Heterogeneous impact of the COVID-19 pandemic on lung, colorectal and breast cancer incidence in Hungary: results from time series and panel data models.

OBJECTIVE: During the COVID-19 pandemic, health system resources were reallocated to provide care for patients with COVID-19, limiting access for others. Patients themselves also constrained their visits to healthcare providers. In this study, we analysed the heterogeneous effects of the pandemic on the new diagnoses of lung, colorectal and breast cancer in Hungary. DESIGN: Time series and panel models of quarterly administrative data, disaggregated by gender, age group and district of residence. PARTICIPANTS: Data for the whole population of Hungary between the first quarter of 2017 and the second quarter of 2021. MAIN OUTCOME MEASURES: Number of patients newly diagnosed with lung, colorectal and breast cancer, defined as those who were hospitalised with the appropriate primary International Classification of Diseases Tenth Revision diagnosis code but had not had hospital encounters with such a code within the previous 5 years. RESULTS: The incidence of lung, colorectal and breast cancer decreased by 14.4% (95% CI 10.8% to 17.8%), 19.9% (95% CI 12.2% to 26.9%) and 15.5% (95% CI 2.5% to 27.0%), respectively, during the examined period of the pandemic, with different time patterns across cancer types. The incidence decreased more among people at least 65 years old than among the younger (p<0.05 for lung cancer and p<0.1 for colorectal cancer). At the district level, both the previously negative income gap in lung cancer incidence and the previously positive income gap in breast cancer incidence significantly narrowed during the pandemic (p<0.05). CONCLUSIONS: The decline in new cancer diagnoses, caused by a combination of supply-side and demand-side factors, suggests that some cancer cases have remained hidden. It calls for action by policy makers to engage individuals with high risk of cancer more in accessing healthcare services, to diagnose the disease early and to prepare for effective management of patient pathways from diagnosis to survival or end-of-life care.

Effects of lower screening activity during the COVID-19 pandemic on breast cancer patient pathways: Evidence from the age cut-off of organized screening.

We examined the effects of the COVID-19 pandemic on the screening, diagnosis and treatment of breast cancer in Hungary based on administrative data until June 2021, covering three pandemic waves. After correcting for trend and seasonality, the number of mammography examinations decreased by 68% in 2020q2, was around its usual level in 2020q3 and was reduced by 20-35% throughout 2020q4-2021q2. The reduction was caused by a combination of supply-side (temporary suspensions of screening) and demand-side (lower screening participation during the pandemic waves) factors. The number of new breast cancer diagnoses and mastectomy surgeries responded with a lag, and were below their usual level by 15-30% in all quarters between 2020q2 and 2021q2, apart from 2020q4, when there was no significant difference. Using a regression discontinuity framework, we found that the partial mastectomy rate (indicative of early diagnosis) dropped more substantially in 2020q2 in the 61-65 years old age group that was just below the age cut-off of organized screening than in the 66-70 years old age group, and this difference was partially offset in 2021q1. We suggest that policymakers need to motivate the target population (by providing both information and incentives) to catch up on missed screenings.

The effect of involuntary retirement on healthcare use.

We analyze the causal effect of involuntary retirement on detailed indicators of healthcare use and mortality. We leverage a pension reform in Hungary which forced public sector workers above the statutory retirement age to full time retirement. Using rich administrative data, we find that on the 3-year horizon, involuntary retirement decreases the number of primary care doctor visits, the use of systemic antiinfectives and respiratory drugs, and the non-zero spending on antiinfectives, the drugs of the alimentary tract and metabolism and of the cardiovascular system. The impact on the latter two drug categories is driven by the drop in income due to involuntary retirement. We conclude that there is little evidence for health deteriorating effects of involuntary retirement and discuss the possible mechanisms behind our results.

Time patterns of precautionary health behaviours during an easing phase of the COVID-19 pandemic in Europe.

Using data from the COVID-19 questionnaire of the Survey of Health, Ageing and Retirement in Europe (SHARE), we investigate the time patterns of precautionary health behaviours of individuals aged 50 years and above during the summer of 2020, an easing phase of the COVID-19 pandemic in Europe. We also examine how these health behaviours differ by the presence of chronic conditions such as hypertension, high cholesterol level, heart disease, diabetes or chronic bronchitis, which can be considered as risk factors for COVID-19. Our results suggest that while on average, people became less precautious during the analysed time period, this is less so for those who are at higher risk. We also document large regional differences in precautionary health behaviours and show that higher-risk individuals are on average more cautious in all regions. We conclude that people adjusted their health behaviours in line with the generally understood risk of the COVID-19 disease. At the same time, our results also point out divergences in the level of willingness to take different precautionary steps.

