Primary Care and Valuing Diabetes Care in Hong Kong: Implica;ons for Developing Health Services in Mainland China A work in progress

Transcription

1 Primary Care and Valuing Diabetes Care in Hong Kong: Implica;ons for Developing Health Services in Mainland China A work in progress Gabriel M Leung and Chao Quan May 7, 2015 Innova&ons in Primary Care Seminar Series Asia Health Policy Program Shorenstein APARC, Stanford University

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4 DM BoD China v US In absolute terms million in China (largest in the world) 1 in 4 of all cases worldwide are in China 29.1 million in US In relakve terms 11.6% of Chinese adults in % of US populakon in 2012 (12.3% of people aged 20 ) Xu et al. JAMA. 2013;310(9): NaKonal Diabetes StaKsKcs Report, CDC IDF Diabetes Atlas Sixth EdiKon Update, InternaKonal Diabetes FederaKon 2014

5 One order of magnitude increase in prevalence 1980: <1% 1994: 2.5% 2010: 11.6% Pre- diabetes Prevalence of 50.1% = million Based on ADA 2010 criteria impaired faskng glucose, impaired glucose tolerance, or raised HbA1c Xu et al. JAMA. 2013;310(9): NaKonal Diabetes Research Group. Zhonghua Nei Ke Za Zhi. 1981;20(11): Pan et al., Diabetes Care. 1997;20(11):

6 An ongoing challenge Develop diabetes at younger age and lower BMI High prevalence of diabetes despite lower levels of obesity normal- weight metabolically obese NutriKon transikon Fast food and refined carbohydrates (e.g. white rice) Economic development and urbanizakon Sedentary occupakons in a service- led, high value- added economy Life style trends Reduced physical ackvity High smoking rates (52.9% of men) Macro impact of socioeconomic development Hu FB. Diabetes Care. 2011;34(6): Xu et al. JAMA. 2013;310(9): Li Q et al., N Engl J Med 2011; 364: Schooling and Leung. JECH. 2010;64:941-9

7 Rule of Halves 69.9% are unaware of their diabetes status US: 27.8% Only 25.8% are receiving treatment for diabetes Of which, only 39.7% had adequate glycaemic control (HbA1c below 7.0%) Underdeveloped and unequal health care access Diabetes treatment guidelines largely based on evidence from non- Asian populakons Xu et al. JAMA. 2013;310(9): NaKonal Diabetes StaKsKcs Report, CDC

8 Economic Cost China spends RMB 173.4b (USD 25 billion) annually on direct diabetes treatment 13% of total medical spending US: direct medical costs of $176b plus indirect costs of $69b Projected annual cost of RMB 360b (USD 60b) by 2030 hjp:// spends- rmb billion- us25- billion- year- diabetes- treatment 2014 NaKonal Diabetes StaKsKcs Report, CDC hjp:// in- china

9 Anatomy of the HK Health System Public Health Personal Health Care System Public (Food and Health Bureau) Private Funding sources Purchasers Providers Department of Health & Centre for Health Protec;on Disease prevenkon and control (communicable and non- communicable diseases) Elderly health Health educakon HIV/AIDS service Maternal and child health Port health Student health Tobacco control Tuberculosis service Government general revenue Hospital Authority 38 hospitals GOPCs, SOPCs (predominantly Western allopathic medicine) Minimal out of pocket fees (waived for the indigent) Western allopathic medicine (73%) Employers Private insurers/ MCOs Private providers Chinese medicine (10%) Dental medicine (12%) Individuals Laboratories (4%) Consumers General populakon Universal coverage Mostly individuals from middle and upper socioeconomic strata (except for Chinese medicine use) Market share Inpatient (bed-days) (admission) 90% 80% 10% 20% Overall outpatient incl. TCM Specialist GP 30% 50% 30% 70% 50% 70%

10 How much does HK spend on health? 120, , ,000 4 HK$ Million 60,000 3 Percent 40, , Financial year TEH % GDP

11 Public and private health spending shares Share of TEH (%) Financial year Public Private 11

12 Health spending by financing source 60 HK s health expenditure by financing source Share of TEH (%) Government Employers Insurance Households Non-profit institutions Others 10 0 Financial year

