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  • 1. The Maine 2007 Diabetes Surveillance System
  • 2. This publication was supported by Cooperative Agreement Number U32/ CCU122694 from the Centers for Disease Control and Prevention/ Division of Diabetes Translation. It’s contents are solely the responsibility of the authors and do not necessarily represent the official view of the CDC.
  • 3. The Maine 2007 Diabetes Surveillance System John E. Baldacci, Governor State of Maine Brenda Harvey, Commissioner Department of Health and Human Services Dora Anne Mills, MD,MPH, Director Maine Center for Disease Control and Prevention Barbara Poirier, Acting Division Director Division of Chronic Disease Katie Meyer, ScD, MPH Chronic Disease Epidemiology Consultant James F. Leonard, MSW, Program Manager Diabetes Prevention and Control Program Dana Ivers, BS Comprehensive Health Planner The Maine Diabetes Prevention and Control Program April 2007
  • 4. Acknowledgements The Maine CDC’s Diabetes Prevention and Control Program would like to acknowledge the ongoing effort made by members of the Diabetes Health System in Maine for the work being done to improve diabetes care throughout the state. The staff of Ambulatory Diabetes Education and Follow-up programs statewide for their continued submission of self-management data, and to the many organizations, especially local Healthy Maine Partnerships who have worked tirelessly to make community environments places that support healthy lifestyles. Finally we thank the members of the Diabetes Advisory Council for their support and direction in helping the Diabetes Prevention and Control Program reach its vision, “Maine enjoys the best diabetes health in the nation as the result of our work in diabetes prevention and management.” Members of the Diabetes Advisory Council: Claudette Bean Medical Care Development Jo-Anne Bushey Medical Care Development Dona Forke H.O.T. Community Partnership Valli Geiger Maine Primary Care Association Cindy Hale Maine Diabetes Prevention and Control Program James Leonard Maine Diabetes Prevention and Control Program Brenda McCormick MaineCare Leslie A. Molleur Northeast Health Care Quality Foundation Mary-Carmela Moreau Anthem Blue Cross and Blue Shield Kristina M. Scrutchfield MaineHealth Maine Diabetes Surveillance System
  • 5. Table of Contents Introduction........................................................................................................1 Executive Summary............................................................................................2 Diabetes Surveillance System............................................................................3 Introduction................................................................................................................................3 Data Sources for the Diabetes Surveillance System..................................................................3 Table 1: Data Sources for the Maine Diabetes Surveillance System.........................................4 Figure 1: The Roll of Data Sources in The Maine Diabetes Surveillance System....................5 Prevalence of Diabetes.......................................................................................6 Introduction................................................................................................................................6 The Maine Behavioral Risk Factor Surveillance System (BRFSS)...........................................6 Table 2: Total Number of People Interviewed and Number of People With Diabetes Interviewed Each Year as Part of the Maine Behavioral Risk Factor Surveillance System......8 Figure 2: Year-specific prevalence of non-gestational diabetes in Maine adults, 1994-2005, BRFSS ......................................................................................................................................9 Figure 3: Age-specific prevalence of diabetes of non-gestational diabetes in Maine adults, 2003-2005, BRFSS..................................................................................................................10 Figure 4: County-specific, age-adjusted diabetes prevalence estimates, Maine BRFSS, 2003-2005................................................................................................................................10 Figure 5: Gender-specific diabetes prevalence estimates, Maine BRFSS, 2003-2005............11 Figure 6: Age-adjusted prevalence of diabetes according to leisure time physical activity....11 Figure 7: Diabetes prevalence according to BMI....................................................................12 Figure 8: Diabetes prevalence according to income................................................................13 Figure 9: Diabetes prevalence according to education............................................................13 Figure 10: Diabetes prevalence in Maine adults with and without high cholesterol...............14 Figure 11: Diabetes prevalence in Maine adults with and without high blood pressure.........14 References................................................................................................................................15 Progress Towards Healthy Maine 2010 and Healthy People 2010 Goals....16 Table 3:Increase the proportion of Maine adults with diabetes who have taken a course or class in managing diabetes to 80 percent.................................................................................16 Table 4: Increase the proportion of Maine ADEF/DSMT Program participants with diagnosis ≤ 5 years to 95 percent. (This is a Maine-specific goal.).........................................................16 Table 5:Increase the proportion of people with diabetes who have an annual eye examination to 85 percent.............................................................................................................................17 Table 6:Increase the proportion of adults with diabetes who have a hemoglobin A1c test at least once a year to 95 percent.................................................................................................17 Table 7:Reduce the rate of lower extremity amputations in adults with diabetes to 1.8 per 1,000 people with diabetes.......................................................................................................17 Table 8:Reduce the diabetes death rate (any cause) to 65 per 100,000 population.................17 Diabetes-Related Hospitalizations in Maine..................................................18 Maine Diabetes Surveillance System
  • 6. Table of Contents Hospitalizations from Diabetes In Maine Residents ...............................................................18 Table 9: Diabetes Related Hospitalizations in Maine (1994-2005).........................................18 Figure 12: Age-adjusted rates of diabetes hospitalization, any listed cause, Maine, 1994-2005, and U.S., 1994-2003.............................................................................................19 Figure 13: Age-adjusted rates of diabetes hospitalization among adults with diabetes, any listed cause, Maine, 2001-2005...............................................................................................20 Figure 14: Age-adjusted rates of diabetes hospitalization, first listed cause, total population, Maine, 1994-2005, and U.S., 1994-2003.................................................................................20 Figure 15: Age-adjusted rates of diabetes hospitalization among adults with diabetes, first listed cause, Maine, 2000-2004...............................................................................................21 Figure 16: Age-adjusted rates of hospitalization for non-traumatic lower extremity amputation, any listed cause, Maine, 1994-2005, and U.S., 1994-2003.................................21 Figure 17: Age-adjusted rates of hospitalization for keto-acidosis, first listed cause, Maine, 1994-2005, and U.S., 1994-2003.............................................................................................22 Figure 18: Age-adjusted rates of hospitalization for cardiovascular disease, first listed, and diabetes, any listed cause, Maine, 1994-2005, and U.S., 1994-2003......................................22 Diabetes Related Deaths in Maine..................................................................23 Introduction..............................................................................................................................23 Deaths from diabetes In Maine Residents ..............................................................................23 Table 10...................................................................................................................................24 Figure 19: Age-adjusted and crude rate of death from diabetes as any cause, Maine, 1994 - 2005..........................................................................................................................................24 Figure 20: Maine’s Age-Specific Mortality Due to Diabetes .................................................25 Figure 21:Age-Adjusted Gender Mortality Due to Diabetes as Any Listed Cause.................26 Figure 22: Age-adjusted Mortality Due to Diabetes as an Underlying Cause of death, Maine, 1994-2005, the US, 1994-2003, and US White, 1994-2003....................................................27 References................................................................................................................................27 Diabetes Treatment, Knowledge and Self-Care Behavior............................28 Introduction..............................................................................................................................28 Treatment and Self-Care Behavior..........................................................................................28 Health Care Visits....................................................................................................................28 Table 11: BRFSS Respondents with Diabetes the Number of Health Care Visits for Diabetes in Past Year ...........................................................................................................................28 Eye care2..................................................................................................................................29 Table 12: Percent of BRFSS Respondents with Diabetes that had an Eye Exam...................29 Foot care...................................................................................................................................29 Table 13: Number of Foot Exams in Past Year for BRFSS Respondents with Diabetes........30 Monitoring Glucose Control....................................................................................................30 Table 14: Frequency of Blood Glucose Monitoring and HbA1c testing.................................30 Smoking...................................................................................................................................31 Immunizations..........................................................................................................................31 Table 15: Percent with Pneumonia or Influenza .....................................................................31 Hypertension and Lipids..........................................................................................................32 Table 16: Percent of Persons with Diabetes Reported they have High Cholesterol................32 Maine Diabetes Surveillance System
