Use of health services by diabetic persons. II. Hospital admissions

Predictors of Diabetes-Specific Knowledge and Treatment Satisfaction Among Costa Ricans

PURPOSE

The purpose of this study was to identify predictors of disease-specific knowledge and patient satisfaction among adult Costa Ricans with type 2 diabetes. Knowledge differences between Costa Ricans and Spanish-speaking US Latinos also were tested. The psychometric viability of a Spanish-language diabetes knowledge and client satisfaction measure with Costa Ricans was reviewed.

METHODS

The Diabetes Knowledge Questionnaire (DKQ) and the Client Satisfaction Questionnaire (CSQ) were administered to 162 Costa Rican adults with type 2 diabetes who were receiving services in the greater San Jose area. Sociodemographic, medical history, and anecdotal information also was collected.

RESULTS

More years of education, younger age, longer diabetes duration, and home glucose monitoring predicted diabetes knowledge. Home glucose monitoring and treatment with only oral hypoglycemics predicted significantly lower patient satisfaction. Costa Ricans exhibited greater diabetes knowledge than respondents in an earlier study with Spanish-speaking Latinos. CSQ psychometric limitations with Costa Ricans were identified.

CONCLUSIONS

The greater diabetes knowledge among Costa Ricans than US Latinos is likely due to more consistent, stable, and accessible care. Older, less educated, and newly diagnosed Costa Rican diabetes patients require more focused attention.

Diabetes team consultation: impact on length of stay of diabetic patients admitted to a short-stay unit

OBJECTIVE

To assess the impact of endocrinology team consultation on hospital stay and clinical outcomes of diabetic patients admitted with a primary non-diabetes-related diagnosis in a short stay unit (SSU).

METHODS

Patients admitted to the SSU between 2001 and 2005. Between 2001 and 2003 there was no endocrinology team consultation available and the management of hyperglycemia was handled by the SSU team alone. From 2003 until 2005 an endocrinology team was in charge of diabetes care. We compared in both periods: prevalence of diabetes, length of hospital stay, mortality, early readmissions and number of patients requiring conventional hospitalization.

RESULTS

In period 2001-2003, 1023 patients were admitted, among which 212 were diabetic (20.7%). Over the years 2003-2005, 892 patients were hospitalized, 223 were diabetic (25%). Clinical characteristics of diabetic patients from both periods were comparable, but glycaemia at admission was higher on the second period (217 mg/dl versus 198 mg/dl). The length of stay of diabetic patients in the second period decreased from 5.49 to 4.90 days. There were no significant differences in mortality (1.4% versus 0.4%) or in early re-admissions among the two periods.

CONCLUSIONS

The intervention of a diabetes team diminished the average length of stay of diabetic patients.

Hospital admissions in diabetic and non-diabetic patients: a case-control study

AIM

To examine differences in morbidity and rates of hospital admission between diabetes patients and patients without diabetes in New Zealand.

METHODS

A 1,123 and 11,325 patients with Types 1 and 2 diabetes in the Southlink Health diabetes register were identified. Types 1 and 2 diabetes patients were matched with non-diabetic patients drawn from primary care patient registers. Hospital admission rates for diabetic complications and general medical conditions, length of stay in hospital, patients readmitted, deaths in hospital and hospital procedures were analyzed for the 3-year period from 2000 to 2002.

RESULTS

Diabetes patients were more likely to be admitted to hospital for any reason than patients without diabetes (odds ratio (OR) 2.55, 95% confidence interval (CI) 2.13-3.04, p<0.001 for Type 1 patients; OR 1.40, CI 1.33-1.48, p<0.001 for Type 2 patients). A 46% (770) of all admissions for Type 1 patients were due to complications arising from diabetes and 33% (4685) for Type 2 patients. Major complications included ischaemic heart disease, heart failure, cataracts and conditions specific to diabetes.

CONCLUSIONS

Increasing prevalence of diabetes will increase demand for hospital services overall, and particularly for inpatient care related to macroangiopathy, ophthalmic and renal problems and peripheral circulatory disorders.

