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PubMed1998

Current estimates of the economic cost of obesity in the United States.

This study was undertaken to update and revise the estimate of the economic impact of obesity in the United States. A prevalence-based approach to the cost of illness was used to estimate the economic costs in 1995 dollars attributable to obesity for type 2 diabetes mellitus, coronary heart disease (CHD), hypertension, gallbladder disease, breast, endometrial and colon cancer, and osteoarthritis. Additionally and independently, excess physician visits, work-lost days, restricted activity, and bed-days attributable to obesity were analyzed cross-sectionally using the 1988 and 1994 National Health Interview Survey (NHIS). Direct (personal health care, hospital care, physician services, allied health services, and medications) and indirect costs (lost output as a result of a reduction or cessation of productivity due to morbidity or mortality) are from published reports and inflated to 1995 dollars using the medical component of the consumer price index (CPI) for direct cost and the all-items CPI for indirect cost. Population-attributable risk percents (PAR%) are estimated from large prospective studies. Excess work-lost days, restricted activity, bed-days, and physician visits are estimated from 88,262 U.S. citizens who participated in the 1988 NHIS and 80,261 who participated in the 1994 NHIS. Sample weights have been incorporated into the NHIS analyses, making these data generalizable to the U.S. population. The total cost attributable to obesity amounted to $99.2 billion dollars in 1995. Approximately $51.64 billion of those dollars were direct medical costs. Using the 1994 NHIS data, cost of lost productivity attributed to obesity (BMI> or =30) was $3.9 billion and reflected 39.2 million days of lost work. In addition, 239 million restricted-activity days, 89.5 million bed-days, and 62.6 million physician visits were attributable to obesity in 1994. Compared with 1988 NHIS data, in 1994 the number of restricted-activity days (36%), bed-days (28%), and work-lost days (50%) increased substantially. The number of physician visits attributed to obesity increased 88% from 1988 to 1994. The economic and personal health costs of overweight and obesity are enormous and compromise the health of the United States. The direct costs associated with obesity represent 5.7% of our National Health Expenditure in the United States.

Coronary Disease↗
PubMed2005

Health, economic evaluation, and critical care.

In the past 2 decades, societal spending on health care has become an international concern. The United States currently spends more than 1.6 trillion dollars per year on health care--approximately 15% of the gross domestic product. The provision of care to critically ill patients accounts for a disproportionate share of these health care dollars--approximately 13% of hospital costs, 4% of national health expenditures, and 0.5% to 1% of the gross domestic product. This enormous investment necessitates careful evaluation of our interventions and their associated expense. Economic evaluation can aid policy makers and health care professionals in comparing the relative and incremental value of disparate and expensive therapies and also inform decisions about which interventions provide good value for the health care dollar. In this review, we will highlight landmark publications over the past decades that have helped to shape the field of economic evaluations for critical care medicine.

Cost-Benefit Analysis↗
PubMed2001

The medical-care cost burden of obesity.

Recent years have seen a dramatic rise in the prevalence of obesity in many countries, stimulating interest in the health and economic consequences of this phenomenon. In this article, we provide a systematic review of the literature on the medical-care cost burden of obesity. Relevant studies were identified using a computerized search of the medical literature for English-language articles published between 1990 and 2001. The 18 studies that met all criteria for inclusion in the review can be classified as modelling or database studies and further distinguished as cross-sectional or longitudinal in nature. The majority of studies that have been conducted are cross-sectional modelling studies, including 10 studies reporting the burden of obesity to national health systems. These suggest that obesity accounts for 5.5-7.0% of national health expenditures in the United States and 2.0-3.5% in other countries for which estimates have been reported. Other studies highlight the burden of obesity from other perspectives, including employers and health plans, as well as the impact of obesity on future disease risks and associated medical-care costs. Despite various methodological limitations, discussed herein, this body of research leads to the inescapable conclusion that obesity exacts an immense economic toll in various countries throughout the world.

Cost of Illness↗
PubMed1987

The economic crisis and its impact on health and health care in Latin America and the Caribbean.

The economic crisis that struck most Latin American and Caribbean countries beginning in 1982 has caused sharp reductions in domestic investment and in imports; domestic consumption has been less affected, while public sector spending has responded in different degrees in different countries. In general, public spending on health decreased, sometimes quite dramatically, but some countries were able to maintain the real value of noninvestment spending for health by central governments. It is much harder to tell what may have happened to output of health services, and still harder to know how health status has been affected. Scattered evidence suggests two conclusions. First, worsened economic conditions can seriously damage health status, with effects on infant mortality and on the patterns of disease and death, especially for children. Second, these repercussions do not have to occur, and public programs designed specifically to maintain basic health services and to assure adequate nutrition are effective in offsetting the worst consequences of economic hardship.

