Diabetes and Associated Risk Factors
in Patients Referred for Physical
Therapy in a National Primary Care
Electronic Medical Record Database
Carmen S Kirkness, Robin L Marcus, Paul C LaStayo, Carl V Asche, Julie M Fritz
Objective.
The prevalence of diabetes (type 2) in the general population has increased dramatically over the last decade, yet patients with diabetes are rarely referred for physical therapy management of their condition. The majority of patients referred for outpatient physical therapy have musculoskeletal-related conditions. Secondary conditions, such as diabetes, may be prevalent in this population, and physical therapists need to be aware of this to adjust interventions and treatment. The purpose of this article is to describe the prevalence of diabetes and the associated risk factors in adults referred for physical therapy in a primary care outpatient setting.Subjects and Methods.
Patients aged 18 years or older referred for physical therapy were identified from the Centricity Electronic Medical Records database during the period of December 13, 1995, to June 30, 2007. Patients were evaluated on the basis of clinical (height, weight, blood pressure, laboratory values), treatment (prescriptions), and diagnostic (ICD-9 codes) criteria to identify the presence of diabetes or associated risk factors (eg, hypertension, elevated triglycerides, low high-density lipoprotein, body mass index, and prediabetes).Results.
There were 52,667 patients referred for physical therapy, the majority of whom were referred for a musculoskeletal-related condition. Approximately 80% of the total study population had diabetes, prediabetes, or risk factors associated with diabetes. The prevalence of diabetes in the study population was 13.2%. Of the diabetes-associated risk factors evaluated, hypertension was the most prevalent (70.4%), and less than half (39.1%) of the study population had an elevated body mass index. Only 20% of the study population had values within normal limits for all clinical, treatment, and diagnostic criteria. Clinical and treatment measurements available to physical therapists identified the majority of associated risk factors.Conclusions.
Although not the primary indications for referral, diabetes and associated risk factors were identified in a high proportion of the study population. The evaluation of associated conditions in the outpatient orthopedic setting needs to be considered for treatment planning adjustments and to optimize care.CS Kirkness, PT, MSc, is Research Associate, Pharmacotherapy Out-comes Research Center, Depart-ment of Pharmacotherapy, Uni-versity of Utah College of Pharmacy, 421 Wakara Way, Suite 208, Salt Lake City, UT 84108 (USA). Address all correspondence to Ms Kirkness at: carmen. [email protected]. RL Marcus, PT, PhD, is Associate Professor, Department of Physical Therapy and Department of Exer-cise and Sport Science, University of Utah.
PC LaStayo, PT, PhD, CHT, is As-sociate Professor, Department of Physical Therapy, Department of Exercise and Sport Science, and Department of Orthopedics, Uni-versity of Utah.
CV Asche, PhD, MBA, is Research Associate Professor, Pharmaco-therapy Outcomes Research Cen-ter, Department of Pharmacother-apy, University of Utah College of Pharmacy.
JM Fritz, PT, PhD, ATC, is Associate Professor, Division of Physical Therapy, University of Utah, and Clinical Outcomes Research Scien-tist, Intermountain Healthcare, Salt Lake City, Utah.
[Kirkness CS, Marcus RL, LaStayo PC, et al. Diabetes and associated risk factors in patients referred for physical therapy in a national pri-mary care electronic medical record database.Phys Ther. 2008; 88:1408 –1416.]
© 2008 American Physical Therapy Association
Diabetes
Special Issue
Post a Rapid Response or find The Bottom Line:
D
iabetes mellitus is a chronic disease in which the body does not regulate blood glu-cose concentrations properly.1 Dia-betes is the sixth leading cause of death in the United States due to complications such as high blood pressure, blindness, kidney disease, nervous system disease, and amputa-tions or to comorbidities associated with diabetes such as heart disease and stroke.1 Approximately 24 mil-lion people (7.8% of the population) in the United States have diabetes, 5.7 million of whom are undiag-nosed.1Ninety to 95 percent of all cases of diabetes fall into the cate-gory of type 2 diabetes, character-ized by insulin resistance and even-tual insulin deficiency. The growth in the incidence and prevalence of diabetes is alarming, as the number of diagnosed cases of diabetes in the United States increased by a factor of 1.4 between 1990 and 1999, with a prevalence of 4.9% to 6.9% of the population.2,3 The prevalence of di-abetes (type 2) in the general popu-lation also has increased dramatically over the last decade, yet patients with diabetes are rarely referred for physical therapy management of their condition.4 – 6 Compounding this apparent epidemic is the fact that 57 million people (25.9%) aged 20 years or older in the United States are prediabetic (ie, blood glucose levels being higher than normal but not yet high enough to be classified as having diabetes).1The increase in diabetes is largely attributed to weight gain.7,8Obesity, measured by body mass index (BMI), increased 74% between 1991 and 2003.9During the same time frame, diabetes increased 61%, reflecting the strong association between obe-sity and the development of diabe-tes.9Obesity, particularly abdominal obesity, is a major risk factor not only for diabetes but also for cardio-vascular disease (CVD) (heart attack and stroke). For additional
