Hypertension in overweight and obese primary care patients is highly prevalent and poorly controlled

BACKGROUND: Although the relationship between body weight and blood pressure (BP) is well established, there is a lack of data regarding the impact of obesity on the prevalence of hypertension in primary care practice. The objective of this study was to assess the prevalence of hypertension and the diagnosis, treatment status, and control rates of hypertension in obese patients as compared to patients with normal weight. METHODS: A cross-sectional point prevalence study of 45,125 unselected consecutive primary care attendees was conducted in a representative nationwide sample of 1912 primary care physicians in Germany (HYDRA). RESULTS: Blood pressure levels were consistently higher in obese patients. Overall prevalence of hypertension (blood pressure >/=140/90 mm Hg or on antihypertensive medication) in normal weight patients was 34.3%, in overweight participants 60.6%, in grade 1 obesity 72.9%, in grade 2 obesity 77.1%, and in grade 3 obesity 74.1%. The odds ratio (OR) for good BP control (<140/90 mm Hg) in diagnosed and treated patients was 0.8 (95% confidence interval [CI] 0.7-0.9) in overweight patients, 0.6 (95% CI 0.6-0.7) in grade 1, 0.5 (95% CI 0.4-0.6) in grade 2, and 0.7 (95% CI 0.5-0.9) in grade 3 obese patients. CONCLUSIONS: The increasing prevalence of hypertension in obese patients and the low control rates in overweight and obese patients document the challenge that hypertension control in obese patients imposes on the primary care physician. These results highlight the need for specific evidence-based guidelines for the pharmacologic management of obesity-related hypertension in primary practice.     

Failure to Intensify Antihypertensive Treatment by Primary Care Providers: A Cohort Study in Adults with Diabetes Mellitus and Hypertension

Background Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications. Objective To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes. Design Non-concurrent prospective cohort study. Patients A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999–2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg). Measurements and Main Results Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were “routine” odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36–3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11–3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose >150 mg/dL (OR 0.54; 95% CI 0.31–0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38–0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41–1.03). Conclusions Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.     

Non-pharmacological treatment of hypertension in primary health care: a 2-year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland

OBJECTIVE: To assess whether lifestyle counselling is effective in non-pharmacological treatment of hypertension in primary health care. DESIGN: Open randomized controlled trial. SETTING: Ten municipal primary health care centres in eastern Finland. PATIENTS: Seven hundred and fifteen subjects aged 25-74 years with systolic blood pressure 140-179 mmHg and/or diastolic blood pressure 90-109 mmHg or antihypertensive drug treatment. INTERVENTIONS: Systematic health counselling given by local public health nurses for 2 years. MAIN OUTCOME MEASURES: Blood pressure, lipids and lifestyle data were collected annually. RESULTS: Among participants with no antihypertensive drug treatment, the net reductions after 1 year both in systolic blood pressure [-2.6 mmHg; 95% confidence interval (CI), -4.7 to -0.5 mmHg] and in diastolic blood pressure (-2.7 mmHg; 95% CI, -4.0 to -1.4 mmHg) were significant in favour of the intervention group. This difference in blood pressure change was maintained during the second year. In participants with antihypertensive drug treatment, no significant difference in blood pressure reduction was seen between the groups during the study. CONCLUSIONS: A relatively modest, but systematic counselling in primary health care can, at least among untreated hypertensive subjects, produce reductions in blood pressure levels that are modest for the individual, but very important from the public health point of view.     

Left ventricular mass change during treatment and outcome in patients with essential hypertension

