Out Of Pocket Payments For Health Care Among The Elderly With Cognitive Frailty In Malaysia

Background Recently, there is a concern on cognitive frailty, as a potent risk factors for dementia, functional disability, poor quality of life and mortality among elderly. Cognitive frailty is a reversible pathological transitional stage between healthy aging and disability; it is associated with increased health care utilization and co-morbidities. The study purpose was to identify socio-demographic characteristics, co-morbidities, and out-of-pocket payments for health care among elderly Malaysians with cognitive frailty. The study included all participants of the third phase of Malaysian representative LRGS-TUA community based study. Multiple types of data were collected through a structured interviewed questionnaire including Fried’s test; Clinical dementia rating test; inpatient and outpatient health care utilization and amount paid. A total of 1,006 participants were interviewed, with 66.18% response rate. Only 730 respondents found satisfying the inclusion criteria of not having physical disability or psychiatric problem, not terminally ill, and no history of alcohol or drugs abuse. The prevalence of cognitive frailty was 4.5%. Males represented 66.6%. Hypertension, high cholesterol level, joint pain, diabetes mellitus, and vision problems, were the most common chronic diseases among cognitive frail elderly in Malaysia (69.7%, 66.7%, 48.5%, 39.4% and 39.4%, respectively). During last six months, cognitive frailty participants utilized outpatient care at governmental clinic, governmental hospitals, and private clinics (60.6%, 21.2%, and 21.2%, respectively). Out of the cognitive frail patients, only 3.0% were admitted to hospitals during last year. Around half (53%) of the study participants were spending less than RM100 per six months for health care out of their pockets, while 26%, 13%, 8% of the study participants were spending RM101 to RM200, RM201 to RM300, and > RM300 every six months out of their pockets for seeking of care, respectively. The mean total out-of-pocket payments for six months seeking of care for elderly Malaysian citizens with cognitive frailty was around RM84 (SD = 96.0) per six months.

patient was given full explanation on the aim of the study and its processes.

Questionnaire
Data were collected through a structured interviewed questionnaire consisting of three different data collection tools that were previously published elsewhere: Fried's test of frailty [13]; clinical dementia rating test score (CDR) [14]; inpatient and outpatient health care utilization and payments assessment tool [15].
The rst part of the questionnaire includes the ve questions of Fried stest; basedonthef ∈ d ∈ gsofthistest, patientsareied ∫ othreecateg or ies: Notail(alsoknownasrobust)(sc or e = 0), pre -Frail(sc or e = 1s test and a score of 0.5 in CDR test at the same sitting.
The third part of the questionnaire included the assessment of patient's medical history covering the previous year inpatient hospitalization and last six months outpatient care. The inpatient and outpatient health care utilization and payments part of the questionnaire was previously designed, validated, and used by Aljunid, Maimaiti [15]. This part of the questionnaire included patient`s socio-economic background, information on morbidity, outpatient and inpatient care utilization, caregivers expenditure and the payer for the health care expenditure. Data collection were done at the primary health care facilities during the year 2019.

