Economic burden and financial vulnerability of injuries among the elderly in Vietnam

Falls are a leading cause of death among elderly people. However, research on the cost of fall-related injuries is limited in Vietnam. We estimated treatment costs and associated factors among 405 elderly patients in Thai Binh hospitals. Costs were estimated through self-reported data on medical and non-medical expenses. Logistic regression and GLM were used to identify payment and affordability factors. Inpatient and outpatient care costs for fall-related injuries were US$98.06 and US$8.53, respectively. 11.85% of participants couldn’t pay for treatment. Payment ability and cost decline were linked to family income, medical history, and hospital stay length. Elderly with fall-related injuries in Vietnam experienced high costs and severe health issues. Primary healthcare services and communication campaigns should be strengthened to reduce disease burden and develop effective fall injury prevention strategies.

Table 1 compares the covariates between inpatients and outpatients in Thai Binh Hospital.Among 405 patients, most of them lived in rural areas (92.10%), were female (60.00%), lived with spouses/partners (67.65%), and had a caregiver (95.80%).349 patients accounting for more than 80.00% of the population had a high school education or lower.Reportedly, 97.53% were covered with health insurance.The median age of this population was 70 years old, with the interquartile range from 65 to 78.The family monthly income of patients was US $ 255.80 (Interquartile Range-IQR = 170.53-341.06)and the poorest income quintiles accounted for 20.0% of participants.Statistically significant differences between inpatient and outpatient participants were reported in education, household income quintiles, and age (p < 0.05).
The treatment and its characteristics reported by the participants were presented in Table 2. Hypertension (34.07%),Skeleton/Cartilage problems (32.84%), and Spine problems(21.73%)were the most common health issues among elderly patients.58.54% were reported falling more than once in the last 12 months.There was a significant difference between inpatient and outpatient in the types of injuries-related falls (p < 0.05), with the number of hard-tissue injury cases, being higher in the inpatient group (90.79%) than in the outpatient group (45.85%).Additionally, 11.85% of participants reported that they were unable to afford the cost of treatment.
Table 3 presents the medical cost of the participants.In general, inpatient payment (median = US $ 98.06, IQR = 56.66;170.52) was higher in comparison with the payment of outpatients (median = US $ 8.53, IQR = 6.39; 14.84).Travel and food were the two main components contributing to the non-medical expenses.The total non-medical cost for the inpatient group was US $ 76.74 (IQR = 42.21;102.32), and for the outpatient group was US $ 6.39 (IQR = 5.54; 12.79).Regarding the direct medical cost, the median for the hospitalized patients was US $ 47.37 (IQR = 21.65;111.67), versus US $ 3.98 (IQR = 2.11; 5.63) for the other group.The results also showed that surgery cost was the major component of direct medical cost, accounting for 79.19% (median = US $ 37.52; IQR = 4.16; 85.27) and 67.95% (median = US $ 2.70; IQR = 1.86; 3.29) of the total cost in inpatient and outpatient groups, respectively.4 and Appendix S1 shows the associated factors related to the ability to afford the payment and the total medical cost.The patients living with their spouse/partner had a higher capacity to pay than those living alone (OR = 2.14, 95% CI = 1.22; 3.76).Education level was associated with a high ability to afford the cost of care.Compared to inpatient participants, outpatients were found to be significantly correlated with a higher ability to afford the costs and lower cost of medicine.The medical cost for fall patients who had a caregiver was lower than for those who did not have one (Coef.= − 1.11, 95% CI = − 1.56; -0.66).Patients who had hard-tissue injuries paid significantly more than those having soft-tissue injuries (Coef.= 1.15, 95% CI = 0.32; 1.98).

Discussion
In this study, the total cost of post-fall treatment for inpatients was found to be US $98 on average, while for outpatients, it was US $8.5.It also demonstrated associations among the median household income, type of fall injuries, and history of health issues with the patient's ability to pay for the cost associated with falls.www.nature.com/scientificreports/Compared to other studies on the same topic, the fall treatment costs of patients in our study were lower 18,21 .This can be explained by disparities in medical expenses between nations as well as differences in healthcare quality.Measures to aid in fall prevention can help to reduce this unjustified cost burden 1 .Similar to previous studies, our study found that direct non-medical costs, including food and travel costs, accounted for most of the total costs that patients must pay 22,23 .However, in some other studies on the same topic, direct medical costs accounted for the highest proportion of patients, being higher than direct non-medical costs.This difference can be explained by the direct cost estimation method used in those studies 15 .Surgical charges constituted the greatest share of hospitalization costs for older patients with fall injuries, with patients with a history of low back pain or hard-tissue injuries paying more than other patients 1 .The higher treatment costs and lower affordability for inpatients compared to outpatients reflected the fact that patients tended to prefer inpatient medical services, resulting in higher administrative costs.To reduce the economic burden on patients with fall injuries, there is a need to enhance high-value medical supply management, regulate medical equipment providers' excessive profits, and fight for cost-effective material selection without sacrificing patient safety 1 .
Our study found that falls patients who live with spouses/partners can afford treatment costs higher than patients who live alone.Besides, when there was a caregiver, patients treated after a fall would have to pay less than other patients.Having spouses or partners can play a critical role in assisting with daily activities, mobility, rehabilitation exercises, or even emotional and psychological support, which is crucial for patients recovering from fall-related injury, ensuring that patients can recover more effectively.Furthermore, the findings in our study show that family members have a vital role in lowering healthcare costs.Spouses or partners can assist in reducing healthcare bills and insurance claims, as well as ensuring that the patient's medical needs are satisfied.Their presence can also reduce the financial burden by perhaps eliminating the need for pricey professional caregivers or lengthier hospital stays.This research emphasizes the value of splitting treatment costs for falling patients who live with spouses/partners.The presence of a spouse or partner offers a sense of financial security and alleviates concerns about paying treatment fees, which can greatly reduce the financial pressure associated with medical treatments 15,24 .This finding suggests that besides fall-prevented programs, caregiver training and support programs can be established to empower spouses/partners to provide effective care and support at home, reducing the need for extensive hospital stays or costly professional assistance.
Some limitations of this study should be acknowledged.The convenience sampling used in the study does not reflect representative results for all patients treated after a fall in Vietnam.Additionally, for a cross-sectional study, www.nature.com/scientificreports/information about the health status or expenditure was collected from patients' self-reports, which might lead to recall errors in cost measurement.Numerous indirect expenditures, such as healthcare personnel, fixed assets, administration, and equipment operating fees, were excluded from the projected cost provided in this study.These expenses were removed owing to time and resource constraints, but they deserve additional future research.

