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Mortality trends in type 2 diabetes mellitus patients in a primary care setting
1994 to 2011
Jelske Dekkers6th year medical student
• Introduction
• Research question
• Patients and methods
• Results• Sociodemographic characteristics
• Mortality rates
• Clinical patient characteristics
• Survival analysis
• Conclusion
• Discussion
• References
Introduction – Diabetes mellitus
• Diabetes mellitus• Type 1
• Type 2 90%
• Prevalence
• 2003:
• Men 36/1000
• Women 39/1000
• 2007
• Men 40.1/1000
• Women 41.6/1000
Introduction – Type 2 diabetes
• Causes• Betacel dysfunction inadequate production of insulin
• Insulin resistance
• Associations• Hypertension
• Obesity Metabolic syndrome or syndrome X
• Hypercholesteromia
• Complications• Cardiovascular disease 2-4 times increased risk of CVD associated death
• Renal disease
• Retinal disease
• Polyneuropathy
Research question
• What is the trend in mortality rates of type 2 diabetes patients compared to the mortality rates of the general Dutch population from 1994 to 2011?
• Is there a difference in clinical characteristics of type 2 diabetes patients from 1994 to 2011?
Patients and methods
• All type 2 diabetes patients in the NMP/HIS database between 1994 and 2011
• NMP/HIS database • Database of all patients with chronic illnesses treated (partially)
in 9 primary care practices
• Includes clinical patients characteristics from every check up
Patients
Patients with type 2 diabetes (partially) treated in primary care, 1994-2011
N = 3748Patients with type 2
diabetes, not treated in primary care
N = 297
Patients with type 2 diabetesN = 4045
Patients with type 2 diabetes with a known date
of diagnosisN = 4014
Patients without a known date of diagnosis
N = 31
Methods; database
Methods – Mortality rates
• Mortality rates type 2 diabetes patients for each year• All patients
• Men
• Women
• Comparison group: general Dutch population, adjusted for age, using CBS Statline Database• Complete population
• Men
• Women
Methods – Clinical patient characteristics
• Bloodpressure
• Body mass index
• HbA1c
• Total cholesterol
• HDL
• Calculated for 1996, 2001, 2006 and 2011
• Clinical characteristics of the patients in the NMP/HIS database only patients (partially) treated in primary care
Results – Sociodemographic characteristics
All patients 1996N = 794
2001N = 1291
2006N = 1917
2011N = 2803
Mean age 65.3(64.4-66.2)
63.3(62.5-64.6)
63.8(63.2-64.6)
65.6(65.1-66.1)
Mean age at diagnosis
59.3(58.4-60.2)
57.9(57.2-58.6)
57.3(56.7-57.9)
57.9(57.4-58.4)
Mean duration of disease in years
6.1(5.7-6.5)
5.7(5.4-6.0)
6.6(6.3-6.9)
7.8(7.6-8.0)
Results – Sociodemographic characteristics, men and women
1996 2001 2006 2011
Mean age men 62.4(61.0-63.8)
60.9(59.9-61.9)
62.4(61.6-63.2)
64.4(63.8-65.0)
Mean age women
67.5(66.3-68.7)
66.2(65.2-67.2)
65.3(64.4-66.2)
67.0(66.3-67.7)
Mean age at diagnosis men
57.0 (55.6-58.4)
55.8(54.8-56.8)
56.2(55.4-57.0)
56.8(56.2-57.4)
Mean age at diagnosis women
61.1(58.9-62.3)
59.9(59.0-60.8)
58.3(57.5-59.1)
59.0(58.3-59.7)
Mean duration of disease in years men
5.6(5.0-6.2)
5.2(4.8-5.6)
6.2(5.8-6.6)
