16
© JAPI • february 2013 • VOL. 61
Original Article
The Costs of Treating Long Term Diabetic Complications
in a Developing Country: A Study from India
Satyavani Kumpatla**, Hemalatha Kothandan***, Shabana Tharkar****, Vijay Viswanathan*
Abstract
Objective: Diabetes is a major public health problem associated with huge economic burden in developing
countries. The aim was to assess the direct costs of treating long-term diabetic complications among hospitalized
subjects with type 2 diabetes.
Methods: A total of 368 (M: F, 254:114) hospitalized patients were divided into groups based on the presence of
complications and were compared with a group without any complications (Group1; n=86), Group2; n=67 with
chronic kidney disease, Group3; n=53 with cardiovascular complications, Group4; n=58 who underwent foot
amputation, Group5; n=66 with retinal complications and Group6; n=38 with presence of two complications. Details
on socio-demography, hospitalization, direct costs of all inpatient care were recorded. The data on expenditure
was obtained from hospital bills.
Results: The patients with foot complications or with presence of two diabetic complications tend to stay long
for every inpatient admission. On an average, patients with foot complications (19020 INR) and those who had
two complications (17633 INR) spent four times more and patients with renal disease (12690 INR),cardiovascular
(13135 INR) and retinal complications (13922 INR) spent three times more than patients without any complications
(4493 INR). The median expenditure for hospital admissions for the previous two years was higher for patients
with foot and cardiovascular complications and it was highest if they had presence of two complications.
Conclusions: The present study highlights the direct cost estimates and economic burden of treating severe long
term diabetic complications. It is therefore important that emphasize should be placed on primary and secondary
preventive measures of diabetes.
D
Introduction
iabetes is termed as ‘pandemic’ in the 21st century, due to
rising prevalence across all countries and it has been granted
the status of ‘public health priority’ in most of the nations.1
People with diabetes mellitus have substantially higher risk of
developing microvascular and macrovascular complications,
dyslipidemia, hypertension and other co morbidities than those
without diabetes.2,3 It’s associated co morbidities exert a huge
economic burden both at the individual level and at national
level.4,5 The cost of diabetes treatment is attributable to long term
complications such as kidney failure, blindness, heart disease,
foot amputations and their economic and social consequences.
In a developing country like India, where most of the cost of
diabetes care is out of pocket expenditure, the patients face an
enormous cost burden, wherein absence of insurance policies
further escalates the same.6
It has been reported that there will be 50.8 million people with
diabetes in India,7 which approximates to 17.8% of the world
diabetes population. The rate of occurrence of diabetes related
complications are also high in India. People with diabetes are
upto four times more likely to develop cardiovascular diseases
and upto 40 times more likely to require lower limb amputation
Assistant Director-Research, ***Chief Study Coordinator, Dept. of
Clinical Trials, ****Epidemiologist, *Managing Director, M.V. Hospital
for Diabetes and Prof. M. Viswanathan Diabetes Research Centre
(WHO Collaborating Centre for Research, Education and Training in
Diabetes), No. 4, Main Road, Royapuram, Chennai - 600 013
Received: 04.07.2011; Revised: 03.08.2011; Re-revised: 21.10.2012;
Accepted: 23.11.2011
**
102
than people without diabetes. Furthermore, diabetes is among
the leading causes of visual impairment, blindness and kidney
failure in adults.8
Data from developed nations like USA and Europe indicate
high costs of diabetes care,9 but data from low and middle income
countries pertaining to economics of diabetes care is sparse.8
A substantial proportion of the costs of diabetes treatment
arise from treating long term complications particularly
cardiovascular, foot and renal diseases. Little is known about
the cost of treating these complications in developing countries.
A fairly comprehensive study from Europe reporting the
expenditure involved in diabetes care concluded that the largest
impact is from diabetes related chronic complications rather
than the direct treatment of diabetes per se.10 Several studies
have reported the direct cost11–13 and one study on indirect and
intangible cost related to diabetes care from India,14 while the
cost of treatment and management of its complications has
not yet been quantified fully. Presence and severity of diabetic
complications, are the most important determinants of treatment,
monitoring these complications, need for hospitalization are
therefore important factors related to costs. There is a general lack
of information on the current costs involved in treating diabetic
complications. Therefore, this study was carried out to assess the
direct costs of treating long term diabetic complications such
as retinal, renal, cardiovascular and foot complications among
hospitalized subjects with type 2 diabetes, in comparison with
the hospital costs for patients with no complications.
Material and Methods
This cross sectional study was conducted at a specialized
© JAPI • february 2013 • VOL. 61
© JAPI • february 2013 • VOL. 61 by the researcher. The questionnaire was administered by a
single research officer who was well trained and entire process
of data collection took about 45 min per patient.
diabetes care centre in Chennai, Tamil Nadu, between June
2008 and December 2009. The centre where the study was
conducted is a hospital exclusively for diabetic patients with
100 beds capacity. The recruited study subjects were type 2
diabetic patients hospitalized with severe long term diabetic
complications and another group without any complications
seeking treatment for management of diabetes during a period of
one and half year. A total of 487 subjects were randomly selected
for this study. Subjects who are in the early stages of diabetic
complications and those with the presence of three or more than
three complications were excluded from the study. A total of 368
(M: F 254:114) subjects were post stratified into groups based
on the presence of long term diabetic complications and were
compared with a group of subjects without any complications.
