Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 40687

AbstractMaterial and MethodsResultsDiscussionConclusionAcknowledgementReferences
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2010 | Month : June | Volume : 4 | Issue : 3 | Page : 2521 - 2530 Full Version

Cost Benefit Analysis Of The Diabetes Self Management Program At A University Health Centre In Malaysia


Published: June 1, 2010 | DOI: https://doi.org/10.7860/JCDR/2010/.764
Al-HADDAD M, IBRAHIM M M I , SULAIMAN S A S, SHAFIE A A, MAARUP N

*(PhD),Lecturer & Researcher, **(PhD),Professor of Social Pharmacy, ****(PhD),Lecturer & Researcher ,Discipline of Social and Administrative Pharmacy, ***(Pharm D).Dean School of Pharmaceutical Sciences,Universiti Sains Malaysia *****(MD),Health Center, Universiti Sains Malaysia

Correspondence Address :
Mahmoud Al-Haddad
( PhD)Lecturer & Researcher
School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia
Email: dr_mahmoud77@hotmail.com
Tel: +6 012 5534547

Abstract

Objectives: This study aims to conduct the Cost Benefit Analysis for the diabetes self management program using the payment card contingent valuation technique at the Health Center of Universiti Sains, Malaysia.
Setting: Health centre of Universiti Sains, Malaysia.
Methods And Materials: A cross sectional study design was used to elicit the patients' maximum willingness to pay money for the diabetes self management program. All costs and benefits of the program were measured for the cost benefit analysis evaluation.
Statistical Analysis: All data were analyzed by using the SPSS software package 12 at a significance level of less than 0.05.
Results: The net benefit of the diabetes self management program was RM7374.50, while the benefit to the cost ratio was equal to 1.2:1. On the other hand, the diabetes self management program would result in a net benefit of RM211418.67, if it resulted in the prevention of the development of one case of end stage renal disease. This study showed that patients with diabetes for more than 2 years had significant higher WTP amounts than those with lower diabetes length. In addition, more educated patients and those with higher incomes showed significant higher WTP amounts than less educated and lower income patients.
Conclusion: WTP has been approved to be a suitable tool for measuring the benefits of the intervention of the diabetes self management program. The diabetes self management program was found to be an effective intervention which would result in net benefits and large savings.

Keywords

CBA; Malaysia; WTP; DSMP; cost

Introduction
It has been estimated that by the year 2025, the number of diabetic patients will reach up to 250-300 million worldwide (1). The first and second National Health and Morbidity surveys found that the prevalence of diabetes in Malaysia has increased from 6.3% in 1985 (2) to 8.3% in 1996 (3) and is expected to worsen with the increase in the life expectancy of the Malaysians (4).

The large cost which is associated with diabetes and its treatment is unsustainable by most health care systems and hence there is increasing use of economic evaluation as a tool to allocate resources. These evaluations can track the current costs and assess the future expenses and resource allocation, which leads to the improvement of the quality of healthcare (5).

Economists within the healthcare sector favour the advice to them on scarce resource allocation by using cost benefit analysis (CBA) (6). The cost benefit analysis facilitates decision making regarding the implementing, withdrawing, or continuing of a program. Net social gains or loss make it easy for making decisions. Furthermore, CBA studies facilitate comparisons between different programs with different outcomes, since all outcomes are converted into monetary values (7).

Willingness to Pay (WTP), which has been widely used in the healthcare and non healthcare areas [8-11], measures both the direct and indirect benefits and provides a method of measuring the individuals’ preferences by asking them how much they are willing to pay for a specific program (12). In addition, the WTP approach is derived directly from the theory of welfare economics, which is considered to be an appropriate method for measuring the individuals’ preferences from a welfare perspective (13). WTP simply means, ‘willingness to forgo (sacrifice)’. The more one is willing to pay, the more he is willing to forgo and the more strongly one feels.

Contingent Valuation (CV) is one of the commonly used techniques for eliciting WTP (14). In CV methods, a hypothetical questionnaire is used to measure the people’s preference for a specific good. This measurement is done by asking people about the maximum amount of money that they are willing to pay in order to have an access to that good or service (15). Therefore, this study aims to conduct a CBA for the diabetes self management program at Universiti Sains, Malaysia (USM), by using the payment card contingent valuation technique.

Material and Methods

Study Design
This cross sectional study was conducted between August 2005 and January 2006.

