Background
Methods
Search strategy
Search terms
Combined with (individually)
|
Combined with (individually)
| |
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India | diabetes | expenditure |
diabetic | expenses | |
“diabetic complications” | cost | |
neuropathy | “economic burden” | |
nephropathy | ||
“renal replacement” | ||
“chronic kidney” | ||
“diabetic foot” | ||
“diabetic ulcer” |
Inclusion criteria
Critical review of the data and quality of the studies
Economic impact on individual and household | Economic impact on health sector and economic sector | ||
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Direct costs
| Hospital, transport, drug costs, foods |
Direct costs (health sector)
| Inpatient care, outpatient care (GPs, district hospitals, pharmacy), long-term care |
Indirect costs
| Loss of income associated with morbidity, mortality and disability |
Indirect costs (economic sector)
| Costs due to absenteeism, permanent disability and mortality |
General | |
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Objective of the study | Cost of drugs: studies that aim to calculate the cost of a specific drug |
General Costs: studies that aim to calculate direct or indirect costs for the diabetes in general, for ambulatory care or for a specific subgroup. | |
Cost of Complication: studies that aim to calculate the cost of a specific complication of diabetes. | |
How is the disease defined? | Diabetes type 1/Diabetes type 2/ Gestational diabetes |
Is the definition clear and precise? | 1 = the definition of the type of diabetes considered is clear and all the morbidities and co-morbidities considered are listed. 0 = the definition is vague and do not include any details of all the morbidities and co-morbidities considered |
Which complications the authors have included? | 1 = more than 4 complications are considered and specified. |
0,5 = up to 3 complications are considered for each patient but they are not specified. | |
0 = no complications are considered or if they are considered there is no clear documentation in their inclusion. | |
Is a clear epidemiological definition provided? | The type of diabetes studied is specified |
SAMPLE
| |
Which is the population sample considered? | Description of the population considered by the study. |
Is the population selected appropriate? | The sample size is sufficiently large and the epidemiological characteristics of the population are in line with the objectives of the study. For example, a large national assessment of diabetes requires a large sample with a balanced population composition in terms of social class, the gender and other factors such as the education level. For a study focused on the costs of drug an appropriate sample could be small but should be focused on a particular health history of patients. |
Are sources for population data reliable? | 1 = self-assessment and questionnaire are confirmed by hospital records or hospitals and practitioners’ bills. |
0,5 = The only sources of data are questionnaire and self-assessment. | |
0 = The sources of data are not defined or are subject to a number of biases. | |
The period of evaluation is appropriate? | A period of evaluation is considered appropriate if is equal or more than 6 months for prevalence- based studies and consider more than 1 year for incidence based studies. |
COSTS
| |
Direct costs: | All resource costs employed to treat patients with diabetes (care and/or assistance). It includes medical and non-medical costs. |
Indirect costs: | All the costs associated with the loss of productivity resulting from morbidity and mortality caused by diabetes. |
Intangible costs: | All the costs associated with all the negative effects caused by the disease leading to deterioration in the quality of life of patients (e.g. isolation, anxiety, pain). |
Healthcare costs
| |
People with the health condition | Premiums and levies paid to collectively financed healthcare systems; out-of-pocket costs of healthcare services and products; transport costs related to treatment; home and car modifications; special diets; domestic care; lost income for unpaid leave to attend treatment. |
Others, including family members | Premiums and levies paid to collectively financed healthcare systems; out-of-pocket costs of healthcare and domestic services and products and home and car modifications for sick family members. |
