What are the costs associated with child and maternal health care within Australia? A study protocol for the use of data linkage to identify health service use, and health system and patient costs

Introduction: The current literature in Australia demonstrates that there are variations in access and outcomes in perinatal care based on socioeconomic factors. However, little has been done looking at the level of out-of-pocket healthcare costs associated with perinatal care. The primary aim of this project will be to quantify health service use and out-of-pocket healthcare expenditure associated with childbearing and early childhood in Queensland, Australia. Methods and analysis: This project will build Australia's first model (called Maternal & Child Cost MOD) of out-of-pocket healthcare expenditure by using administrative data from the Queensland Perinatal Data Collection, of all childbearing women and their resultant children, who gave birth in Queensland between 1 July 2012 and 30 June 2016. The current costs to the health system and out-of-pocket health care expenditure of patients associated with maternity and early childhood health care will be identified. The differences in costs based on indigenous identification, socioeconomic status and geographic location will be assessed using linear regression modelling and counterfactual modelling techniques. Ethics and dissemination: Human Research Ethics approval has been obtained from Townsville Hospital and Health Service Human Research Ethics Committee (HREC) (HREC Reference number: HREC/16/QTHS/223). Consent will not be sought from participants whose de-identified data will be used in this study. Permission to waive consent has been gained from Queensland Health under the Public Health Act 2005.The results of this study will be disseminated through publications in peer-reviewed journals and through presentations at conferences, regionally and nationally. Our target audience is clinicians, health professionals and health policy-makers

Cost of preterm birth to Australian mothers: Assessing the financial impact of a birth outcome with an increasing prevalence

Aim: To examine the differences in return to work time after childbirth; the differences in income; and the differences in out of pocket health-care costs between mothers who had a preterm birth and mothers who delivered a full term baby in Australia. Methods: Using administrative data, the length of time and 'risk' of returning to employment for mothers whose child was born premature relative to those whose child was born full term was reported. Multivariate linear regression models were constructed to assess the difference in maternal income and the differences in mean out-of-pocket costs between mothers who had a preterm birth and mothers who had a full term birth. Results: The mean length of time for mothers of babies born full term to return to work was 1.9 years and for mothers of preterm babies it was 2.8 years. Mothers of preterm babies had a significantly lower median income ah at 0-1, 2-3 and 4-5 years postpartum compared to mothers of full term babies. The adjusted mean out of pocket costs for health care paid by mothers who had a preterm birth was $1298 for those whose child was aged 32-36 weeks; and$2491 for those whose child was aged <32 weeks. This is in comparison to mothers of children born 37 weeks and over, whose mean out of pocket costs were $1059. Conclusion: Mothers who have a preterm birth have longer return to work time, a lower weekly income and also have higher out of pocket costs compared with mothers who have a full term birth

An exploration of potential output measures to assess efficiency and productivity for labour and birth in Australia

Background: In maternity services, as in other areas of healthcare, increasing emphasis is placed on improving “efficiency” or “productivity”. The first step in any efficiency and productivity analysis is the selection of relevant input and output measures. Within healthcare quantifying what is produced (outputs) can be difficult. The aim of this paper is to identify a potential output measure, that can be used in an assessment of the efficiency and productivity of labour and birth in-hospital care in Australia and to assess the extent to which it reflects the principles of woman-centred care. Methods: This paper will survey available perinatal and maternal datasets in Australia to identify potential output measures; map identified output variables against the principles of woman-centred care outlined in Australia’s national maternity strategy; and based on this, create a preliminary composite outcome measure for use in assessing the efficiency and productivity of Australian maternity services. Results: There are significant gaps in Australia’s maternity data collections with regard to measuring how well a maternity service is performing against the values of respect, choice and access; however safety is well measured. Our proposed composite measure identified that of the 63,215 births in Queensland in 2014, 67% met the criteria of quality outlined in our composite measure. Conclusions: Adoption in Australia of the collection of woman-reported maternity outcomes would substantially strengthen Australia’s national maternity data collections and provide a more holistic view of pregnancy and childbirth in Australia beyond traditional measure of maternal and neonate morbidity and mortality. Such measures to capture respect, choice and access could complement existing safety measures to inform the assessment of productivity and efficiency in maternity care

Health inequality in the tropics and its costs: a Sustainable Development Goals alert

Background: It is known that health impacts economic performance. This article aims to assess the current state of health inequality in the tropics, defined as the countries located between the Tropic of Cancer and the Tropic of Capricorn, and estimate the impact of this inequality on gross domestic product (GDP). Methods: We constructed a series of concentration indices showing between-country inequalities in disability-adjusted life years (DALYs), taken from the Global Burden of Disease Study. We then utilized a non-linear least squares model to estimate the influence of health on GDP and counterfactual analysis to assess the GDP for each country had there been no between-country inequality. Results: The poorest 25% of the tropical population had 68% of the all-cause DALYs burden in 2015; 82% of the communicable, maternal, neonatal and nutritional DALYs burden; 55% of the non-communicable disease DALYs burden and 61% of the injury DALYs burden. An increase in the all-cause DALYs rate of 1/1000 resulted in a 0.05% decrease in GDP. If there were no inequality between countries in all-cause DALY rates, most high-income countries would see a modest increase in GDP, with low- and middle-income countries estimated to see larger increases. Conclusions: There are large and growing inequalities in health in the tropics and this has significant economic cost for lower-income countries

