Opportunities to improve diabetes care in the hemodialysis unit: A cohort study in Ontario, Canada

Background: Patients with diabetes receiving chronic in-centre hemodialysis face healthcare challenges. We examined the prevalence of gaps in their diabetes care, explored regional differences, and determined predictors of care gaps. Methods: We conducted a population-based retrospective study between January 1 2016 and January 1 2018 in Ontario Canada. We included adults with prevalent diabetes mellitus receiving in-centre hemodialysis as of January 1 2018 and examined the proportion with 1) insufficient or excessive glycemic monitoring, 2) suboptimal screening for diabetes-related complications (retinopathy and cardiovascular screening), 3) hospital encounters for hypo- or hyperglycemia, and 4) hospital encounters for hypertension in the 2 years prior (January 1 2016-January 1 2018). We then identified patient, provider and health system factors associated with >1 care gap and used multivariable logistic regression to determine predictors. Further, we used Geographic Information Systems to explore spatial variation in gaps. Results: There were 4,173 patients with diabetes receiving in-centre hemodialysis. Mean age was 67 years, 39% were women and the majority were of lower socioeconomic status. Approximately 42% of patients had >1 diabetes care gap, the most common being suboptimal retinopathy screening (53%). Significant predictors of more than one gap included younger age, female sex, shorter duration of diabetes, dementia, fewer specialist visits and not seeing a physician for diabetes. There was evidence of spatial variation in care gaps across our region. Conclusions: There are opportunities to improve diabetes care in patients receiving in-centre hemodialysis, particularly screening for retinopathy. Focused efforts to bring diabetes support to high-risk individuals might improve their care and outcomes.