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 Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 20  |  Issue : 1  |  Page : 48-52

Socio-economic burden of burns: How do the families of patients cope?


Department of Plastic Surgery, Seth GS Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India

Date of Web Publication13-May-2013

Correspondence Address:
Vinita Puri
Head, Department of Plastic Surgery, Seth GS Medical College and KEM Hospital, Parel, Mumbai - 12
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.111783

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  Abstract 

Introduction: A majority of burn injuries in India occur amongst women, primarily in the lower and lower middle class population. The cost of burn treatment is high and the burden is increased because of the poor penetration of medical insurance amongst this unfortunate population. Aims: To study the socio-economic impact burn injuries have on the families of the patients. Materials and Methods: The study was performed using a formulated questionnaire. Twenty-five patients who had been admitted in the burns ward and discharged after treatment in 2011-12 were included in the study. The patients/attendants of the patients were interviewed telephonically and the responses were taken from the patient and/or their attendants and results were studied. Observations: All the patients were female. Amongst the 25 patients studied (n = 25), the average age was 29.44 years, with an average total burn surface area of 32.32%. Average overall expenditure was Rs 89,000 (approx. US$ 1750) of which in the early tangential excision and grafting group (n = 8), the expenditure was Rs. 60,000 (approx. US$1150); in the late grafting group (n = 6), it was Rs. 2,25,000 (approx. US$4320); whereas in the conservative management group (n = 11), it was Rs. 35,863 (approx. US$690). None of the patients were covered by medical insurance. Non-institutional loans and/or sale of assets were required by all respondents to bear the costs. Conclusions: The socio-economic burden of burn injuries is very high and government support is the need of the hour. In patients needing surgery, early tangential excision and grafting has a significant cost-benefit advantage.

Keywords: Socio-economic burden of burns, medical insurance for burns


How to cite this article:
Deshpande ON, Puri V, Vora SS, Shende NN, Choudhary SC. Socio-economic burden of burns: How do the families of patients cope?. Indian J Burns 2012;20:48-52

How to cite this URL:
Deshpande ON, Puri V, Vora SS, Shende NN, Choudhary SC. Socio-economic burden of burns: How do the families of patients cope?. Indian J Burns [serial online] 2012 [cited 2019 Oct 18];20:48-52. Available from: http://www.ijburns.com/text.asp?2012/20/1/48/111783


  Introduction Top


Thermal injuries are amongst the major causes of accidents in India. [1],[2] They occur primarily amongst the female population. [1],[3],[4],[5],[6] The majority of the injuries occur in the household and are not job-related. [7],[8] They are more common amongst the lower and lower middle class populations in both urban and rural areas alike. While accidental injuries remain the most common cause, suicidal and homicidal injuries are not very rare. Most of these patients themselves are not financially independent and not covered by medical insurance, either state-sponsored or otherwise. Burn care being expensive, adversely affects the financial stability of this already disadvantaged population. The social and economic burden the injury entails is more often than not too heavy a burden for the family to bear. [7],[8]


  Aims and Objectives Top


To assess the socio-economic burden of burn injury in a tertiary care hospital in Mumbai and how these costs are reflected as social and economic burdens in the community.


  Materials and Methods Top


This retrospective study was performed using a formulated questionnaire [Table 1]. Twenty-five patients who had been admitted in the burns ward and discharged after treatment in 2011-12 were considered for the study. The patients/attendants of the patients were interviewed telephonically and the responses were taken from the patients and/or their attendants. The results were studied statistically. The burn unit of the hospital has 12 beds and admits only adult female patients. Amongst the admissions in the period of January 2011-December 2012, only 43 patients had telephone numbers which could be contacted. Of those 43, only 25 patients could be reached on phone as the other numbers were not reachable or had changed. The questions were explained in detail to the patients. It was also mentioned that there was no monetary compensation involved. The patients were given a sufficient period of four days after which they were contacted again and their responses were noted. Medical details were studied using medical records. The junior authors were responsible for collection of the data, under the guidance of the senior author who also interpreted the data.
Table 1: Questionnaire

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  Results Top


A total of 25 patients and/or their attendants were included in the study [Table 2]. The average age of the patients was 29.44 years (range 17 years to 56 years). The average total burn surface area (TBSA) was 32.32% (range 15% to 60%). The patients with mixed burns were managed either by early tangential excision and grafting (n = 8), or by late grafting (n = 6). The patients with predominantly first-degree and superficial second-degree burns (n = 11) were managed conservatively with collagen dressings only.
Table 2: Summary of demographic data

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The average duration of hospital stay was 43 days, with a range of 2 days to 120 days. The average overall expenditure incurred was Rs. 89,000 (range Rs. 3,500-9,00,000) of which medical-related expenditure was Rs. 69,000 (range Rs. 2,000-8,00,000), and the non-medical-related expenditure was Rs. 20,000 (range Rs. 1,500-1,00,000). One patient who was managed by late grafting had a total expenditure of Rs. 9,00,000, while another who was managed conservatively had an expenditure of Rs. 3500 only. As both patients were much higher and lower respectively than most others it caused skewing of data as the sample size was small. Hence expenditure incurred was also analyzed by excluding these patients. After these patients were excluded from the analysis, the average overall expenditure incurred was Rs. 57,652 (range: Rs. 12,000-2,50,000), of which medical-related expenditure was Rs. 39,142 (range Rs. 4,000-2,00,000), and the non-medical-related expenditure was Rs. 19,952 (range Rs. 6,000-80,000).

