epidemiology of diabetes: prevalence, complications and health services disparities

¡Viva la Vida con Salud! Centro de Diabetes para Puerto Rico

Epidemiology of Diabetes: Prevalence, Complications and

Health Services DisparitiesRosa Pérez Perdomo, MD, MPH, PhD

Dean Graduate School of Public Health

Medical Sciences Campus

Director of the Diabetes Management Center

Diabetes Management Center

Diabetes Management Center of the Diabetes Center for Puerto Rico Is a repository of information and data related

with diabetes mellitus, specially in Puerto Rico Principal Objectives of the Diabetes

Management Center To obtain, analyze and disseminate data Scientific Investigations Publication of journals, bulletins and scientific

articles

Estado Libre Asociadode Puerto Rico


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Objetives

To discuss diabetes prevalence estimates at world and local level.

To discuss diabetes complications, prevalence estimates and health service utilization rate.

To analyze disparities by age and sex between persons living with diabetes that received services from private and public health insurance companies between 2000-2001 in Puerto Rico.


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Analysis of several sources of data, including: “Behavioral Risk Factor Surveillance System”

(BRFSS) Health Insurance Companies in Puerto Rico

Private and Public (Reform) Four insurance companies (39.4%)

Revision of recent studies

Methodology


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DiabetesPrimary Goal for 2010

Through prevention programs, reduce the disease incidence, its complications and its economic impact, in addition, to improve quality of life for all those persons that had diabetes or that are at risk to develop the disease.

Reference: U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.

Global Prevalence of

Diabetes


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Global Prevalence Estimates, 2000 and 2030

0.0% 1.0% 2.0% 3.0% 4.0% 5.0%

2000

2030 4.4 %

2.8 %

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.


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Diabetes in the World

millions

India

31.731.7

China

20.820.8

USA

17.717.7

Indonesia

8.48.4

Japan

6.86.8

YearYear20002000



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Diabetes in the World

millions

India

79.479.4

China

42.342.3

USA

30.330.3

Indonesia

21.321.3

Japan

8.98.9

YearYear20102010



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Prevalence of Diabetes by Country

* > 18 years only. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1999-2003. Atlanta, GA: United States, Department of Health and Human Services.

** Dunstan DW, Zimmet PZ, Welborn TA, Courten MP, Cameron AJ, Sicree RA, et al. The raising prevalence of diabetes and impaired glucose tolerance. Diabetes Care. 2002; 25(5): 829-834.

*** Warsy AS, el-Hazmi MA. Diabetes mellitus, hypertension and obesity-common multifactorial disorders in Saudis. Eastern Mediterranean Health Journal. 1999; 5(6): 1236-42.


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Prevalence of Diabetes in Adults United States, BRFSS* 1998 - 2003

* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1998-2003. Atlanta, GA: United States, Department of Health and Human Services.


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Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

Prevalence of Diabetes in Adults United States, BRFSS

1990

No Data <4% 4%-6% 6%-8% 8%-10% >10%


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1991-92

No Data <4% 4%-6% 6%-8% 8%-10% >10%



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1993-94

No Data <4% 4%-6% 6%-8% 8%-10% >10%



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1995-96

No Data <4% 4%-6% 6%-8% 8%-10% >10%



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1995

No Data <4% 4%-6% 6%-8% 8%-10% >10%



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1997-98

No Data <4% 4%-6% 6%-8% 8%-10% >10%



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1999

No Data <4% 4%-6% 6%-8% 8%-10% >10%



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2000

No Data <4% 4%-6% 6%-8% 8%-10% >10%



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2001

No Data <4% 4%-6% 6%-8% 8%-10% >10%



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Prevalence of Diabetes in Adults, United States and territories, BRFSS* 2002



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Incidence Estimates of Diabetes Crude and Adjusted Rate by Age, United States 1997 - 2002

Reference: http://www.cdc.gov/diabetes/statistics/incidence/Fig2.htm

Prevalence of Diabetes in Puerto Rico


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Prevalence of Diabetes in Puerto Rico, Household Health Interview Survey 1966 - 1994

Reference: Household Health Interview Survey, Puerto Rico Health. Department, 1966-1994

0

1

2

3

4

5

6

7

1966

1971

1974

1976

1981

1983

1985

1987

1989

1993

Year

Pre

vale

nce

(%)


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Prevalence of Diabetes in Puerto Rico using different Data Sources, 1998 - 2003

9.4

9.6

8.5

9.8

10.5

11.0

4.5

4.9

6.9

Prevalence (%)

BRFSS (1998)**

BRFSS (1999)**

BRFSS (2000)**

BRFSS (2001)**

BRFSS (2002)**

BRFSS (2003)**

Health Insurances (2000)*

Health Insurances (2001)*

Health Insurances +18 (2001)*

* Some health insurances in Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2000 - 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003

** BRFSS = “Behavioral Risk Factor Surveillance System” (>18 años). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1998-2003. Atlanta, GA: United States, Department of Health and Human Services.

