Estimation of the direct cost of epilepsy among Sudanese epileptic patients

doi:10.21203/rs.3.rs-646628/v1

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Estimation of the direct cost of epilepsy among Sudanese epileptic patients

https://doi.org/10.21203/rs.3.rs-646628/v1

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Background

Epilepsy is a common disease, and its economic consequences are manifested in frequent hospital visits, examinations and treatments.

Objective

To estimate the direct costs of epilepsy among Sudanese epileptic patients. Design and

methods

The study was conducted on some clinical cases of epilepsy patients in Sudan. Data on clinical characteristics, utilization of medical services, and costs were collected from 380\ patients using a standardized pre-tested format. The patients’ approval was obtained as necessary.

Results

Direct medical care costs was (2,395 Sudanese Pounds “SDG”, 417 American Dollars “USD”) per year per patient, of which antiepileptic drugs was the major component (1,587 SDG, 276 USD). Other costs are medical consultations and hospitalization charges (SDG 148, 26 USD), investigations cost (146 SDG, 25 USD), and cost of travel to clinics (514 SDG, 90 USD). Nonmedical direct cost - in form of traditional healers' visits were reported by 13.5% of the patients and estimated to be (1,422 SDG, 251 USD) per patient per year. The overall mean annual cost for epilepsy per patient in our clinic was approximately (2,724 SDG, 474 USD).

Conclusion

The economic burden of epilepsy patients is relatively high, and payers in Sudan have many characteristics and significant differences from other countries.

Neurology

Epilepsy

Economic Impact

Seizures are short-term appearances of signs and/or symptoms caused by excessive or synchronized abnormal activities of brain neurons. The definition of epilepsy requires at least one seizure. ¹ The prevalence rate of epilepsy in Sudan was estimated to be about 0.9 per 1000.^2,3The main investigations in patient with suspected epilepsy used are: Electroencephalography (EEG) and neuroimaging (EEG,MRI, SPECT, and PET). ⁴Most people with onset of seizures can achieve seizure control with existing medications.⁵

Costs to society are defined as (a) the direct cost of medical resources devoted to diagnosing and treating persons with the disorder, and (b) the indirect cost from foregone earnings and reductions in household activities because of epilepsy-related morbidity and mortality.⁶In determining the cost of illness, three elements direct costs, indirect costs, and psychological or intangible costs can be considered.^7,8

Direct costs are the easiest to quantify because they are related to the costs of inpatient or outpatient treatment, drug addiction treatment, and various tests and research.⁹Indirect costs include underemployment and unemployment and the associated loss of earnings and excess mortality.⁹A Chinese study showed that the overall mean annual cost for epilepsy per patient was approximately Chinese Yuan, RMB5,253 (USD 773).¹⁰The estimated total cost of the disease in Europe was€15.5 billion in 2004, indirect cost being the single most dominant cost category (€8.6 billion).Direct health care costs were€2.8 billion, outpatient care comprising the largest part (€1.3 billion).Direct nonmedical cost was€4.2 billion.¹¹Another Study in United States showed that the annual cost for the estimated 2.3 million prevalent cases of epilepsy is estimated at $12.5 billion. Indirect costs account for 85% of the total and, with direct costs, are concentrated in people with intractable epilepsy.¹²A study in Nigeria showed that the total direct medical cost/month was N461,820.00 (($3,947.2), the biggest contributor was drug cost N375,350.00($3208.10) or 81.3% of the cost burden. The total estimated direct cost/ year was N5, 541,840.00 ($47,366.15) with a mean cost/ year of N46, 182.00($394.70); 25% of those who worked spent more than 50% of their monthly income of seeking care for epilepsy.¹³Another study in Indian calculated that the total cost per epilepsy case was US$ 344 per year (or 88% of the average income per capita). ¹⁴

Problem Statement:

Epilepsy is a common chronic neurological disorder that affects about 50 million people around the world, 10% of whom are in the Middle East.^14,15 Developing countries carry 90% of the financial burden of epilepsy, as 85% of the world’s 50 million people with epilepsy live in developing countries.¹⁶Epilepsy is an economic burden on individuals and society because of increased health care cost as well as losses in employment, wages, and household work.Epilepsy has significant economic implications in terms of health-care needs, premature death and lost work productivity.¹⁴ According to the World Bank, 30% of the population of the Middle East and North Africa still lives on less than US$ 2 per day.¹⁷ This low income together with the chronicity of epilepsy makes a huge financial burden on patients with epilepsy and their families.

