Health-adjusted Life Research Articles

A shift from motorised travel to active transport: What are the potential health gains for an Australian city?

IntroductionAn alarmingly high proportion of the Australian adult population does not meet national physical activity guidelines (57%). This is concerning because physical inactivity is a risk factor for several chronic diseases. In recent years, an increasing emphasis has been placed on the potential for transport and urban planning to contribute to increased physical activity via greater uptake of active transport (walking, cycling and public transport). In this study, we aimed to estimate the potential health gains and savings in health care costs of an Australian city achieving its stated travel targets for the use of active transport.MethodsAdditional active transport time was estimated for the hypothetical scenario of Brisbane (1.1 million population 2013) in Australia achieving specified travel targets. A multi-state life table model was used to estimate the number of health-adjusted life years, life-years, changes in the burden of diseases and injuries, and the health care costs associated with changes in physical activity, fine particle (<2.5 μm; PM2.5) exposure, and road trauma attributable to a shift from motorised travel to active transport. Sensitivity analyses were conducted to test alternative modelling assumptions.ResultsOver the life course of the Brisbane adult population in 2013 (860,000 persons), 33,000 health-adjusted life years could be gained if the travel targets were achieved by 2026. This was mainly due to lower risks of physical inactivity-related diseases, with life course reductions in prevalence and mortality risk in the range of 1.5%-6.0%. Prevalence and mortality of respiratory diseases increased slightly (≥0.27%) due to increased exposure of larger numbers of cyclists and pedestrians to fine particles. The burden of road trauma increased by 30% for mortality and 7% for years lived with disability. We calculated substantial net savings ($AU183 million, 2013 values) in health care costs.ConclusionIn cities, such as Brisbane, where over 80% of trips are made by private cars, shifts towards walking, cycling and public transport would cause substantial net health benefits and savings in health care costs. However, for such shifts to occur, investments are needed to ensure safe and convenient travel.

Modelled Cost-Effectiveness of a Package Size Cap and a Kilojoule Reduction Intervention to Reduce Energy Intake from Sugar-Sweetened Beverages in Australia.

Interventions targeting portion size and energy density of food and beverage products have been identified as a promising approach for obesity prevention. This study modelled the potential cost-effectiveness of: a package size cap on single-serve sugar sweetened beverages (SSBs) >375 mL (package size cap), and product reformulation to reduce energy content of packaged SSBs (energy reduction). The cost-effectiveness of each intervention was modelled for the 2010 Australia population using a multi-state life table Markov model with a lifetime time horizon. Long-term health outcomes were modelled from calculated changes in body mass index to their impact on Health-Adjusted Life Years (HALYs). Intervention costs were estimated from a limited societal perspective. Cost and health outcomes were discounted at 3%. Total intervention costs estimated in AUD 2010 were AUD 210 million. Both interventions resulted in reduced mean body weight (package size cap: 0.12 kg; energy reduction: 0.23 kg); and HALYs gained (package size cap: 73,883; energy reduction: 144,621). Cost offsets were estimated at AUD 750.8 million (package size cap) and AUD 1.4 billion (energy reduction). Cost-effectiveness analyses showed that both interventions were “dominant”, and likely to result in long term cost savings and health benefits. A package size cap and kJ reduction of SSBs are likely to offer excellent “value for money” as obesity prevention measures in Australia.

Modelled health benefits of a sugar-sweetened beverage tax across different socioeconomic groups in Australia: A cost-effectiveness and equity analysis.

