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"The valuation of the financial cost for

the therapy and regulation of type II diabetes

for which patients are responsible for

in Greece"

By

Dr. Victor G. Papagiannopoulos

Pharmacist & Educator

INTRODUCTION:

Diabetes mellitus is a disease that troubles thousands of people in Greece, bringing on a significant economic cost that is incurred both by the State and the patients.

Searching in the Greek and the International bibliography to find relevant research or studies related to the valuation of the economic cost of diabetes mellitus therapy for which patients are responsible for, I reached a dead end. Most research is about diabetes cost paid either by the State or by the Social Insurance Institutions. Only in very few cases appear some references to the partial costs for which diabetics are responsible for. However, in these cases the matter of the cost is not examined thoroughly, due to the fact that the main objective of these studies was not the cost of diabetes for which diabetic patients are responsible for.

OBJECTIVE:

The main scope of the present research is the valuation of the financial cost of the therapy and the regulation of type II diabetes for which patients are responsible for in Greece, more specifically in the area of Athens.

In this study, I tried to estimate the major factors responsible for that cost. The parameters taken into consideration for the calculation of the cost for the therapy and the regulation of diabetes II are: the cost of the medical visits, the cost of the medication, the cost of the supplementary medical materials and of the laboratory microbiological tests, the cost of hospitalization and the cost of the complications due to diabetes, as well as the cost of the visits to dentists and ophthalmologists. In addition, there has been a valuation of the social cost, the regulation state of diabetes and the general health status, the correlation between the personal costs and diabetes disease, the role of the pharmacist, and finally, recommendations regarding the areas in the health system that need improvement, based on comments by the patients themselves.

RESEARCH DESIGN AND METHODS:

The research was conducted from February 1st to July 30th, 2000.

SAMPLE: At first, I addressed 327 type II diabetic patients, from whom only the 101 accepted to participate in the research. So, the sample consists of 101 diabetic patients diagnosed of suffering from diabetes type II. The analysis of the results shows that only 100 interviewees responded, as one interviewee was exempt due to inadequate data. After the exemption of that one individual, the ratio between the male and female patients was equal.

During the research, all diabetics were following a therapeutic treatment of either only diet, or oral medicine,

or insulin, or a combination of the above.

The sample consisted of (101) individuals-clients of a pharmacy (31) situated in Zografou Municipality (medium socioeconomic area) and individuals-members of .... { = Open Auspices Center for the Aged (O.A.C.A.)}of Zografou Municipality (9), Ilioupoli Municipality (11) (medium socioeconomic area) and Ilion (50) (low socio-economical area).

The age of the diabetic patients ranged on the average 71,8 7,8 years (between 52-92 years). The average height was 165,2 7,8 cm (between 145-185 cm), the average weight was 74,41,2 kg (between 48-110 kg). The BMI ranged on the average 27,24,2 (between 15,5-45,8). 76% of the diabetics were of a lower educational level, 13% of a medium educational level, 7% of a high educational level and 4% of a higher educational level. 98% of the diabetic patients were retired or housewives. Two of the diabetics stated that they worked for 48 and 38 hours a week respectively.

65 out of the 100 diabetic patients were insured in the ... {( = Social Security Institution (S.S.I.)}, 9 in ... {( = National Agricultural Insurance Institute (N.A.I.I.)}, 3 in .... ... {( = Professional & Handicraft Insurance Fund Commercants Insurance Institution (P.H.I.F. C.I.I.)}, 1 in {Banking Fund}, 4 in .... { = Public Utility Services Institution (P.U.S.I.)}, 9 in {Public Fund}, one had private insurance and 8 in smaller social insurance services. 66 out of the 100 were directly insured and the other 19 indirectly insured.

The net monthly income of 14% of the diabetics was 0-100.000 drs., of the 61% 100.001-200.000 drs, of the 23% 200.001-400.000 drs and of the 2% more than 400.001 drs.

36% live alone, 49% are members of a two-person family, 6% are members of a 3-person family, 7% are members of a 4-person family and 2% are members of a 5-member family. 57% stated that no person of their family is working, while 18% answered that only one person of the family is working. 11 out of 100 stated that there is one more person in their family suffering from diabetes and 3 out of 100 stated that there are 2 more persons suffering from diabetes. 10% of diabetics are suffering from diabetes for 20-35 years, 37% for 10-19 years, 27% for 5-9 years, 23% for 2-4 years, and 3% for 6 months to 1 year.

 

SAMPLE CHOICE PROCEDURE

I tried to use a random sample, but representative of the general population of diabetic patients, therefore I addressed my research to diabetic members of Open Auspices Centers for the Aged and clients of a pharmacy. This way I managed to have a different attending doctor for each subject, variety in the medical treatments followed, variety in the medical payments and variety in the seriousness of the disease of diabetes. Moreover, all the individuals of my research were active members of the society and not seriously ill (as for example, bed-ridden people with high therapy costs). I did not address my research to diabetic-patients of hospital outpatient departments or hospitalized diabetics or even diabetics leaving private hospitals, firstly because the filing of the questionnaire was very long (75 min) and secondly, because our research could be accused doctor payments and in the cost of the medical and supplementary medical material used (in the case of preference, on part of the doctor, for medicines and supplementary medical materials from a particular medical company). In addition, the nature of the questions (especially those referred to the economic nature of the matter, wouldnt allow us to submit a questionnaire in the hospital or in private doctors office as the psychological climate would not be the most appropriate and it was very probable that some economic data might have kept the patients from telling the truth. I also did not address hospitals due to the fact that diabetics that I could find there would suffer more severely from diabetes and therefore should be considered as most serious cases. I was concerned that I could not be sure about what would be the real percentage ratio of them compared to the general population of diabetics in Greece, and I would reach false conclusions. Therefore, I chose to include them in my sample absolutely randomly, during the random sample collection. Finally, I did not address private hospitals or private clinics, as the diabetic patients there would be of a higher income and therefore I couldnt possibly know a priori their ratio in respect to the general population of diabetic patients in Greece, which might have also led me to false conclusions. Therefore, I have chosen to include them in my sample absolutely randomly, during the random sample collection.

 

COLLECTION OF RESEARCH MATERIAL

For the collection of research material, I formulated 112 questions that I categorized into 12 groups.

The first group of questions has to do with the demographic and personal data (it includes 26 questions regarding the address, sex, age, height, smoker / non smoker, number of cigarettes per day, educational level, type of profession, working hours per week, social insurance, existence of a private insurance and insurance fees, net monthly income, annual personal or family income, number of persons in the family, working persons in the family and their net monthly income, their sex and age, number of diabetics in the family, first time diagnosis of the disease).

The second group of questions refers to the attending doctors of the diabetic patients (it consists of 17 questions that are divided into four sub-groups with the following subjects: a) doctors specialty and frequency of visits, b) reasons for visiting the doctor, c) doctors fee and d) patients satisfaction level. (All questions in this group are related to the doctors specialization, type of doctor, frequency of visits, reasons of visiting the doctor, doctors fee, justification for the non-formal payment given to the doctor, contributions to the insurance institutions, duration of the medical tests, patients satisfaction level, doctors eagerness, benefits for the patient, frequency of changing doctor and reasons for changing doctor).

