A methodology for an EU cross-country comparison: public expenditure on drug treatment in hospitals Freya Vander Laenen STRUCTURED SESSION Costs of drug treatment Lisbon Addictions 2017, 26/10/2017

Structure Date | Title Background Methodology Results Discussion

1. Background: why compare EU-countries on PE treatment? Date | Title Why a socio-economic study? Drug use and treatment policy => economic burden => challenges for public policy ~ austerity Why a cross-country comparison ? Learn about PE differences in national policies Learn where PE differences come from ~ number of drug users in treatment (per capita)? Unit cost of different types of treatment? …? Learn from other countries

Background => Guide decisions (on distribution) ~ public spending Date | Title => Guide decisions (on distribution) ~ public spending Which (treatment) options? What is the cost of different (treatment) options? What would it cost/save were we to change our (treatment) policy?

2. Methodology: what do we need for comparison? Date | Title valid cross-national comparison common conceptual and methodological framework => Look for international database(s) OECD, WHO, EMCDDA, UN, European Medicines Agency, European Centre for Disease Prevention and Control, World Bank Beware: cross-national descriptive comparison ≠ comparative policy analysis (Ritter et al., 2015)

Methodology: what did we find? Date | Title One database: Eurostat Data for hospitals: unit expenditure (cost per hospitalisation day) Hospital (1) days by primary diagnosis (2) and health care expenditures (1) Data for general, mental health and specialty hospitals (2) ‘mental and behavioural disorders due to psychoactive substance use’ *based upon International Statistical Classification of Diseases and Related Health Problems (ICD): Acute intoxication; Harmful use; Dependence syndrome; Withdrawal state => Average cost per hospital day x hospital days for treating illegal drug disorders

Methodology: limitations Date | Title Only 15 EU MS (no data Greece, Ireland, Italy, Malta, UK) – 8 countries incomplete data on hospital days Only when admission to hospitals Underestimation: No TC, outpatient, prison treatment, GP, … Overestimation inpatient hospital – since no distinction inpatient, emergency, outpatient hospital services Presumption: average cost for one day of e.g. cancer treatment = average cost for one day of SUD treatment ICD-10 – no distinction licit – illicit => overestimation of illicit + > PE for drug use as such Only primary diagnosis -> multiple diagnoses => possible underestimation of SUD Acute drunkenness (in alcoholism) - "Bad trips" (drugs) - Drunkenness NOS - Pathological intoxication - Trance and possession disorders in psychoactive substance intoxication Excl.: intoxication meaning poisoning (T36-T50)

3. Results Hospital days & expenditures illegal drug treatment, EU-15, 2012 Date | Title

Results of drug treatment PE voor EU-15 Date | Title Average of EU-15: 5 € per capita or 0,013% of GDP Large variation across EU member states Western European countries (e.g. Luxembourg, Austria, Germany): above average of EU-15 (7.2 - 39.5 €/capita and 0.022% - 0.056% of GDP) Eastern European countries (e.g. Romania, Lithuania, Bulgaria, Latvia): low hospital expenditures/capita (≤ 0.3 €) and in proportion to the GDP (0.002% of GDP) Why? E.g. Luxembourg: number of hospital days for drug treatment (30/1000 capita ) + cost per hospital day (1328 €) is high versus e.g. Romania (0,5/1000 capita – 83 €/hospital day)

4. Discussion: what proportion of cost did we find? Date | Title Hospital treatment = only part of PE on treatment Data on outpatient, harm reduction, social reintegration, … Proportion of patients in inpatient treatment 11 % (2 % France versus 79 % Luxemburg – EMCDDA, 2014) <-> cost for inpatient opioid detox 168 € - outpatient 7 € (Gossop & Strang, 2000)

Discussion: providing context from international databases Date | Title TDI: data on number of new clients entering treatment in EU => Differences in (use of) types of treatment Treatment gap/coverage: treatment needs versus treatment offer no positive correlation number of SUD ~ rate of hospital occupation => EMCDDA estimate prevalence rates problem drug users & TDI number of clients in treatment

Discussion: providing context from international databases Date | Title Eurostat and OECD databases economic and demographic data data on GDP, population (per capita PE) Eurostat data on healthcare expenditure by function (inpatient, outpatient, long-term, medical goods, prevention) Eurostat data by financing agent (general government, social security, private out-of-pocket) Mix of public and private health financing => differences in PE Eastern European countries lower proportion public financing healthcare (e.g. 54 % Bulgaria; 62 % Hungary) <-> Western European (e.g. 83 % Luxemburg, 77 % Germany) Eurostat: EU statistics on Income and Living Conditions (SILC) Socio-economic variabeles Income, poverty, social exclusion, living conditions What do we need: expenditure by type of health problem

Discussion: providing context Date | Title Even if no data on PE drug treatment… … Provide information on drug (treatment) policy, on health care policy, on financing agent, on drug treatment types and services, … + explain ≠ countries in (drug) treatment expenditures + could be applied to other health problems (+ comparison between)

Discussion: providing context Date | Title The power of “PE studies in times of austerity” => ideally link PE on type of treatment with effect of type of treatment ! EMCDDA Insights - Drug treatment expenditure: a methodological overview – 2017 !