The impact of multimorbidity among adults with cardiovascular diseases on healthcare costs in Indonesia: a multilevel analysis.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of death in Indonesia, accounting for 38% of the total mortality in 2019. Moreover, healthcare spending on CVDs has been at the top of the spending under the National Health Insurance (NHI) implementation. This study analyzed the association between the presence of CVDs with or without other chronic disease comorbidities and healthcare costs among adults (> 30 years old) and if the association differed between NHI members in the subsidized group (poorer) and non-subsidized households group (better-off) in Indonesia. METHODS: This retrospective cohort study analyzed the NHI database from 2016-2018 for individuals with chronic diseases (n = 271,065) ascertained based on ICD-10 codes. The outcome was measured as healthcare costs in USD value for 2018. We employed a three-level multilevel linear regression, with individuals at the first level, households at the second level, and districts at the third level. The outcome of healthcare costs was transformed with an inverse hyperbolic sine to account for observations with zero costs and skewed data. We conducted a cross-level interaction analysis to analyze if the association between individuals with different diagnosis groups and healthcare costs differed between those who lived in subsidized and non-subsidized households. RESULTS: The mean healthcare out- and inpatient costs were higher among patients diagnosed with CVDs and multimorbidity than patients with other diagnosis groups. The predicted mean outpatient costs for patients with CVDs and multimorbidity were more than double compared to those with CVDs but no comorbidity (USD 119.5 vs USD 49.1, respectively for non-subsidized households and USD 79.9 vs USD 36.7, respectively for subsidized households). The NHI household subsidy status modified relationship between group of diagnosis and healthcare costs which indicated a weaker effect in the subsidized household group (ß = -0.24, 95% CI -0.29, -0.19 for outpatient costs in patients with CVDs and multimorbidity). At the household level, higher out- and inpatient costs were associated with the number of household members with multimorbidity. At the district level, higher healthcare costs was associated with the availability of primary healthcare centres. CONCLUSIONS: CVDs and multimorbidity are associated with higher healthcare costs, and the association is stronger in non-subsidized NHI households. Households' subsidy status can be construed as indirect socioeconomic inequality that hampers access to healthcare facilities. Efforts to combat cardiovascular diseases (CVDs) and multimorbidity should consider their distinct impacts on subsidized households. The effort includes affirmative action on non-communicable disease (NCD) management programs that target subsidized households from the early stage of the disease.

Effects of the COVID-19 pandemic on healthcare utilization among older adults with cardiovascular diseases and multimorbidity in Indonesia: an interrupted time-series analysis.

BACKGROUND: The COVID-19 pandemic has disrupted healthcare utilization globally, but little is known about the effects among patients with cardiovascular diseases (CVDs) and other multimorbidities. This study analyzed the impacts of COVID-19 on healthcare utilization for patients aged 30 years and older with cardiovascular diseases (CVDs) with or without other chronic disease comorbidities in Indonesia. METHODS: We designed a retrospective cohort study based on the Indonesian National Health Insurance (NHI) sample data from 2016-2020. We defined healthcare utilization as monthly outpatient and inpatient visits related to chronic diseases at the hospital and primary healthcare levels per 10,000 NHI members. We used interrupted time series analysis to evaluate how the healthcare utilization patterns had changed due to the COVID-19 pandemic. RESULTS: Overall, hospital outpatient visits decreased by 39% when the pandemic occurred (95% Confidence Interval (CI): 0.48,0.76), inpatient visits by 28% (95% CI: 0.62,0.83), and primary healthcare visits by 34% (95% CI:0.55, 0.81). For patients with CVDs and multimorbidity, hospital outpatient and inpatient visit rates were reduced by 36% and 38%, respectively and primary healthcare visits by 32%. Some insignificant differences in the reduction of out-and inpatient visits were observed across diagnosis groups and regions. CONCLUSION: Healthcare utilization among patients with chronic diseases decreased significantly during COVID-19 and consistently across different chronic diseases and regions. To cope with the unmet needs of healthcare utilization in the context of the pandemic, the healthcare system needs to be strengthened to cater to the needs of the population-at-risk, especially for patients with CVDs and multimorbidity.

