Opportunities To Improve Diabetes Care in the Hemodialysis Unit: A Cohort Study in Ontario, Canada

Background: Patients with diabetes receiving chronic, in-center 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-center 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 to January 1, 2018). We then identified patient, provider, and health-system factors associated with more than one 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 4173 patients with diabetes receiving in-center hemodialysis; the mean age was 67 years, 39% were women, and the majority were of lower socioeconomic status. Approximately 42% of patients had more than one 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-center hemodialysis, particularly screening for retinopathy. Focused efforts to bring diabetes support to high-risk individuals might improve their care and outcomes.