RESUMEN
OBJECTIVE: Increasing obesity within the general population has been accompanied by rising rates of diabetes. The extent to which obesity has increased among people with diabetes is unknown, as are the potential consequences for diabetes outcomes. RESEARCH DESIGN AND METHODS: Community medical records (hospital and ambulatory) of all Rochester, Minnesota, residents aged > or =30 years who first met standardized research criteria for diabetes from 1970 to 1989 (n = 1,306) were reviewed to obtain data on BMI and related characteristics as of the diabetes identification date (+/-3 months). Vital status as of 31 December 1999 and date of death for those who died were obtained from medical records, State of Minnesota death tapes, and active follow-up. RESULTS: As of the identification date, data on BMI were available for 1,290 cases. Of the 272 who first met diabetes criteria in 1970-1974, 33% were obese (BMI > or =30), including 5% who were extremely obese (BMI > or =40). These proportions increased to 49% (P < 0.001) and 9% (P = 0.012), respectively, for the 426 residents who first met diabetes criteria in 1985-1989. BMI increased significantly with increasing calendar year of diabetes identification in multivariable regression analysis. Analysis of survival revealed an increased hazard of mortality for BMI > or =41, relative to BMI of 23-25 (hazard ratio 1.60, 95% CI 1.09-2.34, P = 0.016). CONCLUSIONS: The prevalence of obesity and extreme obesity among individuals at the time they first met criteria for diabetes has increased over time. This is disturbing in light of the finding that diabetic individuals who are extremely obese are at increased risk of mortality compared with their nonobese diabetic counterparts.
Asunto(s)
Índice de Masa Corporal , Diabetes Mellitus/epidemiología , Diabetes Mellitus/fisiopatología , Obesidad , Adulto , Glucemia/análisis , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Registros Médicos , Persona de Mediana Edad , Minnesota/epidemiología , Análisis Multivariante , Análisis de Regresión , Factores Sexuales , Fumar , Factores de TiempoRESUMEN
Type 2 diabetes mellitus is a heterogeneous disorder characterized by 2 pathogenic defects, impaired insulin secretion and insulin resistance. The resultant hyperglycemia causes microvascular and macrovascular complications that increase morbidity and mortality in patients with diabetes mellitus. Optimum glycemic control in patients with type 1 and type 2 diabetes mellitus prevents the development of microvascular disease and, to a lesser extent, macrovascular disease. Prandial hyperglycemia may be an independent risk factor for the development of diabetic complications. This article reviews the pathophysiologic mechanisms of glucose metabolism and describes the results of epidemiological and interventional studies that have demonstrated the association of acute and chronic hyperglycemia with the development of diabetic complications. The American Diabetes Association has defined diagnostic and treatment goals for diabetes mellitus, striving to achieve near-normal glycemic control to delay or prevent the development of diabetic complications. A number of oral antidiabetic agents and insulins are currently available for the treatment of type 2 diabetes mellitus in the United States. These agents target fasting and postmeal plasma glucose levels to improve glycemic control. Alone or in combination, these agents have enhanced the clinical approaches to treating diabetes mellitus.