Prevalence of Diabetes by Region, Puerto Rico, BRFSS* 1999

Rincón

Añasco

MocaAguada

AguadillaIsabela

CaboRojo

Lajas

MayaguezHormigueros

Sab

an

a Gra

nd

e

Yauco

Maricao

Las Marías

Gu

ayan

illa

Quebradillas

Camuy

Hati

llo

Arecibo

Ponce

Florida

Barceloneta

Juana Díaz

Orocovis

Veg

a B

aja

Cataño

Vieques

SanSebastián Lares

Utuado

Adjuntas

Peñ

uela

s

Manatí

Jayuya

Ciales

Comerío

Arro

yo

Patillas

Cidra

Trujillo Alto

Caguas

Maunabo

Yabucoa

Junco

sLa

s Pie

dra

s

Humac

ao

Naguabo

Morovis

VegaAlta

ToaAlta

Naranjito

Barran-quitas

Bayam

ónDora

do

ToaBaja

Villalba Aibonito

AguasBuenas

Gu

ayn

ab

o

San

Ju

an

Caro

lina

Can

óvanas

LoízaRío

Grande

Ceiba

Faja

rdo

Luqu

illo

Salinas

Corozal

Cayey

Gurabo

SanLorenzo San

Germán

SantaIsabel

Coamo

GuayamaGuánica

Culebra

Este

Suroeste

Sureste

San Juan

Oeste

8.91 – 15.9612.447.86 – 14.1911.03

4.01 – 11.007.504.91 – 14.329.62

3.20 – 10.176.685.98 – 11.168.57

5.57 – 11.368.469.05 – 16.4312.74

5.27 – 12.779.026.26 – 11.909.08

IC 95%PrevalenceRegionIC 95%PrevalenceRegion

Nordeste

Noroeste

Metropolitana Norte

Norte

Montaña

* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1999. Atlanta, GA: United States, Department of Health and Human Services.


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Prevalence of Diabetes by Sex and Year, Puerto Rico BRFSS* 1997, 2001 - 2003



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Prevalence of Diabetes by Age Group, Puerto Rico BRFSS* 1997, 2001 - 2003



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Prevalence of Diabetes by Age Groups,

Health Insurance Companies in Puerto Rico 2000* y 2001**

* Pérez R, Pérez CM, Disdier OM. Health Disparities between Diabetic Patients under Private and Public Health Coverage in Puerto Rico, 2000. PR Health Sci J. 2003;22:363-368.

** Some health insurances of Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.


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Prevalence of Diabetes by Employment Status, Puerto Rico BRFSS* 1996 - 2000

* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Pérez R, Pérez CM, Disdier OM, Rodríguez LA. Estado de salud de la población adulta de Puerto Rico basado en características seleccionadas del sistema de vigilancia de los factores de riesgo asociados a la conducta: 1996 - 2000. Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; September 2004.

Diabetes Related Complications


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Prevalence of Diabetes Related Complications by Health Insurances, Puerto Rico 2001

2.6

1.8

0.20.6

0 0 00.1

0.9

1.8

0.4 0.3

4.9

3.6

8.5

7.8

1.71.2

Private Health Insurance Companies Public Health Insurance Companies

Reference: Some health insurances in Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.


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Prevalence of Diabetes Related Complications by Age and Health Sector, Puerto Rico 2000

01020304050607080

< 17 18-24 25-34 35-44 45-54 55-64 > 64

Age

Prev

alen

ce (x

1,0

00)

01020304050607080

< 17 18-24 25-34 35-44 45-54 55-64 > 64

Age

Private Health Group Public Health Group

Reference: Pérez R, Pérez CM, Disdier OM. Health Disparities between Diabetic Patients under Private and Public Health Coverage in Puerto Rico, 2000. PR Health Sci J. 2003;22:363-368.

Diabetes Mortality in Puerto Rico


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Leading Causes of Death in Puerto Rico, 2001

18.0

16.3

8.3

5.8

4.2

Percentage (%)

Heart

Cancer

Diabetes

Hypertension

Cerebrovascularaccidents

Reference: Estado Libre Asociado de Puerto Rico. Informe Anual de Estadísticas Vitales, 1999-2001. Secretaría Auxiliar de Planificación, Evaluación, Estadísticas, y Sistemas de Información. División de Estadísticas4


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Mortality Rate by Sex, Puerto Rico 2001

Reference: Estado Libre Asociado de Puerto Rico. Informe Anual de Estadísticas Vitales, 1999-2001. Secretaría Auxiliar de Planificación, Evaluación, Estadísticas, y Sistemas de Información. División de Estadísticas

Utilization of Medical Services, Pharmacy and Laboratories among Diabetic Patients

in Puerto Rico


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Utilization of Clinical Services among Diabetic Patients by Health Insurance, Puerto Rico 2001

Reference: Some health insurances in Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.

