Hospitalizations and deaths from diabetes mellitus in northeastern Brazil between 2010 and 2019

Objective: To identify the epidemiological profile of hospitalizations and deaths due to Diabetes Mellitus , based on secondary data, in the Northeastern Brazilian States, between 2010 and 2019. Methods: Ecological, time series study that used secondary data extracted from the website of the Department of Informatics of the Unified Health System (DATASUS). The population of this study consisted of all hospitalizations and deaths due to Diabetes Mellitus of people living in the Northeastern Brazilian States during the period investigated. The following variables were investigated: age group; sex; color/race; character of care due to hospitalization and deaths due to Diabetes Mellitus . Results: During the period there were fluctuations in the mortality rate, with a decreasing trend, but without statistical significance (p=0.0523). It was observed that older adults, women and browns are more frequent among hospitalizations. In addition, it was found that the older adults suffered more emergency hospitalizations compared to elective ones. There was a statistically significant association in the variables, age group, sex and race and type of care (p<0.001). Older adults, women and browns are the most prevalent among deaths, regardless of the nature of care. Conclusion: Deaths and hospitalizations due to Diabetes Mellitus were more prevalent among older adults, female and brown patients, with a predominance of urgency in care.


___________________________________________________________________________________________________________________________________________________________ INTRODUCTION
Diabetes Mellitus (DM) is one of the main chronic non-communicable diseases (NCDs) and, therefore, is considered the main causal reason for deaths and disabled individuals worldwide, being, therefore, one of the most challenging diseases of the 21 st century. (1)In addition to being a serious public health problem, (2) it stands out due to its great potential for long-term complications, as it affects the vascularization of people affected by the disease and plays an important role in increasing morbidity and mortality. (3)t the microvascular level, lesions appear in the retina that can develop into irreversible blindness (retinopathies), problems in the blood vessels of the kidneys causing chronic kidney disease (nephropathies) and neuronal damage responsible for non-traumatic amputations of the lower limbs (neuropathies).At the macrovascular level, individuals can develop ischemic heart disease, cerebrovascular disease, and peripheral vascular disease, which often lead to hospitalization and therefore mortality. (4)he Global Health Estimates pointed to DM as the ninth leading cause of death worldwide, with about 1.50 million deaths. (5)According to the Global Burden of Disease, in 2021 alone, 529 million people lived with diabetes, or 6.1% of the global population, and it is estimated that between 2021 and 2050, the global prevalence of age-standardized total diabetes will increase by 59.7% (95% CI= 54.7-66.0),resulting in 1.31 billion (95% CI=1.22-1.39)people living with diabetes in 2050. (2)Data from Brazil show that it affects a high number of Brazilians.In 2015, approximately 12 million Brazilians had DM and, in 2017, more than 14 million were estimated, which represents a significant increase in cases per year.DM and other chronic comorbidities are conditions whose treatment is carried out at the level of Primary Health Care (PHC), (8) but complications during treatment can arise and, therefore, the need for hospital care becomes indispensable.These complications cause problems for the individual as a whole, impairing motor function, autonomy and quality of life, generating a strong future impact on the health and economy of individuals, family members and the global economy. (9)orldwide, direct costs related to the care of people with DM range from 2.50% to 15% of national health spending, depending on the local prevalence of cases and the need for more complex care available. (10)The total number of hospitalizations and complications resulting from it have a much higher English | Rev. enferm.UFPI.2024;13:e4232| DOI: 10.26694/reufpi.v13i1.4232cost when compared to expenses with hospitalizations for adverse causes and their aggravations such as cancers or respiratory diseases, for example. (11)ew studies analyze mortality trends for DM, especially in Northeastern Brazil, which is the region with the highest rate of hospitalization for DM. (12)Thus, a study was necessary to analyze hospitalization and mortality rates to configure data that assist in the creation of measures to mitigate DM-related diseases and consequently reduce the number of hospitalizations and their respective costs. (13)Therefore, the objective of this study was to identify the epidemiological profile of hospitalizations and deaths due to Diabetes Mellitus, based on secondary data, in the states of Northeastern Brazil, from 2010 to 2019.