Asunto(s)
Glucemia/análisis , Diabetes Mellitus Tipo 2 , Enfermedad Aguda , Enfermedad Crónica , Diabetes Mellitus Tipo 2/clasificación , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/terapia , Dieta para Diabéticos , Progresión de la Enfermedad , Quimioterapia Combinada , Ingestión de Alimentos/fisiología , Ayuno , Humanos , Hiperglucemia/etiología , Hipoglucemiantes/uso terapéutico , Resistencia a la Insulina , Morbilidad , Guías de Práctica Clínica como Asunto , Factores de RiesgoRESUMEN
OBJECTIVE: This study investigates temporal trends in the prevalence and incidence of persistent proteinuria among people with adult-onset diabetes (age > or =40 years). RESEARCH DESIGN AND METHODS: The complete community-based medical records of all Rochester, Minnesota, residents with a diagnosis of diabetes or diabetes-like condition from 1945 through 1989 were reviewed to determine whether they met National Diabetes Data Group (NDDG) criteria. All confirmed diabetes cases residing in Rochester on 1 January 1970 (n = 446), 1980 (n = 647), and/or 1990 (n = 940) were identified. The medical records of these prevalence cases were reviewed from the time of the first laboratory urinalysis value to the last visit, death, or 1 April 1992 (whichever came first) for evidence of persistent proteinuria (two consecutive urinalyses positive for protein, with no subsequent negative values). Similarly, the medical records of all 1970-1989 diabetes incidence cases (n = 1,252) were reviewed to investigate temporal changes in 1) the likelihood of having persistent proteinuria before the date NDDG criteria was met, i.e., baseline; 2) the risk of persistent proteinuria after baseline; and 3) the relative risk of mortality associated with persistent proteinuria. RESULTS: The proportion of diabetes prevalence cases with persistent proteinuria on or before the prevalence date declined from 20% in 1970 to 11% in 1980 and 8% in 1990. Among the 1970-1989 diabetes incidence cases, 77 (6%) had persistent proteinuria on or before baseline; the adjusted odds declined by 50% with each 10-year increase in baseline calendar year (P<0.001). Among individuals free of persistent proteinuria at baseline, 136 subsequently developed persistent proteinuria; the estimated 20-year cumulative incidence was 41% (95% CI 31-59); the adjusted risk did not differ as a function of baseline calendar year. Survival of individuals with persistent proteinuria relative to those without was reduced but did not differ by baseline calendar year. CONCLUSIONS: The prevalence of persistent proteinuria among people with adult-onset diabetes in Rochester, Minnesota, declined 60% between 1970 and 1990. The decline appears because of a decrease in the proportion of diabetes incidence cases with persistent proteinuria before baseline rather than secular declines in the risk of persistent proteinuria after baseline or secular increases in the risk of mortality associated with persistent proteinuria. Similarity over time in age and fasting glucose at baseline, and at prevalence dates, is evidence that earlier detection of diabetes is not the sole explanation for the decline.
Asunto(s)
Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/fisiopatología , Nefropatías Diabéticas/epidemiología , Proteinuria/epidemiología , Glucemia/análisis , Estudios de Cohortes , Diabetes Mellitus Tipo 2/orina , Femenino , Humanos , Incidencia , Masculino , Registros Médicos , Persona de Mediana Edad , Minnesota/epidemiología , Prevalencia , Probabilidad , Estudios RetrospectivosRESUMEN
Non-insulin-dependent diabetes mellitus (NIDDM) affects approximately 12 million people in the United States. NIDDM is frequently found to coexist with other conditions, such as obesity, dyslipidemia, atherosclerotic vascular disease, and hypertension, which contribute to morbidity and mortality. Although the major clinical objective in the management of NIDDM is to control hyperglycemia, the long-term objective is to prevent microvascular and macrovascular complications. Cardiovascular disease is the major cause of death in NIDDM patients. Although hyperglycemia may be adequately controlled, risk factors for coronary heart disease may remain unchanged. Treatment with metformin controls hyperglycemia and may have positive effects on cardiovascular risk factors. When used alone or in combination with sulfonylureas, metformin tends to stabilize or decrease weight, maintains or reduces insulin levels, has beneficial effects on plasma lipid profiles, and may also have beneficial effects on blood pressure and the fibrinolytic system.
Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/fisiopatología , Angiopatías Diabéticas/epidemiología , Hipoglucemiantes/uso terapéutico , Metformina/uso terapéutico , Enfermedades Cardiovasculares/fisiopatología , Enfermedades Cardiovasculares/prevención & control , Diabetes Mellitus/tratamiento farmacológico , Diabetes Mellitus/epidemiología , Angiopatías Diabéticas/fisiopatología , Angiopatías Diabéticas/prevención & control , Fibrinólisis/efectos de los fármacos , Humanos , Hiperlipidemias/epidemiología , Hipertensión/epidemiología , Resistencia a la Insulina , Obesidad , Agregación Plaquetaria/efectos de los fármacos , Factores de RiesgoAsunto(s)
Enfermedad de Alzheimer/etiología , Demencia/etiología , Diabetes Mellitus Tipo 2/complicaciones , Adulto , Anciano , Enfermedad de Alzheimer/epidemiología , Estudios de Cohortes , Demencia/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Prevalencia , Factores de RiesgoRESUMEN
This population-based retrospective study investigates temporal trends in adult-onset diabetes mellitus prevalence, incidence, and survival. The complete community-based medical records, including laboratory results, of all Rochester, Minnesota, residents with a clinical diagnosis of diabetes or diabetes-like condition were reviewed to identify incidence cases aged 30 years or more from 1945 to 1989 (n = 1,847) and prevalence cases aged 45 years or more on January 1, 1970 (n = 465), January 1, 1980 (n = 689), or January 1, 1990 (n = 973). Glucose values and case definitions were standardized throughout. Observed 10-year survival for 1970 and 1980 prevalence cases was compared with that expected for Minnesota white populations in 1970 and 1980, respectively. Age-adjusted prevalence rose 65% for men and 37% for women between 1970 and 1990. There were marked differences among prevalence groups in treatment type, the proportion diagnosed using glucose tolerance tests, and the proportion categorized as obese. Relative survival for 1980 prevalence cases was not greater than that for 1970 prevalence cases. Age-adjusted incidence rates rose 47% for men and 26% for women between 1960 and 1965 and 1985 and 1989. These findings emphasize the need for heightened surveillance and intervention to reduce the burden of illness from adult-onset diabetes mellitus in the population.
Asunto(s)
Diabetes Mellitus Tipo 2/epidemiología , Distribución por Edad , Anciano , Anciano de 80 o más Años , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidad , Femenino , Prueba de Tolerancia a la Glucosa , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Prevalencia , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Riesgo , Distribución por Sexo , Análisis de SupervivenciaRESUMEN
It is unclear whether persons with diabetes are at increased risk for dementia, including Alzheimer's disease. Existing studies are limited by small sample size, selection bias, and case-control designs. This population-based historical cohort study provides estimates of the risk of dementia and Alzheimer's disease associated with adult onset diabetes mellitus (AODM). The sample included all persons with AODM residing in Rochester, Minnesota, on January 1, 1970, plus all persons diagnosed in Rochester or who moved to Rochester with the diagnosis between January 1, 1970, and December 31, 1984. Individuals were followed through review of their complete medical records from AODM diagnosis until dementia onset, emigration, death, or January 1, 1985. Standardized morbidity ratios for dementia and Alzheimer's disease were calculated, using an expected incidence based on age- and sex-specific rates for the Rochester population. Poisson regression was used to estimate risks for persons with AODM relative to those without. Of the 1,455 cases of AODM followed for 9,981 person-years, 101 developed dementia, including 77 who met criteria for Alzheimer's disease. Persons with AODM exhibited significantly increased risk of all dementia (Poisson regression relative risk (RR) = 1.66, 95% confidence interval (CI) 1.34-2.05). Risk of Alzheimer's disease was also elevated (for men, R = 2.27, 95% CI 1.55-3.31; for women, RR = 1.37, 95% CI 0.94-2.01). These findings emphasize the importance of AODM prevention and prompt additional investigation of the relation between AODM and dementia.
