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A Descriptive Study of Direct Cost of Hospitalized Dengue Cases During Outbreak Period of August to September 2011 in Quezon City, the Philippines

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A Descriptive Study of Direct Cost of Hospitalized Dengue Cases During Outbreak Period of August to September 2011 in Quezon City, the Philippines A Descriptive Study of Direct Cost of Hospitalized Dengue Cases during Outbreak Period of August to September 2011 in Quezon City, the Philippines Master thesis submitted to the Ateneo de Manila Univeristy and the Charité - Universitätmedizin Berlin in partial fulfillment of the requirements for the award of a Master of Science degree in International Health Nandyan Nurlaksana Wilastonegoro September, 2012 Supervisor: Second Marker: Third Marker: ii Table of contents Table of contents iii List of tables and figures v Abbreviation vii Executive summary ix 1. Introduction 1 1.1. Dengue Situation Background 1 1.1.1. Dengue in the Philippines 2 1.1.2. Dengue outbreak in Quezon City 3 1.2. Dengue transmission, clinical manifestation, examination and 4 management 1.2.1. Transmission 5 1.2.2. Clinical manifestation 6 1.2.3. Examination and management 8 1.3. Dengue economic impact 12 1.4 . Paying for healthcare 12 1.5 . Problem statement 13 2. Research questions and study objectives 16 2.1. Research questions 16 2.2. Study objectives 16 3. Methods 17 3.1. Dengue in Quezon City and the Philippines 17 3.2. Data on hospitalized patients in Quezon City during last dengue 17 outbreak in 2011 3.3. Sample size calculation 18 3.4. Estimation on hospitalized dengue treatment cost 20 3.5. Study limitations 22 3.6. Ethical Issues 23 iii 4. Results 24 4.1. Sample size calculation 24 4.2. Demographic characteristics 24 4.2.1. Location 24 4.2.2. Age classification 25 4.2.3. Ward classification 27 4.3. Degree of severity and length of stay 28 4.4. Cost analysis 28 4.4.1. Quirino Memorial Medical Center 29 4.4.2. Quezon City General Hospital 30 4.4.3. Achieving study objectives 31 5. Discussion 33 5.1. Adjusting samples and method 33 5.2. What composed the cost? 34 5.3. Who paid for dengue hospitalization? 37 5.4. Outbreak preparedness 40 6. Conclusion 43 7. Bibliography 46 8. Annexes 50 iv List of tables and figures Table 1. Distribution of hospitalized dengue patients during August to September 25 2011, by district Table 2. Distribution of samples based on adult and pediatric classification 27 Table 3. Samples distribution of hospitalized dengue patients admitted during 27 August to September 2011, by ward classification in Quirino Memorial Medical Center and Quezon City General Hospital Table 4. Dengue cases length of stay (in days) based on severity 28 Table 5. Summary of samples taken in Quirino Memorial Medical Center and 29 Quezon City General Hospital Table 6. Cost analysis of hospitalized adult dengue patients in Quirino Memorial 29 Medical Center Table 7. Cost analysis of hospitalized pediatric dengue patients in Quirino Memorial 30 Medical Center Table 8. Cost analysis of hospitalized adult dengue patients in Quezon City General 31 Hospital Table 9. Cost analysis of hospitalized pediatric dengue patients in Quezon City 31 General Hospital Table 10. Total estimation of direct cost needed for hospitalized dengue patients 32 during period August to September 2011 in Quezon City Table 11. Percentage of patients who got checked with recommended laboratory 36 and diagnostic tools Table 12 PhilHealth utilization rates (%), 2002 – 2006 38 Table 13. Percentage of health insurance coverage in the Philippines 39 v Figure 1. Dengue burden worldwide 1 Figure 2. Manifestation of dengue infection 6 Figure 3. Five years dengue cases trends in Quezon City 14 Figure 4. Dengue cases in Quezon City, year 2011 18 Figure 5. Calculating sample size using Open Epi version 2.3.1. 19 Figure 6. Estimating cost of hospitalized dengue per patient 21 Figure 7. Sample size required for the study 24 Figure 8. Age distribution of dengue patients who admitted in Quirino Memorial 26 Medical Center and Quezon City General Hospital during August to September 2011 Figure 9. Patients classification of pediatric and adults during August to September 26 2011 Figure 10. Average cost propotion of hospitalized dengue patients 32 Figure 11. Dengue incidence rate in the Philippines (per 100,000), 2004 – 2010 40 vi Abbreviation ABCS Acidosis, bleeding, calcium and sugar monitoring aPTT Activated Partial Thromboplastin Time CBC Complete Blood Count CFRs Case Fatality Rates DALYs Disability Adjusted Live Years DENV Dengue virus DF Dengue Fever DHF Dengue Hemorrhagic Fever DoH Department of Health DSS Dengue Shock Syndrome HCT Hematocrit HI Hemagglutination -inhibition HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome ICU Intensive Care Unit IPP Individually -Paying Program IV Intra -venous LGU Local Government Unit MYR Malaysian Ringgit NCR National Capital Region NDHS National Demographic and Health Survey NHIP National Health Insurance Program NSAIDs Non -Steroid Anti Inflammatory Drugs NSS Normal SalineSolution OFW Overseas Filipino Workers program OOP Out -of -pocket PHIC