BackgroundA sugar-sweetened beverage (SSB) tax in Mexico has been effective in reducing consumption of SSBs, with larger decreases for low-income households. The health and financial effects across socioeconomic groups are important considerations for policy-makers. From a societal perspective, we assessed the potential cost-effectiveness, health gains, and financial impacts by socioeconomic position (SEP) of a 20% SSB tax for Australia.Methods and findingsAustralia-specific price elasticities were used to predict decreases in SSB consumption for each Socio-Economic Indexes for Areas (SEIFA) quintile. Changes in body mass index (BMI) were based on SSB consumption, BMI from the Australian Health Survey 2011–12, and energy balance equations. Markov cohort models were used to estimate the health impact for the Australian population, taking into account obesity-related diseases. Health-adjusted life years (HALYs) gained, healthcare costs saved, and out-of-pocket costs were estimated for each SEIFA quintile. Loss of economic welfare was calculated as the amount of deadweight loss in excess of taxation revenue. A 20% SSB tax would lead to HALY gains of 175,300 (95% CI: 68,700; 277,800) and healthcare cost savings of AU$1,733 million (m) (95% CI: $650m; $2,744m) over the lifetime of the population, with 49.5% of the total health gains accruing to the 2 lowest quintiles. We estimated the increase in annual expenditure on SSBs to be AU$35.40/capita (0.54% of expenditure on food and non-alcoholic drinks) in the lowest SEIFA quintile, a difference of AU$3.80/capita (0.32%) compared to the highest quintile. Annual tax revenue was estimated at AU$642.9m (95% CI: $348.2m; $1,117.2m). The main limitations of this study, as with all simulation models, is that the results represent only the best estimate of a potential effect in the absence of stronger direct evidence.ConclusionsThis study demonstrates that from a 20% tax on SSBs, the most HALYs gained and healthcare costs saved would accrue to the most disadvantaged quintiles in Australia. Whilst those in more disadvantaged areas would pay more SSB tax, the difference between areas is small. The equity of the tax could be further improved if the tax revenue were used to fund initiatives benefiting those with greater disadvantage.

Health-adjusted life expectancy in HIV-positive and HIV-negative men and women in British Columbia, Canada: a population-based observational cohort study

We sought to understand whether people living with HIV (PLHIV) ever on highly active antiretroviral therapy (ART) follow a pattern where morbidity is compressed into the last years of life or lessened as people age. We aimed to estimate health-adjusted life expectancy (HALE) among adults living with and without HIV, and examine dependency between causes of comorbidities. The Comparative Outcomes and Service Utilization Trends (COAST) study is a retrospective cohort of adults (≥20 years) including all known PLHIV and a 10% random sample of the general population of British Columbia, and with longitudinal data spanning from April 1, 1996, to Dec 31, 2012. We determined the prevalence of select comorbidities (cardiovascular, respiratory, liver, and renal diseases, and non-AIDS defining cancers because of their high prevalence among PLHIV) by age and sex by use of case-finding algorithms. Deaths were obtained from a vital event registry from British Columbia, Canada. Comorbid-specific HALE was estimated from 20 years of age by HIV status and sex. For each comorbidity, a healthy state was defined as the proportion of life expectancy comorbid-free, and was adjusted on the probability of occurrence of other different comorbidities. The sensitivity of HALE estimates was assessed to the sequencing of select comorbidities for the dependent comorbidity adjustments. Our sample consisted of electronic health records from 9310 HIV-infected and 510 313 uninfected adults over the period April 1, 1996, to Dec 31, 2012. These individuals contributed 49 605 deaths and 5 576 841 person-years over the study period. At exactly age 20 years, HALE was about 31 years (SD 0·16) among men living with HIV and 27 years (0·16) among women living with HIV. In the HIV-negative population, HALE was around 58 years (SD 0·02) for men and 63 years (0·02) for women. These results seem independent of ordering. However, PLHIV, particularly women living with HIV, had much shorter overall life expectancies than did their HIV-negative counterparts in the general population [29·1 years (SD 0·1) vs 65·4 years (0·1)], and thus spent less time in a healthy state. Although we noted little differences in the levels of morbidity compression by HIV status, PLHIV-especially women living with HIV-spent less time in a healthy state. Expanded service delivery interventions to address complex care needs of ageing PLHIV are crucial to address shorter life expectancies, and improve their healthy states. Canadian Institutes of Health Research.

Evaluating compression or expansion of morbidity in Canada: trends in life expectancy and health-adjusted life expectancy from 1994 to 2010.

