The economic burden of diseases in the Nordic countries: A systematic review.

BACKGROUND: Economic burden studies can provide insights into the drivers leading to increasing healthcare costs. It can also provide a more holistic view of how diseases impact the welfare of patients and their families. Having concrete estimates of the economic burden across multiple diseases can help policymakers determine which diseases are economically more burdensome. This study aimed to review and summarise comprehensively economic burden studies across multiple diseases in the Nordic countries between 2000 and 2020. METHODS: According to the 2020 PRISMA statement, a systematic literature review was conducted in PubMed, CINAHL, Academic Search Premier and Global Health databases using key terms related to the economic burden of any disease in Denmark, Finland, Greenland, Iceland, Norway and Sweden. Grey literature was also reviewed. RESULTS: A total of 10,050 potential titles and abstracts were identified and screened, and 254 full-text papers that met the inclusion criteria were evaluated by two independent reviewers. Of these, 119 articles were included in a qualitative synthesis. Twenty-nine had clearly defined comparison groups, thus able to attribute the costs to the disease. Large variations concerning methodology and cost components were noted. Across diseases, the economic burden ranged from EUR 1668 per patient annually for chronic obstructive pulmonary disease to EUR 93,041 for multiple sclerosis. However, estimates varied widely, even within each disease. CONCLUSIONS: Our review highlights the need for more comparable economic burden studies. Future studies should focus on applying robust methodology and homogeneous cost-reporting methods to inform policymakers about which diseases are economically more burdensome.

Similarities and differences between two well-performing healthcare systems: a comparison between the Israeli and the Danish healthcare systems.

BACKGROUND: Denmark and Israel both have highly rated and well-performing healthcare systems with marked differences in funding and organization of primary healthcare. Although better population health outcomes are seen in Israel, Denmark has a substantially higher healthcare expenditure. This has caused Danish policy makers to take an interest in Israeli community care organization. Consequently, we aim to provide a more detailed insight into differences between the two countries' healthcare organization and cost, as well as health outcomes. METHODS: A comparative analysis combining data from OECD, WHO, and official sources. World Health Organization (WHO) and the Organisation for Economic Co-operation and Development (OECD) statistics were used, and national official sources were procured from the two healthcare systems. Literature searches were performed in areas relevant to expenditure and outcome. Data were compared on health care expenditure and selected outcome measures. Expenditure was presented as purchasing power parity and as percentage of gross domestic product, both with and without adjustment for population age, and both including and excluding long-term care expenditure. RESULTS: Denmark's healthcare expenditure is higher than Israel's. However, corrected for age and long-term care the difference diminishes. Life expectancy is lower in Denmark than in Israel, and Israel has a significantly better outcome regarding cancer as well as a lower number of Years of Potential Life Lost. Israelis have a healthier lifestyle, in particular a much lower alcohol consumption. CONCLUSION: Attempting to correct for what we deemed to be the most important influencing factors, age and different inclusions of long-term care costs, the Israeli healthcare system still seems to be 25% less expensive, compared to the Danish one, and with better health outcomes. This is not necessarily a function of the Israeli healthcare system but may to a great extent be explained by cultural factors, mainly a much lower Israeli alcohol consumption.

Lifetime costs and lifetime net public expenditures of smoking.

BACKGROUND: Current estimates of lifetime costs of smoking are largely based on model analyses using etiologic fractions for a variety of diseases or Markov chain models. Direct estimation studies based on individual data for health costs by smoking status over a lifetime are non-existent. METHODS: We estimated lifetime costs in a societal perspective of 18-year-old daily-smokers (continuing smoking throughout adult life) and never-smokers in Denmark, as well as lifetime public expenditures in the two groups. Main outcomes were lifetime net public expenditures and lifetime health costs according to OECD definitions and lifetime earned incomes. Estimates of these outcomes were based on registries containing individual-level data. Confounder-adjusted differences between daily-smokers and never-smokers were interpreted as smoking-attributable lifetime public expenditures and costs. RESULTS: The net lifetime public expenditure is, on average, €20 520 higher for male 18-year-old daily-smokers than for never-smokers, but €9771 lower, for female daily-smokers compared with never-smokers. In male 18-year-old daily-smokers, average lifetime health costs are €9921 higher and average lifetime earned incomes are €91 159 lower than for never-smokers. The corresponding figures are €5849 higher and €23 928 lower, respectively, for women. CONCLUSION: 18-year-old male daily-smokers are net public spenders over their lifetime compared with never-smokers, while the opposite applies for women. In Denmark, smoking is associated with higher lifetime health costs for society and losses in earned incomes-both for men and women.

