Understanding DALYs (disability-adjusted life years)

Estimated disease burden and lost economic productivity due to glucose-6-phosphate dehydrogenase deficiency in Nigerian newborns

Glucose-6-phosphate dehydrogenase (G6PD) deficiency rarely manifests as extreme hyperbilirubinemia [EHB, total serum/plasma bilirubin > 25 mg/dL (428 µmol/L)]. It is a major preventable cause of newborn morbidity and mortality. In resource-constrained communities of Nigeria, experts have observed its significant clinical burden. We accessed a previously published pooled model of G6PD deficiency and determined its prevalence, subsequent risk of EHB, kernicterus, and death to be 26.4% [95% confidence interval (CI): 19.5, 33.2%]; 33.3% (95%CI: 16.6, 50%); and 22.7% (95% CI: 16.5, 28.9%), respectively. The total number of disability-adjusted life years (DALYs) lost to symptomatic G6PD deficiency was 54,251 (95% CI: 6,039, 189,149). Estimated national average economic deficits due to mortality and disability ranged from $309 to $584 million. G6PD deficiency, when symptomatic in Nigerian newborns, is a significant disease burden, placing 1% of annual births at increased risks of neonatal mortality and morbidity, which contribute to significant economic productivity losses.

The nationwide retrospective cohort study by Health Insurance Review and Assessment Service proves that asthma management decreases the exacerbation risk of asthma

Medical costs have recently increased in South Korea due to the rising rate of asthma. Primary clinics serve an important role in asthma management, as they are the first stop for patients presenting with symptoms. The Health Insurance Review and Assessment Service (HIRA) in South Korea has assessed asthma-management quality since 2013, but studies are lacking on whether these assessments have been performed properly and contribute toward reducing asthma exacerbations. Therefore, we investigated whether the HIRA’s quality assessments have decreased asthma exacerbations using national health insurance claims data from 2013 to 2017 of 83,375 primary-clinic and 15,931 tertiary-hospital patients with asthma. These patients were classified into four groups based on disease severity according to the monthly prescribed amount of asthma medication using K-means clustering. The associations between HIRA assessments and asthma exacerbation were analyzed using a generalized estimating equation. Our results showed that exacerbation odds gradually decreased as the HIRA assessments progressed, especially in the mild-severity group, and that exacerbation risk among patients with asthma decreased in the order of assessment grades: “Unsatisfactory,” “Satisfactory,” and “Tertiary.” Therefore, we may conclude that asthma exacerbations may decrease with high quality asthma management; appropriate quality assessment could be helpful in reducing asthma exacerbations.

The Devils in the DALY: Prevailing Evaluative Assumptions

In recent years, it has become commonplace among the Global Burden of Disease (GBD) study authors to regard the disability-adjusted life year (DALY) primarily as a descriptive health metric. During the first phase of the GBD (1990–1996), it was widely acknowledged that the DALY had built-in evaluative assumptions. However, from the publication of the 2010 GBD and onwards, two central evaluative practices—time discounting and age-weighting—have been omitted from the DALY model. After this substantial revision, the emerging view now appears to be that the DALY is primarily a descriptive measure. Our aim in this article is to argue that the DALY, despite changes, remains largely evaluative. Our analysis focuses on the understanding of the DALY by comparing the DALY as a measure of disease burden in the two most significant phases of GBD publications, from their beginning (1990–1996) to the most recent releases (2010–2017). We identify numerous assumptions underlying the DALY and group them as descriptive or evaluative. We conclude that while the DALY model arguably has become more descriptive, it remains, by necessity, largely evaluative.

Leveraging the lessons learned from studies on the cultural context of epilepsy care in Uganda: Opportunities and future directions

In this summary paper, we review the body of research contained in this special issue, The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda, and corollary recommendations for a way forward. We review key findings and conclusions for the studies, which tell a story of culture and care-seeking through discussions and data gleaned from a rich research landscape traversing community village dwellings, shared communal areas, churches, and urban hospitals. The voices and perspectives of over 16,000 study participants inclusive of people living with epilepsy, their neighbors and healthcare workers, traditional healers, and faith leaders are reported. From this, we synthesize findings and prioritize a set of recommendations to advance epilepsy care in Uganda. Progress will require infrastructure strengthening, multilevel educational investments, and an ambitious, extensive program of community sensitization. These proposed priorities and actions outline a way forward through formidable but surmountable challenges but require harmonized efforts by government and other relevant stakeholders, scholars, clinicians, and community leaders. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda.

The cost-effectiveness of a program to reduce intrapartum and neonatal mortality in a referral hospital in Ghana

OBJECTIVE

To evaluate the cost-effectiveness of a program intended to reduce intrapartum and neonatal mortality in Accra, Ghana.

DESIGN

Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis.

METHODS

A program integrating leadership development, clinical skills and quality improvement training was piloted at the Greater Accra Regional Hospital from 2013 to 2016. The number of intrapartum and neonatal deaths prevented were estimated using the hospital's 2012 stillbirth and neonatal mortality rates as a steady-state assumption. The cost-effectiveness of the intervention was calculated as cost per disability-adjusted life year (DALY) averted. In order to test the assumptions included in this analysis, it was subjected to probabilistic and one-way sensitivity analyses.

MAIN OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER), which measures the cost per disability-adjusted life-year averted by the intervention compared to status quo.

RESULTS

From 2012 to 2016, there were 45,495 births at the Greater Accra Regional Hospital, of whom 5,734 were admitted to the newborn intensive care unit. The budget for the systems strengthening program was US $1,716,976. Based on program estimates, 307 (±82) neonatal deaths and 84 (±35) stillbirths were prevented, amounting to 12,342 DALYs averted. The systems strengthening intervention was found to be highly cost effective with an ICER of US $139 (±$44), an amount significantly lower than the established threshold of cost-effectiveness of the per capita gross domestic product, which averaged US $1,649 between 2012-2016. The results were found to be sensitive to the following parameters: DALYs averted, number of neonatal deaths, and number of stillbirths.

CONCLUSION

An integrated approach to system strengthening in referral hospitals has the potential to reduce neonatal and intrapartum mortality in low resource settings and is likely to be cost-effective. Sustained change can be achieved by building organizational capacity through leadership and clinical training.

