Abstract:

Objective:

To describe the care measurements provided to patients with self-reported diabetes mellitus in Brazil.

Methods:

Data from the Brazilian National Health Survey (2013) were used. This is a cross-sectional population-based study in which the subjects with self-reported diabetes mellitus answered questions concerning their use of health services and access to medicine.

Results:

The prevalence of self-reported diabetes mellitus was 6.2%, while 11.5% of the population had never undergone a glucose testing. From the adults with diabetes mellitus, 80.2% had taken medications two weeks before the interview, 57.4% used the Popular Pharmacy Program, 73.2% received medical care, and 47.1% were cared for in the Health Basic Units. In 65.2%, the physician who cared for them in the last appointment was the same from previous ones, 95.3% of the patients were able to perform the required complementary examinations, and 83.3% could go to the appointments with a specialist. About 35.6 and 29.1% of the subjects with diabetes mellitus reported feet and eyes examination, respectively. About 13.4% declared previous hospitalization owing to diabetes or any complications, and 7.0% mentioned limitations in their daily activities owing to the disease. In general, women and the elderly people, those with higher education levels, white, and those living in the south and southeastern regions showed a higher prevalence of the disease and greater access to services, medicine, and appointments.

Discussion:

The care reported by patients with diabetes, which is essential to maintain their quality of life and prevent serious outcomes, seemed, in most cases, to be adequate.

Keywords:
Chronic disease; Diabetes mellitus; Health surveys; Health services; Delivery of health care; Prevalence.

INTRODUCTION

Diabetes mellitus (DM) is a global health problem responsible for 1.5 million deaths in 2012 and 89 million of disability-adjusted life years (DALYS)¹1. World Health Organization. Global status report on noncommunicable diseases 2014 [Internet]. Geneva: World Health Organization; 2014 [cited 2015 Jan 28]. 298 p. Available from: Available from: http://www.who.int/nmh/publications/ncd-status-report-2014/en/
http://www.who.int/nmh/publications/ncd-... , in which most of them are premature deaths that happen many times throughout a person's productive life. The World Health Organization estimates that diabetes will be the seventh largest worldwide cause of deaths in 2030¹1. World Health Organization. Global status report on noncommunicable diseases 2014 [Internet]. Geneva: World Health Organization; 2014 [cited 2015 Jan 28]. 298 p. Available from: Available from: http://www.who.int/nmh/publications/ncd-status-report-2014/en/
http://www.who.int/nmh/publications/ncd-... .

In Brazil, diabetes mortality rate in people aged from 30 to 69 years, in 2012, was of 26.9/100,000 residents (57,876 deaths)²2. Malta DC, Moura L, Prado RR, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4): 599-608.. If multiple causes of the death certificate (DC) are considered, this rate might increase³3. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM, et al. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781): 1949-61., because cardiovascular and cerebrovascular diseases can be associated with diabetes⁴4. Barreto SM, Passos VMA, Almeida SKF, Assis TD. The increase of diabetes mortality burden among Brazilian adults. Rev Panam Salud Pública 2007; 22(4): 239-45..

DM increase is attributed to a combination of factors, such as population aging, fast urbanization, adoption of unhealthy lifestyles (sedentarism, sugar, fat, and calorie-rich food), and consequent increase of excess weight and obesity¹1. World Health Organization. Global status report on noncommunicable diseases 2014 [Internet]. Geneva: World Health Organization; 2014 [cited 2015 Jan 28]. 298 p. Available from: Available from: http://www.who.int/nmh/publications/ncd-status-report-2014/en/
http://www.who.int/nmh/publications/ncd-... ⁵5. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE, Brasil. Ministério da Saúde. Pesquisa Nacional de Saúde: Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. [Internet]. Rio de Janeiro: IBGE; 2014. 181 p. Available from: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf ⁶6. Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet 2011; 378(9785): 31-40. ⁷7. Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants. Lancet 2011; 377(9765): 557-67., besides the higher survival of patients¹1. World Health Organization. Global status report on noncommunicable diseases 2014 [Internet]. Geneva: World Health Organization; 2014 [cited 2015 Jan 28]. 298 p. Available from: Available from: http://www.who.int/nmh/publications/ncd-status-report-2014/en/
http://www.who.int/nmh/publications/ncd-... ⁸8. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2197-223.. There is also an important increase in the number of people that look for and use health services, reflecting on DM economical and social costs.

