Factors Associated with Non-Adherence to Treatment Among Migrants with MDR-TB in Wuhan, China: A Cross-Sectional Study

Background

Multidrug resistant tuberculosis (MDR-TB) has attracted increasing attention in achieving the global goal of tuberculosis (TB) control. China has the second largest TB burden worldwide and has been experiencing large-scale domestic migration. This study aims to explore the effect of migrants on non-adherence to MDR-TB treatment.

Materials and Methods

A cross-sectional study was carried out in Wuhan, China. The exposure cases were migrants who were not locally registered in the residence registration system. The control cases were local residents. Non-adherence cases were patients who were lost follow-up or refused treatment. Chi-square and t-test were used to compare variables between migrants and local residents. Logistic regression models using enter method were used to determine the relationship between migration and non-adherence to treatment. Moderation and medication effects on the association between migrant status and non-adherence were also explored.

Results

We studied 73 migrants and 219 local residents. The migrants, who did not to adhere to treatment (55, 75.3%), was far higher than that of local residents (89, 40.6%). Migrants with MDR-TB had 10.38-times higher difficulty in adhering to treatment (adjusted OR = 10.38, 95% CI 4.62-25.28) than local residents. This additional likelihood was moderated by age and treatment registration group. Migration had an indirect association with non-adherence to treatment via social medial insurance (adjusted OR = 1.05, 95% CI 1.01-1.13).

Conclusion

There a significant increased likelihood of non-adherence to treatment among migrants with MDR-TB, highlighting the importance of improving treatment adherence in this population. Migration prevented migrants from gaining access to social medical insurance and indirectly reduced their likelihood of adherence to treatment.

Comparative Analysis of the Healthcare Delivery System in China and Nigeria: A Review

OBJECTIVES

Equitable distribution of quality healthcare services among different subpopulations in China and Nigeria is inconsistent. This necessitates an examination of potential avenues for improving healthcare provision in both countries. A comparative analysis of both health systems was carried out to provide insights into the progress each nation has made, the obstacles they face, and areas both countries can learn from each other.

METHODS

We assessed 3 key dimensions of these systems using the Hsiao analytical framework. First, we scrutinized the policy levers of the health systems. Next, we evaluated intermediate outcomes, such as access to healthcare and the quality of care. Lastly, we assessed the extent to which the health systems achieve their ultimate goals, including improving citizen health status and enhancing overall patient satisfaction with the healthcare services.

RESULTS

China surpasses Nigeria in terms of better birth outcomes, life expectancy, and management of communicable diseases. Both countries offer minimal protection against out-of-pocket spending on medical bills, which consequently exacerbates the poverty rate.

CONCLUSIONS

China surpasses Nigeria in every health metrics. However, Nigeria's healthcare system offers services to a larger proportion of its populace because of the involvement of the private sector in healthcare delivery. Both countries continue to experience significant challenges, such as limited access to healthcare services in rural areas and overall patient dissatisfaction with the quality of care provided.

Expanding the Catalog of Patient and Caregiver Out-of-Pocket Costs: A Systematic Literature Review

Out-of-pocket (OOP) health care expenditures in the United States have increased significantly in the past 5 decades. Most research on OOP costs focuses on expenditures related to insurance and cost-sharing payments or on costs related to specific conditions or settings, and does not capture the full picture of the financial burden on patients and unpaid caregivers. The aim for this systematic literature review was to identify and categorize the multitude of OOP costs to patients and unpaid caregivers, aid in the development of a more comprehensive catalog of OOP costs, and highlight potential gaps in the literature. The authors found that OOP costs are multifarious and underestimated. Across 817 included articles, the authors identified 31 subcategories of OOP costs related to direct medical (eg, insurance premiums), direct nonmedical (eg, transportation), and indirect spending (eg, absenteeism). In addition, 42% of articles studied an expenditure that the authors did not label as "OOP." A holistic and comprehensive catalog of OOP costs can inform future research, interventions, and policies related to financial barriers to health care in the United States to ensure the full range of costs for patients and unpaid caregivers are acknowledged and addressed.

Building Data Infrastructure for Disease-Focused Health Economics Research

BACKGROUND

Data infrastructure for cancer research is centered on registries that are often augmented with payer or hospital discharge databases, but these linkages are limited. A recent alternative in some states is to augment registry data with All-Payer Claims Databases (APCDs). These linkages capture patient-centered economic outcomes, including those driven by insurance and influence health equity, and can serve as a prototype for health economics research.

OBJECTIVES

To describe and assess the utility of a linkage between the Colorado APCD and Colorado Central Cancer Registry (CCCR) data for 2012-2017.

RESEARCH DESIGN, PARTICIPANTS, AND MEASURES

This cohort study of 91,883 insured patients evaluated the Colorado APCD-CCCR linkage on its suitability to assess demographics, area-level data, insurance, and out-of-pocket expenses 3 and 6 months after cancer diagnosis.

RESULTS

The linkage had high validity, with over 90% of patients in the CCCR linked to the APCD, but gaps in APCD health plans limited available claims at diagnosis. We highlight the advantages of the CCCR-APCD, such as granular race and ethnicity classification, area-level data, the ability to capture supplemental plans, medical and pharmacy out-of-pocket expenses, and transitions in insurance plans.

CONCLUSIONS

Linked data between registries and APCDs can be a cornerstone of a robust data infrastructure and spur innovations in health economics research on cost, quality, and outcomes. A larger infrastructure could comprise a network of state APCDs that maintain linkages for research and surveillance.

Multimorbidity and out-of-pocket expenditure on medicine in Europe: Longitudinal analysis of 13 European countries between 2013 and 2015

Background

Many European Health Systems are implementing or increasing levels of cost-sharing for medicine in response to the growing constrains on public spending on health despite their negative impact on population health due to delay in seeking care.

Objective

This study aims to examine the relationships between multimorbidity (two or more coexisting chronic diseases, CDs), complex multimorbidity (three or more CDs impacting at least three different body systems), and out-of-pocket expenditure (OOPE) for medicine across European nations.

Methods

This study utilized data on participants aged 50 years and above from two recent waves of the Survey of Health, Aging, and Retirement in Europe conducted in 2013 (n = 55,806) and 2015 (n = 51,237). Pooled cross-sectional and longitudinal study designs were used, as well as a two-part model, to analyse the association between multimorbidity and OOPE for medicine.

Results

The prevalence of multimorbidity was 50.4% in 2013 and 48.2% in 2015. Nearly half of those with multimorbidity had complex multimorbidity. Each additional CD was associated with a 34% greater likelihood of incurring any OOPE for medicine (Odds ratio = 1.34, 95% CI = 1.31-1.36). The average incremental OOPE for medicine was 26.4 euros for each additional CD (95% CI = 25.1-27·7), and 32.1 euros for each additional body system affected (95% CI 30.6-33.7). In stratified analyses for country-specific quartiles of household income the average incremental OOPE for medicine was not significantly different across groups.

Conclusion

Between 2013 and 2015 in 13 European Health Systems increased prevalence of CDs was associated with greater likelihood of having OOPE on medication and an increase in the average amount spent when one occurred. Monitoring this indicator is important considering the negative association with treatment adherence and subsequent effects on health.

Out-of-pocket healthcare expenditures of Turkish households living with rare diseases

Introduction

This study aims to determine the out-of-pocket health expenditures of households in Turkey where individuals with rare diseases are residing.

Methods

The research population consisted registered members of associations who are members of the Rare Diseases Network. In addition to the general analysis including all participants, expenditures based on characteristics of disease holders were also calculated.

Results

A total of 439 participants were included in the analysis. We determined that special nutrition was the highest expenditure group and emergency departments were the lowest expenditure group. When all the participants were evaluated, the average cost of rare diseases was found to be Ł22,743 (€2,877). A significant relationship was found between income status and out-of-pocket health expenditures (p = 0.012).

Discussion

Policy makers should consider inclusion of special nutritional products and medical/non-medical devices used in treatment of rare diseases within the scope of reimbursement and the development of orphan drug legislation as the first actions to be taken.

Out-of-pocket cost by cancer stage at diagnosis in commercially insured patients in the United States

AIMS

Out-of-pocket (OOP) costs may constitute a substantial financial burden to patients diagnosed with cancer. Earlier stage diagnosis and treatment of cancers may promote decreased morbidity and mortality, subsequently also lowering costs. To better understand costs experienced by patients with cancer, OOP costs by stage post-diagnosis were estimated.

