The microeconomic impact of out-of-pocket medical expenditure on the households of cardiovascular disease patients in general and specialized heart hospitals in Ibadan, Nigeria

Background

Cardiovascular diseases (CVDs) present a huge threat to population health and in addition impose severe economic burden on individuals and their households. Despite this, there is no research evidence on the microeconomic impact of CVDs in Nigeria. Therefore, this study estimated the incidence and intensity of catastrophic health expenditures (CHE), poverty headcount due to out-of-pocket (OOP) medical spending and the associated factors among the households of a cohort of CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan, Nigeria.

Methods

This study adopts a descriptive cross-sectional study design. A standardized data collection questionnaire developed by the Initiative for Cardiovascular Health Research in Developing Countries was adapted to electronically collect data from all the 744 CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan between 4th November 2019 to the 31st January 2020. A sensitivity analysis, using rank-dependent thresholds of CHE which ranged from 5%-40% of household total expenditures was carried out. The international poverty line of $1.90/day recommended by the World Bank was utilized to ascertain poverty headcounts pre-and post OOP payments for healthcare services. Categorical variables like household socio-demographic and clinical characteristics, CHE and poverty headcounts, were presented using percentages and proportions. Unadjusted and adjusted logistic regression models were used to assess the factors associated with CHE and poverty. Data were analyzed using STATA version 15 and estimates were validated at 5% level of significance.

Results

Catastrophic OOP payment ranged between 3.9%-54.6% and catastrophic overshoot ranged from 1.8% to 12.6%. Health expenditures doubled poverty headcount among households, from 8.13% to 16.4%. Having tertiary education (AOR: 0.49, CI: 0.26–0.93, p = 0.03) and household size (AOR: 0.40, CI: 0.24–0.67, p = 0.001) were significantly associated with CHE. Being female (AOR: 0.41, CI: 0.18–0.92, p = 0.03), household economic status (AOR: 0.003, CI: 0.0003–0.25, p = <0.001) and having 3–4 household members (AOR: 0.30, CI: 0.15–0.61, p = 0.001) were significantly associated with household poverty status post payment for medical services.

Conclusion

OOP medical spending due to CVDs imposed enormous strain on household resources and increased the poverty rates among households. Policies and interventions that supports universal health coverage are highly recommended.

Males with low income and catastrophic illnesses are important risk factors for in-hospital homicide-related deaths in Taiwan from 1998 to 2015: A cross-sectional study

This study aimed to investigate not only the differences in in-hospital deaths between male and female homicides in Taiwan from 1998 to 2015, but also the epidemiological characteristics and long-term trend analysis. We collected data on 76,125 hospitalized patients injured in attempted homicides from January 1, 1998, to December 31, 2015, from the National Health Insurance Research Database (NHIRD), identifying 59,161 male and 16,694 female patients. Age, gender, and index date match. Multiple logistic regression was used to analyze the risks of gender differences in terms of homicide. The death risk of male patients was 1.673 times that of female patients and the mortality risk of low-income male patients was 3.447 times greater than that of non-low-income male patients. Moreover, the in-hospital death risk was 23.584 and 5.064 times higher for male and female patients with catastrophic illness, respectively, compared to patients with noncritical diseases. There is a higher trend of male than female patients hospitalized after an attempted homicide. Gender differences are significantly related to homicide, with males having a higher risk of death risk from homicide than females, especially in terms of low-income and catastrophic illness.

Examining the density in out-of-pocket spending share in the estimation of catastrophic health expenditures

Universal health coverage (UHC) aims to provide access to health services for all without financial hardship. Moving toward UHC while ensuring financial risk protection (FRP) from out-of-pocket (OOP) health expenditures is a critical objective of the Sustainable Development Goal for Health. In tracking country progress toward UHC, analysts and policymakers usually report on two summary indicators of lack of FRP: the prevalence of catastrophic health expenditures (CHE) and the prevalence of impoverishing health expenditures. In this paper, we build on the CHE indicator: we examine the distribution (density) of health OOP budget share as a way to capture both the magnitude and dispersion in the ratio of households' OOP health expenditures relative to consumption or income at the population level. We illustrate our approach with country-specific examples using data from the World Health Organization's World Health Surveys.

