Disability Adjusted Research Articles

How can cyclist injuries be included in health impact economic assessments?

Abstract This paper discusses how injuries sustained while cycling can be included as a component of health impact economic assessment of increased cycling. To include injuries as a component of a health impact assessment, their expected frequency of occurrence and impacts on health must well known. In this respect, incomplete reporting of cyclist injuries in official accident statistics is an obstacle for good health impact assessment. It is convenient to represent injuries in terms of an expected loss of health per cyclist or kilometre cycled, which can be converted to monetary terms to make it comparable with the health benefits. It is suggested that stating health loss in terms of DALYs (Disability Adjusted Life Years) is suitable for this purpose. Examples are given of how to estimate the health loss associated with bicycle injuries. It is more difficult to model the probability of injury. Two approaches are compared. One approach relies on the relationship between distance cycled per year and risk of injury. The other approach is based on the concept of safety-in-numbers. The number of injuries is modelled as a function of the number of cyclists and motor vehicles. Results are found to be greatly influenced by the assumptions made about whether increased cycling occurs as a result of modal shift from motor vehicles or not.

LCIA framework and cross-cutting issues guidance within the UNEP-SETAC Life Cycle Initiative

Increasing needs for decision support and advances in scientific knowledge within life cycle assessment (LCA) led to substantial efforts to provide global guidance on environmental life cycle impact assessment (LCIA) indicators under the auspices of the UNEP-SETAC Life Cycle Initiative. As part of these efforts, a dedicated task force focused on addressing several LCIA cross-cutting issues as aspects spanning several impact categories, including spatiotemporal aspects, reference states, normalization and weighting, and uncertainty assessment. Here, findings of the cross-cutting issues task force are presented along with an update of the existing UNEP-SETAC LCIA emission-to-damage framework. Specific recommendations are provided with respect to metrics for human health (Disability Adjusted Life Years, DALY) and ecosystem quality (Potentially Disappeared Fraction of species, PDF). Additionally, we stress the importance of transparent reporting of characterization models, reference states, and assumptions, in order to facilitate cross-comparison between chosen methods and indicators. We recommend developing spatially regionalized characterization models, whenever the nature of impacts shows spatial variability and related spatial data are available. Standard formats should be used for reporting spatially differentiated models, and choices regarding spatiotemporal scales should be clearly communicated. For normalization, we recommend using external normalization references. Over the next two years, the task force will continue its effort with a focus on providing guidance for LCA practitioners on how to use the UNEP-SETAC LCIA framework as well as for method developers on how to consistently extend and further improve this framework.

Partial disability and labor market adjustment: The case of Spain

Although partially disabled individuals in Spain are allowed to combine disability benefits with a job, the empirical evidence shows that the employment rate of this group of individuals is very low because they have much lower job finding and higher job separation rates than nondisabled workers. Moreover, a decomposition analysis of the equilibrium employment rate shows that the differences in the job finding rates explain 85 percent of the disabled employment gap. To explain these facts, we construct a labor market model with search intensity and matching frictions to identify the incentives and disincentives to work in Spain from the point of view of both disabled workers and employers. According to the model, the high employment rate gap observed between nondisabled and disabled individuals can be partly explained by the presence of a lower level of productivity among disabled individuals that discourages them from looking for jobs. In terms of policy interventions, sensitivity analysis shows that, since the disability condition is permanent, one-off subsidies in new hired positions have a much lower impact on the employment rate and welfare of disabled individuals than long-term policies.

Compassion and Self-compassion: Conceptualization of and Application to Adjustment to Disability

For many, disability may ignite feelings of grief, sadness, loss, and/or emotional pain. Others discover they harbor negative or self-critical thoughts and beliefs (i.e., blame) which compounds and complicates the personal coping process. Adjustment to disability models exist to help persons with disabilities and professionals understand or explain their negative thoughts, feelings, and experiences; yet, they do not overtly discuss or address emerging skills and approaches such as compassion and selfcompassion as a part of the disability adjustment process. In an effort to change this trend, an eclectic theoretical model which infuses self-compassion and compassion-based techniques has been developed. Rehabilitation counselors are provided with an explanation of the ways existing research on compassion and self-compassion can be used to strengthen their application to the adjustment needs of persons with disabilities. Information about how to incorporate compassion and self-compassion into the rehabilitation counseling adjustment process and recommendations are also provided.

