| | Risk of Stroke, Heart Attack, and Diabetes Complications Among Veterans With Spinal Cord InjuryPresented as a poster to American Public Health Association, November 4–8, 2006, Boston, MA. Abstract Banerjea R, Sambamoorthi U, Weaver F, Maney M, Pogach LM, Findley T. Risk of stroke, heart attack, and diabetes complications among veterans with spinal cord injury. ObjectivesTo compare the rates of diabetes and macrovascular conditions in veterans with spinal cord injury (SCI) and to examine variations by patient-level demographic, socioeconomic, access, and health status factors. DesignA retrospective analysis. Diabetes status was classified by merging with diabetes epidemiology cohort using a validated algorithm. Chi-square tests and logistic regressions used to compare rates in macro- and microvascular conditions in veterans with and without diabetes. SettingVeteran Health Administration clinic users in fiscal year (FY) 1999 to FY 2001. ParticipantsSCI patients (N=8769) with diabetes (n=1333), in FY 2000, identified through the SCI registry. InterventionsNot applicable. Main Outcome MeasuresMacrovascular and microvascular conditions in the next year (February 2001). Derived from International Statistical Classification of Diseases, 9th Revision, Clinical Modification, codes in the patient treatment files. ResultsOverall, 15% of SCI veterans were identified with diabetes but this was an underestimate due to high mortality (8%). Among SCI veterans with diabetes, 49% had at least one macrovascular condition and 54% had microvascular conditions compared with 24% and 25% of those without diabetes (P<.001). ConclusionsOur study highlights the highly significant relationship between diabetes and macro- and microvascular conditions in veterans with SCI. Neurologic deficit combined with increased insulin resistance has a greater macrovascular impact on SCI veterans than on those who do not have diabetes. Increasing age and physical comorbidities compound the problem. List of Abbreviations: CI, confidence interval, FY, fiscal year, ICD-9-CM, International Statistical Classification of Diseases, 9th Revision, Clinical Modification, OR, odds ratio, SCI, spinal cord injury, VA, Veterans Affairs, VHA, Veterans Health Administration THE NUMBER OF PEOPLE in the United States living with SCI and disorders has been estimated to range between 222,000 and 285,000.1 Nearly 1 in 5 (44,000) are veterans who are eligible for VHA medical care, and all veterans who sustain SCI are eligible for VA treatment even if the injury was not service related.2 The VHA has the largest single network of SCI care in the nation and provided medical care to 22,800 veterans with SCI in 2004. People with SCI have been reported to have a higher risk for insulin resistance, atherogenic lipid profile, and metabolic syndrome, precursors of diabetes and macrovascular disease,3, 4 compared with age-matched general populations. Indeed, a recent small study suggests that diabetes is an independent risk factor for mortality.5 Studies have underlined the increased prevalence of diabetes in older adults6, 7 and compared with the non-SCI population, aging patients with SCI have less lean body mass and greater adiposity.8 In a recent study of veterans with SCI, around 20% were found to be obese and 33% were overweight.9 Studies also suggest that patients with SCI have premature coronary heart disease that may be due to sedentary lifestyle, weight gain, and metabolic changes.9, 10 Others have observed a higher incidence of hypertension and ischemic heart disease.4, 11 Data from the 1990s indicate that respiratory and cardiovascular conditions combined account for over half of all deaths in patients with SCI.12, 13, 14 Others studies have pointed to the worse outcomes for diabetes patients including epidural abscesses and spinal cord infarctions.15, 16 Thus the effects of increased diabetes risk have added a greater burden of SCI and comorbidities in older patients.6, 7, 17 Increasing prevalence of cardiovascular risk factors is clinically important in managing persons with SCI. Clinicians are well aware of problems in diabetes and its related macrovascular and microvascular conditions in persons with SCI. A cursory examination of the data does not support this view, because prevalence rates do not differ from the general VA population. However, when the analysis is extended to include those who have recently died, the situation changes dramatically. Given the markedly higher death rates in those with both diabetes and SCI, there must be an influx of new cases each year in order for prevalence rates to remain the same. Whether this influx consists of persons with SCI who develop diabetes, or persons with diabetes who develop SCI, is an