  • 7. Table of Contents Table 17:Percent of Persons with Diabetes Reported having Hypertension...........................32 Physical Activity......................................................................................................................32 Diabetes Educational Course...................................................................................................32 Diabetes Self-Management Education (DSME)............................................33 The Maine ADEF Program......................................................................................................33 Using ADEF Program Data to Estimate Referrals to Diabetes Self-Management Education (DSME)....................................................................................................................................34 ..............................................................................................................................................35 Table 18: ADEF/DSME Referrals Per County for 2003-2005................................................35 Table 19: ADEF Participation.................................................................................................35 Distribution of Diabetes by Type.............................................................................................35 Table 20: Distribution of Types of Diabetes............................................................................35 Length of Time From Diagnosis to Referral ...........................................................................36 Figure 23: Length of Time From Diagnosis to Referral..........................................................36 Age Distribution.......................................................................................................................36 Figure 24: Age Distributions of Persons Referred to ADEF/DSME.......................................36 Weight Distribution.................................................................................................................37 Figure 25:Distribution of Body Mass Index (BMI) of ADEF Participants ............................37 Gender Distribution.................................................................................................................38 Figure 26: Gender Distribution of ADEF Participants............................................................38 Hospitalization and Medical Conditions by Gender................................................................38 Figure 27: Hospitalizations of ADEF Participants In year prior to attending ADEF..............38 Table 21:Hospitalizations rates by Gender of ADEF Participants prior to attending ADEF. .39 Hypertension and Heart Disease..............................................................................................40 Figure 28: Percent of ADEF Participants with Heart Disease.................................................40 HbA1c Measures......................................................................................................................40 Figure 29: ADEF Participants with an HbA1c Test ...............................................................40 Eye Exams ..............................................................................................................................41 Figure 30: Percent of ADEF Participants with an Eye Exam ................................................41 Monofilament Test...................................................................................................................41 Figure 31: Percent of ADEF Participants Reported Having a Monofilament test ..................41 References................................................................................................................................42 Maine Diabetes Surveillance System
  • 8. Introduction Introduction Diabetes is a metabolic disorder characterized by high levels of blood-glucose. It is a chronic disease which when mismanaged can result in blindness, digestive problems, leg and foot ulcers, lower-limb amputation, heart disease, kidney disease, kidney failure, coma and death. Recent epidemiological evidence shows an increasing trend of type 2 diabetes in the U.S. population. Maine is one of twenty- two states that has seen prevalence double within the past ten years. There is no known cure for diabetes. It is an expensive disease with yearly costs estimated to be five times greater than for people without diabetes. Despite all of this bad news, medical advances have made it possible for people with diabetes to avoid many of the complications that can develop from the disease. Medical advances are not miracles however and lifestyle modifications are required to realize the full benefits of these advances. Several years have passed since results from two landmark studies demonstrated that many of the complications from diabetes could be avoided through consistent blood-glucose control . Additional studies have also 1 shown that significant reductions in cardiovascular disease (the leading cause of deaths for people with diabetes) can be achieved through targeted medical management and lifestyle modification . 2 Improvements in diabetes management has been a focus of several national quality improvement initiatives. Beginning in 1997, a consortium of organizations developed a set of diabetes-specific performance and outcome measures that would allow for fair comparisons of health care plans, stimulate quality improvement, be based on scientific evidence, and yet be user-friendly to payers and consumers . This report 3 examines trends on selected diabetes process measures to show how medical care in Maine compares to national standards. Medical care is only part of the equation to effective diabetes management. Much of the management of diabetes occurs outside of the medical system. For this reason we look closely at several indicators of self-management in this report. Finally we bring various pieces of data together to highlight where we need to focus our efforts in order to improve outcomes for people with diabetes in Maine. 1 Diabetes Control and Complications Trial, 1997 and United Kingdom Prospective Diabetes Study, 1998. 2 Goede, P., et al. Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes. NEJM. Volume 348:383-393 January 30, 2003 Number 5 3 McLaughlin, S. The Diabetes Quality Improvement Project. Diabetes Spectrum. Volume 13 Number , 2000, Page 5. Maine Diabetes Surveillance System 1
  • 9. Executive Summary Executive Summary Diabetes is an insidious disease that can dramatically lower quality of life. In the past twelve years the prevalence of diabetes in Maine has more than doubled. We have seen rates increase across all age groups, especially in the older segment of our population. With more people living longer and with Maine having the oldest population in the United States, an increased rate of diabetes is of particular concern. Diabetes is a chronic disease requiring daily self-management and planned medical care to reduce the risks of developing complications. There are indications from the data that people are seeing their healthcare provider more often than was reported in our previous study. Preventive measures, to detect early signs and symptoms of complications, are also increasing compared to our 2001 report. And the data show the beginning signs of a downward trend in cardiovascular related hospitalizations. These improvements are encouraging signs and likely the result of the ongoing improvement work being done by many in the Maine healthcare system. There are concerns however. The rate of smoking among people with diabetes continues to remain high. Diabetes and smoking is an especially risky proposition. We need to do more to identify those at risk and encourage treatment. There is also suggestion, through the data, of a decline in referrals to diabetes self-management education (DSME). We have begun a study of barriers to referral and attendance to DSME and plan to release our findings with an action plan this year. DSME in Maine continuously shows a positive impact on clinical outcomes. Referral slippage is of concern. National projections of diabetes trends predict continued increases through 2025. Our health system will experience significant challenges to deliver care to the population, let alone those with a complex disease like diabetes. There is hope and evidence that improved self- management can reduce the likelihood of complications that can develop from diabetes. As more community resources develop for people with chronic diseases, such as walking trails and nutrition programs, we anticipate greater attention to and participation in self- management programs. In summary although the threat of increased diabetes prevalence is a very real one, there is growing evidence of improved diabetes care and greater awareness of the benefits of lifestyle management on the long-term outcomes of people with diabetes. With continued improvement, people in Maine with diabetes can live longer and healthier lives than at any time in the past. Respectfully, Jim Leonard, MSW Director Maine CDC’s Diabetes Prevention and Control Program Maine Diabetes Surveillance System 2
