|
Variable |
Categories |
Frequency |
Percentage (%) |
|
Gender |
Male |
118 |
67.4 |
|
Female |
57 |
32.6 |
|
|
Age class (years) |
31-40 |
13 |
7.4 |
|
41-50 |
27 |
15.4 |
|
|
51-60 |
73 |
41.7 |
|
|
61-70 |
57 |
32.6 |
|
|
71-80 |
5 |
2.9 |
|
|
Marital status |
Separated |
4 |
2.2 |
|
Married and living with spouse |
145 |
82.9 |
|
|
Widowed |
26 |
14.9 |
|
|
Educational level |
Primary |
12 |
6.9 |
|
Secondary |
48 |
27.4 |
|
|
Tertiary |
76 |
43.4 |
|
|
Occupational Status |
Skilled |
129 |
73.7 |
|
Unskilled |
28 |
16.0 |
|
|
Unemployed/ Retired |
18 |
10.3 |
Table 2: Clinical characteristics of the respondents (N=175)
|
Variable |
Frequency |
Percentage (%) |
|
Length of stay (in days) |
||
|
1-7 |
66 |
37.7 |
|
8-14 |
46 |
26.3 |
|
15-21 |
25 |
14.3 |
|
22-28 |
13 |
7.4 |
|
29 and above |
25 |
14.3 |
|
Other Morbid Conditions |
||
|
Diabetes |
11 |
6.3 |
|
Hear Disease |
4 |
2.3 |
|
Hypertension |
121 |
69.1 |
|
No morbid condition |
28 |
16.0 |
|
Others |
11 |
6.3 |
Direct Medical and Non-Medical Costs of Stroke Treatment (Table 3)
The total direct medical and non-medical costs were N30,524,863.20 ($153,391.27) (patients who paid through OOP) and N3,606,530.60 ($18,123.27) (patients with some form of insurance). Also, the mean direct medical cost of acute stroke treatment for respondents who paid out-of-pocket was ?195,672.20± ?170,661.30 while it was ?189,817.40 ± ?77,114.00 for those who had some form of health insurance (p > 0.05). Expenditure on admission/consultation and radiological services were the highest single costs contributing to patients' direct medical cost, ?30,822.90 ($154.89) and ?43,200 ($217.09), respectively; followed by expenditure on drugs ?27,088.00 ($136.12). During hospitalization, all patients underwent radiological studies such as computerized tomography (CT) scan, Magnetic resonance imaging (MRI), X-ray either singly or in some combination. All patients had costs from admission as well as purchased drugs and 108 (61.7%), 65 (37.1%) and 63 (36.0%) were provided with Physiotherapy, Echocardiography, and Carotid Doppler services, respectively.
Table 3: Medical Costs of Stroke Treatment (in Naira), N=175
|
Health Care Services |
N |
Minimum Cost (?) |
Maximum Costs(?) |
Median (?) |
Std. Deviation |
|
Admission/Consultation |
175 |
6,000.00 |
163,000.00 |
30,822.90 |
19,013.2 |
|
Radiological Services |
175 |
1,200.00 |
67,000.00 |
43,200.00 |
19,243.5 |
|
Laboratory Fees |
166 |
4,250.00 |
289,550.00 |
20,750.00 |
47,106.9 |
|
Echocardiography |
65 |
15,000.00 |
45,000.00 |
16,080.80 |
7,092.2 |
|
Drugs |
175 |
2,120.00 |
203,080.00 |
27,085.00 |
40,603.3 |
|
Physical Therapy |
108 |
15,000.00 |
45,000.00 |
15,000.00 |
4,953.0 |
|
Carotid Doppler |
63 |
5,200.00 |
5,200.00 |
5,200.00 |
0.0 |
|
Special Feeding |
21 |
3,000.00 |
60,000.00 |
9,600.00 |
16,162.7 |
|
Transport |
14 |
12,500.00 |
28,000.00 |
17,850.00 |
4,187.2 |
|
Others |
103 |
1,350.00 |
193,410.00 |
12,890.00 |
40,017.8 |
|
Total direct medical and non- medical |
|||||
|
Patients with health insurance (19) |
|
||||
|
Patients without health insurance (156) |
|
||||
|
Average direct medical and non- medical costs Patients with health insurance (19) Patients without health insurance (156) |
|||||
Factors Associated with the Experience of Catastrophic Health Expenditure (Table 5)
Most respondents' households, 95 (54.3%), earned an annual income of less than ?500,000 (Table 4). Out of 175 respondents, 51(29.1%) experienced CHE, while 124 (70.9%) did not. Further analysis revealed that though there were slightly more male respondents (29.7%) than female (28.1%) who experienced CHE, this was not significant(p=0.828). There was also no association between marital status and the experience of CHE (p=0.523).
