BURDEN 2020-Burden of disease in Germany at the national and regional level

Burden of major cancer types in Almaty, Kazakhstan

Globally, cancer is the second leading cause of death, with a growing burden also observed in Kazakhstan. This study evaluates the burden of common cancers in Almaty, Kazakhstan's major city, from 2017 to 2021, utilizing data from the Information System of the Ministry of Health. In Kazakhstan, most common cancers among men include lung, stomach, and prostate cancer, while breast, cervical, and colorectal cancers are predominant among women. Employing measures like disability-adjusted life years (DALYs), we found that selected cancer types accounted for a total DALY burden of 25,016.60 in 2021, with mortality contributing more than disability (95.2% vs. 4.7%) with the ratio of non-fatal to fatal outcomes being 1.4 times higher in women than in men. The share of non-fatal burden (YLD) proportion within DALYs increased for almost all selected cancer types, except stomach and cervical cancer over the observed period in Almaty. Despite the overall increase in cancer burden observed during the time period, a downward trend in specific cancers suggests the efficacy of implemented cancer control strategies. Comparison with global trends highlights the significance of targeted interventions. This analysis underscores the need for continuous comprehensive cancer control strategies in Almaty and Kazakhstan, including vaccination against human papillomavirus, stomach cancer screening programs, and increased cancer awareness initiatives.

[Reference evaluations for estimating prevalence, incidence, and mortality of public health relevant diseases based on routine data]

The routine data of all statutorily insured persons according to the Data Transparency Regulation (DaTraV data) represent a promising data source for the recurrent and timely surveillance of non-communicable diseases (NCDs) in Germany. Thereby, it has become apparent that there is a high demand for reference evaluations that enable quick and regularly repeatable analyses on important NCDs. Against this background, ReFern-01 was initiated, a joint project of the Robert Koch Institute (RKI) and the Federal Institute for Drugs and Medical Devices (BfArM). In collaboration with experts from the field of secondary data analysis and healthcare research, reference evaluations for estimating prevalence, incidence, and mortality for important public health-relevant diseases were developed. First, 11 central NCDs were selected by means of an online survey, and initial case definitions were created in conjunction with a literature review. These were then discussed and agreed upon in a virtual workshop. The created reference evaluations (analysis scripts) allow a standardized estimation of the mentioned epidemiological figures, which are comparable over time and regionally. In addition to providing the results, the scripts will be available at the BfArM for further analysis. Provided that remote access to the analysis of the DaTraV data is available in the future, the results of the ReFern project can strengthen the surveillance of NCDs and support public health actors, for example, in the planning and implementation of health promotion and prevention measures at the federal, state, county, and local levels.

Malaysian burden of disease: years of life lost due to premature deaths

BACKGROUND

In Malaysia, the previous mortality burden has been a significant concern, particularly due to the high prevalence of noncommunicable diseases (NCDs) as the leading cause of death. Estimates of mortality are key indicators for monitoring population health and determining priorities in health policies and health planning. The aim of this study was to estimate the disease burden attributed to 113 major diseases and injuries in Malaysia in 2018 using years of life lost (YLL) method.

METHODS

This study included all deaths that occurred in Malaysia in 2018. The YLL was derived by adding the number of deaths from 113 specific diseases and multiplying it by the remaining life expectancy for that age and sex group. Data on life expectancy and mortality were collected from the Department of Statistics Malaysia.

RESULTS

In 2018, there were 3.5 million YLL in Malaysia. Group II (NCDs) caused 72.2% of total YLL. Ischaemic heart disease was the leading cause of premature mortality among Malaysians (17.7%), followed by lower respiratory infections (9.7%), road traffic injuries (8.7%), cerebrovascular disease (stroke) (8.0%), and diabetes mellitus (3.9%).

CONCLUSIONS

NCDs are a significant health concern in Malaysia and are the primary contributor to the overall burden of disease. These results are important in guiding the national health systems on how to design and implement effective interventions for NCDs, as well as how to prioritise and allocate healthcare resources. Key strategies to consider include implementing health promotion campaigns, adopting integrated care models, and implementing policy and regulatory measures. These approaches aim to enhance health outcomes and the managements of NCDs in Malaysia.

