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National Statistics and Opportunities for Improved Surveillance,
Prevention, and Control
MORBIDITY
Disability
Diabetes is associated with more disability days and therefore increased
loss of productivity as compared with the toll of disability among those
without diabetes. Of those in the working age population (35 to 64 age
group), 23% of people with diabetes reported one or more disability days
(in bed or with restricted activities) in a two-week period compared with
11% of those without diabetes. In the 35 to 64 age group, 9.3% were disabled
for the entire two-week period (i.e., they had had 14 disability days
in the previous two weeks), compared with 2.9% of people without diabetes
(Table 5).
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TABLE 5
Distribution of self-reported number of disability
days in a 2-week period, by age group and diabetes status - Canada
excluding Territories, 1996/97
|
|
# of
disability days
|
% distribution by age group
|
|
35 - 64
|
65+
|
|
With diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
| 0 |
77.3
|
89.1
|
77.7
|
85.6
|
| 1-4 |
8.7
|
5.5
|
5.1
|
4.4
|
| 5-13 |
4.7*
|
2.6
|
3.8*
|
3.2
|
| 14 |
9.3
|
2.9
|
13.4
|
6.7
|
* Estimate has high sampling variability.
Notes: Disability day = a day in bed or with restricted activities.
Cause of disability day is not diabetes-specific. Sample sizes in
the 12-34 age group with diabetes were too small to be expressed as
percentages.
Source: LCDC 1998 - using National Population Health Survey, 1996/97,
Health Share File, preliminary release. |
Of people who reported at least one disability day in the previous two-week
period, those with diabetes had had an average of nine disability days
compared with an average of six among those without diabetes (Table
6).
|
TABLE 6
Mean number of disability days in a 2-week period
among people
reporting at least one disability day, by diabetes status and
age group - Canada excluding Territories, 1996/97
|
|
Mean number of disability days by age group
|
|
12-34
|
35 - 64
|
65+
|
Population (12+yrs.)
|
|
With
diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
|
4.37
|
4.61
|
8.13
|
6.51
|
10.27
|
8.93
|
8.88
|
6.10
|
|
Notes: Cause of disability
day is not diabetes specific. Disability day = a day in bed or with
restricted activities.
Source: LCDC 1998 -
using National Population Health Survey, 1996/97, Health Share File,
preliminary release.
|
Please note that these disability days (in bed or with restricted activities)
are not necessarily due to diabetes, since the specific cause of the disability
was not obtained in the NPHS survey. However, NPHS respondents were asked
to state the main cause of any long-term physical/mental condition or
health problem leading to activity restriction (not equivalent to "disability
day"). In response to this question probing chronic conditions leading
to activity restriction, "disease" was identified as the main cause of
the activity restriction by 64% of people with diabetes aged 35 to 64,
and 66% of people with diabetes aged 65 and over.
General Health Perception
Self-perceived health status has been found to correlate with mortality
rate, indicating that people with poorer self-ratings of health tend to
die sooner than those with higher personal health ratings(13).
Self-perceived health status was much worse among those with diabetes
than those without (Table 7).
Among the working age population (35 to 64 years), 34% of people with
diabetes perceived their general health as fair or poor compared with
only 9% of people without diabetes. Similarly, in the over 65 age group,
43% of people with diabetes as compared with 19% without rated their general
health as fair or poor.
|
TABLE 7
Distribution of general health perception, by
age group and
diabetes status - Canada excluding Territories, 1996/97
|
|
Perception of general health
|
% distribution by age group
|
|
35 - 64
|
65 and over
|
|
With diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
| Poor |
12.9
|
1.9
|
12.8
|
5.2
|
| Fair |
21.2
|
7.2
|
30.5
|
13.9
|
| Good |
33.7
|
27.3
|
34.6
|
37.8
|
| Very good |
28.4
|
39.0
|
18.1
|
29.8
|
| Excellent |
3.8*
|
24.6
|
4.1*
|
13.3
|
* Estimate has high sampling variability.
Notes: Diabetes was self-reported. The sample sizes in the 12-34 age
group with diabetes were too small for the percentage to be expressed.
