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The socioeconomics of diabetes from a developing country: A population based cost of illness study
diabetes research and clinical practice 89 (2010) 334–340
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Diabetes Research and Clinical Practice jou rna l hom ep ag e: w ww.e lse v ier .com/ loca te /d iab res
The socioeconomics of diabetes from a developing country: A population based cost of illness study Shabana Tharkar, Arutselvi Devarajan, Satyavani Kumpatla, Vijay Viswanathan * M.V. Hospital for Diabetes and Diabetes Research Centre, No. 4, Main Road, Royapuram, Chennai 13, India
article info
abstract
Article history:
Objective: To assess the annual health care expenditure for a patient with diabetes and
Received 2 March 2010
extrapolate the same to country specific prevalence estimates for 2010.
Received in revised form
Methods: This population based, cost of illness study collected retrospective data for last 12
7 May 2010
months on direct costs (medical and non-medical) through records, indirect cost through
Accepted 13 May 2010
human capital approach and intangible cost by contingent valuation method from diabetes
Published on line 9 June 2010
patients. Results: Out of 4677 subjects screened, 1050 had diabetes and 718 participated in the survey.
Keywords:
The median annual direct and indirect cost associated with diabetes care was estimated at
Diabetes
25,391 INR ($525.5) and 4970 INR ($102.8), respectively. Extrapolating the direct and indirect
Socioeconomics
estimates to Indian population, the annual costs for diabetes would be 1541.4 billion INR
Direct cost
($31.9 billion) in 2010. Two-way sensitivity analysis assuming 10% variation in both preva-
Indirect cost
lence of diabetes and in treatment costs resulted in an estimated cost range of 1230 billion
Intanglible cost measures
INR ($25.5 billion) to 1837.3 billion INR ($38.0 billion).
India
Conclusion: Keeping the future diabetes explosion in mind, this heavy economic burden highlights the urgent need for the decision makers to allocate resources for planning and implementing strategies in prevention and management of diabetes and its complications. # 2010 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
According to the latest edition of IDF Atlas, ‘‘An estimated 50.8 million people will be affected by diabetes in 2010 in India alone’’. Global projections by the year 2025 have estimated a 41 and 170% increase in number of diabetes patients in the developed and developing nations, respectively, of which India contributes to the major proportion [1]. Since diabetes is a chronic disease associated with co-morbidities and complications, it has a substantial impact on the cost of care [2,3]. Financial burden is more on the individuals who have diabetes and an associated co-morbid condition than those who have only diabetes [4]. In addition to this, in countries like India, lack
of access to health care services, lack of national welfare schemes and health insurance coverage for diabetes make the treatment unaffordable resulting in late diagnosis and increased cost in treatment of diabetes and early onset of complications [5]. The IDF statement in 2006 spoke about ‘Diabetes Care for Everyone’ and according to United Nations Human Rights and World Health Organization, after all, access to health care is a matter of human rights and every person with illness must be able to get equality in care irrespective of socioeconomic status [6]. The estimated global expenditures on diabetes will be at least International Dollar (ID) 418 billion in 2010, and at least ID 561 billion in 2030 [7]. Though not distributed evenly across
* Corresponding author at: M.V. Hospital for Diabetes and Diabetes Research Centre, WHO Collaborating Centre for Research, Education and Training in Diabetes, No. 4, Main Road, Royapuram, Chennai 600013, Tamil Nadu, India. Tel.: +91 44 25954913; fax: +91 44 25954919. E-mail addresses: [email protected], [email protected] (V. Viswanathan). 0168-8227/$ – see front matter # 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2010.05.009
diabetes research and clinical practice 89 (2010) 334–340
countries, age and gender, some studies have documented that the total cost of diabetes care in terms of direct and indirect cost is higher [8] and in addition to this the intangible cost due to pain and sufferings are beyond just monetary terms as they include the emotional component to a large extent. Health care economics of diabetes is less explored discipline in India. There are very few studies quoting direct cost of diabetes care but there is no documented evidence on indirect and intangible cost components related to diabetes from a population based study from India. This article attempts to estimate the following: The total direct cost involved in diabetes treatment, its indirect cost and the intangible cost. The current cost of illness study has used descriptive economic analysis to provide an overall picture of diabetes in monetary terms in India, which may serve as a vital source of information for health care organizations and planning bodies to plan and prioritize national health policies and schemes.
2.
Methods
This community based cost of illness (COI) study estimated the direct cost (medical and non-medical) associated with treatment of diabetes and its complications, indirect cost associated with loss in productivity due to diabetes related morbidity and intangible cost associated with pain and sufferings by using prevalence based approach. Our study was designed like any other epidemiological survey, using multistage stratified random sampling technique for collection of the population based data. Map of Chennai city was obtained and five areas pertaining to directions were selected—East, West, North, South and Central Chennai. One zone from each of these areas was selected and every household of the selected colonies from these five zones was surveyed for people who have diabetes and who are currently on treatment under a health care centre. Data was collected by questionnaire method from August to December 2009 by four welltrained interviewers who were involved from the initial stages of the design of the study. The study was approved by the Institution’s Ethics Committee and patient’s written consent was obtained before the interview. All the costs were measured in Indian rupees (INR) and later converted to US dollars ($). Based on average annual currency exchange rate for 2009, 1 US$ = 48.32 INR.
2.1.
Description of questionnaire
Due to non-availability of similar studies from India, a questionnaire was designed exclusively for the current study. It took 3 months to develop the questionnaire involving series of discussions and interviews with diabetes patients. It was pilot tested and modified suitably. The questionnaire elicited the following details: (i) socio-demographic profile, (ii) drugs/ medications and diabetes profile, (iii) direct medical and nonmedical costs (hospital services, consultation, investigations, medication and food and transport), (iv) indirect and intangible cost (human capital approach and willingness to pay by bidding method), and (v) methods of finance. The expenditure incurred for total diabetes management for 1 year was obtained retrospectively subjective to evidence for expendi-
335
ture from the bills and other records or recall and confirmation with other family members to minimise recall bias. Each interview lasted for up to 45 min to 1 h for each patient in his house. The interviewers initially had established a good rapport with the subjects and made them more responsive to the otherwise confidential financial questions.
