Breast Cancer-Related Financial Toxicity in Sri Lanka: Insights From a Lower Middle-Income Country With Free Universal Public Healthcare.

Financial toxicity (FT) describes either objective or perceived excess financial strain due to a cancer diagnosis on the well-being of patients, families, and society. The consequences of FT have been shown to span countries of varied economic tiers and diverse healthcare models. This study attempts to describe FT and its effects in a lower- to middle-income country delivering predominantly public nonfee-levying healthcare. This was a cross-sectional study involving 210 patients with breast cancer of any stage (I to IV), interviewed between 6 and 18 months from the date of diagnosis. Financial toxicity was highly prevalent with 81% reporting 3 or more on a scale of 1 to 5. Costs incurred for travelling (94%), out-of-hospital investigations (87%), and consultation fees outside the public system (81%) were the most common contributors to FT. Daily compromises for food and education were made by 30% and 20%, respectively, with loss of work seen in over one-third. Greater FT was seen with advanced cancer stage and increasing distance to the nearest radiotherapy unit (P = .008 and .01, respectively). Family and relatives were the most common form of financial support (77.6%). In conclusion, FT is substantial in our group, with many having to make daily compromises for basic needs. Many opt to visit the fee-levying private sector for at least some part of their care, despite the availability of an established public nonfee-levying healthcare.

A model for analysis of antibiotic usage in low-income settings.

OBJECTIVES: Quantification of antibiotic usage is an important component of antimicrobial stewardship programmes. We aimed to estimate institutional antibiotic usage and costs using methodology and metrics applicable to low-income settings without electronic health records. METHODS: The DDD per 100 patient-days (DDDs/100 PDs) of antibiotics used in a calendar year was calculated retrospectively from ward registers and inpatient drug records in general surgical wards of a tertiary hospital. The antibiotics were categorized using the Access, Watch, Reserve classification. The annual expenditure on antibiotics was estimated from price lists of the state medication procurer. RESULTS: Annual usage of IV co-amoxiclav, cefuroxime and metronidazole was significantly higher than other antibiotics and certain wards showed outlier use of the same. The IV formulations of co-amoxiclav (5-fold), metronidazole (3-fold) and ciprofloxacin (2-fold) were used in excess of the oral formulation. Proportionate antibiotic usage based on the AWaRe category did not vary significantly between wards. Two wards were outliers for annual expenditure/100 PDs. IV clindamycin and meropenem combined accounted for 43.8% of expenditure on antibiotics. CONCLUSIONS: This study demonstrated intra-institutional variations of annual antibiotic usage and related costs. The metric DDD/100 PDs and the methodology used here are suitable for intra- and inter-institutional analyses of antibiotic usage, particularly in low-income settings.

Patient Satisfaction With Breast Cancer Care Delivery at the National Cancer Institute of Sri Lanka: Does Language Play a Role?

PURPOSE: This study sought to examine whether there was an association between language barriers and patient satisfaction with breast cancer care in Sri Lanka. METHODS: A telephone-based survey was conducted in the three official languages (Sinhala, Tamil, or English) among adult women (older than 18 years) who had been treated for breast cancer within 6-12 months of diagnosis at the National Cancer Institute of Sri Lanka. The European Organisation for Research and Treatment of Cancer Satisfaction with Cancer Care core questionnaire was adapted to assess three main domains (physicians, allied health care professionals, and the organization). All scores were linearly transformed to a 0-100 scale, and subscores for domains were summarized using means and standard deviations. These were also calculated for the Sinhalese and Tamil groups and compared. RESULTS: The study included 72 participants (32 ethnically Tamil and 40 Sinhalese, with 100% concordance with preferred language). The most commonly reported best aspect of care (n = 25) involved affective behaviors of the physicians and nurses. Ease of access to the hospital performed poorest overall, with a mean satisfaction score of 54 (30.5). Clinic-related concerns were highlighted as the worst aspect of the care (n = 10), including long waiting times during clinic visits. Sixty-three percent of Tamil patients reported receiving none of their care in Tamil and 18% reported experiencing language barriers during their care. Tamil patients were less satisfied overall and reported lower satisfaction with care coordination (P = .005) and higher financial burden (P = 0.014). CONCLUSION: Ethnically Tamil patients were significantly less satisfied than their Sinhalese counterparts and experienced more language barriers, suggesting there is a need to improve access to language-concordant care in Sri Lanka.