7.23.3

87.5

62.5

11.84.6

0.0 20.0 40.0 60.0 80.0 100.0

Percentage (%)

Hospital Admissions

Visit to physicians office

Visit to emergencyroom

Public Health Insurance Private Health Insurance


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Utilization of Clinical Services among Diabetic Patients by Sex Health Insurance, Puerto Rico 2001

Reference: Some health insurance of Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.

5.46.5

78.4

81.6

8.510.7

0.0 20.0 40.0 60.0 80.0 100.0

Percentage (%)

HospitalAdmissions

Visit to physician office

Visit to emergency room

Male Female


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Utilization of Pharmacy Services among Diabetic Patients by Health Insurance, Puerto Rico 2001

Reference: Some health insurance of Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.

31.0

13.9

46.2

49.6

Percentage (%)

Insulin

Oral Agent



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Utilization of Pharmacy Services among Diabetic Patients by Sex Health Insurance, Puerto Rico 2001

Reference: Some health insurance services of Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.

24.1

27.6

50.0

45.0

Percentage(%)

Insulin

Oral Agent

Male Female


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Utilization of Laboratory Services among Diabetic Patients by Health Insurance, Puerto Rico 2001

Reference: Some health insurance companies of Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.

19.8

57.2

3.2

48.6

Percentage (%)

Glucose Test

GlycosylatedHemoglobin



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Utilization of Laboratory Service among Diabetic Patients by Sex Health Insurance, Puerto Rico 2001

Reference: Some health insurance companies of Puerto Rico. Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.

31.4

30.1

13.6

9.1

Percentage (%)

Glucose Test

GlycosylatedHemoglobin

Male Female

Economic Cost of Diabetes


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Economic Cost Related with Diabetes by

Health Sector, Puerto Rico 2000


$9,648,415.42

$7,669,238.19

Public Sector

Private Sector


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Average Cost in Diabetic Patients by

Health Sector, Puerto Rico 2000


$229.36

$356.08

Public Sector

Private Sector

Factors Associated with Diabetes

in Puerto Rico


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Association of Clinical and Demographics Characteristics and Diabetes Prevalence by Age Group, Puerto Rico BRFSS 1999

Age < 65 Age 65

Reference: Pérez CM, Pérez R. Prevalence and associated factors of diabetes mellitus in Puerto Rican adults: Behavioral Risk Factor Surveillance System, 1999. PR Health Sci J. 2001;20(2):147-155.

2.16

1.46 1.481.13 1.04

3.22

2.11 2.121.76 1.7

4.81

3.04 3.032.75 2.8

Education (<12) Hypertension Hypercholesterolemia Obesity Female Sex

PO

R (

IC 9

5%)


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Prevalence of Factors Associated with Diabetes, Puerto Rico BRFSS* 2003

45.2%

63.6%

27.3%

Physical Inactivity Overweight /Obesity

Hypertension

* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 2003. Atlanta, GA: United States, Department of Health and Human Services.

Health Disparities in

Cardiovascular Conditions


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Prevalence of Cardiovascular Conditions in a Insured Population by Age, Puerto Rico, 2001

1.5 0.3

7.12.7

14.6

7.2

29.9

17.4

47.8

30.9

61.7

41.4

61.3

51.2

0

10

20

30

40

50

60

70

Pre

va

len

ce

(%

)

0-24 25-34 35-44 45-54 55-64 65-74 75>Age

Private Sector Public Sector

* Cardiovascular Conditions included the following: hypertension, coronary artery disease, congestive heart failure, cerebrovascular disease and transient

ischemic attack. ** P-value <0.001 Difference by age was statistically significant.