Patients with type 2 diabetes had higher rates of hospitalization than the general population

OBJECTIVE

We describe the rate, causes, and predictors of hospitalization for all patients with type 2 diabetes in a diabetes clinic in Turin, Italy and compare their hospitalization rates with those of the general population.

STUDY DESIGN AND SETTING

All patients were recruited and followed up for hospital admissions from January 1996 to June 2000. The role of risk factors was analyzed with a conditional proportional hazard model for repeated events.

RESULTS

More than 50% of the patients had been admitted to hospital at least once for any cause, and 30% had had multiple admissions, accounting for nearly 90% of all days in hospital. For these patients, older age, high glycated hemoglobin level, obesity, insulin treatment, presence of nephropathy, coronary and peripheral artery disease and comorbidity were statistically independent predictors of hospital admission. The standardized hospital admission ratios were 158.8 for men <65 years of age and 113.3 for men > or = 65 years and 245.2 for women <65 years of age and 135.3 for women > or = 65 years of age. The highest ratios were for diabetes, vascular (cardiac and cerebral) diseases, and eye diseases in younger women.

CONCLUSION

Patients with type 2 diabetes, and particularly younger women, had higher rates of hospitalization than the general population, with an excess risk of about 30%.

A comparison of diabetes education administered through telemedicine versus in person

OBJECTIVE

To determine whether diabetes education can be provided as effectively through telemedicine technology as through in-person encounters with diabetes nurse and nutrition educators.

RESEARCH DESIGN AND METHODS

A total of 56 adults with diabetes were randomized to receive diabetes education in person (control group) or via telemedicine (telemedicine group) and were followed prospectively. The education consisted of three consultative visits with diabetes nurse and nutrition educators. The in-person and telemedicine groups were compared using measures of glycemic control (HbA(1c)) and questionnaires to assess patient satisfaction and psychosocial functioning as related to diabetes. Outcome measures were obtained at baseline, immediately after the completion of diabetes education, and 3 months after the third educational visit.

RESULTS

Patient satisfaction was high in the telemedicine group. Problem Areas in Diabetes scale scores improved significantly with diabetes education (adjusted P < 0.05, before vs. immediately after education and 3 months after education), and the attainment of behavior-change goals did not differ between groups. With diabetes education, HbA(1c) improved from 8.6 +/- 1.8% at baseline to 7.8 +/- 1.5% immediately after education and 7.8 +/- 1.8% 3 months after the third educational visit (unadjusted P < 0.001, P = 0.089 adjusted for BMI and age), with similar changes observed in the telemedicine and in-person groups.

CONCLUSIONS

Diabetes education via telemedicine and in person was equally effective in improving glycemic control, and both methods were well accepted by patients. Reduced diabetes-related stress was observed in both groups. These data suggest that telemedicine can be successfully used to provide diabetes education to patients.

The impact of cardiovascular disease on medical care costs in subjects with and without type 2 diabetes

OBJECTIVE

We examined whether cardiovascular disease (CVD) affects medical care costs differently in subjects with and without diabetes and explored the impact of CVD on costs across the dimensions of age and diabetes duration.

RESEARCH DESIGN AND METHODS

We compared the prevalence of CVD and medical care costs for subjects with and without CVD in all 16,180 full-year health maintenance organization members in 1999 who had been diagnosed with type 2 diabetes and in control members matched by year of birth and sex. We ascertained diagnoses from the Kaiser Permanente Northwest Region's electronic ambulatory medical record and from hospital discharge datafiles. Utilization from these and other data systems were multiplied by unit costs.

RESULTS

CVD was 76% more prevalent in subjects with diabetes, but the risk ratios of more severe forms of CVD were even greater. Risk ratios for CVD were greatest in younger subjects. Cost profiles for subjects with both CVD and diabetes differed markedly from those with diabetes but without CVD. In the latter group, costs grew steadily with age, whereas in the former group, costs peaked in the 55- to 64-year age group before declining with age.