Out-of-Pocket expenditure and patient experience of care under-Indonesia's national health insurance: A cross-sectional facility-based study in six provinces.

BACKGROUND: Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance. METHODS: Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants. RESULTS: The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less). CONCLUSION: Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC.

Does Trastuzumab Offer Good Value for Money for Breast Cancer Patients with Metastasis in Indonesia?

OBJECTIVE: Breast cancer is the most common cancer in Indonesia, with Indonesia's breast cancer mortality rate being the highest among Southeast Asian countries. This study aims to evaluate the cost-effectiveness and budget impacts of adding trastuzumab to chemotherapy versus chemotherapy alone for HER2-positive breast cancer patients in Indonesia. METHODS: We performed a Markov model-based economic evaluation to assess cost-effectiveness, cost-utility, and budget impact. Utility data, direct medical costs, and indirect costs were obtained primarily from interviewing patients. Clinical effectiveness data, on the other hand, were obtained from systematic reviews and real-world data and represented through progression free survival, overall survival, and quality-adjusted life years (QALYs). RESULT: From a healthcare provider's perspective, the total costs for the combined group were USD 14,516, while chemotherapy alone cost USD 7,489. While the cost-effectiveness analysis showed that the combination group had a higher total cost by USD 7,027, PFS was longer in the chemotherapy alone group, with a difference of 2.2 months. The ICER was USD 17,307 for every QALY gained. The total cost of adding trastuzumab over a 5-year period was USD 589 million. CONCLUSION: In conclusion, this economic evaluation suggests that the addition of trastuzumab to standard chemotherapy is not cost-effective in terms of PFS and OS compared with chemotherapy alone.
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Direct Medical Cost of Type 2 Diabetes Mellitus and Its Associated Complications in Indonesia.

OBJECTIVES: To estimate the direct medical cost of type 2 diabetes mellitus (T2DM) and its complications in the Indonesian population from a payer perspective using a prevalence-based approach. METHODS: The direct medical costs in 2016 were estimated using the database of Indonesia's National Health Insurance, known as Jaminan Kesehatan Nasional, which included diagnosis-related group costs and unbundled costs for patients accessing advanced care. The study population included people aged 30 years or older having a diagnosis of T2DM. T2DM and its related complications were identified using the International Classification of Diseases, 10th Revision, code. Hypoglycemia and all complications listed in the Diabetes Severity Complications Index were included. Descriptive analysis was conducted. Costs were converted to 2016 US dollar equivalent. RESULTS: Of the 18.9 million Jaminan Kesehatan Nasional members who accessed secondary and tertiary care, 812 204 (4%) were identified with T2DM, of which 57% had complications. The most common complication was cardiovascular diseases (24%). The total direct medical cost was US $576 million, with 56% spent on hospitalization, 38% on specialist visits, 4% on unbundled non-diabetes-related medication, and 2% on unbundled anti-hyperglycemic medications. Approximately 74% of the total costs was used for the management of people with complications. People with complications (US $930/person/year ± US $1480/person/year) incurred twice the cost of those without complications (US $421/person/year ± US $745/person/year). CONCLUSION: The direct medical cost for management of people with T2DM in Indonesia was high. Early diagnosis and optimal management of T2DM to prevent complications may reduce the costly sequelae and have a possibility of cost savings.

The sensitivity of hospital coding to prices: evidence from Indonesia.

This study examines a newly introduced DRG system in Indonesia. We use secondary data for 2015 and 2017 from Jaminan Kesehatan Nasional (JKN), a patient level dataset for Indonesia created in 2014 to record public and private hospitals' claims to the national health insurance system to investigate whether there is an association between changes in tariffs paid and the severity of inpatient activity recorded in hospitals. We find a consistent small, positive and statistically significant correlation between changes in tariffs and changes in concentration of activity, indicating discretionary but limited coding behaviour by hospitals. The results indicate that reducing price differentials may mitigate discretionary coding, but that the benefits of this are limited and need to be compared to the potential risk of having to rebase all prices upwards.