7.6(7.3-7.9)
Mean duration of disease in years women
6.4(5.9-6.9)
6.3(5.9-6.7)
6.9(6.5-7.3)
8.0(7.6-8.4)
Results; mortality
1996 2001 2006 2011
All 794 1291 1917 2803
Deceased 36 37 47 76
Men 349 619 968 1444
Deceased 20 15 20 44
Women 445 672 949 1359
Deceased 16 22 27 32
Mortality rates in comparison to the Dutch population
Year Mortality rate diabetic patients in % (95% CI)
Adjusted mortality rate general population in %
Mortality rate diabetic men in %(95% CI)
Adjusted mortality rate men general population in %
Mortality rate diabetic women in %(95% CI)
Adjusted mortality rate women general population in %
1994 4.9(3.3-6.5)
3.2 4.4(2.0-6.8)
3.2 5.2(3.0-7.4)
3.1
1995 2.6(1.4-3.8)
3.1 2.2(0.6-3.8)
3.6 2.9(1.3-4.5)
3.0
1996 4.5(3.1-5.9)
3.0 5.7(3.3-8.1)
3.3 3.6(1.9-5.3)
3.1
1997 4.8(3.4-6.2)
3.2 5.6(3.3-7.9)
3.4 4.2(2.4-6.0)
3.0
1998 4.7(3.3-6.1)
2.7 4.4(2.4-6.4)
3.1 5.0(3.1-6.9)
3.0
1999 4.5(3.2-5.8)
2.9 4.0(2.2-6.8)
2.9 5.0(3.2-6.8)
2.9
2000 3.0(2.0-4.0)
2.7 2.7(1.4-4.0)
3.1 3.3(1.9-4.7)
2.8
2001 2.9(2.0-3.8)
2.5 2.4(1.2-3.6)
2.3 3.3(1.9-4.7)
2.5
2002 2.9(2.0-3.8)
2.6 2.9(1.6-4.2)
2.4 2.8(1.6-4.0)
2.7
Mortaliy rates – 2
2003 2.6(1.8-3.4)
2.5 2.6(1.4-3.8)
2.4 2.5(1.4-2.6)
2.6
2004 2.1(1.4-2.8)
2.4 1.7(0.8-2.5)
2.3 2.4(1.4-3.4)
2.5
2005 3.3(2.5-4.1)
2.5 3.0(1.9-4.1)
2.4 3.5(2.3-4.7)
2.6
2006 2.5(1.8-3.2)
2.3 2.1(1.2-3.0)
2.4 2.8(1.8-3.8)
2.3
2007 3.2(2.4-4.0)
2.3 3.2(2.1-4.3)
2.4 3.2(2.1-4.3)
2.3
2008 2.7(2.0-3.4)
2.3 2.6(1.7-3.5)
2.3 2.7(1.7-3.7)
2.3
2009 2.7(2.1-3.3)
2.3 2.2(1.4-3.0)
2.3 3.3(2.3-4.3)
2.3
2010 2.1 (1.6-2.6)
2.3 2.8(1.7-3.9)
2.3 1.4(0.6-2.0)
2.4
2011 2.7(2.1-3.3)
2.4 3.0(2.1-3.9)
2.3 2.4(1.6-3.2)
2.5
Year Mortality rate diabetic patients in % (95% CI)
Adjusted mortality rate general population in %
Mortality rate diabetic men in %(95% CI)
Adjusted mortality rate men general population in %
Mortality rate diabetic women in %(95% CI)
Adjusted mortality rate women general population in %
Mortality figures – all patients
Mortality figures – men
Mortality figures - women
Clinical patient characteristics
1996 2001 2006 2011
Mean systolic bloodpressure
151,2(149.4-153.0)N = 568
148.4(147.3-149.5)N = 954
143.9(143.0-144.8)N = 1479
139.8(139.2 – 140.4)N = 2279
Mean diastolic bloodpressure
83.7(82.9-84.5)N = 567
82.3(81.7-82.9)N = 954
80.8(80.3-81.3)N = 1473
78.6(78.2-79.0)N = 2277
Mean body mass index
28.6(28.2 – 29.0)N = 544
29.3(29.0 – 29.6)N = 923
29.7(29.4 – 30.0)N = 1375
30.1(29.9 – 30.3)N = 2121
Mean HbA1 c 55.3(53.4 – 57.2)N = 362
54.5(53.5 – 55.5)N = 662
53.4(52.7 – 54.0)N = 1191
53.5(53.0 – 54.0)N = 2238
Mean total cholesterol
6.10(5.98 – 6.22)N = 418
5.38(5.30 – 5.46)N = 764
4.88(4.81 – 4.95)N = 1089
4.53(4.48 – 4.58)N = 2156
Kaplan Meier survival analysis
Kaplan Meier Survival analysis; men and women
Conclusion
• Mortality rates declined between 1994 and 2011
• Since 2000 there is no difference in mortality
• In 2010 diabetic women had a lower mortality rate
• The mean bloodpressure and cholesterollevel have decreased significantly from 1996 to 2011
• In our study population 50% of all type 2 diabetics would still be alive 20 years after diagnosis