informa-tion on fat and CVD, see the articles by Stehno-Bittel10and Cade11in this issue. All cardiovascular risk factors (except smoking) are more preva-lent in patients with diabetes, and an elevated risk for CVD often exists in people who are prediabetic.12 Asso-ciated risk factors related to diabetes, prediabetes, and CVD are over-weight and obesity, elevated systolic and diastolic blood pressure, and dyslipidemia (high blood cholesterol and triglycerides).13 People with multiple risk factors are most likely to develop diabetes and CVD.14 These risk factors also are associated with greater deficits in health-related quality of life.15
The management principles of diabe-tes target not only abnormally high glucose levels but also elevated blood pressure and cholesterol lev-els.16 Diet, exercise, and pharmaco-therapy are suggested ways to man-age diabetes.16 –18 The Standards of Medical Care in Diabetes (2008) rec-ommends physical activity for the prevention and management of dia-betes and its related comorbidities.19 Observational and clinical trial data suggest that as little as 30 minutes per day of moderate-intensity physi-cal activity can reduce the incidence of diabetes and cardiovascular events.20,21 It is recommended that health care providers encourage and counsel their patients about physical activity because of the strong medi-cal evidence identifying exercise as being beneficial.16,19,22Presently, the role of the physical therapist in man-aging diabetes and prediabetes should include exercise testing for cardiovascular risk assessment and monitoring of glycemic (blood glu-cose) and nonglycemic (blood pres-sure, BMI, skin condition, balance testing) variables during exercise and other interventions.23
The American Physical Therapy As-sociation’s Vision Statement for Physical Therapy 2020 suggests
con-sumers will have direct access to physical therapists in all environ-ments (ie, patient/client manage-ment, prevention and wellness ser-vices).24 The increasing numbers of individuals with diabetes and predi-abetes, coupled with the compound-ing associated cardiovascular risk factors, highlight the importance of identifying patients with these con-ditions in outpatient physical ther-apy settings. Improved recognition could positively affect outcomes, particularly for patients with condi-tions known to be adversely affected by diabetes (eg, peripheral neuropa-thy, frozen shoulder, ankle fractures, stroke, myocardial infarction), and expose an opportunity for physical therapists to improve the overall health of patients through exercise advice and education regardless of the primary reason for the physical therapy referral. Currently, the fre-quency of physical therapists’ con-tact with people who have diabetes, prediabetes, or associated risk fac-tors in outpatient physical therapy settings is unknown.
The purpose of this article is to de-scribe the prevalence of those adults with diabetes and those with associ-ated risk factors who are referred for physical therapy in a primary care outpatient setting. From this, sugges-tions for identifying and managing patients or clients in a physical ther-apy environment will be discussed.
Method
Database Description
This study used a cohort design uti-lizing data from December 13, 1995, to June 30, 2007. The data used for this study were extracted from the Centricity electronic medical record (EMR) research database.* The Cen-tricity EMR database is used by more than 20,000 clinicians and contains longitudinal ambulatory electronic * GE Healthcare Institute, N16 W22419 Water-town Rd, Waukesha, WI 53186.
health data for more than 7.4 million patients, including, but not limited to, demographic data, vital signs, lab-oratory orders and results, medica-tion list entries and prescripmedica-tions, and diagnoses or problems. A variety of practice types are represented in the database, ranging from solo pri-mary care practitioners to commu-nity clinics, academic medical cen-ters, and large integrated delivery networks. Approximately two thirds of the participating clinicians prac-tice in primary care settings. Each practice downloads blinded clinical data into a central repository. A data expert team at Centricity EMR then cleans and standardizes the data. Cleaning of data requires fixing data problems that obviously are incor-rect (eg, BMI⬎500). Once this pro-cess is complete, the data are moved into a reporting data set that is avail-able for use for primary care re-search and quality of care projects. Because data are entered into the database daily, the most current data are available for research.16 This EMR database allows for the incorpo-ration of clinical data, such as chief complaint data, comprehensive lab-oratory values, and vital signs. Thus, an EMR allows the use of combina-tions of these parameters to identify patients, which can be valuable in maximizing the identification of pa-tients. Such data also enable research into treatment outcomes based on clinical parameters such as vital signs and laboratory values.
