INTORDUCTION
Welcome to my final blog for the Critical Foundations in Health Disciplines course! The focus of this course has been on the Canadian healthcare system, how we define health, how the determinants of health impact health, how vulnerable populations interact with our health system, and what health and healthcare may look like in the future. To understand how all these areas of health intertwine, I investigated diabetes as a chronic disease and have provided a more in-depth analysis of the disease, factors contributing to its prevalence, and how the healthcare system needs to change to address gaps in care for people living with diabetes.
BACKGROUND
Chronic disease has become a major health issue in Canada as approximately 44% of Canadian adults are living with a chronic disease (Government of Canada, 2018; Figure 1). Yet based on current models of chronic disease, only diabetes is showing a continued upward trajectory (Hamm et al., 2019). Approximately 35% of adults in Newfoundland and Labrador (NL) are living with diabetes or pre-diabetes and prevalence is projected to rise by another 21% over the next 10 years (Canadian Diabetes Association, 2021b). Even more alarming is that its prevalence is even higher for First Nations people, adults with low incomes compared to adults with higher incomes, and adults without a high school education compared to those with a university degree (Canadian Diabetes Association, 2021b; Figure 2).
Over the last 40 years, NL has seen an increase of 232% in healthcare spending with the worst healthcare performance outcomes, lowest life expectancy, and highest rate of chronic disease in Canada (Health Accord NL, 2021; Figure 3). As diabetes is a major contributor of kidney disease, cardiovascular disease, amputation and blindness and requires extensive education and monitoring, it places a large burden on the provincial health care system with costs expected to reach $80 million by the year 2031 (Canadian Diabetes Association, 2021a; 2021b).
HEALTH MODELS AND THE IMPACT OF THE DETERMINANTS OF HEALTH
The backbone of modern medicine and our current healthcare system is the biomedical model of health, which is disease-centered and focuses on diagnoses and treatment based on physiological and biological factors (Suzuki, 2013). However, the model does not take into account environmental, psychological and social factors that can also impact health (Suzuki, 2013); it assumes that health problems are not influenced by factors beyond the individual.
Yet, upon examination of the statistics related to diabetes prevalence and complications, it is obvious that factors beyond the individual do indeed impact health outcomes. The social-ecological model of health explains how levels of influence, such as intra- and interpersonal factors, have a reciprocal relationship with the individual; that an individual's behaviour affects their relationships, social environment, and health outcomes, and also the behaviour itself is affected by the levels of influence (Golden & Earp, 2012; National Cancer Institute, 2005).
The Banting and Best Diabetes Centre (2021) states that "social determinants that are not adequately addressed by the health care system often have the greatest impact on diabetes and its related outcomes". For example, Indigenous people in Canada were subjected to colonialization processes and intergenerational trauma that resulted in low educational achievement, mental health issues, and lower self-esteem - all of which can contribute to low health literacy and in turn poor health outcomes (National Collaborating Centre for Aboriginal Health, 2019). Health literacy is an individual's capacity to not only understand health information, but to find, obtain and use that information to make well-informed decisions about their health (Centers for Disease Control and Prevention, 2021). Adequate health literacy is an important component of healthcare delivery, is associated with improved health outcomes, and plays a crucial role in chronic disease management (Rheault et al., 2019; National Collaborating Centre for Aboriginal Health, 2019). Individuals with low health literacy often have lower rates of medication adherence, poorer understanding and management of their disease, lower likelihood to participate in health prevention strategies, higher rates of hospitalization and poorer overall health (Rheault et al., 2019). This can be problematic for a disease like diabetes as management and treatment is a complex process dependent on a certain level of understanding.
Similarly, Pilkington et al. (2011) believe that income is another strong predictor of diabetes-related health outcomes. Individuals with lower incomes typically have poorer outcomes, whereas those with higher incomes tend to have better health outcomes (Pilkington et al., 2011). Those with higher incomes can afford higher levels of education, which can lead to a better understanding of the disease and its management. They also can afford medications and diabetic supplies and are not as dependent on insurance plans for reimbursement. Out-of-pocket expenses can cost the average Canadian approximately 3% of their yearly salary (Canadian Diabetes Association, 2021b), therefore it is not surprising that many individuals are not adherent with their treatment plans.
