European Heart Journal (2006) 27, 16101619 doi:10.

1093/eurheartj/ehi733

Clinical research
Disease management

Economic burden of cardiovascular diseases in the enlarged European Union

Jose Leal1*, Ramon Luengo-Fernandez1, Alastair Gray1, Sophie Petersen2, and Mike Rayner2
1 Department of Public Health, Health Economics Research Centre, Oxford University, Old Road Campus, Oxford OX3 7LF, UK; and 2 Department of Public Health, British Heart Foundation Health Promotion Research Group, Oxford University, Old Road Campus, Oxford OX3 7LF, UK

Received 6 May 2005; revised 20 December 2005; accepted 22 December 2005; online publish-ahead-of-print 22 February 2006

See page 1521 for the editorial comment on this article (doi:10.1093/eurheartj/ehl075)

KEYWORDS
Cardiovascular disease; Coronary heart disease; Cerebrovascular diseases; Cost-of-illness study; Europe

Aims Cardiovascular disease (CVD), together with its main components, coronary heart disease (CHD), and cerebrovascular diseases, is the main source of morbidity and mortality in the European Union (EU), but to date, there has not been any systematic cost-of-illness study to assess the economic impact of CVD in the EU. Methods and results CVD-related expenditure was estimated using aggregate data on morbidity, mortality, and healthcare resource use. Healthcare costs were estimated from expenditure on primary, outpatient, emergency, and inpatient care, as well as medications. Costs of unpaid care and lost earnings due to morbidity and premature death were included in the study. CVD was estimated to cost the EU E169 billion annually, with healthcare accounting for 62% of costs. Productivity losses and informal care represented 21% and 17% of costs, respectively. CHD represented 27% and cerebrovascular diseases 20% of overall CVD costs. Conclusion CVD is a leading public health problem. Our study is the rst to assess the economic burden of CVD across the EU, and our results should help policy makers evaluate policy impact and prioritize research expenditures. However, because of data unavailability, our study has important limitations, which highlight the need for more accurate and comparable CVD-specic information.

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Introduction
The Council of Ministers of the European Union (EU) has emphasized that cardiovascular disease (CVD) is the largest cause of sickness and morbidity and a major cause of death and premature death and of reduced quality of life for the citizens of the EU.1 CVD [dened as International Classication of Diseases (ICD)-10 category I00I99] causes over 1.5 million deaths in the EU and is the main cause of years of life lost from early death.2 The most common CVDs are coronary heart disease (CHD; ICD-10 category I20I25) and cerebrovascular disease (ICD-10 category I60I69), accounting for 40 and 25% of CVD deaths, respectively.2 However, despite CVD being the main cause of morbidity and mortality in the EU, there has been no systematic cost-of-illness study to assess its economic impact. Cost-ofillness studies not only estimate the resources consumed in disease prevention, detection, and treatment but also estimate the opportunity costs of relatives providing care for patients and the foregone economic productivity associated with inability to work due to disability or premature death.

The objectives of this study were to provide an estimate of the economic costs of CVD for the EU, including healthcare costs, informal care costs, and productivity loss, and to estimate the proportion of total CVD cost attributable to CHD and cerebrovascular diseases.

Methods
Methodological background
Cost-of-illness analyses involve the identication, measurement, and valuing of resources related to an illness. A societal perspective was adopted with all costs being considered, not only healthcare costs but also those falling outside the healthcare sector, including opportunity costs associated with unpaid care and productivity losses associated with premature death or morbidity. An annual time frame was adopted for our analysis, whereby all costs within the most recent year for which data were available were measured. Costs were converted to 2003 prices using the health component of the consumer price index for each country,3 with earnings being adjusted using wage ination indices.47 National currencies were converted to Euros (E) using 2003 exchange rates. However, as comparisons using currency exchange rates do not necessarily reect real price differences between countries, we also employed the purchasing power parity (PPP) method.9 The PPP method measures the price of the same bundle of goods in different countries using

* Corresponding author. Tel: 44 1865 226690; fax: 44 1865 226842.

E-mail address: jose.leal@dphpc.ox.ac.uk

& The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Economic burden of CVDs in the enlarged EU Euros as a common currency, thus allowing the comparison of costs, adjusted for cost of living, between countries.3 International sources,811 national ministries, and statistical institutes were consulted for epidemiological and healthcare utilization data. When data were not obtained from these sources, the published literature was consulted. If no data were found, extrapolations were performed from similar countries. A country was judged to be similar if it shared comparable gross national income, healthcare expenditure per capita, physician density, life expectancy, and location. We employed a top-down approach to calculate total expenditure using aggregate data on morbidity, mortality, hospital admissions, and other related indicators. A summary of the methods used is given here; for a more detailed overview of methods used, see Supplementary material.

1611 The estimated and actual resource use were evaluated together with the resulting variation on total healthcare cost estimates.

Hospital inpatient care

Inpatient care was estimated from the number of CVD-related days in hospital, including day case admissions and rehabilitation sessions. Disease-specic average length of stay and hospital discharges were obtained,8,9 and multiplied together to obtain the total number of CVD-related inpatient days.

Healthcare unit costs

Unit costs of an inpatient day were obtained from national sources or, when unavailable, by dividing the total expenditure on inpatient care by the total number of hospital inpatient days for all causes. No such information was available for Malta and Cyprus, and unit costs were then derived using the coefcient from a regression of hospital cost onto health expenditure per capita for all countries. Unit costs for primary, outpatient, and emergency care were obtained in a similar fashion. However, to cost these activities, we made extensive use of an economic evaluation undertaken in 12 countries.25 If no information was available, regression techniques were used to estimate unit costs using data from other countries. Unit costs are reported in Table 1.

