Global, regional, and national quality of care index of cervical and ovarian cancer: a systematic analysis for the global burden of disease study 1990-2019.

BACKGROUND AND OBJECTIVE: Cervical cancer is the most preventable and ovarian cancer is the most lethal gynecological cancer. However, in the world, there are disparities in health care performances resulting in differences in the burden of these cancers. The objective of this study was to compare the health-system quality of care and inequities for these cancers using the Quality of Care Index (QCI). MATERIAL AND METHODS: The 1990-2019 data of the Global Burden of Disease (GBD) was analyzed to extract rates of incidence, prevalence, mortality, Disability-Adjusted Life Years (DALYs), Years of Life Lost (YLL), and Years of healthy life lost due to disability (YLD) of cervical and ovarian cancer. Four indices were developed as a proxy for the quality of care using the above-mentioned rates. Thereafter, a Principal Components Analysis (PCA) was applied to construct the Quality of Care Index (QCI) as a summary measure of the developed indices. RESULTS: The incidence of cervical cancer decreased from 1990 to 2019, whereas the incidence of ovarian cancer increased between these years. However, the mortality rate of both cancers decreased in this interval. The global age-standardized QCI for cervical cancer and ovarian cancer were 43.1 and 48.5 in 1990 and increased to 58.5 and 58.4 in 2019, respectively. QCI for cervical cancer and ovarian cancer generally decreased with aging, and different age groups had inequitable QCIs. Higher-income countries generally had higher QCIs for both cancers, but exceptions were also observed. CONCLUSIONS: Uncovering disparities in cervical and ovarian cancer care across locations, Socio-Demographic Index levels, and age groups necessitate urgent improvements in healthcare systems for equitable care. These findings underscore the need for targeted interventions and prompt future research to explore root causes and effective strategies for narrowing these gaps.

National and subnational burden of leukemia and its risk factors, 1990-2019: Results from the Global Burden of Disease study 2019.

BACKGROUND: Hematologic malignancies have a great essential role in cancer global burden. Leukemia which two major subtypes based on the onset, is one of the common subtypes of this malignancy. METHOD: For the GBD 2019 study, cancer registry data and vital registration system were used to estimate leukemia mortality. The Meta-Regression-Bayesian Regularized Trimmed (MR-BRT), Cause of Death Ensemble model (CODEm) and Spatiotemporal Gaussian Process Regression (ST-GPR) were used to model our data and estimate each quantity of interest. Mortality to incidence ratios (MIR) were used to generate incidence and survival from mortality rate. Prevalence and survival were used to generate years lived with disability (YLDs). Age-specific mortality and life expectancy at the same age were used to estimate years of life lost (YLLs). The sum of YLLs and YLDs generates DALYs. RESULTS: The total national incidence of leukemia increased from 6092 (UI 95%: 3803-8507) in 1990 to 6767 (4646-7890) new cases in 2019. However, leukemia age-standardized incidence ratio(ASIR) decreased from 11.6 (8-14.8) to 8.9 (6.2-10.3) new cases per 100,000 in this exact period. At the national level, deaths from leukemia increased 1.5-fold between 1990 and 2019, from 3287 (2284-4201) to 4424 (3137-5030), whereas the age-standardized death rate(ASDR) decreased from 8.3 (6.1-9.8) in 1990 to 6 (4.3-6.8) per 100,000 in 2019. In the study period, total leukemia DALYs decreased 12.2% and reached 162850 (110681-188806), in 2019. The age-standardized DALYs decreased 36.7% from 324.3 (224.8-413.4) in 1990 to 205.3 (140.3-237.8) in 2019. ASDR, DALYs, YLLs, and YLDs rate to high BMI was increasing while smoking and occupational exposure to benzene and formaldehyde were decreasing in the study period. CONCLUSION: This study provided a better understanding of leukemia burden and to reduce controversies of leukemia across Iran. The leukemia status alteration of the country, is trackable.

Global and regional quality of care index (QCI) by gender and age in oesophageal cancer: A systematic analysis of the Global Burden of Disease Study 1990-2019.