CONCLUSIONS

The types of CVD present in diabetic patients are more likely to be more severe and therefore more costly than in similar subjects without diabetes. CVD also disproportionately affects younger diabetic subjects. Finally, when CVD is present in diabetes, more costs occur earlier in life as well as earlier in the course of diabetes.

Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) are life-threatening acute metabolic complications of diabetes mellitus. Although there are some important differences, the pathophysiology, the presenting clinical challenge, and the treatment of these metabolic derangements are similar. Each of these complications can be seen in type 1 or type 2 diabetes, although DKA is usually seen in patients with type 1 diabetes and HHNS in patients with type 2 disease. The clinical management of these syndromes involves careful evaluation and correction of the metabolic and volume status of the patient, identification and treatment of precipitating and comorbid conditions, a smooth transition to a long-term treatment regimen, and a plan to prevent recurrence.

Diabetes in New Zealand

While the ethnic make up of the New Zealand population is predominantly European, the Polynesian population, consisting of indigenous New Zealand Maori and more recent immigrants from the other Pacific Islands is increasing rapidly. The prevalence of diabetes in these Polynesians is high. There is also an increasing prevalence of obesity, and obesity is a greater problem amongst Polynesian people. The number of elderly people in the population is increasing. All of these demographic changes are increasing the incidence and prevalence of Type 2 diabetes. The incidence of Type 1 diabetes is also rising, although the reasons for this are unknown. Diabetic nephropathy is the most common cause of end stage renal failure in New Zealand. Polynesian people with diabetes, and in particular Maori, have a very high rate of diabetic nephropathy and develop renal failure at a more rapid rate than European patients with nephropathy relating to Type 1 diabetes. The propensity for Maori patients with Type 2 diabetes to develop renal failure may relate to a younger age at the onset of diabetes, a genetic susceptibility to nephropathy, and socio-economic or cultural factors leading to less adequate medical care.

Diabetes knowledge and its determinants in a Mexican population

PURPOSE

The purpose of this study was to measure the level of diabetes knowledge in a representative group of Mexican individuals with diabetes and to identify the factors that influence it.

METHODS

A validated questionnaire was administered to 570 outpatients; 11.2% had Type 1 diabetes, 36.4% had Type 2 diabetes treated with insulin, and 52.2% had Type 2 diabetes treated with oral agents. Samples for HbA1c determination also were obtained.

RESULTS

The percentage of correct answers in each section of the questionnaire was low. Type 1 patients had the highest scores, followed by the insulin-treated Type 2 patients; those with chronic complications also had high scores. Educational background, attendance at diabetes courses, age, and HbA1c concentration were the main predictors of knowledge. Attendance at courses was influenced by the severity of the disease.

CONCLUSIONS

The amount of patient knowledge about diabetes-related issues was low in this representative Mexican population. The educational efforts were focused on those with the worst metabolic control and/or with diabetes complications.

Evaluation of a diabetes education program in Newcastle, NSW

OBJECTIVE

To assess the level of coverage and effectiveness of diabetes education provided by the Newcastle Diabetes Education and Stabilisation Centre (DESC) to people taking insulin.

RESEARCH DESIGN AND METHODS

A community based survey of people presenting a prescription for insulin to retail pharmacies in the Hunter Region. The study characterised participants and non-participants in the DESC program by social and demographic factors and assessed the knowledge, blood glucose control and symptoms of diabetic complications they reported. The study also assessed their attitude towards diabetes and diabetic self-care and their feelings towards and use of clinical services.

RESULTS

There were 229 respondents, 75% had attended the DESC course, however single males living in rural areas were significantly less likely to attend. Course attenders were more likely to do blood tests and visit an ophthalmologist and podiatrist than non-attenders, but were not more knowledgable about diabetes or reported fewer complications. Despite high levels of use of health care services including eye care, by people with diabetes, and an overall positive attitude to diabetes management, the study revealed a widespread ignorance of the serious consequences of diabetes.

