diabetes atlas for the region of peel - chapter 8 ... · community systems needed in the long-term...

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insidE

Highlights

Introduction

List of Exhibits

Exhibits and Findings

Discussion and Implications

Conclusions and Implications

Appendix 8.A – Research Methodology

References

autHors

Anne-Marie Tynan

Jonathan T. Weyman

Jane Y. Polsky

Maria I. Creatore

Peter Gozdyra

Gillian L. Booth

Richard H. Glazier

Chapter8

Community-Based hEalth sErvicEs and Diabetes

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HigHligHtsissue• Accesstoandregularuseofhealthservicesis

essentialfortheprevention,earlydiagnosisandoptimalmanagementofdiabetesaswellasthepreventionofdiabetes-relatedconditions.

• Diabetesisaleadingcauseofblindness,heartdisease,strokeandkidneyproblems.Gooddiabetescareandmanagementcanpreventordelaytheonsetofthesecomplica-tions.Becausediabetescanbecomplicatedtomanage,peoplewiththisdiseaserequireclosefollow-upbyamultidisciplinaryteamofhealthcareprofessionals,whichmayincludetheirprimarycareprovider,diabeteseducators(nurseanddietitian)andarangeofspecialists(includinganeyecarespecialistandendocrinologist),asneeded.Peoplewithdiabetesalsoplayanessentialroleintheirownself-care.

• ThepurposeofthischapteristoexaminethedistributionofandgeographicaccesstohealthserviceprovidersinPeelwhoareinvolvedincaringforpeoplewithdiabetes.Thespatialdistributionandaccessibilitytofamilyphysi-cians/generalpractitioners,diabetesspecialists(i.e.,endocrinologists,ophthalmologists,optometrists)anddiabeteseducationpro-gramsisthefocusofthischapter.

Key Findings

• Therewasafairlyevendistributionoffamilyphysicians/generalpractitioners(FPs/GPs)acrossPeelregionwithahigherconcentrationlocatedincentralMississauga.FPs/GPswerealsowelldistributedinrelationtoconcentra-tionsofadultsaged20+withdiabetes.

• InnorthandnortheastBramptonandinmanypartsofCaledon,therewerelongertraveldistancestothenearestlocationofanFP/GPthanintherestofPeel.

• Therewasgoodoveralldistributionofeyespecialists(i.e.,ophthalmologistsandoptom-etrists,andespeciallyoptometrists),butfewer

endocrinologists,whowerelocatedalmostexclusivelynearmajorhospitalsinPeel.ManyareasinPeelhadtraveldistancesof5kmormoretothenearestendocrinologistandpartsofwestBramptonandmostofCaledonhadtraveldistancesof10kmormore.

• DiabeteseducationprogramswereofferedatrelativelyfewlocationsinPeel.ProgramswerescatteredthroughoutMississaugaandBramptonandfoundinonlyonelocationinCaledon(inBolton).Currently,fewornodiabeteseducationprogramsarelocatedintherapidlydeveloping,higherimmigrationandhighdiabetesareaofnorth,northeastandeastBrampton.

implications • Althoughgeographicaccesstohealthservices

inPeelwasfairlygood,thereareotheraspectsofhealthserviceaccessthatwasnotcapturedintheseanalyses,butneverthelessareimpor-tantfacilitatorsofoverallpopulationhealth.Theseincludedifficultiesusingservicesduetoculturalandsocialfactors,physicianswhomaybelocatednearbybutareclosedtoacceptingnewpatients,waittimestogetanappointmentandlongdistancestoserviceproviderswithoutadequateformsoflocalpublictransportation.

• GiventhegrowthinimmigrationandrisingratesofdiabetesinPeel,itisimportantthatPublicHealthandmunicipalplannerstakeintoaccounttheethnoculturalpreferencesofcertainpopulationsub-groupswhendeter-miningthekindsofprogramsandhealthservicesthatbestsuitcommunityneeds,includingtheiraccessibility.

• Diabeteseducationprogramsandotherdiabe-tesservicesplayacriticalroleinthetreatmentofdiabetesanditscomplications.Theexpan-sionofdiabeteseducationprogramsandsatellitecentresshouldbebasedonpopulationneedsandbelocatedinrelativelyunderservedareas.ProgramsalsoneedtodeliverculturallyappropriateservicesthataddresstheneedsofthepopulationlivinginPeel.

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introductionHealth services and diabetes Diabetesisoneofthemostcommonlyencoun-teredconditionsinprimarypractice1accountingfornearlysevenmillionvisitstofamilyphysi-cians/generalpractitioners(FPs/GPs)eachyearinOntarioalone.2Ontariansaged20andolderwithdiabeteshadameanof7.3FP/GPvisitsperyear.3

Peoplewithdiabetesrequireaccesstogoodqualityhealthcaretohelpthemnavigatetheoftencomplicatedpathwayassociatedwithmanagingtheirdisease.Intensivemanagementofriskfactorsassociatedwithdiabetescomplicationscanreducetherateofmajorcomplicationssuchasheartattacks,stroke,amputationanddeathbyupto50%.4Regularmanagement,aswellascontinuityofcare(definedasacontinuousrelationshipbetweenpatientsandtheircarepro-viderssustainedovertime),isveryimportantforachievingbetteroutcomesforchronicdiseasessuchasdiabetes.5,6Althoughthemajorityofdiabetespatientsaremanagedbyprimarycareproviders,accesstospecialists(e.g.,endocrinolo-gistsandophthalmologists)isnecessaryformorecomplexdiabetesproblemsandpatientswithtype1diabetes.7