2.2.
Definitions
Direct cost can be defined as the costs of medical care in relation to diagnosis and treatment of diabetes and its complications. It includes costs for routine lab investigations, physician’s services, ambulances, inpatient or outpatient care, rehabilitation, community health services, medication and transport. Of all the cost components, this is the least controversial measurement and easily assessable measure. It is expressed as median direct medical cost for treating diabetes per annum. Indirect cost can be defined as loss work days due to absenteeism because of time spent in visiting the hospital for diabetes care or during admission into the hospital according to the patient’s and/or the care takers average daily income. It cannot be directly and easily measured or calculated. There is considerable debate following the assessment of indirect cost component of the COI studies. However, the human capital approach developed by Rice et al. [9,10] is considered to be the most reliable estimate [11] and was hence adopted in the current study. Indirect cost by human capital approach is based on the earnings, present and future lost by the patient/care giver as a result of illness or care of the patient or the wages paid to get the work done due to absenteeism. It is a relatively simple and reliable method if the records are available and the questionnaire assessed all the above details. The daily average earnings were multiplied by the number of days absent from work. Generally, the worth of homemakers also should be assessed [12]. Pertaining to India, the estimates for homemakers were obtained by multiplying the average market cost of housekeeping (i.e.) 17,000 INR ($351.8) per month [13,14]. Intangible costs are the most difficult to assess and are usually related to pain and sufferings due to illness and other factors which reduce the quality of life. One method of estimating the value of intangible cost is by contingent valuation method, which is based on the elicitation of levels of willingness to pay (willingness to pay) to remain free from disease or its complications by the patient. Few studies have so far estimated the intangible costs incurred during other illness like osteoarthritis [15], to reduce the complications in diabetes and for participation in diabetes risk reduction programs [16,17]. In the current study, the patients were asked how much minimum amount they are willing to spend per month to prevent/control future complications. The initial bid amount was then increased in equal increments of 50 INR until the patient was no more willing to pay further. The estimates for intangible costs in monetary terms is always controversial, as there is no real existing market and the values obtained are arbitrary.
2.3.
Statistical analysis
Data was entered in Microsoft Excel and was double checked and validated. The statistical package of SPSS version 10 was
336
diabetes research and clinical practice 89 (2010) 334–340
used for analysis. As the distribution of the costs were skewed, median cost rather than mean is reported and the range is shown in parenthesis for better perception. Statistical significance testing was done by Median test/Kruskal–Wallis test as appropriate. Transformed linear regression model was computed to determine the variables significantly associated with increased cost. Sensitivity analysis was done for the estimates based on assumptions made to provide lower and upper limits for the results.
3.
Results
3.1.
Sample description
A total of 4677 subjects were initially interviewed for presence of diabetes and those under treatment. Around 1050 surveyed subjects had diabetes and were currently under treatment (22.5% prevalence). Of these, 718 (male: 52.7%; female: 47.3%) respondents wished to participate in the survey after signing their written consent (response rate: 68.3%). The surveyed subjects visited all types of health care centres like private clinics (38%), government centres (18%) and super-speciality centres (44%), thus making it a representative sample. The mean age of the surveyed population was 56 years. Literacy rate was high and 92% of the sample had attained at least school education. Around 19% of the subjects were in the I tertile of income <10,000 INR (<206.95$) per month, while 31.6% earned between 10,000 and 30,000 INR (206.95–620.9$) (II tertile) while the remaining 40% earned an average of more than 30,000 INR (>620.9$) a month (III tertile). There was an equal distribution in chronicity of the illness and 68% of the diabetes subjects had at least one complication. The overall prevalence of uncontrolled blood sugar or hyperglycemia was around 39%. These socio-demographic and general characteristics are shown in Table 1.
3.2.
Direct cost measures
The total direct cost per annum was estimated to be 25,391 INR ($525.5). The cost incurred during hospital admission for management of diabetes was the highest contributor—12,992 INR ($269) (51%) to the total direct cost, followed by 8595 INR ($178) (34%) was being spent for drugs and monitoring diabetes every year. The subjects spent around 2932 INR ($61) (11.5%) for an average of two OP visits annually. Detailed summary of the cost estimates involved in direct medical and non-medical cost for diabetes care are presented in Table 2.
3.3. Annual treatment costs associated with complications and glycemic status: direct, indirect and intangible cost The total direct cost was substantially higher for the overall sample than its other components. Diabetes patients who did not have any complications spent 6520 INR ($134.9) for their diabetes care, while presence of three and above complications escalated the direct cost to 32,500 INR ($672.6) per annum. Loss in income due to absenteeism from work for the patient and primary care giver for diabetes related illness, the
Table 1 – Socio-demographic description of the study subjects. Socio-demographic details
Number (%)
Total sample, N Mean age (in years)
718 56
Age in years 29 30–49 50
15 (2.1) 185 (25.8) 518 (72.1)
Gender Male Female
380 (52.9) 338 (47.1)
Education Illiterate School Graduation and above
60 (8.3) 368 (51.3) 290 (40.4)
Occupation Skilled/unskilled Executive/professional Business Retired/H.W./unemployed
96 126 115 381
Income per month 10,000 10,001–30,000 30,001 and above
138 (19.3) 227 (31.6) 353 (49.1)
Duration of diabetes in years 5 5.1–10 10.1
235 (32.7) 200 (28.0) 283 (39.4)
Complications Nil One Two Three Four and above
123 263 156 61 17
(13.4) (17.5) (16.0) (53.1)
(17.1) (36.6) (21.7) (8.4) (2.3)
annual indirect cost was estimated to be around 4970 INR ($102.8). Indirect costs were higher for those diabetes patients who had three or more complications, due to time spent seeking medical care for diabetes management. Loss of man days per year resulting in loss in productivity increased both for patient and primary care giver according to the number of complications. Table 3 presents the direct, indirect and intangible costs involved in diabetes care according to the number of complications. Patients willingness to pay to manage their diabetes well and prevent further complications in future (intangible cost) was derived at 2000 INR per month ($41.1). Hence the intangible cost arbitrarily can be estimated as 24,000 INR per annum ($496.7). However, for those patients whose HbA1C < 7 the direct cost estimates were higher while those who had poor glycemic control (HbA1C > 7) had significant higher indirect costs.
