The Alberta First Nations Project to Screen for Limb, I-Sight, Cardiovascular and Kidney (SLICK) - Complications using Mobile Diabetes Clinics

Health and the Information Highway Division, Health Canada
February 2004

Table of Contents

• 1.0 Introduction
• 2.0 Project Description
• 3.0 Achievements
  • 3.1 Goals Reached
  • 3.2 Additional Successes
  • 3.3 Unreached Goals
  • 3.4 Documents or Products Generated
• 4.0 Main Impact
  • 4.1 Human Resources Impact
  • 4.2 Privacy and Protection of Information
  • 4.3 Policy and Research Implications
• 5.0 The Future
• 6.0 Communications
• 7.0 References
• Appendix

1.0 Introduction

The SLICK Project arose from epidemiological studies which have shown that diabetes and its complications, including circulatory problems in lower limbs, retinal damage in the eyes, and heart and kidney damage, have a major impact on public health costs in First Nations populations. The prevalence rates of diabetes, adjusted for age, are 3.6 and 5.3 times higher among First Nations men and women compared to the general population of Canadian men and women respectively (Young 1999). Individuals with diabetes among the First Nations are also at increased risk of experiencing complications more frequently than the general population in Canada. In the First Nations people, it has been projected that by the year 2016, lower extremity amputations, the rate of cardiovascular disease and the rate of individuals starting kidney dialysis will increase by 10 fold and blindness will increase 5 fold (Blanchard 1997). Furthermore, the cost of diabetes care for a status aboriginal has been shown to be higher than for a person with diabetes from the general population (Jacobs 2000). The SLICK Project was proposed as an intervention to reduce the burden of this public health disorder in Alberta First Nations communities. Its purpose was generally to increase awareness of the disease, to improve diabetic services, increase early identification of diabetes complications, encourage clients to arrange appropriate follow-up care with long-term outcomes of improving client health, decreasing the prevalence of diabetes complications and reducing the socioeconomic cost of diabetes in the First Nations populations of Alberta.

2.0 Project Description

The SLICK Project was a collaborative endeavor between the University of Alberta, Alberta First Nations and Health Canada, which was coordinated by the Implementation Committee of the Aboriginal Diabetes Initiative. The purpose of the project was to overcome barriers to access a comprehensive, coordinated and integrated screening program for limb, eye, cardiovascular and kidney complications of diabetes throughout First Nations communities in Alberta. To achieve the goals of the project, two vans were setup with the necessary equipment required to conduct a battery of screening tests for complications in limbs, eyes, cardiovascular and kidneys according to the Canadian Diabetes Association (CDA) evidence-based clinical practice guidelines for screening, education and community-based care. These mobile units were deployed into all forty-four Alberta First Nations communities to conduct screening tests for the known diabetic population, to increase population awareness of the complications and the consequences of the complications and to encourage clients to arrange appropriate follow-up care.

The two mobile units were equipped with advanced information and communication technologies staffed by qualified health care personnel. The equipment included Bayer DCA 2000 instruments for measurement of hemoglobin A_1C (to assess blood sugar control) and to measure urine microalbumin / creatinine ratios (to assess kidney function). A Cholestech LDX Analyzer was used to measure blood sugar levels and lipid profiles. Urine dipsticks were used to detect large proteins and white blood cells as indicators of kidney failure or infection respectively. Photographers trained by a senior technician at the Royal Alexandra Hospital used a Zeiss 450 Fundus Camera and a Kodak Professional DCS 760 Digital camera to capture high resolution, three-dimensional retinal images. These were captured in the field and delivered electronically to retinal specialists at the Tele-Ophthalmology Unit at the Royal Alex Hospital in Edmonton for interpretation.

All equipment is commercially available. The DCA 2000 and Cholestec LDX instruments are used in some diabetes education centers, occasional pharmacies and during research studies, to our knowledge, in Canada. We were dissatisfied with the quality assurance processes suggested by the manufacturers and therefore we contracted our own (see below, CEQAL). The Fundus Camera and digital camera combinations are also used in limited locations in Canada. They were selected by our ophthalmological colleagues based on their previous experience, and customize (Tennant, 2000) . Difficulties encountered with technology included problems with quality assurance initially, corrected by contracting CEQAL (see below), and various times that cameras or computers were non-operational. Lap tops were used in the field to capture data, and 2 motherboards failed, likely due to extensive use and transportation. A spare formatted lap top was required to prevent operation down time. Likewise, fundus cameras failed a couple of times, along with problems with digital cameras and connection cords, such that camera "crises" occurred approximately every few months, with some instances of batching. All the problems were unique and did not repeat themselves. More stringent processes were put in place for packing, unpacking and handling, and a back up camera is being sought so that cameras can be on rotation between the "shop" where technicians can ensure they are clean and in working condition, and the field.

3.0 Achievements

3.1 Goals reached

Purpose of the SLICK Program

The purpose of the SLICK program (which is on-going - February 2004) is to provide local access to comprehensive, coordinated and integrated screening programs for the renal, retinal, cardiac, and foot complications of diabetes among First Nations communities in Alberta, to provide the screening results in a timely and secure fashion to clients and their caregivers, and to promote appropriate follow-up and the integration of these screening services within a comprehensive multi-disciplinary diabetes prevention, care and treatment program.

The goals of the program were formulated as:

• To increase accessibility to appropriate diabetes care for First Nations people
• To provide quality diabetes care to First Nations diabetic clients
• To provide diabetes care in a quantity deemed appropriate to First Nations
• To foster integration, coordination and/or/collaboration of health services across the diabetes continuum of care
• To reduce the complications of diabetes in First Nations
• To provide cost-effective diabetes care to First Nations
• To identify lessons learned in developing and implementing a First Nations diabetes care project and sharing these with other jurisdictions/regions/settings interested in establishing similar programs
• To ensure that the technology used meets First Nations diabetes care requirements
• To ensure that privacy is maintained during the collection, usage and disclosure of personal health information

Were the goals achieved?