CONCLUSIONS

People with diabetes taking insulin in the Hunter Region have an overall positive attitude to diabetes and a high level of participation in a formal diabetes education program. Attendance was associated with increased use of eye care and foot care services, despite little demonstrable effect on knowledge or self-reported diabetes control.

Utilisation of health services by aboriginal Australians with diabetes

Diabetes is a major public health problem for Aboriginal Australians. We wished to determine the extent and pattern of health service utilisation by Aboriginal people with diabetes in central Australia. Medical records of all Aboriginal people known to have diabetes (n = 374), identified by a previous study, were examined for attendance to health services in central Australia. All had non-insulin-dependent diabetes. Between January 1984 and December 1986, Aboriginal adults with diabetes were admitted to hospital on 694 occasions, accounting for 10.8% of adult Aboriginal admissions. The crude admission rates were 0.78 and 0.84 per diabetes-year for men and women, respectively. The age-adjusted relative risks for admission, compared with Aboriginal non-diabetic patients, were 2.93 (95% C.I., 2.62-3.26) for men and 2.46 (95% C.I., 2.28-2.66) for women. If admission for conditions associated with diabetes are excluded, the admission rates were similar for the two groups. Infection was the most common reason for attendance to a health service, representing 41.7% and 39.8% of male and female admissions, and 21.8% and 26.3% of male and female outpatient attendances. Aboriginal patients with diagnosed diabetes suffer high morbidity and contribute disproportionately to health system costs.

Influence of bed supply and health care organization on regional and local patterns of diabetes related hospitalization

This paper undertakes both a macro- and micro-scale analysis of the influences exerted by the health care system on patterns of hospitalization. The health disorder of diabetes mellitus is used as the case study and the analyses are based on New Zealand data sets. The article first examines the extent to which both the supply and organization of primary and secondary health care affect rates of hospitalization. The macro-scale analysis investigates the applicability of Roemer's Law to regional variations in diabetes hospitalization. The organizational control of hospital utilization via doctor gatekeeping functions and interaction between health services are then examined at the local level. This analysis assumes a population based approach using the Canterbury Register of Insulin-treated diabetic persons as the study population. Diabetes discharge rates were found to be most highly correlated with hospital bed supply in 5 of the 8 years studied (1979-1986). Stepwise regression analysis indicated area rates of diabetes hospitalization were significantly influenced by resource factors even after controlling for differences in the socio-demographic characteristics of the area populations. This confirmed the presence of Roemer's Law at the aggregate level with rates of diabetes hospitalization appearing to have more to do with the availability of medical resources than to population needs. At the local level, hospital admission patterns were found to vary by general practitioner age, practice type found to vary by general practitioner age, practice type and diabetic caseload. Overall, insulin-treated diabetic patients most likely to be hospitalized were those in the care of young doctors new to general practice, and those who attended doctors who had small diabetic caseloads. Solo practitioners had the lowest rates of patient hospitalization. There were marked disparities in patient access to specialist diabetes education and clinical outpatient services by patient age, duration of diabetes and attendance on primary care. Overall, no significant differences were found in the propensity for hospitalization between users and non-users of these specialist services. This does not imply however, service ineffectiveness but rather is indicative of the complexity of the local diabetes care organization and the differing needs of the insulin-treated diabetic population within the community as a whole.

Must diabetes be a fatal disease in Africa? Study of costs of treatment

OBJECTIVE

To estimate the costs of diagnosis and treatment of diabetes in Tanzania.

DESIGN

Costs estimated from the reported and recorded experience of patients with newly presenting diabetes in 1989-90 and of diabetic patients first seen in 1981-2.

SETTING

Muhimbili Medical Centre, Dar es Salaam.

SUBJECTS

464 patients (315 men and 149 women). 262 patients diagnosed during 1 September 1989-31 August 1990 (group 1) and 202 during 1 June 1981-31 August 1982 (group 2).