Financial risk protection in health care in Bangladesh in the era of Universal Health Coverage

BACKGROUND

Ensuring financial risk protection in health care and achieving universal health coverage (UHC) by 2030 is one of the crucial Sustainable Development Goals (SDGs) targets for many low- and middle-income countries (LMICs), including Bangladesh. We examined the critical trajectory of financial risk protection against out-of-pocket (OOP) health expenditure in Bangladesh.

METHODS

Using Bangladesh Household Income and Expenditure Survey data from 2005, 2010, and 2016, we examined the levels and distributions of catastrophic health expenditure (CHE) and impoverishment incidences. We used the normative food, housing, and utilities method, refining it by categorizing households with zero OOP expenses by reasons.

RESULTS

OOP expenditure doubled between 2005 and 2016 (USD 115.6 in 2005, USD 162.1 in 2010, USD 242.9 in 2016), accompanied by rising CHE (11.5% in 2005, 11.9% in 2010, 16.6% in 2016) and impoverishment incidence (1.5% in 2005, 1.6% in 2010, 2.3% in 2016). While further impoverishment of the poor households due to OOP expenditure (3.6% in 2005, 4.1% in 2010, 3.9% in 2016) was a more severe problem than impoverishment of the non-poor, around 5.5% of non-poor households were always at risk of impoverishment. The poorest households were the least financially protected throughout the study period (lowest vs. highest quintile CHE: 29.5% vs. 7.6%, 33.2% vs. 7.2%, and 37.6% vs. 13.0% in 2005, 2010, and 2016, respectively). The disparity in CHE among households with and without chronic illness was also remarkable in 2016 (25.0% vs. 9.1%).

CONCLUSION

Financial risk protection in Bangladesh exhibits a deteriorated trajectory from 2005 to 2016, posing a significant challenge to achieving UHC and, thus, the SDGs by 2030. The poorest and chronically ill households disproportionately lacked financial protection. Reversing the worsening trends of CHE and impoverishment and addressing the inequities in their distributions calls for implementing UHC and thus providing financial protection against illness.

Analysis of US Household Catastrophic Health Care Expenditures Associated With Chronic Disease, 2008-2018

This cross-sectional study evaluates trends in catastrophic health care expenditures associated with chronic diseases in US households from 2008 to 2018.

Measuring Multidimensional Health Poverty in China

This article defines the concept of “multidimensional health poverty,” considering both the monetary aspects and multidimensional health deprivation of health poverty. Moreover, we set up the multidimensional health poverty index (MHPI) to measure health poverty in China by revising the traditional A-F MPI method, specifically we use the Catastrophic Health Expenditure (CHE) as a sufficient condition and income poverty as a necessary condition, and take physical, mental, and social health into account. The measurement result evidences that physical health, monetary dimensions (CHE and income poverty), and mental health contribute most to health poverty in China. In addition, the MHPI is significantly higher in rural areas than urban because of higher out-of-pocket medical payments and health deprivation in more dimensions. Compared with the traditional method, the MHPI is more accurate, stable, and comprehensive, making it more suitable for measuring health poverty.

Rare yet catastrophic presentation of undiagnosed antiphospholipid syndrome

A previously well 31-year-old woman initially presented to the emergency department with pneumonia, however, was found to be hypertensive and have new-onset cardiomegaly. She was admitted for intravenous antibiotics and concurrently a series of investigations were conducted to investigate hypertension and cardiomegaly. During the course of admission, she developed acute kidney injury and was found to have acute chronic occlusion in the abdominal aorta. She was diagnosed with catastrophic antiphospholipid syndrome. This is a rare form of antiphospholipid syndrome with a high mortality rate. Thus, it is important that clinicians are aware of this syndrome to facilitate early diagnosis and initiation of treatment.