Questionnaire Design
A payment card WTP CV survey was undertaken to measure the patients' maximum WTP for the Diabetes Self Management Program (DSMP) (Table/Fig 1) appendix 1.In this questionnaire, patients were briefed about diabetes and the prevalence and the burden of diabetes on the diabetic patients. Then, they were briefed on the impact and the advantages of DSMP. Finally, they were asked to choose an amount that they are willing to pay to join DSMP from a scale given at the end of the page ( Appendix1). They were reminded that the amount that they paid could be used for other things if they chose not to join the program, by telling them, “Keep in mind your current income and what would you give up if you made the payment ".

Willingness to Pay Amounts
A pilot study was conducted to measure the WTP amounts by using an open-ended questionnaire. The amounts that patients were willing to pay in the pilot study were used as a guide to set up the WTP amounts in the final study. Bids in the final study ranged from RM0 to RM400, with RM25 as an incremental (RM0, RM25, RM50, RM75, up to RM400) value. People who were willing to pay more than RM400 were given the opportunity to set up the maximum amount that they were willing to pay for the program, by giving them space to state that amount. This study differs a bit from the previous studies in which WTP amounts were written on a scale, rather than written separately. Putting WTP amounts in a scale gave the respondents the freedom to precisely select the exact amount that they were willing to pay. In the old method, patients are provided with a series of amounts and they had to select the maximum amount that they are willing to pay. In the old method, patients who are willing to pay a bit more than the selected amount, but less than the next stated amount, would have to choose the lower amount which was close to their intended amount. For example, let us say that the series of amounts are RM10, RM20, RM30, etc. and respondent was willing to pay RM14. But the stated amounts were either RM10 or RM20. Therefore, they would choose RM10. In the current study, patients had the choice to exactly select the maximum amount that they are willing to pay, by ticking their maximum WTP amount on the provided scale.


Study Population and Participants
The USM Health Centre serves around 350 type 2 diabetic patients, which vary in their educational and ethnic backgrounds. Staffs, pensioners and dependents who were type 2diabetic at the USM main campus and were willing to join DSMP were eligible to be included in the study. Out of 350 patients, 135 patients successfully answered the questionnaire.


Cost Benefit Analysis Study Perspective
This study was conducted from the societal perspective by using the WTP technique which measured both indirect and intangible benefits.


Data Collection Procedure
All type 2 diabetic patients at the USM main campus who agreed to join the study were contacted and a specific date and time was set to meet and interview them. During the interview, the patients were informed about the study and verbal informed consent was obtained from each of them. They were given an average of 15 minutes to complete the questionnaire. All costs incurred in this study were obtained from the Human Resource Department of Health Centre.


Benefits and Costs Calculations for the Diabetes Self Management Program
The mean amounts that patients were willing to pay were considered as the benefits of the intervention. On the other hand, since DSMP started a few months after the commencement of this survey, all costs included in the DSMP were easily calculated. The DSMP consisted of four sessions, with an average of 90 minutes each. One session was conducted by a medical doctor, two sessions were conducted by two pharmacists and one session was conducted by a lecturer from the School of Pharmacy. During the program, a nurse took blood pressure and Body Mass Index (BMI) measurements during each visit. The HbA1c test was done three times during the program. For each HbA1c test done, a syringe, a needle, a tube for the blood sample and a swap were used. Materials and refreshments were served to patients at every session. The total costs incurred during the program were calculated. Salaries of the educators were calculated, based on the time spent during the course. All costs of laboratory tests and educational materials were added together and the time spent by the staff for measuring BP and taking blood samples was also calculated. Finally, the costs of using the class room, chairs, laptop, LCD and screen were added to the total cost after assuming 5 years of life span on them and 20 years life span on the counselling room. Finally, the total costs were divided by the total number of patients to calculate the cost per patient who joined the program. Since the counselling room and the equipments were used for other programs and functions, the costs for using them were calculated by using the percentage of utilizing them for the DSMP, which was found to be 12.5%. As part of the sensitivity analysis, DSMP was assumed to result in the prevention of the development of one case of end stage renal disease. Based on this assumption, the age of diabetes onset, life expectancy of the Malaysians, the years of end stage renal disease saved and annual cost of dialysis in Malaysia were considered and measured for CBA.


Statistical Analysis
The Mann Whitney U test was used to measure the difference between WTP amounts, based on the patients’ demographics. The Kruskal Wallis test was used to measure the difference whenever there were more than 2 groups. All the analyses were conducted by using the SPSS software package version 12 at a significance level of less than 0.05.

