1. Mortality trends in type 2 diabetes mellitus patients in a primary care setting 1994 to 2011 Jelske Dekkers 6th year medical student

2. Introduction Research question Patients and methods Results Sociodemographic characteristics Mortality rates Clinical patient characteristics Survival analysis Conclusion Discussion References

3. Introduction – Diabetes mellitus Diabetes mellitus Type 1 Type 2  90% Prevalence 2003: Men 36/1000 Women 39/1000 2007 Men 40.1/1000 Women 41.6/1000

4. Introduction – Type 2 diabetes Causes Betacel dysfunction  inadequate production of insulin Insulin resistance Associations Hypertension Obesity Metabolic syndrome or syndrome X Hypercholesteromia Complications Cardiovascular disease  2-4 times increased risk of CVD associated death Renal disease Retinal disease Polyneuropathy

5. Research question What is the trend in mortality rates of type 2 diabetes patients compared to the mortality rates of the general Dutch population from 1994 to 2011? Is there a difference in clinical characteristics of type 2 diabetes patients from 1994 to 2011?

6. Patients and methods All type 2 diabetes patients in the NMP/HIS database between 1994 and 2011 NMP/HIS database Database of all patients with chronic illnesses treated (partially) in 9 primary care practices Includes clinical patients characteristics from every check up

7. Patients Patients with type 2 diabetes (partially) treated in primary care, 1994-2011 N = 3748 Patients with type 2 diabetes, not treated in primary care N = 297 Patients with type 2 diabetes N = 4045 Patients with type 2 diabetes with a known date of diagnosis N = 4014 Patients without a known date of diagnosis N = 31

8. Methods; database

9. Methods – Mortality rates Mortality rates type 2 diabetes patients for each year All patients Men Women Comparison group: general Dutch population, adjusted for age, using CBS Statline Database Complete population Men Women

10. Methods – Clinical patient characteristics Bloodpressure Body mass index HbA1c Total cholesterol HDL Calculated for 1996, 2001, 2006 and 2011 Clinical characteristics of the patients in the NMP/HIS database  only patients (partially) treated in primary care

11. Results – Sociodemographic characteristics All patients1996 N = 794 2001 N = 1291 2006 N = 1917 2011 N = 2803 Mean age65.3 (64.4-66.2) 63.3 (62.5-64.6) 63.8 (63.2-64.6) 65.6 (65.1-66.1) Mean age at diagnosis 59.3 (58.4-60.2) 57.9 (57.2-58.6) 57.3 (56.7-57.9) 57.9 (57.4-58.4) Mean duration of disease in years 6.1 (5.7-6.5) 5.7 (5.4-6.0) 6.6 (6.3-6.9) 7.8 (7.6-8.0)

12. Results – Sociodemographic characteristics, men and women 1996200120062011 Mean age men62.4 (61.0-63.8) 60.9 (59.9-61.9) 62.4 (61.6-63.2) 64.4 (63.8-65.0) Mean age women 67.5 (66.3-68.7) 66.2 (65.2-67.2) 65.3 (64.4-66.2) 67.0 (66.3-67.7) Mean age at diagnosis men 57.0 (55.6-58.4) 55.8 (54.8-56.8) 56.2 (55.4-57.0) 56.8 (56.2-57.4) Mean age at diagnosis women 61.1 (58.9-62.3) 59.9 (59.0-60.8) 58.3 (57.5-59.1) 59.0 (58.3-59.7) Mean duration of disease in years men 5.6 (5.0-6.2) 5.2 (4.8-5.6) 6.2 (5.8-6.6) 7.6 (7.3-7.9) Mean duration of disease in years women 6.4 (5.9-6.9) 6.3 (5.9-6.7) 6.9 (6.5-7.3) 8.0 (7.6-8.4)

13. Results; mortality 1996200120062011 All794129119172803 Deceased36374776 Men3496199681444 Deceased20152044 Women4456729491359 Deceased16222732

14. Mortality rates in comparison to the Dutch population YearMortality rate diabetic patients in % (95% CI) Adjusted mortality rate general population in % Mortality rate diabetic men in % (95% CI) Adjusted mortality rate men general population in % Mortality rate diabetic women in % (95% CI) Adjusted mortality rate women general population in % 19944.9 (3.3-6.5) 3.24.4 (2.0-6.8) 3.25.2 (3.0-7.4) 3.1 19952.6 (1.4-3.8) 3.12.2 (0.6-3.8) 3.62.9 (1.3-4.5) 3.0 19964.5 (3.1-5.9) 3.05.7 (3.3-8.1) 3.33.6 (1.9-5.3) 3.1 19974.8 (3.4-6.2) 3.25.6 (3.3-7.9) 3.44.2 (2.4-6.0) 3.0 19984.7 (3.3-6.1) 2.74.4 (2.4-6.4) 3.15.0 (3.1-6.9) 3.0 19994.5 (3.2-5.8) 2.94.0 (2.2-6.8) 2.95.0 (3.2-6.8) 2.9 20003.0 (2.0-4.0) 2.7 (1.4-4.0) 3.13.3 (1.9-4.7) 2.8 20012.9 (2.0-3.8) 2.52.4 (1.2-3.6) 2.33.3 (1.9-4.7) 2.5 20022.9 (2.0-3.8) 2.62.9 (1.6-4.2) 2.42.8 (1.6-4.0) 2.7

