Epidemiology of Diabetes: Prevalence, Complications and Health Services Disparities

1
Epidemiology of Diabetes Prevalence
Complications and Health Services Disparities

• Rosa Pérez Perdomo MD MPH PhD
• Dean Graduate School of Public Health
• Medical Sciences Campus
• Director of the Diabetes Management Center

2
Diabetes Management Center

• Diabetes Management Center of the Diabetes Center
  for Puerto Rico
• Is a repository of information and data related
  with diabetes mellitus specially in Puerto Rico
• Principal Objectives of the Diabetes Management
  Center
• To obtain analyze and disseminate data
• Scientific Investigations
• Publication of journals bulletins and scientific
  articles

3
Objetives

• To discuss diabetes prevalence estimates at world
  and local level.
• To discuss diabetes complications prevalence
  estimates and health service utilization rate.
• To analyze disparities by age and sex between
  persons living with diabetes that received
  services from private and public health insurance
  companies between 2000-2001 in Puerto Rico.

4
Methodology

• Analysis of several sources of data including
• Behavioral Risk Factor Surveillance System
  (BRFSS)
• Health Insurance Companies in Puerto Rico
• Private and Public (Reform)
• Four insurance companies (39.4)
• Revision of recent studies

5
DiabetesPrimary Goal for 2010

• Through prevention programs reduce the disease
  incidence its complications and its economic
  impact in addition to improve quality of life
  for all those persons that had diabetes or that
  are at risk to develop the disease.

Reference U.S. Department of Health and Human
Services. Healthy People 2010 Understanding and
Improving Health. 2nd ed. Washington DC U.S.
Government Printing Office November 2000.
6

• Global Prevalence of
• Diabetes

7
Global Prevalence Estimates 2000 and 2030
4.4
2.8
Reference Wild S Roglic G Green A Sicree R
King H. Global prevalence of diabetes. Diabetes
Care. 2004 27(5) 1047-1053.
8
Diabetes in the World
Year2000
millions
Reference Wild S Roglic G Green A Sicree R
King H. Global prevalence of diabetes. Diabetes
Care. 2004 27(5) 1047-1053.
9
Diabetes in the World
Year2010
millions
Reference Wild S Roglic G Green A Sicree R
King H. Global prevalence of diabetes. Diabetes
Care. 2004 27(5) 1047-1053.
10
Prevalence of Diabetes by Country
18 years only. Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1999-2003. Atlanta GA
United States Department of Health and Human
Services. Dunstan DW Zimmet PZ Welborn TA
Courten MP Cameron AJ Sicree RA et al. The
raising prevalence of diabetes and impaired
glucose tolerance. Diabetes Care. 2002 25(5)
829-834. Warsy AS el-Hazmi MA. Diabetes
mellitus hypertension and obesity-common
multifactorial disorders in Saudis. Eastern
Mediterranean Health Journal. 1999 5(6) 1236-42.
11
Prevalence of Diabetes in Adults United States
BRFSS 1998 - 2003
BRFSS Behavioral Risk Factor Surveillance
System (18 years). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1998-2003. Atlanta GA
United States Department of Health and Human
Services.
12
Prevalence of Diabetes in Adults United States
BRFSS
1990
Reference Mokdad et al. Diabetes Care
2000231278-83.
13
Prevalence of Diabetes in Adults United States
BRFSS
1991-92
Reference Mokdad et al. Diabetes Care
2000231278-83.
14
Prevalence of Diabetes in Adults United States
BRFSS
1993-94
Reference Mokdad et al. Diabetes Care
2000231278-83.
15
Prevalence of Diabetes in Adults United States
BRFSS
1995-96
Reference Mokdad et al. Diabetes Care
2000231278-83.
16
Prevalence of Diabetes in Adults United States
BRFSS
1995
Reference Mokdad et al. Diabetes Care
2000231278-83.
17
Prevalence of Diabetes in Adults United States
BRFSS
1997-98
Reference Mokdad et al. Diabetes Care
2000231278-83.
18
Prevalence of Diabetes in Adults United States
BRFSS
1999
Reference Mokdad et al. Diabetes Care
2000231278-83.
19
Prevalence of Diabetes in Adults United States
BRFSS
2000
Reference Mokdad et al. Diabetes Care
2000231278-83.
20
Prevalence of Diabetes in Adults United States
BRFSS
2001
Reference Mokdad et al. Diabetes Care
2000231278-83.
21
Prevalence of Diabetes in Adults United States
and territories BRFSS 2002
BRFSS Behavioral Risk Factor Surveillance
System (18 years). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1998-2003. Atlanta GA
United States Department of Health and Human
Services.
22
Incidence Estimates of Diabetes Crude and
Adjusted Rate by Age United States 1997 - 2002
Reference http//www.cdc.gov/diabetes/statistics/
incidence/Fig2.htm
23

