Costs associated with cardiovascular disease create a significant burden for society and they seem to be globally underestimated

Cardiovascular disease (CVD) is responsible for more deaths worldwide than any other condition, and a large proportion of healthcare budgets is spent on its diagnostics, treatment and prevention. Globally, there were an estimated 422.7 million prevalent cases of CVD (95% uncertainty interval (UI) 415.53 to 427.87 million cases) in 2015.1 The age-standardised prevalence of CVD varied significantly by country. There were 12.59 million deaths (95% UI 12.38 to 12.80 million deaths) due to CVD in 1990, increasing to 17.92 million deaths (95% UI 17.59 to 18.28 million deaths) in 2015. The financial burden of CVD is also increasing. In 2009, the CVD-related costs amounted to €106 billion (9% of total healthcare expenditure across the European Union). Less than 10 years later, in 2017, the overall CVD costs have been estimated at €210 billion a year.2 Ischaemic heart disease was the leading cause of CVD health losses globally, as well as in each world region, followed by stroke. About a half of the CVD burden is caused by direct healthcare costs, 26% by work productivity losses and 21% by informal care. Despite the fact that the loss of productivity results in a significant burden for individual CVD patients, their families, caregivers and society as a whole, it is a relatively underexplored topic. Most studies devoted to the CVD burden are focused only on direct costs (costs related to goods, services and other resources used for treatment and prevention of CVD). Indirect costs, which refer to productivity gains or losses relating to illness or death, are much less likely to become an object of studies. The article ‘Patient and caregiver productivity loss and indirect costs associated with cardiovascular events in Europe’3 by Kornelia Kotseva from Imperial College of London and her colleagues from Paris Bichat Hospital and Ghent University is devoted to this insufficiently studied problem, and in this regard is of great interest for both cardiologists and public health specialists. This article presents the results of original research assessing productivity loss and indirect costs in the year following an acute coronary syndrome (ACS) and a stroke. This comprehensive approach to the assessment of both patients’ and caregivers’ productivity loss and indirect costs is unique, because previous research mostly focused on patients’ absenteeism, presenteeism, early retirement or unemployment and premature mortality. In addition, cost-effectiveness strongly depends on social determinants. Hence, results obtained in one country may not be valid in another. The undoubted value of that study is the fact that it was conducted in seven European countries, including Belgium, France, Poland, Portugal, Spain, Switzerland and the United Kingdom. The analysis of productivity losses in ACS and stroke patients was based on contemporary methodology. Patients’ work absenteeism, presenteeism and caregiver time were studied by means of a validated questionnaire (productivity cost questionnaire) and combined with time-off due to initial hospitalisation/sick-leave. Hours lost were valued according to country labour cost (€2018). In total, 394 patients, including 196 post-ACS patients and 198 patients who had a stroke in the period from 3 to 12 months (average 6–7 months) before inclusion were recruited during a routine consultation at cardiologist's and neurologist's practice. All patients included in the study were working after the index event (70% were ‘white-collar’ employees). The study demonstrated substantial productivity losses and indirect costs in the first year following cardiovascular events – ACS (mostly myocardial infarction) and strokes (99% of which were ischaemic). Similar conclusions showing that CVD imposes substantial morbidity and mortality-related productivity costs were reached in a big review by Adam Gordois and colleagues.4 The high importance of the approach used by Kornelia Kotseva and coauthors with regard to inclusion in the study of patients with both ACS and stroke should be emphasised, because these are the two most serious cardiovascular complications associated with a large economic burden for society. The different impact of these cardiovascular events on patients' daily lives is well known, although the comparative analysis of productively losses and indirect costs associated with these complications revealed interesting and somewhat unexpected results. The mean total productivity time loss for ACS and stroke was similar: 70 workdays for ACS and 68 for stroke (25% of annual workdays). After ACS patients lost 59 workdays due to absenteeism and presenteeism, and their caregivers lost 11 workdays helping patients, after stroke – 80 and 73 workdays, accordingly. The total mean indirect cost per case was €13,953 for ACS and €13,773 for stroke. Thus the productivity loss estimates were not higher after a stroke compared to ACS as usually expected. This could be connected with the peculiarities of the included stroke patients – most of them had 0–1 scores on the modified Rankin Scale and were able to work after the stroke. As only patients who returned to work after ACS and stroke were included in the study by Kotseva and coauthors, the assessment of indirect costs applies only to this group of patients and does not apply to those patients who died (who had 100% productivity losses) or lost their ability to work as a result of cardiovascular events. Thus it is obvious that the total indirect costs of ACS and strokes are much more significant. A more comprehensive approach considering indirect costs in all patients who had ACS and strokes (not only those who returned to work) may be the focus of further research. The study revealed some country-specific differences for patient and caregiver indirect costs after cardiovascular events. Although differences were modest, the results highlight the heterogeneity across countries, which could be explained by different labour costs, social security, employment and caregiver practices (Figure 1). The data emphasise a high burden of cardiovascular events not only for patients themselves, but also for their close relatives and families. Mean patient and caregiver annual indirect costs in acute coronary syndrome and stroke. ACS: acute coronary syndrome; BE: Belgium; CH: Switzerland*; ES: Spain; FR: France; PL: Poland; PT: Portugal; UK: United Kingdom. Hourly labour costs in Euros adjusted for PPP (EuroStat 2017, updated to 2018 using the labour cost index): Belgium: 37.03; France: 32.8; Poland: 17.64; Portugal: 17.54; Spain: 22.58; Switzerland***: 32.71; United Kingdom: 25.33. Exchange rates per 1 Euro (EuroStat 2017): 1.11 CHF, 4.25 PLN, 0.89 GBP. *Based on N = 9 patients. **Due to the way healthcare for stroke patients is set up in Switzerland, patients who were recruited into the study had mild neural consequences from the stroke hence relatively low costs. ***FSO: Federal Statistical Office; Switzerland is not included in the Eurostat report; the 2014 labour cost value from FSO was updated to 2018 using the Swiss wage index. The P value for difference in annual indirect cost ACS versus stroke was not significant (Student's t-test P = 0.92). A large proportion of patients who survived after ACS and stroke and were included in the study had elevated low-density lipoprotein cholesterol levels, despite being on lipid-lowering therapy. Similar results regarding post-ACS patients were obtained in the EUROASPIRE V study.5 More aggressive secondary prevention including more aggressive lipid lowering are crucial to obtain better outcomes in this very high cardiovascular risk population. Another way to improve the outcomes and thus to reduce the CVD cost burden is to increase the uptake rates of cardiac rehabilitation (CR). Unfortunately, despite its well proved positive impact on cardiovascular mortality and a high class of recommendations according to the current guidelines,6 CR is significantly underused in European countries. According to a recent analysis also performed by Kotseva et al.,7 the coverage of CR in EUROASPIRE IV coronary heart disease patients after ACS and revascularisation procedures was only 41%. Although the authors considered CR accomplished if patients attended at least half of the recommended sessions, the rehabilitation group showed much better control of certain risk factors at follow-up, such as smoking and low physical activity. Some limitations of the study, including a small sample size in some countries, are well discussed by the authors. The paper by Kotseva et al.3 is devoted to a very important healthcare problem, because productivity loss and the indirect costs of both patients and their caregivers are major contributors to total costs associated with CVD worldwide. The results of the study may be used to inform and populate societal economic evaluations in CVD and also to guide policy-makers who are focused on reducing the overall burden of CVD and achieving specific global health targets for CVD. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.