Justification:

Patients with any age can develop epilepsy. Cost of illness (COI) studies have become increasingly important in both the substance and the rhetoric of developing interventions in battling illness and injury.¹⁸The burden on the families of epilepsy patients is heavy especially in the developing countries, since these countries rarely have a well-developed insurance system or social security program that covers epilepsy-related costs. The burden may be even more intractable than the epilepsy itself.¹⁹The economic burden caused by epilepsy has not been adequately examined in the developing countries. Even the studies that do exist neglect important economic concepts, leading to a significant underestimation of the burden.¹⁹ Cost of epilepsy in African region didn't receive enough attention in the literature. In fact no study on the costs of epilepsy had been carried out in Sudan. We would like to achieve accurate Information about costs of epilepsy in Sudan. Better cost data will make economic assessment a tool for decision-making and help increase investment and resource allocation for epilepsy treatment.

Objectives:

General Objectives:

To estimate the Direct Cost of Epilepsy among patients attending private, governmental and charity clinics in Khartoum, Sudan 2014.

Specific Objectives:

To estimate the Direct Cost of Epilepsy among patients attending private clinic in Khartoum, Sudan 2014.
To estimate the Direct Cost of Epilepsy among patients attending governmental clinic in Khartoum, Sudan 2014.
To estimate the Direct Cost of Epilepsy among patients attending charity clinic in Khartoum, Sudan 2014

Study design: Cross sectional study.
Analyses of cost of illness can be either “prevalence-based” (examining the costs incurred on a cross-sectional basis) or “incidence-based” (measuring changes in the cost profile over the course of the disease in a longitudinal analysis); the latter is slightly more difficult logistically). ²⁰
Study area: Subjects with epileptic seizures were randomly recruited from three sectors; charity clinic, governmental hospital outpatient clinic and a private clinic :

All the clinics are located in Sudan, Khartoum state.
Sudan is now the third largest country in Africa and also the third largest country in the Arab world (estimated population is little over 30 million people)
Khartoum is the second largest city in Sudan and Khartoum State, together With Omdurman and Khartoum Bahri; it forms the cultural and industrial heart of the nation.
The clinics are:

Daoud's charity Neurological Referral Clinic is a charity clinic, in which neurologists, psychiatrists, physicians, and medical registrars tend to see patients every week on Friday, which is the weekend, and many patients attend this clinic; they are from Khartoum state, but also many of them from different states of Sudan. Also the clinic has and an active epilepsy program.
Fateh Elrahman Elbasheeroutpatient Clinic.
Private Neurological Clinic, in which a qualified neurologist tend to see patients every day except for Friday.

Study population: Patients who attend Daoud's charity Neurological Referral Clinic.

Inclusion Criteria: includes

1) All Ages;

2) Nationality: Sudanese;

3) Patient with epilepsy.

- Exclusion Criteria: Patients that attend these Clinics who are non-epileptic.

Sampling:
Sample technique: Random sampling.
Sample size is calculated using the formula = Z2*p (1-p) /d2
A prevalence rate of epilepsy of 0.9 per 1000 was estimated.^2.3
According to that; prevalence= 0.09%.
The sample size will be 3.84*0.09 (1- 0.09) /0.0016 = 197 (+10%non-responders) = 217

Data collection:Data collection and Tools:
Detailed informations about the following were obtained through Pre-tested questionnaires from patients with epilepsy :

Personal data:

Age:
Gender:
Educational Level
Marital Status
Annual household income (RMB) Income
Residence
Present Employment
Health insurance

2. Variables Related to Epilepsy:

Age at seizure onset /duration of epilepsy
Frequency of seizures per month
Seizure type.
Etiology: Idiopathic, organic.
AED type
- Valproate
- Carbamazepine
- Lamotrigine
- Phenobarbital
- Phenytoin
- Topiramate
Dose of the AED drug

Variables Related to the Direct Cost of Epilepsy:

Neurologic care:
Number of outpatient contacts per year.
Number of A&E contacts per year.
Number of hospital visits per year was.
Duration of hospital stay.
The indication for hospitalization.
Number doctors/professionals consulted for epilepsy
What was the delay (in months) in diagnosis of epilepsy.

