The impact of aging on long-term care in Europe and some potential policy responses

The Economic Value of Non-professional Care: A Europe-Wide Analysis

BACKGROUND

This paper had two aims. Firstly, to provide a broader view of the profile of non-professional caregivers in Europe, and secondly, to estimate the economic value of the non-professional caregiving.

METHODS

The European Quality of Life Survey 2016/2017, carried out by Eurofound, was used. The target population of the survey was adults who care for a relative or friend in a total of 33 European countries. The opportunity cost method was used to estimate the economic value of caregiving, in which two of the activities forgone were analysed: paid activities (restricted to caregivers who were employed), for which the average gross wage of each country was used; and unpaid activities, for which the minimum gross wage of each country was used.

RESULTS

There were more than 76 million non-professional caregivers in Europe that provide care for a relative or friend. This figure represents 12.7% of the population in Europe. The estimated time devoted to non-professional care in Europe reached 72 301.5 million hours in 2016. Sharp differences were found among countries. The economic value of that time is estimated at 576 000 million of euros, which represented about 3.63% of Europe's gross domestic product (GDP).

CONCLUSION

This study shows the very important number of resources dedicated to the non-professional care of dependent people and their economic valuation. These results may be helpful in prospective analyses estimating future needs on professional and non-professional and for designing of long-term care (LTC) policies in Europe.

The economic value of time of informal care and its determinants (The CUIDARSE Study)

Objective

The main aims of this paper are to analyse the monetary value of informal care time using different techniques and to identify significant variables associated with the number of caregiving hours.

Data and methods

A multicentre study in two Spanish regions in adult caregivers was conducted. A total sample of 604 people was available. A multivariate analysis was performed to identify the variables associated with the number of hours of caregiving time. In the monetary valuation of informal care provided, three approaches were used: replacement cost method, opportunity cost and contingent valuation (willingness to pay and willingness to accept).

Results

The main determinants of the amount of time of informal care provided were age, gender, the level of care receiver´s dependence and the professional care services received (at home and out of home). The value estimated for informal care time ranges from EUROS 80,247 (replacement cost method) to EUROS 14,325 (willingness to pay), with intermediate values of EUROS 27,140 and EUROS 29,343 (opportunity cost and willingness to accept, respectively). Several sensitivity analyses were performed over the base cases, confirming the previous results.

Conclusions

Time of informal care represents a great social value, regardless of the applied technique. However, the results can differ strongly depending on the technique chosen. Therefore, the choice of technique of valuation is not neutral. Among the determinants of informal care time, the professional care received at home has a complementary character to informal care, while the formal care outside the home has a substitute character.

What Persons with Chronic Health Conditions Need to Maintain or Return to Work-Results of an Online-Survey in Seven European Countries

Chronic health conditions represent the major share of the disease burden in Europe and have a significant impact on work. This study aims to: (1) identify factors that have a negative or positive impact on the work lives of persons with chronic health conditions; (2) explore the needs of these persons to maintain a job or return to work and (3) compare these results with respect to these persons' occupational status. An online survey was performed in seven European countries. Open-ended survey questions were analyzed using qualitative methods. In total, 487 participants with six chronic health conditions participated. The majority of participants named work-related aspects (such as career development, stress at the workplace, work structure and schedule as well as workload), support of others and attitudes of others as being the factors positively and negatively impact their work lives the most. Our study shed light on the importance of changing the attitudes of supervisors and co-workers to counteract stigmatization of persons with chronic health conditions in the workplace. In conclusion, this study provides a basis for developing new strategies of integration and reintegration at work for persons with chronic health conditions in European countries.

The impact of slow economic growth on health sector reform: a cross-national perspective