MATERIALS AND METHODS

A retrospective analysis was conducted using Optum's de-identified Integrated Claims-Clinical dataset with Enriched Oncology, which includes data from commercially insured members (June 1, 2015-July 31, 2020). Mean annual and cumulative OOP costs (co-pay + co-insurance + deductible) (2020 USD) were reported through a 3-year period post-cancer diagnosis among adult commercially insured members (not including Medicare Advantage members) diagnosed with staged breast, cervical, colorectal, lung, ovarian, or prostate cancer between January 1, 2016 and June 30, 2020 with continuous enrollment for ≥1-month post-diagnosis.

RESULTS

A total of 7,494 eligible members were identified who were diagnosed with breast, cervical, colorectal, lung, ovarian, or prostate cancer. A greater proportion of OOP costs were incurred in year 1 post-diagnosis but remained relatively high through year 3 post-diagnosis. Cumulative mean OOP costs were as high as $35,243 (lung stage IV) per commercially insured patient by year 3 post-diagnosis and were generally higher among those diagnosed at later stages (III/IV) than those diagnosed at earlier stages (I/II) across all cancers.

LIMITATIONS

Generalizability of these results is limited to those with commercial health insurance coverage. Additionally, cancer staging was dependent on accuracy of staging as recorded in the electronic medical record and as determined by Optum's proprietary algorithm using natural language processing.

CONCLUSION

Cumulative mean OOP costs among commercially insured patients during the 3-year period post-cancer diagnosis were substantial and generally higher among those with later stage cancer diagnoses. Diagnosis of cancer at earlier stages may allow for more timely treatment and lessen patient OOP costs.

Out-of-Pocket expenditure and patient experience of care under-Indonesia's national health insurance: A cross-sectional facility-based study in six provinces

BACKGROUND

Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance.

METHODS

Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants.

RESULTS

The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less).

CONCLUSION

Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC.

Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis

PURPOSE

Rising patient out-of-pocket (OOP) costs and financial distress have been associated with reduced access to and delays in care. We evaluated whether OOP and total costs for common hand procedures have increased from 2008 to 2016 and identified key drivers of these costs.

METHODS

Using the IBM MarketScan Research Databases, we identified patients who underwent trigger finger release, open carpal tunnel release, thumb carpometacarpal joint arthroplasty, cubital tunnel release, or open treatment of distal radius fracture in the outpatient setting between 2008 and 2016. Patient OOP costs included copayment, coinsurance, and deductible payments. Costs not directly related to medical care, such as transportation and childcare costs, were not included. The overall cost was defined as the sum of the patient OOP cost and insurer reimbursements. We calculated changes in OOP and total overall costs over the study period. We also performed multivariable linear regressions to evaluate the associations between costs and procedure type, insurance type, region, and site of service.

RESULTS

The mean patient OOP cost increased by 55% to 71% and the total overall cost increased by 20% to 45%, depending on the procedure, between 2008 and 2016. Facility overall costs increased by 38%, whereas professional overall costs increased by 9%. Procedures performed in an office-based setting were associated with the lowest patient OOP and total overall costs, whereas high-deductible health plans were associated with the highest OOP costs.

CONCLUSIONS

Patient OOP and total overall costs increased for the most common hand procedures between 2008 and 2016, driven by a substantial increase in facility costs. Office-based procedures were associated with the lowest costs.

CLINICAL RELEVANCE

To alleviate the rising patient cost burden, hand surgeons could incorporate OOP cost considerations into shared decision-making tools, identify patients who may benefit from financial counseling, and shift procedures to an office-based setting.

The No Surprises Act: A Conservative Band-Aid to Protect Business as Usual

Hailed as a major reform, the No Surprises Act (NSA) is a profoundly conservative law that aims neither to reform design of insurance, to regulate fees, nor to limit health care spending. The NSA mitigates a perverse but narrow problem: unpredictable and uncontrollable high out-of-pocket bills for individuals who are unable to receive care within their insurance network. However, the NSA neglects to address the broader high medical costs, limited choice of caregivers, and the resulting insecurity and unfairness that characterize American health care. It allows caregivers to extract high payments and insurers to restrict choice of caregivers. Insurers can continue to employ ineffective cost controls that generate unpredictable high out-of-pocket costs for patients-and high levels of denial of payments to doctors and hospitals. The law amputated the most politically and visibly gangrenous consequences of unregulated private insurance in the United States in ways that enable business as usual in private health insurance to persist, subject to unnecessarily complex arbitration rules that magnify administrative waste.

Estimating the Cancer Treatment Cost for 5 Common Types of Cancer with Separating Out-of-Pocket and Governmental Costs in Afghanistan, 2020

The objective this study was to estimate the cost of cancer treatment services for 5 common types of cancer (Breast, Esophageal, Colorectal, Stomach and lung) by the public sector and patients. This study was a cross-sectional study that conducted using the medical records of patients who were registered in the Jamhuriyat Hospital from 1, 2020 to 12, 2020. The prevalence-based approach was used to estimate the costs of five major cancer types. The data of 769 patients were eligible to include for the analysis. The considered cost of services was obtained from the average cost in 3 private hospitals in Kabul. Also all costs converted in to US dollar using the exchange rate of each USD equaling to AFN 77 in 2020. The data was analyzed using Ms. Excel Program. The total number of patients with 5 types of cancer were 769. Of these, female, in the age group of 40-60 years and were illiterate. The most common cancers based on the cancer treatment services' costs of health services was breast cancer, followed by esophagus, colorectal, stomach and lung. Moreover, the most common cancers based on the cancer treatment services' costs of health services which cancer patients needed was breast cancer, followed by esophagus, colorectal, stomach and lung.  Moreover, total cost of cancer treatment is US$590,662.98, in which Patients paid USD 82,537 of it out-of-pocket. The costs of cancer treatment services for 5 common types of cancer are high which a considerable portion are paid by patients. There is a need for the government to pay more attention to the provision of these services and to increase the centers providing these services and the existing facilities. Also, support of the international community in this process can enable more people to access these services and reduce the economic burden on patients.

Households' Direct Economic Burden Associated with Chronic Non-Communicable Diseases in Saudi Arabia

Households' economic burden associated with chronic non-communicable diseases (NCDs) is a deterrent to healthcare access, adversely impacting patients' health. Therefore, we investigated the extent of out-of-pocket (OOP) spending among individuals diagnosed with chronic NCDs among household members in Riyadh, Saudi Arabia. Face-to-face interviews were conducted among households in Riyadh Province from the beginning of January 2021 to the end of June 2021. The respondents were asked to record OOP spending throughout the past three months in their health. A generalized linear regression model was used to determine the effects of several factors on the level of OOP spending. A total of 39.6% of the households studied had at least one member with a chronic NCD. Diabetes patients spent an average of SAR 932 (USD 248), hypertension patients SAR 606 (USD 162), and hypothyroid patients SAR 402 (USD 107). It was shown that households with older and more educated members had greater OOP spending. Households with an employed head of household, more family members, higher SES status, health insurance coverage, and urban residency had significantly higher OOP expenditure. The burden of OOP spending for chronic NCD households remains high, with some disparities. The research offers important information for decision making to lower OOP cost among NCD households.

Who benefits from tuberculosis outpatient services in Enugu state, Nigeria? A benefit incidence analysis

OBJECTIVES

Nigeria is one of the 30 high-burden countries for TB and currently, recurrent costs of TB treatment services are largely dependent on donor-funding, with government providing the health facilities. This study aims to assess the benefit incidence of TB treatment services so as to determine if the poor and rural dwellers preferentially benefit from such services that were subsidized by government and donors.

METHODS

A survey of patients (n = 202) accessing TB treatment services was conducted between 2019 and 2020 in five purposively selected rural and urban health facilities in Enugu state. Socio-economic status (SES) was estimated using household assets ownership. Benefits of TB services were measured by multiplying the unit cost of utilization of different services while the net benefit was calculated by subtracting out-of-pocket (OOP) payments incurred from the benefits. We estimated the benefit for 1 month and the benefit for the whole TB treatment course (6 months). Concentration index was used to determine the level of equity in spending across the socio-economic quintiles.

RESULTS

56.4% of the respondents were from urban facilities. 100% had used TB drugs in the past months, 73% had undergone a Gene-Xpert test, and 67% had had a consultation. All patients received TB drugs without OOP payment, but 90% paid for X-ray. Urban respondents captured a disproportionally higher share of benefit from TB services. The concentration index was -0.025 for net benefit from TB services across different quintiles, indicating the pro-poor distribution of TB services in Nigeria.

CONCLUSIONS

The benefit from TB services had a pro-poor distribution, but urban respondents obtained a disproportionally higher share of gross and net benefit from TB services. Funding for TB services needs to be secured to promote the equitable access to TB services.