The sustainability of premium payment of national health insurance's self-enrolled members in Jakarta Greater Area.

BACKGROUND:  The sustainability of the National Health Insurance (NHI) program heavily relies on the premium of its member. The negligence of a large number of members to pay the premium lead to the failure of the Social Security Agency for Health (SSAH) to deliver its services. This study aims at analyzing important factors that influence the sustainability of premium payment of NHI's self-enrolled members in the Jakarta Greater Area. DESIGN AND METHODS: This study performed an econometric analysis from the panel and the same respondent's data in 2015 and 2017. The population of the study was NHI's self-enrolled members who lived in the City of Jakarta, Bogor, Depok, Tangerang, Bekasi, (Jakarta Greater Area) and it represents the urban area of Indonesia. The ordinal logistic regression model was used to determine the type of sustainability NHI premium payment. RESULTS: The survey shows that around 28.3% of self-enrolled members do not pay the NHI insurance premium regularly. Applying ordered logit this study statistically confirms that age of household head, income per month, never experience economic hardship, 1st/2nd class registration, and benefits of SSAH are positively correlated with compliance rate to pay NHI insurance premium. Whereas tobacco consumption, health-seeking behavior, and the 2016 increase of premium are negatively correlated with regular premium payment. CONCLUSIONS: This study calls for policy intervention to improve compliance of premium payment such as i) massive promotion of insurance literacy and benefits of insurance through a health professional, internet, and government officer; ii) expanding auto-debit and installment premium payment; iii) incentive for paying premium regularly and not smoking; and iv) improving access and quality of health services.

Guidance toward the implementation of multicriteria decision analysis framework in developing countries.

INTRODUCTION: Multiple Criteria Decision Analysis (MCDA) is increasingly used in health care mainly because it moves decision-making from ad hoc to an evidence-based and comprehensive process. Developing countries with more restricted financial and human research capacities, however, should consider their own methods of MCDA development and implementation. Areas covered: An MCDA framework to improve procurement decisions of off-patent pharmaceuticals was developed for developing countries and adapted to Indonesia, Kazakhstan and Vietnam during three policy workshops. Based on the experience of these workshops and one joint workshop with international experts and decision makers from multiple developing countries, general recommendations were formulated on how to implement MCDA specifically in developing countries. We provide 17 practical MCDA implementation recommendations in four major areas, including (1) MCDA objectives; (2) technical considerations of MCDA tool; (3) development and customization of MCDA tool and (4) policy implementation of MCDA in decision-making. Expert commentary: These practical MCDA recommendations for developing countries contribute to feasible, transparent, stepwise, iterative and standardized decision-making in health care.

The binding of cellulase variants to dislocations: a semi-quantitative analysis based on CLSM (confocal laser scanning microscopy) images.

Binding of enzymes to the substrate is the first step in enzymatic hydrolysis of lignocellulose, a key process within biorefining. During this process elongated plant cells such as fibers and tracheids have been found to break into segments at irregular cell wall regions known as dislocations or slip planes. Here we study whether cellulases bind to dislocations to a higher extent than to the surrounding cell wall. The binding of fluorescently labelled cellobiohydrolases and endoglucanases to filter paper fibers was investigated using confocal laser scanning microscopy and a ratiometric method was developed to assess and quantify the abundance of the binding of cellulases to dislocations as compared to the surrounding cell wall. Only Humicola insolens EGV was found to have stronger binding preference to dislocations than to the surrounding cell wall, while no difference in binding affinity was seen for any of the other cellulose variants included in the study (H. insolens EGV variants, Trichoderma reesei CBHI, CBHII and EGII). This result favours the hypothesis that fibers break at dislocations during the initial phase of hydrolysis mostly due to mechanical failure rather than as a result of faster degradation at these locations.

Enzyme affinity to cell types in wheat straw (Triticum aestivum L.) before and after hydrothermal pretreatment.

