Assessing the Burden of Disease and Injury in Metropolitan Los Angeles

Metropolitan Service Planning Area Health Office (SPA 4) SPA 4 VIEWPOINT

ASSESSING THE BURDEN OF DISEASE AND INJURY IN METROPOLITAN LOS ANGELES

SPA 4 BEST PRACTICE COLLECTION RELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES

M. RICARDO CALDERÓN, SERIES EDITOR

Summer 2001

Los Angeles County Department of Health Services • Public Health

At a Glance METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)

241 North Figueroa Street, Room 312 Los Angeles, California 90012 (213) 240-8049

The Best Practice Collection is a publication of the Metropolitan Service Planning Area (SPA 4). The opinions expressed herein are those of the editor and writer(s) and do not necessarily reflect the official position or views of the Los Angeles County Department of Health Services. Excerpts from this document may be freely reproduced, quoted or translated, in part or in full, acknowledging SPA 4 as the source.

Internet: http://www.lapublichealth.org/SPA 4

The SPA 4 Best Practice Collection fulfills the Los Angeles County Department of Health Services (DHS) local level goal to restructure and improve health services by “establishing and effectively disseminating to all concerned stakeholders comprehensive data and information on the health status, health risks, and health care utilization of Angelinos and definable subpopulations”.1 It is a program activity of the SPA 4 Information Dissemination Initiative created with the following goals in mind: To highlight lessons learned regarding the design, implementation, management and evaluation of public health programs To serve as a brief theoretical and practical reference for program planners and managers, community leaders, government officials, community based organizations, health care providers, policy makers and funding agencies regarding health promotion and disease prevention and control To share information and lessons learned in SPA 4 for community health planning purposes including adaptation or replication in other SPA’s, counties or states

LOS ANGELES COUNTY BOARD OF SUPERVISORS

Gloria Molina, First District Yvonne Brathwaite Burke, Second District Zev Yaroslavsky, Third District Don Knabe, Fourth District Michael D. Antonovich, Fifth District DEPARTMENT OF HEALTH SERVICES Fred Lead, Acting Director Jonathan E. Fielding, MD, MPH.

Director of Public Health and County Health Officer

James Haughton, MD, MPH. Medical Director, Public Health

BEST PRACTICE COLLECTION TEAM M. Ricardo Calderón, Series Editor Manuscript Author & SPA 4 Area Health Officer

Carina Lopez, MPH.

Project Manager, Information Dissemination Initiative

Elika Derek

Manuscript Author & SPA 4 Intern

To advocate a holistic and multidimensional approach to effectively address gaps and disparities in order to improve the health and well-being of populations The SPA 4 Information Dissemination Initiative is an adaptation of the Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collection concept. Topics will normally include the following: 1. SPA 4 Viewpoint: An advocacy document aimed primarily at policy and decision-makers that outlines challenges and problems and proposes options and solutions.

2. SPA 4 Profile: A technical overview of a topic that provides information and data needed by public, private and personal health care providers for program development, implementation and/or evaluation.

3. SPA 4 Case Study: A detailed real-life example of policies, strategies or projects that provide important lessons learned in restructuring health care delivery systems and/or improving the health and well being of populations.

4. SPA 4 Key Materials: A range of materials designed for educational or training purposes with up-to-date authoritative thinking and know-how on a topic or an example of a best practice.

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ASSESSING THE BURDEN OF DISEASE AND INJURY IN METROPOLITAN LOS ANGELES

Table of Contents I.

II.

III.

INTRODUCTION

4

BACKGROUND INFORMATION

4

IV.

THE BURDEN OF DISEASE TECHNOLOGY

1.

2.

V.

THE BURDEN OF DISEASE IN METROPOLITAN LOS ANGELES

6 8

Cost-Effectiveness Policy Development

ADAVANTAGES AND LIMITATIONS Incommensurability of longevity and quality of life Subjectivity on disability weights Invalidity of epidemiological estimates Exclusion of co-morbidity

Exclusion of Economic costs of illnesses Incapability of reflecting recent disease trends

12

1.

2.

3.

4.

5.

6.

VI.

CONCERNS AND CHALLANGES

1.

2.

3.

4.

5.

VII.

DISCUSSION

1.

2.

3.

VIII.

CONCLUSIONS

16

IX.

REFERENCES

17

Political Technical Financial Managerial Operational

13 14 14 14 15 15 14 15 15

15

SPA 4 and Los Angeles County SPA 4 and other SPAs 5 Future Research Needs

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INTRODUCTION

I. INTRODUCTION In the next few decades, considerable changes and challenges will be experienced in global health. Conditions that contributed significantly to disability and death are being overshadowed by other circumstances. Specifically, non-communicable diseases, such as tobacco-related illness and depression, are contributing more to morbidity and mortality than the communicable diseases.

