The economic burden of pediatric gastroenteritis to Bolivian families: a cross-sectional study of correlates of catastrophic cost and overall cost burden

Rachel M Burke 0 1 Emily R Smith 1 Rebecca Moritz Dahl 1 Paulina A Rebolledo 1 2 Maria del Carmen Caldern 7 Beatriz Caipa 6 Edgar Chavez 5 Rolando Pinto 4 Luis Tamayo 9 Carlos Tern 8 ngel Veizaga 5 Remy Zumaran 6 Volga Iiguez 3 Juan S Leon 1 10 11 0 Laney Graduate School, Emory University , Atlanta, GA , USA 1 Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta, GA , USA 2 Division of Infectious Diseases, Emory University School of Medicine , Atlanta, GA , USA 3 Instituto de Biologia Molecular y Biotecnologia, Universidad Mayor de San Andres , La Paz , Bolivia 4 Hospital del Nino Manuel Ascencio Villarroel , Cochabamba , Bolivia 5 Hospital Boliviano Holandes , El Alto , Bolivia 6 Hospital Materno-Infantil , La Paz , Bolivia 7 Hospital Mario Ortiz Suarez , Santa Cruz , Bolivia 8 Centro Pediatria, Hospital Albina R. Patino , Cochabamba , Bolivia 9 Hospital del Nino , La Paz , Bolivia 10 Hubert Department of Global Health, Rollins School of Public Health, Emory University , Atlanta, GA , USA 11 Department of Environmental Health, Rollins School of Public Health, Emory University , Atlanta, GA , USA Background: Worldwide, acute gastroenteritis causes substantial morbidity and mortality in children less than five years of age. In Bolivia, which has one of the lower GDPs in South America, 16% of child deaths can be attributed to diarrhea, and the costs associated with diarrhea can weigh heavily on patient families. To address this need, the study goal was to identify predictors of cost burden (diarrhea-related costs incurred as a percentage of annual income) and catastrophic cost (cost burden 1% of annual household income). Methods: From 2007 to 2009, researchers interviewed caregivers (n = 1,107) of pediatric patients (<5 years old) seeking treatment for diarrhea in six Bolivian hospitals. Caregivers were surveyed on demographics, clinical symptoms, direct (e.g. medication, consult fees), and indirect (e.g. lost wages) costs. Multivariate regression models (n = 551) were used to assess relationships of covariates to the outcomes of cost burden (linear model) and catastrophic cost (logistic model). Results: We determined that cost burden and catastrophic cost shared the same significant (p < 0.05) predictors. In the logistic model that also controlled for child sex, child age, household size, rural residence, transportations taken to the current visit, whether the child presented with complications, and whether this was the child's first episode of diarrhea, significant predictors of catastrophic cost included outpatient status (OR 0.16, 95% CI [0.07, 0.37]); seeking care at a private hospital (OR 4.12, 95% CI [2.30, 7.41]); having previously sought treatment for this diarrheal episode (OR 3.92, 95% CI [1.64, 9.35]); and the number of days the child had diarrhea prior to the current visit (OR 1.14, 95% CI [1.05, 1.24]). Conclusions: Our analysis highlights the economic impact of pediatric diarrhea from the familial perspective and provides insight into potential areas of intervention to reduce associated economic burden. - Background Worldwide, acute gastroenteritis causes substantial morbidity and mortality in children under five years of age, with 1.4 billion episodes and 1.7 to 3 million deaths each year [1]. Diarrhea accounts for 21% of all child deaths in low and middle income countries (LMIC) [2]. Gastroenteritis presents an economic burden to both healthcare systems and patient families [3-5]. Though various studies have attempted to quantify the costs associated with pediatric diarrhea from the state perspective [3-12], fewer studies have specifically examined the perspective of the patients family [8-10,13-16], despite the burden that these costs may represent. Though health insurance may cover some costs associated with pediatric diarrhea, patient families often still incur substantial direct (i.e., out-of-pocket) and indirect (i.e., lost income) expenses [16-19]. Studies have estimated average total familial costs (direct and indirect) per episode of hospitalized pediatric diarrhea ranging from US$19.86 in Kenya (2007USD [6]) to US$215.88 in Mexico (2003USD [11]). Direct costs, alone, for a pediatric diarrhea episode have ranged from US$12.89 per case in Brazil (2007USD [13]) to US$31.83 per case in Vietnam (2004USD [4]). In a low-resource setting, these costs can represent a large proportion of a familys overall budget. In one study in India, direct costs incurred per diarrheal episode ranged 2.2 5.8% of the households annual income [14]. The ratio of total incurred costs for a single diarrheal episode as a percentage of annual family income, termed the cost burden, has been infrequently studied. Nonetheless, large cost burdens incurred from healthcare expenses can have a serious effect on a familys overall current and future economic situation, especially for families already on the edge of poverty (reviewed in [20,21]). Healthcare costs that cause poverty (e.g. by forcing a family to spend money needed for food or other basic necessities) are termed catastrophic [22]. There is little consensus in the literature as to the exact calculations and cut-offs that are most appropriate for defining catastrophic costs [23,24]. Some advocate the use of a cut-off based on expenditures as a percentage of capacity to pay (non-subsistence spending) [22,25,26]. However, when detailed information on household expenditures is not available, the use of a cut-off based on cost burden may be useful. While a cost burden of 10% of annual income is often used to define catastrophic cost [24,27], lower limits can also be catastrophic for poor households [21,28]. For example, in a study of catastrophic healthcare costs in Thailand, a cost burden of 10% of monthly income was utilized, which is equivalent to approximately 1% of annual income [29]. Bolivia has one of the lower GDPs in South America (per-capita 2013 GDP US$5,500) [30] and has high rates of child mortality. As of 2012, for every 1,000 live births in Bolivia, 41 children die before age five, with an estimated 8% of these deaths from diarrhea [31]. The cumulative financial impact of these diarrheal episodes may be severe in this setting, where 30% of the population lives on under US$2 per day (2009 est.) [30]. Although Bolivia does have a health program (Seguro Universal Materno-Infantil, SUMI) that covers children under five, families must register to benefit from free care [32]. In addition, free treatment to registered families may not be enforced (e.g. oversight, intentionally), benefits are only available at public healthcare settings, and not all potential treatments are eligible for coverage. Further, if medications are out of stock at the treating facility, caregivers may need to purchase drugs from pharmacies where SUMI does not apply. Thus, Bolivian families may still incur substantial costs related to pediatric diarrhea. The goal of this study was to characterize the (...truncated)