Download Cardio-Vascular Diseases

International Health Care
Management
Part 2b
Steffen Fleßa
Institute of Health Care Management
University of Greifswald
1
Epidemiology of Non-Infectious Diseases
2 Demand for Health Services
2.1 Determinants of Demand: Overview
2.2 Demographic and Epidemiologic Transition
2.3 Epidemiology of Infectious Diseases
2.4 Epidemiology of Non-Infectious Diseases
2.4.1 Overview
2.4.2 Example: Diabetes Mellitus Type II
2.4.3 Example: Cervix Uteri Carcinoma
2.5 Risk Factors
2.6 Filter Between Need and Demand
2
2.4.1 Overview
• Problem:
– Multi-Cause-Multi-Effect Model
– Not yet a general concept
• Problems of Distinction:
– Infectious diseases may become chronic
– Infections have a certain role in chronic-degenerative
diseases
• i.e. Cervix Carcinoma, Gastric Cancer, Liver Cancer
• i.e. Caries
3
Relevance (WHO 2007)
4
Development (WHO 2007)
5
Cardio-Vascular Diseases
Mortality (per 100.000 pop., age adjusted)
WHO-Region
Africa
Americas
South-East Asia
European
Eastern
Mediterranean
Western Pacific
Global
Germany
CardioVascular
Diseases
404
214
395
354
455
Cancer
Injuries
144
132
111
144
100
133
63
106
80
95
245
315
211
142
132
141
72
87
29
6
Fatalities Due to Cardio-Vascular Diseases
7
Mortality in Germany
• Cardio-Vascular Diseases
• 450.000 fatalities annually (49 % of total fatalities in Germany)
• Cancer
• 210.000 fatalities annually (23 % of total fatalities in Germany)
• Stroke (ICD 430-438)
• 110.000 fatalities annually (estimated; 12 % of total fatalities in
Germany)
• Consequence:
– The absolute risk of dying from a chronic disease in
developing countries is higher than it is in Germany
– The relative risk (in comparison to other diseases) is lower in
developing countries
8
Cardio-Vascular Diseases
• Type:
• Coronary Insufficiency:
• Caused by an absolute or partial lack of blood flow to
the coronary arteries; acute coronary insufficiency
leads to angina pectoris (attack like pain in the area
of the heart with a characteristic feeling of
constriction)
• Myocardial Infarction (Heart Attack):
• Partial death of cells in the heart muscle caused by
an acute lack of oxygen (ischemia)
• 85.000 fatalities annually
9
Development of Casualties
• 1845: 0,05 % of death cases due to cardio-vascular
diseases
• High increase in phase three and four of the
epidemiologic transition
• Decline since 1990
–
–
–
–
Less in women than in men
USA: less in Caucasian than in Afro-American population
Higher survival rate since 1990
Lower rates of second and third time infarcts since 1990
10
Cancer
• Collective name for more than 100 diseases that can
occur in any part of the body.
• Rapid development of abnormal cells that grow
beyond their normal limits
• Cancer cells destroy adjacent tissue and spread to
other organs (metastases)
• Metastases are the main cause of death in cancer
11
Epidemiology
• Mortality:
– Main cause of death worldwide
• 7,6 Million death cases annually worldwide (13 % of total fatalities),
thereof
– Forms of cancer with high mortality:
•
•
•
•
•
Lung cancer (1,3 Mio.)
Gastric cancer (1 Mio.)
Liver cancer (662.000 )
Colon cancer (655.000)
Breast cancer (502.000)
– Spread: 70 % of worldwide death cases due to cancer in developing
countries
– Estimations: 11,3 Mio. death cases due to cancer worldwide in 2030
12
Examples
• Note: extremely varying spatial distribution
– Genetic disposition
• i.e. low risk of melanoma in Asians and Africans
– Habitat / Exposition
• i.e. skin cancer in Australia
– Behavior
• i.e. liver cancer  alcohol, mold
• i.e. lung cancer  smoking
13
14
15
16
17
18
Cause
• Basic Problems:
– Manifestation long time after exposition
– Stochastic relation of exposition and occurrence of disease
– Temporal or spatial association of exposition and disease is challenging
• Trigger:
– Ultraviolet or radioactive radiation
– Chemicals, i.e. asbestos, smoke
• Problem of “Indoor Smoke” in developing countries
– Biological triggers, i.e.
