ARIZONA DIABETES INDICATORS ANNUAL REPORT 2008 July 2008 Arizona Diabetes Coalition Surveillance Committee Arizona Department of Health Services Diabetes Prevention and Control Program Arizona Diabetes Indicators Annual Report: July 2008 Prepared by: Kai-Ning Khor, MPH Epidemiologist Bureau of Chronic Disease Prevention & Control Arizona Department of Health Services Cynthia Melde, MS Epidemiologist Bureau of USDA Nutrition Programs Arizona Department of Health Services Ross Merritt, MPH Former Epidemiologist Bureau of Chronic Disease Prevention & Control Arizona Department of Health Services ACKNOWLEDGMENTS This report was produced with the support and input from the following organizations and individuals: Arizona Department of Health Services (Timothy Flood, Jessica Han, Patricia Herrmann, Keith Laubham, Christopher Mrela); Inter Tribal Council of Arizona, Inc. Epidemiology Center (Zeenat Mahal), Indian Health Service (Jody Sekerak, Charles Rhodes) and many other individuals contributed to the effort of collecting the data that went into this report. We thank all who were involved in the project. Funding for this report was derived, in part, from the State-Based Programs to Reduce the Burden of Diabetes, Cooperative Agreement (U32/CCU910621-05) between the Arizona Department of Health Services and the Centers for Disease Control and Prevention of the U.S. Department of Health Human Services. Suggested citation: Arizona Diabetes Coalition, Surveillance Committee. Arizona Diabetes Indicators Annual Report 2008. Arizona Department of Health Services, Diabetes Prevention and Control Program. July 2008. Arizona Department of Health Services Division of Public Health Prevention Services 2 July 2008 ARIZONA DIABETES COALITION SURVEILLANCE COMMITTEE MEMBERS Chair Zeenat Mahal, MBBS, MS Inter Tribal Council of Arizona, Inc. Members Scott Endsley, MD, MSc Health Services Advisory Group Howard Eng, DrPH, MS Rural Health Office / University of Arizona Gleebah Enos, MSW National Institutes of Health NIDDK Tim Flood, MD, MPH Arizona Department of Health Services Marina Ghaly, RN, MS University Physicians Health Plans Trish Herrmann, MS, RD Arizona Department of Health Services Kai-Ning Khor, MPH Arizona Department of Health Services Daniel Napoliello, RN, BSN, MA TriWest Alliance Carmen Ramirez, BA Arizona Department of Health Services Charles Rhodes, MD Indian Health Service - Phoenix Area Jody Sekerak, MBA, MHSA Indian Health Service Arizona Department of Health Services Division of Public Health Prevention Services 3 July 2008 TABLE OF CONTENTS Page Executive Summary ….……….……………………….…………………………….….. Introduction ……………………….…………………………………..…………………. Methodology and Data Sources…….…………………………………………………… A. PRECURSOR CONDITIONS AND PRIMARY PREVENTION 1. Proportion of Mothers with Diabetes During Pregnancy …….…………….. 2. Proportion of Babies with Macrosomia …………………….……………….. 3. Pre-School Children who are Overweight ……………….…………………. 4. Proportion of Adults who are Considered Physically Active ………….… 5. Proportion of Adolescents who are Considered Physically Active………… 6. Proportion of Adults who are Overweight …………………………………... 7. Proportion of Adolescents Who Are Overweight……………...................... 8. Proportion of Adults who are Obese ………………………………………… 9. Proportion of Arizonans Consuming Inadequate Servings of Fruits and Vegetables Daily ………………………………………………...... 10. Proportion of Arizonans who are Current Smokers………………………… 11. Proportion of Adolescents who are Current Smokers……………………… B. SECONDARY PREVENTION 12. Proportion of Adults with Diabetes…………….………………………………. 13. Proportion of Adults with Diabetes Receiving Influenza Vaccination……… 14. Proportion of Adults with Diabetes Receiving Pneumococcal Vaccination. 15. Proportion of Adults with Diabetes who are Current Smokers……………. . 16. Percentage of Diabetic Patients Receiving One or More A1C Tests During the Last 12 Months…………….…………………………. 17. Percentage of Diabetic Patients Receiving At Least One Microalbuminuria Test during the Last 12 Months …………………………. 18. Eye Examination ……………………….……………………………………... 19. Foot Examination ……………………………………………………………… 6 7 8 9 10 10 11 12 12 13 13 14 15 15 16 17 18 19 20 22 23 24 C. TERTIARY PREVENTION 20. Uncontrolled Hypertension ……….…………………………………………… 21. Lipid Profile …………………………………………………………………….. 22. Hospitalizations ……………………………………………………………….. 23. New Cases of End Stage Renal Disease (ESRD) in Diabetics…………….. 24. Lower Extremity Amputation …………………………………………………. 25 26 29 31 31 D. MORTALITY 25. Proportion of Deaths with Diabetes as the Underlying Cause………………. 32 E. RESOURCES 26. Registries ………………………………………………………………………. 27. Patient Self-Management Education Including Nutrition Education ……... 28. Standards of Care Recommendations……................................................ 33 34 35 Arizona Department of Health Services Division of Public Health Prevention Services 4 July 2008 F. DISCUSSION 29. Important Issues Not Addressed……………………………………………… 30. Limitations and Procedures……................................................................. 37 38 GLOSSARY……………………………………………………………………………….. 39 REFERENCES………………….………………………………………………………… 40 Arizona Department of Health Services Division of Public Health Prevention Services 5 July 2008 EXECUTIVE SUMMARY ™ Increase in women with diabetes while pregnant. ™ After years of decline, diabetes while pregnant is once again on the rise in Arizona. There has been a 34% increase in the rate of diabetes while pregnant from 2002 to 2006. ™ The number of hospitalizations and the amount of hospital charges for diabetesrelated hospitalizations is outpacing Arizona’s population growth and the rate of inflation. There was over $3.5 billion in charges in 2006, not counting the charges in the VA system and the Indian Health Service. Increase in babies with macrosomia (birth weight > 9 lbs, or 4,000 grams). Since 2004, the rate of babies with macrosomia has steadily increased. Macrosomia can be a result of uncontrolled gestational diabetes. ™ ™ Blood pressure (hypertension) The goal for diabetic patients is less than 130/80, but as low as 41% of diabetic patients had their blood pressures measured. The relative successes of the Indian Health Service on many secondary and prevention indicators. Cholesterol The LDL goal for diabetic patients is less than 100, while the HDL goal for diabetic patients is above 40. As low as 41% of diabetic patients had a lipid panel within the last year. Amidst an epidemic of diabetes, the three Indian Health Service units reported having a relatively high success rate for several secondary prevention indicators, such as vaccinations for influenza and pneumonia, and microalbuminuria tests. Arizona Department of Health Services Division of Public Health Prevention Services Many diabetic patients are not getting the tests they need. A1C test This test shows blood glucose levels during the past two to three months. As low as 70 percent of diabetic patients during the past year received the A1C test. Obesity among Arizona adults is at its highest ever. Currently, 22.9% of Arizona adults are obese, a 13.2% increase from 1992, when only 9.7% of Arizona adults were obese. Arizona has failed to reach the Healthy People 2010 goal of 15% since 1999. ™ The rapid pace at which hospitalizations and the total amount of hospital charges related to diabetes are increasing. 6 July 2008 SELECTED DIABETES INDICATORS IN ARIZONA Introduction It is estimated that about 375,000 adults in Arizona had diabetes in 2006, and another 125,000 are living with undiagnosed diabetes. Diabetes continues to be a serious health problem in Arizona and the United States. At the national level, the Healthy People 2010 goal for diabetes states, “Through prevention programs, reduce the disease and economic burden of diabetes, and improve the quality of life for all persons who have or are at risk for diabetes.” This report has 27 indicators that address primary, secondary, tertiary prevention categories and process objectives. The purpose of this document is to measure the annual progress of diabetes control efforts. The objectives were chosen with several criteria: 1. The objectives need to reflect activities that have occurred recently so programmatic and surveillance changes can be made accordingly and quickly. 