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

The Economic Burden of Type 2 Diabetes Mellitus in Pakistan: A Cost of Illness Study

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is a highly prevalent disease with a chronic nature and poses a significant health burden worldwide, with no exception in Pakistan. Hence, this study aimed to explore the financial burden of T2DM in Pakistan through cost of illness analysis.

METHODS

A prevalence-based, cross-sectional study was conducted using a structured data collection tool from the patient's perspective. Through structured interviews by trained data collectors, the data regarding direct medical costs, direct non-medical costs, and indirect costs were collected and further verified through prescriptions and bills. After testing the normality of data, mean and median with interquartile range were used to present cost data, while non-parametric tests, i.e., the Mann-Whitney U test and the Kruskal-Wallis test, were used to assess factors associated with costs, as cost data were not normally distributed.

RESULTS

The study included 522 participants, with a majority being female (54%) and aged between 41 and 60 years (64%). The mean annual total cost per patient was USD 235.1 (median = USD 162.8), comprising direct medical costs, 93.2% (mean = USD 219.2; median = USD 150.0), direct non-medical costs, 5.3% (mean = USD 12.4; median = USD 7.1), and indirect costs, 1.5% (mean = USD 3.5; median = USD 1.9). Costs were significantly higher for patients with advanced age, high literacy, higher household incomes, duration of diabetes, more than one complication, and using combination therapy.

CONCLUSIONS

The economic burden of T2DM in Pakistan is substantial, with medication costs being the largest component. Effective management strategies and policy interventions are crucial to mitigate this burden and improve the economic and health outcomes for diabetic patients.

Exploring the Interrelationships between Diabetes, Nutrition, Anxiety, and Depression: Implications for Treatment and Prevention Strategies

Across the world, diabetes, depression, and anxiety symptoms have gained widespread recognition as significant public health issues. Recent research has unveiled a mutually influential relationship between diabetes and these two mental health conditions, where each disorder impacts the course and outcomes of the others. The role of nutrition emerges as pivotal in preventing and treating depression, anxiety, and diabetes. A thorough literature review was undertaken to investigate the reciprocal effects between anxiety, depression, and diabetes, including their impact on the development and severity of each condition. Additionally, the effects of nutrition on the prevention and management of depression, anxiety, diabetes, and related complications in at-risk individuals were assessed. Our findings show that mental disorders, such as depression and anxiety, increase the risk of developing type 2 diabetes and are associated with poorer glycemic control, increased diabetes-related complications, and higher mortality rates. Conversely, diabetes is also linked with an increased risk of developing depression and anxiety. The biological, psychological, and social factors that contribute to the comorbidity between these two conditions are complex and multifaceted. Therefore, an integrated approach to the management of both conditions is critical for improving patient outcomes and reducing the overall burden of disease. Nutritional interventions should be utilized to reduce the risk of diabetes in patients with anxiety and depression as well as enhance mental health in patients with diabetes.

Relationship between nutritional status and anxiety and depression in hospitalized diabetic patients in Turkey

BACKGROUND

Anxiety and depression often coexist in patients with chronic diseases. We evaluated the nutritional status of diabetic patients and its relationship with anxiety and depression.

METHODS

Demographic, diabetic information (disease duration, treatment, hospitalization) information and anthropometric measurements (weight, height, waist, and hip circumference) were recorded. The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression. 24-h food records were obtained to determine daily energy and nutrient intake.

RESULTS

In this study of 222 patients, the rates of anxiety, depression and anxious depression were 23.8%, 21.6%, 12.2%, respectively. Those who skipped medication/insulin doses and did not exercise regularly had significantly higher anxiety and depression scores. Anxiety and depression scores were positively correlated with disease duration, waist circumference, waist/hip, and waist/height. Being married, engaging in regular exercise, and increased vitamin B₆ consumption were inversely related to anxiety and depression. According to food records, patients with anxiety and depression have a higher proportion of energy from dietary carbohydrates. Anxiety and depression scores were negatively related to dietary energy, protein, fat, some vitamin (retinol, group B, C, and D), and mineral (K, Mg, P, Fe, Zn, Cu) intake.

CONCLUSIONS

Maintaining healthy body weight, compliance with medication/insulin treatment, and regular exercise may help in the prevention of anxiety and depression in hospitalized diabetic patients. Alternatively, anxiety and depression may adversely affect body weight, compliance with treatment, and engaging in regular exercise. Prospective studies are needed to determine the direction of causality.

Economic burden of type 2 diabetes in Iran: A cost-of-illness study

Background and Aims

Type 2 diabetes mellitus (T2DM) is a prevalent public health problem worldwide, and the economic burden of the disease poses one of the main challenges for health systems in low- and middle-income countries. This study aimed to estimate the economic burden of T2DM in Iran, in 2018.

Methods

This was a cost-of-illness study. Three hundred and seventy-five patients with T2DM who were referred to Imam Reza and Sina's educational and therapeutic centers and Asad Abadi clinic in Tabriz, Iran, in 2018 were included. A researcher-constructed checklist was used for data collection. Data were analyzed using EXCEL and SPSS software version 22.

Results

Total economic burden of diabetes was estimated at 152,443,862,480.3 (purchasing power parity [PPP], Current International $) (approximately 7.69% of GDP, PPP, Current International $). The mean total direct and indirect costs were 11,278.68 (PPP) (62.35% of mean total cost) and 6808.88 (PPP, Current International $) (37.64% of the total cost), respectively. The mean total direct medical cost and the direct nonmedical cost were 10,819.43 (PPP, Current International $) (59.81% of mean total cost) and 459.24 (PPP, Current International $) (2.53% of mean total cost) per patient, respectively. Besides, the mean direct medical cost was 6.18 times the total per capita expenditure on health, and the total direct medical cost was 8.9% times the total expenditure on health.

Conclusion

Diabetes imposes a substantial economic burden on patients, health systems, and the whole economy. Besides, since the cost of the disease in patients treated with insulin and those with diabetes complications is significantly higher, the reinforcement of self-care measures and focusing on modifying lifestyle (dietary modification and physical activity) in patients with T2DM can significantly reduce the costs of the disease.

Economic Burden of Diabetic Mellitus Among Patients on Follow-up Care in Hospitals of Southwest Shewa Zone, Central Ethiopia

BACKGROUND

Diabetes has emerged as one of the most serious health issues of the twenty-first century. Diabetes and its complications expose individuals and their families to catastrophic healthcare costs, which have a severe impact on the country's economy. Though the prevalence of diabetes is rising quicker in Ethiopia, little is known about its economic impact. Hence, this study aimed to determine the total cost of diabetic mellitus and associated factors among patients attending hospitals in Southwest Shewa zone, Central Ethiopia.

METHODS

The study was conducted among diabetes patients who were on care and treatment from September to October 2020. Direct costs were calculated using the micro-costing technique, while indirect costs were calculated using the human capital approach. The statistical significance of cost difference between the groups of patient characteristics was determined using Wilcoxon and Kruskal-Wallis mean rank sum tests, and the factors associated with a total cost of illness were identified with Generalized Linear Model (GLM).

RESULTS

Out of the planned patients, 398 have responded and were included in the analysis; making a response rate of 98.5%. The mean monthly total cost of diabetic mellitus was US$ 37.7(95% CI, 23.45-51.95). Direct and indirect costs constituted 76.2% and 23.8% of the total cost, respectively. The mean direct and indirect cost of diabetic mellitus per patient per month was US$ 28.73(95% CI, 17.17-40.29) and US$ 9.50 (95% CI, 1.99-16.99) respectively. Statistical mean cost differences were observed by gender, age groups, family size, and comorbidities. The total cost of illness was associated with residence (p=0.007), family size (p=0.001), presence of co-morbidities (p=0.04), and history of ever-stopping treatments (p<0.0001).

CONCLUSIONS

The total cost of diabetes condition was relatively high compared to other related literatures. The medical expenditures accounted for most direct costs for diabetic patients. As a result, the government should provide sufficient resources to safeguard patients against catastrophic medical costs. Efforts should be made to enhance access to diabetes care, and the supply of diabetic medications at all levels of health facilities.

Cost of Illness Analysis of Type 2 Diabetes Mellitus: The Findings from a Lower-Middle Income Country

BACKGROUND

Diabetes is a major chronic illness that negatively influences individuals and society. Therefore, this research aimed to analyze and evaluate the cost associated with diabetes management, specific to the Pakistani Type 2 diabetes population. Research scheme and methods: A survey randomly collected information and data from diabetes patients throughout Pakistan out-patient clinics. Direct and indirect costs were evaluated, and data were analyzed with descriptive and inferential statistics.

RESULTS

An overall of 1839 diabetes patients participated in the study. The results have shown that direct and indirect costs are positively associated with the participants' socio-demographic characteristics, except for household income and educational status. The annual total cost of diabetes care was USD 740.1, amongst which the share of the direct cost was USD 646.7, and the indirect cost was USD 93.65. Most direct costs comprised medicine (USD 274.5) and hospitalization (USD 319.7). In contrast, the productivity loss of the patients had the highest contribution to the indirect cost (USD 81.36).

CONCLUSION

This study showed that direct costs significantly contributed to diabetes's overall cost in Pakistan and overall diabetes management estimated to be 1.67% (USD 24.42 billion) of the country's total gross domestic product. The expense of medications and hospitalization mostly drove the direct cost. Additionally, patients' loss of productivity contributed significantly to the indirect cost. It is high time for healthcare policymakers to address this huge healthcare burden. It is time to develop a thorough diabetes management plan to be implemented nationwide.

Cardiovascular Morbidity, Quality of Life, and Cost of Care among Diabetic Patients: A Comparative Study from a Tertiary Care Hospital of Uttarakhand, India

Objectives:

Diabetes is commonly observed to be associated with several comorbidities, out of which cardiovascular comorbidities are most frequently observed. The present study has been done to estimate the proportion of cardiovascular comorbidities among patients of diabetes and to compare it with that of matched nondiabetics. It also aimed to compare the quality of life (QOL) scores and the cost of treatment between diabetics and nondiabetics with cardiovascular comorbidities.

Methodology:

A hospital-based comparative analytical study was conducted in a tertiary care hospital of Uttarakhand, India. One hundred and ninety-five diabetic were compared with an equal number of age- and gender-matched nondiabetics. We compared the two groups for the presence of comorbidities by Chi-square test and for QOL and cost of care by independent t-test. Regression was done to study factors associated with direct cost incurred for treatment among diabetics with cardiovascular comorbidity.

Results:

The present study reported about four-time higher risk (odds ratio: 3.9; confidence interval: 2.5–6.1) of comorbidities of cardiovascular system (CVS) among diabetics as compared to nondiabetics. QOL scores were reported to be significantly lower among diabetics with comorbidities of CVS in comparison to nondiabetics. Significant predictors of direct cost among diabetics were religion, marital status, income, and use of alcohol.

Conclusion:

Cardiovascular comorbidities have been reported to be four times higher among diabetics in comparison to nondiabetics, leading to an adverse effect on QOL and increased expenditure on treatment.

Systematic Review of Polyherbal Combinations Used in Metabolic Syndrome

Background: Metabolic syndrome (MetS) is a multifactorial disease, whose main stay of prevention and management is life-style modification which is difficult to attain. Combination of herbs have proven more efficacious in multi-targeted diseases, as compared to individual herbs owing to the "effect enhancing and side-effect neutralizing" properties of herbs, which forms the basis of polyherbal therapies This led us to review literature on the efficacy of herbal combinations in MetS. Methods: Electronic search of literature was conducted by using Cinnahl, Pubmed central, Cochrane and Web of Science, whereas, Google scholar was used as secondary search tool. The key words used were "metabolic syndrome, herbal/poly herbal," metabolic syndrome, clinical trial" and the timings were limited between 2005-2020. Results: After filtering and removing duplications by using PRISMA guidelines, search results were limited to 41 studies, out of which 24 studies were evaluated for combinations used in animal models and 15 in clinical trials related to metabolic syndrome. SPICE and SPIDER models were used to assess the clinical trials, whereas, a checklist and a qualitative and a semi-quantitative questionnaire was formulated to report the findings for animal based studies. Taxonomic classification of Poly herbal combinations used in animal and clinical studies was designed. Conclusion: With this study we have identified the potential polyherbal combinations along with a proposed method to validate animal studies through systematic qualitative and quantitative review. This will help researchers to study various herbal combinations in MetS, in the drug development process and will give a future direction to research on prevention and management of MetS through polyherbal combinations.

Estimating the cost of interventions to improve water, sanitation and hygiene in healthcare facilities across India

Introduction

Despite increasing utilisation of institutional healthcare in India, many healthcare facilities (HCFs) lack access to basic water, sanitation and hygiene (WASH) services. WASH services protect patients by improving infection prevention and control (IPC), which in turn can reduce the burden of healthcare-associated infections (HAIs). However, data on the cost of implementing WASH interventions in Indian HCFs are limited.

Methods

We surveyed 32 HCFs across India, varying in size, type and setting to obtain the direct costs of providing improved water supply, sanitation and IPC-supporting infrastructure. We calculated the average costs of WASH interventions and the number of HCFs nationwide requiring investments in WASH to estimate the financial cost of improving WASH across India’s public healthcare system over 1 year.

Results

Improving WASH across India’s public healthcare sector and sustaining services among upgraded facilities for 1 year would cost US$354 million in capital costs and US$289 million in recurrent costs from the provider perspective. The most costly interventions were those on water (US$238 million), linen reprocessing (US$112 million) and sanitation (US$104 million), while the least costly were interventions on hand hygiene (US$52 million), medical device reprocessing (US$56 million) and environmental surface cleaning (US$80 million). Overall, investments in rural HCFs would account for 64.4% of total costs, of which 52.3% would go towards primary health centres.

Conclusion

Improving IPC in Indian public HCFs can aid in the prevention of HAIs to reduce the spread of antimicrobial resistance. Although WASH is a necessary component of IPC, coverage remains low in HCFs in India. Using ex-post costs, our results estimate the investment levels needed to improve WASH across the Indian public healthcare system and provide a basis for policymakers to support IPC-related National Action Plan activities for antimicrobial resistance through investments in WASH.

Effect of comorbidities on direct cost among type 2 diabetes mellitus (T2DM) patients in tertiary care government hospital in Uttarakhand, India: A primary data analysis of out of pocket expenditure

BACKGROUND AND AIMS

The objective of present study was to estimate and compare the direct cost between diabetics and age and gender matched non-diabetics. It also aimed to estimate and compare the effect of various comorbidities on direct cost between cases and controls, while simultaneously trying to determine the predictors of direct cost among T2DM patients.

METHODS

A hospital-based pair matched case-control study was conducted in a tertiary care hospital in Garhwal division of Uttarakhand, India to accomplish the objectives of study. Regression analysis was applied to determine the predictors of direct cost among diabetics.

RESULTS

Mean annual direct cost among diabetics was estimated to be US$ 104.6 (Indian Rupees (INR) 7338.9)) in comparison to US$ 27.8 (INR 1905.8) among non-diabetics. The total cost among cases was significantly higher than controls, if they had comorbidities from CVS, nervous, ophthalmic, respiratory and musculoskeletal system. Gender, education, duration of diabetes and number of comorbidities were significant predictors in estimating the direct cost among cases. For each one-year increase in duration of diabetes, direct cost increased by 13.1 unit.

CONCLUSIONS

The study provides us conclusive evidence of significantly higher expenditure among diabetics in comparison to non-diabetics. An effect on direct cost among diabetics was observed with types and increasing number of comorbidities.

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.

Global and regional estimates and projections of diabetes-related health expenditure: Results from the International Diabetes Federation Diabetes Atlas, 9th edition

AIMS

Diabetes and its complications have a significant economic impact on individuals and their families, health systems and national economies.

METHODS

The direct health expenditure of diabetes was calculated relying on the following inputs: diagnosed and undiagnosed diabetes prevalence estimates, United Nations population estimates, World Health Organization health expenditure per capita and ratios of health expenditure for people with diabetes compared to people without diabetes.

RESULTS

The estimated global direct health expenditure on diabetes in 2019 is USD 760 billion and is expected to grow to a projected USD 825 billion by 2030 and USD 845 billion by 2045. There is a wide variation in annual health expenditures on diabetes. The United States of America has the highest estimated expenditure with USD 294.6 billion, followed by China and Brazil, with USD 109.0 billion and USD 52.3 billion, respectively. The age group with the largest annual diabetes-related health expenditure is 60-69 years with USD 177.7 billion, followed by 50-59 years, and 70-79 years with USD 173.0 billion and USD 171.5 billion, respectively. Slightly higher diabetes-related health expenditure is seen in women than in men (USD 382.6 billion vs. USD 377.6 billion, respectively). The same difference is expected to be present in 2030 and 2045.

CONCLUSIONS

There were large disparities between high-, middle- and low-income countries with total health expenditures in high-income countries being over 300 times those in low-income countries. The ratio for annual direct health expenditure per person between these groups of countries is more than 38-fold.

Medical Costs of Patients with Type 2 Diabetes in a Single Payer System: A Classification and Regression Tree Analysis

BACKGROUND AND OBJECTIVES

Many studies and systematic reviews have estimated the healthcare costs of diabetes using a cost-of-illness approach. However, in the studies based on this approach patients' heterogeneity is rarely taken into account. The aim of this study was to stratify patients with type 2 diabetes into homogeneous cost groups based on demographic and clinical characteristics.

METHODS

We conducted a retrospective cost-of-illness study by linking individual data on health services utilization retrieved from the administrative databases of Emilia-Romagna Region (Italy). Direct medical costs (either all-cause or diabetes-related) were calculated from the perspective of the regional health service, using tariffs for hospitalizations and outpatient services and the unit costs of prescriptions for drugs. The determinants of costs identified in a generalized linear regression model were used to characterize subgroups of patients with homogeneous costs in a classification and regression tree analysis.

RESULTS

The study population consisted of a cohort of 101,334 patients with type 2 diabetes, followed up for 1 year, with a mean age of 70.9 years. Age, gender, complications, comorbidities and living area accounted significantly for cost variability. The classification tree identified ten patient subgroups with different costs, ranging from a median of €483 to €39,578. The two subgroups with highest costs comprised dialysis patients, and the largest subgroup (57.9%) comprised patients aged ≥ 65 years without renal, cardiovascular and cerebrovascular complications.

CONCLUSIONS

Classification of patients into homogeneous cost subgroups can be used to improve the management of, and budget allocation for, patients with type 2 diabetes.

Diabetes Mellitus Complications and Associated Factors Among Adult Diabetic Patients in Selected Hospitals of West Ethiopia

Background / Introduction:

The prevalence of type 1 and type 2 diabetes mellitus (DM) is increasing worldwide. The prevalence might even be higher in low-income countries. As a result, type 1 and type 2 DM and their complications are imposing a high burden on patients (e.g. hospitalization, disability and death). In Ethiopia, there are limited studies focusing on the complications of type 1 and type 2 DM. Thus, we assessed the prevalence of type 1 and type 2 DM complications and associated factors in selected hospitals in western Ethiopia.

Methods:

This cross-sectional study included 257 adult patients with DM attending the chronic care clinics of Nedjo general and Nekemte referral hospitals. The study was carried out between March 1 and April 30, 2016 using a pre-tested self-administered questionnaire and chart review.

Results:

Of the 257 patients, 87 (33.9%) had ≥1 DM complication. Acute and chronic complications accounted for 9.3% and 24.5% of the total DM patients, respectively. The age of the patients (p=0.024), family history of DM (p=0.038), DM duration (p=0.015), DM regimen (p=0.041), and the occurrence of other chronic diseases (p=0.006) were significantly associated with DM complications.

Conclusion:

The findings of this study revealed that 1 out of 3 adults with DM have ≥1 complication in our chronic ambulatory care clinics. Diabetic keto-acidosis was the most common acute complication whereas hypertension was the most common chronic complication. The presence of DM complications was associated with the age of the patients, duration of DM, family history of DM, DM regimen and the presence of other chronic diseases.

Type 2 diabetes mellitus in Bangladesh: a prevalence based cost-of-illness study

BACKGROUND

The economic burden of type 2 diabetes has not been adequately investigated in many low- and lower middle-income countries, including Bangladesh. The aim of this study was to estimate the cost-of-illness of type 2 diabetes and to find its determinants in Bangladesh.

METHODS

A cross-sectional study was conducted in 2017 to recruit 1253 participants with type 2 diabetes from six diabetes hospitals, providing primary to tertiary health care services, located in the northern and central regions of Bangladesh. A structured questionnaire was used for face-to-face interviewing to collect non-clinical data. Patients' medical records were reviewed for clinical data and hospital records were reviewed for hospitalisation data. Cost was calculated from the patient's perspective using a bottom-up methodology. The direct costs for each patient and indirect costs for each patient and their attendants were calculated. The micro-costing approach was used to calculate direct cost and the human capital approach was used to calculate indirect cost. Median regression analysis was performed to identify the determinants of average annual cost.

RESULTS

Among the participants, 54% were male. The mean (±SD) age was 55.1 ± 12.5 years and duration of diabetes was 10.7 ± 7.7 years. The average annual cost was US$864.7 per patient. Medicine cost accounted for 60.7% of the direct cost followed by a hospitalisation cost of 27.7%. The average annual cost for patients with hospitalisation was 4.2 times higher compared to those without hospitalisation. Being females, use of insulin, longer duration of diabetes, and presence of diabetes complications were significantly related to the average annual cost per patient.

CONCLUSIONS

The cost of diabetes care is considerably high in Bangladesh, and it is primarily driven by the medicine and hospitalisation costs. Optimisation of diabetes management by positive lifestyle changes is urgently required for prevention of comorbidities and complications, which in turn will reduce the cost.

Economic Impact of Diabetes in South Asia: the Magnitude of the Problem

PURPOSE OF REVIEW

To critically assess and identify gaps in the current literature on the economic impact of diabetes in South Asia.

RECENT FINDINGS

The total annual (direct medical and non-medical and indirect) costs for diabetes care in South Asia range from $483-$2637 per patient, and on an average 5.8% of patients with diabetes suffer catastrophic spending i.e. when households reduce basic expenditure by 40% to cope with healthcare costs. The mean direct costs per patient are positively associated with a country's gross domestic product (GDP) per capita, although there is wide heterogeneity across South Asian countries. With an estimated 84 million people suffering from diabetes in South Asia, diabetes imposes a substantial economic burden on individuals, families, and society. Since the disease burden increasingly occurs in the most productive midlife period, it adversely affects workforce productivity and macroeconomic development. Diabetes-related complications lead to markedly higher treatment costs, causing catastrophic medical spending for many households, thus underscoring the importance of preventing diabetes-related complications.

Cost-of-illness of type 2 diabetes mellitus in low and lower-middle income countries: a systematic review

Background

Diabetes is one of the world’s most prevalent and serious non-communicable diseases (NCDs). It is a leading cause of death, disability and financial loss; moreover, it is identified as a major threat to global development. The chronic nature of diabetes and its related complications make it a costly disease. Estimating the total cost of an illness is a useful aid to national and international health policy decision making. The aim of this systematic review is to summarise the impact of the cost-of-illness of type 2 diabetes mellitus in low and lower-middle income countries, and to identify methodological gaps in measuring the cost-of-illness of type 2 diabetes mellitus.

Methods

This systematic review considers studies that reported the cost-of-illness of type 2 diabetes in subjects aged 18 years and above in low and lower-middle income countries. The search engines MEDLINE, EMBASE, CINAHL, PSYCINFO and COCHRANE were used form date of their inception to September 2018. Two authors independently identified the eligible studies. Costs reported in the included studies were converted to US dollars in relation to the dates mentioned in the studies.

Results

The systematic search identified eight eligible studies conducted in low and lower-middle income countries. There was a considerable variation in the costs and method used in these studies. The annual average cost (both direct and indirect) per person for treating type 2 diabetes mellitus ranged from USD29.91 to USD237.38, direct costs ranged from USD106.53 to USD293.79, and indirect costs ranged from USD1.92 to USD73.4 per person per year. Hospitalization cost was the major contributor of direct costs followed by drug costs.

Conclusion

Type 2 diabetes mellitus imposes a considerable economic burden which most directly affects the patients in low and lower-middle income countries. There is enormous scope for adding research-based evidence that is methodologically sound to gain a more accurate estimation of cost and to facilitate comparison between studies.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3772-8) contains supplementary material, which is available to authorized users.

Clinical management of type 2 diabetes in south Asia

Compared with other ethnic groups, south Asian people with type 2 diabetes tend to develop the disease at a younger age and manifest with higher glycaemia, dyslipidaemia, nephropathy, and cardiovascular diseases. Additionally, specific issues that can affect treatment of type 2 diabetes in south Asia include poor awareness of the disease, delay in diagnosis, inadequate treatment, the use of ineffective and often harmful alternative medicines, and frequent non-compliance with lifestyle recommendations and drug treatment. Disease development at younger ages, delayed diagnosis, and inadequate management result in early development of severe complications and premature mortality. In this Series paper, we describe the challenges associated with the increasing burden of type 2 diabetes in south Asia and discuss ways to improve clinical care of people with the disorder in the region (defined to include Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka). Treatment of diabetes in south Asia needs to be individualised on the basis of diverse and heterogeneous lifestyle, phenotype, environmental, social, cultural, and economic factors. Aggressive management of risk factors from diagnosis is necessary to reduce the risk of microvascular and macrovascular complications, focusing on provision of basic treatments (eg, metformin, low-cost statins, and blood pressure-lowering drugs) and other interventions such as smoking cessation. Strengthening of the primary care model of care, better referral linkages, and implementation of rehabilitation services to care for patients with chronic complications will be important. Finally, improvement of physicians' skills, provision of relevant training to non-physician health-care workers, and the development and regular updating of national clinical management guidelines will also be crucial to improve diabetes care in the region.

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.

The association of diabetes-related self-care activities with perceived stress, anxiety, and fatigue: a cross-sectional study

PURPOSE

Many people with type 2 diabetes (T2DM) do not sustain sufficient diabetes-related self-care activities (DRSCA) in their daily lives. To provide additional information about the positive influence of DRSCA, this study was conducted to examine whether DRSCA were associated with reduced perceived stress, anxiety, and fatigue among people with T2DM and to explore the level of DRSCA, perceived stress, anxiety, and fatigue and their association with background information.

PATIENTS AND METHODS

This study was a cross-sectional survey including 251 participants aged 18 years and older recruited from two hospitals in the eastern part of China. The study utilized self-report questionnaires that consisted of background information, DRSCA, perceived stress, anxiety, and fatigue. Hierarchical multiple regression analysis was conducted to explore the association of DRSCA with perceived stress, anxiety, and fatigue while adjusting for background information.

RESULTS

The results indicated that the level of self-care activities, stress, and fatigue was around middle level. The prevalence of anxiety was 19%. A high level of DRSCA was likely to reduce perceived stress but was not linked to anxiety and fatigue. Women were more susceptible to stress and anxiety, and people who had diabetes for >5 years were more likely to have anxiety. The background information included diabetes duration, standardized diabetes education, and high social support, all of which are factors that may influence DRSCA.

CONCLUSION

The findings suggest that improving the level of DRSCA might effectively reduce perceived stress. The potential benefits of DRSCA can provide both motivational and evaluative data for self-care programs. In addition, the findings show that DRSCA were not linked to anxiety and fatigue, which implies that their positive influence on anxiety and fatigue may be offset by the load of frequent DRSCA. It is suggested that helping patients to make tailored plans to integrate DRSCA into their daily lives is needed. Meanwhile, in the background information, it is suggested that standardized diabetes education and high social support can benefit DRSCA; in improving psychological health, more attention should be paid to women and patients with diabetes duration <5 years.

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.

Prevalence and factors associated with anxiety and depression among type 2 diabetes in Qassim: A descriptive cross-sectional study

OBJECTIVES

To assess the prevalence of anxiety and depression and to identify their associated risk factors among people with type 2 diabetes mellitus.

METHODS

A cross-sectional, single-centre study that included 300 adults with type 2 diabetes mellitus was conducted at The Diabetic Center of King Saud Hospital in the Qassim region. Anxiety and depression were measured by using the Hospital Anxiety and Depression Scale (HADS). Multivariable analysis using multiple logistic regression was conducted to evaluate the combined effect of various factors associated with anxiety and depression, adjusting for confounding variables.

RESULTS

Overall, 43.6% (95% CI: 37.9-49.3%) and 34.8% (95% CI: 29-40%) of the participants experienced anxiety and depression, respectively. Anxiety was more common among patients who had poor social support (OR 5.35, P 0.001). Anxiety was less common among retired people (OR 0.36, P 0.048) and those having diabetes for more than ten years (OR 0.39, P 0.006). In contrast, depression was more common among patients who had received moderate (OR 2.47, P 0.031) or low social support (OR 6.62, P 0.000) but less common among those having diabetes for more than ten years (OR 0.44, P 0.022).

CONCLUSION

This study showed that the prevalence of anxiety and depression is high among adults with type 2 diabetes mellitus. These results should alert clinicians to identify and treat anxiety and depression as part of multidisciplinary diabetes care. Larger community-based studies are needed to identify the magnitude of these problems and their related factors.

Impact of 24-hour helpline service for people with diabetes

Objective:

To evaluate the impact and effectiveness of 24-hour helpline service in providing information and educating patients about self-management of diabetes.

Method:

The study was conducted at Baqai Institute of Diabetology & Endocrinology (BIDE), a tertiary diabetes care center, Karachi, Pakistan. People with diabetes attending the outpatient department from November 2012 to October 2014 were included in this study. After providing diabetes education, a helpline number was provided for emergency situations. Calls of registered patients were received by diabetes educators stationed at the BIDE around the clock. Data was collected through specially designed interface of HMS (health management system) in which the current complaint of caller and the advice of educator was recorded.

Result:

A total of 4842 calls were received. Out of those, 4268 (88%) were made by Type-2 diabetics and 526 calls (10%) were made by Type-1 diabetics. The average age of patients was 47.6 years. Three seventy-four calls (7.7%) were received with complaint of Hypoglycemia (72-80mg/dl). Six hundred and ninety-eight calls (14.4%) were received with complaint of hyperglycemia (>200mg/dl). Insulin dose was adjusted on 935 calls (19.3%). Calls regarding other special situations such as (insulin handling, technique, medicine information) 2014 (41.6%) were received.

Conclusion:

Station based 24-hour telephonic helpline service is an effective tool for providing continuous support to people with diabetes and their families, for the self-management of diabetes. It can help in the management of various acute complication of diabetes, thereby preventing unnecessary hospital visits and admission.

Patient satisfaction with doctor-patient interactions: a mixed methods study among diabetes mellitus patients in Pakistan

BACKGROUND

Patient satisfaction with doctor-patient interactions is an indicator of physicians' competence. The satisfaction of diabetes patients is rarely studied in public diabetes clinics of Pakistan. Thus, this study aims to analyse the association between patient satisfaction and five dimensions of medical interaction: technical expertise, interpersonal aspects, communication, consultation time, and access/availability.

METHODS

A cross-sectional mixed methods study was conducted during July and August 2015 in the largest public diabetes outpatient clinic in Punjab province. We used the criterion sampling method to identify 1164 patients who: (i) were adult (18 years and above), (ii) had diabetes mellitus, (iii) had made at least three previous visits to the same clinic. The data was collected through face-to-face interviews. The structured part of the questionnaire was based on demographic characteristics and the Patient Satisfaction Questionnaire (PSQ-III). We translated the questionnaire into Urdu and pretested it with 25 patients in a similar context. Data storage and analysis were carried out using SPSS (version 22.0). Bivariate analyses and multinomial logistic regression model were used to generate the quantitative findings. Out of the 1164 eligible patients approached for interviews, 1095 patients completed the structured questionnaire and 186 respondents provided qualitative information in comments section. We conducted a thematic content analysis of qualitative responses in order to explain the quantitative findings.

RESULTS

Demographic characteristics such as gender, education and occupation were significantly associated with the levels of patient satisfaction. The dimensions of doctor-patient interaction were significantly associated with patient satisfaction: technical expertise (OR = .87; 95% CI = .84-.91), interpersonal aspects (OR = .82; 95% CI = .77-.87), communication (OR = .83; 95% CI = .78-.89), time dimension (OR = .90; 95% CI = .81-.99) and access/availability (OR = .78; 95% CI = .72-.84). Several factors involving doctors' incompetence, such as inappropriate handling of critical cases, inaccurate diagnose, excessive reliance on medical tests, absence of physical examination, non-availability of specialist doctors, and experimentation by trainee doctors were related to patient dissatisfaction.

CONCLUSION

The findings of this study highlight a need to develop the interpersonal and clinical skills of doctors in order to improve the quality of doctor-patient interactions in public clinics for diabetes in Pakistan. Prospective researches should explore context-specific factors that form patient satisfaction.

Association of good glycemic control and cost of diabetes care: Experience from a tertiary care hospital in Bangladesh

AIM

The present study was undertaken to assess the cost-effectiveness of good glycemic control in a population of Bangladeshi people with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study was conducted among 496 registered patients with >1year duration of diabetes. Glycated hemoglobin A1c level <7% was judged as the cut-off value for good glycemic control. All treatment-related records from the last year were collected from patients' guide books and all cost components were calculated.

RESULTS

Among patients, 31% had good glycemic control. The average annual cost was US$ 314 per patient. Patients with poor glycemic control were significantly more likely to have complications [(p=0.049) OR 1.5] and comorbidities [(p=0.02) OR 1.5]. The annual cost increased rapidly with complications/comorbidities. In multivariable logistic regression analysis, gender (p=0.003) and cost of care (p=0.006) were significantly associated with glycemic control, and the presence of any comorbidities/complications was associated with 1.8-fold higher odds of poor glycemic control (p=0.013 95% CI: 1.131-2.786).

CONCLUSION

Good glycemic control can lead to substantial cost saving through prevention and control of complications.

Prevalence and determinants of depressive and anxiety symptoms in adults with type 2 diabetes in China: a cross-sectional study

OBJECTIVES

To evaluate the prevalence and determinants of anxiety and depression and to assess their impact on glycaemic control in participants with type 2 diabetes mellitus.

DESIGN

A cross-sectional study.

SETTING

Community-based investigation in Xuzhou, China.

PARTICIPANTS

893 Chinese men and women aged 18-84 years who fulfilled the inclusion criteria.

METHODS

People with type 2 diabetes completed the Pittsburgh Sleep Quality Index and the Zung Self-Rating Anxiety and Depression Scales. Demographic and physiological characteristics were recorded. Multiple logistic regression was used to evaluate the combined effect of factors associated with anxiety and depression and to assess the effects of anxiety and depression on glycaemic control.

RESULTS

The prevalence of depressive symptoms and anxiety symptoms was 56.1% and 43.6%, respectively. Multivariate logistic regression analysis indicated that anxiety symptoms were associated with being woman, low income, chronic disease, depressive symptoms and poor sleep quality. Depressive symptoms were associated with being woman, older age, low education level, being single, diabetes complications, anxiety symptoms and poor sleep quality. Glycaemic control was not related to anxiety symptoms (OR=1.31, 95% CIs 0.94 to 1.67) or depressive symptoms (OR=1.23, 95% CI 0.85 to 1.63). A combination of depressive symptoms and anxiety symptoms was associated with poor glycaemic control (relative excess risk due to interaction: 4.93, 95% CI 2.09 to 7.87; attributable proportion due to interaction: 0.27, 95% CI 0.12 to 0.45).

CONCLUSIONS

There was a high prevalence of depressive and anxiety symptoms in this Chinese sample of participants, although depression and anxiety were not singly associated with glycaemic control. However, a combination of depressive and anxiety symptoms was negatively correlated with glycaemic control in participants with type 2 diabetes.

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.

Can the Direct Medical Cost of Chronic Disease Be Transferred across Different Countries? Using Cost-of-Illness Studies on Type 2 Diabetes, Epilepsy and Schizophrenia as Examples

Objectives

To systematically review cost of illness studies for schizophrenia (SC), epilepsy (EP) and type 2 diabetes mellitus (T₂DM) and explore the transferability of direct medical cost across countries.

Methods

A comprehensive literature search was performed to yield studies that estimated direct medical costs. A generalized linear model (GLM) with gamma distribution and log link was utilized to explore the variation in costs that accounted by the included factors. Both parametric (Random-effects model) and non-parametric (Boot-strapping) meta-analyses were performed to pool the converted raw cost data (expressed as percentage of GDP/capita of the country where the study was conducted).

Results

In total, 93 articles were included (40 studies were for T₂DM, 34 studies for EP and 19 studies for SC). Significant variances were detected inter- and intra-disease classes for the direct medical costs. Multivariate analysis identified that GDP/capita (p<0.05) was a significant factor contributing to the large variance in the cost results. Bootstrapping meta-analysis generated more conservative estimations with slightly wider 95% confidence intervals (CI) than the parametric meta-analysis, yielding a mean (95%CI) of 16.43% (11.32, 21.54) for T₂DM, 36.17% (22.34, 50.00) for SC and 10.49% (7.86, 13.41) for EP.

Conclusions

Converting the raw cost data into percentage of GDP/capita of individual country was demonstrated to be a feasible approach to transfer the direct medical cost across countries. The approach from our study to obtain an estimated direct cost value along with the size of specific disease population from each jurisdiction could be used for a quick check on the economic burden of particular disease for countries without such data.

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.

Counting the Cost of Diabetes in the Solomon Islands and Nauru

AIM

To determine the costs associated with diabetes to governments, people with diabetes and their carers, and its impact on quality of life in two Pacific Island countries--the Solomon Islands and Nauru.

MATERIALS AND METHODS

This cross-sectional cost of illness study was conducted on 330 people with type 2 diabetes (197 from the Solomon Islands and 133 from Nauru) using a structured cost of illness survey questionnaire adapted from the Australian DiabCo$t study. Quality of life was measured by the EQ-5D Visual Analogue Scale.

RESULTS

There were 330 respondents (50% female; mean duration of diabetes 10.9 years; mean age 52.6 years). The estimated annual national cost of diabetes incurred by the Solomon Islands government was AUD 12.8 million (AUD 281 per person/year) and by Nauru government was AUD 1.2 million (AUD 747 per person/year). The major contribution to the government costs was inpatient services cost (71% in the Solomon Islands and 83% in Nauru). Annual expenditure for diabetes was approximately 20% of the governments' annual health care expenditure. Considerable absenteeism and retirement from work due to diabetes was found.

CONCLUSIONS

This study found substantial public and personal costs associated with diabetes. The findings provide objective data on which health policy, funding and planning decisions about the prevention and control of diabetes in the Solomon Islands and Nauru can be reliably based and subsequently evaluated.

Provider costs for prevention and treatment of cardiovascular and related conditions in low- and middle-income countries: a systematic review

BACKGROUND

The burden of cardiovascular disease (CVD) and CVD risk conditions is rapidly increasing in low- and middle-income countries, where health systems are generally ill-equipped to manage chronic disease. Policy makers need an understanding of the magnitude and drivers of the costs of cardiovascular disease related conditions to make decisions on how to allocate limited health resources.

METHODS

We undertook a systematic review of the published literature on provider-incurred costs of treatment for cardiovascular diseases and risk conditions in low- and middle-income countries. Total costs of treatment were inflated to 2012 US dollars for comparability across geographic settings and time periods.

RESULTS

This systematic review identified 60 articles and 143 unit costs for the following conditions: ischemic heart disease, non-ischemic heart diseases, stroke, heart failure, hypertension, diabetes, and chronic kidney disease. Cost data were most readily available in middle-income countries, especially China, India, Brazil, and South Africa. The most common conditions with cost studies were acute ischemic heart disease, type 2 diabetes mellitus, stroke, and hypertension.

CONCLUSIONS

Emerging economies are currently providing a base of cost evidence for NCD treatment that may prove useful to policy-makers in low-income countries. Initial steps to publicly finance disease interventions should take account of costs. The gaps and limitations in the current literature include a lack of standardized reporting as well as sparse evidence from low-income countries.

Economic burden and catastrophic cost among people living with type2 diabetes mellitus attending a tertiary health institution in south-east zone, Nigeria

BACKGROUND

Diabetes mellitus (DM) is a life-long illness that affects the quality of life, requiring close monitoring and control. Type 2 DM is preventable and controllable but increasing cost of care could hinder access to quality care because of inability to pay leading to high morbidity, mortality and productivity losses. The people living with diabetes mellitus (PLWD) in Nigeria have high risk for high economic burden and catastrophic expenditure not only because they make frequent visits to the health facilities, report late with complications but also pay out of pocket at the point of accessing care. The aim of this study was to assess the magnitude of economic burden borne and catastrophic costs incurred by PLWD in Nigeria.

METHODS

Cross-sectional descriptive survey design was used to study a sample of 308 type2 PLWD managed at a tertiary health institution, South east Nigeria using semi-structured, prevalidated questionnaire. Data collection period was 2 months.

RESULTS

The major findings were economic burden of type 2 DM of N56,245 ($356). Catastrophic direct cost was 45 % at 30 % threshold (the determinant level for catastrophic spending set). All socio-economic status (SES) groups suffered catastrophic expenditure but the poorest quartile had the highest incidence.

CONCLUSIONS

Economic burden of DM was high for PLWD who also suffered high catastrophic costs due to the impact of out of pocket payment. PLWD need financial protection especially for the poorest since they buy from the same market and incur same costs. Policy decision making to assist the PLWD cope with cost of care is needful in Nigeria and nations with related problems.

The Economic Costs of Type 2 Diabetes: A Global Systematic Review

BACKGROUND

There has been a widely documented and recognized increase in diabetes prevalence, not only in high-income countries (HICs) but also in low- and middle-income countries (LMICs), over recent decades. The economic burden associated with diabetes, especially in LMICs, is less clear.

OBJECTIVE

We provide a systematic review of the global evidence on the costs of type 2 diabetes. Our review seeks to update and considerably expand the previous major review of the costs of diabetes by capturing the evidence on overall, direct and indirect costs of type 2 diabetes worldwide that has been published since 2001. In addition, we include a body of economic evidence that has hitherto been distinct from the cost-of-illness (COI) work, i.e. studies on the labour market impact of diabetes.

METHODS

We searched PubMed, EMBASE, EconLit and IBSS (without language restrictions) for studies assessing the economic burden of type 2 diabetes published from January 2001 to October 2014. Costs reported in the included studies were converted to international dollars ($) adjusted for 2011 values. Alongside the narrative synthesis and methodological review of the studies, we conduct an exploratory linear regression analysis, examining the factors behind the considerable heterogeneity in existing cost estimates between and within countries.

RESULTS

We identified 86 COI and 23 labour market studies. COI studies varied considerably both in methods and in cost estimates, with most studies not using a control group, though the use of either regression analysis or matching has increased. Direct costs were generally found to be higher than indirect costs. Direct costs ranged from $242 for a study on out-of-pocket expenditures in Mexico to $11,917 for a study on the cost of diabetes in the USA, while indirect costs ranged from $45 for Pakistan to $16,914 for the Bahamas. In LMICs-in stark contrast to HICs-a substantial part of the cost burden was attributed to patients via out-of-pocket treatment costs. Our regression analysis revealed that direct diabetes costs are closely and positively associated with a country's gross domestic product (GDP) per capita, and that the USA stood out as having particularly high costs, even after controlling for GDP per capita. Studies on the labour market impact of diabetes were almost exclusively confined to HICs and found strong adverse effects, particularly for male employment chances. Many of these studies also took into account the possible endogeneity of diabetes, which was not the case for COI studies.

CONCLUSIONS

The reviewed studies indicate a large economic burden of diabetes, most directly affecting patients in LMICs. The magnitude of the cost estimates differs considerably between and within countries, calling for the contextualization of the study results. Scope remains large for adding to the evidence base on labour market effects of diabetes in LMICs. Further, there is a need for future COI studies to incorporate more advanced statistical methods in their analysis to account for possible biases in the estimated costs.

Survey of knowledge-attitude-practice concerning insulin use in adult diabetic patients in eastern India

Objectives:

The study was conducted to assess knowledge, attitude, and practice regarding insulin use among diabetic patients in tertiary care hospitals.

Materials and Methods:

Type 1 and 2 diabetic patients, aged 18 years and above, attending the Medicine/Endocrinology out-patient department or admitted as in-patients in three hospitals in and around Kolkata were enrolled. A pretested structured questionnaire comprising of 51 items was administered through face-to-face interview. Responses from 385 subjects were analyzed.

Results:

Both higher educational and higher economic standards were associated with better understanding of insulin use. Longer duration of diabetes and its treatment (oral anti-diabetic drugs and insulin) were associated with better knowledge of some parameters. Female subjects were less aware of HbA_1c as a monitoring tool. Among current insulin users, 70% had never used a glucometer; only 27.33% carried simple carbohydrates for use in hypoglycemic attacks; and 32% failed to rotate sites for insulin injection.

Conclusion:

Knowledge and attitude were satisfactory on the whole but deficiencies in practice were pronounced, which can potentially be removed through appropriate counseling.

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.

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.

Urbanization and prevalence of type 2 diabetes in Southern Asia: A systematic analysis

BACKGROUND

Diabetes mellitus is one of the diseases considered to be the main constituents of the global non-communicable disease (NCD) pandemic. Despite the large impact that NCDs are predicted to have, particularly in developing countries, estimates of disease burden are sparse and inconsistent. This systematic review transparently estimates prevalence of type 2 diabetes mellitus in Southern Asia, its association with urbanization and provides insight into the policy challenges facing the region.

METHODS

The databases Medline and PubMed were searched for population-based studies providing estimates of diabetes prevalence in the Southern Asia region. Studies using WHO diagnostic criteria of fasting plasma glucose (FPG) ≥7.0mmol/L and/or 2h-plasma glucose (2hPG) ≥11.1mmol/L were included. Data from eligible studies was extracted into bubble graphs, and trend lines were applied to UNPD figures to estimate age-specific prevalence in the regional population. Estimates specific to sex, area of residency, and diagnostic method were compared and trends analysed.

RESULTS

A total of 151 age-specific prevalence estimates were extracted from 39 studies. Diabetes prevalence was estimated to be 7.47% for 2005 and 7.60% for 2010. Prevalence was strongly associated with increased age, male gender and urban residency (P < 0.001).

CONCLUSION

Diabetes prevalence in Southern Asia is high and predicted to increase in the future as life expectancy rises and the region continues to urbanise. Countries in this region need to improve NCD surveillance and monitoring so policies can be informed with the best evidence. Programs for prevention need to be put in place, and health system capacity and access needs to be assessed and increased to deal with the predicted rise in NCD prevalence.

Diagnostic accuracy of direct ophthalmoscopy for detection of diabetic retinopathy using fundus photographs as a reference standard

AIMS

To determine the diagnostic accuracy of direct ophthalmoscopy for the presence and severity of diabetic retinopathy (DR) using fundus photographs as a reference standard.

METHODS

Patients with type 2 diabetes attending the outpatient department (OPD) of a tertiary care diabetes center, from October 2009 to March 2010 were recruited in the study after obtaining signed informed consent. Patients with type 1 diabetes and gestational diabetes or having eye problems were excluded. After checking visual acuity, direct ophthalmoscopy of each eye was done by diabetologist, followed by photography of two fields of retina by fundus camera. DR was graded by a retinal specialist, according to International Diabetic Retinopathy Disease Severity Scale. According to severity, patients with DR were grouped into non-sight threatening diabetic retinopathy (NSTDR) and sight threatening diabetic retinopathy (STDR). Sensitivity and specificity of direct ophthalmoscopy for detection of any retinopathy, NSTDR and STDR was calculated.

RESULTS

A total of 728 eyes were examined by direct ophthalmoscopy as well as fundus photography. Sensitivity (95% CI) of direct ophthalmoscopy for any retinopathy, NSTDR and STDR was found to be 55.67% (50.58-60.78), 37.63% (32.67-42.59) and 68.25% (63.48-73.02) respectively. Whereas, specificity of direct ophthalmoscopy was found to be 76.78% (72.45-81.11), 71.27% (CI: 66.63-75.91) and 90.0% (86.93-93.07) for any retinopathy, NSTDR and STDR respectively.

CONCLUSION

The sensitivity and specificity of direct ophthalmoscopy performed by the diabetologist for the presence and severity of DR was lower compared to the recommended level of sensitivity and specificity of a screening test of DR.

Comparing the disease profiles of adult patients with type 2 diabetes mellitus attending four public health care facilities in Malaysia

AIM

We examined disease profiles of patients with type 2 diabetes mellitus (T2D) at four different public health facilities in Malaysia to determine which site would be the most suitable for early and intensive diabetes care against diabetes-related complications.

METHODS

This study analysed 57,780 T2D patients in the Adult Diabetes Control and Management registry database in the year 2009. The four public health facilities were hospital with specialists (HS), hospital without specialists (HNS), health clinics with family medicine specialists (CS) and health clinic without doctors (CND). Descriptive analyses were used to examine age, duration of diseases, intervals from the onset of diabetes to co-morbidities (hypertension and dyslipidaemia) and complication of T2D patients at the four public health facilities.

RESULTS

Patients were significantly older in HS. Patients with T2D at HS had significantly longer duration of diabetes, hypertension and dyslipidaemia. Health clinics, both the CS and the CND, were seeing T2D patients with shorter duration of macrovascular and microvascular complications.

CONCLUSION

Public health clinics in this country managed T2D patients who were younger and at the early stage of diabetes, hypertension, dyslipidaemia and complications. Thus, primary care physicians are best positioned to provide early and intensive diabetes care for this group of T2D patients to prevent the development of diabetes-related complications.

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.

Diabetes related knowledge among residents and nurses: a multicenter study in Karachi, Pakistan

BACKGROUND

Assessment of knowledge among resident trainees and nurses is very important since majority of patients admitted in hospital have underlying diabetes which could lead to adverse clinical outcomes if not managed efficiently. Therefore, the purpose of this study was to evaluate and compare the knowledge related to the management of diabetes among registered nurses (RN) and trainee residents of internal medicine (IMR), family medicine (FMR) and surgery (SR) at tertiary care hospitals of Karachi, Pakistan.

METHODS

A validated questionnaire consisting of 21 open ended questions related to diabetes awareness was acquired through a study done at Thomas Jefferson University Hospital, Philadelphia with the permission of primary author.

RESULTS

169 IMR, 27 FMR, 86 SR and 99 RN completed a questionnaire that assessed the knowledge related to different aspects of management of diabetes. The results were further stratified by participant's specialty and level of training. The percentage of knowledge based questions answered correctly was found to be low. The overall mean correct percentage among all the participants was 50% +/- 21. There was no statistical difference in terms of knowledge between IMR & FMR residents (64% +/- 14 vs. 60% +/- 16, p = 0.47) respectively. The total scores of SR and RN were quite low (40% +/- 16 & 31% +/- 15 respectively).SR and RN were found to have profound deficit in both inpatient and outpatient knowledge of diabetes. We did not observe any improvement in level of knowledge of FMR & SR with increase in duration of their training (p = 0.47 & 0.80 respectively). In contrast, improvement in the level of knowledge of IMR was observed from first to second year of their training (p = 0.03) with no further improvement thereafter. RN's didn't respond correctly on most of the items related to in-patient management of diabetes (Mean score 40% +/- 20).

CONCLUSION

As there are no prior studies in our setting evaluating knowledge related to diabetes management among residents and nurses, this study is of paramount importance. Based on these results, considerable knowledge gaps were found among trainee residents and nurses pointing towards need of providing additional education to improve the delivery of diabetes care.

Challenges of training diabetes nurse educator in Iran

BACKGROUND

The purpose of this study was to describe the first attempts and performance of health system in Iran in training specialist nurses in the field of diabetes- related care and education.

MATERIALS AND METHODS

This was a qualitative content analysis. Three diabetes management planners in the Ministry of Health and Medical Education, three provincial executive authorities of diabetes in the health system and ten nurses who worked as diabetes nurse educators (DNEs) participated in this study. Data obtained through semi-structured face-to-face interviews, a focus group, existing documents, field notes, and multiple observations. Data analysis was guided by the conventional approach of qualitative content analysis.

FINDINGS

Three major themes and six sub-themes were emerged through data analysis. Main themes were: (a) decentralization diabetes nurse educator training without any management (stop education due to transition training responsibility to provincial health authorities and lack of supervision of managers on training); (b) try to reform nursing education infrastructures (try to train qualified educators who were candidate for teaching to DNEs, try to reform undergraduate nursing curriculum); (c) failure of DNE curriculum (lack of consistency between content and timing with the curriculum objectives and lack of attention to learn evaluation process).

CONCLUSIONS

The findings of this study reflected the failure and multiple challenges in educating nurses working in diabetes units. Despite the fact that important roles were defined for nurses in the action plan for preventing and controlling diabetes, any specific action was not done in preparing nurses for these roles.