BACKGROUND: The aim of this study was to examine the quality of care by age and gender in oesophageal cancer using Global Burden of Disease (GBD) database. METHODS: Patients aged 20 and over with oesophageal cancer were included in this longitudinal study using GBD 1990-2019 data. We used the Socio-Demographic Index (SDI) to classify the regions. We used Principal Component Analysis (PCA) method to calculate the Quality of Care Index (QCI). The QCI was rescaled into a 0-100 single index, demonstrating that the higher the score, the better the QC. RESULTS: The age-standardized QCI for oesophageal cancer dramatically increased from 23.5 in 1990 to 41.1 in 2019 for both sexes, globally. The high SDI regions showed higher QCI than the rest of the regions (45.1 in 1990 and 65.7 in 2019) whereas the low SDI regions had the lowest QCI, which showed a 4.5% decrease through the years (from 13.3 in 1990 to 12.7 in 2019). Globally, in 2019, the QCI showed the highest scores for patients aged 80-84, reported 48.2, and the lowest score for patients aged 25-29 reported 31.5, for both sexes. Globally, in 2019, age-standardized Gender Disparity Ratio (GDR) was 1.2, showing higher QCI in females than males. CONCLUSION: There were fundamental differences in the QCI both globally and regionally between different age groups as well as between males and females. To achieve the goal of providing high-quality services equally to people in need in all over the world, health systems need to invest in effective diagnostic services, treatments, facilities, and equipment and to plan for screening and surveillance of high-risk individuals.

Patient experience with chronic obstructive pulmonary disease: a nationally representative demonstration study on quality and cost of healthcare services.

Introduction: Due to insufficient data on patient experience with healthcare system among patients with chronic obstructive pulmonary disease (COPD), particularly in developing countries, this study attempted to investigate the journey of patients with COPD in the healthcare system using nationally representative data in Iran. Methods: This nationally representative demonstration study was conducted from 2016 to 2018 using a novel machine-learning based sampling method based on different districts' healthcare structures and outcome data. Pulmonologists confirmed eligible participants and nurses recruited and followed them up for 3 months/in 4 visits. Utilization of various healthcare services, direct and indirect costs (including non-health, absenteeism, loss of productivity, and time waste), and quality of healthcare services (using quality indicators) were assessed. Results: This study constituted of a final sample of 235 patients with COPD, among whom 154 (65.5%) were male. Pharmacy and outpatient services were mostly utilized healthcare services, however, participants utilized outpatient services less than four times a year. The annual average direct cost of a patient with COPD was 1,605.5 USDs. Some 855, 359, 2,680, and 933 USDs were imposed annually on patients with COPD due to non-medical costs, absenteeism, loss of productivity, and time waste, respectively. Based on the quality indicators assessed during the study, the focus of healthcare providers has been the management of the acute phases of COPD as the blood oxygen levels of more than 80% of participants were documented by pulse oximetry devices. However, chronic phase management was mainly missed as less than a third of participants were referred to smoking and tobacco quit centers and got vaccinated. In addition, less than 10% of participants were considered for rehabilitation services, and only 2% completed four-session rehabilitation services. Conclusion: COPD services have focused on inpatient care, where patients experience exacerbation of the condition. Upon discharge, patients do not receive appropriate follow-up services targeting on preventive care for optimal controlling of pulmonary function and preventing exacerbation.

Effect of air pollution on disease burden, mortality, and life expectancy in North Africa and the Middle East: a systematic analysis for the Global Burden of Disease Study 2019.

