Introduction

Diabetes mellitus represents a group of chronic metabolic diseases that are associated with impaired glucose tolerance. An estimated 8.4%(451 million cases) of the global population in 2017 were affected by diabetes(type 1 and type 2) with prevalence rates projected to increase to 9.9% by 2045 [1]. In Australia, diabetes is a national health priority [2], with the prevalence of diabetes in adults aged 20 to 79 years estimated at 6.5%(>1.1 million cases) [3] increasing to 12.3% in women aged 50 years and older [4].

The burden of diabetes for individuals, society and health care systems is high. The global burden of disease study reported in 2013 that diabetes was the seventh leading cause of years lived with disability (YLD) globally, and the tenth in Australia [5]. Contributing to the burden of this disease is the myriad comorbid physical conditions associated with diabetes, including coronary artery disease(CAD), stroke, retinopathy and kidney disease [2]. There is also a high prevalence of depression and distress in people living with diabetes, which can adversely impact a person’s level of wellbeing [6]. Poor wellbeing also can be attributed to other factors associated with the disease(e.g. physical impairment, pain), and its ongoing management(e.g. lifestyle adjustment, financial hardship) [6]. Consequently, people living with diabetes tend to have complex chronic health care needs, which require team-based approaches to health care, as well as high levels of health service use [2].

People with diabetes are often required to engage in ongoing self-care practices to effectively manage blood glucose levels, and to reduce the risk of developing diabetes-related complications and comorbidities [2]. Self-care can include regular blood glucose monitoring, foot care, medication use, utilisation of other health care services, and dietary and lifestyle management [7]. Clinical guidelines for the prevention and management of diabetes recommend that evidence-based lifestyle interventions be used to control blood glucose prior to prescribing medications [2]. When a person with diabetes is unable to maintain optimal metabolic control with lifestyle interventions alone, they may be prescribed a range of medications to manage diabetes and related health complications. This can include medications to assist with the management of hyperglycaemia, hyperlipidaemia, hypertension, peripheral vascular disease and mood [2]. Consequently, people living with diabetes can be receiving multiple medications, which require ongoing health monitoring by primary care providers [8].

In addition to standard care, many people with diabetes consult complementary medicine (CM) health care practitioners (e.g., naturopaths, chiropractors, massage therapists) and use CM treatments (e.g., nutritional supplements, herbal medicines, relaxation techniques) to help manage the condition [9–11]. A study from 2010 reported 43% of Australian adults with type 2 diabetes used CM in the previous 12 months [9]; this is higher than that reported in a 2012 US study in which 25% of adults aged 65 years and older with diabetes used CM in the previous year [11]. The Australian study also identified people with diabetes who use CM, compared to non-users, as more likely to have exercised in the previous 2 weeks, and attend exercise or social support groups in the previous 12 months [9]. An additional US study identified participants receiving adjunct naturopathic care for inadequately controlled type 2 diabetes as showing improvements in most patient-reported outcomes, such as improved glucose monitoring, mood and physical activity levels [12]. Meta-analyses of randomised controlled trials have found that the herbal medicines Trigonella foenum-graecum(fenugreek) and Allium sativum(garlic) significantly reduce fasting blood glucose levels [13, 14].

Poor management of diabetes can result in serious health complications and physical disability, contributing further to the overall burden of the disease [2]. Medication persistence and adherence in type 2 diabetes can reduce unexpected hospital admissions and associated health care costs [8]. However, non-adherence to prescribed treatments for diabetes is common due to medication side-effects, inconvenience, cost and various other factors [8]. For example, people with diabetes using multiple medications, compared to those who take fewer medications, report poorer quality of life [9]. Due to the complexity of managing diabetes for both patients and practitioners, guidelines also recommend self-management (for type 2 diabetes) as a component of an evidence-based program involving patient education and support tailored to the individual [2]. Poor management of diabetes is a particular concern for women as they are at significantly greater risk of stroke compared to men [15].

The estimated direct health care costs of diabetes in Australia in 2017 was AU$6.9 million(or AU$7,820 per person) [3]. However, the total financial burden of diabetes is likely to be much higher, as this figure does not include indirect costs, such as inability to work and provision of government benefits; it also does not consider the cost of self-care practices or the use of CM, the latter not being considered part of the mainstream health care system in Australia. The economic burden of self-care of chronic illness by individuals and households is often overlooked in Australia in favour of analyses that centre on the macro-economy and the cost to government [16].

