diabetes, which is characterized by insulin. deficiency and an absolute requirement 90% have type 2 diabetes, which is char- acterized by defects in …
Diabetes Hospitalization Report
Pennsylvania Health Care Cost Containment Council November 2002 2001 Data
Key Findings
The number of hospitalizations where diabetes was either the principal or a secondary diagnosis rose by 168 percent between 1997 and 2001, increasing from 255,858 to 298,941 hospitalizations In 2001, these hospitalizations represented 165 percent of all inpatient hospitalizations up from 147 percent in 1997 In 2001, there were 243 hospitalizations with a principal or secondary diagnosis of diabetes for every 10,000 Pennsylvania residents up from 213 in 1997 Of the 298,941 hospitalizations involving diabetes, 75 percent 22,526 hospitalizations were a direct result of diabetes ie, diabetes was the principal diagnosis of the hospital admission In 2001 alone, these hospitalizations accounted for over 127,000 hospital days and incurred over 424 million in hospital charges The rate of hospitalizations that were a direct result of diabetes increased by 102 percent between 1997 and 2001 Over the past 5 years, these hospitalizations accounted for over 614,000 hospital days and incurred almost 16 billion in hospital charges This is substantial given that some of
these hospitalizations may be preventable if appropriate care is provided on an outpatient basis While the number and rate of hospitalizations for Type 1 diabetes has decreased over the past few years, the number and rate of hospitalizations for Type 2 diabetes has increased steadily Between 1997 and 2001, the hospitalization rate for diabetes increased across all age groups The largest increases were amongst the 30-39 and 40-49 age groups where the hospitalization rates increased by 261 percent and 184 percent respectively African Americans continued to have the highest rates of hospitalization for diabetes, as well as the highest rates of lower extremity amputations and hospitalization for endstage renal disease In general, counties in Western and Northeastern Pennsylvania tended to have rates of hospitalization for end-stage renal disease that were higher than the statewide average, while counties in Southeast Pennsylvania generally had rates below the statewide average Counties in Northeastern Pennsylvania tended to have rates of lower-extremity amputation that were higher than the statewide average
Diabetes Hospitalization Report
What is diabetes?
D
iabetes is a
chronic disease in which the body does not produce enough or properly use insulin a hormone needed to convert blood sugar into energy There are two main
types of diabetes Type 1 diabetes usually appears in children or young adults and accounts for 5 to 10 of all diagnosed cases of diabetes With Type 1 diabetes, the body does not produce enough insulin, so people with Type 1 diabetes must receive daily insulin injections Type 2 diabetes is the most common form of diabetes, estimated to account for about 90 to 95 of all diagnosed cases of diabetes With Type 2 diabetes, the body is resistant to insulin and cannot use it properly While most people with Type 2 diabetes control their disease through oral medications, diet, and exercise, the Centers for Disease Control and Prevention CDC estimates that 40 of people with Type 2 diabetes require insulin injections There is a third type of diabetes known as gestational diabetes This develops in 2 to 5 of all pregnancies but the diabetes usually disappears when the pregnancy is over In rare instances, other specific types of diabetes may also result from specific genetic syndromes, surgery, drugs, and other illnesses
Foreword
D
Diabetes
in Pennsylvania
According to the Behavioral Risk Factor Surveillance Survey conducted in 2001 by the Pennsylvania Department of Health in conjunction with the CDC, 67 percent of residents 18 years of age and older were told by a doctor that they had diabetes The national median was 66 percent
iabetes is a widespread, chronic disease caused by the inability of the body to produce or properly use insulin a hormone needed to convert blood sugar into energy It is a costly condition associated with significant levels of morbidity and mortality Diabetes predisposes people to numerous complications, including heart disease, hypertension and stroke It is the leading cause of new cases of blindness, end stage renal failure, and non-traumatic lower extremity amputation Without question, diabetes is a serious and growing health concern
Diabetes cases on the rise
The prevalence of diabetes nationally is widespread and increasing across age groups According to the CDC, there was a 33 increase in the prevalence of diabetes among adults
Diabetes Hospitalization Report 1
during the 1990s While part of the increase can be attributed to an aging population, it is also associated with the
increase in obesity among Americans Among people aged 30 to 39, the CDC found a 70 increase in diabetes between 1990 and 1998 more than twice the rate of increase in the general population Because the potential for long-term complications increases the longer people live with the disease, this trend has significant implications for the quality of life for those with diabetes as well as for health care costs The prevalence of Type 2 diabetes which may be prevented or delayed if those at high-risk make recommended lifestyle changes is increasing at an alarming rate For example, Type 2 diabetes is now appearing in children and adolescents; this was uncommon until recently The increase in Type 2 diabetes among younger age groups should focus additional attention on this condition It appears as if the individual and societal burdens imposed by this disease will only continue to grow Recent announcements by the US Department of Health and Human Services suggest that nearly 16 million Americans have a condition known as pre-diabetes and are likely to develop diabetes within a decade unless they make changes in diet and exercise Given the enormous impact of this disease on the cost and
quality of health care, it remains essential to continue to make the diagnosis and treatment of people with diabetes a high priority
Why look at hospitalizations for diabetes?
