Public health utility of cause of death data : applying empirical algorithms to improve data quality

Background: Accurate, comprehensive, cause-specific mortality estimates are crucial for informing public health decision making worldwide. Incorrectly or vaguely assigned deaths, defined as garbage-coded deaths, mask the true cause distribution. The Global Burden of Disease (GBD) study has developed methods to create comparable, timely, cause-specific mortality estimates; an impactful data processing method is the reallocation of garbage-coded deaths to a plausible underlying cause of death. We identify the pattern of garbage-coded deaths in the world and present the methods used to determine their redistribution to generate more plausible cause of death assignments. Methods: We describe the methods developed for the GBD 2019 study and subsequent iterations to redistribute garbage-coded deaths in vital registration data to plausible underlying causes. These methods include analysis of multiple cause data, negative correlation, impairment, and proportional redistribution. We classify garbage codes into classes according to the level of specificity of the reported cause of death (CoD) and capture trends in the global pattern of proportion of garbage-coded deaths, disaggregated by these classes, and the relationship between this proportion and the Socio-Demographic Index. We examine the relative importance of the top four garbage codes by age and sex and demonstrate the impact of redistribution on the annual GBD CoD rankings. Results: The proportion of least-specific (class 1 and 2) garbage-coded deaths ranged from 3.7% of all vital registration deaths to 67.3% in 2015, and the age-standardized proportion had an overall negative association with the Socio Demographic Index. When broken down by age and sex, the category for unspecified lower respiratory infections was responsible for nearly 30% of garbage-coded deaths in those under 1 year of age for both sexes, representing the largest proportion of garbage codes for that age group. We show how the cause distribution by number of deaths changes before and after redistribution for four countries: Brazil, the United States, Japan, and France, highlighting the necessity of accounting for garbage-coded deaths in the GBD

Table_2_Change of serum uric acid and progression of cardiometabolic multimorbidity among middle aged and older adults: A prospective cohort study.DOCX

BackgroundHyperuricemia is prevalent and associated with individual cardiometabolic diseases, highlighting the potential role of serum uric acid (SUA) in the development and progression of cardiometabolic multimorbidity (CMM, the coexistence of diabetes, heart disease, or stroke). This study aimed to examine the role of SUA change in the progression of CMM.MethodsThis prospective cohort study used data from the China Health and Retirement Longitudinal Study, included 4,820 participants aged 45 years or above with three complete surveys at 2011 (baseline), 2015, and 2018. SUA level at survey 2011 and 2015 was used to measure SUA change as keeping or rising to hyperuricemia, and keeping or declining to non-hyperuricemia. CMM progression was defined as the first report of CMM or additional report of cardiometabolic diseases during survey 2015 and 2018. We used logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) of SUA change on CMM progression.ResultsDuring the follow-up of around 7 years, 519 (10.8%) of the participants kept or rose to hyperuricemia from survey 2011 to 2015, and 311 (6.5%) experienced CMM progression from survey 2015 to 2018. Participants who kept or rose to hyperuricemia had 1.86 (95% CI, 1.29, 2.68) increased odds of CMM progression compared with those who kept or declined to non-hyperuricemia. Specifically, keeping or rising to hyperuricemia (vs. keeping or declining to non-hyperuricemia) was associated with 2.01 times higher odds (95% CI, 1.18, 3.43) of incident diabetes and 1.67 times higher odds (OR:1.67; 95% CI, 1.15, 2.43) of incident cardiovascular diseases following diabetes.ConclusionKeeping or rising to hyperuricemia was associated with CMM progression, particularly with incident cardiovascular diseases following diabetes. These findings suggest that monitoring SUA change may provide innovative insights into the prevention of CMM, especially in the secondary prevention of CMM (i.e., preventing further progression to cardiovascular diseases among patients with diabetes).</p

Table_3_Change of serum uric acid and progression of cardiometabolic multimorbidity among middle aged and older adults: A prospective cohort study.DOCX