Individuals with diabetes often report high utilisation rates of public health care services, particularly women [17]; yet, little is known about the utilisation and cost of accessing private health/self care services in this population. Given the importance of effective diabetes management in preventing potentially serious health complications and comorbidities, which can have a significant impact on financial burden and quality of life, it is critical to understand how people with diabetes utilise all types of health care in order to better inform health services planning and policy development. This is particularly relevant for older women as they are over-represented in the ageing population, experience symptoms of chronic illness differently to men [18] and have specific health needs (often not met by formal expert-led care) [19]. Furthermore, women are known to be greater users of CAM [20]. As such, this project provides an important contribution towards examining the ways in which CAM self-care relates to women’s over-representation in chronic illness and their broader disadvantage. Consequently, this study aims to describe the prevalence of health care utilization (including conventional, self-care, and CM) and out-of-pocket expenditure associated with such use for the management of diabetes in Australian women aged 45 years and older.

Materials and Methods

Results

Consultations with health care practitioners

The majority of women (88.3%; n = 346) consulted at least one health care practitioner in the previous 12 months for their diabetes. Specifically, 84.6% (n = 332) consulted a medical doctor, 44.4% (n = 174) consulted a nurse or allied health practitioner, and 20.4% (n = 80) consulted a CM practitioner in the previous 12 months.

Table 1 shows the average number of participant consultations with each category of health care practitioner, by years since diagnosis of diabetes and severity of diabetes over the past 12 months. Women who reported a diabetes severity rating of 5 or more points (out of 10) had a greater number of consultations with health care practitioners (p<0.001), specifically medical doctors (p<0.001) and nurses/allied health practitioners (p<0.001), compared to women who provided a diabetes severity rating of less than 5 points. Overall, women had attended on average 6.9 consultations with health care practitioners for their diabetes in the previous 12 months.

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Table 1. Consultations with health care practitioners by years since diagnosis of diabetes and severity of diabetes over the past 12 months.

https://doi.org/10.1371/journal.pone.0255573.t001

Use of CM products and practices

Table 2 shows the average number of CM products and practices used by participants, by years since diagnosis of diabetes and severity of diabetes over the past 12 months. There was no statistically significant association between the number of different CM products and practices used for diabetes and severity of diabetes (p = 0.329), or years since diagnosis with diabetes (p = 0.896).

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Table 2. Use of complementary health products and practices by years since diagnosis of diabetes and severity of diabetes over the past 12 months.

https://doi.org/10.1371/journal.pone.0255573.t002

Out-of-pocket expenses

The out-of-pocket expenses by years since diagnosis of diabetes and severity of diabetes over the past 12 months are presented in Table 3. Women who had been diagnosed with diabetes 10 or more years ago reported greater out-of-pocket expenditure for prescription medications, than women who had been diagnosed with diabetes within the past 10 years (p = 0.042). Women who provided a diabetes severity rating of 5 or more points (out of 10) reported greater out-of-pocket expenditure for CM practitioners (p = 0.039) and prescription medications (p = 0.002), compared to women who provided a diabetes severity rating of less than 5 points.

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Table 3. Out-of-pocket expenses by years since diagnosis of diabetes and severity of diabetes over the past 12 months.

https://doi.org/10.1371/journal.pone.0255573.t003

On average, the annual combined out-of-pocket health care expenditure reported by women with diabetes in this study was AU$492.60 per person. Using 2016 Australian population census data to extrapolate these findings to a national population of women with diabetes, and assuming an average individual out-of-pocket expenditure in line with that of the women from this study (AU$492.60), we estimate the total out-of-pocket expenditure associated with diabetes treatment for Australian women aged 50 years and over to be approximately AU$252 million per annum. Of this total figure, approximately AU$70 million per annum was spent on CM (practitioners: AU$32 million per annum; products and practices: AU$38 million).

