Original article
The Burden of Disease in Germany at the National and Regional Level
Results in Terms of Disability-adjusted Life Years (DALY) from the BURDEN 2020 Study
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Background: Summary measures such as disability-adjusted life years (DALY) are becoming increasingly important for the standardized assessment of the burden of disease due to death and disability. The BURDEN 2020 pilot project was designed as an independent burden-of-disease study for Germany, which was based on nationwide data, but which also yielded regional estimates.
Methods: DALY is defined as the sum of years of life lost due to death (YLL) and years lived with disability (YLD). YLL is the difference between the age at death due to disease and the remaining life expectancy at this age, while YLD quantifies the number of years individuals have spent with health impairments. Data are derived mainly from causes of death statistics, population health surveys, and claims data from health insurers.
Results: In 2017, there were approximately 12 million DALY in Germany, or 14 584 DALY per 100 000 inhabitants. Conditions which caused the greatest number of DALY were coronary heart disease (2321 DALY), low back pain (1735 DALY), and lung cancer (1197 DALY). Headache and dementia accounted for a greater disease burden in women than in men, while lung cancer and alcohol use disorders accounted for a greater disease burden in men than in women. Pain disorders and alcohol use disorders were the leading causes of DALY among young adults of both sexes. The disease burden rose with age for some diseases, including cardiovascular diseases, dementia, and diabetes mellitus. For some diseases and conditions, the disease burden varied by geographical region.
Conclusion: The results indicate a need for age- and sex-specific prevention and for differing interventions according to geographic region. Burden of disease studies yield comprehensive population health surveillance data and are a useful aid to decision-making in health policy.
Epidemiological measures such as incidence, prevalence, and deaths are essential for monitoring population health. However, examining them in isolation cannot adequately assess the significance of various diseases. Assessment of the burden of disease in the general population is therefore becoming increasingly important in supporting health policy decision-making. Summary measures of population health integrate a variety of diseases as a cause of health impairment (morbidity) and death (mortality). The significance of the different diseases for population health can be measured by applying standardized rules (1, 2). Thus, the disability-adjusted life year (DALY) measures the total burden of disease comprising mortality (years of life lost due to death [YLL]) and morbidity (years lived with disability [YLD]) (3, 4, 5, 6). DALY are health gap measures which quantify deviations of the current population health from a defined norm. In contrast, health expectancy measures (for example, healthy life years) represent the remaining years of life spent in good health (7).
The metrics YLL, YLD and DALY date back to the Global Burden of Disease (GBD) study (4, 8, 9). This study estimates the burden of disease for global comparisons according to variables such as sex, age and country. Since the GBD study has only limited access to data at a national level and must therefore draw upon universal assumptions and extensive statistical methods, evaluation of the burden of disease has so far not been possible for Germany at the sub-national level. Yet decisions about health care require information below the federal level. So, regional burden of disease analyses are of considerable additional value for the assessment of population health because they provide information for guiding and prioritizing health care and prevention measures. Based on an improved data basis, the pilot project BURDEN 2020 (�The Burden of Disease in Germany at the National and Regional Level�) adapted the method used for measuring disease burden on the example of selected diseases and injuries with high public health relevance (eBox). The use of claims data from statutory health insurances and own health surveys enabled for the first time regional analyses of selected diseases. Based on this continuously available information, burden of disease analyses can become a permanent component of public health surveillance in Germany (10).
Method
The burden of disease concept quantifies in life years any deviation in population health from an �ideal� health status per reference year (eMethods section 1.1) (4). The mortality-related burden of disease (years of life lost due to death [YLL]) is calculated by multiplying the number of deaths with the standard remaining life expectancy at the age when death occurs. The methodology is described in detail elsewhere (11, 12). The morbidity-related burden of disease (years lived with disability [YLD]) provides a population-based quantification of years lived with health impairments. It is calculated from the prevalence of disease or injury, the distribution of the diseased population according to severity grades (severity distributions) and, for periodically occurring diseases, also the average duration of illness as well as severity-specific weights (disability weights) (eMethods section 1.1, [13]).
The initial assumption is that each diseased person lives one year with a disability per reporting year. The average duration of symptoms is also taken into account for episodic disabilities. Furthermore, the years lived with disability are converted to a unit of time equivalent to the YLL by applying disability weights (14, 15). Disability weights multiply each severity grade by a value between 0 (state of full health) and less than 1 (1 would be equivalent to death) (15, 16). A greater weight corresponds to a greater disability and results in a higher burden of disease (eMethods section 1.2). The DALY is the sum of YLL and YLD and is interpreted by the GBD study as years of healthy life lost (4).