The third group of questions refers to the cost of the pharmaceutical treatment (it includes 9 questions related to the type of the medicines, the dosage pattern followed, the participation percentage of the patients to the social insurance institution when buying their medicines from pharmacy, type of diagnosis written in the prescription booklet, frequency of buying the medicines with or without a medical prescription (either of the social insurance institution or not), cost of medicines taken for the regulation of diabetes disease, as well as cost of the rest of the medicine taken not directly related to diabetes).

The fourth group of questions concerns the social cost (it includes 8 questions about the % percentage reduction of the activities of the patients, the hours per week dedicated by another family member to do tasks the patient himself is not capable of performing, the services offered by Open Auspices Centers for the Aged, % percentage of reduction of professional activities, reduction of annual income due to diabetes and whether the patients have found that diabetes is a barrier for their career).

The fifth group of questions refers to the cost of complications due to diabetes (it includes 12 questions related to the kind of complications due to diabetes, hospitalization due to these complications (hospitalization duration, diagnosis during the admission in the hospital, specialty of the attending doctor in the hospital, as well as the pharmaceutical treatment followed during hospitalization), expense level in the hospital, non-formal payments, if any; coverage of the expenses by the social insurance institution, loss of income due to hospitalization, recovery and loss of income due to patient being considered having a handicap.)

The sixth group of questions relates to the cost of the supplementary medical material and the laboratory tests (it includes 10 questions about the coverage of the expenses by the social security institution, the amount of the money spent on a monthly basis, the frequency of blood-glucose and urine acetone self-testing, the frequency of glucose and other laboratory tests performed in the Social Security Institution (SSI), the hospital and the private laboratory centers and the cost of these tests).

The seventh group of questions relates to the hospital expenses in a hospital during the last 12 months (it includes 8 questions concerning the number of admissions in the hospital, the type of hospital (public or private), the diagnosis during admission, total costs of hospitalization of the last 12-month period, days of hospitalization and payments (non-formal or formal) to the doctors and to the medical staff).

The eighth group of questions concerns the regulation status of diabetes as well as an estimation of the overall health status of the patients (it includes 7 questions in relation to the indication of glycosylated haemoglobin during the last measurement, indication of blood-glucose in fast (during the last measurement), the indication of the blood-glucose after lunch (2 hours after dinner) (during the last measurement), mean of the daily hypoglycemia number, the self-characterization of their overall health quality, the quantitative self-characterization of the patients overall health and finally, the comparison correlation between the glucose value and the self-characterization of their health.

The ninth group of questions has to do with the personal expenses and their relation to diabetes mellitus (it includes 3 questions related to the % percentage increase in the nutrition, clothing and shoe costs, everyday living costs, expenses for information about diabetes, subscriptions to various associations, and the % increase of the personal costs in comparison to those of the other members of the family).

The tenth group of questions relates to the cost of the visits to other doctors and is separated into 2 subgroups: one refers to the cost of the visits to dentists (it includes 6 questions) and the other to the cost of the visits to ophthalmologists (it includes 6 questions). All questions relate to the frequency of the regular visits, to the kind of doctor, to his payment (formal or non-formal) and to the percentage of the doctors payment that the insurance covers.

The eleventh group of questions relates to the role of the pharmacist (it includes 3 questions concerning the active role of the pharmacist, the choice of the appropriate medicine, the dosage and the matters of nutrition and diabetes).

The twelfth group of questions has to do with diabetic patient suggestions about the improvement of the existing health system in Greece (it includes one question).

The majority of the questions were open, so it was easy to record the precise answer of the interviewee. In the closed questions, the dionymic scale was used (yes, no).

Duration of the questionnaire: 30-90 min. Mean duration time: 75 min.

 

DIFFICULTIES I ENCOUNTERED

According to the guidelines set for the protection of the personal data, we could not have access to files with diabetic patients names, so it was very difficult to find subjects following a random sample collection. However, we have been helped a lot in this difficult task by the Municipality Services of Zografou and Ilion, as well as by the staff of Zografou, Ilion and Ilioupolis Open Auspices Centers for the Aged that have successfully brought us in contact with those diabetics willing to participate in our research. Unfortunately, no other Municipality has expressed a similar interest in participating in our research. In some cases, municipalities demanded that the patients they would introduce us to, sign a statement before the filing of the questionnaire, declaring that they accept to reveal any personal data of financial nature (i.e. their income) on their own free will, and that they wouldnt make any claim either from the Municipality or from us. These Municipalities have been excluded from our research due to the psychological impact this would have on the patients when filing out the questionnaire, leading to an inappropriate climate and reserved answers by the patients who would probably not give truthful responses about their personal data. The Panhellenic Federation of the diabetic Associations and Unions in Greece has also informed their members about our research and has invited anyone interested to participate in it to communicate with us; unfortunately, none of them has contacted us. Also some pharmacists informed their clients about our research and invited them, too, to contact us if they wished to participate in it; in this case no diabetic has contacted us so far. Only the customers of a pharmacy did accept to participate in the project and that was managed due to the excellent relations of the pharmacist with his clients.

Despite these difficulties, I tried to make a random selection of the subjects, to have equity between men and women, to have a satisfactory sample size as the size of similar studies is greater or equal. Finally, I performed a self-testing of my random sample collection that confirms there was indeed a random sample collection (Table 1).

Table 1 Classification per sex, age and educational level

Educational

Level

Total

Sex

Age

(X2 test ↑↓)

 

 

Men

Women

52-70

71-92

Low

76

36

40

27

49

Medium

13

6

7

10

3

High

7

5

2

4

3

Higher

4

3

1

3

1

Total

100

50

50

44

56


We note that above, the educational level is not related to the sex, but to the age as an X2 test analysis performed has shown a semantic level of <0.05 for the relation between the educational level and the age. Specifically, the higher the age of the diabetic, the more possible that he is of a lower educational level. That is also confirmed by the fact that individuals of age 71-92 years were at their youth during the First and the Second World War when it was difficult or even impossible to study.

I have also tried to examine the matter of the therapy cost and of diabetes regulation that is paid entirely by the patients themselves; for that reason the questionnaire included 112 spot-on relevant questions. Besides these spot-on questions and the overall examination of the matter, what added to the success of the present research was the fact that the interview has taken place in a friendly climate of mutual trust. The staff of Open Auspices Centers for the Aged had introduced us to the diabetics participating in the project, and therefore, they didnt consider us strangers. That helped a lot in the correct submission of the questions. The conversation lasted 75 min (mean time), which also contributed to the correct and honest answering of the questions.

A constant control of the answers was performed through conversation. If an answer seemed to be unrealistic (i.e. a zero doctors payment, without the patient being indigent or having special relations with the doctor friendly, familial or other), the question was asked again later on, when a stronger relation and trust with the interviewee had developed, and the second answer was recorded.

Finally, a self-testing of the reliability of the patients answers was performed which confirm it successfully (Table 2)

Table 2

Blood glucose rates in fast

Quality classification of their Health

 

Bad

So

and so

Medium

Good

Excellent

No answer

Total

95-120

 

 

5

6

1

 

12

125-160

1

6

19

23

 

 

49

161-195

3

2

12

5

 

1

23

200-280

3

1

4

4

1

 

13

300-340

1

 

1

 

 

1

3

Total interviewees

8

9

41

38

2

2

100


In Table 2, the Spearman criterion shows a correlation coefficients rate rs=-0.252, asymptotic p=0.011 with a semantic level up to 95%. As a result, there is indeed a correlation between the morning blood glucose rates in fast and the quality qualification of the diabetics health by the patients themselves. More specifically, the more the blood glucose rates are increasing, the worse the patients themselves are qualifying their health.

