Never too early: Tackling chronic disease to extend healthy life years

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In late 2011 , with a view towards contributing to the debate surrounding the EU’s European Innovation Partnership on Active and Healthy Ageing, the Economist Intelligence Unit undertook this study of ways to manage the rising tide of chronic disease. This research, which was sponsored by Abbott, focuses on tackling chronic disease as one of the chief ways of extending healthy life years in Europe.

With a view towards contributing to the debate surrounding the EU’s European Innovation Partnership on Active and Healthy Ageing, the Economist Intelligence Unit undertook this study of ways to manage the rising tide of chronic disease. This research, which was sponsored by Abbott, focuses on tackling chronic disease as one of the chief ways of extending healthy life years in Europe. As an initial step, the Economist Intelligence Unit convened a panel of experts on November 21st in Brussels to discuss the focus of the study. This report is based on the insights gained in that discussion, as well as on extensive desk research and subsequent in-depth interviews with 35 experts in chronic disease and healthy ageing.

The research considers the effects of poor co-ordination among healthcare providers, governments, civil society, private employers and the public on making the necessary changes to the healthcare system to improve the healthy longevity of both individuals and the system. It identifies best practice initiatives in prevention, early intervention and management of chronic diseases that can contribute to healthy ageing. In addition, it highlights effective ways to shift the focus from reactive, hospital-based care of the sick towards a proactive, preventive and patient-centred approach to improving health.

Paul Kielstra was the principal researcher of this study. Delia Meth-Cohn and Aviva Freudmann were the authors. Conrad Heine, Trevor McFarlane and Stephanie Studer contributed research and interviews.

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Never too early: Tackling chronic disease to extend healthy life years

  1. 1. Never too earlyTackling chronic diseaseto extend healthy life yearsA report from the Economist Intelligence UnitSponsored by Abbott
  2. 2. Never too early: Tackling chronic disease to extend healthy life years Contents Introduction 2 About this research 4 Executive summary 5 Heading off chronic disease: New approaches to prevention 7 l A preventable scourge 7 l Changing incentives14 l Market-driven prevention16 The role of employers: Workplace initiatives to tackle chronic disease18 l Mission: Healthier workers19 l Healthier companies, too 20 l What works? 21 Managing chronic disease: Rethinking provision of care 23 l The separate worlds of acute and chronic care 23 l Managing chronic care: keys to success 25 l High touch and high tech 26 Conclusion 28 Appendix: Interview programme and expert panel participants 29 © The Economist Intelligence Unit Limited 2012
  3. 3. Never too early: Tackling chronic disease to extend healthy life years Introduction “We are in the age of the old. Let’s celebrate,” says Mary Baker, president of the European Brain Council. The premise of her statement, especially for Europe, is indisputable. The United Nations Population Division reports that life expectancy in Europe has risen by an average of ten years since 1960 and two years in the past decade alone. It forecasts that average life spans across Europe will rise from 75 years currently to 82 years by 2050. This is of course good news, but even good news can have a dark side. In the case of Europe’s longevity, the sunny outlook is clouded by the fact that not all those extra years will necessarily be healthy ones. The advanced years of many Europeans will be prematurely burdened by the need to cope with one or more chronic diseases, the incidence of which is climbing alarmingly. Moreover, the rising tide of chronic illness is threatening the viability of Europe’s healthcare systems, which are ill-equipped to cope financially, operationally or strategically with increasing numbers of long-term patients. That said, increased longevity promises opportunities too, as the swelling ranks of older Europeans represents a largely untapped human resource. To raise awareness of those opportunities, the European Union has established the European Innovation Partnership (EIP) on Active and Healthy Ageing, part of a broader programme aimed at improving co-ordination between the EU and member states to encourage innovation. The specific aim of the EIP on Active and Healthy Ageing is to find ways to add an average of two healthy life years for each European by 2020. Like much of the debate around extending healthy life years, the EIP focuses almost exclusively on improving care for Europeans over the age of 65. Yet better care for the aged is only one aspect of ensuring healthy ageing; the other is ensuring that people arrive at old age in a healthy condition in the first place. The health practices of people in their 40s and 50s—and much earlier as well—has a © The Economist Intelligence Unit Limited 2012
  4. 4. Never too early: Tackling chronic disease to extend healthy life years significant impact on their health in their later years. Indeed, some health experts suggest that the focus on health should begin at birth, and perhaps even before— in other words, that it is never too early to start taking steps that result ultimately in a healthier and longer old age. “The strategy for healthy ageing should be a continuum from birth,” says Desmond O’Neill, president of the European Union Geriatric Medicine Society. “The challenge is not to take the foot off the pedal.” This study hopes to make a contribution to European efforts to extend healthy life years by focusing on what can be done well before retirement to increase the odds for healthy longevity. The focus is in particular on measures to prevent and manage chronic diseases, since these have the greatest impact on the health of older Europeans. The research considers the effects of poor co-ordination among healthcare providers, governments, civil society, private employers and the public on making the necessary changes to the healthcare system to improve the healthy longevity of both individuals and the system. It identifies best practice initiatives in prevention, early intervention and management of chronic diseases that can contribute to healthy ageing. In addition, it highlights effective ways to shift the focus from reactive, hospital-based care of the sick towards a proactive, preventive and patient-centred approach to improving health. © The Economist Intelligence Unit Limited 2012