3.4.
Determinants of cost in India
Transformed linear regression model with direct cost as dependent variable showed that higher education (29 (18.2– 57.5), 0.004) (b coefficient (95% confidence interval), p-value)
337
diabetes research and clinical practice 89 (2010) 334–340
Table 2 – Details of total direct cost per annum in Indian rupees for management of diabetes. Cost details
Hospital admission
Direct medical cost Doctor fees Lab investigations Other investigations Admission charge Medicine charges
550 2250 1892 4300 1500
(100–2300) (50–9135) (230–5000) (150–20,000) (500–17,653)
Direct non-medical cost Transportation Food Miscellaneous Accommodation for alternate care giver
600 600 300 1000
(30–60,000) (48–10,000) (50–3300) (200–1700)
Management and monitoring Hypoglycemic medication SMBG Other accessories
Ambulatory care 320 (20–8400) 1050 (10–3048) 850 (50–12,000) – –
202 190 200 120
– – –
(12–7500) (10–2400) (15–2000) (50–1000)
6000 (50–93,600) 2595 (720–42,000) 872 (80–16,850)
Average cost during hospitalization Average cost for diabetes OP visits
12,992 2932
Total direct cost per person per annum [in INR] Total direct cost per person per annum [in US$]
25,391 (2375–317,886) 525.5 (49.2–6578.8)
1 US$ = 48.32 INR. Values are expressed in median (range) in INR. Total direct cost per annum = hospital admission (IP) + ambulatory care (OP): an average of two OP visits per annum + medication and monitoring costs + other accessories. Miscellaneous—communication, alteration in family due to patient’s/care giver’ absence.
increased duration of diabetes (51.3 (15.0–77.5), 0.001), increased hospital admission rates (60.8 (34.8–74.3), <0.0001) and higher economic status (35.5 (8.9–62.9), 0.025) significantly increased cost for diabetes care, while higher income status (29.7 (1.6–57.8), 0.016) was the only significant variable associated with indirect cost.
3.5.
Cost of diabetes in India
The median cost estimates per year can be extrapolated to the Indian population, taking the statistics from IDF Atlas 4th edition which reports that 50.8 million Indians will have diabetes in 2010. Considering the median total direct cost to be
Table 3 – Median cost per annum—direct, indirect and intangible costs based on number of complications and glycemic status. Patient
Number of complications Nil One Two Three and above
Primary care giver
Loss of man days/year
Loss of median income/year
Loss of man days/year
4 5 7 15
1000 1666 6650 28,000*
3 5 5 10
Loss of median income/year 1000 1000 1500 2237
Direct cost
Indirect cost
Number of complications Nil One Two Three Four
6520 9760 15,000 32,500* 37,500*
1750 1500 1800 5000 16,225
1500 2000 2000 2500 7500
HbA1C 7 >7.1–8.9 9
25,750 24,525 22,000
4275 14,130 14,750
500 2000 2000
Values are in INR. HbA1C test was not done at all levels of health centres. Hence statistics computed from available data. p < 0.01 (Median test).
*
Intangible cost
338
diabetes research and clinical practice 89 (2010) 334–340
Table 4 – Two-way sensitivity analysis assuming a 10% variation in costs and number of patients. Cost measures
Hospital admission
Number of people with diabetes in 2010: 50.8 million; 10% increase: 55.88 million Annual direct medical costs 644.9 Annual direct non-medical costs 153.7 Annual management and monitoring costs Total annual direct costs Annual indirect costs Total annual direct and indirect costs Number of people with diabetes in 2010: 50.8 million; 10% decrease: 45.72 million Annual direct medical costs 431.7 Annual direct non-medical costs 102.9 Annual management and monitoring costs Total annual direct costs Annual indirect costs Total annual direct and indirect costs
Out patient visits
Total (INR)
Total (US$)
136.5 43.8
781.4 197.4 581.9 1560.7 276.6 1837.3
16.2 4.1 12.0 32.3 5.7 38.0
91.3 29.3
523.1 132.2 389.5 1044.8 185.2 1230
10.8 2.7 8.1 21.6 3.8 25.5
The above figures are in billions.
$525.5 per person, the annual direct cost for diabetes care in India would be $26.7 billion and the median annual indirect cost estimate of $102.8 per person would result in $5.2 billion annually for India. The estimated overall median cost (direct + indirect cost) attributed to diabetes mellitus in India would be $31.9 billion, wherein, 83.7% of the total cost is attributable to direct cost and 16.3% to indirect cost.
3.6.
Sensitivity analysis
Table 4 presents the results of two-way sensitivity analysis assuming a 10% variation in the annual prevalence of diabetes and the total cost involved in the treatment (direct and indirect costs). This range allowed sufficient variation in both prevalence and costs to be explored in relation to the overall values obtained in the basic model. With an increase of 10% in the costs as well as the number of cases the overall annual costs jumps from $31.9 billion to $38.0 billion registering an increase of $6.1 billion while a 10% decrease generated $25.5 billion.
Thus even a 10% variation either in the number of cases or in the costs has a large impact.
3.7.