Diabetescaredependsonthedailycommitmentofthepersonwithdiabetestoself-managementpractices,preferablywiththesupportofanintegrateddiabeteshealthcareteam.8-10Thediabeteshealthcareteamshouldbemulti-andinter-disciplinary.Itshouldestablishandsustainacommunicationnetworkamongthehealthandcommunitysystemsneededinthelong-termcareofthepersonwithdiabetes.Membersofthecoreteamshouldincludeafamilyphysician/generalpractitionerand/oraspecialist,anddiabetesedu-cators(e.g.,nurseanddietitian).8-13Thepersonwithdiabetesandhisorherfamilyshouldalsobecentralmembersoftheteam.Familysupporthasbeenshowntobenefitthepersonwithdiabetes.14Themembershipoftheteammayalsoincludenumerousotherpersonnel(e.g.,pharmacist).

Individualswithdiabetesoftenhavemultiplechronicconditionsmakingdiabetesmanagement

morechallenging.Diabetestreatmentisoftencomplexandcanbeexpensive,makingitoneofthemostburdensomeandcostliestchronicdiseasesofourtime.3Asaresultofthecomplex-ityofthedisease,itisessentialthathigh-qualityhealthservicesbeprovidedtoassistpatientsandtheirfamiliesdealingwiththemanyfacetsofdiabetespreventionandcare.

Family Physicians/general Practitioners (FPs/gPs)WhenOntarianshaveanewhealthproblemtheyusuallyvisittheirfamilyphysician/generalpractitioner(FP/GP)first.FPs/GPscontributetothedeliveryofmosthealthservicesinOntario,includingdiabetesdiagnosis,treatmentandmanagement.InOntario,alargeproportionofdiabetesmanagementisshoulderedbyFPs/GPs,withthree-quartersofthepopulationreceivingdiabetescarefromtheirFP/GPonly.2Infact,FPs/GPsidentifydiabetesasoneofthemostcommonchronicdiseasesmanagedinprimaryhealthcare.15,16Ontarianslivingwithdiabetesvisitaphysiciantwiceasoftenasmembersofthegeneralpopulation.2

FP/GPsalsoscreenpatientswhomaybeatriskfordevelopingdiabetes.TheCanadianDiabetesAssociation(CDA)ClinicalPracticeGuidelinesrecommendroutinescreeningfordiabeteseverythreeyearsforalladultsaged40yearsandolder.17Earlierandmorefrequentscreeningiswarrantedinspecifichigh-riskgroups,includingindividu-alsofAsian,African,HispanicandAboriginaldescent.17Screeningalsoidentifiesindividualswithpre-diabetes,whichreferstohigherthannormallevelsofbloodglucose,butnotyethighenoughtobediagnosedastype2diabetes.Althoughnoteveryonewithpre-diabeteswilldeveloptype2diabetes,manywill.17

Itisimportanttoidentifypre-diabetes,becausetheprogressiontodiabetescanbepreventedordelayedbylifestylechangesinvolvingdietaryimprovements,increasedphysicalactivityandmodestweightloss(5%–7%ofbodyweight),aswellastakingcertainmedications.18,19Furthermore,researchhasshownthatsomelong-termcomplicationsassociatedwithdiabe-

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tes–suchascoronaryheartdisease(CHD)andnervedamage–maybeginduringpre-diabetes.20Screeninginprimarycarecandetectpeoplewhoseestimatedcardiovasculardisease(CVD)riskishighandpotentiallymodifiable.21

Regulardiabetescareisimportantduetothelargenumberofroutinescreeningtestsandadjustmentstotreatmentregimensrequiredtooptimizethecontrolofdiabetesandassociatedriskfactors.3Thelong-termcomplicationsofdiabetescanbedelayedorpreventedthroughspecificinterventions,suchastightcontrolofbloodsugarlevels,cholesterolandbloodpressurelevels.4Goodglycemic(glucose)controlisas-sociatedwiththepreventionordelayofdiabetescomplicationsincludingdiabeticeyedisease,kidneydiseaseandneuropathy.17

Regulardiabetesmanagementiscritical.Patientswithdiabeteswhofailedtoseeaprimarycarephysicianduringthepreviousyearhadatwo-foldhigherriskofbeinghospitalizedorbeingseeninanemergencydepartmentforuncontrolleddiabetes(bloodsugartoohighortoolow).22Incontrast,patientswhohadaregularproviderandvisitedaphysicianmorefrequentlyhadfewer

oftheseepisodes.22IthasalsobeenshownthatpersonswithdiabeteswhosawtheirFP/GPatleastthreetimesayearwereone-thirdlesslikelytorequireadiabetes-relatedamputationoverthenextfiveyearscomparedwiththosewithfewerannualvisits.23

Forpatientswithdiabetes,havinganongoingre-lationshipwiththesamehealthcareprovidernotonlyfacilitatescontinuityofcare,butprovidesanopportunitytolearnmoreaboutthelong-termmanagementofthedisease.Aregularprimarycareproviderconductsimportantroutinescreen-ingsthatcanidentifyandsubsequentlyhelpmodifyandmanagetheriskfactorsfordiabetes-relatedcomorbidities(concurrentconditions).Theyalsoprovidetheongoingsupportandcarethatpatientswithdiabetesneedtohelpthemnotonlywiththeday-to-daymanagementoftheirdisease,buttodirectthemtootherresourcesandcareasrequired.5,24Primarycareprovidersalsointegratediabetescarewithpreventivehealthcare,providelifestylecounselling,providecareforotheracuteandchronicconditions,andcoordinatecareamongvariousspecialists,teamsandinstitutions.