Incidence of Catastrophic Health Expenditure and Its Determinants in Cancer Patients: A Systematic Review and Meta-analysis

BACKGROUND

Cancer is the third leading cause of mortality in the world, and cancer patients are more exposed to financial hardship than other diseases. This paper aimed to review studies of catastrophic healthcare expenditure (CHE) in cancer patients, measure their level of exposure to CHE, and identify factors associated with incidence of CHE.

METHODS

This study is a systematic review and meta-analysis. Several databases were searched until February 2020, including MEDLINE, Web of Science, Scopus, ProQuest, ScienceDirect and EMBASE. The results of selected studies were extracted and analyzed using a random effects model. In addition, determinants of CHE were identified.

RESULTS

Among the 19 studies included, an average of 43.3% (95% CI 36.7-50.1) of cancer patients incurred CHE. CHE varied substantially depending on the Human Development Index (HDI) of the country in which a study was conducted. In countries with the highest HDI, 23.4% of cancer patients incurred CHE compared with 67.9% in countries with the lowest HDI. Key factors associated with incidence of CHE at the household level included household income, gender of the household head, and at the patient level included the type of health insurance, education level of the patient, type of cancer and treatment, quality of life, age and sex.

CONCLUSION

The proportion of cancer patients that incur CHE is very high, especially in countries with lower HDI. The results from this review can help inform policy makers to develop fairer and more sustainable health financing mechanisms, addressing the factors associated with CHE in cancer patients.

Association between livelihood capital and catastrophic health expenditure among patients with critical illness: a cross-sectional study in rural Shandong, China

OBJECTIVE

The objective of this study is to examine the association between livelihood capital and catastrophic health expenditure (CHE).

DESIGN

Between July and August 2019, a cross-sectional study was conducted in critically ill patients.

SETTING

Shandong, China.

PARTICIPANTS

1041 households with critically ill patients from 77 villages.

PRIMARY AND SECONDARY OUTCOME MEASURES

We defined expenditure as being catastrophic if a household's out-of-pocket payments were greater than or equal to 40% of their capacity to pay. Using the sustainable livelihoods framework, this study explored the associations between CHE and the various forms of livelihood capital-inclusive of human capital, natural capital, physical capital, financial capital and social capital. χ² tests, t-tests, Wilcoxon tests and binary logistic regression analysis were performed to examine these associations.

RESULTS

The incidence of CHE among households with critically ill patients was 76.37% in this study. Better livelihood capital was significantly associated with lower incidence of CHE. After controlling for confounding factors, households with healthier patients (OR 0.47, 95% CI 0.23 to 0.96), more real estate ownership (OR 0.35, 95% CI 0.19 to 0.67) and better economic status (OR 0.33, 95% CI 0.18 to 0.62) were associated with a reduction in the occurrence of CHE.

CONCLUSIONS

Livelihood capital was significantly associated with CHE in rural families with critically ill patients. This association suggests that, in addition to providing health insurance to the critically ill, more attention should be paid to their ability to create and preserve livelihood capital.

Financial Protection Indexes and the Iranian Health Transformation Plan: A Systematic Review

Background: On May 5, 2014, the Iranian Ministry of Health and Medical Education launched the Health Transformation Plan (HTP) as a major healthcare reform to curb out-of-pocket (OOP) expenses and protect people from catastrophic health expenditures (CHEs). Therefore, in this study, we conducted a comprehensive literature search with the aim of systematically investigating the impacts of HTP on OOP and CHE after the implementation of the plan. Method: Web of Science, PubMed, Scopus, Embase, and Iranian bibliographic thesauri and repositories such as MagIran, Elmnet, and Scientific Information Database were searched. Studies published between May 2014 and December 2020 that reported the impact of HTP on the financial indicators under investigation in this study (OOP and CHEs) that were conducted in Iran. Estimated pooled change both for OOP and CHEs was calculated as effect size utilizing meta-analytical techniques. Also, heterogeneity among studies was assessed with the I2 statistics. Results: Seventeen studies were included, nine of which evaluated the OOP index, six studies assessed the CHEs index, and two studies examined both the OOP and CHEs indexes. The OOP was found to decrease after the implementation of the HTP (with an estimated decrease of 13.02% (95% CI: 9.09-16.94). Also, CHEs experienced a decrease of 5.80% (95% CI: 3.85-7.74). Conclusion: The findings show that the implementation of HTP has reduced health costs. In this regard and in order to keep reducing the costs that many people are unable to pay, the government and other organizations involved in the health system should provide sustainable financial resources in order to continue running HTP. However, there remain gaps and weaknesses that can be solved through discussion with all the actors involved.

