The interplay between excess weight and hyper-glycemia on NCDs in Italy: results from a cross-sectional study.

PURPOSE: To evaluate the prevalence of chronic comorbidities according to BMI classes and assess the interplay between excess body weight and blood glucose abnormalities in increasing the risk of major chronic diseases. METHODS: The study is based on data from the Health Search/IQVIA Health LPD Longitudinal Patient Database, an Italian general practice registry, with data obtained from electronic clinical records of 800 general practitioners throughout Italy. Data relative to the year 2018 were analyzed. The study population was classified according to BMI (normal weight, overweight, and obesity classes 1, 2 and 3) and glucose metabolism status (normoglycemia-NGT; impaired fasting glucose-IFG; diabetes mellitus-DM). Comorbidities were identified through ICD-9 CM codes. RESULTS: Data relative to 991,917 adults were analyzed. The prevalence of overweight was 39.4%, while the prevalence of obesity was 11.1% (class 1: 7.9%, class 2: 2.3%, class 3: 0.9%). In the whole population, the prevalence of DM and IFG was 8.9% and 4.2%, respectively. Both overweight and obesity were associated with an increasing prevalence of glucose metabolism alterations and a large array of different chronic conditions, including cardio-cerebrovascular diseases, heart failure, chronic kidney disease, osteoarticular diseases, depression, sleep apnea, and neoplasms of the gastrointestinal tract. Within each BMI class, the presence of IFG, and to a greater extent DM, identified subgroups of individuals with a marked increase in the risk of concomitant chronic conditions. CONCLUSION: Addressing the double burden of excess weight and hyperglycemia represents an important challenge and a healthcare priority.

The changing relationship between bodyweight and longevity in high- and low-income countries.

Standard measures of bodyweight (overweight and obese, for example) fail to reflect differences across populations and technological progress over time. This paper builds on the pioneering work of Hans Waaler (1984) and Robert Fogel (1994) to empirically estimate how the relationship between body mass index (BMI) and longevity varies across high-, middle-, and low-income countries. Importantly, we show that these differences are so profound that the share of national populations above mortality-minimizing bodyweight is not clearly greater in countries with higher overweight and obesity rates (as traditionally defined)-and in fact, relative to current standards, a larger share of low-income countries' populations can be unhealthily heavy.

Lifetime costs of overweight and obesity in Italy.

We use longitudinal electronic clinical data on a large representative sample of the Italian population to estimate the lifetime profile costs of different BMI classes - normal weight, overweight, and obese (I, II, and III) - in a primary care setting. Our research reveals that obese patients generate the highest cost differential throughout their lives compared to normal weight patients. Moreover, we show that overweight individuals spend less than those with normal weight, primarily due to reduced expenditures beginning in early middle age. Our estimates could serve as a vital benchmark for policymakers looking to prioritize public interventions that address the obesity pandemic while considering the increasing obesity rates projected by the OECD until 2030.

Outpatient healthcare costs associated with overweight and obesity in Italy.

BACKGROUND: To evaluate outpatient healthcare expenditure associated with different levels of BMI and glucose metabolism alterations. METHODS: The study is based on a representative national sample of adults, with data obtained from electronic clinical records of 900 Italian general practitioners. Data relative to the year 2018 were analyzed. The study population was classified according to BMI (normal weight, overweight, and obesity classes 1, 2, and 3) and glucose metabolism status (normoglycemia - NGT; impaired fasting glucose - IFG; diabetes mellitus - DM). Outpatient health expenditures include diagnostic tests, specialist visits, and drugs. RESULTS: Data relative to 991,917 adults were analyzed. Annual per capita expenditure rose from 252.2 Euro among individuals with normal weight to 752.9 Euro among those with class 3 obesity. The presence of obesity determined an excess cost, particularly among younger individuals. Within each BMI class, the presence of IFG or DM2 identified subgroups of individuals with substantially higher healthcare expenditures. CONCLUSIONS: Outpatient healthcare costs markedly increased with increasing BMI in all age categories, particularly among individuals below 65. Addressing the double burden of excess weight and hyperglycemia represents a significant challenge and a healthcare priority.

Psychotropic drug purchases during the COVID-19 pandemic in Italy and their relationship with mobility restrictions.

Recent literature on the mental health consequences of social distancing measures has found a substantial increase in self-reported sleep disorders, anxiety and depressive symptoms during lockdown periods. We investigate this issue with data on monthly purchases of psychotropic drugs from the universe of Italian pharmacies during the first wave of the COVID-19 pandemic and find that purchases of mental health-related drugs have increased with respect to 2019. However, the excess volumes do not match the massive increase in anxiety and depressive disorders found in survey-based studies. We also study the interplay between mobility, measured with anonymized mobile phone data, and mental health and report no significant effect of mobility restrictions on antidepressants and anxiolytics purchases during 2020. We provide three potential mechanisms that could drive the discrepancy between self-reported mental health surveys and psychotropic drugs prescription registries: (1) stockpiling practices in the early phases of the pandemic; (2) the adoption of compensatory behavior and (3) unexpressed and unmet needs due to both demand- and supply-side shortages in healthcare services.