BACKGROUND: Wheat straw used for bioethanol production varies in enzymatic digestibility according to chemical structure and composition of cell walls and tissues. In this work, the two biologically different wheat straw organs, leaves and stems, are described together with the effects of hydrothermal pretreatment on chemical composition, tissue structure, enzyme adhesion and digestion. To highlight the importance of inherent cell wall characteristics and the diverse effects of mechanical disruption and biochemical degradation, separate leaves and stems were pretreated on lab-scale and their tissue structures maintained mostly intact for image analysis. Finally, samples were enzymatically hydrolysed to correlate digestibility to chemical composition, removal of polymers, tissue composition and disruption, particle size and enzyme adhesion as a result of pretreatment and wax removal. For comparison, industrially pretreated wheat straw from Inbicon A/S was included in all the experiments. RESULTS: Within the same range of pretreatment severities, industrial pretreatment resulted in most hemicellulose and epicuticular wax/cutin removal compared to lab-scale pretreated leaves and stems but also in most re-deposition of lignin on the surface. Tissues were furthermore degraded from tissues into individual cells while lab-scale pretreated samples were structurally almost intact. In both raw leaves and stems, endoglucanase and exoglucanase adhered most to parenchyma cells; after pretreatment, to epidermal cells in all the samples. Despite heavy tissue disruption, industrially pretreated samples were not as susceptible to enzymatic digestion as lab-scale pretreated leaves while lab-scale pretreated stems were the least digestible. CONCLUSIONS: Despite preferential enzyme adhesion to epidermal cells after hydrothermal pretreatment, our results suggest that the single most important factor determining wheat straw digestibility is the fraction of parenchyma cells rather than effective tissue disruption.

Are smokers rational addicts? Empirical evidence from the Indonesian Family Life Survey.

BACKGROUND: Indonesia is one of the largest consumers of tobacco in the world, however there has been little work done on the economics addiction of tobacco. This study provides an empirical test of a rational addiction (henceforth RA) hypothesis of cigarette demand in Indonesia. METHODS: Four estimators (OLS, 2SLS, GMM, and System-GMM) were explored to test the RA hypothesis. The author adopted several diagnostics tests to select the best estimator to overcome econometric problems faced in presence of the past and future cigarette consumption (suspected endogenous variables). A short-run and long-run price elasticities of cigarettes demand was then calculated. The model was applied to individuals pooled data derived from three-waves a panel of the Indonesian Family Life Survey spanning the period 1993-2000. RESULTS: The past cigarette consumption coefficients turned out to be a positive with a p-value < 1%, implying that cigarettes indeed an addictive goods. The rational addiction hypothesis was rejected in favour of myopic ones. The short-run cigarette price elasticity for male and female was estimated to be-0.38 and -0.57, respectively, and the long-run one was -0.4 and -3.85, respectively. CONCLUSIONS: Health policymakers should redesign current public health campaign against cigarette smoking in the country. Given the demand for cigarettes to be more prices sensitive for the long run (and female) than the short run (and male), an increase in the price of cigarettes could lead to a significant fall in cigarette consumption in the long run rather than as a constant source of government revenue.

Role of supramolecular cellulose structures in enzymatic hydrolysis of plant cell walls.

The study of biomass deconstruction by enzymatic hydrolysis has hitherto not focussed on the importance of supramolecular structures of cellulose. In lignocellulose fibres, regions with a different organisation of the microfibrils are present. These regions are called dislocations or slip planes and they are known to be more susceptible to various forms of degradation such as acid hydrolysis. Traditionally the cellulose within these regions has been assumed to be amorphous, but in this study it is shown by use of polarized light microscopy that dislocations are birefringent. This indicates that they have a crystalline organisation. Dislocations may be entry points for endoglucanases. Using a fluorescent labelled endoglucanase combined with confocal fluorescence microscopy, it is shown that the enzyme selectively binds to dislocations during the initial phase of the hydrolysis. Using a commercial cellulase mixture on hydrothermally treated wheat straw, it was found that the fibres were cut into segments corresponding to the sections between the dislocations initially present, as has previously been observed for acid hydrolysis of softwood pulps. The results indicate that dislocations are important during the initial part of enzymatic hydrolysis of cellulose. The implications of this phenomenon have not yet been recognized or explored within cellulosic biofuels.

