Regional differences in clinical care among patients with type 1 diabetes in Brazil: Brazilian Type 1 Diabetes Study Group

Diabetology & Metabolic Syndrome

Marilena M Cordeiro¹  Deborah L Jezini¹  Flavia M Santos¹  João Sooares Felicio¹  Alberto Ramos¹  Karla F Rezende¹  Naira H Melo¹  Renan Montenegro¹  Ana Paula Montenegro¹  Cristina Façanha¹  Rossana Azulay¹  Manuel Faria¹  Odelissa S Matos¹  Alexis D Guedes¹  Reine Marie C Fonseca¹  Leticia B Araujo¹  Nelson Rassi¹  Flaviane A Prado¹  Hermelinda C Pedrosa¹  Monica Tolentino¹  Luiz Antonio Araujo¹  Daniela Aline Pereira¹  Marisa Helena C Coral¹  Alessandra T Zucatti¹  Luis Henrique Canani¹  Mirela J Azevedo¹  Gustavo A Cardozo¹  Suzana Lavigne¹  Balduino Tschiedel¹  Ana Cristina R Faria¹  Rosangela Rea¹  Emerson Sampaio¹  Henriqueta G Almeida¹  Janice Sepulvida¹  Saulo C Silva¹  Patricia Dualib¹  Sergio A Dib¹  MariadeFátimaS Guedes¹  Fernando C Robles¹  Antonio C Pires¹  Maria C Foss-Freitas¹  Milton C Foss¹  Fernanda G Penha¹  Roberta Salvodelli¹  Lenita Zajdenverg¹  Thais D Manna¹  Renata M Noronha¹  Luiz E Calliari¹  Maria do Carmo Arruda-Marques¹  Marcia Nery¹  Renata S Berardo¹  Jorge L Luescher¹  Marilena M Cordeiro¹  Neuza Braga¹  Melanie Rodacki¹  Carlos Antonio Negrato¹  Lucianne R Tannus¹  Alessandra S Matheus¹  Adriana C Forti¹  Roberta A Cobas¹  Marília B Gomes¹ 

[1] Unit of Diabetes, Universidade Estadual do Rio de Janeiro, Avenida 28 de Setembro, 77, 3o andar, CEP 20.551-030, Rio de Janeiro, Brazil

关键词: Economic status;    Chronic complications;    Cardiovascular risk factors;    Glycemic control;    Type 1 diabetes;   

Others  :  814848
DOI  :  10.1186/1758-5996-4-44

 received in 2012-06-29, accepted in 2012-09-19,  发布年份 2012

【 摘 要 】

Background

To determine the characteristics of clinical care offered to type 1 diabetic patients across the four distinct regions of Brazil, with geographic and contrasting socioeconomic differences. Glycemic control, prevalence of cardiovascular risk factors, screening for chronic complications and the frequency that the recommended treatment goals were met using the American Diabetes Association guidelines were evaluated.

Methods

This was a cross-sectional, multicenter study conducted from December 2008 to December 2010 in 28 secondary and tertiary care public clinics in 20 Brazilian cities in north/northeast, mid-west, southeast and south regions. The data were obtained from 3,591 patients (56.0% females and 57.1% Caucasians) aged 21.2 ± 11.7 years with a disease duration of 9.6 ± 8.1 years (<1 to 50 years).

Results

Overall, 18.4% patients had HbA1c levels <7.0%, and 47.5% patients had HbA1c levels ≥ 9%. HbA1c levels were associated with lower economic status, female gender, age and the daily frequency of self-blood glucose monitoring (SBGM) but not with insulin regimen and geographic region. Hypertension was more frequent in the mid-west (32%) and north/northeast (25%) than in the southeast (19%) and south (17%) regions (p<0.001). More patients from the southeast region achieved LDL cholesterol goals and were treated with statins (p<0.001). Fewer patients from the north/northeast and mid-west regions were screened for retinopathy and nephropathy, compared with patients from the south and southeast. Patients from the south/southeast regions had more intensive insulin regimens than patients from the north/northeast and mid-west regions (p<0.001). The most common insulin therapy combination was intermediate-acting with regular human insulin, mainly in the north/northeast region (p<0.001). The combination of insulin glargine with lispro and glulisine was more frequently used in the mid-west region (p<0.001). Patients from the north/northeast region were younger, non-Caucasian, from lower economic status, used less continuous subcutaneous insulin infusion, performed less SBGM and were less overweight/obese (p<0.001).