Diabetes is often considered an ambulatory care sensitive condition one in which timely and effective primary care will likely reduce hospitalizations For this reason, hospitalization rates particularly for complications of diabetes may indicate failures in diabetes management including access to health care, inadequate care by health care providers, and poor patient adherence to needed lifestyle and behavior changes While some hospitalizations for diabetes are expected, appropriate preventive care can reduce the need for many of these hospitalizations
Act 98 Steps to improve and monitor care
In order to help provide access to appropriate medical supplies as well as education for managing diabetes, Pennsylvanias General Assembly enacted Act 98 in October of 1998 This law mandates that private and group health insurance plans cover the cost of diabetic supplies such as insulin, blood glucose monitors, and testing strips used by people with diabetes to monitor and treat their disease It also requires
coverage for self-management training and nutritional counseling so that people with diabetes have the appropriate information to help them manage their disease At the time Act 98 was enacted, the Pennsylvania Health Care Cost Containment Council PHC4 noted the laws potential to reduce hospitalizations for diabetes if more people complied with appropriate diabetes protocols as a result
2 Diabetes Hospitalization Report
This report represents a commitment by PHC4 to track hospitalizations for diabetes after the enactment of Act 98 and is the first PHC4 report to include data after Act 98 became fully effective For the most part, it examines hospitalizations where diabetes is the principal diagnosis, focusing on admissions that are a direct result of diabetes These hospitalizations are the main component of this analysis because they are more likely to reflect changes in diabetes care and management that have occurred since Act 98 took effect It may be viewed in conjunction with prior reports to identify trends before and after enactment of the mandate It should be recognized that Act 98 does not exist in a vacuum Over the past several years, the Pennsylvania Department of Health,
the American Diabetes Association ADA, individual Health Maintenance Organizations, hospitals, and physicians have made continuous efforts to educate people with diabetes about their disease and assist them with monitoring and treatment of their diabetes The federally funded Medicare program has expanded the benefits it offers to people with diabetes The development of new medications has advanced the treatment of diabetes All this has occurred during a time when the prevalence of diabetes has been rising Therefore, while this report presents hospitalization data both before and after the enactment of the mandate, it is not possible to directly attribute any changes in hospitalizations for diabetes to Act 98
Who should be interested in this report?
