Assessing the Burden of Disease and Injury in Los Angeles County Using Disability-Adjusted Life Years

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1 Reserch Articles Assessing the Burden of Disese nd Injury in Los Angeles County Using Disbility-Adjusted Life Yers Gerld F. Kominski, PhD,b Pul A. Simon, MD, MPH c,d Alex Ho, MD, MPH c Jeffrey Luck, PhD, MBA,b Yee-Wei Lim, MD,b Jonthn E. Fielding, MD, MPH, MBA,e SYNOPSIS Objective. This study ws designed to ssess the burden of nd injury in the Los Angeles County popultion using Disbility-Adjusted Life Yers (DALYs), composite mesure of premture mortlity nd disbility tht equtes to yers of helthy life lost. Methods. DALYs, strtified by gender nd rce/ethnicity, were clculted for 105 helth conditions nd ggregted groups of conditions for the Los Angeles County popultion for Yers of Life Lost (YLLs) were clculted using 1997 county mortlity sttistics nd published life tbles. Yers Lived with Disbility (YLDs) were derived from ge- nd gender-specific incidence nd disbility dt from the Globl Burden of Disese Study. Results. DALYs produced substntilly different rnking of nd injury burden thn did mortlity rtes lone. The leding five cuses of DALYs for mles in the county were ischemic hert, violence, lcohol dependence, drug overdose nd other intoxictions, nd depression. For femles, the leding five cuses were ischemic hert, lcohol dependence, dibetes, depression, nd osteorthritis. Differences in the rnk order were lso observed by rce/ethnicity. The ge-djusted rte of DALYs for ll helth conditions combined ws highest in Africn Americns (190 per 1,000), followed by Americn Indins (149 per 1,000), whites (113 per 1,000), Ltinos (94 per 1,000), nd Asins/Pcific Islnders (77 per 1,000). Conclusions. The DALYs mesure is promising new tool to improve the cpcity of locl helth deprtments nd other helth gencies to ssess popultion helth nd estblish n evidence bse for public helth decisions. Deprtment of Helth Services, University of Cliforni, Los Angeles (UCLA), School of Public Helth, Los Angeles, CA b UCLA Center for Helth Policy Reserch, Los Angeles, CA c Office of Helth Assessment nd Epidemiology, Los Angeles County Deprtment of Helth Services, Los Angeles, CA d Deprtment of Epidemiology, UCLA School of Public Helth, Los Angeles, CA e Los Angeles County Deprtment of Helth Services, Los Angeles, CA Address correspondence to: Gerld F. Kominski, PhD, UCLA Center for Helth Policy Reserch, Weyburn Ave., Suite 300, Los Angeles, CA 90024; tel ; fx ; e-mil 2002 Assocition of Schools of Public Helth 185

2 186 Reserch Articles Historiclly, efforts to ssess nd injury burden hve been hmpered by the lck of single mesure of burden tht ccounts for both morbidity nd mortlity. To ddress this limittion t the interntionl level, the Disbility-Adjusted Life Yers (DALYs) mesure ws developed decde go to ssess globl ptterns of nd injury burden nd to project future trends. 1,2 DALYs combine the impcts of premture mortlity nd disbility ssocited with vrious helth conditions. One DALY equtes to one yer of helthy life lost. DALYs hve been used to mesure burden in both developed nd developing countries 3 5 nd to ssess the lloction of Ntionl Institutes of Helth (NIH) funding in the United Sttes. 