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Diabetes and Associated Risk Factors in Patients Referred for Physical Therapy in a National Primary Care Electronic Medical Record Database

CS Kirkness, PT, MSc, is Research Associate, Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, University of Utah College of Pharmacy, 421 Wakara Way, Suite 208, Salt Lake City, UT 84108 (USA)
RL Marcus, PT, PhD, is Associate Professor, Department of Physical Therapy and Department of Exercise and Sport Science, University of Utah
PC LaStayo, PT, PhD, CHT, is Associate Professor, Department of Physical Therapy, Department of Exercise and Sport Science, and Department of Orthopedics, University of Utah
CV Asche, PhD, MBA, is Research Associate Professor, Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, 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 Scientist, Intermountain Healthcare, Salt Lake City, Utah

Address all correspondence to Ms Kirkness at: carmen.kirkness{at}pharm.utah.edu

Submitted April 30, 2008; Accepted August 4, 2008

	Abstract

 
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.

	Introduction

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Diabetes mellitus is a chronic disease in which the body does not regulate blood glucose concentrations properly.¹ Diabetes 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 amputations or to comorbidities associated with diabetes such as heart disease and stroke.¹ Approximately 24 million people (7.8% of the population) in the United States have diabetes, 5.7 million of whom are undiagnosed.¹ Ninety to 95 percent of all cases of diabetes fall into the category of type 2 diabetes, characterized by insulin resistance and eventual 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 diabetes (type 2) in the general population 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).¹

The increase in diabetes is largely attributed to weight gain.^7,8 Obesity, measured by body mass index (BMI), increased 74% between 1991 and 2003.⁹ During the same time frame, diabetes increased 61%, reflecting the strong association between obesity and the development of diabetes.⁹ Obesity, particularly abdominal obesity, is a major risk factor not only for diabetes but also for cardiovascular disease (CVD) (heart attack and stroke). For additional information on fat and CVD, see the articles by Stehno-Bittel¹⁰ and Cade¹¹ in this issue. All cardiovascular risk factors (except smoking) are more prevalent in patients with diabetes, and an elevated risk for CVD often exists in people who are prediabetic.¹² Associated risk factors related to diabetes, prediabetes, and CVD are overweight 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 diabetes target not only abnormally high glucose levels but also elevated blood pressure and cholesterol levels.¹⁶ Diet, exercise, and pharmacotherapy are suggested ways to manage diabetes.^16–18 The Standards of Medical Care in Diabetes (2008) recommends physical activity for the prevention and management of diabetes and its related comorbidities.¹⁹ Observational and clinical trial data suggest that as little as 30 minutes per day of moderate-intensity physical 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 medical evidence identifying exercise as being beneficial.^16,19,22 Presently, the role of the physical therapist in managing diabetes and prediabetes should include exercise testing for cardiovascular risk assessment and monitoring of glycemic (blood glucose) and nonglycemic (blood pressure, BMI, skin condition, balance testing) variables during exercise and other interventions.²³

The American Physical Therapy Association's Vision Statement for Physical Therapy 2020 suggests consumers will have direct access to physical therapists in all environments (ie, patient/client management, prevention and wellness services).²⁴ The increasing numbers of individuals with diabetes and prediabetes, coupled with the compounding associated cardiovascular risk factors, highlight the importance of identifying patients with these conditions in outpatient physical therapy settings. Improved recognition could positively affect outcomes, particularly for patients with conditions known to be adversely affected by diabetes (eg, peripheral neuropathy, 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 frequency of physical therapists’ contact with people who have diabetes, prediabetes, or associated risk factors in outpatient physical therapy settings is unknown.

The purpose of this article is to describe the prevalence of those adults with diabetes and those with associated risk factors who are referred for physical therapy in a primary care outpatient setting. From this, suggestions for identifying and managing patients or clients in a physical therapy environment will be discussed.

	Method

Top Abstract Introduction Method Results Discussion Conclusions References

 
Database Description

This study used a cohort design utilizing 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 Centricity EMR database is used by more than 20,000 clinicians and contains longitudinal ambulatory electronic health data for more than 7.4 million patients, including, but not limited to, demographic data, vital signs, laboratory orders and results, medication list entries and prescriptions, and diagnoses or problems. A variety of practice types are represented in the database, ranging from solo primary care practitioners to community clinics, academic medical centers, and large integrated delivery networks. Approximately two thirds of the participating clinicians practice 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 incorrect (eg, BMI >500). Once this process is complete, the data are moved into a reporting data set that is available for use for primary care research 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 incorporation of clinical data, such as chief complaint data, comprehensive laboratory values, and vital signs. Thus, an EMR allows the use of combinations of these parameters to identify patients, which can be valuable in maximizing the identification of patients. 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 analysis included all adult patients 18 years of age who were referred for physical therapy. Referral for physical 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 having a relevant physical therapy ICD-9 code^4–6,25 (ie, Endocrine and metabolic 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], Injury [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 before 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 physical therapy to ensure that they were active in the database at least 395 days prior to the referral/clinical note date. Application of these criteria resulted in the identification of 52,667 patients from the initial population of 7,935,736. The patients identified from the database during these calendar years then were described based on having diabetes or the presence of risk factors for diabetes (elevated blood glucose level, abdominal obesity [BMI], low high-density lipoprotein [HDL] cholesterol, elevated tricglycerides, hypertension). Patients were indicated by an encrypted ID number and had no traceable personal health information within the database.

