|Year : 2022 | Volume
| Issue : 4 | Page : 70-75
Economic impact of hypertension in Urban chitradurga: A cross-sectional study
Kailash Naren1, Vijayalaxmi Mangasuli1, SB Vijeth2, AM Amrutha1, Nidaanjum Ahmed1, Bhagyalaxmi Sidenu1
1 Department of Community Medicine, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India
2 Department of General Medicine, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India
|Date of Submission||16-Jul-2022|
|Date of Decision||04-Aug-2022|
|Date of Acceptance||17-Aug-2022|
|Date of Web Publication||27-Oct-2022|
Department of Community Medicine, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The high level of out-of-pocket expenditures (OOPEs) increases the risk for catastrophic expenditure and may further increase the risk of impoverishment.
Objective: To know the economic impact of hypertension (HTN) in urban Chitradurga.
Materials and Methods: A cross-sectional study was conducted among 196 hypertensives aged more than 18 years taking treatment for more than 1 year. Newly diagnosed hypertensives and with other debilitating illness were excluded. This study was done in urban field practice area of Chitradurga, for a period of 3 months. Subjects were selected by simple random sampling by line listing all cases. Sociodemographic data and cost of treatment were collected. Along with this cost of consultation, medicine, travel, diagnostic cost, patient's wage lost for treatment and other expenditure details was collected.
Results: It was found that most of the subjects were above the age of 60 years and unemployed. Only 29.6% of the participants chose to seek care from government hospitals. Around 67.9% of participants had associated comorbidities. Median monthly OOPE toward HTN was found to be Rs. 600 (400–750). When this was analyzed separately for hospitalized and nonhospitalized cases, total cost of expenditure due to HTN was Rs. 2583 and Rs. 700, respectively. The monthly direct cost of subjects seeking care in private hospitals is Rs. 850 which is Rs. 650 more than what the subjects who seek care in government hospitals pay. Total monthly cost was Rs. 400 and Rs. 1050 for government and private hospitals, respectively.
Conclusion: High OOPE makes it a necessity for intervention.
Keywords: Burden, cost, economy, hypertension
|How to cite this article:|
Naren K, Mangasuli V, Vijeth S B, Amrutha A M, Ahmed N, Sidenu B. Economic impact of hypertension in Urban chitradurga: A cross-sectional study. MRIMS J Health Sci 2022;10:70-5
|How to cite this URL:|
Naren K, Mangasuli V, Vijeth S B, Amrutha A M, Ahmed N, Sidenu B. Economic impact of hypertension in Urban chitradurga: A cross-sectional study. MRIMS J Health Sci [serial online] 2022 [cited 2023 Jan 30];10:70-5. Available from: http://www.mrimsjournal.com/text.asp?2022/10/4/0/359949
| Introduction|| |
Hypertension (HTN) is one of the most common lifestyle “Silent Killer” disease today, with every third person having suffering from it. Noncommunicable diseases (NCDs) are the important causes of mortality and morbidity in India, among them HTN is major risk factor. HTN is defined as systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg, according to new 2017 American Heart Association guidelines.
HTN is attributable to 10.8% of all deaths in India, whereas approximately 9.4 million deaths occur each year worldwide and many of those who die never knew they were affected. If left uncontrolled, HTN causes stroke, myocardial infarction, cardiac failure, dementia, renal failure and blindness, causing human suffering and imposing severe financial and service burdens on health systems., About 33% urban and 25% rural Indians are hypertensive. Of these, 25% rural and 42% urban Indians are aware of their hypertensive status. Only 25% rural and 38% of urban Indians are being treated for HTN. One-tenth of rural and one-fifth of urban Indian hypertensive population have their blood pressure under control. Overall, the prevalence of HTN in low-income and middle-income countries was 32.3% in 2015. Hence, it is imperative that the economic impact of the disease must be studied intensely. HTN is becoming one of the most costly health conditions worldwide and this cost is likely to continue to grow because of a rising prevalence and an ageing society. Although research on the global economic effects of NCDs is still in a nascent stage, economists are increasingly expressing concern that NCDs will result in long-term economic impacts on labor supply, capital accumulation, and gross domestic product worldwide with the consequences most severe in developing countries. In a study from Jamaica, 59% of those affected with chronic disease experienced financial difficulties and in many cases avoided medical treatment as a result. Another study from Burkina Faso found that the probability of catastrophic financial consequences more than doubled in households affected by chronic illness. In Russia, chronic disease resulted in 5.6% lower median per person income. Data from India show that the out-of-pocket expenditure (OOPE) by the households on NCD care is on a rising trend, up from 31.6% in 1995–1996 to 47.3% in 2004, India spent INR 44 billion out of pocket due to HTN which was INR 6.39 billion in 1995–96. Around 2/3rd of all hypertensive patients live in low- and middle-income countries, which delineates the high economic burden of HTN in these countries.
