Chapter 3

Cost of Cardiovascular Diseases

Cardiovascular diseases have a significant economic impact in Canada.  In its report, Economic Burden of Illness in Canada, 1998, Health Canada estimated the total cost of cardiovascular diseases on the health sector of the Canadian economy to be $18,472.9 million (11.6% of the total cost of all illnesses), which includes a direct cost of $6,818.1 million (8.1% of the total direct cost of all illnesses) and an indirect cost of $11,654.8 million (15.4% of the total indirect cost of all illnesses). 

“Direct costs are defined as the value of goods and services for which payment was made and resources used in treatment, care and rehabilitation related to illness or injury.  The five direct cost components in this report are organized and measured in terms of hospital care expenditures; drug expenditures; physician care expenditures; expenditures for care in other institutions; and additional direct health expenditures (including other professionals, capital, public health, prepayment administration, health research, etc). Other direct costs borne by patients or other payers (such as costs for transportation to health providers, special diets and clothing) are not included.

Indirect costs are defined as the value of economic output lost because of illness, injury-related work disability, or premature death.  The three indirect cost components in this report are measured in terms of the value of years of life lost due to premature death (mortality costs), and the value of activity days lost due to short-term and long-term disability (morbidity costs due to long- and short-term disability). Other indirect costs, including the value of time lost from work and leisure activities by family members or friends who care for the patient, are not included in this report.” (EBIC)

 

In 1998, the total economic burden of illness was $159,434.5 million dollars - $83,954.9 million in direct costs and $75,479.6 million in indirect costs.  $38,266.0 million of total costs could not be assigned to any particular disease category.  These “unattributable” costs constituted a significant proportion (24.0%) of the total costs.  Thus, the total costs related to cardiovascular diseases could be much higher.   

The direct, indirect and total costs for 1998 were less than those incurred in 1993, when calculated using 1998 dollars (Table 3-1).  There is no clear explanation for this.  However, unattributable costs were much higher in 1998 compared to 1993 (38,266.0 million compared to 29, 443.6 million, respectively) representing an increase from 17.6% to 24.0% of total costs.  Their impact on the cost of cardiovascular diseases is uncertain.  Nonetheless, understanding how to control costs and maximize efficiency is an imperative.

Table 3 - 1

Table 3-1        Cost Components of Cardiovascular Diseases, Canada,
1993 and 1998 (in 1998 $000,000s)

Cost Type

Cost

(in 1998 $000,000s)

Change*

 

1993

1998

$

%

Direct Costs

$7,845.5

$6,818.1

-$1,027.4

-13.1

Indirect Costs

$13,193.7

$11,654.8

-$1,538.9

-11.7

Total Costs

$21,039.2

$18,472.9

-$2,566.3

-12.2

* Interpretation is confounded by the increase in “unattributable” costs between 1993 and 1998.

Source: Health Canada.  Economic Burden of Illness in Canada, 1998 (Catalogue #H21-136/1998E).
Ottawa: Public Works and Government Services Canada; 2002.

 

In terms of the direct costs of cardiovascular diseases in Canada in 1998, the major cost components were: hospital care ($4,161.8 million; 61.0% of CVD direct costs), drugs ($1,772.8 million; 26.0%), physician care ($822.3 million; 12.1%), and additional direct health expenditures including research ($61.2 million; 0.9%).

The major components of the indirect cost of cardiovascular diseases in 1998 were: costs due to mortality (as cost of premature death) ($8,250.0 million; 70.8% of CVD indirect costs), morbidity due to long-term disability ($3,151.5 million; 27.0%), and morbidity due to short-term disability ($253.3 million; 2.2%).

Direct and Indirect Costs of Cardiovascular Disease Compared to Other Diagnostic Categories

In 1998, costs attributable to cardiovascular diseases were the largest among all diagnostic categories in terms of total cost, followed by musculoskeletal, cancer and injuries (Figure 3-1). 

Figure 3 - 1


In terms of direct costs, cardiovascular diseases were the most costly disease category and 1.5 times higher than mental disorders, the next largest disease category.  Although they were third highest in indirect costs after musculoskeletal conditions and cancer, the difference between cardiovascular diseases and cancer was small.  There was a significant drop (approximately $2 billion) between these two conditions and the fourth-ranked diagnostic category (injuries).  

Demographics of the Costs of Cardiovascular Diseases

The costs of cardiovascular diseases in Canada were higher for men than for women in all categories except drugs (Table 3-2).  Costs were highest in the 65+ year age group for all components, except for long-term and short-term disability, both of which were highest in the 35-64 year age group (Table 3-3).  Costs were low in the <35 year age group in comparison to older Canadians.

