DIABETES CARE PROGRAM OF NOVA SCOTIA NOVA SCOTIA DIABETES STATISTICS REPORT

Transcription

1 DIABETES STATISTICS REPORT 2016

2 June 2016 Published by: Diabetes Care Program of Nova Scotia 1276 South Park St, Bethune Building, Suite 548 Halifax, NS B3H 2Y9 Tel: Fax: Website:

3 DIABETES STATISTICS REPORT 2016 DIABETES STATISTICS REPORT 2016

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5 THE The Diabetes Care Program of Nova Scotia (DCPNS) works closely with the Nova Scotia Health Authority, the IWK Health Centre, the Department of Health and Wellness, and diabetes care providers from across the province. The Program advises 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 To improve, through leadership and partnerships, the health of Nova Scotians living with, affected by, or at risk of developing diabetes. VISION The DCPNS is a trusted and respected program that values partnerships, and supports integrated approaches to the prevention and management of diabetes. We envision a Nova Scotia where there are fewer cases of diabetes, complication rates for those with diabetes are reduced, and where all Nova Scotians with diabetes have access to the resources they need to live well. DIABETES STATISTICS REPORT 2016 i

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7 ACKNOWLEDGEMENTS The Diabetes Care Program of Nova Scotia (DCPNS) 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 Wellness and the Nova Scotia Health Authority with data to support quality diabetes care in Nova Scotia. Special Thanks: Jennifer Payne, Epidemiologist, Project Lead & Editor Diabetes Care Program of Nova Scotia Robin Read, Data/Surveillance Consultant Diabetes Care Program of Nova Scotia Ann Dent, Data Analyst Diabetes Care Program of Nova Scotia Pam Talbot, Diabetes Surveillance/Project Consultant Diabetes Care Program of Nova Scotia Peggy Dunbar, Provincial Program Manager Diabetes Care Program of Nova Scotia Additional Thanks: The Public Health Agency of Canada (Canadian Chronic Disease Surveillance System) for the financial support to enable the preparation and broad-based distribution of this report. Business Intelligence & Analytics Health Information Office Nova Scotia Department of Health and Wellness Assistant Editor: Andrea Estensen Diabetes Care Program of Nova Scotia DIABETES STATISTICS REPORT 2016 iii

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9 TABLE OF CONTENTS EXECUTIVE SUMMARY... 1 INTRODUCTION... 5 SECTION 1 - BURDEN CHAPTER 1: PREVALENCE... 7 CHAPTER 2: INCIDENCE CHAPTER 3: MORTALITY SECTION 2 - COMORBIDITY CHAPTER 4: HYPERTENSION SECTION 3 - HEALTH SERVICES UTILIZATION CHAPTER 5: TOTAL HOSPITAL DAYS CHAPTER 6: HOSPITAL ADMISSIONS CHAPTER 7: ADMISSION LENGTH OF STAY CHAPTER 8: PRIMARY CARE OFFICE VISITS CHAPTER 9: SPECIALIST PHYSICIAN OFFICE VISITS APPENDICES Appendix A: The CANADIAN CHRONIC DISEASE SURVEILLANCE SYSTEM Appendix B: COMPARISON OF CRUDE MEASURES OF DIABETES BURDEN, COMORBIDITY, AND HEALTH SERVICES UTILIZATION BY ZONE AND FORMER DISTRICT HEALTH AUTHORITIES (DHAS), RELATIVE TO Appendix C: PREVALENT CASES BY AGE GROUP AND SEX FOR, THE ZONES, AND THE FORMER DISTRICT HEALTH AUTHORITIES (DHAS), 2013/ Appendix D: CRUDE AND AGE-STANDARDIZED RATES AND RATE RATIOS IN, THE ZONES, AND THE FORMER DISTRICT HEALTH AUTHORITIES (DHAS), 2013/ DIABETES STATISTICS REPORT 2016 v

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11 EXECUTIVE SUMMARY This report provides an overview of the estimated burden of diabetes in Nova Scotia to March 31, Derived from the Canadian Chronic Disease Surveillance System (CCDSS), 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 (hypertension), and health services utilization (hospitalizations and visits to primary care providers and specialist physicians) are provided for the population with diabetes as compared to the population without diabetes. Key Findings In Nova Scotia By March 2014, approximately 11.4% (1 in 9), or 93,000, adults aged 20+ were living with diabetes. The crude prevalence varied across Zones, from 9.7% to 13.6%, with the highest figure for the Eastern Zone. The crude prevalence of diabetes increased with increasing age and as a result, more than one in four adults over the age of 70 had diabetes. The crude prevalence of diabetes in Nova Scotia increased from 9.9% in 2008/09 to 11.4% in 2013/14, an increase of 15.2% in 5 years. More than 5,400 new cases of diabetes were identified in 2013/14 (approximately 450 new cases per month). There was less variation in the crude incidence of diabetes by Zone (6.2 per 1000 to 1 per 1000 than there was in prevalence of diabetes by Zone (9.7% to 13.1%). People with diabetes, as compared to people without diabetes in 2013/14: Were 3 times more likely to have hypertension. Made twice as many visits to primary care (9.4 visits). Made twice as many visits to specialist physicians (4.4 visits) and accounted for 25% of all specialist physician visits. Were 3 times as likely to be hospitalized. Spent on average 4 more days in hospital. There were considerable variations in the burden of diabetes across age groups: Crude prevalence rates were highest in those aged and 80+ at approximately 32% for males (1 in 3) and 26% for females (1 in 4). Crude incidence rates peaked for those aged at 17 per 1000 for males and 12 per 1000 for females. Crude mortality rates were highest in those aged at 4.2 times that of the non-diabetes population. Those aged were 7 times more likely to have hypertension than those without diabetes. Those aged and had the highest rate of specialist physician visits, relative to those without diabetes, most likely reflective of pregnancy and reproductive issues. DIABETES STATISTICS REPORT

12 Directions/Call To Action Individuals with diabetes are living longer. This is the most likely explanation for the growth in the prevalence of diabetes. As diabetes is well known to be a progressive disease, longer duration of diabetes confers more complex treatment regimens (multiple medications, initiation of insulin therapy), as well as increases the risk of diabetes-related complications and comorbidities. Action: Improved diabetes management, including glycemia, blood pressure, blood lipids, smoking avoidance/cessation, and disease distress/stress management/reduction early and throughout the disease process have been shown to reduce diabetes complications. Information systems in support of quality improvement should be used to define high-risk populations in support of targeted interventions. (See DCPNS Registry and on-site reports.) Timely access and more intensive approaches to both lifestyle modifications and pharmacological treatments are recommended in most individuals, along with the continued and renewed focus on self-care. (See DCPNS Triage and Discharge Guidelines in support of timely self-management and the DCPNS Insulin Dose Adjustment Policies & Guidelines to support timely initiation and titration of insulin, and DCPNS Insulin Pump Initiation for Children and Youth Guidelines and DCPNS Insulin Pump Initiation for Young Adults/Adults.) Care guidelines that address safety and quality of life, using a frailty lens, are essential with the aging of Nova Scotia s population and the reported growth in prevalence in the oldest age groups. (See DCPNS Diabetes Guidelines for Frail Elderly Residents in or Awaiting Long-Term Care.) Continued support of Provincial initiatives focused on hypertension awareness, prevention, and management is essential to provide timely and necessary focus for those with or at risk of diabetes, stroke, cardiovascular, and renal diseases. (See My Blood Pressure Card Initiative and My Blood Pressure Challenge.) Targeted interventions, aimed at our younger age groups, are strongly recommended. These need to focus on improved glycemia and blood pressure management to reduce the heightened risk of foot, eye, and kidney disease. (See DCPNS Insulin Dose Adjustment Polices & Guidelines Manual, 2016 as well as Patient Self-Adjustment of Insulin resources.) Engaging persons with diabetes in individual treatment plans that address blood glucose as well as blood pressure and blood lipids is an important way to improve overall diabetes management with a renewed focus on selfmanagement. The incidence of diabetes in Nova Scotia remains a concern, particularly in certain subgroups of the population. Action: Health promotion and disease prevention messages and policies are key to the future of a healthy Nova Scotia. DIABETES STATISTICS REPORT