2. Easily obtainable objectives are desired due to limited staffing and resources of the ADHS Diabetes Prevention and Control Program. 3. The objectives must be able to monitor trends to determine whether progress was achieved. 4. The objectives must cover the wide range of activities of the Arizona Diabetes Coalition and its members. The following objectives have been categorized into four groups: (a) Precursor Conditions and Primary Prevention, (b) Secondary Prevention, (c) Tertiary Prevention, and (d) Process Objectives. Arizona Department of Health Services Division of Public Health Prevention Services 7 July 2008 Methodology In 1999, the Surveillance Committee of the Arizona Diabetes Council selected a set of indicators important to the Council’s partners that would provide information to measure the annual progress of diabetes control efforts by various agencies and health care systems in Arizona. Each organization has its own methods of collecting data on selected indicators; therefore, both the numerator and denominator have been defined in this report for clarification. These definitions may or may not correspond with all national standards or measurements of care as promulgated by the American Diabetes Association, Medicare Standards, Healthy People 2010, HEDIS® Comprehensive Diabetes Care, FACCT Diabetes Standards or the American Associations of Diabetes Educators Standards. Each reporting organization has its own characteristics that are listed below. However, all information reported in this document is from users of the sources (Agencies) or self-reported through surveys. Limitations are stated for each of the indicators within the relevant category. The information from Indian Health Service (IHS) is obtained from a database of chart audits, where a percentage of each IHS area’s diabetic patient charts are audited. The percentages described in this report only represent the percentages of those charts that were audited. Audit FY2003 Navajo Phoenix Tucson All Charts audited (#) 1,625 2,662 1,155 30,192 Total in registry (#) 16,205 19,968 3,960 110,305 Percent audited (%) 10% 13% 29% 27% Audit FY2007 Navajo Phoenix Tucson All Charts audited (#) 1,578 6,596 1,193 54,415 Total in registry (#) 18,400 18,258 3,099 123,979 Percent audited (%) 9% 36% 38% 44% For this report, two new indicators were added to help in describing progress in primary and secondary prevention. Specifically, measurements on diabetes prevalence and pneumococcal vaccinations were added. Data Sources ™ Arizona Association of Community ™ Indian Health Service (IHS) Health Centers (AACHC) ™ Arizona Department of Health ™ Veterans Affairs medical Center (VA) Services (ADHS) ™ Pediatric Nutrition Surveillance ™ Youth Risk Behavior Surveillance System (PedNSS) System (YRBSS) ™ Healthcare Effectiveness Data and ™ Behavior Risk Factor Surveillance Information Set (HEDIS®) Arizona Department of Health Services Division of Public Health Prevention Services System (BRFSS) 8 July 2008 A. 1. PRECURSOR CONDITIONS AND PRIMARY PREVENTION (Prevention of Diabetes Mellitus) Proportion Of Mothers With Diabetes During Pregnancy: Mothers with diabetes during pregnancy are defined as those mothers who have chronic diabetes and/or women who develop diabetes during pregnancy (gestational diabetes). Figure 1a presents the count of birth certificates indicating the prevalence of maternal diabetes expressed per 1,000 live births from 2002 to 2006. The graph reveals that the rate of diabetes has been increasing over the past five years. Figure 1b represents the age distribution of deliveries by mothers with diabetes, which seem to be on the rise as well. Figure 1a. Percentage of Mothers with Diabetes (Chronic or Gestational) 20022006, All Races. Rate of Diabetes per 1,000 Live Births 35 29.7 Number per 1,000 30 24.5 23.5 25 31.6 21.4 20 15 10 5 0 2002 2003 2004 2005 2006 Source: Arizona Health Status and Vital Statistics 2002-2006, ADHS. % of Deliveries Figure 1b. Age Distribution for Deliveries Associated with Diabetes, 2002-2006. 10 9 8 7 6 5 4 3 2 1 0 8.1 7.4 5.1 3.8 1.8 4.8 5.2 30-39 2.3 1.9 1.6 0.6 2003 < 20 20-29 3.9 3.6 0.7 2002 7.6 6.8 2.4 1.0 0.7 2004 2005 40+ 1.0 2006 Source: Arizona Health Status and Vital Statistics 2002-2006, ADHS. Arizona Department of Health Services Division of Public Health Prevention Services 9 July 2008 2. Rate Of Babies With Macrosomia (Birth weight ≥ 4,000 Grams): Table 1 shows the rate of babies with macrosomia for 1998-2006. The rate of macrosomia among births to mothers with diabetes has been steadily decreasing for the past seven years, although the rates are still extremely high compared to all births. Table 1. Births to Diabetic Mothers of Infants Weighing at or Greater than 4,000 Grams, 1998 – 2006, All Races. Births of Infants > Rate Per 1,000 Live 4,000 Grams (9 lbs) to Births to Mothers Mothers with Diabetes with Diabetes 1998 353 192.8 1999 251 142.9 2000 332 171.2 2001 320 169.1 2002 342 166.7 2003 304 156.6 2004 352 153.8 2005 407 143.0 2006 434 134.7 Source: Birth Database 1998-2006, ADHS. Year 3. Births of All Infants > 4,000 Grams (9 lbs) 6900 6593 6796 7297 7364 7439 7269 7463 7821 Rate Per 1,000 Live Births 88.5 81.9 80.0 85.6 84.3 81.9 77.8 77.9 76.6 Pre-School Children Who Are Overweight: This indicator is defined as low-income two to four-year-old children in the Arizona WIC Program, Inter Tribal Council of Arizona, Inc. (ITCA) WIC Program, and Navajo WIC Program, with weight for height ≥ 95th percentile (see Table 2). Table 2. WIC Participants, Children Ages 2-4, and Program Characteristics. Source Year Number of Clients Percent Overweight State of Arizona WIC Program 2005 51,843 12.8% ITCA WIC Program 2005 5,001 24.2% Navajo WIC Program 2005 9,109 16.5% Source: Pediatric Nutrition Surveillance System, CDC, 2005. Arizona Department of Health Services Division of Public Health Prevention Services 10 July 2008 4. Proportion Of Adults Who Are Considered Physically Active: These data are obtained from the self-reports of the Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a telephone survey that has been conducted monthly since 1992 and results are reported annually. Figure 2a shows the proportion of Arizona Adults who meet the recommendations for physical activity (30+ minutes of moderate physical activity, five or more days per week or vigorous physical activity for 20+ minutes three or more days per week). Figure 2b shows the proportion of Arizonans Adults (age 18 and older) who are physically inactive (that is, they reported that they did not participate in physical activity during leisure time during the past month). Based on the trend line presented, the percentage of adults in Arizona who participate in no leisure-time physical activity has been decreasing since 2000. Figure 2a. Proportion of Arizona Adults Who Met the Recommendations for Moderate or Vigorous Activity in the Past Month, 2001-2005. Percent 75 50 56.4 55.1 51.7 49.2 50.6 46.2 Males Females 25 0 2001 2003 2005 Source: Behavior Risk Factor Surveillance System, CDC, 2001 – 2005. Figure 2b. Proportion of Arizona Adults Not Participating in Physical Activity in the Past Month, 1992-2006. 