This trend is predicted to continue and non-communicable diseases are expected to account for 60% of deaths in developing countries and 70% to 80% in the developed world.

“The burden of any condition can be divided into two components: the years of life lost due to premature mortality and the years of life lived with disability”.

The Global Burden of Disease (GBD), Volume I, 1996.

A new study was undertaken in 1992 under the direction of Christopher J. L. Murray and Alan Lopez to better appreciate demographic disease patterns. The Global Burden of Disease and Injury Project (GBD) was a collaborative effort between the World Health Organization (WHO), the World Bank, and the Harvard School of Public Health. The purpose of the project was to (1) include non-fatal disease and injuries in the analysis of international health policy; (2) decouple epidemiological assessment from advocacy to develop more objective disability and mortality estimates, and (3) quantify the burden

of disease allowing for cost-effective analysis.1 A goal of the GBD methodology was to clarify the ethical decisions inherent in its methodology. In this way, the authors encouraged informed debate and further development of the established GBD methodology. In 1996, the first set of results was published under the title "The Global Burden of Disease”.

Volume I of this series described the practical application of GDB and the rationale for the methodology chosen. This volume also contained region specific estimates of the burden of disease using the metrics of Disability Adjusted Life Years (DALYs); that is, Years of Life Lost (YLLs) and Years Lived with Disability (YLDs) stratified by age group and sex in eight different regions of the world.

A critical challenge in global health is the allocation of scarce medical research and medical care resources.

More specifically, the challenge is how to improve life expectancy and

“There are two classes of Disability Adjusted Life Years (DALYs): Years of Life Lost (YLLs) due to premature mortality, and Years Lived with Disability (YLDs) adjusted for the severity of disability.”

GBD, Volume I, 1996. the quality of life. Such an effort requires the effective allocation of resources to reduce major causes of disease burden and health disparities among poor and affluent populations. Estimates of life expectancy at birth are useful to assess trends and the distribution of life expectancy

in a population. However, when this method is applied to a culturally diverse population like Los Angeles County, significant inequalities in life expectancy among different population and ethnic groups are masked.

The reason why the Global Burden of Disease Study became a major landmark was the development of a new system to assess nonfatal health outcomes and, thus, the capacity to measure the burden of major disease and injuries regardless of their lethality.

This paper investigates how the traditional measures to assess nonfatal health outcomes compare to the Burden of Disease as a new method for disability assessment.

This publication utilizes the Burden of Disease and Injury as a new technique to evaluate the health of the SPA 4 population. Generally, crude morbidity and mortality data do not capture fully the impact of non-fatal health outcomes and injuries. These statistics have several drawbacks that diminish their practical usefulness for decision and policy-making. Therefore, a discussion regarding the use of the Burden of Disease and Injury SPA 4 compared to crude morbidity and mortality is warranted including utilization implications and future research needs.

II. BACKGROUND INFORMATION The mission of public health is to protect, maintain and improve the health of the population with adequate resources. The allocation of resources is critical in meeting the health needs of a population. In Los Angeles County, several attributes make it a point of interest to public health and health policy makers, such as population diversity, lack of access to health care,

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BACKGROUND INFORMATION

health disparities between affluent and poor communities and increasing trends in certain health conditions. In January 2000, the Los Angeles County Department of Health Services and The UCLA Center for Health Policy Research published The Burden of Disease of Los Angeles County.

The study measured the burden of disease in Los Angeles instead of the traditional morbidity and mortality analysis. In this report, the same methodology is used to assess the disease burden for the Metropolitan Los Angeles Service Planning Area (SPA 4).

These issues are addressed by GBD according to three fundamental goals: 1. Incorporate non-fatal health outcomes into assessments of health status, 2. Separate epidemiology from advocacy to reach objective, independent and demographically plausible assessments of disease burdens for various diseases and conditions, and 3. Measure the burden of disease and injury in a currency that can be employed to evaluate the cost-effectiveness of interventions in terms of cost per unit of disease burden averted.

The DALY measures the gap between the actual health of a population and some ideal, hypothetical norm. It incorporates a discount rate for time preference and an age-weighting factor. It takes into account the higher social value given to young adults in most societies. Theses factors have important implications for policymaking since DALYs weigh the burden of diseases of children less than those of adults.

