Economic uncertainty and cardiovascular disease mortality

Previous studies have found a link between economic conditions, such as recessions and unemployment, and cardiovascular disease as well as other health outcomes. More recent research argues that economic uncertainty—independently of unemployment—can affect health outcomes. Using data from England and Wales, we study the association between fluctuations in economic uncertainty and cardiovascular disease mortality in the short term for the period 2001–2019. Controlling for several economic indicators (including unemployment), we find that economic uncertainty alone is strongly associated with deaths attributed to diseases of the circulatory system, ischemic heart disease and cerebrovascular disease. Our findings highlight the short-term link between economic conditions and cardiovascular health and reveal yet another health outcome that is associated with uncertainty

Economic crisis, austerity and unmet healthcare needs: the case of Greece

Background: The programme for fiscal consolidation in Greece has led to income decrease and several changes in health policy. In this context, this study aims to assess how economic crisis affected unmet healthcare needs in Greece. Methods: Time series analysis was performed for the years 2004 through 2011 using the EU-SILC database. The dependent variable was the percentage of people who had medical needs but did not use healthcare services. Median income, unemployment and time period were used as independent variables. We also compared self-reported unmet healthcare needs drawn from a national survey conducted in pre-crisis 2006 with a similar survey from 2011 (after the onset of the crisis). A common questionnaire was used in both years to assess unmet healthcare needs, including year of survey, gender, age, health status, chronic disease, educational level, income, employment, health insurance status, and prefecture. The outcome of interest was unmet healthcare needs due to financial reasons. Ordinary least squares, as well as logistic regression analysis were conducted to analyze the results. Results: Unmet healthcare needs increased after the enactment of austerity measures, while the year of participation in the survey was significantly associated with unmet healthcare needs. Income, educational level, employment status, and having insurance, private or public, were also significant determinants of unmet healthcare needs due to financial reasons. Conclusions: The adverse economic environment has significantly affected unmet health needs. Therefore health policy actions and social policy measures are essential in order to mitigate the negative impact on access to healthcare services and health status

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. Methods: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model—a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates—with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality—which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. Findings: The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2–100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1–290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1–211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4–48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3–37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7–9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. Interpretation: Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. Funding: Bill & Melinda Gates Foundation

Essays on inequalities in health and health care during economic recessions

During the past decade, Greece faced an unprecedented economic crisis and signed an economic adjustment programme (EAP) that brought about changes and reforms to the Greek health system. Comprised of three empirical studies, this thesis focuses on the impact of the Greek crisis on the health sector, with a particular interest in the responses to and implications of the crisis across socioeconomic groups. The first paper studies how household spending behaviour and responses towards health care have changed across socioeconomic groups in the face of an economic shock and the relevant health policy measures. Our analysis suggests that the income elasticity of household health expenditure (HHE) is below unity and exhibits a significant increase after the introduction of the EAP. Thus, households exhibit greater health care consumption responses to changes in their income. Contrary to high socioeconomic status (SES) groups, lower SES households did not become more sensitive to income changes in the post-EAP period, and have been more “protective” about their health care consumption. Focusing on the older population, the second study concentrates on the potential changes and implications in terms of financial protection against health payments during the Greek recession. We find that the headcount and overshoot of catastrophic health expenditure (CHE) increased during the crisis, with low-income and households with multimorbid patients being disproportionately affected. Prior to the crisis, CHE was mainly due to inpatient and nursing care. During the recession, however, the contribution of pharmaceutical spending to CHE substantially increased. Our analysis also reveals that there are widening inequalities in the risk of CHE across socioeconomic groups after the onset of the crisis. The third paper mainly focuses on population health status. It studies how economic climate and uncertainty influence fertility decisions and responses across population groups, and further investigates whether economic conditions during pregnancy impact newborn health. Our findings generally suggest that birth weight and pregnancy length are procyclical. We also report heterogeneity in the relationship between economic conditions during pregnancy and newborn health across socioeconomic groups, with the birth outcomes of high-SES newborns being responsive to economic volatility only in the first trimester of pregnancy. Further, economic adversity during the preconception period increases the probability that women who conceive are highly educated and married. After accounting for selection, we find that newborns exposed to the crisis while in utero tend to be lighter, with the effect being more detrimental for low-SES children

Subjective social status, social network and health disparities: empirical evidence from Greece

Background Several studies suggest that socioeconomic status affects (SES) affects self-rated health (SRH), both in Greece and internationally. However, prior research mainly uses objective measures of SES, instead of subjective evaluations of individuals’ social status. Based on this, this paper aims to examine (a) the impact of the economic dowturn on SRH in Greece and (b) the relationship between subjective social status (SSS), social network and SRH. Methods The descriptive analysis is based on four cross-sectional surveys conducted by the National School of Public Health, Athens, Greece (2002, 2006, 2011, 2015), while the data for the empirical investigation were derived from the 2015 survey (Health + Welfare Survey GR). The empirical strategy is based on an ordinal logistic regression model, aiming to examine how several variables affect SRH. Size of social network and SSS are among the independent variables employed for the empirical analysis Results According to our findings, average SRH has deteriorated, and the percentage of the population that reports very good/good SRH has also decreased. Moreover, our empirical analysis suggests that age, existence of a chronic disease, size of social network and SSS affect SRH in Greece. Conclusion Our findings are consistent with the existing literature and confirm a social gradient in health. According to our analysis, health disparities can be largely attributed to socioeconomic inequalities. The adverse economic climate has impact on socioeconomic differences which in turn affect health disparities. Based on these, policy initiatives are necessasy in order to mitigate the negative impact on health and the disparities caused by economic dowturn and the occuring socioeconomic inequalities

