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Out-Of-Pocket Expenditures, Indirect Costs and Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Thailand

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Out-Of-Pocket Expenditures, Indirect Costs and Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Thailand PharmacoEconomics Open DOI 10.1007/s41669-017-0057-9 ORIGINAL RESEARCH ARTICLE Out-of-Pocket Expenditures, Indirect Costs and Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Thailand 1,2 1,3 4 1,5,6 Pimwara Tanvejsilp • Mark Loeb • Jonathan Dushoff • Feng Xie Ó The Author(s) 2017. This article is an open access publication Abstract medical records, and the hospital billing database. Patients Background Thailand’s hospitals may adopt different were followed from January 2014 to March 2015. Relevant supervision approaches to improve tuberculosis (TB) OOP expenditures collected during the interviews included treatment adherence. (1) healthcare costs and other medications costs (e.g. Objective The aim of this study was to compare out-of- vitamins, antibiotics, anti-cough) occurring in private pocket (OOP) expenditures, indirect costs, and health-re- healthcare units; and (2) costs of transportation, food, and lated quality of life (HRQoL) among TB patients who accommodation. Productivity loss was measured using the received pharmaceutical care (pharmacist-led patient edu- self-reported amount of time a patient was unable to work cation and telephone consultation), home visit, and self- due to TB, travel time to and from the hospital, time spent administered therapy (SAT) in Thailand. at the hospital (waiting time, consultation time, and hos- Methods We conducted a prospective study to collect OOP pitalizations), and time spent accompanying family mem- expenditures, indirect costs, and HRQoL from a subsample bers on outpatient visits or during hospitalizations. Cost of 104 adult pulmonary TB patients who started treatment differences among treatment strategies were adjusted for between January and May 2014 in three hospitals. The baseline characteristics by generalized linear models three sources of data included patient interviews, patient (GLMs). All costs were converted to international dollars (I$). Results A total of 256 eligible patients who started pul- Electronic supplementary material The online version of this monary TB treatment during the specified period were article (doi:10.1007/s41669-017-0057-9) contains supplementary material, which is available to authorized users. approached, with 104 patients being included in the anal- ysis (29, 38, and 37 patients receiving pharmaceutical care, & Pimwara Tanvejsilp home visit, and SAT, respectively). Mean OOP expendi- [email protected]; [email protected] tures per patient receiving pharmaceutical care, home visit, 1 Department of Health Research Methods, Evidence, and and SAT were I$907.56 [confidence interval (CI) Impact, McMaster University, Hamilton, ON, Canada I$603.80–I$1269.41], I$148.47 (CI I$109.49–I$194.89), 2 and I$95.35 (CI I$69.11–I$129.63), respectively. The Department of Pharmacy Administration, Faculty of Pharmaceutical Sciences, Prince of Songkla University, GLM indicated statistically significantly lower OOP Hatyai, Songkhla 90112, Thailand expenditures for patients receiving either home visit or 3 Department of Pathology and Molecular Medicine, McMaster SAT (ratio of mean costs 0.247, CI 0.142–0.427; and University, Hamilton, ON, Canada 0.318, CI 0.187–0.540, respectively) than those receiving 4 Department of Biology, McMaster University, Hamilton, pharmaceutical care. Patient’s indirect costs for receiving ON, Canada pharmaceutical care, home visit, and SAT were I$1925.68 5 Program for Health Economics and Outcome Measures (CI I$922.06–I$3284.94), I$2393.66 (CI I$1435.01– (PHENOM), Hamilton, ON, Canada I$3501.98), and I$833.33 (CI I$453.87–I$1263.45), 6 Centre for Evaluation of Medicines, St. Joseph’s Healthcare respectively. The GLM found no statistically significant Hamilton, Hamilton, ON, Canada differences in indirect costs for the home visit and SAT P. Tanvejsilp et al. groups (ratio of mean costs 1.904, CI 0.754–4.802; and The economic burden of TB has a significant, multi- 0.792, CI 0.289–2.175, respectively) when pharmaceutical faceted impact on low- and middle-income countries [6]. care was set as the reference. Mean utility scores [EuroQol Patients may have poor compliance to medications due to five-dimensional three-level (EQ-5D-3L)] at baseline and financial burden, resulting in worsening health, potential treatment end were 0.679 and 0.830, 0.713 and 0.905, and spread of the disease, and/or death [6]. One of the World 0.708 and 0.913 for patients receiving pharmaceutical care, Health Organization (WHO) global targets for reducing home visit, and SAT, respectively. economic impact is to push forward the provision of TB Conclusion Pharmaceutical care patients experienced the diagnosis and treatment, free of charge, through national highest OOP expenditures, compared with home visit and universal health coverage [3, 7, 8]. SAT patients. Home-visit patients reached the highest Thailand established national universal coverage in indirect costs and utility score improvements. A