Health and long-term care of the elderly with dementia in rural Thailand: a cross-sectional survey through their caregivers

OBJECTIVE

To describe the circumstances of the elderly with dementia and their caregivers' characteristics in order to examine factors related to activities of daily living (ADL) and household income to propose a long-term care policy for rural areas of Thailand.

SETTING

A cross-sectional study at the household level in three rural regions of Thailand where there were initiatives relating to community care for people with dementia.

PARTICIPANTS

Caregivers of 140 people with dementia were recruited for the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Socioeconomic characteristics including data from assessment of ADL and instrumental ADL and the Thai version of Resource Utilisation in Dementia were collected. Descriptive statistics were used to explain the characteristics of the elderly with dementia and the caregivers while inferential statistics were used to examine the associations between different factors of elderly patients with dementia with their dependency level and household socioeconomic status.

RESULTS

Eighty-six per cent of the dementia caregivers were household informal caregivers as half of them also had to work outside the home. Half of the primary caregivers had no support and no minor caregivers. The elderly with dementia with high dependency levels were found to have a significant association with age, dementia severity, chance of hospitalisation and number of hospitalisations. Though most of these rural samples had low household incomes, the patients in the lower-income households had significantly lower dementia severity, but, with the health benefit coverage had significantly higher chances of hospitalisation.

CONCLUSION

As the informal caregivers are the principal human resources for dementia care and services in rural area, policymakers should consider informal care for the Thai elderly with dementia and promote it as the dominant pattern of dementia care in Thailand.

Forecasting imbalances of human resources for health in the Thailand health service system: application of a health demand method

BACKGROUND

For an effective health system, human resources for health (HRH) planning should be aligned with health system needs. To provide evidence-based information to support HRH plan and policy, we should develop strategies to quantify health workforce requirements and supply. The aim of this study is to project HRH requirements for the Thai health service system in 2026. HRH included in this study were doctors, dentists, nurses, pharmacists, medical technicians (MTs), physiotherapists (PTs), and Thai traditional medicine (TTM) practitioners.

METHODS AND RESULTS

The study mainly relied on the secondary data in relation to service utilization and population projection together with expert opinions. Health demand method was employed to forecast the HRH requirements based on the forecasted service utilizations. The results were then converted into HRH requirements using the staffing norm and productivity. The HRH supply projection was based on the stock and flow approach in which current stock and the flow in and out were taken into account in the projection. The results showed that in 2026, nurses are likely to be in critical shortages. The supply of doctors, pharmacists, and PTs is likely to be surplus. The HRH requirements are likely to match with the supply in cases of dentists, MTs, and TTM practitioners.

CONCLUSION

In 2026, the supply of key professionals is likely to be sufficient except nurses who will be in critical shortages. The health demand method, although facing some limitations, is useful to project HRH requirements in such a situation that people are accessible to health services and future service utilizations are closely linked to current utilization rates.

Schizophrenia interventions in Vietnam: primary results from a cost-effectiveness study

Schizophrenia is a highly disabling mental health disorder that imposes a considerable economic burden on a health care system. This paper aimed to examine the cost and effectiveness of alternative pharmaceutical interventions and the effects of family intervention (FI) for schizophrenia from the government perspective in order to introduce the most cost-effective intervention applicable to Vietnam. A Markov model was developed to estimate costs and health outcome over patients' lifetimes when using typical and atypical antipsychotic drugs, alone or in combination with family intervention. Health outcome was measured in terms of disability-adjusted life years averted. Monte Carlo simulation was used for uncertainty analysis. According to our findings, interventions using typical or atypical drugs combined with FI were found to be the most effective and least costly compared to a 'do-nothing' scenario. Interventions using atypical drugs alone were estimated to be much less favourable due to a considerably higher cost. This is a very first attempt on cost-effectiveness analysis of interventions for schizophrenia in Vietnam, and recommendations are made for future research to determine the most cost-effective intervention.

Economic burden of schizophrenia: empirical analyses from a survey in Thailand

BACKGROUND

Evidence consistently indicates that schizophrenia is a costly disease although it is not a high prevalence disorder. There are a few studies in developing countries but no study in Thailand reporting the cost of schizophrenia from a societal perspective. Health policy makers need to be aware of the cost of health care for people with schizophrenia as well as the economic burden on patients and families.

