DFWHC Foundation



50285656833870Dallas-Fort Worth Hospital Council FoundationSEPTEMBER2011Diabetes in Dallas CountyProvider ReportPam Doughty, Ph.D. and Jaylene Jones, B.S.Sponsored by Sanofi250 Decker Dr. Irving TX 75062Table of Contents Page NumberIntroduction3Diabetes Key Facts3Methodology4Results5 - Table 1: Diabetes Frequency w/in Top Conditions for Inpatients/Outpatients6 - Table 2: Comparisons Between Hospital Product Lines7 - Table 3: Top Five Diagnoses w/ Diabetes as Underlying Condition8 - Table 4: Zip Code Demographics10Discussion11Conclusion14References15Appendices16 - Appendix 1: Top Diagnoses and Percentage of Those with Diabetes by Product Line17 - Appendix 2: Map 1 - Dallas County Population by Zip Code and Diabetes Incidence20 - Appendix 2: Map 2 - Diabetes Frequency by Zip Code21 - Appendix 3: Map 1 - Available Food for Resources22 - Appendix 3: Map 2 - Diabetic Patient Resources23 - Appendix 3: Map 3 - Fast Food Availability24 - Appendix 4: Map 1 - Medical Resources25 - Appendix 5: Map 1 - Median Income by Zip Code26 - Appendix 5: Map 2 – Unemployment Rate by Zip Code27 - Appendix 6: Map 1 – Local Parks and Recreation Centers28 - Appendix 7: Map 1 - Average Length of Stay by Zip Code29 - Appendix 8: Map 1 – Patient Mortality Rate by Zip Code30 - Appendix 8: Map 2 – Percent of Patients Discharged to Other Facilities31INTRODUCTIONDiabetes is the seventh leading cause of death in the US.Direct Medical Costs = $116 BillionIndirect Medical Costs = $58 BillionDallas County Texas’ rate of diabetes is 11.4% while the rate in Texas is 9.6%Kidney FailureMore common in patients with diabetes – 45% of all kidney failure patients have diabetesChest Pain - 46% of ER patients who complain of chest pain are diabeticsPatients with Heart Failure 45%-59% of patients with CHF have diabetesComorbidity of Diabetes – 35% of the top five inpatient diagnosis have diabetes as an underlying conditionAverage Length of StayDiabetes as a primary diagnosis = 2.81 daysDiabetes as a secondary = 6.02 daysAll other diagnoses without diabetes as a comorbidity =4.48 daysDallas County Zip Code with the most negative environmental factors for diabetic patients is 75227Type two diabetes diagnoses in the United States have continued to increase, especially among states with high incidences of obesity. Examples of states with high prevalence of obesity are Texas, Kentucky, Louisiana, South Carolina and Tennessee with a rate of 31%. Mississippi has the highest rate of obesity with 34% of their population categorized as obese or morbidly obese. Other state populations are beginning to show increased rates of obesity with 30.9% in Michigan and 30.4% in Oklahoma and Missouri ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2011</Year><RecNum>365</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>365</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">365</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>U.S. Obesity Trends</title></titles><edition>July 21, 2011</edition><dates><year>2011</year><pub-dates><date>August 26, 2011</date></pub-dates></dates><publisher>Centers for Disease Control and Prevention</publisher><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>1. Diabetes has become the seventh leading cause of death and affects 25.8 million people in the United States ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2011</Year><RecNum>363</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>363</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">363</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>National diabetes fact sheet: 2011</title></titles><edition>2001</edition><dates><year>2011</year><pub-dates><date>July 22, 2011</date></pub-dates></dates><publisher>Centers for Disease Control and Prevention</publisher><urls><related-urls><url>. Patients with diabetes experience a reduction in quality of life and suffer complications, which include heart disease, stroke, high blood pressure, blindness, kidney disease, nervous system disease (neuropathy), and amputation ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2011</Year><RecNum>363</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>363</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">363</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>National diabetes fact sheet: 