Georgia epidemiology report, Vol. 19, no. 11 (Nov. 2003)

November 2003

volume 19 number 11

Division of Public Health http://health.state.ga.us
Kathleen E. Toomey, M.D., M.P.H. Director
State Health Officer
Epidemiology Branch http://health.state.ga.us/epi
Paul A. Blake, M.D., M.P.H. Director
State Epidemiologist
Mel Ralston Public Health Advisor
Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D.
Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
Georgia Department of Human Resources
Division of Public Health Epidemiology Branch
Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588
Fax: (404) 657-7517
Please send comments to: Gaepinfo@dhr.state.ga.us
The Georgia Epidemiology Report is a publication of the Epidemiology Branch,
Division of Public Health, Georgia Department of Human Resources

Diabetes in Georgia:
Defining the Problem and Identifying
Areas for Improvement
Introduction
Diabetes is one of the most common, serious, and costly chronic diseases in Georgia and the United States. Type 2 diabetes now affects more than 7% of adults in the United States,1 compared with less than 5% in 1990. 2 National data indicate that hospitalization costs for diabetes have more than doubled from 1997 ($44 billion) to 2002 ($92 billion). 3 Even after adjusting for age, sex, and race/ethnicity, persons with diabetes incur medical expenses five times that of persons without diabetes. 3
This report describes trends in diabetes, differences in prevalence and mortality rates by demographic characteristics, the burden of diabetes-related hospitalizations, self-management practices, and opportunities for improvement in clinical practice in Georgia.
Methods
Data from the Georgia Behavioral Risk Factor Surveillance System (BRFSS) in 2000 and 2001 were aggregated and analyzed to assess diabetes self-management patterns and risk behaviors among adult Georgians. The BRFSS is a survey conducted throughout the year by the Division of Public Health, Georgia Department of Human Resources. Each year, over 4,000 randomly selected adults 18 years of age and older are interviewed by telephone. To compare people with and without diabetes, behavioral prevalence estimates were age-adjusted using the US standard population (year 2000 projected population).
We analyzed data from death certificates filed on residents of Georgia with an underlying cause of death coded as diabetes (ICD-10 codes E10-E14) in 2000. To calculate mortality rates, we used the 2000 United States Bureau of Census population for Georgia as the denominator; we used the direct method of calculating age-adjusted rates based on the US standard population.
Using the hospital discharge database compiled by the Georgia Hospital Association for nonfederal acute-care hospitals in Georgia, we selected hospitalization records with principal discharge diagnosis of diabetes (ICD-9 code 250) in year 2000. Diabetes-related complications were determined by using the following ICD-9 codes: CVD, 390-448; lower extremity amputation, 84.1 (procedure code); end-stage renal disease, 585, 586, V56, V42.0, V45.1; diabetic ketoacidosis, 250.1.
The Georgia Medical Care Foundation provided data on Medicare beneficiaries. Analyses for specific quality indicators were based on a definition of diabetes as two outpatient visits at least 30 days apart or one inpatient visit with a diagnosis of diabetes during a one-year period.
Results
Trends in Diabetes Prevalence Among adults 18 years and older in Georgia, 6.8% (approximately 411,000 adults) know that they have diabetes. Because the early symptoms of diabetes may be mild, the actual prevalence of the disease is estimated to be 50% higher than the prevalence of those with diagnosed diabetes. 4 Therefore, the total number of adults with diabetes, including an estimated 205,000 individuals who are unaware they have diabetes, is about 616,000, or 10.5% of the adult population in Georgia. The percentage of adults who know they have diabetes is higher in the southern half and northwestern corner of Georgia.
The prevalence of diabetes has increased substantially over the last decade. In Georgia from 1994 through 2001, the prevalence of diabetes has increased at an average annual rate of 8% per year (Figure 1).
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Diabetes is more common among older people. Approximately 1% of Georgians from 18 through 29 years of age have the disease, but more than 16% of those greater than 60 years of age are affected (Figure 2).
The prevalence of diabetes is higher in women (7.4%) than men (6.2%), and higher among blacks (9.4%) than whites (6.0%). The prevalence of diabetes among black women is almost twice as high as in any other race-sex group (Figure 3).