The high level of OOPEs increases the risk for catastrophic expenditure and may further increase the risk of impoverishment. The so called diabetic capital, India is now moving toward achieving highest prevalence of HTN. To optimize the use of limited healthcare resources and better meet future demands for health services. It is critical to have an understanding of the economics of HTN, including assessment of its economic impact. The economic impact of HTN is estimated using the following indices: Direct medical costs, direct nonmedical costs, morbidity costs, mortality costs, intangible costs and cost of illness. Hence, this study aims at computing the various economic parameters to study the economic impact of HTN in urban Chitradurga.
| Materials and Methods|| |
This is a cross-sectional study conducted among 196 hypertensives. The prevalence of HTN in urban area 33.8%, with allowable error of 20% considering 95% confidence interval and power as 80%). Diagnosed cases of hypertensives since more than 1 year who are taking treatment for the same with or without other chronic diseases aged more than 18 years were included in the study. Newly diagnosed hypertensives and patients with other debilitating illnesses were excluded from the study. This study was done in urban field practice area of Department of Community Medicine in Chitradurga District for a period of 3 months (April 2021 to June 2021).
The total population of urban field practice area is 23,800 and total population of adults above the age of 18 years was 12,280. Total hypertensives in our study area were 2456. Eligible for the study were 454 according to eligibility criteria. One hundred and ninety-six were selected by simple random sampling. [Figure 1]
After the clearance from Institutional Ethics Committee, line listing of all the hypertensives was done by house-to-house visit in the urban field practice area. Subjects who fulfilled the inclusion criteria were listed separately. Samples were collected by simple random sampling among these subjects, till we reached the desired sample size. Written informed consent was obtained. Sociodemographic data and cost of treatment were collected. Along with this, cost of consultation, medicine, travel, diagnostic cost, patient's wage lost for treatment, and other expenditure details were collected. Direct cost is the expenditures incurred because of the illness. Direct costs included personal medical care costs or personal nonmedical costs such as the cost of transport to a health provider. For the present study, direct costs included medical costs such as registration fee, consultation fee, other hospital charges, investigation charges, cost of medicines, nonmedical costs such as travel cost and food cost. Indirect costs refer to the invisible costs associated with lost productivity and income owing to disability or death. Catastrophic health expenditure was calculated by considering total health expenditure spent by households annually for all type of services and the annual income of the household. The health expenditure was said to be catastrophic when the total health expenditure is more than 10% of the annual income. Recall period was fixed as 1 month for Out Patient (OP) care costs and 1 year for hospitalizations. Diseases such as diabetes, cardiac, and renal diseases were considered as comorbidities. Privacy and confidentiality of the respondents were maintained as far as possible.
After collecting the data, it was entered in Excel sheet and analyzed using SPSS software IBM SPSS (Statistical Package for social Sciences) version 20, USA. Economic impact was calculated as direct cost, indirect cost, OOPE, and total cost of illness.(Median cost). Interquartile ranges were expressed for median values. Data expressed as frequencies and their percentages in tables and graphs. Mann–Whitney U-test was applied to compare the mean ranks between the groups with significance level at P < 0.05.
| Results|| |
Most of the subjects (40.3%) were above the age of 60 years. In this study, the number of male subjects (52%) was almost equal to females (48%). Majority of the subjects were Hindu (74.5%) by religion. Vast members of the study pool were married (84.2%). Most of them were unemployed (55.1%) and around 10.2% were disabled. Majority of the subjects had no formal education (22.4%), but at the same time, around 9.7% were graduates. Furthermore, salaried and self-employed subjects combined for 47.9% of the total. While 15.8% were agriculturists by occupation. Most of the subjects belonged to nuclear families (75.5%). Around 69.3% of them did not have any insurance [Table 1].
The patients who were diagnosed with HTN <3 years (40.8%) ago make up majority of the study. While those diagnosed for more than 10 years make up 12.8% only. It is interesting to note 29.6% of the subjects chose government hospital as choice of health facility of seeking care. While majority of them (70.3%) chose private Clinic and hospital as choice of health care facility to seek care. Around 67.9% of the hypertensive subjects were found to have associated co-morbidities such as diabetes mellitus, coronary heart disease, chronic kidney disease, stroke, and thyroid conditions. Around 25.6% patients were hospitalized because of HTN-related problems in the last year [Table 2].