• Prevalence of Diabetes in Puerto Rico

24
Prevalence of Diabetes in Puerto Rico Household
Health Interview Survey 1966 - 1994
Reference Household Health Interview Survey
Puerto Rico Health. Department 1966-1994
25
Prevalence of Diabetes in Puerto Rico using
different Data Sources 1998 - 2003
Some health insurances in Puerto Rico. Pérez
R Pérez CM Rodriguez LA Disdier OM. Boletín
Estadístico del Centro para el Manejo de Datos de
Diabetes - Prevalencia de diabetes
complicaciones y uso de servicios relacionados a
la diabetes en Puerto Rico Grupo comercial
versus reforma de salud año 2000 - 2001. Puerto
Rico Diabetes Data Management Center Department
of Biostatistics and Epidemiology Graduate
School of Public Health Medical Sciences Campus
University of Puerto Rico volume 2 June 2003
BRFSS Behavioral Risk Factor Surveillance
System (18 años). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1998-2003. Atlanta GA
United States Department of Health and Human
Services.
26
Prevalence of Diabetes by Region Puerto Rico
BRFSS 1999
Quebradillas
Barceloneta
Cataño
Aguadilla
Toa Baja
Loíza
Manatí
Dorado
Isabela
Arecibo
Hatillo
Vega Alta
Camuy
Vega Baja
Florida
Aguada
Carolina
Moca
Toa Alta
San Juan
Trujillo Alto
Bayamón
Guaynabo
Luquillo
Río Grande
Rincón
Canóvanas
Fajardo
San Sebastián
Ciales
Corozal
Añasco
Utuado
Morovis
Naranjito
Lares
Gurabo
Aguas Buenas
Ceiba

Las Marías
Comerío
Juncos
Barran- quitas
Jayuya
Hormigueros
Mayaguez
Orocovis
Caguas
Adjuntas
Naguabo
Las Piedras
Maricao
Cidra
San Lorenzo
Villalba
Aibonito
San Germán
Humacao
Sabana Grande
Cabo Rojo
Cayey
Coamo
Yauco
Yabucoa
Culebra
Guayanilla
Peñuelas
Maunabo
Lajas
Ponce
Juana Díaz
Patillas
Salinas
Arroyo
Santa Isabel
Guayama
Guánica
Vieques
IC 95
Prevalence
Region
IC 95
Prevalence
Region
Oeste
5.27 12.77
9.02
6.26 11.90
9.08
San Juan
Norte
5.57 11.36
8.46
9.05 16.43
12.74
Sureste
Metropolitana Norte
3.20 10.17
6.68
5.98 11.16
8.57
Suroeste
4.01 11.00
7.50
4.91 14.32
9.62
Noroeste
Este
Nordeste
8.91 15.96
12.44
7.86 14.19
11.03
BRFSS Behavioral Risk Factor Surveillance
System (18 years). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1999. Atlanta GA United
States Department of Health and Human Services.
27
Prevalence of Diabetes by Sex and Year Puerto
Rico BRFSS 1997 2001 - 2003
BRFSS Behavioral Risk Factor Surveillance
System (18 years). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1997-2003. Atlanta GA
United States Department of Health and Human
Services.
28
Prevalence of Diabetes by Age Group Puerto Rico
BRFSS 1997 2001 - 2003
BRFSS Behavioral Risk Factor Surveillance
System (18 years). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1997-2003. Atlanta GA
United States Department of Health and Human
Services.
29
Prevalence of Diabetes by Age GroupsHealth
Insurance Companies in Puerto Rico 2000 y 2001
Pérez R Pérez CM Disdier OM. Health
Disparities between Diabetic Patients under
Private and Public Health Coverage in Puerto
Rico 2000. PR Health Sci J. 200322363-368.
Some health insurances of Puerto Rico. Pérez R
Pérez CM Rodriguez LA Disdier OM. Boletín
Estadístico del Centro para el Manejo de Datos de
Diabetes - Prevalencia de diabetes
complicaciones y uso de servicios relacionados a
la diabetes en Puerto Rico Grupo comercial
versus reforma de salud año 2001. Puerto Rico
Diabetes Data Management Center Department of
Biostatistics and Epidemiology Graduate School
of Public Health Medical Sciences Campus
University of Puerto Rico volume 2 June 2003.
30
Prevalence of Diabetes by Employment Status
Puerto Rico BRFSS 1996 - 2000
BRFSS Behavioral Risk Factor Surveillance
System (18 years). Pérez R Pérez CM Disdier
OM Rodríguez LA. Estado de salud de la población
adulta de Puerto Rico basado en características
seleccionadas del sistema de vigilancia de los
factores de riesgo asociados a la conducta 1996
- 2000. Diabetes Data Management Center
Department of Biostatistics and Epidemiology
Graduate School of Public Health Medical
Sciences Campus University of Puerto Rico
September 2004.
31

