Diabetes Mellitus in the Pacific: Public Health Issues

Dr. Kimberly Oman Fiji School of Medicine Diploma in Medicine Revised September 2002

Notes on 2002 version

Prices are mostly from 1996, with some updates as noted Since then, captopril (expensive) has been replaced with enalapril (cheaper) At the time of the exercise, I based my calculations on the pharmacy cost of pravastatin which had been studied in randomized controlled trials, but was over $100/month. Since then, many doctors prescribe Indian lovastatin at private pharmacies (approx $8/month) The principles remain the same even though the numbers have changed, and will continue to change.

Epidemiology of Type I Diabetes

Country Finland USA UK France Prevalence per 1000 2.2 1.0 0.7 0.24

India China
Japan Tropical Africa

0.06 0.7 0.09

0.03 0.03

Age-adjusted prevalence (%) of Type II Diabetes age 30-64 (downloaded WHO 1998)
Country of origin Group USA white %men 5 %women 7.2

India

Fiji - Indofijian Fiji - Indigenous

S India rural S India urban Durban SA Dar es Salam Tanzania Hindu Dar es Salam Tanzania Muslim Rural (Sigatoka) Urban (Suva) Rural (Sigatoka Urban (Suva)

3.7 11.8 14.4 17.8 18.0

23.0

1.7 11.2 20.8 13.2 16.6

16.0

23.6 2.1 5.2

20.3 1.7 11.9

Country of origin Papua New Guinea

Group Highlanders rural Highlands periurban Costal rural Costal periurban

%men 0 0 2.7 8.2 0-2.5

%women 0 0 0 4.8 2.3-3.3

New Caledonia

Kiribati Nauru
Tuvalu

Rural
Urban Funafuti

4.0
15.8

4.6
13.4

40.6
1.3

42.0
6.3

Western Samoa
Niue Cook Islands

Rural
Urban

2.1
10.7 7.9 7.0

4.9
10.4 10.4 10.1

Complications of Diabetes Mellitus

Hypoglycemia Diabetic ketoacidosis / hyperosmolar coma Retinopathy Nephropathy Neuropathy Amputations Macrovascular disease (strokes, ischemic heart disease)
peripheral neuropathy autonomic neuropathy

Diabetes Mellitus: Burden of disease to the individual

Being diagnosed as sick despite feeling well Doctor visits Need to take medications Complications

Premature death

Blindness Amputations Heart attacks and stroke General unwellness

Diabetes Mellitus: Burden of disease to the family

Premature disability (especially strokes, amputations, blindness)

Loss of income Loss of productivity: childcare, domestic duties Need for family to care for unwell individual (loss of employment opportunities) Transporting patient for clinic visits

Premature death
Loss / grief

Diabetes: Burden to the Nation (1)

Need for clinic visits for glycemic control Patient education

Insulin

Oral hypoglycemic agents Related conditions (CAD, HTN, hyperlipidemia)

Doctors, nurses, health centres, lab support Dieticians, health educators, TIME Refrigerators, syringes, Education!! Reliable drug distribution infrastructure Expensive drugs, hospitals, Coronary care units

Diabetes: Burden to the Nation (2)

Nephropathy Retinopathy Amputations Early infirmity Premature death

Dialysis ($$$$$) Opthamologists, laser machines Surgeons, hospitals, antibiotics, prostheses Loss of taxable income, need for home carers, pensions

Natural history vs. clinical course of disease for Type I Diabetes (1)
Time Week one NATURAL HISTORY STARTS HERE Disease manifestations Polydipsia, polyphagia, polyuria DKA: DIAGNOSIS MADE Insulin started CLINICAL COURSE STARTS HERE Hypoglycemia (occasional) Hyperglycemia / DKA (with intercurrent illness

Rest of patients life

Natural history vs. clinical course of disease for Type I Diabetes (2) Natural history = clinical course of dz
Time After decades Disease manifestations Retinopathy, Nephropathy, Peripheral Neuropathy, Cardiovascular Disease Blindness, renal failure, amputations, heart attacks, strokes DEATH

Then

Natural history vs. clinical course of disease for Type II Diabetes (1)
Age Manifestations

Age 25 (does natural Undiagnosed gestational diabetes history start even earlier?) Several large infants by c-section Age 30 Age 35 Undiagnosed glucose intolerance Takes up a sedentary job Coworkers bring in sweets every day Becomes obese Overt diabetes (by fasting blood glucose) but no one checked

Age 40

clinical course of disease for Type II Diabetes (2)

Natural history vs.