Asunto(s)
Demencia/etiología , Diabetes Mellitus Tipo 2/complicaciones , Distribución por Edad , Anciano , Anciano de 80 o más Años , Enfermedad de Alzheimer/etiología , Estudios de Cohortes , Demencia/epidemiología , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Vigilancia de la Población , Análisis de Regresión , Riesgo , Factores de Riesgo , Salud UrbanaRESUMEN
OBJECTIVE: Despite widespread acceptance of continuous insulin infusion (CII) over bolus insulin injection (BII) for treatment of diabetic ketoacidosis (DKA), there are no population-based studies demonstrating whether CII has resulted in lower morbidity and mortality. RESEARCH DESIGN AND METHODS: We addressed this issue using a provider-linked database and retrospectively reviewing the complete medical records of all incidence cases of diabetes among Rochester, Minnesota, residents from 1950 to 1989 with a discharge diagnosis of DKA. This population-based study describes the consequences of the widespread change in treatment modality outside the confines of a controlled clinical trial. RESULTS: Among the diabetes incident cohort, there were 59 subjects with confirmed first episodes of DKA during 1950-1992; 29 of 30 subjects treated with BII occurred before 1970. All 29 CII cases occurred between 1976 and 1992. Sex, etiology, diabetes duration, and age at DKA were similar for the two groups. The proportion of obese individuals (BII = 2/28, CII = 8/21; P = 0.01) differed between groups. The CII group exhibited higher glucose values (BII = 24.9 +/- 8.5 mmol/l, CII = 37.1 +/- 15.1 mmol/l; P = 0.002) and lower bicarbonate values (BII = 7.7 +/- 3.0 nmol/l, CII = 6.2 +/- 2.9 nmol/l; P = 0.04) upon admission. The mean quantity of insulin administered was higher in the BII group than in the CII group (179 +/- 140 and 99 +/- 70 U, P < 0.006). The outcome of hypoglycemia occurred more frequently in the BII group than in the CII group (BII = 8/30, CII = 1/29; P = 0.03). The proportion with hypokalemia, neurological deficit, myocardial arrhythmia, or mortality did not differ significantly between groups. CONCLUSIONS: Our findings suggest the introduction of CII was accompanied by a decreased incidence of hypoglycemia.
Asunto(s)
Cetoacidosis Diabética/tratamiento farmacológico , Insulina/administración & dosificación , Insulina/uso terapéutico , Adulto , Bicarbonatos/sangre , Glucemia/metabolismo , Bases de Datos Factuales , Diabetes Mellitus/epidemiología , Diabetes Mellitus Tipo 1/epidemiología , Femenino , Humanos , Incidencia , Infusiones Intravenosas , Inyecciones Intravenosas , Inyecciones Subcutáneas , Insulina/efectos adversos , Masculino , Registros Médicos , Minnesota/epidemiología , Obesidad , Potasio/sangre , Estudios RetrospectivosAsunto(s)
Colelitiasis/tratamiento farmacológico , Hipercolesterolemia/tratamiento farmacológico , Ácido Ursodesoxicólico/uso terapéutico , Humanos , Hipercolesterolemia/etiología , Cirrosis Hepática Biliar/complicaciones , Cirrosis Hepática Biliar/tratamiento farmacológico , Ácido Ursodesoxicólico/farmacologíaRESUMEN
BACKGROUND: Despite the significant public health burden of lower-extremity amputations in diabetes mellitus, few data are available on the epidemiology of lower-extremity amputations in diabetes mellitus in the community setting. METHODS: A retrospective incidence cohort study based in Rochester, Minn, was conducted. RESULTS: Among the 2015 diabetic individuals free of lower-extremity amputation at the diagnosis of diabetes mellitus, 57 individuals underwent 79 lower-extremity amputations (incidence, 375 per 100,000 person-years; 95% confidence interval, 297 to 467). Among the 1826 patients with non-insulin-dependent diabetes mellitus, 52 underwent 73 lower-extremity amputations, and the subsequent incidence of lower-extremity amputation among these residents was 388 per 100,000 person-years (95% confidence interval, 304 to 487). Of the 137 insulin-dependent diabetic patients, four subsequently underwent five lower-extremity amputations (incidence, 283 per 100,000 person-years; 95% confidence interval, 92 to 659). Twenty-five years after the diagnosis of diabetes mellitus, the cumulative risk of one lower-extremity amputation was 11.2% in insulin-dependent diabetes mellitus and 11.0% in non-insulin-dependent diabetes mellitus. When compared with lower-extremity amputation rates for Rochester residents without diabetes, patients with non-insulin-dependent diabetes mellitus were nearly 400 times more likely to undergo an initial transphalangeal amputation (rate ratio, 378.8) and had almost a 12-fold increased risk of a below-knee amputation (rate ratio, 11.8). In this community, more than 60% of lower-extremity amputations were attributable to non-insulin-dependent diabetes mellitus. CONCLUSIONS: These population-based data document the magnitude of the elevated risk of lower-extremity amputation among diabetic individuals. Efforts should be made to identify more precisely risk factors for amputation in diabetes and to intervene in the processes leading to amputation.
