{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T18:39:09Z","timestamp":1785782349137,"version":"3.56.0"},"reference-count":47,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2020,9,30]],"date-time":"2020-09-30T00:00:00Z","timestamp":1601424000000},"content-version":"unspecified","delay-in-days":29,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2020,8,7]]},"published-print":{"date-parts":[[2020,9]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To estimate average annual expenditures per person, total economic burden and distress health financing associated with the treatment of five cardio-metabolic diseases (CMDs\u2014hypertension, diabetes, heart disease (angina, myocardial infarction and heart failure), stroke and chronic kidney disease) in three metropolitan cities in South Asia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Cross-sectional surveys.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>We analysed community-based baseline data from the Centre for cArdio-metabolic Risk Reduction in South Asia (CARRS) Study collected in 2010\u20132011 representing Chennai and New Delhi (India), and Karachi (Pakistan).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>We used data from non-pregnant adults (\u226520 years) from the aforementioned cities that responded to a cost-of-illness questionnaire. We estimated health utilisation and expenditures among those reporting taking treatment(s) for the aforementioned CMDs in the last 1\u2009year. We converted all costs to International Dollars (Int$ 2011) and inflated to 2018 values. The annual costs per person were stratified by city, sociodemographic characteristics, contributor of costs and financing methods. The total economic burden of CMDs for each city was projected using age-standardised prevalence and per-person costs of diseases reported in CARRS, applying these to population data from the most recent census. We also calculated distress financing (DF) as having to borrow or sell assets to pay for CMD treatment and identified sociodemographic groups at most risk of DF using multiple regression.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 16\u2009287 CARRS participants, 2883 (17.7%) reported receiving treatment for CMDs. The total annual expenditures reported per patient for CMDs ranged from Int$358 to Int$2425. Medications constituted 46% of total direct expenditures and out-of-pocket (OOP) expenditures accounted for nearly 80% of financing these health expenditures. Total economic burdens of CMDs were Int$0.42 billion, Int$3.4 billion and Int$1.4\u2009billion in Chennai, New Delhi and Karachi, respectively. Overall, 36.1% experienced DF, and women (OR=4.4), unemployed (OR=10.7) and uninsured (OR=8.1) adults experienced higher odds of DF.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>CMDs are associated with large economic burdens in South Asia. Due to most payments coming from OOP expenditures and limited insurance, the odds of DF are high.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2019-036317","type":"journal-article","created":{"date-parts":[[2020,9,30]],"date-time":"2020-09-30T16:40:23Z","timestamp":1601484023000},"page":"e036317","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":14,"title":["Healthcare utilisation and expenditure patterns for cardio-metabolic diseases in South Asian cities: the CARRS Study"],"prefix":"10.1136","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3929-235X","authenticated-orcid":false,"given":"Priti","family":"Gupta","sequence":"first","affiliation":[{"name":"Centre for Chronic Disease Control, New Delhi, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kalpana","family":"Singh","sequence":"additional","affiliation":[{"name":"Centre for Chronic Disease Control, New Delhi, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roopa","family":"Shivashankar","sequence":"additional","affiliation":[{"name":"Centre for Chronic Disease Control, New Delhi, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kavita","family":"Singh","sequence":"additional","affiliation":[{"name":"The Centre for Chronic Conditions and Injuries (CCCI), Public Health Foundation of India, New Delhi, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ajay","family":"Vamadevan","sequence":"additional","affiliation":[{"name":"Centre for Chronic Disease Control, New Delhi, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"V","family":"Mohan","sequence":"additional","affiliation":[{"name":"Madras Diabetes Research Foundation, Chennai, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad Masood","family":"Kadir","sequence":"additional","affiliation":[{"name":"Community Health Sciences, Aga Khan University, Karachi, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikhil","family":"Tandon","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Metabolism & Diabetes, All India Institute of Medical Sciences, New Delhi, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"K M","family":"Narayan","sequence":"additional","affiliation":[{"name":"Global Health, Emory University School of Public Health, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorairaj","family":"Prabhakaran","sequence":"additional","affiliation":[{"name":"Centre for Chronic Disease Control, New Delhi, India"},{"name":"The Centre for Chronic Conditions and Injuries (CCCI), Public Health Foundation of India, New Delhi, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammed K","family":"Ali","sequence":"additional","affiliation":[{"name":"Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2020,9,30]]},"reference":[{"key":"2026062608041091000_10.9.e036317.1","unstructured":"World Health Organization . 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Available: https:\/\/www.ahrq.gov\/professionals\/education\/curriculum-tools\/population-health\/baldwin.html [Accessed 30 Mar 2019]."},{"key":"2026062608041091000_10.9.e036317.7","unstructured":"Vellakkal S . Economic implications of chronic diseases in India. South Asia Netw Chronic Dis 2009."},{"key":"2026062608041091000_10.9.e036317.8","doi-asserted-by":"crossref","unstructured":"Mahal A , Karan A , Engelgau M . The economic implications of non-communicable disease for India. health, nutrition and population (HNP) discussion paper, 2010.","DOI":"10.1596\/13649"},{"key":"2026062608041091000_10.9.e036317.9","unstructured":"Gupta I , Kandamuthan S , Upadhyaya D . Economic impact of cardiovascular diseases in India. Delhi: Institute of Economic Growth, 2006."},{"key":"2026062608041091000_10.9.e036317.10","first-page":"121","article-title":"Measuring the economic and social consequences of CVDs and diabetes in India and Pakistan","volume":"1","author":"Govender","year":"2007","journal-title":"Biosci Trends"},{"key":"2026062608041091000_10.9.e036317.11","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1080\/13696998.2019.1600523","article-title":"Comparative financing analysis and political economy of noncommunicable diseases","volume":"22","author":"Jakovljevic","year":"2019","journal-title":"J Med Econ"},{"key":"2026062608041091000_10.9.e036317.12","doi-asserted-by":"publisher","DOI":"10.1186\/1478-4505-11-31"},{"key":"2026062608041091000_10.9.e036317.13","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2458-12-701"},{"key":"2026062608041091000_10.9.e036317.14","doi-asserted-by":"publisher","DOI":"10.1177\/2047487315580891"},{"key":"2026062608041091000_10.9.e036317.15","unstructured":"International Union For Health Promotion and Education (IUHPE) . 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Available: https:\/\/clc.gov.in\/clc\/node\/572 [Accessed 6 Aug 2018]."},{"key":"2026062608041091000_10.9.e036317.20","unstructured":"Paycheck . Revised Delhi minimum wage April 2018. Available: https:\/\/paycheck.in\/salary\/minimumwages\/delhi [Accessed 6 Aug 2018]."},{"key":"2026062608041091000_10.9.e036317.21","unstructured":"Paycheck . Minimum wage in Pakistan. Available: https:\/\/paycheck.pk\/salary\/minimum-wages\/ [Accessed 6 Aug 2018]."},{"key":"2026062608041091000_10.9.e036317.22","unstructured":"Xu K . Financing WHOD of HS, allocation E and R. distribution of health payments and catastrophic expenditures methodology, 2005."},{"key":"2026062608041091000_10.9.e036317.23","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0020821"},{"key":"2026062608041091000_10.9.e036317.24","unstructured":"World DataBank . 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