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EUROPEAN JOURNAL OF PUBLIC HEALTH 2003; 13 (3 SUPPLEMENT): 51–54 Fact or fiction?
C.E. DE BEAUFORT, A. REUNANEN, V. RALEIGH, F. STORMS, L. KLEINEBREIL, R. GALLEGO, C. GIORDA, K. MIDTHJELL, M. JECHT, I. DE LEEUW, E. SCHOBER, G. BORAN, G. TOLIS * Diabetes mellitus is one of the major causes of morbidity and mortality in EU/EFTA countries. Monitoring risk factorsfor diabetes and its complications will offer the possibility to evaluate the development in time as well as the influenceof possible interventions. In this investigation a list with core and secondary indicators is proposed. Availability of theseindicators and their data sources is discussed. An important variability of data sources is used in EU/EFTA countries,interfering with the comparability of the outcome. Further harmonisation as well as continuous evaluation of datasources will be necessary to provide reliable tools to monitor diabetes mellitus and its outcome on a routine basis.
Keywords: complications, diabetes mellitus, European Union, indicators
Diabetes mellitus is an important cause of increasing was then undertaken to assess the availability of these morbidity and mortality worldwide.1–4 The prevalence of indicators in the different member states.
type 2 (non-insulin dependent) diabetes mellitus is in- creasing rapidly5 and the WHO predicts that 235 million METHODOLOGY
people worldwide will suffer from diabetes in 2025. This The first step was the establishment of a list of relevant increase can be attributed to changing lifestyles, in indicators. In working group meetings with represent- particular a growing imbalance between energy intake atives of 15 EU/EFTA countries, the potential indicators and expenditure.6–8 While many people with diabetes can lead a normal life, they are also at increased risk of serious complications, including cardiovascular, renal and eye complications, although these may be postponed risk factors for complications of diabetes and; or even prevented by early diagnosis and appropriate the epidemiology of complications of diabetes.
For each group, one or more indicators were defined Given the implications for health policy, establishment (table 1). They were divided in two groups: a core (n=8) of a system for monitoring the prevalence of diabetes and secondary indicator (n=23). The core group consists mellitus, its risk factors and complications will create an of indicators, providing information on proven risk important tool to inform policies that can modify the factors or outcomes. Except for the incidence of type I outcome of this serious chronic disease.
diabetes, their outcome can be influenced by public As part of a project to test the feasibility on generating a health interventions or by improved medical care.
set of comprehensive, comparable indicators, a tentative Regular information on trends in these indicators is con- list has been established by a working group of national representatives of most EU/EFTA countries. A pilot study The group of secondary indicators provides informationon processes and intermediate outcome. Monitoring ofthese indicators offers the possibility to compare and – ifnecessary – to intervene at an earlier disease stage. The * C.E. de Beaufort1, A. Reunanen2, V. Raleigh3, F. Storms4, L. Kleinebreil5, R. Gallego6, C. Giorda7, K. Midthjell8, M. Jecht9, I. de Leeuw10, E. Schober11, influence of health care systems can be compared. As background variables necessary for interpretation, age, 1 Clinique Pédiatrique Luxemburg, GDLuxemburg sex, and socio-economic status are required.