PURPOSE I. Increase accessibility: Overcome barriers to access a comprehensive, coordinated and integrated screening program for limb, eye, cardiovascular and kidney complications of diabetes.

1. Was the goal of increased accessibility to diabetes care achieved for First Nations peoples?
   At total of 1,151 clients were enrolled in the SLICK Project and were screened from all forty-four Alberta First Nations communities in mobile clinics between December 5th, 2001 and July 22nd, 2003.
   
   An additional 357 clients came to the SLICK van to find out whether they had diabetes. While this was not an a priori goal of the project, a protocol had been devised to anticipate this eventuality. This was for two reasons. Firstly, it was known that the accuracy of the clients' assurances of whether they had diabetes or not might be questionable, given a high rate of "self-screening" that was known to be happening amongst this population (self blood glucose monitoring performed by family members). Capillary glucose monitoring was also being performed on clients by well meaning health professionals. While sometimes the results of these screening efforts revealed frank diabetes that was then confirmed by a physician, many times there was resulting ambiguity as to the meaning of the testing results (contradictory results on different occasions, lack of confirmation by physician or conventional lab testing, denial and lack of follow up). Secondly it was known from the results of discussions with grass-roots stakeholders during the conception of the SLICK project that screening for diabetes itself, as opposed to the complications of diabetes, was desired by this population. Therefore it was anticipated that a number of individuals would come to the van for these purposes. These clients were subsequently categorized as "NON - SLICK", although a significant number, as will be shown later, turned out to have diabetes.
   
   Distribution of SLICK clients by gender and age
   
   
   
   The location of the 44 First Nations communities visited in the SLICK project is shown on a provincial map which also shows the areas covered by the three Federal Treaties with the First Nations in Alberta (Treaty 8, north, Treaty 7, south and Treaty 6, middle.
   
   
   Click on the image to enlarge or here (opens a new window).
2. Was quality screening for diabetes programs provided?
   The Canadian Diabetes Association evidence-based clinical practice guidelines with respect to screening, education and community-based care were implemented in these communities:
   
   The two mobile units transported the equipment including the Bayer DCA 2000 instruments for measurement of hemoglobin A_1C (to assess blood sugar control) and to measure urine microalbumin / creatinine ratios (to assess kidney function) and the Cholestech LDX Analyzer to measure blood sugar levels and lipid profiles. Urine dipsticks were used to detect large proteins and white blood cells as indicators of kidney failure or infection respectively.
   
   Trained photographers used a Zeiss 450 Fundus Camera and a Kodak Professional DCS 760 Digital camera to capture high resolution, three-dimensional retinal images which were then delivered to retinal specialists at the Tele-Ophthalmology Unit at the Royal Alex Hospital in Edmonton for interpretation.
   
   Physical exam maneuvers included a screen for peripheral neuropathy (monofilament wire screening), cardiovascular (blood pressure, waist and hip measurements, weight and height) and eye testing (including testing for visual acuity and eye pressure testing with tonometry for glaucoma).
3. Was the diabetes complications screening in a quantity appropriate to First Nations peoples?
   SLICK had a target goal of three visits per year to clients which was based on statistics provided by Alberta Health and Wellness on the prevalence of diabetes among First Nations Communities in Alberta (~ 10 % of population on reserve: 60,000, i.e. 6,000, although 1/3 of these cases would be undiagnosed). Accordingly SLICK reached only about one quarter of the intended recipients (1151). In most cases, communities received two visits due to scheduling time constraints.
4. Was the goal of fostering integration, coordination and or collaboration of health services across the diabetes continuum of care achieved?
   Collaboration with retinal specialists has been exceptional. However, the qualitative evaluation indicated that some Health Centre nurses did not feel completely "in the loop". Resources have not allowed for an evaluation of the extent of coordination and collaboration experienced by general practitioners who care for these patients. However, anecdotal interactions and reports from general practitioners have been uniformly favorable. No comments have been received from traditional laboratories that would alternatively conduct some of the tests.
5. Were the complications of diabetes reduced in First Nation peoples?
   Baseline data is available at Alberta Health and Wellness which participates in the NDSS (National Diabetes Surveillance System). However, in the short time frame of this project, this goal is difficult, if not impossible, to assess. Considerable data has been accumulated and assuming permission from First Nations to examine the NDSS specifically for the SLICK clients screened, an assessment of this goal may yet be achieved.
6. Was cost-effective screening for diabetes complications provided for First Nations peoples?
   Based on an economic analysis of the cost of delivering these services directly versus the standard mode of delivery, evaluable SLICK costs were determined to be $357 per service rendered compared to $505 by the standard mode. Not including the initial set-up costs, it was less expensive to travel to the communities for screening as compared to transporting clients to a larger centre for screening. This economic analysis considers only the direct screening costs, whereas, huge economic benefits and greatly improved quality of life may be important considerations difficult to quantify at this stage of the project, given the time-course and the morbidity of diabetic complications.
7. Were there lessons learned in developing and implementing a First Nations diabetes care project which may be shared with other jurisdictions, regions or settings interested in establishing similar programs?
   The following comments came from qualitative evaluation:
   
   
   • Ensure that all testing equipment is functional prior to entering a community.
   • Improved lines of communication among concerned professionals need to be established to improve client benefits.
   • With improved awareness of diabetes complications, clients are ready for additional information on how diabetes and medications may affect other conditions such as arthritis, bone diseases, menopause and aging.
   • Clients may require that attending physicians have information consistent with an increased awareness of the complications of diabetes as enhanced by the SLICK project.
8. Did the technology used meet First Nation diabetes care requirements?
   The state of technology as assessed by the quantitative data acquired and the qualitative evaluation was seen as being of a very high standard. The high level of technology employed presented some challenges to users initially in terms of the operation of specific computer software employed in retinopathy screening. In addition, since the cameras were not designed for mobile deployment, continued assembling and disassembling took its toll on connections and lenses. Since communities lacked effective (and safe, private) internet connectivity, lap top computers were necessary to store information prior to transmission.
9. Were privacy concerns met during the course of the project?
   No concerns about privacy have arisen during or following the visits, suggesting that the care taken by the screening teams and the overseeing committee to respect this right has been achieved.

