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Journal ArticleDOI

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013 : quantifying the epidemiological transition

28 Nov 2015-The Lancet (Elsevier)-Vol. 386, Iss: 10009, pp 2145-2191
TL;DR: Patterns of the epidemiological transition with a composite indicator of sociodemographic status, which was constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population, were quantified.
About: This article is published in The Lancet.The article was published on 2015-11-28 and is currently open access. It has received 1609 citations till now. The article focuses on the topics: Years of potential life lost & Disability-adjusted life year.

Summary (4 min read)

Introduction

  • The Global Burden of Disease study 2013 (GBD 2013) seeks to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to allow comparisons of health loss to be made over time and across causes, age-sex groups, and geographies.
  • 1, 2 These measures are crucial to track health progress, strengthen policy decisions, assess programme effects and results, and inform health service and research priorities.
  • Such holistic measures of population health, encompassing both disability and mortality levels and patterns in populations, are also attracting interest as part of the discussion around the Sustainable Development Goals . [3] [4] [5].
  • 1, 2 The GBD not only provides detailed metrics for specific causes, but also generates summary measures, such as DALYs and HALE, which enable comparative assessments of broad epidemiological patterns across countries and different time periods.
  • The unfolding of the HIV epidemic and the rise of adult mortality, especially among men in Eastern Europe and Central Asia, have called into question the notion of a universal pattern of epidemiological change that occurs with sociodemographic development. 2, [10] [11] [12] [13].

Study design

  • GBD 2013 uses a hierarchy of causes that organises 306 diseases and injuries into four levels of classification, the rationale for which has been described previously.
  • 2, 19 The first level distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries.
  • Details of data sources and estimation methods used to deal with missing data and multiple measurements for the same country-age-sex-year group have been described previously.
  • Disease and injury incidence and prevalence and computation of YLDs have been estimated in line with similar principles of identification and assessment of the quality of all available sources for 2337 sequelae of the 301 diseases and injuries.
  • Various statistical estimation methods were used depending on the details of specific diseases, the most common approach being the application of a Bayesian metaregression model, DisMod-MR 2.0.

Years lived with disability

  • The authors did this by summing the first draw of the 1000 draws for YLLs and YLDs and then repeating for each subsequent draw.
  • The authors calculated 95% uncertainty intervals (UIs) using the 25th and 975th ordered draw of the DALY uncertainty distribution.

Healthy life expectancy

  • The authors calculated HALE in accordance with the methods outlined by Salomon and colleagues.
  • In brief, the authors used Sullivan's method 22 to incorporate information about average levels of health experienced at different ages into an abridged life table to produce estimates of life expectancy that are adjusted for reductions in functional health status relating to prevalent health conditions.
  • Calculation of HALE relies on three inputs from GBD 2013: life tables by sex, country, and year; estimates of the prevalence of 2337 sequelae by age, sex, country and year; and disability weights for 235 unique health states that collectively cover the range of functional health losses and symptoms associated with the 2337 sequelae.
  • The authors combined information about prevalence and disability weights into measures of the overall rate of YLDs per person in each age-sex-country group.
  • The authors make the strong assumption that uncertainty in YLDs per person is independent of uncertainty in age-specific death rates to calculate uncertainty distributions for HALE.

Decomposition of variance and epidemiological transition

  • In demographic transition, a characteristic evolution occurs in populations over time towards reduced fertility rates, reduced mortality rates, and an older age distribution of the population.
  • 23, 24 We aimed to construct a single composite variable to represent both demographic status and socioeconomic development to explore the patterns of the epidemiological transition.the authors.the authors.
  • The authors used hierarchical regression to decompose variance in log DALY rates into components related to the sociodemographic status, intercountry variation, year, and fraction explained by the interactions of the other variables.
  • The authors divided the variance of each random effect by total variance to decompose variance into different factors.

Decomposition of epidemiological patterns

  • The authors decomposed the variance of DALY rates for GBD level 2 causes into contributions from sociodemographic status, year, country, and unexplained sources (residual; table 2).
  • Sociodemographic status explained more than 50% of the variance for diarrhoea, lower respiratory infections and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable diseases; musculoskeletal disorders; and other NCDs.
  • By contrast, time invariant intercountry variation was an important component of the variance in DALY rates for all causes, ranging from a low of 1129% for neonatal disorders to 9123% for self-harm and interpersonal violence.
  • Some important causes of global YLLs are not strongly related to sociodemographic status because they are largely country-specific, such as neglected tropical diseases and malaria, neoplasms, and intentional injuries.
  • As sociodemographic status rises, the steady decreases in YLLs and increases in YLDs cause the proportion of total DALYs attributable to YLDs to steadily rise from 99% at the lowest level of sociodemographic status to 491% in the highest vigintile.

