BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-010992 on 5 July 2016. Downloaded from Catastrophic health expenditure: a comparative analysis of empty-nest and non-empty-nest households with seniors in Shandong, China. For peer review only Journal: BMJ Open Manuscript ID bmjopen-2015-010992 Article Type: Research Date Submitted by the Author: 05-Jan-2016 Complete List of Authors: Yang, Tingting; Shandong University, School of Public Health Chu, Jie; Shandong Center for Disease Prevention and Control Zhou, Chengchao; School of Public Health, Shandong Univeristy Medina, Alexis; Stanford University, Rural Education Action Program (REAP) Li, Cuicui; Shandong university, School of Public Health Jiang, Shan; Shandong university, School of Public Health Zheng, Wengui; Weifang Medical College Sun, Liyuan; Shandong University of Finance and Economics Liu, Jing; Shandong University, Sdhool of Public Health <b>Primary Subject Health services research http://bmjopen.bmj.com/ Heading</b>: Secondary Subject Heading: Health economics Keywords: catastrophic health expenditure, elderly, empty-nest, determinants, China on September 26, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-010992 on 5 July 2016. Downloaded from 1 2 3 4 Catastrophic health expenditure: a comparative analysis of 5 6 empty-nest and non-empty-nest households with seniors in 7 8 9 Shandong, China. 10 11 Tingting Yang1, Jie Chu2, Chengchao Zhou1, Alexis Medina3, Cuicui Li1, 12 13 1 4 5 1 14 Shan Jiang , Wengui Zheng , Liyuan Sun ,Jing Liu 15 For peer review only 16 17 1 18 School of Public Health, Shandong University, Jinan, 250012,China; 19 2Shandong Centre for Disease Control and Prevention, Jinan, 250014,China; 20 3 21 Freeman Spogli Institute, Stanford University, Stanford, CA 94305, USA; 22 4School of Public Health and Health Administration, Weifang Medical College, 23 24 Weifang , 261053, China; 25 5School of Accountancy, Shandong University of Finance and Economics, Jinan, 26 250014, China 27 28 29 30 *Corresponding Author: Chengchao Zhou (Associate Prof.), School of Public Health, 31 32 Shandong University; 44 Wen-hua-xi Road, Jinan, Shandong, 250012, China 33 http://bmjopen.bmj.com/ 34 Tel: (+86) 531 8838 1567 Fax: (+86) 531 8838 2553 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 1 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 26 BMJ Open: first published as 10.1136/bmjopen-2015-010992 on 5 July 2016. Downloaded from 1 2 3 4 Abstract 5 6 Objective: To compare the catastrophic health expenditure (CHE) prevalence 7 8 and its determinants between empty-nest and non-empty-nest elderly households. 9 10 Setting: Shandong province of China. 11 12 Participants: A total of 2761 elderly households are included in the analysis. 13 Results: CHE incidence among elderly households was 44.9%. The CHE 14 15 incidenceFor of empty-nest peer singles (59.3%, review P=0.000, OR=3.19) only and empty-nest couples 16 17 (52.9%, P=0.000, OR=2.45) are both statistically higher than that of non-empty-nest 18 19 elderly households (31.4%). An inverse association was observed between CHE 20 21 incidence and income level in all elderly household types. Factors including one or 22 23 more household elderly members with non-communicable chronic diseases in the past 24 25 6 months, one or more elderly household members being hospitalized in the past year, 26 27 and lower household income are significant risk factors for CHE in all three 28 29 household types (P<0.05). Health insurance status was found to be a significant 30 determinant of CHE among empty-nest singles and non-empty-nest households 31 32 (P<0.05). 33 http://bmjopen.bmj.com/ 34 Conclusions: CHE incidence among elderly households is high in China. 35 36 Empty-nest households are at higher risk for CHE than non-empty-nest ones. Based 37 38 on these findings, we suggest that special insurance be developed to broaden the 39 40 coverage of health services and heighten the reimbursement rate for empty-nest 41 on September 26, 2021 by guest. Protected copyright. 42 elderly in the existing health insurance schemes. Financial and social protection 43 44 interventions are also essential for identified at-risk subgroups among different types 45 of elderly households. 