Conclusion
The results of this study show that fall injuries pose a significant financial burden to the elderly, especially to those who live alone and patients with low incomes.Fall prevention programs are essential to reduce the risk of falls, and the financial burden on the patient's family and society.In addition, caregivers and medical staff should be propagated and instructed on how to prevent falls, especially when taking care of patients with chronic conditions such as stroke and high blood pressure to improve their knowledge of fall prevention.Fall prevention for the elderly will not only relieve people from the economic burden but also improve their health outcomes.

Study design and sample
A

Measurement and instrument
Older patients were introduced briefly to the study's purpose, as well as their benefits and rights while participating.After asking them to sign a written informed consent, thirty-minute face-to-face interviews were performed via a structured questionnaire by trained undergraduate medical students from the Thai Binh University of Medicine and Pharmacy.The collected information from the structured questionnaire is described below:

Primary outcome
Cost of fall injury treatment.Cost per inpatient and outpatient visit were computed by asking the patients to report their expenditure on fall injuries and look at their hospital bills after fall treatment.Data collectors helped patients list all the cost components for fall-injury treatment.The patients then estimated the costs for each activity.The unit costs comprised of two categories (1) direct medical costs (health examination, medication, lab test, hospitalization cost, surgery, and other direct medical costs) and (2) direct non-medical costs (travel and food expenses) 25 .The total cost of fall injury treatment was calculated by summing the total cost for direct medical care after deducting the covered health insurance and other direct non-medical costs.All cost data were obtained in Vietnamese Dong (VND), and the final values were given in US dollars, with 23,465 VND equaling 1 US dollar at the 2019 conversion cost.
Ability to afford the expenditure.We estimated the ability to pay by asking patients to report whether they fully or partially paid or were unable to pay for the fall injury treatment.
Predictor variables Social demographic.We asked participants to self-report their Living area (Urban/Rural), Age, Gender (Male/ Female), Level of education (No school/Primary school/High school/Above high school), Marital status (Single, Divorced, Widow/Living with a spouse or partner), Having a caregiver (Yes/No), Monthly household income.In addition, we asked the participants whether they had health insurance.

Data analysis
STATA version 14.0 (Stata Corp. LP, College Station, United States of America) was utilized to analyze the collected data.For descriptive analysis, the Chi-square test and Man-Whitney test were used to compare the difference of various covariates (Social-demographic and Treatment and illness) among the inpatient and outpatient participants.Generalized linear models, with Gaussian family and identity-link, and Logistic regression model were used to identify the associated factors related to total payment and the ability to afford the expenditure.We utilized a forward stepwise selection strategy, which included variables having a p-value of < 0.2 of the loglikelihood ratios tests, along with regression models to construct the reduced model.A p-value of less than 0.05 was statistically significant.
Treatment and illness.The participants self-reported some clinical indicators, such as Type of patient (Inpatient/Outpatient), History of health issues (Hypertension/Cardiovascular/Ear problems/Spine problems/Skelton or Cartilage problem/Other), Number of falls (Once/More than once), Type of current fall injuries (Soft tissue injuries/Hard tissue injuries), Duration of hospitalization.

Table 1 .
Comparison of socioeconomic status and behavior between inpatient and outpatient.

Table 2 .
The characteristics of treatment and illness of the participants.

Table 3 .
The medical cost of treatment among patients with fall injury.Unit: US $ n number of patients responding to the questions, % Percentage by unit cost, IQR interquartile range.
Vol.:(0123456789) Scientific Reports | (2023) 13:19254 | https://doi.org/10.1038/s41598-023-46662-3 cross-sectional study was conducted from August 2018 to February 2019 in seven hospitals of Thai Binh province, including Thai Binh Provincial General Hospital and six district hospitals (Kien Xuong, Quynh Phu, Tien Hai, Thai Thuy, Dong Hung, and Hung Ha).The selection criteria for participants included (1) 60 years of age and above; (2) Hospitalization (inpatient and outpatient) due to a fall; (3) No cognitive impairment.Participants who suffered from severe injuries and were not able to answer the questionnaire were excluded from the study.Respondents were recruited using the convenience sampling method.A total of 430 patients joined this study with a response rate of 94.2%.