If you have type 1 diabetes, your body does not make any insulin and You can get type 2 diabetes at any age. This type of diabetes usually goes away …
Diabetes Hospitalization Report
2004 Data
Pennsylvania Health Care Cost Containment Council
November 2005
T
he Pennsylvania Health Care Cost Containment Council
Key Findings
The number of hospitalizations where diabetes was the principal diagnosis rose by almost 86 percent between 2000 and 2004 growing from 21,842 to 23,725 hospitalizations The rate of increase has slowed over the past two years, with increases of less than one percent between 2002 and 2003 and between 2003 and 2004, compared to increases of three and four percent in previous years In 2004 alone, the hospitalizations where diabetes was the principal diagnosis accounted for over 131,800 hospital days and incurred over 673 million in hospital charges While the number and rate of hospitalizations for type 1 diabetes have decreased from 2000 to 2004, the number and rate of hospitalizations for type 2 diabetes have increased steadily during this period Between 2000 and 2004, hospitalization rates for diabetes increased with age The most pronounced increase was in the 20-39 age group, where admission rates jumped 260 percent African Americans continued to have the highest rates of hospitalization for diabetes,
as well as the highest rates of lower extremity amputations and hospitalizations for end-stage renal disease Medicare was the primary payor for 490 percent of the hospitalizations for diabetes as a principal diagnosis Private insurers had the next highest percentage at 253 percent Multiple hospitalizations for diabetes are common and costly Some 154 percent of patients with diabetes were hospitalized two or more times in 2004 Certain populations, including Medicaid and Medicare recipients, were more likely to have recurrent hospitalizations
PHC4 is an independent state agency responsible for addressing the problem of escalating health costs and ensuring the quality of health care in Pennsylvania PHC4 fosters competition in the health care market through the collection, analysis, and dissemination of quality health care information
D
iabetes is a widespread, chronic disease caused by the inability of the body to produce or prop-
diabetes, including women with gestational diabetes, has increased 61 percent and is projected to more than double by 2050
erly use insulin It is characterized by high blood sugar levels Diabetes predisposes people to costly 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 The increasing number of older Americans, coupled with increasing rates of obesity and the trend toward more sedentary lifestyles, suggests that diabetes will continue to remain a serious and growing health concern well into the future 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 The Behavioral Risk Factor Surveillance Survey, conducted in 2004 by the Pennsylvania Department of Health in conjunction with the Centers for Disease Control and Prevention CDC, indicates an estimated 8 percent of Pennsylvania residents 18 years of age and older were told by a doctor that they had diabetes The US estimated percentage was 7 percent Since 1991, the number of American adults with
Diabetes is a costly disease
A study commissioned by the American Diabetes Association ADA estimated that in 2002: The direct medical costs attributable to diabetes reached 92 billion On average, people with
diabetes incurred approximately 13,243 in health care expenditures in 2002, while people without diabetes incurred approximately 2,560 in expenditures Another 40 billion in indirect costs ie, disability, work loss, and premature mortality were attributed to diabetes in the United States Men with diabetes have 31 more lost workdays and 79 more bed days per year, on average, than men without diabetes Women with diabetes had 06 more lost workdays and 81 more bed days, on average, than women without diabetes The ADA study further estimated that more than 176,000 cases of permanent disability in 2002 were attributable to diabetes
P
rediabetes is a term used to distinguish people who are at increased risk of developing diabetes People with prediabetes have blood sugar levels which are higher than normal, but not high enough
for a diagnosis of type 2 diabetes While people with prediabetes are at an increased risk of developing type 2 diabetes, progression to diabetes among those with prediabetes is not inevitable Studies suggest that weight loss and increased physical activity among people with prediabetes may prevent or delay diabetes and may return blood sugar levels to normal In