As shown in [Table 3], the patients with predominantly superficial burns (first-degree and superficial second-degree) who were managed conservatively by collagen dressings had the least average duration of stay and expenses. Amongst patients with deeper burns, those who underwent early tangential excision and grafting had lower expenses and a lower average duration of hospital stay as compared to patients who were managed conservatively to begin with and debrided and grafted later.
Table 3: Details of expenditure

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None of the patients who were included in this study had any social or economic security in the form of medical insurance. All the costs that were incurred for the treatment had to be borne by the families themselves. The cost incurred by the hospital has not been included in the expenses mentioned. Seven patients had to resort to selling off their assets in terms of jewels and land to bear the costs. A further seven had to resort to raising money from non-institutional sources like friends, relatives and moneylenders.

Of the 25 patients evaluated three patients were self-employed with a monthly family income ranging from Rs. 4000 to Rs. 45000 with an average of Rs. 11200. Two lost their job, while one patient had a decrease in her monthly income. Seven families had one person each who became unemployed as he/she had to devote time to the patient. Seven families lost part of their livelihood because of absence from work. As a result, 15 of the 25 families had a decrease in their monthly income. The average family income after the burn injury was Rs. 8220, which ranged from Rs. 3000 to Rs. 45000.

The economic burden is further reflected in the fact that all the patients claimed that their overall economic condition had deteriorated [Table 4] and [Table 5]. On a subjective scale, 10 patients claimed to have suffered mild deterioration in their economic condition, 11 had a moderate deterioration, while for four patients, the deterioration was severe. The social condition of the patients and their families was affected too. While only one patient claimed that there had been no change in the social status after the injury, the other 24 claimed that there was a significant fall. Ten patients termed the deterioration as mild, another 10 as moderate, while 4 patients claimed that the burn injury had led to a severe deterioration in the social status of the patient and the family. To study the change in income further, the percentage decrease in the monthly income after injury to that before injury was calculated [Table 5]. Thirteen patients had a less than 25% decrease, 11 patients had a 25 to 50% decrease and one patient had a 50 to 75% decrease in the monthly family income. The total expenses incurred were also calculated as multiples of family income before burn injury [Table 4]. Three patients had total expenses that were equal to or less than their monthly family income. Ten patients incurred expenses that were between 2 and 5 times their monthly income. Six patients had expenses 5 to 10 times the monthly income while another 6 had a total expense that was more than 10 times the monthly family income. These statistics also correlate, but only to an extent, with the subjective perception of deterioration in economic and social status [Table 5]. Though some patients did not have any change in their monthly income, the use of savings or sale of assets made them feel subjectively that there was a worsening of their economic/social status.
Table 4: Objective evaluation of decrease in income and change in socio-economic status

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Table 5: Subjective perception of social and economic deterioration in relation to objective decrease in income and/or sale of assets

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All the five patients who were engaged in academic pursuits had to interrupt their studies because of the burn injury. While recovery and convalescence was a major cause, all the students also said that the deterioration in the social and economic condition were to some extent responsible.


  Discussion Top


It is a known fact that management of burns is resource and time-intensive. [7],[8] Most patients require a long duration of hospital stay, and significant costs are involved. The study has been done at a municipal hospital where there are no admission charges and bed charges. The charges for surgical procedures are minimal at Rs. 1000 (US$20), and are also often waived off. There are no charges for other procedures (like catheterization, central venous access, dressings, etc.) as well as physician or nursing fees. Most of the drugs required for treatment and the dressing materials are available free of cost. The patients however have to bear the costs whenever drugs which are not on the scheduled list of the hospital pharmacy are used. These usually include higher antibiotics, advanced dressing materials, albumin, plasma and nutritional supplements. The hospital poor box charity fund further helps the patients towards costs incurred in procuring these non-scheduled drugs.

The predominant patients are women from the lower and lower middle class. [1],[3],[6],[7] Most of these burn injuries are accidental. At our burns unit, patients with predominantly superficial burns are treated conservatively with collagen sheet dressings only and this has shown a good success rate. Collagen sheet is not available on the scheduled drug list of the hospital and the cost has to be borne by the patient. Also, superficial burns usually do not require extensive use of higher antibiotics and as a result the overall costs incurred are less. This is also reflected in the fact that the total hospital stay and overall costs are low in this group.