BACKGROUND: It is uncertain whether reduction of left ventricular (LV) mass during antihypertensive treatment predicts reduces cardiovascular complications of hypertension. METHODS: A total of 172 prospectively identified patients with essential hypertension without complications of hypertension at baseline and follow-up echocardiograms 5.5 +/- 3.0 years apart, were followed an additional 4.8 +/- 2.9 years. Antihypertensive treatment was determined by primary physicians. RESULTS: After the second echocardiograms, cardiovascular events occurred in 24 patients (14%). Fewer of the 91 patients with unchanged or decreased LV mass experienced cardiovascular events than of the 81 patients whose LV mass increased during follow-up (8.8% [95% confidence interval (CI): 3.9%-13.7%] v 19.8% [95% CI 12.6%-27.0%]; P =.04) despite greater baseline LV mass in the former group (118 g/m(2) [95% CI 111-125] v 95 g/m(2) [95% CI 88-102]; P <.0001). Absence or presence of LV hypertrophy on the follow-up echocardiogram was the strongest predictor of relatively low (9.2% [95% CI 5%-13.4%]) v high (28.6% [95% CI 17.1%-40.1%]; P =.004) rates of subsequent morbid events. In multivariate analyses, only LV mass index at follow-up consistently predicted adverse outcomes. CONCLUSIONS: The LV mass reduction during antihypertensive treatment is associated with reduced rate of complications of essential hypertension. Our data further suggest that development or regression of LV hypertrophy during antihypertensive treatment may be more closely linked to prognosis than are changes in clinic blood pressure.     

Gender disparities in blood pressure control and cardiovascular care in a national sample of ambulatory care visits

The purpose of this study was to provide an analysis of gender-based disparities in hypertension and cardiovascular disease care in ambulatory practices across the United States. Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we conducted a cross-sectional analysis of patient visits with their primary care providers and examined the association between gender and blood pressure control, use of any antihypertensive medication or initiation of new therapy for patients with uncontrolled hypertension, and receipt of recommended therapy for select cardiovascular conditions. Multivariable models were estimated to examine the association between gender and each outcome controlling for other variables. A total of 12 064 patient visits were identified (7786 women and 4278 men). Among patients with hypertension, women were less likely than men to meet blood pressure control targets (54.0% versus 58.7%; P<0.02). In multivariate analyses, women aged 65 to 80 years were less likely than men to have controlled hypertension (odds ratio: 0.62; 95% CI: 0.45 to 0.85). There was no association between gender and use of any antihypertensive medication or initiating a new therapy among patients with uncontrolled hypertension. In multivariate analyses, women were less likely than men to receive aspirin (odds ratio: 0.43; 95% CI: 0.27 to 0.67) and beta-blockers (odds ratio: 0.60; 95% CI: 0.36 to 0.99) for secondary prevention of cardiovascular disease. Our study highlights the persistent gender disparities in blood pressure control and cardiovascular disease management and also reveals the inadequate delivery of cardiovascular care to all patients.     

Use of beta-blockers for uncomplicated hypertension in the elderly: a cause for concern

Beta-blockers are less beneficial than other antihypertensive drugs in the elderly with hypertension. All elderly patients in Ontario, Canada (population over 3.5 million elderly) without co-morbidities who were first treated for hypertension with a beta-blocker were studied in a retrospective population-based cohort study (1994-2002) to determine the characteristics of those prescribed beta-blockers. Of the 194,761 patients in our cohort, 25 485 (13%) were prescribed a beta-blocker as their first antihypertensive agent. On multivariate analysis, factors significantly associated with being prescribed a beta-blocker as first-line therapy included male sex (adjusted odds ratio (OR) 1.06 [95% CI 1.03-1.09] vs women), younger age (adjusted OR 1.67 [95% CI 1.55-1.79] for patients aged 66-69 vs those aged 85 or older), residence in a long-term care facility (adjusted OR 1.19 [95% CI 1.04-1.35] vs living in the community) and lower socioeconomic status (adjusted OR 1.07 [95% CI 1.02-1.12], for lowest quintile vs highest quintile). Patients with diabetes were substantially less likely to be prescribed beta-blockers (adjusted OR 0.42 [95% CI 0.40-0.44]). Greater efforts are required to educate physicians to select other drugs for initial therapy in older patients with uncomplicated hypertension.     

