Vol 6, No 04 (2018)

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Anindita et al IJSRE Volume 06 Issue 04 April 2018 Page 7912 Volume||6||Issue||04||April-2018||Pages-7912-7920||ISSN(e):2321-7545 Website: http://jsae.in Index Copernicus Value- 76.10 DOI: http://dx.doi.org/10.18535/ijsre/v6i4.02

A Prospective Study To Assess The Out of Pocket Expenditure Among Psychiatric

Patients Attending Tertiary Care Service

Authors

Anindita1, Sandhya Ghai2, Nitasha Sharma3, ⃰ Shankar Prinja4

From National Institute of Nursing Education and ⃰ School of Public Health, PGIMER, Chandigarh

ABSTRACT

Introduction: Mental illnesses are commonly linked with a higher disability and burden of disease, than many physical illnesses. The World Health Organization noted that one in every four people is affected by a mental disorder at some stage of life. Out of pocket payment is the major health financing mechanisms across most of developing countries, often present an enormous burden on underprivileged households. The costs of treatment of psychiatric patients are frequently high enough so that households are unable to get them back from existing resources and hence ultimately slip deeper into poverty. Aim: To assess the out of pocket expenditure of the patients attending psychiatry outpatient services and admitted in psychiatry ward. Methods: A prospective study was undertaken in the department of psychiatry at a tertiary institute of North India to measure the out of pocket expenditure of patients seeking care from OPD or admitted in ward. This study was conducted during the month of July – August 2016 on 200 patients. 10% patients were randomly selected from one day OPD attendance to interview and inpatients were totally enumerated. Socio demographic proforma to assess socio demographic profile and semi structured interview schedule for measuring out of pocket expenditure were used. Results: The result of the study had shown that among out patients transportation cost was higher (mean 827.81). There was a minimal consultation fee in PGIMER (mean 12.00) and negligible expenditure for psychotherapy (mean 1.67). Among Inpatients hospital bed charges was higher than other cost (mean 6988.25). Total expenditure of hospitalization was high (mean 22311). Among outpatients 63.3% patients had expenditure up to Rs 2500 for last one month and among inpatients 65% patients had expenditure up to Rs 25000 for present hospitalization. Prevalence of catastrophic health expenditure among outpatients was 18.9% and among inpatients it was 25%. Conclusion: Higher transportation cost indicated patients from far distance had come for follow-up and continued their treatment and higher bed charges among inpatients indicated patients had long duration of stay. Special attention given by medical personnel towards the treatment expenditure of patients can help them to reduce their economic burden and continued their treatment.

Key word: Out of pocket expenditure

INTRODUCTION:

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Anindita et al IJSRE Volume 06 Issue 04 April 2018 Page 7913

There are 1.5 crore people suffering from various mental disorders in India. Epilepsy and hysteria were seen significantly high in rural areas.3

Out of pocket payment is one of the major health financing mechanisms across most of the developing countries including India, related to enormous burden on underprivileged households. The treatment costs are high enough so that households are unable to adjust with them from existing resources and hence ultimately slip deeper into below the poverty level. Literature shows that the technology based medical care, the number of illness episodes as well as the presence of household members with chronic illness; hospitalizations are important factors leading to catastrophic expenditure.4

As psychiatric disorderis a long term illness, cost of curative care is varied due to poor compliance and poor outcome also. Increasing burden is probably due to lack of resources, low budget for mental health services, poor availability and accessibility of treatment, underutilization of existing services, and stigma attached to mental illnesses. High economical load may affect choice of treatment and discourage patients from getting right care which elevate course of suffering and cause of poor outcome. Besides of cost of treatment families of psychiatric patients can be deprived due to stress of coping to ill behaviour, social restriction, getting stigmatized and having indirect expenditure also. Reduced expenditure of psychiatric treatment can help not only in early diagnosis and prompt care but also in ongoing follow up and improving drug compliance. Educational intervention is essential to develop physicians’ knowledge related to costs of medicine as well as therapy and to increase their willingness to consider costs when prescribing.5 So, estimated out of pocket expenditure helped to identify the status of burden and would be helpful to provide cost effective adequate care to the patients that reduce drop out of cases, improve prognosis and outcome.

MATERIAL AND METHOD

A prospective study was undertaken in the department of psychiatry at a tertiary institute of North India to measure the out of pocket expenditure of patients seeking care from OPD or admitted in ward. This study was conducted during the month of July – August 2016 on 200 patients. Among 200 patients 180 patients were from outpatient department and 20 patients were admitted in psychiatry ward. 10% patients were randomly selected from one day OPD attendance to interview and inpatients were totally enumerated. Socio demographic proforma to assess socio demographic profile and semi structured interview schedule for measuring out of pocket expenditure were used.

