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Can J Diabetes xxx (2014) 1e2

Canadian Journal of Diabetesjournal 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 2014Accepted 27 February 2014Available online xxx

* Address for correspondence: Jann Paquette-WarreFamily Medicine, Schulich School of Medicine & DPublic Health and Family Medicine, The University ofmond St., London, Ontario N6A3K7, Canada.

E-mail address: Jann.Paquette-Warren@schulich.u

1499-2671/$ e see front matter � 2014 Canadian Diahttp://dx.doi.org/10.1016/j.jcjd.2014.02.029

Diabetes is one of the most common and preventable chronicdiseases, yet an estimated 3.7 million Canadians are projected todevelop the disease by 2018/2019 (1). Diabetes poses a significantburden 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 thegrowing burden of diabetes has been significant (1,3,4). In 2005, thefederal government allocated $18 million per year for the CanadianDiabetes Strategy,which focuses on the prevention andmanagementof diabetes. In 2010/2011, $55millionwere allocated to theAboriginalDiabetes Initiative (5). In addition, the provinces and territoriesinvested in diabetes strategies: $648million from2008 through 2012for the Ontario Diabetes Strategy, which allocated $118 million (18%)for increased access to team-based care (including the Regional Co-ordination Centres, Diabetes Education Programs and other initia-tives); $19 million (3%) for diabetes prevention initiatives; $150million (23%) for a diabetes registry and the BaselineDiabetesDatasetInitiative (BDDI); $63 million (10%) for insulin pump therapy; $220million (34%) for chronic kidney disease services and $78 million(12%) for bariatric centres of excellence (6). This new funding was inaddition to previously endorsed diabetes services through theOntarioMinistry 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 wasnegligible (6). This was highlighted in 2 recent reports by theauditor generals of Ontario (6) and the federal government (5). Thefederal report (5) discussed concerns about coordination betweenfunded activities and the lack of clear priorities, measures anddeliverables to develop and establish an effective strategy or toassess its degree of success. This was said to result from the failureto engage key stakeholders and the inadequate development of a

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clear research plan at the outset and throughout implementationThe Ontario report (6) noted that although some deliverables weremet, there was duplication of services and not enough emphasis onprevention. Impact measurement requirements were set, andhealth system outcome indicators were identified for assessingquality of care, but reporting did not necessarily occur, and therewere no performance checks by government officials. In summary,the reports concluded that to date, no substantive evidence existsto demonstrate whether investments by the government haveaffected the prevalence and associated costs of diabetes (5,6), andno framework exists to guide the comprehensive evaluation ofdiabetes prevention and management strategies systematically (7).As such, a formal evaluation strategy needs to be developed toaccompany new investments and initiatives to improve the healthof patients with diabetes.

The purpose of evaluation and assessment of performance is toprovide healthcare decision makers with appropriate informationabout the state of their healthcare system (5,6). To understand themultifaceted mechanisms and processes underlying care, multi-level performance indicators (including, but not limited to, clinicalprocesses and outcomes) are required, along with assessment ofcausal pathways between activities and outcomes (7,8). A frame-work is needed to guide the evaluation of health research andinitiatives and to facilitate policy innovations. Such a frameworkshould be 1) system focused; 2) comprehensive, by including pre-vention, identification and management of diabetes and associatedcomplications; and 3) flexible in its application.

If this type of framework were developed and aligned with newfunding strategies, stakeholders would be better able to 1) identifycare gaps; 2) enhance transparency and accountability; 3)encourage policy change with economic implications and 4) pro-vide direction for future investments and programs. The frameworkshould be developed in collaboration with key stakeholders (e.g.diabetes, evaluation, policy, and healthcare system experts, deci-sion makers, etc.) and should build on existing literature to capturethe standards and benchmarks of diabetes care across the health-care system and environmental contexts.

S.B. Harris, J. Paquette-Warren / Can J Diabetes xxx (2014) 1e22

There is a growing need to sustain the costs of managingpatients with diabetes while striving for high-quality care. Mak-ing use of an evidence-based evaluation framework would facil-itate the assessment of the health and economic impacts of newor previously endorsed chronic disease management programsand models of care and would facilitate policy innovations toreduce the financial and public health burden of diabetes.Investments in diabetes strategies are substantial, and now is thetime to evaluate.

References

1. Public Health Agency of Canada. Diabetes in Canada: Facts and figures from apublic health perspective 2011. http://www.phac-aspc.gc.ca/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011/pdf/facts-figures-faits-chiffres-eng.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 thedesired results: Lessons on access to primary care from Ontario’s patientenrolment 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 Generalof 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 value-for-money audits and reviews, section 3.03, Diabetes management strategy2012;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 careprogrammes and views on high quality diabetes care: are we in need of astandardized framework? Int J Integr Care 2008;8:1e15.

8. Hulscher ME, Laurant MG, Grol RP. Process evaluation on quality improvementinterventions. Qual Saf Health Care 2003;12:40e6.