Employers: This report can help employers better understand the impact that diabetes has upon their workforce Diabetes involves substantial direct and indirect costs to employers that include: Direct medical costs In 1997 alone, the direct medical and treatment costs for diabetes in the United States was estimated to be 44 billion The ADA further estimated that in 1997, the per capita costs of health care for people with diabetes
amounted to 10,071, while health care costs for people without diabetes amounted to 2,699 Indirect costs While the indirect costs of diabetes are difficult to quantify, they are nevertheless substantial In addition to the direct medical cost of diabetes, the ADA attributed another 37 billion in disability costs to diabetes in the United States in 1997 alone Lost productivity The ADA estimated that, nationally, over 14 million lost days from work outside the home were attributable to diabetes in 1997 According to the ADA, people with diabetes, age 18-64, lost 83 days from work, while people without diabetes lost only 17 days from work The ADA further reported that nearly 75,000 workers nationwide are disabled because of diabetes
Diabetes Hospitalization Report 3
Employers interested in learning more about diabetes can visit the following Web site, wwwdiabetesatworkorg, which includes an online diabetes and health resource kit to help businesses assess the impact of diabetes in the workplace It also provides easy-to-understand information for employers to help their employees manage their diabetes and take steps toward reducing the risk for diabetes-related complications such as
heart disease Physicians: Physicians may be aided by recognition of the widespread and costly impact of diabetes and seek to adopt proven methods of improving diabetes outcomes They may, in turn, support initiatives in their communities and their individual
practices to improve the delivery of care, thereby empowering their patients to improve selfmanagement Managed Care Plans: Managed care plans can use this report to evaluate the ways in which their plans and their network physicians might improve diagnosis, management and treatment of diabetes Policy Makers: This report can provide policy makers and the public with information on a serious and growing health problem, underscoring the importance of prevention, earlier diagnosis and improved diabetes care and outcomes in Pennsylvania
Preventive care means better results
complications, thereby improving ones health and quality of life PHC4s recent report entitled Measuring the Quality of Pennsylvanias Commercial HMOs showed a statistically significant correlation between well-controlled Hemoglobin A1c levels which represent the average amount of blood sugar over several months and a lower number of hospitalizations for diabetes
In addition, the Diabetes Control and Complications Trial DCCT, the largest, most comprehensive diabetes study ever conducted, showed that keeping blood glucose levels as close to normal as possible slows the onset and progression of eye, kidney, and nerve diseases caused by diabetes
F
or people with diabetes, the key to a healthy life is to follow prescribed treatment plans involving nutrition, exercise, and medication It has been shown that appropriate preventive care can minimize hospitalizations and
4 Diabetes Hospitalization Report
How many hospitalizations involve diabetes?
Diabetes was the principal or secondary diagnosis in 165 of hospitalizations for Pennsylvania residents in 2001, up from 147 in 1997 In 2001, there were almost 300,000 hospitalizations with a diagnosis of diabetes This represents approximately 1 out of every 6 hospitalizations for Pennsylvania residents in 2001
Number Hospitalizations with a Diabetes Diagnosis Hospitalizations without a Diabetes Diagnosis Total 298,941 1,513,957 1,812,898
Percent 165 835 1000
Diabetes Hospitalization Report 5
How many hospitalizations involve diabetes?
The number of hospitalizations involving
diabetes where diabetes was either the principal or a secondary diagnosis of the hospital admission rose by 168 between 1997 and 2001, increasing from 255,858 to 298,941 hospitalizations In 2001, there were approximately 243 hospitalizations with a diagnosis of diabetes either as a principal or secondary diagnosis for every 10,000 Pennsylvania residents up from approximately 213 in 1997 Overall, the hospitalization rate has increased by 143 since 1997
Hospitalization Rate for Diabetes Principal or Secondary Diagnosis per 10,000 PA residents
Hospitalizations for Diabetes Principal or Secondary Diagnosis Number of Hospitalizations 255,858 259,604 270,474 286,297 298,941
Year 1997 1998 1999 2000 2001
Average Age 673 673 673 673 672
6 Diabetes Hospitalization Report
Hospitalizations for diabetes: principal vs secondary diagnosis
Of the 298,941 hospitalizations with a diabetes diagnosis, 75 had diabetes listed as the principal diagnosis, suggesting that the reason for the hospital admission was a direct result of diabetes These hospitalizations are the main focus of this analysis because they are likely to be more immediately affected by changes in diabetes
care and management The remaining hospitalizations with a diabetes diagnosis had diabetes listed as a secondary diagnosis 925 In these cases, the principal reason for the hospital admission may or may not be a direct result of diabetes Such hospitalizations include those with long-term complications of diabetes such as heart disease and renal failure
Hospital Admissions
Hospital Days Average Length of Stay 57 59 58 Total Days 127,892 1,619,808 1,747,700
Hospital Charges Average Charge 18,832 20,972 20,811 Total Charges 424,230,192 5,797,261,175 6,221,491,367 Average Age 565 681 672
Hospitalizations with Diabetes as Principal Diagnosis Diabetes as Secondary Diagnosis Total
Number 22,526 276,415 298,941
Percent 75 925 1000
Diabetes Hospitalization Report 7
How have hospitalizations for diabetes changed over the past few years?