  5. 5. Never too early: Tackling chronic disease to extend healthy life years About this research In late 2011, with a view towards contributing to the debate surrounding the EU’s European Innovation Partnership on Active and Healthy Ageing, the Economist Intelligence Unit undertook this study of ways to manage the rising tide of chronic disease. This research, which was sponsored by Abbott, focuses on tackling chronic disease as one of the chief ways of extending healthy life years in Europe. As an initial step, the Economist Intelligence Unit convened a panel of experts on November 21st in Brussels to discuss the focus of the study. This report is based on the insights gained in that discussion, as well as on extensive desk research and subsequent in-depth interviews with 35 experts in chronic disease and healthy ageing. We would like to thank all participants in the expert panel and the interview programme, who are listed in the Appendix. The Economist Intelligence Unit bears sole responsibility for the content of this study. The findings and views expressed in the report do not necessarily reflect the views of the sponsor. Paul Kielstra was the principal researcher of this study. Delia Meth-Cohn and Aviva Freudmann were the authors. Conrad Heine, Trevor McFarlane and Stephanie Studer contributed research and interviews. © The Economist Intelligence Unit Limited 2012
  6. 6. Never too early: Tackling chronic disease to extend healthy life years Executive summary The promise of healthy ageing in Europe is l This scourge is largely preventable. Scientists clouded by the rising incidence of chronic believe that much of the disease burden can be disease. These diseases, whose hallmark is prevented, or at least substantially delayed, a gradual and long-term deterioration of through a combination of primary prevention function rather than a sudden acute event, measures, screening and early intervention. increasingly threaten both the quality of life of l An ounce of prevention is worth a pound of older Europeans and the ability of healthcare cure. The “four basics” of primary prevention systems to cope with their demands. In the are already well known: a healthy diet, regular absence of reforms in both the care of individual exercise, avoiding tobacco and eschewing patients and the overall design of healthcare excessive alcohol intake. systems themselves, the rising tide of chronic illness threatens to overwhelm the resources of l Prevention also includes early diagnosis and healthcare by mid-century, ensuring that ageing intervention. While primary prevention focuses is a burden and not an opportunity for Europe. on healthy living, secondary prevention (early screening and diagnosis) and tertiary prevention (early intervention to slow the progress of Most of the work on healthy ageing, including diseases identified) also play important roles in the European Union’s Innovation Partnership reducing the burden of chronic disease. on Active and Healthy Ageing, focuses on how to improve care for the aged. This study refocuses l It is never too early to tackle chronic diseases attention on getting people to old age in a such as cardiovascular and respiratory illnesses, healthier condition by looking at what can be Type 2 diabetes, cancer, dementia, kidney and done throughout people’s lives to increase the liver diseases, obesity and being overweight. odds for healthy longevity. Here are some of the Indeed, healthy practices begun in infancy—and key findings of this research: perhaps even earlier, in vitro—can help to forestall the onset of disease. l Chronic diseases threaten to overwhelm Europe’s healthcare system. Between 70% and l Care of chronic conditions has distinct 80% of European healthcare costs are spent on needs compared to acute care, and must be chronic care, amounting to €700bn in the EU. refashioned accordingly. To ensure appropriate Chronic diseases account for over 86% of deaths care for chronic disease sufferers as well as free in the EU. up medical resources for acute-care patients, © The Economist Intelligence Unit Limited 2012
  7. 7. Never too early: Tackling chronic disease to extend healthy life years communities and healthcare systems should better position than doctors and hospitals to direct more resources to wellness, prevention and provide time-intensive coaching and personal disease management programmes for chronic attention to patients. patients. l Employers and health insurers have major l Healthcare should be integrated and contributions to make in fighting chronic patient-centred to the greatest extent disease. Health and wellness programmes possible. Integration of medical services and are increasingly being offered by progressive other services such as mental health, in-home employers as a way to ensure that older workers sanitary care, and instruction in self-monitoring are able to remain on the job longer. Health and self-care methods are crucial components of insurers are also increasingly sponsoring health creating an integrated, patient-centred chronic and wellness programmes as incentives to care system. This is particularly important for encourage healthy lifestyles and practices. patients suffering from more than one chronic l Mental healthcare is an important part of the disease, who often must co-ordinate their own mix in the prevention and treatment of chronic care among silo-like specialised care providers illnesses. Researchers have found that isolation under the current system. and loneliness among those whose function is l Healthcare should be devolved as far as impaired owing to chronic disease aggravates possible down the provider chain. As part of their condition. Several promising initiatives aim patient-centred healthcare, patients should at reducing that loneliness through individual be encouraged to do as much as possible for case management and personal health coaching. themselves, with appropriate support from a In general, healthcare providers are increasingly variety of providers—not all of them necessarily incorporating mental health services as part of specialised doctors. Pharmacists, nurses, treatment for chronic-care patients. community workers, home care workers and others can all play a part, and are often in a © The Economist Intelligence Unit Limited 2012
  8. 8. Never too early: Tackling chronic disease to extend healthy life years 1 Heading off chronic disease New approaches to prevention “An ounce of prevention is worth a pound of cure,” wrote who have reached retirement age have had at least two chronic American statesman Benjamin Franklin in the 18th century. conditions. Although Europeans are increasingly living longer Although his dictum was meant to apply to all facets of on average, the high incidence of chronic disease at retirement life—and not only to medical cures—his wisdom is nowhere age suggests that for far too many this longevity will not more applicable than in 21st century Europe. Today in Europe, necessarily mean many years of healthy, full functioning. many pounds of cure are being expended to fight chronic illnesses that in many cases could have been prevented in For Europe’s healthcare systems—and the national budgets the first place. that largely support them—this trend also suggests an unhealthy future. According to the European Public Health A preventable scourge Alliance (EPHA), between 70% and 80% of European Chronic disease is shaping up as a modern-day scourge. healthcare costs are spent on chronic diseases. This According to the European Chronic Disease Alliance, a corresponds to €700bn in the EU, and this figure is expected coalition of medical professional organisations, over 100 to rise in the coming years, according