Diabetic Retinopathy Screening – Ontario Scaling-Up O

Research Program Title Author Poster # Patient Engagement Comprendre l’engagement des patients partenaires de S Chipenda-Dansokho, O Drescher, B Roy, 1 l’Action diabète Canada dans une perspective de parcours M-C Tremblay, S Dupéré, J Dogba de vie Patient Engagement Patients As Teachers: Applying Patient Partners’ Expertise R. Ndjaboue, B. Boudreault, F. Frigon- 2 to Improve Diabetes Management and Care Tremblay, S. Chipenda Dansokho, J. Dogba, R. Price, P. Delgado, A.M. McComber, O. Drescher, M-C. Tremblay, J. McGavock, H. Witteman Patient Engagement Diabetes Complications Risk Calculator : Gathering Risk R. Ndjaboue, I. Farhat, C-A. Ferlatte, G. 3 Models Based on What Matters to People Living with Ngueta, D. Guay, S. Delorme, S. Straus, N. Diabetes Ivers, C. Yu, B. Shah, H. Witteman Diabetic Identifying Barriers and Enablers to Attending Diabetic MJ Dogba, M Brent, C Bach, Z van Allen, S 4 Retinopathy/Patient Retinopathy Screening in Immigrants from Ethnocultural Asad, J Grimshaw, N Ivers, F Légaré, H O. Engagement Minority Groups Witteman, J Squires, X Wang, O Sutakovic, O Drescher, M Zettl, N McCleary, M-C Tremblay, S Linklater, A Randhawa, GY Wang, J Presseau, Diabetic Experience with Telemedicine Diabetic Retinopathy R Martens, W Thickson, M Jovanovic, D 5 Retinopathy Screening in British Maberley Columbia

Diabetic First Case Use of Population-Based Diabetic Retinopathy J. Cao, S. Isaackz, M. Chang, J. Bowen, V. 6 Retinopathy Screening in Ontario Rac, M. Greiver, C. Pow, R. Merritt, C. Whiteside, O. Sutakovic, M. H. Brent Diabetic Diabetic Retinopathy Screening – Ontario scaling-up O. Sutakovic, D. Sissmore, R. Merritt, V. Rac, 7 Retinopathy strategy S. Kosar , V. Chaudhary, T. Sheidow, J. Noble, D. Wong, M. Brent Health Technology Insights into impact of Tele-retina screening for diabetic Aleksandra Stanimirovic, Sonia Meerai, Troy 8 Assessment and retinopathy among women of low socio-economic status Francis, Nida Shahid Valeria E. Rac Network Analytics (SES)

Research Program Title Author Poster # Health Technology Tele-retina (TR) screening of diabetic retinopathy among at A Stanimirovic, T Francis, N Shahid, O 9 Assessment and risk populations: an economic analysis Sutakovic, R Merritt, MH. Brent, VE Rac Network Analytics Innovations in T1D Does Sodium Glucose Linked Transporter (SGLT) Inhibition Bruce Perkins, Nancy Cardinez, Andrej 10 Improve Performance of the Artificial Pancreas in Type 1 Orszag, Marcelo Falappa, Leif Erik Lovblom, Diabetes? Devrim Eldelekli, Daniel Scarr, Ahmad Haidar Innovations in T1D Nothing About Us Without Us: Identifying Research Nika D. Klaprat, Todd Duhamel, Jonathan 11 Priorities for Exercise and Type 1 Diabetes McGavock

Innovations in T1D T1ME Trial: Type 1 diabetes virtual self-Management G Booth, N Ivers, L Lipsombe, R Shulman, G 12 Education and support Lakhanpal, M Chan, S de Sequeira, B Perkins Innovations in T1D Phase 2 clinical trial testing safety and efficacy of topical P Fernyhough 13 pirenzepine to treat diabetic neuropathy Knowledge Identification of Barriers and Facilitators to Follow-Up for L MacCallum, J Kellar, A Mathers, J Moore, G 14 Translation People with Diabetes by Community Pharmacists Lewis, L Dolovich

Knowledge Environmental scan on KT tools to prevent diabetes S Desroches, L Adisso, S Delorme, H English, 15 Translation complications A Freitas, S Hickes, N Ivers, M Kastner, A Lapointe, F Légaré, J Marin, F Moukambi, R Piché, F Proust, M-C Tremblay, C Yu Knowledge Shared Decision Making via Personal Health Record S Davis 16 Translation Technology as Routine Practice for Youth with Type 1 Diabetes

Knowledge Lifestyle knowledge translation strategies to prevent type 2 F Proust, S Desroches, M-C Tremblay 17 Translation diabetes among Indigenous Peoples of America

Knowledge INtegrating sex and gender considerations into a Légaré F, Lee-Gosselin H, Borduas F, 18 Translation Continuing professional deveLopment activity on Monette C, Parent N, Bilodeau A, Tanguay D, Stacey D, Gagnon MP, Roch G, Dogba MJ,

Research Program Title Author Poster # DEpression and Diabetes (INCLuDED): protocol for a non- Brussière A, Tremblay MC Bélanger AP, Jose randomized controlled trial C, Desroches S, Gaudreau A, Remy Lamarche D, Vigneault L, Robitaille H, Blair L, Deom Tardif A, Moukambi F, Rhugenda S-M Indigenous Peoples Indigenous Youth Mentorship Program J McGavock, A McComber, P Sadi 19 Health Indigenous Peoples Providing culturally safe care to Atikamekw living with M‐C Tremblay, M Bradette‐Laplante, H 20 Health diabetes in Manawan, Quebec: Identifying barriers and Witteman, J Dogba, E Careau, J‐S Paquette, facilitators from different vantage points P Breault, S Échaquan, D Niquay, F Roberston Sex and Gender The Health Researcher’s Toolkit: Why Sex & Gender Matter R Mason, N Hussain, P Rochon 21

Training and Glucose in the Diet Influences Intestinal Fat Absorption: P Stahel, C Xiao, A Nahmias, GF Lewis 22 Mentoring Nutritional implications for heart disease in those with diabetes Training and Food Insecurity and Hospitalization among Canadians with N Gupta, Z Sheng 23 Mentoring Diabetes

Training and Diabetes Action Canada Training and Mentoring Enabling Mathieu Bélanger, André Carpentier, 24 Mentoring Program Michelle Murray

Digital Health Building a proof of concept National Diabetes Repository M Greiver, N Drummond, D Manca, MT 25 Lussier, A Singer, K Aubrey-Bassler, D Willison, D Mumford, C Pow, T Chen, A Bhatt Aging, Community Engaging Stakeholders in the Development and Evaluation J Ploeg, M Markle-Reid, R Valaitis, K Fisher, 26 and Population of the Aging, Community R Ganann, A Gruneir, W Johnson, F Légaré, L Health and Health Research Unit (ACHRU) – Community Mansell, Partnership Program (CPP) W Montelpare, P Reid, F Tang, R Upshur

Research Program Title Author Poster # Aging, Community High Volume Emergency Department Use in Older Adults K Fisher, A Gruneir, J Bakal, C Sadowski, L 27 and Population with Diabetes: ACHRU Community Partnership Program Favotto, R Perez, D Eurich, R Ganann, C Health Lindeman, L Mansell, M Markle-Reid, J Ploeg, F Tang, R Valaitis, T Williamson

Comprendre l’engagement des patients partenaires de l’Action diabète Canada dans une perspective de parcours de vie S Chipenda-Dansokho1, O Drescher1, B Roy2, M-C Tremblay1, S Dupéré2, MJ Dogba1 * 1Vice-décanat à la pédagogie et au développement professionnel continu, Département de Médecine Familiale et Médecine d’Urgence, Université Laval, 2Faculté des Sciences Infirmières, Université Laval

Introduction Résultats (partie qualitative) • Les patients partenaires se sentent valorisés et croient contribuer au processus, mais ne sont pas toujours L'engagement des patients est au cœur du travail du Recrutement : 11 patients partenaires interviewés en certains de leur impact au delà du processus de réseau Action diabète Canada. Les patients date (6 femmes, 5 hommes de différents âges et participation: partenaires ont été impliqués depuis la création du occupations; tous avec un niveau d’études « Je suis content de ma participation, et de temps réseau, et ce recul de trois ans nous offre une postsecondaires). Encore 3 à 5 personnes à interviewer. en temps je crois que j’ai un petit impact. Mais occasion unique d’examiner la nature et l’impact de qu'est-ce que ça va faire on ne le sait pas. » leur participation sur le réseau, ainsi que leur Nos analyses préliminaires suggèrent quelques grandes perspective sur la participation des autres acteurs. lignes à examiner: Objectifs • Les expériences/parcours de vie des partenaires patients déterminent les raisons de leur participation. Examiner comment et dans quelle mesure les « DAC c’est un peu dans mon profil parce que expériences de vie des patients partenaires influencent j’ai toujours travaillé […] pour aider les gens » la nature de leur participation dans l’Action diabète Canada • Bien que les patients partenaires aient tous en + Évaluer l'expérience du partenaire patient dans le Discussion commun une expérience du diabète, ils jouent réseau. diverses rôles et apportent des perspectives Les résultats présentés sont préliminaires. Les => Optimiser la stratégie d’implication des patients différentes reflétant leurs parcours et motivations. prochaines étapes seront de compléter les entrevues partenaires dans l’Action diabète du Canada. individuelles et réaliser le sondage en ligne; ensuite « Je suis un patient orienteur [...] mon travaille d’élargir l’équipe de recherche pour inclure des patients est d’informer et sensibiliser les médecins » Méthodes partenaires dans le processus d'analyse des données et « Si je peux aider la recherche à mieux la rédaction de rapports ou d’articles. • Approche conceptuelle/méthodologique : parcours comprendre le diabète […] c'est formidable. de vie. • Devis : méthodes mixtes (qualitatives et • Les partenaires patients sont impliqués à différents quantitatives) simultanées. niveaux de l'organisation/prise de décision et participent avec différents niveaux d’intensité. Leur participation semble être influencée non seulement par des facteurs individuels, mais aussi par des Références facteurs organisationnels/contextuels: : 1. Harrison JD et al., Health Expectations, 1-10, 2019 « si les chercheurs veulent [valoriser] leur Entrevues individuelles Sondage en ligne 2. Johansson V., American Journal of Bioethics, 14(6), 29-31, 2014. statut, y faut qui publient en anglais [donc pour 3. Roy B & De Koninck M., Rev can santé publique, 104(2), 2013, e154- (en cours) (à venir) nous] il faut quasiment être bilingue … » e158. Contact: @_DiabetesAction [email protected] #DACWorkshop2019 2

Patients As Teachers: Applying Patient Partners' Expertise to Improve Diabetes Management and Care R. Ndjaboue, B. Boudreault, F. Frigon-Tremblay, S. Chipenda Dansokho, J. Dogba, R. Price, P. Delgado, A.M. McComber, O. Drescher, M-C. Tremblay, J. McGavock, H. Witteman

Introduction Results Patients’ knowledge for health professionals: Patients have unique and valuable expertise that can Patients’ knowledge for other patients: . Being diagnosed with diabetes can be frightening and this potential fear should be addressed by health professionals help: . Accepting that you have diabetes is an important “When I got the diagnosis ten years ago, I actually thought . Other patients improve self-management step towards living well it was a death sentence.” . Health professionals provide more patient- “Get over any anger or denial and live life.” . Diabetes puts a burden on patients and their families centered care. . People with diabetes don’t have to be defined or “Check in on the parents because it is hard on the parents limited by diabetes too.” Objectives “We have the choice if we will control the diabetes of if we will allow the diabetes to control our life.” . Health professionals influence patients’ attitudes about . Capture practical knowledge about living well with their health and diabetes . Diabetes is a constant, chronic condition with good diabetes “Tell people when they do something right, what they are days and bad days . Identify areas for improvement in diabetes self- doing well.” “It is never going to be perfect. Diabetes is like a management and care constant rollercoaster [...] Really, it’s a marathon, . Health professionals can reinforce or alleviate the blame not a sprint.” and shame that patients may feel Methods “There is a lot of shame in diabetes. It’s one of the only . Self-management requires learning chronic illnesses where the people who live with it are . Design: Qualitative descriptive study “Get information, attend conferences, read about constantly blamed for how their disease is managed.” . Partnership: 3 patient partners as team members; diabetes.” . Patients are people with lives beyond their diabetes 8 patient partners reviewed results & gave feedback. . Managing diabetes requires support, a good team, “You really have to work to understand your patients. And flexibility, and taking responsibility . Population: 21 men and women living with diabetes that’s a much broader understanding than what the A1C “It’s my responsibility to be in charge of my life.” (type 1, type 2, or pre-diabetes) with diverse is.” backgrounds (incl. Indigenous peoples & immigrants) . It’s important for health professionals to provide care that . Video Interviews: (a) What makes you feel healthy? Discussion respects patients’ social, cultural, and historical contexts “As an Indigenous patient [...] I expect health professionals (b) What knowledge, wisdom or advice do you want . Patients’ insights may be of use to other people to speak to me as an equal, as a human being.” to share with other patients about how to live well living with diabetes and to health professionals. . Health professionals should ensure their knowledge about with diabetes? . We created video learning modules from the videos. diabetes is up to date (c) What knowledge, wisdom or advice do you want . Next steps: evaluate videos’ effects on patients’ . Patients need to be able to ask questions until they fully to share with health professionals caring for people knowledge and emotions and future health understand living with diabetes to help them provide better care? professionals’ (e.g., medical students, nursing . Patients want to be part of decision making about their care . Analyses by 3 independent reviewers students) knowledge, emotions, and empathy. “As patients, we can feel like guinea pigs.”