In 1996, 34.5 million DALYs were lost in the United States. The U.S. major causes of DALY differs significantly from the rest of the world in that 9 out of 10 causes include injuries and non-communicable diseases, whereas communicable diseases are the major cause of DALYs in the world.2 In Los Angeles County, chronic illnesses, drug and substance dependence, and violence and unintentional injuries represent a substantial burden of disease and DALYs lost. Also, HIV/AIDS contributes more to premature death and disability in SPA 4 than it does to the Los Angeles County population as a whole.3 Its impact includes disability and economic loss due to disability, loss of productivity and income for individuals and families, functional

The GBD technology is different from traditional health statistics. Generally, health statistics have characteristics A common currency is required to that limit their practical value for capture the impact of premature policymaking. Statistics are usually death and disability. Researchers have fragmented. Basic mortality data agreed that the appropriate curfor many causes of death is unavailrency is “time (in years) lost through able. This data does not capture the premature death and time (in years) impact of non-fatal health outcomes lived with a disability”. Therefore, GBD of disease and injury on the health established the Disability Adjusted of a population. Some epidemioloLive Year (DALY) as the standardized gists tend to inflate the numbers of measure to express the years of life individuals killed or affected by a parlost to premature death and years ticular disease. These well-intentioned lived with disability --one DALY is one epidemiologists become advocates year of healthy life lost. for the affected population. This is particularly true when there is a need to compete for scarce resources. If these estimates were correct, some individuals with a certain demographic composition would have Figure 1. Disability Adjusted Life Years (DALY’s) to die more than once to substantiate the death numbers claimed. In Disability Adjusted Life Years addition, traditional health statistics DALYs cannot afford policy-makers the opportunity to quantify the cost-effectiveness of various interventions. The appropriate allocation of resources Years of Life Lost Years Lived With Disability is vital since the expectations of the

(YLL) (YLD) population regarding healthcare are

(Resulting from premature death) (Resulting from non-fatal growing, as well as the regulated use

health outcome) of available funding.

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BACKGROUND INFORMATION

impairment and restricted mobility, social stigma and isolation, and psychological stress and family discord.

Some of these implications are more prominent than others depending on the society, country or region. DALYs allow researchers to make national, regional and global assessments of the burden of disease, quantify the impact of major risk factors on health and make projections about future disease burdens. Therefore, the consequences of burden of disease in a population can be reduced given the proper allocation and utilization of resources.

On the other hand, “healthcare decisions” usually follow two directions. Decisions are made based on “evidence” or “opinion”. In addition, decisions about patients or populations are made by combining three factors; namely, “resources, values and evidence”.

Presently, many healthcare decisions are based on values and resources that are components of “opinionbased decision making”. Not enough attention has been paid to evidence obtained as a result of research and scientific investigation. However, this is likely to change since there is an increasing demand and pressure on appropriate utilization of resources.

Furthermore, healthcare decisions must be made explicitly and publicly.

Individuals or institutions making a decision have to describe the evidence that leads them to that specific decision.4 Steps involved in making a decision based on evidence includes conducting surveys, reviewing published literature, evaluating the evidence, and applying the evidence to the care of the patient or population.

DECISION FACTORS

One of the benefits of using the burden of disease technology is that policymakers can plan interventions based on the “impact of non-fatal health conditions”. The impact of such conditions is assessed using evidence currently available in the form of data and statistics. Public health is challenged to allocate resources prioritizing diseases that require attention.

The shift to a system that incorporates evidence-based decision-making, instead of opinion, is inevitable as the pressure escalates for public health sector accountability.

III. THE BURDEN OF DISEASE IN METROPOLITAN LOS ANGELES A GBD report for Metropolitan Los Angeles (SPA 4) can be developed based on the findings presented in the Burden of Disease Report for Los Angeles County. A comparison of the 1997 leading cause of DALY in Los Angeles County and SPA 4 provides a better understanding of the specific needs of SPA 4 populations.

prevail in both populations. However, the fourth cause of premature death in SPA 4 is “HIV/AIDS” while in Los Angeles County it is “Depression”.

In fact, HIV/AIDS does not appear among the ten leading causes of premature death in Los Angeles County as a whole and Depression ranks number seven in SPA 4. This indicates that HIV/AIDS exerts a more adverse impact in SPA 4 residents requiring more focused attention in terms of prevention and healthcare resources.

Planning health interventions for SPA 4 populations must prioritize efforts to reduce the spread of HIV/ AIDS. “Drug overdose/other intoxication” is another unique entity causing premature death and disability in SPA 4. Again, it is not listed as one of the DALY for Los Angeles County as a whole. This is consistent with the trend that the prevalence of drug use is higher in metropolitan settings making efforts to prevent and reduce drug use in Metropolitan Los Angeles a priority. The third condition affecting SPA 4 residents not found in the first ten DALYs of Los Angeles County is “Alzheimer’s/other dementia”. Consequently, the GBD technology highlights disease prevention and control efforts that should be common to all Service Planning Areas in Los Angeles County while, at the same time, points out premature deaths that would go unnoticed otherwise in SPA 4 health planning efforts. In addition, using DALYs in

A comparison of DALYs in Los Angeles County and SPA 4 reveals that the top three causes of premature death

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FIGURE 2

Figure 2. Typical disease course diagram in the determination of DALY.