Burden of Disease of Guillain-Barré Syndrome in Brazil before and during the Zika virus epidemic 2014-2016

OBJECTIVE

To estimate the burden of disease of Guillain-Barré syndrome (GBS) in Brazil in 2014, 1 year before the Zika virus epidemic, and in 2015 and 2016 during the epidemic.

METHODS

The burden of disease of GBS was estimated using the summary measure of population health: Disability Adjusted Life Years (DALY), that combines both mortality (Years of Life Lost YLLs) and morbidity (Years Lived with Disability) components. The study population was composed of GBS hospitalised cases and deaths from the information systems of the Brazilian Unified Health System.

RESULTS

The GBS incidence rate in 2014, 2015 and 2016 was 0.74, 0.96, 1.02/100 000 respectively, and the mortality rate in the same period was 0.08, 0.009 and 0.11/100 000 habitants. The DALYs calculated using the point estimate of GBS disability weight and its values of the confidence interval (0.198 and 0.414) were 5725.90 (5711.79-5742.89) in 2014, 6054.61 (6035.57-6077.54) in 2015 and 7588.49 (7570.20-7610.51) in 2016. The DALYs were high among the male population and in age groups between 20 and 50 years.

CONCLUSIONS

The increase in DALYs in the years 2015 and 2016 compared to 2014 probably resulted from the introduction of ZIKV in Brazil, reinforcing the importance of investments in the prevention of ZIKV infection and in the care of GBS patients.

Reflection of Epidemiological Impact on Burden of Injury in Tertiary Care Centre, Pre-COVID and COVID Era: "Lockdown, a Good Fortune for Saving Life and Limb"

Road traffic injuries continue to be a major public health concern and are a leading cause of death and injury across the world. Road transport remains the most favoured mode of transport for both freight and passenger movement in India. As per the World Health Organization, approximately 1.35 million people die annually on the world’s roads, and another 20 to 50 million sustain nonfatal injuries as a result of road traffic crashes. These injuries and deaths have an immeasurable impact on the families affected, whose lives are often changed irrevocably by these tragedies, and on the communities in which these people lived and worked. India ranks 1 in the total number of traffic-related deaths across the 199 countries reported in the World Road Statistics, 2018, followed by China and the USA due to its large population (India, 21.7, and China, 18.6, fatalities per 100,000), although several Central American and African countries have higher fatality rates. During COVID-19 (coronavirus disease-19) pandemic, a national lockdown was implemented by Government of India from 24 March to 31 May 2020, in four phases to control the spread of SARS CoV-2 (severe acute respiratory syndrome coronavirus-2) infection. In our observational study, we compared the epidemiology of trauma patients of two periods from 1 April to 31 May 2019 and 24 March to 31 May 2020 and found out that unique concept of lockdown with stringent implementation of discipline, alcohol ban, behavioural change in visiting family and friends as minimum as possible, promoting work from home and digital classes for school and colleges lead to phenomenal decrease in traffic-related injuries and fatality. The lockdown has grossly decreased ‘disability-adjusted life year’(DALY), an outcome indicator for cost-effective analysis, which is calculated as the value of future years of healthy life lost to morbidity/disability and future years of life lost to premature mortality.

Integrating trials into a whole-population cohort of children and parents: statement of intent (trials) for the Generation Victoria (GenV) cohort

Background

Very large cohorts that span an entire population raise new prospects for the conduct of multiple trials that speed up advances in prevention or treatment while reducing participant, financial and regulatory burden. However, a review of literature reveals no blueprint to guide this systematically in practice. This Statement of Intent proposes how diverse trials may be integrated within or alongside Generation Victoria (GenV), a whole-of-state Australian birth cohort in planning, and delineates potential processes and opportunities.

Methods

Parents of all newborns (estimated 160,000) in the state of Victoria, Australia, will be approached for two full years from 2021. The cohort design comprises four elements: (1) consent soon after birth to follow the child and parent/s until study end or withdrawal; retrospective and prospective (2) linkage to clinical and administrative datasets and (3) banking of universal and clinical biosamples; and (4) GenV-collected biosamples and data. GenV-collected data will focus on overarching outcome and phenotypic measures using low-burden, universal-capable electronic interfaces, with funding-dependent face-to-face assessments tailored to universal settings during the early childhood, school and/or adult years.

Results

For population or registry-type trials within GenV, GenV will provide all outcomes data and consent via traditional, waiver, or Trials Within Cohorts models. Trials alongside GenV consent their own participants born within the GenV window; GenV may help identify potential participants via opt-in or opt-out expression of interest. Data sharing enriches trials with outcomes, prior data, and/or access to linked data contingent on custodian’s agreements, and supports modeling of causal effects to the population and between-trials comparisons of costs, benefits and utility. Data access will operate under the Findability, Accessibility, Interoperability, and Reusability (FAIR) and Care and Five Safes Principles. We consider governance, ethical and shared trial oversight, and expectations that trials will adhere to the best practice of the day.

Conclusions

Children and younger adults can access fewer trials than older adults. Integrating trials into mega-cohorts should improve health and well-being by generating faster, larger-scale evidence on a longer and/or broader horizon than previously possible. GenV will explore the limits and details of this approach over the coming years.

The Burden of Pediatric Musculoskeletal Diseases Worldwide

Global burden of disease (GBD) refers to the economic and human costs resulting from poor health. The disability-adjusted life year is a measure of life lost from premature death and life not lived at 100% health. Surgery has long been neglected in the distribution of resources for global health. Because of years of life lived with a disability and the large proportion of children in a population, pediatric musculoskeletal conditions early in life can contribute to the GBD. Fortunately, the World Health Organization has recently promoted essential surgical services through its Emergency and Essential Surgical Care Project and Global Initiative.