Table 5 shows that there is generally a higher occurrence of CHE among respondents with lower educational level (61.5%) compared to those with at least a secondary level education (29.2%) (p?0.001). Also, there was a significant association between the length of hospital stay and the experience of CHE (p?0.001). There was a significant association between the presence of a co-morbid condition and the experience of CHE (χ2= 10.35, p=0.001). Of the respondents who incurred CHE, 50 (98.0%) had other morbid conditions while only 1 (2.0%) of respondents with CHE had no other morbid health condition.
There is also a significant association between the incidence of patients who were discharged against medical advice and occurrence of CHE (p=0.041). About 75% of those who were discharged against medical advice had already incurred CHE as at the time of discharge.
There was no association between respondents' mode of payments and occurrence of catastrophic health expenditure (p=0.175). However, a larger proportion (94.1%) of respondents who had CHE paid through out-of-pocket compared to 5.9% who paid through social health insurance.
Discussion
This study estimates the direct costs of acute episode of stroke among 175 patients consecutively admitted in a tertiary hospital facility. The average health care expenditure on acute stroke treatment for respondents who paid out-of-pocket was ?195,672.20 ($983) ±?170,661.30 ($858) and ?189,817.40 ($954) ±?77,114.00 ($388) for those whose OOP expenditure were subsidized by health insurance. These estimated medical costs are substantially lower compared to costs reported in other studies carried out in developed settings. For instance, a study conducted in Japan on the average cost of treating first episode of stroke revealed a mean cost of $6887 [13]. A similar study conducted in Italy estimated the mean treatment cost of stroke at $3289 ± $1640 [13]. The lower average cost of managing first stroke episode in the study setting could be as a result of limited quality of health care services available. While it is intuitive to assume that the costs of medical services will be a function of the general quality of health care services in terms of better treatment technology, research has also shown that higher quality of medical services is generally related to higher medical expenditures [19].
Table 4: Annual Income Distribution of Respondents' Households and Experience of Catastrophic Health Expenditure
|
Annual Income (?) N Percentage (%) |
||
|
100,000-300,000 |
83 |
47.4 |
|
300,000-500,000 |
12 |
6.9 |
|
500,000-700,000 |
23 |
13.1 |
|
700,000-900,000 |
6 |
3.5 |
|
900,000-1,000,000 |
11 |
6.3 |
|
Over 1,000,0000 |
40 |
22.9 |
|
Incurred Catastrophic health expenditure 51 29.1 No catastrophic health expenditure 124 70.9 |
||
Table 5: Factors Associated with the Experience of Catastrophic Health Expenditure (CHE)
|
Respondents' Characteristics |
Had CHE |
Had no CHE |
||||
|
n |
% |
n |
% |
χ2 |
p-value |
|
|
Gender |
0.047 |
0.828 |
||||
|
Male |
35 |
29.7 |
83 |
70.3 |
||
|
Female |
16 |
28.1 |
41 |
71.9 |
||
|
Marital Status |
1.29 |
0.523 |
||||
|
Separated/Divorced |
1 |
25.0 |
3 |
75.0 |
||
|
Married |
40 |
27.6 |
105 |
72.4 |
||
|
Widowed |
10 |
38.5 |
16 |
61.5 |
||
|
Level of Education |
46.7 |
?0.001 |
||||
|
No Formal Education |
24 |
61.5 |
15 |
38.5 |
||
|
Primary |
8 |
66.7 |
4 |
33.3 |
||
|
Secondary |
14 |
29.2 |
34 |
70.8 |
||
|
Tertiary |
5 |
6.6 |
71 |
93.4 |
||
|
Length of Stay(days) 23.44 ?0.001 1-7 12 18.2 54 81.8 8-13 20 45.5 24 54.5 14-20 14 53.8 12 46.2 21-27 0 11 100 >28 5 17.9 23 82.1 |
||||||
|
Presence of Co-morbid Conditions |
10.55 |
0.001 |
||||
|
Yes |
50 |
34.0 |
97 |
66.0 |
||
|
No |
1 |
3.6 |
27 |
96.4 |
||
|
Discharged Against Medical Advise |
4.169 |
0.041 |
||||
|
Yes |
3 |
75.0 |
1 |
25.0 |
||
|
No |
48 |
28.1 |
123 |
71.9 |
||
|
Respondents' Mode of Payment |
1.54 |
0.175 |
||||
|
NHIS |
3 |
15.8 |
16 |
84.2 |
||
|
Out of Pocket (self, family, friends) |
48 |
30.8 |
108 |
69.2 |
||
The Length of stay (LOS) has been a known predictor of cost of care in most studies because it affects the total medical cost of patients' admission [20]. More than half of the respondents in this study were admitted for over seven days. Usually, the LOS alongside the degree of severity of stroke should be significantly related to higher average medical costs among patients as shown in many studies [2, 3,21], but in some cases, medical costs could still vary among stroke patients with the same hospital stay [22-23]. In our study, the cost of medical treatment was significantly associated with higher LOS. The study revealed that fewer patients with LOS beyond 20 days experienced CHE. However, it is known that the overall experience of CHE in this study may not reflect the full extent of CHE as a result of the decision to include only patients diagnosed of having stroke and admitted for the first time during the period of the study. This is plausible since the estimate the costs of the first acute episode of stroke had been set out. In order to do this, patients whose conditions were critical were excluded. The major co-morbidity observed is hypertension, indicating that this medical condition is the most common risk factor for having stroke. A related study among stroke patients confirmed hypertension as the major identifiable risk factor for stroke. The study reported that 85.2% of the stroke patients in the study also had hypertension as a co-morbid condition [7].
