Cost of ambulatory care of diabetes mellitus: a study from north India

Financial burden of seeking diabetes mellitus care in India: Evidence from a Nationally Representative Sample Survey

Background

Diabetes mellitus (DM) is a major public health concern in India, and entails a severe burden in terms of disability, death, and economic cost. This study examined the out-of-pocket health expenditure (OOPE) and financial burden associated with DM care in India.

Methods

The study used data from the latest round of the National Sample Survey on health, which covered 555,115 individuals from 113,823 households in India. In the present study, data of 1216 individuals who sought inpatient treatment and 6527 individuals who sought outpatient care for DM were analysed.

Results

In India, 10.04 per 1000 persons reported having DM during the last 15 days before the survey date, varying from 6.94/1000 in rural areas to 17.45/1000 in urban areas. Nearly 38% of Indian households with diabetic members experienced catastrophic health expenditure (at the 10% threshold) and approximately 10% of DM-affected households were pushed below the poverty line because of OOPE, irrespective of the type of care sought. 48.5% of households used distressed sources to finance the inpatient costs of DM. Medicines constituted one of the largest proportion of total health expenditure, regardless of the type of care sought or type of healthcare facility visited. The average monthly OOPE was over 4.5-fold and 2.5-fold higher for households who sought inpatient and outpatient care, respectively, from private health facilities, compared with those treated at public facilities. Notably, the financial burden was more severe for households residing in rural areas, those in lower economic quintiles, those belonging to marginalised social groups, and those using private health facilities.

Conclusion

The burden of DM and its associated financial ramifications necessitate policy measures, such as prioritising health promotion and disease prevention strategies, strengthening public healthcare facilities, improved regulation of private healthcare providers, and bringing outpatient services under the purview of health insurance, to manage the diabetes epidemic and mitigate its financial impact.

Cost of diabetes and its complications: results from a STEPS survey in Punjab, India

BACKGROUND

Diabetes mellitus is an obtrusive universal health emergency in developed and developing countries, including India. With the exponential rise of epidemiological conditions, the costs of treating and managing diabetes are on an upsurge. This study aimed to estimate the cost of diabetes and determine the determinants of the total cost among diabetic patients.

METHODS

This cross-sectional study was executed in the northern state of Punjab, India. It involves the multi-stage area sampling technique and data was collected through a self-structured questionnaire adapted following the "WHO STEPS Surveillance" manual. Mann-Whitney U and Kruskal-Wallis tests were performed to compare the cost differences in socio-demographic variables. Lastly, multiple linear regression was conducted to determine and evaluate the association of the dependent variable with numerous influential determinants.

RESULTS

The urban respondents' average direct and indirect costs are higher than rural respondents. Age manifests very eccentric results; the highest mean direct outpatient care expenditure of ₹52,104 was incurred by the respondents below 20 years of age. Gender, complications, income, history of diabetes and work status were statistically significant determinants of the total cost. Study reports a rapid increase in the median annual direct and indirect cost from ₹15,460 and ₹3572 in 1999 to ₹34,100 and ₹4200 in 2021.

CONCLUSIONS

The present study highlights that the economic jeopardy of diabetes can be managed by educating people about diabetes and its associated risk factors. The economic burden of diabetes could be restrained by formulating new health policies and promoting the use of generic medicines. The result of the study directs that expenditure on outpatient care is to be reimbursed under the 'Ayushman Bharat-Sarbat Sehat Bima Yojana'.

Rising cost of insulin: A deterrent to compliance in patients with diabetes mellitus

BACKGROUND AND AIMS

The rapid increase in burden of type 2 diabetes mellitus (T2DM), poses a huge medico-economic challenge, especially when the cost of care is funded by out-of-pocket expenses. The aim of this review is to highlight various issues associated with rising cost of insulin, prevalence of cost-related insulin underuse, insulin related cost-saving behaviors, and viable solutions for the benefit of patients with T2DM receiving insulin.

METHODS

Electronic databases (PubMed and Google Scholar) from 2000 to 2020 were searched using the key terms uncontrolled diabetes mellitus, insulin therapy, glycemic control, direct cost, indirect cost, out-of-pocket expenses, cost-related insulin underuse, cost-saving behaviors, and biosimilar insulin in developed countries and India.

RESULTS

In majority of the patients with T2DM on monotherapy, addition of another oral antidiabetic agent is required. Despite these measures, the target glycemic goals are not achieved in majority of the patients resulting in various complications. These complications can be prevented and target glycemic goals can be achieved with early initiation of insulin therapy. However, rising cost is a major deterrent to the lifelong use of insulin. This results in non-compliance and further deterioration of glycemic control. Recently, biosimilar insulins have revolutionized the management of T2DM and look promising from the economic point of view.

CONCLUSIONS

Biosimilar insulins are likely to further enhance the compliance of patients and should be used whenever feasible in patients with DM. However, the patient, along with prescriber should be allowed to make shared, informed decisions regarding the insulin they wish to use.

Financial burden for families of children with type 1 diabetes: a cross-sectional survey from North India

Introduction

Type 1 diabetes (T1D) incurs substantial out-of-pocket expenses (OOPE) on insulin and diabetes-related supplies. The information on OOPE is scarce from low- and middle-income countries. We aimed to estimate annual OOPE for children with T1D attending our diabetes clinic located in North India.

Methods

An online survey was conducted among parents of 380 children with T1D (mean age: 10.3 ± 4.6 years). Modified BG Prasad scale was used to estimate the socioeconomic status (SES).

Results

The mean duration of T1D was 3.6 ± 2.6 years; 54.9% of children were boys. The median HbA1c (IQR) was 7.9% (5–15%). 51.9% belonged to lower or lower-middle SES. Mean annual spending on glucose monitoring, insulin administration, and laboratory investigations were Indian Rupee (INR) 21,576, INR 28,965, and INR 5069, respectively (total INR 55,185, IQR: 26,575–105,027). The cost of a single visit to the doctor was approximately INR 2889. Thirty children required hospitalization during the last year, which costs INR 27,495 on average. 30.3% had more than 50% of their total family income spent on diabetes care, with a significant negative correlation with their SES (r =  – 0.738, p = 0.00). Only 11.6% were receiving financial support from any agency. 36.6% of families had to borrow money; the OOPE exceeded income from all sources in 8.2% of families.

Conclusions

There is a high financial burden of T1D care for North Indian children, almost on the verge of losing sustainability. Further studies are warranted to furnish larger OOPE data to guide policy decisions aimed at reducing direct costs to patients.

Cost of Ambulatory Care in Diabetes: Findings From a Non-Communicable Disease Clinic of a Tertiary Care Institute in Eastern India

Background: This study was conducted to evaluate the cost of ambulatory care of diabetes in a non-communicable disease (NCD) clinic in eastern India.

Methods: This hospital-based cross-sectional cost description study was conducted from July to August 2018. A total of 192 diagnosed cases aged 18-70 years with a minimum history of one year since diagnosis attending the NCD clinic for the first time were included. Information was collected using a pre-tested schedule based on the cost of illness approach that consisted of socio-demographic details, disease status, and cost of ambulatory care. Cost of the drugs was calculated using a standardized repository of drug costs. The estimated expenditure of previous three months was calculated and extrapolated to one year to calculate yearly expenditure.

Results: The mean age of the study participants was 43.93±10.41 years and the mean duration of diabetes was 6.64±6.08 years. The median direct cost due to diabetes was Rs 9560 (136.57 USD) annually. It was higher in females (Rs 10,056, 143.45 USD) than in males (Rs 9020, 128.85 USD). In direct medical costs, a major part was constituted by the drugs, oral hypoglycemic agents, and/or insulin (approximately 70%).

Conclusions: In an ambulatory framework too, diabetes causes a substantial financial burden on the individual in India. In the wake of resource constraints in Indian health settings, the public health system needs to be adequately strengthened by policymakers to address the growing number of diabetics and long-standing complications.

