|Year : 2017 | Volume
| Issue : 2 | Page : 131-136
Cost of seizure disorder care among some selected patients in Northwestern Nigeria
Aliyu Ibrahim1, Lukman F Owolabi1, Auwalu S Salihu2, Hasiya T Ismail3
1 Neurology Unit, Department of Medicine, Bayero University Kano, Kano, Nigeria
2 Department of Psychiatry, Bayero University Kano, Kano, Nigeria
3 Neurology Unit, Department of Medicine, Aminu Kano Teaching Hospital Kano, Nigeria
|Date of Web Publication||5-Oct-2017|
Neurology Unit, Department of Medicine, Bayero University Kano/Aminu Kano Teaching Hospital, No 1, Zaria Road, Kano
Source of Support: None, Conflict of Interest: None
Background: Estimated costs of seizure disorder care are overall high due to its high frequency in the general population, especially in developing countries. Considerable variability exists between seizure disorder patients, which poses significant socioeconomic burden to the society. Materials and Methods: A cross-sectional descriptive study with a “bottom-up” design from the societal perspective where information on the costs associated with seizures disorder was evaluated. The direct (medical and non-medical) and indirect (using the “human capital” approach) costs per month for adult outpatients with seizure disorder was estimated. All data were analyzed using IBM SPSS statistics software, version 20.0. Results: The mean healthcare cost per patient per month was ₦11,096.03 ($58.33). The direct and indirect cost of care per patient per month was ₦9,004.73 ($45.71) and ₦2091.30 ($10.62) respectively. The principal direct cost drivers were drugs and other medications amounting to ₦4041.68 ($20.52) per patient and a total of ₦371,835.00 ($1887.49) per month for all the patients in the study. The estimated healthcare cost per patient when annualized was found to be ₦133,152.39 ($675.90), while the total annual healthcare cost for all the patients in the study per year was ₦12,250,020.00 ($62,182.84). Conclusions: On the background of poor remunerations, high unemployment, and out-of-pocket payments the high costs of care among adults may lead to catastrophic societal expenditures for seizure disorder care, which significantly contribute to poor adherence and secondary treatment gap.
Keywords: Bottom-top approach, direct cost, indirect cost, seizure disorder, societal perspective
|How to cite this article:|
Ibrahim A, Owolabi LF, Salihu AS, Ismail HT. Cost of seizure disorder care among some selected patients in Northwestern Nigeria. Niger J Basic Clin Sci 2017;14:131-6
|How to cite this URL:|
Ibrahim A, Owolabi LF, Salihu AS, Ismail HT. Cost of seizure disorder care among some selected patients in Northwestern Nigeria. Niger J Basic Clin Sci [serial online] 2017 [cited 2019 Jul 19];14:131-6. Available from: http://www.njbcs.net/text.asp?2017/14/2/131/216052
| Introduction|| |
Reports have shown that despite disease variability from patient to patient, the societal costs for seizure are overall high, due to its high frequency in the general population. Ranges in cost estimates vary widely, depending on the method and focus of the analysis used, that is whether direct and indirect costs were included or the disease is of new onset or already established. Enormous data about the economic cost of seizures and its implications exists in the developed world. This however is lacking in most developing countries, where the disorder is usually treated without acknowledging consequences of catastrophic health expenditures for patients and families due to the predominant out of pocket payments for health and the lower national income and healthcare expenditure per capita.,
Antiepileptic treatment is indicated after two unprovoked seizures or a single unprovoked seizure if there is an increased risk of a second unprovoked seizure, which include abnormal neurological examination, abnormal electroencephalogram (epileptiform discharges), or evidence of a structural central nervous system (CNS) abnormality presumed to be the underlying cause of the seizure. Optimal seizure control is achieved with only medication, which is the mainstay of treatment in most patients with seizure. However, about one-third will fail medical treatment only, in addition to their possible adverse side effects which rather necessitates exploring other more expensive treatment options like diet, hormonal manipulation therapies, surgery (resective and functional), neurostimulation (devices), and behavioral modification techniques.,,
In Nigeria, the prevalence of epilepsy in defined communities from previous reports varies from 5/1,000 to 37/1,000.,, Most of the publications from developed countries assess the costs of the disease using annual cost estimates, because it is difficult to define an episode of care. However, due to logistic difficulties in terms of patient follow-up, studies from most developing countries in contrast, use hospital-based monthly cost estimates, which are subsequently then annualized. The paucity of information on the cost of seizure disorder and the differential variability in health expenditures, insurance coverage, and health seeking patterns  in our environment prompted this work.