[Utilizing Routine Health Insurance Data for Calculation of Disease Frequencies in the Project BURDEN 2020]

OBJECTIVE

The concept of disease burden enables a comprehensive analysis of the health status of a population. Key indicators are years of life lost due to mortality (YLL) and morbidity (years lived with disability, YLD), summarised in the DALY indicator (disability adjusted life years). These indicators are suitable for planning prevention, health care or provision of health services. With the project BURDEN 2020, funded by the German Federal Joint Committee's Innovation Fund, a national and regionalised calculation of burden of disease for Germany is being carried out for the first time, based on the methodology of the international "Global Burden of Disease" study.

METHODS

Calculation of YLD requires data on the frequency and severity of diseases, with routine health insurance data constituting an important data source. Case definitions for 18 selected diseases and severity levels for 11 of these diseases were developed in expert meetings. Based on these case definitions, the AOK Research Institute (WIdO) calculated disease frequencies from health utilisation data of patients insured with the AOK. A specific concept for prevalence calculation takes into account the dynamics of an open cohort of insurees. For severity levels, the results of the AOK insurees were extrapolated to the total population in Germany according to age and gender groups. For disease frequencies, the results were additionally adjusted for morbidity and estimated on regional levels.

RESULTS

Disease frequencies measured by prevalences or rates are available for 18 diseases from seven categories (cardiovascular diseases, diabetes, cancer, mental disorders, dementia, COPD and lower respiratory tract infections) at the regional levels of the 16 federal states and 96 regional planning areas. Severity distributions are provided on the national level stratified by age groups and gender. The results and documentation of methods are available at www.krankheitslage-deutschland.de (in German language).

CONCLUSION

Routine health insurance data are an important data source in the BURDEN 2020 project because regional figures and, in some cases, severity levels can be determined on the basis of a large number of cases. A comprehensive publication of results creates transparency and allows reutilisation of methods in further projects. Future research should extend burden of disease calculations to other diseases. In addition, there is an increasing demand for health data linkage.

Busch M, Haller S, Hapke U, Neuhauser H, Reitzle L, Scheidt-Nave C, Schlotmann A, Steppuhn H, Thom J, Ziese T, Rommel A. The Burden of Disease in Germany at the National and Regional Level

BACKGROUND

.Summary measures such as disability-adjusted life years (DALY) are becoming increasingly important for the standardized assessment of the burden of disease due to death and disability. The BURDEN 2020 pilot project was designed as an independent burden-of-disease study for Germany, which was based on nationwide data, but which also yielded regional estimates.

METHODS

DALY is defined as the sum of years of life lost due to death (YLL) and years lived with disability (YLD). YLL is the difference between the age at death due to disease and the remaining life expectancy at this age, while YLD quantifies the number of years individuals have spent with health impairments. Data are derived mainly from causes of death statistics, population health surveys, and claims data from health insurers.

RESULTS

In 2017, there were approximately 12 million DALY in Germany, or 14 584 DALY per 100 000 inhabitants. Conditions which caused the greatest number of DALY were coronary heart disease (2321 DALY), low back pain (1735 DALY), and lung cancer (1197 DALY). Headache and dementia accounted for a greater disease burden in women than in men, while lung cancer and alcohol use disorders accounted for a greater disease burden in men than in women. Pain disorders and alcohol use disorders were the leading causes of DALY among young adults of both sexes. The disease burden rose with age for some diseases, including cardiovascular diseases, dementia, and diabetes mellitus. For some diseases and conditions, the disease burden varied by geographical region.

CONCLUSION

The results indicate a need for age- and sex-specific prevention and for differing interventions according to geographic region. Burden of disease studies yield comprehensive population health surveillance data and are a useful aid to decision-making in health policy.