Income gradient of pharmaceutical panic buying at the outbreak of the COVID-19 pandemic.

We analyze the timing, magnitude, and income dependence of pharmaceutical panic buying around the outbreak of the COVID-19 pandemic in Hungary. We use district-level monthly and daily administrative data on detailed categories of pharmaceutical purchases, merge them to income statistics, and estimate multilevel panel models. Our main results are as follows. First, the days of therapy (DOT) of pharmaceutical purchases increased by more than 30% in March 2020, when major lockdown measures were announced. This pattern holds for almost all categories of pharmaceuticals. Second, shortly after the panic reactions, the aggregate amount of pharmaceutical purchases returned to their preshock levels; however, the frequency of pharmacy visits decreased. Third, the panic buying reaction was significantly stronger in richer geographical areas, where-according to the daily data-people also reacted earlier to the pandemic-related news. Overall, the results suggest that panic buying of pharmaceuticals can have detrimental effects on vulnerable populations.

Regional differences in diabetes across Europe - regression and causal forest analyses.

We examine regional differences in diabetes within Europe, and relate them to variations in socio-economic conditions, comorbidities, health behaviour and diabetes management. We use the SHARE (Survey of Health, Ageing and Retirement in Europe) data of 15 European countries and 28,454 individuals, who participated both in the 4th and 7th (year 2011 and 2017) waves of the survey. First, we estimate multivariate regressions, where the outcome variables are diabetes prevalence, diabetes incidence, and weight loss due to diet as an indicator of management. Second, we study the heterogeneous impact of demographic, socio-economic, health and lifestyle indicators on the regional differences in diabetes incidence with causal random forests. Compared to Western Europe, the odds of a new diabetes diagnosis over a six-year horizon is 2.2-fold higher in Southern and 2.6-fold higher in Eastern Europe. Adjusting for individual characteristics, the odds ratio decreases to 1.8 in the South-West and to 2.0 in the East-West dimension. These remaining differences are mostly explained by country-specific healthcare indicators. Based on the causal forest approach, the adjusted East-West difference is essentially zero for the lowest risk groups (tertiary education, employment, no hypertension, no overweight) and increases substantially with these risk factors, but the South-West difference is much less heterogeneous. The prevalence of diet-related weight loss around the time of diagnosis also exhibits regional variation. The results suggest that the regional differences in diabetes incidence could be reduced by putting more emphasis on diabetes prevention among high-risk individuals in Eastern and Southern Europe.

Caesarean delivery and the use of antidepressants.

BACKGROUND: The high ratio of caesarean sections (C-sections) is a major public health issue in the developed world; but its implications on maternal mental health are not well understood. METHODS: We use individual-level administrative panel data from Hungary between 2010 and 2016 to analyze the relationship between caesarean delivery and antidepressant consumption, an objective indicator of mental health. We focus on low-risk deliveries of mothers without subsequent birth in 3 years, and include around 135 000 observations. RESULTS: After controlling for medical and socio-economic variables, antidepressant use before delivery is associated with an elevated risk of C-section (adjusted OR = 1.10, 95% CI 1.05-1.14) and C-section is associated with a higher probability of antidepressant use within 1-3 years after delivery (e.g. adjusted OR = 1.21, 95% CI 1.12-1.30, within 3 years after delivery, among mothers without pre-delivery antidepressant consumption). Our data restriction ensures that the results are not driven by a mechanical impact of decreasing fertility on the continuation of antidepressant use after a C-section. CONCLUSIONS: The results suggest that C-section is associated with worse mental health over the 1- to 3-year horizon after birth. This relationship is particularly important if a caesarean delivery is not necessary due to medical reasons, and physicians as well as expectant mothers should be made aware of the potential mental health implications of the mode of delivery.

The effect of primary care availability on antibiotic consumption in Hungary: a population based panel study using unfilled general practices.