Measuring catastrophe in paying for healthcare: A comparative methodological approach by using National Sample Survey, India

Healthcare expenditure significantly varies among various segments of the population. The appropriate measures of catastrophic health expenditure (CHE) will help to unravel the real burden of spending among households. Present study provides a link between the theoretical insights from Grossman's model and various methodological approaches for the estimation of CHE by using data from the three rounds of nationally representative Consumer Expenditure Surveys, India. Statistical analysis has been carried out by using multivariate logistic regression to identify the major determinants of CHE. Findings indicate that the occurrence of CHE has increased during 1993-2012. Rural residents and households with varying age composition such as with higher numbers of children and elderly were at higher risk. Economic status is significantly associated with CHE and increased demand for healthcare. The measurements differ as per the methodological approaches of CHE and definition of household's capacity to pay. Approach-based variations in the results can be of key importance in determining trends and magnitude in CHE. Despite these variations in measurements, study finds a limited incidence of CHE among the disadvantaged segment of the population though a greater share was devoted to health expenditure in recent years. Better risk pooling mechanism is required to address the healthcare needs of the disadvantaged segment such as elderly, children, poor and rural population in India.

Impoverishment impact of out-of-pocket payments for healthcare in rural Bangladesh: Do the regions facing different climate change risks matter?

INTRODUCTION

Out-of-pocket (OOP) payments for healthcare severely affect the current consumption, future health and earnings capacity of poor/underprivileged households and hence it is crucial for priority setting. This study assesses the variation in overall as well as disease-specific impoverishment impact of OOP payments between the regions experiencing different climate change risks, defined as high disaster-prone (HDP) areas and low-disaster-prone (LDP) areas, in Bangladesh.

MATERIALS AND METHODS

This paper estimated three poverty measures, such as poverty headcount, poverty intensity and normalized poverty gap for all ailments, catastrophic events, diseases types (communicable, non-communicable (NCDs), and accident and injury), illness conditions (acute and chronic) and hospitalization using 3,791 randomly selected rural households (1,203 from HDP and 2,588 from LDP areas) across the regions. Cost of basic need approach was used for estimating poverty line expenditure.

RESULTS

About 13 percent households annually fall into poverty due to OOP outlays for healthcare. Despite having significantly (p-value≤0.01) less OOP payments (HDP areas: BDT 5,117; LDP areas: BDT5,811) the impoverishment impact of OOP payments for healthcare in HDP areas (16.5%) has substantially higher than LDP areas (11.3%). Population in HDP areas, especially char (river island; 19.55 percent) and haor (water submerged; 16.80 percent) are more susceptible to any level of OOP payments due to low level of earnings. Catastrophic healthcare expenditure (61.79%) and NCDs (14.29 percent) are exacerbating the poverty level in Bangladesh. Both absolute and relative average poverty gap are more widen in HDP than LDP areas due to catastrophic OOP outlays for healthcare.

CONCLUSION

The impoverishment effect due to OOP payments for healthcare in both HDP and LDP areas are high, especially for NCDs and catastrophic healthcare expenditure. However, the situation is bit worse in HDP areas. Preventing the escalation of NCDs as well as catastrophic expenditure and hence reducing the level of impoverishment thereof call for restricting tobacco use, increasing physical activity, encouraging to intake healthy diets, ensuring food safety, controlling air pollution, and improving mental health. Moreover, government should give more emphasis, especially in the HDP areas, on making community clinics more functional through providing screening equipment and training to the Community Health Care Providers for early detection of NCDs, and ensuring availability of medicine all the time. Note that other than community clinics, there is little option for providing healthcare in HDP areas due to poor functionality of public facilities as well as lack of private facilities in HDP areas.