13 Delaying the onset of the disease in at-risk individuals and their families, as well as slowing its progression in those with established disease, would result in significant benefit to individuals, families, and the health care system. Provincial initiatives focused on wellness and risk factor reduction are required to impact incidence rates (prevention or delayed development of diabetes), complications progression, and provide added support for diabetes self-management. The growing emphasis on integrated chronic disease management and prevention through team-based care and the Health Home will help to ensure upstream messaging and the delivery of risk-reduction programming at the community level. Initiatives aimed at women of reproductive age will improve birth outcomes and reduce risks of subsequent diabetes and metabolic abnormalities in both the woman and her infant. These initiatives should promote planned pregnancy, preconception care/counseling, early screening for diabetes, individualized care plans, breastfeeding, and routine postpartum care and screening (See DCPNS Pregnancy and Diabetes Guidelines: Approaches to Practice, 2014). There is continued concern regarding the burden of diabetes in vulnerable populations including First Nations, African Canadians, and new immigrant communities. These populations may require different resources to support both primary prevention as well as disease management initiatives. - Women of reproductive age who are also members of these vulnerable communities are deserving of more active and targeted initiatives aimed at improving outcomes for them and their children. People with diabetes have much greater risks of complications and comorbidities; this is most significant in our youngest 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. As the majority of the cases in the youngest age groups are predominately type 1 cases, seamless transitional care from pediatric to adult care is required as well as continued, easily accessible supports throughout the lifespan. (See DCPNS Moving on with Diabetes Adolescent Transition Resources [provider, patient, and parent/caregiver materials].) DIABETES STATISTICS REPORT

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15 INTRODUCTION The Diabetes Care Program of Nova Scotia (DCPNS) is pleased to provide this fourth report about the burden of diabetes in Nova Scotia and each of the four Health Management Zones. This report is aimed primarily at decision-makers within the NSHA, Health Management Zones, and Diabetes Centres. However, it is also intended that this document will act as a resource for those working in the area of diabetes prevention and management, and that the 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. Many aspects of this report remain the same as those in the earlier version, Nova Scotia Diabetes Statistics Report 2011; however, some changes are also noted below. Some of these changes will make comparison to earlier reports difficult. Structure of the Report In keeping with the 2011 version, the report is broken into chapters that are organized into three sections: burden, comorbidity, and health services utilization. Each chapter is formatted in a similar manner with summary text at the front, followed by the exhibits. All chapters begin by focusing on the most recent year of data, 2013/14, and results are presented by Zone, age group, and sex for the province as a whole, followed by time trends (2009/10 to 2013/14) for the province and each Zone. Both crude and standardized rates are presented so that Zones can understand their absolute burden of diabetes in real numbers (i.e., crude rates represent real people) as well as compare their rates against other jurisdictions where populations may differ in age structure (i.e., standardized rates). Each chapter also contains data for each of the former District Health Authorities, compared to their Zone, creating a bridge between the results of this report with the 2011 report. The case rules for several comorbidities/complications are currently under review by the CCDSS Scientific Committee. Therefore, in the comorbidity section, there is only one chapter remaining, which focuses on hypertension. Appendices B, C and D contain information for each of the former District Health Authorities as well as the new Health Management Zones, providing a bridge to the 2011 report. Appendix B contains a summary table of results across the chapters showcasing crude rather than standardized figures displayed in the 2011 report. Appendix C contains current prevalence figures by age group and sex. Appendix D provides current crude and age-standardized figures for hypertension and health services utilization. Analyses The analyses in this report are based on the methodology of the CCDSS, first developed by the Public Health Agency of Canada in 1997 as part of the original National Diabetes Surveillance System. This system takes advantage of administrative health data (practitioner billings, hospital discharge) available across all provinces and territories to develop a long-term monitoring system to estimate the combined burden of type 1 and type 2 diabetes. This report was produced using the CCDSS software, version More detail is provided in Appendix A. DIABETES STATISTICS REPORT

16 Exclusion of Children and Youth (Under Age 20) In contrast with the CCDSS methodology and national reporting, this report restricts analyses to those aged 20+ years. The DCPNS believes that children and adolescents with diabetes represent a very special population. The majority of these individuals have type 1 diabetes. Management with insulin is often complex and variable during these years of rapid growth; and interdisciplinary team-based support is necessary and essential. While preventing long-term complications is the ultimate goal, avoidance of acute complications (hypoglycemia, hyperglycemia, and diabetic ketoacidosis) is of the utmost, immediate importance. Diabetes in those under age 20 is relatively rare (there were approximately 800 cases (including types 1, 2 and prediabetes categories) in Nova Scotia to December 31, ), and the comorbidities usually associated with diabetes, if found in this young population, are not likely related to diabetes. The DCPNS feels strongly that the story of this disease and its progression in the young population would be lost if combined with that of the general diabetes population as reported by the CCDSS (i.e., the population aged 1+). 1 Source: Diabetes Care Program of Nova Scotia Registry. Halifax, NS; 2016 DIABETES STATISTICS REPORT

17 SECTION I - BURDEN CHAPTER 1 PREVALENCE Prevalence is defined as the number of individuals (new and existing) with a 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 (2013/14) As of March 31, 2014, approximately 93,000 (11.4%) of Nova Scotia adults aged 20+ were living with diabetes. In 2013/14, there was substantial variation in the crude prevalence of diabetes in the population aged 20+ across Zones, ranging from 9.7% to 13.6% (Exhibits 1-1 and 1-2). Comparison of agestandardized prevalence figures across the Zones revealed both smaller values and less variation (8.1% to 9.6%), indicating that differences in population structure (e.g., older versus younger population) accounted for some of the variation between Zones. Analyses by age group and sex revealed that the crude prevalence of diabetes was similar for both males and females in the through age groups and increased in a similar manner with increasing age. In the age group and thereafter, males were more likely than females to have diabetes (Exhibit 1-3). It is striking that even by age 40-49, both males and females had more than a 5% chance of having diabetes, and this risk increased substantially with each increasing 10-year age group through to the age group (prevalence of approximately 28%). The largest increase in crude prevalence across the age groups occurred when moving from the age group to the age group, with the overall prevalence almost doubling from 12% to 21%. The highest crude prevalence for both males and females was in the and 80+ age groups, at approximately 32% for males and 26% for females. Nova Scotia Time Trends (2009/10 to 2013/14) Trends in the age-standardized prevalence of diabetes revealed an increase over time, from 8.2% to 8.6% (Exhibit 1-4). The crude prevalence figures were stable over time for those aged (Exhibit 1-5). There was a small increase in prevalence over time for those aged and a larger increase over time for those aged 70 and older. DIABETES STATISTICS REPORT

18 SECTION I - BURDEN Zone Time Trends (2009/10 to 2013/14) Analyses of time trends revealed an increase in age-standardized prevalence over time for each Zone (Exhibits 1-4 and 1-6 to 1-9). Over the last five years, the age-standardized prevalence figures for the Eastern and Western Zones were consistently higher than those for Nova Scotia, whereas the figures for the Central Zone were lower than for the province. NOTE: Data about diabetes prevalence were derived from the Canadian Chronic Disease Surveillance Strategy (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

19 SECTION I - BURDEN EXHIBITS Exhibit 1-1 Crude and Age-Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia, the Zones, and the Former District Health Authorities (DHAs), 2013/14 Province and Zones and former DHAs Number of Diabetes Cases Population Aged 20+ Crude Diabetes Prevalence (%) Age-Standardized Diabetes Prevalence (%) 93, , Western 22, , South Shore 6,667 50, Southwest 7,349 51, Annapolis Valley 8,526 69, Northern 15, , Colchester East Hants 7,038 61, Cumberland 3,614 28, Pictou County 4,577 39, Eastern 19, , Guysborough Antigonish Strait 4,667 38, Cape Breton 15, , Central 35, , Exhibit 1-2 Crude Diabetes Prevalence for the Population Aged 20+ in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central Crude Diabetes Prevalence (%) DIABETES STATISTICS REPORT

20 SECTION I - BURDEN Exhibit 1-3 Crude Diabetes Prevalence for the Population Aged 20+ in Nova Scotia by Age Group and Sex, 2013/14 Crude Diabetes Prevalence (%) Total Age Group Male Female Combined Exhibit 1-4 Trend in Age-Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and the Zones, 2009/10 to 2013/14 Age- Standardized Diabetes Prevalence (%) Western Northern Eastern Central Exhibit 1-5 Trend in Crude Diabetes Prevalence for the Population Aged 20+ in Nova Scotia by Age Group, 2009/10 to 2013/14 Crude Diabetes Prevalence (%) DIABETES STATISTICS REPORT

21 SECTION I - BURDEN Exhibit 1-6 Trend in Age-Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia, Western Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Diabetes Prevalence (%) Western SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 1-7 Trend in Age-Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Diabetes Prevalence (%) Northern CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

22 SECTION I - BURDEN Exhibit 1-8 Trend in Age-Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Diabetes Prevalence (%) Eastern GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 1-9 Trend in Age-Standardized Diabetes Prevalence for the Population Aged 20+ in Nova Scotia and Central Zone, 2009/10 to 2013/14 Age- Standardized Diabetes Prevalence (%) Central DIABETES STATISTICS REPORT

