In Nigeria where healthcare services and accessibility are poor

Document Sample
In Nigeria where healthcare services and accessibility are poor Powered By Docstoc
					                                                                   PROGNOSTIC INDICES              OF    DIABETES MORTALITY
Introduction: Diabetes mellitus is an impor-        Anthonia Okeoghene Ogbera, MBBS, MPH; Sunny Chinenye, MBBS;
tant cause of morbidity and mortality world-                 Asabamaka Onyekwere, MBBS; Olufemi Fasanmade, MBBS
wide and the burden associated with it is felt
more in developing countries. Communicable
diseases, as opposed to non-communicable
diseases, remain a top priority in developing       INTRODUCTION
countries like Nigeria. This report sets out to
highlight the current status of diabetes-related
                                                                                                  In Nigeria, where healthcare
                                                         Diabetes mellitus (DM) is a chronic
hospitalizations in Nigeria and also to make
                                                    metabolic disorder that is estimated to       services and accessibility are
comparisons with past reports. This goal will be
achieved primarily by determining the prog-         affect ,150 million people. A doubling        poor, diabetes mellitus is
nostic factors associated with diabetes mortal-     of this figure is expected in the near
ity and also noting the duration of hospital stay   future, especially in the African and         associated with a high disease
for the major causes of diabetes deaths.            Asian continents.1–2
                                                         Gross underreporting of DM occurs
Method: From January through December
2006, subjects with diabetes mellitus (DM) in       in African countries and may, in part,
a tertiary hospital in Nigeria were prospectively   be due to the absence of research
studied after admission to assess their short-      funding and lack of technical expertise.      cant contribution to disease burden in
term outcome which was defined as death.
                                                    Nearly a decade ago, the prevalence of        Nigeria is highly underscored. Most of
The total mortality, causes of death, associated
complications and duration of hospital stay
                                                    DM in Nigeria was 2.2%.3 Isolated             the reports on morbidity and mortality
were noted. The predictive factors for DM           reports from some regions of Nigeria          rates of diabetes in Nigeria were made
morbidity were evaluated using chi test,            have found prevalence rates to range          in the 1960s and 1970s and there-
logistic regression. Students t test was comput-    from 0.9–8.3%.4,5                             fore may not reflect the current situa-
ed for quantitative data.
                                                         Diabetes mellitus is associated with     tion.4,9–10 These reports showed that
Results: A total of 1,327 subjects were             considerable morbidity and mortality.5        diabetes ketoacidosis was the most
admitted to the Medical wards for the duration      In Nigeria, where healthcare services         common acute complication and cause
of the study and the crude death rate was 11%.      and accessibility are poor, DM is             of DM fatalities.
DM related admissions made up 206 (15%) of          associated with a high disease burden.6            This study sets out to bridge the
all the medical admissions and the case fatality
                                                    People with diabetes have been shown          information gap on DM in Nigeria; we
rate was 33 (16%). The most common reasons
for DM admission were hyperglycaemic emer-          to have higher mortality rates than           documented the patterns of DM mor-
gencies (HE), 88 (40%) and hypertension, 44         people without diabetes, although mor-        tality and morbidity, prognostic factors
(21%). The most common causes of deaths             tality rates depend on the location and       affecting fatal outcomes, and DM-re-
were HE, 15 (46%) and DM foot ulcers (DFU),         the specific group reported.7 In Africa,      lated hospitalization lengths of stay. The
10 (30%) while DFU and cerebrovascular
                                                    DM probably has the highest morbidity         information from this report will be of
accident (CVA) had the highest case fatality
rates of 28% and 25% respectively. DFU had          and mortality rates of all chronic non-       clinical significance to clinical research-
the most prolonged duration of admission            infective diseases.8 Unfortunately, in        ers and clinicians who provide health
ranging from 15–122 days. DFU, CVD and              Nigeria, communicable diseases remain         services for people with DM.
having type 2 DM were highly predictive of          the priority health condition for the
fatal outcomes. The odds ratio and 95% CI for
these factors were 4.5 (1.5–12.7), 3.0 (0.9–
                                                    Ministry of Health. The importance of
9.92 and 3.1 (0.7–14) respectively.                 noncommunicable diseases as a signifi-        METHODOLOGY
Conclusion: DFU and HE are potentially                                                                This prospective study was carried
remediable causes of mortality in DM. DFU
                                                                                                  out in a tertiary facility in Nigeria. This
as seen by the prolonged hospital stay imposes
                                                         From the Department of Medicine,         facility has three medical wards: two
a huge burden on health resources. Better and
                                                    Lagos State University Teaching Hospital,
early intervention of DFU is necessary to                                                         male and one female ward. The total
                                                    Ikeja, Lagos State (AOO, AO, OF); the
reduce the resultant disease burden. (Ethn
                                                    Department of Medicine, University of         bed capacity for the three wards is 63
Dis. 2007;17:721–725)                                                                             (25 beds for females and 38 for males).
                                                    Port-Harcourt Teaching Hospital, PortHar-
                                                    court (SC), Nigeria.                          The medical wards cater to people
Key Words: Diabetes Mellitus, Hospitaliza-
tion Length of Stay                                                                               $12 years of age. This study took place
                                                        Address correspondence and reprint
                                                                                                  from January to December 2006. The
                                                    requests to: Anthonia Okeoghene Ogbera,
                                                    MPH; Lagos State University Teaching          total number of all the medical and
                                                    Hospital; Ikeja; Lagos State; Nigeria; 01-    DM-related admissions to the medical
                                                    7917077;                  wards were documented. For the DM-