Source: LCDC 1998 - using National Population Health Survey 1996/97,
Health Share File, preliminary release. |
Health Care Utilization
- Outpatient Visits
On the basis of physician reports (IMS Canadian Disease and Therapeutic
Index data), 79% of all visits to physicians for diabetes over a 12-month
period are made by patients aged 50 years and older. This has been
consistent from 1992 to 1996. According to the most recent data (Figure
4), the proportion of visits by age group increased with age,
peaking at 60 to 69 years (30.3%) and then declined. Treatment (new
or refill medication prescribed) and non-treatment visits followed
the same pattern with increasing age. The proportion of treatment
visits to total visits ranged from 58% in the youngest age group to
74% in the 60 to 69 year age group.
The number of visits per person in 1996 by age group (Figure
5) indicates that the largest percentage of single visits occurred
in the youngest age group. The proportions with four or more visits
and 11 or more visits increased with increasing age.
Self-Reported Consultations with Medical Doctor. People
with diabetes in all age groups reported more frequent visits (not
necessarily diabetes-specific) to medical doctors in the previous
year than did those without diabetes (Table
8). The highest difference was in the 35 to 64 age group, in which
people with diabetes reported an average of seven visits to a family
doctor or general practitioner in the previous 12 months compared
with an average of three visits by people without diabetes.
|
FIGURE 4
Age distribution of treatment* and non-treatment diabetes
visits to physicians - Canada excluding Territories, 1996
* Diabetes medication prescribed
Source: LCDC 1997 - using IMS Canadian Disease and Therapeutic Index
- year ending December, 1996.
FIGURE 5
Diabetes visits to physicians by age group -
Canada excluding Territories, 1996
Source: LCDC 1997 - using IMS Canadian Disease
and Therapeutic Index - year ending December, 1996.
Diabetes Education. Diabetes is a condition that requires
a great deal of self-management. Diabetes education is a key foundation
of adequate diabetes control. The proportion of Canadians with diabetes
who receive formal diabetes education is unknown.
|
TABLE 8
Mean number of visits* to a family
doctor or general practitioner in previous 12 months,
by age group and diabetes status - Canada excluding Territories,
1996/97
|
|
Mean number of visits by age group
|
|
12-34
|
35 - 64
|
65+
|
Population (12+yrs)
|
|
With
diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
|
4.09
|
2.74
|
7.36
|
2.92
|
7.04
|
4.43
|
7.00
|
3.04
|
|
* Visits are not diabetes-specific
Note: Visit = see or
talk on the telephone with a family doctor or general practitioner
about personal physical, emotional or mental health.
Source: LCDC 1998
- using National Population Health Survey, 1996/97, Health Share
File, preliminary release.
|
Self-Reported Homecare Service Utilization. Home care
use was nearly twice as high among people aged 65 and older with diabetes
as among those without. In this age group, 16% of people reported
receiving home care in the previous year compared with 9% of those
without diabetes (NPHS 1996/97).
Self-Reported Frequency of Eye Examinations. The Canadian
Diabetes Association's 1998 clinical practice guidelines recommend
annual screening for diabetes-related eye disease (retinopathy) for
those with Type 1 diabetes, beginning five years after diagnosis,
and at least every four years for those with Type 2 diabetes who have
no or minimal retinopathy(14).
From NPHS 1996/97 data, it is clear that people with diabetes do
have more frequent eye examinations than those without. Over 60% of
people with diabetes reported having had an eye examination within
the previous year compared with 40% of those without diabetes (Table
9).
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TABLE 9
Period of time since last eye examination,
by diabetes status and age group -
Canada excluding Territories, 1996/97
|
|
Time period since last exam
|
Mean number of visits by age group
|
|
12-34
|
35 - 64
|
65+
|
Population (12+yrs)
|
|
With
diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
With diabetes
|
Without diabetes
|
| Less than 1yr ago |
54.1
|
37.7
|
57.2
|
39.7
|
70.2
|
55.7
|
62.8
|
40.9
|
| 1-2 yrs ago |
---
|
17.6
|
25.2
|
20.8
|
15.0
|
18.6
|
20.4
|
19.3
|
| 2-3 yrs ago |
---
|
11.0
|
8.9
|
13.8
|
6.5*
|
11.4
|
7.6
|
12.4
|
| 3+ yrs ago |
---
|
25.9
|
7.5
|
21.3
|
8.2
|
13.6
|
8.5
|
22.1
|
| Never |
---
|
7.8
|
---
|
4.4
|
---
|
0.8
|
---
|
5.3
|
* Estimate has high sampling variability.
