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      Impact of a Natural Disaster on Diabetes : Exacerbation of disparities and long-term consequences

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          Abstract

          OBJECTIVE

          To examine the impact of Hurricane Katrina on the health of individuals with diabetes.

          RESEARCH DESIGN AND METHODS

          This was an observational study in 1,795 adults with an A1C measurement 6 months before and 6−16 months after Hurricane Katrina in three health care systems: private (Tulane University Hospital and Clinic [TUHC]), state (Medical Center of Louisiana at New Orleans [MCLNO]), and Veterans Affairs (VA). Glycemic control (A1C), blood pressure, and lipids before the hurricane were compared with the patients' first measurement thereafter. The CORE Diabetes Model was used to project life expectancy and health economic impact.

          RESULTS

          Mean predisaster A1C levels differed between MCLNO and VA patients (mean 7.7 vs. 7.3%, P < 0.001) and increased significantly among MCLNO patients to 8.3% ( P < 0.001) but not among VA and TUHC patients. Mean systolic blood pressure increased in all three systems (130–137.6 mmHg for TUHC and 130.7–143.7 for VA, P < 0.001; 132–136 for MCLNO, P = 0.008). Mean LDL cholesterol increased in the VA (97.1–104.3 mg/dl) and TUHC patients (103.4–115.5; P < 0.001). Hurricane Katrina increased modeled direct, indirect, and total health care costs and also reduced life expectancy as well as quality-adjusted life expectancy, with the economic impact being quite substantial because of the large population size affected. We estimate a lifetime cost of USD $504 million for the adult population affected, with the largest economic impact seen among MCLNO patients.

          CONCLUSIONS

          A major disaster had a significant effect on diabetes management and exacerbated existing disparities. These effects may have a lasting impact on both health and economic implications.

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          Most cited references23

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          UKPDS 60: risk of stroke in type 2 diabetes estimated by the UK Prospective Diabetes Study risk engine.

          People with type 2 diabetes are at elevated risk of stroke compared with those without diabetes. Relative risks have been examined in earlier work, but there is no readily available method for predicting the absolute risk of stroke in a diabetic individual. We developed mathematical models to estimate the risk of a first stroke using data from 4549 newly diagnosed type 2 diabetic patients enrolled in the UK Prospective Diabetes Study. During 30 700 person-years of follow-up, 188 first strokes (52 fatal) occurred. Model fitting was carried out by maximum likelihood estimation using the Newton-Raphson method. Diagnostic plots were used to compare survival probabilities calculated by the model with those calculated using nonparametric methods. Variables included in the final model were duration of diabetes, age, sex, smoking, systolic blood pressure, total cholesterol to high-density lipoprotein cholesterol ratio and presence of atrial fibrillation. Not included in the model were body mass index, hemoglobin A1c, ethnicity, and ex-smoking status. The use of the model is illustrated with a hypothetical study power calculation. This model forecasts the absolute risk of a first stroke in people with type 2 diabetes using variables readily available in routine clinical practice.
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            Disasters and the heart: a review of the effects of earthquake-induced stress on cardiovascular disease.

            There is growing evidence that stress contributes to cardiovascular disease. Chronic stress contributes to the atherosclerotic process through increased allostatic load, which is mediated by the neuroendocrine and immune systems (sympathetic nervous system and hypothalamus-pituitary adrenal axis) and related chronic risk factors (insulin resistance syndrome, hypertension, diabetes, and hyperlipidemia). In addition, acute stress can trigger cardiovascular events predominantly through sympathetic nervous activation and potentiation of acute risk factors (blood pressure increase, endothelial cell dysfunction, increased blood viscosity, and platelet and hemostatic activation). Earthquakes provide a good example of naturally occurring acute and chronic stress, and in this review we focus mainly on the effects of the Hanshin-Awaji earthquake on the cardiovascular system. The Hanshin-Awaji earthquake resulted in a 3-fold increase of myocardial infarctions in people living close to the epicenter, particularly in women, with most of the increase occurring in nighttime-onset events. There was also a near doubling in the frequency of strokes. These effects may be mediated by changes in hemostatic factors, as demonstrated by an increase of D-dimer, von Willebrand factor, and tissue-type plasminogen activator (tPA) antigen. Blood pressure also increased after the earthquake, and was prolonged for several weeks in patients with microalbuminuria.
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              Archimedes: a trial-validated model of diabetes.

              To build a mathematical model of the anatomy, pathophysiology, tests, treatments, and outcomes pertaining to diabetes that could be applied to a wide variety of clinical and administrative problems and that could be validated. We used an object-oriented approach, differential equations, and a construct we call "features." The level of detail and realism was determined by what clinicians considered important, by the need to distinguish clinically relevant variables, and by the level of detail used in the conduct of clinical trials. The model includes the pertinent organ systems, more than 50 continuously interacting biological variables, and the major symptoms, tests, treatments, and outcomes. The level of detail corresponds to that found in general medical textbooks, patient charts, clinical practice guidelines, and designs of clinical trials. The model is continuous in time and represents biological variables continuously. As demonstrated in a companion article, the equations can simulate a variety of clinical trials and reproduce their results with good accuracy. It is possible to build a mathematical model that replicates the pathophysiology of diabetes at a high level of biological and clinical detail and that can be tested by simulating clinical trials.
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                Author and article information

                Journal
                Diabetes Care
                diacare
                dcare
                Diabetes Care
                Diabetes Care
                American Diabetes Association
                0149-5992
                1935-5548
                September 2009
                19 June 2009
                : 32
                : 9
                : 1632-1638
                Affiliations
                [1] 1Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana;
                [2] 2Southeastern Louisiana Veterans Healthcare System, New Orleans, Louisiana;
                [3] 3Department of Biostatistics, Tulane University School of Public Health, Tulane University, New Orleans, Louisiana;
                [4] 4Department of Epidemiology, Tulane University School of Public Health, Tulane University, New Orleans, Louisiana;
                [5] 5Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California;
                [6] 6Department of Health Systems Management, Tulane University School of Public Health, Tulane University, New Orleans, Louisiana.
                Author notes
                Corresponding author: Vivian Fonseca, vfonseca@ 123456tulane.edu .
                Article
                0670
                10.2337/dc09-0670
                2732170
                19542210
                f5164349-9734-4638-9839-2b8edc67b73a
                © 2009 by the American Diabetes Association.

                Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

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                Categories
                Original Research
                Epidemiology/Health Services Research

                Endocrinology & Diabetes
                Endocrinology & Diabetes

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