Brain disorders represent 35% of the total disease burden in Europe and 37% of the total disease burden in European regions with very low child mortality and low adult mortality; the latter group includes Italy.1 The negative socioeconomic impact of this burden is reflected in two fundamental issues: consumption of resources and state of health.2
Brain disorders represent 35% of the total disease burden in Europe and 37% of the total disease burden in European regions with very low child mortality and low adult mortality; the latter group includes Italy.1 The negative socioeconomic impact of this burden is reflected in two fundamental issues: consumption of resources and state of health.2
In recent years, the European Brain Council (EBC), a co-ordinating council formed by European organisations in psychiatry, neurology, neurosurgery, basic neuroscience and European patient associations, has encouraged and supported projects aimed at analysing the socioeconomic burden of brain disorders in Europe. These initiatives were ultimately intended to provide recommendations on research, teaching and awareness in public health.
Within the EBC, the pan-European study on Cost of Disorders of the Brain in Europe (CDBE) aimed at reporting the best possible estimates of the cost of 12 brain disorders (addiction, affective disorders, anxiety disorders, tumours, dementia, epilepsy, migraine and other headaches, multiple sclerosis, Parkinson’s disease, psychotic disorders, stroke and trauma) based on the existing literature, using an ad hoc cost model.3 Other disorders of the brain, such as amyotrophic lateral sclerosis and neuromuscular and developmental disorders, were not included in the CDBE because of heterogeneity or lack of epidemiological and/or cost data.
In the CDBE, costs were assessed under a societal perspective. Included were healthcare costs regardless of who pays (the individual, a private insurer or the public through taxes and social insurance), as well as costs outside the medical sector.
The aggregated results for Italy from the CDBE study have been published elsewhere4 and are reviewed in this article.
Materials and Methods
The methodological bases with regard to the epidemiological analyses and cost studies for this review have been described in detail elsewhere.1 In brief, data from European cost-of-illness studies were collected. Direct medical and non-medical costs and indirect costs were included in the analysis. Intangible costs (i.e. the economic value of disease-related pain, suffering and loss of quality of life) could not be considered. All economic data were transformed to euros and were referred to 2004. The cost data were expressed in an international measure, the purchasing power parity (€PPP) exchange rate, which allows comparisons of economic data between countries by equalising the purchasing power of different currencies for a given basket of goods.
Cost Model
Three major sources of data were combined to predict the cost of these brain disorders: economic data, epidemiological data and international statistics. Disease-specific prevalence data and the annual cost of a case with the defined disease were collected separately. Bottom-up cost studies conducted at patient level were included to estimate the disease costs for 2004. The total cost of a single disorder was thus the product of the prevalence and the cost per case. When Italian epidemiological and cost data were not available for an individual brain disorder, the values were predicted by the model by extrapolating data from other European countries. Prevalence data were stratified according to age, gender and disorder severity, if applicable. The validated model and prediction methods, as well as the sensitivity analysis to test the cost model, have been described in detail elsewhere.3,4,5 The key parameters employed in the costing model were tested in a sensitivity analysis.
Results
Prevalence
The CDBE study was based on the prevalence of the 12 brain disorders as estimated for 2004.1 Estimates for Italy are reported in Table 1. No country-specific prevalence data were available at that time for illicit drug dependence and psychotic disorders, including schizophrenia and schizoaffective and delusional disorders.
For brain tumours and trauma, incidence data were also available. The overall age-standardised incidence rate of malignant brain tumour for Italy was estimated at 6.2 per 100,000 in men and 4.2 per 100,000 in women.6 As for brain trauma, incidence rates were reported for the calendar year 1998 at between 250 and 314 per 100,000 in Romagna and Trentino, with peaks at one to four, 20–30 and ≥70 years of age.7
Based on these rates, in Italy the estimated total number of individuals with any of the 12 brain disorders considered was 12.4 million in 2004, i.e. more than 20% of the Italian population. The distribution of estimated cases with brain disorders in Italy by clinical condition is presented in Figure 1.
Cost per Patient
The cost per patient for each of the 12 brain disorders is shown in Figure 2. The highest cost was found for brain tumours and multiple sclerosis, whereas the lowest was for anxiety disorders and migraine.
Total Cost of Brain Disorders
The direct, indirect and total costs of the 12 brain disorders in Italy, calculated in €PPP million, was estimated at €40.8 billion (see Table 2). The sensitivity tests gave an estimated cost range of €30.9–51.0 billion.
The most relevant sources of expenditure were psychotic/affective disorders and addiction (€18.7 billion), followed by neurological (€12.4 billion) and neurosurgical disorders (€1.0 billion). Dementia was the most expensive brain disorder (€8.6 billion). Among the neurological disorders, migraine was most costly (€3.5 billion), followed by stroke (€3.4 billion) and epilepsy (€2.3 billion). Direct medical costs were the leading cost item for psychiatric and neurosurgical disorders, direct non-medical costs for dementia and indirect costs for neurological disorders.
Cost of Brain Disorders by Resource Items
These data are presented in detail in Table 3. Direct medical and non-medical costs amounted to €17.1 billion and €11.1 billion, respectively, or 42 and 27% of total costs, respectively. Brain disorders represented 14% of the total direct healthcare costs in Italy, with 7% of the total drug sales attributed to the treatment of brain disorders.
