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This sample was 66.6% female, 60.6 % Hispanic, and 12.9% African American. The average age was 43.9, ranging from infancy to 92 years old. Only 16.6% of all patients had private health insurance. Patients in Central Texas had the highest prevalence of diabetes, hyperlipidemia, and metabolic disease compared to the other regions (p<.05, Figure 1, 2, 4). Hypertension was lowest in the South Texas region, though statistically insignificant (p=.056, Figure 3). More than 50% of patients with diagnosed diabetes also had hyperlipidemia and hypertension (metabolic syndrome). Race and ethnicity varied significantly by region, with the highest proportions of Hispanics in South Texas and the highest proportions of African Americans and Asians in North Texas (p=.000). Minor regional variations existed among Caucasians. We found no significant gender or age differences by region.

Introduction

Diabetes and Associated Diseases in Primary Care: Regional Differences in Texas

Ryan Horton, Swati Avashia MD, Jason Hill M.S. Sandra Burge PhDThe University of Texas Health Science Center at San Antonio

Conclusions

Type 2 diabetes is a common disease that costs the United States roughly $218 billion dollars1 every year. When diabetes is complicated with metabolic syndrome it is even more important to diagnose and initiate treatment because it “varies substantially by

ethnicity and is associated with several potentially modifiable lifestyle factors2.” Researchers have analyzed the prevalence of this common disease in different regions of the United States and found it is most prevalent in the Southern and Appalachian states and least prevalent in the Midwest and the Northeast3. However, little is known about the regional variation of diabetes and its commonly associated diseases across Texas (North, Central, and South). This study aims to identify those regional differences in the prevalence of diabetes and its associated diseases. Additionally, patient demographic characteristics in different regions of Texas are presented.

Methods

In 2006, the National Health Statistics Report documented that disease prevalence in ambulatory patients was: 27.9% hypertension, 16.19% hyperlipidemia, and 11.8% diabetes4. The prevalence of these diseases observed in RRNet clinics, while variable by region, is far higher than national averages. Central Texas presented with the highest reporting of all diseases, at proportions more than double the national average. This patient sample was far less likely to have private health insurance, compared to the 2006 National Health Statistics Report patient (16.6% versus 60.5%).4 This sample characteristic is likely due to residency programs providing health care to the underserved, which may also explain why the prevalence of chronic disease was so high. A puzzling finding was the low prevalence of diabetes, hyperlipidemia, hypertension, and metabolic syndrome in the southern region of Texas, despite this region having the highest population of Hispanics. Hispanics are known to have the highest prevalence of diabetes (13.9%) compared to African Americans (10.2%) and Caucasians (6.2%) so it is unusual that patient visits in a highly Hispanic region would have low rates of diabetes5. One likely explanation is that the residency programs in Harlingen and McAllen Texas serve a disproportionate number of young, healthy, pregnant mothers. The high rates of healthy pregnancy at these sites likely skewed this data. Primary care clinicians should become very familiar with the epidemiology of chronic disease within their own communities and regions. We found wide regional variations of diabetes and its associated diseases in a single state, and comparatively low rates of diabetes in a region where we expected to find more. This information should remind physicians that quality chronic disease management requires a thorough understanding of one’s community.

References1. American Diabetes Association. http://www.diabetes.org/, 20112. The Metabolic Syndrome: Prevalence and Associated Risk Factor Findings in the US Population From the

Third National Health and Nutrition Examination Survey, 1988-1994. Yong-Woo Park, MD, PhD; Shankuan Zhu, MD, PhD; Latha Palaniappan, MD; Stanley Heshka, PhD; Mercedes R. Carnethon, PhD; Steven B. Heymsfield, MD. Arch Intern Med. 2003;163:427-436

3. Diabetes Prevalence and Diagnosis in US States: analysis of health Surverys. Goodarz Danaei, Ari B. Friedman, Shefali Oza, Christopher JL Murray, Majid Ezzati. Population Health Metrics, 7:16, 2009.

4. National Ambulatory Medical Care Survey: 2006 Summary. Cherry DK, Hing E, Woodwell DA, Rechtsteiner EA. National Health Statistics Report 2008.

5. Epidermiologic correlates of NIDDM in Hispanics, whites and blacks in the U.S. population. Harris MI. Diabetes Care 14 (Suppl. 3):639-648, 1991.

Subjects Medical students documented 726 outpatient visits from 9 family medicine residency programs across Texas. Eligible patients included all patient-visitors seeing a physician in the study clinics during the study period. Measurement A Visit Survey documented patient demographics, vital signs, reasons for visit, diagnoses, health education, medications prescribed, diagnostic tests ordered, non-medical treatments, referrals to specialists and admissions to hospitals. The Northern region consisted of Dallas, Fort Worth, and Garland. The Central region consisted of San Antonio and Austin. The Southern region consisted of Corpus Christi, McAllen, and Harlingen.Procedure Over a one-month period, students identified half-days for data collection, then randomly selected a physician to shadow. During the physician’s clinic session, the student invited all the physician’s patients to participate in the study. After informed consent, students observed the visit and completed the Visit Survey.

AcknowledgementsThis study was conducted in The Residency Research Network of Texas (RRNeT) with support from the Office of the Medical Dean at UTHSCSA and the Health Resources and Services Administration (Award # D54HP16444).

Fig. 1: Diabetes by Region

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Fig. 3: Hypertension by Region

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Fig. 2: Hyperlipidemia by Region

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Fig. 4: Metabolic Syndrome by Region

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Fig. 5: Ethnicity of Patients by Region

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Sample Percentage

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