d i a b e t e s care program of nova scotia Nova Scotia diabetes

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1 d i a b e t e s care program of nova scotia Nova Scotia diabetes statistics report

2 March 2008 Published by: 1278 Tower Road, Bethune Building, Room 577 Halifax, NS B3H 2Y9 Tel: (902) Fax: (902) Web site:

3 NOVA SCOTIA DIABETES STATISTICS REPORT 2008 i

4 THE DIABETES CARE PROGRAM OF NOVA SCOTIA The (DCPNS) is one of eight provincial programs funded by the Nova Scotia Department of Health. Working closely with all District Health Authorities, Diabetes Centres, and diabetes care providers, this Program advises the Ministry on service delivery models; establishes, promotes, and monitors adherence to diabetes care guidelines; provides support, services, and resources to diabetes healthcare providers; and collects, analyzes, and distributes diabetes-related data for Nova Scotia. MISSION Through leadership, to improve the health of Nova Scotians affected by or at risk of developing diabetes mellitus. As a program, we envision VISION Broad support for sufficient and equitable access to quality Diabetes Centres and programs. Collaboration through partnerships with others to achieve enhanced health status. Enhanced use of information and information systems for support of persons with or at risk of developing diabetes mellitus. Individuals and groups who are interested and committed to the prevention and cure of diabetes and its complications. ii

5 ACKNOWLEDGEMENTS The would like to acknowledge and thank those directly involved in the development of this document. The preparation of this report reflects many hours of dedicated work to provide the Nova Scotia Department of Health and the District Health Authorities with data to support quality diabetes care in Nova Scotia. Special Thanks to: Igor Grahovac, Data Analyst Jennifer Payne, Epidemiologist Peggy Dunbar, Coordinator Jill Casey, Former Senior Research Analyst Population Health Research Unit Community Health and Epidemiology, Dalhousie University Kevin Topley, Former Research Analyst Population Health Research Unit Community Health and Epidemiology, Dalhousie University The Public Health Agency of Canada (National Diabetes Surveillance System) for the financial support to enable the preparation and broad-based distribution of this report. Our assistant writers and editors: Kim Dionne Cynthia Lank iii

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7 T A B L E O F C O N T E N T S EXECUTIVE SUMMA RY INTRODUCTION.. 3 SECTION I BURDEN CHAPTER 1 PRE VALENCE CHAPTER 2 INCIDENCE CHAPTER 3 MORTALIT Y SECTION II COMORBIDITY CHAPTER 4 CARDIO VASCULAR DISEASE. 35 CHAPTER 5 ACUTE MYOCARDIAL INFARCTION CHAPTER 6 ISCHEMIC HEART DISEASE CHAPTER 7 STROKE. 65 CHAPTER 8 UNS TABLE ANGINA.. 75 CHAPTER 9 HYPERTENSION.. 85 CHAPTER 10 HEART FAILURE CHAPTER 11 NEPHROPATH Y CHAPTER 12 RETINOPATH Y CHAPTER 13 LOWER EXTREMITY AMPUTATION. 125 SECTION III HEALTH SE RVICES UTILIZ ATION CHAPTER 14 HOSPI TAL ADMISSIONS. 135 CHAPTER 15 HOSPI TAL MEDIAN LENGTH OF S TAY 145 CHAPTER 16 GENERAL PRACTITIONER OFFICE VISITS. 153 CHAPTER 17 SPECIALIST PHYSICIAN OFFICE VISITS. 163 APPENDICES APPENDIX A THE NATIONAL DIABETES SURVEILLANCE SYSTEM. 175 APPENDIX B COMPARISON OF MEASURES OF DIABETES BURDEN, COMORBIDITY, AND HEALTH SERVICES UTILIZATION BY DHA RELATIVE TO NOVA SCOTIA APPENDIX C PREVALENT CASES BY AGE GROUP AND SEX FOR NOVA SCOTIA AND THE DHAS (2005/06) v

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9 EXECUTIVE SUMMARY This report provides an overview of the estimated burden of diabetes in Nova Scotia to March 31, Derived from the National Diabetes Surveillance System (NDSS), this report provides information on the population age 20+ in Nova Scotia and includes figures related to prevalence (all current cases of diabetes) and incidence (newly diagnosed cases). Mortality, morbidity (complications), and health services utilization (hospitalizations and visits to general practitioners and specialists) are provided for the population with diabetes as compared to the population without diabetes. Key findings In Nova Scotia Approximately 8.7% (1 in 11), or 67000, adults are living with diabetes. The crude prevalence rate varies across District Health Authorities (DHAs) from 7.2% to 10.8%, with the highest rates in Cape Breton, South West, and South Shore DHAs. Prevalence has increased in Nova Scotia by 20% over the past five years. The prevalence of diabetes increases with increasing age, and as a result 1 in 5 adults over the age of 70 has diabetes. Over 5800 new cases of diabetes are diagnosed each year (approximately 500 new cases per month). In contrast to the increase in prevalence, the incidence rate has remained stable over the same time period. The crude incidence rate did not vary much by DHA (from 6.6 to 8.7 per 1000), with the exception of the South Shore DHA (10.7 per 1000). People with diabetes, as compared to people without diabetes, are: 2 times more likely to die each year 3 times more likely to have cardiovascular disease 6 times more likely to have nephropathy (kidney disease) 7 times more likely to have retinopathy 11 times more likely to have a lower extremity amputation 2 times more likely to be hospitalized, and to have slightly longer lengths of stay There are considerable variations in rates across comorbidities by age group, with the highest rates noted for those aged 20 to 49 years. As compared to people without diabetes, people between 20 and 39 with diabetes were 12 times more likely to have cardiovascular disease, 25 times more likely to have hypertension, and 25 to 35 times more likely to have nephropathy and retinopathy, respectively. Directions/Call To Action Individuals living longer with diabetes most easily explain the growth in prevalence of diabetes. As diabetes is well known to be a progressive disease, longer duration of diabetes confers more complex treatment regimens (multiple medications), as well as increased risks of diabetes-related complications and comorbidities. Action: Strict diabetes control, including glycemia, blood pressure, and blood lipids, has been shown to reduce both macrovascular and microvascular complications. Intensive approaches to 1

10 both lifestyle modifications and pharmacological treatments are recommended, along with the continued focus on self-care. More rapid response to metabolic abnormalities would be one way to improve diabetes management as well as targeted interventions aimed at foot, eye, and kidney disease. Although the incidence of diabetes has not increased, neither has it decreased. Action: Health promotion and prevention messages are key to the future of a healthy Nova Scotia. Delaying the onset of the disease in at-risk individuals and their families, and slowing its progression would result in significant benefit to individuals, families, and the health care system. People with diabetes have much greater risks of complications and comorbidity; this is most significant in our younger age groups. Action: Nova Scotia must continue to refine its approach to the adolescent and young adult populations with diabetes to ensure that programs, services, and supports are in place to provide continued access to required health care services and specialty teams. 2

11 INTRODUCTION The (DCPNS) is pleased to provide this third report about the burden of diabetes in Nova Scotia and each of the nine District Health Authorities (DHAs). This report is aimed primarily at decision-makers within the Diabetes Centres, the DHAs, and the Nova Scotia Departments of Health and Health Promotion and Protection. However, it is also intended that this document will act as a resource for all those working in the area of diabetes prevention and management, and that this report will help stimulate further discussion around the information needs of decision-makers to create, envision, and deliver policies that will better serve the residents of Nova Scotia in the years to come. There have been a number of modifications made to this report from previous years as outlined below: Crude and Standardized Rates Both crude and standardized rates are presented across many of the chapters so that DHAs can understand both their absolute burden of diabetes in terms of real numbers (i.e., crude rates) as well as be able to compare their rates against other jurisdictions whose populations may differ by age and sex making the comparison more difficult (i.e., standardized rates). The crude prevalence and incidence numbers highlighted in this report provide the DHAs with a much better understanding of the true numbers of people living with and developing diabetes in their jurisdictions. Time Trends With over five years of data (2001/02 to 2005/06), time trends have now been added to the sections on burden, comorbidity, and health services utilization (with the exception of median length of stay), both for Nova Scotia as a whole and for each of the DHAs. Comparative Data Results are now presented to allow each DHA to compare its results against Nova Scotia as a whole, rather than against each other - the provincial numbers are more stable and therefore more suitable for benchmarking purposes. A comparison of the DHA figures to the Nova Scotia figures across all report measures is available in Appendix B. Reorganization The document has undergone some reorganization on various levels, including consolidating the prose in each chapter, grouping the chapters according to section headings, and introducing a list of exhibits for each chapter for easy reference. Once again, it is hoped that this report can both inform and stimulate debate and discussion in the area of diabetes in Nova Scotia. Your suggestions and feedback on how to continue to improve this reporting process are always welcomed and appreciated. 3

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13 SECTION I BURDEN CHAPTER 1 PREVALENCE Prevalence is defined as the number of individuals (new and existing) with diagnosed disease in a given population at a given point in time. Prevalence is affected by both the number of new cases of a disease (incidence) and the death rate (mortality) among existing cases. Nova Scotia (2005/06) For the year 2005/2006, there was a substantial variation in the crude prevalence of diabetes in the population aged 20+ across DHAs, ranging from 7.2% to 10.8% (Exhibits 1-1 and 1-2). However, a comparison of standardized prevalence figures across the DHAs revealed that there was much less variation in prevalence across the province (6.8% to 8.6%), suggesting that the wider variation in crude prevalence was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes prevalence itself varied to this degree across the province. Analyses by age group and sex revealed the prevalence of diabetes was similar for both males and females in their 20s through until their 40s, and increased in a similar manner with increasing age; once in their 50s, males were more likely than females to have diabetes (Exhibit 1-3). What is striking is that even by their 40s, males and females both had approximately a 5% chance of having diabetes and that this risk increased by approximately 5% with each increasing 10-year age group through to age 79 (prevalence rate of 25%). The largest increase in prevalence across the age groups occurred in moving from the 50s to the 60s, with the overall prevalence moving from 10% to 17%. The highest prevalence for both males and females was in the age group, reaching a high of over 25% for males and over 20% for females (1 in 4, and 1 in 5, respectively). Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the crude prevalence of diabetes revealed an increase over time, from 7.3% to 8.7% (a 19% increase over the five-year period), as did the standardized prevalence figures (6.5% to 7.5%), which were consistently lower than the crude rates (Exhibit 1-4). In terms of time trends by age group, the prevalence figures were stable for those in their 20s, hovering at approximately 1.0%, but there was an increase for each age group after that point, reaching a prevalence over 20% for those aged 70-79, and with evidence of a trend of increasing prevalence over time for those over age 60 (Exhibit 1-5). 5