Technological Progress and Health Convergence: The Case of Penicillin in Postwar Italy.

Throughout history, technological progress has transformed population health, but the distributional effects of these gains are unclear. New substitutes for older, more expensive health technologies can produce convergence in population health outcomes but may also be prone to elite capture and thus divergence. We study the case of penicillin using detailed historical mortality statistics and exploiting its abruptly timed introduction in Italy after WWII. We find that penicillin reduced both the mean and standard deviation of infectious disease mortality, leading to substantial convergence across disparate regions of Italy. Our results do not appear to be driven by competing risks or confounded by mortality patterns associated with WWII.

The future of the elderly population health status: Filling a knowledge gap.

The aging process in OECD countries calls for a better understanding of the future disease prevalence, life expectancy (LE) and patterns of inequalities in health outcomes. In this paper we present the results obtained from several dynamic microsimulation models of the Future Elderly Model family for 12 OECD countries, with the aim of reproducing for the first time comparable long-term projections in individual health status across OECD countries. We provide projections of LE and prevalence of major chronic conditions and disabilities, overall, by gender and by education. We find that the prevalence of main chronic conditions in Europe is catching-up with the United States and significant heterogeneity in the evolution of gender and educational gradients. Our findings represent a contribution to support policymakers in designing and implementing effective interventions in the healthcare sector.

Disease burden and economic impact of diagnosed non-alcoholic steatohepatitis in five European countries in 2018: A cost-of-illness analysis.

BACKGROUND AND AIMS: Non-alcoholic steatohepatitis (NASH) is a chronic disease that can progress to end-stage liver disease (ESLD). A large proportion of early-stage NASH patients remain undiagnosed compared to those with advanced fibrosis, who are more likely to receive disease management interventions. This study estimated the disease burden and economic impact of diagnosed NASH in the adult population of France, Germany, Italy, Spain and the United Kingdom in 2018. METHODS: The socioeconomic burden of diagnosed NASH was estimated using cost-of-illness methodology applying a prevalence approach to estimate the number of adults with NASH and the attributable economic and wellbeing costs. Given undiagnosed patients do not incur costs in the study, the probability of diagnosis is central to cost estimation. The analysis was based on a literature review, databases and consultation with clinical experts, economists and patient groups. RESULTS: The proportion of adult NASH patients with a diagnosis ranged from 11.9% to 12.7% across countries, which increased to 38.8%-39.1% for advanced fibrosis (F3-F4 compensated cirrhosis). Total economic costs were €8548-19 546M. Of these, health system costs were €619-1292M. Total wellbeing costs were €41 536-90 379M. The majority of the undiagnosed population (87.3%-88.2% of total prevalence) was found to have early-stage NASH, which, left untreated, may progress to more resource consuming ESLD over time. CONCLUSIONS: This study found that the majority of economic and wellbeing costs of NASH are experienced in late disease stages. Earlier diagnosis and care of NASH patients could reduce future healthcare costs.

How health policy shapes healthcare sector productivity? Evidence from Italy and UK.

The English (NHS) and the Italian (SSN) healthcare systems share many similar features: basic founding principles, financing, organization, management, and size. Yet the two systems have faced diverging policy objectives since 2000, which may have affected differently healthcare sector productivity in the two countries. In order to understand how different healthcare policies shape the productivity of the systems, we assess, using the same methodology, the productivity growth of the English and Italian healthcare systems over the period from 2004 to 2011. Productivity growth is measured as the rate of change in outputs over the rate of change in inputs. We find that the overall NHS productivity growth index increased by 10% over the whole period, at an average of 1.39% per year, while SSN productivity increased overall by 5%, at an average of 0.73% per year. Our results suggest that different policy objectives are reflected in differential growth rates for the two countries. In England, the NHS focused on increasing activity, reducing waiting times and improving quality. Italy focused more on cost containment and rationalized provision, in the hope that this would reduce unjustified and inappropriate provision of services.

Trends in age-related disease burden and healthcare utilization.