Healthcare expenditure
The following categories of CVD healthcare service were included: primary care, accident and emergency (A&E) care, hospital inpatient care, outpatient care, and medications. Other types of activities relating to the prevention of CVD such as health education in community-based settings were not included because of the difculties in identifying activity levels. For Germany, France, and the Netherlands, CVD-related healthcare expenditure was derived from cost-of-illness studies.1214 In the Netherlands, pharmaceutical expenditure was updated using the latest data.15 To account for private spending on healthcare, in countries reporting public resource use only, estimates were inated using the proportion of private spending on healthcare.9

Expenditure on medication
In the UK, Spain, Belgium, Finland, and Italy, CVD-related pharmaceutical expenditure was obtained from national sources.2630 For the remaining OECD countries, this gure was obtained from OECD databases.9 For those countries where CVD-related pharmaceutical expenditure could not be obtained, we assumed that the proportion of total pharmaceutical expenditure attributable to CVD was similar to the average in those countries where expenditure had been established (variation around this average was found to be low in countries with available data). Only Germany,12 France,13 and the Netherlands14 provided information on the proportion of CVD pharmaceutical expenditure attributable to CHD and cerebrovascular diseases. As the proportion of pharmaceutical expenditure due to CVD in these three countries was relatively similar to the proportion across remaining EU countries, the averaged proportions from Germany, France, and the Netherlands (i.e. 22% for CHD and 9% for stroke) were applied to the remaining countries.

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Health service utilization

The methods used to estimate CVD-related healthcare utilization are described subsequently; these methods were also used to determine CHD- and cerebrovascular disease-related utilization.

Primary care
Primary care activities consisted of CVD-related visits to general practitioners (GPs), together with GP visits to patients homes, and, where available, visits to or by a primary care nurse. National sources1619 were used to derive CVD-related consultations in the UK, Finland, Malta, and Belgium. For the remaining countries, the total number of consultations was obtained, and those related to CVD were derived by applying the proportion of hospital discharges due to CVD, assuming that a proportion of patients leaving inpatient care due to CVD would be followed up in GP consultations.

Non-health service costs

Non-health service costs comprise informal care costs, productivity costs attributable to mortality and morbidity, patient travel costs, and out-of-pocket expenses (e.g. child care, home aids, and overthe-counter medication). However, as little information was found on patient travel and out-of-pocket expenses across countries, only informal care and productivity costs were estimated.

Hospital outpatient care

Outpatient care comprised specialist consultations taking place in outpatient wards, clinics, or patients homes. National data2022 were used to obtain the number of CVD-related outpatient visits in the UK, Portugal, and Lithuania. For the remaining countries, the total number of consultations was obtained, and the proportion related to CVD was estimated by applying the proportion of hospital discharges, as before, assuming that CVD-patients being discharged from hospital were followed in an outpatient setting.

Estimation of informal care costs

Informal care costs were equivalent to the opportunity cost of unpaid care, i.e. the time (work and/or leisure) that carers forgo, valued in monetary terms, to provide unpaid care for relatives suffering from CVD. It was hypothesized that only people with CVD who were severely hampered in daily activities would receive informal care. Hours of informal care were estimated by calculating the number of people with CVD who were hampered in daily activities because of health problems.3 Using data from a European study,31 we determined the probability of receiving care for those people with limiting conditions, which was then applied to the number of people with limiting CVD. Finally, the proportion of care given by carers of working age was determined,31 the number of hours spent by each informal carer was obtained from a UK survey,32 and these were multiplied by the number of informal carers in each age group.

Accident and emergency

A&E care consisted of all CVD-related hospital emergency visits. For Denmark and the UK, national sources23,24 provided the total number of CVD-related A&E attendances. For the remaining countries, all-cause attendances were obtained, and the proportion of CVD-related hospital discharges was applied. This was assumed to be a good approximation of people with CVD attending A&E. For the earlier categories, the assumptions used to estimate resource use in countries with no CVD-related data were also applied to countries where these data were available.

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Table 1 Average unit costs in the EU, by country, 2003 Country Mortality losses Yearly earnings (E) Males Females Morbidity losses Daily earnings (E) Informal care Hourly earnings (E) Active carers 134 151 81 31 188 22 131 125 138 76 18 118 94 16 15 171 44 153 35 62 17 59 90 138 135 17 19 10 4 24 3 16 16 17 9 2 15 12 2 2 21 6 19 4 8 2 7 11 17 17 Inactive carers 9 7 5 1 9 1 11 7 8 3 1 6 9 1 1 8 3 7 1 3 1 3 3 10 7 21 21 12 3 20 7 11 18 43 8 4 32 22 4 5 30 11 25 12 11 7 14 12 80 35 37 28 17 7 92 22 30 36 45 8 5 101 23 7 8 25 20 82 21 21 12 24 59 211 139 59 534 50 75 130 22 50 122 126 69 17 103 25 18 17 131 44 117 16 36 21 47 76 250 107 319 501 256 110 773 73 267 524 625 389 41 349 541 51 42 761 217 400 91 296 66 240 321 610 830 Healthcare unit costs (E) GP visit Outpatient visit A&E visit Inpatient day

Austria Belgium Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta The Netherlands Poland Portugal Slovakia Slovenia Spain Sweden UK

33 518 36 700 21 742 8 015 48 346 5 877 33 198 30 325 42 373 18 411 5 289 30 346 22 109 3 973 4 404 41 326 10 765 38 162 8 565 15 969 5 036 14 284 22 803 32 920 39 760

26 814 32 296 14 595 5 974 38 814 4 408 26 890 24 969 32 836 14 753 4 231 19 671 21 004 3 178 3 587 33 700 9 146 28 827 7 174 11 296 3 777 12 737 15 960 28 614 28 779

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In order to value the amount of unpaid care time, the hourly wage rate33 was applied to informal care provided by those carers of working age and employed. For those carers in retirement or not working, the hourly minimum wage34 was applied. For those countries with no minimum wage, the wage of the worst paid sector was used.