Hospitalizations from Diabetes People with diabetes are more likely to be hospitalized than people without diabetes. In 2000, diabetes was the primary cause of more than 13,300 hospitalizations in Georgia, totaling an estimated 68,000 hospital days. In Georgia in 2000, hospital charges for persons hospitalized with a primary discharge diagnosis of diabetes or diabetic ketoacidosis were approximately $138 million.
Diabetes was also a contributing factor to thousands of other hospitalizations. In 2000, 29.5% of Georgia residents hospitalized with CVD, 27.4% of those hospitalized with end-stage renal disease, and 49.5% of those with a lower extremity amputation had diabetes.

Diabetes Mortality Diabetes is the 6th most common cause of death in Georgia. In 2000, there were almost 1,500 people for whom diabetes was the primary cause of death. Diabetes, however, contributes to many more deaths. For every death for which diabetes is the primary cause, approximately two other people die with diabetes as a contributing cause.

In Georgia and in the rest of the United States, death rates from diabetes have been increasing (Figure 4). From 1980 to 2000, the age-adjusted death rate from diabetes in Georgia increased from 18.5 to 22.6 per 100,000, an average annual increase of 1% per year. The increase cannot be attributed to an aging population, because the age-adjusted rate takes into account the changes in the age distribution of the population.

Death rates for diabetes as the primary cause of death increase dramatically with age among all race and ethnic groups. In Georgia the death rate in 2000 was 1.7 per 100,000 adults aged 25 to 34 years and 284.6 per 100,000 adults aged 85 years and older.
Death rates are higher for blacks than for whites. The Georgia death rate in 2000 for black males was about one and a half times that for white males, and the death rate for black females was more than twice that for white females.
Risk Behaviors for Diabetes Research indicates that approximately 14% or more deaths in the United States were attributed to activity patterns and diet.5 The Diabetes Prevention Program Study found a reduction in the incidence of onset of diabetes by 58% in the test group that made lifestyle modifications. 6 Lifestyle intervention showed positive effects in individuals regardless of age, sex, race, or ethnicity.6
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In Georgia, people with diabetes are more likely than people without diabetes to be overweight or obese, to have been told they have high blood pressure, or to have been told they have high blood cholesterol (Table 1). A high percentage (81%) of adults with diabetes eat less than the recommended five fruit and vegetable servings per day, 32% get no leisure time physical activity, and 28% smoke cigarettes (Table 1).

Data from Medicare confirm that many elderly patients with diabetes are not receiving recommended preventive care. Approximately 25% of Medicare enrollees with diabetes in Georgia do not receive annual A1C testing. The percentage of Medicare enrollees receiving dilated eye exams (46%) falls well below the Healthy People 2010 objective (Table 2). Only 13% of persons with diabetes aged 65 and over receive annual microalbuminuria tests, despite the high risk for developing kidney disease (Table 2).

Conclusions
Recent information about diabetes in Georgia indicates that 1) the prevalence of diabetes is increasing rapidly in Georgia, 2) older people and blacks are more likely to have diabetes, and 3) the death rate from diabetes has been rising in Georgia for nearly two decades. Although the reasons for the increasing prevalence and death rate are not precisely known, the increased percentage of Georgians who are overweight or physically inactive -- two of the primary risk factors for diabetes -- are likely involved.

Clinical Practice Recommendations The Clinical Practice Recommendations developed by the American Diabetes Association set standards of medical care for persons with diabetes. 7 Surveys of patients with diabetes in Georgia indicate that substantial numbers of patients are receiving less than the recommended minimal level of care. The percentage of adults with diabetes in Georgia receiving the recommended level of care ranges from 89% visiting a health professional during the past year to 43% receiving aspirin therapy (Table 2). For services for which there is a Healthy People 2010 objective, Georgia meets the national goal for only three objectives two or more A1C (glycated hemoglobin or HbA1c ) tests per year, receipt of diabetes education, and receipt of aspirin therapy. This suggests that there are many areas for improvement in provider and patient education.