Aging is a strong risk factor for many chronic diseases. However, the impact of an aging population on the prevalence of chronic diseases and related healthcare costs are not known. We used a prevalence-based approach that combines accurate clinical and drug prescription data from Health Search CSD-LPD. This is a longitudinal observational data set containing computer-based patient records collected by Italian general practitioners (GP) and up-to-date healthcare expenditures data from the SiSSI Project. The analysis is based on data collected by 900 GP on an unbalanced sample of more than 1 million patients aged 35+, observed in different time periods between 2005 and 2014. In 2014, 86% of the Italian adults older than 65 had at least one chronic condition, and 56.7% had two or more. Prevalence of multiple chronic diseases and healthcare utilization increased among older and younger adults between 2004 and 2014. Indeed, in the last 10 years, average number of prescriptions increased by approximately 26%, while laboratory and diagnostic tests by 27%. The average number of DDD prescribed increased with age in all the observed years (from 114 in 2005 to 119.9 in 2014 for the 35-50 age group and from 774.9 to 1,178.1 for the 81+ patients). The alarming rising trends in the prevalence of chronic disease and associated healthcare costs in Italy, as well as in many other developed countries, call for an urgent implementation of interventions that prevent or slow the accumulation of metabolic and molecular damage associated with multiple chronic disease.

Heterogeneity in long term health outcomes of migrants within Italy.

This article examines the long term physical and mental health effects of internal migration focusing on a relatively unique migration experience concentrated over a short period between 1950 and 1970 from the South to the North of Italy. We find a positive and statistically significant association between migration, its timing and physical health for migrant females, which we show are likely to represent rural females in both the early and the late cohort. We find less defined evidence of migration-health association for mental health. We link our findings to the economic transition and labor market transformation that Italy witnessed in that era. Male migrants were likely to be positively selected to migration, but harsh working conditions were likely to downplay this differential. On the contrary, women migrants, by and large, would not engage in the formal labor market avoiding the ill effects of working environments, at the same time benefiting from better living conditions and health care in the destination regions.

Public Health Insurance and Household Portfolio Choices: Unravelling Financial "Side Effects" of Medicare.

Large, unpredictable and not fully insurable health-care costs represent a source of background risk that might deter households' financial risk taking. Using panel data from the Health and Retirement Study, we test whether universal health insurance, like Medicare for over-65 Americans, shields against this risk promoting stockholding. We adopt a fixed-effects estimation strategy, thereby taking into account household-level heterogeneity in health status and private insurance coverage. We find that, before Medicare eligibility, households in poor health, who face a higher risk of medical expenses, are less likely to hold stocks than their healthier counterparts. Yet, this gap is mostly eliminated by Medicare. Notably, the offsetting is primarily experienced by households in poor health and without private health insurance over the observation period.

Drug therapy adherence and health outcomes in the presence of physician and patient unobserved heterogeneity.

Understanding the role that drug adherence has on health outcomes in everyday clinical practice is central for the policy maker. This is particularly true when patients suffer from asymptomatic chronic conditions (e.g., hypertension, hypercholesterolaemia, and diabetes). By exploiting a unique longitudinal dataset at patient and physician level in Italy, we show that patients and physicians unobserved characteristics play an important role in determining health status, at least as important as drug adherence. Most importantly, we find that both adherence and prescribed treatment regimen effects are highly heterogeneous across physicians, highlighting their crucial role in shaping patients' health status.

Excess body weight increases the burden of age-associated chronic diseases and their associated health care expenditures.

Aging and excessive adiposity are both associated with an increased risk of developing multiple chronic diseases, which drive ever increasing health costs. The main aim of this study was to determine the net (non-estimated) health costs of excessive adiposity and associated age-related chronic diseases. We used a prevalence-based approach that combines accurate data from the Health Search CSD-LPD, an observational dataset with patient records collected by Italian general practitioners and up-to-date health care expenditures data from the SiSSI Project. In this very large study, 557,145 men and women older than 18 years were observed at different points in time between 2004 and 2010. The proportion of younger and older adults reporting no chronic disease decreased with increasing BMI. After adjustment for age, sex, geographic residence, and GPs heterogeneity, a strong J-shaped association was found between BMI and total health care costs, more pronounced in middle-aged and older adults. Relative to normal weight, in the 45-64 age group, the per-capita total cost was 10% higher in overweight individuals, and 27 to 68% greater in patients with obesity and very severe obesity, respectively. The association between BMI and diabetes, hypertension and cardiovascular disease largely explained these elevated costs.

Who is responsible for your health: is it you, your doctor or the new technologies?

The aim of the paper is to disentangle the roles that patients, physicians and technology can have on patient health outcomes. The analysis focuses on patients suffering from hypercholesterolemia. Using a large and detailed dataset of patients collected by the Italian College of General Practitioners (SIMG) over the period 2001-2006, we observe the existence of heterogeneity in the time needed to reach an optimal level of health stock. We firstly explore whether patients recovering faster exhibit lower hospitalization rates. Secondly, we study the determinants of the speed of recovery to a good health status. Results suggest that a 10% increase in the speed of recovery reduces hospitalization rates by 1% in the general sample and by 1.25% in patients in primary prevention. Furthermore, we show that recovering to a good health status is a multifaceted phenomenon, with technology explaining from 54 to 68% of the total effect.