important question that can be answered in future studies as this project collects additional data years. In addition, the increased longevity of persons with SCI, which, on average, is now 20 years or more after their injury, and may be up to 40 years for younger patients,18, 19 underscores the importance of aging and its comorbidities in the population with SCI. However, the association between SCI, macrovascular disease and diabetes in persons with SCI and specifically veterans with SCI, has not been determined on a large scale population. The primary aim of this study was to examine prevalence of diabetes among VHA clinic users with SCI, and compare rates of macrovascular and microvascular conditions in SCI veterans with and without diabetes. Methods  Veterans With SCIs or Disorders Our data include information from the spinal cord disorders registry, which consists of a refined cohort of veterans who use VHA medical care, have an SCI diagnosis, and use SCI-specific health care services (SCI inpatient bed section or SCI outpatient clinic stop). The current spinal cord disorders registry requires that the facility enter information about the veteran regarding their demographics, level and completeness of injury, etiology, and other characteristics. However, because it is voluntary, not all veterans with SCI or disorders are recorded on the registry. Participation is less common at non-SCI center facilities (F. Weaver, PhD, personal communication, July 5, 2006). The spinal cord disorders registry is cumulative (N=36,987) and has patients with dates of onset of SCI condition through December 2006. The exclusionary criteria were: (1) those who had no date of onset; (2) date of onset occurred later than our baseline year (FY 2000); and (3) those who died during or before FY 1999. This yielded a sample of 11,281. These data were further merged with those who used the VHA system in FY 1999–2001 and were still alive at the end of our study outcome year of FY 2001, yielding a final sample (n=8769). Use was measured by any inpatient or face-to-face outpatient visits in the VHA. Thus we arrived at our cohort of SCI veterans who were using the system in FY 1999–2001, had a diagnosis of SCI as of September 30, 2000, and were alive at the end of FY 2001 (n=8769). Veterans With SCI and Diabetes We merged our cohort of SCI veterans using the VHA clinics (n=8769) with the diabetes epidemiology cohort of FY 1999 and FY 2000 (N=738,371). Diabetes epidemiology cohort is a multi-year, dynamic cohort of patients with diabetes who use the VHA for health care. Details of identification and construction of the cohort are described elsewhere.20 In the final cohort 1333 veterans (15% of n=8769) with SCI were identified and flagged as also having a diagnosis of diabetes (the remaining 85%, n=7436, were flagged as nondiabetes patients). Measures: Dependent Variables Macrovascular conditions We identified the presence of any macrovascular condition(s) based on conditions derived from ICD-9-CM diagnosis codes in the VHA inpatient and outpatient files in the year 2000. Macrovascular conditions included stroke (codes 431, 433.00, 434.00, 435.8-.9, 438.0, 435.00), coronary artery disease (codes 410.0, 411.0, 411.1, 411.81−.89, 412–413, 413.0, 414, 414.00), congestive heart failure (codes 402.01, 402.11, 402.91, 404.01, 404.11, 404.91, 428, 428.0−.1, 428.9), arrhythmia (codes 423, 423.0−.2, 423.8−.9, 427.31), peripheral vascular disease (codes 250.7, 440.2, 440.20, 440.8−.9, 442.2−.3, 443), and gangrene (code 785.4). Microvascular conditions Microvascular conditions were also identified through ICD-9-CM codes and included renal conditions (codes 274.1, 274.10−.11, .19, 403.10, 403.90−.91, 404.10−.13, 404.90−.93, 581.0–583.0, 585–587, 590.0, 593.6, 593.9, 753.12−.14), nephritis (codes 250.4, 403.00−.01, 404.00−.03, 405.01, 453.3, 584, 580.0, 590.1−.3, 590.8, 593.81, 866), end-stage renal disease (codes 458.21, E879.1, V56, V451), dialysis (389.5, 392.7, 394.2−.3, 399.5, 549.8), retinopathy (codes 250.50−.53, 362.0−.02), ulcers (codes 700, 681.10−.11, 682.7, 707.1, 730.76−.77), and amputation (code 841.0). Independent Variables Independent variables consisted of veteran's demographic, economic, access to care, and health status characteristics measured in FY 2000. In addition, we included life style variables (eg, substance abuse) and level of SCI injury. These were derived from the VHA administrative and Medicare claims data. Demographic characteristics were represented by sex, race and ethnicity (white, black, Latino, other), age (<50y, 50–64y, 65–74y, ≥75y), and marital status (married vs others). Region (Northeast, Midwest, South, West), urbanicity (urban, rural), and Medicare fee-for-service enrollment (FY 2000, FY 