PopulationHealth S1

Measures of Burden of Diseases in Population
Siswanto Agus Wilopo Department of Public Health Gadjah Mada University
Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id
Introduction
In its 1948 charter, the World Health Organization (WHO) defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. important ideological conceptualization, for mostpractical purposes, objectives of health programs are more readily defined in terms of prevention or treatment of disease. to be able to diagnose and classify specific diseases to the extent that such classification aids in determining which health intervention programs would be most useful.
Measures of Disease Frequency
Disease Frequency 3
Population
Group of people with a common characteristic like age, race, sex
Disease Frequency 4
Two types of populations, based on whether membership is permanent or transient:

Fixed population: membership is permanent and defined by an event
Ex. Atomic bomb survivors
Dynamic population: membership is transient and defined by being in or out of a "state.

Ex. Residents of the City of Boston
Disease Frequency 5
Disease Frequency
Want to quantify disease occurrence in a population
Measures of disease frequency should take into account:

Number of individuals affected with the disease Size of source population Length of time the population was followed
Disease Frequency 6
Ex. Hypothetical Frequency of AIDS in Two Cities

# New Cases City A 58 City B 35 Time Period 1995 1995-96 Population 25,000 7,000
Annual "rate" of AIDS City A = 58/25,000/1yr = 232/100,000/1 yr City B= 35/7,000/2yrs = 17.5/7000/1 yr = 250/100,000/1 yr
Make it easy to compare rates by using same population unit (say, per 100,000 people) and time period (say, 1 year)
Disease Frequency 7
Three Classes of Mathematical
Parameters
Used to relate number cases of disease size of population and time Ratio: division of one number by another, numbers don't have to be related Proportion: numerator is subset of denominator, often expressed as a percentage Rate: time is an intrinsic part of denominator, term is most misused Need to specify if measure represents events or people
Disease Frequency 8
Prevalence :(P)
Quantifies number of existing cases of disease in a population at a point or during a period of time
P = Number of existing cases of disease / Number in total population (at a point or during a period of time) Ex. City A has 7000 people with arthritis on Jan 1st, 1999 Population of City A = 70,000 Prevalence of arthritis on Jan 1st = .10 or 10%
Disease Frequency 9
Incidence
Quantifies number of new cases of disease that develop in a population at risk during a specified time period
Three key concepts:

New disease events, or for diseases that can occur more than once, usually first occurrence of disease Population at risk (candidate population) - can't have disease already, should have relevant organs Time must pass for a person to move from health to disease
Disease Frequency 10
Two Types of Incidence Measures

Cumulative Incidence (Abbreviated CI) Incidence Rate (Abbreviated IR)
Two Types of Incidence Measures (Continued)

Cumulative incidence = Number of new cases of disease Number in candidate population over a specified period of time
Two Types of Incidence Measures (Continued)

Cumulative incidence estimates the probability or risk that a person will develop disease DURING A SPECIFIED TIME.
Note that the candidate population is comprised of people who are at risk of getting the disease Used mainly for fixed populations because its assumes that everyone is followed for the entire time period
Example: Cumulative incidence of Sudden Infant Death Syndrome during first year of life Population Cases of SIDS Cumulative Incidence over one year 1,000 livebirths 10 10/1,000 or 1%
Note that all livebirths are at risk

Age and Breast Cancer Risk

As shown by these cumulative incidence figures, the biggest single risk factor for breast cancer is age.
SOURCE: National Cancer Institute SEER Cancer Statistics Review
Age
25 30 35 40 45 50 55
Cumulative risk
One in 19,608 One in 2,525 One in 622 One in 217 One in 93 One in 50 One in 33
Age
60 65 70 75 80 85 0ver 85
Cumulative risk
One in 24 One in 17 One in 14 One in 11 One in 10 One in 9 One in 8
Cumulative incidence calculation assumes that you have followed the entire population for the entire follow-up period. For example, it assumes you have followed all of the livebirths for one year or until SIDS occurred. Often you can't follow everyone for entire time period In a dynamic population, individuals enter population over time, become lost, etc. So length of follow-up is not uniform for all Incidence rates do not make assumption of complete follow-up
Incidence rate (IR) = # new cases of disease person-time of observation in candidate population
This measure is a true rate because it directly integrates time into the denominator.
Accrual of Person-Time
Jan
1980
Subject 1 Subject 2 Subject 3
Jan
1990
Jan
1999
10 Person-Years (PY) 10 PY
------------------x
------------------x
-----------------------------------20 PY 40 PY
X = outcome of interest, thus the incident rate is 2/40 PY
Some Ways to Accrue 100PY

100 people followed 1 year each = 100 py
10 people followed 10 years each= 100 py
50 people followed 1 year plus 25 people followed 2 years = 100 py