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BACKGROUND INFORMATION

SPA 4 also allows health providers and policymakers to compare the costeffectiveness of various preventive and curative health interventions designed for the population.

The evaluation of the leading causes of death by sex and race provides insight into how these factors contribute to health disparities among SPA 4 populations. Sex and race explain huge variations in adult mortality. They account for complex causation factors within social, community and economic environments, such as income, education, employment, social capital, income inequality, proximal behavioral

One of the major benefits of using the burden of disease methodology is that policymakers will be able to plan interventions based on the impact of non-fatal health conditions. and environmental factors. Table 2 lists the 20 leading causes of disease burden by sex in SPA 4. “Acute Lower Respiratory Illness (ALRI)” is the leading cause of disease burden in men and women. This finding is supported by reports indicating tobacco-related conditions as the leading cause of premature death and disability in the United States. This also correlates with Los Angeles County and SPA 4 data listing “coronary heart disease” as the leading cause of DALY. Further examination of the data reveals HIV cases to be significantly higher in males than females. Public health practitioners must address the behavioral factors contributing to this health disparity. These factors may include homosexual and bisexual relationships and type of safe sex

Using the DALYs for SPA 4 allows health providers and policymakers to compare the cost-effectiveness of various preventive and curative health interventions designed for the population. practices. Hence, it is crucial to consider behavioral differences prior to developing interventions, especially to address health conditions according gender.

IV. THE BURDEN OF DISEASE TECHNOLOGY Health assessment based on this new approach can be used as follows: (a) to highlight variations in disease patterns among different geographic places to conduct a cross sectional assessment. This assessment could be done in Los Angeles County where each SPA has disease patterns that may vary in magnitude and severity. (b) GBD could also provide predictions of future changes in disease burden taking into account demographic changes and disease trends.

This application would be especially important in Los Angeles County since the ethic composition of the population is continuously changing.

For example, an influx of immigrants into Metropolitan Los Angeles could significantly alter disease trends requiring redirection of services or resources. (c) The burden of disease technology could also be used as a tool to assess the outcome of interventions aimed at changing disease patterns and assist in the evaluation of such interventions.

If the future burden of disease and injury in SPA can be projected, county and state policymakers could determine whether interventions implemented today would help decrease the burden of disease in the future.

This would be a crucial endeavor, particularly when evaluating the cost effectiveness of interventions. This would assist policymakers and public health institutions to answer questions such as: “Did we allocate the proper resources?”, “Did we avoid loss of years of healthy life?”, “Were we able to decrease the disease burden for the population?”, etc. Therefore, cost-effectiveness becomes an important consideration through the application of the burden of disease technology.

1. Cost-Effectiveness What the burden of disease estimates at any moment reflects the amount of health care that is already being provided to the population, in addition to other actions that protect or damage health. Where treatment is possible, whether preventive, curative or palliative, the effectiveness of the intervention is defined as a “reduction” in the disease burden that the treatment produces.7 Although existing treatments have contributed to reduce disease burdens, this does not mean that all remaining disease burden can be eliminated. An intervention that reduces the disease burden can make the condition or disease less probable, less severe, of shorter duration, or less likely to result in death. Also, its effectiveness can be measured in the same units (DALYs) allowing for comparison across interventions that treat different problems and produce different outcomes. This comparison illustrates how interventions differ significantly in how much they can improve

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LEADING CAUSES OF DEATH & DISABILITY IN THE US AND LOS ANGELES COUNTY Table 1. The ten (10) leading causes of death and disability in the US, Los Angeles County and SPA 4 based on disability-adjusted life years (DALY) in 1997. 5

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SEX-SPECIFIC DISEASE BURDEN IN SPA 4 Table 2. Sex-specific disease burden for 20 leading causes of death for SPA 4 in 1998. 6

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SEX-SPECIFIC CAUSES OF DEATH IN SPA 4

Graph 1. Leading cause of death in males in SPA 4

Graph 2. Leading cause of dealth in females in SPA 4

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THE BURDEN OF DISEASE TECHNOLOGY

health. For example, curing a case of tuberculosis saves the patient and disrupts transmission to others also.

Consequently, the total health gain measured in years can exceed an individual's life expectancy. On the other hand, various types of health care provide the equivalent of less than one full day of additional healthy life.8 The healthcare sector and its policymaking aims to ensure the best health status possible for the population according to limited resources. This is equivalent to saying that it is possible to measure the gains in health that are attributable to different actions, and in some way to “add them up”. Taking into account the total health of a population, this “adding-up” must include individuals, health problems and treatments or interventions. Without these comparisons, health fails to be a global concept making the burden of disease limited to separate diseases of particular individuals. In essence, the concept of effectiveness follows automatically from the concept of “best-attainable health” after factors such as financial constraints and resource limitations are introduced”. Hence, it is appropriate to consider cost-effectiveness as a criterion for maximizing health gains.