Orthopaedic Trauma in Low-resource Settings: Measuring Value

There is increasing recognition of both the impact and value of trauma care in low- and middle-income countries (LMICs). However, data supporting the value of musculoskeletal trauma care specifically are lacking. This review discusses methods of economic analysis relevant to low-resource settings and provides a review of cost studies related to orthopaedic trauma care in these settings. In general, microcosting methods are preferred in LMICs because of the lack of databases with aggregate cost data. It is important that studies use a societal perspective that includes the indirect costs of treatment in addition to direct costs of medical care. Cost-effectiveness studies most commonly report cost per disability-adjusted life year, particularly in LMICs, but quality-adjusted life years are an acceptable alternative that is based on more empiric data. There are solid economic data supporting potential cost savings and improved outcomes with intramedullary nailing for femoral shaft fractures. Trauma care hospitals and educational initiatives have also been found to be highly cost-effective. However, very little data exist to support other interventions in orthopaedic trauma. Orthopaedic surgeons should strive to understand these methodologies and support the conduct of rigorous economic analysis to better establish the value of musculoskeletal trauma care in LMICs.

Health and Heating in the City of Temuco (Chile). Monetary Savings of Replacing Biomass with PV System in the Residential Sector

The paper conducts a comprehensive analysis of replacing residential use of wood burning stoves for heating with photovoltaic systems for the generation of electricity using storage batteries (PV + storage systems). The research focuses on the city of Temuco (Southern Chile) as a case study, since this city has a high use of firewood for heating (80% of households) and also because this city has been declared by authorities as an area saturated with suspended particles. The total cost corresponds to the acquisition of systems. The reduction of monetary value of the impact of polluting emissions, resulting from the combustion of firewood, on health and traffic accidents is calculated. The interactive tool GDB Compare has been used to calculate the impact of pollution on health both in terms of attributable deaths and disability-adjusted life years. The monetary value of the impact on health has been calculated using two alternative approaches: the value of statistical life and the human capital approach. To identify firewood use requirements, heating degree–days has been used for temperatures ≤15 °C and ≤18 °C. The emissions avoided calculations have been refined, including emissions associated with the manufacture and transport of systems through the life cycle analysis. For all scenarios, the main results show that the savings outweigh the costs.

Variability in the burden of disease estimates with or without age weighting and discounting: a methodological study

OBJECTIVES

This study examines the impact of the type of method used on the estimation of the burden of diseases.

DESIGN

Comparison of methods of estimating disease burden.

SETTING

Four metrics of burden of disease estimation, namely, years of potential life lost (YPLL), non-age weighted years of life lost (YLL) without discounting and YLL with uniform or non-uniform age weighting and discounting were used to calculate the burden of selected diseases in three countries: Australia, USA and South Africa.

PARTICIPANTS

Mortality data for all individuals from birth were obtained from the WHO database.

OUTCOMES

The burden of 10 common diseases with four metrices, and the relative contribution of each disease to the overall national burden when each metric is used.

RESULTS

There were variations in the burden of disease estimates with the four methods. The standardised YPLL estimates were higher than other methods of calculation for diseases common among young adults and lower for diseases common among the elderly. In the three countries, discounting decreased the contributions of diseases common among younger adults to the total burden of disease, while the contributions of diseases of the elderly increased. After discounting with age weighting, there were no distinct patterns for diseases of the elderly and young adults in the three countries.

CONCLUSIONS

Given the variability in the estimates of the burden of disease with different approaches, there should be transparency regarding the type of metric used and a generally acceptable method that incorporates all the relevant social values should be developed.

Cost-effectiveness of childhood pneumococcal vaccination program in Ethiopia: results from a quasi-experimental evaluation

BACKGROUND

Ethiopia was among the 15 countries that, together accounted for 64% of the world's severe episodes of pneumonia among children below the age of 5 in 2011. To reduce this burden, the 10-valent pneumococcal conjugate vaccine (PCV 10) was introduced into the general childhood national immunization program in Ethiopia in 2011. However, there is little evidence on its cost-effectiveness, and the aim of this study was to estimate the cost-effectiveness of the introduction of PCV 10 vaccination in the Ethiopian setting.

METHODS

The cost-effectiveness analysis was carried out based on a quasi-experimental evaluation of implementing PCV 10 at the Butajira rural health program site in Ethiopia. The intervention and the control groups consisted 876 and 1010 children, respectively. Using data from program site's surveillance system database as a framework, health outcome and vaccination data were collected from medical records, immunization registration books and reports. Disability- Adjusted Life Year (DALY) was a main health outcome metric complimented by incidence of acute lower respiratory infection/1000-person years. Vaccination and treatment costs were collected by document review and cross-sectional household survey.

RESULTS

In the intervention cohort, 626 of 876 (71.5%) children received PCV 10 vaccination. Until the first year of life, the incidence of acute lower respiratory infection was higher in the intervention group. After the first year of life, the incidence rate was 35.2 per 1000-person years in the intervention group compared to 60.4 per 1000-person years in the control group. The incremental cost-effectiveness ratio (ICER) per averted DALY for the intervention group during the total follow-up period was (2013 US$) 394.3 (undiscounted) and 413.8 (discounted). The ICER per averted DALY excluding the first year of life was (2013 US$) 225 (undiscounted) and 292.7 (discounted).

CONCLUSION

Compared to the WHO's suggested cost-effectiveness threshold value, the results indicate that the general childhood PCV 10 vaccination was a cost-effective intervention in the Butajira rural health program site.

Coping as a mediator between locus of control, competence beliefs, and mental health: A systematic review and structural equation modelling meta-analysis

OBJECTIVE

This systematic review and two-staged structural equation modelling meta-analysis (TSSEM) aimed to examine whether coping mediates the associations between locus of control, competence beliefs, and mental health in the general population and clinical samples.

METHODS

Eligible studies published until May 2017 were identified through systematic searches of PubMED and EMBASE. The review included 19 studies and the meta-analysis 15 studies.

RESULTS

The review supports the assumption that coping mediates the associations between locus of control and competence beliefs, and mental health. TSSEM using a pooled sample of 3986 respondents and 225 cross-sectional effect sizes indicated that maladaptive coping mediates the association between maladaptive locus of control and mental health problems. On the contrary, adaptive coping did not mediate this association and was only significantly associated with competence beliefs and adaptive locus of control but, unexpectedly, not with mental health. Both maladaptive and adaptive locus of control but not competence beliefs had direct links to mental health problems that were independent of coping.

CONCLUSION

Interventions should not only focus on enhancing adaptive coping as it might be more promising to diminish maladaptive locus of control, which may result in reduced maladaptive coping and, finally, improved mental health.

