Lifetime costs of overweight and obesity in Italy.

We use longitudinal electronic clinical data on a large representative sample of the Italian population to estimate the lifetime profile costs of different BMI classes - normal weight, overweight, and obese (I, II, and III) - in a primary care setting. Our research reveals that obese patients generate the highest cost differential throughout their lives compared to normal weight patients. Moreover, we show that overweight individuals spend less than those with normal weight, primarily due to reduced expenditures beginning in early middle age. Our estimates could serve as a vital benchmark for policymakers looking to prioritize public interventions that address the obesity pandemic while considering the increasing obesity rates projected by the OECD until 2030.

Outpatient healthcare costs associated with overweight and obesity in Italy.

BACKGROUND: To evaluate outpatient healthcare expenditure associated with different levels of BMI and glucose metabolism alterations. METHODS: The study is based on a representative national sample of adults, with data obtained from electronic clinical records of 900 Italian general practitioners. Data relative to the year 2018 were analyzed. The study population was classified according to BMI (normal weight, overweight, and obesity classes 1, 2, and 3) and glucose metabolism status (normoglycemia - NGT; impaired fasting glucose - IFG; diabetes mellitus - DM). Outpatient health expenditures include diagnostic tests, specialist visits, and drugs. RESULTS: Data relative to 991,917 adults were analyzed. Annual per capita expenditure rose from 252.2 Euro among individuals with normal weight to 752.9 Euro among those with class 3 obesity. The presence of obesity determined an excess cost, particularly among younger individuals. Within each BMI class, the presence of IFG or DM2 identified subgroups of individuals with substantially higher healthcare expenditures. CONCLUSIONS: Outpatient healthcare costs markedly increased with increasing BMI in all age categories, particularly among individuals below 65. Addressing the double burden of excess weight and hyperglycemia represents a significant challenge and a healthcare priority.

The future of the elderly population health status: Filling a knowledge gap.

The aging process in OECD countries calls for a better understanding of the future disease prevalence, life expectancy (LE) and patterns of inequalities in health outcomes. In this paper we present the results obtained from several dynamic microsimulation models of the Future Elderly Model family for 12 OECD countries, with the aim of reproducing for the first time comparable long-term projections in individual health status across OECD countries. We provide projections of LE and prevalence of major chronic conditions and disabilities, overall, by gender and by education. We find that the prevalence of main chronic conditions in Europe is catching-up with the United States and significant heterogeneity in the evolution of gender and educational gradients. Our findings represent a contribution to support policymakers in designing and implementing effective interventions in the healthcare sector.

Disease burden and economic impact of diagnosed non-alcoholic steatohepatitis in five European countries in 2018: A cost-of-illness analysis.

BACKGROUND AND AIMS: Non-alcoholic steatohepatitis (NASH) is a chronic disease that can progress to end-stage liver disease (ESLD). A large proportion of early-stage NASH patients remain undiagnosed compared to those with advanced fibrosis, who are more likely to receive disease management interventions. This study estimated the disease burden and economic impact of diagnosed NASH in the adult population of France, Germany, Italy, Spain and the United Kingdom in 2018. METHODS: The socioeconomic burden of diagnosed NASH was estimated using cost-of-illness methodology applying a prevalence approach to estimate the number of adults with NASH and the attributable economic and wellbeing costs. Given undiagnosed patients do not incur costs in the study, the probability of diagnosis is central to cost estimation. The analysis was based on a literature review, databases and consultation with clinical experts, economists and patient groups. RESULTS: The proportion of adult NASH patients with a diagnosis ranged from 11.9% to 12.7% across countries, which increased to 38.8%-39.1% for advanced fibrosis (F3-F4 compensated cirrhosis). Total economic costs were €8548-19 546M. Of these, health system costs were €619-1292M. Total wellbeing costs were €41 536-90 379M. The majority of the undiagnosed population (87.3%-88.2% of total prevalence) was found to have early-stage NASH, which, left untreated, may progress to more resource consuming ESLD over time. CONCLUSIONS: This study found that the majority of economic and wellbeing costs of NASH are experienced in late disease stages. Earlier diagnosis and care of NASH patients could reduce future healthcare costs.

Trends in age-related disease burden and healthcare utilization.