RESULTS

The average annual direct cost of diabetes care in 1989-90 was $287 for a patient requiring insulin and $103 for a patient not requiring insulin. Purchase of insulin accounted for 68.2% ($156) of the average annual outpatient costs for patients requiring insulin. For patients not requiring insulin the cost of oral hypoglycaemic drugs and treatment of chronic complications and infections accounted for 42.5% ($29.3) and 48.8% ($33.7) of costs respectively. Cost of outpatient care of diabetic patients for the whole of Tanzania was estimated at $2.7m, *75,128 (32.2%) of which was for insulin. Doctors' and nurses' costs accounted for 0.2% of total costs of outpatient care. The annual direct inpatient care costs were estimated at $1.25m. Around 0.2% of the Tanzanian population aged 15 years and over used the equivalent of 8% of the total government health expenditure, which was $47,4088,382.

CONCLUSION

Diabetes places a severe strain on the limited resources of developing countries. If African patients with diabetes have to pay for their treatment most will be unable to do so and will die.

[Level of knowledge of patients with type II diabetes mellitus in primary care]

A personal interview to 148 patients was carried out with the aim of getting to know the level of information of type II diabetic patients at an Urban Health Center in Santander. A validated questionnaire made up of 14 questions on general aspects of diabetis, dietetic habits and capability to handle complications was used. The Cronbach's alpha coefficient of questionnaire was 0.69. The correct answer average was 6.3 (IC = 5.9-6.5). Patients were best informed about general aspects and had much less information with regard to the handling of complications and to their diet. The differences among these three sections of questions were significative (p less than 0.001). The patients under diet treatment obtained worse results than those treated with oral hipoglucemiants and insulin. Our results are worse than those reported by other similar populations at a national level. Also, and due to the differences in knowledge within this group, we believe that the establishment of groups and subgroups when educating diabetic patients is possible and also highly recommended.

Utilization trends and risk factors for hospitalization in diabetes mellitus

A population-based prevalence cohort of 1,111 residents of Rochester, Minnesota, who had diabetes mellitus on Jan. 1, 1975, was subjected to follow-up assessment for hospitalizations through Dec. 31, 1980. On the basis of these data, hospitalization rates were calculated for various clinical types of diabetes, and a risk factor analysis was done for non-insulin-dependent diabetes mellitus (NIDDM) to identify high-risk persons for subsequent intervention studies. The adjusted incidence density of hospitalization was 141.6 per 1,000 person-years for NIDDM and 331.3 per 1,000 person-years for insulin-dependent diabetes. Although the modeled clinical characteristics accounted for little variability in NIDDM-related hospitalization, age modified by the effect of gender was the strongest risk factor found (multivariate hazard ratios: 1.0 and 1.43, respectively, for male and female patients younger than 65 years old; 1.88 and 1.83, respectively, for male and female patients 65 years old or older); coronary heart disease, diabetic retinopathy, and persistent proteinuria were associated with a 50% increased risk. Although older patients with NIDDM (especially men) are at greatest risk for a first hospitalization, clinical factors alone seem inadequate to account for these hospitalizations. The effect of Medicare's prospective payment systems (PPS) was studied by using a data base for Olmsted County, Minnesota, to determine whether PPS decreased the rate of hospitalizations among patients with diabetes. Among Olmsted County residents 65 years of age or older, the adjusted rate of diabetes-associated hospitalizations decreased from 26.5 per 1,000 person-years in 1980 to 16.7 in 1985, whereas the adjusted rate of all other hospitalizations increased from 259.5 per 1,000 person-years to 261.9. Thus, PPS may have reduced hospitalization rates in elderly patients with diabetes.

Adherence to high-carbohydrate, high-fiber diets

Successful diabetes management demands a high degree of adherence. Adherence to medical prescriptions, particularly special diets, is notoriously poor. A study of 40 individuals with IDDM and NIDDM who were followed an average of 23 months found good or excellent dietary adherence in 70% of subjects; only 5% demonstrated poor adherence. Adherence was assessed objectively based on carbohydrate, fat, and fiber intakes reported in 24-hour food recalls, 7-day food frequency surveys, and home food records. High dietary fiber intake may independently enhance adherence, perhaps by increasing satiety or because of the simplicity of the concept. Good communication between the health professional and patient is also fundamental to all stages of dietary adherence. Use of adherence-enhancing techniques throughout adoption of new diet behaviors promotes long-term adherence to high-carbohydrate, high-fiber diets.