23 SECTION I - BURDEN CHAPTER 2 INCIDENCE Incidence rate is defined as the proportion of new cases of a disease diagnosed in a given population during a given time period (i.e., annual occurrence of new cases). Note: In this chapter, time trends are shown for 10-year periods (all other chapters focus on the most recent 5-year period). Time trends in the diabetes incidence rates over the last 10 years reveal a slow decline that began approximately five years ago (2009/10). There is concern that this stems from changes in coding of diabetes on practitioner billings, rather than indicating a true decrease in incidence. Caution should be exercised in interpreting absolute values. Rather, the focus should be on interpreting relative trends, i.e., by age group, sex, and over time. Nova Scotia (2013/14) In 2013/14, more than 5,400 new cases of diabetes were diagnosed among adults aged 20+ in Nova Scotia (7.4 per 1000 population). In 2013/14, there was variation in the crude incidence rates of diabetes in the population aged 20+ across Zones, ranging from 6.2 to 1 per 1000 population (Exhibits 2-1 and 2-2). Comparison of age-standardized incidence rates across Zones revealed both smaller figures and less variation in incidence of diabetes (5.5 to 6.8 per 1000), indicating that differences in population structure (e.g., older versus younger population) accounted for some of the variation between Zones. Analyses by age group and sex revealed that the crude incidence rate of diabetes was similar for both males and females in the and age groups and increased in a similar manner with increasing age. In the age group and thereafter, males were more likely than females to be newly diagnosed with diabetes (Exhibit 2-3). The largest increase in the crude incidence rate across the age groups occurred when moving from the age group to the age group, during which the risk of being newly diagnosed with diabetes approximately doubled from 5.6 per 1000 to 10.2 per The highest crude incidence rate for males and females was in the age group at approximately 17 per 1000 for males and 12 per 1000 for females. Nova Scotia Time Trends (2004/05 to 2013/14) Time trends in the age-standardized diabetes incidence rate revealed little change over time during the first five years of the period, hovering at approximately 7.8 per 1000 (Exhibit 2-4). However, this rate appeared to steadily decrease over the following five years. The crude incidence figures were stable over time for those under age 50, ranging from approximately 1 per 1000 for those in the age group to approximately 6 per 1000 for those in the age group. There was evidence of a decrease in incidence over time for all DIABETES STATISTICS REPORT

24 SECTION I - BURDEN age groups over 50, starting in approximately 2009/10. The rate of decrease appears to increase with increasing age, i.e., the biggest decreases are in the oldest age groups (Exhibit 2-5). Zone Time Trends (2009/10 to 2013/14) Analyses of time trends revealed stable age-standardized incidence rates for all Zones during the first five years of the ten-year period, and then a steady decrease after 2009/10 (Exhibits 2-4 and 2-6 to 2-9). Over the ten-year period, the age-standardized diabetes incidence rates for Eastern and Western Zones were consistently higher than those for Nova Scotia, whereas the figures for Central Zone were lower than for the province. NOTE: Data about diabetes incidence were derived from the Canadian Chronic Disease Surveillance System (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

25 SECTION I - BURDEN EXHIBITS Exhibit 2-1 Crude and Age-Standardized Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia, the Zones, and the Former District Health Authorities (DHAs), 2013/14 Province and Zones and former DHAs Number of New Diabetes Cases At-Risk Population Aged 20+* Crude Diabetes Incidence Rate (per 1000) Age-Standardized Diabetes Incidence Rate (per 1000) 5, , Western 1, , South Shore , Southwest , Annapolis Valley , Northern , Colchester East Hants , Cumberland , Pictou County , Eastern 1, , Guysborough Antigonish Strait , Cape Breton , Central 2, , * Equivalent to population in 2013/14 less prevalent diabetes cases in 2012/13 Exhibit 2-2 Crude Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central Crude Diabetes Incidence Rate (per 1000) DIABETES STATISTICS REPORT

26 SECTION I - BURDEN Exhibit 2-3 Crude Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia by Age Group and Sex, 2013/14 Crude Diabetes Incidence Rate (per 1000) Total Age Group Male Female Combined Exhibit 2-4 Age- Standardized Diabetes Incidence Rate (per 1000) Trend in Age-Standardized Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia and the Zones, 2004/05 to 2013/14 Western Northern Eastern Central Exhibit 2-5 Crude Diabetes Incidence Rate (per 1000) Trend in Crude Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia by Age Group, 2004/05 to 2013/ DIABETES STATISTICS REPORT

27 SECTION I - BURDEN Exhibit 2-6 Trend in Age-Standardized Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia, Western Zone, and its Former District Health Authorities, 2004/05 to 2013/14 Age- Standardized Diabetes Incidence Rate (per 1000) Western SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 2-7 Trend in Age-Standardized Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2004/05 to 2013/14 Age- Standardized Diabetes Incidence Rate (per 1000) Northern CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

28 SECTION I - BURDEN Exhibit 2-8 Trend in Age-Standardized Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2004/05 to 2013/14 Age- Standardized Diabetes Incidence Rate (per 1000) Eastern GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 2-9 Trend in Age-Standardized Diabetes Incidence Rates for the Population Aged 20+ in Nova Scotia and Central Zone, 2004/05 to 2013/14 Age- Standardized Diabetes Incidence Rate (per 1000) Central DIABETES STATISTICS REPORT

29 SECTION I - BURDEN CHAPTER 3 MORTALITY Mortality rate is defined as the proportion of people diagnosed with a disease in a given population in a given time period who died. A comparison of mortality rates can highlight whether people in one group die at a younger age than people in another group. Mortality is affected by both the progression and management of the disease, including the existence of one or more comorbid diseases secondary to diabetes (e.g., heart disease). Nova Scotia (2013/14) In 2013/14, approximately 3.2% of Nova Scotia adults aged 20+ with diabetes died, compared to less than 1.0% of adults without diabetes. In 2013/14, there was little variation in the crude mortality rates in the population aged 20+ with diabetes across Zones, ranging from 2.9% to 3.6% (Exhibits 3-1 and 3-2). Comparison of agestandardized mortality rates across Zones revealed both smaller figures and less variation in mortality in the population with diabetes (1.0% to 1.2%), indicating that differences in population structure (e.g., older versus younger population) accounted for most of the variation between Zones. The age-standardized mortality rate ratios revealed a 1.8 to 1.9 times greater risk of death in the population with diabetes, relative to the population without diabetes. Analysis by age group and sex revealed that in 2013/14, those with diabetes were more likely to die than those without diabetes, and this finding was true for both males and females and for all age groups (Exhibit 3-3). The crude mortality rates for males were higher than for females within age groups, and this finding was true for both the populations with and without diabetes (Exhibit 3-3). In 2013/14, people with diabetes were twice as likely to die as those without diabetes until age 70, at which point the differences in mortality rate diminished with age. Nova Scotia Time Trends (2009/10 to 2013/14) Time trends in the age-standardized mortality rate ratios revealed virtually no change over time, hovering at approximately (Exhibit 3-4). Individuals with diabetes had a 2 times greater risk of dying in a given year than individuals without diabetes. The crude mortality rate ratios decreased with increasing age (Exhibit 3-5). The most recent ratios were approximately 4.3 for those in the age group and 1.3 for those 80 years of age and older. Caution should be exercised when interpreting the results for those in the age group because of the small number of deaths. DIABETES STATISTICS REPORT

30 SECTION I - BURDEN Over time, the crude mortality rate ratios were consistently higher for each younger age group and remained stable over time. Caution should be exercised when interpreting the results for those in the age group because of the small number of deaths. The crude mortality rate ratios were stable over time for those aged 50 and over, with evidence of unstable values for those aged Zone Time Trends (2009/10 to 2013/14) Analyses of time trends revealed no overall difference in the age-standardized mortality rate ratios for all Zones, although there was some instability in the values (Exhibits 3-4 and 3-6 to 3-9). The age-standardized mortality rate ratios for the Zones were virtually no different than those for the province as a whole, and over time. NOTE: Data about mortality among those with and without diabetes were derived from the Canadian Chronic Disease Surveillance Strategy (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

31 SECTION I - BURDEN EXHIBITS Exhibit 3-1 Crude and Age-Standardized Mortality Rates and Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2013/14 Province and Zones Diabetes status (1=yes) Number of Deaths Population Aged 20+ Crude Mortality Rate (%) Crude Mortality Rate Ratio Age- Standardized Mortality Rate (%) Age- Standardized Mortality Rate Ratio 1 3,002 93, , , Western , , , Northern , , , Eastern , , , Central 1 1,027 35, , , Exhibit 3-2 Crude Mortality Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central Crude Mortality Rate (%) DIABETES STATISTICS REPORT

