Suchergebnisse

Background: The European Union (EU) Directive on Patients' Rights in Cross-border Healthcare clarified the entitlements to medical care in other EU Member states. However, little is known about whether EU citizens have been travelling or are willing to travel to receive care. This study aimed to measure the determinants of cross-border patient mobility and willingness to travel to receive medical care in the EU, before and after the adoption of the Directive. Methods: We used individual data from the Eurobarometer 210 (2007) and 425 (2014). In the 2 years, 53 439 EU citizens were randomly selected. We performed a logistic regression on the cross-border patient mobility and willingness to travel to other EU countries to use healthcare services as a function of the year (2007 or 2014), adjusting for age, gender, education and country size. Results: In 2007, 3.3% of citizens reported cross-border mobility and 4.6% in 2014. The odds of cross-border patients' mobility were 11% higher in 2014, compared with 2007 [odds ratio (OR) 1.11, 95% confidence interval (CI) 1.02-1.21]. Also, mobility was 19% higher in males (OR 1.19, 95% CI 1.08-1.30) and 20% higher amongst the more educated (OR 1.20, 95% CI 1.09-1.31). However, the odds decreased 11% per decade of age (OR 0.89 per decade, 95% CI 0.85-0.93) and country size. In 2014, the willingness to travel decreased by 20% compared with 2007. Conclusions: Cross-border patient mobility is more likely amongst the younger, the more educated and those from smaller countries. The directive does not seem to have promoted mobility at a large scale among the neediest citizens. ; publishersversion ; published

ABSTRACT - Over the recent years, decentralization has been adopted in many health systems. The question however remains of whether local actors do better than the central government. We summarize the main insights from economic theory on the impact of decentralization and its empirical validation. Theory suggests that the decision to decentralize results from a trade-off between its advantages (like its capacity to cater to local tastes) and costs (like inter-regional spillovers). Empirical contributions point that decentralization results in better health outcomes and higher expenditures, resulting in ambiguous consequences on efficiency; equity consequences are controversial and address the relevance of redistribution mechanisms. ; RESUMO - Apesar de muitos sistemas de saúde terem optado recentemente pela descentralização, fica por esclarecer se os governos locais têm um melhor desempenho do que os centrais. Este artigo sumariza os principais resultados da teoria económica sobre o impacto da descentralização e a sua validade empírica. A decisão de descentralizar resulta duma arbitragem entre as vantagens, como a adaptação às preferências, e os inconvenientes, como as externalidades inter-regionais. Os estudos empíricos sugerem que a descentralização permite ganhos em saúde mas também despesas maiores, com consequências ambíguas em termos de eficiência, e que as consequências para a equidade, sendo controversas, indicam a relevância dos mecanismos de redistribuição. ; info:eu-repo/semantics/publishedVersion

A B S T R A C T – Over the recent years, decentralization has been adopted in many health systems. Thequestion however remains of whether local actors do better than the central government.We summarize the main insights from economic theory on the impact of decentraliza-tion and its empirical validation. Theory suggests that the decision to decentralize resultsfrom a trade-off between its advantages (like its capacity to cater to local tastes) and costs(like inter-regional spillovers). Empirical contributions point that decentralization results inbetter health outcomes and higher expenditures, resulting in ambiguous consequences onefficiency; equity consequences are controversial and address the relevance of redistributionmechanisms. ; R E S U M O - Apesar de muitos sistemas de saúde terem optado recentemente pela descentralização, fica por esclarecer se os governos locais têm um melhor desempenho do que os centrais. Este artigo sumariza os principais resultados da teoria económica sobre o impacto da descentralização e a sua validade empírica. A decisão de descentralizar resulta duma arbitragem entre as vantagens, como a adaptação às preferências, e os inconvenientes, como as externalidades inter-regionais. Os estudos empíricos sugerem que a descentralização permite ganhos em saúde mas também despesas maiores, com consequências ambíguas em termos de eficiência, e que as consequências para a equidade, sendo controversas, indicam a relevância dos mecanismos de redistribuição. ; info:eu-repo/semantics/publishedVersion