The objective of this study was to investigate whether morbidity in Canada, at the national and provincial levels, is compressing or expanding by tracking trends in life expectancy (LE) and health-adjusted life expectancy (HALE) from 1994 to 2010. "Compression" refers to a decrease in the proportion of life spent in an unhealthy state over time. It happens when HALE increases faster than LE. "Expansion" refers to an increase in the proportion of life spent in an unhealthy state that happens when HALE is stable or increases more slowly than LE. We estimated LE using mortality and population data from Statistics Canada. We took health-related quality of life (i.e. morbidity) data used to calculate HALE from the National Population Health Survey (1994-1999) and the Canadian Community Health Survey (2000-2010). We built abridged life tables for seven time intervals, covering the period 1994 to 2010 and corresponding to the year of each available survey cycle, for females and males, and for each of the 10 Canadian provinces. National and provincial trends were assessed at birth, and at ages 20 years and 65 years. We observed an overall average annual increase in HALE that was statistically significant in both Canadian females and males at each of the three ages assessed, with the exception of females at birth. At birth, HALE increased an average of 0.2% (p = .08) and 0.3% (p < .001) annually for females and males respectively over the 1994 to 2010 period. At the national level for all three age groups, we observed a statistically non-significant average annual increase in the proportion of life spent in an unhealthy state, with the exception of men at age 65, who experienced a non-significant decrease. At the provincial level at birth, we observed a significant increase in proportion of life spent in an unhealthy state for Newfoundland and Labrador (NL) and Prince Edward Island (PEI). Our study did not detect a clear overall trend in compression or expansion of morbidity from 1994 to 2010 at the national level in Canada. However, our results suggested an expansion of morbidity in NL and PEI. Our study indicates the importance of continued tracking of the secular trends of life expectancy and HALE in Canada in order to verify the presence of compression or expansion of morbidity. Further study should be undertaken to understand what is driving the observed expansion of morbidity in NL and in PEI.

Describing the population health burden of depression: health-adjusted life expectancy by depression status in Canada.

Few studies have evaluated the impact of depression in terms of losses to both premature mortality and health-related quality of life (HRQOL) on the overall population. Health-adjusted life expectancy (HALE) is a summary measure of population health that combines both morbidity and mortality into a single summary statistic that describes the current health status of a population. We estimated HALE for the Canadian adult population according to depression status. National Population Health Survey (NPHS) participants 20 years and older (n = 12 373) were followed for mortality outcomes from 1994 to 2009, based on depression status. Depression was defined as having likely experienced a major depressive episode in the previous year as measured by the Composite International Diagnostic Interview Short Form. Life expectancy was estimated by building period abridged life tables by sex and depression status using the relative risks of mortality from the NPHS and mortality data from the Canadian Chronic Disease Surveillance System (2007-2009). The Canadian Community Health Survey (2009/10) provided estimates of depression prevalence and Health Utilities Index as a measure of HRQOL. Using the combined mortality, depression prevalence and HRQOL estimates, HALE was estimated for the adult population according to depression status and by sex. For the population of women with a recent major depressive episode, HALE at 20 years of age was 42.0 years (95% CI: 40.2-43.8) compared to 57.0 years (95% CI: 56.8-57.2) for women without a recent major depressive episode. For the population of Canadian men, HALE at 20 was 39.0 years (95% CI: 36.5-41.5) for those with a recent major depressive episode compared to 53.8 years (95% CI: 53.6-54.0) for those without. For the 15.0-year difference in HALE between women with and without depression, 12.3 years can be attributed to the HRQOL gap and the remaining 2.7 years to the mortality gap. The 14.8 fewer years of HALE observed for men with depression equated to a 13.0-year HRQOL gap and a 1.8-year mortality gap. The population of adult men and women with depression in Canada had substantially lower healthy life expectancy than those without depression. Much of this gap is explained by lower levels of HRQOL, but premature mortality also plays a role.

The effects of built environment attributes on physical activity-related health and health care costs outcomes in Australia

Attributes of the built environment can positively influence physical activity of urban populations, which results in health and economic benefits. In this study, we derived scenarios from the literature for the association built environment-physical activity and used a mathematical model to translate improvements in physical activity to health-adjusted life years and health care costs. We modelled 28 scenarios representing a diverse range of built environment attributes including density, diversity of land use, availability of destinations, distance to transit, design and neighbourhood walkability. Our results indicated potential health gains in 24 of the 28 modelled built environment attributes. Health care cost savings due to prevented physical activity-related diseases ranged between A$1300 to A$105,355 per 100,000 adults per year. On the other hand, additional health care costs of prolonged life years attributable to improvements in physical activity were nearly 50% higher than the estimated health care costs savings. Our results give an indication of the potential health benefits of investing in physical activity-friendly built environments.