Hospitalizations with a principal diagnosis of diabetes may be preventable because appropriate care can generally be provided on an outpatient basis If patients reach the point where they must be hospitalized for diabetes, a breakdown in diabetes care or access to care may have already occurred The rate of hospitalization where
diabetes was the principal diagnosis increased steadily from 1997 to 2001 The overall change from 166 hospitalizations per 10,000 Pennsylvania residents in 1997 to 183 in 2001 represents an increase of 102 Hospitalizations where diabetes was the principal diagnosis accounted for over 127,000 hospital days and incurred over 424 million in hospital charges in 2001 Over the past 5 years, these hospitalizations accounted for over 614,000 hospital days and incurred almost 16 billion in hospital charges
Hospitalization Rate for Diabetes Principal Diagnosis per 10,000 PA residents
Hospitalizations for Diabetes Principal Diagnosis
Year 1997 1998 1999 2000 2001 Number of Hospitalizations 19,924 20,552 21,149 21,842 22,526 Average Age 568 565 559 563 565
Hospitalizations for Diabetes - Principal Diagnosis
Days Number of Hospitalizations 1997 1998 1999 2000 2001 Total 19,924 20,552 21,149 21,842 22,526 105,993 Average Days 61 58 57 57 57 58 Total Days 122,429 119,955 120,269 123,737 127,892 614,282 Average Charges 12,938 13,593 14,631 16,124 18,832 15,106 Charges Total Charges 243,435,971 267,760,341 309,445,684 352,201,624 424,230,192 1,597,073,812
8 Diabetes
Hospitalization Report
Hospitalization rates for Type 1 diabetes as the principal diagnosis decreased by 252 between 1997 and 2001
Hospitalization rates for Type 2 diabetes as the principal diagnosis increased by 683 between 1997 and 2001 This reflects the increase in the prevalence of Type 2 diabetes over the past several years
Hospitalization Rate for Type 2 Diabetes Principal Diagnosis per 10,000 PA residents
Hospitalization Rate for Type 1 Diabetes Principal Diagnosis per 10,000 PA residents
Hospitalizations for Type 1 Diabetes Principal Diagnosis
Number of Hospitalizations 12,340 11,215 10,769 10,017 9,453 Average Age 510 489 472 461 450
Hospitalizations for Type 2 Diabetes Principal Diagnosis
Number of Hospitalizations 7,584 9,337 10,380 11,825 13,073 Average Age 663 655 651 650 648
Year 1997 1998 1999 2000 2001
Year 1997 1998 1999 2000 2001
Note: ICD9CM codes were used to differentiate between Type 1 and Type 2 diabetes These codes define Type 1 as insulin dependent and Type 2 as non-insulin dependent Because people with Type 2 diabetes may use insulin, there could be variation among hospitals with regard to how these
cases are coded Any interpretation of the data in regard to differences between Type 1 and Type 2 diabetes must be made with this in mind
Diabetes Hospitalization Report 9
How have hospitalizations for diabetes changed over the past few years?
Short-term complications of diabetes include acute, life-threatening events such as diabetic ketoacidosis and diabetic coma Hospitalizations for these events might be an immediate reflection of how well patients are managing their diabetes The hospitalization rate for these complications has remained relatively constant since 1997
Hospitalization Rate for Short-Term Complications of Diabetes Principal Diagnosis per 10,000 PA residents Year
Hospitalizations for Short-Term Complications of Diabetes Principal Diagnosis Number of Hospitalizations
8,327 8,075 8,293 8,174 8,415
Average Age
488 473 464 463 460
1997 1998 1999 2000 2001
10 Diabetes Hospitalization Report
How do hospitalizations for diabetes differ by age group?
In 2001, patients age 60 and over accounted for almost half 496 of hospitalizations for diabetes The hospitalization rate for diabetes increased with age In addition to having higher rates of
hospitalization, older patients tended to have longer average lengths of stay than their younger counterparts In general, the average charges also tend to increase among older age groups Patients age 60 and over accounted for a disproportionate share of hospital days and charges While these patients accounted for just under half of all hospitalizations with a principal diagnosis of diabetes, they accounted for 583 of days and 527 of charges
Hospitalization Rates per 10,000 population in PA
Hospitalizations for Diabetes, by Age
Hospital Admissions Age Category 0-9 10-19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 and over Total
Hospital Days Average Length of Stay 28 25 31 39 51 63 68 68 64 57 Total Number of Days 1,163 2,824 3,819 8,084 15,725 21,750 24,600 30,703 19,224 127,892
Hospital Charges Average Charge 7,699 7,649 11,162 17,114 20,454 22,271 22,505 19,672 17,504 18,832 Total Charges 3,233,739 8,589,461 13,629,012 35,271,874 62,712,621 77,279,001 82,0 
09,297 89,325,444 52,179,743 424,230,192
Number 420 1,123 1,221 2,061 3,066 3,470 3,644 4,540 2,981 22,526
Percent 19 50 54 91 136 154 162 202 132 1000
1997 24 59 76 92 136 241 346 474 508
166
2001 27 65 83 116 161 245 367 498 565 183
Note: Diabetes was the principal diagnosis of these hospitalizations
Diabetes Hospitalization Report 11
How do hospitalizations for diabetes differ by age group?