Inclusion criteria
Participants are included in the study if they were: Malaysian citizens; aged 60 years old or above; have no physical disability (i.e. bedridden, using wheel chair); not terminally ill; have no psychiatric problem (i.e. Dementia and Alzheimer disease); have no history of alcohol or drugs abuse.  15.2%, and 15.2%, respectively), no cognitive frail cases were from Johor. Males represented 66.6% of the total sample. None of the single participants were diagnosed as cognitive frail cases. Participants with cognitive frailty were almost distributed evenly among age groups starting from 65 to 80 years old (n = 11,9,11). Out of the cognitive frail cases, 72.7% (n = 24) were with school level of education; the majority of the cognitive frail participants (97%, n = 32) were not working and are categorized under low income group of people. Table No. 2 shows the co-morbidities among the study participants. Hypertension, high cholesterol level, vision problems, and diabetes mellitus were the most common chronic diseases among elderly people in Malaysia (54.9%, 52.2%, 35.8% and 27.7%, respectively). More speci cally, hypertension, high cholesterol level, joint pain, diabetes mellitus, and vision problems, were the most common chronic diseases among cognitive frail elderly in Malaysia (69.7%, 66.7%, 48.5%, 39.4% and 39.4%, respectively). It was noticeable that hypertension, high cholesterol level were more prevalent (73.1% and 69.2%, respectively) among elderly with other frailty types compared to not frail, pre-frail, and cognitive frail elderly. Additionally, 78.8% of cognitive frail participants expressed well health during the last two weeks. Furthermore, 15% of cognitive frail participants reported seeking health care at public and private clinics, none of them sought hospital care during past two weeks. Table 3 shows the outpatient health care utilization ndings of the study participants during the past six months. In total, 81.8% (n = 27) of the cognitive frail patients reported a mean of 2.26 visits (with a maximum of 5 visits) for health care facilities seeking for treatment during the last 6 months. One way Anova test was conducted to examine the presence of signi cant differences between cognitive frail participants and other groups of elderly participants, namely: not frail, pre-frail, and other frailties. No statistically signi cant difference found in the number of visits among all participants (F = 2.451, P value = 0.062). During the past six months, cognitive frail patients utilized outpatient care at the governmental clinic, governmental hospitals, and private clinics (60.6%, 21.2%, and 21.2%, respectively); none of them sought outpatient care at private hospital, traditional medicine healers, and alternative health care. Around half of the cognitive frail patients (45.4%; n = 15) visited governmental clinic more than one time (with a maximum of 3 visits). Only 18.1% (n = 6) of the cognitive frail patients visited outpatient clinic at governmental hospitals more than one time (with a maximum of 3 visits). All cognitive frail patients whom visited private clinic (n = 7, 21.2%) did that one time only.    Did you seek any treatment as an outpatient for the illness that you suffered in the last six months? How many times did you get treatment in private clinic during the last 6 months?

Results
Non hospitals. Figure 1 shows the type of vehicles used for transport to outpatient health care facilities during the past six months. The most common type of vehicles used among cognitive frail elderly and all elderly categories (Not frail, pre-frail, other frailties) were private cars and motorcycles, while public transport was not commonly used. Figure 2 shows the study participant`s total spending categories out of their pockets for seeking of care during past six months. As shown in Fig. 2 Figure 3 shows the type and percentage of spending of the study participants out of their pockets for seeking health care during the past six months. As shown in Fig. 3, the biggest payment driver components of care for elderly patients are special food cost (37.0%) and clinic charges (31.1%).
Additional justi cations for lower Malaysian OOP spending compared to other countries is the lower Malaysians` health care utilization rates of elderly, lower GDP per capita of Malaysia compared to European countries; both can be considered as reasonable justi cation for such cost variations. Additionally, Sociodemographics and co-morbidity variations of the participants among different studies, different adopted tests for frailty assessment, and participants' selection methods of the studies can also be another factors that can affect the cost of cognitive frail elderly. Recall bias of the health care utilization and payments data from elderly participants and low prevalence rate of cognitive frailty among Malaysians can be considered as the main limitations of the current study.

Conclusion
Cognitive frailty is not recognized as a prevalent syndrome among elderly Malaysians compared to other countries. Elderly Malaysians with cognitive frailty are probably expressing good health status and well controlled co-morbidities. The OOP payments for seeking of care among cognitive frail elderly Malaysians is not different from that of not frail, pre-frail, and other types of frailty. Cognitive frailty is not considered as a costly phenomena among elderly Malaysians. Written consent for participate was obtained from study participants, the form was approved by the ethics committees.

Consent to publish
Not applicable

Availability of data and materials
Supporting data of the study can be accessed through contacting the corresponding author and after approval from the National University of Malaysiafaculty of medicine to take part of the data.

Figure 2
Total spending categories out of pocket for seeking of care during past six months.

Figure 3
Type and percent of OOP payments for care during past six months.