OBJECTIVE: We analyse the effect of primary care availability on antibiotic consumption and on the quality of antibiotic prescribing behaviour. DESIGN: Retrospective panel design, secondary analysis of settlement-level administrative panel data (n=2320 settlements, T=72 months). PARTICIPANTS AND SETTING: We analyse antibiotic consumption of the population of villages in Hungary, over years 2010 to 2015. We exploit the geographical and time variation in unfilled (mainly single-handed) general practices as a source of exogenous variation in the availability of primary care. We control for socioeconomic characteristics and settlement fixed effects in a panel regression framework. OUTCOME MEASURES: Antibiotic expenditures and days of therapy (DOT); consumption of narrow-spectrum and broad-spectrum antibiotics; consumption of Access, Watch and Reserve antibiotics according to the AWaRe categorisation; number of visits to the general practitioner (GP). RESULTS: If the general practice of a village becomes unfilled, the number of GP visits decreases on average by 9.3% (95% CI 5.6% to 12.9%), antibiotics DOT decrease on average by 3.2% (95% CI 1.0% to 5.4%) and expenditures on antibiotics decrease on average by 2.5% (95% CI 0.3% to 4.7%). The negative effect on antibiotic consumption is stronger in settlements where secondary care is less available, and where antibiotics were previously overprescribed. The quality of prescribing behaviour measured by the relative changes in the narrow-spectrum vs broad-spectrum as well as the Access versus Watch and Reserve antibiotics deteriorates significantly as a consequence of worse primary care availability. CONCLUSIONS: Limited availability of primary care reduces the consumption of antibiotics and at the same time impairs the quality of prescriptions through a decrease of the number of doctor-patient encounters.

The closer the better: does better access to outpatient care prevent hospitalization?

In 2010-2012, new outpatient service locations were established in poor Hungarian micro-regions. We exploit this quasi-experiment to estimate the extent of substitution between outpatient and inpatient care. Fixed-effects Poisson models on individual-level panel data for years 2008-2015 show that the number of outpatient visits increased by 19% and the number of inpatient stays decreased by 1.6% as a result, driven by a marked reduction of potentially avoidable hospitalization (PAH) (5%). In our dynamic specification, PAH effects occur in the year after the treatment, whereas non-PAH only decreases with a multi-year lag. The instrumental variable estimates suggest that a one euro increase in outpatient care expenditures produces a 0.6 euro decrease in inpatient care expenditures. Our results (1) strengthen the claim that bringing outpatient care closer to a previously underserved population yields considerable health benefits, and (2) suggest that there is a strong substitution element between outpatient and inpatient care.

[Early experience with minimal invasive treatment of thirty-one thoracolumbar injury cases]. / Korai tapasztalataink thoracolumbalis gerincsérülések minimálinvazív mutéti kezelésével.

The authors report on their experience with minimal invasive treatment of thirtyone thoracolumbar injury cases. The medical charts, radiological documentation (preop CT and MRI scans, postop CT scans at 3 and 6 months) were analysed retrospectively. All pedicle screws were inserted appropriately, there was no neurological deterioration or surgical site infection postoperatively. There were three cases of radiological loss of correction, however, these were clinically irrelevant. There were no screw loosening or implant failure observed. According to our experience, which coincedes with literature data, this minimally invasive percutaneous pedicle screw technique can be recommended for the treatment of thoracolumbar injury.

How does retirement affect healthcare expenditures? Evidence from a change in the retirement age.

Using individual-level administrative panel data from Hungary, we estimate causal effects of retirement on outpatient and inpatient care expenditures and pharmaceutical expenditures. Our identification strategy is based on an increase in the official early retirement age of women, using that the majority of women retire upon reaching that age. According to our descriptive results, people who are working before the early retirement age have substantially lower healthcare expenditures than nonworkers, but the expenditure gap declines after retirement. Our causal estimates from a two-part (hurdle) model show that the shares of women with positive outpatient care, inpatient care, and pharmaceutical expenditures, respectively, decrease by 3.0, 1.4, and 1.3 percentage points in the short run due to retirement. These results are driven by the relatively healthy, by those who spent some time on sick leave and by the less educated. The effect of retirement on the size of positive healthcare expenditures is generally not significant.

Policy objective of generic medicines from the investment perspective: The case of clopidogrel.

The objective of generic drug policies in most countries is defined from a disinvestment perspective: reduction in expenditures without compromising health outcomes. However, in countries with restricted access of patients to original patented drugs, the objective of generic drug policies can also be defined from an investment perspective: health gain by improved patient access without need for additional health budget. This study examines the investment aspect of generic medicines by analyzing clopidogrel utilization in European countries between 2004 and 2014 using multilevel panel data models. We find that clopidogrel consumption was strongly affected by affordability constraints before the generic entry around 2009, but this effect decayed by 2014. After controlling for other variables, utilization had a substantially larger trend increase in lower-income European countries than in the higher-income ones. Generic entry increased clopidogrel consumption only in lower- and average-income countries but not in the highest-income ones. An earlier generic entry was associated with a larger effect. The case of clopidogrel indicates that the entrance of generics may increase patient access to effective medicines, most notably in lower-income countries, thereby reducing inequalities between European patients. Policymakers should also consider this investment aspect of generic medicines when designing pharmaceutical policies.