Group1 consisted of type 2 diabetic patients without any
diabetic complications (n= 86, M:F=49:37). Group 2 subjects
were patients with chronic kidney disease (n= 67,M:F=50:17).
Group 3 consisted of patients with cardiovascular complications
(n = 53, M:F=37:16).Group 4 were type 2 diabetic patients who
had undergone a foot amputation (n=58,M:F=42:16). Group 5
patients had severe retinal complications (n=66; M:F 49:17) who
underwent cataract surgery or laser photocoagulation treatment.
Group 6 consisted of patients having presence of any of the
above two complications (n = 38, M:F=27:11). Group 3 patients
had cardiovascular complications and underwent treatment in
private hospitals and were referred to the specialized diabetes
care centre for routine management of diabetes. The remaining
study group subjects were enrolled at diabetes care centre.
A written informed consent was obtained from all the study
participants and the ethics committee of the institution approved
the study.
Statistical analysis
Mean ± Standard Deviation (SD) and proportions are
reported for the variables. Due to the skewed distribution of
the cost variables, the median values and ranges are reported
and median test was used for group comparison. For other
multiple group comparisons, non parametric Kruskal Wallis
One Way ANOVA was used followed by Mann-Whitney U
test. P values are adjusted for multiple comparisons by using
Bonferroni correction method. χ2 test with Yate’s correction was
used for comparison of proportions. Non-parametric Kendall’s
correlation coefficient test was used to determine the association
of age, HbA1c and duration of diabetes with total cost. Multiple
linear regression analysis was carried out for evaluating the
association of cost on various subject characteristics. Total
treatment cost which includes laboratory charges, medical
consultations, medicine cost, hospitalization charges, other
investigations cost, and transportation charges was log
transformed due to the skewness. The total cost was regressed
against categorized age by 10 years, gender, duration of diabetes,
HbA1c, number of hospitalized days and the risk group (the
coefficient on complication group represents the estimated total
cost involved in treating the complications compared to the cost
on group without any complications). A p value of <0.05 was
considered statistically significant. SPSS package (version 16.0)
was used for statistical analysis.
Results
It was found that 6.8% of the total study subjects were aged
between 30–39 years (n=25, M:F 16:9), 14.9% were aged between
40–49 years (n=55, M:F 39:16), 39.7% were aged between 50–59
years (n=146, M:F 90:56) and 38.6% were aged equal to or more
than 60 years (n=142, M:F 109:33). The Socio-demographic,
clinical and treatment details of the study groups are shown
in Table 1. The mean age of the study subjects was 57.9 ±10.7
years and the mean duration of diabetes was 13.6±8.6 years. The
subjects with presence of complications were older compared
to the subjects without any diabetic complications. BMI was
similar in all the study groups. The group of subjects with
complications had longer duration of diabetes than group 1
subjects without complications. A significant proportion of
subjects in the complications study groups (Group 2 to Group 6)
had positive family history of diabetes complications than Group
1 (p=0.001). It was shown that more than 50% of the subjects
in Group 2 to Group 6 had school education. Occupational
status varied among the study groups (p =0.008). Majority of
subjects (70%) were from an urban location in the four study
groups. Approximately, half of the subjects had a total family
income per month less than 10,000 INR (215 US$) in the four
study groups. The personal habits such as smoking, alcohol
consumption and tobacco chewing were similar in all the study
groups (p = 0.443), Majority of them (66%) were treated with oral
hypoglycemic agents alone in group 1, whereas most of them
were on combination of oral hypoglycemic agents and insulin
treatment in the complications study groups.
The data collection was done by administering a well
designed questionnaire (Appendix). The questionnaire was
pretested on 15 patients and necessary modifications were made
in the questionnaire. The study questionnaire contained the
details such as socio-demographic, diabetes history, presence
of diabetes complications, education status, occupation details,
family history of diabetes and diabetic complications, habits,
treatment details, family income, hospitalization details,
Socio economic status and direct cost of all inpatient care.
Anthropometric details such as height and weight were recorded
and body mass index (BMI) (kg/m2) was calculated using the
standard formula. Biochemical details including fasting and
postprandial glucose values, HbA1c%, urea and creatinine values,
renal function reports, lipid profile values were recorded from
the investigations report during hospitalization.
The direct medical and non medical costs were recorded. The
direct medical cost per unit per patient was assessed based on
the expenditure for medical consultations, laboratory charges,
medicines, hospital admission charges, surgery expenses, money
spent on other investigations such as radiological examination,
echocardiogram, scan, doppler and biothesiometry etc and the
non medical costs include the cost of accompanying attendant
and the transportation charges. Number of days hospitalized,
reasons for hospitalization and surgery details were also
recorded for the study subjects. Details of expenditure on
hospitalization for the previous 2 years and mode of payment of
hospital bills were also obtained. None of the participants refused
to answer any of the questions. The current data on expenditure
was obtained from the hospital bills and the previous 2 years
expenditure details were obtained from the records or original
bills maintained by the patients. The patients provided the bills
to the researcher and the individual cost estimate was calculated
© JAPI • february 2013 • VOL. 61 17
The biochemical details of the study groups are shown in Table
2. A significant difference was seen in fasting and postprandial
glucose values between the study groups (p =0.017 and p = 0.003).