2011</title></titles><edition>2001</edition><dates><year>2011</year><pub-dates><date>July 22, 2011</date></pub-dates></dates><publisher>Centers for Disease Control and Prevention</publisher><urls><related-urls><url>. In 2010, the United States’ fiscal cost of diabetes was $116 billion for direct medical costs and $58 billion for indirect costs, such as disability, work loss and premature mortality ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2011</Year><RecNum>363</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>363</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">363</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>National diabetes fact sheet: 2011</title></titles><edition>2001</edition><dates><year>2011</year><pub-dates><date>July 22, 2011</date></pub-dates></dates><publisher>Centers for Disease Control and Prevention</publisher><urls><related-urls><url>. Diabetes affects 11.4% of the population in Dallas County, which is above both the state average of 10% and the national average of 8% ADDIN EN.CITE <EndNote><Cite><Author>TDSHS</Author><Year>2011</Year><RecNum>364</RecNum><DisplayText><style face="superscript">3</style></DisplayText><record><rec-number>364</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">364</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>TDSHS</author></authors></contributors><titles><title>Diabetes data: surveillance and evaluation</title></titles><edition>2011</edition><dates><year>2011</year><pub-dates><date>July 29,2011</date></pub-dates></dates><publisher>Texas Department of State Health Services</publisher><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>3. Dallas County is urban with a population of 2.4 million people in about 880 square miles (approximately 2,692 people per square mile). The median income is $46,044. The population is 53.5% white, 22.3% black with 38.3% of Hispanic Origin. The total number of people in Dallas County diagnosed with diabetes is 273,600 and of those 25,992 are of Hispanic origin. The question remains why this county has such a high frequency of diabetes and what factors possibly contribute to this elevated prevalence. Contributing factors to diabetes prevalence are obesity, lack of physical activity, family history and environmental resources, such as the availability of fresh fruits and vegetables, healthcare access and neighborhood parks/recreation center availability. This study focuses on the environmental factors that could influence the control of diabetes in Dallas County.METHODOLOGYThe DFWHC Foundation (“Foundation”) has a claims data warehouse, managed by the Information, Quality and Safety Center (IQSC), that receives claims data from 77 North Texas hospitals. The claim records are available from 2001 for inpatients and 2006 for outpatients. Fields within the claim record include a patient’s demographic data; payor type; up to 25 diagnosis codes; 25 procedure codes; severity of disease; total charges and charges for individual services and is risk adjusted. The Foundation developed the regional enterprise master patient index (REMPI), which allows the tracking of any patient over time, hospital, and payor. The REMPI has an algorithm that accurately matches 99% of all patient encounters. To date, there are 23 million patient encounters and over 7.3 million uniquely identified patients in the warehouse. Currently, 80% of new patient encounters are already patients in the claims data warehouse. In order to better understand the demographic and environmental influences on diabetic patients, the diabetes project applied the data received from the Foundation warehouse and geographically mapped these results. Blinded patient data from the IQSC was mapped using the residential zip codes for each patient in Dallas County ADDIN EN.CITE <EndNote><Cite><Author>Atlas</Author><Year>2011</Year><RecNum>366</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>366</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">366</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>Zip Atlas</author></authors></contributors><titles><title> Texas zip codes, map and detailed profile</title></titles><volume>Zip Atlas. (2011). Texas zip codes, map and detailed profile. Retrieved from </volume><edition>2011</edition><dates><year>2011</year><pub-dates><date>July 