BACKGROUND: Air pollution is the sixth highest risk factor for attributable disability-adjusted life-years (DALYs) in North Africa and the Middle East, but the relative importance of different subtypes of air pollution and any potential differences in their health effects by population demographics or country-level socioeconomic factors have not been fully explored. The objective of this study was to investigate the effect of high ambient particulate matter less than 2·5 µm in size (PM) and ambient ozone air pollution on disease burden, mortality, and life expectancy in 21 countries in the North Africa and the Middle East super-region from 1990 to 2019 using the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study estimates. METHODS: The study data were derived from GBD 2019, examining data from 1999 to 2019 in North Africa and the Middle East. In this study, the types of air pollution investigated included PM pollution and ambient ozone pollution. PM pollution itself was categorised as household air pollution from solid fuels and ambient PM pollution. The burden attributable to each risk factor, directly or indirectly, was incorporated in the population attributable fraction to estimate the total attributable deaths and DALYs. The summary exposure value (SEV) as the relative risk-weighted prevalence of exposure was extracted to compare the distribution of excess risk times the exposure level in a population where everyone is at maximum risk and ranges from zero (no excess risk exists in a population) to 100 (highest risk). The effect of air pollution on life expectancy was estimated via a cause-deleted life table analysis. FINDINGS: The age-standardised DALYs rate attributable to air pollution declined by 44·5%, from 4884·2 (95% uncertainty interval 4381·5-5555·4) to 2710·4 (2317·3-3125·6) per 100 000 from 1990 to 2019. Afghanistan (6992·3, 5627·7-8482·7), Yemen (4212·4, 3241·3-5418·1), and Egypt (4034·8, 3027·7-5138·6) had the highest age-standardised DALYs rates attributable to air pollution in 2019 per 100 000, whereas Türkiye (1329·2, 1033·7-1654·7), Jordan (1447·3, 1154·2-1758·5), and Iran (1603·0, 1404·7-1813·8) had the lowest rates. During the study period, the age-standardised SEV of air pollution (PM and ambient ozone in total) decreased by 10·9% (5·8-17·7%) in the super-region, whereas the SEV of ambient ozone pollution alone increased by 7·7% (0·7-14·3%). Among the components of PM pollution, the SEV of ambient PM pollution increased by 40·1% (25·2-63·7%); however, the SEV of household air pollution from solid fuels decreased by 70·6% (64·1-77·0%). Among the investigated types of air pollution, 98·9% of the DALYs from air pollution in the super-region were attributable to PM pollution. If air pollution had been lowered to the theoretical minimum risk exposure levels for 2019, then the average life expectancy would have been 1·6 years higher. INTERPRETATION: The burden attributable to air pollution substantially decreased in the study period across the super-region as a whole. Most of the burden from air pollution is attributed to PM pollution, the exposure to which has substantially increased in the past three decades. Interventions and policies that reduce population exposure to PM pollution could potentially increase the average life expectancy in the super-region. This finding calls for concerted efforts from governments and public health authorities in the super-region to tackle air pollution as an important threat to population health. FUNDING: Bill & Melinda Gates Foundation.

Quality and cost of healthcare services in patients with diabetes in Iran: Results of a nationwide short-term longitudinal survey.

Aims: To investigate the journey of patients with diabetes in the healthcare system using nationally-representative patient-reported data. Methods: Participants were recruited using a machine-learning-based sampling method based on healthcare structures and medical outcome data and were followed up for three months. We assessed the resource utilization, direct/indirect costs, and quality of healthcare services. Results: One hundred fifty-eight patients with diabetes participated. The most utilized services were medication purchases (276 times monthly) and outpatient visits (231 times monthly). During the previous year, 90% of respondents had a laboratory fasting blood glucose assessment; however, less than 70% reported a quarterly follow-up physician visit. Only 43% had been asked about any hypoglycemia episodes by their physician. Less than 45% of respondents had been trained for hypoglycemia self-management. The annual average health-related direct cost of a patient with diabetes was 769 USD. The average out-of-pocket share of direct costs was 601 USD (78.15%). Medication purchases, inpatient services, and outpatient services summed up 79.77% of direct costs with a mean of 613 USD. Conclusion: Healthcare services focused solely on glycemic control and the continuity of services for diabetes control was insufficient. Medication purchases, and inpatient and outpatient services imposed the most out-of-pocket costs.

The burden of childhood and adolescent cancers in North Africa and the Middle East (NAME) region: findings from the Global Burden of Disease study 2019.

