Q&A: First Nations – Diabetes in Canada’s Indigenous Populations

Dean_Eurich_headshot

Endocrine News talked to Dean Eurich, PhD, MSc, BSP, who led researchers in a study that looked at First Nations communities and type 2 diabetes in Canada. He discusses the issues in treating this indigenous population, working with the Canadian government, and creating the Reorganizing the Approach to Diabetes through the Application of Registries (RADAR) project.

As diabetes rates skyrocket, perhaps no groups are hit harder than aboriginal populations. First Nations communities in particular are three to five times more likely to develop type 2 diabetes and its subsequent burdens than the general Canadian population. So a group of researchers led by Dean Eurich, PhD, MSc, BSP, research chair in Chronic Disease Prevention and Management and associate professor in the School of Public Health at the University of Alberta, Canada, in partnership with Okaki Health Intelligence Inc. started the Reorganizing the Approach to Diabetes through the Application of Registries (RADAR) project, “developed in alignments with federal calls for innovative, culturally relevant, community-specific programs for people with type 2 diabetes, developed and delivered in partnership with target communities.”

The project is ongoing, but the study protocol was published earlier this year in BMC Health Services Research. The authors conclude that they hope “RADAR, in combination with other similar initiatives, may bridge the gap between First Nations health and the general population, and reduce diabetes-related morbidity and premature mortality.”

Endocrine News caught up with Eurich to discuss the RADAR project, its background and design, its challenges and victories.

Endocrine News: Tell me about the background of this study.

Dean Eurich: I think the impetus of the study really came about from the simple fact that we know people of First Nations descent are at significant increased risk of poorer health outcomes and mortality. In Alberta, there’s about a 12-year gap in mortality between First Nations and non-First Nations people. This is clearly driven by social, economic, and political reasons, but also just underlying health gaps are quite significant in the population. In Canada, and Alberta for sure, diabetes is one of the major diseases, and that is increasing in incidence in patients of First Nations descent. So we really wanted to look at how can we improve some of the outcomes around diabetes and diabetes management in the First Nations population. There’ve been lots of studies that show that diabetes care and their outcomes are significantly worse compared to the general population. Given my interest in diabetes as an area that we thought we could dive into and try to improve some of their outcomes.

One of the challenges in working with First Nations is that they’re geographically very diverse throughout the province. They’re very high up in the north and all the way down to the south, to the U.S. border, so trying to think of a program that could reach out to some of these very isolated communities that have First Nations patients with diabetes was really a challenge for us. When we first started thinking about the project we were quite certain that if we could put a diabetes nurse or a pharmacist or a physician or a dietician in each one of these communities to work with these patients on their diabetes, we’d likely improve their outcomes, because most of these communities are very limited in terms of their resources around medical staff and access to medical care. The downside of that is it’s just not feasible. That’s not a sustainable model.

So, in talking with a number of experts in First Nations communities, we came up with the RADAR model, which was really to try to improve diabetes care in these remote, isolated communities, but also do it in a sustainable manner. The way we thought we could do that is that if we had an electronic registry system, an electronic medical record system that was integrated, and that if we had a care coordinator who was a nurse or a dietician or someone along those lines who could then work with those communities remotely to try to identify their high-risk patients and work with the front-line healthcare staff to improve the outcomes for those patients. That’s kind of where RADAR all came about.

EN: The care coordinators are able to work remotely?

DE: How the model works is that we do send the care coordinator to the communities for the first couple weeks to provide some education and also to make sure that the front-line staff understand the study but more importantly understand the software that is going to be used to try to manage the population. Some of these communities are not actively engaged with the use of electronic medical records yet so it’s a change for the staff to go from a paper-based record to a fully online system that we have to use for this type of project, so there’s some education around that. Once that first couple weeks of education are done, the care coordinator comes back to the central location – Edmonton, Alberta – and works with the communities on a weekly basis to manage their patients.

EN: You talk about location being a barrier. In your paper you also write about the cultural barriers.