Child↗
PubMed1999

Medical costs of smoking in the United States: estimates, their validity, and their implications.

OBJECTIVE: To compare estimates of the medical costs of smoking in the United States and to consider their relevance to assessing the costs of smoking in developing countries and the net economic burden of smoking. DATA SOURCES: A Medline search through early 1999 using keywords "smoking" and "cost", with review of article reference lists. STUDY SELECTION: Peer-reviewed papers examining medical costs in a single year, covering the non-institutionalised American population. DATA EXTRACTION: Methods underlying study estimates were identified, described, and compared with attributable expenditure methodology in the literature dealing with costs of illness. Differences in methods were associated with implied differences in findings. DATA SYNTHESIS: With one exception, the studies find the annual medical costs of smoking to constitute approximately 6-8% of American personal health expenditures. The exception, a recent study, found much larger attributable expenditures. The lower estimates may reflect the limitation of analysis to costs associated with the principal smoking-related diseases. The higher estimate derives from analysis of smoking-attributable differences in all medical costs. However, the finding from the most recent study, also considering all medical costs, fell in the 6-8% range. CONCLUSIONS: The medical costs of smoking in the United States equal, and may well exceed, the commonly referenced figure of 6-8%. This literature has direct methodological relevance to developing countries interested in assessing the magnitude of their current cost-of-smoking burden and their future burdens, with differences in tobacco use histories and the availability of chronic disease treatment affecting country-specific estimates. The debate over the use of gross or net medical cost estimates is likely to intensify with the proliferation of lawsuits against the tobacco industry to recover expenditures on tobacco-produced disease.

Developing Countries↗
PubMedDate not supplied

Dialysis for everybody? At any cost?

During the last fifty years medicine has made enormous progress. However the "mechanical disease model" has introduced the concept of disease as a biological disorder and, at the same time, has shifted the objective of the doctor's action: the patient is identified with the disease and the latter being curable, there are no limits to the doctor's action. This behaviour has two different implications: one is referred to the tremendous increase of the expenditure and the second is related to the changes in death's physiognomy. Today death is no longer a moment, but a process whose practical outcome is the dilution (from hours to months) of the boundary between life and death. Equity is one of the main principles of every health systems: all the members of a community should have equal opportunities to receive medical treatment. Every year approximately 1250 million Euros (2% of the total health expenditure) are spent in Italy for nearly 41,000 patients on chronic dialysis. In terms of macro economy and of balanced health policy, no ethical principles can justify the absorption of such a huge quantity of resources by such a small number of patients. We must establish some rules, but it is obvious that such rules cannot be based on the identification of criteria that exclude patient groups based on statistical parameters, and on the sum of risk factors. Viceversa, the exclusion and/or withdrawal from RRT must depend on the possibilities of individual patients to maintain the essential characteristics of human beings or on the patient's opinion that there is a lack of proportion between means and results. Doctors cannot presume that the best solution coincides with the extension of patients' life. Their assistance must not aim at mere survival neglecting the quality of life. In order to start an in depth discussion, solid ethical and methodological references can be found in the "Clinical Practice Guidelines on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis". This topic can no longer be postponed. Should the nephrological community be unable to find a shared basis for discussion beyond hypocrisy, the valuable doctor-patient relationship (which is vital for all medical procedures) will be replaced by the "taxpayer-mediated" approach. In this case, following the principles of social good, the political community will compel doctors to mediate a conflict between collective interests and individual interests, and doctors will no longer be able to act in compliance with the ethical principles of "avoiding harm".

Humans↗
PubMed2001

The contribution of reproductive ill-health to the overall burden of perceived illness among women in southern India.

OBJECTIVE: To investigate women's perceptions of the overall burden of illness among a sample of women in southern India. METHODS: A community-based sample of 421 young married women in a subdistrict about 70 kilometres from Bangalore, Karnataka State, India, were interviewed monthly for one year. At each visit, information on the symptoms of all forms of illness they had experienced was elicited with the aid of a checklist. Details were obtained on the durations of episodes of illness and on health-seeking behaviour and costs. The symptoms were subsequently coded in accordance with the International Classification of Diseases (ICD-10). FINDINGS: Reproductive ill-health accounted for half of all illness-days and for 31% of total curative health expenditure. The 1990 Global Burden of Disease study estimated that 27.4% of disability-adjusted life years (DALYs) lost in Indian women aged 15-44 years were attributable to reproductive ill-health. CONCLUSIONS: Our study indicates that this dimension of morbidity, when measured in terms of women's subjective experiences, makes a larger contribution to the burden of illness than that suggested by the DALY approach. This lends justification to the high priority attached to reproductive ill-health in India.

Adolescent↗
PubMed2005

[The influence of alcohol drinking on medical care expenditures among National Health Insurance beneficiaries].