Costs with DM might reach 15% of the annual health budget of a country⁹9. Zhang P, Zhang X, Brown J, Vistisen D, Sicree R, Shaw J, et al. Global healthcare expenditure on diabetes for 2010 and 2030. Diabetes Res Clin Pract 2010; 87(3): 293-301.. Estimates of the annual total cost of care with the diseased subject in Brazil reach more than two thousand dollars per patient, considering direct (medicine, tests, procedures and supplies, professional visits, and hospital expenses in emergency services, besides nonmedical expenses such as transportation and purchase of dietetic products) and indirect costs (absence at work, loss of productivity, and early retirement)¹⁰10. Bahia LR, Araujo DV, Schaan BD, Dib SA, Negrato CA, Leão MPS, et al. The costs of type 2 diabetes mellitus outpatient care in the Brazilian public health system. Val Health 2011; 14(5 Suppl 1): S137-40..

Surveys that include questions about self-reported diabetes from the early disease diagnosis by a physician have provided estimates of diabetes valid prevalence¹¹11. Iser BPM, Malta DC, Duncan BB, de Moura L, Vigo Á, Schmidt MI. Prevalence, Correlates, and Description of Self-Reported Diabetes in Brazilian Capitals - Results from a Telephone Survey. PLoS ONE. 2014;9(9):e108044. ¹²12. Schmidt MI, Duncan BB, Hoffmann JF, Moura L, Malta DC, Carvalho RM. Prevalence of diabetes and hypertension based on self-reported morbidity survey, Brazil, 2006. Rev Saude Publica 2009; 43: 74-82. ¹³13. Okura Y, Urban LH, Mahoney DW, Jacobsen SJ, Rodeheffer RJ. Agreement between self-report questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure. J Clin Epidemiol 2004; 57(10): 1096-103., working as the population prevalence proxy. In 2013, the Brazilian National Health Survey (NHS) included several questions concerning self-reported diabetes and access to care measurements, which enable the assessment of aspects associated with care received by DM subjects.

This study aimed at describing care measurements that have been provided to patients with self-reported DM in Brazil.

METHODS

This is a cross-sectional study that applies data from the Brazilian NHS conducted in 2013, which is a home survey using a three-stage cluster sampling. The census sectors or a combination of sectors were the sampling primary units (SPUs); homes were the second-stage units; and residents aged 18 years or older were the third-stage units. A fixed number of private homes in each census sector was established through simple randomized sampling⁵5. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE, Brasil. Ministério da Saúde. Pesquisa Nacional de Saúde: Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. [Internet]. Rio de Janeiro: IBGE; 2014. 181 p. Available from: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf.

Within each home, from the list of residents developed in the interview, a resident aged 18 years or older was chosen to answer a specific questionnaire⁵5. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE, Brasil. Ministério da Saúde. Pesquisa Nacional de Saúde: Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. [Internet]. Rio de Janeiro: IBGE; 2014. 181 p. Available from: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf. The selected sample was composed of 81,357 domiciles, among which 69,994 were occupied and, therefore, eligible for the investigation. With an 8.1% nonresponse rate, the information was collected in 64,348 homes. More details about the methodology can be seen in specific publications⁵5. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE, Brasil. Ministério da Saúde. Pesquisa Nacional de Saúde: Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. [Internet]. Rio de Janeiro: IBGE; 2014. 181 p. Available from: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf ¹⁴14. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Júnior S, et al. National Health Survey in Brazil: design and methodology of application. Cien Saude Colet 2014; 19(2): 333-42..

Indicators concerning DM were described as to the access and use of services, access to medications, health, and prevention promotion measurements (Chart 1). The indicators were classified according to gender, age groups, race/skin color, and educational level for Brazil and specific macroregions. For data analysis, expansion factors or sample weights were used for the SPUs, the domiciles and all the residents, and for the chosen resident⁵5. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE, Brasil. Ministério da Saúde. Pesquisa Nacional de Saúde: Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. [Internet]. Rio de Janeiro: IBGE; 2014. 181 p. Available from: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf. Indicators were presented through the prevalence and its respective 95%CI, and the differences between the strata were assessed through the 95%CI interposition.

The Research Ethics National Committee approved the NHS project in June 2013, under protocol number 328.159.

RESULTS

Table 1 presents the synthesis of indicators on the presence of diabetes and care associated with the disease in Brazil and in large areas. About 6.2% of the participants, with lower percentages in the north (4.3%) and northeastern (5.4%) regions of the country (Table 1), reported medical diagnosis of DM. About 11.5% of the interviewed subjects mentioned that they never took a test to measure blood glucose.