Cost-effectiveness can also be used to compare different treatments for the same condition, decide if one intervention is better than another, and determine if it the same outcome is achieved at lower cost, or a better outcome at the same cost.9 However, since the outcome can be disease-specific, it is not necessary to compare different health problems. In addition, there is no need to compare individuals as long as it is assumed that for every outcome, every individual receives some type of intervention.

2. Policy Development The burden of disease approach aids is useful in health decision-making, program development and policy review. A more comprehensive view of the current and future health needs positions is conducive to better policymaking, good health and more effective programs and services. These programs and interventions would actually target relevant diseases and decrease their burden in the population. DALYs can be used as reliable and promising measures of health assessment. The DALY could become the official feature of disease surveillance within the next few years.10 It could replace morbidity and mortality measures as the principal indicator for reporting health needs and selecting new priorities at local, state and national level. The DALY is more indicative of future disease patterns and, thus, can support public health efforts to decrease the disease burden by developing interventions today. The use of the burden of disease identifies elements that will improve current methodology, particularly, the exploration of risk factors, the sorting out of inter-related diseases, and future work on the descriptive epidemiology of disease categories.

V. ADVANTAGES AND LIMITATIONS As with any new approach to providing appropriate healthcare, “pros and cons” must be evaluated before implementation begins. The burden of disease offers advantages over the exclusive use of mortality data. It gives weight to the future of fitness in physical, social or occupational terms. Programs can be more effective when they consider future health issues. Projections of the future disease burden and risk factors are

“Disease burden (numbers of death by cause) can be partitioned in three separate ways for different age, sex and regional groupings (Murray et al 1994). One partition is by risk factor –genetic, behavioral, environmental and physiological. The second is by disease. The third is by consequence –premature mortality at different ages and different types of disability (e.g. sensory, cognitive functioning, pain, affective state, etc.)’.

GBD, Volume I, 1996.

useful to inform policymaking. The DALYs can be projected on the basis of continuing secular trends to allow a prediction of the burden of disease at any future time. This characteristic of the DALY is of crucial importance making it a powerful approach. It is also imperative for program planning and policy development. Policymakers have to be assured that what they are putting into action today will indeed be beneficial in decreasing the disease burden in the future for a specific population.

The advantage of the DALY is that it can help health planners to identify the most pressing health concerns in their areas. When it is combined with financial information, it can give an indication of whether appropriate

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ADVANTAGES AND LIMITATIONS amounts of money are being spent on the “right” conditions affecting a population. Therefore, one of the central themes of using the burden of disease method is whether it is cost-effective. Resources must be allocated giving more attention to the most prominent health issues. Public health advocates need to know when overspending is justified and which resources are most relevant. Funding research studies may also serve to be beneficial. They provide results that allow further refinement of current methodologies and evaluation of future objectives. Research is needed to understand the complex interrelated web of socioeconomic factors like education, employment, income, social capita, and distal and proximal behavioral and environmental factors such as diet, physical activity, tobacco use and health care, along with physiological factors such as blood pressure, cholesterol levels and the genetic component of disability and mortality.11

“Disaggregation of disease burden by risk factor helps guide policy concerning primary and secondary prevention, including development of new preventive measures. Disaggregation by disease helps guide policy concerning cure, secondary prevention and palliation; and disaggregation by consequence helps guide policies for rehabilitation”

GBD, Volume I, 1996.

Nevertheless, there are several drawbacks with the use of this technology.

Limitations can be divided into the following six categories: 1. Incommensurability of Longevity and Quality of Life A criterion is needed to compare longevity with the quality of life of an individual. Even if an individual’s life expectancy is high, the years lived healthy or with disability is the critical issue. Disability decreases quality of life despite longevity. The burden of disease must allow for comparisons to determine how each year lived contributes to the overall well being and quality of an individual’s life.

2. Subjectivity of Disability Weights Another problem that arises is the actual use of concept of “burden”.

Should it be limited to disability?

Should it be broadened to handicap?

Or should it look beyond individuals and careers? Whose values should be used to assign burden weights to non-fatal illnesses? A decision needs to be made on what the ideal health status should be. In order to make this decision, value choices must be made including how long people “should” live and whether years of healthy life are worth more in young adulthood than in early or late life. If a year of life now is worth more than a year 20 years from now, it should be determined if all individuals are equal, and how we should compare years of life lost with life lived with disabilities of differing severities.

Establishing a population’s consensus on what the value choices should be is imperative in determining disability weights.

3. Invalidity of Epidemiological Estimates Epidemiological estimates tend to overestimate the actual disease burden taking place in a population. Erroneous estimations could result in the improper classification of a disease or condition leading to an incorrect allocation of resources.

