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Table of Contents
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 26-29

Assessment of economic Burden and quality of life in stable coronary artery disease patients

1 Department of Clinical Research, Delhi Institute of Pharmaceutical Sciences and Research, New Delhi, India
2 Department of Medicine, Lady Hardinge Medical College, New Delhi, India

Date of Submission14-Jun-2018
Date of Decision25-Aug-2018
Date of Acceptance18-Feb-2019
Date of Web Publication18-Feb-2019

Correspondence Address:
Lalit Kumar
Department of Clinical Research, Delhi Institute of Pharmaceutical Sciences and Research, M.B Road, Pushp Vihar, Sector- 3, New Delhi - 110 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJMS.INJMS_1_18

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Background: Coronary artery disease (CAD) is known to adversely impact the quality of life (QOL) of the patients and poses an economic burden to the family and society. However, the same has not been estimated in India. Objectives: To estimate the annual economic burden (direct and indirect cost) and QOL in stable CAD patients at a Government Tertiary Care Hospital of Delhi, India. Materials and Methods: A cross-sectional study was carried out in a Government Tertiary Care Hospital of Delhi using a convenient sample of 113 CAD patients. A prestructured pretested questionnaire was used to collect information on direct and indirect costs of therapy for CAD patients, and QOL assessment was done using SF-36 questionnaire. Results: The total average annual cost incurred by patients of stable CAD was Indian National Rupees 15691.45, of which 78.49% was attributable to direct cost (drugs, supplements, diagnostic tests, and transportation charges) while 21.5% to the indirect costs (wage loss of the patient and caretaker, during the days of hospitalization). Both the components of QOL, namely, physical component score (PCS) and mental component score (MCS) were reduced in the stable CAD patients. PCS was 35.53 and MCS was 39.16. Conclusion: CAD poses not only an economic burden on the patient, family, and the society but is also associated with impairment of QOL of the patient too.

Keywords: Direct cost, indirect cost, mental health score, physical health score, quality of life

How to cite this article:
Kumar L, Prakash A, Gupta S K. Assessment of economic Burden and quality of life in stable coronary artery disease patients. Indian J Med Spec 2019;10:26-9

How to cite this URL:
Kumar L, Prakash A, Gupta S K. Assessment of economic Burden and quality of life in stable coronary artery disease patients. Indian J Med Spec [serial online] 2019 [cited 2023 Jun 9];10:26-9. Available from: http://www.ijms.in/text.asp?2019/10/1/26/252469

  Introduction Top

Coronary artery disease (CAD) is the leading cause of death in developed and developing countries. In 2015, 7.4 million people died from CAD globally. It is estimated that in 2020, CAD will be responsible for a total of 11.1 million deaths worldwide.[1] In 2016, there is an estimated 62.5 million and 12.7 million years of life lost prematurely due to CAD in India and the US, respectively. CAD was estimated to account for around 15%–20% and 6%–9% of all deaths in India and the US.[2] In addition to mortality, CAD is also responsible for morbidity and loss of quality of life (QOL). The treatment of CAD is expensive and can consume a major part of patient income as the patients require treatment for a longer duration of time. In India, direct cost of CAD could be 200 billion rupees. This would increase to 800 billion rupees if 100% of the CAD patients received necessary treatment. Indirect costs would make the cost even higher.[3] CAD has significant physical, emotional, and social impact for patients; so, evaluating their QOL is necessary for assessing the success of treatment and it may be used for modifying or improving the treatment given, or for providing treatment alternatives.[4] There have virtually been no attempts in India to estimate the direct and indirect cost in CAD patients seeking treatment. The present study was designed to assess the economic burden (direct and indirect cost) and QOL in stable CAD patients.

  Materials and Methods Top

Study design and setting

A cross-sectional study was conducted at a government tertiary care hospital. Primary data were collected from patients suffering from CAD and seeking treatment at the hospital. Data collection was performed between August 2017 and January 2018.

Eligibility criteria

All diagnosed cases of stable CAD patients (angina pectoris, a history of myocardial infarction, or the presence of plaque) above age 18, diagnosed for at least 1 year seeking treatment at the hospital, without any history of admission in the preceding 6 months or cardiology intervention (percutaneous coronary intervention or coronary artery bypass grafting) during the same period were included in the study. The patients recommended for bypass surgery or angioplasty and terminally ill patients were excluded from the study.[5]

Sampling methodology and procedure

Ethical clearance was obtained from Institutional Ethics Committee. The identity of the hospital is not being disclosed to maintain the confidentiality of information. Nonprobability convenience sampling method was adopted to select the sample of 113 patients suffering from CAD. Patients were directly recruited while they came for their regular checkups in the outpatient department (OPD) of the hospital. Written informed consent was also obtained before starting any interview for the patient.