Contact: 1. [email protected] @_DiabetesAction 2. [email protected] #DACWorkshop2019 3

Diabetes Complications Risk Calculator : Gathering Risk Models Based on What Matters to People Living with Diabetes R. Ndjaboue, I. Farhat, C-A. Ferlatte, G. Ngueta, D. Guay, S. Delorme, S. Straus, N. Ivers, C. Yu, B. Shah, H. Witteman

Introduction Fig 1: Study selection Results People living with diabetes report1 that: . We built capacity in patient-oriented research by . Health professionals often discuss risks of involving patient partners from the start. complications in vague and fear-inducing ways. . Risks of diabetes complications often fail to . This scoping review will provide an overview of integrate psychological and social aspects of existing risk prediction models of diabetes diabetes complications and how to apply them.

Objective . By collating high-quality prediction models, our To identify prediction models (mathematical formulas) findings will offer a springboard toward further about complications of diabetes that apply to people research already living with prediabetes or diabetes Discussion Methods . Engaging patients required translating scientific . Design: Scoping review2 language and actively including patients’ interests . Patient partnership: 8 patient partners helped and views about the risks of complications develop the search strategy and 2 patient partners are members of the research team. . Our findings will help inform health decision-making regarding preventive actions and factors to target in . Databases: Ovid-Medline and Embase order to avoid or delay complications. . Population: People with prediabetes and all types of diabetes, regardless of age and gender. . Our findings may contribute to risk assessment in . Screening and data extraction: Done treatment decision making and clinical guidelines independently by two individuals . Data abstraction, risk of bias assessment: To be References conducted using established data extraction tools 1. Dogba MJ et al., Health Expect. 2017;21(2), 549-559 . Reporting: To be reported using validated and well- 2. Levac D et al., Implement Sci.2010; 5, 69 3 recognized tools and reporting standards 3. Tricco A et al., Ann Intern Med. 2018;169(7):467-473.

Contact: 1. [email protected] @_DiabetesAction 2. [email protected] #DACWorkshop2019 4 RESULTS IDENTIFYING BARRIERS AND ENABLERS TO ATTENDING Qualitative analysis is currently underway. Barriers and enablers for Chinese participants are summarized below: DIABETIC RETINOPATHY SCREENING IN IMMIGRANTS FROM ETHNOCULTURAL MINORITY GROUPS Theoretical Domain Example Theme Knowledge Many participants had little/no knowledge of diabetic retinopathy screening MJ Dogba, MD PhD1,5, M Brent, MD3, C Bach, MA1, Z van Allen, MA2, S Asad, MSc2, J Grimshaw, MD, PhD2, N Ivers, MD, PhD4, F Légaré, MD, PhD1,5, H O. Witteman, PhD1,2,5, J Squires, RN, PhD2, X Wang, MSc2, O Sutakovic, MD3, O Drescher, MSc1, M Zettl, MA1, N McCleary, PhD2, M-C Tremblay, PhD1, S Linklater, MSc2, A Randhawa, GY Wang, J Presseau, PhD2 Skills Communicating in second language is a barrier

1 Department of Family Medicine and Emergency Medicine, Laval University, Quebec 4 Women’s College Research Institute, Toronto Social/Professional Role Consulting a doctor when ill is a cultural habit and may 2 Ottawa Hospital Research Institute (OHRI), Ottawa 5 Center for Research on Primary Care and Services at Laval University & Identity act as an enabler 4 3 University Health Network (UHN), Toronto (CERSSPL-UL), Quebec Beliefs about Capabilities Low confidence in ability to communicate effectively with health care providers ISSUE METHODS Optimism Benefits of screening outweigh downsides Beliefs about Consequences Beliefs about harms from screening Low diabetic retinopathy screening attendance Recruitment and interview processes were culturally adapted and supported by our Reinforcement No negative/positive past experiences influencing their Immigrants belonging to ethnocultural minority groups are : patient partners and community organizations. F. ex., interviews were either conducted decision to get screened • at increased risk of developing diabetes and diabetic retinopathy; in participants’ homes, in community organizations or over the phone. Willingness varied from resolute to ambivalent • less likely to access health services, including screening and treatment for Intention diabetic retinopathy; Goals Screening may be a priority if other conditions are met Individual interviews conducted in native language of participants • less likely to engage in research compared to non-immigrants. (e.g. reminder from the clinic) Canada accepts an estimated 250,000 new immigrants annually, the majority Memory, Attention, Difficulty remembering appointment dates coming from South Asia, China and Africa. & Decision Making Environmental Context Several participants travel to China regularly and seek 13 13 13 and Resources medical services there; Language barriers at clinic STUDY OBJECTIVES South Asian African Chinese Identify barriers and enablers of diabetic retinopathy screening immigrants immigrants immigrants Social Influences Opinion of doctor is a strong enabler (Hindi/ Urdu) (French) (Mandarin) to develop interventions Emotion Worry about negative effects of screening on eyes Phase 1. Identify the barriers and enablers of DRS attendance among Behavioural Regulation Writing appointment in calendar vs relying on memory 3 ethnocultural groups in Ontario and Quebec; Phase 2. Identify intervention components best suited to address identified Phase 1: Qualitative analysis using the Theoretical Domains Framework barriers among these 3 groups DISCUSSION This study is one of the first to explore barriers and enablers of ethnocultural Phase 2: Mapping barriers and enablers to Behaviour Change Techniques to inform INVOLVING PATIENTS IN RESEARCH minority immigrants living with diabetes from different socio-cultural backgrounds. culturally tailored intervention for the 3 groups Our Patient Experts Culturally sensitive interventions will be developed. ARE COLLABORATE key members of our team in discussions and on study components immigrants from a South Asian,Chinese on potential intervention strategies or francophone African background CONTRIBUTE SUPPORT their lived expertise with diabetes participant recruitment from their communities their cultural expertise to maintain data collection cultural relevance 5

Experience with Telemedicine Diabetic Retinopathy Screening in British Columbia R Martens, W Thickson, M Jovanovic, D Maberley

Department of Ophthalmology and Visual Sciences (1)

Introduction Program Future Directions

Diabetic retinopathy can be a preventable and Number of patients screened over 5 years 500 treatable illness if attended to early. Rural communities 450 • Serves over 70 400 We hope to expand screening to all remote 350 communities in BC across Canada have decreased access to screening 300 communities in BC. Increased uptake of screening 250 and thus a higher prevalence of more progressed 200 • 450 diabetic patients in communities we visit to reach the other 75% of 150 Number of patients of Number illness at the time of diagnosis. The rate of diabetes in 100 reached per year 50 patients in these communities. Our goal is further

0 2014 2015 2016 2017 2018 Indigenous people is 2.5-5X higher than that of the Year • In 4 years the involvement of community members in all future

Figure 1: Number of patients in British Columbia screened through the general population, and a high proportion live rurally tele-medicine programs based out of Carrier Sekani and Seabird Island population being directions. Use of technology when appropriate for with decreased access to care. screened has nearly example OCT for screening. • The program is staffed Anyone with diabetes needs a screening exam once a doubled with Indigenous people year. • 15% of patients and the development has screened have evidence Addressing known and been driven by the of diabetic retinopathy unknown barriers communities it serves. Percent of screened patients with diabetic retinopathy which include access to

16 healthy food, education

12 about diabetes, road

8 conditions, access and Objective 6 Percent of patients of Percent 4 coverage of

Original design was to assess cost effectiveness of tele- 0 medications and 2014 2015 2016 2017 2018 Figure 5: HbA1c in measurement at clinic visits between 2014-2018 Year ophthalmology for rural screening (2002). This evolved at the mobile diabetes clinics pharmacy supplies Figure 2: Number of patients in British Columbia screened through the tele-medicine programs who have evidence of diabetic retinopathy on into a service delivery program in an effort to improve scnreening access to early detection, screening and improve standard of care. The program evolved with input from • Of the communities Increased follow up by increasing awareness and the communities, and assessments made in conjunction served, 25% of diabetics availability of program. Ultimately understanding the with epidemiologists, family physicians, nurses, and get screened needs in the communities we are serving and

other diabetic care workers. Figure 4: Age groups of patients between 2014-2018 at the mobile • Screening includes diabetes clinics working towards meeting those. The end objective was to decrease prevalence and weight, waist progression of diabetic retinopathy in rural circumference, BMI, A1C, Indigenous communities in British Columbia, and to lipid profile, References deliver thorough diabetic care and screening addressing microalbumin:creatinine Jin A. Aboriginal Diabetes Initiative (ADI) funded Mobile Screening and Management Projects – Synthesis Report. other micro and macrovascular complications of ratio as a measure of Hooper P, Boucher MC, Cruess A, et al. Excerpt from the Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy. Canadian Journal of diabetes as ancillary benefits of the retinopathy nephropathy, and diabetic Ophthalmology/Journal canadien d'ophtalmologie. 2017;52:S45-S74

Figure 5: Body Mass Index 2014-2018 at the mobile diabetes clinics Naqshbandr, Harris, Esler, & Antwi-Nsiah. Global complication of type 2 diabetes in Indigenous peoples: A program. retinopathy screening. comprehensive review. Diabetes Research and Clinical Practice. 82 (2008) 1-17.