Economic costs of hospitalisation and length of stay in diabetes with coexisting hypertension with correlation to laboratory investigations: Where does India stand? A 5-year ground report

INTRODUCTION

The coexistence of diabetes mellitus (DM) and hypertension (HTN) worsens clinical outcomes and contributes to increased morbidity and mortality.

OBJECTIVE

This study aims to analyse the length of stay and healthcare costs by calculating the direct and indirect costs of diabetes with coexisting hypertension in North India.

METHODS

A prospective observational study was conducted at the medicine department of the three different hospitals.

RESULTS

The patients' mean age was (M = 53.8, SD = 11.5) years. Out of 1914 patients, 53.65% were female. Our study revealed that the median cost of medical supplies and equipment was 21.2 $. The median cost of dialysis was 47.5 $; the median cost of hospitalisation was 142.6 $. The treatment's median direct cost was 188.5 $, followed by the overall median cost of 295.6 $. The maximum overall cost of treatment was observed at 603.9 $. It was observed that maximum LOS was 14 days for patients having BPS between 140 and 159 mmHg and BPD between 110 and 119 mmHg, and minimum LOS was found 3.5 days.

CONCLUSION

The present study highlighted that diabetes coexisting hypertension poses a high-economic burden on patients. This study explored that highly significant result for BPS, BPD, FBS and HbA₁ c, whereas the significant results were obtained when RBS is compared with LOS and treatment costs. Our study concluded that mean difference of 9.24 $ in patients having FBS was 261-290 mg/dL and >290 mg/dL. The LOS is increased by 6.57 days for patients with BPS between 140 and 159 mmHg compared with BPS between 180 and 209 and above mmHg, which lowers treatment costs by -21.31$.

Socioeconomic Burden of Type 2 Diabetes with Complications on Families: A Hospital-Based Study in Puducherry

Introduction India is on the verge of diabetes mellitus (DM) epidemic. Within the near future, DM will put a big burden on India’s already vulnerable and resourced health care system. The objectives of the study were to (1) estimate DM treatment-related out-of-pocket expenditure (OOPE) among type 2 DM patients with complications from a tertiary care hospital and (2) estimate the economic burden on the household income of these patients due to DM treatment-related OOPE.

 

Methods A hospital-based cross-sectional study was conducted among known type 2 diabetic individuals with complications admitted in a tertiary care hospital. Using a structured pretested questionnaire required data, such as sociodemographic details, direct costs, and indirect costs in health care of DM, which were collected by a personal interview method.

Results Males constituted around 57% of the 100 patients who participated in the study. The average age of the population was 56 ± 10.03 years. The mean monthly income of family (in Indian Rupees [INR]) was 10,375.00 ± 9,201.55. Total expenditure includes the cost of medication, investigation, consultation fee, transportation, and miscellaneous expenditure. The average monthly OOPE in the management of DM for government and private facilities was INR 74 and 1,540, respectively. Among the total cost, the highest share was accrued toward medicines followed by diagnostics, miscellaneous, and transportation. There were 22% of families incurring catastrophic expenditure at the highest threshold of 40%. Socioeconomic status, history of at least one hospitalization in the past 6 months, and type of medications were factors found to be associated with costs.

Conclusion Heavy economic burden highlights the urgent need for the health care agencies and policy bodies to plan and prioritize local health policies and DM management schemes accordingly.

Social impact of end-stage renal disease requiring hemodialysis among patients with type-2 diabetes and their caregivers in Bengaluru, Karnataka

Introduction:

Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD) requiring hemodialysis. The social impact of a chronic disease like this is far reaching and often difficult to quantify.

Objectives:

To assess the social impact of ESRD among type 2 diabetics requiring hemodialysis and their caregivers.

Methods:

A cross-sectional study was carried out between February 2017 and 18 among patients with type 2 diabetes requiring hemodialysis and their caregivers, attending the dialysis unit at St. John's Medical College Hospital, Bengaluru, India. Social impact was assessed under the domains of stress (physiologic and psychologic), quality of life (QOL), cost of care, self-perceived burden, and caregiver burden. Study tools used were semi-structured interview schedule for sociodemographic data, details regarding diabetes, hemodialysis and cost of care, EuroQol-5D-3L, hemodialysis stressor scale, Cousineau Self-Perceived Burden Scale, and Caregiver Burden Scale.

Results:

A total of 160 participants were included. Majority were males (78%) between 46 and 60 years of age. Most participants experienced moderate stress due to hemodialysis (65%) and moderate self-perceived burden (47.5%). Five (10.6%) participants reported full health, while one (0.6%) reported poor health. Anxiety/depression (80.6%) was the top reported problem among all domains of QOL. Caregiver burden was moderate (53.9%). Annual median cost of direct medical expenditure was ₹258,600 (interquartile range [IQR]: 197,400–433,500) and ₹16,500 (IQR: 9,600–32,100) for nonmedical.

Conclusion:

We conclude that the social impact of ESRD among type 2 diabetics requiring hemodialysis and their caregivers was moderate. Routine counseling of patients receiving haemodialysis and support groups for patients as well as caregivers will help reduce the impact.

Economic menace of diabetes in India: a systematic review

AIM

Diabetes mellitus is recognised as a major chronic pandemic disease that does not consider any ethnic and monetary background. There is a dearth of literature on the cost of diabetes in the Indian context. Therefore, the present study aims to capture the evidence from the literature on the cost of diabetes mellitus in India.

METHODS

An extensive literature was reviewed from ACADEMIA, NCBI, PubMed, ProQuest, EBSCO, Springer, JSTOR, Scopus and Google Scholar. The eligibility criterion is based on 'PICOS' procedure, and only those studies which are available in the English language, published between 1999 and February 2019, indexed in ABDC, EBSCO, ProQuest, Scopus and peer-reviewed journals are included.

RESULTS

A total of thirty-two studies were included in the present study. The result indicates that the median direct cost of diabetes was estimated to be ₹18,890/- p.a. for the north zone, ₹10,585/- p.a. for the south zone, ₹45,792/- p.a. for the north-east zone and ₹8822/- p.a. for the west zone. Similarly, the median indirect cost of diabetes was ₹18,146/- p.a. for the north zone, ₹1198/- p.a. for the south zone, ₹18,707/- p.a. for the north-east and ₹3949/- p.a. for the west zone.

CONCLUSION

The present study highlighted that diabetes poses a high economic burden on individuals/households. The study directed the need to arrange awareness campaign regarding diabetes and associated risk factors in order to minimise the burden of diabetes.

Healthcare utilisation and expenditure patterns for cardio-metabolic diseases in South Asian cities: the CARRS Study

OBJECTIVE

To estimate average annual expenditures per person, total economic burden and distress health financing associated with the treatment of five cardio-metabolic diseases (CMDs-hypertension, diabetes, heart disease (angina, myocardial infarction and heart failure), stroke and chronic kidney disease) in three metropolitan cities in South Asia.

DESIGN

Cross-sectional surveys.

SETTING

We analysed community-based baseline data from the Centre for cArdio-metabolic Risk Reduction in South Asia (CARRS) Study collected in 2010-2011 representing Chennai and New Delhi (India), and Karachi (Pakistan).

PARTICIPANTS

We used data from non-pregnant adults (≥20 years) from the aforementioned cities that responded to a cost-of-illness questionnaire. We estimated health utilisation and expenditures among those reporting taking treatment(s) for the aforementioned CMDs in the last 1 year. We converted all costs to International Dollars (Int$ 2011) and inflated to 2018 values. The annual costs per person were stratified by city, sociodemographic characteristics, contributor of costs and financing methods. The total economic burden of CMDs for each city was projected using age-standardised prevalence and per-person costs of diseases reported in CARRS, applying these to population data from the most recent census. We also calculated distress financing (DF) as having to borrow or sell assets to pay for CMD treatment and identified sociodemographic groups at most risk of DF using multiple regression.