Using economic and social data to improve veterinary vaccine development: Learning lessons from human vaccinology

The drivers of vaccine development are many and varied. They include, for example, recognition of the burden of a vaccine-targeted disease, prioritisation of the multiple problems associated with a disease, consideration of the differing socio-economic situations under which vaccines are used, the influence of advocacy groups, and assessment of the feasibility of large-scale vaccine manufacture and distribution. In the field of human health, data-driven development of vaccines is becoming increasingly common through the availability of reliable information on the Global Burden of Disease (GBD) and stringent evaluations of vaccination programmes utilising empirical data on costing and effectiveness, and standardised cost-effectiveness thresholds. The data generated from such analyses allow policymakers, implementing partners, industries and researchers to make decisions based on the best, and most contextually relevant, available evidence. In this paper, we wish to explore the current use of economic and social data for the development of veterinary vaccines. Through comparison with the development of human vaccines, we will look for opportunities in animal health sciences to better integrate socio-economic data and analyses into the process of veterinary vaccine selection, development, and field implementation. We believe that more robust animal health impact assessments could add value to veterinary vaccine development by improving resource allocation and animal disease management.

Economic benefit of neurosurgical intervention for infant hydrocephalus in Haiti

OBJECTIVE

Previous models have been utilized in other low- and middle-income countries (LMICs) to explore and assess the cost, sustainability, and effectiveness of infant hydrocephalus treatment. However, similar models have not been implemented in Haiti due to a paucity of data, epidemiology, and outcomes for hydrocephalus. Therefore, the authors utilized previously described economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at a neurosurgery referral center, Hospital Bernard Mevs (HBM), in Port-au-Prince, Haiti.

METHODS

The authors conducted a retrospective review of data obtained in all children treated for hydrocephalus at the HBM from 2008 to 2015. The raw data were pooled with previously described surgical outcomes for hydrocephalus in other LMICs. Modeling was performed to determine outcomes, neurosurgical costs, disability-adjusted life years (DALYs), and economic benefits of Haitian hydrocephalus treatment during this time frame. Standard account methodology was employed to calculate cost per procedure. Using these formulas, the net economic benefit and cost/DALY were determined for hydrocephalus treatment at HBM from 2008 to 2015.

RESULTS

Of the 401 patients treated during the study period, 158 (39.4%) met criteria for postinfectious hydrocephalus, 54 (13.5%) had congenital hydrocephalus, 38 (9.5%) had myelomeningocele, 19 (4.7%) had aqueductal stenosis, and 132 (33%) were not placed into a category. Overall, 317 individuals underwent surgical treatment of their hydrocephalus, averting 3077 DALYs. The total cost of the procedures was $754,000, and the cost per DALY ranged between $86 and $245. The resulting net economic benefit for neurosurgical intervention ranged from $2.5 to $5.5 million.

CONCLUSIONS

This work demonstrates the substantial economic benefit of neurosurgical intervention for the treatment of pediatric hydrocephalus at a single hospital in Haiti. Based on DALYs averted, the need for additional centers offering basic neurosurgical services is apparent. A single center offering these services for several days each month was able to generate between $2.5 to $5.5 million in economic benefits, suggesting the need to develop neurosurgical capacity building in Haiti. Ultimately, prevention, screening, and early surgical treatment of these infants represent a public health and socioeconomic requisite for Haiti.

[Health impact assessment of the Program Healthy Centers in the Autonomous City of Buenos Aires, ArgentinaAvaliação do impacto na saúde do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires, Argentina]

Objective

To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact.

Methods

In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs).

Results

The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p<0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes.

Conclusions

The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.

The disease burden associated with Campylobacter spp. in Germany, 2014

Bacteria of the genus Campylobacter are an important cause of human illness worldwide. Campylobacter infections are expressed as gastroenteritis and can lead to severe sequelae like reactive arthritis, Guillain-Barré syndrome, irritable bowel syndrome and inflammatory bowel disease. In Germany, Campylobacter-associated gastroenteritis cases are notifiable but there is no reporting obligation for the sequelaes and the disease burden is clearly underestimated. The aim of our study was to quantify reliably the current disease burden of all Campylobacter spp.-associated diseases for Germany with the method of disability-adjusted life years (DALYs). DALYs combine mortality and morbidity in a single summary measure, whereby one DALY represents the loss of one year in full health. For acute gastroenteritis, we estimated 967 DALYs of which only 484 DALYs were detected within the reporting system. Overall, we estimated that 8811 DALYs were caused by the campylobacter-related diseases known so far. 98% of the DALYs were associated with morbidity and 2% with mortality. Mortality was caused by the health outcomes Gastroenteritis and Guillain-Barré syndrome exclusively.

(Outcome) Measure for (Intervention) Measures: A Guide to Choosing the Appropriate Noninvasive Clinical Outcome Measure for Intervention Studies in Celiac Disease

There is an unmet need for diagnostic and treatment interventions for celiac disease. Both clinical trials and real-world studies require careful selection of clinical outcome measures. Often, neither serology nor histology is an appropriate primary outcome. This article reviews various measures of intestinal function and nutrition, patient-reported outcome measures for symptoms and for health-related quality of life, and measures of sickness burden as they apply to intervention studies for celiac disease. A series of case studies is presented to illustrate key considerations in selecting outcome measures for dietary interventions, pharmacologic interventions, and real-world studies.

Cost-Effectiveness Analysis of Humanitarian Hand Surgery Trips According to WHO-CHOICE Thresholds

PURPOSE

Hand surgery outreach programs to low- and middle-income countries (LMICs) provide much-needed surgical care to the underserved populations and education to local providers for improved care. The cost-effectiveness of these surgical trips has not been studied despite a long history of such efforts. This study aimed to examine the economic impact of hand surgery trips to LMICs using data from the Touching Hands Project and ReSurge International. We hypothesized that hand surgery outreach would be cost-effective in LMICs.

METHODS

We analyzed data on the cost of each trip and the surgical procedures performed. Using methods from the World Health Organization (WHO-Choosing Interventions That Are Cost-Effective [WHO-CHOICE]), we determined whether the procedures performed during the outreach trips would be cost-effective.