Between 1997 and 2001, the hospitalization rate for diabetes increased across all age groups The largest increases were amongst the 30-39 and 40-49 age groups where the hospitalization rates increased by 261 and 184 respectively
Hospitalization Rate for Diabetes, by Age Comparison between 1997 and 2001 per 10,000 population in PA
Note: Diabetes was the principal diagnosis of these hospitalizations
12 Diabetes Hospitalization Report
How do hospitalizations for diabetes differ by gender and age?
Hospitalization Rate for Diabetes, by Gender per 10,000 population in PA
Males and females had similar hospitalization rates for diabetes
There was, however, variation across age categories Males had higher rates beginning at age 30
Hospitalization Rate for Diabetes, by Gender and Age per 10,000 population in PA
Note: Diabetes was the principal diagnosis of these hospitalizations
Diabetes
Hospitalization Report 13
How do hospitalizations for diabetes differ by race/ethnicity?
The hospitalization rate for non-Hispanic African Americans in Pennsylvania was nearly three times that of whites in 2001 According to national figures from the CDC, non-Hispanic African Americans are 20 times more likely to have diabetes than non-Hispanic whites of similar age
Hospitalization Rate for Diabetes, by Race/Ethnicity per 10,000 population in PA
Note: Diabetes was the principal diagnosis of these hospitalizations
14 Diabetes Hospitalization Report
How do hospitalizations for diabetes differ by payor type?
Hospitals indicated that Medicare was the primary payor for over half 503 of the hospitalizations for diabetes as a principal diagnosis Private insurers had the next highest percentage at 267
Hospital Admissions
Hospital Days Average Length of Stay 67 48 47 32 51 57 Total Number of Days 75,662 28,587 19,220 1,997 2,426 127,892
Hospital Charges Average Charge 20,703 17,072 18,276 9,308 13,979 18,832 Total Charges 234,395,355 102,706,418 74,582,577 5,864,062 6,681,780 424,230,192
Payor Medicare Private Insurers Medicaid Self Other Total
Number
11,321 6,016 4,081 630 478 22,526
Percent 503 267 181 28 21 1000
Payor Medicare Private Insurers Medicaid Self Other Total
Average Age 704 439 406 384 460 565
Percent with End-Stage Renal Disease 177 129 92 24 117 143
Percent with Amputation 133 91 62 44 100 106
Note: Diabetes was the principal diagnosis of these hospitalizations Includes other government payors and hospitalizations where the payor was unknown or designation was invalid Percent undergoing amputation during the hospitalizations included in this analysis
Diabetes Hospitalization Report 15
How do hospitalizations for diabetes differ by county?