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Diabetes specialistsEndocrinologistsReferraltoanendocrinologistisoneofanumberofmeasuresavailabletoprimarycareproviderstoaidpatientswhoarenotmeetingtherapeutictargets.Mostendocrinologistsprovidespecial-izedcarefordiabetesandhaveexpertiseinmanagingcomplexdiabetesregimens.However,othertypesofphysicians,includingspecialistsingeneralinternalmedicine,mayalsospecializeindiabetesmanagement.Endocrinologistsmayworkineitherhospitalorcommunity-basedset-tings,oftenincloseproximitytocentresofferingdiabeteseducationprograms.Althoughmanypatientswithdiabeteswillnotneedspecialistcareinordertoachievetreatmenttargets,specializedhealthcareprovidedbyendocrinologistsshouldbeavailabletothosewhodo.

ophthalmologists and optometristsEyeproblemsareacommoncomplicationofdiabetesthatcanleadtoseriouslossofvisionorblindness.Fortunately,visionlossassociatedwithdiabetesmaybeavertedthroughpreven-tionstrategies,earlydetectionandtreatment.Accesstoanophthalmologistoroptometristwithexperienceindetectingdiabeticeyedisease(retinopathy)isessentialforpreventingvisionloss.25TheCanadianDiabetesAssociation(CDA)ClinicalPracticeGuidelinesrecommendthatallpatientswithdiabetesundergoregularscreen-ingandevaluationfordiabeticretinopathybyanexpertprofessional(i.e.,ophthalmologistoroptometrist).Todoso,adilatedeyeexaminationshouldbeperformedatthetimeofdiabetesdiagnosis(forthosewithtype2diabetes)andan-nually(inallpatientswithdiabetes).17InOntario,routineretinalscreeningandotheressentialeyeservicesforpeoplewithdiabetesarecoveredbytheOntarioHealthInsuranceProgram(OHIP).26

diabetes education programsEducationisessentialinthetreatmentofdiabetesandpeoplewithdiabetesareencouragedtotakeanactiveroleintheday-to-daymanagementoftheirownhealthcare(self-management).27However,self-managementrequirescertainskills.

Theseskillscanbelearnedfromprofessionalssuchasnurses,registereddietitiansandtraineddiabeteseducatorslocatedwithinacommunity-orhospital-baseddiabeteseducationprogram,oraprimarycarepracticesetting(e.g.,FamilyHealthTeam).Otherimportantdiabetesprofes-sionalsmayincludeasocialworker,psychologist,footcarespecialist(podiatristorchiropodist),pharmacistorphysiotherapist.Diabeteseduca-tionprogramscommonlyoffergroupaswellasindividualcounsellingtopatientsonstrategiestomaintainahealthydiet,undertakeregularphysicalactivity,controlbloodsugarlevelsandreducetheriskofcomplications,includinghowtorecognizehypoglycemic(lowbloodsugar)reactionsandtreatthemappropriately.27Mostprogramsalsoprovideadvancedtrainingonhowtoself-administerinsulinandadjustitsdose.Effectivelyeducatingpeoplelivingwithdiabetestobettermanagetheirconditioncanleadtoimprovedglucosecontrolandmayreducetheirlikelihoodofdevelopingdiabetescomplications.10Thus,individualswithdiabetesplayakeyroleinmanagingtheirdiseaseandimprovingtheirownqualityoflife.

geographic access to health servicesGeographicaccesstoprimarycareisanimportantfacilitatorofoverallpopulationhealth.28Whilehavinggoodgeographicaccessisnotalwayssufficientforpeopletoaccessthehealthcaretheyneed,itisanessentialprerequisiteforcare.Forexample,geographicproximitytoafamilydoctormaynotnecessarilymeanthatdoctoristakingonnewpatients.29Additionally,language,social,culturalandtransportationissuescanalsoactasbarrierstocaredespitegeographicproximitytoahealthcareprovider.

Inthischapter,thegeographicdistributionofdiabetescareprovidersinPeelisexamined.Theservicesprovidedbyfamilyphysicians/generalpractitioners(FPs/GPs),specialists(e.g.,endo-crinologists,ophthalmologists/optometrists)anddiabeteseducationprogramsarestudied.Inaddi-tion,geographicaccesstoservices(representedbytraveltimetodiabetescareprovidersanddiabeteseducationprograms)isexploredinrelationtotheprevalenceofdiabetesinPeel.

