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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 18-22

Out-of-Pocket expenditure for diagnosis of lung cancer: A significant pretreatment financial burden – Study from a tertiary care cancer center in North India

1 Department of Community Medicine, IGMC, Shimla, India
2 Department of Community Medicine, Dr. YSPGMC, Nahan, Himachal Pradesh, India

Date of Submission31-Jan-2018
Date of Decision27-May-2018
Date of Acceptance24-Jun-2018
Date of Web Publication14-Feb-2019

Correspondence Address:
Gopal Ashish Sharma
House No -136, Ram Niwas, Sunny Side, Solan - 173 212, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_16_18

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Background: The incidence of catastrophic expenditure due to health-care costs is growing and is estimated to be one of the major contributors to poverty. The need to pay out-of-pocket can also mean that households do not seek care when they need it. The total economic burden of cancer therapy amounts to the mean of 36,812 Indian National Rupee (INR). Out of this, 40% comprises expenditure incurred before coming to the hospital. Objectives: This study assessed the total out-of-pocket expenditure (OOPE) of lung cancer patients before they seek services for treatment at a tertiary care center. Materials and Methods: This was an institution-based cross-sectional survey in newly diagnosed and registered lung cancer patients > 18 years old. Self-designed, pretested, semi-structured questionnaire for sociodemographic details and direct costs incurred under various subsets was used. Data were analyzed using Epi Info version Results: Out of 91 patients registered, 73 (80.2%) were male. The median OOPE was 19000 INR (range: 8000–40,000). We found that the total mean expenditure (19,516.48 ± 6488.22) was almost ten times their per capita income (2012.444 ± 1283.09). The total mean direct medical costs incurred were 8974.73 ± 5252 INR and direct nonmedical costs incurred were 10,574.73 ± 4414 INR. This study further showed that the direct nonmedical costs incurred were significantly higher (P = 0.02) than the direct medical costs. Similarly, the costs incurred on diagnostics were significantly higher (P < 0.001) as compared to the cost incurred on medicines. Conclusion: Lung cancer patients face the burden of OOPE at every stage, starting from the initial visit to a local health facility till the final diagnosis and treatment at a tertiary health-care facility. More measures are warranted to curtail preregistration and pretreatment expenses such as preventing people from traveling long distances just for imaging and diagnostic facilities and hence curtailing nonmedical cataclysmic expenditure.

Keywords: Direct costs, lung cancer patients, out-of-pocket expenditure

How to cite this article:
Barwal VK, Thakur A, Mazta SR, Sharma GA. Out-of-Pocket expenditure for diagnosis of lung cancer: A significant pretreatment financial burden – Study from a tertiary care cancer center in North India. CHRISMED J Health Res 2019;6:18-22

How to cite this URL:
Barwal VK, Thakur A, Mazta SR, Sharma GA. Out-of-Pocket expenditure for diagnosis of lung cancer: A significant pretreatment financial burden – Study from a tertiary care cancer center in North India. CHRISMED J Health Res [serial online] 2019 [cited 2022 Aug 13];6:18-22. Available from: https://www.cjhr.org/text.asp?2019/6/1/18/252286

  Introduction Top

The incidence of catastrophic expenditure due to health-care costs is growing and is now being estimated to be one of the major contributors to poverty.[1] The need to pay out-of-pocket can also mean that households do not seek care when they need it. As per the recent National Sample Survey Organization estimate, nearly 30% of rural and 20% of urban households who did not seek health care for a recent self-reported morbidity cited lack of financial resources as the reason for nonutilization of medical care.[2],[3] One of the important diseases which lead to catastrophic health expenditure is cancer. In majority of patients, cancer diagnosis is not only a health and psychological burden but also a major financial burden. Out of more than a million newly diagnosed cancer patients per year in India, nearly half of them are suitable for curative-aimed cancer-directed therapy. If for financial reasons, the patients do not seek or are reluctant for treatment, we are actually denying them the benefits of cancer care. We focused our research on lung cancer, which is the leading cause of death worldwide, accounting for 13% (1.82 million) of all cancer cases and 19.4% of all cancer deaths in 2012.[4] In India also, it is one of the most common cancers accounting for 6.8% of all malignancies.[5] According to the GLOBOCAN 2012 report, the estimated incidence of lung cancer in India was 70,275 in all ages and both sexes.