addition to the 182 million Americans with diabetes, the Centers for Disease Control and Prevention estimates that an additional 41 million Americans, ages 40 to 74, may have prediabetes Research has shown that, despite not having diabetes, people with prediabetes are already at risk for other adverse health outcomes, such as heart disease and stroke
PHC4 Diabetes Hospitalization Report 2004 Data 1
The number of hospital admissions for diabetes increased by almost 86 percent between 2000 and 2004; however, during this period, the annual rate of increase has slowed from a high of 43 percent to about 05 percent for the past two years
One way to monitor the cost and quality of care received by Pennsylvanians with diabetes is to look at the number of hospital admissions for diabetes Such admissions add to the high cost of this disease and suggest that people with diabetes might not have sufficient access to appropriate care In 2004, there were 23,725 hospital admissions for diabetes in Pennsylvania These hospital admissions include those in which diabetes was the principal diagnosis, thereby suggesting that the reason for the admission was a direct result of diabetes Hospital
admissions for diabetes may be preventable because appropriate care can generally be provided in a physicians office or on an outpatient basis If a patient reaches the point where he or she must be hospitalized for diabetes, a breakdown in diabetes care or access to care may have already occurred Hospital admissions for diabetes accounted for more than 673 million in hospital charges and almost 132,000 hospital days in 2004 Totals for the past five years reach more than 26 billion in hospital charges and over 649,000 days in the hospital
Table 1 Hospital Admissions for Diabetes, Principal Diagnosis, 2000-2004
Number of Hospital Admissions 2000 2001 2002 2003 2004 Total 21,842 22,526 23,496 23,614 23,725 115,203 Days Average Days 57 57 56 57 56 56 Total Days 123,737 127,892 132,038 133,915 131,827 649,409 Hospital Charges Average Charge 16,210 18,883 23,182 27,156 28,395 22,908 Total Charges 354,062,503 425,357,579 544,686,623 641,267,081 673,663,573 2,639,037,085
Although the rate of hospital admissions for diabetes increased 73 percent between 2000 and 2004, this rate has leveled off since 2002
In 2004, there were 191 hospital admissions for diabetes for every 10,000
Pennsylvania residents of 178 in 2000
Figure 1 Hospital Admission Rates for Diabetes, Principal Diagnosis, 2000-2004
This represents a 73 percent increase from the rate
2 PHC4 Diabetes Hospitalization Report 2004 Data
Hospital admission rates for type 2 diabetes continued to increase 29 percent between 2000 and 2004; however, admission rates for type 1 diabetes continued to decrease 18 percent between 2000 and 2004
There are two main types of diabetes: type 1 and type 2 diabetes Type 1 diabetes usually appears in children or young adults and accounts for 5 percent to 10 percent 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, the most common form of diabetes, is estimated to account for about 90 percent to 95 percent 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, some people with type 2 diabetes may also need to take daily insulin
injections There has been a dramatic increase in type 2 diabetes in recent years Not only is type 2 diabetes appearing more frequently in adults, but alarmingly children and adolescents are also being diagnosed with type 2 diabetes Because type 2 diabetes may be prevented or delayed if those at high-risk make recommended lifestyle changes, this increase is cause for concern While part of the increase may be attributed to an aging population, it is largely a consequence of the dramatic increase in obesity In Pennsylvania, the percentage of obese adults increased from 19 percent to 24 percent between 1998 and 2004
Figure 2 Hospital Admission Rates for Type 1 Diabetes, Principal Diagnosis, 2000-2004
Figure 3 Hospital Admission Rates for Type 2 Diabetes, Principal Diagnosis, 2000-2004
PHC4 Diabetes Hospitalization Report 2004 Data 3
Hospital admission rates for diabetes vary by age and race
Hospital admission rates for diabetes increased with age; however, the most pronounced change between 2000 and 2004 as seen in previous years was in the 20-39 age category, where admission rates jumped 260 percent
Table 2 Hospital
Admissions, Hospital Admission Rates, Hospital Days, and Charges for Diabetes, by Age, 2004
Hospital Admission Rates per 10,000 population in PA
Hospital Admissions Age Category 0 - 19 20 - 39 40 - 59 60 - 79 80 and over Total
Hospital Days Average Length of Stay 27 37 56 67 62 56 Total Number of Days 4,478 13,577 41,297 53,210 19,265 131,827
