Mortality of patients with type 2 diabetes in Taiwan: A 10-year nationwide follow-up study
Introduction
Diabetes mellitus (DM) is an epidemic disease in the world. Marked changes in human health behaviors and lifestyle have resulted in higher incidence and prevalence of DM [1]. It has been recently estimated that the global prevalence of diabetes is 8.3% [2]. The number of people with diabetes is also rising because of population growth, aging, urbanization, and increasing prevalence of obesity and physical inactivity. The potential for increase in patients with diabetes is greatest in Asia [3].
Type 2 DM has become an important public health threat for the ethnic Chinese population living in mainland China, Hong Kong, Taiwan, and Singapore, with a prevalence of one-fifth of the adult population [4]. Given the genetic susceptibility and rapid westernization of food and lifestyle, a striking increase in incidence and prevalence of type 2 DM is anticipated [5]. The rapid increase in incidence and prevalence of type 2 DM is a health or medical issue and an economic and social problem for most governments. In developed countries, the largest increase in the number of type 2 DM is recorded in the elderly population aged more than 65 years, but the larger part of new onset type 2 DM occurred in the 45–64 year old population,2 who are vulnerable to premature death from various complications related to DM.
Increased public awareness on the adverse health consequences of type 2 DM has resulted in intensive monitoring and aggressive clinical management of DM worldwide. However, type 2 DM still accounts for a considerable number of deaths from discrete complications each year globally. Hence, cause-specific mortality statistics based on the underlying-cause-of-death (UCOD) recorded on the death certificate are important to compare the cause-of-death statistics between countries and across time. Most countries follow the guidelines determined by the World Health Organization (WHO) and would register mortality data according to the UCOD [6]. The UCOD is characterized as the disease or injury that triggers the sequence of morbid events leading directly to death. Information on the UCOD of diabetic patients may help estimate the disease burden of DM.
Although several previous studies have suggested an association between urbanization and higher type 2 DM incidence [7], [8], only few studies have examined the association of urbanization with mortality in DM. Taiwan introduced a universal health insurance to cover all citizens in 1995. The national health insurance (NHI) program was intended to assure the accessibility of health care at acceptable cost [9] and eliminate the financial barrier that prevents the poor from receiving health care services. Recognizing the association between urbanization and mortality in patients with type 2 DM under the above medical care system is important. This study aimed to investigate the distribution of UCOD in a nationally representative sample of type 2 DM patients. In addition, this study also sought to assess the influence of urbanization on the risk of mortality in patients with type 2 DM.
Section snippets
Source of data
Data investigated in this study were retrospectively retrieved from the medical claims of the National Health Insurance Research Database (NHIRD) provided by the Bureau of National Health Insurance (BNHI). NHIRD provides all inpatient and ambulatory medical claims for about 99% of Taiwanese [10]. To confirm the accuracy of claim files, the BNHI performs periodical expert reviews on a random sample for every 50–100 ambulatory and inpatient claims [9]. Therefore, information attained from NHIRD
Results
Approximately 52.1% of the patients in our study cohort were males and patients aged 50–69 years accounted for more than half of the patients. Approximately 30.6% of the patients first appeared in the medical claims for type 2 DM in 2000, whereas 7–10% were first seen in the subsequent years between 2001 and 2008. Most of the patients lived in areas with higher urbanization. With respect to the co-morbidity noted three years prior to date of recruitment, the most prevalent co-morbidity was
Discussion
We conducted a 10-year population-based follow-up study and found that the leading causes of death in Taiwanese patients with type 2 DM included neoplasms and cardiovascular diseases (CVD). In addition, compared with female type 2 DM patients, male patients had a higher risk of mortality within 10 years. The risk of mortality was also significantly associated with older ages, lesser urbanization, and higher co-morbidity scores.