While some of the patients had some of the costs of treatment covered under the National Health Insurance Scheme (NHIS), their average medical cost was not significantly different from that of the patients whose payments were made through OOP. Hence, the need to develop a more robust social health insurance scheme that will reduce the burden of OOP and increase access to affordable health care services. Among all the patients, the highest individual cost of service was from the purchase of drugs and laboratory fees, followed by the cost of other items which the patients also had to purchase such as walking aids and wheelchairs. However, the average cost for radiological services was the highest contributing cost to a patients' total healthcare expenditure, followed by the cost of admission. The reason was that almost all the patients had to undergo either the CT or MRI and in some cases, both. These expensive services were on a Public-Private Partnership arrangement and not subsidized in any way.
The occurrence of CHE was observed among only 51(29.1%) acute stroke patients. Generally, the experience of CHE is expected to be higher than what it is in this study considering that majority of the patients covered their medical bills through OOP. However, the costs here only captured medical bills for one acute stroke episode and would expectedly be higher if different stroke episodes within a year were considered. A study conducted in the United States on the lifetime costs of stroke showed that the costs incurred as a result of nursing home stays and long term ambulatory care services were quite substantial. This suggests that major costs are incurred beyond the first two years after stroke"[23]. Consequently, the experience of CHE will be higher if the long-term economic impact of stroke with on-going treatment, rehabilitation, and re-admissions to hospital were considered. Overall, the level of education and presence of other morbid conditions were independently associated with the experience of CHE.
In this study, there were more males118 (67.4%) than females 57 (32.6%) as stroke patients. Until recently, in most African societies, men are mostly the breadwinners, and thus, the male gender is made to provide for almost all the financial needs of their respective families. As a result of this, they are more likely to develop medical conditions such as hypertension or stroke due to the excessive stress that comes with the economic demands of the family, especially if the man has access to limited financial resources. Furthermore, studies have found that men are more likely to engage in more health risk behaviors that could increase the chances of ill-health [20, 24]. An hospital-based study of the care and costs of acute ischemic stroke in Japan also had a larger proportion of male patients (69%) compared females [12]. Also, some research has shown that men are likely to suffer stroke than women during ages from 85 years and above[25, 26]. However, an epidemiological model of stroke incidence developed from a review of literature by a study in the United States showed that the relative risks of having stroke differ with respect to stoke sub-types [19]. The study reported that the relative risk of having subarachnoid stroke was higher in women and the risk of intracerebral hemorrhagic stroke higher in men while the incidence rate of ischemic stroke was similar among both men and women during the review period [19]. The level of education among the patients appear to be quite high as 70.8% had at least a secondary education.
Conclusion and Recommendation
This study showed that the cost of managing acute stroke is significant, especially for patients with low income. Also, there was inadequate level of insurance or other prepayment schemes that would have mitigated the high level of CHE that was found. Majority of payments for healthcare by consumers were made using out of pocket spending (OOPS). Considering that stroke often requires permanent dependence, long-term financial protection should be provided for acute stroke patients in Nigeria. Further studies are on indirect costs as well as the cost of rehabilitative care for stroke patients are suggested as this might provide detailed information on all aspects of costs of stroke management. Policy and decision makers will find such information useful particularly in increasing financial risk protection for stroke patients; thereby reducing their experience of catastrophic health expenditure and preventing them from impoverishment as a result of huge medical costs.
Limitation
This study is not without limitations. First, only the 175 patients that were admitted and subsequently discharged during the period of data collection were included in the analysis. The study did not include stroke patients who failed to survive the indexed episode of acute stroke. As such, the direct costs reported might have been underestimated. Also, the sample size was not large enough to further evaluate the impact of covariates, such as patients' socio-demographic and clinical characteristics on the mean/median direct costs of stroke treatment.
Competing Interests
Authors declare that there are no competing interests.
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