Manifestations

Age Age 55

Age 55-59

Hospitalized for MI Raised random blood glucose discovered Elevated serum creatinine No one checked fundi DIAGNOSIS MADE CLINICAL COURSE STARTS HERE Starts diet therapy Fails to lose weight Started on oral hypoglycemic agents Poor compliance

Natural history vs. clinical course of disease for Type II Diabetes (3) Natural history much longer than clinical course Age Manifestations

Age 60

Congestive heart failure Foot ulcer leads to amputation Complains of poor vision Advanced retinopathy noted
DIES of 3rd myocardial infarction

Age 62

Reducing the burden of disease due to diabetes mellitus

Primary prevention

Secondary prevention

Prevent diabetes from developing

Early diagnosis Control of blood sugar - does this reduce complications?

YES! - first demonstrated in 1998 for Type 2 Tertiary prevention

Recognizing complications at early treatable stage

Diabetes in the United States

Plenty of doctors and dieticians Plenty of specialists Diabetes educators Many educated and highly motivated patients Self-help groups for patients Home glucose monitoring is widespread Many patients not educated about their diabetes Cultural, language and financial barriers Many doctors who communicate poorly Many poorly-controlled diabetics

BUT

Diabetes in Ethiopia

Very impoverished nation 85% live in isolated rural areas Few drugs, poor access to health clinics Terrible or nonexistent roads Limited diagnostic capability Many other serious health problems 75% of diagnosed rural diabetics are Type One: WHY?

Type one diabetes in Ethiopia

Most must travel 20km to get insulin supplies (poor or non-existent roads) 1/4 must travel over 100 km (3-5 day journey) Often short supplies - only given 1-2 months insulin Use minimal insulin to survive (to conserve supplies) leading to severe wasting Few long-term survivors

Type 2 diabetics: why bother?

Diabetes in the Pacific

Many diabetics Limited public awareness of diabetes Fewer resources Understaffed, very busy clinics Not enough doctors, dieticians and nurses Problems with distribution of medications and supplies Problems with remoteness and transportation

Basic exercise in economics: A trip to Cost-u-Less

How much does a television cost? a small radio? Which will you buy:
If the bill comes to you? If the bill comes to daddy?

If Daddy has 10 children and they buy expensive things every week, what will happen when Daddy goes broke?
No schooling House and car repossessed by the bank No food ETC ETC

Health economic issues in Diabetes Mellitus

Should you spend 10x as much for a medication

If there is significant benefit? If there is marginal / equivocal benefit? If it is only available in the major centers?

What are the relative costs of health care worker time compared with medications? If you spend health resources on world-class care for your own patients, will less be available for patients in remote settings? Is it ethical to spend more health resources on some patients than others? (ie. the articulate, the educated, the prominent, etc.)

Approaches to lowering the burden of disease due to diabetes

International Regional (Pacific Islands) National Provincial District Local

Hospital Health Centre Community

Important principle: Your mother does not work here!

Common statements: There ought to be a program There ought to be a policy The government ought to They should

Look to ourselves - there is much we can do THE BEST IS THE ENEMY OF THE GOOD!!!

Medication costs (Fijian $) 1996

Glibenclamide 5 mg Glipizide 5 mg Tolbutamide 500 mg Metformin 850 mg Isophane insulin 10 U Syringes (one) - 1 ml HCTZ 50 mg Atenolol 50 mg Propranolol 40 mg Captopril 12.5 mg Pravastatin 10 mg (BNF-97) Home glucose monitor Test strips (50)

$0.006 $0.07 $0.01 $0.04 $0.12 $0.10 $0.005 $0.04 $0.01 $0.07 $1.73 $43.00 $35.00

National level decision making (1)

Should all diabetic patients be monitored with HbA1C 4 times a year? Cost (1999)

Moral issue

$10 per test (excluding transport costs) 30,000 diabetics in Fiji $10/test x 4 tests per year x 30,000 = 1.2 million dollars! If transporting lab specimens outside of the major centers is a problem, is it ethical to only test at major centers?