Inclusion/Exclusion Criteria
The patient population for this anal-ysis included all adult patientsⱖ18 years of age who were referred for physical therapy. Referral for physi-cal therapy was defined by having a Current Procedural Terminology (CPT) code for physical therapy
(4018F, 20970, 21310, 28890,
62367-62368, 77520-77525, 90810-90815, 90823-90829, 90847, 90857, 92506, 98925-98929, 99509), or if the term “physical therapy” was
used within the clinic notes, and hav-ing a relevant physical therapy ICD-9 code4 – 6,25 (ie, Endocrine and meta-bolic disease [250], Central nervous system [331–335, 337, 340 –344, 348], Peripheral nervous system [350, 352–353, 356 –357, 359], Oral cavity jaw [524], Genitourinary [618], Musculoskeletal [710 –759], Congenital [741, 755–756], Signs and symptoms [780 –778, 791], In-jury [805– 848, 885– 897, 905, 922– 928, 959], or Factors affecting health status [v43.6x, v49.6-v49.7] within a 6-month time frame (3 months be-fore or after the date of referral/ clinic note). Patients also had to have at least one documented activity date prior to the date of referral for phys-ical therapy to ensure that they were active in the database at least 395 days prior to the referral/clinical note date. Application of these crite-ria resulted in the identification of 52,667 patients from the initial pop-ulation of 7,935,736. The patients identified from the database during these calendar years then were de-scribed based on having diabetes or the presence of risk factors for dia-betes (elevated blood glucose level, abdominal obesity [BMI], low high-density lipoprotein [HDL] choles-terol, elevated tricglycerides, hyper-tension). Patients were indicated by an encrypted ID number and had no traceable personal health informa-tion within the database.
Identification of Diabetes and Associated Risk Factors
Determination of the presence of di-abetes or associated risk factors was completed using 3 different identifi-cation criteria (clinical, diagnostic, and treatment) available within the EMR database.
Clinical criteria. Patients were cat-egorized clinically for diabetes and each of the following risk factors: impaired fasting glucose, elevated BMI, low HDL cholesterol, elevated triglycerides, and high blood
pres-sure (Tab. 1). The selected risk fac-tors correlate with the American Di-abetes Association (ADA) risk factor assessment that predicts the risk of developing diabetes and are measur-able in the EMR (ie, excluding family history, history of gestational diabe-tes, and habitual physical activity).26 The clinical criteria identifying dia-betes and associated risk factors were derived from clinical practice guidelines established by the ADA27 and from the third report of the Ex-pert Panel on Detection, Evaluation, and Treatment of High Blood Choles-terol in Adults (Adult Treatment Panel, or ATP III 2001).28 Modifica-tion to the clinical practice guide-lines was made to 1 of the 5 criteria: waist circumference. Because mea-surements of waist circumference are rarely available in clinical data, BMI was used as a proxy measure and was calculated from the pa-tients’ height and weight measure-ments. Some studies29 –31 have shown that BMI and waist circumfer-ence are highly correlated and that each factor independently contrib-utes a significant risk for diabetes. Clinical criteria for identifying diabe-tes and associated risk factors in-cluded clinical components that are available to physical therapists in clinical practice such as blood pres-sure, height, and weight. Additional clinical criteria such as laboratory test values may or may not be avail-able to physical therapists on a rou-tine basis but are useful for identify-ing risk factors.
Diagnostic criteria. Diagnostic criteria for identification of diabetes and associated risk factors were based on the ICD-9 classification codes usually ascribed to a patient for these conditions after the clinic visit. This information is becoming increasingly accessible to physical therapists with the advent of EMR in clinical practice. Patients catego-rized using the diagnostic criteria were identified with any one of the
following codes: ICD-9-CM 278.0 (Central or abdominal obesity), ICD-9-CM 272.1 (Hyperglyceridemia), ICD-9-CM 401.x (Hypertension), and
ICD-9-CM 250.x0 or ICD-9-CM
250.x2 (Diabetes).
Treatment criteria. The treat-ment criteria for diabetes and associ-ated risk factors were defined as pre-scriptions recorded for the patient that would indicate treatment of di-abetes or an associated risk factor. This information could be obtained by physical therapists from a pa-tient’s medical history. Patients iden-tified using treatment criteria were those with a prescription for any one of the following drugs or drug class-es: (1) weight-loss agents (sibutra-mine hydrochloride, orlistat), (2) triglyceride-lowering agents (fi-brates, niacin), (3) antihypertensives (angiotensin converting enzyme in-hibitors, angiotensin receptor block-ers, calcium channel blockblock-ers,
beta-blockers, thiazide diuretics,
antihypertensive vasodilators, and
combinations of these agents), and (4) drugs used for diabetes (sulfonyl-ureas, metformin, thiazolidinedio-nes, meglitinides, alpha-glucosidase inhibitors, and combinations of these agents).
Analysis
Descriptive analysis was conducted to describe the study population characteristics by demographic fac-tors, geographic location, insurance status, condition prompting referral for physical therapy, and presence of diabetes or associated risk factors. The prevalence of diabetes was es-tablished as a percentage of patients with a clinical, treatment, or diagnos-tic indication for diabetes over all patients in this sample.
Using the 3 types of identification criteria (clinical, treatment, and diag-nostic), the frequency of patients with diabetes and patients with asso-ciated risk factors was described in 2 ways: (1) the frequency for each cri-terion was individually evaluated to
ascertain which method identified patients most commonly and (2) an overall evaluation, where the patient had to have only 1 of the 3 criteria out of normal range to be classified as being diabetic or as having an as-sociated risk factor.