Table 3 - 2

Table 3-2        Selected Costs, Cardiovascular Diseases by Sex, Canada, 1998 (in $000,000s)

Component

Males

Females

All

Hospital Care

$2,338.0

$1,823.8

$4,161.8

Drugs

$836.0

$903.2

$1,772.8

Physician Care

$432.3

$389.2

$822.3

Mortality (as cost of premature death)

$5,280.1

$2,970.0

$8,250.0

Long-Term Disability

$1,976.3

$1,175.2

$3,151.5

Short-Term Disability

$176.3

$77.0

$253.3

Source:    Health Canada. EBIC On-line. Policy Research Division, Strategic Policy Directorate. 
URL: <http://www.ebic-femc.hc-sc.gc.ca/> Date of access: February, 2003.

 

 

 

 Table 3 - 3

Table 3-3        Selected Costs, Cardiovascular Diseases by Age Group, Canada, 1998 (in $000,000s)

Component

Age Group

 

0-14 years

15-34 years

35-64 years

65+ years

Hospital Care

$47.5

$97.9

$1,278.0

$2,730.3

Drugs

$10.6

$46.0

$735.3

$963.3

Physician Care

$7.2

$31.8

$323.5

$459.8

Mortality (as cost of  premature death)

$36.5

$215.5

$3,891.2

$4,106.8

Long-Term Disability

Data N/A

$208.8

$1,664.6

$1,061.3

Short-Term Disability

Data N/A

$44.6

$166.1

$42.7

Source:   Health Canada. EBIC On-line. Policy Research Division, Strategic Policy Directorate. 
URL: <http://www.ebic-femc.hc-sc.gc.ca/> Date of access: February, 2003.

 

Costs of Cardiovascular Diseases by Province/Territory

Per capita health costs related to cardiovascular diseases vary among the provinces and territories (Figure 3-2).  The variation may be due to differences in physician practices or coding practices across the country.  Table 3-4 outlines selected costs for cardiovascular diseases by province/territory.

 Figure 3 - 2

 

 

 

 Table 3 - 4

Table 3-4        Selected Costs, Cardiovascular Diseases by Province/Territory, Canada, 1998 (in $000,000s)

Province

Category

 

Hospital Care

Drugs

Physician Care

Mortality
(as cost of premature death)

Long-Term Disability

Short-Term Disability

British Columbia

532.5

192.5

95.4

939.7

394.8

41.8

Alberta

349.0

143.1

60.0

674.2

309.5

23.7

Saskatchewan

116.7

52.5

23.9

299.7

49.9

4.8

Manitoba

153.2

59.0

25.3

346.2

143.1

8.9

Ontario

1,521.0

770.6

383.3

2,957.8

1,084.8

95.6

Quebec

1,096.4

411.7

178.2

2,231.6

668.0

52.1

New Brunswick

106.1

42.6

16.8

230.2

203.4

8.9

Prince Edward Island

18.8

8.8

2.0

37.9

20.0

1.2

Nova Scotia

150.5

59.2

24.8

304.4

146.2

11.4

Newfoundland

91.3

28.1

11.7

213.1

131.8

5.0

Yukon

3.8

1.5

0.1

Data N/A

Data N/A

Data N/A

Northwest Territories

22.3

3.0

0.8

10.3

Data N/A

Data N/A

Source:   Health Canada. EBIC On-line. Policy Research Division, Strategic Policy Directorate. 
URL: <http://www.ebic-femc.hc-sc.gc.ca/> Date of access: February, 2003.

 

Direct and Indirect Costs of Cardiovascular Disease by Disease Subcategory

Ischemic heart disease led stroke (30.6% versus 17.2% respectively) as the leading contributor to hospital care costs for cardiovascular diseases (Table 3-5).  Among birth defects, congenital cardiovascular disease contributed to 37.2% of hospital care costs. 

In 1998, hypertension was the leading contributor to drug costs among cardiovascular diseases (49.6% of cardiovascular disease drug costs).  Drugs for ischemic heart disease accounted for 28.9% of the cost of cardiovascular disease drugs.

One-third (33.5%) of the costs associated with mortality (as cost of premature death) due to cardiovascular diseases were attributed to acute myocardial infarction.  When combined with all other listings of ischemic heart disease, this percentage rose to 58.7%.  Stroke also made a major contribution to mortality costs (15.2%).  Among all birth defects, congenital cardiovascular disease contributed to 47.0% of the cost associated with mortality (as cost of premature death).

The major contributors to costs of long-term disability due to cardiovascular diseases were ischemic heart disease (18.0%) and stroke (13.2%).

