From the local disparities to national realities: Mapping and multilevel modeling of catastrophic health expenditure in Bangladesh using HIES 2016

In developing nations, catastrophic health expenditures have become an all-too-common occurrence, threatening to push households into impoverishment and poverty. By analyzing the Household Income and Expenditure Survey 2016, which features a sample of 46,080 households, this study provides a comprehensive district-by-district analysis of the variation in household catastrophic health expenditures and related factors. The study utilizes a multilevel logistic regression model, which considers both fixed and random effects to identify factors associated with catastrophic health expenditure. The findings of the study indicate that districts located in the eastern and southern regions are at a significantly higher risk of experiencing catastrophic health expenditures. A potential explanation for this trend may be attributed to the high prevalence of chronic diseases in these districts, as well as their economic conditions. The presence of chronic diseases (AOR 5.45 with 95% CI: 5.14, 5.77), presence of old age person (AOR 1.50 with 95% CI: 1.39, 1.61), place of residence (AOR 1.40 with 95% CI: 1.14, 1.73) are found to be highly associated factors. Additionally, the study reveals that the thresholds used to define catastrophic health expenditures exhibit substantial variation across different regions, and differ remarkably from the threshold established by the WHO. On average, the thresholds are 23.12% of nonfood expenditure and 12.14% of total expenditure. In light of these findings, this study offers important insights for policymakers and stakeholders working towards achieving universal health coverage and sustainable development goals in Bangladesh.

Prevalence and Determinants of Catastrophic Healthcare Expenditures in Iran From 2013 to 2019

OBJECTIVES

Protecting people against financial hardship caused by illness stands as a fundamental obligation within healthcare systems and constitutes a pivotal component in achieving universal health coverage. The objective of this study was to analyze the prevalence and determinants of catastrophic health expenditures (CHE) in Iran, over the period of 2013 to 2019.

METHODS

Data were obtained from 7 annual national surveys conducted between 2013 and 2019 on the income and expenditures of Iranian households. The prevalence of CHE was determined using a threshold of 40% of household capacity to pay for healthcare. A binary logistic regression model was used to identify the determinants influencing CHE.

RESULTS

The prevalence of CHE increased from 3.60% in 2013 to 3.95% in 2019. In all the years analyzed, the extent of CHE occurrence among rural populations exceeded that of urban populations. Living in an urban area, having a higher wealth index, possessing health insurance coverage, and having employed family members, an employed household head, and a literate household head are all associated with a reduced likelihood of CHE (p<0.05). Conversely, the use of dental, outpatient, and inpatient care, and the presence of elderly members in the household, are associated with an increased probability of facing CHE (p<0.05).

CONCLUSIONS

Throughout the study period, CHE consistently exceeded the 1% threshold designated in the national development plan. Continuous monitoring of CHE and its determinants at both household and health system levels is essential for the implementation of effective strategies aimed at enhancing financial protection.

Regional catastrophic health expenditure and health inequality in China

Background

Catastrophic health expenditures (CHE) can trigger illness-caused poverty and compound poverty-caused illness. Our study is the first regional comparative study to analyze CHE trends and health inequality in eastern, central and western China, exploring the differences and disparities across regions to make targeted health policy recommendations.

Methods

Using data from China's Household Panel Study (CFPS), we selected Shanghai, Henan and Gansu as representative eastern-central-western regional provinces to construct a unique 5-year CHE unbalanced panel dataset. CHE incidence was measured by calculating headcount; CHE intensity was measured by overshoot and CHE inequality was estimated by concentration curves (CC) and the concentration index (CI). A random effect model was employed to analyze the impact of household head socio-economic characteristics, the household socio-economic characteristics and household health utilization on CHE incidence across the three regions.

Results

The study found that the incidence and intensity of CHE decreased, but the degree of CHE inequality increased, across all three regions. For all regions, the trend of inequality first decreased and then increased. We also revealed significant differences across the eastern, central and western regions of China in CHE incidence, intensity, inequality and regional differences in the CHE influencing factors. Affected by factors such as the gap between the rich and the poor and the uneven distribution of medical resources, families in the eastern region who were unmarried, use supplementary medical insurance, and had members receiving outpatient treatment were more likely to experience CHE. Families with chronic diseases in the central and western regions were more likely to suffer CHE, and rural families in the western region were more likely to experience CHE.

Conclusions

The trends and causes of CHE varied across the different regions, which requires a further tilt of medical resources to the central and western regions; improved prevention and financial support for chronic diseases households; and reform of the insurance reimbursement policy of outpatient medical insurance. On a regional basis, health policy should not only address CHE incidence and intensity, but also its inequality.

Association of Catastrophic Health Expenditure With the Risk of Depression in Chinese Adults: Population-Based Cohort Study

BACKGROUND

Depression is one of the most common mental illnesses, and it may have a lasting effect on one's whole life. As a form of financial hardship, catastrophic health expenditure (CHE) may be associated with depression. However, current evidence about the relationship between CHE and the risk of depression is insufficient.

OBJECTIVE

This study aimed to explore the relationship between CHE and the risk of depression among Chinese adults.

METHODS

In this study, we used 3 waves of the China Family Panel Studies (CFPS) from 2012, 2016, and 2018. The CFPS are a nationally representative study covering 25 of 31 provinces in Chinese mainland and representing nearly 94.5% of the total population. We selected eligible household heads as participants, divided them into 2 groups by CHE events at baseline (exposed group: with CHE; unexposed group: without CHE), and followed them up. Households with CHE were defined as having out-of-pocket medical expenditures exceeding 40% of the total household nonfood expenditure, and people with depression were identified by the 8-item Centre for Epidemiological Studies Depression Scale (CES-D). We first described the baseline characteristics and used logistical regression to estimate their effects on CHE events. Then, we used Cox proportional hazard models to estimate adjusted hazard ratios and 95% CIs of depression among participants with CHE compared with those without CHE. Finally, we analyzed the subgroup difference in the association between CHE and depression.

RESULTS

Of a total of 13,315 households, 9629 were eligible for analysis. Among them, 6824 (70.9%) were men. The mean age was 50.15 (SD 12.84) years. Only 987 (10.3%) participants had no medical insurance. The prevalence of CHE at baseline was 12.9% (1393/9629). Participants with a higher family economic level (adjusted odds ratio [aOR] 1.15, 95% CI 1.02-1.31) and with the highest socioeconomic development level (aOR 1.18, 95% CI 1.04-1.34) had a higher prevalence of CHE than reference groups. During a median of 71 (IQR 69-72) person-months of follow-up, the depression incidence of participants with CHE (1.41 per 1000 person-months) was higher than those without CHE (0.73 per 1000 person-months). Multivariable models revealed that the adjusted hazard ratio for the incidence of depression in participants with CHE was 1.33 (95% CI 1.08-1.64), and this association appeared to be greater in participants without outpatient services (for interaction, P=.048).

CONCLUSIONS

CHE was significantly associated with increased risk of depression among Chinese adults. Concentrated work should be done to monitor CHE, and more efforts to ensure financial protection need to be made to prevent depression, especially for people with high health care needs.

