Impact of non-communicable disease multimorbidity on health service use, catastrophic health expenditure and productivity loss in Indonesia: a population-based panel data analysis study

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Abstract

Objectives

To examine non-communicable diseases (NCDs) multimorbidity level and its relation to households’ socioeconomic characteristics, health service use, catastrophic health expenditures and productivity loss.

Design

This study used panel data of the Indonesian Family Life Survey conducted in 2007 (Wave 4) and 2014 (Wave 5).

Setting

The original sampling frame was based on 13 out of 27 provinces in 1993, representing 83% of the Indonesian population.

Participants

We included respondents aged 50 years and above in 2007, excluding those who did not participate in both Waves 4 and 5. The total number of participants in this study are 3678 respondents.

Primary outcome measures

We examined three main outcomes; health service use (outpatient and inpatient care), financial burden (catastrophic health expenditure) and productivity loss (labour participation, days primary activity missed, days confined in bed). We applied multilevel mixed-effects regression models to assess the associations between NCD multimorbidity and outcome variables,

Results

Women were more likely to have NCD multimorbidity than men and the prevalence of NCD multimorbidity increased with higher socioeconomic status. NCD multimorbidity was associated with a higher number of outpatient visits (compared with those without NCD, incidence rate ratio (IRR) 4.25, 95% CI 3.33 to 5.42 for individuals with >3 NCDs) and inpatient visits (IRR 3.68, 95% CI 2.21 to 6.12 for individuals with >3 NCDs). NCD multimorbidity was also associated with a greater likelihood of experiencing catastrophic health expenditure (for >3 NCDs, adjusted OR (aOR) 1.69, 95% CI 1.02 to 2.81) and lower participation in the labour force (aOR 0.23, 95% CI 0.16 to 0.33) compared with no NCD.

Conclusions

NCD multimorbidity is associated with substantial direct and indirect costs to individuals, households and the wider society. Our study highlights the importance of preparing health systems for addressing the burden of multimorbidity in low-income and middle-income countries.

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Most cited references 42

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Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.

Karen Barnett, Stewart Mercer, Michael Norbury … (2012)

Long-term disorders are the main challenge facing health-care systems worldwide, but health systems are largely configured for individual diseases rather than multimorbidity. We examined the distribution of multimorbidity, and of comorbidity of physical and mental health disorders, in relation to age and socioeconomic deprivation. In a cross-sectional study we extracted data on 40 morbidities from a database of 1,751,841 people registered with 314 medical practices in Scotland as of March, 2007. We analysed the data according to the number of morbidities, disorder type (physical or mental), sex, age, and socioeconomic status. We defined multimorbidity as the presence of two or more disorders. 42·2% (95% CI 42·1-42·3) of all patients had one or more morbidities, and 23·2% (23·08-23·21) were multimorbid. Although the prevalence of multimorbidity increased substantially with age and was present in most people aged 65 years and older, the absolute number of people with multimorbidity was higher in those younger than 65 years (210,500 vs 194,996). Onset of multimorbidity occurred 10-15 years earlier in people living in the most deprived areas compared with the most affluent, with socioeconomic deprivation particularly associated with multimorbidity that included mental health disorders (prevalence of both physical and mental health disorder 11·0%, 95% CI 10·9-11·2% in most deprived area vs 5·9%, 5·8%-6·0% in least deprived). The presence of a mental health disorder increased as the number of physical morbidities increased (adjusted odds ratio 6·74, 95% CI 6·59-6·90 for five or more disorders vs 1·95, 1·93-1·98 for one disorder), and was much greater in more deprived than in less deprived people (2·28, 2·21-2·32 vs 1·08, 1·05-1·11). Our findings challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas. Scottish Government Chief Scientist Office. Copyright © 2012 Elsevier Ltd. All rights reserved.

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The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

Aram V Chobanian, George L Bakris, Henry R Black … (2003)

"The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure" provides a new guideline for hypertension prevention and management. The following are the key messages(1) In persons older than 50 years, systolic blood pressure (BP) of more than 140 mm Hg is a much more important cardiovascular disease (CVD) risk factor than diastolic BP; (2) The risk of CVD, beginning at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg; individuals who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension; (3) Individuals with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD; (4) Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); (5) Most patients with hypertension will require 2 or more antihypertensive medications to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease); (6) If BP is more than 20/10 mm Hg above goal BP, consideration should be given to initiating therapy with 2 agents, 1 of which usually should be a thiazide-type diuretic; and (7) The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with and trust in the clinician. Empathy builds trust and is a potent motivator. Finally, in presenting these guidelines, the committee recognizes that the responsible physician's judgment remains paramount.