| Materials and Methods|| |
This cross-sectional descriptive study that enrolled patients with seizure disorder was conducted in the neurology clinic of federal tertiary hospital, which is located within Kano metropolis, from July 1, 2014 to December 31, 2015. The bottom-up approach was used in generating estimates of the direct cost of seizures. This design estimated the number and types of health care, social services, and family member resources used by individuals with seizures. The cost-of illness which estimates the financial burden of the seizures was analyzed from the societal perspectives that attempts to capture full costs without regard to which individuals or entities are incurring the costs, i.e., the total cost incurred by the individuals and/or their family. Any additional expenses related to various comorbidities (like hypertension, diabetes, cardiac diseases, bronchial asthma, chronic obstructive pulmonary disease, peptic ulcer disease, migraine headache, etc.) were included, because some degree of uncertainty remains concerning the causal relationship between seizures and the associated comorbidity, i.e., calculating the cost of patient with, rather than cost of seizures only.
The inclusion criteria include, all newly diagnosed patients aged 14 years and above, who have presented with at least two or more unprovoked seizures, a single unprovoked seizure if there is an increased risk of a second unprovoked seizure required for the diagnosis of epilepsy, after a written informed consent is given by them, their parents/caregivers in children who were not old enough to give their assent.
Excluded from the study were patients whose diagnosis of seizures could not be determined clinically, have only a single provoked seizure, have refused to give consent/assent, or patients who have not utilized any form of health service in the past 2 months. The sampling frame was from the total number of new seizure patients booked which averages between 8 and 10 present on each clinic day, and consecutive patients were then selected for the study.
Definition of terms
Educational level was defined as the highest level of individual education completed, categorized into four groups: No formal education, primary (1–6 years), secondary (7–12 years), and tertiary (≥13 years).
Modified socioeconomic scoring of educational qualification and occupation into classes 1–5 was used for the study, by assigning socioeconomic scores to education and occupation.
- Class 1: High skilled worker/professional/businessman/managers/large scale traders/contractors
- Class 2: Senior government employee
- Class 3: Junior government employee/middle-scale trader/high scale farming/religious or community leader and clergy/retiree/teacher/technicians
- Class 4: Artisan/security agents/sentries
- Class 5: Unemployed/student/apprentice/subsistence farming/driver/motorcyclist/laborer/messenger/low-level skilled worker.
Direct medical costs are the costs incurred for medical products and services used to prevent, detect, and/or treat a disease. These include cost of medications, medical supplies, healthcare professional's time/consultation fees, hospitalization, investigations, and diagnostic procedures.
Direct non-medical costs entail any costs for services that are results of illness or disease, but do not involve purchasing medical services. These costs are consumed to purchase services other than medical care and include resources spent on transportation, food/special diets, lodging, child or family care expenses, home aides, other out of pocket expenses, telecommunication, and other social services.
Indirect costs are the costs of reduced productivity that result from morbidity and mortality, which are important sources of resource consumption. Morbidity costs are incurred from missing household or work absenteeism (i.e., lost productivity) whereas mortality costs represent the years lost as a result of premature death, estimated based on the human capital approach, i.e., lost school or workdays multiplied by the wage rate. The mean cost of health care for the disease per month in the last 2 months prior to presentation was used in the analysis to reduce recall bias. All relevant costs due to the disease were based on official Naira exchange rate of $1 that was approximately ₦197.00 during the period of study.
Standard protocol approvals and patient consent
The Hospital Research and Ethics Review Committee approved the study. All patients or their surrogates completed written informed consent prior to their evaluation and the provisions of the Helsinki declaration were respected in the study.