Identification of Diabetes and Associated Risk Factors

Determination of the presence of diabetes or associated risk factors was completed using 3 different identification criteria (clinical, diagnostic, and treatment) available within the EMR database.

Clinical criteria.
Patients were categorized clinically for diabetes and each of the following risk factors: impaired fasting glucose, elevated BMI, low HDL cholesterol, elevated triglycerides, and high blood pressure (Tab. 1). The selected risk factors correlate with the American Diabetes Association (ADA) risk factor assessment that predicts the risk of developing diabetes and are measurable in the EMR (ie, excluding family history, history of gestational diabetes, and habitual physical activity).²⁶ The clinical criteria identifying diabetes and associated risk factors were derived from clinical practice guidelines established by the ADA²⁷ and from the third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel, or ATP III 2001).²⁸ Modification to the clinical practice guidelines was made to 1 of the 5 criteria: waist circumference. Because measurements of waist circumference are rarely available in clinical data, BMI was used as a proxy measure and was calculated from the patients’ height and weight measurements. Some studies^29–31 have shown that BMI and waist circumference are highly correlated and that each factor independently contributes a significant risk for diabetes. Clinical criteria for identifying diabetes and associated risk factors included clinical components that are available to physical therapists in clinical practice such as blood pressure, height, and weight. Additional clinical criteria such as laboratory test values may or may not be available to physical therapists on a routine basis but are useful for identifying risk factors.

Treatment criteria.
The treatment criteria for diabetes and associated risk factors were defined as prescriptions recorded for the patient that would indicate treatment of diabetes or an associated risk factor. This information could be obtained by physical therapists from a patient's medical history. Patients identified using treatment criteria were those with a prescription for any one of the following drugs or drug classes: (1) weight-loss agents (sibutramine hydrochloride, orlistat), (2) triglyceride-lowering agents (fibrates, niacin), (3) antihypertensives (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, beta-blockers, thiazide diuretics, antihypertensive vasodilators, and combinations of these agents), and (4) drugs used for diabetes (sulfonylureas, metformin, thiazolidinediones, meglitinides, alpha-glucosidase inhibitors, and combinations of these agents).

Analysis

Descriptive analysis was conducted to describe the study population characteristics by demographic factors, geographic location, insurance status, condition prompting referral for physical therapy, and presence of diabetes or associated risk factors. The prevalence of diabetes was established as a percentage of patients with a clinical, treatment, or diagnostic indication for diabetes over all patients in this sample.

Using the 3 types of identification criteria (clinical, treatment, and diagnostic), the frequency of patients with diabetes and patients with associated risk factors was described in 2 ways: (1) the frequency for each criterion 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 associated risk factor.

	Results

Top Abstract Introduction Method Results Discussion Conclusions References

 
The demographics of the study population are shown in Table 2. A total of 52,667 patients with a mean age of 52.0 years (SD=16.2) were identified as being referred for physical therapy. Sixty-five percent of the sample was female. Of the conditions identified as the primary reason for physical therapy referral, the majority were musculoskeletal conditions (76.9%), followed by referrals for an injury (16.9%); only 2.2% of the patients were referred with diabetes as the apparent primary indication. 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 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).

	Discussion

Top Abstract Introduction Method Results Discussion Conclusions References

 
This article examines the prevalence of diabetes and risk factors associated with diabetes in a population of adults referred for outpatient physical therapy care. Using a large national EMR database, we were able to capture a geographically diverse cohort of patients representative of conditions that are typically seen in outpatient physical therapist practice. Using clinical, treatment, and diagnostic parameters permitted the identification of patients with diabetes or risk factors associated with diabetes 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 associated 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 Examination Survey (NHANES), which examined diabetes in adults aged 20 years in the United States, found the unadjusted prevalence to be 9.3% (1999–2002).³² The difference in prevalence could indicate that people seeking care from a primary care physician are different from the general US population and thus that those who are being referred for physical therapy have more health problems. Diabetes prevalence increases with age; people with diabetes aged 60 years or older are 2 to 3 times more likely to report an inability to walk 0.4 km (0.25 mile), climb stairs, do housework, or use a mobility aid compared with people without diabetes in the same age group.¹ Although the severity of diabetes and the patients’ health status were not objectives of this study, the proportion of those referred for physical therapy with diabetes alone warrants further investigation into the health of those who attend physical therapy. 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 proportion of our study population who were obese or overweight (40.0%) was lower than for the US adult population (65.7%) (NHANES 1999–2002).³² One reason for this discrepancy may be that our study population comprised patients who were generally young and healthy, with the majority being referred for physical therapy for musculoskeletal-related problems; 20% had no diabetes or associated risk factors. Body mass index is an independent predictor of the risk for developing diabetes.³⁴ In our study population, half of those patients with diabetes had a BMI within the normal range. This finding could indicate that the distribution of body mass may be influencing the BMI in this population. Abdominal adiposity has been shown to increase the risk for diabetes.³⁴ Although waist circumference measurements were not available in the EMR database, waist circumference measurements have been shown to independently predict diabetes.³⁵ This may indicate that, in the physical 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 development 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 hypertensive. Because of the elevated risk of CVD for patients with diabetes, the high prevalence of high blood pressure in this population is a concern. The low documentation of hypertension treatment in the EMR also is of concern, as this may underrepresent the risk if identifying hypertension by medication alone. We suggest that physical therapists use a detailed systems review in an attempt to identify the multiple diabetes risk factors, specifically, elevated blood glucose and hypertension. A significant proportion of the population referred for outpatient physical therapy has risk factors that affect cardiovascular health overall, of which diabetes is a major contributor. Consequently, physical therapy interventions should be adjusted to accommodate these risk factors and designed to mitigate the adverse sequelae associated with diabetes. Such adjustments may include improving the overall health of patients through exercise advice and education, regardless of the primary reason for the physical therapy referral.

