Progress and directions in refining the global burden of disease approach: a response to Williams

Demographic, health, physical activity, and workplace factors are associated with lower healthy working life expectancy and life expectancy at age 50

Although retirement ages are rising in the United Kingdom and other countries, the average number of years people in England can expect to spend both healthy and work from age 50 (Healthy Working Life Expectancy; HWLE) is less than the number of years to the State Pension age. This study aimed to estimate HWLE with the presence and absence of selected health, socio-demographic, physical activity, and workplace factors relevant to stakeholders focusing on improving work participation. Data from 11,540 adults in the English Longitudinal Study of Ageing were analysed using a continuous time 3-state multi-state model. Age-adjusted hazard rate ratios (aHRR) were estimated for transitions between health and work states associated with individual and combinations of health, socio-demographic, and workplace factors. HWLE from age 50 was 3.3 years fewer on average for people with pain interference (6.54 years with 95% confidence interval [6.07, 7.01]) compared to those without (9.79 [9.50, 10.08]). Osteoarthritis and mental health problems were associated with 2.2 and 2.9 fewer healthy working years respectively (HWLE for people without osteoarthritis: 9.50 years [9.22, 9.79]; HWLE with osteoarthritis: 7.29 years [6.20, 8.39]; HWLE without mental health problems: 9.76 years [9.48, 10.05]; HWLE with mental health problems: 6.87 years [1.58, 12.15]). Obesity and physical inactivity were associated with 0.9 and 2.0 fewer healthy working years respectively (HWLE without obesity: 9.31 years [9.01, 9.62]; HWLE with obesity: 8.44 years [8.02, 8.86]; HWLE without physical inactivity: 9.62 years [9.32, 9.91]; HWLE with physical inactivity: 7.67 years [7.23, 8.12]). Workers without autonomy at work or with inadequate support at work were expected to lose 1.8 and 1.7 years respectively in work with good health from age 50 (HWLE for workers with autonomy: 9.50 years [9.20, 9.79]; HWLE for workers lacking autonomy: 7.67 years [7.22, 8.12]; HWLE for workers with support: 9.52 years [9.22, 9.82]; HWLE for workers with inadequate support: 7.86 years [7.22, 8.12]). This study identified demographic, health, physical activity, and workplace factors associated with lower HWLE and life expectancy at age 50. Identifying the extent of the impact on healthy working life highlights these factors as targets and the potential to mitigate against premature work exit is encouraging to policy-makers seeking to extend working life as well as people with musculoskeletal and mental health conditions and their employers. The HWLE gaps suggest that interventions are needed to promote the health, wellbeing and work outcomes of subpopulations with long-term health conditions.

Cross-Cultural Adaptation and Psychometric Properties of the Children's Hope Scale in Indonesia: Adapting a Positive Psychosocial Tool for Adolescents With Thalassemia

Background: Hope is regarded positively as a factor in achieving a higher quality of life, particularly in chronic disease patients. Objectives: This study aims to adapt, validate, and establish the reliability of the Children's Hope Scale (CHS) questionnaire in Indonesian adolescents with thalassemia. Methods: The current study used iterative mixed methods. The data collection procedure was divided into three stages: instrument translation and cultural adaptation, validation, and reliability. The Content Validity Index (CVI) was used to assess the translated instrument's content validity, importance, contextual relevance, and acceptability of wording. Confirmatory factor analysis (CFA) was used to determine the factor structure of the CHS. Pearson correlation analyses were used to determine the associations between the two hope subscales. Cronbach's alpha coefficient and test-retest data were used to determine its reliability. Results: The CVI values ranged from 0.80 to 1.00. The CFA has shown that the two-factor model has adequate fitness factors. The Cronbach's alpha for the Indonesian CHS was 0.705, and the test reliability rate (CI 95%) was 0.81 (.73-.91). Conclusion: The CHS is a valid and reliable instrument for assessing hope in Indonesia. Additional research should be conducted to adapt and evaluate the CHS in other samples and social context in order to verify the factor consistency.

Metric partnerships: global burden of disease estimates within the World Bank, the World Health Organisation and the Institute for Health Metrics and Evaluation

The global burden of disease study—which has been affiliated with the World Bank and the World Health Organisation (WHO) and is now housed in the Institute for Health Metrics and Evaluation (IHME)—has become a very important tool to global health governance since it was first published in the 1993 World Development Report. In this article, based on literature review of primary and secondary sources as well as field notes from public events, we present first a summary of the origins and evolution of the GBD over the past 25 years. We then analyse two illustrative examples of estimates and the ways in which they gloss over the assumptions and knowledge gaps in their production, highlighting the importance of historical context by country and by disease in the quality of health data. Finally, we delve into the question of the end users of these estimates and the tensions that lie at the heart of producing estimates of local, national, and global burdens of disease. These tensions bring to light the different institutional ethics and motivations of IHME, WHO, and the World Bank, and they draw our attention to the importance of estimate methodologies in representing problems and their solutions in global health. With the rise in the investment in and the power of global health estimates, the question of representing global health problems becomes ever more entangled in decisions made about how to adjust reported numbers and to evolving statistical science. Ultimately, more work needs to be done to create evidence that is relevant and meaningful on country and district levels, which means shifting resources and support for quantitative—and qualitative—data production, analysis, and synthesis to countries that are the targeted beneficiaries of such global health estimates.

Metric partnerships: global burden of disease estimates within the World Bank, the World Health Organisation and the Institute for Health Metrics and Evaluation

The global burden of disease study-which has been affiliated with the World Bank and the World Health Organisation (WHO) and is now housed in the Institute for Health Metrics and Evaluation (IHME)-has become a very important tool to global health governance since it was first published in the 1993 World Development Report. In this article, based on literature review of primary and secondary sources as well as field notes from public events, we present first a summary of the origins and evolution of the GBD over the past 25 years. We then analyse two illustrative examples of estimates and the ways in which they gloss over the assumptions and knowledge gaps in their production, highlighting the importance of historical context by country and by disease in the quality of health data. Finally, we delve into the question of the end users of these estimates and the tensions that lie at the heart of producing estimates of local, national, and global burdens of disease. These tensions bring to light the different institutional ethics and motivations of IHME, WHO, and the World Bank, and they draw our attention to the importance of estimate methodologies in representing problems and their solutions in global health. With the rise in the investment in and the power of global health estimates, the question of representing global health problems becomes ever more entangled in decisions made about how to adjust reported numbers and to evolving statistical science. Ultimately, more work needs to be done to create evidence that is relevant and meaningful on country and district levels, which means shifting resources and support for quantitative-and qualitative-data production, analysis, and synthesis to countries that are the targeted beneficiaries of such global health estimates.

World health by place: the politics of international health system metrics, 1924-c. 2010

This article examines the development of health system metrics by international organizations, exploring their relationship to the politics of world health. Current historiography treats measurement either as progressive illumination or adopts a critical stance, viewing indicators as instruments of global governance by powerful nations. We draw on diverse statistical publications to provide an empirical overview of change and continuity, beginning with the League of Nations Health Organization, which initiated health system statistics, and concluding with the World health report 2000, with its controversial comparative rankings. We then develop analysis and explanation of these trends. Population indicators appeared consistently owing to their protective function and compatibility with development thinking. Others, related to provision, financing, and coverage, appeared more sporadically, owing to changing trends and assumptions in international health. While partly affirming the critical literature, metrics were also used by peripheral or resistant actors to challenge or influence policy at the centre.