Disability-adjusted life years associated with chronic comorbidities among people living with and without HIV: Estimating health burden in British Columbia, Canada

Life span of people living with HIV (PLWH) has increased dramatically with the advent of modern antiretroviral therapy. As a result, comorbidities have emerged as a significant concern in this population. To describe the burden of chronic comorbidities among PLWH and HIV-negative individuals in British Columbia (BC), Canada, we estimated disability-adjusted life years (DALYs) related to these comorbidities. Based on a population-based cohort in BC, antiretroviral-treated adult PLWH and 1:4 age-sex-matched HIV-negative controls were followed for ≥1 year during 2001-2012. DALYs combined years of life lost to premature mortality (YLLs) and due to disability (YLDs), and were estimated following the Global Burden of Diseases' approaches. DALYs associated with non-AIDS-defining cancers, diabetes, osteoarthritis, hypertension, dementia, cardiovascular (CVD), kidney, liver and chronic obstructive pulmonary diseases were each measured for 2008-2012. Among PLWH, DALYs attributed to non-AIDS-related cancers were also estimated for 2013-2020. We observed that at baseline, our matched cohort consisted of 82% males with a median age of 40 years (25th-75th percentiles: 34-47). During 2008-2012, 7042 PLWH and 30,640 HIV-negative individuals were alive, where PLWH experienced a twofold higher DALYs associated with chronic comorbidities (770.2 years/1000 people [95% credible intervals: 710.2, 831.6] vs. 359.0 [336.0, 382.2]). Non-AIDS-defining cancers and CVD contributed the highest DALYs in both populations, driven by YLLs rather than YLDs. Among PLWH, we estimated increasing DALYs attributable to non-AIDS-defining cancers with 91.7 years/1000 people (77.4, 106.0) in 2013 vs. 97.6 (81.0, 115.2) in 2020. In this study, we showed that PLWH experience a disproportionate burden of chronic comorbidities compared to HIV-negative individuals. The observed disparities may relate to differential health behaviors, residual HIV-related inflammation, and ART-related toxicities. As aging shapes future healthcare needs, our findings highlight the need to enhance prevention and management of comorbidities as part of HIV care.

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

Objectives

Quantifying the combined impact of morbidity and mortality is a key enabler to assessing the impact of COVID-19 across countries and within countries relative to other diseases, regions, or demographics. Differences in methods, data sources, and definitions of mortality due to COVID-19 may hamper comparisons. We describe efforts to support countries in estimating the national-level burden of COVID-19 using disability-adjusted life years.

Methods

The European Burden of Disease Network developed a consensus methodology, as well as a range of capacity-building activities to support burden of COVID-19 studies. These activities have supported 11 national studies so far, with study periods between January 2020 and December 2021.

Results

National studies dealt with various data gaps and different assumptions were made to face knowledge gaps. Still, they delivered broadly comparable results that allow for interpretation of consistencies, as well as differences in the quantified direct health impact of the pandemic.

Discussion

Harmonized efforts and methodologies have allowed for comparable estimates and communication of results. Future studies should evaluate the impact of interventions, and unravel the indirect health impact of the COVID-19 crisis.

Socioeconomic disparities in endometrial cancer survival in Germany: a survival analysis using population-based cancer registry data

PURPOSE

Area-based socioeconomic deprivation has been established as an important indicator of health and a potential predictor of survival. In this study, we aimed to measure the effect of socioeconomic inequality on endometrial cancer survival.

METHODS

Population-based data on patients diagnosed with endometrial cancer between 2004 and 2014 were obtained from the German Centre for Cancer Registry Data. Socioeconomic inequality was defined by the German Index of Socioeconomic Deprivation. We investigated the association of deprivation and overall survival through Kaplan-Meier curves and Cox proportional regression models.

RESULTS

A total of 21,602 women, with a mean age of 67.8 years, were included in our analysis. The observed 5-year overall survival time for endometrial cancer patients living in the most affluent districts (first quintile) was 78.6%. The overall survival rate decreased as the level of deprivation increased (77.2%, 73.9%, 76.1%, 74.7%, for patients in the second, third, fourth, and fifth quintile (most deprived patients), respectively). Cox regression models showed stage I patients living in the most deprived districts to have a higher hazard of overall mortality when compared to the cases living in the most affluent districts [Hazard ratio: 1.20; 95% Confidence interval (0.99-1.47)] after adjusting for age, tumor characteristics, and treatment.