Financial protection in health among the middle-aged and elderly: Evidence from the Greek economic recession

Since the late 2000s, the Greek economy has entered a long period of recession, with reforms and retrenchment in health care being among the main public policy priorities. This study investigates the extent to which financial protection in health has changed among older households during the Greek crisis. We focus on the middle-aged and elderly, the heavy users of health services, who have faced a substantial health and financial burden during the crisis. Our analysis shows that the headcount and overshoot of catastrophic health expenditure (CHE) substantially increased from 2007 to 2015, suggesting that financial protection has eroded to a great extent. Prior to the crisis, CHE was mainly due to inpatient care, followed by outpatient care and medicines. However, the contribution of spending for outpatient medicines to CHE substantially increased during the study period. The headcount of CHE rose across all socioeconomic groups we examined, with low-income households and households with chronic patients being disproportionately affected. In 2007, we do not report signs of socioeconomic inequalities in the risk of CHE. On the contrary, our results show that households of low socioeconomic status are more likely to incur CHE in 2015, revealing substantial inequalities in the risk of CHE. This finding raises significant distributional and equity concerns. Strengthening financial protection among older households is an imperative challenge for the Greek health system, and several policy responses need to be adopted towards this direction.

Assessing the household economic burden of non-communicable diseases in India: evidence from repeated cross-sectional surveys

BACKGROUND

Financing for NCDs is encumbered by out-of-pocket expenditure (OOPE) assuming catastrophic proportions. Therefore, it is imperative to investigate the extent of catastrophic health expenditure (CHE) on NCDs, which are burgeoning in India. Thus, our paper aims to examine the extent of CHE and impoverishment in India, in conjunction with socio-economic determinants impacting the CHE.

METHODS

We used cross-sectional data from nationwide healthcare surveys conducted in 2014 and 2017-18. OOPE on both outpatient and inpatient treatment was coalesced to estimate CHE on NCDs. Incidence of CHE was defined as proportion of households with OOPE exceeding 10% of household expenditure. Intensity of catastrophe was ascertained by the measure of Overshoot and Mean Positive Overshoot Indices. Further, impoverishing effects of OOPE were assessed by computing Poverty Headcount Ratio and Poverty Gap Index using India's official poverty line. Concomitantly, we estimated the inequality in incidence and intensity of catastrophic payments using Concentration Indices. Additionally, we delineated the factors associated with catastrophic expenditure using Multinomial Logistic Regression.

RESULTS

Results indicated enormous incidence of CHE with around two-third households with NCDs facing CHE. Incidence of CHE was concentrated amongst poor that further extended from 2014(CI = - 0.027) to 2017-18(CI = - 0.065). Intensity of CHE was colossal as households spent 42.8 and 34.9% beyond threshold in 2014 and 2017-18 respectively with poor enduring greater overshoot vis-à-vis rich (CI = - 0.18 in 2014 and CI = - 0.23 in 2017-18). Significant immiserating impact of NCDs was unraveled as one-twelfth in 2014 and one-eighth households in 2017-18 with NCD burden were pushed to poverty with poverty deepening effect to the magnitude of 27.7 and 30.1% among those already below poverty on account of NCDs in 2014 and 2017-18 respectively. Further, large inter-state heterogeneities in extent of CHE and impoverishment were found and multivariate analysis indicated absence of insurance cover, visiting private providers, residing in rural areas and belonging to poorest expenditure quintile were associated with increased likelihood of incurring CHE.

CONCLUSION

Substantial proportion of households face CHE and subsequent impoverishment due to NCD related expenses. Concerted efforts are required to augment the financial risk protection to the households, especially in regions with higher burden of NCDs.

Measurement and determinants of catastrophic health expenditure among elderly households in China using longitudinal data from the CHARLS

BACKGROUND

Catastrophic health expenditure (CHE) among the Chinese elderly warrants attention. However, the incidence, intensity and determinants of CHE have not been fully investigated. This study explores the incidence, intensity and determinants of CHE among elderly Chinese citizens, i.e., those aged 60 years or older.

