The Brazilian Nationwide Population Screening Program for Diabetes, conducted in 2001, diagnosed 346,168 new cases. Although unexpected, approximately 65,000 previously diabetic individuals participated. We describe their characteristics compared to new cases, based on data obtained by a follow-up study of a subsample of 4991 positively screened from a representative sample of 90,106 individuals. Two groups were analyzed regarding factors associated with adherence to treatment, healthcare services utilization, and compliance to pharmacological treatment: 497 with newly diagnosed diabetes and 257 individuals with previous diabetes diagnosis who were not under treatment at the screening program. For this group, healthcare service utilization was lower when compared with the new cases (OR = 0.06; 95% CI: 0.03–0.12). Diabetes status (OR = 0.23; 95% CI: 0.14–0.37), a healthy behavior score (OR = 0.53, 95% CI: 0.34–0.83), and glucose levels at screening (altered, OR = 5.01; 95% CI: 2.38–10.6 and likely and very likely DM OR = 11.2; 95% CI: 6.85–18.4) were independently associated with pharmacological treatment.
Worldwide, the prevalence of diabetes mellitus (DM) continuous to rise, being an international health burden (1). The increase of individuals with DM is expected to happen mainly in developing countries due to the growth and aging of populations, urbanization, obesity, and sedentary behavior [
In 2001, the Brazilian Ministry of Health, with the collaboration of state and municipal health authorities and medical societies, implemented a National Campaign for the Reorganization of Diabetes Mellitus Care (CNDDM) [
The Brazilian Nationwide Population Screening Program for Diabetes (BNPSPD), was one of several components of the National Plan, being conducted through primary healthcare services during March 6th and April 7th, 2001 and have been previously described [
This study was proposed considering the magnitude of the results obtained in the BNPSPD and the difficulties perceived and presented in other investigations [
A detailed description of the follow-up study of individuals positively screened during the screening program is described in detail elsewhere [
Among 4991 (Figure
Sample of positively screened individuals during the BNPSPD, included in the follow-up study, Brazil, 2002. DM, diabetes mellitus; BNPSPD: Brazilian Nationwide Population Screening Program for Diabetes.
For the screening program, standardization and classification were defined for tests results according to which recommendations were made to individuals who participated varying from repeat test in 3 years to immediate consultation with physician (Table
Classification of screening test results and recommendations made to individuals who participated in the BNPSPD, brazil, 2001.
mg/dL | Categories | Recommendation | |
---|---|---|---|
Fasting capillary glucose | <100 | Normal | Repeat test in 3 years |
100 to 125 | Borderline | Schedule future appointment | |
126 to 199 | Altered | Order fasting serum glucose and recommend return medical appointment | |
≥200 | Likely DM | Order fasting serum glucose and schedule future appointment | |
≥270 | Very likely DM | Immediate consultation with physician | |
Nonfasting capillary glucose | <140 | Normal | Repeat test in 3 years |
140 to 199 | Borderline | Schedule future appointment | |
≥200 | Likely DM | Order fasting serum glucose and recommend return medical appointment | |
≥270 | Very likely DM | Immediate consultation with physician |
BNPSPD: Brazilian Nationwide Population Screening Program for Diabetes.
Gender, age, schooling, glucose blood test result in the program, adhesion to pharmacological and nonpharmacological treatment for diabetes, and health care services utilization were analyzed. Individuals who informed to be under medical followup were considered utilizing health care services. In order to quantify adherence to non-pharmacological recommendations, a numeric score (from 0–7) was developed in which one point was given to each healthy behavior referred by the individual: weight control, ingestion of food with low levels or no salt, preference to low-fat food, ingestion of fruits or vegetables at least twice a day, avoiding or not smoking, regular physical activity, and monitoring glycemic levels at least once every three years.
All data were collected on standardized forms, double entered into an electronic database, and analyzed using the survey data analysis function of STATA, version 8.2. Univariate analysis was performed considering the sampled primary healthcare units (PHUs) as the basic unit of the conglomerate (PSU, primary strata unit) while subnational regions were considered as the strata. Odds ratios and 95% confidence intervals were estimated for variables analyzed. All variables significantly associated with healthcare services utilization and compliance to pharmacological treatment in bivariate analysis (
A total of 497 individuals in the NCD group (control group) and 257 individuals in the PDIWT group were analyzed. The majority of the individuals analyzed in both groups were women (56.3% in NCD group and 57.2% in PDIWT group; Table
Clinical and demographic characteristics of BNPSPD participants considering the two groups analyzed. Brazil, 2001.