Factors Associated With Community Based Health Insurance Healthcare Service Utilization of Households in South Gondar Zone, Amhara, Ethiopia. A Community-Based Cross-Sectional Study

In Ethiopia, community-based health insurance was implemented to promote equitable access to sustainable quality health care and increase financial protection. The purpose of this study was to identify factors associated with community-based Health Insurance, Health Care Service Utilization of Households in the South Gondar Zone. A community-based cross-sectional study was employed. Data were collected among 619 randomly selected households in the south Gondar zone. Chi-square and binary logistic regression analyses with a P-Value of less than .05 were used to determine the association. Out of the total households, 511(82.6%) were using the CBHI scheme for health care service utilization. Residence, marital status, education level, occupation status, family size, presence of under-five children in the household, presence of elders in the households, nearest health institution, presence of chronic illness in the household's, time taken to reach health institution, an attitude of a household were the determinant factors of community-based health insurance scheme health care service utilization of households. It is recommended that the local, regional and national governments, policymakers on optimal actions, NGOs, and other supporting organizations shall improve or scale-up the scheme by providing awareness to the community based on these significant factors and the attitude of households.

Household Catastrophic Health Expenditure from Oral Potentially Malignant Disorders and Oral Cancer in Public Healthcare of Malaysia

OBJECTIVE

Oral cancer causes a significant disease burden and financial distress, especially among disadvantaged groups. While Malaysia has achieved universal health coverage via its highly subsidized public healthcare, patient and family expenditure for treatment of oral potentially malignant disorders (OPMD) and oral cancer remains a concern in the equitability of care. This study thus aims to estimate household out-of-pocket (OOP) expenditures and the extent of catastrophic healthcare expenditure (CHE) while identifying its predictors.

METHODS

This three-part study consists of a cross-sectional survey to collect sociodemographic and health utilization data of patients, a retrospective medical record abstraction to identify resources consumed, and cost modeling to simulate expenditures in two tertiary public hospitals. Loss of productivity was calculated based on absenteeism related to disease management in the hospital. OOP payments for transport, care in public healthcare facilities, and other healthcare expenditures were tallied. A CHE was defined as OOP spendings of more than 10% from total annual household income. Multivariable logistic regression was further applied to identify the association between sociodemographic factors and the incidence of CHE.

RESULTS

A total of 52 patients with OPMD and 52 with oral cancer were surveyed and medical records were abstracted. A Kruskal-Wallis test showed a statistically significant difference in OOP share over household income between OPMD, early- and late-stage cancer, χ2(2)=51.05, p<0.001, with the mean percentage of 9%, 22%, and 65% respectively. This study found that the prevalence of CHE in the first year of diagnosis was 86.5% for oral cancer and 19.2% for OPMD. Indian ethnicity (OR=6.24, p=0.046) and monthly income group 'less than USD 2,722' (OR=14.32, p=0.023) were shown as significant predictors for CHE.

CONCLUSIONS

Our study demonstrated the provision of subsidies may not be adequate to shield the more vulnerable group from CHE when they are diagnosed with OPMD and oral cancer.

Out-of-Pocket Expenditure on Medical Services Among Older Adults: A Longitudinal Analysis

The upturn in life expectancy and its consequence, population aging, are challenging labor, pension, and social-security systems throughout the developed world. The focal aim of this study is to measure the extent of out-of-pocket funding of healthcare services by the older adult population. The study has three objectives: to profile the healthcare services for which older adults pay out of pocket, profile the older adults who pay out of pocket for medical services and detect changes over the years, and identify predictors of out-of-pocket healthcare services funding by older adults. The study is predicated on the SHARE-Israel database (SHARE—Survey of Health, Ageing and Retirement in Europe). Relating to information yielded by the last two waves of SHARE-Israel (Wave 7 and Wave 8), it sheds light on the characteristics of those who reported having paid out-of-pocket for medical services. A large majority of the older-adult population in Israel that consumes healthcare services is asked to pay for services out of pocket. Having supplemental health insurance, personal state of health and changes in it, and economic resources are found to have the strongest effect on the probability of out-of-pocket funding. The motive of financial and/or social support that older adults receive from and/or give to their immediate surroundings makes it more likely that they will pay out of pocket for healthcare services. The probability of such funding varies between nationalities and immigration statuses. It is found with emphasis that the share of out-of-pocket funding of healthcare in older adult households' total annual income is trending upward. Furthermore, economic motives are central in determining whether such expenditure will stabilize over time. The findings stress the need to enhance the healthcare system's awareness of the profile of older adults who find it necessary to pay out of pocket for healthcare services.

The Impact of Public, Private, and Out-of-Pocket Health Expenditures on Under-Five Mortality in Malaysia

Health financing in Malaysia is intensely subsidised by public funding and is increasingly sourced by household out-of-pocket financing, yet the under-five mortality rate has been gradually increasing in the last decade. In this context, this study aims to investigate the relationship between public, private, and out-of-pocket health expenditures and the under-five mortality rate in Malaysia using the autoregressive distributed lag (ARDL) estimation technique, whereby critical test values are recalculated using the response surface method for a time-series data of 22 years. The findings reveal that out-of-pocket health expenditure deteriorates the under-five mortality rate in Malaysia, while public and private health expenditures are statistically insignificant. Therefore, an effective health financing safety net may be an option to ensure an imperative child health outcome.

Substantial Out-of-Pocket Health Expenditure on Prenatal Check-Ups: Estimates from a Sample of Pregnant Women in Cartagena, Colombia

OBJECTIVE

We aimed to estimate out-of-pocket (OOP) health expenditures and the indirect costs related to prenatal check-ups in pregnant women seen in a maternity hospital in the Colombian Caribbean region.

METHODS

We described the economic costs of pregnant women, with no age limits, who attended prenatal check-ups in a maternity hospital. To estimate OOP and indirect costs owing to prenatal check-ups in pregnant women, a survey was constructed, where the woman was asked about some sociodemographic variables, to characterize those attending the prenatal check-ups. Absolute and relative frequencies, averages and confidence intervals were used to characterize the population and estimate OOP and indirect costs in pregnant women. The latter were estimated from the percentile method. A bootstrapping was performed to reduce the bias within the analysis.

RESULTS

In total, 56 pregnant women were surveyed, with an average age of 25.9 years (±6.2). All women surveyed had OOP associated to the prenatal check-up in at least one cost-item, and the OOP ranged between $0.3 and $108.7. Transportation was the item with the highest frequency of expenses, followed by food, other expenses, and drugs. The mean of OOP expenditures was $24.3 (CI 95% $18.1-31.4) for women who attended their prenatal check-up.

DISCUSSION

Considering the estimated OOP health expenditures caused by prenatal check-ups by household income, women living with <1 minimum wage spend 7% of their income in a prenatal check-up. In women with 1-2 and >2-3 minimum wages, these proportions were 5%, 3%, respectively. Unfortunately, this makes prenatal care a significant source of economic burden, impacting poor households in Cartagena.

Understanding the financial burden of incomplete abortion: An analysis of the out-of-pocket expenditure on postabortion care in eight public-sector health care facilities in Dakar, Senegal

Timely access to treatment is essential for women when they experience abortion complications. Out-of-pocket (OOP) expenditure is a known barrier to health care access. In 2018, we assessed the financial burden of accessing postabortion care (PAC) borne by women in Dakar, Senegal, where studies estimate that half of poor women with complications obtain PAC. We interviewed 729 women following discharge from PAC. Women reported expenditures on transportation, admission, treatment, family planning, hospitalisation, complementary tests, prescriptions, other medicines and materials. We compare women's OOP on PAC by expenditure category, type of treatment and facility type, and use multiple generalised linear regression analysis to explain variation in overall OOP and forecast it under alternate scenarios. The average OOP was USD $93.84. At health centres it was $65.47 and at hospitals it was $120.47. The average cost of PAC using dilation and curettage was $112.37, manual vacuum aspiration was $99.84, and misoprostol $61.80. Overall OOP on PAC amounts, on average, to 15% of the average monthly salary for women living in Dakar. Strategies that emphasise timely access to misoprostol for treating complications in primary care settings will address the contribution of OOP costs to Senegal's appreciable unmet need for PAC among the poor.

