Cost of care of atopic dermatitis in India.

BACKGROUND: Atopic dermatitis (AD) is a common dermatologic condition with a prevalence varying from 5% to 15%, and it has been rising over time. Several studies from developed countries have revealed the substantial economic burden of AD on health care budgets. There has been no research however on the cost of care of AD from India a country where health care is self-funded with no health insurance or social security provided by the government. AIM: The aim of our study was to assess prospectively the cost of care of AD in children in an outpatient hospital setting in India.
METHODS: A total of 40 children with AD, <10 years of age, registered in the pediatric dermatology clinic at our institute were enrolled for the study. All patients were followed-up for 6 months. Demographic information, clinical profile, severity, and the extent of AD were recorded in predesigned performa. Caregivers were asked to fill up a cost assessment questionnaire specially designed for the study. It had a provision for measuring direct, indirect, and provider costs.
RESULTS: Of the 40 patients, 37 completed the study. Mean total cost for AD was Rs. 6235.00 ± 3514.00. Direct caregiver cost was Rs. 3022.00 ± 1620.00 of which treatment cost constituted 77.2 ± 11.1%. The total provider cost (cost of consultation, nursing/paramedical staff and infrastructure was Rs. 948.00, which was 15.2% of the total cost of care and the mean indirect cost calculated by adding loss of earnings of parents due to hospital visits was Rs. 2264.00 ± 2392.00 (range: 0-13,332). The mean total cost depending on the severity of AD was Rs. 3579.00 ± 948.00, Rs. 6806.00 ± 3676.00 and Rs. 8991.00 ± 3129.00 for mild, moderate and severe disease, respectively.
CONCLUSIONS: AD causes a considerable drain on the financial resources of families in India since the treatment is mostly self-funded. Cost of care of AD is high and comparable to those of chronic physical illness, such as diabetes mellitus, and this cost is higher in severely ill-patients. This study is an attempt to highlight the cost of care of AD and the need for conducting more studies to sensitize the government and insurance agencies to economic aspects of AD.

What was known?

Atopic dermatitis is associated with substantial economic burden on health care budgets.

However, there has been no research on the cost of care of atopic dermatitis from India where health care is self-funded with no health insurance, or social security is provided by the government.

Introduction

The burden of chronic dermatoses like atopic dermatitis (AD) is difficult to measure, as the potential areas of impact are multiple. Although AD may erroneously be considered a mild skin ailment, it is a chronic disorder with significant personal, social and financial consequences for the patient, family and society. It imposes a range of costs on individuals, families and the state. Parts of this economic burden are obvious and measurable like health and social service needs, lost employment and reduced productivity, impact on families and caregivers [Table 1]. The parts that cannot be measured or are difficult to measure in monetary terms are called intangible costs and include effects on the patients in the form of stigma, stress and treatment side effects and on the caregivers in the form of stress and disturbed sleep cycle.

Table 1

Components of cost packages

Prevalence of AD is high and by the age of 7 years, an estimated prevalence of AD worldwide was 5–15%.[123] In India, a 12 months period prevalence was found to be between 2.4% and 6%.[4] Prevalence of the disease is gradually increasing and environmental exposure in the modern milieu may have a role in causation and exacerbation of the disease.[5]

Atopic dermatitis has a deep impact on the family budget, with an increasing cost in proportion to the increasing severity of the disease. Unlike other chronic diseases, in spite of its morbidity, it draws very little attention due to its nonfatal nature. This is probably also the reason why its economic burden has not been studied before in India.

Several studies have tried to document the cost of AD in terms of treatment expenses, family spending, loss of manpower, etc.[678910111213141516] These studies, have however not evaluated the cost in relation to the severity of illness and the outcome. These estimates are significant in identification of areas for future intervention.

Although, there are Indian studies documenting the burden of other diseases; to the best of our knowledge there are no studies from India attempting to assess the cost of care of AD. The aim of our study was to assess the cost of care of AD in children in an outpatient hospital setting.

