Diabetes mellitus medication use and catastrophic healthcare expenditure among adults aged 50+ years in China and India: results from the WHO study on global AGEing and adult health (SAGE)

Out-of-pocket expenditure among patients with diabetes in Bangladesh: A nation-wide population-based study

Background and objectives

Diabetes has become one of the fastest growing public health emergencies worldwide. The objective of this study was to estimate the average annual out-of-pocket cost of diabetes treatment as well as to find out the catastrophic health expenditure (CHE) and their determinants in Bangladeshi context.

Data and methods

The study utilised data from the most recent nationally representative Household Income and Expenditure Survey 2016-2017. The incidence of CHE was estimated by applying 10% and 25% of the annual total household expenditure threshold levels. The factors associated with CHE was presented as adjusted odds ratio with 95% confidence intervals.

Results

The annual average out-of-pocket cost per diabetes patient was US$ 323 (BDT 25,473). The cost of medication was the main cost driver contributed for 75.43% of the total out-of-pocket cost. The incidence of CHE was 14.34%, and 5.86% of the study households for 10% and 25% of the threshold levels, respectively. The patient aged more than 60 (AOR: 4.89; CI 0.82 to 28.95), uneducated (AOR: 1.83; CI 0.25 to 2.12), comorbid condition (AOR: 1.62; CI 0.94 to 2.79), small household size (AOR: 3.20; CI 0.58 to 17.51), rural resident (AOR: 1.85; CI 0.46 to 1.57), poorest asset quintile (AOR: 4.06; CI 1.43 to 13.87) and private facility type (AOR: 8.16; CI 3.46 to 19.;25) were significantly associated with the incidence of CHE due to diabetes treatment.

Conclusions

There are considerable out-of-pocket costs needed for diabetes care in Bangladesh. The evidence of catastrophic expenditure suggests the urgent need to improve financial risk protection to ensure access to care.

Catastrophic health expenditure and its inequality in rural China: based on longitudinal data from 2013 to 2018

BACKGROUND

Catastrophic health expenditure (CHE) is an important indicator of measuring health inequality. Previous studies mainly focused on specific vulnerable populations rather than a wider range of vulnerable areas through panel data. Rural China is often associated with an underdeveloped economy and insufficient health resources. This study aims to update the information on the extent of and trends in the incidence and inequality of CHE among the households of rural China through longitudinal survey data.

METHODS

Data were obtained from three waves of the China Health and Retirement Longitudinal Study (CHARLS): 2013, 2015, and 2018. In total, 2,575 households were included in the analysis. CHE was defined as household health expenditures exceeding 40% of non-food expenditures. Inequality in CHE was measured using the concentration curve and concentration index. The contribution to CHE inequality was decomposed using the concentration index decomposition method.

RESULTS

The incidence of CHE was 0.2341 (95% CI: 0.22, 0.25) in 2013, 0.2136 (95% CI: 0.20, 0.23) in 2015, and 0.2897 (95% CI: 0.27, 0.31) in 2018 in rural China. The concentration curve lay above the equality line, and the concentration index was negative: -0.1528 (95% CI: -0.1941, -0.1115) in 2013, -0.1010 (95% CI: -0.1442, -0. 0577) in 2015, and -0.0819 (95% CI: -0.1170, -0.0467) in 2018. Economic status, age, and chronic diseases were the main contributors to inequality in CHE.

CONCLUSIONS

The incidence of CHE in rural China displayed an upward trend from 2013 to 2018, although it was not continuous. Furthermore, a strong pro-low-economic inequality in CHE existed in rural China. Mainly economic status, age, and chronic diseases contributed to this pro-low-economic inequality. Health policies to allocate resources and services are needed to satisfy the needs of rural households and provide more accessible and affordable health services. More concern needs to be directed toward households with chronic diseases and older persons to reduce the incidence of CHE and promote health equality.

The Economic Cost of Rising Non-communicable Diseases in India: A Systematic Literature Review of Methods and Estimates

BACKGROUND AND OBJECTIVES

India has one of the world's highest proportions of out-of-pocket expenditure (OOPE) payments. The low share of public health expenditure coupled with the double burden of disease (communicable and non-communicable) has a direct financial impact on individual OOPE and an indirect impact in the form of decreasing life expectancy, reduced productivity, and hence a negative impact on economic growth. This systematic review aims to compare and assess the estimated economic cost of non-communicable diseases (NCDs) in India and ascertain the methods used to derive these estimates.

METHODS

This paper reviews the past 12-year (2010-22) literature on the economic impact of health shocks due to NCDs. Three databases were searched for the literature: PubMed, Scopus, and Google Scholar. Thematic analysis has been performed to analyse the findings of the study.

RESULTS

The OOPE was very high for NCDs. The increasing cost was high and unaffordable, pushing many people into financial distress measured by catastrophic payments and rising impoverishment.

CONCLUSION

The results indicate both the direct and indirect impact of NCDs, but the indirect burden of loss of employment and productivity, despite its relevance, has been less studied in the literature. A robust economic analysis will allow an evidence-based policy decision perspective to reduce the rising burden of NCDs.