Hospital Charges Average Charge 11,957 22,146 31,826 32,843 24,899 28,395 Total Charges 19,537,535 81,122,559 235,796,078 259,821,535 77,385,866 673,663,573
Number 1,634 3,663 7,409 7,911 3,108 23,725
Percent 69 154 312 333 131 1000
2000 51 92 191 423 517 178
2004 51 116 207 424 510 191
At a rate of 461 per 10,000, non-Hispanic African American residents had hospital admission rates for diabetes three times that of non-Hispanic whites 161 per 10,000 According to the Centers for Disease Control and Prevention, on average, non-Hispanic African Americans are 16 times as likely to have diabetes than non-Hispanic whites of similar age Overall, males and females had similar hosp 
ital admission rates for diabetes in 2004, 202 and 181 per 10,000 respectively
Figure 4 Hospital Admissions for Diabetes by Payor Type, 2004
Hospital
admissions vary by payor type
Medicare was the primary payor for almost half 490 of the hospitalizations for diabetes as a principal diagnosis Private insurers had the next highest percentage at 253 percent
Includes other government payors and hospitalizations where the payor was unknown or designation was invalid
4 PHC4 Diabetes Hospitalization Report 2004 Data
Multiple hospitalizations for diabetes are common
In 2004, 154 percent of patients with diabetes were hospitalized two or more times Certain populations, including Medicaid and Medicare recipients, were more likely to have recurrent hospitalizations
Figure 5 Multiple Hospitalizations for Patients with Diabetes, 2004
Hospital admission rates vary by county
In 2004, the lowest rate of hospital admissions for diabetes was 67 hospitalizations per 10,000 residents in Union County Philadelphia had the highest hospital admission rate in Pennsylvania at 377 per 10,000 residents
Map 1 Hospital Admission Rates for Diabetes, by County, 2004 per 10,000 residents
Rates are adjusted for age and sex differences among county
populations Source: PHC4 inpatient data and US Census 2004 data
PHC4 Diabetes Hospitalization Report 2004 Data 5
Complications associated with diabetes are often severe and can be life-threatening Figure 6 Hospital Admission Rates for Uncontrolled Diabetes, Principal Diagnosis, 2000-2004
For 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 complications, thereby improving ones health and quality of life Hospital admissions for uncontrolled diabetes reflect on the quality of outpatient and other health care, and should be of interest to comprehensive health care delivery systems The hospital admission rate for uncontrolled diabetes has declined slightly since 2001 Short-term complications of diabetes include acute, life-threatening events, such as diabetic ke
Figure 7 Hospital Admission Rates for Short-Term Complications of Diabetes, Principal Diagnosis, 2000-2004
toacidosis and diabetic coma Hospitalizations for these events may be an immediate reflection of how
well patients are managing their diabetes The hospital admission rate for short-term complications of diabetes increased by 11 percent between 2000 and 2002, then declined slightly in 2003 and 2004 The long-term complications of diabetes include chronic problems such as heart disease, stroke, amputation, kidney disease, neurologic complications, vascular disease, and eye disease that develop over a period of years or even decades Hospitalizations for these events may be a reflection of how well paof time The hospital admission rate for long-term complications of diabetes increased slightly each year from 2000 to 2004
Figure 8 Hospital Admission Rates for Long-Term Complications of Diabetes, Principal Diagnosis, 2000-2004
tients are managing their diabetes over a long period
6 PHC4 Diabetes Hospitalization Report 2004 Data
Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States
According to the Centers for Disease Control and Prevention, comprehensive foot care programs that include regular examinations and patient education could reduce amputation rates by 45 percent to 85 percent In
2004, there were 39 hospital admissions for a lower extremity amputation with either a principal or secondary diagnosis of diabetes for every 10,000 Pennsylvanians The hospital admission rate for lower extremity amputation has decreased slightly over the past five years from a rate of 43 per 10,000 in 2000 Hospital admission rates for lower extremity amputation varied by county from a low of zero hospitalizations per 10,000 residents in Forest County to a high of 63 in Philadelphia County At a rate of 64 per 10,000, non-Hispanic African American residents had a lower extremity amputation rate 73 percent higher than that of nonHispanic whites 37 per 10,000 in 2004 According to the American Diabetes Association, among people with diabetes, African Americans are 15 to 25 times more likely to suffer from lower limb amputations Overall, males had a lower extremity amputation rate of 51 per 10,000, and females had a rate of 27 per 10,000 The rate for males was approximately 88 percent higher than the rate for females