Factors associated with catastrophic health expenditure in sub-Saharan Africa: A systematic review

OBJECTIVE

A non-negligible proportion of sub-Saharan African (SSA) households experience catastrophic costs accessing healthcare. This study aimed to systematically review the existing evidence to identify factors associated with catastrophic health expenditure (CHE) incidence in the region.

METHODS

We searched PubMed, CINAHL, Scopus, CNKI, Africa Journal Online, SciELO, PsycINFO, and Web of Science, and supplemented these with search of grey literature, pre-publication server deposits, Google Scholar®, and citation tracking of included studies. We assessed methodological quality of included studies using the Appraisal tool for Cross-Sectional Studies for quantitative studies and the Critical Appraisal Skills Programme checklist for qualitative studies; and synthesized study findings according to the guidelines of the Economic and Social Research Council.

RESULTS

We identified 82 quantitative, 3 qualitative, and 4 mixed-methods studies involving 3,112,322 individuals in 650,297 households in 29 SSA countries. Overall, we identified 29 population-level and 38 disease-specific factors associated with CHE incidence in the region. Significant population-level CHE-associated factors were rural residence, poor socioeconomic status, absent health insurance, large household size, unemployed household head, advanced age (elderly), hospitalization, chronic illness, utilization of specialist healthcare, and utilization of private healthcare providers. Significant distinct disease-specific factors were disability in a household member for NCDs; severe malaria, blood transfusion, neonatal intensive care, and distant facilities for maternal and child health services; emergency surgery for surgery/trauma patients; and low CD4-count, HIV and TB co-infection, and extra-pulmonary TB for HIV/TB patients.

CONCLUSIONS

Multiple household and health system level factors need to be addressed to improve financial risk protection and healthcare access and utilization in SSA.

PROTOCOL REGISTRATION

PROSPERO CRD42021274830.

Catastrophic health expenditure in the Northern midlands and mountainous areas and its determinants, Vietnam from 2014 to 2020: a cross-sectional study

OBJECTIVES

The study assesses households' catastrophic health expenditure (CHE) by income group, urban versus rural area, and influencing factors in the Northern midlands and mountainous areas of Vietnam.

DESIGN/SETTING

A cross-sectional study with the four waves of data from 2014, 2016, 2018 and 2020 Vietnam household living standards surveys was used.

PARTICIPANTS

The number of participants in this study were 1658, 1661, 1659 and 1662 households in 2014, 2016, 2018 and 2020, respectively. We included households residing in the Northern midlands and mountain areas of Vietnam.

OUTCOMES MEASURE

We examined out-of-pocket health payments and capacity to pay by income groups and place of residence, the incidence of CHE and impoverishment. A logistic regression model was used to examine the influence of demographic and socioeconomic characteristics on CHE.

RESULTS

The findings showed a remarkable decrease in CHE between 2014 and 2016, followed by a considerable increase between 2016 and 2018. The CHE rates in the region were between 3.5% and 5%, with the highest value observed in 2014. In addition, the differences in household CHE rates according to income and place of residence were observed. The results also indicated that medical impoverishment ranged between 3.4% and 3.9%. Overall, factors such as the burden of disease, rural settlements, increasing use of healthcare services, visiting private health facilities and having an old-aged person in the household were significantly and positively associated with CHE. By contrast, households that were wealthier, participated in health insurance, had a household head employed and female-headed households, were negatively associated with CHE.

CONCLUSIONS

The findings provide useful information that can guide policy-makers to design policies, and interventions necessary to reduce CHE in the region, narrow the gap between the rich and the poor, the rural and urban settlements, and ensure universal health coverage.

What Policy Approaches Were Effective in Reducing Catastrophic Health Expenditure? A Systematic Review of Studies from Multiple Countries

BACKGROUND

The United Nations set a goal for universal health coverage in all countries by 2030 and selected the catastrophic health expenditure (CHE) indicator as an assessment tool for this goal. Many countries have strived to reduce household CHE. However, no study has compared countries whose policies have had a remarkable effect on decreasing CHE. Therefore, the purpose of this systematic literature review is to find appropriate methods for measuring CHE that can help us to analyze the impact of health policies and identify countries whose health policies are most effective in reducing CHE.

METHOD

PubMed and Web of Science were searched. Studies that measured the incidence or intensity of CHE in multiple years were included. Two independent reviewers screened the literature, extracted the data, and analyzed the studies selected. Thirty-eight studies met the inclusion criteria for the review. We classified the selected research papers to random sampling and quasi-experimental studies.

RESULTS

We graphically presented the results of CHE incidence and intensity rates reported in the collected papers as a time series data set. Since most studies did not use sample weights, it was not easy to confirm whether the time series changes of CHE are significant. Therefore, we could find only two countries that had policy effects. Both countries established policies that focus on the poor.

CONCLUSION

There are so many studies that analyze CHE, but policies that are effective in reducing CHE are unknown. This study uses a systematic literature review methodology to determine effective policies by comparing CHE time series trends among countries. As a policy implication, it was found that because CHE is defined as the ratio of the ability to pay to medical expenses, a policy of differential medical expenses that is based on income level is effective.

Incidence and determinants of catastrophic health expenditure among low-income Malaysian households

INTRODUCTION

Catastrophic health expenditure (CHE) incurs when out-of-pocket health expenditure (OOPHE) exceeds a certain threshold, therefore exposing households to financial hardship, with the low-income population being most vulnerable. Data related to the incidence and determinants of CHE among the low-income population in Malaysia are lacking. This study aims to determine the incidence and determinants of CHE among Malaysian lowincome households.

METHODOLOGY

This is a cross-sectional study using data from 6,720 low-income households from the national Household Expenditure Survey (HES) 2016 conducted from May 2016 till February 2017. The data were analysed using IBM SPSS software 25.0. OOPHE in this study included all spending on healthcare products and services by the household. CHE was identified in households with OOPHE of at least 10% of total monthly income.

RESULTS

The incidence of CHE at the threshold of 10% household income was 1.7% (n=112). The determinants of CHE were households with any accident or medical insurance (p<0.001), having less than five members in a household (p<0.001), presence of elderly (p=0.024), and hospitalisation (p=0.021). In contrast, employment of the head of household (p=0.003) and having a child aged ≤5 years old (p=0.033) protect households from CHE.

CONCLUSION

In the context of this study, the incidence of CHE among the low-income Malaysian population was low, indicating that a majority of the low-income population is protected from financial catastrophe. Regardless, the determinants of CHE among low-income population should be considered in future health policies.

A STUDY OF CATASTROPHIC HEALTH EXPENDITURES IN INDIA - EVIDENCE FROM NATIONALLY REPRESENTATIVE SURVEY DATA: 2014-2018

Abstract

Background: India is taking steps to provide Universal Health Coverage (UHC). Out-of-pocket (OOP) health care payment is the most important mechanism for health care payment in India. This study aims to investigate the effect of OOP health care payments on catastrophic health expenditures (CHE).

Methods: Data from the National Sample Survey Organization, Social Consumption in Health 2014 and 2018 are used to investigate the effect of OOP health expenditure on household welfare in India. Three aspects of catastrophic expenditure were analyzed in this paper: (i) incidence and intensity of ‘catastrophic’ health expenditure, (ii) socioeconomic inequality in catastrophic health expenditures, and (iii) factors affecting catastrophic health expenditures.

