Broad decline in incidence rate of diabetes-related complications in US

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1. The rate of diabetes-related complications declined significantly from 1990-2010. 

2. Despite reductions in incidence rates, the overall burden of diabetes-related complications continued to grow due to an increase in diabetes prevalence amongst the aging baby-boom generation. 

Evidence Rating Level: 2 (Good) 

Study Rundown: This population incidence study drew on several nationally representative hospitalization registries to examine trends in incidence of diabetes-related complications (lower-extremity amputation, end-stage renal disease, acute myocardial infarction, stroke, and death from hyperglycemic crisis) in the United States from 1990 to 2010.  Given advances in acute clinical care, health care system improvements, health promotion efforts and preventive care for diabetic patients, advances in intensive interventions of revascularization, this study represents an important opportunity to look for evidence of efficacy of diabetes management in the U.S. population.

Key findings include a reduction in the incidence rate of acute myocardial infarction attributable to diabetes, which has narrowed to be about as common as stroke; reductions in incidence rates were smallest for end-stage renal disease, which actually increased over the two decades among older adults.  Furthermore, there were large declines in the relative risks of complications attributable to diabetes for acute myocardial infarction, stroke, amputation, and end-stage renal disease from 1990 to 2010.

Strengths of the study include its ability to draw together rich and diverse databases in order to provide a population-level view of diabetic complications in the US; furthermore, the authors conducted sensitivity analyses to ensure that changes were analyzed in light of increased detection of diabetes over these decades.  Drawbacks include the fact that the authors were unable to assess trends in all important complications (such as diabetic retinopathy, hypoglycemia, neuropathy, peripheral vascular disease, and other complications of Type 2 diabetes such as cognitive decline and Alzheimer’s disease), and the data were not specific enough to report incidence rates between type 1 and 2 diabetes.

Click to read the study, published today in NEJM

Relevant Reading: Projection of the year 2050 burden of diabetes in the US adult population

In-Depth [population incidence study]: This study drew on data from several large national surveys and population registers in order to examine the trends of incidence in diabetes-related complications in the United States from 1990 to 2010.  Complications of interest included: lower-extremity amputation, end-stage renal disease, acute myocardial infarction, stroke, and death from hyperglycemic crisis.  Cases for each of these conditions were defined based on ICD codes that mentioned both the event of interest and were associated with a diagnosis of diabetes.  The case rates were calculated with two sets of denominators: first, with the US population of persons 20 years of age or older with diagnosed diabetes, and second, with the overall US population in this age group.  The authors conducted sensitivity analyses to account for the potential effect of a large increase in detection of diabetes on incidence rates.

Over the 20-year period, the number of adults reporting a diagnosis of diabetes increased from 6.5 million to 20.7 million.  The rates of all five complications declined significantly over the period: for myocardial infarction, there were 95.6 fewer cases per 10,000 person-year (95% CI, 76.6 to 114.6); for lower-extremity amputations there were 30.0 fewer cases per 10,000 person-years (95% CI, 17.4 to 42.6).  There was a statistically significant (p<0.05) linear trend for decreasing rates of incidence across all five complications among adults diagnosed with diabetes.  The greatest declines in diabetes-related complications in both absolute and relative terms were observed in adults over 75 years of age.  The relative risk of events associated with diabetes decreased across all five complications between 1990 and 2010.  Importantly, when using the entire population denominator (which accounts for increasing prevalence of diabetes), there was a decline in rates of acute myocardial infarction and death from hyperglycemic crisis (2.7 and 0.1 fewer cases per 10,000 respectively), but not for the other complications.

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