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list oF ExHiBitsExhibit 8.1 Locationsoffamilyphysicians/generalpractitioners(FPs/GPs)[2009]anddistributionofadultsaged20+withdiabetes[2007],bycensustract[2006],inresidentialareas[2009],inPeelregion

Exhibit 8.2 Locationsofdiabetesspecialists(endocrinologists,ophthalmologistsandoptom-etrists)[2011]anddistributionofadultsaged20+withdiabetes[2007],bycensustract[2006],inresidentialareas[2009],inPeelregion

Exhibit 8.3 Locationsofdiabeteseducationprograms[2011]inPeelregion

Exhibit 8.4 Locationsofdiabeteseducationprograms[2011]anddistributionofadultsaged20+withdiabetes[2007],bycensustract,inresidentialareas[2009],inPeelregion

Exhibit 8.5 Modelledtraveldistancealongtheroadnetwork[2009]tothenearestlocationofafamilyphysician/generalpractitioner(FP/GP)[2009],inPeelregion

Exhibit 8.6 Modelledtraveldistancealongtheroadnetwork[2009]tothenearestlocationofanendocrinologist[2011],inPeelregion

Exhibit 8.7 Modelledtraveldistancealongtheroadnetwork[2009]tothenearestlocationofanophthalmologistoroptometrist[2011],inPeelregion

Exhibit 8.8 Modelledtraveldistancealongtheroadnetwork[2009]tothenearestlocationofadiabeteseducationprogram[2011],inPeelregion

Exhibit 8.9 Spatialrelationshipbetweentheaverageroadnetworkdistancetothenearestfamilyphysician/generalpractitioner(FP/GP)[2009]andage-andsex-standardizeddiabetesprevalencerate-ratios*[2007],bycensustract[2006],inPeelregion

Exhibit 8.10 Spatialrelationshipbetweentheaverageroadnetworkdistancetothenearestendocrinologist[2011]andage-andsex-stan-dardizeddiabetesprevalencerate-ratios*[2007],bycensustract[2006],inPeelregion

Exhibit 8.11 Spatialrelationshipbetweentheaverageroadnetworkdistancetothenearesteyespecialist(ophthalmologistoroptometrist)[2011]andage-andsex-standardizeddiabetesprevalencerate-ratios*[2007],bycensustract[2006],inPeelregion

Exhibit 8.12 Spatialrelationshipbetweentheaverageroadnetworkdistancetothenearestdiabetes(DM)educationprogram[2011]andage-andsex-standardizeddiabetesprevalencerate-ratios*[2007],bycensustract[2006],inPeelregion

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ExHiBits and Findings

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Findings:

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•

There was a fairly even distribution offamily physicians/general practitioners (FPs/GPs) throughout Peel region. In central Mississauga there was a higher concentration of FPs/GPs, possibly due to the higher population density in this area (see Exhibits 1.9 and 1.10).

There was a small pocket in central Brampton with fewer FPs/GPs as well as fewer FPs/GPs located in the newly developing areas of north, east and northwest Brampton.

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On

t a r i oLa k e

Adults aged 20+with diabetes

Locations of familyphysicians/generalpractitioners

1 dot equals 100adults with diabetes

Family physician/general practitioner

Residential AreaOther Land Use

Census Tract Boundary

Municipal Boundary

Industrial Area

Freeway or Highway

International Airport

0 5 10 km

0 2.5 5 km

Exhibit 8.1. Locations of family physicians/general practitioners (FPs/GPs) [2009] and distribution of adults aged 20+ with diabetes [2007], by census tract [2006], in residentialareas [2009], in Peel region

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There was a clustering of diabetes specialists in and around Mississauga City Centre and along major roads in Brampton. Specialists were generally located near hospitals in Peel region (see Exhibit 8.3).

Eye services were well distributed in Mississauga with the exception of south and southeast Mississauga. There were also fewer eye services in parts of north, northwest and southeast Brampton and in Caledon (with the exception of Bolton).

Endocrinologists were not as well distributed as eye services. Almost all endocrinologists in Peel were located near major hospitals in Brampton and Mississauga (see Exhibit 8.3).

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Locations of diabetesspecialists

Endocrinologist

Ophthalmologist

Optometrist


Adults aged 20+ with diabetes



Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.2. Locations of diabetes specialists (endocrinologists, ophthalmologists and optometrists) [2011] and distribution of adults aged 20+ with diabetes [2007], by census tract [2006], in residential areas [2009] of Peel region

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Diabetes education programs were scattered throughout Mississaugaand Brampton. There wasone program located in Caledon(in Bolton). Diabetes educationprograms were located on-site athospitals, community health centres andfamily health teams. Satellite programswere located at other sites in Peel.

There were no diabetes education programs located in the rapidly developing areas of east and northeast Brampton.

Note: This map shows the locations of on-site and satellite diabetes education programs/services offered by family health teams (FHTs), community health centres (CHCs) or hospitals in Peel. Diabetes education programs/services offered through individual or other family physician/general practitioner(FP/GP) practices are not shown on this map.

BramptonCivicHospital

TrilliumHealthCentre

MississaugaLAMP CHC

CreditValleyHospitaland FHT

SummervilleFHT

Wise ElephantFHT

LMC Centre

Bramalea CHC

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Locations of diabeteseducation programs


Community HealthCentre (CHC)

Family HealthTeam (FHT)

Hospital withDiabetes EducationProgram

LMC EndocrinologyCentre

Satellite program


Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.3. Locations of diabetes education programs [2011] in Peel region

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Few, if any, diabetes educationprograms were located in some areasthat had relatively high concentrationsof adults with diabetes. These areas includeparts of east, northeast and northwest Brampton,and south and northwest Mississauga.

