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Article Excerpt
Abstract
The main objective of the analysis in this article is to do a health economic study of a preventive program that may influence the risk of hip fractures for people age 65 and older. The analysis of health promoting measures aimed at the prevention of hip fractures shows that there is a large potential for reducing costs and achieving significant health benefits within the older groups of the population. Prevention of hip fractures in the "best cities" seems to be cost-effective because it dominates a situation without any prevention. This implies a reduction in the total costs for society and an improvement in the quality of life and life expectancy. (JEL D61, I12, I18)
Hip Fractures and Society
Hip fractures are related to mortality and early death in people over the age of 65, especially among women. People who are affected have a lower health-related quality of life, a shorter life span, and negative consequences for the well being of their families [Braithwaite et al., 2003]. The economic consequences are significant. Around 17,000 hip fractures occur every year in Sweden, at a total cost for society of over 3 billion SEK [Zethraues and Gerdtham, 1998].
Individuals with osteoporosis (brittle bones) run a very high risk of hip fractures [Cooper, 1995]. In Sweden, 6% of women over the age of 50 and 50% of women over the age of 85 are estimated to suffer from osteoporosis [Kanis et al., 2000]. In the U.S., as many as 15% of women over the age of 50, and 70% of women over the age of 80, are believed to meet the criteria for osteoporosis [Melton, 1995]. Internationally, it has been estimated that about 40% of women and 14% of men, will experience at least one osteoporotic fracture after the age of 50. About one third of these will be hip fractures [Lips, 1997].
It is possible to reduce the risk of hip fractures. Earlier literature has focused on preventative measures like drug treatment [Willis, 2002]. Other possibilities to prevent fractures may be to influence the individual's behavior as well as the nature of the environment. While these aspects have been mentioned, no health economic studies have taken them into consideration. Earlier studies in Sweden show a significant cost reduction and an improved health-related quality of life when hip fractures are prevented with drug treatment [Jonsson et al., 1995; Willis et al., 2001; Willis, 2002; Zethraues and Gerdtham, 1998]. There is, thus, an explorative area concerning other types of measures that aim at preventing hip fractures. If it is proven that measures within this area are effective, it may have a large impact for the health care industry.
"Healthy cities" is a program within the World Health Organizations (WHO), which seeks to put healthcare on the agenda of public decision makers. A few cities within the Skaraborg County Council in Sweden have been selected as "healthy cities." These cities are part of a national program at the National Institute of Public Health, which started in the 1980s. In October of 1987, a countywide preventive program was initiated by the Skaraborg County Council [Svanstrom and Svanstrom, 1989; Svanstrom et al., 1996; Ader, 1994; Ader et al., 2001].
Safety is important to the entire population. It is, however, important to work strategically and to analyze what and how big the risks are, who is affected, and how many different groups are affected, as well as which factors may be the subject of efficient preventive measures. National programs for children and the elderly focus on safety. By developing a register of injuries, the importance of developing information, which may contribute to creating efficient preventive measures, has been understood.
Objectives and Methods
The main objective of the analysis in this article is to do a health economic study of a preventive program within "healthy cities." The analysis is limited to programs that may influence the risk of hip fractures for people age 65 and older. It is focused on finding a potential for improvements, as well as to identify, quantify, and evaluate the importance of possible differences between the best program and another specific program.
This is a retrospective study of the development of the incidence of injuries during the period from 1987 to 2001. Regression analysis will be used when it is necessary in order to make the trend analysis more precise.
The annual reports of the cities involved are analyzed, and they have been supplemented by interviews with people responsible for the city programs to identify and thereby, quantify the measures during the evaluated period. All available action plans from the 1990s for the cities involved have been analyzed. The goal was to obtain information about which resources have been available and how resources have been used for promoting health among the elderly, with a particular focus on the prevention of hip fractures. The estimate of resources is made for three different groups: (1) Specific expenses for preventive measures for elderly city residents; (2) The monetary value and the number of hours of human resources, which have been mobilized within the cities for preventive measures directed at elderly residents; (3) The number of hours, which have been mobilized through volunteer organizations.
The consequences of hip fractures have been analyzed before in several articles. Empirical health economic studies, which use Swedish data, have been published in scientific journals. The data in these articles will be used in this analysis mainly concerning: (1) Costs due to fractures; (2) How hip fractures affect the risk of mortality and the health-related quality of life. The analysis has a limited societal perspective and is based on the principles of cost-utility analysis. This means that the costs for health care and other services will be compared to the consequences for individuals regarding mortality and death. In this case, costs refer to the cost of illness (COI). (1)
The data, which constitutes the basis for the analysis, have a wider perspective compared with other analyses of the prevention of hip fractures. We will consider all cases, regardless of whether the osteoporosis was previously known or not.
The effects of preventive measures will be highlighted, regarding the costs for prevention, treatment and care, as well as concerning the level of health for the population over the age of 64.
The costs and health effects of hip fractures have been calculated in previous studies [Jonsson et al., 1995, 1999; Willis et al., 2001; Willis, 2002; Zethraues and Gerdtham, 1998]. We proceed from the results of these studies and compare them to information in the CPP at the SU. (2) The reported costs indicate the value of the resources used in health care, social services, and elderly care, which are directly connected to hip fractures. These may be considered an acceptable estimate of the long-term marginal costs. The patients are over the age of 64 and, therefore, do not participate in the societal production. No writer, however, has previously estimated the cost for the loss of productivity for the patients' families as a consequence of the time they lose in connection with their family member's hip fracture. We do not know the extent of this effect and will not consider it in the analysis.
The measurement of health effects is based on the quality-adjusted life year (QALY) concept [Williams, 1974, 1995; Kaplan, 1988], which provides the number of years of life adjusted by the health-related quality of life. The derivation of health effects is based on the number of QALY, which may be gained per avoided fracture. This corresponds to the loss of QALY that has been presented in earlier published articles. The effect, measured by the values of QALY, varies by age and the level of difficulties after...
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