The present analysis takes into account a selection of diseases and injuries (henceforth referred to as causes of burden of disease). Using the GBD four-level classification system (17), this selection includes at least one cause from the three main groups of causes of disease (level 1) of the GBD classification (eTable 1):
- communicable, maternal, neonatal, and nutritional diseases
- non-communicable diseases
- injuries.
These main groups are further subdivided at levels 2 to 4 into more specific causes of burden of disease. Thus, non-communicable diseases, for instance, include neurological disorders (level 2), which in turn include headache disorders at level 3. The latter distinguish between migraine and tension type headache at level 4. The selection for the present study was conducted at Level 3 (a total of 172 causes of burden of disease) and includes 19 of the quantitatively most important causes (around 53% of the burden of disease calculated for Germany for 2017 by the GBD study) (18) (eTable 2).
The calculation of YLD is based on primary and secondary data sources, in particular age, sex and, in most cases, morbidity-adjusted claims data of patients insured by the local statutory health care fund AOK (eTable 3) (13, 19, 20, 21, 22). Survey data on pain and addiction disorders (23, 24, 25), road traffic accident statistics (26), and groundwork done within the GBD study were also used (27). For both YLL and YLD uncertainty concepts (95% uncertainty intervals [UI]) were developed and merged (13). YLD were adjusted for age-related multimorbidity to avoid overestimation of the total (13, 28). The results are reported as absolute values as well as crude rates and age-standardized rates per 100 000 population (pop) for the year 2017 (European standard population 2013 [29]).
Results
The selected causes of burden of disease in the German population in 2017 produced 12.1 million DALY (UI: 11.9�13.1) (30). Women account for 6.0 million DALY (UI: 5.9�6.8), about as much burden of disease as men with 6.1 million DALY (UI: 6.0�6.6).
Without standardizing for age, this translates into a relative 14 584 DALY per 100 000 population, with a lower rate for women (14 303 DALY) than for men (14 872 DALY). When comparing all examined causes of burden of disease, ischemic heart disease (IHD) had the highest overall rate (2321 DALY), followed by low back pain (1735 DALY). At ranks 3 to 5 follow tracheal, bronchial, and lung cancer (henceforth referred to as �lung cancer� for short) with a rate of 1197 DALY, headache disorders with 1032 DALY, and chronic obstructive pulmonary disease (COPD) with 1004 DALY. Gender comparisons show clear differences with regard to the respective causes of burden of disease (Figure 1). IHD is ranked first for men (2969 DALY) and second for women with 1690 DALY after low back pain (1825 DALY). Furthermore, ranks 3 to 5 for women are occupied by headache disorders (1274 DALY), breast cancer (1130 DALY), and Alzheimer�s disease and other dementias (henceforth �dementias� for short) (911 DALY). In men, on the other hand, lung cancer (1542 DALY), COPD (1115 DALY), and diabetes mellitus (1028 DALY) are ranked 3 to 5. Alcohol use disorders produce more than three times as much burden of disease in males than in females. In contrast, women experience more than twice as much burden of disease from depressive disorders.
A differentiated breakdown of the burden of disease at level 4 (eFigure 1) demonstrates hardly any significant shifts at the upper ranks in comparison with level 3. It is evident, however, that certain level-4 causes are responsible for the degree of level-3 burden of disease (eTable 4). Thus, type 2 diabetes (level 4) is responsible for 95% of the DALY of diabetes mellitus (Level 3), migraine accounts for 94% of the DALY of headache disorders, and major depression for 93% of the burden of disease due to depressive disorders.
In relative terms, the burden of disease increases with age overall and for both sexes, although ranking and, in turn, the importance of the selected causes of burden of disease vary with age (Table, eTable 5). Headache disorders, low back pain, road injuries, alcohol use disorders, and anxiety disorders lead the DALY rankings in younger adulthood. Cardiovascular diseases, stroke, dementias, diabetes mellitus, and COPD dominate with advancing age (eTable 5, [30]). An age-related decrease of DALY rates is evident for lung cancer, alcohol use disorders, and headache disorders.
The disease-specific significance of mortality and morbidity for population health is reflected in the relative contribution of YLL and YLD to DALY. Whereas the burden of disease for pain and mental disorders is entirely attributable to morbidity, the relative contribution of mortality for the other causes of burden of disease varies (Figure 2). For instance, the proportion of burden of disease due to death (YLL) is 34% for diabetes mellitus and 97% for lung cancer. The proportions differ only slightly between the sexes (with the exception of road injuries and alcohol use disorders, for example). With increasing age, the relative contribution of mortality to DALY also increases for most causes of burden of disease (30).