District Diabetes Centres in the United Kingdom. A report on a workshop held by the Diabetes Education Study group on behalf of the British Diabetic Association

Dissatisfaction with standards of diabetes care in general, and the traditional diabetic clinic in particular, is widespread. Problems include the large numbers of attenders, short consultation times (often with inexperienced medical staff), lack of continuity and prolonged waiting times. Standards of education and control fall woefully below those that are desired. In recent years several different strategies have been adopted to provide solutions, including general practitioner cooperative care schemes to reduce numbers and improve community care, the appointment of diabetes specialist nurses to take on the major educational role, and the commissioning of special education units designed to remove the educational element from the traditional clinic environment. Lately consideration has been given to the development of Diabetes Centres, to provide more comprehensive diabetes care, both educational and clinical. A workshop was held in January 1987 to analyse in greater detail the concept of Diabetes Centres and the consequences of their implementation.

Use of hospital services by elderly diabetics: the Frederica study of diabetic and fasting hyperglycaemic patients aged 60-74 years

The use of hospital services was studied in 228 patients with known diabetes (KD) (52 insulin treated. 101 diet plus oral hypoglycaemic agents (OHAs), 66 diet treated and 9 without treatment) and 87 subjects with fasting hyperglycaemia (FH) found by screening of a well-defined population aged 60-74 years. Ninety per cent were NIDDM as evaluated by a high C-peptide response on glucagon stimulation. Information about all admissions during the year before ascertainment was obtained from the complete regional computerized hospital registration system. The overall average admission rate per year for KD males was 0.47 and for females 0.50. The average number of bed-days occupied per person-year was 6.8 for KD males and 8.2 for females. These rates are 2-3 times higher than those of the general population. Insulin treated NIDDM patients had a rate of 23.9, whereas IDDM patients had a rate of 15.2 bed-days per person-year. The corresponding figures for patients treated with OHAs were 3.5 and for patients treated with diet 4.6. FH had overall bed-day occupancy rates of 0.50 and 1.09 for males and females, respectively, which was less than half of that expected from the general population. IF discharge diagnosis (principal and/or subsidiary) had been used for identification of hospitalized patients with diabetes the bed-days used by KD patients would have been underestimated by 15.3%, most pronounced for diabetics treated with OHAs (21.1%) or diet (21.6%).

Epidemiology of insulin-dependent diabetes mellitus in Canterbury, New Zealand

A prospective study of incidence and prevalence of insulin-dependent diabetes mellitus in persons under 20 years was conducted over a 4-year period (1 February 1982-1 February 1986) for the Canterbury Hospital Board (total population 342,000) area in New Zealand. A central register for the area was established at the beginning of the study period. Degree of ascertainment was close to 100%. Average annual incidence was 11.7 persons per 100,000 (females: 10.6 per 100,000; males: 12.7 per 100,000) with no significant sex difference or temporal trends. Incidence peaks were seen for both sexes in the pubertal ages (females: 11 years; males: 13 years), with minor peaks occurring for both sexes in the pre-school ages. Age of onset was significantly younger in females than males. A seasonal variation in incidence was seen for males, with peaks in late autumn and mid-winter. 5.7% of the new diabetics had a first-degree relative with insulin-dependent diabetes mellitus. Islet cell cytoplasmic antibodies were detected in 68% of new diabetics and in 0% of age- and sex-matched healthy controls. Thyroid, gastric and adrenal auto-antibodies were seen more frequently in diabetics than in controls, but this difference was not significant. Prevalence of insulin-dependent diabetes on 1 February 1982 was 1.00 per 1000 and 1.05 per 1000 on 1 February 1986. The insulin-dependent diabetes mellitus incidence characteristics noted for the Canterbury Hospital Board area are similar to those reported for European and North American populations.