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EUROPEAN JOURNAL OF PUBLIC HEALTH 2003; 13 (3 SUPPLEMENT): 51–54
Fact or fiction?
C.E. DE BEAUFORT, A. REUNANEN, V. RALEIGH, F. STORMS, L. KLEINEBREIL, R. GALLEGO, C. GIORDA,
K. MIDTHJELL, M. JECHT, I. DE LEEUW, E. SCHOBER, G. BORAN, G. TOLIS *
Diabetes mellitus is one of the major causes of morbidity and mortality in EU/EFTA countries. Monitoring risk factorsfor diabetes and its complications will offer the possibility to evaluate the development in time as well as the influenceof possible interventions. In this investigation a list with core and secondary indicators is proposed. Availability of theseindicators and their data sources is discussed. An important variability of data sources is used in EU/EFTA countries,interfering with the comparability of the outcome. Further harmonisation as well as continuous evaluation of datasources will be necessary to provide reliable tools to monitor diabetes mellitus and its outcome on a routine basis. Keywords: complications, diabetes mellitus, European Union, indicators
Diabetes mellitus is an important cause of increasing was then undertaken to assess the availability of these
morbidity and mortality worldwide.1–4 The prevalence of
indicators in the different member states.
type 2 (non-insulin dependent) diabetes mellitus is in-
creasing rapidly5 and the WHO predicts that 235 million
METHODOLOGY
people worldwide will suffer from diabetes in 2025. This
The first step was the establishment of a list of relevant
increase can be attributed to changing lifestyles, in
indicators. In working group meetings with represent-
particular a growing imbalance between energy intake
atives of 15 EU/EFTA countries, the potential indicators
and expenditure.6–8 While many people with diabetes
can lead a normal life, they are also at increased risk of
serious complications, including cardiovascular, renal
and eye complications, although these may be postponed
risk factors for complications of diabetes and;
or even prevented by early diagnosis and appropriate
the epidemiology of complications of diabetes.
For each group, one or more indicators were defined
Given the implications for health policy, establishment
(table 1). They were divided in two groups: a core (n=8)
of a system for monitoring the prevalence of diabetes
and secondary indicator (n=23). The core group consists
mellitus, its risk factors and complications will create an
of indicators, providing information on proven risk
important tool to inform policies that can modify the
factors or outcomes. Except for the incidence of type I
outcome of this serious chronic disease.
diabetes, their outcome can be influenced by public
As part of a project to test the feasibility on generating a
health interventions or by improved medical care.
set of comprehensive, comparable indicators, a tentative
Regular information on trends in these indicators is con-
list has been established by a working group of national
representatives of most EU/EFTA countries. A pilot study
The group of secondary indicators provides informationon processes and intermediate outcome. Monitoring ofthese indicators offers the possibility to compare and – ifnecessary – to intervene at an earlier disease stage. The
* C.E. de Beaufort1, A. Reunanen2, V. Raleigh3, F. Storms4, L. Kleinebreil5,
R. Gallego6, C. Giorda7, K. Midthjell8, M. Jecht9, I. de Leeuw10, E. Schober11,
influence of health care systems can be compared. As
background variables necessary for interpretation, age,
1 Clinique Pédiatrique Luxemburg, GDLuxemburg
sex, and socio-economic status are required.
2 National Public Health Institute, Helsinki, Finland
3 Commission for Health Improvement, London, UK
A questionnaire on available data and data sources in the
4 MESOS Diabetes Centrum, Bilthoven, the Netherlands
different countries was forwarded to all participants in
order to get accurate information on the actual situation
8 The Norwegian University of Science and Technology, Verdal, Norway
9 GK Havelhohe Med Klinik/Diabetologie, Berlin, Germany
11 University Children’s Hospital, Vienna, Austria
Eleven out of 15 participating countries provided data on
12 Adelaide and Health Hospital, Dublin, Ireland
13 Hippokratis General Hospital, Athens, Greece
Four countries did not provide any data. Various reasons
Correspondence: Dr C.E. de Beaufort, Clinique Pédiatrique, 4 rue Barblé,
1210 Luxembourg, GD de Luxembourg, e-mail: debeaufort.carine@chl.lu
were given , among which absence of existing data, no
EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 13 2003 NO. 3
Table 1 Proposed Indicators to monitor Diabetes Mellitus: Core indicators/Secondary indicators
• BMI – % of general population ≥30 kg/m2
• Annual incidence of Type 1 diabetes by age /100,000 population 0–14 years
• Prevalence of diabetes mellitus /1000 population
Prevalence of persons with impaired glucose tolerance and/or diet only
Risk factors for complications in persons with diabetes
Percent with lipid profile in last 12 monthsa DiabCare/SPSN
Percent of those tested with total cholesterol >5 mmol/l
With HDL <1.15 mmol/l (<1.0 mmol/l)
With triglycerides >2.3 mmol/l (2.0 mmol/l)
Percent with microalbuminuria in last 12 m
Percent tested in last 12 ma DiabCare/SPSN
Percent of the persons with diabetes who are smoking
Percent with BMI ≥25 kg/m2, ≥30 kg/m2 DiabCare/SPSNAge at diagnosis by 10 year age bands
Percent with fundus inspection in last 12ma UNNa /RSa /DiabCare
Percent with proliferate retinopathy in last 12m
Percent who received laser treatment <3 months after diagnosis of proliferative
• Annual incidence of blindness due to diabetic retinopathy/total annualincidence of blindness
Percent with serum creatinine tested in last 12 ma DiabCare/SPSN
Percent with ESRF – serum creatinine ≥400 µmol/l (WHO definition) – in last12 months
• Annual incidence of dialysis and or transplantation (renal replacement therapy inpatients with diabetes /1,000,000 general population
• Prevalence (stock) of dialysis/transplantation (renal replacement therapy) in patientswith diabetes /1,000,000 general population
Annual incidence of amputations above the ankle (if available: non traumatic,
medical in patients with diabetes /100,000 general population
Annual incidence of stroke in patients with diabetes /100,000 general
Annual incidence of myocardial infarction in patients with diabetes /100,000
• Annual death rate in patients who have as primary or any cause of deathdiabetes mellitus /100,000 general population, adjusted for European StandardPopulation
• Annual death rate in the general population from all causes /100,000 generalpopulation, adjusted for European Standard Population
• Core indicatorICD 9: Diabetes mellitus 250; ICD 10: Diabetes mellitus E10–14HES: Health Examination Survey; HIS: Health Interview Survey; UNN: Unique national Number; RS: Reimbursement Structure; SPSN: Sentinel PracticeSurveillance network; DiabCare: Annual data collection of diabetic patients, by Primary or Secondary Care, so far on voluntary basis. Variable number ofindicators included. Main aim: evaluate and improve clinical care (St Vincent declaration 19.); HDR: Hospital Discharge Records
European Union diabetes indicators
representative data, or not easy accessible data. From the
information on the number of persons with diabetes.