HbA1c% was similar in all the study groups (p = 0.132). Lipid
profile was also similar except LDL and VLDL cholesterol in all
103
18
© JAPI • february 2013 • VOL. 61
Table 1: Demographic, clinical and treatment details of the study groups
Group 1
(Without
complications)
N=86
50(58.1)
1(1.2)
Values are
50:17
59.4±8.8a
25.6±4.2
16.1±8.4 a
Values are
40(59.7)
26(38.8)
Group 3
(Cardio
vascular)
N=53
mean ±SD
37:16
59.1±9.7 a
26.2±4.4
16.8±9.7 a
n%
39(73.6)
15(28.3)
5(5.8)
38(44.2)
37(43.0)
6(7.0)
2 (3.0)
44(65.7)
19(28.4)
2(3.0)
4(7.5)
29(54.7)
17(32.1)
3(5.7)
6(10.3)
43(74.1)
8(13.7)
1(1.7)
3(4.5)
51(77.3)
10(15.2)
2(3.0)
1(2.6)
27(71.1)
9(23.7)
1(2.6)
0.023
1(1.2)
11(12.8)
5(5.8)
16(18.6)
16(18.6)
12(13.9)
25(29.1)
2(3.0)
6(9.0)
4(6.0)
22(32.8)
4(6.0)
17(25.4)
12(17.9)
3(5.7)
6(11.3)
4(7.5)
13(24.5)
5(9.4)
9(17.0)
13(24.5)
4(6.9)
8(13.8)
------7(12.1)
1(1.7)
19(32.8)
19(32.8)
1(1.5)
7(10.6)
1(1.5)
24(36.4)
2(3.0)
15(22.7)
16(24.2)
1(2.6)
5(13.2)
2(5.3)
9(23.7)
-------10(26.3)
11(28.9)
0.008
68(79.1)
18(20.9)
47(70.1)
20(29.9)
39(73.6)
14(26.4)
34(58.6)
24(41.4)
47(71.2)
19(28.8)
21(55.3)
17(44.7)
0.049
25(29.1)
40(46.5)
21(24.4)
35(52.2)
27(40.3)
5(7.5)
19(35.8)
22(41.5)
12(22.6)
37(63.8)
16(27.6)
5(8.6)
30(45.5)
27(40.9)
9(13.6)
25(65.8)
10(26.3)
3(7.9)
<0.0001
<0.0001
<0.0001
5(5.8)
4(4.7)
3(3.5)
3(4.5)
6(9.0)
2(3.0)
6(11.3)
4(7.5)
2(3.8)
3(5.2)
2 (3.4)
-------
7(10.6)
4(6.1)
--------
2(5.3)
-------------
0.443
7(8.1)
79(91.9)
7(10.4)
60(89.6)
11(20.8)
42(79.2)
10(17.2)
48(82.8)
21(31.8)
45(68.2)
5(13.2)
33(86.8)
0.003
57(66.3)
3(3.5)
26(30.2)
4(6.0)
6(9.0)
57(85.1)
3(5.7)
5(9.4)
45(84.9)
5(8.6)
4(6.9)
49(84.5)
5(7.6)
10(15.2)
51(77.3)
4(10.5)
9(23.7)
25(65.8)
<0.0001
M:F
Age (years)
BMI (kg/m²)
Dur DM (Years)
49:37
51±11.4
26.3±5.1
7.6±6.0
FH-DM
FH-DC
Education
Illiterate
School
Graduation/Post graduation
Professional
Occupation
Unskilled worker
Skilled worker
Office job
Business
Professional
Retired/Unemployed
House wife
Location
Urban
Rural
Family Income (INR)
<10,000
10,000-20,000
>20,000
Habits
Smoking
Alcohol
Tobacco chewing
Diet details
Veg
Non-veg
Treatment details
OHA
Insulin
OHA+Insulin
Group 2
(Renal)
N=67
Group 4
(Foot)
N=58
Group 5
(Retinal)
N=66
Group 6
(Two
complications)
N=38
P Value
between
groups
42:16
62.7±9.7 a
25.4±3.8
13.8±9.9 a
49:17
59.7±9.9 a
25.5±3.7
16.2±6.7 a
27:11
60.4.±10.6 a
24.8±3.7
14.2±8.1a
0.199
<0.0001
0.404
<0.0001
29(50.0)
7(12.1)
41(62.1)
17(25.8)
24(63.2)
7(18.4)
0.230
0.001
Dur DM – Duration of Diabetes; FH-DM-Positive Family history of diabetes; FH -DC – Positive Family history of Diabetic Complications; P< 0.05; a
Vs group 1
the study groups. Urea and creatinine levels showed significant
difference between the study groups (p<0.0001).