RESULTS

Of 16 287 CARRS participants, 2883 (17.7%) reported receiving treatment for CMDs. The total annual expenditures reported per patient for CMDs ranged from Int$358 to Int$2425. Medications constituted 46% of total direct expenditures and out-of-pocket (OOP) expenditures accounted for nearly 80% of financing these health expenditures. Total economic burdens of CMDs were Int$0.42 billion, Int$3.4 billion and Int$1.4 billion in Chennai, New Delhi and Karachi, respectively. Overall, 36.1% experienced DF, and women (OR=4.4), unemployed (OR=10.7) and uninsured (OR=8.1) adults experienced higher odds of DF.

CONCLUSION

CMDs are associated with large economic burdens in South Asia. Due to most payments coming from OOP expenditures and limited insurance, the odds of DF are high.

Gender differences in the risk factors for high and very high blood glucose levels: A study of Kerala

BACKGROUND AND AIMS

Worldwide, lifestyle is a significant risk factor for diabetes. Lifestyle changes can lead to differences in the extent of risk of diabetes among women and men. Kerala, a state with one of the best health indicators in India, has a high prevalence of diabetes. This study aimed at comparing the variations in the risk factors for HBG and VHBG among adult women and men in Kerala.

METHODS

Data from the fourth round of the National Family Health Survey (2015-16) used to examine the differences in the risk factors for HBG and VHBG in men and women aged 15-49 years. We used bivariate, multivariate and Population Attributable Risk (PAR) techniques for analysing the data.

RESULTS

Bivariate results have shown the pattern of HBG and VHBG prevalence in women and men was same among all the age groups; however, men show a higher HBG and VHBG than women in all the age groups. Prevalence of HBG and VHBG was higher in women with a primary education, who were poor and not working as compared to their male counterparts. PARs results show that the prevalence of VHBG was higher among obese men and women as compared to normal men and underweight women. Prevalence of HBG was higher among men as compared to women due to alcohol use and weekly consumption of non-vegetarian food.

CONCLUSIONS

The study suggests that there is an urgent need for targeted intervention programs to address the problem of HBG and VHBG in both men and women in Kerala to control blood glucose levels.

Drug Prescription Patterns and Cost Analysis of Diabetes Therapy in India: Audit of an Endocrine Practice

AIMS

The aim of this study was to analyze the current trend in the use of antidiabetes as well as other drugs for comorbidities along the duration of diabetes. The study also aimed to analyze the direct drug cost to patients.

SETTINGS AND DESIGN

Retrospective cross-sectional study.

SUBJECTS AND METHODS

Data captured in clinic electronic medical records of an endocrine practice was analyzed.

STATISTICAL ANALYSIS USED

Data was analyzed descriptively using machine learning codes on python platform.

RESULTS

Records of 489 people who attended the clinic during the 6-month period were retrieved. Data of 403 people with diabetes were analyzed after exclusion of incomplete data. Use of antidiabetic drug increased from 1.44 (0.78) [mean (standard deviation)] in people with a duration of diabetes <5 years to 3.18 (1.05) in people with 20+ years of diabetes. The mean number of antidiabetic drug usage seems to plateau at 15 years of diabetes. About 46% of people with 20+ years of diabetes required insulin therapy. Prescription patterns involving a combination of different drug classes in patients were also analyzed. The cost of diabetes therapy increases linearly along the duration of diabetes.

CONCLUSION

This study provides valuable insights on temporal prescription patterns of antidiabetic drugs from an endocrine practice. Metformin remains the most preferred drug across the entire duration of diabetes. Dipeptidyl peptidase-4 inhibitors seem to be fast catching up with sulfonylureas as a second-line treatment after metformin. After 20 years or more of diabetes duration, 46% people would require insulin for glycemic control.

The economic impact of non-communicable diseases among households in South Asia and their coping strategy: A systematic review

Background

Out of pocket payment (OOPP), is the major health financing mechanism in South Asia region. With the rising burden of non-communicable diseases (NCDs), the region is facing a high financial burden. However, the extent and nature of economic impact caused by treatment and management of NCDs at the household level is yet unknown.

Method

We conducted a systematic review using Medline and Embase databases. Only peer-reviewed quantitative studies published between January 2000 to December 2016 assessing OOPP or catastrophic health expenditure or impoverishment or financial coping strategy due to at least one of the four major NCDs—cardiovascular diseases(CVDs), diabetes, cancer, chronic respiratory disease in South Asia region was included in the review. The review is registered in PROSPERO no: CRD42017059345.

Results

A total of 21 studies (of 2693 records identified) met the inclusion criteria. The economic impact was most frequently studied in CVDs and in terms of OOPP. The studies collectively indicated high OOPP, higher likelihood of catastrophic expenditure and impoverishment for inpatient care for these major NCDs which was visible in all income levels. Borrowing and selling off assets were the most common forms of coping strategies adopted and varied inconsistently between urban and rural households. The true extent of the economic impact, however, remains difficult to determine due to methodological heterogeneity regarding outcomes reported and measures employed for calculation of OOPP, catastrophic expenditure, and impoverishment across these four major NCDs and between nations.

Conclusion

The economic impact due to treatment and management of CVDs, diabetes, cancer and chronic respiratory diseases among households in South Asia seems dire. Given the lack of sufficient evidence the review stresses the need for further research in the region to develop evidence-informed nationally tailored prepayment mechanisms covering NCDs to reduce economic vulnerability and standardization of tools measuring the economic impact for generating comparable estimates.

Direct and indirect cost of diabetes care among patients with type 2 diabetes in private clinics: a multicenter study in Punjab, Pakistan

BACKGROUND

Diabetes mellitus (DM) has a very high prevalence and poses a huge financial encumbrance on patients. This study aimed to evaluate the cost of diabetes care among patients with type 2 diabetes in private clinics of southern Punjab, Pakistan.

RESEARCH DESIGN AND METHODS

This was a descriptive, cross-sectional, prevalence-based, cost-of-illness (COI) study conducted in six private clinics of southern Punjab from July to September 2016, using a pretested questionnaire. Study participants were recruited using a random selection method. Continuous variables, including direct and indirect costs, were summarized using descriptive statistics. Inferential statistics were also used to analyze the correlation between the variables and cost.

RESULTS

The mean annual direct cost per patient with diabetes was estimated to be 332 USD. Medications accounted for the largest share (60.4%) of this cost. Age, locality, high socioeconomic status, and prolonged disease duration were significantly associated with the direct costs of illness (p < 0.05). Moreover, 19% of total earnings among very low-income patients were spent on diabetes care.

CONCLUSIONS

A substantial proportion of patients' income is spent on diabetes care in Punjab. Our findings support the substantial individual and societal burden caused by diabetes.

Costos de un programa de atención primaria en salud para manejo dela hipertensión arterial en Colombia

Objetivo Determinar el costo de la atención de la hipertensión arterial, su impacto en el estadio de la enfermedad en un grupo de pacientes de una IPS en Tunja Boyacá Colombia.Metodología estudio transversal de costo-efectividad. Se estudiaron 172 historias clínicas de pacientes con HTA de Tunja Colombia.Resultados El costo de atención promedio en primer nivel fue de $184 631 pesos mes/paciente, el 61% es gasto en talento humano, 20% en laboratorios y 10% en medicamentos. El cumplimiento frente a lo programado fue de 72.1%.Conclusiones El talento humano consume más del 50% de los recursos en el manejo de la HTA pero repercute en su control y manejo positivamente. Las cifras tensionales demuestran un manejo controlado de los pacientes del programa, el 61% de los mismos tenían cifras normales y 53% demuestran una clasificación en los estadios normales. La hipertensión arterial consume gran cantidad de recursos, por lo que deberá ser objeto de estudio por equipos multidisciplinarios de salud, en la búsqueda de alternativas de manejo más eficientes.

The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study: Design and methods to address mental healthcare gaps in India

INTRODUCTION

Depression and diabetes are highly prevalent worldwide and often co-exist, worsening outcomes for each condition. Barriers to diagnosis and treatment are exacerbated in low and middle-income countries with limited health infrastructure and access to mental health treatment. The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study tests the sustained effectiveness and cost-effectiveness of a multi-component care model for individuals with poorly-controlled diabetes and depression in diabetes clinics in India.

