Subnational inequalities in years of life lost and associations with socioeconomic factors in pre-pandemic Europe, 2009-19: an ecological study.

BACKGROUND: Health inequalities have been associated with shorter lifespans. We aimed to investigate subnational geographical inequalities in all-cause years of life lost (YLLs) and the association between YLLs and socioeconomic factors, such as household income, risk of poverty, and educational attainment, in countries within the European Economic Area (EEA) before the COVID-19 pandemic. METHODS: In this ecological study, we extracted demographic and socioeconomic data from Eurostat for 1390 small regions and 285 basic regions for 32 countries in the EEA, which was complemented by a time-trend analysis of subnational regions within the EEA. Age-standardised YLL rates per 100 000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease study. Geographical inequalities were assessed using the Gini coefficient and slope index of inequality. Socioeconomic inequalities were assessed by investigating the association between socioeconomic factors (educational attainment, household income, and risk of poverty) and YLLs in 2019 using negative binomial mixed models. FINDINGS: Between Jan 1, 2009, and Dec 31, 2019, YLLs lowered in almost all subnational regions. The Gini coefficient of YLLs across all EEA regions was 14·2% (95% CI 13·6-14·8) for females and 17·0% (16·3 to 17·7) for males. Relative geographical inequalities in YLLs among women were highest in the UK (Gini coefficient 11·2% [95% CI 10·1-12·3]) and among men were highest in Belgium (10·8% [9·3-12·2]). The highest YLLs were observed in subnational regions with the lowest levels of educational attainment (incident rate ratio [IRR] 1·19 [1·13-1·26] for females; 1·22 [1·16-1·28] for males), household income (1·35 [95% CI 1·19-1·53]), and the highest poverty risk (1·25 [1·18-1·34]). INTERPRETATION: Differences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA. FUNDING: Research Council of Norway; Development, and Innovation Fund of Hungary; Norwegian Institute of Public Medicine; and COST Action 18218 European Burden of Disease Network.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study.

BACKGROUND: Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest. METHODS: DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries. RESULTS: Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low. CONCLUSIONS: The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Burden of disease attributable to risk factors in European countries: a scoping literature review.

OBJECTIVES: Within the framework of the burden of disease (BoD) approach, disease and injury burden estimates attributable to risk factors are a useful guide for policy formulation and priority setting in disease prevention. Considering the important differences in methods, and their impact on burden estimates, we conducted a scoping literature review to: (1) map the BoD assessments including risk factors performed across Europe; and (2) identify the methodological choices in comparative risk assessment (CRA) and risk assessment methods. METHODS: We searched multiple literature databases, including grey literature websites and targeted public health agencies websites. RESULTS: A total of 113 studies were included in the synthesis and further divided into independent BoD assessments (54 studies) and studies linked to the Global Burden of Disease (59 papers). Our results showed that the methods used to perform CRA varied substantially across independent European BoD studies. While there were some methodological choices that were more common than others, we did not observe patterns in terms of country, year or risk factor. Each methodological choice can affect the comparability of estimates between and within countries and/or risk factors, since they might significantly influence the quantification of the attributable burden. From our analysis we observed that the use of CRA was less common for some types of risk factors and outcomes. These included environmental and occupational risk factors, which are more likely to use bottom-up approaches for health outcomes where disease envelopes may not be available. CONCLUSIONS: Our review also highlighted misreporting, the lack of uncertainty analysis and the under-investigation of causal relationships in BoD studies. Development and use of guidelines for performing and reporting BoD studies will help understand differences, avoid misinterpretations thus improving comparability among estimates. REGISTRATION: The study protocol has been registered on PROSPERO, CRD42020177477 (available at: https://www.crd.york.ac.uk/PROSPERO/ ).

Burden of infectious disease studies in Europe and the United Kingdom: a review of methodological design choices.

This systematic literature review aimed to provide an overview of the characteristics and methods used in studies applying the disability-adjusted life years (DALY) concept for infectious diseases within European Union (EU)/European Economic Area (EEA)/European Free Trade Association (EFTA) countries and the United Kingdom. Electronic databases and grey literature were searched for articles reporting the assessment of DALY and its components. We considered studies in which researchers performed DALY calculations using primary epidemiological data input sources. We screened 3053 studies of which 2948 were excluded and 105 studies met our inclusion criteria. Of these studies, 22 were multi-country and 83 were single-country studies, of which 46 were from the Netherlands. Food- and water-borne diseases were the most frequently studied infectious diseases. Between 2015 and 2022, the number of burden of infectious disease studies was 1.6 times higher compared to that published between 2000 and 2014. Almost all studies (97%) estimated DALYs based on the incidence- and pathogen-based approach and without social weighting functions; however, there was less methodological consensus with regards to the disability weights and life tables that were applied. The number of burden of infectious disease studies undertaken across Europe has increased over time. Development and use of guidelines will promote performing burden of infectious disease studies and facilitate comparability of the results.

