Cost saving potential in cardiovascular hospital costs due to reduction in air pollution
Introduction
After the famous Meuse Valley fog in 1930, the Belgian pathologist Firket was one of the first scientists to demonstrate the harmful effects of air pollution on public health (Firket, 1936, in Nemery et al., 2001). Eighty-five years later, significant improvement has been made in the scientific knowledge regarding the effects of air pollutants on the respiratory and cardiovascular system. Numerous epidemiological studies and reviews have demonstrated an association between cardiovascular diseases and acute and chronic exposures to Particulate Matter (PM) with an aerodynamic diameter < 10 μm (PM10) or < 2.5 μm (PM2.5) (Hansen et al., 2012, Rückerl et al., 2011, Brook et al., 2010) and Nitrogen Dioxide (NO2) (Carracedo-Martínez et al., 2010, Shah et al., 2013).
Several international studies and reviews have shown evidence that lowering air pollution exposure leads to less adverse health effects (e.g. Burnett et al., 2014, Pope et al., 2008, Wellenius et al., 2006, WHO Regional office for Europe, 2013). In an era in which the importance of sustainable development and its impact on environment and public health gains more and more recognition worldwide, this outcome forced policy makers to tackle the problem of air pollution. These days, more stringent air quality standards than ever before are applied in the United States (National ambient air quality standards (US EPA, 2015, March 9)), the European Union (Council Directive, 2008/50/EC; The Clean Air Policy Package (European Commission, 2013)) and other countries. Although Belgium still remains one of the most polluted regions in Europe concerning particulate air pollution, it performs relatively well in keeping its air pollution exposure below the European Union air quality guidelines. Despite this observation, adverse health effects still occur at exposure levels well below these guidelines (Beelen et al., 2014). Moreover, the air pollution guidelines published by the World Health Organization (WHO) are stricter and therefore more protective towards public health than the European Union standards (WHO, 2005).
The economic implications of air pollution-related illnesses for society are inevitable but are often overlooked and/or underestimated by policy makers (Landrigan, 2012, Guo et al., 2010, Pervin et al., 2008). However, reductions in air pollution exposure, at every level, are expected to result in a reduction in total external costs. From this perspective, economic data are needed for the debate on priority settings in public health.
In the current study, the aim was to estimate the total averted hospital costs (one component in the total societal cost calculation) in Belgium attributable to a decrease in cardiovascular emergency admissions associated with a short-term reduction in PM10, PM2.5, and NO2. Two reduction scenarios were considered. First, we analyzed the impact of a 10% reduction in short-term air pollution exposure for the study population and extrapolated the effects to a national level. In a second scenario, we assume a reduction of the pollutants towards the levels of the WHO-guidelines and calculate the impact at national level for Belgium. Case-crossover analyses were used (Maclure, 1991) to estimate the impact of air pollutants on emergency admissions for ischemic heart diseases, heart rhythm disturbances, and heart failure. The derived risk functions were used in a hospital cost analysis.
This study might be valuable for policy makers, as the estimated risk functions contribute to the quantification of air pollution related cardiovascular diseases and the hospital cost calculations might guide subsequent cost-benefit analyses.
Section snippets
Emergency admissions
Hospital discharge data on emergency admissions from January 1st 2007 until July 1st 2012 were obtained from UZ Brussels (University Hospital Brussels, Belgium). UZ Brussels is an academic general hospital founded by the Vrije Universiteit Brussel in 1977. The hospital has 721 beds and admits approximately 30,000 patients a year. The emergency department is open 24 h a day treating approximately 65,000 patients a year.
Patients at interest were identified with the following primary discharge
Sample
In total, 4663 patients were identified in the registry database. 47 patients were excluded because of invalid or missing zip code. One patient with an extreme length of stay of more than 500 days and four patients without hospitalization overnight were excluded from the analyses. Depending on the temperature criterion, the number of control days per case ranged from 0 to 22. On average, each case had 7.9 control days. The 219 (4.7%) cases without control days were not included in the analysis. A
Discussion
This study provides a direct insight in the avoidable marginal external costs for society for acute hospital care due to air pollution. We estimated that only a 10% decrease in weekly average PM10 exposure results in 2.16% less emergency hospitalizations for heart rhythm disturbances and 2.44% less emergency hospitalizations for ischemic heart disease. In Belgium, this would result in 3,701,648€ and 5,195,520€ saved hospital costs in one year for these two diseases respectively. The estimates
Acknowledgment
This research has been supported by a research fund of the Vrije Universiteit Brussel (Grant number: IRP DEFIS 42028). There are no competing interests. We would like to express our gratitude to Dr. Karen Pien for her valuable help in the data extraction and Kasper Cockx for his work regarding the development of the maps in the supplementary data section.
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