Enhancing virtual care for patients with diabetes and understanding their experiences during the pandemic

How can we deliver quality diabetes care in a virtual environment?

Members of the Division of Endocrinology at St. Michael’s recognized right away that the virus, the public health interventions and the new methods of care delivery would impact people who live with diabetes.

For example, preliminary reports suggested that people with diabetes are at higher risk of dangerous outcomes of COVID-19, such as requiring critical care or ventilation.

Dr. Gillian Booth, Dr. Andrew Advani and Dr. Catherine Yu – three endocrinologists with different research focuses – launched the CONNECT study – short for COVID-19 and Diabetes: Clinical Outcomes and Navigated NEtwork Care Today.

“There was a lot of worry, fear and uncertainty amongst people with diabetes,” said Dr. Advani, who is also a researcher at the Keenan Research Centre for Biomedical Science. “Social distancing measures were introduced and persons with diabetes didn’t have the usual face-to-face contact with their usual support network that is critical for effective self-management.”

The CONNECT study aims to address these potential gaps. It has two parts and involves  physicians in the Department of Medicine, researchers at the Li Ka Shing Knowledge Institute (LKSKI), a diabetes educator, a social worker, people living with diabetes, and researchers from other Toronto hospitals.

The first part addresses the risk of developing COVID-19 for those who are living with diabetes.

“We get a lot of questions from our patients about this,” said Dr. Booth, who is also a scientist at the MAP Centre for Urban Health Solutions. “Using large databases of hospital admissions, we aim to answer this question for our patients of whether diabetes really is a risk factor for poor outcomes from COVID-19 in Canada and, if so, what causes this increased risk.”

The team also hopes to learn whether fear of the virus stopped people with diabetes from accessing emergency care when they needed it. This information, the researchers say, will be useful to prepare for potential future waves of the virus.

The second part involves interviewing patients living with diabetes to learn how to make sure virtual care strategies make sense for them.

“By listening to patient voices, we hope to be able to continually improve the care of persons with diabetes,” said Dr. Catherine Yu, who is also a scientist at the LKSKI. “We hope that, by sharing these experiences, we will be able to help other health-care providers improve the care that they provide too.”

The research team is recruiting team members and aims to work with patients soon.

“It’s clear that virtual care is likely to be part of the fabric of the way health-care is delivered in the future,” Dr. Advani said. “It’s been a steep learning curve and we are all continuing to learn. If some type of virtual care is going to stay with us, we need to learn what works best for health-care providers, patients and their families so that we can deliver the best care, with the best patient experiences and the best outcomes.”

St. Michael’s researchers receive more than $4-million in federal funding to better understand the impact of COVID-19

Three MAP projects were funded in the federal government’s recent, highly competitive COVID research competition: Drs. Sharmistha Mishra, Darrell Tan and Dan Werb. Congratulations also to our Li Ka Shing colleagues Drs. Amol Verma and Fahad Razak!

The federal government is awarding more than $4 million to four research projects from St. Michael’s Hospital exploring questions related to COVID-19.

The funding, announced Thursday, is part of a $109M investment over one year for COVID-19 research. This will support 139 research teams across Canada and will focus on accelerating the development, testing, and implementation of measures to mitigate the rapid spread of COVID-19 and its negative consequences on people, communities, and health systems.

These projects will explore why COVID-19 unfolded differently across Canadian provinces, how a short course of medication might help people recently exposed to COVID-19, what data can tell us about how to organize hospital services to produce better outcomes for COVID-19 patients, and how services might be adjusted to prevent drug overdoses during the pandemic.

The Government of Canada is providing the funding through CIHR and the International Development Research Centre (IDRC), in partnership with Alberta Innovates (AI), Michael Smith Foundation for Health Research (MSFHR), Research Manitoba (RM), Research Nova Scotia (RNS), Saskatchewan Health Research Foundation (SHRF), and the New Brunswick Health Research Foundation (NBHRF).

Here is a closer look at the MAP research projects:

Examining the different provincial responses to the pandemic

Dr. Sharmistha Mishra

Dr. Sharmistha Mishra, a Scientist at the Li Ka Shing Knowledge Institute (LKSKI), will study and compare how COVID-19 unfolded across Canadian provinces to better understand which populations are most at-risk. Using available data to examine the impact of public health measures on certain population groups in the first wave of the pandemic can inform the way we respond to future waves. Learn more

Can a short course of medication prevent COVID-19 infection in people exposed to the virus?

Dr. Darrell Tan

This project, led by Dr. Darrell Tan, Scientist at the MAP Centre for Urban Health Solutions, looks at whether a course of medication may prevent infection in those recently exposed to COVID-19.

The research team will study the efficacy of a prevention strategy called post-exposure prophylaxis (PEP). People who were recently exposed to the virus will take a short course of medication. The goal is to find out if taking an oral medication called lopinavir/ritonavir (LPV/r) – which is currently used as PEP for HIV exposure – for 14 days will prevent further infection.

They will use an innovative ‘ring’-based study design, a method used successfully to help eradicate smallpox and evaluate a vaccine for Ebola. For this study, a ‘ring’ is defined as exposed contacts around confirmed COVID-19 cases. These rings will then be randomized to either the study drug or control (no study drug) condition.

If the trial is effective, this strategy could be immediately implemented both in Canada and around the world as the drug is globally available. Learn more

How has the pandemic impacted access to care for people who inject drugs?

Dr. Daniel Werb

The COVID-19 pandemic impeded the ability of people who inject drugs to access proper services that could help them avoid illness or death, including safe injection sites and clinics that provide addiction treatment and access to stable housing.

