Franco Sassi

Priority actions for the non-communicable disease crisis

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US

Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness.

9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

Obesity and the Economics of Prevention

The obesity epidemic is spreading to low-income and middle-income countries as a result of new dietary habits and sedentary ways of life, fuelling chronic diseases and premature mortality. In this report we present an assessment of public health strategies designed to tackle behavioural risk factors for chronic diseases that are closely linked with obesity, including aspects of diet and physical inactivity, in Brazil, China, India, Mexico, Russia, and South Africa. England was included for comparative purposes. Several population-based prevention policies can be expected to generate substantial health gains while entirely or largely paying for themselves through future reductions of health-care expenditures. These strategies include health information and communication strategies that improve population awareness about the benefits of healthy eating and physical activity; fiscal measures that increase the price of unhealthy food content or reduce the cost of healthy foods rich in fibre; and regulatory measures that improve nutritional information or restrict the marketing of unhealthy foods to children. A package of measures for the prevention of chronic diseases would deliver substantial health gains, with a very favourable cost-effectiveness profile.

Time spent on informal and formal care giving for persons with dementia in Sweden

The authors, including special contributions from health and obesity experts Marc Suhrcke, Tim Lobstein, Donald Kenkel and Francesco Branca, challenge the perception that explanations for the obesity epidemic are simple and solutions are within reach. A detailed look at the data reveals a more complicated picture, one in which even finding objective evidence on the phenomenon is a difficult task.

Social inequalities in obesity and overweight in 11 OECD countries

The purpose of this paper was to explore the time spent on caring by families of persons with dementia in Sweden. As part of a European Commission project, interviews were carried out on a sample of 92 carers, caring for persons with dementia. The interviews focused on time spent on caring, IADL, ADL and surveillance, as well as formal support received and used. Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night). Formal care input and informal support, in terms of ADL increased with dementia severity. A regression analysis showed that dementia severity, behavioural disturbances and coping were associated with the amount of informal care. This study gives some new perspectives on informal care giving for persons with dementia and support strategies in general. Some carers do carry a very heavy 24 h responsibility. This aspect of caring must be addressed by the development of well-targeted respite and relief support programmes.

Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial

BACKGROUND Evidence of inequalities in obesity and overweight is available mostly from national studies. This article provides a broad international comparison of inequalities by education level and socio-economic status, in men and women and over time. METHODS Data from national health surveys of 11 OECD countries were used. The size of inequalities was assessed on the basis of absolute and relative inequality indexes. A regression-analysis approach was used to assess differences between social groups in trends over time. RESULTS Of the countries examined, USA and England had the highest rates of obesity and overweight. Large social inequalities were consistently detected in all countries, especially in women. Absolute inequalities were largest in Hungary and Spain with a difference of 11.6 and 10% in obesity rates in men, and 18.3 and 18.9% in women, respectively, across the education spectrum. Relative inequalities were largest in France and Sweden with poorly educated men 3.2 and 2.8 times as likely to be obese as men with the highest education (18 and 17 times for women in Spain and Korea, respectively). Pro-poor inequalities in overweight were observed for men in USA, Canada, Korea, Hungary, Australia and England. Inequalities remained virtually stable during the last 15 years, with only small variations in England, Korea, Italy and France. CONCLUSION Large and persistent social inequalities in obesity and overweight by education level and socio-economic status exist in OECD countries. These are consistently larger in women than in men.

Socioeconomic disparities in the uptake of breast and cervical cancer screening in Italy: a cross sectional study

Abstract Objective: To undertake an economic evaluation of nurse telephone consultation using decision support software in comparison with usual general practice care provided by a general practice cooperative. Design: Cost analysis from an NHS perspective using stochastic data from a randomised controlled trial. Setting: General practice cooperative with 55 general practitioners serving 97 000 registered patients in Wiltshire, England. Subjects: All patients contacting the service, or about whom the service was contacted during the trial year (January 1997 to January 1998). Main outcome measures: Costs and savings to the NHS during the trial year. Results: The cost of providing nurse telephone consultation was £81 237 per annum. This, however, determined a £94 422 reduction of other costs for the NHS arising from reduced emergency admissions to hospital. Using point estimates for savings, the cost analysis, combined with the analysis of outcomes, showed a dominance situation for the intervention over general practice cooperative care alone. If a larger improvement in outcomes is assumed (upper 95% confidence limit) NHS savings increase to £123 824 per annum. Savings of only £3728 would, however, arise in a scenario where lower 95% confidence limits for outcome differences were observed. To break even, the intervention would have needed to save 138 emergency hospital admissions per year, around 90% of the effect achieved in the trial. Additional savings of £16 928 for general practice arose from reduced travel to visit patients at home and fewer surgery appointments within three days of a call. Conclusions: Nurse telephone consultation in out of hours primary care may reduce NHS costs in the long term by reducing demand for emergency admission to hospital. General practitioners currently bear most of the cost of nurse telephone consultation and benefit least from the savings associated with it. This indicates that the service produces benefits in terms of service quality, which are beyond the reach of this cost analysis.