The total economic burden of cancer therapy amounts to the mean cost of 36,812 Indian National Rupee (INR) of a patient in India. Out of this total expenditure, 40% comprises expenditure incurred before coming to the hospital.[6] There is a paucity of published literature on out-of-pocket expenses incurred particularly by lung cancer patients and specifically for the expenses not related to lung cancer treatment. This means the expenditure incurred for diagnostic and imaging facilities along with traveling, boarding, and lodging facilities while visiting secondary- and tertiary-level hospitals (as a few specialists are available only in these institutions) for the purpose of workup and arriving at a final diagnosis of lung cancer. The purpose of this study was to determine out-of-pocket expenditure (OOPE) incurred by lung cancer patients before registration at a tertiary care cancer center of Himachal Pradesh. In the present study, we noted socioeconomic characteristics of patients who seek care at the cancer center (which is our point of the first contact with the patients) along with descriptive analysis of the direct medical and nonmedical costs incurred by these patients.

Aims and objectives

  1. To describe the sociodemographic characteristics of lung cancer patients and find their total OOPE before they seek services for treatment at a tertiary care cancer center
  2. To assess and compare expenditure incurred for direct and indirect medical costs.

  Materials and Methods Top

This was an institution-based descriptive cross-sectional study done at a tertiary care cancer center in Himachal Pradesh. It was a part of larger study on the quality of life of lung cancer patients who were receiving treatment at this center. Consecutive sampling was done, and all the newly registered lung cancer patients >18 years who came for treatment during the study period, i.e., from August 1, 2011, to April 2012 were included in the study. Patients with significant impairment of hearing, speech, and cognitive function were excluded from the study as participants. A daily list of new lung cancer patients was taken from the registration counter. Those who consented to participate in the study were administered pretested self-designed semi-structured questionnaires. Questionnaires included details about the sociodemographic profile of the patients as well as direct costs incurred (medical and nonmedical). In INR, direct costs are defined as the sum of (a) medical costs-out-of-pocket payments paid for diagnosis and treatment of lung cancer patients by households and net of any reimbursements, and (b) nonmedical costs are payments related to the use of health services, such as payments for transportation, accommodation or food, and net of any reimbursements to the individual who made the payments inclusive of one attendant accompanying the patient. The interviews of the patients were done as soon as possible after registration at a time when they were waiting for treatment, i.e., chemotherapy or radiotherapy or were admitted in the indoor wards. All the questions with regard to charges incurred in the past on various aspects such as consultation, medicines, diagnostics, travel, and lodging were enquired retrospectively from the onset of symptoms to the registration of individual as a lung cancer patient in the cancer center. The expenses of an attendant accompanying the patient were also included.

Data collected were entered into a computer in MS Excel Spreadsheet 2007. Statistical analysis was done using MS Excel 2007, and statistical tests were performed using the Epi Info version 7.2.1, Centre for disease control (CDC), Atlanta, USA. Prior permission for the study was taken from the ethics committee of the institution.

  Results Top

In all, 112 adult (≥18 years) patients were registered at the center during the above study period. Out of these, 21 refused to participate in the study. Hence, we had a total of 91 patients who completed the questionnaire. Seventy-three patients (80.2%) were male. The mean age of the study population was 59.24 ± 10.53 years (61.49 ± 9.51 for males and 52.83 ± 11.81 for females), and the median age was 60 years. A majority of the patients (34.1%) were in the age group of 60–69 years. Most of the males were high school pass (47.9%). Most of the females (77%) were only educated up to primary school. As per occupation, most of the male patients in the study population were in government job (32.9%) or were agriculturist (31.5%). The females were mostly homemakers (50%). After applying modified BG Prasad classification,[7] most of the study participants belonged to Classes II and III in males and Classes III and IV in females [Table 1].
Table 1: Sociodemographic characteristics of the study population (n=91)

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In our study, the total overall direct (mean) costs came out to be 19,516.48 ± 6488.21 INR. Out of which, total (mean) medical costs incurred were 8974.73 INR. The total direct nonmedical costs incurred were 10,574.73 INR. Expenses incurred on nonmedical resources such as travel, and lodging were significantly higher than the overall medical costs (P < 0.05) [Table 2].
Table 2: Total medical, nonmedical, and overall costs in terms of Indian National Rupee (n=91)

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In medical expenditures, the total costs of investigative procedures and tests were 5370.73 INR and expense incurred for taking medication in any form amounted to 3019.78 INR from out-of-pocket. In our study, the participants were spending almost double the amount on diagnostic procedures in comparison to medication and it turned out to be statistically significant also (P < 0.05).