32 SECTION I - BURDEN Exhibit 3-3 Crude Mortality Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2013/14 Crude Mortality Rate (%) M - DM M - No DM F - DM F - No DM Total Age group Exhibit 3-4 Trend in Age-Standardized Diabetes Mortality Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2009/10 to 2013/14 Age- Standardized Mortality Rate RaKo Western Northern Eastern Central Exhibit 3-5 Trend in Crude Diabetes Mortality Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia by Age Group, 2009/10 to 2013/14 Crude Mortality Rate RaKo DIABETES STATISTICS REPORT

33 SECTION I - BURDEN Exhibit 3-6 Trend in Age-Standardized Mortality Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Western Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Mortality Rate RaKo Western SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 3-7 Age- Standardized Mortality Rate RaKo Trend in Age-Standardized Mortality Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Northern CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

34 SECTION I - BURDEN Exhibit 3-8 Age- Standardized Mortality Rate RaKo Trend in Age-Standardized Mortality Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Eastern GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 3-9 Trend in Age-Standardized Mortality Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and Central Zone, 2009/10 to 2013/14 Age- Standardized Mortality Rate RaKo Central DIABETES STATISTICS REPORT

35 SECTION 2 COMORBIDITY CHAPTER 4 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 HTN 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. Nova Scotia (2013/14) In 2013/14, approximately 74% of Nova Scotia adults aged 20+ with diabetes had HTN, compared to 25% of adults without diabetes. In 2013/14, there was some variation in the crude HTN rates in the population aged 20+ with diabetes across the Zones, ranging from 72% to 79% (Exhibits 4-1 and 4-2). Comparison of agestandardized HTN rates across the Zones revealed that the variation persisted in the population with diabetes (41% to 48%), indicating that differences in population structure (e.g., older versus younger population) cannot explain the smaller variability in the age-standardized rates. The age-standardized HTN rate ratios revealed a 2.1 times greater risk of HTN in the population with diabetes, relative to the population without diabetes. Analysis by age group and sex revealed that in 2013/14, those with diabetes were more likely to have HTN than those without diabetes, and this finding was similar for both males and females and for all age groups (Exhibit 4-3). The crude HTN rates for males and females were similar up to age For those age 50 and older, females had higher crude HTN rates than males. This finding was true for both the populations with and without diabetes (Exhibit 4-3). In 2013/14, overall people with diabetes were 3 times as likely to have hypertension; however, in those aged 20-39, people with diabetes were 7 times more likely to have hypertension than those without diabetes. When comparing those with diabetes to those without diabetes, the ratio of the crude HTN rates was greater for the youngest age group than for the older age groups (e.g., ~ 7.1 for those years of age and 1.2 for those 80 years of age and older. (Exhibit 4-5). 1 Gilbert RE, Rabi D, LaRochelle P, et al. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Treatment of hypertension. Can J Diabetes 2013;37(suppl 1): S117-S118. DIABETES STATISTICS REPORT

36 SECTION 2 COMORBIDITY Nova Scotia Time Trends (2009/10 to 2013/14) Time trends in the age-standardized HTN rate ratios revealed virtually no change over time, hovering at approximately (Exhibit 4-4). People with diabetes were twice as likely to have HTN as individuals without diabetes. The crude HTN rate ratios decreased with increasing age (Exhibit 4-5). The most recent ratios were approximately 7.1 for those in the age group, approximately 3.4 for those in the age group, and 1.2 for those 80 years of age and older Over time, the crude HTN rate ratios were consistently higher for each younger age group with evidence of an increasing trend over time. Zone Time Trends (2009/10 to 2013/14) Analyses of time trends revealed stable age-standardized HTN rate ratios over time for all Zones (Exhibits 4-4 and 4-6 to 4-9). The age-standardized HTN rate ratios for the Zones were virtually no different from those for the province as a whole, over time. NOTE: Data about HTN among those with and without diabetes were derived from the Canadian Chronic Disease Surveillance Strategy (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

37 SECTION 2 COMORBIDITY Exhibit 4-1 Crude and Age-Standardized HTN Rates and Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2013/14 Province and Zones Diabetes status (1=yes) HTN Diagnosis Population Aged 20+ Crude HTN Rate (%) Crude HTN Rate Ratio Age- Standardized HTN Rate (%) Age- Standardized HTN Rate Ratio 1 69,600 93, , , Western 1 16,799 22, , , Northern 1 11,555 15, , , Eastern 1 15,595 19, , , Central 1 25,614 35, , , Exhibit 4-2 Crude HTN Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central Crude HTN Rate (%) DIABETES STATISTICS REPORT

38 SECTION 2 COMORBIDITY Exhibit 4-3 Crude HTN Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2013/14 10 Crude HTN Rate (%) M - DM M - No DM F - DM F - No DM Exhibit Total Age Group Trend in Age-Standardized HTN Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2009/10 to 2013/14 Age- Standardized HTN Rate RaKo Western Zone Northern Zone Eastern Zone Central Zone Exhibit 4-5 Trend in Crude HTN Rate Ratio for the Population Aged 20+, with/without Diabetes, in Nova Scotia by Age Group, 2009/10 to 2013/14 Crude HTN Rate RaKo DIABETES STATISTICS REPORT

39 SECTION 2 COMORBIDITY Exhibit 4-6 Trend in Age-Standardized HTN Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Western Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized HTN Rate RaKo Western Zone SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 4-7 Trend in Age-Standardized HTN Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized HTN Rate RaKo Northern Zone CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

40 SECTION 2 COMORBIDITY Exhibit 4-8 Trend in Age-Standardized HTN Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized HTN Rate RaKo Eastern GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 4-9 Trend in Age-Standardized HTN Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and Central Zone, 2009/10 to 2013/14 Age- Standardized HTN Rate RaKo Central DIABETES STATISTICS REPORT

41 SECTION 3 HEALTH SERVICES UTILIZATION CHAPTER 5 TOTAL HOSPITAL DAYS The focus of this chapter is to describe hospital use as measured by the total number of hospital days per person experienced over the course of a year (i.e., hospital day rate as days/person), comparing all people with diabetes relative to all people without diabetes, regardless of whether each person was individually admitted to hospital during the year. This summary measure does not distinguish between whether people with diabetes were at higher risk of being hospitalized than people without diabetes (see Chapter 6, Hospital Admissions), or whether once in hospital, people with diabetes were likely to stay longer than those without diabetes (see Chapter 7, Admission Length of Stay). 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 directly related to the diabetes (i.e., comorbid conditions) such as cardiovascular disease and nephropathy. People with diabetes who are hospitalized for conditions unrelated to their diabetes, and who undergo 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 (2013/14) In 2013/14, Nova Scotia adults aged 20+ with diabetes were hospitalized for an average of 2.8 days per person, compared to 0.6 days per person for adults without diabetes. As a whole, people with diabetes were hospitalized for more than 260,600 days, accounting for more than one third of all hospital days (approximately 723,000). In 2013/14, there was little variation in the crude hospital day rate in the population with diabetes across Zones, ranging from 2.2 to 3.6 days per person (Exhibits 5-1 and 5-2). Comparison of agestandardized hospital day rates across Zones revealed smaller figures but the variation remained (1.2 to 2.6 days per person), indicating that differences in population structure (e.g., older versus younger population) cannot explain the variation across Zones. Analysis by Zone revealed that the age-standardized hospital day rate ratios revealed a 2.5 to 4.5 times as many days in hospital for people with diabetes, relative to people without diabetes. Analysis by age group and sex revealed that, on average, those with diabetes experienced substantially more hospital days per person than those without diabetes, and this finding was true for both males and females and for all age groups (Exhibit 5-3). The crude hospital day rate was similar for males and females over age 40. For those in the age group, females had a higher hospital day rate than males, and this difference was larger among those with diabetes, compared to those without diabetes. When comparing those with diabetes relative to those without diabetes, the ratio of the crude hospital day rate diminished with increasing age, yet remained close to by ages DIABETES STATISTICS REPORT