The Burden of Premature Mortality in Turkey in 2001 and 2008

BACKGROUND

Standard expected years of life lost (SEYLL) is a measure that is used to evaluate losses due to premature deaths.

AIMS

The present study provides an analysis of premature mortality in Turkey for the years 2001 and 2008 and supplies evidence for making policies and setting health agendas over the long term.

STUDY DESIGN

Cross-sectional study.

METHODS

This study calculated SEYLL by gender, age group and causes of death in Turkey in 2014. The SEYLL measure counts the years lost in a population as a result of premature mortality and is computed by multiplying the number of deaths and standard life expectancy at the age at which death occurs.

RESULTS

The burden of premature mortality in Turkey was calculated as 4 104 253 SEYLL and 4 472 443 SEYLL in 2001 and 2008, respectively. Among these 42.7% and 43.9% of SEYLL were in females in 2001 and 2008, respectively. The leading five causes of premature mortality in the Turkish population in 2001 were cardiovascular system diseases (34.72%), perinatal conditions (12.69%), neoplasms (12.51%), external causes of injury (7.66%), and infections and parasitic diseases (6.57%). In 2008, the major causes were cardiovascular diseases (41.17%), neoplasms (14.63%), respiratory system diseases (9.81%), perinatal conditions (5.59%), and external causes of injury (5.29%).

CONCLUSION

The majority of the burden of premature mortality in Turkey is attributable to non-communicable diseases. While premature deaths from infections and parasitic diseases, perinatal conditions and congenital anomalies decreased between 2001 and 2008, deaths from cardiovascular diseases, neoplasms and respiratory system diseases increased dramatically. Coordinated efforts for effective national prevention programs (such as regular monitoring of adults for early diagnosis of cardiovascular diseases and for malignancies by family physicians) should be developed by policy makers to decrease preventable and premature deaths from non-communicable diseases.

Burden of ischaemic heart disease and cerebrovascular diseases in Serbia without Kosovo and Metohia, 2000

BACKGROUND

To provide estimates of cardiovascular disease burden to guide future health strategies and interventions and enable improvements in health and performance of the health care system to be monitored.

DESIGN

A descriptive study.

METHODS

The study was performed in Serbia without Kosovo and Metohia for the year 2000. Disability-adjusted life years (DALY) was used to provide a comprehensive assessment of premature mortality (years of life lost; YLL) and disability attributable (years lived with disability; YLD) to ischaemic heart disease (IHD) and cerebrovascular diseases, and to estimate the attributable and avoidable burden of these diseases caused by smoking, hypertension, overweight/obesity, physical inactivity, alcohol consumption and an inadequate consumption of fruit and vegetables.

RESULTS

IHD was responsible for 150 889 DALY (16.28/1000 population), and cerebrovascular diseases were responsible for 136 090 DALY (14.49/1000 population). There were considerably more YLL for both IHD and stroke than YLD. For both diseases DALY rates increased with ageing in men and women. The risk factors most responsible for IHD and stroke burden were smoking, physical inactivity, hypertension and overweight/obesity. Sex and age differences were present in the burden attributable to various risk factors.

CONCLUSION

Despite limitations the DALY estimates represent a useful measure of the size of the health problem. The DALY and related estimates for cardiovascular disease can be used as a guide for the prevention of IHD and stroke as well as the evaluation of future health gains by reducing population exposure to lifestyle and related risk factors.

Disability weights from a household survey in a low socio-economic setting: how does it compare to the global burden of disease 2010 study?

Background

The global burden of disease (GBD) 2010 study used a universal set of disability weights to estimate disability adjusted life years (DALYs) by country. However, it is not clear whether these weights can be applied universally in calculating DALYs to inform local decision-making. This study derived disability weights for a resource-constrained community in Cape Town, South Africa, and interrogated whether the GBD 2010 disability weights necessarily represent the preferences of economically disadvantaged communities.

Design

A household survey was conducted in Lavender Hill, Cape Town, to assess the health state preferences of the general public. The responses from a paired comparison valuation method were assessed using a probit regression. The probit coefficients were anchored onto the 0 to 1 disability weight scale by running a lowess regression on the GBD 2010 disability weights and interpolating the coefficients between the upper and lower limit of the smoothed disability weights.

Results

Heroin and opioid dependence had the highest disability weight of 0.630, whereas intellectual disability had the lowest (0.040). Untreated injuries ranked higher than severe mental disorders. There were some counterintuitive results, such as moderate (15th) and severe vision impairment (16th) ranking higher than blindness (20th). A moderate correlation between the disability weights of the local study and those of the GBD 2010 study was observed (R²=0.440, p<0.05). This indicates that there was a relationship, although some conditions, such as untreated fracture of the radius or ulna, showed large variability in disability weights (0.488 in local study and 0.043 in GBD 2010).

Conclusions

Respondents seemed to value physical mobility higher than cognitive functioning, which is in contrast to the GBD 2010 study. This study shows that not all health state preferences are universal. Studies estimating DALYs need to derive local disability weights using methods that are less cognitively demanding for respondents.

Putting health metrics into practice: using the disability-adjusted life year for strategic decision making

BACKGROUND

Implementing organizations are pressured to be accountable for performance. Many health impact metrics present limitations for priority setting; they do not permit comparisons across different interventions or health areas. In response, Population Services International (PSI) adopted the disability-adjusted life year (DALY) averted as its bottom-line performance metric. While international standards exist for calculating DALYs to determine burden of disease (BOD), PSI's use of DALYs averted is novel. It uses DALYs averted to assess and compare the health impact of its country programs, and to understand the effectiveness of a portfolio of interventions. This paper describes how the adoption of DALYs averted influenced organizational strategy and presents the advantages and constraints of using the metric.

METHODS

Health impact data from 2001-2011 were analyzed by program area and geographic region to measure PSI's performance against its goal of doubling health impact between 2007-2011. Analyzing 10 years of data permitted comparison with previous years' performance. A case study of PSI's Asia and Eastern European (A/EE) region, and PSI/Laos, is presented to illustrate how the adoption of DALYs averted affected strategic decision making.

RESULTS

Between 2007-2011, PSI's programs doubled the total number of DALYs averted from 2002-2006. Most DALYs averted were within malaria, followed by HIV/AIDS and family planning (FP). The performance of PSI's A/EE region relative to other regions declined with the switch to DALYs averted. As a result, the region made a strategic shift to align its work with countries' BOD. In PSI/Laos, this redirection led to better-targeted programs and an approximate 50% gain in DALYs averted from 2009-2011.

CONCLUSIONS

PSI's adoption of DALYs averted shifted the organization's strategic direction away from product sales and toward BOD. Now, many strategic decisions are based on "BOD-relevance," the share of the BOD that interventions can potentially address. This switch resulted in more targeted strategies and greater program diversification. Challenges remain in convincing donors to support interventions in disease areas that are relevant to a country's BOD, and in developing modeling methodologies. The global health community will benefit from the use of standard health impact metrics to improve strategic decision making and more effectively respond to the changing global burden of disease.

