Epidemiology of Diabetes: Prevalence, Complications and ......¡Viva la Vida con Salud! Centro de...

¡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 HealthMedical 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 dataScientific 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

11.0

7.4 7.1 7.0

5.0

Prev

alen

ce (%

)

Puerto Rico(2003)*

Australia(2002)**

UnitedStates (2003)*

Arabia(1999)***

Alaska(2003)*

* > 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

7.16.76.5

6.15.65.4

0.01.02.03.04.05.06.07.08.0

1998 1999 2000 2001 2002 2003

Prev

alen

ce (M

ean

%)

* 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

7.0

6.56.0

5.45.1

4.9

7.16.7

6.2

5.65.35.1

4.04.44.85.25.66.06.46.87.27.68.0

1997 1998 1999 2001 2001 2002

Year

Inci

denc

e (x

1,0

00)

CrudeAdjusted

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

Prev

alen

ce(%

)


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

9.4

9.68.5

9.810.5

11.0

4.54.9

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 comercialversus 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

Aguadilla Isabela

CaboRojo

Lajas

MayaguezHormigueros

Saba

naG

rand

e

Yauco

Maricao

Las Marías

Gua

yani

lla

Quebradillas

Camuy

Hat

illo

Arecibo

Ponce

Florida

Barceloneta

Juana Díaz

Orocovis

Vega

Baj

a

Cataño

Vieques

SanSebastián Lares

Utuado

AdjuntasPe

ñuel

as

Manatí

Jayuya

Ciales

Comerío

Arroyo

Patillas

Cidra

TrujilloAlto

Caguas

Maunabo

Yabucoa

Junc

osLa

s Pi

edra

s

Humacao

Naguabo

Morovis

VegaAlta

ToaAlta

Naranjito

Barran-quitas

Bay

amón

Dor

ado

ToaBaja

Villalba Aibonito

AguasBuenas

Gua

ynab

o

San

Juan

CarolinaC

anóvanas

LoízaRíoGrande

Ceiba

Faja

rdo

Luquillo

Salinas

Corozal

Cayey

Gurabo

SanLorenzoSan

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

9.511.1

9.010.5 10.5 10.4 10.8 11.2

Prev

alen

ce (%

)

1997 2001 2002 2003Year

Male Female* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral

Risk Factor Surveillance System 1997-2003. Atlanta, GA: United States, Department of Health and Human Services.


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

26.8

22.1

1.2

23.2

1.0

8.2

26.2

23.7

2.3

8.7

23.6

1.4

7.4

24.2

8.5

25.1

0

5

10

15

20

25

18-34 35-54 55-74 >74

Año

Prev

alen

ce (%

)

1997 2001 2002 2003



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Prevalence of Diabetes by Age Groups,Health Insurance Companies in Puerto Rico 2000* y 2001**

3.25

8.38

16.21

7.99

14.65

1.470.630.17

15.9115.31

0.3

3.61

0.72

1.65

0

2

4

6

8

10

12

14

16

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

Prev

alen

ce (%

)

2000 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 comercialversus 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

4.7

14.3

11.6

13.2

14.414.4

6.8

3.9

6.0 5.8

3

5

7

9

11

13

15

1996 1997 1998 1999 2000Age Group

Prev

alen

ce (%

)

Unemployed Employed

* 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

2.61.8

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

Cerebrov

ascular

Acci

dents

Amputations

Artropath

y

Dupuitren

Diagnosti

cRen

al Fail

urePoly

neurit

isReti

nopathy

Ischem

ic Hea

rt Dise

aseAthero

sclero

sis

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: Grupocomercial 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.

Cerebrovascular Accidents AmputationsRenal Failure Retinopathy

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

60.064.8

Rat

e (x

100

,000

)

Male Female

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: Grupocomercial 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

87.562.5

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: Grupocomercial 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

78.481.6

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: Grupocomercial 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 Diabetesin 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

POR

(IC

95%

)


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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 0.37.1

2.7

14.67.2

29.9

17.4

47.8

30.9

61.7

41.4

61.3

51.2

0

10

20

30

40

50

60

70Pr

eval

ence

(%)

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 transientischemic 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

0.84,4370.31,4202.011,17211.061,857Overall

8.16103.828614.71,11244.53,364≥ 75

4.98011.627212.01,97445.37,45665-74

2.31,3340.84456.93,91235.420,18155-64

1.18770.32533.12,51021.517,28445-54

0.54250.1981.11,0449.58,75435-44

0.32340.04390.54484.03,54925-34

0.11560.01270.081720.61,269≤ 24

PrevalenceNPrevalenceNPrevalenceNPrevalenceN

CerebrovascularAccident/Transient

Ischemic Attack

Congestive Heart Failure

Coronary Artery Disease

HypertensionAge group (years)

Health Sector: Private


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Prevalence of Specific Cardiovascular Conditions by Age Group and Health Sector, Puerto Rico, 2001

0.15430.96,6871.39,7848.766,037Overall

0.62426.32,6407.63,17531.413,151≥ 75

0.31452.91,4325.52,76729.014,49365-74

0.1941.81,2953.12,27624.918,15355-64

0.1440.97401.299714.711,96945-54

0.0190.43380.43256.15,39535-44

0.0180.21530.11262.32,02925-34

0.010.03890.041180.3847≤ 24

PrevalenceNPrevalenceNPrevalenceNPrevalenceN

CerebrovascularAccident/Transient

Ischemic Attack

Congestive Heart Failure

Coronary Artery Disease

HypertensionAge group (years)

Health Sector: Public


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Prevalence of Cardiovascular Conditions in an Insured Population by Sex, Puerto Rico, 2001

(11.68-15.44)13.5177,830(12.57-12.74)12.777,276(14.16-14.32)14.2100,421Both

(11.62-11.77)11.788,668(10.2-10.4)10.335,801(15.72-16.00)15.952,867Public

(15.98-16.08)16.089,162(12.80-13.00)12.941,608(15.97-16.24)16.147,554Private

CI 95%PrevalenceNCI 95%PrevalenceNCI 95%PrevalenceN

TotalMaleFemaleHealth Sector

Sex

* Cardiovascular Conditions included the following: hypertension, coronary artery disease, congestive heart failure, cerebrovascular accident, transientischemic 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 glycosylatedhemoglobin 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. BoletínEstadístico 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 andEpidemiology, Graduate School of Public Health, Medical SciencesCampus, 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 EstadísticasWild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.


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ReferencesDunstan DW, Zimmet PZ, Welborn TA, Courten MP, Cameron AJ, SicreeRA, 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.

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