RESULTS

For the 14 hand surgery trips, 378 patients received surgical treatment. Trips varied in the country where interventions were provided, the number of patients served, the severity of the conditions, and the total cost. The cost per disability-adjusted life-year averted ranged from United States (US)$222 to $1,525, all of which were very cost-effective according to WHO-CHOICE thresholds. The cost-effectiveness of global hand surgery was comparable to that of other medical interventions such as multidrug-resistant tuberculosis treatment in similar regions. We also identified a lack of standardized record keeping for these surgical trips.

CONCLUSIONS

Hand surgeries performed in LMICs are cost-effective based on WHO-CHOICE criteria. However, a standardized record-keeping method is needed for future research and longitudinal comparison. Understanding the economic impact of hand surgery global outreach is important to the success and sustainability of these efforts, both to allocate resources effectively and to identify areas for improvement.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

An Alternative Mathematical Modeling Approach to Estimating a Reference Life Expectancy

Background. Reference life expectancies inform frequently used health metrics, which play an integral role in determining resource allocation and health policy decision making. Existing reference life expectancies are not able to account for variation in geographies, populations, and disease states. Using a computer simulation, we developed a reference life expectancy estimation that considers competing causes of mortality, and is tailored to population characteristics. Methods. We developed a Monte Carlo microsimulation model that explicitly represented the top causes of US mortality in 2014 and the risk factors associated with their onset. The microsimulation follows a birth cohort of hypothetical individuals resembling the population of the United States. To estimate a reference life expectancy, we compared current circumstances with an idealized scenario in which all modifiable risk factors were eliminated and adherence to evidence-based therapies was perfect. We compared estimations of years of potential years life lost with alternative approaches. Results. In the idealized scenario, we estimated that overall life expectancy in the United States would increase by 5.9 years to 84.7 years. Life expectancy for men would increase from 76.4 years to 82.5 years, and life expectancy for women would increase from 81.3 years to 86.8 years. Using age-75 truncation to estimate potential years life lost compared to using the idealized life expectancy underestimated potential health gains overall (38%), disproportionately underestimated potential health gains for women (by 70%) compared to men (by 40%), and disproportionately underestimated the importance of heart disease for white women and black men. Conclusion. Mathematical simulations can be used to estimate an idealized reference life expectancy among a population to better inform and assess progress toward targets to improve population health.

Disability weights for infectious diseases in four European countries: comparison between countries and across respondent characteristics

Background

In 2015, new disability weights (DWs) for infectious diseases were constructed based on data from four European countries. In this paper, we evaluated if country, age, sex, disease experience status, income and educational levels have an impact on these DWs.

Methods

We analyzed paired comparison responses of the European DW study by participants’ characteristics with separate probit regression models. To evaluate the effect of participants’ characteristics, we performed correlation analyses between countries and within country by respondent characteristics and constructed seven probit regression models, including a null model and six models containing participants’ characteristics. We compared these seven models using Akaike Information Criterion (AIC).

Results

According to AIC, the probit model including country as covariate was the best model. We found a lower correlation of the probit coefficients between countries and income levels (range r_s: 0.97–0.99, P < 0.01) than between age groups (range r_s: 0.98–0.99, P < 0.01), educational level (range r_s: 0.98–0.99, P < 0.01), sex (r_s = 0.99, P < 0.01) and disease status (r_s = 0.99, P < 0.01). Within country the lowest correlations of the probit coefficients were between low and high income level (range r_s = 0.89–0.94, P < 0.01).

Conclusions

We observed variations in health valuation across countries and within country between income levels. These observations should be further explored in a systematic way, also in non-European countries. We recommend future researches studying the effect of other characteristics of respondents on health assessment.

Disability Weights for Pediatric Surgical Procedures: A Systematic Review and Analysis

BACKGROUND

Metrics to measure the burden of surgical conditions, such as disability weights (DWs), are poorly defined, particularly for pediatric conditions. To summarize the literature on DWs of children's surgical conditions, we performed a systematic review of disability weights of pediatric surgical conditions in low- and middle-income countries (LMICs).

METHOD

For this systematic review, we searched MEDLINE for pediatric surgery cost-effectiveness studies in LMICs, published between January 1, 1996, and April 1, 2017. We also included DWs found in the Global Burden of Disease studies, bibliographies of studies identified in PubMed, or through expert opinion of authors (ES and HR).

RESULTS

Out of 1427 publications, 199 were selected for full-text analysis, and 30 met all eligibility criteria. We identified 194 discrete DWs published for 66 different pediatric surgical conditions. The DWs were primarily derived from the Global Burden of Disease studies (72%). Of the 194 conditions with reported DWs, only 12 reflected pre-surgical severity, and 12 included postsurgical severity. The methodological quality of included studies and DWs for specific conditions varied greatly.

INTERPRETATION

It is essential to accurately measure the burden, cost-effectiveness, and impact of pediatric surgical disease in order to make informed policy decisions. Our results indicate that the existing DWs are inadequate to accurately quantify the burden of pediatric surgical conditions. A wider set of DWs for pediatric surgical conditions needs to be developed, taking into account factors specific to the range and severity of surgical conditions.

Economic benefit of carpal tunnel release in the Medicare patient population

OBJECTIVE The epidemiology of carpal tunnel syndrome (CTS) has been extensively researched. However, data describing the economic burden of CTS is limited. The purpose of this study was to quantify the disease burden of CTS and determine the economic benefit of its surgical management. METHODS The authors utilized the PearlDiver database to identify the number of individuals with CTS in the Medicare patient population, and then utilized CPT codes to identify which individuals underwent surgical management. These data were used to calculate the total number of disability-adjusted life years (DALYs) associated with CTS. A human capital approach was employed and gross national income per capita was used to calculate the economic burden. RESULTS From 2005 to 2012 there were 1,500,603 individuals identified in the Medicare patient population with the diagnosis of CTS. Without conservative or surgical management, this results in 804,113 DALYs without age weighting and discounting, and 450,235 DALYs with age weighting and a discount rate of 3%. This amounts to between $21.8 and $39 billion in total economic burden, or $2.7-$4.8 billion per year. Surgical management of CTS has resulted in the aversion of 173,000-309,000 DALYs. This has yielded between $780 million and $1.6 billion in economic benefit per year. Endoscopic carpal tunnel release provided between $11,683 and $23,186 per patient at 100% success while open carpal tunnel release provided between $10,711 and $22,132 per patient at 100% success. The benefit-cost ratio at its most conservative is 2.7:1, yet could be as high as 6.9:1. CONCLUSIONS CTS is prevalent in the Medicare patient population, and is associated with a large amount of economic burden. The surgical management of CTS leads to a large reduction in this burden, yielding extraordinary economic benefit.