PURPOSE II. Education : To increase knowledge about diabetes and its complications, change behavior and attitudes by fostering a desire in clients to arrange follow-up care and actively seek treatment for their diabetes and identified complications.

1. SLICK activities included the education of clients as well as providers about the program itself and about appropriate screening for diabetes.
2. Clients received an information sheet about the program at their initial visit, and a booklet about diabetes and it's complications from the Aboriginal Wellness Diabetes program in Edmonton (North), or material from the Chinook Aboriginal Diabetes program (Lethbridge - South).
3. Clients received appropriate small gifts, e.g. fridge magnets, pencils, pins, to remind them of the SLICK visit and its purpose.
4. Health Center staff received Golf shirts for assisting with the program.
5. Associated physicians received mouse pads, all with the SLICK logo.
6. Clients received a copy of their screening test results at the time of service delivery and were informed of the implications of the results and recommendations regarding the need for follow-up with primary care providers.

PURPOSE III. Community-Based Care : To promote the integration, coordination and collaboration of community services including primary care physicians, community health nurses, community health representatives, nutritionists, lab services, referral services and ophthalmology consultants to provide interdisciplinary and comprehensive shared care.

1. Each SLICK van was staffed by a trained nurse and retinal photographer.
2. Community health nurses, home care nurses and community health representatives at each community facilitated SLICK visits.
3. Information collected at a SLICK visit was recorded in a clinical database.
4. Copies of results from screening were sent to clients' primary care physicians and stored at respective community health centres.
5. The Tele-Ophthalmology Unit at the Royal Alexandra Hospital coordinated follow-up eye care.
6. This model of shared care that entails ongoing communication of all members of the health care team has been shown to increase the commitment and participation of the person with diabetes in an active treatment program (Greenhalgh 1994).

3.2 Additional successes

Qualitative Assessment of SLICK was carried out to evaluate the perceived success of the program from the participants and the health center providers' perspective. The comments provide additional information related to the success of the program beyond its tangible objectives.

Accessibility

1. Clients reported that having the mobile unit come directly into their community was appreciated.
2. The effort within the communities to get house bound clients to the mobile unit by means of other transportation increased overall accessibility.
3. SLICK was described as the "one-stop-shopping" of screening programs. And the easy access to the various complications screening tools was much appreciated by clients.

Quality and Quantity of Services

1. Client comments about SLICK service providers were consistently positive.
2. Use of Aboriginal screening staff was appreciated, especially if they spoke Cree or provided a "cultural connection" for the participants.
3. Testing results were conveyed by means of symbols using "happy faces" or "sad faces" which were easy to understand and provided a comfort level when receiving potentially unwelcome news.
4. Nurses reported that testing for eye problems was an important aspect of the screening since clients perceived the loss of sight as the worst complication of diabetes.
5. Clients reported that the extra care taken by the screening team and the local health unit to make clients feel comfortable with the screening process was greatly appreciated. This included arranging for transportation when needed, having snacks and drinks available and the encouragement to speak to their peers about their experience. Clients also expressed appreciation with the time taken by screening staff to explain the testing procedure and the expected outcomes.

Privacy Issues

Clients were unanimous with respect to their approval of the sensitivity shown by the screening teams and with their commitment to client privacy and confidentiality.

3.3 Unreached Goals

1. A total of 1151 clients were enrolled in SLICK and seen for their initial visit between December 2001 and July 2003. Approximately one in four of these clients returned for a follow-up visit in the same period. Analysis of the clinical findings relative to follow-up visits may show whether clients may have been complication free on their initial visit and simply decided that a follow-up visit in the time of the project was not required. Alternatively this drop-off in follow-up visits was due to some other reason. A goal of three visits per year to individuals was not universally achieved. Although some communities received three SLICK visits, most received two.
   
   In retrospect, the SLICK schedule predictions were unrealistic: 15 to 20 minutes were used in initial calculations regarding number of clients to be seen per day. One to 3 hours turned out to be the true requirement. This included about 1 hour for completing surveys, consents, physical exams and lab procedures, and up to another full hour for retinal photography. Appropriate counseling could also take significant time, on average 20 -30 minutes. Thus, 5-6 clients were seen per day rather than the predicted 10-20.
   
   In addition, a constant threat to SLICK operations was the competing demands of other health related issues in the Health Centers. Thus accommodating SLICK more than twice yearly would be too taxing on the health center human resources, which are stretched at the best of times (difficulties recruiting and retaining nurses).
2. SLICK had as one of its goals, to reduce the complications of diabetes in First Nations peoples in Alberta. Although baseline data is available through Alberta Health and Wellness which participates in the National Diabetes Surveillance System, it was not possible to access this data within the current study for comparison purposes. This information may be available at a later date in follow-up studies, if the First Nations people consent to a) further participation in NDSS - under discussion, and b) linkage of their data from this project.