Investigations:
Brain MRI scan head Angiography,EEG, VEEG, Blood levels of AEDs, Other blood/urine tests for epilepsy or its treatment.

Drugs used
(Where do you buy your drugs?)
Cost of the drug

What is your expenditure (Rs/year) on the following?
Consultation fee
Investigations
Cost of drugs
Hospitalization charges
Travel for various purposes related to epilepsy

reimbursement of your medical expenditure

Transportation (distance from Hospital)

Other consultations

Data analysis: All collected data was entered into the computer using the statistical package program for social science (SPSS) to analyze the data via simple descriptive statistics. (Analyzer is specialized personnel in SPSS).

Ethical concern: Consent was obtained verbally from All patients, and from the local ethical committee
Limitations of the study:
The Indirect cost is not estimated
Sample size is small.

Epilepsy was defined as the occurrence of at least two unprovoked seizures separated by 24 hour more. A total of 380 PWE were recruited into the study, (52%) were male and (48%) being female. The median age was 20 years (IQR: 15–29), and the median duration of epilepsy was 8 years (IQR: 3–14).60% were diagnosed with focal epilepsy, 30% with generalized seizures and 10% with unclassified seizures. Direct costs such as consultation fee, paraclinical exams, hospitalization fee and price of AEDs were obtained from the PWE and their families. Some PWE consulted traditional healers on an irregular basis; for each PWE who did, we asked what it costs them every year (in cash and in kind), under normal circumstances, to visit the traditional healer because of epilepsy. The average traditional medicine expenditure for a normal year was divided by 12 to obtain monthly costs. Direct medical care costs was (2,395 Sudanese Pounds “SDG”, 417 American Dollars “USD”) per year per patient, of which antiepileptic drugs was the major component (1,587 SDG, 276 USD). Other costs are medical consultations and hospitalization charges (SDG 148, 26 USD), investigations cost (146 SDG, 25 USD), and cost of travel to clinics (514 SDG, 90 USD). Non medical direct cost - in form of traditional healers' visits were reported by 13.5% of the patients and estimated to be (1,422 SDG, 251 USD) per patient per year.

To the best of our knowledge, this is the first study investigating the economic cost of epilepsy in Sudan. Our study evaluated the direct costs associated with epilepsy. Epilepsy has important soci-economic costs to a population. In order to determine healthcare priorities, it is important to estimate these costs. This is especially so with the introduction of the newer antiepileptic drugs and the resurgence of new surgical treatment options, which have the potential to considerable, increase the cost of treating epilepsy. The costs of epilepsy may vary with the severity of disease, time since diagnosis, efficacy of antiepileptic drugs treatment, and health insurance coverage. We obtained data from 380 patients, we found a predominance of focal seizures. Almost 75 % of our patients were well control and they were seizure- free, this similar to what was reported worldwide.²⁰Almost 40% of our patients were receiving monotherapy and 60% polytherapy. In case of treatment of epilepsy monotherapy is superior to polytherapy, to reduce the chance of development of side effects of the drugs and to reduce the risk of interaction with other drugs. ^21–22

