Catastrophic health expenditure and multimorbidity among older adults in Brazil

Bernardes, Gabriella Marques; Saulo, Helton; Fernandez, Rodrigo Nobre; Lima-Costa, Maria Fernanda; Andrade, Fabíola Bof de

doi:10.11606/s1518-8787.2020054002285

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Original Article • Rev. Saúde Pública 54 • 2020 • https://doi.org/10.11606/s1518-8787.2020054002285 copy

Catastrophic health expenditure and multimorbidity among older adults in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE:

To estimate the relation between catastrophic health expenditure (CHE) and multimorbidity in a national representative sample of the Brazilian population aged 50 year or older.

METHODS:

This study used data from 8,347 participants of the Estudo Longitudinal de Saúde dos Idosos Brasileiros (ELSI – Brazilian Longitudinal Study of Aging) conducted in 2015–2016. The dependent variable was CHE, defined by the ratio between the health expenses of the adult aged 50 years or older and the household income. The variable of interest was multimorbidity (two or more chronic diseases) and the variable used for stratification was the wealth score. The main analyses were based on multivariate logistic regression.

RESULTS:

The prevalence of CHE was 17.9% and 7.5%, for expenditures corresponding to 10 and 25% of the household income, respectively. The prevalence of multimorbidity was 63.2%. Multimorbidity showed positive and independent associations with CHE (OR = 1.95, 95%CI 1.67–2.28, and OR = 1.40, 95%CI 1.11–1.76 for expenditures corresponding to 10% and 25%, respectively). Expenditures associated with multimorbidity were higher among those with lower wealth scores.

CONCLUSIONS:

The results draw attention to the need for an integrated approach of multimorbidity in health services, in order to avoid CHE, particularly among older adults with worse socioeconomic conditions.

DESCRIPTORS:
Middle Aged; Aged; Multimorbidity; Socioeconomic Factors; Cost of Illness; Catastrophic Expenditure

Variables		%	95%CI
Sex
	Female	54.0	51.1–56.9
	Male	46.0	43.1–48.9
Age (years)
	50–59	46.9	42.6–51.3
	60–69	30.0	28.1–31.9
	70–79	15.8	14.0–17.8
	80+	7.3	6.0–8.8
Marital status
	No marital relationship	36.8	33.9–39.8
	With marital relationship	63.2	60.2–66.1
Education
	No study	12.3	10.0–14.9
	1–3 years	18.7	17.1–20.4
	4–7 years	31.6	29.1–34.2
	8+ years	37.4	34.6–40.4
	Proportion of older adults in the household	70.7	69.2–72.2
Multimorbidity
	No	36.8	34.6–39.1
	Yes	63.2	60.9–65.4
	Medications (mean)	2.2	2.1–2.3
Functional limitation
	No	84.4	83.0–85.7
	Yes	15.6	14.3–17.0
Private Health Insurance
	No	74.1	1.4–76.7
	Yes	25.9	23.3–28.6
Catastrophic health expenditure
	10% cutoff point	17.9	16.4–19.5
	25% cutoff point	7.5	6.6–8.4

Expenditure	Out-of-pocket
Expenditure	%	95%CI
Medication	65.1	63.0–67.3
Dentist	12.2	10.7–13.7
Medical consultation	11.1	9.8–12.4
Examination	8.7	7.5–10.0
Physiotherapist	1.4	1.0–1.7
Caregiver	0.8	0.4–1.2
Hospitalization	0.5	0.3–0.7
Psychologist	0.5	0.3–0.6
Nutritionist	0.2	0.1–0.3
Occupational therapist	0.0	0.0–0.07
Speech therapist	0.0	0.0–0.1

Variables		Catastrophic expenditure
Variables		≥ 10% OR (95%CI)	≥ 25% OR (95%CI)
Sex (ref. ^a ref.ᵃ: reference category : female)
	Male	0.59 (0.51-0.70) ^b b p < 0.001	0.53 (0.42–0.68) ^b b p < 0.001
Age (years)		1.03 (1.02–1.04) ^b b p < 0.001	1.02 (1.01–1.04) ^b b p < 0.001
Marital status (ref. no)
	Yes	0.73 (0.64-0.82) ^b b p < 0.001	0.59 (0.51-0.70) ^b b p < 0.001
Years of study		0.99 (0.98–1.01)	1.00 (0.98–1.02)
Wealth score (ref. ^a ref.ᵃ: reference category : 1st quintile)
	2nd quintile	1.28 (1.02–1.60) ^c c p < 0.05	1.36 (1.03–1.79) ^c c p < 0.05
	3rd quintile	1.16 (0.93–1.43)	1.09 (0.81–1.46)
	4th quintile	0.94 (0.72–1.23)	0.89 (0.63–1.24)
	5th quintile (richest)	0.92 (0.69–1.23)	1.04 (0.72–1.49)
Proportion of older adults in the household		1.01 (1.01–1.01) ^b b p < 0.001	1.01 (1.00–1.01) ^b b p < 0.001
Physical activity (ref. ^a ref.ᵃ: reference category : no)
	Yes	0.79 (0.67-0.93) ^d d p < 0.01	0.84 (0.68–1.04)
	Multimorbidity (ref. ^a ref.ᵃ: reference category : no)
	Yes	2.45 (2.11–2.84) ^b b p < 0.001	1.83 (1.47–2.28) ^b b p < 0.001
	No. of medications	1.34 (1.30–1.39) ^b b p < 0.001	1.27 (1.22–1.32) ^b b p < 0.001
Functional limitation (ref. ^a ref.ᵃ: reference category : no)
	Yes	2.45 (2.15–2.78) ^b b p < 0.001	2.26 (1.78–2.87) ^b b p < 0.001
Private health insurance (ref. ^a ref.ᵃ: reference category : no)
	Yes	1.36 (1.15–1.60) ^b b p < 0.001	1.49 (1.17–1.88) ^b b p < 0.001

Variables		Catastrophic expenditure
Variables		10% OR (95%CI)	25% OR (95%CI)
Sex
	Male	0.69 (0.58–0.81) ^a a p < 0.001	0.59 (0.45–0.76) ^a a p < 0.001
Age		1.02 (1.01–1.03) ^a a p < 0.001	1.01 (1.01–1.01) ^b b p < 0.01
Education (8+ years)
	Did not study	0.65 (0.50–0.85) ^b b p < 0.01	0.64 (0.45–0.91) ^c c p < 0.05
	1–3 years	0.71 (0.57–0.89) ^b b p < 0.01	0.75 (0.59–0.96) ^c c p < 0.05
	4–7 years	0.79 (0.67–0.93) ^d d p < 0,01	0.82 (0.65–1.04)
Wealth score		0.95 (0.92–0.98) ^b b p < 0.01	0.96 (0.90–1.01)
Proportion of older adults in the household		1.01 (1.00–1.01) ^a a p < 0.001	1.01 (1.00–1.01) ^b b p < 0.01
Multimorbidity
	Yes	1.95 (1.67–2.28) ^a a p < 0.001	1.40 (1.11–1.76) ^b b p < 0.01
Functional limitation
	Yes	2.06 (1.79–2.37) ^a a p < 0.001	2.04 (1.62–2.56) ^a a p < 0.001
Private health insurance
	Yes	1.28 (1.07–1.53) ^b b p < 0.01	1.40 (1.11–1.76) ^b b p < 0.01

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[1] Correspondence: Fabíola Bof de Andrade Av. Augusto De Lima, 1715 30190-002 Belo Horizonte, MG, Brasil E-mail: fabiola.bof@fiocruz.br