3.4 Documents or products generated

Document /Product Name	Available in Paper and/or Electronic Form	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name /Number
Template(s) for vendor RFP
Template(s) for vendor contract(s)
User Guide(s) and/or Training Manual(s)	Yes, SLICK Manual	No	Yes: SLICK Manual
Template(s) for equipment testing	QA through contract with CEQAL
Policy and Procedure Manual(s)	Yes (SLICK Manual: both for SLICK and for lab procedures)	No	Yes: SLICK Manual
Job Descriptions and/or recruitment material	Yes, for Van staff
Software Application(s), includes: EHR application Security /access alert software Telehealth scheduling software Other	Yes, SLICK clinical database, and oph-thalmology software	Yes for oph-thalmology software	Yes: provided to Patricia Huntly
Standards, includes: Data (includes minimal data sets) Image Messaging Other	QA standards Safety standards	No	Yes: SLICK Manual
Clinical Training Protocols
Clinical Program Protocol(s)	SLICK Manual	No	Yes: SLICK Manual
Video Conference Protocols and Etiquette Guide
Quality Assurance Procedures	YES:	No	Yes: SLICK Manual
Confidentiality and Privacy documents
Consent Forms	YES	No	Yes: SLICK Manual
Sustainability Plan

Quality of services provided was assured by implementation of CDA approved guidelines, and by on-going continuing education of team members. A rigorous quality assurance program was instituted with respect to the laboratory testing, with the assistance of CEQAL. What follows is an excerpt from a standard letter that is sent to physicians receiving SLICK results:

The following information may be useful to you regarding the mobile testing of blood and urine for this project. The Canadian External Quality Assessment Laboratory (CEQAL) has assessed the analytical performances of the analyzers that are being used in SLICK. This performance assessment utilized sample sets covering the clinical range of interest with accuracy target values assigned by credentialed reference methods. For HBA1 c , the base of accuracy was the DCCT Reference laboratory at the University of Missouri. This laboratory operates the glycated hemoglobin A1 c standardization program in the United States and served as the core laboratory for the Diabetes Control and Complications Trial (DCCT). The base of accuracy for the lipid measurements was CEQAL's Reference Method Laboratory, which is a member of the Cholesterol Reference Method Laboratory Network (CRMLN). CRMLN operates under the aegis of the CDC and serves as the accuracy base for the lipid standardization program in the United States and Internationally. The day to day analytical performance of the SLICK analyzers is monitored in the field through the use of internal quality control programs (two levels) and analyte specific blinded external quality assessment programs. Our QC coordinator monitors these quality control programs on a regular basis.

Hemoglobin A1 cis measured in whole blood using the Bayer DCA2000®+. For this test, this analyzer operates with a CV 2.5% and an average bias of 6.19% for a total error of 12.1%. These performance characteristics are similar to those that are currently being achieved at major testing centres in urban communities.

The urinarymicroalbumin / creatinine ratiois also being determined using the Bayer DCA2000®+ analyzer. A mid-stream urine sample is collected and tested by urinary dipstick* for the presence of hemoglobin (RBC's), leukocyte esterase (WBC's) and protein. Subsequently, the sample is analyzed to determine the microalbumin:creatinine ratio. If the ratio is abnormal, you should arrange to repeat the test. Treatment should be initiated if 2 tests out of three are positive. For mciroalbumin, this analyzer operates with a CV of 3.5 % and an average bias of 0.74 % for a total error of 7.6%. For creatinine, it operates with a CV of 2.1% and an average bias of -4.28% for a total error of 8.4%. These performance characteristics are similar to those that are currently being achieved at major testing centers in urban communities.

* if the WBC's > 25 we will ask patients to see you to rule out a UTI, if protein is greater than trace we will ask the patient to see you for a serum creatinine, protein / creatinine ratio (or 24 hour urine for protein and creatinine clearance).

Total cholesterol, HDL cholesterol, triglycerides, calculated LDL and glucose are all measured using a single testing cassette on the Cholestech LDX™ analyzer. The performance characteristics for these tests on this analyzer are as follows:

Analyte	CV (%)	Average Bias (%)	Total Error (%)
Total cholesterol	2.68	0.86	6.1
HDL cholesterol	1.95	- 0.06	3.9
Triglycerides	2.38	- 0.66	5.3
Glucose	1.97	- 2.75	6.6

These performance characteristics are similar to those that are currently being achieved at major testing centers in urban communities.

All of the above tests are being performed by trained First Nations nurses, in the Communities, thus facilitating access to testing for this population .

Another document generated was a summary of clinical outcomes, used for various presentations and education about SLICK to communities (see appendix ).

4.0 Main Impact

The SLICK Project is being seen as a success by the First Nations communities, as the program has been embraced both by the communities and the diabetic clients living in them.

The collaboration between the First Nations and Inuit Health Branch (of Health Canada) and the University of Alberta to implement this program through the efforts of an academic health services researcher has provided a successful model for delivery of health care services. On-going research to evaluate both the clinical and social aspects of this collaboration will provide direction for future applications of this model.

The main impact of this study is that high technology health care that might otherwise only be available in larger centres was delivered personally to forty-four First Nation communities throughout the Province of Alberta. Over one-thousand individuals were screened for diabetic complications following other studies which showed a very high prevalence of diabetes among First Nation populations, not only in Alberta, but in Canada. The high prevalence of this disease associated with increased morbidity and reduced quality of life, and the associated burden of health care is current problem of enormous proportions. The SLICK project may provide a unique way to address this very serious health problem in Alberta, which may be applicable to other regions or provinces of the Country. By actively screening for signs of developing complications in First Nation populations, an opportunity is created to provide early treatment to individuals identified in the screening process which may have significant consequences for reducing the morbidity of the complications. Secondly, SLICK offered a means to assess the progress of complications from one period to another, providing care-givers a much improved chance of matching treatment to severity. Thirdly, education of the population about diabetes and its complications was one of the purposes of the project to provide increased understanding for those afflicted or affected and to enable individuals to feel that they personally could have some role in mediating the consequences of this disease.

4.1 Human Resources Impact

By improving the knowledge and skills of health care givers and care receivers in the First Nations communities may have a huge impact on the ability of care givers to recognize symptoms of diabetic complications, improve their ability to provide screening for the complications, and on the ability of those with diabetes to recognize that they may be experiencing complications. Furthermore, with increased understanding of the complications and how they may be controlled, care receivers may be better able to take a more active role in addressing factors which may serve to reduce the severity or rate of progression of complications.