 

STATISTICAL METHODS

All ramp variables have been shown in Tables of descriptive statistical method (number of non lost notes, Mean and Median rates, standard deviation (SD), first (p 25%) and third (p 75%) quarter, width (Min.-Max.). Moreover, for the categorical data there have been constructed Tables of interrelation (frequency, percentages).

For the comparison of all the demographic and clinical data of the patients, as far as it concerns the overall cost of diabetes used for the non parametric sign test of Wilcoxon (Wilcoxon rank sum test) and for the Spearman (rs) correlation coefficient).

For all 2x2 Tables the Fishers Exact control was used for the testing of the independency of the examined variables. In the cases, where the interrelation Tables were of a 2xk type, where k ordered statistical categories, the non-parametric Kruskal-Wallis control (K-W) has been applied.

The testing for the interrelations among the ramp variables has been performed with the use of the Spearman (rs) correlation coefficient. When the coefficient rate was close to 1, it meant a positive correlation that equaled to an increase at the rates of a parameter while the rates of the other were also increasing. On the contrary, rs rates closest to 1 meant a negative correlation (increase of the rates of a size that was accompanied by a decrease at the rates of the other).

All testing were two-sided and the semantic level equals to 0.05. Where p<0.05 there were statistically important differences. Typical differences existed in the cases where 0,05 < p < 0,10. Data evaluation has been performed with the statistical package S.A.S. 8.1.

RESULTS

FINDINGS INTERPRETATION RESULTS

It is obvious that findings are showing that diabetes causes a substantial financial cost for the diabetic patient. That cost comes from the patients partial payment for the fee of the doctor who is regulating the diabetes, the pharmaceutical treatment, the hospitalization, the supplementary medical materials, the laboratory microbiological tests and the dentists and ophthalmologists payments.

 

COST OF THE MEDICAL VISITS

a. Conclusions

As far as it concerns the medical visits, I have noted that the majority of diabetic patients are being attended by a general practitioner for the regulation of diabetes. The choice of the doctors specialty to regulate diabetes does not depend on age (rate p=0,2359 =0,05), but on the educational level (rate p=0,0002 =0,05), as well as on the annual income (rate p=0,0247 =0,05) of diabetics.

The wealthier and the more educated the patient is, the most likely is for him to choose a physician specializing in treating diabetics. On the other hand, the less wealthy and the less educated the diabetic is, the most likely is for him to choose a general practitioner.

The choice of the kind of doctor (hospital doctor, doctor provided by the social insurance, private doctor) who is going to regulate the diabetes of the patient depends on the annual income of the patient (rate p=0,401 =0,05). The wealthier the diabetic is, the most likely is for him to choose a private doctor and most unlikely to choose a doctor provided by the social insurance.

In general, the majority of diabetics (81%) are visiting the doctors provided by their social insurance institution, usually 5-9 times per semester. That enables them to have their diabetes regulated properly, to have their medicines prescribed (62%) (in order to buy them from their pharmacy paying only a portion of the total cost) and finally, for various medical tests (11%). 18% of the patients are visiting the private and hospital doctors 2-3 times per semester. That means that there is a relationship between the kind of the doctor chosen (hospital, doctor provided by social insurance, or private doctor) and the frequency of the visits (rate p=0,00476, =0,05).

Only a small number of patients have the intention to pay a non-formal fee to the doctor, ranging from 2.000 to 5.000 Drs., because they believe he will pay more attention to them during the examination or to pay him back for the special care he offered them during the examination. The cost level of this non-formal payment depends on the kind of the doctor and on the place the examination is being performed (rate p<0,001, =0,05). Private doctors receive higher non-formal payments, following in diminishing order by the hospital doctors in their private office visits, the doctors provided by the social insurance in their private office, the hospital doctors in the hospital and finally, the doctors provided by the social insurance while at the institution they work for.

The duration of the medical examination depends on the kind of the doctor (hospital, social insurance doctor, private doctor), as well as on the place where the medical examination takes place (rate p<0,001 Kruskal-Wallis test, =0,05). The examination in the hospital doctors office lasts about 60 minutes, at the private doctors office 19 minutes, at the hospital doctor while in the hospital 17 minutes, at the social insurance doctors office 17 minutes and finally, at the social insurance doctors in the institution he works 7 minutes.

The majority of the patients (48%) are satisfied in a percentage of 90-100% with their doctor, whom in most cases, they consider eager to be of service. After they have visited their doctor, the majority (63%-78%) believe that they have benefited by having all their queries answered, learning new information about their disease, their health and the ways of facing diabetes, as well as that they have been helped in self-regulating their disease. Therefore, 92% of the diabetic patients havent changed their doctor since they were first diagnosed as having diabetes. Almost half of those who have changed doctor have not done so because they were not dissatisfied with the service.

Of those diabetics offering non-formal payments to their doctors, half believe that their doctor offers them services based on the amount of the fee they pay, and a quarter of them believe that the doctor offers them more services than he ordinarily would.

The mean annual cost of diabetics for doctors payments to regulate their diabetes is 24.440 Drs.

b. Conclusions interpretation

i) The reason that diabetics, most probably prefer the doctors provided by their particular social insurance institution is financial. First, they are not required to pay this doctor a fee and second, when these doctors prescribe medication, the patient is required to pay only a portion of the overall cost. Therefore, the poorer the patients are, the most probable it is that they choose the doctor of their social insurance institution. Besides, the majority of the interviewees are retirees with low incomes. That conclusion is supported further by the findings of another question, where 62% of the diabetics are visiting the doctor of the social insurance institution to get a prescription for the medicine they need, so that they can pay only a portion of the overall value at the pharmacy.

ii) They also prefer general practitioners, due to the fact that there are not enough physicians who are diabetes specialists on the list of doctors provided by the social insurance. That is why the less wealthy the diabetics are, the more likely it is for them to choose a general practitioner. As we can see, though, from the answers given to another question, 31% of diabetics wish there were physicians who are diabetes specialists in their social insurance service.

Despite that, it is also noted that the lower the educational level of the patient, the more the patients prefer a general practitioner and that is so, most probably, because they havent understood yet how much more a diabetes specialist could help them with the regulation of diabetes. Usually non-educated individuals do not like changes in general, and it is therefore especially difficult for them to understand why they should change their general practitioner who has been their attending physician, in favor of a diabetes specialist.

It is also possible that older people who also have other illnesses prefer having a general practitioner take care of their overall health, since he will take care of their diabetes as well as any other illnesses they might have. It is also noted that in Greece, until recently, diabetes has been attended by an endocrinologist, something that is also heightened by the high frequency percentage of the visits ranging from 5-9 per semester. However, it needs to be mentioned here that in most of the social insurance institutions (SSI, PHB, etc) the doctor is obliged not to prescribe anything more than the quantity of medicines set for a month. Therefore, a 6-time frequency of visits is the usual one, however, greater frequency implies that the doctor probably attends the patient not only for the diabetes, but for other diseases, too.