Note: This map shows the locations of on-site and satellite diabetes education programs/services offered by family health teams (FHTs), community health centres (CHCs) or hospitals in Peel. Diabetes education programs/services offered through individual or other family physician/general practitioner(FP/GP) practices are not shown on this map.

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Locations of diabeteseducation programs


Community HealthCentre (CHC)Hospital

LMC EndocrinologyCentreSatellite program

Adults aged 20+ with diabetes


Family HealthTeam (FHT)


Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.4. Locations of diabetes education programs [2011] and distribution of adults aged 20+ with diabetes [2007], by census tract [2006], in residential areas [2009], of Peel region

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In many areas of Mississauga, Brampton and a few areas in Caledon, there was a relatively short travel distance of 3,000 metres or less to the nearest family physician/general practitioner (FP/GP).

Many areas of Caledon had distances of more than 5,000 metres to the nearest FP/GP, as did small pockets of northeast, east and west Brampton.

Overall, road distances to the location of the nearest FP/GP were relatively short across Peel region.

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Modelled distance (m) to nearest FP/GP

1,001 – 3,0003,001 – 5,000

501 – 1,000

5,001 – 10,00010,001 – 13,352


Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.5. Modelled travel distance along the road network [2009] to the nearest location of a family physician/general practitioner (FP/GP) [2009], in Peel region

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Many areas in Peel had road networktravel distances of more than 5,000 metres tothe nearest endocrinologist. Parts of west Bramptonand most of Caledon had travel distances of morethan 10,000 metres.

Areas with shorter travel distances (3,000 metres or less) to the nearest endocrinologist were found in central Brampton and central and west Mississauga.

Findings:

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O n t a r i o

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Modelled distance (m) to nearest endocrinologist

1,001 – 3,0003,001 – 5,000

75 – 1,000

5,001 – 10,00010,001 – 43,520


Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.6. Modelled travel distance along the road network [2009] to the nearest location of an endocrinologist [2011], in Peel region

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Road network travel distances to thenearest eye specialist were relativelyshort (3,000 metres or less) throughout muchof Mississauga, in central Brampton and in eastCaledon (Bolton).

There were longer travel distances (more than 5,000 metres)to an ophthalmologist or optometrist throughout westand northeast Brampton, and most of Caledon (withthe exception of Bolton and Caledon Village).

Findings:

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Modelled distance (m) to nearest eye specialist

1,001 – 3,0003,001 – 5,000

21 – 1,000

5,001 – 10,00010,001 – 18,546


Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.7. Modelled travel distance along the road network [2009] to the nearest location of an eye specialist (ophthalmologist or optometrist) [2011], in Peel region

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Road network travel distances to the nearest diabetes education program were relatively short (3,000 metres or less) in east, central, west and northeast Mississauga, central and north Brampton and east Caledon (Bolton).

Travel distances to the nearest diabetes education program were slightly longer (more than 5,000 metres)in parts of south, north and northeast Mississauga, andeast, northeast, west and southwest Brampton, andthroughout most of Caledon.

Findings:

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Modelled distance (m) to nearest diabetes education program

1,001 – 3,0003,001 – 5,000

66 – 1,000

5,001 – 10,00010,001 – 18,840


Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.8. Modelled travel distance along the road network [2009] to the nearest location of a diabetes education program [2011], in Peel region

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There were relatively short to mediumtravel distances (5,000 metres or less)to the nearest family physician/generalpractitioner (FP/GP) (compared to the rest of Peel)in areas such as north, northeast, east and northwestBrampton, and northeast Mississauga where diabetesrates were high (at least 20% higher than the GTA).

Portions of southwest Brampton and south Mississauga had lower diabetes rates and short travel distances to the nearest FP/GP (2,000 metres or less).Most of Caledon had low diabetes rates but relatively long distances (more than 5,000 metres) to the nearest FP/GP.

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Diabetes Rate-ratio*

253 8,2525,0002,000

≥ 1.20

≤ 0.80

0.81 – 1.19

Avg distance (m) to nearest FP/GP

DIABETESHIGH

*Rate-ratio calculated as:

Overall Greater Toronto Area (GTA) diabetes rate: 9.0%

census tract rate for pop. aged 20+GTA rate for pop. aged 20+


Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.9. Spatial relationship between the average road network distance to the nearestfamily physician/general practitioner (FP/GP) [2009] and age- and sex-standardized diabetes prevalence rate-ratios* [2007], by census tract [2006], in Peel region

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Findings:

• The vast majority of high diabetes areas in Peel (with diabetes rates at least 20% higher than the GTA average rate of 9.0%)had average road network distancesbetween 3,001 to 10,000 metres to thenearest endocrinologist. These areas were located innorth, east, northwest and southwest Brampton, andnorth, north-central and northeast Mississauga.

Areas in south Mississauga with lower diabetes rates (at least 20% lower than the GTA average) had average road network travel distances of 10,000 metres or less to the nearest endocrinologist.