AIMS OF THE STUDY

This study aims to provide a detailed breakdown of the costs attributed to schizophrenia including the consumption of public health care resources by people with schizophrenia and the negative consequences on patients and families due to productivity losses.

METHODS

Data from a survey conducted in 2008 among people in treatment for schizophrenia were used to estimate annual medical costs for treatment including outpatient services, hospitalization and patient travel. Indirect costs were estimated for reported productivity losses of patients and families. Uncertainty analysis was performed using Monte Carlo simulation methods. We tested the sensitivity of varying assumptions about market wages to estimate productivity losses. All cost estimates are adjusted to 2008 using the Consumer Price Index and reported in Thai baht (THB). The average annual exchange rate of Thai baths to one US dollar was 33.5 in 2008.

RESULTS

The annual overall cost of schizophrenia was estimated to be THB 87 000 (USD 2600) (95% CI: 83 000, 92 000) per person or THB 31 000 million (USD 925 million) (95% CI: 26 000, 37 000) for the entire population with schizophrenia in Thailand. Indirect costs due to high unemployment, absenteeism and presenteeism of patients and families accounted for 61% of the total economic burden of schizophrenia. The largest component of direct medical cost was for hospitalizations (50%), followed by outpatient services and drug costs. Sensitivity analyses suggest that using labor force survey and socioeconomic status survey provided similar results, while lost productivity when the minimum wage was used was significantly less.

DISCUSSION

Productivity loss due to unemployment is the major contributor to the cost of schizophrenia. Due to data unavailability we did not include intangible costs (e.g. costs associated with pain and suffering or impact on quality of life) and direct non-health care costs (e.g. costs related to law enforcement and the criminal justice system). The survey sample is representative of only people who were in contact with mental health services and is not necessarily representative of all people with schizophrenia.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

In priority setting it is important that policy makers are aware of the high direct and indirect costs of schizophrenia. Providing optimal treatment (e.g. medication in combination with psychosocial interventions) could reduce some costs such has hospitalization but this may require increased investment in mental health care and time spent by patients and caregivers.

Using utilisation data to estimate future demand for medical internists: the impact of demographic demand driver in Thailand

The demand for medical doctors can be estimated in many ways. The most challenging approach is the model based on population demand and anticipated contextual factors. The eighth national medical education meeting of Thailand in 2009 called for the need to estimate future demand for medical specialists in Thailand to proper plan for postgraduate trainings of royal colleges of medical specialists. This research was to estimate future demand for medical internists in 2021 in Thailand using utilisation data as the proxy of population demand for medical care. Inpatient data of 2009 from the universal coverage and the civil servant medical benefit schemes were grouped into the Thai diagnosis related group version 5. Age-sex specific utilisation rates by DRG or Major Diagnostic Category (the first two digits of DRG) were matched to the workloads of the specialists in internal medicine. Assumptions were made for comprehensively predicting the demand. Different proportions of time were allocated to fulfill inpatient care, outpatient consultations, academic meetings and administrative function for doctors at community hospitals, general hospitals and regional hospitals including teaching activities for doctors at teaching hospitals. The population pyramid of 2021 was used to forecast future demand taking account of casemix utilisation by each age-sex stratum in 2009. The results show the effects of demographic changes on the number of internists needed. Female reproductive age adults in 2021 need fewer internists than female reproductive age adults in 2009. The elderly in 2021 need an additional of 60 to 70 percent more internists than the elderly of 2009. Overall demands for the internists increase 34 percent over 12 years, while the growths of the population over 14 years and of the elderly populations are 11 and 64 percent respectively. Further fine-tuning of the model for forecasting demand for subspecialty especially the gerontologist is warranted to check for consistency of distribution of subspecialties within the internal medicine. Future policy research is needed for managing production and distribution of the required medical specialists according to needs in different geographical areas.

Cost-effectiveness of pharmacological and psychosocial interventions for schizophrenia

BACKGROUND

Information on cost-effectiveness of interventions to treat schizophrenia can assist health policy decision making, particularly given the lack of health resources in developing countries like Thailand. This study aims to determine the optimal treatment package, including drug and non-drug interventions, for schizophrenia in Thailand.