This paper assesses recent health sector reform strategies across Europe adopted since the onset of the 2008 financial crisis. It begins with a brief overview of the continued economic pressure on public funding for health care services, particularly in tax-funded Northern European health care systems. While economic growth rates across Europe have risen a bit in the last year, they remain below the level necessary to provide the needed expansion of public health sector revenues. This continued public revenue shortage has become the central challenge that policymakers in these health systems confront, and increasingly constrains their potential range of policy options. The paper then examines the types of targeted reforms that various European governments have introduced in response to this increased fiscal stringency. Particularly in tax-funded health systems, these efforts have been focused on two types of changes on the production side of their health systems: consolidating and/or centralizing administrative authority over public hospitals, and revamping secondary and primary health services as well as social services to reduce the volume, cost and less-than-optimal outcomes of existing public elderly care programs. While revamping elderly care services also was pursued in the social health insurance (SHI) system in the Netherlands, both the Dutch and the German health systems also made important changes on the financing side of their health systems. Both types of targeted reforms are illustrated through short country case studies. Each of these country assessments flags up new mechanisms that have been introduced and which potentially could be reshaped and applied in other national health sector contexts. Reflecting the tax-funded structure of the Canadian health system, the preponderance of cases discussed focus on tax-funded countries (Norway, Denmark, Sweden, Finland, England, Ireland), with additional brief assessments of recent changes in the SHI-funded health systems in the Netherlands and Germany. The paper concludes that post-2008 European reforms have helped stretch existing public funds more effectively, but seem unlikely to resolve the core problem of inadequate overall public funding, particularly in tax-based health systems. This observation suggests that ongoing Canadian efforts to consolidate and better integrate its health care providers, while important, may not eliminate long-term health sector-funding dilemmas.

The Valuation of Informal Care in Cost-of-Illness Studies: A Systematic Review

BACKGROUND

There is a growing interest in incorporating informal care in cost-of-illness studies as a relevant part of the economic impact of some diseases.

OBJECTIVE

The aim of this paper was to review the recent literature valuating the costs of informal care in a group of selected diseases from 2005 to 2015.

METHODS

We carried out a systematic review on the economic impact of informal care, focusing on six selected diseases: arthritis or osteoarthritis, cancer, dementia, mental diseases, multiple sclerosis and stroke.

RESULTS

We selected 91 cost-of-illness articles. The average weight attributed to the informal care cost over the total cost was highly relevant for dementia, stroke, mental diseases, cancer and multiple sclerosis. The most frequent valuation method applied was the opportunity cost method, followed by the proxy good method. The annual cost of informal care presented a high variability depending on the disease and geographic location. Distinguishing by type of illness, the disease with the highest annual value of informal caregiving was dementia, followed by mental illness and multiple sclerosis. The average hourly unit cost was €11.43 (2015 values), varying noticeably depending on the geographic location.

CONCLUSION

This paper identifies several aspects that should be enhanced to promote comparability between studies and countries, and it sends key messages for incorporating informal care costs to adequately measure the economic impact of diseases.

Inequity in long-term care use and unmet need: two sides of the same coin

We investigate the determinants of several LTC services and unmet need using data from a representative sample of the non-institutionalised disabled population in Spain in 2008. We measure the level of horizontal inequity and compare results using self-reported versus a more objective indicator of unmet needs. Evidence suggests that after controlling for a wide set of need variables, there is not an equitable distribution of use and unmet need of LTC services in Spain; formal services are concentrated among the better-off, while intensive informal care is concentrated among the worst-off. The distribution of unmet needs for LTC services depends on the service considered and on whether we focus on subjective or objective measures. In 2008, only individuals with the highest dependency level had universal coverage. Our results show that inequities in most LTC services and unmet needs among this group either remain or even increase for formal services.

An apocalyptic vision of ageing in China: Old age care for the largest elderly population in the world

According to the National Bureau of Statistics of China, by 2010 the number of people aged 60 or over had reached 178 million in China or 13% of its population. With the largest elderly population in the world in absolute numbers, China faces a challenge of providing care for the elderly both in the present and the future. Unlike old age pensions and health protection for the elderly, in Chinese society elderly care had never been considered to be a social problem but rather the individual family's responsibility. After the turn of the millennium, as the repercussions of increasingly ageing demographics, the results of the One-Child Policy and drastic changes in traditional family structures gradually became more apparent, this issue of elderly care has increasingly become one of the most pressing concerns for the ageing society. As there is little existing research on this particular topic, this article aims to shed light on elderly care in China, focusing on the care of elderly needing assistance with activities of daily living, since this group of elderly are most in need of care, their numbers having risen to 33 million in 2010. This article argues it is urgent for China to switch from informal family-based elderly care to the state's formal long-term care, illustrates that a model of social insurance (e.g. as in Germany) is advocated by many Chinese scholars and points out the ways in which it is different from both the commercialized models (e.g. as in the USA) and state organized "Beveridge" models (e.g. as in Sweden).