to the EPHA. Worldwide, million European citizens—or 40% of the population above the figures are even more dramatic. The World Economic Forum the age of 15—have a chronic disease. That proportion rises calculates that the global economic impact of the five leading progressively through the age ranks, with the result that non-communicable diseases (NCDs)—cardiovascular disease, Europeans reaching retirement age are more likely than not chronic respiratory disease, cancer, diabetes and mental ill- to suffer from at least one chronic condition. According to the health—could total US$47trn by 2030 (see Chart 1). Unless the World Health Organization (WHO), two out of three Europeans rising tide of chronic disease is reversed, such costs—which Chart 1 Doubling the burden by 2030 Chronic disease cost burden, 2010 and 2030 (VSL estimates*) (US$ tr) 2010: total 22.8 0.5 14.8 5.1 2.4 High income Upper middle income Lower middle income Low income 2030: total 43.4 1.0 19.7 17.4 5.3 *The VSL approach is used to estimate the economic burden of NCDs in 2010 and to project that burden in 2030. The VSL data are taken to be the value of life of a representative median-aged member of the corresponding national population. Constructing the VSL estimates/projections requires the estimation of DALYs in 2010 and 2030. Source: The Global Economic Burden of NCDs, World Economic Forum and Harvard School of Public Health, 2011. © The Economist Intelligence Unit Limited 2012
  9. 9. Never too early: Tackling chronic disease to extend healthy life yearsinclude output loss as well as direct healthcare spending— found that eating a Mediterranean diet, regular exercise, notcould have a severe impact on national economies and their smoking, and maintaining a healthy weight collectively addedhealthcare systems. 15 years to an average woman’s life span and 8.5 years to an average man’s life span.One of the main reasons healthcare systems around the worldare ill-suited to dealing with chronic disease is that they “These measures are so well known as to be almost banal,” sayswere designed to respond to acute, short-term illnesses and Professor James Vaupel, founding director of the Max Planckinjuries, rather than to prevent and manage the gradual, long- Institute for Demographic Research in Rostock, Germany, andterm deterioration that characterises chronic disease. Indeed, head of its Laboratory of Survival and Longevity. “The bottomthe rising ride of chronic disease represents a sea change in line is, you are more likely to reach age 80 if you listen to whatthe type of illnesses affecting people worldwide. More than your mother told you.” But the trend towards healthier living60% of deaths worldwide are due to NCDs, killing 36 million is weak, at best. “People think they need expensive food topeople each year, according to the World Economic Forum. have a good diet, but the Mediterranean diet is cheap andChronic diseases account for over 86% of deaths in the EU, smoking costs lots of money,” notes Piet van den Brandt,according to the Chronic Disease Alliance. professor of epidemiology at Maastricht University and author of the Dutch study. A 2010 study by the OECD and the EuropeanAstoundingly, scientists believe that much of this scourge Commission found that over one-half of adults living in the EUis preventable—or at least can be substantially delayed. are overweight or obese, and that the rate of obesity has moreAccording to the WHO and the NCD Alliance, simple measures than doubled over the past 20 years (see Chart 2). Similarly,that fall under the rubric of “primary prevention”, such as although smoking rates have fallen, smoking is still very mucheating a healthy diet, avoiding tobacco use and excessive part of the culture in many parts of Europe.alcohol, and increasing physical activity can prevent 80% ofpremature heart disease, 80% of Type 2 diabetes and 40% of all Prevention is not only a matter of healthier living. Earlycancers. A recent large longitudinal study in the Netherlands diagnosis and the right kind of early intervention and disease Chart 2 Growing girths Overweight and obese populations in Europe, males (representative sample of countries) (%) Overweight Obese 60 60 50 50 51.5 45.5 45.0 44.8 40 40 43.7 43.5 42.5 41.0 41.0 40.1 39.6 39.2 30 30 30.7 20 20 22.1 20.5 17.8 16.1 15.7 14.9 14.8 10 10 13.4 13.4 11.8 10.5 10.3 8.3 0 0 Bulgaria Denmark England Finland France Germany Italy Poland Russia Slovakia Spain Sweden Switzerland Note: Overweight defined as % Body Mass Index 25-29.9; and obesity defined as % Body Mass Index 30+. Source: International Association for the Study of Obesity, 2011. © The Economist Intelligence Unit Limited 2012
  10. 10. Never too early: Tackling chronic disease to extend healthy life years management—known as secondary and tertiary towards single-organ and single-occurrence prevention—can also make considerable events—such as heart attacks or acute contributions to reducing mortality from chronic appendicitis—rather than on the less dramatic diseases. (For fuller definitions of primary, long-term deterioration of function associated secondary and tertiary prevention, please see with chronic disease. box, “Prevention: Three lines of defence”.). As a result, most funds expended in the Shifting priorities healthcare system are directed towards solving Although policymakers are well aware of the shift yesterday’s problems rather than today’s and in the nature of the burden on the healthcare tomorrow’s problems. In particular, vast sums system, that knowledge has yet to be translated are directed towards fighting diseases when into an overhaul of the system. Funds are still they are close to killing patients rather than directed in the same way they have been all earlier in life when they are not immediately life along—to caring for hospital-bound patients, threatening. “About 27% of [US] Medicare spend and to treating diseases after they occur rather is in the last year of a patient’s life,” notes Dr Paul than trying to prevent them from occurring. Keckley, executive director of the Deloitte Center Much of healthcare spending is still oriented for Health Solutions. “The policy debate is, is it Prevention: Three lines of defence The medical system has developed a typology aspirin to prevent a first or second heart attack. for the wide range of practices covered by Alternatively, secondary prevention might the general term “prevention”. Preventive consist of an enhanced regimen of screening measures are carried out by both individuals and and monitoring to track the progress of the healthcare providers, and fall into three general categories: disease as well as monitor response to therapies and track any required adjustments in dosing. l Primary: Primary prevention aims to protect In some cases, drug therapies can be introduced healthy people from developing a disease in to delay or slow down development of a disease the first place, through such measures as good such as Alzheimer’s. nutrition, regular exercise, avoiding tobacco and alcohol, and receiving regular medical l Tertiary: For patients who already have check-ups. Primary prevention may also extend illnesses such as diabetes, heart disease, to population-wide measures such as