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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