How to include informal care in economic evaluations

Economic evaluations of health interventions aim to support decision making in healthcare. To effectively do so, evaluations need to include all relevant costs and effects of an intervention. Informal care provided by family or friends is an important element of care for many patients, but can have a profound impact on the health and well-being of carers. Therefore, informal care should be considered in economic evaluations of health interventions. Different methods to do so exist. This paper provides an overview of state-of-the-art methods available for this purpose, illustrated with practical examples. Since the choice of measurement and valuation technique depends on the type and perspective of the economic evaluation, this paper supports researchers in choosing the appropriate techniques to include informal care in their economic evaluation of a health intervention. We discuss the different approaches to measuring and valuing informal care, covering both partial and full valuation methods, allowing inclusion as costs or effects.

Silver paper: the future of health promotion and preventive actions, basic research, and clinical aspects of age-related disease--a report of the European Summit on Age-Related Disease

BACKGROUND. In September 2008, under the French Presidency of the European Union and with the support of the Polish Minister of Health, a European Summit on Age-Related Disease was organised inWroclaw (Poland). At this meeting, European politicians, gerontologists and geriatricians gathered to discuss a common approach to future challenges related to age-related disease. Politicians and decision-makers from the European Union and Ministers of Health and their deputies from many European countries raised the problems and difficulties to be tackled in a growing population with a high burden of disease, and asked scientists to write a consensus document with recommendations for future actions and decisions. Scientists and clinicians worked in parallel in three different groups, on health promotion and preventive actions, basic research in age-related disease, and clinical aspects of disease in older people. Beforehand, the format of the paper with recommendations was discussed, and it was finally agreed that, for a better understanding by decision- makers, it would be divided in two different columns: one with facts that were considered settled and agreed by most experts (under the heading We know), and a second with recommendations related to each fact (We recommend). No limit on the number of topics to be discussed was settled. After careful and detailed discussion in each group, which in most cases included the exact wording of each statement, chairpersons presented the results in a plenary session, and new input from all participants was received, until each of the statements and recommendations were accepted by a large majority. Areas with no consensus were excluded from the document. Immediately after the Summit, the chairpersons sent the document both to the main authors and to a list of experts (see footnote) who had made presentations at the summit and agreed to review and critically comment on the final document, which is presented below. As regards the scientific aspects of the planning of the Summit, several organisations, under the leadership of the EUGMS, were asked both to review the program and to suggest names of speakers and participants. After the Summit, the Boards of these organizations (European Union Geriatric Medicine Society (EUGMS), International Association of Gerontology and Geriatrics-European Region (IAGGER), European Association of Geriatric Psychiatry (EAGP), International Society of Gerontechnology (ISG) and International Society for the Study of the Aging Male (ISSAM) agreed to consider the document as an official paper, and help with its dissemination. The name Silver Paper was used, recalling the grey or silvery hair of our older citizens, as an easy reference. It has been sent officially to several bodies of the European Union and to Health Ministers of most European countries; and will be published in other languages in local journals. Its declared intention is to foster changes in policies which may, in the future, reduce the burden of disease in old age.

An ecological study on the relationship between supply of beds in long-term care institutions in Italy and potential care needs for the elderly

Background

The ageing population in Europe is putting an ever increasing demand on the long-term care (LTC) services provided by these countries. This study analyses the relationship between the LTC institutional supply of beds and potential care needs, taking into account the social and health context, the supply of complementary and alternative services, along with informal care.

Methods

An observational, cross-sectional, ecological study was carried out. Statistical data were obtained from the Italian National Institute of Statistics and Ministry of Health. Indicators, regarding 5 areas (Supply of beds in long term care institutions, Potential care needs, Social and health context, Complementary and alternative services for the elderly, Informal care), were calculated at Local Health Unit (LHU) level and referred to 2004.

Two indicators were specifically used to measure supply of beds in long term care institutions and potential care needs for the elderly. Their values were grouped in tertiles. LHU were classified according to the combination of tertiles in three groups: A. High level of supply of beds in long term care institutions associated with low level of potential care needs; B. Low level of supply of beds in long term care institutions associated with high level of potential care needs; C. Balanced level of supply of beds in long term care institutions with potential care needs. For each group the indicators of 5 areas were analysed.

