BACKGROUND: The cost of treatment for infectious shock in intensive care in Vietnam is unknown. METHODS: We prospectively investigated hospital bills for adults treated for septic and dengue shock in Vietnam and calculated the proportion who faced catastrophic health care expenditures. RESULTS: The median hospital bills were US$617 for septic shock (n=100) and US$57 for dengue shock (n=88). Catastrophic payments were incurred by 47% (47/100) and 13% (11/88) of patients with septic shock and dengue shock, respectively, and 56% (25/45) and 84% (5/6) fatal cases of septic shock and dengue shock respectively. CONCLUSIONS: Further advocacy is required to moderate insurance co-payments for costly critical care interventions

Chau Nguyen, VV

Hao Nguyen, V

McBride, A

Thuy Duong, B

Thwaites, CL

Turner, HC

Transactions of the Royal Society of Tropical Medicine and Hygiene

English

BACKGROUND:The cost of treatment for infectious shock in intensive care in Vietnam is unknown. 

METHODS:We prospectively investigated hospital bills for adults treated for septic and dengue shock in Vietnam and calculated the proportion who faced catastrophic health care expenditures. 

RESULTS:The median hospital bills were US$617 for septic shock (n=100) and US$57 for dengue shock (n=88). Catastrophic payments were incurred by 47% (47/100) and 13% (11/88) of patients with septic shock and dengue shock, respectively, and 56% (25/45) and 84% (5/6) fatal cases of septic shock and dengue shock respectively. 

CONCLUSIONS:Further advocacy is required to moderate insurance co-payments for costly critical care interventions

McBride, Angela

Chau Nguyen, V Vinh

Thwaites, C Louise

Turner, Hugo C

Oxford University Research Archive

Catastrophic health care expenditure due to septic shock and dengue shock in Vietnam

Background  The cost of treatment for infectious shock in intensive care in Vietnam is unknown.    Methods  We prospectively investigated hospital bills for adults treated for septic and dengue shock in Vietnam and calculated the proportion who faced catastrophic health care expenditures.    Results  The median hospital bills were US$617 for septic shock (n=100) and US$57 for dengue shock (n=88). Catastrophic payments were incurred by 47% (47/100) and 13% (11/88) of patients with septic shock and dengue shock, respectively, and 56% (25/45) and 84% (5/6) fatal cases of septic shock and dengue shock respectively.    Conclusions  Further advocacy is required to moderate insurance co-payments for costly critical care interventions

Angela McBride (5767439)

B Thuy Duong (16284758)

V Vinh Chau Nguyen (16284761)

C Louise Thwaites (16284764)

Hugo C Turner (16279046)

V Hao Nguyen (16284767)