Results

A total of 135 diabetic patients successfully responded to the questionnaire. The mean WTP amount of the respondents was RM121.19 (I USD = 3.50 RM). Therefore, the total benefits of the program were RM42416.50, since there were around 350 diabetic patients at the USM Health Centre (Table/Fig 2)summarizes the respondents’ characteristics, in which females were willing to pay more than males, but not up to a significant level. On the other hand, patients with diabetes for a period of 2 years or more were significantly willing to pay higher than those with diabetes for a period of less than 2 years (p=0.033). Malays were willing to pay more than the Chinese and the Indians, but not significantly. Patients with a family size of less than 5 persons were willing to pay higher than those with a family size more than 5 persons, but not up to a significant level. In contrast, patients who were more educated and with a monthly income of more than RM1500 were willing to pay significantly higher than those who were less educated and earning a monthly income of RM1500 or less (p<0.001 and p=0.004, respectively).


On the other hand,(Table/Fig 3) shows the healthcare providers’ costs if the DSMP was given by the physician, lecturer and two pharmacists. It was found that the healthcare provider’scost per patient, per program was RM20.18.


In addition,(Table/Fig 4) shows the costs incurred by other than healthcare providers. These costs include HbA1c tests and the costs of all disposable materials which were used for taking blood samples, such as syringes, needles, plasters and swaps. Other costs included that of the educational materials given to patients, refreshments during the classes, costs of communications and reminders, the cost of using laptops in addition to the cost of the LCD screen and finally, the cost of using the table, chairs and the room. The life span of the laptop, screen, LCD, tables and chairs were estimated to be 5 years, while the life span of the room was estimated to be 20 years. The total non healthcare provider’s costs were found to be RM79.94 per patient, per program. Thus, the total costs of the program equalled the sum of the healthcare providers’ costs. The non health providers’ costs equalled RM100.12 per patient, per program. Therefore, the total costs for 350 patients were estimated to be RM35, 042.


Cost Benefit Ratio
In this section, the net benefits per patient from the program were calculated. Since there were around 350 diabetic patients at the USM Health Centre, the net benefit of the program was calculated after assuming that all patients would participate in the program. Based on the assumption that DSMP was conducted by a medical physician, a pharmacy lecturer and 2 pharmacists and that the life span of the equipments = 5 years, the net benefits of DSMP was found to be equal to RM7374.50, while the benefit to cost ratio was found to be equal to 1.2:1.


On the other hand, the net benefits of DSMP were calculated, based on the assumption that DSMP would result in the prevention of the development of one case of end stage renal disease. It was assumed that the age of diabetes onset in the studied group was 47.5 years and that end stage renal disease develops after 20 years from the onset of diabetes. The life expectancy in Malaysia is assumed to be 75 years and the annual cost of dialysis as RM33958 (16). Therefore, the number of years saved is 7.5 years, which results in a net saving of RM204, 044.17 after 3% discounting. Thus, DSMP would result in a net benefit of RM211, 418.67 by the prevention of the development of one case of end stage renal disease.

Discussion

Scarce resource allocation has been illustrated recently by decision makers. Net benefits can be easily calculated by using CBA, since costs and benefits are in monetary values. In the Cost Effectiveness Analysis (CEA), it is difficult to know whether a new intervention results in a positive net benefit or not. In CEA analysis, the only ratio between the cost and the effectiveness, such as the cost per life year gained, were obtained (17). Resource allocation based on CEA is difficult due to; (a) CEA evaluations provide decision makers no guidance about the forgone alternative when implementing the program (opportunity cost) and (b) CEA evaluations cannot be used to compare between different programs with different outcomes, since the outcomes should be the same natural units (12). During budget constraints, CBA can be used to calculate the net benefits of different interventions and to rank these interventions, based on the net benefit gained. According to the welfare economic theory, “the benefit to an individual of a service or intervention is defined as the individual’s maximum willingness to pay for the service or intervention” (17) .


This study showed that patients with diabetes for more than 2 years had significantly higher WTP amounts than those with lower diabetes length. In addition to that, more educated patients and those with higher incomes showed significantly higher WTP amounts than the less educated and lower income patients. Many other studies found a significant correlation between incomes and WTP amounts (18),(19),(20) and a significant correlation between WTP and education (21). WTP was found to besignificantly correlated with the length of the study, since more educated people had higher incomes and could better understand the future benefits and consequences of the program. On the other hand, no support of range or midpoint bias was found from this study, since a scale of WTP amounts was given to the patients and the patients were given the freedom to choose the exact amount that they were willing to pay. In this study, the range which was given to patients was RM0 to RM400 and the mean and median of the patients’ responses were RM121.19 and RM100.00, respectively. Similar findings were found in a study which compared the payment card and dichotomous choice methods, which found no evidence of finding midpoint or range bias in using the PC method (22).