Percent Difference in Diabetes Hospitalization Rates
Note: Diabetes was the principal diagnosis of these hospitalizations Rates are adjusted for age and sex differences among county populations Source: PHC4 inpatient data and US Census Bureau, Census 2000 data
16 Diabetes Hospitalization Report
Patient County of Residence Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia
Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata
Difference from Statewide Hospitalization Rate 346 below 141 above 226 below 92 below 390 below 186 below 230 below 223 below 258 below 171 below 177 above 396 above 243 above 508 below 306 below 152 above 37 below 340 below 37 above 127 below 306 below 41 below 01 above 140 below 152 below 238 above 512 above 152 below 343 above 279 below 305 below 138 below 160 above 138 below
Patient County of Residence Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York
Difference from Statewide Hospitalization Rate 23 below 279 below 73 above 424 below 220 below 171 above 466 below 196 above 194 above 163 below 205 below 304 below 170 below 26 below 65 below 199 below 796 above 520 below 445 below 278 above 474 below 111 below 299 below 393 below 315 below 385 below 137 above 444 below 60 below 81 below 28 above 251 above 272
below
Diabetes Hospitalization Report 17
Diabetes-Related Hospitalizations
W
hile not the focus of this analysis, hospitalizations with diabetes as a secondary diagnosis are important because they provide an overall picture of hospital admissions that involve diabetes This information may help to provide an indication of the magnitude of diabetes in Pennsylvania Patients with diabetes as a secondary diagnosis are hospitalized for a wide variety
of reasons, but some of the major reasons for admission include the long-term complications of diabetes for example, diseases of the circulatory system which include heart disease The following chart shows, by body system, why these people were admitted to the hospital Only the ten body systems with the highest number of admissions are individually displayed
Hospitalizations where Diabetes was a Secondary Diagnosis
Hospital Admissions Hospital Days Average Length of Stay 49 66 63 54 65 54 58 109 60 46 67 59 Total Number of Days 477,743 204,378 157,439 125,238 147,072 71,209 54,475 91,151 48,844 35,769 206,490 1,619,808 Hospital Charges Average Charge 23,369 20,486 21,955 18,577 20,749 18,868 15,076 16,227 23,525 16,203 19,617
20,972
Hospitalizations relating to the Circulatory System Respiratory System Musculoskeletal System Digestive System Nervous System Kidney Urinary System Skin, Subcutaneous Tissue Breast Mental Diseases Disorders Hepatobiliary System Pancreas Endocrine System All other body systems Total
Number 96,675 31,075 25,007 22,996 22,535 13,067 9,393 8,365 8,160 7,711 31,431 276,415
Percent 350 112 90 83 82 47 34 30 30 28 114 1000
Total Charges 2,259,194,345 636,607,704 549,044,599 427,216,999 467,579,954 246,754,105 141,609,737 135,740,153 191,962,694 124,943,929 616,606,956 5,797,261,175
18 Diabetes Hospitalization Report
Long-Term Complications of Diabetes
C
omplications associated with diabetes are often severe and can be life-threatening The longterm complications of diabetes include chronic problems such as heart disease, stroke, blindness, amputation and kidney disease that develop over a period of years or even decades While most of this report focuses on hospitalizations where diabetes was the principal diagnosis, the following pages include
Hospital Days Hospital Admissions 5,142 26,785 11,967 28,659 158,587 14,580 32,326 Average Length of Stay 114 74 63 69 58 73 74
Total Number of Days 58,856 198,926 75,801 198,899 920,238 106,225 239,840
hospitalizations where diabetes was either the principal or a secondary diagnosis Because diabetes is often listed as a secondary diagnosis in cases of long-term complications, including both principal and secondary diagnoses in this analysis allows for a complete counting of diabetesrelated complications For this analysis, patients with multiple complications are counted in each appropriate category
Hospital Charges Average Charge 41,123 27,954 22,601 21,397 22,208 22,333 26,174 Total Charges 211,455,841 748,746,618 270,463,152 613,215,431 3,521,959,695 325,609,077 846,100,716 InHospital Average Average Mortality Age Severity 31 49 21 19 34 58 33 671 647 623 648 710 722 697 16 18 16 15 17 18 17
Complications Lower Extremity Amputation End-Stage Renal Disease Eye Disease Neurologic Complications Heart Disease Stroke Other Vascular Disease
To provide a picture of diabetes and its complications, the following pages display in-depth information about hospitalizations for non-traumatic lower extremity amputation and end-stage renal disease also known as kidney failure These specific complications were
selected for further analyses since diabetes is the leading cause of both conditions
As defined by MediQual Atlas Outcomes, which refers to a patients level of illness upon admission to the hospital These scores range from minimally sick severity score 0 to maximum probability of death severity score 4
