Treatable mortality and health care related factors across European countries.

Introduction: Despite the improvements in European health systems, a large number of premature deaths are attributable to treatable mortality. Men make up the majority of these deaths, with a significant gap existing between women and men's treatable mortality rate in the EU. Aim: This study aims to identify the healthcare-related factors, including health expenditures, human and physical resources, and hospital services use associated with treatable mortality in women and men across European countries during the period 2011-2019. Methods: We use Eurostat data for 28 EU countries in the period 2011-2019. We estimate a panel data linear regression with country fixed effects and quantile linear regression for men and women. Results: The results found (i) differences in drivers for male and female treatable mortality, but common drivers hold the same direction for both sexes; (ii) favorable drivers are GDP per capita, health expenditures, number of physicians per capita, and (only for men) the average length of a hospital stay, (iii) unfavorable drivers are nurses and beds per capita, although nurses are not significant for explaining female mortality. Conclusion: Policy recommendations may arise that involve an improvement in hospital bed management and the design of more specific policies aimed at healthcare professionals.

Home- versus centre-based EXercise InTervention in patients with Heart Failure (EXIT-HF trial): A pragmatic randomized controlled trial.

INTRODUCTION: The limited accessibility and the lack of adherence explain, in part, the low proportion of heart failure (HF) patients undergoing exercise-based cardiac rehabilitation (CR) programs. Home-based programs showed to be as effective and less costly than centre-based ones and might address those obstacles. Whether the evidence from international studies can be applied to our population is still unclear. OBJECTIVES: To compare the clinical and economic impact of a home-based versus centre-based CR intervention in HF patients. METHODS: This is a single-center, single-blind, parallel groups, non-inferiority pragmatic randomized control trial. Adult HF patients (n=120) will be randomized to either a centre-based or home-based CR program. In both groups' patients will participate in a 12-week combined CR program with 2 sessions per week. Exercise training (ExT) protocol consists of a combination of endurance [(at 60%-80% of peak oxygen uptake (VO2peak)] and resistance training (elastic bands). Those allocated to the home-based program will start with 4-5 supervised ExT sessions to familiarize themselves with the training protocol and then will continue the remaining sessions at home. The primary endpoint is the change in VO2peak at the end of the 12-week program. Secondary outcomes include alterations in circulating biomarkers, physical fitness, physical activity, quality of life, diet, psychological wellbeing, dyspnea, and cost-effectiveness analyses. RESULTS: Patients are currently being recruited for the study. The study started in November 2019 and data collection is anticipated to be completed by December 2022. This is the first study in Portugal comparing the traditional CR program with a home-based program in HF patients. Our study results will better inform healthcare professionals who care for HF patients regarding CR.

Consumption of Non-Prescribed Drugs in Portugal During the Pandemic in 2021.

Objectives: Portugal liberalised the over-the-counter drugs market in 2005 and provides universal healthcare coverage in a mainly Beveridge-type health system. However, the COVID-19 pandemic has forced healthcare to change how services were delivered, especially increasing remote consultations in primary care. This analysis aims to find the drivers for taking non-prescribed drugs during the pandemic in Portugal. Specifically, it seeks to understand the role of taking prescribed drugs and attending remote medical appointments in the self-medication decision. Methods: In this observational study, we used data collected during the pandemic in Centre Region of Portugal and estimated logistic regression for the whole sample and stratified by sex. Results: The main findings show that people taking prescribed medications and attending a remote consultation are more likely to take non-prescribed drugs. Also, reporting unmet healthcare needs seems to motivate people to choose self-medication. Conclusion: Policy implications are pointed out concerning the health risks raised from self-medication, the role of the pharmacist advising non-prescribed drugs, and the related health risks arising from unmet healthcare needs.

Impact of a COmprehensive cardiac REhabilitation framework among high cardiovascular risk cancer survivors: Protocol for the CORE trial.