About 80% of subjects with diabetes reported the use of oral hypoglycemic agents and/or insulin, with a higher percentage in the southeastern region (84.6%) when compared with northeastern (76%) and mid-western (75.6%) regions. The Programa Farmácia Popular (Popular Pharmacy Program) was the source of drug acquisition for 57.4% of the participants (Table 1).

From the 73.2% referring diabetes and those who received medical care in the last 12 months, 47.1% had their last appointment in a Health Basic Unit (HBU); the same physician from the previous appointments conducted it for 65.2%. Appointment frequency performed by the same doctor was significantly higher in the southern region (72.9%) when compared with the northeastern region (58.9%).

More than 95% of those who needed additional examinations reported on being able to take them (Table 1). This rate reaches 99% in the southern region. With regard to a specialist visit, 83.3% referred being able to go to all the necessary appointments. This percentage reached 91.5% in the midwestern region. About 35.6 and 29.1% of the subjects had their eyes and feet examined 12 months before the interview, respectively. About 13.4% of the patients with DM reported hospitalization, and 7.0% of the DM subjects mentioned a severe or very severe degree of limitations in their daily activities.

As to gender, Table 2 shows a higher proportion of men (15.8%) than women (7.8%) who have never taken an examination to measure blood glucose. The disease diagnosis was more frequent in the female sex (7.0 versus 5.4%). Use of medicine to control DM was reported more by men (81.2%). Hospitalizations were mentioned by 15% of the men and 12.2% of women. The severe/very severe level of limitations in daily activities was mentioned by 6.6% of men and 7.4% of women.

With regard to age range, the percentage of subjects who said they never took a blood glucose test was higher in the age group of 18 to 29 years (19.4%), with a progressive decrease until the age group of 65 to 74 years. Diabetes diagnosis increases progressively with growth, from 0.6% between 18 and 29 years to around 20% in the 65-year-old population. The use of oral medicine and/or insulin for diabetes was mostly reported by people with diabetes aged 65 to 74 years old when compared with those aged 18 to 59 years old (Table 3).

Table 4 introduces the indicators for educational level. The proportion of people who have never taken a blood glucose test was higher (14.2%) in the group with lower educational level, which is in contrast with 2.9% among those with higher education. Diabetes diagnosis was reported by 9.6% of the adults who did not finish middle school, and it decreased with higher educational level. Use of diabetes drugs was higher in the group with higher educational level (90.8%), whereas the drug acquisition through Programa Farmácia Popular was more usual in the groups with lower educational level (63.9%). Subjects with a lower educational level showed more appointments in a HBU. The performance of eye and feet tests 12 months before the interview was more common among those with higher educational level. Subjects with lower educational level presented more hospitalization frequency and more reports of severe/very severe limitation level (Table 4).

Diabetes diagnosis was less frequent in mulatto skin subjects than in those who reported being white. Black skin subjects were the ones who most acquired drugs in Farmácia Popular (69.4%), and the mulatto ones showed more appointments in the HBU (Table 5).

DISCUSSION

Results from the NHS showed that a great majority of adults had already measured their blood glucose level. About 6.2% of the adult population who referred diabetes diagnosis represented a population contingent of 9.1 million subjects with diabetes⁵5. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE, Brasil. Ministério da Saúde. Pesquisa Nacional de Saúde: Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. [Internet]. Rio de Janeiro: IBGE; 2014. 181 p. Available from: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf. About 70% received medical care in the last year and four-fifth were under drug treatment, with more than half of them receiving their drugs through Programa Farmácia Popular . The appointment was in the HBU for around 45% of the subjects who were taken care for DM, and in most of them, the physician in the last appointment was the same from previous ones. Almost all the patients could do the required examinations, and the majority of patients could go to all the appointments with a specialist. However, only 40 and 30% underwent an examination in the last year for their eyes and feet, respectively. Hospitalization owing to DM or other complication was seen in 13.4%, and other 7.0% reported limitations in their daily activities. Women and the older population, of higher educational level, white subjects, and residents living in the southern and southeastern regions declared more diagnosis and more access to medications and appointments.

