# Out-of-Pocket Expenditure and Challenges Faced by Patients Undergoing Heart Valve Replacement in Follow-Up Care at a Tertiary Care Center in South India: A Mixed Methods Study

## TL;DR

This study examines the financial and nonfinancial challenges faced by patients undergoing heart valve replacement in South India, finding high out-of-pocket costs and suggesting telemedicine as a potential solution.

## Contribution

The study introduces a mixed methods approach to assess both financial and nonfinancial challenges in post-surgery follow-up care for heart valve patients in India.

## Key findings

- Median out-of-pocket expenditure for follow-up visits was Rs. 765, with significant financial burden observed.
- 60.14% of patients faced catastrophic health expenditures, with costs increasing with travel duration and accompaniment.
- Telemedicine is proposed as a solution to reduce challenges related to distance and expense.

## Abstract

Background

Heart valve replacement surgery is one of the most commonly performed cardiac surgeries in India. Post-surgery, the patient requires lifetime anticoagulation therapy with regular follow-up, leading to financial and nonfinancial burdens for the patients. This study aimed to determine the out-of-pocket (OOP) expenditure (OOPE) for follow-up visits to the heart valve clinic and explore and assess the challenges faced by patients during these follow-ups.

Methodology

This mixed methods study was conducted at a tertiary care center from June 2018 to August 2018, focusing on patients attending the Valve Replacement clinic. The qualitative component of the study involved conducting three focus group discussions, which were transcribed and manually analyzed using thematic analysis to generate categories. The monthly OOPE and the proportion of irregular patients were assessed using a pretested and validated questionnaire developed based on the findings from the qualitative study. The data from the quantitative study were entered into EpiData version 3.1 (EpiData, Odense, Denmark) and analyzed using Stata 14 (StataCorp., College Station, TX).

Results

The median (interquartile range [IQR]) total OOPE for patients was Rs. 765 (475-1,100). The median (IQR) direct and indirect expenditures were Rs. 420 (210-600) and Rs. 590 (330-948), respectively. The patients faced difficulties in the categories of financial, travel, hospital, family, and personal. Out of a total of 143 participants, 86 (60.14%) had incurred catastrophic health expenditures. The cost also significantly increased with the presence of an accompanying person and longer travel durations.

Conclusions

The major difficulties faced by the patients were distance and expense. Telemedicine can help overcome these challenges by decentralizing follow-up care to the primary care level.