Time unit for person-time = year, month or day Person-time = person-year, person-month, person-day
Ex. Cohort study of the risk of breast cancer among women with hyperthyroidism
Followed 1,762 women ---> 30,324 py
Average of 17 years of follow-up per woman Ascertained 61 cases of breast cancer Incidence rate = 61/30,324 py = .00201/y = 201/100,000 py (.00201 x 100,000 p/100,000 p)
Review of Dimensions
Prevalence = people people people people people people-time no dimension
Cumulative incidence =
no dimension dimension is time 1
Incidence rate
Relationship between prevalence and incidence

P / (1-P) = IR x D
Prevalence depends on incidence rate and duration of disease (duration lasts from onset of disease to its termination)
If incidence is low but duration is long - prevalence is relatively high If incidence is high but duration is short prevalence is relatively low
Conditions for equation to be true:

Steady state
IR constant
Distribution of durations constant Note that if the prevalence of disease is low (less than 10%), the equation simplifies to P = IR x D
Figuring duration from prevalence and incidence

Lung cancer incidence rate = 45.9/100,000 py
Prevalence of lung cancer = 23/100,000

D= P IR = 23/100,000 p 45.9/100,000 py =0.5 years
Conclusion: Individuals with lung cancer survive 6 months from diagnosis to death
Uses of Prevalence and Incidence Measures

Prevalence: administration, planning, some research
Incidence: etiologic research (problems with prevalence since it combines IR and D), planning
Common measures of disease frequency for public health

Crude death (mortality) rate: Total number of deaths from all causes 1,000 people For one year (also cause-specific, age-specific, race-specific death rate)
Common measures of disease frequency for public health

Live-birth rate or crude birth rate:
total number of livebirths For one year 1,000 people (sometimes women of childbearing age)
Infant mortality rate:

# deaths of infants under 1 year of age 1,000 live-birth For one year
Attack rate:
# cases of disease that develop during ________defined period_______ # in pop. at risk at start of period
(usually used for infectious disease outbreaks)

Case fatality rate:

# of deaths for a defined period of time # cases of disease
Survival rate:
# living cases for a defined period of time # cases of disease
Boston Globe Report on Celebrity Skiing Deaths
Although skiing has inherent risks, it isnt more dangerous than other common activities. The nationwide comparisons below do not reflect differing numbers of participants.
Is this statement accurate? What are the numbers in the following charts? Incidence? Prevalence? or something else?
Skiing deaths (1996-97 season)36
Skiing deaths (1984-97 average)..34
Accidental Deaths: How does skiing compare to other sports? Remember to consider the missing denominators when making your assessment.
Deaths in other sports Parachuting39 Scuba diving.....104 Recreational boating (1996)716 Drownings in swimming, boating and water sports (1995)...4,500 Bicycling (1996)800
SOURCE: News reports, National Ski Patrol
Accidental Deaths: How does skiing compare to other activities? Remember to consider the missing denominators when making your assessment.
Other Deaths Auto Accidents (1995)42,000 Choking on food (1994) ...2,900 Hit by falling object (1994)..800 Falls in Bathtub (1994).4,500 Struck by lightning (1996)..800
SOURCE: News reports, National Ski Patrol
Four Issues Measuring Burden of Diseases:

Reasons and Approaches for Measuring Health and Disease Composite Summary Measures of Population Health Comparisons and Trends in Disease Burden Burden of Risk Factors
Reasons and Approaches for Measuring Health and Disease

Rationale Measuring Health and Disease Counting Disease Severity of Disease Mortality Demographic and Epidemiologic Transitions Morbidity and Disability Measuring Disability Data for Decisions
Assessing a Health System with Data: Historical Example
The health care dilemma in Ghana. The distribution of funds and personnel for primary health care compared with costly hospital-based care is in inverse proportion to the numbers of people that need to be reached. The health care pyramid for Ghana is upside down!
Source: United Nations Population Division, World Population Prospects: The 2002 Revision Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id Population Database, Copyright Siswanto Agus
The Demographic and Epidemiologic Transitions

Changes in the pattern of disease proceed in two steps: demographic transition, when mortality from infectious disease and undernutrition decline with a marked drop in under-five mortality plus a reduction in fertility; epidemiologic transition, with a change in disease pattern.
Composite Summary Measures of Population Health

Rationale for Composite Measures Uses of Composite Indicators Types of Composite Summary Measures
Figure 1-1 Survivorship Curve of a Hypothetical Population, Showing the Areas of Health Expectancies. Source: C. J. L. Murray et al., Summary Measures of Population Health (Geneva, Switzerland: World Health Organization, 1999). Reprinted with permission.
Composite Indicators
Healthy Life Year Disability-Adjusted Life Year Quality-Adjusted Life Year The Health-Adjusted Life Expectancy
Figure 1-2 The HeaLY Model: Loss of Healthy Life from Disability and Death
Figure 1-3 :Different Patterns of Healthy Life Lost. Source: A. A. Hyder, G. Rotllant, and R. H. Morrow, Measuring the Burden of Disease: Healthy Life Years, 1998, American Journal of Public Health, 88, pp. 196202. Reprinted with permission.
Summary
Valuing Life: Social Value Issues Expectation of Life Valuing Life Lived at Different Ages Valuing Future Life Compared with Present Life: Discounting Valuing Life for Its Economic and Social Productivity Valuing Equity in Relation to Efficiency
Data for Composite Measures

Types of Data Demographic Data.
Mortality. Morbidity. Variables
Checking Data
Comparison of Total Numbers. Relationship Between Variables. Sensitivity Analysis.
Disease Groups: Classification Implementing a Burden of Disease Study
Figure 1-5 Burden of Disease in New Zealand, 1996, by Age (a) and Ethnicity (b and c). Source: New Zealand Ministry of Health. (2001).
Note: Total DALYs lost in New Zealand for 1996 = 500,000.