Out-of-Pocket Spending for Cancer Medication, Financial Burden, and Cost Communication with Oncologists in the Last Six Months of Life in Israel

Honest communication between oncologists and patients is important in alleviating the financial burden of cancer care. This study explored patient-relative-oncologist communication regarding the affordability of out-of-pocket (OOP) medication and the extent to which this communication addresses itself to the families' financial burden. A cross-sectional survey was conducted among primary caregivers of deceased cancer patients. About 43% of relatives said that they and/or the patients had paid out of pocket for medications during the last six months of the patient's life. Most (73%) oncologists suggested an OOP medication without asking about financial ability, 43% hardly explained the advantages of an OOP medication, and 52% hardly explained any treatment alternatives. Older age and female gender were related to less communication about an OOP medication, and better education, greater affluence, and having private health insurance were related to more communication. About 56% of relatives said that OOP payment for medications inflicted a very heavy or heavy financial burden on patients and their households. Physicians' interest in financial ability and giving explanation lightened the burden. Given the difficulty of explaining the complex interactions of cost and clinical outcomes, oncologists need to be better educated in skills that would enable them to communicate costs more openly and should consider the cost of a treatment when prescribing it.

Socioeconomic Factors Contributing to Antibiotic Resistance in China: A Panel Data Analysis

The relationship between socioeconomic factors and antibiotic resistance (ABR) prevalence remains a knowledge gap in China. In this study, our aim was to examine the association between ABR prevalence and socioeconomic factors across 30 provinces in mainland China. We used two measures of level of ABR: the proportion of methicillin-resistant Staphylococcus aureus (MRSA), third-generation cephalosporin-resistant Escherichia coli (3GCREC), and third-generation cephalosporin-resistant Klebsiella pneumoniae (3GCRKP), and the aggregate resistance. The data of ABR prevalence, education, gross domestic product (GDP) per capita, out-of-pocket (OOP) health expenditure, physician density, hospital bed density, and public toilet density during 2014 and 2018 in 30 provinces in mainland China were included. We examined the association between ABR prevalence and potential contributing socioeconomic factors using panel data modeling. In addition, we explored this relationship in the eastern, central, and western economic zones. Our results indicated that GDP per capita was significantly positively correlated with ABR in mainland China and the eastern economic zone; however, significantly positive associations did not exist in the central and western economic zones. Surprisingly, both higher GDP per capita and higher OOP health expenditure were associated with a higher level of MRSA, but a lower level of 3GCREC; higher physician density was associated with a lower level of MRSA, but a higher level of 3GCREC. In addition, ABR prevalence presented a decline trend during 2014 and 2018. Our study showed the potential associ-ations between resistance and GDP per capita, OOP health expenditure, physician density. It high-lights that the social and economic determinants can be of importance in tacking the development and spread of ABR in mainland China.

Utilization Impact of Cost-Sharing Elimination for Preventive Care Services: A Rapid Review

Consumer cost-sharing has been shown to diminish utilization of preventive services. Recent efforts, including provisions within the Affordable Care Act, have sought to increase use of preventive care through elimination of cost-sharing for clinically indicated services. We conducted a rapid review of the literature to determine the impact of cost-share elimination on utilization of preventive services. Searches were conducted in PubMed, Scopus, and CINAHL Complete databases as well as in grey literature. A total of 35 articles were included in qualitative synthesis and findings were summarized for three clinical service categories: cancer screenings, contraceptives, and additional services. Impacts of cost-sharing elimination varied depending on clinical service, with a majority of findings showing increases in use. Studies that included socioeconomic status reported that those who were financially vulnerable incurred substantial increases in utilization. Future investigations on additional clinical services are warranted as is research to better elucidate populations who most benefit from cost-sharing elimination.

Out-of-pocket and private pay in clinical genetic testing: A scoping review

Full coverage of the cost of clinical genetic testing is not always available through public or private insurance programs, or a public healthcare system. Consequently, some patients may be faced with the decision of whether to finance testing out-of-pocket (OOP), meet OOP expenses required by their insurer, or not proceed with testing. A scoping review was conducted to identify literature associated with patient OOP and private pay in clinical genetic testing. Seven databases (EMBASE, MEDLINE, CINAHL, PsychINFO, PAIS, the Cochrane Database of Systematic Reviews, and the JBI Evidence-Based Practice database) were searched, resulting in 83 unique publications included in the review. The presented evidence includes a descriptive analysis, followed by a narrative account of the extracted data. Results were divided into four groups according to clinical indication: (1) hereditary breast and ovarian cancer, (2) other hereditary cancers, (3) prenatal testing, (4) other clinical indications. The majority of studies focused on hereditary cancer and prenatal genetic testing. Overall trends indicated that OOP costs have fallen and payer coverage has improved, but OOP expenses continue to present a barrier to patients who do not qualify for full coverage.

Adaptation of WHO's generic tuberculosis patient cost instrument for a longitudinal study in Africa

The WHO developed a generic 'TB patient cost survey' tool and a standardized approach to assess the direct and indirect costs of TB incurred by patients and their households, estimate the proportion of patients experiencing catastrophic costs, and measure the impact of interventions to reduce patient costs. While the generic tool is a facility-based cross-sectional survey, this standardized approach needs to be adapted for longitudinal studies. A longitudinal approach may overcome some of the limitations of a cross-sectional design and estimate the economic burden of TB more precisely. We describe the process of creating a longitudinal instrument and its application to the TB Sequel study, an ongoing multi-country, multi-center observational cohort study. We adapted the cross-sectional WHO generic TB patient cost survey instrument for the longitudinal study design of TB Sequel and the local context in each study country (South Africa, Mozambique, Tanzania, and The Gambia). The generic instrument was adapted for use at enrollment (start of TB treatment; Day 0) and at 2, 6, 12 and 24 months after enrollment, time points intended to capture costs incurred for diagnosis, during treatment, at the end of treatment, and during long-term follow-up once treatment has been completed. These time points make the adapted version suitable for use in patients with either drug-sensitive or drug-resistant TB. Using the adapted tool provides the opportunity to repeat measures and make comparisons over time, describe changes that extend beyond treatment completion, and link cost survey data to treatment outcomes and post-TB sequelae. Trial registration: ClinicalTrials.gov: NCT032516 August 1196, 2017. Abbreviations: DOTS: Directly observed treatment, short-course; DR-TB: Drug-resistant tuberculosis; MDR-TB: Multi-drug resistant tuberculosis; NTP: National Tuberculosis Programme; TB: Tuberculosis; USD: United States Dollar; WHO: World Health Organization.

Access to essential anticancer medicines for children and adolescents in Europe

BACKGROUND

Essential anticancer medicines are an indispensable component of multidisciplinary treatment of paediatric malignancies. A European Society for Medical Oncology (ESMO) study reported inequalities in the availability of anticancer medicines for adult solid tumours and provided a model for the present survey. The aim of this survey was to assess the accessibility of essential medicines used in paediatric cancer patients aged 0 to 18 years across Europe from 2016 to 2018.

METHODS

A list of medicines was drawn with input from the European Society for Paediatric Oncology (SIOP Europe) Clinical Research Council referring to the World Health Organization Model List of Essential Medicines for Children (WHO EMLc) 2017. A survey was sent to nominated national clinician and pharmacist rapporteurs and parent associations in up to 37 countries; answers were obtained from 34 countries.

RESULTS

The full survey list contained 68 medicines, including 24 on the WHO EMLc 2017. Health professionals reported that 35% of all medicines were prescribed off-label in at least one country and that 44% were always available in >90% of countries. Only 63% of the EMLc 2017 medicines were reported as always available. The main determinant of unavailability was shortages, reported for 72% of medicines in at least one country. Out-of-pocket costs were reported in eight countries. Twenty-seven percent of orally administered medicines were never available in child-friendly formulations. Parents detailed individual efforts and challenges of facilitating ingestion of oral medicines as prescribed. Inequalities in access to pain control during procedures were reported by parents across Europe.

CONCLUSIONS

Children and adolescents with cancer in Europe experience lack of access to essential medicines. Urgent actions are needed to address shortages, financial accessibility, availability of safe age-appropriate oral formulations, and pain management across Europe.

Catastrophic Health Expenditure among Chronic Patients Attending Dessie Referral Hospital, Northeast Ethiopia

BACKGROUND

Catastrophic health expenditure is health spending that is not covered by a health-care plan. These costs tend to escalate over time, due to chronic illnesses. Catastrophic health expenditure leads to decreased use of health services and poorer treatment outcomes. This study measured the extent of and factors associated with catastrophic health expenditure among chronically ill patients attending Dessie Referral Hospital in northeast Ethiopia.

METHODS

An institution-based cross-sectional study design was used to quantify catastrophic health expenditure among 302 chronically ill patients from May 25, 2018 to June 30, 2018. A stratified sampling technique was used to select the study participants. Descriptive and inferential statistics were computed using SPSS 20.

RESULTS

Catastrophic health expenditure was found in 194 (64.2%, 95% CI 58.8%-70.5%) of chronic patients. Costly service (151, 50%), transport (104, 34.4%), and pharmaceuticals (189, 62.6%) were the reasons for catastrophic health expenditure among chronic patients. Factors associated with catastrophic health expenditure were age <30 years (AOR 7.74, CI 0.94-63.62; P=0.01), patient monthly income

CONCLUSION

Two-thirds of chronic patients had catastrophic health expenditure. Starting and strengthening various health-insurance schemes will make chronic-care services more accessible and affordable.