Expenditure was divided into two types, direct and indirect expenditure. Direct expenditure include bed charges, consultation fees, expenditure of medicine, therapy, food, transportation, investigation, lodging and indirect expenditure include wage loss of the patient and caregiver. Wage loss include paid for the childcare, household activity, professional work, social work, attendance in school or university or loss of income of patient as well as primary caregiver due to inability to attend all those work for the reason of present mental illness. Semi structured interview schedule was made on that component for measuring out of pocket expenditure with the help of reviewing literature and expert opinion.

Inclusion criteria were patients who will be prepared to take part in the study, will be cooperative, will give inform consent and understand Hindi or English. Exclusion criteria were patient with chronic medical illness, primary memory disorder and patient without relatives will be excluded from the study.

Administrative approval was taken from Department of Psychiatry, PGIMER, Chandigarh. Institute Ethics Committee of PGIMER had given ethical clearance for the study. Written inform consent was taken from the subjects and caregivers who were willing to take part after explaining about the research study and reassure them about confidentiality. There was no interference in check-up of the subjects due to data collection in outpatient department and in the care of hospitalized subjects.

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20-25 minutes was taken for interviewing each subject. Data about out of pocket expenditure among out patients was collected for last one month. A 24 hours alternate survey was conducted among inpatients to estimate total expenditure of present hospitalization. Every alternative day data was collected from inpatients regarding direct and indirect expenditure during ongoing period of stay. Attendant of the admitted patients validated the data given by patients and gave confirmation. After that total out of pocket expenditure was calculated for ongoing period of present hospitalization. Data was analyzed by Descriptive statistics (Mean, Range and Standard deviation) and SPSS analysis.

RESULTS:

The socio-demographic profile of 200 patients who were enrolled in present study is summarized in the table number 1 below. The data was described with the help of percentage. The mean age ± SD of 200 patients was 41.40±14.41 (Range 18-77). 37.5 % of the patients were in the age group of 31-45 years. 52.5 % patients were females and majority (65%) of them were married. 24.5 % patients had completed their secondary education and 41% patients were unskilled worker and nearby 70.5% patients were Hindus. 55.5% patients belonged to nuclear families and 51.5 % of them were from rural background. Per capita income per month of 42% patients was up to Rs3000. The mean of per capita per month income ± SD of 200 patients was 6448.10 ±7506.16 (Range300-50000).

Table 1: Socio demographic profile of the patients attending psychiatric care service N=200

Variables n (%)

Age *

18-30 31-45 46-60 >60

52(26.0)

75(37.5)

52(26.0) 21(10.5)

Gender

Male Female

95(47.5)

105(52.5)

Marital status

Single Married

Widowed/ Divorced/ Separated

53(26.5)

130(65.0)

17(8.5)

Educational Status

Illiterate Primary Secondary Higher secondary Post high school diploma Graduate

Post graduate/ Masters

20(10.0) 44(22.0)

49(24.5)

27(13.5) 8(4.0) 33(16.5) 19(9.5)

Occupational Status

Skilled Worker Semi skilled worker Unskilled worker Housewife/Household Retired

Student Unemployed

36(18) 12(6.0) 6(3.0)

82(41.0)

17(8.5) 19(9.5) 28(14.0)

Religion

Hinduism

Muslim/ Christianity Sikhism

141(70.5)

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Anindita et al IJSRE Volume 06 Issue 04 April 2018 Page 7915 CLINICAL PROFILE OF THE SUBJECTS

Table 2 depicts that 78.5 % patients were psychotic, 20 % were non psychotic and 1.5% patients were suffering from organic illness. 42.5% patients came to PGIMER by self, 32% patients had been brought by family members or relatives. 22.5% patients were referred by medical personal and 3.0 % patients were referred by other department of PGIMER for psychiatry consultation.

Table 2: Clinical profile of the patients attending psychiatric care service

N= 200

Variables n (%)

Working Diagnosis Psychotic Non psychotic Organic 157(78.5) 40(20) 3(1.5)

Source of referral

Self

Family/Relative/others Medical personal Other department of PGI

85(42.5)

64(32) 45(22.5) 6(3.0)

Monthly out of pocket expenditure among out patients attending psychiatry OPD

Table 3 depicts that most amount of expenditure went to transportation (mean 827.81) among outpatients for last one month. There was a minimum consultation fee in PGIMER (mean 12.00) and negligible expenditure for psychotherapy (mean 1.67).

