Does a gender medicine approach contribute to reduce inequalities and costs in the management of chronic non communicable diseases? Andrea Peracino, Alberto

Does a gender medicine approach contribute to reduce inequalities and costs

in the management of chronic non communicable diseases?

Andrea Peracino, Alberto Lombardi13 Ottobre 2012

BOLOGNA - STABAT MATER ARCHIGINNASIOwww.gendermedicine.org

How much high is the economic burden on NHSs derived from a limited knowledge on and a non

appropriate medical approach to, gender inequalities?

Quality of Life Index www.economist.com

2005

• material well being • health • family relations• job security• social and community activities• political freedom and security • gender equality

2010• cost of living• culture and leisure • economy • environment• freedom • health • infrastructure • safety and risk• climate

Figure 1

Source:The Lancet 2012; 380: 1011-1029 (DOI:10.1016/S0140-6736(12)61228-8)

Terms and Conditions

Life expectancy in countries in the WHO European region, 2010 (or latest available data) Data from

WHO health for all database

http://www.thelancet.com/journals/lancet/article/S0140-6736(12)61228-8/abstract

http://www.thelancet.com/popup?fileName=footer-terms

Figure 1

Source The Lancet 2008; 372: 2124-2131

Life expectancy (LE) and healthy life years (HLYs) at 50 years of age (all EU countries)

Deaths for Men in Europe Deaths for Women in Europe

EHN-ESC European Cardiovascular Disease Statistics 2012

Deaths < 65 for Men in Europe Deaths < 65 for Women in Europe


Disability-adjusted life years lost by cause, 2002, Europe

in men in women


Figure 9

The Lancet 2012; 380: 1011-1029 (DOI:10.1016/S0140-6736(12)61228-8)


Female unemployment rates in selected European countries by age, 2011

Data from the Labour Force Survey



Figure 10

The Lancet 2012; 380: 1011-1029 (DOI:10.1016/S0140-6736(12)61228-8)


differences between women and men in healthy life years, years not in good health and life expectancy at birth in selected European countries

Data from the Eurostat database.2008 data for Italy and UK.



Total numbers of deaths by cause and sex, Europe(European Cardiovascular Diseases Statistics 2012)

Men Women Total

Coronary Heart Disease 356.366 324.984 681.350

Stroke 191.784 272.140 463.924

Other CVD 321.660 443.920 765.580

Stomach cancer 36.552 23.962 60.514

Colo-rectal cancer 78.561 66.141 144.702

Lung cancer 184.354 73.675 258.029

Breast cancer 897 89.953 90.850

Respiratory disease 201.613 176.692 378.305

prevalence of smoking, boys aged 15 years, 2009/10, Europe


prevalence of smoking, girls aged 15 years, 2009/10, Europe


change in smoking rates among 15 year olds, by sex, 1993/94 to 2009/10, Europe


proportion of 11 year olds participating in 1 hour or more of MVPA per day, by sex, 2009






proportion of 11 year olds watching 2 or more hours of television per day, by sex, 2009, Europe






percentage of total healthcare expenditure on CVD in the EU, 2009, by resource use category EHN-ESC European Cardiovascular Disease Statistics 2012

total cost of CVD, CHD and Cerebrovascular diseases, 2009, EU


CVD CHD Cerebrovascular Disease

€ mio % of total

€ mio % of total

€ mio % of total

Direct Health care costs

106,157

54% 19,868

33% 19,102 50%

Productivity loss due to mortality

26,963 14% 12,014

20% 4,812 13%

Productivity loss due to morbidity

18,874 10% 5,530

9% 3,329 9%

Informal care costs

43,560 22% 22,812

38% 11,116 29%

Total 195,554

60,225

38,360

direct health care costs in some country cost of CVD, CHD and Cerebrovascular

diseases, 2009 EHN-ESC European Cardiovascular Disease Statistics 2012


€ mio cost per

capita

% of total

€ mio cost per

capita

% of total

€ mio cost per

capita

% of total

Italy 14,488 €241 10% 2,572

€43 2% 2,706 €45 2%

France 12,731 €198 6% 1,682

€26 1% 1,530 €24 1%

Germany 30,679 €374 11% 5,414

€66 2% 5,963 €73 2%

Spain 7,935 €173 8% 1,463

€32 1% 1,067 €23 1%

UK 9,636 €156 6% 1,997

€32 1% 1,979 €32 1%

indirect health care costs in some country cost of CVD, CHD and

Cerebrovascular diseases, 2009, € mio (* estimated) EHN-ESC European Cardiovascular Disease Statistics 2012


Product. losses due to mortality

Product. losses dueto morbility

Informal care

Product. losses due to mortality

Product. losses due to morbility

Informal care

Product. losses dueto mortality

Product. losses due tomorbility

Informal care

Italy 2,097 1,810* 6,865

862 430* 3,468 392 460* 640*

France 2,049 2,482 3,153

690 904 2,201 418 456 858

Germany

7,584 5,659 14,501

3,332

1,381 7,492 1,124 694 4,121

Spain 1,369 940 4,899

588 244 2,242 264 211 860

UK 4,466 2,715 4,215

2,474

1,022 1,915 702 354 1,118

cost/benefit ratio in prevention

Cardiovascular model: popultion attribuable risk -PAR

diet and physical activity PAR =32,8%apo B/apo AI ratio PAR = 12,5% weigh/hip ratio PAR 5,0%blood pressure PAR =1,8%

global PAR = 52,1%


Cardiovascular model: primary and secundary prevention

In the last ten years it has been observed (*) :

An increase of percentage of physycal activity in women (from 29,5 to 30,8%) and a decrease in men (from 33,5 to 32,9%).