6 In this report, we describe the use of DALYs to ssess the burden of nd injury in lrge urbn popultion, compre the results to those of more trditionl mesures of burden (crude mortlity nd premture mortlity), nd discuss the potentil benefits nd limittions of using the DALYs methodology t the locl helth deprtment level to ssess nd prioritize popultion helth needs. METHODS DALYs mesure popultion-level burden bsed on mortlity nd disbility rtes. They represent the sum of () the number of Yers of Life Lost (YLLs) to premture mortlity, summed cross given popultion, nd (b) the number of Yers Lived with Disbility (YLDs), djusted for level of disbility nd summed cross the given popultion. Becuse one purpose of our study ws to demonstrte tht DALYs cn be used domesticlly for ssessing burden, we clculted DALYs for the Los Angeles County popultion in 1997 using the sme methods s in the Globl Burden of Disese (GBD) Study. 2 Clcultion of YLLs The YLL component ws clculted using morlity rtes derived from publicly vilble deth records. All 1997 deths records for individuls residing in Los Angeles County (N = 60,072) were eligible for inclusion in the nlysis. Two hundred eighty-six (0.5%) were excluded becuse of insufficient informtion on the deth certificte. The remining 59,786 reports were grouped by underlying cuse of deth into 105 nd injury ctegories s defined in the GBD Study. 2 The underlying cuse of deth is denoted using Interntionl Clssifiction of Diseses, Ninth Revision (ICD-9) codes. Stndrd life tbles for mles nd femles from the GBD study (indicting remining life expectncy t ech yer of ge) were then used to clculte YLLs. 2 These tbles re bsed on different dt sources for men nd women. For women, the stndrd life tbles use the mximum life expectncy observed interntionlly, i.e., 82.5 yers for Jpnese women. For men, the stndrd life tbles re bsed on n idel life expectncy (80.0 yers) developed using models of the true biologicl mle/femle difference in life expectncy, controlling for other risk fctors. 7 YLLs were clculted for ech nd injury ctegory s the difference between life expectncy nd ge t deth in months, summed cross the totl county popultion, nd by gender nd rce/ethnicity (i.e., Africn Americn, Americn Indin/Alsk Ntive, Asin/Pcific Islnder, Ltino, nd white). We strtified our nlyses ccording to rce/ethnicity to exmine potentil disprities in burden. Dt on rce/ ethnicity were obtined directly from the deth records, which re subject to misclssifiction. 8 Clcultion of YLDs Clcultion of YLDs requires estimtes of nd injury incidence, the frequency of ssocited disbilities, nd the verge durtion nd severity of the disbilities. 7 For the GBD Study, nd disbility incidence nd durtion for rnge of conditions were estimted bsed on n exhustive review of the published nd unpublished literture nd input from experts in epidemiology. 2 The severity of disbilities ws quntified in the GBD study using disbility weights, rnging from 0 (perfect helth) to 1 (deth), developed by n interntionl pnel of helth cre providers. 2 For exmple, treted ngin pectoris hs disbility weight of for ll ges, wheres untreted unipolr mjor depression hs weight of for ll ges. Becuse of the reltive lck of incidence nd disbility dt for the Los Angeles County popultion, we imputed nd disbility rtes nd ssigned disbility weights using the sme methodology s in the GBD study, but with updted rtes. To estimte YLDs in the county popultion, 2 we used updted ge- nd gender-specific YLD-to-YLL rtios nd YLD rtes for ech nd injury ctegory for Estblished Mrket Economy (EME) countries obtined from the Hrvrd University School of Public Helth Burden of Disese Unit (Personl communiction, Ctherine Michud, MD, PhD, Jnury 1999). YLDs for ech ge/gender strtum in the county popultion were estimted in one of two wys: (1) if the EME YLD-to-YLL rtio ws stble (defined s 10 in the GBD study), this rtio ws multiplied by the county s YLLs to determine the county s YLDs; or (2) if

