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Your Life Your Health - Population Perspective: Adult Diabetes in Southeast Texas Inter-professional Collaboration and Health Outcomes

W Bryan Sims MSN, APRN-BC, FNP

July 16, 2009

Your Life Your Health - The Examiner

(Editor's Note: Major (Retired) Bryan Sims is the Chief Medical Officer for SETMA and heads SETMA's Office of Evidenced-Based Medicine. In collaboration with others, he is leading the development of SETMA's Medical Home and is working on his Doctorate as an Advanced Nurse Practitioner.

The following paper was prepared in partial fulfillment of one of his Doctoral courses. Diabetes is a growing problem in American, in Texas and in Southeast Texas. If it were an infectious disease it would qualify for the designations of "endemic" and "pandemic."

Major Sims' paper gives the rationale for SETMA's formation of our Diabetes Center of Excellence and for our development of a state-of-the-art diabetes disease management tool. It is also why SETMA is routinely auditing the diabetes care received by our patients based on the standards of NCQA, NQF, PQRI and Physician Consortium for Performance Improvement.)

Introduction

Diabetes mellitus is a progressive disease of the endocrine system. More specifically, diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. As a function of time, the chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels (Noble, 2001).

Diabetes results from the body's failure to produce insulin (Type I) or from insulin resistance combined with relative insulin deficiency (Type II). The majority of persons with diabetes have Type II diabetes accounting for as much as 90% of this disease population ("Texas Diabetes Council," 2009). Recent estimates indicate that 27.2 million children and adults in the United States, or 9% of the population, suffer from this progressive disease. ("American Diabetes Association," 2009). Of those with diabetes, approximately 6.8 million are unaware that they have the disease.

Epidemiological Significance

According to the 2007 estimates, Diabetes Prevalence in Texas accounts for 10.3% of the overall 9.0% prevalence in the US. These data are from the Texas Behavioral Risk Factor Surveillance System (BRFSS) for persons who are eighteen years of age and older. They include both Type 1 and Type 2 Diabetes. The report includes those with diabetes who reported being told by their provider that they have diabetes. Women with who developed gestational diabetes were not included in the prevalence estimates ("Texas Diabetes Council," 2008).

These estimates indicate that the prevalence of the disease in Texas increased from 7.9% in 2006 to 10.3% in 2007. Explanations that may account for this increase include the rise in reported cases of diabetes and increased obesity rates. The BRFSS had a substantially larger reporting sample in 2007 than in previous years and possibly provided a more accurate estimate. Estimates provided by the BRFSS for diabetes prevalence are based on survey responses. Increased screening efforts may have resulting in more persons with diabetes being more aware of the presence of the disease rather than an increase in actual prevalence.

In Texas, males with diabetes age 18 and older account for 853,751 cases or 9.9% of this population. The prevalence among women in this age group was even higher with 942,698 reported cases or 10.8% ("Texas Diabetes Council," 2009). The highest percentage of persons with diabetes in Texas is seen among Black, non-Hispanics who represent 244,590 cases or 12.9%. Hispanics have nearly as many cases accounting for 721,779 or 12.3% of the aggregate. The lowest demographic with diabetes is White, non-Hispanics with 751,235 reported cases or 8.5% ("Texas Diabetes Council," 2009). Assessing persons with diabetes by age also reveals the highest percentage of cases exist among elderly, Black, non-Hispanics. This subgroup of the diabetic population are 65 years and older. White non-Hispanics ages 18-44 represent the lowest prevalence in the state accounting for only 3% of cases ("Texas Diabetes Council," 2009).

Diabetes prevalence in Southeast Texas is twice the United States estimates. In Jefferson County 15% of the population or an estimated 28,142 persons aged eighteen years and older have been diagnosed with diabetes ("Texas community diabetes surveys: Summary report," 2007). Among Texans with diabetes, 12% are male and 17% are female in the Jefferson County area. According to recent estimates, 19% of Texans with diabetes in Jefferson County are Black while Hispanics represent the fewest at 12% in the county. The reverse is true in south Texas where Hispanic population densities surpass other ethnicities considerably.