We performed statistical analyses with IBM SPSS statistics software, version 20.0 (SPSS Inc. IBM, Armonk, NY). Quantitative variables were summarized using mean and standard deviation (SD) for normally distributed data or median and interquartile ranges for skewed data. Categorical variables were summarized as frequencies and percentages.
| Results|| |
Socio-demographic characteristics of patients
During the study period, 100 consenting patients with seizure disorder were enrolled in the neurology clinic with a response rate of 92% (61 males and 31 females). The median (SD) age of the patients was 28.5 ± 17.2 years (interquartile range of 14–73 years). Forty-eight (52.2%) of them were single and 26 (28.3%) do not have any form of formal education (denoting any certified form of formal education). Majority 71 (77.2%) reside in an urban setting and almost half (48.9%) of them lived in a cement plastered mud house with metal roofing sheets, depicting likelihood of staying in a high-density area. [Table 1] summarizes the socio-demographic characteristics of the study sample population.
|Table 1: Baseline sociodemographic characteristics of the study population (n=92)|
Click here to view
Cost of care for adult seizure disorder
The study found that total cost of treatment per month was 1 million and 20,835 naira (₦1,020,835.00) with an average cost of illness per patient per month of 11,096 naira 3 kobo (₦11,096.03). The financial cost when annualized then amounts to 12 million, 250,020 naira (₦12,250,020.00) equivalent to sixty-two thousand one hundred and eighty-two dollars eighty four cents ($62,182.84). The average annual financial estimate per patient was one hundred and thirty three thousand one hundred and fifty two naira thirty-nine kobo (₦133,152.39), equivalent to six hundred and sixty-five dollars ninety cents ($ 675.90). See [Table 2] for details of estimates of seizure care.
Further breakdown of monthly healthcare expenses from the study showed a direct cost of care per patient per month of nine thousand and four naira, seventy-two kobo (₦9004.72), which comprise 81.2% of the total costs of care incurred. The principal direct medical cost driver was from drugs and medications, estimated at four thousand and forty one naira sixty-eight kobo ((₦4041.68) per patient per month comprising approximately 51.1% of the expenditures. The direct nonmedical cost per month; however, comprised only about 12.1% of the total direct cost of care per month. Total direct and indirect cost of care for all the patients per month from the study was eight hundred and twenty-eight thousand four hundred and thirty-five naira (₦828,435.00) and one hundred and ninety-two thousand four hundred naira (₦192,400.00) which comprised of about 81.2% and 18.8% respectively. Further breakdown of the indirect cost of care per patient per month was two thousand and ninety one naira thirty-one kobo (₦2091.31) equivalent to ten dollars and sixty-two cents (($ 10.62).
[Table 3] shows further breakdown of average costs of care per month by sociodemographic variables, which showed that the mean monthly cost of care where higher in; females, those residing in rural area, with socioeconomic class 1, having at least a secondary school certificate, living in a bungalow/duplex house, having a partial/focal type of seizure, and sponsored by a spouse. The total cost of care per month for the 19 patients with less than 18 years of age, was one hundred and eighty two thousand nine hundred and five naira only (₦ 182,905.00), which comprise about 17.9% of the total cost per month. Only 20 (21.7%) patients were able to pay for their health expenses by themselves, while the family shoulders the financial burden of the remaining as shown in [Figure 1].