Healthcare system (public and private) | Hospitals; primary care services; nursing homes; pharmaceuticals; domiciliary care; rehabilitation; home nursing; medical specialists; general practitioners; community healthcare services; ambulance services; paramedical services; specialist equipment; diagnostic tests; training; research; infrastructure; equipment; preventive programmes; administration |
Business/industry/employers (includes government employers) | Premiums and levies paid to collectively financed healthcare systems; preventive programmes |
Government (excluding health care system) | Specialist equipment/infrastructure modifications; community support services; residential support services; preventive programmes (e.g. education and training) |
Other resource use
| |
People with the health condition | Legal representation; childcare |
Others, including family members | Damage to property (e.g. for substance abuse, smoking), crime-related costs (e.g. for substance abuse) |
Healthcare system (public and private) | None |
Business/industry/employers (includes government employers) | Worker replacement costs (recruitment, training, retraining); cost of implementing and adhering to regulation and legislation |
Government (excluding health care system) | Regulation, inspection and monitoring; child welfare services; disability support services; courts services; police services; prison services; emergency/fire services; cost of administering additional taxes, levies and benefits. |
Production losses
| |
People with the health condition | Lost income due to unpaid sick leave (absenteeism), treatment related time off work, temporary unemployment, reduced on-the job productivity (‘presenteeism’), premature retirement through morbidity or early mortality, unwanted job changes, loss of opportunities for promotion and education; loss of unpaid production while ill. |
Others, including family members | Loss of income and unpaid production while caring for sick family members and friends. |
Healthcare system (public and private) | None |
Business/industry/employers (includes government employers) | Lost paid and unpaid output due to sickness (absenteeism for paid output), treatment-related time off work, temporary unemployment, reduced capacity, reduced on-the job productivity (‘presenteeism’), work injury, premature retirement through morbidity or early death |
Government (excluding health care system) | None |
Intangible costs
| |
People with the health condition | Quality of life (health, functioning, psychosocial impacts, including loss of leisure time), premature loss of life |
Others, including family members | Psychosocial costs related to family members’ suffering; Quality of life lost providing care to family members |
Healthcare system (public and private) | None |
Business/industry/employers (includes government employers) | Employee morale |
Government (excluding health care system) | Deadweight loss of additional taxation |
Appropriateness
| |
Does the study include the relevant costs? | 1 = the costs included are relevant for the objective of the stud. (minimum of 80% of the costs included in the section costs of this table) |
0,5 = the inclusion of the costs is partial | |
0 = there are missing a large number of costs that should be included or there is no specification of the costs included | |
Are the inclusion of the costs appropriate for the objective of the study? | 1 = considering the aim, all the necessary type of costs are included. (for ex for the evaluation of direct costs of a drug treatment all the costs borne by the patients directly and by the health care are included) |
0,5 = Only partial relevant costs are included. There are missing of some important costs related to the aim of the study. | |
0 = Although the study aim is to consider a general costs of diabetes or a costs of drug or complications there are included only a category of costs (for ex direct costs). | |
Has the Diabetes severity Index been used? | 1 = Yes |
0 = No | |
Is adequate documentation and justification given for cost components, data and sources, assumptions and methods? | 1 = detailed justifications are given for all the approach and methods adopted. The exclusion and inclusion of categories of cost and data are well motivated. All the sources are documented. |
0,5 = partial justification is given for the methods and approach adopted. There is limited or absence of justifications for the inclusion or exclusion of costs. The documentation is scarce and not precise. | |