  • 10. Maine’s Diabetes Surveillance System Diabetes Surveillance System Introduction Surveillance is defined as “the ongoing, systematic collection, analysis, and interpretation of health data…used for planning, implementing, and evaluating public health interventions and programs.”1 Surveillance data are used to identify public health resources needed at multiple levels and to provide baseline measures for gauging the impact and outcome of public health efforts. In 1998, the Maine Center for Disease Control And Prevention’s (then known as Maine Bureau of Health) Diabetes Control Program (DCP) developed a surveillance system designed primarily to document the burden of diabetes in Maine, identify trends in diabetes over time, and explore differences in diabetes prevalence and experience with respect to various personal characteristics. In 2001 the DCP released its first comprehensive report using this surveillance system. “The Maine 2001 Diabetes Surveillance System” reported on diabetes prevalence, morbidity, mortality, and preventive practices. In this second publication we continue to report on trends in these four critical areas, progress made, and areas to focus on. Diabetes is a chronic disease with no known cure. Although not curable, the disease is manageable. Several studies have shown that complications from diabetes are avoidable or can be diminished through consistent management. There has been a large increase in diabetes prevalence in recent years with continued increases predicted through 2020 by the CDC. The future health of those with diabetes is largely dependent on consistent management. As we read through this report we look for opportunities to improve outcomes of people with diabetes. A cardinal area for improvement is within preventive practices. We are aiming to increase more people to engage in preventative practices and hope to see lower proportions of complications as a result. Data Sources for the Diabetes Surveillance System As defined, surveillance requires the ongoing and systematic analysis of health data, and it is therefore essential that data sources provide valid and reliable data on a consistent basis. In the table below, we outline the specific surveillance contribution of the six data sources that form the foundation of the Maine Diabetes Surveillance System. 1 Klaucke DN, Thacker SB, Parrish RG, et al. Guidelines for evaluating surveillance systems. MMWR 1998;37:1-18 Maine Diabetes Surveillance System 3
  • 11. Maine’s Diabetes Surveillance System Table 1: Data Sources for the Maine Diabetes Surveillance System. Data Source Data Contributed Availability Behavioral Risk Factor Diabetes and diabetes risk factor Yearly Surveillance System (BRFSS) prevalence estimates in adults Death certificates Mortality rate estimates Yearly Hospital discharge data Estimates of hospitalization rates Yearly Vital statistics Maine population estimates Yearly U.S. Census Bureau Socioeconomic characteristics 10 year surveys Maine Ambulatory Diabetes Clinical data on ADEF program Yearly Education and Follow-up participants (ADEF) Program Figure 1 provides a graphic representation of the roles of various data sources in the surveillance system. Each data source contributes to the overall picture of the burden of diabetes in Maine. State census data inform us of the demographic composition of the population in the state. Hospital discharge data provide a foundation for tracking and comparing hospitalization rates. Mortality data are used to calculate diabetes-related deaths and to compare Maine and national rates. BRFSS data are used to estimate the prevalence of diabetes in the adult population and to explore relations between diabetes and variables that are commonly associated with diabetes. Finally, the ADEF Program data system, which provides county referral rates for diabetes self-management education (DSME), is used to describe the population that was referred to ADEF and that participated in the ADEF Program. Maine Diabetes Surveillance System 4
  • 12. Maine’s Diabetes Surveillance System Figure 1: The Roll of Data Sources in The Maine Diabetes Surveillance System State Level National Level Population U.S./ State Demographic County Level Populat ion State Population Census Dat a Data Synthetic Estimates Demographics Socioeconomic Compared to Nat ional Stratification State DM Hospital DM Related Rate of DM Related Hospitalizat ion Rate Discharge Data Primary/ Secondary Hospitalizat ions Compared to National Rate Mort ality DM as Primary/ Rate of DM State DM Related Data Secondary cause Related Deaths Mort ality Rate Compared to National Rate DM Module State/ County DM State/ County DM BRFSS Behaviors Rates Behaviors Rates Compared to Data Demographics Demographics National Rates ADEF/ Referrals DSMT Demographics State/ County Data Clinical Values & Referral and Education Process Education/ Clinical Outcomes Information County/ Town Demographic & DM Profile Planning & Exist ing Resources Resource National St andards Allocat ion DPCP & ADEF/ DSMT Partnership Informat ion From Data Informs Process Maine Diabetes Surveillance System 5
  • 13. Prevalence of Diabetes Prevalence of Diabetes Introduction In this chapter we present data on the number and percentage of people with diabetes in Maine as measured by a statewide survey. Raw numbers (counts) document the absolute burden of disease in the population and can be useful for health care planning. The percentage of the population that has diabetes during a particular time period, also called prevalence, controls for changes in the population size and provides an estimate of the per capita burden of diabetes. Along with absolute counts and the prevalence of diabetes, we present data on variables that are commonly associated with diabetes, including obesity, physical activity, and socioeconomic status. The Maine Behavioral Risk Factor Surveillance System (BRFSS) We used the Maine Behavioral Risk Factor Surveillance System (BRFSS), an annual telephone survey, to estimate the prevalence of diabetes in adults.1 The BRFSS collects information from randomly selected participants on their health status, demographic characteristics, and participation in various health behaviors. Over the past 12 years, between 1,250 to 4,600 Maine residents have been surveyed annually. This sample is used to calculate prevalence estimates that are representative of Maine’s adult population as a whole. The BRFSS operates in all 50 states and 4 territories, allowing comparisons of state and national data. A few points about the BRFSS deserve attention. As a telephone survey, BRFSS excludes people without individual telephones, including those in nursing homes, prisons, college dormitories, and the homeless. Therefore, the BRFSS survey does not completely represent all segments of Maine’s population. In addition, the BRFSS response rate has declined in the past decade, and approximately fifty (50) percent of sampled individuals complete the BRFSS survey. To the extent that those who respond to the survey are more or less likely to have diabetes than the general population, prevalence estimates from the BRFSS will be inaccurate. Further, the BRFSS data are only as good as the accuracy of participants’ self-reported responses. With respect to self-reported diabetes, data will be limited by the extent to which people with diabetes have been diagnosed. Currently, national data suggest that about sixty-six (66) percent of those with diabetes have been diagnosed. 2 If Maine data mirror national data, we would expect that the true diabetes prevalence is about fifty (50) percent higher than that reported on the BRFSS survey. Maine Diabetes Surveillance System 6
  • 14. Prevalence of Diabetes The BRFSS diabetes question does not distinguish between type 1 and type 2 diabetes, which are clinically distinct, have different etiologies, and have different preventive and treatment options. Type 1 is an autoimmune condition in which pancreatic beta-cells, which produce insulin, are destroyed3. This requires people with type 1 diabetes to supplement their blood with insulin3. Type 2 diabetes is a condition that develops gradually, starting with insulin insensitivity, in which body cells do not appropriately utilize insulin, and resulting in full diabetes3. Documented risk factors for type 2 diabetes include low physical activity and weight gain3. Type 2 diabetes is the most common form of diabetes, representing about ninety-five (95) percent of all diabetes3. Therefore, we can safely assume that most diabetes reported on the BRFSS will be type 2. The BRFSS survey samples only adults and we are unable to report prevalence estimates for diabetes among those younger than age 18. Generally, diabetes developed before adulthood is assumed to be type 1 diabetes; however, evidence documents that type 2 diabetes is increasing among children and adolescents4. A primary hypothesis for this phenomenon is the dramatic increase in obesity among the young4. Despite these limitations, the BRFSS remains our only source for statewide estimates for many health conditions and behaviors. The BRFSS data are sufficiently sensitive to document the increase in diabetes shown in national surveys, including those that include blood glucose testing. In addition, the relations between diabetes and risk factors observed in the BRFSS data also mirror those illustrated in the scientific literature. The first two columns of Table 2 show the number of people who were interviewed in each of the past 12 years and the number who reported having been diagnosed with non-gestational diabetes. In the next two columns we present the total number of people in the state that are represented by the sampled population and the estimate of how many people would have reported having diabetes if we had interviewed everybody in the state rather than only a sample. Again, note that these data assume that BRFSS respondents are representative of Maine’s population as a whole. The final column of Table 2 provides the estimated prevalence of non- gestational diabetes in Maine along with its ninety-five (95) percent confidence interval (95% CI). Confidence intervals are a measure of the margin of error associated with each estimate due to sampling and random variability. For example, an estimate of four (4) percent with a 95% CI of 2-6 percent represents a margin of error of +/- 2 percent (4-2=2 and 4+2=6). The number of people in Maine estimated to have diabetes increased from about 34,000 to 77,000 from 1994 through 2005. The increased burden of diabetes will translate into increases in necessary medical services and corresponding increases in the overall cost of health care in Maine due to diabetes. Maine Diabetes Surveillance System 7