It could also prevent appropriate interventions to be implemented and worsen the disease burden. Hence the lack of validity of some epidemiological estimates could initiate a causal chain of events that could potentially halt progress towards achieving good health. Additionally, limitations exist on the DALY measure and its YLD component.12 They have a tendency to be under or overstate certain health conditions.

4. Exclusion of Co-Morbidity Consideration must be given regarding how two conditions can have a synergistic effect to increase the burden of disease. Generally, disability, in terms of YLL or YLD, is attributed to a specific condition although each condition possesses a different disability weight. However, how can disability weights be assigned in a comorbidity scenario? The problem is that almost all disability and disease burden analyses exclude the co-morbidity status. For example, some diseases are themselves a risk factor for other conditions. This would make the total disease burden the result of interrelated factors that make the process of averting a disease burden extremely difficult.

5. Exclusion of the Economic Costs of Illnesses Treating disability in the United States is a multi-million dollar expenditure every year. There are

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CONCERNS AND CHALLENGES

two major economic costs associated with illness: (a) the cost of medical care used to diagnose and treat the illness, and (b) the loss of income associated with decreased productivity and labor supply.13 Some people cannot cover the cost of major illness, although they can accommodate the costs of small health concerns. The burden of disease fails to account for the costs tied to an illness. It is crucial to address the economic costs associated with illness.

This could serve as a better indication of what measures are needed to reduce the disease burden along with its associated fiscal implications.

6. Incapability to Reflect Recent Disease Trends DALY estimates do not account for recent trends in terms of incidence or disease patterns. There is also a possibility for gender and race bias, particularly accurate measures of disease incidence and prevalence for men, women and ethnic populations. Other biases that could occur are related to socioeconomic status, age and level of education. These are questions that must be answered and their responses considered prior to the burden of disease assessing in a population.

Lastly, using the burden of disease approach tends to focus on individual outcomes and health interventions.

Consideration must be given to the “processes” that generate ill health and influence access to health care. It also needs to address the behaviors that profoundly influence and affect health.

For example, tobacco use is presently one of the leading causes of death and disability worldwide. By the year 2020, tobacco will be the number one cause of morbidity and mortality in the world surpassing the disease burden caused

by HIV/AIDS.14 This highlights an important point. The trend is that more

deaths are being caused by noncommunicable diseases than communicable ones. This trend emphasizes the importance of addressing behavioral factors that underlie certain health conditions. Therefore, it is important to incorporate behavioral element into health assessments and make projections of the impact of non-fatal health outcomes.

VI. CONCERNS AND CHALLENGES Acceptance of the use of the burden of disease technology depends upon the confidence in its success. Various sectors and/or stakeholders in SPA 4 may find difficulties with different aspects of this methodology as follows: 1. Political: As previously described, the burden of disease methodology can serve as a useful tool to inform and influence policymaking. However, the extent to which findings of burden of disease studies influence health policies depends on the practices of funding and allocation of resources. Areas of concern are the amount of money, time and resources invested and the reliability of study outcomes. The use of this novel technology will become more commonplace as it proves to be more reliable, produces better results, and assesses more effectively health outcomes.

2. Technical: There is a need to explore the methodology and test its reliability and validity. It is important to avoid refinement to a point that denies access to those who are involved in epidemiology and medical statistics health service organizations. Some terms and concepts --such as the DALY and YLD- are exclusively used for the burden of disease technology. Additionally, methodological issues must be strengthened making GBD more

sensitive to gender and health issues.

Such efforts would increase its value as a tool for health assessment and analysis.

3. Financial: There is a significant imbalance between investments in health research and the burden of disease. In the past, health research has focused on morbidity and mortality data and risk factors are associated with each cause of death. Now with the Burden of Disease and Injury, the focus has shifted to “future projections” of a population’s health status. Future cost considerations arise with GBD utilization. This can result in a reorientation and direction of available funds to new areas of health research.

4. Managerial: Acceptance of the burden of disease approach will grow if (a) it becomes useful to policymakers, (b) local public health practitioners learn to use it in local settings, (c) its results become a necessary prelude to cost-effectiveness studies, and (d) if it is incorporated into health sector resource allocation methods.15 This will

“While improving the people’s health may not be the sole, or even dominant, basis on which priorities are established, information on the magnitude of different health problems (diseases, injuries or risk factors) and understanding of the costeffectiveness of different options for intervention can have a powerful influence on health sector priorities”.

GBD, Volume I, 1996.

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DISCUSSION

be a considerable challenge to overcome in order to play a prominent role within the health community and be managed effectively and efficiently.

5. Operational: The implementation of the burden of disease technology must take into account socioeconomic data, standardization of definitions, ethnic variations, and the evaluation of disability. If these factors are indeed considered, operational challenges will be minimized, if not eliminated.