New cases (NCD) | Previously diabetic individuals without treatment (PDWIT) | |
(%) | (%) | |
Male | 217 (43.7) | 110 (42.8) |
Female | 280 (56.3) | 147 (57.2) |
40–49 | 127 (25.6) | 75 (29.2) |
50–59 | 160 (32.2) | 69 (26.8) |
60–69 | 131 (26.4) | 76 (29.6) |
70 or more | 79 (15.9) | 37 (14.4) |
Illiterate | 121 (24.6) | 55 (21.5) |
Elementary education incomplete | 282 (57.4) | 139 (54.3) |
Elementary education complete or + | 88 (17.9) | 62 (24.2) |
North | 22 (4.4) | 17 (6.6) |
Northeastern | 138 (27.8) | 44 (17.1) |
Midwestern | 28 (5.6) | 24 (9.3) |
Southeastern | 236 (47.5) | 119 (46.3) |
South | 73 (14.7) | 53 (20.6) |
Borderline | 137 (27.6) | 185 (72.0) |
Altered | 75 (15.1) | 18 (7.0) |
Likely and very likely | 285 (57.3) | 54 (21.0) |
<4 | 404 (81.3) | 203 (79.0) |
≥4 | 93 (18.7) | 54 (21.0) |
*Borderline ≥ 100 < 126 mg/dL, altered ≥ 126 < 200 mg/dL, likely and very likely ≥200 mg/dL.
BNPSPD: Brazilian Nationwide Population Screening Program for Diabetes.
Among the NCD groups, 92.2% individuals referred utilization of health care services, significantly higher proportion than among the PDWIT group (33.1%;
Comparison of factors potentially associated to healthcare service utilization and pharmacological treatment in the two groups analyzed. Brazil, 2001.
New cases (NCD) | Previously diabetic individuals without treatment (PDWIT) | |||
Service utilization | Pharmacological treatment | Service utilization | Pharmacological treatment | |
Male | 197/217 (90.8) | 168/217 (77.4) | 41/110 (37.3) | 39/110 (35.5) |
Female | 261/280 (93.2) | 221/280 (78.9) | 44/147 (29.9) | 43/147 (29.3) |
40–49 | 113/127 (89.0) | 92/127 (72.4) | 21/75 (28.0) | 19/75 (25.3) |
50–59 | 152/160 (95.0) | 126/160 (78.7) | 23/69 (33.3) | 22/69 (31.9) |
60–69 | 122/131 (93.1) | 104/131 (79.4) | 29/76 (38.2) | 28/76 (36.8) |
70 or more | 71/79 (89.9) | 67/79 (84.8) | 12/37 (32.4) | 13/37 (35.1) |
Illiterate | 107/121 (88.4) | 94/121 (77.7) | 14/55 (25.5) | 15/55 (27.3) |
Elementary education incomplete | 266/282 (94.3) | 229/282 (81.2) | 48/139 (34.5) | 48/139 (34.5) |
Elementary education completed or + | 79/88 (89.8) | 60/88 (68.2) | 23/62 (37.1) | 19/62 (30.6) |
Score <4 | 376/407 (93.1) | 323/407 (80.0) | 76/203 (37.4) + | 73/203 (36.0) + |
Score ≥4 | 82/93 (88.2) | 66/93 (71.0) | 9/54 (16.7) + | 9/54 (16.7) + |
Borderline | 125/137 (91.2) | 78/137 (56.9)* | 25/185 (13.5)* | 22/185 (11.9)* |
Altered | 68/75 (90.7) | 57/75 (76.0)* | 17/18 (94.4)* | 15/18 (83.3)* |
Likely and very likely DM | 265/285 (93.0) | 254/285 (89.1)* | 43/54 (79.6)* | 45/54 (83.3)* |
North | 19/22 (86.4) | 13/22 (59.1) | 9/17 (52.9) | 8/17 (47.1) |
Northeastern | 118/138 (85.5) | 103/138 (74.6) | 11/44 (25.0) | 12/44 (27.3) |
Midwestern | 27/28 (96.4) | 24/28 (85.7) | 8/24 (33.3) | 9/24 (37.5) |
Southeastern | 226/236 (95.8) | 193/236 (81.8) | 39/119 (32.8) | 38/119 (31.9) |
South | 68/73 (93.2) | 56/73 (76.7) | 18/53 (34.0) | 15/53 (28.3) |
**Borderline ≥ 100 < 126 mg/dL, altered ≥ 126 < 200 mg/dL likely and very likely ≥200 mg/dL.
When variables significantly associated to the evaluated outcomes in bivariate analysis (
Factors associated to healthcare service utilization and pharmacological treatment in multivariate analysis. Brazil, 2001.