CONCLUSION

Our results indicate differences in endometrial cancer survival according to socioeconomic deprivation among stage I patients. Considering data limitations, future studies with access to individual-level patient information should be conducted to examine the underlying causes for the observed disparity in cancer survival.

Recommendations to plan a national burden of disease study

Background

The InfAct (Information for Action) project is a European Commission Joint Action on Health Information which has promoted the potential role of burden of disease (BoD) approaches to improve the current European Union-Health Information System (EU-HIS). It has done so by raising awareness of the concept, the methods used to calculate estimates and their potential implications and uses in policymaking. The BoD approach is a systematic and scientific effort to quantify and compare the magnitude of health loss due to different diseases, injuries, and risk factors with estimates produced by demographic characteristics and geographies for specific points in time. Not all countries have the resources to undertake such work, and may therefore start with a more restricted objective, e.g., a limited number of diseases, or the use of simple measures of population health such as disease prevalence or life expectancy. The main objective to develop these recommendations was to facilitate those countries planning to start a national burden of disease study.

Results

These recommendations could be considered as minimum requirements for those countries planning to start a BoD study and includes following elements: (1) Define the objectives of a burden of disease study within the context of your country, (2) Identify, communicate and secure the benefits of performing national burden of disease studies, (3) Secure access to the minimum required data sources, (4) Ensure the minimum required capacity and capability is available to carry out burden of disease study, (5) Establish a clear governance structure for the burden of disease study and stakeholder engagement/involvement, (6) Choose the appropriate methodological approaches and (7) Knowledge translation. These were guided by the results from our survey performed to identify the needs of European countries for BoD studies, a narrative overview from four European countries (Belgium, Germany, The Netherlands and Scotland) and the summary of a comparative study of country health profiles with national health statistics.

Conclusions

These recommendations as minimum requirements would facilitate efforts by those European countries who intend to perform national BoD studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00652-x.

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

BACKGROUND

The cause of death statistics in Germany include a relatively high share (26% in 2017) of ill-defined deaths (IDD). To make use of the cause of death statistics for Burden of Disease calculations we redistribute those IDD to valid causes of death.

METHODS

The process of proportional redistribution is described in detail. It makes use of the distribution of the valid ICD-codes in the cause of death data. We use examples of stroke, diabetes, and heart failure to illustrate how IDD are reallocated.

RESULTS

The largest increases in the number of deaths for both women and men were found for lower respiratory infections, diabetes mellitus, and stroke. The numbers of deaths for these causes more than doubled after redistribution.

CONCLUSION

This is the first comprehensive redistribution of IDD using the German cause of death statistics. Performing a redistribution is necessary for burden of disease analyses, otherwise there would be an underreporting of certain causes of death or large numbers of deaths coded to residual or unspecific codes.

The COVID-19 Disease Burden in Germany in 2020—Years of Life Lost to Death and Disease Over the Course of the Pandemic

BACKGROUND

The SARS-CoV-2 pandemic presented major challenges to the health sector in 2020. The burden of disease arising from COVID-19 can be expressed as the number of years of life lost to disease or death. For example, death at age 40 involves a loss of far more years of life than death at age 80.

METHODS

The disability-adjusted life years (DALY) lost to COVID-19 were calculated as the sum of the years of life lost through death (YLL) and the number of years lived with disability (YLD), on the basis of laboratory-confirmed notifiable cases of SARS-CoV-2 infection in Germany in 2020 (documented as of 18 January 2021). The methodology was based on that used in the Global Burden of Disease Study. Pre-existing diseases do not enter into the determination of YLL; rather, the residual life expectancy that is applied in this calculation corresponds to a mean age-specific level of morbidity.

