Discussion 6: Health Status in the European Union

European Journal of Internal Medicine 32 (2016) e13–e14

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European Journal of Internal Medicine

journal homepage: www.elsevier.com/locate/ejim

Letter to the Editor

No correlation between health care expenditure and mortality in the European Union

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Fig. 1. Trends of aggregate health care expenditures and mortality in the European Union from the year 2000 to the year 2013 (Fig. 1a), and correlation between variation of health care expenditures and mortality over the same period normalized for data of the year 2000 (Fig. 1b).

Keywords: Health care expenditure Health care costs Mortality Deaths

There is ongoing debate about the impact of aggregate health care expenditure on health outcomes, and it also remains quite uncertain whether increasing health spending may be a significant factor for decreasing death rates. In 1991, Mackenbach published an interesting analysis to establish whether a higher national level of health care expenditure could be associated with a larger degree of success in decreasing mortality within the European Community [1], concluding that no association existed between deaths and health care funding. Interestingly, no other comprehensive evidence has been published so far in Europe. Therefore, in order to establish whether or not any relationship exists between aggregate health care expenditure and mortality in the European Union in recent years, we analyzed data of overall mortality in the 28 European countries from the year 2000 to the year 2013, combined with those of the concomitant expenditure for health care (all functions). Health care costs were reported as per capita expenditure, including all financing agencies and all health care providers (i.e., both private and public). Mortality data were extracted from the official website of the European Union [2], whereas health care costs were retrieved from the Organization for Economic Co- operation and Development (OECD) [3]. For each year after the 2000, a ratio was calculated for both mortality and health care expenditure to normalize the data.

The results of our analysis are shown in Fig. 1. From the year 2000 to the year 2013, health care costs have constantly increased in the countries of the European Union, nearly doubling at the end of the observational period (Fig. 1a). At variance, the mortality trend did not follow a consistent trend from the year 2000 to the year 2013, exhibiting peaks (e.g., in the year 2003) and troughs (e.g., in the year 2004) (Fig. 1a). When the ratio of health care expenditures and mortality of each single year (both normalized for the data of the year 2000) were correlated, the line of the resulting equation was nearly flat, exhibiting a Spearman's correlation coefficient of 0.55 (95% CI, −0.01 to 0.84; p = 0.054) (Fig. 1b).

Taken together, the results of our analysis confirm previous data published by Mackenbach in the 1991 [1], in that no apparent associa- tion currently exists between health care expenditure and success in reducing total mortality in countries of the European Union. Although the European and local funding of the health care systems has consis- tently increased over the past 15 years by more than 2-fold, and will probably continue to raise in the forthcoming years, the yearly mortality in Europe has remained virtually unchanged (i.e., 4.88 million deaths in

http://dx.doi.org/10.1016/j.ejim.2016.02.025 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rig

the 2000 compared to 4.99 million deaths in the 2013, i.e., +3%). This lack of association remained virtually unchanged using data of mortality rate rather than the overall mortality, wherein the population in the European Union has increased by less than 4% over the past 15 years, from 487 to 505 million inhabitants (2). Accordingly, the resulting Spearman's correlation between mortality rate and health care expen- ditures remained far from being statistically significant (r = −0.22; 95% CI, −0.69 to 0.38; p = 0.471).

The foremost and obvious conclusion of this study is that the amount of money spent on health care in the European Union is probably not producing comparable health benefits. Notably, a similar analysis per- formed between the years 2000 and 2004 in the US also found little cor- relation between reduced mortality and increased spending on patients [4]. In Europe, the only other recent analysis about health care costs and outcomes was published in 2006, concluding that an increase in health care expenditure may be associated with improvements in infant

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e14 Letter to the Editor

mortality, but only marginally in relation to life expectancy [5], thus providing further support to our data based on the total European population.

Therefore, and to put it simple, it is probably a matter of spending better rather than spending more on health care, in order to prevent that the (limited) available resources are wasted in suboptimal ways. A deepened root cause analysis based on reliable outcome indicators seems necessary to establish the main paths of care failure and correct the route toward a more effective health care spending. The lack of accountability for the overall quality and costs of care and a flawed approach that targets more care irrespective of the quality of that care are potential underlying drawbacks that should be addressed by future health care policies at the national and supranational levels.

Conflict of interest statement

All authors have no actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within 3 years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

References

[1] Mackenbach JP. Health care expenditure and mortality from amenable conditions in the European Community. Health Policy 1991;19:245–55.

[2] European Union. Mortality and life expectancy statistics. http://ec.europa.eu/ eurostat/statistics-explained/index.php/Mortality_and_life_expectancy_statistics# Main_tables. [Last access, 22 February 2016].

[3] Organisation for Economic Co-operation and Development. Health Expenditure and Financing. http://stats.oecd.org/index.aspx?DataSetCode=SHA. [Last access, 22 February 2016].

[4] Rothberg MB, Cohen J, Lindenauer P, Maselli J, Auerbach A. Little evidence of correla- tion between growth in health care spending and reduced mortality. Health Aff (Millwood) 2010;29:1523–31.

[5] Nixon J, Ulmann P. The relationship between health care expenditure and health outcomes. evidence and caveats for a causal link. Eur J Health Econ 2006;7:7–18.

Giuseppe Lippi Section of Clinical Biochemistry, University of Verona, Verona, Italy

Corresponding author at: Section of Clinical Biochemistry, University Hospital of Verona, P.le Ludovico Scuro 10,

Verona 37134, Italy. E-mail addresses: [email protected]; [email protected].

Camilla Mattiuzzi Service of Clinical Governance, General Hospital of Trento, Trento, Italy

Gianfranco Cervellin Emergency Department, Academic Hospital of Parma, Parma, Italy

22 February 2016