METHODS

A Markov model was used to evaluate the cost-effectiveness of typical antipsychotics, generic risperidone, olanzapine, clozapine and family interventions. Health outcomes were measured in disability adjusted life years. We evaluated intervention benefit by estimating a change in disease severity, taking into account potential side effects. Intervention costs included outpatient treatment costs, hospitalization costs as well as time and travel costs of patients and families. Uncertainty was evaluated using Monte Carlo simulation. A sensitivity analysis of the expected range cost of generic risperidone was undertaken.

RESULTS

Generic risperidone is more cost-effective than typicals if it can be produced for less than 10 baht per 2 mg tablet. Risperidone was the cheapest treatment with higher drug costs offset by lower hospital costs in comparison to typicals. The most cost-effective combination of treatments was a combination of risperidone (dominant intervention). Adding family intervention has an incremental cost-effectiveness ratio of 1,900 baht/DALY with a 100% probability of a result less than a threshold for very cost-effective interventions of one times GDP or 110,000 baht per DALY. Treating the most severe one third of patients with clozapine instead of risperidone had an incremental cost-effectiveness ratio of 320,000 baht/DALY with just over 50% probability of a result below three times GDP per capita.

CONCLUSIONS

There are good economic arguments to recommend generic risperidone as first line treatment in combination with family intervention. As the uncertainty interval indicates the addition of clozapine may be dominated and there are serious side effects, treating severe patients with clozapine is advisable only for patients who do not respond to risperidone and only in the presence of a stricter side effect monitoring system than currently exists.

Health outcomes of schizophrenia in Thailand: Health care provider and patient perspectives

BACKGROUND

Patient views are considered an important measure in schizophrenia. There are no studies of the association between patient and clinician perspectives in Thailand. The objectives of this study were to (a) describe the patterns of clinician-rated psychiatric symptoms and patient ratings of health related quality of life and (b) quantify the association between clinician and patient-rated measures.

METHOD

The cross-sectional study included a stratified representative sample of 307 patients with schizophrenia or schizoaffective disorder in treatment at mental health services during the survey period. Clinicians measured illness severity using the Brief Psychiatric Rating Scale-Expanded while patients rated their health-related quality of life using a six-dimensional EuroQoL instrument. Pearson correlation coefficient and hierarchical regression analyses were used to quantify the association between schizophrenia outcomes elicited from patients and health care providers.

RESULTS

There was only a modest association between patient-rated and clinician-rated outcomes. In a regression model clinician-rated symptoms explained 33% of patient satisfaction with their quality of life. Negative, cognitive and mood symptoms but not the positive symptoms were significant predictors of patient-rated quality of life.

CONCLUSION

Policy makers and clinicians need to be aware that clinician-rated and patient-rated outcomes are very different. Improving quality of life of people with schizophrenia requires greater attention be given to negative, cognitive and mood symptoms.

Schizophrenia in Thailand: prevalence and burden of disease

Background

A previous estimate of the burden of schizophrenia in Thailand relied on epidemiological estimates from elsewhere. The aim of this study is to estimate the prevalence and disease burden of schizophrenia in Thailand using local data sources that recently have become available.

Methods

The prevalence of schizophrenia was estimated from a community mental health survey supplemented by a count of hospital admissions. Using data from recent meta-analyses of the risk of mortality and remission, we derived incidence and average duration using DisMod software. We used treated disability weights based on patient and clinician ratings from our own local survey of patients in contact with mental health services and applied methods from Australian Burden of Disease and cost-effectiveness studies. We applied untreated disability weights from the Global Burden of Disease (GBD) study. Uncertainty analysis was conducted using Monte Carlo simulation.

Results

The prevalence of schizophrenia at ages 15-59 in the Thai population was 8.8 per 1,000 (95% CI: 7.2, 10.6) with a male-to-female ratio of 1.1-to-1. The disability weights from local data were somewhat lower than the GBD weights. The disease burden in disability-adjusted life years was similar in men (70,000; 95% CI: 64,000, 77, 000) and women (75,000; 95% CI: 69,000, 83,000). The impact of using the lower Thai disability weights on the DALY estimates was small in comparison to the uncertainty in prevalence.

Conclusions

Prevalence of schizophrenia was more critical to an accurate estimate of burden of disease in Thailand than variations in disability weights.