                                                    Ethnicity & Disease, Volume 17, Autumn 2007                                          721

related admissions, we abstracted data
                                             Table 1. Reasons for admissions for subjects with DM
including: biodata, admittance diagno-
sis, comorbidities, length of hospital            Admission diagnosis                                               Frequency
stay, and mortality data.                    Hyperglycemic emergencies (HE)                                         82   (40%)
    The diagnosis of DM was made             Poorly controlled blood pressure                                       44   (21%)
using the WHO 199911 criteria for            DM foot ulcers (DFU)                                                   36   (17.5%)
                                             Cerebrovascular disease (CVD)                                          20   (9.8%)
those who did not have a prior history       Hypoglycemia                                                            7   (3%)
of DM. For those with a prior history of     Peptic ulcer disease (PUD)                                              6   (3%)
DM, records were checked to ascertain        Tropical hand ulcer (TDHS)                                              2   (1%)
                                             Koch’s disease                                                          2   (1%)
that the 1984 WHO 12 diagnostic
                                             Retroviral infection                                                    1   (0.7%)
criteria for diagnosis of DM were used.      Chronic renal failure                                                   6   (3%)
    The patients were prospectively          TOTAL                                                                 206   (100%)
studied after admission to assess their
hospitalization outcomes. We gathered
information at frequent intervals from       the one-year period of the study. Di-           spectively. Hyperglycemic emergencies
the wards’ registers, which document         abetes mellitus-related admissions made         referred to diabetic ketoacidosis (DKA)
the admittance diagnosis, information        up 206 (15%) of all the medical                 and hyperosmolar non-ketotic state
related to hospital stay, and hospitaliza-   admissions. The total deaths recorded           (HONKS). DKA accounted for 72
tion outcome. The primary outcome            for the duration of study was 150, thus         (88%) while HONKS accounted for
was adverse outcome or death and the         giving a crude death rate of 11.3%. Of          10 (12%) of all the hyperglycaemic
risk factors associated with it were         the DM-related admissions, 33 (16%)             emergencies.
studied. Case fatality and crude death       died, 166 (80%) were discharged, and 7              The various hospitalization diagno-
rates were computed and the prognostic       (4%) insisted on being discharged from          ses for subjects with DM are shown in
factors for fatal outcomes were deter-       the hospital against medical advice.            Table 1. The mean age (SD) of subjects
mined. Admission and case fatality data                                                      with hypertension was 61 (12) years of
were compared in three age groups;           Some clinical features of                       age and the female:male ratio for those
#34 years of age, 35 to 64 years of age      hospitalized subjects with DM                   with hypertension was 1:1.2. Six DM
and $65 years of age. The numbers of             The male:female ratio of the medical        subjects presented with cerebral vascular
those discharged by the attending            and DM admissions were 1.1:1 and                accident (CVA) and also had a prior
physicians and those discharged against      1.6:1, respectively. Patients with type 1       history of hypertension, thus accounting
medical advice were also noted.              DM and type 2 DM made up 26 (13%)               for 30% of all cases of DM and CVA.
    Length of hospital stay was comput-      and 180 (87%) of the total DM patients
ed for those who were discharged by the      hospitalized, respectively. The mean age        Hospitalization duration of
attending physicians and comparisons         and standard deviation (SD) of all the          diabetic admissions
were made between the various DM             DM subjects was 55 (14) years and the               The mean (SD) hospital stay of DM
hospitalization diagnoses. Statistic tests   range was 17–91 years of age. The               admissions was 23 (17 days) and the
used included Student’s t test, chi          mean ages (SD) of the subjects with             range of this duration was 4–122 days.
square and logistic regression to de-        type 1 DM and type 2 DM were 29                 The mean (SD) of length of hospital
termine and compare means, compari-          (11) and 59 (6) years, respectively. The        stay and range for DM foot ulceration
son of qualitative data and odds ratio.      difference in ages between subjects             (DFU) was 51(27) days, ranging from
Significance level was set at a P value      with type 1 DM and those with type              15–122 days. Length of stay for di-
,.05. The statistical package used for       2 DM was statistically significant              abetes ketoacidosis and cerebrovascular
analysis was SPSS version 11.                (P5.000001).                                    disease were 13 (7) and 30 (8) days,
    This study was approved and con-                                                         respectively. For subjects with DM who
sent given by the research and ethics        Hospitalization patterns for DM                 were admitted for control of elevated
committee of the hospital.                       Some of the comorbidities – hyper-          blood pressure, the mean (SD) length of
                                             tension or poorly controlled blood              hospital stay was 21(10) days. The
                                             pressure, peptic ulcer disease, retroviral      length of stay for those admitted with
RESULTS                                      infection, Koch’s disease, and congestive       DKA, CVA and hypertension were
                                             heart failure – occurred in 44 (21%),           compared with that of DFU; statistical-
   A total of 1,327 subjects were            6 (3%), 1 (0.5%) 3 (1.5%%) and                  ly significant differences of .00001, .03
admitted to the medical wards within         3(1.5%) of all the DM subjects, re-             and .000001 were found.