Modes of payment
Irrespective of socioeconomic status, the expenditure incurred for treatment and management of diabetes in India was mostly met through the personal savings account (60%). The next common method of payment was through selling or mortgaging properties like land, house, etc. and borrowing loans with high interest rates (39%). The methods of payment based on income status are presented in Fig. 1. The I tertile income group met their expenses mostly through borrowing loan or selling/mortgaging their properties (60%) while the higher income group spent from their savings (81%). As the income status improved from low to high, spending from savings increased and mortgaging properties and borrowing loan significantly decreased. Coverage through health insurance
Fig. 1 – Methods of payment for diabetes care based on income status. Borrowing loan and mortgaging or selling properties was commoner among low income group, however indicating burden and debt trap. Payment through savings was more common in higher income group.
diabetes research and clinical practice 89 (2010) 334–340
was observed only among the high income group, where again it was just 2%.
4.
Discussion
It is for the first time in India that an epidemiological approach has been used for estimating the cost of illness related to diabetes and its complications including the indirect and intangible components together. Hence the diabetes cost burden had so far been under estimated in the previous studies [18]. The findings reported in this study demonstrate the economic burden of diabetes which is profound in developing nations like India. The current study has produced many important and key findings. Among all the cost measures, direct cost was the single largest contributor to the overall expenditure and further, admission into hospital for treatment of various comorbidities associated with diabetes is again the major contributor for direct cost. Many studies [19,20] are in accordance with these results, perhaps hypothesising that awareness on secondary prevention is poor among the diabetes patients in India necessitating certain policies and programs to be introduced by the government for effective management of diabetes and preventing complications. Additional supporting evidence to this statement is the effect of poor glycemic control and presence of complications on increasing cost of care, as shown in this study. A European study also showed similar results and concluded that diabetes related chronic complications led to higher direct cost than diabetes per se [21]. More than 80% of the total diabetes spending is in the developed economies, while over 70% of people with diabetes live in developing nations. As per IDF atlas 4th edition, the US accounts for 52.7% of the total diabetes spending worldwide, whereas, India, which has largest diabetes population, spends 1% of the global total. Given that the cost of care is similar in other Indian states, the total cost for diabetes (direct and indirect cost) in this study is $31.9 billion, while the allotted national health budget for the current fiscal year 2009–2010 is a meagre $4.5 billion. These findings may be helpful to the decision makers to consider the heavy costs associated with diabetes while planning health budget in future. However said and done, these costs of illness estimates for diabetes are said to further steadily increase in future due to the rising prevalence of diabetes in India alongside the rising inflation. The current study had tried to include most of the cost components, but indirect cost due to early mortality and presenteeism was not included, in such case the magnitude of the indirect cost in this study could be underestimated. In addition to this, the number of days of absence from work resulting in loss of income could not be recalled accurately, again resulting in lower values of indirect cost. It is also important to mention that recall bias is unavoidable and this however has been adjusted by sensitivity analysis. The study has identified all the components related to cost and the magnitude of each component is described in detail. The major determinant of direct and indirect cost is high income status while direct cost was also associated with increased duration of diabetes and presence of complications.
339
Studies from India and other developed countries have produced similar results [22,23] which is a well established fact. It was also interesting to note that diabetes patients with poor glycemic control had indirect costs three times more than those with good glycemic control due to more losses in productivity and income. Since the occurrence of complications and other co-morbidities increase with poor glycemic control, these patients often tend to get admitted into hospital for management of their conditions resulting in frequent absenteeism from work. Also, those with good control had to spend more to achieve the targets and hence had higher direct costs. In India diabetes is highly prevalent among high socioeconomic status while some complications are higher among the low income people resulting in a huge burden to meet the expenses. Amidst the worst global recession in recent times and skyrocketing prices for every commodity, payment towards diabetes care has become more difficult especially to the people employed in private sector as all the health insurance policies and reimbursement benefits were laid off for the employees and as a result most of the expenses were met out of pocket for their diabetes care. As such, the study showed that most of the patients (60%) spent money from personal savings account for their diabetes care. Insurance companies in India do not provide total coverage for diabetes, hence none of the patients from low and middle income group had insurance while only 2% of high income group were dependent on insurance. Most of the low income group borrowed loan or mortgaged their properties to meet their expenses, which again is a reminder to the policy makers to correct the discrepancies and thereby prioritize and frame policies for economics of diabetes care. Studies related to economics of diabetes in India are very few and limited to direct cost among hospital sample which may be biased and hence cannot be compared with our results. The cost of diabetes care in developed nations like the United States has escalated from $91.8 billion in 2002 [24] to $119.4 billion in 2007 [25]. The direct cost for diabetes care for other developed and developing nations was also alarmingly high even a decade ago: Australia: $720 million, Japan: $16.94 billion, China: $3.5 billion and South Asia: $5 billion [26]. Our results also elicit the huge cost burden related to diabetes. Furthermore, the economic costs of undiagnosed diabetes are not included and beyond the scope of the study, which therefore may under estimate the results [27]. However, there are diverse health care setups in India, in which case the pattern of direct and indirect cost may differ from the urban setting and rural or peri-urban setup. Hence generalizability of these results may be limited to an urban setup in India. For instance data from Chronic Care Foundation shows that direct cost is high in urban areas and it is the indirect cost which is high in rural India [28]. This study largely contributes to data on economics of diabetes care in India and provides a basis for formulating strategies by International Health Organizations, policy makers, decision makers and the Government for meeting the challenges of diabetes care cost and making every person with diabetes receive the treatment that they deserve.
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diabetes research and clinical practice 89 (2010) 334–340
Acknowledgements We greatly appreciate the efforts of our epidemiology team consisting of Mr. P. Abraham, Mrs. A. Ruth, and Mr. K. Suresh for data collection and entry. The statistical assistance provided by Ms. R. Meenakshi is acknowledged. Our special thanks to Mr. R. Bhaskar, Financial Controller, Department of Finance and Economics, DRC for his continuous support and guidance. We are indebted to all our diabetes patients who were willing to spend up to 1 h for the interview process and had even answered some of the sensitive questions.