70 60 51.3 Percent 50 33.5 33.3 40 38.6 34.1 30 24.7 23.7 23.7 21.9 22.6 20 11.3 Healthy People 2010 Objective (20%) 10 14.6 13 14.4 0 1992 1994 1996 1998 2000 2002 2004 2006 Source: Behavior Risk Factor Surveillance System, CDC, 1990 – 2006. Arizona Department of Health Services Division of Public Health Prevention Services 11 July 2008 5. Proportion Of Adolescents Who Are Considered Physically Active: This information is compiled from high school students surveyed from the 2003 and 2005 Youth Risk Behavioral Surveillance System (YRBSS). The survey included students in grades 9 through 12. These figures represent self-reported data (see Table 3). Table 3. Self-reported Physical Activity Among Youth During Past Seven Days. 2003 2005 No vigorous or moderate physical activity 7.7% 8.7% Vigorous activity for 20 minutes or more/ 3 or more days 66.9% 62.5% Moderate activity 30 minutes or more/ 5 or more days 29.2% 28.1% Participated in recommended physical activity in past week* 72.2% 32.3% Source: YRBS, 2003-2005. Arizona Department of Education (www.ade.state.az.us) * The recommended amount of physical activity for children changed from 2003 to 2005, to at least 60 minutes of moderate intensity physical activity on most days (Division of Nutrition, Physical Activity and Obesity, CDC). 6. Proportion Of Adults Who Are Overweight: All respondents to the Arizona BRFSS with a Body Mass Index (BMI) that is between 25.0 and 29.9 are considered overweight. BMI is defined as weight in kilograms divided by height in meters squared (w/h2). The figures do not include survey respondents with missing, don’t know or refused answers. Figure 3 shows the proportion of Arizonans whose BMI exceeds the lower limit of overweight adults during a 10-year period. Figure 3. Proportion of Arizonans Whose Body Mass Index (BMI) Exceeds the Lower Limit of Overweight, 1992-2002. Percent Proportion Of Arizonans Who Are Overweight or Obese (BMI > 25) 70 60 50 40 30 20 10 0 39.4 40.0 44.9 49.0 48.7 47.1 49.5 51.6 56.0 56.0 56.2 57.1 56.1 56.2 59.6 Healthy People 2010 Objective (15%) 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 HP2010 Overweight Source: Behavior Risk Factor Surveillance System, CDC, 1992 – 2006. Arizona Department of Health Services Division of Public Health Prevention Services 12 July 2008 7. Proportion of Adolescents Who Are Overweight or At Risk to Become Overweight: This information is complied from high school students in grades 9 through 12 responding to the 2003 and 2005 Youth Risk Behavioral Surveys. These figures represent self-reported data from all children who participated in the survey. From 2003 to 2005, the rate of children who were overweight increased from 10.8% to 11.9% (see Figure 4). For children under age 19, BMI is calculated by height and weight measurements and then compared to the percentile for the respective age (About BMI for Children and Teens, 2007). Figure 4. Percentage of Students Grades 9 through 12 Who are Overweight or At Risk, 2003 - 2005. 25 Percent 20 15 13.6 10 5 13.6 10.8 At Risk 11.9 Overweight 0 2003 2005 Source: Arizona YRBS 2003-2005, www.ade.state.az.us. 8. Proportion Of Adults Who Are Obese: All respondents to the Arizona Behavioral Risk Factor Survey with a Body Mass Index (BMI) that is 30.0 or higher are considered obese. BMI is defined as weight in kilograms divided by height in meters squared (w/h2). The figures do not include survey respondents with missing, don’t know and refused answers. The level of obesity has continued to rise above the Healthy People 2010 Objective of 15 percent (see Figure 5). Figure 5. Proportion of Arizona Adults Whose Body Mass Index Exceeds the Lower Limit of Obese, 1992-2006. Proportion Of Adults Who Are Obese 25 21.2 21.1 19.2 18.5 19.6 20.1 Percent 20 15.1 12.7 13.3 12.4 13.1 12.3 15 10 22.9 9.7 11.7 Healthy People 2010 Objective (15%) 5 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Arizona HP2010 Source: Behavior Risk Factor Surveillance System, CDC, 1992 – 2006. Arizona Department of Health Services Division of Public Health Prevention Services 13 July 2008 9. Proportion Of Arizonans Consuming Inadequate Servings Of Fruits And Vegetables Daily: This indicator is defined as adults age 18 and older who self-reported eating less than five servings of fruits and vegetables per day in the Arizona BRFSS. Figure 6 shows that the percentage of adults who consume an inadequate amount of fruits and vegetables has remained stable over the past six years. Figure 6. Proportion of Arizonans Consuming Less Than 5 Servings of Fruits or Vegetables Per Day, 1992-2006. Proportion Of Arizonans Who Are Not Eating "5-A-Day" 100 Percent 80 75.5 77.3 76.4 75.7 75.5 82.6 90.9 69.8 74.5 77.3 76.9 76.8 76.3 74 63.1 60 40 Healthy People 2010 Objective (50%) 20 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Arizona HP2010 Source: Behavior Risk Factor Surveillance System, CDC, 1992 – 2006. Arizona Department of Health Services Division of Public Health Prevention Services 14 July 2008 10. Proportion of Arizonans Who are Current Smokers: This indicator is defined as self-reported current smokers by adults age 18 and older who participated in the Arizona BRFSS. During the 15 year period, the year 2006 had the lowest proportion of Arizonans who were current smokers (18.2%) (See Figure 7). Figure 7. Proportion of Arizonans Who Are Current Smokers, 1992-2006. 25 Percent 20 19.2 20.9 23 22.9 23.7 21.1 21.8 20.1 21.5 23.4 18.6 20.8 18.5 20.2 18.2 15 Healthy People 2010 Objective (14%) 10 5 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Arizona HP2010 Source: Behavior Risk Factor Surveillance System, CDC, 1992 – 2006. 11. Proportion of Adolescents Who are Current Smokers: This information is compiled from students in grades 9 through 12 who participated in the 2003 and 2005 YRBSS. Figure 8 shows the self-reported smoking behavior among these students. Figure 8. The Percentage of Students Grades 9 through 12 Who Smoke. YRBS 2003 - 2005: Arizona High School Survey for Smoking 60 58.9 58.2 Percent 50 2003 2005 40 30 20.9 21.4 20 7.3 10 7.5 0 % of students who ever tried cigarette smoking, even one or two puffs % of students who smoked % of students who smoked cigarettes on one or more of cigarettes on 20 or more of the past 30 days the past 30 days Source: YRBS, 2003 - 2005. Arizona Department of Education, www.ade.state.az.us. Arizona Department of Health Services Division of Public Health Prevention Services 15 July 2008 B. SECONDARY PREVENTION (Prevention of complications among persons who already have clinically diagnosed Diabetes Mellitus) 1. Percentage of Adults with Diabetes: This indicator comes from the BRFSS and represents the percentage of adults in Arizona who have been told by a doctor that they have diabetes (see Figure 9). The number has been increasing steadily since 2003, and has more than doubled since 1990. % of Arizona adults with diagnosed diabetes Figure 9. The Prevalence of Diagnosed Diabetes Among Adults in Arizona and the U.S., 1994 –2006. 9 8.5 8 7.5 7 6 5 4 6.6 6.3 4.9 3.9 Arizona 3 U.S. 2 1 0 1990 1995 2000 2001 2002 2003 2004 2005 2006 Source: Behavior Risk Factor Surveillance System, CDC, 1990 – 2006. Arizona Department of Health Services Division of Public Health Prevention Services 16 July 2008 2. Percentage of Adults with Diabetes Receiving Influenza Vaccination in the Last Year: Number of persons age 18 or older who report that they have been told by a doctor that they have diabetes and have received a flu shot in the past year (see Figures 10a and 10b). Persons with diabetes are at increased risk of hospitalization, morbidity, and mortality associated with influenza. Influenza vaccination has the potential to improve morbidity and mortality outcomes among persons with diabetes. This process indicator provides information about the quality of diabetes care provided. Figure 10a. The Percentage of Adults with Diabetes Receiving Influenza Vaccination in the Last Year, 2001-2006. 100% 90% 80% 74.2% 61.9% Percent (%) 70% 60% 50% 65+ 42.0% 43.0% 18-64 TOTAL 40% 30% 36.7% 32.2% 20% 10% 0% 2001 2002 2003 2004 2005 2006 Source: Behavior Risk Factor Surveillance System, CDC, 2001 – 2005. Percent Figure 10b. The Percentage of Adults with Diabetes Receiving Influenza Vaccination in the Last Year, Selected Indian Health Service Sites, 2007. 