722                                            Ethnicity & Disease, Volume 17, Autumn 2007
                                                                    PROGNOSTIC INDICES OF DIABETES MORTALITY - Ogbera et al

                                                                                                        surprising given the projected world-
Table 2. Causes of deaths in DM subjects
                                                                                                        wide increase in the prevalence of DM,
Causes of death                      % of total DM deaths                  Case fatality rate           especially in developing countries.1–2
HE                                          15 (46%)                              18%                   With this projected increase in preva-
CVA                                          5 (16%)                              25%                   lence rates in DM, the morbidity and
DFU                                         10 (30%)                              28%                   mortality rates are expected to assume
Hypoglycemia                                 1 (3%)                               14%
CRF                                          1 (3%)                               16%
                                                                                                        an upward trend especially in regions of
Bleeding PUD                                  1(3%)                               16%                   the world where healthcare services are
  HE5 Hyperglycemic emergencies; CVA5cerebral vascular accident; DFU5diabetic foot ulcer; CRF5chronic
                                                                                                        at best sub-optimal for the rapidly
renal failure; PUD5peptic ulcer disease.                                                                expanding populations.
                                                                                                            In our study, the majority of
                                                                                                        hospitalized subjects had type 2 DM
Diabetes Mellitus-Related                                  Two times more males than females            and their mean age was 55 years. This
Mortality                                              with DM died and this difference was             overwhelming preponderance of type 2
    The total medical deaths recorded                  statistically significant ( x [2] test 5         DM is in conformity with global views
during the study was 150, thus giving                  17.7 (P5.0008).                                  concerning the predominance of type 2
a crude death rate of 11.3%. The                           Clinical features, morbidity and             DM among diabetics.12
male:female ratio of those who died is                 mortality data of the subjects according             More than half of the DM subjects
1.6:1 and the mean age of the DM                       to the age classes are shown in Table 3.         were admitted for management of
patients who died was 58 (14) years.                                                                    hyperglycemic emergencies of which
    Diabetes mellitus-related deaths                                                                    DKA and severe hypertension were
made up 22% or one of five of all the                  DISCUSSION                                       predominant. Although the duration
medical deaths. The case fatality rate for                                                              of DM was not documented in this
DM was 33 (16%) and the male:female                        Diabetes mellitus is a significant           report, it is pertinent to note that a small
ratio of the DM-associated mortality was               contributor to medical morbidity and             percentage (10%) of those presenting
2:1.There was no significant difference                mortality worldwide; it is even more             with hyperglycemic emergencies were
between the case fatality rate and the                 apparent in developing countries like            only diagnosed at presentation with
crude death rate (P,.05). Type 1 DM                    Nigeria.12–13 The determination of the           acute complication of DM. Arterial
accounted for 2(6%)of all deaths while                 risk factors that are predictive of DM           hypertension is a common cardiovascu-
type 2 DM accounted for 31(94%) of all                 mortality are important in view of               lar disease in Africans and carries high
deaths. The causes of DM deaths and                    prevailing shortcomings such as man-             mortality and morbidity rates. Reported
case fatality rates are showed in Table 2.             agement capacity and resource availabil-         prevalence rates of hypertension in
    Diabetes mellitus foot ulceration                  ity in the region for the management of          Nigerians with DM range from 29–
was found to be the most important                     DM. In this report, DM admissions                40%.15–16 Because hypertension was
factor affecting fatal outcome of DM.                  accounted for 15% of all medical                 not recorded in subjects ,35 years of
The odds ratio and 95% confidence                      admissions and 22% of all medical                age, it is thus not surprising that the
interval (CI) for DFU were 4.46 and                    deaths. These facts demonstrate a wors-          mean age of DM subjects with hyper-
1.5–12.7. The odds ratio and CI for                    ening condition for DM-related admis-            tension was found to be 61 years.
CVA, type 2 DM, DKA, being male,                       sions and deaths in Nigeria. An earlier              The case fatality rate of 16% is
elderly and hypertensive were 3, 0.9–                  study by Ogbera et al14 reported                 higher than the crude mortality rate of
9.92; 3.16, 0.703–14; 2.51, 0.9–6.39;                  cumulative DM admission rates and                all the medical admissions (11%), but
1.52, 0.68–3.37; and 0.286, 0.08–0.99,                 death rates of 10% and 7.6%, respec-             this difference was not statistically
respectively. Only 1 (17%) of the DM                   tively. These figures were obtained from         significant. The case fatality rate for
subjects with CVA and a prior history of               a 10-year survey from 1990–2000.14               DM was lower than that reported by the
hypertension died.                                     The findings of this report are not              author14 previously and Ndububa17 et al

Table 3. Morbidity and mortality data according to the age groups

Age Classes                                 DM admissions                          Hypertension                     DM-related deaths
,34 years                                       20 (10%)                              0                                   2 (6%)
35–64 years                                    116 (56%)                             23 (52%)                            19 (57.6%)
.65 years                                       70 (34%)                             21 (48%)                            12 (36.4%)

                                                    Ethnicity & Disease, Volume 17, Autumn 2007                                                 723