Identification of some bioactive compounds from Trignonella foenumgraecum as possible inhibitors of PPARϒ for diabetes treatment through molecular docking studies, pharmacophore modelling and ADMET profiling: An in-silico study

Oral antidiabetic agents including the peroxisome proliferator-activated receptor gamma (PPARγ) agonists are available for the clinical management of diabetes mellitus (DM) but most are characterized by many adverse effects. In this study, we explore the antidiabetic properties of phytoconstituents from Trigonellafeonumgraecum (Fabaceae) as potential agonist of PPARγ; using in silico molecular docking, molecular mechanics generalized surface area (MM/GBSA)free binding energy prediction, Pharmacophore modeling experiment, and Pharmacokinetic/ toxicity analysis. One hundred and forty (140) compounds derived from Trigonellafeonumgraecum were screened by molecular docking against protein target PDB 3VI8. Results obtained from binding affinity (BA) and that of binding free energy (BFE) revealed five 5 compounds; arachidonic acid (CID_10467, BA -10.029, BFE -58.9), isoquercetin (CID_5280804, BA -9.507kcal/mol, BFE -56.33), rutin (CID_5280805, BA -9.463kcal/mol, BFE -56.33), quercetin (CID_10121947, BA -11.945kcal/mol, BFE -45.89) and (2S)-2-[[4-methoxy-3-[(pyrene-1-carbonylamino)methyl]phenyl]methyl]butanoic acid (CID_25112371, BA -10.679kcal/mol, BFE -45.73); and were superior to the standard; Rosiglitazone with a docking score of -7.672. Hydrogen bonding was notable in the protein-ligand complex interaction, with hydrophobic bond, polar bond and pipi stacking also observed. Their Pharmacokinetic/ toxicity profile showed varying druggable characteristics, but; arachidonic acid had the most favorable characteristics. These compounds are potential agonists of PPARγ and are considered as antidiabetic agents after successful experimental validation.

Individual-Level Health Care Costs Attributable to Noncommunicable Diseases: A Longitudinal Study Based on the Older Adults in China

Noncommunicable chronic diseases among the elderly population represent a significant economic burden in China. However, previous disease-related health cost studies lacked representation of older adults and comparability of the burden of multiple chronic diseases. The objective of this study was to determine the fraction of health care costs attributable to the 6 most prevalent chronic diseases and comorbidities in the sample of older adults. This study employed data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), with 3 waves in 2011, 2014, and 2018, and included 18 349 observations in total. Outpatient costs, inpatient costs, and total health care costs were included in this study. Based on a 2-part random effects model, the effect of chronic disease on health service utilization was first explored by constructing a dummy variable for whether or not to utilize health care, followed by estimation of attributable costs in the population with health care utilization. Among the older adults in the sample, hypertension, heart disease, cataracts, arthritis, stroke or Cerebrovascular disease (CVD) and chronic lung disease are the 6 most prevalent chronic conditions. The costs attributable to the 6 chronic diseases mentioned above were 36.00% of outpatient costs, 55.92% of inpatient costs, and 45.05% of total health care costs for older adults. Of these, heart disease, stroke or CVD, and chronic lung disease accounted for 22.11%, 13.24%, and 10.56% of total health care costs, respectively. Moreover, the proportion of health care costs attributable to chronic diseases was higher for older adults who were male, lived in urban areas, and had a lower level of education. The proportion of health care costs attributable to chronic diseases is substantial among older adults in China. Health care costs associated with chronic diseases can be decreased with well-targeted interventions and comprehensive access to health services.

Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature

Background

Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP.

Results

The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP.

Conclusion

The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00886-3.

Socio-Economic and Rural-Urban Differences in Healthcare and Catastrophic Health Expenditure Among Cancer Patients in China: Analysis of the China Health and Retirement Longitudinal Study

Objective: In China, cancer accounts for one-fifth of all deaths, and exerts a heavy toll on patients, families, healthcare systems, and society as a whole. This study aims to examine the temporal trends in socio-economic and rural-urban differences in treatment, healthcare service utilization and catastrophic health expenditure (CHE) among adult cancer patients in China. We also investigate the relationship between different types of treatment and healthcare service utilization, as well as the incidence of CHE.

Materials and Methods: We analyzed data from the 2011 and 2015 China Health and Retirement Longitudinal Study, a nationally representative survey including 17,224 participants (234 individuals with cancer) in 2011 and 19,569 participants (368 individuals with cancer) in 2015. The study includes six different types of cancer treatments: Chinese traditional medication (TCM); western modern medication (excluding TCM and chemotherapy medications); a combination of TCM & western medication; surgery; chemotherapy; and radiation therapy. Multivariable regression models were performed to investigate the association between cancer treatments and healthcare service utilization and CHE.