Cost-effectiveness of investing in sidewalks as a means of increasing physical activity: a RESIDE modelling study.

BackgroundStudies consistently find that supportive neighbourhood built environments increase physical activity by encouraging walking and cycling. However, evidence on the cost-effectiveness of investing in built environment interventions as a means of promoting physical activity is lacking. In this study, we assess the cost-effectiveness of increasing sidewalk availability as one means of encouraging walking.MethodsUsing data from the RESIDE study in Perth, Australia, we modelled the cost impact and change in health-adjusted life years (HALYs) of installing additional sidewalks in established neighbourhoods. Estimates of the relationship between sidewalk availability and walking were taken from a previous study. Multistate life table models were used to estimate HALYs associated with changes in walking frequency and duration. Sensitivity analyses were used to explore the impact of variations in population density, discount rates, sidewalk costs and the inclusion of unrelated healthcare costs in added life years.ResultsInstalling and maintaining an additional 10 km of sidewalk in an average neighbourhood with 19 000 adult residents was estimated to cost A$4.2 million over 30 years and gain 24 HALYs over the lifetime of an average neighbourhood adult resident population. The incremental cost-effectiveness ratio was A$176 000/HALY. However, sensitivity results indicated that increasing population densities improves cost-effectiveness.ConclusionsIn low-density cities such as in Australia, installing sidewalks in established neighbourhoods as a single intervention is unlikely to cost-effectively improve health. Sidewalks must be considered alongside other complementary elements of walkability, such as density, land use mix and street connectivity. Population density is particularly important because at higher densities, more residents are exposed and this improves the cost-effectiveness. Health gain is one of many benefits of enhancing neighbourhood walkability and future studies might consider a more comprehensive assessment of its social value (eg, social cohesion, safety and air quality).

Influencing factors on healthy life expectancy in adults in Beijing

To understand the main influencing factors related to healthy life expectancy (HALE) among adults in Beijing. The calculation on health-adjusted life expectancy was performed by Sullivan METHODS. Data from the self-reported health survey program on adults in Beijing 2012 was gathered. Hierarchical ordered probit model was used to estimate the severity-weighted prevalence of disability and then combined with the period life table to obtain the HALE. Factors associated with the severity-adjusted prevalence of the disabled were analyzed under the generalized additive models (GAM). The main influencing factors of HALE would include age (t=40.351, P<0.001), sex (t=9.689, P<0.001), levels of education (t=5.021, P< 0.001), exercise (t=5.487, P<0.001) and alcohol intake (t=-2.380, P=0.017) etc. The influence of per capita monthly income (χ(2) =3.949, P=0.044) showed as non-linear. Levels of income would directly influence the severity-weighted prevalence of the disability, which also affecting the HALE. Programs on improving healthy life style and health care in women should be promoted.

Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa.

BackgroundStroke poses a growing human and economic burden in South Africa. Excess sugar consumption, especially from sugar-sweetened beverages (SSBs), has been associated with increased obesity and stroke risk. Research shows that price increases for SSBs can influence consumption and modelling evidence suggests that taxing SSBs has the potential to reduce obesity and related diseases. This study estimates the potential impact of an SSB tax on stroke-related mortality, costs and health-adjusted life years in South Africa.MethodsA proportional multi-state life table-based model was constructed in Microsoft Excel (2010). We used consumption data from the 2012 South African National Health and Nutrition Examination Survey, previously published own and cross price elasticities of SSBs and energy balance equations to estimate changes in daily energy intake and BMI arising from increased SSB prices. Stroke relative risk, and prevalent years lived with disability estimates from the Global Burden of Disease Study and modelled disease epidemiology estimates from a previous study, were used to estimate the effect of the BMI changes on the burden of stroke.ResultsOur model predicts that an SSB tax may avert approximately 72 000 deaths, 550 000 stroke-related health-adjusted life years and over ZAR5 billion, (USD400 million) in health care costs over 20 years (USD296-576 million). Over 20 years, the number of incident stroke cases may be reduced by approximately 85 000 and prevalent cases by about 13 000.ConclusionsFiscal policy has the potential, as part of a multi-faceted approach, to mitigate the growing burden of stroke in South Africa and contribute to the achievement of the target set by the Department of Health to reduce relative premature mortality (less than 60 years) from non-communicable diseases by the year 2020.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3085-y) contains supplementary material, which is available to authorized users.