Randomized controlled economic evaluation of asthma self-management in primary health care

In this randomized controlled economic evaluation we compared guided asthma self-management with usual asthma care according to guidelines for Dutch family physicians. Nineteen family practices were randomized, and 193 adults with stable asthma (98 self-management, 95 usual care) were included and monitored for 2 years. We hypothesized that introducing self-management would not compromise asthma control and cost would be equal to or lower than in usual care. Patient-specific cost data were collected, preference-based utilities were assessed, and incremental cost per quality-adjusted life year (QALY) and successfully treated week gained was calculated. Self-management patients gained 0.039 QALY (95% confidence interval [CI], 0.003 to 0.075) and experienced 81 (95% CI, 78 to 84) successfully treated weeks in 2 years' time; the corresponding figures for usual care were 0.024 (95% CI, -0.022 to 0.071) and 75 (95% CI, 72 to 78). Total costs were 1,084 euros(95% CI, 938 to 1,228) for self-management and 1,097 euros (95% CI, 933 to 1,260) for usual care. Self-management patients consumed 1,680 (95% CI, 1,538 to 1,822) puffs of budesonide, usual care patients 1,897 (95% CI, 1,679 to 2,115). Mean productivity cost due to limited activity days was 213 euros lower among self-management patients. When all costs were included, self-management was cost-effective on all outcomes. The probability that self-management was cost-effective relative to usual care in terms of QALYs was 52%. We conclude that guided self-management is a safe and efficient alternative approach compared with asthma treatment usually provided in Dutch primary care.     

Risk factors for primary prevention of cardiovascular disease and risk reduction by lipid control: the OMEGA study risk factor sub-analysis

To identify risk factors for cardiovascular disease (CVD) in hypertensive patients with no history of CVD being treated with antihypertensive drugs, we examined subgroup data (n?=?13?052) from the prospective, observational Olmesartan Mega Study to Determine the Relationship between Cardiovascular Endpoints and Blood Pressure Goal Achievement (OMEGA) study. Risk factors for CVD, stroke and coronary heart disease (CHD) were examined using a Cox proportional hazards model. In addition, the effect of statin therapy at baseline on CHD prevention was analyzed in dyslipidemic patients. The factors significantly related to CVD were female (hazard ratio [HR]?=?0.637, 95% confidence interval [CI] 0.428–0.948), older age (65–69 years: HR?=?2.165, 95% CI 1.214–3.861; 70–74 years: HR?=?2.324, 95% CI 1.294–4.174; ≥75 years: HR?=?2.448, 95% CI 1.309–4.578), family history of CHD (HR?=?1.993, 95% CI 1.249–3.179), diabetes (HR?=?2.287, 95% CI 1.700–3.078), current smoking (HR?=?2.289, 95% CI 1.512–3.466) and alcohol drinking socially (HR?=?0.589, 95% CI 0.379–0.913). Diabetes was a risk factor for both stroke and CHD, while age, family history of CHD, and sodium intake score were risk factors for stroke alone. Sex, dyslipidemia, smoking and exercise habits were risk factors for CHD alone. The risk of CHD in dyslipidemic patients on statin treatment was comparable to the risk in patients without dyslipidemia (HR?=?1.134, 95% CI 0.604–2.126). However, in dyslipidemic patients not on statin treatment, the HR increased to 1.807 (95% CI 1.156–2.825). In conclusion, some risk factors for CVD in hypertensive patients being treated with antihypertensive drugs with no history of CVD differed between CHD and stroke. These results suggest the importance of managing dyslipidemia with a statin for primary prevention of CHD, as well as the importance of hypertension therapy.     

Characteristics Associated With Antihypertensive Treatment and Blood Pressure Control: A Population-Based Follow-Up Study in Peru