• Diabetes Related Complications

32
Prevalence of Diabetes Related Complications by
Health Insurances Puerto Rico 2001
Reference Some health insurances in Puerto Rico.
Pérez R Pérez CM Rodriguez LA Disdier OM.
Boletín Estadístico del Centro para el Manejo de
Datos de Diabetes - Prevalencia de diabetes
complicaciones y uso de servicios relacionados a
la diabetes en Puerto Rico Grupo comercial
versus reforma de salud año 2001. Puerto Rico
Diabetes Data Management Center Department of
Biostatistics and Epidemiology Graduate School
of Public Health Medical Sciences Campus
University of Puerto Rico volume 2 June 2003.
33
Prevalence of Diabetes Related Complications by
Age and Health Sector Puerto Rico 2000
Private Health Group
Public Health Group
Reference Pérez R Pérez CM Disdier OM. Health
Disparities between Diabetic Patients under
Private and Public Health Coverage in Puerto
Rico 2000. PR Health Sci J. 200322363-368.
34

• Diabetes Mortality in Puerto Rico

35
Leading Causes of Death in Puerto Rico 2001
Reference Estado Libre Asociado de Puerto Rico.
Informe Anual de Estadísticas Vitales 1999-2001.
Secretaría Auxiliar de Planificación Evaluación
Estadísticas y Sistemas de Información.
División de Estadísticas4
36
Mortality Rate by Sex Puerto Rico 2001
Reference Estado Libre Asociado de Puerto Rico.
Informe Anual de Estadísticas Vitales 1999-2001.
Secretaría Auxiliar de Planificación Evaluación
Estadísticas y Sistemas de Información.
División de Estadísticas
37

• Utilization of Medical Services Pharmacy and
  Laboratories among Diabetic Patients
• in Puerto Rico