Conflict of interest We declare that we have no conflict of interest.
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Contents lists available at ScienceDirect
Diabetes Research and Clinical Practice jou rna l hom ep ag e: w ww.e lse v ier .com/ loca te /d iab res
The socioeconomics of diabetes from a developing country: A population based cost of illness study Shabana Tharkar, Arutselvi Devarajan, Satyavani Kumpatla, Vijay Viswanathan * M.V. Hospital for Diabetes and Diabetes Research Centre, No. 4, Main Road, Royapuram, Chennai 13, India
article info
abstract
Article history:
Objective: To assess the annual health care expenditure for a patient with diabetes and
Received 2 March 2010
extrapolate the same to country specific prevalence estimates for 2010.
Received in revised form
Methods: This population based, cost of illness study collected retrospective data for last 12
7 May 2010
months on direct costs (medical and non-medical) through records, indirect cost through
Accepted 13 May 2010
human capital approach and intangible cost by contingent valuation method from diabetes
Published on line 9 June 2010
patients. Results: Out of 4677 subjects screened, 1050 had diabetes and 718 participated in the survey.
Keywords:
The median annual direct and indirect cost associated with diabetes care was estimated at
Diabetes
25,391 INR ($525.5) and 4970 INR ($102.8), respectively. Extrapolating the direct and indirect
Socioeconomics
estimates to Indian population, the annual costs for diabetes would be 1541.4 billion INR
Direct cost
($31.9 billion) in 2010. Two-way sensitivity analysis assuming 10% variation in both preva-
Indirect cost
lence of diabetes and in treatment costs resulted in an estimated cost range of 1230 billion
Intanglible cost measures
INR ($25.5 billion) to 1837.3 billion INR ($38.0 billion).
India
Conclusion: Keeping the future diabetes explosion in mind, this heavy economic burden highlights the urgent need for the decision makers to allocate resources for planning and implementing strategies in prevention and management of diabetes and its complications. # 2010 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
According to the latest edition of IDF Atlas, ‘‘An estimated 50.8 million people will be affected by diabetes in 2010 in India alone’’. Global projections by the year 2025 have estimated a 41 and 170% increase in number of diabetes patients in the developed and developing nations, respectively, of which India contributes to the major proportion [1]. Since diabetes is a chronic disease associated with co-morbidities and complications, it has a substantial impact on the cost of care [2,3]. Financial burden is more on the individuals who have diabetes and an associated co-morbid condition than those who have only diabetes [4]. In addition to this, in countries like India, lack
of access to health care services, lack of national welfare schemes and health insurance coverage for diabetes make the treatment unaffordable resulting in late diagnosis and increased cost in treatment of diabetes and early onset of complications [5]. The IDF statement in 2006 spoke about ‘Diabetes Care for Everyone’ and according to United Nations Human Rights and World Health Organization, after all, access to health care is a matter of human rights and every person with illness must be able to get equality in care irrespective of socioeconomic status [6]. The estimated global expenditures on diabetes will be at least International Dollar (ID) 418 billion in 2010, and at least ID 561 billion in 2030 [7]. Though not distributed evenly across
* Corresponding author at: M.V. Hospital for Diabetes and Diabetes Research Centre, WHO Collaborating Centre for Research, Education and Training in Diabetes, No. 4, Main Road, Royapuram, Chennai 600013, Tamil Nadu, India. Tel.: +91 44 25954913; fax: +91 44 25954919. E-mail addresses: [email protected], [email protected] (V. Viswanathan). 0168-8227/$ – see front matter # 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2010.05.009
diabetes research and clinical practice 89 (2010) 334–340
countries, age and gender, some studies have documented that the total cost of diabetes care in terms of direct and indirect cost is higher [8] and in addition to this the intangible cost due to pain and sufferings are beyond just monetary terms as they include the emotional component to a large extent. Health care economics of diabetes is less explored discipline in India. There are very few studies quoting direct cost of diabetes care but there is no documented evidence on indirect and intangible cost components related to diabetes from a population based study from India. This article attempts to estimate the following: The total direct cost involved in diabetes treatment, its indirect cost and the intangible cost. The current cost of illness study has used descriptive economic analysis to provide an overall picture of diabetes in monetary terms in India, which may serve as a vital source of information for health care organizations and planning bodies to plan and prioritize national health policies and schemes.
2.
Methods
This community based cost of illness (COI) study estimated the direct cost (medical and non-medical) associated with treatment of diabetes and its complications, indirect cost associated with loss in productivity due to diabetes related morbidity and intangible cost associated with pain and sufferings by using prevalence based approach. Our study was designed like any other epidemiological survey, using multistage stratified random sampling technique for collection of the population based data. Map of Chennai city was obtained and five areas pertaining to directions were selected—East, West, North, South and Central Chennai. One zone from each of these areas was selected and every household of the selected colonies from these five zones was surveyed for people who have diabetes and who are currently on treatment under a health care centre. Data was collected by questionnaire method from August to December 2009 by four welltrained interviewers who were involved from the initial stages of the design of the study. The study was approved by the Institution’s Ethics Committee and patient’s written consent was obtained before the interview. All the costs were measured in Indian rupees (INR) and later converted to US dollars ($). Based on average annual currency exchange rate for 2009, 1 US$ = 48.32 INR.
2.1.
Description of questionnaire
Due to non-availability of similar studies from India, a questionnaire was designed exclusively for the current study. It took 3 months to develop the questionnaire involving series of discussions and interviews with diabetes patients. It was pilot tested and modified suitably. The questionnaire elicited the following details: (i) socio-demographic profile, (ii) drugs/ medications and diabetes profile, (iii) direct medical and nonmedical costs (hospital services, consultation, investigations, medication and food and transport), (iv) indirect and intangible cost (human capital approach and willingness to pay by bidding method), and (v) methods of finance. The expenditure incurred for total diabetes management for 1 year was obtained retrospectively subjective to evidence for expendi-
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ture from the bills and other records or recall and confirmation with other family members to minimise recall bias. Each interview lasted for up to 45 min to 1 h for each patient in his house. The interviewers initially had established a good rapport with the subjects and made them more responsive to the otherwise confidential financial questions.