23, 2011</date></pub-dates></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>4. Using Census data, and other data sources, ADDIN EN.CITE <EndNote><Cite><Author>USDHS</Author><Year>2011</Year><RecNum>369</RecNum><DisplayText><style face="superscript">2,5,6</style></DisplayText><record><rec-number>369</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">369</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>USDHS</author></authors></contributors><titles><title>National diabetes information clearinghouse</title></titles><edition>2011</edition><dates><year>2011</year><pub-dates><date>August 1, 2011</date></pub-dates></dates><publisher>U.S. Department of Health Services</publisher><urls><related-urls><url> app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">368</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>USCensusBureau</author></authors></contributors><titles><title>State &amp; county quickfacts</title></titles><edition>2011</edition><dates><year>2011</year><pub-dates><date>August 1, 2011</date></pub-dates></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>CDC</Author><Year>2011</Year><RecNum>363</RecNum><record><rec-number>363</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">363</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>National diabetes fact sheet: 2011</title></titles><edition>2001</edition><dates><year>2011</year><pub-dates><date>July 22, 2011</date></pub-dates></dates><publisher>Centers for Disease Control and Prevention</publisher><urls><related-urls><url> maps were developed to depict the environmental influences of those diabetic patients. Permission to utilize warehouse information was obtained from the hospitals through the North Texas Healthcare Quality and Information Center (NTHIQC). No patient level data was used for this research, other than aggregate zip code data. Using a business intelligence tool, aggregated data was pulled for any person receiving a primary diagnosis of diabetes and inpatients/outpatients that had any comorbidity of diabetes and all other encounters within calendar years 2008-2009. ArcGIS, a geographical mapping system, was then used to spatially join those primary diabetes diagnoses frequencies with their corresponding zip codes. These maps were analyzed to determine the location of medical, nutritional, recreational resources and patients by zip code.RESULTSDallas County’s top five primary diagnoses in 2010 were pneumonia, septicemia, other rehabilitation, urinary tract infection, and acute kidney failure. Of those top five primary diagnoses, those patients with an underlying condition of diabetes were 29% for pneumonia, 39% for septicemia, 31% for other rehabilitation, 34% of urinary tract infection and 45% of acute kidney failure (See Table 1). Those with diabetes had a higher mortality percentage than those without in four of the five top inpatient diagnoses revealing that a co-morbidity of diabetes increases your risk for mortality. Dallas County’s top seven diagnoses for emergency room department (ER) patients were acute URI unspecified, Otitis media, abdominal pain, chest pain unspecified, urinary tract infection, headache and other chest pain. Within those top seven diagnoses, 20%-45% had an underlying condition of diabetes. Specifically, of all patients who came to the ER with chest pain as a diagnosis, 21%-25% had a comorbidity of diabetes. Of patients presenting with abdominal pain, urinary tract infections and headache, 10% also had diabetes (See Table 1).Table 1: Diabetes Frequency within the Top Conditions for Inpatients and Outpatients for the Dallas County AreaTop Five Diagnosis INPATIENTS 2009-2010 Dallas CountyNumber of PatientsNumber of Patients with Diabetes% with DiabetesMortality %Mortality % with DiabetesPneumonia4,3591,27929%3.1%3.5%Septicemia3,1421,21739%21.4%23.0%Other Rehabilitation2,81687231%0.1%0.1%Urinary Tract Infection2,44782234%0.5%0.6%Acute Kidney Failure Unspecified2,3551,06845%3.2%3.5%Top Seven Diagnosis ER VISITS 2009-2010 DallasNumber of PatientsNumber of Patients with Diabetes% with DiabetesMortality %Mortality % with DiabetesAcute URI Unspecified23,9793922%0%0%Otitis Media18,576840%0%0%Abdominal Pain14,6771,51610%0%0%Unspecified Chest Pain14,5113,01021%0%0%Urinary Tract Infection14,3021,2549%0%0%Headache13,5311,2289%0%0%Other