This study resulted in a net benefit of RM7374.50, while resulting in a net benefit of RM211, 418.67 after assuming that DSMP would result in the prevention of the development of one case of end stage renal disease. Based on the findings by Caro et al., (2002), it was found that 52% of the total costs of diabetes complications were due to macrovascular disease, while 21% were due to nephropathy, 17% were due to neuropathy and 10% were due to retinopathy (23). Therefore, various serious complications could result from diabetes and in this study, end stage renal disease was the only assumption which was considered in the analysis. Other expensive and costly complications like cardiovascular disease, retinopathy and neuropathy (24) could be prevented by the program. As a result, such educational programs would result in much more economical savings and improving patients’ quality of life. Many other studies used WTP as a measurement of the benefits of programs or interventions in CBA evaluations. One study used CBA to evaluate a pharmacy promotion program for hypertensive patients in Canada, which found that the benefits of the pharmacy promotion program were almost ten fold higher than it’s total costs (25). Furthermore, WTP was used to calculate CBA for Red Cross Services in Austria, which considered the mean WTP as the benefit of the program. In their study, the benefits of the Red Cross Services were found to be equal or slightly higher than the running costs (26). Moreover, Insulin Lispro was compared with regular insulin in Australia by conducting the CBA study. The patients were surveyed by using WTP to measure the additional amounts of money that they are willing to pay for insulin Lispro. The net benefits from this study resulted in the listing of new drugs in the Australian formulary (27). Thus, this study provides valued information for policy makers about the monetary values of DSMP, which can be used to facilitate their decision making process. Therefore, as a conclusion, WTP has been found to be a suitable tool for measuring the benefits of DSMP intervention. Significant higher WTP amounts were found with patients having diabetes for a longer period and those who were more educated and with higher incomes. After evaluating CBA, the net positive benefits which resulted from the analysis were found to be RM7374.50, while RM211, 418.67 could be saved from the prevention of the development of one case of end stage renal disease. Many other diabetes complications could be prevented with proper diabetes management, which could result in a higher quality of life and reduce the economical burden of diabetes patients and its complications. Therefore, this study provides the decision and policy makers at the USM Health Centre valuable information about the value and benefits which could result from DSMP.

Conclusion

WTP was approved to be a suitable tool for measuring the benefits of the intervention of the diabetes self management program. The benefit-cost ratio was 1.2:1, with net savings of RM7374.50. Many life threatening complications which have not been addressed in this study, could be prevented by the diabetes self management program, that would result in tremendous savings.

Limitations of Study
This study faced many limitations such as the difficulty in recruiting patients and the small sample size and many of the findings were based on assumptions which are very common in pharmacoeconomics evaluations. As diabetes is a chronic disease and results in many serious complications, it was very difficult to measure the exact number of complications that could be prevented due to the program. Therefore, an assumption of preventing the development of one case of renal failure was assumed. Thus, future researches are recommended to include larger sample sizes and to include many other preventable complications due to diabetes in the CBA. Educational programs which would reflect a more accurate picture about the actual impact and the benefit of diabetes educational programs should be included.

Acknowledgement

This educational program was partially supported by the Secretariat of Healthy Campus and an incentive grant from Universiti Sains, Malaysia. Our thanks to the HealthCenter of University Sains, Malaysia, School of Pharmaceutical Sciences and National Poison Center. Special thanks to: Assoc. Prof. Dr. Mohd Baidi Bahari, Dr. Nurulain bt Abdullah Bayanuddin, Mr. Azaharudin b. Awang Ahmad, Ms. Sulastri bt Samsudin, Ms. Asdariah bt Misnan, Che Gayah bt Omar, Che Rubia, Jameaton and Dr. Mohamed Azmi Hassali who contributed greatly for the success of this program.