As blood glucose performance is essential to diagnose diabetes, the results were in agreement. They show that the northern region, with a higher percentage of people who have never taken the test, was also the region that presented the lowest percentage of diagnosed disease. Similarly, the southeastern region showed the highest prevalence of diagnosis and the lowest number of subjects who have never taken the test. Similar results concerning the regional distribution were seen in the telephonic survey called Vigitel¹¹11. Iser BPM, Malta DC, Duncan BB, de Moura L, Vigo Á, Schmidt MI. Prevalence, Correlates, and Description of Self-Reported Diabetes in Brazilian Capitals - Results from a Telephone Survey. PLoS ONE. 2014;9(9):e108044. and in other studies of national scope¹⁵15. Brasil. Ministério do Planejamento Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatísticas - IBGE, Brasil. Pesquisa Nacional por amostra de domicílios (PNAD 2008). Um panorama da saúde no Brasil: acesso e utilização dos serviços, condições de saúde e fatores de risco e proteção à saúde: 2008.; Rio de Janeiro: IBGE 2010. ¹⁶16. Freitas LRS, Garcia LP. Evolução da prevalência do diabetes e deste associado à hipertensão arterial no Brasil: análise da Pesquisa Nacional por Amostra de Domicílios, 1998, 2003 e 2008. Epidemiol Serv Saude 2012; 21(1): 7-19.. These differences might be associated with availability and distance from health services (more access in the south and southeastern regions) and with sociodemographic and nutritional characteristics of each studied population (younger populations in the northeastern and northern of the country, for example)¹⁷17. Malta DC, Iser BPM, Andrade SSC, Moura L, Oliveira TP, Bernal RTI. Tendência da prevalência do diabetes melito autorreferido em adultos nas capitais brasileiras, 2006 a 2012. Epidemiol Serv Saude 2014; 23(4): 753-60..

For most of the indicators associated with health care, the southeastern region showed more prevalence, differently from the north and northeastern regions, although there were higher variations between the regions. This could happen, in part, because the health assistance and care depend not only on the availability of these services but also on the population understanding and their own acceptance of the disease, linked to the educational level of the population¹⁸18. Goldman N, Lin IF, Weinstein M, Lin YH. Evaluating the quality of self-reports of hypertension and diabetes. J Clin Epidemiol 2003; 56(2): 148-54..

Decrease in the percentage of people who have never taken a blood glucose level, age advance, and increase in the percentage of people who mentioned diabetes are justified results, owing to the disease chronic characteristic and the national¹⁹19. Brasil. Ministério da Saúde. Estratégias para o cuidado da pessoa com Doença Crônica. Diabetes mellitus. [Internet]. Brasília: Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica; 2013 [cited 2015 Jan 21]. 160 p. Available from: Available from: http://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... and international²⁰20. American Diabetes Association. Standards of Medical Care in Diabetes-2015. Diabetes Care 2015; 38(Suppl_1): S1-94. guidelines to track the disease after 45 years old, in the absence of known risk factors.

Diabetes medical diagnosis and the percentage of people who could never be diagnosed through glycemia measurement were equally higher among those with lower educational level. Thus, even with lower access to diagnosis, this group seems to be more vulnerable to the occurrence of the disease. Brazilian studies using data from the Home Sample National Survey (PNAD) had already seen the existence of a social gradient in the occurrence of chronic diseases, with a higher prevalence among the population with lower educational level and income¹⁶16. Freitas LRS, Garcia LP. Evolução da prevalência do diabetes e deste associado à hipertensão arterial no Brasil: análise da Pesquisa Nacional por Amostra de Domicílios, 1998, 2003 e 2008. Epidemiol Serv Saude 2012; 21(1): 7-19. ²¹21. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9): 3755-68..

We must also consider that a low educational level is usually focused on the older population, which could influence on the found disease frequency²¹21. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9): 3755-68.. In addition, the educational level, as a socioeconomic level proxy, is associated with differences in the access to health promotion practices such as healthy food, physical activity, and more access to health services²¹21. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9): 3755-68. ²²22. WHO, Fiocruz. Pesquisa Mundial de Saúde 2003. O Brasil em números. RADIS Comunicação em Saúde [Internet]. 2004; (23). Available from: http://www.ensp.fiocruz.br/publi/radis
http://www.ensp.fiocruz.br/publi/radis... ²³23. Travassos C, Oliveira EXG, Viacava F. Geographic and social inequalities in the access to health services in Brazil: 1998 and 2003. Cien Saude Colet 2006; 11(4): 975-86..