Results: The odds of incidence and intensity of CHE were higher for the poorer households. Using the logistic regression model, it was observed that the odds of incidence of CHE was higher among the households with at least one child aged less than 5 years, one elderly person, one secondary educated female member, and if at least one member in the household used a private healthcare facility for treatment. The multiple regression model showed that the intensity of CHE was higher among households with members having chronic illness, and if members had higher duration of stay in the hospital. Subsidizing healthcare to the households having elderly members and children is necessary to reduce CHE.

Conclusion: Expanding health insurance coverage, increasing coverage limits, and inclusion of coverage for outpatient and preventive services are vital to protect households. Strengthening public primary health infrastructure and setting up a regulatory organization to establish policies and conduct regular audits to ensure that private hospitals do not increase hospitalizations and the duration of stay is necessary.

Disease-Specific Out-of-Pocket Payments, Catastrophic Health Expenditure and Impoverishment Effects in India: An Analysis of National Health Survey Data

BACKGROUND

In India, more than two-thirds of the total health expenditure is incurred through out-of-pocket expenditure (OOPE) by households. Morbidity events thus impose excessive financial risk on households. The Sustainable Development Goals Target 3.8 specifies financial risk protection for achieving universal health coverage (UHC) in developing countries. This study aimed to estimate the impact of OOPE on catastrophic health expenditure (CHE) and impoverishment effects by types of morbidity in India.

METHODS

Data came from the 75th round of the National Sample Survey (NSS) on the theme 'Social consumption in India: Health', which was conducted during the period from July 2017 to June 2018. For the present study, 56,722 households for hospitalisation, 29,580 households for outpatient department (OPD) care and 6285 households for both (OPD care and hospitalisation) were analysed. Indices, namely health care burden, CHE, poverty head count ratio and poverty gap ratio using standard definitions were analysed.

RESULTS

Households with members who underwent treatment for cancers, cardiovascular diseases, psychiatric conditions, injuries, musculoskeletal and genitourinary conditions spent a relatively high amount of their income on health care. Overall, 41.4% of the households spent > 10% of the total household consumption expenditure (HCE) and 24.6% of households spent > 20% of HCE for hospitalisation. A total of 20.4% and 10.0% of households faced CHE for hospitalisation based on the average per capita and average two capita consumption expenditure, respectively. Health care burden, CHE and impoverishment was higher in households who sought treatment in private health facilities than in public health facilities.

CONCLUSION

Our study suggests that there is an urgent need for political players and policymakers to design health system financing policies and strict implementation that will provide financial risk protection to households in India.

Trends and determinants of catastrophic health expenditure in China 2010-2018: a national panel data analysis

BACKGROUND

Catastrophic health expenditures (CHE) are out-of-pocket payments (OOP) that exceed a predefined percentage or threshold of a household's resources, usually 40 %, that can push households into poverty in China. We analyzed the trends in the incidence and intensity, and explored the determinants, of CHE, and proposed policy recommendation to address CHE.

METHODS

A unique 5-year national urban-rural panel database was constructed from the China Family Panel Studies (CFPS) surveys. CHE incidence was measured by calculating headcount (percentage of households incurring CHE to the total household sample) and intensity was measured by overshoot (degree by which an average out of pocket health expenditure exceeds the threshold of the total sample). A linear probability model was employed to assess the trend in the net effect of the determinants of CHE incidence and a random effect logit model was used to analyse the role of the characteristics of the household head, the household and household health utilization on CHE incidence.

RESULTS

CHE determinants vary across time and geographical location. From 2010 to 2018, the total, urban and rural CHE incidence all showed a decreasing tend, falling from 14.7 to 8.7 % for total households, 12.5-6.6 % in urban and 16.8-10.9 % in rural areas. CHE intensity decreased in rural (24.50-20.51 %) and urban (22.31-19.57 %) areas and for all households (23.61-20.15 %). Inpatient services were the most important determinant of the incidence of CHE. For urban households, the random effect logit model identified household head (age, education, self-rated health); household characteristics (members 65 + years, chronic diseases, family size and income status); and healthcare utilization (inpatient and outpatient usage) as determinants of CHE. For rural areas, the same variables were significant with the addition of household head's sex and health insurance.

CONCLUSIONS

The incidence and intensity of CHE in China displayed a downward trend, but was higher in rural than urban areas. Costs of inpatient service usage should be a key intervention strategy to address CHE. The policy implications include improving the economic level of poor households, reforming health insurance and reinforcing pre-payment hospital insurance methods.

National and Provincial Estimates of Catastrophic Health Expenditure and its Determinants in Nepal

BACKGROUND

Despite various supply-side efforts, out of pocket expenditure occupies a considerable portion of healthcare financing in Nepal. With the recent process of federalization in country, there is additional scope for contextualized planning at provincial level to prevent catastrophic health expenditure among Nepalese households. In this context, this study intends to estimate the proportion of population facing catastrophic health expenditure at national and provincial level and identify the determinants of catastrophic health expenditure.

METHODS

This study involved analysis of Nepal Living Standard Survey III, which was a cross sectional study. Out of 5,988 households comprising 28,460 individuals, data from total of 7,911 individuals who reported having acute or chronic illness was extracted and analyzed in the study.

RESULTS

In the study, 11.11% of households had faced catastrophic health expenditure. Catastrophic health expenditure was found to be 11.3% in Province 1, 9.4% in Province 2, 10.7% in Bagmati Province, 10% in Gandaki Province, 11.7% in Lumbini Province, 13.3% in Karnali Province and 13.4% in Sudurpaschim Province. Household size, literacy status of household head, consumption quintile, urban or rural residence, type of illness and type of health facility visited were identified as determinants of catastrophic health expenditure.

CONCLUSIONS

A tenth of households, most of whom lying below poverty line, residing in rural areas, suffering from chronic illness are facing catastrophic healthcare burden. The government needs to pursue its equity-oriented strategies preventing catastrophic health expenditure and impoverishment associated with it.

Decomposition of changes in socioeconomic inequalities in catastrophic health expenditure in Kenya

BACKGROUND

Catastrophic health expenditure (CHE) is frequently used as an indicator of financial protection. CHE exists when health expenditure exceeds a certain threshold of household consumption. Although CHE is reported to have declined in Kenya, it is still unacceptably high and disproportionately affects the poor. This study examines the socioeconomic factors that contribute to inequalities in CHE as well as the change in these inequalities over time in Kenya.

METHODS

We used data from the Kenya household health expenditure and utilisation (KHHEUS) surveys in 2007 and 2013. The concertation index was used to measure the socioeconomic inequalities in CHE. Using the Wagstaff (2003) approach, we decomposed the concentration index of CHE to assess the relative contribution of its determinants. We applied Oaxaca-type decomposition to assess the change in CHE inequalities over time and the factors that explain it.

RESULTS

The findings show that while there was a decline in the incidence of CHE, inequalities in CHE increased from -0.271 to -0.376 and was disproportionately concentrated amongst the less well-off. Higher wealth quintiles and employed household heads positively contributed to the inequalities in CHE, suggesting that they disadvantaged the poor. The rise in CHE inequalities overtime was explained mainly by the changes in the elasticities of the household wealth status.