Objectives: Recent literature points out that elderly people are psychologically resilient to COVID-19, but the studies were performed in specific contexts. We measured the link between the worsening of mental health symptoms, the epidemiologic situation, and control measures among European people aged 50 or older. Methods: We used data from the 2020 wave of SHARE, merged with Oxford COVID-19 Government Response Tracker data (n = 38,358). We modeled the risk of worsening of depression, anxiety, sleeping trouble, and loneliness symptoms' self-perception, as functions of control measures and 7-days death incidence, using logistic regressions. Results: The worsening of anxiety and depression perception were more common (16.2 and 23.1%, respectively), compared to that of sleeping troubles and loneliness (8.1 and 11.5%, respectively). The worsening of depression and anxiety perception was negatively related to the rigor of control measures. The seven-days death incidence was positively linked to all symptoms except sleeping troubles. Conclusion: Older people were the most exposed to death risk and were affected psychologically by the COVID-19 epidemiological situation; yet control measures were protective (or neutral) to their mental health condition.

Background Despite an overall reduction in suicide, educational disparities in suicide have not decreased over the last decade. The mechanisms behind educational disparities in suicide, however, remain unclear: low educational status may increase the risk of suicide ("causation") or low educational status and suicide may share confounders. This paper assesses whether educational disparities in suicide (EDS) are more likely to be due to causation. Method The DEMETRIQ study collected and harmonized register-based data on mortality follow-up from forty population censuses from twelve European populations. More than 102,000 suicides were registered over 392 million person-years. Three analyses were carried out. First, we applied an instrumental variable approach that exploits changes in the legislation on compulsory educational age to instrument educational status. Second, we analyzed EDS by age under the hypothesis that increasing EDS over the life cycle supports causation. Finally, we compared EDS in men and women under the assumption that greater EDS in women would support causation. Findings The instrumental variable analysis showed no evidence for causation between higher education and suicide, for men or women. The life-cycle analysis showed that the decrease of educational inequalities in suicide between the baseline 1991 period and the 2001 follow-up period was more pronounced and statistically significant in the first three younger age groups. The gender analysis indicated that EDS were systematic and greater in men than in women: the rate ratio of suicide for men with low level of education (RR = 2.51; 95%CI:2.44–2.58) was higher than the rate ratio in women (RR = 1.32; 95CI%:1.26–1.38). Interpretation Overall, there was little support for the causation hypothesis, suggesting that the association between education and suicide is confounded. Educational inequalities in suicide should be addressed in early life by early targeting of groups who struggle to complete their education and display higher risk of mental disorder or of mental health vulnerabilities.

Background Despite an overall reduction in suicide, educational disparities in suicide have not decreased over the last decade. The mechanisms behind educational disparities in suicide, however, remain unclear: low educational status may increase the risk of suicide ("causation") or low educational status and suicide may share confounders. This paper assesses whether educational disparities in suicide (EDS) are more likely to be due to causation. Method The DEMETRIQ study collected and harmonized register-based data on mortality follow-up from forty population censuses from twelve European populations. More than 102,000 suicides were registered over 392 million person-years. Three analyses were carried out. First, we applied an instrumental variable approach that exploits changes in the legislation on compulsory educational age to instrument educational status. Second, we analyzed EDS by age under the hypothesis that increasing EDS over the life cycle supports causation. Finally, we compared EDS in men and women under the assumption that greater EDS in women would support causation. Findings The instrumental variable analysis showed no evidence for causation between higher education and suicide, for men or women. The life-cycle analysis showed that the decrease of educational inequalities in suicide between the baseline 1991 period and the 2001 follow-up period was more pronounced and statistically significant in the first three younger age groups. The gender analysis indicated that EDS were systematic and greater in men than in women: the rate ratio of suicide for men with low level of education (RR = 2.51; 95%CI:2.44–2.58) was higher than the rate ratio in women (RR = 1.32; 95CI%:1.26–1.38). Interpretation Overall, there was little support for the causation hypothesis, suggesting that the association between education and suicide is confounded. Educational inequalities in suicide should be addressed in early life by early targeting of groups who struggle to complete their education and display higher risk of mental disorder or of mental health vulnerabilities.