Diabetes Hospitalization Report 19
Lower Extremity Amputations
I
n 2001, there were 42 hospitalizations for a lower extremity amputation with either a principal or secondary diagnosis of diabetes for every 10,000 Pennsylvanians a rate that has remained steady over the past five years
Hospitalization Rate for Lower Extremity Amputations, by Year per 10,000 PA residents
Hospitalizations for Lower Extremity Amputations, by Year
Number of Hospitalizations 5,019 5,318 5,271 5,255 5,142 Average Age 667 672 666 669 671
Year 1997 1998 1999 2000 2001
The rate of lower extremity amputation with a diagnosis of diabetes increased with age Agespecific rates have remained relatively constant since 1997 The rate for residents age 80 and over showed a slight increase during that time
Hospitalization Rate for Lower Extremity Amputations, by Age Comparison between
1997 and 2001 per 10,000 population in PA
20 Diabetes Hospitalization Report
iabetes is the leading cause of non-traumatic lower extremity amputations in the United States According to the CDC, foot care programs that include regular examinations and patient education could prevent up to 85 of these amputations
Hospitalization Rate for Lower Extremity Amputations, by Gender per 10,000 population in PA
D
The amputation rate was higher among men than women
Hospitalization Rate for Lower Extremity Amputations, by Race/Ethnicity per 10,000 population in PA
The highest amputation rate was among nonHispanic African Americans These figures support findings from the ADA suggesting that this population is 15 to 25 times more likely to undergo lower limb amputations
Diabetes Hospitalization Report 21
Lower Extremity Amputations
Percent Difference in Lower Extremity Amputation Rates
Rates are adjusted for age and sex differences among county populations Source: PHC4 inpatient data and US Census Bureau, Census 2000
data
22 Diabetes Hospitalization Report
Patient County of Residence Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata
Difference from Statewide Hospitalization Rate 138 below 74 above 472 below 176 above 337 below 32 below 141 below 162 below 267 below 135 below 50 below 330 above 605 above 614 below 359 below 307 below 178 below 343 below 730 above 90 below 272 below 271 above 58 below 63 above 361 below 187 above 1178 above 38 below 342 below 178 below 161 below 74 above 25 above 484 below
Patient County of Residence Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York
Difference from Statewide Hospitalization Rate 46 above 144 below 207 below 144 below 317 above 78 above 261 below 118 below 157 below 233 below 44 above 362
below 226 above 405 above 527 above 91 above 448 above 559 below 389 below 333 above 266 below 140 above 462 below 786 below 292 below 04 below 155 below 256 below 82 above 165 below 58 below 80 above 40 below
Diabetes Hospitalization Report 23
End-Stage Renal Disease
I
n 2001, there were 218 hospitalizations for end-stage renal disease with either a principal or secondary diagnosis of diabetes for every 10,000 Pennsylvanians While this rate had been increasing, the rate decreased slightly between 2000 and 2001
Hospitalization Rate for End-Stage Renal Disease, by Year per 10,000 PA residents
Hospitalizations for End-Stage Renal Disease, by Year
Year 1997 1998 1999 2000 2001 Number of Hospitalizations 24,641 25,063 25,550 27,455 26,785 Average Age 643 644 644 648 647
In general, the rate of hospitalization involving end-stage renal disease with a diagnosis of diabetes increases with age For residents age 40 and over, the rate was higher in 2001 than it was in 1997 For residents under age 40, the rate remained steady from 1997 to 2001
Hospitalization Rate for End-Stage Renal Disease, by Age Comparison between 1997 and 2001 per 10,000 population in PA
24 Diabetes Hospitalization Report
ccording to the ADA, diabetes is the leading cause of treated end-stage renal disease, accounting for 43 of new cases In Pennsylvania, it is estimated that over 2,000 new cases of renal disease related to diabetes are diagnosed each year The CDC suggests that treatment to better control blood pressure and blood glucose levels could reduce diabetes-related kidney failure by about 50
A
Hospitalization Rate for End-Stage Renal Disease, by Gender per 10,000 population in PA
Hospitalization Rate for End-Stage Renal Disease, by Race/Ethnicity per 10,000 population in PA
Men had a slightly higher rate of hospitalization involving diabetes and end-stage renal disease than did women
The rate of hospitalization involving end-stage renal disease for non-Hispanic African American residents was more than twice the rate for nonHispanic white residents These figures support findings from the ADA suggesting that this population is 26 to 56 times more likely to suffer from kidney disease
Diabetes Hospitalization Report 25
End-Stage Renal Disease
Percent Difference in
Hospitalization Rates involving End-Stage Renal Disease