Health, well-being, and measuring the burden of disease

This essay asks whether the global burden of diseases, injuries, and risk factors (GBD) should be measured in terms of their consequences for health, as maintained by most of those who are attempting to measure the GBD, or in terms of their consequences for well-being, as argued by John Broome. It answers that the burden of disease should be understood in terms of the consequences of disease for health, and it defends the wider efforts to measure health by those who are in other ways skeptical of the project of measuring the GBD.

The association between serious psychological distress and emergency department utilization among young adults in the USA

PURPOSE

Psychological problems could lead to several adverse health outcomes and were strongly correlated with cigarette smoking and alcohol consumption. In addition, patients treated in EDs were vulnerable to psychological problems. We therefore examined the population-level association between serious psychological distress (SPD) and emergency department (ED) use among young adults in the USA. We also studied the additive effects of SPD, cigarette smoking, and alcohol consumption on the ED presentation.

METHODS

The study sample contains 16,873 individuals, using data from the National Health Interview Survey, from 2004 to 2006. Bivariate analyses with chi-square tests and logistic regression analyses are performed.

RESULTS

Young adults having SPD were 2.05 times more likely to go to an ED. People having SPD and being a current smoker were 2.52 times more likely to use services in an ED. However, people having SPD and being a heavy drinker did not have a significantly elevated risk of ED use.

CONCLUSION

An association between SPD and ED use among US young adults is established in this study. Attempts to decrease excess ED use and the development of strategies to improve mental health among young adults are needed to improve patient health and reduce the health-care burden of high costs and deteriorating ED care quality.

Innovation and the burden of disease: retrospective observational study of new and emerging health technologies reported by the EuroScan Network from 2000 to 2009

OBJECTIVES

Medical innovation in developed countries has been linked to burden of disease, with more innovation in areas representing greater investment return. This study used horizon scanning or early awareness and alert activity as a novel measure of innovation to determine whether new and emerging health technologies reported by international horizon scanning agencies reflected diseases constituting the greatest burden.

METHODS

This was a retrospective observational study of the 20 member agencies of EuroScan (the International Information Network on New and Emerging Health Technologies), representing 17 developed countries. Burden of disease was defined as disability-adjusted life-years, taken from the 2004 World Health Organization Global Burden of Disease estimates. This analysis focused on 102 specific diseases within 21 broader groups. Horizon scanning output was measured as the number of technologies reported by EuroScan member agencies between 2000 and 2009.

RESULTS

At best there was a weak association between innovation and burden of disease. An apparent high-level association was dependent on just three high-prevalence disease groups: malignant neoplasms, neuropsychiatric conditions, and cardiovascular disease. Disaggregating broader groups into specific diseases further weakened the association. Innovation is disproportionately strong in cancer and nonischemic heart disease and disproportionately weak in mental health.

CONCLUSIONS

Innovations reported by early awareness and alert systems do not always reflect conditions accounting for the highest morbidity and mortality. The results do not support previous reports of a positive relationship between burden of disease and innovation, but accord with evidence of notable discrepancies among key groups. Factors other than disease burden drive innovation.

Concurrence of dermatological and ophthalmological morbidity in onchocerciasis

Prevalence of skin and eye disorders in African onchocerciasis (river blindness) is well documented. However, less is known about their joint occurrence. Information on concurrence may improve our understanding of disease pathogenesis and is required to estimate the disease burden of onchocerciasis. We analysed data from 765 individuals from forest villages in the Kumba and Ngambe Health districts, Cameroon. These data were collected in 1998, as baseline data for the evaluation of the African Programme for Onchocerciasis Control. Concurrence of symptoms was assessed using logistic regression. Onchocerciasis was highly endemic in the study population (63% nodule prevalence among males aged ≥20). Considerable overall prevalences of onchocercal visual impairment (low vision or blindness: 4%), troublesome itch (15%), reactive skin disease (19%), and skin depigmentation (25%) were observed. The association between onchocercal visual impairment and skin depigmentation (OR 9.0, 95% CI 3.9-20.8) was partly explained by age and exposure to infection (OR 3.0, 95% CI 1.2-7.7). The association between troublesome itch and reactive skin disease was hardly affected by adjustment (adjusted OR 6.9, 95% CI 4.2-11.1). Concluding, there is significant concurrence of morbidities within onchocerciasis. Our results suggest a possible role of host characteristics in the pathogenesis of depigmentation and visual impairment. Further, we propose a method to deal with concurrence when estimating the burden of disease.

Health perceptions in Latin America

The influence of cultural patterns and economic conditions on health perceptions in Latin America is studied using the results of the 2007 Gallup World Poll. The differences in health satisfaction between countries around the world have a robust association with variables that may reflect cultural differences rather than with aggregate economic variables or traditional health indicators. Simple health self-rating indicators reveal huge cultural differences in health perceptions in Latin America. However, within each country, differences correlate strongly with individuals' economic and health conditions. Lower-income groups recognize more health problems, but are less tolerant of some of them than the rich.

National mental health programme: Manpower development scheme of eleventh five-year plan

Mental disorders impose a massive burden in the society. The National Mental Health Programme (NMHP) is being implemented by the Government of India to support state governments in providing mental health services in the country. India is facing shortage of qualified mental health manpower for District Mental Health Programme (DMHP) in particular and for the whole mental health sector in general. Recognizing this key constraint Government of India has formulated manpower development schemes under NMHP to address this issue. Under the scheme 11 centers of excellence in mental health, 120 PG departments in mental health specialties, upgradation of psychiatric wings of medical colleges, modernization of state-run mental hospitals will be supported. The expected outcome of the Manpower Development schemes is 104 psychiatrists, 416 clinical psychologists, 416 PSWs and 820 psychiatric nurses annually once these institutes/ departments are established. Together with other components such as DMHP with added services, Information, education and communication activities, NGO component, dedicated monitoring mechanism, research and training, this scheme has the potential to make a facelift of the mental health sector in the country which is essentially dependent on the availability and equitable distribution mental health manpower in the country.

Estimation of impact of surgical disease through economic modeling of cleft lip and palate care

BACKGROUND

Assessing burden of disease encompasses the prevalence of disease entities, but it is the impact that affects the populace. Similarly, optimal evaluation of intervention programs shows impact rather than simply an enumeration of services. Economic effects are a fungible measure but are difficult to assess. Modeling of economic effects was used to evaluate a cleft program in Nepal and to demonstrate impact of alleviating this subset of the surgical burden of disease.

METHODS

The database of patients who underwent care at a cleft center in Katmandu in 2005 was used. Disability adjusted life years averted were calculated. Using both GNI per capita and Value of a Statistical Life, the economic value to the individuals and to society was calculated.

RESULTS

The two methods yielded a conservative and a generous estimate of economic impact of treating cleft lip and palate. Using GNI per capita, cleft lip repair added between $856 and $6,598 to lifetime individual income. For cleft palate, this ranged from $2,293 to $17,278. Using Value of a Statistical Life, cleft lip repair added between $56,919 and $143,363, and cleft palate between $152,372 and $375,412.

CONCLUSIONS

The immense economic gain realized by an intervention addressing a small proportion of the surgical burden of disease indicates the importance of these conditions to public health and well-being. This methodology also lends itself to broader use and to further refinement as a means of evaluation of interventions. This has implications for health policy and for funding and resource allocation for surgical conditions in the developing world.