Table 2. Percentage of Persons with Diabetes Who Receive Recommended Routine Care

Recommendation Minimal Frequency for Routine Care 7

Healthy

BRFSS

Medicare

People 2010 Assessment* Assessment

Objectives 2000-2001

2001

Visit to health professional

-

89%

-

Self glucose monitoring daily

60%

51%

-

A1C test, 2 per year

50%

82%

-

Received diabetes education

60%

62%

-

Received nutrition therapy

-

-

-

Physical activity recommended*

-

64%

-

Blood pressure measured, each visit

-

-

-

Lipid test, 1 per year

-

-

57%

Receiving aspirin therapy*

30%

43%

-

Advised not to smoke

-

-

-

Foot exam, 1 per year

75%

67%

-

Dilated eye exam, 1 per year

75%

64%

46%

CVD risk assessment, 1 per year

-

-

-

Influenza vaccine, 1 per year

-

48%

42%

Pneumonia vaccine, ever*

-

48%

-

Microalbuminuria test,

1 per year

-

-

13%

Dental exam, 1 per year

75%

-

-

- Data not available * BRFSS data were aggregated for 2000-2001. Recommendations listed with asterisk have only one year of data
available. ** Based on Medicare cohort definition of diabetes as a diagnosis of diabetes during 2 outpatient visits at least 30
days apart or 1 inpatient visit.

The data in this report suggest that a high percentage of adults with diabetes do not get the recommended levels of physical activity, eat enough fruits and vegetables, or quit smoking, which may be contributing to diabetes-related morbidity and mortality. The data in this report also suggest that some Georgians who have diabetes are not receiving the routine care that they should be receiving. Routine care, such as A1C testing, lipid tests, dilated eye exams, and foot exams, can help people with diabetes keep the disease under better control by detecting and treating complications promptly.
References
1. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286:1195-200.
2. Mokdad AH, Ford ES, Bowman BA, Nelson DE, Engelgau MM, Vinicor F, Marks JS. Diabetes trends in the U.S.: 1990-1998. Diabetes Care 2000;23:1278-83.
3. American Diabetes Association. Economic costs of diabetes in the U.S. in 2002. Diabetes Care 2003; 26: 917-932.
4. Centers for Disease Control and Prevention, Division of Diabetes Translation. 2002 National Diabetes Fact Sheet.
5. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12.
6. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or Metformin. N Eng J Med 2002; 346: 393-403
7. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2003;26:S33-S50
Written by Nkenge Jack, M.P.H., Manxia Wu, M.D., M.P.H., Kristen Mertz, M.D., M.P.H., and Kenneth Powell, M.D., M.P.H.

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The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

November 2003

Volume 19 Number 11

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for August 2003

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for August 2003
2003 51
1525 6 4 65
792 1 23 6 2 0 3 0 1 0
228 43 3 5 13 1 0 23

Previous 3 Months Total

Ending in August

2001

2002

2003

260

215

207

8763

8723

7251

51

39

25

17

20

12

277

283

197

5113

4939

3740

14

13

9

311

104

74

107

147

45

4

3

8

1

3

0

5

6

6

1

0

0

8

10

2

0

0

0

650

711

725

98

367

259

36

32

12

94

100

66

146

179

86

197

191

71

6

3

1

118

165

89

Previous 12 Months Total

Ending in August

2001

2002

2003

637

600

624

32341

33815

33834

151

144

97

32

59

28

1051

909

820

19088

18767

17242

98

100

68

811

627

462

422

479

402

13

13

30

1

4

9

51

43

36

8

3

1

25

28

23

0

0

0

1608

1848

1885

335

1398

1821

108

102

93

300

301

356

580

716

655

836

787

641

22

19

6

583

619

464

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.
** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

Report Period
Latest 12 Months: 10/02-09/03 Five Years Ago: 10/98-09/99 Cumulative: 07/81-09/03

Total Cases Reported* <13yrs >=13yrs Total

0

1,624 1,624

16

1,675 1,691

211

26,934 27,145

Percent Female

AIDS Profile Update
Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown

24.9

34.3

7.5

1.5

11.3

1.8

43.5

25.0

36.0

15.7

3.8

20.1

1.6

22.8

18.1

47.1

16.9

5.3

13.8

1.9

15.0

Race Distribution (%) White Black Other

21.6 73.9

4.5

19.8 77.8

2.4

33.3 64.1

2.6

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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