BackgroundHyperuricemia is prevalent and associated with individual cardiometabolic diseases, highlighting the potential role of serum uric acid (SUA) in the development and progression of cardiometabolic multimorbidity (CMM, the coexistence of diabetes, heart disease, or stroke). This study aimed to examine the role of SUA change in the progression of CMM.MethodsThis prospective cohort study used data from the China Health and Retirement Longitudinal Study, included 4,820 participants aged 45 years or above with three complete surveys at 2011 (baseline), 2015, and 2018. SUA level at survey 2011 and 2015 was used to measure SUA change as keeping or rising to hyperuricemia, and keeping or declining to non-hyperuricemia. CMM progression was defined as the first report of CMM or additional report of cardiometabolic diseases during survey 2015 and 2018. We used logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) of SUA change on CMM progression.ResultsDuring the follow-up of around 7 years, 519 (10.8%) of the participants kept or rose to hyperuricemia from survey 2011 to 2015, and 311 (6.5%) experienced CMM progression from survey 2015 to 2018. Participants who kept or rose to hyperuricemia had 1.86 (95% CI, 1.29, 2.68) increased odds of CMM progression compared with those who kept or declined to non-hyperuricemia. Specifically, keeping or rising to hyperuricemia (vs. keeping or declining to non-hyperuricemia) was associated with 2.01 times higher odds (95% CI, 1.18, 3.43) of incident diabetes and 1.67 times higher odds (OR:1.67; 95% CI, 1.15, 2.43) of incident cardiovascular diseases following diabetes.ConclusionKeeping or rising to hyperuricemia was associated with CMM progression, particularly with incident cardiovascular diseases following diabetes. These findings suggest that monitoring SUA change may provide innovative insights into the prevention of CMM, especially in the secondary prevention of CMM (i.e., preventing further progression to cardiovascular diseases among patients with diabetes).</p

Table_1_Change of serum uric acid and progression of cardiometabolic multimorbidity among middle aged and older adults: A prospective cohort study.DOCX

BackgroundHyperuricemia is prevalent and associated with individual cardiometabolic diseases, highlighting the potential role of serum uric acid (SUA) in the development and progression of cardiometabolic multimorbidity (CMM, the coexistence of diabetes, heart disease, or stroke). This study aimed to examine the role of SUA change in the progression of CMM.MethodsThis prospective cohort study used data from the China Health and Retirement Longitudinal Study, included 4,820 participants aged 45 years or above with three complete surveys at 2011 (baseline), 2015, and 2018. SUA level at survey 2011 and 2015 was used to measure SUA change as keeping or rising to hyperuricemia, and keeping or declining to non-hyperuricemia. CMM progression was defined as the first report of CMM or additional report of cardiometabolic diseases during survey 2015 and 2018. We used logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) of SUA change on CMM progression.ResultsDuring the follow-up of around 7 years, 519 (10.8%) of the participants kept or rose to hyperuricemia from survey 2011 to 2015, and 311 (6.5%) experienced CMM progression from survey 2015 to 2018. Participants who kept or rose to hyperuricemia had 1.86 (95% CI, 1.29, 2.68) increased odds of CMM progression compared with those who kept or declined to non-hyperuricemia. Specifically, keeping or rising to hyperuricemia (vs. keeping or declining to non-hyperuricemia) was associated with 2.01 times higher odds (95% CI, 1.18, 3.43) of incident diabetes and 1.67 times higher odds (OR:1.67; 95% CI, 1.15, 2.43) of incident cardiovascular diseases following diabetes.ConclusionKeeping or rising to hyperuricemia was associated with CMM progression, particularly with incident cardiovascular diseases following diabetes. These findings suggest that monitoring SUA change may provide innovative insights into the prevention of CMM, especially in the secondary prevention of CMM (i.e., preventing further progression to cardiovascular diseases among patients with diabetes).</p

DataSheet1_Sleep Problems Associate With Multimorbidity: A Systematic Review and Meta-analysis.docx