It is also probable that the preference for the general practitioner by the lower economical levels is due to the fact that the patient will pay only one combined doctors fee. It is usual the existence of a doctor (like a general practitioner) able to attend other diseases, too, unless the patient has to visit two kind of doctors of different specializations, a general practitioner and a diabetes specialist or endocrinologist in which case he would have to pay two medical fees, which means he would spend twice the amount.

iii) The frequency of the visits and the kind of doctor (hospital, doctor provided by the social insurance, or private doctor) a patient visits is most probably related to economical reasons. Only the doctors provided by the social insurance can prescribe medicines for which the diabetic will pay only a potion of the cost. The bigger social insurance services, especially THE SOCIAL SECURITY INSTITUTION (SSI) and PROFESSIONAL & HANDICRAFT INSURANCE FUND (PHB), prohibit doctors to prescribe more medication than the patient can consume within a month. In fact, some social insurance services press their doctors to prescribe only one box of medicine per prescription, especially when it comes to diabetes that is a chronic disease. This concerns the diabetics, who in response to a question, 22% of them state that they ask their doctors to prescribe more medication per prescription. This indicates that those of the insured who arent financially well off visit more often than needed the doctors provided by the social insurance, exclusively for the prescribing of their medication.

iv) The amount of the non-formal payment to the doctor depends on the kind of doctor (hospital, doctor provided by social insurance, or private doctor) as well as on where the medical examination takes place. Private doctors receive larger amounts of money, followed by the hospital doctors in their private office, and social insurance doctors in their private office, hospital doctors at the hospital, and finally social insurance doctors at the organizations office.

The amount of the non-formal doctors payment, is likely to depend on whether the doctor is being paid by the diabetics social security institution or not. The more diabetics believe that doctors are not paid at all or at least not up to a level they deserve by the state or the social insurance institution, the more money they offer him in order, according to their statements, for the doctor to pay special attention to them during the examination or just to express their gratitude for taking good care of them.

An important factor in the amount of these payments is the time a doctor spends with the patient for the medical examination. The longer the examination lasts, the higher is the non-formal payment.

v) The duration of the medical examination is related to the kind of the doctor (hospital, social insurance, or private doctor) as well as to the place where the examination is being performed. The duration is bigger for the hospital doctor in his private office; it is decreasing significantly and is about the same for the private doctor, the hospital doctor in the hospital and the social insurance doctor in his private office. Finally, it is reduced even more for the social insurance doctor in his organizations office. It is possible that this relationship depends on the workload of the doctor. The less busy the doctor is, the smaller the number of patients he sees for medical examination and the more the medical examination will last. The doctors who are more busy are the social insurance doctors at the public office, where they see all the insured coming in, without an appointment. On the contrary, the rest of the doctors see patients only by appointment. Finally, the hospital doctor sees the fewest number of patients in his private office, therefore, he is able to dedicate the more time than the others.

Moreover, the duration of the medical examination may be of some importance for the frequency with which the diabetic is visiting the doctor. It is possible if the duration of the examination lasts longer, the more often the patient is visiting the doctor, due to the fact that the doctor has developed a more complete overall view of the patients health.

vi) The eagerness and the efficiency of the doctors in respect to their duties is high, as stated by the majority of the diabetic patients and it is also shown both by the diabetics satisfaction and by the fact that the patients do not want to replace their doctor (almost never), as well as by the fact that they state they benefit after their visit to the doctor.

The fact that 22% of the diabetics state that their queries are not answered, 35% state that they havent learnt anything more about their disease, 37% that werent helped to understand what to do in order to self-regulate the disease, 14% that were informed for the progress of their health, and 29% that they werent informed about the ways of facing their disease is being analyzed further on. It is possible that the social insurance doctors, especially to whom the majority of the patients go, do not have the time due to heavy workload (large number of daily visits, according to the contract they have signed with the social insurance service they belong to) to completely satisfy the patients within the few moments that the examination lasts. Moreover, as it has been found out, the patients go to these doctors not only about matters of diabetes but for other illnesses, too, which means that the time dedicated by the doctor for diabetes is shorter and depends on the seriousness of the other illnesses. It is also probable that as diabetic type II patients are mostly older people, they might have a reduced understanding and apprehension of the guidelines applied by their doctors, and therefore they could require more time for the examination. In addition, if we take into consideration the fact that the majority of these people are of a low educational level, which means that the doctor has to spend more time to explain the guidelines and information provided, we can easily appreciate the problem. So, it is obvious that within a short time of 10-20 minutes that the doctor has in his disposition, it is very difficult for the patients, regardless of the efforts of the doctor, to comprehend all the information that is provided. That is probably the main reason for the high frequency of the visits, between 5-9 times per semester, to the social insurance doctors.

 

COST OF THE PHARMACEUTICAL TREATMENT

The diabetic patients who buy medication that is taken orally, with a prescription from a social insurance institution doctor, pay 25% of the cost of the medication. Diabetics taking insulin have the right to receive it for free with a prescription from their social insurance doctor.

The majority of the patients are taking medication prescribed by the doctor of their social insurance institution. Only 6% of them are buying their medication from the pharmacy without a prescription (given that they are well aware, from previous visits to their doctor, that they have to follow a long-term treatment with certain medicine). They have said that the small cost of the medication is the main reason for not having obtained a prescription, while at the same time that helps them avoid the bureaucratic procedures of having the social insurance doctor prescribe the medication. They consider that many regular visits to the doctor are not necessary, as they do not benefit by them. As it has been mentioned previously, the majority of the patients visit their doctor once a month, mainly for the prescription of their medication that the doctors are required to prescribe in adequate quantities for one month. That is also confirmed by the answers the diabetics gave to another relevant question.

The mean annual cost for medication regulating diabetes is 33.187 drs. and for medication not related to diabetes is 76.524 drs.

Expenses for medication related to diabetes do not depend on the sex or the annual income of the patients, but on their age. On the other hand, the amount of the cost for medication not related to diabetes does not depend on sex, age or the annual income of the diabetic patient.

Diabetes and other illnesses are affecting equally men and women, rich and poor. The pharmaceutical treatment is the same for all of them and the medicine is not a commodity that can be pared down for financial reasons. Rich and poor, men and women are buying the medication prescribed by their doctor, as these are definitely necessary.

Type II diabetes appears mainly in older people, 50 years or more, and the pharmaceutical treatment depends on the duration of the disease. So, in the primary stages it is treated with the appropriate diet, after some years it is treated with oral medicine and after 8-10 years of treatment with oral medicines, with insulin. It is therefore understood that the expenses concerning the medication for treating diabetes vary with respect to the patients age.

On the contrary, the expenses for medication not related to diabetes, are not affected by the age of the patient, as the pharmaceutical treatment is the same for every disease regardless of the age (we are referring to older people).

 

SOCIAL COST

58% of diabetics have not reduced their weekly activities due to diabetes, while 34% have reduced them by 1-50%. That reduction is not related to the sex, age or income, but to the educational level. The higher the educational level, the lesser the reduction of activities. Perhaps this relationship between high educational level and activities can be explained by the fact that well educated people can organize better their lives and are able to find ways to perform their activities, no matter the obstacles they face. Moreover, it is likely that they are able, due to their education, to estimate better whether the reason for the reduction of their activities is diabetes. Therefore, they do use diabetes as an excuse for everything that is happening in their lives.