2 National Public Health Institute, Helsinki, Finland 3 Commission for Health Improvement, London, UK A questionnaire on available data and data sources in the 4 MESOS Diabetes Centrum, Bilthoven, the Netherlands different countries was forwarded to all participants in order to get accurate information on the actual situation 8 The Norwegian University of Science and Technology, Verdal, Norway 9 GK Havelhohe Med Klinik/Diabetologie, Berlin, Germany 11 University Children’s Hospital, Vienna, Austria Eleven out of 15 participating countries provided data on 12 Adelaide and Health Hospital, Dublin, Ireland 13 Hippokratis General Hospital, Athens, Greece Four countries did not provide any data. Various reasons Correspondence: Dr C.E. de Beaufort, Clinique Pédiatrique, 4 rue Barblé,
1210 Luxembourg, GD de Luxembourg, e-mail: debeaufort.carine@chl.lu were given , among which absence of existing data, no EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 13 2003 NO. 3 Table 1 Proposed Indicators to monitor Diabetes Mellitus: Core indicators/Secondary indicators
• BMI – % of general population ≥30 kg/m2 • Annual incidence of Type 1 diabetes by age /100,000 population 0–14 years • Prevalence of diabetes mellitus /1000 population Prevalence of persons with impaired glucose tolerance and/or diet only Risk factors for complications in persons with diabetes Percent with lipid profile in last 12 monthsa DiabCare/SPSN Percent of those tested with total cholesterol >5 mmol/l With HDL <1.15 mmol/l (<1.0 mmol/l) With triglycerides >2.3 mmol/l (2.0 mmol/l) Percent with microalbuminuria in last 12 m Percent tested in last 12 ma DiabCare/SPSN Percent of the persons with diabetes who are smoking Percent with BMI ≥25 kg/m2, ≥30 kg/m2 DiabCare/SPSNAge at diagnosis by 10 year age bands Percent with fundus inspection in last 12ma UNNa /RSa /DiabCare Percent with proliferate retinopathy in last 12m Percent who received laser treatment <3 months after diagnosis of proliferative • Annual incidence of blindness due to diabetic retinopathy/total annualincidence of blindness Percent with serum creatinine tested in last 12 ma DiabCare/SPSN Percent with ESRF – serum creatinine ≥400 µmol/l (WHO definition) – in last12 months • Annual incidence of dialysis and or transplantation (renal replacement therapy inpatients with diabetes /1,000,000 general population • Prevalence (stock) of dialysis/transplantation (renal replacement therapy) in patientswith diabetes /1,000,000 general population Annual incidence of amputations above the ankle (if available: non traumatic, medical in patients with diabetes /100,000 general population Annual incidence of stroke in patients with diabetes /100,000 general Annual incidence of myocardial infarction in patients with diabetes /100,000 • Annual death rate in patients who have as primary or any cause of deathdiabetes mellitus /100,000 general population, adjusted for European StandardPopulation • Annual death rate in the general population from all causes /100,000 generalpopulation, adjusted for European Standard Population • Core indicatorICD 9: Diabetes mellitus 250; ICD 10: Diabetes mellitus E10–14HES: Health Examination Survey; HIS: Health Interview Survey; UNN: Unique national Number; RS: Reimbursement Structure; SPSN: Sentinel PracticeSurveillance network; DiabCare: Annual data collection of diabetic patients, by Primary or Secondary Care, so far on voluntary basis. Variable number ofindicators included. Main aim: evaluate and improve clinical care (St Vincent declaration 19.); HDR: Hospital Discharge Records European Union diabetes indicators representative data, or not easy accessible data. From the information on the number of persons with diabetes.
8 core indicators, only one was available in all countries Computerisation of the social security is another source (table 2). Data collection was performed through different through which all those persons treated with oral hypo- sources. Obesity was reported either through Health glycemic agents or insulin can be identified. However, Examination Surveys (HES) or Health Interview Surveys those whose diabetes is treated by diet alone will be (HIS). Prevalence of diabetes was also documented included by only some sources, causing variation in the through different sources with, in several countries, results obtained from HES. Some countries use a unique Incidence of type 1 diabetes in children has been studied national number that can be linked to the reimbursement extensively in the EURODIAB ACE study.13,14 Using structure of the health care system and thus provide the same methodology, a comparable data set was Table 2 Availability of core indicators to monitor diabetes in EU/EFTA countries
Obesity: % of general population with a BMI ≥30 kg/m2 9 Annual incidence of Type 1 diabetes by age /100.000 100,000 population 0–14 years Prevalence of diabetes mellitus /1000 population Annual incidence of blindness due to diabetic retinopathy/total annual incidence of blindness Annual incidence of dialysis and/or transplantation (renal replacement therapy in patientswith diabetes /1,000,000 general population Prevalence (stock) of dialysis/transplantation (renal replacement therapy) in patients withdiabetes /1,000,000 general population Annual death rate in patients who have as primary or any cause of death diabetes mellitus/100,000 general population Annual death rate in the general population from all causes /100,000 general population, adjusted for European Standard Population Table 3 Available secondary indicators in EU/EFTA countries
