ca/documents/get-involved/WEB_Eng.CDA_Report_.pdf. Accessed May 29, 2013. 3. Glazier RH, Kopp A, Schultz SE, et al. All the right intentions but few of the desired results: Lessons on access to primary care from Ontario’s patient enrolment models. Healthcare Q 2012;15:17e21. 4. Hutchison B, Levesque JF, Strumpf E, et al. Primary health care in Canada: Systems in motion. Milbank Q 2011;89:256e88. 5. Office of the Auditor General of Canada. 2013 Spring report of the Auditor General of Canada. Promoting diabetes prevention and control. http://www.oag-bvg.gc.ca/ internet/English/parl_oag_201304_05_e_38190.html. Accessed May 22, 2013. 6. Office of the Auditor General of Ontario. 2012 Annual report. Reports on valuefor-money audits and reviews, section 3.03, Diabetes management strategy 2012;82e106). http://www.auditor.on.ca/en/reports_en/en12/2012ar_en.pdf. Accessed March 27, 2013. 7. Borgermans LA, Goderis G, Ouwens M, et al. Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework? Int J Integr Care 2008;8:1e15. 8. Hulscher ME, Laurant MG, Grol RP. Process evaluation on quality improvement interventions. Qual Saf Health Care 2003;12:40e6.
