Control Of Type 2 Diabetes Mellitus In Urban China

The number of diabetic patients increased rapidly in China, from 4.8 million(1980) to 23.8 million(2003), and to 39.8 million(2007). In 2025, it was predicted tobe 46 million. Type 2 diabetes constitutes about 90 to 95 percents of all diabetes.China carries the next highest diabetes burden in the world after India having thehighest number of diabetic patients. Type 2 diabetes is highly prevalent in the agedpopulation. Since more than 100 million Chinese are at or after age of 65 years andthe number increases continuously, there will be a rapid growth of old diabeticpatients. Higher prevalence of diabetes mellitus are usually found in big cities and theprevalence increases much more significantly in big cities than in small cities or ruralareas.Since type 2 diabetes is incurable, the main roles of diabetic management are toreach aggressive control hyperglycemia and to prevent or delay the occurrence ofchronic complications. With the development of medicine, the treatment regimen andmanagement algorithm become more important and were focused on by healthcarecare systems. While, it is not neglected that type 2 diabetes exerts a considerable tollon health resources of the country. The chronicity of the disease and diabeticcomplications also place a heavy burden on diabetic patients, their families and thesociety. Equally important, the quality of life of diabetic patients needs much moreemphasis due to the pursuing of fulfillment of well-being.The management of more than 30 million diabetic patients has become a toughsocial and medical problem to our country. And the management of DM should beevidenced by results from well-designed, strict-implemented, multidisciplinary,big-sampled epidemiologic surveys and clinical trials. While, there are not manyevidences at hand now in China. To provide clues and give evidences to managementand control of type 2 diabetes, we carried out this multi-center and cross-sectionalstudy in four major Chinese cities representing the east, west, north and south ofmainland China: Shanghai, Chengdu, Beijing and Guangzhou, respectively. The study subjects were 1524 outpatients and 516 inpatients from clinics or wards of a total of20 hospitals, using a two-phase subject enrolment process, by face-to-face interviewwith a unique questionnaire. Using multidisciplinary methods(epidemiology,endocrinology, sociology, and health economics), this study is to know themanagement status and blood glucose control, to estimate the prevalence of chroniccomplication, to assess the treatment satisfaction and quality of life of T2DM patients,and to examine the economic burden of type 2 diabetes mellitus with or withoutcomplications.Specifically,1. A cross-sectional study was conducted to examine the management status oftype 2 diabetic outpatients. The study subjects were 1524 outpatients continuouslyrecruited from 15 hospitals in 4 major cities of China. The subjects were interviewedface-to-face by trained interviewers using a questionnaire capturing information ontreatment regimens, self-management and related factors. Among the 1524 outpatients,9(0.6%) took the first line therapy of lifestyle intervention, 1005(66.1%) took oralhyperglycemic agents and 635 of the 1005 took two or more agents combinationtherapy, and 506(33.3%) had insulin injected. The proportion of outpatients acceptinginsulin therapy increased with prolong of diabetic duration(χ²_trend=132.670, P=0.000).1207(79.3%) outpatients reported that they were knowledgeable about type 2 diabetesand diabetic management. 1356(89.1%) outpatients complied with diet control.1121(73.7%) outpatients monitored FBG or PBG, 844(55.5%) had their blood glucoseexamined no more than 4 times per month and 277(18.2%) more than 4 times permonth. Only 691(45.6%) outpatients once examined their HbA1c and 890(58.8%) didno less than 1 times exercises per week. 1400(92.9%) complied with doctor's adviceon medication.We examined the influential factors of self-management after adjustment ofpotential confounding factors. The results showed that duration of diabetes(aOR=1.06,95%CI:1.03-1.09); education level(aOR=2.02, 95%CI:1.74-2.35); family history ofT2DM(aOR=I.64, 95%CI:1.19-2.27); diagnosed in tertiary hospital(aOR=1.54,95%CI: 1.12-2.10); educated by doctors(aOR=1.48, 95%CI: 1.04-2.10); communicatedwith doctors(aOR=3.13, 95%CI:2.31-4.23) were associated significantly with masterof knowledge about type 2 diabetes and diabetic management. With respect to dietcontrol and regular exercises, those ageing and self-knowing diabetes or diabeticmanagement were more likely to control their diet(aOR=1.05, 95%CI:1.03-1.07; aOR=2.8, 95%CI:1.85-3.88, respectively) or