0 = absence or minimal presence of documentation and justification | |
Are important limitations discussed regarding the cost components, data, assumptions and methods? | 1 = all the most important limitations are discussed. In same cases some minor limitation is discussed. |
0,5 = one or only not important limitations are discussed. | |
0 = there is no discussion around the limitations of the study. | |
METHODS
| |
Which is the epidemiological approach employed? | A) Prevalence-based: estimates the total cost of a disease in a given population for a given period. (Static) |
B) Incidence-based: estimates the potential averted costs if new (incident) cases are prevented. (Dynamic) | |
Is the data representative of the study population? | 1 = prevalence-based |
0, 5 = Incidence based | |
0 = no definition of the approach considered | |
Which approach in quantification of the costs were used? | A) Top-down approach refers to aggregate data available at national level, and involves a process of relating the overall health care spending to the individual diseases. From a methodological point of view to estimate the costs with the top-down method is crucial an excellent databases. |
B) The bottom-up approach refers to the direct consumption of resources, including epidemiological data, the cost of individual factors and the costs by the product, the average consumption of resources and its price/cost. | |
Was the approach appropriate? | 1 = bottom-up approach. |
0,5 = top down. | |
0 = no approach defined/ or impossibility to infer the approach employed | |
Which is the method used to evaluate the value of health? | A) Human Capital approach (generally recommended) |
B) Friction Costs approach. | |
C) Willingness to pay. | |
How is used the discount? | Discounting is an economic method that captures an individual’s preference for income today rather than income in the future. This time preference is often explained by the opportunity-cost of interest. Income earned today can earn interest through investment. |
Is the approach appropriate? | Discounting is relevant for direct and indirect costs and health outcomes that accrue past the first year. |
How are estimated the costs and health outcomes ? | A) Total disease costs: estimating of the total health-care expenditure of people diagnosed with diabetes. |
a) Sum_All Medical costs: Identify all patients with a diagnosis and sum costs | |
b)Sum_Diagnosis Specific: Identify all patients with a primary diagnosis and sum costs for treatments for that diagnosis | |
B) Incremental costs: estimating the increase in costs that is attributable solely to the presence of the diabetes: | |
a) Matched Control: Identify all patients with a diagnosis and sum cost. Subtract out the average cost of the sample to find incremental costs for treatment; alternatively, subtract out the average cost of a matched cohort instead | |
b) Regression_Method: Identify all patients with a diagnosis, complete a regression analysis and indicate the individual β for each diagnosis | |
Identify all patients with a diagnosis, find a matched cohort (similar to a clinical trial) and complete a regression analysis to quantify the individual β for each diagnosis – gold standard | |
Is the estimation method of the cost of diabetes appropriate? | 1 = Incremental costs method. |
0,5 = Total disease costs | |
0 = no methods designed or impossibility to retrieved a clear method from the study. | |
Are the deviation standard and the means calculated? | 1 = both, standard deviation and Means are calculated. 0,5: only one of them is calculated. 0: none of them is calculated |
Is a sensitivity analysis performed? | 1 = the sensitivity analysis is performed and the results are clearly shown. |
0,5 = some linear regression method are employed to correlate the variables | |
0 = no sensitivity analysis or linear regression are performed. | |
If yes, is it performed on: | 1) Important (uncertain) parameter estimates |
2) Key assumptions | |
3) Point estimates | |
Which statistical methods are used | 1 = the statistical analysis is performed with consistent statistical formulas. The formulas used should non-parametrical statistical hypothesis test. |
0,5 = the statistical analysis is performed but only with few statistical tools. | |
0 = no statistical methods are used. |
Findings