Epidemiology of newly diagnosed hypertensives in a tertiary care hospital in a developing country

ABSTRACTBackground: Cardiovascular diseases are the main cause of death in most countries and the past two decades have shown a global increase. Hypertension (HTN) was found to be the leading risk factor in 2010 as qualified by Disability Adjusted Life Years. Epidemiological studies in this regard in Sri Lanka are scarce. Thus, describing epidemiological patterns of HTN in the Sri Lankan population will help policy makers in planning preventive healthcare programs and aid in preparing strategies to cope with the increasing demand for healthcare facilities. Methods: This is a cross-sectional descriptive study conducted at the Teaching Hospital Peradeniya, Sri Lanka, among newly diagnosed hypertensives according to the JNC 7 report, attending the hypertensive clinic through referral. Data were collected by an interviewer administered structured questionnaire, and epidemiological patterns were analyzed. Results: Among 244 newly diagnosed hypertensives, the mean age was 58.3 years (SD = 12.3) and the majority were females. 66.8% had stage 2 HTN (>160 mmHg) at the time of first presentation to a tertiary care center. There was no statistically significant difference of the stage of HTN based on sex, education level, occupation, marital status, consumption of alcohol, and smoking. Conclusion: Majority of the population had very high blood pressure at first diagnosis, indicating delay in the detection of HTN at an early stage. Therefore, measures to increase the probability of early detection of HTN will be useful in reducing morbidity and mortality associated with HTN.

Individual and dyadic coping in chronic pain patients.

The purpose of the current cross-sectional study was to test the associations between individual coping responses to pain, dyadic coping, and perceived social support, with a number of pain outcomes, including pain intensity, functional disability, and pain adjustment, in a sample of N = 43 patients suffering from chronic pain in Switzerland. In contrast to previous research, we were interested not only in specific pain coping but also in more general stress coping strategies and their potential influence on pain outcomes. Analyses were performed using correlation and regression analyses. “Praying and hoping” turned out to be an independent predictor of higher pain intensity and higher anxiety levels, whereas both “coping self-instructions” and “diverting attention” were associated with higher well-being, less feelings of helplessness, and less depression and anxiety. We further found a link between “focusing on and venting emotions” and “worse pain adjustment”. No significant relationship between dyadic coping and social support with any of our pain outcomes could be observed. Overall, our results indicate that individual coping strategies outweigh the effects of social support and dyadic coping on pain-related outcomes and pain adjustment. However, results need to be interpreted with caution given the small sample size.

Employment and absenteeism in working-age persons with multiple sclerosis

Aims: To better understand the impact of the clinical course of multiple sclerosis (MS) and disability on employment, absenteeism, and related factors.Materials and methods: This study included respondents to the North American Research Committee on Multiple Sclerosis Registry spring 2015 update survey who were US or Canadian residents, aged 18–65 years and reported having relapsing-remitting MS (RRMS), secondary progressive MS (SPMS), or primary progressive MS (PPMS). The RRMS and SPMS participants were combined to form the relapsing-onset MS (RMS) group and compared with the PPMS group regarding employment status, absenteeism, and disability. Multivariable logistic regression was used to examine the relationship between employment-related outcomes and factors that may affect these relationships.Results: Of the 8004 survey respondents, 5887 (73.6%) were 18–65 years of age. The PPMS group (n = 344) had a higher proportion of males and older mean age at the time of the survey and at time of diagnosis than the RMS group (n = 4829). Female sex, age, age at diagnosis, cognitive and hand function impairment, fatigue, higher disability levels, ≥3 comorbidities, and a diagnosis of PPMS were associated with not working. After adjustment for disability, the employed PPMS sub-group reported similar levels of absenteeism to the employed RMS sub-group.Limitations: Limitations of the study include self-report of information and the possibility that participants may not fully represent the working-age MS population.Conclusions: In MS, employment status and absenteeism are negatively affected by disability, cognitive impairment, and fatigue. These findings underscore the need for therapies that prevent disability progression and other symptoms that negatively affect productivity in persons with MS to enable them to persist in the workforce.

