Prediabetes and Type 2 Diabetes

Care for People of All Ages

Resources The Quality Standard In Brief Advisory Committee About

Summary

The following quality standard addresses care for children and adults who are at risk of developing prediabetes or type 2 diabetes or who already have a diagnosis of either.

It includes the assessment, diagnosis, and management of prediabetes and type 2 diabetes. It applies to all settings.

This quality standard does not include guidance on prevention efforts for the general public, although it does provide advice on how to prevent progression from prediabetes to type 2 diabetes.

Scope of This Quality Standard

This quality standard addresses care for children and adults who are at risk of developing prediabetes or type 2 diabetes or who already have a diagnosis of either. It does not address the prevention of type 2 diabetes in the general population, although it does provide guidance on risks and lifestyle factors that may affect the progression from prediabetes to type 2 diabetes.

This quality standard applies to all settings.

This quality standard does not include care for pregnant people with type 2 diabetes. For a quality standard that addresses care for people with type 1 or type 2 diabetes who become pregnant, or people diagnosed with gestational diabetes, please refer to the Diabetes in Pregnancy quality standard.

This quality standard includes nine quality statements on areas identified by the Type 2 Diabetes Quality Standard Advisory Committee and several health and social service organizations working with Indigenous populations as having high potential to improve the quality of care in Ontario for people at risk for or living with prediabetes and type 2 diabetes.

Why This Quality Standard Is Needed

Diabetes is a chronic disease characterized by hyperglycemia. It can lead to serious complications, a diminished quality of life, and a substantially reduced life expectancy. In 2019, an estimated 4.4 million Ontarians were living with diabetes and prediabetes (type 1 diabetes, diagnosed and undiagnosed type 2 diabetes, and prediabetes combined). Treating diabetes and its complications is estimated to cost the health care system $1.5 billion in direct costs. Roughly 90% of all cases of diabetes are type 2 diabetes.

People with diabetes are at risk of developing serious, acute complications (e.g., severe hypoglycemia); long-term microvascular complications affecting the eyes, kidneys, and nerves; and cardiovascular disease. Keeping blood glucose levels in the target range and a healthy, balanced diet and physical activity are essential for managing type 2 diabetes and reducing the risk of acute and chronic complications.

The factors that increase the risk of type 2 diabetes are multifaceted and can be social as well as genetic/biological. Certain populations experience higher rates of type 2 diabetes, such as those with low income; people of African, Arab, South Asian, or Hispanic descent; and Indigenous populations. One Canadian survey from 2011 found that participants in the lowest income group had roughly four times the prevalence of type 2 diabetes than those in the highest income group. In Ontario, the prevalence of self-reported diabetes is roughly twice as high for South Asian people (8.1%) and Black people (8.5%) as it is for White people (4.2%). Indigenous populations are three to five times more likely to have type 2 diabetes than are non-Indigenous Canadians.

In addition to disparities in the rates of type 2 diabetes across specific populations, there are also variations in the rates of diabetes-related outcomes across Ontario’s geographical regions. Hospitalizations for cardiovascular conditions, chronic dialysis or kidney transplant, and lower-extremity amputation were highest in northern Ontario, particularly among First Nations communities, and in predominantly rural areas in southern Ontario (between 2006/07 and 2010/11). Data from 2017/18 show that the rates of amputation among people with type 2 diabetes was 35 times higher in the James and Hudson Bay Coasts sub-region than in the Eastern York Region sub-region, which had the lowest rates of amputation (Discharge Abstract Database [DAD], provided by the Institute for Clinical Health Sciences [ICES]).

Emergency department visits for type 2 diabetes and associated complications also varied significantly across the province: In 2017/18, the Scarborough South sub-region had rates 25 times higher than the Bolton-Caledon sub-region (National Ambulatory Care Reporting System). In the same year, the James and Hudson Bay Coasts sub-region had the highest rate of hospital readmissions for type 2 diabetes and associated complications when compared with other sub-regions. The James and Hudson Bay Coasts and Northern sub-regions also had the highest rates of inpatient hospital discharge for people with a recorded diagnosis of type 2 diabetes (Discharge Abstract Database, extracted using IntelliHealth).

This quality standard focuses on the needs of all people with type 2 diabetes, with particular consideration given to the populations that are more susceptible to type 2 diabetes and its associated complications. Based on evidence, consultations with people who have type 2 diabetes, and clinical expert consensus, the nine quality statements that make up this quality standard provide guidance on high-quality care. Accompanying indicators will help care providers and organizations monitor and improve the quality of care for people with prediabetes and type 2 diabetes living in Ontario.

Our Population-Focused Approach

We used a population-focused approach to better understand the experiences and needs of populations with the highest prediabetes and type 2 diabetes burden and greatest gaps in access to diabetes care (based on a review of the literature): Indigenous, Black, South Asian, and other racialized populations, and populations living on a low income. Ontario Health undertook three approaches:

Strategically selecting participants for the quality standard advisory committee to include people with expertise and experience in working with communities at greater risk for prediabetes and type 2 diabetes
Using culturally sensitive and safe clinical practice guidelines
Consulting with Indigenous organizations and Indigenous health care delivery partners

The consultations we undertook were not exhaustive; but within our established time frame for quality standard development, we engaged a range of partners: The Indigenous Primary Health Care Council, Ontario Federation of Indigenous Friendship Centers, Métis Nation of Ontario, Ontario Native Women’s Association, Sioux Lookout First Nations Health Authority, and Weeneebayko Area Health Authority. We consulted these partners before each meeting of the quality standard advisory committee and presented recommendations from these consultations to the committee. These consultations resulted in content that better reflects the experiences and needs of Indigenous people, including:

Adding a quality statement
Expanding the principles and values section
Rewording sections of the quality standard
Revising the patient guide

In addition to our consultations with organizations serving Indigenous communities, we received feedback and guidance from the Alliance for Healthier Communities and community health centres for perspectives on how to best meet the needs of low-income, racialized, and specifically Black and South Asian populations.