Contact: [email protected] @_DiabetesAction [email protected] #DACWorkshop2019 6

First Case Use of Population-Based Diabetic Retinopathy Screening in

Ontario 1 2 2 JessicaJ. Cao1, S.Cao Isaackz, Olivera2, M. Chang Sutakovic2, J. Bowen, Michael3, V. Rac3 ,H. M. Brent Greiver4, C. Pow5, R. Merritt6, C. Whiteside7, O. Sutakovic8, M. H. 8 1FacultyBrent of Medicine, University of Toronto, 2Department of Ophthalmology & Vision Sciences, University of Toronto 1Faculty of Medicine, University of Toronto, 2Connected Care, University Health Network, 3Toronto Health Economics and Technology Assessment Collaborative, 4Department of Family & Community Medicine, University of Toronto and North York General Hospital, 5National Diabetes Repository, 6South Riverdale Community Health Centre, 7Diabetes Action Canada, 8Department of Ophthalmology & Vision Sciences, University of Toronto Introduction Approach Implications Diabetic Retinopathy (DR) is the leading cause of vision A proof-of-concept study will consist of a trial held at 3 Our approach to DR screening is a first case use of loss in working age Canadians. In Ontario, 35% of community health centres (CHCs) in Toronto. digital assets to enable population health management individuals living with diabetes have not received regular in Ontario. eye exams. This trial may provide a rationale for applying a The Toronto Tele-retinal Screening Program began in population-based approach to DR screening across 2013 to improve access to DR screening, but screening Ontario and nationally. We will also be able to assess rates remain low.1 the efficacy of tele-retina services in handling an Table 1. DR Screening Rates In Ontario2 increased need for DR screening. Large cities Small cities Rural areas Unknown Screened 516,885 (62.3%) 151,315 (68.2%) 62,798 (68.6%) 8,680 (59.7%) Future directions Unscreened 300,796 (36.8%) 70,524 (31.8%) 28,781 (31.4%) 5,866 (40.3%) We aim to show that this first use for a population- CHC study centre Objectives based approach to data management can be feasible Patients who did not receive an eye exam in the past 425 days and effective for DR. We propose a population-based approach to DR will be determined using administrative healthcare datasets screening in order to improve health outcomes for Our ultimate goal is to diabetic patients. We aim to: Run data in CHC Alliance to re-identify expand the use of a 1. Identify and engage patients in their own care for DR patients using the Alliance database population-based data screening management approach for 2. Improve accessibility and awareness of DR screening, Each CHC receives list of patients needing screening other diabetes especially for vulnerable populations complications, as well as other chronic diseases. 3. Protect vision and prevent complications due to DR Mail letters, followed by phone calls to patients. Provide individualized education and offer tele-retina screening. Post- Identify Engage Care intervention patient patient intervention References follow-up Monitor screening rates, patient outcomes, and ongoing care. 1. Felfeli T., Brent M.H., et al., Toronto tele-retinal screening program for detection of diabetic retinopathy and macular edema. Can J Ongoing Ophthalmol. 2019 Apr 1;54(2):203–11). monitoring Compare screening rates to control 2. Institute for Clinical Evaluative Sciences. Improving screening for diabetic group of people living with diabetes retinopathy in Ontario. 2015.

Contact: [email protected] @_DiabetesAction www.diabetesaction.ca #DACWorkshop2019 7

Diabetic Retinopathy Screening – Ontario scaling-up strategy

O. Sutakovic1, D. Sissmore2, R. Merritt3, V. Rac4, S. Kosar5 , V. Chaudhary6, T. Sheidow7, J. Noble8, D. Wong8, M. Brent1,8

1Department of Ophthalmology, University Health Network - TWH; 2 Patient partner, 3 South Riverdale CHC, 4UHN-TGH, 5 Northern Ontario School of Medicine Dept. of Surgery, 6McMaster University Dept. of Surgery, 7 Western University Department of Ophthalmology, 8Department of Ophthalmology & Vision Sciences, University of Toronto Introduction Methods Results The program has expanded to 46 active sites: • Diabetic Retinopathy (DR) is a serious, sight-threatening To address the low rate of DR screening in at risk • Toronto 13 mobile sites (South Riverdale; Parkdale, complication of diabetes and is the leading cause of populations, a new approach has been developed Flemington Park; Anishnawbe Health Toronto; Black blindness in working age Canadians. using telemedicine - Tele Retina2. Creek; Scarborough SAFHT 2 sites, Etobicoke LAMP 2 • DR is asymptomatic in the early stage, if left untreated, it sites; UNISON 4 sites) can lead to severe vision loss, and even blindness. • Toronto 4 stationary sites (Toronto General, Mt. Sinai, • Unfortunately, many people living with diabetes do not St. Michael, and Women's Collage Hospital) have access to regular eye examinations. • Sudbury (Manitoulin Island) 13 sites • Younger adults with type-1 diabetes, Indigenous • London (University of Western Ontario) 2 sites peoples, recent immigrants and residents of inner cities • Hamilton (McMaster University) 10 sites and remote areas have lower screening rates. • Kingston (Queen’s University) • Brampton • Thunder Bay (Red Lake, Sioux Lookout). In the last 2 years more than 4154 people living with diabetes have been screened by Tele-Retina program. Discussion • A technician travels between sites with the mobile • Our goal is to ensure that every person living with camera; provides the DR screening eye exam and diabetes has access to DR screening. diabetes education to each person screened. • Findings from a recent study found Tele-retina to be • The images and data are uploaded to Ontario more cost-effective than a standard of care eye Telemedicine Network (OTN). examination for DR screening in under-screened urban • A retina specialist evaluates images remotely and and rural communities3. sends a report with care recommendations to the Primary Care Provider via OTN. • We are still facing challenges with respect to identifying, engaging and providing follow-up monitoring for the Objectives many people requiring DR screening in Ontario. Data from Institute of Evaluative Sciences (ICES) study In 2016 Ontario had 5 screening centers in Toronto References discovered that more than 400,000 adults living with under the leadership of Dr. Brent and in Sudbury 1. Institute for Clinical Evaluative Sciences. Improving screening for DR in Ontario. 2015 diabetes in Ontario, had NOT had an eye examination 2. T. Felfeli; R. Alon; R. Merritt; M.H. Brent. Can J Ophthalmol. 2019 April 1:54 (2) 203-11 (Manitoulin Island) under the leadership of Dr. Kosar. over the 2-year period (2011-13) 1. 3. A. Stanimirovic; T. Francis; N. Shahid; O. Sutakovic; M. H. Brent; V. Rac. Can J Ophthalmol. submitted Dec 2018 Contact: [email protected] @_DiabetesAction www.diabetesaction.ca #DACWorkshop2019 8

Insights into impact of Tele-retina screening for diabetic retinopathy among women of low socio-economic status (SES) Aleksandra Stanimirovic 1-4 ; Sonia Meerai 1,3,6; Troy Francis 1,3-5 ; Nida Shahid 1,3-5 ; Valeria E. Rac 1-5,7

1Toronto Health Economics and Technology Assessment (THETA) Collaborative; 2Diabetes Action Canada, CIHR SPOR Network; 3Ted Rogers Centre for Heart Research; 4University Health Network – Toronto General Research Institute, Ontario, Canada; 5Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto; 6Gender, Feminist & Women's Studies, York University; 7Peter Munk Cardiac Centre Introduction Methods

• By 2025, 5 million Canadians dx with diabetes Population • More common among men, YET lower SES, 75% • Patients** ≥18 who identify as women, low SES, women completed/refused tele-retina screening; • Diabetic retinopathy (DR) - primary vision • Healthcare providers; Program administrators and complication of diabetes & leading cause of blindness Decision makers in adults (DR prevalence in women 26%) Design • Vision loss costs projected to $30billion/year (2032) • Ethnographic study; in-depth semi-structured • Tele-ophthalmology - delivers eye care at distance interviews and documentation review • Screening for DR to incidence of blindness Analysis • Adverse associations - screening, gender & income Grounded Theory method3 • The first Ontario study to focus on DR screening • Systematic coding of data and theme abstraction - practices in women of low SES aiming to improve key facilitators/barriers to implementation & adoption their health outcomes and quality of care • Thematic analysis – interview transcripts, notes, and Figure 1: Adapted from McGibbon & McPherson, 20111 - Synergies of observation notes in stages: open; axial; & selective Oppression: A Framework for Addressing SDH Inequities coding Objectives Intervention Outcomes Using a Multi-Construct Intersectionality framework* 1 by McGibbon and McPherson (Figure 1), the Primary outcomes: key factors (facilitators, barriers objective is: and processes) – facilitate/impede implementation & . To understand patients’; providers’; administrators’; adoption Tele-retina screening program and decision makers perceptions of Secondary outcomes: perceptions and experiences of facilitators/barriers associated with Tele-retina patients, providers, administrators, and decision makers program implementation and adoption in South Riverdale Community Care Health Centre (SRCHC) References . *Figure 1 illustrates how the frameworks of 1. McGibbon E., McPherson C. Women’s Health UL,10(1):2011 59-86 intersectionality and social determinants of health Figure 2: Adapted from: Tele-retina Program Process Map2 2. Brent, M.,et al. 2014. HQO operate in a synergistic manner Sites**: Anishnawabe Health TO, Flemingdon HC, LAMP CHC, Parkdale CHC, 3. Strauss and Corbin. Grounded Theory in Practice. Book. 1997. Scarborough Academic FHT; SRCHC, Unison Health & Community Services

Contact: [email protected] @_DiabetesAction www.diabetesaction.ca #DACWorkshop2019 Tele-retina (TR) screening of diabetic retinopathy among at risk populations: an economic analysis A Stanimirovic1,3,5; T Francis1,3; N Shahid1,3; O Sutakovic2,5; R Merritt6; MH. Brent2,5; VE Rac1,3,4,5 1Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN).; 2Donald K. Johnson Eye Institute, Toronto Western Hospital, Canada;3Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto; 4Ted Rogers Centre for Heart Research at Peter Munk Cardiac Centre; 5Diabetes Action Canada, CIHR SPOR Network; 6South Riverdale Community Health Centre 9 Introduction Results • By 2025, 5 million Canadians dx with diabetes1 Costs & Outcomes TR pilot SOC pilot TR PO SOC PO • Diabetic retinopathy (DR) - primary vision complication of diabetes & leading cause of blindness in adults Population (N) 566 28,500 • Costs of vision loss projected to $30billion/year (2032)1 Total program cost $54,205.82 $77,858.96 $1,643,880 $3,920,460 • Tele-ophthalmology - delivers eye care at distance 143 79 5,848 3,997 • Screening for DR to Incidence of blindness # of cases detected • Limited access to optometrist & ophthalmologist for Additional # of 64 1,851 individuals with diabetes residing in certain cases detected neighbourhoods in Toronto 2 • Led to development of mobile DR screening program Figure 1: Adapted from: Tele-retina Program Process Map2 # of cases dx 496 247 19,995 12,480 • Assess cost-effectiveness of new technologies prior to Additional # of Methods 249 7,515 implementation in specific settings; meanwhile benefits cases dx compared with competing alternatives • Decision trees - TR vs SOC in pilot and PO cohorts3 • Cost-effectiveness using health system perspective: Cost/case detected $379.06 $985.56 $281.10 $982.99 Objectives • Cost case detected - True (+); Cost/case dx $109.29 $315.22 $82.21 $314.14 1. To summarize aggregate costs of the Tele-retina • Cost per case correctly diagnosed (dx) - True (+) & Table 1: Summary of key findings pilot and Pan-Ontarian cohort screening program True (-); Discussion/Conclusion 2. To assess the cost-effectiveness of the Tele-retina (TR) screening program in comparison with existing • Tele-retina is a more cost-effective means of standard of care (SOC) diabetic retinopathy (DR) screening for diabetic retinopathy than SOC in screening for patients with diabetes mellitus in pilot urban and rural under-screened communities cohort and in a simulated Pan-Ontarian (PO) cohort • Subsequent studies - focus on evaluations of program’s impact on prevention of severe vision Intervention loss in these communities Tele-retina – mobile DR screening program2 (Figure 1) References • In 2014 partnership - South Riverdale Community 1. The National Coalition for Vision Health. Vision Loss in Canada. 2011. Health Centre & Dr. Michael H. Brent, Chief of Retina 2. Brent, M.,et al. 2014. HQO Services at the University of Toronto 3. CADTH: Guidelines for the Economic Evaluation of HTA. 2017. • Funded by Toronto Central (TC) LHIN Figure 2: Decision tree TR versus SOC for DR