Aging is a strong risk factor for many chronic diseases. However, the impact of an aging population on the prevalence of chronic diseases and related healthcare costs are not known. We used a prevalence-based approach that combines accurate clinical and drug prescription data from Health Search CSD-LPD. This is a longitudinal observational data set containing computer-based patient records collected by Italian general practitioners (GP) and up-to-date healthcare expenditures data from the SiSSI Project. The analysis is based on data collected by 900 GP on an unbalanced sample of more than 1 million patients aged 35+, observed in different time periods between 2005 and 2014. In 2014, 86% of the Italian adults older than 65 had at least one chronic condition, and 56.7% had two or more. Prevalence of multiple chronic diseases and healthcare utilization increased among older and younger adults between 2004 and 2014. Indeed, in the last 10 years, average number of prescriptions increased by approximately 26%, while laboratory and diagnostic tests by 27%. The average number of DDD prescribed increased with age in all the observed years (from 114 in 2005 to 119.9 in 2014 for the 35-50 age group and from 774.9 to 1,178.1 for the 81+ patients). The alarming rising trends in the prevalence of chronic disease and associated healthcare costs in Italy, as well as in many other developed countries, call for an urgent implementation of interventions that prevent or slow the accumulation of metabolic and molecular damage associated with multiple chronic disease.

Heterogeneity in long term health outcomes of migrants within Italy.

This article examines the long term physical and mental health effects of internal migration focusing on a relatively unique migration experience concentrated over a short period between 1950 and 1970 from the South to the North of Italy. We find a positive and statistically significant association between migration, its timing and physical health for migrant females, which we show are likely to represent rural females in both the early and the late cohort. We find less defined evidence of migration-health association for mental health. We link our findings to the economic transition and labor market transformation that Italy witnessed in that era. Male migrants were likely to be positively selected to migration, but harsh working conditions were likely to downplay this differential. On the contrary, women migrants, by and large, would not engage in the formal labor market avoiding the ill effects of working environments, at the same time benefiting from better living conditions and health care in the destination regions.

How health policy shapes healthcare sector productivity? Evidence from Italy and UK.

The English (NHS) and the Italian (SSN) healthcare systems share many similar features: basic founding principles, financing, organization, management, and size. Yet the two systems have faced diverging policy objectives since 2000, which may have affected differently healthcare sector productivity in the two countries. In order to understand how different healthcare policies shape the productivity of the systems, we assess, using the same methodology, the productivity growth of the English and Italian healthcare systems over the period from 2004 to 2011. Productivity growth is measured as the rate of change in outputs over the rate of change in inputs. We find that the overall NHS productivity growth index increased by 10% over the whole period, at an average of 1.39% per year, while SSN productivity increased overall by 5%, at an average of 0.73% per year. Our results suggest that different policy objectives are reflected in differential growth rates for the two countries. In England, the NHS focused on increasing activity, reducing waiting times and improving quality. Italy focused more on cost containment and rationalized provision, in the hope that this would reduce unjustified and inappropriate provision of services.

Public Health Insurance and Household Portfolio Choices: Unravelling Financial "Side Effects" of Medicare.

Large, unpredictable and not fully insurable health-care costs represent a source of background risk that might deter households' financial risk taking. Using panel data from the Health and Retirement Study, we test whether universal health insurance, like Medicare for over-65 Americans, shields against this risk promoting stockholding. We adopt a fixed-effects estimation strategy, thereby taking into account household-level heterogeneity in health status and private insurance coverage. We find that, before Medicare eligibility, households in poor health, who face a higher risk of medical expenses, are less likely to hold stocks than their healthier counterparts. Yet, this gap is mostly eliminated by Medicare. Notably, the offsetting is primarily experienced by households in poor health and without private health insurance over the observation period.

Excess body weight increases the burden of age-associated chronic diseases and their associated health care expenditures.

Aging and excessive adiposity are both associated with an increased risk of developing multiple chronic diseases, which drive ever increasing health costs. The main aim of this study was to determine the net (non-estimated) health costs of excessive adiposity and associated age-related chronic diseases. We used a prevalence-based approach that combines accurate data from the Health Search CSD-LPD, an observational dataset with patient records collected by Italian general practitioners and up-to-date health care expenditures data from the SiSSI Project. In this very large study, 557,145 men and women older than 18 years were observed at different points in time between 2004 and 2010. The proportion of younger and older adults reporting no chronic disease decreased with increasing BMI. After adjustment for age, sex, geographic residence, and GPs heterogeneity, a strong J-shaped association was found between BMI and total health care costs, more pronounced in middle-aged and older adults. Relative to normal weight, in the 45-64 age group, the per-capita total cost was 10% higher in overweight individuals, and 27 to 68% greater in patients with obesity and very severe obesity, respectively. The association between BMI and diabetes, hypertension and cardiovascular disease largely explained these elevated costs.