100 90 80 70 60 50 40 30 20 76 67 59 42 IHS - Phoenix IHS - Tucson IHS - Navajo Arizona (2006) Source: Indian Health Service Diabetes Audit 2007 & BRFSS, 2006. Arizona Department of Health Services Division of Public Health Prevention Services 17 July 2008 3. Percentage of Adults with Diabetes Ever Receiving a Pneumococcal Vaccination: This indicator is defined by the number of persons age 18 or older with diabetes and who report that they have ever received a pneumonia shot (see Figures 11a and 11b). Persons with diabetes are at increased risk of hospitalization, morbidity, and mortality associated with pneumonia. Pneumococcal vaccination has the potential to improve morbidity and mortality outcomes among persons with diabetes. This process indicator provides information about the quality of diabetes care provided. Figure 11a. The Percentage of Adults with Diabetes Ever Receiving a Pneumococcal Vaccination, 2001-2006. 100% 90% 80% 72.6% 66.9% Percent (%) 70% 60% 50% 65+ 48.3% 44.6% 18-64 TOTAL 40% 30% 38.8% 39.0% 20% 10% 0% 2001 2002 2003 2004 2005 2006 Source: Behavior Risk Factor Surveillance System, CDC, 2001 – 2005. Percent Figure 11b. The Percentage of Adults with Diabetes Receiving a Pneumococcal Vaccination, Selected Indian Health Service Sites, 2007 100 90 80 70 60 50 40 30 20 91 89 71 48 IHS - Phoenix IHS - Tucson IHS - Navajo Arizona (2006) Source: Indian Health Service Diabetes Audit 2007 & BRFSS, 2006. Arizona Department of Health Services Division of Public Health Prevention Services 18 July 2008 4. Percentage of Adults with Diabetes who are Current Smokers: This indicator was calculated as the percentage of adults that consider themselves current smokers and report that they have been told by a doctor they have diabetes. Among many other negative affects of smoking, it significantly increases one’s risk of cardiovascular disease, especially among persons with diabetes. Quitting smoking is highly encouraged for persons with diabetes. Figure 12a indicates that the rate of smoking among adults who report they have diabetes has been slowly but steadily decreasing since 1995. Figure 12b compares the adults with diabetes current smoking rates for the three Arizona Indian Health Service areas. Figure 12a. The Rate of Being a Current Smoker Among Adults Who Have Been Told by a Doctor That They Have Diabetes. 50 45 40 Percent (%) 35 30 25 25.6 21.7 24.5 21.8 23.3 24.1 20.7 22.3 23.9 23.4 22.8 21.8 17.4 20 15 Healthy People 2010 Objective (14%) 10 5 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Source: Behavior Risk Factor Surveillance System CDC, 1994 – 2006 Figure 12b. The Rate of Being a Current Smoker Among Adults with Diabetes, Selected Indian Health Service Sites, 2007 and Arizona, 2006. 20 Percent 15 17 16 10 11 8 5 0 IHS - Phoenix IHS - Tucson IHS - Navajo Arizona (2006) Source: Indian Health Service Diabetes Audit 2007 & BRFSS, 2006. Arizona Department of Health Services Division of Public Health Prevention Services 19 July 2008 16. Percentage Of Diabetic Patients Receiving One Or More A1C Tests During The Last 12 Months: The numerator for this indicator is the number of diabetic patients who have had at least one A1C test coded as CPT code 83036 in the past year. The denominator is defined as “diabetic patients”, that is persons seen for medical services who also were coded with at least one diagnosis of diabetes (ICD-9 code=250). Measurement of A1C quantifies glucose control over the previous two to three months and is the preferable measure of long-term glycemic control. The Diabetes Quality Improvement Project (DQIP) recommends that health plans and providers be accountable for at least one test per year. Table 4 presents the provider percentages of diabetic patients who received one or more A1C tests during the past year. Figures 13a – 13b use HEDIS Comprehensive Diabetes Care data to show the rate of A1C testing and control among several Arizona health plans. Table 4. Percentage of Diabetic Patients Receiving One or More A1C Tests During the Last 12 Months by Reporting Organization. Source Community Health Centers IHS - Phoenix Area IHS -Tucson Area IHS – Navajo Medicare Fee for Service Medicare HMO (7 groups) VA - Phoenix BRFSS (N=491) HEDIS® Year of Collection FY2003 FY2004 FY2003 FY2007 FY2003 FY2007 FY2003 FY2007 Patient Tested (Numerator) 486 212 2,556 6,134 1,028 1,086 1,609 1,546 Diabetic Patient (Denominator) 529 273 2,662 6,596 1,155 1,193 1,625 1,578 2002 18,940 26,087 Not Available Not Available 4,244 5,238 6,085 7,069 Not Available Not Available 6,017 7,217 8,597 9,660 Not Available Not Available 2001 2002 2000 2001 2002 2003 2006 2006 Percent 91.9% 77.7% 96% 93% 89% 91% 99% 98% 72.6% 88% 85% 80.5% 72.6% 70.8% 73.2% 70.0% 86.6% Notes: ™ Community Health Centers – Information reported from four of the Community Health Centers. ™ IHS Phoenix, Tucson, Navajo – The numbers are based on the IHS Diabetes Audit 2007. ™ Medicare Fee For Service - Figures represent annual exam. Data are currently obtained from claims. ™ Medicare HMO – Figures represent annual exam. Summary HEDIS® data obtained from www.cms.gov. ™ BRFSS – Telephone survey collected in a calendar year. Arizona Department of Health Services Division of Public Health Prevention Services 20 July 2008 Figure 13a. Estimated Percentage of Diabetic Patients who Received Annual A1C test, Arizona, U.S. and Top 10 Percent of Health Plans, 2004– 2006. A1C Testing 92.7 92.5 91.0 90th Percentile 2006 87.5 86.5 84.6 National 2005 2004 86.6 86.2 84.0 Arizona 50 60 70 80 90 100 Percent of cases meeting recommendations Source: Quality Compass® 2007, used with the permission of the National Committee for Quality Assurance (NCQA). Figure 13b. Estimated Percentage of Diabetic Patients whose A1C was not under control (>9.0%), Arizona, U.S. and Top 10 Percent of Health Plans, 2004–2006. Poor A1C Control 20.4 20.9 20.9 90th Percentile 2006 29.7 30.7 32.0 National 28.5 Arizona 0 10 20 30 2005 2004 33.4 34.7 40 50 Percent of cases meeting recommendations Source: Quality Compass® 2007, used with the permission of the National Committee for Quality Assurance (NCQA). Arizona Department of Health Services Division of Public Health Prevention Services 21 July 2008 17. Percentage of Diabetic Patients Receiving at Least One Microalbuminuria Test During the Last 12 Months: Diabetic patients receiving a micoralbuminuria test with the CPT procedure code of 82043 (quantitative microalbumin urine) or 82044 (semi-quantitative microalbumin urine). This test is a measure for early detection of renal disease in people with diabetes. Note: patients with diabetes who already have evidence of renal disease with high protein levels shown in other preliminary basic urine tests do not usually receive a microalbuminuria. This is a difficult factor to consider and certainly accounts for some variability seen between organizations. Table 5 presents the provider percentages of diabetic patients who received at least one microalbuminuria test during the past year. Table 5. Percentage of Diabetic Patients Receiving at Least One Microalbuminuria Test During the Last 12 Months by Reporting Organization. Source Community Health Centers IHS - Phoenix Area IHS -Tucson Area IHS –Navajo Area Year of Collection FY2003 FY2004 FY2003 FY2007 FY2003 FY2007 FY2003 FY2007 Patient Tested (Numerator) 243 88 2,130 4,287 1,155 716 926 1,136 Diabetic Patient (Denominator) 529 207 2,662 6,596 1,155 1,193 1,625 1,578 Percent 45.9% 42.5% 80% 65% 100% 60% 57% 72% Medicare Fee For Service Medicare HMO 2002 Not Available Not Available Not Available 2002 Not Available Not Available Not Available VA - Phoenix 2003 153 9,660 1.6% NOTES: ™Community Health Centers – Information reported from four of the Community Health Centers. ™IHS Phoenix, Tucson, Navajo – The numbers are based on the IHS Diabetes Audit 2007. 