Notes: --- = the sample size is too small to be expressed as a
percentage.
Diabetes was self-reported. Data on eye examination fre quency
are derived from two NPHS variables.
Source:LCDC 1998 - using the National Population Health Survey
1996/97, Health Share File, preliminary release. |
Of those with diabetes, 30% specified their condition as one of
the reasons for an eye examination; other common reasons were "to
make sure all was well" (40%), and "prescription needs changing" (31%).
Self-Reported Blood Pressure Assessment. High blood
pressure (hypertension) contributes to the complications of diabetes,
such as cardiovascular disease and kidney disease (nephropathy). Therefore,
regular blood pressure checks are recommended for people with diabetes.
Based on self-report data that almost all people with diabetes (99%)
have had their blood pressure checked, and over 90% in all age groups
with diabetes have had their blood pressure checked in the previous
year, it appears that the vast majority are being monitored for hypertension
(Table 10).
|
TABLE 10
Percentage of people who reported having
had their blood pressure
taken within the previous year among those who had ever had
their blood pressure taken*, by diabetes status and age group
-
Canada excluding Territories, 1996/97
|
|
Diabetes status
|
% reporting blood pressure taken in previous
year, by age group
|
|
12 - 34
|
35- 64
|
65+
|
| With diabetes |
94.9
|
94.4
|
97.2
|
| Without diabetes |
68.9
|
76.0
|
90.6
|
* 96% of NPHS respondents had had
their blood pressure taken at least once (99% of people with diabetes
and 95% of people with out diabetes).
Note: Diabetes was self-reported.
Source: LCDC 1998 - using the National Population Health Survey
1996/97, Health Share File, preliminary release. |
Medication Use Data from Pharmacies. The total
number of units of diabetes medications dispensed through pharmacies
in Canada has increased for all medication types from 1993 to 1997.
Sulphonylureas were the most common, followed by biguanides, insulin
and alpha-glucosidase inhibitors (1996-1997 only) (Figure
6). For oral hypoglycemic medication, the number of tablets will
vary with daily dosage routines. Given that sulfonylureas are usually
indicated 1-2 times per day compared with the biguanides at 2-3 times
per day, one could expect the actual difference between these two groups
in terms of total number of people receiving the medications to be greater
than that suggested by the graph.
FIGURE 6
Total units* of diabetes medications dispensed
by year - Canada excluding Territories, 1993-1997
* Tablets, capsules and millilitres
Source: LCDC 1997 - using IMS Canada Compuscript- year ending December,
1993, 1994, 1995, 1996, 1997.
Figure 7 compares the distribution
within diabetes medications dispensed by medication type over time.
In the same five-year period, the proportion of sulphonylureas dispensed,
compared with the total, decreased from 68% to 57%, and for biguanides
the proportion increased from 27% to 37%. Insulin as a proportion
of all diabetic medications has remained fairly constant.
FIGURE 7
Distribution of diabetes medications dispensed by year -
Canada excluding Territories, 1993-1997
* Tablets, capsules and millilitres.
Source: LCDC 1997 - using IMS Canada Compuscript- year ending December,
1993, 1994, 1995, 1996, 1997.
Data from Physician Prescriptions. Prescriptions from
general practitioners and family medicine specialists accounted for
86% of all oral hypoglycemic and 63% of all insulin medication units
dispensed in 1997 (Figure 8).
FIGURE 8
Distribution of diabetic medications dispensed by physician
specialty - Canada excluding Territories, 1997
* Tablets, capsules and millilitres.
Source:LCDC 1997 - using IMS Canada Compuscript- year ending December,
1997.
Self-Reported Medication Use. An estimated 28% of
Canadians with diagnosed diabetes were taking only insulin to control
their diabetes, 54% were taking drugs (not insulin), 8% were taking
both insulin and drugs, and 10% were using only diet to control their
condition (Table 11).