Contact: [email protected] @_DiabetesAction www.diabetesaction.ca #DACWorkshop2019 10 Does Sodium Glucose Linked Transporter (SGLT) Inhibition Improve Performance of the Artificial Pancreas in Type 1 Diabetes? Bruce Perkins MD, Nancy Cardinez NP, Andrej Orszag, Marcelo Falappa, Leif Erik Lovblom, Devrim Eldelekli, Daniel Scarr, Ahmad Haidar Table 1: Baseline characteristics INTRO Characteristic Result • Although Artificial Pancreas (AP) systems are beneficial, they still require that patients do Age (years) 45 ± 16 burdensome carbohydrate (carb) counting, Female Sex 6 (50%) and even with this post meal glucose control Diabetes Duration (years) 31 ± 16 is not optimal SGLT inhibition added to the Artificial Pancreas substantially A1c (%) 7.5 ± 0.7 • Empagliflozin is a SGLT inhibitor medication (tablet) that helps to lower blood glucose Ketones (mmol/l) 0.12 ± 0.04 levels independently of insulin improved glucose control, reduced patients’ need for • In this study, we aimed to determine if Table 2: Results Empagliflozin can improve the performance Carb Counting of the AP and reduce carbohydrate counting EMPA No EMPA P‐value burdensome carbohydrate counting and appeared to be safe. Mean Glucose (mmol/L) 7.2 ± 1.6 9.3 ± 1.9 <0.001 burden for patients TiR 3.9‐10.0 mmol/L (%) 83±10 57±24 0.008 Time Below 3.9 mmol/L (%) 6±8 3±5 0.22 METHODS Time Above 10 mmol/L (%) 11±14 40±25 <0.001 • In preparation for the Diabetes Action Insulin Delivered (units) 19.1±11.9 22.5±11.7 0.011 Canada- funded Closed Loop ASSessment 17 Ketones (mmol/l) 0.29±0.16 0.13±0.05 0.002 Simple Meal Announcement study (CLASS17), we have performed a EMPA No EMPA preliminary study on 12 participants Mean Glucose (mmol/L) 8.7 ± 1.6 10.9 ± 2.1 0.003 TiR 3.9‐10.0 mmol/L (%) 66±18 41±27 0.002 • Study Design: Randomized, open label, Time Below 3.9 mmol/L (%) 2±3 2±5 0.92 crossover, non-inferiority Time Above 10 mmol/L (%) 32±18 58±28 0.003 • Setting: Outpatient with an AP (McGill Insulin Delivered (units) 15.7±7.1 17.7±7.2 0.022 Median sensor glucose profiles of the 12 participants for each of the 5 intervention days. Ketones (mmol/l) 0.19±0.13 0.15±0.07 0.34 algorithm) No Meal Announcement • Study duration: 5 intervention days EMPA Non-Cognitive Predictors of Student Success: Non-Cognitive Predictors of Student Success: Mean Glucose (mmol/L) 10.6 ± 1.7 A Pr•edict Interventions:ive Validity Comparison Betw een I) Domest 25mgic and Int Empagliflozinernational Students (Empa) A Predictive Validity Comparison Betw een Domestic and International Students TiR 3.9‐10.0 mmol/L (%) 44±18 once daily or no Empagliflozin Time Below 3.9 mmol/L (%) 1±3 II) meal strategies (carb counting, Time Above 10 mmol/L (%) 55±19 standardized amount announcement [25g], Insulin Delivered (units) 14.6±6.9 Ketones (mmol/l) 0.19±0.08 no meal announcement) Meal Intervention Days: Statistical Comparisons of Time in Range (TiR): 1) AP + Empa + Carb Counting • Empa with Carb Counting vs. No Empa with 2) AP + Empa + Simple Meal Announcement Carb Counting: 83% vs 57%, p=0.008 3) AP + Empa + No Meal Announcement • Empa with Simple Meal Announcement vs. No 4) AP + Carb Counting Empa with Carb Counting: 66% vs 57%, p=0.26 5) AP + Simple Meal Announcement • Empa with No meal announcement vs. No We didn’t test the AP without Empa and Empagliflozin with Carb Counting: 44% vs 57%, TiR=Time in Range (3.9-10.0 mmol/l ) p=0.089 without meal announcement. • Measurement: Sensor glucose (Dexcom G5) were analyzed FUTURE DIRECTION Plasma ketone measurement (safety) • Combination of the AP with Empa may • Statistical Analysis: To account for repeated decrease carb counting burden; a longer measures, paired t-tests were used for duration and larger sample size study is comparisons needed to confirm this RESULTS • Combination of AP with Empa appears to be • Interventions including SGLT resulted in safe for use in an outpatient setting longer time in target range than comparable interventions without SGLT • Use of combination of AP+SGLT+Carb Counting achieved the greatest time in target than any other interventional combination and lowest time in hyperglycemia. Contact: Dr. Bruce Perkins • There were no recorded episodes of DKA or [email protected] severe hypoglycemia during intervention days or between them 11

Nothing About Us Without Us: Identifying Research Priorities for Exercise and Type 1 Diabetes Nika D. Klaprat*, BKin1,2; Todd Duhamel, PhD1,3, Jonathan McGavock, PhD1,2 1. University of Manitoba; 2. Children’s Hospital Research Institute of Manitoba; 3. St. Boniface General Hospital Albrechtsen Research Background/Aim: Centre 250 Phase 1: National Survey Patient engagement is a growing field of interest in health 200 34 research. Engaging patients in health research can lead to study 150 questions and designs that are aligned with relevant priorities. Top 10 research priorities for exercise and type 1 63 100 This study aimed to be the first to identify priorities for physical diabetes are: activity research in type 1 diabetes, as physical activity is one of 50 15 100 three pillars of disease management. 0 Design: 1. What explains the variation in responses that the same person No Questions Submitted Questions An adapted James Lind Alliance model was followed to identify can experience doing the same exercise between different days? One Two Three the top ten research priorities in exercise and type 1 diabetes. Steering Committee: (n=12) 2. Which is the best for maintaining glycemic stability and glucose Patient Partners: (n=7) tolerance: aerobic training, strength training, or a combination of Age Sex Ethnicity Residence both? If a combination, does the order matter? Online survey Conventional Interim Ranking Final P01 35 F C Urban Content Analysis Workshop 3. What modes of exercise (ie activity types, such as walking, P02 60 M C, E Urban Population: cycling, weightlifting, rock climbing, etc) produce the best health P03 27 M C Rural Survey Sample: Individuals with lived experience of type 1 P04 17 M C Urban diabetes in Canada (patient, caregiverCamp or health care provider) benefits while maintaining tight glycemic control? Huronda P05 27 F M, E Urban Steering Committee Sample (n=12): 4. What dietary plans can safely and effectively be followed for an P06 16 F C Rural Note 3 partners identified as more than one category active lifestyle in type 1 diabetes without compromising pre‐ and P07 27 M M Urban post‐exercise glycemic control? H01 35 F ND Urban Caregiver Members: (n=3) 8 patient partners 3 Caregivers 4 Healthcare Providers 5. What is the optimal time of day and exercise prescription Parent # Children C1 Age C2 Age (maximum variation sampling) (example: how often, what type, how intense) in order to Results: C01 Mother 2 17 8 Phase 1: maintain ideal glycemic control and insulin sensitivity? C02 Mother 1 26 N/A 194 submitted 6. What is the best method of preventing post‐exercise hypo‐ or P03 Father 1 6 N/A 115 completed Phase 2: questions hyperglycemia? Health Care Provider Members: (n=4) Specialty Work Setting Experience 7. Will certain glycemic ranges before starting exercise consistently H01 Dietician (P) Clinic 5 years 38 long‐listed 194 questions Four stages conventional content analysis questions result in hypo‐ or hyperglycemia? H02 Dietician (A) Hospital 7 years Phase 3: Long‐List Rankings 1. ~~~~~~~~~~~~~ H03 Physiotherapy Hospital 5 years 2. ~~~~~~~~~~~~~ 3. ~~~~~~~~~~~~~ 4. ~~~~~~~~~~~~~ 8. What effect can various levels of hydration have on blood sugar 5. ~~~~~~~~~~~~~ 6. ~~~~~~~~~~~~~ P07 Nurse Hospital 3.5 years 7. ~~~~~~~~~~~~~ 8. ~~~~~~~~~~~~~ 9. ~~~~~~~~~~~~~ levels during and after exercise? 10. ~~~~~~~~~~~~~ 38 long‐listed Steering committee individually votes for top 24 short‐listed questions ten of long‐listed questions, ranks combined questions 9. How does hypo‐ or hyperglycemia affect muscle growth and Impact: Phase 4: This is the first example of patient priority‐setting for type 1 Top 10 strength training progress, or vice versa? Priorities diabetes and exercise research. The resulting list of priorities 1. ~~~~~~~~~~~~~ 2. ~~~~~~~~~~~~~ 3. ~~~~~~~~~~~~~ 4. ~~~~~~~~~~~~~ 10. What is the effect of climate/temperature on blood sugar control could inform the design of exercise studies for individuals living 5. ~~~~~~~~~~~~~ 6. ~~~~~~~~~~~~~ 7. ~~~~~~~~~~~~~ 24 short‐listed 8. ~~~~~~~~~~~~~ with type 1 diabetes in Canada, in order to support findings that Final priority‐setting workshop with 9. ~~~~~~~~~~~~~ during exercise? questions 10. ~~~~~~~~~~~~~ steering committee are more relevant to patients. Contact: Nika Klaprat Email: [email protected] 12

T1ME Trial: Type 1 diabetes virtual self-Management Education and support G Booth1, N Ivers2, L Lipsombe2, R Shulman3, G Lakhanpal1, M Chan1, S de Sequeira2, B Perkins4 1Unity Health Toronto - St. Michael’s Hospital, 2Womens College Hospital, 3The Hospital for Sick Children, 4Sinai Health System

T1ME Trial Overview Study Design Patient Oriented Research

• For many people living with Type 1 Diabetes (T1D), the The overall study and intervention are co-designed with The PAC is made up of 14 members: demands of self-management place a heavy burden on daily members of the T1D community in the Patient Advisory • 7 in the adult group (25+ years old) and 7 in the emerging life Committee (PAC) and the Healthcare Advisory Committee adults group (17-24 years old) • Current T1D care involves time-consuming in-person visits (HCAC) made up of Certified Diabetes Educators (CDEs). • All diagnosed with T1D from 4 months to 40+ years during working hours, and the capacity for health systems to • Very excited about using an integrated app that allows easier address the needs of patients with T1D is already lagging Insulin pump centres in Ontario access to educators, virtual visits, tools behind • There is a need for technological innovations to create newer, smarter and person-centered methods to deliver What patients want: mHealth Usual Care diabetes self-management education and support Virtual Visits or • To feel encouraged, motivated, and consistently engaged (Intervention) (Control) with their T1D self-management • To decrease the amount of time spent on their diabetes Library • To decrease the worry and stress surrounding their diabetes Virtual Workshops Outcomes: • Control 1) Metabolic control: A1C, CGM data • To feel more connected to their diabetes team symptoms 2) PREMs/PROMs (questionnaires) • Access to reliable tools, information, and support to help • Prevent 3) Health care use & costs (administrative them make daily decisions Figure 1: Self-management of T1D is a constant balancing act complications data) Figure 2: The overall pragmatic study design. Fifteen (15) MOHLTC – Objectives funded ADP clinics / Diabetes Education Program (DEPs) will be recruited Engaging Healthcare Providers To improve the lives of people with T1D by helping them achieve in the intervention arm of the T1ME Trial. People with A1C > 8% will be invited to participate and followed for 12 months. • The HCAC is made up of four CDEs who work in various better diabetes control in a more seamless, patient-friendly diabetes settings manner. • Frequent virtual visits (videochat) • The implementation sub-study is conducting interviews via “High frequency, low touch” virtual care Virtual Visits • Automated reminders, prompts for goal with CDEs from different endocrinology clinics setting, visit summaries High Frequency • Both the HCAC and sub-study are investigating how to best - Shorter, more frequent appointments • Virtual content library with links to videos integrate virtual visits into clinic workflow based on clinician - Reduces extra time and cost for travel, parking Library & resources needs and preferences, in order to make the tool more - Regular contact with diabetes educator • Periodic updates once every 3 weeks effective and successful • Weekly virtual workshops taught by CDE Expected Outcomes on a variety of topics Low Touch Workshops • Q&A sessions 1. Reduction in A1C levels from baseline - Remote, virtual appointments 2. Improved satisfaction in clinical care

Improved Care - Online scheduling and goal setting Figure 3: Specifics of the intervention. Primary feature of the intervention 3. Increased confidence in day-to-day self-management - Central virtual repository of education and resources are the frequent virtual visits between the patient and their educator, supplemented by self-management tools accessible 24/7. 4. Reduced healthcare costs