18. Eye Examination: Percent of diabetic patients receiving a dilated eye examination performed by an eye care professional (ophthalmologist or optometrist) within the past 12 months (see Table 6). The following CPT codes were used to determine whether patients received a dilated eye examination: 92002, 92004, 92012, 92014, 92018, 92019, 99201-99215, and 99241-99245. Figure 14 uses HEDIS® Comprehensive Diabetes Care data to show the rate of dilated eye exams among several Arizona health plans. Arizona Department of Health Services Division of Public Health Prevention Services 22 July 2008 Table 6. Percent of Diabetic Patients with Eye Examination by Reporting Organization. Sources Community Health Centers IHS - Phoenix Area IHS – Tucson Area IHS –Navajo Area Medicare Fee For Service Medicare HMO (7 groups) Year of Collection FY2003 FY2004 FY2003 FY2007 FY2003 FY2007 FY2003 FY2007 Patient Tested (Numerator) 286 81 1,677 3,760 566 656 959 947 Diabetic Patient (Denominator) 529 207 2,662 6,596 1,155 1,193 1,625 1,578 1/01 – 12/02 17,518 26,087 Percent 54.1% 39.1% 63% 57% 49% 55% 59% 60% 67.2% 2001 2002 2000 2001 2002 2003 FY2003 FY2004 Not Available Not Available 1,647 1,673 2,347 2,559 Not Available 26 6,017 7,217 8,597 9,660 Not Available 31 63% 63% 27.4% 23.2% 27.3% 26.5% 66% 84% BRFSS (N=491) 2006 Not Available Not Available 71.1% HEDIS® 2006 Not Available Not Available 47.5% VA - Phoenix VA – Prescott NOTES: ™Community Health Centers - Information reported from four of the Community Health Centers. ™IHS Phoenix, Tucson, Navajo - The numbers are based on the IHS Diabetes Audit 2007. ™Medicare Fee For Service - Figures represent biennial exam. Data are currently obtained from claims. ™Medicare HMO - Figures represent biennial exam. Summary HEDIS® data obtained from www.cms.gov. ™VA - Phoenix - Data is capture based on calendar year and CPT codes. ™VA – Prescott - The information is based on fiscal year. ™BRFSS - Telephone survey collected in a calendar year. ™HEDIS® - Data represents services provided in calendar year 2005. Figure 14. Estimated Percentage of Diabetic Patients who Received an Annual Dilated Eye Exam, Arizona, U.S. and Top 10 Percent of National Health Plans, 2004–2006. Eye Exams 69.3 66.2 64.1 90th Percentile 54.8 51.0 48.8 National 20 30 40 50 2005 2004 47.6 43.7 40.1 Arizona 2006 60 70 80 Source: Quality Compass® 2007, used with the permission of the National Committee for Quality Assurance (NCQA). Percent of cases meeting recommendations Arizona Department of Health Services Division of Public Health Prevention Services 23 July 2008 19. Foot Examination: The foot examination measure is defined as a documented foot examination (CPT code 99239). The examination includes an evaluation of protective sensation, vascular status (i.e., palpation for pulses), and a visual inspection for foot deformities/ulcers. A proper foot exam is a low-cost and effective means to detect complications and assess the risk of future serious complications due to diabetes. Table 7 presents the provider percentages of diabetic patients with recorded foot examination during the past year. Table 7. Percent of Diabetic Patients with Recorded Foot Examination. Source Community Health Centers IHS – Phoenix Area IHS -Tucson Area IHS –Navajo Area Medicare Fee For Service Medicare HMO VA - Phoenix VA – Prescott BRFSS (N=491) Year of Collection FY2003 FY2004 FY2003 FY2007 FY2003 FY2007 FY2003 FY2007 Patient Tested (Numerator) 456 123 1,544 3,100 589 668 764 915 Diabetic Patient (Denominator) 529 273 2,662 6,596 1,155 1,193 1,625 1,578 Percent 86.2% 45.1% 58% 47% 51% 56% 47% 58% 2002 Not Available Not Available Not Available 2002 2000 2001 2002 2003 FY2003 FY2004 Not Available 1,363 1,417 1,344 1,386 Not Available 21 Not Available 6,017 7,217 8,597 9,660 Not Available 30 Not Available 22.7% 19.6% 15.6% 14.4% 71% 70% 2006 Not Available Not Available 65.9% NOTES: ™ Community Health Centers - Information reported from four of the Community Health Centers. ™ IHS - Phoenix Area - Foot examination is gathered by chart audits. ™ IHS Tucson Area - The numbers are based on the IHS Diabetes Audit 2003, there were a total of 3,960 clients in their registry, of those 1,155 were audited. ™ Medicare Fee for Service - Information not available. ™ Medicare HMO - Information not available. ™ VA - Phoenix - Data is collected based on calendar year, percent of patients seen in the podiatric clinic not associated with specific CPT code. ™ VA – Prescott - The information is based on fiscal year. ™ BRFSS - Telephone survey collected in a calendar year. Arizona Department of Health Services Division of Public Health Prevention Services 24 July 2008 C. TERTIARY PREVENTION (Prevention of impairment from diabetes complications) 20. Uncontrolled Hypertension: In this report, a person has uncontrolled hypertension if the average blood pressure was above 130/80 mm/Hg during the last 12 months. Table 8 presents the percentages of diabetic patients with uncontrolled hypertension. Table 8. Percent of Diabetic Patients with Uncontrolled Hypertension by Reporting Organization. Year of Collection FY2003 FY2004 FY2003 FY2007 FY2003 FY2007 FY2003 FY2007 Patient Tested (Numerator) 210 112 1,571 3,298 404 537 975 757 Diabetic Patient (Denominator) 344 273 2,662 6,596 1,155 1,193 1,625 1,578 Percent 61.1% 41.0% 59% 50% 35% 45% 60% 48% Medicare Fee For Service 2002 Not Available Not Available Not Available Medicare HMO 2002 Not Available Not Available Not Available VA - Phoenix 2000 2001 2002 2003 2,813 4,733 5,068 6,131 6,017 7,217 8,597 9,660 VA - Prescott FY2003 26 31 Source Community Health Centers IHS - Phoenix Area IHS -Tucson Area IHS –Navajo Area 46.8% 65.6% 59.0% 63.5% 84% NOTES: ™ Community Health Centers - Information reported from four of the Community Health Centers. ™ IHS - Phoenix Area - The numbers are based on the IHS Diabetes Audit 2007. ™ IHS - Tucson Area - The numbers are based on the IHS Diabetes Audit 2007. ™ IHS - Navajo - The numbers are based on the IHS Diabetes Audit 2007. ™ Medicare Fee for Service - Information not available. ™ Medicare HMO - Information not available. ™ VA - Phoenix - Current data was collected based on calendar year. ™ VA – Prescott - The information is based on fiscal year. Arizona Department of Health Services Division of Public Health Prevention Services 25 July 2008 21. Lipid Profile: Lipid profile was calculated as the percentage of diabetic patients who had a lipid panel within the last 12 months (see Table 9). The CPT code 80061 was used to identify patients who had a lipid panel. CPT code 80061 includes total serum cholesterol, direct measurement of high density lipoproteins and triglycerides. Figures 15a, 15b and 15c use HEDIS Comprehensive Diabetes Care data to show the rate of LDL-cholesterol control among several Arizona health plans. Figure 15d compares the adults with diabetes estimated percentage with LDL cholesterol that was <130 mg/dL for the three Indian Health Service areas in Arizona. Table 9. Percent of Diabetic Patients Who Had a Lipid Panel Within the Last Year by Reporting Organization. Sources Community Health Centers IHS - Phoenix Area IHS -Tucson Area IHS – Navajo Area Medicare Fee For Service Medicare HMO (7 groups) VA - Phoenix VA - Prescott HEDIS® Year of Collection FY2003 FY2004 FY2003 FY2007 FY2003 FY2007 FY2003 FY2007 Patient Tested (Numerator) 454 42 1,997 4,881 601 799 1,089 1,184 Diabetic Patient (Denominator) 529 66 2,662 6,596 1,155 1,193 1,625 1,578 Percent 85.8% 63.6% 75% 74% 52% 67% 67% 75% 1/01 – 12/02 20,330 26,087 77.9% Not Available Not Available 4,279 4,470 5,275 6,162 Not Available 22 6,017 7,217 8,597 9,660 Not Available 31 89% 91% 71.1% 61.9% 61.4% 63.8% 78% 71% Not Available Not Available 92.3% 2001 2002 2000 2001 2002 2003 FY2003 FY2004 2006 NOTES: ™ Community Health Centers - Information reported from four of the Community Health Centers. ™ IHS – Phoenix, Tucson, Navajo - This information is the percent of patients with cholesterol measured, which amounts to the same thing, as those patients are likely to have had the other profile components. ™ Medicare Fee For Service - Figures represent biennial exam. Data are currently