Direct Costs of Healthcare among Patients with Deliberate Self-harm: A Pilot Study from a Tertiary Care Hospital in South India

HIGHLIGHTS

Deliberate self-harm leads to a significant impact on health and economic conditions of patients’ families. Consumption of pesticides and tablets are the commonest form of DSH. Among different types of DSH, pesticide consumption is associated with a higher cost of hospitalization.

INTRODUCTION

According to the World Health Organization (WHO), approximately 800,000 people die of suicide in a year, of which 110,000–168,000 die from pesticide self-poisoning. 79% of global suicides occur in low-and-middle income countries.¹ In a developing country such as India, poisoning-associated mortality is the fourth most common cause of mortality and varies from 15 to 30%.² As the Indian economy is predominantly agrarian, poisoning leads to a substantial financial burden. Deliberate self-harm is more common in the productive age of 32 years which adds to the economic burden. Understanding the economic burden of poisoning can impact policy change.³ In Sri Lanka, an average of USD31.83 was spent per patient with DSH and the cost was highest for pesticide poisoning (USD49.12)⁴ whereas in Bangladesh, the cost of hospitalization was estimated to be USD 98.40 per patient.⁵ However, data on the direct and indirect costs of treating patients with poisoning is scanty in India. This pilot study aims to look at the profile of poisoning in a tertiary care hospital in South India and to estimate the direct cost of treatment.

MATERIALS AND METHODS

RESULTS

A total of 107 patients were admitted over a period of 1 year with a diagnosis of DSH. The most common poison consumed was pesticide in 38 (35.5%) patients followed by tablet overdose in 34 (31.8%) as seen in Table 1. A male preponderance was noted (51.4%) with a mean ± SD age of 30.0 ± 9.0 years. The predominant mode of poison consumption was ingestion of the liquid form. Gastrointestinal symptoms (84.1%) were the most common clinical feature at presentation followed by the involvement of the central nervous system 71 (44.8%). Prior to presenting to our center, 81 (76%) patients received treatment in a primary or secondary level hospital of which 72 (67.3%) had received a gastric lavage and 17 (15.9%) received atropine. Twenty-two (20.6%) patients required an intensive care therapy while 19 (17.8%) required a ventilator support and 5 (4.7%) required vasopressors.

The result of the cost analysis is presented in Table 2. The median (IQR) cost of admission was ₹13,690 (8,970–28,890) [USD195.57 (128.14, 412.71)] as denoted in Table 1. The pesticide consumption significantly increased the direct cost of care by 67% (95% CI: 13–78,146 %) as compared to non-pesticide poisoning.

The need for the intensive care unit (ICU) admission increased the cost by 6.67 (95% CI: 4.87–9.07) times. In patients on ventilator, the direct cost significantly increased by 7.33 (95% CI: 7.27–10.21) times. Inotropes were also found to significantly increase the patient’s costs by 5.54 (95% CI: 2.37 82–12.94) times more as compared to the patients not requiring inotropes (p <0.001). The direct cost in the VAP patients was found to be significantly increased by 11.65 (95% CI: 5.84–23.29) times more as compared to the patients with no VAP (p <0.001).

DISCUSSION

Deliberate self-harm due to poisoning is an important cause of morbidity and mortality in India and other developing nations.^6–8 Studies have shown that in South Asian countries such as Sri Lanka and Bangladesh, a substantial proportion of income was spent on poisoning; however, Indian data with regard to the cost of care in DSH is not robust.^3,5 The most common cause of DSH is organophosphorus compounds in India, as noted in our study as well.⁹ In addition to the clinical morbidity, poisoning causes a significant economic burden; the incidence is higher in young age-group (15–40 years) who are the breadwinners of their families^10,11 In our cohort, there was a 67% increase in the direct cost attributed to pesticide poisoning as compared to the non-pesticide DSH, similar to Nambiar et al., where organophosphorus was the most common poison consumed (34%) and incurred the highest cumulative expenditure (₹830,000) and the highest expenditure per admission (₹18,500).¹²

In our study, one in five patients required intensive care therapy. Besides a need for an intensive care, the intensive care-related supports such as inotropes and development of VAP infection were also associated with a higher healthcare costs. Hence, nationally implemented policies curtailing free access to highly hazardous pesticides that are associated with increased need for intensive care and mechanical ventilation will decrease the economic burden due to the direct costs in resource limited nation such as ours, with high proportion of DSH due to pesticides.¹³

The limitations of our study were our inability to assess the indirect costs and loss of wages due to hospitalization and the economic impact of the costs on the family of the patients since this is a retrospective study.

CONCLUSIONS

Deliberate self-harm leads to a significant economic burden to patients and their families. Pesticide-based poisoning is the most important cause for DSH and also incurs a higher direct cost compared to non-pesticide poisoning.

ORCID

Rohit Barnabas https://orcid.org/0000-0001-7612-506X

Bijesh Yadav https://orcid.org/0000-0002-5764-1373

Jonathan Jayakaran https://orcid.org/0000-0001-7045-2457

Karthik Gunasekaran https://orcid.org/0000-0002-8615-5753

Jacob Johnson https://orcid.org/0000-0001-6170-7542

Kishore Pichamuthu https://orcid.org/0000-0002-6977-1183

Ramya Iyadurai https://orcid.org/0000-0001-8453-6205

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