42 SECTION 3 HEALTH SERVICES UTILIZATION Nova Scotia Time Trends (2009/10 to 2013/14) Time trends in the age-standardized hospital day rate ratios revealed virtually no change, hovering at approximately 3.0 (Exhibit 5-4). Adults with diabetes experienced 3 times as many days in hospital as adults without diabetes. The crude hospital day rate ratios decreased with increasing age for those aged 40 and older (Exhibit 5-5). The crude hospital day rate for those in the age group was identical to the rate in the age group. There was little evidence of change over time by age group. Zone Time Trends (2009/10 to 2013/14) Analysis of time trends revealed relative stability in the age-standardized hospital day rate ratios over time for most Zones (Exhibits 5-4 and 5-6 to 5-9). There was evidence of an unusually high value in 2013/14 for Northern Zone in the age-standardized hospital day rate ratios. This appears to be due to an extremely high value in the former Pictou County Health Authority for that year, which in turn, is likely a result of the influence of a small number of hospitalizations for young people experiencing an unusually long length of stay. Caution should be exercised in interpreting this one data point. Note that the results for hospital admissions do not show this same anomaly. Other than the unusual value for Northern Zone in 2013/14, the age-standardized hospital day rate ratios were virtually no different from those for the province as a whole, over time. NOTE: Data regarding hospitalizations, for those with and without diabetes, were derived from the Canadian Chronic Disease Surveillance System (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

43 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 5-1 Crude and Age-Standardized Hospital Day Rates and Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2013/14 Province and Zones Diabetes Status (1=Yes) Total Hospital Days Population Aged 20+ Crude Hospital Day Rate (Days/Person) Crude Hospital Day Rate Ratio Age- Standardized Hospital Day Rate (Days/Person) Age- Standardized Hospital Day Rate Ratio 1 260,632 93, , , Western 1 67,340 22, , , Northern 1 43,228 15, , , Eastern 1 71,456 19, , , Central 1 78,608 35, , , Exhibit 5-2 Crude Hospital Day Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central Crude Hospital Day Rate (days/person) DIABETES STATISTICS REPORT

44 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 5-3 Crude Hospital Day Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2013/ Crude Hospital Day Rate (Days/Person) M - DM M - No DM F - DM F - No DM Exhibit Total Age Group Trend in Age-Standardized Hospital Day Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2009/10 to 2013/14 Age- Standardized Hospital Day Rate RaKo Western Zone Northern Zone Eastern Zone Central Zone Exhibit 5-5 Trend in Crude Hospital Day Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia by Age Group, 2009/10 to 2013/14 Crude Hospital Day Rate RaKo DIABETES STATISTICS REPORT

45 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 5-6 Trend in Age-Standardized Hospital Day Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Western Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Hospital Day Rate RaKo Western Zone SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 5-7 Trend in Age-Standardized Hospital Day Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Hospital Day Rate RaKo Northern Zone CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

46 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 5-8 Trend in Age-Standardized Hospital Day Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2009/10 to 2013/2014 Age- Standardized Hospital Day Rate RaKo Eastern Zone GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 5-9 Trend in Age-Standardized Hospital Day Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and Central Zone, 2009/10 to 2013/14 Age- Standardized Hospital Day Rate RaKo Central Zone DIABETES STATISTICS REPORT

47 SECTION 3 HEALTH SERVICES UTILIZATION CHAPTER 6 HOSPITAL ADMISSIONS The focus of this chapter is to describe hospital use as measured by the number of hospitalizations per 100 people over the course of a year (i.e., admission rate), comparing all people with diabetes relative to all people without diabetes, regardless of whether each person was individually admitted to hospital during the year. 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 (2013/14) In 2013/14, Nova Scotia adults aged 20+ with diabetes experienced 22.5 admissions per 100 people compared to 7.4 admissions per 100 people for adults without diabetes. As a whole, the population with diabetes experienced more than 21,000 hospital admissions, accounting for approximately 28% of all admissions (approximately 74,600). In 2013/14, there was a fair degree of variation in the crude admission rate within the population with diabetes across Zones, ranging from 17.9 to 27.4 admissions per 100 people (Exhibits 6-1 and 6-2). Comparison of age-standardized admission rates across Zones revealed both smaller figures and less variation (14.0 to 20.9 admissions per 100 people), indicating that differences in population structure (e.g., older versus younger population) accounted for only some of the variation between Zones. Analysis by Zone of the age-standardized admission rates revealed that people with diabetes experience between 2.2 and 2.6 times the number of hospitalizations compared to people without diabetes. Analysis by age group and sex revealed that those with diabetes were substantially more likely to experience a hospital admission than those without diabetes, and this finding was true for both males and females and for all age groups (Exhibit 6-3). The crude admission rate for females was higher than for males in the age group, and, to a lesser extent, this was also true for the age group; likely an indication of admissions for pregnancy/childbirth. The number of admissions for males and females were similar for those in the age group; and by age 60, males were more likely to be hospitalized than females. This finding was true for both the population with and without diabetes. When comparing those with diabetes to those without diabetes, the ratio of the crude admission rates diminished with increasing age but was still approximately 1.3 at age 80. DIABETES STATISTICS REPORT

48 SECTION 3 HEALTH SERVICES UTILIZATION Nova Scotia Time Trends (2009/10 to 2013/14) Time trends in the ratio of the age-standardized admission rate ratios revealed virtually no change over time, hovering at approximately 2.4 (Exhibit 6-4). Adults with diabetes were more than twice as likely to be admitted to hospital as individuals without diabetes. The ratio of crude admission rates decreased with increasing age for those age 40 and older (Exhibit 6-5). The ratio for the age group was similar to that of the age group. There was little evidence of change over time by age group. Zone Time Trends (2009/10 to 2013/14) Analyses of time trends revealed relatively stable ratios for the age-standardized admission rates over time for most Zones (Exhibits 6-4 and 6-6 to 6-9). The age-standardized admission rate ratios for the Zones were virtually no different than those for the province as a whole, although the figures were variable within the Zones over time. NOTE: Data regarding hospitalizations, for those with and without diabetes, were derived from the Canadian Chronic Disease Surveillance System (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

49 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 6-1 Crude and Age-Standardized Admission Rates and Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2013/14 Province and Zones Diabetes Status (1=Yes) Number of Admissions Population Aged 20+ Crude Admission Rate (Admissions /100 People) Crude Admission Rate Ratios Age- Standardized Admission Rate (Admissions /100 People) Age- Standardized Admission Rate Ratios 1 21,017 93, , , Western 1 5,415 22, , , Northern 1 3,765 15, , , Eastern 1 5,435 19, , , Central 1 6,401 35, , , Exhibit 6-2 Crude Admission Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central Crude Admission Rate (admissions/100 people) DIABETES STATISTICS REPORT

50 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 6-3 Crude Admission Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2013/14 5 Crude Admission Rate (Admissions/100 People) M - DM M - No DM F - DM F - No DM Total Age Group Exhibit 6-4 Trend in Age-Standardized Admission Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2009/10 to 2013/14 Age- Standardized Admission Rate RaKo Western Zone Northern Zone Eastern Zone Central Zone Exhibit 6-5 Trend in Crude Admission Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia by Age Group, 2009/10 to 2013/14 Crude Admission Rate RaKo DIABETES STATISTICS REPORT

51 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 6-6 Trend in Age-Standardized Admission Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Western Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Admission Rate RaKo Western Zone SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 6-7 Trend in Age-Standardized Admission Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Admission Rate RaKo Northern Zone CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

52 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 6-8 Trend in Age-Standardized Admission Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized Admission Rate RaKo Eastern Zone GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 6-9 Trend in Age-Standardized Admission Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and Central Zone, 2009/10 to 2013/14 Age- Standardized Admission Rate RaKo Central Zone DIABETES STATISTICS REPORT

53 SECTION 3 HEALTH SERVICES UTILIZATION CHAPTER 7 ADMISSION LENGTH OF STAY The focus of this chapter is to describe hospital use as measured by the length of stay (LOS) per admission as experienced by people who were hospitalized over the course of a year (i.e., admission LOS rate as days/admission), comparing all hospitalized people with diabetes relative to all hospitalized people without diabetes. This measure addresses whether people with diabetes, once admitted to hospital, are more likely to stay longer in hospital than people without diabetes. This measure differs from total hospital days (see Chapter 5, Total Hospital Days), which is more of a summary measure of hospital utilization. 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 who also experienced a stay in hospital. NOTE: Admission Length of Stay is not formally part of the CCDSS health services utilization framework. DCPNS has chosen to extend the CCDSS methodology to this measure to provide added information about those individuals once admitted to hospital, comparing people with diabetes to those without. Nova Scotia (2013/14) In 2013/14, Nova Scotia adults aged 20+ with diabetes who were hospitalized stayed for an average of 12.4 days per admission, compared to 8.7 days per admission for adults without diabetes. As a whole, the population with diabetes were hospitalized for more than 260,600 days, accounting for approximately one third of all hospital days (approximately 723,000) see Chapter 5, Total Hospital Days. In 2013/14, there was very little variation in the crude admission LOS rate within the population with diabetes across Zones, ranging from 11.5 to 13.2 days per admission (Exhibits 7-1 and 7-2). Comparison of age-standardized admission LOS rates across Zones revealed both smaller figures but even more variation (7.7 to 11.1 days per admission), indicating that the differences in population structure (e.g., older versus younger population) are masking the real extent of the variation between Zones. Analysis by Zone of the age-standardized admission LOS rate ratios revealed that people with diabetes experience between 1.4 and 1.5 times the number of days per admission compared to people without diabetes. Analysis by age group and sex revealed that, on average, those age 40 and older with diabetes stayed in hospital longer than those without diabetes, and this finding was true for both males and females and for all age groups (Exhibit 7-3). The admission LOS rate was similar for males and females between the ages of 40 and 49. Females 80 years of age and older had a substantially higher number of DIABETES STATISTICS REPORT