One US study reported that CVD are involved in the preponderance of
Conclusion
We found that neoplasm accounts for the largest proportion of deaths in Taiwanese patients with type 2 DM, implying that cancer screening programs is important in patients with type 2 DM. Patients with type 2 DM should be carefully assessed for liver and biliary, lung, and colorectal neoplasms. Our study also indicated an increased risk of mortality in type 2 DM patients residing in areas with lesser urbanization, which may suggest inadequacy of health care and cancer screening for type 2 DM
Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgments
This study was partially supported by a grant with National Scientific Council (NSC101-2314-B-006-076-MY3), who however has no role in this study. The interpretation and conclusions contained herein do not represent those of BNHI, Department of Health or NHRI.
References (31)
- et al.
Global estimates of diabetes prevalence in adults for 2013 and projections for 2035 for the IDF Diabetes Atlas
Diabetes Res Clin Pract
(2014) - et al.
Prevalence of type 2 diabetes mellitus of Chinese populations in Mainland China, Hong Kong, and Taiwan
Diabetes Res Clin Pract
(2006) - et al.
Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases
J Clin Epidemiol
(1992) - et al.
Maximum utilization of the life table method in analyzing survival
J Chronic Dis
(1958) - et al.
Mortality and causes of death in type 2 diabetic patients. A long-term follow-up study in Osaka District, Japan
Diabetes Res Clin Pract
(1989) - et al.
Global and societal implications of the diabetes epidemic
Nature
(2001) - et al.
The rising global burden of diabetes and its complications: estimates and projections to the year 2010
Diabet Med
(1997) - et al.
Prevalence of diabetes and impaired fasting glucose in the Chinese adult population: International Collaborative Study of Cardiovascular Disease in Asia (InterASIA)
Diabetologia
(2003) - (2004)
- et al.
Multilevel examination of diabetes in modernising China: what elements of urbanisation are most associated with diabetes?
Diabetologia
(2012)
Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections
Diabetes Care
Taiwan's new national health insurance program: genesis and experience so far
Health Aff (Millwood)
Does universal health insurance make health care unaffordable? Lessons from Taiwan
Health Aff (Millwood)
Risk of Parkinson disease onset in patients with diabetes: a 9-year population-based cohort study with age and sex stratifications
Diabetes Care
Risk of malignant neoplasms of liver and biliary tract in diabetic patients with different age and sex stratifications
Hepatology
Cited by (19)
Prevalence of diabetic macrovascular complications and related factors from 2005 to 2014 in Taiwan: A nationwide survey
2019, Journal of the Formosan Medical AssociationSchizophrenia in type 2 diabetes mellitus: Prevalence and clinical characteristics
2018, European PsychiatryMajor depressive disorder in patients with type 2 diabetes mellitus: Prevalence and clinical characteristics
2018, Journal of Affective DisordersCitation Excerpt :Globally, DM and its complications substantially burden personal and public health. Asia has the increasing trend in the prevalence of DM because of population growth, ageing, urbanisation, and an increasing prevalence of obesity and physical inactivity (Amos et al., 1997; Lin et al., 2015). In China, a significant rising prevalence of DM was observed from less than 1% in 1980 to 5.5% in 2001, and 9.7% in 2007 (Chan et al., 2009; Chen et al., 2012; Lin et al., 2015).
Impact of Anxiety Disorders on Mortality for Persons With Diabetes: A National Population-Based Cohort Study
2017, PsychosomaticsCitation Excerpt :Future studies are needed to further investigate the association between ADs and possible protective effect on adverse health effects in people with DM. This study found male sex to be a risk factor for mortality in people with DM, consistent with previous studies,7,18,34,35 though Morrish et al.36 did not find a sex difference. The possible reason is that women are more capable of identifying physical symptoms and more willing to seek help.
Prevalence of Depressive Disorder in Persons With Type 2 Diabetes: A National Population-Based Cohort Study 2000–2010
2017, PsychosomaticsCitation Excerpt :Diabetes mellitus, a chronic and disabling disease, is epidemic worldwide with a global prevalence of 8.3%, and it contributes to disability-adjusted life years.1–3
- 1
Both authors contributed equally to this article.