Methods

All children <10 years attending the pediatric dermatology clinic at our center during the period July 1, 2007–June 30, 2008 were screened, and those who met the selection criteria and gave written informed consent were inducted. A sample size of 40 patients was predetermined to yield adequate statistical power. The inclusion criteria were children <10 years of age and diagnosed to have AD on the basis of UK working party criteria questionnaire.[17] Children with any comorbid dermatological or medical illness and families with more than one member suffering from a chronic illness were excluded. All recruited patients were followed-up for 6 months.

Demographic information, clinical profile of the patients were recorded. Severity and extent of AD was estimated according to scoring of atopic dermatitis[18] index and patients were graded into three categories: Mild (score < 25), moderate (score between 25 and 50) and severe (score > 50).

The cost assessment questionnaire was specifically designed for this study [Annexures I–III]. It had a provision for measuring direct, indirect and provider costs[181920] [Table 1]. The cost of the drugs was calculated from the information and the bills provided by patients and their families. The providers cost were obtained from hospital data. Patients were assessed using the demographic and clinical profile sheet and cost assessment questionnaire. Information from caregiver was obtained 4 times, once at baseline, then at 2 months, 4 months and at 6 months.

Standard deviation and ranges were calculated for continuous data means. Chi-square test was applied for discrete data percentages and numbers. Correlation coefficients were calculated for the relationship between two variables and Kruskal–Wallis test was applied for the comparison of severity among three groups in AD.

Results

Of the 40 patients, 37 completed the study. The demographic details and disease characteristics of the patients are given in Tables 2 and 3. Majority of the patients is visiting the clinic were from Chandigarh or neighboring townships and had a monthly income of more than Rs. 3000/month. The average number of visits to the hospital during this period was 6.5 (range: 2–8) and the average number of flares were 3.0/patient, which could account for the greater number of visits.

Table 2

Demographic details of the patients recruited in the study

Table 3

Clinical and treatment details in the study group

Total cost was calculated as the sum of the mean caregiver cost, provider cost and indirect cost. Calculation of costs over the entire 6 months period revealed that mean total cost was Rs. 6235.00 ± 3514.00 (range: 2304–17,764). Out of this total cost; caregiver, provider and indirect cost along with its proportion in relation to the total cost are given in Table 4. Caregiver cost constituted 50.2%, while provider cost was 18.1% of the total cost of care.

Table 4

Total treatment costs in rupees and proportion of different components in percentage of the total cost

The cost of drugs amounted to approximately 73.7% of the caregiver cost, followed by mean cost for travel, Rs. 773.00 ± 834.00 (25.6%). The cost of registration and file making was only Rs. 20. No laboratory investigations were done in the patients as none of them were on systemic therapy such as azathioprine, cyclosporine and steroids or phototherapy.

Similarly, the consultation cost was 66.1% of the provider cost [Table 5]. Indirect cost is calculated by adding loss of earnings of parents due to hospital visits. Calculation of costs over the entire 6 months period revealed that mean indirect cost was Rs. 2264.00 ± 2392.00 (range: 0–13,332).

Table 5

Provider costs in rupees

Cost of care of AD according to the severity is given in Figure 1. There was statistically significant difference in mean total cost (P = 0.0001) depending upon disease severity.

Figure 1

Cost of atopic dermatitis according to severity

Discussion

Skin diseases have been cited among the top 15 medical conditions for which prevalence and health care spending increased the most between 1987 and 2000 in the US.[21] Besides direct health care cost, indirect costs like salary/wages lost due to productivity loss and decreased health-related quality-of-life have a significant bearing on patients and their families. Quantification of these costs is challenging, yet important, as only then can studies of the cost-effectiveness of therapeutic interventions be designed. Despite methodological variations in calculating the cost of AD, the consistent finding is that the AD causes a significant economic burden on the patient and his/her family. This fact has been extensively documented by a number of studies in Western literature that have estimated the cost of care of AD.[678910111213141516] However, information from developing countries is scarce. The studies that are available suggest that there could be differences in socio cultural and treatment milieus in different countries. Thus, our endeavor in this study was to calculate the cost of care of AD in an outpatient setting in a developing country.

