ASSESSING CATASTROPHIC HEALTHCARE EXPENDITURES IN THE EMERGENCY SURGICAL CARE OF CHILDREN WITH INTUSSUSCEPTION: INSIGHTS FROM A TERTIARY HOSPITAL IN NIGERIA

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I. Chukwu¹, S. Ekpemo¹ , L. Okonkwo¹, C. Uchendu¹, C. Isaac-Chukwu ², U. Ezomike³

1. Department of Surgery, Federal Medical Centre, Umuahia
2. Accounts Department, University of Nigeria Teaching Hospital, Enugu.
3. Sub-department of Pediatric Surgery, University of Nigeria Teaching Hospital, Enugu.

Abstract

Background: Emergency and essential surgery should be affordable, accessible, and timely. However, this is not the narrative in our setting as patients present late with complications requiring operative treatment which has an attendant healthcare expenditure often tending towards household income depletion. This study assessed the proportion of patients who incurred catastrophic healthcare expenditures following operative treatment for intussusception in our facility. Catastrophic healthcare expenditure was defined as spending >10% of Gross Domestic Product per capita. Health care expenditures were reported in US dollars.

Materials & Methods: A prospective cohort study of children 15 years of age and younger who were operatively treated for intussusception at the Paediatric Surgery unit of Federal Medical Centre, Umuahia from January 2017 to December 2020.

Results: Sixty-six (84.6%) out of the 78 children who presented with intussusception within the period had 72 laparotomies. Only 6.1% (4/66) of the patients were enrolled in the National Health Insurance Scheme. The insured patients presented earlier than the uninsured patients (median 4 versus 6 days, p=0.04). The median total health expenditure was $458 (Inter Quartile Range $372.4 – $707.1) for the uninsured patients. The total health expenditure exceeded 10% of GDP per capita ($209.71) for all the uninsured patients but not for any of the insured patients, giving an overall catastrophic expenditure rate of 93.9%(62/66). The median daily health expenditure was about one-third of 10% of GDP per capita for those who were uninsured.

Conclusion: All the uninsured patients experienced catastrophic health
expenditures; with onset from the fourth day on admission. Financial risk protection by implementing payment strategies aimed at reducing user fees to non-catastrophe levels may help.

Keywords: Catastrophic health expenditure; Children; Intussusception; Out-of-pocket payment.

Introduction

Acute intestinal obstruction is a priority area as contained in the third edition of the Disease Control Priorities (DCP).¹ Intussusception is the commonest cause of acute intestinal obstruction in infancy and early childhood.² Intussusception occurs when a segment of the bowel invaginates into an adjacent part of thev bowel leading to ischemic necrosis of the bowel; which can be life-threatening.^1,3 Intussusception has an annual incidence of 34 in 100 000 infants; accounting for 1 death in every 10 admissions in under-5 in Africa.⁴ This suggests a significant contribution to infant and under-5 mortality rate^.1,2 A large portion of patients in Africa still present late with complications with a tendency to operative treatment.^2,3-5 It has been noted that the cost of health care for intussusception is higher with delayed presentation. With the over-reliance on out-of-pocket (OOP) expenditure in sub-Saharan Africa, many families are likely to forgo health care rather than experience financial hardship.^3,6-11 This implies a significant threat to Universal Health Coverage and attainment of Sustainable Development Goal (SDG).³

Financial risk protection for children requiring emergency surgery guarantees access to safe and quality health services without incurring catastrophic health expenditure which has been defined as out-of-pocket payment of greater than 40% of non-food household expenditure or greater than 10% annual household expenses.^8,12-14 When the annual household expenditure is not known or unreliable, the Gross Domestic Product per capita may be used.^14,15 Three point seven billion people, globally, are at risk of catastrophic health expenditure if they will require surgery; with 81.3 million people driven to financial catastrophe annually.¹⁵ The risk of experiencing catastrophic health expenditure in the surgical care of children is disproportionately high in the low-and middle-income countries with many households incurring debt, selling assets, anxiety, depression, disruption of family relationships, neglect of siblings and sacrificing basic goods and services including education.^8,10,16-18

Operative treatment for intussusception like other emergency surgeries in children are unplanned and unavoidable.^3,5 The Global Initiative for Children’s Surgery (GICS), in a recent report, stated that data related to financial catastrophe in the surgical care of children is scant.¹⁶ There is a need to quantify the proportion of patients who encounter financial catastrophe in the operative treatment of intussusception. This will guide, inform and advance local, national, regional and global policies on the care of these children especially where financial risk protection is concerned. This study adds to the body of work dealing with the problem of access to timely emergency and essential surgical care for children in Africa. It uncovers the proportion of families who undergo household income depletion in other to get emergency surgical care for intussusception while highlighting the role of healthcare insurance.

Our aim was to assess the proportion of patients who will experience financial catastrophe following operative treatment of intussusception among the insured and uninsured children. We also sought to identify the effect of the health insurance on time to presentation, time to surgery, length of hospital stay and mortality in these patients. We hypothesized that a significant proportion of children’s families incur financial catastrophe during hospital admission for operative treatment of intussusception especially those who are uninsured.

MATERIAL AND METHODS
Study design and setting
A prospective cohort study of children 15 years of age and younger who were operatively treated for intussusception at the paediatric surgery unit of Federal Medical Centre, Umuahia from 1st January 2017 to 31st December 2020. This study was conducted in line with Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines. Federal Medical Centre, Umuahia is a public tertiary hospital situated in the South-eastern part of Nigeria with a well-established Paediatric Surgery Unit. The study was approved by the Health Research and Ethics Committee of Federal Medical Center, Umuahia with reference number: FMC/QEH/G.596/Vol.10/545. The minimum sample size for this study was defined using the WHO recommendation of the sample size for health studies19 and determined to be 59. Using the proportion of children in the low and middle income countries who encountered financial catastrophe following surgical care as estimated in a previous study, 94.9%16 and a confidence level of 90%; 59 patients will be required to estimate the proportion of patients with catastrophic health expenditure allowing a precision of 5% and an attrition rate of 10%.