Psychological distress increases the risk of falling into poverty amongst older Australians: the overlooked costs-of-illness

Background: This paper aimed to identify whether high psychological distress is associated with an increased risk of income and multidimensional poverty amongst older adults in Australia. Methods: We undertook longitudinal analysis of the nationally representative Household Income and Labour Dynamics in Australian (HILDA) survey using modified Poisson regression models to estimate the relative risk of falling into income poverty and multidimensional poverty between 2010 and 2012 for males and females, adjusting for age, employment status, place of residence, marital status and housing tenure; and Population Attributable Risk methodology to estimate the proportion of poverty directly attributable to psychological distress, measured by the Kessler 10 scale. Results: For males, having high psychological distress increased the risk of falling into income poverty by 1.68 (95% CI: 1.02 to 2.75) and the risk of falling into multidimensional poverty by 3.40 (95% CI: 1.91 to 6.04). For females, there was no significant difference in the risk of falling into income poverty between those with high and low psychological distress (p = 0.1008), however having high psychological distress increased the risk of falling into multidimensional poverty by 2.15 (95% CI: 1.30 to 3.55). Between 2009 and 2012, 8.0% of income poverty cases for people aged 65 and over (95% CI: 7.8% to 8.4%), and 19.5% of multidimensional poverty cases for people aged 65 and over (95% CI: 19.2% to 19.9%) can be attributed to high psychological distress. Conclusions: The elevated risk of falling into income and multidimensional poverty has been an overlooked cost of poor mental health

Out-of-pocket healthcare expenditure in Australia: trends, inequalities and the impact on household living standards in a high-income country with a universal health care system

Background: Poor health increases the likelihood of experiencing poverty by reducing a person's ability to work and imparting costs associated with receiving medical treatment. Universal health care is a means of protecting against the impoverishing impact of high healthcare costs. This study aims to document the recent trends in the amount paid by Australian households out-of-pocket for healthcare, identify any inequalities in the distribution of this expenditure, and to describe the impact that healthcare costs have on household living standards in a high-income country with a long established universal health care system. We undertook this analysis using a longitudinal, nationally representative dataset - the Household Income and Labour Dynamics in Australia Survey, using data collected annually from 2006 to 2014. Out of pocket payments covered those paid to health practitioners, for medication and in private health insurance premiums; catastrophic expenditure was defined as spending 10% or more of household income on healthcare. Results: Average total household expenditure on healthcare items remained relatively stable between 2006 and 2014 after adjusting for inflation, changing from $3133 to$3199. However, after adjusting for age, self-reported health status, and year, those in the lowest income group (decile one) had 15 times the odds (95% CI, 11.7-20.8) of having catastrophic health expenditure compared to those in the highest income group (decile ten). The percentage of people in income decile 2 and 3 who had catastrophic health expenditure also increased from 13% to 19% and 7% to 13% respectively. Conclusions: Ongoing monitoring of out of pocket healthcare expenditure is an essential part of assessing health system performance, even in countries with universal health care

Out-of-pocket healthcare expenditure and chronic disease – do Australians forgo care because of the cost?

Although we do know that out-of-pocket healthcare expenditure is relatively high in Australia, little is known about what health conditions are associated with the highest out-of-pocket expenditure, and whether the cost of healthcare acts as a barrier to care for people with different chronic conditions. Cross-sectional analysis using linear and logistic regression models applied to the Commonwealth Fund international health policy survey of adults aged 18 years and over was conducted in 2013. Adults with asthma, emphysema and chronic obstructive pulmonary disease (COPD) had 109% higher household out-of-pocket healthcare expenditure than did those with no health condition (95% CI: 50-193%); and adults with depression, anxiety and other mental health conditions had 95% higher household out-of-pocket expenditure (95% CI: 33-187%). People with a chronic condition were also more likely to forego care because of cost. People with depression, anxiety and other mental health conditions had 7.65 times higher odds of skipping healthcare (95% CI: 4.13-14.20), and people with asthma, emphysema and chronic obstructive pulmonary disease had 6.16 times higher odds of skipping healthcare (95% CI: 3.30-11.50) than did people with no health condition. People with chronic health conditions in Canada, the United Kingdom, Germany, France, Norway, Sweden and Switzerland were all significantly less likely to skip healthcare because of cost than were people with a condition in Australia. The out-of-pocket cost of healthcare in Australia acts as a barrier to accessing treatment for people with chronic health conditions, with people with mental health conditions being likely to skip care. Attention should be given to the accessibility and affordability of mental health services in Australia

