The economic burden of pediatric gastroenteritis to Bolivian families: a cross-sectional study of correlates of catastrophic cost and overall cost burden

Abstract

Background: Worldwide, acute gastroenteritis causes substantial morbidity and mortality in children less than five years of age. In Bolivia, which has one of the lower GDPs in South America, 16% of child deaths can be attributed to diarrhea, and the costs associated with diarrhea can weigh heavily on patient families. To address this need, the study goal was to identify predictors of cost burden (diarrhea-related costs incurred as a percentage of annual income) and catastrophic cost (cost burden ≥ 1% of annual household income).

Methods: From 2007 to 2009, researchers interviewed caregivers (n = 1,107) of pediatric patients (<5 years old) seeking treatment for diarrhea in six Bolivian hospitals. Caregivers were surveyed on demographics, clinical symptoms, direct (e.g. medication, consult fees), and indirect (e.g. lost wages) costs. Multivariate regression models (n = 551) were used to assess relationships of covariates to the outcomes of cost burden (linear model) and catastrophic cost (logistic model).

Results: We determined that cost burden and catastrophic cost shared the same significant (p < 0.05) predictors. In the logistic model that also controlled for child sex, child age, household size, rural residence, transportations taken to the current visit, whether the child presented with complications, and whether this was the child's first episode of diarrhea, significant predictors of catastrophic cost included outpatient status (OR 0.16, 95% CI [0.07, 0.37]); seeking care at a private hospital (OR 4.12, 95% CI [2.30, 7.41]); having previously sought treatment for this diarrheal episode (OR 3.92, 95% CI [1.64, 9.35]); and the number of days the child had diarrhea prior to the current visit (OR 1.14, 95% CI [1.05, 1.24]).

Conclusions: Our analysis highlights the economic impact of pediatric diarrhea from the familial perspective and provides insight into potential areas of intervention to reduce associated economic burden.

Figure 1

Histogram of cost burden incurred for a single episode of pediatric diarrhea in a sample of 551 Bolivian infants seeking care for acute diarrheal illness, 2007 – 2009. Over 40% of Bolivian families in our study spent at least 1% of their annual income on a single episode of pediatric diarrhea. The black bars represent number of patients in each cost burden category, with total number of patients at the top of the column. Each column (cost burden category) represents a range of one percentage point, for example, 0% = 0 - <1%. (N = 551).

Figure 2

Interaction of number of days with diarrhea and complications on cost burden incurred for a single episode of diarrhea, in a sample of 551 Bolivian infants seeking care for acute diarrheal illness, 2007–2009. For children who present with no complications, each additional day with diarrhea prior to treatment contributes to an increasingly greater cost burden. For those children who present with at least one complication, each additional day contributes to a greater cost burden until 12 days, at which point additional days contribute to a lower cost burden. The gray squares represent the contribution of number of days with diarrhea to the log₁₀ of cost burden for children presenting with no complication. The black diamonds represent the contribution of number of days with diarrhea to the log₁₀ of cost burden for children presenting with at least one complication. (N = 291).

Figure 3

Interaction of number of days with diarrhea and complications on risk of catastrophic cost for a single episode of diarrhea, in a sample of 551 Bolivian infants seeking care for acute diarrheal illness, 2007–2009. The likelihood of experiencing a catastrophic cost decreases slightly as the difference in the number of days with diarrhea increases, when comparing those with a complication to those without a complication. When comparing children with no difference in complication status, the likelihood of catastrophic cost increases as the number of days with diarrhea increases. The black diamonds represent the point estimate for the odds ratio comparing children with at least one complication to those with none. The black bars are the 95% Confidence Intervals of these odds ratios. The gray squares represent the point estimate for the odds ratio associated with differences in the number of days with diarrhea, among children with no differences in their complication status. The gray bars are the 95% Confidence Intervals of these odds ratios. The dotted gray line represents an odds ratio of 1. We present odds ratios for differences in number of days with diarrhea from 0 to 14 days. (N = 295).