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Amiri S, Mirahmadizadeh A, Seyfi S. The Expense of Insulin in Individuals with Insulin-Dependent Diabetes in Fars Province based on Prescribed Prescriptions including Insulin. EBHPME. 2020; 4 (4) :217-224
URL: http://jebhpme.ssu.ac.ir/article-1-303-en.html
Epidemiology Department, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
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Background: Diabetes is considered one of the most prevalent chronic diseases in the world, and if it is not cured, it can have many side effects and expenses. The current study has been conducted to calculate the cost of insulin applied in patients with insulin-dependent diabetes who are younger than 19 years old in 2016 and 2017.
Methods: The current study is a descriptive and cross-sectional study. We investigated all registered prescriptions of social security and health insurance in this study. The price of each insulin was calculated through the official website of the Food and Drug Administration (FDA). Ultimately, the cost of insulin has been calculated based on gender, age group, and insurance types under the age of 19 in patients with insulin-dependent diabetes and those without insulin-dependent diabetes. Data has been analyzed using SPSS24. The frequency command is used to obtain the percentages.
Results: In this study, 1135105 insured cases younger than 19 years old were investigated, which females consisted almost half of the insured cases (51 %), and most of them were in the age group of 2-7 years (34 %), and 50 % of the participants in this study were covered by social security insurance. The treatment of each patient with insulin-dependent diabetes included a cost of $ 1187 and $ 1309, respectively, in 2016 and 2017, and $ 1.4 and $ 1.7 respectively (1$ = 42,000 Rials), for each person under the age of 19 in the general population.
Conclusion: The results achieved by the mentioned study explained that nearly remarkable cost is spent on preparing insulin for patients with Type 1 Diabetes Mellitus every year. This amount is increasing, and it is essential to predict insulin needs for the future according to the insulin consumption changes.
 
Key words: Insulin, Diabetes, Type 1 diabetes, Diabetes mellitus, Cost
Introduction
 
Type 1 Diabetes Mellitus (T1DM) is an autoimmune disease that is regularly diagnosed in the early ages of life (1) and is considered the most prevalent endocrine disorder in children (2). CDC findings suggest that 5 to 10 % of all diabetes cases belong to Type 1 Diabetes Mellitus (3). The frequency rate of Type 1 Diabetes Mellitus has increased in recent decades in all parts of the world, notably in children (4, 5). It is calculated that 40 million people in the world have Type 1 Diabetes Mellitus, and 78,000 people are added to this statistic annually (6). Type 1 Diabetes Mellitus has long-term complications that may increase mortality (7). Agency for Healthcare Research and Quality (AHRQ) reported that $ 34 billion spent on health cases in 2005 was related to diabetes (8). A recent study conducted by the American Diabetes Association in 2005 shows that patients with diabetes spend an average of $ 16,752 a year on medical expenses. Approximately half of this amount (57 %) is related to treatment, including the cost of diabetes medications. (9) The average health costs for diabetes patients are 2.3 times higher than for patients without diabetes in the United States (10). A study conducted in Scotland, hospitalization rates and hospitalization costs for patients with diabetes was 2.1 and 2.2 times higher than the general population, respectively (11). A study conducted in the US indicated that the whole medical cost of type 1 diabetes is $ 6.9 million (1). A study conducted in Brazil based on the National Brazilian Health Care System (NBHCS) recognized that each patient with type 1 diabetes needs $ 1319.15 annually to treat it (12).
A study conducted in Iran indicated that the whole diagnostic cost of Type 2 Diabetes Mellitus in 2009 was estimated at $ 3.78 billion, including direct costs (medical and non-medical) at $ 2.04 ± 2.08 billion and its indirect costs include $ 1.73 million. The average direct and indirect costs were $ 842.6 ± 102 and $ 864.8, respectively. Complications (48.9 %) and drugs (8.23 %) were among the main elements of direct costs (13). Another study conducted in 2009 in Iran showed that the treatment and controlling the patients with diabetes included the cost annually $ 14.5 ± 3.152 and $ 52.8 ± 5.8, respectively, which shows that the costs of diabetics are 2.92 times the costs of people without diabetes. Most direct costs have been spent on medicines and devices and hospitalization in diabetic patients (14).
Most studies conducted on diabetes include Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus (T2DM) or type 2 diabetes alone (10, 15), and little information is available about the cost of treating insulin-dependent diabetes. Insulin should be daily injected for Regular care for Type 1 Diabetes Mellitus, and they should be continually monitored, which indicates the cost of care and time needed (16). Since there is no information about the cost of insulin-dependent diabetes, principally the cost of treating Type 1 Diabetes Mellitus with insulin and its yearly changes in Iran, this study was conducted to estimate the cost of insulin-dependent diabetes in the under-19 age group in 2016 and 2017 in Iran. The under-19 age group is more likely to have type 1 diabetes.
Materials and Methods
Prescript insulin registered in insurance databases in 2016 and 2017 was used in this descriptive study. All registered prescriptions of Social Security and Health Insurances (by covering 98% of the total population) were investigated. During the year, all prescriptions of each person were collected based on the national code utilizing the KU-TOOLS tool in Excel. The type of insulin and its dose for one year were calculated for
each person. The family physician database was utilized to get age and sex information for all individuals younger than 19 years old. Hence, there were 1,135,105 insured persons younger than 19 years old. We used Excel software to integrate family physician information and medicine information based on the national code. Telephone communication was held with all people who had more than two years of prescription insulin, and 200 people had no history of insulin to ensure that insulin-based estimates and based on prescription are reliable. Kappa agreement coefficient is
high and equal to 96.2 % (95.8 % to 96.5 %). Conclusively, we have estimated all insulin and its dose used in people younger than 19 years old. SPSS24 has been used to analyze the data. In this study, we employ the frequency command to calculate the frequency and percentage. Moreover, the split command was employed before the frequency for calculations by gender and age group. The official website of the Food and Drug Administration (FDA) was used to calculate the price of each insulin (17). The following table shows the price of each type of insulin:
At last, the cost of insulin in patients with insulin-dependent diabetes and those without insulin-dependent diabetes has been estimated based on gender, age group, and types of insurance at the age of younger 19. This design was recorded with the code of ethics IR.SUMS.REC. 1397. 982 in Shiraz University of Medical Sciences. In this study, the personal information of patients was not used, however, after contacting them, their informed consent was first asked.
 