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Key Words

• chronic illness
• health expenditure
• out-of-pocket

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MESH Headings Collapse

Grants

• no funding

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Assessing the Impact of Out-of-Pocket Expenditures for Prevention of COVID-19 Infection on Households: Evidence From Malaysia

COVID-19 infection resulted in significant economic implications to patients as well as a considerable financial burden to the general population for preventive measures. A descriptive study was conducted among staff at one of the public universities in Malaysia to estimate the monthly out-of-pocket expenditures for preventive measures used for COVID-19 infection. The study tool includes questions on household out-of-pocket expenditure and the measurements of the impact of the expenditure on household income. It was found that the average cumulative monthly expenditures related to the preventive measures were US$ 45.90 (Ringgit Malaysia 187.77), which was 4.3% of the household income. The highest expenditures were for traditional and complementary medicine followed by nutraceutical/supplements and disposable facemask. 8% of the households in this study incurred more than ten per cents of their monthly household income for expenditures related to COVID-19 preventive measures. Several households are experiencing substantial financial implications for preventive measures related to COVID-19 infection. This study highlights the out-of-pocket expenditures incurred for preventive measures were substantial for certain households. Effective initiatives from the government on providing subsidized protective personal equipment and a cost-sharing approach could help to alleviate the household financial burden.

Prediction of out-of-pocket health expenditures in Rwanda using machine learning techniques

Introduction

in Rwanda, the estimated out-of-pocket health expenditure has been increased from 24.46% in 2000 to 26% in 2015. Despite the existence of guideline in estimation of out-of-pocket health expenditures provided by WHO (2018), the estimation of out-of-pocket health expenditure still have difficulties in many countries including Rwanda.

Methods

the purpose of this paper was to figure out the best model which predicts the out-of-pocket health expenditures in Rwanda during the process of considering various techniques of machine learning by using the Rwanda Integrated Living Conditions Surveys (EICV5) of 14580 households (2018).

Results

our findings presented the model which predict the out-of-pocket health expenditures with higher accuracy and was found as treenet model. Furthermore, machine learning techniques were used to judge which predictor variable was important in our prediction process and comparison of the performance of the algorithms through train accuracy and test accuracy metric measures. Finally, the findings show that the tests of accuracy of the models were 50.16% for multivariate adaptive regression splines (MARS) model, 74% decision tree model, 87% for treenet model, 83% for random forest model, gradient boosting 81%, predictor total consumption played a significant role in the model for all tested models.

Conclusion

finally, we conclude that the total consumption of the household came out to be the most important variable which is consistently true to all the algorithms tested. The findings from our study have policy implications for policy makers in Rwanda and in the world generally. We recommend the government to significantly increase public spending on health. Domestic financial resources are key to moving closer to universal health coverage (UHC) and should be increased on a long-term basis. In addition, these results will be useful for the future to assess the out-of-pocket health expenditures dataset.

How much do Indians pay for tuberculosis treatment? A cost analysis

Setting

India's National Tuberculosis Elimination Programme (NTEP) covers diagnostic and therapeutic costs of TB treatment. However, persons living with TB (PLWTB) continue to experience financial distress due to direct costs (payment for testing, treatment, travel, hospitalization, and nutritional supplements) and indirect costs (lost wages, loan interest, and cost of domestic helpers).

Objective

To analyze the magnitude and pattern of TB-related costs from the perspective of Indian PLWTB.

Design

We identified relevant articles using key search terms ('tuberculosis,' 'India,' 'cost,' 'expenditures,' 'financing,' 'catastrophic' and 'out of pocket') and calculated variance-weighted mean costs.

Results

Indian patients incur substantial direct costs (mean: US$46.8). Mean indirect costs (US$666.6) constitute 93.4% of the net costs. Mean direct costs before diagnosis can be up to four-fold that of costs during treatment. Treatment in the private sector can result in costs up to six-fold higher than in government facilities. As many as one in three PLWTB in India experience catastrophic costs.

Conclusion

PLWTB in India face high direct and indirect costs. Priority interventions to realize India's goal of eliminating catastrophic costs from TB include decreasing diagnostic delays through active case finding, reducing the need for travel, improving awareness and perception of NTEP services, and ensuring sufficient reimbursement for inpatient TB care.

Examining the distribution of benefits of a free Maternal and Child Health programme in Enugu State, Nigeria: a benefit incidence analysis

OBJECTIVE

To determine the population groups that benefit from a Free Maternal and Child Health (FMCH) programme in Enugu State, South-east Nigeria, so as to understand the equity effects of the programme.

METHOD

A community-based survey was conducted in rural and urban local government areas (LGAs) to aid the benefit incidence analysis (BIA) of the FMCH. Data were elicited from 584 randomly selected women of childbearing age. Data on their level of utilisation of FMCH services and their out-of-pocket expenditures on various FMCH services that they utilised were elicited. Benefits of the FMCH were valued using the unit cost of providing services while the net benefit was calculated by subtracting OOP expenditures made for services from the value of benefits. Costs were calculated in local currency (Naira (₦)) and converted to US Dollars. The net benefits were disaggregated by urban-rural locations and socio-economic status (SES). Concentration indices were computed to provide the level of SES inequity in BIA of FMCH.

RESULTS

The total gross benefit incidence was ₦2.681 million ($7660). The gross benefit that was consumed by the urban dwellers was ₦1.581 million ($4517.1), while the rural dwellers consumed gross benefits worth ₦1.1 million ($3608.20). However, OOP expenditure for the supposedly FMCH was ₦6 527 580 (US$18 650.2) in the urban area, while it was ₦3, 194, 706 (US$ 9127.7) among rural dwellers. There was negative benefit incidence for the FMCH because the OOP exceeded the gross benefits at the point of use of services. There was no statistically significant difference in the benefit incidence and OOP expenditure between the urban and rural dwellers and across socio-economic groups.

CONCLUSION

The distribution of the gross benefits of the FMCH programme indicates that it may not have achieved the desired aim of enhanced access particularly to the low-income population. Crucially, the high level of OOP erased whatever societal gain the FMCH was developed to provide. Hence, there is a need to review its implementation and re-strategise to reduce OOP and achieve greater access for improved effectiveness of the programme.

Association Between Supplemental Private Health Insurance and Burden of Out-of-Pocket Healthcare Expenditure in China: A Novel Approach to Estimate Two-Part Model with Random Effects Using Panel Data

Introduction

Private health insurance (PHI) is an important supplement to the basic health insurance schemes in the Chinese healthcare system. However, there is an absence of evidence on whether the strategy of engaging PHI to reduce burden is effective in China. As such, we aimed to investigate the association between supplemental PHI and the out-of-pocket (OOP) burden of household healthcare expenditure in China.

Methods

We conducted a panel data analysis using data from three waves of China Health and Retirement Longitudinal Study (CHARLS). Specifically, a two-part model (TPM) with a first-stage probit and second-stage generalized linear model (GLM) framework was used to analyze the data. To account for individual-level random effects in both stages and their correlation in the TPM analysis, we proposed a generalized structural equation modeling (GSEM) approach to implement the estimation. The proposed approach allowed us to simultaneously analyze the association of PHI with the probability of having any healthcare and the OOP burden conditional on having any healthcare expenditure.

Results

Using the GSEM estimates, we found that supplemental PHI was significantly associated with a higher probability (4.29 percentage points) of having any OOP healthcare expenditure but a lower OOP burden conditional on having any expenditure (−2.37 percentage points). Overall, supplemental PHI was insignificantly associated with a lower OOP burden (−1.05 percentage points).

Discussion

Our findings suggested that supplemental PHI in China may be able to effectively improve access to healthcare while keeping the OOP healthcare expenditure burden flat. Also, GSEM is a feasible method to estimate random-effect TPMs.

The financial impact of a breast cancer detected within and outside of screening: lessons from the Australian Lifepool cohort

OBJECTIVE

To determine the government and out-of-pocket community costs (out-of-hospital medical services and prescription medicines) associated with screen-detected and community-detected cancers (i.e. cancers detected outside of Australia's organised screening program [BreastScreen]).

METHODS

We analyse administrative data on government-subsidised medical services and prescription medicines for 568 Victorian women diagnosed with breast cancer or ductal carcinoma in situ (DCIS). Using multivariable regression analysis, we estimate the government and out-of-pocket community costs incurred in the three years after diagnosis for screen-detected cancers and community-detected cancers. Additionally, we estimate the government costs associated with diagnosis within and outside of BreastScreen.