  • 15. Prevalence of Diabetes The estimated prevalence of non-gestational diabetes has steadily increased over the 12-year period. The prevalence in 2005 represents over a one hundred (100) percent increase from 1994 (Table 2), a significant increase with respect to clinical and public health practice, as well as in statistical terms (p-value < 0.001). Table 2. The total number of BRFSS participants, the number of participants who reported having been diagnosed with diabetes, the estimated total number of Maine adults, and the number of Mainers estimated, from BRFSS, to have diabetes. The estimated prevalence of diabetes is shown with 95% confidence intervals, Maine BRFSS, 1994-2005. Table 2: Total Number of People Interviewed and Number of People With Diabetes Interviewed Each Year as Part of the Maine Behavioral Risk Factor Surveillance System Estimated Participants who Maine population Number in Total number diabetes Year reported having represented by those Maine with of participants prevalence diabetes interviewed diabetes (95% CI) 1994 1,380 56 928,972 34,114 3.7 (2.6-4.8) 1995 1,277 48 921,401 32,331 3.5 (2.5-4.5) 1996 1,699 84 930,422 39,449 4.2 (3.2-5.2) 1997 1,698 80 932,908 45,848 4.9 (3.8-6.0) 1998 1,615 73 932,982 33,495 3.6 (2.7-4.5) 1999 1,671 98 935,935 50,415 5.4 (4.3-6.5) 2000 4,599 284 944,287 56,449 6.0 (4.9-7.1) 2001 2,417 172 962,803 64,931 6.7 (5.5-7.9) 2002 2,435 188 988,747 71,557 7.2 (6.1-8.3) 2003 2,392 195 1,006,519 74,792 7.4 (6.3-8.5) 2004 3,530 293 1,029,406 76,683 7.5 (6.5-8.5) 2005 3,960 337 1,035,699 77,219 7.5 (6.6-8.4) Maine’s age distribution is older than the United States as a whole, a trend that is increasing with time, as demonstrated by the difference between the crude and age- adjusted prevalence rates shown in Figure 2. The crude prevalence is based only on the number of people with diabetes in Maine and the size of Maine’s population. The age-adjusted prevalence is what Maine’s prevalence would be if Maine had the age- distribution of the United States as a whole in year 2000. For the past five years, the crude prevalence was higher than the age-adjusted prevalence because Maine’s population was older than the nation’s population. The difference between the crude and age-adjusted prevalence is more pronounced in recent years, a function of Maine’s age distribution moving toward older ages faster than the nation’s in recent years. Together, these findings suggest that Maine can expect an increasing burden of diabetes in the future. In addition, this increase will likely exceed that expected nationally due to the aging United States population. Maine Diabetes Surveillance System 8
  • 16. Prevalence of Diabetes An observed increase in the prevalence of a disease may result from an increase in the development of new cases of disease (called incidence) or could represent a spurious increase due to improved diagnosis. Data from the National Health and Nutrition Examination Survey (NHANES) support a true increase in diabetes incidence, but studies also show that the percentage of people with undiagnosed diabetes has declined over time (Diabetes Care, Dec. 2004 article). Figure 2: Year-specific prevalence of non-gestational diabetes in Maine adults, 1994-2005, BRFSS 8 7.2 7.5 7.5 7.5 6.7 7 6.0 7.0 6.8 6.8 Percent with Diabetes 6 5.4 6.7 6.4 4.9 5.8 5 4.2 5.2 3.7 3.6 4 3.5 4.7 Crude 4.2 Age-Adjusted 3 3.6 3.5 3.4 2 1 0 1994 1996 1998 2000 2002 2004 . Thus far, we have presented single year estimates of diabetes prevalence. However, to increase the reliability of prevalence estimates within population subgroups, we calculated 3-year average prevalence estimates. Unless otherwise indicated, subgroup prevalence shown in the following figures represent 3-year averages from years 2003 through 2005. Maine Diabetes Surveillance System 9
  • 17. Prevalence of Diabetes Figure 3 displays age-specific prevalence estimates and 95% confidence intervals for adults in the state. On average, 7.5 percent of Maine adults 18 years of age and older reported ever having been diagnosed with diabetes by a health care provider. The prevalence of diagnosed diabetes increases with age, as demonstrated by the chart. Approximately 17 percent of residents 65 and older have been diagnosed with diabetes, compared to 9.2 percent of people ages 45-64. Adults ages 18-44 have the lowest rate of diagnosed diabetes, estimated at about 2.5 percent. Figure 3: Age-specific prevalence of diabetes of non-gestational diabetes in Maine adults, 2003-2005, BRFSS. 20 18 Percent with Diabetes 16 14 12 10 8 16.6 6 4 9.2 7.5 2 2.5 0 All Ages 18-44 45-64 65+ Figure 4: County-specific, age-adjusted diabetes prevalence estimates, Maine BRFSS, 2003-2005. 16.0 Percent with Diabetes 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 no rd O n e oo in Fr nd Li x Ha lin rk nn k ec ga is m c at t hi o be k W t n sc co se o So ho o ol Ke oc at as ald to Sa aqu Pe x f o Ar gg Yo Kn eb rla k Cu s to nc er St Pi bs ng an da nc co os m dr W An Maine Diabetes Surveillance System 10
  • 18. Prevalence of Diabetes We calculated county-specific diabetes prevalence estimates using 5-years of data, from 2003 through 2005 (Figure 4). There is much overlap in the 95 percent confidence intervals among the counties and between any one county and the overall state estimate, demonstrating a large amount of variability in the estimates. In addition, observed differences among counties may, to some extent, represent differences in how likely an individual is to be diagnosed with diabetes in one county as compared to another. The prevalence of diabetes is slighter higher among men (8.3 percent) than among women (6.7 percent), but this difference is not statistically significant. Figure 5: Gender-specific diabetes prevalence estimates, Maine BRFSS, 2003-2005. Diabetes Prevalence according to Gender 10 9 Percent with Diabetes 8 7 6 5 4 8.3 6.7 3 2 1 0 Male Female Physical activity and body weight are causal factors in the development of type 2 diabetes3. In the Maine BRFSS, diabetes prevalence was significantly higher among respondents who reported having no leisure time physical activity (13.2 percent) compared to the prevalence among those who reported engaging in any leisure time physical activity (5.9 percent). Figure 6: Age-adjusted prevalence of diabetes according to leisure time physical activity Age-adjusted diabetes prevalence according to activity level, Maine adults, BRFSS, 2003-2005 16 14 Percent with 12 Diabetes 10 8 13.2 6 4 5.9 2 0 Leisur e t ime physical act ivit y No leisur e t ime physical act ivit y Activity level Maine Diabetes Surveillance System 11
  • 19. Prevalence of Diabetes Similarly, diabetes was strongly associated with weight, as measured by the Body Mass Index (BMI) (Figure 7). The BMI is commonly used to determine healthy weight and is calculated as weight (in kilograms) divided by height (in meters) squared. A BMI less than or equal to 25 is considered a healthy weight, a BMI between 26 and 30 are overweight, and one greater than 30 is obese. We found that only 2.4 percent of those with BMIs less than 26 reported having diabetes, compared with 7.1 and 17.6 percent of BRFSS respondents who were overweight or obese, respectively. Each increase was statistically significant, as represented by the non-overlapping confidence intervals. A recent study found that type 2 diabetes is more likely to be diagnosed among obese individuals than among non-obese, which may account for some of the prevalence differences shown in figure 7. Figure 7: Diabetes prevalence according to BMI. Diabetes prevalence according to weight, Maine adults, BRFSS, 2003-2005 25 20 Percent with Diabetes 15 10 17.6 5 7.1 0 2.4 Healthy w eight Overw eight Obese Weight status Maine Diabetes Surveillance System 12
  • 20. Prevalence of Diabetes Many health outcomes are associated with income, education, and insurance status. In the BRFSS data, Mainers who reported an income of less than $15,000 per year were about three times as likely to report having been diagnosed with diabetes than were people who reported incomes of more than $25,000 (Figure 8). Similarly, more education was associated with a lower prevalence of diabetes—those with less than high school were about three times as likely to have diabetes as people who graduated from college (Figure 9). Insurance status, however, was not associated with diabetes in these data (data not shown). This might reflect the availability of insurance for low-income people, as well as the possibility that those without insurance are unlikely to receive a diagnosis of diabetes. Figure 8: Diabetes prevalence according to income. Age-adjusted diabetes prevalence according to income, Maine adults, BRFSS, 2003-2005 20 Percent with Diabetes 18 16 14 12 10 8 15.1 6 10.2 4 5.1 2 0 <$15,000 $15-25,000 >$25,000 Incom e Figure 9: Diabetes prevalence according to education. Age-adjusted diabetes prevalence according to education attainment, Maine adults, BRFSS. 2003-2005 18 Percent with Diabetes 16 14 12 10 8 14.0 6 4 8.8 6.8 2 4.8 0 <High school graduate High school graduat e Some college College graduate Education attainm ent Maine Diabetes Surveillance System 13
  • 21. Prevalence of Diabetes People with diabetes are at greater risk of cardiovascular disease. An essential component of managing diabetes is managing cardiovascular disease risk factors, including cholesterol, hypertension, and smoking. People with high cholesterol or hypertension were significantly more likely to have diabetes than people without these health conditions. The prevalence of diabetes among people with high cholesterol was about 14 percent, compared to approximately 6 percent among those without high cholesterol (Figure 10). The difference in diabetes prevalence was similar, though slightly greater, among those with and without hypertension (Figure 11). Smoking was not associated with diabetes (data not shown). Figure 10: Diabetes prevalence in Maine adults with and without high cholesterol. Prevalence of diabetes in Maine adults with and without high cholesterol, BRFSS 2003-2005 18 16 Percent with Diabetes 14 12 10 8 14.3 6 4 5.8 2 0 Told high cholesterol Not told high cholest erol Figure 11: Diabetes prevalence in Maine adults with and without high blood pressure. Prevalence of diabetes among Maine adults with and without high blood pressure, BRFSS 2003-2005 25 Percent with Diabetes 20 15 10 18.6 5 3.6 0 High blood pressure No high blood pressure Maine Diabetes Surveillance System 14