Results: The age-adjusted prevalence of cancer increased from 1.37% to 1.84% between 2011 and 2015. More urban patients (54%) received cancer treatment than rural patients (46%) in 2015. Patients with high socio-economic status (SES) received a higher proportion of surgical and chemotherapy treatments compared to patients with low SES in 2015. Incidence of CHE declined by 22% in urban areas but increased by 31% in rural areas. We found a positive relationship between cancer treatment and outpatient visits (OR = 2.098, 95% CI = 1.453, 3.029), hospital admission (OR = 1.961, 95% CI = 1.346, 2.857) and CHE (OR = 1.796, 95% CI = 1.231, 2.620). Chemotherapy and surgery were each associated with a 2-fold increased risk of CHE.

Conclusions: Significant improvements in health insurance benefit packages are necessary to ensure universal, affordable and patient-centered health coverage for cancer patients in China.

Catastrophic Health Expenditure on Private Sector Pharmaceuticals: A Cross-Sectional Analysis from the State of Odisha, India

India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha—a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities—yet with the second-highest rates of CHE across India (24%). We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket, and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. We find that 36.3% (95% uncertainty interval: 32.7–40.1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0.2% (0.1–0.4) of CHE overall. Eighty-six percent of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. The private sector for pharmaceuticals fulfills an essential health system function in Odisha—supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs.

Using artificial intelligence reading label system in diabetic retinopathy grading training of junior ophthalmology residents and medical students

PURPOSE

Evaluate the efficiency of using an artificial intelligence reading label system in the diabetic retinopathy grading training of junior ophthalmology resident doctors and medical students.

METHODS

Loading 520 diabetic retinopathy patients' colour fundus images into the artificial intelligence reading label system. Thirteen participants, including six junior ophthalmology residents and seven medical students, read the images randomly for eight rounds. They evaluated the grading of images and labeled the typical lesions. The sensitivity, specificity, and kappa scores were determined by comparison with the participants' results and diagnosis gold standards.

RESULTS

Through eight rounds of reading, the average kappa score was elevated from 0.67 to 0.81. The average kappa score for rounds 1 to 4 was 0.77, and the average kappa score for rounds 5 to 8 was 0.81. The participants were divided into two groups. The participants in Group 1 were junior ophthalmology resident doctors, and the participants in Group 2 were medical students. The average kappa score of Group 1 was elevated from 0.71 to 0.76. The average kappa score of Group 2 was elevated from 0.63 to 0.84.

CONCLUSION

The artificial intelligence reading label system is a valuable tool for training resident doctors and medical students in performing diabetic retinopathy grading.

Catastrophic health expenditure and mental health in the older Chinese population: The moderating role of social health insurance

OBJECTIVES

Catastrophic health expenditure (CHE) has considerable effects on household living standards, but little is known regarding the relationships between CHE and people's mental health. Using China as an example, this study examines the association between CHE and mental health and investigates whether the association differs between those with and without social health insurance (SHI).

METHODS

The data came from three waves of the China Health and Retirement Longitudinal Study (CHARLS 2011, 2013, and 2015, N = 13,166). We focused on older people aged 60 and above. We built panel data regression and quantile regression models to analyse the data.

RESULTS

Incurring CHE is significantly associated with poor mental health. The association is weakened among older people receiving SHI, which indicates that SHI has a protective effect. Moreover, the association between CHE and mental health and the protective effect of SHI are stronger among those with mild or moderate mental health problems.

DISCUSSION

Our findings provide empirical evidence that encourages the integration of psychologically informed approaches in health services. We also urge governments in low- and middle-income countries to consider more generous health financing mechanisms for older people with greater healthcare needs.

Financial protection effects of private health insurance: experimental evidence from Chinese households with resident basic medical insurance

BACKGROUND

After achieving universal basic medical insurance coverage, Chinese government put the development of private health insurance (PHI) on its agenda to further strengthen financial risk protection. This paper aims to assess the level of financial protection that PHI provides for its insured households on the basis of resident basic medical insurance (RBMI).

METHODS

We employed balanced panel data collected between 2015 and 2017 from the China Household Finance Survey (CHFS). Catastrophic health expenditure (CHE) and impoverishment due to health spending were applied to measure the financial protection effects. Random effects panel logistic regression model was performed to identify the factors associated with CHE and impoverishment among households covered by RBMI. In the robustness test, the method of propensity score matching (PSM) was employed to solve the problem of endogeneity.

RESULTS

From 2015 to 2017, the CHE incidence increased from 12.96 to 14.68 % for all sampled households, while the impoverishment rate decreased slightly from 5.43 to 5.32 % for all sampled households. In 2015, the CHE incidence and impoverishment rate under RBMI + PHI were 4.53 and 0.72 %, respectively, which were lower than those under RBMI alone. A similar phenomenon was observed in 2017. Regression analysis also showed that the households with RBMI + PHI were significantly less likely to experience CHE (marginal effect: -0.054, 95 %CI: -0.075 to -0.034) and impoverishment (marginal effect: -0.049, 95 %CI: -0.069 to -0.028) compared to those with RBMI alone. The results were still robust after using PSM method to eliminate the effects of self-selection on the estimation results.

CONCLUSIONS

In the context of universal basic medical insurance coverage, the CHE incidence and impoverishment rate of Chinese households with RBMI were still considerably high in 2015 and 2017. PHI played a positive role in decreasing household financial risk on the basis of RBMI.