The increasing significance of disease severity in a burden of disease framework.

Recent estimates have reiterated that non-fatal causes of disease, such as low back pain, headaches and depressive disorders, are amongst the leading causes of disability-adjusted life years (DALYs). For these causes, the contribution of years lived with disability (YLD) - put simply, ill-health - is what drives DALYs, not mortality. Being able to monitor trends in YLD closely is particularly relevant for countries that sit high on the socio-demographic spectrum of development, as it contributes more than half of all DALYs. There is a paucity of data on how the population-level occurrence of disease is distributed according to severity, and as such, the majority of global and national efforts in monitoring YLD lack the ability to differentiate changes in severity across time and location. This raises uncertainties in interpreting these findings without triangulation with other relevant data sources. Our commentary aims to bring this issue to the forefront for users of burden of disease estimates, as its impact is often easily overlooked as part of the fundamental process of generating DALY estimates. Moreover, the wider health harms of the COVID-19 pandemic have underlined the likelihood of latent and delayed demand in accessing vital health and care services that will ultimately lead to exacerbated disease severity and health outcomes. This places increased importance on attempts to be able to differentiate by both the occurrence and severity of disease.

Methodological considerations in injury burden of disease studies across Europe: a systematic literature review.

BACKGROUND: Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies. METHODS: We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021. RESULTS: We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables. CONCLUSIONS: Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability of injury BoD estimates across Europe and beyond.

Burden of Disease of COVID-19: Strengthening the Collaboration for National Studies.

Objectives: Quantifying the combined impact of morbidity and mortality is a key enabler to assessing the impact of COVID-19 across countries and within countries relative to other diseases, regions, or demographics. Differences in methods, data sources, and definitions of mortality due to COVID-19 may hamper comparisons. We describe efforts to support countries in estimating the national-level burden of COVID-19 using disability-adjusted life years. Methods: The European Burden of Disease Network developed a consensus methodology, as well as a range of capacity-building activities to support burden of COVID-19 studies. These activities have supported 11 national studies so far, with study periods between January 2020 and December 2021. Results: National studies dealt with various data gaps and different assumptions were made to face knowledge gaps. Still, they delivered broadly comparable results that allow for interpretation of consistencies, as well as differences in the quantified direct health impact of the pandemic. Discussion: Harmonized efforts and methodologies have allowed for comparable estimates and communication of results. Future studies should evaluate the impact of interventions, and unravel the indirect health impact of the COVID-19 crisis.

A systematic literature review of disability weights measurement studies: evolution of methodological choices.

BACKGROUND: The disability weight is an essential factor to estimate the healthy time that is lost due to living with a certain state of illness. A 2014 review showed a considerable variation in methods used to derive disability weights. Since then, several sets of disability weights have been developed. This systematic review aimed to provide an updated and comparative overview of the methodological design choices and surveying techniques that have been used in disability weights measurement studies and how they evolved over time. METHODS: A literature search was conducted in multiple international databases (early-1990 to mid-2021). Records were screened according to pre-defined eligibility criteria. The quality of the included disability weights measurement studies was assessed using the Checklist for Reporting Valuation Studies (CREATE) instrument. Studies were collated by characteristics and methodological design approaches. Data extraction was performed by one reviewer and discussed with a second. RESULTS: Forty-six unique disability weights measurement studies met our eligibility criteria. More than half (n = 27; 59%) of the identified studies assessed disability weights for multiple ill-health outcomes. Thirty studies (65%) described the health states using disease-specific descriptions or a combination of a disease-specific descriptions and generic-preference instruments. The percentage of studies obtaining health preferences from a population-based panel increased from 14% (2004-2011) to 32% (2012-2021). None of the disability weight studies published in the past 10 years used the annual profile approach. Most studies performed panel-meetings to obtain disability weights data. CONCLUSIONS: Our review reveals that a methodological uniformity between national and GBD disability weights studies increased, especially from 2010 onwards. Over years, more studies used disease-specific health state descriptions in line with those of the GBD study, panel from general populations, and data from web-based surveys and/or household surveys. There is, however, a wide variation in valuation techniques that were used to derive disability weights at national-level and that persisted over time.