Conclusions

A majority of patients, mainly in the north/northeast and mid-west regions, did not meet metabolic control goals and were not screened for diabetes-related chronic complications. These results should guide governmental health policy decisions, specific to each geographic region, to improve diabetes care and decrease the negative impact diabetes has on the public health system.

【 授权许可】

   
2012 Gomes et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Borchers AT, Uibo R, Gershwin ME: The geoepidemiology of type 1 diabetes. Autoimmun Rev 2010, A355-A365.
• [2]The DIAMOND Project Group: Incidence and trends of childhood type 1 diabetes worldwide 1990–1999. Diabet Med 2006, 23(8):857-866.
• [3]EURODIAB ACE Study Group: Variation and trends in incidence of childhood diabetes in Europe. Lancet 2000, 355:873-876.
• [4]Negrato CA, Dias JPL, Teixeira MF, Dias A, Salgado MH, Lauris JR, Montenegro RM Jr, Gomes MB, Jovanovic L: Temporal trends in incidence of Type 1 diabetes between 1986 and 2006 in Brazil. J Endocrinol Invest 2010, 33:373-377.
• [5]Laing SP, Swerdlow AJ, Slater SD, Burden AC, Morris A, Waugh NR, Gatling W, Bingley PJ, Patterson CC: Mortality from heart disease in a cohort of 23,000 patients with insulin-treated diabetes. Diabetologia 2003, 46(6):760-765.
• [6]The Diabetes Control and Complications Trial Study Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Eng J Med 1993, 329:977-986.
• [7]The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group: Intensive diabetes treatment and cardiovascular disease in patients with diabetes type 1. N Engl J Med 2005, 353:2643-2653.
• [8]Aschner P, Horton E, Leiter LA, Munro N, Skyler JS: Practical steps to improving the management of type 1 diabetes: recommendations from the Global Partnership for Effective Diabetes Management. Int J Clin Pract 2010, 64:305-315.
• [9]Censo: Instituto Brasileiro de Geografia e Estatística (IBGE). 2010. http://www.ibge.gov.br/censo webcite
• [10]Indicadores Econômicos dos Países da América Latina - Ano. 2011. http://www.abinee.org.br/abinee/decon/decon55a.htm webcite
• [11]Gomes MB, Coral M, Cobas RA, Dib SA, Canani LH, Nery M, Freitas MCF, Faria M, Felicio JS, da Silva SC, Pedrosa H, Costa e Forti A, Rea RR, Pires AC, Montenegro R Jr, Oliveira JE, Rassi N, Negrato CA, On behalf of the Brazilian Type 1 Diabetes Study Group (BrazDiab1SG): Prevalence of adults with type 1 diabetes who meet the goals of care in daily clinical practice: A nationwide multicenter study in BrazilDiabetes. Res Clin Pract 2012.
• [12]American Diabetes Association: Clinical Practice Recommendations. Diabetes Care 2011, 34:S11-S61.
• [13]Daniels SR, Greer FR, Committee on Nutrition: Blood pressure levels for girls and boys by age and height percentile. Pediatrics 2008, 122:198-208.
• [14]CDC Growth Charts: United States. http://www.cdc.gov/nchs/data/ad/ad314.pdf webcite
• [15]Friedwald WT, Levy R, Fredrickson DS: Estimations of serum low density lipoprotein cholesterol without use of preparative ultracentrifuge. Clin Chem 1972, 18:499-502.
• [16]Censo: Instituto Brasileiro de Geografia e Estatística (IBGE). 2000. http://www.ibge.gov.br/censo webcite
• [17]Malerbi DA, Franco LJ: Multicenter study of the prevalence of diabetes mellitus and impaired glucose tolerance in the urban Brazilian population aged 30–69 yr. The Brazilian Cooperative Group on the Study of Diabetes Prevalence. Diabetes Care 1992, 15:1509-1516.