Urban-rural differences in catastrophic health expenditure among households with chronic non-communicable disease patients: evidence from China family panel studies

Background

The prevalence of chronic non-communicable diseases (NCDs) challenges the Chinese health system reform. Little is known for the differences in catastrophic health expenditure (CHE) between urban and rural households with NCD patients. This study aims to measure the differences above and quantify the contribution of each variable in explaining the urban-rural differences.

Methods

Unbalanced panel data were obtained from the China Family Panel Studies (CFPS) conducted between 2012 and 2018. The techniques of Fairlie nonlinear decomposition and Blinder-Oaxaca decomposition were employed to measure the contribution of each independent variable to the urban-rural differences.

Results

The CHE incidence and intensity of households with NCD patients were significantly higher in rural areas than in urban areas.

The urban-rural differences in CHE incidence increased from 8.07% in 2012 to 8.18% in 2018, while the urban-rural differences in CHE intensity decreased from 2.15% in 2012 to 2.05% in 2018. From 2012 to 2018, the disparity explained by household income and self-assessed health status of household head increased to some extent. During the same period, the contribution of education attainment to the urban-rural differences in CHE incidence decreased, while the contribution of education attainment to the urban-rural differences in CHE intensity increased slightly.

Conclusions

Compared with urban households with NCD patients, rural households with NCD patients had higher risk of incurring CHE and heavier economic burden of diseases. There was no substantial change in urban-rural inequality in the incidence and intensity of CHE in 2018 compared to 2012. Policy interventions should give priority to improving the household income, education attainment and health awareness of rural patients with NCDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10887-6.

Digital technology, tele-medicine and artificial intelligence in ophthalmology: A global perspective

The simultaneous maturation of multiple digital and telecommunications technologies in 2020 has created an unprecedented opportunity for ophthalmology to adapt to new models of care using tele-health supported by digital innovations. These digital innovations include artificial intelligence (AI), 5th generation (5G) telecommunication networks and the Internet of Things (IoT), creating an inter-dependent ecosystem offering opportunities to develop new models of eye care addressing the challenges of COVID-19 and beyond. Ophthalmology has thrived in some of these areas partly due to its many image-based investigations. Tele-health and AI provide synchronous solutions to challenges facing ophthalmologists and healthcare providers worldwide. This article reviews how countries across the world have utilised these digital innovations to tackle diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration, glaucoma, refractive error correction, cataract and other anterior segment disorders. The review summarises the digital strategies that countries are developing and discusses technologies that may increasingly enter the clinical workflow and processes of ophthalmologists. Furthermore as countries around the world have initiated a series of escalating containment and mitigation measures during the COVID-19 pandemic, the delivery of eye care services globally has been significantly impacted. As ophthalmic services adapt and form a "new normal", the rapid adoption of some of telehealth and digital innovation during the pandemic is also discussed. Finally, challenges for validation and clinical implementation are considered, as well as recommendations on future directions.

Evaluation of a novel artificial intelligence-based screening system for diabetic retinopathy in community of China: a real-world study

PURPOSE

To evaluate the performance of an AI-based diabetic retinopathy (DR) grading model in real-world community clinical setting.

METHODS

Participants with diabetes on record in the chosen community were recruited by health care staffs in a primary clinic of Zhengzhou city, China. Retinal images were prospectively collected during December 2018 and April 2019 based on intent-to-screen principle. A pre-validated AI system based on deep learning algorithm was deployed to screen DR graded according to the International Clinical Diabetic Retinopathy scale. Kappa value of DR severity, the sensitivity, specificity of detecting referable DR (RDR) and any DR were generated based on the standard of the majority manual grading decision of a retina specialist panel.

RESULTS

Of the 193 eligible participants, 173 (89.6%) were readable with at least one eye image. Mean [SD] age was 69.3 (9.0) years old. Total of 321 eyes (83.2%) were graded both by AI and the specialist panel. The κ value in eye image grading was 0.715. The sensitivity, specificity and area under curve for detection of RDR were 84.6% (95% CI: 54.6- 98.1%), 98.0% (95% CI: 94.3-99.6%) and 0.913 (95% CI: 0.797-1.000), respectively. For detection of any DR, the upper indicators were 90.0% (95% CI: 68.3-98.8), 96.6% (95% CI: 92.1-98.9) and 0.933 (95% CI: 0.933-1.000), respectively.

CONCLUSION

The AI system showed relatively good consistency with ophthalmologist diagnosis in DR grading, high specificity and acceptable sensitivity for identifying RDR and any DR.

TRANSLATIONAL RELEVANCE

It is feasible to apply AI-based DR screening in community.

PRECIS

Deployed in community real-world clinic setting, AI-based DR screening system showed high specificity and acceptable sensitivity in identifying RDR and any DR. Good DR diagnostic consistency was found between AI and manual grading. These prospective evidences were essential for regulatory approval.