Quantifying the Financial Savings of Motion Correction in Brain MRI: A Model-Based Estimate of the Costs Arising From Patient Head Motion and Potential Savings From Implementation of Motion Correction.

BACKGROUND: Patient head motion is a major concern in clinical brain MRI, as it reduces the diagnostic image quality and may increase examination time and cost. PURPOSE: To investigate the prevalence of MR images with significant motion artifacts on a given clinical scanner and to estimate the potential financial cost savings of applying motion correction to clinical brain MRI examinations. STUDY TYPE: Retrospective. SUBJECTS: In all, 173 patients undergoing a PET/MRI dementia protocol and 55 pediatric patients undergoing a PET/MRI brain tumor protocol. The total scan time of the two protocols were 17 and 40 minutes, respectively. FIELD STRENGTH/SEQUENCES: 3 T, Siemens mMR Biograph, MPRAGE, DWI, T1 and T2 -weighted FLAIR, T2 -weighted 2D-FLASH, T2 -weighted TSE. ASSESSMENT: A retrospective review of image sequences from a given clinical MRI scanner was conducted to investigate the prevalence of motion-corrupted images. The review was performed by three radiologists with different levels of experience using a three-step semiquantitative scale to classify the quality of the images. A total of 1013 sequences distributed on 228 MRI examinations were reviewed. The potential cost savings of motion correction were estimated by a cost estimation for our country with assumptions. STATISTICAL TEST: The cost estimation was conducted with a 20% lower and upper bound on the model assumptions to include the uncertainty of the assumptions. RESULTS: 7.9% of the sequences had motion artifacts that decreased the interpretability, while 2.0% of the sequences had motion artifacts causing the images to be nondiagnostic. The estimated annual cost to the clinic/hospital due to patient head motion per scanner was $45,066 without pediatric examinations and $364,242 with pediatric examinations. DATA CONCLUSION: The prevalence of a motion-corrupted image was found in 2.0% of the reviewed sequences. Based on the model, repayment periods are presented as a function of the price for applying motion correction and its performance. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 6 J. Magn. Reson. Imaging 2020;52:731-738.

Benefit-Cost Analysis of the Danish Sun Safety Campaign 2007-2015: Cost Savings from Sunburn and Sunbed Use Reduction and Derived Skin Cancer Reductions 2007-2040 in the Danish Population.

BACKGROUND: Ninety percent of skin cancers are avoidable. In Denmark, 16,500 cases of melanoma and keratinocyte cancers were registered in 2015. The Danish Sun Safety Campaign has campaigned since 2007, targeting overexposure to ultraviolet radiation. During 2007-2015, the key indicators of skin cancer, i.e. sunbed use and sunburn, showed annual reductions of 6% and 1%, respectively. OBJECTIVES: We aimed to examine the financial savings to society as a result of the campaign reductions in skin cancer cases (2007-2040), and to examine the campaign's cost-benefit and return on investment (ROI). METHODS: The analysis is based on existing data: (1) annual population-based surveys regarding the Danish population's behavior in the sun; (2) skin cancer projections; (3) relative risks of skin cancers from sunburn and sunbed use and (4) historical cancer incidences, combined with new data; (5) benefits from the avoided costs of skin cancer reductions; and (6) the costs of the Danish Sun Safety Campaign. RESULTS: The results were based on a reduction of 9000 skin cancer cases, saving €29 million of which €13 million were derived from sunburn reductions and €16 million from reductions in sunbed use. The ROI was €2.18. CONCLUSION: Skin cancer prevention in Denmark is cost effective. Every Euro spent by the Danish Sun Safety Campaign saved the Danish health budget €2.18 in health expenses.

Correction to: Benefit-Cost Analysis of the Danish Sun Safety Campaign 2007-2015: Cost Savings from Sunburn and Sunbed Use Reduction and Derived Skin Cancer Reductions 2007-2040 in the Danish Population.

Abstract, Results, first sentence, which previously read: "The results were based on a reduction of 9000 skin cancer cases, saving €47 million of which €29 million were derived from sunburn reductions and €16 million from reductions in sunbed use."

Relay model for recruiting alcohol dependent patients in general hospitals--a single-blind pragmatic randomized trial.