The protocol for appointments from the Brazilian Department of Health for basic attention preconizes an annual medical appointment for diabetes¹⁹19. Brasil. Ministério da Saúde. Estratégias para o cuidado da pessoa com Doença Crônica. Diabetes mellitus. [Internet]. Brasília: Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica; 2013 [cited 2015 Jan 21]. 160 p. Available from: Available from: http://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , which has been achieved in more than 80% of the people with diabetes. Appointment access was high and without variation as per sex, age, educational level, race/color, but with some regional variations: lower access in the northeastern region, and higher in the southeastern region. Access to specialists and examinations was also high; thus, the Unified Health System (SUS) has been favoring equity in the access to health care²⁴24. Magalhães Júnior HM. Redes de Atenção à Saúde: rumo à integralidade. Divulgação em Saúde para Debate 2014; 52: 15-37..

The Brazilian Department of Health recommends that every person with DM take a feet examination annually, with the aim of finding risk factors for ulcer and amputation¹⁹19. Brasil. Ministério da Saúde. Estratégias para o cuidado da pessoa com Doença Crônica. Diabetes mellitus. [Internet]. Brasília: Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica; 2013 [cited 2015 Jan 21]. 160 p. Available from: Available from: http://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . Similarly, retinopathy tracking must begin in the moment of type 2 diabetes diagnosis and after five years of type 1 diabetes, and it should be done every year¹⁹19. Brasil. Ministério da Saúde. Estratégias para o cuidado da pessoa com Doença Crônica. Diabetes mellitus. [Internet]. Brasília: Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica; 2013 [cited 2015 Jan 21]. 160 p. Available from: Available from: http://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ²⁰20. American Diabetes Association. Standards of Medical Care in Diabetes-2015. Diabetes Care 2015; 38(Suppl_1): S1-94.. Retinopathy is first asymptomatic, and its detection requires the performance of eye deep testing. These were the critical points of care provided to DM bearers: only 1/3 reported feet examination, whose frequency was even lower among mulatto color bearers, and only 35.6% took the ophthalmological assessment in the last year before the interview, with lower percentages among the less-educated subjects. Such frequencies were very below the results found for the North American population in the 2007-2010 period, when more than 70% of the diabetes patients reported annual examination of feet and eye²⁵25. Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of Goals in US. Diabetes Care, 1999-2010. N Engl J Med 2013; 368(17): 1613-24..

The fact that the frequency of hospitalizations and limitations from the disease was higher among the less-educated people can be a reflex of the biggest difficulties of disease acceptance and adhesion to treatment of this group²⁶26. Ross NA, Gilmour H, Dasgupta K. 14-year diabetes incidence: the role of socio-economic status. Health Rep 2010; 21(3): 19-28., especially in the previous years. However, lower use of drugs, even today, in this group, indicates the need of more attention to this population stratum in strategies to promote health. Access to diagnose and specialized services, such as performance of additional examinations, seems to be a facilitator for the white adults, which could be associated with the population socioeconomic level.

In general, hospitalizations happened in the presence of DM complications²⁷27. Borges NB, Ferraz MB, Chacra AR. The cost of type 2 diabetes in Brazil: evaluation of a diabetes care center in the city of São Paulo, Brazil. Diabetol Met Syndr 2014; 6(1): 122. ²⁸28. Oliveira AF, Valente JG, Leite Ida C, Schramm JM, Azevedo AS, Gadelha AM. Global burden of disease attributable to diabetes mellitus in Brazil. Cad Saude Pub 2009; 25(6): 1234-44. ²⁹29. Rosa R, Nita ME, Rached R, Donato B, Rahal E. Estimated hospitalizations attributable to diabetes mellitus within the public healthcare system in Brazil from 2008 to 2010: study DIAPS 79. Rev Assoc Med Bras 2014; 60(3): 222-30.. In Brazil, from 2008 and 2010, DM reached around 1.3 million hospitalizations in the public network; thus, it is responsible for 8 to 12% of the hospital expenses from SUS. Of the total, 10.6% of hospitalizations were owing to diabetes itself, and 36.6% were associated with chronical complications of the disease²⁹29. Rosa R, Nita ME, Rached R, Donato B, Rahal E. Estimated hospitalizations attributable to diabetes mellitus within the public healthcare system in Brazil from 2008 to 2010: study DIAPS 79. Rev Assoc Med Bras 2014; 60(3): 222-30.. The NHS showed that 13.4% of those who mentioned diabetes had already been hospitalized, and this frequency tended to be higher in younger, less educated, and nonwhite men.