Estimation of productivity costs

Productivity costs included the foregone earnings related to CVDattributable mortality and morbidity. The productivity loss from CVD-mortality was estimated by calculating the sum of the age- and sex-specic products of the following: (i) number of CVD-related deaths;10 (ii) number of remaining work years at the time of death (in order to estimate the likely earnings that an individual who died would otherwise have received from paid employment); (iii) annual earnings;33 (iv) economic activity and unemployment rates.11 As these costs will be incurred in future years, future earnings were discounted to present values using a 3.5% annual rate.35 Morbidity costs were those costs associated with CVD-attributable absence from work, estimated by multiplying the number of certied days off work due to CVD by the daily earnings.33 The number of CVD-related working days lost was obtained for Austria36 and the UK.37 For the remaining countries, the total number of working days lost due to all diseases was obtained and the proportion related to CVD was estimated by applying the proportion of CVD-hospital bed days in the working age population. We hypothesized that there was a positive correlation between the number of days in hospital and the working-days lost.

However, absent workers are likely to be replaced, and so the morbidity loss as computed earlier will be an overestimate of the actual loss. Hence, we estimated the friction period, i.e. the period of employees absence from work due to illness before the employee is replaced, to be 90 days.38 The friction period adjusted morbidity loss was then estimated by multiplying the unadjusted productivity loss by the friction period and then dividing this product by the average duration of each spell of work incapacity, estimated in this study to be 232 days.39

Sensitivity analysis
The effects of 20% changes in healthcare costs, informal care costs, and earnings for males and females were examined. In addition, as GP, outpatient, and A&E visits were estimated using subjective assumptions, the effect of 50% changes in these categories was tested. We also assessed the effects of discounting on productivity costs by using rates of 0 and 10%. Furthermore, we compared the actual total CVD-related healthcare expenditure in France, Germany, the Netherlands, and the UKthe countries with extensive CVD-specic healthcare informationwith the estimated total for these countries had it been necessary to estimate every resource category in these countries.

Results
Costs of CVDs
Healthcare costs CVD accounted for over 126 million hospital bed days in the EU, representing 277 hospital bed days per 1000 population (Table 2). The number of inpatient days varied

Economic burden of CVDs in the enlarged EU

Table 2 Resource units per 1000 population in the EU, by country, 2003 Country Mortality losses Deaths M F Working years losta M F Morbidity losses Work days lost Informal care Hours of informal care Active carers 200 266 227 1113 388 467 557 180 676 222 766 424 228 406 601 469 93 330 1020 310 1292 326 454 1217 1135 591 2768 2069 1275 3131 2175 3607 5239 2442 3823 1958 3879 1325 2484 3023 4110 2518 636 2600 2383 3573 2316 2370 1887 3940 5405 3156 Inactive carers 2943 2538 1159 4283 1685 5817 5134 2769 4902 2637 5307 1421 2297 3368 4865 2902 857 2660 3562 3475 3042 2642 2287 3194 3395 3336 8 7 4 12 6 14 16 7 12 6 14 5 7 10 13 8 2 10 10 10 9 8 6 11 14 10 315 631 154 412 191 240 422 1098 1570 135 476 210 415 188 570 250 135 345 332 266 561 162 330 218 442 687 295 308 284 1237 133 393 94 256 544 255 1049 80 242 402 95 359 55 122 350 43 1036 177 191 268 32 315 28 7 79 84 19 55 31 26 101 75 35 36 71 15 34 30 15 31 23 123 28 55 61 36 11 51 489 212 98 342 189 349 539 210 340 152 469 208 201 325 573 200 39 446 327 122 268 170 122 320 323 277 Hampered individuals Healthcare units GP visit Outpatient visit A&E visit Inpatient day

Austria Belgium Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta The Netherlands Poland Portugal Slovakia Slovenia Spain Sweden UK Total EU
a

2.0 1.7 2.3 2.6 1.9 3.2 1.9 1.3 2.0 2.2 3.1 1.7 1.9 3.3 2.6 1.5 1.7 1.5 2.2 1.8 2.5 1.7 1.5 2.4 1.9 1.9

3.0 2.1 2.6 3.1 2.0 4.2 2.2 1.5 2.9 2.5 3.7 1.6 2.4 4.4 3.4 1.8 2.1 1.6 2.4 2.1 2.8 2.1 1.8 2.6 2.1 2.3

3.6 3.1 3.9 4.1 3.6 8.9 4.8 2.4 3.7 4.0 6.9 3.4 2.8 11.6 6.1 2.6 2.0 3.0 7.1 3.0 5.0 2.4 2.9 2.7 3.3 3.7

0.9 1.2 1.4 1.1 1.5 1.7 1.4 0.8 1.4 0.8 2.6 1.3 0.7 2.3 1.1 1.2 0.5 1.5 1.4 1.3 0.7 0.5 0.9 1.0 0.8 1.1

Working years lost are those years lost in the working age population before taking into account economic activity rates and unemployment.

