Cost of surgery and catastrophic expenditure in people admitted to hospital for injuries: estimates from a cohort study in Vietnam

Background: Little is known of the effect that surgery has on out-of-pocket health-care expenditure or on catastrophic health payments in low-income settings. Our study aims to estimate the surgery cost paid out-of-pocket by injury patients admitted to a provincial hospital in Vietnam and the risk of catastrophic expenditure at 12 months after discharge.

Methods: We conducted a prospective cohort study in a provincial hospital in Vietnam. Participants were patients admitted to hospital due to injuries, aged 18 years or older, had a current residential address in the province (Thai Binh province), and consented to participate in the study. We collected data during hospital stay and at 1 month, 2 months, 4 months, and 12 months after discharge. Out-of-pocket costs incurred by injured people and their caregivers associated with care and treatment were collected. These covered all direct expenses incurred during hospital stay (surgery, emergency department, diagnostic examinations, medication, equipment, transportation, hospital stay, and others-eg, meals for both participants and their caretakers) and during follow-up (ongoing health checks, medication, meals, and transportation to outpatient clinic). Cost data were collected from the hospital bill and collected during face-to-face interviews with participants and their caretakers. The main outcome variables were surgery during hospital stay, total out-of-pocket payment, and catastrophic expenditure, defined as the out-of-pocket payment exceeding 40% of non-subsistence spending, by 12-month follow-up. Modified Poisson regression was used to determine the association between surgery and the risk of catastrophic expenditure.

Findings: Of 892 participants recruited during admissions to hospital, surgery was undertaken in 634 participants, including 354 minor (40%) and 280 major (31%) surgeries. The mean costs of major and minor surgery were US$129 (SD 90) or 30·0% of the total medical care costs during hospital stays and US$68 (SD 41) or 33·6%, respectively. By 12 month follow-up, mean total direct out-of-pocket costs was US$625 (SD 603). Of 732 participants, 432 (59%) faced catastrophic expenditure. Specifically, this was 84% among those with major surgery, 47% with minor surgery, and 48% with no surgery. Compared with those with no surgery, the adjusted risk of catastrophic expenditure was only significantly higher for those had major surgery (RR 1·45 [95% CI 1·24-1·69]).

Interpretation: Costs of surgery create substantial financial burden for people admitted to hospital for injuries in Vietnam; although major surgery accounting for around 30% of total medical costs it is strongly associated with risk of catastrophic health payments. Although injury prevention efforts need greater investment, there is also a need to reform health-care insurance mechanisms to minimise the impact of out-of-pocket costs.

Funding: Atlantic Philanthropies.