who reported rates of 22% and 21%,           this study, DFU was found to be highly          which may be attributed largely to
respectively. More male deaths than          predictive of a fatal outcome as in-            better DM awareness, better manage-
female deaths were recorded, thus being      dicated by an odds ratio of 4.46 and            ment modalities and improved access to
male was found to be predictive of a fatal   95% CI of 1.5–12.7 (P5.005).                    insulin than what was common a few
DM outcome. An overwhelming ma-                  Cerebral vascular accident (CVA)            decades ago.
jority (94%) of the DM-related deaths        accounted for 16% of all DM deaths
occurred in those with type 2 DM; type       and had the second highest case fatality        REFERENCES
2 DM had a prognostic impact on DM           rate. It was also highly predictive of fatal     1. Engelgau MM, Narayan KM, Saaddine JB,
                                             DM outcome.                                         Vinicor F. Addressing the burden of diabetes
death. Hyperglycemic emergencies were
                                                                                                 in the 21st century: better care and primary
found to be the most common reasons              The significance of DFU as contrib-             prevention. J Am Soc Nephrol, 2003;(7 Suppl
for DM-related admissions and deaths,        utory to a high disease burden is further           2):S88–91.
following trends found throughout the        validated by the findings of prolonged           2. Zimmet P. The burden of type 2 diabetes: are
African continent.18–21 The case fatality    hospitalization. The mean length of                 we doing enough? Diabetes Metab. 2003;29:
                                             hospital stay for subjects with DM was              6S9–18.
rate for HE in this report is lower than
                                                                                              3. Akinkugbe OO, Akinyanju OO. Final report
that reported by the author in a previous    51 days. This duration of hospitaliza-
                                                                                                 – national Survey on non-communicable
study.14 In the present study, 87% of        tion was higher than any of other major             diseases in Nigeria. Lagos: Federal Ministry
DM patients had type 2; the remaining        causes of DM deaths and the difference              of Health; 1997.
patients had type 1 diabetes. The overall    was statistically significant. The pres-         4. Osuntokun O, Taylor L. Diabetes mellitus in
                                             ence of hypertension was not a signifi-             Nigerians. A study of 832 patients. West Afr
incidence of DKA was, however, 88%,
                                                                                                 Med J. 1976;28:155–159.
which suggests that the majority of          cant contributory factor to DM out-
                                                                                              5. Akanji AO, Adetunji A. The pattern of
hyperglycemic emergencies in Nigerian        come; only one of the subjects with                 presentation of foot lesions in Nigerian di-
type 2 patients were DKA. This finding       CVA died. This finding is contrary to               abetic patients. West Afr J Med. 1990;9:1–4.
is contrary to findings from the United      a Nigerian study of 51 hypertensive and          6. Ogbera A, Fasanmade O, Ohwovoriole A.
States and Europe where the majority of      54 normotensive type 2 diabetic Niger-              High costs, low awareness and a lack of care—
                                             ians in which stroke-associated deaths              the diabetic foot in Nigeria. Diabetes Voice.
hyperglycemic emergencies in type 2                                                              2006;51:30–32.
patients are due to HONKS. In a review       occurred in 8 subjects (7.6%), and all
                                                                                              7. Fuller JH. Mortality trends and causes of