Contact: [email protected] @_DiabetesAction [email protected] #DACWorkshop2019 13 Phase 2 clinical trial testing safety and efficacy of topical pirenzepine

to treat diabeticF neuropathy

Paul Fernyhough Div. of Neurodegenerative Disorders, St. Boniface Hospital Albrechtsen Research and Dept. of Pharmacology & Therapeutics, University of Manitoba, Winnipeg, Manitoba, Canada

Background Figure 1 normal diabetes The Company Persons with diabetes suffer a range of  WinSanTor Inc – based in San Diego, CA, USA complications and diabetic neuropathy is the most  Directors are Drs. Fernyhough, Calcutt (UCSD) and prevalent. The disease leads to a dying-back of Kotra (UHN) nerve fibers in peripheral tissues that triggers pain  CEO Stanley Kim and sensory loss. There are no treatments other  Licensed IP from University of Manitoba than palliative approaches. A company WinSanTor  Providing novel formulation of topical pirenzepine Inc has been established to generate new therapies http://kennedylab.med.umn.edu/ for this disease. Preclinical studies revealed that Left caption reveals the stocking and glove distribution of diabetic Trial Design antimuscarinic drugs were able to augment nerve sensory neuropathy in patients with type 1 or type 2 diabetes. The right caption are sections through human skin showing loss of nerve fibers in Performed by Dr. Vera Bril at University of Toronto regeneration in animal models of type 1 and type 2 diabetes.  Randomized double-blind placebo controlled study diabetes (Calcutt et al, 2017, Journal of Clinical  Recruit up to 60 persons with type 2 diabetes (n=12 Investigation). A proof of concept study has been placebo) performed in persons with type 2 diabetes with Preliminary data  Mild to moderate presentation of neuropathy (from Drs. Nigel Calcutt (UCSD) and Arthur Vinik (EVMS)) established diabetic neuropathy. Patients were  Exclusion criteria – pain and/or sural nerve treated with topical oxybutynin, an over-the-counter Figure 2 amplitude less then 1 microvolt antimuscarinic drug, and this therapy improved  Daily topical treatment with pirenzepine at 2 doses quality of life (QOL) indices and levels of nerve on both lower limbs fibers in the skin.  Skin biopsy taken at start and end of 5 month study  Norfolk-QOL-DN and Toronto Neuropathy Score Research Aims  In collaboration with WinSanTor Inc set up phase 2 trial in persons with type 2 diabetes Conclusions  Recruiting to start summer 2019  At end of study if pirenzepine safe then phase 3 trial  Topical formulation of pirenzepine to be tested for can go ahead safety Proof of concept clinical trial by Drs. Calcutt and Vinik. Type 2 patients  Evidence of efficacy will enhance ability to fund a received daily topical treatment with oxybutynin. Nerve fiber levels in the  5 month treatment distal leg were quantified at the beginning and end. phase 3 trial  Clinical endpoints will be QOL and nerve fiber  Phase 3 trial with sites in North America and Europe levels in the skin planned for 2021

Contact Paul Fernyhough [email protected] Acknowledgments @_DiabetesAction www.winsantor.com #DACWorkshop2019 14

Identification of Barriers and Facilitators to Follow-Up for People with Diabetes by Community Pharmacists L MacCallum1,2, J Kellar2, A Mathers2, J Moore3, G Lewis1,4, L Dolovich2

1 Banting & Best Diabetes Centre, Faculty of Medicine, University of Toronto; 2 Leslie Dan Faculty of Pharmacy, University of Toronto; 3 The Center for Implementation; 4 Department of Medicine and Department of Physiology, University of Toronto Introduction Results Environmental Negative Influences for Follow-Up Constructs in the Environment Mean Score Ontarians living with type 1 or type 2 diabetes are 346 pharmacists responded (4.76 % response rate) Domain (SD) eligible for MedsCheck for Diabetes (MCD) annual Pharmacist Respondent Characteristics (n=346) Sufficient reimbursement 2.67 (1.66) reviews and follow-ups. The reviews are conducted by a Variable Mean (SD) community pharmacist with the goal to ensure people Satisfactory public awareness 2.89 (1.52) with diabetes are getting optimal benefit from their Age 45.4 (11.5) medications. In the first 3.5 years of the program, 406, Sufficient financial support 2.93 (1.80) 694 people with diabetes received a MCD, indicating Years as a pharmacist in Canada 16.6 (11.9) Satisfactory workflow 3.04 (1.66) good uptake of the program. 97% of these recipients did not, however, receive a follow-up appointment. More Medication reviews per month (personal) 11.8 (17.8) Good networks with physicians 3.19 (1.66) than 1/3 of those that had received a MCD had a diabetes-related emergency room visit or hospitalization Minutes per review 43.3 (22.9) Satisfactory information technology 4.14 (1.91) in the year prior and those 66 years of age and older Satisfactory amount of competing priorities 4.23 (1.73) received an average of 11 prescription medications in 33.8% were Certified Diabetes Educators the year prior, indicating they had complex medication Most Positive Influences for Follow-Up needs. Role clarity: Although pharmacists indicated a clear TDF Domain Mean Score understanding of their role in follow-up in diabetes care, they (SD) indicated that their role was less clear to people with diabetes Objectives Beliefs about consequences for people with 6.08 (1.13) and other health care providers. Identify the barriers and facilitators for community diabetes pharmacists providing follow-up to people with diabetes. Knowledge 5.93 (0.99) Discussion These results will inform the next stage of the research Skills 5.44 (1.44) It is not the pharmacist’s knowledge, skills and beliefs which will develop and evaluate strategies to improve Social Influences 5.36 (1.32) about their roles and responsibilities that are influencing follow-up for people with diabetes by community Optimism 5.20 (1.58) the low rate of follow-up for people with diabetes in pharmacists using quality improvement methods. Ontario. Rather it is the pharmacy environment and Most Negative Influences for Follow-Up reinforcement that are the most negative influences. Methods TDF Domain Mean Score Public awareness of the pharmacist’s role in follow-up is A survey was designed using the Theoretical Domains (SD) also an area that requires attention. Strategies to Framework (TDF) which provides a framework for Reinforcement 3.0 (1.89) improve follow-up should be focused in these areas. looking at what is influencing health care provider Environment and resources 3.3 (1.81) behaviour. Pharmacists in the Diabetes Pharmacists References Network and those registered with the Ontario College 1. MacCallum L, et al., Can J Diabetes 2017 (41) 253:258 of Pharmacists were invited to participate. Supported by an Innovation Fund grant from the Canadian Foundation for Pharmacy

Contact: [email protected] @_DiabetesAction #DACWorkshop2019 15

Environmental scan on KT tools to prevent diabetes complications Sophie Desroches1 (researcher), Lionel Adisso (graduate student), Sasha Delorme (patient), Howard English (patient), Adriana Freitas (research coordinator), Serena Hickes (patient), Noah M. Ivers (clinician researcher), Monika Kastner (researcher), Annie Lapointe (research coordinator), France Légaré (researcher), Johanne Marin (research assistant), Felicien Moukambi (research coordinator and poster presenter), Richard Piché (patient), Françoise Proust (postdoctoral fellow), Marie-Claude Tremblay (researcher), Catherine Yu (clinician researcher).

1 Institute of Nutrition and Functional Foods; School of Nutrition, Faculty of Agriculture and Food Sciences, Université Laval, Quebec City, Quebec, Canada.

Introduction Eligibility criteria of tools Conclusion Considering the increase in the prevalence of diabetes and its complications in Canada, it is imperative to 1 Used to prevent diabetes complications This environmental scan will inform patients, caregivers, document the existing KT tools for preventing diabetes health professionals as well as other relevant 2 Used in a real-life setting complications and to make them accessible to stakeholders of available KT tools to avoid unnecessary Should make use of any instructional method or knowledge users (e.g. patients, caregivers and health 3 duplication and move knowledge into action promptly for professionals). material better patient care. The scan will also identify gaps and Created and/or used in a Canadian context (written in 4 contributes to the development and the further Objectives English or French) implementation of evidence-informed KT tools for To conduct an environmental scan on existing Canadian 5 Created and/or used by a recognized organization preventing diabetes complications. KT tools to prevent diabetes complications. 6 Created in 2013 and over Methods Results Searching for tools Checklist We searched Canadian KT tools to prevent diabetes Kidney complications through research team members and their Knowledge quiz General networks as well as three electronic scientific databases Decision support (MEDLINE, EMBASE, CINAHL), Google and Twitter. Mental disorders Clinical pathway

Heart Risk assessment Selecting eligible tools and extracting data Case study We performed an iterative process in which two Foot KT strategies Personal notebook Complications reviewers selected eligible tools and extracted data 0 4 8 12 16 0 2 4 6 8 10 independently. Discrepancies in judgement were resolved by discussion to reach consensus, or with a Both patients and health professionals Patients third reviewer. in the scan

Patients

Patient-oriented research tool? Health

Four patient partners from DAC patient circles joined our From the 31 tools included Health professionals

research team . Patient partners contributed to all professionals users Target Who delivers the phases of the study. 0 5 10 15 20 0 6 12 18

@_DiabetesAction Contact:: [email protected] #DACWorkshop2019 16

Shared Decision Making via Personal Health Record Technology as Routine Practice for Youth with Type 1 Diabetes Selena Davis, PhD University of Victoria, School of Health Information Science

Introduction Methods Phase 2 Results An optimal approach to making health decisions is A mixed methods investigation. Phase 1 utilized a user- Quantitative & qualitative data shared decision making (SDM) between patient and centered design approach to map SDM tasks to PHR were congruent (Table 1). care provider. The literature indicates that SDM has had functions by youth (aged 18-24 with T1D) and providers. Table 1: NPT mechanisms: mean scores & descriptive themes Perceived Mean NPT Descriptive Themes Exemplar Quotes 1 * variable implementation success . Designed for function Phase 2 used a triangulation convergence design Score ±sd Coherence Converging views of meaning ‐ a game “This is fundamental to where we need to go with healthcare. I see it as an Outcomes: changing technology enabling mechanism to put the ownership of a person’s care more in their court, to and cohesive with the broader digital health ecosystem, approach for a pre-implementation process evaluation. shift the paradigm we have in our system from a didactic provider‐dominated • positively affect meaning and health care service to one that is truly person‐centred.” ― sense making Sensibility of change “once we involve our patients, it is likely that we will have a better chance to have work personal health records (PHR) present an opportunity The implementation work, integration potential, and engagement in more compliant patients and better outcomes too, like less complications for self-management diabetes.” for improvement in SDM and patient engagement in Cognitive Sharing ownership of the work “helping diabetes management and strengthening the relationship between me perceived outcomes were described by youth and Participation and my healthcare provider. They have to be a little more involved in my life and I have to be clearer in my communications with them.” decision making commitment and 4.6±0.45 self-management decision making. For youth with type providers using survey, NPT measurement instrument engagement work Enabling involvement “If the higher ups support e‐PHR, they must provide the protected time and the (4.5/5) resources and the infrastructure that’s needed.” 2 Collective Action Uncovering the Assessing fit “we have more work to do across the system around truly enacting a person‐ 1 diabetes (T1D), health decisions are needed often, (NoMAD ), and semi-structured interviews. • become routine challenges of building centred approach to care. If the culture of care does not reflect the SDM via PHR, it collective action won’t be well supported or used.” operational effort work (3.9/5) Investing in “e‐PHR is likely to be sponsored in theory but not resourced to the extent it needs to and technology is well rooted in their lives. As such, this work 3.6±0.53 • descriptive the change be.” Phase 1 Results Adapting to “Patients automatically assume that you are checking lab work for them daily. But research aimed to investigate how PHR technology can change I don’t necessarily have the time to be going through and making sure their HbA1c themes: care is together is in target. So, I think figuring out where is the ownership?”