Valuation of health states in the US study to establish disability weights: lessons from the literature

The metric of disability-adjusted life years (DALYs) has become the global standard of measuring burden of disease. DALYs are comprised of years of life lost due to premature mortality and years of healthy life lost due to living with disability. In order to calculate the second part of the DALY equation, disease specific disability weights have to be established, i.e. measures for the decline of health associated with these disease states, which vary between zero for perfect health and one for death. Although these disability weights are key for estimating DALYs, there have not been many comprehensive studies with empirical determinations of them. This article describes a systematic review on the state of the art with respect to empirically determining disability weights. Based on this review, a multi-method approach is outlined, which has also been implemented in a US study to measure burden of disease. This approach involves the use of psychometric methodology as well as economic trade-off methods for determining the value of health states. It is conceptualized as a disaggregated approach, where the disability weight of any health state can be calculated if the attributes of this health state are known. The US study received the collaboration of experts from more than 20 institutes of the National Institutes of Health and of the Centers for Disease Control and Prevention. First results will be available by the end of this year.

Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: a 10/66 Dementia Research Group population-based survey

BACKGROUND

Disability in elderly people in countries with low and middle incomes is little studied; according to Global Burden of Disease estimates, visual impairment is the leading contributor to years lived with disability in this population. We aimed to assess the contribution of physical, mental, and cognitive chronic diseases to disability, and the extent to which sociodemographic and health characteristics account for geographical variation in disability.

METHODS

We undertook cross-sectional surveys of residents aged older than 65 years (n=15 022) in 11 sites in seven countries with low and middle incomes (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Disability was assessed with the 12-item WHO disability assessment schedule 2.0. Dementia, depression, hypertension, and chronic obstructive pulmonary disease were ascertained by clinical assessment; diabetes, stroke, and heart disease by self-reported diagnosis; and sensory, gastrointestinal, skin, limb, and arthritic disorders by self-reported impairment. Independent contributions to disability scores were assessed by zero-inflated negative binomial regression and Poisson regression to generate population-attributable prevalence fractions (PAPF).

FINDINGS

In regions other than rural India and Venezuela, dementia made the largest contribution to disability (median PAPF 25.1% [IQR 19.2-43.6]). Other substantial contributors were stroke (11.4% [1.8-21.4]), limb impairment (10.5% [5.7-33.8]), arthritis (9.9% [3.2-34.8]), depression (8.3% [0.5-23.0]), eyesight problems (6.8% [1.7-17.6]), and gastrointestinal impairments (6.5% [0.3-23.1]). Associations with chronic diseases accounted for around two-thirds of prevalent disability. When zero inflation was taken into account, between-site differences in disability scores were largely attributable to compositional differences in health and sociodemographic characteristics.

INTERPRETATION

On the basis of empirical research, dementia, not blindness, is overwhelmingly the most important independent contributor to disability for elderly people in countries with low and middle incomes. Chronic diseases of the brain and mind deserve increased prioritisation. Besides disability, they lead to dependency and present stressful, complex, long-term challenges to carers. Societal costs are enormous.

FUNDING

Wellcome Trust; WHO; US Alzheimer's Association; Fondo Nacional de Ciencia Y Tecnologia, Consejo de Desarrollo Cientifico Y Humanistico, Universidad Central de Venezuela.

Adjusting life for quality or disability: stylistic difference or substantial dispute?

This paper focuses on the contrast between describing the benefit of a healthcare intervention as gain in health (QALY-type ideas) or a disability reduction (DALY-type ideas). The background is an apparent convergence in practice of the work conducted under both traditions. In the light of these methodological developments, we contrast a health planner who wants to maximise health and one who wants to minimise disability. To isolate the effect of framing the problem from a health or a disability perspective, we do not use age-weighting in calculating DALY and employ a common discounting methodology and the same set of quality of life weights. We find that interventions will be ranked in a systematically different way. The difference, however, is not determined by the use of a health or a disability perspective but by the use of life expectancy tables to determine the years of life lost. We show that this feature of the DALY method is problematic and we suggest its dismissal in favour of a fixed reference age rendering the use of a health or a disability perspective merely stylistic.

Life years at risk: a population health measure from a prevention perspective

This paper aims to present life years at risk (LYAR), a new measure of population health needs for primary, secondary and tertiary prevention, which classifies health outcomes by care type and distinguishes between positive and negative outcomes. It is determined by the probability of ill-health event, population size and life years lost, based on expected incidence, prevalence and mortality. The LYAR consists of two components: the observed LYAR, available using disability adjusted life years, and the avoided LYAR. Three examples are given to illustrate the calculation and application of the measure. The advantages, disadvantages and policy implications are also discussed.

The impact of stroke in Italy: First step for a National Burden of Disease Study

PURPOSE

To calculate the impact of stroke in Italy in 1998, expressed in terms of disability adjusted life years (DALYs) according to the WHO Global Burden of Disease (GBD) Study.

METHOD

The data on first-ever stroke incidence (FES), remission rate and case fatality derived from the health information system and a research on post-FES disability of the Friuli Venezia-Giulia (FVG) Region, were used to compute the years of life lived with disability (YLDs), which were added to the years of life lost due to premature mortality (YLLs), calculated from stroke mortality data, to obtain the DALYs. The results were extrapolated to the rest of Italy after examination of national stroke registries data.

RESULTS

Standardized estimated incidence of FES in FVG in 1998 was lower (135 cases of FES per 100 000 inhabitants) than that reported in other published national and international studies. Estimated case fatality rate and distribution of post-FES disability did not differ from other similar studies. About 100 000 YLLs and 273 000 YLDs due to FES were estimated in 1998 for Italy.

CONCLUSIONS

The estimated proportion of the YLDs on total DALYs (27%) is comparable with that obtained in the EURO-A group (the European area including Italy) of the GBD 2000 Study (31%), and the Australian BoD Study (35%).

How to evaluate whether a new technology in the operating room is cost-effective from society's viewpoint

The hospital operating room is one of the most important and costly environments in health care. Given the current reductions in reimbursement and limited resources, hospital administrators and operating room managers have to be careful about adopting new technologies into the operating room. Operating rooms must balance the improved care a new technology can provide with its additional costs. Economic analysis provides systematic methods to guide decisions by quantitatively assessing the value of a new technology.

Societal costs of air pollution-related health hazards: A review of methods and results

This paper aims to provide a critical and systematic review of the societal costs of air pollution-related ill health (CAP), to explore methodological issues that may be important when assessing or comparing CAP across countries and to suggest ways in which future CAP studies can be made more useful for policy analysis. The methodology includes a systematic search based on the major electronic databases and the websites of a number of major international organizations. Studies are categorized by origin - OECD countries or non-OECD countries - and by publication status. Seventeen studies are included, eight from OECD countries and nine from non-OECD countries. A number of studies based on the ExternE methodology and the USA studies conducted by the Institute of Transportation are also summarized and discussed separately. The present review shows that considerable societal costs are attributable to air pollution-related health hazards. Nevertheless, given the variations in the methodologies used to calculate the estimated costs (e.g. cost estimation methods and cost components included), and inter-country differences in demographic composition and health care systems, it is difficult to compare CAP estimates across studies and countries. To increase awareness concerning the air pollution-related burden of disease, and to build links to health policy analyses, future research efforts should be directed towards theoretically sound and comprehensive CAP estimates with use of rich data. In particular, a more explicit approach should be followed to deal with uncertainties in the estimations. Along with monetary estimates, future research should also report all physical impacts and source-specific cost estimates, and should attempt to estimate 'avoidable cost' using alternative counterfactual scenarios.