3 Assessing Burden of Disese nd Injury in LA County Using DALYs 187 the EME YLD-to-YLL rtio ws unstble becuse of low mortlity (defined s 10 in the GBD study), the EME YLD rte ws used to determine the county s YLDs by pplying this rte to the county popultion estimted by the Census Bureu for These YLD clcultions were done for ech ge ( 1, 1, 2 4, 5 9, 10 14, , 85) nd gender strtum nd then summed cross strt to obtin totls for ech nd injury ctegory. We could not clculte seprte YLDs by rce/ ethnicity becuse we did not hve comprehensive dt on nd disbility rtes by rce/ethnicity. Clcultion of DALYs Prior to summing the YLLs nd YLDs within ech nd injury ctegory, we pplied the sme geweighting nd discounting fctors used in the GBD study to ech ge nd gender strtum. 2 Age-weighting quntifies the perception tht yer of helthy life hs greter socil vlue during erly dulthood thn during erlier or lter life. Therefore, younger nd older ge ctegories re weighted somewht less thn 1.0, while ge ctegories during erly working dulthood re weighted greter thn 1.0. The discounting fctors ccount for the perception tht current yer is worth more thn future yer of helthy life nd tht future yers need to be expressed in present vlue terms. YLLs nd YLDs tht extended beyond the current yer into the future, therefore, were discounted, i.e., divided by 1.03 n, where n is the number of yers in the future, to produce present vlue for YLLs nd YLDs. This sme clcultion is used to clculte the present vlue of costs nd benefits in cost-effectiveness studies. 9 We exmined the sensitivity of our finl results, s presented below, to removl of both ge-weighting nd discounting, nd found no substntil differences in the findings. After pplying the ge-weighting nd discounting fctors to ech ge nd gender strtum, we summed the YLLs nd YLDs within the 105 nd injury ctegories to produce DALYs. Rte clcultions Rtes per 1,000 popultion were clculted for YLLs, YLDs, nd DALYs by gender nd rce/ethnicity using Tble 1. Leding cuses of crude mortlity, YLLs, nd DALYs, Los Angeles County, 1997 Crude mortlity YLLs DALYs Number of Number of Number of Rnk Cuse deths Rnk Cuse deths Rnk Cuse deths 1 14, , , ,168 2 Homicide 35, ,872 3 Lung cncer 3,772 3 Lung cncer 27,414 3 Homicide/other violence 45,548 4 Pneumoni 3, , ,449 5 COPD 2,671 5 Motor vehicle crshes 19, , ,747 6 Suicide 15,339 6 Osteorthritis 39,811 7 Colon cncer 1,483 7 HIV/AIDS 14, ,351 8 Homicide 1,247 8 Cirrhosis 14,123 8 Lung cncer 29,875 9 Brest cncer 1,242 9 Brest cncer 13,288 9 COPD 29, Hypertension 1, , Motor vehicle crshes 29, Cirrhosis 1, COPD 13, Drug overdose/other intoxictions 28, Alzheimer s / 12 Pneumoni 12, Alzheimer s / other dementis 1,000 other dementis 27, Inflmmtory hert 13 Inflmmtory hert 13 HIV/AIDS 20, , Motor vehicle crshes Drug overdose/other 14 Cirrhosis 18,263 intoxictions 10, Prostte cncer Colon cncer 10, Endocrine nd metbolic s 17,541 Includes myocrditis nd pericrditis COPD = chronic obstructive pulmonry YLLs = Yers of Life Lost

4 188 Reserch Articles Tble 2. Comprison of leding cuses of DALYs by gender, Los Angeles County, 1997 Mle Femle Cuse Percent Cuse Percent Homicide/other violence Drug overdose/other intoxiction Osteorthritis 4.4 Osteorthritis Motor vehicle crshes 3.7 Alzheimer s /other dementis Brest cncer HIV/AIDS 3.3 COPD 3.3 Lung cncer 3.2 Lung cncer Percentge of the totl number of DALYs in ech popultion group COPD = chronic obstructive pulmonry 1997 county popultion projections bsed on the 1990 Census. 