Reflexive Reflecting on value “by engaging patients in their care this way and providing them with this kind of be designed to enable SDM and integrated into practice Developed a functional model for efficient and care monitoring empowerment and increasing frequency of contact, that would translate into better outcomes.” is person-centred reflection and ― to engage youth with T1D in self-management decision- SDM via PHR (e-PHR) (Figure 2). appraisal work Monitoring and adapting “the effects will only be evident if we are purposeful about bringing that forward and measuring it.” *(1=strongly disagree, 5 = strongly agree) making. The research was framed by Normalization Observed a moderate level of agreement between patients 2 Process Theory (NPT) (Figure 1). and care providers (Cohen's kappa 0.60-0.74). Discussion The e-PHR functional model may be translated into detailed system design and operational requirements. Framed by NPT, participants demonstrated investment in sense-making, commitment and appraisal work; however, integration of e-PHR into normal clinical Figure 1: NPT Guiding Theoretical Framework practice will only be attained when systemic effort is Research Questions invested to enact it. Further research is needed here. 1.Are the PHR functions correctly mapped to the SDM References elements in functional model conceptualized in the 1. Légaré F. and Whitteman, H., Shared decision-making: examining key literature 3 in order to operationalize SDM? elements and barriers to adoption into routine clinical practice, Health Aff., vol. 32, no. 2, pp. 276 – 284, 2013. 2.What is the ‘normalization potential’ of SDM via PHR 2. May, C.R.et al., Using Normalization Process Theory in feasibility studies in clinical practice to engage youth with T1D in self- and process evaluations of complex healthcare interventions: a systematic management decision-making? review, Implement. Sci., vol. 13, no. 1, p. 80, Dec. 2018. 3. Davis S. et al. Shared decision-making using personal health record 3.What is the work that participants do, individually and technology: a scoping review at the crossroads. J Am Med Informatics collectively, to integrate SDM via PHR into practice? Figure 2: e-PHR functional model for the integration of SDM via PHR Assoc. 2017 Jan 31;24(4):857–66. Contact: [email protected] @_DiabetesAction www.diabetesaction.ca #DACWorkshop2019 Lifestyle knowledge translation strategies to prevent type 2 diabetes among Indigenous Peoples of America 1,2 2 1 INSTITUT SUR LA NUTRITION ET Françoise Proust , Sophie Desroches , Marie-Claude Tremblay LES ALIMENTS FONCTIONNELS 1 Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Québec QC G1V 0A6, Canada ([email protected]) 2 Institute of Nutrition and Functional Foods; School of Nutrition, Faculty of Agriculture and Food Sciences, Université Laval, Québec QC G1V 0A6, Canada 17 Background Results Conclusions  This review indicates that community-level • Type 2 diabetes (T2D) Characteristics of the 10 included studies: 201 10 . 1997 to 2018 . 9 (USA) + 1 (Canada) lifestyle KT strategies aimed at changes in disproportionally affects diet and physical activity may contribute to indigenous populations studies studies . 6 (Youth) + 4 (Adults) . 8 ( , ) + 2 ( only) found included . 9 (Diet & Exercice) . lasted 3 months to 5 years beneficially influence clinical parameters • Lifestyle habits are + 1 (Exercice only) and behaviors associated with T2D risk in known to play an important role in the Indigenous communities apparition of T2D, its delay & prevention,  However, the population ought to be very but conventional T2D prevention willing to change their behavior to properly programs targeting lifestyle have only follow the implemented program and thus limited success in these populations see beneficial results  This is why it is important to carry out • Hence, it is important to portray existing collaborative work and conduct participatory programs or knowledge translation (KT) research with partner communities tools to further built KT tools specifically  This review will thus help us to design, built, for Indigenous peoples that meet their and implement, with partner Indigenous needs to reach T2D prevention goals communities, an effective, culturally adapted KT strategies for preventing T2D Objective Factors facilitating or preventing the success of a diabetes prevention intervention: Facilitators Barriers To review existing KT strategies related to Future steps . Supportive social networks (reinforcement) . Apparent resignation or ‘denial’ with the disease lifestyle habits that are used to prevent The next steps of this project will be: . Trained health coaches (motivation) . Lack of motivation and retention T2D specifically in Indigenous populations Step 2: Adapt and evaluate factors that could of North America . Use of Toolbox to facilitate goal attainment . Limited funds for personal counselling facilitate and/or be a barrier to the adoption of healthy behaviors (diet and exercise) Methods Step 3: Implement the most effective lifestyle KT strategies for preventing T2D

Patient-oriented research The further steps of this project will be conducted in partnership with interested indigenous communities on the basis of a participatory research, involving partners from these communities from the identification of needs up to the implementation of@_ theDiabetesAction study model @_DiabetesAction #DACWorkshop2019#DACWorkshop2019 18

INtegrating sex and gender considerations into a Continuing professional deveLopment activity on DEpression and Diabetes (INCLuDED): protocol for a non-randomized controlled trial Légaré F1,2, Lee-Gosselin H3, Borduas F4, Monette C4, Parent N4, Bilodeau A5, Tanguay D3, Stacey D6,7, Gagnon MP8, Roch G8,9, Dogba MJ1,2, Brussière A10, Tremblay MC2 Bélanger AP11, Jose C12, 13, Desroches S14, Gaudreau A15, Remy Lamarche D15, Vigneault L15, Robitaille H1, Blair L1, Deom Tardif A1,2, Moukambi F1, Rhugenda S-M1. Contact: [email protected] BACKGROUND METHODOLOGY: Flowchart of the non-randomized controlled trial

Depression & type 2 diabetes (T2D) Intervention group . are commonly seen in primary care. Participants receive a sex- Measures immediately after Measures 3 months after . are closely interrelated: 30% of people with T2D and gender- sensitive training: acceptabilty and training: impact on have depressive symptoms; & people with CPD training impact on behavioural behavioural intentions depression are about 60% more likely to develop Healthcare intentions type 2 diabetes. professionals (QC, ON, NB) Participants receive same Measures immediately after Measures 3 months after . affect women and men differently: the prevalence training, but omitting sex- training: acceptabilty and training: impact on of depression is higher among women with diabetes and gender- sensitive impact on behavioural behavioural intentions (23.8%) than among men (12.8%). content intentions Control group MAIN OBJECTIVES . Stakeholders, we have designed a CPD activity on UTILITY OF THE TRIAL 1Université Laval Primary Care Research Centre (CERSSPL- depression and T2D that includes sex and gender UL), Quebec City 2Faculty of Medicine, Université Laval, Results will demonstrate: Quebec City 3Institute for Women, Societies, Equality and considerations. 4 . the potential of CPD to support consideration of Equity, Université Laval, Quebec City Médecins francophones du Canada, Montreal 5Institut du Savoir Montfort, Ottawa sex and gender in clinical behaviours. 6School of Nursing, Faculty of Health Sciences, University of . We aim to assess the impact of the CPD activity on its Ottawa, Ottawa 7Ottawa Hospital Research Institute 8Faculty of 9 acceptability and on the behavioural intentions of health Nursing, Université Laval, Quebec City CHU de Québec – Codisigned strategies could be : Université Laval Research Center, Quebec City 10Faculty of professionals after training and 3 months later. Medicine, McGill University, Montreal 11Faculty of Social . adapted to other diseases Sciences, Université Laval, Quebec City 12Department of Family Medicine, University of Sherbrooke, Moncton 13Maritimes SPOR . Assess acceptabilty and impact of sex- and gender- Support Unit, Moncton 14Institute of Nutrition and Functional Foods, School of Nutrition, Université Laval, 15Patients sensitive CPD activity on depression & T2D. reprensentatives Indigenous Youth Mentorship Program

19 IYMP The Intervention Pilot Results

Hypothesis and Questions Planning 0.06 The main hypothesis for our Pathways 2 IYMP Implementation research team was that IYMP would remain High school mentors meet twice a week. The first day, they develop an activity plan which * p = 0.04 effective after scaling up (i.e. rippling) from 5 to 13 communities across Canada. We also explored the emphasizes vigorously active low organized games, and healthy nutrition; together the 0.04 questions: Does IYMP promote mino-bimaadiziwiin among youth mentors? and what are the essential mentors decided roles and responsibilities to ensure successful delivery of each activity. 0.02 conditions for successful implementation of IYMP in schools?

0.00 W aist Z Score W aist Previous Findings and Methods -0.02 Efficacy Studies: Previous studies by our group revealed that children involved in IYMP experience less -0.04

weight gain and growth around their waist compared to 0.10 IYMP children not in the program (Pediatrics 2014). 0.08 Control 0.06 Reductions in waist circumference remain significant

0.04 following scaling from 1 to 4 communities (n=580) Experimental Design: Using a 2-year cross over design, Photovoice-derived theory for T2D prevention 0.02 grounded in mino-pimatisiwin (Ross, Blacksmith we are delivering IYMP to ~1000 children across 13 0.00 Jr, Rusnak – Pimicikamak First Nation 2018 communities in Canada. We are measuring risk factors -0.02 What Do the Mentors Think? -0.04 for type 2 diabetes as well as quality of life/wellbeing. z-score BMI Changein “I had fun and gained more experience in leadership.” -0.06 “(I liked) Learning new games and (learning) coping with other people”. -0.08 “I am benefiting from this program … (I am) learning how to be a better person for myself and for Qualitative Studies: Using Photovoice Methodology, we -0.10 AYMP Control others that are around me.” are also exploring the role IYMP plays in supporting “They (the grade 4 students) listen more often and to respect one another.” adolescent mentors. Mentors are taught concepts of Implementation The grade 4 students learned “How to respect others and eating right.” miyo-pimatisiwin/mino-bimaadiziwiin and asked to take The second day, they deliver the activity to grade 4 students, which includes a healthy snack And… “Communicating with others, cooperation and respecting others.” photos that represent this concept. If IYMP supports (fruits and vegetables) and 45-minutes of physical activity, based on the Circle of Courage. living miyo-bimadiziwiin, adolescents are also asked to The majority of mentors noted how being in the program changed their own behaviour. capture images that reflect how it does that? “(I am benefiting my community by) being a good mentor, (I) stop littering and don’t swear or smoke when a child is around.” Implementation Science: Using measures of fidelity Being part of the program would help mentors to: “Stay in school and be a good mentor.” coupled with focus group sessions/interviews we are “I do think that the mentor program is good for this community because we teach the kids new things determining the essential conditions for implementing and to participate in activities and it also teaches the mentors to be good role models for the kids.” IYMP in different community settings.

Participating in IYMP is associated with a lower risk for type 2 diabetes among Indigenous Youth IYMP Network

Proposed Expansion

From 2016-2019 IYM

After the activity was delivered, and the elementary students went home, the mentors sat in With additional funding coming from 5-year a circle and shared thoughts about the day. Each mentor would discuss one thing they renewal of our Pathways team grant ($1.5M) we plan to expand to an additional thought went well, and one thing they thought they could improve on. 15-20 communities across Canada.

We will explore the impact our gatherings have on the social network of participants.

We will also study the transition of IYMP from a research-based intervention study, to a non-for-profit program that will work with Kahnawá:ke provincial/local governments to offer IYMP in as many schools as possible.

IYMP Theoretical Framework 12 years of Rippling: IYMP Expansion Over Time IYMP is guided by the medicine wheel IYMP was initially delivered in one community by a single teachings of many Indigenous cultures that youth leader and 10 adolescent mentors. Preliminary wellness is achieved through a balance of results revealed impressive improvements in body mental, emotional, physical and spiritual composition aong youth exposed to the intervention. This We would like to acknowledge the funding support provided by the health. Additionally, IYMP incorporates the initial success attracted 5 new communities and through concepts of respect, relevance, responsibility a CIHR operating grant (2013-2016) we examined the following agencies: and reciprocity into program delivery. These sustained impact of IYMP after this expansion. Between elements are embedded in the training of 2016 and 2023 we will expand to 12 then ideally >25 mentors and passed along to Indigenous communities and become a non-profit organization children in the program. 20

Providing culturally safe care to Atikamekw living with diabetes in Manawan, Quebec: Identifying barriers and facilitators from different vantage points Marie‐Claude Tremblay1, Maude Bradette‐Laplante1, Holly Witteman1, Maman Joyce Dogba1, Emmanuelle Careau1, Jean‐Sébastien Paquette1, Pascale Breault1, Sandro Échaquan2, Daniel Niquay3, France Roberston3 1Université Laval, Québec, QC, Canada, 2Community of Manawan, Manawan, QC, Canada, 3Native Friendship Center of Lanaudière, Joliette, QC, Canada Introduction Results Figure 2. Barriers and facilitators for culturally safe healthcare in Indigenous patients.  Manawan is one of the three Atikamekw communities (First Nations) in Québec, about 180 km from the nearest Barriers Facilitators service city, Joliette (prevalence of diabetes in the community estimated at 25,6% of adults (1)).  The family medicine teaching clinic of St‐Charles Borromée (SCB), located in Joliette, is mandated to collaborate Colonialism and social determinants of health with Manawan health services to provide care, but experiences difficulties following‐up on and answering the needs of Indigenous patients living with diabetes. (1) Experiences of stigma in the health care system (1) Sensitize HP to discrimination. (2) Implement a  Community and health professionals (HP) want to explore new avenues and alternative approaches related to lead to patients not consulting. (2) Historical mistrust. systematic plan for handling complaints on racism. cultural aspects of care. Organisation of the health care system (1) Hire Indigenous‐friendly health structures and hire Conceptual framework* (1) Difficulty to consider the Atikamekw values. (2) more Indigenous staff. (2) Consider Atikamekw values Difficulty to implement patient‐centered approach. Dimensions Concept and cultural specificities.

