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

1
Does a gender medicine approach contribute to
reduce inequalities and costs in the management
of chronic non communicable diseases?

• Andrea Peracino, Alberto Lombardi
• 13 Ottobre 2012
• BOLOGNA - STABAT MATER ARCHIGINNASIO
• www.gendermedicine.org

2
How much high is the economic burden on NHSs
derived from a limited knowledge on and a non
appropriate medical approach to, gender
inequalities?
3
Quality of Life Index www.economist.com

• 2005

• 2010

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

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

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Figure 1
Life expectancy in countries in the WHO European
region, 2010 (or latest available data) Data from
WHO health for all database
SourceThe Lancet 2012 380 1011-1029
(DOI10.1016/S0140-6736(12)61228-8)
Terms and Conditions
5
Figure 1
Life expectancy (LE) and healthy life years
(HLYs) at 50 years of age (all EU countries)
Source The Lancet 2008 372 2124-2131
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Deaths for Men in Europe
Deaths for Women in Europe

EHN-ESC European Cardiovascular Disease
Statistics 2012
7
Deaths lt 65 for Men in Europe
Deaths lt 65 for Women in Europe

EHN-ESC European Cardiovascular Disease
Statistics 2012
8
Disability-adjusted life years lost by cause,
2002, Europe in men
in women
EHN-ESC European Cardiovascular Disease
Statistics 2012
9
Figure 9
Female unemployment rates in selected European
countries by age, 2011 Data from the Labour
Force Survey
The Lancet 2012 380 1011-1029
(DOI10.1016/S0140-6736(12)61228-8)
Terms and Conditions
10
Figure 10
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.
The Lancet 2012 380 1011-1029
(DOI10.1016/S0140-6736(12)61228-8)
Terms and Conditions
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(No Transcript)
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prevalence of smoking, boys aged 15 years,
2009/10, Europe EHN-ESC European Cardiovascular
Disease Statistics 2012
13
prevalence of smoking, girls aged 15 years,
2009/10, Europe EHN-ESC European Cardiovascular
Disease Statistics 2012
14
change in smoking rates among 15 year olds, by
sex, 1993/94 to 2009/10, Europe EHN-ESC European
Cardiovascular Disease Statistics 2012
15
proportion of 11 year olds participating in 1
hour or more of MVPA per day, by sex, 2009
EHN-ESC European Cardiovascular Disease
Statistics 2012
16
proportion of 13 year olds participating in 1
hour or more of MVPA per day, by sex, 2009
EHN-ESC European Cardiovascular Disease
Statistics 2012
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proportion of 15 year olds participating in 1
hour or more of MVPA per day, by sex, 2009
EHN-ESC European Cardiovascular Disease
Statistics 2012
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proportion of 11 year olds watching 2 or more
hours of television per day, by sex, 2009, Europe
EHN-ESC European Cardiovascular Disease
Statistics 2012
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proportion of 13 year olds watching 2 or more
hours of television per day, by sex, 2009,
Europe EHN-ESC European Cardiovascular Disease
Statistics 2012
20
proportion of 15 year olds watching 2 or more
hours of television per day, by sex, 2009,
Europe EHN-ESC European Cardiovascular Disease
Statistics 2012
21
percentage of total healthcare expenditure on
CVD in the EU, 2009, by resource use category
EHN-ESC European Cardiovascular Disease
Statistics 2012
22
total cost of CVD, CHD and Cerebrovascular
diseases, 2009, EU EHN-ESC European
Cardiovascular Disease Statistics 2012
CVD CVD CHD CHD Cerebrovascular Disease 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
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direct health care costs in some country cost of
CVD, CHD and Cerebrovascular diseases, 2009
EHN-ESC European Cardiovascular Disease
Statistics 2012
CVD CVD CVD CHD CHD CHD Cerebrovascular Disease Cerebrovascular Disease Cerebrovascular Disease
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
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indirect health care costs in some country cost
of CVD, CHD and Cerebrovascular diseases, 2009,
mio ( estimated) EHN-ESC European
Cardiovascular Disease Statistics 2012
CVD CVD CVD CHD CHD CHD Cerebrovascular Disease Cerebrovascular Disease Cerebrovascular Disease
Product. losses due to mortality Product. losses due to morbility Informal care Product. losses due to mortality Product. losses due to morbility Informal care Product. losses due to mortality Product. losses due to morbility 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
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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

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cost/benefit ratio in prevention

• 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)

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cost/benefit ratio in prevention

• HPV vaccination model
• The 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 Markovs 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
  112370.76)

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cost/benefit ratio in prevention

• 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?

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cost/benefit ratio in prevention

• 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.

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cost/benefit ratio in prevention

• Pharmaceutical research
• After 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.

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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 womens
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
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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
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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 gt 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 655679.

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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 655679)
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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)
the burden of NCD and BD
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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
the burden of NCD and BD