Our study showed that direct medical care costs was (2,395 Sudanese Pounds “SDG”, equivalent to 417 American Dollars “USD”) per year per patient, of which antiepileptic drugs was the major component. This findings concurs with data from other developing countries where AEDs constitute a major expenditure in epilepsy management. ^23–24 Direct cost includes the cost of resources consumed when health care, social services, and patient or family member services are used to prevent, diagnose, treat, or rehabilitate persons with epilepsy. It is so difficult to compare our results with those studies conducted in other countries, since supply, availability, price, and consumption of health care differ widely. Direct cost of epilepsy in our study (417 American Dollars per patient per year) was higher than that in India (93 USD per patient) and in China (372 USD per patient) and Nigeria (163 USD per patient) this can be explained by the fact that antiepileptic drugs followed by the frequent outpatient clinic visits, both of them account for a majority of the overall out-of-pocket epilepsy-related expenditures in addition to non medical direct cost in form of traditional healers' visits were reported by 13.5% of the patients and estimated to be (1,422 SDG, 251 USD) per patient per year.^25–26−27 Direct costs of epilepsy in our study was still lower than that from South Africa, USA and Europe.^28–29−30We found a positive correlation of seizure frequency with increased medication, hospitalization, and direct costs. Direct cost increased dramatically with the increasing number of AEDs especially new AEDs where the price is generally higher than that of traditional AEDs.The drugs combination rate is higher in this study, which can be also attribute to increase direct medical costs.Seizuure severity is an index integrating seizure frequency, seizure type and side effects of treatment. Patients with more serious and complex seizures had to accept more frequent doctor visits, and drug adjustment or dose increasing, which all increase their economic burden.

Consent for publication

Not applicable.

Availability of data and materials

The materials datasets used and/or analyzed during this study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions

All authors participated in planning the study, data collection, results and discussion sections.

Fisher RS, van Emde Boas W, Blume W, Elger C, Genton P, Lee P, Engel J Jr. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epile psy (ILAE) and the International Bureau for Epilepsy (IBE).Epilepsia. 2005 Apr;46(4):470-2.

Benamer HT, Grosset DG. A systematic review of the epidemiology of epilepsy in Arab countries. Epilepsia. 2009 Oct;50(10):2301-4.

Younis YO. Epidemiology of epilepsy among school populations in Khartoum Province, Sudan. J Trop Med Hyg. 1983 Dec;86(6):213-6.

Perkin GD. Epilepsy in later childhood and adulthood. In: Warrell DA, Cox TM, Firth JD, editors. Oxford Textbook of Medicine [e-book]. 5^th ed. Oxford: Oxford University Press; 2010 [cited 2014 Jan 25]: 24-5-1. Available from:World Health Organization-led HINARI Access to Research in Health programme.

Begley, C. E., Famulari, M., Annegers, J. F., Lairson, D. R., Reynolds, T. F., Coan, S., Dubinsky, S., Newmark, M. E., Leibson, C., So, E. L. and Rocca, W. A. (2000), The Cost of Epilepsy in the United States: An Estimate from Population-Based Clinical and Survey Data. Epilepsia, 41: 342–351.

Hodgson TR, Meiners MR. Cost-of-illness methodology: a guide to current practices and procedures. Milbank Q 1982;60:429-62.

Gerard K, Donaldson C, Maynard AK. The cost of diabetes. Diabetic Med 1988;6: 164-70.

Patchlatko CH. Economic aspects of epilepsy-an introduction. In: Patchlatko CH, Beran RG, eds. Cost of epilepsy: proceedings of the 20th International Epilepsy Congress. WehrlBaden, Germany: Ciba-Geigy Verlag: 1995
Jacoby A1, Buck D, Baker G, McNamee P, Graham-Jones S, Chadwick D. Uptake and costs of care for epilepsy: findings from a U.K. regional study. Epilepsia. 1998 Jul;39(7):776-86.

Hong Z, Qu B, Wu XT, Yang T-H, Zhang Q, Zhou D. (2009) Economic burden of epilepsy in a developing country: a retrospective cost analysis in China.Epilepsia50:2192–2198.

Pugliatti M1, Beghi E, Forsgren L, Ekman M, Sobocki P. Estimating the cost of epilepsy in Europe: a review with economic modeling. Epilepsia. 2007 Dec;48(12):2224-33.

Begley CE1, Famulari M, Annegers JF, Lairson DR, Reynolds TF, Coan S, Dubinsky S, Newmark ME, Leibson C, So EL, Rocca WA. The cost of epilepsy in the United States: an estimate from population-based clinical and survey data. Epilepsia. 2000 Mar;41(3):342-51.

B Ezeala-Adikaibe, I Onwuekwe, S Ekenze, J Achor, J Onwukwe. Estimated Direct Cost Of Treating Epilepsy Per Month In Southeast Nigeria.. The Internet Journal of Neurology. 2009 Volume 13 Number 1.