The effect of age and time to death on primary care costs: the Italian experience.

A large body of literature shows that time to death (TTD) is by far a better predictor of health spending than age. In this paper, we investigate if this finding holds true also in presence of primary care costs (pharmaceuticals, diagnostic tests and specialist visits) in Italy, where they represent an important share (about 30%) of the total health care expenditure (HCE). Our analysis is based on a large sample of the Italian population (about 750,000 individuals), obtained from the Health Search-SiSSI database, which contains patient-level data collected routinely by General Practitioners in Italy since 2002. We study individuals aged 19 and older, over the period 2006-2009. By means of a two-part model which accounts for the presence of zero expenditure, our findings show that age represents the most important driver of primary care costs in Italy, although TTD remains a good predictor. These results suggest that age and TTD can have a different role in shaping health care costs according to the component of health expenditure examined. Therefore, our advice to policy makers is to use disaggregated models to better disentangle these contributions and to produce more reliable health spending forecasts.

The impact of cost-sharing schemes on drug compliance in Italy: evidence based on quantile regression.

OBJECTIVES: In this article we investigate the causal effect of cost-sharing schemes on compliance with statins in a quantile regression framework. METHODS: We use the health search CSD-LPD data, a longitudinal observational dataset containing computer-based patient records collected by Italian general practitioners. We exploit a series of natural experiments referring to several introductions of co-payment schemes in some of the Italian regions between 2000 and 2009. We adopt an extended difference-in-differences approach to provide quantile estimates of the impact of co-payments on compliance. RESULTS: We find that (i) introduction of co-payments hurts residents of regions with worse quality and provision of health care; (ii) within these regions, co-payments were particularly harmful for high compliers; (iii) gender, clinical history and geographic residence are important determinants of compliance among poor compliers; (iv) compliance decreases with the potency and dosage of statins, particularly for poor compliers. CONCLUSIONS: In the presence of inefficient health-care provision, co-payments are harmful for drug compliance, and this is especially true for patients who are originally good compliers.

Energy efficiency as a unifying principle for human, environmental, and global health.

A strong analogy exists between over/under consumption of energy at the level of the human body and of the industrial metabolism of humanity. Both forms of energy consumption have profound implications for human, environmental, and global health. Globally, excessive fossil-fuel consumption, and individually, excessive food energy consumption are both responsible for a series of interrelated detrimental effects, including global warming, extreme weather conditions, damage to ecosystems, loss of biodiversity, widespread pollution, obesity, cancer, chronic respiratory disease, and other lethal chronic diseases. In contrast, data show that the efficient use of energy-in the form of food as well as fossil fuels and other resources-is vital for promoting human, environmental, and planetary health and sustainable economic development. While it is not new to highlight how efficient use of energy and food can address some of the key problems our world is facing, little research and no unifying framework exists to harmonize these concepts of sustainable system management across diverse scientific fields into a single theoretical body. Insights beyond reductionist views of efficiency are needed to encourage integrated changes in the use of the world's natural resources, with the aim of achieving a wiser use of energy, better farming systems, and healthier dietary habits. This perspective highlights a range of scientific-based opportunities for cost-effective pro-growth and pro-health policies while using less energy and natural resources.

Pharmaceutical price controls and minimum efficacy regulation: evidence from the United States and Italy.

OBJECTIVE: This article examines the relationship between drug price and drug quality and how it varies across two of the most common regulatory regimes in the pharmaceutical market: minimum efficacy standards (MES) and a mix of MES and price control mechanisms (MES + PC). DATA SOURCES: Our primary data source is the Tufts-New England Medical Center-Cost Effectiveness Analysis Registry which have been merged with price data taken from MEPS (for the United States) and AIFA (for Italy). STUDY DESIGN: Through a simple model of adverse selection we model the interaction between firms, heterogeneous buyers, and the regulator. PRINCIPAL FINDINGS: The theoretical analysis provides two results. First, an MES regime provides greater incentives to produce high-quality drugs. Second, an MES + PC mix reduces the difference in price between the highest and lowest quality drugs on the market. CONCLUSION: The empirical analysis based on United States and Italian data corroborates these results.

The efficiency frontier approach to economic evaluation of health-care interventions.