Table 1. Price of insulin by type in Iranian Rail and USD PPP adjusted
Types of insulin Price
Iranian Rial USD, PPP adjusted
Novo rapid 353,700 19.9
Lantus 870,000 48.9
Regular 140,000 7.9
NPH 140,000 7.9
Novo mix 353,700 19.9
Apidra 311,600 17.5
Levemir 355,000 19.9
Biphasic 188,400 10.6
 
 
Results
In this study, 1135105 insured cases younger than 19 years old were investigated, which females consisted almost half of the insured cases (51 %), and most of them were in the age group of 2-7 years (34 %), and 50 % of the participants in this study were covered by social security insurance. Table 2 shows the details of the participants' demographic characteristics in the study.
Novo rapid insulin is the most used among all insulins used in both sexes and different age groups and insurance types. Biphasic and Levemir insulin has been used less compared to other insulins. Table 3 shows the details of consuming insulin types by gender, age groups, and types of insurance booklets.
Novo rapid insulin had been the most extensively used one among all the insulins
used, but Lantus insulin had been the most expensive. Table 4 shows the dose of insulin used along with their price as well as their change percentage.
Most of the costs spent on insulin-dependent diabetes treatment had been related to females and the age group of 14-19 years old and social security insurance. Table 5 shows the cost related to treating insulin-dependent diabetes by gender, age group, type of insurance booklet, and their percentage of changes.
The cost of treating each person with insulin-dependent diabetes in 2016 and 2017 had been $ 1187 and $ 1309, respectively, and $ 1.4 and $ 1.7, respectively for each person younger than the age of 19 in the general population. Table 6 shows the costs to treat each patient with insulin-dependent diabetes and each insured person under 19 years old by gender, age groups, and types of insurance booklet.
 

 
Table 2. Demographic characteristic of participants and patients; and prevalence (per 100,000) of
IDDM during 2016 – 17 in Fars province
Variable Participants Patients
Frequency 2016 2017
No. % No. Prevalence No. Prevalence
Sex
  • Male
  • Female
 
582,122
552,983
 
51.3
48.7
 
653
683
 
112.1
123.5
 
747
806
 
128.3
145.7
Age group
  • < 2
  • 2 - 7
  • 8 - 13
  • 14 - < 19
 
135,203
395,499
351,314
253,089
 
11.9
34.8
30.9
22.3
 
1
173
537
625
 
0.7
43.7
152.9
246.9
 
9
229
630
685
 
6.6
57.9
179.3
270.7
Type of Insurance
  • SSI a
  • IHI b(Urban)
  • IHI (Rural)
 