Table 3: Monthly out of expenditure among patients attending psychiatry care services in OPD basis

N= 180

Type of family

Nuclear Extended Joint 111(55.5) 6(3.0) 83(41.5)

Locality of subject

Urban Rural

97(48.5)

103(51.5)

Category of percapita per month income**

Up to 3000 3001-6000 >6000

84(42.0)

48(24.0) 68(34.0)

*Age Mean ± SD (41.40±14.410) Range (18-77) ** Category of Income Mean ± SD (6448.10 ±7506.16) Range (300-50000)

Out of pocket expenditure Mean Std. Error of Mean Std. Deviation Range Consultation Fees

Diagnostic expenditure Expenditure For Medicine Expenditure of food and lodging

Expenditure For ECT Expenditure For Psychotherapy Expenditure For Transportation

Total Direct Expenditure Total Indirect Expenditure

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Anindita et al IJSRE Volume 06 Issue 04 April 2018 Page 7916 Out of pocket expenditure for present hospitalization among patients admitted in psychiatry ward

Table 4 depicts that most expenditure of inpatients went to bed charges (mean 6988.25). Mean expenditure for food was 5541. Mean of diagnostic expenditure was 1360 and mean of medicine expenditure was 1272.95. Expenditure for ECT was minimum (mean 266.50). Total expenditure of hospitalization was high (mean 22311).

Table 4: Out of pocket expenditure for hospitalization among patients admitted in psychiatry ward N=20

Indirect Expenditure

Indirect expenditure is wage loss of patient as well as primary caregiver due to inability to attend various essential works for the reason of present episode of mental illness which include paid for the childcare, household activity, professional work, attendance in school or university or loss of income. Every patient did not have indirect expenditure because family member tried a lot to compensate that expenditure as much as possible. Among out patients 129 (71.7 %) patients had no indirect expenditure and only 51(28.3 %) patients had indirect expenditure. Among admitted patients 16 (80 %) patients had no indirect expenditure and only 4 (20%) patients had indirect expenditure.

Total out of pocket expenditure

To assess total out of pocket expenditure, it was categorized and it has been shown in table 5 and table 6. Table 5 depicts that total out of pocket expenditure was up to Rs2500 among 63.3% of outpatients for last one month. 17.2% outpatients had total out of pocket expenditure in between (2501-5000) Rs and 19.4 % patients had more than Rs 5000 expenditure per month.

Table 5: Frequency of total out of pocket expenditure within one month among psychiatric outpatients N= 180

Table 6 depicts that among 20 admitted patients 65 % patients had expenditure up to Rs25000 for present hospitalization. 25% inpatients had expenditure in between (25001-50000) Rs and only 10% patients had more than Rs 50,000 total out of pocket expenditure during their present hospitalization.

Out of pocket expenditure Mean Std. Error of Mean Std. Deviation Range Expenditure of bed charges

Expenditure For ECT Diagnostic expenditure Expenditure For Medicine

Expenditure For Food Expenditure For Transportation

Total Direct Expenditure Total Indirect expenditure

Total expenditure

6988.25

266.50 1360.50 1272.95 5541.00 2622.25 18721.45

3590.00 22311.45

2433.82 131.48 380.52 372.73 1064.09

493.50 3272.17 2184.56 4314.63

10884.37 587.98 1701.75 1666.88 4758.73 2206.98 14633.58

9769.66 19295.62

48000 2210 5750 6843 15000

7000 57460 40000 66160

Total out of pocket expenditure per month n (%)

Up to 2500 2501-5000

>5000

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Anindita et al IJSRE Volume 06 Issue 04 April 2018 Page 7917 Table 6: Frequency of total out of pocket expenditure among admitted patients during present hospitalization

N= 20

Figure 1 depicts that among direct expenditure, transportation cost was higher than other expenditure (32.31%). Expenditure of psychotherapy (0.07%) and consultation fees (0.47%) were negligible. ECT charges were 2.24 %, Diagnostic expenditure was 9.52%, expenditure of food and lodging was 26.89 % and expenditure for medicine was 28.50%.

Figure 1: Distribution of total direct expenditure of psychiatric patients seeking treatment in OPD basis Figure 2 depicts that among direct expenditure of admitted patients’ bed charges was higher than other expenditure (39%). Expenditure for food was 31%, for transportation was 14%, diagnostic expenditure was 8%, expenditure for medicine was 7 % and expenditure of ECT was only 1%.

Figure 2: Distribution of total direct expenditure of admitted patients during present hospitalization Catastrophic Health Expenditure:

Catastrophic health expenditure describes the proportion of a household's income used for health care. It shows the extent to which healthcare expenditure affects other expenses (the extent to which household is forced to sacrifice other basic needs, by selling assets and becoming impoverished).

Catastrophic health expenditure was taken as out of pocket expenditure was more than 25% of family income. It means health expenditure affected food pattern and daily needs of patients and family member.

Consultation fee, 0.47

Diagnostics, 9.52

Medicine, 28.50

Food & lodging, 26.89 Ect, 2.24

Psychotherapy, 0.07

Transportation, 32.31

N= 180

Bed Charges 39%

Ect 1% Diagnostic

8% Medicine

7% Food

31% Transportation

14% N= 20

Total out of pocket expenditure during present hospitalization n (%)

up to 25000 25001-50000

>50000

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Prevalence of catastrophic health expenditure among outpatients was found 18.9% means out of 180 patients 34 patients had catastrophic health expenditure. Prevalence of catastrophic health expenditure among inpatients was found 25% means out of 20 inpatients 5 patients had catastrophic health expenditure.

DISCUSSION:

Mental and behavioural illness has a great impact on individual, family and community. Individuals go through from distressing clinical symptoms of the disorder and also suffer as they are not capable of contributing in work or leisure activities due to discrimination. They become worried for not being able to carry out their responsibilities towards their close ones and become fearful that they would be a burden over them.

estimated that one in four families has at least one member c u r r e n t l y s u f f e r i n g f r o m a m e n t a l o r b e h a v i o r a l d i s o r d e r . These families are required not only to provide physical and

emotional support, but to bear the negative impact of stigma a n d d i s c r i m i n a t i o n p r e s e n t i n a l l p a r t s o f t h e w o r l d .

There is approximately one member in four families suffering from mental or behavioural illness. Those families have necessities not only of physical and psychological support, but also the ability to bear the negative blow of stigma and discrimination present in society. Burden on those families includes economic difficulties, stress and coping with the illness and disturbed behaviour, the disturbance in household tasks and the restriction of social participation. Expenses for the treatment are borne by the family member because insurance is unavailable and mental illness is not covered. Families in which one person has mental problem formulate a number of adjustments and compromises for other members of that particular family and they cannot achieve their full potential in work, social relationships and leisure. These human aspects of burden of mental illness are not easy to assess and quantify. Families have to set much time to look after the mentally ill person, and suffer from social and economical deprivation as he or she is not entirely productive.

Gadit conducted a study on out of pocket expenditure among depressive patients getting treatment from private psychiatric clinics in Pakistan.6 200 subjects were enrolled in the study. 85% of them had expenses between Rs 2436 to 4814 per month. In present study most of the outpatients had total expenditure up to 2500Rs per month. It suggests that present group had less expenditure. Consultant was aware about cost of medications and they kept it in their mind at the time of prescribing medication. As all outpatients were chronically ill and they got treatment in long term basis at minimum dose of medication and there was some favourable factors to the less amount of out of pocket expenditure. Patient got hospital supply medication free of cost irrespective of their poverty level.

Gadit proposed that majority of patients used public bus for their transportation.6In the present study transportation cost of outpatients was higher 827.81± 1913.95. Higher travel cost among outpatients reflected that people came for treatment from long distance and they continued their follow up.

Previous study suggests that costs for laboratory investigation were negligible as lesser emphasis was given on laboratory tests in psychiatry field.6 Present study indicated minimum expenditure for consultation fee in PGIMER 12.00±5.22 and negligible expenditure for psychotherapy 1.67±12.84 among outpatients. As it was a government institution, fees of doctors was set in a negligible amount and most of the time psychotherapy or any counselling session was done in free of cost until any particular psychotherapy was recommended in long term basis for a specific individual.

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proportion of expenditure on health7. In present study catastrophic health expenditure was taken as out of pocket expenditure was more than 25% of family income. It means health expenditure affected food pattern and daily needs of patients and family member. Prevalence of catastrophic health expenditure among outpatients was found 18.9% means out of 180 patients 34 patients had catastrophic health expenditure. Prevalence of CHE among inpatients was found 25% means out of 20 inpatients 5 patients had catastrophic health expenditure.

Wu et al had worked on economic burden among schizophrenic patients of United States in the year of 2002. Excess annual cost of schizophrenic patients was quantified in that project. Excess annual indirect cost were sketched in 4 components: unemployment, reduce productivity in workplace, premature mortality due to suicide and human capital approach based on market wages was used by family care giver.8 In the present study, 200 patients were taken as study subject irrespective of any particular disease. Among them majority had psychosis (78.5%) but only 14% patients were unemployed and 41% did household tasks. So disability among psychiatric patients was not drastically found. Indirect cost was not so high. Among out patients 28.3 % patients had indirect expenditure and among admitted patients only 20 % of patients had indirect expenditure. Chronic patients were more productive than acute cases and they served some amount of responsibilities in their professional area and in their family also. Therefore, indirect expenditure was found comparatively less in the present study.