| Discussion|| |
Our study is a preliminary report from a tertiary hospital on the estimated cost of care of newly diagnosed patients with seizure disorder from societal perspective in northwestern Nigeria. This comprises of about 81.2% of direct and 18.8% of indirect monthly costs of care per patient respectively. These annual estimates were higher than previous studies from other geographically distinct regions of Nigeria [Table 4]., This could possibly be explained by the lower cost of older antiepileptic drugs (AEDs) used by previous studies from Nigeria or their focus on only the direct costs of seizures with differential underestimation of the total cost of care for patients with seizure while excluding the cost of associated comorbidities like hypertension and diabetes in patients with seizures. Additionally, by way of speculation the differential variability of health insurance coverage, health-seeking behavior, patterns of clinical practice, and healthcare system frameworks from our study may have accounted for these differences., Costs from developing countries like Burundi, Columbia, and India were lower than our estimates, possibly because of their lower per capita income and also the use of mainly cheaper generic antiepileptic medications especially in the latter.,,, Estimates from Europe (United Kingdom, Italy, Denmark), North America (with the exception of some American Islands), and China were obviously higher than our estimates which may be a reflection of their better system of healthcare financing for illnesses, a high national income and healthcare expenditure per capita.,,,
The most important cost category from our study was direct medical costs, especially cost of AEDs which form a significant percentage of the cost of illness. This is similar to previous studies reported from Nigeria, and in most countries worldwide., It is however noteworthy that an extensive cost of seizure study from Europe  showed the indirect costs as the single most predominant cost category whereas the cost of AEDs represents a small proportion probably because the analysis was based on older drugs which may have underestimated the costs., The average transport costs incurred to reach the health facility per patient per month may be small, but it becomes a substantial amount if patient follow-up visits to clinics continue to be regular and considering the duration of treatment for seizures which usually last for not less than 24 months, after excluding the occasional accident and emergency visits by some of these patients.
A drawback of our study design is that we did not collect intangible cost and the total costs of care per patient using a longitudinal follow-up, but instead extrapolated the monthly estimates from a cross-sectional assessment of financial costs per year, which may or may not correlate to future financial difficulties, which the patient might incur. Additionally, the study did not capture the costs incurred from logistic delays while undergoing preliminary investigations in public hospitals in our resource challenged setting. Furthermore, the study did not capture measures of income by the patient or other source of financial support adjusted for inflation, which tends to overstate the effects on economic growth despite devaluation of the local currency to the dollar as at the time of this publication.
Even though our study was limited to a tertiary health facility, it however gives a preliminary insight into the major cost components and provides an idea of the financial burden that seizure disorder pose on its patients. The strength of our study lies in that to the best of our knowledge there is no previous published from northwestern Nigeria on the cost analysis of care of seizure disorder patients. Other methods that may aid in getting an exact estimate of total expenses incurred per patient even though logistically difficult to keep by the patient or their relatives are the use of patient diaries. This may lead to selective dropout especially of the less well-educated and socially engaged.
| Conclusion|| |
Our study tried to evaluate the costs of care borne by the patient and their family using their meager resources, which was found to be high study tried to evaluate the costs of care borne by the patient and their family using their meagre resources, which was found to be high. This should draw the attention of policy makers on the economic aspects of seizure disorder care from the societal perspective in order to improve its overall outcomes. On the background of poor remunerations and high unemployment, out-of-pocket payments can lead to catastrophic health expenditures for seizure disorder care that can significantly contribute to poor adherence and secondary treatment gap in our environment.
Financial support and sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial or not for profit sectors.
Conflicts of interest
There authors declare no conflicts of interest.
| References|| |
Pugliatti M, Beghi E, Forsgren L, Ekman M, Sobocki P. Estimating the cost of epilepsy in Europe: A review with economic modelling. Epilepsia 2007;48:2224-33.
Penberthy LT, Towne A, Garnett LK, Perlinet RJ, DeLorenzo RJ. Estimating the economic burden of status epilepticus to the health care system. Seizure 2005;14:46-51.
Chin JH. Epilepsy Treatment in Sub-Saharan Africa: Closing the gap. Afr Health Sci 2012;12:186-92.
Country statistics and global health estimates by WHO and UN partners. Available from: http//:www.who.int/gho//en/
. [Accessed 2016 Oct 12].
Fisher RS, Van Emde Boas W, Blume W, Elger C, Genton P, Lee P, et al
. Epileptic Seizures and Epilepsy: Definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia 2005;46:470-2.
Burakgazi E, French JA. Treatment of Epilepsy in Adults. Epileptic Disord 2016;18:228-39.
Kwan P, Arzimanoglou A, Berg AT, Brodie MJ, Allen Hauser W, Mathern G, et al
. Definition of Drug Resistant Epilepsy: Consensus proposal by the ad hoc task force of the ILAE Commission on Therapeutic Strategies. Epilepsia 2010;51:1069-77.
Brodie MJ, Bamagous GA, Norrie JD, Kwan P. Patterns of Treatment Response in Newly diagnosed Epilepsy. Neurology 2012;78:1548-54.