Background: The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods: We extracted GDP, government spending in 184 countries from 1980-2015, and health spend data from 1995-2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings: We estimated that global spending on health will increase from US$9·21 trillion in 2014 to $24·24 trillion (uncertainty interval [UI] 20·47-29·72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5·3% (UI 4·1-6·8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4·2% (3·8-4·9). High-income countries are expected to grow at 2·1% (UI 1·8-2·4) and low-income countries are expected to grow at 1·8% (1·0-2·8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133-181) per capita in 2030 and $195 (157-258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157-258) per capita was available for health in 2040 in low-income countries. Interpretation: Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential. Funding: Bill & Melinda Gates Foundation. ; publishersversion ; published

Background: An adequate amount of prepaid resources for health is important to ensure access to health services and for the pursuit of universal health coverage. Previous studies on global health financing have described the relationship between economic development and health financing. In this study, we further explore global health financing trends and examine how the sources of funds used, types of services purchased, and development assistance for health disbursed change with economic development. We also identify countries that deviate from the trends. Methods: We estimated national health spending by type of care and by source, including development assistance for health, based on a diverse set of data including programme reports, budget data, national estimates, and 964 National Health Accounts. These data represent health spending for 184 countries from 1995 through 2014. We converted these data into a common inflation-adjusted and purchasing power-adjusted currency, and used non-linear regression methods to model the relationship between health financing, time, and economic development. Findings: Between 1995 and 2014, economic development was positively associated with total health spending and a shift away from a reliance on development assistance and out-of-pocket (OOP) towards government spending. The largest absolute increase in spending was in high-income countries, which increased to purchasing power-adjusted $5221 per capita based on an annual growth rate of 3·0%. The largest health spending growth rates were in upper-middle-income (5·9) and lower-middle-income groups (5·0), which both increased spending at more than 5% per year, and spent $914 and $267 per capita in 2014, respectively. Spending in low-income countries grew nearly as fast, at 4·6%, and health spending increased from $51 to $120 per capita. In 2014, 59·2% of all health spending was financed by the government, although in low-income and lower-middle-income countries, 29·1% and 58·0% of spending was OOP spending and 35·7% and 3·0% of spending was development assistance. Recent growth in development assistance for health has been tepid; between 2010 and 2016, it grew annually at 1·8%, and reached US$37·6 billion in 2016. Nonetheless, there is a great deal of variation revolving around these averages. 29 countries spend at least 50% more than expected per capita, based on their level of economic development alone, whereas 11 countries spend less than 50% their expected amount. Interpretation: Health spending remains disparate, with low-income and lower-middle-income countries increasing spending in absolute terms the least, and relying heavily on OOP spending and development assistance. Moreover, tremendous variation shows that neither time nor economic development guarantee adequate prepaid health resources, which are vital for the pursuit of universal health coverage. Funding: The Bill & Melinda Gates Foundation. ; publishersversion ; published

Between 2005 and 2007, important reinforcements of the tobacco legislation have been implemented in Portugal, which may have affected smoking patterns. The aim of this study was to measure the change in prevalence of first- and second-hand smoking (SHS) among adults, and its socio-demographic patterning in Portugal from 2005 to 2014. Data from the last two Portuguese National Health Interview Surveys (2005 and 2014) were used. The changes in daily smoking and SHS were measured using Poisson regressions, stratifying by sex and survey year. The inequalities were measured using relative inequality indexes (RII). From 2005 to 2014, there was a reduction in SHS (75%-54% among men, and 52%-38% among women), and a reduction in smoking among men (27%-26%), and an increase among women (9%-12%). SHS reduction was more marked among less privileged people. Among Portuguese men, inequalities in daily smoking have increased slightly, while among women the gap favoring low-educated reduced. Between 2005 and 2014, SHS decreased, but not daily smoking, particularly among women. Additionally, socioeconomic inequalities in smoking increased. Future policies should simultaneously tackle smoking and SHS prevalence, and their socioeconomic patterning. More comprehensive policies such as comprehensive national (non-partial) bans, combined with price increases could be more effective. ; This study is part of the project SILNE-R "Enhancing the e ectiveness of programs and strategies to prevent smoking by adolescents: a realist evaluation comparing seven European countries", which was funded by the European Union's Horizon 2020 research and innovation program under the SILNE-R Grant Agreement number 635056. ; info:eu-repo/semantics/publishedVersion