Similarly, in the subhead of direct nonmedical cost category, lung cancer patients were incurring expenses much more on travel due to long journeys than on arranging for accommodation and stay during the course of treatment. Average costs incurred on combined journey and travel were 5613.19 INR and lodging accounted with mean costs of 2985.71 INR [Table 3].
Table 3: Comparison of various subcategories with the costs incurred

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  Discussion Top

The sociodemographic characteristics and details of costs incurred are representative of lung cancer patients in our setting. Lung cancer generally affects the elderly age group.[8] A study by Kirmani et al. found it to be highest (33.6%) in 51–60 years' age group and 28.9% between 61and 70 years.[9] In the present study also, the majority of patients were in the age group of 50–69 years (67%). The overall mean age of the lung cancer patients was 59.24 ± 10.53 years (61.49 ± 9.51 for males and 52.83 ± 11.81 for females), and the median age was 60 years. However, in a study in the UK,[10] the overall mean age was found to be 71 ± 9.8 years while Mong et al.[11] found it to be 70.1 ± 10.9 years. The mean of monthly per capita household income of our study participants was 2012 INR, while in a study conducted at AIIMS in 2007, it was found to be 1749 INR.

According to US-based study done by Cipriano et al. from 1992 to 2003, a patient diagnosed with lung cancer at age 72 in 2000 would have incurred an average of $645/month in health-care expenditures before diagnosis.[12] Similarly, in a multicentric study conducted at China in 2012–2014 by Huang et al., OOPE of newly diagnosed cancer patients was $4947 (4875–5020) accounting for 57.5% of annual household income.[13] However, it is important to mention that the above study included all the cancer patients in evaluation and lung cancer patients were only a part of the evaluation. In another study done at one of the premier institutes of India at AIIMS in 2007, the costs reported were 14597 INR.[5] In our study, the total direct costs came out to be 19000 ± 6469 INR. Another study done in 2011 by Nair et al. reported that around 18% of cancer patients delayed their treatment even after they were diagnosed for cancer. More importantly, 27% reported financial barriers as the reason for delaying decision for treatment.[14] In a study done in Spain,[15] the expenditure incurred for diagnosis of lung cancer ranged from €71,417 to €522,946, depending on the stage and histology of lung cancer. Another study by Arca et al.[16] found the costs of lung cancer diagnosis ranging from €3692 to €5070 depending upon the histology of cancer. We found the amount of OOPE burden sustained before initiation of treatment in our study (19,000 INR) to be strikingly ten times higher than the average per capita income of 1850 INR per household.

Here, it is worth mentioning that we found a minimum range of zero under the head of total medical costs which pertain to government employees as they are reimbursed for their medical expenses. Similarly, minimum ranges of zero in the accommodation subhead under nonmedical costs were due to their accommodation arrangements overnight at a relative's place.