“The DALYs have the following six major uses to underpin health policy.

The first five relate to measurement of burden of disease; the final one values the relative priority of interventions in terms of cost-effectiveness: -Assessing performance -Generating a forum for informed debated of values and priorities -identifying national control priorities -allocating training time for clinical and public health practitioners -allocating research and development resources -allocating resources across health interventions”

GBD, Volume I, 1996.

VII. DISCUSSION SPA 4 is able to research the burden of disease and incorporate non-fatal health outcomes into assessments of health status for the first time. Comparisons with other SPAs is also possible using their burden of disease data to determine which conditions cause greater disease burdens to Los Angeles County populations. The utilization of DALYs into SPA assessments provides a better appreciation of health status.

More importantly, the disease burden in SPA 4 can be used as a “currency” or tool to evaluate current strategies and programs, as well as the cost-effectiveness of future programs and interventions still at a development phase. The cost would be in terms of cost per unit of disease averted.

1. SPA 4 and Los Angeles County The purpose to utilize Global Burden of Disease and Injury Technology in SPA 4 is to inform health decision-making, program development and policymaking in a way that addresses more effectively the needs of the population. According to DALYs, SPA 4 has a slightly higher rate than the rest of the county. The higher rates may be attributable to factors such as socioeconomic status, race, ethnicity, access to health care and other demographic factors amongst other reasons. Alcohol dependence is the second cause of DALY after coronary health disease in SPA 4. Alcohol dependence is also a burden of mental illness and its impact has been grossly underestimated by traditional approaches that account for death and not disability. The data also indicates that communicable diseases such as HIV/AIDS are a significant cause of DALY in Metropolitan Los Angeles. HIV/AIDS is the 13th cause of DALY in Los Angeles County but 4th in SPA 4.16 Therefore, the traditional use of morbidity and mortality is impor-

tant but non-traditional approaches such as the burden of disease technology is also vital to properly plan for the health needs of SPA 4 residents and be relevant to demographic patters of disease and disability.

2. SPA 4 and other SPAs “The Burden of Disease Report for Los Angeles County” lists the top ten leading causes of DALY for all eight Service Planning Areas in Los Angeles. Most SPAs have coronary heart disease as the leading cause of DALY except SPA 1 and SPA 6 where alcohol dependence and homicide/violence top the DALY list, respectively. Homicide/violence is ranked third in SPA 4. The higher DALYs in these two SPAs could well be attributed to their unique demographic structure. SPA 4 is also the only SPA that had HIV/AIDS on its DALY top ten list. This unique characteristic has important programmatic and financial implications. It also requires research on healthcare seeking behavior, behavior change communication, and individual or group risk behaviors.

However, evaluating individual health outcomes and health interventions will not suffice. In order to address HIV/ AIDS in SPA 4, health decision-makers and policymakers will need a better understanding of social, economic, cultural and educational factors that influence risky behaviors.

3. Future Research Needs Information on the leading causes of DALY by race/ethnicity for SPA 4 is not yet available for analysis. It could be a valuable tool to assess the burden of disease for each sub-population group.

Metropolitan Los Angeles has a diverse racial and ethnic makeup and insights regarding how DALYs are different between racial/ethnic groups could explain existing health disparities. Race/ ethnicity could also be a risk factor for a given disease burden. For example,

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CONCLUSIONS

more attention could be given to particular disease burdens among Hispanics since they comprise a larger percentage of the SPA 4 population.

Future studies might also want to disentangle connected to health actions that “treat” versus health actions that “promote” health. Research should also be sensitive to differences in health consequences in different settings.

The Global Burden of Disease and Injury method could also be a valuable tool for women health advocates. As described earlier, there are differences in disease burden for men and women in SPA 4. Resource mobilization could increase the allocation of resources for women’s health. Research is, therefore, the commodity needed to improve the overall healthcare delivery system including health promotion and disease prevention and control. Additional research would enable SPA 4 to assess the cost-effectiveness of current programs, policies and services and, more importantly, to evaluate the (a) attainment of good health, (b) responsiveness of the system to the legitimate expectations of SPA 4 population, and (c) fairness in financial contribution among different stakeholders and populations.

VIII. CONCLUSIONS The purpose of this report was to provide an analysis of the application of the Global Burden of Disease and Injury technology in Metropolitan Los Angeles (SPA 4). Accordingly, • Information included in this publication could serve as the basis for health priority setting and decision-making in SPA 4. The integration of burden of disease concepts into existing and future program development could shape and redirect strategic thinking and funding including organization and deployment of resources.