Burden of non-communicable disease studies in Europe: a systematic review of data sources and methodological choices.

BACKGROUND: Assessment of disability-adjusted life years (DALYs) resulting from non-communicable diseases (NCDs) requires specific calculation methods and input data. The aims of this study were to (i) identify existing NCD burden of disease (BoD) activities in Europe; (ii) collate information on data sources for mortality and morbidity; and (iii) provide an overview of NCD-specific methods for calculating NCD DALYs. METHODS: NCD BoD studies were systematically searched in international electronic literature databases and in grey literature. We included all BoD studies that used the DALY metric to quantify the health impact of one or more NCDs in countries belonging to the European Region. RESULTS: A total of 163 BoD studies were retained: 96 (59%) were single-country or sub-national studies and 67 (41%) considered more than one country. Of the single-country studies, 29 (30%) consisted of secondary analyses using existing Global Burden of Disease (GBD) results. Mortality data were mainly derived (49%) from vital statistics. Morbidity data were frequently (40%) drawn from routine administrative and survey datasets, including disease registries and hospital discharge databases. The majority (60%) of national BoD studies reported mortality corrections. Multimorbidity adjustments were performed in 18% of national BoD studies. CONCLUSION: The number of national NCD BoD assessments across Europe increased over time, driven by an increase in BoD studies that consisted of secondary data analysis of GBD study findings. Ambiguity in reporting the use of NCD-specific BoD methods underlines the need for reporting guidelines of BoD studies to enhance the transparency of NCD BoD estimates across Europe.

Diabetes free life expectancy and years of life lost associated with type 2 diabetes: projected trends in Germany between 2015 and 2040.

BACKGROUND: Type 2 diabetes (T2D) causes substantial disease burden and is projected to affect an increasing number of people in coming decades. This study provides projected estimates of life years free of type 2 diabetes (T2D) and years of life lost ([Formula: see text]) associated with T2D for Germany in the years 2015 and 2040. METHODS: Based on an illness-death model and the associated mathematical relation between prevalence, incidence and mortality, we projected the prevalence of diagnosed T2D using currently available data on the incidence rate of diagnosed T2D and mortality rates of people with and without diagnosed T2D. Projection of prevalence was achieved by integration of a partial differential equation, which governs the illness-death model. These projected parameters were used as input values to calculate life years free of T2D and [Formula: see text] associated with T2D for the German population aged 40 to 100 years in the years 2015 and 2040, while accounting for different assumptions on future trends in T2D incidence and mortality. RESULTS: Assuming a constant incidence rate, women and men at age 40 years in 2015 will live approximately 38 years and 33 years free of T2D, respectively. Up to the year 2040, these numbers are projected to increase by 1.0 years and 1.3 years. Assuming a decrease in T2D-associated excess mortality of 2% per year, women and men aged 40 years with T2D in 2015 will be expected to lose 1.6 and 2.7 years of life, respectively, compared to a same aged person without T2D. In 2040, these numbers would reduce by approximately 0.9 years and 1.6 years. This translates to 10.8 million and 6.4 million [Formula: see text] in the German population aged 40-100 years with prevalent T2D in 2015 and 2040, respectively. CONCLUSIONS: Given expected trends in mortality and no increase in T2D incidence, the burden due to premature mortality associated with T2D will decrease on the individual as well as on the population level. In addition, the expected lifetime without T2D is likely to increase. However, these trends strongly depend on future improvements of excess mortality associated with T2D and future incidence of T2D, which should motivate increased efforts of primary and tertiary prevention.

Redistributing ill-defined causes of death - a case study from the BURDEN 2020-project in Germany.

BACKGROUND: The cause of death statistics in Germany include a relatively high share (26% in 2017) of ill-defined deaths (IDD). To make use of the cause of death statistics for Burden of Disease calculations we redistribute those IDD to valid causes of death. METHODS: The process of proportional redistribution is described in detail. It makes use of the distribution of the valid ICD-codes in the cause of death data. We use examples of stroke, diabetes, and heart failure to illustrate how IDD are reallocated. RESULTS: The largest increases in the number of deaths for both women and men were found for lower respiratory infections, diabetes mellitus, and stroke. The numbers of deaths for these causes more than doubled after redistribution. CONCLUSION: This is the first comprehensive redistribution of IDD using the German cause of death statistics. Performing a redistribution is necessary for burden of disease analyses, otherwise there would be an underreporting of certain causes of death or large numbers of deaths coded to residual or unspecific codes.