 Table 3 - 5

Table 3-5        Selected Costs for Cardiovascular Diseases Diagnostic Subcategory, Canada, 1998 ($000,000s)

Cardiovascular Disease Condition

Cost

$000,000

(% of CVD Costs in Category)

 

Hospital Care

Drugs

Mortality (as cost of premature death)

Long-term Disability

Aortic Aneurysm

$103.2

(2.5%)

 

$236.9

(2.9%)

 

Cerebrovascular Disease (excluding Stroke)

$158.8

(3.8%)

 

 

$71.8

(2.3%)

Stroke

$714.4

(17.2%)

 

$1,255.4

(15.2%)

$415.7

(13.2%)

Cerebral Infarction

 

$29.1

(1.7%)

 

 

Ischemic Heart Disease (including AMI)

$1,274.8

(30.6%)

$512.7

(28.9%)

$4,845.8

(58.7%)

$567.9

(18.0%)

Ischemic Heart Disease (not including AMI)

 

 

$2,081.5

(25.2%)

$346.6

(11.0%)

Acute Myocardial Infarction (AMI)

 

 

$2,764.3

(33.5%)

$221.3

(7.0%)

Hypertension

 

$880.0

(49.6%)

 

 

Congenital CVD

$48.5

(37.2% of birth defects)

 

$168.3

(47.0% of birth defects)

 

Source:   Health Canada.  Economic Burden of Illness in Canada, 1998 (Catalogue #H21-136/1998E). 
Ottawa: Public Works and Government Services Canada; 2002.

 

Methodology

The Economic Burden of Illness in Canada, 1998 report includes a description of the methodology for determining direct and indirect costs (p. 1).  The full report is available at the following Web site: http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/ebic-femc98/

“With the exception of mortality costs, a prevalence-based approach was used to estimate all direct and indirect costs that accrued to existing (or prevalent) cases of illness, injury, or disability in 1998.  This approach makes the best use of the survey and administrative data that are available for calculating core direct and indirect costs and, in turn, for distributing these costs across primary diagnostic categories. A limitation of this approach is that the data do not always allow for an assessment of the impact of co-morbid conditions.

“For mortality costs, an incidence-based human capital approach most commonly used in cost-of-illness studies was used.  Mortality cost estimates are based on the discounted value of current and future costs of premature deaths occurring in 1998, rather than a prevalence-based approach in which estimates would be based on the 1998 dollar value of premature deaths that occurred prior to 1998. While it would have been preferable to use a prevalence-based approach for all cost components, this approach is used here for several reasons: the availability of reliable statistics, the relative simplicity of calculations compared with other methods, and consistency across studies using the same approach.  The limitations of this approach, which include the possibility of over-estimating mortality costs and under-valuing psychosocial consequences, are discussed further in the mortality cost chapter and EBIC 1993.”

Discussion

Cardiovascular diseases are the most costly contributors to both direct and indirect health costs in Canada - they are also largely preventable.   Approximately 80% of the population has at least one modifiable risk factor for cardiovascular diseases. Therefore, decreasing these risk factors in the population can have a great impact on reducing the costs of cardiovascular disease.

The commonly held perception is that cardiovascular diseases affect primarily older people.  While many of the health care costs are associated with individuals 65 years of age and over, cardiovascular diseases among younger adults also have a major economic impact.  Preventing cardiovascular diseases in this age group, then, has long-term economic implications.   

Hospitalization for cardiovascular diseases costs over $4 billion annually.  Since hospitalization rates increase with age (see Chapter 2) and the number of individuals over the age of 65 years in Canada is growing, hospital costs are likely to increase in the future.

The number of prescription drugs for cardiovascular diseases has been increasing.  Thus, the cost due to prescription drugs is also likely to increase in the future.

The Economic Burden of Illness in Canada, 1998 faced significant challenges in the use of existing data to describe the economic burden of illness in Canada from a health perspective.  One major obstacle that EBIC faced is that health care costs associated with other aspects of health problem management, such as home care, residential care and therapy are difficult to capture and difficult to assign to particular disease categories and are, therefore, assigned as “unattributable” costs.   The high proportion of “unattributable” costs makes analysis and interpretation of the data difficult, and calls for a refinement and improvement in data collection.  In addition, greater detail in the data analysis would permit tracking of changes in one cost component in relation to others for specific diseases. 

The most recent report on the economic burden of illness uses data from 1998.  While this is useful from a research perspective, the time lag limits its application for surveillance.  Policy-makers who are making decisions for the year 2003 need more current information.

Implications for Action

·                Invest in the prevention and reduction of risk factors for cardiovascular diseases to decrease the economic burden of cardiovascular diseases in Canada.

·                Develop effective and less expensive alternatives to hospital care for cardiovascular disease problems to mitigate against the anticipated increase in hospital costs associated with acute care.

·                Improve the timeliness and quality of existing administrative data and develop additional data sources to enhance the use of economic data for surveillance purposes.