The indirect costs are very difficult to measure. However, these add significantly to the overall costs of cancer care and put a great burden on the cancer patients and families.[17] In our study, the proportionate share of costs pertaining to nonmedical expenditure such as transportation, accommodation, and food was reported to be 54% of total overall expenditure and was found to be statistically significant also (P < 0.05). These results were similar to those of previous studies that nonmedical costs incurred are significantly higher than the medical ones, like Lansky et al. had even reported that out-of-pocket nonmedical costs are more than the medical costs and were consuming up to 26% of the weekly budget.[18] In nonmedical cost category, Fleming et al. reported that the main component of cost was patient stay, representing between 62% and 84% of the total costs.[19] Contrary to this, we found that the share of costs incurred on transportation was considerably high and this came out to be highly significant (P < 0.001). This is so because, in India and particularly in our state like Himachal Pradesh with difficult topographical terrains, patients have to traverse very long distances in order to seek tertiary care services. This is the likely reason for higher values in mean (5613 INR) costs of transportation in our study, i.e., almost two times that of accommodation (2985 INR). Some of the patients along with attendants are unable to return to their far-off native places on the same day, thereby leading to forced increased expenses for their overnight stay arrangements. Although the Government of Himachal Pradesh has notified free travel for a cancer patient along with an attendant in government-run buses since the year 2005, it is pertinent to note that the patient has already born a considerable amount of expenditure until the time of final diagnosis and registration as a cancer patient.[20] In direct medical cost category, a retrospective cohort study by Lokhandwala et al. using the 5% medicare claim data found that average total diagnostic assessment cost per patient was $7567 for lung cancer.[21] In another study in Greece by Zarogoulidou et al.,[22] the diagnosis direct cost of 113 patients included was €117,939. In our study, the costs on account of diagnostic modalities (5370 INR) were more than the costs incurred on medication and treatment part (3019 INR). This might be due to the fact that in Himachal Pradesh, radiological diagnostic modalities such as computed tomography, magnetic resonance imaging and confirmatory bronchoscopy, fine-needle aspiration cytology, and histopathological services are available at a very few selected centers. These centers also face a perennial shortage of expert manpower like radiologists and pathologists. In some of the institutions in peripheral areas, the state government has started providing logistics for these services under public–private partnership (PPP) model, but availability of human resource still remains a major concern.

There may have been underestimating of the actual expenditures as we have outliers in the form of government employees who are reimbursed the expenses as well as there are a few patients who stayed at a relative's place and hence the costs incurred are minimal.

One of the limitations of this study was that we did not include the patients as well as the attendants/caregivers' loss of income due to their absence from work. Another limitation was that we included the expenditure incurred only up to the final diagnosis and registration as a cancer patient, and it did not include the final treatment expenses. This would have indirectly added to the overall cost incurred on the lung cancer patient. Further studies can incorporate this aspect into their research. As we asked retrospectively about the expenditure incurred and the time gap from the start of the symptoms to seeking medical care in some patients was >6 months ago, there may have been some recall bias.

  Conclusion Top

Lung cancer patients face the burden of OOPE at every stage, starting from the initial visit to a local health facility till the final diagnosis and treatment at a tertiary health-care facility. They have already spent a considerable amount on preliminary investigations and diagnostic tests, apart from forced travel and stay during their referral to higher centers. Expenses of the accompanying attendants also add up to the overall financial burden. In the past, the government has focused more on measures to decrease or cover expenses of cancer treatment, for example, providing free services to all the below poverty line patients, but this facility can be availed only after diagnosis, labeling, and registration of the patient. The government is also providing them free traveling in the state road transport buses. However, more measures are warranted to curtail the preregistration and pretreatment expenses. Retrospective reimbursement, partial or complete, after confirmation of diagnosis could prove to be very beneficial for the poor patients.

The policymakers have to seriously look into other measures such as strategies to increase the specialist workforce in peripheral institutions. This will prevent people from traveling long distances just for imaging and diagnostic facilities and thereby curtailing nonmedical cataclysmic expenditure. The sphere of PPP can be increased by impanelling and incentivizing more private hospitals in the outskirts of cities.

The authors have empirical evidence that many patients are misdiagnosed as tuberculosis and put on antitubercular treatment for long periods. Failure of treatment and worsening of symptoms forces them for further alternative workup for lung cancer, which not only leads to delay in final diagnosis but also substantial increase in the direct as well as indirect costs. As lung cancer is one of the most common cancers in India, as well as in the state of Himachal Pradesh, the medical officers working in the peripheral institutions should be sensitized about keeping lung cancer as a differential diagnosis for similar chest symptomatics and thereby reducing unnecessary referral for diagnosis and hence the OOPE.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Morbidity, Health Care and the Condition of the Aged NSS 60 Round (January – June 2004) National Sample Survey Organisation Ministry of Statistics and Programme Implementation Government of India; March, 2006. Available from: http://www.mospi.nic.in/sites/default/files/publication_reports/507_final.pdf. [Last accessed on 2017 Dec 30].  Back to cited text no. 3
GLOBCAN 2012. Estimated Cancer Incidence Mortality and Prevalence Worldwide in 2012. International Agency for Research on Cancer WHO. Available from: http://www.globocan.iarc.fr/Default.aspx. [Last accessed on 2017 Dec 25].  Back to cited text no. 4
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  [Table 1], [Table 2], [Table 3]

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