2.2.
Definitions
Direct cost can be defined as the costs of medical care in relation to diagnosis and treatment of diabetes and its complications. It includes costs for routine lab investigations, physician’s services, ambulances, inpatient or outpatient care, rehabilitation, community health services, medication and transport. Of all the cost components, this is the least controversial measurement and easily assessable measure. It is expressed as median direct medical cost for treating diabetes per annum. Indirect cost can be defined as loss work days due to absenteeism because of time spent in visiting the hospital for diabetes care or during admission into the hospital according to the patient’s and/or the care takers average daily income. It cannot be directly and easily measured or calculated. There is considerable debate following the assessment of indirect cost component of the COI studies. However, the human capital approach developed by Rice et al. [9,10] is considered to be the most reliable estimate [11] and was hence adopted in the current study. Indirect cost by human capital approach is based on the earnings, present and future lost by the patient/care giver as a result of illness or care of the patient or the wages paid to get the work done due to absenteeism. It is a relatively simple and reliable method if the records are available and the questionnaire assessed all the above details. The daily average earnings were multiplied by the number of days absent from work. Generally, the worth of homemakers also should be assessed [12]. Pertaining to India, the estimates for homemakers were obtained by multiplying the average market cost of housekeeping (i.e.) 17,000 INR ($351.8) per month [13,14]. Intangible costs are the most difficult to assess and are usually related to pain and sufferings due to illness and other factors which reduce the quality of life. One method of estimating the value of intangible cost is by contingent valuation method, which is based on the elicitation of levels of willingness to pay (willingness to pay) to remain free from disease or its complications by the patient. Few studies have so far estimated the intangible costs incurred during other illness like osteoarthritis [15], to reduce the complications in diabetes and for participation in diabetes risk reduction programs [16,17]. In the current study, the patients were asked how much minimum amount they are willing to spend per month to prevent/control future complications. The initial bid amount was then increased in equal increments of 50 INR until the patient was no more willing to pay further. The estimates for intangible costs in monetary terms is always controversial, as there is no real existing market and the values obtained are arbitrary.
2.3.
Statistical analysis
Data was entered in Microsoft Excel and was double checked and validated. The statistical package of SPSS version 10 was
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used for analysis. As the distribution of the costs were skewed, median cost rather than mean is reported and the range is shown in parenthesis for better perception. Statistical significance testing was done by Median test/Kruskal–Wallis test as appropriate. Transformed linear regression model was computed to determine the variables significantly associated with increased cost. Sensitivity analysis was done for the estimates based on assumptions made to provide lower and upper limits for the results.
3.
Results
3.1.
Sample description
A total of 4677 subjects were initially interviewed for presence of diabetes and those under treatment. Around 1050 surveyed subjects had diabetes and were currently under treatment (22.5% prevalence). Of these, 718 (male: 52.7%; female: 47.3%) respondents wished to participate in the survey after signing their written consent (response rate: 68.3%). The surveyed subjects visited all types of health care centres like private clinics (38%), government centres (18%) and super-speciality centres (44%), thus making it a representative sample. The mean age of the surveyed population was 56 years. Literacy rate was high and 92% of the sample had attained at least school education. Around 19% of the subjects were in the I tertile of income <10,000 INR (<206.95$) per month, while 31.6% earned between 10,000 and 30,000 INR (206.95–620.9$) (II tertile) while the remaining 40% earned an average of more than 30,000 INR (>620.9$) a month (III tertile). There was an equal distribution in chronicity of the illness and 68% of the diabetes subjects had at least one complication. The overall prevalence of uncontrolled blood sugar or hyperglycemia was around 39%. These socio-demographic and general characteristics are shown in Table 1.
3.2.
Direct cost measures
The total direct cost per annum was estimated to be 25,391 INR ($525.5). The cost incurred during hospital admission for management of diabetes was the highest contributor—12,992 INR ($269) (51%) to the total direct cost, followed by 8595 INR ($178) (34%) was being spent for drugs and monitoring diabetes every year. The subjects spent around 2932 INR ($61) (11.5%) for an average of two OP visits annually. Detailed summary of the cost estimates involved in direct medical and non-medical cost for diabetes care are presented in Table 2.
3.3. Annual treatment costs associated with complications and glycemic status: direct, indirect and intangible cost The total direct cost was substantially higher for the overall sample than its other components. Diabetes patients who did not have any complications spent 6520 INR ($134.9) for their diabetes care, while presence of three and above complications escalated the direct cost to 32,500 INR ($672.6) per annum. Loss in income due to absenteeism from work for the patient and primary care giver for diabetes related illness, the
Table 1 – Socio-demographic description of the study subjects. Socio-demographic details
Number (%)
Total sample, N Mean age (in years)
718 56
Age in years 29 30–49 50
15 (2.1) 185 (25.8) 518 (72.1)
Gender Male Female
380 (52.9) 338 (47.1)
Education Illiterate School Graduation and above
60 (8.3) 368 (51.3) 290 (40.4)
Occupation Skilled/unskilled Executive/professional Business Retired/H.W./unemployed
96 126 115 381
Income per month 10,000 10,001–30,000 30,001 and above
138 (19.3) 227 (31.6) 353 (49.1)
Duration of diabetes in years 5 5.1–10 10.1
235 (32.7) 200 (28.0) 283 (39.4)
Complications Nil One Two Three Four and above
123 263 156 61 17
(13.4) (17.5) (16.0) (53.1)
(17.1) (36.6) (21.7) (8.4) (2.3)
annual indirect cost was estimated to be around 4970 INR ($102.8). Indirect costs were higher for those diabetes patients who had three or more complications, due to time spent seeking medical care for diabetes management. Loss of man days per year resulting in loss in productivity increased both for patient and primary care giver according to the number of complications. Table 3 presents the direct, indirect and intangible costs involved in diabetes care according to the number of complications. Patients willingness to pay to manage their diabetes well and prevent further complications in future (intangible cost) was derived at 2000 INR per month ($41.1). Hence the intangible cost arbitrarily can be estimated as 24,000 INR per annum ($496.7). However, for those patients whose HbA1C < 7 the direct cost estimates were higher while those who had poor glycemic control (HbA1C > 7) had significant higher indirect costs.