The Index Number (IN) was calculated for each of these indicators.

Results

Specific factors that need to be carefully considered were highlighted in each of the three defined groups. The highest level of alternative services such as long-stay hospital discharges in residence region (IN = 125), home care recipients (HCR) (IN = 123.8) were reported for Group A. This group included North regions. The highest level of inappropriate hospital discharges in (IN = 124.1) and out (IN = 155.8) the residence region, the highest value of families who received help (IN = 106.4) and the lowest level of HCR (IN = 68.7) were found in Group B. South regions belong to this group. The highest level of families paying a caregiver (IN = 115.8) was shown in Group C. Central regions are included in third group.

Conclusion

Supply of beds in long term care institutions substantially differs across Italian regions, showing in every scenario some imbalances between potential care needs and other studied factors. Our study suggests the need of a comprehensive rethinking of care delivery "system".

Casualized employment and turnover intention: home care workers in Ontario, Canada

The purpose of this paper is to examine the associations between casualized employment and turnover intention in home care. Casualized employment refers to employment conditions of non-permanent contracts, part-time or casual hours, involuntary hours, on-call work, split shifts, pay per visit, and hourly pay with variable hours. Casualized employment also refers to perceived employment insecurity and labour market insecurity. Data are from a survey of 991 visiting nurses, therapists and home support workers in a medium-sized city in Ontario, Canada. Results show that, controlling for many other factors, casual hours and perceived employment insecurity and labour market insecurity are positively and on-call work is negatively associated with home care workers' turnover intention. Non-permanent contract, part-time hours, involuntary hours, split shifts, and non-salaried pay are features of the market-modelled home care work environment and therefore may not be associated with turnover intention. Results provide evidence on the effects of casualized employment strategies on home care workers' turnover intention.

Muscle strength in the Mataró aging study participants and its relationship to successful aging

BACKGROUND AND AIMS

Successful aging is a worldwide aim, but its related factors and instruments of measurement are currently hotly debated. To investigate the relationship between muscle strength and functional capacity, and its association with successful aging.

METHODS

A population-based cross-sectional study was performed in Mataró (Spain). Included in the study were 313 subjects (153 men, 160 women) aged 70 years and over. Physical and cognitive functions were assessed, as well as muscle strength, nutritional status, lifestyle factors, and associated morbidities.

RESULTS

A state of successful aging (SA), defined as optimal functional and cognitive capacities with absence of cancer, stroke, cardiovascular or pulmonary chronic diseases, was found in 20% of women and 32% of men. SA was associated with higher muscle strength in comparison with the non-SA condition. Muscle strength measurements were higher in men, and decreased with age, poor balance, decreased functional capacity, and impaired cognitive status. It was also associated with higher academic level, regular exercise, and nutritional status in both genders. Multivariate analysis showed that independent variables related to SA were: hand grip, arthrosis, deafness and unipodal balance test, but not age or gender.

CONCLUSIONS

Muscle strength is positively associated with the successful aging condition, and may be one of its functional links, reflecting the integrated health status of old men and women. The systematic inclusion of the measurement of muscle strength may be helpful in clinical evaluation of the elderly.

Functional status and depressive symptoms among older adults from residential care facilities in the Czech Republic

BACKGROUND

Depressive symptoms are common among older adults, particularly those living in long-term care facilities. However, little is known about factors associated with depressive symptoms among long-term care residents in the Czech Republic and in other Eastern European countries. Moreover, the role of mobility and pain in depressive symptoms among long-term care residents is relatively understudied.

OBJECTIVE

We examined the relationship between functional status and depressive symptoms in 308 older adults from residential care facilities (RCFs) in the Czech Republic.

METHOD

We used baseline data from two randomized controlled trials testing the effects of dance and reminiscence therapies on quality of life in older RCF residents. Functional status was measured as cognitive function, general ability to perform basic Activities of Daily Living (ADLs), mobility, and functional limitation by pain. Depressive symptoms were measured using the 15-item Geriatric Depression Scale.

RESULTS

In multiple regression analyses adjusted for sociodemographic factors and taking antidepressants, we found that cognitive function and functional limitation by pain were most strongly associated with depressive symptoms. The ability to perform basic ADLs and mobility were also related to depressive symptoms.

CONCLUSION

Our findings suggest factors that may be important in efforts to improve psychological well-being in this population.