54 SECTION 3 HEALTH SERVICES UTILIZATION days per admission than males. This finding was true for both the population with and without diabetes. Having diabetes added approximately 2 to 3 days per admission for most age groups. Nova Scotia Time Trends (2009/10 to 2013/14) Time trends in the age-standardized admission LOS rate ratios revealed virtually no change over time, hovering at approximately 1.5 (Exhibit 7-4). Adults with diabetes remained in hospital 1.5 times longer than adults without diabetes. In terms of time trends by age group, the ratio of the crude number of days spent in hospital per admission generally decreased with increasing age. By age 80 and older, there was no difference between those with diabetes and those without diabetes (Exhibit 7-5). Across all age groups, the ratios varied from 1.0 to 1.5, varying to a lesser degree than those of hospital admissions (see Chapter 6, Exhibit 6-5). There was little evidence of change over time by age group. Zone Time Trends (2009/10 to 2013/14) Analysis of time trends revealed relative stability in the age-standardized admission LOS rates over time for most Zones (Exhibits 7-4 and 7-6 to 7-9). There was evidence of an unusually high value in 2013/14 for Northern Zone in the age-standardized admission LOS rate ratios. This appears to be due to an extremely high value in the former Pictou County Health Authority for that year, which in turns, is likely a result of the influence of a small number of hospitalizations for young people experiencing an unusually long length of stay. Caution should be exercised in interpreting this one data point. Note that the results for hospital admissions do not show this same anomaly. Other than the unusual value for Northern Zone in 2013/14, the age-standardized admission LOS rate ratios were virtually no different from those for the province as a whole, over time. NOTE: Data regarding hospitalizations, for those with and without diabetes, were derived from the Canadian Chronic Disease Surveillance System (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

55 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 7-1 Crude and Age-Standardized Admission LOS Rates and Rate Ratios for the Hospitalized Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2013/14 Province and Zones Diabetes Status (1=Yes) Total Hospital Days Number of Admissions Crude Admission LOS Rate (Days/ Admission) Crude Admission LOS Rate Ratios Age- Standardized Admission LOS Rate (Days/ Admission) Age- Standardized Admission LOS Rate Ratios 1 260,632 21, ,139 53, Western 1 67,340 5, ,819 11, Northern 1 43,228 3, ,978 9, Eastern 1 71,456 5, ,840 11, Central 1 78,608 6, ,209 20, Exhibit 7-2 Crude Admission LOS Rates for the Hospitalized Population Aged 20+, with/without Diabetes (DM), in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central Crude Admission LOS Rate (days/admission) DIABETES STATISTICS REPORT

56 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 7-3 Crude Admission LOS Rates for the Hospitalized Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2009/10 to 2013/ Crude Admission LOS Rate (Days/Admission) Total Age Group M - DM M - No DM F - DM F - No DM Exhibit 7-4 Trend in Age-Standardized Admission LOS Rates for the Hospitalized Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2009/10 to 2013/14 Age- Standardized Admission LOS Rate RaKo Western Zone Northern Zone Eastern Zone Central Zone Exhibit 7-5 Trend in Crude Admission LOS Rate Ratios for the Hospitalized Population Aged 20+, with/without Diabetes, in Nova Scotia by Age Group, 2009/10 to 2013/14 Crude Admission LOS Rate RaKo DIABETES STATISTICS REPORT

57 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 7-6 Trend in Age-Standardized Admission LOS Rate Ratios for the Hospitalized Population Aged 20+, with/without Diabetes, in Nova Scotia, Western Zone, and its Former District Health Authorities, 2009/10 to 2013/ Age- Standardized Admission LOS Rate RaKo Western Zone SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 7-7 Trend in Age-Standardized Admission LOS Rate Ratios for the Hospitalized Population Aged 20+, with/without Diabetes, in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2009/10 to 2013/ Age- Standardized Admission LOS Rate RaKo Northern Zone CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

58 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 7-8 Trend in Age-Standardized Admission LOS Rate Ratios for the Hospitalized Population Aged 20+, with/without Diabetes, in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2009/10 to 2013/ Age- Standardized Admission LOS Rate RaKo Eastern Zone GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 7-9 Trend in Age-Standardized Admission LOS Rate Ratios for the Hospitalized Population Aged 20+, with/without Diabetes, in Nova Scotia and Central Zone, 2009/10 to 2013/ Age- Standardized Admission LOS Rate RaKo Central Zone DIABETES STATISTICS REPORT

59 SECTION 3 HEALTH SERVICES UTILIZATION C HAPTER 8 PRIMARY CARE OFFICE VISITS The focus of this chapter is to describe how frequently people visit a primary care practitioner (PCP) over the course of a year (i.e., PCP visit rate as visits/person), comparing all people with diabetes relative to all people without diabetes. Diabetes is a complex, chronic, multi-systemic disease that is progressive in nature. As such, people with diabetes are heavy users of the health care system. While a substantial proportion of people with diabetes are followed exclusively by a primary care practitioner, specialist physician 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 (2013/14) In 2013/14, Nova Scotia adults aged 20+ with diabetes made an average of 9.4 PCP visits per person, compared to 4.3 visits per person for adults without diabetes. Overall, the population with diabetes made approximately 880,000 visits to primary care practitioners, accounting for nearly 22% of all such visits (~ 4 million). In 2013/14, there was little variation in the PCP visit rate in the population with diabetes across Zones, ranging from 9.0 to 1 visits per person (Exhibits 8-1 and 8-2). Comparison of the agestandardized PCP visit rates revealed both smaller values and less variation in the population with diabetes across the province (7.3 to 7.5), indicating that differences in population structure (e.g., older versus younger population) accounted for most of the variation between Zones. Analysis by Zones, of the age-standardized PCP visit rate ratios revealed that people with diabetes made between 1.8 and 1.9 as many visits to PCPs compared to people without diabetes. Analysis by age group and sex revealed that those with diabetes had a higher PCP per person than those without diabetes (in 2013/14, an average of approximately 4 more visits), and this finding was true for both males and females and for all age groups (Exhibit 8-3). The crude PCP visit rate for females was higher than for males until age 70, although the difference diminished with increasing age. By age 70, males and females had a similar PCP visit rate. This finding was true for both the populations with and without diabetes. 1 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;9: Gilbert RE, Rabi D, LaRochelle P, et al. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Treatment of hypertension. Can J Diabetes 2013;37(suppl 1): S117-S118 DIABETES STATISTICS REPORT

60 SECTION 3 HEALTH SERVICES UTILIZATION When comparing those with diabetes to those without diabetes, the crude PCP visit rate diminished with increasing age but was still 1.3 times higher at age 80. Nova Scotia Time Trends (2009/10 to 2013/14) Time trends in the age-standardized PCP visit rate ratios revealed virtually no change over time, hovering at approximately 1.8 (Exhibit 8-4). On average, people with diabetes have approximately twice as many PCP office visits as people without diabetes In terms of time trends by age group, the ratio of the crude PCP visit rates decreased with increasing age for those age 40 and older. The ratio for the age group was virtually no different than that of the age group (Exhibit 8-5). There was little evidence of change over time by age group. Zone Time Trends (2009/10 to 2013/14) Analyses of time trends revealed stable age-standardized PCP visit rate ratios for all Zones (Exhibits 8-4 and 8-6 to 8-9). The age-standardized PCP visit rate ratios for the Zones were virtually no different than those for the province as a whole, and over time. NOTE: Data about primary care practitioner visits among those with and without diabetes were derived from the Canadian Chronic Disease Surveillance System (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

61 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 8-1 Crude and Age-Standardized PCP Rates and Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2013/14 Province and Zones Diabetes Status (1=Yes) Number of PCP Visits Population Aged 20+ Crude PCP Visit Rate (Visits/ Person) Crude PCP Visit Rate Ratio Age- Standardized PCP Visit Rate (Visits/ Person) Age- Standardized PCP Visit Rate Ratio 1 87, , , , Western 1 21, , , , Northern 1 14, , , , Eastern 1 19, , , , Central 1 32, , , , Exhibit 8-2 Crude PCP Visit Rate for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central PCP Visit Rate (visits/person) DIABETES STATISTICS REPORT