Cigarette smoking in Indonesia: examination of a myopic model of addictive behaviour.

Using aggregated panel data taken from three waves of the Indonesian Family Life Survey (1993-2000), this article tests the myopic addiction behaviour of cigarette demand. Sensitivity analysis is done by examining a rational addiction behavior of cigarette demand. The results provide support for myopic addiction. The short- and long-run price elasticities of cigarette demand are estimated at -0.28 and -0.73 respectively. Excise taxes are more likely to act as an effective tobacco control in the long-run rather than a major source of government revenue.

Bovine colostrum modulates immune activation cascades in human peripheral blood mononuclear cells in vitro.

Bovine colostrum (BC) is the thick yellow fluid a lactating cow gives to a suckling calf during its first days of life to support the growth of the calf and prevent gastrointestinal infections until the calf has synthesized its own active immune defense system. BC contains a complex system of immune factors and has a long history of use in traditional medicine. In an approach to evaluate the effects of bovine colostrum (BC) on the T-cell/macrophage interplay, we investigated and compared the capacity of BC containing low and high amounts of lactose and lactoferrin to modulate tryptophan degradation and neopterin formation in unstimulated and mitogen-stimulated human peripheral blood mononuclear cells (PBMC). The present study shows significant immunomodulatory effects of these BC preparations in human PBMC, either by enhancing or suppressing the occurrence of a Th-1 type immune response. The amount of lactose present in BC seems to diminish the activity of BC in our test system, since BC with higher amounts of lactose attenuated the stimulatory as well as the suppressive activity of BC.

The selection of an appropriate count data model for modelling health insurance and health care demand: case of Indonesia.

We apply several estimators to Indonesian household data to estimate the relationship between health insurance and the number of outpatient visits to public and private providers. Once endogeneity of insurance is taken into account, there is a 63 percent increase in the average number of public visits by the beneficiaries of mandatory insurance for civil servants. Individuals' decisions to make first contact with private providers is affected by private insurance membership. However, insurance status does not make any difference for the number of future outpatient visits.

The financial burden of HIV care, including antiretroviral therapy, on patients in three sites in Indonesia.

This paper assesses the extent of the financial burden due to out-of-pocket payments for health care incurred by people living with HIV (PLHIV) and the effect of this burden on their financial capacity. Data were collected in a cross-sectional survey of 353 PLHIV from three cities in Indonesia (Jakarta, Jogjakarta and Merauke). Respondents in Jakarta were sampled from one hospital and one non-governmental organization working with PLHIV. In Jogjakarta and Merauke, all HIV patients on antiretroviral therapy (ART) who came to selected hospitals during the interview period were asked to participate in the survey. The survey collected data on the frequency and extent of payments for HIV-related care, with answers cross-checked against medical records. Results show that PLHIV had different burdens of payments in the different geographical areas. On average, respondents in Jogjakarta spent 68%, and PLHIV on ART in Jakarta spent 96%, of monthly expenditure for HIV-related care, indicating a substantial financial burden for many ART patients. These patients depended on several sources of finance to cover the costs of their care, with donations from their immediate family being the most common method, selling assets and payments from personal income being the second most common method in Jakarta and Jogjakarta, respectively. Most PLHIV in these two areas did not have insurance. In Merauke, there were little observed out-of-pocket payments because the government covers medical costs via the local budget and health insurance for the poor. The results of this study confirm previous findings that providing subsidized ART drugs alone does not ensure financial accessibility to HIV care. Thus, the government of Indonesia at central and local levels should consider covering HIV care additional to providing antiretroviral drugs free of charge. Social health insurance should also be encouraged.