As has been mentioned, the human resources on reserve are stretched in some places more than others, with respect to qualified nurses (public health and home care), on whom this project relied heavily. Community Health Representatives (CHR's) were often called upon to support the teams, which they did generously. Being members of the Communities, they provided significant expertise in community issues and were responsible for "buy in".

Central management of the project was a challenge. There was heavy reliance on the Aboriginal Diabetes Initiative Diabetes Regional Coordinator at FNIHB, a very busy position, which cannot adequately manage SLICK. The administrative assistant helped, and a specific SLICK coordinator was hired out of the University of Alberta with CHIPP funds. Even this was often not enough, and required many hours of the lead applicant's time for management aspects. This challenge of adequate resources for project management continues to date. The ability of the University of Alberta to provide meaningful and detailed data analysis has been hampered by the requirement to be managing day to day aspects of the project rather than providing an overall direction, with on-going interpretation of data to plan further services.

4.2 Privacy and Protection Information

SLICK has functioned with great sensitivity to the privacy and security of health information (see informed consent signed by each individual) and to the issues surrounding the collection of data on aboriginal peoples.

Data storage has been behind the firewall of the Capital Health Authority, in Edmonton, as a contribution from Capital Health Information Systems to the project, and data dissemination has been cautious and sensitive to the requirements to share aggregate data first and foremost with the communities where it was collected.

4.3 Policy and Research Implications

See comments below regarding the future. In addition to the cost minimization analysis done by the quantitative evaluation, showing potential cost-effectiveness, only long term follow up and further analysis will reveal the true cost-benefit ratio of a project of this magnitude.

The qualitative evaluation shows true acceptance and satisfaction consistent with the expected preference of having services delivered close to home, with a minimum of personal inconvenience. Whether the intense effort required for this convenience can be justified will require further analysis, probably theoretical modeling. This will have to factor in models of care for chronic disease, where there is inherent inertia in seeking optimal medical care. Resources should be devoted to these further analyses of this costly mode of health service delivery, as suggestions have been made that it be expanded to other areas of the country. The excellent initial database should allow this on-going analysis.

5.0 The Future

Recommendations for SLICK (from the "quantitative evaluation")

• A central management system is required which will allow for the development of a strong infrastructure within the SLICK project.
• Project management methodology needs to be clarified
• A control center for the SLICK program should be established
• Adherence to a schedule is important to cost effective planning
• Accountability for materials and equipment needs to be established
• To ensure complete information tracking, a regular schedule of reports, deliverables and updates needs to be implemented.
• A weekly download of data listing is suggested so that acquired data may be reviewed in a timely manner.
• Clarification of ownership and purchasing of equipment should be established to ensure a positive working environment among all SLICK partners.

As of February 2004 the future of SLICK is not assured. While the project is on-going it is doing so on the basis of extraordinary dedication of the University of Alberta / FNIHB partnership, with funding post- CHIPP coming from FNIHB nursing, and the Aboriginal Diabetes Initiative at FNIHB. The University of Alberta continues to contribute in kind, and the Tele Ophthalmology Project continues to provide the service of reading and reporting the retinal images.

The lack of clarity on the renewal of the ADI funding (set to terminate March 2004) is threatening the continuation of this project. Even with renewed ADI funding however, SLICK will need on-going, independent program funding to continue to operate, since ADI funding is insufficient, and needs to be devoted to other areas such as promotion and prevention. Two submissions to Treasury Board are on the table presently regarding SLICK. Only the successful negotiation of solid fiscal support will enable the implementation of the excellent points made above by the "quantitative evaluation", and will indicate that SLICK has matured from a "pilot project" to a program.

6.0 Communications

SLICK has been described and presented at various fora.

Oral presentations:

Community networking to enhance control of chronic disease. ACADRE conference,

CIHR funded Cardiovascular / Respiratory diseases workshop. February 2002

Gestational Diabetes, and the epidemic of Diabetes. Region 4 FNIHB Nurses Symposium. March 2002

The Challenge of Diabetes and the response of Alberta First Nations. Co-Management FNHIB Committee, Region 4, Chiefs and Health Directors, October 2002

SLICK: progress report. Calgary Therapeutics conference October 2003

SLICK update. Region 4 FNIHB Home Care conference, November 2003

SLICK update. Presentation to Senior Nurses, FNIHB, February 2004

Presentations at National and International meetings:

• 48. Dr. E. Toth (University of Alberta), Dr. D. Strong (FNIHB), and the Alberta First Nations Diabetes Implementation Committee. Alberta First Nations Address Diabetes: The SLICK Project (Screening for Limbs, I (Eyes), Cardiac and Kidneys. Canadian Society for Telehealth Meeting, October 2001
• 49. Sandra Shade, Ellen Toth, David Strong, and the Alberta First Nations Diabetes Implementation Committee. Alberta First Nations and Complications of Diabetes: The SLICK Project. National Aboriginal Diabetes Association Meeting, January 2002
• 50. Pauline Shaw, Lisa Guirguis, Ellen Toth for the DOVE Investigators.Aboriginal participation in the DOVE study. National Aboriginal Diabetes Association Meeting, January 2002
• 54. Mathew Tennant, Mark Greve, Linda Steinhauer, Sandra Shade, Ellen Toth, David Strong, and the Alberta First Nations Diabetes Implementation Committee. SLICK ( Screening for Limbs, I-Eyes, Cardiac and Kidneys) in Alberta First Nations, American Diabetes Association meeting, Diabetes, vol 51: suppl 2, A558
• 60. David Strong, Mathew Tennant, Mark Greve, Linda Steinhauer, Sandra Shade, Ellen Toth, and the Alberta First Nations Diabetes Implementation Committee SLICK ( Screening for Limbs, I-Eyes, Cardiac and Kidneys) in Alberta First Nations., poster, Canadian Diabetes Association Meeting, Vancouver 2002 Can J Diabetes (suppl):26, 2002
• 65. Toth EL, Strong D, Tennant M, Greve M, Steinhauer L, Shade S, Implementation Committee of the aboriginal diabetes Initiative. SLICK (Screening for Limbs, I-Eyes, Cardiac and Kidneys) in Alberta First Nations International Diabetes federation Meeting, Paris, France, August 2003.
• 67. Sylvia Gladue, Linda Steinhauer, Sandra Shade, David Strong, Ellen Toth, and the Alberta First Nations Diabetes Implementation Committee. Implementing SLICK ( Screening for Limbs, I-Eyes, Cardiac and Kidneys) in Alberta First Nations: the first 1000 clients. Canadian Diabetes Association, Ottawa ON, October 15-18, 2003. [Canadian Journal of Diabetes forthcoming].
• 72. Lorraine Trojan, Beryl Jacobson , Ellen Toth, David Strong, David Seccombe and the Aboriginal Diabetes Initiative Committee. Quality Control of Point Of Care Testing in the S.L.I.C.K. ( Screening for Limbs, I-eyes, Cardiovascular and Kidney ) Program. Canadian Diabetes Association, Ottawa ON, October 15-18, 2003. [Canadian Journal of Diabetes forthcoming].

Finally 4 abstracts have been presented at the recent NADA meeting (January 2004), and are reproduced here in their entirety because of their relevance:

#1: 18 months and 1800 visits in SLICK ( Screening for Limbs, I-Eyes, Cardiac and Kidneys) Ellen Toth, Sylvia Gladue, Lorraine Trojan, David Strong, Mark Greve, Matt Tennant, Audrey Inoue and the ICADI (Implementation Committee of the Aboriginal Diabetes Initiative). Alberta First Nations, University of Alberta and Health Canada.

SLICK operates two vans that have traveled to all 44 of Alberta's First Nations Communities for the purposes of implementing the Canadian Diabetes Association Clinical Practice Guidelines for screening for control and complications. 1508 unique clients have been seen to July 2003, of whom 1151 had diabetes previously diagnosed, and 357 attended to get screened for diabetes. Of those with diabetes 52% had retinal photographs taken of whom 25% had never had a previous dilated retinal exam and 16% had not had an exam in greater than 2 years. In those individuals the incidence of retinopathy was 7% and 4% respectively. Overall, 70% had normal retinal examinations and could be reassured.

Complications such as obesity, cardiac risk factors, foot abnormalities, and urine protein leakage, were relatively high. This workshop will cover: # 1. General description and acceptance of SLICK, # 2. Quality Assurance in SLICK, # 3. Main results of SLICK, # 4. Clients wishing to be tested for diabetes ("Non-SLICK"), #5. Follow up in SLICK.

SLICK has received a successful evaluation and on-going funding.

Start up funding from CHIPP (Canadian Health Infostructure Partnership Program)

#2: Screening for Diabetes and it's complications as part of the Alberta Diabetes Strategy. Ellen Toth, Dawn Friesen, Phil Burke, Terri Gammer. University of Alberta and Alberta Health and Wellness.

In May 2003 Minister Gary Mar announced the 10 year Alberta Diabetes Strategy, comprising four components of which one was to provide resources for "screening for diabetes and it's complications" in aboriginal 'off reserve' and remote Alberta communities.

A specialized team will travel to Métis Settlements and other remote communities in a van transporting portable testing equipment and a retinal camera. Screening of clients with known diabetes will include retinal photography, and lab testing for A_1C, lipids and microalbuminuria. Consenting individuals wishing to be screened for diabetes will be pre-screened with portable technology and a pre-specified protocol. Comparisons will be made to fasting venous glucose (the standard). Individual counseling will be provided to all clients by a certified diabetes educator.

The burden of diabetes is greater in aboriginals and those who are geographically and socio-economically disadvantaged. The Alberta Diabetes Strategy recognizes this disparity and will take steps to re-dress the inequity.

Funded by Alberta Health and Wellness

#3: Screening for Diabetes in Aboriginal Populations. Is it really a good idea? Sharona Supernault, Norry Kaler, Ellen Toth. University of Alberta and British Columbia.

Screening individuals or communities to find undiagnosed diabetes may be a good idea because:

1. There is a lot of undiagnosed diabetes
2. Diabetes is easy and relatively cheap to test for
3. Diagnosis might mean good treatment can be provided
4. Good treatment might mean prevention of harmful and costly complications

Screening individuals or communities to find undiagnosed diabetes may be a bad idea because:

1. There might not be access to good treatment
2. There is no proof that earlier diagnosis leads to better treatment, less complications, or less costs
3. Individuals may not want to know if they have diabetes: they may fear labeling, consequences at work, or at home.
4. Communities may feel vulnerable and exposed.

Every person and community should have the opportunity to explore these issues

#4: Feasibility of Screening for diabetes in Aboriginal populations in Alberta - The BRAID Study (Believing we can Reduce Aboriginal Incidence of Diabetes) Norry Kaler, Ellen Toth, University of Alberta

Introduction: It is estimated that one in four First Nations people over the age of 45 have diabetes. Diabetes prevalence rates underestimate the rates of existing diabetes by as much as 50%. In addition, diabetes is preceded by impaired glucose tolerance, a stage of carbohydrate intolerance that has been shown to be manageable by lifestyle or pharmacologic interventions. Preventing glucose intolerance from progressing to full blown diabetes may prove cost effective. However methods to detect glucose intolerance in widespread screening programs are cumbersome because they either involve fasting (fasting glucose and glucose tolerance tests) or are not standardized (hemoglobin A_1C). Insulin resistance underlies glucose intolerance and diabetes.