Country-specific results

  • For most countries, changes in HALE were positive for both men and women between 1990 and 2013, and the differences were significant.
  • As life expectancy increases, the gap between life expectancy and HALE widens, increasing to more than 10 years at a life expectancy of 77 years for women and 78 years for men.
  • The leading causes of DALYs vary substantially across regions, representing both different levels of sociodemographic status and distinct regional patterns.
  • In central Latin America, violence, ischaemic heart disease, diabetes, low back and neck pain, and road injuries comprise the top five causes.
  • Other examples of distinct regional patterns include the high ranking of COPD in east Asia, the dominance of malaria in west Africa, and the dominance of HIV/AIDS in eastern and southern sub-Saharan Africa.

Discussion

  • Life expectancy at birth rose by 62 years between 1990 and 2013, while HALE at birth increased by 54 years during the same interval; worldwide, agestandardised DALY rates fell by 27%, also known as Global health is improving.
  • Notably, the predictable rise in YLD rates for some causes (such as musculoskeletal disorders, diabetes mellitus, and mental and substance use disorders) driven by population ageing is not well recognised in the literature about the epidemiological transition.
  • The substantial effect of country variation on the epidemiological transition pattern reinforces the importance of estimating the burden of disease for each country individually.
  • Such a measure is susceptible to variation in the meaning attached to categorical descriptions of limitation levels, both between individuals and over time, as seen in related survey items on health status. [50] [51] [52].
  • Controlling for sociodemographic status, substantial variation exists for DALY rates between countries.

Research in context

  • In 2012, results from the first complete revision of the Global Burden of Disease (GBD) since the first assessment in 1993 became available.
  • This effort was called the GBD 2010 study and reported on disability-adjusted life-years and health-adjusted life expectancy (HALE) by country for 1990 and 2010 based on analyses of an extensive data collection effort to collate all available information on causes of death and disease occurrence in 187 countries.
  • In response to the need for up-to-date information about the health of populations to inform health policy decision making, a decision was made to produce annual updates.
  • The GBD 2013 is the first of these annual updates.
  • In previous papers on the GBD 2013 study, the authors have documented the new data and new methods used to assess mortality and morbidity by country and over time.

Added value of this study

  • Here, the authors present the results for the aggregation of mortality and morbidity in terms of DALYs and HALE by country and for the time period 1990 to 2013.
  • The authors examined to what extent the changes in DALYs since 1990 by disease and country can be explained by a composite indicator of sociodemographic status, constructed from income per person, years of schooling after age 15 years, median age of the population and total fertility rate.
  • These GBD 2013 results for the period 1990 to 2013 for DALYs and HALE supersede all previously published GBD findings on DALYs and HALE.

Implications of all the available evidence

  • Numbers of DALYs and crude and age-standardised DALY rates for communicable diseases, maternal, neonatal, and nutritional disorders have decreased since 1990.
  • For non-communicable diseases, the number of DALYs have increased, crude rates have remained stable, and age-standardised rates have decreased.
  • Global health is improving but population increase and ageing are keeping the crude rates of DALYs constant, showing that progress in health does not mean fewer demands on health systems.
  • The epidemiological transition, as quantified using their sociodemographic status indicator, accounts for much of the variation between countries and over time for most communicable, maternal, and neonatal causes but not for many non-communicable causes such as cardiovascular disease.
  • The large variation in burden that is not associated with sociodemographic status emphasises the need for ongoing detailed assessments of DALYs and HALE at the country level to inform health policies.

Europe PMC Funders Author Manuscripts

  • The epidemiological transition based on predicted YLL and YLD rates per 100 000 people as a function of the level of sociodemographic status by vigintile and broken down into GBD level 2 causes.
  • These predicted levels control for variation explained by year and country.
  • Decomposition of variance in 2013 global DALY rates per 100 000 people for GBD level 2 causes using hierarchical regression.

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Citations
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TL;DR: The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) as discussed by the authors was used to estimate the incidence, prevalence, and years lived with disability for diseases and injuries at the global, regional, and national scale over the period of 1990 to 2015.

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References
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TL;DR: In this article, a comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study, and the authors aimed to calculate disease burden globally and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time.

7,020 citations

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Christopher J L Murray1, Theo Vos2, Rafael Lozano1, Mohsen Naghavi1  +366 moreInstitutions (141)
TL;DR: The results for 1990 and 2010 supersede all previously published Global Burden of Disease results and highlight the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account.

6,861 citations

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Mohsen Naghavi1, Haidong Wang1, Rafael Lozano1, Adrian Davis2  +728 moreInstitutions (294)
TL;DR: In the Global Burden of Disease Study 2013 (GBD 2013) as discussed by the authors, the authors used the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data.

5,792 citations

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Theo Vos1, Ryan M Barber1, Brad Bell1, Amelia Bertozzi-Villa1  +686 moreInstitutions (287)
TL;DR: In the Global Burden of Disease Study 2013 (GBD 2013) as mentioned in this paper, the authors estimated the quantities for acute and chronic diseases and injuries for 188 countries between 1990 and 2013.

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Frequently Asked Questions (5)
Q1. What contributions have the authors mentioned in the paper "Global, regional, and national disability-adjusted life years (dalys) for 306 diseases and injuries and healthy life expectancy (hale) for 188 countries, 1990–2013: quantifying the epidemiological transition" ?