Results
The demographics of the study pop-ulation are shown in Table 2. A total of 52,667 patients with a mean age of 52.0 years (SD⫽16.2) were iden-tified as being referred for physical therapy. Sixty-five percent of the sample was female. Of the condi-tions identified as the primary reason for physical therapy referral, the ma-jority were musculoskeletal condi-tions (76.9%), followed by referrals for an injury (16.9%); only 2.2% of the patients were referred with dia-betes as the apparent primary indica-tion. Only 19.2% (10,124/52,667) of the total sample had fasting glucose, BMI, triglyceride, low HDL, and blood pressure values within normal ranges. Patients with values within
Table 1.
Definitions of Criteria Indicating the Presence of the Conditiona Condition Clinical Criteria
Diagnostic Criteria
(ICD-9 Code)25 Treatment Criteria
Diabetes FPGⱖ126 mg/dL27 250.x0 or 250.x2 Sulfonylureas
Metformin TZDs Meglitinides
Alpha glucosidase inhibitors Fixed-dose combinations Risk factor
IFG FPG 100–125 mg/dL27 N/A N/A
Elevated BMI ⬎25 kg/m2 5,27,28 278.0 Sibutramine hydrochloride
Orlistat Elevated TG ⱖ150 mg/dL27,28 272.1 Fibrates Low HDL ⬍40 mg/dL (men) or ⬍50 mg/dl (women)27,28 N/A Niacin Hypertension Systolic BPⱖ130 mm Hg or diastolic BPⱖ85 mm Hg27,28 401.x ACE inhibitors ARBs CCBs Beta-blockers TZDs Antihypertensive vasodilators
Combinations of antihypertensive agents aFPG⫽fasting plasma glucose, IFG⫽impaired fasting glucose, BMI⫽body mass index, TG⫽trigycerides, HDL⫽high-density lipoprotein, BP⫽blood pressure, ACE⫽angiotensin converting enzyme, ARB⫽angiotensin receptor blockers, CCB⫽calcium channel blockers, TZD⫽thiazide diuretics, N/A⫽not available.
normal ranges were significantly younger than patients with values outside normal ranges (average age, 40.9 years [SD⫽14.0] versus 54.6 years [SD⫽15.6]; P⬍.001), with a higher proportion of female patients (74.0% versus 63.8%, respectively). Table 3 shows the proportion of the study population with risk factor val-ues that were beyond normal ranges. The prevalence of diabetes, identi-fied by a clinical, treatment, or diag-nostic indication for diabetes, was 13.2% in this study population. A high proportion (9.9%) of the study population was considered predia-betic, that is, having blood glucose levels that were elevated but not high enough to be considered dia-betic. More than three quarters (80.8%) of the study population had one or more associated risk factors for developing diabetes: elevated blood pressure (70.4%), overweight or obese (39.1%), elevated levels of low HDL (20.0%), or elevated triglyc-erides (16%). Of those with diabetes, 51.5% (3,575/6,944) had a normal BMI.
Diabetes and associated risk factors are identified by clinical, treatment, and diagnostic criteria in Table 3. As expected, the clinically based crite-ria captured more patients at risk than either the treatment or diagnos-tic criteria. Only 4 risk factors (BMI, triglycerides, blood pressure, and di-abetes) had values within the data-base that allowed all 3 criteria to be identified. There was a 5% to 8% de-crease in the proportion of patients with diabetes identified when clini-cal (7.1%), treatment (8.7%), and di-agnostic (4.9%) criteria were used independently. Of the patients with diabetes, 65.8% (4,569/6,944) were classified by treatment and 53.9% were classified by clinical criteria. In contrast, more than 65% of the pa-tients with high blood pressure were identified clinically, while the treat-ment and diagnostic criteria
identi-Table 2.
Population Demographics (N⫽52,667) Variable
No. of
Patients %
Age (y): mean⫽52.0, SD⫽16.2 Sex Female 34,628 65.7 Male 18,039 34.3 Race/ethnicity Black 1,357 2.6 Hispanic 1,771 3.4 Native American 32 0.1 Oriental/Asian 520 1.0 Other 880 1.7 Undetermined 21,352 40.5 Unknown 5,653 10.7 White 21,102 40.1 Region Midwest 3,979 7.6 Northeast 37,153 70.5 South 4,810 9.1 West 6,725 12.8 Payment type Insurance, commercial 26,949 51.2 Medicare 8,017 15.2 Medicaid 715 1.4 Self-pay 687 1.3 Unknown 16,299 30.9 Condition at referrala
Endocrine and metabolic disease (250) 1,171 2.2 Central nervous system (331–335, 337, 340–344, 348) 377 0.7 Peripheral nervous system (350, 352–353, 356–357, 359) 1,254 2.4 Oral cavity jaw (524) 92 0.2 Genitourinary (618) 37 0.1 Musculoskeletal (710–759) 40,485 76.9 Congenital (741, 755–756) 45 0.1 Signs and symptoms (780–787, 791) 2,593 4.9 Injury (805–848, 885–897, 905, 922–928, 959) 8,623 16.4 Factors affecting health status (v43.6x, v49.6-v49.7) 126 0.2 No risk factors (mean age⫽40.9 years, SD⫽14.0) 10,124 19.2
Female 7,495 74
fied only 32.4% and 7.4% of the pa-tients with high blood pressure, respectively. Of the patients with high blood pressure, 95.6% (35,582/ 37,098) were classified by clinical criteria and 46.1% were classified by treatment criteria.