Mortality

Mortality rates from diabetes and complications from having this disease are staggering. According to the Centers for Disease Control (CDC), diabetes is ranked as the seventh leading cause of death in the United States (Heron, Hoyert, Xu, Scott, & Tejada-Vera, 2008). Mortality rates in Southeast Texas constitute 34.7% incidence among those with diabetes according to the most recent estimates ("Texas community diabetes surveys: Summary report," 2007). It is also useful to look at mortality data alongside prevalence. Aggregates for Jefferson, Victoria, Nueces, Uvalde, Lubbock, and Bowie Counties have mortality rates higher than Texas as a whole.

According to the Texas Diabetes Fact Sheet (2008), the 2005 diabetes mortality rate for Texas was 30 deaths per 100,000 persons. The data from this report also included mortality rates for each race/ethnicity as it applied to the 2005 population. Among those with diabetes, 21 per 100,000 whites (non-Hispanic) died with diabetes reported as the primary cause of death. Another 52 per 100,000 Hispanics died from diabetes as well as 55 per 100,000 blacks (non-Hispanic). Persons who fall in the "Other" category accounted for 15 per 100,000 deaths with diabetes as the reported cause ("Texas Diabetes Council," 2008). This analysis indicates mortality rates (per 100,000) for Blacks (non-Hispanic) and Hispanics were more than double that of Whites (non-Hispanic).

Associated Complications

Complications associated with diabetes include acute exacerbation of the disease state, retinopathy, nephropathy, neuropathy, hypertension, hyperlipidemia, cardiovascular disease and stroke (Noble, 2001). According to the Texas Community Surveys Summary Report (2007), current estimates show 65% of Texans in Jefferson County with diabetes have hypertension. Another 26% have hypertension without diabetes. Similarly, 70% of persons with diabetes also have hyperlipidemia. The data also shows that 32% of the population has hyperlipidemia without diabetes. Those with cardiovascular disease or reported history of stoke who also have diabetes represent and estimated 24% of the population. Persons with heart disease or stroke without having diabetes were reported at 7% of the overall population.

Economic Impact

The national cost of diabetes in the U.S. in 2007 exceeds $174 billion annually ("Texas Diabetes Council," 2008). Included in this estimate is the $116 billion in direct medical expenditures attributed to diabetes, as well as the $58 billion in reduced national productivity. Current data show that people with diagnosed diabetes have medical expenditures nearly 2.3 times higher than those without diabetes (CDC, 2008). Approximately $1 in $10 health care dollars is attributed to diabetes. When the data are adjusted for age and geography, the medical expenditures for people with diabetes remain more than twice those without diabetes ("American Diabetes Association," 2009) .

In Texas, the cost of hospitalizations attributed to diabetes was $3.7 billion according to a 2003 cost analysis ("Texas Diabetes Council," 2008). Admissions for cardiovascular disease attributed to diabetes exceeded 66,000 in the same year. The loss of productivity and overall cost of disease management in Texas exceeds US costs per capita given that the overall disease burden is 1.3% higher in Texas. In addition, the greatest numbers of persons with diabetes in Texas earn less than $25,000 per year accounting for 15.8% of the total population ("Texas Diabetes Council," 2009).

Conclusion

Diabetes mellitus is one of the most devastating endocrine diseases known. Diabetes accounts for 5,593 deaths annually demanding more than $117 billion dollars in treatment costs in Texas alone. In addition, diabetes is frequently debilitating and results in a profound decrement in quality of life. Continued research aimed at improved treatment modalities and ultimately a cure are badly needed. A more robust effort and improved methods by providers and nurses to better educate the public regarding healthy lifestyle choices to prevent this disease are recommended.

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