However, there are diabetics that need the help of another person, member of their family or not, to help them with tasks they themselves are incapable to perform. The mean weekly hours that another person is occupied with that task is 3. Not to forget though, that diabetes is a disease causing many complications, and depending on the seriousness of the illness and the age of the patient (usually elderly people), it causes diabetics to need help from others in order for them to perform various tasks.

Finally, according to the scant data available (due to the fact that the majority of the interviewees are retirees and housewives), it is noted that diabetes is an obstacle to a persons career and leads to the reduction of annual income, as well as affecting the diabetics professional occupation. That is also backed up by a project elaborated in Japan1. Diabetes and especially the non-regulated one, causes weakness and feeling of sickness (see also, symptoms of hypoglycaemia and hyperglycaemia in the general part) that decrease the effective working hours. If we add to that the reduction caused by diabetes complications, its easy to understand that the effective working hours are being reduced resulting in the decrease of income for self-employed professionals and become an obstacle to the progress of the career of those working as employees. Fortunately, in Greece, as far as it concerns those people working as employees, the State requires that diabetic patients be treated favorably, like people with special needs. Moreover, if the disability due to diabetes is more than 67%, all patients, regardless their profession, benefit from a reduction in taxes.

Finally, Open Auspices Centers for the Aged have helped a lot in the diagnosis and the therapy of diabetes with the regular blood-glucose measurement of their members. In some Open Auspices Centers for the Aged, in fact, they are also measuring the cholesterol, the triglycerides and the blood pressure of their members. In addition, there is a doctor in every Open Auspices Centers for the Aged examining those members that want to and prescribing for them all the medications approved by the National Agricultural Insurance Institute (NAII). Such doctor services are used only by a few of the members. Not to forget though, as mentioned previously, that almost half of the diabetic type II patients are not aware of the fact that they suffer from diabetes, so the task of Open Auspices Centers for the Aged to diagnose and treat diabetes is very important.

 

DIABETES COMPLICATIONS

The majority of diabetics (60%) do not suffer from any diabetes complications. The main complications of diabetes were those related to eyes: cataract (8), glaucoma (3), loss of sight (6), other complications of they eyes (6), problems in the blood circulation (5), blood vessel problems (3), blood pressure (3), neuropathology (4), multi-neuropathology (2), kidney problems (4), strokes (3), erection problems in men (3), hearing problems (2), heart problems (3) and stomach problems (1). Finally, another problem is the amputation of some body parts(2).

Eight of the patients who had diabetes complications were hospitalized due to the complications.

The complications having appeared to the diabetics of my sample are exactly the same to those appearing to all diabetes worldwide and are presented in detail in the general part of the present project.

 

SUPPLEMENTARY MEDICAL MATERIAL AND LABORATORY TEST COST

The majority of the diabetic patients (81%) stated that their social insurance does not cover expenses, either partially or entirely, for supplementary medical supplies that are needed (blood glucose measurement device, strips for the blood glucose measurement device, strips for the urine glucose measurement, lancets for the piercing of the fingers, syringes for insulin, alcohol, cotton-wool and glucose pills). Almost half of the insulin-dependent diabetics have a blood glucose measurement device and are regularly buying syringes for their insulin injection, as well as strips for the measurement of their blood glucose, with the cost partially or totally covered by their social insurance service.

30% of the diabetics are capable of self-measuring their blood glucose level 1-4 times per week, 23% of them are measuring the glucose of the urine approximately 7-10 times per week, while only 5% are measuring urine acetone with approximately the same frequency.

The main reason for not measuring their glucose levels more often is mostly the fear of having their expenses increased (51%), the fact that they dont find it necessary to do it (45%), the fact that their attending doctor has not advised them to do so (27%), and the fact that they cannot do it by themselves (7%). The mean of a diabetics expenses for the supplementary medical materials is 36.606 drs. per year.

A significant percentage of diabetics chooses the Social Security Institution for their blood glucose measurements (35%), a public hospital (6%), a private laboratory (33%) and Open Auspices Centers for the Aged (39%) with a frequency of 2, 1, 6 and 6 times per semester respectively. The mean of a diabetics annual expenses for private laboratory tests is 866 drs. In the contact we had with the Social Insurance Institutions of SSI, NAII and the PUBLIC FUND, (the majority of the insured belong to these social insurance institutions) we were informed that the expenses made by the type II diabetic non-insulin dependent patients were not covered by these institutions. Because of that, as well as due to the high cost, the fact that they do not consider it necessary, and the fact that their attending doctor has not recommended it, only one out of three patients performs a self-measurement of the blood glucose, often with a mean of 1-4 times per week. From the interview we did, we found that most of the diabetics believe that they are not able to evaluate the rates resulting from the self-measurement they have done (that is, they cannot use these rates to self-adjust their diet or the dosage of their medication) due to lack of education and knowledge. All of them are writing down the rates resulting by the self-measurement, in order to show them to their doctor the next time they visit him.

 

HOSPITALIZATION COST

During the last year, 11 interviewees had been hospitalized, 10 of them in a public hospital. 7 were hospitalized only once during the last year, while 3 were hospitalized twice.

The days of hospitalization ranged from 2-30 days. The mean annual expenses of their hospitalization, including the payments to doctors and to medical staff, were 4.300 drs. for the total of the diabetics.

 

DIABETES REGULATION STATUS AND VALUATION OF THE OVERALL HEALTH STATUS OF THE PATIENTS

The criterion for the diabetes regulation status is the measurement of the glycosylated haemoglobin that is being performed by 10% of the patients only. 3 out of 10 appear to have rates equal or lower to 7, which indicates a satisfactory regulation.

90% of the diabetics either do not know what this examination is or have done it only once, which is probably happening due to the fact that their attending doctor regulating their diabetes are mainly general practitioners (71%) and not diabetes specialists (who would most likely advise them to do it).

All patients are doing blood glucose monitoring in fast in the morning. 12% present rates up to 120mg/dl, that is normal, 49% of them present rates 125-160ml/dl that are bearable and the rest present rates higher than 160mg/dl meaning that they have not regulated the diabetes. That is probably due to the fact that 71% of diabetics prefer to have a general practitioner instead of a diabetes specialist , who is the most suitable one for regulating their diabetes.

The non blood-glucose monitoring, 2 hours after lunch, is being carried out only by 15% of the patients and it shows that 7 of them present rates below 180 mg/dl, which indicates good regulation of the disease, while the rest present higher rates and are considered not to be regulated.

The reason that there are only a few patients who do the after-lunch monitoring is probably that most patients are attended by a GP instead of a diabetes specialist, and that they are probably concerned about the financial cost of the extra monitoring. It is also likely that the patients do not consider it as something important to do, as shown by the findings.

There is no inter-dependence between the morning blood-glucose monitoring in fast and the blood-glucose rates taken 2 hours after noon lunch. However, we cannot back up with certainty something like that, as such a correlation has been under research only in 15 individuals (due to the fact that the rest 85 diabetics are not keeping up with the after-lunch monitoring.

The quality classification done by most diabetics themselves, regarding their health, is medium in 41% and good in 38%. The mark they are giving it, considering 100 as excellent, is 50-60 (35%) and 65-80 (40%). As shown by the Kruskal-Wallis criterion, too, (asymptotic p<0,001) there is a correlation between the quality and quantity classification of their health. That proves also that the patients are not answering accidentally, when they are asked to qualify qualitatively and quantitatively their health. Interviewees have shown that in general, they consider their diabetes as a minor health problem when compared to other health problems, such as arthritis that causes pain or other problems due to advanced age.

