Stephen J. Sepe

Trends in Diabetes and Diabetic Complications, 1980–1987

OBJECTIVE Although diabetes is a major source of morbidity and mortality in the United States, only recently has a unified national surveillance system begun to monitor trends in diabetes and diabetic complications. RESEARCH DESIGN AND METHODS We established a diabetes surveillance system using data for 1980–1987 from vital records, the National Health Interview Survey, the National Hospital Discharge Survey, and the Health Care Financing Administrations records to examine trends in the prevalence and incidence of diabetes, diabetes mortality, hospitalizations, and diabetic complications. RESULTS From 1980 through 1987, the number of individuals known to have diabetes increased by 1 million—to 6.82 million. Age-standardized prevalence for diabetes increased 9% during this period, from 25.4 to 27.6/1000 U.S. residents (P = 0.03). The incidence of diabetes increased among women (P = 0.003), particularly among those > 65 yr old (P = 0.02). Age-standardized mortality rates (for diabetes as either an underlying or contributing cause) per 100,000 individuals with diabetes declined 12%, from 2350 to 2066. Annual mortality rates from stroke (as an underlying cause and diabetes as a contributing cause) and diabetic ketoacidosis declined 29% (P = 0.003) and 22% (P < 0.001), respectively. During these 8 yr, hospitalization rates for major CVD and stroke (as the primary diagnoses and diabetes as a secondary diagnosis) increased 34% (P = 0.006) and 38% (P = 0.01), respectively. Also during this period, hospitalization rates increased 21% for diabetic ketoacidosis (P = 0.01) and 29% for lower-extremity amputations (P = 0.06). From 1982 through 1986, treatment for end-stage renal disease related to diabetes increased > 10% each year (P < 0.001). The prevalence of diagnosed diabetes was nearly twice as high in blacks as in whites (P = 0.04). Blacks also had increased rates of lower-extremity amputation (P = 0.02), diabetic ketoacidosis (P < 0.001), and end-stage renal disease (P = 0.01). CONCLUSIONS Diabetes surveillance data will be useful in planning, targeting, and evaluating public health efforts designed to prevent and control diabetes and its complications.

Epidemiology and Prevention of Periodontal Disease in Individuals With Diabetes

Objective This article reviews the epidemiological evidence of the relationship between diabetes and periodontal disease, possible physiological mechanisms for the association, and effects of interventions on the occurrence and severity of periodontal disease among individuals with diabetes. Research Design And Methods A comprehensive qualitative review of published literature in the area was performed. Results Much of the research in this area was found to contain methodological problems, such as failing to specify the type of diabetes, small sample sizes, and inadequate control of covariates such as age or duration of diabetes. Conclusions Trends indicate that periodontal disease is more prevalent and more severe among individuals with diabetes. This trend may be modified by factors such as oral hygiene, duration of diabetes, age, and degree of metabolic control of diabetes. Generally, poor oral hygiene, a long history of diabetes, greater age, and poor metabolic control are associated with more severe periodontal disease. The association of diabetes and periodontal disease may be due to numerous physiological phenomena found in diabetes, such as impaired resistance, vascular changes, altered oral microflora, and abnormal collagen metabolism. With some modifications, the same prevention and treatment procedures for periodontal disease recommended for the general population are appropriate for those with diabetes. People with diabetes who appear to be particularly susceptible to periodontal disease include those who do not maintain good oral hygiene or good metabolic control of their diabetes, those with diabetes of long duration or with other complications of diabetes, and teenagers and pregnant women.