Chest Pain13,2172,98025%0%0%Data was pulled to review the percentage of other diagnoses that had a comorbidity of diabetes. The results are reported for the number of patients with other diagnoses that had a minimum of 10% of that population with diabetes. In Appendix 1, the results are reported by hospital service line, number of patients with a specific diagnoses and the number of patients reporting a comorbidity of diabetes. Each color in Appendix 1 under Product Line represents a hospital service line and colors are continued in Table 2. Some of the diagnoses with a high percentage of diabetes as comorbidity are heart failure at 59%, acute/chronic respiratory failure at 51%, and chronic obstructive asthma and E. coli septicemia at 41%.The statistics in Appendix 1 were summarized by product line for Table 2. The product lines with the most admissions in 2008-2009 for Dallas County are cardiology, pulmonary and medicine. Of those in the top three, cardiology and neurology have the largest percentages of diabetic patients at 42% and 41% respectively. Cardiology, Pulmonary and Medicine product lines compose the highest percentage of patients in Dallas County in 2008-2009.Table 2: Comparisons between Hospital Product LinesProduct LineNumber of PatientsPercentage of TotalPatients with Diabetes% with DiabetesBehavioral20324%25912%General Surgery7641%25934%Oncology14583%25417%Orthopedics32596%87127%Gastroenterology34886%83125%Neurology44618%162741%Medicine1240622%412332%Pulmonary1297823%427834%Cardiology1403325%600042%Diabetes19773%194698%Totals =SUM(ABOVE) 56856100% =SUM(ABOVE) 2044836%In 2008-2009, 35% of the top 5 inpatient diagnoses in Dallas County had diabetes as an underlying condition; the top is pneumonia (see Table 3). The data was analyzed to determine the top four zip codes in Dallas County with the highest percentage of the top five diagnoses. These zip codes were 75227, 75217, 75150, and 75149. Table 3 describes the comparison between those zip codes and Dallas County as a whole. Zip code 75227 had the highest incidence of pneumonia (33%) compared with Dallas County (29.3%); septicemia was (47.9%) compared with Dallas County (38.7%); acute kidney failure (57.4%) compared with Dallas County (45.4%). Other rehabilitation diagnosis was highest in 75217 (50.8%) compared with Dallas County (30.9%) and of urinary tract infection (42.6%) compared with Dallas County (33.6%).Table 3: Top Five Diagnoses with Diabetes as an Underlying ConditionDiagnosisDallas County752277521775150751491Pneumonia29.3%33.0%24.0%22.5%31.2%2Septicemia38.7%33.3%47.9%34.4%25.0%3OTH Rehabilitation30.9%43.1%50.8%32.4%39.3%4Urinary Tract Infection33.6%40.9%42.6%41.9%33.9%5Acute Kidney Failure45.4%57.4%55.9%42.1%38.5%The length of stay for all patients was calculated by subtracting the discharge date from the admit date. Those without either a discharge date or an admit date were removed; such patients were identified as outpatients. Comparing those with diabetes and those without diabetes, patients with a comorbidity of diabetes (6.02) stayed an extra one and one half days longer than those without diabetes (4.48), which is a 26% increase. Those patients with a primary diagnosis of diabetes stayed an average of 2.81 days. Appendix 7, Map 1 is a map of the length of stay by zip code for all patients (those with and without diabetes). The zip codes with the highest length of stay were 75208, 75245, 75210 and 75247 with an average of 5.5-6.3 days. Within the four identified zip codes, all had stays longer (4.8-5.0 days) than the average of Dallas County of 4.4 days. Mortality was analyzed by using the discharge status in the claims data. Only deaths that occurred during a hospital stay were included in the figures reported. The “death master” index mortalities were not included. The percentage of inpatient mortalities by patient zip code was mapped to show the zip codes with the highest percentage for mortality (Appendix 8, Map 1). The zip codes with the highest percentage of mortality were zip codes 75208, 75104 and 75247 with patient deaths at 5%-16.8% of the patient population. Within the four zip codes with the highest number of diabetic patients, zip code 75149 had the highest percentage of patients who had died (3%-4.9%). The average mortality rate for Dallas County was .1%-1.8%.Overall, 89%-92% of all hospital patients are discharged to home either with or without home healthcare. Those patients that did not get discharged to home were transferred to other costly care centers because they were not well enough to go home. Those who did not go home or were not transferred to another facility died, left without medical advice or were transferred to a psychiatric unit. Appendix 8, Map 2 and Map 3 show the percentage of patients that were transferred to another facility. In the zip codes in which diabetes is most prevalent, a high percentage of patients are sent to other hospital facilities, i.e. nursing homes and short term care facilities. The zip codes with the highest percentage of patients in Dallas County that were transferred to another facility were 75230 and 75225 with 16.2% - 23% of all inpatients. Within the four zip codes with the highest percentage of diabetic patients, zip code 75150 had the highest percentage with 12.3%-16.1% of the patient population transferred to another hospital facility.The demographics of those four zip codes were pulled from Census data to determine if the zip codes identified had any demographics that might explain some of the frequency of diagnoses with diabetes as an underlying factor. The overall median age, gender, race and ethnicity are shown in Table 4 as well as the percentage with diabetes in those four demographic categories. The median age was late twenties to early thirties; however, the median age of diabetics ranged from 58-63 years. A higher percentage of Hispanics live in zip codes 75217 and 75227 than in the remainder of Dallas County. Nationally, 24.4% of African Americans or Hispanics have diabetes, while in 75217 and 75227, 74% or greater of the diabetic population are African American or Hispanic ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2011</Year><RecNum>363</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>363</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">363</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>National diabetes fact sheet: 2011</title></titles><edition>2001</edition><dates><year>2011</year><pub-dates><date>July 22, 2011</date></pub-dates></dates><publisher>Centers for Disease Control and Prevention</publisher><urls><related-urls><url>. Zip codes 75149 and 75150 had a majority of white residents with 71.2% and 76.9% respectively, in which 60% have diabetes. All four zip codes had a very close split of 50/50 of males and females. However, females overall had a higher percentage of diabetes than the male population in each highlighted zip code.Table 4: Zip Code Demographics?75217752277514975150AgeMedian Age27 Years28 Years31 Years33 YearsMedian Age w/ Diabetes58 Years58 Years60 Years63 YearsGenderMale50.4%48.5%48.1%48.2%Males w/ Diabetes36.6%43.7%43.0%43.1%Female49.6%51.5%51.9%51.8%Female w/Diabetes63.4%56.3%57.0%59.9%Race/EthnicityCaucasian34.6%35.6%71.2%76.9%Caucasian w/ Diabetes21.8%22.5%60.3%60.7%African American34.8%37.1%15.2%10.4%African American w/Diabetes39.9%48.0%17.4%14.0%Hispanic46.4%43.1%16.8%16.1%Hispanic w/ Diabetes35.1%26.2%16.3%18.6%Asian0.3%1.4%3.0%4.0%Asian w/ Diabetes0.2%0.9%3.2%2.1%Other30.3%25.8%10.6%8.7%Other w/ Diabetes2.7%2.1%2.6%4.3%The four zip codes that were identified as having the highest frequency of diabetic patients were mapped using ArcGIS software in order to overlay environmental factors that could influence the health of those patients. The results revealed that the incidence of diabetes was not correlated with a higher population (see Map 1 and Map 2 in Appendix 2). The zip code with the highest number of diabetic patients was 75227. In the Appendix 3 maps, zip code 75227 clearly shows that supermarkets and food banks are not within a mile walking distance or a five minute driving distance of inhabitants, and fast food restaurants are prolific. Convenience stores were the most prevalent (See Appendix 3.Map 1). Hospitals are not found within walking distance or a five minute driving distance of the zip codes with the most prevalent incidence of diabetes, and clinics are in clusters and not evenly spread throughout the four zip codes (See Appendix 4). The zip codes with the highest prevalence of diabetes had high unemployment and low income (See Maps 1 and 2 in the Appendix 5). Recreational