Discussion
This article examines the prevalence of diabetes and risk factors associ-ated with diabetes in a population of adults referred for outpatient physi-cal therapy care. Using a large na-tional EMR database, we were able to capture a geographically diverse co-hort of patients representative of conditions that are typically seen in outpatient physical therapist prac-tice. Using clinical, treatment, and diagnostic parameters permitted the identification of patients with diabe-tes or risk factors associated with di-abetes in this setting.
As expected, diabetes was rarely the primary condition for which patients were referred for physical therapy, yet a significant proportion (80%) of the study population had diabetes, prediabetes, or risk factors associ-ated with diabetes. The prevalence of diabetes in the study population was 13.2%. In comparison, the only nationally representative survey, the National Health and Nutrition Exam-ination Survey (NHANES), which ex-amined diabetes in adults agedⱖ20
years in the United States, found the unadjusted prevalence to be 9.3% (1999 –2002).32 The difference in prevalence could indicate that peo-ple seeking care from a primary care physician are different from the gen-eral US population and thus that those who are being referred for physical therapy have more health problems. Diabetes prevalence in-creases with age; people with diabe-tes aged 60 years or older are 2 to 3 times more likely to report an inabil-ity to walk 0.4 km (0.25 mile), climb stairs, do housework, or use a mobil-ity aid compared with people with-out diabetes in the same age group.1 Although the severity of diabetes and the patients’ health status were not objectives of this study, the propor-tion of those referred for physical therapy with diabetes alone warrants further investigation into the health of those who attend physical ther-apy. For an additional perspective on this point, see the article by Cohn33 in this issue.
Excess body weight often is seen in patients with diabetes. The propor-tion of our study populapropor-tion who were obese or overweight (40.0%) was lower than for the US adult pop-ulation (65.7%) (NHANES 1999 – 2002).32One reason for this discrep-ancy may be that our study popula-tion comprised patients who were generally young and healthy, with
the majority being referred for phys-ical therapy for musculoskeletal-related problems; 20% had no diabe-tes or associated risk factors. Body mass index is an independent predic-tor of the risk for developing diabe-tes.34In our study population, half of those patients with diabetes had a BMI within the normal range. This finding could indicate that the distri-bution of body mass may be influenc-ing the BMI in this population. Ab-dominal adiposity has been shown to increase the risk for diabetes.34 Al-though waist circumference mea-surements were not available in the EMR database, waist circumference measurements have been shown to independently predict diabetes.35 This may indicate that, in the physi-cal therapy clinic, using BMI alone to identify individuals with diabetes would greatly underestimate those with diabetes.
Although being overweight or obese is an important health issue, other risk factors that contribute to the de-velopment of diabetes seem more prevalent.36 –38 It is estimated that 60% of people with diabetes have hypertension.39 Our data suggest that elevated blood pressure may be an important indicator of patients with diabetes who are referred for physical therapy, as 95.8% of those patients with diabetes were hyper-tensive. Because of the elevated risk
Table 3.
Diabetes and Associated Risk Factors of Study Population by Clinical, Treatment, and Diagnostic Criteria (N⫽52,667)a
Condition
Total Study Population Clinical Criteria Treatment Criteria Diagnostic Criteria
n % n % n % n %
Diabetes 6,944 13.2 3,742 7.1 4,569 8.7 2,555 4.9 Risk factors
Impaired fasting glucose 5,227 9.9 5,227 9.9 N/A N/A
Elevated body mass index 20,608 39.1 19,669 37.3 283 0.5 1,372 2.6 Elevated triglycerides 8,374 15.9 7,716 14.7 1,237 2.3 277 0.5 Low high-density lipoprotein 10,513 20.0 10,349 19.6 402 0.8 N/A
High blood pressure 37,098 70.4 35,582 67.6 17,087 32.4 3,878 7.4 aN/A⫽measures of treatment and diagnosis not available.