Body weight, eating patterns, and physical activity: the role of education.

In this article, we empirically study the role of education attainment on individual body mass index (BMI), eating patterns, and physical activity. We allow for endogeneity of schooling choices for females and males in a mean and quantile instrumental variables framework. We find that completion of lower secondary education has a significant positive impact on reduction of individual BMI, containment of calorie consumption, and promotion of physical activity. Interestingly, these effects are heterogeneous across genders and distributions. In particular, for BMI and calorie expenditure, the effect of education is significant for females and is more pronounced for women with high body mass and low physical activity. On the other hand, the effect of education on eating patterns is significant mainly for males, being more beneficial for men with elevated calorie consumption. We also show that education attainment is likely to foster productive and allocative efficiency of individuals in the context of BMI formation. Given that the literature suggests that education fosters development of cognition, self-control, and a variety of skills and abilities, in our context it is thus likely to promote lifetime preferences and means of individuals, which in turn enable them to achieve better health outcomes. Education also provides exposure to physical education and to school subjects enhancing individual deliberative skills, which are important factors shaping calorie expenditure and intake. Finally, we show that in the presence of strong socioeconomic inequalities in BMI, education is likely to have a pronounced impact on healthy BMI for the disadvantaged groups, represented in our framework by females.

The effect of age and time to death on primary care costs: the Italian experience.

A large body of literature shows that time to death (TTD) is by far a better predictor of health spending than age. In this paper, we investigate if this finding holds true also in presence of primary care costs (pharmaceuticals, diagnostic tests and specialist visits) in Italy, where they represent an important share (about 30%) of the total health care expenditure (HCE). Our analysis is based on a large sample of the Italian population (about 750,000 individuals), obtained from the Health Search-SiSSI database, which contains patient-level data collected routinely by General Practitioners in Italy since 2002. We study individuals aged 19 and older, over the period 2006-2009. By means of a two-part model which accounts for the presence of zero expenditure, our findings show that age represents the most important driver of primary care costs in Italy, although TTD remains a good predictor. These results suggest that age and TTD can have a different role in shaping health care costs according to the component of health expenditure examined. Therefore, our advice to policy makers is to use disaggregated models to better disentangle these contributions and to produce more reliable health spending forecasts.

The impact of cost-sharing schemes on drug compliance in Italy: evidence based on quantile regression.

OBJECTIVES: In this article we investigate the causal effect of cost-sharing schemes on compliance with statins in a quantile regression framework. METHODS: We use the health search CSD-LPD data, a longitudinal observational dataset containing computer-based patient records collected by Italian general practitioners. We exploit a series of natural experiments referring to several introductions of co-payment schemes in some of the Italian regions between 2000 and 2009. We adopt an extended difference-in-differences approach to provide quantile estimates of the impact of co-payments on compliance. RESULTS: We find that (i) introduction of co-payments hurts residents of regions with worse quality and provision of health care; (ii) within these regions, co-payments were particularly harmful for high compliers; (iii) gender, clinical history and geographic residence are important determinants of compliance among poor compliers; (iv) compliance decreases with the potency and dosage of statins, particularly for poor compliers. CONCLUSIONS: In the presence of inefficient health-care provision, co-payments are harmful for drug compliance, and this is especially true for patients who are originally good compliers.

Energy efficiency as a unifying principle for human, environmental, and global health.

A strong analogy exists between over/under consumption of energy at the level of the human body and of the industrial metabolism of humanity. Both forms of energy consumption have profound implications for human, environmental, and global health. Globally, excessive fossil-fuel consumption, and individually, excessive food energy consumption are both responsible for a series of interrelated detrimental effects, including global warming, extreme weather conditions, damage to ecosystems, loss of biodiversity, widespread pollution, obesity, cancer, chronic respiratory disease, and other lethal chronic diseases. In contrast, data show that the efficient use of energy-in the form of food as well as fossil fuels and other resources-is vital for promoting human, environmental, and planetary health and sustainable economic development. While it is not new to highlight how efficient use of energy and food can address some of the key problems our world is facing, little research and no unifying framework exists to harmonize these concepts of sustainable system management across diverse scientific fields into a single theoretical body. Insights beyond reductionist views of efficiency are needed to encourage integrated changes in the use of the world's natural resources, with the aim of achieving a wiser use of energy, better farming systems, and healthier dietary habits. This perspective highlights a range of scientific-based opportunities for cost-effective pro-growth and pro-health policies while using less energy and natural resources.