RESULTS

305 641 years of life were lost to COVID-19 in Germany in 2020. The percentage of DALY lost by persons under 70 was 34.8% in men and 21.0% in women. 99.3% of the COVID-19 disease burden was accounted for by death (YLL). The daily average years of life lost due to death was lower for COVID-19 than for the major non-communicable diseases. Persons who died of COVID-19 lost a mean of 9.6 years of life; those who were under 70 when they died lost a mean of 25.2 years of life. Men lost more years of life than women (11.0 vs. 8.1 years).

CONCLUSION

The effects of COVID-19 on public health can be expressed through the burden of disease indicators. This method yields additional information that should be put to use early in the course of future outbreaks.

Years of Life Lost to Death—A Comprehensive Analysis of Mortality in Germany Conducted as Part of the BURDEN 2020 Project

BACKGROUND

Knowing which diseases and causes of death account for most of the years of life lost (YLL) can help to better target appropriate prevention and intervention measures. The YLL in Germany for specific causes of death were estimated as part of the BURDEN 2020 project at the Robert Koch Institute.

METHODS

Data from cause-of-death statistics were used for the analysis. ICD codes were grouped into causes of death categories at different levels of disaggregation. The YLL were estimated by combining each cause of death with the remaining life expectancy at the age of death. Deaths and YLL were compared by sex, age category, and regional distribution.

RESULTS

Approximately 11.6 million years were estimated to be lost in Germany in 2017, of which 42.8% were lost by women and 57.2% by men. The largest number of YLL were due to (malignant) neoplasms (35.2%), followed by cardiovascular diseases (27.6%), gastrointestinal diseases (5.8%), and neurological diseases (5.7%). Deaths at younger ages had a greater impact on population health if expressed in YLL: the death share of persons under age 65 was 14.7%, but the years of life lost in this age group amounted to 38.3% of all YLL. The most common causes of death in this group include accidents, self-injury and violence, malignant neoplasms, and alcohol-related diseases.

CONCLUSION

A large proportion of YLL is borne by young and middle-aged persons. These findings emphasize the need to introduce preventive strategies early in life to reduce the YLL at younger ages, as well as to prevent risk factors for diseases in older ages.

Reflections on key methodological decisions in national burden of disease assessments

BACKGROUND

Summary measures of population health are increasingly used in different public health reporting systems for setting priorities for health care and social service delivery and planning. Disability-adjusted life years (DALYs) are one of the most commonly used health gap summary measures in the field of public health and have become the key metric for quantifying burden of disease (BoD). BoD methodology is, however, complex and highly data demanding, requiring a substantial capacity to apply, which has led to major disparities across researchers and nations in their resources to perform themselves BoD studies and interpret the soundness of available estimates produced by the Global Burden of Disease Study.

METHODS

BoD researchers from the COST Action European Burden of Disease network reflect on the most important methodological choices to be made when estimating DALYs. The paper provides an overview of eleven methodological decisions and challenges drawing on the experiences of countries working with BoD methodology in their own national studies. Each of these steps are briefly described and, where appropriate, some examples are provided from different BoD studies across the world.

RESULTS

In this review article we have identified some of the key methodological choices and challenges that are important to understand when calculating BoD metrics. We have provided examples from different BoD studies that have developed their own strategies in data usage and implementation of statistical methods in the production of BoD estimates.

CONCLUSIONS

With the increase in national BoD studies developing their own strategies in data usage and implementation of statistical methods in the production of BoD estimates, there is a pressing need for equitable capacity building on the one hand, and harmonization of methods on the other hand. In response to these issues, several BoD networks have emerged in the European region that bring together expertise across different domains and professional backgrounds. An intensive exchange in the experience of the researchers in the different countries will enable the understanding of the methods and the interpretation of the results from the local authorities who can effectively integrate the BoD estimates in public health policies, intervention and prevention programs.

