RESOURCE UTILIZATION AND COST OF RHEUMATIC FEVER (RF)
Maria Teresa Terreri1
Marcos Bosi Ferraz2
José Goldenberg3
Cláudio Len1
Maria Odete E. Hilário4
1 Pediatric Rheumatologist. Allergy, Immunology and
Rheumatology Division – Dept. of Pediatrics.
2 Associate Professor. Clinical Epidemiology Unit/ Rheumatology Division – Department
of Medicine.
3 Associate Professor. Rheumatology Division – Department of Medicine
4. Associate Professor, Head. Allergy, Immunology and Rheumatology Division – Dept.
of Pediatrics.
Universidade Federal de São Paulo – Escola Paulista de Medicina. UNIFESP-São Paulo, Brazil.
Correspondence to:
Maria Teresa Terreri
Rua Loefgreen 2381, Ap.141.
São Paulo – SP, Brazil
CEP 04040-004
Fax: 5511-55791590
Key Indexing Terms: Rheumatic Fever – Children – Costs – Cost of Illness – Resource utilization – Economic Aspects
Short running footline: Costs in Rheumatic Fever
ABSTRACT; INTRODUCTION; PATIENTS AND METHODS; RESULTS; DISCUSSION; REFERENCES
Introduction: Rheumatic fever (RF) is the most frequent and important cause of acquired cardiovascular disease in childhood and adolescence. Inadequate anti-streptococcal prophylaxis leads to excessive and unnecessary expenses related to RF treatment. The socioeconomic impact of this disease in Brazil, including utilization of resources, and direct and indirect costs of RF to patients and their families and to society are largely unknown. The aim of the present study was to evaluate the utilization of resources, and direct and indirect costs related to the RF patients in a tertiary center caring for low-income patients in the city of São Paulo, Brazil.
Patients and Methods: One hundred patients with RF younger than 18 years of age, with a follow-up of at least one year, were sequentially selected for the study. Inclusion criteria were: patients under 18 years old, follow-up in the Clinic for at least one year, and ability of the patient or guardian to provide complete information on a questionnaire. Additional data were collected from the patients medical charts. The utilization of resources was evaluated for each patient, throughout the entire course of the disease. The Brazilian currency (reais) was converted to US$ in the year of the study (in 1998 – 1US$= R$1.15). Costs were determined for the patients and their families as well as for the society, using parameters from three different systems: the national public health system, named "Unified Health System", used by most lower income groups; the Brazilian Medical Association, which regulates charges and fees utilized by health plans and insurance companies; and costs charged by the Private practitioners, paid out the patients’ own pocket.
Results: The RF population studied belonged to a low socioeconomic level. The mean monthly family income was US$ 625.2. The illiteracy rate among the parents was 16%. The mean disease duration was 3.9 years (range 1 to 10 years). Patients had a total of 1,657 medical consultations, 22 hospital admissions and 4 admissions to the Intensive Care Unit (ICU). Two patients underwent cardiac surgery. Work absenteeism among parents was calculated as 22.9%, equivalent to 901 days of missed work. Approximately 5% of the parents lost their jobs. The patients showed a high rate of school failure (22%). Considering the public system as a reference, direct, indirect and total costs for the society per 100 patients, throughout the entire disease duration of RF were US$ 105,860 (US$ 271/ patient/ year), US$ 18,803 (US$ 48/ patient/ year) and US$ 124,663 (US$ 319/ patient/ year), respectively. When health care plan and private systems were taken as reference, the total costs were US$ 423,550 and US$ 684,351, respectively.
Conclusions: RF and rheumatic heart disease have an important socioeconomic impact in Brazil, and costs of RF comprise approximately 1.3% of the annual family income. The estimated annual costs of RF for the society, in Brazil, is US$ 51,144,347.00.