Between 2005 and 2007, important reinforcements of the tobacco legislation have been implemented in Portugal, which may have affected smoking patterns. The aim of this study was to measure the change in prevalence of first-and second-hand smoking (SHS) among adults, and its socio-demographic patterning in Portugal from 2005 to 2014. Data from the last two Portuguese National Health Interview Surveys (2005 and 2014) were used. The changes in daily smoking and SHS were measured using Poisson regressions, stratifying by sex and survey year. The inequalities were measured using relative inequality indexes (RII). From 2005 to 2014, there was a reduction in SHS (75%–54% among men, and 52%–38% among women), and a reduction in smoking among men (27%–26%), and an increase among women (9%–12%). SHS reduction was more marked among less privileged people. Among Portuguese men, inequalities in daily smoking have increased slightly, while among women the gap favoring low-educated reduced. Between 2005 and 2014, SHS decreased, but not daily smoking, particularly among women. Additionally, socioeconomic inequalities in smoking increased. Future policies should simultaneously tackle smoking and SHS prevalence, and their socioeconomic patterning. More comprehensive policies such as comprehensive national (non-partial) bans, combined with price increases could be more effective. ; publishersversion ; published

Background: Although socioeconomic inequalities in health have long been observed in Europe, few studies have analysed their recent patterning. In this paper, we examined how educational inequalities in self-reported health have evolved in different European countries and welfare state regimes over the last decade, which was troubled by the Great Recession. Methods: We used cross-sectional data from the EU-SILC survey for adults from 26 European countries, from 2005 to 2014 (n = 3,030,595). We first calculated education-related absolute (SII) and relative (RII) inequalities in poor self-reported health by country-year, adjusting for age, sex, and EU-SILC survey weights. We then regressed the year- and country-specific RII and SII on a yearly time trend, globally and by welfare regime, adjusting for country fixed effects. We further adjusted the analysis for the economic cycle using GDP growth, unemployment, and income inequality. Results: Overall, absolute inequalities persisted and relative inequalities slightly widened (betaRII = 0.0313, p<0.05). There were substantial differences by welfare regime: Anglo-Saxon countries experienced the largest increase in absolute inequalities (betaSII = 0.0032, p<0.05), followed by Bismarkian countries (betaSII = 0.0024, p<0.001), while they reduced in Post-Communist countries (betaSII = -0.0022, p<0.001). Post-Communist countries also experienced a widening in relative inequalities (betaRII = 0.1112, p<0.001), which were found to be stable elsewhere. Adjustment for income inequality only explained such trend in Anglo-Saxon countries. Conclusions: Educational inequalities in health have overall persisted across European countries over the last decade. However, there is considerable variation across welfare regimes, possibly related to underpinning social safety nets and to austerity measures implemented during this 10-year period.

Background Evidence is accumulating on the impact of the recent economic crisis on health and health systems across Europe. However, little is known about the effect this is having on physicians - a crucial resource for the delivery of healthcare services. This paper explores the adaptation to the crisis of public sector physicians and their ability to keep performing their functions, with the objective of gaining a better understanding of health workers' resilience under deteriorating conditions. Methods We conducted a survey among 484 public primary care and hospital physicians in Portugal's capital city area and explored their perceptions of the crisis, adaptation and coping strategies. We used ordinal and logistic regression models to link changes in hours worked and intentions to migrate with physicians' characteristics and specific answers. Results We found little evidence of physicians changing their overall allocation of working time before and after the crisis, with their age, types of specialisation, valuation of job flexibility and independence significantly associated with changes in public sector hours between 2010 and 2015. Being divorced, not Portuguese, of younger age, and working a high number of hours per week, were found to increase the probability of physicians considering migration, the same as having a poor opinion of recent government health policies. On the other hand, enjoying their current working environment, not wanting to disrupt provision of service, and leisure time were found to protect against scaling down public sector hours or considering migration. Conclusions Our work on Portuguese physicians contributes to the debate on health workers' resilience, showing the value of understanding the influence of personal characteristics and opinions on their adaptation to changing circumstances, before designing policies to improve their working conditions and retention. ; publishersversion ; published