locations and parks were mapped for the Dallas County zip codes (See Appendix 6.Map 1). The map revealed that there were a small number of parks within a mile walking distance and only one recreation center near zip code 75227. Overall, the zip codes with the highest prevalence of diabetes had a very low income (< $35,000), an unemployment rate between 6.3% and 9.8%, few supermarkets, few food banks, few hospitals and clustered medical clinics. However, there were many convenience stores and fast food restaurants. Patients with diabetes had a greater likelihood of dying or be transferred to another facility because they were too ill to go home.DISCUSSIONDiabetes is often a comorbidity of other chronic illnesses and their symptoms. According to the CDC, diabetes is the main cause of kidney failure 2. Within the top five inpatient diagnoses in Dallas County, the fifth is acute kidney failure with more than 46% of patients having a comorbidity of diabetes with an average of 49% among the four highlighted zip codes. Pneumonia is the top diagnosis in Dallas County, and diabetes is a major co-morbidity of that disease. Although the outpatient data revealed a lower percentile of diabetes, the diagnosis of chest pain and abdominal pain relate to chronic conditions (like CHF) in which diabetes is also a high co-morbidity. The data brings to light that even when diabetes is not a primary diagnosis, it is a prominent condition related to several of the top inpatient diagnoses in Dallas County.Cardiology and Neurology hospital product lines have the highest percentage of diabetes as comorbidity. These product lines include heart attack and stroke, which are known risk factors for those with diabetes. A high percentage of patients with respiratory conditions also had diabetes as comorbidity. Increasing the medical, nutritional and recreational resources for those with a comorbidity of diabetes could reduce the incidence of heart disease and stroke by improving their control of diabetes.Patients with a primary diagnosis of diabetes stayed an average of only 2.81 days. Patients are admitted to the hospital due to uncontrolled glucose levels. The average length of stay may represent the average number of days it takes to bring the patients glucose levels low enough to be discharged from the hospital. Those with diabetes as a comorbidity experienced significantly longer stays, an average of 25% more than those without diabetes. The complications presented with diabetes as an underlying factor may cause patients to become more ill and need more time to recover from disease or injury.Patients with a comorbidity of diabetes in Dallas County in specific zip codes were more likely to be transferred to another health facility, more likely to die and stay longer in the first hospital than other patients without diabetes. These results may be due to the higher concentration of patients with diabetes than other zip codes. Diabetes affects the patient’s overall health, especially as comorbidity, and is more likely to cause a patient to stay hospitalized 25% longer, die or be transferred to another health facility instead of being discharged home. There is quite a divergence in population characteristics of the four zip codes researched as discussed previously. Such a significant difference in demographics suggests that community resources may be a factor for diabetes prevalence. Using the Arc GIS mapping software allowed the data to be spatially analyzed providing a picture of the resources available to the residents of these zip codes. The limited availability of these resources can greatly influence the health behaviors of those living in the community. Medically, only two hospital systems are in the four zip codes with high diabetes prevalence and one is a mental health hospital, demonstrating a paucity of 24 hour health care access for the residents of these zip codes. Appendix 3, Maps 3 and 4, illustrate the food deserts of these zip codes. Zip code 75227 does not have a supermarket available to its population, only convenience stores. Brown, Vargas, Ang and Pebley suggest that the socioeconomic environment and the traveling distance to supermarkets are associated with higher rates of obesity in that area ADDIN EN.CITE <EndNote><Cite><Author>Brown</Author><Year>2008</Year><RecNum>362</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>362</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">362</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brown, A.