Diabetes. Health Care Disparities: Medical Evidence. A Constellation of Complications. Every 24 hours.

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1 Health Care Disparities: Medical Evidence Diabetes Effects 2.8 Million People in US 7% of the US Population Sixth Leading Cause of Death Kenneth J. Steier, DO, MBA, MPH, MHA, MGH Dean of Clinical Education TouroCOM Every 24 hours. 3,6 new cases are diagnosed 58 people die of diabetes-related complications 225 people have a diabetes-related amputation 12 people with diabetes progress to end-stage renal disease 55 people with diabetes become blind Peripheral Vascular Disease Gastropathy A Constellation of Complications Dyslipidemia Erectile Dysfunction Renal Disease Diabetes Cardiovascular Disease Peripheral Neuropathy Retinopathy/ Macular Edema Autonomic Neuropathy Hypertension Diabetes Care in the U.S. Improvements Needed Goal Percent at Goal A1C < 7. 43% (18% at > 9.5) LDL < 1 11% (58% at > 13) BP < 14/9 (ADA goal is 13/8) 66% Dilated Eye Exam 63% Foot Exam 55% Projected Increase (%) Projected Increase in the US Population with Diagnosed Diabetes by 22 by Ethnicity NHANES III and Behavioral Risk Factors Surveillance Study Adapted from American Diabetes Association. Diabetes Care. 23;26: X-1

2 Age-adjusted prevalence (%) Prevalence of Type 2 Diabetes Physician-diagnosed diabetes Non-Latino African Mexican Non-Latino African Mexican American American American American Harris MI et al. Diabetes Care. 1998;21: Previously undiagnosed diabetes Trends in Diabetes Prevalence ( ) Age (years) Ethnicity Non-Latino African Mexican American American Prevalence of type 2 diabetes is 2-3 times higher in Latinos than Caucasians Highly correlated with prevalence of obesity (r =.64, P <.1) American Diabetes Association. Facts and Figures. Mokdad et al. Diabetes Care. 2;23:1278. Complications The Leading Cause of: Adult Blindness Kidney Failure Non-traumatic amputations Major cause of: Heart Disease Patients (%) Prevalence of Complications in Type 2 Diabetes 4 2 Prevalence of Retinopathy in Type 2 Diabetes 4 59 years 6 years (per million/population) New Cases of End-Stage Renal Disease Age Range of Amputations per 1, DM patients Caucasian African-American Mexican-American Stroke Klein et al. In: Harris et al, eds. Diabetes in America, 2nd ed Reiber et al. In: Harris et al, eds. Diabetes in America, 2nd ed USRDS. Am J Kidney Dis. 1994;24:879. What Aren t Patients Achieving Blood Glucose Goals? Physicians not setting appropriate glycemic targets Type 2 DM is progressive Type of medication used Insulin therapy used only as a threat Monitoring Parameters Every visit BP and foot exam HgbA1C every three to six months Annual eye exam, lipid level, microalbumin X-2

3 Principles of Treatment Define target goal Education is essential Monitoring glycemic control Lifestyle modification Stepwise and combination drug therapy Estimated Costs Direct: $132 billion annually (HHS) Indirect: Disability and Premature Death Pre-diabetes Approximately 41 million more Americans aged 4-74 HHS Diabetes Prevention Program of 3 pre-diabetics found that diet and exercise, with moderate weight loss, can decrease incidence of developing Diabetes by nearly 6 per cent At-risk Groups African-American Hispanic American Indian Alaska Native Three Major Types Type 1 5 to 1% IDDM Type %.NIDDM disparities Gestational Diabetes.disparities African-Americans 2.4 times as likely to have diabetes as whites Maximal incidence women age Diabetic eye disease 19% more common in African-American men than white men Lower extremity amputation much more common in AA. X-3