Rheumatic fever (RF) is the most frequent and important cause of acquired cardiovascular disease in childhood and adolescence, posing a financial burden on the patient, the family and the society.1 The incidence of RF in families of low socioeconomic level living in underdeveloped, overpopulated countries, is approximately 100 cases/100,000 children.2 The prevalence of RF in this countries is 5.3/1000 healthy school-age children.3
The cost of RF is high, due to repeated medical consultations, hospital admissions, particularly of patients with rheumatic heart disease, expenses with clinical and surgical treatment, and the physical and psychological burden on the patients and their families. In addition, there is a substantial cost related to considerable losses of productivity for the society and to individual suffering.2
The specific aim of the present study was to evaluate the utilization of resources, and the impact of RF for children and adolescents with RF, attending in a tertiary health care hospital which provides care to low income patients in the city of São Paulo and to determine the direct and indirect costs related to RF patients, their families and the society. As a secondary aim we compare the costs of RF using values for fees and services from three different levels of organization of health care: the National Public Health System, Brazilian Medical Society and fees practiced by private practitioners.
One hundred patients were sequentially selected during a three month period among those attending the Pediatric Rheumatology Unit of the Federal University of São Paulo (UNIFESP), at Hospital São Paulo, with diagnosis of RF based on the modified Jones’ criteria (DAJANI et al, 1992)4. Our unit is part of a public general hospital supported by federal government. Inclusion criteria were: age under 18 years old, follow-up in the Clinic for at least one year, and ability of the patient or guardian to provide complete information on a questionnaire. The questionnaire was administered by one of the researcher (MTT) and included demographic data, clinical data, prescriptions, use of primary and secondary prophylaxis with benzathine penicillin G, information on hospitalizations and cardiac surgery, consultation in other health care facilities, socioeconomic status of the family, travel expenses incurred for treatment and number of workdays lost by the guardian and school days lost by the patient due to the disease. Additional data were collected from the patients medical charts in order to compare with the patients or guardians information, and for calculation of costs, including number of medical visits, number of days in the hospital, laboratory tests performed during hospital stays and clinical visits, and medications taken by the patient throughout the entire course of the disease. We evaluated the medical prescription and medical reports from other institutions and care providers to obtain patients data prior to the enrollment in our clinic.
For the analysis of costs, direct costs were those resulting from direct interventions in the disease based on other methodologic studies5,6. Direct costs attributed to the patients/family were: medical consultations, laboratory tests, transportation and costs of other services; direct costs attributed to the society were consultations not paid by the patient/family, hospital admissions, cardiac catheterizations and surgery, medications and laboratory tests provided by the hospital or public clinics, as well as expenses in the hospital not formally reimbursed by the public health system, which are ultimately paid by the society. Indirect costs for the patients/family were those resulting from deductions subtracted from the parent's salary by the employer, as a result of medical consultations or hospital admissions for the treatment of the disease; indirect costs for the society were the production losses related to sick days. The Brazilian currency (reais) was converted to US$ in the year of the study (in 1998 – 1US$= R$1.15).
The cost for each utilized resource was estimated based on the standard reimbursement fees and charges for services and procedures from the Unified Health System (government), which reflects the costs with a patient covered by the public health system. This system was considered as the reference to derive the costs for two other groups: 1) Index of reimbursement of services and procedures from the Brazilian Medical Association, which regulates fees charged by health plans and insurance companies, paid by the patients or families; and 2) Prices charged by private hospitals and practitioners, obtained by taking the mean of the fees charged by three private hospitals and three private laboratories, reflecting the costs of patients using private health services. Prices of prescription medications were obtained from the index of prices for public pharmacies (Pharmacy Guide, Official Diary, executive secretary, document no. 37, May 1992). Prices of medications provided free-of-charge by public outpatient clinics were calculated based on prices of the public "Central of Medications". Travel expenses were calculated by estimating the costs with public transportation (bus, metro or train) or private transportation (cost of gasoline for a round trip of an estimated distance of 10 km to the hospital plus cost of 2-hour parking). It was assumed that patients who used health insurance plans and private patients used private transportation.
The loss of income was calculated from the proportion of missed workdays due to the disease, in relation to the mean family income. These losses were attributed to the patient when the guardian had his (her) daily wage subtracted from the monthly salary, and to the society if it was considered a sick pay.