CONCLUSION

Inequalities in CHE are persistent in Kenya and are largely driven by the socioeconomic status of the households. This implies that the existing financial risk protection mechanisms have not been sufficient in cushioning the most vulnerable from the financial burden of healthcare payments. Understanding the factors that sustain inequalities in CHE is, therefore, paramount in shaping pro-poor interventions that not only protect the poor from financial hardship but also reduce overall socioeconomic inequalities. This underscores the fundamental need for a multi-sectoral approach to broadly address existing socioeconomic inequalities.

Ethical aspects of the COVID-19 crisis: How to deal with an overwhelming shortage of acute beds

The current outbreak of SARS-CoV-2 has and continues to put huge pressure on intensive care units (ICUs) worldwide. Many patients with COVID-19 require some form of respiratory support and often have prolonged ICU stays, which results in a critical shortage of ICU beds. It is therefore not always physically possible to treat all the patients who require intensive care, raising major ethical dilemmas related to which patients should benefit from the limited resources and which should not. Here we consider some of the approaches to the acute shortages seen during this and other epidemics, including some guidelines for triaging ICU admissions and treatments.

CAPS criteria fail to identify most severely-ill thrombotic antiphospholipid syndrome patients requiring intensive care unit admission

PURPOSE

Catastrophic antiphospholipid syndrome (CAPS), the most severe manifestation of antiphospholipid syndrome (APS), is characterised by simultaneous thromboses in multiple organs. Diagnosing CAPS can be challenging but its early recognition and management is crucial for a favourable outcome. This study was undertaken to evaluate the frequencies, distributions and ability to predict mortality of "definite/probable" or "no-CAPS" categories of thrombotic APS patients requiring admission to the intensive care unit (ICU).

METHODS

This French national multicentre retrospective study, conducted from January 2000 to September 2018, included all APS patients with any new thrombotic manifestation(s) admitted to 24 ICUs.

RESULTS

One hundred and thirty-four patients (male/female ratio: 0.4; mean age at admission: 45.4 ± 15.0 years), who experienced 152 CAPS episodes, required ICU admission. The numbers of definite, probable or no-CAPS episodes, respectively, were: 11 (7.2%), 60 (39.5%) and 81 (53.3%). No histopathological proof of microvascular thrombosis was the most frequent reason for not being classified as definite CAPS. Overall, 35/152 (23.0%) episodes were fatal, with comparable rates for definite/probable CAPS and no CAPS (23% vs. 28.8% respectively, p = 0.4). The Kaplan-Meier curve of estimated probability of survival showed no between-group survival difference (log-rank test p = 0.5).

CONCLUSIONS

In this study, CAPS criteria were not associated with mortality of thrombotic APS patients requiring ICU admission. Further studies are need evaluate the adequacy of CAPS criteria for critically-ill APS patients.

Decomposing inequality in catastrophic health expenditure for self-reported hypertension household in Urban Shaanxi, China from 2008 to 2013: two waves' cross-sectional study

OBJECTIVE

Despite the latest wave of China's healthcare reform initiated in 2009 has achieved unprecedented progress in rural areas, little is known for specific vulnerable groups' catastrophic health expenditure (CHE) in urban China. This study aims to estimate the trend of incidence, intensity and inequality of CHE in hypertension households (households with one or more than one hypertension patient) in urban Shaanxi, China from 2008 to 2013.

METHODS

Based on the fourth and the fifth National Health Service Surveys of Shaanxi, we identified 460 and 1289 households with hypertension in 2008 and 2013, respectively for our analysis. We classified hypertension households into two groups: simplex households (with hypertension only) and mixed households (with hypertension plus other non-communicable diseases). CHE would be identified if out-of-pocket healthcare expenditure was equal to or higher than 40% of a household's capacity to pay. Concentration index and its decomposition based on Probit regressions were employed to measure the income-related inequality of CHE.

RESULTS

We find that CHE occurred in 11.2% of the simplex households and 22.1% of the mixed households in 2008, and the 21.5% of the simplex households and the 46.9% of mixed households incurred CHE in 2013. Furthermore, there were strong pro-poor inequalities in CHE in the simplex households (-0.279 and -0.283) and mixed households (-0.362 and -0.262) both in 2008 and 2013. The majority of observed inequalities in CHE could be associated with household economic status, household head's health status and having elderly members.

CONCLUSION

We find a sharp increase of CHE occurrence and the sustained strong pro-poor inequalities for simplex and mixed households in urban Shaanxi Province of China from 2008 to 2013. Our study suggests that more concerns are needed for the vulnerable groups such as hypertension households in urban areas of China.

Extent and determinants of catastrophic health expenditure for tuberculosis care in Chongqing municipality, China: a cross-sectional study

OBJECTIVE

To investigate the extent and associations of patient/diagnostic delay and other potential factors with catastrophic health expenditure (CHE) for tuberculosis (TB) care in Chongqing municipality, China.

DESIGN

A cross-sectional study.

SETTING

Four counties of Chongqing municipality, China.

PARTICIPANTS

A total of 1199 patients with active pulmonary TB beyond 16 years and without mental disorders were consecutively recruited in the four counties' designated TB medical institutions.

OUTCOME MEASURES

The incidence and intensity of CHE for TB care were described. The association between patients' 'sociodemographic and clinical characteristics such as patient delay, diagnostic delay, forms of TB, health insurance status and hospitalisation and CHE were analysed using univariate and multivariate logistic regression.

RESULTS

The incidence of CHE was 52.8% and out-of-pocket (OOP) payments were 93% of the total costs for TB care. Compared with patients without delay, the incidence and intensity of CHE were higher in patients who had patient delay or diagnostic delay. Patients who experienced patient delay or diagnostic delay, who was a male, elderly (≥60 years), an inhabitant, a peasant, divorced/widow, the New Cooperative Medical Scheme membership had greater risks of incurring CHE for TB care. Having a higher educational level appeared to be a protective factor. However, hospitalisation was not associated with CHE after controlling for other variables.

CONCLUSION

The incidence and intensity of CHE for TB care are high, which provides baseline data about catastrophic costs that TB-related households faced in Chongqing of China. Variety of determinants of CHE implicate that it is essential to take effective measures to promote early seeking care and early diagnosis, improve the actual reimbursement rates of health insurance, especially for outpatients, and need more fine-tuned interventions such as precise poverty alleviation to reduce catastrophic costs of the vulnerable population.