10 Rtes were ge-djusted to the 1990 U.S. popultion. RESULTS Tble 1 shows the 15 leding cuses of nd injury burden in the county popultion bsed on mesures of crude mortlity (number of deths), premture mortlity (YLLs), nd DALYs. Although ischemic hert led the list for ll three mesures, there ws considerble vrition in the rnk order of the other conditions. For exmple, lcohol dependence ws 2nd on the DALYs list but only 29th bsed on YLLs nd 39th bsed on crude mortlity. Similrly, depression nd osteorthritis were mong the leding cuses of DALYs but ccounted for very little burden bsed on crude mortlity nd YLLs. Conversely, pneumoni ws 4th on the crude mortlity list but dropped to 12th bsed on YLLs nd 21st bsed on DALYs. The 10 leding cuses of DALYs by gender re shown in Tble 2. led the list in both mles nd femles. However, homicide/other violence, drug overdose/other intoxiction, motor vehicle crshes, nd HIV/AIDS ccounted for higher percentges of DALYs in mles thn femles., stroke, Alzheimer s/other dementis, nd brest cncer ccounted for higher percentges in femles thn mles., depression, nd osteorthritis were mong the leding cuses of DALYs in both groups. Substntil vrition in the DALYs rnkings ws observed by rce/ethnicity (Tble 3). For exmple, ischemic hert ws the leding cuse of DALYs in whites, homicide/other violence the leding cuse in Africn Americns, nd lcohol dependence the leding cuse in both Ltinos nd Asins/Pcific Islnders. HIV/AIDS nd sthm were mong the leding 10 cuses of DALYs in Africn Americns but were not mong the leding cuses in the other rcil/ ethnic groups. For ll conditions combined, the ge-djusted DALYs rte ws higher in mles (119 per 1,000) thn femles (94 per 1,000) (Tble 4). This difference ws ttributble to 50% higher rte of YLLs in mles (67 per 1,000) thn in femles (44 per 1,000). The DALYs rte lso vried by rce/ethnicity nd ws highest in Africn Americns (190 per 1,000), followed by Americn Indins/Alsk Ntives (149 per 1,000), whites (113 per 1,000), Ltinos (94 per 1,000), nd Asins/Pcific Islnders (77 per 1,000). DISCUSSION This study is the first tht we re wre of to use DALYs to ssess the burden of nd injury in the United Sttes t locl or regionl popultion level. The findings suggest tht DALYs produce substntilly different rnking of nd injury burden from tht produced by mortlity rtes lone. For exmple, lcohol nd other drug dependence, depression, nd rthritis impose substntil burden in the Los Angeles County popultion not reflected in county mortlity sttistics. In ddition, the findings highlight the

5 Assessing Burden of Disese nd Injury in LA County Using DALYs 189 Tble 3. Comprison of leding cuses of DALYs by rce/ethnicity, Los Angeles County, 1997 Asin/Pcific Islnder Blck Ltino White Cuse Percent b Cuse Percent b Cuse Percent b Cuse Percent b Osteorthritis Alzheimer s / other dementis COPD Motor vehicle crshes Unintended firerm injury Homicide/other violence Lung cncer HIV/AIDS Asthm COPD Homicide/other violence Osteorthritis Motor vehicle crshes Drug overdose/other intoxiction Cirrhosis COPD Lung cncer Alzheimer / other dementis Osteorthritis Drug overdose/other intoxiction Americn Indins/Alsk Ntives were not included in this nlysis becuse of insufficient numbers. b Percentge of the totl number of DALYs in ech popultion group COPD = chronic obstructive pulmonry importnce of violence s leding cuse of both YLLs nd DALYs mong mles in the county, nd lso highlight the importnce of hert nd dibetes in ll popultion groups. The results further document the considerble disprities in burden cross popultion groups in the county s reflected, for exmple, in the finding tht the DALYs rte for the Tble 4. Age-djusted rtes per 1,000 popultion of YLLs, YLDs, nd DALYs, by gender nd rce/ethnicity, Los Angeles County, 1997 Vrible YLLs YLDs DALYs Gender Mle Femle Rce/ethnicity Africn Americn Americn Indin or Alsk Ntive Asin/Pcific Islnder Ltino White YLDs = Yers Lived with Disbility YLLs = Yers of Life Lost Africn Americn popultion ws more thn twice s high s the rte for either the Ltino or Asin/Pcific Islnder popultion. Although the DALYs mesure represents potentil dvnce in popultion helth ssessment becuse it ddresses the impcts of nd injury on both the quntity nd qulity of life, it is importnt to note tht the mesure hs been the subject of some debte. 