Indirect costs were €12.6 billion (31%), mostly due to production loss for sick leave. The total cost of brain disorders (direct and indirect) represented 3% of the country’s gross national product.
Cost of Brain Disorders per Inhabitant
The overall cost of brain disorders per Italian citizen has been estimated at €706 per year. A more detailed breakdown is provided in Table 4.
Discussion
In this review, the estimated cost of 12 brain disorders in Italy in 2004 highlights a relevant economic burden for the country, as it accounts for up to 3% of gross national product and costs each citizen €706 per year.
Psychiatric disorders account for more than half of the total costs, especially psychotic and affective disorders. Schizophrenia in particular is one of the most costly psychiatric illnesses.8 Anxiety and migraine are fairly inexpensive per single patient but, due to their high prevalence, they are very expensive at a societal level.
While affective disorders are the most costly brain disorders in Europe,3 dementia is the most costly brain disorder in Italy. This difference can be explained by an underestimation of the number of affective disorders in Italy due to scarce epidemiological reports in relation to cultural attitudes. Italians are less prone than other Europeans to consider depression a medical problem and thus worthy of medical care. A survey has shown that medical advice in view of the depressive symptoms was never sought by 62% of the subjects classified as suffering from major depression.9 However, having three or more physician visits and drug therapies was twice as common and having four or more instrumental examinations was three times as common in patients with major depression compared with non-depressed individuals. Significant loss of productivity at work or as part of global activities was four times more common in patients with major depression than in non-depressed individuals.
Alcohol consumption is widespread in Italian communities, and a large proportion of the population drinks above the World Health Organization (WHO)-established cut-off, i.e. 40g/day for males and 20g/day for females.10 ‘Heavy drinking’ is significantly higher in females compared with males, with regional differences that are important to consider from a socioeconomic perspective. In the past 20 years, Italian lifestyles have changed radically, and alcohol habits have changed, with increased consumption especially in the young adult female population; this can be attributed to women’s emancipation and a social levelling-off between the genders.11 From a health economic perspective, the burden of high alcohol consumption must be viewed not only as a ‘brain’ disorder (dependence) but also as a cause of increased morbidity (hepatic cirrhosis, gastrointestinal disorders, cardiomyopathy, poly-neuropathy, haemorrhagic stroke and mortality); its burden accounts for up to 5% of the gross national product of industrialised European countries.12
Gerzeli and co-workers13 have estimated that the societal costs in the first six months following stroke were €11,600 per patient, 53% of which was direct medical costs, 39% direct non-medical costs and 8% indirect costs. Age, disability level and type of hospital ward were the most significant predictors of such costs.
The drug costs for brain disorders account for only 7% of the total Italian drug market. In Italy direct medical costs compared with non-medical costs were proportionally higher for neurosurgical and psychiatric disorders and for migraine and stroke. The direct non-medical costs especially dominated multiple sclerosis and dementia, the difference being due to the clinical features of the diseases and/or their differential management.
The overall economic burden of brain disorders in Italy, as well as in other European settings, is very likely underestimated due to lack of reliable prevalence and economic data for some disorders. Moreover, as for stroke, brain tumour and trauma, the costs are grossly underestimated as they are based on incidence. The costs of brain trauma were between €5,622 and €8,951, as predicted from other European countries. However, based on the Diagnosis Related Group (DRG) system, the estimated cost of severe brain trauma with tracheostomy due to prolonged coma was €53,922 in Emilia Romagna, and €10,134 if based on the DRG for craniotomy due to trauma, even in patients with a mild to moderate injury. Based on DRG, mildly injured patients admitted to the hospital with head concussion cost between €2,286 and €4,078. Furthermore, the cost of admission to an Italian hospital is €940 per day in neurosurgical wards and close to €2,000 per day in intensive care units.14
Methodological Considerations
Study design, population sampling method and accuracy of assessment and diagnosis vary among studies. Crude rates reflect different population age structures, and comparisons between age-and sex-standardised rates to a common referral population are almost always unavailable. Prevalence is not univocally expressed, and estimates can be found as point-prevalence, one-year prevalence or lifetime prevalence.
Most of the cost-of-illness studies considered for implementing the cost model were prevalence-based and bottom-up, a design that is limited to small samples of patients and might preclude inferences to the general target population. Most of the reported health economic studies do not include indirect nor intangible costs. Also, due to co-morbidity, allocating patients to different groups of disorders can be problematic, and double-counting of costs may be underestimated. If cost studies are incidence-based, they cover only the first year with disease, which is generally the most expensive.
For age-related conditions such as dementia and stroke, recruitment of elderly populations is complex and potentially affected by selection bias, as individuals are more easily enrolled from institutions.15 On the other hand, severe cognitive disorders and old age may lead to higher refusal rates, interfering with the health economic assessment. Epidemiological and cost data on child-related disorders are especially scarce.
Conclusions
Due to the ageing of the Italian population, the socioeconomic burden of brain diseases is expected to increase remarkably. Qualified research is needed in this field using prospective designs and standardised screening instruments in order to obtain comparable epidemiological and cost data at a national and international level. ■