The Impact of a Tax on Sugar-Sweetened Beverages on Health and Health Care Costs: A Modelling Study.

This paper aims to estimate the consequences of an additional 20% tax on sugar-sweetened beverages (SSBs) on health and health care expenditure. Participants were adult (aged > = 20) Australians alive in 2010, who were modelled over their remaining lifetime. We used lifetable-based epidemiological modelling to examine the potential impact of a 20% valoric tax on SSBs on total lifetime disability-adjusted life years (DALYs), incidence, prevalence, and mortality of obesity-related disease, and health care expenditure. Over the lifetime of adult Australian alive in 2010, seemingly modest estimated changes in average body mass as a result of the SSB tax translated to gains of 112,000 health-adjusted life years for men (95% uncertainty interval [UI]: 73,000–155,000) and 56,000 (95% UI: 36,000–76,000) for women, and a reduction in overall health care expenditure of AUD609 million (95% UI: 368 million– 870 million). The tax is estimated to reduce the number of new type 2 diabetes cases by approximately 800 per year. Twenty-five years after the introduction of the tax, there would be 4,400 fewer prevalent cases of heart disease and 1,100 fewer persons living with the consequences of stroke, and an estimated 1606 extra people would be alive as a result of the tax. The tax would generate an estimated AUD400 million in revenue each year. Governments should consider increasing the tax on sugared drinks. This would improve population health, reduce health care costs, as well as bring in direct revenue.

Health-Adjusted Life Expectancy (HALE) in Korea: 2005-2011.

Health-Adjusted Life Expectancy (HALE) is a summary measurement that estimates the average number of years that a person at a given age can expect to live an equivalent of full health. HALE has not been previously reported at national or regional levels in Korea. This study aimed to measure HALE from 2005 to 2011 in Korea at both the national and regional levels as part of the Korean National Burden Study of 2012. To measure life expectancy (LE) and HALE, we used the life table method and an approach proposed by Sullivan. We used three main data sets to estimate HALE: probability of death, prevalence of disease, and disability weights. Overall, LE and HALE have increased from 2005 to 2011. For example, in 2011, LE and HALE at birth in males were 77.6 and 65.8 years, respectively, and 84.4 and 68.9 in females. It might be assumed that the overall health status of Korean population has been increasing. However, we confirmed that a gap between LE and HALE still exists. Additionally, we found out that there was a significant difference between LE and HALE among various sub-regions. This study is the first to measure HALE using our own database, including disability weight that reflected Korean preferences. Finally, the Korean government and society should make an effort to reduce the gap between LE and HALE and to reduce regional differences.

Living longer with disability in China and G20 nations: a quantitative model for the Sustainable Development Goal for health post-2015: a reproducible study

BackgroundEvidence from the Global Burden of Disease Study 2010 is consistent with the expectation that, in China, where the number of healthy years lost to disability at birth in 2010 was 7·95 years compared with the median of 10·51 (median absolute deviation=1·15) of G20 nations, post-2015 a society living longer will lose an increasing number of years to non-fatal disease and injury. We generated the conditional hypothesis that this expansion of morbidity also has economic effects: in 2012, with a per-person total health expenditure of 480 purchasing power parity in international dollars, China was the third lowest spender among the G20 nations (median 2222, median absolute deviation 1723). We reviewed published work on convergence of health status and analysed data from the Global Health Data Exchange (GHDx) of the Institute for Health Metrics and Evaluation, the University of Washington, Seattle, WA, USA, and from the WHO Health Expenditure Statistics Database. MethodsReproducibility can improve evidence-based research, engage stakeholders, and promote transparency among health policy makers. For these reasons, this study uses open-access R software and public repositories of the GHDx (454 410 records) and the WHO Health Expenditure Statistics Database (164 220 records); our statistical inference can be downloaded from GitHub, and reproduced and improved by fellow researchers. We tested the multiple linear model that, within the reference population of G20 nations, per-person total health expenditure is related to health-adjusted life expectancy (HALE) and the number of years lived with disability (YLD). FindingsIn our reference population, the log transformation of per-person total health expenditure is positively related to HALE and YLD (R2 0·61; F-statistic 33; p<0·001; variance inflation factor 1·35), with YLD showing the strongest incremental effect: per-person total health expenditure increases exponentially by 1·47 times (95% CI 1·21–1·79) per additional year of disability versus 1·11 times (95% CI 1·05–1·17) per additional year of health-adjusted life expectancy. InterpretationWe generated the conditional hypothesis that post-2015 in China, if YLD and HALE converge towards the median of G20 nations, per-person total health expenditure will grow from 480 to 2195 purchasing power parity in international dollars (95% CI 1827–2636). Our results lent support to the conclusion that YLD and HALE are relevant quantities for an evidence-based assessment of the sustainability of the health development agenda in China and G20 nations post-2015. FundingUniversity of Bergamo, Bergamo, Italy.