2001) was also determined and controlled for in analysis. Health status measures included physical comorbidity (number of conditions), severe mental illness, other mental illness, and substance abuse. Physical comorbidity was measured using the Selim index (physical index) derived from ICD-9-CM codes.21 Mental illness included schizophrenia (ICD-9-CM code 295), bipolar disorder (codes 296), anxiety (codes 300.0, 300.2, 300.3), depression (codes 296.2, 296.3, 300.4, 309.1, 311) and posttraumatic stress disorder (code 309.81), other psychosis (codes 296.9, 297−298), and other mental illnesses (codes 300.5−.9, 308.0, 300, 309.0−.00). Life style factors Substance abuse included presence of substance abuse (alcohol, tobacco, drug) by ICD-9-CM codes (drug abuse: codes 292, 304, 305.2−.9, tobacco: code 305.1; opium: code 304; alcohol abuse: codes 291.1−.9, 303, 305.0, 265.2, 357.5, 425.5, 571.0, 571.2−.3, 535.3, 790.3). SCI level of injury and duration To compensate for high levels of missing data in the registry (28%) regarding SCI level of injury, we have supplemented information from the VHA and Medicare patient treatment files. With the supplementation, we now have only 2.2% missing. To the extent permitted by the data, we controlled for the effect of level of SCI and/or neurologic deficit and duration of SCI in our regression analysis. Statistical Procedures We used chi-square tests to test unadjusted subgroup differences in the dependent variables. To examine the relationship between macrovascular and microvascular conditions and diabetes, we conducted chi-square tests for each patient characteristic. For example, we tested the relationship between macrovascular and microvascular conditions and diabetes for men and women separately. Although the battery of tests may seem unconventional, such approaches have been used to study subgroup differences in antidepressant use.22, 23, 24 Olfson et al22 used a battery of analyses to analyze subgroup differences in antidepressant use over time. Rosenthal et al23 (see their table 5) also used the same technique to assess ORs of death among patients from VA versus private sectors within subpopulation groups. Further, we used multiple logistic regressions to examine the prevalence of diabetes and to compare macrovascular and microvascular conditions between those with and without diabetes by demographic (sex, race and ethnicity, marital status), economic (VHA means status), and health status (physical comorbidity, other mental illness) and life style (substance abuse) characteristics. We transformed parameter estimates from logistic regressions to ORs for ease of interpretation. Due to multiple comparisons and the large population size, we considered variables to be statistically significant only if P was less than .01. Sensitivity Analysis To ensure robustness of the findings, we also repeated all the analyses, including those patients who died during the observation period. Examination of these results revealed that findings remained similar compared with the results reported in this study. For example, among those with SCI, for macrovascular conditions the adjusted OR for diabetes was OR equal to 2.05 (95% CI, 1.81–2.32) (data not shown in tabular form). Similarly, the adjusted OR for diabetes on microcirculatory conditions was OR equal to 2.83 (95% CI, 2.51–3.19). Summary of findings from these analyses are available from the first author on request. Results Table 1 (column 1) describes VHA users with SCI identified from the spinal cord disorders registry as of September 30, 2000, and alive at the end of our study. The study population was overwhelmingly male (98%) and 60% were white. The median age was 55 with 25% over the age of 65. Presence of comorbid physical conditions was common (67%). Veterans living in rural (nonmetro) areas constituted 27% of the population and 28% and 29% of veterans with SCI had macrovascular and microvascular conditions, respectively (not shown in table). Table 1 (column 2) displays the prevalence of diabetes by veteran characteristics. Overall, 15% (n=1333) of veterans with SCI were diagnosed with diabetes as of FY 2000. A higher proportion of the elderly, racial minorities, low income, and disabled patients and those with comorbid conditions had diabetes than did SCI clinic users under age 50, whites, those with copay (ie, insurance copayment for service), and those without comorbid physical conditions. In general those with paraplegia had a higher proportion of diabetes (17.2%) than those with tetraplegia (12.3%). Results from a multivariate logistic regression on diabetes (column 3) also confirmed these relationships. Adjusted OR at 95% CI indicated that with increasing duration of the SCI (>10y) the proportion