Researchers noted a spike in overdoses in March and April 2020, which interrupted a yearlong trend of declining overdoses. While this spike appeared to be related to the pandemic, there was no evidence to prove the relationship. This project will aim to better understand how people who inject drugs have been impacted by COVID-19 and how support services can support this population during the pandemic.

This project, led by Dr. Daniel Werb, a Scientist at the MAP Centre for Urban Health Solutions, will use unique access to clinical data of people who inject drugs in Canada to examine the ways that the pandemic affects this group of people by assessing their clinical outcomes to people’s self-reported behaviors.

This research will help identify who is at highest risk of both COVID-19 and overdose and how those risks interact. It will also track how social distancing measures impact people who inject drugs who want to use services to prevent overdose in Toronto, such as addictions treatment access, supervised injection services, and street drug checking. Learn more

Toronto’s COVID-19 divide: The city’s northwest corner has been ‘failed by the system’

This excellent Toronto Star piece includes interviews with three MAP scientists: Drs. Jim Dunn, Stephen Hwang, and Rick Glazier. It also refers to our report on primary care gaps in Ontario, and includes maps from our Ontario Community Health Profiles Partnership website.

When Toronto Public Health released its map of neighbourhoods hardest hit by COVID-19, for people in the city’s northwest it felt like déjà vu.

It looked strikingly similar to the map showing where chronic diseases like diabetes are highest. It mirrored a 2014 report highlighting Toronto neighbourhoods facing the biggest social and economic disadvantages. It might as well have been any number of maps showing some of the city’s highest concentrations of poverty in highrises or lowest post-secondary education.

Every time, the same northwest neighbourhoods pop out — a cluster of communities spanning a large swath of Toronto, wedged between Dufferin St. and Highway 427 to the west, running south from Steeles Ave. to Eglinton Ave.

…When Ontario researchers examined the geography of primary care gaps in the province, they found that areas of the province with the highest needs were getting the lowest levels of care. In Toronto, those areas clustered in the city’s northwest corner and in south Scarborough.

“You’ve got a lot of poverty of opportunities and of services, and some of (that) is lack of health care,” said Dr. Rick Glazier, a senior scientist at ICES and the lead author of the 2018 report.

Access to a family physician has been vital in the pandemic, Glazier noted — especially in the early months when it was difficult to get tested. Primary care doctors and nurses were crucial in providing advice on how to get tested, how to self-isolate, or when go to the emergency department.

The northwest has strong Community Health Centres, which offer a unique model of care and have deep roots in these neighbourhoods. CHCs like Rexdale and Black Creek are mandated to address the health of the community and the social determinants of health, and serve anyone who needs care, even if they are uninsured.

“I can’t say enough wonderful things about them,” said Glazier, a family doctor himself. But he added that they cover a small proportion of the population, and underserviced areas need more.

Unity Health Toronto experts issue help guide Ontario’s back to school plans

A group of pediatric health experts is advising the Ontario government how to help children get back to school safely in the fall.

The group, which is led by SickKids and includes MAP scientist Dr. Sloane Freeman, pored over evidence around COVID-19 risk to children and developed a guidance document for the safe reopening of schools. The document also examines the impact of the pandemic on children and youth.

Toronto Trailblazers 2020: Janet Smylie is tracking COVID-19 in Indigenous communities

One of Canada’s first Métis physicians is leading the charge in assessing the pandemic’s impact on people who live both on- and off-reserve

For over 25 years, Janet Smylie, one of Canada’s first Métis doctors, has made it her mission to bring awareness to the injustices faced by the Indigenous community and to foster progress in the country’s health-care system.

Not only has she practised and taught medicine in urban, rural and remote Indigenous communities, but Smylie developed and directs Well Living House, the Indigenous health research unit at St. Michael’s Hospital in Toronto. There, she is also a public health researcher at the Centre for Urban Health Solutions, and holds a Canadian Institutes of Health Research Applied Public Health Research Chair in Indigenous Health Knowledge and Information – all the while continuing her work as a staff physician.

Having grown up in a large family that always encouraged advocating for your people and speaking out on injustice, Smylie was raised to be a torchbearer.

“Much of my family had already done a lot of heavy lifting in their lives, which meant I grew up with opportunities and privileges that mitigated some of the harms linked to anti-Indigenous racism and gender inequality,” she says. “I ended up not really understanding why we have a society in which some people are devalued and have less access to social resources because of gender, identity, race, ethnicity, economic status, sexual orientation, ability.

“Of course I get many of the ‘isms’ – I have my intersectional share of them as a two-spirited Métis mother and grandmother,” she continues, “but at a fundamental level, I still try and question, ‘Why does it have to be this way?’  The tension between the values I was brought up with and the day-to-day injustices fuels my commitment to action.”

Racial disparities of COVID-19 are a consequence of racist social structures

Dr. LaRon E. Nelson recently coauthored the paper Understanding COVID-19 Risks and Vulnerabilities among Black Communities in America: The Lethal Force of Syndemics for the journal Annals of Epidemiology. The term ‘syndemic’ refers to a set of two or more interacting afflictions that result in a disproportionate burden on a population. 

“Black communities are bearing the brunt of COVID-19 throughout the United States,” Nelson said. “The data show that we are not all at equal risk during this pandemic, and this is a racialized disease.”

The paper discusses how multiple historical and current factors are responsible for the Black community experiencing the lethal force of COVID-19. Conditions such as chattel slavery, mortgage redlining practices, political gerrymandering, employment discrimination, healthcare provider biases, and a lack of Medicaid expansion are manifestations of the structural racism that all contribute to this result.