  • 22. Prevalence of Diabetes References 1. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data and Questionnaire. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, 1994-2003. 2. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults. The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998;21:518-524. 3. National Diabetes Data Group. Diabetes in America, 2nd edition. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95-1468, 1995. 4. Bloomarden ZT. Type 2 diabetes in the young: the evolving epidemic. Diabetes Care 2004;27:998-1010. 5. Gregg EW, Cadwell BL, Cheng YJ, et al. Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the U.S. Diabetes Care 2004;27:2806-12. Maine Diabetes Surveillance System 15
  • 23. Healthy Maine 2010 Progress Towards Healthy Maine 2010 and Healthy People 2010 Goals In 2002, the Maine CDC (formerly Bureau of Health) released Healthy Maine 2010: Longer and Healthier Lives, which specifies goals and objectives for ten health priority areas, including chronic disease. Outlined in the chronic disease chapter are six diabetes objectives covering diabetes education, eye examinations, HbA1c testing, lower extremity amputations, and the diabetes death rate. Healthy Maine 2010 is available online at www.maine.gov/dhhs/boh/healthy_maine_2010.htm Of the six objectives issued in Healthy Maine 2010, five are also referenced in CDC’s Healthy People 2010. Healthy People 2010 extends beyond these to additionally include objectives relating to the development of diabetes in the population, foot examinations and sores, gestational diabetes, and other indicators. For complete Healthy People 2010 publication, please go to www.healthypeople.gov In this chapter, we document how Maine is progressing towards the six Healthy Maine 2010 goals. Where an objective is listed in both Healthy Maine 2010 and Healthy People 2010, we include both national and state-level baseline estimates, current status (where available), and objectives. Because Maine’s baseline levels were generally different from the baseline levels of the nation as a whole, the goals in Healthy Maine 2010 often differ from those in Healthy People 2010. Current status is assessed using the most recent data, which differs across datasets. We report 2003, 2004, and 2005 BRFSS data and 2005 hospitalization and death data. Table 3:Increase the proportion of Maine adults with diabetes who have taken a course or class in managing diabetes to 80 percent. Year(s) U.S. Estimate Maine Estimate 2003 55% 61.2% 2005 55.5% (2004) 60.4% 2010 goal 60% 80% Table 4: Increase the proportion of Maine ADEF/DSMT Program participants with diagnosis ≤ 5 years to 95 percent. (This is a Maine-specific goal.) Year(s) U.S. Estimate Maine Estimate 2003 Not applicable 77% 2005 Not applicable 79% 2010 goal Not applicable 95% Maine Diabetes Surveillance System 16
  • 24. Healthy Maine 2010 Table 5:Increase the proportion of people with diabetes who have an annual eye examination to 85 percent. Year(s) U.S. Estimate Maine Estimate 2003 50.9% 72.9% 2005 Not available 75.4% 2010 76% 85% Table 6:Increase the proportion of adults with diabetes who have a hemoglobin A1c test at least once a year to 95 percent. Year(s) U.S. Estimate Maine Estimate 2003 24% 86% 2005 Not available 91.3% 2010 goal 50% 95% Table 7:Reduce the rate of lower extremity amputations in adults with diabetes to 1.8 per 1,000 people with diabetes. Year(s) U.S. Estimate Maine Estimate 2003 4.8 2.7 2005 Not available 1.8 2010 goal 2.9 1.8 *These estimates are for people age 18 and older as reported to the BRFSS. Table 8:Reduce the diabetes death rate (any cause) to 65 per 100,000 population. Year(s) U.S. Estimate Maine Estimate 2003 78 (2002) 80.8 per 100,000 population 2005 Not Available 77.5 2010 goal 45 65 Maine Diabetes Surveillance System 17
  • 25. Hospitalizations Diabetes-Related Hospitalizations in Maine Hospitalizations from Diabetes In Maine Residents We show the number of hospitalizations for diabetes as the first listed cause or as any listed cause of hospitalization, and the number of hospitalizations with a first listed cause of cardiovascular disease and secondary cause of diabetes (Table 9). To allow comparisons with national data, we included only individuals whose diabetes diagnosis was listed in fields 1 through 7 of the hospitalization database, where field 1 provides the first-listed, or principle, diagnosis, the reason for hospitalization, and fields 2-7 are secondary, or contributing, causes of hospitalization. Comparing 1994 and 2005, the absolute number of hospitalizations for diabetes as any cause increased by about 25-30 percent. People with diabetes are at higher risk for cardiovascular disease morbidity and death. There were approximately 5,500 hospitalizations in 2005 for cardiovascular disease (as first listed) with any mention of diabetes. Table 9: Diabetes Related Hospitalizations in Maine (1994-2005) Year Diabetes as the first-listed Diabetes as any cause of Cardiovascular disease cause of hospitalization hospitalization as first-listed, diabetes as second-listed 1994 1,489 16,352 5,666 1995 1,475 16,674 5,804 1996 1,422 17,608 6,300 1997 1,540 18,188 6,737 1998 1,541 19,086 6,784 1999 1,719 19,420 6,451 2000 1,746 20,543 6,718 2001 1,774 20,777 6,446 2002 1,644 20,770 6,174 2003 1,695 21,354 6,095 2004 1,592 21,679 5,838 2005 1,513 20,863 5,529 Figure 12 presents age-adjusted hospitalization rates for diabetes as any listed cause in Maine residents from 1994 through 2005 and in U.S. residents from 1994 through 2003. From 1994 to 2005, the age-adjusted hospitalization rate in Maine increased from 126 to 135 per 10,000 population. Maine’s rate appears to have leveled off in 2000, with a decline in the final year of observation. It is unclear whether the reduced rates will remain or continue to decline or whether they represent random variability. Like Maine, the U.S. rates have increased over the past decade, from a rate of 138 in 1994 to a rate of 176 per 10,000 in 2005. Age- adjusted rates of the U.S. remained higher than those for Maine throughout the time period, which may be accounted for, in part, by differences in racial/ethnic composition. Maine Diabetes Surveillance System 18
  • 26. Hospitalizations Figure 12: Age-adjusted rates of diabetes hospitalization, any listed cause, Maine, 1994-2005, and U.S., 1994-2003. 200 180 160 Rate per 10,000 population 140 120 Maine 100 U.S. 80 60 40 20 0 1993 1995 1997 1999 2001 2003 2005 Maine Diabetes Surveillance System 19
  • 27. Hospitalizations Diabetes hospitalization rates for Maine adults with diabetes are shown in Figure 13. We were unable to compare Maine’s rates to the U.S. rates because the U.S. rates reflect the total population with diabetes, while Maine has data on the number of adults with diabetes only. We restricted the analysis to the past 5 years in order to limit the effect of bias due to improved diabetes diagnosis over time. Between 2001 and 2005, rates have declined from 273 to 223 per 1,000 people with diabetes, though the change has not been incremental over time. Figure 13: Age-adjusted rates of diabetes hospitalization among adults with diabetes, any listed cause, Maine, 2001-2005. 300 250 Rater per 1,000 population 200 150 100 50 0 2000 2001 2002 2003 2004 2005 2006 Between 1994 and 2005, there was minimal variability in the rates of hospitalization for diabetes as the first listed cause shown in Figure 14. In Maine, those rates varied between 10.7 and 13.2 per 10,000 population. The U.S. had higher rates, with 18.9 and 20.4 hospitalizations per 10,000 population. Figure 14: Age-adjusted rates of diabetes hospitalization, first listed cause, total population, Maine, 1994-2005, and U.S., 1994-2003 25 Rate per 10,000 population 20 15 Maine U.S. 10 5 0 1993 1995 1997 1999 2001 2003 2005 Maine Diabetes Surveillance System 20
  • 28. Hospitalizations Among Mainers with diabetes, the age-adjusted rates of hospitalization for diabetes as the first listed cause declined from 37.2 to 23.6 per 1,000 between 2001 and 2005 as shown in Figure 15. However, these declines were inconsistent, with drop to just under 30 per 1,000 in 2002 followed by an increase nearly as high as that in 2001. Figure 15: Age-adjusted rates of diabetes hospitalization among adults with diabetes, first listed cause, Maine, 2000-2004. 40 Rate per 1,000 population 35 30 25 20 15 10 5 0 2000 2001 2002 2003 2004 2005 2006 The Maine rates of hospitalization for non-traumatic lower extremity amputations have been variable over the past decade, with an apparent trend downwards, especially in the last year of observation (2005) as shown in Figure 16. Approximately 2.0 to 2.5 people per 10,000 total population have been hospitalized per year. U.S. rates were slightly higher, with about 2.5 to 3.0 per 10,000. Figure 16: Age-adjusted rates of hospitalization for non-traumatic lower extremity amputation, any listed cause, Maine, 1994-2005, and U.S., 1994-2003. Rate per 10,000 populatin 3.5 3.0 2.5 2.0 Maine 1.5 U.S. 1.0 0.5 0.0 1993 1995 1997 1999 2001 2003 2005 Maine Diabetes Surveillance System 21
  • 29. Hospitalizations Hospitalization rates for keto-acidosis appear to have increased in both Maine and the U.S. over the observation period as shown in Figure 17. In 1994 there were 2.3 hospitalizations for keto-acidosis (first listed cause) per 10,000 Mainers and 2.9 per 10,000 in 2005 . In the U.S., hospitalization rates increased from 3.4 per 10,000 to 4.0 from 1994 to 2003. Figure 17: Age-adjusted rates of hospitalization for keto-acidosis, first listed cause, Maine, 1994-2005, and U.S., 1994-2003. Rate per 10,000 population 4.5 4 3.5 3 2.5 Maine 2 U.S. 1.5 1 0.5 0 1993 1995 1997 1999 2001 2003 2005 Cardiovascular disease is a major cause of morbidity among people with diabetes. In Figure 18 we present hospitalization rates of cardiovascular disease as first listed cause with any mention of diabetes as a contributing cause. Between 1994 and 2005, age-adjusted rates in Maine have declined from 43.6 to 35.1 per 10,000. Over the same time period (through 2003), U.S. rates have increased. In 1994, rates for Maine and the U.S. were about the same, with 44 hospitalizations per 10,000; By 2003, the U.S. rate had increased to 50.6 hospitalizations per 10,000, while the Maine rate was slightly lower at 40.3 per 10,000. Figure 18: Age-adjusted rates of hospitalization for cardiovascular disease, first listed, and diabetes, any listed cause, Maine, 1994-2005, and U.S., 1994-2003. Rate per 10,000 population 60 50 40 Maine 30 U.S. 20 10 0 1993 1995 1997 1999 2001 2003 2005 Maine Diabetes Surveillance System 22