Table 3 shows the details of direct costs of treating severe
long term diabetic complications during hospitalization between
the study groups. The diabetic patients with foot complications
or with the presence of two diabetic complications tend to
stay longer for every inpatient admission. The total median
expenditure including laboratory charges, medical consultations
,medicines, hospital charges, charges for other investigations and
transportation charges was more in the complications groups
(Group 2 to Group 6) compared to the group without any
complications (Group 1). The expenditure for laboratory charges
and medical consultations was high for diabetic patients with
foot complications (Group 4) than their counterparts with the
presence of other severe diabetic complications such as chronic
kidney disease, cardiovascular and retinal complications. The
transportation charges and medicines cost was significantly
104
higher in Group 4 to Group 6. The expenditure on doing other
investigations which includes echo cardiography, doppler and
biothesiometry, scan, radiological examination, etc was similar in
all the study group subjects with the presence of complications.
On an average, diabetic patients with foot complications (19020
INR) and those who have presence of two complications (17633
INR) spent 4 times more and patients with chronic kidney disease
(12690 INR), cardiovascular complications (13135 INR) and
retinal complications (13922 INR) spent three times more than
patients without any complications (4493 INR). The total median
expenditure for the hospital admissions in the previous 2 years
was significantly higher for patients with foot complications
(150000 INR) and cardiovascular complications (200000 INR)
and it was highest if they have presence of two complications
(282500 INR).
The total cost correlated significantly with age (r=0.178,
p<0.0001) and duration of diabetes (r=0.177, p<0.0001) but
© JAPI • february 2013 • VOL. 61
© JAPI • february 2013 • VOL. 61 19
Table 2 : Comparison of biochemical details among the study groups
Group 1 (Without
complications)
N=86
Plasmaglucose (mg/dl)
Fasting
162.2±61.9
Postprandial
248.8±92.2
8.9±2.2
HbA1C (%)
Total Chol (mg/dl)
175.3±50.2
Triglycerides(mg/
161.8.±72.3
dl)
HDL - Chol (mg/
42.8±9.7
dl)
LDL – Chol (mg/
115.5±69.2
dl)
VLDL – Chol (mg/
25.5±13
dl)
Urea (mg/dl)
24.0±7.1 b
Creatinine
0.72±0.17 b
(mg/dl)
Group 2
(Renal)
N=67
Group 3
(Cardiovascular)
N=53
Group 4
(Foot)
N=58
Group 5
(Retinal)
N=66
Group 6 (Two
complications)
N=38
P Value
173.1±54.6
255.5±75
8.8±2.0
166.6.±57.2
193±108.5
161±75.4
214.5±84
9.2±2.1
167.5±54.2
166 ±95.2
146.8±53.9
219.7±70.6
9.8±1.9
148±47.6
166.2±95.9
157.3±58.8
242±83.7
9.4±1.8
162.8±49.9
167±98.9
131.3.±39.9a
202.3±52.2a
9.4±2.2
149.3±34.5
137.2±59.1
0.017
0.003
0.132
0.076
0.277
37.6±8.7
38.3±14.2
38.4±18.1
37.8±11.7
35.3±11.1
0.106
89.3±27.4
90.6±35.5
89.5±39.1
94.2±35.5
93±27.9
0.025
33.8±19.1
28.7±15.3
22±14
31.3±23.2
24.5±14.0
0.035
72.7 ±27.9
2.3±1.0
38.8±22.1a,b
1.2±0.8 a, b
33.4±19.9 b
1.08±0.7 b
40.4±24.3 a, b
1.3±0.9 a, b
39.7±22.8 a, b
1.2±0.74 b
<0.0001
<0.0001
Values are in mean ± SD; p<0.03; a Vs group1, b Vs Group 2
Table 3 : Details of expenditure for treating diabetic complications among the study groups
No of Days
Hospitalized
Lab Charges
(INR)
Medical
consultations
(INR)
Medicines
(INR)
Hospital
charges(INR)
Other
investigations
(INR)
Transportation
charges
(INR)
Total
expenditure
(INR)
Previous
2 years
expenditure
(INR)
Group 1
(Without
complications)
N=86
1
(1-8)
1215
(250-5800)
350
(150-1050)
Group 2
(Renal)
N=67
Group 3
(Cardiovascular)
N=53
Group 4
(Foot)
N=58
Group 5
(Retinal)
N=66
Group 6 (Two
complications)
N=38
P value between
groups
4
(1-12) a
3600 a,e
(865-6980)
1000 a
(100-3000)
4
(1-11) a
3135 a
(915-9390)
1050 a, e
(100-4200)
6
(3-30) a, b,c
3715 a,e
(350-10501)
1500 a, b,e
(200-9425)
5
(2-20) a, d
3218 a
(750-9900)
800 a
(100-4900)
6
(2-25) a, b,c, e
3635 a
(1395-8275)
1075 a
(200-7050)
<0.0001
800
(200-5000)
1083
(100-4395)
450
(200-2810)
1500 a
(450-8500)
4010 a
(1450-16505)
1050 a
(250-2930)
1800 a, b
(300-12000)
4100 a
(580-24015)
1200 a
(300-2080)
2000 a
(480-20000)
6907 a, b, c
(3400-53740)
1240 a
(120-5972)
2000 a, b
(150-9330)
4738 a
(500-43215)
1200 a
(250-3280)
2500 a, b, c
(300-20000)
6527 a, b, c
(1430-20205)
1279 a
(250-4500)
<0.0001
300
(50-10000)
650 a,e
(100-30000)
500 a
(100-24000)
1000 a
(200-15000)
1000 a, b
(100-30000)
1000 a
(120-35000)
<0.0001
4493
(2640-17095)
12690 a
(4465-57415)
13135 a
(3130-62530)
19020 a, b, c
(10070-86520)
13922 a
(4800-66165)
17633 a, b, c, e
(6140-49260)
<0.0001
30000
