Cost of acute respiratory illness episode and its determinants among community-dwelling older adults: a four-site cohort study from India

Introduction

Advocacy for the provision of public health resources, including vaccine for the prevention of acute respiratory illnesses (ARIs) among older adults in India, needs evidence on costs and benefits. Using a cohort of community-dwelling adults aged 60 years and older in India, we estimated the cost of ARI episode and its determinants.

Methods

We enrolled 6016 participants in Ballabgarh, Chennai, Kolkata and Pune from July 2018 to March 2020. They were followed up weekly to identify ARI and classified them as acute upper respiratory illness (AURI) or pneumonia based on clinical features based on British Thoracic Society guidelines. All pneumonia and 20% of AURI cases were asked about the cost incurred on medical consultation, investigation, medications, transportation, food and lodging. The cost of services at public facilities was supplemented by WHO-Choosing Interventions that are Cost-Effective(CHOICE) estimates for 2019. Indirect costs incurred by the affected participant and their caregivers were estimated using human capital approach. We used generalised linear model with log link and gamma family to identify the average marginal effect of key determinants of the total cost of ARI.

Results

We included 2648 AURI and 1081 pneumonia episodes. Only 47% (range 36%-60%) of the participants with pneumonia sought care. The mean cost of AURI episode was US$13.9, while that of pneumonia episode was US$25.6, with indirect costs comprising three-fourths of the total. The cost was higher among older men by US$3.4 (95% CI: 1.4 to 5.3), those with comorbidities by US$4.3 (95% CI: 2.8 to 5.7) and those who sought care by US$17.2 (95% CI: 15.1 to 19.2) but not by influenza status. The mean per capita annual cost of respiratory illness was US$29.5.

Conclusion

Given the high community disease and cost burden of ARI, intensifying public health interventions to prevent and mitigate ARI among this fast-growing older adult population in India is warranted.

Patient satisfaction with access, affordability and quality of diabetes care at Mohalla Clinics in Delhi, India

Introduction

Mohalla Clinics have been set up to provide curative care for minor ailments free of cost within walking distance in the urban slums, thus making primary care more accessible and affordable. Studies evaluating patient satisfaction with treatment of chronic conditions, such as diabetes, in these clinics are lacking.

Methods

A survey of 400 type 2 diabetes patients was conducted, split equally between Mohalla clinics (MC) and Private clinics (PC) in Delhi. Responses were analyzed using STATA17, applying appropriate statistical tests for the data type (Chi-square test, Mann-Whitney U test, Wilcoxon signed rank test, or two-sample t test).

Results

Satisfaction level was high in both groups with no significant difference between mean satisfaction scores of MC patients and PC patients (Mean 3.79 vs. 3.85 respectively, p = 0.4). However, MC patients reported a significant improvement in their satisfaction score after switching to MC (Mean 3.79 vs. 3.3 for the previous facility, p < 0.05). Physician interaction with the patients was the most important factor in influencing the satisfaction score. Proximity to the clinic was the second most important factor for MC patients but was not as important for PC patients. Surprisingly, treatment success was considered an important factor for satisfaction level by < 10% MC and < 20% PC patients only, pointing to the need for patient education across both the groups. None of the MC patients mentioned free treatment as a contributory factor to high satisfaction, perhaps because most shifted from a government setup to MC. PC patients had more frequent follow-up visits and blood glucose monitoring, and longer consultation duration compared to MC patients, which were offset by access factors, thus not causing much difference to the satisfaction score between the two groups.

Conclusion

Mohalla clinics are making diabetes treatment accessible and affordable for the marginalized population of Delhi, despite not being designed or fully equipped to care for chronic diseases such as diabetes that require multi-specialty care to monitor and manage multiple co-morbidities and long-term complications. Positive perception of physician interaction and convenient location of the clinics are the two major contributors to the high satisfaction patients expressed with diabetes care at these clinics.