• A comparison of traditional approaches to assess risk factors and health outcomes (morbidity and mortality) with the Burden of Disease and Injury approach demonstrates that the new technology provides a better appreciation of the health status and wellbeing of the SPA 4 population, particularly the years of life lost due to premature death and disability.

• The Burden of Disease and Injury technology is useful to (a) evaluate the outcomes programs and interventions specific to SPA 4 demographic patterns of disease, (b) predict future changes in the burden of disease in the SPA, and (c) highlight variations in disease patterns compared to Los Angeles County and the United States.

• The burden of disease and injury in SPA 4 is caused by both communicable and non-communicable diseases.

“HIV/AIDS, Drug Overdose/Other Intoxications and Alzheimer’s/Other Dementia” represent health issues among the first ten causes of DALY in SPA 4 that are not found in the Los Angeles County nor the U.S. top ten DALY list. This information is vital for strategic health planning purposes to ensure that programs, policies and services are relevant to the needs of the population.

• The conventional understanding is that the three main killers in the United States are heart disease, cancer and stroke. Accordingly, interventions targeting four modifiable behaviors ---tobacco use, lack of physical activity, poor nutrition and alcohol consumption--- could have an enormous impact on the health status and wellbeing of American populations. While this continues to be true, the Global Burden of Disease and Injury provides additional information to properly guide “specific” health decision and policymaking for “specific” target populations and geographical locations.

• The Global Burden of Disease and Injury provides a new methodology for health planers, policymakers, program developers and the medical and public health community as a whole, to better assess and plan to protect, maintain and improve the health status and wellbeing of invidual, families and communities.

• Alcohol Dependence is a significant contributor to SPA 4’s disease burden and Los Angeles County as a whole. This also highlights the critical importance of mental illness as a cause of death and disability and the need to develop strategic alliances and partnerships with mental health providers.

” In most decision making arenas, priorities are determined by many factors such as budgetary inertia (where programs this year are those funded last year), vocal political constituencies, the effects of past investment decisions in hospitals or other infrastructure, funding agency agendas, perceived public health crises and maximizing health gain for the population given the available resources”.

GBD, Volume I, 1996.

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REFERENCES

IX. REFERENCES 1. Murray CJL, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 Projected to 2020. Cambridge, Mass: Harvard School of Public Health; 1996.

2. Michaud CM, Murray CLJ, Bloom BR. Burden of Disease-Implications of Future Research. JAMA, Vol. 285 No. 5; 2001.

3. The Burden of Disease in Los Angeles County: A Study of the Patterns of Morbidity and Mortality in the County Population. Los Angeles County Department of Health Services and The UCLA Center for Health Policy Research; 2000.

4. Evidence Based Decision Making; An Evidence Based reference site for healthcare decision makers: www. evidencebased.net 5. The Burden of Disease in Los Angeles County: A Study of the Patterns of Morbidity and Mortality in the County Population. Los Angeles County Department of Health Services and The UCLA Center for Health Policy Research; 2000.

6. Los Angeles County Department of Health Services. SPA4 Health Statistics, 1998.

8. Musgrove P. Cost-Effectiveness and Health Sector Reform. Seminar on Health Sector Reform in Latin America, Buenos Aires, Argentina, March 14-16 1994.

9. Musgrove P. Cost-Effectiveness and Health Sector Reform. Seminar on Health Sector Reform in Latin America, Buenos Aires, Argentina, March 14-16 1994.

16. The Burden of Disease in Los Angeles County: A Study of the Patterns of Morbidity and Mortality in the County Population. Los Angeles County Department of Health Services and The UCLA Center for Health Policy Research; 2000.

10. International Burden of Disease Network: Atlanta Report. www.ibdn.net.

11. Michaud CM, Murray CLJ, Bloom BR. Burden of Disease-Implications of Future Research. JAMA, Vol. 285 No. 5; 2001.

12. The Burden of Disease in Los Angeles County: A Study of the Patterns of Morbidity and Mortality in the County Population. Los Angeles County Department of Health Services and The UCLA Center for Health Policy Research; 2000.

13. Gertler P, Gruber J. Insuring Consumption Against Illness. NBER Working Paper No.W6035, 1997.

14. Murray CJL, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 Projected to 2020. Cambridge, Mass: Harvard School of Public Health; 1996.

15. International Burden of Disease Network: Atlanta Report. www.ibdn.net.

7. Haddix A, Teutsch S, Shaffer P, Dunet D. A Practical Guide to Prevention Effectiveness: Decision and Economic Analyses. New York: Oxford University Press, 1996.

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Metropolitan Service Planning Area (SPA 4) 241 North Figueroa Street, Room 312 Los Angeles, California 90012 Tel: (213) 240-8049 Fax: (213) 202-6096 www.lapublichealth.org Š 2001 SPA 4

Assessing the Burden of Disease & Injury in Metropolitan Los Angeles

Summer 2001