14 SECTION I BURDEN District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same increase in prevalence over time (Exhibits 1-6 to 1-14). In most cases, crude figures for the DHAs were higher than those for Nova Scotia as a whole, but upon standardization, the differences in these rates narrowed substantially. Prevalence figures for both South West and Cape Breton DHAs remained higher than those for the province as a whole. Note: Data about diabetes prevalence were derived from the National Diabetes Surveillance System (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. 6

15 SECTION I BURDEN EXHIBITS Exhibit 1-1 Exhibit 1-2 Exhibit 1-3 Exhibit 1-4 Exhibit 1-5 Exhibit 1-6 Exhibit 1-7 Exhibit 1-8 Exhibit 1-9 Exhibit 1-10 Exhibit 1-11 Exhibit 1-12 Exhibit 1-13 Exhibit 1-14 Crude and Age-Sex Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Prevalence for the Population Aged 20+ in Nova Scotia by Age Group and Sex, 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in Diabetes Prevalence for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 7

16 SECTION I BURDEN Exhibit 1-1 Crude and Age-Sex Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Region (DHA) Population Aged 20+ Diabetes Cases Crude Diabetes Prevalence Rate (%) Standardized Diabetes Prevalence Rate (%) Nova Scotia 772,998 66, Annapolis Valley (3) 67,817 6, Cape Breton (8) 108,327 11, Capital Health (9) 324,611 23, Colchester East Hants (4) 59,639 4, Cumberland (5) 28,141 2, Guysborough Antigonish Strait (7) 39,160 3, Pictou County (6) 39,735 3, South Shore (1) 51,665 5, South West (2) 52,831 5, Exhibit 1-2 Crude Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 8

17 SECTION I BURDEN Exhibit 1-3 Diabetes Prevalence for the Population Aged 20+ in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 1-4 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 9

18 SECTION I BURDEN Exhibit 1-5 Trend in Diabetes Prevalence for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 1-6 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 10

19 SECTION I BURDEN Exhibit 1-7 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 1-8 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 11

20 SECTION I BURDEN Exhibit 1-9 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit 1-10 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 12

21 SECTION I BURDEN Exhibit 1-11 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit 1-12 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 13

22 SECTION I BURDEN Exhibit 1-13 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit 1-14 Trend in Crude and Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 14

23 SECTION I BURDEN CHAPTER 2 INCIDENCE Incidence is defined as the number of new cases of a disease diagnosed in a given population during a given time period (i.e., annual occurrence of new cases). Nova Scotia (2004/05) For the year 2004/2005, there was a substantial variation in the crude incidence rates of diabetes in the population aged 20+ across DHAs, ranging from 6.6/1000 to 10.7/1000 population (Exhibits 2-1 and 2-2). However, a comparison of standardized rates across the DHAs revealed that there was much less variation in incidence across the province (5.9 to 8.3/1000 population), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes incidence itself varied to this degree across the province. Analyses by age group and sex revealed that the incidence of diabetes was similar for both males and females in their 20s and 30s and increased in a similar manner with increasing age; once in their 40s, males were more likely than females to be newly diagnosed with diabetes (Exhibit 2-3). The largest increase in incidence across the age groups occurred in moving from the 40s to the 50s, during which the risk of diabetes more than doubled (5/1000 to approximately 12/1000). The highest incidence rate for males was in the age group (17/1000), and similarly for females in the age group (15/1000). Nova Scotia Time Trends (2001/02 to 2004/05) Time trends in the crude incidence of diabetes revealed no change over time, hovering at approximately 7.6/1000, and this was also true for the standardized rates (6.6/1000), which were consistently lower than the crude rates (Exhibit 2-4). In terms of time trends by age group, the incidence figures were stable for those under age 50, ranging from approximately 1/1000 for those in their 20s to over 5/1000 for those in their 40s, but there was slight evidence of a decrease in incidence for those over 50; although, the incidence figures for the over 50 age groups remained over 10/1000 (Exhibit 2-5). 15

24 SECTION I BURDEN District Time Trends (2001/02 to 2004/05) Analyses of time trends by DHA revealed the same stability in incidence rates over time (Exhibit 2-6 to 2-14). In most cases, crude figures for the DHAs were higher than those for Nova Scotia as a whole, but upon standardization, the differences in these rates narrowed substantially. Upon standardization, there were negligible differences in incidence figures across each DHA as compared with Nova Scotia as a whole. Note: Data about diabetes incidence were derived from the National Diabetes Surveillance System (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. NDSS incidence figures are derived using a 2-year window and therefore these data lag by 1 year (2004/05) relative to other data presented in this report (2005/06). 16

25 SECTION I BURDEN EXHIBITS Exhibit 2-1 Exhibit 2-2 Exhibit 2-3 Exhibit 2-4 Exhibit 2-5 Exhibit 2-6 Exhibit 2-7 Exhibit 2-8 Exhibit 2-9 Exhibit 2-10 Exhibit 2-11 Exhibit 2-12 Exhibit 2-13 Exhibit 2-14 Crude and Age-Sex Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and the DHAs, 2004/05 Crude Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and the DHAs, 2004/05 Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia by Age Group and Sex, 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia, 2000/01 to 2004/05 Trend in Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia by Age Group, 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2000/01 to 2004/05 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and South West (SWH), 2000/01 to 2004/05 17

26 SECTION I BURDEN Exhibit 2-1 Crude and Age-Sex Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and the DHAs, 2004/05 Population at risk (20+) New Diabetes Cases Crude Diabetes Incidence rate (per 1,000) Standardized Diabetes Incidence rate (per 1,000) Expected New Cases Nova Scotia 766,115 5, ,027 Annapolis Valley (3) 64, Cape Breton (8) 108, Capital Health (9) 322,542 2, ,983 Colchester East Hants (4) 59, Cumberland (5) 27, Guysborough Antigonish Strait (7) 38, Pictou County (6) 39, South Shore (1) 51, South West (2) 52, Exhibit 2-2 Crude Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and the DHAs, 2004/05 18

27 SECTION I BURDEN Exhibit 2-3 Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia by Age Group and Sex, 2004/05 Exhibit 2-4 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia, 2000/01 to 2004/05 19

28 SECTION I BURDEN Exhibit 2-5 Trend in Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia by Age Group, 2000/01 to 2004/05 Exhibit 2-6 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2000/01 to 2004/05 20

29 SECTION I BURDEN Exhibit 2-7 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2000/01 to 2004/05 Exhibit 2-8 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2000/01 to 2004/05 21

30 SECTION I BURDEN Exhibit 2-9 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2000/01 to 2004/05 Exhibit 2-10 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2000/01 to 2004/05 22

31 SECTION I BURDEN Exhibit 2-11 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2000/01 to 2004/05 Exhibit 2-12 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2000/01 to 2004/05 23

32 SECTION I BURDEN Exhibit 2-13 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2000/01 to 2004/05 Exhibit 2-14 Trend in Crude and Standardized Diabetes Incidence Rates (per 1000) for the Population Aged 20+ in Nova Scotia and South West (SWH), 2000/01 to 2004/05 24

33 SECTION I BURDEN CHAPTER 3 MORTALITY Mortality is defined as the number of people diagnosed with a disease in a given population in a given time period who died. Mortality is affected by the severity of the disease, including the existence of one or more comorbid diseases resulting from diabetes (e.g., heart disease). Nova Scotia (2005/06) For the year 2005/2006, there was a substantial variation in the crude mortality rates within the population aged 20+ with diabetes across DHAs, ranging from 1.9% to 3.4% (Exhibits 3-1 and 3-2). However, a comparison of standardized rates across the DHAs revealed that there was much less variation in mortality within the population with diabetes across the province (0.8% to 1.5%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes mortality itself varied to this degree across the province. The ratio of standardized mortality rates revealed a 1.5 to 3.0 times greater risk of mortality in the population with diabetes, relative to the population without diabetes. Crude mortality rates by age group and sex again revealed that those with diabetes were more likely to die than those without diabetes, and that this was true both for males and females, and for both younger and older age groups. The mortality rate for males was higher than for females, and this remained true within the subgroups of those with diabetes (Exhibit 3-3). When comparing those with diabetes to those without diabetes, the ratio of mortality rates was much greater for the younger age group than for the older age group. Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized mortality rates revealed no change over time, hovering at just under 2.0 times that of the non-diabetes population (Exhibit 3-4). In terms of trends by age group, the mortality rate ratios decreased with increasing age, ranging from roughly 1.7 for those over 80 to roughly 2.3 for those in their 40s (Exhibit 3-5). The largest rate ratios by far were seen for those in their 20s and 30s, reaching a current level of almost 5. There was little evidence of any change over time by age group, except for those aged 20-39; although, this must be interpreted with caution given the small rates of events. 25

34 SECTION I BURDEN District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same stability in mortality rate ratios over time (Exhibits 3-6 to 3-14). Generally speaking, the mortality rate ratios for the DHAs were no different than those for the province as a whole. Of note is the high rate ratio for Cumberland DHA in the last year, which may be a result of instability in the rates (few numbers), but their overall figures were in keeping with the rest of the province. Note: Data about mortality among those with and without diabetes were derived from the National Diabetes Surveillance System (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. 26

35 SECTION I BURDEN EXHIBITS Exhibit 3-1 Exhibit 3-2 Exhibit 3-3 Exhibit 3-4 Exhibit 3-5 Exhibit 3-6 Exhibit 3-7 Exhibit 3-8 Exhibit 3-9 Exhibit 3-10 Exhibit 3-11 Exhibit 3-12 Exhibit 3-13 Exhibit 3-14 Diabetes Mortality Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude Mortality Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 Mortality Rates for the Population Aged 20+, with/without Diabetes (DM) in Nova Scotia, by Age Group and Sex, 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 27

36 SECTION I BURDEN Exhibit 3-1 Diabetes Mortality Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number of Deaths Population Aged 20+ Crude Mortality Rate (%) Standardized Mortality Rate (%) Nova Scotia 1 1,731 66, , , Annapolis Valley (3) , , Cape Breton (8) , , Capital Health (9) , , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore , , South West , , Rate Ratio Exhibit 3-2 Crude Mortality Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 28

37 SECTION I BURDEN Exhibit 3-3 Mortality Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 3-4 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 29

38 SECTION I BURDEN Exhibit 3-5 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 3-6 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 30

39 SECTION I BURDEN Exhibit 3-7 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 3-8 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 31