An increase of statin use in men 45-54 year old (from 2,5% to 16,8%) and in women after 65 year old (from 1,9% a 13,5%). The increase after 65° year of life in men went from 1,9% to 38,9 % and from 3,5% to 32,8% in women.

The statin use in both gender between 45 and 60 year of life is under the primary prevention reccomandation (NEJM 2010; 362: 2150-1).

(*) Centers for Disease Control and Prevention- CDC (NEJM 2010; 362: 2155-65)


HPV vaccination modelThe cost in Italy of HPV related disease is estimated to be between

€ 200 and € 250 million per year, of which € 210 million are absorbed by the screening and treatment of precancerous lesions and cancer of the cervix (Francesco Mennini: Vaccine 2009; 27: A54-A61).

Using the Markov’s model it has been possible to estimate the threshold of affordability for vaccination which is 9,569 and 26,361 per Quality Adjusted Life Year - QALY gained respectively by the use of bivalent or quadrivalent vaccine

The value for the quadrivalent vaccine (which is also valid for genital warts) allows a reduction of expenditure to 68.6% (€ 140-170 miliardi)

In terms of lives is calculated a reduction of 63,3%, 1.432 new cases of cervical cancer and 513 deaths, compared to using only screening (Francesco Mennini :Gynecologic Oncology 2009; 112:370.76)


Are gender bias in the National Health Systems approach to women MI?

Are the two days more in Intensive Care Units stay of women

modifying the cost/return ratio from DRG?Are the stents use in women (NEJM 2007; 356: 898-1009 e

Circulation 2007; 115: 833-39) raising questions on women specific protocols?


Pharmaceutical research

The alarm raised in 2000 (NEJM 2000; 343: 475-80) and 2001 (JAMA 2001; 286: 708-13), on the minor presence of women in the development and risk/effectiveness trials of many drugs is still unsatisfied.


Pharmaceutical researchAfter years the representation of women is fairly over the 30% of

enrolled subjects. In American Heart Association studies it is shown that sex-specific results were discussed in only 31% of primary trial publications. Women accounted for 53% of all individuals with hypertension, 50% with diabetes, 51% with heart failure, 49% with hyperlipidemia and 46% with coronary artery disease. By contrast the representation of women in the analyzed trials is higher than the average among trials in hypertension (44%), diabetes (40%) and stroke (38%) and lowest for heart failure (29%), coronary artery disease (25%) and hyperlipidemia (28%).

Enrollment of women in randomized clinical trials has increased over time but remains low relative to their overall representation in disease populations. Efforts are needed to reach a level of representation that is adequate to ensure evidence-based gender-specific recommendations.

Circ Cardiovasc Qual Outcomes. 2010; 3: 135-42.

Years ago a “gender challenge” has been launched by WHO to nations and international organizations. The call was for: a better appreciation of risk factors involving women’s health; the development of preventive strategies to lessen the impact of diseases that disproportionately plague older women (e.g., coronary heart disease, osteoporosis and dementia); an increased emphasis on understanding why men die sooner than women (World Health Organization, 1998, The World Health Report 1998, Geneva).

gender challenge

With the claim “Stop the global epidemic non communicable disease“ the WHO was launching its strategic “2008-2013 Action Plan for the Global Strategy for the Prevention and Control of non-communicable Diseases” drawn up by the Secretariat as requested by the Health Assembly in resolution WHA60.23.

The aim was to work in partnership to prevent and control the 4 non-communicable diseases - cardiovascular diseases, diabetes, cancers and chronic respiratory diseases and the 4 shared risk factors - tobacco use, physical inactivity, unhealthy diets and the harmful use of alcohol. Unfortunately WHO is missing the fifth common risk: the indoor and outdoor pollution! The increase of urbanization channels the five risk factors in an even more explosive melting pot of injury to the human health.

the burden of NCD and BD


Major chronic non-communicable diseases (NCDs) - primarily cardiovascular disease (CVD), cancer, chronic obstructive pulmonary disease (COPD) and diabetes - are responsible for 85% of the deaths and 70% of the burden of disease in Europe.Atherosclerosis Supplements 2009; 10: 1-30

The Disorders of the Brain -BD in Europe are responsible for around 15,8 million DALYs (26,6% of global DALYs) in the population aged > 15 age: 7,3 million for men (23,4%), 8,5 million for women (30,1%).

H.U. Witchen, F. Jacobi et alii European Neuropsychopharmacology 2011; 21: 655–679.

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size and burden of Mental Disorders and other Disorders of the Brain in Europe 2010 (H.U. Witchen, F. Jacobi et alii European Neuropsychopharmacology 2011; 21: 655–679)

The economic burden (direct and indirect costs) of BDs in Europe of € 798 billion/year exceeds the € 200 billion spent to manage cardiovascular disease and the 150 billion spent on cancer management (Eur Neuropsychopharmacology 2011; 21 (10): 718-79)


While the effect of gender, age and cultural behavior on the health both of women and men has been widely studied, attention to the impact of the gender differences on the patho-physiology and, therefore, on the management of the most common social diseases such as the group of chronic Non Communicable Diseases (NCD) (e.g. cardiovascular disease, diabetes, obesity, chronic obstructive pulmonary diseases and some tumors) and the group of Brain Disorders (BD) (e.g. dementias, depression, anxiety and mood disorders, to list a few) is both needed and lacking


Documents

Does a gender medicine approach contribute to reduce inequalities and costs in the management of chronic non communicable diseases? Andrea Peracino, Alberto