The Population Health Model (POHEM): an overview of rationale, methods and applications.

The POpulation HEalth Model (POHEM) is a health microsimulation model that was developed at Statistics Canada in the early 1990s. POHEM draws together rich multivariate data from a wide range of sources to simulate the lifecycle of the Canadian population, specifically focusing on aspects of health. The model dynamically simulates individuals’ disease states, risk factors, and health determinants, in order to describe and project health outcomes, including disease incidence, prevalence, life expectancy, health-adjusted life expectancy, quality of life, and healthcare costs. Additionally, POHEM was conceptualized and built with the ability to assess the impact of policy and program interventions, not limited to those taking place in the healthcare system, on the health status of Canadians. Internationally, POHEM and other microsimulation models have been used to inform clinical guidelines and health policies in relation to complex health and health system problems. This paper provides a high-level overview of the rationale, methodology, and applications of POHEM. Applications of POHEM to cardiovascular disease, physical activity, cancer, osteoarthritis, and neurological diseases are highlighted.

A Triple Aim Framework For The Performance Assessment Of Disease Management Programs

Objectives: A structured and comprehensive assessment of disease management implementations is not straightforward due to the broadness of the interventions and the various evaluation possibilities. The aim of this study was to develop a comprehensive framework for outcome measurement of disease management programs based on the triple aim framework of the Institute for Healthcare Improvement to facilitate future performance assessment using multi-criteria decision analysis (MCDA). Methods: Based on literature review and our expertise in performing economic evaluations in disease management we identified domains of outcomes for each aim of the triple aim framework. For each domain we identified indicators to assess the performance of disease management programs. Results: The first aim of the framework, population health improvement, was subdivided into the domains health-adjusted life years, mortality, wellbeing, health-related quality of life (HrQol), complications, symptoms, clinical outcomes, healthy behaviour, knowledge, and self-management skills. The second aim, improvement of patient experience, was subdivided into patient involvement, patient centeredness, continuity of care, coordination, communication, information systems, safety and access. The third aim of cost reductions distinguished program, medical and nonmedical costs. Potential Indicators of the identified sub-criteria include the ASCOT (Adult Social Care Outcomes Toolkit) for measuring wellbeing, smoking rates and BMI (Body Mass Index) to measure healthy behaviour, the EuroQol-5D and Short Form-36 for measuring physical, mental and social HrQol, different dimensions of the PACIC (Patient Assessment of Chronic Illness Care) and CAHPS (Consumer Assessment of Healthcare Providers and Systems) for measuring patient experience and several measurement tools for measuring friction costs and costs of informal care. Conclusions: In designing a structured outcome-based framework for the performance evaluation of disease management programs we paved the way for future work including a comprehensive evaluation of disease management using MCDA. MCDA not only requires measurement of indicators but also weighting of their relative importance.

Costing the Morbidity and Mortality Consequences of Zoonoses Using Health-Adjusted Life Years.