571,939
312,509
250,657
 
50.4
27.5
22.1
 
702
430
204
 
122.7
137.6
81.4
 
826
482
245
 
144.4
145.2
97.7
Total 1.135.105 100% 1336 117.6 1553 136.8
a = Social security insurance
b = Iranians health insurance
 
Table 3. Insulin consumption (vials) in patients with IDDM by sex, age groups and Insurance,
in 2016-17 in south of Iran
Type of Insulin Year sex Age groups Type of Insurance
Male Female < 2 2 - 7 8 - 14 15 - 19 SSI a IHI b(U) IHI (R)
Novo rapid 2016 11787 13023 0 1451 8759 14600 14352 7781 2677
2017 15347 17095 1 2554 12466 17421 18156 10632 3654
Lantus 2016 10152 11407 7 1326 7410 12816 12797 6483 2279
2017 12866 14443 14 2046 10366 14883 16250 8159 2900
Regular 2016 643 748 9 279 418 685 642 474 275
2017 514 531 27 236 310 472 436 367 242
NPH 2016 884 1069 15 385 521 1032 925 659 369
2017 746 780 35 302 386 803 677 508 341
Novo mix 2016 264 168 0 36 95 301 422 10 0
2017 284 163 0 22 62 363 433 14 0
Apidra 2016 81 62 0 6 76 61 123 5 15
2017 416 322 0 52 323 363 673 45 20
Levemir 2016 53 37 0 15 18 57 44 41 5
2017 296 291 1 205 108 273 293 230 64
Biphasic 2016 0 1 0 0 0 1 0 1 0
2017 0 3 0 0 2 1 0 3 0
Sum   2016 23,864 26,515 31 3,498 17,297 29,553 2,9305 15,454 5,620
2017 30,469 33,628 78 5,417 24,023 34,579 3,6918 19,958 7,221
Change rate (%) 27.7 26.8 151.6 54.9 38.9 17.0 26.0 29.1 28.5
 
 

 
Table 4. Doses (vials) and cost expenditure (USD, PPP adjusted) of insulin 1n 2016-17 in south of Iran
Types of insulin 2016 2017 Change rate (%)
Doses (vial) Cost, USD PPP adjusted Doses (vial) Cost, USD PPP adjusted Both Doses (vials) and cost
Amounts % Amounts %
Novo rapid 24,810 493,088 31.09 32,442 644,771 31.71 30.8
Lantus 21,559 1,053,927 66.44 27,309 1,335,020 65.65 26.7
Regular 1391 10,943 0.69 1045 8,221 0.40 -24.9
NPH 1953 15,364 0.97 1526 12,005 0.59 -21.8
Novo mix 432 8,586 0.54 447 8,884 0.44 3.5
Apidra 143 2,504 0.16 738 12,922 0.64 416.1
Levemir 90 1,795 0.11 587 11,709 0.58 552.2
Biphasic 1 11 0.00 3 32 0.00 200.0
Total 50,379 1,586,217 100 64,097 2,033,563 100 27.23
 
 
Table 5. Cost expenditure (USD, PPP adjusted) of insulin by sex, age groups and type of insurance
in IDDM in 2016-17 in south of Iran
Variable 2016 2017 2-year proportion (%) Change rate (%)
Sex male 750,284 962,723 47.3 28.3
female 835,933 1,070,839 52.7 28.1
Age groups < 2 531 1,212 0.05 128.2
2- 7 100,004 160,449 7.20 60.4
8 -13 547,289 769,044 36.37 40.5
14 - < 19 938,393 1,102,858 56.38 17.5
Type of Insurance SSI 934,576 1,190,225 58.70 27.4
IHI (U) 481,598 622,734 30.51 29.3
IHI (R) 170,043 220,603 10.79 29.7
 
Table 6. Average cost expenditure (USD, PPP adjusted) of insulin in population and IDDM patient in age < 19 by sex, age groups and Insurance in 2016-17 in south of Iran
Variable Number of
population
In 2016 In 2017
Population Patients Population Patients
Average
cost
No. Average
cost
Average
cost
No. Average
cost
Sex Male 582,122 1.28 653 1,148.98 1.65 747 1,288.79
Female 552,983 1.51 683 1,223.91 1.93 806 1,328.59
Age groups < 2 135,203 0.00 1 531.00 0.00 9 134.66
2- 7 395,499 0.25 173 578.06 0.40 229 700.65
8 -13 351,314 1.55 537 1,019.16 2.18 630 1,220.71
14 - < 19 253,089 3.70 625 1,501.43 4.35 685 1,610.01
Type of Insurance SSI 571,939 1.63 702 1,331.31 2.08 826 1,440.95
IHI (U)a 312,509 1.54 430 1,120.00 1.99 482 1,291.98
IHI (R)b 250,657 0.67 204 833.55 0.88 245 900.42
a urban area
b rural area
 