METHODS
Ecological, time series study that used secondary data extracted from the website of the Department of Informatics of the Unified Health System (DATASUS).Data extracted from DATASUS were recorded in the SUS Hospital Information System (SIH-SUS) and Mortality Information System of the Ministry of Health (SIM-MH).The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) of the EQUATOR Network was used to guide and develop the research. (14)he study population consisted of all hospitalizations and deaths due to DM of people living in the Northeastern Brazilian States during the investigated period: Alagoas, Bahia, Ceará, Maranhão, Paraíba, Pernambuco, Piauí, Rio Grande do Norte and Sergipe.The Northeast region has a total area of 1,554,291 km² and approximately 57,071,564 million inhabitants. (15)he following variables were investigated: age group; sex; color/race; character of care due to hospitalization and deaths due to DM.After collection in the information systems, the data were exported and tabulated in the Microsoft Office Excel® software, in which descriptive statistical analysis (absolute and relative frequency) was performed.The mortality rate was calculated by the ratio between deaths and hospitalizations for Diabetes Mellitus, and the result was multiplied by 100.It is noteworthy that the choice of variables was due to the availability in the information systems used.
Regarding the temporal analysis, it is noteworthy that the raw data of hospitalizations and deaths due to Diabetes Mellitus, in each year, after tabulated in a Microsoft Excel® spreadsheet, were imported into the free software Joinpoint Regression Program version 4.6.0.0 (14).It is noteworthy that the aforementioned software was developed with the purpose of analyzing cancer trends; however it has been widely used, currently, in epidemiological research, due to its potential in the analysis of temporal patterns.The Annual Percentage Change (APC) was calculated using a 95% confidence interval (95% CI), in which negative and positive APC values indicate, respectively, a decreasing and increasing trend.In addition, bivariate analyses were performed using the R software, version 4.0.2®, in which the Chi-Square independence test (x 2 ) and odds ratio (OR) were used.In the Chi-Square test (x 2 ), p<0.05 was considered necessary for the rejection of the null hypothesis.A 95% confidence interval (95% CI) was adopted, which was used to conclude about the Chi-Square hypothesis test (x 2 ), considering that if it contains the value 1, it means that there is no difference regarding the two investigated variables. (17)t is noteworthy that this study used secondary data, which are openly available on the DATASUS website, which do not allow the identification of individuals and, therefore, there is no need for evaluation by the Research Ethics Committee (REC).However, it is noteworthy that all ethical precepts of the relevant legislation were respected, in accordance with resolutions 466/12 of the National Health Council, which deals with aspects of human dignity and 580/18, which deals with ethical aspects in research of strategic interest to the Unified Health System (SUS).

Source: research data (2021).
Table 1 shows that older patients suffered more emergency hospitalizations compared to elective hospitalizations.There was a statistically significant association in the variables, age group, sex and race and type of care (p<0.001).It was found that the age group from 30 to 39 years (OR=1.17),as well as women (OR=1.07)and individuals of mixed race (OR=1.24)have more chances of emergency care than elective.Table 2 shows that older adults, women and brown individuals are the most prevalent among DM deaths, regardless of the nature of care.It was observed that there was no statistically significant association between the investigated variables.

