Transcript Slide 1

Diabetes and Associated Diseases in Primary Care:
Regional Differences in Texas
®
Ryan Horton, Swati Avashia MD, Jason Hill M.S. Sandra Burge PhD
The University of Texas Health Science Center at San Antonio
Introduction
Methods
Type 2 diabetes is a common disease that costs the
United States roughly $218 billion dollars1 every year.
When diabetes is complicated with metabolic
syndrome it is even more important to diagnose and
initiate treatment because it “varies substantially by
ethnicity and is associated with several potentially
modifiable lifestyle factors2.” Researchers have
analyzed the prevalence of this common disease in
different regions of the United States and found it is
most prevalent in the Southern and Appalachian states
and least prevalent in the Midwest and the Northeast3.
However, little is known about the regional variation
of diabetes and its commonly associated diseases
across Texas (North, Central, and South). This study
aims to identify those regional differences in the
prevalence of diabetes and its associated diseases.
Additionally, patient demographic characteristics in
different regions of Texas are presented.
Subjects Medical students documented 726
outpatient visits from 9 family medicine residency
programs across Texas. Eligible patients included all
patient-visitors seeing a physician in the study
clinics during the study period.
Measurement A Visit Survey documented patient
demographics, vital signs, reasons for visit,
diagnoses, health education, medications prescribed,
diagnostic tests ordered, non-medical treatments,
referrals to specialists and admissions to hospitals.
The Northern region consisted of Dallas, Fort
Worth, and Garland. The Central region consisted of
San Antonio and Austin. The Southern region
consisted of Corpus Christi, McAllen, and
Harlingen.
Procedure Over a one-month period, students
identified half-days for data collection, then
randomly selected a physician to shadow. During
the physician’s clinic session, the student invited all
the physician’s patients to participate in the
study. After informed consent, students observed the
visit and completed the Visit Survey.
This sample was 66.6% female, 60.6 % Hispanic, and
12.9% African American. The average age was 43.9,
ranging from infancy to 92 years old. Only 16.6% of all
patients had private health insurance. Patients in
Central Texas had the highest prevalence of diabetes,
hyperlipidemia, and metabolic disease compared to the
other regions (p<.05, Figure 1, 2, 4). Hypertension was
lowest in the South Texas region, though statistically
insignificant (p=.056, Figure 3). More than 50% of
patients with diagnosed diabetes also had
hyperlipidemia and hypertension (metabolic
syndrome). Race and ethnicity varied significantly by
region, with the highest proportions of Hispanics in
South Texas and the highest proportions of African
Americans and Asians in North Texas (p=.000). Minor
regional variations existed among Caucasians. We
found no significant gender or age differences by
region.
Fig. 1: Diabetes by Region
Sample Percentage
Results
40
30
28.1
30
North
Central
South
20
33
30
26
20
North
Central
South
10
Prevalence of Diabetes
Fig. 3: Hypertension by Region
Sample Percentage
Sample Percentage
40.3
39.4
40
0
Fig. 2: Hyperlipidemia by Region
50
50
100
80
56
60
56.8
46.3
40
North
Central
South
20
10
0
Prevalence of Hypertension
0
Prevalence of Hyperlipidemia
Sample Percentage
50
Fig. 5: Ethnicity of Patients by Region
Fig. 4: Metabolic Syndrome by
Region
27.6
Hispanic
72.9
40
North
Central
South
25.4
30
20
63.1
17
13.4
34.1
African
American
North
13.7
2.6
Central
23.6
Caucasian
South
21.4
24.2
10
14.6
0
Asian
Prevalence of Metabolic Disease
1.8
0.4
0
Conclusions
Sample
50 Percentage 100
In 2006, the National Health Statistics Report documented that disease prevalence in ambulatory patients
was: 27.9% hypertension, 16.19% hyperlipidemia, and 11.8% diabetes4. The prevalence of these diseases
observed in RRNet clinics, while variable by region, is far higher than national averages. Central Texas
presented with the highest reporting of all diseases, at proportions more than double the national average.
This patient sample was far less likely to have private health insurance, compared to the 2006 National
Health Statistics Report patient (16.6% versus 60.5%).4 This sample characteristic is likely due to residency
programs providing health care to the underserved, which may also explain why the prevalence of chronic
disease was so high.
A puzzling finding was the low prevalence of diabetes, hyperlipidemia, hypertension, and metabolic
syndrome in the southern region of Texas, despite this region having the highest population of Hispanics.
Hispanics are known to have the highest prevalence of diabetes (13.9%) compared to African Americans
(10.2%) and Caucasians (6.2%) so it is unusual that patient visits in a highly Hispanic region would have low
rates of diabetes5. One likely explanation is that the residency programs in Harlingen and McAllen Texas serve
a disproportionate number of young, healthy, pregnant mothers. The high rates of healthy pregnancy at these
sites likely skewed this data.
Primary care clinicians should become very familiar with the epidemiology of chronic disease within their
own communities and regions. We found wide regional variations of diabetes and its associated diseases in a
single state, and comparatively low rates of diabetes in a region where we expected to find more. This
information should remind physicians that quality chronic disease management requires a thorough
understanding of one’s community.
Acknowledgements
This study was conducted in The Residency
Research Network of Texas (RRNeT) with
support from the Office of the Medical Dean at
UTHSCSA and the Health Resources and
Services Administration (Award #
D54HP16444).
References
1.
2.
3.
4.
5.
American Diabetes Association. http://www.diabetes.org/, 2011
The Metabolic Syndrome: Prevalence and Associated Risk Factor Findings in the US Population From the
Third National Health and Nutrition Examination Survey, 1988-1994. Yong-Woo Park, MD, PhD;
Shankuan Zhu, MD, PhD; Latha Palaniappan, MD; Stanley Heshka, PhD; Mercedes R. Carnethon, PhD;
Steven B. Heymsfield, MD. Arch Intern Med. 2003;163:427-436
Diabetes Prevalence and Diagnosis in US States: analysis of health Surverys. Goodarz Danaei, Ari B.
Friedman, Shefali Oza, Christopher JL Murray, Majid Ezzati. Population Health Metrics, 7:16, 2009.
National Ambulatory Medical Care Survey: 2006 Summary. Cherry DK, Hing E, Woodwell DA,
Rechtsteiner EA. National Health Statistics Report 2008.
Epidermiologic correlates of NIDDM in Hispanics, whites and blacks in the U.S. population. Harris MI.
Diabetes Care 14 (Suppl. 3):639-648, 1991.