The disvalue of death in the global burden of disease

In the Global Burden of Disease study, disease burden is measured as disability-adjusted life years (DALYs). The paramount assumption of the DALY is that it makes sense to aggregate years lived with disability (YLDs) and years of life lost (YLLs). However, this is not smooth sailing. Whereas morbidity (YLD) is something that happens to an individual, loss of life itself (YLL) occurs when that individual's life has ended. YLLs quantify something that involves no experience and does not take place among living individuals. This casts doubt on whether the YLL is an individual burden at all. If not, then YLDs and YLLs are incommensurable. There are at least three responses to this problem, only one of which is tenable: a counterfactual account of harm. Taking this strategy necessitates a re-examination of how we count YLLs, particularly at the beginning of life.

Burden of road traffic injuries related to delays in implementing safety belt laws in low- and lower-middle-income countries

OBJECTIVE

Delayed implementation of effective road safety policies must be considered when quantifying the avoidable part of the fatal and nonfatal injuries burden. We sought to assess the avoidable part of disability-adjusted life years (DALYs) lost due to road traffic injuries related to delays in implementing road safety laws in low- and lower-middle-income countries.

METHODS

We chose one country for each of the regions of the World Health Organization (WHO) and World Bank (WB) country income levels. We used freely available data sets (WHO, International Traffic Safety Data and Analysis Group, the WB). Delays in implementation were calculated until 2013, from the year mandatory use of safety belts by motor vehicle front seat occupants was first introduced worldwide. We used life expectancy tables and age groups as social values in the DALY calculation model. From the estimated total burden, avoidable DALYs were calculated using estimates of the effectiveness of seat belt laws on fatal and nonfatal injuries combined, as extracted from published international reviews of evidence.

RESULTS

From the reference year 1972, implementation delays varied from 27 years (Uzbekistan) to 41 years in Bolivia (no seat belt law as of 2013). During delays, total absolute numbers of DALYs lost due to road traffic injuries reached 8,462,099 in Nigeria, 7,203,570 in Morocco, 4,695,500 in Uzbekistan, 3,866,391 in Cambodia, 3,253,359 in Bolivia, and 3,128,721 in Sri Lanka. Using effectiveness estimates ranging from 3 to 20% reduction, the avoidable burden of road traffic injuries for car occupants was highest in Uzbekistan (avoidable part from 1.2 to 10.4%) and in Morocco (avoidable part from 1.5 to 12.3%). In countries where users of public transport and pedestrians were the most affected by the burden, the avoidable parts ranged from 0.5 to 4.4% (Nigeria) and from 0.5 to 3.4% (Bolivia). Burden of road traffic injuries mostly affected motorcyclists in Sri Lanka and Cambodia where the avoidable parts were less than 2% in both countries. In all selected countries, burden of traffic injuries mostly affected men (about 80%) as well as young people (15-34 years).

CONCLUSIONS

Despite limited data availability in low- and middle-income countries, the avoidable part of the burden related to delayed intervention is measurable. These results can be used to convince countries to avoid delaying the provision of better protection to road users.

Estimating the burden of rabies in Ethiopia by tracing dog bite victims

In developing countries where financial resources are limited and numerous interests compete, there is a need for quantitative data on the public health burden and costs of diseases to support intervention prioritization. This study aimed at estimating the health burden and post-exposure treatment (PET) costs of canine rabies in Ethiopia by an investigation of exposed human cases. Data on registered animal bite victims during the period of one year were collected from health centers in three districts, i.e. Bishoftu, Lemuna-bilbilo and Yabelo, to account for variation in urban highland and lowland areas. This data collection was followed by an extensive case search for unregistered victims in the same districts as the registered cases. Victims were visited and questioned on their use of PET, incurred treatment costs and the behavioral manifestations of the animal that had bitten them. Based on the collected data PET costs were evaluated by financial accounting and the health burden was estimated in Disability-Adjusted Life Years (DALYs). In total 655 animal bite cases were traced of which 96.5% was caused by dog bites. 73.6% of the biting dogs were suspected to be potentially rabid dog. Annual suspected rabid dog exposures were estimated per evaluated urban, rural highland and rural lowland district at, respectively, 135, 101 and 86 bites, which led, respectively, to about 1, 4 and 3 deaths per 100,000 population. In the same district order average costs per completed PET equaled to 23, 31 and 40 USD, which was significantly higher in rural districts. Extrapolation of the district results to the national level indicated an annual estimate of approximately 3,000 human deaths resulting in about 194,000 DALYs per year and 97,000 exposed persons requiring on average 2 million USD treatment costs per year countrywide. These estimations of the burden of rabies to the Ethiopian society provide decision makers insights into the potential benefits of implementing effective interventions.

Screening adolescents for substance use: The role of NPs in school settings

NPs have a key role in screening for adolescent substance use in school settings. This article provides evidence-based information on the prevalence and consequences of adolescent substance use, discusses standardized substance use screening and brief interventions using the CRAFFT tool, and suggests relevant practice and policy implications.

Burden of injury of serious road injuries in six EU countries

BACKGROUND

Information about the burden of (non-fatal) road traffic injury is very useful to further improve road safety policy. Previous studies calculated the burden of injury in individual countries. This paper estimates and compares the burden of non-fatal serious road traffic injuries in six EU countries/regions: Austria, Belgium, England, The Netherlands, the Rhône region in France and Spain.

METHODS

It is a cross-sectional study based on hospital discharge databases.

POPULATION

of study are patients hospitalized with MAIS3+ due to road traffic injuries. The burden of injury (expressed in years lived with disability (YLD)) is calculated applying a method that is developed within the INTEGRIS study. The method assigns estimated disability information to the casualties using the EUROCOST injury classification.