improving cancer or chronic musculoskeletal pain, tertiary air and water quality, mass immunisation, and prevention consists of measures to slow down strengthening family and community ties to physical deterioration. Such measures might promote mental health. include participating in cardiac or stroke rehabilitation programmes, joining chronic pain l Secondary: After risk factors have been management groups, or participating in support found to be present, and/or signs of an illness groups for patients with mental or psychological have actually appeared, secondary intervention problems. While these measures are technically consists of screening for illnesses, particularly no longer strictly preventive—the patient has when risk factors are present, and early already been diagnosed with the disease—they intervention measures to slow the progress of do help to limit the debilitating effects of the the disease while it is still in its early stages. illness, and thereby improve quality of life and For example, a patient with signs of a heart extend life years in comparative health. condition might take daily low dosages of © The Economist Intelligence Unit Limited 2012
  11. 11. Never too early: Tackling chronic disease to extend healthy life years better to reinvest those resources in preventative Available data on the benefits of early diagnosis management of chronic disease, or is it better to and intervention point in the same direction as spend an inordinate amount of resources on end- that on the impact of healthier lifestyles. In the of-life care.” case of many chronic diseases, the onset of the disease can be delayed, and its progress slowed, Similarly in Europe, the Organisation for by secondary and tertiary prevention measures Economic Cooperation and Development has as well as primary prevention measures. determined that only 3% of current health expenditure in Europe is invested in prevention and in public health programmes (see Chart Advances in genomics are helping doctors to 3). This shows the extent of the difficulty of the identify risk factors, which in turn helps them shift from curative to preventive investment. to identify vulnerable population groups, as And yet for healthcare professionals, the link well as population groups likely to respond between early prevention and intervention, to specific treatments. Various screening and on the one hand, and healthy longevity, on diagnostic devices are then used to identify the other, is clear. “Every single measure of individuals at risk or showing early signs prevention—say, reducing smoking or obesity of disease. Identifying risk factors and/or or cholesterol—means that during the ageing biological markers—any protein or other period your quality of life will be much better,” substance in the blood whose concentration says Bernat Soria, a former minister of health can indicate the presence or future onset of a in the Spanish government. Clearly, the healthy disease—provides a powerful incentive for both longevity of both individuals and healthcare patients and doctors to take further action systems would be well served by a reordering of to prevent the onset of the disease or slow the current spending priorities. its progress. Chart 3 Prevention: Making a start Proportion of European health expenditure invested in organised public health and prevention programmes, 2008 (%) 7.0 7.0 6.0 6.0 6.0 5.7 5.0 5.0 4.9 4.0 4.0 4.1 4.0 3.9 3.7 3.6 3.0 3.0 3.0 2.9 2.8 2.7 2.7 2.0 2.0 2.4 2.3 2.1 2.0 1.8 0.7 0.7 1.6 1.6 1.0 1.0 1.4 1.4 0.0 0.0 Slovenia Sweden Romania Finland Bulgaria (2007) Hungary Germany Slovak Republic EU average Czech Republic Belgium Spain Switzerland (2007) Norway France Austria Iceland Latvia (2007) Denmark (2007) Lithuania Italy Poland Estonia Netherlands Sources: OECD Health Data 2010; Eurostat Statistics Database, 2010.10 © The Economist Intelligence Unit Limited 2012
  12. 12. Never too early: Tackling chronic disease to extend healthy life years “The latest statistics from the International rate of early-intervention patients was around Diabetes Federation show that 50% of people 43%, compared with 56% for the control group with diabetes do not know that they have it,” of long-term hemodialysis patients. Within the notes Dr Maha Taysir Barakat, medical director first 90 days, the mortality rate for participants at the Imperial College London Diabetes Centre in the early intervention programme was 20%, in Abu Dhabi. “The challenge is how to increase compared with 39% for the control group. the chance that those who don’t know they have diabetes will take the test and go to a health “Screening is a very good idea for renal disease, provider who can help them. The sooner you because when we are effective, we are very start managing someone with diabetes, the effective,” says Johannes Mann, professor better the long-term outcome. That will have an of medicine and head of the Department of impact on extending healthy lives.” Nephrology, Hypertension and Rheumatology at Schwabing General Hospital in Germany. “Screening is especially effective when we From diagnosis to treatment prevent people from going on to dialysis. I see no There is also promising clinical work under way negative aspects to screening for kidney disease. to identify the biological markers—such as the For other diseases, the case can be different. build-up of plaques and tangles in the brain— There has been a long debate about prostate that point to the likely future development cancer, for example, where you might be able to of Alzheimer’s disease, the principal form recognise the disease earlier but not necessarily of dementia. Many doctors argue that early change its course.” screening to determine if such markers are present can lead to a regimen of exercises, diet changes and possible drug therapies, which Improving the links between diagnosis and together can delay the onset of the disease and treatment is crucial if preventive healthcare is slow its progress once it appears. Researchers to be effective. Among other things, it would are also trying to develop a clearer view on provide a needed incentive to shift resources what biological markers, and especially in what from treating the sick to preventing illness. concentrations, would prove the effectiveness of However, this process is not simple. In particular, different therapies in fighting the disease. there is a thicket of conflicting scientific studies on the costs and benefits associated with screening and early intervention. For example, Similarly, clinicians generally believe that mammography to detect breast cancer in measuring certain biological markers in the women—once considered an obvious health blood or urine can identify patients at risk of measure—has fallen into controversy. Some kidney diseases, can detect diseases in the respectable research institutes have found an earliest stages, and through early detection unexpectedly strong probability that, in some can be treated effectively. A clinical trial, populations, mammography could yield false published in the Clinical Journal of the American positives or highlight pre-cancers unlikely Society of Nephrology Studies in 2007, showed to become full-fledged cancers, but which promising results in terms of lower death and nonetheless lead to interventions. These studies hospitalisation rates after participation in suggest that, for the populations in question, an early intervention programme. The trial if a highly sensitive test is used, the probability compared results obtained for around 1,000 of a false positive may exceed the likelihood of hemodialysis patients enrolled in such a finding real cancers and saving lives—in effect programme, and another 1,000 patients in a saying that, statistically, the costs of the test control group. By the end of one year, the death exceeds its benefits in such cases. © The Economist Intelligence Unit Limited 2012 11