Trusting the evidence in evidence-based practice: use of fetal fibronectin testing for threatened preterm labour in remote far North Queensland

Background: Threatened preterm labour is a common reason for medical transfer from remote communities, however many transferred women do not deliver preterm. A tool for prediction of preterm birth such as fetal fibronectin may reduce transfers and the related social and economic costs. Aim: To review the use of fetal fibronectin testing in women transferred for threatened preterm labour from Cape York to Cairns Hospital between 2011 and 2015 and determine the role testing could play in reducing transfers and associated costs. Materials/methods: Royal Flying Doctor Service and Cairns Hospital records were accessed with women transferred solely for threatened preterm labour included in the study. Fetal fibronectin testing, hospital admission, outpatient stays and birth outcome data was collated and analysed. The National Hospital Cost Data Collection, round 19 was used to assign costs. Results: Forty-seven women were included in the study however only 20 underwent fetal fibronectin testing. Transfer of 30 women who had either a negative test or were not tested but delivered at term resulted in 41 inpatient nights and 443 excess outpatient nights, costing an estimated A$61,579. Aeromedical transfers were estimated to cost a further$151,500. Conclusion: Adherence to clinical guidelines and greater availability and use of fetal fibronectin testing in Cape York has the potential to reduce aeromedical transfers for threatened preterm labour. Substantial inpatient and excess outpatient stays could be avoided with associated reduction in health system and social costs. Strategies to improve adherence to guidelines and increase access to testing are required

Patient co-payments for women diagnosed with breast cancer in Australia

Purpose: Among Australian women, breast cancer is the most commonly diagnosed cancer. The out-of-pocket cost to the patient is substantial. This study estimates the total patient co-payments for Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for women diagnosed with breast cancer and determined the distribution of these costs by Indigenous status, remoteness, and socioeconomic status. Methods: Data on women diagnosed with breast cancer in Queensland between 01 July 2011 and 30 June 2012 were obtained from the Queensland Cancer Registry and linked with hospital and Emergency Department Admissions, and MBS and PBS records for the 3 years post-diagnosis. The data were then weighted to be representative of the Australian population. The co-payment charged for MBS services and PBS prescriptions was summed. We modelled the mean co-payment per patient during each 6-month time period for MBS services and PBS prescriptions. Results: A total of 3079 women were diagnosed with breast cancer in Queensland during the 12-month study period, representing 15,335 Australian women after weighting. In the first 3 years post-diagnosis, the median co-payment for MBS services was AU$748 (IQR, AU$87–2121; maximum AU$32,249), and for PBS prescriptions was AU$ 835 (IQR, AU$480–1289; maximum AU$5390). There were significant differences in the co-payments for MBS services and PBS prescriptions by Indigenous status and socioeconomic disadvantage, but none for remoteness. Conclusions: Women incur high patient co-payments in the first 3 years post-diagnosis. These costs vary greatly by patient. Potential costs should be discussed with women throughout their treatment, to allow women greater choice in the most appropriate care for their situation

Evidence of overuse? Patterns of obstetric interventions during labour and birth among Australian mothers

Background: There is global concern for the overuse of obstetric interventions during labour and birth. Of particular concern is the increasing amount of mothers and babies experiencing morbidity and mortality associated with caesarean section compared to vaginal birth. In high-income settings, emerging evidence suggests that overuse of obstetric intervention is more prevalent among wealthier mothers with no medical need of it. In Australia, the rates of caesarean section and other obstetric interventions are rising. These rising rates of intervention have been mirrored by a decreasing rate of unassisted non-instrumental vaginal deliveries. In the context of rising global concern about rising caesarean section rates and the known health effects of caesarean section on mothers and children, we aim to better characterise the use of obstetric intervention in the state of Queensland, Australia by examining the characteristics of mothers receiving obstetric intervention. Identifying whether there is overuse of obstetric interventions within a population is critical to improving the quality, value and appropriateness of maternity care. Methods: The association between demographic characteristics (at birth) and birth delivery type were compared with chi-square. The percentage of mothers based on their socioeconomic characteristics were reported and differences in percentages of obstetric interventions were compared. Multivariate analysis was undertaken using multiple logistic regression to assess the likelihood of receiving obstetric intervention and having a vaginal (non-instrumental) delivery after accounting for key clinical characteristics. Results: Indigenous mothers, mothers in major cities and mothers in the wealthiest quintile all had higher percentages of all obstetric interventions and had the lowest percentages of unassisted (non-instrumental) vaginal births. These differences remained even after adjusting for other key sociodemographic and clinical characteristics. Conclusions: Differences in obstetric practice exist between economic, ethnic and geographical groups of mothers that are not attributable to medical or lifestyle risk factors. These differences may reflect health system, organisational and structural conditions and therefore, a better understanding of the non-clinical factors that influence the supply and demand of obstetric interventions is required