Their majority has not shown any complications due to diabetes and they are all active members of the society, as the older of them, 92 years old, is an Open Auspices Centers for the Aged member.

So, most of them are healthy and in addition, they are able to evaluate their health correctly.

The fact that the patients are estimating correctly the status of their health is also shown by the interdependence between the morning blood-glucose monitoring in fast and the quality classification of their health (Spearmans cc=0,252, asymptotic rate p=0,11 and semantic level 95%).

The results of correlation between glycosylated haemoglobin and the quality classification of health, as well as between 2-hour after noon lunch blood-glucose rates and the qualitative and quantitative classification of health should not be taken into consideration, as they apply to very few individuals only, and could lead one to wrong conclusions. Most of the diabetics (90%) are not performing glycosylated haemoblobin monitoring or noon after-lunch blood-glucose monitoring.

 

PERSONAL EXPENSES AND DIABETES

The majority of the diabetics (71%) believe that they have increased their expenses for nutrition due to diabetes. The average increase of the expenses concerning nutrition is 27%. Diabetes in primary stages is regulated with diet and in more serious stages both with diet and pharmaceutical treatment. Usually, the diet being followed by the diabetic patients requires that a specific quantity of calories be taken per day, as well as a specific ratio of proteins, carbohydrates and fat. Food sources that satisfy these two needs are expensive. Not to forget, that diabetes used to be called the disease of the rich due to the high costs to regulate it.

Concerning expenses for clothing and shoes, practically all interviewees (98%) answered that they have not increased their expenses due to diabetes. That is so, because almost none of them have had any complications, including ulcers in the feet or in any other part of the body, due to diabetes, since they did not have the illness for many years.

Concerning the increase of the living expenses, such as electricity, water supply and telephone bills, the majority (93%) have answered that they havent increased their expenses.

Moreover, they all answered that they have no expenses buying relevant print material (books, magazines) related to diabetes, neither are they members of Associations for diabetics. So, they are not spending any money for information regarding diabetes. That is probably due to the fact that they consider diabetes as a minor health problem, comparing it to other health problems appearing to older retirees, due to their advanced age. We should be reminded that 98% of our sample were retirees and housewives.

Regarding the increase of the expenses in everyday life compared to the other members of their family, they have all answered (that is those who have answered that question), except for one (many of them are living alone), that they have more expenses, averaging approximately 34%. That increase is probably due to the increased expenses for their nutrition.

 

COST OF THE VISITS TO OTHER DOCTORS

a. Dentist

Only a few diabetics (13%) are visiting regularly, once a semester usually, their dentist to have a dental check up. The majority (62%) is visiting the dentist only when they have a dental problem and 24% is not visiting him at all, as they wear dentures.

It is possible that most diabetic patients do not understand the importance of having regular dental check ups. As it has already been mentioned, usually one visit to the dentist per six months is advisable because diabetes affects the veins of the gum, and if untreated, can cause gum problems, resulting in the loss of the teeth and in having to wear dentures. 28% of those interviewed are already wearing dentures.

The very few of them that regularly visit a dentist, almost unanimously, prefer the dentist of their choice, as opposed to the hospital dentist or the dentists designated by their social insurance institution.

Probably, this is so because most of the social insurance institutions do not designate any dentist or if they do, they do not cover all the dental expenses.

In general, in Greece the dentist is paid directly by the patient, in cash. The social insurance institution does not cover these expenses, except for some exceptions.

It doesnt appear to be an inter-dependence between the frequency of the visits per semester and the kind of the dentists (hospital dentists, social insurance dentists, private dentists). However, it is impossible to extract serious conclusions due to the small number (13) of the interviewees, who regularly visited dentists.

b. Ophthalmologists

Diabetes often causes complications of the eyes, therefore, an eye examination once every six months is necessary. Usually, that examination includes fundoscopy.

42% of the diabetics are regularly visiting their ophthalmologist for an eye examination. We note that 7% of the patients are visiting their ophthalmologist for a check up and 4% due to diabetes. 44% of the patients do not visit an ophthalmologist regularly because they feel there is no need to.

Therefore, diabetics are not used to have an eye examination, such as a fundoscopy, at regularly intervals for the prevention of diabetes complications. It is very possible that they have not yet realized or maybe they have not been informed of the great importance and necessity for such an examination. They believe that they are not required to visit an ophthalmologist if they dont have a sight problem.

There is no evidence of correlation between the frequency of the visits to the ophthalmologist and the kind of the ophthalmologist (hospital , social insurance, or private ophthalmologist) visits.

c. Final conclusion

Diabetic patients, most likely, have not been informed or they do not realize the great importance and necessity of having preventive examinations at regular intervals in order to prevent complications that diabetes may cause to their teeth and eyes.

Most of them are not have such examinations.

The average annual expenses for the visits to the dentist and to the ophthalmologist at regular intervals is 12.690 drs. and represent 6,69% of the total annual expenses for diabetes.

 

PHARMACISTS ROLE

As shown by the findings of the present research, 15% of the diabetics are consulting their pharmacist regarding the kind of medication and the dosage they should take for the regulation of diabetes. 9% of them are asking information about nutrition related to diabetes. The advice usually asked from the pharmacist does not depend on the sex, age, educational level or the annual income of the diabetic patient.

It is worth mentioning that all diabetics 15 individuals asking their pharmacist for advice, are clients of the same pharmacy, from the clientele of which 31 diabetics have been interviewed as the whole.

Most probably, most of the diabetic patients are not seeking advice from their pharmacist concerning the kind of medicine and the medicines dosage, or nutrition matters, as their attending doctors have already informed them adequately about such matters. However, if the pharmacist himself wishes to offer information and advice, he can play a very important role. As time goes on, he can be the personal pharmacist of the patient, having previously gained the trust of the patient for his scientific qualifications and as long as he is willing to help doctors in their task, by answering patient questions that might need further clarification and explaining the difficult to understand terms or guidelines given to the patient.

It is also very likely that the pharmacy clients have developed certain intimacy and trust with their pharmacist and do not have difficulty talking openly with him about their real income and expenses, as for instance about the non-formal payments given to the doctors.

 

SUGGESTIONS FOR IMPROVEMENT

91% of the diabetic patients wish that some improvements be made to the existing health system, as far as it concerns diabetics.

Most of them are asking for improvements regarding the provision of the supplementary medical materials by the social insurance institution. These materials include the devices for the blood-glucose monitoring, the strips used for glucose and urine monitoring, the alcohol, the wool-cotton, the syringes and the glucose tablets. Suggested improvements have to do with the free provision, in adequate quantities, of all the needed supplementary medical materials. At the moment, most of the social insurance institutions are not giving them to anyone else but the insulin-dependent patients and even then, only under special terms and conditions depending on each social insurance institution.

A great percentage though, most of them SSIs insured, are asking that their social insurance institution provide them with all the medicines they need in sufficient quantities, so that they wont have to visit their attending doctor so often just to have him prescribe these medicines. Many of them are asking also to get for free those medicines they need for diabetes or at least in low prices, as diabetes is a chronic disease.