15. Mortaliy rates – 2 20032.6 (1.8-3.4) 2.52.6 (1.4-3.8) 2.42.5 (1.4-2.6) 2.6 20042.1 (1.4-2.8) 2.41.7 (0.8-2.5) 2.32.4 (1.4-3.4) 2.5 20053.3 (2.5-4.1) 2.53.0 (1.9-4.1) 2.43.5 (2.3-4.7) 2.6 20062.5 (1.8-3.2) 2.32.1 (1.2-3.0) 2.42.8 (1.8-3.8) 2.3 20073.2 (2.4-4.0) 2.33.2 (2.1-4.3) 2.43.2 (2.1-4.3) 2.3 20082.7 (2.0-3.4) 2.32.6 (1.7-3.5) 2.32.7 (1.7-3.7) 2.3 20092.7 (2.1-3.3) 2.32.2 (1.4-3.0) 2.33.3 (2.3-4.3) 2.3 20102.1 (1.6-2.6) 2.32.8 (1.7-3.9) 2.31.4 (0.6-2.0) 2.4 20112.7 (2.1-3.3) 2.43.0 (2.1-3.9) 2.32.4 (1.6-3.2) 2.5 YearMortality rate diabetic patients in % (95% CI) Adjusted mortality rate general population in % Mortality rate diabetic men in % (95% CI) Adjusted mortality rate men general population in % Mortality rate diabetic women in % (95% CI) Adjusted mortality rate women general population in %

16. Mortality figures – all patients

17. Mortality figures – men

18. Mortality figures - women

19. Clinical patient characteristics 1996200120062011 Mean systolic bloodpressure 151,2 (149.4-153.0) N = 568 148.4 (147.3-149.5) N = 954 143.9 (143.0-144.8) N = 1479 139.8 (139.2 – 140.4) N = 2279 Mean diastolic bloodpressure 83.7 (82.9-84.5) N = 567 82.3 (81.7-82.9) N = 954 80.8 (80.3-81.3) N = 1473 78.6 (78.2-79.0) N = 2277 Mean body mass index 28.6 (28.2 – 29.0) N = 544 29.3 (29.0 – 29.6) N = 923 29.7 (29.4 – 30.0) N = 1375 30.1 (29.9 – 30.3) N = 2121 Mean HbA1 c55.3 (53.4 – 57.2) N = 362 54.5 (53.5 – 55.5) N = 662 53.4 (52.7 – 54.0) N = 1191 53.5 (53.0 – 54.0) N = 2238 Mean total cholesterol 6.10 (5.98 – 6.22) N = 418 5.38 (5.30 – 5.46) N = 764 4.88 (4.81 – 4.95) N = 1089 4.53 (4.48 – 4.58) N = 2156

20. Kaplan Meier survival analysis

21. Kaplan Meier Survival analysis; men and women

22. Conclusion Mortality rates declined between 1994 and 2011 Since 2000 there is no difference in mortality In 2010 diabetic women had a lower mortality rate The mean bloodpressure and cholesterollevel have decreased significantly from 1996 to 2011 In our study population 50% of all type 2 diabetics would still be alive 20 years after diagnosis The first 20 years after diagnosis women have a better survival probability than men After 20 years, men have a better survival

23. Discussion Strengths Large NMP/HIS database with sociodemographic and clinical patient characteristics of the majority of our study population Comparison group: complete Dutch population Weaknesses No clinical patient characteristics of patients who weren’t treated in primary care  possible underestimation of clinical characteristics Transsition from NMP to HIS as primary source of information in 2006-2008  voids in yearly check ups and information Second hand information Only all cause mortality, no information about cardiovascular associated deaths

24. Discussion Other studies on this subject Mortality rates of type 2 diabetes patients are declining Relative mortality risk compared to control group is declining Most studies still found a signifant difference between mortality rates of diabetics and non-diabetics Greater study population Earlier period Other health care systems Follow up study Correlation between declining mortality rates and declining bloodpressure and cholesterol Clinical characteristics of all type 2 diabetes patients, including those of patients not treated in primary care

25. Questions or other discussion points?

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