The demographic and clinical characteristics of the patients are presented on Table 1. There was a predominance of female patients (58%); the mean age at disease onset was 9.2 years, and the mean disease duration was 3.9 years. The most frequent initial maifestation (isolated or associated) was arthritis 68% of the patients, followed by carditis (49%) and chorea (32%). The socioeconomic characteristics are shown on Table 2. The mean family monthly income was US$ 625. Mean number of family members was 5.1, and approximately 16% of the parents were illiterate.
Table 3 summarizes total numbers of medical consultations, hospital admissions, laboratory tests, the main medications and cardiac surgeries. Of the 1,859 medical consultations, 202 occurred outside our institution, prior to enrollment of the patient in the Rheumatology Clinic. Admissions in our hospital were due to carditis (20 patients) and chorea (2 patients). The most frequently used medicines were benzathine penicillin G (98% of the patients) and acetylsalicylic acid (ASA) 500mg tablets (49% of the patients). Other medications as well as laboratory tests were considered but not listed because of the low frequency they were used. All patients had erythrocyte sedimentation rate (ESR) and antistreptolysin-O (ASO) titer determined, at a mean of one test/patient/year. Two hundred-two laboratory tests were performed elsewhere. Cardiac surgeries were mitral valvuloplasty on two occasions in one patient, and aortic valve replacement, mitral valvuloplasty and mitral commissurotomy in another patient. Patients did not have medical consultations or hospital admissions in other health care facilities besides our hospital during the follow-up period.
Direct (consultations, hospital admissions, catheterism, cardiac surgeries, medications, laboratory tests and transportation) and indirect total costs for the society at large are presented on Table 4. Considering the public system as a reference, direct, indirect and total costs for the society per 100 patients, throughout the entire disease duration of RF were US$ 105,860 (US$ 271/ patient/ year), US$ 18,803 (US$ 48/ patient/ year) and US$ 124,663 (US$ 319/ patient/ year), respectively. When health care plan and private systems were taken as reference, total costs were US$ 423,550 and US$ 684,351, respectively.
Direct (consultations, medications, laboratory tests and transportation) and indirect costs for the patient/family are shown on table 5. Considering the public system as a reference, direct, indirect and total costs were US$ 37,692, US$ 334 and US$ 38,026, respectively. When health care plan and private systems were taken as reference, total costs were US$ 185,647 and US$ 383,930, respectively.
Travel expenses incurred by the patients and their guardians, related to medical consultations, laboratory tests or hospital admissions, were calculated based on a total of 2,667 visits. There were 12,391 bus trips, 1,914 metro trips and 796 train trips. Seventeen patients used private transportation for at least one of their visits, comprising a total of 167 trips.
Indirect costs were estimated based on the losses of school or workdays. Forty-three (22.9%) of fathers or mothers missed 901 workdays. Of these missed workdays, 16 caused daily wages to be deducted from monthly salaries. The remaining 885 were considered sick day, and losses were attributed to the society. Nine guardians (4.8%) lost their jobs due to work absenteeism related to the child’s disease. Indirect costs estimated based on the mean monthly income (US$ 21 per day) were US$ 334 and US$ 18,803 attributed to the patient/family and to the society, respectively. Eighty-four patients lost 1,812 school days since the beginning of their illness, at a mean of 21.6 days/patient. School absenteeism was due to disease activity or to medical consultations and/or laboratory tests. Twenty-two children failed to be promoted to the next grade in school (0.06 failures/patient/ year).
Considering the incidence of RF in Brazil to be similar to that in other underdeveloped countries, which is reported as approximately 100/100,000 individuals/year, we can estimate the costs of RF for the population of the city of São Paulo (11 million inhabitants), the State of São Paulo (20 million inhabitants) and the country as a whole (160 million inhabitants). The annual costs, considering that all patients diagnosed are treated, were estimated at US$ 3,516,174, US$ 6,393,043 and US$ 51,144,347, respectively. The estimated total costs for Brazil correspond to 0.007% of the Gross National Product (in 1998). Of this 3.2% were alocated to the public health care system. We estimated that 0.2% were alocated to the care of RF.