obtained from claims. ™ Medicare HMO - Figures represent biennial exam. Summary HEDIS® data obtained from www.cms.gov. ™ VA - Phoenix - Current data was collected based on calendar year. ™ VA – Prescott - The information is based on fiscal year. Based in full lipid profile in the prior 2 years. ™ HEDIS® - Data represents services provided in calendar year 2005. Arizona Department of Health Services Division of Public Health Prevention Services 26 July 2008 Figure 15a. Estimated Percentage of Diabetic Patients Who Received Annual LDL-Cholesterol Test, Arizona, U.S. and Top 10 Percent of Health Plans, 2004–2006. LDL-Cholesterol Screening 95.4 94.9 93.4 90th Percentile National 92.3 91.0 88.4 Arizona 92.7 92.6 88.9 50 60 70 80 90 2006 2005 2004 100 Percent of cases meeting recommendations Source: Quality Compass® 2007, used with the permission of the National Committee for Quality Assurance (NCQA). Figure 15b. Estimated Percentage of Diabetic Patients Who LDL Cholesterol was <100 mg/dL, Arizona, U.S. and Top 10 Percent of Health Plans, 2004– 2006. LDL-Cholesterol Controlled (<100 mg/dL) 52.6 90th Percentile 47.5 2006 2005 43.8 40.2 National 38.3 36.0 Arizona 20 30 40 50 60 70 Percent of cases meeting recommendations (no data in 2004) Source: Quality Compass® 2007, used with the permission of the National Committee for Quality Assurance (NCQA). Arizona Department of Health Services Division of Public Health Prevention Services 27 July 2008 Figure 15c. Estimated Percentage of Diabetic Patients whose LDL Cholesterol was <130 mg/dL, Arizona, U.S. and Top 10 Percent of Health Plans, 2004–2006. LDL-Cholesterol Controlled (<130 mg/dL) 68.9 65.5 61.6 90th Percentile National 55.7 52.0 60.6 2006 2005 2004 63.9 59.9 62.5 Arizona 25 35 45 55 65 75 Percent of cases meeting recommendations Source: Quality Compass® 2007, used with the permission of the National Committee for Quality Assurance (NCQA). Figure 15d. Estimated Percentage of Diabetic Patients whose LDL Cholesterol was <130 mg/dL, Selected Indian Health Service Sites, 2007 and Arizona, 2006. 70 Percent 60 64 62 62 64 IHS - Phoenix IHS - Tucson IHS - Navajo Arizona (2006) 50 40 30 20 Source: Indian Health Service Diabetes Audit 2007 & Quality Compass® 2007, used with the permission of the National Committee for Quality Assurance (NCQA). Arizona Department of Health Services Division of Public Health Prevention Services 28 July 2008 22. Hospitalizations: The numerator for this indicator is defined as an inpatient discharge from the hospital that had an ICD9-CM of 250 in any of the discharge diagnosis fields in the database. Table 10a. Hospital Discharges for Diabetes-Related Inpatient Discharge Diagnoses, Nonfederal Facilities Only, 1992-2006. Diabetes Diabetes Average Total Discharges Discharge Length Stay Charges (Number) Rate* (Days)^ 1992 33,036 76.7 6.1 $402,768,934 1993 32,758 74.8 5.8 $429,237,924 1994 36,788 81.6 5.3 $493,820,743 1995 44,088 93.4 5.4 $669,148,220 1996 50,762 103.0 4.9 $775,551,399 1997 54,848 106.3 4.7 $881,891,382 1998 54,425 101.1 4.9 $925,712,245 1999 59,359 105.8 4.8 $1,065,316,017 2000 66,695 110.4 4.8 $1,337,609,106 2001 70,278 116.7 4.8 $1,486,475,577 2002 76,670 120.3 4.5 Not Available 2003 82,585 146.6 4.9 $2,183,374,194 2004 92,989 154.6 4.9 $2,748,003,084 2005 99,111 158.0 5.0 $3,185,883,475 2006 102,827 160.0 5.1 $3,528,216,562 Source: ADHS Hospital Discharge Database, 1992-2006. *Diabetes-related discharges per 1,000 discharges from all causes. ^Beginning in 2000, length-of-stay was calculated using diabetes as the first-listed diagnosis. Year of Discharge 180.0 160.0 160.0 140.0 105.8 120.0 100.0 76.7 80.0 60.0 40.0 20.0 20 06 20 05 20 04 20 03 20 02 20 01 20 00 19 99 19 98 19 97 19 96 19 95 19 94 19 93 0.0 19 92 Rate (per 1,000 discharges from all causes) Figure 16a. Hospital Discharges for Diabetes-Related Inpatient Discharge Diagnoses, Non-Federal Facilities, 1992-2006*. Source: ADHS Hospital Discharge Database, 1992-2006. *Diabetes-related discharges per 1,000 discharges from all causes. Arizona Department of Health Services Division of Public Health Prevention Services 29 July 2008 Figure 16b. Total Charges for Diabetes-Related Inpatient Hospitalizations, NonFederal Facilities, 1992-2006*. 4,000,000,000 $3,528,215,562 Total Charges ($) 3,500,000,000 3,000,000,000 2,500,000,000 2,000,000,000 $1,337,609,106 1,500,000,000 1,000,000,000 402,768,934 500,000,000 06 20 05 20 20 04 03 20 02 20 01 20 00 98 99 20 19 19 19 97 96 19 95 19 94 19 93 19 19 92 0 Source: ADHS Hospital Discharge Database, 1992-2006. Data on charges from 2003 were not statistically reliable. *Diabetes-related discharges per 1,000 discharges from all causes. NOTES: ™ From 2003 – 2006, the date of admission was used to group charges by year. This may result in discrepancies in reports that use the date of discharge to group charges by year. Hospital discharge data from 2002 did not meet necessary data quality standards. ™ This information is based on the calendar year. Table 10b. Hospital Discharges for Diabetes-Related Discharge Diagnoses from Federal Facilities for Selected Years. Source VA - Phoenix Year Number of Discharges for Diabetes Diabetes Discharge Rate Average Length of Stay (Days) 2002 2003 188 251 2,980 3,950 6.5 6.8 IHS Areas- Phoenix, Tucson, 1996 Not Available 325 Not Available and Navajo NOTES: ™ VA - Phoenix Area - Discharge rate computed as number of diabetes discharges per 100,000 discharges from all causes. ™ IHS Area - No response was provided for the current year, but for the 1996 period, discharge rate computed as number of diabetes-related discharges per 100,000 discharges. Arizona Department of Health Services Division of Public Health Prevention Services 30 July 2008 23. New Cases of End Stage Renal Disease (ESRD) in Persons with Diabetes: Based on the End Stage Renal Disease (ESRD) Network #15 Data System, the incidence of ESRD and prevalence of ESRD patients on dialysis has increased (see Table 11). Table 11. Number of End Stage Renal Disease: Patients with Diabetes Diagnosis ESRD Incidence ESRD Dialysis Prevalence ESRD Deaths 2000 2001 2002 2003 2004 2005 2006 916 980 956 963 1,008 985 1,055 2,608 2,782 2,866 3,032 3,191 3,333 3,508 622 680 778 694 724 733 709 Source: ESRD Network #15 Data System, 2000-2006. 24. Lower Extremity Amputation: This indicator consists of patients with diabetes that had one or more extremity amputations during the reporting year. Lower extremity amputations include those procedures coded with the following ICD-9 diagnosis codes: 84.10-leg amputation, 84.11-toe amputation, 84.12-foot amputation, 84.13-ankle through joint amputation, 84.14-ankle through lower leg amputation, 84.15-leg below knee amputation, 84.16-knee through joint amputation, 84.17-leg above knee amputation, 84.18-leg through hip amputation, and 84.19-leg and hip amputation. Table 12 presents the hospital numbers of diabetic patients with lower extremity amputations. Table 12. Number of Lower Extremity Amputations Among Hospitalized Diabetic Patients. Source Hospital Discharge Database (HDDB) VA - Phoenix 1999 2000 2001 2002 2003 2004 2005 2006 824 1,176 1,126 1,201 Not Avail. 