did regular exercises(aOR=1.02,95%CI:1.01-1.04; aOR=1.78, 95%CI:1.34-2.37, respectively). When it comes toblood monitoring, patients undergoing insulin therapy(aOR=1.92, 95%CI:1.42-2.60),with higher education (aOR=1.27, 95%CI:1.12-1.45), those believe that better glucosecontrol can prevent chronic complication from occurring (aOR=1.51,95%CI:1.03-2.22), those have the knowledge of diabetes and diabeticmanagement(aOR=2.09, 95%CI:1.54-2.85) were more preferable to monitor theirblood glucose.2. To explore the influences of patients' self-management to glycaemic controlamong type 2 diabetic mellitus(T2DM) outpatients in urban China, a cross-sectionalstudy was carried out in 1524 T2DM outpatients from 15 hospitals in 4 major cities ofChina. Questionnaire interview was used by trained surveyors to collect data ongeneral characters and self-management. HbA1c test was applied to measure bloodglucose in the centralized hospital in each city. Logistic regression was used toexamine the association between self-management components including diet control,knowledge, blood monitoring and regular exercises and level of HbA1c. A total of1511 T2DM outpatients completed the HbA1c test and mean HbA1c was 8.11±1.65%.Among the 1511 outpatients, 206(13.6%) had HbA1c＜6.5%, 408(27.0%) between6.5%-7.5%, 897(59.4%)＞7.5%. Diabetic duration was positively related with poorHbA1c control(χ²_trend=101.670, P=0.000). Multivariate analysis showed that patientswho were under diet control(OR=0.57, 95%CI: 0.38-0.83), knowledgeable onDM(OR=0.74, 95%CI: 0.56-0.99), compliance behavior(OR=0.63,95%CI:0.40-0.98), having regular monitoring on blood glucose(≤4 times/month:OR=0.58, 95%CI: 0.40-0.83;＞4times/month: OR=0.68, 95%CI: 0.51-0.91) andexamining HbA1c(≥3 times per year: OR=0.33, 95%CI:0.23-0.48; 0-3 times per year:OR=0.57, 95%CI:0.43-0.74) were more likely to have a better glycaemic controlindicated by HbA1c.3. To determine the prevalence of the main chronic complications among urbanChinese T2DM outpatients, to examine the distribution of chronic complicationsamong different demographics strata, and to describe the relationship betweencomplications and age, as well duration since diagnosis, this cross-sectionalhospital-based study was carried out in 4 major Chinese cities of China. Of the 1,524study participants, 637(41.8%) were male, and the mean age of the subjects was63.3±10.2 years. At least one chronic complication was diagnosed in 792 individuals (52.0%) of the study participants; 509(33.4%) presented with macrovascularcomplications and 528(34.7%) with microvascular complications. The prevalence ofcardiovascular and cerebrovascular conditions, neuropathy, ocular lesions,nephropathy and foot disease were 30.1%, 14.8%, 17.8%, 10.7%, 10.7% and 0.8%,respectively. The prevalence of chronic complications varied between cities, andsignificantly increased with age and duration of diagnosed diabetes. The overallprevalence of complications among female patients was significantly higher than inmale patients(χ²=9.75, P=0.002). The prevalence of complications also variedbetween patients from different regions of China(χ²=8.763, P=0.033). Both theoverall prevalence of complications(χ²_trend=91.90, P=0.000) and the prevalence of allconsidered conditions increased with age(all P-values＜0.05). After adjusting for age,the overall prevalence of complications significantly increased with disease duration(χ²=106.290, P=0.000) and all considered conditions increased with diabetic duration(all P-values＜0.05).4. First, to evaluate the reliability, validity and responsiveness of diabetestreatment satisfaction questionnaire status version(DTSQs) among Chinese type 2diabetic mellitus(T2DM) outpatients, a cross-sectional study was carried out in 749T2DM outpatients from seven hospitals in Guangzhou and Shanghai, China. Thediabetes treatment satisfaction questionnaire status version was self-filled by patients,with helps from interviewers for those having difficulties in reading. Split-halfreliability correlation coefficient, Cronbachαand Spearman' rho were used to test thereliability. Exploratory factor analysis(EFA) and confirmatory factor analysis(CFA)were employed separately to examine the construct validity of the scale. Theresponsiveness of the scale was appraised by the multiple analysis of covariance(MANCOVA). The split-half correlation coefficient was 0.807 and the Cronbach awas 0.717 of the six items of treatment satisfaction. The three factors extracted byEFA explained 67.66% of the overall variance. The relativeχ² was 4.95 and DK was0.18 in goodness of test by CFA. The vector of treatment satisfaction, perceivedhyperglycemia and hypoglycemia were different in males