Economic burden and determinants among hospitalized patients with epilepsy in Thailand

Abstract

Background

Epilepsy has a significant impact on individuals’ lives, as well as on society and the economy, due to its unpredictable nature and the financial burden it places on those affected. Even though Thai citizens hold health benefits or health insurance, excess costs can occur; thus, this study aimed to describe the direct medical costs among hospitalized patients with epilepsy from both social and patient perspectives. Moreover, the factors associated with costs were investigated.

Methods

This was a prevalence-based cost-of-illness study using data from the Thailand National Health Security Office database. Patients who were diagnosed with epilepsy (ICD-10 code G40) and admitted to the hospital in the fiscal year 2022 were included. Direct medical costs were reported from societal and patient perspectives. A generalized linear model with gamma distribution and log-link function was employed to investigate the factors influencing these costs.

Results

Among 31,635 epilepsy visits, the mean direct medical costs from a societal and patient perspective were 1,043.45 PPP-USD and 14.02 PPP-USD per visit, respectively. From a societal perspective, patients who underwent procedures experienced a substantial increase of 120.9% in costs compared to those without procedures, while hospital stays exceeding one week showed a significant 750.1% increase in costs compared to shorter stays. Furthermore, female sex, older age, and the presence of comorbidities or complications significantly increase costs. From the patient’s perspective, those with comorbidities or complications during admission had a 56.0% increase compared to those without such conditions. Moreover, elderly patients, those who underwent procedures, and individuals with extended hospital stays were associated with increased costs.

Conclusions

Factors influencing costs were hospital stay duration, comorbidities or complications, and types of procedures.

Introduction

Epilepsy is a common medical disorder affecting individuals of all ages, races, and social stratifications worldwide [1, 2]. A previous study estimated the incidence rate of epilepsy to be 47–61 per 100000 person-years [3,4,5]. Population estimates from national registers have indicated an epilepsy prevalence of 0.7% [6]. Individuals with epilepsy experienced an average reduction in life expectancy (11.84 years in males [95% CI: 11.66–12.00)] and 10.91 years in females [95% CI: 10.70–11.11]) [7].

Epilepsy is an unpredictable condition that increases the risk of injury and mortality in patients, while also affecting their quality of life, mental well-being, and living in society. Moreover, these effects can increase household stress levels [8,9,10,11]. In addition, patients with epilepsy and their families experience financial burdens associated with treatment expenses, including both direct and indirect costs, resulting from the patient’s reduced capacity to work and engage in daily life [12,13,14], including early retirement, unemployment, reduced working hours, and seizure-related absenteeism [12]. Furthermore, factors related to direct costs encompass insurance coverage and the level of hospital care in Thai patients with epilepsy [15].

Epilepsy treatment takes a long time and has long-term effects on the economic status of patients and their families. Direct costs represent nearly half (39.0- 48.5%) of the total costs that epilepsy patients and their families pay [16, 17]. The direct costs of treating epilepsy patients in different countries varied across income levels: low-income, lower-middle income, upper-middle income, and high-income were 54, 359, 1986, and 3160, respectively. The direct healthcare cost in Southeast Asia is $764 per person [18].

Previous direct cost studies in Thailand have focused on specific demographics, such as children undergoing surgery or expenses associated with particular treatments [19, 20]. However, there are no details of the direct medical costs for the entire hospitalized patient’s population nationwide. Almost all Thai citizens have healthcare coverage supported by the government. However, some expenses may not be covered, especially for additional treatments beyond standard care. Therefore, healthcare costs consist of both government-supported expenses and patient out-of-pocket payments. Thus, this study aimed to examine the direct costs across the entire national hospitalized patient’s population from societal and patient perspectives. This can be beneficial in enhancing cost management services and developing a standard of care for individuals with epilepsy.

Methodology

Study design and study population

This prevalence-based cost-of-illness study was performed from societal and patient perspectives using the Thailand National Health Security Office (NHSO) database. This database covers approximately 80% of Thailand’s population [21]. The inclusion criteria were patients diagnosed with epilepsy using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) with code G40, and admitted to the hospital during the fiscal year 2022 (October 1, 2021, to September 30, 2022). Patients who were discharged with (1) normal delivery, (2) undelivered, (3) normal child discharged with mother, (4) normal child discharged separately, and (5) stillbirths (a total of 8 cases) were excluded from this study.

The study outcome was an assessment of the direct costs associated with healthcare. Two perspectives were covered: the societal, which included hospital expenditures and costs covered by health insurance schemes, and the patient, which included prices paid by individuals for health treatments not covered by their insurance.

Statistical methods

Categorical data are reported as frequency and percentage, while continuous data are reported as mean with standard deviation (SD), median, maximum, and minimum. Direct medical cost data were recorded in Thai Baht (THB) and then converted to 2022 purchasing power parity in US dollars (PPP-USD) (11.736 THB = 1 PPP-USD) [22], which was reported as the mean and SD, including both societal and patient perspectives. Subgroup analysis of costs was conducted based on demographic characteristics. Generalized linear models (GLMs) with gamma distribution and log-link function were used to investigate the driving factors of costs. Statistical analyses were performed using the Stata 15.0 software (Stata Corp.).