Years of life lost due to premature death in Serbia (excluding Kosovo and Metohia)

OBJECTIVE

To provide an assessment of the mortality burden in Serbia (excluding Kosovo and Metohia).

METHODS

The study was undertaken using data for Serbia, excluding Kosovo and Metohia, for the year 2000. Years of life lost (YLL), the mortality component of disability-adjusted life years, was determined from the average life expectancy at each age of death while discounting future years by 3% per annum. YLL was calculated using life expectancy at that age based on standard life tables, with life expectancy at birth fixed at 82.5 years for females and 80.0 years for males.

RESULTS

Premature mortality was responsible for 814,022 YLL, after discounting future years at 3% per annum and weighting for age. Males lost 462,050 years and females lost 351,972 years. Cardiovascular diseases and cancers dominated the burden of premature mortality. Ischaemic heart disease was the leading single cause of YLL for males, followed by stroke, lung cancer, inflammatory heart disease, self-inflicted injuries, road traffic accidents, colorectal and stomach cancers, and chronic obstructive pulmonary disease. Each contributed over 10,000 YLL. For females, cerebrovascular disease was the leading cause of YLL, followed by ischaemic heart disease, breast and lung cancer, and diabetes mellitus. YLL due to premature death gives greater weight to those conditions that affect younger people. Consequently, a ranking of diseases by YLL differs from a ranking based on unadjusted numbers of deaths. In comparison with data from the Global Burden of Disease study (2000) for the world population and the EURO-A region, the mortality burden in Serbia is closer to that in developed than developing countries. Standardization was performed using the direct method, with the world population used as the standard.

CONCLUSIONS

The national health priority areas, relevant to the mortality burden, should include cardiovascular diseases, cancers, diabetes mellitus, self-inflicted injuries and road traffic accidents.

The Global Burden of Disease assessments--WHO is responsible?

The Global Burden of Disease (GBD) concept has been used by the World Health Organization (WHO) for its reporting on health information for nearly 10 years. The GBD approach results in a single summary measure of morbidity, disability, and mortality, the so-called disability-adjusted life year (DALY). To ensure transparency and objectivity in the derivation of health information, WHO has been urged to use reference groups of external experts to estimate burden of disease. Under the leadership and coordination of WHO, expert groups have been appraising and abstracting burden of disease information. Examples include the Child Health Epidemiology Reference Group (CHERG), the Malaria Monitoring and Evaluation Reference Group (MERG), and the recently established Foodborne Disease Burden Epidemiology Reference Group (FERG). The structure and functioning of and lessons learnt by these groups are described in this paper. External WHO expert groups have provided independent scientific health information while operating under considerable differences in structure and functioning. Although it is not appropriate to devise a single "best practice" model, the common thread described by all groups is the necessity of WHO's leadership and coordination to ensure the provision and dissemination of health information that is to be globally accepted and valued.

Integrated risk-benefit analyses: method development with folic acid as example

With the introduction of novel and functional foods, there is increasing need for an integrated quantitative risk-benefit assessment of foods. Consensus about a quantitative risk-benefit assessment mirroring the risk assessment approach has been reached during a recent EFSA workshop. In line, we propose a risk-benefit model that consists of: (1) hazard and benefit identification, (2) hazard and benefit characterization through dose-response functions, (3) exposure assessment, and (4) risk-benefit integration. The DALY, which combines morbidity and mortality serves as common health measure. The overall health impact of bread fortified with folic acid in the Netherlands has been simulated. The case study showed how the risk-benefit approach may assist a policy maker in decisions on food fortification programs. It illustrates general problems regarding the data demands, the assumptions and uncertainties. A simple sensitivity analysis showed which assumptions were most crucial. Modest fortification (140 microg/100 g bread) seems reasonable to improve public health but the results hinge on the assumptions one makes for the association between colorectal cancer and high folate intake. A precautious policymaker may very well decide against folic acid fortification. The often debated increase in masked vitamin B(12)-deficiency appears negligible compared to the health gain resulting from prevented neural tube defects.

Distribución del presupuesto sanitario público de Cataluña del año 2005 entre las 17 categorías CIE-9-MC

OBJECTIVES

To describe the distribution of the Catalan public healthcare budget for 2005 among the 17 ICD-9-CM (International Classification of Diseases, Ninth revision, clinical modification) categories.

MATERIAL AND METHOD

The methodology comprised 2 phases: an initial phase in which the global budget was distributed by type of healthcare (hospital, outpatient or pharmacological care), and a second phase in which the expenditure was distributed by the type of care among the ICD-9-CM categories. In the first phase, this distribution was based on information enabling the various budget items to be assigned to the different types of care. Various elements were used for the distribution by categories, depending on each type of care: hospital stay, outpatient visit or consumption by therapeutic subgroup.

RESULTS

Distribution of the budget was as follows: 46.6% for specialized care, 27.5% for pharmacological care, and 20.0% for primary care; 5.9% was not distributed. Of the 17 categories, that accounting for the largest percentage (17.3%) was "diseases of the circulatory system" (VII), followed by category VIII, "diseases of the respiratory system" which totaled 10.9%. The budget was concentrated in 5 categories, the 2 mentioned above plus category V "mental disorders" (9.4%), category II "tumors" (9.1%) and category IX "disorders of the digestive system" (7.7%), which accounted for 54.4% of the total budget. The internal composition of each category showed major variations.

CONCLUSION

The distribution of the budget offers a point of reference for health planning and management.

Evaluating the discriminatory power of EQ-5D, HUI2 and HUI3 in a US general population survey using Shannon's indices

Objectives

To compare quantitatively the discriminatory power of the EQ-5D, HUI2 and HUI3 in terms of absolute and relative informativity, using Shannon’s indices.

Methods

EQ-5D and HUI2/3 data completed by a sample of the general adult US population (N = 3,691) were used. Five dimensions allowed head-to-head comparison of informativity: Mobility/Ambulation; Anxiety/Depression/Emotion; Pain/Discomfort (EQ-5D; HUI2; HUI3); Self-Care (EQ-5D; HUI2); and Cognition (HUI2; HUI3). Shannon’s index and Shannon’s Evenness index were used to assess absolute and relative informativity, both by dimension and by instrument as a whole.

Results

Absolute informativity was highest for HUI3, with the largest differences in Pain/Discomfort and Cognition. Relative informativity was highest for EQ-5D, with the largest differences in Mobility/Ambulation and Anxiety/Depression/Emotion. Absolute informativity by instrument was consistently highest for HUI3 and lowest for EQ-5D, and relative informativity was highest for EQ-5D and lowest for HUI3.