BackgroundOver one-quarter of the world's adult population has hypertension, yet achieving adequate treatment or control targets remains a challenge.ObjectiveThis study sought to identify, longitudinally, characteristics associated with antihypertensive treatment and blood pressure (BP) control among individuals with hypertension.MethodsData from individuals enrolled in the population-based CRONICAS Cohort Study (adults ≥35 years, living in 4 different rural/urban and coastal/high-altitude Peruvian settings) with hypertension at baseline were used. Antihypertensive treatment and BP control were assessed at baseline and at 15 months. Multinomial logistic regressions were used to estimate relative risk ratios (RRR) and 95% confidence intervals (95% CI) of factors associated with antihypertensive treatment and BP control at follow-up.ResultsAt baseline, among 717 individuals with hypertension (53% women, mean age 61.5 ± 12.4 years), 28% were unaware of their hypertension status, 30% were aware but untreated, 16% were treated but uncontrolled, and 26% were treated and controlled. At follow-up, 89% of unaware and 82% of untreated individuals persisted untreated, and only 58% of controlled individuals remained controlled. Positive predictors of receiving treatment and being controlled at follow-up included age (RRR: 0.81; 95% CI: 0.73 to 0.91 for every 5 years) and family history of a chronic disease (RRR: 0.53; 95% CI: 0.31 to 0.92 vs. no history); whereas Puno rural site (RRR: 16.51; 95% CI: 1.90 to 143.56 vs. Lima) and male sex (RRR: 2.59; 95% CI: 1.54 to 4.36) were risk factors. Systolic BP at baseline (RRR: 1.27; 95% CI: 1.16 to 1.39 for every 5 mm Hg) and male sex (RRR: 1.75, 95% CI: 1.02 to 2.98) were risk factors for being treated but uncontrolled at follow-up.ConclusionsLarge gaps in treatment of hypertension were observed. Targeting specific populations such as men, younger individuals, or those without family history of disease may increase coverage of antihypertensive treatment. Also, targeting male individuals or those with higher systolic BP could yield better rates of BP control in the short term.     

Predictors of self-reported noncompliance with antihypertensive drug treatment: a prospective cohort study

BACKGROUND: Persistence and compliance are different aspects of the broader concept of adherence to drug treatment. In a prior study, determinants of nonpersistence in a group of patients newly prescribed antihypertensive medications were examined. OBJECTIVE: To determine noncompliance among those who were persistent with therapy. METHODS: A prospective cohort study was conducted, in which individuals prescribed a new antihypertensive monotherapy were identified through a network of 173 pharmacies. Participants were interviewed by telephone twice during a three-month period. At the end of this period, individuals who reported still taking the medication initially prescribed were included in the analysis. Self-reported noncompliance was measured at three months. Data were analyzed using a multivariate logistic regression model. RESULTS: Of 509 eligible participants, 118 (23.2%) reported noncompliance with their drug treatment. Noncompliance was significantly associated with the use of angiotensin-converting enzyme inhibitors (adjusted OR [AOR] 3.0; 95% CI 1.17 to 7.92) compared with the angiotensin II receptor blocker losartan, and with the belief that hypertension is not a risk factor for cardiovascular diseases (AOR 2.0; 95% CI 1.21 to 3.33). On the other hand, noncompliance was inversely associated with the use of more than four pills of medication per day (AOR 0.3; 95% CI 0.15 to 0.64). CONCLUSIONS: Compliance with drug treatment could be improved by proper selection of medication, and by attempts to correct the false perceptions patients may have about hypertension. Further research is needed to better understand the clinical significance of a higher number of pills as a predictor of good compliance. Further research is also needed using different means of measuring noncompliance.     

Correlates of hypertension control in a primary care setting

BACKGROUND: Numerous clinical trials have demonstrated reduction in cardiovascular events as a result of lowering blood pressure (BP). Despite these findings, BP control rates, especially in primary care settings, remain suboptimal. This study describes hypertension control and its predictors, using data from a sample of 631 adult patients drawn from an established primary care practice. METHODS: Data were obtained through chart review and patient survey during a 3-month period. The BP control was the outcome in a logistic regression model identifying demographic and clinical predictors of control. RESULTS: Compared to patients with low Framingham Risk Scores (FRS), individuals with moderate and high scores had reduced odds of achieving control (69% reduction, 95% confidence interval [CI] 0.19-0.65; 82% reduction, 95% CI 0.10-0.36, respectively). Being female reduced the odds of control by 61% (95% CI 0.26-0.66). Having diabetes mellitus (DM) (95% CI 0.21-0.79) or impaired fasting glucose (IFG; fasting glucose >109 but <126 mg/dL) (95% CI 0.10-0.40) reduced the odds of control by 64% and 82%, respectively. For each additional point on a physician-rated patient knowledge scale, the odds of having controlled BP increased 78% (95% CI 1.44-2.56). Each additional co-morbid condition positively associated with control (34% increase in odds, 95% CI 1.15-1.86). Age (95% CI 0.98-1.02) and body mass index (BMI) (95% CI 0.97-1.04) had no effect. CONCLUSIONS: Higher FRS, female sex, DM, and IFG negatively correlated with control. Patient knowledge and number of co-morbid conditions correlated positively. Age and BMI did not correlate with control. The most disturbing finding in our study was that higher risk patients who stand to benefit most from BP control were least likely to be controlled, despite being on more antihypertensive medications. These findings may be helpful to primary care providers in reaching patient hypertension control goals.     