Results

Patient demographic and clinical characteristics

Based on the data of individual patients (n = 24,053), most were male (66.0%) and covered by the welfare scheme health insurance (63.9%). More than 35% of the participants were over 50 years of age. Moreover, 81.0% of the patients had only one admission. There were 31,635 visits, with most hospital stays less than two days. Interestingly, 94.4% of the patients were discharged with improved status (Table 1).

Table 1 Characteristics of epilepsy patients

Medical direct cost by societal perspective

From a societal perspective, the overall direct cost per visit for 31,635 visits was 1,043.45 PPP-USD (SD 2,602.91) or 413.38 PPP-USD per day (SD 349.74). In the subgroup analysis, the mean of patients with hospital stays longer than a week was 5,738.35 (SD 9,434.33). The Social Security Scheme (SSS) presented the highest mean direct cost at 6,753.08 (SD 14,776.65) (Table S1).

Patients undergoing procedures had a mean direct cost per visit of 1,678.27 (SD 3,806.53), three times higher than that of non-procedures. Patients who underwent procedures such as non-operative intubation of the gastrointestinal and respiratory tracts, continuous invasive mechanical ventilation, or transfusion of blood and blood components had approximately three times the mean direct cost compared to those who did not undergo such procedures (Table S1).

Several factors influence direct medical costs. Male patients showed a 4.8% increase in costs compared to females. The elderly presented a 3.9% rise in costs compared to children under 18. Patients with comorbidities or complications during admission showed a 33.2% increase compared with those without comorbidities. The cost of the procedures increased by 120.9% compared to patients who did not undergo any procedures. Notably, hospital stays exceeding one week experienced a significant 750.1% increase in cost compared to patients without prolonged stays (Table 2). The five common comorbidities and complications that incurred the greatest costs were shock, respiratory failure, pneumonia, central nervous system (CNS) infection, and acute kidney failure (Table S2). Additionally, continuous invasive mechanical ventilation emerged as the procedure with the most significant impact on the cost (Table S3).

Table 2 Factors driving direct medical costs by societal perspective (n = 31635 visits)

Medical direct cost by patient perspective

From an individual perspective, the assessment of overall direct cost per visit had a mean of 14.02 PPP-USD (SD 7.17) or 6.29 PPP-USD per day (SD 26.20). The cost increase was related to the length of hospital stay and the number of patients whose hospital stay was longer than a week. The mean was 57.84 (SD 262.29). When the discharge status was dead, the mean direct cost was 107.00 (SD 500.28) (Table S4).

The direct cost per visit of primary health insurance schemes in Government or State Enterprise Officers (mean 6.73 PPP-USD) or Social Security Scheme (mean 2.25 PPP-USD) has a lower cost than the patient who has Welfare scheme (mean 14.04 PPP-USD) or Universal Coverage Scheme (mean 14.55 PPP-USD) (Table S4).

Patients who underwent procedures had a higher mean direct cost per visit than those who did not have procedures, except for anatomic and physiologic measurements and manual examinations of the nervous system and sensory organs (Table S4).

Several factors influenced the direct medical costs. Specifically, the Elderly reported an 18.3% increase in costs compared with children under 18. Patients with comorbidities or complications during admission showed a 56.0% increase compared with patients without these conditions. Patients undergoing procedures incurred a substantial increase of 29.5% in costs compared with those without a procedure. Notably, patients with hospital stays exceeding one week presented a significant 603.8% increase in costs compared to patients without prolonged stays (Table 3). The five common comorbidities and complications with the most significant costs were shock, pneumonia, respiratory failure, heart disease, and chronic renal failure (Table S2). Additionally, diagnostic procedures for the spinal cord and spinal canal structures emerged as the procedure with the greatest impact on cost (Table S3).

Table 3 Factors driving direct medical costs by patient perspective (n = 31635 visits)

Discussion

Medical direct cost by societal perspective

The societal perspective represents society’s most significant cost of medical care among hospitalized patients. The patient does not pay these expenses but is covered by the welfare state or another agency representing society and supporting those costs.

