Monitoring the prevalence of diabetes and the quality of care using electronic health data Roberto Gnavi 1 Roberta Picariello 1, Graziella Bruno 2, Carlo Giorda 3, Giuseppe Costa 1,4 1 Epidemiology Unit ASL TO3, Piedmont Region; 2 Department of Internal Medicine, University of Torino; 3 Metabolism and Diabetes Unit, ASL TO5, Piedmont Region; 1,4 Department of Public Health, University of Torino, Italy EUROEPI 2010, Florence, 8 th November 2010
Background Worldwide prevalence of diabetes is estimated to be 2.8%, but in more developed societies has reached about 6% The number of people with diabetes is increasing: in the next 20 years the number of persons with diabetes will more than double (an epidemic) Mortality is up to three times greater than that of non-diabetic people To increase the survival of diabetic patients, changes in lifestyle, appropriate drug treatment, regular glycaemic control, and the continuous surveillance of health status are necessary Surveillance systems monitoring the occurrence of the disease over geographical areas and time and the quality of care received by persons with diabetes are needed to allow timely identification of critical cal points and rational planning of interventions
Objectives To report a selection of results from a population-based surveillance program, implemented in the city of Turin (900,000 inhabitants) Italy, based on administrative databases and aimed to monitor the occurrence of diabetes and the quality of care
Population with diabetes: data sources Exemption from payment: exemption from payment of drugs and laboratory tests because of a diagnosis of DM Regional Drug Prescriptions Database: All residents who had at least two prescriptions of antidiabetic drugs (ATC A10A and A10B) in 2003 Hospital Discharge Database: All residents discharged with a primary or secondary diagnosis of diabetes (ICD9 CM 250) from 1995 to 2002
Distribution of persons with diabetes by source of ascertainment 31 st July 2003 Exemption from payment for drugs 27.417 4.837 3.068 4.780 Hospital discharges 19.043 (1995-2002) 10.157 9.355 1.185 1.038 n = 34420 Drug Prescriptions Turin Population Register 21.735 (at least two prescriptions in to 2003) include people alive and resident on 31 st July 2003 to determine individual educational level
Prevalence of diabetes in residents of Turin; 2003 Three sources Adjusted for undercount (capture recapture) n % n % difference (%) Gender Donne 17135 3,66 21810 4,66 78,6 Uomini 17285 4,02 21035 4,90 82,2 Age < 65 12907 1,86 16718 2,40 77,2 65 74 11591 10,27 14222 12,60 81,5 > 75 9922 11,10 11905 13,31 83,4 ALL 34420 3,83 42845 4,77 80,4
Prevalence of diabetes by educational level in residents > 20 ys. old; Turin 2003 Men Women Prevalence (%) PRR* Prevalence (%) PRR* (95% CI) (95% C I) (95% C I) (95% C I) Educational level High 4.49 1. 00 2.55 1.00 (4.35-4.63) (2.44-2.67) Medium 5.67 1.26 3.95 1.55 (5.52-5.82) (1.21-1.32) (3.84-4.06) (1.47-1.63) Low 10.41 2.32 8.80 3.45 (10.2-10.6) (2.23-2.41) (8.61-8.98) (3.28-3.62) * Adjusted for age Nutr Metab Cardiovasc Dis 2008; 18:678-682
To monitor the quality of the process of care of diabetes Regional Register Diabetes 27.417 3.068 residents 4.837 in (14%) 4.780 (14%) Hospital discharges 19.043 34420 residents in Turin with diabetes 10.157 1.038 1.185 (3%) Torino Population Register Drug Prescriptions 21.735 to include people alive on 31st July 2003 to determine individual educational level to determine census tract median income 1 year Regional data base of ambulatory and outpatient care Drug prescriptions Hospital discharges therapy (insulin, oral drugs, diet only) circulatory disease