Map 2 Lower Extremity Amputation Rates, by County, 2004 per 10,000 residents
Rates are adjusted for age and sex differences among county populations Source: PHC4 inpatient data and US Census 2004 data
PHC4 Diabetes Hospitalization Report 2004 Data 7
Diabetes is the leading cause of treated end-stage renal disease, accounting for 43 percent of new cases
According to the Centers for Disease Control and Prevention, detection and treatment of early diabetic kidney disease by lowering blood pressure can reduce decline in kidney function In 2004, there were 208 hospital admissions for end-stage renal disease with either a principal or secondary diagnosis of diabetes for every 10,000 Pennsylvanians The hospital admission rate for endstage renal disease decreased 69 percent from 223 percent in 2000 to 208 percent in 2004 Hospital admission rates for end-stage renal disease varied by county from a low of 99 hospital admissions per 10,000 residents in Chester County to a high of 378 in Fayette County At a rate of 370 per 10,000, non-Hispanic African American residents had a hospital admission rate for end-stage renal disease nearly twice that of nonHispanic whites 194 per 10,000 in 2004 According to the American Diabetes Association,
African Americans with diabetes are 26 to 56 times more likely to suffer from kidney disease
Map 3 Hospital Admission Rates Involving End-Stage Renal Disease, by County, 2004 per 10,000 residents
Rates are adjusted for age and sex differences among county populations Source: PHC4 inpatient data and US Census 2004 data
8 PHC4 Diabetes Hospitalization Report 2004 Data
Conclusion
Diabetes has an enormous impact not only on individuals, but also on the cost and quality of health care While hospitalizations with a principal diagnosis of diabetes are the main focus of this analysis, the number of hospitalizations where diabetes was either the principal or secondary diagnosis provides an important look at the overall picture In 2004, there were 327,370 hospitalizations with a principal or secondary diagnosis of diabetes, compared to 286,297 in 2000 Diabetes was the principal or secondary diagnosis in 175 percent of all hospitalizations for Pennsylvania residents in 2004 up from 16 percent in 2000 Therefore, continued efforts are needed to better diagnose, prevent and manage
diabetes
Hospitalizations with a Diagnosis of Diabetes Total
without
Figure 9 Hospitalizations with and without Diabetes Diagnosis, 2004
with
Number Percent 327,370 1,870,625 175 825 100 Hospitalizations without a Diagnosis of Diabetes 1,543,255
Data Notes
This report examines hospitalizations where the discharge occurred between January 1 and December 31, 2004 The analysis includes Pennsylvania residents who were admitted to Pennsylvania hospitals Out-of-state residents hospitalized in Pennsylvania were excluded, as were Pennsylvania residents hospitalized in another state This analysis does not include data on patients treated in the physicians office or in an outpatient setting, or patients treated in the emergency department and then released Further, these figures reflect hospitalizations, not persons For example, an individual hospitalized on two separate occasions during this time period was counted twice Unless otherwise specified, the analysis is based on hospital admissions with a principal diagnosis of diabetes PHC4 collects one principal diagnosis and eight secondary diagnoses for each medical record 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 The following ICD9CM codes were used to identify uncontrolled diabetes: 25002, 25003 The following ICD9CM codes were used to identify short-term complications of diabetes: 250xy; where, x1,2,3 and y0,1,2,3 The following ICD9CM codes were used to identify long-term complications of diabetes: 250xy; where, x4,5,6,7,8,9 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 The following ICD9CM codes were used to differentiate between type 1 and type 2 diabetes: 250xy in which y1,3 indicates type 1 diabetes and y0,2 indicates type 2 diabetes Hospitalization rates for 2000, 2001, 2002, 2003 and 2004 were calculated using US Census Bureau population estimates for the corresponding year
PHC4 Diabetes Hospitalization Report 2004 Data 9
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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