(5000-100000)
100000 a
(20000-300000)
200000 a, b, e
(20000-500000)
150000 a, b, e
(12000-500000)
100000 a
(12000-500000)
282500 a, b, c,e
(25000-450000)
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
1 US$ = 46.50INR (approximately); Values are median (range) in Indian Rupees; P <0.03, a Vs. Group 1, b Vs. Group 2, c Vs. Group 3, d Vs. Group 4,
e Vs. Group 5
showed no correlation with HbA1c (r=0.063, p=0.092). Correlation
of HbA1c with duration of hospital stay was also non-significant
(r=0.071, p=0.072). The results of regressing the total treatment
cost showed that duration of diabetes [regression coefficient
(0.098), p=0.018], number of hospitalized days [regression
coefficient (0.70), p<0.001] and the risk group (regression
coefficient (0.106, p=0.016) were significantly associated with
total expenditure. The overall model was statistically significant
(p<0.0001) with an adjusted R square = 0.588.
study population and it also shows the details of the severe
diabetic complications among the study groups. Majority of
them were hospitalized to undergo cataract surgery or laser
photocoagulation treatment (22.3%) and foot amputation (19%).
The other reasons for hospitalization were due to elevated
renal parameters (18.8%) and to manage cardiovascular
complications(16.6%).About 6.8% were admitted to have a
general checkup,6.5% due to severe hyperglycemia and 3.3%
because of frequent hypoglycemic symptoms. A small proportion
of subjects were admitted due to several other reasons related to
Table 4 shows the reasons for hospitalization of the
© JAPI • february 2013 • VOL. 61 105
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© JAPI • february 2013 • VOL. 61
Table 4: Reasons for hospitalization and details of severe
diabetic complications of the study population
Reasons for hospitalization
Total n=368
Cataract Surgery/Laser photocoagulation Treatment
Foot Amputation
Elevated Renal Parameters
Cardiovascular
General Check Up
Severe Hyperglycemia
Hypoglycemic symptoms
Back Pain /Shoulder Pain
Dental Problems
Urinary Tract Infection
Fever
Foot Infection/Neuropathic Symptoms
Complications
Surgery details
Foot Amputation (n=58)
Ray/Toe Amputation
Below Knee
Fore Foot/Mid Foot
Above Knee
Retinal (n=66)
Cataract Surgery
Laser photocoagulation Treatment
Cardiovascular (n=53)
CABG
Heart Attack/MI
Angioplasty
CAD
Chronic Kidney Disease (n=67)
Stage I
Stage II
Stage III
Stage IV
Two complications (n=38)
CABG+Laser Treatment
CABG + Toe Amputation
CABG+ Fore Foot Amputation
Heart Attack + Cataract Surgery
Cataract Surgery + Below knee Amputation
Cataract + Toe Amputation
Cataract +renal problem
n(%)
82(22.3)
70(19.0)
69(18.8)
61(16.6)
25(6.8)
24(6.5)
12(3.3)
6(1.6)
6(1.6)
6(1.6)
4(1.0)
3(0.9)
38(65.5)
14(24.1)
4(6.9)
2(3.4)
51(77.3)
15(22.7)
31(58.5)
11(20.8)
6(11.3)
5(9.4)
16(23.9)
20(29.9)
19(28.4)
12(17.9)
3(7.9)
6(15.8)
1(2.6)
6(15.8)
2(5.3)
11(28.9)
9(23.7)
diabetes. The detailed description of the surgery procedures are
also provided in Table 4. Figure 1 shows the mode of payment
of hospital bills for inpatient admissions. Approximately, 50%
was from the personal savings and 10 – 15 % made the payment
through borrowing loans, company reimbursement and by
selling property such as land, house, etc. In a small proportion
(7%) of subjects, the mode of payment was by mortgage and
medical insurance.
Discussion
Management and treatment of diabetes is one of the most
expensive conditions. Due to its chronicity and the associated
complications, the cost of diabetes treatment is increased by
two to four times than the people without diabetes.15 Even
the presence of a single comorbid condition like hypertension
increases the cost of management of disease by 1.5 times when
compared to those diabetic patients who do not have any other
associated co morbidities.16
Total direct costs of diabetes are highest in US ($116 billion)
106
PersonalSavings
7%
11%
BorrowingLoan
Mortgage
48%
12%
Company
Reimbursement
8%
Selling Property
14%
Medical Insurance
Fig. 1 : Shows the mode of payment of hospital bills for inpatient
admission in the study population.
and a larger proportion of $58 billion is spent annually just
to treat diabetes related chronic complications9. The overall
annual direct economic burden of diabetes in 2002 was $ 2.44
billion among urban population of china and the estimate was
recently updated to $ 2.29 billion.17,18 In south Asia, the direct cost
involved in diabetes management is US$ 5 billion and indirect
costs a total of US$ 10 billion. Such cost related data varies from
country to country and hence cannot compare the cost estimates.