BACKGROUND: Cancer survivors are challenging patients, as they often present increased cardiovascular risk. In this background, cardio-oncology rehabilitation frameworks for specific cancer patients have been proposed. However, optimal program designs, as well as their overall safety and efficacy in different subsets of patients, are not fully ascertained. DESIGN: Single-center, pragmatic, prospective, randomized controlled trial performed in Portugal aiming to evaluate the impact of a center-based cardiac rehabilitation program, consisting of exercise training, nutritional counselling, psychosocial management and lifestyle behavior change, compared to community-based exercise training, in cancer survivors. METHODS: Adult cancer survivors (N = 80) exposed to cardiotoxic cancer treatment and/or with previous cardiovascular disease will be randomized (1:1) to receive either an eight-week cardiac rehabilitation program or community-based exercise training. Primary endpoint is cardiorespiratory fitness; secondary endpoints are physical activity, psychosocial parameters, blood pressure, body composition, lipids and inflammatory parameters. Physical function, quality of life, fatigue, health literacy, and feasibility will be assessed; a cost-effectiveness evaluation will also be performed. Between-group differences at baseline and in the change from baseline to the end of the study will be tested with unpaired t-tests or Mann-Whitney U test. Paired t-tests or Wilcoxon signed-rank test will be performed for within-group comparisons. CONCLUSION: This trial will address the overall impact of a contemporary cardiac rehabilitation program framework in cancer survivors, as compared to a community-based exercise training. Given the higher cardiovascular risk in several groups of cancer patients, our results could provide novel insights into optimized preventive strategies in this complex patient population.

Voluntary private health insurance demand by Portuguese seniors before the COVID-19 pandemic.

AIMS: The Portuguese health system is mainly described as a National Health Service (NHS), but it also has some Bismarckian features. On top of these two layers of health insurance coverage, there is a market for voluntary private health insurance (VPHI). Usually, seniors are not eligible for this type of health insurance and this may serve as a complement or supplement to the NHS. The purpose of this work is to identify the main factors associated with holding a VPHI policy among seniors before the COVID-19 pandemic. MATERIAL AND METHODS: We use data collected by the National Health Survey of 2019/20 and estimate a multivariate logistic regression. RESULTS: The main findings show that VPHI may be bought by seniors as a facilitator to access health care, either specialised or dental care. While oral health is not covered by the NHS, specialist care is only available after referral by a gatekeeper and requires a long waiting time to be scheduled. Results show that people who had an appointment with a dentist or a specialist in the last 12 months are more likely to have a VPHI policy. Additionally, it was found that people benefiting from occupation-based insurance schemes are less likely to buy private health insurance. CONCLUSION: The current Portuguese health system organization based on different layers of health protection raises some issues concerning equity to health care access by seniors.

Life expectancy at 65, associated factors for women and men in Europe.

In Europe, the epidemiological transition has already taken place, while the demographic transition continues. Life expectancy at 65 is expanding for both women and men. The primary aim of this work is to identify the factors associated with life expectancy at 65 for women and men in Europe. The second aim is to confirm the influence of cultural factors on life expectancy. Finally, the link between spending on pensions, soil pollution, and life expectancy is also tested. Data for 31 European countries for the period 2004-2018 have been collected to estimate a linear panel data model. Life expectancy at 65 for women and men is the dependent variable. Independent variables are grouped into socioeconomic, cultural, and environmental conditions. The main result of this work is the importance of GDP per capita, and education and pension expenditure in explaining the heterogeneity of life expectancy at 65 across countries. Other significant results include the association of cultural characteristics, air pollution, and soil pollution with life expectancy. The design of policies for older adults and the improvement of their health and active life should consider not only differences in education but cultural characteristics, too. European directives that disregard people's cultural differences may not have the expected result. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00695-1.

Factors Contributing to Self-Medication and Consumption of Non-Prescribed Drugs in Portugal.

Objectives: This work sets out to find the relationship between taking non-prescribed drugs and predisposing, enabling and need factors. Specifically, our main aim is to find the relationship between taking non-prescribed drugs and the lack of health care. Methods: We used data from the last 2019 National Health Survey and estimate logistic regressions for the whole sample and stratified by sex. Results: The most striking finding is that people self-medicating with non-prescribed drugs seem to be replacing health care when this is not used because of financial constraints or distance from provider. This suggests that non-prescribed drugs are a fast, affordable, alternative to health care. Other findings show that income and the financial resources to cope with unexpected expenditure are considerations in taking these drugs. Health and needs are other factors triggering their consumption. Conclusion: Policy measures need to be aimed at improving access to medical care, providing responses to health needs such as those arising from chronic pain, and improving health literacy.