The higher proportion of people referring hospitalization and limitations in their daily activities owing to the disease or its complications in the younger group reinforces the impact of the disease in quality of life, mainly, among subjects at productive age, thus affecting the aptitude to work¹⁰10. Bahia LR, Araujo DV, Schaan BD, Dib SA, Negrato CA, Leão MPS, et al. The costs of type 2 diabetes mellitus outpatient care in the Brazilian public health system. Val Health 2011; 14(5 Suppl 1): S137-40. ²⁷27. Borges NB, Ferraz MB, Chacra AR. The cost of type 2 diabetes in Brazil: evaluation of a diabetes care center in the city of São Paulo, Brazil. Diabetol Met Syndr 2014; 6(1): 122.. This finding might also be related to the occurrence of type 1 diabetes, which brings changes to younger people's lifestyle, especially, through the disease acute symptoms²⁰20. American Diabetes Association. Standards of Medical Care in Diabetes-2015. Diabetes Care 2015; 38(Suppl_1): S1-94. or even the possibility of lower adhesion to care practices among the younger subjects, as it is pointed out in a North American study²⁵25. Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of Goals in US. Diabetes Care, 1999-2010. N Engl J Med 2013; 368(17): 1613-24.. In a study about disease load conducted in 2009, on the other hand, the higher proportion of DALYs was seen among adults aged 45 to 69 years, despite the lower time of life to be lost by this age range²⁸28. Oliveira AF, Valente JG, Leite Ida C, Schramm JM, Azevedo AS, Gadelha AM. Global burden of disease attributable to diabetes mellitus in Brazil. Cad Saude Pub 2009; 25(6): 1234-44.. Furthermore, disease complications and hospitalizations would be more expected in the population with worse glycemic control and more disease time¹⁹19. Brasil. Ministério da Saúde. Estratégias para o cuidado da pessoa com Doença Crônica. Diabetes mellitus. [Internet]. Brasília: Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica; 2013 [cited 2015 Jan 21]. 160 p. Available from: Available from: http://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ²⁷27. Borges NB, Ferraz MB, Chacra AR. The cost of type 2 diabetes in Brazil: evaluation of a diabetes care center in the city of São Paulo, Brazil. Diabetol Met Syndr 2014; 6(1): 122..

The NHS also indicated the percentage of diabetics who used drugs two weeks before the interview in about 80%. Although the disease diagnosis is more frequent in women, the use of drugs tends to be higher among men. The higher search of women for health services, already reported in literature²¹21. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9): 3755-68., is in agreement to the lower percentage of not taking blood glucose testing, which can favor the female gender with an early diagnosis and, therefore, with the adoption of nonpharmacological measurements to control the disease, contrary to men. Similarly, lower use of drugs among younger adults (18 to 29 years) is possibly associated with a more recent diagnosis and a less-advanced disease, which are situations that favor the control through nonpharmacological measurements such as diet and physical activity. In diabetes treatment, non-pharmacological measurements can or cannot be complemented with drugs (oral hypoglycemic agent and, if necessary, insulin)¹⁹19. Brasil. Ministério da Saúde. Estratégias para o cuidado da pessoa com Doença Crônica. Diabetes mellitus. [Internet]. Brasília: Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica; 2013 [cited 2015 Jan 21]. 160 p. Available from: Available from: http://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ³⁰ 30. Duncan BB, Schmidt MI, Giugliani ERJ, Duncan MS, Giugliani C. Medicina Ambulatorial, Condutas de Atenção Primária Baseadas em Evidências. 4a ed. Porto Alegre RS: ArtMed; 2013. 1952 p..