Levofloxacin treatment of active tuberculosis and the risk of adverse events

BACKGROUND: Fluoroquinolones are commonly used in the treatment of tuberculosis (TB) for drug-sensitive patients who are intolerant to first-line antituberculous agents or who are infected with drug-resistant organisms. Despite increasing use of these agents, there is little information on their tolerance outside of clinical trial settings. OBJECTIVES: To compare overall rate of major adverse events associated with levofloxacin-containing regimen to standard therapy. METHODS: Cases (levofloxacin-containing regimen) were matched by age and sex to their control subjects (standard first-line TB drugs). Eligible patients were identified from the provincial TB database from 2001 to 2004. Drug safety was assessed by evaluation of the nature of the adverse event, the likelihood of association with the study medications, and severity. Only major side effects, that is, those who had a severe or moderate adverse event that was categorized to be definitely, probably, or possibly related to the TB medications, were considered for the analysis. RESULTS: During the 3-year study period, 102 patients received levofloxacin, and 358 patients received first-line agents for treatment of active TB. There were no significant differences between the two groups except for indication (82% of patients in the levofloxacin group had an antecedent adverse event to first-line TB drugs, whereas 18% received levofloxacin because of resistance) and concurrent use of first-line drugs (majority of patients in the levofloxacin arm were not receiving concurrent isoniazid or rifampin). The rate of any major adverse event was almost half among those using levofloxacin as among those on standard therapies (rate ratio, 0.60; 95% confidence interval [CI], 0.44 to 0.82). After adjustment for the differences in exposure of concomitant medications, the rate of any major adverse event was similar between the levofloxacin and control arms (adjusted rate ratio, 0.83; 95% CI, 0.66 to 1.03). Furthermore, there was no difference between the levofloxacin and control arms with respect to CNS (adjusted rate ratio, 0.94; 95% CI, 0.61 to 1.43), GI tract (adjusted rate ratio, 0.81; 95% CI, 0.58 to 1.13), skin (adjusted rate ratio, 0.65; 95% CI, 0.38 to 1.10), or musculoskeletal (MSK) [adjusted rate ratio, 0.87; 95% CI, 0.48 to 1.60] related adverse events when adjusted for concomitant drugs. The results of the secondary analysis for the rate of major adverse events within the first 100 days were similar to the primary analysis. The time to the first major adverse event was similar between the levofloxacin group and the control group (adjusted hazards ratio, 1.01; 95% CI, 0.76 to 1.34). CONCLUSIONS: Concomitant use of a levofloxacin-containing regimen resulted in a similar rate of adverse events compared with conventional first-line regimens when used for treatment of active TB, despite a history of adverse events.     

Left ventricular concentric geometry during treatment adversely affects cardiovascular prognosis in hypertensive patients

Left ventricular (LV) mass and geometry predict risk for cardiovascular events in hypertension. Regression of LV hypertrophy (LVH) may imply an important prognostic significance. The relation between changes in LV geometry during antihypertensive treatment and subsequent prognosis has not yet been determined. A total of 436 prospectively identified uncomplicated hypertensive subjects with a baseline and follow-up echocardiogram (last examination 72+/-38 months apart) were followed for an additional 42+/-16 months. Their family doctor gave antihypertensive treatment. After the last follow-up echocardiogram, a first cardiovascular event occurred in 71 patients. Persistence of LVH from baseline to follow-up was confirmed as an independent predictor of cardiovascular events. Cardiovascular morbidity and mortality were significantly greater in patients with concentric (relative wall thickness > or =0.44) than in those with eccentric geometry (relative wall thickness <0.44) in patients presenting with LVH (P=0.002) and in those without LVH (P=0.002) at the follow-up echocardiogram. The incidence of cardiovascular events progressively increased from the first to the third tertile of LV mass index at follow-up (partition values 91 and 117 g/m2), but for a similar value of LV mass index it was significantly greater in those with concentric geometry (OR: 4.07; 95% CI: 1.49 to 11.14; P=0.004 in the second tertile; OR: 3.45; 95% CI: 1.62 to 7.32; P=0.001 in the third tertile; P<0.0001 in concentric versus eccentric geometry). Persistence or development of concentric geometry during follow-up may have additional prognostic significance in hypertensive patients with and without LVH.     