Ref | Author | Year | Study design | Diabetes type | Type of complication | Sample size | Data collection period | Region |
---|---|---|---|---|---|---|---|---|
[28] | Abdi et al. | 2012 | RCT | 1 and 2 | 350 | *** | Southern India | |
[29] | Adiga et al. | 2010 | CS | 2 | 238 | 2008 | Karnataka | |
[30] | Bjork et al. | 2003 | CS | 1 and 2 | 5516 | Jan-Sep 1999 | National | |
[31] | Grover et al. | 2005 | COH | 1 and 2 | 50 | *** | Northern India | |
[32] | Joshi et al. | 2013 | CS | 2 | 166 | Feb-Apr 2010 | Punjab | |
[33] | Kuchake et al. | 2010 | CS | 2 | 163 | Jul 2009- Feb 2010 | Maharashtra | |
[34] | Kumar et al. | 2008 | COH | 2 | 819 | 2005 | Delhi | |
[35] | Kumpatla et al. | 2013 | CC | 2 | 368 | Jun 2008-dec 2009 | Chennai | |
[36] | Ramachandran et al. | 2007 | CS | 2 | 556 | 1998 - 2005 | 7 states | |
[37] | Rao et al. | 2011 | CS | ** | 1858 | Jan - Jun 2004 | National | |
[38] | Rayappa et al. | 1999 | CS | 1 and 2 | 611 | 1997 - 1998 | Bangalore | |
[39] | Shivaprakash et al. | 2012 | COH | 1 and 2 | 200 | 2005 and 2010 | Mangalore | |
[40] | Shobhana et al. | 2000 | CC | 2 | 270 | Jan - Jun 1998 | Chennai | |
[41] | Shobhana et al. | 2002 | CS | 1 | 209 | Jan - Oct 2000 | Chennai | |
[42] | Shobhana et al. | 2000 | CS | 2 | 596 | 1999 | Chennai | |
[43] | Tharkar et al. | 2010 | CS | 2* | 718 | Aug -Dec 2009 | Chennai | |
[44] | Akari et al. | 2013 | COH | 1 and 2 | 150 | Feb-July 2012 | Hanamkonda | |
[45] | Satyavany et al. | 2014 | CS | 2 | 209 | Aug 2008- Jan 2010 | ** | |
[46] | Tharkar et al. | 2009 | CS | 2 | 443 | Oct- Dec 2007 | ** |
Ref | Author | Year of data | INR per USD | Health system costs INR (USD current value/USD 2014 value)/person | Individual/household costs INR (USD current value/USD 2014 value)/person | ||
---|---|---|---|---|---|---|---|
Direct
|
Indirect
|
Direct
|
Indirect
| ||||
[28] | Abdi et al. | 2012* | 53.06 | Drug consumption (DDD1/100 bed days) 13.42 (0.25) (0.26) | |||
[29] | Adiga et al. | 2008 | 39.41 | Annual costs of consultations and drugs 19,076.07(484.04/535.14) | |||
[44] | Akari et al. | 2012 | 53.06 | Average cost for patient with diabetes complication (including costs of drugs, consultations, hospitalisation, (314.15/325.69), without (29.91/30.17) | |||
[30] | Bjork et al. | 1999 | 42.49 | Total costs, annual (drugs, monitoring, check-ups, hospitalisation) 7,159 (168.49/240.73) | |||
[31] | Grover et al. | 2005* | 43.40 | Total costs over 6 months (incl. consultations, investigations, nursing, infrastructure) 205.55(4.74/5.78) | Total costs over 6 months (incl. drugs, food, travel) 4,966.42 (114.43/139.47) | Total costs (income loss, patient and caregiver) 2,086.74(48.08/58.60) | |
[32] | Joshi et al. | 2010 | 46.61 | Cost per consultation 166 (3.56/3.89) | |||
[33] | Kuchake et al. | 2010 | 46.61 | Cost per consultation 116.85 (2.51/2.74) | |||
[34] | Kumar et al. | 2005 | 43.40 | Total costs per year (incl. consultations, tests, drugs, monitoring) 6,212.4 (143.14/174.76)2 | |||
[35] | Kumpatla et al. | 2009 | 48.76 | Total cost without complication 4,493 (92.15/102.24), with complication(s) 15,280 (313.37/347.69)3 | |||
[36] | Ramachandran et al. | 2005 | 43.4 | Total costs (incl. drugs, tests, consultations, hospitalisation, surgery, median) 8,130 (187.33/228.32)5 | |||
[37] | Rao et al. | 2004 | 45.60 | Costs per hospitalisation 5925(136.5/172) | |||
[38] | Rayappa et al. | 1999 | 39.10 | Annual societal costs (incl. routine, monitoring, tests, hospital) 1,305.20 (33.38/47.69) | Annual societal costs 15,376.30 (393.25/561.86) | Annual costs (incl. routine, monitoring, tests, hospital) 15460.40 (395.41/564.95) | Annual costs 3,572.5 (91.37/130.55) |
[45] | Satyavany et al. | 2010 | 46.61 | Total annual costs for a patient with Kidney problems associated with diabetes: 392,920 (8450/9224.06)[transplantation]; 61,170 (1,315/1435.46) [dialysis]; 12,664(272296.62)[CKD stages]; 3,214 (69/75.32)[without complications] | |||
[39] | Shivaprakash et al. | 2005 | 43.40 | Cost per consultation 363(8.36/10.19) | |||
[40] | Shobhana et al. | 1999 | 39.1 | Costs during 6 months (incl. consultation, surgery, hospitalisation, tests, drugs, transport)12,055(308.31/440.506 | |||
[41] | Shobhana et al. | 2000 | Values for both currencies as provided in the article | Total annual costs (including drugs, tests, consultation, hospital, transport) Inpatient 15,596(331.8/468.65), Outpatient 8,578(200.7/277.3) | |||