Socioeconomic Burden of Type 2 Diabetes with Complications on Families: A Hospital-Based Study in Puducherry

Introduction India is on the verge of diabetes mellitus (DM) epidemic. Within the near future, DM will put a big burden on India’s already vulnerable and resourced health care system. The objectives of the study were to (1) estimate DM treatment-related out-of-pocket expenditure (OOPE) among type 2 DM patients with complications from a tertiary care hospital and (2) estimate the economic burden on the household income of these patients due to DM treatment-related OOPE.

 

Methods A hospital-based cross-sectional study was conducted among known type 2 diabetic individuals with complications admitted in a tertiary care hospital. Using a structured pretested questionnaire required data, such as sociodemographic details, direct costs, and indirect costs in health care of DM, which were collected by a personal interview method.

Results Males constituted around 57% of the 100 patients who participated in the study. The average age of the population was 56 ± 10.03 years. The mean monthly income of family (in Indian Rupees [INR]) was 10,375.00 ± 9,201.55. Total expenditure includes the cost of medication, investigation, consultation fee, transportation, and miscellaneous expenditure. The average monthly OOPE in the management of DM for government and private facilities was INR 74 and 1,540, respectively. Among the total cost, the highest share was accrued toward medicines followed by diagnostics, miscellaneous, and transportation. There were 22% of families incurring catastrophic expenditure at the highest threshold of 40%. Socioeconomic status, history of at least one hospitalization in the past 6 months, and type of medications were factors found to be associated with costs.

Conclusion Heavy economic burden highlights the urgent need for the health care agencies and policy bodies to plan and prioritize local health policies and DM management schemes accordingly.

Exendin-4 regulates endoplasmic reticulum stress to protect endothelial progenitor cells from high-glucose damage

BACKGROUND

High glucose affects the function of endothelial cells by increasing oxidative stress. Studies have found that exendin-4 can improve wound healing in diabetic mice and mice with normal blood glucose. However, the mechanism of exendin-4 in endothelial progenitor cells under high-glucose condition has not been fully elucidated.

METHODS

Diabetic mouse models were established to investigate the effects of exendin-4 on endothelial progenitor cells in diabetic mice. Serum superoxide dismutase (SOD) and malondialdehyde (MDA) were determined by WST-8 and thiobarbituric acid (TBA) colorimetry, respectively. Cell viability, apoptosis and reactive oxygen species (ROS) were detected by 3-(4, 5-Dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) and flow cytometry. Gene and protein expressions were determined by Quantitative reverse transcription PCR (qRT-PCR) assay and Western blot (WB).

RESULTS

The results showed that in diabetic mice, exendin-4 did not affect blood glucose or body weight, moreover, it improved aortic diastolic function, increased SOD activity and down-regulated malondialdehyde (MDA) level in the mice. In addition, exendin-4 also increased endothelial progenitor cell (EPCs) viability and reduced cell apoptosis through inhibiting p38 MAPK pathway and reducing endoplasmic reticulum stress and ROS.

CONCLUSION

Exndin-4 can alleviate diabetes-caused damage to mice, moreover, it reduced endoplasmic reticulum stress and ROS through inhibiting p38 MAPK pathway in MPCs cells under high-glucose condition, thus increasing cell viability and reducing cell apoptosis.

Evaluating access to oral anti-diabetic medicines: A cross-sectional survey of prices, availability and affordability in Shaanxi Province, Western China

OBJECTIVES

To assess the availability and affordability of oral anti-diabetic medicines in Shaanxi Province, Western China.

METHODS

In 2015, the prices and availability of 8 anti-diabetic medicines covering 31 different dosage forms and strengths were collected in six cities of Shaanxi Province. A total of 72 public hospitals and 72 private pharmacies were sampled, using a modified methodology developed by the World Health Organization (WHO) and Health Action International (HAI). Medicine prices were compared with international reference prices to obtain a median price ratio. For urban residents, affordability was assessed as the lowest-paid unskilled government workers to purchase cost of standard treatment in days' wages; for rural residents, days' net income was used.

RESULTS

The mean availabilities of originator brands (OBs) and generics were 34.3% and 28.7% in public hospitals, and 44.1% and 64.4% in the private pharmacies. OBs and the lowest priced generics (LPGs) were procured at 12.38 and 4.52 times the international reference price in public hospitals, and 10.26 and 2.81 times the international reference prices in private pharmacies. Treatments with OBs were unaffordable even for urban residents. The affordability of the LPGs was good, except for acarbose, repaglinide and pioglitazone.

CONCLUSIONS

Most anti-diabetic medicines cannot met the WHO's availability target (80% availability) in Shaanxi Province. The high prices of OBs had severely influenced the affordability of medicines, especially for the rural residents. Effective policies should be initiated to ensure the Chinese people a better access to more affordable anti-diabetic medicines.