3.4.
Determinants of cost in India
Transformed linear regression model with direct cost as dependent variable showed that higher education (29 (18.2– 57.5), 0.004) (b coefficient (95% confidence interval), p-value)
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Table 2 – Details of total direct cost per annum in Indian rupees for management of diabetes. Cost details
Hospital admission
Direct medical cost Doctor fees Lab investigations Other investigations Admission charge Medicine charges
550 2250 1892 4300 1500
(100–2300) (50–9135) (230–5000) (150–20,000) (500–17,653)
Direct non-medical cost Transportation Food Miscellaneous Accommodation for alternate care giver
600 600 300 1000
(30–60,000) (48–10,000) (50–3300) (200–1700)
Management and monitoring Hypoglycemic medication SMBG Other accessories
Ambulatory care 320 (20–8400) 1050 (10–3048) 850 (50–12,000) – –
202 190 200 120
– – –
(12–7500) (10–2400) (15–2000) (50–1000)
6000 (50–93,600) 2595 (720–42,000) 872 (80–16,850)
Average cost during hospitalization Average cost for diabetes OP visits
12,992 2932
Total direct cost per person per annum [in INR] Total direct cost per person per annum [in US$]
25,391 (2375–317,886) 525.5 (49.2–6578.8)
1 US$ = 48.32 INR. Values are expressed in median (range) in INR. Total direct cost per annum = hospital admission (IP) + ambulatory care (OP): an average of two OP visits per annum + medication and monitoring costs + other accessories. Miscellaneous—communication, alteration in family due to patient’s/care giver’ absence.
increased duration of diabetes (51.3 (15.0–77.5), 0.001), increased hospital admission rates (60.8 (34.8–74.3), <0.0001) and higher economic status (35.5 (8.9–62.9), 0.025) significantly increased cost for diabetes care, while higher income status (29.7 (1.6–57.8), 0.016) was the only significant variable associated with indirect cost.
3.5.
Cost of diabetes in India
The median cost estimates per year can be extrapolated to the Indian population, taking the statistics from IDF Atlas 4th edition which reports that 50.8 million Indians will have diabetes in 2010. Considering the median total direct cost to be
Table 3 – Median cost per annum—direct, indirect and intangible costs based on number of complications and glycemic status. Patient
Number of complications Nil One Two Three and above
Primary care giver
Loss of man days/year
Loss of median income/year
Loss of man days/year
4 5 7 15
1000 1666 6650 28,000*
3 5 5 10
Loss of median income/year 1000 1000 1500 2237
Direct cost
Indirect cost
Number of complications Nil One Two Three Four
6520 9760 15,000 32,500* 37,500*
1750 1500 1800 5000 16,225
1500 2000 2000 2500 7500
HbA1C 7 >7.1–8.9 9
25,750 24,525 22,000
4275 14,130 14,750
500 2000 2000
Values are in INR. HbA1C test was not done at all levels of health centres. Hence statistics computed from available data. p < 0.01 (Median test).
*
Intangible cost
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diabetes research and clinical practice 89 (2010) 334–340
Table 4 – Two-way sensitivity analysis assuming a 10% variation in costs and number of patients. Cost measures
Hospital admission
Number of people with diabetes in 2010: 50.8 million; 10% increase: 55.88 million Annual direct medical costs 644.9 Annual direct non-medical costs 153.7 Annual management and monitoring costs Total annual direct costs Annual indirect costs Total annual direct and indirect costs Number of people with diabetes in 2010: 50.8 million; 10% decrease: 45.72 million Annual direct medical costs 431.7 Annual direct non-medical costs 102.9 Annual management and monitoring costs Total annual direct costs Annual indirect costs Total annual direct and indirect costs
Out patient visits
Total (INR)
Total (US$)
136.5 43.8
781.4 197.4 581.9 1560.7 276.6 1837.3
16.2 4.1 12.0 32.3 5.7 38.0
91.3 29.3
523.1 132.2 389.5 1044.8 185.2 1230
10.8 2.7 8.1 21.6 3.8 25.5
The above figures are in billions.
$525.5 per person, the annual direct cost for diabetes care in India would be $26.7 billion and the median annual indirect cost estimate of $102.8 per person would result in $5.2 billion annually for India. The estimated overall median cost (direct + indirect cost) attributed to diabetes mellitus in India would be $31.9 billion, wherein, 83.7% of the total cost is attributable to direct cost and 16.3% to indirect cost.
3.6.
Sensitivity analysis
Table 4 presents the results of two-way sensitivity analysis assuming a 10% variation in the annual prevalence of diabetes and the total cost involved in the treatment (direct and indirect costs). This range allowed sufficient variation in both prevalence and costs to be explored in relation to the overall values obtained in the basic model. With an increase of 10% in the costs as well as the number of cases the overall annual costs jumps from $31.9 billion to $38.0 billion registering an increase of $6.1 billion while a 10% decrease generated $25.5 billion.
Thus even a 10% variation either in the number of cases or in the costs has a large impact.
3.7.