62 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 8-3 Crude PCP Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2013/14 Crude PCP Visit Rate (Visits/Person) Total Age Group M - DM M - No DM F - DM F - No DM Exhibit 8-4 Trend in Age-Standardized PCP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2009/10 to 2013/14 Age- Standardized PCP Visit Rate RaKo Western Zone Northern Zone Eastern Zone Central Zone Exhibit 8-5 Trend in the Crude PCP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia by Age Group, 2009/10 to 2013/14 Crude PCP Visit Rate RaKo DIABETES STATISTICS REPORT

63 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 8-6 Trend in the Age-Standardized PCP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Western Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized PCP Visit Rate RaKo Western Zone SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 8-7 Age- Standardized PCP Visit Rate RaKo Trend in the Age-Standardized PCP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Northern Zone CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

64 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 8-8 Age- Standardized PCP Vist Rate RaKo Trend in the Age-Standardized PCP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Eastern Zone GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 8-9 Trend in the Age-Standardized PCP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and Central Zone, 2009/10 to 2013/14 Age- Standardized PCP Visit Rate RaKo Central Zone DIABETES STATISTICS REPORT

65 SECTION 3 HEALTH SERVICES UTILIZATION CHAPTER 9 SPECIALIST PHYSICIAN OFFICE VISITS The focus of this chapter is to describe how frequently people visit a specialist physician (SP) over the course of a year (i.e., SP visit rate as visits/person), comparing all people with diabetes relative to all people without diabetes. Diabetes is a complex, chronic, multi-systemic disease that is progressive in nature. People with diabetes are heavy users of the health care system. While the majority of people with diabetes are followed exclusively by a primary care practitioner, specialist physician 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 (2013/14) In 2013/14, Nova Scotia adults aged 20+ with diabetes made an average of 4.4 specialist physician office visits per person, compared to 1.6 visits per person for adults without diabetes. Overall, the population with diabetes had made approximately 406,000 SP visits, accounting for approximately 25% of all specialist physician office visits (~1.6 million). In 2013/14, there was some variation in the crude SP visit rate in the population with diabetes across Zones, ranging from 3.4 to 5.0 visits per person (Exhibits 9-1 and 9-2). Comparison of the agestandardized SP visit rates revealed both smaller values and less variation in the population with diabetes across the province (2.9 to 3.7 visits per person), indicating that differences in population structure (e.g., older versus younger population) accounted for some of the variation between Zones. Analysis by Zone of the age-standardized SP visit rate ratios revealed that people with diabetes made between 2.1 and 2.3 times as many visits compared to people without diabetes. Analysis by age group and sex revealed that those with diabetes made more SP office visits than those without diabetes (in 2013/14, an average of ~ 2 more visits/person), and this finding was true for both males and females and for all age groups (Exhibit 9-3). The crude SP visit rate for females was higher than for males until age 60. For those age 60-69, the crude SP visit rate was similar for males and females; and by age 70, males made more visits than females. This finding was true for both the populations with and without diabetes. The highest crude SP visit rate for females under the age of 60 was in the age group, most likely reflective of pregnancy and reproductive issues. 1 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;9: Gilbert RE, Rabi D, LaRochelle P, et al. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Treatment of hypertension. Can J Diabetes 2013;37(suppl 1): S117-S118. DIABETES STATISTICS REPORT

66 SECTION 3 HEALTH SERVICES UTILIZATION The crude SP visit rate ratios decreased with increasing age but was still above 1.0 at age 80 for the population with diabetes relative to those without diabetes. Nova Scotia Time Trends (2009/10 to 2013/14) Time trends in the age-standardized SP visit rate ratios revealed virtually no change over time, hovering at approximately 2.2 (Exhibit 9-4). On average, people with diabetes have approximately twice as many SP visits as people without diabetes. In terms of time trends by age group, the crude SP visit rate ratios decreased with increasing age. The most recent rate ratio was approximately 3.0 for those in the age group and 1.3 for those 80 of age and older (Exhibit 9-5). There was little evidence of change over time for most age groups, although the ratio of the crude SP visit rate for those in the age group decreased slightly over time. Zone Time Trends (2009/10 to 2013/14) Analyses of time trends revealed stable ratios for the age-standardized SP visit rates over time for all Zones (Exhibits 9-4 and 9-6 to 9-9). The age-standardized SP visit rate ratios for the Zones were virtually no different from those for the province as a whole, and over time. NOTE: Data about specialist physician visits among those with and without diabetes were derived from the Canadian Chronic Disease Surveillance System (CCDSS) (see Appendix A). Given that the CCDSS 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. DIABETES STATISTICS REPORT

67 SECTION 3 HEALTH SERVICES UTILIZATION EXHIBITS Exhibit 9-1 Crude and Age-Standardized SP Visit Rates and Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2013/14 Province and Zones Diabetes Status (1=Yes) Number of SP Visits Population Aged 20+ Crude SP Visit Rate (Visits/ Person) Crude SP Visit Rate Ratio Age- Standardized SP Visit Rate (Visits/ Person) Age- Standardized SP Visit Rate Ratio 1 406,226 93, ,196, , Western 1 80,261 22, , , Northern 1 52,085 15, , , Eastern 1 98,753 19, , , Central 1 175,078 35, , , Exhibit 9-2 Crude SP Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia, the Zones, and the Former District Health Authorities, 2013/14 Western South Shore Southwest Annapolis Valley Northern Colchester East Hants Cumberland Pictou County DM No DM Eastern Guysborough Antigonish Strait Cape Breton Central SP Visit Rate (visits/person) DIABETES STATISTICS REPORT

68 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 9-3 Crude SP Visit Rates for the Population Aged 20+, with/without Diabetes (DM), in Nova Scotia by Age Group and Sex, 2013/14 Crude SP Visit Rate (Visits/Person) Total Age Group M - DM M - No DM F - DM F - No DM Exhibit 9-4 Trend in Age-Standardized SP Visit Rate Ratios for Population Aged 20+, with/without Diabetes, in Nova Scotia and the Zones, 2009/10 to 2013/14 Age- Standardized SP Visit Rate RaKo Western Northern Eastern Central Exhibit 9-5 Trend in Crude SP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia by Age Group, 2009/10 to 2013/14 Crude SP Visit Rate RaKo DIABETES STATISTICS REPORT

69 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 9-6 Trend in Age-Standardized SP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Western Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Age- Standardized SP Visit Rate RaKo Western SSH SWH AVH SSH: South Shore SWH: Southwest AVH: Annapolis Valley Exhibit 9-7 Age- Standardized SP Visit Rate RaKo Trend in the Age-Standardized SP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Northern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Northern CEHHA CHA PCHA CEHHA: Colchester East Hants CHA: Cumberland PCHA: Pictou County DIABETES STATISTICS REPORT

70 SECTION 3 HEALTH SERVICES UTILIZATION Exhibit 9-8 Age- Standardized SP Visit Rate RaKo Trend in the Age-Standardized SP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia, Eastern Zone, and its Former District Health Authorities, 2009/10 to 2013/14 Eastern GASHA CBDHA GASHA: Guysborough Antigonish Strait CBDHA: Cape Breton Exhibit 9-9 Trend in the Age-Standardized SP Visit Rate Ratios for the Population Aged 20+, with/without Diabetes, in Nova Scotia and Central Zone, 2009/10 to 2013/14 Age- Standardized SP Visit Rate RaKo Central DIABETES STATISTICS REPORT

71 APPENDICES APPENDICES APPENDIX A: THE CANADIAN CHRONIC DISEASE SURVEILLANCE SYSTEM APPENDIX B: COMPARISON OF CRUDE MEASURES OF DIABETES BURDEN, COMORBIDITY, AND HEALTH SERVICES UTILIZATION BY ZONE AND FORMER DISTRICT HEALTH AUTHORITIES (DHAS), RELATIVE TO APPENDIX C: PREVALENT CASES BY AGE GROUP AND SEX FOR, THE ZONES, AND FORMER DISTRICT HEALTH AUTHORITIES (DHAS), 2013/14 APPENDIX D: CRUDE AND AGE-STANDARDIZED RATES AND RATE RATIOS IN, THE ZONES, AND FORMER DISTRICT HEALTH AUTHORITIES (DHAS), 2013/14 DIABETES STATISTICS REPORT