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Table 3 Costs of CVD (E million) in the EU, by country, 2003 Country Primary care Outpatient care A&E Inpatient care Medications Total healthcare costs Production losses due to mortality 500 563 39 218 537 42 462 2 418 7 347 454 186 248 1 797 58 53 24 4 1 102 953 322 67 49 1 142 589 5 209 24 384 Production losses due to morbidity 84 162 5 136 152 6 148 519 2 993 72 55 77 478 6 12 14 0.6 317 529 78 45 15 660 583 3 621 10 768 Informal care Total costs

Austria Belgium Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta The Netherlands Poland Portugal Slovakia Slovenia Spain Sweden UK Total EU

55 135 1 14 20 2 25 1 194 5 559 11 18 27 535 2 11 3 0.6 140 152 32 20 4 161 155 905 9 182

89 89 3 82 66 12 15 545 2 013 21 53 32 319 6 3 4 0.4 162 276 10 65 8 466 506 261 5 108

14 39 3 64 13 2 8 189 1 046 57 6 15 100 1 2 2 0.3 58 14 47 3 5 194 80 72 2 033

1 256 1 101 18 384 785 35 749 6 552 17 519 651 194 288 6 239 39 83 68 3 2 891 1 131 375 95 82 1 625 1 744 15 908 59 814

576 696 22 303 275 24 426 4 137 8 772 800 259 68 4 499 8 52 37 4 957 192 506 95 59 1 570 357 3 725 28 418

1 989 2 060 48 847 1 160 74 1 223 12 616 34 909 1 541 530 429 11 692 55 150 115 9 4 208 1 764 969 279 159 4 016 2 842 20 871 104 556

579 585 13 176 361 21 743 3 420 8 533 306 156 112 2 881 19 39 34 2 1 120 537 392 40 49 1 179 902 6 850 29 050

3 152 3 371 105 1 378 2 210 143 2 576 18 973 53 783 2 372 928 866 16 848 138 255 187 16 6 747 3 783 1 762 430 272 6 997 4 915 36 550 168 757

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signicantly between countries, from 39 per 1000 population in Malta to 573 in Lithuania. The majority of CVD-related doctor consultations were with GPs, representing 687 visits per 1000 population, compared with 315 outpatient visits per 1000 population (Table 2). CVD cost the EU healthcare systems approximately E105 billion in 2003 (Table 3), with this expenditure accounting for 12% of total healthcare expenditure in the EU (Table 4). The percentage of CVD-related healthcare expenditure varied signicantly between countries, from 2% in Malta to 17% in the UK. The major component of CVD-related healthcare expenditure was inpatient care, which accounted for E60 billion, representing 57% of total healthcare costs. However, in Slovakia, inpatient care accounted for 34% of CVD-related costs, whereas in the UK, this proportion accounted for 76% of healthcare costs. CVD-related pharmaceutical expenditure was also a major cost component, representing 27% (E28.4 billion) of total healthcare costs. Again, this proportion varied between countries, from 11% of total healthcare costs in Poland to .50% in Greece and Portugal. The other three cost components (i.e. primary, outpatient, and emergency care) accounted for 16% of costs, with A&E representing the smallest component. CVD represented an annual healthcare cost of E230 per EU citizen (Table 4). The amount spent on healthcare for people with CVD varied widely across the EU, mainly reecting the wealth of each individual country. For example, costs per person varied 19-fold between the lowest spender, Malta (E22 per person) and Germany, which had the highest cost

per capita (E423). However, when price differentials were accounted for using PPP, cost differences between countries narrowed substantially (Table 4). Informal care costs Approximately 4.4 million people with CVD were severely hampered in daily activities, representing 1% of the EU population. However, out of these, 2.85 million received informal care, with 2.95 billion hours used to care for them. Informal care of CVD sufferers was estimated to cost the EU E29 billion (Table 3). Productivity costs CVD accounted for two million deaths in the EU, representing 2.18 million working-years lost. This was estimated to cost about E24.4 billion, after adjustments for working status, and discounting. There were 268.5 million working-days lost because of CVD morbidity (i.e. 591 days per 1000 population). This represented a cost of E28 billion. However, when adjusted using the friction period, this estimate fell to E10.8 billion (Table 3). Total costs Overall, CVD is estimated to have cost the EU economy E169 billion in 2003 (Table 3). Germany and the UK represented over half (54%) of all CVD costs, whereas Malta and Cyprus represented ,0.1%. Of the total cost of CVD, 62% of total costs were due to healthcare, 21% due to productivity losses, and 17% due to informal care.

Economic burden of CVDs in the enlarged EU

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Table 4 Healthcare costs of CVD-related diseases in the EU, by country, 2003 Country CVDs Cost per capita (E) Austria Belgium Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta The Netherlands Poland Portugal Slovakia Slovenia Spain Sweden UK Total EU 247 199 67 83 215 55 235 212 423 140 52 108 204 24 43 255 22 260 46 93 52 80 97 318 352 230 Cost per capita PPP (E) 231 194 74 159 162 96 208 198 379 174 96 91 206 51 90 220 38 240 100 119 107 113 111 261 342 230 % of total health expenditure 11.4 8.5 6.7 14.3 7.0 16.8 11.8 8.4 15.0 10.6 9.3 4.4 10.6 11.5 16.2 7.7 2.0 10.2 15.6 8.0 17.0 7.9 7.1 11.6 17.1 12.0 CHD Cost per capita (E) 55 50 19 21 53 11 55 34 84 32 11 30 48 8 12 64 6 70 14 20 18 16 23 71 84 50 Cost per capita PPP (E) 51 49 21 40 40 20 49 32 75 40 20 25 48 17 25 55 11 65 30 25 37 23 26 58 82 50 % of total health expenditure 2.5 2.1 1.9 3.6 1.7 3.5 2.8 1.4 3.0 2.4 2.0 1.2 2.5 3.7 4.4 1.9 0.6 2.7 4.6 1.7 5.9 1.6 1.7 2.6 4.1 2.6 Cerebrovascular diseases Cost per capita (E) 39 34 10 14 52 10 36 24 94 17 7 24 26 7 10 23 2 76 7 14 8 11 15 53 96 46 Cost per capita PPP (E) 36 33 11 27 39 17 32 22 84 21 14 20 26 15 21 20 4 71 15 17 17 15 17 44 93 46 % of total health expenditure 1.8 1.4 1.0 2.4 1.7 3.0 1.8 0.9 3.4 1.3 1.3 1.0 1.3 3.3 3.8 0.7 0.2 3.0 2.3 1.2 2.6 1.1 1.1 1.9 4.7 2.4