1. Understanding the impact of social determinants on Indigenous health. Language and communication Promote care that is 2. Acknowledging our own social privileges and power position as health care provider. respectful of the cultural (1) Provide interpreter service. (2) Promote the (1) No interpret for patients with limited French 3. Fostering safe communication. identity of the patient learning of basic of Atikamekw language by HP (3) abilities. (2) Use of medical jargon by HP. 4. Recognizing Indigenous health practices as options for intervention. (spiritually, socially and Explain health recommendations in a simple language. emotionally safe care). *Ref: 2,3 Traditional practices and cultural perspectives of health Objective (1) Health education material not suitable for (1) Provide appropriate material. (2) Promote This study aims to identify barriers and facilitators to cultural safety in health care provided to Indigenous patients Atikamewk culture and traditional practices. (2) HP education for HP of Atikamekw culture. (3) Explore and living with diabetes. ignorance of cultural practices, preferences and validate preferences, expectations, values and Methods spiritual aspects of health and disease. perceptions of illness with patients. Discussion  Participatory research approach and descriptive qualitative  Discussions were recorded, transcribed verbatim, design. coded in Nvivo.  Deliberative dialogue workshop allowed discussions with stakeholders about the results and prioritize  Data collected through 3 talking circles with 3 groups of  Deductive thematic analysis was performed. potential solutions. participants (n = 30).  Results were discussed and validated by project  Conclusion. Cultural safety in diabetes care can be enhanced by reducing barriers at the individual level; Figure 1. Three talking circles participants and partners in a deliberative dialogue workshop. however, it is crucial to also to transform existing care models and practices to adapt to Indigenous communities’ needs by partnering with them. References 1. Roy B. Évaluation du PSC 2013‐2018. Manawan, QC, 2017. 3. Smye V. et al Mental Health Commission of Canada, 2010. 2.Ramsden I., Nurs Prax N Z, 83(11), 18‐19, 1990.

Atikamekw living Atikamekw living HP working at the with diabetes in with diabetes in SBC clinic Joliette Manawan 21

The Health Researcher’s Toolkit: Why Sex & Gender Matter R Mason1,2, N Hussain1,2, P Rochon1,3 1Women’s Xchange, Women’s College Hospital 2Dalla Lana School of Public Health, University of Toronto 3Faculty of Medicine, University of Toronto

Introducing the Toolkit Development of the Toolkit Dissemination The seven modules included in this toolkit introduce key concepts, Our sex and gender experts advised a dissemination strategy definitions, and sample cases from research experts on integrating sex focused on specific populations: universities/academia, and gender into a variety of research methodologies – from secondary students/trainees, hospitals/clinical researchers, policy/government, data analysis to concept mapping. community members/patients Communication Plan Unique Visits: 8823

Social Media – Twitter, Instagram Page views: 33864 Email Invitations Average session Newsletter Campaigns duration: 22:30 Website Engagement Twitter Impressions: Conferences/Posters 6000+

Impact

Based on video footage and presentation materials from a Women’s Comprehensive integration of sex and Patient Impact Xchange workshop, we worked with educators, knowledge users and a gender considerations in health Pathway group of sex and gender experts to develop this engaging educational research results in better scientific data. resource. Sex and gender integration is Evidence increasingly a requirement of many Capturing Gendered Patient Experiences funding calls, award applications, and journal submissions. Policies Studies that incorporate a sex and gender lens can influence healthcare Features of the Toolkit policies and the programs developed, Modules Contain Video Lectures and are Designed Using Adult E-Learning driving better patient care and improving Principles health outcomes. A goal we all share. Programs

Interactive with Knowledge Check-Ins, Module Quizzes and Content Reviews The Health Researcher’s Toolkit can help novice and experienced Study Examples Demonstrating Research-Based Application researchers alike reach this goal. AODA Compliant and Free of Cost Practices

Flexibility to choose module according to researcher’s needs

Contact: [email protected] @_DiabetesAction womensxchange.womensresearch.ca #DACWorkshop2019 22

GLUCOSE IN THE DIET INFLUENCES INTESTINAL FAT ABSORPTION: Nutritional implications for heart disease in those with diabetes P Stahel, C Xiao, A Nahmias, GF Lewis Banting & Best Diabetes Centre, University of Toronto, Toronto, ON

Introduction Methods Results & Discussion • Dietary fat is stored in the intestine Aim 1 – Effects of oral glucose on plasma lipids Plasma Lipid Response many hours after a meal1 Blood Sampling PLASMA TRIGLYCERIDES CHYLOMICRON TRIGLYCERIDES

300 p = 0.024 • Glucose consumed several hours after 150 a meal can release stored fats from the 200 2 0 5 hours 8 hours 100 intestine into the blood , increasing the 100 Water High-fat Glucose drink 50 risk for cardiovascular disease drink or Water Glucose % of 5h p = 0.049 % of baseline 0 0 567 Participants 012345678 • Understanding how glucose mobilizes Time (h) Time (h) • 6 healthy volunteers studied on 2 visits fat from the intestine may help prevent  Glucose increased plasma triglycerides, particularly in the cardiovascular disease, particularly in • Volunteer considerations: time commitment, re- intestinally-derived fat particle (chylomicron) fraction diabetes imbursement, comfort of indwelling catheter Intestinal Lipid Mobilization Objectives Aim 2 – Effects of oral glucose on intestinal lipid mobilization ELECTRON MICROSCOPY # of lipid droplets CLD Diameter OF ENTEROCYTES (CLDs) per cell Distribution Aim 1 50 4 p < 0.05 p < 0.05 40 • Characterize the appearance of lipids in 3 Water 0 5 hours 6 hours 30 blood 5 hours after a meal in response 2 Glucose 20 High-fat Glucose drink Duodenal 1 to an oral glucose drink 10 drink or Water biopsy 0 0 % of CLDs CLDs % of Aim 2 1) Microvilli; 2) Mitochondria; 3) Cytoplasmic Lipid >4 Participants Droplet (CLD); 4) TG in ER lumen; 5) TG in Golgi

apparatus; 6) TG in secretory vesicles; 7) TG in [0-0.5) [0.5-1) [1-1.5) [1.5-2) [2-2.5) [2.5-3) [3-3.5) [3.5-4) • Investigate the mechanisms of glucose- • 12 patients undergoing gastroscopy randomized to intercellular space; 8) Nucleus3 CLD Diameter (µm) mediated lipid mobilization by analyzing glucose or water duodenal biopsy samples from  By electron microscopy we can visualize fat particles • Volunteer considerations: written, informed participants undergoing clinical directly in intestinal cells and can see exactly how glucose consent, time commitment, re-imbursement gastroscopy mobilizes those particles References 1) Chavez-Jauregui, R.N., et al., Gastroenterology, 139, 1538-1548, 2010 2) Robertson, M.D., et al., Gut, 52, 834-839, 2003 3) Hung Y-H, et al., Biochim Biophys Acta 1862, 600-614, 2017

Contact: [email protected] @_DiabetesAction #DACWorkshop2019 23

Food Insecurity and Hospitalization among Canadians with Diabetes Neeru Gupta1, Zihao Sheng2

1 Associate Professor, Department of Sociology, University of New Brunswick, Fredericton. 2 Research Data Assistant, University of New Brunswick, Fredericton.

Introduction Results Discussion Studies have found food insecurity to be more prevalent Among persons ages 12 and over living with diabetes, The evidence base is growing on the association among persons living with diabetes. Pathways from 10.5% experienced food insecurity and 4.8% had been between socioeconomic status and differential risk of inequality to health include availability of food and other hospitalized at least once for diabetes or a comorbid hospitalization across population groups, including in societal investments in human capital development.1 ACS condition in the period of observation (2006-2011). contexts of universal healthcare coverage such as Hospitalizations for diabetes and many physical and Canada. Our results reinforce the need to consider food mental comorbidities are considered ambulatory care Figure 1: Household food security insecurity in public health and clinical strategies to sensitive (ACS)  potentially avoidable by interventions status among persons ages 12+ reduce the hospital burden of diabetes. living with diabetes Moderately/severely in primary care, including acting on the underlying food insecure: We also add to the literature recognizing the value of factors that may place patients at greater risk.2 10.5% using linked survey and administrative datasets to support patient-oriented research to inform policy and Objective Food secure: practice. 89.5% To investigate the relationship of food insecurity with the risk of hospitalization for diabetes and its complications. The odds of a person with diabetes being hospitalized Methods were significantly higher among those who experienced income-related food insecurity compared to their We exploit novel datasets available via the Social Data counterparts who were food secure, after controlling for Linkage Environment: the Canadian Community Health other characteristics. Survey (CCHS) linkable to multiple years of hospital 3 records from the Discharge Abstract Database (DAD). Table 1: Odds ratios (and 95% confidence intervals) for the We use linked data on: risk of hospitalization for diabetes or a comorbid condition • Income-related household food insecurity among the Household food security status community-dwelling population ages 12 and over Food insecure (ref: Food secure) 1.66* [1.242.23] living with diabetes, as identified in the CCHS; Gender References Male (ref: Female) 1.09 [0.921.31] • Hospital admissions for diabetes (types 1 and 2) or a 1. Pickett KE, Wilkinson RG. Income inequality and health: a causal Body mass index (kg/m2) 0.99 [0.981.01] chronic physical or mental health ACS condition, as review. Soc Sci Med 2015, 128:316-326. captured in the DAD. Note: * = p<0.05. Odds ratios further adjusted for age group and place of 2. Billings J et al. Impact of socioeconomic status on hospital use in New residence. Comorbidities include heart disease, stroke, depression and York City. Health Aff 1993,12:162-173. We estimate the risk of preventable hospitalization using other chronic ACS conditions. 3. Statistics Canada. CCHS (2000 to 2011) Data Linked to the DAD multiple logistic regression analysis. Source: Linked CCHS and DAD data (n=10,260). (1999/2000-2012/2013) [www.statcan.gc.ca/eng/rdc/cencchs-dad].