Catastrophic health expenditure and impoverishment for type 2 diabetes mellitus patients in a multiethnic province in China using a Blinder-Oaxaca decomposition: A cross-sectional study

This study aimed to compare the catastrophic health expenditure (CHE) and impoverishment of type 2 diabetes mellitus (T2DM) patients between 2 ethnic groups and explore the contribution of associated factors to ethnic differences in CHE and impoverishment in Ningxia Hui Autonomous Region, China.A cross-sectional study was conducted in 2 public hospitals from October 2016 to June 2017. Data were collected by interviewing eligible Hui and Han T2DM inpatients and reviewing the hospital electronic records. Both CHE and impoverishment were measured by headcount and gap. The contributions of associated factors to ethnic differences were analyzed by the Blinder-Oaxaca decomposition technique.Both the CHE and impoverishment of Hui patients before and after reimbursement were significantly higher than those of Han patients. The ethnic differences in CHE and impoverishment headcount after reimbursement were 11.9% and 9.8%, respectively. The different distributions of associated factors between Hui and Han patients contributed to 60.5% and 35.7% of ethnic differences in CHE and impoverishment, respectively. Household income, occupation, and region were significant contributing factors.Hui T2DM patients suffered greater CHE and impoverishment than Han patients regardless of reimbursements from health insurance. Differences in socioeconomic status between Hui and Han patients were the main factors behind the ethnic differences.

Socioeconomic determinants of out-of-pocket pharmaceutical expenditure among middle-aged and elderly adults based on the China Health and Retirement Longitudinal Survey

OBJECTIVE

Out-of-pocket pharmaceutical expenditure (OOPPE) is a considerable burden for middle-aged and elderly adults due to their high prevalence of diseases, insufficient income and absence of medical insurance in China. The objective of this study was to assess the determinants of OOPPE among Chinese middle-aged and elderly adults.

METHODS

This is a cross-sectional study based on the China Health and Retirement Longitudinal Survey conducted in 2015. The Andersen behavioural health model was used to select the factors. Binary multivariable logistic and generalised linear regressions were both applied to examine the determinants of OOPPE.

RESULTS

Of the respondents, 15.28%, 5.20% and 51.35% reported an OOPPE for outpatient services, inpatient services and self-medication, respectively. The OOPPE for outpatient services, inpatient services and self-medication was US$6.66, US$17.93 and US$15.32, respectively. Increased age significantly influenced the likelihood of OOPPE, and older people (aged >65 years) had lower OOPPE for outpatient services. Having health insurance significantly reduced the likelihood of OOPPE for outpatient and inpatient services but increased OOPPE for self-medication. In general, compared with the low-income group, higher income groups had a significantly lower likelihood of having an OOPPE, and when they did the amounts were less. Generally, middle-aged and elderly people with poor self-reported health status, limitation of daily activities, and critical or chronic diseases had a significantly higher likelihood of having an OOPPE and at a significantly higher amount.

CONCLUSION

Policy-making efforts should focus on reducing self-medication OOPPE and alleviating its associated socioeconomic determinants to ease the economic burden of diseases among middle-aged and elderly adults in China.

Incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment for diabetes care in South Africa: a study at two public hospitals in Tshwane

BACKGROUND

Direct out of pocket (OOP) payments for healthcare may cause financial hardship. For diabetic patients who require frequent visits to health centres, this is of concern as OOP payments may limit access to healthcare. This study assesses the incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment amongst diabetic patients in South Africa.

METHODS

Data were taken from a cross-sectional survey conducted in 2017 at two public hospitals in Tshwane, South Africa (N = 396). Healthcare costs and transport costs related to diabetes care were classified as catastrophic if they exceeded the 10% threshold of household's capacity to pay (WHO standard method) or if they exceeded a variable threshold of total household expenditure (Ataguba method). Erreygers concentration indices (CIs) were used to assess socio-economic inequalities. A multivariate logistic regression was applied to identify the determinants of catastrophic health expenditure and impoverishment.

RESULTS

Transport costs contributed to over 50% of total healthcare costs. The incidence of catastrophic health expenditure was 25% when measured at a 10% threshold of capacity to pay and 13% when measured at a variable threshold of total household expenditure. Depending on the method used, the incidence of impoverishment varied from 2 to 4% and the concentration index for catastrophic health expenditure varied from - 0.2299 to - 0.1026. When measured at a 10% threshold of capacity to pay factors associated with catastrophic health expenditure were being female (Odds Ratio 1.73; Standard Error 0.51), being within the 3rd (0.49; 0.20), 4th (0.31; 0.15) and 5th wealth quintile (0.30; 0.17). When measured using a variable threshold of total household expenditure factors associated with catastrophic health expenditure were not having children (3.35; 1.82) and the 4th wealth quintile (0.32; 0.21).

CONCLUSION

Financial protection of diabetic patients in public hospitals is limited. This observation suggests that health financing interventions amongst diabetic patients should target the poor and poor women in particular. There is also a need for targeted interventions to improve access to healthcare facilities for diabetic patients and to reduce the financial impact of transport costs when seeking healthcare. This is particularly important for the achievement of universal health coverage in South Africa.