11,12 For exmple, the use of ge-weighting nd discounting hs been criticized by some reserchers. 13 To ddress this concern, we conducted our nlyses with nd without the ge-weighting nd discounting djustments nd found only miniml differences in the results. Others hve questioned the vlidity nd universlity of the disbility weights becuse of the vlue judgments inherent in the process, e.g., the fct tht the determintion of weights in the GBD Study ws done exclusively by helth cre providers. 14,15 A more recent study exmined vrition in disbility rnkings cross 14 countries nd severl different informnt groups, including individuls with disbilities. 16 This study found significnt vrition in disbility rnkings by country nd informnt group, lthough the rnkings for ll groups combined ws nerly identicl to tht found in the GBD Study. Our nlysis ws further limited becuse the county YLD estimtes were bsed on gender- nd ge-specific YLD/YLL rtios nd YLD rtes for brod geogrphic

6 190 Reserch Articles re (including the United Sttes, Cnd, Jpn, Western Europe, nd Austrli) rther thn dt for the county popultion. If the ctul rtios nd rtes in the county popultion were significntly different from those used in our nlysis, the YLDs nd DALYs reported here my be overstted or understted for specific helth conditions. For exmple, we believe tht YLL rtes my vry substntilly cross ethnic groups within the U.S. nd Los Angeles county, but our results do not reflect these possible differences. Efforts re underwy t the Centers for Disese Control nd Prevention (CDC) to compile U.S. incidence nd disbility dt for DALYs clcultions (Personl communiction, Mtthew McKenn, MD, MPH, Division of HIV/ AIDS Prevention, Ntionl Center for HIV, STD nd TB Prevention, CDC, November 2000). Future efforts by stte nd locl helth deprtments to use DALYs to ssess burden should incorporte these CDC dt s well s stte nd locl dt where vilble. Becuse the nlysis ws bsed on mutully exclusive ctegories of nd injury, we could not ssess the impct of interctions mong sttes. In ddition, becuse DALYs focus on helth outcomes coded using the ICD-9, they do not mesure ttributble risk. 17 For exmple, n estimted one-third of ll deths in the United Sttes in 1990 were ttributble to smoking, poor nutrition, or physicl inctivity. 18 Although DALYs re not exposure-specific, these types of ttributble helth risks re importnt to consider in identifying nd prioritizing opportunities for prevention. For exmple, chronic obstructive pulmonry nd lung cncer were only the 9th nd 10th leding cuses of DALYs mong women, but if combined they would pproch the leding cuse, ischemic hert, highlighting the importnce of developing interventions to reduce smoking mong women in the county. Despite these methodologic nd dt limittions, we believe tht DALYs provide importnt informtion on which to bse decisions on public helth priorities, s long s informtion on burden is combined with rnge of other dt in the priority-setting process. For exmple, informtion on the preventble frction nd cost-effectiveness of vilble interventions is importnt to consider. These findings hve plyed key role in the county helth deprtment s efforts to inform nd, in some cses, persude policy mkers nd community constituencies of the disproportionte helth impcts of violence nd chronic non-infectious s in the county popultion. The results hve been helpful in bridging the divide between those in public helth nd those who provide mentl helth nd drug nd lcohol tretment nd prevention