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Costs of CHD
Healthcare costs CHD cost the healthcare systems of the EU just under E23 billion in 2003 (Table 5). The major component of health expenditure was inpatient care, which accounted for E14 billion (62%) of healthcare costs, followed by pharmaceutical expenditure, which represented 23% (E5.4 billion) of total healthcare costs. Primary, outpatient, and emergency care, accounted for 16% of healthcare costs. Informal care costs Over 678 000 people provided care to CHD patients, representing 702 million hours of care, which was estimated to cost the EU E6.8 billion (Table 5). Productivity costs Approximately one million working years were lost because of CHD mortality, accounting for 44% of all working years lost because of CVD-related deaths, with a cost of E11.7 billion (Table 5). Additionally, 90 million working days were lost because of CHD morbidity, representing a cost of E3.5 billion after adjusting costs using the friction period (E9.1 billion without adjustment). Total costs Overall, CHD is estimated to have cost the EU E45 billion in 2003: one-quarter of the overall cost of CVD. Over half

of these costs (51%) were incurred in healthcare, 34% in productivity losses and 15% in informal care.

Costs of cerebrovascular disease

Healthcare costs The cost of cerebrovascular diseases to the EU healthcare systems was E21 billion in 2003 (Table 6), with 82% (E17 billion) of healthcare costs being inpatient care. When compared with CVD and CHD, pharmaceuticals represented a small proportion, 5% (E1.1 billion), of total healthcare costs. Informal care costs Approximately 697 000 people provided care to those with cerebrovascular disease in the EU, representing 723 million hours of care, which was estimated to cost E7.2 billion (Table 6). Productivity costs Over 430 million working years were lost from deaths due to cerebrovascular disease, which accounted for 20% of all working years lost because of CVD, with a cost of E4.4 billion (Table 6). An additional 44 million working days were lost in the EU because of morbidity from cerebrovascular disease, representing a cost of approximately E1.7 billion after adjusting costs using the friction period (E4.3 billion without adjustment).

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Table 5 Costs of CHD (E million) in the EU, by country, 2003 Country Primary care Outpatient care A&E Inpatient care Medications Total healthcare costs Production losses due to mortality 253 257 23 111 256 19 245 867 3 426 267 90 120 690 29 27 11 2 524 414 117 31 20 472 305 3 078 11 654 Production losses due to morbidity 32 62 4 43 40 1 35 123 805 39 12 23 146 2 3 5 0.3 122 220 26 15 4 239 183 1 361 3 544 Informal care Total costs

Austria Belgium Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta The Netherlands Poland Portugal Slovakia Slovenia Spain Sweden UK Total EU

13 46 0.5 4 7 0.8 8 105 812 3 4 9 127 0.7 3 1 0.3 19 49 6 7 1 42 53 144 1 467

22 30 1 26 22 4 5 50 129 6 12 11 76 2 0.9 1 0.2 48 88 2 24 2 121 173 80 935

3 13 1 20 4 0.5 3 58 464 16 1 5 20 0.2 0.7 1 0.1 25 4 11 1 1 50 27 27 757

278 279 6 95 190 9 177 1 363 4 229 153 37 81 1 515 13 25 17 1 656 340 76 34 15 395 301 3 928 14 215

127 153 5 67 60 0.9 94 463 1 300 176 57 15 990 2 11 8 0.9 386 42 111 30 13 345 78 819 5 355

443 521 14 212 283 15 286 2 040 6 935 354 111 120 2 728 18 41 29 2 1 133 524 207 96 33 954 633 4 997 22 729

128 149 5 44 87 6 176 600 1 979 74 30 31 635 6 12 9 0.7 338 160 80 14 9 289 237 1 698 6 798

856 989 45 409 666 42 742 3 629 13 145 733 244 294 4 199 56 83 53 6 2 118 1 317 430 156 66 1 955 1 359 11 135 44 725

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Total costs Overall, cerebrovascular disease was estimated to have cost the EU E34 billion in 2003: around one-fth of the overall cost of CVD. Of the total cost of cerebrovascular disease, 61% of costs were due to healthcare costs, 18% to productivity losses and 21% to informal care.

Sensitivity analysis
The methods used to estimate primary, outpatient, and emergency care visits in countries where such data were not available were evaluated by applying them to countries where such data were in fact available. Hence, the estimated numbers of GP visits per 1000 population were 422 in Belgium (an underestimate of 32% from actual visits), 396 (26%) in Finland, 67 (235%) in Malta, and 433 (22%) in the UK, which accounted for a variation in the baseline healthcare costs of these countries of 22.1, 20.1, 20.2, and 20.1%, respectively. The estimated number of emergency attendances per 1000 population was nine in the UK (an underestimate of 18% from actual attendances) and 20 (1%) in Denmark, representing a variation in the total baseline CVD-related healthcare costs of 20.06 and 0.02%, respectively. The estimated outpatient visits resulted in a variation in baseline total healthcare costs of 20.6, 21.1, and 2% in Lithuania, Portugal, and the UK, respectively. In addition, we compared the actual total CVD-related healthcare expenditure in France, Germany, the Netherlands, and the UKthe four countries with most

datawith the estimated total for these countries had it been necessary to estimate every resource category in these countries. For France and Germany, the result was an underestimate of 16 and 24%, respectively, whereas for the Netherlands and the UK, the result was an overestimate of 16 and 11%, respectively. Varying inpatient care, medication, A&E, and outpatient unit costs upwards and downwards by 20% produced a variation in the baseline total EU CVD-related costs of +7, +3.4, +0.24, and +0.61%, respectively. Our results did not vary signicantly when the assumptions used to derive primary, outpatient, and A&E cost estimates were varied simultaneously by 50%, resulting in changes in total costs of +4.8%. Without discounting, future foregone earnings costs increased by 4.7%, whereas a 10% discount rate was associated with a reduction of 4.5% in costs.