In order to manage a chronic disease like diabetes, it is crucial that an individual has autonomy, access to healthcare, and is an active participant in their own health care (Rheault et al., 2019); however that can be difficult to do if the determinants of health are not being adequately addressed. It is clear to see how the inequities in the delivery of healthcare to underserved groups such as elderly populations, Indigenous peoples and those with lower socioeconomic status that may be partially to blame for the continued upward trend of diabetes prevalence (Buote et al., 2019; Hamm et al., 2019).
FUTURE DIRECTIONS
Primary health care networks increase community access to health services and have the ability to create and maintain supportive client-provider relationships (Foo et al., 2021; Buote et al., 2019). Foo et al. (2021) stated that when patients with chronic disease have solid relationships with their primary care providers, they have more favourable health outcomes and there is a reduction in health services spending. Care needs to be comprehensive, be coordinated with other healthcare providers, have continuity, and be delivered right from the first point of contact (Foo et al., 2021). As such, primary health care is paramount to chronic disease management and prevention (Buote et al., 2019).
Collaborative care is a topic being addressed by a health task force in NL, called Health Accord NL. This task force was developed to create a framework for improving healthcare in NL and reducing the burden of all chronic diseases on the health system by focusing on the determinants of health and how they impact health outcomes, improving the delivery of health services, and trying to increase prevention and promotion strategies in an effort to keep patients from needing to access care at the tertiary level (Health Accord NL, 2021 [Video]).
In my experience, pharmacists are in an ideal position to partake in diabetes management; they are easily accessible, see patients on a regular basis, and often have well-established relationships with their patients. However, allowing pharmacists to either independently or collaboratively manage patients with diabetes would require some degree of legislative changes in most jurisdictions (Hughes et al., 2017). As well, funding for widespread implementation of these services at the pharmacy level would require some level of government funding as a user-pay model would limit their impact (Hughes et al., 2017).
Also, the Canadian Diabetes Association has developed a campaign strategy to #enddiabetes. This national initiative was developed in response to the growing epidemic of diabetes in Canada and is estimated to save the federal government $20 billion over 7 years if an investment of $150 million can be provided (Figure 4; Canadian Diabetes Association, 2019). Part of this strategy has already been adopted by the government of NL and will be implemented as a 'sugar-sweetened beverage tax' in the coming year to encourage healthier food choices (Government of Newfoundland and Labrador, 2021).
Also worth noting are newer health models like those created by Ochsner Health System in Louisiana. This organization developed a new chronic disease model of care and used technology to create an interactive program to manage chronic disease (Tai-Seale, 2019). The Ochsner Health System created retail spaces called O Bars where clients can shop for devices and apps, implemented digital care teams that interact regularly with clients, and perhaps most importantly, created a new reimbursement model whereby team members are compensated for improved client outcomes and not solely for seeing a client (Tai-Seale, 2019). Similarly, value-based models, as described by the NEJM Catalyst (2017), not only compensate health providers based on positive patient outcomes but they also push suppliers, such as drug manufacturers, to align their drug pricing to patient value which may help reduce drug spending costs (Figure 5). These types of reimbursement model could be the way of the future for reducing health spending and improving health outcomes and patient satisfaction (NEJM Catalyst, 2017).
CONCLUSION
As a pharmacist and resident of NL I am concerned with the current state of our healthcare system and the pressure that has been placed on it because of chronic disease, an aging population, the Covid-19 pandemic, and the rural population in our province. If Health Accord NL can successfully implement their 10-year plan, then not only should there be a reduction in the prevalence of diabetes, but there should also be a reduction in prevalence of chronic disease in general, in healthcare spending, and most importantly, an improvement in health outcomes for the population.
S.
References
Banting & Best Diabetes Centre. (2021). Vulnerable populations/population health.
