Economic Burden and Quality of Life in Patients with Type 2 Diabetes Mellitus between Han and Hui Ethnicity in China

Abstract

Background The prevalence of type 2 diabetes mellitus (T2DM) has been steadily increased globally along with an increasing aging population, rapid unplanned urbanization and the globalization of unhealthy lifestyles. T2DM patients who receive poor management and treatment are prone to the occurrence of complications resulting in high risk of dying prematurely or poor physical or mental health affecting quality of life (QoL). Furthermore, T2DM and its complications can bring about substantial economic loss to the patients, their families, health systems and national economies. Ethnic minorities are the groups of population who have low socio-economic status, low education level and different cultural beliefs. Evidence in China showed that ethnic minorities with diabetes were less likely to use healthcare and delayed receiving care. However, few studies were concerned with the economic burden and QoL comparing ethnic minorities with the majority of the population. Improving disparities in health conditions and economic burden in ethnic minorities are the important issues for strengthening the health system and policy of the country to achieve universal health coverage. Objectives To determine the economic burden and QoL between Hui and Han T2DM patients in Ningxia and explore the effect of patient's ethnicity adjusted by other demo-socioeconomic characteristics, health related behaviors, patient's religious involvement, clinical status, and health care utilization in regard to economic burden and QoL of T2DM patients. Methods A hospital-based cross-sectional study was conducted from October 13, 2016, to June 19, 2017, in two main tertiary public hospitals located in the capital of Ningxia, China. Hui and Han T2DM patients admitted to the study hospitals, were recruited in a ratio of 1:1 consecutively based on inclusion and exclusion criteria. Information including demo-socioeconomic characteristics, health related behaviors, religious involvement, clinical status and health care utilization, QoL, and annual health expenditures for T2DM were collected by face to face interview, reviewing relevant medical records, and consulting the patients' physicians. All eligible patients were interviewed by the research team during their admission. Annual health expenditure due to T2DM included 1) medical costs occurred in health sectors as outpatient and inpatient care, 2) medical costs occurred in other sectors, 3) non-medical costs from patient/family, and 4) costs of productivity loss. The health status and QoL of patients with T2DM were measured by the EuroQol-5 Dimensions-5 Levels questionnaire (EQ- 5D-5L, Chinese version) and Audit of Diabetes Dependent Quality of Life - 19 Questions (ADDQoL-19, Chinese version). The economic burden of annual health expenditures due to T2DM were measured by catastrophic healthcare expenditure (CHE) and impoverishment. Health status and QoL were evaluated using EQ-5D-5L index values and ADDQoL-19 overall average weighted impact (AWI) scores. The low scores indicated poor health and QoL. The effect of ethnicity on economic burden and QoL of T2DM patients was analysed by quantile regression, logistic regression, linear regression and the Blinder-Oaxaca decomposition analysis, respectively. Results A total of 240 Hui T2DM patients and 240 Han T2DM patients were included. Half of the Hui and Han patients were male. The median age of Hui patients was significantly higher than Han patients (61.5, IQR 53, 69 vs 57, IQR 48, 66). Hui patients were more likely to be unemployed and farmers with lower education level and personal monthly income, have lower prevalence of smoking and drinking alcohol, have higher religious involvement, have a shorter duration of T2DM and lower HbA1c level compared with Han patients. Ethnic disparities in annual healthcare expenditures, CHE and impoverishment for T2DM were demonstrated. The quantile of annual healthcare expenditure showed significant ethnic disparities in T2DM patients with complications. Hui patients had significantly lower expenditures at the 10th to 50th quantiles of healthcare expenditure, and significantly higher expenditures at the 90th quantile of expenditure than Han patients when adjusting for socioeconomic and clinical factors. The CHE and impoverishment of Hui patients before and after reimbursement were significantly higher than those of Han patients. Ethnic difference in CHE and impoverishment headcount after reimbursement were 11.9% and 9.8%, respectively. The different distributions of associated factors between Hui and Han patients contributed to 60.5% and 35.7% of ethnic disparities in CHE and impoverishment, respectively. Household income, occupation or region were significant contributing factors. Health status and QoL of Hui T2DM patients were worse than those of Han patients in univariate and multivariate analyses. Lower ADDQoL-19 AWI scores were significantly associated with treatment with insulin, with kidney and macrovascular complications. Lower EQ-5D-5L index values were significantly found in patients with multiple complications, and with skin complications. Patients having active physical activity had significantly higher EQ-5D-5L index values. Conclusions Although the annual healthcare expenditures for T2DM of Hui patients were significantly lower than that of Han patients, Hui patients had a higher catastrophic and impoverishing effect of OOP payment. Hui T2DM patients were more likely to have poor health status and QoL than Han patients. Differences in socioeconomic factors and clinical factors between Hui and Han patients were the main cause of ethnic disparities in economic burden and QoL for T2DM. Appropriate national policy considering the issue of ethnic minorities should be further explored to improve health and subsidize economic burden for T2DM patients.