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Household catastrophic health expenditure: a multicountry analysis.

Christopher Murray, Lewis Evans, J Klavus … (2003)

Health policy makers have long been concerned with protecting people from the possibility that ill health will lead to catastrophic financial payments and subsequent impoverishment. Yet catastrophic expenditure is not rare. We investigated the extent of catastrophic health expenditure as a first step to developing appropriate policy responses. We used a cross-country analysis design. Data from household surveys in 59 countries were used to explore, by regression analysis, variables associated with catastrophic health expenditure. We defined expenditure as being catastrophic if a household's financial contributions to the health system exceed 40% of income remaining after subsistence needs have been met. The proportion of households facing catastrophic payments from out-of-pocket health expenses varied widely between countries. Catastrophic spending rates were highest in some countries in transition, and in certain Latin American countries. Three key preconditions for catastrophic payments were identified: the availability of health services requiring payment, low capacity to pay, and the lack of prepayment or health insurance. People, particularly in poor households, can be protected from catastrophic health expenditures by reducing a health system's reliance on out-of-pocket payments and providing more financial risk protection. Increase in the availability of health services is critical to improving health in poor countries, but this approach could raise the proportion of households facing catastrophic expenditure; risk protection policies would be especially important in this situation.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2021

Publication date (Electronic): 17 February 2021

Volume: 11

Issue: 2

Electronic Location Identifier: e041870

Affiliations

[1 ]departmentNossal Institute for Global Health , The University of Melbourne , Melbourne, Victoria, Australia

[2 ]departmentDepartment of Public Health, Faculty of Medicine, Public Health and Nursing , Universitas Gadjah Mada , Yogyakarta, Indonesia

[3 ]departmentSchool of Public Health and Community Medicine, Institution of Medicine, Sahlgrenska Academy , University of Gothenburg , Gothenburg, Sweden

[4 ]departmentDepartment of Global Health and Population , Harvard T H Chan School of Public Health, Harvard University , Boston, Massachusetts, USA

[5 ]SMERU Research Institute , Jakarta, Indonesia

[6 ]departmentCentre for Health Policy, School of Population and Global Health , The University of Melbourne , Melbourne, Victoria, Australia

[7 ]departmentThe George Institute for Global Health , Peking University Health Science Center , Beijing, China

[8 ]WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases , Melbourne, VIC, Australia

[9 ]departmentCenter for Health Research , Universitas Indonesia , Depok, Indonesia

[10 ]departmentDepartment of Primary Care and Public Health, School of Public Health , Imperial College London , London, UK

Author notes

[Correspondence to ] Kanya Anindya; kanindya@ 123456student.unimelb.edu.au

TM and KA are joint first authors.

Author information

Tiara Marthias http://orcid.org/0000-0001-8226-9473

Kanya Anindya http://orcid.org/0000-0001-6832-0412

Hafizah Jusril http://orcid.org/0000-0002-4748-8061

John Tayu Lee http://orcid.org/0000-0002-1551-4923

Article

Publisher ID: bmjopen-2020-041870

DOI: 10.1136/bmjopen-2020-041870

PMC ID: 7893673

PubMed ID: 33597135

SO-VID: ff8da75c-e9a8-4e25-abd4-d3eb6d82b7b4

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 19 June 2020

Date revision received : 21 January 2021

Date accepted : 28 January 2021

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ScienceOpen disciplines: Medicine

Keywords: public health,health policy,health economics

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ScienceOpen disciplines: Medicine

Keywords: public health, health policy, health economics

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Impact of non-communicable disease multimorbidity on health service use, catastrophic health expenditure and productivity loss in Indonesia: a population-based panel data analysis study

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Abstract

Objectives

Design

Setting

Participants

Primary outcome measures

Results

Conclusions

Related collections

Climate Change and Human Health

Most cited references 42

Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

Household catastrophic health expenditure: a multicountry analysis.

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Cited by 26

Most referenced authors 1,109