Effect of multimorbidity on utilisation and out-of-pocket expenditure in Indonesia: quantile regression analysis

Kanya Anindya,John Tayu Lee,Rifat Atun,Alexander van Heusden,Tianxin Pan,Barbara McPake,Nawi Ng,Tiara Marthias,Yang Zhao

doi:10.1186/s12913-021-06446-9

Abstract

BackgroundMultimorbidity (the presence of two or more non-communicable diseases) is a major growing challenge for many low-income and middle-income countries (LMICs). Yet, its effects on health care costs and financial burden for patients have not been adequately studied. This study investigates the effect of multimorbidity across the different percentiles of healthcare utilisation and out-of-pocket expenditure (OOPE).MethodsWe conducted a secondary data analysis of the 2014/2015 Indonesian Family Life Survey (IFLS-5), which included 13,798 respondents aged ≥40 years. Poisson regression was used to assess the association between sociodemographic characteristics and the total number of non-communicable diseases (NCDs), while multivariate logistic regression and quantile regression analysis was used to estimate the associations between multimorbidity, health service use and OOPE.ResultsOverall, 20.8% of total participants had two or more NCDs in 2014/2015. The number of NCDs was associated with higher healthcare utilisation (coefficient 0.11, 95% CI 0.07–0.14 for outpatient care and coefficient 0.09 (95% CI 0.02–0.16 for inpatient care) and higher four-weekly OOPE (coefficient 27.0, 95% CI 11.4–42.7). The quantile regression results indicated that the marginal effect of having three or more NCDs on the absolute amount of four-weekly OOPE was smaller for the lower percentiles (at the 25th percentile, coefficient 1.0, 95% CI 0.5–1.5) but more pronounced for the higher percentile of out-of-pocket spending distribution (at the 90th percentile, coefficient 31.0, 95% CI 15.9–46.2).ConclusionMultimorbidity is positively correlated with health service utilisation and OOPE and has a significant effect, especially among those in the upper tail of the utilisation/costs distribution. Health financing strategies are urgently required to meet the needs of patients with multimorbidity, particularly for vulnerable groups that have a higher level of health care utilisation.

Highlights

Non-communicable diseases (NCDs) are the leading cause of disease burden worldwide, contributing to approximately three-quarters of total deaths in 2017, with over 85% of premature mortality from NCDs occurring in low-income and middle-income countries (LMICs) [1]
Using a large populationbased survey in Indonesia, our study aims to examine the effect of multimorbidity across the different percentiles of healthcare utilisation and of-pocket expenditure (OOPE)
Our results from quantile regression analysis revealed a more detailed measure of the association between multimorbidity and OOPE that had not been revealed in earlier published studies that have used ordinary least squares (OLS) or generalized linear model (GLM) in the analysis

Summary

Introduction

Non-communicable diseases (NCDs) are the leading cause of disease burden worldwide, contributing to approximately three-quarters of total deaths in 2017, with over 85% of premature mortality from NCDs occurring in low-income and middle-income countries (LMICs) [1]. High levels of OOPE can exacerbate the burden of illness in individuals due to delayed or forgone care, place a strain on personal finances, and lead to an increased likelihood of financial catastrophe, impoverishment and worsening of social determinants of health [9, 10]. These adverse effects have greater consequences for the poor and vulnerable populations [11, 12] and contribute to further widening inequalities in health among population groups [13]. This study investigates the effect of multimorbidity across the different percentiles of healthcare utilisation and out-of-pocket expenditure (OOPE)

Objectives

Methods

Results

Discussion

Conclusion