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849 31,36810,0003,000

≥ 1.20

≤ 0.80

0.81 – 1.19

Avg distance (m) tonearest endocrinolgist

DIABETESHIGH





Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.10. Spatial relationship between the average road network distance to the nearest endocrinologist [2011] and age- and sex-standardized diabetes prevalence rate-ratios* [2007], by census tract [2006], in Peel region

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Many high diabetes census tracts(those having diabetes rates at least20% higher than the GTA average) had traveldistances of 3,000 metres or less to the nearesteye specialist.

Low diabetes areas (with rates at least 20% lower thanthe GTA average) in Mississauga and Brampton also hadtravel distances of 3,000 metres or less to the nearesteye specialist.

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369 13,25610,0003,000

≥ 1.20

≤ 0.80

0.81 – 1.19

Avg distance (m) tonearest eye specialist

DIABETESHIGH





Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.11. Spatial relationship between the average road network distance to the nearesteye specialist (ophthalmologist or optometrist) [2011] and age- and sex-standardized diabetes prevalence rate-ratios* [2007], by census tract [2006], in Peel region

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High diabetes census tracts (with diabetes rates at least20% higher than the GTA average) located in northeast and southwest Brampton, and north and north-central Mississauga had average road network travel distances of 5,000 metres or less to the nearest diabetes education program.

Some high diabetes census tracts located in north and central Brampton, and northeast and central Mississauga had shorter travel distances (5,000 metres or less) to the nearest diabetes education program.

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879 13,2135,0002,000

≥ 1.20

≤ 0.80

0.81 – 1.19

Avg distance (m) to nearest DEP

DIABETESHIGH





Municipal Boundary

Industrial Area

Freeway or Highway


0 5 10 km

0 2.5 5 km

Exhibit 8.12. Spatial relationship between the average road network distance to the nearestdiabetes education program (DEP) [2011] and age- and sex-standardized diabetes prevalence rate-ratios* [2007], by census tract [2006], in Peel region

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discussionInthischapter,thelocationsofandgeographicaccesstofamilydoctors,medicalspecialistsanddiabeteseducationprogramsinrelationtodiabetesprevalenceinPeelisreviewed.

HealthservicesingeneralwerewelldistributedthroughoutPeel.Familyphysiciansandgeneralpractitioners(FPs/GPs)wereparticularlywell-distributedthroughouttheregion.TherewasahigherconcentrationofFPs/GPsincentralMississauga,whichmaybeduetothehigherpopulationdensityinthisarea.TherewerefewerFPs/GPslocatedintherapidlydevelopingareasofnorthandeastBrampton,butroadnetworktraveldistancestoFPs/GPsweregenerallyshort(3,000metresorless)throughoutPeel,includinginareaswithhigherdiabetesrates.ComparedtotherestofPeel,Caledonhadthelongesttraveldistances(morethan5,000metres)tothenearestFP/GP.Giventheruralmake-upofCaledon,itisnotsurprisingthattraveldistanceswouldbeslightlylonger.However,itisunlikelythatresidentsofCaledonwouldconsideradistanceof5,000metres(ormore)tovisitanFP/GPasalongtripespeciallygiventheruralsetting.

Overall,therewasarelativelyevendistributionofandgoodgeographicaccessibilitytoFPs/GPs,whichisapositivefindinggiventhekeyrolethatFPs/GPsplayintheprevention,treatmentandcareforpeoplewithdiabetes.ThisisparticularlyimportantinPeelwherediabetesratesarehighthusnecessitatinggreaterneedforprimarycare.

ItisimportanttonotethatalthoughgeographicaccesstoFPs/GPsinPeelwasquitegood,thereareotheraspectsofaccessthatalsoplayakeyroleinoverallpopulationhealththatcouldnotbemeasured.Suchaspectsincludedwhetherornotphysicianswereopenorclosedtonewpatients,theprovisionoflanguage-specificservicesandculturalsensitivitytothehealthcareneedsofcertainimmigrantgroups.

Medical specialists – endocrinologists, ophthalmologists, optometristsThemajorityofendocrinologists,ophthal-mologistsandoptometristswerelocatedinMississauga(neartheCityCentre)andalongmajorroadsandnearhospitalsinPeel.

Eyeservicesweregenerallywelldistributedthroughouttheregion,butendocrinologistswerenotaswelldistributed.TherewereveryfewlocationsofendocrinologistsoutsidethemajorhospitalsinMississaugaandBrampton.Notsur-prisingly,thelongesttraveldistances(morethan10km)toanendocrinologistwereinCaledon.Whilethetrendforendocrinologiststolocateinhigh-densityareasnearhospitalsisunlikelytochangeintheshort-term,thereismovementtowardendocrinologistsworkinginnon-hospital(community)settings.Thisprovidesfutureopportunitiesfornewspecialtypracticestoopeninhigh-needareas.However,itisnotunusualtotravellongerdistancestoaspecialistregardlessofwhereonelives.Specialistreferralsareoftenbasedonanumberoffactorsincludingthenatureoforfamiliaritywiththespecialistandnotnecessarilyonproximitytothereferringphysi-cianorpatients’ownlocation.

diabetes education programsDiabeteseducationprogramswerescatteredthroughoutMississaugaandBrampton.TherewasonediabeteseducationprograminCaledon(inBolton).

