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Chronic Disease Management in Ontario (Diabetes)

  • dunnettc
  • Mar 10
  • 6 min read

Chronic diseases pose many challenges both to the individual living with them and to our healthcare system.  In Ontario, approximately 1.5 million people are living with Diabetes, 2.4 million if you consider those individuals who are yet to be diagnosed.  This represents a 2.2 billion dollar direct cost to the healthcare system and upwards of 17% of affected household income going towards diabetes care and management (Diabetes Canada, 2024).


Diabetes management requires a collective group of health care practitioners, and a willing patient to be successful.  In Ontario there are resources and guidance available to diabetics to help access the resources of primary care, dieticians, ophthalmologists, pharmacists, and centres for complex diabetes care, if required.  Through these resources, individuals are able to manage their chronic disease through diagnosis, lifestyle change, symptom management and prevention of complications all in an effort to minimize the impact on both the individual and the system.

The Growing Burden of Diabetes in Ontario


The prevalence of diabetes in Ontario increased 35% from 2023 to 2024, with 31% of Ontarians living diabetes or pre-diabetes.  When compared to Alberta, the high diabetes complication impact is sadly the same:

  • 30% of Strokes

  • Leading cause of blindness

  • 40% of heart attacks

  • 50% of kidney failure requiring dialysis

  • 70% of all non-traumatic leg and foot amputations


People with diabetes are over three times more likely to be hospitalized with cardiovascular disease, 20 times more likely to be hospitalized with end-stage renal disease, and almost 20 times more likely to be hospitalized for a non-traumatic lower limb amputation compared to the general population.  And the life span is reduced by the same 5-15 years on average (Diabetes Canada, 2024).


Diabetic Care in Ontario


In Ontario there are a number of supports available to those living with diabetes.  These include hard copy tools such as the Diabetes Passport, available in 16 languages.  This tool can assist with keeping individuals organized with their diabetic care, as the document includes all elements of management: care team members, all medications, when various testing should happen and the results, and a section for goal setting (Province of Ontario, 2025).

The Ontario Health Insurance Plan (OHIP) covers the cost of many aspects of care for diabetics including:


  • Visits to registered dietitians working in a Diabetes Education Program in acute care and community care settings.

  • Individuals with diabetes between age 20 and 64 are covered for a complete eye examination by an optometrist or doctor every 12 months, plus any required follow-up (individuals below 20 and over 65 are also covered for a complete eye exam annually).

  • Medically necessary eye care services provided by doctors are covered by OHIP for all diabetes patients.

  • Financial aid for diabetes related medications and supplies are available for those who qualify.

  • Self-management workshops are available across the province free of charge.

  • Additional education sessions are also available both individually or in a group environment free of charge  (Province of Ontario, 2025).


Ontario was one of the first provinces to publicly fund flash glucose monitors and provide broad coverage for all diabetics.  As of November 30, 2021, Ontarians eligible for the Ontario Drug Benefit program with a valid prescription can receive FreeStyle Libre 2 as a benefit (Province of Ontario, 2024).


Despite all of these opportunities for support, as we noted above, there is still a personal financial burden of between $287 and $5245 for those living with diabetes in Ontario (Diabetes Canada, 2024).


Centres for Complex Diabetes Care


If required, there are Centres for Complex Diabetes Care across the Province of Ontario available for patient access.  These centres offer treatment and management of diabetes and related conditions that require a more comprehensive and team based approach.  The centres are designed to help control both diabetes and complications such as chronic kidney disease, cardiovascular disease, diabetic retinopathy, neuropathy and related conditions (province of Ontario, 2025).

Centres can also provide help for people who have experienced repeated visits to an Emergency Room or who have frequent hospitalizations due to poorly controlled diabetes. In addition to case management, the Centres also provide patients and their families with care navigation, individualized care planning, frequent follow-up/monitoring, and transition/discharge planning.

Once an individual’s diabetes are better controlled, they are referred to a Diabetes Education Program or related community-based program for ongoing support, as described above (Trillium Health Partners, 2025).


Who is Most Affected by Diabetes in Ontario?


In Ontario you are more likely to be diagnosed with diabetes if you:


  • are of Indigenous, Asian, South Asian or African descent

  • are overweight (especially if you carry most of your weight around your middle)

  • have a parent, brother or sister with diabetes

  • have health complications associated with diabetes, such as eye, nerve or kidney problems

  • gave birth to a baby weighing more than 4 kg (9 lbs)

  • had diabetes while you were pregnant

  • have a history of impaired glucose tolerance, impaired fasting glucose or pre-diabetes

  • have high blood pressure

  • have high cholesterol or other high levels of fats in the blood

  • use glucocorticoid medication

  • have been diagnosed with any of the following conditions:

  • polycystic ovary syndrome

  • acanthosis nigricans (darkened patches of skin)

  • schizophrenia

  • obstructive sleep apnea (Province of Ontario, 2025)


These risk factors are important to note so that prevention strategies and management programs can be further targeted to at risk populations. 

