Health as if everybody counted blog
The diabetes crisis: health care not doing its part? *
I do not ordinarily write about the health care industry (and it is an industry). I decided to break this rule after reading a recent report in the Ottawa Citizen on a decision by the Champlain Local Health Integration Network (or LHIN, Ontario's version of a regional health authority) to hire two chiropodists to provide free foot care to diabetics – a service otherwise not covered by provincial health insurance, and therefore unaffordable for many. Lack of appropriate foot care was cited as one of the reasons for the region's high rate of hospitalization for diabetic foot infections, which sometimes lead to amputations.
Diabetes is not an equal-opportunity disabler. As noted in an earlier posting, a pronounced socioeconomic gradient exists in the prevalence of Type 2 diabetes, and limited incomes seriously compromise patients' ability to manage the disease effectively. This helps to explain why diabetes mortality has declined faster among higher-income patients in Ontario. But even aside from these important issues, which suggest at the very least a need to broaden insurance coverage, Ontario's health care system seems not to be doing its part. Province-wide, according to health ministry figures, as of late 2010 fewer than two out of five Ontarians with diabetes had received all three of the tests recommended for diabetes management – blood glucose every six months, cholesterol (LDL) every year, and retinal eye examination every two years – in the appropriate period. (Nationally, a clear socioeconomic gradient exists for receipt of these tests; it would be interesting to know whether the same is true in Ontario.) And a recent article by Tara Kiran and colleagues at the University of Toronto, based on Ontario Health Insurance Plan records, points out that the 2002 introduction of a new billing code specifically to reimburse physicians for diabetes management tasks had, by the end of 2008, led to only modest increases in monitoring.
This is part of a more general, Canada-wide picture. Jeffrey Turnbull, past president of the Canadian Medical Association, has pointed out that in one of the OECD's more expensive health care systems (although it's not one of the more expensive when only public spending is considered) chronic disease management is "woefully inadequate" and "Canada now ranks below Slovenia in terms of effectiveness and last or second last in terms of money spent" on health care. With specific reference to diabetes care, 2008 figures from the Commonwealth Fund show that Canada ranked far behind the Netherlands, New Zealand and the United Kingdom in the percentage of adults with diabetes who received appropriate monitoring.
Now, I am an outsider to most of the quotidian operations of health care institutions; I don't have ready answers. Health system managers seem to be proliferating, yet few signs can be found of the "new management systems and new accountabilities" that Dr. Turnbull called for. Surely it's not unreasonable to ask that health ministries and regional health authorities have routines in place to benchmark diabetes management, and myriad other health care processes, against the world's best and transform the way they do things to match the leaders' performance.
* Tara Kiran provided valuable help with research for this posting. All views expressed are exclusively my own.