Provincial government drug benefit plans could be an important source
of data on the management of diabetes among those who are over 65
years of age. In the over-65 age group, an estimated 198,000 persons
with self-reported diabetes were taking drugs (not insulin) to control
their condition, 59,000 in the same age group were taking only insulin
for their diabetes, and 27,000 people were taking both insulin and
drugs (Table 11).
|
TABLE 11
Self-reported medication use for diabetes,
by age group - Canada excluding Territories, 1996/97
|
|
Age group
|
% distribution of self-reported medication
use for diabetes
(estimated number of cases)
|
|
Diet only
|
Drug/no insulin
|
Drug + insulin
|
Insulin only
|
Other
|
|
12 - 34
|
---
|
---
|
---
|
60.2*
(21,000)
|
0
|
|
35 - 64
|
13.0
(39,000)
|
46.4
(141,000)
|
7.7*
(23,000)
|
32.7
(99,000)
|
---
|
|
65+
|
6.5
(20,000)
|
65.1
(198,000)
|
9.0*
(27,000)
|
19.3
(59,000)
|
---
|
|
All (12+)
|
9.8
(63,000)
|
53.8
(345,000)
|
8.4
(54,000)
|
27.8
(178,000)
|
---
|
|
* Estimate has high
sampling variability.
Notes: Other = unspecified.
-- = the sample size was too small for the percentage to be
expressed. Diabetes and medication use are self-reported. Drug
= any drugs other than insulin
Source: LCDC 1998 - using the National
Population Health Survey 1996/97, Health Share File, preliminary
release.
|
Although the numbers are small, NPHS cohort-based data suggest a
trend toward increased insulin use and decreased non-pharmacologic
management of diabetes (Table
12).
|
TABLE 12
Cohort-based trends in self-reported medication
use for diabetes -
Canada excluding Territories, 1994/95-1996/97
|
|
Medication use
|
% distribution by diabetes group
|
|
Diabetes in 94/95-96/97
|
New diabetes 96/97
|
|
1994/95
|
1996/97
|
1994/95
|
1996/97
|
| No pills/no insulin |
31.5
|
20.8*
|
100
|
56.3*
|
| Pills/no insulin |
47.4
|
47.5
|
0
|
37.4*
|
| Pills + insulin |
---
|
---
|
0
|
---
|
| Insulin only |
17.9*
|
25.5*
|
0
|
---
|
* Estimate has high sam pling vari
abil ity.
Notes: -- = the sample was too small for the percentage to be
expressed. New diabetes 96 = no diabetes in NPHS 1994 but reported
diabetes in NPHS 1996 and reported year of diagnosis was after
1994. An extremely small percentage of respondents who reported
no diabetes in 1994 and 1996 also reported taking insulin only
(n = 4) or pills only (n = 7) in 1994; and insulin only (n = 7),
pills only n = 17), or pills and insulin (n = 3) in 1996.
Diabetes 94/96: n = 713,000 (approx. weighted count). New Diabetes
96: n = 114,000 (approx. weighted count).
Source: LCDC 1998 - using the National Population Health Survey
1994/95-1996/97, Longitudinal Share File, preliminary release. |
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Hospitalizations
Diabetes is usually diagnosed and treated on an outpatient basis
and hence tends to be poorly represented in hospital discharge records.
Furthermore, people with diabetes are usually admitted to hospital
because of the complications of diabetes, hence the presence of diabetes
may not be recorded in the hospital discharge record. For example,
Ontario data in the 1995/96 fiscal year indicated that for 12,046
hospital stays diabetes was given as the most significant cause for
the hospitalization. However, there were another 28,586 hospitalizations
for which diabetes probably affected the length of stay(15).
Current (1995) Rates. There were approximately 34,000
hospital separations (end of hospital stay due to discharge or death)
attributable to diabetes in 1995. This figure represents over 400,000
hospital days for diabetes. The current (1995) age-standardized rates
for diabetes (standardized to the 1991 Canadian population) are 112
hospital separations per 100,000 population (121/100,000 among males;
104/100,000 among females) and 1,368 hospital days per 100,000 population
(1,511/100,000 among males; 1,240/100,000 among females).
The crude 1995 hospitalization rates for diabetes are 115 hospital
separations and 1,427 hospital days per 100,000 per year.