RESULTS

Average government costs for breast cancer diagnosis were similar within and outside of BreastScreen [$808 (lower limit 676; upper limit 940) vs $837 (95%CI 671; 1,003) respectively]; however, women with community-detected cancers incurred an additional $254 (95%CI 175; 332) out-of-pocket. Controlling for differences in known cancer characteristics, compared to screen-detected cancers, community-detected breast cancers were associated with an additional $2,622 (95%CI 644; 4,776) in government expenditure in the three years following diagnosis. Adverse cancer characteristics that were more prevalent in community-detected cancers (high grade, lymph node involvement, HER2 positive receptor status) were associated with increased government and out-of-pocket costs.

CONCLUSIONS

Community-detected breast cancers were associated with increased government and out-of-pocket costs. Implications for public health: These costs should be considered when evaluating current and alternative breast cancer screening strategies.

Comparative analysis of caesarean delivery among out-of-pocket and health insurance clients in Ilorin, Nigeria

Background

Although out-of-pocket (OOP) payment for health services is common, information on the experience in maternal health services especially caesarean delivery (CD) is limited.

Aim

To compare the pregnancy events and financial transactions for CD among OOP and health-insured clients.

Materials and Methods

A comparative (retrospective) study of 200 women who had CD as OOP (100 participants) or health-insured clients (100 participants) over 30 months at Anchormed Hospital, Ilorin, using multistage sampling was conducted. The data were analysed using Chi-square, t-test and regression analysis; P < 0.05 was considered statistically significant.

Results

Of 1246 deliveries, 410 (32.9%) had CD; of these, 186 (45.4%) were health-insured and 224 (54.6%) were OOP payers. The health-insured were mostly civil servants (60.0% vs. 40.0%; P = 0.009) of high social class (48.0% vs. 29.0%; P = 0.001). The payment for CD was higher among OOP (P = 0.001), whereas duration from hospital discharge to payment of hospital bill was higher for the health-insured (P = 0.001). On regression, social class (odds ratio [OR]: 0.23, 95% confidence interval [CI]: -0.0891252-0.112799; P = 0.048), amount paid (OR: 48.52, 95% CI: -7.14-6.68; P = 0.001) and duration from discharge to payment (OR: 28.68, 95% CI: 51.7816-70.788; P = 0.001) were statistically significant among participants. The amount paid was lower (P = 0.001), whereas time interval before payment was longer (P = 0.001) for the public-insured compared to private-insured clients.

Conclusion

OOP payers are prone to catastrophic spending on health. The waiting time before reimbursement to health-care providers was significantly prolonged; private insurers offered earlier and higher reimbursement compared to public insurers. The referral and transportation of health-insured clients during emergencies is suboptimal and deserve attention.

Impact of out-of-pocket costs on patient initiation, adherence and persistence rates for patients treated with anti-vascular endothelial growth factor medicines

IMPORTANCE

Out-of-pocket costs are a key driver of patient decisions to access, adhere and persist with anti-vascular endothelial growth factor (VEGF) therapy. The Medicare Benefits Schedule Review Taskforce proposes a 69% reduction in the scheduled fee for intravitreal injections (item 42 738) which risks increasing out-of-pocket costs for patients and worsening visual outcomes.

BACKGROUND

To determine the impact of out-of-pocket costs on current anti-VEGF utilization rates in patients with neovascular age-related macular degeneration (nAMD) and diabetic macular oedema (DMO).

DESIGN

This is a retrospective cohort drug-utilization analysis.

PARTICIPANTS

This study involved 11 592 patients in Australia diagnosed with nAMD or DMO.

METHODS

A retrospective analysis of electronic, de-identified dispensing records of patients diagnosed with nAMD or DMO who initiated anti-VEGF therapy between January 1, 2016 and December 2018 across Australia. Patients were categorized by treatment facility type: bulk-billing clinics (BBCs) and "rest of market" clinics (ROMCs).

MAIN OUTCOME MEASURES

Dispensing quantities, intervals and persistence rates.

RESULTS

For patients with nAMD who initiated therapy between 2016 and 2018 the mean number of medicines dispensed up to September 30, 2019 was 17.0 for BBC and 13.8 for ROMC patients. For patients with DMO, the mean number of medicines dispensed was 16.5 for BBC patients and 12.5 for ROMC patients. Patients treated at BBCs had higher persistence rates than those treated at ROMCs. DMO patients had higher initiation rates BBCs (46%) vs ROMCs (25%).

CONCLUSIONS AND RELEVANCE

Lower out-of-pocket costs are associated with higher adherence and persistence rates for anti-VEGF therapy in patients with AMD and DMO and higher initiation rates for DMO patients.

Economic Cost of Severe Acute Respiratory Infection Associated to Influenza in Colombian Children: A Single Setting Analysis

BACKGROUND

Influenza is considered a leading public health problem because its large economic burden of disease worldwide, especially in low-and middle-income countries, such as Colombia.

OBJECTIVE

We aimed to estimate the economic costs of influenza-confirmed patients in a pediatric hospital in Cartagena, Colombia.

METHODS

We conducted a retrospective costing analysis. We estimated the direct (direct medical and out-of-pocket expenditures) and indirect costs for influenza-confirmed severe acute respiratory infection cases from a societal perspective. Total economic costs were calculated adding direct medical costs, out-of-pocket expenditures, and indirect costs owing to loss of productivity of caregivers. Mean, median, 95% confidence interval (95% CI) and interquartile range (IQR) of costs were measured. All costs are reported in USD ($1.00 = COP$2000.7) RESULTS: Forty-four cases were included in the analysis: 30 had influenza B, 10 influenza A and B, and 4 influenza AH1N1. Thirty patients were hospitalized in the general ward, 14 went to the intensive care unit. The average duration of stay was ∼9 days (95% CI, 6.3-11.5). The median direct medical cost for hospitalized case in general ward was $743.50 (IQR $590.20-$1404.60) and in intensive care unit $4669.80 (IQR $1614.60-$7801.50). The economic cost per hospitalized case was $1826.10 (IQR $1343.30-$2376.50); direct medical costs represented 93.8% of this cost. The median indirect cost was $82.10 (IQR $41.10-$133.40) and the median out-of-pocket expenditure per case was $45.70 (IQR $29.50-$64.90).

CONCLUSIONS

Severe acute respiratory infection is an important source of economic burden for the health system, families, and society in Colombia. Seasonal influenza vaccination should be strengthened to prevent more cases and save economic resources.

Impact of Critical Illness Insurance on the Burden of High-Cost Rural Residents in Central China: An Interrupted Time Series Study

Critical illness insurance (CII) in China was introduced to protect high-cost groups from health expenditure shocks for the purpose of mutual aid. This study aimed to evaluate the impact of CII on the burden of high-cost groups in central rural China. Data were extracted from the basic medical insurance (BMI) hospitalization database of Xiantao City from January 2010 to December 2016. A total of 77,757 hospitalization records were included in our analysis. The out-of-pocket (OOP) expenses and reimbursement ratio (RR) were the two main outcome variables. Interrupted time series analysis with a segmented regression approach was adopted. Level and slope changes were reported to reflect short- and long-term effects, respectively. Results indicated that the number of high-cost inpatient visits, the average monthly hospitalization expenses, and OOP expenses per high-cost inpatient visit were increased after CII introduction. By contrast, the RR from BMI and non-reimbursable expenses ratio were decreased. The OOP expenses and RR covered by CII were higher than those uncovered. We estimated a significant level decrease in OOP expenses (p < 0.01) and rise in RR (p < 0.01), whereas the slope decreases of OOP expenses (p = 0.19) and rise of RR (p = 0.11) after the CII were non-significant. We concluded that the short-term effect of the CII policy is significant and contributes to decreasing OOP expenses and raising RR for high-cost groups, whereas the long-term effect is non-significant. These findings can be explained by increasing hospitalization expenses, many non-reimbursable expenses, low coverage for high-cost groups, and the unsustainability of the financing methods.

Is the elimination of 'sleeping sickness' affordable? Who will pay the price? Assessing the financial burden for the elimination of human African trypanosomiasis Trypanosoma brucei gambiense in sub-Saharan Africa

Introduction

Programme to eliminate neglected tropical diseases (NTDs) have gained global recognition, and may allow for improvements to universal health coverage and poverty alleviation. It is hoped that elimination of human African trypanosomiasis (HAT) Trypanosoma brucei gambiense (Tbg) would assist in this goal, but the financial costs are still unknown. The objective of this analysis was to forecast the financial burden of direct costs of HAT Tbg to funders and society.