versus females, in poorversus good blood glucose control group. The DTSQs showed good reliability andvalidity among T2DM outpatients and was applicable to Chinese T2DM patients.Then, DTSQ was used to evaluate the treatment satisfaction of the 1524 diabeticoutpatients. The mean score for treatment satisfaction was 23.49±6.33, the medianfor perceived hyperglycemia and hypoglycemia were 3(P25-P75:1-4) and 1(P25-P75:0-2) respectively. Multivariate analysis indicated that the mean score fortreatment satisfaction showed an increase in males(P=0.024), in outpatients havingHbA1c＜7.5%(P=0.000), in outpatients communicating with doctors(P=0.000); andoutpatients with higher treatment satisfaction(aOR=1.08, 95%CI=1.05-1.12) weremore likely to comply with doctor's advice.5. To evaluate the quality of life of diabetic outpatients and to explore the impactof chronic complications of T2DM on quality of life among T2DM outpatients inurban China, a cross-sectional study was carried out in 1524 T2DM outpatientsrecruited from 15 hospitals in 4 major cities of China. Questionnaire interviews wereused to collect data on general characters and complications of T2DM. SF-36questionnaire(version 1) was used and self-completed by patients under the help frominterviewers for those having difficulties in reading.The mean scores of role-physical and Social Functioning subscale were higherthan 80, of general health subscale were less than 50, of other subscales were in 60-80.The scores of most subscales were lower than the norm scores in China or America,and the scores of PCS and MCS were less than 50. The results indicated that thequality of life was lower in diabetic outpatients than in norm population.Complication was a significant predictor leading to poorer SF-36 subscale scores(decreased by 4.68-16.06 scores) and two summary scores(PCS, MCS). The scores ofrole-physical subscale(decreased by 22.45%) and role-emotional subscale(decreasedby 16.28%) decreased much more than the other subscales in patients withcomplication. Overall, QOL was reduced by 11.02% in patients with complication.The QOL had a gradual decrease with the increasing number of complications. Theaverage scores descended from 2.82 to 10.33 in the eight subscales with the increaseof one complication. Knowing diabetic knowledge increased SF-36 subscale scoresand two summary scores(PCS, MCS) by 1.03-11.26%. Diet control increased scoresof vitality subscale, mental health subscale and MCS by 2.22-3.06%. Regularexercises increased scores of physical functioning, role-physical, general health,vitality, social functioning, role-emotional subscales and PCS, MCS by 4.11-20.05%.Self-monitoring blood glucose increased scores of vitality, mental health androle-physical subscales by 5.03%, 4.27% and 2.86% respectively. The eight subscalescores of SF-36 were positively related with treatment satisfaction scores(coefficientsbeing 0.091-0.289 respectively); negatively related with perceived hyperglycemicscores(coefficients being 0.056-0.206, respectively) and hypoglycemic scores (coefficients being 0.060-0.122, respectively).6. To examine the health utilization of diabetic patients and economic burden ofT2DM, a cross-sectional study was carried out in 1524 T2DM outpatients and 516T2DM inpatients recruited from 20 hospitals in 4 major cities of China. Questionnaireinterviews were used to collect data on general characters, health seeking behaviorsand cost of illness during the past 1 month, 6 months. The mean times of visitingoutpatient department(OPD) during the past 1 month were 1.15±1.34 in outpatientsand 1.42±1.97 in inpatients. And during the past 6 months, the average times ofvisiting OPD were 7.33±7.21 in outpatients and 8.52±11.81 in inpatients respectively.The mean hospitalization times during the past 1 year were 0.19±0.48 in outpatientsand 0.56±1.13 in inpatients. Chronic complication significantly led to increasedutilization of OPD services in the past 1(Z=-3.578, P=0.000), 6(Z=-2.472, P=0.000)months and to increased utilization of hospitalization services(Z=-9.296, P=0.000) inthe past 1 year. The annual total cost was estimated to be 5992 CNY in median(9963CNY in mean) per outpatient and 8355 CNY in median(23231 CNY in mean) perinpatient. The annual total cost per patient was estimated to be 6110 CNY in median(12523 CNY in mean) with direct medical cost accounting for 77.7%, directnon-medical cost 17.2% and indirect cost 5.1%. The annual total costs per patient(Z=-9.270, P=0.000),direct medical costs per patient(Z=-8.317, P=0.000) were bothdifferent between patients with and without complications. The annual total costs anddirect medical costs increased with number increasing of complications.