Comparison of Hospitalizations for Diabetes and Selected Diseases,
by Sex, 1995. In order to help put the health care burden
of diabetes into perspective, hospitalizations (calculated as total
number of hospital separations and total number of hospital days)
for diabetes are compared with those for other selected diseases,
namely breast cancer, prostate cancer and HIV/AIDS, which have been
recognized as important public health problems.
In terms of direct health care costs due to hospitalizations in
1995, males had more hospital separations for diabetes than for prostate
cancer or HIV/AIDS (Figure 9),
and also spent more days in hospital for diabetes-related events than
for the other two diseases (Figure
10). Females had more hospital separations due to breast cancer
than to diabetes or HIV/AIDS (Figure
9); however, they spent more days in hospital for diabetes than
for breast cancer or HIV/AIDS (Figure
10).
FIGURE 9
Total number of hospital separations* for diabetes,
cancer (prostate, breast), and HIV/AIDS, by gender -
Canada excluding Territories, 1995
CD-9 Codes: Diabetes (250), Prostate Cancer (185), Breast
Cancer (174, 175), HIV/AIDS (042-044).
* Hospital separations are not person-specific.
Source: LCDC 1998 - using Statistics Canada Morbidity Data
FIGURE 10
Total number of hospital days* for diabetes, cancer
(prostate, breast), and HIV/AIDS, by gender -
Canada excluding Territories, 1995
CD-9 Codes: Diabetes (250), Prostate Cancer (185), Breast
Cancer (174, 175), HIV /AIDS (042-044).
* Hospital days are not person-specific.
Source: LCDC 1998 - using Statistics Canada Morbidity Data
Trends in Hospitalization Rates: 1971-1995. Age-standardized
hospital separation rates and rates of hospital days for diabetes have
continued to decrease among both men and women and in all age groups since
the 1970s (Figures 11 and 12).
Since 1983, the number of hospital days has dropped by 42%, and the number
of hospital separations has decreased by about 25%. This decrease in hospital
utilization most likely reflects a general shift from inpatient (hospital)
to outpatient care in Canada's health care system as well as the understanding
that people with diabetes need to learn how to control their blood sugar
in their normal environment.
FIGURE 11
Age-standardized hospital separation rates (/100,000) for diabetes,
by gender and year - Canada excluding Territories, 1971-1995
ICD-9 Code 250 Diabetes; Standardized to 1991 Canadian
Population
Source: LCDC 1998 - using Statistics Canada Morbidity Data
FIGURE 12
Age-standardized hospital days (/100,000) for diabetes, by gender
and year - Canada excluding Territories, 1971-1995
ICD-9 Code 250 Diabetes; Standardized to 1991 Canadian
Population
Source: LCDC 1998 - using Statistics Canada Morbidity Data
Before the late 1980s, the age-standardized hospital separation
rates and corresponding rates for hospital days were higher among
women than men, but since that time the gap has closed, and now males
have slightly higher rates than females.
Hospitalization by Province. Comparisons by province
show that the three provinces with the highest five-year average (1991-1995)
age-standardized hospital separation rates were Prince Edward Island
(255/100,000), Newfoundland (223/100,000) and Saskatchewan (222/100,000).
The lowest rate was found in Quebec (97/100,000) (Figure
13).
FIGURE 13
Age-standardized hospital separation rates (/100,000) for
diabetes from 1991-1995 (5-year average) by province -
ICD-9 Code 250 Diabetes; Standardized to 1991 Canadian
Population
Source: LCDC 1998 - using Statistics Canada Morbidity Data
Some of the provincial variations in hospitalization rates may be
explained by differences in the number of beds per 1,000 population
per province, differing provincial health policy, and physician practices.
A comparison of age-standardized rates for hospital days shows that
Newfoundland and Saskatchewan had the highest five-year average rates
(1991-1995). Quebec rates were above the national average, suggesting
a longer length of stay in Quebec (Figure
14). Hospital data are not available for Yukon and the Northwest
Territories.
FIGURE 14
Age-standardized hospital days (/100,000) for diabetes from
1991-1995 (5-year average) by province - Canada
ICD-9 Code 250 Diabetes; Standardized to 1991 Canadian
Population
Source: LCDC 1998 - using Statistics Canada Morbidity Data
|