still alive had a lower likelihood of diabetes. Blacks were 53% and Hispanics 74% more likely to have diabetes than whites; those 50 to 64 years of age were more than twice as likely, and those 65 years and older, 3 times more likely to have diabetes than those under 50 years. Presence of more physical comorbidities also increased the likelihood of diabetes by 2 times or more. Lower incomes and disability increased the likelihood of diagnosed diabetes (>30%) compared with those who had copay. A description of macrovascular conditions indicated that, overall, 28% of veterans with SCI had any macrovascular condition (n=2430) and that this proportion varied significantly by the presence of diabetes (columns 4–5). Percentages in these columns reflect row percentages for the diabetes group (column 4) and nondiabetes group (column 5) individually. Overall, only 24% of nondiabetes patients (n=7436) had macrovascular complications compared with 49% for veterans with SCI and diabetes (n=1333). Chi-square results across each row indicated this to be statistically significant across diabetes versus nondiabetes in each category (chi-square results not presented in tables). Table 1 (column 6) presents results of those likely to have macrovascular conditions in FY 2001. An adjusted OR of 2.04 (95% CI, 1.78–2.32) indicated that diabetes patients had twice the likelihood of macrovascular conditions compared with those without diabetes. The likelihood of any macrovascular conditions increased with age, with those 65 years and older 5 times as likely as those under 50 years to have any macrovascular conditions (adjusted OR=5.1; 95% CI, 4.32–6.03). Hispanics and other racial minority groups were less likely to have macrovascular conditions than whites after controlling for diabetes (though they had a higher chance of getting diabetes as seen in column 4). Physical comorbidity (>1) increased the likelihood (adjusted OR=1.85; 95% CI, 1.62–2.11) as did serious mental illness (adjusted OR=1.27; 95% CI, 1.07–1.51); SCI patients over 20 years of age had a lower likelihood (adjusted OR=.79; 95% CI, .68–.92) of macrovascular conditions. Table 1 (columns 7−9) presents the results on microvascular complications. Overall, 29% had microvascular conditions and findings suggest similar patterns, because macrovascular conditions existed with a few differences. Diabetes (adjusted OR=2.96; 95% CI, 2.61–3.37) and older patients (adjusted OR=1.31; 95% CI, 1.12–1.54) with more than 1 comorbidity (adjusted OR=1.75; 95% CI, 1.54–1.98) had a greater likelihood of microvascular complications. However, duration of SCI was not statistically significant in predicting microvascular complications. Table 2 presents results on those SCI patients who died during our study period FY 2000 through 2001. Overall, 8% (n=716) died and as can be seen from the table, a much higher percentage of those who died had diabetes (26%) and macrovascular (54%) or microvascular (47%) conditions, compared with the 15% (diabetes), 28% (macrovascular), and 29% (microvascular) in those who were alive at the end of the study period, indicating a higher prevalence of these in the SCI patients who died. | | |  | Characteristic | Total | Diabetes | |
|---|
| n | % | n | % | |
|---|
| All | 716 | 100 | 186 | 100 | | | Diabetes | | | | | | |  Yes | 186 | 26 | NA | NA | | | No | 530 | 74 | NA | NA | | | Macrovascular conditions | | | | | | | Yes | 386 | 54 | 128 | 69 | | | No | 330 | 46 | 58 | 31 | | | Microvascular conditions | | | | | | | Yes | 338 | 47 | 113 | 61 | | | No | 378 | 53 | 73 | 39 | | | SCI status | | | | | | | Paraplegic | 372 | 52 | 122 | 66 | | | Tetraplegia | 327 | 46 | 61 | 33 | | | Missing | 17 | 2 | 3 | 2 | | | Duration of SCI (y) | | | | | | | <10 | 213 | 30 | 48 | 26 | | | 10–19 | 152 | 21 | 35 | 19 | | | 20–29 | 125 | 17 | 36 | 19 | | | ≥30 | 226 | 32 | 67 | 36 | | | | |
Discussion This study examined the prevalence of diabetes and compared the rates of macrovascular conditions among veterans with SCI. A significant number of SCI patients who were alive during our study period had diabetes (15%) similar to the general older population (>60y),25 and as the study indicates, patients with SCI and diabetes were more likely to suffer from macrovascular conditions (49%) than those without diabetes. Because diabetes is often associated with increased immobility and weight gain and SCI patients fit this profile, the risks of macrovascular conditions for them are higher than non-SCI patients. Rates of microvascular conditions were also high (54%) among diabetes patients, and retinopathy and renal failure were highly prevalent. However, it has to be noted that these prevalence rates underestimate the true prevalence and lead to the misleading conclusion