Governments are routinely involved in the biosecurity of agricultural and food imports and exports. This involves controlling the complex ongoing threat of the broad range of zoonoses: endemic, exotic and newly emerging. Policy-related decision-making in these areas requires accurate information and predictions concerning the effects and potential impacts of zoonotic diseases. The aim of this article was to provide information concerning the development and use of utility-based tools, specifically disability-adjusted life years (DALYs), for measuring the burden on human disease (morbidity and mortality) as a consequence of zoonotic infections. Issues and challenges to their use are also considered. Non-monetary utility approaches that are reviewed in this paper form one of a number of tools that can be used to estimate the monetary and non-monetary 'cost' of morbidity- and mortality-related consequences. Other tools derive from cost-of-illness, willingness-to-pay and multicriteria approaches. Utility-based approaches are specifically designed to capture the pain, suffering and loss of functioning associated with diseases, zoonotic and otherwise. These effects are typically complicated to define, measure and subsequently 'cost'. Utility-based measures will not be able to capture all of the effects, especially those that extend beyond the health sector. These will more normally be captured in financial terms. Along with other uncommon diseases, the quality of the relevant epidemiological data may not be adequate to support the estimation of losses in utility as a result of zoonoses. Other issues in their use have been identified. New empirical studies have shown some success in addressing these issues. Other issues await further study. It is concluded that, bearing in mind all caveats, utility-based methods are important tools in assessing the magnitude of the impacts of zoonoses in human disease. They make an important contribution to decision-making and priority setting across all sectors. In doing so, they highlight the relative importance of the burden of zoonotic disease globally.

HealthPaths: Using functional health trajectories to quantify the relative importance of selected health determinants

BACKGROUND It is widely known that that there is a significant dispersion in health status, as well as a strong correlation between health status and socio-economic status. But considerable uncertainty remains as to the quantitative importance of the various explanatory factors typically cited in this context. As health status is intrinsically a reflection of co-evolving dynamic processes, it is important to take a lifetime perspective when seeking to understand its determinants. The ―bottom line‖ measure of overall population health is, though, health-adjusted life expectancy (HALE), which is an aggregation of individuals’ health-adjusted life lengths (HALLs). OBJECTIVE In an exploratory mode, we intend to provide a realistic assessment of the relative importance of selected health determinants of HALE. METHODS This paper first draws on very detailed estimates of the covariates of vector-valued functional health trajectories, using the National Population Health Survey (Statistics Canada). We then use longitudinal microsimulation to draw out their implications by synthesising first a realistic base case ‒ specifically, a representative longitudinal population sample ‒ and then a series of exploratory counterfactual populations. Comparisons between and among counterfactuals and the base case are then used to estimate the quantitative importance of various factors in accounting for HALE. RESULTS Several surprising results emerged. Of the four risk factors explicitly examined, obesity had the smallest impacts on HALE: moving from the fifth to the 95 th percentiles of BMI increased HALE 1.5 and 2.5 years for men and women, respectively. Eliminating smoking increased HALE by five and four years, while moving from the lowest to the 1 University of Ottawa, Canada. E-Mail: Michael.Wolfson@uOttawa.ca. 2 University of Ottawa, Canada. Wolfson & Rowe: HealthPaths: Comparative Impacts of Health Determinants 942 http://www.demographic-research.org highest levels of education had similar effects of about five years for both men and women. Perhaps surprisingly, moving from the fifth to the 95 th percentiles of the psycho-social factor, Antonovsky’s sense of coherence, had the greatest impact on estimated HALE, with increases of 5.5 to six years. CONCLUSIONS While the analysis is exploratory, the results show the analytical potential of tightly coupling detailed empirical analysis of complex longitudinal data with microsimulation modelling. Substantively, the results of the analysis contribute to the evidence that the widespread public health preoccupation with the ―obesity epidemic‖ is over-stated, while psycho-social and mental health problems continue to be seriously underemphasised.

Why equal treatment is not always equitable: the impact of existing ethnic health inequalities in cost-effectiveness modeling.