40 SECTION I BURDEN Exhibit 3-9 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit 3-10 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 32

41 SECTION I BURDEN Exhibit 3-11 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit 3-12 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 33

42 SECTION I BURDEN Exhibit 3-13 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit 3-14 Trend in Diabetes Mortality Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 34

43 CHAPTER 4 CARDIOVASCULAR DISEASE Increasingly, diabetes is being recognized as a cardiovascular disease (CVD). Cardiovascular disease is the primary cause of death among people with diabetes. 1 People with diabetes have higher mortality rates following a cardiovascular (CV) event, and experience CV events at a significantly younger age than people without diabetes. 2 In addition to high blood glucose, other CV risk factors are common in people with diabetes. These risk factors include high blood pressure, high LDL-cholesterol ( bad cholesterol), low HDL-cholesterol ( good cholesterol), high triglycerides, obesity, abdominal obesity, and sedentary lifestyle. Smoking, microalbuminuria (protein in the urine due to diseased kidneys), and family history of CVD further increase this already high-risk profile. Comprehensive diabetes management must address global risk through comprehensive screening for risk factors and a multifaceted approach to preventing CV events that uses medications (ACE inhibitors and other blood pressure-lowering agents, low-dose ASA, statins) and lifestyle approaches (weight loss, healthy eating, regular exercise, smoking cessation and stress management). 3 Nova Scotia (2005/06) For the year 2005/2006, there was much variation in the crude CVD rates within the population aged 20+ with diabetes across DHAs, ranging from 6.2% to 13.6% (Exhibits 4-1 and 4-2). However, a comparison of standardized rates across the DHAs revealed that there was much less variation in CVD within the population with diabetes across the province (3.1% to 6.6%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related CVD itself varied to this degree across the province. The ratio of standardized CVD rates revealed a 2.4 to 3.3 times increase in the risk of CVD in the population with diabetes, relative to the population without diabetes. Crude CVD rates by age group and sex again revealed that those with diabetes were more likely to have CVD than those without diabetes and that this was true for both males and females, and for both younger and older age groups. The CVD rate for males was higher than for females and this remained true across the subgroups of those with diabetes (Exhibit 4-3). 1 Roglic G, Unwin N, Bennett PH, et al. The burden of mortality attributable to diabetes: Realistic estimates for the year Diabetes Care. 2005;28: Booth GL, Rothwell D, Fung K, Tu JV. Diabetes and Cardiac Disease. In: Hux JE, Booth G, Laupacis A (eds). Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical Evaluative Sciences. 2002: Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2):S-S

44 When comparing those with diabetes to those without diabetes, the ratio of the CVD rates in the younger age group was much greater than for the older age group. Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized CVD rates revealed no change over time, hovering at approximately 3.0 times that of the non-diabetes population (Exhibit 4-4). In terms of trends by age group, the CVD rate ratios decreased with increasing age, ranging from approximately 1.8 for those over age 80 to approximately 6.5 for those in their 40s (Exhibit 4-5). The largest rate ratios by far were for those in their 20s and 30s, reaching a current level of approximately 12. There was little evidence of any change over time by age group, except for those aged 20-39, where there was some evidence of a decrease. District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same stability in CVD rate ratios over time (Exhibits 4-6 to 4-14). Generally speaking, the CVD rate ratios for the DHAs were no different than those for the province as a whole; although, those for Pictou County DHA appeared to be consistently higher than the provincial figures but also appeared to have decreased over time. Note: Data about cardiovascular disease (CVD) among those with and without diabetes were derived from the National Diabetes Surveillance Strategy (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. In addition, given the rarity of these cardiovascular events, particularly among the younger age groups, extreme caution should be used in interpreting trends as actual change over time. 36

45 EXHIBITS Exhibit 4-1 Exhibit 4-2 Exhibit 4-3 Exhibit 4-4 Exhibit 4-5 Exhibit 4-6 Exhibit 4-7 Exhibit 4-8 Exhibit 4-9 Exhibit 4-10 Exhibit 4-11 Exhibit 4-12 Exhibit 4-13 Exhibit 4-14 CVD Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude CVD Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 CVD Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 37

46 Exhibit 4-1 CVD Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number With at Least 1 CVD Diagnosis Population Aged 20+ Crude CVD Rate (%) Standardized CVD Rate (%) Rate Ratio Nova Scotia 1 5,726 66, , , Annapolis Valley (3) , , Cape Breton (8) 1 1,586 11, ,593 96, Capital Health (9) 1 1,400 23, , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Exhibit 4-2 Crude CVD Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 38

47 Exhibit 4-3 CVD Rates for the Population Aged 20+, with/without Diabetes (DM) in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 4-4 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 39

48 Exhibit 4-5 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 4-6 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 40

49 Exhibit 4-7 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 4-8 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 41

50 Exhibit 4-9 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit 4-10 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 42

51 Exhibit 4-11 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit 4-12 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 43

52 Exhibit 4-13 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit 4-14 Trend in CVD Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 44

53 CHAPTER 5 ACUTE MYOCARDIAL INFARCTION Diabetes is a major risk factor for heart attack (acute myocardial infarction [AMI]). Indeed, AMIs are seen on average 15 to 20 years earlier in people with diabetes compared to those without. 1 This may be due to the high prevalence of coronary disease risk factors in people with diabetes such as high blood glucose, high blood pressure, high cholesterol, obesity, and sedentary lifestyle. While the amount of damage sustained during an AMI appears to be similar in people with and without diabetes, cardiac function is significantly decreased in those with diabetes. 2 People with diabetes are thus more prone to heart failure, shock, and other complications during the early phases of an AMI. 3 In addition, mortality at 30 days and at one year after an AMI is significantly higher in people with diabetes. 4 Among AMI survivors, those with diabetes are much more likely to be re-admitted to hospital with another MI, unstable angina, or congestive heart failure within one year. Addressing all risk factors is essential in order to prevent AMIs. Nova Scotia (2005/06) For the year 2005/2006, there was less variation in the crude AMI rates within the population with diabetes across DHAs, ranging from 1.1% to 2.2%, relative to the variation in CVD as a whole (see Chapter 4), but the actual rates were substantially lower (Exhibits 5-1 and 5-2) than those for CVD as a whole (6.2% to 13.8%). However, a comparison of standardized rates revealed that there was even less variation in AMI rates within the population with diabetes across the province (0.5% to 1.3%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related AMI itself varied to this degree across the province. The ratio of standardized AMI rates revealed a 2.1 to 5.2 times increase in the risk of AMI in the population with diabetes, relative to the population without diabetes. This was far more variable than the range for CVD as a whole. Crude AMI rates by age group and sex again revealed that those with diabetes were more likely to have an AMI than those without diabetes, and that this was true for both males and females, and for both younger and older age groups. 1 Roglie G, Unwin N, Bennett PH, et al. The burden of mortality attributable to diabetes: Realistic estimates for the year Diabetes Care. 2005:28: Booth GL, Rothwell D, Fung K, Tu JV. Diabetes and Cardiac Disease. In: Hux JE, Booth G, Laupacis A (eds). Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical Evaluative Sciences. 2002: Mak KH, Moliterno O, Granger CB, et al, for the GUSTO-1 Investigators. Influence of diabetes mellitus on clinical outcome in the thrombolytic era of acute myocardial infarction. Global Utilization of Strepokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. J Am Coll Cardiol. 1997;30: Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2):S1-S

54 The AMI rate for males was higher than for females and this remained true across the subgroups of those with diabetes (Exhibit 5-3). When comparing those with diabetes to those without diabetes, the ratio of the AMI rates was much greater in the younger age group than for the older age group. Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized AMI rates revealed no change over time, hovering at approximately 3.0 (Exhibit 5-4). In terms of trends by age group, the AMI rate ratios decreased with increasing age, ranging from approximately 1.8 for those over age 80 to approximately 5.0 for those in their 40s. Overall, individuals with diabetes had AMIs at three times the rate of individuals without diabetes (Exhibit 5-5). The largest rate ratios by far were for those in their 20s and 30s, reaching a current level of approximately 17. There was little evidence of any change over time across most age groups, with some evidence of a decrease among those in their 40s but potentially no change among those aged 20-39; although, this must be interpreted with caution given the small rates of events. District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in AMI rate ratios over time (Exhibits 5-6 to 5-14). Generally speaking, the AMI rate ratios for the DHAs were no different than those for the province as a whole; although, the figures were far more variable within the DHAs over time, something that may be explained by the infrequency of AMI events (smaller numbers), particularly among the younger age groups. Note: Data about acute myocardial infarction (AMI) among those with and without diabetes were derived from the National Diabetes Surveillance System (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. In addition, given the rarity of these cardiovascular events, particularly among the younger age groups, extreme caution should be used in interpreting trends as actual change over time. 46

55 EXHIBITS Exhibit 5-1 Exhibit 5-2 Exhibit 5-3 Exhibit 5-4 Exhibit 5-5 Exhibit 5-6 Exhibit 5-7 Exhibit 5-8 Exhibit 5-9 Exhibit 5-10 Exhibit 5-11 Exhibit 5-12 Exhibit 5-13 Exhibit 5-14 AMI Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude AMI Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 AMI Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 47

56 Exhibit 5-1 AMI Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number With at Least 1 AMI Diagnosis Population Aged 20+ Crude AMI Rate (%) Standardized AMI Rate (%) Nova Scotia 1 1,017 66, , , Annapolis Valley (3) , , Cape Breton (8) , , Capital Health (9) , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Rate Ratio Exhibit 5-2 Crude AMI Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 48

57 Exhibit 5-3 AMI Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 5-4 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 49

58 Exhibit 5-5 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 5-6 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 50

59 Exhibit 5-7 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 5-8 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 51

60 Exhibit 5-9 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit 5-10 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 52

61 Exhibit 5-11 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit 5-12 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia And Pictou County (PCHA), 2001/02 to 2005/06 53

62 Exhibit 5-13 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit 5-14 Trend in AMI Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 54