  • 30. Diabetes Related Mortality in Maine Diabetes Related Deaths in Maine Introduction Maine’s Office of Data, Research and Vital Statistics collects mortality data in accordance with the National Center for Health Statistics guidelines. Mortality data provide a source of demographic, geographic, and cause of death information for all deaths in Maine. State-level mortality data are processed following a standard protocol created by the National Center for Health Statistics, making mortality data comparable to other state data. Mortality data have limitations, especially where diabetes is concerned. Diabetes is co-morbid to many conditions causing death and is believed to be under-reported as a cause of death on death certificates. 1-2 Despite this, mortality data are uniformly reported and may offer valuable information on trends over time and state-to-nation comparisons. Deaths from diabetes In Maine Residents The following table shows the number of deaths of all causes in Maine residents, the number of deaths due to diabetes as any cause or as the underlying cause of death, and the percentage of total deaths that had diabetes listed as a cause of death. During the 12-year period, 1994 to 2005, the absolute number of deaths from diabetes as any cause increased by 26 percent, and the number of deaths due to diabetes as the underlying cause of death increased by 24 percent. Diabetes also grew to account for a greater percentage of all deaths over the 12-year period. The percentage of total deaths that were due to diabetes as any cause increased from 8.4 percent in 1994 to 9.5 percent in 2005, an increase of 13 percent. Similarly, the percentage of total deaths due to diabetes as the underlying cause increased from 2.7 percent in 1994 to 3.0 percent in 2005, an increase of 11 percent. These data are consistent with other evidence of a growing burden of diabetes in Maine and the nation. However, the possibility that these numbers may, to some degree, reflect improved coding of diabetes, as a cause of death should not be discounted. Maine Diabetes Surveillance System 23
  • 31. Diabetes Related Mortality in Maine Table 10 Year Total deaths in Diabetes as any cause of Diabetes as underlying cause of Maine death (percentage of total death (percentage of total deaths) deaths) 1994 11,292 951 (8.4%) 307 (2.7%) 1995 11,375 1,016 (8.9%) 307 (2.7%) 1996 11,333 945 (8.3%) 296 (2.6%) 1997 11,607 1,067 (9.2%) 288 (2.5%) 1998 11,739 1,073 (9.1%) 328 (2.8%) 1999 12,233 1,108 (9.1%) 348 (2.8%) 2000 12,337 1,187 (9.6%) 356 (2.9%) 2001 12,403 1,199 (9.7%) 398 (3.2%) 2002 12,670 1,249 (9.9%) 405 (3.2%) 2003 12,525 1,225 (9.8%) 397 (3.2%) 2004 12,441 1,154 (9.3%) 382 (3.1%) 2005 12,769 1,218 (9.5%) 382 (3.0%) Figure 19 tracks crude and age-adjusted death rates for diabetes as any listed cause in Maine residents from 1994 through 2005. Over this period, the crude death rate increased from 7.7 to 9.2 per 10,000 population, or about 20 percent. A large part of Maine’s increase appears due to the aging of Maine’s population, based on comparison to the age-adjusted death rate. The age-adjusted death rate is the rate that would be observed in Maine if Maine had, the same age distribution as the United States had in year 2000. The crude death rate is only slightly higher than the age-adjusted rate in 1994, but these rates diverge over time. With a stable age distribution equal to that of the nation in year 2000, Maine’s diabetes death rate would have increased from 7.3 to 7.7 per 10,000 population. Figure 19: Age-adjusted and crude rate of death from diabetes as any cause, Maine, 1994 - 2005. 12.0 Death rate per 10,000 population 10.0 8.0 Crude rate 6.0 Age-adjusted rate 4.0 2.0 0.0 1993 1995 1997 1999 2001 2003 2005 Year Maine Diabetes Surveillance System 24
  • 32. Diabetes Related Mortality in Maine Figure 20 illustrates age-specific death rates per 10,000 in Maine due to diabetes as any listed cause, 1994-2005. As expected, the largest number of diabetes deaths occurred in those aged 75 years and older, with rates per 10,000 people between 66 (in 1994) and 84 (in 2000). Figure 20: Maine’s Age-Specific Mortality Due to Diabetes 90 84 82 78 77 80 76 75 75 73 72 Death rate per 10,000 population 69 66 67 70 60 50 0 to 44 45 to 64 40 65 to 74 34 33 31 75 plus 28 29 29 30 29 28 28 28 30 26 20 5.6 5.7 6.0 5.8 5.5 10 5.4 5.2 5.3 5.0 4.4 4.5 5.0 0.2 0.2 0.2 0.2 0.3 0.2 0.3 0.3 0.3 0.4 0.3 0.3 0 1993 1995 1997 1999 2001 2003 2005 Year Maine Diabetes Surveillance System 25
  • 33. Diabetes Related Mortality in Maine Figure 21 displays age-adjusted, gender- and year-specific rates of death from diabetes as any listed cause, for years 1994 through 2005. Based on these data, it appears that greater increases in the age-adjusted diabetes death rate may have occurred in men than in women over this 12-year period, although death rates for men increase about 2 per 10,000 over this time-frame, the trend does not appear to increase consistently over time. Figure 21:Age-Adjusted Gender Mortality Due to Diabetes as Any Listed Cause 12 10.2 9.6 9.5 9.6 10 9.2 9.1 9.2 8.8 8.7 8.7 Death rate per 10,000 population 8.1 8.0 8 7.5 7.3 7.1 7.0 7.0 6.7 6.7 6.9 6.7 6.5 6.4 6.3 Female 6 Male 4 2 0 1993 1995 1997 1999 2001 2003 2005 Year Maine Diabetes Surveillance System 26
  • 34. Diabetes Related Mortality in Maine The age-adjusted death rate of diabetes as an underlying cause of death does not increase consistently over time during the 12-year period, 1994-2005. Starting and ending at 2.4 per 10,000 population (Figure 22). Upon closer examination we see a decrease from 2.4 (in 1994) to 2.1 (in 1997) per 10,000 population, then an increase to 2.7 (in 2001 and 2002) followed by a decrease to 2.4 (in 2005). Across the 1994– 2003 time period, national diabetes death rates increased, but the national year- specific estimates and the national data specific to whites display greater stability due to the larger sample. Figure 22: Age-adjusted Mortality Due to Diabetes as an Underlying Cause of death, Maine, 1994-2005, the US, 1994-2003, and US White, 1994-2003. 3 2.7 2.7 2.6 2.5 2.5 2.4 2.5 2.5 2.5 2.4 Age-Adjusted Death rate per 10,000 population 2.5 2.5 2.3 2.3 2.3 2.3 2.2 2.2 2.3 2.3 2.3 2.3 2.3 2 2.2 2.2 2.1 2.1 2.1 Maine 1.5 U.S. U.S. white 1 0.5 0 1992 1994 1996 1998 2000 2002 2004 2006 Year References 1. Andresen EM, Lee JA, Pecoraro RE, Koepsell TD, Hallstrom AP, Siscovick DS. Underreporting of diabetes on death certificates, King County, Washington. Am J Public Health 1993;83:1021-1024. 2. Bild DE, Stevenson JM. Frequency of recording diabetes on US death certificates: analysis of the 1986 National Mortality Followback Survey. J Clin Epidemiol 1992;45:275-281. Maine Diabetes Surveillance System 27
  • 35. Diabetes Treatment, Knowledge, and Self-Care Behavior Diabetes Treatment, Knowledge and Self-Care Behavior Introduction Here we assess several treatment practices by comparing BRFSS responses to national standards of care. These data provide information on the medical care and self-care of Mainers with diabetes. The American Diabetes Association (ADA) publishes annual clinical practice recommendations for the care of people with diabetes. The treatment and self-care indicators presented here are discussed in the ADA Clinical Practice Recommendations: 20071. Although BRFSS cannot be used to examine all ADA recommendations, data are available on many topics described in the recommendations. Unless otherwise indicated, all analyses represent the combined population of BRFSS respondents from 2003-2005. Treatment and Self-Care Behavior Health Care Visits We considered the number of visits with a health care provider per year as an indication of medical management. This treatment indicator provides a measure of the number of visits with a health provider, but does not capture appointments that were recommended but not made or those made but not kept. Among respondents with diabetes: • 12 percent reported not having had a visit with a healthcare provider in the past year. • Approximately 9 percent had one visit with a health care provider, 24 percent had 2-3 visits, • 28 percent had 4 visits, • 27 percent had 5 or more visits with a healthcare provider in the past 12 months. Table 11: BRFSS Respondents with Diabetes the Number of Health Care Visits for Diabetes in Past Year Number of visits with health care provider for Percent with response (95% CI) diabetes in past 12 months 5 or more 27.0 (23.5 – 30.8) 4 28.2 (24.8 – 31.9) 2 or 3 24.1 (20.8 – 27.8) 1 8.6 (6.5 – 11.3) None 12.1 (9.7-15.1) Maine Diabetes Surveillance System 28
  • 36. Diabetes Treatment, Knowledge, and Self-Care Behavior Eye care2 Diabetic retinopathy is the most common cause of blindness in adults2. People with diabetes need regular eye examinations. In people living with diabetes for two decades, more than 60 percent of people with type 2 diabetes and most people with type 1 diabetes will have developed retinopathy2. ADA recommendations state that people with type 2 diabetes should receive annual eye examinations, with the option of less frequent exams (2-3 years) under advice of an eye care professional2. People with type 1 diabetes should also receive annual eye exams, although their first exam is not needed until 3-5 years after diagnosis2. We report the time since last dilated eye exam and whether told by a physician that diabetes is affecting eyes. Approximately 73 percent of people with diabetes had had a dilated eye exam within the past year, 12 percent had a dilated eye exam between 1 and 2 years ago, and approximately 7 percent reported never having had a dilated eye exam. Nearly a quarter reported having been told by a physician that diabetes is affecting their eyes. Table 12: Percent of BRFSS Respondents with Diabetes that had an Eye Exam Time since last dilated eye exam Within one year 72.7 (68.9 – 76.3) Within 2 years 12.3 (9.9 – 15.2) More than two years ago 8.3 (6.3 – 10.8) Never 6.6 (4.6 – 9.4) Told by physician that diabetes is affecting 23.5 (20.3 – 27.1) eyes Foot care People with diabetes should have an annual foot examination to identify foot conditions prior to the development of more serious complications3. People with high-risk foot conditions should be evaluated more frequently than once a year3. This is especially important in populations at highest risk for foot ulcers or amputations including men, those with poor glucose control or vascular complications, and those having had diabetes for ten years plus3. We present data on the number of foot exams BRFSS participants reported having in the past year and whether they have ever had a foot sore that took at least 4 weeks to heal. Among people with diabetes: • about 70 percent reported having at least one foot exam during a visit to a health provider in the past year, Maine Diabetes Surveillance System 29