Now, patients are required to pay 25% of the total value of the medicines for diabetes, exempt for insulin, which is free. In fact, some social insurance institutions, such as SSI and PHB, require that their doctors prescribe no more than one or two boxes of tablets in every prescription they issue, given that this quantity will not exceed the total amount needed for a month. Moreover, all social insurance institutions require doctors to prescribe only medications that are included in a certain list. Medication not included in that list, although it has been given a circulation approval by the National Medicines Association, cannot be prescribed, unless it cannot be substituted by another medication and always on the condition that it be with the usual social insurance doctors prescription. The doctor will also state in writing the reasons why this particular medication is necessary for the particular patient. Very few doctors, however, have the time and the flexibility, by the social insurance institution they collaborate with, to write such statements.

Many diabetic patients (31%) would like to have their social insurance institutions, such as SSI, provide doctors who are diabetes specialists. Several complained about the inconvenience of waiting for their turn in the waiting lists of SSI, in order to visit a doctor and therefore, they are asking for the improvement of the services provided by their social insurance institution.

Many of them believe that the doctors payments have to be raised and become proportionate to the services provided by the doctors. Maybe they believe that this way they will be able to avoid paying non-formal fees to them. They are also asking to get an allowance due to diabetes, as well as a raise in their pension by the State, in order to be able to face the financial cost of diabetes, averaging 189.480 drs. annually. Indeed, diabetes bears an annual cost representing the 8,87% of the annual income of a diabetic patient. So, the raise in income these people are asking for, is very logical, as it concerns not only themselves, and all the people involved (retirees, diabetics and doctors), so that they will all be able to handle the expenses.

 

COST OF THE REGULATION OF DIABETES

In order to calculate the total annual cost for the regulation of diabetes, we have calculated all the expenses diabetic patients spend annually for the following: visits to doctors who are regulating their diabetes and are prescribing the medication, visits to ophthalmologists and dentists for the prevention of diabetes complications, medications for diabetes or other diseases, supplementary medical supplies (such as blood-glucose and urine and blood acetone monitoring, lancets for blood testing and insulin syringes), laboratory microbiological tests due to diabetes, and finally, expenses for hospitalization during the last 12 months (hospitalization expenses, doctors and medical staff payments).

The total average annual cost of diabetes for a type II diabetic patient is 189.480 drs. and represents the 8,87% of his average annual income, which is 2.135.040 drs. The cost of medicines not related to diabetes represents the 40% of the total cost of diabetes regulation. A very important role plays also the cost of the doctors (13%), the cost of the strips needed for the measurement of blood-glucose (12%) and finally, the cost of the medicines related to diabetes (18%).

The total annual cost of diabetes does not depend on the age, the mass body indicator, the annual income, the health status of the patient, as the patient himself is classifying it, the smoking, the number of persons in the family living in the same household with the patient, the existence of other diabetic family members, as well as on the morning blood-glucose rates in fast (which is something that stands for an objective measure for the valuation of diabetes regulation of these patients).

All individuals, regardless of their income, are naturally spending some money without considering the cost, in order to be healthy. The self-preservation instinct overrides concerns about high necessary expenses to take care of their health. Perhaps that is the reason that the cost does not depend on the age, on how the patients themselves are classifying their own health status, whether they are obese (which is expressed by the mass body indicator), the smoking, the fact that they live alone or together with other members of their family, the fact that there is also another person in their family suffering from diabetes, or on the diabetes regulation status expressed by their morning blood-glucose rate.

All diabetics, according to their opinion, are trying to regulate their diabetes the best they can by spending any amount of money needed, no matter how high. Their opinion is based mainly to the self-preservation instinct, on the information they get by their doctor and on the exchange of views with the other diabetics which has resulted in a certain mentality. That mentality is very difficult to change. For example, there are a lot of diabetic patients who do not visit regularly a dentist and an ophthalmologist for preventative check-ups, although their doctors are suggesting so, because they believe that they have to visit these doctors only if they have a particular health problem.

On the other hand, the average annual cost is related to the disease duration, the sex, the educational level, the profession, the specialty of the doctor regulating their diabetes, the existence of complications due to the disease and the fact of being members of a Open Auspices Centers for the Aged.

More specifically, diabetes cost is higher for women patients, for persons with medium or high/higher education, for housewives, for persons attended by a diabetes specialist, for those who are not members of Open Auspices Centers for the Aged but are clients of the same pharmacy, for persons suffering from diabetes for many years and finally, for those who suffer from complications of the disease.

It is expected that the existence of complications due to diabetes, as well as the duration of the disease of diabetes (that is the years during which someone is aware that he suffers from diabetes) are increasing the total annual cost of diabetes. The possible explanation for that could be that diabetes in primary stages is being regulated with special diet only, while in further stages with oral medicine and finally, at the most advanced stages with insulin. Moreover, the longer the duration of the disease, the more often we see complications due to diabetes.

Women are spending more money than men. It is widely known, according to the science of psychology, that men consider matters related to their body health and safety more important than women do. But, at the same time, men are considering very much the financial costs regardless any danger that may arise from that situation. So, it is very likely that men are cutting down on expenses risking possible negative consequences to their health.

Moreover, housewives are spending more money than retirees and self-employed. Probably, that difference is due to the difference between the two sexes. It is also probable that retirees and self-employed are giving greater importance to financial matters and cut down on expenses, even those related to their health. The fact that they have worked a lot in their lives in order to be able to earn the income they are getting now, makes them spend very little compared to housewives whose incomes depend on that of their husbands.

It is also noted that individuals with medium or high/higher education spend more money on diabetes than individuals having a lower education. Most probably, the most educated realize and understand the necessity of the various means and ways of facing diabetes and of the partial expenses that are arising from them. For instance, they have realized the necessity of monitoring their blood-glucose by themselves with the special device for the blood-glucose monitoring. This awareness of the necessity to do certain things to control diabetes leads these people to do what is necessary and bear the appropriate cost. So, their expenses are higher.

Also, the doctors specialty seems to affect the level of the expenses. Those who are visiting a diabetes specialist instead of a GP or a doctor of any other specialty are spending more money. Diabetes specialists are the most appropriate doctors for attending diabetics. Usually, GPs are not so pedantic when it comes to the frequency of the visits for the regulation of diabetes, to dentists and ophthalmologists for the preventive check-ups, or with the frequency of the blood-glucose and urine tests. Diabetes specialists, however, are trying to regulate the diabetes of their patients the best they can and they are usually applying an intense therapy pattern for diabetes, so they require visits more often, as well as the blood-glucose and urine measurements in general, and they are also prescribing more effective medicines, resulting in increased expenses for the patients.

Also, according to another relevant research, the intensified therapy pattern of diabetes (that diabetes specialists usually apply) prolongs the life of the diabetic patient and prevents complications, but at the same time increases the cost of the therapy. Other researches have reached the same conclusions, also.

Finally, it is noted that the clients of the pharmacy situated in Zografou, are spending more money than Open Auspices Centers for the Aged members. The diabetic clients of this particular pharmacy are seeking the advice of their pharmacist for matters concerning diabetes and are advised by him to follow the intensified therapy that, as mentioned in the previous paragraph, costs more. It is also probable due to the fact that the clients of the particular pharmacy have developed an intimacy with their pharmacist and trust him they are not having difficulty in talking with him about their real income and expenses, as for example revealing the non-formal payments amounts given to doctors by the patients.