Population with an increased risk of severe COVID-19 in Germany. Analyses from GEDA 2019/2020-EHIS.

Only a minority of people who test positive for COVID-19 develop a severe or critical form of the disease. Many of these have risk factors such as old age or pre-existing conditions and, therefore, are at the focus of protective measures. This article determines the number of people at risk in Germany and differentiates them according to age, sex, education, household type and federal state. The analyses presented here are based on data from the German Health Update (GEDA) 2019/2020-EHIS, which was carried out as a nationwide cross-sectional telephone-based survey between April 2019 and October 2020. The definition of being at increased risk of severe COVID-19 is primarily based on a respondent's age and the presence of pre-existing conditions. Around 36.5 million people in Germany are at an increased risk of developing severe COVID-19. Of these, 21.6 million belong to the high-risk group. An above-average number of people at risk live alone. The prevalence of an increased risk is higher among middle-aged men than among women of the same age, and significantly higher among people with a low level of education than among people with a high level of education. The highest proportion of people with an increased risk live in Saarland and in the eastern German federal states. When fighting the pandemic, it is important to account for the fact that more than half of the population aged 15 or over is at increased risk of severe illness. Moreover, the regional differences in risk burden should be taken into account when planning interventions.

Prevalence of back and neck pain in Germany. Results from the BURDEN 2020 Burden of Disease Study.

Back and neck pain are widespread and can significantly reduce quality of life. A cross-sectional telephone survey (N=5,009) was carried out between October 2019 and March 2020 to gain a valid estimate of the prevalence of back and neck pain among adults in Germany. In addition to the frequency and intensity of back and neck pain, the study collected information about quality of life and comorbidity. The findings showed that 61.3% of respondents reported back pain in the last twelve months. Lower back pain was reported about twice as often as upper back pain, with 15.5% of respondents stating that they experienced chronic back pain. 45.7% reported neck pain, and 15.6% of respondents have experienced lower and upper back pain in addition to neck pain in the past year. Women are affected by all types of pain more often than men. About half of the respondents categorise their back or neck pain as moderate; older respondents report significantly more pain episodes per month than younger respondents. The results described here provide a comprehensive picture of the population-related limitations associated with back and neck pain and are used within the framework of the BURDEN 2020 study to quantify key indicators of burden of disease calculation.

Population vulnerability to COVID-19 in Europe: a burden of disease analysis.

BACKGROUND: Evidence has emerged showing that elderly people and those with pre-existing chronic health conditions may be at higher risk of developing severe health consequences from COVID-19. In Europe, this is of particular relevance with ageing populations living with non-communicable diseases, multi-morbidity and frailty. Published estimates of Years Lived with Disability (YLD) from the Global Burden of Disease (GBD) study help to characterise the extent of these effects. Our aim was to identify the countries across Europe that have populations at highest risk from COVID-19 by using estimates of population age structure and YLD for health conditions linked to severe illness from COVID-19. METHODS: Population and YLD estimates from GBD 2017 were extracted for 45 countries in Europe. YLD was restricted to a list of specific health conditions associated with being at risk of developing severe consequences from COVID-19 based on guidance from the United Kingdom Government. This guidance also identified individuals aged 70 years and above as being at higher risk of developing severe health consequences. Study outcomes were defined as: (i) proportion of population aged 70 years and above; and (ii) rate of YLD for COVID-19 vulnerable health conditions across all ages. Bivariate groupings were established for each outcome and combined to establish overall population-level vulnerability. RESULTS: Countries with the highest proportions of elderly residents were Italy, Greece, Germany, Portugal and Finland. When assessments of population-level YLD rates for COVID-19 vulnerable health conditions were made, the highest rates were observed for Bulgaria, Czechia, Croatia, Hungary and Bosnia and Herzegovina. A bivariate analysis indicated that the countries at high-risk across both measures of vulnerability were: Bulgaria; Portugal; Latvia; Lithuania; Greece; Germany; Estonia; and Sweden. CONCLUSION: Routine estimates of population structures and non-fatal burden of disease measures can be usefully combined to create composite indicators of vulnerability for rapid assessments, in this case to severe health consequences from COVID-19. Countries with available results for sub-national regions within their country, or national burden of disease studies that also use sub-national levels for burden quantifications, should consider using non-fatal burden of disease estimates to estimate geographical vulnerability to COVID-19.