About 39.3% of the subjects were diagnosed with HTN as they visited the hospital with the symptom of giddiness. Moreover, 31.1% of the patients were diagnosed with HTN on regular checkups. Only a mere 4.1% were diagnosed after having a stroke [Table 3].
|Table 3: Symptoms of study participants when they diagnosed with hypertension|
Click here to view
Median monthly OOPE toward HTN was found to be Rs. 600 which was a burden for common people residing in our setting. Median total cost of illness was Rs. 900 which when analyzed separately for males and females it was Rs. 850 and Rs. 900, respectively. Whereas, median direct cost due to HTN was found to be Rs. 666.
The monthly direct cost of subjects seeking care in private hospitals is Rs. 850 which is Rs. 650 more than what the subjects who seek care in government hospitals pay. The total cost borne by patients with comorbidities is Rs. 700, whereas patients without comorbidities pay only Rs. 625 monthly for their care. The monthly total cost of subjects who have been hospitalized with HTN related condition was significantly higher (Rs. 2258). Even their monthly indirect cost was high (Rs. 300). These findings show the high complication cost owing to their high burden [Table 4].
|Table 4: Monthly cost of illness in comparison with their clinical characteristics (n=196)|
Click here to view
On a monthly basis, subjects who went to private hospitals spent Rs. 400 on drugs, whereas their counterparts spent only Rs. 50. Moreover, also the patients with comorbidities spent Rs. 100 more than that of their counterparts [Table 5].
|Table 5: Monthly cost of drugs in comparison with their clinical characteristics (n=196)|
Click here to view
In our study, we found that, cost incurred toward HTN is reducing according their socioeconomic status (SES), i.e., in Class 1 SES patients the direct cost was found to be Rs. 750, whereas in Class 5, SES patients it was found to be Rs. 100.
In our study, 30 (15.3%) of the study participants had catastrophic health expenditure toward HTN. Catastrophic health expenditure was compared with gender, religion, marital status, SES, type of family, insurance and employment status. It was found that gender, SES, type of family, and employment status were significantly associated with the catastrophic health expenditure.(P < 0.05) This was more among males (73.3%) and people staying in the nuclear family (50%). As the SES was going down, their catastrophic expenditure increased, might be due to unplanned cost. Moreover, also it was more among unemployed (53.2%), retired, and disabled [Table 6].
| Discussion|| |
Our study shows that HTN was almost equally prevalent among both sexes, whereas their average cost of illness was significantly different which was more among females. Around 55% of the study participants are unemployed. Most of the participants were above the age of 60 years in our study, which is the age of retirement. On consideration of these factors, it is not a surprise that the average indirect cost of illness is very less.
There are studies which showed more cost incurred by females compared to males. Similar findings were noted in our study with monthly cost incurred by females was Rs. 900 (median) and males was Rs. 850 (median). The higher average cost of illness seen in females might be due to their changing healthcare-seeking behavior as they are more concerned about their health nowadays.
The average monthly cost of HTN in subjects seeking care in government hospital was found to be Rs. 650 less than that of subjects seeking care in private health care center. This might due to the high cost of drugs borne by the subjects seeking care from private hospitals as mentioned below. While in one study done in Malwani slum in Mumbai, the subjects seeking care in government hospitals were only paying Rs. 150 less than that of subjects seeking care in private hospitals.
In our study, the monthly cost of drugs required for HTN in patients seeking care in government hospitals was found to be Rs. 50, whereas subjects seeking care in private health facilities spent Rs. 400, which is equal to the cost of illness borne by the subjects who went to government hospital. A similar study done in Mumbai showed same results.
Cost of illness due to HTN of subjects seeking care in private hospitals was almost three times more costly than subjects seeking care in government hospitals. Only 29.6% of the subjects were using government facilities. The remaining 70.4% were using private hospitalization. This in turn leads to increased cost of illness and OOPE.
In our study, 15.3% had catastrophic health expenditure toward HTN. Gender, SES, type of family, and employment status were significantly associated with the catastrophic health expenditure. In a study done by Swetha et al., 14.86% experienced catastrophic health expenditure toward chronic illness and SES was significantly associated with this.
