ABSTRACT
Introduction: Access to diabetes management programs is crucial to control the increasing contribution of diabetes to the global burden of disease. However, evidence regarding whether such services are equally accessible for all population groups is still lacking, particularly in the context of low-middle-income countries and under the National Health Insurance (NHI). This study aimed to assess the extent of socioeconomic and geographical inequalities in the use, quality, and outcome of a diabetes management program for beneficiaries of Indonesian NHI. Methods: A total of 628 participants in the NHI diabetes management program in Banyumas District, Indonesia, were included in 2021 in this cross-sectional study. The main variables measured were regular visits to primary care facilities, standard medication, and glycemic control. The rate difference and rate ratio of age-sex standardized prevalence rates, as well as multiple logistic regressions, were used to measure the extent of inequalities. Results: Around 70% of participants regularly visited primary care facilities and received standard medication, but only 35% had good glycemic control. Highly educated participants were more likely to have regular visits compared to low-educated participants (odds ratio [OR] 1.92; 95% confidence interval [95% CI]: 1.04-3.56). Based on employment and type of NHI beneficiaries, a small extent and even reverse inequalities were found although these findings were insignificant statistically. Urban residents were also more likely to have regular visits (OR 6.61; 95% CI: 2.90-15.08), receive standard medication (OR 9.73; 95% CI: 3.66-25.90), and have good glycemic control (OR 3.85; 95% CI: 1.68-8.83) compared to rural residents. Conclusions: Evidence on the extent of socioeconomic inequalities is inconclusive but substantial geographical inequalities in the use, quality, and outcome of diabetes management programs exist among Indonesian NHI beneficiaries. Future implementation policies of the program should consider particularly the geographical characteristics of participants to avoid and reduce inequalities and, hence, the disease burden of diabetes.
ABSTRACT
OBJECTIVE: Liver cirrhosis and hepatocellular carcinoma (HCC) are chronic liver diseases that can cause serious health problems. Meanwhile, the methods used to detect liver cirrhosis and HCC are limited. Apolipoprotein A1 (ApoA1) is a protein that makes up high-density lipoprotein (HDL), which plays a role in liver cirrhosis and HCC, and can be used as a biomarker. This study aims to determine the ability of ApoA1 to detect and differentiate liver cirrhosis and hepatocellular carcinoma. METHODS: This cross-sectional study was conducted on 47 patients with liver cirrhosis and HCC at Margono Soekarjo Regional General Hospital, Purwokerto, Indonesia. This study also involved 33 healthy participants from blood donors at the Blood Transfusion Unit, Indonesian Red Cross, Banyumas. Serum ApoA1 levels were analyzed by ELISA method. Receiver Operating Characteristics (ROC) were used to evaluate the diagnostic power of ApoA1 and differentiate between cirrhotic, HCC, and healthy patients. Multivariate binary logistic regression test to determine the most influential variables on the incidence of cirrhosis, HCC, and health. RESULTS: ApoA1 was able to differentiate cirrhosis from HCC, cirrhosis from healthy and HCC from healthy, with sensitivity 56.7%, 86.7%, 70.6%, specificity 70.6%, 93.9%, 84.9%, respectively, and AUC 68.5%, 92.6%, 75.0%. AFP (p = 0.002, OR 1.004) and bilirubin (p = 0.021, OR 1.259) were variables that contributed to cirrhosis - HCC. Age (p = 0.011, OR 0.766) and AST (p = 0.003, OR 0.834) are variables that play a role in health - cirrhosis. ALT (p = 0.024, OR 0.965) and PT (p = 0.004, OR 0.253) are variables that play a role in healthy - HCC. CONCLUSION: ApoA1 was best for detecting healthy from cirrhosis, followed by healthy from HCC and cirrhosis from HCC. ApoA1 is not the primary variable determining the incidence of cirrhosis - HCC, healthy - HCC, and healthy - HCC.