Project: The ¹³C Breath Test is a novel test that is effective at detecting diabetes, and is highly correlated with insulin resistance in recently conducted insulin clamp studies. We have conducted ¹³C Breath Tests in 50 aboriginal individuals without pre-existing diabetes. Breath test results correlated strongly with weight, waist circumference, BMI, and fasting glucose, but not with A_1C.

Significance: This project aims to establish the role of the ¹³C Breath Test in a screening protocol for Type 2 diabetes. Comparisons with venous glucose levels are planned, as well as long term follow up. This data will help communities in their efforts to resources for diabetes prevention.

Supported by ACADRE / CIHR

As the above abstracts show, the work initiated in SLICK is expanding to other areas. The province of Alberta is funding a "SLICK - like" initiative off reserve in Métis Settlements and other remote communities, and including a screening for diabetes component, which is much wished for in communities, including those involved in SLICK. The collaboration and relationships built up in SLICK between the University and the Communities allows exploration of new, relevant projects, while not abandoning SLICK continuation and renewal.

7.0 References

Greenhalgh PM. Shared care for diabetes. A systematic review. Br J Gen Pract; 67: 1-35, 1994.

Jacobs P. Blanchard JF. James RC. Depew N. Excess costs of diabetes in the Aboriginal population of Manitoba, Canada. Canadian Journal of Public Health. Revue Canadienne de Sante Publique. 91(4):298-301, Jul-Aug 2000

Blanchard J, Green C et al. Projecting future diabetes prevalence in Manitoba First Nations. 4th International Conference on Diabetes and Aboriginal People, San Diego, 1997.

Tenant MTS, Rudnisky CJ, Hinz BJ, MacDonald IM, Greve MDJ. Tele-Ophthalmology via Stereoscopic Digital Imaging: A Pilot Project. Diabetes Technology and Therapeutics: 2(4), p 583...2000.

Young TK. National Steering Committee for the First Nations and Inuit Regional Health Survey. Final Report, 1999.

Appendix

Clinical Outcomes

All data presented below must be viewed in the context of a potentially biased sample of clients. Degree of control or complications could be higher in this sample recruited by community workers who could have selected the clients about whom they were most concerned. On the other hand, denial with respect to diabetes and its complications is high in these populations as it is in others, which may be responsible for lack of attendance of those with most difficulties. Ultimately, clients presenting to the SLICK vans were volunteers, representing roughly 25% of clients believed to have diabetes in these communities* . Data presented are from the 3 SLICK databases generated: the "clinical database" collects personal identifiers, demographic variables, details of diabetes diagnosis and treatment, some historical clinical factors (e.g. history of gestational diabetes in women), and clinical exam results, and lab results during the SLICK visit. The "survey" database includes the responses to a 53-item questionnaire administered at first visits, regarding experiences with health services for diabetes, history of screening activities for complications, presence of complications, treatments for complications, knowledge of diabetes, and one indicator of socio-economic status (degree of schooling). Finally, results of ophthalmology screening (retinal photography) are entered into the "ophthalmology database".

1. Diabetes Control and Complications

Poor glycemic control has been shown to be closely related to the onset and prevalence of the secondary complications of diabetes. The graph below s show s blood sugar control in a range of age groups spanning 10 to 90 years . can't see age ranges ... by Treaty region at their initial visit. In each age group it can be seen that poor glycemic control is manifested in all age groups . and in all Treaty regions. Overall, metabolic control of diabetes as indicated by a hemoglobin A_1C of < or > than 7% high blood glucose levels was seen in 38.5 % of clients. While 7% is the cut-off for "good" control recently advocated in the revised Canadian Diabetes Association clinical practi ce g uidelines, Males and females had equally poor control of their diabetes.

2. Obesity as a risk factor for cardiovascular complications

Body Mass Index (BMI) is calculated by dividing the body weight in kilograms by the square of the height in meters. This index correlates well with body fat when age is considered as well and waist size. In this population there is a tendency for central fat distribution since the average waist size for both men and women is 110 cm putting 94.5% of women and 73.7% of men at risk for cardiovascular complications. Normal waist circumferences are <88 and <102 cms for women and men respectively. Unfortunately, the mere presence of diabetes regardless of weight or waist circumference already puts this population at great cardiovascular risk. In this population of clients, therefore, aggressive secondary intervention is required.

Ideal = BMI < 25 kg/m²
Overweight = BMI > 25 and < 30 kg/m²
Very overweight (obese) = BMI > 30 kg/m²

One-third of SLICK clients have had heart or circulatory problems. Sixteen percent had had a heart attack (significantly more prevalent in males than females) and six percent had had a heart operation.

3. Dyslipidemia

The majority of SLICK clients, males and females, had unfavorable cholesterol profiles. Approximately half of clients had high total cholesterol levels and a significant portion of the population (44.2%) had low levels of "good" cholesterol (HDL). Only 36.4% of clients had favorable ratios of total cholesterol to HDL (high density lipids). Dyslipdemia appears to be a significant problem in this population. About one in five survey respondents were on prescription medicine for high cholesterol at the initial visit. For every person who had a previous diagnosis of hyperlipidemia there was one new finding of abnormal values.

4. Blood Pressure

A diagnosis of hypertension requires several successive measurements of consistently high pressure. Since these statistics were based on the initial visit only, the reading must be interpreted with caution. Approximately one-third or 36.3% of SLICK clients at first visit, were found to have high blood pressure. Over one half of all clients had a reading that was higher than the range which is recommended (less than 130 / 80) as a target for diabetic individuals Despite the fact that the majority of female clients had a waist circumference that put them at risk for hypertension, the proportion of females with a high blood pressure reading was significantly lower than the proportion of male clients with a similar reading. Approximately half of the SLICK clients had previously been diagnosed with high blood pressure and 41% were on anti-hypertensive medication at the initial visit.