72 APPENDICES DIABETES STATISTICS REPORT

73 APPENDICES Appendix A: The Canadian Chronic Disease Surveillance System (CCDSS) Introduction In 1997, Health Canada launched the National Diabetes Surveillance System (NDSS), taking advantage of administrative health data available across all provinces and territories to monitor diabetes and its complications, and to provide comparable national data to assist in policy development. By 2009, the Public Health Agency of Canada assumed responsibility for the NDSS and expanded it beyond diabetes to include several other chronic conditions, the first of which was hypertension. To reflect this broader mandate, the NDSS became the Canadian Chronic Disease Surveillance System (CCDSS). Data Sources The CCDSS methodology uses three data sources: 1. The Insured Patient Registry contains longitudinal information regarding every Nova Scotia resident registered as a beneficiary of provincial Medical Services Insurance (MSI) including demographic information such as sex, date of birth, and patient geography. Members of the Canadian Armed Forces and the RCMP are not captured in this database as their health care services are covered federally. The Insured Patient Registry was used to determine the Nova Scotia population eligible for health care services in each year. Dates of death derived from provincial Vital Statistics are incorporated into the Insured Patient Registry. 2. The MSI Physician Billings Database contains administrative records for each insured health service rendered in the province by a health care provider and paid for by the Nova Scotia provincial healthcare system. This database also includes shadow-billing records for both physicians being remunerated through alternative payment structures (APS) as well as salaried nurse practitioners. The completeness of shadow billing has improved over the years. Patient-level information collected on these billing records includes demographics and diagnostic codes. The database is used to identify individuals with diabetes and hypertension as well as visits to providers. For the purposes of the CCDSS, the analysis is restricted to claims for physicians and nurse practitioners. 3. The Canadian Institute for Health Information Discharge Abstract Database (CIHI DAD) contains a comprehensive administrative transcription of each discharge from a Nova Scotia hospital facility as well as similar information for out-of-province discharges for Nova Scotia residents. This database contains individual patient-level information including patient demographics, diagnoses, and procedures performed. All codes in the diagnostic fields (16 fields for , 25 fields since 2001) of the CIHI DAD were used to identify individuals with diabetes and/or comorbidities. The database is also used to derive hospitalization information including total hospital days, hospital admission rates, and rates of admission length of stay. Note that admissions to non-acute care facilities (i.e., the Nova Scotia Hospital a mental health facility) are excluded from consideration for the diabetes portion of the CCDSS. DIABETES STATISTICS REPORT

74 APPENDICES Methodology This report is based on Version 2015 of the CCDSS decision rules and associated programming code. The CCDSS methodology consists of SAS 1 code that is used to apply case definitions to administrative health data to derive the measures described below. Prevalence and Incidence Individuals were determined to be incident cases (i.e., newly diagnosed), if within a two-year period they had, for the first time, either: Two claims (MSI Physician Billings) with a diagnosis of diabetes (ICD-9: 250). OR One hospitalization (CIHI DAD) with a diagnosis of diabetes (ICD-9: 250, ICD- 10: E10-E14). The year of diagnosis was considered to be the first year of this two-year period if visits occurred in both years. From the year of diagnosis (incident year) onward, an individual was considered to be a prevalent case no additional criteria were required in subsequent years to maintain his/her status as a prevalent diabetes case. Cases of gestational diabetes were excluded (ICD-9: , V27; ICD-10: O1, O21-95, O98, O99, Z37) Crude prevalence was calculated as the number of prevalent cases divided by the total population (based on the Insured Patient Registry). Crude incidence rates were calculated as the number of incident cases divided by the population at risk. The population at risk is calculated by subtracting the previous year s number of prevalent cases from the current year s total population (i.e., once an individual is considered a prevalent case of diabetes, that individual is no longer eligible to become a newly diagnosed case of diabetes in the next year). Note: Time trends in the diabetes incidence rates over the last 10 years reveal a decline that began approximately five years ago (2009/10). There is concern that this decline stems from changes in the coding of diabetes on provider billings, rather than indicating a true decrease in incidence. Caution should be exercised in interpreting absolute values; rather, the focus should be on interpreting relative trends, (i.e., by age group, sex, and over time.) Mortality Mortality rates were calculated for the population with and without diabetes, as the number of deaths in the population divided by the total population. Date of death was derived from the Insured Patient Registry. 1 SAS Software, Version 9.3 for Windows. SAS Institute Inc., Cary, NC, USA. DIABETES STATISTICS REPORT

75 APPENDICES Comorbidity Crude rates of comorbidity were calculated separately for those with and without diabetes, as the number of people in the population with the comorbidity divided by the total population. Hypertension was assessed by way of a case definition, similar to diabetes: two claims (MSI Physician Billings ICD-9: ) or one hospitalization (CIHI DAD ICD-10: , 115) with a diagnosis of hypertension in a two-year period, and cases accumulate across years. Note: The CCDSS Scientific Committee is currently reviewing the case definitions of several comorbidities, and therefore these conditions have been removed from the current version of this report. Hospitalizations An individual was determined to have had a hospitalization if there was any record of a hospital admission in the CIHI DAD in a given year. The CCDSS approach to analyzing length of stay produces crude rates of total hospital days separately for those with and without diabetes, dividing the total number of hospital days by the total population, whether admitted or not (Total Hospital Days, Chapter 5). This summary measure does not distinguish between whether people with diabetes are at higher risk of being hospitalized than people without diabetes, or whether once in hospital, people with diabetes are likely to stay longer than those without diabetes. For these reasons, two chapters in this report describe whether people with diabetes experience more hospitalizations than those without diabetes, and once hospitalized, whether they remain in hospital for longer periods of time than those without diabetes. Hospital Admissions (Chapter 6): this measure describes hospital use as measured by the number of hospitalizations over the course of a year (i.e., admission rate), comparing all people with diabetes relative to all people without diabetes, regardless of whether each person was individually admitted to hospital during the year. Admission Length of Stay (Chapter 7): this measures/describes hospital use as measured by the length of stay (LOS) per admission as experienced by people who were hospitalized over the course of a year (i.e., admission LOS rate), comparing all hospitalized people with diabetes relative to all hospitalized people without diabetes. This measure addresses whether people with diabetes, once admitted to hospital, are more likely to stay longer in hospital than people without diabetes. This measure differs from total hospital days (see Chapter 5, Total Hospital Days), which is more of a summary measure of hospital utilization. DIABETES STATISTICS REPORT

76 APPENDICES Office Visits (Primary Care Provider and Specialist Physician) Visits to primary care providers and specialist physicians were derived for each individual by counting the number of MSI billings in the database, by provider category (primary care provider vs specialist physician). Crude visit rates (visits/person) were then calculated separately for those with and without diabetes. Standardized Rates and Rate Ratios Across this report, both crude and age-standardized rates are presented. Age-standardized rates were calculated using the 1991 Census data from Statistics Canada as the standard, to allow figures for different regions to be compared with one another, taking away variability that could result from the differences in the age structure of the population. For example, the population of Eastern Zone is older than that of Central Zone, so the crude rates of diabetes would be expected to be higher in Eastern Zone. A comparison of age-standardized rates between Zones may reveal differences that cannot be attributed to differences in the population age structure of the Zones. For the chapters other than prevalence and incidence, age-standardized rate ratios were calculated, (i.e., a ratio was calculated as the age-standardized rate among those with diabetes divided by the age-standardized rate among those without diabetes). These calculations provide the reader with a sense of the excess burden or risk associated with having diabetes by taking away the variability that could result from the differences in the age structure across populations. Cautions and Limitations The CCDSS case definition for diabetes is such that once an individual is identified as having diabetes, they are then considered a prevalent case from that point onward. In other words, that individual never has to satisfy any further case definition criteria. This definition is a concern when an individual is suspected as having diabetes, and may in fact be coded in billing as having diabetes, but later is found not to have the disease (i.e., a false positive case). The Public Health Agency of Canada is currently reviewing this concern and is considering adopting exit criteria to prevent an accumulation of false positive cases over time. DIABETES STATISTICS REPORT

77 APPENDICES Appendix B: Comparison of Crude Measures of Diabetes Burden, Comorbidity, and Health Services Utilization by Zone and Former District Health Authorities (DHAs), Relative to Nova Scotia Zones: CZ: Central Zone EZ: Eastern Zone WZ: Western Zone NZ: Northern Zone Former DHAs: AVH: Annapolis Valley CBDHA: Cape Breton CEHHA: Colchester East Hants CHA: Cumberland GASHA: Guysborough Antigonish Strait PCHA: Pictou County SSH: South Shore SWH: Southwest NOTE: Figures for the Zones and former DHAs can be compared against those of Nova Scotia (i.e., benchmarking) to identify areas for future action and to understand whether these areas of concern are isolated or, are in fact, part of a more general pattern. Zones, followed by former DHAs, are listed alphabetically starting just above or just below the row containing the Nova Scotia figures; no hierarchal methods have been applied to the order of appearance DIABETES STATISTICS REPORT