Methods

In order to estimate the total costs to health services and individuals: (1) potential elimination programmes were defined; (2) the direct costs of programmes were calculated; (3) the per case out-of-pocket payments (OOPs) by programme and financial risk protection indicators were estimated. The total estimated costs for control and elimination programme were reported up till 2020 in international dollars. The mean results for both direct programme costs and OOPs were calculated and reported along with 95% CIs.

Results

Across sub-Saharan Africa, HAT Tbg maintaining ‘Control’ would lead to a decline in cases and cost US$630.6 million. In comparison, the cost of ‘Elimination’ programme ranged from US$410.9 million to US$1.2 billion. Maintaining ‘Control’ would continue to cause impoverishment and financial hardship to households; while all ‘Elimination’ programme would lead to significant reductions in poverty.

Conclusion

Overall, the total costs of either control or elimination programme would be near US$1 billion in the next decade. However, only elimination programme will reduce the number of cases and improve financial risk protection for households who are impacted by HAT Tbg.

Household Costs of Diarrhea by Etiology in 7 Countries, The Global Enterics Mulitcenter Study (GEMS)

Background

Although there are many overlapping features, pediatric diarrheal diseases can vary in severity, duration, clinical manifestations, and sequelae according to the causal pathogen, which in turn can impact the economic burden on patients and their families. We aimed to evaluate the household costs of diarrheal disease by pathogen in 7 countries.

Methods

We analyzed data from the Global Enteric Multicenter Study (GEMS), a prospective, age-stratified, matched case–control study of moderate to severe diarrheal disease among children aged 0–59 months in 7 low-income countries; 4 in Africa (Kenya, Mali, Mozambique, The Gambia) and 3 in Asia (Bangladesh, India, Pakistan). Demographic, epidemiological, economic, and clinical data were collected, and a stool sample was obtained for microbiological analysis at enrollment. We used a multivariate generalized linear model to assess the effect of rotavirus, Cryptosporidium, heat-stable toxin (ST)–producing enterotoxigenic Escherichia coli (ETEC [ST only or LT plus ST]), Shigella, Campylobacter jejuni, norovirus GII, Vibrio cholerae O1, age, gender, in/outpatient, and country on total costs to the patient/family.

Results

Household out-of-pocket costs were higher in Mali than any other country. Within countries, household cost differences between pathogens were minimal and not statistically significantly different.

Conclusions

We found no significant differences in household costs by pathogen. Despite data limitations, understanding pathogen-specific household costs (or lack thereof) is useful, as decision-makers could consider broader illness cost information and its relevance to a particular pathogen’s economic burden and contribution to poverty when deciding which pathogens to target for interventions.

Inequity & burden of out-of-pocket health spending: District level evidences from India

Background & objectives:

Numerous studies have highlighted the regressive and immiserating impact of out-of-pocket (OOP) health spending in India. However, most of these studies have explored this issue at the national or up to the State level, with an associated risk of overlooking intra-State diversities in the health system and health-seeking behaviour and their implication on the financial burden of healthcare. This study was aimed to address this issue by analyzing district level diversities in inequity, financial burden and impoverishing impact of OOP health spending.

Methods:

A household survey of 62,335 individuals from 12,134 households, covering eight districts across three States, namely Gujarat, Haryana and Rajasthan was conducted during 2014-2015. Other than general household characteristics, the survey collected information on household OOP [sum total of expenditure on doctor consultation, drugs, diagnostic tests etc. on inpatient depatment (IPD), outpatient depatment (OPD) or chronic ailments] and household monthly consumption expenditure [sum total of monthly expenditure on food, clothing, education, healthcare (OOP) and others]. Gini index of consumption expenditure, concentration index and Kakwani index (KI) of progressivity of OOP, catastrophic burden (at 20% threshold) and poverty impact (using district-level poverty thresholds) were computed, for these eight districts using the survey data. The concentration curve (of OOP expenditure) and Lorenz curve (of consumption expenditure) for the eight districts were also drawn.

Results:

The distribution of OOP was found to be regressive in all the districts, with significant inter-district variations in equity parameters within a State (KI ranges from −0.062 to −0.353). Chhota Udepur, the only tribal district within the sample was found to have the most regressive distribution (KI of −0.353) of OOP. Furthermore, the economic burden of OOP was more pronounced among the rural sample (CB of 19.2% and IM of 8.9%) compared to the urban sample (CB of 9.4% and IM of 3.7%).

Interpretation & conclusions:

The results indicate that greater decentralized planning taking into account district-level health financing patterns could be an effective way to tackle inequity and financial vulnerability emerging out of OOP expenses on healthcare.

Economic burden, impoverishment, and coping mechanisms associated with out-of-pocket health expenditure in India: A disaggregated analysis at the state level

INTRODUCTION

The high share of out-of-pocket (OOP) health expenditure imposes an extreme financial burden on households, and they have to incur a substantial amount of expenditure to avail health care services. This study analyses the inter-state differentials in the economic burden of OOP health expenditure, resultant impoverishment impact, and sources of finance used as coping mechanisms.

MATERIALS AND METHODS

The study is based on health expenditure survey, namely the 71^st Round on "Key Indicators of Social Consumption in India: Health," (2014) conducted in India by the National Sample Survey Organisation. The study uses headcount, payment gap, and concentration index to measure the economic burden, impoverishment impact of OOP health expenditure, and the level of inequality.

RESULTS

On the basis of results, the states can be divided into four distinct categories: (1) States with low economic burden and low poverty impact of OOP health expenditure, (2) low economic burden and high poverty impact of OOP health expenditure, (3) high economic burden and low poverty impact of OOP health expenditure, and (4) high economic burden and high poverty impact of OOP health expenditure.

CONCLUSIONS

Inter-state differentials in OOP health expenditure and impoverishment need proper attention of the government especially the policy makers.

The Payer and Patient Cost Burden of Open Breast Conserving Procedures Following Percutaneous Breast Biopsy

OBJECTIVES

Percutaneous core-needle biopsy (PCNB) is the standard of care to biopsy and diagnose suspicious breast lesions. Dependent on histology, many patients require additional open procedures for definitive diagnosis and excision. This study estimated the payer and patient out-of-pocket (OOP) costs, and complication risk, among those requiring at least 1 open procedure following PCNB.

METHODS

This retrospective study used the Truven Commercial database (2009-2014). Women who underwent PCNB, with continuous insurance, and no history of cancer, chemotherapy, radiation, or breast surgery in the prior year were included. Open procedures were defined as open biopsy or lumpectomy. Study follow-up ended at chemotherapy, radiation, mastectomy, or 90 days-whichever occurred first.

RESULTS

In total, 143 771 patients (mean age 48) met selection criteria; 85.1% underwent isolated PCNB, 12.4% one open procedure, and 2.5% re-excision. Incidence of complications was significantly lower among those with PCNB alone (9.2%) vs 1 open procedure (15.6%) or re-excision (25.3%, P < .001). Mean incremental commercial payments were US $13 190 greater among patients with 1 open procedure vs PCNB alone (US $17 125 vs US $3935, P < .001), and US $4767 greater with re-excision (US $21 892) relative to 1 procedure. Mean patient OOP cost was US $858 greater for 1 open procedure vs PCNB alone (US $1527 vs US $669), and US $247 greater for re-excision vs 1 procedure.

CONCLUSIONS

A meaningful proportion of patients underwent open procedure(s) following PCNB which was associated with increased complication risk and costs to both the payer and the patient. These results suggest a need for technologies to reduce the proportion of cases requiring open surgery and, in some cases, re-excision.

Care-Seeking Patterns and Direct Economic Burden of Injuries in Bangladesh

This study provides a comprehensive review of the care-seeking patterns and direct economic burden of injuries from the victims’ perspective in rural Bangladesh using a 2013 household survey covering 1.17 million people. Descriptive statistics and bivariate analyses were used to derive rates and test the association between variables. An analytic model was used to estimate total injury out-of-pocket (OOP) payments and a multivariate probit regression model assessed the relationship between financial distress and injury type. Results show non-fatal injuries occur to 1 in 5 people in our sample per year. With average household size of 4.5 in Bangladesh--every household has an injury every year. Most non-fatally injured patients sought healthcare from drug sellers. Less than half of fatal injuries sought healthcare and half of those with care were hospitalized. Average OOP payments varied significantly (range: $8–$830) by injury type and outcome (fatal vs. non-fatal). Total injury OOP expenditure was $355,795 and $5000 for non-fatal and fatal injuries, respectively, per 100,000 people. The majority of household heads with injuries reported financial distress. This study can inform injury prevention advocates on disparities in healthcare usage, OOP costs and financial distress. Reallocation of resources to the most at risk populations can accelerate reduction of preventable injuries and prevent injury related catastrophic payments and impoverishment.