Data collection tool

A prestructured pretested questionnaire was used. The questionnaire collected information on the following aspects: sociodemographic characteristics, clinical history, medication and medication costs, traveling cost, loss of wages, etc. Data were collected to ascertain both direct and indirect costs. The “cost of illness” approach was followed to calculate the direct and indirect cost. Direct cost included the expenditure on medicine, supplements, diagnostic tests, investigation costs, and transportation charges. The indirect cost included wage loss of the patient and his/her caretaker during the days of travel to hospital for follow-up visits and investigations.[6] To measure the QOL, SF-36 (short form health survey) was also administered to the same patients. It is a generic, multipurpose, short-form health survey with only 36 questions. The eight domains that the SF36 measures are as follows: vitality (VT), physical functioning (PF), bodily pain (BP), general health (GH) perception, physical role functioning (RP), emotional role functioning (RE), social role functioning (SF), and mental health (MH). These eight scaled scores are the weighted summation of the questions on their section. Physical component score (PCS) correlates most highly with PF, RP, and BP while mental component score (MCS) correlates most highly with MH, RE, and SF. VT and GH have noteworthy correlation with both components. The lowest score means a low QOL. The highest score means good QOL.[7]

Data analysis

Data analysis was performed using MS-Office Excel software and Quality Metric health Outcomes™ scoring software 5.1. Continuous variables are reported as means ± standard deviation. Categorical variables are reported as proportions (%). Total costs, direct medical costs, and indirect costs are computed as the annual costs per patient. All the cost values are presented in Indian National Rupees (INR). The per capita income or average income was calculated by taking the total annual income divided by the total number of family members of the individual. Annual expenditure incurred per patient on the treatment of CAD was estimated. The expenditure incurred on the OPD visits occurred regularly at definite intervals of time (expenditure on medicine, traveling, diagnostics).

  Results Top

General characteristics

A total of 113 patients who were diagnosed and treated for the event of CAD were enrolled in the study. Male to female ratio was found to be 1:1.82, 40 patients (35.4%) were males and 73 patients (64.6%) were females. The average age of the patients was 54.35 ± 12.09 years with average body mass index of 23.41 ± 5.199 kg/m2. Only 46 (40.7%) of the individuals were earning members, while the remaining were dependent. The average income of the patients was INR 100991.16 per annum. Hypertension and diabetes mellitus, alone or in combination, were present as comorbidities in over three-fourths of the individuals.

Cost analysis

Each individual on an average visited hospital 14.15 days in a year (4%), with no physician consultation charges. Even the blood investigations performed at the hospital were not chargeable for the individuals since it was a government facility. The average annual economic burden of CAD was INR 15691.43 per year. The direct cost which includes drugs, laboratory test cost, and transportation charges was INR 12317.39 (78.5%) per patient, and the indirect cost which includes loss of wages due to loss of services was INR 3374.04 (21.5%) per patient. The direct cost consumed 12.19% and indirect cost consumed 3.34% of the average annual income, with the total treatment consuming on an average 15.53% of the patient's annual income. All the costs and services are shown in [Table 1].
Table 1: Services and cost

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Quality of life

The PCS and MCS are psychometrically based scores computed on the SF-36 questionnaire.

The Physical component summary and mental component summary of all the patients was lower than Normal health score (score50) and as various individual components (of both PCS and MCS). PCS was 35.53 and MCS was 39.16; individual scores were PF = 35.1, RP = 35.81, BP = 39.19, GH = 31.32, VT = 41.35, SF (social functioning) =35.96, RE = 30.78, and MH = 43.78.

  Discussion Top

The World Health Organization Global Status 2010 report on noncommunicable diseases (NCDs) states that NCDs are the most prevalent cause of mortality worldwide.[8] Ischemic heart disease was the fourth largest cause of years of life lost due to premature mortality in 2010, up from its eighth ranking in 1990.[9] The increasing health burden of CAD significantly translates into increased economic burden and loss of QOL. CAD does pose a mammoth cost burden. Cardiovascular disease was estimated to cost the European Union 169 billion Euro annually, with healthcare accounting for 62% of costs. Further, CAD represented 27% of the overall cardiovascular disease costs.[10]

The present study has been carried out in a government tertiary care hospital of New Delhi to determine the economic burden of stable CAD and the QOL of these patients. In spite of free hospitalization, emergency care, consultation, diagnostics, medicine, and supplement supplies, the total cost of treatment was INR 15,691.45 per year and the average income of the CAD patients per year was INR 100,991.16. The per capita net national income of India for 2016–2017 fiscal was Rs. 103,870, which is approximately same as the average income of the CAD individuals of the study group.[11] The treatment consumed 15.53% of the annual household income.