Older Europeans' experience of unmet health care during the COVID-19 pandemic (first wave).

BACKGROUND: During the COVID-19 pandemic the utilization of health services has changed. People were living in a very different social, economic and epidemiological context. Unmet health care is expected to happen. The purposes of this work are i) to compare the differences between unmet care across countries, ii) to find the main factors which are associated with unmet health care, which includes giving up and postponing medical care, as well as denial of medical care provision by the health services, and iii) to determine if health systems' characteristics and government decisions on lockdown were related to unmet care. METHODS: We have used the most recent dataset collected by the SHARE-COVID Survey during the summer of 2020. These data cover all EU countries and are applied to people over 50. We have estimated a set of logistic regressions to explain unmet health care. RESULTS: The results indicate that women, people who are slightly younger, with higher education and income, who find it hard to make ends meet each month, and people with poorer health were more likely to experience unmet health care. We also found that in health systems with high out-of-pocket payments people are more likely to give up health care while in countries with previous high levels of unmet health needs this likelihood was the opposite; people in countries with a high number of beds per capita and with a Beveridge-type health system were reporting less postponement of health care. CONCLUSION: Some policy measures may be suggested such as social and economic measures to mitigate loss of income, expansion of the points and forms of access to health care to improve utilisation.

Health and life satisfaction factors of Portuguese older adults.

Portugal has some peculiar features concerning older age. Despite long life expectancy, the share of healthy life years in older ages is small. The decreasing relationship between age and life satisfaction in Portugal has recently been pointed out. The absence of knowledge about self-assessed health and life satisfaction of the population of older Portuguese motivates this analysis. This work aims to find the drivers of self-assessed health and life satisfaction and their relationship for older Portuguese (older than 70). Two ordered logistic regressions are estimated using data from the National Health Survey of 2019. Endogeneity of self-assessed health is tested in the regression of life satisfaction. The main descriptive result shows that older people in Portugal tend to report a low health status but a high level of life satisfaction. We also found that despite the general decrease across age and after controlling for determinants, life satisfaction seems to display a U-shape, and the likelihood of being life satisfied increases with age from the age group of 70-74 on. The main determinants of self-assessed health and life satisfaction include the existence of chronic diseases, physical limitations in daily life, and depression indicators. But the findings also show that social interactions and income play a part in the way people report health and life satisfaction. Some policy measures could be taken to jointly improve the health and life satisfaction.

Burnout and health status differences among primary healthcare professionals in Portugal.

BACKGROUND: This paper is focused on two indicators which may be considered as proxies of individuals' well-being: self-assessed health and burnout intensity. There is little research relating these concepts with the type of the primary healthcare setting, its urbanization density and the region. The aims of this work are threefold: (i) to find determinant factors of individual health status and burnout, (ii) to find possible differences across different types of health care units, differently urbanized areas, and different administrative regions, and (iii) to verify if there are differences in between GPs and nurses. METHODS: Data was gathered from an online questionnaire implemented on primary health care. A sample of 9,094 professionals from all 1,212 primary health care settings in Portugal mainland was obtained from an online questionnaire filled from January and April 2018. Statistical analyses include the estimation of two ordered probits, one explaining self-assessed health and the other the burnout. RESULTS: The individual drivers for good health and lower levels of burnout, that is, better well-being, are estimated for GPs and nurses. Main findings support that, first, nurses report worst health than GPs, but the latter tend to suffer higher levels of burnout, and also that, 'place' effects arising from the health unit settings and regional location are more significant in GPs than in nurses. However, urbanization density is not significantly associated with health or burnout. CONCLUSIONS: A set of policy recommendations are suggested to improve the healthcare workforce well-being, such as improving job satisfaction and income. These policies should be taken at the health care unit level and at the regional administrative level.

Multi-layer health insurance coverage, medical services use and health in a Universal National Health System, the case of Portugal.