large-scale 2002 [9]. All Thai citizens are covered under one of the prospective study is required in order to strengthen evi- three public insurance schemes, namely the Civil Servant dence to support policy making regarding the most efficient Medical Benefits Scheme (CSMBS), the Social Security use of limited resources for the management of TB. Scheme (SSS), and the Universal Coverage Scheme (UCS). Access to public TB diagnostic services and treatment is free of charge in Thailand. The national TB program adopts the daily dose regimen whereby most drug-sus- Key Points for Decision Makers ceptible patients take TB medication themselves at home and visit a health center or a district hospital at least once a Differences in patient characteristics [e.g. public month for a medication refill. Patients with multidrug-re- insurance coverage, socioeconomic status, disease sistance TB (MDR-TB) are required to visit the nearest severity, and distance to tuberculosis (TB) services] health center every day for treatment. among patients receiving different strategies had a There are barriers to the implementation of directly high impact on a large variation in financial burden. observed therapy (DOT), a WHO recommended strategy to The willingness of non-local patients to pay out of promote adherence for pulmonary TB patients [10], in their own pockets when seeking TB care at a resource-constrained countries [11, 12]. Other supportive university hospital outside their district may be strategies are therefore tailored to a country-specific con- atypical in other settings. Caution should be text [13–15]. In Thailand, three alternative supervision exercised when generalizing the research findings to approaches, pharmaceutical care (pharmacist-led health other populations. education), home visit, and self-administered therapy (SAT), are adopted by referral hospitals to improve adherence to TB treatment; however, evidence on the economic impact associated with these approaches is lim- ited. To update the evidence of costs incurred by TB 1 Introduction patients in Thailand, the objective of this longitudinal prospective study was to compare the out-of-pocket (OOP) Tuberculosis (TB) imposes a significant impact on not just expenditures, indirect costs, and HRQoL for TB patients the public healthcare system but also on patients and their who received pharmaceutical care compared with home families. Patients have to pay out of their own pockets for visit and SAT in Thailand. the cost of healthcare, food, and transportation when seeking care and receiving TB diagnosis and treatment at a health center or hospital [1]. 2 Methods Many TB patients are economically productive adults [2], and productivity loss due to the disease is the main 2.1 Data Source and Target Population driver of indirect costs [1]. A systematic literature review reported that the financial burden of TB borne by patients This was a prospective cohort study that followed patients was composed of three parts: 20% direct medical costs for at least 6 months or until the treatment course was [range in international dollars (I$) I$0–I$801.70], 20% complete. Recruitment was between January and May direct non-medical costs (range I$0–I$1271.40), and 60% 2014, while the data were collected from January 2014 to indirect costs (range I$29.80–I$2184.00) [3]. In addition to March 2015. OOP expenditures such as co-payment and the economic impact, TB causes pain and psychological healthcare costs not covered by public health insurance (i.e. suffering, and consequently results in a reduction in the non-essential drugs, seeking care outside their service area) health-related quality of life (HRQoL) of patients [4, 5]. were retrieved from the hospital billing database, while Costs and QOL of Pulmonary Tuberculosis in Thailand other OOP expenditures, productivity loss, and HRQoL Most patients were interviewed while waiting in the clinic. were obtained through patient interviews. Eligible patients who missed the interview at the clinic The clinical data of patients were retrieved from patient visit were contacted and interviewed by telephone within medical records and TB registration records. Costs were 14 days after the clinic visit. If patients could not be separately estimated in two main phases: pre-TB treatment reached by telephone, they were interviewed at their next period (from illness onset to TB diagnosis) and TB treat- clinic visit. Patients were interviewed using a questionnaire ment period (from the start to completion of TB treatment). developed by the authors (Online Appendix 1) and con- All costs were calculated in Thai currency, adjusted using sisting of three parts: (1) sociodemographic information the cumulative inflation rate from the year of data collec- (first visit only); (2) OOP expenditures and productivity tion (1.89% in 2014) to 2015 [16], and then converted to I$ loss (the value of paid and unpaid production loss due to using the 2015 purchasing power parity (PPP) conversion illness, time spent seeking treatment, disability [20]); and factor of private consumption [12.958 local currency unit (3) HRQoL measured using the EuroQol five-dimensional (LCU) per I$] [17].
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