An example for a striking gender difference can be given through the DALY rates for road injuries. Although road injuries are responsible for the greatest burden of disease for both sexes for the ages between 15 and 34 years, the rate for males is almost 2.4 times higher (362 versus 154 DALY per 100 000 population) (Figure 1). With increasing age, more DALY resulting from road injuries are evident in men than in women for almost all age groups. This is mainly due to fatal road injuries (YLL), while the share of YLD is similar in both sexes (eFigure 2).
Sub-national differences are evident at the level of the 96 spatial planning regions (abbreviated to SPR), both in individual causes of burden of disease (30) and in the total of all DALY calculated so far (age-standardized per 100 000 population) (Figure 3, Map I). Overall, the regions Emscher-Lippe (North Rhine-Westphalia) and Bremerhaven have the highest burden of disease, relatively speaking, while the SPRs Munich and South Upper Rhine (Baden-Wurttemberg) have the lowest (30). Furthermore, similar sub-national patterns in the distribution of DALY emerge for certain causes of burden of disease. Higher DALY values are evident for IHD (Figure 3, Map II) in the SPRs in eastern Germany, which is exemplary for many cardiovascular diseases. On the other hand, the burden of disease for COPD (Figure 3, Map III) is highest particularly in the SPRs in western Germany and Berlin. This is similar for lung cancer. A clear difference is evident between the northern and southern SPRs for depressive disorders due to a, relatively speaking, smaller burden in northern Germany, with Berlin and Hamburg being exceptions (Figure 3, Map IV).
Discussion
The present analysis provides an overview of the burden of disease caused by disability and death in Germany for 19 of the most important causes of burden of disease for the year 2017. The advantage of looking at burden of disease as opposed to isolated information on deaths and disease prevalence is that the impact of disease (YLD) and death (YLL) on population health can be compared using a standardized summary measure. The analysis was carried out using a uniform and transparent methodology and an improved, more complete, and sub-nationally differentiated database as compared with the GBD study. Although a comparison of the results with the findings of the GBD study for the year 2017 (17, 18) is only possible to a limited degree, on the whole it does show many matches for Germany. The causes of the highest burden of disease include
- IHD
- low back pain
- lung cancer
- headache disorders
- COPD
- diabetes mellitus.
Gender differences were particularly apparent in the other ranks. In females, breast cancer contributes significantly to the burden of disease, while dementias also ranks highly. In males, the burden of disease from alcohol use disorders and from road injuries is higher.
Given the high level of detail of the results, it is possible to identify which single causes of burden of disease (level 4) account for the largest proportion of disease-specific DALY (level 3), for example type 2 diabetes within diabetes mellitus and migraine within headache disorders. Furthermore, the results show that the significance of certain causes of burden of disease varies with increasing age. Whereas headache disorders and alcohol use disorders lead the DALY rankings for both sexes in younger adulthood, the burden of cardiovascular diseases and dementias rises with increasing age. The comparison of morbidity-related and mortality-related burden of disease highlights the different needs for action. Thus, morbidity-related burden of disease from mostly chronic, but rarely fatal illnesses such as pain disorders and mental disorders can be reduced if sequelae and severe forms of the disease are avoided. The high proportion of mortality-related burden of disease, for example due to cancer or cardiovascular disorders, indicates a high primary need for prevention (35) and the necessity to increase survival times of those affected by providing suitable forms of treatment.
In detail, males and females differ in their share of burden of disease due to death or disability. Whereas the mortality rate due to hypertensive heart disease is higher in women than in men, the opposite applies for alcohol use disorders: Here, alcohol-related mortality is significantly higher in men. Patterns for cardiovascular diseases, COPD, and depressive disorders, amongst others, become evident when the results are differentiated down to a sub-national level. On the one hand, these findings raise questions about possible regional care needs. On the other hand, they help to identify other fields of action which should be further substantiated by sub-national analyses of environmental, behavioral, relational as well as metabolic risk factors (35).