Conflict of Interest
None

References

1.
Barrett EJ. Diabetes Epidemic Is a Worldwide Threat. Clin Diabetes. 2004 January 1, 2004;22(1):47-8.
2.
First national health and morbidity survey. Malaysia:, Institute of Public Health, Ministry of Health 1985.
3.
Second national health and morbidity survey. Malaysia:, Institute of Public Health, Ministry of Health 1996.
4.
Zaini A. Where is Malaysia in the midst of the Asian epidemic of diabetes mellitus? Diabetes Research and Clinical Practice. 2000;50(Supplement 2):S23-S8.
5.
Noyes K, Holloway RG. Evidence from Cost-Effectiveness Research. NeuroRX. 2004;1(3):348-55.
6.
COOKSON R. Willingness to pay methods in health care: a sceptical view. Health Economics. 2003;12:891-4.
7.
Zarnke KB, Levine MAH, O'Brien BJ. Cost-Benefit Analyses in the Health-Care Literature: Don't Judge a Study by Its Label. Journal of Clinical Epidemiology. 1997;50(7):813-22.
8.
Zarkin GA, Cates SC, Bala MV. Estimating the willingness to pay for drug abuse treatment: A pilot study. Journal of Substance Abuse Treatment. 2000;18(2):149-59.
9.
Blaine TW, Lichtkoppler FR, Jones KR, Zondag RH. An assessment of household willingness to pay for curbside recycling: A comparison of payment card and referendum approaches. Journal of Environmental Management. 2005;76(1):15-22.
10.
Zhongmin X, Guodong C, Zhiqiang Z, Zhiyong S, Loomis J. Applying contingent valuation in China to measure the total economic value of restoring ecosystem services in Ejina region. Ecological Economics. 2003;44(2-3):345-58.
11.
Jim CY, Chen WY. Recreation-amenity use and contingent valuation of urban greenspaces in Guangzhou, China. Landscape and Urban Planning. 2006;75(1-2):81-96.
12.
Birch S, Gafni A, O'Brien B. Willingness to Pay and the Valuation of Programmes for the Prevention and Control of Influenza. PharmacoEconomics. 1999;16(6):55-61.
13.
Birch S, Donaldson C. Valuing the benefits and costs of health care programmes: where's the ‘extra’ in extra-welfarism? Social Science & Medicine. 2003;Sect. 1121.
14.
Donaldson C, Hundley V, Mapp T, Donaldson C. Willingness To Pay: A Method For Measuring Preferences For Maternity Care? Birth: Issues in Perinatal Care. 1998;25(1):32-9.
15.
Hashimoto K, Nakamura T, Wada I, Yoshida K, Satoh S, Abo M, et al. HOW GREAT IS WILLINGNESS TO PAY FOR RECOVERY FROM SEQUELAE AFTER SEVERE TRAUMATIC BRAIN INJURY IN JAPAN? Journal of Rehabilitation Medicine. 2006;38(2):141-3.
16.
MD. Yusof FA. Cost Effectiveness Analysis of Erythropoietin Therapy in the Ministry of Health Dialysis Programme. Penang: University Sains Malaysia; 2006.
17.
Bala MV, Mauskopf JA, Wood LL. Willingness to Pay as a Measure of Health Benefits. PharmacoEconomics. 1999;15(1):9-18.
18.
Liu L, Neilson WS. Endogenous private health investment and the willingness to pay for public health projects: The effects of income. Economics Letters. 2005;87(3):415-20.
19.
Asenso-Okyere WK, Osei-Akoto I, Anum A, Appiah EN. Willingness to pay for health insurance in a developing economy. A pilot study of the informal sector of Ghana using contingent valuation. Health Policy. 1997;42(3):223-37.
20.
Sadri H, MacKeigan LD, Leiter LA, Einarson TR. Willingness to Pay for Inhaled Insulin: A Contingent Valuation Approach. PharmacoEconomics.2005;23(12):1215-27.
21.
Dong H, Kouyate B, Snow R, Mugisha F, Sauerborn R. Gender's effect on willingness-to-pay for community-based insurance in Burkina Faso. Health Policy. 2003;64(2):153-62.
22.
Ryan M, Scott DA, Donaldson C. Valuing health care using willingness to pay: a comparison of the payment card and dichotomous choice methods. Journal of Health Economics. 2004;23(2):237-58.
23.
Caro JJ, Ward AJ, O'Brien JA. Lifetime Costs of Complications Resulting From Type 2 Diabetes in the U.S. Diabetes Care. 2002 March 1, 2002;25(3):476-81.
24.
O'Brien JA, Shomphe LA, Kavanagh PL, Raggio G, Caro JJ. Direct medical costs of complications resulting from type 2 diabetes in the U.S. Diabetes Care. 1998 July 1, 1998;21(7):1122-8.
25.
Cote, I., Gregoire, J.-P., Moisan J, Chabot I, Lacroix G. A Pharmacy-Based Health Promotion Programme in Hypertension: Cost-Benefit Analysis. PharmacoEconomics. 2003;21(6):415-28.
26.
Hackl F, Pruckner GJ. Demand and supply of emergency help: An economic analysis of Red Cross services. Health Policy. 2006;77(3):326-38.
27.
Davey P, Grainger D, MacMillan J, Rajan N, Aristides M, Dobson M. Economic Evaluation of Insulin Lispro versus Neutral (Regular) Insulin Therapy Using a Willingness-To-Pay Approach. PharmacoEconomics. 1998;13(3):347-58.

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com