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Current Trends Continuing Diabetes Care -- Rhode Island, 1991

The annual economic impact of diabetes mellitus in the United States is an estimated $92 billion (1), primarily reflecting the treatment of both acute (e.g., diabetic ketoacidosis and hypoglycemic coma) and chronic (e.g., atherosclerotic cardiovascular disease, blindness, renal failure, neuropathy, and amputation of extremities) complications (2). The complications of diabetes may be prevented or delayed through intensive treatment (3) and through early detection and treatment of complications (4,5). To characterize continuing care of diabetes in Rhode Island in 1991, the Rhode Island Department of Health initiated a Diabetes Care Survey (DCS) in conjunction with its statewide Health Interview Survey (HIS) in 1990. This report summarizes the results of that survey.

Questions about the frequency of continuing diabetes care were based on standards published in 1989 that recommend persons using insulin visit a physician at least quarterly and persons not using insulin visit a physician at least semiannually. The standards also recommend examination by an "eye doctor" at least annually for persons aged 12-30 years with a diagnosis of diabetes of at least a 5-year duration and for all persons aged greater than or equal to 30 years with diabetes (4). CDC has defined such examinations as "dilated eye examinations" (5).

The 1990 HIS used random-digit-dialing to survey 3118 households in Rhode Island; 2588 (83%) persons responded. One adult (aged greater than or equal to 18 years) respondent in each household was asked about the sociodemographic characteristics, health status, and health-related behaviors of all household members. In 1991, 150 (71%) of 212 adult HIS respondents who reported having been told by a doctor that they had diabetes in 1990 were recontacted for the DCS and asked about health status and diabetes care.

Of the 150 respondents, 89% were aged greater than or equal to 40 years, 52% were aged greater than or equal to 65 years, and 54% were women. Forty-three percent had not graduated from high school, and 45% had family incomes at or less than 200% of the poverty level * . In approximately one third (34%), diabetes had been diagnosed within the preceding 5 years. Almost all (95%) received diabetes care from a physician. Almost half (48%) used oral hypoglycemic agents; 31% used insulin.

Of the 84 respondents with noninsulin-treated diabetes, nearly all (99%) had visited a health-care provider at least twice during the preceding year. Of the 54 respondents with insulin-treated diabetes, 61% had visited a provider four times during the preceding year. During the preceding year, 72% of the respondents who were eligible for a dilated eye examination had received one.

Respondents aged less than 40 years were less likely to have visited a health-care provider for regular diabetes care (53%) than were respondents aged 40-64 years (86%) or greater than or equal to 65 years (95%) (Table 1). Men were less likely than woman to have had a dilated eye examination during the preceding year (60% versus 84%, respectively). Reported by: D Goldman, MPH, J Fulton, PhD, D Perry, J Feldman, MD, Rhode Island Diabetes Control Program, Rhode Island Dept of Health. Epidemiology and Statistics Br, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The control of complications and costs of diabetes requires that persons with diabetes have access to continuing medical care for this disease. The findings in this report indicate that in Rhode Island, most persons with diabetes reported receiving dilated eye examinations in accordance with current recommendations. In comparison, other recent assessments indicate that during 1989, only 49% of adults with diagnosed diabetes in the United States had dilated eye examinations during the preceding year (6); in addition, during 1992, 33%-60% of patients with diabetes who were receiving care at three of the largest health maintenance organizations in the United States also had received yearly eye examinations (7 ).

Since 1979, efforts of the Rhode Island Diabetes Control Program have been directed toward reducing barriers to care and ensuring eye examinations for persons with diabetes; the program has especially focused on persons with low income and those with no health insurance. Components of the multifaceted campaign to ensure eye care for persons with diabetes include 1) distribution of information, including materials developed by the National Institutes of Health as a part of the National Eye Health Education Program, through sites (e.g., the offices of primary-care physicians and podiatrists, clinics, emergency rooms, hospitals, worksites, pharmacies, and Lions clubs) that promote annual eye examinations among persons with diabetes; 2) distribution of national standards for eye care by mail to all primary-care providers, through presentations to selected medical staff at all Rhode Island hospitals, and through publication of articles assessing and promoting diabetic eye care in Rhode Island; and 3) direct diabetes-care interventions through neighborhood health centers associated with the Providence Ambulatory Health Care Foundation.

The findings in this report also indicate that in Rhode Island, persons with insulin-treated diabetes visit health-care providers less frequently than is recommended; persons aged less than 40 years were least likely to visit providers at regular intervals. Possible reasons for lack of continuing care in this age group include lack of health insurance, self-perceived good health, and short duration of disease -- and therefore, fewer complications (5).

The Rhode Island Diabetes Control Program and its Diabetes Professional Advisory Council have used these and other findings to develop a statewide diabetes control plan. These findings also may be used as a baseline for evaluating interventions. To facilitate this process, the advisory council has established a surveillance committee to develop an overall surveillance plan to be coordinated with the statewide diabetes control plan.

Although public health surveillance is integral to the control of infectious diseases, the role of state-based surveillance is less well established in the control of diabetes and other chronic conditions. The Rhode Island DCS is an innovative and useful tool for the surveillance of diabetes health-care patterns and practices and may serve as a model for other states with diabetes control programs.

References

  1. American Diabetes Association, Inc. Direct and indirect costs of diabetes in the United States in 1992. Alexandria, Virginia: American Diabetes Association, Inc, 1993.

  2. Herman WH, Teutsch SM, Geiss LS. Diabetes mellitus. In: Amler W, Dull HB, eds. Closing the gap: the burden of unnecessary illness. New York: Oxford University Press, 1987.

  3. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med 1993;329:977-86.

  4. Committee on Professional Practice. Position statement: standards of medical care for patients with diabetes mellitus. Diabetes Care 1989;12:365-8.

  5. CDC. The prevention and treatment of complications of diabetes mellitus. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1991.

  6. Brechner RJ, Cowie CC, Howie LJ, Herman WH, Will JC, Harris MI. Ophthalmic examination among adults with diagnosed diabetes mellitus. JAMA 1993;270:1714-8.

  7. Herman WH, Dasbach EJ. Diabetes, health insurance, and health-care reform. Diabetes Care 1994;17:611-3.

    • Poverty statistics are based on a definition originated by the Social Security Administration in 1964, subsequently modified by federal interagency committees in 1969 and 1980, and prescribed by the Office of Management and Budget as the standard to be used by federal agencies for statistical purposes.


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