Rates are adjusted for age and sex differences among county populations Source: PHC4 inpatient data and US Census Bureau, Census 2000 data
26 Diabetes Hospitalization Report
Patient County of Residence Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata
Difference from Statewide Hospitalization Rate 536 below 281 above 345 below 252 above 325 below 361 below 151 above 294 below 281 below 94 above 330 above 828 above 288 above 422 below 364 below 28 below 65 above 224 below 126 below 293 above 194 below 74 below 339 below 114 below 42 above 643 above 225 above 122 above 1061 above 192 above 171 below 71 below 135 above 01 below
Patient County of Residence Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter
Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York
Difference from Statewide Hospitalization Rate 13 above 372 below 351 above 112 below 117 below 10 above 148 below 28 below 215 above 92 below 52 above 451 below 194 below 160 above 141 above 128 above 329 above 478 below 499 below 97 above 182 below 441 above 134 below 00 below 711 above 166 below 231 above 96 above 438 above 80 below 151 above 17 above 378 below
Diabetes Hospitalization Report 27
Data Notes
This report examines hospitalizations where the discharge occurred between January 1 and December 31, 2001 Pennsylvania residents admitted to Pennsylvania hospitals are included in the analysis Out-of-state residents hospitalized in Pennsylvania are excluded because their care was not likely impacted by the passage of Act 98 Pennsylvania residents hospitalized in another state are not included because PHC4 does not have access to that information This analysis does not include data on patients treated in the physicians office, in an outpatient setting, or patients treated in the emergency department and then released Further, these figures reflect
hospitalizations, not persons For example, if an individual was hospitalized on two separate occasions during this time period, they were counted twice Some sections of this analysis are broken down by principal diagnosis and secondary diagnosis PHC4 collects one principal diagnosis and eight secondary diagnoses for each medical record this is consistent with the federal UB-92 data collection If a diabetes code appears in any of the eight secondary diagnosis positions, it is counted as a hospitalization with a secondary diagnosis of diabetes The data were reported as submitted to PHC4 by the hospitals If a hospital did not provide complete information, the number of hospitalizations would be undercounted The hospital charges reported are charges associated with the entire hospitalization not just the treatment associated with diabetes and do not include physician fees Further, while charges are a standard way of reporting data, they do not reflect the actual costs of the treatment, nor do they reflect the payment that the hospital may have actually received The following ICD9CM codes International Classification of Diseases, Ninth Revision, Clinical Modification were used to
identify hospitalizations with a diagnosis of diabetes: 250xy; where, x0,1,2,3,4,5,6,7,8,9 and y0,1,2,3
28 Diabetes Hospitalization Report
The following ICD9CM codes were used to identify short-term complications of diabetes: 25002, 25003 and 250xy; where, x1,2,3 and y0,1,2,3 The following ICD9CM codes were used to identify lower extremity amputations: 841y where, y0,1,2,3,4,5,6,7 and a diabetes code was in the record Records including codes for a traumatic amputation 8950, 8951, 8960, 8961, 8962, 8963, and 897x where, x0,1,2,3,4,5,6,7 were excluded The following ICD9CM codes were used to identify end-stage renal disease: 25040 25043, 585, 586, V420, V560, V568, 99662, 99673, and 99681 and a diabetes code was in the record ICD9CM codes were used to differentiate between Type 1 and Type 2 diabetes The fifth digit of the ICD9CM code ie, y in 250xy classifies the type of diabetes The following specifies the definition of the fifth-digit subclassification Note that this classification is based on the definition of insulin dependent and not insulin using Fifth-digit 0 subclassifies the diagnosis as Type 2 [non-insulin dependent type] [adult-onset type] or unspecified type, not
stated as uncontrolled Fifth-digit 1 subclassifies the diagnosis as Type 1 [insulin dependent type] [juvenile type], not stated as uncontrolled Fifth-digit 2 subclassifies the diagnosis as Type 2 [non-insulin dependent type] [adult-onset type] or unspecified type, uncontrolled Fifth-digit 3 subclassifies the diagnosis as Type 1 [insulin dependent type] [juvenile type], uncontrolled Hospitalization rates for 1997, 1998, and 1999 were calculated using US Census Bureau population estimates Hospitalization rates for 2000 and 2001 were calculated using US Census Bureau, Census 2000 data
Diabetes Hospitalization Report 29
Pennsylvania Health Care Cost Containment Council
Marc P Volavka, Executive Director
225 Market Street, Suite 400 Harrisburg, PA 17101 Phone: 717-232-6787 Fax: 717-232-3821
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