of 138 admissions to the University          the stroke-related deaths occurred in the           deaths in diabetes patients. Diabetes and
Diabetes Treatment Center at Parkland        hypertensive group causes of death.26               Metabolism. 1993;13:96–99.
                                                                                              8. Onen C. Diabetes morbidity and mortality in
Memorial Hospital in Dallas for mod-
                                                                                                 Botswana: a retrospective analysis of hospital
erate-to-severe DKA, only 30 (0.2%)                                                              based data on diabetic patients, 1980–1994.
had type 2 diabetes, based on treatment      CONCLUSION                                          International Diabetes Digest. 1998;13:96–99.
history and/or autoantibody status.22                                                         9. Greenwood BM, Taylor J. The complications
This observed difference may be partly           This study has shown that predictive            of diabetes in Nigerians. Tropical Geographic
due to poor characterization of DM and       factors for DM mortality include di-                Medicine. 1968;20:1–12.
                                             abetes foot ulceration, hyperglycaemic          10. Adetuyibi A. Diabetes in the Nigerian African.
the hyperglycemic emergencies in Ni-                                                             Review of long term complications. Tropical
geria.                                       emergencies, type 2 DM, being male
                                                                                                 Geographic Medicine. 1976;28:155–159.
    Diabetes foot ulceration, which was      and being elderly. The outcomes seen in         11. World Health Organization. Definition, di-
the second most common cause of              this report may be attributed to poor               agnosis and classification of diabetes and its
death, had the highest case fatality rate.   glycemic control, as well as poor guide-            complications. Reports of a WHO Consulta-
                                             lines for management.                               tion. Geneva: World Health Organization;
This entity is recognized as one of the                                                          1999.
most devastating complications of DM,            Though healthcare services are still
                                                                                             12. World Health Organization. Reports of
which imposes a heavy burden on DM           inadequate in Nigeria, this report has              a WHO study group. Geneva, WHO Tech-
patients. The reported prevalence rates      shown a decline in DM fatality rates,               nical Reports Series 1985, no. 727.
                                                                                             13. Chale S, Swai A, Mujinla P, Mclarty D. Must
of DFU in Nigeria range from 9.5%–
                                                                                                 diabetes be a fatal disease in Africa? Study
14%.23–25 In a previous report, the
author had earlier reported a high case      Though healthcare services are                      of costs and treatment. BMJ. 1992;304:
fatality rate (53%) for hospitalized         still inadequate in Nigeria,                    14. Ogbera AO, Ohwovoriole AE, Soyebi O. Case
patients with DFU.24 Some of the                                                                 fatality among diabetic in-patients. J Clin Sci.
reasons for this high rate of fatality for   this report has shown a decline                     2002;2:18–21.
                                                                                             15. Ikem RT, Kolawole BA. Diabetes register: an
those admitted with DFU range from           in DM fatality rates…                               audit of newly presenting patients in a diabetes
late presentation, erroneous traditional                                                         out-patient clinic. Afr J Endocrinol Metab.
beliefs, and high costs of treatment. In                                                         2002;3:52–54.