Comparison of results from various health economic studies are
complicated by differences in study design, selection of patients,
prevalence rates, health care systems and treatment practices.
Even though there are reports available from India on economics
of diabetes care, literature on cost of treating diabetes related
complications is sparse. Lack of data on the economic burden of
treating diabetes related complications in developing countries
motivated us to plan this study. The present study highlights
the direct cost estimates involved in treating severe long term
diabetic complications such as renal, cardiovascular, retinal
and foot complications in comparison with patients without
any complications.
In terms of discussing the findings of the current study, it is
worth mentioning that, the direct healthcare costs for treating
diabetes complications is on the rise. The study revealed that
the average cost of treating and managing diabetes related foot
complications was the highest among all other complications of
diabetes. The duration of stay in the hospital, number of visits
made for post surgical dressings, hospital charges, laboratory
charges and medical consultations are the factors which were
significantly related to the increased cost. The duration of
hospital stay was substantially longer in patients with foot
complications and those who had presence of two complications.
Such information on hospital stay days and costs may help to
emphasize earlier intervention and prevention of complications
of diabetes. Diabetes patients with presence of two complications
came second in the rankings of highest direct health care cost
estimates per admission. As expected, the group without any
complications, had reduced cost pattern for all the parameters,
irrespective of glycemic status which is evident that high costs
for diabetes care is not due to the disease but due to its associated
complications. In the current study, the group of patients without
any complications were younger and had shorter duration of
diabetes. It is well known that with increasing age and duration
of diabetes the patients develop diabetic complications. Our
© JAPI • february 2013 • VOL. 61
© JAPI • february 2013 • VOL. 61 results support this well established fact that complications get
worsen with longer duration of diabetes.
and its complications constitutes 86% of direct costs and 95% of
the indirect costs.23 The assessment of indirect costs is beyond
the scope of the current study and hence it is limited to direct
healthcare costs alone. On comparison with multiple groups the
study has thus shown that major proportion of direct healthcare
costs is due to diabetes complications and not due to actual
diabetes treatment. Published reports from other studies are in
favour of the above results.24–26
The total expenditure correlated significantly with age and
duration of diabetes. The expenditure involved in treating long
term complications was significantly associated with duration
of diabetes, number of hospitalized days and presence of
complications in the current study. The model explained 58.8%
of the variations.
There are few limitations to our study. It is important to
note that the data collected is from a specialized diabetes care
centre and the generalizability of results may be limited to
certain private health care centres, the projected cost estimates
were mainly based on urban patients whose pattern of disease
may be different compared to rural patients. We could not
assess the indirect cost and the cost of care for structured and
comprehensive assessment of disability in this study. The cost
estimate, especially for non-medical cost such as transportation
charges, was to some extent based on patient recall which
could have had recall bias. With this study design, there is the
possibility of many confounding factors related to cost. Despite
these limitations, the findings from this study are significant and
important for medical care cost of diabetes in India. The data are
current and cover the direct costs involved in treating different
long term diabetic complications.
The total expenditure for treating renal, cardiovascular and
retinal complications was more or less similar among type 2
diabetic patients. The expenditure incurred on transportation
and medicines was high for people with foot and retinal
complications and with presence of two complications. Patients
with foot and those who had presence of two complications
spent 4 times more and patients with renal, cardiovascular
and retinal spent 3 times more in comparison with patients
without any complications. The total expenditure for 2 years
related to treating these complications was high for foot and
cardiovascular complications and it was highest if they had two
complications. Though the number of days of hospitalization
for the cardiovascular complication group was less compared
to the other groups, the expenditure incurred for the previous
2 years was the highest.
In developed countries, diabetic foot care accounts for up
to 20% of total health care resources available for diabetes. In
developing countries, it has been estimated that foot problems
may account for as much as 40% of the resources available. In
western countries, the economic cost of a diabetic foot ulcer is
thought to be between US$ 7000 and US$ 10,000 where healing
is complicated and amputation required, this cost may increase
to as much as US$ 65,000 per person. Diabetic foot ulceration
and amputations were estimated to cost US health care payers
$10.9billion in 200119,20 and the corresponding UK estimates
based on the same methodology were that 5% of total national
health service expenditure in 2001 (£3 billion) was attributable
to diabetes. The total annual cost of diabetes related foot
complications was estimated to be £252 million.21 The above cost
estimates shows that prevention is the best option to tackle this
costly treatment and managing these complications.
India, as such has the largest number of people with diabetes
than any other country and foot problems and amputations
remain very common.27 This may considerably increase the cost
of treatment unless intervention policies are framed to prevent
and control diabetes complications. Significant reductions in
amputations can be achieved by well-organised diabetic foot
care teams and by good diabetes control. Special interventions
should be planned and implemented in susceptible individuals
and populations through modifications of risk factors and
determinants.
