Governments have tried to reconcile the tensions arising from ageing populations, technological innovations, patients' expectations and the scarcity of resources by containing costs. These efforts were implicitly motivated by the belief that health is a cost and as such must be controlled. More recently, researchers, decision makers and politicians have started to wonder what the contribution of health to the economy is exactly and whether strict healthcare expenditure caps make sense on economic grounds. Several recent studies have tried to understand the relationship between health and wealth, health and productivity, health and quality of life.
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"The contribution of health to the economy in the European Union" (Suhrcke M et al, 2005), a study financed by DG SANCO, demonstrates that increases in health expenditure can be justified purely on economic grounds. Health can be seen as an investment, the returns of which may be high, perhaps even higher than those of undisputed sectors like education.
"The Impact of ageing on public expenditure: projections for the EU25 Member States on pensions, healthcare, long-term care, education and unemployment transfers (2004-2050)", a study by the ECOFIN Council, uses a sophisticated modelling analysis to project future public spending in major public sectors (healthcare, long-term care, pensions, etc). Its findings conclude that a priori, there are no economic reasons why countries should not devote a larger share of resources to healthcare: increased government intervention can be justified if the income elasticity of demand is such that demand outpaces income growth, and also if investment in technology is more than compensated by improved quality and/or productivity.
"HealthCast 2020: creating a sustainable future", a PriceWaterHouseCoopers survey, concludes that since healthcare is a global issue, there can be global recommendations to counteract the progressive limitless increase of expenditures and costs. These may be achieved through cross-sector collaboration, motivating physicians to achieve high levels of performance, sharing costs with patients and using innovative technology.
From the studies above, it can be said that a broader vision is required, one that would see healthcare budgets within a more general consideration of public money allocation based upon expected returns and not merely one that sees healthcare budget as something to be constrained per se. Technological innovation plays an important role in this scenario since it has been acknowledged as an important determinant for better health.
Click here to view a more complete analysis of the three above-mentioned reports and the key conclusions that can be drawn in an article by Dr Rosanna Tarricone, Eucomed Director Economic Affairs and co-Director of the Master of International Health Care Management, Economics and Policy at the Bocconi University School of Management.
This edition of Medical Technology Focus looks at one area where advances in medical technology have made a remarkable contribution to health and quality of life: the treatment of cerebral aneurysms.
A brain aneurysm, also called a cerebral or intracranial aneurysm, is an abnormal bulging outward of one of the arteries in the brain. Brain aneurysms are often discovered when they rupture, causing bleeding into the brain or the space closely surrounding the brain; this can lead to a stroke, brain damage and death.
Ten to fifteen percent of patients will die before reaching the hospital and over 50 percent will die within the first thirty days after rupture. Of those who survive, about half suffer some permanent neurological deficit. Brain aneurysms can occur in people of all ages, but are most commonly detected in those aged 35 to 60. Women are more likely to get a brain aneurysm than men, with a ratio of 3:2. Diagnosis of a ruptured cerebral aneurysm is commonly made by finding signs of subarachnoid haemorrhage on a CT scan (Computerized Tomography, sometimes called a CAT scan).
The CT scan is a computerized test that rapidly X-rays the body in cross-sections, or slices, as the body is moved through a large, circular machine. If the CT scan is negative but a ruptured aneurysm is still suspected, a lumbar puncture is performed to detect blood in the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord. To determine the exact location, size and shape of an aneurysm (ruptured or unruptured), neuroradiologists will use either cerebral angiography or tomographic angiography. Cerebral angiography, the traditional method, involves introducing a catheter (small plastic tube) into an artery (usually in the leg) and steering it through the blood vessels of the body to the artery involved by the aneurysm. A special dye, called a contrast agent, is injected into the patient's artery and its distribution is shown on X-ray projections. This method may not detect some aneurysms due to overlapping structures or spasm.
Computed Tomographic Angiography (CTA) or Magnetic Resonance Angiography are alternatives to the traditional method and can be performed without the need for arterial catheterization. This test combines a regular CT or MRI scan with a contrast dye injected into a vein. Once the dye is injected into a vein, it travels to the brain arteries, and images are created using a scan. These images show exactly how blood flows into the brain arteries.
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Sometimes patients describing "the worst headache in my life" are actually experiencing one of the symptoms of brain aneurysms related to having a rupture. Other ruptured cerebral aneurysm symptoms include:
In about 40 percent of cases, people with unruptured aneurysms will experience some or all of the following symptoms:
Unruptured aneurysms can also be incidentally found when patients undergo a Magnetic Resonance Imaging (MRI) or Computer Tomography scan (CT) check up.