Discussion

Performance in terms of absolute and relative informativity of the common dimensions of the three instruments varies over dimensions. Several dimensions are suboptimal: Pain/Discomfort (EQ-5D) seems too crude with only 3 levels, and the level descriptions of Ambulation (HUI3) and Self-Care (HUI2) could be improved. In absence of a formal measure, Shannon’s indices provide useful measures for assessing discriminatory power of utility instruments.

Burden of tuberculosis in Serbia

The objective of this study is to estimate the burden of tuberculosis (TB) in Serbia in the period 1992-2002 based on incidence, mortality, and disability adjusted life years (DALY). The average age-adjusted TB incidence rate in the period 1992-2002 was 36.7/100,000 in males and 21.4/100,000 in females. During the period observed, TB incidence levelled of after a long period of decreasing trend during the preceding several decades. The incidence showed slightly increasing tendency in males and decreasing one in females. The average age-adjusted mortality rate was 4.1/100,000 in males and 1.3/100,000 in females. Mortality rates significantly decreased in both males (P = .0001) and females (P = .0001). The burden of TB (DALY) was 0.70/1000 for males and 0.26/1000 for females. DALY rates significantly decreased in both males (P = .009) and females (P = .008). TB incidence and mortality as well as DALY rates increased with aging.

The economic costs of road traffic crashes: Australia, states and territories

In this paper, we obtain detailed data on road traffic crash (RTC) casualties, by severity, for each of the eight state and territory jurisdictions for Australia and use these to estimate and compare the economic impact of RTCs across these regions. We show that the annual cost of RTCs in Australia, in 2003, was approximately Dollars 17 b, which is approximately 2.3% of the Gross Domestic Product (GDP). Importantly, though, there is remarkable intra-national variation in the incident rates of RTCs in Australia and costs range from approximately 0.62 to 3.63% of Gross State Product (GSP). The paper makes two fundamental contributions: (i) it provides a detailed breakdown of estimated RTC casualties, by state and territory regions in Australia, and (ii) it presents the first sub-national breakdown of RTC costs for Australia. We trust that these contributions will assist policy-makers to understand sub-national variations in the road toll better and will encourage further research on the causes of the marked differences between RTC outcomes across the states and territories of Australia.

Packaging health services when resources are limited: the example of a cervical cancer screening visit

BACKGROUND

Increasing evidence supporting the value of screening women for cervical cancer once in their lifetime, coupled with mounting interest in scaling up successful screening demonstration projects, present challenges to public health decision makers seeking to take full advantage of the single-visit opportunity to provide additional services. We present an analytic framework for packaging multiple interventions during a single point of contact, explicitly taking into account a budget and scarce human resources, constraints acknowledged as significant obstacles for provision of health services in poor countries.

METHODS AND FINDINGS

We developed a binary integer programming (IP) model capable of identifying an optimal package of health services to be provided during a single visit for a particular target population. Inputs to the IP model are derived using state-transition models, which compute lifetime costs and health benefits associated with each intervention. In a simplified example of a single lifetime cervical cancer screening visit, we identified packages of interventions among six diseases that maximized disability-adjusted life years (DALYs) averted subject to budget and human resource constraints in four resource-poor regions. Data were obtained from regional reports and surveys from the World Health Organization, international databases, the published literature, and expert opinion. With only a budget constraint, interventions for depression and iron deficiency anemia were packaged with cervical cancer screening, while the more costly breast cancer and cardiovascular disease interventions were not. Including personnel constraints resulted in shifting of interventions included in the package, not only across diseases but also between low- and high-intensity intervention options within diseases.

CONCLUSIONS

The results of our example suggest several key themes: Packaging other interventions during a one-time visit has the potential to increase health gains; the shortage of personnel represents a real-world constraint that can impact the optimal package of services; and the shortage of different types of personnel may influence the contents of the package of services. Our methods provide a general framework to enhance a decision maker's ability to simultaneously consider costs, benefits, and important nonmonetary constraints. We encourage analysts working on real-world problems to shift from considering costs and benefits of interventions for a single disease to exploring what synergies might be achievable by thinking across disease burdens.

Deriving utility scores for co-morbid conditions: a test of the multiplicative model for combining individual condition scores

BACKGROUND

The co-morbidity of health conditions is becoming a significant health issue, particularly as populations age, and presents important methodological challenges for population health research. For example, the calculation of summary measures of population health (SMPH) can be compromised if co-morbidity is not taken into account. One popular co-morbidity adjustment used in SMPH computations relies on a straightforward multiplicative combination of the severity weights for the individual conditions involved. While the convenience and simplicity of the multiplicative model are attractive, its appropriateness has yet to be formally tested. The primary objective of the current study was therefore to examine the empirical evidence in support of this approach.

METHODS

The present study drew on information on the prevalence of chronic conditions and a utility-based measure of health-related quality of life (HRQoL), namely the Health Utilities Index Mark 3 (HUI3), available from Cycle 1.1 of the Canadian Community Health Survey (CCHS; 2000-01). Average HUI3 scores were computed for both single and co-morbid conditions, and were also purified by statistically removing the loss of functional health due to health problems other than the chronic conditions reported. The co-morbidity rule was specified as a multiplicative combination of the purified average observed HUI3 utility scores for the individual conditions involved, with the addition of a synergy coefficient s for capturing any interaction between the conditions not explained by the product of their utilities. The fit of the model to the purified average observed utilities for the co-morbid conditions was optimized using ordinary least squares regression to estimate s. Replicability of the results was assessed by applying the method to triple co-morbidities from the CCHS cycle 1.1 database, as well as to double and triple co-morbidities from cycle 2.1 of the CCHS (2003-04).

RESULTS

Model fit was optimized at s = .99 (i.e., essentially a straightforward multiplicative model). These results were closely replicated with triple co-morbidities reported on CCHS 2000-01, as well as with double and triple co-morbidities reported on CCHS 2003-04.

CONCLUSION

The findings support the simple multiplicative model for computing utilities for co-morbid conditions from the utilities for the individual conditions involved. Future work using a wider variety of conditions and data sources could serve to further evaluate and refine the approach.

The epidemiology of multiple sclerosis in Europe

Multiple sclerosis (MS) is a chronic and potentially highly disabling disorder with considerable social impact and economic consequences. It is the major cause of non-traumatic disability in young adults. The social costs associated with MS are high because of its long duration, the early loss of productivity, the need for assistance in activities of daily living and the use of immunomodulatory treatments and multidisciplinary health care. Available MS epidemiological estimates are aimed at providing a measure of the disease burden in Europe. The total estimated prevalence rate of MS for the past three decades is 83 per 100,000 with higher rates in northern countries and a female:male ratio around 2.0. Prevalence rates are higher for women for all countries considered. The highest prevalence rates have been estimated for the age group 35-64 years for both sexes and for all countries. The estimated European mean annual MS incidence rate is 4.3 cases per 100,000. The mean distribution by disease course and by disability is also reported. Despite the wealth of epidemiological data on MS, comparing epidemiological indices among European countries is a hard task and often leads only to approximate estimates. This represents a major methodological concern when evaluating the MS burden in Europe and when implementing specific cost-of-illness studies.

Economic evaluations of non-communicable disease interventions in developing countries: a critical review of the evidence base

BACKGROUND

Demographic projections suggest a major increase in non-communicable disease (NCD) mortality over the next two decades in developing countries. In a climate of scarce resources, policy-makers need to know which interventions represent value for money. The prohibitive cost of performing multiple economic evaluations has generated interest in transferring the results of studies from one setting to another. This paper aims to bridge the gap in the current literature by critically evaluating the available published data on economic evaluations of NCD interventions in developing countries.