that the rates of diabetes are similar to the rates in the general population. One of the reasons for this is due to the higher mortality rate of SCI patients with diabetes and macrovascular complications in any given year. For example, in the FY 2000 to 2001 study period, cumulatively 8% (n=716) of deaths occurred, confounding the true prevalence rates for diabetes and macrovascular complications. In fact, the large number of deaths can represent the ultimate macrovascular complication, but because we do not have the cause of death recorded, these complications were not included in the rates we present. These rates are therefore a lower bound of the true rates, which are those leading to the clinician's concerns. Table 2 attests to this reasoning and clearly points to the high risk of SCI patients developing serious macrovascular and microcirculatory problems and facing high rates of mortality when diagnosed with diabetes. Again, the appearance of a protective effect of SCI duration in the population that is alive is also misleading. We suspect that those with longstanding SCI who are disposed to develop diabetes are more likely to die, leaving the remaining patients who are healthier. We need longitudinal data spanning at least 10 years to examine the complex relationship between incident diabetes among veterans with SCI and their mortality and macro- and microcirculatory conditions. Study Limitations The strengths of this study include a large registry of SCI patients with details on levels of SCI injury and duration of SCI; an accurate ascertainment of diabetes, and ICD-9-CM diagnosis codes to capture macrovascular and comorbid conditions. However, there are some weaknesses in our data that include lack of information on the duration and progression of diabetes or prediabetes conditions prior to our diabetes epidemiology cohort FY 1999 and FY 2000 cohort identification of diabetes patients. Further the SCI level of injury (tetraplegia vs paraplegia) was used as a proxy of severity. It must also be noted that we did not include physiologic risk factors such as body mass index, blood pressure, glycosylated hemoglobin levels, cholesterol, urine protein, and medications (statins, angiotensin-converting enzyme inhibitor) as independent variables in our study. In addition, our sample consisted of an older, predominantly male population. The number of falls could not be accounted for and hence the more recent SCIs due to falls were not distinguished from longer duration SCIs. Conclusions The findings of generally similar diabetes prevalence rates in persons living with SCI and in the general VHA population on the one hand, and the clinician's perception of problems with diabetes in SCI patients on the other hand, both seem to be based on the higher mortality and end-stage difficulties faced by persons with SCI, rather than on the actual numbers at any given point in time. Our results are skewed in favor of those who are more healthy because there is a high mortality rate (8%) in the first year; if this is extrapolated over the many years of SCI this can indeed represent a major selection bias in all cross-sectional studies, which can only be addressed by following this group of SCI patients over a long period prospectively. To summarize, despite these limitations, our findings collectively point to the very high rates of diabetes and related mortality, and its significant association to the presence of macrovascular conditions and microcirculatory problems among SCI patients, which present challenges to delivering quality care to this special population. With the high prevalence of additional physical comorbidities and increasing age typical of the veteran population, there is a greater need to increase the awareness and prioritize health care management for these disabled patients with special needs. 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a Department of Veteran Affairs, Health Services Research and Development Service Center for Health Care Knowledge and Management, East Orange, NJ b School of Public Health, University of Medicine and Dentistry of New Jersey, Newark, NJ c New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ d Midwest Center for Health Services & Policy Research, VA Hospital, Hines, IL.  Reprint requests to Ranjana Banerjea, PhD, VA New Jersey Healthcare System, 385 Tremont Ave (Mail Stop 129), East Orange, NJ 07018
Supported by the VA Clinical Service Research and Development and the Health Services Research Enhancement Award Program (grant no. REA-03-021). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. PII: S0003-9993(08)00386-9 doi:10.1016/j.apmr.2007.12.047 Published by Elsevier Inc. | |
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