Empirical Analysis of the Status and Influencing Factors of Catastrophic Health Expenditure of Migrant Workers in Western China

Objective: To understand the current situation and influencing factors of catastrophic health expenditure (CHE) of migrant workers in Western China. Method: Sample data were obtained by cluster random sampling. Data were entered and sorted using Epidata 3.1 and SPSS 21.0. The statistical analysis involved a descriptive analysis, chi-square tests, multivariate unconditional logistic regression, and multiple correspondence analysis (MCA). Results: A total of 1271 households were surveyed, and the incidence of CHE was 12.5% (159/1271). The multivariate logistic regression showed that households with elderly people over 65 years old (0R = 2.05, 95% CI = 1.42–2.97), children under five years old (0R = 2.61, 95% CI = 1.53–4.48), at least one person with no basic medical insurance (0R = 2.96, 95% CI = 2.08–4.23), chronically ill patients (0R = 1.85, 95% CI = 1.23–2.77), and hospitalized patients (0R = 3.61, 95% CI = 2.31–5.62) contributed to the risk of CHE. Compared to migrant workers in the >30,000 Yuan household per capita annual income group, the 10,001–20,000 Yuan income group (0R = 2.35, 95% CI = 1.44–3.82) and ≤10,000 Yuan income group (0R = 3.72, 95% CI = 2.09–6.62) had a higher risk of CHE occurrence. Compared to migrant workers in the university and above head-of-household education group, those in the primary level or below education group (0R = 5.90, 95% CI = 3.02–11.5) had a higher risk of CHE occurrence. MCA revealed a strong interrelationship between the following risk factors and CHE: household per capita annual income ≤10,000 Yuan, primary school education level or below for the head of the household, and having at least one person in the household with no basic medical insurance. Conclusions: CHE incidence amongst migrant workers in Western China is a serious issue, and policymakers should pay more attention to these migrant workers’ households that are more prone to CHE than others, so as to decrease the incidence of CHE in this group.

How disability insurance reforms change the consequences of health shocks on income and employment

This paper examines whether Dutch disability insurance reforms have helped or hindered employment opportunities of workers that are facing unanticipated shocks to their health. An important component of the reforms was to make employers responsible for paying sickness benefits and to strengthen their sickness monitoring obligations. This may stimulate preventive and reintegration activities by firms. Using administrative data on hospitalizations, we conclude that both financial incentives and monitoring obligations have substantially lowered DI receipt and increased the employment of workers after a health shock.

Out-of-Pocket Payments, Catastrophic Health Expenditure and Poverty Among Households in Nigeria 2010

BACKGROUND

There is high reliance on out-of-pocket (OOP) health payments as a means of financing health system in Nigeria. OOP health payments can make households face catastrophe and become impoverished. The study aims to examine the financial burden of OOP health payments among households in Nigeria.

METHODS

Secondary data from the Harmonized Nigeria Living Standard Survey (HNLSS) of 2009/2010 was utilized to assess the catastrophic and impoverishing effects of OOP health payments on households in Nigeria. Data analysis was carried out using ADePT 6.0 and STATA 12.

RESULTS

We found that a total of 16.4% of households incurred catastrophic health payments at 10% threshold of total consumption expenditure while 13.7% of households incurred catastrophic health payments at 40% threshold of nonfood expenditure. Using the $1.25 a day poverty line, poverty headcount was 97.9% gross of health payments. OOP health payments led to a 0.8% rise in poverty headcount and this means that about 1.3 million Nigerians are being pushed below the poverty line. Better-off households were more likely to incur catastrophic health payments than poor households.

CONCLUSION

Our study shows the urgency with which policy makers need to increase public healthcare funding and provide social health protection plan against informal OOP health payments in order to provide financial risk protection which is currently absent among high percentage of households in Nigeria.

Catastrophic healthcare expenditure and impoverishment in tropical deltas: evidence from the Mekong Delta region

BACKGROUND

Universal health coverage implies that people obtain the health services they need without experiencing financial hardship. While the factors contributing to catastrophic health expenditure (CHE) among households are well understood, few studies have examined this relationship in the context of environmentally vulnerable regions, such as tropical deltas. This study aims to examine the disparities in the prevalence of CHE and impoverishment due to out-of-pocket (OOP) healthcare payments in the Mekong Delta in comparison with rest of Vietnam. It also intends to investigate the associations between economic and environmental shocks, CHE and the impoverishment from healthcare payments.

METHODS

Using data from the Vietnam Household Living Standards Survey 2012, the prevalence of CHE was estimated from the fraction of healthcare costs in relation to household consumption expenditure. The poverty headcount was estimated using the total household consumption expenditure considering both with and without OOP expenditure for healthcare in comparison with the national poverty-line. Simple and multiple logistic regression models were used to examine the associations between geography, health systems, environmental and demographic variables and OOP healthcare expenditure related CHE, and impoverishment respectively.

RESULTS

Both the level of OOP household healthcare expenditure and the proportion of households suffering from impoverishment as the result of such payments were higher in the Mekong Delta region compared to rest of Vietnam. Although the results from the multiple regression analysis showed that households in the Mekong Delta region were significantly less likely to suffer from CHE, they were significantly more likely to be impoverished due to OOP healthcare expenditure. While health insurance membership did not have a significant effect on either outcomes, households that faced an economic or an environmental shock in past 5 years were considerably more likely to suffer from CHE and impoverishment from OOP healthcare payments.

CONCLUSIONS

The findings suggest that the financial protection capacity of health insurance schemes in Vietnam should be improved and expanded to reduce impoverishment as the result of OOP healthcare payments, particularly in the Mekong Delta region. Additional investments in disaster preparedness strategies can further help to reduce the financial burden of households in this environmentally vulnerable region.

Determinants of Catastrophic Dental Health Expenditure in China

This study explored catastrophic health expenditure in China, due to out-of-pocket payments for dental care, and its associated individual- and contextual-level factors. We pooled data from 31,566 adults who participated in the third National Oral Health Survey with province-level data from different sources. We defined catastrophic dental health expenditure (CDHE) as payments for dental services and/or medication for dental problems during the last year that exceeded the 10% and 20% of the household income. The association of individual and contextual factors with catastrophic dental health expenditure was evaluated using two-level logistic regression models with individuals nested within provinces. Socioeconomic position (education and household income), household size and dental status (pain in teeth or mouth and number of teeth) were the individual-level factors associated with CDHE among the full sample of participants; and, also, among those who used dental services in the past year. Greater gross domestic product per capita was the only contextual factor associated with CDHE, and only at the lower income threshold. This study shows that out-of-pocket expenses for dental services may put a considerable, and unnecessary, burden on households' finances. Our findings also help characterise those households more likely to face catastrophic expenditure on health if they have to pay for dental services.

The Incidence and Prevalence of Thromboangiitis Obliterans in Taiwan: A Nationwide, Population-based Analysis of Data Collected from 2002 to 2011

OBJECTIVE

To estimate the incidence and prevalence of thromboangiitis obliterans in Taiwan in the period spanning from 2002 to 2011.

METHODS

We identified all incident and prevalent cases with a diagnosis of thromboangiitis obliterans (International Classification of Diseases, Ninth Revision code 443.1) in the period spanning from 2002 to 2011 using Taiwan's National Health Insurance Research Database. We calculated the age- and sex-specific incidence and prevalence rates of thromboangiitis obliterans during the study period.

RESULTS

From 2002 to 2011, 158 patients were diagnosed with thromboangiitis obliterans; of these, 76% were men. Most (63%) of the patients were <50 years old when they were first diagnosed. After reaching 20 years of age, the incidence rate increased with age and peaked among those aged ≥60 years. The average incidence rate of thromboangiitis obliterans during the 2002-2011 period was 0.068 per 105 years. The incidence of thromboangiitis obliterans decreased with time, from 0.10 per 105 years in 2002 to 0.04 per 105 years in 2011. The prevalence increased from 0.26 × 10-5 in 2002 to 0.65 × 10-5 in 2011.