38
Utilization of Clinical Services among Diabetic
Patients by Health Insurance Puerto Rico 2001
Reference Some health insurances in Puerto Rico.
Pérez R Pérez CM Rodriguez LA Disdier OM.
Boletín Estadístico del Centro para el Manejo de
Datos de Diabetes - Prevalencia de diabetes
complicaciones y uso de servicios relacionados a
la diabetes en Puerto Rico Grupo comercial
versus reforma de salud año 2001. Puerto Rico
Diabetes Data Management Center Department of
Biostatistics and Epidemiology Graduate School
of Public Health Medical Sciences Campus
University of Puerto Rico volume 2 June 2003.
39
Utilization of Clinical Services among Diabetic
Patients by Sex Health Insurance Puerto Rico
2001
Reference Some health insurance of Puerto Rico.
Pérez R Pérez CM Rodriguez LA Disdier OM.
Boletín Estadístico del Centro para el Manejo de
Datos de Diabetes - Prevalencia de diabetes
complicaciones y uso de servicios relacionados a
la diabetes en Puerto Rico Grupo comercial
versus reforma de salud año 2001. Puerto Rico
Diabetes Data Management Center Department of
Biostatistics and Epidemiology Graduate School
of Public Health Medical Sciences Campus
University of Puerto Rico volume 2 June 2003.
40
Utilization of Pharmacy Services among Diabetic
Patients by Health Insurance Puerto Rico 2001
49.6
Oral Agent
46.2
13.9
Insulin
31.0
Percentage ()
Public Health Insurance
Private Health Insurance
Reference Some health insurance of Puerto Rico.
Pérez R Pérez CM Rodriguez LA Disdier OM.
Boletín Estadístico del Centro para el Manejo de
Datos de Diabetes - Prevalencia de diabetes
complicaciones y uso de servicios relacionados a
la diabetes en Puerto Rico Grupo comercial
versus reforma de salud año 2001. Puerto Rico
Diabetes Data Management Center Department of
Biostatistics and Epidemiology Graduate School
of Public Health Medical Sciences Campus
University of Puerto Rico volume 2 June 2003.
41
Utilization of Pharmacy Services among Diabetic
Patients by Sex Health Insurance Puerto Rico
2001
45.0
Oral Agent
50.0
27.6
Insulin
24.1
Percentage()
Male
Female
Reference Some health insurance services of
Puerto Rico. Pérez R Pérez CM Rodriguez LA
Disdier OM. Boletín Estadístico del Centro para
el Manejo de Datos de Diabetes - Prevalencia de
diabetes complicaciones y uso de servicios
relacionados a la diabetes en Puerto Rico Grupo
comercial versus reforma de salud año 2001.
Puerto Rico Diabetes Data Management Center
Department of Biostatistics and Epidemiology
Graduate School of Public Health Medical
Sciences Campus University of Puerto Rico
volume 2 June 2003.
42
Utilization of Laboratory Services among Diabetic
Patients by Health Insurance Puerto Rico 2001
Reference Some health insurance companies of
Puerto Rico. Pérez R Pérez CM Rodriguez LA
Disdier OM. Boletín Estadístico del Centro para
el Manejo de Datos de Diabetes - Prevalencia de
diabetes complicaciones y uso de servicios
relacionados a la diabetes en Puerto Rico Grupo
comercial versus reforma de salud año 2001.
Puerto Rico Diabetes Data Management Center
Department of Biostatistics and Epidemiology
Graduate School of Public Health Medical
Sciences Campus University of Puerto Rico
volume 2 June 2003.
43
Utilization of Laboratory Service among Diabetic
Patients by Sex Health Insurance Puerto Rico
2001
Reference Some health insurance companies of
Puerto Rico. Pérez R Pérez CM Rodriguez LA
Disdier OM. Boletín Estadístico del Centro para
el Manejo de Datos de Diabetes - Prevalencia de
diabetes complicaciones y uso de servicios
relacionados a la diabetes en Puerto Rico Grupo
comercial versus reforma de salud año 2001.
Puerto Rico Diabetes Data Management Center
Department of Biostatistics and Epidemiology
Graduate School of Public Health Medical
Sciences Campus University of Puerto Rico
volume 2 June 2003.
44

• Economic Cost of Diabetes

45
Economic Cost Related with Diabetes by Health
Sector Puerto Rico 2000
Reference Pérez R Pérez CM Disdier OM. Health
Disparities between Diabetic Patients under
Private and Public Health Coverage in Puerto
Rico 2000. PR Health Sci J. 200322363-368.
46
Average Cost in Diabetic Patients by Health
Sector Puerto Rico 2000
Reference Pérez R Pérez CM Disdier OM. Health
Disparities between Diabetic Patients under
Private and Public Health Coverage in Puerto
Rico 2000. PR Health Sci J. 200322363-368.
47