Correction to: Population vulnerability to COVID-19 in Europe: a burden of disease analysis.

[This corrects the article DOI: 10.1186/s13690-020-00433-y.].

Association between Living with Children and the Health and Health Behavior of Women and Men. Are There Differences by Age? Results of the "German Health Update" (GEDA) Study.

Does the health of women and men living with and without minor children differ, and are age differences evident in the association? For self-rated general health, depression, back pain, overweight, smoking and sporting inactivity, the GEDA data 2009-2012 (18-54 years, n = 39,096) were used to calculate prevalence for women and men stratified by parental status (living with children: yes/no) and age. Moreover, we calculated odds ratios and predictive margins, performing logistic regressions with interaction terms of parental status and age. Women and men aged 45-54 living with children are healthier than those not living with children. Parents aged 18-24 smoke more frequently and do less sport; young mothers are also more likely to be overweight and suffer from back pain than women not living with children. In multivariable analysis, the interaction of living with children and age is significant for all outcomes (except depression and back pain in men). Living with children is an important social determinant of health, highly dependent on age. It is to be discussed whether the bio-psycho-social situation has an influence on becoming a parent, or whether parenthood in different phases of life strains or enhances health.

Assessing the quality of cause of death data in six high-income countries: Australia, Canada, Denmark, Germany, Japan and Switzerland.

OBJECTIVES: To assess the policy utility of national cause of death (COD) data of six high-income countries with highly developed health information systems. METHODS: National COD data sets from Australia, Canada, Denmark, Germany, Japan and Switzerland for 2015 or 2016 were assessed by applying the ANACONDA software tool. Levels, patterns and distributions of unusable and insufficiently specified "garbage" codes were analysed. RESULTS: The average proportion of unusable COD was 18% across the six countries, ranging from 14% in Australia and Canada to 25% in Japan. Insufficiently specified codes accounted for a further 8% of deaths, on average, varying from 6% in Switzerland to 11% in Japan. The most commonly used garbage codes were Other ill-defined and unspecified deaths (R99), Heart failure (I50.9) and Senility (R54). CONCLUSIONS: COD certification errors are common, even in countries with very advanced health information systems, greatly reducing the policy value of mortality data. All countries should routinely provide certification training for hospital interns and raise awareness among doctors of their public health responsibility to certify deaths correctly and usefully for public health policy.

Reflections on key methodological decisions in national burden of disease assessments.

BACKGROUND: Summary measures of population health are increasingly used in different public health reporting systems for setting priorities for health care and social service delivery and planning. Disability-adjusted life years (DALYs) are one of the most commonly used health gap summary measures in the field of public health and have become the key metric for quantifying burden of disease (BoD). BoD methodology is, however, complex and highly data demanding, requiring a substantial capacity to apply, which has led to major disparities across researchers and nations in their resources to perform themselves BoD studies and interpret the soundness of available estimates produced by the Global Burden of Disease Study. METHODS: BoD researchers from the COST Action European Burden of Disease network reflect on the most important methodological choices to be made when estimating DALYs. The paper provides an overview of eleven methodological decisions and challenges drawing on the experiences of countries working with BoD methodology in their own national studies. Each of these steps are briefly described and, where appropriate, some examples are provided from different BoD studies across the world. RESULTS: In this review article we have identified some of the key methodological choices and challenges that are important to understand when calculating BoD metrics. We have provided examples from different BoD studies that have developed their own strategies in data usage and implementation of statistical methods in the production of BoD estimates. CONCLUSIONS: With the increase in national BoD studies developing their own strategies in data usage and implementation of statistical methods in the production of BoD estimates, there is a pressing need for equitable capacity building on the one hand, and harmonization of methods on the other hand. In response to these issues, several BoD networks have emerged in the European region that bring together expertise across different domains and professional backgrounds. An intensive exchange in the experience of the researchers in the different countries will enable the understanding of the methods and the interpretation of the results from the local authorities who can effectively integrate the BoD estimates in public health policies, intervention and prevention programs.

Corrigendum: Migraine and tension-type headache in Germany. Prevalence and disease severity from the BURDEN 2020 Burden of Disease Study.

[This corrects the article on p. 2-24 in vol. 5.].