INTRODUCTION: Despite the significant burden of childhood and adolescent cancers, no specific studies recently discussed the burden of cancer in this group in the North Africa and the Middle East (NAME) region. Therefore, we aimed to study the burden of cancers in this group in this region. MATERIALS AND METHODS: We retrieved the Global Burden of Disease (GBD) data for children and adolescent cancers (0-19 years old) in the NAME region from 1990 to 2019. 21 types of neoplasms were grouped as "neoplasms", comprising 19 specific cancer groups as well as "other malignant neoplasms" and "other neoplasms". Three significant parameters of incidence, deaths, and Disability-Adjusted Life Years (DALYs) were studied. The data are presented with 95% uncertainty intervals (UI), and reported rates per 100,000. RESULTS: In 2019, almost 6 million (95% UI: 4.166 M-8.405 M) new cases and 11,560(9770-13,578) deaths due to neoplasms occurred in the NAME region. Incidence was higher in females (3.4 M), while deaths (6226 of overall 11,560) and DALYs (501,118 of overall 933,885) were estimated as higher in males. Incidence rates did not significantly change since 1990, while deaths and DALYs rates declined significantly. After excluding "other malignant neoplasms" and "other neoplasms", leukemia was responsible for the highest number of incidence and deaths (incidence: 10,629(8237-13,081), deaths: 4053(3135-5013), followed by brain and central nervous system cancers (incidence: 5897(4192-7134), deaths: 2446(1761-2960)), and non-Hodgkin lymphoma (incidence: 2741 (2237-3392), deaths: 790(645-962)). Incidence rates of neoplasms were similar for most countries, but countries varied more in terms of death rates. Afghanistan 8.9(6.5-11.9), Sudan 6.4(4.5-8.6), and the Syrian Arab Republic 5.6(4.3-8.3) had the highest overall death rates. CONCLUSION: The NAME region is observing relatively constant incidence rates and a decreasing pattern in the deaths and DALYs. Despite this success, several countries are lagging behind in development. Different issues such as economic problems, armed conflicts and political instabilities, lack of equipment or experienced staff or poor distribution, stigmatization and disbelief in the healthcare systems account for unfavorable numbers in some countries. Such problems require urgent solutions as new sophisticated and personalized cares raise the alarm for even more inequalities between high and low-income countries.

A 30-year trend of ischemic heart disease burden in a developing country; a systematic analysis of the global burden of disease study 2019 in Iran.

BACKGROUND: Evaluating the burden of ischemic heart disease (IHD) as the first cause of mortality worldwide is necessary to develop healthcare policies. This study aimed to report the national and subnational IHD burden and risk factors in Iran according to the Global Burden of Disease (GBD) study 2019. METHODS: We extracted, processed, and presented the results of the GBD 2019 study regarding incidence, prevalence, deaths, years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life years (DALYs), and attributable burden to risk factors of IHD in Iran during 1990-2019. RESULTS: Age-standardized death and DALY rates decreased by 42.7% (95% uncertainty interval, 38.1-47.9) and 47.7% (43.6-52.9) during 1990-2019, slower since 2011 and reached 163.6 deaths (149.0-176.2), 2842.7 DALYs (2657.0-3103.1) per 100,000 persons in 2019. Meanwhile, with a lower reduction of 7.7% (6.0-9.5), the incidence rate reached 829.1 new cases (719.9-945.2) per 100,000 persons in 2019. High systolic blood pressure and elevated low-density lipoprotein cholesterol (LDL-C) contributed to the highest deaths, and DALYs age-standardized rates in 1990 and 2019. They followed by high fasting plasma glucose (FPG), and high body-mass index (BMI) with an upward trend of contribution from 1990 to 2019. A convergence pattern in the provincial death age-standardized rate was observed, with the lowest rate in Iran's capital city; 84.7 deaths per 100,000 (70.6-99.4) in 2019. CONCLUSION: The incidence rate reduced remarkably lower than the mortality rate, which necessitates promoting primary prevention strategies. Also, interventions should be adopted to control growing risk factors like high FPG, and high BMI.

National and subnational burden of brain and central nervous system cancers in Iran, 1990-2019: Results from the global burden of disease study 2019.

INTRODUCTION: Central nervous system cancers (CNS cancers) impose a significant burden upon healthcare systems worldwide. Currently, the lack of a comprehensive study to assess various epidemiological indexes of CNS cancers on national and subnational scales in Iran can hamper healthcare planning and resource allocation in this regard. This study aims to fill this gap by providing estimates of CNS cancer epidemiological measures on national and subnational levels in Iran from 1990 to 2019. MATERIALS AND METHODS: This study is a part of Global Burden of Disease (GBD) 2019 that contains epidemiological measures including prevalence, incidence, mortality, Disability-Adjusted Life Years (DALYs), Years Lived with Disability (YLDs), and Years of Life Lost (YLLs) of CNS cancers. Age standardization was utilized for comparing different provinces. RESULTS: In 2019, 5811 (95% Uncertainty Interval: 2942-7046) national new cases and 3494 (1751-4173) deaths due to CNS cancers were reported. National age-standardized incidence (ASIR), deaths (ASDR), and DALYs rates were 7.3 (3.7-8.8), 4.6 (2.3-5.5), and 156.4 (82.0-187.0) per 100,000 in 2019, respectively. Subnational results revealed that ASDR and ASIR have increased in the past 30 years in all provinces. Although incidence rates have increased in all age groups and genders since 1990, death rates have remained the same for most age groups and genders except for young patients aged under 15, where a decrease in mortality and YLLs can be observed. CONCLUSION: The incidence, deaths, and DALYs of CNS cancers increased at national and subnational levels. These findings should be considered for planning and resource allocation.