• Factors Associated with Diabetes
• in Puerto Rico

48
Association of Clinical and Demographics
Characteristics and Diabetes Prevalence by Age
Group Puerto Rico BRFSS 1999
Age Age 65
Reference Pérez CM Pérez R. Prevalence and
associated factors of diabetes mellitus in Puerto
Rican adults Behavioral Risk Factor Surveillance
System 1999. PR Health Sci J. 200120(2)147-155.
49
Prevalence of Factors Associated with Diabetes
Puerto Rico BRFSS 2003
BRFSS Behavioral Risk Factor Surveillance
System (18 years). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 2003. Atlanta GA United
States Department of Health and Human Services.
50
Health Disparities in Cardiovascular Conditions
51
Prevalence of Cardiovascular Conditions in a
Insured Population by Age Puerto Rico 2001
Cardiovascular Conditions included the
following hypertension coronary artery disease
congestive heart failure cerebrovascular disease
and transient ischemic attack. P-value Difference by age was statistically significant.
52
Prevalence of Specific Cardiovascular Conditions
by Age Group and Health Sector Puerto Rico 2001
53
Prevalence of Specific Cardiovascular Conditions
by Age Group and Health Sector Puerto Rico 2001
54
Prevalence of Cardiovascular Conditions in an
Insured Population by Sex Puerto Rico 2001
Cardiovascular Conditions included the
following hypertension coronary artery disease
congestive heart failure cerebrovascular
accident transient ischemic attack and other
cardiovascular-related claims.
55
Conclusions

• Prevalence of diabetes in Puerto Rico is higher
  than in United States and exceeds the estimates
  at world level.
• Economic and human cost of diabetes are huge and
  represent a real problem for public health.
• Low rate of laboratory services utilization for
  glycosylated hemoglobin test could be an
  indicator of poor prevention measures in both
  sectors but specially in the public sector.
• Many factors related with the development of
  diabetes are modifiable and controllable
  therefore effectives strategies of prevention are
  recommended.

56
References

• Pérez R Pérez CM Disdier OM. Health Disparities
  between Diabetic Patients under Private and
  Public Health Coverage in Puerto Rico 2000. PR
  Health Sci J. 200322363-368.
• Pérez R Pérez CM Rodriguez LA Disdier OM.
  Boletín Estadístico del Centro para el Manejo de
  Datos de Diabetes - Prevalencia y uso de
  servicios relacionados a la diabetes en Puerto
  Rico Grupo comercial versus reforma de salud
  año 2000. Puerto Rico Diabetes Data Management
  Center Department of Biostatistics and
  Epidemiology Graduate School of Public Health
  Medical Sciences Campus University of Puerto
  Rico volume 1 January 2002.

57
References

• Pérez R Pérez CM Rodriguez LA Disdier OM.
  Boletín Estadístico del Centro para el Manejo de
  Datos de Diabetes - Prevalencia de diabetes
  complicaciones y uso de servicios relacionados a
  la diabetes en Puerto Rico Grupo comercial
  versus reforma de salud año 2001. Puerto Rico
  Diabetes Data Management Center Department of
  Biostatistics and Epidemiology Graduate School
  of Public Health Medical Sciences Campus
  University of Puerto Rico volume 2 June 2003.
• Centers for Disease Control and Prevention.
  Behavioral Risk Factor Surveillance System
  1996-2003. Atlanta GA United States Department
  of Health and Human Services.
• Estado Libre Asociado de Puerto Rico. Informe
  Anual de Estadísticas Vitales 1999-2001.
  Secretaría Auxiliar de Planificación Evaluación
  Estadísticas y Sistemas de Información.
  División de Estadísticas
• Wild S Roglic G Green A Sicree R King H.
  Global prevalence of diabetes. Diabetes Care.
  2004 27(5) 1047-1053.

58
References

• Dunstan DW Zimmet PZ Welborn TA Courten MP
  Cameron AJ Sicree RA et al. The raising
  prevalence of diabetes and impaired glucose
  tolerance. Diabetes Care. 2002 25(5) 829-834.
• Warsy AS el-Hazmi MA. Diabetes mellitus
  hypertension and obesity-common multifactorial
  disorders in Saudis. Eastern Mediterranean Health
  Journal. 1999 5(6) 1236-42.
• Pérez CM Pérez R. Prevalence and associated
  factors of diabetes mellitus in Puerto Rican
  adults Behavioral Risk Factor Surveillance
  System 1999. PR Health Sci J. 200120(2)147-155.
  
• Pérez R Pérez CM Disdier OM Rodríguez LA.
  Estado de salud de la población adulta de Puerto
  Rico basado en características seleccionadas del
  sistema de vigilancia de los factores de riesgo
  asociados a la conducta 1996 - 2000. Diabetes
  Data Management Center Department of
  Biostatistics and Epidemiology Graduate School
  of Public Health Medical Sciences Campus
  University of Puerto Rico September 2004.

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