METHODS

We identified and reviewed the methodological quality of 32 economic evaluations of NCD interventions in developing countries. Developing countries were defined according to the World Bank classification for low- and lower middle-income countries. We defined NCDs as the 12 categories listed in the 1993 World Bank report Investing in Health. English language literature was searched for the period January 1984 and January 2003 inclusive in Medline, Science Citation Index, HealthStar, NHS Economic Evaluation Database and Embase using medical subheading terms and free text searches. We then assessed the quality of studies according to a set of pre-defined technical criteria.

RESULTS

We found that the quality of studies was poor and resource allocation decisions made by local and global policy-makers on the basis of this evidence could be misleading. Furthermore we have identified some clear gaps in the literature, particularly around injuries and strategies for tackling the consequences of the emerging tobacco epidemic.

CONCLUSION

In the face of poor evidence the role of so-called generalised cost-effectiveness analyses has an important role to play in aiding public health decision-making at the global level. Further research is needed to investigates the causes of variation among cost, effects and cost-effectiveness data within and between settings. Such analyses still need to take a broad view, present data in a transparent manner and take account of local constraints.

The economics of HIV/AIDS in low-income countries: the case for prevention

There are two approaches to reducing the burden of sickness and death associated with the human immunodeficiency virus (HIV), which leads to acquired immunodeficiency syndrome (AIDS): treatment and prevention. Despite large international aid flows for HIV/AIDS, the needs for prevention and treatment in low- and middle-income countries outstrip the resources available. Thus, it becomes necessary to set priorities. With limited resources, should the focus of efforts to combat HIV/AIDS be on prevention or treatment? I discuss the range of prevention and treatment alternatives and examine their cost effectiveness. I consider various arguments that have been raised against the use of cost-effectiveness analysis in setting public policy priorities for the response to HIV/AIDS in developing countries. I conclude that promoting AIDS treatment using antiretrovirals in resource-constrained countries comes at a huge cost in terms of avoidable deaths that could be prevented through interventions that would substantially lower the scale of the epidemic.

[Disability-adjusted life years: an instrument for defining public health priorities?]

BACKGROUND

The objective of this paper is the study of a health indicator allowing surveillance and evaluation of the overall health of the Paris population, and providing information to help prioritize possible choices among preventive and curative actions. Moreover, comparison between results obtained for Paris with a global health indicator, "Disability-adjusted life years" (DALYs) and available bibliographical data will enable clarifying some points about summary measures of health.

METHODS

The method used is that of the Global Burden of Disease. It allows a ranking of diseases using an indicator called DALYs. This indicator integrates mortality and morbidity components by summing expected years of life lost due to premature mortality and calculated years of healthy life lost. DALYs were calculated using local mortality data and published regional disabilities tables from the World Health Organisation (WHO).

RESULTS

There were a total of 242 061 DALYs for Paris for the year 1999. The six leading specific causes are: alcoholic psychosis and dependence (accounting for 6.5% of the total), lung cancers (5.7%), ischaemic hearth disease (4.8%), depression (4.4%), dementias (4.2%), and arthritis (3.9%). Men contributed the majority of DALYs for the first three. For four of the six leading causes, the majority of DALYs came from years lived with disability, rather than mortality. Only for lung cancer and ischaemic hearth disease was the majority of DALYs from years of life lost by mortality.

CONCLUSION

The results for Paris are used to illustrate how DALYs can illuminate debates about public health priorities. Such data can inform the population about health condition and provide decision makers with global health indicators. The next step will be to estimate the DALYs from local morbidity data when available, and compare these results to those based on the World Health Organisation tables, which are not sensitive to local results other than those due to mortality. Future steps include further evaluation and development of this method for surveillance, assessment and evaluation of public health actions. However, some of the results obtained with this indicator underline the limits of this kind of analysis.

[Burden, attitudes and social support in the families of patients with long-term physical diseases]

AIMS

To describe in a sample of 646 relatives of patients with physical long-term illnesses: a) the relatives' burden of care; b) the relatives' attitudes towards the patients; c) the social and professional support received by the families.

METHODS

The study has been carried out in 30 Italian geographic areas randomly selected taking into account geographic location and population density. The sample has been consecutively recruited in 139 specialised units for the treatment of chronic heart, brain, diabetes, kidney, and lung diseases. Family burden was evaluated in relation to: a) family's socio-demographic variables and patients' clinical variables; b) relatives' attitudes toward the patient; c) social and professional support; d) geographic area and population density.

OUTCOME MEASURES

Family Problems Questionnaire, physical illness version (QPF-O) and Social Network Questionnaire (QRS).

RESULTS

The consequences of caregiving most frequently reported were constraints in social and recreational activities, and feelings of loss. Burden was more marked in relatives of patients with higher physical disabilities, with neurological illnesses, and in relatives with lower support by their social network.

CONCLUSIONS

These data highlight the need to provide psychological and practical support to caregivers of patients with long-term physical diseases on the basis of the evaluation of their needs for care.

Family burden in long-term diseases: a comparative study in schizophrenia vs. physical disorders

This study explored burden and social networks in families of patients with schizophrenia or a long-term physical disease. It was carried out in 169 specialised units (mental health department, and units for the treatment of chronic heart, brain, diabetes, kidney, lung diseases) recruited in 30 randomly selected geographic areas of Italy. The study sample consisted of 709 key relatives of patients with a DSM-IV diagnosis of schizophrenia and 646 key relatives of patients with physical diseases. Each relative was asked to fill in the Family Problems Questionnaire (FPQ) and the Social Network Questionnaire (SNQ). In all selected pathologies, the consequences of caregiving most frequently reported as always present in the past 2 months were constraints in social activities, negative effects on family life, and a feeling of loss. Objective burden was higher in brain diseases, and subjective burden was higher in schizophrenia and brain diseases than in the other groups. Social support and help in emergencies concerning the patient were dramatically lower among relatives of patients with schizophrenia than among those of patients with physical diseases. In the schizophrenia group, both objective and subjective burden were significantly higher among relatives who reported lower support from their social network and professionals. The results of this study highlight the need to provide the families of those with long-term diseases with supportive interventions, including: (a) the management of relatives' psychological reactions to patient's illness; (b) the provision of information on the nature, course and outcome of patient's disease; (c) training for the relatives in the management of the patient's symptoms; and (d) the reinforcement of relatives' social networks, especially in the case of schizophrenia.

Can the value choices in DALYs influence global priority-setting?