• Viruses
– Hepatitis B Virus and Liver cancer
– Human Papilloma Virus (HPV) and cervical carcinoma
• Bacteria
– Helicobater pylori and gastric cancer
• Parasites
– Schistosomiasis and bladder cancer
• Fungi
– i.e. Aspergillus fungi and liver cancer
19
2.4.2 Example: Diabetes Mellitus Type II
• 2010 (WHO-Statics):
– 382 million diabetics worldwide
– 90 % T2DM
– 80 % of diabetics live in middle or low income
countries
• 2035: (estimates of the International Diabetes
Federation)
– 471 million cases
– Seventh leading cause of death worldwide
20
T2DM
• Type-2-Diabetes
• Chronic Degenerative Disease
– Insulin resistance
– Inadequate insulin secretion of β-cells, spectrum reaches
from predominant insulin resistance accompanied by a
relative lack of insulin to a predominant defect of insulin
secretion accompanied by insulin resistance
• Treatment
– Diet
– Oral therapy
– Insulin replacement therapy
21
Distribution
Source: Kaitlin et al. 2012
22
Complications
•
Micro Vascular Complications
–
Retinopathy (retinal diseases)
–
Nephropathy (kidney disease, dialysis)
•
Macro Vascular Complications
–
Heart Attack
–
Stroke
•
Neuropathy (neurological diseases)
•
Diabetic Foot Ulcers (circulatory disorders of extremities)
23
Diabetes in Cambodia
• WHO STEPS (2010): Population 25-64 years:
–
–
–
–
2.9 % countrywide
5.6% urban
2.4% rural
exposure to NCD risk factors: 80% had at least one risk factor
•
• Cambodia epidemiologic survey
– Siem Riep province: 4.8 %
– Kampong Cham province: 11.4 %
–
Source: WHO 2011
24
Model
Healthy
Undiagnosed,
no complications
Diet
OAD, no
complications
Insulin
Insulin,
complication
25
Model
Healthy
Undiagnosed,
no complications
Undiagnosed,
complication
Diet
OAD, no
complications
Insulin
OAD,
complication
Insulin,
complication
26
Model
Healthy
Undiagnosed,
no complications
Undiagnosed,
complication
Diet
OAD, no
complications
Insulin
OAD,
complication
Insulin,
complication
27
Model
Healthy
Undiagnosed,
no complications
Undiagnosed,
complication
1
2
1
Diet
OAD, no
complications
Insulin
1
1
2
2
OAD,
complication
non-T2DM
death
Insulin,
complication
T2DM
death
28
Diagnosed and Undiagnosed Cases
300000
250000
Cases
200000
150000
100000
50000
0
2008
2013
2018
2023
2028
Time [Years]
diagnosed
undiagnosed
29
Diagnosed Cases With and Without
Complications
120000
100000
Cases
80000
60000
40000
20000
0
2008
2013
2018
2023
2028
Time [Years]
complication
no complication
30
Therapy of Diagnosed Cases
120000
Cases
100000
80000
60000
40000
20000
0
2008
2013
2018
2023
2028
Time [Years]
diet
OAD
insulin
31
Budget Impact
70
4000000
60
Cost p.a. [USD]
3500000
50
3000000
2500000
40
2000000
30
1500000
20
1000000
10
500000
0
2008
2013
2018
2023
Cumulative Costs [million USD]
4500000
0
2028
Time [Years]
costs p.a.
cumulative costs
32
Impact of OAD Coverage
(current = 12.5 %)
300000
Incremental Cost per Life
Saved: 800 US$
295000
(r=5%)
Death Cases T2DM
290000
285000
280000
275000
270000
265000
260000
255000
250000
Current
0%
25%
50%
75%
100%33
Impact of Insulin Coverage
(basic = 12.5 %)
292000
Incremental Cost per Life
Saved: 3392 US$
Death Cases T2DM
290000
(r=5%)
288000
286000
284000
282000
280000
Current
0%
25%
50%
75%
100%34
2.4.3 Example: Cervix Uteri Carcinoma
• Agent: Humane Papilloma Virus (HPV)
– Numerous subtypes, few of them carcinogenic
• Incidence: 500.000 new cases and 270.000 fatalities
worldwide p.a.