[42] | Shobhana et al. | 1999 | 42.49 | Total annual costs (incl. drugs, tests, consultation, hospital, surgery, transport) private hospital 4,510 (106.1/151.59), public hospital 246 (5.8/8.29) | |||
[43] | Tharkar et al. | 2009 | 48.76 | Total annual costs (incl. consultation, drugs, investigation, transport, food, miscellaneous, accommodation for alternate caregiver, management) 25,391 (520.73/577.76) | |||
[46] | Tharkar et al. | 2007 | 44.11 | Total costs hospital admission during 2 years (Incl. drugs, investigations, miscellaneous, admin), without comorbidities 28,000 (634.78/728.73), with comorbidities 38,000 (861.48/988.99) |
Different types and perspectives of costs
Health system perspective
Direct costs
Ref | Drug | Test/investigation | Monitoring | Transport | Hospitalisation | Consultation | Surgery | Food |
---|---|---|---|---|---|---|---|---|
[33] | Cost per consultation 116.85 (2.51) | |||||||
[34] | Costs per year 3,324.45 (76.60) | Costs per year 1803.35 (41.55) | Costs per year 322.75 (7.44) | Costs per year 875.85 (20.18)2 | ||||
[35] | Costs without complications 800 (8.20), with complications 1,960 (40.20)3 | Costs without complications 300(6.15), with complications 830 (17.02)3 | Hospital charges without complications 1,083 (22.21), with complications 5,256.4 (107.80)3 | Costs without complications 350 (7.18), with complications 1,085 (22.25)3 | ||||
[36] | Median costs at 3,250 (74.88)6 | Median costs at 1,000 (23.04)6 | Median costs at 8,000 (184.33)6 | Median costs at 800 (18.43)6 | Median costs 13,750 (316.82)6 | |||
[37] | Costs per hospitalisation 5,925 (136.5) | |||||||
[29] | Annual costs, 18,623.94 (472.57) | Annual costs, 452.13 (11.47) | ||||||
[38] | Annual monitoring and lab costs 822.6 (21.04) | Annual costs 8,678.6 (221.96) | ||||||
[39] | Cost per consultation 363(8.36) | |||||||
[40] | Costs during 6 months 3,000 (76.7)7 | Costs during 6 months 1,435 (36.70)7 | Costs during 6 months 225 (5.75)7 | Costs during 6 months 3,650 (93.4)7 | Costs during 6 months 1,900 (48.59)7 | |||
[41] | Annual costs Inpatient 6,840 (145.5), Outpatient 6,150 (130.8) | Annual costs Inpatient 630 (13.4), Outpatient 400 (8.4) | Annual costs 5,000 (106.3) | Annual GP and specialist costs Inpatient 550 (11.5), Outpatient 420 (8.8) | ||||
[42] | Annual costs, private hospital 3,000 (70.6), public 735 (17.3) | Annual costs, private hospital 360 (8.5), public hospital 240 (5.6) | Annual costs, private hospital 240 (5.6), public hospital 192 (4.5) | Annual costs private hospital 5,000 (117.7), public hospital 0.0 | Annual GP and specialist costs, private hospital 600 (14.12), public hospital 670 (15.7) | Annual costs private hospital 9,000 (211.8) | ||
[43] | Annual costs Hospital 1,500 (30.76) | Annual costs, hospital 2,250 (46.14), ambulatory 1,050 (21.53) | Annual costs, hospital 600 (12.30), ambulatory 202 (4.14) | Annual costs, hospital 550 (10.37), ambulatory 320 (6.56) | Annual costs, hospital 600 (12.30), ambulatory 190 (3.89) | |||
[46] | Average cost per hospitalisation, without comorb. 184 (4.17), without comorb. 2,098 (47.56), outpatient without comorb. 456 (10.34), with comorb. 488 (11.06) | Average cost per hospitalisation, without comorb 903 (20.47), with comorb 968 (21.94), outpatient without comorb. 373 (8.46), with comorb. 405 (9.18) | Cost per hospital admission, without comorb. 18650 (422.80), with comorb. 2,1000 (476.08) | |||||
[45] | Transplantation 40,400(869); dialysis 7250 (156); CKD 1,500 (156); No complications 800 (17) | Transplantation 64,925 (1.396); dialysis 2800 (60); CKD 3,625 (78); No complications 1,214 (26) | Transplantation 3,250 (70); dialysis 3480 (75); CKD 625(13); No complications 300(6) | Transplantation 21,5000(4,624); dialysis 22,000 (473); CKD 4,010(86);No complications 1,082(23) | Transplantation 67,000 (1,441); dialysis 32,200 (692); CKD 1,000 (121); No complications 350 (8) | Total cost for Transplantation 392,920 (8,450) | ||
[44] | Average per patients: Without complications 380 (7) with complications 3,769 (69) | Average per patient 1,598 (29.45) | Average cost per patient 7,800 (143.75) | Average cost per patient 2,191 (40.37) | ||||
[31] | Costs during 6 months 3,076.28 (67.46) | Costs during 6 months 277.80 (6.09) | Costs during 6 months 458.96 (10.04) | Costs during 6 months 72.66 (1.59) | ||||
[30] | Annual costs 2,435 (57.31) | |||||||
Totall1 | 12 | 10 | 2 | 6 | 11 | 11 | 3 | 2 |