METHODS

Data were obtained from three waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013 and 2015. The cut-off points used in this study for CHE were 10% of the total expenditures and 40% of non-food expenditure. Under the guidance of Andersen's model of health services utilization, this study used logistic regression analysis to explore the determinants of CHE.

RESULTS

The incidence of CHE defined as more than 40% of non-food expenditure rose over the study period, 2011-2015, from 20.86% (95% CI: 19.35 to 22.37%) to 31.00% (95% CI: 29.28 to 32.72%). The intensity of CHE also increased. The overshoot (O) based on non-food expenditure rose from 3.12% (95% CI: 2.71 to 3.53%) to 8.75% (95% CI: 8.14 to 9.36%), while the mean positive overshoot (MPO) rose from 14.96% (95% CI: 12.99 to 16.92%) to 28.23% (95% CI: 26.26 to 30.19%). Thus, the problem of CEH was even more serious in 2015 than in 2011. Logistic regression revealed that households were more likely to face CHE if they had a spouse as a household member, reported an inpatient event in the last year, reported an outpatient visit in the last month, were disabled, were members of a poor expenditure quartile, lived in the middle and western zones or resided in an urban area. In contrast, CEH was not significantly affected by respondents being older than 75 years or having a chronic health condition, by household size or by insurance type.

CONCLUSIONS

Key policy recommendations include the gradual improvement of medical assistance and the expansion of the use of health insurance to reduce household liability for health expenditures.

Estimating Catastrophic Health Expenditures from Household Surveys: Evidence from Living Standard Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) from Sub-Saharan Africa

BACKGROUND

Out of pocket (OOP) payments for healthcare remain a significant health financing challenge in sub-Saharan Africa (SSA). Understanding the drivers and impacts of this financial health burden is both an economic and a public health priority.

OBJECTIVE

This study examines how the burden of OOP health expenditures varies with different thresholds for financial catastrophe.

METHODS

The analysis is based on Livings Standards Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) for five SSA countries-Ethiopia, Malawi, Nigeria, Tanzania, and Uganda. We estimate the degree by which OOP payments as share of total household non-food expenditures exceed either the 15 or 25% threshold.

RESULTS

For the countries considered, the severity of OOP payments is substantial-the average positive overshoot (beyond the 25% threshold) is above 10%, except for Nigeria. This reflects a higher percentage of OOP in total household health expenditures-compared to taxes and contributions-especially among the poor in these specific countries. Regarding sensitivity of distribution of catastrophic health expenditures, we find that households with low non-food expenditures are more likely to incur catastrophic payments with the exception for Uganda where catastrophic payments increase with the increase of non-food household expenditures.

CONCLUSION

The burden of catastrophic health expenditures remains large. In order to reduce this burden, public health expenditures need to be expanded as an alternative. This calls for renewed attention to expand public revenues as the most sustainable methods of financing health expenditures in Africa.

The burden of household out-of-pocket health expenditures in Ethiopia: estimates from a nationally representative survey (2015-16)

In Ethiopia, little is known about the extent of out-of-pocket health expenditures and the associated financial hardships at national and regional levels. We estimated the incidence of both catastrophic and impoverishing health expenditures using data from the 2015/16 Ethiopian household consumption and expenditure and welfare monitoring surveys. We computed incidence of catastrophic health expenditures (CHE) at 10% and 25% thresholds of total household consumption and 40% threshold of household capacity to pay, and impoverishing health expenditures (IHE) using Ethiopia's national poverty line (ETB 7184 per adult per year). Around 2.1% (SE: 0.2, P < 0.001) of households would face CHE with a 10% threshold of total consumption, and 0.9% (SE: 0.1, P < 0.001) of households would encounter IHE, annually in Ethiopia. CHE rates were high in the regions of Afar (5.8%, SE: 1.0, P < 0.001) and Benshangul-Gumuz (4.0%, SE: 0.8, P < 0.001). Oromia (n = 902 000), Amhara (n = 275 000) and Southern Nations Nationalities and Peoples (SNNP) (n = 268 000) regions would have the largest numbers of affected households, due to large population size. The IHE rates would also show similar patterns: high rates in Afar (5.0%, SE: 0.96, P < 0.001), Oromia (1.1%, SE: 0.22, P < 0.001) and Benshangul-Gumuz (0.9%, SE: 0.4, P = 0.02); a large number of households would be impoverished in Oromia (n = 356 000) and Amhara (n = 202 000) regions. In summary, a large number of households is facing financial hardship in Ethiopia, particularly in Afar, Benshangul-Gumuz, Oromia, Amhara and SNNP regions and this number would likely increase with greater health services utilization. We recommend regional-level analyses on services coverage to be conducted as some of the estimated low CHE/IHE regional values might be due to low services coverage. Periodic analyses on the financial hardship status of households could also be monitored to infer progress towards universal health coverage.

Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion-The ATOLMA Registry

OBJECTIVES

To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients.

BACKGROUND

ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce.

METHODS

This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI).

RESULTS

In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the catheterization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1-0.36), p < 0.001).

CONCLUSIONS

Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life.

Impact of Medical Debt on the Financial Welfare of Middle- and Low-Income Families across China

BACKGROUND

Medical debt is a persistent global issue and a crucial and effective indicator of long-term family medical financial burden. This paper fills a research gap on the incidence and causes of medical debt in Chinese low- and middle-income households.

METHOD

Data were obtained from the 2015 China Household Finance Survey, with medical debt measured as borrowings from families, friends and third parties. Tobit regression models were used to analyze the data. The concentration index was employed to measure the extent of socioeconomic inequality in medical debt incidence.

RESULTS

We found that 2.42% of middle-income families had medical debt, averaging US$6278.25, or 0.56 times average household yearly income and 3.92% of low-income families had medical debts averaging US$5419.88, which was equivalent to 2.49 times average household yearly income. The concentration index for low and middle-income families' medical debt was significantly pro-poor. Medical debt impoverished about 10% of all non-poverty households and pushed poverty households deeper into poverty. While catastrophic health expenditure (CHE) was the single most important factor in medical debt, age, education, and health status of householder, hospitalization and types of medical insurance were also significant factors determining medical debt.

CONCLUSIONS

Using a narrow definition of medical debt, the incidence of medical debt in Chinese low- and middle-income households was relatively low. But, once medical debt happened, it imposed a long-term financial burden on medical indebted families, tipping many low and middle-income households into poverty and imposing on households several years of debt repayments. Further studies need to use broader definitions of medical debt to better assess the long-term financial impact of medical debt on Chinese families. Policy makers need to modify China's basic medical insurance schemes to manage out-of-pocket, medical debt and CHE and to take account of pre-existing medical debt.

A catastrophic antiphospholipid syndrome complicated with heparin-induced thrombocytopaenia, successfully managed with double filtration plasmapheresis, steroids and a direct thrombin inhibitor

A middle-aged woman with history of antiphospholipid syndrome, admitted to our hospital for lethargy and persistent chest pain, developed during hospitalisation intracerebral transverse sinus and sigmoid vein thromboses, retinal thromboses, acute renal failure and cardiac involvement associated with thrombocytopaenia. Diagnosis of catastrophic antiphospholipid syndrome was made and treated with IV steroids, heparin infusion and double filtration plasmapheresis (DFPP) without fresh frozen plasma. Heparin-induced thrombocytopaenia was second diagnosed because of persistent severe thrombocytopaenia after 2 weeks of treatment associated with positive conversion of antibodies against platelet factor 4, and a positive functional assay. The clinical course was complicated by cerebellar haematomas that appeared a few days after the last session of DFPP. Heparin-induced thrombocytopaenia was managed by administration of argatroban, a direct thrombin inhibitor with an increase in platelet count. Neurologically, the patient recovered completely and was discharged on vitamin K antagonist treatment and regular dialysis.