Background—The Global Burden of Disease Study 2013 ( GBD 2013 ) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. 

Change in DALYs for GBD level 3 causesIncreasing and decreasing global DALYs for GBD level 3 causes from 1990 to 2005 (A) and 2005 to 2013 (B). 

The epidemiological transition based on predicted YLL and YLD rates per 100 000 people as a function of the level of sociodemographic status by vigintile and broken down into GBD level 2 causes. 

Survivorship curve stratified by disability weight in 2013Health survivorship function showing the fraction of a birth cohort alive at each age exposed to 2013 death rates, with the fraction of time spent at each age by the birth cohort decomposed by level of disability weight. 

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–60· 18) 71·7 3(6 8·65 –73· 93) 63·1 9(5 9·90 –66· 28)U zbek ista n64 ·58 (63· 81–6 5·34 )57 ·60 (55· 50–5 9·50 )70 ·64 (69· 96–7 1·43 )61 ·90 (59· 14–6 4·24 )65 ·38 (64· 24–6 6·43 )58 ·25 (56· 04–6 0·37 )70 ·95 (69· 86–7 2·09 )62 ·35 (59· 76–6 4·81 )66 ·64 (63· 73–6 9·56 )59 ·60 (56· 48–6 2·60 )72 ·95 (70· 38–7 5·91 )64 ·25 (61· 01–6 7·69 )Cen tral Eur ope 67·2 5(6 7·09 –67· 41) 59·2 7(5 6·95 –61· 29) 74·9 0(7 4·74 –75· 04) 65·2 9(6 2·56 –67· 72) 70·6 4(7 0·59 –70· 69) 62·0 7(5 9·52 –64· 25) 78·1 0(7 8·05 –78· 16) 67·6 3(6 4·59 –70· 24) 73·1 4(7 2·84 –73· 45) 64·3 0(6 1·76 –66· 57) 80·0 9(7 9·83 –80· 31) 69·3 9(6 6·32 –72· 11)A lban ia71 ·02 (70· 35–7 1·64 )61 ·83 (59· 17–6 4·26 )76 ·24 (75· 66–7 6·77 )65 ·74 (62· 76–6 8·51 )71 ·53 (70· 46–7 2·58 )62 ·64 (59· 98–6 5·15 )77 ·62 (76· 54–7 8·60 )67 ·00 (63· 88–6 9·82 )72 ·68 (69· 64–7 5·97 )63 ·85 (60· 53–6 7·08 )79 ·32 (76· 65–8 1·80 )68 ·64 (64· 96–7 1·89 )B osni aan dH erze govi na69 ·36 (69· 14–6 9·56 )61 ·24 (58· 87–6 3·32 )76 ·71 (76· 39–7 7·06 )66 ·88 (63· 95–6 9·43 )72 ·55 (72· 33–7 2·78 )63 ·09 (60· 24–6 5·71 )78 ·74 (78· 51–7 9·01 )68 ·01 (64· 91–7 0·72 )74 ·36 (73· 42–7 5·24 )65 ·23 (62· 44–6 7·69 )80 ·63 (79· 73–8 1·58 )70 ·05 (67· 03–7 2·93 )B ulga ria 68·3 1(6 8·13 –68· 49) 60·0 2(5 7·61 –62· 15) 74·7 8(7 4·60 –74· 96) 65·1 3(6 2·34 –67· 56) 69·0 6(6 8·91 –69· 21) 60·8 3(5 8·37 –62· 96) 76·2 0(7 6·01 –76· 37) 66·2 4(6 3·32 –68· 84) 71·2 3(7 0·72 –71· 70) 62·7 5(6 0·29 –64· 94) 77·8 1(7 7·39 –78· 25) 67·6 4(6 4·72 –70· 37)C roat ia68 ·71 (68· 52–6 8·90 )60 ·96 (58· 66–6 2·97 )76 ·69 (76· 44–7 6·96 )67 ·03 (64· 21–6 9·46 )72 ·43 (72· 24–7 2·61 )63 ·91 (61· 43–6 6·08 )79 ·99 (79· 70–8 0·29 )69 ·49 (66· 43–7 2·13 )74 ·18 (73· 61–7 4·67 )65 ·52 (62· 97–6 7·85 )81 ·29 (80· 71–8 1·86 )70 ·62 (67· 48–7 3·43 )C zech Rep ublic 67·8 2(6 7·69 –67· 94) 59·6 1(5 7·25 –61· 68) 75·4 5(7 5·29 –75· 61) 65·5 0(6 2·63 –68· 02) 73·0 1(7 2·89 –73· 13) 63·5 7(6 0·79 –65· 96) 79·4 4(7 9·29 –79· 57) 68·3 5(6 5·21 –71· 15) 75·3 3(7 4·98 –75· 71) 65·6 2(6 2·75 –68· 06) 80·9 3(8 0·56 –81· 30) 69·7 9(6 6·58 –72· 65)Lancet.