63 CHAPTER 6 ISCHEMIC HEART DISEASE Ischemic heart disease (IHD), also called coronary artery disease is caused by a hardening or thickening of the walls of the blood vessels that supply blood and carry oxygen to the heart. People with diabetes are at greatly increased risk of IHD as chronic high blood glucose levels and high cholesterol levels can result in the increased deposits of fatty materials (known as plaque) on the interior walls of blood vessels. If the blood supply to the heart is restricted because of these narrowed blood vessels, pain and heart dysfunction result. Ischemic heart disease is a major cause of congestive heart failure. Aggressive metabolic control is essential to reducing risk. Nova Scotia (2005/06) For the year 2005/2006, there was less variation in the crude IHD rates within the population with diabetes across DHAs, ranging from 2.9% to 7.3%, relative to the variation in CVD as a whole (see Chapter 4), but the rates (Exhibits 6-1 and 6-2) were generally lower than those for CVD as a whole (6.2% to 13.8%). However, a comparison of standardized rates revealed that there was much less variation in IHD within the population with diabetes across the province (1.4% to 3.3%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related IHD itself varied to this degree across the province. The ratio of standardized IHD rates revealed a 2.4 to 3.8 times increase in the risk of IHD in the population with diabetes, relative to the population without diabetes. This was approximately the same as the range for CVD as a whole (Chapter 4, Exhibit 4-1). Crude IHD rates by age group and sex again revealed that those with diabetes were more likely to have IHD than those without diabetes, and that this was true for both males and females and for both younger and older age groups. The IHD rate for males was higher than for females, and this remained true across the subgroups of those with diabetes (Exhibit 6-3). When comparing those with diabetes to those without diabetes, the ratio of the IHD rates was much greater in the younger age group than for the older age group. 55

64 Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized IHD rates among those with diabetes revealed no change over time, hovering at approximately 3.0 three times that of those without diabetes (Exhibit 6-4). In terms of trends by age group, the IHD rate ratios decreased with increasing age, ranging from approximately 2.0 for those over age 80 to approximately 6.0 for those in their 40s (Exhibit 6-5). The largest rate ratios by far were for those in their 20s and 30s, reaching a current level of approximately 15. There was little evidence of any change over time across most age groups, but there was evidence of a substantial drop in the IHD rate ratio among those aged District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in IHD rate ratios over time (Exhibits 6-6 to 6-14). Generally speaking, the IHD rate ratios for the DHAs were no different from those for the province as a whole; although, the figures were somewhat variable within the DHAs over time. There was far more variability in the results for both Guysborough Strait Antigonish and Colchester East Hants DHAs, but the recent figures were consistent with the provincial figures. Note: Data about ischemic heart disease (IHD) among those with and without diabetes were derived from the National Diabetes Surveillance (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. In addition, given the rarity of these cardiovascular events, particularly among the younger age groups, extreme caution should be used in interpreting trends as actual change over time. 56

65 EXHIBITS Exhibit 6-1 Exhibit 6-2 Exhibit 6-3 Exhibit 6-4 Exhibit 6-5 Exhibit 6-6 Exhibit 6-7 Exhibit 6-8 Exhibit 6-9 Exhibit 6-10 Exhibit 6-11 Exhibit 6-12 Exhibit 6-13 Exhibit 6-14 IHD Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude IHD Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 IHD Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA) 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 57

66 Exhibit 6-1 IHD Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number With at Least 1 IHD Diagnosis Population Aged 20+ Crude IHD Rate (%) Standardized IHD Rate (%) Nova Scotia 1 2,852 66, , , Annapolis Valley (3) , , Cape Breton (8) , ,132 96, Capital Health (9) , , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Rate Ratio 2.5 Exhibit 6-2 Crude IHD Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 58

67 Exhibit 6-3 IHD Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 6-4 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 59

68 Exhibit 6-5 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 6-6 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 60

69 Exhibit 6-7 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 6-8 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 61

70 Exhibit 6-9 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit 6-10 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 62

71 Exhibit 6-11 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit 6-12 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 63

72 Exhibit 6-13 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit 6-14 Trend in IHD Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 64

73 CHAPTER 7 STROKE Stroke is the consequence of interrupted blood flow to brain. Stroke can vary in severity from passing weakness or tingling to profound paralysis, coma, or death. Both males and females of all ages with diabetes are at greatly increased risk of stroke compared to those without diabetes. The increased risk may be due to the high prevalence of stroke risk factors in people with diabetes including high blood pressure and high cholesterol. Clinical practice guidelines stress the importance of a multifaceted approach to global risk reduction that includes lifestyle modifications (weight loss through healthy eating and regular exercise), smoking cessation, vascular protection with ACE inhibitors and low-dose ASA, and aggressive cholesterol lowering with statins alone or in combination with other medications. 1 Nova Scotia (2005/06) For the year 2005/2006, there was little variation in the crude stroke rates within the population with diabetes across DHAs, ranging from 0.9% to 1.8%, relative to the variation in CVD as a whole (Chapter 4), but the actual rates (Exhibits 7-1 and 7-2) were substantially lower than those for CVD as a whole (6.2% to 13.8%). A comparison of standardized rates revealed that there was even less variation in stroke, within the population with diabetes across the province (0.2% to 0.6%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related stroke itself varied to this degree across the province. The ratio of standardized stroke rates revealed a 1.8 to 4.0 times increase in the risk of stroke among the population with diabetes, relative to the population without diabetes. This was more variable than the range for CVD as a whole (Chapter 4, Exhibit 4-1). Crude stroke rates by age group and sex again revealed that those with diabetes were more likely to have a stroke than those without diabetes, and that this was true for both males and females, and for both younger and older age groups. The stroke rate for males was higher than for females, and this remained true across the subgroups of those with diabetes (Exhibit 7-3). When comparing those with diabetes to those without diabetes, the ratio of the stroke rates was much greater in the younger age group than for the older age group. 1 Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2):S1-S

74 Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized stroke rates revealed no change over time, hovering around 2.8 (Exhibit 7-4). This means that people with diabetes were on average 3 times more likely than those without diabetes to suffer from a stroke. In terms of trends by age group, the stroke rate ratios decreased with increasing age, ranging from approximately 1.9 for those over age 80 to approximately 5.0 for those in their 40s (Exhibit 7-5). The largest rate ratios by far were for those in their 20s and 30s reaching a current level of approximately 12. There was little evidence of any change over time across most age groups, with some evidence of a decrease among those in their 40s but potentially no change in those aged 20-39; although, this must be interpreted with caution given the small rates of events. District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in stroke rate ratios over time (Exhibits 7-6 to 7-14). Generally speaking, the stroke rate ratios for the DHAs were no different from those for the province as a whole; although, the figures were somewhat variable within the DHAs over time. Note: Data about stroke among those with and without diabetes were derived from the National Diabetes Surveillance Strategy (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. In addition, given the rarity of these cardiovascular events, particularly among the younger age groups, extreme caution should be used in interpreting trends as actual change over time. 66

75 EXHIBIT S Exhibit 7-1 Exhibit 7-2 Exhibit 7-3 Exhibit 7-4 Exhibit 7-5 Exhibit 7-6 Exhibit 7-7 Exhibit 7-8 Exhibit 7-9 Exhibit 7-10 Exhibit 7-11 Exhibit 7-12 Exhibit 7-13 Exhibit 7-14 Stroke Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude Stroke Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 Stroke Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 67

76 Exhibit 7-1 Stroke Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number With at Least 1 Stroke Procedure Population Aged 20+ Crude Stroke Rate (%) Standardized Stroke Rate (%) Nova Scotia , , , Annapolis Valley (3) , , Cape Breton (8) , , Capital Health (9) , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Rate Ratio Exhibit 7-2 Crude Stroke Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 68

77 Exhibit 7-3 Stroke Rates for the Population Aged 20+, with/without Diabetes (DM) in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 7-4 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 69

78 Exhibit 7-5 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 7-6 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 70

79 Exhibit 7-7 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 7-8 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 71

80 Exhibit 7-9 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit 7-10 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 72

81 Exhibit 7-11 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit 7-12 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 73

82 Exhibit 7-13 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit 7-14 Trend in Stroke Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 74

83 CHAPTER 8 UNSTABLE ANGINA Angina is characterized by chest pain or discomfort caused by reduced blood supply to the heart muscle. Unstable angina (UA) is a precursor to, and a potent predictor of, an acute myocardial infarction (MI). It typically has a sudden onset with sudden worsening and recurrence over days or weeks. Patients with diabetes are far more likely than those without to be admitted to hospital for UA, to have longer hospital stays, and have significantly higher mortality rates at one month and one year after admission. 1 Nova Scotia (2005/06) For the year 2005/2006, there was little variation in the crude UA rates within the population with diabetes across DHAs, ranging from 0.9% to 1.8%, relative to the variation in CVD as a whole (see Chapter 4), but the actual rates (Exhibits 8-1 and 8-2) were substantially lower than those for CVD as a whole (6.2% to 13.8%). A comparison of standardized rates revealed that there was even less variation in UA within the population with diabetes across the province (0.5% to 1.4%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related UA itself varied to this degree across the province. The ratio of standardized UA rates revealed a 2.5 to 5.5 times increase in the risk of UA among the population with diabetes, relative to the population without diabetes. This was more variable than the range across DHAs in CVD as a whole (Chapter 4, Exhibit 4-1). Crude UA rates by age group and sex again revealed that those with diabetes were more likely to have UA than those without diabetes, and that this was true for both males and females, and for both younger and older age groups. The UA rate for males was higher than for females, and this remained true across the subgroups of those with diabetes (Exhibit 8-3). When comparing those with diabetes to those without diabetes, the ratio of the UA rates was much greater for the younger age group than for the older age group. 1 Booth GL, Rothwell D, Fung K, Tu JV. Diabetes and Cardiac Disease. In: Hux JE, Booth G, Laupacis A (eds). Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical Evaluative Sciences. 2002:

84 Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized UA rates revealed no change over time, hovering at approximately 3.3 (Exhibit 8-4). People with diabetes were on average 3 times more likely to suffer from UA than those without diabetes. In terms of trends by age group, the UA rate ratios decreased with increasing age, although to a lesser degree than for CVD as a whole, ranging from approximately 2.0 for those over age 80 to approximately 6.0 for those in their 40s. The largest rate ratios by far were for those in their 20s and 30s, reaching a current level of approximately 13 (Exhibit 8-5). There was little evidence of any change over time across most age groups, but evidence of a substantial drop in the UA rate ratio among those aged District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in UA rate ratios over time (Exhibits 8-6 to 8-14). Generally speaking, the UA rate ratios for the DHAs were no different from those for the province as a whole; although, the figures were somewhat variable within the DHAs over time, reflecting the impact of small changes in small numbers over time. There was far more variability in the results for both Guysborough Strait Antigonish and Colchester East Hants DHAs, but recent figures were consistent with the provincial figures. Note: Data about unstable angina (UA) among those with and without diabetes were derived from the National Diabetes Surveillance Strategy (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. In addition, given the rarity of these cardiovascular events, particularly among the younger age groups, extreme caution should be used in interpreting trends as actual change over time. 76