4 Hispanics As of 22, two million Hispanic adults, about 8.2% of the Hispanic population had diabetes Hispanics 1.5 times more likely to have diabetes than whites Mexican-Americans, the largest group, more than twice as likely as whites In 22, death rate from Diabetes 6% higher or Hispanics than whites American Indians/Alaska Natives 2.3 times as likely as whites to have diabetes As of 24, 14.9 per cent of this population in the Indian Health Service had a diagnosis of diabetes Most common among American Indians in the southeastern US and Arizona (27.8%) Asian American and Pacific Islander Diabetes is the fifth leading cause of death In Hawaii, native Hawaiians more than 5.7 times as likely as whites (in Hawaii) to have diabetes Overall, this population 2. times more likely to have diabetes than whites. African-Americans 2.4 times more likely to be diagnosed with Diabetes In 21, 2.3 times more likely to start treatment for end-stage renal disease from diabetes In 22, 1.5 times more likely to be hospitalized In 22, 3% more likely to need lower extremity amputation In 22, 2.2 times more likely to due from diabetes Hispanic Americans Asians and Pacific Islanders In Hawaii, Native Hawaiians have more than twice the rate of diabetes Asians 2% less likely than whites to die from diabetes Native Hawaiians in Hawaii more than 5.7 times to die from diabetes Filipinos living in Hawaii have more than 3 times the death rate as whites living in Hawaii. Insulin Sensitivity Index (µmol L -1 m -2 min -1 pmol -1 L -1 ) Insulin Sensitivity in Healthy Subjects in Various Ethnic Groups * N=34 N=9 N=18 N=16 *P =.23 vs. Caucasians. Data are geometric means. Adapted from: Chiu KC, et al. Diabetes Care. 2;23(9): * * X-4

5 Prevalence (% of adults) Prevalence of the Insulin Resistance Syndrome in the US Population Progressive Nature of Type 2 Diabetes IGT Endogenous Insulin Insulin Resistance Postprandial Blood Glucose Diabetes Normal Normal Blood Glucose *Age adjusted 2 years of age Ford ES et al. JAMA. 22;287: Years Avg Dx 9-12 yrs* UKPDS: Glucose Control Study Results Intensive Blood- Glucose Control Change in risk P value Any diabetes-related endpoint 12%.29 Diabetes-related deaths 1% NS Myocardial infarction 16%.52 Microvascular disease 25%.99 Stroke 14% NS Effect of Each 1% Rise in A1C on Risk of Developing Complications 1-Year follow-up in older-onset patients Incidence of retinopathy Progression of retinopathy Progression to PDR Visual loss Proteinuria Amputation Ischemic heart death Adapted from UKPDS Group. Lancet. 1998; 352: Klein. Diabetes Care 18: , Risk Ratio and 95% CI Rate of Initiation of Treatment for ESRD per 1, Diabetics Age-adjusted Rate of hospitalization per 1, diabetics African Americans Men 54.3 Women Men Women African American Ratio 2.3 Men Ratio 2. Women Ratio 1.5 X-5

6 Age-adjusted rate for lower extremity amputation per 1, Diabetic Patients African-Americans 5.3 s 4.1 Age-adjusted Diabetes Death Rates per 1, African Americans 49.5 s 22.2 Ratio 1.3 Ratio 2.2 Age-adjusted percentage of persons over 2 with a high cholesterol Age-adjusted ratio of person 18 and over who had received a flu shot in 21 African American Men 12.4 Women 17.7 Men 16.5 Women 18.1 African American Ratio.8 Ratio.8 Rate of Initiation of treatment for ESRD in Hispanic Diabetics per 1, Diabetic Population Hispanic/Latino Men 39.4 Women Men Women Age-adjusted Death Rates per 1, Hispanic Ratio 1.5 women Ratio 1.4 men Ratio 1.6 X-6

7 Impact of Therapies on A1C Levels Therapy A1C Reduction Diet and Exercise.5-2.% Sulfonylureas and Glitinides % Metformin % α-glycosidase Inhibitors.5-1. % Thiazolidinedione.5-1.% Insulin >5.% Nathan, D. Oct 22. N Engl J Med, Vol. 347, No.17 No Difference In Complications When Good Control Is Achieved San Luis Valley Study Caucasian and Latino (n=279) - Similar glucose control in both study groups - Similar severity of retinopathy, nephropathy and diabetic neuropathy Hamman RF et al. Diabetes. 1989; 38;1231. Hamman RF et al. Diabetes Care. 1991;14 (suppl 3):655. Whose Responsible? Health Care System? Federal Government? State Government? Physicians and other health care? providers The Patients? Genetics? Also Multifactorial Government Private Industry Medical Societies Solutions Individual Physicians Medical School Education Residency Training References s/ ons/ esreport/25/ Additional References Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington DC: National Academies Press;23. Brown AF, Gross AG, et al. Income-related differences in the use of evidence-based therapies in older persons with diabetes mellitus in for-profit managaed care. J AM Geriatr Soc. 23 May:51(5) X-7

8 The END Thank you. X-8