1,302 1,377 1,336 51 43 54 48 47 Not Avail. Not Avail. Not Avail. NOTES: ™ Hospital Discharge Database - The HDDB data is for inpatient amputations from nonfederal facilities only. ™ IHS - These data are not available. Some of these amputations occur in non-IHS facilities. In older American Indian adult male populations (Veterans), diabetes care (especially amputation) for a significant number of urban and reservation dwellers may be delivered in VA Medical Centers. Arizona Department of Health Services Division of Public Health Prevention Services 31 July 2008 D. MORTALITY 25. Mortality: This indicator is defined as the count and rate of all deaths in Arizona with a diabetes diagnosis (ICD9 code = 250.xx) listed as the underlying cause of death (see Figure 17). The deaths attributed to diabetes as the underlying cause underestimates the actual mortality burden of diabetes. According to the CDC, diabetes is three times as likely to be listed as a contributing cause of death than as the underlying cause of death. The leading underlying cause of death for deaths with diabetes listed as a contributing cause is cardiovascular disease. Approximately one third of cases of diabetes are undiagnosed. Diabetes is listed on the death certificates of only approximately half of the decedents who actually had diabetes. Figure 17. Deaths in Arizona with the Underlying Cause of Death Listed as ICD-9 code 250 (Diabetes, 1992-2006*). DEATHS DUE TO DIABETES AS THE UNDERLYING CAUSE 22.3 1,200 17.4 16.6 19.7 18.8 18.7 18.3 19.5 20.0 19.0 19.9 20.3 20.7 20.1 24 19.0 21 18 15 900 600 300 1,046 653 645 767 810 898 946 993 1,006 1,201 12 1,196 1,124 1,040 1,180 1,188 9 6 3 0 Rate (per 100,000 Census Population) Number of Deaths 1,500 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Year Rate (per 100,000 Census Population) Source: Arizona Health Status and Vital Statistics, 1992-2006, ADHS. * Rates are per 100,000 population, age-adjusted to the U.S. 2000 Census data. Arizona Department of Health Services Division of Public Health Prevention Services 32 July 2008 D. RESOURCES 26. Registries: The registries measure is loosely defined as those managed care systems (HMOs, VA, IHS Area, CHC’s) that have a registry of diabetic patients, or an ability to easily identify the patients electronically in a given practice setting. The term registry cannot readily be defined because the definition of registry may vary from entity to entity. Each source responded to this measure with a binary (yes/no) response to the question as to whether or not the entity has a registry of diabetic patients. Table 13 summarizes the organizations with diabetes registry. Table 13. Number of reporting organizations with diabetes registry. Source Community Health Centers Has a Registry Some IHS - Phoenix Area Yes IHS - Tucson Area Yes IHS – Navajo Area Yes Medicare Fee For Service Yes Medicare HMO Yes VA - Phoenix No NOTES: ™ Community Health Centers - Two of the 12 community health centers currently have registries of their diabetic patients. In the future, the plan is for all of the community health centers to have their own registries of diabetic patients. ™ Medicare Fee For Service - SDPS can be queried for all 250.0 ICD-9 codes which may or may not approximate the prevalence of diabetes among Medicare beneficiaries. Please note SDPS cannot be considered a complete data source. According to Health Services Advisory Group (HSAG), most plans with a case management program maintain disease registries, including for diabetes. ™ Medicare HMO - According to Health Services Advisory Group (HSAG), most plans with a case management program maintain disease registries, including for diabetes. Arizona Department of Health Services Division of Public Health Prevention Services 33 July 2008 27. Patient Self-Management Education Including Nutrition Education: This is a patient-survey based measure used to determine whether or not patients with diabetes are receiving the necessary education to help them manage their disease. The proper management of diabetes relies extensively on the patients’ knowledge and understanding of their disease. Therefore, patients must be properly educated in order to successfully self-manage their blood sugar levels, plan meals and exercise. Table 14 summarizes the providers’ number of diabetic patients who received self-management classes. Table 14. Number of Diabetic Patients Who Received Self-Management Classes. Source Year of Collection Diabetic Patients Completing Educational Programs Total Number Of Diabetic Patients FY2003 FY2004 FY2003 FY2007 FY2003 FY2007 FY2003 FY2007 460 161 2,050 4,090 312 704 1,056 931 711 207 2,662 6,596 1,155 1,193 1,625 1,578 64.7% 77.8% 77% 62% 27% 59% 65% 59% VA - Phoenix 2000 2001 2002 2003 1,098 1,246 1,650 1,869 6,017 7,217 8,597 9,660 18.2% 17.3% 19.2% 19.3% BRFSS 2000 2001 2002 2003 2004 2005 2006 Not Available 55.0% 47.8% 55.2% 48.6% 54.8% 55.3% 57.4% Community Health Centers IHS - Phoenix Area IHS -Tucson Area IHS - Navajo Area Not Available Percent NOTES: ™ Community Health Centers - The type of education and the extent to which the information is provided to the patients varies from entity to entity. Patients provided a binary (yes/no) response as to whether or not they had completed a diabetes educational program. ™ IHS - Phoenix Area - During this period, 63% of the patients with diabetes received formal diet education, 55.8% received exercise information, and 72% received other information such as selftesting procedures and insulin injection technique. This sum is greater than 100% because some patients received more than one type of education. ™ IHS Tucson Area - The numbers are based on the IHS Diabetes Audit 2003, there were a total of 3,960 clients in their registry, of those 1,155 were audited. ™ Medicare - Not Available. Arizona Department of Health Services Division of Public Health Prevention Services 34 July 2008 28. Standards of Care Recommendations: The Standards of Care are presented in Table 15. Table 15. Standards of Care Recommended by the American Diabetes Association. Indicator Recommendations Diabetes SelfManagement Education (DSME) People with diabetes should receive DSME according to national standards when their diabetes is diagnosed and as needed thereafter. DSME should address psychosocial issues, since emotional well-being is strongly associated with positive diabetes outcomes. Mental Health Preliminary assessment of psychological and social status should be included as part of the medical management of diabetes. This should include, but is not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetesrelated quality of life, resources (financial, social, and emotional), and psychiatric history. Screening for problems such as depression, eating disorders, and cognitive impairment is needed when adherence to the medical regimen is poor. Physical Activity To improve glycemic control, assist with weight maintenance, and reduce risk of CVD, at least 150 minutes per week of moderate-intensity aerobic physical activity and/or at least 90 minutes per week of vigorous aerobic exercise is recommended. In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance exercise 3 times per week, targeting all major muscle groups. Weight Check at each visit. Weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. Arizona Department of Health Services Division of Public Health Prevention Services 35 July 2008 Glycemic Control Self-monitoring of blood glucose (SMBG) should be carried out 3+ times daily for patients using multiple insulin injections. For patients using less frequent insulin injections, oral agents, or medical nutrition therapy alone, SMBG is useful in achieving glycemic goals. A1C (<7) Test quarterly if treatment changes or not meeting goals. Test at least 2 times per year if stable. Microalbuminuria Test yearly if urinalysis is negative for protein. Smoking Cessation Advise ALL patients not to smoke. Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. Dilated Eye Exam People with diabetes should receive a dilated eye exam annually. Optimal glycemic and blood pressure control can substantially reduce the risk and progression of diabetic retinopathy. Neuropathy All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests. Blood pressure = <130/80 mm/Hg Comprehensive Foot Exam Lipid Profile Test at each regular diabetes visit. People with diabetes should have a comprehensive foot examination and foot self-care education annually to identify risk factors predictive of ulcers and amputations. Test yearly (less frequent if normal). (LDL ≤ 100 mg/dl HDL ≥ 40 mg/dl Triglycerides ≤ 150 mg/dl) Aspirin Therapy Use aspirin therapy (75-162 mg/day) as secondary prevention in those with a history of CVD. Use as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk. Immunizations Annually provide an influenza vaccine to all diabetic patients older than 6 months of age. Provide at least one lifetime pneumococcal vaccine for adults with diabetes. Source: Standards of Medical Care in Diabetes – 2007. (January 2007). Diabetes Care 30 (Supplement 1): S14-S41. Arizona Department of Health Services Division of Public Health Prevention Services 36 July 2008 F. DISCUSSION 29. Important Issues Not Addressed: Several measures were identified but have been omitted due to the lack of reasonably comparable data to support their inclusion. These measures are as follows: i) ii) iii) Elementary and Middle School-Aged Children Who were Overweight Use of ACE inhibitors Aspirin Therapy It is recommended that these items be evaluated in the future. It will be necessary to determine the best way to identify and collect the data needed to support each measure. 30. Limitations and Procedures: Arizona Department of Health Services’ (ADHS) Bureau of Vital Statistics• Births, deaths, and fetal deaths from original documents filed with the ADHS and from transcripts of original certificates affecting Arizona residents currently living in other states. • Death records/certificates of Arizonans who have died outside the U.S. are not included. • Cost Reporting and Discharge Data Review collect information about both hospital inpatient discharges and emergency room visits. • The Bureau of Public Health Statistics requires short-stay nonfederal hospitals to submit uniformly to ADHS every six months. This excludes patient information from federal, territorial, or other small hospitals/hospices (e.g. Indian Health Service). • Population Denominators are projections from Arizona Department of Economic Security (DES) http://www.workforce.az.gov/. Information from: http://www.azdhs.gov/plan/index.htm CDC Behavioral Risk Factor Surveillance System (BRFSS)• BRFSS is on an on-going data collection system for adult health-related behaviors of noninstitutionalized residents ages 18 and older. A standardized questionnaire (~75 questions) is used. Questions determined by the state BRFSS coordinator and CDC. • Only one adult per household is interviewed. Participants are not compensated. • Random sampling telephone survey, using disproportionate stratified sampling, random digit dialing, and a Computer Assisted Telephone Interviewing (CATI) system. • Sample size of 4,700 over a 12-month period surveyed (sample size 95 percent confidence interval of ±3 percent). Potential to represent 96.3 percent of all households with telephones in Arizona (DES, 2000). • Monthly data files sent to the Arizona BRFSS program and reports are prepared. Data is weighted based on Arizona population demographics, including number of adults and telephone lines in the household, cluster size, stratum size and age/race/sex distribution of the general population. Information from: http://www.cdc.gov/brfss and http://www.azdhs.gov/plan/brfs/ CDC Youth Risk Behavior Surveillance System (YRBSS) – • Every two years since 1991, students (grades 9-12) have been selected from a representative Arizona Department of Health Services Division of Public Health Prevention Services 37 July 2008 sample of high schools in a state to take self-reported paper and pencil questionnaires. • These questionnaires are administered to determine the prevalence of risk factors and behaviors: unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, unhealthy dietary behaviors and physical inactivity. • A limitation is that it is a self-reported questionnaire so under or over-reporting of behaviors cannot be determined. • Data represents only those who attend a high school. (About 6% of those aged 16 -17 not enrolled in a high school are not represented.) Not all 50 states participate in the survey, skewing nationwide estimates. • Survey takes 10 minutes for the facilitator to distribute and to read the directions. It takes 35 minutes for the students to take. • Arizona meets the three YRBSS weighting criteria: surveys with a scientifically drawn sample, appropriate documentation, and an overall response rate of at least 60%. Data are weighted to adjust for school and student non-responses and to make the data representative of the population of students from which the sample was drawn. Generally, data are weighted based on student sex, grade, and race/ethnicity. Information from: http://apps.nccd.cdc.gov/yrbss/ Arizona Department of Health Services Division of Public Health Prevention Services 38 July 2008 GLOSSARY ACE Inhibitors Angiotensin-Converting Enzyme Inhibitors (Blood Pressure Lowering Medicines). BRFSS Behavioral Risk Factor Surveillance System, CDC Centers for Disease Control and Prevention. CDE Certified Diabetes Educator (“Gold Standard”). CHS Contract Health Services. Denominator Number of total diabetic population who were served through the agency. FACCT Foundation for Accountability - a consortium of healthcare organizations, professional groups and governmental agencies. FFS Fee for Service. HEDIS® Health plan Employer Data Information Set - a product of the National Committee on Quality Assurance. The source for data contained in this publication is Quality Compass® 2007 and is used with the permission of the National Committee for Quality Assurance (NCQA). Any analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA. HSAG Health Services Advisory Group (Arizona Medicare Quality Improvement Organization). IHS Indian Health Service, U.S. Department of Health and Human Services. There are 12 IHS Area Offices nationwide serving American Indian and Alaska Native population. Phoenix Area IHS Provides services to tribes in Arizona (EXCEPT Pascua Yaqui, Tohono O’odham Nation and Navajo Nation), Nevada and part of Utah (Approx. 46 federally recognized tribes). Tucson Area IHS Provides services to Tohono O’odham Nation and Pascua Yaqui Tribe of Arizona. Navajo Area IHS Provides services to the Navajo Nation in Arizona, New Mexico and Utah. ITCA, Inc. Consists of 20 member tribes in Arizona, and serves and collaborates with all tribes in Arizona, Nevada and Utah. ITCA Epidemiology Center The Epidemiology Center was established by the U.S. Department of Health and Human Services through the Indian Health Service in 1996. Numerator Number of diabetic patients who experienced a specific health event. SDPS Standard Data Processing System. VAMC Veterans Affairs Medical Center. YRBSS Youth Risk Behavior Surveillance System. Arizona Department of Health Services Division of Public Health Prevention Services 39 July 2008 REFERENCES 1. ADHS Hospital Discharge Database, 1992-2006. 2. Arizona Department of Education (www.ade.state.az.us) YRBS, 2003-2005. 3. Arizona Health Status and Vital Statistics 2002-2006, ADHS. 4. Behavior Risk Factor Surveillance System, CDC 1990-2007. 5. Birth Database 1998-2006, ADHS. 6. Bureau of Public Health Statistics, Arizona Department of Health Services. BRFSS 2006: Health status and health risk behaviors of Arizonans. Phoenix, AZ: Arizona Department of Health Services, 2007. Available at http://www.azdhs.gov/plan/brfs/reports/rpt06.pdf. 7. Centers for Disease Control and Prevention, U.S. Department of Health Services. About BMI for Children and Teens. Atlanta, GA: May, 2007. Available at: http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.htm. 8. ESRD Network #15 Data System, 2000-2006. 9. Indian Health Service Diabetes Audit 2007. 10. National Center for Chronic Disease Prevention and Health Promotion. 11. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. Healthy People 2010, Vol. I, 5:1-38, 1999. Washington, DC: U.S. Government Printing Office. 12. Pediatric Nutrition Surveillance System, Centers for Disease Control and Prevention, 2005. 13. Quality Compass 2007, used with permission of the National Committee for Quality Assurance (NCQA). Arizona Department of Health Services Division of Public Health Prevention Services 40 July 2008