Heavy alcohol drinking is an important risk factor for some lifestyle-related diseases. However, the relationship between drinking habits and medical care expenditures has not been elucidated in a Japanese general population. We examined this relationship in a 9-year cohort study. Study participants were 2039 National Health Insurance beneficiaries aged 40-69 years living in a rural Japanese community. The baseline survey, with medical check-up, was performed in 1989 or 1990 and the subjects' drinking habits were estimated by questionnaire. Medical care use and costs were monitored by linkage with the National Health Insurance claim history files at baseline survey through the end of March 2000. Men who were daily heavy drinkers (ethanol intake > or =69 g per day) had significantly higher medical costs compared to participants who drank less, within 5 years after baseline. This difference was 2000 yen per month after adjusting for age, body mass index, smoking, systolic blood pressure, glycosuria, serum total cholesterol and alanine aminotransferase. Daily heavy male drinkers also had a higher hazard ratio for total mortality compared to occasional drinkers, by the Cox proportional hazard model (hazard ratio: 1.81), although it did not reach statistical significance (P = 0.153). In women, medical costs were almost the same for occasional and daily drinkers. Total medical costs among Japanese men aged 20 years and over may be decreased by about 8400 billon yen per year if we assume a 20% decrease in daily heavy drinkers. To reduce national medical costs, it is important to promote a program for heavy drinkers, as described in the "Health Japan 21" initiative, the Japanese national health promotion guidelines for the first 10 years of the 21st century.

Adult↗
PubMed1987

Health maintenance organizations: just what the doctor ordered?

Following its recent reorganisation of the management of the hospital sector of the NHS, the Government is currently engaged in a review of the primary health care sector. Certain of its proposals may be interpreted as suggesting movement towards a system modelled on American-style Health Maintenance Organizations (HMOs). This article seeks to explore the context in which HMOs have developed, to assess their current performance and to evaluate their potential impact on the health delivery system. It suggests that they must be understood primarily in the context of initiatives aimed at reducing health expenditure, and finds that the cost advantages claimed for them are achieved through reduced utilization rather than through greater efficiency. It also argues that this reduced utilisation is likely to increase inequalities in health care.

Cost Control↗
PubMed1983

An alternative health delivery system for the chronically ill elderly.

The present health care system is fragmented, uncoordinated, and too costly for the chronically ill, elderly patient. Project OPEN provides preventive health and social services in order to reduce costs and provide more effective care. This alternative delivery system is based on a consortium brokerage model which provides functional assessment, care plan development and service coordination. A randomized sample of 338 elderly individuals participated in a time series experiment. Client functional status, service utilization, and all health costs were collected for six months. The results indicated a maintenance in functioning levels, a decrease in acute hospitalizations, and a 20% reduction in health care costs for the demonstration participants as compared to the control group. Project OPEN provided more effective care while simultaneously reducing health expenditures to the chronically ill elderly.

Activities of Daily Living↗
PubMed1999

An equitable way to pay for universal coverage.

This article describes a way to finance universal health care coverage that preserves much of the current financing system and replaces funds obtained from regressive sources with revenue from more progressive ones. New funding would be needed for 24 percent of health expenditures and would be raised through an increase in the federal personal income tax. Premiums are eliminated since their cost is the same to everyone regardless of income. Cost sharing and out-of-pocket spending for medically necessary services are also abolished. In a more equitably financed system, employers would pay a new payroll tax that raised the same amount of money they currently spend for employee health insurance premiums; this would require a payroll tax of about 7 percent. Revenue from an increase in federal personal income taxes would replace household out-of-pocket expenditures for medically necessary services and payments for insurance premiums. For the average, middle-income family, the tax increase would total $731 in 1998. In exchange for the tax increase, no American or American employer would need to buy health insurance or face out-of-pocket charges for any medically indicated health care.

Federal Government↗
PubMed2002

Inpatient dermatology: characteristics of patients and admissions in a Spanish hospital.

BACKGROUND: Inpatient dermatology has not been properly described in many countries. National differences might be important in the evaluation of its usefulness and the applicability of politics of health expenditure restrictions. OBJECTIVE: To describe inpatient activity and readmission rates in a dermatology department in Spain. STUDY DESIGN: Cross-sectional prospective study in a single hospital. SETTING: Secondary care hospital of the National Health Service in Pontevedra (Spain). METHODS: From May 1997 to December 2000, all discharge sheets (1048) were included in the study, codified and described. RESULTS: Surgery was the reason for admission in 37% of the inpatients. The most frequent diagnosis were: neoplasm (36%), infection (15%), psoriasis (10%), other (10%), dermatitis (6%) and drug reaction (5%). Readmission rates were 1.8% within 30 days, and 12.5% within 1 year. CONCLUSIONS: Inpatient dermatology is different in different countries. Compared with what has been described in the USA or UK, our data suggest an important surgical content of inpatient dermatology in Spain, not reported in those countries. Medical diagnoses also differ, consisting of more infections, and less psoriasis and dermatitis in our setting. Readmission rates are low when compared with previously published ones, a finding that supports a long-term benefit of hospitalization.