Burden of diabetic retinopathy in mainland China: Protocol for an updated systematic review and meta-analysis of prevalence and risk factors to identify prevention policies

BACKGROUND

Diabetic retinopathy (DR) is the leading cause of vision loss in adults of working age. Although existing systematic reviews of the prevalence of DR for mainland China have been reported, but several studies have been newly reported. Further some potential factors for DR are still discrepant and inconclusive. The aim of current research is to identify relevant literature regarding the prevalence of DR and DR-related factors in mainland China. In addition, we will project the number of individuals affected with DR in mainland China in years 2030 and 2050.

METHODS

This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. To identify publications in English or Chinese languages on the prevalence of DR in mainland China, a comprehensive step-by-step search of the PubMed, Embase, Web of Science, VIP Chinese Periodical, and China National Knowledge Infrastructure (CNKI) databases will be performed. Two reviewers will independently review the studies for eligibility according to the predefined inclusion and exclusion criteria. The quality of the included studies will be evaluated according to the National Health Institute Quality Assessment tool and Quality Assessment Manual. A random-effect model (DerSimonian-Laird method) will be used for the meta-analysis. Heterogeneity and publication bias among studies will be estimated by the I statistic and Begg funnel plot, respectively.

RESULTS

This systematic review study will provide an evidence of prevalence, risk factors, and national burden for DR in mainland China.

CONCLUSION

The study will give an explicit evidence to provide preventative measures of DR.PROSPERO registration number: CRD42018094565.

Socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over in China, Ghana, and India

BACKGROUND

The 2015 Global Burden of Disease Study estimated that oral conditions affect 3.5 billion people worldwide with a higher burden among older adults and those who are socially and economically disadvantaged. Studies of inequalities in the use of oral health services by those in need have been conducted in high-income countries but evidence from low- and middle-income countries (LMICs) is limited. This study measures and describes socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over, in China, Ghana and India.

METHODS

A cross-sectional analysis of national survey data from the WHO SAGE Wave 1 (2007-2010) was conducted. Study samples in China (n = 1591), Ghana (n = 425) and India (n = 1307) were conditioned on self-reported need for oral health services in the previous 12 months. The binary dependent variable, unmet need for oral health services, was derived from questions about self-reported need and service use. Prevalence was estimated by country. Unmet need was measured and compared in terms of relative levels of education and household wealth. The methods were logistic regression and the relative index of inequality (RII). Models were adjusted for age, sex, area of residence, marital status, work status and self-rated health.

RESULTS

The prevalence of unmet need was 60, 80, and 62% in China, Ghana and India respectively. The adjusted RII for education was statistically significant for China (1.5, 95% CI:1.2-1.9), Ghana (1.4, 95% CI: 1.1-1.7), and India (1.5, 95% CI:1.2-2.0), whereas the adjusted RII for wealth was significant only in Ghana (1.3, 95% CI:1.1-1.6). Male sex was significantly associated with self-reported unmet need for oral health services in India.

CONCLUSIONS

Given rapid population ageing, further evidence of socioeconomic inequalities in unmet need for oral health services by older adults in LMICs is needed to inform policies to mitigate inequalities in the availability of oral health services. Oral health is a universal public health issue requiring attention and action on multiple levels and across the public private divide.

Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda

Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.

Action to address the household economic burden of non-communicable diseases

The economic burden on households of non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, poses major challenges to global poverty alleviation efforts. For patients with NCDs, being uninsured is associated with 2-7-fold higher odds of catastrophic levels of out-of-pocket costs; however, the protection offered by health insurance is often incomplete. To enable coverage of the predictable and long-term costs of treatment, national programmes to extend financial protection should be based on schemes that entail compulsory enrolment or be financed through taxation. Priority should be given to eliminating financial barriers to the uptake of and adherence to interventions that are cost-effective and are designed to help the poor. In concert with programmes to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's Sustainable Development Goals.

Improvement of the reduction in catastrophic health expenditure in China's public health insurance

This study aimed to locate the contributing factors of Catastrophic Health Expenditure (CHE), evaluate their impacts, and try to propose strategies for reducing the possibilities of CHE in the context of China’s current public health insurance system. The financial data of all hospitalization cases from a sample hospital in 2013 were gathered and used to determine the pattern of household medical costs. A simulation model was constructed based on China’s current public health insurance system to evaluate the financial burden for medical service on Chinese patients, as well as to calculate the possibilities of CHE. Then, by adjusting several parameters, suggestions were made for China’s health insurance system in order to reduce CHE. It’s found with China’s current public health insurance system, the financial aid that a patient may receive depends on whether he is from an urban or rural area and whether he is employed. Due to the different insurance policies and the wide income gap between urban and rural areas, rural residents are much more financially vulnerable during health crisis. The possibility of CHE can be more than 50% for low-income rural families. The CHE ratio can be dramatically lowered by applying different policies for different household income groups. It’s concluded the financial burden for medical services of Chinese patients is quite large currently, especially for those from rural areas. By referencing different healthcare policies in the world, applying different health insurance policies for different income groups can dramatically reduce the possibility of CHE in China.

Diabetes and Hypertension in India: A Nationally Representative Study of 1.3 Million Adults

IMPORTANCE

Understanding how diabetes and hypertension prevalence varies within a country as large as India is essential for targeting of prevention, screening, and treatment services. However, to our knowledge there has been no prior nationally representative study of these conditions to guide the design of effective policies.