PRIORITIES FOR HEALTH ECONOMIC METHODOLOGICAL RESEARCH: RESULTS OF AN EXPERT CONSULTATION.

The importance of economic evaluation in decision making is growing with increasing budgetary pressures on health systems. Diverse economic evidence is available for a range of interventions across national contexts within Europe, but little attention has been given to identifying evidence gaps that, if filled, could contribute to more efficient allocation of resources. One objective of the Research Agenda for Health Economic Evaluation project is to determine the most important methodological evidence gaps for the ten highest burden conditions in the European Union (EU), and to suggest ways of filling these gaps. The highest burden conditions in the EU by Disability Adjusted Life Years were determined using the Global Burden of Disease study. Clinical interventions were identified for each condition based on published guidelines, and economic evaluations indexed in MEDLINE were mapped to each intervention. A panel of public health and health economics experts discussed the evidence during a workshop and identified evidence gaps. The literature analysis contributed to identifying cross-cutting methodological and technical issues, which were considered by the expert panel to derive methodological research priorities. The panel suggests a research agenda for health economics which incorporates the use of real-world evidence in the assessment of new and existing interventions; increased understanding of cost-effectiveness according to patient characteristics beyond the "-omics" approach to inform both investment and disinvestment decisions; methods for assessment of complex interventions; improved cross-talk between economic evaluations from health and other sectors; early health technology assessment; and standardized, transferable approaches to economic modeling.

Quantifying the Burden of Multiple Myeloma Across Europe

Background: In recent years there has been an increasing focus on the costs of managing patients with Multiple Myeloma (MM). Novel agents such as immunomodulators and proteasome inhibitors have been added into the treatment pathway alongside conventional management options including intensive chemotherapy, stem cell transplantation, and supportive care. Commissioners of healthcare have evaluated these additional costs in the context of clinical outcomes such as response rates, progression free survival and overall survival. However, relatively little attention has been paid to disease burden which we argue is an important dimension alongside costs and outcomes.Objective:To estimate the burden of disease associated with MM in the European Union.Methods: A literature review was undertaken to identify assessments of disease burden in MM. A de novo analysis was undertaken to quantify disease burden across the European Union, using Disability Adjusted Life Years (DALYs). DALYs represent the sum of Years of Life Lost (YLL) due to premature mortality and the Years Lost due to Disability (YLD) for a condition. We use long-term projections for incidence, mortality, and life expectancy to estimate DALYs in 5 year intervals out to 2030. Finally, we ran a hypothetical scenario to explore the impact of potential improvements in treatment outcomes.Results: Across the European Union we estimate a total of over 175,000 DALYs for 2015 attributable to MM; which is equivalent to more than 34.5 DALYs per 100,000 population. Disease burden appears to vary considerably by country, partly as a function of incidence rates. For the EU as a whole, MM incidence is projected to increase from approximately 35k new cases to over 43k by 2030. Over the same time period, deaths due to MM are projected to increase from 21.5k to over 27k. Using data from Eurostat and Globocan, we estimate that DALYs for MM in the EU will increase from 175k to approaching 290k by 2030. In terms of DALYs per 100,000 population, this represents a more than 60% projected increase from 34.4 to 55.6 DALYs per 100,000. In our hypothetical scenario, a 1-year increase in overall survival reduced the number of DALYs in the EU by 16,000 for 2020 and by 19,000 for 2030.Discussion: Incorporation of new treatments in the management of myeloma in the last decade has helped improve the median survival of patients. However, as population life expectancy increases, incidence of MM and associated disability is expected to increase substantially. New treatments represent a significant opportunity to reduce this burden. We estimate that a 1-year increase in life expectancy for MM patients would be associated with a 7% reduction in DALYs. Further research is required to confirm DALY estimates in MM but we argue that DALYs provide a useful metric for healthcare commissioners. DisclosuresSchey:Celgene, Takeda: Honoraria; Celgene, Johnson & Johnson: Speakers Bureau; Celgene: Consultancy. Morris:Cogentia UK: Research Funding. Maguire:Cogentia UK: Research Funding. Dhanasiri:Celgene: Employment, Equity Ownership.