Objectives To analyse the temporal and geographical diffusion of antivascular endothelial growth factor (anti-VEGF) interventions, and its determinants in a National Health System (NHS). Setting NHS Portuguese hospitals. Participants All inpatient and day cases related to eye diseases at all Portuguese public hospitals for the period 2002–2012 were selected on the basis of four International Classification of Diseases 9th revision, Clinical Modification (ICD-9-CM) codes for procedures: 1474, 1475, 1479 and 149. Primary and secondary outcome measures We measured anti-VEGF treatment rates by year and county. The determinants of the geographical diffusion were investigated using generalised linear modelling. Results We analysed all hospital discharges from all NHS hospitals in Portugal (98 408 hospital discharges corresponding to 57 984 patients). National rates of hospitals episodes for the codes for procedures used were low before anti-VEGF approval in 2007 (less than 12% of hospital discharges). Between 2007 and 2012, the rates of hospital episodes related to the introduction of anti-VEGF injections increased by 27% per year. Patients from areas without ophthalmology departments received fewer treatments than those from areas with ophthalmology departments. The availability of an ophthalmology department in the county increased the rates of hospital episodes by 243%, and a 100-persons greater density per km2 raised the rates by 11%. Conclusions Our study shows a large but unequal diffusion of anti-VEGF treatments despite the universal coverage and very low copayments. The technological innovation in ophthalmology may thus produce unexpected inequalities related to financial constraints unless the implementation of innovative techniques is planned and regulated

BACKGROUND: Many risk behaviours in adolescence are socially patterned. However, it is unclear to what extent socioeconomic position (SEP) influences adolescent drinking in various parts of Europe. We examined how alcohol consumption is associated with parental SEP and adolescents' own SEP among students aged 14-17 years. METHODS: Cross-sectional data were collected in the 2013 SILNE study. Participants were 8705 students aged 14-17 years from 6 European cities. The dependent variable was weekly binge drinking. Main independent variables were parental SEP (parental education level and family affluence) and adolescents' own SEP (student weekly income and academic achievement). Multilevel Poisson regression models with robust variance and random intercept were fitted to estimate the association between adolescent drinking and SEP. RESULTS: Prevalence of weekly binge drinking was 4.2% (95%CI = 3.8-4.6). Weekly binge drinking was not associated with parental education or family affluence. However, weekly binge drinking was less prevalent in adolescents with high academic achievement than those with low achievement (PR = 0.34; 95%CI = 0.14-0.87), and more prevalent in adolescents with >€50 weekly income compared to those with ≤€5/week (PR = 3.14; 95%CI = 2.23-4.42). These associations were found to vary according to country, but not according to gender or age group. CONCLUSIONS: Across the six European cities, adolescent drinking was associated with adolescents' own SEP, but not with parental SEP. Socio-economic inequalities in adolescent drinking seem to stem from adolescents' own situation rather than that of their family. ; This study is part of the SILNE-R project, which is supported by the European Union's Horizon 2020 research and innovation programme, under grant agreement 635056; and of the project 'Tackling socio-economic inequalities in smoking (SILNE)', which is funded by the European Commission, Directorate-General for Research and Innovation, under the FP7-Health-2011 programme, with grant agreement number 278273. This work was also supported by the Spanish Network on Addictive Disorders [grant number RD12/0028/0018]

Background The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods We extracted GDP, government spending in 184 countries from 1980-2015, and health spend data from 1995-2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings We estimated that global spending on health will increase from US$9.21 trillion in 2014 to $24.24 trillion (uncertainty interval [UI] 20.47-29.72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5.3% (UI 4.1-6.8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4.2% (3.8-4.9). High-income countries are expected to grow at 2.1% (UI 1.8-2.4) and low-income countries are expected to grow at 1.8% (1.0-2.8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133-181) per capita in 2030 and $195 (157-258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157-258) per capita was available for health in 2040 in low-income countries. Interpretation Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential. ; Peer reviewed