CONCLUSION

This is the first epidemiologic study of thromboangiitis obliterans using claims data from a general population in Taiwan. This nationwide, population-based study found that the incidence and prevalence of thromboangiitis obliterans in Taiwan in the 2002-2011 period were lower than those in other countries before 2000. This study also revealed a trend of decreasing incidence with simultaneous increasing prevalence of thromboangiitis obliterans in Taiwan from 2002 to 2011.

Diagnosis and classification of the antiphospholipid syndrome

The antiphospholipid syndrome (APS) is defined by the occurrence of venous and arterial thromboses, often multiple, and recurrent fetal losses, frequently accompanied by a moderate thrombocytopenia, in the presence of antiphospholipid antibodies (aPL). Some estimates indicate that the incidence of the APS is around 5 new cases per 100,000 persons per year and the prevalence around 40-50 cases per 100,000 persons. The aPL are positive in approximately 13% of patients with stroke, 11% with myocardial infarction, 9.5% of patients with deep vein thrombosis and 6% of patients with pregnancy morbidity. The original classification criteria for the APS were formulated at a workshop in Sapporo, Japan, in 1998, during the 8th International Congress on aPL. The Sapporo criteria, as they are often called, were revised at another workshop in Sydney, Australia, in 2004, during the 11th International Congress on aPL. At least one clinical (vascular thrombosis or pregnancy morbidity) and one laboratory (anticardiolipin antibodies, lupus anticoagulant or anti-β2-glycoprotein I antibodies) criterion had to be met for the classification of APS.

Structural social determinants and catastrophic illnesses in municipalities in the Colombian department of Valle del Cauca

OBJECTIVE

To explore possible associations between self-reported prevalence of catastrophic illnesses such as chronic renal failure, HIV/AIDS and cancer and a set of structural social determinants.

METHODS

Ecological study using data from the 2005 Population Census conducted by the National Administrative Department of Statistics (DANE), focusing on municipalities in the Colombian department of Valle del Cauca that experienced the highest prevalence rates for catastrophic illnesses during 2000-2005. Associations were measured with Pearson's chi-squared statistic and Fisher's Exact Test. Prevalence ratios were calculated, with 95% confidence intervals.

RESULTS

Statistically significant associations were observed between catastrophic illnesses and social structural determinants in the form of illiteracy, deficient sanitary infrastructure, quality of housing units and access to health services.

CONCLUSIONS

A role was observed for social determination of catastrophic illnesses in this context. However, additional analyses are required that recognize the complexity of health-determining processes and that explore the interrelationships among social, structural, behavioral and psychosocial determinants in depth.

Household catastrophic medical expenses in eastern China: determinants and policy implications

BACKGROUND

Much of research on household catastrophic medical expenses in China has focused on less developed areas and little is known about this problem in more developed areas. This study aimed to analyse the incidence and determinants of catastrophic medical expenses in eastern China.

METHODS

Data were obtained from a health care utilization and expense survey of 11,577 households conducted in eastern China in 2008. The incidence of household catastrophic medical expenses was calculated using the method introduced by the World Health Organization. A multi-level logistic regression model was used to identify the determinants.

RESULTS

The incidence of household catastrophic medical expenses in eastern China ranged from 9.24% to 24.79%. Incidence of household catastrophic medical expenses was lower if the head of household had a higher level of education, labor insurance coverage, while the incidence was higher if they lived in rural areas, had a family member with chronic diseases, had a child younger than 5 years old, had a person at home who was at least 65 years old, and had a household member who was hospitalized. Moreover, the impact of the economic level on catastrophic medical expenses was non-linear. The poorest group had a lower incidence than that of the second lowest income group and the group with the highest income had a higher incidence than that of the second highest income group. In addition, region was a significant determinant.

CONCLUSIONS

Reducing the incidence of household catastrophic medical expenses should be one of the priorities of health policy. It can be achieved by improving residents' health status to reduce avoidable health services such as hospitalization. It is also important to design more targeted health insurance in order to increase financial support for such vulnerable groups as the poor, chronically ill, children, and senior populations.

Catastrophic antiphospholipid syndrome: a case series

BACKGROUND

Antiphospholipid syndrome (APS) is an autoimmune disease with clinical manifestations of arterial and venous thrombosis, obstetric manifestations, and the presence of antiphospholipid antibodies or lupus anticoagulant. Catastrophic APS is a rare variant of APS, defined as acute failure of at least three tissues, organs or systems caused predominantly by small vessel thrombosis confirmed by histopathologic evidence. Catastrophic APS develops rapidly and leads to death in 30% of cases.

METHODS

We evaluated 11 patients with catastrophic APS -8 of them with a probable diagnosis of catastrophic APS and 3 with a definite diagnosis--admitted to Beilinson hospital during the period 2003-2011.

RESULTS

Overall venous events numbered 18 and overall arterial events 10. The event duration per patient was 2.6 +/- 1.2 weeks (mean +/- SD). Deep vein thrombosis of the legs was quite common (7 events), as was venous intraabdominal thrombosis (10 events). Eight patients had microangiopathic anemia with schizocytes seen in the blood smear. The mean +/- SD hemoglobin level was 10.3 +/- 3.6 g/dl and the mean +/- SD creatinine level 0.98 +/- 0.78 mg/dl. All our patients had high acute-phase reactant and all had lupus anticoagulant positivity, The most common positive antibodies were immunoglobulin G anticardiolipin (8 patients) and IgG beta2-glycoprotein (7 patients). During the events warfarin was stopped and the patients were given intravenous heparin. All the patients received steroids in variable doses. Five patients underwent plasma exchange, two patients received rituximab and two patients intravenous immunoglobulin.

CONCLUSIONS

Catastrophic APS, a rare syndrome, is important because of its major morbidity and mortality among young patients.

Catastrophic health care spending and impoverishment in Kenya

BACKGROUND

Many health systems in Africa are funded primarily through out-of-pocket payments. Out-of-pocket payments prevent people from seeking care, can result to catastrophic health spending and lead to impoverishment. This paper estimates the burden of out-of-pocket payments in Kenya; the incidence and intensity of catastrophic health care expenditure and the effect of health spending on national poverty estimates.

METHODS

Data were drawn from a nationally representative health expenditure and utilization survey (n = 8414) conducted in 2007. The survey provided detailed information on out-of-pocket payments and consumption expenditure. Standard data analytical techniques were applied to estimate the incidence and intensity of catastrophic health expenditure. Various thresholds were applied to demonstrate the sensitivity of catastrophic measures.

RESULTS

Each year, Kenyan households spend over a tenth of their budget on health care payments. The burden of out-of-pocket payments is highest among the poor. The poorest households spent a third of their resources on health care payments each year compared to only 8% spent by the richest households. About 1.48 million Kenyans are pushed below the national poverty line due to health care payments.

CONCLUSIONS

Kenyans are becoming poorer due to health care payments. The need to protect individuals from health care related impoverishment calls for urgent reforms in the Kenyan health system. An important policy question remains what health system reforms are needed in Kenya to ensure that financial risk protection for all is achieved.

Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries

OBJECTIVE

Compare patterns of catastrophic health expenditures in 12 countries in Latin America and the Caribbean.

MATERIAL AND METHODS

Prevalence of catastrophic expenses was estimated uniformly at the household level using household surveys. Two types of prevalence indicators were used based on out-of-pocket health expense: a) relative to an international poverty line, and b) relative to the household's ability to pay net of their food basket. Ratios of catastrophic expenditures were estimated across subgroups defined by economic and social variables.

RESULTS

The percent of households with catastrophic health expenditures ranged from 1 to 25% in the twelve countries. In general, rural residence, lowest quintile of income, presence of older adults, and lack of health insurance in the household are associated with higher propensity of catastrophic health expenditures. However, there is vast heterogeneity by country.

CONCLUSIONS

Cross national studies may serve to examine how health systems contribute to the social protection of Latin American households.

[Assessment of human health risk upon acute inhalational exposure to chemical substances]

To provide the safety of the population and environment with the occurrence of man-caused catastrophes due their increase is now an urgent problem. Toxic hazard coefficients were calculated for hydrogen sulfide in the settlements located in a possible chemical pollution area in the Orenburg gas-chemical complex. Assessment of the hazard of toxic effects to the population upon exposure to hydrogen sulfide has indicated that there may be toxic effects in the inhabitants of the study nearby inhabited localities. The findings do not characterize the possible severity of intoxication so it is necessary to develop a system of criteria for the differentiation of the severity of negative effects in order to evaluate the hazard of acute chemical exposures.

Do microfinance programs help families insure consumption against illness?

Families in developing countries face enormous financial risks from major illness both in terms of the cost of medical care and the loss in income associated with reduced labor supply and productivity. We test whether access to microfinancial savings and lending institutions helps Indonesian families smooth consumption after declines in adult health. In general, results support the importance of these institutions in helping families to self-insure consumption against health shocks.

Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda

There is currently considerable discussion between governments, international agencies, bilateral donors and advocacy groups on whether user fees levied at government health facilities in poor countries should be abolished. It is claimed that this would lead to greater access for the poor and reduce the risks of catastrophic health expenditures if all other factors remained constant, though other factors rarely remain constant in practice. Accordingly, it is important to understand what has actually happened when user fees have been abolished, and why. All fees at first level government health facilities in Uganda were removed in March 2001. This study explores the impact on health service utilization and catastrophic health expenditures using data from National Household Surveys undertaken in 1997, 2000 and 2003. Utilization increased for the non-poor, but at a lower rate than it had in the period immediately before fees were abolished. Utilization among the poor increased much more rapidly after the abolition of fees than beforehand. Unexpectedly, the incidence of catastrophic health expenditure among the poor did not fall. The most likely explanation is that frequent unavailability of drugs at government facilities after 2001 forced patients to purchase from private pharmacies. Informal payments to health workers may also have increased to offset the lost revenue from fees. Countries thinking of removing user charges should first examine what types of activities and inputs at the facility level are funded from the revenue collected by fees, and then develop mechanisms to ensure that these activities can be sustained subsequently.

Cross-scale interactions, nonlinearities, and forecasting catastrophic events

Catastrophic events share characteristic nonlinear behaviors that are often generated by cross-scale interactions and feedbacks among system elements. These events result in surprises that cannot easily be predicted based on information obtained at a single scale. Progress on catastrophic events has focused on one of the following two areas: nonlinear dynamics through time without an explicit consideration of spatial connectivity [Holling, C. S. (1992) Ecol. Monogr. 62, 447-502] or spatial connectivity and the spread of contagious processes without a consideration of cross-scale interactions and feedbacks [Zeng, N., Neeling, J. D., Lau, L. M. & Tucker, C. J. (1999) Science 286, 1537-1540]. These approaches rarely have ventured beyond traditional disciplinary boundaries. We provide an interdisciplinary, conceptual, and general mathematical framework for understanding and forecasting nonlinear dynamics through time and across space. We illustrate the generality and usefulness of our approach by using new data and recasting published data from ecology (wildfires and desertification), epidemiology (infectious diseases), and engineering (structural failures). We show that decisions that minimize the likelihood of catastrophic events must be based on cross-scale interactions, and such decisions will often be counterintuitive. Given the continuing challenges associated with global change, approaches that cross disciplinary boundaries to include interactions and feedbacks at multiple scales are needed to increase our ability to predict catastrophic events and develop strategies for minimizing their occurrence and impacts. Our framework is an important step in developing predictive tools and designing experiments to examine cross-scale interactions.

The development of insidious disability in activities of daily living among community-living older persons

PURPOSE

To determine how often disability in essential activities of daily living develops insidiously, and to evaluate whether the likelihood of insidious disability differs on the basis of physical frailty.

METHODS

We conducted a prospective study of 754 nondisabled, community-living persons aged 70 years or older. Participants were categorized according to the presence or absence of physical frailty, which was defined on the basis of gait speed. Participants were subsequently followed with monthly telephone interviews for 3 years to determine the occurrence of disability in bathing, dressing, walking, or transferring, and to ascertain exposure to precipitating events, which included acute hospital admissions and other illnesses, injuries, or problems leading to restricted activity.

RESULTS

For first episodes of disability, 73 (36%) of 203 developed insidiously among the 322 participants who were physically frail and 26 (18%) of 141 developed insidiously among the 432 participants who were not physically frail (P <0.001). Physical frailty was the only factor that was associated significantly with the development of insidious disability, with an adjusted odds ratio of 2.4 (95% confidence interval: 1.4 to 4.1). The likelihood that an episode of disability was insidious increased progressively, from 29% of the 344 first episodes to 65% of the 155 fourth or higher episodes (P for trend <0.001).

CONCLUSION

Disability in essential activities of daily living often occurs insidiously, particularly among older persons who are physically frail or who have had prior episodes of disability.

Measuring financial protection in health in the United States

One rationale for health insurance coverage is to provide financial protection against catastrophic health expenditures. This article defines a lack of financial protection as household spending on health care when: (1) out-of-pocket (OOP) health expenditures exceed 10% of family income; (2) out-of-pocket expenditures exceed an absolute level of 2000 US dollars per family member on an annual basis; and (3) combined out-of-pocket and prepaid health expenditures exceed 40% of family income. The article explores how the likelihood of households in the United States surpassing these thresholds varies by income level, extent of insurance coverage, and the number of chronic conditions. The results show clearly that there is a lack of financial protection for health services for a wide segment of the US population-particularly so for poor families and those with multiple chronic conditions. The results are placed in an international context. Similar studies in other countries would allow for more in-depth comparisons of financial protection than are currently possible.

Catastrophic cheerleading injuries

BACKGROUND

There are few epidemiologic studies of cheerleading injuries.

PURPOSE

To develop a profile of catastrophic injuries in cheerleading and to describe relevant risk factors.

STUDY DESIGN

Retrospective cohort study.

METHODS

We reviewed 29 of 39 incidents of cheerleading injuries reported to the National Center for Catastrophic Sports Injury Research from 1982 to 2002.