Improving Lifestyles, Tackling Obesity: The Health and Economic Impact of Prevention Strategies

BackgroundBreast and cervical cancer screening are widely recognized as effective preventive procedures in reducing cancer mortality. The aim of this study was to evaluate the impact of socioeconomic disparities in the uptake of female screening in Italy, with a specific focus on different types of screening programs.MethodsA cross-sectional study was conducted using data from the 2004-2005 national health interview survey. A sample of 15, 486 women aged 50-69 years for mammography and one of 35, 349 women aged 25-64 years for Pap smear were analysed. Logistic regression models were used to estimate the association between socioeconomic factors and female screening utilization.ResultsEducation and occupation were positively associated with attendance to both screening. Women with higher levels of education were more likely to have a mammogram than those with a lower level (OR = 1.28; 95% CI = 1.10-1.49). Women of intermediate and high occupational classes were more likely to use breast cancer screening (OR = 1.77; 95% CI = 1.55-2.03, OR = 1.63; 95% CI = 1.40-1.91) compared to unemployed women. Women in the highest occupational class had a higher likelihood of cervical cancer screening compared to those in the lowest class (OR = 1.81; 95% CI = 1.63-2.01). Among women who attended screening, those with lower levels of education and lower occupational classes were more likely than more advantaged women to attend organized screening programs rather than being screened on the basis of their own initiative.ConclusionsInequalities in the uptake of female screening widely exist in Italy. Organized screening programs may have an important role in increasing screening attendance and tackling inequalities.

Searching literature databases for health care economic evaluations: how systematic can we afford to be?

Overweight and obesity rates have been increasing relentlessly over recent decades in all industrialised countries, as well as in many lower income countries. OECD analyses of trends over time support the grim picture drawn in the international literature and so do projections of overweight and obesity rates over the next ten years. The circumstances in which people have been leading their lives over the past 20-30 years, including physical, social and economic environments, have exerted powerful influences on their overall calorie intake, on the composition of their diets and on the frequency and intensity of physical activity at work, at home and during leisure time. Many countries have been concerned not only about the pace of the increase in overweight and obesity, but also about inequalities in their distribution across social groups, particularly by socio-economic status and by ethnic background. Les taux de surpoids et d’obesite ne cessent d’augmenter depuis plusieurs decennies dans tous les pays industrialises, ainsi que dans beaucoup de pays ayant un revenu plus faible. Les analyses consacrees par l’OCDE aux tendances structurelles confirment le sombre tableau qui a ete brosse dans les publications internationales, tout comme le font les previsions etablies sur les taux de surpoids et d’obesite pour les dix prochaines annees. Les conditions dans lesquelles vivent les individus depuis vingt ou trente ans, notamment sur le plan materiel, social et economique, ont tres fortement influe sur leur ration calorique globale, la composition de leur alimentation, ainsi que la frequence et l’intensite de leur activite physique au travail, a la maison et pendant les loisirs. Beaucoup de pays sont preoccupes non seulement par le rythme auquel progressent le surpoids et l’obesite, mais aussi par le caractere inegal de leur repartition entre les categories sociales, en particulier selon la situation socioeconomique et l’origine ethnique.

Socio-economic disparities in access to treatment and their impact on colorectal cancer survival

Background. As the health care economic-evaluation literature continues to grow, a need for sound methods to conduct systematic reviews of the existing evidence is emerging. So far, reviews of economic evaluations have relied upon noncomprehensive sources and have adopted simplistic search methods, both likely to lead to biased results. Objective. To provide evidence of the performance of alternative approaches for identifying published health care economic evaluations and to illustrate what forms of bias may affect systematic reviews of such studies. Methods. The sensitivity and specificity of alternative search strategies were tested for the period January to March 1997, using seven major medical and social science literature databases, one economic evaluation database and a published bibliography. Studies were selected blindly by pairs of reviewers (agreement 94.1%–96.5%), using a two-stage procedure. Results. By limiting the scope of a review to Medline and by using appropriate search strategies, researchers may significantly reduce the number of nonrelevant references retrieved by their electronic searches (sensitivity 72%, specificity 75%, compared with more extensive strategies), which require exclusion by manual screening. The yield of searches based on specialized bibliographies and databases may be different because of variations in selection criteria, coverage and time lag for inclusion of references. Conclusions. Medline is the key source for reviews of economic evaluations. Researchers may select from the search strategies proposed in this paper the one that offers an optimal balance between sensitivity and specificity in relation to the aims of their review. Manual searches and searches of databases other than Medline have a limited incremental yield. The sensitivity of all search strategies increases when tighter methodological standards are set, but more research is needed on methods for identifying methodologically sound studies.