BackgroundA critical first step toward incorporating equity into cost-effectiveness analyses is to appropriately model interventions by population subgroups. In this paper we use a standardized treatment intervention to examine the impact of using ethnic-specific (Māori and non-Māori) data in cost-utility analyses for three cancers.MethodsWe estimate gains in health-adjusted life years (HALYs) for a simple intervention (20% reduction in excess cancer mortality) for lung, female breast, and colon cancers, using Markov modeling. Base models include ethnic-specific cancer incidence with other parameters either turned off or set to non-Māori levels for both groups. Subsequent models add ethnic-specific cancer survival, morbidity, and life expectancy. Costs include intervention and downstream health system costs.ResultsFor the three cancers, including existing inequalities in background parameters (population mortality and comorbidities) for Māori attributes less value to a year of life saved compared to non-Māori and lowers the relative health gains for Māori. In contrast, ethnic inequalities in cancer parameters have less predictable effects. Despite Māori having higher excess mortality from all three cancers, modeled health gains for Māori were less from the lung cancer intervention than for non-Māori but higher for the breast and colon interventions.ConclusionsCost-effectiveness modeling is a useful tool in the prioritization of health services. But there are important (and sometimes counterintuitive) implications of including ethnic-specific background and disease parameters. In order to avoid perpetuating existing ethnic inequalities in health, such analyses should be undertaken with care.

Population health and burden of disease profile of Iran among 20 countries in the region: from Afghanistan to Qatar and Lebanon.

Population health and disease profiles are diverse across Iran's neighboring countries. Borrowing the results of the country-level Global Burden of Diseases, Injuries, and Risk Factors 2010 Study (GBD 2010), we aim to compare Iran with 19 countries in terms of an important set of population health and disease metrics. These countries include those neighboring Iran and a few other countries from the Middle East and North Africa (MENA) region. We show the pattern of health transition across the comparator countries from 1990 through 2010. We use classic GBD metrics measured for the year 2010 to indicate the rank of Iran among these nations. The metrics include disability-adjusted life years (DALYs), years of life lost as a result of premature death (YLLs), years of life lost due to disability (YLDs), health-adjusted life expectancy (HALE), and age-standardized death rate (ASD). Considerable and uniform transition from communicable, maternal, neonatal, and nutritional (CMMN) conditions to non-communicable diseases (NCDs) was seen between 1990 and 2010. On average, ischemic heart disease, lower respiratory infections, and road injuries were the three principal causes of YLLs, while low back pain and major depressive disorders were the top causes of YLDs in these countries. Iran ranked 13th in HALE and 12th in ASD. The function of Iran's health care, measured by DALYs, was somewhat in the middle of the HALE spectrum for the comparator countries. This intermediate position becomes rather highlighted when Afghanistan, as outlier, is taken out of the comparison. Effective policies to reduce NCDs need to be formulated and implemented through an integrated health care system. Our comparison shows that Iran can learn from the experience of a number of these countries to devise and execute the required strategies.

Health transition in Iran toward chronic diseases based on results of Global Burden of Disease 2010.

Drawing on the results of the country-level Global Burden of Diseases, Injuries, and Risk Factors 2010 Study, we attempted to investigate the drivers of change in the healthcare system in terms of mortality and morbidity due to diseases, injuries, and risk factors for the two decades from 1990 to 2010. We decomposed trends in mortality, cause of death, years of life lost due to disability, disability-adjusted life years (DALYs), life expectancy, health-adjusted life expectancy, and risk factors into the contribution of total increase in population size, aging of the population, and changes in age-specific and sex-specific rates. We observed a decrease in age-specific mortality rate for both sexes, with a higher rate for women. The ranking of causes of death and their corresponding number of years of life lost remained unchanged between 1990 and 2010. However, the percentages of change indicate patterns of reduction for most causes, such as ischemic and hemorrhagic stroke, hypertensive heart disease, stomach cancer, lower respiratory infections, and congenital anomalies. The number of years lost due to disability caused by diabetes and drug use disorders has significantly increased in the last two decades. Major causes of DALYs, such as injuries, interpersonal violence, and suicide, showed increasing trends, while rates of communicable diseases, neonatal disorders, and nutritional deficiencies have declined significantly. Life expectancy and health-adjusted life expectancy increased for both sexes by approximately 7 years, with the highest rate of increase pertaining to females over the age 30. Time trend information presented in this paper can be used to evaluate problems and policies specific to medical conditions or risk factors. Despite recent improvements, implementing policies to reduce the number of deaths and years of life lost due to road traffic injury remains the highest priority for Iranian policymakers. Immediate action by Iranian researchers is required to match Iran's decreasing mortality rate due to liver and stomach cancers to a rate comparable to the global level. Prevention and treatment plans for mental disorders, such as major depressive disorder, anxiety disorder, and particularly drug use disorders, should be considered in reforms of the health, education, and judiciary systems in Iran.