Asunto(s)
Amputación Quirúrgica/estadística & datos numéricos , Diabetes Mellitus Tipo 2/complicaciones , Pierna/cirugía , Pie Diabético/cirugía , Femenino , Humanos , Incidencia , Masculino , Minnesota/epidemiología , Oportunidad Relativa , Estudios RetrospectivosRESUMEN
Hypothyroidism is associated with an increased risk of coronary artery disease. This observation may in part be related to the lipid abnormalities in patients with this condition. The lipid profiles of 268 patients with primary hypothyroidism and 27 with secondary hypothyroidism, who were examined in the Thyroid Clinic at the Mayo Clinic during a 1-year period, were reviewed. Hyperlipidemia was commonly associated with both primary and secondary hypothyroidism. The lipid values decreased with treatment of hypothyroidism. Type IIa hyperlipidemia was the most common lipid abnormality in patients with primary hypothyroidism, whereas type IIb was the most common in those with secondary hypothyroidism. Total/high-density lipoprotein cholesterol and low-density lipoprotein/high-density lipoprotein cholesterol ratios were increased in both male and female patients with primary and secondary hypothyroidism, and they decreased with restitution of the euthyroid state, although this decrease achieved statistical significance only in female patients. Significant associations with total thyroxine were noted for total cholesterol and triglycerides and with thyroid-stimulating hormone (thyrotropin) for total cholesterol and low-density lipoprotein cholesterol. Thus, both primary and secondary hypothyroidism are commonly associated with an atherogenic lipid profile, which improves with replacement of thyroid hormone. Even after restitution of the euthyroid state, however, the lipid profile remains atherogenic in male patients. In comparison with primary hypothyroidism, the lipid profile is more atherogenic in secondary hypothyroidism because of the lower high-density lipoprotein cholesterol levels associated with this condition.