DISCUSSION
In this study, it was found that there were fluctuations in the mortality rate, with a decreasing trend, but without statistical significance. However, it is noteworthy that the findings of this study may be related to the actions of the Family Health Strategy (FHS), considering that the increase in FHS coverage makes it possible to improve health care, which, in turn, can cause a reduction in the number of hospitalizations and mortalities due to preventable causes. (20)orroborating the findings of this study, in which hospitalizations were more frequent in older adults, women and browns, an ecological study, with data from the SUS, pointed to higher hospitalization rates among females and older adults, and an increasing trend in the groups of children and adolescents and browns. (12)emales had a higher prevalence in the number of hospitalizations than males, focusing mainly on urgency.This is in disagreement with the findings of a study carried out in the capitals of the Southeast, between 2018 and 2021, in which most hospitalizations occurred in males. (21)A study conducted in Portugal on the impact of DM on multiple avoidable admissions showed that women are more likely to have multiple admissions. (22)This may be related to the factors that the woman has that may trigger a higher incidence in the number of hospitalizations, such as advanced age, family history of DM, hypertension, use of corticosteroids, polycystic ovary syndrome or having had, in a previous pregnancy, pre-eclampsia or eclampsia. (4)his study showed that the brown race had a higher prevalence in the number of hospitalizations for DM, which corroborates the findings of the capitals of Belo Horizonte and Vitória, in which most hospitalizations also occurred in brown patients, and differs from São Paulo, which had a predominance of hospitalizations for DM in white patients. (21)hus, one study conducted in Piauí showed that the older adults between 60 and 69 years were the age groups that were most hospitalized for DM. (23)The higher number of hospitalizations in older age groups is noticeable and this may be related to the demographic aging process and the prevalence of risk factors for the development of diabetes mellitus that increases in this population, as well as complications, which imply a high number of hospitalizations and consequently a greater probability of increasing deaths. (24)nglish | Rev. enferm.UFPI.2024;13:e4232| DOI: 10.26694/reufpi.v13i1.4232 As for the number of deaths, there was a predominance of older adults, which corroborates the findings of a research carried out in Manaus, in which the mortality rate corresponded to 87.8% in this age group. (25)This fact may be associated with the degeneration of body systems that occur at this age, which are natural physiological processes and can provide greater fragility to these people, in addition to the lack of adequate care. (26)n this study, deaths prevailed in the female public, which contrasts a study that sought to investigate sex differences in mortality trends due to diabetes mellitus in Brazil, 1980-2012, and concluded that DM in Brazil went from a pattern of higher mortality among women compared to men to equality or even male predominance. (27)However, a study carried out in São Paulo points out results similar to this study, which found a majority of predominantly female deaths from DM. (19) The response to this higher mortality in women, especially in middle age, is considered to be due to the excess of work activity and daily family care that often overloads all their time, and this causes them to seek less and less or postpone going to the health service to screen problems, as well as the inequity that DM and other diseases bring to their lives. (28)In addition, this higher number of deaths in the female population is attributed to a higher number of diagnoses, treatment and notification of DM in female certificates. (29)In addition, it is important to mention that mortality data can be underreported, since, frequently, in the death certificate, DM is not mentioned, but rather its complications, particularly cardiovascular and cerebrovascular complications. (6)egarding deaths by race, the study showed that the most predominant race was brown with 76.03% of elective deaths and 81.58% of emergency deaths, as well as in a study carried out in Manaus. (25)his may be related to the miscegenation of Brazil, as well as to the fact that the black and brown population suffer greater inequities imposed on the population, which demonstrates the need for more studies that follow these most affected groups with the purpose of formulating health actions the purpose of reducing, above all, complications and, consequently, mortality from DM. (30) It is important to highlight that the study has limitations regarding the unavailability of some information provided by the Hospital Information System (SIH-SUS) about the characteristics of patients and hospitalizations.With regard to contributions, we highlight the collaboration for the health of adults and the older adults, as this study identified that morbidity and mortality from DM affects, above all, older patients and this can provide opportunities for the development of public health policies that try to minimize the negative impact of DM on the health of this population.

CONCLUSION
The epidemiological profile of hospitalization and mortality due to DM in the Northeast of Brazil is composed mainly of women, older adults and brown individuals, who were urgently treated.Regarding mortality, fluctuations were observed, but there was a decreasing trend.
It is noteworthy that these findings can contribute to the planning of prevention and health education actions for the population, together with health professionals, families and patients, in order to reduce the risks of complications considering the characteristics that the disease brings with it and all its challenges imposed throughout life and treatment, and therefore minimize hospitalizations and deaths due to preventable causes.In addition, it is important to strengthen existing actions and policies in Primary Health Care in order to provide improvements in patient care.

Table 1 .
Hospitalizations by nature of care according to age group, sex and race.Floriano, PI, Brazil, 2021.

Table 2 .
Deaths due to the nature of care according to age group, sex and race.Floriano, PI, Brazil, 2021.The categories less than 10 years, and 10 to 19 years, were not included in the Chi-Square test because they have a very small amount of elective care. *