Considering the public system as a reference, total costs for the society per 100 patients, throughout the entire disease duration of RF (direct and indirect costs) were 124,663 (US$ 319/ patient/ year). When health care plan and private systems were taken as reference, total costs were US$ 423,550 and US$ 684,351, respectively. Our results show that RF and rheumatic heart disease present a major financial burden for society in Brazil.
The population in this study was of low socioeconomic level, with a high rate of illiteracy, suggesting that difficulties may have been associated with poor understanding of treatment goals and follow-up of patients. For some patients, diagnosis was delayed for up to two years. Delay in starting secondary prophylaxis with benzathine penicillin G and the high rate of prophylaxis failure (36.4%) found in this study may account for an increased risk of recurrence and rheumatic heart disease. Hospital admissions for chronic rheumatic heart disease are more common among patients 20 to 60 years old7. We have observed a low frequency of hospital admissions in our patients, perhaps because they belonged to a younger age group.
Loss of workdays among parents caused significant psychosocial impact, including deductions of daily wages from the monthly salary, despite justification of absence, and even loss of the job, for some of the parents. This causes aggravation of the socioeconomic problems of these low-income families. School absenteeism and failure is a common problem among low-income populations, which was aggravated among RF children in our study, as indicated by the finding of a high rate of school failure (22%) among patients. We can not attribute this to the medical condition, since the figures of healthy children with the same socioeconomic level are similar in our country.
Although benzathine penicillin G for secondary prophylaxis of RF should be theoretically available through the public system in our country, we found in the present study that the majority of the patients (74%) had to pay for this medication in regular pharmacies sometimes, or at all times, throughout the illness, generating more expenses and possibly decreasing treatment compliance.
We estimate that a mean of US$ 97/year, approximately 1/12 of our current annual minimal wage, was spent by each RF patient/family on direct costs, if the patient was cared by the public system. This amount was five-fold and ten-fold higher if the same patient received care provided by the health insurance plan and private systems, respectively. Whether the people who would use these two other systems would have the same course of disease remains unknown.
In Brazil, hospitals taking care of these patients are underpaid by the public system, which leads to financial deficits compromising further the quality of care. As expected among RF patients, the highest costs were for those with rheumatic heart disease, who required hospital admissions and surgery, and needed more laboratory tests and medications. Direct costs for the patient were US$ 97/patient/ year, adding up to a total of US$ 271/patient/year for the society. Total costs (direct and indirect) were estimated at US$ 97/patient/year and US$ 320/patient/year, for the patient/family and the society, respectively. Prophylaxis with benzathine penicillin G has been shown to prevent disease recurrence, reduce health care costs and decrease the incidence of new cases of the disease8. Secondary prophylaxis with benzathine penicillin G 1,200.000 Units every 21 days costs US$ 23/ patient/year, much less than the direct and indirect costs of RF for the society, estimated as US$ 320/patient/year.
There are costs that could not be calculated, including those resulting from impaired quality of life as a consequence of pain and anxiety, for the patients and their families; limited work opportunities due to physical limitations as these patients reach adulthood; eventual limitations due to school absenteeism or to loss of family income.
In conclusion, our results show that RF and rheumatic heart disease present a major financial burden for society in Brazil. In countries such as ours, financial resources are limited and cost/benefit issues should be carefully analyzed. Therefore, preventive measures should be emphasized whenever possible, including the case of RF. Total costs (direct and indirect), based on reimbursements by our public health system were probably underestimated. In fact, when reimbursement parameters from heath plans and insurance companies and private systems were used, the costs were five and ten-fold higher, respectively. The psychosocial impact of RF in Brazil, as shown by loss of workdays, loss of jobs, school absenteeism and high rates of school failures, was remarkable, and could be associated with further disadvantages, regarding less work opportunities for these children in the future.
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