</author><author>Vargas, R.</author><author>Ang, A.</author><author>Pebley, A.</author></authors></contributors><titles><title> The neighborhood food resource environment and the health of residents with chronic conditions: the food resource environment and the health of residents</title><secondary-title>Journal of General Internal Medicine</secondary-title></titles><periodical><full-title>Journal of General Internal Medicine</full-title></periodical><pages>1137-1144&#xD;</pages><volume>23</volume><number>8</number><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>7. Since nutritious foods and a healthy diet are key behaviors for the control of diabetes, living in a food desert with many fast food restaurants is detrimental for diabetic patients’ health. Even with a chain grocery store, there is no guarantee that fresh, healthy options are offered. In lower income areas, markets often have a smaller, more limited selection of healthy fruits, vegetables and milk products ADDIN EN.CITE <EndNote><Cite><Author>Brown</Author><Year>2008</Year><RecNum>362</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>362</rec-number><foreign-keys><key app="EN" db-id="aetwwzf9o5ea2ge9dr7xvtde0ds005avwstw">362</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brown, A.</author><author>Vargas, R.</author><author>Ang, A.</author><author>Pebley, A.</author></authors></contributors><titles><title> The neighborhood food resource environment and the health of residents with chronic conditions: the food resource environment and the health of residents</title><secondary-title>Journal of General Internal Medicine</secondary-title></titles><periodical><full-title>Journal of General Internal Medicine</full-title></periodical><pages>1137-1144&#xD;</pages><volume>23</volume><number>8</number><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>7. Physical activity is also important in the behavior of diabetes. Although there are some recreation centers and local parks in the area, most have limited hours of availability making it difficult for residents to fully utilize these facilities. The use of parks requires good weather conditions, and Dallas is known for the numerous days over 100° in the summer and fall. The remaining days with good weather are limited in Texas.CONCLUSIONSDiabetes is a complicated disease that has risk factors for cardiac and neurologic comorbidity, especially with uncontrolled diabetes. In order improve the control of glucose levels in diabetic patients, a regular exercise regimen and a diet including fresh fruits and vegetables should be a part of their daily routine. Many diabetic patients in Dallas County do not have access to fresh fruits and vegetables due to the lack of supermarkets within either a one mile walking distance or five mile driving distance. Food banks are few, if nonexistent; in the top four zip codes with high numbers of diabetic patients. Recreational facilities are very rare in low-income areas with the highest prevalence of diabetes. The lack of clinics throughout the county is also a problem as they are clustered together with large distances between these clusters.It may assist diabetic patients in Dallas County to place more supermarkets and food banks with fresh foods in those four zip codes, add low cost recreational sites and more clinics. Community groups may be able to assist by working together to improve the environmental factors for diabetic patients of Dallas County.Longer lengths of stay, higher mortality rates and transfers to other hospital facilities may be the result of poor control of diabetes. Poor control can lead to slower healing time, complications of diabetes itself and increased risk of mortality. Addressing the environmental factors of diabetes could result in longer life, less complications, shorter lengths of stay and better overall health that could help patients combat other illnesses and injuries.The data used in this study was only claims data. Actual observations of the zip code neighborhoods may discover some discrepancies or more evidence of the conclusions in this study. Mortality rate could change with the addition of data from the mortality index for the state of Texas. ADDIN EN.REFLIST References1.U.S. Obesity Trends. Centers for Disease Control and Prevention; 2011. Accessed August 26, 2011.2.National diabetes fact sheet: 2011. Centers for Disease Control and Prevention; 2011. . Accessed July 22, 2011.3.Diabetes data: surveillance and evaluation. Texas Department of State Health Services; 2011. Accessed July 29,2011.4. Texas zip codes, map and detailed profile. 