  13. 13. Never too early: Tackling chronic disease to extend healthy life years The same questions have been raised in screening towards a solid economic case for redirecting and early intervention for respiratory and for funds from treatment to prevention. The absence cardiovascular illnesses. To ensure they detect as of hard data linking specific prevention measures many real cases as possible, clinicians may use to reduced incidence of specific diseases is a highly sensitive measurement, which may also slowing the process of acting on that knowledge yield some false positives. “The classic example to change spending priorities and overhaul an is asthma: we tend to diagnose twice as many outmoded healthcare system. asthmatics as those that actually have asthma,” says Mr Keckley of the Deloitte Centre for Health Changing this state of affairs requires three Solutions. “So we are not particularly good at things. doing these things. There are some great studies that show that our primary care system is failing First, public health officials need to measure to adequately apply the evidence to diagnostics.” systematically the returns on investment of various health prevention measures, Blanket screening does not just carry the particularly for more expensive screening potential danger of adding unnecessary costs and early intervention programmes. Walter to healthcare systems, it also carries the risk Ricciardi, president of the European Public of creating psychological risks to the people it Health Association, believes that his profession is trying to help. Joep Perk, cardiologist and is partly to blame for the lack of evidence-based professor of health sciences, and chairman of medical care so far. “Before, public health people the Joint European Societies’ Task Force for said, ‘prevention is beautiful, let’s do it,’ but Cardiovascular Prevention in Clinical Practice, did not look at the costs and benefits,” he says. points to a programme to screen men over 65 for “It is possible for prevention programmes to abdominal disease. “The psychological effect generate significant savings, but certain ones has not been sufficiently studied. In much of our might also be costly and yield little benefit. The screening work we do not pay enough attention problem is that too often evidence is simply to the unrest that we create in people,” he says. not collected either way.” Professor Ricciardi “I am a national co-ordinator for cardiovascular believes that these programmes need to be able disease prevention, and it is part of my duty to demonstrate value so that policymakers can to speak to doctors about their prevention decide whether to adopt them. (Please see box, methods. One once said to me about screening, “From sickness to health: Abu Dhabi’s radical ‘I do not want to make healthy people sick!’ refocusing initiative” for an innovative attempt to This is the reverse side of the coin. It needs collect this evidence systematically and translate more attention.” it into a new healthcare financing model.) While these concerns over how best to implement Second, healthcare policymakers need to move screening require attention, the overall case away from talking broadly about prevention, for pursuing prevention over cure is clear and screening or treatment for chronic diseases and urgent. Scientists have concluded that most start taking a more differentiated and focused chronic disease is preventable, or at least can view of the efficacy of specific measures for be held at bay for much longer than it is today. preventing or delaying the onset of specific Yet for such knowledge and clinical insights to diseases, for specific groups of people, and be translated into a reorienting of spending identifying those who are most likely to benefit priorities towards prevention, policymakers and those who are likely to be non-responders. must be persuaded of the overall applicability Ironically, the successful push for recognising of the selected clinical trials, which would point chronic disease management as a separate focus12 © The Economist Intelligence Unit Limited 2012
  14. 14. Never too early: Tackling chronic disease to extend healthy life years for healthcare in Europe is now creating an not enough. It makes it difficult in turn for EU obstacle for its better diagnosis and prevention. member states to adopt specific prevention “EU policy does not include any disease-specific strategies to address cardiovascular disease.” policies except for cancer. This is a huge barrier for cardiovascular disease,” says Sophie O’Kelly, Third, healthcare officials will need to find a head of European affairs for the European Society way of overcoming the problem of short-term of Cardiology and a founder of the Chronic costs versus long-term benefits. Investing in Disease Alliance. Diseases are bundled together prevention requires waiting a decade or two as ‘chronic disease’–“which is a start, but it’s to determine the effect of measures and enjoy From sickness to health: Abu Dhabi’s radical refocusing initiative Abu Dhabi may be best known in healthcare seen a 40% improvement in blood glucose levels circles for its alarmingly high and rising rates and a 45% improvement in lipids, plus the costs of obesity and diabetes—and for having lots of the programme are very modest—less than of money to throw at the problem. But the US$20 per person per year.” emirate is actually testing one of the first total- population action plans on chronic disease, With all health data collected and stored in a built around screening, planning and action. universal health database (again developed in- house), Abu Dhabi is now taking the individual The Weqaya prevention programme was results and bundling anonymised data for launched in 2008 by a group of international target groups, such as employers and local health experts within the emirate’s governments. Bundled data help to set local government. Weqaya began with a simple 15- priorities and to measure the level of impact. minute opt-out screen for cardiovascular risks. This form of benchmarking can be used to This covered 95% of the population in its first identify (and praise) best practice which can be few years and in 2011 moved into the second disseminated, and identify those who are not screening round (screening will be repeated at putting in the effort. Of course, the data can least every three years, more often for those at also be aggregated to the population-level to the highest risk). Each screened person receives project the level of demand for health services, an