In conclusion, the study revealed that the excess of the
diabetes mellitus related healthcare costs may be attributable
to complications of diabetes. Strategies that aim at reducing
the escalating cost burden must have a focus on achieving
targeted glycemic control, prompt and effective management
of complications, operationalize regular and early screening for
complications. Awareness creation on primary and secondary
prevention of diabetes and its complications is the need of
the hour, alongside capacity strengthening of medical and
paramedical professionals involved in diabetes care.
Another interesting finding of the current study is the
proportional increase in the cost in relation to the number of
complications. The subjects with multiple complications, on an
average are spending a large proportion of their annual income,
which is again mostly ‘out of pocket’ expenses as shown in the
study, with an evidence of negligible insurance claims. Majority
of the study patients (approximately 50%) depended on personal
savings or either borrowing loan or selling properties to pay
the hospital bills, which highlights the need for health policies
reformation in terms of friendly payment options.
Conflict of Interest
None declared.
Acknowledgement
We are grateful to the patients without whose invaluable
information the study could not have been completed.
Another study from India demonstrated that there is an
increasing trend in expenditure on diabetes care. Expenditure
incurred by both urban and rural subjects in relation to the
number of complications was proportionately increased and they
spent a large percentage of income on diabetes management.13
Appendix
S.
No.
A study from North India also assessed comprehensively
the cost of ambulatory care of diabetes in a small sample. The
largest proportion of the total cost was made up of direct costs
(68%), followed by indirect costs (28.7%) and provider’s costs
(2.8%). The study showed that diabetes is an expensive illness
to treat in developing countries.22 Only the direct health care
costs have been estimated in the present study, while evidence
from published reports suggests that costs of treating diabetes
© JAPI • february 2013 • VOL. 61 21
1.
Name :
2.
Age :
3.
Age at onset of diabetes:
4.
Duration of diabetes:
5.
Gender: (1) Male (2) Female
6. Complications details:
Date:
Do you have any diabetic complications? (1) Yes (2) No
If No,
107
22
© JAPI • february 2013 • VOL. 61
1.
Group 1 (without complications)
2.Renal (Group 2)
1.
Which complication led to hospitalization _______________
3.
2.
No. of days admitted in hospital ________________________
4.Foot complications (Group 4)
3.
5.Retinal complications (Group 5)
Have you undergone any surgery due to the diabetic
complications? (1) Yes (2) No
6.
17. Hospitalization details or reason for hospitalization:
Cardiovascular (Group 3)
Presence of any above 2 complications (Group 6)
Other complications___________________________________
7. Family history:
18. Cost details (INR) during hospitalization:
S. No.
1
2
3
4
5
6
Family history of DM: Family history of other diabetic
complications:
(1) Yes (2) No
If yes, (1) Yes (2) No
If yes,
1. Father
1. D. neuropathy
2. Mother
2. D. nephropathy
3. Both parents
3. HTN
4. Siblings
4. CHD
5. Others
5. D. retinopathy
Locality: (1) Urban (2) Rural
9.
Educational status:
10. Occupation:
1.Illiterate
1.Unskilled worker
2.School
2.
Skilled worker
3.
Office job
3.
Graduate / Post
Graduate
4.Professional
4.Business
5.Professional
6.Retired/Unemployed
7.
House wife
11. Socioeconomic status:
Total family income in Indian rupees per month
1. <10,000
2. 10,000 – 20,000
3. >20,000
Lab charges
14. Are you taking treatment: (1) Yes (2) No
Medical consultations ______________________
Medicines
Hospitalization charges ______________________
Surgery cost
Other investigations ______________________
Transportation charges ______________________
Total expenditure for past 2 years __________________ in rupees
______________________
______________________
20. Mode of payment of hospital bills:
1.
Personal savings
2.
Medical Insurance
3.
Company reimbursement
4.Borrowing loan
6.
1.
Zimmet P, Alberti KG, Shaw J. Global and societal implications of
the diabetes epidemic, Nature 2001;414:782-7.
If yes, (1) OHA (2) Insulin (3) OHA+Insulin
Weight:___________Kgs
Height:___________cms
2.
Morrish NJ, Wang SL, Stevens LK, Fuller JH, Keen H. Mortality
and causes of death in the WHO multinational study of vascular
disease in diabetes. Diabetologia 2001;44(suppl 2):s14–s21.
3.
Wingard DL, Barrett-Connor E, Criqui MH, Suarez L. Clustering
of heart disease risk factors in diabetic compared to non diabetic
adults. Am J Epidemiol 1983;117:19-26.
BMI: ___________Kg/m²
16. Biochemical parameters:
Value
Selling property
References
15. Anthropometric details:
108
______________________
5.Mortgage
13. Habits: (1) Smoking (2) Alcohol (3) Tobacco chewing (4) None
Parameters
Fasting plasma glucose (mg/dl)
Postprandial glucose (mg/dl)
HbA1c %
Serum total cholesterol (mg/dl)
Triglycerides (mg/dl)
HDL cholesterol (mg/dl)
LDL cholesterol (mg/dl)
VLDL cholesterol (mg/dl)
Urea (mg/dl)
Creatinine (mg/dl)
Albumin/Creatinine ratio
Protein/Creatinine ratio
Creatinine clearance (ml/min)
Charges in Indian Rupees
12. Food Habits: (1) Vegetarian (2) Non-vegetarian
Particulars
Lab charges
Medical consultations
Medicines
Hospitalization charges
Other Investigations
Transportation charges
Total expenditure (Rs)
19. Previous 2 years expenditure details:
6. Foot complications
8.