2011. Accessed July 23, 2011.5.National diabetes information clearinghouse. U.S. Department of Health Services; 2011. . Accessed August 1, 2011.6.State & county quickfacts. 2011. Accessed August 1, 2011.7.Brown A, Vargas R, Ang A, Pebley A. The neighborhood food resource environment and the health of residents with chronic conditions: the food resource environment and the health of residents. Journal of General Internal Medicine. 2008;23(8):1137-1144APPENDICESAppendix 1: Top Diagnoses and Percentage of those with Diabetes in Dallas County by Product LineProduct LineDiagnosis 2010 DallasNumber of PatientsPatients with Diabetes% with DiabetesDiabetesDIABETES W/MANIFEST OTH75474599%DiabetesDIABETES KETOACID TYPE II UNCONT44944298%DiabetesDIABETES KETOACID TYPE I UNCONT77475998%CardiologyACUTE/CH DIASTOLIC HEART FAILUR100458959%MedicineRENAL HYPERT UNSPEC/FAILURE100458957%CardiologyACUTE/CH SYS/DIAST HEART FAILURE46123451%PulmonaryACUTE/CHRONIC RESP FAILURE60630751%CardiologyATHEROSCLER NATIVE COR ART184993150%CardiologyCONGESTIVE HEART FAILURE UNSPEC157875148%CardiologyACUTE/CH SYSTOLIC HEART FAILURE152072848%CardiologySUBENDO INFRC INIT EPISODE184384046%PulmonaryCHRONIC OBSTRUCT ASTHMA W/EXAC96340842%MedicineE.COLI SEPTICEMIA56022741%NeurologyCEREBRAL ARTERY OCC W/INFARCT190078841%CardiologyOTH CHEST PAIN158163640%PulmonaryRESPIRATORY FAILURE140055640%MedicineCELLULITIS/ABSCESS TRUNK43617640%CardiologyUNSPEC CHEST PAIN58923039%NeurologyCEREBRAL EMBOLISM W/INFARCT51819638%PulmonaryOBSTRUCT CHRONIC BRONCHITIS W/EXAC210074836%CardiologyCAROTID ARTERY OCCLUS NO INFARCT56720035%MedicineCELLULITIS/ABSCESS LEG156654335%NeurologyINTRACEREBRAL HEMORRHAGE45215935%PulmonaryCHRONIC BRONCH W/ACUTE BRONCHITIS50317334%MedicineURIN TRACT INFECTION UNSPEC244782234%NeurologyTRANS CEREB ISCHEMIA UNSPEC58719734%NeurologyTRANS CEREB ISCHEMIA UNSPEC58719734%GastroenterologyGASTROINTEST HEMORRHAGE UNSPEC52317834%General SurgeryMORBID OBESITY76425934%MedicineOTH REHABILITATION281687231%MedicineC DIFFICILE ENTERITIS49115231%CardiologySYNCOPE & COLLAPSE78423730%PulmonaryPNEUMONIA ORGANISM UNSPEC4359127929%PulmonaryFOOD/VOMIT PNEUMONITIS77522529%GastroenterologyNONINFECT GASTROENTERIT OTH69620129%CardiologyHYPERTENSION UNSPEC47413328%CardiologyATRIAL FIBRILLATION178349128%MedicineOTH POSTOP INFECTION85424328%OrthopedicsLOCALIZED OSTEOARTH UNSPEC LEG132136628%PulmonaryASTHMA UNSPEC W/EXACERBAT93625227%MedicineHYPOSMOLALITY51013727%PulmonaryAC VNUS EMB&THRMB DP VES PRX LW EXT44911826%OrthopedicsLUMBAR DISC DISPLACEMENT49312926%OrthopedicsINTERTROCHANTERIC FX CLOSED59715626%OrthopedicsLOCALIZED PRIMARY OSTEOARTH LEG84822026%MedicineCELLULITIS/ABSCESS ARM42410425%PulmonaryPUL EMBOLI/INFARCT OTH88721224%NeurologyOTH CONVULSIONS4179022%GastroenterologyINTESTINAL OBSTRUCT UNSPEC69215422%MedicineEPILEPSY UNSPEC OTH INTRACT51510520%MedicineDEHYDRATION78315320%Gastroenterology INTESTINAL ADHES W/OBSTR4639420%GastroenterologyDIVERTICULITIS COLON11142040.18OncologyENCOUNTER ANTINEOPLASTIC CHEMO145825417%BehavioralSCHIZOAFFECTIVE UNSPEC101614114%BehavioralPARANOID SCHIZOPHRENIA UNSPEC4415312%BehavioralPSYCHOSIS UNSPEC5756511%center81280Appendix 2.Map 1: Dallas County Population by Code and Diabetes IncidenceAppendix 2.Map 2: Diabetes Frequency by Zip Codecenter-8255 center205105Appendix 3.Map 1: Available Food for PurchaseAppendix 3.Map 2: Diabetic Patient Resources center-243840Appendix 3.Map 3: Fast Food Availability center-215265center252730Appendix 4.Map 1: Medical ResourcesAppendix 5.Map 1: Median Incomecenter-262890Appendix 5.Map 2: Unemployment57340567945Appendix 6.Map 1: Recreation Availabilitycenter-224790center147955Appendix 7.Map 1: Average Length of StayAppendix 8.Map 1: Mortality Percentagecenter-205740Appendix 8.Map 2: Discharge Statuscenter-320040 ................
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