Global, regional, and national burden and quality of care index of liver cirrhosis by cause from global burden of disease 1990-2019.

BACKGROUND AND AIM: Cirrhosis and other chronic liver diseases are complex disorders with a known burden. Currently health systems have different approaches to dealing with this issue. The objective of this study is to describe the burden attributed to and quality of care for cirrhosis and other chronic liver diseases. METHODS: Data of cirrhosis and other chronic liver diseases extracted from Global-Burden-of-Diseases 2019. Four indicators, including mortality to incidence ratio, prevalence to incidence ratio, disability-adjusted-life-years (DALYs) to prevalence ratio, and years-of-life-lost (YLLs) to years-lived-with-disability (YLDs) ratio, were defined and combined by the principal-components-analysis to construct the Quality-of-Care-Index (QCI). RESULTS: The global QCI of cirrhosis increased from 71.0 in 1990 to 79.3 in 2019. The QCI showed a favorable situation in higher SDI countries compared with lower SDI countries, with a QCI of 86.8 in high SDI countries and 60.1 in low SDI countries. The highest QCI was found in Western Pacific Region (90.2), and the lowest was for African Region (60.4). Highest QCI belonged to the 50-54 age group (99.5), and the lowest was for the 30.34 age group (70.9). Among underlying causes of cirrhosis, the highest QCI belonged to alcohol use, followed by hepatitis C and NAFLD with QCIs of 86.1, 85.3, and 81.1. CONCLUSIONS: There was a considerable variation in the QCI of cirrhosis and other chronic liver diseases. Countries with low QCI, mainly located in developing regions, need organized action to control the burden of cirrhosis and its underlying causes and improve their quality of care.

The burden of chronic respiratory disease and attributable risk factors in North Africa and Middle East: findings from global burden of disease study (GBD) 2019.

BACKGROUND: North Africa and Middle East (NAME) has an increasing burden of chronic respiratory diseases (CRDs); however, a systematic understanding of the distribution and trends is not available. We aimed to report the trends of CRDs and attributable risk factors in this region between 1990 and 2019. METHODS: Using data from the Global Burden of Diseases Study (GBD) 2019, cause specific mortality served as the basis for estimating incidence and disability-adjusted life years (DALYs). The burden attributable to risk factors was calculated by a comparative risk assessment and contribution of population ageing and growth was determined by decomposition analysis. RESULTS: The number of deaths due to CRD in 2019 were 128,513 (110,781 to 114,351). In 2019, the age-standardized incidence rate (ASIR) of CRDs was 1052.8 (924.3 to 1209.4) per 100,000 population and had a 10.3% increase and the age-standardized death rate (ASDR) was 36.1 (30.9 to 40.3) with a 32.9% decrease compared to 1990. In 2019, United Arab Emirates had the highest ASIR (1412.7 [1237.3 to 1622.2]) and Afghanistan had the highest ASDR (67.8 [52.0 to 81.3]). CRDs were responsible for 2.91% of total DALYs in 2019 (1.69% due to chronic obstructive pulmonary disease [COPD] and 1.02% due to asthma). With regard to the components of DALYs, the age-standardized rate of years of life lost (YLL) had a - 39.0% (- 47.1 to - 30.3) decrease; while the age-standardized rate of years lived with disability (YLD) had a 13.4% (9.5 to 17.7) increase. Of total ASDRs of CRDs, 31.6% were attributable to smoking and 14.4% to ambient particulate matter pollution. CONCLUSION: CRDs remain a leading cause of death and disability in NAME, with growth in absolute numbers. COPD and asthma were the most common CRDs and smoking was the leading risk factor especially in men. More attention is needed in order to reduce CRDs' burden through appropriate interventions and policies.

Quality of care of peptic ulcer disease worldwide: A systematic analysis for the global burden of disease study 1990-2019.