  • 37. Diabetes Treatment, Knowledge, and Self-Care Behavior • 18 percent reported having visited a health care provider but not having received a foot exam, • 12 percent reported not having visited a health care provider, • 11 percent of respondents with diabetes had a foot sore that took at least 4 weeks to heal. Table 13: Number of Foot Exams in Past Year for BRFSS Respondents with Diabetes Number of foot exams by health care provider in past year Visited health provider in past year and had at least one foot exam 69.8 (65.9 - 73.3) Visited health provider in past year but did not have a foot exam 17.8 (14.9 - 21.2) No visits with a health provider in past year 12.4 (9.9 - 15.4) Ever had a foot sore that took at least four weeks to heal 11.1 (8.8 – 13.7) Monitoring Glucose Control Glycemic control is a key element in preventing major complications from diabetes4, 5 and is associated with decreased microvascular and cardiovascular disease6. Among people with type 2 diabetes, the recommended frequency of self-monitoring of blood glucose will vary according to the specific needs of the individual; however, monitoring frequency should be sufficient to maintain glucose control6. Hemoglobin A1c which reflects mean blood glucose levels over the preceding 2 to 3 months, should be measured at least twice a year6. BRFSS respondents with diabetes reported they monitored their own blood glucose: • 64 percent monitored at least once per day, • 25 percent monitored less than daily, • 10 percent never monitored their own glucose. 91 percent of BRFSS respondents reported having had an HbA1c test in the past year. Table 14: Frequency of Blood Glucose Monitoring and HbA1c testing Frequency of blood glucose monitoring At least daily 64.1 (60.1 – 67.9) Less than daily 25.5 (22.2 – 29.1) Never 10.4 (8.1 – 13.4) Frequency of hemoglobin A1c monitoring in past 12 months Any test 91.3 (88.6 – 93.4) No test in past 12 months 8.7 (6.6 – 11.4) Maine Diabetes Surveillance System 30
  • 38. Diabetes Treatment, Knowledge, and Self-Care Behavior Smoking People with diabetes are at higher risk for cardiovascular disease, as are people who smoke7. Smoking is also associated with the development of complications and the rate at which complications progress7. Smoking cessation counseling is effective in people with diabetes7. However, it is believed that the risks associated with smoking have not been sufficiently communicated to people with diabetes or to providers7. In 2004, 23 percent of the people in Maine with diabetes reported they currently smoke. Age Adjusted 199 199 199 199 199 200 200 200 200 2004 Rates 5 6 7 8 9 0 1 2 3 Population with 22.5 24.9 21.1 19.3 19.1 23.2 26.0 27.2 24.5 23.0 Diabetes Population 25.0 25.3 22.7 22.4 23.3 23.8 23.9 23.6 23.6 21.0 without Diabetes Immunizations People with diabetes: • have abnormalities in immune function and increased risk of morbidity and mortality due to infection • are at high risk for complications, hospitalization, and death from influenza and pneumococcal disease • generally have appropriate immune response to vaccination8. The ADA recommends a pneumococcal and annual influenza vaccinations for people with diabetes8. According to BRFSS data, nearly 56 percent of people with diabetes reported having received a pneumonia vaccine and about 63 percent reported having had a flu shot in the past 12 months. Table 15: Percent with Pneumonia or Influenza Had pneumonia vaccine 55.7 (51.6-59.8) Had flu shot in past 12 months 62.7 (58.8-66.6) Maine Diabetes Surveillance System 31
  • 39. Diabetes Treatment, Knowledge, and Self-Care Behavior Hypertension and Lipids Because of the increased risk for cardiovascular disease among people with diabetes, lipid levels should be evaluated annually in adults9. In clinical trials, treatment of LDL (low-density lipoprotein or “bad cholesterol”) in people with diabetes decreased the occurrence of cardiovascular events9. Nearly 94 percent of adults with diabetes surveyed reported having had their cholesterol tested. Of those about 57 percent were told that they have high cholesterol. Table 16: Percent of Persons with Diabetes Reported they have High Cholesterol Cholesterol tested 93.7 (90.8 – 95.7) Told have high cholesterol 57.1 (51.9 – 62.1.9) Hypertension increases the risk of micro- and macrovascular complications in people with diabetes and is a common comorbid condition in both type 1 and 2 diabetes10. Blood pressure should be measured at every office visit10. In BRFSS, about 64 percent of adults with diabetes reported having high blood pressure, of those, 93 percent reported being treated. Table 17:Percent of Persons with Diabetes Reported having Hypertension Told have high blood pressure 62.4 (57.3-67.5) Treated for high blood pressure if told have high blood 92.5 (89.4 – 95.6) pressure Physical Activity Physical activity has been associated with improved carbohydrate metabolism, decreased obesity, and decreased risk of cardiovascular disease11. Among people who reported having diabetes on the BRFSS survey, 38 percent reported no leisure time physical activity. Diabetes Educational Course Only 57.7 percent (95% CI: 52.2-61.9) of respondents who reported having been diagnosed with diabetes reported having taken a diabetes educational course. Maine Diabetes Surveillance System 32
  • 40. Diabetes Self-Management Education Diabetes Self-Management Education (DSME) “Diabetes Self-Management Education (DSME) is the cornerstone of care for all individuals with diabetes who want to achieve successful health related outcomes”.12 Referral for DSME is recommended for all people with diabetes.12 The benefits to the person with diabetes and health-care cost-savings are well documented in the literature.12, 13,14,15 DSME is a covered medical service in Maine when it is provided through a state and/or national certified program.16 The Maine ADEF Program The Ambulatory Diabetes Education and Follow-up (ADEF) Program is a comprehensive DSME program anchored to the National Standards for Diabetes Self-Management Education. The program was developed in 1979 by the Maine CDC’s Diabetes Control Program (DCP), now know as the Diabetes Prevention and Control Program (DPCP) with the assistance of a Statewide Task Force of Diabetes Educators and is periodically renewed and updated to reflect the current national standards and ADA Clinical Practice Recommendations for care of people with diabetes.1 The ADEF Program is delivered through state-certified sites by health- care professionals educated on the delivery of the program and data reporting responsibilities. Uniform ADEF Program reporting is accomplished using a data form packet (nine-pages) to document DSME services. There are currently 35 ADEF Program sites throughout Maine. Maine Diabetes Surveillance System 33
  • 41. Diabetes Self-Management Education Using ADEF Program Data to Estimate Referrals to Diabetes Self-Management Education (DSME) Ave ADEF Program data are routinely County 2003 2004 2005 Number collected at assessment. The data Androscoggin 164 139 98 134 are a combination of clinical Aroostook 359 338 362 353 measurements taken by health Cumberland 288 202 126 205 care professionals and information Franklin 24 16 10 17 self-reported by program Hancock 68 64 66 66 participants. It should be noted that Kennebec 302 247 226 258 these data represent people who Knox 188 172 121 160 have both been referred to the Lincoln 60 38 37 45 ADEF Program and participated in Oxford 104 55 39 66 Penobscot 220 198 114 177 at least part of the program. Piscataquis 31 35 10 25 Individuals who were referred, but Sagadahoc 68 45 29 47 for whatever reason did not Somerset 107 108 111 109 participate in the program are not Waldo 96 34 19 50 represented in the following data. Washington 32 11 9 17 We also do not distinguish York 351 277 191 273 between people who completed the yearlong ADEF Program from County total 2462 1979 1568 2003 those who completed only some of County not the program. Finally, in certain reported 67 135 339 Totals 2529 2114 1907 2183 portions of the analysis we compare ADEF participants to BRFSS respondents who reported having ever been diagnosed with diabetes. While it is interesting to note similarities and differences, one must remember that BRFSS assesses the lifetime prevalence of diabetes while in what follows, we are studying only 3-years of ADEF participation. Data collected by the DPCP from ADEF program sites throughout the state are tabulated on a regular basis. For years 2003-2005, statewide participation in the ADEF Program decreased each year (Table 18). ADEF Program participation also decreased annually for many of the counties with ADEF sites (Table 18). This trend, if accurate is of significant concern. Given that diabetes prevalence is increasing, we would expect to see year to year growth, not decline, in the DSME referrals. Table 19 shows the number of ADEF participants for the years 1997 through 2005. Maine Diabetes Surveillance System 34