Cost-Effectiveness Analysis of Hepatitis B Vaccination Strategies to Prevent Perinatal Transmission in North Korea: Selective Vaccination vs. Universal Vaccination.

BackgroundTo tackle the high prevalence of Hepatitis B virus (HBV) infection in North Korea, it is essential that birth doses of HBV vaccines should be administered within 24 hours of birth. As the country fails to provide a Timely Birth Dose (TBD) of HBV vaccine, the efforts of reducing the high prevalence of HBV have been significantly hampered.MethodsTo examine the cost-effectiveness of vaccination strategies to prevent perinatal transmission of HBV in North Korea, we established a decision tree with a Markov model consisting of selective, universal, and the country’s current vaccination program against HBV. The cost-effectiveness analysis was performed from societal and payer’s perspectives and evaluated by Disability Adjusted Life Year (DALY).ResultsThe results suggest that introducing the universal vaccination would prevent 1,866 cases of perinatal infections per 100,000 of the birth cohort of 2013. Furthermore, 900 cases of perinatal infections per 100,000 could be additionally averted if switching to the selective vaccination. The current vaccination is a dominated strategy both from the societal and payer’s perspective. The Incremental Cost-Effectiveness Ratio (ICER) between universal and selective vaccination is $267 from the societal perspective and is reported as $273 from the payer’s perspective.ConclusionBased on the assumption that the 2012 Gross Domestic Product (GDP) per capita in North Korea, $582.6 was set for cost-effectiveness criteria, the result of this study indicates that selective vaccination may be a highly cost-effective strategy compared to universal vaccination.

PIN41 - Cost Of Dengue And Cost-Effectiveness Of The Dengue Vaccine In Panama

Dengue is considered to rank fifth among the most costly diseases in terms of public costs, since its annual burden is 750 thousand DALYs¹¯². Panama shows an endemic pattern of cyclical peaks every 3 to 5 years (2005, 2009 and 2014). According to the epidemiological surveillance data, in 2005, Panama experienced one of the largest dengue epidemic; 5,489 dengue cases, 7 hemorrhagic cases and 5 deaths have been confirmed. Its incidence rate was 170 cases per 100,000 inhabitants. Purpose of this study is to assess in different scenarios (routine with or without catch-up cohorts) the impact of a tetravalent dengue vaccine in Panama through a cost-effectiveness analysis, estimating the burden of the disease based on DALY (Disability Adjusted Life Years). A dynamic, compartmental and deterministic, transmission model of the disease was used to estimate the burden of the disease and related costs for several vaccination scenarios with dengue vaccine compared with no vaccination (NV) over 10 years (2017-2026). By using as a reference the WHO criterion for assessing health interventions—from the social perspective, considering indirect effect and under-reporting— the maximum price per dose for the intervention to be cost-effective is estimated in U$51.4 for a vaccination in the nine year-old risk population (R9), U$74.5 for a vaccination in the nine to fifteen year-old risk population (R9+6). Additionally, when the health impact is analyzed in terms of percentage reduction of the total dengue cases by scenario, the results are the following: -26% (R9), -59% (R9+6). These results allow the determination of the maximum price for a cost-effective implementation and show that the wider the immunization schedule, the greater the effect on economy and health.