Innovative Approaches to Diabetes Care in Ontario


In Ontario, steps are being taken to help address and assist those who are more likely to have a diabetes diagnosis.  The growth and complexity of diabetes are exceeding the capacity of family physicians, resulting in the demand for community-based, interprofessional, primary care-led transition clinics (Mathews, 2024). St. Joseph’s healthcare, in London, Ontario has launched a Primary Care Diabetes Support Program.  This innovative approach to diabetes care for high-risk populations, such as medically or socially complex and unattached patients.  Here, a multidisciplinary team focuses on assisting primary care practitioners to build capacity in their practices for diabetes management, as well as empowering patients to become diabetes self-managers (St. Joesph’s Health Care London, 2024).


At Hamilton Health Sciences a program was developed in 2021 called the Surgical Transitions program.  Post-operative patients are able to recover from their surgery at home while being monitored remotely by a virtual care team.  It means patients who may have otherwise had lengthier hospital stays due to co-morbidities such as diabetes, are able to go home and be empowered with support to manage their own care.  This program was developed thanks to provincial funding (Hamilton Health Sciences, 2023).


Diabetes and Surgical Care Impact


How do diabetics impact surgical care? Or, how are diabetics impacted when they require surgery?

In Ontario 1,200 leg and foot amputations are completed annually.  As we determined earlier, 70% of all non-traumatic leg and foot amputations are related to diabetes.  This means 840 amputation surgeries could be avoided each year in this province.  These 840 surgeries represent 140 million dollars in direct amputation health care cost annually (CorHealth, 2021).  This emphasizes the importance of early detection and disease management to avoid diabetes reaching this level of impact.

Additionally, many hospitals offer pre-operative clinic appointments that are often available both in person and virtually depending on the patient’s medical history and co-morbidities.  Any patients who are diabetic are automatically seen in person, increasing the time burden on the system as these appointments are longer and involve more care providers.


Drayton et al. acknowledge in their article Diabetes Mellitus and Perioperative Outcomes: a Scoping Review of the Literature (Drayton, 2022) that diabetes mellitus is frequently encountered in the perioperative period and may increase the risk of adverse perioperative outcomes owing to the potential vascular complications.  However more research is needed to understand this relationship and where targeted interventions will benefit patients most. This is increasingly important as the burden of diabetes increases among surgical patients (Drayton, 2022).


Moving forward – Opportunities in Ontario


Ultimately diabetes can be seen to have significant impact on each patient, their family and the health care system as a whole.  Really great work is happening at a provincial, regional and local level to address care for diabetics and innovative strategies are being implemented at various stages of care.  In order to fully address this chronic disease in Ontario, a few suggestions could be made:

  • Targeted education for the at risk populations pre-diagnosis in an effort to reduce prevalence

  • Strengthening primary care team approach and availability to all diabetics

  • Continue to offer and explore virtual care options to empower patients to take control of their disease

  • Continue to research the impact for diabetics when accessing the healthcare system for procedural and surgical care to ensure more seamless care transitions and recovery


Ontario already has great systems in place, and with additional attention and resource can continue to improve the care of diabetics in the province.

 

References


CorHealth Ontario. (n.d.). Saving lower limbs: Introducing a new Ontario lower-limb preservation strategy. https://www.corhealthontario.ca/WEBINAR_Saving_Lower-Limbs-Introducing_a_new_Ontario_Lower-Limb_Preservation_Strategy-FINAL.pdf

Government of Ontario. (2025, January 23). Preventing and living with diabetes. https://www.ontario.ca/page/preventing-and-living-diabetes



Government of Ontario. (2024, March 9). Ontario providing access to innovative technology for diabetes care. https://news.ontario.ca/en/release/1001234/ontario-providing-access-to-innovative-technology-for-diabetes-care


Mathews, M., Lyons, R., Harris, S., Hedden, L., Choi, Y.-H., Donnan, J., Green, M. E., Harvey, E., Reichert, S. M., Ryan, B., Sibbald, S., & Meredith, L. (2024). Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: Protocol for a multiple-methods study with a convergent parallel design. BMJ Open, 14(6), e088737. https://doi.org/10.1136/bmjopen-2024-088737



Hamilton Health Sciences. (n.d.). Research & innovation. https://www.hamiltonhealthsciences.ca/research-innovation/innovation/


Drayton, D. J., Birch, R. J., D'Souza-Ferrer, C., Ayres, M., Howell, S. J., & Ajjan, R. A. (2022). Diabetes mellitus and perioperative outcomes: A scoping review of the literature. British Journal of Anaesthesia, 128(5), 817–828. https://doi.org/10.1016/j.bja.2022.02.013

 
 
 

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