Objectives: To summarize the evidence on the association between sleep problems and multimorbidity.Methods: Six electronic databases (PubMed, Web of Science, Embase, China National Knowledge Infrastructure, VIP, and Wan fang) were searched to identify observational studies on the association between sleep problems and multimorbidity. A random-effects model was used to estimate the pooled odds ratios (ORs) and 95% confidence intervals for multimorbidity.Results: A total of 17 observational studies of 133,575 participants were included. Sleep problems included abnormal sleep duration, insomnia, snoring, poor sleep quality, obstructive sleep apnea (OSA) and restless legs syndrome (RLS). The pooled ORs (95% CIs) for multimorbidity were 1.49 (1.24–1.80) of short sleep duration, 1.21 (1.11–1.44) of long sleep duration and 2.53 (1.85–3.46) for insomnia. The association of other sleep problems with multimorbidity was narratively summarized due to limited number of comparable studies.Conclusion: Abnormal sleep duration and insomnia are associated with higher odds of multimorbidity, while the evidence on association of snoring, poor sleep quality, obstructive sleep apnea and restless legs syndrome with multimorbidity remains inconclusive. Interventions targeting sleep problems should be delivered for better management of multimorbidity.</p

Global, regional, and national burden of respiratory tract cancers and associated risk factors from 1990 to 2019 a systematic analysis for the Global Burden of Disease Study 2019

BackgroundPrevention, control, and treatment of respiratory tract cancers are important steps towards achieving target 3.4 of the UN Sustainable Development Goals (SDGs)-a one-third reduction in premature mortality due to non-communicable diseases by 2030. We aimed to provide global, regional, and national estimates of the burden of tracheal, bronchus, and lung cancer and larynx cancer and their attributable risks from 1990 to 2019.MethodsBased on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 methodology, we evaluated the incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs) of respiratory tract cancers (ie, tracheal, bronchus, and lung cancer and larynx cancer). Deaths from tracheal, bronchus, and lung cancer and larynx cancer attributable to each risk factor were estimated on the basis of risk exposure, relative risks, and the theoretical minimum risk exposure level input from 204 countries and territories, stratified by sex and Socio-demographic Index (SDI). Trends were estimated from 1990 to 2019, with an emphasis on the 2010-19 period.FindingsGlobally, there were 2·26 million (95% uncertainty interval 2·07 to 2·45) new cases of tracheal, bronchus, and lung cancer, and 2·04 million (1·88 to 2·19) deaths and 45·9 million (42·3 to 49·3) DALYs due to tracheal, bronchus, and lung cancer in 2019. There were 209 000 (194 000 to 225 000) new cases of larynx cancer, and 123 000 (115 000 to 133 000) deaths and 3·26 million (3·03 to 3·51) DALYs due to larynx cancer globally in 2019. From 2010 to 2019, the number of new tracheal, bronchus, and lung cancer cases increased by 23·3% (12·9 to 33·6) globally and the number of larynx cancer cases increased by 24·7% (16·0 to 34·1) globally. Global age-standardised incidence rates of tracheal, bronchus, and lung cancer decreased by 7·4% (-16·8 to 1·6) and age-standardised incidence rates of larynx cancer decreased by 3·0% (-10·5 to 5·0) in males over the past decade; however, during the same period, age-standardised incidence rates in females increased by 0·9% (-8·2 to 10·2) for tracheal, bronchus, and lung cancer and decreased by 0·5% (-8·4 to 8·1) for larynx cancer. Furthermore, although age-standardised incidence and death rates declined in both sexes combined from 2010 to 2019 at the global level for tracheal, bronchus, lung and larynx cancers, some locations had rising rates, particularly those on the lower end of the SDI range. Smoking contributed to an estimated 64·2% (61·9-66·4) of all deaths from tracheal, bronchus, and lung cancer and 63·4% (56·3-69·3) of all deaths from larynx cancer in 2019. For males and for both sexes combined, smoking was the leading specific risk factor for age-standardised deaths from tracheal, bronchus, and lung cancer per 100 000 in all SDI quintiles and GBD regions in 2019. However, among females, household air pollution from solid fuels was the leading specific risk factor in the low SDI quintile and in three GBD regions (central, eastern, and western sub-Saharan Africa) in 2019.InterpretationThe numbers of incident cases and deaths from tracheal, bronchus, and lung cancer and larynx cancer increased globally during the past decade. Even more concerning, age-standardised incidence and death rates due to tracheal, bronchus, lung cancer and larynx cancer increased in some populations-namely, in the lower SDI quintiles and among females. Preventive measures such as smoking control interventions, air quality management programmes focused on major air pollution sources, and widespread access to clean energy should be prioritised in these settings

The global epidemiology and health burden of the autism spectrum: findings from the Global Burden of Disease Study 2021