Technical Performance and Environmental Effects of the Treated Effluent of Wastewater Treatment Plants in the Shenzhen Bay Catchment, China

Technical performance and effluent environmental impact of seven wastewater treatment plant (WWTPs) in the Shenzhen Bay Catchment, China were examined. All WWTPs had good performance in the removal of chemical oxygen demand, biochemical oxygen demand, and suspended solids, while total nitrogen and total phosphorus removal should be enhanced to improve the comprehensive pollutants removal loading rate. The effluent eutrophication effect from WWTPs was in the range of 0.0028–0.0092 kg/m3, and nitrate was the major contributor. The effluent greenhouse gas emission of WWTP1–7 was in the range of 3.23 × 10−5–8.70 × 10−5 kg·CO2/m3. The effluent eutrophication effects and greenhouse gas emission of WWTPs could be reduced by decreasing the effluent total nitrogen concentration. The ecological risk and healthy risk of heavy metals were low. Among examined heavy metals, lead contributed the most to the ecological risk while arsenic contributed most to the human health risk. The human health risk of microbial pollutants of WWTPs1–7 was in the range of 0.0024–0.0042 DALY (Disability Adjusted Life Years). Finally, an ecosystem-based WWTP framework was proposed to systematically include all environmental effects so as to support the sustainable development of WWTPs.

Poor sleep quality in patients with multiple sclerosis: gender differences

ObjectivesMost of the psychological and physical factors associated with poor sleep quality in patients with multiple sclerosis (MS) have a different prevalence in women and men, but whether or not these factors contribute differently to sleep quality in women and men with MS remains unclear. The aim of this study was to identify possible gender differences in factors related to poor sleep quality in MS patients.Material and MethodsWe collected data from 153 patients with MS. Patients filled out the Pittsburgh Sleep Quality Index (PSQI), the Hospital Anxiety and Depression Scale, and one item of the Short Form‐36 regarding pain.ResultsThe best model of predictors of poor sleep quality consisting of gender, depression, anxiety, pain, and the interaction between gender and pain showed that the only variable interacting with gender, which was significantly associated with poor sleep quality was pain (odds ratio [OR] for interaction of pain with male gender was 15.4, 95% CI: 2.4; 39.5). Separate models for men and women consisting of pain, depression, anxiety, after adjustment for age, disease duration, and disability showed that pain was the only variable associated with poor sleep quality in men (OR = 12.7, 95% CI: 1.9; 29.6), whereas depression (OR = 4.1, 95% CI: 1.3; 13.2) and anxiety (OR = 6.8, 95% CI: 2.4; 19.1) were in women.ConclusionsFactors contributing to poor sleep quality in MS patients differ by gender. Depression and anxiety are associated with poor sleep quality in women, whereas pain is in men. This highlights the need to apply gender‐specific approaches to the treatment of sleep disorders.

Deaths, DALY and other related measures of breast cancer in Yemeni women: Findings of the Global Burden of Disease Study (1990–2010)

BackgroundAlthough the rate of breast cancer in Yemen is not high in comparable to other high developed indexed countries, it is among the highest rate of incidence among Yemeni women. ObjectiveThe aim of the study is to estimate the main outcomes of breast cancer using some other parameters such as death rates, Disability Adjusted Life Years (DALY); Years Lived with Disability (YLD); and Years of Life Lost (YLL) among the Yemeni women. MethodsData from Aden Cancer registry was used to describe the incidence of the breast cancer cases over 15 years period (1997–2011). Also data from the Global Burden of Diseases (GBD) from the Institute for Health Metrics and Evaluation (IHME) were used for the analysis of the death rate, DALY, YLD and LLY. ResultsThe age standardized rate of breast cancer among female showed the highest peak at the age group of 45–49 years old (35.1/100,000). Death rates, DALY, YLD and YLL were reported higher in 2010 than in 1990 with almost two folds and show steady increase with increase of age. By using the analysis of the DALY for cases with breast cancer for the year 2009 and YLL analysis for the same year has shown a peak of the mean at the age-group of 50–54 (915.9 and 505.2 per 100,000, respectively). ConclusionFindings from this study support the use of other epidemiological parameters used to express the burden of breast cancer in Yemen by other method than the incidence rate. The burden of breast cancer among Yemeni women was clear health priority and needs a rigorous plan for implementing prevention, and early detection for better control.