46 47 48 Keywords: catastrophic health expenditure, elderly, empty-nest, determinants, 49 50 China 51 52 53 54 55 56 57 58 59 2 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-010992 on 5 July 2016. Downloaded from 1 2 3 4 Strengths and limitations of this study 5 6 7 8 9 This study attempts to compare the catastrophic health expenditure 10 11 (CHE) prevalence between empty-nest and non-empty-nest elderly 12 13 14 households. 15 For peer review only 16 17 18 19 A cross-sectional study to examine the prevalence of CHE and its risk 20 21 factors among households with seniors was conducted in Shandong, 22 23 24 China. 25 26 27 28 29 30 31 Empty-nest elderly households are at higher risk for CHE than 32 33 http://bmjopen.bmj.com/ 34 non-empty-nest ones. 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 3 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 26 BMJ Open: first published as 10.1136/bmjopen-2015-010992 on 5 July 2016. Downloaded from 1 2 3 4 Introduction 5 6 With a significant increase in average life expectancy and a sharp decline in 7 8 fertility under the one-child policy in the past three decades, China experienced a 9 10 considerable increase in both absolute and relative numbers of elderly, and joined the 11 1-4 12 ranks of many other “aging societies” late in the 20th century . A report released in 13 January 2014 by National Bureau of Statistics of People’s Republic of China 14 15 estimatedFor that there peerwere 202.4 million review of people aged 60only and above at the end of 16 17 2013 in China, accounting for 14.9% of the total population5, and representing an 18 19 increase of 1.6% compared with 20106. In recent years, following this trend, a new 20 21 subpopulation of “empty-nest elderly” has emerged in China1. 22 23 Empty-nest elderly refers to those elderly with no children or whose children 24 25 have already left home. These older people either live alone (empty-nest singles) or 26 7 27 with a spouse (empty-nest couples) . A China Research Center on Aging (CRCA) 28 29 report shows that the number of empty-nest elderly reached 100 million in 2013, 30 accounting for about 50% of the total elderly population8. It is estimated that the 31 32 proportion of empty-nest elderly households will reach 90% by 20309. This 33 http://bmjopen.bmj.com/ 34 phenomenon has become an important social problem that cannot be ignored. The 35 36 health care problems facing this population is a critical issue that we will have to 37 38 address in the near future1-2,10. 39 40 According to CRCA data, of the 202.4 million elderly in 2013, more than 100 41 on September 26, 2021 by guest. Protected copyright. 42 million have non-communicable diseases (NCDs) and more than 37 million have 43 8 44 disabilities . This will result in an increase in health service needs, health care 45 utilization, and health expenditure among the elderly11-14. Some researchers have 46 47 demonstrated that the increase in the proportion of older people in a country is an 48 49 important driver of national health expenditure12,15-16. Like many other countries, 50 51 out-of-pocket (OOP) payments are a primary source of health financing in China17-19. 52 53 Coupled with a population with high health needs and poor financial resources, OOP 54 55 payments are likely to push the elderly into financial catastrophe. Previous studies in 56 57 China have indicated that households with elderly family members were at high risk 58 59 4 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-010992 on 5 July 2016. Downloaded from 1 2 3 of catastrophic health expenditure (CHE) 20-21. 4 5 Some studies have shown that empty-nesters have even poorer physical health 6 7 status, higher prevalence for chronic diseases, and lower income than 8 9 non-empty-nesters. Empty-nest households may face a greater risk of experiencing 10 11 CHE than non-empty-nest households22-25. Protecting people, especially for those 12 13 vulnerable people (e.g. older people), from CHE is a desirable objective of health 14 26-29 15 policy worldwideFor peer. Health insurance review has been seen as anonly effective way to protect 16 17 households from CHE. In China, the coverage of health insurance system has 18 increased to 95% by the end of 2014.Under a nearly universal coverage of health 19 20 insurance system, to identify the prevalence and intensity of CHE for empty-nest 21 22 elderly, and to compare the differences in CHE and its determinants between 23 24 empty-nest and non-empty-nest households are helpful for the development of 25 26 policies to protect such population from financial risk with ill health.