Incidence and determinants of catastrophic health expenditures and impoverishment in Pakistan

Reducing post-operative length of stay, is it worth the effort?

BACKGROUND

Studies show that reducing the length of hospital stay (LOS) for surgical patients leads to cost savings. We hypothesize that LOS has a nonlinear relationship to cost of care and reduction may not have a meaningful impact on it. We have attempted to define the relationship of LOS to cost of care. We utilized the itemized bill, generated in real time, for hospital services.

MATERIALS

Adult patients admitted under General, Neuro, and Orthopedic surgery over a 3-month period, with an LOS between 4 and 14 days, were the study population. Itemized bill details were analyzed. Charges in Pakistani rupees were converted to US dollar. Ethical exemption for study was obtained.

RESULTS

Of the 853 patients, 38% were admitted to General Surgery, 27% to Neurosurgery, and 35% to Orthopedics. A total of 64% of the patients had an LOS between 4 and 6 days; 36% had an LOS between 7 and 14 days. Operated and conservatively managed constituted 82% and 18%, respectively. Mean total charge for operated patients was higher $3387 versus $1347 for non-operated ones. LOS was seen to have a nonlinear relationship to in-hospital cost of care. The bulk of cost was centered on the day of surgery. This was consistent across all services. The last day of stay contributed 2.4%-3.2% of total charge.

CONCLUSIONS

For surgical patients, the cost implications rapidly taper in the postoperative period. The contribution of the last day of stay cost to total cost is small. For meaningful cost containment, focus needs to be on the immediate perioperative period.

Confronted With Death: Factors Affecting End of Life Decisions in the Intensive Care Unit

To determine how often care is limited at the end of life and the factors that are associated with this decision, we reviewed the medical records of all patients that passed away in the intensive care units (ICU) of Aga Khan University. We found that a majority of patients had Do-Not-Resuscitate orders in place at the time of death. Our analysis yielded 6 variables that were associated with the decision to limit care. These are patient age, sex, duration of mechanical ventilation, Glasgow Coma Scale (GCS) ≤8 at any point during ICU stay, GCS ≤8 in the first 24 hours following ICU admission, and mean arterial pressure <65 mm of Hg while on vasopressors in the first 24 hours following ICU admission. These variables require further study and should be carefully considered during end of life discussions to allow for optimal management at the end of life.

The inclusion of diagnostics in national health insurance schemes in Cambodia, India, Indonesia, Nepal, Pakistan, Philippines and Viet Nam

The Lancet Commission on Diagnostics highlighted a huge gap in access to diagnostic testing even for basic tests, particularly at the primary care level, and emphasised the need for countries to include diagnostics as part of their universal health coverage benefits packages. Despite the poor state of diagnostic-related services in low-income and middle-income countries (LMICs), little is known about the extent to which diagnostics are included in the health benefit packages. We conducted an analysis of seven Asian LMICs-Cambodia, India, Indonesia, Nepal, Pakistan, Philippines, Viet Nam-to understand this issue. We conducted a targeted review of relevant literature and applied a health financing framework to analyse the benefit packages available in each government-sponsored scheme. We found considerable heterogeneity in country approaches to diagnostics. Of the seven countries, only India has developed a national essential diagnostics list. No country presented a clear policy rationale on the inclusion of diagnostics in their scheme and the level of detail on the specific diagnostics which are covered under the schemes was also generally lacking. Government-sponsored insurance expansion in the eligible populations has reduced the out-of-pocket health payment burden in many of the countries but overall, there is a lack of access, availability and affordability for diagnostic-related services.

Socio-demographic and antenatal risk factors of brain tumor in children and young people: A matched case-control study from Karachi, Pakistan

Background

Brain tumors are a common cause of morbidity, disability, cognitive deterioration and mortality in children, even after treatment. Little is know about the specific causes. The study aimed to assess potential socio-demographic and antenatal factors in primary brain tumor (PBTs) in children and young people (CYP) in Karachi, Pakistan.

Designs and methods

A single center hospital based matched case control study in Karachi, Pakistan. Cases were defined as CYP aged between 5 and 21 years with any histological type and grade of primary brain tumor of any histology, stage or grade. Data were collected from parents of 244 patients at the selected center between 2017 and 2021 via telephonic interview. Controls were 5-21 years old CYP admitted with non-oncological diagnoses matched on age and sex. Matched Odds Ratios for predictors of brain tumor in children were derived. Those of statistical significance were included in a multivariable logistic regression model.

Results

In the adjusted model, lower paternal education (matched adjusted odds ratio (maOR) 2.46; 95% CI 1.09-5.55), higher household monthly income (maOR 3.4; 95% CI 1.1-10.2), antenatal paternal use of addictive substances (maOR 19.5; 95% CI 2.1-179.8), and antenatal maternal use of analgesics during pregnancy (maOR 3.0; 95% CI 1.2-7.9) were all independently predictive of brain tumors.

Conclusion

This matched case-control study found novel associations between maternal use of analgesics, paternal use of addictive substances, higher household income, and lower paternal education and Primary Brain Tumors in Children and Young People. Longitudinal multicenter studies will be required to test these associations prospectively.