Economic costs attributable to modifiable risk factors: an analysis of 24 million urban residents in China
Research article
Abstract
Background
Estimating the economic burden of modifiable risk factors is crucial for allocating scarce healthcare resources to improve population health.
This study quantified the economic burden attributable to modifiable risk factors in an urban area of China.
Methods
The Shanghai Municipal Health Commission dataset covered 2.2 million inpatient admissions for adults (age ≥ 20) in public and private hospitals in 2015 (1,327,187 admissions) and 2020 (837,482 admissions).
The researchers used a prevalence-based cost-of-illness approach by applying population attributable fraction (PAF) estimates for each modifiable risk factor from the Global Burden of Diseases Study (GBD) to estimate attributable costs.
The researchers adopted a societal perspective for cost estimates, comprising direct healthcare costs and productivity losses from absenteeism and premature mortality. Future costs were discounted at 3% and adjusted to 2020 prices.
Results
In 2020, the total societal cost attributable to modifiable risk factors in Shanghai was US$7.9 billion, mostly from productivity losses (67.9%).
Two health conditions constituted most of the attributable societal cost: cancer (51.6%) and cardiovascular disease (31.2%).
Three modifiable risk factors accounted for half of the total attributable societal cost:
- tobacco (23.7%),
- alcohol (13.3%), and
- dietary risks (12.2%).
The economic burden varied by age and sex; most of the societal costs were from males (77.7%), primarily driven by their tobacco and alcohol use.
The largest contributor to societal costs was alcohol for age 20–44, and tobacco for age 45 + .
Despite the COVID-19 pandemic, the pattern of major modifiable risk factors remained stable from 2015 to 2020 albeit with notable increases in attributable healthcare costs from cancers and productivity losses from cardiovascular diseases.
Conclusions
The substantial economic burden of diseases attributable to modifiable risk factors necessitates targeted policy interventions. Priority areas are reducing tobacco and alcohol consumption and improving dietary habits that together constitute half of the total attributable costs.
Tailored interventions targeting specific age and sex groups are crucial; namely tobacco in middle-aged/older males and alcohol in younger males.
More findings: alcohol’s societal costs
Tobacco, alcohol and dietary risks consistently ranked as the highest three risk factors for overall societal costs in 2015 and 2020.
Alcohol use remained the primary risk factor contributing to societal costs for those aged 20–44 years, and tobacco use for those aged 45 and over.
The researchers estimated the total societal costs of modifiable risk factors at US$8.0 billion in 2020. Productivity loss accounted for 67.9% of attributable societal costs at US$5.4 billion with US$2.5 billion from healthcare costs.
The leading risk factors for attributable societal cost were tobacco (23.7%, US$1.9 billion), alcohol (13.3%, US$1.1 billion), dietary risk (12.2%, US$1.0 billion), high body-mass index (9.7%, US$0.8billion), and air pollution (9.4%, US$0.7 billion.
Age-specific and sex-specific societal costs
Attributable societal costs varied by age and sex for risk factors and health conditions. Despite fewer males being hospitalized in 2020, they accounted for most of the societal costs.
- In urban Chinese females, the main societal costs were from unsafe sex (14.4%), high body-mass index (12.3%), dietary risks (12.2%), tobacco (11.5%), and air pollution (11.3%).
- In urban Chinese males, the main societal costs were from were tobacco use (27.2%), alcohol use (15.9%), dietary risks (12.2%), high body-mass index (9.0%), and air population (8.9%).
Attributable societal costs were concentrated in people aged below 45 (20–44 years: 42.2%, 45–64 years: 39.0%, 65 years and over: 18.8%).
- Alcohol use (18.5%) was the largest contributor to societal costs in those aged 20–44 years, and
- Tobacco was the largest contributor to societal costs in people aged 45 and over (45–64 years: 31.3%); 65 years and over (30.9%).
Meaning
Three risk factors (tobacco, alcohol, and dietary risks) accounted for half of the attributable productivity losses and societal costs; while most of the attributable inpatient healthcare costs were from four risk factors (tobacco, dietary risks, air pollution and alcohol).
The economic burden of risk factors varied by age and sex with tobacco use posing the largest burden in older groups (age 45 +), and alcohol use in younger groups (age 20–44). Younger adults aged 20–44 were more affected by behavioral factors such as smoking, alcohol use, and poor diet; while for people aged over 45 years old, costs were driven by both behavioral factors and metabolic risks such as high body-mass index, high systolic blood pressure and high fasting plasma glucose.
The attributable societal cost in urban China was mainly driven by productivity losses (67.9% vs 32.1% for healthcare costs). This was similar to recent studies in Singapore and Japan that found that productivity loss accounted approximately 70% of societal costs.
The study findings offer vital insights into understanding the economic burden of avoidable risk factors in urban China by presenting the relative contributions of various preventable risk factors. This can guide policymakers in prioritizing programs aimed at improving population health and mitigating economic costs.
Tobacco poses a significant threat to public health and was the single leading contributor to healthcare and societal costs. However, progress on effective tobacco control in China has generally been slow and weak despite China being one of the initial signatories to the Framework Convention on Tobacco Control (WHO FCTC) in 2003, and committing to achieving a 100% smoke-free policy in indoor public places and workplaces by 2011.
While alcohol use ranks as the fourth leading risk factor for attributable healthcare costs, it is the second leading risk factor for productivity loss and societal cost (after tobacco). The past few decades have seen rapid economic growth in China, but also a striking increase in alcohol consumption larger than much of the world. Encouragingly, recent per capita alcohol consumption decreased from 7.3 L in 2015 to 5.7 L in 2019. Notably, alcohol use was the primary modifiable risk factor for young adults aged 20–44, accounting for 19% of the total attributable societal economic burden in this group. Alcohol use leads to social harms as well as health harms; although the Healthy China 2030 Action Plan recognizes the importance of reducing alcohol consumption, specific alcohol policy solutions for young adults are lacking.
The economic burden of diseases from modifiable risk factors is considerable on the healthcare system and society at large. It underscores the urgent need for policy-level interventions to address the major avoidable risk factors (tobacco, alcohol and dietary risks) that collectively account for half of the total attributable economic costs. Due to variations by age and sex, interventions should be tailored to target different groups, focusing on behavioral factors in younger adults aged 20–44, and a combination of behavioral and metabolic risks in those aged 45 and above. Policy initiatives aimed at reducing tobacco and alcohol consumption in males should be prioritized to reduce the economic burden associated with modifiable risk factors.