RESULTS

The average burden per MAIS3+ casualty varies between 2.4 YLD and 3.2 YLD per casualty. About 90% of the total burden of injury of MAIS3+ casualties is due to lifelong consequences that are experienced by 19% to 33% of the MAIS3+ casualties. Head injuries, spinal cord injuries and injuries to the lower extremities are responsible for more than 90% of the total burden of MAIS3+ road traffic injuries. Results per transport mode differ between the countries. Differences between countries are mainly due to differences in age distribution and in the distribution over EUROCOST injury groups of the casualties.

CONCLUSION

The analyses presented in this paper can support further improvement of road safety policy. Countermeasures could for example be focused at reducing skull and brain injuries, spinal cord injuries and injuries to the lower extremities, as these injuries are responsible for more than 90% of the total burden of injury of MAIS3+ casualties.

Economic burden of neonatal sepsis in sub-Saharan Africa

Background and significance

The third Sustainable Development Goal for child health, which aims to end preventable deaths of newborns and children less than 5 years of age by 2030, cannot be met without substantial reduction of infection-specific neonatal mortality in the developing world. Neonatal infections are estimated to account for 26% of annual neonatal deaths, with mortality rates highest in sub-Saharan Africa (SSA). Reliable and comprehensive estimates of the incidence and aetiology surrounding neonatal sepsis in SSA remain incompletely available. We estimate the economic burden of neonatal sepsis in SSA.

Methods

Data available through global health agencies and in the medical literature were used to determine population demographics in SSA, as well as to determine the incidence, disease burden, mortality and resulting disabilities associated with neonatal sepsis. The disability-adjusted life years (DALY) associated with successful treatment or prevention of neonatal sepsis in SSA for 1 year were calculated. The value of a statistical life (VSL) methodology was estimated to evaluate the economic burden of untreated neonatal sepsis in SSA.

Results

We conservatively estimate that 5.29–8.73 million DALYs are lost annually in SSA due to neonatal sepsis. Corresponding VSL estimates predict an annual economic burden ranging from $10 billion to $469 billion.

Conclusions

Our results highlight and quantify the scope of the public health and economic burden posed by neonatal sepsis in SSA. We quantify the substantial potential impact of more successful treatment and prevention strategies, and we highlight the need for greater investment in strategies to characterise, diagnose, prevent and manage neonatal sepsis and its long-term sequelae in SSA.

Disease burden of methylmercury in the German birth cohort 2014

This study aimed to estimate the disease burden of methylmercury for children born in Germany in the year 2014. Humans are mainly exposed to methylmercury when they eat fish or seafood. Prenatal methylmercury exposure is associated with IQ loss. To quantify this disease burden, we used Monte Carlo simulation to estimate the incidence of mild and severe mental retardation in children born to mothers who consume fish based on empirical data. Subsequently, we calculated the disease burden with the disability-adjusted life years (DALY)-method. DALYs combine mortality and morbidity in one measure and quantify the gap between an ideal situation, where the entire population experiences the standard life expectancy without disease and disability, and the actual situation. Thus, one DALY corresponds to the loss of one year of life in good health. The methylmercury-induced burden of disease for the German birth cohort 2014 was an average of 14,186 DALY (95% CI 12,915-15,440 DALY). A large majority of the DALYs was attributed to morbidity as compared to mortality. Of the total disease burden, 98% were attributed to mild mental retardation, which only leads to morbidity. The remaining disease burden was a result of severe mental retardation with equal proportions of premature death and morbidity.

Multicriteria decision analysis and core values for enhancing vaccine-related decision-making

Vaccines have the potential to transform the health of all individuals and to reduce the health inequality between rich and poor countries. However, to achieve these goals, it is no longer sufficient to prioritize vaccine development using cost-effectiveness as the sole indicator. During a symposium entitled "Mission Grand Convergence-The Role of Vaccines," held in Siena, Italy, in July 2015, key stakeholders agreed that the prioritization of vaccine development and deployment must use multicriteria decision-making based on the following core concepts: (i) mortality and severity of the disease, (ii) vaccine safety considerations, and (iii) economic evaluation that captures the full benefits of vaccination.

Global smoking-attributable burden of periodontal disease in 186 countries in the year 2015

AIM

We aimed to quantify the smoking-attributable burden of periodontal disease (PD).

METHODS

The association between smoking and PD was evaluated. Population, smoking and PD data from the Global Burden of Disease Study were used, and the burden in different sex and age groups in 186 countries in 2015 calculated, adjusted for PD prevalence and numbers of cigarettes smoked. No adjustment was performed in a sensitivity analysis.

RESULTS

The global smoking-attributable burden was 251,160 disability-adjusted life years (DALYs; 95% uncertainty interval: 190,721-324,241; sensitivity analysis: 344,041 DALYs) or 38.5 million cases. The burden was lower in females than males, and highest in the age group of the 50- to 69-year-olds. On super-regional level, the burden was highest in South-East Asia, East Asia and Oceania (83,052 DALYs), and high-income North America and Asia Pacific (55,362 DALYs). On regional level, it was highest in East Asia (70,845 DALYs), South Asia (30,808 DALYs) and North Africa and the Middle East (24,095 DALYs). On national level, it was highest in China (69,148 DALYs), India (29,362 DALYs) and the United States (12,714 DALYs). The relative smoking-attributable burden ranged between >25% in Suriname and <1% in Chad.

CONCLUSIONS

There is great need to monitor and tackle the smoking-attributable burden of PD.

Guidance on the requirements for the development of microbiological criteria

The European Food Safety Authority asked the Panel on Biological Hazards (BIOHAZ) to deliver a scientific opinion providing: (i) a review of the approaches used by the BIOHAZ Panel to address requests from risk managers to suggest the establishment of microbiological criteria; (ii) guidance on the required scientific evidence, data and methods/tools necessary for considering the development of microbiological criteria for pathogenic microorganisms and indicator microorganisms; (iii) recommendations on methods/tools to design microbiological criteria and (iv) guidelines for the requirements and tasks of risk assessors, compared to risk managers, in relation to microbiological criteria. This document provides guidance on approaches when: (i) a quantitative microbial risk assessment (QMRA) is available, (ii) prevalence and concentration data are available, but not a QMRA model, and (iii) neither a QMRA nor prevalence and/or concentration data are available. The role of risk assessors should be focused on assessing the impact of different microbiological criteria on public health and on product compliance. It is the task of the risk managers to: (1) formulate unambiguous questions, preferably in consultation with risk assessors, (2) decide on the establishment of a microbiological criterion, or target in primary production sectors, and to formulate the specific intended purpose for using such criteria, (3) consider the uncertainties in impact assessments on public health and on product compliance and (4) decide the point in the food chain where the microbiological criteria are intended to be applied and decide on the actions which should be taken in case of non‐compliance. It is the task of the risk assessors to support risk managers to ensure that questions are formulated in a way that a precise answer can be given, if sufficient information is available, and to ensure clear and unambiguous answers, including the assessment of uncertainties, based on available scientific evidence.