individual report, which outlines in a simple and strengthen the case for policy interventions traffic light form the main risk areas, like high such as tobacco control and improving the blood pressure and high body mass index, and walkability of Abu Dhabi. a set of personalised actions, from diet changes and exercise, for example, to visiting the doctor Dr Harrison also plans to use the data to to receive therapy. revolutionise healthcare financing—an issue even in oil-rich Abu Dhabi as chronic diseases “Now we’ve started the second round of skyrocket along with costs. By calculating the screening, we can start to assess trends expected cost of disease over the next decade, across the population and over time, plus see based on the measured risk factors, Abu Dhabi what really works in our population,” says is planning to reimburse disease management Oliver Harrison, Director of Public Health and companies directly for improvements in Policy at the Government of Abu Dhabi. One measured health over time. “This allows us to big success was to get people with problems transfer risk with a new financing model,” he going to see doctors. “In the first round of says. “We have geared the numbers so the more screening we found that one-third of people we pay for health, the more we save on future with diabetes didn’t know they had it, one-half health spend.” with hypertension and two-thirds with high cholesterol. Assessing Weqaya overall, we’ve © The Economist Intelligence Unit Limited 2012 13
  15. 15. Never too early: Tackling chronic disease to extend healthy life years the benefits in lower healthcare costs. “We Putting that insight into practice means a have elections every four years, but medical broader reconfiguration of incentives—one that complications [in the absence of prevention] will goes well beyond the healthcare system. “The appear in 15 to 20 years,” notes Dr Soria. “So real thing we need to crack is how to move the today’s politicians will not pay the future price non-communicable diseases discussion outside for poor prevention measures.” of the healthcare sector, as no one single sector alone will be able to address its complexity,” says Changing incentives Dr Jané-Llopis, head of healthcare programmes In the case of the medical system, incentives are at the World Economic Forum. “We need to align at the core of the short-term bias. Despite the the incentives currently in place for healthy rising tide of chronic illnesses, the incentives living. For example, subsidies for agriculture for practitioners are still to treat the sick should incentivise crops that are beneficial for rather than keep them out of the system. health; incentives should be aligned to promote Healthcare in Europe developed as a sickness walking. Unless we work this out between system rather than a health system, and this government, industry and individuals, there is no is where, generally speaking, it remains. “It’s way we will manage to change our behaviours.” a global phenomenon—the urgent crowds out the important,” says Derek Yach, senior vice- “It has to come from the whole of society to make president of global health and agricultural policy it work,” notes Ms O’Kelly of the European Society for US-based Pepsi-Cola. “Prevention is always of Cardiology. “If you just have a campaign to sacrificed in face of the curative load in front promote fruit and vegetables, but still have of people.” advertising for chocolate bars, one will offset the other. What is needed is comprehensive, In the absence of comprehensive evidence consistent and cross-sectoral co-operation, as linking preventive measures to significantly recommended by our prevention experts.” retarded rates of chronic disease development and therefore lower future costs for healthcare, In addition to joining up the dots to promote “the prevention case often sounds vague and what is healthy, researchers are finding that peer fluffy—but there are specific actions with big support is far more effective than education positive outcomes,” Mr Yach says. “Part of the and proscription in getting people to change problem is that we lump many types of actions behaviour. Generally, Professor Ricciardi says, under the term ‘prevention’. But some of these “The approach has been to say ‘smoking is are done within the health service by doctors and dangerous’, ‘drinking alcohol is dangerous’, nurses, such as screening and vaccination; then but few interventions have understood the others are population-wide measures such as psychology behind those behaviours.” In tobacco taxes, marketing controls, and efforts to contrast, simple reinforcement of healthy reduce salt intake, and for these you need broad- choices, given by an observer or peer group, based partnerships.” makes behavioural change much more likely. This broad approach was articulated 25 years Much of the evidence of this in Europe comes ago in the intergovernmental Ottawa Charter from the Nordic countries, where smaller and for Health Promotion, which concluded that, more homogenous populations make such for change to occur, “healthy choices need personalised, community-based interventions to be the easy choices—for individuals, for easier than in larger, more heterogeneous healthcare providers, and for a wide range populations. The most famous example comes of other stakeholders who have an impact on from the Karelia region in Finland, which public health.” dramatically reduced its high rate of heart14 © The Economist Intelligence Unit Limited 2012
  16. 16. Never too early: Tackling chronic disease to extend healthy life years disease over the past 30 years through concerted rather because of the attention they give to the community action (please see box, “North individuals’ health and well-being. Karelia: Joining the dots”). Such one-on-one interaction, together with Mr Perk of the European Society of Cardiology peer group communication through word of tells of a successful Swedish programme involving mouth, social media and the like, can be far more all 26 primary healthcare centres of Kalmar effective in promoting healthy choices than top- County in south-eastern Sweden. Each centre down exhortations from governments, doctors has a nurse who acts as a ‘lifestyle counsellor’ or any other authority figures. Experiments in for patients, providing a half-year of ‘lifestyle behavioural economics have shown that the very training’. “It’s been hugely successful, chiefly act of tracking and measuring—for example, because we extended it to primary care centres,” recording blood sugar readings for pre-diabetics, Dr Perk says. “If you see after half a year that or tracking athletic performance levels for a target levels (such as blood pressure, blood lipids person prone to overweight—creates an incentive and glucose) are still elevated, then the doctor system that changes behaviour. says, ‘OK, let’s see what else we have in the cupboard. Is it now time for drug treatment?’” Market-driven prevention Insurers, among others, are starting to build Similarly in Denmark, a programme of visits programmes around these insights as a way to by nurses to all citizens over the age of 75 at reduce their future disease burdens. For example, least twice a year has had