Asunto(s)
Hiperlipidemias/etiología , Hipotiroidismo/fisiopatología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , HDL-Colesterol/sangre , LDL-Colesterol/sangre , Femenino , Humanos , Hiperlipidemias/sangre , Hipotiroidismo/sangre , Hipotiroidismo/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Hormonas Tiroideas/uso terapéutico , Triglicéridos/sangreRESUMEN
Hyperinsulinemia is alleged to contribute to the pathogenesis of hypertension and dyslipidemia (hypertriglyceridemia) in the setting of insulin resistance. To assess the association among hyperinsulinemia, hypertension, and hypertriglyceridemia in the absence of insulin resistance, we determined their prevalence in a large cohort of patients with insulinoma (N = 250). In this retrospective case-control study, patients with insulinoma were matched by age, gender, race, and year of operation with 217 control patients admitted to the hospital for elective cholecystectomy. Mean preoperative blood pressure measurements were compared between study patients and control patients. In addition, age-, gender-, and race-specific percentiles of blood pressure were compared with data from the National Health and Nutrition Examination Survey I, and those of triglycerides (N = 65) and cholesterol (N = 70) were compared with Mayo Clinic normal reference data. The study group consisted of 105 men and 145 women; the median age was 41 years (range, 8 to 82). The median duration of symptoms before operation was 1.9 years (range, 0.05 to 40 years). After adjustment for body mass index, no statistically significant differences in systolic and diastolic blood pressure were noted between patients with insulinoma and matched control patients (131 +/- 19 versus 128 +/- 18 mm Hg and 81 +/- 11 versus 79 +/- 9 mm Hg, respectively). No relationship was observed between duration of hyperinsulinemia (as long as 40 years) and blood pressure. The age- and gender-specific percentiles of systolic and diastolic blood pressure of the patients with insulinoma did not differ from the age- and gender-specific percentiles for the general white population.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Hiperinsulinismo/complicaciones , Hipertensión/epidemiología , Hipertrigliceridemia/epidemiología , Insulinoma/complicaciones , Neoplasias Pancreáticas/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Presión Sanguínea , Índice de Masa Corporal , Niño , Femenino , Hospitales de Práctica de Grupo , Humanos , Hiperinsulinismo/sangre , Hipertensión/diagnóstico , Hipertensión/etiología , Hipertrigliceridemia/sangre , Hipertrigliceridemia/etiología , Insulinoma/cirugía , Análisis de los Mínimos Cuadrados , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Neoplasias Pancreáticas/cirugía , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Triglicéridos/sangreRESUMEN
Our previous experience with vertical (nonbanded) gastroplasty proved disappointing because of unsatisfactory maintenance of weight loss. Vertical banded gastroplasty seemed to be an attractive alternative operation because it provided an externally reinforced (banded) stoma that would not enlarge over time. In this study, our aim was to determine prospectively the results of vertical banded gastroplasty used as a primary, weight-reducing procedure in patients with morbid obesity. Seventy consecutive patients with morbid obesity (mean weight, 139 kg), all of whom had obesity-related complications, underwent vertical banded gastroplasty and prospective follow-up. The hospital mortality was nil, and substantial morbidity occurred in 3% (two patients). Long-term achievement and maintenance of satisfactory weight loss, however, were variable. The median weight loss at 1 year after operation was 36.7 kg or 48% of excess body weight. At 3 years postoperatively, however, weight loss was only 32.4 kg or 40% of excess body weight, and only 38% of patients had achieved and maintained a weight loss of 50% or more of their preoperative excess body weight. Vertical banded gastroplasty caused major changes in eating habits, and many patients were unable to eat red meat or untoasted bread; moreover, approximately 30 to 50% of patients continued to vomit once or more per week. Despite theoretically attractive advantages as a weight-reduction operation, vertical banded gastroplasty does not seem to be the optimal procedure for most patients with morbid obesity.
Asunto(s)
Gastroplastia/métodos , Adulto , Factores de Edad , Anciano , Peso Corporal , Estudios de Evaluación como Asunto , Femenino , Estudios de Seguimiento , Gastroplastia/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Estudios Prospectivos , Factores de Tiempo , Pérdida de PesoRESUMEN
The clinical, biochemical, and vascular laboratory measurements potentially associated with the development and/or progression of peripheral occlusive arterial disease (POAD) were assessed during a 4-year period in 110 normal control subjects, 112 patients with POAD without diabetes mellitus, 240 patients with diabetes mellitus without POAD, and 100 patients with diabetes mellitus and POAD. Age, history of hypertension or coronary heart disease, history of cigarette smoking, presence of POAD, systolic blood pressure, and beta-thromboglobulin level were associated with progression of POAD. A multivariate logistic regression model indicated that the presence of diabetes mellitus or POAD or both at baseline, decreased postexercise ankle-brachial index, increased arm systolic blood pressure, and current smoking were independently associated with progression of POAD. This study suggests that cessation of smoking and control of hypertension are essential treatment modifications to decrease the risk of progression of peripheral vascular disease in diabetic patients.