If yes, details _________________________________________
____________________________________________
4.Rubin RJ, Altman WM, Mendelson DN. Healthcare expenditures
for people with diabetes mellitus 1992. J Clin Endocrinol Metabol
1997;84:809A-809 F.
5.
A report of the diabetes health economics study group, WHO and
IDF, 1998. The economics of diabetes and diabetes care. Diabetes
Health Economics 1999.
6.
Kapur A. Influence of socio-economic factors on diabetes care. Int
J Diab Dev Countries 2001;21:77-85.
7.
IDF Diabetes Atlas, Fourth Edition, International Diabetes
Federation, 2009.
8.
International Diabetes Association (2003) Diabetes Atlas, 2nd edition,
International Diabetes Association Brussels.
9.
American Diabetic Association. Economic costs of diabetes in US
in 2007. Diabetes Care 2008;31:596-615.
10. Joshua AR, Valentine WJ, Secnik C. Review of the cost of diabetes
complications in Australia, Canada, France, Germany, Italy and
Spain. Curr Med Res Opin 2005;21:1617-29.
© JAPI • february 2013 • VOL. 61
© JAPI • february 2013 • VOL. 61 23
11.Rayappa PH, Raju KNM, Kapur A, Stefan A, Camilla S, Dilip Kumar
KM. Economic costs of diabetes Care. The Bangalore Urban District
diabetes study. Int J Diab Dev Countries 1999;19:87-96.
19. Shearer A, Scuffham P, Gordois A, Oglesby A. Predicted costs and
outcomes from reduced vibration detection in people with diabetes
in the U.S. Diabetes Care 2003;26:2305-10.
12. Kapur A. Cost of diabetes in India. The CODI study paper presented
at the Novo Nordisk Diabetes update Bangalore, February 2000.
20. Gordois A, Scuffham P, Shearer A, OglesbyA, Tobian JA. The
healthcare costs of diabetic peripheral neuropathy in the US.
Diabetes Care 2003;26:1790-95.
13.Ramachandran A, Shobana R, Snehalatha C, Augustine C,
Murugesan N, Vijay V, et al. Increasing expenditure on health care
incurred by diabetic subjects in a developing country. Diabetes care
2007;30:252-56.
21. Gordois A, Scuffham P, Shearer A, Oglesby A. The healthcare costs
of diabetic peripheral neuropathy in the UK. Diabet Foot 2003;6:6273.
14. Tharkar S, Arutselvi D, Satyavani K, Vijay V. The socioeconomics
of diabetes from a developing country: A population based cost of
illness study. Diabetes Res Clin Pract 2010;89:334-40.
22. Grover S, Avasthi A, Bhansali A, Chakrabarti S, Kulhara P. Cost
of ambulatory care of diabetes mellitus: a study from north India.
Postgrad Med J 2005;81:391-395.
15. Clarke PM, Glasziou P, Patel A, Chalmers J, Woodward M, Harrap
BS, et al. Event rates, hospital utilization and costs associated with
major complications of diabetes: A multi country comparative
analysis. PLoS Med 2010;7(2):e1000236. doi:10.1371/journal.
pmed.1000236.
23. Gonzalez JC, Walker JH, Einarson TR. Cost-of-illness study of type 2
diabetes mellitus in Colombia. Rev Panam Salud Publicat 2009;26:5563.
24. Wang W, McGreevey WP, Fu C, Zhan S, Luan R, Chen W, et al.
Type 2 diabetes mellitus in China: A preventable economic burden.
Am J Manag Care 2009;15:593-601.
16. Tharkar S, Satyavani K, Vijay V. Cost of medical care among type
2 diabetic patients with a co-morbid condition—Hypertension in
India. Diabetes Res Clin Pract 2009;83:263-67.
25.Brown JB, Pedula KL, Bakst AW. The progressive cost of
complications in type 2 diabetes mellitus. Arch Intern Med
1999;159:1873-80.
17. Chen X, Tang L, Chen H, Zhao L, Hu S. Assessing the impact of
complications on the costs of type 2 diabetes in urban china. Chinese
J Diabetes 2003;11:238-41.
26. Govender VM, Ghaffar A, Nishtar S. Measuring the economic and
social consequences of CVD and diabetes in India and Pakistan.
Bioscience Trends 2007;1:121-27.
18. Hu JP, Rao K-Q, Qian JC, Wu J. The study of economic burden of
chronic non-communicable diseases in china. Chinese J Prevention
Control Chronic Non-communicable Dis 2007;15:4.
© JAPI • february 2013 • VOL. 61 27. International Diabetes Federation. Time to act: diabetes and foot
care. Brussels, International Diabetes Federation 2005.
109