8 core indicators, only one was available in all countries
Computerisation of the social security is another source
(table 2). Data collection was performed through different
through which all those persons treated with oral hypo-
sources. Obesity was reported either through Health
glycemic agents or insulin can be identified. However,
Examination Surveys (HES) or Health Interview Surveys
those whose diabetes is treated by diet alone will be
(HIS). Prevalence of diabetes was also documented
included by only some sources, causing variation in the
through different sources with, in several countries,
results obtained from HES. Some countries use a unique
Incidence of type 1 diabetes in children has been studied
national number that can be linked to the reimbursement
extensively in the EURODIAB ACE study.13,14 Using
structure of the health care system and thus provide
the same methodology, a comparable data set was
Table 2 Availability of core indicators to monitor diabetes in EU/EFTA countries
Obesity: % of general population with a BMI ≥30 kg/m2 9
Annual incidence of Type 1 diabetes by age /100.000 100,000 population 0–14 years
Prevalence of diabetes mellitus /1000 population
Annual incidence of blindness due to diabetic retinopathy/total annual incidence of blindness
Annual incidence of dialysis and/or transplantation (renal replacement therapy in patientswith diabetes /1,000,000 general population
Prevalence (stock) of dialysis/transplantation (renal replacement therapy) in patients withdiabetes /1,000,000 general population
Annual death rate in patients who have as primary or any cause of death diabetes mellitus/100,000 general population
Annual death rate in the general population from all causes /100,000 general population, adjusted for European Standard Population
Table 3 Available secondary indicators in EU/EFTA countries
Prevalence of persons with impaired glucose tolerance and/or diet only
Percent of persons with diabetes mellitus with a HbA1c tested in last 12 monthsa 11
Percent of persons tested, who have a HbA1c value >7.5%
Percent of persons with diabetes mellitus with lipid profile in last 12 monthsa 11
Percent of those tested with total cholesterol >5 mmol/l
With HDL <1.15 mmol/l (<1.0 mmol/l)
With triglycerides >2.3 mmol/l (>2.0 mmol/l)
Percent of persons with diabetes mellitus with microalbuminuria tested in last 12 ma 10
Percent of those tested, with microalbuminuria
Percent of persons with diabetes mellitus with Bloodpressure measurement in last 12 ma 11
Percent of those tested with BP >140/90 in last 12 m
Percent of the persons with diabetes mellitus who are smoking
Percent of persons with diabetes mellitus with BMI ≥25 kg/m2, ≥30 kg/m2 9
Age at diagnosis of diabetes mellitus by 10 year age bands
Percent of persons with diabetes mellitus with fundus inspection in last 12ma 10
Percent of those tested, with proliferate retinopathy in last 12m
Percent of those tested who received laser treatment <3 months after diagnosis of proliferative retinopathy
Percent of persons with diabetes mellitus with serum creatinine tested in last 12 ma 5
Percent of those tested with ESRF – serum creatinine ≥400 µmol/l (WHO definition)
Annual incidence of amputations above the ankle (if available: non traumatic but,medical) in patients with diabetes mellitus /100,000 general population
Annual incidence of stroke in patients with diabetes mellitus /100,000 general population
Annual incidence of myocardial infarction in patients with diabetes mellitus /100,000general population
EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 13 2003 NO. 3
established over a 10 year period in all EU/EFTA
the data sources has to be a part of the ongoing
countries. In some countries the registries created have
monitoring. Further harmonisation of data sources will
been continued, whereas in others, they have been
improve comparability of the indicators between the
stopped. Hospital Discharge Records and Reimbursement
EU/EFTA countries, and thus offer a valuable tool to
Structures can provide detailed information on the
evaluate the effect of public health interventions.
incidence and prevalence of renal replacement therapy
Flexibility with respect towards new developments for
(Transplantation and/or dialysis). However, data on
early detection remains necessary. This will allow
hospital discharge will be influenced by the extent to
improved surveillance and improved outcome in the
which care providers reporting diabetes among secondary
diagnostic codes. Mortality in general is well documented but mortality
This project was supported by the Health Monitoring Program,
attributable to diabetes is not available in all countries.
SANCO EU, (2000CVG3–503). The secretarial help of Edith Everwijn is kindly acknowledged.
Secondary indicators were available in 2 to 11 of thecountries (table 3). The most important source is datacollection through Diab Care-like projects. REFERENCES
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