When prescribing any aerobic or resistance exercise component into a comprehensive rehabilitation program, emphasis should be placed on a safe and efficacious progression of the exercise prescription.¹⁸ This should involve monitoring associated risk factors in people with diabetes or at risk for developing diabetes during all exercise regimens, educating the patients about secondary prevention, and addressing balance, strength (force-generating capacity), and fall prevention strategies.²³

A thorough examination enables the physical therapist to monitor the secondary 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 associated medications) completed by the physical therapist can reveal information 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 measurement not typically available to the physical therapist in outpatient practice. 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 medication use is recorded in the initial examination by a physical therapist. Other clinical values routinely available to the physical therapist to evaluate diabetes and associated risk factors are blood pressure, age, BMI, and being a member of a high-risk population (African Americans, Hispanic/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 diabetes or risk factors associated with the development of diabetes, these measures may still underestimate the number of physical therapy outpatients with diabetes or associated risk factors. Coupled with the large number of individuals who are unaware that they are at risk for developing 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 therapist in recognizing chronic conditions such as diabetes, especially considering that it often is not the primary therapy indication, is underscored by the data in this study. This is especially true in light of a growing aging and overweight population. Awareness of diabetes in the outpatient setting is important, as having diabetes may affect both the planning and implementation of treatment, as well as patient-related outcomes. Older people with diabetes demonstrate accelerated loss of skeletal muscle mass and strength³⁸ and have considerable functional impairment associated with reduced health status.⁴² Diabetes is a known risk factor 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 immobilization.⁴⁶ It is likely that diabetes influences a broad spectrum of physical therapy interventions.

The population is aging, obesity rates are rising, lifestyles are increasingly sedentary, and a large proportion of the US population 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 exercise can prevent or delay type 2 diabetes.⁴⁷ Physical therapists can play a key role in facilitating physical activity.^21,33 This management principle alone could play a large role in risk reduction for diabetes. Recommendations for this population include exercising moderately for 150 minutes per week with moderate-intensity aerobic physical activity and in the absence of contraindications; resistance training should be encouraged 3 times per week.⁴⁸

Limitations

The database used in this study originates from the primary care provider office; therefore, related health care data from certain specialists or hospital care would only be captured if reported back to the primary care physician. In addition, these data are only as reliable as the documentation in the patient record. Medical records in any format often are incomplete. Thus, there exists the possibility that some diagnoses, prescription orders, or other miscellaneous 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 influenced the results of this study.

The majority of the EMR data are supplied by primary care physicians, reflecting how diabetes care is delivered in the United States. For example, fasting blood glucose tests would be completed 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,³² the proportion of patients with diabetes or prediabetes could be higher. Although an observational study such as this reflects real-world treatment, it lacks the control of a randomized clinical trial. Thus, we believe these values underestimate 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 appointment. We propose that those being referred for physical therapy were of poorer health than the general population due to the prevalence of diabetes found. Diabetes severity, level of blood glucose control, and progression of disease were not evaluated in this study. The prevalence of diabetes in patients who attend a clinical visit may be different from that of all patients referred for physical therapy. It is possible that patients with diabetes do not seek physical therapy even though they may be referred. Further research to understand the prevalence of diabetes in the physical therapy clinic and possible correlations with the musculoskeletal conditions of interest is a necessary next step. Lastly, there is an underrepresentation of the population at high risk for diabetes in this sample; therefore, the prevalence of diabetes may be higher than the results indicate.

	Conclusions

Top Abstract Introduction Method Results Discussion Conclusions References

 
A high proportion of people referred for physical therapy have diabetes, and an even larger number of individuals have one or more risk factors associated with diabetes. The evaluation of associated conditions in this population should be considered when designing management approaches and a plan of care. Physical therapists have an opportunity to play a critical role in the management of patients with a primary 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.

	Footnotes

 
All authors provided concept/idea/research design, writing, and consultation (including review of manuscript before submission). Dr LaStayo and Dr Asche provided data collection. 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.

^* GE Healthcare Institute, N16 W22419 Watertown Rd, Waukesha, WI 53186.

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