 
Discussion
Diabetes is one of the most significant challenges facing the public health of the 21st century (18). Type 1 Diabetes Mellitus is also a chronic disease that its prevalence is increasing worldwide (19). The current study is one of the studies that has calculated the costs of treating insulin-dependent diabetes based on the follow-up of prescribed prescriptions, including insulin. The results achieved by our study show that insulin costs for patients with insulin-dependent diabetes are estimated at $ 1,586,217 and $ 2,033,563, respectively, in 2016 and 2017. We understand by comparing the results achieved by this study and a study conducted in the United States that the cost of treatment for insulin-dependent diabetes is lower in Iran, and it is due to this fact that the study conducted in the United States calculated the costs of hospitalization in addition to the cost of treatment (1). The cost of treating each patient with insulin-dependent diabetes in 2016 and 2017 was calculated at $ 1.187 and $ 1309, respectively, in our study, which is in agreement with the results of a study conducted in Brazil (12). A study that was conducted to simulate the costs related to insulin-dependent diabetes in Spain showed that the cost of caring for and treating a patient with insulin-dependent diabetes was calculated at $ 3,645 in the first year of diagnosis and $ 1,708 in consequent years, (20) which is in agreement with the results of our study, and the very small difference is because of considering other direct costs of treatment, such as hospitalization. The average cost spent on treating type 1 diabetes in Australia had been $ 570 million annually. The annual cost related to each patient with diabetes had been
$ 4,699, which 13 % of the total costs is allocated to insulin costs (21).
A study conducted in England and Wales to examine the costs related to insulin-dependent diabetes determined that about 93.581 million Pound has been spent on insulin-dependent diabetes in 1991, which 23 million Pound is related to insulin. (22). Another study conducted to estimate the costs related to the disease imposed on the families of children with insulin-dependent diabetes in Sudan showed that the average annual cost of diabetes care was $ 283 for each diabetic child, which 36 % was spent on insulin and 65 %. of total family expenses have been spent for a diabetic child (23), the results of this study are not in agreement with the results achieved by our study, this disagreement may be caused because of the small sample size (147 people) and the selection of urban area in the study of Sudan. Novo Rapid Insulin has been extensively used among all types of insulin in 2016 and 2017, but Lantus insulin was the most expensive one.
Limitations: We determined to conduct this study for the age group younger than 30 years old, but we decided by advising a clinical consultant that this study to be conducted for the under-19 age group due to some cases of Type 2 Diabetes Mellitus in the age group younger than 30 years old. Additionally, we could not study the total population of children younger than 19 years old, but this study has been conducted on 98 % of children younger than 19.
Conclusion
The results achieved by the above study explained that nearly high cost is spent on preparing insulin for patients with type 1 diabetes annually. It is inevitable to predict insulin needs for the future due to the changes in insulin consumption. Also, it is concluded, according to the agreement of the results obtained in this study with the results of other studies, that the method of using insurance archives can be a satisfactory method to estimate the costs of some diseases.
We advise enthusiastic researchers to apply the method used in this study (using the insurance archive) to investigate the costs of some diseases that comply with the method's rules.
Acknowledgments
The authors thank Mr. Engineer Amin Yousefi at the Family Physician Information Registration Center and Dr. Mohammad Mahdi Hashemi, Head of the Social Security Insurance Office, as well as Mr. Engineer Saljuqi, Head of the IT department of the Health Insurance Office, to cooperate with this project.
Conflict of interests
There was no Conflict of interests.
Authors' contributions
Mirahmadizadeh A and Amiri S designed research; Mirahmadizadeh A, Amiri S and Seyfi S conducted research; Mirahmadizadeh A and Amiri S analyzed data; and Seyfi S wrote manuscript. All authors read and approved the final manuscript.
Funding
None.
Type of Study: Original article | Subject: Health Economics
Received: 2020/07/26 | Accepted: 2020/12/20 | Published: 2020/12/20

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