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

Headache disorders are widespread among women and men in Germany and are primarily associated with restrictions on quality of life. The two most common types of headache disorders are migraine and tension-type headache. In order to gain valid estimates of the prevalence of these conditions, a cross-sectional telephone-based survey was conducted among adults in Germany (N=5,009) between October 2019 and March 2020. The frequency, duration, the characteristics and comorbidities associated with headache were measured using the diagnostic criteria defined in the International Classification of Headache Disorders. 57.5% of women and 44.4% of men in Germany stated that they had had a headache in the last twelve months. 14.8% of women and 6.0% of men meet all of the diagnostic criteria for migraine. Tension-type headache affects 10.3% of women and 6.5% of men. Migraine and tension-type headache are predominantly found among people of working age and steadily decrease with age. Migraine is often accompanied by comorbidities such as depressive symptoms and anxiety disorders. People affected by headache disorders tend to receive very little professional medical care, with only a minority seeking treatment within a year. These results provide a comprehensive picture of the population-related impact of headache disorders and are used in the BURDEN 2020 study to quantify key indicators for burden of disease assessment.

[Federal health reporting at the Robert Koch Institute-status quo and current developments]

Health reporting as an integral part of public health plays an important role in the development of strategies and concepts that aim to improve the health of all population groups. This article provides an overview of the definition and tasks of federal health reporting and describes important health reporting components in their current form. The publication format of the Journal of Health Monitoring, which was developed for different user groups of health monitoring, is presented. Examples of the uses and effects of health reporting are also presented. Health reporting is designed as a flexible system: changes in databases as well as forms of communication are taken into account in the further development of health reporting.The further development of health reporting requires close interdisciplinary cooperation between different actors in order to integrate current research results from various scientific disciplines into the processes of health reporting, as well as to further expand the scope and impact of health reporting. In addition, to further develop health reporting on a scientific level, the expansion of participatory elements and a stronger internationalization will be important future tasks.

Prioritising the development of severity distributions in burden of disease studies for countries in the European region

Severity distributions are a means of summarising the range of health loss suffered to disease which enables estimates of disease occurrence to be paired with disability weights to estimate Years Lost to Disability (YLD) in burden of disease studies. There is a lack of current data exploring severity distributions, which has led to the Global Burden of Disease (GBD) study relying on using the same severity distributions across countries and regions across the world. This is also largely true for some national studies, although there are exceptions. Recent evidence has raised concerns that severity distributions are unlikely to be generalisable as major differences arise when using country-specific data to develop severity distributions. These issues raise uncertainties over interpreting YLD estimates, particularly if they are being used to develop and influence policies and to determine priorities across diseases and populations. It is clear that GBD researchers and those carrying out national studies need to work towards ensuring that estimates are based upon country-specific data, and, if possible, that the impact of assumptions are fully tested and understood. There is a lack of strategy about if, where, and how, this could be achieved, particularly around how efforts should be prioritised. This commentary advocates and presents a possible strategic approach to better understanding how efforts may be best placed.

How do world and European standard populations impact burden of disease studies? A case study of disability-adjusted life years (DALYs) in Scotland

Background

Disability-Adjusted Life Years (DALYs) are an established method for quantifying population health needs and guiding prioritisation decisions. Global Burden of Disease (GBD) estimates aim to ensure comparability between countries and over time by using age-standardised rates (ASR) to account for differences in the age structure of different populations. Different standard populations are used for this purpose but it is not widely appreciated that the choice of standard may affect not only the resulting rates but also the rankings of causes of DALYs. We aimed to evaluate the impact of the choice of standard, using the example of Scotland.

Methods

DALY estimates were derived from the 2016 Scottish Burden of Disease (SBoD) study for an abridged list of 68 causes of disease/injury, representing a three-year annual average across 2014-16. Crude DALY rates were calculated using Scottish national population estimates. DALY ASRs standardised using the GBD World Standard Population (GBD WSP) were compared to those using the 2013 European Standard Population (ESP2013). Differences in ASR and in rank order within the cause list were summarised for all-cause and for each individual cause.

Results

The ranking of causes by DALYs were similar using crude rates or ASR (ESP2013). All-cause DALY rates using ASR (GBD WSP) were around 26% lower. Overall 58 out of 68 causes had a lower ASR using GBD WSP compared with ESP2013, with the largest falls occurring for leading causes of mortality observed in older ages. Gains in ASR were much smaller in absolute scale and largely affected causes that operated early in life. These differences were associated with a substantial change to the ranking of causes when GBD WSP was used compared with ESP2013.