Cost-Benefit Analysis of Preconception Care for Women With Established Diabetes Mellitus

OBJECTIVE To determine whether the additional costs of preconception care are balanced by the savings from averted complications. Several studies have demonstrated the efficacy of preconception care in reducing congenital anomalies in infants born of mothers with pre-existing diabetes mellitus. RESEARCH DESIGN AND METHODS This study used literature review, consensus development among an expert panel of physicians, and surveys of medical care personnel to obtain information about the costs and consequences of preconception plus prenatal care compared with prenatal care only for women with established diabetes. Preconception care involves close interaction between the patient and an interdisciplinary health-care team as well as intensified evaluation, follow-up, testing, and monitoring. The outcome measures assessed in this study are the medical costs of preconception care versus prenatal care only and the benefit-cost ratio. RESULTS The costs of preconception plus prenatal care are

An Epidemiologic Model for Diabetes Mellitus: Incidence, Prevalence, and Mortality

17,519/delivery, whereas the costs of prenatal care only are

Epidemiology of Renal Involvement in Diabetes Mellitus

13,843/delivery. Taking into account maternal and neonatal adverse outcomes, the net savings of preconception care are

Financial Implications of Implementing Standards of Care for Diabetes and Pregnancy

1720/enrollee over prenatal care only and the benefit-cost ratio is 1.86. The preconception care program remained cost saving across a wide range of assumptions regarding incidence of adverse outcomes and program cost components. CONCLUSIONS Despite significantly higher per delivery costs for participants in a hypothetical preconception care program, intensive medical care before conception resulted in cost savings compared with prenatal care only. Third-party payers can expect to realize cost savings by reimbursing preconception care in this high-risk population.

Evaluating Outcomes of Pregnancy in Diabetic Women: Epidemiologic Considerations and Recommended Indicators

An epidemiologic model is developed to describe the incidence, prevalence, and mortality of diabetes. Available data are reviewed, analyzed, and applied to the model. The model provides a framework for understanding diabetes on a population basis, and is useful inidentifying needs and facilitating health care planning.

Translation efforts in diabetes and pregnancy.

Chronic renal failure ranks as a leading cause of death among people with diabetes mellitus. Prior to clinical onset of diabetic nephropathy, the kidneys of people with diabetes undergo changes in both function and morphology. Functional changes include increases in glomerular filtration rate (GFR) [1] and urinary albumin excretion [2, 3]. The GFR increases by as as much as 20%–30%. Subsequently, intermittent protein excretion occurs and then increases. Ultimately the GFR decreases and end-stage renal disease occurs [4]. Renal failure develops more than 5 years after the onset of constant proteinuria in people with diabetes [5].

The natural history and epidemiology of diabetic nephropathy : implications for prevention and control

This article examines the financial implications of implementing standards of care for pregnancy among women with diabetes, including both the costs of enhanced treatment and the savings of avoided adverse outcomes. Numerous studies have demonstrated the harmful effects of poor blood glucose control for both mother and fetus. Standards set forth by the American Diabetes Association aim to reduce maternal complications and fetal adverse outcomes, such as congenital malformations. Because the precise configuration of resources required to meet these standards was not outlined in the American Diabetes Association statement, a panel of physicians (all specialists in pregnancy care for women with diabetes) was convened to develop a model program. Implementing such a program during the preconception and prenatal periods will represent an intensification of resource use in the outpatient setting. However, through these preventive measures, medical care costs for maternal and fetal complications can be avoided.

Surveillance for diabetes mellitus--United States, 1980-1989.

Many programs have been applied in various settings to reduce adverse outcomes of pregnancy in women with diabetes. Efforts to standardize criteria and methods for evaluating these programs are relatively recent. Without such standardization, evaluation of the impact of many programs and comparisons among programs have not been possible. We review the suitability of available data sources for monitoring adverse outcomes of pregnancy in women with diabetes in light of epidemiological considerations relevant to selection of indicators of program impact. This article is intended to be a resource to help evaluate in a standardized fashion the impact of programs at a regional, state, or local level. We conclude that primary data (information collected by programs themselves) collected in a standardized manner are necessary for evaluation of programs for diabetes in pregnancy. Secondary data sources alone are of limited value for monitoring outcomes because of underreporting of maternal diabetes, especially in the absence of identified complications. Ultimately, the ability to rigorously assess the impact of efforts to improve outcomes of diabetes in pregnancy may depend on the creation of comprehensive statewide systems to identify women of childbearing age who have diabetes.