Laboratory test and outpatient consultations in persons with diabetes in Turin Test 1 year % 2 year % Glycosylated Hb 71.0 80.1 Cholesterol 64.7 80.3 Microalbuminuria 31.0 46.8 Eye examination 23.6 37.9 ECG 33.3 50.6 Diabetologist 67.5 73.3 GCI * 35.8 55.0 * Guidelines Composite Indicator A1C + two among eye examination / cholesterol / microalbumiuria
Laboratory test and outpatient consultations in persons with diabetes in Turin Gender Eye A1C Cholesterol M.albuminuria Diabetologist examination ECG GCI PR PR PR PR PR PR PR women 1 1 1 1 1 1 1 men 1,01 0,99 1,04 1,01 1,05 1,08 1,02 Age 21-44 1 1 1 1 1 1 1 45-54 0,99 1,11 0,98 1,08 0,96 1,48 1,03 55-64 1,08 1,21 1,05 1,15 0,98 1,81 1,10 65-74 1,11 1,28 0,95 1,17 0,91 1,94 1,04 >=75 0,96 1,01 0,56 0,97 0,55 1,55 0,62 Educational level high 1 1 1 1 1 1 1 medium 1,05 1,04 1,02 1,08 1,11 1,16 1,05 low 1,04 1,00 0,98 1,11 1,08 1,18 1,00 Treatment diet only 1 1 1 1 1 1 1 oral drugs 1,74 1,35 1,97 1,83 1,84 1,36 1,98 insulin 1,84 1,35 2,18 1,98 2,11 1,42 2,21 Diabetes Care 2009;32:1980-1985
Adherence to guidelines in persons with diabetes in Turin by health district of residence; Prevalence Ratios Prevalence Ratio
To monitor the outcomes of care of diabetes Regional Register Diabetes 27.417 4.837 3.068 4.780 (14%) (14%) 10.157 33,036 residents 1.038 Hospital discharges 19.043 residents with diabetes (1 st january 2002) 1.185 (3%) Torino Population Register Drug Prescriptions 21.735 to include people alive on 31st July 2003 to determine individual educational level to determine census tract median income 4 years f.u. MORTALITY All causes Chd Stroke Cancer AMPUTATIONS INCIDENCE Ami Stroke
Outcomes: Standard. Mortality/Incidence Ratio (ref. without diabetes) Men Women n SMR/SIR n SMR/SIR Mortality All 2755 168 2616 175 Circulatory diseases 1012 169 1134 163 CHD 425 214 367 238 Cerebrovascular disease 263 156 321 129 Cancer 835 140 521 140 Incidence Ami 658 195 540 290 Stroke 525 182 535 177 Amputations 113 1022 66 968
Outcomes: mortality/incidence by educational level in diabetic and non diabetic men Diabetics Non diabetics Educational level Medium Elementary Medium Elementary HR HR p for trend HR HR p for trend Mortality All 1.18 1.22 0.001 1.25 1.42 <0.001 Circulatory diseases 1.26 1.21 0.141 1.14 1.22 <0.001 Incidence AMI 1.06 1.05 0.863 1.27 1.33 <0.001 stroke 0.94 1.16 0.087 1.33 1.47 <0.001 Amputations 1.33 1.28 0.450 2.10 2.62 0.002
Outcomes: mortality/incidence by educational level in diabetic and non diabetic women Diabetics Non diabetics Educational level Medium Elementary Medium Elementary HR HR p for trend HR HR p for trend Mortality All 1.02 1.03 0.987 1.07 1.16 <.0001 Circulatory diseases 1.14 1.05 0.659 1.06 1.17 <.0001 Incidence AMI 1.13 1.06 0.909 1.14 1.23 0.002 stroke 0.96 1.08 0.434 1.24 1.38 <.0001 Amputations 0.63 0.30 0.0002 1.20 1.24 0.744
Conclusions It is possible, with administrative data, to identify large cohorts of persons with known diabetes, to calculate the prevalence of the disease, and to monitor prospectively, at population level, several indicators that are used internationally to asses the quality of care This allows, in a simple way and at very low cost, to monitor the epidemiology of diabetes and to identify some strengths and weakness of the care system
Thank you for your attention Roberto.gnavi@epi.piemonte.it