Gender differences in the treatment of hypertension: a community based study in Porto.

OBJECTIVES: To describe the use of antihypertensive drugs in a random sample of adults living in Porto, Portugal, and to identify gender differences in the treatment of hypertension. DESIGN: Observational, cross-sectional. PARTICIPANTS AND METHODS: Nine hundred and fifty-nine participants over 39 years of age, living in Porto, were selected by random digit dialing. For each subject, socioeconomic characterization, family and personal medical history, and information on antihypertensive treatment were obtained through a questionnaire. Blood pressure was measured on a single occasion, and a fasting blood sample was collected. Gender differences in the treatment of arterial hypertension and number and type of drugs were evaluated through the calculation of female:male proportion ratios and 95% confidence intervals (95% CI). RESULTS: Hypertension treatment was more frequent in women than in men (proportion ratio 1.40, 95% CI 1.15-1.72), although no differences were observed among hypertensives aware of their condition (proportion ratio 1.07, 95% CI 0.93-1.22). The female:male proportion ratios of treatment with one drug, fixed combination therapy and free combination therapy were 1.13 (95% CI 0.94-1.36), 0.83 (95% CI 0.34-2.01) and 0.76 (95% CI 0.49-1.19), respectively. In subjects treated with one drug the use of ACE inhibitors/AT-II antagonists was more frequent in men (proportion ratio 0.68, 95% IC 0.46-1.01) and treatment with diuretics higher in women (proportion ratio 1.83, 95% CI 1.04-3.23). In participants treated with combination therapy, ACE inhibitors/AT-II antagonists and diuretics were more frequently used by women and calcium channel blockers and beta-blockers by men (female:male proportion ratios were 1.27, 95% CI 0.96-1.68, 1.24, 95% CI 0.94-1.64, 0.61, 95% CI 0.37-1.02 and 0.74, 95% CI 0.31-1.79, respectively). CONCLUSIONS: Arterial hypertension tended to be more frequently treated among women and different therapeutic options were found according to gender. Gender differences in the awareness of hypertension, sexual specificity of the activity of antihypertensive drugs, and comorbidity may play a role in gender inequalities in the treatment of hypertension in Portugal.     

Factors influencing the cost of hospital care for people with diabetes in Australia

OBJECTIVES: To estimate the incidence of disease and annual disease-specific hospital costs for people with and without diabetes. RESEARCH DESIGN AND METHODS: A comparison of costs of Australian hospital care (1996-1999) in 20,538 persons with diabetes over the age of 35 years, using matched controls. Odds ratios were used to compare the incidence of new episodes of disease in both groups and regression analyses using annual costs, and log-transformed annual costs were used to estimate disease-specific hospital costs. RESULTS: People with diabetes had a higher incidence of all vascular diseases and a range of nonvascular diseases with the greatest difference being for amputation (odds ratio, 5.13; 95% CI, 3.11-8.47). The overall average cost for people with diabetes was 3676 dollars (S.D., 7756) compared to 2670 dollars (S.D., 6045) for controls. Forty percent of the 1005 dollars(95% CI, 927-1084) excess hospital costs were due to higher disease-specific costs, reflecting greater intensity of treatment, with the remainder due to the higher frequency of hospitalization. It was found that although treatment costs for a new comorbidity peaked in the first year for both groups, these higher costs continued over subsequent years for people with diabetes. CONCLUSIONS: The majority of the excess costs is due to the increased frequency of disease requiring hospitalization rather than intensity of treatment. This additional cost is due to extra admissions, increased length of stay per admission, and greater ongoing treatment costs in subsequent years. There continues to be potential for cost containment through improved preventative care.