BACKGROUND: Peptic ulcer disease (PUD) affects four million people worldwide annually and has an estimated lifetime prevalence of 5-10% in the general population. Worldwide, there are significant heterogeneities in coping approaches of healthcare systems with PUD in prevention, diagnosis, treatment, and follow-up. Quantifying and benchmarking health systems' performance is crucial yet challenging to provide a clearer picture of the potential global inequities in the quality of care. OBJECTIVE: The objective of this study was to compare the health-system quality-of-care and inequities for PUD among age groups and sexes worldwide. METHODS: Data were derived from the Global Burden of Disease Study 1990-2019. Principal-Component-Analysis was used to combine age-standardized mortality-to-incidence-ratio, disability-adjusted-life-years-to-prevalence-ratio, prevalence-to-incidence-ratio, and years-of-life-lost-to-years-lived-with-disability-into a single proxy named Quality-of-Care-Index (QCI). QCI was used to compare the quality of care among countries. QCI's validity was investigated via correlation with the cause-specific Healthcare-Access-and-Quality-index, which was acceptable. Inequities were presented among age groups and sexes. Gender Disparity Ratio was obtained by dividing the score of women by that of men. RESULTS: Global QCI was 72.6 in 1990, which increased by 14.6% to 83.2 in 2019. High-income-Asia-pacific had the highest QCI, while Central Latin America had the lowest. QCI of high-SDI countries was 82.9 in 1990, which increased to 92.9 in 2019. The QCI of low-SDI countries was 65.0 in 1990, which increased to 76.9 in 2019. There was heterogeneity among the QCI-level of countries with the same SDI level. QCI typically decreased as people aged; however, this gap was more significant among low-SDI countries. The global Gender Disparity Ratio was close to one and ranged from 0.97 to 1.03 in 100 of 204 countries. CONCLUSION: QCI of PUD improved dramatically during 1990-2019 worldwide. There are still significant heterogeneities among countries on different and similar SDI levels.

Burden of stroke in North Africa and Middle East, 1990 to 2019: a systematic analysis for the global burden of disease study 2019.

BACKGROUND: While several studies investigated the epidemiology and burden of stroke in the North Africa and Middle East region, no study has comprehensively evaluated the age-standardized attributable burden to all stroke subtypes and their risk factors yet. OBJECTIVE: The aim of the present study is to explore the regional distribution of the burden of stroke, including ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage, and the attributable burden to its risk factors in 2019 among the 21 countries of North Africa and Middle East super-region. METHODS: The data of the Global Burden of Disease Study (GBD) 2019 on stroke incidence, prevalence, death, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs) rates, and attributed deaths, DALYs, YLLs, and YLDs to stroke risk factors were used for the present study. RESULTS: The age-standardized deaths, DALYs, and YLLs rates were diminished statistically significant by 27.8, 32.0, and 35.1% from 1990 to 2019, respectively. Attributed deaths, DALYs, and YLLs to stroke risk factors, including high systolic blood pressure, high body-mass index, and high fasting plasma glucose shrank statistically significant by 24.9, 25.8, and 28.8%, respectively. CONCLUSION: While the age-standardized stroke burden has reduced during these 30 years, it is still a concerning issue due to its increased burden in all-age numbers. Well-developed primary prevention, timely diagnosis and management of the stroke and its risk factors might be appreciated for further decreasing the burden of stroke and its risk factors and reaching Sustainable Development Goal 3.4 target for reducing premature mortality from non-communicable diseases.

Rheumatic Heart Disease Is a Neglected Disease Relative to Its Burden Worldwide: Findings From Global Burden of Disease 2019.