• The first 20 years after diagnosis women have a better survival probability than men
• After 20 years, men have a better survival
Discussion
• Strengths• Large NMP/HIS database with sociodemographic and clinical
patient characteristics of the majority of our study population
• Comparison group: complete Dutch population
• Weaknesses• No clinical patient characteristics of patients who weren’t treated in
primary care possible underestimation of clinical characteristics
• Transsition from NMP to HIS as primary source of information in 2006-2008 voids in yearly check ups and information
• Second hand information
• Only all cause mortality, no information about cardiovascular associated deaths
Discussion
• Other studies on this subject• Mortality rates of type 2 diabetes patients are declining
• Relative mortality risk compared to control group is declining
• Most studies still found a signifant difference between mortality rates of diabetics and non-diabetics
• Greater study population
• Earlier period
• Other health care systems
• Follow up study
• Correlation between declining mortality rates and declining bloodpressure and cholesterol
• Clinical characteristics of all type 2 diabetes patients, including those of patients not treated in primary care
Questions or other discussion points?
References
• Rutten G, Grauw de W, Nijpels G, Goudwaard A, Uitewaal P, Van der Does F, Heine R, Ballegooie van E, Verduijn M, Bouma M; NHG-standaard Diabetes Mellitus type 2 (tweede herziening); Huisarts Wet; 49; 137-152; 2006
• www.statline.cbs.nl
• Charlton J, Latinovic R, Gulliford M.C; Explaining the Decline in Early Mortality in Men and Women with Type 2 Diabetes; Diabetes Care; 31; 1761-1766; 2008
• Eliasson M, Talbäck M, Rosén M; Improved survival in both men and women with diabetes between 1980 and 2004 – a cohort study in Sweden; Cardiovascular Diabetology; 7; 32; 2008
• Preis S.R, Hwang S.J, Coady S, Pencina M.J, D’Agostino R.B, Savage P.J, Levy D, Fox C.S; Trends in All-Cause and Cardiovascular Disease Mortality Among Women and Men With and Without Diabetes Mellitus in the Framingham Heart Study, 1950 to 2005; Circulation; 119; 1728-1735; 2009
• Gregg E.W, Cheng Y.J, Saydah S, Cowie C, Garfield S, Geiss L, Barker L.B; Trends in Death Rates Among U.S. Adults With and Without Diabetes Between 1997 and 2006; Diabetes Care; 35; 1252-1257; 2012
• Gulliford M.C, Charlton J; Is Relative Mortality of Type 2 Diabetes Mellitus Decreasing?; Am. J. Epidemiol; 169; 455-461; 2009
• Tierney E.F, Cadwell B.L, Thompson T.J, Boyle J.P, Paxon S.L, Moum K, Engelgau M.M; Reductions in excess mortality rates among people with diabetes by selected cause of death; Journal of Diabetes and Its Complications; 23; 77-82; 2009
• Gregg E.W, Gu Q, Cheng Y.J, Narayan V, Cowle C.C; Mortality Trends in Men and Women with Diabetes, 1971 to 2000; Ann Intern Med; 147; 149-155; 2007
• Lutgers H, Gerrits E, Sluiter W, Ubink-Veltmaat L, Landman G, Links T, Gans R, Smit A, Bilo H; Life Expectancy in a Large Cohort of Type 2 Diabetes Patients Treated in Primary Care (ZODIAC-10); PLoS ONE; vol 4; 8; e6817
• www.nationaalkompas.nl
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