World Health Organization. Epilepsy: fact sheet. Available at: http://www.who.int/mediacentre/factsheets/fs999/en/ . 2009 Accessed May 17, 2014

World Health Organization. Epilepsy in the WHO Eastern Mediterranean region: bridging the gap. Available at: http://www.emro.who.int/dsaf/dsa1039.pdf. 2010 Accessed: May 17, 2014.

de Boer HM. (2002)‘‘Out of the shadows’’: a global campaign against epilepsy.Epilepsia43(suppl 6):7–8

World Bank. Income by region 1981–2005 Available at: http://siteresources.worldbank.org/EXTAR2009/Resources/6223977-1253132981998/6440371-1253210222754/Income_by_Region.pdf , Accessed May 17, 2014

Clabaugh, G. and Ward, M. M. (2008), Cost-of-Illness Studies in the United States: A Systematic Review of Methodologies Used for Direct Cost. Value in Health, 11: 13–21.

Li, L., Li, J., Wu, X., Zhu, Y. and Lei, D. (2011), Considering economic reality in calculating the financial burden of epilepsy in China. Epilepsia, 52: 416–418

20.Cockerell OC, Hart YM, Sander JWAS, et al. The cost of epilepsy in the United Kingdom: an estimation based on the results of two population-based studies. Epilepsy Res 1994; 18:249-60.

21.Erik K St. Louis,1,* William E Rosenfeld,2 and Thomas Bramley.Antiepileptic Drug Monotherapy: The Initial Approach in Epilepsy Management. Curr Neuropharmacol. 2009 Jun; 7(2): 77–82.

22.Erik K St. Louis.Truly “Rational” Polytherapy: Maximizing Efficacy and Minimizing Drug Interactions, Drug Load, and Adverse Effects. Curr Neuropharmacol. 2009 Jun; 7(2): 96–105.

23.Joseph Nelson Siewe Fodjo,a,⁎ Michel Mandro,b Deogratias Wonya'rossi,b Yasemine Inaç,a Francoise Ngave,cRichard Lokonda,d Aimé Anyolito,e Frederik Verelst,f and Robert Colebundersa.Economic Burden of Epilepsy in Rural Ituri, Democratic Republic of Congo. EClinicalMedicine. 2019 Mar; 9: 60–66.

24-Jh Chin.Epilepsy treatment in sub-Saharan Africa: Closing the gap. African health sciences 12(2):186-92 · June 2012 .

25-Hong Z1, Qu B, Wu XT, Yang TH, Zhang Q, Zhou D.Economic burden of epilepsy in a developing country: a retrospective cost analysis in China. Epilepsia. 2009 Oct;50(10):2192-8.

26-Penberthy LT1, Towne A, Garnett LK, Perlin JB, DeLorenzo RJ.Estimating the economic burden of status epilepticus to the health care system. Seizure. 2005 Jan;14(1):46-51.

27-W. MAK, J. K. Y. FONG, R. T. F. CHEUNG & S. L. HO.Cost of epilepsy in Hong Kong: experience from a regional hospital .Seizure 1999; 8: 456–464

28-Charles E. Begley and †Ettore Beghi.The Economic Cost of Epilepsy: A Review of the Literature. Epilepsia, 43(Suppl. 4):3–9, 2002.

29-Leah Wibecan,1,2 Günther Fink,2 Lhab Tshering,3 Verónica Bruno,2 Bryan Patenaude,2 Damber K Nirola,3Chencho Dorji,3 Ugyen Dema,3 Mimi Lhamo Mynak,3 Dilli Ram,3 and Farrah J Mateen1,4 .The Economic Burden of Epilepsy in Bhutan. Trop Med Int Health. 2018 Apr; 23(4): 342–358.

30-Joseph Nelson Siewe Fodjoa,, Michel Mandro b, Deogratias Wonya'rossi b, Yasemine Inaç a, Francoise Ngave c,Richard Lokonda d, Aimé Anyolitoe, Frederik Verelstf, Robert Colebunders. Economic Burden of Epilepsy in Rural Ituri, Democratic Republic of Congo. EClinicalMedicine 9 (2019) 60–66

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Estimation of the direct cost of epilepsy among Sudanese epileptic patients

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Abstract

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Introduction

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