  • 42. Diabetes Self-Management Education Table 18: ADEF/DSME Referrals Per County for 2003-2005 Table 19: ADEF Participation 3500 2884 3000 2529 2500 2270 1989 1915 2114 1786 1907 2000 1694 1500 1000 500 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Distribution of Diabetes by Type The table below (Table 20) shows the distribution of type of diabetes from 2003-2005 ADEF data. Type 1 made up 2 percent of the total while type 2 comprised 98 percent of participants. The gender distribution was similar for both types of diabetes. In addition, Table 20 illustrates the breakdown of treatment methods used by people with type 2 diabetes. Among people with type 2 diabetes, about 46 percent were treated with an oral agent, 41 percent were using diet alone to control their diabetes, about 5 percent were using insulin, and 6 percent were using a combination of insulin and an oral agent. Again, these results were similar for men and women. Table 20: Distribution of Types of Diabetes Type Total % Male % Female % Type 1 2.1 54 2.3 57 1.9 Type 2 – Total 97.9 2,308 97.7 2,983 98.1 Type 2 – Diet 41.1 871 36.9 1,349 44.4 Type 2 - Oral Agent 46.1 1,183 50.1 1,307 43.0 Type 2 – Insulin 4.7 119 5.0 134 4.4 Type 2 - Insulin + Oral 6.1 135 5.7 193 6.4 Maine Diabetes Surveillance System 35
  • 43. Diabetes Self-Management Education Length of Time From Diagnosis to Referral Figure 23: Length of Time From Diagnosis to Referral 21% <=1 year 2-5 13% 66% years >5 years Between 2003 and 2005, about 66 percent of people referred to the ADEF Program reported they were diagnosed with diabetes within the past year. This is up from 63 percent from the previous 3-year period (2000-2002), suggesting the possibility that as the program continued, a greater proportion of ADEF participants were being referred earlier than in the past. In the 2003–2005 time period, 13 percent reported being diagnosed 2-5 years before referral to the ADEF Program, and the remaining 21 percent reported having been diagnosed more than five years before referral. Age Distribution Figure 24: Age Distributions of Persons Referred to ADEF/DSME Percentage of ADEF 20.0 14.9 13.8 participants 15.0 13.1 13.0 10.6 9.4 10.0 6.4 6.5 5.0 5.0 3.7 3.5 0.0 <35 35- 40- 45- 50- 55- 60- 65- 70- 75- 80 39 44 49 54 59 64 69 74 79 Plus Between 2003 and 2005, the proportion of total ADEF participants increased with age up to age 60 and then declined. Each of the 6 five-year age groups between 45 and 74 years old represented between 9 and 15 percent of ADEF participants. People less than 45 and greater than 74 combined represented a quarter of the ADEF population. Maine Diabetes Surveillance System 36
  • 44. Diabetes Self-Management Education Weight Distribution According to data reported 67 percent of the ADEF population were obese (BMI=>30), 24 percent were overweight, and about eight percent were neither overweight nor obese. Figure 25:Distribution of Body Mass Index (BMI) of ADEF Participants Percentage of ADEF 80 67.5 participants 60 40 24.3 8.2 20 0 <25 25-29.9 30+ Maine Diabetes Surveillance System 37
  • 45. Diabetes Self-Management Education Gender Distribution The majority of ADEF participants were women: 55.8 percent were female and 44.2 were male. A similar distribution was observed in the previous 3-year period, 2000-2003. Figure 26: Gender Distribution of ADEF Participants 60 Percentage of ADEF 50 participants 40 30 55.8 20 44.2 10 0 Male Female Hospitalization and Medical Conditions by Gender For the years 2003 thru 2005, prior to attending ADEF Program 1,226 (22.6 percent) ADEF participants reported having been hospitalized at least once for any cause in the year prior to attending ADEF. Approximately 9 percent of participants reported being hospitalized for diabetes. Thus, about 40 percent of those hospitalized were for a diabetes-related cause. Less than 1 percent reported having been hospitalized for a lower extremity amputation (LEA). Figure 27: Hospitalizations of ADEF Participants In year prior to attending ADEF 25 22.6 Percent of ADEF participants 20 15 10 9 5 0.62 0 Any hospitalization Diabetes-related hospitalization LEA hospitalization Type of hospitalization Maine Diabetes Surveillance System 38
  • 46. Diabetes Self-Management Education The proportions match the overall gender breakdown in the ADEF population between 2003 and 2005, 54 percent female and 46 percent male. Therefore, gender does not appear to be associated with all-cause hospitalization. When we examine diabetes-related hospitalizations, we note that males make up the about one half of hospitalizations, 49 percent of diabetes-related hospitalizations were male compared to 51 percent female, this is a decline in percentage from the previous data period (2000 –2003) when males made up the majority at 55 percent. However, when we examine LEA hospitalizations, 70 percent are male. In this ADEF population from 2003-2005, males appear to have experienced a disproportionate burden of LEA related hospitalizations, these percentages are similar to the 2 pervious data periods (2000 –2003) and (1997 –1999) males made up about 70 percent in each data period. This could suggest that females are referred to ADEF at earlier and less severe stages of diabetes. Alternatively, males and females could be referred to ADEF equally, but males at a later stage of disease are more likely to participate. Distribution of all-cause, diabetes-related, and lower extremity amputation (LEA) hospitalization by gender. Table 21:Hospitalizations rates by Gender of ADEF Participants prior to attending ADEF Male Female All-cause hospitalization 46 54 Diabetes-related 49 51 hospitalization LEA hospitalization 70 30 Maine Diabetes Surveillance System 39
  • 47. Diabetes Self-Management Education Hypertension and Heart Disease Between the years 2003 and 2005, 64.2 percent of ADEF Program participants reported having hypertension. Of those, 44 percent were male and 56 percent were female, mirroring the overall distribution of the ADEF population in this time frame. Heart disease was reported by 27 percent of ADEF participants. More males (31 percent) reported having heart disease than females (24 percent) as shown in Figure 28. Figure 28: Percent of ADEF Participants with Heart Disease 35 30 Percentage with heart disease 25 20 15 31 24 10 5 0 Male Female HbA1c Measures For the years 2003 to 2005, 80 percent (5,185 ADEF participants) reported that they had received an HbA1c test in the year prior to attending the program. Of those, 44.2 percent were male and 55.8 percent were female, mirroring the overall distribution of the ADEF population in this time frame. Figure 29: ADEF Participants with an HbA1c Test HbA1c Testing of Participants in the Year Prior to Attending ADEF Program 20% Test No test 80% Maine Diabetes Surveillance System 40
  • 48. Diabetes Self-Management Education Eye Exams Nearly 63 percent of 5,158 participants reported having an eye exam in the year prior to referral to the ADEF Program. Of those, 42.5 percent were male and 57.8 percent were female, showing little difference between men and women in eye exams. Figure 30: Percent of ADEF Participants with an Eye Exam Proportion of ADEF Participants w ith Eye Exam in the Year Prior to Attending ADEF Program 37% Exam No exam 63% Monofilament Test Only approximately a third of ADEF participants received a monofilament sensory test prior to their enrollment in the ADEF Program in the years from 2003 through 2005. Figure 31: Percent of ADEF Participants Reported Having a Monofilament test Proportion of ADEF Participants Who Received a Monofilam ent Test in the Year Prior to Attending ADEF Program 32% Test No t est 68% Maine Diabetes Surveillance System 41
  • 49. Diabetes Self-Management Education References 1. Diabetes Care 2007; 30 (Suppl 1). 2. Fong DS, Aiello L, Gardner TW, et al. Retinopathy in diabetes. Diabetes Care 2004; 27 (Suppl 1):S84-S87. 3. American Diabetes Association. Preventive foot care in diabetes. Diabetes Care 2004; 27 (Suppl 1):S63-S64. 4. The Diabetes Control and Complications Trial Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin- dependent diabetes mellitus. N Engl J Med 1993;329:977-986. 5. UK Prospective Diabetes Study Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998;352:837-853. 6. American Diabetes Association. Tests of glycemia in diabetes. Diabetes Care 2004; 27 (Suppl 1):S91-S93. 7. American Diabetes Association. Smoking and diabetes. Diabetes Care 2004; 27 (Suppl 1):S74-S75. 8. American Diabetes Association. Influenza and pneumococcal immunization in diabetes. Diabetes Care 2004; 27 (Suppl 1):S111-S113. 9. American Diabetes Association. Dyslipidemia management in adults with diabetes. Diabetes Care 2004; 27 (Suppl 1):S68-S71. 10. American Diabetes Association. Hypertension management in adults with diabetes. Diabetes Care 2004; 27 (Suppl 1):S65-S67. 11. American Diabetes Association. Physical activity/exercise and diabetes. Diabetes Care 2004; 27 (Suppl 1):S58-S62. 12. Mensing C, Boucher J, Cypress M, et al. National standards for diabetes self- management education. Diabetes Care 2004;27:S143-S150. 13. Schwartz R, Zaremba M, Knut R. Third party coverage for diabetes education programs. Quality Review Bulletin: Journal of Quality Assurance 1985;11:213-217. 14. Mazzuca SA, Moorman NH, Wheeler ML, et al. The diabetes education study: a controlled trial of the effects of diabetes patient education. Diabetes Care 1986;9:1-10. 15. Brown SA. Effects of educational interventions in diabetes care: a meta-analysis of findings. Nursing Research 1988;37:223-230. 16. Public Law 592. An act to require that diabetes supplies and self-management training be covered by health insurance policies. H.P. 1242-L.D. 1702. Maine Diabetes Surveillance System 42
  • 50. The Department of Health and Human Services (DHHS) does not discriminate on the basis of disability, race, color, creed, gender, age, sexual orientation, or national origin, in admission to, access to or operation of its programs, services, activities or its hiring or employment practices. This notice is provided as required by Title II of the Americans with Disabilities Act of 1990 and in accordance with the Civil Rights Acts of 1964 as amended, Section 504 of the Rehabilitation Act of 1973 as amended, the Age Discrimination Act of 1975, Title IX of the Education Amendments of 1972 and the Maine Human Rights Act. Questions, concerns, complaints, or requests for additional information regarding civil rights may be forwarded to the DHHS’ ADA Compliance/ EEO Coordinator, State House Station #11, Augusta, Maine 04333, 207-287-4289 (V) or 207-287 3488 (V), TTY: 800-606-0215. Individuals who need auxiliary aids for effective communication in programs and services of DHHS are invited to make their needs and preferences known to the ADA Compliance/EEO Coordinator. This notice is available in alternate formats, upon request. Caring..Responsive..Well-Managed..We are DHHS