From our findings, it can be said that economic impact of HTN was very high in our setting. Our study participants would have had even other comorbidities and also other family members. This can also add to their economic impact. This burden can be reduced by employing various methods of primordial and primary prevention (lifestyle modification). As India being a resource-constraint society, the high cost of care points to the need of efficient utilization of resources along with population-based preventive approaches including multisectorial collaborations in HTN control.
Our study might have had recall bias. The results of our study are generalizable and can be applied for future cohort studies. Moreover, even controlling HTN is a cost effective strategy in reducing complication arising out of it like cardiovascular events and deaths. Thus, reducing their inpatient charges indirectly accounting toward their OOPE.
Further research can be done with longer duration and in detail follow-up of the study participants to increase the effectiveness and to address the recall bias. Moreover, even we had a smaller sample size. As recall period is only 1 month for outpatient department costs and 1 year for hospitalization costs in the study. The expenditure incurred before recall period by chronic hypertensives which may include hospitalization was not included. This may be limitation to assess overall economic impact.
| Conclusion|| |
Economic burden of HTN among the study participants was high including both OOPE and catastrophic expenditure, which makes it a necessity for intervention. For the ones already living with the disease economic, safety is a burden.
HTN is a serious health condition which requires timely treatment which causes burden to the family. This can be addressed by government by implementing the various kinds of policies. Like construction of parks, conducting and involving local authorities in awareness program, extending insurance schemes to every citizen. Extension of insurance schemes to drugs and outpatient care might decrease the economic burden of HTN severely on these patients. These insurance schemes can be extended to everyone with awareness of their utilization. If simple preventive measures such as lifestyle modifications including, regular exercise, diet changes, and controlling use of alcohol and tobacco are taken, significant amount can be saved and much more by the prevention of complications due to HTN.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., et al.
The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 report. JAMA 2003;289:2560-72.
James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al.
Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the eighth joint national committee (JNC 8). JAMA 2014;311:507-20.
Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al
. Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens 2014;32:1170-7.
Sarki AM, Nduka CU, Stranges S, Kandala NB, Uthman OA. Prevalence of hypertension in low- and middle-income countries: A systematic review and meta-analysis. Medicine (Baltimore) 2015;94:e1959.
Vasan RS, Beiser A, Seshadri S, Larson MG, Kannel WB, D'Agostino RB, et al.
Residual lifetime risk for developing hypertension in middle-aged women and men: The framingham heart study. JAMA 2002;287:1003-10.
Thakare BS, Adhav A, Kadam S. Economic burden of hypertension care in households of Malwani slum of Mumbai: A cross-sectional study. Int J Res Med Sci 2015;3:2376-81.
Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007;370:1929-38.
Henry Lee A, Andrea Y. Protecting the Poor and the Medically Indigent Under Health Insurance: A Case Study of Jamaica. Report No.: Small Applied Research No. 6. Bethesda, MD: Partnerships for Health Reform Project, Abt Associates Inc; 1999.
Su TT, Kouyaté B, Flessa S. Catastrophic household expenditure for health care in a low-income society: A study from Nouna district, Burkina Faso. Bull World Health Organ 2006;84:21-7.
Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, et al
. The Global Economic Burden of Non-Communicable Diseases. Geneva: World Economic Forum; 2011.
Chockalingam A, Campbell NR, Fodor JG. Worldwide epidemic of hypertension. Can J Cardiol 2006;22:553-5.
Le C, Zhankun S, Jun D, Keying Z. The economic burden of hypertension in rural South-West China. Trop Med Int Health 2012;17:1544-51.
Kalua CM, Bedgood DR, Prenzler PD. Development of a headspace solid phase microextraction-gas chromatography method for monitoring volatile compounds in extended time – Course experiments of olive oil. Anal ChimActa 2006;556:407-14.
World Health Organization. WHO Guide to Identifying the Economic Consequences of Disease and Injury; 2009.
Swetha NB, Shobha S, Sriram S. Prevalence of catastrophic health expenditure and its associated factors, due to out-of-pocket health care expenses among households with and without chronic illness in Bangalore, India: A longitudinal study. J Prev Med Hyg 2020;61:92-7.
Kar SS, Kalidoss VK, Vasudevan U, Goenka S. Cost of care for hypertension in a selected health center of urban Puducherry: An exploratory cost-of-illness study. Int J Commun Dis 2018;3:98-103.
Mohan S, Campbell N, Chockalingam A. Time to effectively address hypertension in India. Indian J Med Res 2013;137:627-31.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]