Grover S et al had worked on cost of care among schizophrenic out patients in North India to assess treatment cost of schizophrenic patients.9 50 out patients with schizophrenia were assessed over the period of 6 months. Result of the study identified that drug cost was high among patients. But in present study cost of medicine was not so high among both outpatient and inpatient, as hospital supplied drugs were given to every patient if they need it.

In previous study total treatment cost of schizophrenic patients was drastically higher among those who were unemployed, frequently visited hospital and were severely ill with disability. But in present study total expenditure among outpatient was considerably found low because of all outpatients were in chronic illness. But the admitted patients were acute cases and had more expenditure for treatment as bed charges were high and duration of stay in hospital for the treatment was approximately 2 months.

Some special consideration for psychiatric treatment was present in that particular study setting. If any admitted patient had poor free card, bed charges and investigation charges was free for them. Hospital supplied drugs were given to them and if any prescribed drug was not in hospital supply then they purchased that particular medicine. Only dietary charges were collected from patients having poor free card. Same consideration was applicable for the staff member also. Beside that they had another advantage to get reinvestment of purchased medication if that was not in hospital supply. All factors had contributed in obtaining less amount of direct and indirect expenditure.

As the result of the study had showed that bed charges of inpatient influence the total expenditure of hospitalization, so it is recommended to reduce bed charges for inpatients. The innovation to reduce the out of pocket expenditure of the patients should come in the field of psychiatry. It is recommended that doctors should be aware about the cost of medication during prescribing it and nurses should be alert about expenditure at the time of providing care. Staying facility can be given to outpatients and their caregivers during their treatment or follow up period or facility for transportation can be provided by bus service from certain area.

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that time or invisible expenditure compensated by family or caregiver of mentally ill patients. As the present study was done only on visible expenditure it is recommended to include the estimation of invisible indirect expenditure in further study.

REFERENCES:

1. Thyloth M, Singh H, Subramanian V. Increasing burden of mental illnesses across the globe: Current status. Indian Journal of social Psychiatry [Internet]. 2016 [Cited 2016 Jan 4]; 32 (3):

254-6.Available from: DOI: 10.4103/0971-9962.193208

Lahariya C, Singhal S, Gupta S, Mishra A. Pathway of care among psychiatric patients attending a mental health institution in central India. Indian J Psychiatry [Internet]. 2010 [Cited 2016 Jan 4]; 52(4):333–8. Available from: www.indianjpsychiatry.org/text.asp?2010/52/4/333/74308

2. Reddy VM, Chandrasekhar CR. Prevalence of mental and behavioural disorders in India: a meta-analysis. Indian J Psychiatry [Internet]. 1998 Apr [Cited 2016 Mar 6]; 40(2):149-57. Available from: www.indianjpsychiatry.org/text.asp?1998/40/2/149/63246

3. Mondal S, Kanjilal B, Peters DH, Lucas H. Catastrophic out-of-pocket payment for health care and its impact on households: Experience from West Bengal, India. Future Health Systems Innovations for equity [Internet].2010 June [Cited 2016 Feb 3]; Available from: www.researchgate.net/publication/266879282...

4. Reichert S, Simon T, Halm EA. Physician’s attitudes about prescribing and knowledge of the costs of common medications. Arch Intern Med [Internet]. 2000[Cited 2016 Mar7]; 160(18):2799-2803. Available from:doi:10.1001/archinte.160.18.2799

5. Gadit AA. Out-of-Pocket expenditure for depression among patients attending private community psychiatric clinics in Pakistan. J Ment Health Policy Econ [Internet]. 2004 April [Cited 2016 Jan 5]; 7(1): 23-8. Available from: https://www.researchgate.net/publication/8456575

6. Ke Xu. Catastrophic health expenditure. The Lancet [Internet]. 2003 September [Cited 2016 July 5]; 362(9388):997 doi: http://dx.doi.org/10.1016/S0140-6736(03)14377-2

7. Wu EQ, Birnbaum HG, Shi L, Ball DE, Kessler RC, Moulis M et al. The Economic Burden of Schizophrenia in the United States in 2002. J Clin Psychiatry [Internet]. 2005[Cited 2016 May 17]; 66(9) :1122-9. Available from: www.medscape.com/medline/abstract/16187769