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Prevalence of Specific Cardiovascular Conditions by Age Group and Health Sector,

Puerto Rico, 2001

Health Sector: Private

Age group (years)

Hypertension Coronary Artery Disease

Congestive Heart Failure

Cerebrovascular Accident/Transient

Ischemic Attack

N Prevalence N Prevalence N Prevalence N Prevalence

≤ 24 1,269 0.6 172 0.08 27 0.01 156 0.1

25-34 3,549 4.0 448 0.5 39 0.04 234 0.3

35-44 8,754 9.5 1,044 1.1 98 0.1 425 0.5

45-54 17,284 21.5 2,510 3.1 253 0.3 877 1.1

55-64 20,181 35.4 3,912 6.9 445 0.8 1,334 2.3

65-74 7,456 45.3 1,974 12.0 272 1.6 801 4.9

≥ 75 3,364 44.5 1,112 14.7 286 3.8 610 8.1

Overall 61,857 11.0 11,172 2.0 1,420 0.3 4,437 0.8


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Prevalence of Specific Cardiovascular Conditions by Age Group and Health Sector,

Puerto Rico, 2001 Health Sector: Public

Age group (years)

Hypertension Coronary Artery Disease

Congestive Heart Failure

Cerebrovascular Accident/Transient

Ischemic Attack

N Prevalence N Prevalence N Prevalence N Prevalence

≤ 24 847 0.3 118 0.04 89 0.03 1 0.0

25-34 2,029 2.3 126 0.1 153 0.2 8 0.01

35-44 5,395 6.1 325 0.4 338 0.4 9 0.01

45-54 11,969 14.7 997 1.2 740 0.9 44 0.1

55-64 18,153 24.9 2,276 3.1 1,295 1.8 94 0.1

65-74 14,493 29.0 2,767 5.5 1,432 2.9 145 0.3

≥ 75 13,151 31.4 3,175 7.6 2,640 6.3 242 0.6

Overall 66,037 8.7 9,784 1.3 6,687 0.9 543 0.1


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Prevalence of Cardiovascular Conditions in an

Insured Population by Sex, Puerto Rico, 2001

Sex

Health Sector

Female Male Total

N Prevalence CI 95% N Prevalence CI 95% N Prevalence CI 95%

Private 47,554 16.1 (15.97-16.24) 41,608 12.9 (12.80-13.00) 89,162 16.0 (15.98-16.08)

Public 52,867 15.9 (15.72-16.00) 35,801 10.3 (10.2-10.4) 88,668 11.7 (11.62-11.77)

Both 100,421 14.2 (14.16-14.32) 77,276 12.7 (12.57-12.74) 177,830 13.5 (11.68-15.44)

* Cardiovascular Conditions included the following: hypertension, coronary artery disease, congestive heart failure, cerebrovascular accident, transient

ischemic attack, and other cardiovascular-related claims.


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Conclusions

Prevalence of diabetes in Puerto Rico is higher than in United States and exceeds the estimates at world level.

Economic and human cost of diabetes are huge and represent a real problem for public health.

Low rate of laboratory services utilization for glycosylated hemoglobin test could be an indicator of poor prevention measures in both sectors, but specially in the public sector.

Many factors related with the development of diabetes are modifiable and controllable, therefore effectives strategies of prevention are recommended.


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References

Pérez R, Pérez CM, Disdier OM. Health Disparities between Diabetic Patients under Private and Public Health Coverage in Puerto Rico, 2000. PR Health Sci J. 2003;22:363-368.

Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2000. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 1, January 2002.


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References

Pérez R, Pérez CM, Rodriguez LA, Disdier OM. Boletín Estadístico del Centro para el Manejo de Datos de Diabetes - Prevalencia de diabetes, complicaciones y uso de servicios relacionados a la diabetes en Puerto Rico: Grupo comercial versus reforma de salud, año 2001. Puerto Rico Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; volume 2, June 2003.

Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1996-2003. Atlanta, GA: United States, Department of Health and Human Services.

Estado Libre Asociado de Puerto Rico. Informe Anual de Estadísticas Vitales, 1999-2001. Secretaría Auxiliar de Planificación, Evaluación, Estadísticas, y Sistemas de Información. División de Estadísticas

Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.


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References

Dunstan DW, Zimmet PZ, Welborn TA, Courten MP, Cameron AJ, Sicree RA, et al. The raising prevalence of diabetes and impaired glucose tolerance. Diabetes Care. 2002; 25(5): 829-834.

Warsy AS, el-Hazmi MA. Diabetes mellitus, hypertension and obesity-common multifactorial disorders in Saudis. Eastern Mediterranean Health Journal. 1999; 5(6): 1236-42.

Pérez CM, Pérez R. Prevalence and associated factors of diabetes mellitus in Puerto Rican adults: Behavioral Risk Factor Surveillance System, 1999. PR Health Sci J. 2001;20(2):147-155.

Pérez R, Pérez CM, Disdier OM, Rodríguez LA. Estado de salud de la población adulta de Puerto Rico basado en características seleccionadas del sistema de vigilancia de los factores de riesgo asociados a la conducta: 1996 - 2000. Diabetes Data Management Center, Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico; September 2004.

epidemiology of diabetes: prevalence, complications and health services disparities

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