Implication of external price referencing and parallel trade on pharmaceutical expenditure: indirect evidence from lower-income European countries.

External price referencing (EPR) is applied more and more frequently worldwide by payers to control pharmaceutical prices. Together with the parallel trade of pharmaceuticals, EPR may result in lower pharmaceutical prices in higher-income countries and higher prices in lower-income countries, which implies that pharmaceutical expenditure grows more rapidly in the latter than in the former group. Our objective was to assess this hypothesis. We used hierarchical linear models on country-level panel data to show that-after controlling for compounding factors such as GDP, the proportion of the old-age population or life expectancy-the annual growth rate of pharmaceutical expenditure was 2.1% points larger in the lower- than in the higher-income members of the European Union between 2000 and 2008. This difference in trends became non-significant (0.6% points) after the onset of the global economic crisis. There was no significant difference between lower- and higher-income countries in the growth rate of non-pharmaceutical health expenditure in either period. Our results indirectly support the presence of price convergence of pharmaceuticals among European countries, and EPR and parallel trade may provide a reasonable explanation to the observed trend difference of pharmaceutical expenditure in the two groups of countries between 2000 and 2008. This higher growth rate of pharmaceutical expenditure put extra burden on public health care budgets in lower-income countries and resulted in disproportionately more cost-containment measures compared to higher-income countries after 2008. It remains to be seen whether the disappearance of the difference in trend growth rates due to special health policy interventions in countries with economic difficulties is temporary or permanent.

Effects of Geographical Accessibility on the Use of Outpatient Care Services: Quasi-Experimental Evidence from Panel Count Data.

In 2010-2012, new outpatient service locations were established in Hungarian micro-regions, which had lacked such capacities before. We exploit this quasi-experiment to estimate the effect of geographical accessibility on outpatient case numbers using both individual-level and semi-aggregate panel data. We find a 24-27 per cent increase of case numbers as a result of the establishments. Our specialty-by-specialty estimates imply that a 1-min reduction of travel time to the nearest outpatient unit increases case numbers for example by 0.9 per cent in internal care and 3.1 per cent in rheumatology. The size of the new outpatient capacities has a separate effect, raising the possibility of the presence of supplier-induced demand. By combining a fixed-effects logit and a fixed-effects truncated Poisson estimator, we decompose the effects into increases in the probability of ever visiting a doctor on the one hand and an increase of the frequency of visits on the other hand. We find that new visits were dominant in the vast majority of specialties, whereas both margins were important for example in rheumatology. Finally, we demonstrate the usefulness of the fixed-effects truncated Poisson estimator in modelling count data by examining its robustness by simulations.

Influence of rumen-protected choline on liver composition and blood variables indicating energy balance in periparturient dairy cows.

Rumen-protected choline (RPC) was evaluated for effects on the lipid and glycogen content of the liver and metabolic variables in the blood plasma of dairy cows. Thirty-two Holstein cows were allocated into two groups (RPC group with RPC supplementation and control group without RPC supplementation) 28 days before the expected calving. Cows were fed the experimental diet from 21 days before calving until day 60 of lactation. The diet of the RPC group was supplemented with 100 g/day of RPC from 21 days prepartum until calving and 200 g/day of RPC for 60 days postpartum, providing 25 and 50 g of choline, respectively. Liver samples were taken by percutaneous needle biopsy, then analysed for total lipid (TLl), triglyceride (TGl) and glycogen (GLYl) contents on days -21, +7, +35 and +60 relative to calving. Blood was collected on the same sampling days and 21 days after calving. Glucose, non-esterified fatty acid (NEFA), ß-hydroxybutyrate (BHBA), triglyceride (TGp), total cholesterol (TCh), urea, ammonia and aspartate aminotransferase (AST) were determined from blood samples. The TLl and TGl contents were 25.0 ± 4.3 g and 25.3 ± 3.8 g per kg wet weight (mean ± SEM), respectively, lower in the RPC group than in the control animals. No significant differences were observed in the GLYl concentrations between the two groups. However, a lower TGl: GLYl ratio was shown in the liver of cows fed the RPC diet as compared to the controls. RPC supplementation decreased BHBA while increasing TGp concentrations were shown in the blood of cows fed the RPC diet, possibly as a consequence of improved lipoprotein synthesis in, and triglyceride excretion from, the liver, together with a reduced rate of ketogenesis.