Sussex Research Online

Spiral - Imperial College Digital Repository

SHORTCOMMUNICATIONTrans R Soc Trop Med Hyg 2019; 00: 1–3doi:10.1093/trstmh/trz064Catastrophic health care expenditure due to septic shock and dengueshock in VietnamAngela McBridea,b,*, B. Thuy Duongb,c, V. Vinh Chau Nguyenc, C. Louise Thwaitesb, Hugo C. Turnerb andV. Hao NguyencaDepartment of Global Health and Infection, Brighton and Sussex Medical School, Falmer, Brighton, England, BN1 9PX; bOxfordUniversity Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam; cHospital for Tropical Diseases, 764 Vo Van Kiet,Quan 5, Ho Chi Minh City, Vietnam*Corresponding author: Telephone: +84819420533; E-mail: a.mcbride@bsms.ac.ukReceived 26 April 2019; revised 17 June 2019; editorial decision 17 June 2019; accepted 18 June 2019Background: The cost of treatment for infectious shock in intensive care in Vietnam is unknown.Methods: We prospectively investigated hospital bills for adults treated for septic and dengue shock inVietnam and calculated the proportion who faced catastrophic health care expenditures.Results: The median hospital bills were US$617 for septic shock (n=100) and US$57 for dengue shock (n=88).Catastrophic payments were incurred by 47% (47/100) and 13% (11/88) of patients with septic shock anddengue shock, respectively, and 56% (25/45) and 84% (5/6) fatal cases of septic shock and dengue shockrespectively.Conclusions: Further advocacy is required to moderate insurance co-payments for costly critical careinterventions.Keywords: cost of illness, septic, severe dengue, shockBackgroundIn low- and middle-income countries (LMICs), where a high bur-den of critical illness is attributable to severe infection, intensivecare units (ICUs) are rapidly expanding in number and capability.Although the cost-effectiveness of critical care for severe infec-tion is understudied in LMICs, extrapolation of data from high-income settings suggests that the costly but lifesaving interven-tions provided in the ICU likely result in net economic gains tosociety.1 But despite the roll-out of universal health insurance inVietnam, patients continue to contribute a significant proportionof their own hospital bills.2 Therefore the conversation aroundcost-effectiveness of critical care in LMICs should be temperedwith an understanding of the burden that such out-of-pocketpayments place on patients and their families.We investigated the total hospital bills and insurance contri-butions for adults treated for the two most frequent causes ofinfectious shock in southern Vietnam, septic shock and dengueshock, and the proportion of patients/families who faced cata-strophic payments for health care.MethodsWe conducted this prospective observational study betweenNovember 2014 and January 2016 on adult ICU at the Hospitalfor Tropical Diseases, a tertiary referral hospital for infectiousdiseases in Ho Chi Minh City, Vietnam. After obtaining writtenconsent, we recorded patient demographics, clinical severity,hospital mortality, hospital bill, insurance status and contribu-tions for adults (≥15 y) admitted with septic shock and dengueshock (with or without haemorrhagic complications or multi-organ failure) as defined by Sepsis 33 and the World HealthOrganization criteria,4 respectively. In line with SustainableDevelopment Goal 3.8.2, a catastrophic payment was definedas occurring when the patient’s out-of-pocket health care pay-ment was >10% of the average annual household expenditurein Vietnam,5 which was estimated to be US$2986.51 in 2014.2,6Cost data were converted to US$ using the average exchangerate over the study period.6 Statistical analyses were conductedusing Stata version 8.0 (StataCorp, College Station, TX, USA);hospital bills were compared by Wilcoxon rank-sum test.© The Author(s) 2019. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.1 of 3ResultsA total of 100 patients were treated for septic shock and 88 haddengue shock. The median hospital bill for septic shock (US$617[interquartile range {IQR} US$283–1170, range US$56–9144])were >10-fold higher than for dengue shock (US$57 [IQR US$-37–92, range US$10–10 379]). Patients admitted with septicshock were older, had more comorbidities and had higher AcutePhysiology, Age, Chronic Health Evaluation (APACHE) II scores atbaseline than patients with dengue shock. Requirement forvasopressor support, mechanical ventilation, haemofiltrationand transfusion was more common among patients with septicshock than dengue shock (Table 1).The proportion of patients incurring catastrophic paymentswas 47% (47/100) for septic shock and 13% (11/88) for dengueshock. The families of 56% (25/45) and 83% (5/6) of patientswho died from septic shock and dengue shock, respectively,incurred catastrophic expenses. Hospital bills were significantlygreater for patients who died from vs survived septic shock(p<0.001) and dengue shock (p<0.001).The proportion of patients with health insurance was 52%(52/100) and 36% (32/88) for septic shock and dengue shock,respectively. Hospital bills were significantly higher amonguninsured vs insured patients with septic shock (p<0.001) anddengue shock (p<0.001). Among patients with catastrophicexpenditures, 30% (14/47) and 36% (4/11) of patients withseptic shock and dengue shock, respectively, had healthinsurance.DiscussionThis study highlights the frequent requirement for patients andfamilies to make catastrophic payments for treatment of infec-tious shock in Vietnam. This is especially true for families ofnon-survivors, who may face the double blow of losing an eco-nomically active member of their household and having to paya large health care bill. The median cost of treatment for septicshock was much greater than for dengue shock. This is likelydue to a combination of a longer ICU stay, increased require-ments for organ support and the cost of antibiotic therapy.Patients with septic shock more frequently had knowncomorbidities when compared with those with dengue shock.This may also have contributed