Buote, R., Asghari, S., Aubrey-Bassler, K., Knight, J. C., & Lukewich, J. (2019). Primary health care services for patients with chronic disease in Newfoundland and Labrador: a descriptive analysis. CMAJ open, 7(1), E8–E14. https://doi.org/10.9778/cmajo.20180091
Canadian Diabetes Association. (2019). About Diabetes 360⁰ [Infographic]. Diabetes Canada. www.diabetesstrategynow.ca/about
Canadian Diabetes Association. (2019). Diabetes 360⁰. Diabetes Canada. www.diabetesstrategynow.ca
Canadian Diabetes Association. (2021a, January). Diabetes in Canada: Backgrounder. Diabetes Canada. www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2021_Backgrounder_Canada_English_FINAL_MAR.pdf
Canadian Diabetes Association. (2021b, January). Diabetes in Newfoundland and Labrador: Backgrounder. Diabetes Canada. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2021_Backgrounder_Newfoundland_FINAL.pdf
Centers for Disease Control and Prevention. (2021). What is health literacy? www.cdc.gov/healthliteracy/learn/index/html
Foo, C., Surendran, S., Jimenez, G., Ansah, J. P., Matchar, D. B., & Koh, G. (2021). Primary Care Networks and Starfield's 4Cs: A Case for Enhanced Chronic Disease Management. International journal of environmental research and public health, 18(6), 2926. https://doi.org/10.3390/ijerph18062926
Golden, S. D., & Earp, J. A. L. (2012). Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education & Behavior Health Promotion Interventions. Health Education & Behavior, 39(3), 364–372. https://doi.org/10.1177/1090198111418634
Government of Canada. (2018). Prevalence of chronic disease among Canadian Adults [Infographic]. Public Health Agency of Canada. www.canada.ca/en/public-health/services/chronic-diseases/prevalence-canadian-adults-infographic-2019.html
Government of Newfoundland and Labrador. (2021). Promoting a healthier Newfoundland and Labrador. Retrieved November 7, 2021 from www.gov.nl.ca/budget/2021/what-you-need-to-know/promoting-a-healthier-newfoundland-and-labrador/
Hamm, N. C, Pelletier, L., Ellison, J., Tennenhouse, L., Reimer, K., Paterson, J. M., Puchtinger, R., Bartholomew, S., Phillips, K. A. M. & Lix, L. M. (2019, June/July). Trends in chronic disease incidence rates from the Canadian Chronic Disease Surveillance System. Health Promotion and Chronic Disease Prevention in Canada, 39(6/7). https://doi.org/10.24095/hpcdp.39.6/7.02
Health Accord NL. (2021). Health Accord for Newfoundland and Labrador: A 10-year Health Transformation [Infographic]. healthaccordnl.ca
Health Accord NL. (2021, April 15). Reimaging Health and Healthcare in Newfoundland & Labrador [Video]. YouTube. www.youtube.com/watch?v=sctX9wLBCq4
Hughes, J. D., Wibowo, Y., Sunderland, B., & Hoti, K. (2017). The role of the pharmacist in the management of type 2 diabetes: current insights and future directions. Integrated pharmacy research & practice, 6, 15–27. https://doi.org/10.2147/IPRP.S103783
National Collaborating Centre for Aboriginal Health. (2019). The prevalence of type 2 diabetes among first nations and considerations for prevention. Retrieved from https://www.nccih.ca/docs/health/RPT-Diabetes-First-Nations-Halseth-EN.pdf
National Cancer Institute. (2005). Theory at a Glance: A guide for health promotion practice. Retrieved October 24, 2021 from www.sbccimplementationkits.org/demandrmnch/wp-content/uploads/2014/02/Theory-at-a-Glance-A-Guide-For-Health-Promotion-Practice.pdf
Pilkington, F. B., Daiski, I., Lines, E., Bryant, T., Raphael, D., Dinca-Panaitescu, M., & Dinca-Panaitescu, S. (2011). Type 2 diabetes in vulnerable populations: community healthcare providers' perspectives on health service needs and policy implications. Canadian journal of Diabetes, 35(5), 503–511. https://doi.org/10.1016/S1499-2671(11)80006-7
Public Health Agency of Canada. (2018). Key Health Inequalities in Canada: A National Portrait [Infographic]. www.canada.ca/content/dam/phac-aspc/documents/services/publications/science-research-data/2.Diabetes_EN_final.pdf
Rheault, H., Coyer, F., Jones, L., & Bonner, A. (2019). Health literacy in Indigenous people with chronic disease living in remote Australia. BMC Health Services Research 19, 523. https://doi.org/10.1186/s12913-019-4335-3
Suzuki, H. (2013). Biomedical Model. In The Encyclopedia of Cross-Cultural Psychology. https://doi.org/10.1002/9781118339893.wbeccp056
Tai-Seale, M., Downing, N. L., Jones, V. G., Milani, R. V., Zhao, B., Clay, B., Sharp, C. D., Chan, A. S., & Longhurst, C. A. (2019). Technology-enabled consumer engagement: Promising practices at four health care delivery organizations. Health Affairs, 38(3), 383-390,390A. http://dx.doi.org/10.1377/hlthaff.2018.05027
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