BACKGROUND: A large proportion of the Danish population consumes more than the officially recommended weekly amount of alcohol. Untreated alcohol use disorders lead to frequent contacts with the health care system and can be associated with considerable human and societal costs. However, only a small share of those with alcohol use disorders receives treatment. A referral model to ensure treatment for alcohol dependent patients after discharge is needed. This study evaluates the i) cost-effectiveness ii) efficacy and iii) overall impact on societal costs of the proposed referral model - The Relay Model. METHOD/DESIGN: The study is a single-blind pragmatic randomized controlled trial including patients admitted to the hospital. The study group (n = 500) will receive an intervention, and the control group (n = 500) will be referred to treatment by usual procedures. All patients complete a lifestyle questionnaire with the Alcohol Use Disorders Identification Test embedded as a case identification strategy. The primary outcome of the study will be health care expenditures 12 months after discharge. The secondary outcome will be the percentage of the target group, who 30 days after discharge, reports at the alcohol treatment clinics. In order to analyse both outcomes, difference-in-difference models will be used. DISCUSSION: We expect to establish evidence as to whether The Relay Model is either cost-neutral or cost-effective, compared to referral by usual procedures. TRIAL REGISTRATION: https://register.clinicaltrials.gov/by identifier: RESCueH_Relay NCT02188043 Project Relay Model for Recruiting Alcohol Dependent Patients in General Hospitals (TRN Registration: 07/09/2014).

Something is amiss in Denmark: a comparison of preventable hospitalisations and readmissions for chronic medical conditions in the Danish Healthcare system and Kaiser Permanente.

BACKGROUND: As many other European healthcare systems the Danish healthcare system (DHS) has targeted chronic condition care in its reform efforts. Benchmarking is a valuable tool to identify areas for improvement. Prior work indicates that chronic care coordination is poor in the DHS, especially in comparison with care in Kaiser Permanente (KP), an integrated delivery system based in the United States. We investigated population rates of hospitalisation and readmission rates for ambulatory care sensitive, chronic medical conditions in the two systems. METHODS: Using a historical cohort study design, age and gender adjusted population rates of hospitalisations for angina, heart failure, chronic obstructive pulmonary disease, and hypertension, plus rates of 30-day readmission and mortality were investigated for all individuals aged 65+ in the DHS and KP. RESULTS: DHS had substantially higher rates of hospitalisations, readmissions, and mean lengths of stay per hospitalisation, than KP had. For example, the adjusted angina hospitalisation rates in 2007 for the DHS and KP respectively were 1.01/100 persons (95%CI: 0.98-1.03) vs. 0.11/100 persons (95%CI: 0.10-0.13/100 persons); 21.6% vs. 9.9% readmission within 30 days (OR = 2.53; 95% CI: 1.84-3.47); and mean length of stay was 2.52 vs. 1.80 hospital days. Mortality up through 30 days post-discharge was not consistently different in the two systems. CONCLUSIONS: There are substantial differences between the DHS and KP in the rates of preventable hospitalisations and subsequent readmissions associated with chronic conditions, which suggest much opportunity for improvement within the Danish healthcare system. Reductions in hospitalisations also could improve patient welfare and free considerable resources for use towards preventing disease exacerbations. These conclusions may also apply for similar public systems such as the US Medicare system, the NHS and other systems striving to improve the integration of care for persons with chronic conditions.

[Uncertain effects of health risk appraisals at worksites]. / Usikker effekt af helbredstjek på arbejdspladsen.

Health risk appraisals take place at Danish worksites even though the effects are unknown. The purpose of this article is to summarise international studies of health risk appraisals at worksites and identify the existing knowledge on the cost-effectiveness and effects on health. The studies show tendencies of small, but positive effects of health risk appraisals in combination with counselling on certain cardiovascular risk factors. It is, however, not possible to determine the economic effects of the efforts.

[International comparisons of health systems]. / Internationale sammenligninger af sundhedssystemer.

International comparisons of health systems are widely used as a method for cross country learning, strategy development at the national level, and to demonstrate accountability. Comparisons may comprise entire health systems or subsystems within these, and may include many or few health systems. This paper describes strengths and weaknesses of different types of comparisons and methodological challenges involved in comparing different health systems. Finally, the paper emphasizes that caution must be exercised when transferring ideas from one system to another.

[Obesity related health care costs assessed from BMI or waist circumference--secondary publication]. / Fedmerelatererede sundhedsomkostninger vurderet ud fra måling af enten BMI eller taljeomkreds--sekundaerpublikation.

Obesity is associated with increased risk of many diseases and mortality. The risk is related to body fat distribution such that abdominal obesity is associated with a greater risk than gluteo-femoral obesity. Individual cumulative health service costs were estimated in relation to waist circumference (WC) and body mass index (BMI). The analyses show that the combination of BMI and WC does not improve the identification of high-risk individuals compared with the use of WC alone. The health service costs increase by 1.24% in women and 2.08% in men pr. cm increase in WC above the normal range.

[Convalescence, sick leave and health economics]. / Rekonvalescens, sygemelding og sundhedsøkonomi.