of CVD for patients with diabetes, the high prevalence of high blood pressure in this population is a con-cern. The low documentation of hy-pertension treatment in the EMR also is of concern, as this may underrep-resent the risk if identifying hyper-tension by medication alone. We suggest that physical therapists use a detailed systems review in an at-tempt to identify the multiple diabe-tes risk factors, specifically, elevated blood glucose and hypertension. A significant proportion of the popula-tion referred for outpatient physical therapy has risk factors that affect cardiovascular health overall, of which diabetes is a major contribu-tor. Consequently, physical therapy interventions should be adjusted to accommodate these risk factors and designed to mitigate the adverse se-quelae associated with diabetes. Such adjustments may include im-proving the overall health of patients through exercise advice and educa-tion, regardless of the primary rea-son for the physical therapy referral. When prescribing any aerobic or re-sistance exercise component into a comprehensive rehabilitation pro-gram, emphasis should be placed on a safe and efficacious progression of the exercise prescription.18 This should involve monitoring associ-ated risk factors in people with dia-betes or at risk for developing diabe-tes during all exercise regimens, educating the patients about second-ary prevention, and addressing bal-ance, strength (force-generating
ca-pacity), and fall prevention
strategies.23
A thorough examination enables the physical therapist to monitor the sec-ondary conditions seen in patients in an outpatient clinic. In addition to the systems review and other tests and measures, the patient’s medical history (past and present and associ-ated medications) completed by the physical therapist can reveal
infor-mation similar to that found in the clinical criteria captured in the EMR database. The EMR clinical criterion of blood glucose used to identify people with diabetes is a measure-ment not typically available to the physical therapist in outpatient prac-tice. The treatment criteria, a good estimate of the prevalence, identified
diabetes in the EMR database
through the medications prescribed. Although not a physical therapy treatment criterion, patient medica-tion use is recorded in the initial ex-amination by a physical therapist. Other clinical values routinely avail-able to the physical therapist to eval-uate diabetes and associated risk fac-tors are blood pressure, age, BMI, and being a member of a high-risk population (African Americans, His-panic/Latino Americans, American Indians, and some Asian Americans and Pacific Islanders).40,41 Our data suggest that although the physical therapist examination (the process of obtaining a history, performing a systems review, and selecting and administering tests and measures)23 provides a wealth of information that may suggest the occurrence of dia-betes or risk factors associated with the development of diabetes, these measures may still underestimate the number of physical therapy outpa-tients with diabetes or associated risk factors. Coupled with the large number of individuals who are un-aware that they are at risk for devel-oping diabetes, physical therapists should expect this underestimation and take it into consideration when planning and implementing physical therapy interventions.
The critical role of the physical ther-apist in recognizing chronic condi-tions such as diabetes, especially considering that it often is not the primary therapy indication, is under-scored by the data in this study. This is especially true in light of a growing aging and overweight population. Awareness of diabetes in the
outpa-tient setting is important, as having diabetes may affect both the plan-ning and implementation of treat-ment, as well as patient-related out-comes. Older people with diabetes demonstrate accelerated loss of skel-etal muscle mass and strength38and have considerable functional impair-ment associated with reduced health status.42Diabetes is a known risk fac-tor for frozen shoulder43 and hip fracture,44,45 and ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to practicing clinicians due to wound complications, soft tissue damage, and prolonged immobiliza-tion.46It is likely that diabetes influ-ences a broad spectrum of physical therapy interventions.
The population is aging, obesity rates are rising, lifestyles are increas-ingly sedentary, and a large propor-tion of the US populapropor-tion comes from ethnic backgrounds at higher risk for the development of diabetes. The Diabetes Prevention Program, a 3-year clinical trial, established that modest weight loss and regular exer-cise can prevent or delay type 2 dia-betes.47 Physical therapists can play a key role in facilitating physical ac-tivity.21,33 This management princi-ple alone could play a large role in risk reduction for diabetes. Recom-mendations for this population in-clude exercising moderately for 150 minutes per week with moderate-intensity aerobic physical activity and in the absence of contraindica-tions; resistance training should be encouraged 3 times per week.48
Limitations
The database used in this study orig-inates from the primary care pro-vider office; therefore, related health care data from certain specialists or hospital care would only be cap-tured if reported back to the primary care physician. In addition, these data are only as reliable as the docu-mentation in the patient record.
Medical records in any format often are incomplete. Thus, there exists the possibility that some diagnoses, pre-scription orders, or other miscella-neous interventions (eg, laboratory tests) may not have been documented in the EMR database. These data would not have been included in the research database, which may have in-fluenced the results of this study. The majority of the EMR data are sup-plied by primary care physicians, re-flecting how diabetes care is delivered in the United States. For example, fast-ing blood glucose tests would be com-pleted for those patients identified by the primary care physician as being at risk. Clinical practice guidelines do not suggest fasting blood glucose tests for screening purposes. Therefore, the data are dependent on the practice patterns of the primary physicians. Due to the high reported prevalence of undiagnosed diabetes,32the propor-tion of patients with diabetes or pre-diabetes could be higher. Although an observational study such as this re-flects real-world treatment, it lacks the control of a randomized clinical trial. Thus, we believe these values under-estimate the prevalence of diabetes and associated risk factors.
The patients identified for this study were those referred for physical therapy. There is no way of knowing how many of the patients who were referred for physical therapy actually attended a physical therapy appoint-ment. We propose that those being referred for physical therapy were of poorer health than the general pop-ulation due to the prevalence of dia-betes found. Diadia-betes severity, level of blood glucose control, and pro-gression of disease were not evalu-ated in this study. The prevalence of diabetes in patients who attend a clinical visit may be different from that of all patients referred for phys-ical therapy. It is possible that pa-tients with diabetes do not seek physical therapy even though they
may be referred. Further research to understand the prevalence of diabe-tes in the physical therapy clinic and possible correlations with the mus-culoskeletal conditions of interest is a necessary next step. Lastly, there is an underrepresentation of the popu-lation at high risk for diabetes in this sample; therefore, the prevalence of diabetes may be higher than the re-sults indicate.