Background: High-quality estimates of the epidemiology of the autism spectrum and the health needs of autistic people are necessary for service planners and resource allocators. Here we present the global prevalence and health burden of autism spectrum disorder from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 following improvements to the epidemiological data and burden estimation methods. Methods: For GBD 2021, a systematic literature review involving searches in PubMed, Embase, PsycINFO, the Global Health Data Exchange, and consultation with experts identified data on the epidemiology of autism spectrum disorder. Eligible data were used to estimate prevalence via a Bayesian meta-regression tool (DisMod-MR 2.1). Modelled prevalence and disability weights were used to estimate health burden in years lived with disability (YLDs) as the measure of non-fatal health burden and disability-adjusted life-years (DALYs) as the measure of overall health burden. Data by ethnicity were not available. People with lived experience of autism were involved in the design, preparation, interpretation, and writing of this Article. Findings: An estimated 61·8 million (95% uncertainty interval 52·1–72·7) individuals (one in every 127 people) were on the autism spectrum globally in 2021. The global age-standardised prevalence was 788·3 (663·8–927·2) per 100 000 people, equivalent to 1064·7 (898·5–1245·7) autistic males per 100 000 males and 508·1 (424·6–604·3) autistic females per 100 000 females. Autism spectrum disorder accounted for 11·5 million (7·8–16·3) DALYs, equivalent to 147·6 (100·2–208·2) DALYs per 100 000 people (age-standardised) globally. At the super-region level, age-standardised DALY rates ranged from 126·5 (86·0–178·0) per 100 000 people in southeast Asia, east Asia, and Oceania to 204·1 (140·7–284·7) per 100 000 people in the high-income super-region. DALYs were evident across the lifespan, emerging for children younger than age 5 years (169·2 [115·0–237·4] DALYs per 100 000 people) and decreasing with age (163·4 [110·6–229·8] DALYs per 100 000 people younger than 20 years and 137·7 [93·9–194·5] DALYs per 100 000 people aged 20 years and older). Autism spectrum disorder was ranked within the top-ten causes of non-fatal health burden for people younger than 20 years. Interpretation: The high prevalence and high rank for non-fatal health burden of autism spectrum disorder in people younger than 20 years underscore the importance of early detection and support to autistic young people and their caregivers globally. Work to improve the precision and global representation of our findings is required, starting with better global coverage of epidemiological data so that geographical variations can be better ascertained. The work presented here can guide future research efforts, and importantly, decisions concerning allocation of health services that better address the needs of all autistic individuals. Funding: Queensland Health and the Bill & Melinda Gates Foundation.</p

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015

Background The scale-up of tobacco control, especially after the adoption of the Framework Convention for TobaccoControl, is a major public health success story. Nonetheless, smoking remains a leading risk for early death anddisability worldwide, and therefore continues to require sustained political commitment. The Global Burden ofDiseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, andnational progress toward achieving smoking-related targets can be assessed.Methods We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimatesof daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured bydisability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohortto better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed outchanges in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smokingprevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using theSocio-demographic Index (SDI).Findings Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI]24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6)reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualisedrates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countrieshad significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] andAzerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India,the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries andterritories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followedsimilar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for femalesmokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex andSDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smokingattributableDALYs in low-SDI to middle-SDI geographies between 2005 and 2015.Interpretation The pace of progress in reducing smoking prevalence has been heterogeneous across geographies,development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should notbe taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobaccoindustry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces arepoised to heighten smoking’s global toll, unless progress in preventing initiation and promoting cessation can besubstantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, andadequately implemented and enforced policies, which might in turn require global and national levels of politicalcommitment beyond what has been achieved during the past 25 years.</p

Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050

BackgroundThe rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020.MethodsWe estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050.FindingsIn 2019, health spending globally reached$8·8 trillion (95% uncertainty interval [UI] 8·7–8·8) or $1132 (1119–1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total,$40·4 billion (0·5%, 95% UI 0·5–0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0–25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this,$13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and$1·4 billion was repurposed from existing health projects. $3·1 billion (22·4$2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7$1519 (1448–1591) per person in 2050, although spending across countries is expected to remain varied.InterpretationGlobal health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all.</h4

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 201