National health policies have been proposed to reduce long-term absenteeism in order to increase labour supply. Convalescence interventions have been developed and optimised and shown to reduce long-term absenteeism and as such they form an integral part of the national health policy. We describe absenteeism and convalescence within an economic perspective. In Denmark, the economic costs of absenteeism amounted to more than 37 billion Danish kroner in 2006, including sick leave benefits and non-productive wage expenditure. Optimising convalescence interventions, if efficacious, is highly cost-effective.

A retrospective analysis of health systems in Denmark and Kaiser Permanente.

BACKGROUND: To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy. METHODS: Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability. RESULTS: A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with 134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP $1,845 (DHS). CONCLUSION: Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.

Waist circumference and body mass index as predictors of health care costs.

BACKGROUND: In the present study we analyze the relationship between body mass index (BMI) and waist circumference (WC) and future health care costs. On the basis of the relation between these anthropometric measures and mortality, we hypothesized that for all levels of BMI increased WC implies added future health care costs (Hypothesis 1) and for given levels of WC increased BMI entails reduced future health care costs (Hypothesis 2). We furthermore assessed whether a combination of the two measures predicts health care costs better than either individual measure. RESEARCH METHODOLOGY/PRINCIPAL FINDINGS: Data were obtained from the Danish prospective cohort study Diet, Cancer and Health. The population includes 15,334 men and 16,506 women 50 to 64 years old recruited in 1996 to 1997. The relationship between future health care costs and BMI and WC in combination was analyzed by use of categorized and continuous analyses. The analysis confirms Hypothesis 1, reflecting that an increased level of abdominal fat for a given BMI gives higher health care costs. Hypothesis 2, that BMI had a protective effect for a given WC, was only confirmed in the continuous analysis and for a subgroup of women (BMI<30 kg/m(2) and WC <88 cm). The relative magnitude of the estimates supports that the regressions including WC as an explanatory factor provide the best fit to the data. CONCLUSION: The study showed that WC for given levels of BMI predicts increased health costs, whereas BMI for given WC did not predict health costs except for a lower cost in non-obese women with normal WC. Combining WC and BMI does not give a better prediction of costs than WC alone.

Economic costs of abdominal obesity.

BACKGROUND: To examine the relationship between waist circumference and future health care costs across a broad range of waist circumference values based on individual level data. METHOD: A prospective cohort of 31,840 subjects aged 50-64 years at baseline had health status, lifestyle and socio-economic aspects assessed at entry. Individual data on health care consumption and associated costs were extracted from registers for the subsequent 7 years. Participants were stratified by presence of chronic disease at entry. RESULTS: Increased waist circumference at baseline was associated with higher future health care costs. For increased and substantially increased waist circumference health care costs rise at a rate of 1.25% in women and 2.08% in men, per added centimetre above normal waistline. Thus, as an example, a woman with a waistline of 95 cm and without co-morbidities can be expected to incur an added future cost of approximately USD 397.- per annum compared to a woman in the normal waist circumference group, corresponding to 22% higher health care costs. CONCLUSIONS: Future health care costs are higher for persons who have an increased waist circumference, which suggests that there may be a potential for significant resource savings through prevention of abdominal obesity.

Preventive health screenings and health consultations in primary care increase life expectancy without increasing costs.

AIMS: The intention was to investigate whether preventive health checks and health discussions are cost effective. METHODS: In a randomized trial the authors compared two intervention groups (A and B) and one control group. In 1991 2,000 30- to 49-year-old persons were invited and those who accepted were randomized. Both intervention groups were offered a broad (multiphasic) screening including cardiovascular risk and a personal letter including screening results and advice on healthy living. Individuals in group A could contact their family physician for a normal consultation whereas group B were given fixed appointments for health consultations. The follow-up period was six years. Analysis was carried out on the "intention to treat" principle. Outcome parameters were life years gained, and direct and total health costs (including productivity costs), discounted by 3% annually. Costs were based on register data. Univariate sensitivity analysis was carried out. RESULTS: Both intervention groups have significantly better life expectancy than the control group (no intervention). Group B and (A) significantly gain 0.14 (0.08) life years more than the control group. There were no differences in average direct (3,255 euro (3,703 euro) versus 4,186 euro) and total costs (10,409 euro (9,399 euro) versus 10,667 euro). The effect in group B is, however, better than in group A with no significant differences in costs. The results are insensitive to a range of assumptions regarding costs, effects, and discount rates. CONCLUSIONS: Preventive health screening and consultation in primary care in 30- to 49-year-olds produce significantly better life expectancy without extra direct and total costs over a six-year follow-up period.