Another study performed in Chandigarh, northern part of India in 2012 calculated the out-of-pocket expenditure (OOP) over two years for 102 CAD patients, of which 95 (93%) were hospitalized one or more times in the preceding 2 years. Only 7 CAD patients were nonhospitalized, and the average OOP expenditure among these was INR 48578. The authors reported that expenditure on medicines/drugs was INR 27,900 (57.4%), on diagnostics (26%, INR 12,698), consultation (9%, INR 4380), and transportation (7.5%, INR 3600). However, since the patients in the Chandigarh study were included from a private super speciality hospital as well as from a tertiary government hospital, the values mentioned seem to be a mixture from the two hospital setups. Therefore, it is not easy to compare the same with the findings from our study, which are solely from a tertiary government hospital of Delhi, where the diagnostics, consultation, and medicines are largely free of cost. In fact, the present study conducted after a gap of 5 years has a lower economic burden amounting to INR 15691.45 only, which is less than one-third that of the Chandigarh study. The disparity in the two figures despite rise in wholesale price index and inflation over this period is attributable to the free services provided at the setup where the study was conducted. The major chunk of OOP in the present study was attributable to medication costs; although some medicines are ordinarily available from the hospital, all CAD-specific medicines are not stocked resulting in the major cost being attributed to medications. However, the moot point is that despite several facilities being available at the health center, the attributable cost of illness in CAD contributed to 15.53% of the average per capita income.

The present study also focused on the QOL in the CAD patients, and all the components of the QOL were found to be impaired. The PCS and the MCSs were reduced indicating a poor QOL and a negative impact on physical, social, and emotional functioning as well. Although the present study did not evaluate the distress financing in the study individuals, the Chandigarh study reported significant distress financing, wherein the individuals or their families had taken loans or sold assets to meet the economic burden posed by CAD.

  Conclusion Top

CAD, one of the major noncommunicable diseases, poses a significant financial burden on the patient and impairs the QOL of the patient. In spite of free services provided by the health care centers, patients have to keep a provision for OOP expenditure, the major chunk of which is on medications. It may be prudent to have appropriate medications stocked health centres through the year, to be able to mitigate the financial burden attributable to purchase of medications by individuals suffering from CAD.


I would like to thank Dana Kopec (dkopec@qualitymetric.com) for giving me the license for SF-36 (License No.-QM041636) and Quality Metric Health outcome™ Scoring Software.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Cardiovascular Diseases (CVDs). World Health Organization; 2018 Available from: http://www.who.int/mediacentre/factsheets/fs317/en/. [Last accessed on 2018 Oct 30].  Back to cited text no. 1
Dey S. Heart Disease Deaths Rise in India by 34% in 26 Years. The Times of India Published; 10 July, 2018. Available from: https://www.timesofindia.indiatimes.com/india/heart-disease-deaths-rise-in-india-by-34-in-15-years/articleshow/64924601.cms. [Last accessed on 2018 Oct 30].  Back to cited text no. 2
Economic Burden. Cadiresearch.org; 2012. Available from: http://www.cadiresearch.org/topic/asian-indian-heart-disease/cadi-india/economic-burden. [Last accessed on 2018 Oct 30].  Back to cited text no. 3
Dueñas M, Salazar A, Ojeda B, Failde I. Health Related Quality of Life in Coronary Patients. IntechOpen; 2012. Available from: https://www.intechopen.com/books/recent-advances-in-cardiovascular-risk-factors/health-related-quality-of-life-in-coronary-patients. [Last accessed on 2018 Oct 30].  Back to cited text no. 4
Pflieger M, Winslow BT, Mills K, Dauber IM. Medical Management of Stable Coronary Artery Disease. American Family Physician; 2011. Available from: https://www.aafp.org/afp/2011/0401/p819.html. [Last accessed on 2018 Oct 30].  Back to cited text no. 5
Sharma V. The Economic Impact of Coronary Heart Disease at Household Level: Evidences from Mumbai city, India. Academia.edu. Available from: http://www.academia.edu/12622728/The_economic_impact_of_coronary_heart_disease_at_household_level_Evidences_from_Mumbai_city_India. [Last accessed on 2018 Oct 30].  Back to cited text no. 6
SF-36. Wikipedia. Wikimedia Foundation; 2018. Available from: https://www.en.wikipedia.org/wiki/SF-36. [Last accessed on 2018 Oct 30].  Back to cited text no. 7
Global Status Report on Noncommunicable Diseases. World Health Organization; 2010. Available from: http://www.who.int/nmh/publications/ncd_report2010/en/. [Last accessed on 2018 Oct 30].  Back to cited text no. 8
Healthdata.org; 2018. Available from: http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_niger.pdf. [Last accessed on 2018 Oct 30].  Back to cited text no. 9
India's Per Capita Income Grows by 8.6% to Rs 1.13 Lakh in FY18. Press Trust of India. Published; 31 May, 2018. Available from: https://www.economictimes.indiatimes.com/news/economy/indicators/indias-per-capita-income-grows-by-8-6-to-rs-1-13-lakh-in-fy18/articleshow/64403632.cms. [Last accessed on 2018 Oct 30].  Back to cited text no. 10
Leal J, Luengo-Fernández R, Gray A, Petersen S, Rayner M. Economic burden of cardiovascular diseases in the enlarged European Union. Eur Heart J 2006;27:1610-9.  Back to cited text no. 11


  [Table 1]

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