Are there differences between unconditional and conditional demand estimates? Implications for future research and policy.

BACKGROUND: Estimations of the demand for healthcare often rely on estimating the conditional probabilities of being ill. Such estimate poses several problems due to sample selectivity problems and an under-reporting of the incidence of illness. This study examines the effects of health insurance on healthcare demand in Indonesia, using samples that are both unconditional and conditional on being ill, and comparing the results. METHODS: The demand for outpatient care in three alternative providers was modeled using a multinomial logit regression for samples unconditional on being ill (N = 16485) and conditional on being ill (N = 5055). The ill sample was constructed from two measures of health status - activity of daily living impairments and severity of illness - derived from the second round of panel data from the Indonesian Family Life Survey. The recycling prediction method was used to predict the distribution of utilization rates based on having health insurance and income status, while holding all other variables constant. RESULTS: Both unconditional and conditional estimates yield similar results in terms of the direction of the most covariates. The magnitude effects of insurance on healthcare demand are about 7.5% (public providers) and 20% (private providers) higher for unconditional estimates than for conditional ones. Further, exogenous variables in the former estimates explain a higher variation of the model than that in the latter ones. Findings confirm that health insurance has a positive impact on the demand for healthcare, with the highest effect found among the lowest income group. CONCLUSION: Conditional estimates do not suffer from statistical selection bias. Such estimates produce smaller demand effects for health insurance than unconditional ones do. Whether to rely on conditional or unconditional demand estimates depends on the purpose of study in question. Findings also demonstrate that health insurance programs significantly improve access to healthcare services, supporting the development of national health insurance programs to address under-utilization of formal healthcare in Indonesia.

Acid phosphatase production by Aspergillus niger N402A in continuous flow culture.

The production of acid phosphatases (E.C.3.1.3.2, ACPs) by Aspergillus niger N402A is regulated by specific growth rate, as well as phosphate availability and pH, as demonstrated by studies in continuous flow culture. Specific ACP activity was highest when A. niger was grown at pH 6.3 (64+/-8 U g(-1)) or pH 2.8 (99+/-11 U g(-1)), at a dilution rate of 0.07 h(-1) and phosphate concentrations below 0.46 mM. ACP production was growth correlated for specific growth rates between 0.07 and 0.13 h(-1). Four different ACPs, including two phytases, were produced by A. niger N402A. The ACP and the phytase with maximal activities at pH 5.5 were differentially expressed at different culture pH values, with greater production at low pH.

Gender role and child health care utilization in Nepal.

OBJECTIVE: To study the gender role in child health care utilization in Nepal. METHODS: We analysed 8112 individual observations of age

Modelling the effectiveness of financing policies to address underutilization of children's health services in Nepal.

OBJECTIVE: To estimate the price responsiveness of utilization of formal children's health-care services in Nepal and to use this information to model the impact on utilization of subsidies or increases in user fees. METHODS: A total of 8112 individual observations (of children aged < 15 years) from 2847 households in 274 communities were obtained from the 1996 Nepal Living Standards Survey. A logit model was applied to determine the net impact of price on a parent or caregiver's decision to seek care for a given instance of illness. The model's coefficients were used to calculate the price responsiveness of utilization decisions. FINDINGS: Parents or caregivers reported that 9.7% of children (788/8112) had been ill or injured in the previous month. Parents reported that they had sought care in 566 (71.8%) of these cases; care was most frequently sought from public providers. The price elasticity of demand for children's health-care services in the formal sector was estimated at -0.16. As prices rise, the demand curve exhibits continuous and declining price elasticity. Overall, a 100% subsidy of user fees would increase current utilization rates by 56%, while a 100% increase in fees would lead to a drop in utilization of only 12%. The differential in utilization across income groups was substantial after changes in fees were implemented. CONCLUSION: While the effect of price on the utilization of children's health-care services in Nepal is statistically significant, the size of the impact is modest. Policies to subsidize fees could increase utilization substantially, while fee increases would lead to modest declines in utilization and generate increased revenue.