MATERIALS AND METHODS

Adults with diabetes, depressive symptoms (Patient Health Questionnaire-9 score≥10), and ≥1 poorly-controlled cardiometabolic indicator (either HbA1c≥8.0%, SBP≥140mmHg, and/or LDL≥130mg/dl) were enrolled and randomized to the intervention or usual care. The intervention combined collaborative care, decision-support, and population health management. The primary outcome is the between-arm difference in the proportion of participants achieving combined depression response (≥50% reduction in Symptom Checklist score from baseline) AND one or more of: ≥0.5% reduction in HbA1c, ≥5mmHg reduction in SBP, or ≥10mg/dl reduction in LDL-c at 24months (12-month intervention; 12-month observational follow-up). Other outcomes include control of individual parameters, patient-centered measures (i.e. treatment satisfaction), and cost-effectiveness.

RESULTS

The study trained seven care coordinators. Participant recruitment is complete - 940 adults were screened, with 483 eligible, and 404 randomized (196 to intervention; 208 to usual care). Randomization was balanced across clinic sites.

CONCLUSIONS

The INDEPENDENT model aims to increase access to mental health care and improve depression and cardiometabolic disease outcomes among complex patients with diabetes by leveraging the care provided in diabetes clinics in India (clinicaltrials.gov number: NCT02022111).

Prevalence of type 2 diabetes and its complications in India and economic costs to the nation

Diabetes, a major lifestyle disorder, has become a global burden, and the prevalence rates are rising steeply in developing economies. Rapid socioeconomic transition with urbanization and industrialization are the main causes for the global diabetes epidemic. Among developing economies, the highest increase in number of people with diabetes is in China followed by India. In India, the epidemic of diabetes continue to increase and is experiencing a shift in diabetes prevalence from urban to rural areas, the affluent to the less privileged and from older to younger people. Diabetes is a progressive disorder leading to complications, which are broadly divided into small vessel or microvascular disease and large vessel or macrovascular disease. Microvascular complications affect the inner part of the eye-the retina known as diabetic retinopathy, the kidney termed as diabetic nephropathy and the peripheral nerves termed as diabetic neuropathy. The macrovascular complications affect the heart, the brain and the peripheral arteries termed as cardiovascular disease, cerebrovascular disease and peripheral vascular disease, respectively. Given the lifelong expenditure associated with diabetes and its complications, individuals, families and the society are unable to cope with the economic, emotional and social disease burden due to diabetes. The economic burden of diabetes can be reduced by providing universal healthcare coverage, access to affordable medicines and early detection and treatment of the disorder. This emphasizes the need for a multi-prolonged strategy to minimize the burden of diabetes and its complications.

Assessment of Economic Impact Among In-Patients with Non-Communicable Diseases in a Private Tertiary Care Hospital in Southern India

INTRODUCTION

Non-communicable diseases (NCDs) are currently responsible for tremendous economic impact on households.

AIM

This study was done to estimate the direct, indirect and total costs incurred by households of in-patients with non-communicable diseases admitted in a Private tertiary care hospital.

MATERIALS AND METHODS

It was a cross-sectional study conducted in a private tertiary care hospital of Mangalore city in June 2012 by interviewing 30 patients and their attenders using a validated interview schedule.

RESULTS

Direct cost constituted 58.6% of the total expenses during the course of stay in the hospital. Mean direct cost was more among patients with cancers (p=0.049). Indirect cost was associated with educational status (p=0.04), occupational status (p<0.001) and socio economic status (ses) (p<0.001) of patients. Total cost was more among patients from upper middle ses households (p=0.012). Direct and indirect cost constituted 5-10% each and total cost > 20% of the annual income of majority of households. Medical insurance scheme was not availed by 26 (86.7%) patients due to ignorance.

CONCLUSION

Economic burden imposed by a single admission among inpatients with NCDs was tremendous on their households. Hence, information on various medical insurance schemes needs to be popularized among people to improve its utilization. Health care providers need to introduce more financial schemes to minimize health care costs among poor households.

Does pharmacist-supervised intervention through pharmaceutical care program influence direct healthcare cost burden of newly diagnosed diabetics in a tertiary care teaching hospital in Nepal: a non-clinical randomised controlled trial approach

BACKGROUND

Cost is a vital component for people with chronic diseases as treatment is expected to be long or even lifelong in some diseases. Pharmacist contributions in decreasing the healthcare cost burden of chronic patients are not well described due to lack of sufficient evidences worldwide. In developing countries like Nepal, the estimation of direct healthcare cost burden among newly diagnosed diabetics is still a challenge for healthcare professionals, and pharmacist role in patient care is still theoretical and practically non-existent. This study reports the impact of pharmacist-supervised intervention through pharmaceutical care program on direct healthcare costs burden of newly diagnosed diabetics in Nepal through a non-clinical randomised controlled trial approach.

METHODS

An interventional, pre-post non-clinical randomised controlled study was conducted among randomly distributed 162 [control (n = 54), test 1 (n = 54) and test 2 (n = 54) groups] newly diagnosed diabetics by a consecutive sampling method for 18 months. Direct healthcare costs (direct medical and non-medical costs) from patients perspective was estimated by 'bottom up' approach to identify their out-of-pocket expenses (1USD = NPR 73.38) before and after intervention at the baseline, 3, 6, 9 and 12 months follow-ups. Test groups' patients were nourished with pharmaceutical care intervention while control group patients only received care from physician/nurses. Non-parametric tests i.e. Friedman test, Mann-Whitney U test and Wilcoxon signed rank test were used to find the differences in direct healthcare costs among the groups before and after the intervention (p ≤ 0.05).

RESULTS

Friedman test identified significant differences in direct healthcare cost of test 1 (p < 0.001) and test 2 (p < 0.001) groups patients. However, Mann-Whitney U test justified significant differences in direct healthcare cost between control group and test 1 group, and test 2 group patients at 6-months (p = 0.009, p = 0.010 respectively), 9-months (p = 0.005, p = 0.001 respectively) and 12-months (p < 0.001, p < 0.001 respectively).

CONCLUSION

Pharmacist supervised intervention through pharmaceutical care program significantly decreased direct healthcare costs of diabetics in test groups compared to control group and hence describes pharmacist's contribution in minimizing direct healthcare cost burden of patients.

Medication adherence and direct treatment cost among diabetes patients attending a tertiary healthcare facility in Ogbomosho, Nigeria

BACKGROUND

Diabetes mellitus (DM) is now prevalent in many countries in sub-Saharan Africa, with associated health and socioeconomic consequences. Adherence to antidiabetic medications has been shown to improve glycaemic control, which subsequently improves both the short- and long-term prognosis of the disease. The main objective of this study was to assess the level of adherence to antidiabetic drugs among outpatients in a teaching hospital in southwestern Nigeria.

METHODS

A cross-sectional study was carried out using the eight-item Morisky Medication Adherence Scale (MMAS-8) among diabetic patients attending the medical outpatients' diabetes clinic of Ladoke Akintola University Teaching Hospital, in Ogbomosho, Oyo State in southwestern Nigeria, during a three-month period (October to December 2013).

RESULTS

A total of 129 patients participated in the study with a male-to-female ratio of 1:1.5. Seventy-eight (60.5%) patients had systemic hypertension as a comorbid condition while the remaining were being managed for diabetes mellitus alone. Only 6 (4.7%) of the patients had type 1 DM while the remaining 123 (95.3%) were diagnosed with type 2 DM. Metformin was the most prescribed oral hypoglycaemic agent (n = 111, 58.7%) followed by glibenclamide (n = 49, 25.9%). Medication adherence was classified as good, medium, and poor for 52 (40.6%), 42 (32.8%), and 34 (26.6%) patients, respectively. Medication costs accounted for 72.3% of the total direct cost of DM in this study, followed by the cost of laboratory investigations (17.6%).