Factors associated with CVD-related healthcare costs

To explore potential reasons for variation in CVD-related health expenditure between countries, we undertook ordinary least-squares (OLS) regression analysis using national income, life expectancy, standardized CVD mortality rates, physician density, and hospital beds per 10 000 population as independent variables. OLS was chosen because it assumes an additive impact of the independent variables on CVD-related health expenditure. Diagnostic statistical tests were performed to evaluate for relevant omitted variables (RESET test), heteroskedasticity

Economic burden of CVDs in the enlarged EU

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Table 6 Costs of cerebrovascular diseases (E million) in the EU, by country, 2003 Country Primary care Outpatient care A&E Inpatient care Medications Total healthcare costs Production losses due to mortality 83 113 7 36 122 9 91 539 1 117 82 43 39 329 11 8 5 0.8 172 203 123 9 11 205 118 888 4 365 Production losses due to morbidity 10 33 1 23 45 1 26 72 435 9 13 17 79 1 3 1 0.1 54 87 23 8 2 115 165 471 1 695 Informal care Total costs

Austria Belgium Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta The Netherlands Poland Portugal Slovakia Slovenia Spain Sweden UK Total EU

9 22 0.2 3 3 0.4 4 45 555 1 4 5 105 0.4 2 0.2 0.1 5 20 2 4 0.6 30 28 61 911

14 14 0.6 15 11 2 3 81 1 168 3 12 5 63 1 0.6 0.3 0.1 41 36 3 13 1 88 90 30 1 696

2 6 0.5 12 3 0.3 1 19 5 7 1 3 24 0.1 0.4 0.1 0.0 10 2 14 1 0.7 36 14 12 175

268 285 5 101 255 10 164 1 115 5 677 143 49 80 1 138 14 31 8 0.6 1 157 199 106 21 17 411 329 5 462 17 043

21 25 0.8 11 10 0.9 15 170 368 29 9 2 160 0.3 2 1 0.1 22.6 7 18 5 2 56 13 133 1 081

314 352 7 141 282 13 187 1 430 7 774 183 75 95 1 490 16 36 10 1 1 237 263 142 43 22 622 474 5 698 20 906

124 151 4 46 118 6 162 527 1 722 66 39 32 704 7 15 4 0.5 273 95 147 9 10 297 309 2 358 7 225

531 649 19 246 567 29 466 2 568 11 048 340 170 183 2 602 36 62 21 2 1 736 647 435 69 45 1 238 1 065 9 415 34 190

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(BreuschPagan test), and signicance of model parameters (t-test). Our results showed that when income data were included in the OLS regression, factors such as CVD mortality rates or life expectancy that might be expected a priori to predict CVD healthcare costs were not statistically signicant (P . 0.05). Figure 1 shows this strong positive correlation between income and CVD-related health expenditure. However, this correlation does not necessarily indicate a causative relationship and could arise, for example, due to systematic differences in how expenditures are calculated.

Discussion
This study is the rst to estimate the costs of CVD in the enlarged EU and the proportion of these costs attributable to CHD and cerebrovascular disease. We estimate the total cost of CVD to be E169 billion a year. A recent study40 in the USA estimated the cost of CVD to be $394 billion (E296 billion). In line with our results, that study found that healthcare expenditure accounted for 61% of costs, which were estimated using comparable resource categories and methods. Productivity losses accounted for the remainder of total costs, although it is unclear how these were estimated. On a per capita basis, the USA devoted $839 (E PPP 715) in CVD-related healthcare, approximately E485 more per citizen than the EU, after adjusting for price differences between the two economies.9

Even though CHD and cerebrovascular diseases account for 64% of all CVD deaths, these two diseases represent 47% of total CVD costs (27 and 20% for CHD and cerebrovascular diseases, respectively). Therefore, other CVDs such as hypertension (ICD-10: I10I15) or other forms of heart disease (ICD-10: I30I52) may account for a signicant proportion of total costs. For example, in Germany, hypertension represented 23% of total CVD costs and other CVDs (i.e. excluding CHD, cerebrovascular diseases and hypertension) accounted for 35% of costs.12 Furthermore, for the 19 EU countries in the OECD, the majority (51%) of CVD-bed days was due to CVDs other than CHD and cerebrovascular diseases.9 Few empirical cost-of-illness, studies have been published to evaluate the impact of other diseases across Europe. As part of a study calculating the global economic burden of diabetes,41 the healthcare costs in the enlarged EU ranged between E32 and E61 billion, signicantly lower than our estimates for CVD. The hospital cost of vertebral fractures across 15-member countries of the EU was estimated to be E377 million,42 signicantly lower than the estimated CVDrelated inpatient costs (E57 billion) for the same countries. Establishing the cost of an illness does not permit us to say whether a country is spending too much or too little on a disease; rather, the main aim of a cost-of-illness study is to help inform decisions concerning allocation of research funding, by providing a measure of the economic burden of particular health problems. At the 2000 Lisbon summit, EU governments called for a better use of research efforts. For this purpose, the Framework Programme was created as the

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J. Leal et al.

Figure 1

Correlation between CVD-healthcare expenditure and national income (GDP). Lt, Lithuania; Pl, Poland; Sk, Slovakia.