The earlier the better: health-related quality of life is inversely related to age of smoking cessation in older former Italian smokers.

Quitting smoking has several health benefits, including an improvement in health-related quality of life. It is not well established if there is a relationship between the age when people stop smoking and health-related quality of life in older adults. The primary aim was to investigate the relationship between health-related quality of life and the age when people quit smoking in a national representative sample of community-dwelling older Italian adults. The secondary aim was to describe the characteristics of older former smokers according to their age when they stopped smoking. Data were drawn from the "Health and use of health care in Italy", a national cross-sectional survey (2004-2005). Seven thousand five hundred and sixty-two former smokers, aged 65years and older, were evaluated by age of smoking cessation. Socio-demographic characteristics, physical activity, the 12-Item Short-Form Health Survey (SF-12) score and its physical (PCS-12) and mental (MCS-12) component summary scores, disability and comorbidities were analyzed. Educational level, marital status and area of residence were associated with a different age of smoking cessation, as a higher level of disability and comorbidity. PCS-12 (β -0.144; p<0.001) and MCS-12 (β -0.077; p<0.001) component scores were lower in subjects who quit smoking later. The relationship was confirmed for the PCS-12 score even after adjustment for socio-demographic, disability and clinical variables (β -0.031; p<0.001), while it disappeared for the MCS-12 score (β -0.010, p=0.307), after adjustment for comorbidities. Physical and mental health-related quality of life is influenced by the age of smoking cessation in older individuals, but this relationship is influenced by comorbidities, particularly depression. Some individual characteristics are related to the age of the person when he/she quit smoking.

Prevalence of and factors associated with homebound status among adults in urban and rural Spanish populations.

BackgroundThere is a marked growth in the number of homebound older adults, due mainly to increased life expectancy. Although this group has special characteristics and needs, it has not been properly studied. This study thus aimed to measure the prevalence of homebound status in a community-dwelling population, and its association with both socio-demographic, medical and functional characteristics and the use of health care and social services.MethodsWe used instruments coming under the WHO International Classification of Functioning (ICF) framework to carry out a cross-sectional study on populations aged 50 years and over in the province of Zaragoza (Spain), covering a total of 1622 participants. Persons who reported severe or extreme difficulty in getting out of the house in the last 30 days were deemed to be homebound. We studied associations between homebound status and several relevant variables in a group of 790 subjects who tested positive to the WHODAS-12 disability screening tool.ResultsPrevalence of homebound status was 9.8 % (95 % CI: 8.4 to 11.3 %). Homebound participants tended to be older, female and display a lower educational level, a higher number of diseases, poorer cognition and a higher degree of disability. In fully adjusted models including disability as measured with the ICF-Checklist, the associated variables (odds ratios and [95 % confidence intervals]) were: female gender (3.75 [2.10–6.68]); urban population (2.36 [1.30–4.29]); WHODAS-12 disability (6.27 [2.56–15.40]); depressive symptoms (2.95 [1.86–4.68]); moderate pain (2.37 [1.30–4.31] and severe pain (3.03 [1.31–7.01]), as compared to the group with no/mild pain; hospital admissions in the previous 3 months (2.98 [1.25–7.11]); and diabetes (1.87 [1.03–3.41]). Adjustment for ICF-Checklist disability had a notable impact on most associations.ConclusionsThe study shows that homebound status is a common problem in our setting, and that being disabled is its main determinant. Socio-demographic characteristics, barriers and chronic diseases can also be assumed to be playing a role in the onset of this condition, indicating the need for further research, including longitudinal studies on its incidence and associated factors.