CONCLUSION

Adherence of diabetes patients in the study sample to their medications was satisfactory. There is a need for the integration of generic medicines into routine care as a way of further reducing the burden of healthcare expenditure on the patients.

Assessment of cost of illness for diabetic patients in South Indian tertiary care hospital

Background:

The impact of diabetes on health-care expenditures has been increasingly recognized. To formulate an effective health planning and resource allocation, it is important to determine economic burden.

Objective:

The objective of this study is to assess the cost of illness (COI) for diabetic inpatients with or without complications.

Methodology:

The study was conducted in the medicine wards of tertiary care hospital after ethical approval by the Institutional Ethical Committee. A total of 116 each diabetic with or without complications were selected and relevant data were collected using COI questionnaire and data were analyzed using SPSS version 20. Mann–Whitney U test is used to assess the statistical significant difference in the cost of treatment of diabetes alone and with complications’. P ≤ 0.05 was considered statistically significant.

Results:

Total COI includes the cost of treatment, investigation, consultation fee, intervention cost, transportation, days lost due to work, and hospitalization. The median of total COI for diabetic care without any complication was Rs. 22,456.97/- per patient per annum and with complication was Rs. 30,634.45/-. Patients on dialysis had to spend 7.3 times higher, and patients with cardiac intervention had to spend 7.4 times higher than diabetic patients without any complication.

Conclusion:

Treatment costs were many times higher in patients with complications and with cardiac and renal interventions. Complications in diabetic patients will increase the economic burden to family and also to the society.

Socioeconomic factors relating to diabetes and its management in India

Diabetes is an escalating problem in India and has major socioeconomic dimensions. Rapid dietary changes coupled with decreased levels of physical activity have resulted in increases in obesity and diabetes in rural and semi-urban areas, as well as in urban-based people living in resettlement colonies. Increasing risk has also been recorded in those who suffered from poor childhood nutrition and in rural-to-urban migrants. Social inequity manifests in disparities in socioeconomic status (SES), place of residence, education, gender, and level of awareness and affects prevention, care, and management. All these population subsets have major socioeconomic challenges: low levels of awareness regarding diabetes and prevention, inadequate resources, insufficient allotment of healthcare budgets, and lack of medical reimbursement. Unawareness and delays in seeking medical help lead to complications, resulting in many-fold increased costs in diabetes care. These costs plunge individuals and households into a vicious cycle of further economic hardship, inadequate management, and premature mortality, resulting in more economic losses. At the societal level, these are massive losses to national productivity and the exchequer. Overall, there is an immediate need to strengthen the healthcare delivery system to generate awareness and for the prevention, early detection, cost-effective management, and rehabilitation of patients with diabetes, with a focus on people belonging to the lower SES and women (with a particular focus on nutrition before and during pregnancy). Because of an enhanced awareness campaign spearheaded through the National Program on Prevention of Cardiovascular Disease, Cancer, Diabetes and Stroke (NCPCDS) initiated by Government of India, it is likely that the level of awareness and early detection of diabetes may increase.

Profile and analysis of diabetes chronic complications in Outpatient Diabetes Clinic of Cipto Mangunkusumo Hospital, Jakarta

Background: Chronic complications of diabetes mellitus have a significant role in increasing morbidity, mortality, disability, and health cost. In the outpatient setting, the availability of data regarding to the chronic complications of type 2 diabetes is useful for evaluation of prevention, education, and patient’s treatment. This study aimed to describe the characteristic of type 2 diabetes chronic complications in outpatient diabetes clinic.Methods: A cross-sectional study was done using 155 patients in Outpatient Diabetes Clinic of Cipto Mangunkusumo Hospital (RSCM), Jakarta in 2010. Secondary data were used from medical record based on history taking, physical examination, diabetic foot assessment, laboratory, neurologic, cardiology, opthalmology, ankle brachial index, and electrography of the patients. Characteristic profiles of the subjects, prevalence of the chronic complications, and its association with diabetes risk factors, such as glycemic control using HbA1c, fasting blood glucose, duration of diabetes, and LDL cholesterol were analyzed using chi square test.Results: Among 155 subjects participated in the study, most of them were women (59%) and elderly (46%). The prevalence of diabetes chronic complications was 69% from all subjects. These chronic complications included microangiopathy, macroangiopathy and mixed complications, with prevalence of 56%, 7% and 27% respectively. Microangiopathy included nephropathy (2%), retinopathy (7%), neuropathy (38%) and mixed complications (53%). Macroangiopathy included coronary heart disease (46%), peripheral arterial disease (19%), stroke (18%), and mixed complication (17%). From the analysis, we found significant association between duration of diabetes and diabetic neuropathy (p = 0.003).Conclusion: Prevalence of diabetes chronic complications in Outpatient Diabetes Clinic of Cipto Mangunkusumo Hospital, mainly dominated by microvascular-related complications including nephropathy, retinopathy, neuropathy and mixed complications. There was statistical significance between diabetes duration and diabetic neuropathy.

Population Study of Urban, Rural, and Semiurban Regions for the Detection of Endovascular Disease and Prevalence of Risk Factors and Holistic Intervention Study: Rationale, Study Design, and Baseline Characteristics of PURSE-HIS

We designed and implemented the PURSE-HIS (Population Study of Urban, Rural and Semiurban Regions for the Detection of Endovascular Disease and Prevalence of Risk Factors and Holistic Intervention Study) to understand the prevalence and progression of subclinical and overt endovascular disease (EVD) and its risk factors in urban, semiurban, and rural communities in South India. The study is also designed to generate clinical evidence for effective, affordable, and sustainable community-specific intervention strategies to control risks factors for EVD. As of June 2012, 8,080 (urban: 2,221; semiurban: 2,821; rural: 3,038) participants >20 years of age were recruited using 2-stage cluster sampling. Baseline measurements included standard cardiovascular disease risk factors, sociodemographic factors, lifestyle habits, psychosocial factors, and nutritional assessment. Fasting blood samples were assayed for putative biochemical risk factors and urine samples for microalbuminuria. All nondiabetic participants underwent oral glucose tolerance test with blood and urine samples collected every 30 min for 2 h. Additional baseline measurements included flow-mediated brachial artery endothelial vasodilation, assessment of carotid intimal medial wall thickness using ultrasonography, screening for peripheral vascular disease using ankle and brachial blood pressures, hemodynamic screening using a high-fidelity applanation tonometry to measure central blood pressure parameters, and aortic pulse wave velocity. To assess prevalence of coronary artery disease, all participants underwent surface electrocardiography and documentation of ventricular wall motion abnormality and function using echocardiography imaging. To detect subclinical lesions, all eligible participants completed an exercise treadmill test. Prospectively, the study will assess progression of subclinical and overt EVD, including risk factor-outcome relation differences across communities. The study will also evaluate community-specific EVD prevention using traditional Indian system of medicine versus recognized allopathic (mainstream) systems of medicine.

Economic burden of diabetes in urban indians

Purpose :

To find out the average economic burden of medical care on a patient with diabetes in Pune, India

Methods :

A semi-open ended questionnaire followed by interview was conducted with patients attending diabetes and ophthalmic out-patient departments. They were asked regarding the duration of diabetes, methods undertaken for blood sugar control and the amount they spend on consultations, laboratory tests, medicines and procedures if any within past year. Expenditure was classified as direct cost (cost of medicines, doctor’s fees, investigations, lasers and surgery) and indirect cost (travel, diet control, health classes and loss of wages). Data was collected regarding the socioeconomic status according to Kuppaswamy classification.

Results :

219 patients participated of whom 129 were males (58.9%). Average annual direct cost of diabetes treatment was Rs 8,822 of which 52.1% was spend on medicines, 3.2% was spend on lasers, 12.6% was spend on surgical procedures, 11.6% spent on investigations and 10.4% was spend on clinician fees. Average annual indirect cost was Rs. 3949 of which 3.4% was spend on travelling purpose, 0.4% was spent on health classes, 4.9% was spent on diet control and 91.3% was loss of wages. Average expenditure done by lower middle class was 23.7% of their income. Average percentage of income for direct and indirect cost was 3.6% and 1.4% respectively. The cost of the treatment formed1.3% of the annual income for those in Socio-economic class I, 1.7% in class II, 3.7% in class III and 23.7% in class IV.

Conclusion :

The cost of managing diabetes was a significant proportion of the patients’ income, especially for those on lower socio-economic scale (class IV).

The global impact of non-communicable diseases on households and impoverishment: a systematic review

The global economic impact of non-communicable diseases (NCDs) on household expenditures and poverty indicators remains less well understood. To conduct a systematic review and meta-analysis of the literature evaluating the global economic impact of six NCDs [including coronary heart disease, stroke, type 2 diabetes mellitus (DM), cancer (lung, colon, cervical and breast), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD)] on households and impoverishment. Medline, Embase and Google Scholar databases were searched from inception to November 6th 2014. To identify additional publications, reference lists of retrieved studies were searched. Randomized controlled trials, systematic reviews, cohorts, case-control, cross-sectional, modeling and ecological studies carried out in adults and assessing the economic consequences of NCDs on households and impoverishment. No language restrictions. All abstract and full text selection was done by two independent reviewers. Data were extracted by two independent reviewers and checked by a third independent reviewer. Studies were included evaluating the impact of at least one of the selected NCDs and on at least one of the following measures: expenditure on medication, transport, co-morbidities, out-of-pocket (OOP) payments or other indirect costs; impoverishment, poverty line and catastrophic spending; household or individual financial cost. From 3,241 references, 64 studies met the inclusion criteria, 75% of which originated from the Americas and Western Pacific WHO region. Breast cancer and DM were the most studied NCDs (42 in total); CKD and COPD were the least represented (five and three studies respectively). OOP payments and financial catastrophe, mostly defined as OOP exceeding a certain proportion of household income, were the most studied outcomes. OOP expenditure as a proportion of family income, ranged between 2 and 158% across the different NCDs and countries. Financial catastrophe due to the selected NCDs was seen in all countries and at all income levels, and occurred in 6-84% of the households depending on the chosen catastrophe threshold. In 16 low- and middle-income countries (LMIC), 6-11% of the total population would be impoverished at a 1.25 US dollar/day poverty line if they would have to purchase lowest price generic diabetes medication. NCDs impose a large and growing global impact on households and impoverishment, in all continents and levels of income. The true extent, however, remains difficult to determine due to the heterogeneity across existing studies in terms of populations studied, outcomes reported and measures employed. The impact that NCDs exert on households and impoverishment is likely to be underestimated since important economic domains, such as coping strategies and the inclusion of marginalized and vulnerable people who do not seek health care due to financial reasons, are overlooked in literature. Given the scarcity of information on specific regions, further research to estimate impact of NCDs on households and impoverishment in LMIC, especially the Middle Eastern, African and Latin American regions is required.

The economic burden of diabetes in India: a review of the literature

BACKGROUND

Diabetes and its complications are a major cause of morbidity and mortality in India, and the prevalence of type 2 diabetes is on the rise. This calls for an assessment of the economic burden of the disease.

OBJECTIVE

To conduct a critical review of the literature on cost of illness studies of diabetes and its complications in India.

METHODS

A comprehensive literature review addressing the study objective was conducted. An extraction table and a scoring system to assess the quality of the studies reviewed were developed.

RESULTS

A total of nineteen articles from different regions of India met the study inclusion criteria. The third party payer perspective was the most common study design (17 articles) while fewer articles (n =2) reported on costs from a health system or societal perspective. All the articles included direct costs and only a few (n =4) provided estimates for indirect costs based on income loss for patients and carers. Drug costs proved to be a significant cost component in several studies (n =12). While middle and high-income groups had higher expenditure in absolute terms, costs constituted a higher proportion of income for the poor. The economic burden was highest among urban groups. The overall quality of the studies is low due to a number of methodological weaknesses. The most frequent epidemiological approach employed was the prevalence-based one (n =18) while costs were mainly estimated using a bottom up approach (n =15).

CONCLUSION

The body of literature on the costs of diabetes and its complications in India provides a fragmented picture that has mostly concentrated on the direct costs borne by individuals rather than the healthcare system. There is a need to develop a robust methodology to perform methodologically rigorous and transparent cost of illness studies to inform policy decisions.

Illness burden, care seeking, and treatment cost among less than 2-year-olds in rural Haryana

OBJECTIVE

To estimate illness burden, treatment sources, and out-of-pocket (OOP) expenditures among <2-y-olds as mortality is higher in this age group.

METHODS

This prospective study was conducted in rural area of Haryana from January through June 2007. At baseline, 6828 children (<2-y-olds) were enrolled from 169 villages of Khizrabad block in Haryana. Thirty trained volunteers interviewed their mothers/caretakers at fortnightly interval to record symptoms and signs of illnesses occurring in past two weeks and the treatment sought. Five supervisors obtained data on Out-of-Pocket (OOP) expenditures from 20 % randomly selected households who had reported illness. The main outcome measures were illness burden, treatment sources and OOP expenditures.

RESULTS

Overall, 8 % (4,893/60,910) of the <2-y-olds suffered from illness during 12 fortnightly surveys. Incidence was estimated to be 2.1 episodes per child per year. Acute respiratory infections (ARI) and diarrhea were the leading illnesses (66.3 % and 19.4 % respectively). Most (98 %) had consulted a health care provider. Village practitioners were the major (71 %) healthcare providers. About 12 % of the children were hospitalized. Consultations were mostly (98 %) with private medical practitioners. Average OOP expenditure was Rs. 444 (95 % CI 299 to 589) per episode; Rs. 203 (95 % CI 188 to 232) and Rs. 5,734 (95%CI 3,336 to 8,131) in the out-patient and in-patient department respectively.

CONCLUSIONS

ARI and diarrhea continue to be the commonest illness among <2-y-olds. Most patients seek care in private sector and pay for the treatment from out-of-pocket source. Access to healthcare needs to be enhanced in public sector to reduce the financial burden.

Diabetes mellitus: Trends in northern India

Diabetes mellitus is becoming a global health issue with more than 80% diabetics living in developing countries. India accounts for 62.4 million diabetics (2011). Indian Council of Medical Research India Diabetes Study (ICMR-INDIAB) study showed highest weighted prevalence rate in the north India among all studied regions. Diabetes in north India has many peculiarities in all aspects from risk factors to control programmers. North Indians are becoming more prone for diabetes and dyslipidemia because rapid westernization of living style and diet due rapid migration to metropolitan cities for employment. North Indian diabetes is plagued with gender bias against females, poor quality of health services, myths, and lack of disease awareness compounded with small number of prevention and awareness programmers that too are immature to counteract the growing pandemic.

Non-communicable diseases in South Asia: contemporary perspectives

INTRODUCTION

Non-communicable diseases (NCDs) such as metabolic, cardiovascular, cancers, injuries and mental health disorders are increasingly contributing to the disease burden in South Asia, in light of demographic and epidemiologic transitions in the region. Home to one-quarter of the world's population, the region is also an important priority area for meeting global health targets. In this review, we describe the current burden of and trends in four common NCDs (cardiovascular disease, diabetes, cancer and chronic obstructive pulmonary disease) in South Asia.

SOURCES OF DATA

The 2010 Global Burden of Disease Study supplemented with the peer-reviewed literature and reports by international agencies and national governments.

AREAS OF AGREEMENT

The burden of NCDs in South Asia is rising at a rate that exceeds global increases in these conditions. Shifts in leading risk factors-particularly dietary habits, tobacco use and high blood pressure-are thought to underlie the mounting burden of death and disability due to NCDs. Improvements in life expectancy, increasing socioeconomic development and urbanization in South Asia are expected to lead to further escalation of NCDs.

AREAS OF CONTROVERSY

Although NCD burdens are currently largest among affluent groups in South Asia, many adverse risk factors are concentrated among the poor, portending a future increase in disease burden among lower income individuals.

GROWING POINTS

There continues to be a notable lack of national surveillance data to document the distribution and trends in NCDs in the region. Similarly, economic studies and policy initiatives addressing NCD burdens are still in their infancy.

AREAS TIMELY FOR DEVELOPING RESEARCH

Opportunities for innovative structural and behavioral interventions that promote maintenance of healthy lifestyles-such as moderate caloric intake, adequate physical activity and avoidance of tobacco-in the context of socioeconomic development are abundant. Testing of health care infrastructure and systems that best provide low-cost and effective detection and treatment of NCDs is a priority for policy researchers.

The financial burden from non-communicable diseases in low- and middle-income countries: a literature review

Non-communicable diseases (NCDs) were previously considered to only affect high-income countries. However, they now account for a very large burden in terms of both mortality and morbidity in low- and middle-income countries (LMICs), although little is known about the impact these diseases have on households in these countries. In this paper, we present a literature review on the costs imposed by NCDs on households in LMICs. We examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. In particular, in the treatment of diabetes, insulin--when required--represents an important source of spending for patients and their families. These financial costs deter many people suffering from NCDs from seeking the care they need. The limited health insurance coverage for NCDs is reflected in the low proportions of patients claiming reimbursement and the low reimbursement rates in existing insurance schemes. The costs associated with lost income-earning opportunities are also significant for many households. Therefore, NCDs impose a substantial financial burden on many households, including the poor in low-income countries. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. In this paper, we identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.

Prevalence and determinants of diabetes mellitus in Puducherry, South India

Background:

Diabetes mellitus is an emerging global health problem. It is a chronic, noncommunicable, and expensive public health disease.

Aims and Objectives:

To determine the prevalence and the risk factors of type 2 diabetes mellitus among the adult population of Puducherry, South India.

Materials and Methods:

This was a population-based cross-sectional study carried out during 1^st May 2007–30^th November 2007 in the rural and urban field practice area of Mahatma Gandhi Medical College and Research Institute, Puducherry. Simple random sampling technique was used for the selection of 1370 adult 20 years of age and above. Main outcome measures were the assessment of the prevalence of prevalence and correlates of diabetes among the adult population. Predesigned and pretested questionnaire was used to elicit the information on family and individual sociodemographic variables. Height, weight, waist, and hip circumference, blood pressure was measured and venous blood was also collected to measure fasting blood glucose, blood cholesterol.

Results:

Overall, 8.47% study subjects were diagnosed as diabetic. The univariate analysis and multivariate logistic regression analysis showed that the important correlates of diabetes mellitus were age, blood cholesterol, and family history of diabetes. The findings were found to be statistically significant.

Conclusions:

In our study we observed that adults having increased age, hypercholesterolemia, and family history of diabetes mellitus are more likely to develop diabetes mellitus.

Social and Economic Implications of Noncommunicable diseases in India

Noncommunicable diseases (NCDs) have become a major public health problem in India accounting for 62% of the total burden of foregone DALYs and 53% of total deaths. In this paper, we review the social and economic impact of NCDs in India. We outline this impact at household, health system and the macroeconomic level. Cardiovascular diseases (CVDs) figure at the top among the leading ten causes of adult (25-69 years) deaths in India. The effects of NCDs are inequitable with evidence of reversal in social gradient of risk factors and greater financial implications for the poorer households in India. Out-of-pocket expenditure associated with the acute and long-term effects of NCDs is high resulting in catastrophic health expenditure for the households. Study in India showed that about 25% of families with a member with CVD and 50% with cancer experience catastrophic expenditure and 10% and 25%, respectively, are driven to poverty. The odds of incurring catastrophic hospitalization expenditure were nearly 160% higher with cancer than the odds of incurring catastrophic spending when hospitalization was due to a communicable disease. These high numbers also pose significant challenge for the health system for providing treatment, care and support. The proportion of hospitalizations and outpatient consultations as a result of NCDs rose from 32% to 40% and 22% to 35%, respectively, within a decade from 1995 to 2004. In macroeconomic term, most of the estimates suggest that the NCDs in India account for an economic burden in the range of 5-10% of GDP, which is significant and slowing down GDP thus hampering development. While India is simultaneously experiencing several disease burdens due to old and new infections, nutritional deficiencies, chronic diseases, and injuries, individual interventions for clinical care are unlikely to be affordable on a large scale. While it is clear that "treating our way out" of the NCDs may not be the efficient way, it has to be strongly supplemented with population-based services aimed at health promotion and action on social determinants of health along with individual services. Since health sector alone cannot deal with the "chronic emergency" of NCDs, a multi-sectoral action addressing the social determinants and strengthening of health systems for universal coverage to population and individual services is required.

Roux-en-Y gastric bypass stands the test of time: 5-year results in low body mass index (30-35 kg/m(2)) Indian patients with type 2 diabetes mellitus

BACKGROUND

Our objective was to evaluate the long-term results of laparoscopic Roux-en-Y gastric bypass on excess weight loss, remission of the metabolic syndrome, and complications in Indian patients with uncontrolled type 2 diabetes mellitus (T2DM) with a body mass index of 30-35 kg/m(2). The setting was a corporate hospital in Mumbai, India.

METHODS

The present prospective observational study was begun in January 2006. A total of 52 patients with uncontrolled T2DM and a body mass index of 30-35 kg/m(2) elected to undergo laparoscopic Roux-en-Y gastric bypass. The duration of T2DM was 3.5-14.5 years (median 8.4). Of the 52 patients, 61.5% had hypertension and 59.6% had dyslipidemia. Remission of T2DM and other components of the metabolic syndrome were assessed. All patients were followed up for 5 years.

RESULTS

The median percentage of excess weight loss was 72.2% at 1 year and 67.8% at 5 years. Of the 52 patients, 84.6% had achieved euglycemia and 73.1% had achieved complete remission, 23.1% partial remission, and 3.84% no remission at 1 year. Weight regain occurred in 8 patients. They required antihypertensive drugs and statins, decreasing the complete remission rate to 57.7% and partial remission rate to 38.5% at 5 years. However, 96.2% improvement in metabolic status was found at the end of 5 years.

CONCLUSION

Laparoscopic Roux-en-Y gastric bypass is a safe, efficacious, and cost-effective treatment for uncontrolled T2DM in patients with a body mass index of 30-35 kg/m(2). Early-onset T2DM, better weight loss, and greater C-peptide levels were predictors of success after surgery. The improvement after surgery in hyperglycemia, hypertension, and dyslipidemia could help in controlling the occurrence of micro- and macrovascular complications and decrease the morbidity and mortality associated with T2DM.

Evaluation of the burden of type 2 diabetes mellitus in population of Puducherry, South India

AIMS

To find out the prevalence of undiagnosed diabetes mellitus and the correlates among the adult population of Puducherry, South India.

METHODS

In this population based cross-sectional study in the rural and urban field practice area of Mahatma Gandhi Medical College and Research Institute, Puducherry, by simple random sampling 1013 adults of 30 years and above, not on anti-diabetics drugs were included. Main outcome measures were the prevalence and correlates of undiagnosed diabetes mellitus among the adult population. Pre-designed and pre-tested questionnaire was used to elicit the information on family and individual socio-demographic variables. Height, weight, waist and hip circumference, blood pressure were measured and venous blood was collected to measure fasting blood glucose and blood cholesterol.

RESULTS

Overall, 10.3% study subjects were diagnosed as diabetic. In univariate analysis age, dilatory habit, tobacco addiction, body mass index, waist hip ratio, hypertension, and total blood cholesterol were found statistically significant. In multivariate logistic regression (LR method) analysis age, residence, education, dietary habit, tobacco addiction, body mass index, waist hip ratio and total blood cholesterol were statistically significant.

CONCLUSIONS

In our study adults having increased age, urban residence, illiterate, non-vegetarian diet, tobacco addiction, obese and high total blood cholesterol were important correlates.

The socioeconomics of diabetes from a developing country: a population based cost of illness study

OBJECTIVE

To assess the annual health care expenditure for a patient with diabetes and extrapolate the same to country specific prevalence estimates for 2010.

METHODS

This population based, cost of illness study collected retrospective data for last 12 months on direct costs (medical and non-medical) through records, indirect cost through human capital approach and intangible cost by contingent valuation method from diabetes patients.

RESULTS

Out of 4677 subjects screened, 1050 had diabetes and 718 participated in the survey. The median annual direct and indirect cost associated with diabetes care was estimated at 25,391 INR ($525.5) and 4970 INR ($102.8), respectively. Extrapolating the direct and indirect estimates to Indian population, the annual costs for diabetes would be 1541.4 billion INR ($31.9 billion) in 2010. Two-way sensitivity analysis assuming 10% variation in both prevalence of diabetes and in treatment costs resulted in an estimated cost range of 1230 billion INR ($25.5 billion) to 1837.3 billion INR ($38.0 billion).

CONCLUSION

Keeping the future diabetes explosion in mind, this heavy economic burden highlights the urgent need for the decision makers to allocate resources for planning and implementing strategies in prevention and management of diabetes and its complications.

Innovative research for equitable diabetes care in India

The emergence of non-communicable diseases (NCD) in South Asia and other low- and middle-income countries presents a growing and costly public health challenge. The surreptitious and rapid escalation of these chronic conditions will soon surpass attempts to quantify and appropriately respond to these overwhelming health threats. Given the elevated risk of cardio-metabolic diseases (diabetes, cardiovascular disease, and kidney disease) and projected morbidity and mortality burdens in the Asian Indian population group, the lack of representative data to support national response strategies will likely result in crippling health and socioeconomic losses. We describe how systematic research may help to reconcile India's data deficits and may be applied towards prioritizing resource allocation and addressing shortfalls in disease prevention and control efforts. Expanding the scope of and contextualizing NCD health research in India may also have tremendous benefits for resource allocation and planning in other developing countries.

[Assessment of diabetes mellitus type 2 treatment costs in the Republic of Serbia]

BACKGROUND/AIM

High morbidity and mortality rates, chronic course of disease and numerous clinical complications, make diabetes mellitus (DM) type 2 bear significant financial burden for healthcare system of Serbia. The aim of this study was to compare true disease-related expenses measured in the random sample of patients originating from the Central Serbia in 2007 and national estimate of total expenses based on available evidence on antidiabetic drugs and insulins acquisition costs in the same fiscal year.

METHODS

The study design was prevalence-based, bottom-up cost of illness analysis. It was implemented on a randomized sample of 99 adults with confirmed diagnosis of DM type 2. During 2007 all direct (drug acquisition, medical services, medical devices usage) and indirect costs associated with their primary disease (premature death, impaired working ability, early retirement, absentism), were taken into account. Other approach was to calculate average national rate of antidiabetic drugs and insulin utilization and sales at the domestic market during the mentioned period of time. Taking into consideration available estimate from the Institute of Public Health of Serbia of 475,000 people with this disease at the national level, we were able to compare these data. Assuming that our sample was enough representative and that the structure of costs was approximately similar at the local and national level, we were able to calculate an estimate of total cost of the disease. All costs were expressed in Serbian official currency, dinar (CSD).

RESULTS

Values of costs measured per patient in our sample in a given year were for drug acquisition 20,352.45 CSD, medical services 24,338.26 CSD, medical devices 3174.46 CSD and loss of productivity and absentism 5547.78 CSD. There were 2 cases of early retirement due to the disease and no cases of dialysis treatment or premature death. A total number of sickness absence days of employed patients, was 1025 and a total number of hospital treatment days was 360. A total amount of all costs was 53,412.96 CSD per patient per year. According to the National Medicines and Medical Devices Agency an overall value of oral antidiabetic drug sales for 2007 per patient was 1835.32 CSD and for insulins and analogs 2948.18 CSD.

CONCLUSION

Comparing true size of national financial burden of DM type 2 with experiences of other authors, we can see that it is comparable with European OECD average. But, if the structure of expenses is taken into account, Serbia is more similar tothose countries reported in the Third World economies. Ourlocal findings on a sample of diabetic population show that real patient expenses were even 2.28 times higher than those estimated at the national level.

Cost of diabetes care in out-patient clinics of Karachi, Pakistan

BACKGROUND

Diabetes Mellitus (DM) is a growing epidemic and the cost of treating diabetes is largely increasing. The objective of this study was to estimate the cost-of-illness of DM among attendees of out-patient clinics in Karachi, Pakistan. This is the first study conducted from a societal perspective to estimate the cost of managing diabetes in Pakistan.

METHODS

A prevalence-based 'Cost-of-Illness' study for diabetes care was conducted in six different out-patient clinics of Karachi, Pakistan from July to September 2006. A pre-tested questionnaire was administered to collect the data from 345 randomly selected persons with diabetes.

RESULTS

The annual mean direct cost for each person with diabetes was estimated to be Pakistani rupees 11,580 (US$ 197). Medicines accounted for the largest share of direct cost (46%), followed by laboratory investigations (32%). We found that increased age, the number of complications and longer duration of the disease significantly increase the burden of cost on society (p < 0.001). Comparing cost with family income it was found that the poorest segment of society is spending 18% of total family income on diabetes care.

CONCLUSION

This study concluded that substantial expenditure is incurred by people with diabetes; with the implication that resources could be saved by prevention, earlier detection and a reduction in diabetes co-morbidities and complications through improved diabetes care. Large scale and cost-effective prevention programs need to be initiated to maximise health gains and to reverse the advance of this epidemic.

Diabetes cost model of a hospital in Thailand

OBJECTIVE

This study aims to formulate a cost model from a provider perspective regarding the direct medical costs for diabetic patients who received care in a 30-bed public hospital in Thailand during the fiscal year of 2001.

METHODS

This study is a retrospective prevalence-based cost of illness study. Data were collected by reviewing the medical record of each patient for the whole year. The statistical analysis employed was the stepwise multiple regression method.

RESULTS

The study covered 186 diabetic patients. It was found that the average cost of caring for a diabetic patient per year was 6331 Thai baht (THB) at 2001 prices (approximately 40 THB = US 1 dollar). A major portion of this cost was spent for pharmacy services, which accounted for 45% of the whole cost, followed by outpatient services (24%), inpatient services (16%), and laboratory investigation (11%). Regarding the model for forecasting the cost, the type of diabetes and its accompanying complications, i.e., hyperlipidemia, cardiovascular accident, hypertension, hyperglycemia, hypoglycemia, gangrene, and diabetic foot, were considered as significant predictor variables (adjusted R(2) = 0.48). The quantitative effects in monetary term of these significant predictors were also demonstrated.

CONCLUSIONS

The results could be beneficial in forecasting the economic burden of diabetes mellitus in Thailand. Furthermore, the results could be used as a financial tool for cost control and disease management at the community hospital level.

[Cost of caring for the diabetic-hypertensive patient in primary care]

OBJECTIVE

To determine the cost of caring for the diabetic-hypertensive patient in primary care.

DESIGN

A cost analysis carried out in family medicine units in Mexico.

SETTING

Family medicine units in Mexico.

PARTICIPANTS

Patients with diabetes and hypertension.

MEASUREMENTS

Include the profile of use of the services and the cost of the care. The profile is defined as the average annual use of primary care services, the unit cost is calculated by reason for use in each of the services used, taking the fixed and variable consumables into account; the average cost by reason for care is calculated from use-cost ratio and the mean annual cost from the total average cost by reason for the care.

RESULTS

The mean annual cost in the family doctor clinic was euro180.65 (95% confidence interval [CI], 168.31-193), in the laboratory, euro48.99 (95% CI, 44.85-53.18), and in the rest of the primary care services, euro41.33 (95% CI, 30.19-52.46). The mean annual primary care cost per patient was euro271 (95% CI, 243.36- 298.65).

CONCLUSION

The primary care costs of the diabetic-hypertensive patient are concentrated in the family doctor and laboratory services.