OBJECTIVE

To determine the prevalence of diabetes and hypertension in India, and its variation by state, rural vs urban location, and individual-level sociodemographic characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional, nationally representative, population-based study carried out between 2012 and 2014. A total of 1 320 555 adults 18 years or older with plasma glucose (PG) and blood pressure (BP) measurements were included in the analysis.

EXPOSURES

State, rural vs urban location, age, sex, household wealth quintile, education, and marital status.

MAIN OUTCOMES AND MEASURES

Diabetes (PG level ≥126 mg/dL if the participant had fasted or ≥200 mg/dL if the participant had not fasted) and hypertension (systolic BP≥140 mm Hg or diastolic BP≥90 mm Hg).

RESULTS

Of the 1 320 555 adults, 701 408 (53.1%) were women. The crude prevalence of diabetes and hypertension was 7.5% (95% CI, 7.3%-7.7%) and 25.3% (95% CI, 25.0%-25.6%), respectively. Notably, hypertension was common even among younger age groups (eg, 18-25 years: 12.1%; 95% CI, 11.8%-12.5%). Being in the richest household wealth quintile compared with being in the poorest quintile was associated with only a modestly higher probability of diabetes (rural: 2.81 percentage points; 95% CI, 2.53-3.08 and urban: 3.47 percentage points; 95% CI, 3.03-3.91) and hypertension (rural: 4.15 percentage points; 95% CI, 3.68-4.61 and urban: 3.01 percentage points; 95% CI, 2.38-3.65). The differences in the probability of both conditions by educational category were generally small (≤2 percentage points). Among states, the crude prevalence of diabetes and hypertension varied from 3.2% (95% CI, 2.7%-3.7%) to 19.9% (95% CI, 17.6%-22.3%), and 18.0% (95% CI, 16.6%-19.5%) to 41.6% (95% CI, 37.8%-45.5%), respectively.

CONCLUSIONS AND RELEVANCE

Diabetes and hypertension prevalence is high in middle and old age across all geographical areas and sociodemographic groups in India, and hypertension prevalence among young adults is higher than previously thought. Evidence on the variations in prevalence by state, age group, and rural vs urban location is critical to effectively target diabetes and hypertension prevention, screening, and treatment programs to those most in need.

Sociodemographic and behavioral characteristics associated with self-reported diagnosed diabetes mellitus in adults aged 50+ years in Ghana and South Africa: results from the WHO-SAGE wave 1

OBJECTIVE

The objective is to identify and describe the sociodemographic and behavioral characteristics of adults, aged 50 years and over, who self-reported having been diagnosed and treated for diabetes mellitus (DM) in Ghana and South Africa.

RESEARCH DESIGN AND METHODS

This is a cross-sectional study based on the WHO Study on global AGEing and adult health (SAGE) wave 1. Information on sociodemographic factors, health states, risk factors and chronic conditions is captured from questionnaires administered in face-to-face interviews. Self-reported diagnosed and treated DM is confirmed through a 'yes' response to questions regarding1 having previously been diagnosed with DM, and2 having taken insulin or other blood sugar lowering medicines. Crude and adjusted logistic regressions test associations between candidate variables and DM status. Analyses include survey sampling weights. The variance inflation factor statistic tested for multicollinearity.

RESULTS

In this nationally representative sample of adults aged 50 years and over in Ghana, after adjusting for the effects of sex, residence, work status, body mass index, waist-hip and waist-height ratios, smoking, alcohol, fruit and vegetable intake and household wealth, WHO-SAGE survey respondents who were older, married, had higher education, very high-risk waist circumference measurements and did not undertake high physical activity, were significantly more likely to report diagnosed and treated DM. In South Africa, respondents who were older, lived in urban areas and had high-risk waist circumference measurements were significantly more likely to report diagnosed and treated DM.

CONCLUSIONS

Countries in sub-Saharan Africa are challenged by unprecedented ageing populations and transition from communicable to non-communicable diseases such as DM. Information on those who are already diagnosed and treated needs to be combined with estimates of those who are prediabetic or, as yet, undiagnosed. Multisectoral approaches that include socioculturally appropriate strategies are needed to address diverse populations in SSA countries.

Nature Cure and Non-Communicable Diseases: Ecological Therapy as Health Care in India

With rapidly increasing rates of non-communicable diseases, India is experiencing a dramatic public health crisis that is closely linked to changing lifestyles and the growth of the middle-class. In this essay we discuss how the practice of Nature Cure provides a way of understanding the scale and scope of the crisis, as it is embodied, and a way to understand key elements of a solution to problems that the crisis presents for institutionalized health care. As institutionalized in contemporary India, Nature Cure involves treatment and managed care using earth, air, sunlight, and water as well as a strict dietary regimen. In this regard, the essay shows how Nature Cure's bio-ecological orientation toward public health, which is grounded in the history of its modern incorporation into India, provides an expansionist, ecological model for holistic care that counters the reductionist logic of bio-medical pharmaceuticalization.