Limitations
Fundamental limitations arise because important illnesses with a high burden of disease (for example, chronic kidney diseases or liver cirrhosis [18]) were initially not considered in the pilot project, resulting in a relevant, but nevertheless still incomplete picture for assessing burden of disease. Furthermore, a large variety of data bases was used because, whenever possible, data sources of high validity and with high spatial resolution were to be used for each of the causes of burden of disease. Whereas claims data are suitable for capturing cases reliably associated with the utilization of the health care system (for example, severe myocardial infarction), it was necessary to rely on survey data for pain disorders. Therefore, specific limitations need to be taken into consideration ([11, 12, 19, 23, 24, 36]; eMethods section 2.1). The biases associated with the respective data sources are counteracted by compensation mechanisms such as morbidity-adjusting extrapolation procedures for the claims data (21). The results based on claims data were checked for consistency as far as possible by using external data sources (see eMethods section 2.1 for a detailed discussion). Furthermore, it was not possible in the course of the project to conduct prevalence estimates based on the survey data for children and adolescents nor at a sub-national level, which resulted in limitations when making comparisons between age groups and between sub-national regions. Suitable statistical methods to close these data gaps, including the use of sub-national estimation methods (37), are currently being tested. With regard to severity distributions, it was necessary for some of the diseases to resort to preliminary work from the GBD study which draws on mainly global, i.e., non-country specific and temporally invariant distributions (see eMethods section 2.2 for methodological critique) (38). Non-country specific disability weights were fully adopted from the GBD study (39) (see eMethods section 2.2 for methodical criticism).
Fazit
All results of the BURDEN 2020 project are entered into a health information system (www.daly.rki.de). They therefore represent an important element of public health surveillance at the Robert Koch Institute. The epidemiological measures based on claims data, such as prevalence, for example, are also readily available according to age, sex, and region (www.krankheitslage-deutschland.de). The BURDEN 2020 project is therefore useful to inform decision-making processes in health policy, such as the implementation of federal framework recommendations according to the German prevention law or regional morbidity-oriented planning. It can also be extended to include further diseases and may be supplemented by time series, forecasts, and other assessments (health impact assessments).
Finanzierung
The study �BURDEN 2020 � The Burden of Disease in Germany at the National and Regional Level� is supported by the innovation fund of the Federal Joint committee (project number: 01VSF17007). BURDEN 2020 was also supported by staff assigned to the project �Development of a National Mental Health Surveillance System at the RKI�, funded by the German Federal Ministry of Health (grant number: ZMI5�2519FSB402).
Project participants
BURDEN 2020 Study Group: Alexander Rommel, Elena von der Lippe, Annelene Wengler, Michael Porst, Aline Anton, Janko Leddin, Thomas Ziese (Robert Koch Institute, RKI), Helmut Schr�der, Katrin Sch�ssel, Gabriela Br�ckner, Jan Breitkreuz (AOK Research Institute, WIdO), Dietrich Plass, Heike Gruhl (German Environmental Agency, UBA)
Acknowledgments
We would like to thank Anna Kast (WIdO) for her support with information technology and database management as well as with the extrapolations. We would also like to thank Dr. med. Nina Buttmann-Schweiger (RKI) for her advice on operationalizing cancer-related secondary data and for her valuable comments on the article. Our thanks go to the scientific advisory board of the BURDEN 2020 project for its methodological advice on calculating burden of disease.
Conflict of interest statement
See funding reference for funding of individual staff and authors.
The authors confirm that no conflict of interest exists.
Manuscript received on 01 May 2022, revised version accepted on 29 August 2022.
Translated from the original German by Dr. Grahame Larkin MD
Corresponding author
Michael Porst, M.Sc.
Robert Koch Institute
Department of Epidemiology and Health Monitoring
FG24 Health Reporting
General-Pape-Str. 62�66, 12101 Berlin, Germany
Cite this as:
Porst M, von der Lippe E, Leddin J, Anton A, Wengler A, Breitkreuz J, Sch�ssel K, Br�ckner G, Schr�der H, Gruhl H, Pla� D, Barnes B, Busch MA, Haller S, Hapke U, Neuhauser H, Reitzle L, Scheidt-Nave C, Schlotmann A, Steppuhn H, Thom J, Ziese T, Rommel A: The burden of disease in Germany at the national and regional level�results in terms of disability-adjusted life years (DALY) from the BURDEN 2020 study. Dtsch Arztebl Int 2022; 119: 785�92. DOI: 10.3238/arztebl.m2022.0314
►Supplementary material
eReferences, eMethods section, eTables, eFigures, eBox:
www.aerzteblatt-international.de/m2022.0314
AOK Research Institute (WIdO), Berlin: Dr. phil. Jan Breitkreuz, Dr. phil. nat. Katrin Sch�ssel, Gabriela Br�ckner, Helmut Schr�der, Dr. med. Andreas Schlotmann
German Federal Environment Agency, Department II 1 Environmental Hygiene, Berlin: Dr. PH Dietrich Pla�, Heike Gruhl
Robert Koch Institute, Department 3, Infectious Disease Epidemiology, Berlin: Dr. med. Sebastian Haller
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