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Diabetes Mellitus: Patterns of Pharmaceutical Use in Manitoba

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Diabetes Mellitus: Patterns of Pharmaceutical Use in Manitoba Diabetes Mellitus: Patterns of Pharmaceutical Use in Manitoba by Kim¡ T. G. Guilbert A Thesis submitted to The Faculty of Graduate Studies in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCE Faculty of Pharmacy The University of Manitoba Winnipeg, Manitoba @ Kimi T.G. Guilbert, March 2005 TIIE UMYERSITY OF MANITOBA F'ACULTY OF GRADUATE STTJDIES +g+ù+ COPYRIGIIT PERMISSION PAGE Diabetes Mellitus: Patterns of Pharmaceutical Use in Manitoba BY Kimi T.G. Guilbert A ThesisÆracticum submitted to the Faculty of Graduate Studies of The University of Manitoba in partial fulfillment of the requirements of the degree of MASTER OF SCIENCE KIMI T.G. GTIILBERT O2()O5 Permission has been granted to the Library of The University of Manitoba to lend or sell copies of this thesis/practicum, to the National Library of Canada to microfïlm this thesis and to lend or sell copies of the film, and to University Microfilm Inc. to publish an abstract of this thesis/practicum. The author reserves other publication rights, and neither this thesis/practicum nor extensive extracts from it may be printed or otherwise reproduced without the author's written permission. Acknowledgements Upon initiation of this project I had a clear objective in mind--to learn more. As with many endeavors in life that are worthwhile, the path I have followed has brought me many places I did not anticipate at the beginning of my journey. ln reaching the end, it is without a doubt that I did learn more, and the knowledge I have been able to take with me includes a wider spectrum than the topic of population health and medication utilization. In achieving my goal I would like to acknowledge the many people, all of whom contributed to my learning process. Firstly, I would like to thank Dr. Colleen Metge, my advisor, for her enduring enthusiasm and knowledge in support of this research project. She provided both the original inspiration which directed me toward this area of research and the vision with which to pursue future research. To my committee members; Dr. David Collins, for his valuable advice and accessibility, and Dr. Lavern Vercaigne for sharing his knowledge and clinical skill set. A special thank-you to Dr. Jane Griffith who graciously stepped in as a committee member near the end of the project. I would also like to thank the Manitoba Center For Health Policy for providing the structure and support needed to accomplish this type of population health research. I especially would like to acknowledge Charles Burchill, Senior Systems Analyst, and Marina Yogendran, Systems Analyst, for freely sharing their time and skill. A special thanks to Drs. Anita Carrie and Patricia Schroeder. The many meetings they attended allowed for free dialogue and sharing of ideas which contributed greatly to the thought process, an important part of scholarship. Many thanks to my family. Thank you to my husband, Steven Lawrie, for his support and patience. Thank you to my son, Tomi, for literally kicking me awake as I worked in the early hours of the morning and for being patient and calmly waiting for 'play-time' with Mom during your first 18 months of life. Thank-you to Naomi Guilbert and Hiroshi Koshiyama who provided me with perspective and to Fubuki Daiko for providing a much needed outlet. Thank you to Sadako Mizobuchi for your enduring support. Finally, I cannot express enough thanks to my father and mother, Norman and Sachiko Guilbert, who patiently waited for me, first to choose a career path and then to f,rnish this project. They provided me the values, skills and attitude with which I was able to finish what I started and to acquire knowledge from the process. TABLE OF CONTENTS Abstract 1 Preface 2 CHAPTER ONE Background : Understanding Diabetes 4 A. Pathophysiology 4 B. Etiology 5 C. Epidemiology of Diabetes I D. Treatment of Diabetes 12 E. Secondary Complications of Diabetes 15 F. Diabetes Control & Complications Trial(DCCT)& 17 United Kingdom Prospective Diabetes Study Group CHAPTER TWO Literature Review 21 lntroduction to Research Questions 31 CHAPTER THREE Research Methods 33 A. lntroduction 33 B. Study Design 33 C. Data Source 35 D. Data Management & Cohort ldentification 43 E. Measurement Tools 46 F. Descriptive (Demographic) Variables 49 G. Analysis Plan 54 CHAPTER FOUR Results 59 A. Cohort Characteristics 59 B. Missing Data 71 C. Considerations for Reporting Data 72 D. Access Rates 73 E. lntensity Rates: Prescription Claims 75 F. lntensity Rates: Different Drug Classes 82 G. lntensity Rates: Defined Daily Doses 84 H. Costs 86 CHAPTER FIVE Discussion 89 CHAPTER SIX Conclusion 98 REFERENCES 100 Appendix A. CMA Guidelines for treating Diabetes Appendix B. SAS Programming Appendix C. Winnipeg Areas Appendix D. Manitoba Regions Appendix E. Variable List Table of Tables & Figures Table 1. Risk of Type 2 diabetes by Ethnicity 6 Table 2. Proposed Environmental Determinants of NIDDM Based on 8 Findings from Observations (Cross-sectional or Longitudinal Studies) Table 3. Common Examples of Oral Anti-diabetic Drug Treatments 13 Table 4. Goals of Diabetes Care 14 Table 5. Manitoba Health Research Data Repository Files 37 Table 6. ACG Groupings 51 Table 7. Manitoba Regional Groupings 52 Table 8. Cohort derivation according to diabetes definition 64 Table 9. Comparison of Manitoba's AGE Category Distribution to the 65 Diabetic Study's AGE Category Distribution, April 1, 1997 Table 10. Comparison of Manitoba's AGE & SEX Categories Distribution 66 April 1 ,1997 Table 11. Distribution of Diabetic Study population according to 67 Winnipeg areas ordered by increasing premature mortality rate (e.9., Point Douglas has the highest PMR in the City of Winnipeg), 1997 Table 12. Distribution of Diabetic Study population according to 68 urban/rural geographic areas in Manitoba, 1997 Table 13. Comparison of Manitoba's ADG Distribution to the Diabetic 69 Study's ADG Category Distribution, April 1, 1997 Table 14. Distribution of Diabetic Study population according to 70 urban/rural income quintiles in Manitoba, 1997 Table 15. Number of Diabetics in Cohort with Missing Variables 71 Table 16. Claims with missing ATC information 71 Table 17. Numbers of prescription claims for ALL drugs dispensed to the 78 'Anti-diabetic drug (410) using population', by Sex, 1997/98 to 2000101 Figure 1. Prevalence and lncidence of Diabetes in Manitoba, 1994 10 Figure 2. A Model for the Development of Anti-diabetic Drug Utilization 22 lndicators Figure 3. Analytical orientation 34 Figure 4. Denominator Derivation for Diabetic Population, April 1, 45 1997 Figure 5. Cohort Derivation, Overall 1997 -2001 61 Figure 6. Cohort Derivation for 1997/98 and 1998/99 62 Figure 7. Cohort Derivation for 1999/00 and 2000i01 63 Figure 8. Percent of Cohort derived according to diabetes definition 64 Figure 9. Diabetes Prevalence byAge, 1997 65 Figure 10. Diabetes Prevalence by Age and Sex, 1997 66 il ABSTRAGT Statement of the problem The high incidence and prevalence of secondary complications from diabetes in the general population indicate that blood glucose management may not be reaching the level of control that is achievable. In other words, drug therapy is eff,rcacious in large clinical trials but may potentially lack effectiveness within the general population. Comprehensive drug utilization would provide a strong base from which to develop interventions to close the gap between the promise of anti-diabetic drug therapy (its efficacy) and its current (lack of) effectiveness. Methods Using a fixed-sample panel design, several measures of drug utilization (e.g., intensity of use and cost) were applied to a Manitoba population-based cohort of persons with diabetes. Data was accessed through the Population Health Research Data Repository (PHRDR) at the Manitoba Centre for Health Policy. Results The healthier or less 'comorbid' and wealthier segments of the cohort appeared to have the lowest rates of drug use. Conversely, there seemed to be an increase in utilization rates which followed the cohort members as their comorbidity status increased and/or their socioeconomic status decreased. Unexpected however, was the appearance of higher access among males. Conclusion Pharmaceutical use patterns and prescription drug costs for persons with diabetes in the Manitoba population can be described using the population demographics available with administrative claims data. The descriptions presented are hypothesis generating; future analyses should examine apparent differences in pharmaceutical use. Preface The incidence and prevalence of diabetes mellitus has been increasing in epidemic proportions across the globe. Data available from the National Diabetes Surveillance Strategy (NDSS), a Canadian organization, demonstrated the prevalence in adults was 4.8% while population based studies indicate the true prevalence as much as 30 to 50% higher than NDSS.T This means that in Canada greater than7Yo of the population may be diabetic.2 ln Manitoba alone more than 4,000 new cases are diagnosed each year, which translates into more than 55,000 Manitobans suffering from diabetes.3 Implications of this disease, through secondary complications, include widespread damage to major biological systems within the body including blindness due to retinopathy. There is widely accepted scientific evidence from the DCCT (Diabetes Control and Complications Trial) and UKPDS (United Kingdom Prospect Diabetes Study Group) trials demonstrating that achieving euglycemia, normal blood glucose levels, results in reducing secondary complicatio.rs.o-s A major part of this control is achieved through drug therapy. The high incidence and prevalence of secondary complications in the general population indicate that management of blood glucose levels may not be reaching the level of control achieved in the DCCT and UKPDS trials, and outlined as goals in the Canadian Diabetes Association Clinical Practice Guidelines.a-s ln other words, drug therapy is efficacious in large clinical trials but may potentially lack effectiveness within the general population.
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