Pre-hospital Delay as Determinant of Ischemic Stroke Outcome in an Italian Cohort of Patients Not Receiving Thrombolysis

Pre-hospital delay in acute stroke is critical to the administration of thrombolysis and affects patients' clinical outcome. In this study, the impact of pre-hospital delay on the outcome of ischemic stroke was investigated in an Italian cohort of patients who did not receive thrombolysis. Data from a cohort of 1847 patients, suffering from first-ever ischemic stroke and referred to an in-hospital clinical pathway were analyzed retrospectively. The relationship between pre-hospital delay and 1-month mortality was assessed with adjustment for demographics, premorbid disability, and stroke severity, which was graded according to the Scandinavian Stroke Scale, with higher scores indicating less severity. Five hundred and twelve patients (27.7%) arrived at hospital within 2 hours of symptom onset. A significant correlation was found between early arrival and a reduced risk of 1-month mortality (hazard ratio .65; 95% confidence interval .48-.89; P = .02). There was a significant interaction (P = .01) between pre-hospital delay and the neurological score on mortality in the multivariate model, and the survival advantage of early admission was significant only for patients with scores on the Scandinavian Stroke Scale less than 18 (hazard ratio .54; 95% confidence interval .34-.85; P = .008). Our study suggests that reducing pre-hospital delay can increase the probability of survival in patients with ischemic stroke, especially those who are most severely affected. Even if the patients cannot benefit from thrombolysis, survival rates can be increased provided that they are managed according to standardized care processes.

Global Patterns of QALY and DALY Use in Surgical Cost-Utility Analyses: A Systematic Review.

BackgroundSurgical interventions are being increasingly recognized as cost-effective global priorities, the utility of which are frequently measured using either quality-adjusted (QALY) or disability-adjusted (DALY) life years. The objectives of this study were to: (1) identify surgical cost-effectiveness studies that utilized a formulation of the QALY or DALY as a summary measure, (2) report on global patterns of QALY and DALY use in surgery and the income characteristics of the countries and/or regions involved, and (3) assess for possible associations between national/regional-income levels and the relative prominence of either measure.Study DesignPRISMA-guided systematic review of surgical cost-effectiveness studies indexed in PubMed or EMBASE prior to December 15, 2014, that used the DALY and/or QALY as a summary measure. National locations were used to classify publications based on the 2014 World Bank income stratification scheme into: low-, lower-middle-, upper-middle-, or high-income countries. Differences in QALY/DALY use were considered by income level as well as for differences in geographic location and year using descriptive statistics (two-sided Chi-squared tests, Fischer’s exact tests in cell counts <5).ResultsA total of 540 publications from 128 countries met inclusion criteria, representing 825 “national studies” (regional publications included data from multiple countries). Data for 69.0% (569/825) were reported using QALYs (2.1% low-, 1.2% lower-middle-, 4.4% upper-middle-, and 92.3% high-income countries), compared to 31.0% (256/825) reported using DALYs (46.9% low-, 31.6% lower-middle-, 16.8% upper-middle-, and 4.7% high-income countries) (p<0.001). Studies from the US and the UK dominated the total number of QALY studies (49.9%) and were themselves almost exclusively QALY-based. DALY use, in contrast, was the most common in Africa and Asia. While prominent published use of QALYs (1990s) in surgical cost-effectiveness studies began approximately 10 years earlier than DALYs (2000s), the use of both measures continues to increase.ConclusionAs global prioritization of surgical interventions gains prominence, it will be important to consider the comparative implications of summary measure use. The results of this study demonstrate significant income- and geographic-based differences in the preferential utilization of the QALY and DALY for surgical cost-effectiveness studies. Such regional variation holds important implications for efforts to interpret and utilize global health policy research. PROSPERO registration number: CRD42015015991