to the increased length of ICUstay and organ support requirements.Having health insurance protected against but did not com-pletely prevent catastrophic hospital bills. Thus, together with thecontinued expansion of health insurance coverage in Vietnam, strat-egies are needed to protect insured patients from very large co-payments for the high-cost interventions they receive in the ICU.Very few studies have reported patient costs for critical carein LMICs. A single-centre study in Thailand (an upper-middleTable 1. Demographics, hospital bills and insurance contributions for patients with septic shock and dengue shockSeptic shock (n=100) Dengue shock (n=88)Patient characteristicsAge, years, median (25th–75th centile) 53 (41–63) 25 (19–32)Male, n (%) 55 (55) 31 (35)Charlson Comorbidity Index, median (25th–75th centile) 1 (0–3) 0 (0–0)Duration of ICU admission, days, median (25th–75th centile) 3 (2–5) 1 (1–2)Duration of hospital admission, days, median (25th–75th centile) 7 (2–14) 5 (4–7)Death in hospital, n (%) 45 (45) 6 (6.8)Baseline APACHE II score, median (25th–75th centile) 18.5 (14–23) 4 (3–8)Organ support required, n (%)Vasopressors 86 (86) 12 (13.6)Mechanical ventilation 51 (51) 11 (12.5)Haemofiltration 27 (27) 9 (10.2)Transfusion (packed red cells, fresh frozen plasma, platelets) 22 (22) 11 (12.5)Hospital bill and catastrophic costsProportion with health insurance (any), n (%) 52 (52) 32 (36.4)Hospital bill, US$, median (25th–75th centile) 617 (283–1170) 57 (37–92)Proportion of hospital bill co-paid by insured patients, %, median(25th–75th centile)26.3 (23.4–36.1) 22.4 (21.9–23.8)Proportion with catastrophic expenses, n (%) 47 (47.0) 11 (12.5)Proportion of patients with insurance with catastrophic expenses, n (%) 14/47 (29.8) 4/11 (36.4)Costs of health care in non-survivors Septic shock (n=45) Dengue shock (n=6)Proportion of bereaved families with catastrophic expenses, n (%) 25 (55.5) 5 (83.3)Hospital bill, US$ (patients with insurance), median (25th–75th centile) 241 (95–960) 521 (236–1321)Hospital bill, US$ (patients without insurance), median (25th–75th centile) 960 (301–1468) 7773 (5624–7956)Cost data are expressed in nominal prices.A. McBride et al.2 of 3income country) reported the median hospital bill for patientswith septic shock (2011–2015) as US$2792. The authors of thestudy did not find a significant difference in costs between survi-vors and non-survivors, which is at odds with our results.7Our study has limitations. We did not have access to itemizedbills and our data were collected from a tertiary hospital, thusour patients may have had more severe disease and/or accessto high-cost medical interventions not available in district orprovincial hospitals. We did not account for health care costsbefore or after hospitalization. In addition, we did not calculatepatients’/informal caregivers’ direct non-medical and productiv-ity costs; a longitudinal study is under way to investigate these.Including such costs will likely increase the proportion facingcatastrophic health expenditures. Further, applying an arbitrarythreshold for catastrophic expenditures may not reflect the trueability of patients and families to absorb large health care bills.ConclusionsIn Vietnam, both insured and uninsured patients treated in theICU for septic shock and dengue shock frequently face cata-strophic bills for their hospital care. Our results indicate theneed for ongoing advocacy with policymakers to moderate co-payments for high-cost critical care interventions.Authors’ contributions: DBT, CLT, NVVC, NVH and AMB conceived thestudy. DBT and NVVC designed the study protocol. DBT and NVH carriedout the clinical assessment. AMB, CLT and HCT carried out the analysisand interpretation of data. AMB, HCT and CLT drafted the manuscript.DBT, NVVC and NVH critically revised the manuscript for intellectual con-tent. All authors read and approved the final manuscript. AMB and CLTare guarantors of the paper.Acknowledgements: We thank the patients who consented to take partin this study and the doctors, nurses and nursing aids of the adult ICUat the Hospital for Tropical Disease, Ho Chi Minh City, Vietnam.Funding: This work was supported by the Wellcome Trust (203905/Z/16/Z and 106680/B/14/Z).Competing interests: None declared.Ethical approval: Ethical approval was obtained in advance from theethics committees of the Hospital for Tropical Diseases, Ho Chi Minh City,Vietnam and the Oxford Tropical Research Ethics Committee, Oxford, UK.References1 Thwaites CL, Angus DC, Nguyen Thi Hoang M, et al. Current challengesin the management of sepsis in ICUs in resource-poor settings andsuggestions for the future. Intensive Care Med. 2017;43(5):612–24.2 Lofgren C. Catastrophic health expenditure in Vietnam: studies of problemsand solutions [dissertation]. Umeå, Sweden: Umeå University; 2014.3 Singer M, Deutschman CS, Seymour C, et al. The third internationalconsensus definitions for sepsis and septic shock (Sepsis-3). JAMA.2016;315(8):801–10.4 World Health Organization. Dengue guidelines for diagnosis, treat-ment, prevention and control: new edition. Geneva: World HealthOrganization; 2009.5 World Health Organization. Monitoring Sustainable Development Goals –Indicator 3.8.2. Available at: https://www.who.int/health_financing/topics/financial-protection/monitoring-sdg/en/ (accessed 26 March 2019).6 OFX. Historical exchange rates. Monthly average rates. Available at:https://www.ofx.com/en-au/forex-news/historical-exchange-rates/monthly-average-rates/ (accessed 26 March 2019).7 Khwannimit B, Bhurayanontachai R. The direct costs of intensive caremanagement and risk factors for financial burden of patients withsevere sepsis and septic shock. J Crit Care. 2015;30(5):929–34.Transactions of The Royal Society of Tropical Medicine and Hygiene3 of 3

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Catastrophic health care expenditure due to septic shock and dengue shock in Vietnam

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