Estimating regimen-specific costs of chemotherapy for breast cancer: Observational cohort study

BACKGROUND

One goal for high-quality patient care is communicating treatment costs to patients, yet cost information can be elusive. This is especially relevant for breast cancer care, for which numerous guideline-concordant adjuvant chemotherapy regimens exist. The objective of the current study was to generate cost estimates for such regimens from payers' and patients' perspectives in a large, insured US population.

METHODS

Adult women who had incident breast cancer diagnosed between 2008 and 2012 (from the MarketScan database), had no secondary malignancy within 1 year of diagnosis, and received chemotherapy within 3 months of diagnosis were included (n = 14,643). Total and out-of-pocket costs were calculated using all claims within 18 months of diagnosis and were normalized to 2013 US dollars. The extended estimating equations method was used to assess cost by regimen adjusting for demographic and clinical factors.

RESULTS

Among patients who did and did not receive trastuzumab, the median insurance payments were $160,590 and $82,260, respectively, and the median out-of-pocket payments were $3381 and $2724, respectively. Among patients who did not receive trastuzumab, 25% paid more than $4712, and 10% of patients paid more than $7041. For patients who did receive trastuzumab, 25% paid more than $5604, and 10% paid more than $8384. Among patients who were covered by high-deductible health plans, the median out-of-pocket cost was $5158, 25% paid at least $8128, and 10% paid ≥ $11,344.

CONCLUSIONS

The costs of breast cancer chemotherapy vary widely across regimens, and patients bear a substantial out-of-pocket burden. Cancer 2016;122:3447-3455. © 2016 American Cancer Society.

Out-of-pocket Cost Burden in Pediatric Inflammatory Bowel Disease: A Cross-sectional Cohort Analysis

BACKGROUND

Pediatric inflammatory bowel disease (IBD), consisting of Crohn's disease (CD) and ulcerative colitis (UC), can result in significant morbidity requiring frequent health care utilization. Although it is known that the overall financial impact of pediatric IBD is significant, the direct out-of-pocket (OOP) cost burden on the parents of children with IBD has not been explored. We hypothesized that affected children with a more relapsing disease course and families in lower income strata, ineligible for need-based assistance programs, disparately absorb ongoing financial stress.

METHODS

We completed a cross-sectional analysis among parents of children with IBD residing in California using an online HIPAA-secure Qualtrics survey. Multicenter recruitment occurred between December 4, 2013 and September 18, 2014 at the point-of-care from site investigators, informational flyers distributed at regional CCFA conferences, and social media campaigns equally targeting Northern, Central, and Southern California. IBD-, patient-, and family-specific information were collected from the parents of pediatric patients with IBD patients younger than 18 years of age at time of study, carry a confirmed diagnosis of CD or UC, reside in and receive pediatric gastroenterology care in California, and do not have other chronic diseases requiring ongoing medical care.

RESULTS

We collected 150 unique surveys from parents of children with IBD (67 CD; 83 UC). The median patient age was 14 years for both CD and UC, with an overall 3.7 years (SD 2.8 yr) difference between survey completion and time of IBD diagnosis. Annually, 63.6%, 28.6%, and 5.3% of families had an OOP cost burden >$500, >$1000, and >5000, respectively. Approximately one-third (36.0%) of patients had emergency department (ED) visits over the past year, with 59.2% of these patients spending >$500 on emergency department copays, including 11.1% who spent >$5000. Although 43.3% contributed <$500 on procedure and test costs, 20.0% spent >$2000 in the past year. Families with household income between $50,000 and $100,000 had a statistically significant probability (80.6%) of higher annual OOP costs than families with lower income <$50,000 (20.0%; P < 0.0001) or higher income >$100,000 (64.6%; P < 0.05). Multivariate analysis revealed that clinical variables associated with uncontrolled IBD states correlated to higher OOP cost burden. Annual OOP costs were more likely to be >$500 among patients who had increased spending on procedures and tests (odds ratio [OR], 5.63; 95% confidence interval [CI], 2.73-11.63), prednisone course required over the past year (OR, 3.19; 95% CI, 1.02-9.92), at least 1 emergency department visit for IBD symptoms (OR, 2.84; 95% CI, 1.33-6.06), at least 4 or more outpatient primary medical doctor visits for IBD symptoms (OR, 2.82; 95% CI, 1.40-5.68), and history of 4 or more lifetime hospitalizations for acute IBD care (OR, 2.60; 95% CI, 1.13-5.96).

CONCLUSIONS

Previously undocumented, a high proportion of pediatric IBD families incur substantial OOP cost burden. Patients who are frequently in relapsing and uncontrolled IBD states require more acute care services and sustain higher OOP cost burden. Lower middle income parents of children with IBD ineligible for need-based assistance may be particularly at risk for financial stress from OOP costs related to ongoing medical care.

Impact of Out-of-pocket Costs on Varenicline Utilization and Persistence

Background: Varenicline is a smoking cessation medication. Objectives: We analyzed patients' out-of-pocket costs and utilization of and persistence with varenicline. Methods: De-identified claims data in the MarketScan® Commercial Claims and Encounters Database were analyzed retrospectively. Participants were all patients at least 18 years of age continuously enrolled in plans during 2009. Plans were categorized according to restriction (no coverage; prior authorization; smoking cessation program requirement; no restrictions) and out-of-pocket cost for a 30-day supply (low: Collapse

Key Words

• out-of-pocket
• smoking cessation
• utilization
• varenicline

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Out-of-pocket fertility patient expense: data from a multicenter prospective infertility cohort

PURPOSE

The high costs of fertility care may deter couples from seeking care. Urologists often are asked about the costs of these treatments. To our knowledge previous studies have not addressed the direct out-of-pocket costs to couples. We characterized these expenses in patients seeking fertility care.

MATERIALS AND METHODS

Couples were prospectively recruited from 8 community and academic reproductive endocrinology clinics. Each participating couple completed face-to-face or telephone interviews and cost diaries at study enrollment, and 4, 10 and 18 months of care. We determined overall out-of-pocket costs, in addition to relationships between out-of-pocket costs and treatment type, clinical outcomes and socioeconomic characteristics on multivariate linear regression analysis.

RESULTS

A total of 332 couples completed cost diaries and had data available on treatment and outcomes. Average age was 36.8 and 35.6 years in men and women, respectively. Of this cohort 19% received noncycle based therapy, 4% used ovulation induction medication only, 22% underwent intrauterine insemination and 55% underwent in vitro fertilization. The median overall out-of-pocket expense was $5,338 (IQR 1,197-19,840). Couples using medication only had the lowest median out-of-pocket expenses at $912 while those using in vitro fertilization had the highest at $19,234. After multivariate adjustment the out-of-pocket expense was not significantly associated with successful pregnancy. On multivariate analysis couples treated with in vitro fertilization spent an average of $15,435 more than those treated with intrauterine insemination. Couples spent about $6,955 for each additional in vitro fertilization cycle.

CONCLUSIONS

These data provide real-world estimates of out-of-pocket costs, which can be used to help couples plan for expenses that they may incur with treatment.

Budget impact analysis of conversion from cyclosporine to sirolimus as immunosuppressive medication in renal transplantation therapy

Objectives

The aim of this study was to determine budget impact of conversion from cyclosporine (CsA) to sirolimus (SRL) in renal transplant therapy (RTT) from the perspective of insurance organizations in Iran.

Methods

An Excel-based model was developed to determine cost of RTT, comparing current CsA based therapy to an mTOR inhibitor-based therapy regimen. Total cost included both cost of immunosuppressive agents and relative adverse events. The inputs were derived from database of Ministry of Health and insurance organizations, hospital and pharmacy based registries, and available literature that were varied through a one-way sensitivity analysis. According to the model, there were almost 17,000 patients receiving RTT in Iran, out of which about 2,200 patients underwent the operation within the study year. The model was constructed based on the results of a local RCT, in which test and control groups received CsA, SRL, and steroids over the first 3 months posttransplantation and, from the fourth month on, CsA, mycophenolate mofetil (MMF), and steroids were used in the CsA group and SRL, MMF, and steroids were administered in the SRL group, respectively.

Results

The estimated cost of RTT with CsA was US$4,850,000 versus US$4,300,000 receiving SRL. These costs corresponded to the cost saving of almost US$550,000 for the payers.

Conclusion

To evaluate the financial consequence of adding mTOR inhibitors to the insurers’ formulary, in the present study, a budget impact analysis was conducted on sirolimus. Fewer cases of costly adverse events along with lower required doses of MMF related to SRL based therapies were major reasons for this saving budgetary impact.