Modes of payment
Irrespective of socioeconomic status, the expenditure incurred for treatment and management of diabetes in India was mostly met through the personal savings account (60%). The next common method of payment was through selling or mortgaging properties like land, house, etc. and borrowing loans with high interest rates (39%). The methods of payment based on income status are presented in Fig. 1. The I tertile income group met their expenses mostly through borrowing loan or selling/mortgaging their properties (60%) while the higher income group spent from their savings (81%). As the income status improved from low to high, spending from savings increased and mortgaging properties and borrowing loan significantly decreased. Coverage through health insurance
Fig. 1 – Methods of payment for diabetes care based on income status. Borrowing loan and mortgaging or selling properties was commoner among low income group, however indicating burden and debt trap. Payment through savings was more common in higher income group.
diabetes research and clinical practice 89 (2010) 334–340
was observed only among the high income group, where again it was just 2%.
4.
Discussion
It is for the first time in India that an epidemiological approach has been used for estimating the cost of illness related to diabetes and its complications including the indirect and intangible components together. Hence the diabetes cost burden had so far been under estimated in the previous studies [18]. The findings reported in this study demonstrate the economic burden of diabetes which is profound in developing nations like India. The current study has produced many important and key findings. Among all the cost measures, direct cost was the single largest contributor to the overall expenditure and further, admission into hospital for treatment of various comorbidities associated with diabetes is again the major contributor for direct cost. Many studies [19,20] are in accordance with these results, perhaps hypothesising that awareness on secondary prevention is poor among the diabetes patients in India necessitating certain policies and programs to be introduced by the government for effective management of diabetes and preventing complications. Additional supporting evidence to this statement is the effect of poor glycemic control and presence of complications on increasing cost of care, as shown in this study. A European study also showed similar results and concluded that diabetes related chronic complications led to higher direct cost than diabetes per se [21]. More than 80% of the total diabetes spending is in the developed economies, while over 70% of people with diabetes live in developing nations. As per IDF atlas 4th edition, the US accounts for 52.7% of the total diabetes spending worldwide, whereas, India, which has largest diabetes population, spends 1% of the global total. Given that the cost of care is similar in other Indian states, the total cost for diabetes (direct and indirect cost) in this study is $31.9 billion, while the allotted national health budget for the current fiscal year 2009–2010 is a meagre $4.5 billion. These findings may be helpful to the decision makers to consider the heavy costs associated with diabetes while planning health budget in future. However said and done, these costs of illness estimates for diabetes are said to further steadily increase in future due to the rising prevalence of diabetes in India alongside the rising inflation. The current study had tried to include most of the cost components, but indirect cost due to early mortality and presenteeism was not included, in such case the magnitude of the indirect cost in this study could be underestimated. In addition to this, the number of days of absence from work resulting in loss of income could not be recalled accurately, again resulting in lower values of indirect cost. It is also important to mention that recall bias is unavoidable and this however has been adjusted by sensitivity analysis. The study has identified all the components related to cost and the magnitude of each component is described in detail. The major determinant of direct and indirect cost is high income status while direct cost was also associated with increased duration of diabetes and presence of complications.
339
Studies from India and other developed countries have produced similar results [22,23] which is a well established fact. It was also interesting to note that diabetes patients with poor glycemic control had indirect costs three times more than those with good glycemic control due to more losses in productivity and income. Since the occurrence of complications and other co-morbidities increase with poor glycemic control, these patients often tend to get admitted into hospital for management of their conditions resulting in frequent absenteeism from work. Also, those with good control had to spend more to achieve the targets and hence had higher direct costs. In India diabetes is highly prevalent among high socioeconomic status while some complications are higher among the low income people resulting in a huge burden to meet the expenses. Amidst the worst global recession in recent times and skyrocketing prices for every commodity, payment towards diabetes care has become more difficult especially to the people employed in private sector as all the health insurance policies and reimbursement benefits were laid off for the employees and as a result most of the expenses were met out of pocket for their diabetes care. As such, the study showed that most of the patients (60%) spent money from personal savings account for their diabetes care. Insurance companies in India do not provide total coverage for diabetes, hence none of the patients from low and middle income group had insurance while only 2% of high income group were dependent on insurance. Most of the low income group borrowed loan or mortgaged their properties to meet their expenses, which again is a reminder to the policy makers to correct the discrepancies and thereby prioritize and frame policies for economics of diabetes care. Studies related to economics of diabetes in India are very few and limited to direct cost among hospital sample which may be biased and hence cannot be compared with our results. The cost of diabetes care in developed nations like the United States has escalated from $91.8 billion in 2002 [24] to $119.4 billion in 2007 [25]. The direct cost for diabetes care for other developed and developing nations was also alarmingly high even a decade ago: Australia: $720 million, Japan: $16.94 billion, China: $3.5 billion and South Asia: $5 billion [26]. Our results also elicit the huge cost burden related to diabetes. Furthermore, the economic costs of undiagnosed diabetes are not included and beyond the scope of the study, which therefore may under estimate the results [27]. However, there are diverse health care setups in India, in which case the pattern of direct and indirect cost may differ from the urban setting and rural or peri-urban setup. Hence generalizability of these results may be limited to an urban setup in India. For instance data from Chronic Care Foundation shows that direct cost is high in urban areas and it is the indirect cost which is high in rural India [28]. This study largely contributes to data on economics of diabetes care in India and provides a basis for formulating strategies by International Health Organizations, policy makers, decision makers and the Government for meeting the challenges of diabetes care cost and making every person with diabetes receive the treatment that they deserve.
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Acknowledgements We greatly appreciate the efforts of our epidemiology team consisting of Mr. P. Abraham, Mrs. A. Ruth, and Mr. K. Suresh for data collection and entry. The statistical assistance provided by Ms. R. Meenakshi is acknowledged. Our special thanks to Mr. R. Bhaskar, Financial Controller, Department of Finance and Economics, DRC for his continuous support and guidance. We are indebted to all our diabetes patients who were willing to spend up to 1 h for the interview process and had even answered some of the sensitive questions.
Conflict of interest We declare that we have no conflict of interest.
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