Contact: [email protected] @_DiabetesAction #DACWorkshop2019 Diabetes Action Canada Training and Mentoring Enabling Program Mathieu Bélanger1&2, André Carpentier2, Michelle Murray1

1Centre de formation médicale du Nouveau-Brunswick, 2Faculté de médecine et des sciences de la santé, Université de Sherbrooke 24 Introduction and objectives What do we do? Training and Funding opportunities

The Diabetes Action Canada (DAC) Training and  We offer training and funding (see next section); CMDO Winter Camp annually; winter Mentoring Enabling Program aims to strengthen patient-  We partnered in the development of the Indigenous Diabetes Canada annually; fall oriented research (POR) capacity for diabetes and its Peoples’ Learning Pathways Training; Trainee Days complications in Canada. Our main objectives are:  We populated a list of complementary training relevant Training English POR Training 1 to 2 sessions annually  Building capacity in patient-oriented research; to POR; French POR Training 1 to 2 sessions annually  Preparing the next generation of diabetes  Dr. Monica Parry and her research team developed Mentorship Program $10,000 per year researchers across Canada in POR methods; Patient Engagement Partnerships in Clinical Trials 3 to 4 awards annually  Enabling the research activities of other programs. (PEP-CT) Patient Partner and Researcher decision aids. Internship Program $10,000 per year What are our guiding principles? How do we stay up to date? 3 to 4 awards annually

Funding Postdoctoral Fellowship $50,000 per year for a  Mobilizing existing expertise;  Training and Mentoring Steering Committee Meetings; Program two-year period 1 to 2 awards annually  Supporting careers in patient-oriented diabetes  Ongoing evaluation of all training sessions; research;  Ongoing collection of information from supported Some of our partners  Collaborating with patients, healthcare providers, trainees; and other professionals in research training;  Program evaluation by an external research team.  CMDO (Cardiometabolic, Diabetes and Obesity  Building capacity to apply research evidence; Research Network of the Fonds de recherche du  Ensuring capacity for meaningful patient How do we engage patient partners? Québec – Santé) engagement.  Diabetes Canada  Co-facilitate POR Training Sessions;  DREAM (Diabetes Research Envisioned and How did we develop our strategy?  Review and evaluate Mentorship, Internship and Accomplished in Manitoba) Postdoctoral applications;  Can-SOLVE CKD  Consultations within the DAC Network;  Participate on our Training and Mentoring Steering  Maritime SPOR SUPPORT Unit  Discussions with partners such as CMDO, Strategy Committee. for Patient-Oriented Research (SPOR) SUPPORT  Québec SPOR SUPPORT Unit Units, Diabetes Canada; DAC needs identified:  Research Chair, Knowledge Translation and   In person training  Salary awards Implementation Survey administered to DAC members;   Funding for travel to training Webinars   Literature review.  Mentoring programs Research Chair, Patient-Centred Outcomes

Contact: [email protected] @_DiabetesAction www.diabetesaction.ca #DACWorkshop2019 25

Building a proof of concept National Diabetes Repository M Greiver1, N Drummond2, D Manca2, MT Lussier 3, A Singer4, K Aubrey-Bassler5, D Willison6, D Mumford, C Pow 7, T Chen 7, A Bhatt1 1Department of Family and Community Medicine, University of Toronto, 2Department of Family Medicine, University of Alberta, 3Department of Family Medicine and Emergency Medicine, University of Montreal, 4Department of Family Medicine, University of Manitoba, 5Department of Family Medicine, Memorial University, 6Institute of Health Policy, Management and Evaluation University of Toronto, 7North York General Hospital, Diabetes Action Canada BACKGROUND DATA ACCESS PROCESS and GOVERNANCE FRAMEWORK

 Diabetes Action Canada, a national chronic disease Oversight of the use of the data is through a robust network funded through the Strategy for Patient- Research Governing Committee. Oriented Research (SPOR) has built a national RESEARCH GOVERNING COMMITTEE diabetes data repository. 50% patients and their care providers 20% health care professionals  De-identified record-level health-related data is kept in 30% researchers and subject experts a secure environment and managed to provide access PATIENT ADVISORY CIRCLE to approved researchers. Collective Circle – main focus: “Research must be in the best interest of patients with diabetes.  The Secure Analytical Virtual Environment (SAVE) is aligned to ISO 27001 information security standards providing researchers a platform to conduct analytics while preserving privacy and the rights of patients.  Support multi-provincial studies with harmonized data elements to enable comparison amongst provinces.

OUR DATA at a GLANCE SECURE ANALYTICAL VIRTUAL ENVIRONMENT NEXT STEPS The Repository contains Electronic Medical Record data from primary  Accommodate Patient-reported outcomes and experience 104,965 5 196 care repositories in five Canadian measures, information, genomics, administrative and social data. Patients Provinces Clinics provinces.  Demonstrate new uses of EMR data (to identify quality AB MB ON QC NL Total improvement opportunities through mathematical modeling)  Linkage with health administrative data to include new models of health care and delivery, including coordinated care and integrated # Health Care visits: 6,385,831 care for those with complex needs. # Vaccination records: 441,547  Using high-performance computing and advanced analytics to # Health Conditions: 1,201,705 enable the use of Artificial Intelligence to analyze the relationships # Lab records: 25,474,083 and patterns with treatment and patient outcomes. # Prescriptions: 7,871,057  Explore novel techniques to link anonymized data and to securely # Health Providers: 985 transfer data across provincial borders into our national data # Referrals: 527,384 repository.

Data period: 1991 - 2018 Data completeness [email protected] @_DiabetesAction http://repository.diabetesaction.ca #DACWorkshop2019 (647) 355-1939 26

Engaging Stakeholders in the Development and Evaluation of the Aging, Community and Health Research Unit (ACHRU) – Community Partnership Program (CPP) J Ploeg1, M Markle-Reid1, R Valaitis1, K Fisher1, R Ganann1, A Gruneir2, W Johnson3, F Légaré4, L Mansell5, W Montelpare6, P Reid3, F Tang3, R Upshur7 on Behalf of the ACHRU CPP team 1School of Nursing, McMaster University, 2Department of Family Medicine, University of Alberta, 3Patient/Caregiver Research Partner, ACHRU, Ontario, 4Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Laval University, 5Patient/Caregiver Research Partner, ACHRU, Alberta, 6Department of Applied Human Sciences, University of Prince Edward Island, 7Bridgepoint/Sinai Health System

Introduction & Objectives Selected Examples of How We Are Deliverables Engaging Stakeholders • The ACHRU-CPP is a 6-month self-management program for • Improved quadruple aim outcomes (i.e., population older adults with diabetes and other chronic conditions and their health, patient/caregiver experiences, providers a 1) Patient and caregiver research partners share similar goals and family/friend caregivers satisfaction, and cost) were involved in developing the program and research study; • Need for ACHRU-CPP was identified by patients and primary • Scale-up plan in alignment with provincial policy priorities care providers 2) Patients and caregiver research partners helped identify study outcomes that were relevant to them • Reduced unplanned hospital admissions and emergency • ACHRU-CPP was shown to be feasible to implement and 3) Stakeholders (patients, caregivers, local service providers, and department visits effective in improving quality of life decision-makers) will be involved as members of local • Increased patient-oriented research capacity community advisory boards (CABs), a steering committee, and a Objectives: patient advisory council, and will inform all aspects of the 1) Co-design adaptations to ACHRU-CPP with older adults, research (See Governance Structure Model below) family/friend caregivers, and providers 2) Examine patient and caregiver engagement in the research process 3) Examine the effectiveness of the ACHRU-CPP on health outcomes and service costs in Ontario, Quebec & Prince Edward Island 4) Explore patient, caregiver, provider and manager experiences with the ACHRU-CPP program Next Steps 5) Plan for scale-up of the ACHRU-CPP program • The findings will provide information on the implementation, impact and scalability of ACHRU-CPP.

Collective Impact Approach • This model could form the standard for delivery of community-based diabetes care across Canada A Collective Impact Approachb is being used to engage patient and community research partners, and other stakeholders. This model is based on 5 conditions: 1) Common agenda, shared vision 2) Shared evaluation measures References 3) Mutually reinforcing activities, clear roles and responsibilities ACHRU-CPP 4) Continuous, open communication a) Markle-Reid, M., et al., J Am Geriatr Soc, 66(2), 263-273, 2018. Governance Structure 5) Backbone support organizations to foster spread and scale-up b) Kania, J., & Kramer, M. SSIR, 9(1), 36-41, 2011. Model

Contact: Dr. Jenny Ploeg This work is supported by the Canadian Institutes of Health Research [email protected] SPOR Primary and Integrated Health Care Innovations Network: Programmatic Grants (Funding Reference Number: KPG-156883) and https://achru.mcmaster.ca/ Diabetes Action Canada. High Volume Emergency Department Use in Older Adults with Diabetes: ACHRU Community Partnership Program K Fisher1, A Gruneir2,3, J Bakal2, C Sadowski2, L Favotto3, R Perez3, D Eurich2, R Ganann1,C Lindeman2, L Mansell4, M Markle-Reid1, J Ploeg1,F Tang5, R Valaitis1, T Williamson6, on Behalf of the ACHRU CPP team

1McMaster University, 2University of Alberta, 3ICES, 4Patient/Caregiver Research Partner, ACHRU, Alberta, 5Patient/Caregiver Research Partner, ACHRU, Ontario, 6University of Calgary

Figure 2: Average 2-Year Non-ED Service Use (2015) Introduction Results 50 High ED Users CIHI Comparator Pop'n Comparator 27 The Aging, Community and Health Research Unit (ACHRU) o Number of older adults increased in all three groups from 2011 to 2015: 40 Community Partnership Program (CPP) seeks to strategically Table 1:Older Adults with Diabetes (2011-2015) 30

enroll participants who are high volume users of emergency Volume 20 2011 2015 departments (EDs). To identify such individuals, we are 10 High ED Users 40,197 51,659 undertaking a series of analyses using the Dynamic Cohort (high 0 ED users) from the Canadian Institute for Health Information CIHI Comparator 106,519 110,486 GP Visits Specialist Visits Total Hospital (CIHI) linked with other administrative data sources in both Ontario Population-Based Comparator 467,897 580,903 Healthcare Service Days and Alberta. Our objectives are to understand the health and Potential Impacts social factors relating to high system use in older adults with o For all years, high ED users relative to comparators were older, rural, from a lower income group, prescribed more drugs (including diabetes and multimorbidity. This will inform the ACHRU trial Inclusion of high ED users in the trial will enable testing of antidepressants), and less healthy o recruitment strategies to ensure inclusion of people with the CPP in this vulnerable group and identification of characteristics similar to those of high systems users. Table 2: Socio-Demographic and Health Characteristics (2015) adaptations needed to maximize its effectiveness. High ED users are high users of other healthcare services, The focus of this poster is on preliminary analyses from Ontario. Factor High ED (%) CIHI (%) Pop’n (%) o suggesting the importance of integrating the CPP with Age (85+) 20.2 16.7 13.6 primary care and other service sectors to reduce patient Methods and system burden. Rural 20.0 12.7 12.6 Results suggest that important areas of focus in the CPP o Overall inclusion criteria for cohorts being compared: o st include multimorbidity, mental health, and systems o diabetes diagnosis prior to April 1 (2011-2015) Income (low) 24.9 20.9 20.6 66+ years of age navigation to assist with social determinants of health. o Charlson (3+) 36.9 15.9 17.4 o community-dwelling o Ontario resident Meds – Mean (SD) 14.8 (6.9) 11.2 (5.5) 10.9 (6.0) Next Steps o Compared three cohorts (2011-2015): Older adults with diabetes are an increasing patient population o CIHI Dynamic High ED User Cohort: ED Use - Mean (SD) 4.8 (5.5) 1.6 (0.8) 2.7 (3.3) that experience many challenges related to managing diabetes o top 10% with respect to number of ED visits for fiscal year and other chronic conditions. Interventions like the CPP are Figure 1: Prevalence of Multimorbidity (2015) o CIHI Dynamic Cohort Comparator: needed to enhance self-management, increase independence o random selection from the 90% of non-high ED users 60% and reduce burden in this vulnerable population. at least 1 ED visit for fiscal year 50% o 40% o Population-Based Cohort Comparator: 30% Acknowledgements o random selection of 25% of the Ontario population of 20% older adults with diabetes, including non-ED users 10% 0% This study was supported by ICES, which is funded by an annual grant

o Linked to administrative data at ICES to obtain selected socio- Proportion 0 1 2 3 4 or more from the MOHLTC. The opinions and conclusions reported here are those demographic, chronic condition and service use characteristics Number of Chronic Conditions of the authors and independent of the funding sources. No endorsement High ED User CIHI Comparator Pop'n Comparator by ICES or the Ontario MOHLTC is intended or should be inferred. Contact: Dr. Kathryn Fisher This work is supported by the Canadian Institutes of Health Research SPOR Primary and Integrated Health Care Innovations Network: [email protected] Programmatic Grants (Funding Reference Number: KPG-156883) and https://achru.mcmaster.ca/ Diabetes Action Canada.