FINAL CONCLUSIONS

  1. The majority of type II diabetic patients is regularly attended by a GP for their diabetes and by a doctor provide by the social insurance institution, whom they visit approximately 5 to 9 times every six months, mainly to get prescriptions for the medication they need to regulate their diabetes. The patient pays the doctor non-formal fees (off the books) in order to get a more careful examination. The average annual cost of a doctor reaches up to 24.440 drs. for every diabetic patient.
  2. The duration of the medical visit ranges from 7 min. at the insurance institution doctor at his place of work (the social insurance institution), to 17-19 min. for the social insurance doctor at his private office, the hospital doctor at the hospital and the private doctor, and 60 min. for the hospital doctor at his private office.
  3. The majority of the patients seem to be satisfied by the services provided by their doctor, who is willing to be at their service. Most of the diabetic patients believe that they have been benefited after the visit to the doctor.
  4. The average annual cost for medicines related to diabetes is 33.187 drs. and appears to be higher for the older population.
  5. The average annual cost for medication not related to diabetes therapy is 76.524 drs.
  6. Most diabetics buy their medication with a doctors prescription, collaborating with their social insurance institution, and pay a portion of the overall cost of the medication.
  7. Type II diabetes has caused a 42% decrease in the weekly activities of the diabetic patients. The greater the decrease is, the higher is their educational level.
  8. 60% of type II diabetics is not suffering by any complications due to diabetes. Most often complications are related to the eyes, the bloodstream system, the neural system and the renal operation.
  9. The average annual cost for buying the blood-glucose measurement strips is 22.484 drs., for the urine glucose measurement strips is 6.324 drs., for th lancets is 2.117 drs., for insulin syringes is 5.681 drs. and for laboratory microbiological tests in a private laboratory is 1.732 drs.
  10. The most popular weakly frequencies of blood-glucose monitoring is 1-4 times, for urine glucose is 7-10 times and for urine acetone is 7-10 times, too. The reason patients are not doing more measurements is purely financial, especially since they do not think it is something necessary to do and on the other hand, their attending doctor has not suggested that the do it.
  11. The average cost of hospitalization (hospitalization, including doctors and medical staff payments) during the last 12 months before my research was 4.300 drs.
  12. Only 10% of the diabetic patients are performing glycosylated haemoglobin tests. 12% and 61% of them show a blood-glucose rate in fast below 120 and 160 mg/dl accordingly. 79% believe that they have a medium to good health status and 75% classify their health from 50-80 with 100 as perfect. The morning blood-glucose rates in fast are related to the quality classification of the health by the patients themselves. The more the blood-glucose rates are increasing, the more the health classification worsens.
  13. Diabetes also causes an increase in the noutrition expenses by 26,6% and personal expenses in everyday life increase by 34,2%compared to members of the family that are healthy. Expenses for special books, magazines or subscriptions in associations related to diabetes vary, while expenses for shoes, clothing and other living expenses (DEI Public Electricity Works, HTO Hellenic Telecommunications Organization, EYDAP Athens Piraeus Water Supply Company, etc) increase by 0,7% and 2,7% accordingly.
  14. The majority (62%) of diabetics is visiting the dentist only when there is a certain problem and 24% of them is not visiting him at all since they wear dentures.
  15. Only 42% of the diabetic patients is regularly visiting the ophthalmologist, usually once every six months.
  16. The average annual cost for the visits to a dentist and an ophthalmologist is 12.690 drs.
  17. Whether the pharmacist is going to play an important role as a councilor of the diabetic on various matters, such as to the kind of the medicine, the dosage, and nutrition depends on how thorough the doctors are, as well as on how knowledgeable and eager the pharmacist is to help, and on whether the patients trust him.
  18. The majority of diabetics are asking for free and sufficient quantities of medicines and supplementary medical materials related to diabetes. They are also asking that their social insurance institution provide doctors who are diabetes specialists, as well as for allowances due to diabetes or for an increase in their pension, so that they can afford the extra expenses.
  19. The average annual overall cost of diabetes for laboratory tests, medicines, supplementary medical materials, doctors, dentists and ophthalmologists, and expenses of hospitalization is 189.480 drs., while the average annual income of these patients is 2.135.040 drs. That means that the expenses for diabetes amount to 8,87% of a diabetics income.
  20. The cost of medication not related to diabetes is 40% of the overall cost for diabetes. The cost of the doctors (13%) and of the medicines related to diabetes (18%) represents an important part in that cost.
  21. The annual overall cost of diabetes is higher in women, in persons with medium or high/higher education, in housewives, in persons being attended by a diabetes specialist, in the clients of the pharmacy, in those persons suffering from diabetes for more years, and finally, in persons suffering by the complications of diabetes. It does not depend on the age, the mass body indicator, the annual income, the quantitative classification of health by the patients themselves ranging from 0-100%, the smoking, the number of persons living in the same household, the number of the diabetic persons in the same family or the morning blood-glucose rates in fast.

 

CONCLUSIONS

  1. The findings of the present research show that the therapy cost of type II diabetes is high in Greece.
  2. The services provided would be very much improved if social insurance institutions contracted with a sufficient number of doctors who are diabetes specialists.
  3. An increase in the doctors payments by the social insurance institution with which they have a contract and the improvement of the contracting terms signed between the doctors and the particular social insurance institution, would help the elimination of the non-formal payments (off the books) phenomenon.
  4. It would be very helpful if the social insurance institutions would reconsider the possibility of giving the medicines and the supplementary medical materials for free and in sufficient quantities for every prescription (at least in quantities covering the three-month needs of the patients), which would significantly contribute to the convenience of the patient, to the increase of the effectiveness and efficiency of the doctors, as well as to the reduction of costs burdening the diabetic patient.
  5. A monthly allowance given to the diabetic patients would very much help to compensate for the income loss due to expenses for i) the reduction of their activities because of diabetes, ii) the utilization of other individuals (relatives or not) to do certain tasks that diabetics cannot do themselves because of the diabetes iii) the increased personal expenses regarding mainly nutrition.
  6. Establishment of educational programs on diabetes by hospitals, the Ministry of Health, the social insurance institutions, the various unions for diabetics or other institutions on diabetes and training of diabetic patients to self-regulate diabetes matters, as well as to care for their overall health, would contribute to better regulation of diabetes and to the improvement of the overall health status of diabetic patients, and would also reduce diabetes complication and of the frequency of hospitalization. This way, the cost to diabetics for diabetes therapy would be reduced. There are already successful educational programs in foreign countries.
  7. Pharmacists can play an important role by advising diabetics on various matters relating to more effective pharmaceutical treatments, the dosage of the medication and diet matters. The existence of educational programs for pharmacists to better educate them about diabetes so they can be in a position to give advice and supplement the doctors job, would be more a matter for the government and the existing social security institutions to take into serious consideration. Thus, it is very important that pharmacists are able to offer their services free of charge, without burdening financially either the State or the social insurance institutions or the patients themselves.
  8. The decrease in bureaucratic procedures in the mechanism of the social insurance institutions is a must, especially when it comes to the matter of the access to the attending doctors on the social insurance institutions list, to the supply of the medicines and the supplementary medical materials and to obtaining medical diagnostic and laboratory tests in some diagnostic medical centers that have contracts with the social insurance institutions.

 

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