13 Health spending by healthcare func;on and financing source (2010/11) Inpatient curative care Day patient hospital services Ambulatory services Home care 94 6 Rehabilitative and extended care 97 3 Long-term care Ancillary services to health care Medical goods outside the patient care setting 3 97 Prevention and public health services 91 9 Health programme administration and health insurance Investment in medical facilities Share of TEH (%) Public Private

14 Hong Kong has spent relatively less on health compared to OECD countries (2010) 9,000 8,000 United States 7,000 Per Capita TEH (US$ PPP) 6,000 5,000 4,000 3,000 2,000 1,000 Switzerland Netherlands Denmark Canada Austria Germany France Belgium Sweden Australia United Kingdom Ireland Japan Iceland New Zealand Spain Finland Portugal Italy Greece Slovenia Hong Kong SAR, China Slovak Republic Korea Czech Republic Israel Hungary Chile Poland Estonia Mexico Norway Singapore Luxembourg ,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 Per Capita GDP (US$ PPP)

15 although public spending is commensurate with the different levels of public revenue between countries (2010) 5,000 4,500 Norway Per Capita Public Expenditure on Health (US$ PPP) 4,000 3,500 3,000 2,500 2,000 1,500 1, Slovak Republic Hong Kong SAR, China Poland Chile Mexico United States Denmark Switzerland Germany Austria Canada France Belgium Sweden United Kingdom Australia Ireland Japan New Zealand Iceland Italy Finland Spain Greece Portugal Slovenia Czech Republic Israel Korea Hungary Estonia Singapore Luxembourg 0 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 Per Capita Public Revenues (US$ PPP)

16 Highly subsidized public service User charges as a percentage of cost, % Inpatient Specialist outpatient Accident & Emergency General outpatient User fee Government subsidy

17 Mainland China vs HKSAR China mainland Hong Kong SAR PopulaKon (million) of which Urban 691 N/A Rural 657 N/A GDP per capita (constant 2005 US$) Total health spending per capita Total health spending as % of GDP 5.1% 5.2% General government (government + social) spending as % of total government spending 12.5% 13.5% PharmaceuKcals as share of total health spending N/A 11.9%

18 Financing mix $US at 2005 price level China mainland THE per capita Financing mix Gov t SHI PHI OOP % 32.4% 0% 46.4% % 19.3% 3.7% 55.9% % 37.4% 2.8% 34.8% Hong Kong SAR % N/A 12.3% 32.4% % N/A 12.3% 32.3% % N/A 14.9% 34.9%

19 Service delivery supply Human resources China mainland Hong Kong SAR Western allopathic doctors per populakon Chinese medicine prackkoners per populakon Nurses per populakon Hospitals Hospitals per populakon of which Public Private Hospital beds per populakon of which Public Private Primary care providers Primary care providers per populakon N/A 57.7

20 Data Sources Hospital Authority Clinical Management System 6.1 million unique pakents during InpaKents, outpakents (primary care and specialist) and accident & emergency ajendances Demographics Diagnosis and procedure codes Basic clinical data Laboratory results MedicaKons

21 PopulaKon Coverage of HA Percentage of HK population attending public services 45 (%) Inpatient A&E GOPC SOPC Total

22 Ascertainment of diabetes WHO (2011) ADA (2015) HKU Any of the following: HbA1c Fas;ng plasma glucose OGTT 1 One measurement 6.5% ( 48 mmol/mol) One measurement 7.0mmol/l ( 126mg/dl) One measurement 11.1 mmol/l ( 200mg/dl) Random plasma glucose One measurement 11.1 mmol/l ( 200mg/dl) with symptoms TWO measurements of 11.1 mmol/l on separate days ICD- 9 diagnosis codes 250.x ICPC- 2 diagnosis code T89 & T90 1 OGTT (Venous plasma glucose 2 h auer ingeskon of 75g oral glucose load)

23 LAB GLUCOSE TESTS (n=318,502) HbA1c (n=188,584) FasKng glucose (n=109,899) OGTT (n=7,872) TWO random glucose (n=12,147) ATTENDANCE DIAGNOSIS CODES (n=362,658) InpaKent (n=170,562) Specialist outpakent (n=2,259) General outpakent (n=186,109) A&E (n=3,728) EXCLUDE AGE UNDER 20 AT TIME OF DIAGNOSIS (n=1,028) TOTAL PATIENTS (n=680,132)