85 EXHIBITS Exhibit 8-1 Exhibit 8-2 Exhibit 8-3 Exhibit 8-4 Exhibit 8-5 Exhibit 8-6 Exhibit 8-7 Exhibit 8-8 Exhibit 8-9 Exhibit 8-10 Exhibit 8-11 Exhibit 8-12 Exhibit 8-13 Exhibit 8-14 UA Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude UA Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 UA Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 77

86 Exhibit 8-1 UA Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number With at Least 1 UA Diagnosis Population Aged 20+ Crude UA Rate (%) Standardized UA Rate (%) Nova Scotia , , , Annapolis Valley (3) , , Cape Breton (8) , , Capital Health (9) , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Rate Ratio Exhibit 8-2 Crude UA Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 78

87 Exhibit 8-3 UA Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 8-4 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 79

88 Exhibit 8-5 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 8-6 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 80

89 Exhibit 8-7 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 8-8 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 81

90 Exhibit 8-9 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit 8-10 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 82

91 Exhibit 8-11 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit 8-12 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 83

92 Exhibit 8-13 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit 8-14 Trend in UA Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 84

93 CHAPTER 9 HYPERTENSION Hypertension (HTN), or high blood pressure, is a very common comorbidity in people with diabetes and is a potent risk factor for diabetes-related microvascular and macrovascular diseases. Accordingly, clinical practice guidelines recommend frequent monitoring of blood pressure and aggressive management of hypertension to reach a target of <130/80 mm Hg. 1 Many people with diabetes will require three or more blood pressure-lowering agents (in addition to lifestyle modifications) to achieve this target. 2 Nova Scotia (2005/06) For the year 2005/2006, there was considerable variation in crude HTN rates within the population with diabetes across DHAs, ranging from 1.4% to 9.3%, relative to the variation in CVD as a whole (see Chapter 4), but the actual rates (Exhibits 9-1 and 9-2) were generally lower than those for CVD as a whole (6.2% to 13.8%). A comparison of standardized rates revealed that there was even less variation in HTN within the population with diabetes across the province (0.5% to 1.4%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related HTN itself varied to this degree across the province. The ratio of standardized hypertension rates revealed a 2.4 to 4.7 increase in the risk of HTN among the population with diabetes, relative to the population without diabetes. This was far more variable than the range for CVD as a whole (Chapter 4, Exhibit 4-1). Crude HTN rates by age group and sex again revealed that those with diabetes were more likely to have HTN than those without diabetes, and that this was true for both males and females, and for both younger and older age groups. In contrast to CVD as a whole, HTN rates for males and females were similar in the age group but were higher among females in the older age group (Exhibit 9-3). When comparing those with diabetes to those without diabetes, the ratio of the HTN rates was much higher in the younger age group than for the older age group. 1 Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2):S1-S UK Prospective Diabetes Study Group. Tight blood pressure and control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:

94 Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized HTN rates revealed no change over time, hovering at approximately 3.3 (Exhibit 9-4). People with diabetes were on average 3 times more likely to suffer from HTN than those without diabetes. In terms of trends by age, the HTN rate ratios decreased with increasing age, ranging from approximately 1.8 for those over age 80 to approximately 5.0 for those in their 40s (Exhibit 9-5). The largest rate ratios by far were for those in their 20s and 30s, reaching a current level of approximately 27, the highest rate ratio of all of the family of CVD diseases. There was little evidence of any change over time across most age groups, with slight evidence of a decrease among those aged and those aged 20-39; although, this must be interpreted with caution given the small rates of events. District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in HTN rate ratios over time (Exhibits 9-6 to 9-14). Generally speaking, the HTN rate ratios for the DHAs were no different from those for the province as a whole; although, the figures were somewhat variable within the DHAs and Pictou County DHA appeared to be generally higher than the provincial figures. Note: Data about hypertension (HTN) among those with and without diabetes were derived from the National Diabetes Surveillance Strategy (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. In addition, given the rarity of these cardiovascular events, particularly among the younger age groups, extreme caution should be used in interpreting trends as actual change over time. 86

95 EXHIBITS Exhibit 9-1 Exhibit 9-2 Exhibit 9-3 Exhibit 9-4 Exhibit 9-5 Exhibit 9-6 Exhibit 9-7 Exhibit 9-8 Exhibit 9-9 Exhibit 9-10 Exhibit 9-11 Exhibit 9-12 Exhibit 9-13 Exhibit 9-14 HTN Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude HTN Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 HTN Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 87

96 Exhibit 9-1 HTN Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number With at Least 1HTN Diagnosis Population Aged 20+ Crude HTN Rate (%) Standardized HTN Rate (%) Nova Scotia 1 2,741 66, , , Annapolis Valley (3) , , Cape Breton (8) 1 1,088 11, ,502 96, Capital Health (9) , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Rate Ratio Exhibit 9-2 Crude HTN Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 88

97 Exhibit 9-3 HTN Rates for the Population Aged 20+, with/without Diabetes (DM) in Nova Scotia, by Age Group and Sex, 2005/06 Exhibit 9-4 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 89

98 Exhibit 9-5 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 9-6 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 90

99 Exhibit 9-7 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 9-8 Trend in HTN Rate Ratio for the Population Aged 20+in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 91

100 Exhibit 9-9 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit 9-10 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 92

101 Exhibit 9-11 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit 9-12 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 93

102 Exhibit 9-13 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit 9-14 Trend in HTN Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 94

103 CHAPTER 10 HEART FAILURE Heart failure (HF) is a life-threatening condition characterized by the heart s inability to properly pump blood. As a result, fluid may accumulate in body tissues (e.g., the lungs) causing organ failure. The most common causes of HF are coronary artery disease and congestive heart failure (CHF). Major risk factors include diabetes and smoking. Rates of hospitalization for CHR are much higher in people with diabetes than in those without diabetes, regardless of age or sex. 1 As seen with other cardiovascular complications, individuals with diabetes have higher admission rates for CHF (independent of age and sex) and longer hospital stays. 2 Treatment involves medications, reduced sodium intake, smoking cessation, exercise, and sufficient rest. Nova Scotia (2005/06) For the year 2005/2006, there was considerable variation in the crude HF within the population with diabetes across DHAs, ranging from 1.8% to 3.3%, relative to the variation in CVD as a whole (see Chapter 4), but the actual rates (Exhibits 10-1 and 10-2) were generally lower than those for CVD as a whole (6.2% to 13.6%). A comparison of standardized rates revealed that there was far less variation in HF within the population with diabetes across the province (0.6% to 1.2%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related HF itself varied to this degree across the province. The ratio of standardized HF rates revealed a 2.8 to 4.6 times increase in the risk of HF among the population with diabetes, relative to the population without diabetes. This is far more variable than the range for CVD as a whole (Chapter 4, Exhibit 4-1). Crude HF rates by age and sex again revealed that those with diabetes were more likely to have HF than those without diabetes, and that this was true for both males and females, and for both younger and older age groups. Unlike CVD as a whole, HF rates for males and females were similar in the age group but were higher among females in the older age group (Exhibit 10-3). When comparing those with diabetes to those without diabetes, the ratio of HF rates was much greater for the younger age group for the older age group. 1 Booth GL, Rothwell D, Fung K, Tu JV. Diabetes and Cardiac Disease. In: Hux JE, Booth G, Laupacis A (eds). Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical Evaluative Sciences. 2002: Booth GL, Rothwell D, Fung K, Tu JV. Diabetes and Cardiac Disease. In: Hux JE, Booth G, Laupacis A (eds). Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical Evaluative Sciences. 2002:

104 Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized HF rates revealed no change over time, hovering at approximately 3.6 (Exhibit 10-4). People with diabetes were on average 3.5 times more likely to suffer from HF than those without diabetes. In terms of trends by age, the HF rate ratios decreased with increasing age, ranging from approximately 2.0 for those over age 80 to approximately 15 for those in their 40s (Exhibit 10-5). The largest rate ratios by far were seen for those in their 20s and 30s, reaching a current level of approximately 16. There was little evidence of any change over time across most age groups, with slight evidence of a decrease among those aged and those aged 20-39; although, this must be interpreted with caution given the small rates of events District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in HF rate ratios over time (Exhibits 10-6 to 10-14). Generally speaking, the HF rate ratios for the DHAs were no different from those for the province as a whole; although, the figures were somewhat variable within the DHAs. Some DHAs appeared slightly above the provincial figures (Annapolis Valley, Pictou County, and South Shore) and another appeared slightly below (Cumberland) these figures over time. Note: Data about heart failure (HF) among those with and without diabetes were derived from the National Diabetes Surveillance System (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. In addition, given the rarity of these cardiovascular events, particularly among the younger age groups, extreme caution should be used in interpreting trends as actual change over time. 96

105 EXHIBITS Exhibit 10-1 Exhibit 10-2 Exhibit 10-3 Exhibit 10-4 Exhibit 10-5 Exhibit 10-6 Exhibit 10-7 Exhibit 10-8 Exhibit 10-9 Exhibit Exhibit Exhibit Exhibit Exhibit HF Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude HF Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 HF Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 97

106 Exhibit 10-1 HF Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Nova Scotia Diabetes Status (1=with DM) Number With at Least 1 HF Diagnosis Population Aged 20+ Crude HF Rate (%) Standardized HF Rate (%) 1 1,501 66, , , Annapolis Valley (3) , , Cape Breton (8) , , Capital Health (9) , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Rate Ratio Exhibit 10-2 Crude HF Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 98

107 Exhibit 10-3 HF Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 10-4 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 99

108 Exhibit 10-5 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 10-6 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 100

109 Exhibit 10-7 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 10-8 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 101

110 Exhibit 10-9 Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 102

111 Exhibit Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 103

112 Exhibit Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit Trend in HF Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 104

