The epidemiology and economics of diabetes-related health care

Abstract

Diabetes imposes a substantial burden of disease and consumes a significant proportion of health care resources worldwide – nowhere more so than in China. The prevalence of diabetes in China has increased over the past few decades, yet rates of treatment and control remain low. Prevention and control of diabetes is a one of the four non-communicable diseases prioritised in the Healthy China 2030 strategic plan. To address this public health issue, I analysed the epidemiology and economics of diabetes care in this thesis, principally using the Special Administrative Region of Hong Kong but also supplemented by other East Asian health systems, as post-development exemplars to inform evidence-based health policy in mainland China. Diabetes-related avoidable hospital admissions are a growing concern in Beijing, Hong Kong SAR, Singapore, and Japan. Spending on these admissions increased from 2006 to 2014 with annual medical expenditures for people with an avoidable admission at six to twenty times higher than those for people without such an admission. While spending on diabetes care has increased from 2006 to 2014, I found the increased expenditure provided value for money as the quality of health care also improved resulting in an overall positive net value in Hong Kong SAR. Health spending can provide value for money as quality improvements can outweigh the increased expenditure. To aid economic and policy evaluation on diabetes care, I developed a comprehensive suite of analytical tools that were externally validated in large majority Chinese population-based cohorts from Hong Kong SAR, mainland China, and Singapore. Both our HKU-SG risk scores and CHIME diabetes outcomes model improved on existing risk prediction tools. The parsimonious use of clinical predictors in the HKU-SG risk scores allows wider implementation of individual-level risk estimation in diverse Chinese settings, while the CHIME simulation model can be used by health planners and policy makers to develop population-level strategies that optimize long term health outcomes. The utilisation of these models is aided by my systemic review and meta-analysis of health-related quality-of life studies to derive a reference set of utility values for the wide range of diabetes-related complications. I applied these policy modelling tools to assess the impact of different risk factor control targets and varying control rates on future health and economic burdens in China. Based on a nationally representative survey, few adults with diabetes in China achieved optimal control of glycaemia and blood pressure. The health burden and direct economic costs of inadequate risk factor control for people with diabetes in mainland China is projected to be substantial and is potentially avoidable by achieving the Healthy China 2030 strategic plan. Diabetes prevention and control is an essential component of the roadmap to a healthier China by 2030. My research in Hong Kong SAR and other East Asian health systems strengthens evidence-based policy in mainland China. Further research on implementation strategies will be crucial to help reduce the health and economic burden from diabetes and achieve the goal of a healthy China.