Discussion

The results of this study provide important insights regarding public and private health care utilisation by middle-aged and older Australian women living with diabetes. The type and range of health practitioners that women are consulting for their diabetes seems to support current practice guidelines. For instance, medical doctors were the most commonly consulted health practitioner by women with diabetes. This finding aligns with current guidelines, which position general practitioners as central to the long-term management and oversight of patients with diabetes [2]. Current practice guidelines also emphasise the importance of self-care and lifestyle interventions for the management of diabetes, and the need for multi-disciplinary team-based care to help address these recommendations [29]. Given the modest prevalence of use of both allied health practitioners and CM practitioners by participants in this study, it is possible that many women with diabetes may be receiving multi-disciplinary care. Notwithstanding, we are unable to determine whether the care received by women with diabetes aligns with patient preferences [30] or is coordinated across all health services. Closer examination of these issues is therefore warranted.

Our analysis suggests approximately AU252 million is spent out-of-pocket for diabetes management by Australian women aged 50 years and over. The individual cost calculated from our study (AU492.60) figure is significantly lower than the AU7,820 per person aged 20–79 years as estimated in 2017 by the International Diabetes Federation (IDF) [3]; however, the expense estimates provided by the IDF encompass a wide range of ages, health services and costs incurred at all levels of government beyond those borne by individuals and households out-of-pocket. Equally, it is not clear whether these previous estimates include out-of-pocket expenses for individuals with diabetes, particularly in relation to self-care and CM health services, as these generally sit outside the conventional, government-funded health system in Australia [31]. It is important that future estimates of total health service expenditure explicitly account for the full range of health services and treatments by individuals with diabetes.

There are a known number of cost-saving interventions for diabetes, including pharmacotherapy(e.g. the use of ACE inhibitors for hypertension, angiotensin receptor blockers or early irbersartan treatment for the prevention of end-stage renal disease), and multi-component treatments for diabetic risk factor control and early detection of both type 1 and type 2 diabetes [32]. Intensive lifestyle coaching, health behaviour counselling and screening interventions were also found to be cost-effective. However, effective implementation of these types of interventions is dependent on patients having adequate health literacy, self-efficacy and problem-solving skills [33]. Many primary care practitioners may not have the time or training required to provide the intensive support needed by patients to effectively implement and sustain lifestyle change [34]; although, emerging evidence does suggest CM practitioners, such as naturopaths, may be able to fill this health service gap [12, 35]. Given that some CM practices have been shown to be cost-effective in managing other chronic diseases [36], further interrogation of the economic impact of utilising diverse health services to manage diabetes is needed. Also, in light of the differences in out-of-pocket spending patterns observed (in our analysis) between women with varying levels of symptom severity, future economic research should give separate attention to the impact of using multiple health services for individuals experiencing diabetes symptoms of low and high severity.

An interesting observation in our study was that women diagnosed with diabetes 10 or more years prior to completing the questionnaire (compared to less than 10 years) had higher out-of-pocket expenses for prescription medications. This finding is important as it highlights that a longer duration of diabetes is associated with greater risk of comorbidities and, subsequently, a greater real or perceived need for treatments. Even though increasing diabetes duration is associated with higher risk of comorbidity [37] (and greater actual/perceived need for prescribed medication), effective management of diabetes arguably extends beyond pharmaceutical treatment. In fact, diabetes management requires long-term coordinated team-based communication between all types of health care providers, patients and health care systems [2]. Future research should examine the challenges of such care co-ordination and the impact of co-morbidities on health service use in older women with diabetes.

Conclusions

The findings of this study suggest older Australian women may use a range of conventional, nursing/allied health, CM and self-care interventions/services to manage their diabetes and pay a considerable amount out-of-pocket to access this care, The economic burden placed on these women warrants further investigation to understand how health care services (and the integration of such services) can better address the biopsychosocial needs of this population. Examining how multi-disciplinary, patient-centred and evidence-based health care services can be effectively delivered to women living with diabetes will assist with the translation of these findings into clinical guidelines and care.

Acknowledgments

This research was completed using data collected through the 45 and Up Study (www.saxinstitute.org.au). The 45 and Up Study is managed by the Sax Institute in collaboration with major partner Cancer Council NSW; and partners: the National Heart Foundation of Australia (NSW Division); NSW Ministry of Health; NSW Government Family & Community Services—Ageing, Carers and the Disability Council NSW; and the Australian Red Cross Blood Service. We thank the many thousands of people participating in the 45 and Up Study.