Service utilization OR (95% CI) | Pharmacological treatment OR (95% CI) | |
---|---|---|
New cases | 1 | 1 |
Previously diabetic individuals under treatment | 0.06 (0.03–0.13) | 0.23 (0.14−0.37) |
≥4 | 1 | 1 |
<4 | 0.62 (0.34–1.13) | 0.53 (0.34–0.83) |
Borderline | 1 | 1 |
Altered | 2.22 (0.62–7.93) | 5.01 (2.38−10.6) |
Likely and very likely DM | 1.20 (0.59–2.46) | 11.2 (6.85−18.4) |
*Borderline ≥ 100 < 126 mg/dL, altered ≥ 126 < 200 mg/dL, likely and very likely ≥200 mg/dL.
Factors significantly associated to pharmacological treatment were diabetes status (OR = 0.23; 95% CI: 0.14–0.37), healthy behavior score of 4 or higher (OR = 0.53; 95% CI: 0.34–0.83), altered blood glucose level (OR = 5.01; 95% CI: 2.38–10.57), and blood glucose in the level of likely and very likely diabetes (OR = 11.22; 95% CI: 6.85–18.40; Table
The Brazilian Ministry of Health implemented the National Program of Detection of Diabetes Mellitus as a component of the Plan for the Care of Diabetes and Hypertension, recognizing that the early identification, assistance, follow up of people with diabetes, and health care service utilization in the basic health units are crucial elements to health control. It was also recognized that assistance was not systematic in the country [
The participation of previously diabetic individuals in the screening program showed the need for a better understanding of the components involved and possible influence in health service utilization. A possible explanation to justify this may be related to difficulties in the management of the disease and its treatment [
In both groups, females, individuals with incomplete elementary schooling, and those of 50–69 years of age predominated. The age of individuals that were not under treatment was similar to those considered new cases. For variables such as gender and age, results are in accordance with the observations of other studies [
Most of the individuals presented less than four healthy behaviors (81.3% and 79.0%, NCD and PDWIT, resp.) demonstrating difficulties to establish and to keep non-pharmacological procedures.
The analysis of demographic variables in the process of adhesion and health service utilization does not show results that may point out a specific profile of individuals. According to results of bivariate analysis, the only variable that reached statistical significance was schooling, considering pharmacological treatment as the outcome. However, health system utilization in this study, as in others [
Health care service utilization was significantly higher among NCD, showing that the objective diagnosis and service utilization is achieved. If health care utilization was lower among PDIWT, special strategies should be necessary in this group in order to include them in the health system. The healthy behavior score and blood glucose levels in the screening were also associate to health service utilization in the bivariate analysis; however the association disappeared after logistic regression.
According to multivariate analysis, PDIWT group presents 23% of the chance of an NCD to treat the condition and has a healthy behavior score <4 corresponding to a 53% chance of pharmacologically treating the condition compared to individuals with four or more healthy behaviors. These data indicate a strong relationship between the acquisition and maintenance of healthy behaviors and the treatment of diabetes. The pharmacological treatment reaches a higher proportion of individuals with higher blood glucose levels considering that these individuals tend to be more symptomatic and, as a consequence, look for treatment. It is, however, interesting to emphasize that, when health service utilization is taken into consideration, glucose levels and healthy behavior scores were not statistically significant.
Population-based studies on adhesion to treatment and health service utilization are not explored in the literature, making the importance of results of the program more evident. In the present study, the variable actually associated with health service utilization was the diagnosis of a new case.
Possible limitations of this study must be considered. Information was obtained in a self-referred process by patients. Data were not directly obtained, nor a measurement was done or other registers were simultaneously employed. Other authors underscored this kind of limitation [
In summary, results obtained are in accordance with those of the literature, showing that demographic variables do not make a specific profile of adhesion to pharmacological treatment and health service utilization. The greater service utilization verified among NCD indicates a relevant result of the National Plan and, particularly, of the Program, as a screening strategy and further service utilization. Part of the PDIWT group was recovered by the health system; however, strategies specially directed to this group deserve consideration. Importantly, the work developed in health system by the available programs should be revisited and optimized in order to obtain a better support for patients with chronic diseases such as, according to this study, diabetes.