Philippines Health Insurance Corporation PhilHealth Philippines Health Insurance Corporation vii PhP Philippines Peso PT Prothrombin Time QCGH Quezon City General Hospital QMMC Quirino Memorial Medical Center RL Ringer Lactate SP Sponsored Program USD United States Dollar USG Ultrasonography WBC White Blood Count WHO World Health Organization WHO - SEARO World Health Organization – South East Asia Regional Office WHO - TDR World Health Organization and the Special Program for Research and Training in Tropical Diseases WHO -WPRO World Health Organization – Western Pacific Regional Office viii Executive Summary Since the first report of dengue hemorrhagic fever during 1953 to 1954, dengue has remained as a common major problem of hospitalization and death among children and adults in the Philippines. Moreover, around 1.8 billion people worldwide are at risk of dengue especially those who live in tropical countries. Dengue is not only making morbidity and mortality problem, but it also create economic burden to patients when having dengue. Dengue manifestations vary from mild to severe cases. In mild cases, some patients could have home treatment, while some others and patients with more severe signs and symptoms have to be admitted in hospitals, especially patients in critical phase that could become shock up to fatal cases. These problems are even worse when patients have to struggle with the disease and after the disease gets resolved, patients still have to deal with medication costs during admission days in hospitals. Some patients who get covered by insurance or those who are at wealthy level might seen the treatment cost as not really a problem, but National Demographic and Health Survey (NDHS 2008) stated that only 42% of Filipinos were covered with insurance, means that the majority of Filipinos had to deal with medical services payment themselves and the poverty rate was at 32.9% (Romualdez 2011). This study is trying to capture a picture of direct dengue hospitalization cost in Quezon City during outbreak period of August to September 2011. Quezon City was chosen due to it is located in the National Capital Region (NCR) of the Philippines which is the most populated city in NCR with high density of population. Quezon City is also experiencing escalating cases of dengue within last five years. Thus, the amount of money that is spent just for dengue hospitalization especially during outbreak period is estimated also increasing year by year. To get the total direct cost estimation of hospitalized dengue cases, average direct cost per patient should be generated as well. ix The method was using data extraction form and tried to collect data from medical records of patients regarding any expenses during admission days of patients in hospitals. It was trying to figure out list of drugs and intra venous (IV) fluids therapy, laboratory and diagnostic tools, and room and other expenses. Then the lists were converted into costs, based on price list of each item from hospitals. Quirino Memorial Medical Center was chosen as national public hospital representative located in Quezon City, while Quezon City General Hospital was chosen as a public hospital owned by Quezon City government. Samples were taken in this study, and it was proportioned to sample size which means dengue proportion in districts within Quezon City is represented in the samples taken, and the calculation of required samples was using an open source interned based software, Open Epi, accessed through www.OpenEpi.com. In estimating average cost per patient, patients was classified as pediatric or adult cases and admitted in general ward or intensive care unit in hospitals. Then cost per patient was taken on average in each category, and all patients were listed to get the average cost among all categories. The estimation of total cost was gathered by multiplying the generated average cost per patient with total hospitalized dengue cases in Quezon City during outbreak period of August to September 2011. The total direct cost spent for dengue hospitalization cases has been estimated at PhP 22,016,913.81. It was estimated in Quezon City during outbreak period of August to September 2011. The average cost generated per patient was PhP 6,865.27 and the biggest proportion that composed the direct cost was costs for laboratory and diagnostic tool (57%), followed by room and other expenses (29%), and drugs and fluids therapy (14%). This estimation of total direct cost of hospitalized dengue cases is aimed as information that within two months during outbreak period, the amount of money that was spent was huge and dengue trend in Quezon City is not showing decreasing cases but going up. If there is no better anticipation from government and the society, the total cost would be higher and higher in the following years. Public health intervention should be better or at least more intensified in order x to solve problems that created by dengue. But this comes as the study limitation, that the study did not measure cost spent in public health intervention, also the indirect costs during hospitalization of dengue patients i.e.
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