Conclusions
A high proportion of people referred for physical therapy have diabetes, and an even larger number of individ-uals have one or more risk factors as-sociated with diabetes. The evaluation of associated conditions in this popu-lation should be considered when de-signing management approaches and a plan of care. Physical therapists have an opportunity to play a critical role in the management of patients with a pri-mary condition (eg, musculoskeletal disorder) and to affect a secondary condition (eg, diagnosis of diabetes). Future research is necessary to realize the impact that physical therapists can have in preventing the progression of patients with risk factors for diabetes to the development of this disease.
All authors provided concept/idea/research design, writing, and consultation (including review of manuscript before submission). Dr LaStayo and Dr Asche provided data collec-tion. Ms Kirkness and Dr Marcus provided data analysis. Ms Kirkness provided project management and facilities/equipment. Exempt approval for this study was given by the University of Utah Institutional Review Board.
This was a nonfunded study.
This article was received April 30, 2008, and was accepted August 4, 2008.
DOI: 10.2522/ptj.20080129
References
1Centers for Disease Control and Preven-tion. National diabetes fact sheet: general information and national estimates on dia-betes in the United States, 2007. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ ndfs_2007.pdf. Accessed July 18, 2008.
2Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the US: 1990 –1998. Di-abetes Care.2000;23:1278 –1283.
3Mokdad AH, Ford ES, Bowman BA, et al. The continuing increase of diabetes in the US.Diabetes Care.2001;24:412.
4Forrest C, Nutting P, Starfield B. Family physician referral patterns. J Fam Pract.
2002;51:215–222.
5Freburger J, Holmes G, Carey T. Physician referrals to physical therapy for the treat-ment of musculoskeletal conditions.Arch Phys Med.2003;84:1839 –1849.
6Jette AM, Davis K. A comparison of hospital-based and private outpatient physical therapy practices. Phys Ther.
1991;71:366 –381.
7Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of US adults.Am J Epidemiol.1997;146:214 –222.
8Koh-Banerjee P, Wang Y, Hu F, et al. Changes in body weight and body fat dis-tribution as risk factors for clinical diabe-tes in US men. Am J Epidemiol. 2004; 159:1150 –1159.
9Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001.
JAMA.2003;289:76 –79.
10Stehno-Bittel L. Intricacies of fat. Phys Ther. 2008;88:1265–1278.
11Cade WT. Diabetes-related microvascular and macrovascular diseases in the physical therapy setting. Phys Ther. 2008;88: 1322–1335.
12Hu FB, Stampfer MJ, Haffner SM, et al. El-evated risk of cardiovascular disease prior to clinical diagnosis of type 2 diabetes.
Diabetes Care.2002;25:1129 –1134.
13Eckel R, Kahn R, Robertson R, Rizza R. Preventing cardiovascular disease and dia-betes: a call to action from the American Diabetes Association and the American Heart Association. Diabetes Care. 2006; 29:1697–1699.
14Yusuf HR, Giles WH, Croft JB, et al. Impact of multiple risk factor profiles on deter-mining cardiovascular disease risk. Prev Med.1998;27:1–9.
15Li C, Ford ES, Mokdad AH, et al. Clustering of cardiovascular disease risk factors and health-related quality of life among US adults. Value Health. 2008 Jan 8 [Epub ahead of print].
16Clark JMJ, Sterrett JJ, Carson DS. Diabetes guidelines: a summary and comparison of the recommendations of the American Di-abetes Association, Veterans Health Ad-ministration, and American Association of Clinical Endocrinologists. Clin Ther.
2000;22:899 –910.
17Turcotte LP, Fisher JS. Skeletal muscle in-sulin resistance: roles of fatty acid metab-olism and exercise. Phys Ther.2008;88: 1279 –1296.
18Gulve EA. Exercise and glycemic control in diabetes: benefits, challenges, and ad-justments to pharmacotherapy.Phys Ther. 2008;88:1297–1321.
19Standards of Medical Care in Diabetes, 2008. Diabetes Care. 2008;31(suppl 1): S12–S54.
20Bassuk S, Manson J. Epidemiological evi-dence for the role of physical activity in reducing risk of type 2 diabetes and car-diovascular disease.J Appl Physiol2005; 99:1193–1204.
21Deshpande AD, Dodson EA, Gorman I, Brownson RC. Physical activity and diabe-tes: opportunities for prevention through policy.Phys Ther. 2008;88:1425–1435.
22Morrato EH, Hill JO, Wyatt HR, et al. Are health care professionals advising patients with diabetes or at risk for developing di-abetes to exercise more? Diabetes Care.
2006;29:543–548.
23Guide to Physical Therapist Practice. 2nd ed.Phys Ther.2001;81:9 –746.
24American Physical Therapy Association, (HOD 06 – 00 –24 –35). APTA Vision Sen-tence and Vision Statement for Physical Therapy 2020. Available at: www.apta. org/AM/Template.cfm?Section⫽About_ APTA&CONTENTID⫽19078&TEMPLATE⫽ /CM/ContentDisplay.cfm. Accessed April 24, 2008.