DE: Absolutely. I think there are very significant cultural differences between First Nations and non-First nations. And one of the reasons that we’ve seen the big spike in diabetes has been a movement away from some of the more traditional meals and activities that the First Nations were doing. As they become more, for lack of a better term, westernized in terms of what we tend to eat, they’re just more susceptible to diabetes. Making sure that any intervention and any activity that we undertake fits within their cultural belief system and their cultural norms is very important for us to ensure that the intervention is going to be successful. They have a different way of looking at health. It’s much broader than non-First Nations look at health. We needed to make sure we took that into account when trying to improve their outcomes.

EN: Communication breakdown sounds like another challenge.

DE: Yes. A lot of these communities are still using paper-based charts, and that information is not easily accessible to individuals in health centers. Just to give you as more concrete example: In Alberta, we have a system called Netcare. It doesn’t matter which physician you go see. When you get a lab test order or an x-ray or any of those types of procedures, it’s entered into an online database. If you’re a certified healthcare professional with access to Netcare, you can go in a look at patients’ lab results, etc. so you can make better informed decisions about their care. When a patient shows up at a pharmacy, the pharmacist can look online to see what drugs they’ve had filled, not only within their pharmacy but anywhere else in the province.

In many First Nations communities, they didn’t have access to Netcare. They didn’t have the software that ensured that the connections were secure, and they didn’t have their privacy impact completed within the communities. So many of these providers in the First Nations communities, especially the providers on reserve, they didn’t have access to some of the information that should be available freely to them to help manage their patients.

One of the things that RADAR did for many of these communities is that we got them access to the Netcare system so they could see their patients’ labs, drugs, etc., online and in real time, which again, we hope will improve outcomes by having that information available to them.

EN: This is an ongoing project, but can you share some results you’ve seen so far?

DE: Sure. Around the whole idea of the relay, in one of the communities we went to, the community was set up so that there was a healthcare center on reserve. And then literally about 300 meters away, was a physician clinic providing care to First Nations and non-First Nations people off reserve. We brokered the very first meeting between the health administrators between those two health sites. Even though they’re in the same community, the health systems are so different, the way the funding and model works that they actually hadn’t talked to each other.

And what was quite surprising to us is that for diabetes patients, one of the key parts of care is making sure they get their eyes checked on an annual basis. This community was about three-and-a-half hours away from an urban center and so the non-First Nations physicians were sending all their patients into the urban center, so it was a three-and-a-half hour drive each way. What they didn’t realize was that on the First Nations reserve, within that health center, they actually had a machine in place that physicians could remotely look in at the eyes of patients to provide remote access to eye care (tele-opthalmology). So one of the good things that came out of the meeting, instead of patients traveling three and a half hours to get their eye care done, they use tele-ophthalmology within the First Nations reserve. All the patients, regardless of whether they’re First Nations or non-First Nations, they can go over to the healthcare center to get their tele-ophthalmology done. That’s been a big win.

The other big win is that the frontline staff have become much more educated around diabetes care. The care coordinators have provided a lot of resources to them to help manage care.

When we started the project, about 50% of First Nations patients had standard process of care measures within the last year. Simple things like getting their blood glucose levels checked, those types of things. I do know that’s gone up significantly. That’s one of the key things that we aim for, to make sure everyone has their bloodwork done in a timely fashion so that changes in medications and things like that can be done.

I think there’s been significant improvements in the communications among healthcare professionals. There’s been a large uptick of education among the frontline staff in the communities. And just the ability to recognize and recall these individuals to get the appropriate process of care measures done in a timely fashion has been a big success so far. Whether or not that translates into improved health outcomes and reduced complications is a little farther down the line, but we’re hoping that by improving the process of care, that we see improvements in outcomes as well.

EN: What’s something endocrinologists should take away from this study?

DE: I think the biggest one is the significant care gaps that are happening. Many of the patients that we’ve been dealing with, they go and see a specialist because they’re running into kidney problems, eye problems, or cardiovascular system problems. So they see their specialist, but they don’t really have anyone back in the communities providing that frontline care. From a specialist point of view, they tend to assume that the family doctor is providing the basic primary care for individuals, but in many of these patients, that’s simply not happening because there aren’t enough resources in the community to provide that.

— Derek Bagley is the senior editor of Endocrine News. He wrote about how the travel ban impacted an Endocrine Society member in the September issue.

 

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