The SUS distributed free medicine in the health basic network, including diabetes medications such as hypoglycemic agents, insulins, and inputs such as ribbons for glycemia and glycosuria. In 2011, the Programa Farmácia Popular in Brazil started to distribute free medicine for noncommunicable chronic diseases (hypertension, diabetes, and asthma), which can also help the access to these drugs³¹31. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022 [Internet]. Brasilia: Ministério da Saúde; [cited 2012 Jan 11]. 148 p. Available from: http://portal.saude.gov.br/ portal/saude/profissional/area.cfm?id_area=1818.
http://portal.saude.gov.br/ portal/saude... . Although the NHS has seen a high access to drugs through population, mainly among the most educated ones, more than 50% of them used the Programa Farmácia Popular , more frequently among the less-instructed adults and nonwhite ones; these results are similar to other studies³²32. Boing AC, Bertoldi AD, Boing AF, Bastos JL, Peres KG. Access to medicines in the public sector: analysis of users of the Brazilian Unified National Health System. Cad Saude Pub 2013; 29(4): 691-701. ³³33. Costa KS, Francisco PMSB, Barros MBA. Conhecimento e utilização do Programa Farmácia Popular do Brasil: estudo de base populacional no município de Campinas-SP. Epidemiol Serv Saúde 2014; 23(3): 397-408.. The medicine acquisition for diabetes with more frequency among the less-educated subjects characterizes one of the program objectives, which is to provide the population with lower social conditions and free access to treatment³¹31. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022 [Internet]. Brasilia: Ministério da Saúde; [cited 2012 Jan 11]. 148 p. Available from: http://portal.saude.gov.br/ portal/saude/profissional/area.cfm?id_area=1818.
http://portal.saude.gov.br/ portal/saude... . A study performed in Campinas, in 2008, had already highlighted this relation³³. Similarly, the HBU is more searched by the population with less educational level and nonwhite, thus reinforcing the role of SUS and basic attention in equity of care. Initial results from the National Survey about Access, Use, and Promotion of Rational Use of Drugs in Brazil (PNAUM), also conducted in 2013, indicated that 61% of diabetes medications were obtained in the SUS network and 18% through the Programa Farmácia Popular ³⁴34. Brasil. Ministério da Saúde. Pesquisa Nacional sobre Acesso, Utilização e Promoção do uso Racional de Medicamentos no Brasil - PNAUM. Primeiros resultados [Internet]. Brasília/DF: Ministério da Saúde; 2014 [cited 2015 Mar 2]. Available from: Available from: http://www.ufrgs.br/pnaum
http://www.ufrgs.br/pnaum... .

This is a study based on questionnaire data, which is an important limitation; therefore, control data of risk factors and larger measurements of health promotion were not assessed at this moment. Thus, its focus is restricted to care process. Studies in other countries, based on national surveys of health with several clinical and laboratorial examinations²⁵25. Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of Goals in US. Diabetes Care, 1999-2010. N Engl J Med 2013; 368(17): 1613-24., can go beyond process questions to compare clinical outcomes with previously established goals of care. In addition, diabetes diagnosis data and received care were self-reported by the interviewed participants; therefore, they are subject to report biases and depend on the disease acknowledgement by the subjects. Future analyses might be carried out to compare the reported and measured DM, because the NHS has also done biochemistry measurements in a subsample with the glycated hemoglobin (HbA1c)⁵5. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE, Brasil. Ministério da Saúde. Pesquisa Nacional de Saúde: Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. [Internet]. Rio de Janeiro: IBGE; 2014. 181 p. Available from: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf.

CONCLUSION

The study including data from the NHS allowed describing a panorama of diagnosis and care associated with DM in Brazil. Estimates point out that 1 in each of the 15 adults in Brazil reveal diabetes diagnosed by a physician.

Given the wide expansion of the public basic attention networks and health plans, access and coverage are possibly much larger than in previous years and indicate advances in diabetes care, although there are still some important challenges.

The small differences seen between population strata concerning the received health care emphasize the role of SUS in minimizing health inequities. It is important to also emphasize that the engagement of chronical disease bearers in their care is essential to maintain patients' quality of life and to prevent more severe outcomes¹⁹19. Brasil. Ministério da Saúde. Estratégias para o cuidado da pessoa com Doença Crônica. Diabetes mellitus. [Internet]. Brasília: Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica; 2013 [cited 2015 Jan 21]. 160 p. Available from: Available from: http://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . Favorable outcome in the glycemic control comes from the interaction of factors, such as motivation and adhesion of patients, of the counseled and received treatment, and of the organization and access to health services. The actions from the Plan of Actions to Fight Noncommunicable Chronic Diseases (2011-2022)³¹31. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022 [Internet]. Brasilia: Ministério da Saúde; [cited 2012 Jan 11]. 148 p. Available from: http://portal.saude.gov.br/ portal/saude/profissional/area.cfm?id_area=1818.
http://portal.saude.gov.br/ portal/saude... , with surveillance measurements, health promotion, protocols for full attention to diabetes patients, besides free drugs for noncommunicable chronic diseases, are essential to fight diabetes in Brazil.

References

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History