5. Kidney Complications

Two tests were used in SLICK to measure urine protein. In the absence of white blood cells, the urine dipstick can detect the presence of large proteins in the urine. Based on this test, male clients had significantly more protein detected than female clients. A greater portion of males also had abnormal levels of smaller proteins (microalbuminuria) detected in the urine. Approximately one-third of females had abnormal microalbumin / creatinine ratios compared to approximately one-half of males. These results suggest that male clients are at greater risk for diabetic nephropathy

Infections, such as urinary tract infections, are more common in the diabetic population in general. More female clients (19.2%) were found to have a possible urinary tract infection by having greater than 25 white blood cells on a urine dipstick, compared to 4.6% for males.

Only 15.5% of clients were previously identified by the survey as having kidney problems, and only half of that group (7.7%) reported receiving treatment for kidney problems. This suggests that many individuals had undiagnosed kidney complications which were discovered with this screening project. Screening for microalbuminuria could serve as a key factor in identifying early nephropathy in this population.

SLICK screening for protein in the urine of clients is shown.. Microalbuminuria, in yellow, as an early marker of diabetic nephropathy was found in a high proportion of age groups from 30 to 79 years, second only to those identified as having normal urine protein levels. This finding is particularly significant, in that it had not been seen previously and that, at this stage, is reversible. Therefore, follow-up care has the potential to significantly reduce the prevalence of this complication in the population. Unfortunately significant proteinuria (or macroalbuminuria, in red, indicates likely irreversible kidney function and the future requirement for dialysis or transplantation. Nevertheless even in this population intensive management of blood pressure, glucose and cardiovascular risk can significantly reduce morbidity, delaying need for renal replacement therapy.

The next graph shows the protein in the urine findings compared to control of blood glucose. Those clients in good glycemic control are shown on the left side of the graphs (first four columns) while those with poor glycemic control are shown on the right. These data suggest a correlation between glycemic control the prevalence of factors which lead to diabetic nephropathy.

Limb Complications

Next are shown the prevalence of foot complications in First Nation communities in Alberta. Overall, two thirds of SLICK clients had no abnormality detected on their initial foot exam and approximately one in five were found to be in the moderate to high-risk categories with sensory loss, foot deformities or ulcers. Men were significantly more likely to have foot complications associated with diabetes.

Individuals in risk category 1 have some sensory loss and require preventive care including frequent foot inspection, management of callouses, in-grown toenails, etc. Risk category 2 (orange, 16.2%) individuals have deformities that likely require protective footwear. Individuals in category 3 (red, 4.5%) already have had amputation or are presently affected by foot ulcers.

Degree of abnormal foot exams are shown in relation to categories of glucose control, once again indicating that better control of diabetes is more likely to be associated with better foot exam status.

I-Eye Complications

Three in four clients (green bars) showed no signs of retinopathy. The red bars show clients who were found to have retinopathy at their initial SLICK visit. Of this group, more males than females showed signs of retinopathy (34.8% vs. 24.4%) respectively. About half of SLICK clients seen at the initial visit were not screened for retinopathy. Reasons for this included: screening was not indicated based on previous exams, consent was not granted due to fear of side effects from eye drops, ie. blurred vision, importance of retinopathy screening was not emphasized or technical difficulties may have been experienced.

Only approximately 10% of clients photographed needed to be referred to a tertiary care center for treatment (7%) or for photography (3% technically inadequate photos), meaning that the program could successfully manage 90% of clients by this form of "telehealth".

The following 2 photographs show different degrees of retinal abnormalities. The first shows a hemorrhage, which could be followed remotely to determine the need for laser therapy, the second shows severe retinal damage that may benefit from eye surgery (vitrectomy).

Once again the influence of glycemic control on presence or absence of retinopathy is shown:

In summary these baseline data show an expected but significant degree of complications of diabetes in First Nations clients attending the SLICK vans. The challenge then is to monitor these abnormalities, and attempt to intervene. SLICK presently has good resources and is well set up to deal with the retinal complications, reducing morbidity and the chances of blindness significantly. Improving diabetes control and decreasing the other complications is a more daunting task that requires the efforts of multiple players. First and foremost the patient, having received appropriate counseling and support and education about diabetes, needs to become a central driving force in his or her health care team. Education about diabetes complications avoidance must be available, continued access to regular screening for the degree of complications must continue, and physician and health professional resources must be available to manage glycemic control, blood pressure, lipids, and other risk factors or behaviours.¹

Research Questions
Do we need this if it has been addressed in an evaluation of the goals?

(Please refer to the Evaluation Model below)

The overall purpose of the evaluation is to establish whether SLICK is a worthwhile program, to assess its efficiency, effectiveness and efficacy, and to determine if the program activities lead to the goals and outcomes outlined. The evaluation will therefore aim to answer the following questions:

1. How have knowledge and attitudes about diabetes and diabetes health care services changed among clients, providers and community leaders since the onset of the SLICK program?
2. How have behaviours related to diabetes care changed among clients since the onset of the SLICK program?
3. How has the quality of life of SLICK clients changed since the onset of the program?
4. How satisfied with the SLICK program are clients, providers (CHNs, CHRs, General Practitioners/Family Doctors, Ophthalmologists, Nutritionists), community leaders (Health Directors, Chiefs) and administration (Implementation Committee, Alberta Health and Wellness, Regional Health Authorities) with the program? How do these groups feel about the accessibility, quality and quantity of services, about the technology used, and about privacy issues? What complaints and suggestions do these groups have about the program?
5. Has this program been cost effective?
6. How do the clinical outcomes of diabetes compare before and after the SLICK program?
7. What are the characteristics of SLICK clients and providers, and what are the administrative outcomes of the program?

Evaluation Model

View Table - Purpose of evaluation: To determine if the SLICK Program is worthwhile and explore its efficiency, effectiveness and efficacy.

Endnotes