25Physician ICD-9-CM 2004: International Classification of Diseases, Clinical Modi-fication.9th spiral-bound ed. Chicago, IL: AMA Press; 2004.
26Am I at Risk for Type 2 Diabetes? Taking Steps to Lower Your Risk of Getting Dia-betes. In: National Diabetes Information Clearinghouse.Bethesda, MD: National In-stitute of Diabetes and Digestive and Kid-ney Diseases, National Institutes of Health, US Dept of Health and Human Services; December 2006. NIH Publication No. 07– 4805.
27American Diabetes Association. Position statement: standards of medical care in di-abetes.Diabetes Care.2005;28(suppl 1): S4 –S36.
28Expert Panel on Detections, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the third report of the National Cholesterol Educa-tion Program (NCEP) expert panel on de-tection, evaluation, and treatment of high blood cholesterol in adults (adult treat-ment panel III). JAMA. 2001;285: 2486 –2497.
29Dalton M, Cameron AJ, Zimmet PZ, et al. Waist circumference, waist-hip ratio, and body mass index and their correlation with cardiovascular disease risk factors in Australian adults.J Intern Med.2003;254: 555–563.
30Hans TS, Williams K, Sattar N, et al. Anal-ysis of obesity and hyperinsulinemia in the development of metabolic syndrome: San Antonio Heart Study. Obes Res. 2002; 10:923–931.
31Iwao S, Iwao N, Muller DC, et al. Does waist circumference add to the predictive power of the body mass index for coro-nary risk?Obes Res.2001;9:685– 695.
32Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and impaired fast-ing glucose in adults in the US population: National Health and Nutrition Examina-tion Survey 1999 –2002. Diabetes Care.
2006;29:1263–1268.
33Cohn R. Economic realities associated with diabetes care: opportunities to ex-pand delivery of physical therapist ser-vices to a vulnerable population. Phys Ther.2008;88:1417–1424.
34Wilson PWF, Meigs JB, Sullivan L, et al. Prediction of incident diabetes mellitus in middle-aged adults: the Framingham Off-spring Study.Arch Intern Med.2007;167: 1068 –1074.
35Janiszewski P, Janssen I, Ross R. Does waist circumference predict diabetes and cardiovascular disease beyond commonly evaluated cardiometabolic risk factors? Di-abetes Care.2007;30:3105–3109.
36Feskens EJ, Kromhout D. Cardiovascular risk factors and the 25-year incidence of diabetes mellitus in middle-aged men: the Zutphen Study. Am J Epidemiol. 1989; 130:1101–1108.
37Haffner SM, Stern MP, Hazuda HP, et al. Cardiovascular risk factors in confirmed prediabetic individuals: Does the clock for coronary heart disease start ticking before the onset of clinical diabetes? JAMA.
1990;263:2893–2898.
38Park SW, Goodpaster BH, Strotmeyer ES, et al. Accelerated loss of skeletal muscle strength in older adults with type 2 diabe-tes: the Health, Aging, and Body Compo-sition Study. Diabetes Care. 2007;30: 1507–1512.
39Hypertension in Diabetes Study Group (HDS 1). Prevalence of hypertension in newly presenting type 2 diabetic patients and the association with risk factors for cardio-vascular and diabetic complica-tions.J Hypertens.1993;11:309 –317.
40American Diabetes Association. Economic costs of diabetes in the US in 2007. Dia-betes Care.2008;31:596 – 615.
41Centers for Disease Control and Preven-tion. National diabetes fact sheet: general information and national estimates on dia-betes in the United States, 2005. Available at: http://www.cdc.gov/diabetes/pubs/ pdf/ndfs_2005.pdf.
42Sinclair AJ, Conroy SP, Bayer AJ. Impact of diabetes on physical function in older peo-ple.Diabetes Care.2008;31:233–235.
43Thomas SJ, McDougall C, Brown ID, et al. Prevalence of symptoms and signs of shoulder problems in people with diabe-tes mellitus. J Shoulder Elbow Surg.
2007;16:748 –751.
44Melton L, Leibson C, Achenbach S, et al. Fracture risk in type 2 diabetes: update of a population-based study. J Bone Miner Res.2008 Mar 18 [Epub ahead of print].
45Janghorbani M, Van Dam R, Willett W, Hu F. Systematic review of type 1 and type 2 diabetes mellitus and risk of fracture.Am J Epidemiol.2007;166:495–505.
46Chaudhary SB, Liporace FA, Gandhi A, et al. Complications of ankle fracture in patients with diabetes.J Am Acad Orthop Surg.2008;16:159 –170.
47Knowler W, Barrett-Connor E, Fowler S, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or met-formin.N Engl J Med.2002;346:393– 403.
48Sigal RJ, Kenny GP, Wasserman DH, et al. Physical activity/exercise and type 2 dia-betes: a consensus statement from the American Diabetes Association.Diabetes Care.2006;29:1433–1438.