RESULTS

Twenty-seven of the injured cheerleaders were women. There were 1.95 direct catastrophic injuries per year or 0.6 injuries per 100,000 participants. The rate of injuries among college cheerleaders was five times that of high school participants. The most common stunts performed at the time of injury were a pyramid (9) or a basket toss (8). Catastrophic injuries included 17 severe head injuries, resulting in 13 skull fractures and 2 deaths; 8 cervical fractures or major ligament injuries; 3 spinal cord contusions; and 1 concomitant head injury and cervical fracture.

CONCLUSIONS

Suggestions for reducing catastrophic injuries in cheerleaders include enhancing the number and training of spotters, mandating floor mats for complex stunts, restricting complex stunts when surfaces are wet, and encouraging safety certification of coaches. Pyramids and basket tosses should be limited to experienced cheerleaders who have mastered all other skills and should be performed with spotters and landing mats.

Catastrophic spine injuries in American football, 1977-2001

OBJECTIVE

Cervical spinal cord injuries have been the most common catastrophic football injury and the second leading direct cause of death attributable to football skills. This study looks at the 25-year (1977-2001) experience with catastrophic neck injuries and examines not only the incidence but also the cause of injury and variables that have either increased or decreased these injuries.

METHODS

Data were collected on a national level from all organized football programs, including public school, college, professional, and youth programs, through personal contact and questionnaires on each catastrophic football injury. Funded by the National Collegiate Athletic Association, the National Federation of State High School Associations, and the American Football Coaches Association, data were collected by the National Center for Catastrophic Sports Injury Research, University of North Carolina at Chapel Hill (Frederick O. Mueller, Director, and Robert C. Cantu, Medical Director).

RESULTS

Teaching the fundamental techniques of the game, equipment standards, and improved medical care both on and off the playing field have led to a 270% reduction in permanent spinal cord injury from a peak of 20 per year during the period 1971 to 1975 to 7.2 per year during the past 10 years.

CONCLUSION

The type of injury, activity at the time of injury, level of play, and whether the injury was incurred in a game or practice are presented. On the basis of the data, recommendations are given for reducing catastrophic cervical spine injury in football.

Preparation can take the sting out of catastrophic care costs

Managing care of high-cost capitated patients can be a real challenge. But there are basic strategies capitated groups can use to minimize the costs before they reach catastrophic proportions and become budget busters.

Catastrophic pediatric sports injuries

The high school sports of wrestling, gymnastics, ice hockey, baseball, track, and cheerleading should receive closer attention to prevent injury. Safer equipment and sport-specific conditioning should be provided and injuries strictly monitored. Greater attention must also be paid to swimming and diving techniques, and continued observation is needed for heat stroke and heat intolerance in sports such as football, wrestling, basketball, track and field, and cross-country. An increased awareness of commotio cordis in sports other than baseball should include ice hockey, football, track field events, and lacrosse. American football because of the sheer numbers and associated catastrophic injury potential must continue to be monitored at the highest medical levels!

Abdominal catastrophe: visceral injury as a cause of peritonitis in patients treated by peritoneal dialysis

OBJECTIVE

Peritonitis is considered an acceptable and controllable risk in patients undergoing chronic peritoneal dialysis (PD). In contrast, peritonitis due to visceral leakage represents a true "abdominal catastrophe" because of striking morbidity and mortality. To delineate the incidence, causes, and outcomes of catastrophic peritonitis, we compared patients who developed peritonitis due to documented visceral leakage with patients who developed peritonitis due to enteric organisms without evidence of visceral leakage.

DESIGN

Retrospective chart review.

SETTING

PD Unit located in tertiary care referral center.

PATIENTS

230 patients treated by PD between January 1988 and June 1996.

MAIN OUTCOME MEASURES

All episodes of PD-related peritonitis occurring over an 8-year period. Hospital course of all patients with or without renal failure who were treated at University Hospitals of Cleveland for ischemic bowel disease, cholecystitis, viscus perforation, or diverticulitis.

RESULTS

Anatomically documented visceral injury caused 32.5% of episodes of enteric bacterial peritonitis in 72 patients between January 1988 and June 1996. The overall incidence of this "abdominal catastrophe" was 11.3%, or 26 of a total of 230 patients treated by PD. Of the 26 patients, 50% died, 30.7% survived but switched permanently to hemodialysis, and only 19.2% remained on, or returned to, PD. Compared to renal failure patients treated by hemodialysis or transplantation and to non-renal failure patients, the incidence of abdominal catastrophe was 20-60 times greater in patients treated by PD.

CONCLUSIONS

Evidence for injury of an abdominal organ should be sought in all patients treated by PD who develop peritonitis with enteric organisms. Surgical intervention is definitive for diagnosis, and if performed early may reduce morbidity and mortality.

Health insurance and the financial impact of IDDM in families with a child with IDDM

OBJECTIVE

To examine the health insurance experience and out-of-pocket health care costs of families with a child with IDDM.

RESEARCH DESIGN AND METHODS

A case-control study of 197 families with a child with IDDM and 142 control families with no diabetic children was conducted. IDDM-affected families were identified from the Allegheny County IDDM Registry. Brothers and sisters of the parents in the IDDM-affected families were asked to participate as control subjects. Health insurance coverage and the money that families spent on health care services and supplies not reimbursed by insurance (out-of-pocket costs) were assessed by questionnaire.

RESULTS

No difference was found between the IDDM-affected and control families in the percentages with or without insurance. Families with low household incomes ($10,000-$19,999) were at the greatest risk for having no insurance. While coverage provided by private plans was similar between the IDDM-affected and control families, many families had no reimbursement for insulin (10%), syringes (10%), or blood testing strips (30%). Out-of-pocket expenses were 56% higher in the IDDM-affected families than in the control families. Seventeen percent of the IDDM-affected families had expenses over 10% of their household income. This particularly affected families with low household incomes. Pre-existing illness clauses and insurance denial affected only a small proportion of the case families.

CONCLUSIONS

These data illustrate that most families with a child with IDDM have health insurance, yet still incur larger out-of-pocket health care costs than do families without the presence of diabetes. IDDM-affected families likely face a number of economic decisions regarding health insurance and the use of health care.

Asset spend-down in nursing homes. Methods and insights

The issue of how many elderly are affected by catastrophic nursing home expenses is a major part of the debate over if and/or how to reform long-term-care financing. Currently, there is some discussion regarding the magnitude of this catastrophic event, referred to as "asset spend-down", among the elderly. National data suggest the magnitude is small, while state-specific studies indicate it is greater. In addition, the literature regarding asset spend-down has presented two different measures of its magnitude, further confusing the issue. These two measures, each based on different denominators, have often been presented without adequate explanation. In this study, the authors review both measures and analyze reasons for the differences observed across studies. Major reasons identified include the type of sample used, the mix of payor source at admission, the length of time covered by the data, data on payor source/Medicaid eligibility, and the ability to observe multiple nursing-home stays within the data. Using the measure based on the number of persons who are private pay at admission, these studies indicate that approximately one fourth will eventually deplete assets. The second measure, based on a count of Medicaid residents at a point in time, indicates approximately one third were private pay when admitted. Study results indicate that national studies have underestimated the extent of spend-down due to national-level data limitations, while state-specific studies inevitably refect the specific state data set available and circumstances particular to each state. More state studies and a better understanding of asset transfer are needed.