• [18]Critério de classificação econômica Brasil, ABEP. 2010. http://www.abep.org/novo/Content.aspx?SectionID=84 webcite
• [19]Sociedade Brasileira de Diabetes: Diretrizes da SBD/2011. Jardim Londrina, SP: AC Farmaceutica Ltda; 2011.
• [20]Gill GV, Yudkin JS, Keen H, Beran D: The insulin dilemma in resource-limited countries. A way forward? Diabetologia 2011, 54:19-24.
• [21]Garg SK, Rosenstock J, Ways K: Optimized basal-bolus insulin regimens in type 1 diabetes: insulin glulisine versus regular human insulin in combination with basal insulin glargine. Endocr Pract 2005, 11:11-17.
• [22]Meece J: Pharmacoeconomic Advantages of Insulin Analogs. US Pharm 2006, 31:12:HS42-HS50.
• [23]Robertson KJ, Schoenle E, Gucevt Z, Mordhorst L, Gall MA, Ludvgsson J: Insulin detemir compared with NPH insulin in children and adolescents with type 1 diabetes. Diabet Med 2007, 24:27-34.
• [24]Murphy NP, Keane SM, Ong KK, Ford-Adams M, Edge JA, Acerini CL, Dunger DB: Randomized cross-over trial of insulin glargine plus lispro or NPH plus regular human insulin in adolescents with type 1 diabetes on intensive insulin regimens. Diabetes Care 2003, 26:799-804.
• [25]Zgibor JC, Songer TJ, Kelsey SF, Weissfeld J, Drash AL, Becker D, Orchard TJ: The Association of Diabetes Specialist Care Practices and Glycemic Control in Patients With Type 1 Diabetes. Diabetes Care 2000, 23:472-476.
• [26]Fagulha A, Santos I e Grupo de estudo da Diabetes Mellitus: Controle Glicémico e Tratamento da Diabetes tipo 1 da criança e adolescente em Portugal. Acta Med Port 2004, 17:173-179.
• [27]White NH, Sun W, Cleary PA, Tamborlane WV, Danis RP, Hainsworth DP, et al.: Effect of prior intensive therapy in type 1 diabetes on 10-year progression of retinopathy in the DCCT/EDIC: comparison of adults and adolescents. Diabetes 2010, 59:1244-1253.
• [28]Skeie S, Kristensen BB, Carlsen S, Sandberg S: Self-monitoring of blood glucose in type 1 diabetes patients with insufficient metabolic control: focused self-monitoring of blood glucose intervention can lower glycated hemoglobin A1C. J Diab Science Technol 2009, 3:83-88.
• [29]Zgibor JC, Wilson RR, Orchard TJ: Has Control of Hypercholesterolemia and Hypertension in Type 1 Diabetes Improver Over Time? Diabetes Care 2005, 28:521-526.
• [30]Tolonen N, Forsblom C, Thorn L, Wadén J, Rosengård-Bärlund M, Saraheimo M, Heikkilä O, Pettersson-Fernholm K, Taskinen MR, Groop PH, FinnDiane Study Group: Relationship between lipid profiles and kidney function in patients with type 1 diabetes. Diabetologia 2008, 51:12-20.
• [31]Vigitel. http://www.portal.saude.gov.br/portal/arquivos/pdf/ webcite vigitel 2008.pdf
• [32]Bryden KS, Dunger DB, Mayou RA, Peveler RC, Neil HA: Poor prognosis of young adults with type 1 diabetes. Diabetes Care 2003, 26:1052-1057.
• [33]Cobas RA, Santos B, Silva PCB, Neves R, Gomes MB: Progression to microalbuminuria in patients with type 1 diabetes: a seven-year prospective study. Diabetol Metab Syndr 2011, 3:21. BioMed Central Full Text
• [34]Maahs DM, Kinney GL, Wadwa P, Snell-Bergeon JK, Dabelea D, Hokanson J: Hypertension prevalence, awareness, treatment, and control in an adult type 1 diabetes population and comparable general population. Diabetes Care 2005, 28:301-306.