Global Assessments of Disease Burden

The Global Burden of Disease Mortality. Disability. Disease Burden. Age and Disease Distributions. Other Ways Burden Can Be Measured Future Projections
Figure 1-9 Global Burden of Disease, 2000, by Income Level of Countries.
Source: World Health Organization. (2000)

Figure 1-10 Global Burden of Disease 2000 by Disease Groups
Source: Murray, Lopez, Mathers et al. (2001).

Figure 1-11 Proportion of Disease Burden by Disease Groups in Selected Regions, 2000
Source: Murray, Lopez, Mathers et al. (2001).

Burden of Risk Factors

An analysis of risk factors that underlie many important disease conditions can be useful for assisting policy decisions concerning health promotion and disease reduction interventions. Risk factors include an array of human behaviors, nutritional deficiencies and excesses, substance abuse, and certain characteristics such as hypertension
Figure 1-12 Linkages of risk factors with health outcomes
The Burden of Selected Major Risk Factors

focused on the quantification of trends in mortality and, more recently, burden of disease. reliable and comparable analyses of risks to health, key for preventing disease and injury, have not been quantified as well. Most analyses of the relation of risk factors to specific diseases have been done in the context of individual risk factors, in limited settings, and with wide variations in the criteria for risk assessment. This has made comparisons of risk factors on a population health level difficult.
Attributable DALY (% of global DALY-Total 1.46 billion)
Figure 1-13 Mortality (a) and Burden of Disease (b) Due to Leading Global Risk Factors. Source: Ezzati, Lopez, VanderHoorn. (2002).
Infectious and Non-Infectious Disease burden: epidemiologic polarization

I am growing into a big problem
Conclusion
The first step in the pursuit of population health improvement is the measurement of health and disease. Measurement is required to establish the magnitude of disease problems, define causal factors, explore potential solutions, and determine the impact of interventions.
Composite summary measures of population health based on the amount of healthy life lost from disability and from death have been developed to serve that purpose. Trends in disease burden provide important clues to the success of ongoing health programs and the need for development of new interventions. Health systems across the world are greatly affected by changes in disease profiles and population dynamics
Looking at the horizon with confidence
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PopulationHealth S1

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Measures of Burden of Diseases in Population

Siswanto Agus Wilopo Department of Public Health Gadjah Mada University

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Measures of Disease Frequency

Two types of populations, based on whether membership is permanent or transient:

Dynamic population: membership is transient and defined by being in or out of a "state.

Measures of disease frequency should take into account:

Ex. Hypothetical Frequency of AIDS in Two Cities

Three Classes of Mathematical

Three key concepts:

Two Types of Incidence Measures

Two Types of Incidence Measures (Continued)

Two Types of Incidence Measures (Continued)

Note that all livebirths are at risk

Age and Breast Cancer Risk

X = outcome of interest, thus the incident rate is 2/40 PY

Some Ways to Accrue 100PY

50 people followed 1 year plus 25 people followed 2 years = 100 py

no dimension dimension is time 1

Relationship between prevalence and incidence

Conditions for equation to be true:

Figuring duration from prevalence and incidence

Prevalence of lung cancer = 23/100,000

Uses of Prevalence and Incidence Measures

Common measures of disease frequency for public health

Common measures of disease frequency for public health

Infant mortality rate:

(usually used for infectious disease outbreaks)

Case fatality rate:

Boston Globe Report on Celebrity Skiing Deaths

Skiing deaths (1996-97 season)36

Skiing deaths (1984-97 average)..34

Four Issues Measuring Burden of Diseases:

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Reasons and Approaches for Measuring Health and Disease

Assessing a Health System with Data: Historical Example

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

The Demographic and Epidemiologic Transitions

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Composite Summary Measures of Population Health

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Data for Composite Measures

Disease Groups: Classification Implementing a Burden of Disease Study

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Note: Total DALYs lost in New Zealand for 1996 = 500,000.

Global Assessments of Disease Burden

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Figure 1-9 Global Burden of Disease, 2000, by Income Level of Countries.

Source: World Health Organization. (2000)

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Copyright Siswanto Agus Wilopo, sawilopo@yahoo.com http://www.mkia-kr.ugm.ac.id or http://www.chnrl.net.id

Figure 1-10 Global Burden of Disease 2000 by Disease Groups