724                                            Ethnicity & Disease, Volume 17, Autumn 2007
                                                                      PROGNOSTIC INDICES OF DIABETES MORTALITY - Ogbera et al

16. Oli JM, Ikeh VO. Diabetes mellitus and            21. Parson W, MacDonald FW, Sharper A.                 26. Kolawole BA, Leslie Ajayi AA. Prognostic
    hypertension in an African population. Journal        African diabetics necropsied at Mulago hospi-          indices for intra-hospital mortality in Nigerian
    of the Royal College of Physicians of London.         tal Kampalar Uganda, 1957–1966. East Afr               diabetic NIDDM patients: role of gender and
    1986;20:32–35.                                        Med J. 1968;45:89–99.                                  hypertension. J Diabetes Complications.
17. Ndububa DA, Erhabor GE. Diabetic mor-             22. Newton CA, Philip R. Diabetes ketoacidosis in          2000;14:84–89.
    talities in Ilesa, Nigeria: a retrospective           type 1 and type 2 diabetes mellitus. Arch Intern
    study. Cent Afr J Med. 1994;40:291–                   Med. 2004;164:1925–1931.                           AUTHOR CONTRIBUTIONS
    292.                                              23. Dagogo JS. Pattern of diabetes foot ulcer in       Design concept of study: Ogbera, Onyekwere,
18. Ahmed AM, Ahmed NH, Abdella ME.                       Port-Harcourt, Nigeria. Pract Diabetes Digest.         Fasanmade
    Pattern of hospital mortality among diabetic          1991;2:75–80.                                      Acquisition of data: Ogbera, Chinenye,
    patients in Sudan. Practical Diabetes Interna-    24. Ogbera AO, Fasanmade A, Ohwovoriole AE,                Fasanmade
    tional. 2000;17:41–44.                                Adediran O. An assessment of the disease           Data analysis and interpretation: Ogbera,
19. Corrigan CB, Ahren B. Ten years experience            burden of foot ulcers with diabetes mellitus           Fasanmade
    of a diabetes clinic in northern Tanzania. East       attending a teaching hospital in Lagos, Nigeria.   Manuscript draft: Ogbera, Chinenye, Onyek-
    Afr Med Journal. 1968;45:89–90.                       International Journal of Lower Extremity               were, Fasanmade
20. Lutalo SKK, Mubongo N. Some clinical                  Wounds. 2006;5:1–6.                                Statistical expertise: Ogbera
    and epidemiological aspects of diabetes           25. Ogbera AO, Adedokun A, Fasanmade O,                Acquisition of funding: Fasanmade
    mellitus in an endemic disease register in            Ohwovoriole AE, Ajani M. The ‘‘foot at risk’’      Administrative, technical, or material assis-
    Zimbabwe. East Afr Med J. 1985;62:433–                in diabetes mellitus. Int J Endocrinol Metab.          tance: Onyekwere, Fasanmade
    445.                                                  2005;4:165–173.                                    Supervision: Chinenye, Fasanmade

                                                      Ethnicity & Disease, Volume 17, Autumn 2007                                                           725

Shared By: