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Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila
Journal of Clinical Neuroscience xxx (xxxx) xxx
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Clinical study
Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila Mario Prado Jr ⇑, Roland Dominic Jamora Section of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines- Manila, Manila, Philippines
a r t i c l e
i n f o
Article history: Received 9 November 2019 Accepted 12 January 2020 Available online xxxx Keywords: Cost of illness study Parkinson’s Disease Direct costs Indirect costs
a b s t r a c t Background: Cost of illness (COI) studies are used to estimate the economic burden of a particular disease. The chronicity of Parkinson’s disease (PD) and its lack of treatment make its projected economic burden to grow substantially over the next few decades. Methods: To evaluate the cost of having PD, a COI study was done in a public tertiary hospital in Metro Manila, Philippines. PD patients who were consecutively seen at out patient clinic for a period of six months were included in this study and were interviewed using a ready-made financial burden questionnaire. To identify the possible factors that may affect the cost, European Quality of Life 5 Dimensions (EQ5D), Montreal Cognitive Assessment-Philippines (MoCA-P), Hospital Anxiety and Depression ScalePilipino (HADS-P), Unified Parkinson’s Disease Rating Scale (UPDRS) motor and activities of daily living (ADL) scores, Schwab and England ADL and Hoehn and Yahr scoring were also administered. Results: Thirty three consecutive PD patients (mean age: 58.4 yrs, men: 52%) were identified. The annual total cost of PD per capita was Php 308,796 (USD 6175) with direct cost accounting for 23% and indirect cost 77%. The main cost components for direct medical, direct non-medical and indirect cost were pharmacotherapy (97%), home care (42.6%) and productivity loss (100%) respectively. The factors observed to have high cost of PD included being male, married, employed, the presence of wearing off phenomenon, low MOCA-P and HADS-P, low Schwab and England ADL and increasing Hoehn and Yahr stage. Conclusion: This study showed that PD is a costly neurodegenerative disease that may pose a significant economic burden on patients, health care system and society. Ó 2020 Elsevier Ltd. All rights reserved.
1. Introduction Parkinson’s Disease (PD) is a chronic, progressive, degenerative, neurological condition characterized by slowness of movement, rigidity, tremor and postural disturbances predominantly affecting older population [1,2]. The chronicity of this condition and its lack of treatment make its projected economic burden to grow substantially over the next few decades, impacting on patients and their families, the health care system and society as a whole [1,3,4].
Abbreviations: PD, Parkinson’s disease; COI, Cost of Illness; EQ5D, European Quality of Life 5 Dimensions; MoCA-P, Montreal Cognitive Assessment-Philippines; HADS-P, Hospital Anxiety and Depression-Pilipino; UPDRS, Unified Parkinson’s Disease Rating Scale; S and E ADL, Schwab and England Activities of Daily Living; H and Y, Hoehn and Yahr; Php, Philippine Peso. ⇑ Corresponding author. Tel.: +639985438062. E-mail addresses: [email protected] (M. Prado Jr), [email protected] (R.D. Jamora).
In western countries, cost of illness (COI) studies are used to estimate the impact of a particular disease. In the United States (US), the estimated economic burden is USD 14–23 billion annually [3,5]. The average medical cost per patient ranges from USD 18,500 to 27,000; the bulk of which goes to nursing homes and productivity losses [2,5]. In United Kingdom (UK), where the prevalence of PD is around 100–180 per 100,000, the economic burden is significantly lower at 351–599 million UK pounds and is attributed to lower number of population and consequently, less number of PD patients. As per capita cost however, each patient is estimated to pay at least 28,000 UK pounds which is higher than those in the US [2,4,6]. COI studies in Asia are sparse [1]. Currently, there are only three researches about medical economics of PD in Asia [1,7,8]. In the study of Zhao et al, the estimated economic burden of PD in Singapore is USD 23–41 million which is 0.7–1.2% of Singapore’s total health budget for 2009. This is lower compared to other western countries because Singapore has a low population and prevalence of PD, which is only 0.3% [1]. Per capita, a Singaporean patient is
https://doi.org/10.1016/j.jocn.2020.01.057 0967-5868/Ó 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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M. Prado Jr, R.D. Jamora / Journal of Clinical Neuroscience xxx (xxxx) xxx
estimated to pay USD 10,129. This estimate is significantly higher compared to a patient from Shanghai, China and India who have to pay an average of USD 925 and USD 707 per year respectively [7,9]. There are multiple factors that influence the cost of PD. The cost increases by 3,500 USD per year if the patient is diagnosed before the age of 45 years old. In patients more than 85 years old, sex becomes a factor; females have higher cost than males [3]. This is attributed to the propensity of female patients to be admitted in a nursing home [3]. Although not statistically significant, there is a propensity to pay higher in older patients [2,4,6]. Multiple studies consistently implicate the severity of PD as one of the cost drivers of this disease, measured by Hoehn and Yahr (H and Y) stage [2,4,6]. Cost is estimated to double each H and Y stage after stage 2 [2,4,6]. It is also noted that there’s a six-fold increase in mean annual expenditure between stages H and Y 0/1 and stages H and Y 5/6 [2,4,6]. Dodel and Zhao also noted this association in their study [1,2,4,6]. The presence of fluctuations in motor ability and dyskinesias and the time spent in the off state are also significant predictors of PD cost [2,4,6,8]. Findley pointed out that increasing the time spent in off state is associated with higher costs for both direct costs associated with medical expenses and professional care from 25,630 UK pounds in <25% off state to 62,147 UK pounds in >75% off state. Other constant factors that increase the cost of PD include high ADL and worst HRQoL [1,2,4]. The factors mentioned above are studies from western population and may not be applicable to people of Asian descent [1]. For example, in Singapore, factors such as higher education, employed status, younger age and higher duration of PD increase cost [1]. This is in agreement with a similar study conducted in China but adding the number of follow ups in the list [9]. This study aims to estimate the cost of having PD among patients seen at a tertiary hospital and to have a better understanding of the clinical, sociodemographic, and HRQoL factors that may predict the total, direct, and indirect cost of having PD in a developing country like the Philippines. Currently, the prevalence and the economic burden of PD in the Philippines is unknown. To date, this is the first COI study in PD to be conducted in the country.
2. Significance of the study Studies examining the costs of PD are sparse in Asia so the economic burden of this disease is unknown. Further, most studies of the factors that predict the cost of PD are done on western countries hence these factors are not necessarily applicable to population of Asia. Moreover, the health care system is different from country to country. With the recent overhaul of the national health insurance program in the Philippines, policy makers and decision makers may use this COI study as guide to distribute the resources properly and equitably to different diseases. Further, once factors affecting cost are determined, the decision makers may be able to create a policy or public health program that will prevent that factor from increasing the cost of PD. For example, if the severity of PD increases the direct-non medical cost because of more frequent number of follow ups, then an intensive medical management among patients in H and Y Stages 1 or 2 can be done to prevent progression to H and Y 4 or 5. Identification and management of these cost factors will save a lot of resources not only for the patients and their family, but more for the whole government as a whole. Further, a detailed knowledge of the cost allocation would provide a solid basis on which health care priorities can be rationally set. Lastly, this study will provide important information for cost-
effectiveness and cost-benefit analyses in the future. This, we conducted a study looking into the cost of having PD among Filipino patients seen at a public tertiary hospital in Metro Manila, Philippines. 3. Methods 3.1. Study design This is a prevalence based descriptive research that used societal and health care system perspective. It included patients from the out patient department (OPD) of a public tertiary hospital in Metro Manila. Interview and chart review using a data gathering tool was done prospectively. Direct cost was estimated using the bottomup approach while indirect cost was estimated using the human capital method. This study also estimated costs using PD as the primary diagnosis only. 3.2. Sample size and study population Follow up patients with PD who were consecutively seen at OPD for a period of six months were included in this study. A pre-made informed consent was given prior to inclusion or exclusion of patient. Inclusion Criteria: 1) Filipino > 18 years old 2) fulfilled the Movement Disorder Society criteria for Parkinson’s Disease 3) At least 1 year follow up Exclusion Criteria: 1) Foreigner and below 18 years old 2) Patients with incomplete data on chart 3) Patients with alternative cause of Parkinsonism such as those with secondary parkinsonism, arterioslerotic pseudoparkinsonism, Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP) and Corticobasal Ganglionic Degeneration (CBDG) 3.3. Data collection and cost calculation A data gathering tool was created for this study. The tool was divided into five parts: Informed Consent, Demographics, Financial Burden Questionnaire and Measures of Factors Affecting the cost of PD. Demographics, date of diagnosis, duration of illness, co-morbid diseases, measures of disease severity [Hoehn and Yahr (H and Y) stage], motor and activities of daily living (ADL) parts of the Unified Parkisnon’s Disease Rating Scale (UPDRS), Schwab and England ADL (S and E ADL), Montreal Cognitive Assessment-Philippines (MOCA-P), PD-related pharmacotherapy and the presence of deep brain stimulation (DBS) surgery were obtained from the chart or interview. For PD related pharmacotherapy, all drugs used by the patient over a 12-month period were enumerated with the frequency and duration included. Drugs prescribed for other diseases (e.g. heart disease) or for symptoms that were not primarily related to PD were excluded. The costs of different drugs were estimated using Compendium of Philippine Medicine if the price was unknown to the patient. A financial burden questionnaire was also designed to specifically obtain the necessary data from the patients and their caregivers in this study. It included direct medical cost, direct
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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M. Prado Jr, R.D. Jamora / Journal of Clinical Neuroscience xxx (xxxx) xxx
non-medical cost and indirect cost which includes productivity loss and informal care and was based on study by Segel et al. [10] A detailed breakdown of the cost components and their derivation is given in the appendix. Direct costs was calculated using the tertiary hospital OPD service rates. Equipment purchased cost was obtained using the manufacturers price list. Indirect costs was estimated using years of productive life lost multiplied by the minimum wage in the country if the latest wage was unknown. A conservative approach to costing was employed. To identify factors that may affect the cost of having PD, a locally validated health related quality of life, the European Quality of Life 5 Dimension (EQ-5D) was obtained. The MoCA-P, Hospital Anxiety and Depression Scale-Pilipino (HADS-P), H and Y scale were used to measure cognitive impairment, depression and anxiety and disease severity. The locally validated MoCA-P and HADS-P were used in this study. The measures were as follows: Unified Parkinson’s Disease Rating Scale (UPDRS) – activities of daily living (Part II) and clinician-scored monitored motor evaluation (Part III) of UPDRS. Schwab and England ADL scale. MOCA-P –a score < 26 was indicative of mild cognitive impairment. Hospital Anxiety and Depression Scale- Philippines (HADS-P) – a score of >11 signified anxiety and depression [11]. EuroQol – 5D – This study used the utility and VAS scores [12]. 4. Results 4.1. Patient characteristics Thirty-three patients were included in the study (Table 1). The mean (SD) age of the patients was 58.4 (10.6). Most were males (52%), with secondary and tertiary type of education (both 39%), married (79%) and unemployed (87.9%). The mean (SD) duration of PD was 4.9 years (3.6) and majority were on H and Y stage 1 (30%). The mean (SD) UPDRS motor and ADL scores were 17.1 (11.7) and 16.2(8.9) respectively. Most have S and E ADL of >70 (54.5%) and wearing off phenomenon (54.5%). Most have at least mild cognitive impairment (MCI) (90.9%) and some form of anxiety (75.8%). Most of them have no co-morbidities. The mean (SD) EQ5D VAS score was 60.4 (21.3) and all five dimensions of ED5D have a score close to 2. No one had DBS.
Table 1 Characteristics of study patients at baseline (n = 33). Characteristics
N(%)
Service patients Age Males
32 (97) 17 (52)
Education Primary Secondary Tertiary Vocational
6 (18.0) 13 (39.0) 13 (39.0) 2 (6.0)
Marital status Married Unemployment Duration of PD H and Y 1 2 2.5 3 4 5 UPDRS Motor UPDRS ADL S and E ADL <70 >70 Wearing off Yes (Duration) No Moca-P >26 <26 HADS-P <11 >11 Co-morbids 0 1 2 3 EQ5D VAS score Mobility Self care ADL Pain Anxiety Presence of DBS
Median (Range)
Mean (SD)
59 (42–83)
58.4 (10.6)
4 (1–16) 2 (1–5)
4.9 (3.6) 2.4 (1.2)
15 (1–41) 14 (1–37) 80 (10–100)
17.1 (11.7) 16.2 (8.9) 69.7 (26.4)
30 (1–180)
50.3 (46.5.1)
21 (2–29)
19.1 (5.9)
16 (1–26)
14.9 (5.8)
60 (10–95)
60.4 (21.3) 1.8 1.6 1.9 2.0 2.0 0
26 (79.0) 29 (87.9)
10 (30.0) 7 (21.0) 4 (12.0) 4 (12.0) 7 (21.0) 1 (3.0)
15 (45.5) 18 (54.5) 18 (54.5) 15 (45.5) 3 (9.1) 30 (90.9) 8 (24.2) 25 (75.8) 18 (55.0) 8 (24.0) 4 (12.0) 3 (9.0)
4.2. Cost of Parkinson’s Disease The total annual cost of PD per Filipino patient seen at a public tertiary hospital in Metro Manila was Php 308,796. The distribution of individual cost components was shown in Table 2. Most of the annual cost came from indirect cost (77.0%) followed by direct medical cost (21.9%) and direct non-medical cost (1.1%). All indirect costs were contributed by productivity loss secondary to early retirement. Majority of those who retired early were due to PD (66.7%) while the rest were due to old age (16.7%) or other non-specified reasons (16.7%). Only three continued to work despite their illness. Although most of PD patients have informal care provider (63.6%), none of these caregivers stopped from work. All of the caregivers were their first degree relatives. Most of the direct medical cost was supplied by PD pharmacotherapy (97.2%). Levodopa carbidopa was used in all patients. Some combined it with biperiden (33.3%) or pramipexole (12.1%). Other drugs used include azilect, selegeline and amantadine. Only few received drugs to control non-motor symptoms like constipation, anxiety and spasticity (15%). Only two were admitted in the hospital due to fall and muscle cramping. Hospitalization and out-
patient consultation has small contribution on total annual cost (0.2% and 0.1% respectively). Total indirect medical cost has also contributed little to the total annual cost (1.1%) with physical therapy (0.6%), house modification (0.3%) and transportation (0.3%) as its three cost drivers. 4.3. Factors affecting the cost The insufficient number of samples preclude simple and multiple regression analyses. The factors examined and their total annual cost with their components were tabulated (Table 3). Being male, married, employed and the presence of wearing off were observed to have higher cost of PD. On the other hand a Moca P and HADS-P of >26 and 11 respectively, were observed to have lower total annual cost. PD patients with higher S and E ADL have to pay higher than those with S and E ADL lower than 70. In terms of age and education, PD patients at 50–59 age range with tertiary education were noted to pay higher cost. PD patients at H and Y stage 2 with 1 comorbidity were also noted to pay higher cost of PD.
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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M. Prado Jr, R.D. Jamora / Journal of Clinical Neuroscience xxx (xxxx) xxx
Table 2 Breakdown of cost incurred by Parkinson’s disease patients over a 12-month period. Mean (SD)Php
Median (Interquartile range) Php
Percentage of total cost
Direct cost Direct medical cost Hospitalization Outpatient Pharmacotherapy Hospice care Labs Medical Supplies Total direct medical cost
660.6 (3,653.9) 249.7 (829.2) 65,599.7 (42,697.9117) 0 213.0 (6 4 8) 821.1 (3,113.0) 67,483.5 (43640.7)
0 0 59,130.0 0 0 0 60,616.0
0.2 0.1 21.2 0 0.1 0.3 21.9
Direct non-medical cost Home care/PT Aids and modification Transportation Fee Total direct non-medical cost
1,478.8 (5,271.7) 972.7 (3,245.1) 1,016.5 (2,163) 3,468.0 (6,297.6)
0 0 400.0 800.0
0.5 0.3 0.3 1.1
Indirect cost Productivity loss Informal care Indirect cost per annum Total cost of PD per capita per annum:
3,217,454.6 (8,887,122.0) 0 237,818.2 (590,354.0) 308,796 (623,105.1)
960,000.0 0 66,000.0 132,700.0
– 0 77.0 100
5. Discussion In this study, we found the annual total cost of having PD per patient examined in one tertiary public hospital to be Php 308,796 (USD 6,175). This is significantly lower compared to three similar studies conducted in United States (US) in 2013, 2006 and 2005 (USD 22,129, USD 23,101 and USD 18,528 respectively) [3,5]. This is also lower compared to the annual cost of PD in United Kingdom and Germany (UK pounds 28,700 and 65.5 German franks) [2,4,6]. In Asian countries, Singapore reported higher annual total cost of PD (USD 10,129) although China reported less (USD925) [1,9]. The lower cost is due to the type of the patients examined. In this study, only patients from a single hospital were included and most were charity patients. None of these patients had DBS and only few had polypharmacy. Most of the total annual cost of PD is contributed by productivity loss in US, UK, Singapore and China (49.4%, 43%, 60.2% and 73% respectively) similar to what we have observed, although much higher (77.0%) [1–4,9]. In the countries mentioned, the major contributor of productivity loss is reduced employment or early retirement. In Singapore, despite the late mean age of diagnosis of 62 which is close to the official retirement age in that country, productivity loss still accounts for USD 6,100 of the total annual cost of PD (61.5%) [1]. In our study, early retirement is the sole contributor to indirect loss. The second largest contributor to the annual total cost of PD is the direct medical cost (21.9%). This was also observed in Singapore (22.5%), China (43%), the US and United Kingdom (UK) [1–3,9]. In this study, significant contribution was provided by pharmacotherapy to direct medical cost (97%) and almost none from hospitalization, outpatient consults, hospice care, laboratories and medical supplies (3%). This was similar to that in Singapore and China but not in US and UK where the bulk of the direct medical cost came from either hospitalization or nursing care [1–3,9]. Although, pharmacotherapy tops the list for direct medical cost in Singapore, hospitalization and nursing care are also mentioned as important contributors [1]. Payment for OPD in a public tertiary hospital in Metro Manila is also subsidized by the government contributing to the low direct cost. The family oriented culture of Filipinos may be one of the main reasons why there are no PD patients enrolled in any nursing homes in the Philippines. The high cost of PD pharmacotherapy is probably due to the high cost of PD drugs locally [13]. Most PD
drugs are not included in the Philippine government’s maximum retail drug prices which is imposed by the country’s Department of Health (DOH) and could reduce costs by 50%. These drugs also have high procurement prices [13]. Although charity institutions provide assistance to those who cannot afford, the long list of requirements combined with low rate of approval and long waiting time prevent patients from seeking help from these institutions. This was evident in the study as only two patients sought medical assistance from financial institutions while the rest bought their medicines using out-of-pocket scheme (93.9%). To give an example of how costly a PD drug in the Philippines is, a patient who takes levodopa carbidopa four times a day would need to spend around USD 1,500 dollars per year just to be compliant to his/her medications. The average annual family income of a Filipino family is USD 3,808 [13]. There are several factors that may affect the annual total cost of PD. In US, there is a USD 3,500 per year increase for PD patients under age 45. Females of age 85 and above also has high propensity to be admitted in a nursing home, increasing the direct medical cost of PD [3]. In the UK, there was an increasing trend for age but it was not significant. The stage of PD appeared to impact the cost as well, as cost was estimated to double per each H and Y stage after 2. There was also a six-fold increase in mean annual expenditure between stages H and Y 0/1 and stage 5 [2,4]. This trend was also seen in Germany, in addition to the presence of fluctuations in motor ability, dyskinesias and duration of off state as factors that may influence the cost [6]. Higher education, employed status, younger age and longer duration were associated with higher total cost in Singapore [1]. In China, the frequent number of outpatient visits and H and Y stage were the identified factors [9]. Unfortunately, the sample size was not met for a regression analysis to be done. This was due to lack of time and the resources. Although, it was observed that being in pay service, younger age of having PD, male sex, tertiary education, being married, being employed, lower S and E ADL, having off state, lower MoCA-P, lower HADS-P, having one co-morbidity and increasing stage of PD appear to increase the total cost of PD. 6. Limitations Due to limited funding and time, this study covered only patients seen at a public tertiary hospital in Metro Manila. The study population was small and the result of this study may not
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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M. Prado Jr, R.D. Jamora / Journal of Clinical Neuroscience xxx (xxxx) xxx Table 3 Factors that affect may affect the cost of PD. Characteristics
Total direct medical cost
Total direct non-medical
Total indirect cost
Total cost
Class Charity Pay
63,013 (35,849) 210,533
3,201 (6206) 12,000
147,750 (288,824) 3,120,000
213,964 (307,591) 3,342,533
Age 40–49 50–59 60–69 >70
142,897 (43,656) 98,797 (59,962) 55,959 (25,804) 51,821 (26,889)
1,193 7,071 1,442 3,960
88,666 (77,291) 639,000 (1,072,981) 75,600 (327,351) 0
154,520 (81,847) 744,868 (1,130,842) 132,992 (335,673) 55,781 (21,418)
Sex Male Female
69,502 (56,487) 65,338 (25,492)
5,479 (7,994) 1,330 (2,641)
415,764 (788,171) 48,750 (82,816)
490,746 (834,574) 115,419 (89,056)
Education Primary Secondary Tertiary Vocational
46,859 67,897 82,025 39,417
3,217 4,876 1,987 3,950
(4,197) (9,071) (3,431) (3,323)
37,000 (76,312) 273,230 (420,090) 320,500 (885,987) 114,000 (8,485)
87,076 (91,046) 346,004 (444,788) 404,512 (931,277) 157,367 (3,616)
Marital status Single Married
81,502 (42,554) 63,709 (43,969)
5,158 (7,444) 3,012 (6,037)
65,142 (93,429) 284,307 (658,339)
151,804 (116,198) 351,029 (696,402)
Employment Employed Unemployed
107,869 (78,656) 61,913 (35,335)
3,403 (5,741) 3,477 (6,464)
780,000 (1,560,000) 163,034 (299,627)
891,272.5 (1,634,629) 228,424 (319,812)
H and Y 1 2 2.5 3 4 5
50,958 (36,901) 73,726 (67,947) 109,985 (49,912) 79,713 (23,955) 65,335 (7,288) 21,900
790 (982) 7,806 (10,173) 1,690 (2,926) 1,760 (1,527) 4,130 (7,314) 10,400
159,000 (370,332) 550,285 (1,137,416) 300,000 (600,000) 83,000 (66,241) 143,142 (83,744) 0
210,749 631,817 411,675 164,473 212,608 32,300
S and E ADL <70 >70
61,712 (17,009) 72,293 (57,382)
3,692 (5,476) 3,281 (7,062)
103,600 (91,851) 349,666 (787,365)
169,004 (101,470) 425,240 (831,121)
Wearing Off Yes No
83,913 (49,906) 47,767 (23,775)
3,445 (5,461) 3,494 (7,377)
461,692 (816,654) 74,000 (91,996)
461,692 (816,654) 125,262 (107,085)
Moca-P >26 <26
1,262 (1,695) 67,014 (42,440)
72,169 (65,717) 3,688 (6,558)
48,000 (83,138) 256,800 (616,437)
121,431 (147,956) 327,503 (650,324)
HADS-P <11 >11
66,252 (62,112) 67,877 (37,595)
5,524 (10,293) 2,810 (4,485)
598,500 (1,094,952) 122,400 (240,343)
670,276 (1,155,967) 193,087 (265,396)
Co-morbids 0 1 2 3
67,284 80,386 55,636 50,068
4,175 2,155 2,732 3,706
219,000 (368,144) 444,750 (1,082,323) 0 116,000 (120,199)
290,459 (389,295) 527,291 (1,140,814) 58,368 (18,250) 169,775 (141,298)
(19,920) (38,659) (55,886) (1,545)
(37,233) (67,747) (23,149) (20,461)
(1,075) (9,674) (5,653) (5596)
(7,781) (4,111) (5,112) (3,000)
be generalizable to the whole population. Although the population included both pay and charity patients, more charity patients were included so the cost of PD may be underestimated. Other reasons why estimates of this study may be lower include: recall bias, secondary diagnoses or complications were not included and the approach to estimation was conservative. Also only one public tertiary hospital was included. This study did not determine the best course of action with respect to PD which can be provided by cost benefit or cost analyses studies. 7. Conclusion In conclusion, this study showed that PD is a costly neurodegenerative disease that may pose a significant economic burden on patients, health care system and society. Since a large share of the total cost comes from pharmacotherapy, a program to reduce the requirements for medical assistance or a bill to lower the procurement prices of these medicines might be needed. After all, if
(380,829) (1,200,985) (645,430) (76,683) (93,121)
PD is controlled by these drugs, these patient may not need to retire early, decreasing the productivity loss and in turn the total annual cost of PD.
8. Ethical consideration This study was submitted and approved by the local Research Ethics Board. All data gathered were anonymized and kept confidential. Names were not recorded on the data collection form. There were no foreseeable risks to study subjects and no direct benefits for study subjects. Expenses for this study was shouldered by the principal investigator. The principal investigator discloses no conflict of interest in any form.
Sources of support This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References [1] Zhao YJ, Tan CS, Li SC, et al. Economic Burden of Parkinson’s disease in Singapore. Eur J Neurol 2011;18:519–26. https://doi.org/10.1111/j.14681331.2010.03210.x. [2] Findley L, Aujla M, Bain PG, et al. Direct economic impact of parkinson’s disease: a reesearch survery in the United Kingdom. Mov Disord 2003;18:1139–89. https://doi.org/10.1002/mds.10507. [3] Kowal SL, Dall TM, Chakrabarti R, et al. The current and projected economic burden of Parkinson’s disease in the United States. Mov Disord 2013;28:312–8. https://doi.org/10.1002/mds.25292. [4] Findley LJ, Wood E, Lowin J, et al. The economic burden of advanced Parkinson’s Disease: an analysis of a UK patient dataset. J Med Econ 2011;14–1:130–9. https://doi.org/10.3111/13696998.2010.551164. [5] Huse DM, Schulan K, Orsini L, et al. Burden of illness in Parkinson’s disease. Mov Disord 2005;20(11):1449–54. https://doi.org/10.1002/mds.20609.
[6] Dodel RC, Eggert KM, Singer MS, et al. Costs of drug treatment in Parkinson’s disease. Mov Disord 1998;13(2):249–54. https://doi.org/10.1002/ mds.870130209. [7] Ragothaman M, Govindappa ST, Rattihalli R, et al. Direct costs of managing Parkinson’s Disease in India: concerns in a developing country. Mov Disord 2006;21(10):1755–8. https://doi.org/10.1002/mds.21035. [8] Dodel RC, Singer M, Kohne-Volant R, et al. The economic impact of Parkinson’s disease: an estimation based on a 3 month prospective analysis. Pharmaeconomics 1998;14(3):299–312. https://doi.org/10.2165/00019053199814030-00006. [9] Wang G, Cheng Q, Zheng R, et al. Economic burden of Parkinson’s Disease in a developing country: a retrospective cost analysis in Shanghai, China. Mov Disord 2006;21(9):1439–43. https://doi.org/10.1002/mds.20999. [10] Segel J. Cost-of-Illness Studies—A Primer. RTI Int 2006;1(38). [11] Lourdes M, Guzman RE De. The Validation of the Hospital Anxiety and Depression Scale ( HADS-P ) among the medically-ill Filipino patients in Philippine General Hospital A V. 2016; (January 2014). [12] Schrag A, Selai C, Jahanshahi M, et al. The EQ-5D- a generic quality of life measure – is a useful instrument to measure quality of life in patients with Parkinson’s disease. J Neurol neurosurg Psychiatry 2000;69(1):67–73. https:// doi.org/10.1136/jnnp.69.1.67. [13] Jamora RDG, Miyasaki JM. Treatment gaps in Parkinson’s disease care in the philippines. Neurodegenerative Dis Manage 2017;7(4):245–51. https://doi. org/10.2217/nmt-2017-0014.
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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Clinical study
Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila Mario Prado Jr ⇑, Roland Dominic Jamora Section of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines- Manila, Manila, Philippines
a r t i c l e
i n f o
Article history: Received 9 November 2019 Accepted 12 January 2020 Available online xxxx Keywords: Cost of illness study Parkinson’s Disease Direct costs Indirect costs
a b s t r a c t Background: Cost of illness (COI) studies are used to estimate the economic burden of a particular disease. The chronicity of Parkinson’s disease (PD) and its lack of treatment make its projected economic burden to grow substantially over the next few decades. Methods: To evaluate the cost of having PD, a COI study was done in a public tertiary hospital in Metro Manila, Philippines. PD patients who were consecutively seen at out patient clinic for a period of six months were included in this study and were interviewed using a ready-made financial burden questionnaire. To identify the possible factors that may affect the cost, European Quality of Life 5 Dimensions (EQ5D), Montreal Cognitive Assessment-Philippines (MoCA-P), Hospital Anxiety and Depression ScalePilipino (HADS-P), Unified Parkinson’s Disease Rating Scale (UPDRS) motor and activities of daily living (ADL) scores, Schwab and England ADL and Hoehn and Yahr scoring were also administered. Results: Thirty three consecutive PD patients (mean age: 58.4 yrs, men: 52%) were identified. The annual total cost of PD per capita was Php 308,796 (USD 6175) with direct cost accounting for 23% and indirect cost 77%. The main cost components for direct medical, direct non-medical and indirect cost were pharmacotherapy (97%), home care (42.6%) and productivity loss (100%) respectively. The factors observed to have high cost of PD included being male, married, employed, the presence of wearing off phenomenon, low MOCA-P and HADS-P, low Schwab and England ADL and increasing Hoehn and Yahr stage. Conclusion: This study showed that PD is a costly neurodegenerative disease that may pose a significant economic burden on patients, health care system and society. Ó 2020 Elsevier Ltd. All rights reserved.
1. Introduction Parkinson’s Disease (PD) is a chronic, progressive, degenerative, neurological condition characterized by slowness of movement, rigidity, tremor and postural disturbances predominantly affecting older population [1,2]. The chronicity of this condition and its lack of treatment make its projected economic burden to grow substantially over the next few decades, impacting on patients and their families, the health care system and society as a whole [1,3,4].
Abbreviations: PD, Parkinson’s disease; COI, Cost of Illness; EQ5D, European Quality of Life 5 Dimensions; MoCA-P, Montreal Cognitive Assessment-Philippines; HADS-P, Hospital Anxiety and Depression-Pilipino; UPDRS, Unified Parkinson’s Disease Rating Scale; S and E ADL, Schwab and England Activities of Daily Living; H and Y, Hoehn and Yahr; Php, Philippine Peso. ⇑ Corresponding author. Tel.: +639985438062. E-mail addresses: [email protected] (M. Prado Jr), [email protected] (R.D. Jamora).
In western countries, cost of illness (COI) studies are used to estimate the impact of a particular disease. In the United States (US), the estimated economic burden is USD 14–23 billion annually [3,5]. The average medical cost per patient ranges from USD 18,500 to 27,000; the bulk of which goes to nursing homes and productivity losses [2,5]. In United Kingdom (UK), where the prevalence of PD is around 100–180 per 100,000, the economic burden is significantly lower at 351–599 million UK pounds and is attributed to lower number of population and consequently, less number of PD patients. As per capita cost however, each patient is estimated to pay at least 28,000 UK pounds which is higher than those in the US [2,4,6]. COI studies in Asia are sparse [1]. Currently, there are only three researches about medical economics of PD in Asia [1,7,8]. In the study of Zhao et al, the estimated economic burden of PD in Singapore is USD 23–41 million which is 0.7–1.2% of Singapore’s total health budget for 2009. This is lower compared to other western countries because Singapore has a low population and prevalence of PD, which is only 0.3% [1]. Per capita, a Singaporean patient is
https://doi.org/10.1016/j.jocn.2020.01.057 0967-5868/Ó 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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estimated to pay USD 10,129. This estimate is significantly higher compared to a patient from Shanghai, China and India who have to pay an average of USD 925 and USD 707 per year respectively [7,9]. There are multiple factors that influence the cost of PD. The cost increases by 3,500 USD per year if the patient is diagnosed before the age of 45 years old. In patients more than 85 years old, sex becomes a factor; females have higher cost than males [3]. This is attributed to the propensity of female patients to be admitted in a nursing home [3]. Although not statistically significant, there is a propensity to pay higher in older patients [2,4,6]. Multiple studies consistently implicate the severity of PD as one of the cost drivers of this disease, measured by Hoehn and Yahr (H and Y) stage [2,4,6]. Cost is estimated to double each H and Y stage after stage 2 [2,4,6]. It is also noted that there’s a six-fold increase in mean annual expenditure between stages H and Y 0/1 and stages H and Y 5/6 [2,4,6]. Dodel and Zhao also noted this association in their study [1,2,4,6]. The presence of fluctuations in motor ability and dyskinesias and the time spent in the off state are also significant predictors of PD cost [2,4,6,8]. Findley pointed out that increasing the time spent in off state is associated with higher costs for both direct costs associated with medical expenses and professional care from 25,630 UK pounds in <25% off state to 62,147 UK pounds in >75% off state. Other constant factors that increase the cost of PD include high ADL and worst HRQoL [1,2,4]. The factors mentioned above are studies from western population and may not be applicable to people of Asian descent [1]. For example, in Singapore, factors such as higher education, employed status, younger age and higher duration of PD increase cost [1]. This is in agreement with a similar study conducted in China but adding the number of follow ups in the list [9]. This study aims to estimate the cost of having PD among patients seen at a tertiary hospital and to have a better understanding of the clinical, sociodemographic, and HRQoL factors that may predict the total, direct, and indirect cost of having PD in a developing country like the Philippines. Currently, the prevalence and the economic burden of PD in the Philippines is unknown. To date, this is the first COI study in PD to be conducted in the country.
2. Significance of the study Studies examining the costs of PD are sparse in Asia so the economic burden of this disease is unknown. Further, most studies of the factors that predict the cost of PD are done on western countries hence these factors are not necessarily applicable to population of Asia. Moreover, the health care system is different from country to country. With the recent overhaul of the national health insurance program in the Philippines, policy makers and decision makers may use this COI study as guide to distribute the resources properly and equitably to different diseases. Further, once factors affecting cost are determined, the decision makers may be able to create a policy or public health program that will prevent that factor from increasing the cost of PD. For example, if the severity of PD increases the direct-non medical cost because of more frequent number of follow ups, then an intensive medical management among patients in H and Y Stages 1 or 2 can be done to prevent progression to H and Y 4 or 5. Identification and management of these cost factors will save a lot of resources not only for the patients and their family, but more for the whole government as a whole. Further, a detailed knowledge of the cost allocation would provide a solid basis on which health care priorities can be rationally set. Lastly, this study will provide important information for cost-
effectiveness and cost-benefit analyses in the future. This, we conducted a study looking into the cost of having PD among Filipino patients seen at a public tertiary hospital in Metro Manila, Philippines. 3. Methods 3.1. Study design This is a prevalence based descriptive research that used societal and health care system perspective. It included patients from the out patient department (OPD) of a public tertiary hospital in Metro Manila. Interview and chart review using a data gathering tool was done prospectively. Direct cost was estimated using the bottomup approach while indirect cost was estimated using the human capital method. This study also estimated costs using PD as the primary diagnosis only. 3.2. Sample size and study population Follow up patients with PD who were consecutively seen at OPD for a period of six months were included in this study. A pre-made informed consent was given prior to inclusion or exclusion of patient. Inclusion Criteria: 1) Filipino > 18 years old 2) fulfilled the Movement Disorder Society criteria for Parkinson’s Disease 3) At least 1 year follow up Exclusion Criteria: 1) Foreigner and below 18 years old 2) Patients with incomplete data on chart 3) Patients with alternative cause of Parkinsonism such as those with secondary parkinsonism, arterioslerotic pseudoparkinsonism, Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP) and Corticobasal Ganglionic Degeneration (CBDG) 3.3. Data collection and cost calculation A data gathering tool was created for this study. The tool was divided into five parts: Informed Consent, Demographics, Financial Burden Questionnaire and Measures of Factors Affecting the cost of PD. Demographics, date of diagnosis, duration of illness, co-morbid diseases, measures of disease severity [Hoehn and Yahr (H and Y) stage], motor and activities of daily living (ADL) parts of the Unified Parkisnon’s Disease Rating Scale (UPDRS), Schwab and England ADL (S and E ADL), Montreal Cognitive Assessment-Philippines (MOCA-P), PD-related pharmacotherapy and the presence of deep brain stimulation (DBS) surgery were obtained from the chart or interview. For PD related pharmacotherapy, all drugs used by the patient over a 12-month period were enumerated with the frequency and duration included. Drugs prescribed for other diseases (e.g. heart disease) or for symptoms that were not primarily related to PD were excluded. The costs of different drugs were estimated using Compendium of Philippine Medicine if the price was unknown to the patient. A financial burden questionnaire was also designed to specifically obtain the necessary data from the patients and their caregivers in this study. It included direct medical cost, direct
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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non-medical cost and indirect cost which includes productivity loss and informal care and was based on study by Segel et al. [10] A detailed breakdown of the cost components and their derivation is given in the appendix. Direct costs was calculated using the tertiary hospital OPD service rates. Equipment purchased cost was obtained using the manufacturers price list. Indirect costs was estimated using years of productive life lost multiplied by the minimum wage in the country if the latest wage was unknown. A conservative approach to costing was employed. To identify factors that may affect the cost of having PD, a locally validated health related quality of life, the European Quality of Life 5 Dimension (EQ-5D) was obtained. The MoCA-P, Hospital Anxiety and Depression Scale-Pilipino (HADS-P), H and Y scale were used to measure cognitive impairment, depression and anxiety and disease severity. The locally validated MoCA-P and HADS-P were used in this study. The measures were as follows: Unified Parkinson’s Disease Rating Scale (UPDRS) – activities of daily living (Part II) and clinician-scored monitored motor evaluation (Part III) of UPDRS. Schwab and England ADL scale. MOCA-P –a score < 26 was indicative of mild cognitive impairment. Hospital Anxiety and Depression Scale- Philippines (HADS-P) – a score of >11 signified anxiety and depression [11]. EuroQol – 5D – This study used the utility and VAS scores [12]. 4. Results 4.1. Patient characteristics Thirty-three patients were included in the study (Table 1). The mean (SD) age of the patients was 58.4 (10.6). Most were males (52%), with secondary and tertiary type of education (both 39%), married (79%) and unemployed (87.9%). The mean (SD) duration of PD was 4.9 years (3.6) and majority were on H and Y stage 1 (30%). The mean (SD) UPDRS motor and ADL scores were 17.1 (11.7) and 16.2(8.9) respectively. Most have S and E ADL of >70 (54.5%) and wearing off phenomenon (54.5%). Most have at least mild cognitive impairment (MCI) (90.9%) and some form of anxiety (75.8%). Most of them have no co-morbidities. The mean (SD) EQ5D VAS score was 60.4 (21.3) and all five dimensions of ED5D have a score close to 2. No one had DBS.
Table 1 Characteristics of study patients at baseline (n = 33). Characteristics
N(%)
Service patients Age Males
32 (97) 17 (52)
Education Primary Secondary Tertiary Vocational
6 (18.0) 13 (39.0) 13 (39.0) 2 (6.0)
Marital status Married Unemployment Duration of PD H and Y 1 2 2.5 3 4 5 UPDRS Motor UPDRS ADL S and E ADL <70 >70 Wearing off Yes (Duration) No Moca-P >26 <26 HADS-P <11 >11 Co-morbids 0 1 2 3 EQ5D VAS score Mobility Self care ADL Pain Anxiety Presence of DBS
Median (Range)
Mean (SD)
59 (42–83)
58.4 (10.6)
4 (1–16) 2 (1–5)
4.9 (3.6) 2.4 (1.2)
15 (1–41) 14 (1–37) 80 (10–100)
17.1 (11.7) 16.2 (8.9) 69.7 (26.4)
30 (1–180)
50.3 (46.5.1)
21 (2–29)
19.1 (5.9)
16 (1–26)
14.9 (5.8)
60 (10–95)
60.4 (21.3) 1.8 1.6 1.9 2.0 2.0 0
26 (79.0) 29 (87.9)
10 (30.0) 7 (21.0) 4 (12.0) 4 (12.0) 7 (21.0) 1 (3.0)
15 (45.5) 18 (54.5) 18 (54.5) 15 (45.5) 3 (9.1) 30 (90.9) 8 (24.2) 25 (75.8) 18 (55.0) 8 (24.0) 4 (12.0) 3 (9.0)
4.2. Cost of Parkinson’s Disease The total annual cost of PD per Filipino patient seen at a public tertiary hospital in Metro Manila was Php 308,796. The distribution of individual cost components was shown in Table 2. Most of the annual cost came from indirect cost (77.0%) followed by direct medical cost (21.9%) and direct non-medical cost (1.1%). All indirect costs were contributed by productivity loss secondary to early retirement. Majority of those who retired early were due to PD (66.7%) while the rest were due to old age (16.7%) or other non-specified reasons (16.7%). Only three continued to work despite their illness. Although most of PD patients have informal care provider (63.6%), none of these caregivers stopped from work. All of the caregivers were their first degree relatives. Most of the direct medical cost was supplied by PD pharmacotherapy (97.2%). Levodopa carbidopa was used in all patients. Some combined it with biperiden (33.3%) or pramipexole (12.1%). Other drugs used include azilect, selegeline and amantadine. Only few received drugs to control non-motor symptoms like constipation, anxiety and spasticity (15%). Only two were admitted in the hospital due to fall and muscle cramping. Hospitalization and out-
patient consultation has small contribution on total annual cost (0.2% and 0.1% respectively). Total indirect medical cost has also contributed little to the total annual cost (1.1%) with physical therapy (0.6%), house modification (0.3%) and transportation (0.3%) as its three cost drivers. 4.3. Factors affecting the cost The insufficient number of samples preclude simple and multiple regression analyses. The factors examined and their total annual cost with their components were tabulated (Table 3). Being male, married, employed and the presence of wearing off were observed to have higher cost of PD. On the other hand a Moca P and HADS-P of >26 and 11 respectively, were observed to have lower total annual cost. PD patients with higher S and E ADL have to pay higher than those with S and E ADL lower than 70. In terms of age and education, PD patients at 50–59 age range with tertiary education were noted to pay higher cost. PD patients at H and Y stage 2 with 1 comorbidity were also noted to pay higher cost of PD.
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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M. Prado Jr, R.D. Jamora / Journal of Clinical Neuroscience xxx (xxxx) xxx
Table 2 Breakdown of cost incurred by Parkinson’s disease patients over a 12-month period. Mean (SD)Php
Median (Interquartile range) Php
Percentage of total cost
Direct cost Direct medical cost Hospitalization Outpatient Pharmacotherapy Hospice care Labs Medical Supplies Total direct medical cost
660.6 (3,653.9) 249.7 (829.2) 65,599.7 (42,697.9117) 0 213.0 (6 4 8) 821.1 (3,113.0) 67,483.5 (43640.7)
0 0 59,130.0 0 0 0 60,616.0
0.2 0.1 21.2 0 0.1 0.3 21.9
Direct non-medical cost Home care/PT Aids and modification Transportation Fee Total direct non-medical cost
1,478.8 (5,271.7) 972.7 (3,245.1) 1,016.5 (2,163) 3,468.0 (6,297.6)
0 0 400.0 800.0
0.5 0.3 0.3 1.1
Indirect cost Productivity loss Informal care Indirect cost per annum Total cost of PD per capita per annum:
3,217,454.6 (8,887,122.0) 0 237,818.2 (590,354.0) 308,796 (623,105.1)
960,000.0 0 66,000.0 132,700.0
– 0 77.0 100
5. Discussion In this study, we found the annual total cost of having PD per patient examined in one tertiary public hospital to be Php 308,796 (USD 6,175). This is significantly lower compared to three similar studies conducted in United States (US) in 2013, 2006 and 2005 (USD 22,129, USD 23,101 and USD 18,528 respectively) [3,5]. This is also lower compared to the annual cost of PD in United Kingdom and Germany (UK pounds 28,700 and 65.5 German franks) [2,4,6]. In Asian countries, Singapore reported higher annual total cost of PD (USD 10,129) although China reported less (USD925) [1,9]. The lower cost is due to the type of the patients examined. In this study, only patients from a single hospital were included and most were charity patients. None of these patients had DBS and only few had polypharmacy. Most of the total annual cost of PD is contributed by productivity loss in US, UK, Singapore and China (49.4%, 43%, 60.2% and 73% respectively) similar to what we have observed, although much higher (77.0%) [1–4,9]. In the countries mentioned, the major contributor of productivity loss is reduced employment or early retirement. In Singapore, despite the late mean age of diagnosis of 62 which is close to the official retirement age in that country, productivity loss still accounts for USD 6,100 of the total annual cost of PD (61.5%) [1]. In our study, early retirement is the sole contributor to indirect loss. The second largest contributor to the annual total cost of PD is the direct medical cost (21.9%). This was also observed in Singapore (22.5%), China (43%), the US and United Kingdom (UK) [1–3,9]. In this study, significant contribution was provided by pharmacotherapy to direct medical cost (97%) and almost none from hospitalization, outpatient consults, hospice care, laboratories and medical supplies (3%). This was similar to that in Singapore and China but not in US and UK where the bulk of the direct medical cost came from either hospitalization or nursing care [1–3,9]. Although, pharmacotherapy tops the list for direct medical cost in Singapore, hospitalization and nursing care are also mentioned as important contributors [1]. Payment for OPD in a public tertiary hospital in Metro Manila is also subsidized by the government contributing to the low direct cost. The family oriented culture of Filipinos may be one of the main reasons why there are no PD patients enrolled in any nursing homes in the Philippines. The high cost of PD pharmacotherapy is probably due to the high cost of PD drugs locally [13]. Most PD
drugs are not included in the Philippine government’s maximum retail drug prices which is imposed by the country’s Department of Health (DOH) and could reduce costs by 50%. These drugs also have high procurement prices [13]. Although charity institutions provide assistance to those who cannot afford, the long list of requirements combined with low rate of approval and long waiting time prevent patients from seeking help from these institutions. This was evident in the study as only two patients sought medical assistance from financial institutions while the rest bought their medicines using out-of-pocket scheme (93.9%). To give an example of how costly a PD drug in the Philippines is, a patient who takes levodopa carbidopa four times a day would need to spend around USD 1,500 dollars per year just to be compliant to his/her medications. The average annual family income of a Filipino family is USD 3,808 [13]. There are several factors that may affect the annual total cost of PD. In US, there is a USD 3,500 per year increase for PD patients under age 45. Females of age 85 and above also has high propensity to be admitted in a nursing home, increasing the direct medical cost of PD [3]. In the UK, there was an increasing trend for age but it was not significant. The stage of PD appeared to impact the cost as well, as cost was estimated to double per each H and Y stage after 2. There was also a six-fold increase in mean annual expenditure between stages H and Y 0/1 and stage 5 [2,4]. This trend was also seen in Germany, in addition to the presence of fluctuations in motor ability, dyskinesias and duration of off state as factors that may influence the cost [6]. Higher education, employed status, younger age and longer duration were associated with higher total cost in Singapore [1]. In China, the frequent number of outpatient visits and H and Y stage were the identified factors [9]. Unfortunately, the sample size was not met for a regression analysis to be done. This was due to lack of time and the resources. Although, it was observed that being in pay service, younger age of having PD, male sex, tertiary education, being married, being employed, lower S and E ADL, having off state, lower MoCA-P, lower HADS-P, having one co-morbidity and increasing stage of PD appear to increase the total cost of PD. 6. Limitations Due to limited funding and time, this study covered only patients seen at a public tertiary hospital in Metro Manila. The study population was small and the result of this study may not
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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M. Prado Jr, R.D. Jamora / Journal of Clinical Neuroscience xxx (xxxx) xxx Table 3 Factors that affect may affect the cost of PD. Characteristics
Total direct medical cost
Total direct non-medical
Total indirect cost
Total cost
Class Charity Pay
63,013 (35,849) 210,533
3,201 (6206) 12,000
147,750 (288,824) 3,120,000
213,964 (307,591) 3,342,533
Age 40–49 50–59 60–69 >70
142,897 (43,656) 98,797 (59,962) 55,959 (25,804) 51,821 (26,889)
1,193 7,071 1,442 3,960
88,666 (77,291) 639,000 (1,072,981) 75,600 (327,351) 0
154,520 (81,847) 744,868 (1,130,842) 132,992 (335,673) 55,781 (21,418)
Sex Male Female
69,502 (56,487) 65,338 (25,492)
5,479 (7,994) 1,330 (2,641)
415,764 (788,171) 48,750 (82,816)
490,746 (834,574) 115,419 (89,056)
Education Primary Secondary Tertiary Vocational
46,859 67,897 82,025 39,417
3,217 4,876 1,987 3,950
(4,197) (9,071) (3,431) (3,323)
37,000 (76,312) 273,230 (420,090) 320,500 (885,987) 114,000 (8,485)
87,076 (91,046) 346,004 (444,788) 404,512 (931,277) 157,367 (3,616)
Marital status Single Married
81,502 (42,554) 63,709 (43,969)
5,158 (7,444) 3,012 (6,037)
65,142 (93,429) 284,307 (658,339)
151,804 (116,198) 351,029 (696,402)
Employment Employed Unemployed
107,869 (78,656) 61,913 (35,335)
3,403 (5,741) 3,477 (6,464)
780,000 (1,560,000) 163,034 (299,627)
891,272.5 (1,634,629) 228,424 (319,812)
H and Y 1 2 2.5 3 4 5
50,958 (36,901) 73,726 (67,947) 109,985 (49,912) 79,713 (23,955) 65,335 (7,288) 21,900
790 (982) 7,806 (10,173) 1,690 (2,926) 1,760 (1,527) 4,130 (7,314) 10,400
159,000 (370,332) 550,285 (1,137,416) 300,000 (600,000) 83,000 (66,241) 143,142 (83,744) 0
210,749 631,817 411,675 164,473 212,608 32,300
S and E ADL <70 >70
61,712 (17,009) 72,293 (57,382)
3,692 (5,476) 3,281 (7,062)
103,600 (91,851) 349,666 (787,365)
169,004 (101,470) 425,240 (831,121)
Wearing Off Yes No
83,913 (49,906) 47,767 (23,775)
3,445 (5,461) 3,494 (7,377)
461,692 (816,654) 74,000 (91,996)
461,692 (816,654) 125,262 (107,085)
Moca-P >26 <26
1,262 (1,695) 67,014 (42,440)
72,169 (65,717) 3,688 (6,558)
48,000 (83,138) 256,800 (616,437)
121,431 (147,956) 327,503 (650,324)
HADS-P <11 >11
66,252 (62,112) 67,877 (37,595)
5,524 (10,293) 2,810 (4,485)
598,500 (1,094,952) 122,400 (240,343)
670,276 (1,155,967) 193,087 (265,396)
Co-morbids 0 1 2 3
67,284 80,386 55,636 50,068
4,175 2,155 2,732 3,706
219,000 (368,144) 444,750 (1,082,323) 0 116,000 (120,199)
290,459 (389,295) 527,291 (1,140,814) 58,368 (18,250) 169,775 (141,298)
(19,920) (38,659) (55,886) (1,545)
(37,233) (67,747) (23,149) (20,461)
(1,075) (9,674) (5,653) (5596)
(7,781) (4,111) (5,112) (3,000)
be generalizable to the whole population. Although the population included both pay and charity patients, more charity patients were included so the cost of PD may be underestimated. Other reasons why estimates of this study may be lower include: recall bias, secondary diagnoses or complications were not included and the approach to estimation was conservative. Also only one public tertiary hospital was included. This study did not determine the best course of action with respect to PD which can be provided by cost benefit or cost analyses studies. 7. Conclusion In conclusion, this study showed that PD is a costly neurodegenerative disease that may pose a significant economic burden on patients, health care system and society. Since a large share of the total cost comes from pharmacotherapy, a program to reduce the requirements for medical assistance or a bill to lower the procurement prices of these medicines might be needed. After all, if
(380,829) (1,200,985) (645,430) (76,683) (93,121)
PD is controlled by these drugs, these patient may not need to retire early, decreasing the productivity loss and in turn the total annual cost of PD.
8. Ethical consideration This study was submitted and approved by the local Research Ethics Board. All data gathered were anonymized and kept confidential. Names were not recorded on the data collection form. There were no foreseeable risks to study subjects and no direct benefits for study subjects. Expenses for this study was shouldered by the principal investigator. The principal investigator discloses no conflict of interest in any form.
Sources of support This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057
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Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References [1] Zhao YJ, Tan CS, Li SC, et al. Economic Burden of Parkinson’s disease in Singapore. Eur J Neurol 2011;18:519–26. https://doi.org/10.1111/j.14681331.2010.03210.x. [2] Findley L, Aujla M, Bain PG, et al. Direct economic impact of parkinson’s disease: a reesearch survery in the United Kingdom. Mov Disord 2003;18:1139–89. https://doi.org/10.1002/mds.10507. [3] Kowal SL, Dall TM, Chakrabarti R, et al. The current and projected economic burden of Parkinson’s disease in the United States. Mov Disord 2013;28:312–8. https://doi.org/10.1002/mds.25292. [4] Findley LJ, Wood E, Lowin J, et al. The economic burden of advanced Parkinson’s Disease: an analysis of a UK patient dataset. J Med Econ 2011;14–1:130–9. https://doi.org/10.3111/13696998.2010.551164. [5] Huse DM, Schulan K, Orsini L, et al. Burden of illness in Parkinson’s disease. Mov Disord 2005;20(11):1449–54. https://doi.org/10.1002/mds.20609.
[6] Dodel RC, Eggert KM, Singer MS, et al. Costs of drug treatment in Parkinson’s disease. Mov Disord 1998;13(2):249–54. https://doi.org/10.1002/ mds.870130209. [7] Ragothaman M, Govindappa ST, Rattihalli R, et al. Direct costs of managing Parkinson’s Disease in India: concerns in a developing country. Mov Disord 2006;21(10):1755–8. https://doi.org/10.1002/mds.21035. [8] Dodel RC, Singer M, Kohne-Volant R, et al. The economic impact of Parkinson’s disease: an estimation based on a 3 month prospective analysis. Pharmaeconomics 1998;14(3):299–312. https://doi.org/10.2165/00019053199814030-00006. [9] Wang G, Cheng Q, Zheng R, et al. Economic burden of Parkinson’s Disease in a developing country: a retrospective cost analysis in Shanghai, China. Mov Disord 2006;21(9):1439–43. https://doi.org/10.1002/mds.20999. [10] Segel J. Cost-of-Illness Studies—A Primer. RTI Int 2006;1(38). [11] Lourdes M, Guzman RE De. The Validation of the Hospital Anxiety and Depression Scale ( HADS-P ) among the medically-ill Filipino patients in Philippine General Hospital A V. 2016; (January 2014). [12] Schrag A, Selai C, Jahanshahi M, et al. The EQ-5D- a generic quality of life measure – is a useful instrument to measure quality of life in patients with Parkinson’s disease. J Neurol neurosurg Psychiatry 2000;69(1):67–73. https:// doi.org/10.1136/jnnp.69.1.67. [13] Jamora RDG, Miyasaki JM. Treatment gaps in Parkinson’s disease care in the philippines. Neurodegenerative Dis Manage 2017;7(4):245–51. https://doi. org/10.2217/nmt-2017-0014.
Please cite this article as: M. Prado and R. D. Jamora, Cost of Parkinson’s disease among Filipino patients seen at a public tertiary hospital in Metro Manila, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.057