Risk-benefit Assessment of Foods in Sweden -Developing a Working Procedure

Background: Assessments of food-related health risks and benefits performed by national or international experts are still to a large extent separate processes. Diets, foods, and even single food ingredients, may potentially be associated with both beneficial and adverse health effects. Therefore in some cases it is important to consider both health risks and benefits, by assessing the balance between potential risks and benefits, ideally by expressing risk and benefit on the same scale. In Sweden risk-benefit assessments in the food sector are the responsibility of the Risk and Benefit Assessment Department at the National Food Agency (NFA), which brings together the scientific disciplines toxicology, nutrition and microbiology and related fields. In 2012 a project was initiated to develop a general procedure for risk-benefit assessments at the NFA. The results of this project, and an in-house working procedure, have been published in a governmental report [1] and presented at the Scientific conference “Shaping the Future of Food Safety Together” hosted by the European Food Safety Authority (EFSA) in Milan, Italy, in October 2015 (http://www.efsaexpo2015.eu/). The objectives of the project were to: • Summarize previous national and international experiences in the field of risk-benefit assessment • Develop a working procedure for practical use at the NFA • Test the procedure in a case study Grey Literature Principles of Risk-benefit Assessment From the overview and evaluation of the risk and benefit assessment literature it was concluded that no international consensus on the general principles or approaches for conducting risk assessment of foods and food components has so far been EFSA [2] was used as a starting point for the development of the proposed NFA procedure for risk benefit assessment. Tiered, stepwise approaches have been the preferred procedure benefit assessments. In such an approach the nature of the question and the availability and type of data on for example food composition, exposure and health consequences determine at what tier the assessment can be stopped. The advantage of a stepwise methodology is that it is conceptually easy to use by the assessors and promotes transparency of the process. The NFA Procedure for Risk-benefit The developed risk-benefit assessment procedure contains three assessment of risks and benefits separately to a quantitative assessment expressing risks and benefits on the same scale: 1) Initial assessment of risks and benefits separately 2) Enhanced assessment where different metrics for risks a 3) Expressing risks and benefits on the same scale, for example mortality or DALYs (Disability Adjusted Life Years). Fig. 1. The relation between the three different steps in the NFA working procedure (1). Dialogue between the risk-benefit assessor and the risk Case Study of the Risk-benefit The procedure was applied in a case study to assess the risk and benefits with a decreased content of nitrite and salt in processed meat, when done in combination with a decreased maximum storage temperature [3]. The potential health benefits for the gener risk of exceeding ADI and lower risk of high blood pressure of decreased nitrite and salt intake was weighed against an increased risk of Eneroth et al.; EJNFS, 6(2): 75-78, 2016; Article no.EJNFS.20 76 reached. The workflow suggested by in the majority of published risk

Breast and Ovarian Cancer in Young Women of the Arabian Gulf Region: Relationship to Age

It is widely known that cancer is a disease of “old-age”. However available data show that this is not the case for many types of cancers. Incidences of breast and ovarian cancers have varying rates of change with age. Breast cancer data of Arabian-gulf women, show that the incidence rates increase with age and reach a maximum at 39 year. It then declines linearly with age to about 55 years. The rate of increase and its changes with age are similar to those of many other countries. In the premenopausal phase the relationship between incidence and age could be adequately modeled using a linear model for the logarithmic transformations of age and incidence. Similar observations are made for the ovarian cancer incidences. Results: It is shown that the rate of increase in breast and ovarian cancer incidence with respect to age is increasing in the premenopausal ages. Moreover, the burden of the disease with respect to mortality and “Disability Adjusted Life Years” or DALY, varied considerably among the six gulf countries. Conclusions: We conclude, based on the age incidence relationship that the number of cancer cases may double in the next period that follows our study period (1998-2009). Moreover, if the six countries have identical relationship between age and the two types of cancer, there should be an integrated and unified effort to have a common strategy for prevention and control.