World health by place: the politics of international health system metrics, 1924-c. 2010

This article examines the development of health system metrics by international organizations, exploring their relationship to the politics of world health. Current historiography treats measurement either as progressive illumination or adopts a critical stance, viewing indicators as instruments of global governance by powerful nations. We draw on diverse statistical publications to provide an empirical overview of change and continuity, beginning with the League of Nations Health Organization, which initiated health system statistics, and concluding with the World health report 2000, with its controversial comparative rankings. We then develop analysis and explanation of these trends. Population indicators appeared consistently owing to their protective function and compatibility with development thinking. Others, related to provision, financing, and coverage, appeared more sporadically, owing to changing trends and assumptions in international health. While partly affirming the critical literature, metrics were also used by peripheral or resistant actors to challenge or influence policy at the centre.

Burden of salmonellosis, campylobacteriosis and listeriosis: a time series analysis, Belgium, 2012 to 2020

Salmonellosis, campylobacteriosis and listeriosis are food-borne diseases. We estimated and forecasted the number of cases of these three diseases in Belgium from 2012 to 2020, and calculated the corresponding number of disability-adjusted life years (DALYs). The salmonellosis time series was fitted with a Bai and Perron two-breakpoint model, while a dynamic linear model was used for campylobacteriosis and a Poisson autoregressive model for listeriosis. The average monthly number of cases of salmonellosis was 264 (standard deviation (SD): 86) in 2012 and predicted to be 212 (SD: 87) in 2020; campylobacteriosis case numbers were 633 (SD: 81) and 1,081 (SD: 311); listeriosis case numbers were 5 (SD: 2) in 2012 and 6 (SD: 3) in 2014. After applying correction factors, the estimated DALYs for salmonellosis were 102 (95% uncertainty interval (UI): 8-376) in 2012 and predicted to be 82 (95% UI: 6-310) in 2020; campylobacteriosis DALYs were 1,019 (95% UI: 137-3,181) and 1,736 (95% UI: 178-5,874); listeriosis DALYs were 208 (95% UI: 192-226) in 2012 and 252 (95% UI: 200-307) in 2014. New actions are needed to reduce the risk of food-borne infection with Campylobacter spp. because campylobacteriosis incidence may almost double through 2020.

The socio-economic burden of snakebite in Sri Lanka

Background

Snakebite is a major problem affecting the rural poor in many of the poorest countries in the tropics. However, the scale of the socio-economic burden has rarely been studied. We undertook a comprehensive assessment of the burden in Sri Lanka.

Methods

Data from a representative nation-wide community based household survey were used to estimate the number of bites and deaths nationally, and household and out of pocket costs were derived from household questionnaires. Health system costs were obtained from hospital cost accounting systems and estimates of antivenom usage. DALYs lost to snakebite were estimated using standard approaches using disability weights for poisoning.

Findings

79% of victims suffered economic loss following a snakebite with a median out of pocket expenditure of $11.82 (IQR 2–28.57) and a median estimated loss of income of $28.57 and $33.21 for those in employment or self-employment, respectively. Family members also lost income to help care for patients. Estimated health system costs for Sri Lanka were $ 10,260,652 annually. The annual estimated total number of DALYS was 11,101 to 15,076 per year for envenoming following snakebite.

Interpretation

Snakebite places a considerable economic burden on the households of victims in Sri Lanka, despite a health system which is accessible and free at the point of care. The disability burden is also considerable, similar to that of meningitis or dengue, although the relatively low case fatality rate and limited physical sequelae following bites by Sri Lankan snakes means that this burden may be less than in countries on the African continent.

Snakebite predominantly affects poor people in the rural tropics. The effect that snakebite has on these populations, both economically and in terms of death and disability, is poorly understood. We used data from a national household survey of snakebite in Sri Lanka to estimate the burden of death and disability and to calculate the financial cost of a snakebite episode for the Sri Lankan health system and for Sri Lankan households. We found that the burden of snakebite was considerable, similar to that of common diseases like meningitis or dengue and that treating snakebite cost the Sri Lankan government over $10 million each year. Despite health care being free in Sri Lanka, almost 80% of households experienced additional costs and loss of income following a snakebite; such costs are disastrous for poor rural workers.

Are Quality-Adjusted Life Years a Good Proxy Measure of Individual Capabilities?

BACKGROUND

There is a debate in the health economics literature concerning the most appropriate way of applying Amartya Sen's capability approach in economic evaluation studies. Some suggest that quality-adjusted life years (QALYs) alone are adequate while others argue that this approach is too narrow and that direct measures of capability wellbeing provide a more extensive application of Sen's paradigm.

OBJECTIVE

This paper empirically explores whether QALYs provide a good proxy for individual capabilities.

METHODS

Data is taken from a multinational cross-sectional survey of individuals with seven health conditions (asthma, arthritis, cancer, depression, diabetes, hearing loss, heart disease) and a healthy population. Each individual completed the ICECAP-A measure of capability wellbeing for adults and six health utility instruments that are used to generate QALYs, including EQ-5D and SF-6D. Primary analysis examines how well health utility instruments can explain variation in the ICECAP-A using ordinary least squares regression.

RESULTS

The findings show that all seven health conditions have a negative association on overall capability as measured by the ICECAP-A index. Inclusion of health utility instruments into separate regressions improves the predictive power of capability but on average, explains less than half of the variation in capability wellbeing. Individuals with arthritis appear to be less inhibited in terms of capability losses when accounting for health utility, yet those who have depression record significant reductions in capability relative to the healthy population even after accounting for the most commonly used health utility instruments.

CONCLUSION

The study therefore casts doubt on the ability of QALYs to act as a reliable proxy measure of individuals' capability.