From a societal perspective, the overall direct cost per visit for 31,635 visits was 1,043.45 PPP-USD, representing approximately 5.0% of Thailand’s GDP per capita (20,772.3 PPP-USD in 2022) [23]. In the subgroup analysis, the mean direct cost for patients with a hospital stay longer than a week, the mean was 5,738.35 PPP-USD. The patients under the SSS presented the highest mean direct cost. Additional data analysis revealed that SSS patients had longer hospital stays (average 7.82 days), which was more than double compared to other healthcare schemes. This extended length of stay likely contributed to higher mean direct costs compared to other schemes. The direct cost per visit from a societal perspective in Thailand is higher than that from the patient perspective because nearly 100% of Thai citizens have the right to receive treatment without incurring personal expenses. However, if the treatment period is prolonged, additional costs will be associated with hospital stay, including room and board fees, patient meals, and other medical expenses, resulting in higher overall costs. When comparing studies of countries classified according to the World Bank income category, specifically those in the upper-middle-income group like Thailand, it was found that Thailand’s overall direct cost is higher than that of China but lower than those of Bulgaria and Mexico. However, these findings are lower than the direct costs reported in high-income countries such as Korea, the United Kingdom, and the United States [18]. Additionally, the findings were higher in the same region than in India, Indonesia, and China [18, 24, 25].

Several factors influenced the direct medical costs. Specifically, patients undergoing procedures incurred a substantial increase of 120.9% in costs compared with those without a procedure. Essential and common procedures, such as non-operative intubation of the gastrointestinal and respiratory tracts, continuous invasive mechanical ventilation, or transfusion of blood and blood components, significantly impact costs. Consequently, patients who undergo these procedures incur higher costs per visit than those who do not. This finding is consistent with those of previous studies in China and the United States, where procedures such as mechanical ventilation, surgery, and blood product administration have been reported to increase the total cost of patient care [26, 27].

Notably, patients who stayed in the hospital for more than a week presented a 750.1% increase in cost compared to patients without prolonged stays. Patients who require prolonged beds usually have difficulty controlling symptoms and require complex treatment, resulting in high costs. The results of this study align with those of previous studies in China, Oman, and Turkey, which reported that the length of hospital stay is associated with higher costs [27,28,29].

Medical direct cost by patient perspective

These are the costs patients must pay for disease care. They represent expenses not covered by the welfare state, including non-reimbursable medical expenses the patient must bear.

From an individual perspective, the mean overall direct cost per visit had a mean of 14.02 PPP-USD, representing approximately 0.1% of Thailand’s GDP per capita (20,772.3 PPP-USD in 2022) [23]. The Thai population has a medical care scheme supported by the government. In most patients, no treatment costs result in low costs from the patient’s perspective. Expenses typically arise from costs exceeding reimbursement rights or special requests, such as private rooms or medications that are not eligible for reimbursement. Although Thailand has comprehensive medical coverage, out-of-pocket costs are higher than those in some northeastern South African countries [30]. The direct cost per visit of primary health insurance schemes in Government or State Enterprise Officers (mean 6.73 PPP-USD) or Social Security Scheme (mean 2.25 PPP-USD) has a lower cost than the patient who has Welfare scheme (mean 14.04 PPP-USD) or Universal Coverage Scheme (mean 14.55 PPP-USD). The welfare and universal coverage schemes have higher costs from the patient perspective because they represent the fundamental rights of Thai citizens, which do not cover certain items such as room rates and special meals. By contrast, Government or State Enterprise Officers’ schemes cover these expenses. The Social Security Scheme is a beneficial medical care scheme for working-age workers who work in private organizations and are not official government workers. Most individuals can work, are healthy, and often experience minor illnesses. The results of this study are similar to those of studies in the United States, which reported different rights to medical treatment resulting in different costs, with commercially insured patients incurring higher costs than Medicaid and Medicare patients with supplemental insurance [31, 32].

Several factors influenced the direct medical costs. Specifically, patients with comorbidities or complications during admission showed a 56.0% increase compared with those without comorbidities. The five most common comorbidities and complications that exerted the most significant costs were shock, pneumonia, respiratory failure, heart disease, and chronic renal failure. According to the study results, more than 80% of patients had comorbidities or complications. These patients are more challenging to treat and incur higher costs than regular patients. In particular, those with complications have higher costs. Previous studies have shown that comorbidities or complications during admission, such as diabetes, chronic pulmonary disease, stroke, dementia, myocardial infarction, congestive heart failure, depression, and CNS infections [27, 31, 33], are associated with increased costs.

Conclusions

Direct medical costs from a societal perspective are higher than those from a patient perspective because the Thai population has a comprehensive treatment coverage scheme, resulting in minimal out-of-pocket expenses. Factors influencing costs from both perspectives include the length of hospital stay: extended stays lead to higher costs. Patients with comorbidities or complications and those who underwent the procedures also had increased costs.

However, it is difficult to predict epilepsy. Emphasizing treatment and symptom control is crucial to prevent severe relapses and reduce the need for hospital admissions and procedures, thereby lowering costs from a societal perspective. Moreover, additional government coverage benefits can further reduce costs from a patient perspective.

Limitations

Although this study examined medical direct costs in a large population, this study has some limitations. First, it only examines hospital-related medical direct costs, excluding outpatient care expenses. Second, due to the use of secondary data, we couldn’t capture indirect costs (such as productivity loss and caregiver burden) or non-medical direct costs (including transportation and special equipment). A prospective study incorporating these additional cost components in out-patients would provide a more comprehensive understanding of the total economic burden of epilepsy.