a positive impact as a supplement to care provided by medical on the target population—not because of any professionals, Techniker Krankenkasse, a German medical services that the nurses perform, but insurer, has offered its “TK-Gesundheitscoach” North Karelia: Joining the dots A key to ensuring well-targeted intervention professionals provided anti-smoking assistance, is to involve a wide range of public and private and food stores made healthy options available. sector organisations in a joint campaign. A case in point is the North Karelia Project in Finland. The pilot proved so successful that it was In 1971 the representatives of this Finnish rolled out across Finland. In North Karelia, province petitioned the national government meanwhile, improvements continued for many for help in dealing with the high level of heart years: between 1972 and 2002, average serum disease. The result was a five-year pilot scheme, cholesterol levels dropped by around 18%. later extended for several decades, which Deaths from coronary heart disease fell by focused on reducing risk factors, in particular 87% between 1972 and 2002, compared with a smoking and poor diet. decline of 75% in the entire country. Much of the work involved campaigns giving The keys to the project’s success, according to people information on why and how to change Finland’s National Public Health Institute, were their own behaviour. These efforts required the community commitment and organisation, the co-operation of health services, community flexible use of multiple strategies, and, above groups, schools and non-governmental all, the collaboration of numerous players organisations (NGOs), as well as supermarkets including health providers, industry and and other relevant companies. Healthcare government. © The Economist Intelligence Unit Limited 2012 15
  17. 17. Never too early: Tackling chronic disease to extend healthy life years programme since 2008. All insureds with chronic to subscribers who prove they have made regular diseases who meet certain criteria are eligible visits to a gym. for a personal coach, who contacts the insured by telephone and, on a voluntary basis, supports Similarly in South Africa, the US and Canada, the patient’s therapy, monitors its success, the Discovery insurance company offers a and increases the patient’s abilities of self- points-based system of rewards for insureds who management. The key is the ongoing relationship exercise, buy healthy foods or reach specified built on trust between the coach and the patient, goals for athletic performance. Participants which creates an incentive for patients to earn points for specified healthy behaviours co-operate. and thereby rise through various levels, from blue to gold—with rewards adjusted to starting The results are tangible. When the programme levels of fitness. As they rise through the began, the Techniker Krankenkasse launched fitness measurement system, participants are a longitudinal study to track results and the given rewards, ranging from reduced insurance outcomes so far are positive. For every chronic premiums to expenses-paid holidays. To support disease, participants report significantly better the programme, Discovery formed alliances with subjective health than the control group. These various partners, such as supermarkets to offer better results are saving the company money. discounts on certain healthy foods, and with For patients with cardiac disease, lower rates airlines to offer discounted flights. of heart failure and heart attack could mean a very significant reduction in costs. The final This type of short-term reward, along with the evaluation of the project’s outcome is planned for reinforcement offered by measurement and July 2013. personal attention, support a shift to healthy habits more decisively than do the promise of In addition to creating incentives through a healthier life decades from now. This insight personal reinforcement of healthy choices, underlies the development of healthy lifestyle insurers are starting to offer financial incentives and early diagnosis programmes among for healthy behaviours, such as visiting doctors insurers and employers. Policymakers, too, are for screening purposes, and disincentives for experimenting with both carrots and sticks such unhealthy ones, such as smoking. In Germany, as smoking bans, high taxes on unhealthy foods several health insurers (Krankenkasse) are and subsidised rates for sports facilities. starting to offer rebates on healthcare premiums16 © The Economist Intelligence Unit Limited 2012
  18. 18. Never too early: Tackling chronic disease to extend healthy life years 2 The role of employers Workplace initiatives to tackle chronic disease Employers, too, can play a crucial role in tackling chronic economic output each year as a result, and that translates into disease early and an increasing number of companies are a concern for all large companies. “What employers are really focusing on improving employee health. A recent survey by interested in is a healthy workforce today,” says Natalie-Jane Towers Watson, a human resources consultancy, found that Macdonald, UK manager of BUPA. “But the things they do also while only 30% of companies in Europe, the Middle East and help individuals to be healthier as they move into old age.” Africa (EMEA) had a global health strategy in place, a further 47% intended to introduce one in the next five years. Although The main hurdle with relying on businesses to be an integral these strategies include numerous elements, in 77% of cases part of the health puzzle is that healthcare is still relatively they currently or will involve wellness and health promotion. low on the business agenda—and companies are certainly not incentivised to invest heavily in employee health for the sake The reason for the spread of employee health programmes of a healthier retired population in the future. Nevertheless, is not altruism. Chronic diseases exert a high toll on labour companies are increasingly seeing the business value of taking productivity (see Chart 4). The World Economic Forum a more proactive approach to maintaining health. A Harvard estimated that high-income countries lose US$26trn in Business School study found that the return on investment of a Chart 4 Output suffers Total economic cost of chronic disease, US, 2003 (US$ bn) Treatment expenditures (Total = US$277 bn) Lost economic output (Total = US$1,047 bn) 300 300 280 250 271 250 200 200 150 171 150 100 100 105 105 94 50 65 50 48 46 45 33 27 14 0 22 0 Cancers Hypertension Mental Heart Pulmonary Diabetes Stroke disorders disease conditions Source: The Milken Institute, 2009. © The Economist Intelligence Unit Limited 2012 17