113 CHAPTER 11 NEPHROPATHY Healthy kidneys function as filters that rid the body of toxic by-products of normal metabolism and help maintain stable fluid, salt, acid, and hormone levels. Over time, diabetes can damage the kidneys, leading to diabetic kidney disease (nephropathy) one of the most serious and costly complications of diabetes. The presence of diabetes greatly increases a person s risk of developing end-stage renal disease (kidney failure) requiring dialysis or kidney transplantation. People with diabetic nephropathy tend to have multiple and often serious comorbidities and after starting chronic dialysis have a significantly increased risk of mortality compared to individuals without diabetes. 1 The onset and/or progression of nephropathy can be slowed or prevented through excellent blood glucose and blood pressure control. All people with diabetes should be screened regularly for protein in the urine, the earliest marker of nephropathy. 2 In addition to predicting risk of developing nephropathy, even a small amount of urinary protein (microalbuminuria) is a potent independent risk factor for cardiovascular disease. If detected early enough, progression of kidney disease can be slowed or halted with appropriate medications and through excellent blood glucose, blood pressure, and blood lipid control as well as smoking cessation. Chronic renal impairment is a contraindication for a number of diabetes medications. Nova Scotia (2005/06) For the year 2005/2006, there was little variation in the crude nephropathy rates among the population with diabetes across DHAs, ranging from 1.0% to 2.0% (Exhibits 11-1 and 11-2). A comparison of standardized rates revealed that there was even less variation in nephropathy within the population with diabetes across the province (0.3% to 1.0%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related nephropathy itself varied to this degree across the province. The ratio of standardized nephropathy rates revealed a 2.8 to 8.0 times increase in risk for nephropathy among the population with diabetes, relative to the population without diabetes. Crude nephropathy rates by age group and sex again revealed that those with diabetes were more likely to have nephropathy than those without diabetes, and that this was true for both males and females, and for both younger and older age groups; although, the male/female difference was less pronounced in the younger age group as compared with the older age group (Exhibit 11-3). 1 Oliver J, Lok CE, Shi J, Rothwell D. Dialysis Therapy for Persons with Diabetes. In: Hux JE, Booth G, Laupacis A (eds). Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical Evaluative Sciences. 2002: Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2):S1-S

114 When comparing those with diabetes to those without diabetes, the ratio of nephropathy rates was much greater for the younger age group than for the older age group. Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized nephropathy rates revealed no real change over time hovering at approximately 5.5 (Exhibit 11-4). People with diabetes were on average 6 times more likely to suffer from nephropathy than those without diabetes. In terms of trends by age group, the nephropathy rate ratios decreased with increasing age, ranging from approximately 2.5 for those over age 80 to approximately 15 for those in their 40s (Exhibit 11-5). The largest rate ratios by far were for those in their 20s and 30s, reaching a current level of approximately 24. There was little evidence of any change over time across most age groups; although, there was evidence of a substantial drop in the figures for the youngest age group. This finding must be interpreted with caution given the small rates of events. District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in nephropathy rate ratios over time (Exhibits 11-6 to 11-14). Generally speaking, the nephropathy rate ratios for some DHAs (Annapolis Valley and Guysborough Antigonish Strait) were generally below the provincial figures whereas another DHA (Colchester East Hants) appeared to be higher than the provincial figures over time. Note: Data about nephropathy among those with and without diabetes were derived from the National Diabetes Surveillance System (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. 106

115 EXHIBITS Exhibit 11-1 Exhibit 11-2 Exhibit 11-3 Exhibit 11-4 Exhibit 11-5 Exhibit 11-6 Exhibit 11-7 Exhibit 11-8 Exhibit 11-9 Exhibit Exhibit Exhibit Exhibit Exhibit Nephropathy Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude Nephropathy Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 Nephropathy Rates for the Population Aged 20+, with/without Diabetes (DM) in Nova Scotia by Age Group and Sex, 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 107

116 Exhibit 11-1 Nephropathy Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number With at Least 1 Nephropathy Diagnosis Population Aged 20+ Crude Nephropathy Rate (%) Standardized Nephropathy Rate (%) Nova Scotia , , Annapolis Valley (3) , , Cape Breton (8) , , Capital Health (9) , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Rate Ratio Exhibit 11-2 Crude Nephropathy Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 108

117 Exhibit 11-3 Nephropathy Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 11-4 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 109

118 Exhibit 11-5 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 11-6 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 110

119 Exhibit 11-7 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 11-8 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 111

120 Exhibit 11-9 Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 112

121 Exhibit Trend in Nephropathy Rate R for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 113

122 Exhibit Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit Trend in Nephropathy Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 114

123 CHAPTER 12 RETINOPATHY Diabetes can cause changes in the blood vessels that supply the retina. In the early stages of retinopathy, these blood vessels leak fluid or blood causing the retina to swell. In more advanced stages, the blood vessels become blocked and part of the retina dies. Scar tissue forms and pulls at the retina, which can cause it to detach leading to partial or complete vision loss. Retinopathy is the leading cause of adult-onset blindness and the longer the duration of diabetes, the greater the risk of retinopathy. Excellent blood glucose and blood pressure control can delay the onset or slow the progression of retinopathy. All people with type 2 diabetes should be screened for retinopathy at diagnosis of diabetes and every one to two years thereafter. People with type 1 diabetes over age 15 should be screened annually starting 5 years after the onset of diabetes. 1 Nova Scotia (2005/06) For the year 2005/2006, there was substantial variation in the crude retinopathy rates among the population with diabetes across DHAs, ranging from 5.0% to 17.0% (Exhibit 12-1 and 12-2). A comparison of standardized rates revealed that there was little change in the variation of retinopathy within the population with diabetes across the province (3.9% to 15.0%). However, the absolute numbers decreased, suggesting that some of the variation seen in the crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related retinopathy itself varied to this degree across the province. The ratio of standardized retinopathy rates revealed a 3.9 to 9.7 times increase in the risk of retinopathy among the population with diabetes, relative to the population without diabetes. Crude retinopathy rates by age group and sex again revealed that those with diabetes were more likely to have retinopathy than those without diabetes, and that this was true for both males and females, and for both younger and older age groups, yet there was no difference by sex within each age group (Exhibit 12-3). When comparing those with diabetes to those without diabetes, the ratio of retinopathy rates was much greater for the younger age group (20-64) than for the older age group. 1 Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2): S1 S

124 Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized retinopathy rates revealed a decrease over time, reaching a current level of approximately 7.0 (Exhibit 12-4). People with diabetes were on average 7 times more likely to suffer from retinopathy than for those without diabetes. In terms of trends by age group, the retinopathy rate ratios decreased with increasing age, ranging from approximately 1.8 for those over age 80 to approximately 9.0 for those in their 50s (Exhibit 12-5). The largest rate ratios by far were for those in their 20s and 30s, reaching a current level of approximately 36. There was little evidence of any change over time across most age groups; although, there was evidence of a decrease for those in their 40s and a substantial decrease for those aged District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed a general drop in retinopathy rate ratios over time (Exhibits 12-6 to 12-14). Generally speaking, the retinopathy rate ratios for some DHAs (Cape Breton, Colchester East Hants) were below the provincial figures whereas other DHAs (Annapolis Valley, Cumberland) appeared to be higher than the provincial figures over time. Note: Data about retinopathy among those with and without diabetes were derived from the National Diabetes Surveillance Strategy (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. 116

125 EXHIBITS Exhibit 12-1 Exhibit 12-2 Exhibit 12-3 Exhibit 12-4 Exhibit 12-5 Exhibit 12-6 Exhibit 12-7 Exhibit 12-8 Exhibit 12-9 Exhibit Exhibit Exhibit Exhibit Exhibit Retinopathy Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude Retinopathy Crude Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 Retinopathy Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 117

126 Exhibit 12-1 Retinopathy Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number With at Least 1 Retinopathy Diagnosis Population Aged 20+ Crude Rate (%) Standardized Rate (%) Nova Scotia 1 6,360 66, , , Annapolis Valley (3) 1 1,044 6, ,130 61, Cape Breton (8) , ,194 96, Capital Health (9) 1 2,404 23, , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , Rate Ratio Exhibit 12-2 Crude Retinopathy Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 118

127 Exhibit 12-3 Retinopathy Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 12-4 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 119

128 Exhibit 12-5 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 12-6 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 120

129 Exhibit 12-7 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 12-8 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 121

130 Exhibit 12-9 Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 122

131 Exhibit Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 123

132 Exhibit Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit Trend in Retinopathy Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 124

133 CHAPTER 13 LOWER EXTREMITY AMPUTATION Foot problems are a major cause of morbidity and mortality in people with diabetes, accounting for approximately one-fifth of all diabetes-related hospital admissions in North America. 1 In a patient with neuropathy or peripheral vascular disease, a minor trauma to the foot leads to skin ulceration and infection, gangrene, and ultimately amputation. Compared to people without diabetes, people with diabetes are significantly more likely to have an amputation, have a poorer prognosis for the contralateral limb, and have higher mortality rates following amputation. Prevention of amputation requires a multidisciplinary approach to patient education, regular screening for risk factors, and aggressive management of non-healing ulcers. 2 Nova Scotia (2003/04 to 2005/06) For the period 2003/04 to 2005/06, there was a small amount of variation in the crude lower extremity amputation (LEA) rates within the population with diabetes across the DHAs, ranging from 0.50% to 0.92% (Exhibits 13-1 and 13-2). A comparison of standardized rates for this period revealed that there was little change in the variation of LEA within the population with diabetes across the province (0.19% to 0.58%. However, the absolute numbers decreased, suggesting that some of the variation seen in the crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related LEAs varied to this degree across the province. The ratio of standardized LEA rates revealed a 5.9 to 14.1 times increase in the risk of LEA among the population with diabetes, relative to the population without diabetes. Crude LEA rates by age group and sex again revealed that those with diabetes were more likely to have a LEA than those without diabetes, and that this was true for both males and females, and for both younger and older age groups. However, the rates for females over age 65 approached those for males aged (Exhibit 13-3). When comparing those with diabetes to those without diabetes, the ratio of LEA rates was much greater for the younger age group than for the older age group. 1 Mayfield JA, Reiber GE, Sander LJ, et al. Preventive foot care in people with diabetes. Diabetes Care. 1999;22: Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2): S1 S

134 Nova Scotia Time Trends (2000/01 to 2004/05)* Time trends in the ratio of the standardized LEA rates revealed no change over time, hovering at approximately 11.5 (Exhibit 13-4). Persons with diabetes were on average 11 times more likely to have an LEA than those without diabetes. In terms of trends by age, the LEA rate ratios decreased with increasing age, ranging from approximately 4.5 for those over age 80 to 20.0 for those in their 50s (Exhibit 3-5). The largest rate ratios by far were for those in their 40s (approximately 65) followed closely by those in their 20s and 30s (approximately 40). There was evidence of a substantial increase over time in the LEA rate ratio for those in their 40s, and for those in their 20s and 30s. District Time Trends (2000/01 to 2004/05)* Analyses of time trends by DHA revealed no change in the LEA rate ratios over time (Exhibit 13-6 to 13-14). Generally speaking, the LEA rate ratios for most DHAs revealed the same stable trend; although, the figures for some DHAs (Colchester East Hants and Guysborough Antigonish Strait) were generally below the provincial figures and other DHAs (Cape Breton and Cumberland) appeared to be generally higher than the provincial figures over time. It should be noted that the figures for Pictou County DHA were far higher than the provincial figures but have now decreased to meet the provincial figure. Note: Data about LEAs among those with and without diabetes were derived from the National Diabetes Surveillance Strategy (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. Given the small number of LEAs in a given year, Nova Scotia figures are provided for the three-year period April 1, 2003 to March 31, 2006 to yield more stable results. *Similarly, wherever time trend data are presented, three-year averages are calculated and plotted on the midpoint of the period (e.g., 2001/02 figures are an average of those from 2000/02, 2001/02, and 2002/03). 126

