Vulnerable Populations/Population Health

Diverse group of peopleProgram Leader: Dr. Lorraine Lipscombe

The program expands and strengthens the impact of the knowledge generated by the core group of University of Toronto-based diabetes population health scientists by bringing together front-line clinicians and public health and policy researchers to help frame research questions, and directly shape health policy. Key areas of focus are:

  • Identifying strategies to improve outcomes in socially disadvantaged populations with diabetes or at risk for diabetes;
  • Identifying priorities and building capacity for high quality research in diabetes population health; and
  • Informing changes in clinical practice and health system policies that affect these populations in Canada.

Program Activities

The BBDC Vulnerable Populations/Population Health Group is working closely with Diabetes Action Canada on a number of population health initiatives:

  1. Identifying Individuals at Risk

In our current health care system, many individuals with diabetes miss out on screening and early treatment of complications. Further, a disproportionate burden of diabetes complications are seen in lower income groups and other vulnerable populations.

SOLUTION:  Identify more efficient and effective health system strategies to promote optimal diabetes care and self-management, and engage individuals at potential risk for complications directly to seek screening, early treatment for complications and improved self-management.

  1. Identify health system solutions to support complex diabetes care

With increasing complexity of diabetes care and multiple competing demands, primary care teams have difficulty tracking the surveillance of diabetes complications and outcomes.

 SOLUTION:  Provide technology solutions for improved communication between the individual patient and primary care team to continually identify risk factors and timely interventions to improve outcomes (e.g. EMR-linked dashboard alerts, mobile apps that link to lab results and self-monitoring tools).

  1. Address determinants of health that contribute to poorer diabetes outcomes
    Social determinants that are not adequately addressed by the health care system often have the greatest impact on diabetes and its related outcomes.. These include socio-economic, cultural, geographic and other factors that affect health outcomes.

 SOLUTION: Identify health policies to optimize access to treatment, preventive and social services, and improve health system integration with community-engaged leadership and services including housing, food security, family responsibilities, transportation, to name a few.

  1. Effect Health System Change through Strategic Partnering to Leverage Existing Resources

Using linked administrative healthcare data, the Institute for Clinical and Evaluative Science (ICES) has established algorithms to identify the vast majority of Ontarians with the diagnosis of diabetes and related risk factors as well as other chronic conditions that increase overall risk and health system cost. Our group has been working on innovative ways to expand data holdings to obtain richer information regarding the population with diabetes. We plan to establish population data repositories for diabetes support innovative observational studies and pragmatic clinical trials that will evaluate new models of care to improve the health of patients with diabetes. To date, no data-informed solutions have emerged for improving outcomes for persons living with diabetes and its related complications.

 SOLUTION: Build on existing partnerships and collaborations with provincial and national organizations and policymakers that collect data for individuals with a diagnosis of diabetes, to create a communication strategy that would provide patients and providers with the information necessary to engage in the above solutions.