Adult↗
PubMed1994

Children in foster care in the state of Washington. Health care utilization and expenditures.

OBJECTIVE: To determine and compare health care utilization and expenditures of children in foster care with those of other children and to identify and describe high-cost children in foster care. DESIGN: Analysis of the Medicaid program claims data in the state of Washington. POPULATION: A total of 1631 children in foster care and 5316 children in the Aid to Families With Dependent Children (AFDC) program in 1990. The children were ages 0 through 7 years and eligible for Medicaid continuously during the study year. MAIN OUTCOME MEASURES: Health care utilization and expenditures classified by types of health service and health care provider; proportion of children with 1990 expenditures exceeding $10,000 and most prominent diagnoses associated with their health care utilization. RESULTS: Mental health services were used by 25% of children in foster care compared with 3% of AFDC children (P < .001), and supportive services of visiting nurses and physical therapists were used by 13% of children in foster care and 1% of AFDC children (P < .001). Twice as many children in foster care than AFDC children used medical equipment or specialist services or were hospitalized (P < .001). Mean health care expenditures in 1990 were $3075 for children in foster care and $543 for AFDC children (P < .001). High-cost children included 8% of children in foster care and 0.4% of AFDC children. Among the high-cost children in foster care (n = 106), 59% had mental disorders and 31% had congenital conditions. CONCLUSIONS: Results suggest a higher prevalence and greater complexity of illnesses, particularly mental disorders, among children in foster care. Despite the high utilization and cost of mental health services, previous research suggests there may be underutilization of these services compared with need. Appropriate allocation of resources is essential if foster care agencies are to adequately meet the diverse and compelling needs of children in foster care.

Child↗
PubMed2003

Applying WHO's health systems performance assessment in Pakistan: critical reflections.

The World Health Organization (WHO) proposed a health systems performance assessment framework in 2000, which met with quick and often severe criticisms in terms of process, methods and utility. However, a country specific reflection for the potential application of this framework has not been published to-date from South Asia. This paper reviews the recent literature and critiques and analyzes the potential for applying the framework in Pakistan. Deconstruction of the framework into its five component parts--health (level, distribution), responsiveness (level, distribution) and fair financing--allows an assessment of data needs for generation of specific indicators. This paper proposes that three of the five components may be attempted in Pakistan due to the availability of specific data; however the two components of responsiveness will require the collection of new primary data and present a considerable challenge. The conduct of a burden of disease study, assessment of health expenditures using household consumption surveys, and use of numerous national surveys will allow for optimal utilization of available information in Pakistan. The assimilation and analysis of available data will also be critical in informing national health decision-making.

Data Collection↗
PubMed2001

Changes in public health in South Africa from 1876.

The present population in South Africa, roughly 43 million inhabitants, is made up of Africans (77.2%), whites (10.5%), Coloureds (mixed race) (8.8%) and Indians (2.5%). In 1900 the infant mortality rate (IMR) among Africans was 330 per 1,000 live births; this has now fallen to 50-60. In Soweto, a primarily African city, IMR averages 20-25. Life expectancy in the past was only 25-30 years; by 1995, this reached 63 years. However, this could fall again due to the rapidly spreading HIV/AIDS epidemic. Life expectancy could fall to 40-45 years by 2010 with the AIDS epidemic being the cause of half of all deaths--a disastrous change from the previous relatively commendable public health situation. Formerly, the most common causes of deaths in young people were infections, diseases associated with malnutrition and gastroenteritis. Adults died almost solely from infections, including typhoid, dysentery, malaria and tuberculosis (TB). Even though diseases associated with malnutrition are less common today, many infections still remain a major problem, particularly TB, which is increasing. As late as 1970, Africans who reached 50 years had longer life expectancy than whites due to the low prevalences of the chronic diseases of lifestyle. This is no longer so, due to the recent rises in non-communicable disorders/diseases, principally obesity in women, hypertension, diabetes, stroke and the cancers of prosperity. In the not so distant future, the level of control of HIV/AIDS related diseases will be the major health/disease regulating factor among Africans. Among white, Coloured and Indian populations, there have been falls in the mortality rates of the young and, despite rises in lifestyle diseases, increases in life expectancy are continuing. For all populations other important public health regulatory factors include water supply, sanitation, clinic/hospital services and personal environmental factors, employment, dietary pattern and intake, smoking practices and alcohol consumption and physical activity, particularly in urban dwellers. Unfortunately, public health expenditure, also a highly regulating factor, has fallen from 8.2% of the gross domestic product in 1994 to 4.1% in 2000.

Health Status Indicators↗