135 EXHIBITS Exhibit 13-1 Exhibit 13-2 Exhibit 13-3 Exhibit 13-4 Exhibit 13-5 Exhibit 13-6 Exhibit 13-7 Exhibit 13-8 Exhibit 13-9 Exhibit Exhibit Exhibit Exhibit Exhibit LEA Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2003/04 to 2005/06 Crude LEA Rates for the Population Aged 20+, with/without Diabetes (DM),.in Nova Scotia and the DHAs, 2003/04 to 2005/06 LEA Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2003/04 to 2005/06 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia, 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2000/01 to 2004/05 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2000/01 to 2004/05 127

136 Exhibit 13-1 LEA Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2003/04 to 2005/06 Diabetes Status (1=with DM) *Number With at Least 1 LEA Procedure Population Aged 20+ Crude LEA Rate (%) Standardized LEA Rate (%) Nova Scotia , , Annapolis Valley (3) , , Cape Breton (8) , , Capital Health (9) , , Colchester East Hants (4) , , Cumberland (5) , , Guysborough Antigonish Strait (7) , , Pictou County (6) , , South Shore (1) , , South West (2) , , * Number reflects cases over the 3-year period (2003/04 to 2005/06). Rate Ratio Exhibit 13-2 Crude LEA Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2003/04 to 2005/06 128

137 Exhibit 13-3 LEA Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2003/04 to 2005/06 Exhibit 13-4 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia, 2000/01 to 2004/05 129

138 Exhibit 13-5 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2000/01 to 2004/05 Exhibit 13-6 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2000/01 to 2004/05 130

139 Exhibit 13-7 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2000/01 to 2004/05 Exhibit 13-8 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2000/01 to 2004/05 131

140 Exhibit 13-9 Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2000/01 to 2004/05 Exhibit Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2000/01 to 2004/05 132

141 Exhibit Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2000/01 to 2004/05 Exhibit Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2000/01 to 2004/05 133

142 Exhibit Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2000/01 to 2004/05 Exhibit Trend in LEA Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2000/01 to 2004/05 134

143 SECTION III HEALTH SERVICES UTILIZATION CHAPTER 14 HOSPITAL ADMISSIONS Analyses of data about admissions to hospital are performed to compare hospital use in the population with diabetes compared to the population without diabetes. Diabetes is associated with hospitalization for acute events related to the diabetes itself such as diabetic ketoacidosis, hyperglycemia, severe hypoglycemia, and acute infections. People with diabetes are also likely to be hospitalized because of other health conditions that may or may not be secondary to the diabetes (i.e., comorbid conditions), such as cardiovascular disease and nephropathy. Finally, people with diabetes who are hospitalized for conditions unrelated to their diabetes such as surgeries and minor procedures are more likely to experience a longer length of stay in hospital for that condition, relative to people without diabetes. Nova Scotia (2005/06) For the year 2005/2006, there was a fair degree of variation in the crude hospital admission rates within the population with diabetes across DHAs, ranging from 28.5% to 46.0% (Exhibits 14-1 and 14-2). However, a comparison of standardized rates revealed that there was much less variation in hospital admissions within the population with diabetes across the province (22.2% to 37.5%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related hospital admission rates varied to this degree across the province. The ratio of standardized hospital admission rates revealed a 2.1 to 2.6 times increase in the risk of hospital admission in the population with diabetes, relative to the population without diabetes. Crude hospital admission rates by age group and sex again revealed that those with diabetes were more likely to have a hospital admission than those without diabetes, and that this was true for both males and females, and for both younger and older age groups (Exhibit 14-3). There was slight evidence that the hospital admission rate for females with diabetes was higher than that for males in the younger age group (20-64) whereas the opposite was true for the older age group. 135

144 SECTION III HEALTH SERVICES UTILIZATION Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized hospital admission rates revealed no change over time, hovering at approximately 2.3 (Exhibit 14-4). People with diabetes were on average twice as likely to be admitted to hospital than those without diabetes. In terms of trends by age group, the hospital admission rate ratios were substantially higher for those aged (2.85) as compared with those over 65 (1.6), and there was little evidence of any change over time within both age groups (Exhibit 14-5). District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in hospital admission rate ratios over time (Exhibits 14-6 to 14-14). Generally speaking, the hospital admission rate ratios for the DHAs were no different than those for the province as a whole; although, the figures were far more variable within the DHAs over time. Note: Data about hospital admissions among those with and without diabetes were derived from the National Diabetes Surveillance System (NDSS) (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. 136

145 SECTION III HEALTH SERVICES UTILIZATION EXHIBIT S Exhibit 14-1 Exhibit 14-2 Exhibit 14-3 Exhibit 14-4 Exhibit 14-5 Exhibit 14-6 Exhibit 14-7 Exhibit 14-8 Exhibit 14-9 Exhibit Exhibit Exhibit Exhibit Exhibit Hospital Admission Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude Hospital Admission Rates for the Population Aged 20+ with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 Hospital Admission Rates for the Population Aged 20+ with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 137

146 SECTION III HEALTH SERVICES UTILIZATION Exhibit 14-1 Hospital Admission Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Number of Admissions Population Aged 20+ Crude Admission Rate (%) Standardized Admission Rate (%) Nova Scotia 1 23,398 66, , , Annapolis Valley (3) 1 2,073 6, ,875 61, Cape Breton (8) 1 5,194 11, ,910 96, Capital Health (9) 1 6,649 23, , , Colchester East Hants (4) 1 1,627 4, ,739 54, Cumberland (5) 1 1,087 2, ,569 25, Guysborough Antigonish Strait (7) 1 1,412 3, ,415 35, Pictou County (6) 1 1,590 3, ,544 36, South Shore (1) 1 1,665 5, ,235 46, South West (2) 1 2,095 5, ,129 47, Rate Ratio Exhibit 14-2 Crude Hospital Admission Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 138

147 SECTION III HEALTH SERVICES UTILIZATION Exhibit 14-3 Hospital Admission Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 14-4 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 139

148 SECTION III HEALTH SERVICES UTILIZATION Exhibit 14-5 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 14-6 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 140

149 SECTION III HEALTH SERVICES UTILIZATION Exhibit 14-7 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 14-8 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 141

150 SECTION III HEALTH SERVICES UTILIZATION Exhibit 14-9 Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 142

151 SECTION III HEALTH SERVICES UTILIZATION Exhibit Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 143

152 SECTION III HEALTH SERVICES UTILIZATION Exhibit Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit Trend in Hospital Admission Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 144

153 SECTION III HEALTH SERVICES UTILIZATION CHAPTER 15 HOSPITAL MEDIAN LENGTH OF STAY The length of a hospital stay can provide information on the severity of illness and the complexity of care for a patient. Nova Scotia (2005/06) For the year 2005/2006, there was little variation in the median length of stay (LOS) within the population with diabetes across DHAs, ranging from 5 to 6 days (Exhibits 15-1 and 15-2). The difference in median LOS for those with diabetes as compared to those without diabetes ranged from 1 to 2 days longer, except for Capital Health where the difference was 3 days. Median LOS values by age group and sex again revealed that those with diabetes stayed longer in hospital than those without diabetes (Exhibit 15-3). There was little evidence of male/female difference in the younger age group with diabetes, but among those over age 65, females were more likely to have a longer median LOS than males. This pattern was also true for the population without diabetes. District Health Authorities (2005/06) Analyses of median LOS by DHA revealed the same general trends as seen for Nova Scotia as a whole; although, there was some variation within individual DHAs (Exhibits 15-4 to 15-12). Again, there was evidence that the median LOS values for males and females with diabetes were no different in the younger age group but that females were more likely than males to have a longer stay in the older age group. The only exception was for Cumberland DHA where males with diabetes in the younger age group had a longer median LOS value than females. It should also be noted that the median LOS figures for Cape Breton DHA were higher for both sexes and both age groups compared to Nova Scotia as a whole. Note: Data about length of stay for hospital admission among those with and without diabetes were derived from the National Diabetes Surveillance System (NDSS) (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. 145

154 SECTION III HEALTH SERVICES UTILIZATION EXHIBITS Exhibit 15-1 Exhibit 15-2 Exhibit 15-3 Exhibit 15-4 Exhibit 15-5 Exhibit 15-6 Exhibit 15-7 Exhibit 15-8 Exhibit 15-9 Exhibit Exhibit Exhibit Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Annapolis Valley (AVH) by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Cape Breton (CBDHA) by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Capital Health (CH) by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Colchester East Hants (CEHHA) by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Cumberland (CHA) by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Guysborough Antigonish Strait (GASHA) by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Pictou County (PCHA) by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in South Shore (SSH) by Age Group and Sex, 2005/2006 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in South West (SWH) by Age Group and Sex, 2005/

155 SECTION III HEALTH SERVICES UTILIZATION Exhibit 15-1 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/2006 Diabetes Status (1=with DM) Median LOS (days) Difference by Diabetes Status (days) Nova Scotia Annapolis Valley (3) Cape Breton (8) Capital Health (9) Colchester East Hants (4) Cumberland (5) Guysborough Antigonish Strait (7) Pictou County (6) South Shore (1) South West (2) Exhibit 15-2 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/

156 SECTION III HEALTH SERVICES UTILIZATION Exhibit 15-3 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/2006 Exhibit 15-4 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Annapolis Valley (AVH) by Age Group and Sex, 2005/

157 SECTION III HEALTH SERVICES UTILIZATION Exhibit 15-5 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Cape Breton (CBDHA) by Age Group and Sex, 2005/2006 Exhibit 15-6 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Capital Health (CH) by Age Group and Sex, 2005/

158 SECTION III HEALTH SERVICES UTILIZATION Exhibit 15-7 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Colchester East Hants (CEHHA) by Age Group and Sex, 2005/2006 Exhibit 15-8 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Cumberland (CHA) by Age Group and Sex, 2005/

