Dr.Vijay Viswanathan MD, PhD,FRCP Head & Chief Diabetologist M.V.Hospital for Diabetes & Prof.M.Viswanathan Diabetes Research Centre Royapuram, Chennai

How do patients pay for diabetes care in India? $ – `` > $ Percentage Tharkar et al. Diabetes Res Clin Pract 2010;89:334–40

Ind Jof Nephrology, May 2014 / Vol 24

Almost 70% of the Indian population is in the below-poverty-line category, and although the cost spent on dialysis is comparatively cheaper than other countries,90% of the Indians cannot afford it. Khanna U et al,2009, Indian J Nephrol

Cross sectional – Two centers between August 2008 and January 2010 ( Specialized diabetes care center, exclusively treating diabetic patients & another private hospital. Total of 209 ( M:F=133:76) Type two Diabetic subjects. Pretested questionnaire consisting of the details on expenditure toward the care and management of CKD and diabetes was administered by interviewing the patient. Materials and Methods STUDY SUBJECTS GROUP 1 Undergone renal transplantaion GROUP 2 CKD diabetic patients who were on hemodialysis. GROUP 3 Patients with CKD prior to ESRD. GROUP 4 Type 2 Diabetic patients without any complications

GROUP 1 Expenditure on laboratory charges (initial admission) Medical consultations (initial admission) Medicines cost (monthly)& Expenditure per hospitalization (surgery cost, bed charges, nursing charges,etc.) GROUP 2 Dialysis charges Bed charges & nursing charges GROUP3&4 Bed charges & Nursing charges Details of direct cost per unit per patient were assessed based on

GROUP 1 (transplantation ) n=12 GROUP 2 (dialysis) n=45 GROUP 3 (I-IV CKD stages) n =66 GROUP 4 (without complications) n=86 P value betwee n groups Total expenditure () Transplantati on or Hemodialysis diabetes 360,000(774 USD) 36, ,000) 30,200(649USD) 49,500(1,064 USD) (6, ,500) 14,400(310 USD) 12,700 (273 USD) (4,465-57,415) 3214 (69 USD) (250-10,000) Total expenditure for previous 2 years 345,000(7,7419 USD) 25, , ,000 (10,753 USD)* (10,000- 1,000, ,000 (2150 USD)* (20, ,000) 30,000 (645 USD)*,**,# (5, ,000) < Costs associated with chronic kidney disease among study groups 1USD=46.50 INR(approx)

On an average, diabetic patients with CKD prior to ESRD spent more per hospitalization than patients without any complications. The total median expenditure for previous two years showed significant differences between the study groups (group 1: 345,000; group 2: 500, 000; group 3: 100,000; group 4: 30,000). The total median expenditure for hospital admissions in two years was significantly higher for patients on hemodialysis than transplantation (P < ). The source of funds for the expenditure in treating CKD was mainly personal savings (46%), followed by medical insurance (23%), mortgage (12.4), loan (10.0%),company reimbursement (6.2%), & sale of property ( 2.4% ) RESULTS

The cost for a diabetic person on hemodialysis was four times higher compared to people prior to the ESRD stage. The results of the current study reveal that the median cost involved in renal transplant was 3,92,920 INR (USD 8450). The total medicine cost and consultation fees in treating both diabetes and CKD was significantly higher for patients on renal transplantation. The total median expenditure for hospital admissions in two years was significantly higher for patients on dialysis than transplantation. Thus, on a long-term basis, renal transplant remains a cheaper option of treatment. DISCUSSION

As the number of donor kidneys are limited, many of the patients already on dialysis require lifelong dialysis. The huge amount which is being spent on diabetes can be brought down by preventing patients from progressing to stage III chronic kidney disease and also to end ‑ stage renal failure with post event cardiovascular disease. Improvement in diabetes control has the potential to reduce direct costs involved in the treatment of complications DISCUSSION, contd

TARGET 7 % INITIATIVE

AIM Target 7% initiative programme aims to encourage and support the adoption of effective measures for control of diabetes and its complications among our patients

The objective of the study is to improve the glycemic status of diabetic patients who are having poor control of blood glucose levels and bringing down their HbA1c below 7%. Patient having HbA1c > 9% were given Red sticker HbA1c 7-8% were given Yellow sticker HbA1c < 7% were given Green sticker

 Total no of subjects enrolled  After enrollment the patient were motivated to bring down their HbA1c by sending 2 SMS in a period of 1 month interval.  The following SMS were sent as a reminder 1 st SMS- “5 tools of diabetes management Exercise, diet, drug, monitoring & lifestyle change” 2 nd SMS- “Is your blood glucose under control, Check it now. Do regular exercise & eat healthy diet as per your diet chart”

Results Baseline HbA1c

Follow up results  Follow up data showed a significant reduction in the HbA1c

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