Asunto(s)
Arteriopatías Oclusivas/epidemiología , Angiopatías Diabéticas/epidemiología , Arteriopatías Oclusivas/etiología , Femenino , Humanos , Modelos Logísticos , Masculino , Análisis Multivariante , Oportunidad Relativa , Pronóstico , Factores de RiesgoRESUMEN
A population-based prevalence cohort of 1,111 residents of Rochester, Minnesota, who had diabetes mellitus on Jan. 1, 1975, was subjected to follow-up assessment for hospitalizations through Dec. 31, 1980. On the basis of these data, hospitalization rates were calculated for various clinical types of diabetes, and a risk factor analysis was done for non-insulin-dependent diabetes mellitus (NIDDM) to identify high-risk persons for subsequent intervention studies. The adjusted incidence density of hospitalization was 141.6 per 1,000 person-years for NIDDM and 331.3 per 1,000 person-years for insulin-dependent diabetes. Although the modeled clinical characteristics accounted for little variability in NIDDM-related hospitalization, age modified by the effect of gender was the strongest risk factor found (multivariate hazard ratios: 1.0 and 1.43, respectively, for male and female patients younger than 65 years old; 1.88 and 1.83, respectively, for male and female patients 65 years old or older); coronary heart disease, diabetic retinopathy, and persistent proteinuria were associated with a 50% increased risk. Although older patients with NIDDM (especially men) are at greatest risk for a first hospitalization, clinical factors alone seem inadequate to account for these hospitalizations. The effect of Medicare's prospective payment systems (PPS) was studied by using a data base for Olmsted County, Minnesota, to determine whether PPS decreased the rate of hospitalizations among patients with diabetes. Among Olmsted County residents 65 years of age or older, the adjusted rate of diabetes-associated hospitalizations decreased from 26.5 per 1,000 person-years in 1980 to 16.7 in 1985, whereas the adjusted rate of all other hospitalizations increased from 259.5 per 1,000 person-years to 261.9. Thus, PPS may have reduced hospitalization rates in elderly patients with diabetes.
Asunto(s)
Diabetes Mellitus Tipo 2/terapia , Hospitalización/estadística & datos numéricos , Análisis Actuarial , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Estudios de Cohortes , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/economía , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/economía , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Estudios de Seguimiento , Hospitalización/economía , Hospitalización/tendencias , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Alta del Paciente/estadística & datos numéricos , Prevalencia , Sistema de Pago Prospectivo/economía , Factores de Riesgo , Factores Sexuales , Factores de TiempoRESUMEN
To elicit the opinions of practicing internists who had graduated from a single internal medicine residency program about the adequacy of their training and its relevance to their medical practice, we mailed a survey to 1,342 physicians who had spent at least 1 year in the Mayo internal medicine residency training program. Of this group, 703 alumni (52%) responded to the survey, 532 of whom were currently practicing internal medicine. Our detailed analysis was based on responses from these 532 and, for some aspects of evaluation, on the 121 general internists who had completed residency training after 1970. Of the respondents, 42% spent more than 80% of their time in general medicine, and 53% had at least some subspecialty practice; 55% were involved in teaching, 20% in some research, and 37% in various administrative duties. In 27%, all patient-care activities involved primary care, an increase from 18% in a 1979 survey and 9% in 1972. Of those who were subspecialists, 67% spent more than half their time in subspecialty practice. Of those who were trained after 1970, 90% were board certified. Most respondents thought that their training in the internal medicine subspecialties was adequate, that additional procedure training was needed in joint aspiration, line placement, and flexible sigmoidoscopy, and that many allied medical areas were important to their practice and necessitated additional training. Although virtually all respondents assessed their inpatient training as adequate, only 42% were fully satisfied with their outpatient training. Alumni surveys can be useful in restructuring a residency program to meet the needs of the trainees.