Prevalence of persons with impaired glucose tolerance and/or diet only Percent of persons with diabetes mellitus with a HbA1c tested in last 12 monthsa 11 Percent of persons tested, who have a HbA1c value >7.5% Percent of persons with diabetes mellitus with lipid profile in last 12 monthsa 11 Percent of those tested with total cholesterol >5 mmol/l With HDL <1.15 mmol/l (<1.0 mmol/l) With triglycerides >2.3 mmol/l (>2.0 mmol/l) Percent of persons with diabetes mellitus with microalbuminuria tested in last 12 ma 10 Percent of those tested, with microalbuminuria Percent of persons with diabetes mellitus with Bloodpressure measurement in last 12 ma 11 Percent of those tested with BP >140/90 in last 12 m Percent of the persons with diabetes mellitus who are smoking Percent of persons with diabetes mellitus with BMI ≥25 kg/m2, ≥30 kg/m2 9 Age at diagnosis of diabetes mellitus by 10 year age bands Percent of persons with diabetes mellitus with fundus inspection in last 12ma 10 Percent of those tested, with proliferate retinopathy in last 12m Percent of those tested who received laser treatment <3 months after diagnosis of proliferative retinopathy Percent of persons with diabetes mellitus with serum creatinine tested in last 12 ma 5 Percent of those tested with ESRF – serum creatinine ≥400 µmol/l (WHO definition) Annual incidence of amputations above the ankle (if available: non traumatic but,medical) in patients with diabetes mellitus /100,000 general population Annual incidence of stroke in patients with diabetes mellitus /100,000 general population Annual incidence of myocardial infarction in patients with diabetes mellitus /100,000general population EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 13 2003 NO. 3 established over a 10 year period in all EU/EFTA the data sources has to be a part of the ongoing countries. In some countries the registries created have monitoring. Further harmonisation of data sources will been continued, whereas in others, they have been improve comparability of the indicators between the stopped. Hospital Discharge Records and Reimbursement EU/EFTA countries, and thus offer a valuable tool to Structures can provide detailed information on the evaluate the effect of public health interventions.
incidence and prevalence of renal replacement therapy Flexibility with respect towards new developments for (Transplantation and/or dialysis). However, data on early detection remains necessary. This will allow hospital discharge will be influenced by the extent to improved surveillance and improved outcome in the which care providers reporting diabetes among secondary diagnostic codes.
Mortality in general is well documented but mortality This project was supported by the Health Monitoring Program, attributable to diabetes is not available in all countries.
SANCO EU, (2000CVG3–503).
The secretarial help of Edith Everwijn is kindly acknowledged.
Secondary indicators were available in 2 to 11 of thecountries (table 3). The most important source is datacollection through Diab Care-like projects.
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Serrano Rios M. Relationship between obesity and the collection of these secondary indicators is not considered increased risk of major complications in non-insulin dependent by any of the countries as representative for the whole diabetes mellitus. Eur J Clin Invest 1998;28S2:14-1748.
country. For some of indicators different data sources were Abbasi F, Brown BW Jr, Lamendola C, McLaughlin T, Reaven GM. Relationship between obesity, insulin resistance, and coronary heart disease risk. J Am Coll Cardiol 2002;40:937-43.
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diabetes, 1995-2025: prevalence, numerical estimates andprojection. Diabetes Care 1998;21:1414-31.
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Gu K, Cowie CC, Harris MI. Mortality in adults with and In a first analysis, a surprising lack of comparable data and without diabetes in a national cohort of the US population: data sources was observed. While infectious diseases are 1971-1993. Diabetes Care 1998;21:1138-45.
carefully monitored world wide, this group of non- Diabetes Control and Complications Trial Research Group. The effect of intensive treatment on diabetes on the communicable diseases, is not monitored in a continuous development and progression of long term complications in type way. Despite the increase in prevalence, the human and 1 diabetes mellitus. N Engl J Med 1993;329:977-86.
economic burden of the disease and its complications, UK prospective Diabetes Study Group 34. Effect of intensive bloodglucose control with metformin on complications in comparable data is scarce on national or representative overweight patients with type 2 diabetes. Lancet 1998;352:854-65.
level in different EU/EFTA countries. Monitoring Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, diabetes mellitus is very important since early inter- Lachin JM, Walker EA, Nathan DM. Reduction in the incidence oftype 2 diabetes with lifestyle intervention or metformin. N Engl J vention may prevent or delay serious complication. These indicators could play a role in the evaluation of public Diabetes Prevention Program Research Group. Costs health interventions and tracking changes in quality of associated with the primary prevention of type 2 diabetesmellitus in the diabetes prevention program. Diabetes Care care. A core group of indicators as well as a secondary group are proposed for short and long-term implementa- The Diabetes Control and Complications Trial Research tion. Different data sources are proposed, although for Group. The relationship of glycemic exposure (HbA1c) to the riskof development and progression of retinopathy in the Diabetes some indicators a clear preference is identified. Due to Control and Complications Trial. Diabetes 1995;44:968-83.
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