The classical treatment for aneurysms is called "clipping". A section of the skull is removed (craniotomy). The surgeon then spreads the brain tissue apart and places a tiny metal clip across the neck of the aneurysm to stop blood flow into the aneurysm. After clipping the aneurysm, the bone is secured in its original place, and the wound is closed. Endovascular therapy instead is a minimally invasive procedure that accesses the treatment area from within the blood vessel. In the case of aneurysms, this treatment is called coil embolization, or "coiling". In contrast to surgery, endovascular coiling does not require open surgery. Instead, the surgeon uses real-time X-ray technology to visualize the patient's vascular system and treat the disease from inside the blood vessel.
Endovascular treatment of brain aneurysms involves insertion of a catheter (small plastic tube) into the femoral artery in the patient's leg and navigating it through the vascular system, into the head and into the aneurysm. Tiny platinum coils are threaded through the catheter and deployed into the aneurysm, blocking blood flow into the aneurysm and preventing rupture. The coils are made of platinum so that they can be visible via X-ray and be flexible enough to conform to the aneurysm shape. This endovascular coiling, or filling, of the aneurysm is called embolization and can be performed under general anesthesia or light sedation.
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Tiny platinum coils are threaded through a microcatheter and pushed into the aneurysm. The coils are flexible enough to conform to the aneurysm shape. |
The aneurysm is filled in with coils, obstructing the flow of blood into the aneurysm. Each coil is attached to a delivery wire, allowing the physician to reposition or withdraw the coil to ensure ideal placement. Once properly positioned within the aneurysm, the coil is detached from the delivery wire using an electrolytic detachment process (electrical charge). |
The only multi-centre prospective randomized clinical trial comparing surgical clipping and endovascular coiling of ruptured aneurysm is the International Subarachnoid Aneurysm Trial (ISAT)[1]. The study found that, in patients equally suited for both treatment options, endovascular coiling treatment produces substantially better patient outcomes than surgery in terms of survival free of disability at one year. The relative risk of death or significant disability at one year for patients treated with coils was 22.6 percent lower than in surgically-treated patients.
The study results were so compelling that the trial was halted early after enrolling 2143 of the planned 2500 patients because the trial steering committee determined it was no longer ethical to randomize patients to neurosurgical clipping. Long-term follow-up will be essential to assess the durability of the substantial early advantage of endovascular coiling over conventional neurosurgical clipping for the treatment of brain aneurysms. It is important to note that patients enrolled in the ISAT were evaluated by both a neurosurgeon and an endovascular coiling specialist, and both physicians had to agree that the aneurysm was treatable by either technique. This study provides compelling evidence that, if medically possible, all patients with ruptured brain aneurysms should receive an endovascular consultation as part of the protocol for the treatment of brain aneurysms.
Although no multi-centre randomized clinical trial comparing endovascular coiling and surgical treatment of unruptured aneurysms has yet been conducted, retrospective analyses have found that endovascular coiling is associated with less risk of bad outcomes, shorter hospital stays and shorter recovery times compared with surgery. Studies have shown that average hospital stays are more than twice as long with surgery as compared to endovascular coiling treatment[2]. Four times as many surgical patients report new symptoms or disability after treatment as compared to coiled patients[3]. There can also be a dramatic difference in recovery times. One study showed that surgically-treated patients had an average recovery time of one year compared to coiled patients who recovered in 27 days[3].
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Angiogram of an aneurysm before treatment. The aneurysm is the dark bulge on the vessel. |
Angiogram of an aneurysm after endovascular coiling treatment. The aneurysm has been filled in with coils, so blood can no longer flow into the aneurysm. The aneurysm now appears as a silver bulge on the angiogram. |
Studies carried out in Denmark and the UK highlight that 14-15% of the adult population is absent from work due to headaches, and that the number of days missed from work ranged from around 1100 to 1300 days per 1000 employed people per year. The number of days with reduced effectiveness at work was estimated to be four times higher. With regards to migraine, the average cost per patient per year is an estimated €590 in some Western European countries. This figure can however vary greatly from one country to the next. For example, the cost estimate for migraine in Sweden is around €100 per patient, compared to €900 in Germany! More information.
When you have a headache at work
Persistent and/or recurring headaches can be a symptom of a severe condition such as a brain aneurysm (see table with symptoms above) and should not be taken lightly. The advice of a specialist should be sought without delay.
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[1] Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002: 360: 1267-74.
[2] Johnston SC, et. al. Surgical and Endovascular Treatment of Unruptured Cerebral Aneurysms at University Hospitals. Neurology. 1999; 52:1799-1805
[3] Johnston SC, et.al. Endovascular and Surgical Treatment of Unruptured Cerebral Aneurysms: Comparison of Risks. Ann Neurology. 2000; 48:11-19