24 Number of diabetes cases identified by diagnosis criterion OGTT A&E Specialist outpatient 2x Random glucose HbA1c Fasting glucose OGTT Random glucose Inpatient Specialist outpatient General outpatient A&E Inpatient General outpatient Fasting glucose HbA1c All cases HbA1c Fasting glucose Inpatient General outpatient '000 cases

25 PaKents outside the public sector Number of cases was adjusted for individuals who had only sought care from the private sector EsKmated the proporkon of pakents with diabetes, strakfied by age and sex, who only sought follow- up care in private sector Based on Government s ThemaKc Household Survey 2011 Follow- up care for pa&ents with diabetes (overall figures) Both public and Public Sector Private sector private No follow- up Male 84.7% 8.5% 1.9% 4.9% Female 87.1% 7.5% 1.1% 4.3% Census and StaKsKcs Department. ThemaKc Household Survey Report No. 45. Hong Kong SAR

26 Incidence and Prevalence Counted as an incident case in the year of diagnosis date, then excluded from the numerator and denominator for subsequent years PaKents with a diagnosis date before Jan 1, 2007 were classed as pre- exiskng diabetes and excluded from the incidence figures. New cases were assumed to have occurred at the beginning of each calendar year; thus, the person- Kme at- risk was: (Mid- year populakon aged 20y or over Cases of diabetes on January 1 of that year) x 1 year Prevalence was calculated as the number of diabetes pakents alive on January 1 divided by the Hong Kong populakon eskmate (aged 20y or over) on January 1 PopulaKon eskmates of residents based on Government Census & StaKsKcs Department published figures

27 Prevalence of diagnosed diabetes in Hong Kong, % (2013) Prevalence in 2013 (%) Male Female Both Sexes % Overall: 8.9% total Age

28 Incidence of diagnosed diabetes in Hong Kong, per 1,000 person- years (2013) Incidence in 2013 (per 1,000 person-years) Male Female Both Sexes per 1,000 person-years Overall: total Age

29 ComparaKve Prevalence for HKSAR vs mainland China Prevalence of 8.9% in Hong Kong auer adjuskng for pakents who only use private care in 2013 unadjusted prevalence of 8.2% EsKmated prevalence (by populakon- based teskng) of 11.6% among mainland Chinese adults in 2010 Prevalence of 14.3% in urban developed areas 69.9% unaware of their diabetes status Hong Kong is the most and longest developed Chinese city ConservaKvely assuming 27.8% are unaware as per US à actual prevalence rate of 12.3% Xu et al. JAMA. 2013;310(9): NaKonal Diabetes StaKsKcs Report, CDC

30 Stable incidence rate, by age group Incidence rate by age group, per 1000 person- years Incidence rate, per 1000 person- years Year Total

31 Measuring gains in health status Assessed changes in mean modifiable 5- year risk using UKPDS and Hong Kong- specific (CUHK) risk predickon models Compared across four 2- year periods: , , and Calculated the latest risk eskmates in each period keeping age (and diabetes durakon) at baseline values Thus the difference between risk eskmates reflected changes in risk factors potenkally ajributable to clinical care (modifiable risk)

32 Modifiable risks and other covariables UKPDS Stroke UKPDS CHD CUHK Stroke CUHK CHD CUHK Mortality Systolic BP AnK- hypertensives Lipid rako / Cholesterol HbA1c Urine ACR egfr Haemoglobin Other factors StaKns Age, Sex, Smoking, DuraKon of DM, (and AF for stroke) AnK- glycaemics Age, Hx of CHD StaKns Age, Sex, Smoking, DuraKon of DM ACE- Inhibitors Co- linearity? Age, Sex, Peripheral arterial disease, Hx of Cancer, BMI, Insulin use Stevens, R.J. et al., Clin Sci (Lond). 2001;101: ;. Kothari V et al., Stroke Jul;33(7): Yang X. et al, Diabetes Care Jan;30(1):65-70;. Yang X. et al. Arch Intern Med Mar 10;168(5):451-7.

