Catastrophic health expenditures in acute coronary syndrome patients at Dokuz Eylul University Hospital and affecting factors

Introduction and Aim: Out-of-pocket Health Expenditures (OOPs) and Catastrophic Health Expenditures (CHE) indicators are important indicators against financial effects of the illness. The aim of this study is to determine CHE and OOPs in the patients applied to Dokuz Eylül University Hospital between October-December 2014 owing to Acute Coronary Syndrome (ACS) pre-diagnosis and whose treatment had been initiated and also identify affecting factors. Method : The study is composed of two phases as quantitative and qualitative. In the first phase, patients hospitalized due to ACS at the Dokuz Eylül University hospital involved between October-December 2014 were reached through telephone calls. The first interview was carried out in the first three days following patient's discharge and the second one was performed one month later, the date when treatment of patients had been commenced. Qualitative data were collected in the second phase of the research. In-depth interviews were obtained by contacting a total of 15 individuals including health care providers (3 lecturers, 3 residents), hospital executive managers (3) and patients (3 with CHE, 3 without CHE). Interviews were performed between January-March 2015. Dependent variables of the research are OOPs and CHE variables. OOPs is expenses that patient spends within one month when his/her complaint due to ACS has initiated. CHE means that if it is 10% exceed of threshold value of monthly income for per person compared to equivalent household income. SPSS 15.0 programme was used in quantitative analyses. All interviews were transcribed to texts for qualitative analyses, than codes and sub-codes were created by reading and analysed by the content analysis method. Ethics committee approval and official permissions were obtained for the research. Findings: Of 208 individuals hospitalized with ACS pre-diagnosis, 83.2% (173) were reached in research period. While 10.1% (21 individuals) denied participating in the study, 6.7% (14 persons) could not be reached. The mean OOPs was 201 . Fifty-nine percent of ACS patients had OOPs while CHE was determined in 23.1%. While unpaid medical equipment by Social Security Institution (SSI) accounted for 58% of a total of OOPs (mean 115.9 ), in the second line contribution fee of academic staff examinations (private examination) forming 15% of OOPs (mean 30.7 ). In addition, 40% of patients had OOPs at the pharmacy (mean 16.5 ). When the income gets lower, CHE rate increases significantly (p:0.036). With regard to occupational class, there was a significant difference between self-employed&employer and the other groups (CHE rate 41%) (p:0.013). Moreover, CHE rate was significantly higher for those recommended to have surgical treatment (54%) compared to those not recommended (20%) and those doing OOPs in return for loan (88%) compared to those doing the payment with their monthly income (12%) (respectively, p:0.006 and p:0.0001). There was no significant difference statistically in terms of CHE rate according to sex, age group, education level, social security type (p>0.05). In the qualitative part of the research, SSI, medical practices regulations and health system came into prominence for three groups (doctors, patients and managers) at similar levels. University hospital problems and ethical issues were mostly mentioned by hospital executive managers. Payment system based on performance was determined to be as common issue, mostly mentioned by hospital executives and doctors. The effect on expenditures by hospital executives was brought to the fore by doctors while the efffect of doctors was emphasized by patients. Private health services and patients' expectations, however, were most commonly highlighted issue by both patients and doctors. As a result of qualitative analyses, the main theme emerged was health reforms (Transformation Programme in Health). Result: SSI applications do not sufficiently protect patients applying to university hospital with ACS in terms of OOPs and CHE. It draws attention that health transformation programme increases OOPs and CHE and creates new terms and concepts such as payment based on performance, medical practices regulations, ethical issues and privatization in health. The negative characteristics of these reforms should be retackle, corrected to reduce OOPs/CHE and repayment cover should be extended by SSI for patients with ACS.