Diabetes mellitus, socioeconomy and self-rated health : Population-based studies in cohorts registered in the diabetes incidence study in Sweden

Field: Medicine (Health Sciences)

The studies presented in this thesis analyzed the impact of diabetes \nmellitus on socioeconomy and selfrated health, focusing on how the \nconsequences of diabetes develop during the first decade after the \ndiagnosis. \n \n \n \nThe Diabetes Incidence Study in Sweden, DISS, prospectively registers all \nincid ent cases of diabetes in the age group 15 to 34 years; \napproximately 400 new cases per year, of whom 65 percent are men and 35 \npercent women. The cases registered in DISS in 1983 and 1992 and control \ngroups from the general population were selected for the study. Data on \nhealthcare utilization, health-related quality of life, socioeconomic \ncharacteristics, and satisfaction with health services were collected via \na mailed questionnaire in the younger cohort I year after diagnosis, and \nin the older cohort 8 years after diagnosis. Costing was based on average \nnational costs of care collected by the Federation of Swedish County \nCouncils and the Swedish Council on Technology Assessment in Health Care, \nand on sales prices of the National Corporation of Swedish Pharmacies. \nHospital daycare costs were derived from a comparative analysis at five \nhospitals in Stockholm. \n \n \n \nAnalyses of the utilization and costs of care showed that the first year \nafter diabetes diagnosis was associated with per capita costs of care \nequaling 5.6 times those for the general population, and 8 years after \ndiagnosis 3.8 times those for the population controls. One year after \ndiabetes diagnosis, the annual excess costs of care were US$ 4743 among \nmen and US$ 4976 among women (1997 prices). Hospital inpatient care \naccounted for more than 50 percent of the excess costs. Eight years after \ndiagnosis, the excess costs were US$ 2010 among men and US$ 2734 among \nwomen. The higher costs for women were mainly related to more frequent \nuse of hospital outpatient care, but also to intensive home monitoring. \n \n \n \nA review of gender equity in diabetes care in Sweden, including \npopulation-based studies published during 1990 through 1998, showed that \nin several studies diabetic women had reported more frequent outpatient \ncontacts, less patient satisfaction, an a lower health-related quality of \nlife than diabetic men. Gender differences had not been reported in the \nlevel of glycaemic control. Young and middle-aged men with diabetes have \na high excess all-cause mortality as compared to non-diabetic men. A \ntrend toward stronger social gradient in mortality among women than men \nwith diabetes had been reported in one nationwide study. \n \n \n \nThe impact of gender and socioeconomic factors on self-rated health in \nthe diabetic and control groups was examined in multivariable analyses \nwhere the dependent variable was the 'general health perceptions' score \nfrom the SWED-QUAL questionnaire. A model including a wide range of \nsociodemographic variables explained 6 percent of the variance in \nself-rated health I year after diabetes diagnosis and 13 percent of the \nvariance 8 years after diagnosis. Female gender predicted poor self-rated \nhealth 8 years after diagnosis but not I year after diagnosis. A study \naddressing the relationships between dissatisfaction with care, \nhealthcare utilization, and self-rated health showed that dissatisfaction \nwas associated with poor self-rated health both in the diabetic and \ncontrol groups. Socioeconomic variables were not independent predictors \nof dissatisfaction after adjustment for self-rated health. A significant \nassociation between female gender and dissatisfaction with care was found \n8 years after diabetes diagnosis but not I year after diagnosis. \n \n \n \nThe combined impact of gender and socioeconomic status on the prognosis \nof diabetes and other chronic diseases should be investigated in further \nstudies. Monitoring the impact of gender should become an integrated part \nof quality management in diabetes care. A question for future health \nsystems research is how the investments in medical care during the first \n10 years after diabetes diagnosis impact on the use and costs of care 10 \nto 20 years later, when a higher incidence of long-term complications can \nbe expected. Economic analyses and simulation models based on randomized \ncontrolled trials do not produce evidence about the real-life investments \nin diabetes care nor about the factual pay-off in terms of quality and \nquantity of life. For these purposes, followup, studies in unselected \ndiabetic populations living in realworld health systems are needed.