Conclusion

Disease rankings based on DALY ASRs are strongly influenced by the choice of standard population. While GBD WSP offers international comparability, within-country analyses based on DALY ASRs should reflect local age structures. For European countries, including Scotland, ESP2013 may better guide local priority setting by avoiding large disparities occurring between crude and age-standardised results sets, which could potentially confuse non-technical audiences.

[ICD coding of causes of death: challenges for calculating the burden of disease in Germany]

In the project BURDEN 2020 - "The burden of disease in Germany and its regions" - the years of life lost (YLL) due to premature mortality are calculated on the basis of official cause-of-death statistics. This requires the identification and redistribution of the so-called ill-defined ICD codes. "Ill-defined" means that an ICD code does not sufficiently reflect the cause of death, such that it is not informative for the calculation of the burden of disease.The first steps on the way to calculating cause-specific YLL are presented. Different frameworks of ill-defined codes are compared. The number of deaths with ill-defined codes that can be found in the German cause-of-death statistics in absolute and relative terms are analyzed, including how they are distributed by age, sex, and region.According to the WHO framework, 15.6% of the 925,200 deaths in Germany in 2015 can be identified as ill-defined. According to the framework of the Institute for Health Metrics and Evaluation (IHME) in the Global Burden of Disease Study (GBD), the proportion of ill-defined codes is 26.6%. The ICD-related distribution patterns hardly differ between WHO and IHME classifications. Considerable differences exist between the federal states, with shares of ill-defined codes between 16 and 35% (IHME framework).The cause-of-death statistics in Germany contain a considerable proportion of ill-defined codes. The differences between the federal states can only partially be explained by different electronic data processing. Due to further dissemination and improvement of electronic data collection, higher quality of cause-of-death statistics can be expected in the future.

The impact of worldwide, national and sub-national severity distributions in Burden of Disease studies: A case study of cancers in Scotland

Background

Increasingly Burden of Disease (BOD) measures are being used to influence policy decisions because they summarise the complete effects of morbidity and mortality in an equitable manner. An important element of producing non-fatal BOD estimates are severity distributions. The Global Burden of Disease (GBD) study use the same severity distributions across countries due to a lack of available country-specific data. In the Scottish BOD (SBOD) study we developed national severity distributions for cancer types. The main aim of this study was to consider the extent to which the use of worldwide severity distributions in BOD studies are influencing cross-country comparisons, by comparing weighted-average disability weights (DW) based on GBD severity distributions with nationally derived severity distributions in Scotland for cancer types.

Methods

We obtained individual records from the Scottish Cancer Registry for 21 cancer types and linked these to registered deaths. We estimated prevalent cancer cases for 2016 and assigned each case to sequelae using GBD 2016 study definitions. We compared the impact of using severity distributions based on GBD 2016, a Scotland-wide distribution, and distributions specific to deprivation strata in Scotland, on the weighted-average DW for each cancer type.

Results

The relative difference in point estimates of weighted-average DW based on GBD 2016 worldwide severity distributions compared with Scottish national severity distributions resulted in overestimates in the majority of cancers (17 out of 21 cancer types). The largest overestimates were for gallbladder and biliary tract cancer (70.8%), oesophageal cancer (31.6%) and pancreatic cancer (31.2%). Furthermore, the use of weighted-average DW based on Scottish national severity distributions rather than sub-national Scottish severity distributions stratified by deprivation quintile overestimated weighted-average DW in the least deprived areas (16 out of 18 cancer types), and underestimated in the most deprived areas (16 out of 18 cancer types).

Conclusion

Our findings illustrate a bias in point estimates of weighted-average DW created using worldwide severity distributions. This bias would have led to the misrepresentation of non-fatal estimates of the burden of individual cancers, and underestimated the scale of socioeconomic inequality in this non-fatal burden. This highlights the importance of not interpreting non-fatal estimates of burden of disease too precisely, especially for sub-national estimates and those comparing populations when relying on data inputs from other countries. It is essential to ensure that any estimates are based upon country-specific data as far as possible.