  19. 19. Never too early: Tackling chronic disease to extend healthy life years comprehensive, well-run programme could be as German companies also feel the impact of high as 600%, while the World Economic Forum’s rising healthcare costs passing through the head of health programmes, Dr Jané-Llopis, says system and raising employer contributions. In “the most conservative figures are a return on addition, they are strongly motivated to tackle investment of US$3-4 for every one US dollar.” the growing skills shortage by keeping a steadily ageing workforce healthy and productive. In Mission: Healthier workers the past, “companies fired people who were sick There are three main driving forces for companies rather than working on improving the labour to introduce healthcare programmes, weighted environment,” notes Professor Norbert Klusen differently across countries: the rising cost of Germany’s Techniker Krankenkasse, a health of covering employees’ healthcare costs; the insurance fund. “That has changed completely. shortage of skills and the need to retain workers Employers ask us to analyse absenteeism and as they get older; and the growing burden of create prevention programmes. We have done so absenteeism and low productivity through for thousands of companies and they are working ill health. quite successfully.” US companies tend to be the most advanced in Klaus Böttcher, head of the department of providing healthcare because they pay directly performance and contract management for for medical costs. “The US has the ‘advantage’ KKH Allianz, a German health insurer, has seen of being saddled with medical costs at corporate a similar change in attitudes as businesses level, giving companies an incentive to recognise the implications of ageing populations. improve the health of their employees,” says Until very recently, companies encouraged Sean Sullivan, president and chief executive early retirement as a way to maintain healthy of the Institute for Health and Productivity workforces. “Now company leaders realise that Management. “Keeping employees out of hospital this was not a good idea,” he says. “They are has a direct impact on the bottom line.” (For an not able to find enough young, highly qualified example of a comprehensive corporate approach workers, so they ask us to collaborate and offer to preventive health, please see box, “Dow: A prevention programmes.” focus on prevention”.) Dow: A focus on prevention Dow is a global leader in corporate healthcare. It continues throughout their career, assessing started developing healthcare programmes ten health risks, followed by counselling and years ago and has developed a comprehensive referral where necessary. and strategic approach to preventive health. A team of health promotion managers runs a Dow has rolled out preventive health broad variety of activities and initiatives all programmes for all its employees worldwide and feeding into each other. Dow Health Days, for claims the payback is substantial. It has seen example, focus on a specific issue (Walk at Dow a 23% reduction in smoking among employees Day, Dow No-Tobacco Day). There are opt-in since 2004 and an improvement in weight at six-week group programmes focusing on areas a time when the rest of the country is getting like stress resistance or weight management. heavier. Its targets are to reduce key indicators, In addition, there is more targeted outreach such as average levels of smoking, body through a Health Assessment Programme, which mass index, blood pressure and so on, by ten begins when employees join the company and percentage points over ten years.18 © The Economist Intelligence Unit Limited 2012
  20. 20. Never too early: Tackling chronic disease to extend healthy life years BMW has embraced this shift as a way to ensure Healthier companies, too that it remains competitive. In 2007 the luxury Reducing absenteeism has been one of the major German car company realised that the average focuses of corporate healthcare programmes age of its workers in its Dingolfing plant in in the UK and France, where companies feel Bavaria would rise from 39 to 47 over the less direct pressure from rising medical costs. next decade. Rather than seeking to find and Unilever has led the way in the UK with the train younger workers, the company looked at launch of a pilot “Fit Business” programme in redesigning production to help older workers 2009, which was rolled out across the UK in 2010 keep working and remain healthy. after showing a decline of 19% in sick leave, a reduction in obesity of 26% and reduced risk The first step was research. BMW created of developing cardiovascular diseases. At a Line 2017, with 41 volunteer employees who cost of only £35,000, the returns from lower collectively matched the demographics that sick leave alone were threefold. Unilever’s were expected to exist at the plant in that programme focuses on free health checks with year. They employed a research team to collect clear explanations of what is being measured, information from the employees on all the and easy-to-use advice on nutrition and exercise. aches and pains they experienced on the job, The programme is evaluated on three criteria: as well as suggestions on how conditions might absenteeism, employee involvement and a survey be improved to reduce or eliminate these. on the impact on attitudes towards work and life. Employees on the experimental line also voted on which of these changes they thought would A French railway operator. SCNF. is also focusing be most desirable. on reducing absenteeism through its new healthcare scheme. Average days lost to non- None of the innovations was huge: they included work-related illness has been rising steadily, items such as softer flooring, adjustable growing by 14% between 2007 and 2010. So the worktables, easy exercises and lighter work company launched a “Healthier Life” scheme shoes. The health implications were, however, in February 2012, following a successful pilot dramatic. Absenteeism due to sick leave dropped project in Brittany. All workers will be screened from 7% to 2%. The company also benefited for body mass index and those regarded as financially. Although the speed of the line was overweight will receive advice on diet and reduced by one-third, productivity increased exercise and will be monitored on a monthly by 7% and had an almost zero error rate. When basis. The company has set a target to reduce sick the experiment ended, the volunteers returned leave by 32%. to their old lines, but BMW is rolling out the changes—and researching new ones—across all The focus of the programmes can vary depending its Bavarian plants. on the needs of the staff. One particularly serious concern for many firms is stress, which the Towers “Enabling older employees to be productive Watson survey listed as the leading health issue longer is not just about helping workers stay among EMEA companies. KKH-Allianz developed healthy; it’s about creating an environment an anti-stress programme for a hospital in conducive to health, activity, and continuous Hannover where nurses faced high stress levels. learning,” says Dr Michael Hodin, executive A multi-pronged approach, which combined director of the Global Coalition on Aging. “The advice on how to work in a way that reduced or result will help extend active and healthy years eliminated stress, how to live with heightened in employment and, more importantly, is the key stress levels and programmes in muscle to winning the competitiveness race of the 21st relaxation, has reduced the number of sick days century,” he says. markedly, and let people stay on the job longer. © The Economist Intelligence Unit Limited 2012 19

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