• Transmission: primarily through sexual intercourse
• Prevention:
– Vaccination (three vaccines prior to first sexual intercourse)
– Screening
• VIA: visual inspection with acetic acid
• Pap smear
• Genetic testing
35
Source: WHO 2006
Screening
36
Cervix Uteri Carcinoma
• Treatment:
– pre-invasive: cryotherapy, “cold coagulation”
– invasive: surgery, radiotherapy
37
clearance
Model
Men
non-infected and healthy
INFECTION
Men
infected and healthy
cryotherapy
progression
Women
infected and healthy
invasion
Women
with lesion
Women
cancer
mortality
treatment
vaccination
spontaneous
healing
Women
non-infected and healthy
Women
death
38
Parameter
System
Transition
Medical
Intervention parameters
Cost parameters
Sexual activity
Parameter
“Healthy, infected” to “lesion”
“Lesion” to “cancer”
“Cancer” to “death”
Infectiosity
Effectiveness vaccine
Compliance vaccine
Age VIA screening
Compliance VIA
Compliance Cryotherapy
Screening interval
Treatment effectiveness
VIA
Cryotherapy
Treatment National Hospital
Vaccination
Value
16 yrs.
8 yrs.
2 yrs.
50 %
90 %
75 %
30-49
50 %
75 %
3 yrs.
25 %
2.5 US$
7.5 US$
800 US$
22.5 US$
Median age at first intercourse (women/men)
20.8/22.1 yrs.
Median age at marriage (women/men)
20.3/22.6 yrs.
39
Case Development Cambodia
30000
25000
cases
20000
15000
10000
5000
0
2010
2020
Death Cases
2030
2040
2050
2060
2070
Time [Years]
Incidence pre-invasive cancer
2080
2090
2100
2110
Incidence invasive cancer
40
Incremental Cost Effectiveness Ratio
(ICER) of Treatment
5000
4500
ICER [US$ / YLS]
4000
3500
3000
2500
2000
1500
1000
500
0
0
500
eff=10 %
1000
1500
2000
2500
Treatment cost p.c. p.a. [US$]
eff=25 %
eff = 50 %
l=4 yrs
3000
3500
4000
ICER=1000
41
Cost of Treatment
Treatment Budget [US$ p.a.]
14000000
12000000
10000000
8000000
6000000
4000000
2000000
0
2010
2020
2030
2040
eff=10 %
2050
eff=25 %
2060
2070
Time [Years]
eff=50 %
2080
2090
2100
2110
l=4 yrs
42
Screening (w/o Treatment)
5000
4500
4000
Fatalities
3500
3000
2500
2000
1500
1000
500
0
2010
2020
2030
Basic
2040
Standard
2050 2060 2070
Time [Years]
Long
Once
2080
VIA 20
2090
2100
2110
Via 80
43
Vaccination (w/o Treatment)
5000
4500
4000
Fatalities
3500
3000
2500
2000
1500
1000
500
0
2010
2020
2030
Basic
2040
Standard
2050
2060
2070
Time [Years]
E90C50
E90C100
2080
E50C75
2090
2100
2110
Short
44
Combined Intervention
5000
4500
4000
Fatalities
3500
3000
2500
2000
1500
1000
500
0
2010
Basic
2020
2030
Screen only
2040
Treat only
2050 2060 2070
Time [Years]
Vaccine only
2080
Screen+Treat
2090
2100
2110
Screen+Treat+Vacc
45
Combined Intervention
14000000
12000000
Budget [US$]
10000000
8000000
6000000
4000000
2000000
0
2010
Screen only
2020
2030
Treat only
2040
2050 2060 2070
Time [Years]
Vaccine only
2080
Screen+Treat
2090
2100
2110
Screen+Treat+Vacc
46