Osakwe C, Otte WM, Alo C. Epilepsy prevalence, potential causes and social beliefs in Ebonyi State and Benue State, Nigeria. Epilepsy Res 2014;108:316-26.
Danesi MA, Oni K. Profile of Epilepsy in Lagos, Nigeria. Trop Geogr Med 1983;35:9-13.
Osuntokun BO, Adeuja AO, Nottidge VA, Bademosi O, Olumide A, Ige O, et al
. Prevalence of the epilepsies in Nigerian Africans: A community-based study. Epilepsia 1987;28:272-9.
Hodgson TA, Meiners MR. Cost of illness methodology: A guide to current practices and procedures. Milbank Mem Fund Q Health Soc 1982;60:429-62.
Ughasoro MD, Onwujekwe OE, Ojinnaka NC. Economic Cost of Treatment of Childhood Epilepsy in Enugu, Southeast Nigeria. Int J Technol Assess Health Care 2014;30:469-74.
Eisenberg JM. Clinical Economics: A Guide to Economic Analysis of Clinical Practices. JAMA 1989;262:2879-86.
Ryvlin P. Optimizing therapy of seizures in specific clinical situations: Are the exceptions the rule? Neurology 2006;67:s1-2.
Ogunlesi AT, Dedeke IOF, Kuponiyi OT. Socioeconomic Classification of Children attending Specialist Paediatric centres in Ogun state, Nigeria. Niger Med Pract 2008;54:21-5.
Sanya EO, Kolo PM, Adekeye A, Mustapha K, Ademiluyi BA, Ajayi K. Cost of Epilepsy care in a Nigerian Teaching Hospital. Niger Postgrad Med J 2013;20:266-71. [Full text]
Ezeala-Adikaibe BA, Onwuekwe I, Ekenze S, Achor J, Onwukwe J. Estimated Direct Cost Of Treating Epilepsy Per Month In Southeast Nigeria. Internet J Neurology 2013;13:9661.
Nsengiyumva G, Druet-Cabanac M, Nzisabira L, Preux P, Vegnenegre A. Economic Evaluation of Epilepsy in Kremba (Burundi): A Case-Controlled Study. Epilepsia 2004;45:673-7.
Fandino F, Silfvenius H. Worldwide disparities in Epilepsy care: A Latin America outlook. Epilepsia 1999;40:48-54.
Thomas SV, Sarma PS, Alexander M, Pandit L, Shekar L, Trivedi C, et al
. Economic burden of Epilepsy in India. Epilepsia 2001;42:1052-60.
Krishman A, Sahariah SU, Kapoor SK. Cost of Epilepsy in Patients attending a Secondary level Hospital in India. Epilepsia 2004;45:289-91.
Begley CE, Beghi E. The Economic Cost of Epilepsy: A Review of the Literature. Epilepsia 2002;43:3-9.
Cockrell OC, Hart YM, Sander JW, Sorvon SD. The cost of Epilepsy in United Kingdom: An estimation based on the result of two population-based studies. Epilepsy Res 1994;18:249-60.
Theodore WH, Spencer SS, Wiebe S, Langfitt JT, Ali A, Shafer PO, et al
. Epilepsy from North America Epilepsy: A Report Prepared under the Auspices of the Global Campaign Against Epilepsy, the International Bureau for Epilepsy, the International League Against Epilepsy and the World Health Organisation. Epilepsia 2006;47:1700-22.
Hong Z, Qu B, Wu X, Yang T, Zhang Q, Zhou D. Economic Burden of Epilepsy in a developing country: A retrospective cost in china. Epilepsia 2009;50:2192-8.
Senanayake N, Roman GC. Epidemiology of Epilepsy in developing countries. Bull World Health Organ 1993;71:247-58.
Jennum P, Gyllenborg J, Kjellberg J. The social and economic consequences of epilepsy: A Controlled National Study. Epilepsia 2011;52:949-56.
Ipingbemi AE. Management, Treatment Outcome and Cost of Epilepsy in a tertiary health facility in Northern Nigeria. Internet J Med Update 2015;10:25-36.
[Table 1], [Table 2], [Table 3], [Table 4]