Primary Health Services Utilization in Greece: Studying the Past for Planning the Future

Σκοπός του συγκεκριμένου άρθρου είναι η μελέτη της χρήσης των πρωτοβάθμιων υπηρεσιών υγείας στην Ελλάδα. Για το σκοπό αυτό αναλύθηκαν, μέσω των μεθόδων Logistic και Linear Regression, δεδομένα από πανελλαδική έρευνα η οποία υλοποιήθηκε το έτος 2006. Η πιθανότητα χρήσης υπηρεσιών υγείας προσδιορίζεται από το φύλο, την ύπαρξη χρόνιας νόσου, το αυτό-αξιολογούμενο επίπεδο υγείας και την ηλικία, ενώ ο λογάριθμος του αριθμού των επισκέψεων προσδιορίζεται από το φύλο, την ύπαρξη χρόνιας νόσου, τη γεωγραφική περιφέρεια, το εισόδημα και την αντίληψη σχετικά με την απειλή από τα ιατρικά προβλήματα. Η χρήση πρωτοβάθμιων υπηρεσιών υγείας συσχετίζεται επομένως με τις αντιλήψεις των ατόμων αλλά και με παράγοντες οι οποίοι εκφράζουν τις ανάγκες υγείας ή το κοινωνικοοικονομικό επίπεδο.The objective of this paper is to study healthcare utilization in Greece. Thedata were derived from a national survey conducted in 2006, and analysed through Logistic and Linear Regression. The likelihood of primary healthcare utilization is determined by the gender, the existence of a chronic disease, the self-rated health and the age, while the logarithm of the visitsto primary health services is determined by the gender, the existence of a chronic disease, the income, the geographical region and the perceived threat from the health condition. Thus, primary healthcare utilization is determined by beliefs, health need as well as socioeconomic factors

Estimating a cost-effectiveness threshold for healthcare decision-making in the Greek NHS

Background: The introduction of new health technologies improves quality of life and longevity, but also imposes additional strains in the scarce resources of the health system. Consequently, decisions on the adoption of new technologies are typically based, among other criteria, on the difference between costs and outcomes among competing alternatives. This paper aims to estimate a cost-effectiveness threshold that can be used as an input in the decision-making process for the funding (or reimbursement) of health technologies in Greece. Methods: For a 30-year period, we calculate the Quality-Adjusted Life Expectancy (QALE) of the Greek population and regress it against per capita public health expenditure, using an instrumental variable approach and controlling for a set of covariates. The estimated coefficients of expenditure on QALE are used to inform a cost-effectiveness threshold, estimatead as the cost per QALY gained through a permanent increase in per capita spending. Results: Based on the estimated coefficient of health expenditure, we estimate a base case cost-effectiveness threshold of €27,117 per QALY gained for the Greek healthcare system, from a third-party payer perspective. Conclusions: In the Greek healthcare system, which is currently in the stage of establishing a comprehensive health technology assessment process, decision rules which are not based on heuristics or “rules of thumb”, are essential

Economic uncertainty and cardiovascular disease mortality

Previous studies have found a link between economic conditions, such as recessions and unemployment, and cardiovascular disease as well as other health outcomes. More recent research argues that economic uncertainty—independently of unemployment—can affect health outcomes. Using data from England and Wales, we study the association between fluctuations in economic uncertainty and cardiovascular disease mortality in the short term for the period 2001–2019. Controlling for several economic indicators (including unemployment), we find that economic uncertainty alone is strongly associated with deaths attributed to diseases of the circulatory system, ischemic heart disease and cerebrovascular disease. Our findings highlight the short-term link between economic conditions and cardiovascular health and reveal yet another health outcome that is associated with uncertainty

Are happy people healthier? An instrumental variable approach using data from Greece

Background: From a theoretical perspective, several studies indicate that happiness and health are—in some extent—interrelated. Despite the mechanisms explaining the relationship between happiness and health, there is still no consensus regarding this link. Using recently collected primary data, this study aims to examine the relationship between happiness and health, and identify potential heterogeneity in the association depending on socioeconomic status (SES). Methods: This study draws on data from a nationally representative cross-sectional survey, conducted by the Greek National School of Public Health in 2015. We applied an instrumental variable (IV) approach to address the endogeneity, arising from the simultaneous determination of happiness and health. Controlling for several confounders (ie, socioeconomic, demographic, lifestyle, social capital variables) we employed several IV models, including two-stage least squares, IV probit and bivariate probit models. Results: We report strong evidence of a relationship between happiness and health. This association remains strong after correcting for endogeneity, and is robust across different specifications. Further, we find a positive relationship between happiness and self-rated health (SRH) for low educated, but not for high educated. Similarly, we find a strong relationship between happiness and health for the lower socioeconomic strata, but not for the higher ones. Conclusions: Overall, we show that happiness is positively associated with health. Further, happiness significantly influences SRH in low-SES individuals, but this association wanes for the higher socioeconomic strata. This finding has significant implications for health promotion, prevention and public health, and suggests that policymakers have a wider array of choices for improving health and tackling health inequalities