BACKGROUND: IQWiG commissioned an international panel of experts to develop methods for the assessment of the relation of benefits to costs in the German statutory health-care system. PROPOSED METHODS: The panel recommended that IQWiG inform German decision makers of the net costs and value of additional benefits of an intervention in the context of relevant other interventions in that indication. To facilitate guidance regarding maximum reimbursement, this information is presented in an efficiency plot with costs on the horizontal axis and value of benefits on the vertical. The efficiency frontier links the interventions that are not dominated and provides guidance. A technology that places on the frontier or to the left is reasonably efficient, while one falling to the right requires further justification for reimbursement at that price. This information does not automatically give the maximum reimbursement, as other considerations may be relevant. Given that the estimates are for a specific indication, they do not address priority setting across the health-care system. CONCLUSION: This approach informs decision makers about efficiency of interventions, conforms to the mandate and is consistent with basic economic principles. Empirical testing of its feasibility and usefulness is required.

Are primary care physicians, public and private sector specialists substitutes or complements? Evidence from a simultaneous equations model for count data.

In this paper, we examine the relationships between health care visits to general practitioners, public and private sector specialists using data from Italy, which has a mixed public-private health care system. We develop a simultaneous equations model that allows for the discreteness of measures of utilization and estimate this model using maximum simulated likelihood. Once common unobserved heterogeneity is properly accounted for, general practitioners, public and private specialists are found to be substitute sources of medical care. In contrast, a naive model finds they are complements.

Drug compliance, co-payment and health outcomes: evidence from a panel of Italian patients.

This paper studies the relationship between medical compliance and health outcomes - hospitalization and mortality rates - using a large panel of patients residing in a local health authority in Italy. These data allow us to follow individual patients through all their accesses to public health care services until they either die or leave the local health authority. We adopt a disease specific approach, concentrating on hypertensive patients treated with ACE-inhibitors. Our results show that medical compliance has a clear effect on both hospitalization and mortality rates: health outcomes clearly improve when patients become more compliant to drug therapy. At the same time, we are able to infer valuable information on the role that drug co-payment can have on compliance, and as a consequence on health outcomes, by exploiting the presence of two natural experiments during the period of analysis. Our results show that drug co-payment has a strong effect on compliance, and that this effect is immediate.

Affordability of medicines and patients' cost-reducing behaviour: empirical evidence based on SUR estimates from Italy and the UK.

INTRODUCTION: Studies have demonstrated that co-payments on medication reduce the consumption of both non-essential and essential drugs, and that the latter can lead to worse health outcomes. Far less is known about how patients cope with the cost of medication, particularly if affordability is an issue, and how this compares across two countries with different prescription charge policies. Therefore, the aim of this article is to explore empirically how, and to what extent, costs incurred by patients influence their decision-making behaviour in accessing medicines. METHODS: Based on the findings from focus groups, a questionnaire was designed that addressed medication cost issues relevant to patients in both the UK and Italy. Using an econometric model, several hypotheses are tested regarding patients' decision-making behaviour and how it is influenced by health status, sociodemographic characteristics and the novel concept of a self-rated affordability measure. RESULTS: Quite a large percentage of patients (70.3% in the UK and 66.5% in Italy) stated they have to think about the cost of medicines at least sometimes. Respondents adopted numerous cost-reducing strategies, subdivided into (i) those initiated by patients and (ii) those involving self-medication. Their use was strongly influenced by income and drug affordability problems, but the self-rated affordability measure was a stronger predictor. Commonly used strategies were not to get prescribed drugs dispensed at all, prioritizing by not getting all prescribed items dispensed or delaying until the respondent got paid. Furthermore, respondents with affordability issues were also cost-conscious when self-medicating with over-the-counter (OTC) products for minor conditions such as dyspepsia. Despite patients in both countries using cost-reducing strategies, their use was more pronounced in the UK, where the prescription charge was significantly higher than in Italy. DISCUSSION/CONCLUSION: The results from this study provide detail on the kinds of strategies patients use to reduce the cost burden of prescription charges, and support previous research showing they may be foregoing essential medication. Because the same questionnaire was applied in two European countries, where the national health systems aim to provide healthcare services that are accessible to all citizens in need, it offers interesting insights for policy makers in other countries, where patients may have to pay a larger share of their drugs out-of-pocket, such as the US.

Determinants of access to physician services in Italy: a latent class seemingly unrelated probit approach.

We examine access to general practitioners and specialists who work in the public and private sectors in Italy using a seemingly unrelated system of probits. We use a latent class formulation that provides a rich and flexible functional form and can accommodate non-normality of response probabilities. The empirical analysis shows that patient behavior can be clustered in two latent classes. We find that income strongly influences the mix of services. Richer individuals are less likely to seek care from GP's and more likely to seek care from specialists, and especially private specialists. Health status and societal vulnerability are the most important indicators of class membership.