The "disability adjusted life years" (DALYs) are increasingly used as a tool for decision-making and for describing the distribution of the Global Burden of Disease. The "DALY" combines information about mortality and morbidity, with several value choices such as disability weighting, age-weighting and discounting. These value choices imply that life years are assigned different value, depending on the age and the health state they are in. How robust is the distribution of DALYs to changes in these value choices, and are the choices transparent at the point of use? We calculated the burden attributed to "developmental disability due to malnutrition" and "major depression" with alternative value choices in a simple sensitivity analysis. In particular, we explored the relation between disability weight, health state description and incidence rate. The formulae and information needed was found in the World Health Organisation (WHO) publications using DALYs, and in a survey among international health workers. We found that alternative age-weights, disability weights and discount rate led to an inversion in the ranking of the burden of the two conditions. The DALY loss attributed to "developmental disability due to malnutrition" increased from 14 to 90%, while that of "major depression" sunk from 86 to 10%. The value choices currently used, tend at underestimating the disease burden attributed to young populations and to communicable diseases and this goes against the renewed efforts of the WHO of targeting diseases that are typical of poor populations. While the value choices may be changed, lack of transparency is a more profound problem. At the point of use, the number of DALYs attributed to a condition cannot be fully disaggregated. Hence, one cannot know which part of a DALY loss reflects the age group affected, the prevalence, the mortality rates, the disability weight assigned to it, or to how the condition has been defined. A more transparent and useful approach, we believe, would be to present the years lost due to a disease, and the years lived with a disease separately, without disability weights, age-weights and discounting. This would keep the best of the DALY approach and come closer to the aim of disentangling science from advocacy.

The post-war public health effects of civil conflict

Civilian suffering from civil war extends well beyond the period of active warfare. We examine longer-term effects in a cross-national analysis of World Health Organization data on death and disability broken down by age, gender, and type of disease or condition. We find substantial long-term effects, even after controlling for several other factors. We estimate that the additional burden of death and disability incurred in 1999 alone, from the indirect and lingering effects of civil wars in the years 1991-1997, was nearly double the number incurred directly and immediately from all wars in 1999. This impact works its way through specific diseases and conditions, and disproportionately affects women and children.

Opportunities for an improved role for nurses in psychoactive substance use: Review of the literature

Nurses form a core component of many health care systems so their role in responding to problems related to psychoactive substance use is crucial. They are often under-utilized, mainly because of anxieties concerning role adequacy, legitimacy, lack of support and failure to implement interventions in a variety of settings. Nurses have unique opportunities through interactions they have with young people, families and significant others. Training and career preparation should encompass development of innovative strategies, taking a leading role in management of substance use patients, involvement in the treatment of the homeless mentally ill, HIV-infected individuals and persons with dual disorders of mental health and substance use. Future directions should focus on developing skills for critical thinking, preventive and therapeutic interventions, clinical judgement, effective organizational capacity and team work. Barriers such as scope of practice, authority, ethical and legal issues surrounding health care for substance use need to be addressed.

Global burden of disease: huge inequities in the health status in developing and developed countries

This paper outlines the Global Burden of Disease study which was conducted for the 1993 World Bank Development Report. The study revealed huge differences in premature death and disability in the world regions examined; sub-Saharan Africa and India had the highest burden of disease. This paper also examines how the large differences in burden of disease between developed and developing countries can be explained by economic factors, highlighting research findings that suggest egalitarian societies are likely to have better health status than countries with capitalistic, market-based economies. This study then examines the efforts of the Global Forum for Health Research to create an integrated approach to global health policy formulation, using global burden of disease data, and concludes with the assertion that adopting such an approach nationally would also assist developed countries like Canada in better dealing with future health challenges.

Cross-national agreement on disability weights: the European Disability Weights Project

Background

Disability weights represent the relative severity of disease stages to be incorporated in summary measures of population health. The level of agreement on disability weights in Western European countries was investigated with different valuation methods.

Methods

Disability weights for fifteen disease stages were elicited empirically in panels of health care professionals or non-health care professionals with an academic background following a strictly standardised procedure. Three valuation methods were used: a visual analogue scale (VAS); the time trade-off technique (TTO); and the person trade-off technique (PTO). Agreement among England, France, the Netherlands, Spain, and Sweden on the three disability weight sets was analysed by means of an intraclass correlation coefficient (ICC) in the framework of generalisability theory. Agreement among the two types of panels was similarly assessed.

Results

A total of 232 participants were included. Similar rankings of disease stages across countries were found with all valuation methods. The ICC of country agreement on disability weights ranged from 0.56 [95% CI, 0.52–0.62] with PTO to 0.72 [0.70–0.74] with VAS and 0.72 [0.69–0.75] with TTO. The ICC of agreement between health care professionals and non-health care professionals ranged from 0.64 [0.58–0.68] with PTO to 0.73 [0.71–0.75] with VAS and 0.74 [0.72–0.77] with TTO.

Conclusions

Overall, the study supports a reasonably high level of agreement on disability weights in Western European countries with VAS and TTO methods, which focus on individual preferences, but a lower level of agreement with the PTO method, which focuses more on societal values in resource allocation.

Costs of schizophrenia and other psychoses in urban Australia: findings from the Low Prevalence (Psychotic) Disorders Study

OBJECTIVE

To estimate the costs associated with the treatment and care of persons with psychosis in Australia based on data from the Low Prevalence Disorders Study (LPDS), and to identify areas where there is potential for more efficient use of existing health care resources.

METHOD

The LPDS was a one-month census-based survey of people with psychotic disorders in contact with mental health services, which was conducted in four metropolitan regions in 1997-1998. Mental health and service utilization data from 980 interviews were used to estimate the economic costs associated with psychotic disorders. A prevalence-based, 'bottom-up' approach was adopted to calculate the government and societal costs associated with psychosis, including treatment and non-treatment related costs.

RESULTS

Annual societal costs for the average patient with psychosis are of the order of 46,200 Australian dollars , comprising 27,500 Australian dollars in lost productivity, 13,800 Australian dollars in inpatient mental health care costs and 4900 Australian dollars in other mental health and community services costs. Psychosis costs the Australian government at least 1.45 billion Australian dollars per annum, while societal costs are at least 2.25 billion Australian dollars per annum (including 1.44 billion Australian dollars for schizophrenia). We also report relationships between societal costs and demographic factors, diagnosis, disability and participation in employment.

CONCLUSIONS

Current expenditure on psychosis in Australia is probably inefficient. There may be substantial opportunity costs in not delivering effective treatments in sufficient volume to people with psychotic disorders, not intervening early, and not improving access to rehabilitation and supported accommodation.

Allocation of resources and psychosis

OBJECTIVE

This commentary reviews current expenditure on psychosis in Australia, identifies discretionary expenditure that could be used more efficiently, discusses the factors influencing resource allocation and intervention selection decisions, and suggests priorities for change.

METHOD

Cost-of-illness findings from the Low Prevalence Disorders Study (LPDS), and related service use and psychosocial data, are used to highlight patterns of expenditure on psychosis and potential resource allocation issues. Arguments are also presented suggesting that mental health resource allocation in Australia should be informed primarily by treatment efficiency, equity and humanitarian considerations, not differences in the global burden of disease. However, our evidence-base about the effectiveness and costs associated with individual treatments, programmes, and organizational structures is also shown to be limited.

CONCLUSIONS

The patterns of service use and expenditure on psychosis suggest certain imbalances, including an over-reliance on hospitalization, low levels of supported community accommodation, and inadequate provision of evidence-based psychosocial treatments, rehabilitation and supported employment programmes. We need to identify and develop efficient interventions and programmes, re-orientate our services to better utilize those interventions, increase community awareness, improve monitoring of outcomes and costs, and undertake timely evaluations at multiple levels, from the individual to the societal perspective.