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main instrument for European research funding with a budget of E2.3 billion for health research.43 Studies such as ours enable comparisons between the burden of different diseases, aiding decision makers to prioritize scarce research funds to areas with the highest burden.44 Furthermore, if such studies are performed at regular intervals, they can measure the impact of health policy decisions. In the European setting, they could potentially be used to monitor the effect of interventions aiming to reduce the burden of CVD, such as legislation to curb smoking on CVD. In order to be in a better position to inform policy decisions aimed at reducing the burden of disease improved information on epidemiology, and accurate information on resource use and unit costs is imperative. Although the EU recognizes the importance of CVD-related comprehensive information in its Member States,1 very little specic information was available for this exercise for a majority of countries. We were therefore compelled to make many assumptions and extrapolations. Comparability of epidemiological estimates between countries is also important. For example, MONICA data45 from France suggested that ofcial mortality statistics underreported deaths from CVD compared with other countries and showed a 75% underestimate in CHD deaths. Reports2 have highlighted that French doctors have a much higher rate of reporting death from other causes than that of other countries. Therefore, our mortality costs for France, and possibly for other countries, will be underestimates. There were also problems of comparability in resource use information. For instance, some countries reported the total number of visits to doctors and emergency departments on the basis of information collected from statistical institutes; however, other countries based this information on surveys. In a similar fashion, unit costs were derived from numerous sources and extrapolations were made using multivariate analysis. As in other international costing

studies,46 we found wide differences in unit costs, especially in physician visits and hospitalizations. These differences may be due to inter-country variations in duration of consultations, but may also be related to differences in denitions and methodologies. Furthermore, some of the available unit costs were based on fees rather than costs, with fees being set centrally for the purposes of providing incentives or transferring funds within the healthcare system rather than to depict true costs. Hence, it is very difcult to make unit costs more comparable, as their exact nature is hard to identify. A more uniform costing methodology across the EU would have been difcult to perform but might have provided more accurate cost estimates, reecting the true costs of CVD and easing the interpretation of our results. Finally, our estimates are likely to be an underestimate. Some categories of healthcare costs, such as health education, were not included because of data limitations; however, other studies have shown these to represent a small proportion of total costs.39,47 Furthermore, patient travel and out-of-pocket expenses were not included but were found not to be of particular importance in other diseases.47,48 However, it is not clear whether the impact of these omissions will affect our results substantially and further research is required in this area. Additional research is also necessary to assess the costs incurred by working people with CVD returning to their post but whose productivity is diminished because of illness. Despite these acknowledged and important data limitations, our study is the rst to quantify the burden of CVD in the EU. We believe that our study will be of particular interest to European policy makers. It highlights, above everything else, the need for comparable and accurate information on the prevalence, mortality, and resource use associated with CVD in the countries of the EU.

Economic burden of CVDs in the enlarged EU

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19. Ministry of Health. First National Health Interview Survey. Malta, Annual Reports of Government Departments. http://www.health.gov. mt/ministry/dhi/survey/his.html/ (6 September 2004) 20. NHS Executive. Trust Financial Returns. Leeds: NHS Executive; 2004. 21. Lithuanian Health Information Centre. Health Statistics of Lithuania. http://www.lsic.lt/html/en/lhic.htm/ (1 September 2004) 22. Direccao-Geral da Saude L. Centros de Saude e HospitaisRecursos e pro ducao do SNS 2002. http://www.dgsaude.pt/ (31 August 2004) 23. Danmarks Statistik. Social conditions, health and justice. http:// www.statbank.dk/statbank5a/default.asp?w51280/ (6 September 2004) 24. Department of Health. Hospital episode statistics, England 20022003. www.dh.gov.uk/ (31 August 2004) 25. Heaney D, Shorvon S, Sander J, Boon P, Komarek V, Marusic P, Dravet C, Perucca E, Majkowski J, Lopes Lima J, Arroyo S, Tomson T, Ried S, van Donselaar C, Eskazan E, Peeters P, Carita P, Tjong-a-Hung I, Myon E, Taieb C. Cost minimization analysis of antiepileptic drugs in newly diagnosed epilepsy in 12 European countries. Epilepsia 2001;41:S37S44. 26. Department of Health. Prescription Cost Analysis: England 2003. London: Department of Health; 2004 27. Instituto Nacional de la Salud. Indicadores de la prestacion farmaceutica. Volumen III no 1 y 2. Madrid: Ministerio de Sanidad y Consumo; 2001. 28. Institut National dAssurance Maladie Invalidite. Rapport Annuel 2003 de lINAMI. http://inami.fgov.be/presentation/fr/annual-report/2003/ ar2003-fr.htm/ (3 June 2004) 29. National Agency for Medicines. Drug consumption at wholesale prices in 20002003. http://www.nam./english/ (14 June 2004) 30. Ministero della Salute. Luso dei farmaci in ItalyRapporto Nazionale 2003. Roma: Ministerio della Sallute; 2004. 31. Comas-Herrera A, Costa-Font J, Gori C, di Maio A, Patxot C, Pickard L. European Study on Long-Term Care Expenditure. Brussels: ECDG Employment and Social Affairs. http://www.emcc.eurofound.eu.int/ print/source/eu04039s.html/ (24 May 2004) 32. Ofce of National Statistics. In: Summereld C, Babb P, eds. Social Trends No. 34. 2004 ed. HMSO: London; 2004. 33. Paternoster A. Annual Gross Earnings: Results from Member States, Acceeding and Candidature Countries, and Switzerland. Theme 325/ 2003. Statistics in Focus, EUROSTAT; 2003. 34. Paternoster A. Minimum Wages: EU Member States, Candidate Countries and the US 2004. 10/2004. Statistics in Focus, EUROSTAT; 2004. 35. HM Treasury. Green Book, Appraisal and Evaluation in Central Government. http://greenbook.treasury.gov.uk/ (24 May 2004) 36. Austrian Statistical Central Ofce. Statistical Yearbook 2004. http:// www.statistik.at/jahrbuch_2004/englisch/start.shtml/ (26 May 2004) 37. Department for Work Pensions Information Centre. Days of certied incapacity. Version 10. http://www.dwp.gov.uk/ (28 May 2004) 38. Koopmanschap M, van Ineveld B. Towards a new approach for estimating indirect costs of disease. Soc Sci Med 1992;34:10051010. 39. Liu J, Maniadakis N, Gray A, Rayner M. The economic burden of coronary heart disease in the UK. Heart 2002;88:597603. 40. American Heart Association. Economic cost of cardiovascular diseases. Heart Disease and Stroke Statistics. American Heart Association; 2005. 41. International Diabetes Federation. Diabetes e-atlas: costs of diabetes. http://www.eatlas.idf.org/ (20 November 2005) 42. Finnern HW, Sykes DP. The hospital cost of vertebral fractures in the EU: estimates using national datasets. Osteoporos Int 2003;14:429436. 43. Community Research Development Information Service. Sixth framework programme. http://www.cordis.lu/ (31 January 2005) 44. Gross CP, Anderson GF, Powe NR. The relation between funding by the National Institutes of Health and the burden of disease. N Engl J Med 1999;340:18811887. 45. WHO Monica Project. MONICA Monograph and Multimedia Sourcebook: Worlds Largest Study of Heart Disease, Stroke, Risk Factors and Population Trends 19792002. World Health Organization; 2003. 46. Urdahl H, Knapp M, Edgell E, Ghandi G, Haro J. Unit costs in international economic evaluations: resource costing of the Schizophrenia Outpatient Health Outcomes Study. Acta Psychiatr Scand 2003;107:4147. 47. Dewey HM, Thrift AG, Mihalopoulos C, Carter R, Macdonell RAL, McNeil JJ, Donnan GA. Cost of stroke in Australia from a societal perspective results from the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke 2001;32:24092416. 48. Kernick DP, Reinhold DM, Netten A. What does it cost the patient to see the doctor? Br J Gen Pract 2000;50:401403.