The Impact of the Psychiatrist on the Life Care Plan

A life care plan is a tool that is used for medical treatment planning and management purposes in many settings, including legal and forensic applications. This article summarizes the life care planning process and emphasizes the role of the psychiatrist in establishing a strong medical foundation for the plan. The psychiatrist's expertise in determining the nature and extent of the evaluee's psychiatric illness, prognosis, need for and likely benefit from treatment, and costs of care inform the life care planning process. Advising life care planners on these matters is a natural extension of the work of psychiatrists and forensic psychiatrists, who are accustomed to providing medical opinions to the courts. There are specific challenges when the psychiatrist creates recommendations for the life care plan; they include determining long-term prognosis, devising treatment plans, and identifying malingering. These questions are explored to assist the psychiatrist in providing the foundation for a life care plan.

Rare case of catastrophic antiphospholipid syndrome with spontaneous intracranial haemorrhage

Catastrophic antiphospholipid syndrome (CAPS) is a rare but severe form of antiphospholipid syndrome (APS). The syndrome manifests itself as a rapidly progressive multiorgan failure that is believed to be caused by widespread micro-thrombosis. Seldom does bleeding comanifest with thrombosis. We present a patient with APS who presented with nausea, vomiting and fatigue, and rapidly progressed into multiorgan failure before being diagnosed with CAPS. The clinical course was complicated by an atraumatic intracranial haemorrhage which demanded discontinuation of anticoagulation. The patient was treated with high dose steroid, intravenous immunoglobulin, followed by weekly rituximab infusion. Although the trigger for CAPS was not obvious during her hospital stay, she was diagnosed with acute cytomegalovirus (CMV) infection soon after discharge. In this case report, we explore the differential diagnoses of CAPS, investigate the possibility of CMV infection as a potential trigger, present the therapeutic challenges of anticoagulation and discuss the emerging use of rituximab.

[Case series and clinical analysis of 14 cases of catastrophic antiphospholipid syndrome]

OBJECTIVE

Catastrophic antiphospholipid syndrome (CAPS), also known as Asherson's syndrome, is a special subtype of antiphospholipid syndrome (APS) characterized by multiple intravascular thrombosis involving multiple organs systems or tissues simultaneously or continuously, high titer antiphospholipid antibodies and high mortality rate. This article's aims was to analyze the clinical manifestation, laboratory examination and treatment therapy of CAPS for the purpose of improving the understanding, diagnosis and treatment of the disease in clinical practice.

METHODS

Retrospective analysis and descriptive statistics were applied to the clinical manifestations and laboratory findings of 14 CAPS cases from APS Shanghai Database (APS-SH) with catastrophic antiphospholipid.

RESULTS

Of the 14 CAPS patients, 12 cases satisfied the 2003 CAPS Classification Criteria accepted in the 10th International Congress on Antiphospholipid Antibody, and were diagnosed as definite APS and 2 cases were diagnosed as probable CAPS. Three cases were categorized as primary APS and 11 as APS secondary to systemic lupus erythematosus (SLE). Infection was mostly commonly seen before the onset of CAPS, followed by SLE activity and surgery. Among the involved organs, systems and tissues, brain and lung were most commonly affected sites of arterial thrombosis while peripheral vein was most commonly affected in venous thrombosis events among the clinical events. Triple positivity of anticardiolipin antibody (aCL), anti-β2 glyeoprotein I antibody (aβ2GPI), lupus anticoagulant (LA) were detected in 54.55% of the patients. Thrombocytopenia and decreased hemoglobin were frequently seen in the CAPS patients, and the majority proved to be hemolytic anemia. Of all the cases, 6 ended with death. The triple therapy strategy (anticoagulants, glucocorticoid, intravenous immunoglobulin and/or plasma exchange) could help to improve prognosis, cyclophosphamide and rituximab might benefit the patients with other comorbidities such as SLE and micro-angiopathic hemolytic anemia (MHA).

CONCLUSION

CAPS patients suffer from life-threatening acute multiple small vessel thrombosis with high titer of antiphospholipid antibody, potentially leading to multiple organ failure and a poor prognosis, thus early diagnosis and sufficient treatment are critical to prevent the progression of disease and improve the prognosis.