159 SECTION III HEALTH SERVICES UTILIZATION Exhibit 15-9 Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Guysborough Antigonish Strait (GASHA) by Age Group and Sex, 2005/2006 Exhibit Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in Pictou County (PCHA) by Age Group and Sex, 2005/

160 SECTION III HEALTH SERVICES UTILIZATION Exhibit Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in South Shore (SSH) by Age Group and Sex, 2005/2006 Exhibit Hospital Median LOS for the Population Aged 20+, with/without Diabetes (DM), in South West (SWH) by Age Group and Sex, 2005/

161 SECTION III HEALTH SERVICES UTILIZATION C H A P T E R 1 6 GENERAL PRACTIONER OFFICE VISITS Diabetes is a complex, chronic, multisystemic disease that is progressive in nature. As such, people with diabetes are heavy users of the healthcare system. While the vast majority of people with diabetes are followed exclusively by a general practioner (GP), specialist care is often required to manage the disease and its related complications. 1 Comprehensive diabetes management requires regular screening for blood glucose, blood pressure, and lipid control. In addition, routine screening for foot problems, neuropathy (nerve damage), retinopathy (eye disease), nephropathy (kidney disease), sexual dysfunction, depression, and anxiety is essential for early detection and ongoing treatment of these conditions. 2 Nova Scotia (2005/06) For the year 2005/2006, there was a fair amount of variation in the crude GP office visit rates within the population with diabetes across DHAs, ranging from 5.9 to 7.8 visits per person (Exhibits 16-1 and 16-2). However, a comparison of standardized rates revealed that there was much less variation in GP office visit rates within the population with diabetes across the province (4.7 to 7.0), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related GP office visit rates varied to this degree across the province. The ratio of standardized GP office visit rates revealed a 1.7 to 1.9 times increase in the rate of GP office visits in the population with diabetes, relative to the population without diabetes. Crude rates for GP office visits by age group and sex again revealed that those with diabetes were more likely to have GP office visits than those without diabetes, and that this was true for both males and females, and for both younger and older age groups (Exhibit 16-3). There was evidence that the GP office visit rate for females with diabetes was almost double that of males in the age group; whereas, there was no difference in the rates among those over Jaakkimainen L, Shah BR, Kopp A. Sources of Physician Care for People with Diabetes. In: Hux JE, Booth G, Laupacis A (eds). Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical Evaluative Sciences. 2002: Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2): S1 S

162 SECTION III HEALTH SERVICES UTILIZATION Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized rates of GP office visits for the diabetes population revealed no change over time, hovering at approximately 1.8 times that of those without diabetes (Exhibit 16-4). In terms of trends by age group, the GP office visit rate ratios were substantially higher for those aged (2.1) as compared with those over 65 (1.3), and there was little evidence of any change over time within both age groups (Exhibit 16-5). District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in GP office visit rate ratios over time (Exhibits 16-6 to 16-14). Generally speaking, the GP office visit rate ratios for the DHAs were no different than those for the province as a whole; although, the figures for South Shore DHA were consistently lower than those of the province as a whole, and the figures for South West DHA were consistently higher than those of the province as a whole. Note: Data about general practitioner (GP) visits among those with and without diabetes were derived from the National Diabetes Surveillance Strategy (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. 154

163 SECTION III HEALTH SERVICES UTILIZATION EXHIBITS Exhibit 16-1 Exhibit 16-2 Exhibit 16-3 Exhibit 16-4 Exhibit 16-5 Exhibit 16-6 Exhibit 16-7 Exhibit 16-8 Exhibit 16-9 Exhibit Exhibit Exhibit Exhibit Exhibit GP Office Visit Rate Ratios for the Population Aged 20+in Nova Scotia and the DHAs, 2005/06 Crude GP Office Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 GP Office Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 155

164 SECTION III HEALTH SERVICES UTILIZATION Exhibit 16-1 GP Office Visit Rate Ratios for the Population Aged 20+in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Total GP Visits Population Aged 20+ Crude GP Rate Standardized GP Rate Nova Scotia 1 482,695 66, ,646, , Annapolis Valley (3) 1 45,179 6, ,615 61, Cape Breton (8) 1 81,738 11, ,533 96, Capital Health (9) 1 181,529 23, ,182, , Colchester East Hants (4) 1 35,158 4, ,975 54, Cumberland (5) 1 16,559 2, ,883 25, Guysborough Antigonish Strait (7) 1 26,569 3, ,613 35, Pictou County (6) 1 21,826 3, ,334 36, South Shore (1) 1 39,522 5, ,661 46, South West (2) 1 34,317 5, ,275 47, Rate Ratio Exhibit 16-2 Crude GP Office Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 156

165 SECTION III HEALTH SERVICES UTILIZATION Exhibit 16-3 GP Office Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 16-4 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 157

166 SECTION III HEALTH SERVICES UTILIZATION Exhibit 16-5 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia by Age Group, 2001/02 to 2005/06 Exhibit 16-6 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 158

167 SECTION III HEALTH SERVICES UTILIZATION Exhibit 16-7 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Exhibit 16-8 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 159

168 SECTION III HEALTH SERVICES UTILIZATION Exhibit 16-9 Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Exhibit Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 160

169 SECTION III HEALTH SERVICES UTILIZATION Exhibit Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Exhibit Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 161

170 SECTION III HEALTH SERVICES UTILIZATION Exhibit Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Exhibit Trend in GP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 162

171 SECTION III HEALTH SERVICES UTILIZATION CHAPTER 17 SPECIALIST PHYSICIAN OFFICE VISITS Diabetes is a complex, chronic, multisystemic disease that is progressive in nature. As such, people with diabetes are heavy users of the healthcare system. While the vast majority of people with diabetes are followed exclusively by a general practioner (GP), specialist physician (SP) care is often required to manage the disease and its related complications. 1 Comprehensive diabetes management requires regular screening for blood glucose, blood pressure, and lipid control. In addition, routine screening for foot problems, neuropathy (nerve damage), retinopathy (eye disease), nephropathy (kidney disease), sexual dysfunction, depression, and anxiety is essential for early detection and ongoing treatment of these conditions. 2 Nova Scotia (2005/06) For the year 2005/2006, there was a slight amount of variation in the crude SP visit rates within the population with diabetes across DHAs, ranging from 2.0 to 2.9 visits per person (Exhibits 17-1 and 17-2). However, a comparison of standardized rates revealed that there was much less variation in SP office visit rates within the population with diabetes across the province (1.9% to 2.6%), suggesting that the wider variation in crude rates was a result of different population structures, i.e., older or younger populations in some districts, and not because diabetes-related SP office visit rates varied to this degree across the province. The ratio of standardized SP office visit rates revealed a 2.1 to 2.5 times increase in the rate of SP office visits in the population with diabetes, relative to the population without diabetes. Crude SP office visit rates by age group and sex again revealed that those with diabetes were more likely to have SP office visits those without diabetes, and that this was true for both males and females, and for both younger and older age groups (Exhibit 17-3). There was evidence that the SP office visit rate for females with diabetes was almost double that of males in the age group; whereas, there was no difference in the rates among those over Jaakkimainen L, Shah BR, Kopp A. Sources of Physician Care for People with Diabetes. In: Hux JE, Booth G, Laupacis A (eds). Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical Evaluative Sciences. 2002: Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003;27(suppl 2): S1 S

172 SECTION III HEALTH SERVICES UTILIZATION Nova Scotia Time Trends (2001/02 to 2005/06) Time trends in the ratio of the standardized SP office visit rates revealed the slightest decrease, reaching a current figure of approximately 2.2 (Exhibit 17-4). People with diabetes, on average, visit specialists 2 times more often than those without diabetes. In terms of trends by age group, the SP office visit rate ratios were substantially higher for those aged (2.8) as compared with those over 65 (1.3), and there was some evidence of a decrease in the younger age group, but no evidence of any change for those over 65 (Exhibit 17-5). District Time Trends (2001/02 to 2005/06) Analyses of time trends by DHA revealed the same general stability in SP office visit rate ratios over time (Exhibits 17-6 to 17-14). Generally speaking, the SP office visit rate ratios for the DHAs were no different from those for the province as a whole; although, the figures for Colchester East Hants DHA reveal a substantial decrease over time, to be equivalent to the provincial figures. Note: Data about specialist physician (SP) visits among those with and without diabetes were derived from the National Diabetes Surveillance System (NDSS) (see Appendix A). Given that the NDSS figures were derived from administrative health data, caution should be used in interpreting the exact figures, and more emphasis should be placed on interpreting relative trends. 164

173 SECTION III HEALTH SERVICES UTILIZATION EXHIBIT S Exhibit 17-1 Exhibit 17-2 Exhibit 17-3 Exhibit 17-4 Exhibit 17-5 Exhibit 17-6 Exhibit Exhibit 17-8 Exhibit 17-9 Exhibit Exhibit Exhibit Exhibit Exhibit SP Office Visit Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Crude SP Office Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 SP Office Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia, by Age Group and Sex, 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia, by Age Group, 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Annapolis Valley (AVH), 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Cape Breton (CBDHA), 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Capital Health (CH), 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Colchester East Hants (CEHHA), 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Cumberland (CHA), 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Guysborough Antigonish Strait (GASHA), 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and Pictou County (PCHA), 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and South Shore (SSH), 2001/02 to 2005/06 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia and South West (SWH), 2001/02 to 2005/06 165

174 SECTION III HEALTH SERVICES UTILIZATION Exhibit 17-1 SP Office Visit Rate Ratios for the Population Aged 20+ in Nova Scotia and the DHAs, 2005/06 Diabetes Status (1=with DM) Total SP Visits Population Aged 20+ Crude SP Rate Standardized SP Rate Nova Scotia 1 179,028 66, , , Annapolis Valley (3) 1 15,145 6, ,819 61, Cape Breton (8) 1 34,303 11, ,769 96, Capital Health (9) 1 68,541 23, , , Colchester East Hants (4) 1 11,139 4, ,632 54, Cumberland (5) 1 5,700 2, ,293 25, Guysborough Antigonish Strait (7) 1 10,303 3, ,936 35, Pictou County (6) 1 8,015 3, ,151 36, South Shore (1) 1 13,116 5, ,293 46, South West (2) 1 12,613 5, ,498 47, Rate Ratio Exhibit 17-2 Crude SP Office Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia and the DHAs, 2005/06 166

175 SECTION III HEALTH SERVICES UTILIZATION Exhibit 17-3 SP Office Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2005/06 Exhibit 17-4 Trend in SP Office Visit Rate Ratio for the Population Aged 20+ in Nova Scotia, 2001/02 to 2005/06 167