Values That Are the Foundation of This Quality Standard

This quality standard was created, and should be implemented, according to the Patient Declaration of Values for Ontario. This declaration “is a vision that articulates a path toward patient partnership across the health care system in Ontario. It describes a set of foundational principles that are considered from the perspective of Ontario patients, and serves as a guidance document for those involved in our health care system.”

These values are:

Respect and dignity
Empathy and compassion
Accountability
Transparency
Equity and engagement

People with prediabetes and type 2 diabetes benefit from care providers or care teams with the knowledge, skills, and judgment to provide evidence-based treatment for prediabetes and type 2 diabetes while also addressing all health care needs. The goal of management is to improve symptoms; reduce or delay complications associated with type 2 diabetes; and improve function, quality of life, and prognosis.

People with prediabetes and type 2 diabetes also benefit from relationships with care providers who respect their priorities and recognize their diversity and specific needs, and who have the capacity to address the social determinants of health. Care providers should consider that many of the lifestyle factors that put people with prediabetes and type 2 diabetes at risk of complications, such as diet, physical activity levels, and stress, are driven by the social determinants of health—a person’s income, employment, physical and geographical ability to access healthy and affordable food, and experiences of discrimination. Care providers can better support people with prediabetes and type 2 diabetes by acknowledging that some of these barriers may make it harder for some people than others to follow a healthy diet, lose weight, or increase physical activity levels.

Management of prediabetes and type 2 diabetes in Indigenous populations should follow the same guidance as those for the general population. However, care providers should be aware of the historical context of the lives of Indigenous Peoples throughout Canada and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities, as well as recognizing their strength and resilience. Approaches to care can include holistic healing and healers for people and communities and should be tailored to address these needs.

The residential school experience, Indian hospitals, the Sixties Scoop, and other policies of colonization have had negative effects on the health of survivors and their descendants. Some residual health effects include stunted growth, greater insulin sensitivity, lowered metabolic rate, increased gestational complications in people who are pregnant, and lowered immune system development and function. Accumulatively, these physical effects, combined with trauma and ongoing discrimination, have led to increased rates of obesity and made Indigenous people more prone to developing prediabetes and type 2 diabetes.

How to Use This Quality Standard

Quality standards inform patients, clinicians, and organizations about what high-quality care looks like for health conditions or processes deemed a priority for quality improvement in Ontario. They are based on the best evidence.

Guidance on how to use quality standards and their associated resources is included below.

For People With Prediabetes or Type 2 Diabetes

This quality standard consists of quality statements. These describe what high-quality care looks like for people who are at risk of developing or who have prediabetes or type 2 diabetes.

Within each quality statement, we’ve included information on what these statements mean for you, as someone with prediabetes or type 2 diabetes.

In addition, you may want to download the accompanying patient guide on type 2 diabetes, to help you and your family have informed conversations with your health care providers. Inside, you will find questions you may want to ask as you work together to make a plan for your care.

For Care Providers and Organizations

The quality statements within this quality standard describe what high-quality care looks like for people who are at risk of developing or who have prediabetes or type 2 diabetes.

They are based on the best evidence and designed to help you know what to do to reduce gaps and variations in care.

Many care providers and organizations are already providing high-quality evidence-based care. However, there may be elements of your care that can be improved. This quality standard can serve as a resource to help you prioritize and measure improvement efforts.

Tools and resources to support you in your quality improvement efforts accompany each quality standard. These resources include indicators and their definitions (Appendix 1) to help you assess the quality of care you are delivering and identify gaps in care and areas for improvement. While it is not mandatory to use or collect data when using a quality standard to improve care, measurement is key to quality improvement.

There are also a number of resources online to help you, including:

Our patient guide on type 2 diabetes, which you can share with patients and families to help them have conversations with you and their other health care providers. Please make the patient guide available where you provide care
Our measurement resources, which include our data tables to help you identify gaps in care and inform your resource planning and improvement efforts, and our measurement guide of technical specifications for the indicators in this standard
Our Getting Started Guide, which includes links to templates and tools to help you put quality standards into practice. This guide shows you how to plan for, implement, and sustain changes in your practice
Quorum, an online community dedicated to improving the quality of care across Ontario. This is a place where health care providers can share information, inform, and support each other, and it includes tools and resources to help you implement the quality statements within each standard
Quality Improvement Plans, which can help your organization outline how it will improve the quality of care provided to your patients, residents, or clients in the coming year
The Health Equity Impact Assessment tool, which can help your organization consider how programs and policies impact population groups differently. This tool can help maximize positive impacts and reduce negative impacts, with an aim of reducing health inequities between population groups

Timeline for This Quality Standard

This quality standard was completed in May 2021.

Evidence to Improve Care