WhilesomelocationsinBramptonandMississaugadidnothaveadiabeteseducationprogram,traveldistancestothenearestpro-gramwere5,000metresorlessinmanypartsofMississaugaandBrampton,andinBolton(withinCaledon).Slightlylongerdistances(morethan5,000metres)todiabeteseducationprogramswerefoundinhigh-diabetesareasinnortheastandsouthwestBrampton,andnorthandnorth-centralMississauga.Conversely,somehigh-diabetescensustractslocatedinnorthandcentralBrampton,andnortheastandcentralMississaugahadaveragedistances5,000metresorlesstothenearestdiabeteseducationprogram.

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limitatioN of tHese aNalysesAcoupleoflimitationsoftheseanalysesdeservemention.Thephysicallocationsanddistributionoffamilyphysicians/generalpractitioners(FPs/GPs)throughoutPeelregionisshown.However,noassessmenttodetermineiftheFPs/GPsattheselocationswereactuallyacceptingnewpatientswasconducted.Aspreviouslydiscussedinthischapter,accessdoesnotonlyrefertoproximitybutalsotowhetheranindividualproviderisacceptingnewpatients.

Secondly,itisimportanttonotethatonlythelocationsofon-siteandsatellitediabeteseducationprograms/servicesofferedbyfamilyhealthteams(FHTs),communityhealthcentres(CHCs)orhospitalsinPeelwasincluded.Neitherdiabeteseducationprograms/servicesofferedthroughindividualorotherFP/GPpractices,norsatelliteservicesofferedlessthanonceaweekwereanalyzed.

conclusions and iMPlicationsPeelishometorapidnewdevelopmentandlargerecentimmigrantandvisibleminoritypopula-tions,particularlyindividualsofSouthAsianheritage(seeChapter4foradefinitionofvisibleminorityusedinthisatlas).Thesegroupshaveconsiderablyhigherratesofdiabetescomparedwithotherethnicgroups.Thisrelationshipwasmostevidentinthehigh-diabetesareasinwest,centralandnortheastMississauga,aswellaseast,central-west,northandnortheastBrampton–areasthatarehometoahighconcentrationofvisibleminoritiesandrecentimmigrants(seeChapter4formoreinformationaboutethnicityandimmigrationinrelationtodiabetesinPeelregion).ThesedemographictrendssuggesttheneedtodevelopeffectiveprogramstopreventdiabetesandtotargetimmigrantsofallagegroupsinrapidlyexpandingareasofPeel.30BecausetheremaybeahighproportionofresidentswhomaynotspeakEnglishinareaswithhighratesofdiabetes,thereisalsoaneed

toprovidelanguage-specifichealthservicesintheseareas.

Theimportanceofculturally-specificservicesisperhapsoneofthemostimportantissuesinhealthserviceprovisioninPeel.Traditionaldiabetescaresystemsdesignedformainstreampopulationsareoftenoflimitedrelevancetoculturally-diversepopulations.Suchsystemscommonlyemphasizereducingbehaviouralriskfactorsandthebenefitsofself-carebehav-iours,butignorethesocial,cultural,economicandphysicalenvironmentsinwhichlifestylepracticesareshapedandconstrained.17Thereisgrowingevidencetoshowthatdiabetespreventionandmanagementstrategiesthatoffergroupsupportandservicesprovidedbyamultidisciplinary/community-basedteamwithanunderstandingoftheculturalandsocioeco-nomicrealitiesofthetargetethnicgroupareassociatedwithimprovedclinicaloutcomesandreducedethnicdisparities.31-39

Policy-makersmustpreparefortherisingburdenofdiabetesonhealthcareresourcesbyensuringthatprimarypreventionstrategiesareinplace.40Althoughdiabetescanbepreventedthroughlifestylechangesaimedatincreasingactivityandimprovingdiet,providingtheseinterventionsonanindividualbasismaynotal-waysbefeasible.40Effectivepreventionstrategiesmust:identifyhigh-riskpopulationsandtheirmodifiableriskfactors;optimizeurbanplanningandresourceavailabilitytoaddressthe“dia-betogenic”environment(i.e.,anenvironmentwherepeoplehaveeasyaccesstohighfat,highcaloriefoods);andimplementpubliceducationcampaignstopromotehealthierlifestyles.40

NewlydevelopingareasinPeelregionmaybeideallocationsforimplementingpopulation-basedpreventionstrategies.NortheastandeastBrampton,inparticular,areareaswithalargein-fluxofnewresidentsandmoregrowthplannedforthefuture(seeChapter1).Futureplansshouldfocusontheprovisionofcommunity-basedhealthcarepreventionandmanagementprogramsaimedathigh-riskgroupsintheseareas.Programsshouldbedevelopedanddeliv-

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eredinpartnershipwithtargetcommunitiesandshouldreflectlocalethnoculturalrepresentation.