[Anterior cervical fusion on the lower cervical spine: own clinical experience]. / Az alsó nyaki gerincszakasz elülso spondylodesise során nyert klinikai tapasztalataink.

Both acute and chronic instability of the cervical spine can be succesfully treated by anterior crevical fusion. The main goal is to create a spondylodesis through which the instable motion segments are fixed in the position defined by the surgeon. The spondylodesis is realised by the bone healing of the intervertebral space. The consolidation itself is facilitated by the operative stabilisation of the segments involved, and also by the implantation/transplantation of the osteoproductive/osteoinductive materials. The sooner consolidation is achieved, the more likely it is to be able to avoid the material dependent complications and/or that of dislocation. So as to support this theory a retrospective clinical/radiological study was performed. During this the length and the safety of the consolidation was measured by applying various anterior cervical plating systems. A total of 485 patients having cervical injuries or degenerative disc disease were treated by anterior cervical plating. For bone transplantation partly pure autolog spongious partly autolog cortico-spongious morsalised bone chips, furthermore autolog tricortical bone block were applied. A standard protocoll was used for data collection, evaluation and also follow-up. The patients treated with plate systems were divided into 3 groups: Group 1: Non-locked H-plate system with autogeneous cancellous bone (155 trauma patients, for a total of 210 cervical motion segments, 1.35 segments/patients). Group 2: Non-locked H-plate system with tricortical autograft (167 patients, for a total of 290 cervical motion segments, 1.73 segments/patients). Group 3: Locked cervical plate system with tricortical autograft (73 patients, for a total of 110 cervical motion segments, 1.5 segments/patients). Patients treated with standalone cage belong to group 4. These cages were filled with autogenous cortico-spongiosus bone chips (90 patients, for a total of 90 cervical motion segments, 1.0 segments/patients). Evaluations included postoperative clinical, X-ray and CT examination, and follow-ups at 6, 16, 52, and 104 weeks. We established three grades, and classified the degree of bony fusion between the graft and vertebra: not-yet-fused, fused or non-union. When evaluating the results the following statements/observations were made: a) There is a fast and safe consolidation in the case of those patients that underwent dinamic disc osteosynthesis (p = 0.00001). b) Whereas performing fixation with non-locked or locked screw plate systems and strutgrafted with tricortical autograft created prolonged healing requiring months and developed non-unions more often (non-locked screw-plate system versus locked screw-plate system) (p > 0.05). c) Using locked screw-plate fixation systems non-union rate in our study was 21%, suggesting that this form of fixation has only a limited use. d) In our study complete consolidation without pseudoarthrosis was achieved by using standalone cages filled with autolog cortico-spongiosus bone chips, but bony healing was delayed due to cage coating and the substitution of pure autogenous spongiosa for cortico-spongiosus bone chips. It is recommended to treat acute/chronic instability of the cervical spine both by using non-fixed plate system with autolog cancellosus bone and by standalone cage filled with cortico-spongiosus bone chips as well. It is worth keeping in mind that by applying this lattest an extra surgery to harvest the graft will be avoided.

Favorable early outcome of carotid artery stenting without protection devices.

BACKGROUND AND PURPOSE: Protection devices are increasingly used in carotid artery stenting. However, no randomized trial has been conducted to evaluate the efficacy of such devices, and arguments have also been formulated against their routine use. We set out to investigate the complication rates associated with carotid artery stenting performed without protection devices. Applicability of covered stents in the carotid system was also evaluated. METHODS: Between January 2001 and July 2003, 245 consecutive patients (260 hemispheres) underwent carotid artery stenting. No protection devices were applied. Covered stents were implanted in 31 (12.1%) cases. The incidence of complications during the intervention and the subsequent 30-day follow-up period was recorded. RESULTS: The technical success rate was 98.8%. One postprocedural nonneurological death (0.4%) occurred. Neurological complications (inclusive of transient ischemic attacks) were observed in 14 cases (5.4%). The rate of major complications (death, major stroke, and myocardial infarction) was 1.6% among the symptomatic and 1.5% among the asymptomatic cases. The rate of minor strokes was 3.2% in the symptomatic and 1.5% in the asymptomatic group. Of the neurological complications, 64.3% occurred postprocedurally. No ipsilateral neurological complications were detected in the subgroup treated with covered stents. CONCLUSIONS: Carotid artery stenting without protection devices appears to be safe. Most of the neurological complications could not have been prevented with protection devices, because they occurred after the intervention. The application of covered stents may reduce the rate of embolization-related complications in the periprocedural period.