The Portuguese health system has the peculiar characteristic of being a Beveridge-Bismarck type aiming at universal coverage. On top of the national health system coverage, there is a second coverage provided to some professionals, plus a third layer of coverage that can be acquired by taking out voluntary private health insurance. The aim of this work is to ascertain whether people benefiting from supplemental multi-layer health coverage (on top of the existing National Health System) have more consultations, either with general practitioners or with specialists, and enjoy better health status. We used data from the National Health Survey from 2014 to estimate a recursive system of ordered probits. The main results confirm that multi-layer health coverage is correlated with the use of more specialist consultations, but not with more GP consultations. It is also correlated with better health status. These results may indicate the existence of moral hazard, induced demand and/or 'access effect'. Regarding policy matters, the measures aimed to reduce waiting times, improve patient choice, and increase access could counteract such results and mitigate the potential inequity of access and health status, and also excessive use of medical services that can happen under double health coverage.

Self-assessed health among older people in Europe and internet use.

BACKGROUND: About ten years ago, an age-related digital divide was identified, where 'the elderly' denoted a group of people at risk of losing the benefits of a digital society. The aims of this work are to find a relationship between self-assessed health and internet use by older people in European countries and to ascertain whether this relationship differs in countries with a more developed eHealth policy. MATERIALS AND METHODS: An ordered logistic regression is estimated for all countries in the sample and for two countries subsets which differ in their eHealth performance. Individual data is collected by SHARE. The classifying criterion of eHealth performance is based on the 'eHealth' policy dimension of the indicator used to construct the Digital Economy and Society Index. The average marginal effects are computed for the variable of internet use. RESULTS: Results show that older people who use the internet tend to report better health status. This relationship however may not hold for low levels of health and it is stronger in countries with low eHealth performance. CONCLUSION: Policy measures on eHealth not only contribute to people's health but also help to alleviate critical situations such as the one created by the Covid-19 pandemic.

Drivers for emigration among healthcare professionals: Testing an analytical model in a primary healthcare setting.

This paper aims to contribute to the discussion on health workforce migration, notably by testing an analytical model of the individual drivers for a professional to decide to emigrate. A large database was obtained from all primary health care units on mainland Portugal. A professional satisfaction survey was conducted and information on social-economic, labour and job satisfaction characteristics, including burnout, was obtained. Results showed that healthcare professionals who reported intention to emigrate are mostly male, young, not married, and more educated; they consider their income insufficient for their needs, and show higher levels of burnout at work and professional dissatisfaction. This profile is slightly different for GPs and nurses. The results obtained contribute to the discussion on what motivates primary health care professionals, including GPs and nurses, to emigrate. They also provide insight into the design of policy measures that may mitigate the intention of these healthcare professionals in general to emigrate.

Public satisfaction with health system coverage, empirical evidence from SHARE data.

People's satisfaction with the health system, including the coverage provided, has been a concern for some years now but research into the main explanatory factors is in progress. This work focuses on European countries plus Israel, using the SHARE database to find what determines people's satisfaction with the basic coverage provided by the health system of each country. On top of the usual individual socioeconomic characteristics, other explanatory factors were also considered. These include, at individual level, trust in others, political positioning, and risk aversion; at country level, they include access to specialist care and the type of health system financing. Estimation of an ordered logistic model found that the main predictors for satisfaction with a health system's basic coverage include trust in others, unmet health needs, self-assessed health, free access to specialists, health system financed through social insurance, and out-of-pocket payments. These results provide the basis for possible policies designed to improve people's satisfaction.

Primary health care patient satisfaction: Explanatory factors and geographic characteristics.

OBJECTIVE: To determine the factors that explain the levels of patient satisfaction and the role of geographical characteristics. DESIGN: Questionnaires to patients of Primary Health Care (PHC) units in Portugal Mainland distributed to each unit according to their size; codes were distributed to guarantee single responses; the questionnaire was anonymous and confidential. SETTING: Primary Health Care units in Portugal Mainland. PARTICIPANTS: Primary health care patients. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Overall patient satisfaction. RESULTS: The main results indicate that the most significant dimension explaining overall patient satisfaction index is the satisfaction regarding general practitioner (GP) care, and the two other most significant explanatory variables of satisfaction are to be enrolled in a GP list and education. The bigger is the size of a PHC unit the lower is satisfaction. In rural areas, the level of satisfaction is higher than in urban areas. Comparing to the Lisbon metropolitan area, all other regions show a higher satisfaction in access dimension. CONCLUSIONS: These results contribute to the creation of strategic information relevant to the evaluation of the various models of Primary Health Care, to the commissioning and definition of health policies.

Voluntary private health insurance demand determinants and risk preferences: Evidence from SHARE.

The demand for voluntary private health insurance (VPHI) in universal coverage health systems in Europe raises some questions. The aim of this paper is to determine the factors that explain the decision to purchase VPHI, to analyse the role of individual risk attitudes and self-assessed health (SAH) in purchasing VPHI, to explore the factors that explain individual risk preferences, and to test how SAH relates to those preferences. To achieve this aim, two recursive simultaneous probits are estimated using data collected by SHARE, wave 6. The main results indicate that people who are more satisfied with the health system coverage are more likely to buy VPHI; SAH is negative correlated with VPHI, but being a risk taker contributes to that decision; however, being a risk taker is positively influenced by good health status. This paper contributes to the discussion on the role of SAH and risk preferences in the decision to buy VPHI. It brings new insights for the health insurance companies and for health policy makers. HIGHLIGHTS: People who are more satisfied with the health system coverage are more likely to buy voluntary private health insurance. The longer the planning horizon assumed by individuals, the greater the likelihood they are risk takers. People reporting being risk takers are more likely to have taken out voluntary private health insurance. Self-assessed health influences the decision to buy voluntary private health insurance in two ways: a direct one, where better health lowers the odds of having insurance, and an indirect one through risk taking, which increases the odds of having insurance. Contributions of this work are mainly for health policy makers and insurance companies.

EU health systems classification: a new proposal from EURO-HEALTHY.

BACKGROUND: In accordance the WHO framework of health system functions and by using the indicators collected within the EURO-HEALTHY project, this work aims to contribute to the discussion on the classification of EU health systems. METHODS: Three methods were used in this article: factor analysis, cluster analysis and descriptive analysis; data were mainly collected from the WHO and Eurostat databases. RESULTS: The most relevant result is the proposed classification of health systems into the following clusters: Austria-Germany, Central and Northern Countries, Southern Countries, Eastern Countries 'A' and Eastern Countries 'B'. CONCLUSIONS: The proposed typology contributes to the discussion about how to classify health systems; the typology of EU health systems allows comparisons of characteristics and health system performance across clusters and policy assessment and policy recommendation within each cluster.

eHealth, ICT and its relationship with self-reported health outcomes in the EU countries.

This work contributes to the discussion on the relationship between ICT and ehealth solutions in primary care, and self-reported health and health status in the European Union. The method used is an ordinary least squares linear model. The results show that there is no significant relation between self-reported health outcomes and ICT and ehealth indexes, except for self-reported chronic health problems. The more advanced that countries are in ICT, the larger is the share of people reporting a chronic health problem. This provides evidence on the existence of a link between chronic patients and ICT development.

The Challenge of Complementary and Alternative Medicine After Austerity: A Response to Recent Commentaries.

Complementary and Alternative Medicine (CAM) is frequently used in Portugal and it contributes to the improvement of people's health. CAM and Western Medicine (WM) are taken as complements both in the diagnosis and the treatment stage. The Portuguese health system is able to generate certified CAM professionals but the provision of CAM care and services is not included in the national health system. In times of austerity, this is not expected to change and access to CAM care continues to be out-of-pocket health expenditure. But the future for health in Portugal may well involve including CAM therapies in an integrated health system.

Substitutes or complements? Diagnosis and treatment with non-conventional and conventional medicine.

BACKGROUND: Portugal has a strong tradition of conventional western healthcare. So it provides a natural case study for the relationship between Complementary/Alternative Medicine (CAM) and Western Medicine (WM). This work aims to test the relationship between CAM and WM users in the diagnosis and treatment stages and to estimate the determinants of CAM choice. METHODS: The forth Portuguese National Health Survey is employed to estimate two single probit models and obtain the correlation between the consumption of CAM and WM medicines in the diagnosis and treatment stages. RESULTS: Firstly, both in the diagnosis and the treatment stage, CAM and WM are seen to be complementary choices for individuals. Secondly, self-medication also shows complementarity with the choice of CAM treatment. Thirdly, education has a non-linear relationship with the choice of CAM. Finally, working status, age, smoking and chronic disease are determinant factors in the decision to use CAM. CONCLUSION: The results of this work are relevant to health policy-makers and for insurance companies. Patients need freedom of choice and, for the sake of safety and efficacy of treatment, WM and CAM healthcare ought to be provided in a joint and integrated health system.