Otherfactorsalsoplayaroleinwhetherpatientsusediabeteseducationservices.FewerthanhalfoftheprimarycarephysicianssurveyedinPeel(andHalton)regionfollowedtheCanadianDiabetesAssociation(CDA)recommendationtoreferpatientstodiabetesself-managementeducationprograms.41Commonreasonsfornotreferringwerepatients’unwillingnesstoattend,lackofevening/weekendappointments,languagebarriers,longreferralwaitinglistsandinconvenientlocationforpatients.41Theadditionofdiabeteseducatorson-siteinfamilyphysican/generalpractitioner(FP/GP)officesmightenhanceFP/GPreferralsanduptakeinpatientparticipation.41

Toaddresstheburdenofdiabetes,Ontariolaunchedacomprehensivediabetesstrategythatbuildsoninternationallyacceptedbestpracticesandthegrowingbodyofevidencesupportingtheorganizationofhealthcarearoundchronicdiseasemanagement.42Thestrategyincludeseffortstopreventdiabetesonset,improveaccesstoinformationandeducationalmaterialsthatpromotediabetesself-management,enhanceaccesstocomprehensive,team-basedcareforpeoplewithdiabetes,andsupporttheoptimalmanagementofdiabetesinclinicalpracticethroughthedevelopmentofaprovince-widediabetesregistry.42

Theavailabilityofandaccesstohighqualityhealthcareservicesareimportantfactorsinthepreventionandmanagementofdiabetes.Primarycareprovidersplaykeyrolesinhelpingpatientscopewiththeday-to-daymanagementofthedisease,whichmaybecomplicatedandoverwhelmingformany.Otherservices,suchasmedicalspecialistsanddiabeteseducationprograms,arealsoessentialtoreducethecurrentandfutureburdenofdiabetes.However,provid-ingadditionalhealthserviceswillnotfullysolvetheissueofoverallaccess.Futureplanstoextendkeydiabetes-relatedhealthservicesinPeelshouldincludeconsiderationofhowtoovercomeadditionalbarrierstoaccessbesidesgeographiclocation.Theseincludelanguage

andculturaldifferences,thecurrentpolicythatimposesathree-monthwaitforOntarioHealthInsurancePlan(OHIP)fornewimmigrants,thelackofaconvenient,fastandwell-connectedpublictransportationsystem,andsensitivitytoservicesthatmaybedifficulttocomplywithormaybeinappropriateinlightoflocalresidents’valuesandbeliefs.

aPPEndix 8.a – rEsEarcH MEtHodologyData sources

locations of Family Physicians/general Practitioners, specialists and diabetes Education Programs • Thelocationsoffamilyphysicians/general

practitioners(FP/GP)presentedinthischapterwerereceivedfromtheCorporateProviderDatabase(CPDB;2009/10)housedattheInstituteforClinicalEvaluativeSciences(ICES).

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• Thelocationsofdiabetesspecialists–endocri-nologists,ophthalmologists,andoptometrists–werereceivedfromtheInstituteforClinicalEvaluativeSciences(ICES;2011).

• Thelocationsofdiabeteseducationprogramswerereceivedfromtwosources:DiabetesRegionalCoordinationCentres(2011)andPeelPublicHealth(2011).

diabetes Prevalence• Age-andsex-standardizeddiabetesprevalence

ratesper100peoplewerecalculatedusingtheOntarioDiabetesDatabase(ODD)andotheradministrativedatasourcesheldattheInstituteforClinicalEvaluativeSciences(ICES)(seeAppendix2.Aforamoredetaileddescription).

aNalysisThedistributionofandgeographicaccessibilitytofamilyphysicians/generalpractitioners(FPs/GPs),endocrinologists,ophthalmologistsandoptometrists,diabeteseducationprogramsandassociatedsatellitelocationsacrossPeelregionwasexamined.

• Thedistributionoftheseresourceswasexam-inedbyusingsymbolstodepicttheirlocationsthroughoutPeel(e.g.,locationsofFPs/GPsacrosstheregion).Thismethodprovidedanopportunitytodeterminewhereserviceswerelocatedandwhethercertainservicesexistedinspecificneighbourhoods.Dotdensitymappingwasusedtodepictconcentrationsofadultsaged20orolderwithdiabetesacrossPeel.Onthesemaps,onedotrepresented100adults20orolderwithdiabetes.Dotswereplacedatrandomlocationswithinresidentialareasofcensustracts,basedonthenumberofadultsaged20yearsorolderwithdiabetesthatlivedinagivencensustract.Thisallowedforthecomparisonofthedistributionofdiabetes-relatedhealthservicesinPeelregionwithspatialconcentrationsofadultsaged20yearsorolderwithdiabetes.

• Accessoraccessibility,asshownontheacces-sibilitymaps,wasmeasuredastheshortestdistancealongthestreetnetworktothenearestresourcelocation(e.g.,FP/GP)fromeachpointina150-metregridofstartingpointslocatedacrossPeelregion.Thatis,thedistancealongthenetworkofstreetsandhighwaysfromeachstartingpointtothenearestlocationofeachtypeofhealthservicewasmeasured.

• Thespatialrelationshipbetweentheseac-cessibilitymeasuresandratesofdiabetesprevalencethatwereeithermuchhigher(20%ormore)ormuchlower(20%orless)thantheGTAaveragediabetesrateof9%wasevalu-ated.ForeachPeelcensustract,thediabetesratewasdividedbytheoverallGTArateinordertocalculatearate-ratio.CensustractswithdiabetesratesthatweremeaningfullyhigherthanintheGTAasawhole(rate-ratioof≥1.2)weredepictedinshadesofred,whiletractswithratesmuchlowerthanintheGTA(rate-ratioof≤0.80)weredepictedinshadesofblue.AllcensustractswhoseratesdidnotdiffersubstantiallyfromtheGTArate(rate-ratiobetween0.81and1.19)weredepictedusingasinglegreycolour.

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