Background Rheumatic heart disease (RHD) takes a heavy toll in low- and middle-income countries. We aimed to present worldwide estimates for the burden of the RHD during 1990 to 2019 using the GBD (Global Burden of Disease) study. Methods and Results Sociodemographic index (SDI) and age-period-cohort analysis were used to assess inequity. The age-standardized death, disability-adjusted life years, incidence, and prevalence rates of RHD were 3.9 (95% uncertainty interval, 3.3-4.3), 132.9 (95% uncertainty interval, 115.0-150.3), 37.4 (28.6-46.7), and 513.7 (405.0-636.3) per 100 000 in 2019, respectively. The age-standardized incidence and prevalence rates increased by 14.4% and 13.8%, respectively. However, disability-adjusted life years and death rates decreased by 53.1% and 56.9%, respectively. South Asia superregion had the highest age-standardized disability-adjusted life years and deaths. Sub-Saharan Africa had the highest age-standardized incidence and prevalence rates. There was a steep decline in RHD burden among higher-SDI countries. However, only age-standardized deaths and disability-adjusted life years rates decreased in lower-SDI countries. The age-standardized years of life lost and years lived with disability rates for RHD significantly declined as countries' SDI increased. The coefficients of birth cohort effect on the incidence of RHD showed an increasing trend from 1960 to 1964 to 2015 to 2019; however, the birth cohort effect on deaths attributable to RHD showed unfailingly decreasing trends from 1910 to 1914 to 2015 to 2019. Conclusions There was a divergence in the burden of RHD among countries based on SDI levels, which calls for including RHD in global assistance and funding. Indeed, many countries are still dealing with an unfinished infectious disease agenda, and there is an urgency to act now to prevent an increase in future RHD burden.

Trends in Global, Regional, and National Burden and Quality of Care Index for Liver Cancer by Cause from Global Burden of Disease 1990-2019.

Despite the tremendous burden of liver cancer and its underlying causes on humankind, there appear to be heterogeneities in coping approaches. The objective of this study was to compare the burden and the quality-of-care of liver cancer by causes among different countries and regions in both sexes and various age groups 1990-2019. Data of liver cancer and underlying causes, including hepatitis B virus (HBV), hepatitis C virus (HCV), alcohol use, nonalcoholic steatohepatitis (NASH), and other causes were obtained from the Global Burden of Diseases 2019. Incidence, prevalence, death, and disability-adjusted life-years (DALYs) were assessed. Principal component analysis was used to combine age-standardized mortality-to-incidence ratio, DALY-to-prevalence ratio, prevalence-to-incidence ratio, and years of life lost-to-years lived with disability into a single proxy named Quality of Care Index (QCI). Globally, the age-standardized incidence, DALYs, and death rates decreased from 1990 to 2019, while the QCI scores increased by 68.5%. The QCI score of liver cancer was from as high as 83.3 in high Sociodemographic Index (SDI) countries to values as low as 26.4 in low SDI countries in 2019. Japan had the highest QCI score (QCI = 100). The age-standardized death rates of liver cancer due to all underlying causes were decreasing during the past 30 years, with the most decrease for HBV. Consistently, the global QCI scores of liver cancer due to HBV, HCV, alcohol use, NASH, and other causes reached 53.5, 61.8, 54.3, 52.9, and 63.7, respectively, in 2019. Conclusion: Although the trends in burden are decreasing and the QCI improved from 1990 to 2019 globally, there is a wide gap between countries. Given the inequities in health care quality, there is an urgent need to address discrimination and bridge the gap.

Current Inequities in Smoking Prevalence on District Level in Iran: A Systematic Analysis on the STEPS Survey.

BACKGROUND: The prevalence of tobacco smoking and its burden on societies is not homogenous at the national and district levels. This nationwide study aimed to investigate current inequalities in the prevalence of smoking at the district level and the association of smoking behaviors with gender, wealth, education, and urbanization in Iran. STUDY DESIGN: A cross-sectional study. METHODS: This study was conducted by analyzing the data of the STEPS survey 2016 with 30 541 participants. The small-area estimation method using the Bayesian spatial hierarchical multilevel regression model was employed to generate district-level prevalence of all types of smoking by gender. The inequalities between the groups by wealth, education, and urbanization were investigated via concentration index. RESULTS: The prevalence rates of current daily cigarette smoking were found to be at the range of 4.6-40.9 and 0-4.5 among men and women, respectively. Current daily cigarette smoking was higher in men than in women: 19.0 (95% CI: 9.5-28.7) vs 0.7 (95% CI: 0-6.9). Women with lower wealth, education, or urbanization were more likely to smoke tobacco or be exposed to secondhand smoking. On the other hand, men with higher wealth or education indices were more likely to smoke tobacco. Men with lower wealth, education, or urbanization were more likely to be exposed to secondhand smoking. CONCLUSION: The smoking behavior varied significantly at the district level in Iran. Gender, wealth, education, and urbanization were determinants of smoking prevalence.