Patients with mixed burns, who present to us early, undergo early excision and grafting. Patients who present to our unit late are treated conservatively at first and then managed by late grafting for the raw areas. Patients who are first managed conservatively and later grafted undergo daily dressings with silver sulfadiazine cream until the eschar separates and the raw area is suitable for grafting. This typically is a time-consuming process and results in a longer hospital stay. Also, there is an increased requirement of antibiotics and nutritional supplements for these patients and this is reflected in the total costs incurred which are significantly higher than those managed with early tangential excision and grafting. Because early excision of dead tissue helps control infection and protein loss, these patients have a low overall requirement of antibiotics and nutritional supplements, and subsequently, the total costs incurred are lower.

The hospitalization costs have to be borne directly by the patients and their families themselves because of low penetration of medical insurance in the lower and lower middle class. To raise finances, loans have to be taken and assets have to be sold off. What is worrisome is that the loans are taken from non-institutional sources which may lead to exploitation of the patient because of typically high interest rates. Thus burn injury drains the families of their finances and patients report deterioration in the economic and social status. All the five student-patients had to interrupt their studies and social and economic deterioration is a contributing factor to this dropout.

There has been no similar study performed before in the Indian context. [7],[8] The sample size of this study is small, and data is subject to bias and skew. Because of the small sample size, the study is in effect a pilot study. As a follow-up, we intend to evaluate and analyze data in a prospective manner in the future. It shall also help us to evaluate objective parameters like Disability Adjusted Life Years and Quality of Life indices. Hence more studies are needed to fully understand the gravity of this problem. This can also help in formulation of government policies for the benefit of this class.


  Conclusions Top


The study proves that the socio-economic burden of burn injury is very high. Medical expenses are a huge burden and the personal and per capita income of the family reduced significantly after injury, both of which have a close relationship with the injury severity. However, non-medical-related expenses too are a significant contributor towards the total costs. Non-institutional loans are taken by a few families to tide over the crisis, while some families have to sell off their immovable assets to bear the costs of treatment. Loans taken from non-institutional sources are frequently illegal, and at very high interest rates. Loss of job is a common occurrence for the patient and the attendants, and this contributes to worsening of the situation. Students frequently have to interrupt their studies. There is poor penetration of medical insurance in the community and as a result there is no economic safety net to tide over the crisis.

The study also highlights the economic advantage of early tangential excision and grafting in the management of mixed and deep burns. It is also important to note that this same group also has a lower average hospital stay. Thus, we believe that early tangential excision and grafting not only reduces morbidity, mortality and duration of hospital stay but also decreases costs significantly. As such, the economic advantages are immense. The acceptance of the patient and the family to undergo early excision may increase if these advantages are explained.

Formal legislation is urgently needed to compel employers to purchase injury or medical insurance for employees and their families and to also increase penetration of insurance at large in the community. Universal implementation of government-sponsored insurance schemes is essential. Inclusion of burn-related medications in the schedule of government hospital pharmacies, and setting up of skin banks in the government sector will help reduce costs. In addition, social support to the affected patients and their families is essential. Sensitization of the Corporate sector to contribute to burn care as part of Corporate Social Responsibility, involvement of Non-Government Organizations, Social Service organizations and formation of burn patients support groups will be helpful.

 
  References Top

1.Ahuja RB, Bhattacharya S. Burns in the developing world and burn disasters. BMJ 2004;329:447-9.  Back to cited text no. 1
    
2.Ahuja RB, Bhattacharya S. An analysis of 11,196 burn admissions and evaluation of conservative management techniques. Burns 2002;28:555-61.  Back to cited text no. 2
    
3.Ahuja RB, Bhattacharya S, Rai A. Changing trends of an endemic trauma. Burns 2009;35:650-6.  Back to cited text no. 3
    
4.Uthkarsh PS, Suryanarayana SP, Gautham MS, Shivraj NS, Murthy NS, Pruthvish S. Profile of injury cases admitted to a tertiary level hospital in south India. Int J Inj Contr Saf Promot 2012;19:47-51.  Back to cited text no. 4
    
5.Kavita R, Girish N, Gururaj G. Burden, characteristics, and outcome of injury among females: Observations from Bengaluru, India. Womens Health Issues 2011;21:320-6.  Back to cited text no. 5
    
6.Chakraborty S, Bisoi S, Chattopadhyay D, Mishra R, Bhattacharya N, Biswas B. A study on demographic and clinical profile of burn patients in an Apex Institute of West Bengal. Indian J Public Health 2010;54:27-9.  Back to cited text no. 6
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7.Eldad A, Stern Z, Sover H, Neuman R, Ben Meir P, Wexler MR. The cost of an extensive burn survival. Burns 1993;19:235-8.  Back to cited text no. 7
    
8.Ahachi CN, Fadeyibi IO, Abikoye FO, Chira MK, Ugburo AO, Ademiluyi SA. The direct hospitalization cost of care for acute burns in Lagos, Nigeria: A one-year prospective study. Ann Burns Fire Disasters 2011;24:94-101.  Back to cited text no. 8
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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