In our study, the cost of care of AD amounted to Rs. 6235.00 for a period of 6 months and by extrapolation the annual cost comes to approximately Rs. 12,000–13,000 which is not significantly different from that of diabetes mellitus and schizophrenia in India.[22]

Out of this total cost caregiver, provider and indirect costs were approximately Rs. 3022.00, 948.00, and 2264.00 respectively. The cost of medicines (38.6%) and travel costs (31.7%) accounted for approximately 70.0% of the total costs. The hospital provided no medicines to patients with AD, so the patients had to spend this amount out of their pocket. This is in contrast to Western countries where the state or insurance companies bear the cost of treatment.

The total cost of AD increased with increasing severity of the disease. It was approximately Rs. 3579.00, 6807.00 and 8991.00 for mild, moderate and severe disease respectively. One of the few studies assessing cost of AD in relation to severity, from Australia, in 48 children aged 4 months to 15 years and a control group of 46 children with diabetes revealed that the mean annual direct costs to families was Aus $330 (Rs. 10,466.00), $818 (Rs. 25,943.00), and $1255 (Rs. 39,803.00) for the mild, moderate, and severe groups, respectively, compared with Aus $444 (Rs. 14,079.00) for the control group of diabetic children. The findings of both the above mentioned studies[1523] were similar to our own though the costs cannot be directly compared due to variations in methodology, differences in health care systems, economic and social set-up differences, variation in the study population (general practitioner vs. hospital), number of cost components included and variation in the severity of study population.

Our study shows that the cost of treatment of AD in India may not be significantly different from that reported from many developed countries, but the caregiver and provider cost proportions are different, and the main brunt of the financial burden is borne by the family. The monthly income of an average Indian at the time of this study was approximately Rs. 4000 which may differ considering a rural or urban placement and regular versus contractual wages.[24] Considering that there is no social security system in place in India at present, a 6 months cost of treatment of AD of approximately Rs. 6000 is significant in these patients amounting to about 25% of the total earnings for the period. Since AD is a disease with remissions and relapses, the cost of care would actually be recurring and much higher.

The number of visits made to the hospital is an important determinant of the total cost, and frequent visits to the hospital due to relapses are commonly observed in AD. This further increases the cost of care especially in the case of frequent visits. Hence, reducing the number of visits to the hospital may be one of the most effective ways of cutting down on costs.

Methodological lacunae or shortcomings of our study include a small sample size, short duration of study, lack of proper validation of the instruments to measure costs, inability to measure certain types of indirect costs (difficult to compute) resulting in a possible underestimation of indirect costs and exclusion of inpatients or patients on systemic therapy or phototherapy.

Comparing these studies clearly shows that while the differing study methodologies may not allow us to estimate the true total cost of AD, even then these figures reveal a significant economic burden of the disease. To the best of our knowledge, the health insurance cover for dermatologic diseases is practically nonexistent in India. This study is an attempt to highlight the cost of care of a common dermatologic disease in children and the need for intervention by the governmental and nongovernmental organizations by way of provision of resources for disease management. More studies on a larger subset of patients, including severe AD or inpatient costs are required in the future as it will help in the formulation of guidelines for better management of AD and facilitate improved allocation of resources available for management of dermatological conditions in our country.

What is new?

Cost of treatment of AD in India is not significantly different from that reported from many developed countries, but the caregiver and provider cost proportions are different and the main brunt of the financial burden is borne by the family. Huge vulval epidermoid cysts like in our case have never been reported till date

The 6 months cost of treatment of AD of approximately Rs. 6000 (about 25% of the total earnings in majority of our patients), which is not significantly different from that of diabetes mellitus and schizophrenia according to a study conducted in our hospital in the Departments of Psychiatry and Endocrinology. Since AD is a disease with remissions and relapses, the cost of care would actually be recurring and much higher.

COST of registration and clinic file making

Cost of investigations

Cost of treatment

Providers cost

Loss of earnings of the caregivers