33 CUHK formulae undereskmated the risk of death ROC curve Death at 5-years, % True positive rate AUC= Predicted Observed Male Female Overall False positive rate Male Female True positive rate AUC= True positive rate AUC= False positive rate False positive rate

34 UKPDS overeskmated the risk of CHD ROC curve CHD at 5-years, % True positive rate AUC= Predicted Observed Male Female Overall False positive rate Male Female True positive rate AUC= True positive rate AUC= False positive rate False positive rate

35 Both formulae overeskmated the risk of stroke UKPDS CUHK True positive rate AUC= True positive rate AUC= False positive rate False positive rate UKPDS: Stroke at 5-years, % CUHK: Stroke at 5-years, % Predicted Observed Predicted Observed Male Female Overall Male Female Overall

36 Known caveats of risk predickon models Original Framingham CHD risk assessment tools overeskmated the risk of CHD for Chinese populakons UKPDS overeskmated coronary heart disease and stroke risk in type 2 diabetes mellitus for Chinese populakons CUHK models suffered from co- linearity and lack of widely available clinical measurements We are currently working on calibrakng our own risk predickon eskmates Liu J. et al., JAMA Jun 2;291(21): Yang X. et al., Am J Cardiol Mar 1;101(5): Yang X. et al, Diabetes Care Jan;30(1):65-70.

37 Defining subcohorts Divided the diabetes pakents based on the year of diagnosis into four subcohorts: Pre (defined by full data availability) Divided up pakents based on age of diabetes onset: Under vs at least 60y at onset

38 CharacterisKcs of Diabetes pakents Diagnosis cohort Characteris;cs Before En;re sample PaKents, n 186, ,585 86,696 80, ,164 Date of Date of Cohort entry date Jan 1, 2006 Date of diagnosis diagnosis diagnosis - Mean age at cohort entry (SD), y (12.08) (12.96) (13.53) (13.29) (12.8) Mean years since diagnosis (SD) 7.46 (6.18) 1.37 (0.59) 1.12 (0.6) 1.15 (0.6) 3.76 (5.01) Sex, n (%) Male (47.2) (48) (52) (50.9) (48.9) Female (52.8) (52) (48) (49.1) (51.1) Mean BMI (SD), kg/m (4.01) (4.19) (4.31) 26.1 (4.33) (4.18) Smoking status, n (%) Current (6.8) 7908 (7.4) 8433 (9.7) 7328 (9.2) (7.9) Former (15.9) (14.7) (14.8) (15.2) (15.3) Non- smoker (77.4) (77.8) (75.4) (75.6) (76.8)

39 HbA1c, % Before Overall Diagnosis cohort

40 Under 60 years of age HbA1c, % Before Overall Diagnosis cohort

41 60 years and over HbA1c, % Before Overall Diagnosis cohort

42 Systolic BP, mmhg Before Overall Diagnosis cohort

43 Under 60 years of age Systolic BP, mmhg Before Overall Diagnosis cohort

44 60 years and over Systolic BP, mmhg Before Overall Diagnosis cohort

45 Lipid ratio (Total:HDL-Cholesterol) Before Overall Diagnosis cohort

46 Under 60 years of age Lipid ratio (Total:HDL-Cholesterol) Before Overall Diagnosis cohort

47 60 years and over Lipid ratio (Total:HDL-Cholesterol) Before Overall Diagnosis cohort

48 Urine Albumin:Creatinine ratio Before Overall Diagnosis cohort

49 Under 60 years of age Urine Albumin:Creatinine ratio Before Overall Diagnosis cohort

50 60 years and over Urine Albumin:Creatinine ratio Before Overall Diagnosis cohort

51 UKPDS-predicted 5 year risk for CHD, % Before Overall Diagnosis cohort

52 Under 60 years of age UKPDS-predicted 5 year risk for CHD, % Before Overall Diagnosis cohort

53 60 years and over UKPDS-predicted 5 year risk for CHD, % Before Overall Diagnosis cohort

54 UKPDS-predicted 5 year risk for Stroke, % Before Overall Diagnosis cohort

55 Under 60 years of age UKPDS-predicted 5 year risk for Stroke, % Before Overall Diagnosis cohort

56 60 years and over UKPDS-predicted 5 year risk for Stroke, % Before Overall Diagnosis cohort

57 CUHK-predicted 5 year risk for Stroke, % Before Overall Diagnosis cohort

58 Under 60 years of age CUHK-predicted 5 year risk for Stroke, % Before Overall Diagnosis cohort

59 60 years and over CUHK-predicted 5 year risk for Stroke, % Before Overall Diagnosis cohort

60 Net value of benefits and spending We are analyzing the uklizakon data to empirically eskmate the value of saved medical treatment costs from avoiding diabetes- related complicakons such as CHD and stroke. We will also eskmate the monetary value of improved survival based on different assumpkons of the value of a life- year.