services. In disseminting the findings in locl forums, we hve found tht yers of helthy life lost is the most understndble conceptuliztion of the DALYs mesure nd n extremely compelling construct mong both professionl nd ly udiences. These dt hve lso been used to support successful requests for externl funding, including physicl ctivity promotion cmpign funded by the CDC nd community-bsed nutrition intervention supported by the Cliforni Deprtment of Helth Services. In ddition, the dt hve been used to lobby successfully for portion of the Mster Tobcco Settlement funds to be reserved for chronic prevention progrms. In summry, the DALYs mesure represents promising new tool for improving the cpcity of locl helth deprtments nd other helth gencies to ssess nd prioritize popultion helth needs. To increse the vlidity of the mesure t the locl nd regionl levels, efforts will be needed to refine the YLD clcultions by incorporting locl estimtes of incidence nd pplying disbility weights tht re specific to the U.S. popultion nd importnt subpopultions. The uthors thnk Lrry Portigl, MS, nd Mrc Strssburg, DrPH, of the Los Angeles County Deprtment of Helth Services for their ssistnce in conducting the nlyses reported here. They lso thnk Ctherine Michud, MD, PhD, of the Hrvrd University School of Public Helth for ssisting them in using the Globl Burden of Disese methodology nd her review of preliminry nlyses. REFERENCES 1. World Bnk. World Development report 1993: investing in helth. New York: Oxford University Press; Murry CJL, Lopez AD, editors. The globl burden of : comprehensive ssessment of mortlity nd disbility from s, injuries, nd risk fctors in 1990 nd projected to Cmbridge (MA): Hrvrd University Press; Lozno R, Murry CJ, Frenk J, Bobdill JL. Burden of ssessment nd helth system reform: results of study in Mexico. J Int Dev 1995;7: Gwtkin DR, Guillot M, Heuveline P. The burden of mong the globl poor. Lncet 1999;354: Melse JM, Essink-Bot ML, Krmers PGN, Hoeymns N. A ntionl burden of clcultion: Dutch disbilitydjusted life-yers. Am J Public Helth 2000;90: Gross CP, Anderson GF, Powe NR. The reltion between funding by the Ntionl Institutes of Helth nd the burden of. N Engl J Med 1999;340: Murry CJL, Achry AK. Understnding DALYs. J Helth Econ 1997;16: Rosenberg HM, Murer JD, Sorlie PD, Johnson NJ, McDormn MF, Hoyert DL, et l. Qulity of deth

7 Assessing Burden of Disese nd Injury in LA County Using DALYs 191 rtes by rce nd Hispnic origin: summry of current reserch. Vitl Helth Stt ;128: Gold MR, Siegel JE, Russell LB, Weinstein MC, editors. Cost-effectiveness in helth nd medicine. New York: Oxford University Press; Census Bureu (US) to 1999 nnul time series of county popultion estimtes by ge, sex, rce, nd Hispnic origin [cited 2002 My 31]. Avilble from: URL: csrh.php 11. Murry CJL, Lopez AD. The utility of DALYs for public helth policy nd reserch: reply. Bull World Helth Orgn 1997;75: Syers BM, Fliedner TM. The critique of DALYs: counter-reply. Bull World Helth Orgn 1997;75: Annd S, Hnson K. Disbility-djusted life yers: criticl review. J Helth Econ 1997;16: Arnesen T, Nord E. The vlue of DALY life: problems with ethics nd vlidity of disbility djusted life yers. BMJ 1999;319: Jmes KC, Foster SD. Weighting-up disbility. Lncet 1999;354: Ustun TB, Rehm J, Chtterji S, Sxen S, Trotter R, Room R, Bickenbch J. Multiple-informnt rnking of disbling effects of different helth conditions in 14 countries. WHO/NIH Joint Project CAR Study Group. Lncet 1999;354: Evns RG, Stoddrt GL. Producing helth, consuming helth cre. Soc Sci Med 1990;31: McGinnis JM, Foege WH. Actul cuses of deths in the United Sttes. JAMA 1993;270:

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