National level decision making (2)

Should all diabetics with hypertension be treated with captopril? (1999 pre-enalapril exercise) Assumptions

Cost to the nation per year:

Captopril $1,533,000 Atenolol/HCTZ $292,000

1/3 of diabetics have hypertension (10,000 in Fiji) Rx: captopril 25 mg po tds ($0.42/d) OR atenolol 100 mg po daily & HCTZ 25 mg po daily ($0.08/d)

Extra cost for captopril: $1,241,000/year

UPDATE: enalapril is now about $0.02 for 5 mg

Enalapril 20 mg/d ($.08/d) = $292,000 cost to Fiji

Options for spending $1.2 million to lower the disease burden from Diabetes mellitus (1)
Health care workers $10k/yr ($5/hr) Health care workers $20k/yr ($10/hr) Health care workers $60k/yr ($30/hr) (dieticians, doctors, nurses, community workers, educators) Overseas expert visits (20 days @ $1000/day) 4-wheel drive vehicles ($50,000) Boats for island visits ($25,000)

120 HCWs 60 HCWs 20 HCWs

30 visits
24 cars 48 boats

million to lower the disease burden from Diabetes mellitus (2)

Diabetic education and treatment options

120 HCWs x 1940 hours/HCW/yr / 30,000 diabetics = 7.8 hrs/diabetic/yr

Television and radio commercials Educational program in the schools Other community awareness programs Hemodialysis ($50,000/yr) - 24 patients (which ones???) (???CAPD) Laser machine to treat retinopathy (?cost)

National level decision making (3)

How often should diabetic patients see a doctor? Assumptions:

Sample calculation: monthly visits 30,000 x 12 visits/yr x 1/6 hr/visit x 1920 hours/yr/doctor (40-hr week) Need 31 doctor full-time equivalents (FTEs)

30,000 diabetics in Fiji 10 minutes per visit

National level decision making (4)

How often should diabetic patients see a doctor? (2) Summary

How do you get extra doctor FTEs?

Monthly visits: 31 doctor FTEs Every 2 months: 16 doctor FTEs Every 3 months: 10 doctor FTEs OR: see patients monthly for 3 minutes: 10 doctor FTEs

Work existing doctors harder for the same pay (leading to migration, loss to private practice) Recruit doctors from overseas Train nurses and nurse practitioners

National level decision making (5)

What is the economic impact of replacing tolbutamide with glipizide? Assumptions:

Tolbutamide 500 mg po tds: $11/yr Glipizide 5 mg po bd: $51/yr Assume 10% of diabetics on glipizide 30,000 diabetics in Fiji

Estimated cost to Fiji per year: $112,000

Yearly $ of ideal diabetic control (Fiji health budget: $26/head)

Metformin 850 mg po tds Isophane Insulin 25U nocte Enalapril 20 mg po daily Lovastatin 10 mg po daily ($8/m) Home glucose monitor (1/5 of total cost per year) Test strips (2x/wk) HbA1C 4x/year PLUS clinic visits, dieticians, lab tests, specialist services for complications, etc.

$44 $190 $29 (2002) $96 (2002) $9 $73 $40 Total: $481 ($385 without statins)

Lessening the burden of disease at the national level - resource allocation (1)

Development of treatment guidelines

Based on evidence Economic analysis

Epidemiology (determining # of diabetics) Education / training of health care workers

Initial training Continuing medical education / in-service training

Lessening the burden of disease at the national level - resource allocation (2)

Hiring more staff Medications Equipment Laboratory support Transportation Facilities to treat complications

Lessening the burden of diabetes mellitus at the local level (hospital and/or district level)

More effective clinic visits

Organize support services Empower other doctors and health care workers
Teaching Evidence-based guidelines and protocols Dieticians Diabetic educators Evidence-based practice More time with patients

Issues for Fiji (exercises)

Metformin is more expensive than sulphonourea medications. Is it worth the extra cost?

Rules: confine your search to:

Cochrane Collaboration New England Journal of Medicine Annals of Internal Medicine ACP Journal Club Lancet British Medical Journal Journal of the American Medical Association Medical Journal of Australia Journal Watch (General Internal Medicine) No internet surfing (except major guidelines) Recent textbooks including UpToDate Clinical evidence