Supplementary material
Supplementary material is available at European Heart Journal online.

Acknowledgements
This project was funded by a grant from the European Heart Network and the British Heart Foundation. The Health Economics Research Centre (HERC) obtains nancial support from the National Health Service Research Capacity Development (NHSRCD) programme. We are grateful to Nicola Boulton, Judit Simon, Jorge Felix, and Annelie Niklasson for useful contributions to this project. The comments from three anonymous reviewers are also acknowledged. Conict of interest: none declared.

References
1. Council of the European Union. 2586th Council MeetingEmployment, Social Policy, Health and Consumer Affairs. http://ue.eu.int/Newsroom/ (29 November 2004) 2. Petersen S, Peto V, Rayner M, Leal J, Luengo-Fernandez R, Gray A. European Cardiovascular Disease Statistics. London: British Heart Foundation; 2005. 3. EUROSTAT. Data explorer. http://www.europa.eu.int/comm/eurostat/ (23 September 2004) 4. Latvijas Statistika. Basic socio-economic indicators. http://www.csb.lv/ avidus.cfm/ (19 May 2004) 5. Statistical Service of the Republic of Cyprus. Labour statistics. http://www.mof.gov.cy/mof/cystat/statistics.nsf/labour_en/labour_ en?OpenDocument/ (19 May 2004) 6. Organisation for Economic Co-operation Development. OECD Economic Outlook No. 76Statistical Annex Tables. http://www.oecd.org/ document/61/0,2340,en_2649_201185_2483901_1_1_1_1,00. html/ (24 May 2004) 7. International Monetary Fund. Republic of Slovenia: Selected Issues and Statistical Appendix. International Monetary Fund. IMF Country Report No. 04/149. Washington D.C. www.imf.org/external/pubs/ft/scr/2005/ cr05254.pdf/ (19 May 2004) 8. World Health Organisation: Regional Ofce for Europe. European health for all database. http://www.euro.who.int/hfadb/ (4 May 2004) 9. Organisation for Economic Co-operation Development. OECD Health Data 2004: A comparative analysis of 30 countries. 2nd ed. Version 08/06/ 2004. http://www.oecd.org/health/healthdata/ (10 September 2004) 10. World Health Organisation. WHO mortality database. http://www.who. int/research/en/ (3 May 2004) 11. International Labour Ofce Bureau of Statistics. LABORSTA Internet. http://laborsta.ilo.org/ (24 May 2004) 12. Statisches Bundesamt. Gesundheit: Krankheitkosten. Presseexemplar. Wiesbaden, Statisches Bundesamt. www.destatis.de/ (24 May 2004) 13. Paris V, Renaud T, Sermet C. Des comptes de la sante par pathologie: un prototype pour lannee 1998. Dossiers solidarite et sante no.2. Paris: Ministere des Solidarites de la Sante et de la Famille; 2003. www. ` sante.gouv.fr/drees/dossiersolsa/200302.htm/ (1 June 2004) 14. Department of Public HealthErasmus University. Cost of illness in the Netherlands. http://www.rivm.nl/kostenvanziekten/site_en/ (1 June 2004) 15. Foundation for Pharmaceutical Statistics. Facts and gures. http:// sfk.nl/ (2 June 2004) 16. Royal College of General Practitioners. In: McCorkmick A, Fleming D, Charlton J, eds. Morbidity Statistics from General Practice: Fourth National Study 19911992. HMSO: London; 1995. 17. Kiiskinen U, Vartiainen E, Pekurinen M, Puska P. Does prevention of cardiovascular diseases lead to decreased cost of illness? Twenty years of experience from Finland. Prev Med 1997;26:220226. 18. Institut Scientique de Sante Publique Belge. Enquete de Sante par Interview. http://www.iph.fgov.be/sasweb/his/fr/index.htm/ (2 September 2004)

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